Every finding on record at Shelby Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain a homelike dining environment for seven anonymous resident council residents of eight reviewed for homelike environment. Findings include: On 4/28/26 at 12:15 PM, it was observed the main dining room was empty with no residents occupying the room during the lunch meal. Subsequent observations made on 4/29/26 at 12:20 PM and 4/30/26 at 12:23 PM, also revealed the main dining room with no residents eating the lunch meal. A review of the resident council meeting minutes for the months of January 2026-April 2026 revealed a discussion by the residents in the group of wanting dining rooms open so they could eat together instead of eating alone in their rooms. On 4/29/26 at 10:40 AM, a group meeting was conducted with eight group members and asked about dining in the facility, the group indicated they would like the main dining room to be reopened as soon as possible so they could eat together again. Further questioning of the group about the dining room revealed that it had been closed for meals since the beginning of January 2026 due to the facility being short staffed in the dining room. On 04/29/2026 at 12:39 PM, an interview was conducted with Dietary Manager (DM) D, and they were asked about the closure of the main dining room. DM D indicated the main dining room, and another smaller dining room had been closed since January 2026 due to dining being short staffed saying they understand the residents would like to eat together. On 4/29/26 at 1:00 PM, an interview was conducted with the Administrator (NHA) regarding the closure of the main dining room at the facility. The NHA confirmed the main dining room had been closed since February 2026 due to being short staffed. A review of a facility policy titled, Homelike Environment Reviewed: 2.3.2026 revealed the following, Policy Overview: Residents are provided with a . homelike environment .Guidelines: Staff provides person-centered care that emphasizes the residents' .comfort, independence, and personal needs and preferences.

This citation pertains to Intake 2982336.Based on interview and record review, the facility failed to ensure a copy of the care plan and updates were provided to the resident or the resident representative for one resident (R120) of two reviewed for participation in care planning. Findings include: On 04/28/2026 at 1:53 PM, two resident representatives (Representatives one and two) were seated bedside with R120. The two representatives were listed on the resident's face sheet as contacts for R120. The representatives reported R120 had been at the facility since 03/27/26 and expressed concerns and frustrations about the timing of care and lack of information provided. It was reported the representatives had been told R120 was no longer receiving physical (PT) or occupational therapy (OT) and themselves, or the Power of Attorney (POA) had been informed or received an explanation. The representatives also reported two messages were left with the with Director of Nursing (DON) on Friday (4/24/26) and they had not heard back. A review of the medical record documented R120's therapy end date as 04/27/26. On 04/28/2026 at 2:44 PM, the Director of Rehab Services (DORS) reported they were trying to clarify R120's status in order to continue with Rehabilitations Services which included PT and OT. The end date of 04/27/26 was reported as correct but there seemed to be some miscommunication as they had to determine if R120 met the need for skilled care. The DORS reported no notification for the end of services had been given the POA.On 04/28/2026 at 4:08 PM, a third listed representative of R120, reported an email had been sent to the social worker and others about care concerns and what was happening with the resident and no reply had yet been received. The representative also indicated frustration with timely response or any response to queries about R120.On 04/28/29 at 4:29 PM, Physician C had entered during an observation of wound care for R120. The Administrator also arrived at the door with Social Worker (SW) B to R120's room around this time and reported on some communications with the representatives of R120. On 04/29/2026 at 11:41 AM, a phone call was made to the POA. The POA reported they had sent a professional email Saturday (04/25/26) morning to the SW B, the Administrator and the Medical Director about concerns with the care for R120 did not hear from anyone over the weekend (did not expect to hear over the weekend) and waited until the end of business the following Monday. The POA had not heard back from them and attempted to call the Medical Director and a message was left. The POA commented it was tough to tell who you were leaving a message for due to the voicemail recording indicating you reached extension xyz (recording on voicemail). The POA reported they did finally get a call from (Physician C) on Tuesday (04/28/26) who filled in all the details that should have been given prior to that point. The POA further reported they felt updates should have been given all along and commented requests had fallen on deaf ears and staff always, regardless of who it was, pass the buck and you get the run around. Information has not been consistent. The POA was asked if they had a copy of the care plan and reported they had not received one. The POA recalled the orientation meeting but did not receive a care plan at that time. On 04/29/2026 at 4:25 PM, SW B reported R120 representatives and the POA did attend the initial care conference, and the standard of practice would be to offer and provide a copy of the plan of care and orders to the POA at the time of the care conference. SW B reported their contact with the POA was to update them on insurance reviews and discharge plans. SW B reported any representative under the contacts in the electronic medical record (EMR) could receive information about R120 from staff. SW B confirmed an email had been received from the POA related to care concerns and it had been sent to the administrator and other staff. SW B reported no prior contact with R120's representatives other than the POA. A review of the care conference notes in the EMR dated 03/30/26 and 03/31/26 revealed the checks under section seven titled Plan of Care were left blank.On 04/30/2026 at 8:27 AM, the administrator reported they had communicated with the POA who was reported to be at their wits end. On 04/30/2026 at 10:02 AM, Unit Manager (UM) E reviewed the progress noted for R120 and noted some representative complaints about wound care and R120 not eating and if staff were even trying to assist R120. UM E reported they had addressed these concerns with them and acknowledged the staff may be able to do better. On 04/30/2026 at 10:31 AM, Licensed Practical Nurse (LPN) F reported R120's family had asked them about the wound dressings and R120 not eating enough.On 04/30/26 at 2:53 PM, the DON acknowledged the identified concerns and reported there was a new team in place, and they were actively working on improvements in patient care.A review of the record for R120 revealed R120 was admitted into the facility on [DATE]. Diagnoses included Dementia, Heart Disease, and Pressure Ulcer of the Sacral (lower back and tailbone area).The April 2026 Treatment Administration Record (TAR) documented order changes for the heel wounds on 04/05 and 04/16 and the addition of a right lower extremity wound on 04/18. A treatment initiated 04/22 for a skin tear on the top of the left foot. The Minimum Data Set (MDS) dated , 04/02/26 documented, severe cognitive impairment, the dependence on staff for lower body dressing, toileting, rolling left and right in bed, sitting at the side of the bed and transfer. Substantial/Maximal assistance was required for upper body dressing.The active care plan initiated 03/27/26 documented, Difficulty Hearing .Impaired Vision .risk for fall . chronic pain . self-care deficit . indwelling urinary catheter . pressure ulcer .encourage and assist to reposition . at nutritional risk .A review of the care plan additions since the original care conferences included: Cognitive risk of Fluctuation initiated, 04/06/26 . resident wishes to return to community home, initiated 04/06/26 . At risk for changes in behavior and mood, initiated 04/06/26 . Risk for dehydration, initiated 04/07/26 . has anemia, initiated 04/07/26 . has hypothyroidism, initiated 04/07/26 . monitor nutritionally pertinent labs initiated 04/07/26, RD to evaluate and make diet change recommendations, initiated 04/07/26 . risked constipation, initiated 04/07/26 .Actual infection of urinary tract, initiated 04/15/26 . A wound consult note date 04/24/26 noted the three existing wounds to the buttocks had merged into one. A review of the progress notes did not indicate contact to the POA related to changes in the care plan and wounds.A review of the facility policy titled, Change in Condition Notification with reviewed date of 02/02/26, revealed, It is the policy of the facility to notify the resident, his or her attending physician/practitioner, and the resident's designated representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident, the resident's physician/practitioner, and the resident's designated representative when there is: An accident or incident involving the resident which results in an injury and has the potential for requiring physician/practitioner intervention. A significant change in the resident's physical, mental, or psychosocial status, such as deterioration which includes life-threatening conditions or clinical complications. A need to alter the resident's medical treatment significantly such as: A new treatment. Discontinuation of current treatment due to adverse consequences, an acute condition, or exacerbation of a chronic condition .

Based on observation, interview, and record review, the facility failed to ensure indwelling catheter and hand hygiene infection control practices were followed for one resident (R1) out of one reviewed for catheter care and hand hygiene during care. Findings include:A review of the Electronic Medical Record (EMR) for R1 revealed they were admitted into the facility on [DATE] with diagnoses of neuromuscular dysfunction of bladder, obstructive and reflex uropathy, and unspecified dementia. The most recent Minimum Data Set (MDS) dated [DATE] section H revealed that R1 had an indwelling catheter. Section C of R1's MDS revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. A review of R1's active orders revealed: Maintain (name of indwelling catheter) Catheter and provide care every shift. Catheter Size/French: 18Balloon Cubic Centimeters (CC): 10 Diagnosis: Neurogenic Bladder every shift for (name of indwelling catheter) care, dated 3/5/2026 On 04/28/2026 at 6:25 AM, an observation of R1's catheter bag revealed it was hooked onto their bed in a low position and was partially touching the floor with the rest of the bag leaning onto their fall mat. On 04/28/2026 at 9:29 AM, an observation of R1's catheter bag revealed that it was still partially touching the floor with the rest leaning onto their fall mat. On 04/28/2026 at 12:22 PM, an observation of R1's catheter bag revealed it was hooked to the bed in a low position and was fully on the floor slightly under their bed. On 04/30/2026 at 8:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) Manager A. They stated the standard for catheter care is that the bag should be covered for privacy and should not be hanging onto the floor. LPN A said that catheter care should be provided every shift and as needed and if a resident has a low bed, there should still be a bridge between the floor and the bag. On 04/30/2026 at 10:53 AM, an interview was conducted with the Director of Nursing (DON). They stated catheter bags should be kept off the floor and below the level of the resident's bladder. The DON stated if a resident has a low bed, there should be a barrier between the bag and the floor such as a basin. A review of a facility policy titled Catheter Care, last reviewed 2/2/2026, revealed that It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. On 04/28/2026 at 3:47 PM, incontinence care was observed with Licensed Practical Nurse (LPN) H and certified nursing assistant (CNA) I. The staff donned gloves and an isolation gown and entered the beside of R120. R120 was incontinent of stool and was cleaned up with disposable wipes. The staff members did not change after the cleaning of the stool. The staff proceeded to place clean linen and a new brief and did not change gloves. At 3:50 PM, the wound nurse placed on an isolation gown and then entered the room. R120 was turned onto their right side and the wound nurse cleaned multiple wounds. The wound nurse then took off their gloves and reached into their pockets for additional gloves without first completing had hygiene, put on new gloves. A review of the facility policy titled, Hand Hygiene revised 04/14/23 revealed, To provide guidelines to staff for proper hand hygiene techniques that will aid in the prevention and transmission of infections. SITUATIONS IN WHICH HANDWASHING WITH SOAP AND WATER IS NECESSARY:Included but not limited to: When hands are visibly dirty; When hands are visibly soiled with blood or other body fluids; Before and after eating; After using the restroom; After caring for a person with known or suspected infectious diarrhea; SITUATIONS IN WHICH USING SOAP AND WATER OR ALCOHOL BASED HAND RUB CAN BE USED: Included but not limited to: Between direct contact with residents; Before performing invasive procedures; Before applying and after removing personal protective equipment (PPE), including gloves; Before preparing or handling medications; Before and after handling clean or soiled dressings, linens, etc.; Before performing resident care procedures; Before and after providing care to residents in isolation; Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's skin; After handling contaminated objects, equipment, dressings, etc .

Based on observation, interview, and record review the facility failed to ensure repositioning and dressing changes were completed timely for one resident (R120) of five reviewed for pressure ulcer care and skin management. Findings include: On 04/28/2026 at 1:53 PM, family of R120 reported concerns with the bed sores and wound care for the bilateral heel wounds and the coccyx/sacral/buttocks of R120. They expressed observations of R120 not being turned for four hours and the heel boots not being placed back on during the times they had visited R120. They had concern that the wounds had worsened or increased since admission. They further noted the Low Air Loss (LAL) mattress went out or turned off intermittently and had to be unplugged then plugged back to get it working. A sign handwritten on a folded piece of lined notebook paper indicated to do this. They further noted the dressings to the feet/heel had been completed on Thursday (04/23/26) and did not get changed until Sunday. Family reported they the facility was never fully staffed on the weekends. R120 was observed and was laying on their back in bed dressed in a hospital style gown. The head of the bed was up around 30-45 degrees. A wedge at the left side did not extend sufficiently under R120's torso to shift R120 toward the right side and off their back and buttocks. A view of the heel dressings with the family revealed they were dated 04/27/26. R120 was queried about care and provided similar answers to varied questions. R120 had Pressure Releaving Ankle Foot Orthotic (PRAFO) boots on both feet. At 3:01 PM, R120 continued on their back as before. A review of the Treatment Administration Record documented the dressings were to be changed on the evening shift. The dressing to the buttocks was schedule for the day shift. At 3:33 PM continued in bed as before with a new nurse and aide.On 04/28/2026 at 3:47 PM, an observation of R120's coccyx/buttocks wound was completed with the wound care nurse. The dressing was saturated with drainage or incontinence. The wound had blackened slough (necrotic/dead/non-viable skin tissue) to a majority of the base and some bleeding was observed. The skin around the fist size open wound was a mixture of pink and purple and did not fully blanch when the wound nurse touched it. The wound nurse reported the wound looked like it was slightly deeper under the edges of the wound. R120 exhibited some body stiffening and moans with repositioning. The doctor had come in and also wanted to observe the wound.On 04/29/2026 at 8:12 AM, R120 was in on their back side in bed with no visible wedge at the side of the torso. The head of the bed was up around 30-45 degrees. R120 had a hospital style gown on, oxygen on via a nasal cannula, and PRAFO boots on. The call light was clipped to the bed at the left side. At 10:59 AM, staff were observed to exit the room. The roommate reported staff had not been checking on R120 as much before the survey team arrived. R120 was observed turned toward right side, with a wedge device under the left side of the torso, the PRAFO boots on and the head of the bed up around 30-45 degrees. At 12:49 PM, the Certified Nursing Assistant (CNA) G exited the room with the meal tray and reported R120 and had not eaten much, just a banana. R120's position was observed to be unchanged. At 1:40 PM, R120 continued facing toward the right as before, their head up 30-45 degrees. A check of the dressings to the feet with family noted they were dated for 04/27/26. A review of the Treatment Administration Record (TAR) documented the dressings were to be done daily on the evening shift. They were documented as changed. charted as done, by Licensed Practical Nurse (LPN) H. At 1:57 PM, 2:18 PM, and 2:29 PM, R120 remained in the same position. The family also reported staff had not changed the position of R120. R120 had been in a similar position around three and a half hours.On 04/30/2026 at 10:02 AM, Unit Manager (UM) E reported a conversation with family about positioning, R120 not eating enough and dressing changes and that these had been resolved. The dressings to the feet were discussed and UM E reported the dressing to the feet are to be done daily on the evening shift and the coccyx wound is changed by the day shift. On 04/30/26 at 2:53 PM, the Director of Nursing (DON) reported dressings are to be changed as ordered and dependent residents repositioned every two hours as the standard of practice.A review of the record for R120 revealed R120 was admitted into the facility on [DATE]. Diagnoses included Dementia, Heart Disease, and Pressure Ulcer of the Sacral (lower back and tailbone area).The Minimum Data Set (MDS) dated , 04/02/26 documented, severe cognitive impairment, the dependence on staff for lower body dressing, toileting, rolling left and right in bed, sitting at the side of the bed and transfer. Substantial/Maximal assistance was required for upper body dressing.The active care plan initiated 03/27/26 documented, Difficulty Hearing .Impaired Vision .risk for fall . chronic pain . self-care deficit . indwelling urinary catheter . pressure ulcer .encourage and assist to reposition . at nutritional risk .A review of the wound notes from admission dated 03/30/26 documented these issues: Location: Left heel. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury (pressure-induced wound that begins in the underlying muscle and fat layers, often with intact or discolored skin) Length (centimeters-cm): 2.99 Width (cm): 4.08 Depth (cm); .Location: Right Achilles. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury .Length (cm): 0.87 Width (cm): 1.22 Depth (cm): 0 .Location: Coccyx. Issue type: Pressure ulcer / injury .Pressure ulcer staging: Unstageable pressure ulcer / injury. Unstageable ulcer due to slough (non-viable skin tissue) and or eschar (non-viable tissue) .Length (cm): 3.23 Width (cm): 2.34 Depth (cm): 0 .Location: Right gluteus (buttock). Issue type: Pressure ulcer / injury .Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury .Length (cm): 3.91 Width (cm): 2.47 Depth (cm): 0 .Location: Left gluteus. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound was present on admission. Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 1.78 Width (cm): 1.59 Depth (cm): 0 . The Braden (at risk for skin breakdown) score was 13/23. A score less than 18 indicated greater risk for skin breakdown. A wound consult note dated 04/24/26 noted the three existing wounds to the buttocks had merged into one. A review of the progress notes did not indicate contact to the POA related to changes in the care plan and wounds. A review of the facility policy titled, Skin and Wound Guidelines revised 02/04/26, revealed, To describe the process steps required for identification of residents at risk for the development of pressure injuries, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations . Skin alterations and pressure injuries are evaluated and documented by the licensed nurse . Deep Tissue Injury - Persistent non-blanchable deep red, maroon, or purple discoloration. Unstageable - Obscured full-thickness skin and tissue loss .

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for two residents (R1 and R12) out of two reviewed for care plans. Findings include: R1 On 04/28/2026 at 6:25 AM, R1's catheter bag was observed to be hooked onto their bed in a low position and was partially touching the floor with the rest of the bag leaning onto their fall mat. A review of the Electronic Medical Record (EMR) for R1 revealed they were admitted into the facility on [DATE] with diagnoses of neuromuscular dysfunction of bladder, obstructive and reflex uropathy, and unspecified dementia. The most recent Minimum Data Set (MDS) dated [DATE] section H revealed R1 had an indwelling catheter. Section C of R1's MDS revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. A review of R1's active orders revealed: Maintain (name of indwelling catheter) Catheter and provide care every shift. Catheter Size/French: 18Balloon Cubic Centimeters (CC): 10 Diagnosis: Neurogenic Bladder every shift for (name of indwelling catheter) care, dated 3/5/2026. A review of R1's most recent care plan dated 3/11/2026 did not reveal a care plan with interventions for catheter care. An interview was conducted with Licensed Practical Nurse (LPN) Manager A on 4/20/2026 at 9:52 AM. They stated every resident who is on a catheter should have a care plan for it. However, LPN Manager A could not locate a catheter care plan in the EMR for R1. An interview was conducted with the Director of Nursing (DON) on 4/30/2026 at 10:53 AM. They confirmed R1 should have had a care plan for their catheter created during their admission process. A facility policy titled Care Plan- Comprehensive and Revision, last reviewed 2/2/2026, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. R12 A review of the clinical record for R12 revealed R12 was admitted into the facility on [DATE] with diagnoses that included (Post Traumatic Stress Disorder) PTSD, Dementia and Parkinson's. The active care plan initiated did not include interventions for PTSD. On 04/28/2026 at 3:32 PM, R12 was observed to return to their room. R12 was seated in a wheelchair and wheeled themself independently. On 04/29/2026 at 10:25 AM, R12 reported they enjoyed activities like going to the casino and watching bingo. R12 expressed everything was fair but could use a few more activities they liked. R12 and their visitor confirmed PTSD from R12's stint in the armed services. A review of the facility policy titled, Trauma Informed Care revised 03/10/25 revealed, It is the policy of this facility to ensure that any resident identified as a trauma survivor receives culturally competent, trauma-informed care in accordance with professional standards of practice to avoid triggers that may re-traumatize the resident. GENERAL GUIDELINES: The Social Services employee, or designee, will screen each resident for a history of trauma upon admission, annually, with a significant change or as deemed necessary as part of the Social Services admission Assessment. If the resident identifies any concerns of trauma or trauma related symptoms, the Social Services employee, or designee, will offer and follow-up on obtaining a formal psych consult if the resident and/or responsible party agrees. Social Services employee, or designee, will notify the psychiatry team to utilize a trauma informed approach to treat the resident accordingly. The Social Services employee, or designee, will create a trauma informed care plan, which will account for the residents' experiences, preferences, and cultural differences to ensure the resident feels safe and to eliminate triggers that may cause re-traumatization of the resident .

This citation pertains to intake 2568581.Based on observation, interview and record review, the facility failed to ensure resident care needs were met timely for six residents (R707, R700, R708, R709, R706, and R704) of twelve reviewed for resident care. Findings include: R707On 09/04/25 at 9:23 AM, R707 was interviewed and reported their number one concern was that staff do not answer the call bell all the time. R707 reported the call system had been down on their unit for at least a month and a half and they had been given a small hand bell to ring when help was needed. R707 further reported they did not feel safe with the call system down, especially when put in the bathroom. R707 noted the hand bell was not brought into the bathroom. R707 noted they required staff assistance to get up (using a stand lift) and could not ring the bell more than two or three times before they dropped it due to numbness in the hands. R707 was observed to have bilateral wrist and hand splints. R707 reported they just wanted a little respect as yesterday it was an hour and a half before they were assisted to the restroom and that was too long to hold pee. R700On 09/04/25 at 9:25 AM, R700 was interviewed in their room. They were sitting up in their wheelchair and dressed. The call lights were observed to be hanging on the wall over the junction box. The resident was asked about the call lights and indicated they were not working. When asked how they request assistance from staff the resident reported they have a bell to ring, and they looked around but were not able to locate their bell. R700 noted the need for assistance with dressing, transfer and bathing. R708 and R709On 09/04/25 at 9:34 AM, R708 and R709 reported the call light system had been down for a long time. R708 reported when their roommate R709 had first come to their room, R708 observed R709 leaning over the side of the bed having a breathing problem and neither of them had a working call light to alert staff. Both further noted one can only ring the hand bell a short amount of time. R709 further noted they felt like they were not being heard. R708 reported they were more independent and R709 noted they needed assistance to transfer and use the restroom. R706On 09/04/25 at 10:56 AM, R706 was observed to be in bed dressed in a hospital gown. The wheelchair and walker were away from the bed. The walker at the foot of the bed and the wheelchair. R706 reported they had told staff just after breakfast they wanted to be changed, dressed and up in their wheelchair and did not recall the exact time. R706 tugged at their gown and reported they had other clothes they could wear. A urine odor was noted and R706 noted they needed to be changed. R706 was asked about what they needed help with and reported to shower and get dressed. R706 was then observed to ring their hand bell and no one came. An observation of the hall revealed no staff in the hall of the unit and one at the nurse station who did not no response to the hand bell ring. At 11:08 AM R706 rang again with no staff response. At 11:24 AM, Certified Nursing Assistant (CNA) C reported they could hear a bell and would just have to walk down the hall and ask the resident who it was. R704On 09/04/25 at 12:27 PM, R704 reported it was hard to hear their call bell as they were down at the end of the hall. R704 reported they need help with things like a brief change, and it could vary from five minutes to a couple hours for the wait time. R704 reported staff really can't tell who it is that is ringing the bell and what happens if the need is more urgent. On 09/04/24 at 12:38 PM, Licensed Practical Nurse (LPN) D reported the call light system was an electrical issue and most every unit was affected. LPN D reported each new admission is given a hand bell. LPN D further commented it was hard to distinguish where ring was coming from, and they may not hear it if not in the immediate area. At 12:45 PM, CNA E reported call light system problems going back four months and reported it was difficult when more than one resident was ringing their handbell at the same time. CNA E noted one would have to go to the rooms of the residents and ask if they had rung their bell. At 1:19 PM, CNA H reported they had worked on the 300 unit and was told the unit call system was not working and the residents had been given hand bells, but had not had any specific training or program change related to resident assistance or monitoring, At 1:45 PM, the Assistant Maintenance Director (AMD) reported the call system had been down for three and a half weeks after a repair blew out two other boards. It was completely down on five units at the facility. The AMD did not have a date for the completion of the repair. On 09/04/25 at 2:16 PM, the Director of Nursing (DON) was asked about the call system outage and reported new admits are given hand bell and staff are expected to round on the residents. The DON confirmed unit one, three, five, seven and nine had the call light outage. The DON was asked about discussion of an action plan in the Quality Assurance (QA) meetings and reported they were not sure if there was a formal education plan written, but it was discussed.A request for an action plan for call lights from QA was requested to be provided if available on 09/04/25 at 3:23 PM via email and not received prior to survey exit.A review of the QA committee agenda received 09/04/25 at 2:33 PM via email revealed no specific reference to the call light outage. The Administrator documented, Our Monthly QA Agenda/Template remains the same for every month.A review of a facility invoice dated 07/11/25 noted parts had been ordered for the call system. Ongoing expenses for the call system were documented on 08/06/25, 08/11/25 and 08/15/25. The August expense report noted there were three units down. Additional document review for communications with the repair company noted an outage from 06/26/25 for the entire 900 unit.On 09/04/25 at 3:05 PM, the Inservice Director provided education from a March 2025 plan of correction for call lights out of reach and an example of notes from a unit staff five-minute huddle/meeting dated June 11, 2025, for units 300, 500 and 700 that documented call lights are to be responded to in a timely manner. A review of the facility policy titled, Care Plan - Comprehensive and Revision dated 08/08/22, documented, A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A review of the policy titled, Accommodation of Needs dated 08/21/23, documented, The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodation for the individual needs and preferences of a resident .A review of the facility policy titled, Call Light Accessibility and Timely Response dated 08/16/23 documented, The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet and bathing facility to allow residents to call for assistance. Call light will directly relay to a staff member or centralized location to ensure appropriate response.

This citation pertains to intake MI00153799. Based on observation, interview, and record review, the facility failed to maintain a sanitary environment in one of one kitchenettes located off the main dining room. Findings include: Review of a complaint intake received 6/19/25, noted that on 6/18/25, the cupboard located underneath the sink in the main dining room kitchenette, was observed to be wet and stained with mold. On 7/9/25 at 10:20 AM, the kitchenette located off the main dining room was observed with the Administrator. The cabinet located under the sink was observed with water damaged doors. The particle board was swollen and warped from past water damage. The bottom shelf of the cabinet was wet, and there was a black, mold-like substance on the surface. The Administrator stated he was unaware of the problem with the cabinet, and would have it cleaned right away. On 7/9/25 at 10:30 AM, the Administrator stated they had spoken over the phone with the Maintenance Supervisor and said that Maintenance wasn't aware it looked as bad as it did. The Maintenance Supervisor stated the issue with the cabinet was seasonal due to the warmer weather and humidity.

This citation pertains to intake MI00151590 Based on interview and record review, the facility failed to promptly identify, assess, and contact physician for an acute change in condition for one resident (R902) out of two reviewed for change in condition, resulting in pain and hospitalization . Findings include: A review of intake MI00151590 noted the following, This facility failed to provide [R902] with a timely evaluation of a head injury that likely was the cause of [R902's] mental status change and instead appeared to choose to attempt to sedate them. A review of the medical record revealed that R902 admitted into the facility on [DATE] with the following medical diagnoses, Acute Posthemorrhagic Anemia and Gastrointestinal Hemorrhage. A review of the admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status(BIMS)assessment score of 15/15 indicating an intact cognition. It was also noted on the MDS that R902 did not have any behaviors on admission. R902 also required staff assistance with bed mobility and transfers. Further review of the progress notes revealed the following, Effective Date: 3/12/2025.Cena (Certified Nursing Assistant) emptied foley catheter at 0600 (6:00 AM) and the bag was 550 [milliliters] and full of blood. Effective Date:3/12/2025. Transition of Care: Apixaban (Blood Thinner) 5 MG twice daily. Monitor for spontaneous bleeding. Effective Date: 3/21/2025. Writer notified by cena that resident had fallen .When asked what happen resident stated, I was trying to get out of bed, to come and tell you that a small bunny came and kissed me. I grabbed the reacher to help me stand and I fell . Effective Date:3/22/205. Resident experiencing brief moment of confusion, c/o dizziness, SPO2(oxygen level) checked 88% RA (Room Air) . Effective Date: 3/24/2024. Pt. (Patient) receiving o2(Oxygen) at 2 lpm (liters per minute), noncompliant with o2 therapy, pt. constantly removes nasal cannula. Pt. constantly removes nasal cannula. Pt. not easily redirected, constantly removing top shirt . Effective Date: .3/26/2025Writer entered resident room and observed resident was sitting on floor opposite side of bed. Resident was trying to put her shoes on. Resident foley was pulled out and laying on the bed .Resident stated [they] were trying to get out of this place .Writer notified DON (Director of Nursing), supervisor and family .Writer is being very uncooperative and combative. Writer notified (Medical Doctor) of resident's combativeness and ordered a onetime order of Haldol 5mg (milligrams) . On 4/2/2025 at 11:24 AM, an interview was conducted with Licensed Practical Nurse (LPN) C. LPN C reported they were R902's nurse on 3/26/2025 and had to send them to the hospital. LPN C reported they had taken care of R902 once before and this was a complete change in behavior for them. LPN C reported R902 was very combative, picking their skin, and attempting to hurt themselves and others. LPN C reported they originally were directed to give R902 Haldol for the new behaviors and then eventually sent them to the hospital. On 4/2/2025 at 12:00, and interview was conducted with Certified Nursing Assistant (CNA) B. CNA B reported that they cared for R902 the day they went to the hospital. CNA B reported they were informed by the nurse that R902 had fallen and when they went in the room R902 was saying that they were trying to kill them and would not calm down. CNA B reported they put R902 at the nurse's station and took turns sitting with them. CNA B reported that R902 was digging in their skin, taking off their oxygen, and picking at their skin. CNA B indicated this was not normal behavior for R902, and they had taken care of them previously. CNA B reported the nurse was on the phone with the Director of Nursing (DON) and they were telling them what to do. CNA B reported R902 was sent out after hitting them and digging and peeling their skin off. On 4/2/2025 at 2:00 PM, an interview was conducted with the DON. The DON was queried if anyone had reported that R902 had a foley bag full of blood as indicated in the progress notes. The DON reported no one reported that to them and they were unsure if the physician team was ever notified. The DON was queried regarding the documented confusion following R902's falls. The DON reported that when someone has a unwitnessed fall, they complete the neurochecks and will send them out if there is a change. The DON reported they know R902 came into the facility with a 15/15 BIMS score but was unsure if there was always some underlying confusion. The DON was asked about giving R902 Haldol, instead of sending them out when there was a change in their behaviors. The DON stated they were unable to answer why the physician made that decision, but they sent R902 out when they began picking their skin and hitting people. A review of a facility policy titled, Change in Condition Notification noted the following, The nurse will notify the resident, the resident's physician/practitioner, and the resident's designated representative when there is: A significant change in the resident's physical, mental, or psychosocial status, such as deterioration which includes life-threatening conditions of clinical complications.

This citation pertains to Intake MI00151476. Based on interview and record review, the facility failed to provide supervision during medication administration for one resident (R900) out of one reviewed for self administration of medications. Findings include: On [DATE] at 9:43 AM, a phone interview was conducted with R900's Family Member (FM) E. FM E reported they were told the day that the resident died they complained about being short of breath (SOB). FM E reported that they were informed the nurse put the nebulizer mask on R900 and left the room. FM E reported they were informed when the nurse came back R900 was found to be unresponsive. A review of the medical record revealed that R900 admitted into the facility on [DATE] with the following medical diagnoses, Chronic Obstructive Pulmonary Disease (COPD) and Acute Respiratory Failure with Hypoxia. A review of the Minimum Data Set assessment (MDS) revealed a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] indicating an impaired cognition. R900 also required staff assistance with bed mobility and transfers. No self-administration of medication assessment and/or care plan was observed in the medial record. Further review of the progress notes revealed the following, Effective Date: [DATE] at 9:43. Type: Nursing-Progress Note .Resident had complaints of SOB, resident instructed to sit up as [R900] was laying flat. Writer was able to administer medications PO (by mouth) with no issues. Writer started breathing treatment to assist with SOB, on returning 10 minutes later, resident was slump over to the right, face mask off and non-responsive to verbal or physical stimuli . On [DATE] at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they expect for the nurse to stay with a resident while a nebulizer treatment is going and if they have to leave, then someone needs to be in the room with them. A review of a facility policy titled, Nebulized Medication Treatments noted the following, .Stay with resident during nebulizer treatment unless it has been determined that resident can use nebulizer on own. (a self-medication assessment must be completed.

Based on observation, interview, and record review, the facility failed to stock, demonstrate sufficient Infection Control practices, and don/doff (put on/take off) Personal Protective Equipment (PPE- gown, gloves, and masks) for three residents (R141, R17 and R106) in isolation and precautions out of three reviewed for Infection Control (IC). Findings include: R141 On 3/3/2025 at 11:57 AM, R141's call light was activated, and their intravenous (IV) machine was heard beeping. R141 had a PPE caddy on their door, with a sign stating they were on contact isolation (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment) and should don gloves, mask, and gloves when entering room. On 3/3/2025 at 12:01 PM, a nurse was observed entering R141's room without putting on any PPE. The nurse was then observed to silence the IV machine, come back out and grab supplies to disconnect the IV machine from R141. The nurse was then observed to reenter R141's room without putting on PPE and disconnected R141's IV machine from the resident only donning gloves. A review of the medical record revealed R141 admitted into the facility on [DATE] with the following medical diagnoses, Osteomyelitis, Left Ankle and Foot. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 3/15 indicating an impaired cognition. R141 also required staff assistance with bed mobility and transfers. On 3/5/2025 at 11:30 AM, an interview was completed with Infection Control Preventionist (ICP) D. ICP D stated their expectation of staff entering a contact isolation room is that they don all appropriate PPE and stated the signs on the door clearly list what they should be putting on prior to entering the room and performing care. ICP D confirmed the nurse that entered R141 should have put on all appropriate PPE needed for contact precaution, including a gown, prior to disconnecting their IV. 38207 R17 On 3/3/25 at 10:53 AM, an observation of R17's room revealed signage which indicated R17 was on EBP (Enhanced Barrier Percautions -set of infection control practices). A PPE caddy (storage unit for PPE) on R17's door was observed to contain no gloves or face masks. On 3/4/25 at 11:00 AM and 3:52 PM, R17's caddy was observed to contain no face masks. On 3/4/25 at 3:56 PM, R17 and confidential family member S were interviewed and asked if staff consistently wore PPE when providing care for R17. R17 and family member S stated, I don't think so. On 3/5/25 at 9:38 AM, R17's caddy was observed to contain no gowns or face masks. On 3/5/25 at 11:47 AM, ICP D was interviewed about their expectations for PPE which should be available in the door caddy of residents on EBP. ICP D indicated that the caddy should be fully stocked with gloves, gowns, and face masks. ICP D indicated the nurses on the units should be replacing the PPE in the caddy as needed. A review of R17's EMR revealed that R17 was most recently admitted to the facility on [DATE] with diagnoses that included Kidney failure and Post traumatic stress disorder (PTSD) (Mental health condition). R17's Nursing Admission Evaluation completed on 2/26/25 revealed that R17 had an intact cognition and required assistance for all activities of daily living (ADL's) including catheter care. 49699 R106 On 03/20/2025 at 07:35 AM, Licensed Practical Nurse (LPN) B retrieved the glucometer tray from medication carts bottom drawer and entered R106's room that had a PPE [NAME] on the door with a sign specifying what PPE to don (gown, gloves, and mask) for the room. LPN B was observed to place glucometer tray and blood pressure cuff on R106's bed without a barrier, hand hygiene was not performed, PPE was not used. LPN B was not satisfied with the reading obtained for R106's blood pressure and left the room to obtain a wrist blood pressure machine. No hand hygiene performed. Upon completion of these tasks LPN B took the equipment and left R106's room. Hand hygiene was not performed. Blood pressure equipment was returned to nursing station, the glucometer tray replaced in medication cart without cleaning. No hand hygiene was performed upon leaving R106's room. On 3/4/2025 at 2:00 PM, LPN B was asked what the cleaning protocol was for the glucometer and blood pressure cuffs. LPN B stated the glucometer tray, the glucometer, and the blood pressure cuffs were supposed to be cleaned with bleach wipes. The Equipment cleaning policy was requested but not received by end of survey.

Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for six residents (R1, R15, R41, R53, R78, and R110 ) of six residents reviewed for call light accessibility. Findings include: Resident R1 On 3/3/25 at 11:15 AM, R1's call light was observed on their wheelchair out of reach. An interview was conducted with R1 and confidential family member O and they were asked about the call light being out of reach. Family member O confirmed that [R1's] call light had been observed to be out of reach on multiple occasions when they had visited them. A review of R1's electronic medical record (EMR) revealed that R1 was most recently admitted to the facility on [DATE] with diagnoses that included Cellulitis (Bacterial skin infection) of left lower leg and Heart failure. R1's most recent minimum data set assessment (MDS) dated [DATE] revealed that R1 had a moderately impaired cognition and was dependent and/or required maximum assistance for all activities of daily living (ADLs) other than eating. R78 On 3/4/25 at 4:35 PM, R78's call light was unable to be located in their room. R78 was interviewed regarding the location of their call light and did not know where their call light was located. Upon further observation, R78's call light was located in a shut dresser drawer out of reach and sight. A review of R78's EMR revealed that R78 was most recently admitted to the facility on [DATE] with diagnoses that included, Sepsis (Infection) and Paroxysmal atrial fibrillation (Irregular Heartbeat). R78's most recent minimum data set assessment dated [DATE] revealed that R78 had a moderately impaired cognition and was fully dependent and/or required maximum assistance for all activities of daily living (ADLs) other than toileting and eating. R110 On 3/5/25 at 10:22 AM, R110 was observed in bed with their call light hanging underneath their bed on the floor out of reach and sight. On 3/5/25 at 10:30 AM, Nurse/LPN (Licensed Practical Nurse) P was interviewed and asked what their expectations were for call light accessibility in residents' rooms. Nurse P stated, The call light should be in reach of the resident. A review of R110's EMR revealed that R110 was most recently admitted to the facility on [DATE] with diagnoses that included Epilepsy (Brain Disorder) and Asthma (Inflamed Airways). R110's Nursing Admission Assessment (NAA) dated 2/27/25 revealed that R110 had a moderately impaired cognition and required assistance for all ADLs. 49699 R15 At 03/03/25 at 09:28 AM, R15 was noted sitting in a wheelchair, on the window side at the foot of bed, with call light located at top of the bed just below the pillow. When queried whether R15 could get to the light, R15 indicated it is real hard because the room is tight in this area (foot of bed on window side of bed). On 03/03/25 at 09:28 AM R15 was facing the window in a wheelchair, consuming thier lunch from the overbed table. There was not room for R15 to turn the wheelchair around in order to access the call light located on the opposite side of the bed up near the pillow. On 3/4/2025 a review of the Electronic Medical Record (EMR) revealed R15 was admitted on [DATE] with diagnoses of Alzheimer's Disease, Anxiety, and Cardiac Disease. The EMR further revealed a Basic Inventory of Medical Status score of 13, indicating intact cognition. R41 On 03/03/25 at 09:17 AM, R41's call light was out of reach, secured on the night stand's top drawer handle. R41 was looking for it. When R41 saw it, they were unable to reach it. On 03/03/25 at 01:07 PM, R41's call light was attached to the night stand's top drawer handle out of reach. On 03/04/25 at 11:08 AM, R41's call light was noted to be woven between two pillows against the head of the bed. When R41 was queried regarding the location of their call light they began to look for it and was unable to find it becoming frustrated. A review of the EMR revealed R41 was admitted on [DATE] with diagnoses of Urinary Tract Infection, Cervical Disc Disorder with Myelopathy, and Anxiety. The EMR further revealed a BIMS score of 14 indicating intact cognition. R53 On 03/03/25 at 10:23 AM, R53 was sitting in their wheelchair. Call light was noted on opposite of bed from resident. R53 was asked where the call light was and was unable to locate it. A review of the EMR revealed R53 was admitted on [DATE] with a diagnoses of Diabetes, Type 2 Dementia, Mood Disorder and Anxiety. The EMR further revealed a BIMS score of 03 indicating severe impaired cognition. On 3/5/25 at 11:04 AM, the Administrator (NHA) was interviewed regarding call light accessibility for the residents. The NHA indicated the call light should be within reach of the resident. A facility policy titled Call Light Accessibility and Timely Response, Issued Date: 8/16/2023 was reviewed and revealed the following, Policy Overview: The purpose of this policy is to assure that the facility is adequately equipped with a call light at each residents' bedside .to allow residents to call for assistance. Staff will ensure that call lights are within reach of residents' .The call system will be accessible to residents in their room at bedside .

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and labeled for two residents (R51 and R78) of ten residents reviewed, three of thirteen medication carts. Findings include: R78 On 3/3/25 at 1:30 PM, an observation was made of a medicine cup filled with a red liquid on R78's dresser. R78 was interviewed and asked about the medicine cup on their dresser and stated, I think it's cough medicine. R78 was asked if they self-administered their medication and said nursing administered their medications to them. On 3/3/25 at 1:35 PM, Unit Nurse Manager, Licensed Practical Nurse (LPN) I was requested to come to R78's room and was shown the medicine cup on R78's dresser and asked about it. LPN I indicated the medicine cup contained a protein supplement and removed the medicine cup from R78's dresser and discarded it. A review of R78's electronic medical record (EMR) indicated the following physician's order, Start date: 1/22/25; End date: 3/5/25. Order: House Liquid Protein Source One time a day for Protein assistance. Further review of R78's EMR revealed R78 was most recently admitted to the facility on [DATE] with diagnoses that included, Sepsis (Infection) and Paroxysmal atrial fibrillation (Irregular Heartbeat). R78's most recent minimum data set assessment dated [DATE] revealed R78 had a moderately impaired cognition and was fully dependent and/or required maximum assistance for all activities of daily living (ADLs) other than toileting and eating. 49102 R51 On 03/03/25 at 9:25 AM, R51 was observed sitting up in bed finishing their breakfast tray. A bottle of Vitamin C and a bottle of Vitamin B-12 were observed sitting on the night stand. When asked about the bottles, R51 stated, Those are my bottles, I take one of each pill every day. On 03/04/25 at 1:15 PM, R51 was observed sitting up in the bed watching television. The same bottles of Vitamin C and Vitamin B-12 was observed on the nightstand. A review of R51's medical record revealed they were admitted to the facility on [DATE] with diagnoses including mild dementia, generalized anxiety disorder, adjustment disorder and hypertensive heart disease. A review of R51's Minimum Data Set, dated dated dated [DATE] revealed the Brief Interview for Mental Status score of 15 indicating intact cognition. On 03/04/25 at 1:18 PM, the Director of Nursing (DON) was asked to accompany surveyor to R51's room. Upon entering R51's room, the DON noted the two bottles of vitamins on the bedside table. The DON stated R51 has not been assessed for self administration of medications and should not have medications at the bedside. 49699 On 03/04/25 at 02:10 PM, during a review of the low numbered medication cart with Licensed Practical Nurse (LPN) A, on Unit 100, a narcotic (Norco) tablet was found in a medicine cup, partially dissolved. LPN A revealed they had given a resident the narcotic with they're other medication and the resident spit it out. LPN A explained they were waiting for a second nurse to dispose of the medication appropriately. On 03/04/25 at 02:35 PM, during review of the high numbered medication cart for unit 300 with LPN F, A KwikPen Humalog insulin pen was noted without a label or date. LPN F indicated the KwikPen should have a label and date. On 3/4/2025 at 03:00 PM, review of medication storage and labeling for Unit 400 medication , low number cart with LPN B, two KwikPen Humalog insulin were found without identifying label or open date. On 03/04/2025 at 2:30 PM, an interview with the Director of Nursing (DON) revealed that wasted narcotics are to be wasted in the container that renders the medication harmless, at the time the medication is not going to be used after removing from the medication cart. The DON revealed this process requires two licensed nurses. On 3/5/25 at 11:04 AM, the Administrator (NHA) was interviewed regarding their expectations for medication storage and labeling. The NHA indicated that all medications should be stored safely. A review of a facility policy titled, Medication and Treatment Storage Issued Date: 8/7/2023 revealed the following, Policy Overview: It is the policy of this facility to ensure accurate labeling and dating of medications for safe administration and safe secure storage .of all medications and treatments. Labeling of medications and biologicals dispensed by the pharmacy will be consistent with applicable federal and State requirements and currently accepted pharmaceutical principles and practices including expiration dates . Medications designed for multiple administration, the label will identify the specific resident for who it was prescribed. Multi-use vials will be dated when the vial is first accessed. All medications requiring refrigeration are stored in refrigerators in the medication room .logs are kept on each refrigerator and temperature levels are recorded daily .

Based on observation, interview and record review, the facility failed to complete an annual PASARR (Preadmission Screen and Resident Review) for one resident (R121) of two residents reviewed for PASARR screening. Findings include: On 03/03/25 at 09:45 AM, R121 was observed lying in bed finishing his breakfast meal. A review of R121's medical record revealed they were admitted into the facility on [DATE] with the following diagnoses of vascular dementia, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and dysphagia. A Minimum Data Set (MDS) assessment dated [DATE] and a Brief Interview for Mental Status (BIMS) score of 12, indicating an mild impairment with cognition. R121 also scored 9 on The Patient Health Questionnaire which indicates severe depression. Further review of R121 medical record revealed a PASARR dated 10/8/23. On 03/05/25 at 12:15 PM an interview occurred with Social Worker C regarding an updated PASARR for R121. Social Worker C confirmed there was not an updated PASARR completed and confirmed PASARR should be updated annually. A request for a facility policy related to PASARRs was requested and not received by the end of survey.

Based on observation, interview, and record review, the facility failed to honor food preferences for one resident (R142) out of one reviewed for food. Findings include: On 3/3/2025 at 12:28 PM, R142's lunch tray was noted to be sitting on their bedside table. A review of their dietary ticket had dislikes-no cucumbers with it highlighted in a pink color. An observation of the side salad revealed cucumbers on the salad. R142 stated they do not like cucumbers, and the kitchen staff often put them on even though they've said they do not want them. A review of the medical record revealed R142 admitted into the facility on [DATE] with the following diagnoses, Cerebral Infarction and Dysphagia. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 10/15 indicating an impaired cognition. R142 also required staff assistance with bed mobility and transfers. On 3/5/2025 at 9:43 AM, an interview was conducted with Dietary Manager (DM) Q. DM Q stated the dietary staff should read the tray ticket, and they highlight it to make sure it is seen. DM Q stated that floor staff should also be checking before they give the resident the tray. A review of a facility policy titled Food Preferences and Select Menus noted the following, The facility will provide meals that accommodate resident allergies, intolerances, and food preferences.

Based on observation, interview, and record review, the facility failed to apply a hand splint as ordered for one resident (R89) of two residents reviewed for range of motion. Findings include: On 3/03/25 at 9:25 AM, R89 was observed lying in bed with arms folded and both hands on their chest. Two hand splints were observed on top of the dresser across the room. O3/03/25 at 10:45 AM, R89 was observed still lying in bed with their hands and arms still in the same position. Two hand splints were still observed to be on the dresser across the room. R89 explained they cannot use their arms or hands. R89 demonstrated attempting to move their right arm and was observed to lift it about 2 inches off of their chest and was unable to move their fingers. R89 explained when they were first admitted they were able to move their arms and hands more than they can now and stated, but due to neglect, now they are like concrete. When R89 was asked if they are supposed to wear the hand splints on the dresser R89 explained that they are supposed to but that no one ever puts them on. On 3/04/25 at 3:03 PM, R89 was observed lying in bed with arms folded and their hands on their chest. Two hand splints were observed on the dresser across the room in the same place and position as previously observed. On 3/05/25 at 8:34 AM, R89 was observed lying in bed with their arms folded and their hands on their chest. Two hand splints were observed on top of the dresser across the room in the same place and position as previously observed the day prior. When asked if anyone had put the splints on R89's hands overnight R89 explained that no one had put them on and that they never do. A review of R89s record revealed they were admitted to the facility on [DATE] for Unspecified injury at unspecified level of cervical spinal cord. Further review revealed a Brief Interview for Mental Status Score of 15, indicating intact cognition. A review of R89's physician orders revealed the following active order: Orthosis/Splint to be applied to: B (both) resting hand splints to be worn at night, as tolerated. Every shift on in the evening off in the morning. Dated 1/15/25 A review of R89's care plan revealed the following: Orthotics: (B) resting hand splints to be worn during the day. Remove & assess skin integrity and skin hygiene. 1/9/25 Restorative splint/brace1-B resting hand splints, to be worn at night as tolerated, remove for hygiene/skin checks. Dated 1/15/25 On 3/05/25 at 8:22 AM, Licensed Practical Nurse (LPN) J explained R89 reported to them that R89's hands are stiffening up because therapy refuses to help and they do not know if R89 has hand splints. On 3/05/25 at 8:31 AM, Certified Nurse Assistant (CNA) M explained R89 is paralyzed and did not know if R89 had hand splints. On 3/04/25 at 3:12 PM, Therapy Director (Staff K) explained R89 was admitted to the facility as a paraplegic with cervical precautions. Staff K explained Occupational therapy was working with R89 from 12/24-1/29 and was doing range of motion for all joints. On 3/5/25 at 9:11 AM, staff K confirmed R89 is supposed to have hand splints on and explained the splints should be applied at night by the nursing staff since the restorative aides are not here at night. On 3/5/25 at 11:58 AM, restorative Certified Nurse Assistant (CNA) N explained R89 wears hand splints at night. On 3/05/25 at 10:31 AM, the Director of Nursing (DON) explained if a resident has hand splints ordered they should be applied and it is a collaborative effort between nursing and therapy. A review of the facility's policy titled Medical Device-Internal and External revealed the following: It is the policy of the facility to accommodate residents who have internal and external medical devices that are within the staff members scope of practice.

Related to MI00150481 Based on interview and record review, the facility failed to ensure one resident (R131) of one reviewed for outside of facility consultations recieved the recommendations from an consultant appointment. Findings Include: Review of the medical record for R131 revealed an admission into the facility on [DATE] with pertinent diagnoses of: Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety. R131 was evaluated by a consulting hearing service. The consulting physician was unable to remove impacted ear wax for R131 and recommended a medication to soften the wax with a return visit in 1-3 months. That order was not noted or carried out. An interview with the responsible Social Worker C revealed the process for communication occurs when the Social Work receives the completed consult/report, reviews the documentation and requests appropriate orders from physician and/or sets up follow up appointment. SW C revealed the consult and the recommendation was missed.

Based on observation, interview, and record review, the facility failed to provide sufficient feeding assistance for one resident (R142) out of one reviewed for Activities of Daily Living (ADL). Findings include: On 3/3/2025 at 12:07 PM, R142's lunch tray was observed sitting on the bedside table. R142 stated they were hungry but waiting for someone to help them eat. R142 stated they were visually impaired and needed feeding assistance. On 3/3/2025 at 12:14, 12:21 and 12:28 PM, R142's tray was still observed sitting on the bedside table, untouched. On 3/3/2025 at 12:31 PM, Physical Therapy was observed entering R142's room and mentioning R142 had not eaten lunch yet. R142 was heard stating they were still waiting for feeding assistance. On 3/3/2025 at 2:30 PM, R142 stated someone did come and help them eat, but the food was cold so they did not eat much. A review of the medial record revealed R142 admitted into the facility on [DATE] with the following diagnoses, Cerebral Infarction and Dysphagia. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 10/15 indicating an impaired cognition. R142 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed R142 was supposed to be a 1:1 feeding assist and were in a trial period. On 3/5/2025 at 8:45 AM, R142's breakfast tray was observed sitting beside their bed. R142 stated they were waiting for somebody to come back because they wanted more French toast. R142 stated they did not know how long they had been waiting for someone to come back, but it had been a while, and they were hungry. On 3/5/2025 at 9:00 AM, R142's breakfast tray was still observed in the room. R142 stated they were still waiting on assistance to finish their breakfast, and they were still hungry. On 3/5/2025 at 9:01 AM, Registered Nurse (RN) E was informed R142 was waiting for someone to help them finish breakfast. RN E stated someone was in there helping and they would go and see if R142 was still hungry. R142 was heard informing RN E that they were still hungry and needed further assistance. On 3/5/2025 at 9:20 AM, Registered Dietitian (RD) R. RD R stated R142 is a 1:1 feed because they are visually impaired. RD R stated R142 should continue to be a 1:1 feed because they just discontinued their tube feeding and should be encouraged to eat on a consistent basis. On 3/5/2025 at 12:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the staff should leave the tray on the cart until staff is ready to go in the room and provide feeding assistance. The DON stated they expect for staff to stay with the resident until they are done assisting the resident. A review of a facility policy titled, Assistance with meals noted the following, .It is the Center's Policy that all patient/residents shall receive assistance with meals in a manner that meets their individual needs and per Plan of Care.

Based on interview and record review, facility failed to ensure comprehensive care plans were developed and updated for two (R51 and R89) of six resident reviewed care plans. Findings include: R51 A review of R51's medical record revealed they were admitted to the facility on [DATE] with diagnoses including mild dementia, generalized anxiety disorder, adjustment disorder and hypertensive heart disease. A review of R51's Minimum Data Set assessment dated [DATE] revealed the Brief Interview for Mental Status score of 15 indicating an intact cognition. Further review of R51's medical record revealed increased behaviors of refusal of care and assistance. Per a nursing progress note dated 2/07/25, R51 had a behavior of speaking loudly to the roommate and being upset about a window being open. The medical record indicated R51 refused bathing and assistance at least weekly during the month of February 2025. Review of the behavioral care plan initated 7/9/24 with interventions revealed there was no review or updated interventions for increased behaviors noted on February, 2025. On 03/05/25 at 12:15 PM, Social Worker C was interviewed regarding R51's care plan and interventions for the increased behaviors and refusal of care. Social Worker C said resident care plans are updated by the interdisciplinary team and confirmed there were no updates added to the care plan to address recent behaviors. 50223 R89 On 3/03/25 at 10:45 AM R89 was observed lying in bed. R89 explained they get nutrition by tube feeding and they cannot have any food or water by mouth. R89 explained they only get out of bed into a chair when therapy is present and they are supposed to have hand splints but, no one applies them. A review of R89s record revealed they were admitted to the facility on [DATE] for Unspecified injury at unspecified level of cervical spinal cord. Further review revealed a Brief Interview for Mental Status Score of 15, indicating intact cognition. A review of R89's care plan revealed the following: Resident is NPO (nothing by mouth) with all nutrition and hydration provided via feeding tube dysphagia, bolus of Novasource renal. Dated 12/23/24 Encourage low fat, low salt intake. Dated 12/31/24 Monitor fluid intake to determine if natural diuretics such as coffee, tea, or cola is contributing to increased urination and incontinence. Dated 12/31/24 Resident is not able to use B/L UE/LE (bilateral upper extremeties/lower extremeties) due to paralysis.Dated 12/27/24 locomotion: gerichair (assistive device) with 1 person physical assist, with gait belt. Dated 12/21/24 Transfer: hoyer x2, cervical collar on at all times, cervical precautions. Dated 12/21/24 Bed mobility:x2, cervical collar on at all times cervical precautions. Dated 12/21/24 Assist resident with ADLs (activities of daily living) and ambulation as needed. Dated 12/31/24 Orthotics: (B) resting hand splints to be worn during the day. Remove & assess skin integrity and skin hygiene. 1/9/25 Restorative splint/brace1-B resting hand splints, to be worn at night as tolerated, remove for hygiene/skin checks. Dated 1/15/25 orthosis: neck brace to be worn at all times. Dated 1/15/25 A review of R89's physician orders revealed the following active orders: Enteral feed five times a day Enteral Nutrition Formula Name: TWOCAL HN 1 can (237ml) five times a day. Flush with 50ml water pre and post. dated 1/28/25. Orthosis/Splint to be applied to:B resting hand splints to be worn at night, as tolerated. Every shift on in the evening. Dated 1/15/25 On 3/04/25 at 3:12 PM, the Therapy Director (Staff K) reviewed R89's careplan when asked if R89 should be wearing a neck brace or hand splints. Staff K explained R89 was admitted on paraplegic cervical precautions and the neck brace was discontinued after R89's three month post operative doctor appointment around the 1st week of February. Staff K confirmed that the neck brace was still on the care plan and that it should have been removed. Staff K explained that R89 should be wearing hand splints during the day but explained they would have to get clarification due to conflicting information on the care plan. On 3/05/25 at 10:31 AM, the Director of Nursing (DON) explained careplans are a collaborative effort among the interdisciplinary team and they are created on admission and then they are updated in the morning meeting if there is a change. R89's care plan was reviewed with the DON and the DON confirmed R89's care plan was not updated nor did it reflect R89's current condition. A facility policy addressing careplans was requested and was not returned by the completion of the survey.

Based on interview and record review, the facility failed to obtain a physician's order for an advance directive (form designed to communicate health care treatments in advance) upon admission for one resident (R106) out of two reviewed for advance directives. Findings include: A review of the medical record revealed R106 admitted into the facility on [DATE] with the following medical diagnoses, Cerebral Infarction and End Stage Renal Disease. A review of the most recent Minimum Data Assessment set revealed a Brief Interview for Mental Status score of 8/15 indicating an impaired cognition. R106 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed there was no advance directive order in place. On 3/5/2025 at 9:15 AM, an interview was conducted with Social Worker (SW) J. SW J stated the admitting nurse puts the code status order in on admission and that social work reviews it at the care conference. SW J stated that the nursing staff is responsible for putting the advance directive orders in and confirming them. On 3/5/2025 at 12:03 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the advance directive order should be entered upon admission. The DON stated they were unaware of why it was not completed with R106. A review of a facility policy titled, Advance Directives-Code Status revealed the following, .If the resident and/or their legal representative has chosen for the resident's code status to be a Full Code: o The physician's order for Full Code status will be entered into Point Click Care (PCC) using the template in the order's tab. From the physician order the resident's Full Code status will auto-populate and be prominently displayed on the resident's chart header in PCC and will also populate to the resident's face sheet.

Based on interview and record review, the facility failed to complete an initial Abnormal Involuntary Movement Scale (AIMS) assessment for one resident (R146) out of one reviewed for antipsychotic medication use. Findings include: A review of the medical record revealed that R146 admitted into the facility on [DATE] with the following diagnoses, Alzheimer's Disease and Brief Psychotic Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 99, indicating R146 was unable to complete assessment and required staff assistance with bed mobility and transfers. Further review of the physician's orders revealed R146 was prescribed Seroquel (Antipsychotic) once daily. Further review of R146's assessments on 3/4/2025 did not reveal an AIMS assessment to detect abnormal movements across the face, lips, tongue, upper extremities, lower extremeities and trunk caused by antipsychotics. On 3/5/2025 at 12:05 PM, an interview was completed with the Director of Nursing (DON). The DON stated the nursing staff should complete an AIMS assessment quarterly whether the resident is being followed by psychiatry or not, if they see the resident is on an antipsychotic. A request for a facility policy related to antipsychotics was requested and not received by the end of survey.

This citation pertains to Intake MI00147833. Based on observation, interview, and record review, the facility failed to ensure a comprehensive nursing assessment was completed and timely acute care emergent hospital transfer for one Resident (R901) of three residents reviewed for care, when R901 sustained a fall with head trauma and bleeding while taking anticoagulant medication. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to assess a change of condition following the fall for R901. A review of R901's medical record revealed, R901 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that include Quadriplegia and Atrial fibrillation (AFIB). A review of R901's quarterly Minimum Data Set (MDS) assessment dated [DATE], noted R901 with a moderate impaired cognition, functional limitation in range of motion upper as impairment on one side, and lower extremity (hip, knee, ankle, foot) impairment on both sides. A review of R901's medications noted, Eliquis (blood thinner) 2.5mg (milligram), Give 1 tablet by mouth two times a day for AFIB. Start [DATE], end indefinite. Monitor for signs and symptoms of bleeding related to use of anticoagulant medication. Start Date: [DATE]. A review of R901's Medication Administration Record (MAR) noted, [DATE]st-9th, the resident was administered the Eliquis as ordered. Further review of R901's medical record revealed, [DATE] 11:21(11:21 AM) Incident Note Text: Observed lying on the floor, on [R901's] right side, in front of [R901's] wheelchair. Call light was not in use, but within reach. Assessed for injuries, with the following noted: bruise noted to right eyelid, superficial scrape to right forearm, 4inch, half-moon, skin tear. NP [Nurse Practitioner] into eval, and assisted with placement of steri strips, to approximate tear. Pressure dressing applied. Resident placed into bed with use of mechanical lift. Bed in lowest position, call light in reach. Resident unable to state how [they] fell , secondary to current mental status, due to UTI (urinary tract infection). Writer spoke with dtr (daughter) . Notified physician notified . A review of the 24-hour report noted, [DATE]. 7am-3pm (shift) Cipro (used to treat infections caused by bacteria) uti (urinary tract infection), IM (intramuscular injection) Rocephin (used to treat many kinds of bacterial infections) x1given, fall shift #1, skin tear RLE (right lower extremity), bruising to R (right) eye area, bruising to tongue. neuro checks. 3pm-11pm (shift) blank. 11pm-7am (shift) hospitalized . On [DATE] at 11:41 AM, Registered Nurse (RN) A was asked about the fall of R901. RN A explained they were down on the low 500 hall which was part of her assigned unit and was told that R901 had a fall saying, The Unit Manager, (UM C) and two CNAs (Certified Nursing Assistants) had gotten [R901] in bed. RN A was asked if R901 was able to explain how they fell . RN A stated, No. [R901] was confused. RN A was asked if R901 had any injuries to their head. RN A explained R901 had some bruising to their right eyelid and bit their tongue. RN A was asked how they monitored R901 after the fall. RN A explained, they started Neuro checks (neurological examination, is a series of tests and questions that evaluate the nervous system). On [DATE] at 12:39 PM, CNA D and CNA E were asked if they found R901 on the floor. CNA D stated, No, a resident found [R901] on the floor. CNA D and E were about the duration of time that R901 on the floor. They were asked the condition of R901 once they observed R901 on the floor. CNA D explained, R901 was very confused and kept talking about the wheels on the wheelchair and not answering the questions. CNA D and E explained this was unlike R901, R901 was more alert, would use their call light, did not try to stand, or get out of their chair without help. On [DATE] at 12:46 PM, UM C was asked about R901's fall. UM C stated when they entered R901's room, R901 was in an awkward position by the mechanical chair. UM C stated, (R901) wasn't speaking right and wouldn't say what happened, R901 was really confused. UM C stated, I went out to get a first aid kit to treat the skin tear. UM C further explained RN A was given the report and took over from there with Nurse Practitioner (NP) B. UM C explained they went back out to the nursing station to start the orders to send R901 out to the hospital. After NP B and RN A exited the resident's room, orders were to start neuro checks and not send the resident to the hospital. On [DATE] at 12:55 PM, NP B was asked about the fall and the reason R901 was not sent out to the hospital after a head injury. NP B refer to their progress note and explained she may have not known about the head injuries because she did not reference them in her note. NP B was asked about the procedure for transferring residents to a higher level of care who are prescribed anticoagulant medications, had an unwitnessed fall, with a visible bruise on the head. NP B explained, it all depends on her assessment and if there is a new onset mental status change. NP B was asked how that can be determined for R901 when she had confusion prior to the fall. NP B explained her assessment after the fall was R901 was stable. A review of R901 hospital records dated [DATE] at 18:41 (6:41 PM) noted, Medical Decision-Making including ED (emergency department) Course and Interventions Assessment: [R901] . presents to the ER (emergency room ) after a seizure . Later in the afternoon [R901] had a witnessed seizure and therefore EMS was called. Upon arrival to the ER the patient was postictal appearing with decreased responsiveness and not following commands. [R901] had clearly bitten [R901's] tongue as [R901] had blood in the mouth and lacerations on the tongue. [R901] does take Eliquis and therefore a level 2 trauma was activated in the setting of fall earlier in the day with seizures now and evidence of trauma, concern for intracranial abnormality. [R901] was evaluated via ATLS (Advanced Trauma Life Support) protocol, and the trauma service was contacted . Shortly after arrival to the ER the patient had another witnessed seizure in the resuscitation area. [R901] was treated with IM (intramuscular) Ativan after which the seizure resolved after approximately 1 minute. After the second seizure [R901] did not return to [R901's] baseline and was having sonorous respirations. During the second seizure [R901] appeared to have bitten [R901's] tongue again as [R901] had more blood in the mouth. The decision was made to intubate the patient for airway protection in the setting of recurrent seizures and unresponsiveness . Further review of R901's medical record pictures revealed, a large deep blood-filled gash on limb, swollen lip, and visible blood indentation of R901's teeth their tongue. On [DATE] at 1:30 PM, the Director of Nursing (DON) was asked about the facility's procedure following an unwitnessed fall of a resident on anticoagulants that has a visible head injury. The DON explained to start neuro checks are first, and if anything changes 911 is called. On [DATE] at 2:19 PM, the Nursing Home Administrator (NHA) was asked if R901 had any falls within the last six months. The NHA, responded via email No- This is [R901's] only fall ever at the facility. On [DATE] at 3:09 PM, Interested Party (IP) explained on [DATE], they called the facility to speak with nursing staff because they had a message for [R901] and spoke with [RN A]. IP explained [RN A] stated, I was just looking up your number, [R901] had a fall. The IP explained RN A stated R901 bit their tongue, had a bruise on the eyelid, and a small skin tear that they were treating. IP stated, I didn't understand why [R901] was not being sent out to the hospital, because no one saw [R901] fall. [R901] is paralyzed and would not be able to put [their] arms out to brace during the fall. The IP explained it was obvious R901 had hit their head and needed to go to the hospital. When the family friend went into the room, R901 was lying in bed, their tongue was swollen so badly, R 901 had difficulty eating any food. IP further explained R901 was able to drink the milkshake the family friend brought in. A review of R901's progress notes revealed the following: [DATE] 14:41 (2:00 PM) Nursing - Infection Note Cipro continues for tx (treatment) of UTI. No adverse reactions noted. No hematuria or dysuria. Increased confusion noted. NP notified, new order noted for Rocephin 1G IM x 1. Administered at 12pm, right deltoid. Awaiting culture results. Resident is needing assistance with feeding at this time. Extra fluids offered frequently. Neuro checks continue, with previous fall this am. [DATE] 14:44 (2:44 PM) Incident Note Text: Med review, new order noted for Rocephin (used to treat bacterial infections) 1G (gram) IM (intramuscular injection) x (time) 1. Administered at 12p (12:00 PM), rt (right) deltoid. Neuro checks in progress and remain within normal limits for resident. [DATE] 15:52 (3:52 PM) Progress Note Date of Service: [DATE] Visit Type: Progress Note Transition of Care: Details: Chief Complain confusion, UTI, fall . Patient seen and examined per nursing staff request post fall from electric wheelchair. Patient has a laceration to [their] left lower leg and abrasion to the right forearm. Patient has had recent confusion and restlessness with a positive urine dip and started on Cipro has been sent to lab for culture and sensitivity . Fall from non-moving wheelchair . Unobserved fall .patient sustained laceration to left lower leg and right forearm. Laceration cleansed and Steri-Strips applied with nursing . patient started on Cipro patient continues to have confusion IM Rocephin one-time ordered . [NP B]. [DATE] 16:17 (4:17 PM) Nursing Progress Note Text: Upon assessment, tongue noted to be swollen with a bite mark noted to right side of tongue, secondary to fall this am. [RN A]. A review of R901's progress notes did not reveal a reference by NP B of R901's head and tongue injury. Further review of R901's progress notes revealed the following: [DATE] 18:09 (6:09 PM) Nursing Progress Note Text: Writer notified by CNA, that resident was having seizure activity. Writer witnessed resident to be having involuntary movements. Writer noted [R901] to be gasping for air, and blood coming from [R901] mouth, secondary to biting [R901's] tongue. Responsive to sternal rub, but agonal breathing noted. 911 phoned . EMS arrived at 5:40, one dose of Narcan administered. Transferred to (name of hospital) via EMS . [DATE] 17:56 (5:56 PM) . Summary for Providers Situation: The Change in Condition/s (CIC) reported on this CIC Evaluation are/were: Altered mental status Falls Seizure At the time of evaluation resident/patient . Primary Diagnosis is: Relevant medical history is: CHF (congestive heart failure) Diabetes Chronic Renal Failure/ESRD. Code Status: Adv Directive: Full Cardiopulmonary Resuscitation (CPR). Advance directives are: Resident/Patient had the following medications changes in the past week: Cipro/Rocephin. Resident/Patient is on anticoagulant other than warfarin: Yes . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Increased confusion (e.g. disorientation). Functional Status Evaluation: Fall . Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Seizure. Nursing observations, evaluation, and recommendations are: . A. Recommendations: IM dose of Rocephin x1, continue with neuro checks, monitor mental status . [DATE] 11:04 Nursing - Progress Note Text: IDT (Interdisciplinary Care Team) met to review fall on [DATE] at 1030. Nurse reports that resident was sitting in room for 15 minutes before being, summoned to room to observe resident on the floor in room lying on her right side with her back facing the door and feet pointed toward the head of her bed, resident could not describe how she got from her electric wheelchair to the floor. Resident had recent change in condition on [DATE]. Staff used mechanical lift to put resident in bed for assessment, nurse observed redness to face more so over right eyelid, left lower leg laceration, and right forearm scrape, first aid rendered to skin sites and neuro checks initiated and wnl (within normal limits), nurse notified DON, provider, and family. Care plan reviewed and updated medication review. Resident was sent out to the hospital. A review of R901's death certificate noted they died four days later. Cause of death Traumatic Subdural Hematoma, significant conditions: Oral Anticoagulant therapy, new onset Seizures, Manner of death accident, date of injury [DATE], fall, at living facility. A of the facility policy titled, Fall Management Guidelines dated [DATE], revealed, POLICY OVERVIEW: The purpose of this policy is to provide guidelines to assist with fall risk identification and fall management of residents in the facility . POST-FALL EVALUATION: If a resident has just fallen or is observed on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities prior to moving the resident. Complete a neurological evaluation using the Neurocheck Evaluation Form when a resident: Has a witnessed fall when the resident has hit their head. Has an unwitnessed fall when a head injury may be suspected or is unknown. After the completion of the initial neurological evaluation with vital signs, continue the evaluations every 30 minutes X 2, every hour x 4, every 4 hours x 6, then every shift x for a total of 3 days . The facility's policy did not address unwitnessed falls with residents that are on anticoagulant medication

This citation pertains to Intake MI00135407. Based on interview and record review, the facility failed to ensure the assessed number of staff were used during shower care for one resident (R901) of three whose falls were reviewed resulting in a resident fall from a shower bed and sustained bruising, lacerations and bleeding to the face and head. Findings include: A review of a complaint for R901 revealed: On 9/14/23, (R901) had one person assisting (them) in a shower and (R901) was dropped during the shower. (R901) sustained multiple fractures to the nose, jaw and skull. Additional injuries included five fractures to the right eye socket, 18-20 stitches on the forehead and a brain bleed. (R901) is currently at the hospital. The complaint further noted: the aides are overworked with 25 or more residents to care for at times, only one person was used for transfer to the shower bed with the lift, there are not enough lifts to provide timely care and the rails on the shower bed were held up by pins and did not function properly. Further concerns reported included not being fed regularly, not awakened to be fed, not given water consistently and incontinence not cleaned up timely. A review of the facility Risk Management Report dated 09/14/23 at 1:18 PM, documented, Resident observed laying on their right side in shower room after rolling out of the shower chair during a staff assisted shower. Laceration observed to right side of forehead with bleeding .Bruising to right flank and right shoulder, Bruising observed to ridge of nose with nasal bleeding present, 911 was called and resident was taken to (hospital name). Daughter at bedside .Occasional labored breathing, Load moaning or groaning, crying, facial grimacing, rigid, fists clenched, knees pulled up, pulling or pushing away, striking out, unable to console, distract or reassure . On 09/27/23 at 12:03 PM, Unit Manager G was asked about R901's fall and reported: The Certified Nurse Assistant (CNA K) was giving R901 a shower and during the shower R901 fell from the shower bed. The railing went down when the CNA turned R901. A number of nurses responded to the fall. R901 was seen on their right side next to the shower bed. The CNA said they were turning R901 and R901 slipped out of the shower bed. R901 was assessed and treated and then picked up with a carrying blanket and sat into a wheelchair. The daughter was present after the fall. The Unit Manger reported there was nasal bleeding and bruising to the bridge of the nose. The Unit Manager was asked about the care plan status and noted R901 was a two person for the lift but was not sure of the shower bed mobility. Unit Manager G reported the CNA was in the shower room by themselves and was let go (terminated) after the incident. Unit manager G was asked about staffing at the time of the fall and reported there were six regular aides and the one shower aide. There was not a second shower aide. On 09/27/23 at 2:03 PM, the Administrator, Director of Nursing (DON) and an Administer-In -Training were present and R901's fall was reviewed. The Administrator reported the root cause was that only one person was used when two should have been. The Administrator admitted the facility was at fault and had educated staff post the fall. The Administrator also reported it was determined the aide did not intentionally injure R901. On 09/27/23 at 2:48 PM, the DON was asked about the events around R901's fall and reported they had been in a meeting at the time of the fall but did go down to see R901. They could tell the face was split and that R901 had nasal bleeding and the head was wrapped. When asked about the cause the DON reported R901 was a two person assist and only one was in the shower with R901. The DON was asked about staffing and reported it was a work in progress and staff have been hired but not all remained with the facility. On 09/27/23 at 2:52 PM, the Maintenance Supervisor was asked about the shower bed used by R901 during the the fall and reported it was functioning properly at the time. It was also reported that they were unaware if any concerns about the shower bed had been reported as there were none entered in the (maintenance) system. On 09/27/23 at 2:58 PM, CNA I was asked about the normal daily routine for R901 and reported they check on R901 at the start of their shift to see if they are wet and R901 was normally dry, R901 would be left in bed until just before lunch, then they would get R901 up and clean up R901 and combed R901's hair and then put R901 out in the lounge for lunch, then after lunch R901 was taken back to bed and checked on until their shift ends. CNA I reported to be on the unit but did not see the transfer of R901 to the shower bed and was not asked to assist in the shower for R901. CNA I reported they would normally give R901 a bed bath. CNA I reported two persons were used by them during a bed bath and transfers. CNA I reported that the unit R901 resided on was a heavy unit with a lot of lifts and two person residents. CNA I reported days when it is crazy and it not able to get a break unless you force it and may not sit down for their whole shift. On 09/27/23 at 4:23 PM, CNA K was asked about the fall incident with R901 and reported, It was a hectic day. I had to do 12-13 showers by myself. CNA K reported they had been scheduled to do a double shift that day. CNA K reported that the shower bed had been broken for years according to the other aides and nurses. CNA K reported that the hoyer lifts were supposed to be two people but aides operated them with one (staff member) all the time in order to transfer residents and get care done. CNA K reported that the daughter had helped transfer R901 to the shower bed. CNA K commented that the daughter was happy that R901 was getting a shower and had never had a shower. CNA K confirmed they were the seventh aide and was assigned to the showers. CNA K reported that the expectation of the DON was to give showers and not bed baths and do whatever it took to get them done. CNA K reported the other staff , nurse and unit managers watched them push resident in and out of the shower room all day by them selves and did not comment or ask if help was needed. CNA K was asked how the fall occurred and reported that they were turning R901 away from them to further clean R901 and when R901 was turned the rail went down and R901 went onto the floor. CNA K then commented, In that building you have to do everything yourself and reported they did what they thought they were expected and had to do. A review of the record for R901 revealed R901 was admitted into the facility on [DATE]. Diagnoses included Alzheimer's, Dementia, Joint Contractures and Diabetes. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition and the need for extensive assistance of two persons for bed mobility and total assist of two persons for transfers. The need for total care assistance of one person was indicated for locomotion, dressing, and personal hygiene. A review of the nursing care plan ADL (activities of daily living) and mobility deficits related to ongoing health events dated 03/09/20 documented, Bathing Hygiene requires two (person) assist .Bed mobility two person assist . A review of the facilty policy titled, Fall Risk / Injury Prevention approved 06/20/22, documented, It is the policy of this facility to assess every resident for fall risk and provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents . A care plan will be completed for each resident to address items identified on the fall risk assessment and/or by the IDT team. The care plan will be updated accordingly. The care plan will include interventions, including recommended assistance, consistent with a resident ' s needs, goals, and current standards of practice in order to reduce the risk of an accident . A review of the facility policy titled, Care Plan - Comprehensive and Revision revised 08/25/23 documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

This citation pertains to intake MI00139057. Based on interview and record review, the facility failed to schedule a follow-up urology appointment as indicated upon admission, adequately document assessments immediately prior to and after the initial insertion of an indwelling catheter (tube inserted into the bladder to drain urine), notify the resident's representative when the catheter was inserted, and failed to recognize the need for outside care, for one resident (R1) of three reviewed, resulting in ineffective coordination of care, resident discomfort, catheter-related complications, and hospitalization . Findings include: A review of intake MI00139057 revealed allegations indicating that the resident's representative was not notified when a urinary catheter was initiated; that the facility did not schedule an outside urology appointment as per hospital instruction; that the resident began to experience increased pain and complications from the catheter; and that the facility failed to recognize that R1 needed to be sent to a higher level of care without family/visitor intervention. The intake included, .On ,d+[DATE], [R1] called me to tell me that they put a catheter in and he didn't know why .On ,d+[DATE], I noticed that [R1's] legs and feet were starting to swell again and I asked to speak to the Dr. again and was told she'd come to see me if she had time. I asked why the catheter was still in and when the urologist appointment was and they said that they didn't schedule one . The intake continued, [On [DATE]] around 5:15 PM, [visitor of R1] got there .took one look at [R1] .could tell he was in pain and extremely lethargic .respiratory rate was fast and .could tell he had [a fever] .[Visitor of R1] asked the nurse about his vitals and asked if [R1's temperature] was taken. The nurse said that when she last checked him, he didn't have a fever .[Visitor of R1 informed the nurse] he has a fever now [asked her to] check again .expressed to the nurse that he looked septic .The nurse made it clear that she was not planning to come in and do another set of vitals and had already called the Dr (Doctor) who was aware of the situation. [Visitor of R1] noticed that he had been throwing up all over the place and had dried throw-up on him . A review of R1's hospital documentation prior to their admission to the facility revealed the following: -[DATE]th, 2023 .Urology Consultation, [DATE] . 1.Bladder unremarkable, prostate enlarged. 2. History of prostate cancer status post radiation therapy in 2004 known to [Outside Urologist B] . 3. BPH (benign prostatic hyperplasia) on Flomax and Proscar (medications to treat enlarged prostate). 4. Rule out urinary retention PVRs (Post-Void Residuals): 292, 121, 168 cc (cubic centimeter also known as mL - milliliters) . 7. Patient to follow-up outpatient with [outside Urologist B] .please continue PVRs if patient is feeling uncomfortable however current PVRs within acceptable range . R1's pre-admission hospital documentation (discharge summary) directed for the resident to follow up with [outside Urologist B] in 1 to 2 weeks. A review of R1's medical record revealed that the resident was admitted into the facility on [DATE] and discharged to the hospital via ambulance (911 called by family) on [DATE]. R1's medical diagnoses upon admission included Unstable Angina, Heart Disease, Anemia, Cardiomyopathy, Thrombocytopenia, Spinal Stenosis, Hypertension, and Benign Prostatic Hyperplasia (BPH) Without Lower Urinary Tract Symptoms. On [DATE], a diagnosis of Retention of Urine, Unspecified, was entered. On [DATE], a diagnosis of Obstructive and Reflux Uropathy, Unspecified, was entered, and on [DATE], a diagnosis of, Neuromuscular Dysfunction of Bladder, Unspecified, was entered. Further review of R1's record revealed that the resident did not have an indwelling urinary catheter in place upon admission. R1's Urinary Incontinence/Dwelling Catheter assessment dated [DATE] indicated that R1 was a candidate for Bladder retraining and experienced functional incontinence (Functional - May be due to physical weakness, poor mobility/dexterity, cognitive impairment, medications. Functional is not related to abnormal urinary tract function). The assessment indicated that mobility was a barrier to toileting for the resident (requires transfer assistance or is non-ambulatory) with no other barriers identified. No additional Urinary/Catheter Assessments were found. A review of R1's orders revealed the following: -F/U (follow up) with [outside Urologist B] in 1 to 2 weeks Urology [Phone Number], Start Date: [DATE]. A review of R1's record revealed that the facility did not coordinate an appointment to see outside Urologist B per the above order and within the ,d+[DATE] week timeframe indicated. Additional review of R1's orders revealed: -Nursing please make FU apt with urology ASAP (as soon as possible) to evaluate (name of indwelling catheter) with elevated PVR (Post-Void Residual) .Start Date: [DATE]. A review of R1's progress notes revealed: -[DATE] 01:10 (AM) Nursing - Progress Note .day 2; resident AO x,d+[DATE] (alert and oriented to person/place), assist x1, continent of bowel, continent of bladder; urinal at bed side. No S/S (signs/symptoms) of pain or distress observed at this time. Edema observed in BLE (bilateral lower extremities). Vitals checked and charted; within range. Meds given and tolerated. Call light and bed remote within reach; resident able to make needs known. Safety maintained. -[DATE] 09:26 (AM) Physician Team - Progress Note .patient seen and examined with complaints of lower extremity edema, abdominal distention, constipation (patient refused a suppository this morning), patient is on a diuretic normally but this medication was stopped due to acute kidney injury while in hospital, Lasix (diuretic) restarted on [DATE]. Patient's [family/friends] at bedside .patient is complaining of difficulty urinating and frequency with urination and some lower abdominal discomfort, PVRs (Post-Void Residuals, a measurement of urine left in the bladder after elimination) ordered. Previous history of prostate cancer with radiation. Repeat labs. Urinary retention Probably secondary to ileus (decreased gastrointestinal movement). Bladder scans in place .Urinary frequency Possible urinary retention. (Name of indwelling catheter) discontinued at hospital recently .Will check post void residuals -[DATE] 19:01 (7:01 PM) Type: Nursing - Progress Note .Pt. (Patient) was receiving hypodermoclysis (administration of fluids under the skin) when nurse arrived, nurse assessed Pt. abdomen and noticed slight bruising to the area where the needle was inserted into the abdomen with increasing bruising going down Pt. left side of abdomen, Hypodermoclysis was removed from left side of abdomen. Pt also received a bladder scan after voiding over 300cc into the urinal which indicated 100cc of urine (left in bladder) and Pt. did not require catherization. Pt. abdominal X-ray results came back with no obstruction, gas noted, no other findings. A review of R1's record revealed the following order:-Initiate Bladder Scan Qs (every shift) x 3 days. May ISC (Intermittent Straight Catheterization) for scan >300 mL (greater than) every shift for urinary retention for 3 Days Please document: Amt (amount) (mL) of scan, If you had to straight cath Y/N (Yes or No), Amount if ISC in (mL) or NA (Not Applicable) -Start Date- [DATE] 1500. The following information was noted related to the above bladder scan order: 1) [DATE] Evening Shift - 250 mL (on scan), No, N/A. 2) [DATE] Night Shift - 746 mL, Yes, 500 mL (obtained from ISC). 3) [DATE] Day Shift - 232 mL, No, N/A. 4) [DATE] Evening Shift - 108 mL, No, N/A. 5) [DATE] Night Shift - 0 mL, No, N/A. 6) [DATE] Day Shift - 200 mL, No, N/A. 7) [DATE] Evening Shift - 373 mL, Yes, 100 mL (obtained from ISC). 8) [DATE] Night Shift - 243 mL, No, N/A. 9) [DATE] Day Shift - 239 mL, No, N/A. (Order completed). A review of R1's orders, progress notes, and assessments, revealed no nursing progress notes or assessments dated [DATE]. An order to initiate a (name of indwelling catheter) catheter (diagnosis: urinary retention) was entered into R1's record on [DATE]. R1's record did not reveal a corresponding nursing assessment and/or progress note related to the initiation of the catheter and associated findings. An assessment of how R1 tolerated the insertion of the indwelling catheter procedure was not found. Documentation that nursing staff notified the resident's representative upon inserting the catheter was not found. Additionally, orders for the care of the catheter were not entered into the record until [DATE]. Continued review of R1's progress notes revealed: -[DATE] 02:25 (AM) Type: Nursing - Progress Note .UA/C&S (Urinalysis/Culture & Sensitivity) ordered; sample collected, placed in refrigerator in soiled utility on Blossom unit. Oncoming nurse will be notified. (Written by Licensed Practical Nurse (LPN) E). Per R1's orders, the UA/C&S was ordered to rule out a Urinary Tract Infection (UTI). -[DATE] 02:27 (AM) Type: Nursing - Progress Note .Resident had C/O (complaints of chest pain); PRN (as needed) Nitroglycerin given x 1 .Vitals checked and charted; within range .No S/S (signs/symptoms) of distress observed at this time. Call light and bed remote within reach; resident able to make needs known. -[DATE] 11:57 (AM) Type: Physician Team - Progress Note LATE ENTRY .Chief Complaint: Follow-up regarding lab results urinary retention and constipation .Urinary retention Ordered (name of indwelling) catheter placement, Continue current medical management, Monitor output, UA (urinalysis) culture and sensitivity .Follow-up with urologist as recommended . -[DATE] 17:39 Type: Physician Team - Progress Note .Patient had a urinalysis available today and negative .Labs: [DATE] urinalysis, negative nitrates, negative leukocytes, negative glucose, small bilirubin, negative blood, cloudy .Follow-up with urologist as recommended . No progress notes dated [DATE] were noted in the resident's record. -[DATE] 14:37 (2:37 PM) Type: Physician Team - Progress Note .[R1] states his swelling is also improving he feels like his legs feel better. He sitting up in the chair awake and alert patient states he would like to go home. Asoon (sic) .Follow-up with urologist as recommended . No progress notes or assessments dated [DATE] through [DATE] were noted in R1's record. -[DATE] 08:03 (AM) Type: Nursing - Progress Note .Rec'd (received) res (resident) in bed alert and verbal. Able to make needs, concerns, and discomfort known. No SOB (shortness of breath) or labored breathing noted. Denies discomfort .(name of indwelling catheter) cath noted with issues, no return. Writer attempted irrigation of catheter without success. Writer changed (name of indwelling catheter) cath per PRN (as needed) orders. 14fr (14 french - size of catheter tube) 5cc balloon inserted with clearish yellow return noted. (Name of indwelling catheter) cath draining well with no issues. (Name of indwelling catheter) anchor placed on left thigh and (name of indwelling catheter) secured. Res educated on wearing leg bag when up ambulating. Endorsed to oncoming to monitor. Pt has f/u with nephrology today. Oriented to use of call light for assistance. Call light within easy reach. All safety and comfort maintained. The physician order, Nurse may irrigate (name of indwelling catheter)/ Suprapubic catheter for mucus threads and/or plugging with 60ml normal saline; may repeat two times (less than or equal to 60ml must return after each irrigation). four times a day for hematuria, was noted to be initiated on [DATE] at 1:00 PM. -[DATE] 23:29 (11:29 PM) Type: Nursing - Progress Note .Resident stated he was having discomfort with (name of indwelling catheter); writer repositioned and irrigated (name of indwelling catheter). Writer assessed resident during shift; resident stated discomfort has decreased. -[DATE] 18:30 (6:30 PM) Type: Nursing - Progress Note .Resident c/o (complained of) pain around his urethra r/t (related to) his catheter; slight tearing noted. Resident refused to allow writer to irrigate his (name of indwelling catheter) stating it does not work and just wants it to be removed. Writer offered A&D (ointment) to help with friction but resident refused. Logged in Dr. book. -[DATE] 11:34 (AM) Type: Nursing - Progress Note .Pt's (name of indwelling catheter) removed at 1118 (AM), writer will monitor for discomfort. The physician order, PVR if >150ml call Urologist for orders [outside Urologist B] .one time only .Start Date: [DATE] 1618 (4:18 PM). The result of the completed order was 95 mL, documented by LPN D. -[DATE] 15:41 (3:41 PM) Type: Physician Team - Progress Note .Pt examined sorting (sitting) up in chair - he states he feels well patient seen per his request to have his (name of indwelling catheter) catheter discontinued. Patient had (name of indwelling catheter) discontinued early in his stay at the facility had urinary retention and (name of indwelling catheter) was reinserted and patient instructed to follow-up with urologist. Patient states he has a history of prostate cancer with radiation on Flomax finasteride and is followed by a urologist . Per nursing staff urine dip collected for cloudy urine. Patient is asymptomatic. Urine collected from (name of indwelling catheter) catheter and results available .Labs: [DATE] urine dip 500 leuks (leukocytes) .Urinalysis collected for cloudy urine. Positive leuks and blood. Patient asymptomatic will recollect specimen and monitor off antibiotics sent for C&S (culture & sensitivity) .Order placed on chart for nursing to make appointment with urology [outside Urologist B] . -[DATE] 12:16 (PM) Type: Nursing - Progress Note .Pt was bladder scanned by writer. Writer noted 1752 initially on the first scan and then 1522 for the second scan. Writer verbally notified NP (Nurse Practitioner) of findings and (name of indwelling catheter) was placed again. NP stated family should follow up with Urology. Written by LPN D. -[DATE] 13:34 (1:34 PM) Type: Physician Team - Progress Note .Pt examined sorting (sic) up in chair stating he does not feel well. Patient had (name of indwelling catheter) catheter discontinued yesterday for urology. Per nursing staff patient [family] agrees received paper orders and provided to facility requesting to have (name of indwelling catheter) discontinued [DATE] and to straight cath for PVRs greater than 150 per nursing. Patient straight cath 1 time last night. He states he is unable to void this morning. Minimal bladder distention noted. Nursing staff aware and monitoring patient for output and straight cathing per urology orders . Assessments/Plans: Urinary retention (name of indwelling catheter) catheter placed and DC'd (discontinued) [DATE] per urology .Patient due to void and monitor for PVR per urology orders . -[DATE] 16:29 (4:29 PM) Type: Nursing - Progress Note .Writer notified MD at 1530 (3:30 PM) of pt having chest pains, nausea, vomiting and diarrhea. MD gave orders to discontinue Atorvastatin and Nitro; labs CBC (complete blood count) and BMP (basic metabolic profile) and EKG (electrocardiogram); SubQ (subcutaneous) hydration Sodium 0.9% 70 ml/hr and Tigan (anti-nausea medication) 1ML q6hrs IM (every 6 hours) for 3 days. Writer will continue to monitor and will notify MD of any other change of condition. R1's final set of vital signs noted in the record included a pulse of 123 documented at 3:52 PM (outside of normal range [,d+[DATE]] and abnormal compared to other pulse rates documented for R1 throughout the duration of his stay at the facility). A normal temperature was documented at 3:52 PM. A pain score of ,d+[DATE] (indicating moderate to severe pain) was documented at 5:44 PM. -[DATE] 17:56 (5:56 PM) Type: Nursing - Progress Note .Writer spoke to [family] about pt's condition. Writer told [family] of orders given for intervention from MD. [Family] stated [they] wanted [R1] to be sent out after interventions were already in place .[Family] spoke with supervisor and said ok to interventions .[Friends of family] came to nurses station demanding pt to be sent out to [hospital]. [Family] called 911 for pt to leave . Written by LPN D. -[DATE] 14:06 (2:06 PM) Type: Physician Team - Discharge Note .[DATE] ([DATE]) patient had chest pain nausea vomiting diarrhea. Medication changes and diagnostics ordered. Per nursing staff patient's [family] wanted her [R1] to be sent out of facility to hospital. [Family] demanding patient to be sent to [hospital] and called 911. On [DATE] at 12:06 PM, LPN D was interviewed via phone. LPN D confirmed that R1 had not come into the facility with a catheter. When queried regarding the procedure for determining if a catheter is to be placed, LPN D stated she thinks that an indwelling urinary catheter is placed if a resident requires ISC three times. LPN D stated that ISC occurs when there is >350 mL found in the bladder after the patient does/tries to void. When queried regarding the resident experiencing a change in condition and subsequently leaving the facility on [DATE], LPN D explained that R1 had been fine at the beginning of her shift from what she can remember. LPN D stated that later, R1 got sick and was throwing up. LPN D indicated she remembered that a supervisor spoke with the resident's family/visitors that day, but could not recall how the resident appeared prior to leaving the facility or if his vital signs had been abnormal. On [DATE] at 1:15 PM, LPN A, the facility's Infection Preventionist, was interviewed. LPN A was queried regarding the initiation of a urinary catheter after performing PVRs. LPN A stated that the order sets have been revised a few times at the facility, but that the PVR order will typically include instructions on when to place a (name of indwelling catheter) catheter. LPN A indicated that urinary retention is not an appropriate diagnoses for the long-term use of a catheter. LPN A indicated that if it is recommended that a resident follow up with an outside specialist, such as a urologist, the facility staff will help scheduled that appointment. When queried regarding what is expected to be documented upon placing a urinary catheter, LPN A stated that a nursing assessment is expected to be documented along with justification for the use of the catheter. On [DATE] at 2:20 PM, the Director of Nursing (DON) was interviewed. The DON indicated that if a recommended follow-up appointment is not made, she expects there to be documentation in the record as to why. The DON indicated that initiating a (name of indwelling catheter) catheter after PVRs depends on the resident and is at the discretion of the provider. The DON added that facility providers document the reason for (name of indwelling catheter) placement and it is expected that the facility staff help arrange a follow-up appointment with a urologist if recommended by the provider. When queried regarding what is expected to be documented upon placing a urinary catheter, the DON stated that a nursing assessment is expected to be documented along with the justification, What they got out of it (amount of urine) .what color it is, how [resident] tolerated the procedure. The DON also indicated that a resident's representative should be notified when a change in the plan of care occurs, such as the placement of an indwelling catheter. A review of R1's death certificate revealed that R1 died on [DATE]. The death certificate listed the following under, Part I - Enter the chain of events - diseases, injuries or complications - that directly caused the death: a. Septic Shock due to Bacteremia due to, b. Likely Complicated UTI (Urinary Tract Infection) and cholecystitis, c. Renal Failure due to sepsis and coagulopathy, d. Acute systolic congestive heart failure . Approximate Interval between Onset and Death = 1 Week - 10 days . A review of the facility's policy/procedure titled, Catheter Use Overview, issue date [DATE], revealed, If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: Documentation of the involvement of the resident and/or representative in the discussion of the risks and benefits of the use of the catheter, removal of the catheter when criteria or indication for use is no longer present, and the right to decline the use of the catheter Timely and appropriate assessments related to the indication for use of an indwelling catheter .Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures.,,Response of the resident during the use of the catheter .Ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting, and addressing such changes . A review of the facility's policy/procedure titled, Catheter Insertion - Indwelling (name of indwelling catheter), issue date [DATE], revealed, .Document procedure in the resident ' s medical record.

Deficient Practice Statement #1 pertaining to intake MI 282: Based on observation, interview, and record review, the facility failed to transfer a resident per the plan of care, affecting one (R129) of eight reviewed for accidents, resulting in a large, deep leg laceration that required a transfer to the hospital and 26 sutures. Findings include: A review of a complaint submitted to the State Agency revealed: It was alleged that facility staff failed to properly transfer the resident, resulting in injury. A review of R129's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on [DATE] and readmitted on [DATE], is severely cognitively impaired, and requires extensive to total assistance from staff for activities of daily living (ADLs). R129's medical diagnoses include Subsequent Encounter For Fracture With Routine Healing, [CONDITION(S)], Alzheimer's Disease, Type 2 Diabetes Mellitus Without Complications, Dysphagia, Moderate Protein-Calorie Malnutrition, Need For Assistance With Personal Care, Muscle Weakness, Difficulty In Walking, [CONDITION(S)] And Collapse, Anxiety, [CONDITION(S)], Pneumonia, [CONDITION(S)], [CONDITION(S)], Laceration Without Foreign Body, Right Lower Leg, Subsequent Encounter, and Sick Sinus Syndrome. A review of R129's care plan revealed: -Transfers: x2 with Hoyer, Date Initiated: 03/09/2020. -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface., Date Initiated: 03/10/2020. -TRANSFER: The resident requires Mechanical Lift, Date Initiated: 12/29/2021. On 10/11/22 at 1:08 PM, Confidential Witness C was interviewed regarding R129's care at the facility. Witness C expressed concern regarding the resident being transferred in an unsafe manner and sustaining an injury to her leg that required a hospital visit and significant amount of sutures. On 10/11/22 at 1:15 PM, R129's right lower leg was observed to have a large C-shaped scar. On 10/11/22 at 1:49 PM, photos of R129's injury sustained in the facility on 11/25/21 were reviewed and revealed a large, bleeding, C-shaped wound with flap of skin on the resident's right lower leg that extended into the subcutaneous (fatty) tissue. A photo of the wound after closure was also reviewed and revealed that it required an extensive amount of sutures for closure. Bruising was also noted around the injury site. A review of R129's progress notes revealed the following: -11/25/2021 21:43 (9:43 PM) .Writer notified by staff nurse that [R129] had obtained a laceration to .leg during a transfer into bed by CENA (Certified Nursing Assistant - CNA). Upon arrival to room, pt. (patient) was in bed lying on her left side with her right leg wrapped up in a bandage. Bandage pulled back and a deep laceration noted thru to the fatty tissue of about 1.5 inches long with bleeding noted. Pressure bandage in place. EMS (emergency medical service) notified to transport pt. to hospital for eval. (evaluation) and treatment. Nurse notified on call doctor and family. D.O.N (Director of Nursing) notified. -11/25/2021 23:52 (11:52 PM) .late entry approximately 7 pm Cena called me to room found pt with a large skin tear on r (right) lower extremity. Cena said it happened during a transfer. family notified and family notified called [hospital] . -11/26/2021 01:48 (AM) .Resident returned from [hospital] via stretcher for treatment of laceration to RLE (right lower extremity) with 26 sutures . A review of R129's hospital documentation dated 11/25/21 revealed: Pt presents to the EC (emergency center) with c/o (complaint of) laceration resulting from transferring from a wheelchair. Pt denies fall. The laceration is on the R leg, lateral calf area. Bleeding is controlled at this time. Pt is from a nursing home with a language barrier so family member at bedside . .Laceration repair. Date/Time: 11/25/2021 11:49 PM .Risks discussed: Infection, pain, poor cosmetic result, poor wound healing and need for additional repair .Laceration details: .Length (cm): 11.5 .Number of sutures: 26 . The hospital documentation also noted that the patient received a [CONDITION(S)] shot. On 10/13/22 at 9:21 AM, Witness C alerted this surveyor to a new skin alteration to R129's left upper arm. Witness C stated they were called to be notified about the skin tear the day before yesterday, but no one could tell them how it happened. On 10/13/22 at 9:56 AM, Licensed Practical Nurse (LPN) W, the facility's Safety Nurse, was interviewed at R129's bedside and queried regarding the new skin tear to her left upper arm. LPN W stated that he was informed that the skin tear was not present two days ago and that the resident requires a Hoyer lift for transfer. LPN W indicated the skin tear could have been from a transfer, or a blood pressure cuff, and added, But not sure .The resident can't tell us .[R129's] skin is very frail and has gotten a lot of injuries, even just boosting her up [in bed]. LPN W assessed the skin tear which was a large, dark, bruised area with the top layer of skin peeled back, revealing wet, red skin underneath. LPN W stated, It's superficial but I'm sure it [CONDITION(S)]. LPN W was then queried regarding the injury R129 sustained to her left lower leg on 11/25/21. LPN W indicated he investigated the incident and determined that the resident's assigned CNA was putting the resident in bed by herself. LPN W explained that as the CNA was bringing R129's legs up to put them in bed, the resident's leg was caught on the bed's metal frame. LPN W showed this surveyor the resident's bed frame, which is metal with a hinge in the middle. The edge and hinge of the frame were noted to be quite hard and sharp. LPN W stated that the assigned CNA, CNA DD, transferred R129 by herself even though the resident required two people for transfers at that time, and the CNA also did not use the Hoyer lift. LPN W stated that a facility-wide in-service was conducted after the injury and added, [The laceration] looked bad .like a dog had attacked her. On 10/13/22 at 10:50 AM, CNA DD, who was assigned to care for R129 on 11/25/21, was interviewed via phone. CNA DD was asked what happened with the resident on the date her leg was cut open. CNA DD would not provide any specific details about the incident. CNA DD stated, The aging body is frail and just a touch can open up in the elderly people. CNA DD further stated that nothing that she does is Consciously malicious. CNA DD explained that on the date of R129's injury, she was assigned to care for 20 residents, 9 of whom required a Hoyer lift for transfers (which requires two staff to operate). CNA DD stated, I told them they were giving me too many people to take care of. I was exhausted. CNA DD stated she felt she was put in a difficult position and added, By hurrying up, having too many people to take care of, you end up hurting someone, which you don't want. On 10/13/22 at 1:30 PM, the Nursing Home Administrator (NHA) was interviewed during the Quality Assurance (QA) task review. When queried regarding the injury to R129's leg, the NHA was unable to provide specific details related to the incident since it happened before her arrival to the facility. The NHA did state that multiple in-services were given to staff regarding safe transfers and that there was a full fall monitoring action plan at that time. The NHA added that CNA DD would not fully discuss the incident and subsequently resigned from working at the facility during a disciplinary meeting. On 10/13/22 at 2:40 PM, the DON was interviewed and queried regarding staff following the plan of care for activities of daily living (ADLs) including transfers. The DON stated that if a resident is a two-person assist, that, I'm going to go get help and come back. The DON denied any current concerns related to residents not being transferred appropriately by staff. A review of the facility's policy/procedure titled, Happy Feet Transfer Program, dated 9/29/2017 revealed, POLICY: All residents admitted to the facility shall be evaluated to determine the safest method of transfer. PROCEDURE: .3. The safest method of transfer (bed to wheelchair transfer and toileting transfer) shall be posted in the resident's room. (i.e. bed to wheelchair transfer is x one and toilet transfer is x one, the posting would be x one). (i.e. bed to wheelchair transfer is x one and toilet transfer is x two, the posting would be x one and BR x two) .6. The nurse manager/designee will document the method of transfer in the ADL book and on the care plan . A review of the facility's policy/procedure titled, Fall Risk/Injury Prevention Assessment, dated 10/1/22 revealed, It is the policy of this facility to assess every resident for fall risk and provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents .The care plan will include interventions, including recommended assistance, consistent with a resident ' s needs, goals, and current standards of practice in order to reduce the risk of an accident . Deficient Practice Statement #2 This citation pertains to intake numbers MI 431. Based on interview and record review the facility failed to monitor one resident (R23), who was a known elopement risk, of eight residents reviewed for accidents, resulting in the resident exiting the building unbeknown to staff and being located outside of the building, approximately thirty yards from a highly traffic congested road. Findings include: On 10/11/22 at 9:17 AM, an incident/accident report (I/A) was reviewed involving R23 and stated the following, 9/8/22 14:30 (2:30 PM): Nursing Description: Resident went outside facility by themselves through a door not connected to a wanderguard (device that triggers alarms and locks monitored doors). Description: Resident was immediately returned inside facility. Injuries Observed At Time of Incident: No injuries observed at time of incident. On 10/11/22 at 9:30 AM, a review of R23's electronic medical record (EMR) revealed multiple elopement assessments in R23's EMR which indicated that R23 was a High Risk To Wander resident. On 10/11/22 at 9:43 AM, a progress note located in R23's EMR revealed the following, 8/6/2022 18:59 (6:59 PM) Nursing-Progress Note Text: The writer observed resident wandering on 900, [R23] was near the exit door attempting to open the door, the nurse on 300 was paged and the writer redirected the resident back to their appropriate unit .the resident does have a wander bracelet on their right ankle. On 10/11/23 at 9:52 AM, further review of R23's EMR revealed that R23 was originally admitted to the facility on [DATE] with diagnoses that included Cerebral infraction (Stroke) and Dementia. R23's most recent minimum data set assessment (MDS) dated [DATE] revealed that R23 had a severely impaired cognition and required extensive assistance for all activities of daily living (ADLs) other than eating. On 10/12/22 at 10:10 AM, Certified Nursing Assistatnt (CNA) N was interviewed regarding the incident involving R23 on 9/8/22. CNA N indicated that they observed [R23] outside the building in the north parking lot at approximately 2:40 PM, when returning from a scheduled break. CNA N stated, I brought [R23] back inside. The exact location where CNA N indicated that they had found R23 was approximately thirty yards from a highly traffic congested road. On 10/12/22 at 10:30 AM, Nurse P was interviewed regarding the incident involving R23 on 9/8/22. Nurse P indicated that they last saw R23 on the unit at approximately 1:30 PM. Nurse P was unable to provide any other information regarding the incident involving R23. On 10/12/22 at 10:39 AM, Nurse Q was interviewed regarding the incident involving R23 on 9/8/22 and indicated that R23 Frequently propels themselves around the building. I redirect them back to their unit. [R23] is busy. Nurse Q had no specific information related to the incident on 9/8/22. On 10/12/22 at 11:15 AM, Nurse W was interviewed regarding the incident involving R23 on 9/8/23. Nurse W stated, I last saw [R23] sitting in their wheelchair at 2:20 PM, we had a code blue (patient in need of immediate medical attention) on another unit and all the nurses went to help out. [R23] must have gotten out then. Nurse W had no further information regarding the incident. On 10/12/22 at 3:30 PM, the Assistant Director of Nursing (ADON) was interviewed regarding the incident involving R23 on 9/8/23. The ADON indicated that based upon an internal investigation of the incident involving [R23], it is speculated that [R23] exited an deactivated alarmed door on the east side of the building during the time that a code blue was occurring in the building. The ADON further indicated that speculation was that [R23] wheeled themself down a sidewalk on the east side of the building into the east parking lot area where they were found by CNA N who was returning from a break. The ADON stated, Based upon our investigation we believe [R23] was out of the building for approximately twenty minutes. On 10/12/22 at 3:39 PM, the facility reported incident (FRI) and the facility's investigation of the incident was reviewed with the Director of Nursing (DON) and the Administrator (NHA). They were asked what the facility expectation was for monitoring residents and preventing facility elopement. They indicated, that all staff are responsible for monitoring residents. The DON stated, It takes a village. On 10/13/22 at 2:30 PM, a facility policy titled Accident and Incident Report Date Approved: 06/20/2022 was reviewed and stated the following, The purpose of this policy is .(f} to prevent re-occurrence of a similar incident; (g) to provide timely follow-up of corrective measures . Deficient Practice Statement #3 Based on observation, interview and record review, the facility failed to supervise a resident during medication administration for one sampled resident (R576) of one resident reviewed for med administration resulting in, medication being taken by the resident without proper supervision. Findings include: On 10/11/22 at 11:21 AM, R576 was observed sitting in their wheelchair, nebulizer mask observed on their table, nebulizer machine on and running. There was no nurse present inside or outside of the room. R576 was asked where the nurse went and stated, They always say they will come back but never do. R576 was asked if the nurse remains in the room during their nebulizer treatments, and they stated, Sometimes they do, and sometimes they don't. A review of R576's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included [CONDITION(S)] Pneumonia, Health Failure and [CONDITION(S)]. Further review of R576's medical record revealed a Minimum Data Set assessment dated [DATE] revealing a Brief Interview for Mental Status score of 10/15 indicating a moderately impaired cognition, and required extensive assistance for Activities of Daily Living. Further review of R576's medical record revealed the following physician's order dated 10/6/22, [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters). 3 ml inhale orally four times a day for Asthma SOB (shortness of breath). Further review of R576's medical record did not reveal an assessment indicating that they could self-administer their own medications. On 10/12/22 at 1:05 PM, R576 was observed sitting up in bed with their nebulizer mask covering their mouth. There was no nurse present inside or outside of the resident's room. On 10/13/22 at 2:36 PM, the Director of Nursing was asked whether a nurse should be present during the administration of a nebulizer treatment, and she explained that staff should stay with the resident until their treatment is complete, unless the resident has an assessment indicating that they can self-administer medications on their own. A review of the facility's Nebulizer Treatment policy revealed the following, o) If the patient is deemed appropriate to self-administer medication the nurse will setup the patient with the medication ready for administration. The medication will continue to remain in the medication cart until at which time the patient needs the medication. The nurse does not need to be present in the room for the entire time of administration. (this should be documented with the order or on the plan of care that the patient may self-administer) See self-administration of drug policy #2070 p) At the completion of the treatment, the medication cup is cleaned with water and allowed to air dry. q) Take apart nebulizer. Wash all parts except tubing and finger valve with soap and water. Rinse with water, dry & store .

Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers and implement pressure ulcer interventions for two (R42 and R111) of three residents reviewed, resulting in facility acquired pressure ulcers, the potential for the worsening of existing pressure ulcers, and/or the development of additional skin impairments. Findings include: R111 On 10/13/22 at 11:04 AM, R111 was observed lying in bed on their back with wound dressings observed on both their left and right elbow. R111 was asked about their wound dressings and explained that they are pressure ulcers that were acquired while staying at the facility. R111 detailed the number of pressure ulcers that they have, and explained that the facility staff are supposed to turn and reposition them, but it is not done consistently due to a lack of staffing. A review of R111's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of R111's medical record revealed a Minimum Data Set assessment dated for 8/30/22 that revealed a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. In addition, R111 required extensive assistance of two persons for bed mobility and transfers. Further review of R111's medical record revealed an admission skin assessment dated for 5/26/22 noting the following: Open Coccyx wound (infected), old surgical wound from knee down to ankle, right trochanter hip surgical incision, and chest, 2 small abrasions. Further review of R111's medical record revealed the following progress notes: 6/20/2022 12:46 (12:46 pm) Nursing - Skin/Wound Note. Writer assessed residents left elbow r/t (related to) wound care consult. Resident was admitted with scabs noted to bilat (bilateral) elbows, 'scab peeled off' according to resident. Tx (treatment) in place for wound and protection. 6/30/2022 09:00 (9:00 am) Type: Wound Rounds Note. [R111] seen for follow up wound management. [R111] has a unstageable to the sacrum. Has DTI (Deep Tissue Injury) to both heels. Now has an unstageable to [their] left elbow On the left elbow there is an unstageable wound measuring 3.2cm (centimeters) x 1.5cm that has irregular edges, with slough (dead tissue), scant drainage, no odor, the periwound is intact ASSESSMENT AND PLAN: .3. The patient needs to be turned frequently . 7/26/2022 14:10 (2:10 pm) Type: Physician Team - Progress Note: Patient was seen today, since staff reported sacral wound worsening, also reported there was a scab on the R (right) -elbow that fell off, pt (patient) already on high protein supplements to promote wound healing. 7/28/2022 10:31 (10:31 am) Type: Nutrition/Dietary Note: Pressure ulcer/wound review. Resident has high protein needs for wound healing. Currently on high protein supplements to promote wound healing .Has stg. (stage) 3 rt. elbow (full thickness skin loss), stg. U (unstageable) left elbow . 7/28/2022 21:08 (9:08 am) Type: Wound Rounds Note: Wound Consult Left elbow stg 4 ulcer (deep wound reaching the muscles, ligaments, or bones), refer to, [electronic medical record] moderate drng (drainage), no clinical evidence of infection, surrounding tissue intact, base granular, Recommend Tx: cleanse with 1/4 str (strength) dakins (topical antiseptic), apply silver alginate (wound dressing) cover with ABD QD (every day). Right elbow stg 4 ulcer, refer to [electronic medical record], moderate drng, no clinical evidence of infection, surrounding tissue intact, base granular, Recommend Tx: cleanse with 1/4 str dakins, apply silver alginate cover with ABD QD . 10/6/2022 14:53 (2:53 pm) Type: Wound Rounds Note HPI (History of Present Illness): seeing pt re: multiple wounds .SKIN: .left elbow stg 4 ulcer, refer to [electronic medical record], moderate drng, no clinical evidence of infection, surrounding tissue intact, base granular. Recommend Tx: apply silver collagen gel cover with foam dressing 3x/week. Right elbow stg 4 ulcer, refer to [electronic medical record], moderate drng, no clinical evidence of infection, surrounding tissue intact, base granular. Recommend Tx: apply silver collagen gel cover with foam dressing 3x/week . A review of R111's care plan revealed the following: Actual Pressure Ulcer Formation Related to: Resident was admitted with-- or has pressure ulcer____, with risk for delayed wound healing secondary to progressing comorbidities, Debility and generalized weakness with decreased physical mobility and bowel/ bladder incontinence daily .Date Initiated: 05/27/2022. Interventions: Frequent turning and repositioning Date Initiated: 07/21/2022 Provide surface support and pressure redistribution, position changes, and off loading daily. Date Initiated: 05/27/2022 . Resident #42 (R42) A review of 42's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE], is severely cognitively impaired, and has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R42's medical record indicated that the resident had recently been readmitted to the facility on [DATE] after being in the hospital for just over a week with pneumonia. A review of R42's skin assessment dated [DATE] revealed that the resident now had a Stage III (full-thickness skin loss) pressure ulcer (no location listed, however, the assessment photo showed the wound on the resident's sacrum). The assessment indicated that the wound was new and present on re-admission from the hospital, however, the After Visit Summary, dated 10/10/22 and corresponding hospital documentation indicated that R42 was admitted into the hospital on 10/2/22 with a Stage II (partial-thickness skin loss with exposed dermis) sacral pressure injury. R42's skin assessment dated [DATE] indicated that pressure ulcer care to be provided in addition to the wound treatment included, Incontinence management .Positioning Wedge .Turning/repositioning program . R42's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Wound Care Order Site: Buttocks 1) Cleanse wound with NS (normal saline) 2) Pat Dry with Gauze 3) Apply silver alginate 4) Cover with foam (date) .every day shift every Tue, Thu, Sat for wound care AND as needed for wound care .Active 10/10/2022. On 10/11/22 at 1:18 PM, R42 was observed lying in bed on her back with the head of the bed slightly elevated. No positioning wedges were being utilized. On 10/12/22 at 11:56 AM, upon entering the room, R42 was observed lying in bed on her back with the head of the bed in high fowler's position. R42 was moaning/calling out. The resident's blanket was pushed off of her, exposing her incontinence brief. R42 motioned to this surveyor to come closer. R42 was making crying/moaning sounds but was unable at this time to verbalize what was wrong. On 10/12/22 at 11:59 AM, Licensed Practical Nurse (LPN) G and Therapy Staff H entered R42's room. LPN G asked the resident if she was having pain to which she said, Yes, my back, my back. R42 was observed with no offloading devices other than foam boots on her feet. R42 continued to moan out. R42's brief was observed to be saturated with urine, which could be seen from the outside of the brief. LPN G and Staff H boosted the resident up in bed and slightly adjusted her positioning. LPN G asked if that helped R42 feel any better to which the resident responded, Yes, a little bit, not much, not much, not much. The resident was positioned as turned towards her right side but still on her back. R42 indicated that her back still hurt to which LPN G offered medication. R42 accepted and as LPN G went to gather the medication, she was queried regarding the resident's brief being wet. LPN G looked at Staff H and both indicated that they had not even looked at the resident's brief to see if it was wet. On 10/12/22 at 12:05 PM, Agency Certified Nursing Assistant (CNA) I entered the hallway and was queried if R42 had been changed yet this shift (day shift). CNA I indicated that the resident had not yet been changed on this shift. LPN G indicated at this time that R42 has skin breakdown and went back into the room to administer pain medication to the resident. On 10/12/22 at 12:15 PM, LPN G and CNA I provided incontinence care to R42. R42's brief was observed to be saturated with urine. A bordered foam dressing dated 10/11/22 was present on R42's sacrum at this time. The dressing appeared soiled and was not intact i.e. the edges were rolled up on one side, exposing the pressure ulcer. CNA I cleaned R42's skin, applied a clean dry brief, and changed the resident's gown. R42 indicated that she now felt a little bit better. The wound dressing was not replaced with a new dressing before staff left the room, and R42 was left lying in bed with no positioning devices to help offload pressure on her sacral pressure ulcer. On 10/13/22 at 8:49 AM, a wound care observation for R42 was conducted with Wound Care Nurse (WCN) Y and CNA Z. Nurse Y stated that R42 recently went to the hospital and had Excoriation, on her bottom at the time, but was readmitted with, A full blown pressure ulcer. R42 was observed lying in bed on her back. When queried about a positioning wedge(s) for the resident, Nurse Y indicated that the resident has one that should be utilized. Upon review of R42's sacrum, the same soiled dressing dated 10/11/22 with rolled edges was present. However, upon closer inspection, the dressing appeared to have caused an additional skin tear (flap of skin seen with bright red, wet tissue underneath) on the resident's right buttock that was not present when incontinence care was observed the previous day. When queried regarding the wound dressing, Nurse Y stated that the assigned nurses can change the dressing as needed (PRN). When informed that the same dressing was observed as not intact the previous day during incontinence care, Nurse Y stated she would have expected the dressing to have been changed at that time. Nurse Y added, That's why I put the PRN orders in. When queried about offloading pressure and turning/repositioning R42, Nurse Y put a positioning wedge under the resident's right side and stated she expects the resident to be turned/repositioned every two hours and for pressure to be offloaded on the resident's wound/backside. On 10/13/22 at 9:56 AM and 11:52 AM, R42 was observed lying in bed in the same position as was observed after wound care completion at 8:49 AM. R42's positioning wedge remained under the right side and the resident did not appear to have been moved in bed. On 10/13/22 at 2:40 PM, the Director of Nursing (DON) was interviewed and asked what her expectation of nurses is if a wound dressing is not intact (has rolled up edges and/or soiled). The DON stated she expects nursing to change the dressing PRN if there is an order. The DON further indicated that dependent residents are expected to be turned/repositioned in bed at least every two hours, and she expects a positioning device to be in place to offload pressure if a resident has a skin concern. A review of R42's care plan revealed: -The resident has bladder incontinence r/t (related to) Alzheimer's, Impaired Mobility Date Initiated: 06/29/2020. -BRIEF USE: The resident uses disposable briefs. Change often and prn (as needed). Date Initiated: 06/29/2020. -Clean peri-area with each incontinence episode. Date Initiated: 06/29/2020. -Risk for Pressure Ulcer Formation related to: generalized debility and weakness as evidenced by: decreased mobility in bed and wheelchair, incontinence of bowel and bladder. Resident need staff assistance with incontinence care, turning and re positioning .Date Initiated: 08/08/2022. -Frequent turning and repositioning. Date Initiated: 10/10/2022. -Provide surface support and pressure redistribution, position changes, and off loading daily. Date Initiated: 10/10/2022. -Provide wound care as ordered by physician and wound consult recommendations. Date Initiated: 10/10/2022. A review of the facility's policy/procedure titled, Skin & Wound Policy, dated 04/2022, revealed, .It is .our policy to follow the treatment plans for any wound / skin concerns as ordered by physicians .6. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .8. Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise, or is wet .

This Citation Pertains to Intake Number MI 506. Based on observation, interview and record review, the facility failed to provide timely emergency care and Cardiopulmonary Resuscitation (CPR), per American Heart Association (AHA) standards, prior to the arrival of Emergency Medical Services (EMS) personnel for one (#701) Resident, who was a full code and collapsed with staff present in their room on [DATE]. This resulted in an Immediate Jeopardy when CPR was not initiated from the time the nurse was notified of Resident #701's collapse at approximately 6:40 AM until EMS arrived at 6:54 AM and found not to have a heartbeat upon evaluation of EMS personnel. Resident #701 subsequently expired on [DATE]. The Immediate Jeopardy (IJ) started on [DATE] and was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] and was asked for a plan to remove the immediacy. The IJ was removed on [DATE], based on the facility's implementation of the removal plan as verified onsite on [DATE]. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings include: Record review revealed Resident #701 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited to extensive assistance to perform Activities of Daily Living (ADLs) including dressing, transferring, ambulation, and hygiene activities. An interview was conducted with Confidential Witness Family Member A on [DATE] at 11:09 AM. When queried regarding Resident #701, Family Member A revealed the Resident had elective back surgery on [DATE] and went to the facility for rehab (therapy) on [DATE]. When asked about the Resident's stay in the facility, Family Member A stated, .(Resident #701) passed away on [DATE] at 6:30 in the morning. We (family) only know that much because we got the run sheet from the ambulance. We weren't called until 7:00 AM. (The facility) told us they didn't use the AED (Automated External Defibrillator) because (Resident #701) was breathing on their own and had a heartbeat but the ambulance said (Resident #701) didn't. Family Member A then stated, (Resident #701) was planning on discharging (to go home) on ,d+[DATE]. Review of Resident #701's progress note documentation in the medical record revealed the following: -[DATE] at 8:44 AM: Nursing . Resident using call light to use the restroom at around 0640. Resident sat up at the side of the bed with walker in hands with CENA next to them. Resident at that time yelled to CENA to 'Go get help right away.' CENA at that time yelled for writer loud enough for writer to hear down at the nurses desk. Writer at that time ran down to (Resident #701's room) and noted resident laying on the floor in between the window and bed with the walker underneath the pt . Resident's head was facing the head of the bed. Resident at that time was having loud kussmaul respirations (deep and labored breathing). Writer immediately ran to the phone to call 911. Extra help from the building was also called. EMS arrived quickly. Writer assessed B/S (blood sugar): 186. Resident had a weak pulse at 54/min., No apparent injury seen. CPR was administered. Resident was transferred to (hospital) . Review of facility provided Resident Accident/Incident Report for Resident #701 revealed the following: -Date of Incident: [DATE]. Time of Incident: 0645 (AM) . Resident slid to the floor becoming entangle in RW (Rolling Walker) after becoming unresponsive . Statement by Staff (Nursing Assistant C) who observed: Attempted to assist Resident to sitting position to get ready to stand- ambulate to BR (bathroom)- urination. Resident asked (Nursing Assistant C) to get help and became unresponsive falling sideways and to the floor . State the effects of the Accident/Incident on the Resident: Unresponsive . Vital Signs: Temperature (Not Documented) Pulse (Not Documented) Respirations (Not Documented) Pulse Ox: Initially 98 % . Initial corrective actions taken . CPR initiated. 911 called. Sent to ER (emergency room ) for further evaluation .Narrative Summary Regarding Fall . Prior to fall Resident with call light on. CNA (Nursing Assistant) entered room. Resident getting self to the side of the bed stating they had to use the bathroom. Walker placed in front of Resident. Resident attempted to stand and sat back down stating they wanted to catch their breath. Resident grabbed (Nursing Assistant) hand and stated, 'Wait, go get the nurse.' At this time, Resident fell to the side and rolled onto the floor. (Resident) was on their right side. CNA remained with Resident while yelling for the nurse. Nurse reports being a few rooms down near the nursing station when they heard the CNA yelling for help. Arrived to room to observe Resident lying on right side, inside the frame of the walker. Hands tightly grabbing the handles of the walker. Resident with irregular, loud breathing pattern- unresponsive to verbal stimuli, unresponsive to tactile stimuli. Staff removed (Resident) hands from the walker, placed (Resident) on back for further assessing. Pulse present with breathing pattern remaining irregular and audible. Staff called 911. Upon 911 entering, compressions were started despite kussmaul breathing and faint pulse present. Resident was then discharged to hospital . Review of Resident #701's medical record documentation and facility provided staffing assignment sheets for [DATE] and [DATE] revealed Licensed Practical Nurse (LPN) I and Nursing Assistant C were assigned to care for the Resident when the Resident experienced cardiorespiratory distress. The assignment sheets additionally revealed multiple other nurses were working in the facility at the time of the emergency event including Midnight Supervisor LPN H, LPN J, LPN K, and LPN L. Review of call light [NAME]-Care report, dated [DATE] to [DATE] for Resident #701's room revealed Resident #701 requested assistance from staff 11 times from 8:30 PM on [DATE] until they left the facility by ambulance. The last time the Resident's call light was utilized was on [DATE] at 6:36 AM. Review of EMS Run Record documentation, dated [DATE] at 7:12 AM, for Resident #701 revealed, Primary Impression: [CONDITION(S)] (heart attack). The documentation further detailed the following Narrative documentation: -Priority 1: Upon arrival find Pt (Patient) laying supine (on back) on floor, unresponsive, apneic (not breathing), and pulseless. Staff states Pt asked staff to call 911 then became unresponsive. BVM (Bag Valve Mask: device used to mechanically provide oxygen to someone who is not breathing by covering their nose and mouth with a mask and squeezing a bag) ventilations initiated (06:57 AM) with manual CPR (06:56 AM). EKG (electrocardiogram)applied (assessment -06:55 AM) and pt initially found to be in PEA (Pulseless Electrical Activity; heart producing electrical activity but not beating) . King Airway (artificial airway for breathing) placed . IO (Intraosseous) access (direct access into the bone marrow to provide medications and fluid in emergency situation) obtained in R (right) tibia . After 30 minutes of ACLS (Advanced Cardiac Life Support) care, Pt noted to be in persistent V-fib (Ventricular fibrillation- ventricles of heart fibrillate, not pump resulting in lack of heart beat and death if not corrected) and transport initiated . Uninterrupted CPR and ventilation's provided for duration of care . The EMS Run Record documentation indicated Resident #701 received five doses of [MEDICATION(S)] (medication to treat lethal heart arrhythmia), [MEDICATION(S)] (medication to reverse effects of narcotics), two doses of [MEDICATION(S)] (antiarrhythmic medication), [MEDICATION(S)] (used to reverse metabolic acidosis in [CONDITION(S)]) and was defibrillated three times prior to their heart rhythm being asystole (no electrical function in the heart) at 7:35 AM on [DATE]. An interview was conducted with EMS Coordinator D on [DATE] at 1:57 PM. When queried regarding EMS care for Resident #701, EMS Coordinator D confirmed emergency services and personnel were dispatched to the facility on [DATE] in response to an emergency medical situation for the Resident. EMS Coordinator D was queried regarding the time frame of care and revealed very specific times are maintained within EMS records. EMS Coordinator D stated, The 911 call was received at 06:43:49 (AM- partial seconds are recorded). A rig was dispatched at 06:44:34 (AM). They (EMS Crew) were in route at 06:47 (AM), on scene at 06:53:06 (AM) and at the patient at 06:54:20 (AM). Coordinator D was then asked if CPR was in process by facility staff when EMS crews arrived and stated, It appears that it was our crews that started CPR. Alpha 4 Rig started CPR. (Resident #701) did not have a pulse. When queried regarding Resident #701's respiratory status including if the Resident was breathing on their own and what interventions the facility had in place at the time of EMS arrival, Coordinator D coordinated a group conversation with EMS Staff E at this time. When asked what occurred when they arrived on scene in response to the 911 call for Resident #711, EMS Staff E revealed, Walked in, patient was on the ground with a non-rebreather (oxygen delivery mask). The medic bent down to check pulse. No pulse and started CPR. When specifically asked if CPR was in progress by staff, Coordinator D and EMS Staff E both stated, No. When asked if the Resident was receiving assisted ventilations with a BVM by staff, Coordinator D reiterated the Resident had a non-rebreather in place at that time EMS arrived. On [DATE] at 2:25 PM, an interview was conducted with Licensed Practical (LPN) Nurse G. When queried regarding emergency medical equipment in the facility, LPN G revealed they thought there was an AED on the 300-hall of the facility. An interview was conducted with Unit Manager Licensed Practical Nurse (LPN) F on [DATE] at 2:30 PM. When queried if they recalled or had cared for Resident #701 while they were at Resident at the facility, Unit Manager LPN F replied, I remember (Resident #701) but I didn't come it until 8:00 that day ([DATE]). When asked if there was an emergency equipment cart and an AED on the unit, Unit Manager LPN F revealed the crash cart was at the nurses' station and the AED is located, passed the next nurses' station on the wall. A tour of the facility at this time revealed the nearest AED was located on the 300-hall of the facility. An interview was conducted with the Director of Nursing (DON), Registered Nurse B, and the facility Administrator on [DATE] at 2:58 PM. When queried regarding Resident #701 on [DATE] including EMS staff stating the Resident did not have a pulse when they arrived at the facility, the DON replied, I was told they had a pulse (by facility staff). When asked why EMS staff indicated the Resident was receiving oxygen via non-rebreather mask but oxygen delivery was not included in facility documentation, the DON replied, They probably forgot to document it. When asked what took place and what care was provided to the Resident by facility staff during the 11 minutes from when EMS was called and then arrived and determined the Resident did not have a pulse, was in PEA, and respiratory distress, the DON stated they were proud of the care the staff had provided to Resident #701. Upon request for a facility policy/procedure pertaining to initiation of CPR and emergency guidelines, the DON indicated the facility did not have a specific policy and stated, We follow CPR guidelines. When asked if AHA CPR guidelines were followed for Resident #701, the DON replied, Tell me a nursing home that could have done better. No response was provided pertaining to the implementation of AHA CPR guidelines. When queried if CPR was administered, the DON indicated it was not. When queried why documentation in the Resident's medical record detailed CPR was administered, an explanation was not provided. On [DATE] at 4:00 PM, a return phone call was received from Night Shift Supervisor Licensed Practical Nurse (LPN) H. LPN H was asked what occurred on [DATE] with Resident #701. LPN H revealed they were paged overhead to call (Resident #701's) unit. LPN H indicated they responded to the page and stated, The nurse (LPN I) told me (Resident #701) had fallen and was unresponsive. LPN H then detailed they went to the Resident's room and stated, (Resident #701) was between the bed and the wall, tangled up in the walker. We managed to get (Resident #701) off the walker and on their back. LPN H revealed, (Nursing Assistant C) told them, (Resident #701) had slumped to the side, pitched forward into walker onto the floor in a sitting position then slumped to side and rolled forward. LPN H then stated, (Resident #701) were kinda on top of their walker. They looked cyanotic (bluish colored skin from poor blood flow and/or inadequate oxygenation). When asked what occurred next, LPN H indicated staff got the Resident on their back and stated, I told somebody to go get a crash cart because (the Resident) would need oxygen and to get an AED in case. LPN H was asked what staff were in the room and replied, There were a couple other nurses in the room, (LPN J), (LPN I), and (LPN K). When asked the roles of each staff member in the emergency code situation, LPN H replied, (LPN J) tried to get a pulse but couldn't. They put a SPO2 on (Resident #701's) finger which said pulse 54. When asked where LPN J tried to get a pulse, LPN H replied, I would imagine pedal and verbalized that LPN J was positioned by the Resident's feet. LPN H then stated, Somebody brought in a crash cart and started them on oxygen. (LPN I) went to start CPR but I told them not to because we had a pulse with the SPO2. LPN H then stated, EMS came in and I just put (Resident #701) on a non-rebreather mask, EMS said we don't have any respirations and took over. When asked what Resident #701's respiratory rate was, prior to EMS arrival, LPN H stated, I'm not sure, did not measure. With further inquiry regarding vital sign measurement prior to EMS arrival, LPN H revealed vital signs were not obtained and the facilities vital sign monitoring machine was not utilized. When asked how the Resident's SPO2 measurement was obtained without the machine, LPN H stated, I had one (personal SPO2 monitor) in my pocket. I think it read heart rate 48 to 54 (beats per minute) and SPO2 in the 90 percent's. When asked if they attempted to manually check the Resident's carotid pulse, LPN H stated, I tried but I couldn't find it. When asked if they attempted to manually palpate a pulse at any other location, LPN H indicated they used their personal SPO2 monitor. When asked if any of the staff involved attempted to palpate a pulse after the initial attempt, LPN H replied, I can't say because somebody brought the crash cart in and I hooked up the oxygen. An interview was conducted with LPN I on [DATE] at 4:35 PM. When queried regarding Resident #701 on [DATE], LPN I indicated they were assigned to care for the Resident that shift. When asked what occurred, LPN I revealed (Nursing Assistant C) was in the room with the Resident and yelled for them. LPN I then stated, (Resident #701) was doing that loud kussmaul respirations. I will never forget that sound. I ran down (to nurses' station), called 911, then called my manager (LPN H). I ran back down there (to Resident's room) and we were fighting to get the walker out from under them. I was getting ready to do CPR and (LPN H) told me to stop because there was a faint pulse. When asked where LPN H had palpated a pulse, LPN I revealed they were unsure and stated they tried to find a pulse again on the Resident's wrist. When asked if they found a pulse, LPN I stated, Then I thought I palpated a pulse, but it was very faint and hard to feel. When asked how long they attempted to locate a pulse, LPN I revealed they were not sure. When queried what other staff were present in the room, LPN I replied, (LPN K) and (LPN L). When asked if LPN J was in the room assisting with the Resident, LPN I replied, No. I remember (LPN K) was making copies and (LPN L) was in the room. When queried if anyone else was able to obtain a distinct pulse, LPN I replied, Only (LPN H) said anything. LPN I proceeded to detail, Once I came back in from calling everyone, (Resident #701's) O2 (oxygen saturation) was really low like 72%. We just got the oxygen on when EMS came. When asked if Resident #701 had a pulse at that time, LPN I stated, I was trying to feel a pulse when EMS came. When queried if the Resident was breathing on their own and what their respiratory rate was LPN I replied, I don't know. When asked about the SPO2 monitor, LPN I revealed, The SPO2 was going in and out. I was trying to warm (Resident #701's) finger to get an SPO2 when EMS came in. LPN I then stated, I seen a 74%. (Resident #701's) hands were getting cool. Face looked pale and hands looked pale. When asked if they counted the Resident's respiratory rate, LPN I revealed they did not count respirations and stated, Maybe six (breaths per minute). When queried why rescue breathing and/or CPR were not initiated, LPN I stated, We just put the oxygen on (Resident #701) and heard they (EMS) were there (in hall). An interview was completed with the DON, Administrator, and Nurse B on [DATE] at 5:20 PM. When queried why CPR was not initiated for Resident #701 by facility staff when a pulse was not quickly palpated by staff per AHA CPR guidelines and why the Resident's respiratory status and heart rate were not assessed, the DON stated, I just talked to (LPN H) and they said they bagged (BVM) them (Resident #701). When queried why LPN I did not reveal that in the interview conducted on [DATE] at 4:00 PM and why they stated a non-rebreather was placed on the Resident , the DON indicated they spoke to LPN H after the interview was completed at 4:00 PM. No further explanation was provided. When queried if use of a BVM for ventilation of Resident #701 was documented in the Resident's medical record, the DON stated, Not documented. When asked why EMS documentation detailed EMS staff initiated BVM ventilation, the DON was unable to provide an explanation. A second interview was conducted with LPN H on [DATE] at 5:27 PM. When told the DON had stated they had additional information to share pertaining to Resident #701, LPN H stated, We had (Resident #701) on a non-rebreather mask but the bag didn't fill up so we started bagging (the Resident) and we didn't have a respiratory rate. When asked if any staff checked for a pulse when the Resident stopped breathing, LPN H replied, No, nobody. When queried if BVM ventilation was in place when EMS arrived, LPN H indicated it was. When queried why EMS staff and documentation revealed CPR including respiratory assistance was initiated by EMS staff, LPN H did not provide an explanation. When asked why they did not share this information previously, LPN H did not provide an explanation. On [DATE] at 5:45 PM, an interview was completed with LPN K. When queried regarding Resident #701 on [DATE], LPN K revealed they were working in a different hall of the facility than Resident #701 resided when the incident occurred. LPN K stated, My supervisor (LPN H) was walking past quickly so I followed (to Resident #701's room). When asked if LPN H was running as though there was an emergency, LPN K revealed they were not running but were walking more quickly than normal. LPN K then stated, At this point, (Resident #701) was breathing but they were turning gray and starting coding (heart stop beating and stop breathing). When asked, LPN K stated, My understanding was that (Resident #701) coded and they started coding (the Resident) because they stopped breathing and didn't have a pulse. I heard someone say starting compressions. LPN K then revealed they left the Resident's room to call a Nurse Stat Code overhead and to prepare documents for the Resident's transfer. An interview was conducted with LPN J on [DATE] at 2:05 PM. Prior to asking LPN J what had occurred on [DATE] regarding Resident #701, LPN J revealed they were made aware of the reason for the interview by the facility. LPN J then stated, I was working the next unit over. When I got to (Resident #701's) room, they were tangled in their walker. Upon request for clarification, LPN J indicated the Resident was on top of their walker. LPN J then stated, Resident #701 was cyanotic with deep snoring, kussmaul breathing. They were unresponsive to a sternal rub. When asked if the Resident had a pulse, LPN J replied, Resident #701 had a pulse ox on their finger, not sure what it read. With further inquiry, LPN J stated, People tried to get radial (pulse) but couldn't. When asked if anyone checked a carotid pulse, LPN J replied, No. LPN J then stated, We put O2 (oxygen) on (Resident #701), it was a non-rebreather. Then put ambu (BVM) on. When queried why the non-rebreather was changed to a BVM and if the Resident had stopped breathing, LPN J was unable to provide an explanation. When asked if the Resident had a pulse while respiratory support was being provided and who assessed the Resident's pulse, LPN J revealed they did not check for a pulse and stated, Not sure who checked a pulse. When queried regarding SPO2 monitoring, LPN J replied, Not sure, it (pulse ox) wasn't on the whole time. LPN J was asked when the SPO2 monitoring device was removed and replied, LPN H took it off. When asked if they were providing ventilations via BVM to Resident #701 when EMS personnel arrived on scene, LPN J indicated they were. When queried why EMS staff stated the Resident was not receiving ventilation support with a BVM, LPN J did not provide an explanation. When asked if the facility AED was placed on the Resident, LPN J revealed the AED was not utilized. On [DATE] at 2:16 PM, an interview was completed with LPN L. When queried regarding Resident #701 on [DATE], LPN L stated, A Nurse Code got called. I grabbed the AED and went to the room. LPN L was unable to provide further information pertaining to the Resident's condition and/or actions taken by staff. On [DATE] at 11:30 AM, the 900-hall emergency supply cart was observed sitting in the entry hall area of the nurses' station. The cart contained a stethoscope, portable suction machine, suction equipment, oxygen tank, non- rebreather oxygen masks and BVMs. A facility vital sign monitoring machine was observed in the hall of the facility on [DATE] at 11:35 AM. The facility blood pressure machine included capability for blood pressure, temperature, and SPO2 monitoring. A wrist style blood pressure monitoring device, temporal thermometer, and portable finger SPO2 monitoring device with a name written in permanent marker were noted in the storage basket on the vital sign machine. An interview was conducted with LPN G at this time. When queried regarding the equipment noted, LPN G stated, Those are a CNA's (Nursing Assistants) personal ones. When asked if they are used to obtain Resident vital signs, LPN G indicated they were. When queried regarding staff use of portable finger SPO2 monitors, LPN G stated, Yeah, a lot of us have them. It's easier to keep them in our pockets. When asked if the portable finger SPO2 monitors are purchased by the facility, LPN G replied, No. An interview was conducted with the Administrator, DON, and Nurse B on [DATE] at 12:00 PM. When queried regarding inconsistencies in staff recollection of the events on [DATE] with Resident #701, lack of documentation of what occurred, EMS documentation/interview, and lack of implementation of CPR guidelines/algorithm per best practice recommendations, the DON replied they did not understand what the problem was. When queried if the AED was connected to the Resident, the Administrator and DON indicated it was not. Upon discussion of AED use guidelines in CPR and if the AED would advise CPR for a cardiac rhythm of PEA, an explanation was not provided for the AED not being implemented. When queried if a portable SPO2 monitor was an acceptable and reliable method per AHA CPR guidelines to assess pulse, the DON indicated staff assessed a pulse. When queried if the assessment followed guidelines, a response was not provided. The Administrator and Nurse B indicated they were aware of the importance of AHA guidelines for CPR and had already implemented staff education. On [DATE] at 12:15 PM, an interview was conducted with Nurse B. When queried regarding staff use of personally owned vital sign monitoring equipment for Residents and how the equipment is monitored to ensure it is functioning appropriately when not owned by the facility, Nurse B stated, The machines (vital sign machines owned by the facility) are checked by a company (to ensure they are working correctly). Nurse B revealed staff personal equipment is not checked. When asked about Resident #701 on [DATE] not having their pulse palpated per AHA CPR standards and staff using personal equipment to determine if the Resident had a heartbeat, Nurse B indicated AHA CPR guidelines were not followed with the use of an SPO2 monitor. An interview was completed with the facility Administrator and Nurse B on [DATE] at 2:53 PM. The Administrator was asked what AHA guidelines/algorithm are when assessing a pulse in an emergency and revealed the guideline is to check the carotid pulse first and for no less than 10 seconds. When queried if AHA CPR guidelines were followed for Resident #701, both the Administrator and Nurse B indicated guidelines and algorithms were not followed and staff would be receiving ongoing education. At this time, the Administrator revealed the facility did not have a policy/procedure pertaining to staff use of personal medical equipment in Resident care. A phone interview was attempted to be completed with Nursing Assistant C on [DATE] at 1:45 PM and 3:37 PM, [DATE] at 2:20 PM and [DATE] at 10:20 AM. A voicemail was unable to be left due to the mailbox being full but an SMS message with a request for a return call was placed. Review of facility policy/procedure entitled, CPR/Do Not Resuscitate order- 911 and Pronouncement of Death (Issue Date: ,d+[DATE]) revealed, Policy: CPR is to be initiated in the event of a Cardiac/Respiratory arrest . Procedure: 1. Call for help- DO NOT leave the Resident. a. Use the intercom or emergency call light to summon staff. b/ Try to get the person to respond . roll the person on his/her back . c. Start chest compressions . e . Push until AED is in place and ready to analyze . f. Then open the airway . use ambu bag . g. Continue chest compressions and 'breaths' via ambu bag .h. Instruct ward clerk or designated person to call 911 . Review of facility policy/procedure entitled, (AED) Automated External Defibrillator (Issue Date: ,d+[DATE]) revealed, Purpose: To assist the nurse in rescue when a suspected [CONDITION(S)] victim has an apparent lack of circulation as indicated by: unresponsiveness: and absence of normal breathing and absence of a pulse or signs of circulation . Review of facility policy/procedure entitled, Accident & Incident Report (Issue Date: ,d+[DATE]) revealed, Purpose: Incident/Accident reports will be completed on any accident or incident involving a Facility Resident . Procedure: The purpose of this policy is . (b) to provide prompt medical care for injured Residents; (c) to monitor frequency, severity, and location of Resident incidents/accidents; (d) to look for Facility of Resident trends . (f) to prevent re-occurrence of a similar incident . (i) to provide an immediate reference source for a more thorough investigation . 1. All accident/incidents will be documented on the Accident/Incident Report form . 2. The form will be completed as follows: a. The nurse who discovers the incident or the nurse assigned to the patient will initially complete the accident/incident report at the time of the incident. b. In addition to the accident/incident report . If the incident is not falls- related, the 'Non Fall Related Team Report' shall be initiated. If the incident does not fall into either category, the nurse and/or any other team member than may have information about the incident should initiate and investigation as to the facts surrounding the incident and document them on the 'Resident Accident Incident' form . A review of the Adult [CONDITION(S)] Algorithm from the American Heart Association website revealed the following: .Victim is unresponsive .Get AED and emergency equipment .Look for no breathing or only gasping and check pulse .Is pulse definitely felt within 10 seconds? No breathing or only gasping, no pulse .CPR Begin Cycles of 30 compressions and 2 breaths. Use AED as soon as it is available . Facility Plan of Removal Element I Resident #701 was a [AGE] year old . admitted on [DATE]. Resident #701 was a full code. The resident had the following diagnosis; Spinal Stenosis, lumbar region with [CONDITION(S)] claudication, Spondylolisthesis, Encounter for other orthopedic aftercare, Type 2 diabetes mellitus with diabetic polyneuropathy, [CONDITION(S)], Obsructive Sleep Apnea (adult) (pediatric), Essential (primary) hypertension, [CONDITION(S)] unspecified, Post Acute Hemorrhagic [CONDITION(S)], Obesity, Gastroesophageal Reflux Disease without Esophagitis, Benign Prosthetic [CONDITION(S)] without Lower Urinary Tract Symptoms, Anxiety Disorder. The resident #701 was discharged on [DATE] to the hospital and no longer resides within the facility. Element II It is the policy of the facility to provide emergency care and CPR per American Heart Association standards and guidelines for residents who are in cardiopulmonary distress. The facility has identified all residents with Full Code status. Element III The facility nursing leadership were reeducated on CPR policy and BLS algorithm. Reeducation of all licensed staff was implemented on [DATE] and will be completed by [DATE]. Nursing leadership were trained and successfully demonstrated the skills for emergency care and CPR per American Heart Association standards and guidelines. Element IV Mock codes will be conducted on all shifts monthly x3 then quarterly thereafter by the Respiratory Therapist. Mock codes will be conducted on hire, annually, and as needed. For actual codes that occur within the facility, all staff involved will be debriefed after each code for continuous quality improvement. Mock codes and actual codes will be audited/reviewed by the Respiratory Therapist or designee for staff compliance monthly x3 and quarterly thereafter. The Director of Nursing and/or designee will be responsible for continued compliance. Element V The Director of Nursing and/or designee will be responsible for continued compliance. Compliance date of [DATE].

This citation pertains to intake numbers 0 and 2. Based on interview and record review, the facility failed to safeguard cash money, credit cards, gift cards, and a driver's license for two residents (#701 and #702) of three residents sampled for misappropriation of funds, resulting in theft, anxiety, and emotional distress. Findings include: On [DATE] at 10:07 AM, Family Member B for Resident # 701 was contacted via phone to confirm the allegations of theft. Family Member B stated, We found out there were charges on their Macy's card and JC Penney's card. Nike shoes and shirts and stuff (were charged). The charges were charged while they were in the nursing home. So we know it wasn't (Resident #701). We reported the charges to the stores but haven't heard anything. We also called the police and filed a police report .Some money was stolen but I am not sure how much. I know at least five dollars because I had left it for a tip for the hair dresser. She had forty dollars tucked away that they didn't get, because it was hidden pretty good. They also stole her driver's license. I am concerned about that because now they know where (Resident #701) lives and I am worried that they will break in their house or something. (Resident #701)'s son is handicapped .He brought (Resident #701)'s purse in and put it in the drawer, he shouldn't have done that. On [DATE] at 10:22 AM, Certified Nursing Assistant (CNA) C was contacted via phone to discuss allegations of theft. CNA C stated, They (the facility) are trying to blame it on me. It was (2 CNA names mentioned). I didn't do it. I was a floater and worked eight days during that pay period .They suspended me. Nurses and CNA's called me and asked me what happened. They blamed it on me because they just didn't want to work those units. CNA C was asked why she thought that the facility had blamed her verses other staff members but did not have an explanation. Within three minutes, at 10:25 AM, CNA C called this surveyor back and stated, Did they report (a third CNA name mentioned) too? She stole a patient's credit card too. On [DATE] at 11:00 AM, Family Member D for Resident #702 was contacted via phone. Family Member D was asked about the alleged theft that took place while Resident #702 was in the facility and stated, I had to do a lot of my own detective work. There was a charge with a delivery from Walmart. I traced the package and got an address. I did one of those live chats (with Walmart) and explained the situation to them. They were real nice about it and refunded the money to (Resident #702). I gave the information to the police. The address was actually a dummy address but I found out that the thief lived on the same road. There were two charge cards stolen, and gift cards to Texas Roadhouse and Outback Steakhouse, and some money but I am not sure exactly how much. (Resident #702) was very upset about it. On [DATE] at 11:16 AM, Resident #702 was contacted via phone and queried in regards to the alleged theft of their credit card, gift cards and cash money. Resident #702 stated, I went to pay my bills (while at the facility) and noticed my credit card missing, then there were charges to Walmart. My daughter and I did some police work. Walmart was real nice and gave me a credit of $58.55. They took two credit cards and two fifty dollar gift cards to Texas Roadhouse and one fifty dollar gift card to the Outback Steakhouse, so they ate good on me. I am so upset about it still, it has been weighing on me. I came there to concentrate on healing and now I am concentrating on this crap ( Resident #702 began crying). I just spoke to the detective and they have four warrants out for her arrest. I guess one from (Facility) and three from other victims. They are waiting on the prosecutor's desk. I guess she refused to go to the police station. I had about forty dollars saved to get my haircut there, I really needed it (a haircut) and still do, but I couldn't because the money was stolen. After all my bills and paying for my insurance supplement I only have one hundred and fifty dollars left out of the month for extra money. So, why me? A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #702 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #702 had a Brief Interview for Mental Status Score (BIMS) of 15 out of 15, indicating an intact cognition. Resident #702 needed extensive hands on assistance with most Activities of Daily Living (ADLs). On [DATE] at 11:37 AM, Detective [NAME] was contacted via phone to discuss the status of the case alleging theft against CNA C. Detective [NAME] stated, Basically an employee (CNA C)was a predator to seniors who were sleeping at the time. The facility helped me thoroughly and were able to set up a room and identify the subject (CNA C). We then got information from the credit card reports (of Resident #701, #702, and Confidential Witness A) and confirmed the address. She used an address of her next door neighbor and a family member two blocks away to have items shipped. On the orders she used her actual phone number and email address so we were able to track it back to her. We got a DNA (deoxyribonucleic acid) search warrant of one of the victim's wallet and I had everything all set and spoke to her (CNA C). I had her coming in and she never showed up and now she won't answer my calls. A review of the Employee Termination Form dated [DATE] revealed that CNA C was employed at the facility on [DATE] and was terminated on [DATE] for theft of facility, resident, visitor, and employee property .Suspending per investigation on [DATE]. Terminated on [DATE] conclusion of investigation .Theft to Resident's spouse (Confidential Witness A), Resident (#701), Resident (#702), facility. The form was signed by the Administrator and Assistant Administrator F. On [DATE] at 12:24 PM, Resident #701 was contacted via phone. Resident #701 stated, There were some charges I think to my Macy's card or something, they were expensive Nike shoes. I called and canceled the cards immediately. I was upset, who wouldn't be? On [DATE] at 12:51 PM, the Administrator was asked for the employee file of CNA C to review the pre-employment screening. The Administrator handed the file over and stated, Just so you know, she does have a flag on her CNA license since (MONTH) (2019) for another incident but she was eligible to work here when we hired her. The pre-employment screening was done on [DATE] and stated that CNA C was eligible to work at the time of hire. A random review of the Licensing and Regulatory Affairs (LARA) website for Nurses Aide Registry revealed that CNA C's license was Revoked. A record review of the MDS dated [DATE] revealed that Resident #702 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #702 needed extensive assistance with ADL's and had a BIMS score of 15 out of 15, indicating an intact cognition. On [DATE] at 2:45 PM, an interview was completed with the Administrator and the Assistant Administrator F in regards to CNA C stealing cash money, credit cards, driver's license and gift cards from Resident #701, #702 and Confidential Witness [NAME] The Administrator stated, It got reported from the wife (Confidential Witness A) of another resident, that was my first one (theft report). We did an incident report. We did some tracing. We looked at assignments. Then (Resident #702) approached (Assistant Administrator F) that they had two credit cards and their driver's license missing, we weren't sure if it was here or at home at first. At first there was no activity on the cards and they closed them but then they got a bill and there were charges on them. Then (Resident #701) said their cards were missing, (Resident #701)was going to make an insurance payment and couldn't. We asked (Resident #701) where everything was and they said they always kept them in their purse in their room. Then we saw a common assignment. We saw that (CNA C) was assigned to each of those units during the time frames. Then we decided to set up a room (to catch her in the act). We assigned her the room. We pretended that we were setting up the room as a new admit that was not yet in the building but the family had brought some stuff in. I took a purse, I put seventeen dollars in it and expired charge cards in the wallet with two Starbucks gift cards and put it in the drawer and left it a little bit open so the purse was visible in the drawer. Then we had that staff member assigned to the room. Day shift didn't take it, we looked, it happened on (CNA C)'s shift. It was gone within 12 hours. Then I called the staff and had them report to me before they went to work. We talked to all of them. Every single one of them (the other CNA's interviewed) it was their permanent hall except for her (CNA C). She was the only float. I talked to her and was very honest and told her all the evidence that we had. Then (Family Member D) called me and explained that they had tracked the packages and found it was right next door to (CNA C). Then we google mapped it and found out the other address was a block away from her. The detective really went to town and found out the next door house was a friend of hers. The other one was her brother .She had left me a voicemail and said she was going to sue and that she didn't take from this wife and this person, and she knew everything that was taken in details, yet we had never even disclosed what was taken to her. We have inserviced everyone (all staff) and now admissions reiterates to not bring in valuable personal belongings. We went around and asked everyone if they wanted to utilize lock boxes in their rooms. We highly encouraged and got a hold of the family if they didn't want the lock box. We inserviced facility wide on the abuse policy again. A review of the facility policy titled Abuse Program: Elder Justice Act Abuse (Neglect, Mistreatment, Misappropriation, Suspicion of Crime, Investigation and Reporting ) issued [DATE] revealed the following: 3. Prevention-The facility shall supervise staff to identify inappropriate behaviors that may result in abuse . 4. Identification-The facility will identify, correct, intervene in situations in which abuse .and/or misappropriation of resident property is more likely to occur .and shall investigate all occurrences for patterns and trends that may constitute abuse .

This citation pertains to intake # Based on observation, interview and record review, the facility failed to transfer and ambulate 1 (#136) resident with a gait belt, and failed to follow the plan of care for 2 (#'s 572 and 52) out of 8 residents reviewed for falls, from a total sample of 32 , resulting in falls with injury. Findings include: Resident #136 On 5/2/18 at 1:00 p.m., a record review of Resident #136's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS also revealed that Resident #136 was utilizing extensive 2 person assist with transfers, required limited assist with walking and bathing and had a Brief Interview of Mental Status (BIMS) score of 03 (severely cognitively impaired). The MDS also stated that Resident #136 had no previous falls. On 5/2/18 at 1:43 p.m., Resident #136 was observed lying in bed and visiting with Confidential Witness T. Resident #136 had a cast on the left lower extremity and the toes were swollen. Confidential Witness T stated, Resident (#136) was supposed to go home and then I get a call at 9:00 at night that she fell in the shower and they sent her to (Hospital) and they did emergency surgery at 12:30 a.m. They (the facility) said it was a new aide that had never taken care of Resident #136 before. We don't want her taking care of Resident (#136) again. Resident #136 was walking around before this. Now they can't even stand on it (the left leg). On 5/03/18 at 10:58 a.m., a review of the Resident Accident/Incident Report dated 3/24/18 8:40 a.m. revealed the following: Shower/bathroom w/ (with) CNA (certified nursing assistant K)-pt (patient-Resident #136) stopped and when CNA K was directing the resident to shower chair pt lowered to ground. Injury status-911 called-exposed/cut of pants-left leg deformed. Pt had on a compression stocking and slipper/gripper socks. Left lower leg was open fx'd (fractured-bone exposed out from skin)-lateral 90 degree angle. Pain-It hurt, it hurt. Narrative Summary Regarding Fall; Just Prior to occurrence resident (#136) was assisted to side of bed by nurse. CNA K entered room in preparation to provide shower to this resident. Nurse and CNA K assisted resident to standing position with walker in front of resident. Resident proceeded to take 3-4 steps with nurse noting balance was steady and proceeded to exit room. CNA K assisted resident into the bathroom. Shower chair in position at resident's (#136) left side. Resident (#136) facing the shower stall and CNA K preparing to have resident pivot to the left to sit in the shower chair. Before the pivot transfer could be started, without warning, resident (#136) started going down to the floor. CNA K was behind resident (#136) at this time and used her knee to brace resident (#136) as she went down. CNA K had her arms around the resident (#136) attempting to control the downward motion. Resident (#136) landed with her legs tucked under her buttocks. CNA K able to reposition right leg out in front of resident without difficulty. Upon adjusting left leg, CNA K noted change in leg alignment and immediately called the nurse. Nurse to bathroom to observe resident (#136) sitting on buttocks with CNA K positioned at resident's back, providing support. Resident (#136) was facing shower. Both legs out in front of resident with knees slightly bent. Nurse noted left lower extremity misaligned just above the ankle. Resident (#136) with compression stockings on her legs. Slight bleeding noted to inner aspect of leg just above ankle. Compression stocking left in place. Area braced and immobilized with pillow, taken to (Hospital) for further evaluation .Resident with fractures of second through fifth metatarsal heads. Weber B-2 fracture (a fracture of outside ankle bone). Moderate to severe osteopenia. On 5/3/18 at 11:15 p.m., the Director of Nursing (DON) was interviewed in regards to the fall of Resident (#136). The DON stated, The CNA K was behind her (Resident #136), she put her thighs behind her to try to break the fall. No gait belt was used. We educated everyone (staff members) on gait belt use. She (CNA K) used it earlier, and it broke. She never asked for a new one. On 5/3/18 at 12:03 PM, an interview via phone was completed with CNA K. CNA K stated, It was (Resident #136)'s shower day. The nurse assisted me to stand her up. We proceeded to go in the shower room. The nurse said (Resident #136) looks to be good with you and left. (Resident #136) has a language barrier, and was trying to tell me something, but couldn't really tell me anything. (Resident #136) paused for a moment, I asked if (Resident#136) was ok .I float so it was hard for me to know what (Resident #136) wanted because I wasn't used to working with them. I tried to help (Resident #136) to sit down, (Resident #136) didn't look right. (Resident #136) seemed tired and worn out from walking. So, I tried to get (Resident #136) on the shower chair, but (Resident #136) completely just fell down, I tried to brace (Resident #136) with my knees. (Resident #136) feet were still forward, so I went to pull the left leg out, but it was not normal. I propped the foot up and went to get the nurse. CNA K was queried in regards to the use of a gait belt with the transfer and ambulation of (Resident #136). CNA K stated, No, I didn't use one, normally I always do. At that time my gait belt was not on me. CNA K was queried about any ramifications she had received as a result of the fall with Resident (#136). CNA K replied, I had an inservice (on gait belts and transfers) and had to refresh what I do and how I do it (with transfers of residents). On 5/03/18 at 1:44 p.m, the Administrator was interviewed about the fall involving (Resident #136). The Administrator stated, She (CNA K) didn't have a gait belt on her. A nurse assisted her (CNA K) and felt that she (Resident #136) was walking well. I believe that if the nurse felt it was safe for her to leave the room, then everything was okay. On 5/3/18 at 2:25 PM, a review of the facility Gait Belt Policy with the issue date of 9/29/17 revealed the following: To provide a safe working environment focused on resident safety, employee safety and overall injury prevention. To maintain a safe working environment the use of gait belts shall be used when transferring/lifting and walking a resident. Unless otherwise indicated. 1. It is recommended that a gait belt shall be worn by the resident during transfers/lifting and walking a resident. Gait belts shall be used with any resident who needs 'Hands On' or manual assistance in moving from one place to another. Resident #572 On 5/3/18 at 9:04 a.m., a record review of Resident (#572's) MDS dated [DATE] revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident (#572) had a BIMS score of 13, indicating an intact cognition. The MDS also revealed that Resident (#572) required extensive, 2 person assist with bed mobility, transfers and toileting needs (including cleaning self after elimination). According to the MDS, (Resident #572) had no previous falls and had a height and weight of 6 foot 2 inches and 304 pounds. On 5/3/18 at 10:03 a.m., a record review of the Resident Accident/Incident Report dated 1/24/18 revealed that Resident (#572) had been in bed and had a bowel movement (BM) and Licensed Practical Nurse (LPN) J was with CNA I preparing to do wound care. CNA I had stepped out of the room and LPN J began to clean the BM off of (Resident #572) when he suddenly switched positions and resident's legs fell out the side of the bed, causing the rest of his body to fall to the floor. On 5/3/18 at 10:05 a.m., a record review of the X-Ray report for (Resident #572) revealed the following: Bilateral comminuted displaced distal femoral fractures (two fractures just above the knee). On 5/3/18 at 10:15 AM, a record review of the Fall Risk Care Plan for Resident #572 revealed the following intervention created on 1/29/18: Use caution when Resident is rolling in bed to ensure legs do not involuntarily roll out of bed due to [MEDICAL CONDITION]. On 5/3/18 at 11:55 AM, an interview was completed with the DON and Senior Occupational Therapist (OT DD ) in regard to the fall of (Resident #572). The DON was queried about the decision of LPN J to complete care to (Resident #572) (cleaning BM) without the assistance of CNA I. The DON stated, The bed mobility portion had already been completed, (Resident #572) was mobile in bed. The resident was in the center of bed. (Resident #572) had a hand on the the trapeze bar, then grabbed the enabler bar, causing ( Resident #572) to fall. Well, that left the licensed nurse in there, she felt it was safe, she made that judgement (to wash Resident #572 without assistance). OT DD stated, (Resident #572) had involuntary and spastic movements and when the resident took their hand off the trapeze bar, it happened with such sudden force that it caused them to fall. (Resident #572) was a big man. When OT DD was queried as to why staff would attempt to do any type of care to Resident #572 while alone in bed if they had involuntary movements, OT DD stated, Well, when (Resident #572) was at home they were independent with bed mobility. On 5/3/18 at 2:25 p.m., an interview was completed via phone with LPN J. LPN J stated, Me and the aide (CNA I) were in there to position (Resident #572) and get (Resident #572) up for the day. I was going to do wound care before we got (Resident #572) up. We put (Resident #572) on their side. The CNA I went to get clean linens. I was going to assist her by getting him clean so we could put (Resident #572) in the chair. When the resident changed positions, they just fell . LPN J was queried about the daily routine and care provided to (Resident #572). LPN J stated, Everyday the aide helps me reposition him in the center of the bed and on (Resident #572) side, she stays there and I do his wound care and then we both get (Resident #572) dressed and use the hoyer lift to get (Resident #572) in their chair. We do this everyday. I like to do (Resident #572's) wound care before they get up for the day. When asked why on this particular day she did not wait for the CNA to assist her, LPN J stated, When she left, I felt he was stable. On 5/3/18 at 2:40 PM, an interview was completed with CNA I, in regards to the fall involving (Resident #572). CNA I stated, I had just stepped out. Me and the nurse (LPN J) were going in to do wound care. She (LPN J) needed a second person to help her for bed mobility because (Resident #572) was a 2 person assist. (Resident #572) used the trap (trapeze bar), I turned (Resident #572) on the right side. (Resident #572) had a BM, I wasn't prepared for that. So, LPN J said she was good, she had (Resident #572) . So I left the room. (Resident #572) was in the middle of the bed. I was out for 10 seconds, the storage closet was outside his room, four doors down. I heard the nurse yell for me so I ran into the room and (Resident #572) was on the floor, kind of like on their knees. CNA I was queried as to how she completed care after (Resident #572) had a BM. CNA I stated, (Resident #572) would use the enabler bar and the trapeze. I would do (Resident #572) with someone else (another person assist) because (Resident #572) was a big guy. On 5/03/18 at 1:52 p.m. the Administrator was interviewed regarding Resident #572's fall. The Administrator stated, (Resident #572) was alert and oriented x 3 and had safety awareness. They centered (Resident #572) in the middle of the bed, they felt that (Resident #572) was safe. On 5/3/18 at 2:30 PM, an interview was completed with Confidential Witness U via phone. Confidential Witness U stated, (Resident #572) just now finally got home. (Resident #572) broke both his legs. (Resident #572) has more leg spasms now since the fractures, I am not sure if they (the spasms) are going to continue or not, but they are quite painful. On 5/3/18 at 2:44 p.m., a record review of the physician progress notes [REDACTED]. Resident (#572) is A&O (alert and oriented) X 3, assist X 2 with ADL'S (activities of daily living) and bed mobility X 2 for Hoyer lift transfers .Resident is paralyzed from the waist down and has involuntary movements when moving his body around . On 5/3/18 at 3:00 PM, a record review of the facility policy titled Falls Management was completed but did not provide any information in relationship to the above incidents. Resident #52 On 5/2/18 at 9:00 a.m., the clinical record for (Resident #52) was reviewed and revealed that the resident was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 3/19/18, indicated a severely impaired cognition and required extensive assistance of two persons for bed mobility. On 5/2/18 at 11:15 a.m. (Resident #52) was observed in bed and was unable to respond to any questions. On 5/2/18 at 1:15p.m. a review of an incident report, dated 4/30/18 at 10:05p.m., indicated the following: CNA trying to change resident's brief, she turn her left side and clean, pt sliding from bed to floor hit back of head on side table's wheel. State the effects of the Accident/Incident: Small bump of resident's back of head. Initial corrective action taken/Recommendation for prevention of similar occurrence: Two person assist to turn resident. On 5/2/18 at 1:45p.m. a review of, Resident Nursing Instructions for (Resident #52) indicated the following: Bed Mobility Support Two+ person physical assist. On 5/2/18 at 4:28 p.m. CNA, N' was queried on bed mobility assistance when changing and re-positioning (Resident #52) in bed. She stated, Two people. 5/2/18 at 4:30 p.m. CNA, O was queried on bed mobility assistance when changing and re-positioning Resident #52 in bed. She stated, Two people are required. CNA O referred to the Kiosk on Resident #52's unit under Nursing Instructions Bed Mobility which indicated that (Resident #52) was a Two+ person physical assist. On 5/3/18 at 1:04 pm Nurse Q was queried regarding the incident which occurred involving (Resident #52) on 4/30/18 at 10:05 p.m. Nurse Q indicated that (Resident #52) was a two person assist with bed mobility and changing. Nurse Q stated, The CNA did not ask for help she turned the resident herself. On 5/3/18 at 2:08 p.m. Safety Nurse R was queried regarding the incident which occurred involving Resident #52 on 4/30/18 at 10:05 p.m. and the level of assistance required when re-positioning and changing the resident in bed. Safety Nurse R stated, She should be a two person assist, the CNA knew that. I educated the CNA on the level of care. Safety Nurse R confirmed that the Resident Nursing Instructions on the Kiosk was where CNAs look to review the level of care that a resident requires. On 5/3/18 at 2:15 p.m. The Director of Nursing (DON) was queried regarding the incident which occurred involving (Resident #52) on 4/30/18 at 10:05 p.m. and the level of assistance required when re-positioning and changing the resident in bed. The DON confirmed what Safety Nurse R had stated. On 5/3/18 at 3:32 p.m. CNA P was queried regarding the incident which occurred involving Resident #52 on 4/30/18 at 10:05 p.m. and the level of assistance required when re-positioning and changing the resident in bed. CNA P indicated that (Resident #52) was a two person assist. CNA P admitted that she was attempting to position the resident by herself and the resident fell out of the bed. CNA P stated, I feel terrible about it. A facility policy/procedure related to Activities of Daily Living (ADL) Care was requested. The DON indicated that the facility did not have an ADL Care policy/procedure.

Based on observation, interview, and record review, the facility failed to prevent, and to implement timely interventions, to promote healing of pressure sores for one (#805) of eight sampled residents reviewed for pressure sores from a total sample of 26, resulting in development of pressure sores, delayed healing, infection, and bone exposure. Findings include: On 3/18/15 at 10:15 AM, wound treatment records for resident #805 were reviewed with the facility wound care nurse (nurse 'E'). Nurse 'E' said that a left leg wound "was worsening and was discussed with the (resident's) Hospice (services) nurse and crushed ([MEDICATION NAME]-antibiotic tablet) is being placed on the wound for the odor." When asked, nurse 'E' stated that, because resident #805 was under the care of Hospice services, the wounds had not been seen by a wound specialist and that a specialist had not been consulted. Nurse 'E' then excused herself to conduct rounds with the facility's wound specialist, who was observed going into another resident's room at that time. On 3/18/15 at 10:50 AM, the clinical record for resident #805 was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was enrolled under Hospice services on 6/12/14 with terminal [DIAGNOSES REDACTED]. Minimum data sets dated 4/3/14 and 1/1/15 noted that the resident had moderate cognitive impairment, was non-ambulatory, had no pressure sores, and required extensive assistance for all activities of daily living (ADLs), including bed mobility. Resident #805 was prescribed a diuretic (water pill) upon admission and throughout the survey due to bilateral lower extremity [MEDICAL CONDITION] noted upon admission and throughout the survey. A review of a "Potential for Impaired Skin Integrity" care plan dated 3/21/14 for resident #805 noted a goal: "Resident's skin will remain free from breakdown." The following history of a healed pressure sore was documented for resident #805: Treatment (wound) records and a physician progress notes [REDACTED]. The pressure sore was identified as a "ruptured blister" and a "3 x (by) 3 cm (centimeter) decubitus ulcer with eschar (dead, leathery tissue)-stage 3 (skin loss through all skin layers)." The wound record noted on 10/16/14 that the wound was "resolved (healed)." A Braden (pressure ulcer risk) assessment dated [DATE] for resident #805 noted that she was at "mild risk" for development of pressure sores. Per a Hospice nurse progress note dated 1/8/15: Resident #805 "has skin breakdown on right calf, appears to be caused by the foam heel (pressure relief) boots....measuring 2 x 1.8 cm and 1 x 1.5 cm, beefy red in color....(discontinue) use of heel boots and begin floating heels while in bed." On 1/8/15, a protective dressing and gauze wrap daily, were prescribed. The wound record for resident #805 noted on 1/12/15 by nurse unit manager 'D', who was the resident's wound care nurse at the time, that the wounds appeared as one wound measuring 5.5 cm by 1.5 cm. There was no documented stage (depth) of the wound. Nurse 'D' noted that this wound was "unavoidable due to loose skin causing pinching in ill fitting foam boots." (The wound records noted that by 3/11/15, the pressure sore had increased in size to 17.5 cm by 3 cm.) On 1/20/15, the physician noted that the right leg wound appeared more red and inflamed "likely mild [MEDICAL CONDITION] (bacterial infection beneath the skin)-will order Keflex (antibiotic)....signs of necrotic (black, dead) tissue-recommend (a wound [MEDICATION NAME] ointment)." On 1/22/15, the wound measured 5 cm by 3 cm per the wound record. Physician notes dated 2/4/15, 2/11/15, and 2/16/15 noted regarding the right leg wound: "....with necrotic tissue-worsening" despite treatment with [MEDICATION NAME] gels and enzymes. On 2/19/15, the wound measured 11 cm by 3.5 cm, per wound records. A progress note by Hospice nurse 'G' dated 2/10/15 for resident #805 noted the following: "....new wound noted on left lower leg approximately 2 x 2 cm. This wound was not noted until 2/19/15 on the wound record. A "Skin-Pressure Ulcers" care plan dated 2/10/15 noted pressure sores to the "right" posterior lower leg. The left leg wound was not mentioned. The goal: "Resident will receive stage appropriate wound care while here at facility." Interventions included: Monitor for possible need of a nutritional supplement. Notify dietary department to evaluate; Notify doctor if treatment is ineffective; Monitor pressure sores for signs/symptoms of infection. On 2/19/15, nurse 'D' noted on the wound record regarding the left leg: The wound measured 6 cm by 2.5 cm....unavoidable....Appears that loose skin of calf was folded and pinched due to use of pillows to elevate legs and float heels...." The wound stage was not documented. The left leg was treated with a wound gel, dressing, and a gauze wrap. On 3/11/15, each pressure sore was treated with a crushed [MEDICATION NAME] tablet. Per wound records, the right leg wound then measured 17.5 cm by 3 cm and the left leg wound measured 13.5 cm by 2.6 cm. The record noted that on 3/3/15 and 3/11/15, the left calf wound had a "foul odor," and that both wounds had "slough" (liquid-like, dead tissue separating from living tissue). Per progress notes by hospice nurse 'F' dated 3/16/15, "....writer discussed with (nurse 'E') to discontinue (the wound debridement enzyme) and changed [MEDICATION NAME] order to 2 tablets per (each) wound for odor...." On 3/18/15 at 11:50 AM, resident #805's wound care by nurse 'L', was observed. When called by name, the resident said, "What!" When told by nurse 'L' that wound care was going to be done, the resident responded, "Okay" while keeping her eyes closed the entire time. The resident was totally immobile. Resident #805 was positioned on her back. A nurse aide alternated holding the resident's right leg and then the left leg up about 18 inches off of the mattress during wound care. Dressings on the back of both calves, had adhered to the wounds and had to be pried away by constantly saturating the dressings with wound cleanser spray. The resident winced in pain. There were large amounts of yellow slough and serous (bloody) drainage on the dressings from very large, open pressure sores running the length of both calves. When nurse 'L' prepared a paste made with wound gel and crushed [MEDICATION NAME]. When the nurse attempted to place the mixture inside of the wounds, from underneath the suspended legs, gravity and the thickness of the mixture, caused much of it to fall down in chunks and not adhere. The nurse proceeded to place dressings and wraps over the wounds. On 3/19/15 at 9:15 AM, resident #805 was observed lying in bed with the breakfast tray at the bedside. The tray card noted that the resident was prescribed a regular diet. There were no dietary supplements observed on the tray or in the room. Bites of food had been fed to the resident and cups of orange juice and coffee were consumed. There was no staff present. On 3/19/15 at 9:24 AM, nurse 'E' and Hospice nurse 'G' were observed talking in the hallway. Nurse 'E' said, "We were discussing if a wound consult (with the specialist) should be done (for resident #805). The left calf is now worse. I saw them yesterday and took some measurements. The right leg is doing better with the interventions we put in place." Hospice nurse 'G' did not offer a response. Nurse 'E' then presented an updated treatment record dated 3/19/15 that noted: Right calf-16.8 cm by 2.5 cm with minimal drainage; Left calf-16 cm by 3.5 cm with "large amount of green slough. Necrotic (black, dead skin) areas." On 3/19/15 at 2 PM, resident #805's family member was at the bedside and the resident's lunch tray. All of the entree and most of the fluids were gone. The family member stated that they had fed the resident and said, "She (resident) eats pretty good when you feed her. It just takes time. She hasn't been able to feed herself since last November. We know they (staff) don't have that kind of time to feed her, so we told them that she really likes (a nutritional drink with additional protein), but she doesn't get it." When asked how the resident's care was at the facility, the family member said, "I'm not happy with the pressure sores on the legs. She had one on her backside too, but that healed up. We were told that they were starting to smell and we could smell it too." When asked if a wound consult was discussed, the family member said, "They started calling us today about it. They never mentioned one before. Why didn't they do that a long time ago?" On 3/19/15 at 3:20 PM, nurse 'E' stated that a new treatment had been ordered for resident #805 after consulting with the facility's wound specialist. When asked if the specialist had seen the resident, nurse 'E' stated that he planned to see her during his next scheduled visit (3/25/15) and that the specialist came to the facility every Wednesday, so he wanted the new treatment started in the interim. When asked why a wound consult was just obtained, but not obtained prior, nurse 'E' said, "Because the left leg was starting to get worse, but the right leg was starting to look better and was getting smaller. I had to familiarize myself with her. I just became the wound nurse last week. (Nurse 'D') was the wound nurse prior to that." On 3/20/15 at 10:10 AM, hospice nurse 'F' was observed preparing the new wound care to resident #805. The previous dressing had adhered to the left calf and had to be pried off by saturating it with normal saline. There was a large amount of yellow/red drainage. Nurse 'F' measured the left calf pressure sore as 13.5 cm by 3 cm with tunneling (an open tract of damaged tissue underneath the skin surface) of 4.5 cm. When asked to describe the wound, nurse 'F' said, "It looks like a stage IV (full thickness skin loss down to underlying structures). Looks like some bone there." The nurse cleaned the wound with normal saline and performed the new treatment. She saturated 4 x 4 dressings with normal saline, sprinkled crushed [MEDICATION NAME] on the dressings and packed them into the wound then placed a padded dressing coated with wound gel on top and wrapped the leg with gauze. When the dressing on the right calf was removed, it contained a large amount of yellow slough. The right calf pressure sore measured 15 cm by 2.5 cm with tunneling of 5.4 cm. Nurse 'F' said, "It has some slough, some granulation (tissue that is healing), and some necrosis at the tip. It is getting smaller and showing some improvement. At one point, it was 17 centimeters." When asked if additional nutritional interventions were discussed to promote healing, nurse 'F' indicated no and did not respond. On 3/20/15 at 11 AM, resident #805's interim physician was asked by phone why a wound consult was ordered. He said, "Because the wound was getting worse. It was not healing." When asked why the consult was not ordered prior due to the extent of the wounds, the physician said, "I don't know. I just started covering for (the primary care physician, who was not a wound specialist) since 3/7 (2015) who is in (another country)." On 3/20/15 at 11:15 AM, nurse 'D' was queried about the development of the pressure sores. She said regarding the right leg wound, "The skin was loose and hanging. The skin was folded and held there causing pressure." She said that the foam boots were "one size fit all." She said the boots "may have shifted with movement," but this was not documented as a contributing factor for development of the wound. When queried, nurse 'D' indicated that, other than removal of the boots, there were no interventions implemented for the loose skin to prevent shearing (layers of skin rubbing against each other when skin is stationary, but underlying tissue moves or tears). When asked why a wound specialist was not previously consulted for resident #805 due to the extent of the wounds, nurse 'D' said, "She is Hospice. I'm not a physician. I can't write the orders. That was hospice' decision. I don't know what they (hospice/physician) discussed. I wasn't there." Nurse 'D' was asked whether she, as the resident's wound care nurse until one week ago, had suggested or discussed a wound consult with Hospice staff or with the physician to help prevent worsening of the wounds. Nurse 'D' said, "I didn't because I didn't expect it them to heal." When asked why, in lieu of the resident's history of a healed pressure sore, nurse 'D' shrugged her shoulders and said, "Well wounds respond differently" and did not elaborate on this comment when asked. When asked whether a physician had told her that the wounds would not heal, nurse 'D' indicated that it was her conclusion. When asked why she did not document the stage of the wounds in her notes when they were initially discovered, nurse 'D' said, "They should have been staged." When asked about nutritional interventions to promote wound healing, nurse 'D' pointed out that the resident was receiving a med pass supplement (MPS) from nursing staff during medication administration three times a day. However, a review of the order revealed that MPS was not ordered until 3/12/15. When asked why, and if additional nutritional interventions, such as vitamins/minerals and foods/drinks fortified with protein were discussed, nurse 'D' said, "I don't know. That would be up to the Dietitian." On 3/20/15 at 12:15 PM, Registered Dietician (RD) 'M' was queried regarding why there were no nutritional interventions to promote wound healing for resident #805 until 3/12/15. The RD said, "She was hospice" and stated that she was not consulted by staff prior to 3/12/15. When asked, the RD stated that she was not told by staff how extensive the wounds were and indicated that this was the reason why MPS was the only supplement/intervention. On 3/20/15 at 2:10 PM and 3:20 PM, the Director of Nursing (DON) and nurse manager 'J' were interviewed regarding the development and interventions for resident #805's pressure sores. When asked why the wounds were determined to be unavoidable and non-healing, the DON said, "Whatever the doctor wrote. Weren't they following her?" When asked if the resident's wounds were discussed by the interdisciplinary team, the DON said, "We discuss wounds every week. We discussed her last week. There's nothing documented about what was discussed. I can't tell you what was discussed. We talked about several residents." The DON did not respond to inquiries regarding other nutritional interventions, besides MPS. Nurse 'J' said that the resident's care was provided and geared "for comfort, not to cure wounds." On 3/23/15 at 8 AM, per review of the facility's "Skin Care guidelines" dated 7/8/14: -For zero to light wound drainage, use wound gel and a dressing; For moderate to heavy drainage, use a calcium alginate dressing. "Evaluate the need for a RD consult to determine the need for wound healing vitamins/minerals and to evaluate the nutritional status and protein level. If no improvement in 2 weeks....Evaluate the need for wound care physician consult." Per review of the facility's "Guidelines for Pressure Ulcers" dated 5/2013: The purpose: "To promote the prevention of pressure ulcer development; promote the healing of pressure ulcers that are present(including prevention of infection to the extent possible) and prevent development of additional pressure ulcers." Definition of skin ulcers: "Pressure ulcer-a localized injury to the skin and/or underlying tissue....as a result of pressure, or pressure in combination with shear and/or friction;" Documentation should include: Stage of the ulcer; "Consult professionals to assist in reducing risk factors and encouraging healing, i.e., RD...."; "In addition, all newly acquired skin impairments and worsening of previous areas must be reported....Documentation of communication will be put in the progress notes by the nurse. Please include the person you spoke with." Per review of the contract/agreement between the Hospice provider and the facility: Hospice services will provide palliative care and management of the resident's terminal illness and "symptom management." Services include: dietary, physician services, medical supplies/drugs related to palliation and management of terminal illness and related conditions; Coordination of care-Resident care management and decisions concerning the plan of care are the responsibility of the Hospice interdisciplinary group; The Hospice and the facility agree to cooperate in reviewing any quality management activities and the appropriateness of care; The facility will provide services to Hospice residents in accordance with "accepted standards of practice" and protect from "injury and infection." ( )

This citation pertains to Intake Number MI 512. Based on interview and record review the facility failed to provide adequate and timely safety interventions in 1 of 4 sampled residents (Resident #101) who had a history of [REDACTED].#101 who a sustained pelvic fracture requiring hospitalization on [DATE]. Findings include: According to the Facility Roster Matrix Resident #101 was not at the facility at the time of the investigation. Review of the Care Area assessment dated [DATE], revealed Resident #101 fell at home and was admitted to the facility on [DATE] for skilled care and rehabilitation to improve her balance and reduce risk of fall. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was an [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] at 5:35 PM. The MDS revealed Resident #101's ability to make daily decision was severely impaired, required the assistance of one staff member for transfers and toilet use, and was able to understand others and express her ideas and wants. The MDS revealed the Resident #101's [DIAGNOSES REDACTED]. Review of the Psychiatric Evaluation dated 2/20/12, revealed Resident #101's insight and judgement were limited. Review of the Falls Care Plan dated 2/14/12 revealed, Resident #101's was at risk for fall/potential for injury related to, decreased mobility, history of fall, metabolic [DIAGNOSES REDACTED], COPD, Myocardia Infarction (heart attack), Cirrhosis (scarring of the liver), high blood pressure, depression, history of alcohol abuse, poor safety awareness, and impulsivity. The Falls Care Plan approaches included - provide assistance as needed for safe performance of activities of daily living, mobility, and transfers, toilet every 2 hours while aware and every 4 hours at night, alarms as ordered, and Star Program. Review of the Star Program (Falls Management) dated 8/11, revealed the purpose of the program was to identify and alert all staff of the residents who are at high risk for falls and initiate individual intervention to potentially reduce the risk of injurious falls. Review of the Resident's Implementation of Care Plan dated 2/12, revealed Resident #101's special care needs included toileting every 2 hours while awake and every 4 hours at night, a sensor pad alarm to her bed and wheelchair, and oxygen via nasal canula. Review of the Physical Therapy assessment dated [DATE] (no time), revealed Resident #101 has increased difficulty with transfer, bed mobility, and difficulty taking steps with rolling walker. The Physical Therapy Assessment revealed Resident #101 was very unsteady, unsafe, confused, and a high risk for falls, very forgetful, and has increased shortness of breath even with mild activity. Review of the Hospital Stay Record "Vascular Interventional - Lab Report" dated 3/6/12 at 6:15 AM, documented Resident #101 "is minimally ambulatory and has severe dementia and has suffered a recent fall". The Hospital Stay Record "Nursing Progress Note" dated 3/6/12 at 5:16 AM, documented Resident #101 was "frustrated she can not remember things, bed alarm on, assessed to turn every two hours, and checked at least every one hour for safety and needs". Hospital Stay Record "Nursing Progress Note" dated 3/6/12 at 11:44 AM documented evidence that Resident #101 had "disorganized thinking,... impaired judgement/lack of safety awareness/impulsive", and "failure to follow instructions". Hospital Stay Record "Nursing Progress Note" dated 3/6/12 2:47 PM documented Resident #101 "is confused, needs assistance with activities of daily living and transfers". Review of the Discharge Instructions and Physician order [REDACTED].#101 for "Repositioning and getting in and out of bed: needs supervision or setup assistance with this task, in and out of chair/bed: needs supervision or setup assistance with this task, walking: needs supervision or setup assistance with this task, mobility: rolling walker, and activity tolerance/distance: 15 feet x 2". Review of the Admission Assessment (nursing) dated 3/6/12 (no time) revealed Resident #101 chief medical complaint on admission was "weakness", uses oxygen at 2 liters per minute", a history of COPD and Asthma, blood oxygen level "88% on room air", "range of motion of lower extremities limited due to bilateral hip arthritis...history of dizziness, no history of fall (inaccurate as had fall at home prior to first admission to the facility on [DATE])", standing balance "unsteady", risk for falls "no", history of pain "no"..."functional activities of daily living: ambulation, (a) unable; to nurses station, unable; toleting, unable;.. and restraint history prior to admission: none". Review of the Alteration in Mobility Care Plan dated 3/6/12 revealed Resident #101 was at risk for decrease mobility due to weakness. Interventions included "instruct resident to use call ight for assistance with transferring and toileting (if resident is cognitively capable of understanding)". In an interview on 5/11/12 at 12:50 PM, Family Member #26 stated when Resident #101 was re-admitted to the facility on [DATE] she requested that sensor alarms be placed on Resident #101 since she had alarms to her bed and wheelchair when she was here previously from 2/10-2/29/12. Family Member #26 stated she informed staff several times that Resident #101 was impulsive, confused, would get out of bed independently, and that the same information was in the paperwork the facility had from the previous admission. Family Member #26 stated the Certified Nursing Assistant (CNA) lowered the bed to the floor stating "that was all she could do". Family Member #26 stated that she requested the nurse call the physician to get an order for [REDACTED]. Family Member #26 stated that the sound of the alarm helped to remind Resident #101 to not get up by herself. Review of the Resident Safety assessment dated [DATE] (no time), revealed Resident #101 was a high risk for fall and Occupational Therapy recommended "bed and chair mobility/tab alarm, due to poor insight into disability, does not always use call light, and demonstrates intermittent confusion". In an interview on 5/8/12 at 9:40 AM, Occupational Therapist (OT) #19 stated she did an evaluation of Resident #101, but did not recall what time the evaluation began. OT #19 stated Resident #101 did not know where she was, had increased anxiety with moving, weight bearing as tolerated, and poor standing posture. OT #19 stated that when Physical Therapy came (to do their assessment) she informed them that Resident #101 was not aware of where she was and would need alarms. Review of the Physical Therapy Daily Communication Worksheet dated 3/7/12 (no time) revealed Resident #101 had a recommendation for wheelchair and bed sensor alarms. In an interview on 5/8/12 at 9:15 AM, Physical Therapist (PT) #17 stated PT and OT gave the completed evaluations to the safety nurse prior to Resident #101 falling. Review of the Resident Accident/incident (A/I) Report dated 3/7/12 (1 day post re-admission) at 4:20 PM, revealed Resident #101 was found in the bathroom lying on her left side on the floor. The A/I Report revealed Resident #101 stated "nobody helped me, I put myself in here, I didn't think I would fall". The A/I Report revealed the initial corrective action to prevent similar occurrence for Resident #101 was to place a sensor pad to the bed and wheelchair, keep her bed in lowest position, and place her on a toileting schedule. The A/I Report revealed Resident #101's injury was a 2 cm skin tear to the left elbow and complaint of left hip pain. Review of the Nursing Progress Notes dated 3/7/12 (no time), revealed the safety nurse was preparing to visit the Resident #101 to complete her safety assessment, when she heard a thud and yells for help. The Nursing Progress Notes indicated Resident #101 "on floor on left side - pants and brief down by knees - no oxygen on - had food in her mouth as she stated she was just finishing a snack". The Nursing Progress Notes revealed Resident #101 stated "she had to go to the bathroom", no one helped her she put herself in the bathroom, and when asked why she did not use the call light to call for help she stated "I don't know". The Nursing Progress Notes revealed an assessment was completed and Resident #101 was assisted back to bed, alarms were paced to bed and chair, oxygen was re-applied, a toileting schedule was ordered and the Star Program implemented due to Resident #101 poor safety awareness/impulsiveness. Review of the Medical Record for Resident #101 revealed there were no care plans in place for safety or fall prevention after her re-admission on 3/6/12 despite a history of falls at home, a history of sensor alarms to her bed and wheelchair on her prior admission to the facility on [DATE], and the need for bed alarms while in the hospital, until 3/7/12 after Resident #101's fall at 4:20 PM. Review of the Nursing Progress Notes dated 3/12/12 (no time) revealed Resident #101 was alert and confused, complaining of 8/10 pain after being medicated, was unable to perform tasks with Physical Therapy, and that a new order to transfer Resident #101 to the hospital for a Computerized Tomography (CT) Scan due to uncontrolled pain was obtained. The Nursing Progress Notes dated 3/13/12 revealed Resident #101 was admitted to the hospital with [REDACTED]. In interviews on 5/4/12 at 10:00 AM and 5/8/12 at 9:20 AM, Director of Nursing (DON) #2 and Physical Therapist (PT) #18 stated all residents on admission and re-admission are assessed by Physical and Occupational Therapy within 24 hours of admission or re-admission, who then make recommendations for the residents safety. A safety nurse then assesses the new or readmitted resident and implements a safety plan. DON #2 and PT #18 stated family concerns about safety interventions, as well as previous admission are taken into consideration, but the re-admission is based on the residents current status. (# )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 682. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT FALLS IN 1 OF 5 SAMPLED RESIDENTS (#101), IN A TOTAL SAMPLE OF 52 RESIDENTS AT RISK FOR FALLS, RESULTING IN THE RESIDENT EXPERIENCING A FALL WITH A RIGHT HIP FRACTURE, hospitalization , AND SUBSEQUENT SURGICAL PLACEMENT OF A SCREW TO THE RIGHT HIP. FINDINGS INCLUDE: THE FACESHEET REVEALED RESIDENT #101 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT ACCIDENT/INCIDENT REPORT DATED 10/25/2011, AND THE FACILITY INVESTIGATION REPORT DATED 11/3/2011, REVEALED RESIDENT #101 WAS OBSERVED STANDING IN THE DOORWAY OF HER ROOM (IDENTIFIED AS ROOM 700) AT 5:20 A.M. ON 10/25/2011 BY A REGISTERED NURSE (RN #3). RESIDENT #101 WAS REPORTED TO HAVE TOLD THE NURSE SHE WAS LOOKING FOR THE BATHROOM. RN #3 RESPONDED TO RESIDENT #101 THAT THE BATHROOM WAS DIRECTLY BEHIND THE RESIDENT. RN #3 WAS REPORTED TO OBSERVE RESIDENT #101 ENTER THE BATHROOM, THEN CLOSE THE DOOR BEHIND HER; NO ASSIST WITH AMBULATION/TRANSFER WAS PROVIDED TO RESIDENT #101 BY RN #3. AT 5:20 A.M., RN #3 WAS REPORTED TO HAVE ENTERED ROOM 707, AND FOUND RESIDENT #101 ON THE FLOOR WITH HER LEGS OUTSTRETCHED AT THE FOOT OF ANOTHER RESIDENT'S BED. RESIDENT #101 WAS DOCUMENTED TO HAVE COMPLAINED OF FACIAL AND RIGHT HIP PAIN. ON 10/26/2011, RESIDENT #101 WAS REPORTED AS SENT TO A LOCAL HOSPITAL FOR EVALUATION, WHERE SHE WAS diagnosed with [REDACTED]. THE RESIDENT TRANSFER FORM DATED 10/12/2011 (UNTIMED) REVEALED RESIDENT #101 REQUIRED ASSISTANCE WITH TRANSFERS (MOVEMENTS FROM SURFACE TO SURFACE), AND UTILIZED A WHEELCHAIR. THE MINIMUM DATA SETS (MDA) DATED 10/21/2011 REVEALED RESIDENT #101 WAS MODERATELY COGNITIVELY IMPAIRED, REQUIRED EXTENSIVE TO LIMITED ASSISTANCE OF ONE PERSON WITH AMBULATION AND TRANSFERS, WAS ASSESSED WITH BALANCE DURING TRANSITIONS AND WALKING AS "NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE," REQUIRED USE OF MOBILITY DEVICES IDENTIFIED AS A WALKER AND WHEELCHAIR, AND HAD EXPERIENCED A FALL WITHIN THE MONTH PRIOR TO ADMISSION. THE RESIDENT SAFETY assessment dated [DATE] (UNTIMED) REVEALED RESIDENT #101 WAS HIGH RISK FOR FALLS. THE PHYSICIAN HISTORY AND PHYSICAL DATED 10/14/2011 (UNTIMED) INCLUDED RESIDENT #101 WAS assessed with [REDACTED]. THE ANCILLARY SERVICES ORDER SHEET DATED 10/14/2011 (UNTIMED), SPECIFIED RESIDENT #101 WAS RECOMMENDED BY THERAPY STAFF TO RECEIVE ASSIST OF ONE PERSON WITH TRANSFERS; THE ORDER WAS SIGNED ON 10/14/2011 BY THE RESIDENT'S PRIMARY CARE PROVIDER (PCP). DURING AN INTERVIEW ON 11/14/2011 AT 2:20 P.M., A PHYSICAL THERAPIST (WITNESS #7) SAID, "IT WOULD HAVE BEEN UNSAFE FOR THIS RESIDENT (#101) TO AMBULATE WITHOUT HER RECEIVING CONTACT GUARD ASSIST; SOMEONE HOLDING ONTO HER. SHE HAD DECREASED BALANCE AND SAFETY AWARENESS THAT WOULD HAVE CONTRIBUTED TO A FALL FOR HER. AS OF 10/24/2011, THIS RESIDENT WAS NOT OK' D FOR USE OF A WALKER IN HER ROOM DUE TO DECREASED SAFETY AWARENESS." DURING AN INTERVIEW ON 11/14/2011 AT 3:05 P.M., RN #3 SAID, "I SAW THE RESIDENT (#101) AT 5:10 A.M. SHE WAS UP WALKING IN HER ROOM. I DIDN'T KNOW HER AMBULATORY STATUS AT THAT TIME. I LEARNED THE RESIDENT'S AMBULATORY STATUS LATER THAT MORNING, AFTER THE RESIDENT'S FALL. THE DIRECTOR OF NURSING POINTED OUT TO ME THE RESIDENT WAS AN ASSIST OF ONE WITH AMBULATION." DURING AN INTERVIEW ON 11/15/2011 AT 9:50 A.M., A CERTIFIED NURSE AIDE (CNA #4) SAID, "I KNOW THE RESIDENT (RESIDENT #101), AND I WAS ASSIGNED TO HER ON 10/25/2011. SHE DIDN'T WALK. WE TRANSFERRED (MOVEMENT FROM SURFACE TO SURFACE) HER FROM HER BED TO A WHEELCHAIR, THEN TO THE TOILET. SHE DIDN'T HAVE A WALKER IN HER ROOM. THERAPY GIVES RESIDENTS A WALKER TO USE IN THEIR ROOM ONLY WHEN THEY'RE SAFE ENOUGH AND STEADY ENOUGH TO USE ONE. SHE (RESIDENT #101) WASN'T SAFE TO WALK FROM HER BED TO HER BATHROOM ON 10/25/2011. THIS RESIDENT WAS A CONTACT GUARD ASSIST WITH AMBULATION/TRANSFERS. THAT MEANT THE RESIDENT NEEDED HANDS ON ASSISTANCE. IF ANYONE WASN'T SURE WHAT THE RESIDENT'S ASSISTANCE LEVEL WAS, THEY JUST NEEDED TO STEP 5 FEET INTO THE RESIDENT'S ROOM AND LOOK ON THE BULLETIN BOARD ON THE WALL. WE KEEP A SHEET THERE ON THE BULLETIN BOARD THAT TELLS THEIR TRANSFER STATUS. THAT RESIDENT (RESIDENT #101) WASN'T SAFE TO WALK FROM HER BED TO THE BATHROOM; SHE'D FALL." DURING AN INTERVIEW ON 11/15/2011 AT 11:00 A.M., THE UNIT MANAGER (WITNESS #8) SAID, "I KNEW THIS RESIDENT (#101). SHE WAS A RESIDENT ON MY HALL. SHE WAS ORDERED TO BE AN ASSIST OF ONE PERSON. ASSIST OF ONE PERSON IS HANDS ON CARE. I REVIEWED THIS RESIDENT'S CHART. I DON'T SEE ANY ORDERS AFTER THE ORDER OF 10/14/2011 TO CHANGE THE RESIDENT'S TRANSFER STATUS FROM THE ORIGINAL ORDER OF ASSIST OF ONE PERSON." DURING AN INTERVIEW ON 11/15/2011 AT 1:10 P.M., A LICENSED PRACTICAL NURSE (LPN #9) SAID, "THE RESIDENT (#101) WAS RECOMMENDED BY THERAPY STAFF, AND SUBSEQUENTLY ORDERED BY HER DOCTOR TO HAVE ASSISTANCE OF ONE PERSON WITH TRANSFERS OF ONE PERSON. THAT MEANS THE RESIDENT SHOULD HAVE RECEIVED HANDS ON ASSISTANCE." THE OPERATIVE/PROCEDURE REPORT DATED 11/1/2011 AT 8:41 A.M., DOCUMENTED RESIDENT #101 WAS hospitalized [DATE], diagnosed with [REDACTED]. DURING A PHONE INTERVIEW ON 11/16/2011 AT 10:15 A.M., THE NURSING HOME ADMINISTRATOR #1 SAID PCP ORDERS WERE TO BE FOLLOWED, AND A RESIDENT ORDERED AN ASSIST OF ONE PERSON REQUIRED FACILITY STAFF TO PROVIDE THAT CARE, HANDS ON, NOT THROUGH OBSERVATION.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 682. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO FOLLOW THE PRIMARY CARE PROVIDER'S (PCP) ORDERS TO PROVIDE ASSISTANCE, BY ONE PERSON, WITH TRANSFERS (MOVEMENTS FROM SURFACE TO SURFACE) FOR 1 OF 5 SAMPLED RESIDENTS (#101), IN A TOTAL SAMPLE OF 52 RESIDENTS, RESULTING IN THE RESIDENT EXPERIENCING A FALL WITH RIGHT [MEDICAL CONDITION], AND SUBSEQUENT SURGICAL PLACEMENT OF A SCREW TO THE RIGHT HIP. FINDINGS INCLUDE: THE PROFESSIONAL STANDARD OF QUALITY FOR DOCTORS' ORDERS STATES, "NURSES MUST OBEY THE ORDERS OF THE PHYSICIAN IN CHARGE OF A PATIENT, UNLESS AN ORDER WOULD LEAD A REASONABLE PERSON TO ANTICIPATE INJURY IF IT WERE CARRIED OUT" (LAW EVERY NURSE SHOULD KNOW, 5TH EDITION, HELEN CREIGHTON). THE FACESHEET REVEALED RESIDENT #101 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT ACCIDENT/INCIDENT REPORT DATED 10/25/2011, AND THE FACILITY INVESTIGATION REPORT DATED 11/3/2011, REVEALED RESIDENT #101 WAS OBSERVED STANDING IN THE DOORWAY OF HER ROOM (IDENTIFIED AS room [ROOM NUMBER]) AT 5:20 A.M. ON 10/25/2011 BY A REGISTERED NURSE (RN #3). THE RESIDENT WAS REPORTED TO HAVE TOLD THE NURSE SHE WAS LOOKING FOR THE BATHROOM. RN #3 RESPONDED TO THE RESIDENT THAT THE BATHROOM WAS DIRECTLY BEHIND THE RESIDENT. RN #3 WAS REPORTED TO OBSERVE THE RESIDENT ENTER THE BATHROOM, THEN CLOSE THE DOOR BEHIND HER; NO ASSIST WITH AMBULATION/TRANSFER WAS PROVIDED TO THE RESIDENT BY RN #3. AT 5:20 A.M., RN #3 WAS REPORTED TO HAVE ENTERED room [ROOM NUMBER], AND FOUND RESIDENT #101 ON THE FLOOR WITH HER LEGS OUTSTRETCHED AT THE FOOT OF ANOTHER RESIDENT'S BED. RESIDENT #101 WAS DOCUMENTED TO HAVE COMPLAINED OF FACIAL AND RIGHT HIP PAIN. ON 10/26/2011, RESIDENT #101 WAS REPORTED AS SENT TO A LOCAL HOSPITAL FOR EVALUATION, WHERE SHE WAS diagnosed with [REDACTED]. THE RESIDENT TRANSFER FORM DATED 10/12/2011 (UNTIMED) REVEALED RESIDENT #101 REQUIRED ASSISTANCE WITH TRANSFERS (MOVEMENTS FROM SURFACE TO SURFACE), AND UTILIZED A WHEELCHAIR. THE MINIMUM DATA SETS (MDA) DATED 10/21/2011 REVEALED RESIDENT #101 WAS MODERATELY COGNITIVELY IMPAIRED, REQUIRED EXTENSIVE TO LIMITED ASSISTANCE OF ONE PERSON WITH AMBULATION AND TRANSFERS, WAS ASSESSED WITH BALANCE DURING TRANSITIONS AND WALKING AS "NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE," REQUIRED USE OF MOBILITY DEVICES IDENTIFIED AS A WALKER AND WHEELCHAIR, AND HAD EXPERIENCED A FALL WITHIN THE MONTH PRIOR TO ADMISSION. THE RESIDENT SAFETY assessment dated [DATE] (UNTIMED) REVEALED RESIDENT #101 WAS HIGH RISK FOR FALLS. THE PHYSICIAN HISTORY AND PHYSICAL DATED 10/14/2011 (UNTIMED) INCLUDED RESIDENT #101 WAS assessed with [REDACTED]. THE ANCILLARY SERVICES ORDER SHEET DATED 10/14/2011 (UNTIMED), SPECIFIED RESIDENT #101 WAS RECOMMENDED BY THERAPY STAFF TO RECEIVE ASSIST OF ONE PERSON WITH TRANSFERS; THE ORDER WAS SIGNED ON 10/14/2011 BY THE RESIDENT'S PRIMARY CARE PROVIDER (PCP). DURING AN INTERVIEW ON 11/14/2011 AT 2:20 P.M., A PHYSICAL THERAPIST (WITNESS #7) SAID, "IT WOULD HAVE BEEN UNSAFE FOR THIS RESIDENT (#101) TO AMBULATE WITHOUT HER RECEIVING CONTACT GUARD ASSIST; SOMEONE HOLDING ONTO HER. SHE HAD DECREASED BALANCE AND SAFETY AWARENESS THAT WOULD HAVE CONTRIBUTED TO A FALL FOR HER. AS OF 10/24/2011, THIS RESIDENT WAS NOT OK' D FOR USE OF A WALKER IN HER ROOM DUE TO DECREASED SAFETY AWARENESS." DURING AN INTERVIEW ON 11/14/2011 AT 3:05 P.M., RN #3 SAID, "I SAW THE RESIDENT (#101) AT 5:10 A.M. SHE WAS UP WALKING IN HER ROOM. I DIDN'T KNOW HER AMBULATORY STATUS AT THAT TIME. WE CAN DIG THROUGH THE RESIDENT'S CHART FOR THE DOCTOR'S ORDERS. I LEARNED THE RESIDENT'S AMBULATORY STATUS LATER THAT MORNING, AFTER THE RESIDENT'S FALL. THE DIRECTOR OF NURSING POINTED OUT TO ME THE RESIDENT WAS AN ASSIST OF ONE WITH AMBULATION." DURING A PHONE INTERVIEW ON 11/16/2011 AT 10:15 A.M., THE NURSING HOME ADMINISTRATOR SAID FACILITY STAFF WERE EXPECTED TO FOLLOW PCP ORDERS."

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 840 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROPERLY IDENTIFY 1 OF 5 SAMPLED RESIDENTS (#501), FROM A TOTAL SAMPLE OF 5, ALL REVIEWED FOR MEDICATION ADMINISTRATION ACCURACY, PRIOR TO MEDICATION ADMINISTRATION, RESULTING IN A SIGNIFICANT MEDICATION ERROR, REQUIRING hospitalization . FINDINGS INCLUDE: RESIDENT # 501, A [AGE] year OLD MALE, WAS admitted to the facility on [DATE] AND discharged on [DATE]. PER THE PHYSICIAN ADMISSION ORDER SHEET, RESIDENT [DIAGNOSES REDACTED]. PER THE FACILITY "MEDICATION AND TREATMENT INCIDENT REPORT" DATED 9/26/11, AT 10:00 A.M., RESIDENT #501 WAS ADMINISTERED MEDICATIONS INTENDED FOR ANOTHER RESIDENT (#505). RESIDENT #505 HAD THE SAME FIRST NAME AS RESIDENT #501. WRONG MEDICATION ADMINISTERED INCLUDED [MEDICATION NAME] 5 MG (MUSCLE RELAXANT), [MEDICATION NAME] 150 MG, (NEUROPATHIC PAIN RELIEVER) [MEDICATION NAME] 160 MG, (NARCOTIC PAIN RELIEVER) [MEDICATION NAME] 50 MG, [MEDICATION NAME] 5 MG, (BLOOD PRESSURE MEDICATIONS) [MEDICATION NAME] 25 MG, (ANTIDEPRESSANT) IRON 324 MG, MULTI VITAMIN WITH MINERALS. ON 9/30/11 AT 11:10 A.M., LPN (LICENSED PRACTICAL NURSE) MANAGER #1 STATED THAT ON 9/26/11, SHE WAS SITTING AT THE NURSE'S STATION WHEN LPN #3 CAME TO HER AND SAID, "I GAVE SOMEONE THE WRONG MEDICATIONS. I LOOKED AT THE NAME BAND, READ THE FIRST NAME AND DIDN'T LOOK AT THE LAST NAME." LPN NURSE MANAGER #1 STATED SHE TOLD HER (#3) TO GET A LIST OF ALL THE MEDICATIONS SHE HAD GIVEN RESIDENT #501. LPN NURSE MANAGER THEN #1 MADE A LIST OF ALL RESIDENT #501'S PRESCRIBED MEDICATIONS AND WHEN HE HAD LAST RECEIVED THEM. LPN NURSE MANAGER #1 THEN INFORMED RESIDENT #501'S PHYSICIAN, WHO WAS ALSO AT THE NURSE'S STATION. ON 9/30/11 AT 11:25 A.M., RESIDENT #501'S PHYSICIAN STATED THAT ON 9/26/11, HE WAS AT THE NURSE'S STATION WHEN HE WAS INFORMED RESIDENT #501 HAD BEEN GIVEN THE "WRONG MEDICATIONS." THE PHYSICIAN SAID HE WAS GIVEN A LIST OF THE RESIDENT'S CURRENT MEDICATIONS AND THE MEDICATIONS HE HAD RECEIVED IN ERROR. HE STATED HE QUICKLY REVIEWED RESIDENT #501'S CLINICAL RECORD AND THEN WENT TO THE ROOM TO ASSESS THE RESIDENT. THE PHYSICIAN SAID, "I SAW IMMEDIATELY HE WAS HYPOXIC (INSUFFICIENT OXYGEN). HIS SKIN WAS CLAMMY... HE DIDN'T LOOK GOOD AND I COULDN'T AROUSE HIM.. I APPLIED PRESSURE TO HIS NAILBED, AND HE HAD NO RESPONSE... HIS VITAL SIGNS AND HEART RATE WERE NORMAL...BUT HE WAS VERY UNRESPONSIVE... I FELT AS SOON AS I SAW HIM HE NEEDED TO BE SENT OUT." THE PHYSICIAN STATED RESIDENT #501 WAS ADMINISTERED OXYGEN AND THAT 911 WAS CALLED. THE PARAMEDICS "ARRIVED QUICKLY." THE PHYSICIAN STATED THE MEDICATIONS ADMINISTERED IN ERROR WOULD CAUSE A DECREASE IN HEART RATE, BLOOD PRESSURE AND RESPIRATIONS, "AND YOU DON'T KNOW WHEN THAT WILL HAPPEN." HE SAID, "UNFORTUNATELY AN ERROR HAD OCCURRED, BUT THE NURSE TOLD IMMEDIATELY." ON 9/30/11 AT 11:45 A.M., LPN #3 WAS INTERVIEWED PER PHONE. WHEN QUERIED BY THE SURVEYOR ABOUT THE INCIDENT, SHE STATED THAT "IT WAS ON MONDAY 9/26 ABOUT 9:30-10:00 A.M., I WAS PASSING MEDS AND WAS ON MY LAST ROOM, AND WAS PULLING (NAME OF RESIDENT)'S MEDICATION." SHE SAID SOMEONE DROPPED OFF A RESIDENT (#501) AND STATED HIS FIRST NAME, WHICH WAS THE SAME FIRST NAME AS THE RESIDENT WHOSE MEDICATIONS SHE WAS PREPARING. LPN #3 STATED THAT "I WALKED OVER LOOKED AT THE WRIST BAND SAW (THE FIRST NAME), ASKED, ARE YOU (FIRST NAME)? HE SAID YES, I AM (FIRST NAME). I FAILED TO LOOK AT THE LAST NAME ON THE WRIST BAND, TO IDENTIFY HIM...I GAVE THE MEDICATIONS." WHEN QUERIED AS TO MEDICATIONS SHE HAD GIVEN, SHE STATED SHE COULD NOT RECALL ALL OF THEM, BUT NAMED SUSTAINED RELEASE [MEDICATION NAME] AND [MEDICATION NAME]. LPN # 3 STATED SHE WENT DOWN THE HALL AND BEGAN ASSESSING RESIDENTS. SHE SAID ABOUT 20 TO 30 MINUTES LATER, SHE WAS APPROACHED BY A CNA (CERTIFIED NURSING ASSISTANT) WHO INFORMED HER THAT A RESIDENT (#505) NEEDED A DRESSING CHANGE. LPN #3 STATED THAT "I TURNED AND LOOKED AT (RESIDENT NAME) IN HIS ROOM AND REALIZED IT WAS A DIFFERENT GUY THAN I HAD GIVEN THE MEDS TO." SHE STATED SHE THEN WENT BACK TO RESIDENT #501, TO WHOM SHE HAD GIVEN THE MEDICATIONS TO AND "LOOKED AT HIS WRIST BAND, AND KNEW I HAD GIVEN HIM THE WRONG MEDS." LPN #3 STATED SHE IMMEDIATELY NOTIFIED HER NURSE MANAGER, AND COMPILED A LIST OF THE MEDICATIONS SHE HAD GIVEN. LPN # 3 STATED, "IT'S ONE OF THE FIRST THINGS YOU LEARN IN NURSING SCHOOL, TO IDENTIFY THE PATIENT. I FAILED TO DO IT AND IT IS MY FAULT. I HAVE NO EXCUSE FOR IT. I AM SICK ABOUT IT." ON 10/3/11 AT 11:20 A.M., THE DON (DIRECTOR OF NURSING) STATED THAT SHE WAS INFORMED ON 9/26/11, BY LPN (LICENSED PRACTICAL NURSE) NURSE MANAGER #1 "THAT THERE HAD BEEN A SIGNIFICANT MEDICATION ERROR." THE DON SAID LPN NURSE MANAGER #1 TOLD HER THAT LPN #3 HAD THAT FAILED TO READ HIS (RESIDENT #501) COMPLETE NAME BAND AND HAD GIVEN HIM (RESIDENT #501) MEDICATIONS PRESCRIBED FOR ANOTHER RESIDENT WITH THE SAME FIRST NAME. PER THE FIRE DEPARTMENT TRANSPORT FORM DATED 9/26/11 AT 11:21 A.M., NARRATIVE NOTES, UPON ARRIVAL AT FACILITY RESIDENT #501 WAS "COOL AND CLAMMY, UNCONSCIOUS WITH SNORING RESPIRATIONS...OD (OVERDOSE) MEDS INCLUDED: [MEDICATION NAME], A BETA BLOCKER AND A CALCIUM CHANNEL BLOCKER...PATIENT WAS GIVEN 2 MG [MEDICATION NAME] (OPIOID ANTAGONIST, USED TO CONTRACT OPIOID OVERDOSE) AND BECAME ALERT TO VERBAL STIMULUS, THEN ALERT TIMES 3 (PERSON, PLACE AND TIME) IN ROUTE TO ACUTE CARE HOSPITAL." PER HOSPITAL emergency room PHYSICIAN NOTES, DATED 9/26/11 AT 12:01 P.M., (RESIDENT #501) PRESENTED "UNRESPONSIVE...DEGREE AT ONSET SEVERE...(RESIDENT #501 )WAS GIVEN [MEDICATION NAME] 2 MG BY EMS (EMERGENCY RESPONSE SYSTEM) AND RESPONDED. OXYGEN SATURATION, HEART RATE AND RHYTHM, RESPIRATIONS WITHIN NORMAL LIMITS." RESIDENT #501'S CONDITION WAS LISTED AS "IMPROVED" AND HE WAS MOVED TO THE OBSERVATION UNIT. PROGRESS NOTES DATED 9/28/11 AT 7:55 A.M. DOCUMENTED (RESIDENT #501) "IS MEDICALLY STABLE. HE CAN BE TRANSFERRED BACK TO THE FACILITY." ( )