Every finding on record at ShorePointe Nursing Center

Based observation, interview, and record review the facility failed secure medications at beside for one (R152) sampled resident. Findings include: On 6/17/26 at 11:34 AM, R152 was observed lying in bed with their overbed table across them and on the table was a medication cup with seven pills in the cup without staff presence. R152 was asked about the medication in the cup and explained they were waiting for applesauce, R152 was observed with a spoon in their hand. Registered Nurse (RN)A was observed enter the room with a straw and was then observed to walk back out the room. On 6/17/26 at 11:37 AM, RN A was asked what time they delivered the medication in the cup to R152 and explained they gave the medications at 10:28 AM. RN A continued and explained, that is the preferred way for R152 to take their medication and was not sure if R152's had a self-administration of medication assessment. A review of R152 medical record revealed, R152 was admitted to the facility on [DATE] with diagnosis of Urinary tract infection. A review of R152's Minimum Data Set (MDS) assessment noted R152 with an intact cognition and required assistance by staff with activities daily living. Further review of R152's medical record did not reveal a self-administration assessment for medication. On 6/18/2026 at 12:29 PM, the Director of Nursing (DON) was asked the facility's procedure with medication administration. The DON reported the resident has to assessed and if they have not been assessed they are not able to take their medications without supervision. A review of the facility's policy titled, Medication and Treatment Storage dated 8/7/23 noted, Policy Overview: It is the policy of this facility to ensure accurate labeling and dating of medications and treatments for safe administration and safe and secure storage of all medication and treatments. General Guidelines: . During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. A review of the facility's policy titled, Medication Self-Administration dated 5.2018 noted, Policy overview: Resident have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Guidelines: . The Medication Self-Administration Safety Screen in [electronic medical record] will be completed by the licensed nurse or respiratory therapist for respiratory medications such as nebulizers and inhalers .

Based on observation, interview and record review, the facility failed to honor the resident's food preferences and ensure accuracy of their food ticket for one resident (R154) of one reviewed for food preferences. Findings include: On 6/16/2026 at 11:27 AM, R154 was observed sitting in their wheelchair, and was asked about their stay in the facility. R154 expressed their dislike for the food citing the taste, temperature and accuracy of their meal ticket. At this time, R154's lunch tray was delivered to them. An observation of R154's food ticket revealed the tray was to consist of the following items: 6-ounce cheese pierogi, hotdog on bun, German style red cabbage, chocolate cream pie, apple juice, fresh fruit of the day, ginger ale and a turkey sandwich. An observation of R154's tray noted the 6-ounce cheese pierogi and fresh fruit were missing. In addition, the resident's meal ticket noted their dislikes as, No Pork. R154 was asked about their dislike of pork and stated, It's for my religion. R154 was asked if they were aware if the hotdog had pork in it and stated, I don't know. R154 was observed to consume the hot dog and stated, I'm so hungry.On 6/16/2026 at 2:07 PM, it was confirmed by the surveyor team sanitarian after an inspection of the kitchen, that the hotdog contained pork. A review of R154's medical record revealed they were admitted into the facility on 5/27/26 with diagnoses which included Failure to Thrive and Chronic Venous Hypertension. Further review the medical record revealed the resident was cognitively intact and required one person assist for activities of daily living. Further review of R154's Face sheet revealed the resident identified as Jewish (Jewish dietary law prohibits the consumption of pork). A review of the facility's Food Preferences and Select Menu revealed the following, .Residents may be assigned a menu that better suits their preferences, religious dietary needs, and lifestyle choices options include: regular lacto-ovo vegetarian, Kosher Style Vegetarian (Pescatarian), Gluten Free, Halal style .

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed for a catheter bag and nebulizer mask for two residents (R7 and R51) of two reviewed for infection control. Findings include: R7 On 06/18/2026 at 9:13 AM, R7 was observed in their room resting in bed with a urinary catheter in place. Their catheter bag was found lying directly on the floor to the side of the bed with one wheel of a rolling bedside table on top of the bag. On 06/18/2026 at 9:19 AM, an interview was conducted with Certified Nursing Assistant (CNA) B after they were observed entering R7's room briefly and then exiting. CNA B said they had just checked on R7, and that the resident was all good but they would be going back into the room to change them. Upon re-entering R7's room and being directed to look at the catheter bag on the floor, CNA B said the catheter bag should not be on the floor and hooked it back onto R7's bed. Review of R7's electronic medical record (EMR) revealed they were admitted into the facility on [DATE] with diagnoses of functional quadriplegia and pressure ulcer of the sacral region, stage 4 (full-thickness skin and tissue loss). Review of R7's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessment could not be completed to evaluate the resident's cognition because the resident is rarely or never understood. On 06/18/2026 at 9:21 AM, an interview was conducted with Licensed Practical Nurse (LPN) C. LPN C said that catheter bags should have a privacy covering and be kept off the floor and changed when needed.On 06/18/2026 at 10:28 AM, an interview was conducted with the Director of Nursing (DON). They stated the facility policy for catheter bags is to change them as needed, and that the bag should be situated off the floor below the patient's waist. They further stated that if the bed is low to the floor, a towel or napkin should be placed under the catheter bag to make sure the bag isn't directly touching the floor. A facility policy titled Catheter Use Overview issued 8/24/2023 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. that include but are not limited to. Insertion, ongoing care, and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. On 6/16/2026 at 2:41 PM, R51's nebulizer mask was observed sitting on their nightstand uncovered with unknown dried secretions noted. On 6/17/2026 at 10:10 AM, R51 was observed sitting in their wheelchair with their overhead table sitting in front of them. The resident's nebulizer mask was observed lying uncovered on the table, and the resident was asked why the mask was sitting there. R51 stated, I took it off because think I've had it on long enough. A review of R51's medical record revealed the resident was admitted into the facility on 6/3/26 with diagnoses which included Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension, and Respiratory Failure. Further review revealed the resident was cognitively intact and required one person assistance for activities of daily living. On 06/17/2026 at 12:30 PM, R51's nebulizer mask was observed lying on their dresser uncovered with unknown dried secretions. On 6/18/2026 at 12:29 PM, the Director of Nursing (DON) was informed of the observations made of the nebulizer masks and acknowledged that nebulizer masks are to be stored in a bag after being cleaned and dried. A review of the facility's policy, Medication and Treatment Storage did not reveal the procedure for the cleaning and storage of nebulizer masks.

Based on interview and record review, the facility failed to ensure three residents (R3, R149, and R197), of five residents reviewed for dignity, were treated in a respectful, dignified manner. Findings include: R3 On 06/16/2026 at 11:55 AM, R3 was interviewed in their room during initial resident screening and reported a concern that during the Sunday (06/14/26) evening shift leading into Monday morning, they asked their nurse about a concern related to their tube feeding and the nurse was rude and dismissive in their response. R3 reported they later heard the same nurse having a verbal altercation with their neighbor [R197] across the hall. R3 was asked if they knew the nurse's name and they stated [Name of Licensed Practical Nurse (LPN) E]. R3 reported they filed a formal complaint with the facility the following day. A review of the facility record for R3 revealed they were admitted to the facility on [DATE] with diagnoses including Aortic Valve Stenosis. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicated R3's cognition was intact. On 06/18/2026 at 10:33 AM, R3 was interviewed in their room and asked to recount their report of overhearing their nurse having a verbal altercation with [R197] on 6/14/26. R3 reported they could hear the nurse across the hall arguing with [R197] and raising [their] voice to the extent that I could tell it was the same nurse that was rude and argumentative with me. R3 was asked who they made a complaint to and they reported [Physical Therapy Assistant (PTA) F]. R3 was asked how the nurse's response made them feel and they reported they were angry and upset and added You shouldn't do this kind of work if you can't treat people better than that. R149 On 06/16/2026 at 1:20 PM, R149 was interviewed in their room during initial resident screening and reported a concern that on Sunday (06/14/26) evening they were having difficulty finding their nurse. R149 reported when the nurse came to their room they attempted to talk to the nurse about a concern they had related to a possible seizure they had earlier in the day and that the nurse's response was rude and abrasive and argumentative. When asked if they knew who the nurse was, they stated [Name of LPN E]. When asked if they interacted with any other staff during the shift they reported Certified Nursing Assistant (CENA) G was working and indicated CENA G was aware of the situation. A review of the facility record for R149 revealed they were admitted to the facility on [DATE] with diagnoses including Lumbar Spinal Stenosis. The BIMS assessment dated [DATE] indicated R149's cognition was intact. On 06/18/2026 at 9:40 AM, R149 was interviewed in their room and reported they called the Director of Nursing (DON) the morning following the incident with LPN E to report their concern and the DON came to their room later that day to speak to them. R149 reported the DON expressed to them that other residents on their unit had complained about the same nurse. R149 was asked if they could recount any other details of their interaction with LPN E and they reported when they indicated to LPN E they were concerned about their medication because their nurse from earlier that day reported they may have had a seizure. R149 reported LPN E stated You don't know you had a seizure and [previous nurse] isn't a doctor, they don't know if you had a seizure. R149 indicated LPN E was instantly argumentative .they scolded me and when I asked [LPN E] why I couldn't find them for so long they very rudely said I'm entitled to my break then they stormed out of the room and slammed my door. When asked how the interaction with LPN E made them feel they stated, I don't want them taking care of me. R197 A review of the facility records for R197 revealed they were admitted to the facility on [DATE] with diagnoses that included Lumbar Spondylosis with surgical intervention. The BIMS assessment dated [DATE] indicated R197's cognition was intact. On 06/17/2026 at 11:23 AM, R197 was interviewed in their room and asked if they recalled having any interaction with a nurse during the Sunday (6/14/26) evening into Monday morning shift earlier in the week. R197 reported they did recall having concerns that night about getting their medication timely and indicated that when they spoke to the nurse about the concern the nurse was very short and rude with me and then started arguing with me about when my medicine was due. [They] were very unprofessional. When asked if they could recall the nurse's name they stated, When [they] first came to my room [they] didn't even introduce themselves .I had never met [them] and didn't know who they were and [they] walked in and said What do you need? real rudely. I found out later [their] name was [LPN E] because some of the neighbors were complaining about [them]. On 06/18/2026 at 10:48 AM, PTA F was interviewed in the therapy gym and reported they did recall speaking to R3 on Monday about their concern with LPN E from the previous evening. They indicated they completed a grievance form and provided the form to the Director of Therapy (DOR). On 06/18/2026 at 11:06 AM, DOR K was interviewed in the therapy office and reported they did receive a grievance form pertaining to R3's concern with LPN E. The grievance form was provided and reviewed. On 06/18/2026 at 11:56 AM, a call was placed to CENA G. No answer was received and no return call was received prior to the completion of the survey. On 06/18/2026 at 12:07 PM, Unit Manager (UM) L was interviewed in their office. They reported being made aware of the concerns related to LPN E on Monday (06/15/26) morning by R3 and they had communicated the concern to the DON. UM L reported the facility completed an investigation and their understanding was LPN E was subject to disciplinary action. A review of the human resources file for LPN E revealed documentation of disciplinary action related to their shift beginning on Sunday 06/14/26 that was incomplete as the document had not been signed or acknowledged by LPN E. On 06/18/2026 at 12:21 PM, the DON was interviewed in the conference room. The DON indicated they were aware of and had investigated the concerns related to LPN E. The DON reported their expectation regarding customer service is, staff should always speak to and treat residents in a respectful manner. On 06/18/2026 at 12:29 PM, LPN E was interviewed via phone call and asked if they recalled having any difficulties being accessible to their residents or having any residents' express concerns on the most recent Sunday evening shift. LPN E reported they recalled a resident being upset about not getting a PRN (as needed) pain medication and stated, They thought I should bring it to them without them asking for it. LPN E was asked if they argued with or had a contentious interaction with any resident and reported they didn't believe they did then stated, I was just having an off night I think. Review of the facility policy Resident Rights dated 02/04/26 revealed the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include butare not limited to the resident's: Right to a dignified existence to: Be treated with respect and dignity.

Based on observation, interview, and record review, the facility failed to provide meal set up for one resident (R53) of two reviewed for activities of daily living. Findings include:On 6/17/26 at 11:46 AM, R53 was observed in bed lying flat on their back with their lunch meal tray covered, to the side of them, and out of their reach. R53 was interviewed about their lunch tray and stated, my bed doesn't work. R53 also indicated they could not access their tray. On 6/17/26 at 11:48 AM, Licensed Practical Nurse (LPN) H was interviewed about R53's lunch tray. LPN H indicated R53's tray should have been set up for them and their bed adjusted to a seated position to allow them to eat their lunch. Nurse H then proceed to adjust the resident's bed and set up their meal. On 6/17/26 at 11:53 AM, Certified Nursing Assistant (CNA) I, was interviewed regarding R53's meals and assistance required. CNA I indicated R53's meals require set up assistance and sometimes dietary staff drop the tray off and don't do anything. On 6/18/26 at 1:25 PM, the Nursing Home Administrator (NHA) was interviewed regarding meal access and assistance for R53 and confirmed meals should be accessible to the resident, and they should receive a minimum of meal set up assistance. A review of R53's electronic medical record (EMR) and their most recent minimum data assessment dated [DATE] revealed that R53 had an intact cognition and required supervision or touching assistance for eating. A review of R53's care plan revealed an intervention which indicated that R53 should be assisted with eating as needed. Further review of R53's EMR revealed that they were admitted to the facility on [DATE] with diagnoses that included Dementia and Kidney failure. A facility policy titled, Assistance with Meals Revision Dates: 7/12/22 was reviewed and revealed the following, Policy: 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. Guidelines: Patients/residents who choose not to eat in the dining room: C. The nursing staff will take the meal into patient/residents' rooms. d. The nursing staff will set up the meal .

This citation pertains to Intake: 2695258Based on observation, interview, and record review, the facility failed to prevent a fall for one resident (R901) of two residents reviewed for falls. Findings include:A review of information submitted to the State Agency (SA) revealed the following, On or around November 18, 2025, [R901] was being moved .The staff member, a CNA (certified nursing assistant), dropped [R901] . [R901] was transported to the hospital for care .A review of R901's medical record revealed they were initially admitted into the facility on [DATE] with diagnoses which included, Quadriplegia, Anxiety, and Muscle Wasting and Atrophy. Further review revealed the resident was moderately cognitively impaired and required 2-person assistance for bed mobility and transfers.On 12/22/25 at 9:45 AM, R901 was observed lying in bed and asked about the fall they sustained in November. R901 explained they fell out of bed and was sent to the hospital after complaining of pain. R901 explained there was one staff member in the room when they fell but could not recall what occurred prior to. R901 also indicated they had a cut on their eyebrow from the fall. A review of R901's care plan revealed the following, Focus: At risk for changes in behavior and mood r/t (related to) dx (diagnosis) of insomnia, Anxiety, Adjustment disorder with mixed disturbance of emotions and conduct, PTSD (post-traumatic stress disorder) r/t to a fall at a previous SNF (skilled nursing facility). Date Initiated: 12/10/2024 .Interventions: Non-Psychopharmacological interventions: Television, going outside, reading, classical music, when possible, provide ADL Care visits with 2 people. Date Initiated: 03/05/2025 .On 12/22/25 at 10:16 AM, an interview was conducted with CNA A, assigned CNA for R901 on the date they fell. CNA A reported she had been assigned to the resident for approximately one month and was familiar with their anxiousness during care. CNA A explained the resident is not necessarily combative but fearful of falling and will tell you they are scared. CNA A reported she started to provide care by removing the resident's brief, turning them on their left side facing the room window. CNA A explained she was positioned behind the resident and began to wipe them. CNA A explained that the resident became anxious and started grabbing the fitted sheet behind themselves in an attempt to hold onto something to prevent themselves from falling however, as the resident continued grabbing the sheet, they started to roll away from them, resulting in a fall to the floor. CNA A was asked if the resident required one or two people when providing care, and she reported two.A review of R901's ADL (activities of daily living) assist prior to their fall on 11/25/25 revealed the following, ADL Assist of x2 bed mobility, x2 toileting A review of the Incident and Accident report dated for 11/25/25 revealed the following, Nurse was notified by CNA that resident had become combative during care and fell out of bed writer observed resident laying on her stomach next to bed .Writer found resident on [their] stomach, face down, with slight bleeding from a right brow laceration .Resident stated that [they] hit their head, [R901] is lightheaded, dizzy, and pain at a 10 MD (medical doctor) was notified here in house and examined patient, MD order to send resident out for planned CT (computer tomography, an imaging test) .A review of hospital documentation dated 11/25/25 revealed the following, .s/p (status post) Fall .Injuries: right upper eye lid laceration .right thigh abrasive injury with pink bruise which appears to be a new injury .On 12/22/25 at 2:00 PM, an interview was completed with the Director of Nursing (DON) regarding R901's fall. The DON explained that CNA A explained the circumstances of the fall differently and would address it with the CNA through proper education.A request for the facility's Fall policy was requested and received the facility's Accident and Injury policy. After review, it did not address the facility's policy and procedures for preventing a fall.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 4/14/25 during an initial observation of the kitchen between 8:45 AM-9:15 AM, the following items were observed: The ice scoop holder was observed with black debris on the inside bottom surface. The tip of the ice scoop was resting in the black debris. When queried, Certified Food Manager (CFM) D stated she would clean it right away. According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not potentially hazardous (time/temperature control for safety food) . The ice machine filter was observed to be dusty. When queried, CFM D provided no explanation. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The interior of the microwave was observed with splattered, dried on food debris. CFM D confirmed the soiled microwave, but provided no further explanation. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In the walk-in cooler, the flooring was soiled with large areas of black stains, and there was dried up milk pooled on the floor underneath the milk crates. CFM D confirmed the soiled floors and stated she would have staff mop the floors right away. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. In the chemical room/janitor's closet, there were 2 unlabeled spray bottles on the shelf, filled with a clear liquid. CFM D stated I think it's just water, but provided no explanation for why the bottles were not labeled. According to the 2017 FDA Food Code section 7-102.11 Common Name, Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly and individually identified with the common name of the material. The floor drain cover underneath the dish machine was completely obstructed and coated with debris and dirt. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. On 4/14/25 at 9:15 AM, the low temperature/chemical sanitizing dish machine was observed. The log for the dish machine was observed hanging on the wall near the dish machine. It was noted that the log had not been completed since breakfast on 4/11. CFM D confirmed that the dish machine should be checked for sanitization daily, 3 time a day (breakfast, lunch, dinner). When queried about the test strips used to check the sanitizer level in the dish machine, CFM D pointed to a container of quaternary ammonia test strips, which were attached to the dish machine log. The dish machine was observed with a bottle of chlorine sanitizer attached. When queried about the availability of chlorine test strips, CFM D stated she would check to see if they had any. A plate simulator sent through the dish machine registered a maximum temperature of 140 degrees Fahrenheit. This surveyor used their own chlorine test strips to test the level of chlorine sanitizer in the dish machine. The strip did not change color to denote the presence of chlorine sanitizer. CFM D stated she would contact a repair company. According to the FDA Food Code section 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness, A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart; P. According to the 2017 FDA Food Code section 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration, Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device. On 4/14/25 at 9:30 AM, the 2nd floor nourishment room was observed. The interior surfaces of the microwave had areas of peeling paint, and the cabinet underneath the sink was observed with 2 towels that had been spread out over the surface. The white towels were stained black with a mold-like substance. On 4/14/25 at 9:35 AM, the 3rd floor nourishment room was observed. The microwave was rusty on the inside top surface and along the front bottom edge. The bottom shelf underneath the sink was observed with water damage and was soiled with a black, mold-like substance.

Based on observation, interview, and record review, the facility failed to ensure meal portion sizes met the nutritional needs of the residents, resulting in the potential for inadequate protein intake, weight loss, and decreased meal enjoyment. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 4/14/25 at 11:15 AM, Dietary [NAME] O was observed serving food at the steam table. Dietary [NAME] O was observed ladling chili into bowls with a 6 ounce ladle. When queried about the portion size for the chili, Dietary [NAME] O stated Is this not right? On 4/14/25 at 11:20 AM, review of the production sheet for the lunch meal, noted that the portion size for the chili was supposed to be 8 ounces. When queried at that time, Certified Food Manager D confirmed that Dietary [NAME] O was using the wrong size ladle. 38207 On 4/15/25 at 10:30 AM, a group meeting was conducted with eight confidential group residents and they were asked about the food at the facility. All group members indicated that food portions could be larger. Examples from the group included being served one individual rib when ribs were served for dinner recently and being served one slice of pizza during another recent dinner.

This citation pertains to Intake MI00152118. Based on observation, interview, and record review, the facility failed to ensure the blood pressure medication (Clonidine) for one resident (R73) of one resident reviewed was administered as needed per physician order Findings include: On 04/15/25 at 9:09 AM, a medication pass observation for R73 was conducted with Licensed Practical Nurse (LPN) E. Prior to the pass of medication LPN E checked the blood pressure of R73. The blood pressure (BP)was documented as 197/96 and a heart rate of 71. LPN E reported they would need to report this to the physician and upon review observed the active physician order dated 04/09/25, Clonidine .1 mg (milligram), give one tablet via a percutaneous endoscopic gastrostomy (PEG) tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) every six hours, PRN (as needed) for hypertension (high BP). Administer for SBP (systolic BP) greater than 160 and notify physician. LPN E administered the clonidine. A review of the previous blood pressures (BP) documented a blood pressure of 196/88 at 5:00 AM on the same morning. A review of the vitals tab in the electronic medical record revealed the next blood pressure was taken by Nurse E at 9:20 AM. A review of the April 2025 Medication Administration Record (MAR) revealed two previous administrations of the PRN clonidine on April 9th and 12th, 2025 (BP 171/71 by LPN E). No additional administrations were documented on the MAR. A further review of the April MAR and physician's orders documented for additional blood pressure medications: Hydralazine scheduled at 6 AM, 2 PM and 10 PM; Furosemide, a water pill, scheduled at 6 AM which was refused on 04/14/25 and 04/15/25; and Carvedilol at nine AM and nine PM. Refusal of the furosemide was not documented in the progress notes as having been reported to the physician. A review of the April 2025 progress notes revealed no documentation of physician notification by the nurse related to the 5 AM blood pressure. A 04/09/25 progress note timed at 1:33 PM documented the as needed clonidine order from the physician and to call the physician if the as needed clonidine had to be administered. On 04/16/25 at 1:56 PM, the blood pressures in the electronic medical record for R73 were reviewed with Unit Manager H. Ten or more blood pressures greater than 160 systolic were documented since the order was initiated. Some of these were noted to have a recheck with a similar value. The Unit Manager reported the expectation was to administer the as needed clonidine as ordered and report out of parameter blood pressures to the physician for review of the prescribed medication regimen. A review of the record revealed R73 was admitted into the facility on [DATE]. Diagnoses included, Stroke, Heart Disease, Chronic Kidney Disease and Malnutrition. The Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition and the need for partial/moderate assistance for most activities of daily living. A review of the National Institute for Health site at [www.nhlbi.nih.gov/health/high-blood-pressure] revealed, .Blood pressures are written as two numbers separated by a slash like this: 120/80 mm Hg. You can say this as 120 over 80 millimeters of mercury or just as 120 over 80. The first number is your systolic pressure - that ' s the force of the blood flow when blood is pumped out of the heart. The second number is your diastolic pressure, which is measured between heartbeats when the heart is filling with blood . A healthy systolic blood pressure is less than 120 mm Hg. A healthy diastolic pressure is less than 80 mm Hg. Your blood pressure is high when you have consistent systolic readings of 130 mm Hg or higher, or diastolic readings of 80 mm Hg or higher. Contact your provider immediately and .Hypertensive Crisis: Higher than 180 systolic pressure or higher than 120 diastolic pressure, Contact your provider immediately.

Based on observation, interview, and record review, the facility failed to ensure that call lights were in reach for three residents (R57, R106, R152) of four residents reviewed for call light accessibility. Findings include: R57 On 4/14/25 at 9:15 AM, an observation was made of R57's call light being on the floor by the side of the bed, out of reach of the resident. On 4/15/25 at 9:27 AM, an observation was made of R57's call light being on the floor, by the bed, out of reach of the resident. R57 was interviewed regarding the location of their call light and stated, I don't know. A record review was completed of R57's electronic medical record (EMR) and revealed that R57 was admitted to the facility on [DATE] with diagnoses that included Atrial fibrillation (Irregular heart rate) and Heart disease. R57's most recent minimum data set assessment (MDS) dated [DATE] revealed that R57 had an intact cognition and required substantial assistance to being dependent for all activities of daily living (ADLs) other than eating. R106 On 4/14/25 at 9:39 AM, an observation was made of R106's call light being on the floor, under the bed, out of reach of the resident. On 4/16/25 at 9:54 AM, R106's call light was observed to be on the floor next to the bed, out of reach of the resident. While the surveyor was in the room with R106, Licensed Practical Nurse (LPN) C entered the room and was asked where R106's call light should be located. LPN C picked up the call light off of the floor and clipped it to R106. On 4/16/25 at 10:08 AM, LPN B was interviewed regarding their expectations regarding call light placement in residents' rooms. LPN B indicated the call light should be clipped to or located beside the resident within their reach. A record review of R106's EMR revealed that R106 was admitted to the facility on [DATE] with diagnoses that included Respiratory failure and Muscle weakness. R106's most recent MDS dated [DATE] revealed that R106 had moderately impaired cognition and required moderate assistance to being dependent for all ADLs other than eating. R152 On 4/14/25 at 9:40 AM, R152's call light was observed to be on the floor by the bed, out of reach of the resident. A record review of R152's EMR revealed that R152 was admitted to the facility on [DATE] with diagnoses that included Respiratory failure and COPD (Chronic obstructive pulmonary disease) (Lung disease). R152's most recent MDS dated [DATE] revealed that R152 had a moderately impaired cognition, was frequently incontinent of urine, and was dependent upon staff for toileting. On 4/16/25 at 1:19 PM, the Administrator (NHA) was interviewed regarding their expectations for placement of call lights in residents' rooms. The NHA indicated all staff should be checking that call lights are in place and accessible to the resident. A review of a facility policy titled, Call Light Accessibility . Issue Date: 8.16.2023 stated, Guidance: Staff will be educated .ensuring residents have access to the call light. Staff will ensure the call light is .within reach of residents .The call system will be accessible to residents while in their room at bedside .

This citation pertains to Intake MI00151407 and MI00151269. Based on observation, interview, and record review, the facility failed to respond to call lights and provide activities of daily living care (ADLs) in a timely manner for one resident (R152) and eight confidential group residents, of thirteen residents reviewed for ADLs. Findings include: R152 On 4/14/25 at 9:40 AM, R152 was met in their room and interviewed regarding the care they received at the facility. R152 indicated they frequently wait a long time for assistance with care. R152 indicated they had been waiting for over an hour to have their brief changed this morning. R152's call light was observed to be on the floor by the bed out of reach of the resident. At 9:50 AM, an observation was made of staff entering R152's room with a breakfast tray, setting the breakfast tray on the resident's bedside table and exiting the room. On 4/15/25 at 9:38 AM, a follow-up visit was conducted with R152. R152 indicated they had a wet brief and proceeded to activate their call light. From 9:38 AM, to 9:51 AM, R152's call light was observed to be activated and multiple staff walked by the resident's room with out answering the call light. At 9:51 AM, staff was observed to enter R152's room, deactivate the call light and exit the room. R152 was interviewed and confirmed the staff that deactivated the call light did not ask them if they needed assistance. R152 then reactivated their call light. At 9:56 AM, the Director of Nursing (DON) was observed to answer R152's call light. On 4/15/25 at 10:00 AM, the DON was interviewed regarding their expectations for staff regarding answering call lights and addressing ADL care needs. The DON indicated that call lights should be answered as soon as possible and the call light should be left on until the care need is met. A record review of R152's electronic medical record (EMR) revealed that R152 was admitted to the facility on [DATE] with diagnoses that included Respiratory failure and COPD (Chronic obstructive pulmonary disease) (Lung disease). R152's most recent minimum data set assessment (MDS) dated [DATE] revealed that R152 had a moderately impaired cognition, was frequently incontinent of urine, and was dependent upon staff for toileting. A review of resident council meeting notes for the months of December 2024 through March 2025 revealed multiple resident concerns related to lack of staff team work resulting in delayed ADL care, long call light wait times, and staff turning off call lights without addressing residents' needs. On 4/15/25 at 10:30 AM, a group meeting was conducted with eight confidential group residents and they were asked about care at the facility. The group indicated that when agency staff (contract staff hired by the facility to assist with providing care to the residents) was working, call lights were not answered and care was not provided timely. A review of a facility policy titled, Call Light .Timely Response Issue Date: 8.16.2023 stated, Guidance: Staff members who see or hear an activated call light are responsible for responding regardless of assignment. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Process: .Turn off call light when resident's request is met.

Based on observation, interview, and record review, the facility failed to provide person centered care plans for two sampled residents (R78 and R46) of three whose care plans were reviewed. Findings include: R78 A review of R78's medical record revealed an initial admission into the facility on [DATE], and a readmitted [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Diabetes, Vascular Dementia, and Post-Traumatic Stress Disorder (PTSD). Further review revealed the resident was cognitively intact and required 1-2 person assist for activities of daily living. A review of R78's care plan did not reveal a care plan for the resident's diagnoses of Post-Traumatic Stress Disorder or Vascular Dementia. On 4/16/25 at 12:01 PM, Social Worker A was asked about R78's missing care plan related to their PTSD and Vascular Dementia and explained she would investigate and get back with the surveyor. At 1:14 PM, Social Worker A followed-up with surveyor and acknowledged the resident did not have a care plan for their diagnoses. On 4/16/25 at 1:56 PM, the Nursing Home Administrator was asked for her expectations for the implementation of care plans and acknowledged there should be appropriate care plans in place, and psych services as needed. 49699 R46 On 4/14/2025 at 10:02 AM, R46 was away from their room receiving a dialysis treatment. An observation of R46's belongings revealed one heel protector on the bedside chair and one on another surface next to the chair. On 4/14/24 at 1:30 PM, an interview with R46 revealed they had just returned from dialysis. R46 did not have their heel protectors on and was in bed on their back. An inquiry revealed R46 was comfortable and did not like the heel protector. A review of the Electronic Medical Record (EMR) revealed R46 was admitted to the facility on [DATE] with pertinent diagnoses of Encephalopathy (chronic degeneration), Diabetes with neuropathy (decrease in sensation), Kidney Disease requiring dialysis, and pressure ulcer of the right heel. Further review of R46's EMR revealed a Basic Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The EMR revealed R46 was depended for all activities of daily living except eating. On 4/15/2025 at 10:37 AM, an interview with Nurse Unit Manager (NUM) H revealed there should be a non-compliance care plan since R46 is known to refuse many aspects of their care. On 4/15/2025 at 10:51 AM, an interview with R46's family revealed R46 often refuses care. On 4/15/2025 at 12:25 PM, an interview with Licensed Practical Nurse (LPN) F revealed R46 often refuses care, does not like the food and requests items not within their dietary restrictions. On 4/15/2025 at 2:00 PM, an interview with Dialysis Nurse (DN), N revealed R46 had high potassium and high phosphorous levels at times. When queried regarding the cause, DN N revealed elevated potassium and phosphorous levels are usually due to non-adherence to a Renal diet. On 4/15/2025 at 2:30 PM, an interview with Dietician M revealed R46 is currently on a Renal Diet. Dietician M further revealed R46 often orders items that are not on the Renal Diet. A review of the EMR did not reveal a care plan regarding non-compliance. A review of the facility's Behavioral Care Services policy revealed the following, .6. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. This process includes, but is not limited to: .e. Care Plan development and implementation .

Based on observation, interview, and record review, the facility failed to ensure the appropriate amount of water flush was provided between administration of individual medications via a percutaneous endoscopic gastrostomy (PEG) tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), for one resident (R73) of four observed during medication administration. Findings include: On 04/15/25 at 9:09 AM, a medication administration via a PEG tube for R73 was observed with Licensed Practical Nurse (LPN) E. LPN E was observed to prepare medications for R73, nine were crushed for administration via R73's PEG tube. The PEG tube was uncapped and the tip of an open graduated 50 milliliter (ml) syringe was placed into the opening. An initial water flush of between 30 and 40 milliliters (mls) was observed to be completed via gravity. (The orders indicated a flush amount of 20-30 ml.) Each of the nine medications had been placed into plastic 30 ml medication cup. The initial medication cup was filled with 20 - 30 mls of water and poured into the syringe, medication remained in the cup and an additional 20-30 ml of water was used to clear the contents of the medication cup. This medication was followed with an additional 20-30 mls of water. Each of the next three medications was flushed with an additional 20-30 ml of water. R73 then reported they were feeling full and may need to throw up. LPN E then paused and added the last five crushed medications to the 30 mls of water in the syringe and flushed with an additional 20-30 mls of water. Upon completion LPN E was asked about combining medications for administration and reported they do combine for some residents but combined administration had not been ordered for R73. On 04/15/25 at 4:46 PM, the LPN Q reported medications via a PEG are given one by one and flushed with five to ten milliliters of water inbetween medications. On 04/15/25 at 4:55 PM, Unit Manager LPN B reported PEG medications are crushed and administered one by one. 20-30 milliliters of water are used to flush before starting and five to ten milliliters is used to flush between medications. On 04/16/25 at 9:52 AM, the Director of Nursing (DON) reported on query the medications are generally administered one at a time via a PEG tube though medications may be combined on consult with the pharmacist and physician. The DON further reported the flush amount between medications was 5-10 ml, but would consult the policy. A review of the facility policy titled, Medication-Enteral Tube Medication Administration issued 09/12/23 revealed, .dilute crushed medications with at least 30 ml of water (or prescribed amount) . If administering more than one medication, flush with 15 ml of water between medications (or prescribed amount) .

Based on observation, interview, and record review, the facility failed to ensure a medication error of less than five percent for one resident (R73) of five residents reviewed for medication observation, resulting in a medication error rate of 12.82%. Findings include: On 04/15/25 at 9:09 AM, a medication administration for R73 via a percutaneous endoscopic gastrostomy (PEG) tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) was observed with Licensed Practical Nurse (LPN) E. LPN E was observed to prepare medications for R73, nine were crushed for administration via R73's PEG tube. The PEG tube was uncapped and the tip of an open graduated syringe was placed into the opening. An initial water flush of between 30 and 40 milliliters (mls) was observed to be completed via gravity. The next four medications were followed with an additional 20-30 mls of water. R73 then reported they were feeling full and may need to throw up. LPN E then paused and added the last five crushed medications all together into the 30 mls of water in the syringe and flushed with an additional 20-30 mls of water. Residual medication was observed to have been left in the syringe. Upon completion LPN E was asked about combining medications for administration and reported they do combine for some residents but combined administration had not been ordered for R73. On 04/16/25 at 9:52 AM, the Director of Nursing (DON) reported on query the medications are generally administered one at a time via a PEG tube though medications, but may be combined on consult with the pharmacist and physician. A review of the facility policy titled, Medication-Enteral Tube Medication Administration issued 09/12/23 revealed, .dilute crushed medications with at least 30 ml of water (or prescribed amount) . Administer each medication separately .

Based on observation, interview, and record review, the facility failed to maintain a tube feeding (TF) pole in a sanitary manner for one sampled resident (R128) of one reviewed for tube feeding sanitation. Findings Include: On 4/14/25 at 2:10 PM, R128 was observed lying in bed with their tube feeding in place noting a bag of Isosource 1.5 cal missing the resident's name, date, time, or order. The tube feeding pole and base were observed to have a very thick layer of brown dried tube feed stuck to it. Also noted were a pair of used gloves on the floor. A review of R128's medical record revealed they were admitted into the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction, Dysphagia, and Diabetes. Further review revealed the resident was severely cognitively impaired and was dependent on enteral feed for nutrition. On 4/15/25 at 8:59 AM, R128's tube feeding pole was observed to have a thick layer of brown tube feeding fluid stuck to it. In addition, there was a pool of wet fluid observed on the floor. On 4/16/25 at 10:50 AM, R128's tube feeding pole was observed to have a thick layer of brown tube feeding fluid stuck to it. On 4/16/25 at 1:04 PM, the Infection Control Preventionist was asked her expectation for the cleanliness of tube feeding poles and explained the pole should be cleaned when observed as soiled. A review of the Cleaning and Disinfection of Resident-Care Equipment policy revealed the following, .3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include .e. for durable medical equipment, such as feeding pumps, staff shall store used/dirty equipment in soiled utility room .

Based on observation, interview and record review, the facility failed to discard expired, label with resident identifier and date when opened biologicals in three of four medications carts and one of four medication rooms reviewed. Findings include: On [DATE] at 8:50 AM, the three [NAME] high medication cart was observed with Licensed Practical Nurse (LPN) P. A dorzolamide eye drop vial was not labeled with a resident identifier nor date opened; glucose strips were not dated when opened; two insulin aspart vials were dated ,d+[DATE] and ,d+[DATE] and expired; A Basalgar insulin pen was not dated when opened; Two Trelegy inhalers were not dated when opened; and a Arnuity inhaler was not dated when opened on the inhaler and did not have an identifier on the inhaler. On [DATE] at 4:46 PM, the two [NAME] medication room was observed with LPN Q. A tuberculin vial was open, but not dated. 49699 On [DATE] at 9:44 AM an observation of the medication cart for revealed Latanoprost Eye drops laying outside of the box, without an identifying label or open date on the bottle. A further observation revealed a bottle of Prednisone Acetate in a box without an identifying label or open date on the bottle. On [DATE] at 9:52 AM, the Director of Nursing (DON) reported expired medication are to be discarded and a dated opened and identifier applied to medications that require them. A review of the facility Prescription Dating/Storage Guidelines effective [DATE] revealed, .insulin lispro: vial expires 28 days after opening or removal from the refrigerator whichever comes first . Tuberculin: Discard vial in use after thirty days . latanoprost: may be stored at room temperature for up to six weeks. A review of the prescribing and manufacturer's information at [https://gskpro.com] revealed, .Safely throw away Trelegy Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler. A review of the prescribing and manufacturer's information at [https://arnuity.com] revealed, .Arnuity Ellipta should be stored inside the unopened moisture-protective foil tray and only removed from the tray immediately before initial use. Discard Arnuity Ellipta 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first .

This citation pertains to Intake: MI00150544. Based on interview, and record review, the facility failed to protect one resident (R901) during an abuse investigation out of four residents reviewed for abuse resulting in fear of retaliation and feeling scared. Findings include: A review of a facility reported incident (FRI) submitted 2/13/25 to the State Agency revealed, It was alleged the facility staff misappropriated resident funds. On 2/25/25 at 10:00 AM, R901 explained back in October (2024) they wanted to open a bank account to deposit their check from social security. They had asked their family to assist but they were taking too long. R901 said they had shared they're frustration to Staff A, and the staff member suggested they (the resident) try to open an account over the phone at Staff A's bank. R901 expressed they did not think this would work because it was over the phone, and they only had a picture of their ID on their phone. R901 reported the bank allowed the account to be opened with R901 as primary and Staff A as secondary. R901 explained things were going ok until they started to have transactions declined when they tried to use the account. R901 expressed they didn't understand why the transactions were getting declined because they knew they had money in the account. R901 stated they communicated this to Staff A, and they (the staff member) would say they will add money to the account. R901 explained this continued to happen and decided to look at the account online for the first time since opening the account in October (2024). Once they signed up for the online access, they noticed Staff A had a gambling/betting app (application) linked and other unauthorized withdrawals were made from the account. R901 wanted to remove Staff A from the account but was unable to over the phone. R901 reported their family member took them to the bank on 2/13/25 at which point bank account was closed and the printed transaction of the account revealed an unauthorized amount total of $18,364.14 was withdrawn from the account by Staff A. R901 reported they canceled the old account and opened a new account. A family member called the police to file a report in which the police met them (the resident and family member) back at the facility. R901 stated, I started crying about it. It had not clicked until then. R901 explained, after the police interview, they were instructed to call 911 if Staff A approached them. The police indicated they would notify the administration staff that Staff A is to not have any contact with them (R901). R901 reported the next morning (2/14/25), Staff A came to they're room and was in their face, very close and said aggressively, I got fired. R901 stated, I told her to back up. Police said to call 911, I wanted to, but it was over there, (pointing to nightstand which was out of reach). Staff A also said, Don't make me lose it. R901 continued telling Staff A to back up. R901 expressed they were scared and was trying to figure out how they were going to defend themselves. R901 said Staff A eventually left. After Staff A left they called the resident 10 times back-to-back. R901 shared a voice mail message dated 2/14/25 at 7:04 AM, Call me ASAP (as soon as possible), at 7:11 AM, You need to talk to me now. and 7:31 AM Answer your phone. The least you can do is talk to me that's what you can do, and you don't even have the respect to do that. Shame on you, [R901] shame on you. R901 expressed they were fearful of retaliation because of this situation, and they will be transferred to another facility. R901 explained they were scared Staff A's sons and or husband my come to the facility and make it to their room and possibly harm them. R901 was asked the impact this incident has had on them. R901 expressed the missing money means they can't pay bills, they can't afford physical therapy they want, and they may not have money to leave after they pass away to their family. R901 stated, I can't go into it, because it will mess with my head. A review of R901's medical record noted, R901 was admitted to the facility on [DATE] with diagnosis of Malignant Neoplasm of Unspecified site of left Breast. A review of R901's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed. R901 with an intact cognition and dependent of staff for activities of daily living. On 2/25/26 at 11:55 AM, Staff A was asked about the bank account with R901. Staff A explained they became friends with R901 when they were a housekeeper. Staff A told me they couldn't get a bank account, and I suggested R901 to try and open one over the phone. Staff A stated, I deposited the checks for R901. Staff A was asked if they used the money for their own personal use. Staff A explained, they did use the account for a gambling/betting app to play games but put the money back. Staff A was asked when they found out they were suspended and explained on Thursday night (2/13/25), R901 told them they couldn't talk to them anymore. Staff A further explained they came into work the next day Friday (2/14/25) at 7:00 AM when Nursing Supervisor (Nurse) B told them they couldn't be in the building because they were suspended. Staff A confirmed, Before I left, I went to [R901's] room and asked [R901] if I needed a lawyer. On 2/25/25 at 11:36 AM, a Family Member (FM) for R901 was asked about the incident. The FM confirmed the account was opened on 10/15/25, and closed 4 months later, on 2/13/25. The FM said they reviewed the transactions print out and once they saw the amount of money taken, they called the police on 2/13/25. The FM reported Staff A called R901 a lot and left voice mails and text messages, with foul language. On 2/26/25 at 8:53 AM, the Nursing Home Administrator (NHA) was asked about the incident and explained they became aware of the bank account incident on 2/13/25 when the police came into the facility. The NHA said they called Staff A on 2/13/25 and left a voice message telling her she was suspended pending investigation. Staff A came in Friday (2/14/25) morning because she said alleged she didn't get the message. The NHA explained they received a call from Nurse B asking what they should do because Staff A was in the building. The NHA said, they directed Nurse B to instruct Staff A to leave the building. On 2/26/25 at 9:33 AM, the Social Worker (SW D) reported on February 12, 2025, they were told R901 was going to the bank to remove a friend from their bank account, because there were small amounts of money missing. SW D explained they informed the NHA that day. SW D reported on February 14, (2025) after around 9:30 AM, R901 told them the friend was Staff A. On 2/26/25 at 2:31 PM, during an interview, Nurse B stated, I saw her (Staff A) at the bistro (located on the first floor) and told her that she had to leave, because she was suspended. Nurse B further explained they called the NHA and the NHA instructed them to tell Staff A to leave and Staff A acted like they didn't know why they had to leave. Nurse B explained Staff A wanted to speak with Dietary Manager (DM C) as they were coming into the building. Nurse B explained they left Staff A with DM C and that was the last time they saw her, until they were told that, Staff A was in R901's room (located on the third floor of the facility). On 2/26/25 at 1:42 PM, NHA reported the management staff were told Staff A was suspended on 2/13/25. The NHA was asked the procedure in protecting a resident when an investigation is ongoing, and when staff are directed to leave the facility. The NHA, explained they typical walk them to door or it has been done over the phone. The NHA was asked how Staff A was able to make it to R901's room, after they were suspended and instructed to leave the facility. The NHA explained they were not sure and it should not have happened. A review of the facility's investigation interviews revealed, .The account was set up and [R901] was able to have a couple large SSI (Social Security Income) deposits into the account and [R901] started paying off bills. [R901] had not thought of anything of it, but started to notice funds were not being available when [R901] would go to use it. [R901] would ask [Staff A] for money. About 2 weeks ago, [R901] had no cash again so [R901] wanted to create a online profile so [R901] could see the activity and transactions on the account. That is when [R901] saw all the gambling transactions. [R901] said that [Staff A] said I told you I do online gambling. [R901] told her to put the money back and [Staff A] said I do. [R901] called the bank back on Wednesday (2/12/25) to see if [R901] could have [Staff A] removed from the account if [R901] went there with [R901's] daughter and the bank said yes. [R901] and [R901's] daughter went to the bank on 2/13/25 and the bank would not allow [R901] to take [Staff A] off the account but they did allow [R901] to close the account. They proceeded with that and had the account closed. They also had the bank print out the history of transactions back to the opening of the account in October 2024. The daughter took the large stack and reviewed with the police. Total amount taken was $18,368.14. The daughter stated it was around $14,030 towards gambling and the resident were purchases at places like [local pharmacy], gas stations, etc. The daughter said she put back $6,193.59, which $570 was from [Staff A], the rest was from gambling winnings. The Police arrived last night (2/13/25) with [R901's] daughter. They said to call 911 if she (Staff A) comes in to the facility. This morning (2/14/25), [Staff A] got in (the facility) somehow and got in [R901's] face saying Do I need to get a lawyer? Your daughters did this to me. She told [R901] that she was the reason she was fired from her job and that she wasn't going to help anymore ever again. She left the room at that point [R901] said [R901] has been texting and calling [R901] ever since last night and the cops said not to block her number right now. Interview conducted 2/14/15 around 10 am in the residents room. Administrator, Assistant Admin, Resident, and Daughters (one on phone) present for interview. Signed and Dated 2/14/25 by the resident, witness and interviewer. Review of the facility's policy titled, Abuse dated 5/24/23 documented, Abuse against residents can be perpetrated by various people within the facility. The facility supports and protects patients, family members, and staff from harm during an investigation of alleged abuse including retribution and retaliation. Protective actions depend upon the people involved. Any allegation of abuse must be immediately reported to the supervisor and the Abuse Prevention Coordinator. The Administrator initiates investigating any allegation of abuse against a patient. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: Immediately removing the resident from contact with the alleged abuser. Evaluation of the physical and psychosocial condition of the resident and providing emotional support to the patient during and after the investigation as needed. Providing a safe and secure environment for all patients If a staff member is the alleged perpetrator, that staff member should be immediately removed from the facility and the schedule pending the outcome of the investigation.

This citation pertains to Intake: MI00150544. Based on interview, and record review, the facility failed to prevent staff misappropriation of resident funds (linking a gambling app and making withdrawals without resident consent from a joint bank account), for one sampled resident (R901) of four reviewed for abuse, resulting in an unauthorized withdrawal totaling $18,368.14. Findings include: A review of a facility reported incident (FRI) submitted 2/13/25 to the State Agency revealed, It was alleged the facility staff misappropriated resident funds. On 2/25/25 at 10:00 AM, R901 explained back in October (2024) they wanted to open a bank account to deposit their check from social security. They had asked their family to assist but they were taking too long. R901 said they had shared they're frustration to Staff A, and the staff member suggested they (the resident) try to open an account over the phone at Staff A's bank. R901 expressed they did not think this would work because it was over the phone, and they only had a picture of their ID on their phone. R901 reported the bank allowed the account to be opened with R901 as primary and Staff A as secondary. R901 explained things were going ok until they started to have transactions declined when they tried to use the account. R901 expressed they didn't understand why the transactions were getting declined because they knew they had money in the account. R901 stated they communicated this to Staff A, and they (the staff member) would say they will add money to the account. R901 explained this continued to happen and decided to look at the account online for the first time since opening the account in October (2024). Once they signed up for the online access, they noticed Staff A had a gambling/betting app (application) linked and other unauthorized withdrawals were made from the account. R901 wanted to remove Staff A from the account but was unable to over the phone. R901 reported their family member took them to the bank on 2/13/25 at which point bank account was closed and the printed transaction of the account revealed an unauthorized amount total of $18,364.14 was withdrawn from the account by Staff A. R901 reported they canceled the old account and opened a new account. A family member called the police to file a report in which the police met them (the resident and family member) back at the facility. R901 stated, I started crying about it. It had not clicked until then. R901 explained, after the police interview, they were instructed to call 911 if Staff A approached them. The police indicated they would notify the administration staff that Staff A is to not have any contact with them (R901). R901 reported the next morning (2/14/25), Staff A came to they're room and was in their face, very close and said aggressively, I got fired. R901 stated, I told her to back up. Police said to call 911, I wanted to, but it was over there, (pointing to nightstand which was out of reach). Staff A also said, Don't make me lose it. R901 continued telling Staff A to back up. R901 expressed they were scared and was trying to figure out how they were going to defend themselves. R901 said Staff A eventually left. After Staff A left they called the resident 10 times back-to-back. R901 shared a voice mail message dated 2/14/25 at 7:04 AM, Call me ASAP (as soon as possible), at 7:11 AM, You need to talk to me now. and 7:31 AM Answer your phone. The least you can do is talk to me that's what you can do, and you don't even have the respect to do that. Shame on you, [R901] shame on you. R901 expressed they were fearful of retaliation because of this situation, and they will be transferred to another facility. R901 explained they were scared Staff A's sons and or husband my come to the facility and make it to their room and possibly harm them. R901 was asked the impact this incident has had on them. R901 expressed the missing money means they can't pay bills, they can't afford physical therapy they want, and they may not have money to leave after they pass away to their family. R901 stated, I can't go into it, because it will mess with my head. A review of R901's medical record noted, R901 was admitted to the facility on [DATE] with diagnosis of Malignant Neoplasm of Unspecified site of left Breast. A review of R901's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed. R901 with an intact cognition and dependent of staff for activities of daily living. On 2/25/26 at 11:55 AM, Staff A was asked about the bank account with R901. Staff A explained they became friends with R901 when they were a housekeeper. Staff A told me they couldn't get a bank account, and I suggested R901 to try and open one over the phone. Staff A stated, I deposited the checks for R901. Staff A was asked if they used the money for their own personal use. Staff A explained, they did use the account for a gambling/betting app to play games but put the money back. Staff A was asked when they found out they were suspended and explained on Thursday night (2/13/25), R901 told them they couldn't talk to them anymore. Staff A further explained they came into work the next day Friday (2/14/25) at 7:00 AM when Nursing Supervisor (Nurse) B told them they couldn't be in the building because they were suspended. Staff A confirmed, Before I left, I went to [R901's] room and asked [R901] if I needed a lawyer. On 2/25/25 at 11:36 AM, a Family Member (FM) for R901 was asked about the incident. The FM confirmed the account was opened on 10/15/25, and closed 4 months later, on 2/13/25. The FM said they reviewed the transactions print out and once they saw the amount of money taken, they called the police on 2/13/25. The FM reported Staff A called R901 a lot and left voice mails and text messages, with foul language. On 2/26/25 at 8:53 AM, the Nursing Home Administrator (NHA) was asked about the incident and explained they became aware of the bank account incident on 2/13/25 when the police came into the facility. The NHA said they called Staff A on 2/13/25 and left a voice message telling her she was suspended pending investigation. Staff A came in Friday (2/14/25) morning because she said alleged she didn't get the message. The NHA explained they received a call from Nurse B asking what they should do because Staff A was in the building. The NHA said, they directed Nurse B to instruct Staff A to leave the building. On 2/26/25 at 9:33 AM, the Social Worker (SW D) reported on February 12, 2025, they were told R901 was going to the bank to remove a friend from their bank account, because there were small amounts of money missing. SW D explained they informed the NHA that day. SW D reported on February 14, (2025) after around 9:30 AM, R901 told them the friend was Staff A. A review the facility's statement interview revealed, Staff A via phone. Please Explain your situation with [R901] and the bank account starting from the beginning. I had gotten to know [R901] a bit and [R901] was trying to cash [R901's] checks but couldn't' because [R901] daughter had [R901's] ID. I said I could maybe see if my bank (local bank) would allow [R901] to open one. Since [R901] had a photo ID [R901] was able to open one with my name on the account. I didn't want my name on the account but they said I had to be. The account was opened and [R901] deposited 1 check into the account and then started paying bills $1000 to medical bills, $1500 to sister and $500 to [R901's] uncle. [R901's] daughter for a debit care and [R901] for one. Did you ever make any transactions through [R901's] account? Yes. I would buy [R901] food and things periodically. Did you know about any [online gambling app] transactions? Yes, a little while ago I realized my account had been linked to [R901's] and not mine so I had transferred $3000.00 in December and $1700.00 to pay [R901] back. I also transferred more at various amounts $80, $40, $20. [R901] would always text me crying about not having funds in the account so I would transfer money to [R901's] account for [R901]. I also transferred $300 at Christmas time because [R901] was crying about not being able to buy for [R901's] grandchildren. I have the texts! Can you sent those to me? Yes. At this time in the interview, [Staff A] began talking in circles, repeating the reimbursements over and over again. She kept saying that family wasn't taking care of [R901] so she was. She said she had transferred enough money to cover what was taken out Whatever I spent, I gave back. [Staff A] I understand that you reimbursed and transferred money to [R901's] money to [R901] but I am still missing a piece of the puzzle. $18,000 were taken out, $14,000 was towards [the online gambling app]. I didn't spend all that, I paid [R901] back around $6,000.00 that I took out. I bought [R901] things. I transferred [R901] money when [R901] asked. I tried to get off the account a couple of months ago but they wouldn't let me. How did [R901] information get on your [online gambling app] account? I punched it in myself. I have my debit card to my account and the debit card to [R901's] account and I got them mixed up. I though I changed the information but I guess it didn't go through. But what about the $14,000? I don't know what to tell you it wasn't me. I kept track of what was spent and I paid it all back. The statements will show how much I took. The statements show around $14,000.00 from [the online gambling app]. How did you track it? We went through it together. So you knew [R901's] account had been linked to [the online gambling app]? Yes but I paid back what I took. [R901's] account is closed as of yesterday. I am not trying to accuse you. I am trying to find out what happened to the additional $8000.00 to 10,000.00 withdrawn by [the online gambling app]. I don't know what to tell you it wasn't me. Interview conducted 2/14/25 around 12:30 PM in the Administrators Office . present for phone interview . signed 2/14/25. A review of the facility's investigation interviews revealed, .The account was set up and [R901] was able to have a couple large SSI deposits into the account and [R901] started paying off bills. [R901] had not thought of anything of it, but started to notice funds were not being available when [R901] would go to use it. [R901] would ask [Staff A] for money. About 2 weeks ago, [R901] had no cash again so [R901] wanted to create a online profile so [R901] could see the activity and transactions on the account. That is when [R901] saw all the gambling transactions. [R901] said that [Staff A] said I told you I do online gambling. [R901] told her to put the money back and [Staff A] said I do. [R901] called the back Wednesday (2/12/25) to see if [R901] could have [Staff A] removed from the account if [R901] went there with [R901's] daughter and the bank said yes. [R901] and [R901's] daughter went to the bank on 2/13/25 and the bank would not allow [R901] to take [Staff A] off the account but they did allow [R901] to close the account. They proceeded with that and had the account closed. They also had the bank print out the history of transactions back to the opening of the account in October 2024. The daughter took the large stack and reviewed with the police. Total amount taken was $18,368.14. The daughter stated it was around $14,030 towards gambling and the resident were purchases at places like [local pharmacy], gas stations, etc. The daughter said she put back $6,193.59, which $570 was from [Staff A], the rest was from gambling winnings. The Police arrived last night (2/13/25) with [R901's] daughter. They said to call 911 if she (Staff A) comes in to the facility. This morning (2/14/25), [Staff A] got in (the facility) somehow and got in [R901's] face saying Do I need to get a lawyer? Your daughters did this to me. She told [R901] that she was the reason she was fired from her job and that she wasn't going to help anymore ever again. She left the room at that point [R901] said [R901] has been texting and calling [R901] ever since last night and the Cops said not to block her number right now. Interview conducted 2/14/15 around 10 am in the residents room. Administrator, Assistant Admin, Resident, and Daughters (one on phone) present for interview. Signed and Dated 2/14/25 by the resident, witness and interviewer. Review of the facility policy titled, Abuse dated 5/24/23 documented, Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint that is not required to treat the patient/resident ' s medical symptoms .Prevention consists of facility systems designed to detect, identify, correct, and prevent the occurrence of abuse. The facility utilizes the Quality Assurance and Performance Improvement Plan (QAPI) process to review care practices, trends, and patient outcomes in order to maintain continued performance improvement .Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur in accordance with the facility ' s Quality Assurance and Performance Improvement Plan (QAPI).

This citation pertains to Intake MI00149892. Based on interview and record review, the facility failed to ensure notification of a room change was provided for two residents (R906, R908) of three reviewed for room changes. Findings include: On 01/30/25 at 9:22 AM, a review of a complaint related to R906 revealed an allegation R906 responsible party (RP) or family was not notified of R906's room change. A phone call was made to the first emergency contact and financially RP designated in the medical record. An advocate designation dated 09/08/21 documented the RP as the advocate for healthcare. The RP reported they had not been notified until two days after R906 was moved and had to ask which room the resident had been moved to when they arrived to visit. The RP further reported the room to which R906 had been moved had a resident who yelled out often and disturbed R906. The RP further noted R906 had a roommate (R908) who was also moved out of the room. A review of the record for R906 revealed R906 was admitted into the facility 07/21/23. Diagnoses included Dementia, Falls and Pain. The Minimum Data Set (MDS) assessment dated [DATE] documented, severely impaired cognition. A review of the progress notes in the electronic medical record revealed no documentation or indication R906 nor the RP had been notified before R906 was moved to a different room. A review of the census data documented R906 had been in the same room from 07/21/23 until moved on 10/08/24. No additional documentation for notification of the room change was provided for R906 prior to survey exit. On 01/30/25 at 9:55 AM, R908 reported they were informed of the room change on 10/08/24 just before it happened and did not like the room they were moved to as it was smaller. R908 reported they were moved because there was a COVID patient who needed the room and was told they were being moved and was not given an option to preview the new room. A nursing note dated 10/11/2024 at (7:33 PM) 19:33 documented, Received resident alert and responsive. Adjusting to current room change . No documentation for prior notification of the resident or family for the room change on 10/08/24 was found in the electronic medical record. A review of the record for R908 revealed R908 was admitted into the facility 09/28/22. Diagnoses included Dementia and Pulmonary Disease. The MDS dated [DATE] documented intact cognition. The electronic medical record profile page documented a daughter as the responsible party for financial items and the first emergency contact. The active care plan initiated 09/29/22 documented a self care deficit for activities of daily living, a potential risk for falls and an impaired thought process or cognitive function. The care plan indicated to present just one thought, idea, question or command at a time. A review of the facility policy titled, Notification of room/roommate change dated 04/18/23 revealed, .The right to receive written notice, including the reason for the change, before the resident's room or roommate is changed .Complete the Notification of Room/Roommate Change Assessment located in the (electronic medical record). Print the Notification of Room/Roommate Change Assessment after completion. Discuss the change with the resident and or the resident's representative, including the reason for the change. Provide the resident or representative with the notification form .

This citation pertains to Intake M100149834: Based on interview and record review, the facility failed to implement care planned interventions to prevent a fall for one (R902) of three residents reviewed for falls. Findings include: Review of the facility record for R902 revealed a most recent admitted [DATE] with diagnoses that included Spina Bifida with Hydrocephalus, Paraplegia, and Epilepsy. R902's most recent care plan included the Focus item Resident is at risk for falls and potential for injury related to seizure diagnosis, impaired physical mobility, paraplegia, history of falls, medication use. One intervention item associated with this care plan stated Place anti-slip pad in wheelchair seat. Further review of R902's facility record revealed a progress note dated 01/08/25 authored by Licensed Practical Nurse (LPN) J indicating they had been notified by staff that R902 had fallen in their room. LPN J indicated they went to the room and R902 was laying on the floor near the wheelchair and a mechanical lift (device used to transfer residents from one surface to another). LPN J indicated R902 was assessed to have no pain or obvious injury and was transferred to their bed then the physician was notified and requested the resident be transferred to the hospital for further assessment. On 01/29/25 at 12:49 PM, LPN J was interviewed and asked to recount what they recalled about R902's fall on 01/08/25. LPN J reported a staff member notified them R902 had fallen in their room. LPN J reported they went to the room and the resident was on the floor and Certified Nursing Assistant (CNA) K was with the resident. CNA K reported they had put the lift sling under the resident to be transferred back to bed and they realized the sling was the wrong size. CNA K reported they went to get another sling and the resident fell from the wheelchair as they were leaving the room. LPN J reported they assessed the resident to have no obvious injuries and then staff transferred the resident back to bed with staff assistance. LPN J reported they called the physician to report the fall and it was recommended the resident be transferred to the hospital to be further assessed. On 01/29/25 at 1:08 PM, CNA K was interviewed via phone call and asked to recount what they recalled regarding R902's fall on 01/08/25. CNA K stated they were preparing to transfer R902 from the wheelchair back to bed. They reported they put the mechanical lift sling under the resident. CNA K stated once they had the sling in place they realized it was too big so they went to retrieve the proper sling. They stated as they were leaving the room they heard a noise and looked back and R902 was on the floor in a position of having slid forward out of the wheelchair. On 01/29/25 at 2:37 PM, the facility Director of Nursing (DON) reported their understanding of the fall involving R902 was the CNA put the mechanical lift sling in place under the resident in the wheelchair and realized it was the wrong size. When they left to get another sling the resident slid out of the chair as they were sitting on the sling. The DON indicated that the resident should not have been left sitting on the sling unattended and that they had stressed this with staff in the past. The DON was asked about R902's care plan intervention for non-slip padding being used in the wheelchair and they indicated the resident was at risk for slipping forward from the chair. The DON reported the expectation is when the sling is put under the resident in the wheelchair they should not be left unattended due to the fall risk. A facility policy or documentation otherwise addressing the issue of a physically compromised resident being left unattended sitting on a lift sling was requested. Although the facility did provide policies addressing resident fall protocols and mechanical lift use, the information provided did not specifically address the identified concern.

This citation pertains to Intake: MI 080. Based on observation, interview and record review, the facility failed to adequately monitor and supervise one sampled Resident (R700) who was deemed incompetent to make medical decisions by two doctors, had a history of elopement attempts and a fluctuating cognition ranging from a BIMS (Brief Interview for Mental Status) score of ,d+[DATE] to ,d+[DATE] (day of elopement). R700 eloped from the facility for an unknown period of time with staff being unaware of the resident's whereabouts. The staff member assigned as a 1:1 for R700 left the resident unsupervised while they went to the restroom. R700 was located approximately 20 minutes later with a beer and a recyclable bag of undisclosed items on their person, revealing they got out. R700 was left unsupervised and found near a busy main road with alcohol, resulting in the likelihood of serious injury, harm, or death. Findings include: A review of Intake MI 080 revealed the following, Incident Summary: On [DATE] at approximately 10pm it was noticed that [R700] was not in [their] room and had left the unit floor. An immediate search was conducted. [R700] was located walking on the sidewalk in front of the building walking towards the driveway. The nurse asked [R700] to return inside the facility with her, which [they] did. [R700] was returned to [their] room . A review of the Incident/Accident report dated on [DATE] and written by Nurse E revealed the following, Code W called, Facility search for patient. Administrator and DON (Director of Nursing) called, patient observed 200 feet from facility at Courtyard gate with beer in hand . A review of R700's medical record revealed that they were admitted into the facility on [DATE], and discharged on [DATE] with diagnoses that included [CONDITION(S)] (loss of ability to understand or express) following Cerebral Infarction (stroke),[CONDITION(S)], Cocaine Abuse and Anxiety. Further review of R700's medical record revealed that R700's Brief Interview for Mental Status score on [DATE] was a ,d+[DATE] indicating a severely impaired cognition, and was independent with Activities of Daily Living. Further review of R700's medical record revealed a Physician Certification of Capacity dated for [DATE] and revealed the following, .As of this date, this resident is: Incompetent to participate in medical treatment, care and custody decision making .The reason that the resident is unable to participate is: Impaired Judgement and Cognition . This document was signed by a physician and a licensed psychologist. A review of R700's elopement assessment dated [DATE] revealed that the resident was high risk for elopement. Further review of R700's medical record revealed the following care plan: Focus: Risk for elopement related dementia process and confusion as evidenced by prior attempts and history of elopement, attempts to get out of building, pulling handles of locked doors. Risk for injury due to elopement attempts. Date Initiated: [DATE]. Interventions: 1:1 sitter to help prevent elopement or leaving building. s/p (status post) incident, [DATE]. Date Initiated: [DATE]. Frequent visual checks throughout each shift. Date Initiated: [DATE]. Place on timed monitoring if elopement attempts continue. Date Initiated: [DATE]. Provide one-on-one staff monitor if resident appears to be involved in active attempts to elope from the building or unit. Date Initiated: [DATE]. Further review of R700's medical record revealed the following progress notes: [DATE] 17:51 (5:51pm) Nursing - Progress Note: late entry approximately 1:00 p.m front desk called stating resident was trying to get out of front door, redirected to unit, afternoon supervisor notified stated she will assess to see if wonder guard (wander guard, a device used for residents at risk of elopement) is needed. [DATE] 23:34 (11:34pm) Behavior Note: Resident resting pacing in hall asking for a cigarette wanted to call family. Asked if i could bring [them] a pack in a.m. [DATE] 13:52 (1:52pm) Behavior Note: Resident exited the facility and the wanderguard was activated at 1320 (1:20pm). Writer followed resident in the circle driveway and [R700] was walking swiftly as I attempted to coax [them] back. [R700] stated 'no, I'm going home, as [R700] was waving [their] arms. [R700] was non compliant with the command to return into the building. Another nurse joined in attempting to talk to [them] and get [them] to turn around and come back. As the nurse followed resident, I came in the building and instructed the receptionist to call 911. I called the administrator and alerted him to the situation. He stated that he'll be here shortly. I followed [R700] in my vehicle having [them] in my direct vision at all times as [they were] walking north on [local street]. I called 911 to give the location. The police and the administrator and I were at [intersection]. The police asked [R700] if [they] will return and [they] stated yes .[R700] was safely back in the building at 1350 (1:50pm) and returned to [their] room. [DATE] 22:32 (10:32pm) Nursing - Progress Note: Late entry for [DATE] at 2015 (8:15pm). Nurse notified writer that she smelled smoke in [R700's room]. Upon investigation the (there) was the scent of smoke. Ashes were observed on the floor next to the bed. When asked if [they] was smoking [they] stated yes. I asked [R700] for the cigarettes and [they] gave me a half empty pack and the lighter. I asked [R700] where [they] put the cigarette out [they] stated 'in my ashtray' and pointed to the garbage can. a wet cigarette was in the can. informed resident that smoking is not allowed. [R700] stated ok I won't do it again.' [DATE] 14:53 (2:53pm ) Nursing - Progress Note: Aprox (approximately) 12:40pm wonder guard was activated, front desk alerted for help. Writer and a few other staff members ran down stairs to assist. Resident noted running at full speed towards assisted living building. Writer, CNA, another nurse and supervisor ran with resident to catch up to [R700]. [R700] remained with in our sight the entire time. Resident continued at full speed toward [local street], [R700] jumped over the brick wall. CNA first to catch up with resident and attempted to talk to [them]. Resident attempted to swing on CNA and was verbally aggressive. Resident proceeded to run again. Staff still right behind [them]. Resident made it to the [local business] on [intersection]. Staff still attempting to redirect resident. Resident stated 'I need a cigarette' 'im trying to go to the store'. We stated that there was a lot of traffic on [local street] and let us just go to the store for [them] so that [they] wouldn't get hit by a car. Resident stated 'let me go in traffic i dont care let me get hit.' Resident still very verbally aggressive and trying to swing on staff at this point. I pointed to the [local] gas station two buildings down from where we were standing and let [R700] know the store was right there and there was no need to cross [local street]. [R700] allowed me to redirect [them] towards store at this point police was already on the corner of [local street] there to assist us. As soon as resident seen police [they] stopped being aggressive. When the police asked [them] where [they were] headed [they] stated 'oh im just headed home with them'. Resident got in to police car was transported back to facility with no problems. Resident transported w/o (without) incident. Shortly after getting back to the unit resident was assigned a 1:1 staff member. CNA stated that Resident walked over to [roommate's bed] and proceeded to spit in the tray of the resident .[R700] proceeded to turn the resident TV off and stated [they] needed some peace and quiet. CNA stated that resident stated that [their] room mate is nosey and always listening to [their] conversations and that [they] better be happy [roommate] doesn't get [their expletive] whopped. MD (medical doctor) was notified, and one time dose of [MEDICATION(S)] (antipsychotic) was administered due to resident behaviors of verbal and physical aggression towards self and others. MD also stated to have psych follow resident if not already. Supervisor present and administered dose to resident left arm . [DATE] 15:54 (3:54pm) SW (social work) was notified by Nursing staff that resident had tried to elope today. SW went to visit resident who was lying in bed .SW asked resident if [they] wanted to leave the facility, resident denied. [They] furthered, 'I was waiting on someone to come and see me.' Resident did not share who [they] were waiting on. [DATE] 17:28 (5:28pm) Behavior Note: Resident anxious with jacket on and requesting for family to pick [them] up. Son told [them] no that he can not pick [them] up. Meds given dinner consumed and resident calmed down to bed. [DATE] 17:26 Nursing Progress Notes. Late entry, resident agitated on and off, sitter at bed side, resident ask writer to call son stating [they are] ready to go home [R700] did everything [they were] supposed to do here, writer called son for resident to talk to, resident on phone yelling at son to come and get [them], resident gave phone back to writer and yelled tell him to come and get me now [R700] is tired of being here, son stated he is at work and could not talk right now. SW notified. [DATE] 23:39 (11:39pm) Nursing- Progress Note. Sitter at bedside to monitor resident. Resident calm but state I want to go home . [DATE] 17:26 (5:26pm) Nursing - Progress Note: late entry, resident agitated on and off, sitter at bed side, resident ask writer to call son stating she is ready to go home she did everything she was suppose to do here, writer called son for resident to talk to, resident on phone yelling at son to come and get [them], resident gave phone back to writer and yelled tell him to come and get me now [R700] is tired of being here, son stated he is at work and could not talk right now, SW notified. [DATE] 23:54 (11:54pm) Nursing- Progress Note. resident yelling in hallway using foul language stating someone stole [their] money, resident became combative, settled down after redirecting, sitter by resident side. [DATE] 01:03 (1:03am) Nursing-Progress Note Writer observed resident was not in room. Immediately searching for resident, notified the administrator and Director of Nursing (DON). Resident located about 200 feet away from facility. Writer asked resident to return to facility. Resident did with no problem. Patient has no c/o (complaints of) pain or discomfort . On [DATE] at 10:35 AM, the door leading out to the courtyard was observed to automatically open for anyone to enter or exit Located at the top right corner of the door was a key observed in the lock. The courtyard was observed to have a wrought iron fence, in addition to a fence door that exited into the parking lot of the facility. On [DATE] at 10:50 AM, a door on the 3rd floor that lead into the facility stairwell was observed to be alarmed however, next to the door was a keypad that required a code to open. Next to the keypad was a piece of paper that had the code listed in order to open and unlock the door. The paper indicated that the code was the current year followed by an asterisk. However, written in red ink were the words, last year. The surveyor entered the code, unlocking the door. On [DATE] at 4:09 PM, an interview was completed with Nurse E regarding the date R700 eloped from the facility. Nurse E explained that they were working the ,d+[DATE]:00pm shift when one of the CNAs approached her and indicated that R700 was not in their room. Nurse E explained that after searching throughout the facility, she got into her car and made a right out of the driveway of the facility, and observed R700 standing by the facility sign (located near the main street leading to the facility). Nurse E explained that she asked R700 to get back into their car, which they did with hesitation. Nurse E explained that the resident had two bags in their hand, and refused her access to the bags. Nurse E explained that R700 initially refused to go through the front doors leading into the facility but eventually complied, causing the door alarms to sound within the facility. Nurse E was asked what time this incident occurred, and explained that it was dark outside, but believes it was before 11:00pm. Nurse E was asked how long the resident had been gone, and stated, No more than ,d+[DATE] minutes. Nurse E was asked about the location of R700's 1:1 sitter when the resident left, and explained that the 1:1 sitter went to the restroom, and [R700] took advantage of them being gone .the CNA slipped up. Nurse E stated, I told her she could have come and gotten me. Nurse E was asked if she knew how R700 exited the facility and explained that she did not know, but that the resident told her that she got out of a secret door. On [DATE] at 8:59 AM, the DON (Director of Nursing) was interviewed regarding the elopement of R700. The DON explained that she was contacted following the implementation of the facility's code for an elopement. She reports that once she arrived the resident had already been located which was by the sign located near the entrance driveway of the facility. Regarding how the resident got out of the facility, she explained that the resident exited through the courtyard by the therapy gym and jumped over the fence to obtain beer. The DON explained that the resident has an order for PRN (as needed beer) due to their previous behaviors which included having someone drop off beer near the courtyard. The DON explained that all the resident needed to do was let the nurse know, and should would have been provided with the beer. The DON was asked what time the resident exited the facility and explained that it was after 9:00pm. The DON was asked about the resident's 1:1 sitter, and explained that R700 had a 1:1 intermittently based on their behaviors, but admitted that the resident had a 1:1 the evening they eloped. The DON was asked if they knew how long the 1:1 sitter left R700 unsupervised, and indicated that she did not know. The DON was asked if the courtyard door is ever alarmed and indicated that the door leading out of the courtyard is not alarmed and that it dings if someone exits through it. The DON was asked who would hear that sound, and explained the receptionist would hear it however, admitted that there are no receptionist staff at the front desk after 8:00pm. On [DATE] at 9:26 AM, an interview was completed with Nurse F regarding the elopement of R700. Nurse F explained that R700 had a history of having their significant other bring them items through the courtyard fence, and that there was supposed to be an order for the resident to have a beer, and to her knowledge, had never seen it carried through. Nurse F explained that the night R700 eloped, the resident did have a 1:1 sitter however, the sitter went to use the restroom directly across from the resident's room without notifying anyone, resulting in R700 leaving. Nurse F explained that they were informed that the resident was not in their room and they began to look for them, leading them outside where R700 was observed walking toward the building. Nurse F was asked what time the incident occurred, and she indicated that it was sometime between ,d+[DATE]:00pm, and is unaware how long the resident had been gone. Nurse F was asked if the resident stated anything about leaving, and Nurse F explained that R700 had what appeared to be a recyclable bag that they held tight to their body. Nurse F explained that R700 patted the bag and stated, I got my beer in my bag. Nurse F stated, [R700] was happy, and I didn't hear from them for the rest of the night .[R700] made it clear that if [they] didn't get their beer, they would get it. Nurse F was asked if she knew how the resident exited the facility and explained that they went out the courtyard doors located by the therapy gym, which has a lock however, the key is always left in the door and that anyone can walk up to it and get in or out. Nurse F explained that she was never advised to lock the door at a specific time, and that she would take it upon herself to lock it for fear of someone entering the facility and causing harm. On [DATE] at 12:14 PM, the Nursing Home Administrator (NHA) was asked about the elopement of R700 and explained that he had received a call that the resident had gotten out, but had returned to the facility. He explained that the resident initially reported that they had gotten out through a secret door but later indicated that they had gone out of the therapy courtyard and climbed over the fence. The NHA explained that there is gate door in the courtyard, and R700 climbed over which is alarmed by a Wanderguard system. The NHA explained that R700 was very able bodied and had gotten out prior with staff chasing them. The NHA also explained that they do not believe that the resident purchased the beer from the store as they did not have a receipt or bag from a store, however, admits that the resident refused to answer how they had obtained the beer. The NHA further explained that after discussion was held regarding R700 being sent to a locked facility, they became aggressive with staff and was petitioned out to the hospital. The NHA was asked about the resident not being supervised by their 1:1, and explained that the 1:1 sitter had gone to the restroom, and was not completely sure how long or how much time had went by, but from his investigation believes the resident had been gone for approximately 15 minutes. On [DATE] at 2:22 PM, an interview was completed with assigned 1:1 sitter, CNA I the night R700 eloped. CNA I explained that she was working a double shift on that date, and had been an assigned 1:1 sitter for R700 before, but usually on the day shift where the resident is often less active and asleep in bed. CNA I admitted that they left the resident unsupervised, and went to the restroom for approximately ,d+[DATE] minutes. CNA I explained that the resident was talking to two other residents and seemed okay. CNA I explained that while in the restroom, Nurse F knocked on the door and explained to her that R700 was missing. CNA I was asked if they remembered the time that they had gone to the restroom, and explained that it was between 9:30pm-10:00pm. CNA I was asked if they knew how the resident exited the facility, and indicated that she did not know. CNA I was asked if they knew where R700 was located and explained that they had heard that the resident was located by the facility sign. CNA I was asked if the resident returned to the facility with anything, and explained that they had a bag that resembled a bag carried by food delivery services, and that R700 had two medium sized beers cans in their possession upon returning. CNA I further stated, I slipped up, I thought [R700] would be okay talking to the two residents in the hallway. On [DATE] at 1:14 PM, the Medical Director was asked his expectations for 1:1 sitters for elopement risk residents, and explained that if the resident requires a 1:1 sitter, the resident should be supervised and in their line of sight at all times. A review of the facility's Elopement Assessment and Deterrence Application of the Wander Alert Bracelet revealed the following, .12. The resident should be monitored frequently during the course of the shift. The frequency should be determined by the degree of risk and past elopement history. This could vary from 1:1 supervision, hourly checks or what has been deemed necessary for safety of resident. The frequency of the monitoring should be noted on the patient's care plan and the direct care staff should be informed for proper carry-through . The Administrator was notified of Immediate Jeopardy on [DATE] at 4:25 PM and a plan of correction was requested to remove the immediacy that began on [DATE]. The facility provided the following removal plan. Immediate Jeopardy was removed on [DATE] and validated by the team on [DATE]. Facility Removal Plan The following measures were taken and implemented to ensure resident safety and remove immediate jeopardy issued on [DATE]. R700, No longer resides in the facility. She now lives in the community with her boyfriend. All residents have been evaluated for elopement risk and those 7 residents identified as at risk have a proper plan of care implemented to ensure safety, to be completed by [DATE] at noon. There is a process, Elopement Prevention Program, for ensuring that all residents at risk for elopement are adequately supervised to ensure their safety, to be completed [DATE] at noon. The IDT (interdisciplinary team) team reviewed that the elopement lists are current and reviewed them with staff in facility, to be completed by [DATE] at noon. The Courtyard door will remain locked until the wander guard system can be updated, completed [DATE] at 5pm. Once the Wanderguard system is updated the door will be open and the courtyard available, weather permitting, while there a receptionist available at the front desk, hours from 8am until 8pm. Residents may only use the courtyard in the presence of staff until system upgrade is finished, completed [DATE] at 5pm. The door to the courtyard will remain locked. Staff and residents were educated through the use of verbal education on the change in use of courtyard and a sign was hung on the door to indicate staff supervision needed, completed [DATE] at 7pm. There are no 1:1 sitter orders for an elopement risk currently however, staff in facility was educated verbally on 1:1 sitter protocol to emphasize uninterrupted supervision of resident, completed [DATE] at 7pm. The Elopement prevention policy and program was reviewed, and verbal re-education is being scheduled for all staff prior to their next working shift, and no later than [DATE]. Date of alleged compliance is [DATE]. Although the Immediacy was removed on [DATE], the facility remained out of compliance at pattern no actual harm with potential for more than minimal harm that is not immediate jeopardy, as sustained compliance could not be verified by the state agency.

This citation pertains to intake MI 160. Based on interview and record review, the facility failed to adequately assess and monitor skin and follow up on documented presence of wounds for one sampled Resident (R708) of three reviewed for pressure ulcers, resulting in the development of unstageable pressure ulcers, the lack of treatment and further assessment of noted skin alterations, and the potential for infection, pain, and debility. Findings include: A review of intake MI 160 revealed, [R708] .decompensated physically and cognitively while [at the facility]. She arrived with difficulty walking only. Now, she can't get out of bed, she doesn't recognize people, she has bed sores that [are] very bad and they have resulted in Hospice . A review of R708's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was admitted into the facility on [DATE] and discharged on [DATE], and indicated that the resident was cognitively intact, had no pressure ulcers or other noted skin conditions, and had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] was added as a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R708's pre-admission hospital documentation dated 6/11/22 noted [CONDITION(S)] blanchable on the resident's coccyx, with moisture-associated [CONDITION(S)] (red and irritated skin at risk of breakdown) with no drainage noted on the resident's buttocks, covered with an adherent foam dressing. R708's facility Baseline Admission Evaluation dated 6/11/22 noted the following: Does the resident have any skin abnormalities? No. A review of R708's care plan revealed: -The resident has potential impairment to skin integrity r/t (related to) fragile skin, general weakness, impaired mobility, periods of incontinence Date Initiated: 06/13/2022. -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 repositioning, Braden score 20. Date Initiated: 06/21/2022. -Monitor skin daily during care for redness, excoriation, or breakdown. Date Initiated: 06/21/2022. -Weekly nursing skin evaluations with showers. Notify PCP (primary care provider) and wound care nurse of any skin changes. Date Initiated: 06/21/2022. A review of R708's progress notes revealed: -6/11/2022 16:53 (4:53 PM) Nursing - Progress Note Note Text: Resident received from [hospital] .DX (diagnoses) covid, s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident is alert to 4 (alert and oriented to person, place, time, and situation), continent to BB (bowel and bladder), x1 assist with ADL (activities of daily living) care, on a regular diet, skin CDI (clean, dry, intact) . -6/13/2022 13:23 (1:23 PM) Nursing - Skin/Wound Note Note Text: Wound care: Second skin assessment: Bruises - BUE (bilateral upper extremities), right hand, bilateral knees, Small scattered scabs - left knee, Old abrasion left hip, Scab LLE (left lower extremity), Scar right hip, Heels dry and intact. -6/23/2022 11:56 (AM) Type: Nutrition/Dietary Note Note Text .Skin intact. No [CONDITION(S)] .Moderate temporal and orbital wasting. Mild deltoid wasting . (This was the only nutrition/dietary note found). No additional progress notes fully addressing the resident's skin were found until the day that the resident was set to discharge to an assisted living facility, written by the former wound care nurse, Nurse G: -7/21/2022 11:38 (AM) Nursing - Skin/Wound Note Note Text: Reported to wound care resident has skin alteration to spine, sacrum, right ischium, treatment in place per facility protocol. Noted resident has had decline in condition, resident refusing medication, meals and care. Physician has recommended hospice family made aware d/t (due to) decline in condition with refusal of intake, medications and care which makes resident unavoidable to skin alterations. A full assessment and details of the reported skin alterations was not found, and no skin treatments were noted for R708 for the duration of the resident's stay at the facility (all physician orders, medication administration records, and treatment administration records were reviewed). The resident's discharge instructions only stated, Dermaseptin to spine, sacrum, ishium (sic), with no further details, or description/assessment of the wounds. A review of all detailed skin assessments completed during R708's stay revealed only one dated 6/30/2022, which noted the following: -Skin Evaluation .Turgor : Poor Elasticity .Skin Color : Normal for ethnic group .Temperature : Cool .Moisture : Clammy .Condition : Dry . Does the resident have any wounds? Yes .Is Wound Care consulted (would be listed in the patient profile)? Yes . The comment section on the 6/30/22 skin evaluation was left blank and a consult for wound care was not found in the resident's record upon review. This skin assessment was the only one found under the assessments tab in the resident's electronic medical record. No corresponding progress note related to this assessment was found. On 9/13/22 at 12:00 PM, Confidential Witness H was interviewed via phone and explained that R708 was discharged from the nursing facility to an assisted living facility on 7/21/22. A home care nurse evaluated R708 at the assisted living facility after she arrived, and informed Witness H that R708 needed to go to the hospital. Witness H indicated that R708 was at the assisted living facility for less than 24 hours after arriving from the nursing facility. Witness H also explained that R708 was found to have bedsores (pressure ulcers) upon discharge from the nursing facility. On 9/13/22 at 12:48 PM, Nurse G, former employee and wound care nurse, was called for an interview. Nurse G did not agree to be interviewed and took this surveyor's name and number down. Nurse G stated she would call this surveyor back within 30 minutes, however, a call back from Nurse G was never received. R708's post-discharge hospital records were obtained on 9/14/22. A review of the records revealed the following: -Emergency documentation dated 7/22/22 noted .It was worth noting the patient had moved from [nursing facility] to the [assisted living facility] just yesterday (7/21/22) .Discharge Summary dated 8/1/22 .Hospital Course .Reason for hospitalization : acute [CONDITION(S)] .A fib .pleural effusions .Hospital Course: [Resident] was sent to the ED (emergency department) by her home care nurse. She recently transferred to [assisted living] from [facility] .also noted to have stage 4 pressure ulcers that surgery debrided .She is scheduled to return to her assisted living with home hospice . The hospital records indicated a bedside debridement of the resident's unstageable sacral wound and thoracic spine wound was done on 7/26/22 revealing a Stage IV sacral wound and a Stage III thoracic spine wound. On 9/14/22 at 9:05 AM, the Director of Nursing (DON) was asked if an assessment should be in place if a wound is noted on a resident's skin to which she replied, Yes. The DON was then asked if a wound/wounds are found, if a treatment should be initiated. The DON replied, Yes. On 9/15/22 at 3:45 PM, the DON was again interviewed and asked specifically about the 6/30/22 skin assessment that indicated R708 had wounds. The DON stated that the nurse might have clicked the assessment by accident. The DON stated that the only wounds on R708 she knew of were seen upon discharge, and that the wound care nurse did not have time to do an assessment. The DON acknowledged that the wounds R708 obtained were facility-acquired but was unable to provide any further information. A review of the facility's policy/procedure titled, Skin & Wound Policy, dated 2/28/22, revealed, A full body, or head to toe, skin and oral cavity assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter .The assessment may also be performed after a change of condition or after any newly identified pressure injury .All wounds will have treatment order from the physician team .Documentation see Appendix B (no appendix B attached) .

This citation pertains to intakes: MI 636, MI 655, MI 345 and MI 499. Based on interview and record review, the facility 1) Failed to identify and treat an acute change in condition timely for two sampled Residents (R500 and R518) of four residents reviewed for a change in condition and 2) Failed to assess, document, and intervene appropriately and timely for two sampled Residents (R511 and R522) out of two residents reviewed for fall and weight gain and implement interventions in a timely manner resulting decline in health, a delay in appropriate treatment, anxiety, pain/prolonged pain, fluid build-up, re-hospitalization s, and feelings of frustration. Findings include: Resident #500 (R500) On [DATE] at 11:59 AM, Confidential Witness J was interviewed via phone regarding the care Resident #500 received while in the care of the facility. Confidential Witness J stated, (Resident #500) was there (admitted at the facility) on a Monday night for rehabilitation. They (the facility) didn't let visitors in. We couldn't go in to see (Resident #500) so we would talk to (Resident #500) over the phone. On Friday morning at about nine o'clock (in the morning), I spoke to (Resident #500) on the phone and (Resident #500) says, 'I am short of breath, they are putting oxygen on me'. I let (Resident #500) go (off the phone) and gave it (the situation) about ten minutes then I called the floor. No one answered. At this point I was getting scared. I talked to the Director of Nursing (DON) .(Resident #500) has never been on oxygen. I told her we really want (Resident #500) to go to the ER (emergency room ), we were scared. She never called me back. I got a call from the Nurse Manager (Nurse Manager L), who said they were giving (Resident #500) a breathing treatment and the Nurse Practitioner (NP M) was going to go in there and evaluate (Resident #500). I asked them to have her (NP M) call me. She did call me back an hour and a half later and I told her we wanted (Resident #500) to go to the hospital, (Resident #500) had never had shortness of breath. I have worked in the medical field in the hospitals for years, so I know some medical stuff. (Resident #500) just had surgery, I was worried (Resident #500) had a PE (pulmonary embolism-a medical emergency resulting from a blood clot forming in the lungs). She (NP M) said (Resident #500) was stable and that they didn't give (Resident #500) a breathing treatment. She (NP M) was aggravated with me and said we would have to send (Resident #500) to the hospital AMA (against medical advice). We felt threatened, if they leave AMA, then we get stuck with the bill. I said it three times, I want (Resident #500) to go back to the hospital! (Resident #500) called me at quarter to one (in the afternoon). (Resident #500) said lunch was going to come in a half an hour. (Resident #500) sounded a little short of breath still. They took the oxygen off of (Resident #500) and gave them a pain pill. When I called (Resident #500's) direct line again, there was no answer. I thought one of two things, either (Resident #500) was sleeping because of the pain pill, or they moved their phone away from (Resident #500). I gave it another hour. I got a call at 03:28 (PM), it was Nurse Manager L saying something about (Resident #500) and the shower and she said they left (Resident #500) for two minutes, she said their heart stopped. I went to the ER, they said they couldn't bring (Resident #500) back. The Death Certificate stated 'Cardiac arrest due to heart disease'. We had a private autopsy performed and are waiting for results. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #500 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #500 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #500 had a brief interview for mental status (BIMS) score of 10 out of 15, indicating moderate impaired cognition and needed extensive assistance with bed mobility and transfers. A record review of the Progress Notes revealed the following for Resident #500: [DATE] 09:54 (AM) RT (Respiratory Therapy) Note .Called to evaluate resident. SpO2 (pulse oxemetry) on room air 79% (Normal is ,d+[DATE] %). O2 (oxygen) placed on resident and SpO2 on 5L (liters) is 93%. [DATE] 10:00 (AM) COMMUNICATION - with Family .Note .Resident's daughter . phoned requesting an update on resident. Informed her that resident was having some SOB (shortness of breath). NP was notified and assessed resident. (Resident #500) was started on oxygen, 5L/NC (nasal cannula), and .O2Sat was ,d+[DATE]%. Resident is now breathing without difficulty, with O2 at 5L/NC. Rapid COVID test was done and results negative. Resident will continue to be monitored. Daughter requested that NP and PCP (Primary Care Physician/Dr. F) call her regarding (Resident #500). Assured daughter that her message would be given to PCP and NP. Daughter verbalized understanding of the above. [DATE] 10:34 (AM) Nursing - Progress Note .Resident in isolation for potential exposure prior to admission, hospital roommate tested positive (for Covid 19). Rapid covid test was negative, Pt (patient) experiencing SOB. Resident consented to N/P (nasopharyngeal) swab for covid 19 .test .lab called for pick up . [DATE] 10:47 (AM) Physician Team - Progress Note Late Entry .Encounter Date: [DATE] Chief Complaint: called into room by nursing re: O2 sat at 81% on 5L O2 .Call from infectious disease at [local hospital] that the patient was exposed to Covid by roommate at [local hospital] Respiratory: Positive for: Dyspnea (difficulty breathing) .Code Status: Full .Respiratory : diminished bilaterally (an abnormal finding of absent or decreased lung sounds usually caused from fluid or air trapped in the lungs), symmetric, No respiratory distress; O2 nasal cannula d/c (discontinued) from O2 canister; reconnected and sats improved .Dyspnea, unspecified .O2 canister not connected to nasal cannula at time of VS (vital signs) RT (Respiratory Therapist) was notified prior to discovery for possible breathing tx (treatment). Nasal cannula reconnected and pt sats improved to 94%. RT deemed updraft (breathing treatment) not needed. Continue to monitor .Contact with and (suspected) exposure to COVID-19 .Per infectious disease team at this time continue to monitor patient off treatment, after 5 days with no fever or chills or symptoms of Covid, repeat testing . Authored by NP M. [DATE] 12:30 (PM) COMMUNICATION - with Family .Note .Spoke with resident's daughter .and update given. Respirations regular, no distress nor difficulty breathing, no SOB noted. O2Sat 94% on 5L/NC. Repeat rapid COVID test was negative. Given pain med about 1115 (AM), for abdominal pain. Had some nausea this am, and did not eat breakfast, but had .juice. Resident is resting comfortably at this time. NP and MD (Medical Doctor/Dr. F) informed that daughter would like to be called, per .request. Questions answered. Daughter verbalized understanding of the above, and stated she is just worried about (Resident #500). NP informed of the nausea and order to be entered. [DATE] 12:38 (PM) Nursing - Progress Note .Resident A&OX3 (alert and oriented to person, place and time) O2 saturation 78 (percent). Respiratory Therapist contacted resident given 5L of oxygen via NC (nasal cannula). O2 saturation progressed to 94%. Resident C/O (complains of) pain in abdomen ,d+[DATE] (6 out of 10, 10 being the worst pain). PRN (as needed) pain medication given. Breakfast given, not tolerated well . [DATE] 12:50 (PM) Nursing - Progress Note .At approximately 0900 (AM) NP was notified of the change in 02 saturation. NP evaluated resident and order to continue oxygen at 5LNC. Rapid Covid test completed results negative. Will continue to monitor resident and notify NP/PCP of any changes. [DATE] 15:45 (03:45 PM) Nursing - Progress Note .At approximately ,d+[DATE] (02:,d+[DATE]:00 PM), CNA informed nurse that resident was having some difficulty breathing. Nurses immediately responded. Resident in chair and unresponsive. Nurse attempted to arouse resident, but resident remained unresponsive and pulseless. Code Blue paged. Resident moved to bed and CPR board placed into position. 911 called at 1508 (03:08 PM). Multiple staff present, including nurses and RT. AED (automated external defibrillator) applied at 1509 (03:09 PM). CPR initiated at 1509. No AED shocks given. CPR continued .EMS arrived at 1514 (03:14 PM), and assumed the Code. EMS continued CPR. Pulse obtained at 1532 (03:32 PM), HR (heart rate)=115. Resident transferred via EMS to [local hospital] .PCP, NP, Daughter .DON, Administrator, UM notified. Resident' s daughter requested .belongings be packed and .will pick them up later today or tomorrow. [DATE] 15:52 (03:52 PM) RT Note .Approximately 14:55 (02:55 PM) .RT/Code Blue called on Resident. Witnessed by CENA (certified educated nursing assistant/CNA). CPR (cardiopulmonary resuscitation) started immediately and 911 called. EMS (Emergency Medical Services) arrived and resident was taken to [local hospital]. A request for a change in condition policy was requested on [DATE] at 10:45 AM, however the facility provided a table the nurses go off of for when to contact the Doctor. It did not address the steps taken for acute changes in condition. On [DATE] at 10:59 AM the DON was interviewed. The DON was asked what the facility does when a resident is having respiratory distress. The DON stated, We soul call RT (Respiratory Therapy), they are here .put them on oxygen and call the Doctor. We would need a Chest X-Ray and some labs. The DON was asked about the orders for Resident #500 on [DATE]. The DON stated, They had (Resident #500) on oxygen and was stabilized. We did covid tests, they were negative. I asked about (Resident #500) prior to me leaving (for the day), Resident #500 was stabilized and had no shortness of breath. I hadn't gone up (to see Resident #500). The DON was asked if she would expect labs and a chest X-Ray ordered for someone that had never been on oxygen before and was placed on an initial dose of five liters to get their oxygen levels up and stated, Yes, I would. On [DATE] at 11:17 AM, NP M was interviewed in regard to what happened to Resident #500 on [DATE]. NP M stated, I was called to see (Resident #500 on that day), their sats were in the 80's (%). Their (Resident #500) behavior was panicky because they were having difficulty breathing and their belly hurt. I was going to order an updraft or whatever but we didn't have to because with the oxygen on they stabilized. RT had noticed the oxygen was disconnected and reconnected it and it went up to 96% or 95%. NP M was asked if they would usually order labs/Chest X-Ray for someone that was requiring five liters of oxygen to get normal saturation levels and had sudden respiratory distress and stated, Yes, but (Resident #500) stabilized. On [DATE] at 10:00 AM, Nurse Manager L was interviewed in regard to Resident #500 on [DATE]. Nurse Manager L stated, It (the change in condition) started in the morning, they got short of breath. RT seen them and put (Resident #500) on five liters of oxygen. I seen them because I had to update the daughter. Nurse Manager L was asked if they thought that starting a resident who had never been on oxygen with five liters was appropriate and stated, That is what Respiratory (therapy) put (Resident #500) on, so I don't know what they do (as far a protocol). We did a Covid test, it was negative. We monitored (Resident #500) throughout the day. The NP was notified. At 12:30 (PM) I updated the daughter again, (Resident #500) was comfortable, had no shortness of breath, but did have some nausea. They were sating at 94% on five liters. Between ,d+[DATE] (02:,d+[DATE]:00 PM), the nurse was called to the room by the CNA and were told (Resident #500) was having difficulty breathing. Nurse Manager L further explained, (Resident #500) was in their chair in a gown in their room. When we got to the room, they paged a code blue. (Resident #500) was not arousable. CPR was started, RT was there. We hooked up the AED, EMS came here and took over, they got a pulse and took them to the hospital. Nurse Manager L was asked if the pulse that EMS was able to get was a normal pulse/rhythm and stated, No, I don't think so. Nurse Manager L was asked if they would expect labs and a chest X-ray ordered for a Resident in respiratory distress and stated, Yes, we called the NP and the Dr, I would expect a chest X-Ray with labs, but that is why we called them (NP M and Dr.F) and had them look at them. They didn't give us new orders. A record review of the hospital records prior to Resident 500's admission to the facility revealed no order for oxygen. A record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:28 PM Dr. F was interviewed and asked about Resident #500 on [DATE] whom was having respiratory distress. The Dr. was asked if a resident with shortness of breath should have a chest X-Ray and/or labs ordered and stated, Most of the time we will order a CMP (complete metabolic panel) and a chest X-Ray. We have to report to the hospital. I am familiar with this case because whenever their is a death, we review it to see what we could have done differently. With (Resident #500), we didn't order more because the RT and the NP were both here. I talked to both of them, the oxygen was disconnected, once put back on, they connected it again, the oxygen went back up to 98 %. By the time it was reported to me, I didn't have time to review the labs and chest X-Ray in the hospital to see where to go from there and compare it to what was going on here. That was my role in this, I was supposed to go through all that from the hospital. Dr. F was asked with Resident #500 having shortness of breath, should their have been more testing ordered to find the cause of the shortness of breath and stated, 100% yes, that is the standard of care. Generally yes, with shortness of breath, we would follow up with a chest X-Ray at the very least. Dr. F was asked if he felt it was appropriate to initiate someone on oxygen who was not on it before, to five liters of oxygen and maintain them there and stated, We would have eventually weaned (Resident #500) off of the oxygen. Dr. F was asked if the family had requested for Resident #500 to go to the hospital and stated, We would have absolutely sent (Resident #500) to the hospital if they wanted that. Dr. F was asked what he felt happened to Resident #500 and stated, I think (Resident #500) had a PE. Resident #518 (R518) On [DATE] at 12:40 PM, Confidential Witness I explained that R518 was admitted into the nursing facility for rehabilitation, contracted COVID-19 and progressively got worse as the days went by as evidenced by the amount of oxygen they were on, in addition to R518's lack of logic and sense. Confidential Witness I explained that the communication with facility staff was very sporadic and explained that they begged the facility to send R518 to the hospital. A review of R518's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R518's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of ,d+[DATE] indicating an intact cognition, and required extensive assistance for transfers, dressing and toilet use. Further review of R518's medical record revealed labs for a complete metabolic panel dated [DATE]. The results were as follows: Comprehensive Metabolic Panel: Sodium: 141. Reference range: ,d+[DATE] Potassium: 4.2. Reference range: 3.,d+[DATE].2 Chloride: 108. Reference range: ,d+[DATE] Carbon [MEDICATION(S)] (CO2): 22. Reference range: ,d+[DATE] Anion Gap: 11. Reference range: ,d+[DATE] Glucose: 156 mg. Reference range: ,d+[DATE] Blood Urea Nitrogen (BUN): 15. Reference range: ,d+[DATE] Creatinine 0.81: Reference range: 0.,d+[DATE].10 Review of R518's progress notes reveal the following: [DATE] 22:50 (10:50pm) Type: Nursing - Admission Note Note Text: Pt (patient) arrived to facility prior to writer oncoming shift at 17:35 (5:35pm) from [hospital]. Pt is A/Ox4 (oriented to person time, place and situation). Able to communicate all wants and needs. Medications taken whole. Vital signs: ,d+[DATE], pulse 86, temp (temperature) 97.3, SP02 92% on room air, respirations 17 [DATE] 23:35 (11:35pm) Type: Nursing - Progress Note Note Text: Pt laying in bed when writer entered room. A&Ox3; able to make needs known. Denies pain. All HS (nighttime) medications given;tolerated well. VS (vital signs) stable and is afebrile. Lungs clear to all lobes. Respirations are even and unlabored. Heart rate; normal rate and rhythm. Pt denies SOB (shortness of breath), chest pain, headache, cough . [DATE] 15:36 (3:36pm) Type: Social Work Note Text: SW (social work) INITIAL ASSESSMENT AND DISCHARGE PLAN. Resident was admitted for rehab secondary to a primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . There is currently no initial indication of any significant concern regarding safety awareness or impulsivity noted in the record. Mood is stable at this time . [DATE] 20:26 (8:26pm)Type: Nursing - Orders - General Note from eRecord Note Text: Pt received in bed. A/Ox3. Able to communicate wants and needs. Meds taken whole and tolerated. No reports of pain or discomfort. Pt has Foley catheter that will be DC'd (discontinued) this shift, draining yellow urine. Pt continent of bowel. Catheter care and peri care provided . No s/s (signs and symptoms) of COVID-19 noted . [DATE] 05:07 (5:07am) Type: Nursing - Progress Note Note Text: Patient alert and oriented x ,d+[DATE]. No complaints of pain or discomfort. Vitals are wnl (within normal limits) for patient baseline. [R518] complains of breakdown on big toe. L (left) Toe is red and chaffed. A&D applied with bandage. Will continue monitoring, updates to follow if changes . [DATE] 16:12 (4:12pm) Type: Nursing - Progress Note Note Text: Patient alert and able to make needs known. BP (blood pressure) ,d+[DATE] P (pulse) 76 T (temperature) 97.0 R (respirations) 18. Medications given as ordered and tolerated well. No c/o pain. No acute distress noted. x2 assist. Incontinent of b/b (bowel and bladder); no BM noted. Appetite well, consumed 100% of meals. Patient in bed at lowest position, knitting . [DATE] 01:06 (1:06pm) Type: Nursing - Progress Note Resident alert and oriented x3. Resident received medication without difficulty. No c/o (complaint of) pain at this time. Resident incontinent of bowel and bladder. Resident resting in bed. Call light in reach. [DATE] 11:59 (11:59am) Type: Nursing - Progress Note resident consented and tested for Covid using BinaxNow rapid testing res (result): Positive . [DATE] 00:57 (12:07am) Type: Nursing - Progress Note Resident alert & responsive, able to make verbally express wants and needs, denies pain, took medication whole, tolerated well . [DATE] 16:18 (4:18pm) Type: Nursing - Progress Note Note Text: Patient A&Ox4; able to make needs known. Asymptomatic. BP ,d+[DATE] P 86 T 98.0 R18. Medications given as ordered and tolerated well. No acute distress noted. x2 assist. Incontinent of b/b; no BM (bowel movement) noted throughout shift. Consumed 100% of meals. Patient resting in bed. Call light and water in reach. Safety maintained. Contact precautions in progress. [DATE] 07:21 (7:21am) Type: Nutrition/Dietary Note Note Text: [R518] A&Ox3 admitted from hospital r/t (related to) [CONDITION(S)] with hx (history) of obesity . Resident consuming >75% of meals on 1800 (calories) ada (American Diabetes Association) diet who is able to feed [themselves] independently . [DATE] 14:52 (2:52pm) Type: Nursing - Progress Note Note Text: A&Ox3; able to make needs known. BP ,d+[DATE] P81 T98.0 R18. All scheduled medications given and tolerated well. No c/o pain. No acute distress noted. x2 assist. Incontinent of b/b; no BM noted throughout shift. Consumed 100% of meals . [DATE] 21:10 (9:10pm) Type: Nursing - Orders - Administration Note Senna ([MEDICATION(S)]) Tablet 8.6 MG (milligrams) Give 1 tablet by mouth two times a day for constipation. not given due loose stools x2 (two times). [DATE] 22:06 (10:06pm) Type: Nursing - Orders - Administration Note Senna Tablet 8.6 MG. Give 1 tablet by mouth two times a day for constipation. Held loose stool. [DATE] 22:18 (10:18pm) Type: Nursing - Progress Note Resident alert and oriented x 3. Resident c/o SOB O2 Stat 82% on room air. Writer applied 2 Liter Oxygen O2 94%. Resident received medication without difficulty. NO c/o pain at this time . [DATE] 17:24 (5:24pm) Type: Nursing - Progress Note Note Text: Resident received in bed sleeping on 2l02 (2 liters of oxygen) N/C (nasal cannula) sp02 95% [CONDITION(S)] noted along with fatigue and weakness, dry tounge (sic) resident encouraged to drink water R/T (related to) dehydration, 2 loose stools throughout shift incontinence care provided, currently in bed resting denies pain, call light and personal items within reach . [DATE] 21:36 (9:36pm) Type: Nursing - Orders - Administration Note Senna Tablet 8.6 MG Give 1 tablet by mouth two times a day for constipation loose stool. [DATE] 22:04 (10:04pm) Type: Nursing - Progress Note Note Text: Resident alert and oriented x3. Resident received medication without difficulty. Resident has a dry cough. Resident c/o pain in leg writer administered PRN (as needed) with positive results. Resident continue to have loose stool, writer held Senna. Resident is resting in bed. Call light in reach. [DATE] 10:42 (10:42am) Type: Nursing - Progress Note Note Text: Alert and orientated x3, able to make all needs known, denying pain,stable respiratory status 93% on 2L NC. All due medications given as order with exception to BP medications due to [CONDITION(S)] (low blood pressure), (,d+[DATE]). NP (nurse practitioner) notified of [CONDITION(S)] and verbal order given to add parameters to BP medications. Writer added HOLD FOR SBP (systolic blood pressure) <110 to BP medications. Resident with noted dry cough, no fever, no complaints of body aches .Resident with fair appetite; 60% of breakfast eaten with supervision due to shaky hands. [DATE] 14:20 (2:20pm) Type: Physician Team - Progress Note Note Text: Encounter Date: [DATE] Chief Complaint: notified of cough and low BP .Review Of Systems: Respiratory : Positive for: Dyspnea on exertion; Cough; Neurological: Positive for: Difficulty walking; Musculoskeletal : Positive for: Muscle weakness; JointPain-Knees; Vitals: Weight: 358.0 LB, Blood Pressure: ,d+[DATE] mmHg, Heart Rate: 93 beats/min, Respiratory Rate: 18 breaths/min, O2Sat: 92 . [DATE] 15:23 (3:23pm) Type: RT Eval (respiratory Therapist Evaluation) Subjective: RN (registered nurse) states resident is more lethargic today Objective: Determine ental (sic) status and well being of Resident Assessment: Resident on phone, States [R518] is just very sleepy today. RN notified. Plan: Continue to monitor. [DATE] 15:45 (3:45pm) Type: Nursing - Progress Note Note Text: IV (intravenous) access obtained to left forearm with 22g (type of needle). Stat blood work obtained at this time (CBC and CMP (complete blood count and comprehensive metabolic panel)). Resident tolerated well. Resident is now being given D5 (dextrose 5%, glucose in water injected into the vein to replace lost fluids) 0.9 NS (normal saline) running at 50 cc/hr. Stat chest xray ordered per covid protocol. [DATE] 17:37 Type: Physician Team - Progress Note Writer changed resident brief. Incontinent to urine. Residents body felt war (warm); temporal temperature taken 99.4. PRN Tylenol given. [DATE] 18:27 (6:27pm) Type: Nursing - Progress Note Note Text: MD (medical doctor) contacted regarding abnormal lab values. Specifically BUN (blood urea nitrogen) and CREATININE (reveals information how well your kidneys are working). MD made aware that resident was currently on D5 0.9% Normal Saline at 50 cc/hr. MD gave verbal order to log into log book for review on Tuesday morning. Also made aware of chest xray pending per covid protocol. A review of R518's lab work ordered on [DATE] were as follows: Comprehensive Metabolic Panel Sodium: 137. Reference range:,d+[DATE] Potassium: 4.9. Reference range: 3.,d+[DATE].2 Chloride:106. Reference range: ,d+[DATE] Carbon [MEDICATION(S)] (CO2): 15. Reference range: ,d+[DATE] Anion Gap: 16. Reference range: ,d+[DATE] Glucose: 183. Reference range: ,d+[DATE] Blood Urea Nitrogen (BUN): 68. Reference range: ,d+[DATE]. Results Repeated (identified as a critical result on the lab results). Creatinine: 6.51. Reference range: 0.,d+[DATE].10 Results Repeated (identified as a critical result on the lab results). [DATE] 14:15 (2:15pm) Type: Physician Team - Progress Note Note Text: Encounter Date: [DATE] Chief Complaint: Review labs; patient status .Currently diagnosed with Covid-19 Review Of Systems: Respiratory : Positive for: Dyspnea on exertion;Cough;Wheezing; Musculoskeletal : Positive for: Muscle weakness; Joint Pain-Knees; Constitutional : Sleeping; Obese; Assessments/Plans: COVID-19 .contact precautions in place labs drawn. continue to monitor Essential (primary) hypertension - I10 d/c BP medications due to low BP trend .Disposition: Continue all current prescription medication and monitor . [DATE] 13:44 (1:44pm) Type: Nursing - Transfer to Hospital Summary resident transferred to [hospital] due to lethargy, low o2 stat, and generalized weakness. [R518's] latest vitals are BP ,d+[DATE] HR 84, Temp. 98.6, resp. 14 and 02 84. [R518] was transferred via EMS at 1300 (1:00pm). family is notified. [DATE] 14:05 (2:05pm) Type: Nursing - Progress Note Lab called with critical lab results. BUN 114 Creatinine 6.42. Resident sent out prior to receiving these results. A review of the labs ordered on [DATE] reflected the following: Basic Metabolic Panel Sodium: 145. Reference range: ,d+[DATE] Potassium: 5.5. Reference range: 3.,d+[DATE].2 Chloride: 114. Reference range: ,d+[DATE] Carbon [MEDICATION(S)] (CO2): 14. Reference range: ,d+[DATE] L Anion Gap: 17. Reference range: ,d+[DATE] Glucose: 131. Reference range: ,d+[DATE] Blood Urea Nitrogen (BUN) 114: Reference range: ,d+[DATE] (identified as a critical result) Creatinine: 6.42. Reference range: 0.,d+[DATE].10 (identified as a critical result) [DATE] 14:49 (2:49pm) Type: Physician Team - Progress Note Note Text: Encounter Date: [DATE] Chief Complaint: patient change in status; continued need to increase O2 via NC with minimal to no improvement in O2 sat, lethargy; stat lab values critical for BUN, WBC; assess need for transfer to hospital .Currently diagnosed with Covid-19. Review Of Systems: Unable to Communicate : Unable to obtain ROS (review of systems) due to patient current status .Vitals: Weight: 358.0 LB, Temperature: 98 F, Blood Pressure: ,d+[DATE] mmHg, Heart Rate: 84 beats/min, Respiratory Rate: 14 breaths/min, O2 Sat: 84 .Constitutional : Obese;Somnolent .Respiratory : Wheezes; diminished Labored breathing . COVID-19 .transfer to hospital Not improving . A review of hospital documentation once R518 was transferred to the hospital, revealed that they were diagnosed with the following: [CONDITION(S)] with Bilateral Pneumonia, Acute [CONDITION(S)], [CONDITION(S)] (end stage renal disease) with elevated Creatinine and Rhabdomyolysis (A breakdown of muscle tissue that releases damaging protein into the blood) which can damage kidneys. On [DATE] at 12:27, an interview was completed with Physician F regarding R518. Physician F indicated that R518 was being followed by another physician however, he was aware that there were concerns about their kidneys, and was placed on fluids however, R518 wouldn't improve therefore they were sent out to the hospital. On [DATE] at 1:58 PM, the Director of Nursing (DON) was asked about the change of condition in R518, and explained that looking at the medical record, it looked liked nursing was giving the information to the doctor. (Also, that the medical record was negative for any notification to R581's family related to a change in condition) No further explanation was provided. A review of the requested Change in Condition policy was reviewed, and was actually a Change of Condition table which did not address responding to an acute change in condition timely. Resident #511 (R511) On [DATE] a review of R511 Electronic Medical Record (EMR) was completed. The EMR reflected R511 was admitted into the facility on [DATE] with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) dated [DATE] reflected R511 scored 04 out of 15 on their Brief Mental Status (BIMS) score assessment, which indicated a severely impaired cognition. R511 also required extensive to dependent two-person assistance with bed mobility and transfer. Review of an Incident and Accident Report reflected that R511 had an unwitnessed fall on [DATE]. The report also revealed the following: Incident Description-Nursing Description: Upon rounds resident observed laying face down on the floor beside [R511] bed Immediate Action Taken-Description: Notified supervisor, assessed for injury and pain, vital signs taken, assisted resident back into bed, cleaned abrasion to nose, Notified MD and daughter. Injuries Observed at Time of Incident-Injury Type: Abrasion, Injury Location: Face, Injury Type: Hematoma, Injury Location: Face. The Incident and Accident report also noted that, [R511] denies pain, but when ask does your nose hurt resident says yes. A review of R511 progress notes revealed the following: Date: [DATE] at 18:04, Nurses Note: upon rounding resident observed lying face down beside bed in bedroom. supervisor notified, resident assessed for injury, abrasion noted to nose and hematoma to right side of forehead, no other injuries noted, notified MD and daughter, neuro checks in place, cleanse nose with normal saline and triple antibiotic applied, prn Tylenol administered. bed in lowest position with body pillows in place. VS ,d+[DATE] HR 90 RR 18 temp 98.1 Sp02 96%. Date: [DATE] at 22:48, Nurses Note: [Physician F] called left message that resident is on [MEDICATION(S)] (Blood Thinner) 20 mg daily r/t (related to) sp (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Date: [DATE] at 08:19, Physician Notes: Assessments/Plans: Fall Physician made aware that there was a fall over the weekend on exam patient shows no signs of fracture appears to be alert and oriented at baseline at this time no x-rays needed continue to monitor closely. Date: [DATE] at 12:12, Nurses Note: RESIDENT RETURNED TO FACILITY FROM (Name of hospital) TRANSPORTED VIA CAR BY FAMILY MEMBER WITH A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . ASSIGNED NURSE MADE AWARE. On [DATE] at 12:45 PM an interview was conducted with Physician F. Physician F stated that he had spoke to the family after R511 discharged and they felt that x-rays should have been completed. Physician F reported that they came and examined R511, and that they did not look that bad. Physician F revealed they were aware that R511 was on [MEDICATION(S)], and they usually sent people out for a Computed Tomography [TRUNCATED]

This citation pertains to intakes MI 721, MI 655 and MI 968. Based on interview and record review, the facility failed to complete accurate skin/wound assessments, monitor the progress of a wound, and initiate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #501 (R501) A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #501 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #501 needed extensive assistance with bed mobility and transfers. A record review of the Physician Orders revealed the following for Resident #501: 12/18/2020-Assess heel and sacral area daily for redness or open areas. Notify physician of abnormal findings. A record review of the Progress Notes for Resident #501 revealed no notes on any skin breakdown or open areas. A record review of the Skin Observation Tool dated 12/27/2020 revealed the following: Left gluteal fold .Right gluteal fold .redness, open area A record review of the Treatment Administration Record for December 2020 and January 2021 revealed no treatment was ordered to address the redness and open areas observed on Resident #501's left and right gluteal folds on 12/27/2020. On 10/20/2021 at 02:29 PM, Wound Nurse K was interviewed. Wound Nurse K was asked what the protocol was for when residents were discovered to have redness or open areas on their skin. Wound Nurse K stated, We would treat it and put in a wound consult. The floor nurse should do what they can and initiate a dressing like a wet to dry (dressing) or [NAME] (barrier cream) or something. If it (the skin) is open, (the staff should) measure it. Wound Nurse K was asked about the observation of Resident #501 having a wound on 12/27/2020 with no measurements or treatments initiated and stated, There should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The review of the facility policy titled Guidelines For Skin & Pressure Ulcers dated 05/18 revealed the following: When assessing an ulcer, it is important to do the following .Differentiate the type of ulcer (pressure related versus non-pressure related. Interventions may vary depending on the specific ulcer. (If an ulcer is not a pressure ulcer it must be clear in the documentation what it is. There must be physician documentation or NP/PA documentation to concur that the ulcer was not from pressure but rather from another cause) .4. Once the assessment has been completed, immediately develop a plan of care with the resident (and family, if available). Be sure to refer to the skin care guidelines (Policy 2146) as a guide to appropriate interventions. In addition, if any skin breakdown is found, the responsible party must be notified immediately. Please document with whom you spoke with in the medical record .11. If there is any change in the patient's skin condition, the nurse or nurse manager should review and revise the patient's care plan accordingly and consult with the director of nursing, physician and/or wound care specialist as needed. 12. If an ulcer is found or develops post admission there must be thorough documentation of the ulcer upon admission or upon its initial discovery. If there is any change in the patient's skin condition, the nurse or nurse manager should review and revise the patients care plan accordingly and consult with the Director of Nursing, physician and /or wound care specialist as needed. 13. In addition, all newly acquired skin impairments and worsening of previous areas must be reported to the resident and /or their legal representative by the nursing department. Documentation of communication will be put in the progress notes by the nurse. Please include the person you spoke with. In addition, at the time of development staff should identify and document factors that they believe affected their ability to prevent or heal a pressure ulcer. Documentation should include: a. Size b. Location c. Depth & stage of ulcer d. Presence or absence of necrosis and slough e. Tunneling or sinus tract f. Condition of the wound bed, evidence of healing such as granulation (where visible ), the presence of eschar and the status of the surrounding skin. g. Monitor the progress toward healing and for potential complications h. Determine if infection is present (peri-wound warmth, swelling, induration [CONDITION(S)], increasing pain or delayed healing). 14. The facility Skin Care Guidelines (See Attachment B) will be implemented until the attending physician is contacted for further treatment orders. For Stage I or II sores, the attending will be contacted within the 24 hours of discovery of the sore, on the day shift. For Stage III or IV sores, the attending will be contacted upon discovery of the sore after the nurse has completed her/his initial assessment of the wound. Resident # 518 (R518) On 10/19/21 at 12:40 PM, an interview was conducted with Confidential Witness I who explained that R518 was admitted to the facility for rehabilitation services, contracted COVID-19 while there, developed open sores on their buttocks, and was made not aware until R518 was admitted into the hospital. A review of R518's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R518's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and required extensive assistance for transfers, dressing and toilet use. A review of R518's progress notes revealed the following, 7/13/2021 22:50 (10:50pm) Type: Nursing - Admission Note. Skin assessment: redness noted to bilateral cheeks, around mouth, and on chin; bruising noted to abdomen; blanchable redness noted to groin; blanchable redness noted to bilateral buttock; small scratch and small bruise noted to right buttock; +1 pitting [CONDITION(S)] noted to right ankle; toenails on right foot discolored and thick; right heel red and blanchable; left leg in cast from toes to thigh, skin around cast openings appropriate to race, warm to touch, toes wiggle. Pt (patient) reported mild pain while assessing,when not moving pain eliminated . Further review of R518's medical record revealed a Wound-Weekly Observation Tool dated 7/19/21, noting the following skin observations: Site: Other-Right greater toe. Description: Bruising. Length: 1 cm (centimeter). Width: 0.5 cm. Further review of R518's medical record revealed a Skin Observation Tool dated for 7/20/21, noting the following skin observations: Site: Other. Description: Cast noted to lower left extremity. Site: Other: Description: Abdominal Folds-Red-[MEDICATION(S)] (anti-fungal medication) in place. There were no other skin assessments located in R518's medical record. Further review of R518's medical record revealed a Braden Scale for Predicting Pressure Sore Risk dated for 7/20/21. R518 scored a 16, placing them At Risk for developing a pressure sore. A review of R518's Care Plan revealed the following, Focus: 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 needs staff assistance with incontinence care, turning and repositioning, Braden score <17 (less than). dx (diagnosis) of DM (Diabetes Mellitus). Date Initiated: 07/22/2021. Interventions: Braden scale to be completed per facility protocol Date Initiated: 07/22/2021. Created on: 07/22/2021. Preventive skin care post incontinence care daily/prn (as needed). Date Initiated: 07/22/2021. Provide surface support and pressure redistribution, position changes, and off loading daily. Date Initiated: 07/22/2021. Weekly nursing skin assessments with showers. Notify physician and wound care nurse of any skin changes. Date Initiated: 07/22/2021. A review of R518's physician orders revealed the following: -Order date, 7/13/21: Assess heel and sacral area daily for redness or open areas. Notify physician of abnormal findings. every evening shift. -Order date, 7/13/21: Cast/ Appliance/ Brace/ Immobilizer Skin Assessment: Please Remove appliance (unless indicated to NOT remove) and evaluate the skin surrounding appliance QS (as much as needed) for pulses and proper skin integrity (free of rashes or issues). Notify physician Immediately of any abnormalities and document details in a progress note. every shift for Patient Safety. -Order date, 7/13/21: Vitamin A&D Ointment (Vitamins A&D (Topical)). Apply to bilateral buttocks topically one time a day for Health &Wellness. -Order date 7/26/21, Consult wound care for DTI (deep tissue injury) and MASD (moisture-associated skin damage. A review of R518's shower sheets did not reveal any body audits or identified areas of concern on their skin. The shower sheets only revealed if the resident had a shower or not, and the date the shower occurred. Further review of R518's medical record revealed that they were discharged from the facility to the hospital on 7/28/21. A review of R518's medical records from their hospital admission revealed the following wound consult dated 7/30/21, Left heel with an unstageable (full thickness tissue loss) pressure injury that measures 3 cm x 3.5 cm, wound base with a black firm necrotic tissue covering, no drainage and no [CONDITION(S)]. Recommend to monitor and float heels off bed .Bilateral buttocks extending from the upper buttocks to the lower buttocks and posterior thigh, including the inner buttock cleft with scattered linear irregular shaped purple marks to the skin. Midline buttock cleft with areas of full thickness tissue loss with a yellow wound base. Perianal skin with purple linear colorations notes .Recommend to apply triad cream to protect and promote healing an autolytic debridement . On 10/20/21 at 12:27 PM, an interview was conducted with R518's physician while at the facility, Physician F. He was interviewed about R518's orders, specifically the order for a wound consult related to the DTI and MASD. Physician F explained that he had not examined any wounds on R518, and that the order was placed after someone explained that it may be necessary. Physician F could not recall who the person was, and stated, I don't remember [R518] having any wounds. On 10/20/21 at 2:29 PM, Wound Care Nurse K was asked about the process in which skin assessments were completed, and she explained that nursing staff completes an admission skin assessment, and then completes another assessment within 24 hours. Thereafter, nursing completes weekly skin assessments. Wound Care Nurse K was asked about all of R518's wounds, and she explained that R518 had rubbing from their cast on their left toes, and had been treating it by cleansing the area, placing a gauze over the area, and keeping their foot elevated. Wound Care Nurse K was asked about treatment to R518's buttocks, and they explained that R518 did have bruising on their buttocks after the resident contracted COVID, and explained that R518's skin started to become sweaty and wicky therefore, they educated staff to turn the resident every two hours, use A&D ointment on their bottom and legs, and float the resident's heels. Wound Care Nurse K denied that their were any open areas on R518's skin the last time the skin was assessed by her, and that she would not know of any skin breakdown unless it was brought to her in the morning meeting. On 10/21/21 at 1:58 PM, the Director of Nursing (DON) was asked about R518 however, she was not familiar with the resident. The DON was asked for her expectations regarding skin breakdown and stated, We want the skin to be free of sores. We've put in a new process in place to assess skin, along with shower sheets. Resident #520 (R520) A review of Intake: MI 968 revealed that the dressing on their wound was not changed daily as ordered. A review of R520's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R520's Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and required extensive assistance for bed mobility, transfers and dressing. A review of R520's medical record revealed the following order dated 7/24/21, Wound Care Order Site: LLE (lower left extremity) 1) Cleanse wound with NS (normal saline) 2) Pat Dry with Gauze 3) Apply Xeroform 4) Cover with ABD (bandage) 5) Wrap in kerlix if indicated 6) Tape - (date and time the tape) every day shift for wound care. Further review of R520's Care Plan revealed the following, Focus: Medical Management Concerns: Pain Concerns, Respiratory Conditions, Wound Care Date Initiated: 07/22/2021 Interventions: Provide for wound care per physician orders. Date Initiated: 07/22/2021 . Further review of R520's medical record revealed their Treatment Administration Record (TAR) for the following dates related to wound care were missing: 7/27/21, 7/28/21, and 7/31/21 and 8/1/21. A review of R520's medical record revealed the following progress note: 8/2/2021 02:10 (2:10am) Nursing - Progress Note Note Text: Resident is A&O x3 (alert and oriented) and able to make all needs known. All scheduled medications given and tolerated. Resident had no c/o (complain of) pain, no s/s (signs and symptoms) of distress and all vitals stable. Resident had c/o dressing to LLE not being changed on daily . On 10/21/21 at 1:58 PM, the DON was asked about R520's TAR missing treatments, and her expectations for the completion of treatments, and she stated, The expectation is that the treatments should be carried out.

Based on observation, interview and record review, the facility failed to supervise a resident during meals, failed to assist with feeding a resident meals regularly, failed to implement new and effective interventions, and evaluate the effectiveness of current interventions to prevent weight loss for two residents (Resident #30 and #73) of seven residents reviewed for nutrition, resulting in the continued loss of weight, malnutrition and the likelihood of a decline in overall health. Findings include: Resident #30 On 07/13/2021 at 12:00 PM, Resident #30 was observed dressed and groomed, sitting in the dining room. Resident #30 was feeding themselves soup with a fork. On 07/13/2021 at 12:33 PM, Resident #30 was observed to be still eating lunch. Resident #30 was holding and eating a half of a sandwich. A record review of the July Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the weights for Resident #30 revealed the following: 7/1/2021 14:26 112.4 Lbs 6/4/2021 19:32 114.0 Lbs 6/1/2021 13:16 114.0 Lbs 6/1/2021 12:58 114.0 Lbs 5/11/2021 13:02 116.2 Lbs 4/1/2021 11:53 118.4 Lbs 3/1/2021 14:40 130.6 Lbs 2/1/2021 13:09 130.6 Lbs 1/1/2021 15:00 130.2 Lbs A record review of the Food Acceptance Records (FAR) for the last 30 days for Resident #30 revealed the following: No documentation was recorded for the following dates for breakfast: 06/16/2021 06/19/2021-06/20/2021 06/22/2021 06/25/2021-06/26/2021 06/28/2021 07/04/2021-07/05/2021 07/08/2021-07/11/2021 No documentation was recorded for the following dates for lunch: 06/16/2021 06/19/2021-06/20/2021 06/22/2021 06/25/2021 06/28/2021 07/04/2021-07/05/2021 07/08/2021-07/11/2021 No documentation was recorded for the following dates for dinner: 06/16/2021 06/19/2021-06/20/2021 06/22/2021 06/25/2021-06/26/2021 07/04/2021-07/05/2021 07/08/2021-07/11/2021 A record review of the Nutrition Notes for Resident #30 revealed the following: 11/24/2020 10:37 AM-Pt (patient) seen in .room up eating breakfast. In good spirits. Speaks positive about .meals finally shared that .does not like oatmeal. Still eats a hot dog every day for lunch for over the last year .finds it enjoyable and .stated you really can not mess up a hot dog . weight at 131# 30d- 130# 60d- 130# 90d- 130# 180 day -144# 1 yr (year) ago 140 BMI (body mass index)- 24 This is a 9% weight loss over the last 6 months unplanned? This does reflect the isolation time frame for the Covid -19 crisis .has not been eating socially .family did visit a few times/week which they would bring foods from home . Plan: 1) I will change the diet to NCS (no carb control). 2) I will add dry cereal and whole milk w/ (with) breakfast. 3) will honor the hot dog for lunch every day. 4) goal is to prevent further weight loss will discuss w/ the care team. Despite us providing .friendly visits w/ recreation and the SW (social worker) .is likely just missing that element of family. c/p (care plan) updated. 2/23/2021 11:01 AM-Pt seen in .room . more confused. Appears calmer in the morning than at night .has been getting upset at night and visiting my office in regards to looking for .daughter or .son. Pt has been doing this more often over the last 2 weeks. I have discussed this change w/ the care team. Pt . has decreased in .eating the last few weeks from nursing reports . Pt has very poor short term memory loss. within 5 minutes .has forgotten what you shared . Pt did have a family visit last week .This change in (their) mood and behavior is impacting .desire to eat .struggles w/ .anxiety and fears . intake is ranging from 0-75% this is a decline from previous eating habits. weight at 131# 30d- 130# 60d- 130# 90d- 131# 180d- 131# 1 yr ago 140#. BMI- 21.8 fine UBW of 140-145#. hx (history) of weight loss from the Covid+ incident in 2020. Psychological services did start .on [MEDICATION(S)] with the hopeful benefits of impacting .mood and appetite. pt is on Med pass 2.0 - 60 cc TID to help add 360 calories. labs of 1/26/21- Hgb (hemoglobin) a1c- is at 8.4% (L) this has increased supporting poor glucose control .Pt has lost . interest in eating. appetite changes noted . all as a progression of .Dementia and emotional changes from what appears to be the social isolation from .routine. PT was very involved w/ activities, family visited frequently and pt did eat downstairs in the social dining room twice a day before the Covid isolation status occurred almost 1 yr ago. Nutritional risk is high .is at high risk for weight loss w/ the decreased intake, decreased appetite, increased wondering around the facility looking for .family. I did adjust a few food selections although the pt does not recall what we talked about. will f/u the effectiveness of the medication. emotional support provided at each encounter. Recreational therapy is trying to incorporate more socialization opportunities in the days ahead . 5/11/2021 2:54 PM .Significant Change Assessment .Pt was very conscious of (their) eating, but over the last 6 months .has been changing in .behavior and Dementia. Pt stopped eating as well .was more focused on family and their location. dx of Dementia .frustration appears to be improving . Pt denies changes in her appetite, but she has lost about 9% of .body weight over the last month. is down to 118# form (sic) .130#. UBW of 140# x 1 yr ago and for many years .weight at 140#. BMI- 19.6. low end of acceptable range .has lost muscle and fat in . face, shoulders, back and all .extremities. The [MEDICATION(S)] may be helping as well as the visits from .family. The combination of the 2 interventions are showing some progress. Pt has dentures and .chewing and swallowing is functional. appetite appears to be improving .will not allow the staff too feed . but .can be redirected easier .I will change to a Regular diet .Goal is to prevent further weight loss .c/p updated. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #30 had a Brief Interview for Mental Status (BIMS) score of seven, indicating an impaired cognition. Resident #30 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30 needed limited assistance with transfers and bed mobility and required supervision and set up for meals. A record review of the nutrition care plan for Resident #30 revealed the following: Focus-Resident w/ Significant weight loss r/t advanced dementia .as well as the Isolation orders r/t the Corona Virus advancing Dementia and poor memory. UBW (usual body weight)of 140# IBW (ideal body weight) of 125#. weight of 5/2021- 118#. 9% loss x 1 month. Date Initiated: 05/11/2021 Created on: 08/14/2020 Goal-No signs or symptoms of [CONDITION(S)] (tremor, fatigue, weakness, diaphoresis or headache or [CONDITION(S)] (excessive thirst, confusion, polyuria, fruity breath or nausea. Interventions .Monitor food acceptance via FAR and offer appropriate substitutes for food items not consumed .monitor weight per order, notify RD (Registered Dietician) with any sig changes in weight .provide Med pass 2.0 supplement - 60 cc (cubic centimeters) TID (three times per day) w/ (with) .medications .provide [MEDICATION(S)] as ordered .take resident to the large dining room for lunch daily. The last two interventions were implemented on 05/11/2021. The rest of the interventions were initiated in 2020. On 07/13/2021 at 04:02 PM, the Registered Dietician (RD) K was interviewed in regard to the continued weight loss or Resident #30. RD K stated, [Resident #30] is a result of COVID. The RD K was asked to what he meant by that statement and explained that the resident had it the virus and recovered from it without any complications. The RD K further stated, Because of the restrictions, (Resident #30) refused to eat. Their Dementia had got worse. The family used to come in a visit them 3-4 times a week. RD K was asked what interventions have been put into place recently since Resident #30 was still losing weight and stated, (Resident #30) can finally eat in the dining room and I took off the restrictions for Diabetes (carb controlled diet). We are trying to get (Resident #30) back in the social environment. 07/14/2021 at 10:48 AM, the Nursing Home Administrator (NHA) was interviewed in regard to Resident #30's weight loss and explained that the facility started the Resident on [MEDICATION(S)] on March 3, 2021 and had stabilized after March. The NHA also stated, We dealt with the Dementia, started (Resident #30) on [MEDICATION(S)] (an antipsychotic medication) and put them on [MEDICATION(S)] (an antidepressant that has a side effect of increased appetite). The NHA was asked about the effectiveness of the interventions and stated, (Resident #30) did not gain (weight) but, they started to not lose anymore weight. Resident #73 On 07/11/2021 at 11:56 AM, Resident #73 was observed to be lying in bed with food on and all around their mouth. On 07/11/2021 at 12:48 PM, Resident # 73 was observed sitting up in bed, the lunch tray was in front of the resident with some food eaten off it. An Unknown Certified Nursing Assistant (CNA) came in to remove the tray. The CNA was asked if Resident #73 needed to be fed and stated, No, (Resident #73) feeds themselves, sometimes they just make a mess (with the food). Then, the CNA asked the Resident if they were done with the tray and removed it. On 07/13/2021 at 11:19 AM, Resident #73 was laying flat on back, slightly diagonal in bed awake with their feet pressed up against the foot board. The room curtain was drawn around the bed. There was a large amount of dark brown liquid all around their mouth and caked in their teeth. The breakfast tray was still in the room. The diet consistency was pureed with nectar thick liquids. There was an orange substance that was 1/3 eaten. Yogurt and cooked cereal were not touched. All of the nectar thick coffee was gone. Mostly all the scrambled eggs were still on the tray. A brown substance was scraped/gone off the plate. On 07/13/2021 at 12:38 PM, Resident #73 was observed lying in bed on their back with the head of the bed elevated 30 degrees. The curtain was pulled around the Resident to block the view from the hallway. The Resident was wearing a hospital gown that was pulled up, exposing their brief. The lunch tray was placed on an over bed table that was directly over the Resident's abdomen. The Resident had their fingers spread out and was scraping the pureed food off their regular glass plate and raking it in their mouth. There was food all over the resident's face, chest, and bedding. As the Resident would try to grab food, they had difficulty grabbing it on the plate, and would reach for it, but would miss the actual food as if the Resident was having trouble seeing it. The Resident had a wet rattle in their throat and was attempting to clear their throat and would cough several times. When attempting to converse with the Resident, their speech was unclear. Resident #73 was asked if they were hungry and stated, Yes, and then grabbed their hot coffee cup and was struggling to remove the lid to drink it. A meal ticket was observed on the meal tray that stated the Resident's name with the following instructions-Divided plate (not used). 1:1 supervision A 8 x 11 bright yellow paper was taped on the wall of Resident #73's room from the speech therapist that read: Puree/Nectar Thick (hand written) IMPORTANT RESIDENT CARE INFORMATION FAMILY AND STAFF PLEASE READ FEEDING and/or SWALLOW PROTOCOL . PRECAUTIONS: Patient must be ALERT! (Circled-close supervision .close/distant supervision .free from distractions .Upright position (75-90 degrees) for ALL ORAL INTAKE . FEEDING: bite size 1/2 tsp Allow additional time to chew food and initiate swallow .alternate liquids and solids. On 07/13/2021 at 12:55 PM, an attempt was made to locate the CNA (CNA M) and Nurse responsible for Resident #73, however they were unable to be located on the floor. On 07/13/2021 at 01:08 PM, Interim Unit Manager E was asked where the CNA and Nurse were for the unit and stated, They are both on lunch. Unit Manager E was asked how do the CNA's know which residents need to be fed. Unit Manager E explained they know by the plan of care in the electronic medical record. Unit Manager E was queried how the new or agency staff were aware of feeding assistance needs and stated, We try to give a good report. On 07/13/2021 at 01:10 PM-01:17 PM, Resident #73 was observed lying in bed with the lunch tray still in front of them. Resident #73 had ate all food, but had even more food all over their face and hands. The curtain was still pulled. CNA M entered the room at 1:17 PM and took the tray. CNA M was asked how they know if people are to be fed and explained the chart will say. CNA M explained that the electronic medical record would give them the information they needed. CNA M was queried as to the lack of feeding assistance with Resident #73 and stated, They must've just changed (the feeding assistance order) because they (Resident #73) used to feed themselves, now I see that they are a feed. A record review of the weights for Resident #73 revealed the following: 7/1/2021 14:19 139.6 Lbs 6/4/2021 19:32 147.0 Lbs 6/1/2021 16:00 147.0 Lbs 5/20/2021 12:49 148.6 Lbs 4/1/2021 14:53 142.8 Lbs 3/1/2021 14:44 151.4 Lbs 2/17/2021 15:58 150.0 Lbs 1/1/2021 15:00 152.0 Lbs 12/1/2020 16:24 150.0 Lbs 11/1/2020 12:27 151.8 Lbs 10/1/2020 17:17 156.4 Lbs A record review of [NAME] physician orders revealed that Resident #73 had the following order: Med Pass 2.0 120 cc BID (twice per day) ordered 9/1/20. A record review of the MDS dated [DATE] for Resident #73 revealed the following: Resident #73 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #73 needed verbal cues and/or physical hands on assist with feeding and needed extensive assist with toileting needs and dressing. A record review of the progress notes revealed the following for Resident #73: 5/26/2021 5:02 PM Nutrition/Dietary Note-This 82 yr (year) old .remains on the Regular / mechanical soft diet w/ pureed soups to help w/ .oral dysphagia. Pt has .own teeth, but are in poor shape many missing. SLP (Speech Language Pathologist) did change the pureed soups this year. Pt is confused .has a divided plate for .meals to help keep .independence but I still feel (Resident #73) needs more help w/ .meals. Noted recently found w/ BM (bowel movement) on (their) tray. This is the first episode of such behavior. Reports of pt eating from 25-100% but also reports of food on the floor and (in their) bed from the housekeepers. This is evidence of the need of more assistance. weight is down to 149# .has been 150-155# this past year UBW of 160-170# prior to that. pt has been slowly eating less over the last 18 months. BMI- 21 which is fine. dx (diagnosis) of [CONDITION(S)], Dementia, [CONDITION(S)] disorder w/ [CONDITION(S)] and dysphagia. All these conditions are progressive and potentially impact .eating. Lipid panel is fine as of 5/3/21. skin good. I still have (Resident #73) on a supplement twice a day .whole milk, fortified cereal, extra ice cream w/ lunch. Nutritional risk for .slowly losing weight and .decrease ability to truly feed themselves r/t (related to) what my professional opinion is .eyesight is decreasing as well .can not tell us, but I suspect it r/t .feeding abilities. Will discuss w/ care team that this pt could benefit from more help w/ .meals. c/p goal update. Keep diet. 5/26/2021 03:12 PM Behavior Note-CNA found in room with bm (bowel movement) on tray, sheets, on fingers, mouth and floor; as if (patient) pt was consuming bm. Writer assessed pt, no s/s of distress. Unit manager notified by cena, psych consult ordered. Will continue to monitor. A record review of the FAR for the last 30 days revealed the following for Resident#73: There was no documentation of meal intake for the following breakfasts: 06/18/2021 06/21/2021-06/22/2021 06/25/2021 06/27/2021-06/28/2021 07/03/2021-07/05/2021 07/10/2021-07/11/2021 There was no documentation of meal intake for the following lunches: 06/18/2021 06/21/2021-06/22/2021 06/25/2021 06/27/2021-06/28/2021 07/04/2021-07/05/2021 07/10/2021-07/11/2021 There was no documentation of meal intake for the following dinners: 06/17/2021-06/18/2021 06/20/2021-06/21/2021 06/24/2021-06/25/2021 07/02/2021-07/04/2021 07/10/2021-07/12/2021 A record review of the care plan for Resident #73 revealed the following: Focus-RISK FOR ASPIRATION RELATED TO: dx (diagnoses) of Dysphagia Date Initiated: 03/04/2021. Goal-Will have no food or fluid aspirated through next 90 day period. Interventions-Position fully upright (~75-90 degrees) and midline for oral intake ~1/2-1 tsp bite size. Encourage small bites. Liquids by cup/straw- one small sip at a time. Alternate solids/liquids. Pt can feed themselves with supervision. Notify nursing/physician and any increase in coughing during oral intake. Date Initiated: 03/04/2021. Focus-Resident is at nutritional risk with risk for weight loss Chronic illness, Need for altered diet r/t dysphagia r.t Parkinson, Dementia UBW 160-170. 12/3/20- resident slowly keeps losing weight currently at 149#. 150-155# over the year 2020. eating less calories overall. Date Initiated: 08/14/2020. Goal-Resident will have no significant wt loss and remain between 150-160# next 90 days Date Initiated: 08/14/2020. Interventions-Diet as ordered .fortified oatmeal every am whole milk every am chocolate milk w/ lunch and dinner 8 oz (ounce) Cranberry juice BID lunch and dinner. incorporate more mashed potatoes into .meals. ice cream w/ dinner. Date Initiated: 08/14/2020 .Monitor and record intake of food on FAR, Offer substitutes for food items not consumed .Resident needs more supervision w/ his meals- set-up and some direction Provide a divided plate at all meals . On 07/13/2021 at 03:45 PM, RD K was interviewed in regard to the weight loss of Resident #73. RD K was asked what they were doing for Resident #73 to prevent further weight loss and stated, (Resident #73) has been relatively stable recently. In the past, they had gotten really bad pneumonia a few times and has dysphagia (difficulty swallowing) before, I see they changed the diet to a pureed. I didn't know that. RD K was asked if he was kept in the loop with these types of changes and stated, Well, normally the speech team would usually tell me when they change things, nursing did this (changed the order and did not tell him) on 07/06/2021. We question (Resident #73)'s eye sight too, but the Guardian does not want to pursue that, they can't really respond to the test. RD K was asked about the feeding habits of the Resident and stated, (Resident #73) needs supervision, we tried them in the dining room, but that didn't go well. I don't like what I am seeing (with the weight loss), I am doing the best I can. RD K was asked how he keeps up on the weight trends in the building and stated that he usually runs a report at the beginning of the month to review the weights but had not had time to do that this month. RD K stated, We would normally talk about them in our weekly meeting, we would normally follow him with the interdisciplinary team, I run the report and we talk about it. On 07/13/2021 at 04:31 PM, an interview was completed with the DON in regard to the weight loss and lack of feeding with Resident #73. The DON explained that the facility meets weekly to discuss weight loss. The DON stated, We did start a QAPI (quality assurance process improvement) last month on it. We noticed the weight discrepancies and started trying to find some issues we had. [RD K] will double on protein, increase their caloric intake, whatever they (the residents) need. The DON was asked how often the facility does weights and stated, On a normal basis we get the weight once a month. Depends on [RD K], and what the patient can handle and things like that. The DON did not provide and explanation as to why the Resident was not being fed. On 07/14/2021 at 10:32 AM, the NHA was queried about weight loss within the facility and stated that they do weekly weight and wound meetings and noticed the facility was flagging for weight loss. The NHA explained that the facility was auditing residents with weight loss for baseline care plans and for the care plans being updated with new interventions. The NHA was asked about the weight loss of Resident #73 and explained that the Resident was to receive a swallow evaluation soon. A review of the facility policy titled QAPI Weight Monitor Policy dated 05/01/2021 revealed the following: .3. Weights will be routinely monitor (sic) monthly on all residents, unless more frequent weight monitoring is deemed necessary .4 . All residents with a 5# weight change (increase or decrease) or 5% weight change within 30 days will be reweighed .11. It will be the responsibilities of the nurse managers to see that recommendations regarding nursing care (more assistance at meals, change in dining location) are implemented. It will also be nursings' responsibility to make appropriate changes to nursing care plans to reflect those changes.

This citation pertains to intake # MI 946. Based on observation, interview and record review, the facility failed to properly position a resident (#702) in bed and utilize the appropriate amount of assistance to complete care for one resident out of three residents reviewed for falls, resulting in Resident #702 being lowered improperly to the floor, causing a fracture, hospitalization , surgery and prolonged unnecessary pain. Findings include: On 2/23/2021 at 8:50 AM, Resident #702 was observed lying in bed. Resident #702 was queried about their recent hospitalization and explained that the head nurse from the nursing home pushed (them) out of bed causing pain and soreness. Resident #702 was asked if they remembered the staff member's name and stated, I am very bad with names. Resident #702 pointed to a bruise on their right forearm that had occurred from the incident and stated it was sore. On 2/23/2021 at 9:25 AM, Roommate A , whom was the roommate of Resident #702 at the time of the incident, was interviewed in regard to what had occurred on the night of 2/6/2021. Roommate A explained that they heard a lot of noise going on with Resident #702 and Certified Educated Nursing Assistant (CENA) C and moved the curtain so they could see what was going on. Upon moving the curtain, Roommate A noticed Resident #702 hanging off the bed and CENA C was on top of the bed trying to position Resident #702 in bed but was unable to so she helped Resident #702 to the floor. Roommate A stated, (Resident #702) must have delicate bones to have needed surgery. A record review of the progress notes for Resident #702 revealed the following: 2/6/2021 00:43 (12:43 AM) .saw residents (#702) attending cena yelling for help, and writer went to room. Resident was laying on (their) left side on floor between bed A and B with (their) head facing towards the foot of the bed and feet towards head of bed. lt (left) leg and lt foot was rotated laterally below the knee with lift boot on, resident asked what happened stated 'I was pushed'. residents roommate then stated 'that girl (CENA C) was cleaning (them) and .the resident (#702) was fighting her (CENA C) (they) did not fall that girl helped (them) down to the floor. Authored by LPN D. 2/7/2021 19:44 (7:44 PM) .Patient was combative and guarding right leg during hygiene care. patient had a recent fall . 2/9/2021 11:45 (AM) .resident displayed increased combativeness and screamed out in pain while receiving care. Left leg appears larger than the right leg with swelling. Warm to touch at left knee. Left leg presents with hard mass to inner thigh. Resident unable to follow instructions. Resident screams when left leg is being touched. Unit Manager notified. PRN (as needed) Pain medication given . 2/9/2021 11:55 (AM) .resident noted with increased pain to left hip/knee. left thigh noted to be larger than right. left knee swollen, warm to touch. appears misaligned. spoke with MD (Medical Doctor), order to increase tyl (Tylenol) # 3 to 2 tablets q (every) 6 (hours) prn & ben gay patches to left hip/knee. MD will be in in am to assess resident . 2/10/2021 12:44 (PM) Physician Team .Patient was seen for; right thigh pain .Patient was seen today per nursing staff request due to the above concerns. Patient had a fall last week and (they were) sent to (local hospital). Imaging in the ER (emergency room ) revealed no fracture and patient was returned to the facility. Patient continues to have significant pain in (their) left leg specially during patient care .remains very confused and .unable to answer questions. A stat left hip and left femur x-ray was ordered which revealed proximal femur fracture .Pressure patient to the hospital ASAP (as soon as possible). 2/16/2021 19:56 (7:56 PM) .readmitted .via ambulance .Admitting DX (diagnosis) L (left) [MEDICAL CONDITION]. Resident has two incision sites, first one has 39 staples, then the second one has 16 staples .Bilateral bruising to feet, left arm bruising and abrasion to buttock . On 2/23/2021 at 11:28 AM, Night Nurse Supervisor B was interviewed regarding the incident that occurred with Resident #702 and CENA C on 2/6/2021. Nurse Supervisor B explained that there was a STAT call overhead, she went to the room (of Resident #702) and seen the nurse (LPN D) and aid (CENA C) in there. The Resident was lying on the ground with their head towards the foot of the bed. Their right leg was extended out, but their left leg was bent out (abnormally). Nurse Supervisor B asked CENA C to demonstrate what happened. CENA C explained to her that she was changing Resident #702 and had them on their left side (furthest away from the CENA), became combative and had to lower Resident #702 to the floor. Night Supervisor B stated, She (CENA C) lowered the resident by getting behind them and I guess the left leg got caught and it looked twisted at the knee. Night Nurse Supervisor B further explained that she told CENA C about happy feet (an in-house program to easily identify level of assistance a resident needs) and Resident #702 being a two person assist. Night Supervisor B stated, (CENA C) told me she was familiar with the resident and had done (Resident #702's) care before alone and could handle it. After that, we sent (Resident #702) to the hospital, if you would have seen how that leg was bent . A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #702 was admitted to the facility most recently on 2/16/2021 with the [DIAGNOSES REDACTED]. Resident #702 had a Brief Interview for Mental Status score of 14, indicating an intact cognition, and needed extensive two person assistance with bed mobility and toileting needs. A record review of Resident #702's Kardex (the care plan utilized by CENA's to determine amount and type of assistance a resident needs) revealed the Resident was a two person assist with bed mobility (initiated 8/26/2020) and toileting was to be completed at bed level with two persons to assist (initiated 9/1/2020). On 2/23/2021 at 12:05 PM and 1:03 PM, an attempt was made to interview CENA C via phone, however she did not answer the phone and did not call back by the end of the survey. A record review of the activities of daily living (ADL) care plan revealed that Resident #702 required two person assistance with personal hygiene, bed mobility, and toileting at bed level. Initiated 8/26/2020. On 2/23/2021 at 12:25 PM, Resident #702 was observed awake in bed. Resident #702 was asked if they had any pain and said they did. Resident #702 lifted their blanket and pointed to their left hip, which revealed two incisions with several intact hip staples with bruising. A record review of the Medication Administration Record [REDACTED]. The pain assessment on the MAR indicated [REDACTED]. On 2/23/21 at 12:36 PM and 1:03 PM, Licensed Practical Nurse (LPN) D was called for an interview but did not answer the phone. There was no return phone call by the end of the survey process. A record review of the X Ray results for Resident #702 revealed the following: 2/6/2021 (hospital) X Ray of bilateral ankles, bilateral legs and pelvis revealed no fracture. 2/10/2021 (facility) X Ray left hip- femoral perihardware fracture (break near previous hip replacement device) at the level of the distal stem. 2/10/2021 (hospital) X Ray of left hip-Mid femur with displacement below the intact prosthesis level soft tissue swelling. On 2/23/2021 at 1:52 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were asked about the incident involving CENA C and Resident #702. The NHA and DON were specifically asked about the training that CENA C got for working with combative residents and of the Kardex. The NHA explained that CENA C was an agency staff and that they get trained by their employer. The NHA further explained that they asked the agency to not send CENA C to work at the facility. The DON explained that when they (agency CENAs) come in the supervisor shows them where everything is. The DON stated, The CENA (C) took it upon herself to care for the resident alone. This is why we didn't use agency before Covid and do not plan to afterwards. The resident was combative and does get combative. We teach CENAs to never roll a resident away from you. She was remorseful about the situation and was in tears. It was truly an accident. We do ask for the training of staff from the agency before they come in. They usually give us an orientation checklist. The DON further explained that after the incident she educated all the staff about handling combative residents and utilizing assistance with transfers/bed mobility/care. A review of the policy titled Happy Feet Transfer Program dated 9/29/2017 did not address bed mobility and utilizing the stated number of assistance.

This Citation Pertains to Intake Number MI 712. Based on observation, interview and record review, the facility failed to to ensure adequate supervision to prevent a fall and timely care and assessment, following a fall for one (#707) of two Residents reviewed, resulting in delay in transfer to an Acute Care Facility and Resident #707 experiencing a cervical spinal fracture. Findings include: Review of intake documentation revealed Resident #707 experienced neck pain after a fall in the facility, was diagnosed with [REDACTED]. An interview was completed with Physician A on 9/23/20 at 9:40 AM. When queried regarding policy/procedure related to transferring Residents to the hospital, Physician A stated, Anytime we want to transfer a patient, it has to go through the DON (Director of Nursing) and the Medical Director (Physician). Physician A was then queried regarding Resident #707 and stated, (Resident #707) has end stage dementia. (The Resident) fell and started having severe neck pain. They (nursing staff) called me and I said to please send out (to hospital). They (nursing staff) said 'No, we need to x-ray and try to manage here.' (Resident #707) ended up having a cervical neck fracture. Physician A then stated, I care about the facility, Residents and nurses. This is extreme. When asked for clarification, Physician A revealed they were Resident #707's primary Physician at the facility and were very concerned why the facility had implemented a policy where they were not allowed to be transferred without Administrative approval. When asked if the Resident was transferred after approval was obtained by the DON and Medical Director, Physician A stated, No. The nurse who came in was brave and just did the right thing for (Resident #707). On 9/23/20 at 11:16 AM, Resident #707 was not present in their room. A cervical collar (Aspen style neck brace) was noted in the room sitting on the dresser near the head of the bed. An interview was completed with Licensed Practical Nurse (LPN) D on 9/23/20 at 11:17 AM. When queried regarding Resident #707's location, LPN D revealed the Resident was sitting near the nurses' station due to being a fall risk. LPN D pointed out the Resident at this time. When queried regarding the Aspen style cervical collar observed in the Residents room, LPN D revealed the Resident had fractured their neck and had to wear a brace. No further explanation was provided. At 11:19 AM on 9/23/20, Resident #707 was observed sitting in a Geri-Chair (high-back reclining wheelchair) directly across from the nurses' station along with multiple other Residents in wheelchairs. Both of the Resident's legs were off the right side of the solid footrest. Resident #707 had a soft neck brace in place. The brace was not snuggly positioned around the Resident's neck and the Resident was able to move their neck from side to side with the brace in place. An interview was completed at this time. When queried what happened to their neck, Resident #707 replied, They said. The Resident did not complete their thought and was pleasant but unable to provide a meaningful response. When asked if they were having pain, Resident #707 stated, It was, but not so bad now. The Resident did not provide further explanation regarding their pain and/or injuries. An interview was conducted with LPN B on 9/23/20 at 11:32 AM. When queried regarding Resident #707's cervical brace/collar, LPN B revealed Resident #707 had fallen in the facility and suffered a broken neck (cervical spinal fracture). When asked if they had been working when the Resident fell , LPN B replied, I worked midnights. (Resident #707) fell about 3:30 (PM) in the afternoon and fell on their head. LPN B continued, (Resident #707) landed on their head. They had rug burn on head. LPN B then stated, (Resident #707) is on Aspirin and [MEDICATION NAME] (medication to prevent blood clots and thin blood). When queried what happened after the Resident fell and interventions implemented by the facility, LPN B stated, They (nursing staff) called the (Resident's) Doctor but somehow the Medical Director got involved and said to just hold the [MEDICATION NAME] and do neuro checks for three days. When asked about facility policy/procedure related to sending Residents to the hospital after a fall with head injury and/or change in condition, LPN B stated, We have a process in place that if there is a transfer, you have to call the DON and Medical Director and they let us know if it is feasible to send (Resident) out. When queried regarding Resident #707 being diagnosed with [REDACTED].#707) was in excruciating pain. They were rocking and holding the back of their neck, their (skin) coloring was off and blood pressure were off. With further inquiry regarding the Resident's condition and treatment, LPN B replied, I called the (Resident's) Doctor and they said to send out (to hospital). LPN B then stated, I did end up sending (Resident #707) out but I got messages from the DON wanting to know what we had done here. LPN B was asked for clarification regarding the messages they received from the DON and revealed the DON had wanted to know if diagnostic testing had been completed in the facility prior to the Resident being transferred to the hospital. When asked if diagnostic testing was completed, LPN B revealed they were not aware of any imaging studies being ordered. LPN B proceeded to state, I called 911 and sent (Resident #707) out. When asked if they had spoken to the Medical Director regarding the transfer, LPN B revealed they left a voicemail. An interview was conducted with Social Worker E on 9/23/20 at 12:10 PM. When queried regarding Resident care in the facility including Resident #707, Social Worker E did not provide a response and indicated documentation was included in Resident medical records. Record review revealed Resident #707 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive assistance to perform Activities of Daily Living (ADLs). Review of progress note documentation in Resident #707's medical record revealed the following: -8/3/20 at 4:29 PM: Discipline: Nursing . At 3:30 PM resident fell out of w/c (Wheelchair), per (Social Worker E) 'resident was scooting forward and not using hands on the wheels and fell forward out of chair landing on the rt (right) side of their body, ROM (Range of Motion) of upper and lower extremities done and weakness noted to upper and lower rt (right) extremities and abrasion to rt forehead and rt thumb has broken fingernail. Writer left a message for Physician with information and spoke with (Physician C) who gave the orders to hold [MEDICATION NAME] and aspirin for 48 hours, q (every) 2-hour neuro checks and log for Dr . Resident was placed w/c wanted to lay in bed, denied any pain at this time and resident placed in bed for comfort . -8/4/20 at 9:24 AM: Discipline: Nursing . 11p (PM) resident in bed with eyes closed s/s (signs/symptoms) pain/ discomfort noted . neuro checks performed q 2 hours as ordered with no abnormalities noted until approx. 5:45 am. resident noted crying rocking back in forth in a fetal position holding left side of head with tremors noted. When asked what hurts, resident stated head & placed hand across back of writers neck to show pain location. Residents face flushed with [MEDICAL CONDITION] noted to eyes . unable to raise head . b/p (Blood Pressure) 235/123 (elevated- normal 120/80) digital, manual b/p 200/100 . Tylenol given spoke with MD order given to transfer to hospital. Supervisor informed; message left with (Medical Director Physician C) r/t (related to) transfer. 911 initiated . 6:15 am resident transferred . Review of Resident #707's SNF to ED Handoff Form dated 8/4/20 at 6:10 AM, revealed, Key Clinical Information: Fall 8/3/20. Reason for Transfer: Uncontrollable pain to back of neck and head post fall. Tylenol 1000 mg (milligrams) given at 6 AM. Vital Signs: BP (Blood Pressure) 200/100 (elevated) . Time: 5:55 AM . Risk Alerts: Falls . Review of Resident #707's care plans revealed a care plan titled, Self-Care Deficit (ADLs): Resident needs assistance with ADLs impaired physical mobility (Initiated: 8/28/20). The care plan included the intervention, Aspen collar at all times (Initiated: 8/28/20). Resident #707 also had a care plan titled, The resident is at risk for falls and potential injury r/t (related to) [MEDICAL CONDITION], Incontinence, antihypertensive, Psychoactive drug use (Created and Initiated: 9/23/20). The care plan interventions included: -2 person assist with transfers (Initiated: 9/23/20) -Anticipate needs Q shift (Initiated: 9/23/20) -Fall assessment per facility protocol (Initiated: 9/23/20) -Monitor for any medication side effects, recent change in medication, abnormal labs, s/s (signs/symptoms) infection, and pain as an increased risk for falls. Report abnormal findings to PCP (Primary Care Provider) (Initiated: 9/23/20) A care plan for falls prior to the fall on 8/4/20 was not noted in the medical record and requested from the facility DON on 9/23/20 by 3:30 PM. An interview was conducted with the DON on 9/23/20 at 2:00 PM. When queried regarding Resident #707's fall with cervical fracture, the DON indicated the Resident did not initially display and/or complain of symptoms which would require them to need to be transferred to the hospital directly following the fall. When queried regarding the Resident experiencing a head injury while taking anticoagulation therapy and risk for intercranial bleeding, the DON stated, We were doing neuro checks. Review of Resident #707's hospital documentation revealed a History and Physical dated 8/4/20. Review of the document detailed, Musculoskeletal: Forehead pain with abrasion . Back and Extremities . Mild L (left) hip tenderness . Diagnostic Results . CT (Computerized Tomography) Head or Brain without Contrast . 3. Right frontal scalp soft tissue swelling . CT Spine Cervical without Contrast . 1. Fracture to the base of the odontoid without significant displacement. 2. Bilateral C1 (Cervical Vertebra number 1) lamina (bone ring surrounding spinal cord) fractures . Course in Emergency Department . Patient who presented from nursing home s/p (status [REDACTED]. per EMS, patient had a mechanical fall and had a small abrasion over the right forehead . patient complained of headache and neck pain his morning . CT C-Spine (Cervical Spine) showed odontiold fracture at the base, and bilateral C1 lamina fractures. Neurosurgery and trauma team were consulted. C-Collar (Cervical Collar) was in place by EMS, ASPEN collar ordered (cervical spine brace which substantially restricts motion) . An interview was conducted with the facility Medical Director Physician C on 9/23/20 at 3:38 PM. When queried regarding Resident #707, Physician C stated, I remember that case. When asked what occurred, Physician C stated, When they (nursing staff) called, they said there was no injury and that the patient was stable. Physician C revealed they had received a follow up call that the Resident had been transferred. Physician C was then asked about facility procedure related to Resident falls including Residents receiving anticoagulation therapy and stated, Do neuro checks with a follow up X-Ray ordered. When asked why an X-Ray order following the fall was not present in Resident #707's medical record, Physician C stated, I didn't assess the patient. (Resident #707) had persistent pain following (the fall) and indicated they were not made aware of the Resident having pain directly after the fall occurred. Physician C was then queried regarding Range of Motion (ROM) assessment for Resident #707 following the fall and their expectations of ROM assessment by nursing staff and replied, No, I wouldn't expect them (nursing staff) to do that. When asked if all transfers to the hospital have to be approved by them, Physician C replied, Yes. Physician C elaborated, The problem was that the nurses were making the decision to transfer and not the Doctors. When asked why they would have to authorize a transfer if another Physician already provided an order to transfer a Resident, Physician C indicated that was not the reason for the procedure and stated they would have to review the incident. Review of Resident #707's Incident and Accident Reports revealed the Resident had fell 13 times in the facility since 1/1/20 in various areas of the facility including their room, the bathroom, and hallway. The falls occurred on 8/3/20, 7/24/20, 7/11/20, 6/18/20 at 5:44 PM, 6/18/20 at 6:27 PM, 6/17/20, 6/14/20, 5/27/20, 5/4/20, 4/26/20, 3/1/20, 1/15/20, and 1/14/20. Review of the Incident and Accident report for the fall that occurred on 8/3/20 revealed, 8/3/20 at 3:30 PM . BIMS 3/15 (severely cognitively impaired) . location of incident . by the Sunshine Room . Statement by (Social Worker E), who observed: Resident was scooting in w/c not using hands on the wheels and fell forward . Please be sure to complete ROM (Range of Motion) assessment to ankles, knees, hips, and shoulders . Swelling: R. (right) forehead . Discoloration: R. eye hematoma R. Forehead . Type of Injury . hematoma . abrasion . Examination revealed: Hematoma abrasion R. forehead. R fingernail broke . Initial corrective action taken/Recommendation for prevention of similar occurrence: Resident placed in w/c. Abrasion/Hematoma cleansed. Non-skin in place, Resident educated on using wheels with propelling . Provided documentation pertaining to the fall also included a CNA Post Fall Questionnaire dated 8/3/20. The form detailed, Can the Resident tell you why the fell : No. If no, why do you think they fell : Propelling self in wc and pushed forward . Have you observed any changes in the Resident lately: Increased confusion . What did you do for the Resident immediately after they fell . Pain addressed with Nurse . What do you think can be done for the Resident to prevent this from happening again? Sitter . What equipment did you see in place at the scene of the fall? (Blank) . A second interview was completed with the DON on 9/23/20 at 4:00 PM. A paper copy of Resident #707's fall care plan from the facilities previous Electronic Medical Record (EMR) was provided and reviewed at this time. The care plan was titled, Etiology: Risk for falls R/T: History of falls . Unable to transfer without assistance As Evidenced By: Impaired mobility; Use of [MEDICAL CONDITION] medications; weakness; impaired vision . (Effective: 8/22/20). Interventions included in the care plan included: -Remind and frequently show Resident how to propel wheelchair with hands instead of feet only (Effective: 8/24/20) -Star Program (Effective 8/24/20) -Encourage Resident to wear gripper socks, if applicable (Effective 8/24/20) -Bed wheels in locked position (Effective 8/24/20) -If appropriate, remind Resident to use call light when needing assistance (Effective 8/24/20) When queried regarding the provided care plans not being created until after the Resident fell and broke their cervical spine and what interventions were in place prior to the fall, the DON did not provide additional documentation. When queried regarding the Resident's fall risk, extensive history of falls and most recent fall resulting in the Resident fracturing their cervical spine, the DON stated, They were using their feet and not their hands while self- propelling in wheelchair. When queried why Resident #707 not assisted to utilize proper wheelchair mobility techniques when observed facility staff prior to the fall, an explanation was not provided. When queried regarding the Resident being in a Geri-chair when that was not included on the care plan as well as observation of their legs off one side of the foot rest and having a soft cervical collar in place and not an Aspen collar, the DON was unable to provide an explanation. Review of facility provided policy/procedure entitled, Falls/Incident Management Program and Committee (Issue Date: 9/28/17) revealed, It is the policy of the facility to identify each Resident at risk for falls and to adequately plan care and implement procedures to prevent falls . Review of facility policy/procedure entitled, Change in a Resident's Condition or Status (Revised May 2017) revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) . d. significant change in the resident's physical/emotional/mental condition . g. need to transfer the resident to a hospital/treatment center . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) .

This Citation Pertains to Intake Number MI 712. Based on interview and record review, the facility failed to ensure timely care and transfer following a change in condition for one (Resident #701) of three Residents reviewed for quality and provision of appropriate care resulting in lack of timely transfer for a Resident experiencing a bowel obstruction (blockage within the intestine which can lead to bowel death, infection, and death if untreated), unnecessary pain, and the likelihood for decline in overall health. Findings include: Review of intake documentation revealed concerns related to delaying transfer of Residents who were experiencing a change in condition. The intake specified, The DON (Director of Nursing) and the Administrator have been blocking and delaying transferring critical patients to the hospital because they are concerned about their (facility) readmission rate. The intake documentation mentioned an incident involving Resident #701 in which the patient was suffering from acute abdominal pain for more than 8 hours and almost had a perforated bowel before they allowed nurses to call the ambulance. The intake expanded, (Health Care Providers and Nursing staff) believe the current Administration is risking Residents lives and well-being in order to improve their admission rate. An interview was completed with Physician A on 9/23/20 at 9:40 AM. When queried regarding policy/procedure related to transferring Residents to the hospital, Physician A stated, Anytime we want to transfer a patient, it has to go through the DON (Director of Nursing) and the Medical Director (Physician). Physician A was then queried regarding Resident #701. Physician A revealed they were the Resident's Physician and stated, The Nurse Practitioner (NP) was at the Resident's bedside and wanted to transfer (Resident #701) to the hospital. The DON said to do an X-Ray at the facility first and the (NP) said no and I ordered the transfer, but the DON blocked my order and would not transfer the patient. Physician A then stated, The patient was in agony and then around midnight a nurse was brave enough to call 911 and just sent (Resident #701) to the hospital. With further inquiry regarding Resident #701 and if they had reviewed/discussed the transfer with facility Administration, Physician A stated, I told them (facility administration) that it was a surgical abdomen and they said they are having too many transfers to the hospital. Physician A reiterated that since the facility implemented a new procedure where Health Care Providers (Physicians and NP's) are not able to transfer Resident's to the hospital without approval by the DON and Medical Director that Resident transfers were being delayed. When asked about treating Residents at the facility, Physician A stated, Sometimes you have dehydration or pneumonia and that can be treated in the nursing home, but other conditions cannot. Physician A continued, I care about the facility, Residents, and nurses. This is extreme. On 9/23/20 at 11:10 AM, an interview was attempted to be completed with Resident #701 but the Resident was unavailable. An interview was completed with Licensed Practical Nurse (LPN) B on 9/23/20 at 11:32 AM. When queried if they were Resident #701's assigned nurse when the Resident had to be transferred to the hospital for a bowel obstruction, LPN B replied, Which time and revealed the Resident had a bowel obstruction in July in which the Nurse Practitioner wanted them to be transferred to the hospital but facility Administration vetoed the transfer. When asked why the Resident was not immediately transferred after their Provider wanted them to be transferred, LPN B stated, Between the Director of Nursing (DON) and Assistant Director of Nursing (ADON) they said no, we can do things here. LPN B continued, We have a process in place that if there is a transfer, you have to call the DON and Medical Director and they let us know if it is feasible to send (Resident) out. With further inquiry regarding Resident #701's transfer in July (7/28/20), LPN B revealed they had worked 16 hours that day. When asked about Resident #701's transfer and medical condition, LPN B stated, Earlier in the day, (Resident #701) complained of gas and asked for Tums or something. I spoke to the Doctor because I knew (Resident #701) had a history of [REDACTED]. With further inquiry, LPN B stated, (Resident #701's) bowel sounds were hypo (hypo is abnormal and indicate decreased bowel activity, active bowel sounds are normal) and (abdomen was) a little distended. They had dry heaves later that evening and then asked for a pain pill. When (Resident #701) took it, they started vomiting immediately when they took a drink (to take pill). LPN B continued, I called (Diagnostic company) for the X-Ray and they said it wasn't ordered as STAT but they would fix it then still didn't come so I called again and they told me there was no (X-Ray) Tech on that night and it wouldn't be done until early in the AM. LPN B was asked how long STAT X-Rays typically and take to have completed and stated, Usually six to eight hours. When asked why the facility was not notified of the delay by the company, LPN B was unable to provide an explanation and indicated delays are not uncommon recently. LPN B proceeded to state, (Resident #701) does not complain much so when they do, you know it is serious. Record review revealed Resident #701 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistance to perform Activities of Daily Living (ADLs). Review of Resident #701's progress note documentation included the following: -7/28/20 at 7:00 AM: Nursing . Patient alert and oriented. C/o (complain of) sharp pain to abdomen, nausea and feeling swollen in abdomen area . Physician notified. No new orders at this time. Logged. -7/28/20 at 11:30 AM: Discipline: Physician Extender . Chief Complaint: acute onset abd (abdominal) pain . Patient seen today as per nursing staff request. Patient lying in bed, having crying, having severe abdominal pain. Rated pain 10 out of 10. Unable to eat or drink anything today. ABD distended, BS (Bowel Sounds) absent. ABD tender upon palpation. Patient has been having nausea but no vomiting. Has been unable to have a bowel movement today, but did have one yesterday. Spoke with (child) via phone, updated on (Resident #701's) current status, wants (Resident #701) . sent over to the hospital . Assessment and Plan: Acute abdomen pain- will send patient to hospital for further evaluation . Plan of Care discussed with (Physician) . -7/28/20 at 5:43 PM: Nursing . Resident is alert and able to voice needs, complaints of stomach pain, no appetite, resident stated has a stabbing feeling in abdomen areas, bowel sound absent in all 4 quadrant, BP (Blood Pressure) 180/80 (elevated) . NP (Nurse Practitioner) was in and assessed resident, ordered to send out to (hospital). Medical director ordered resident to stay in facility and get stat X-ray of abdomen, Resident has been moaning, crying ,and nauseated. Awaiting results, will continue to monitor . -7/28/20 at 6:03 PM: Nursing . STAT abdomen X-Ray results reviewed with MD (Medical Doctor) and Medical Director order to sent resident out the hospital . The notes revealed Resident #701 was readmitted to the facility from the hospital on [DATE] after receiving treatment for [REDACTED]. -8/1/20 at 9:02 AM: Discipline: Physician Extender . Patient seen today as per nursing staff request. Patient lying in bed, was sleepy. Patient stated feeling better, but stomach is still sore . Assessment and Plan: status [REDACTED]. -8/2/20: Discipline: Medical . Chief Complaint: weakness . Assessment and Plan: Acute Abdominal Pain due to ileus and early small bowel obstruction history of remote small bowel resection has resolved avoid constipation . -9/4/20 at 9:53 AM: Nursing - Transfer to Hospital Summary . 9-3-2020 8 PM. Resident noted with dry heaves, states nauseated. states lbm (last bowel movement) 9-2-2020. abd soft, bowels sounds hypo active LLQ (Left Lower Quad), diminished RLQ (Right Lower Quad). Spoke with MD, order for [MEDICATION NAME] (anti-nausea) 4 mg (milligrams) IM (Intramuscular), stat flat plate of abd (abdomen), medication given, X-ray ordered. 930 PM resident request pain pill, taken with sips of water, states nausea better but stomach pain increased. 11 PM spoke with (Diagnostic Imaging Company), states X-ray is scheduled for am, not in as stat. explained order was placed, called & faxed STAT. rep states will move exam to stat & page tech. 9-4-2020 12/1230 am resident c/o (complained of) increased abd pain, questioned X-ray time. resident noted taking sips of water & vomiting within seconds. writer spoke with (Diagnostic Imaging Company), states notes show tech /supervisor was informed but no tech is on duty for the evening, exam will be done in am. Spoke with MD, informed of residents condition & exam to be done in am. Order given to transfer to (emergency room ). supervisor /DON informed. medical director informed . ambulance called for transport . 2 am resident transferred . -9/9/20: Physician Team - H&P (History and Physical) . admitted from an acute care facility after . treated for [REDACTED]. Patient was managed with IV (Intravenous) fluid NG (nasogastric - tube inserted through nose into stomach for suction and decompression) tube and pain management. Small bowel obstruction resolved without any surgical intervention. Currently, patient complains of weakness, it started a week ago . Review of Resident #701's care plans revealed the Resident did not have a care plan in place related to alterations in bowel patterns. On 9/23/20 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding facility policy/procedure pertaining to transferring Residents to the hospital who require a higher level of care, the DON replied, We review the transfers. The DON elaborated, We want to treat (Residents) here if possible. When queried regarding Resident #701's transfers on 7/28/20 and 9/4/20 including the delay between the Resident's symptom onset and transfer for bowel obstructions, the DON revealed they just wanted to wait for the X-Ray which could be completed in the facility. The DON was then queried regarding documentation indicating the Resident's clinical condition not improving while waiting for the X-Ray at the facility, despite any interventions implemented for both transfers, and the length of time between symptom onset and transfer, the DON did not provide further explanation. When asked, the DON indicated bowel rest, repeat diagnostic studies, and NG placement with suction were the typical interventions for a bowel obstruction that did not require surgical intervention. When asked, the DON revealed the facility was not able to provide the level of care necessary if NG tube placement was necessary. An interview was conducted with the facility Medical Director Physician C on 9/23/20 at 3:40 PM. When queried regarding facility policy/procedure related to Resident transfers to the hospital including if they had to approve any/all Resident transfers to the hospital, Physician C revealed the facility implemented a real time review of transfers. With additional query regarding the procedure, Physician C disclosed the procedure was implemented as a method to ensure transfers were appropriate and nurses were not sending out Residents who were able to be treated in the facility. Physician C was then asked why a Resident would not be transferred after being examined by a Nurse Practitioner and having a transfer ordered with Physician collaboration and replied, I don't overrule other Doctors. Physician C expanded that if another Health Care Provider wants to have a Resident transferred then the Resident should be transferred and stated, That is not the reason for the procedure. When asked about Resident #701's treatment and delay in transfer on 7/28/20 and again on 9/4/20 after the Resident had been experiencing signs and symptoms of a bowel obstruction for over 24 hours, Physician C indicated they were not able to currently view the Resident's medical record. Resident #701's medical record was reviewed with Physician C at this time. After reviewing the Resident's medical record with Physician C, they stated, There is no way to diagnose an ileus without an X-ray. We just wanted to wait to have the X-Ray here. When asked how long it typically takes to get an X-Ray at the facility and how long they keep Residents in the facility who are symptomatic, Physician C replied, It can take 24 hours. If it is longer than that, we will just send (to hospital). When asked specifically about documentation indicating Resident #701 had hypoactive bowel sounds on 9/2/20, nausea and abdominal pain with their history of a bowel obstruction in July 2020 and why the Resident was not transferred to the hospital for treatment sooner when a bowel obstruction can be a life threatening condition, Physician C did not provide further explanation. Review of facility policy/procedure entitled, Transfer or Discharge (Revised 10/19) revealed, Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s) . 1. Residents will not be transferred unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician . i. Others as appropriate or as necessary. Review of facility policy/procedure entitled, Change in a Resident's Condition or Status (Revised May 2017) revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) . d. significant change in the resident's physical/emotional/mental condition . g. need to transfer the resident to a hospital/treatment center . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) . Note: Neither policy included direction that the Medical Director and/or DON would have to provide authorization to transfer a Resident to the hospital due to a change in medical condition.

This Citation pertains to Intake MI 768. Based on interview and record review, the facility failed to operationalize policies and procedures to ensure timely completion and pursue results of a urinalysis (diagnostic test to detect and manage a wide range of diseases and infections) for one (#703) of two Residents reviewed for assessment and monitoring, resulting in a significant delay of treatment for [REDACTED]. Findings include: An interview was completed with Resident #703's family member Confidential Witness A on 7/9/20 at 8:15 AM. When queried regarding Resident #703's stay within the facility, Confidential Witness A revealed they (family) had taken the Resident out of the facility due to concerns with the care provided. When asked about their concerns, Confidential Witness A stated, (Resident #703) would complain of having pain and all they would do is give (the Resident) [MEDICATION NAME] (narcotic pain medication) so they would sleep. Confidential Witness A further revealed, (Resident #703) had a stroke and couldn't turn or move (without assistance) and they (facility staff) didn't turn (the Resident) or give them water. With further inquiry, Confidential revealed the Resident was sent to hospital due to a change in condition and the hospital informed them that (Resident #703) had a UTI and was extremely dehydrated. Record review revealed Resident #703 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #703 was transferred to the hospital Emergency Department (ED) on 6/10/20. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to complete Activities of Daily Living (ADLs). The MDS further indicated the Resident did not have a UTI at that time nor have they had a UTI within 30 days prior to MDS completion. Review of Resident #703's medical record revealed a Healthcare Provider Order dated 5/26/20 at 11:15 AM for Urinalysis Complete with Culture to be completed on 5/26. Reason: AMS (Acute Mental Status change) . Order Source: Prescriber Entered . Review of Resident #703's diagnostic testing results revealed results for blood diagnostic testing completed on 5/26/20 but there were no urinalysis results for May 2020 present in the medical record. A single urinalysis result dated as collected and received on 6/4/20 was present in Resident #703's medical record. The results revealed Resident #703 had a UTI and included the following abnormal findings: -Cloudy clarity (abnormal) -Blood 3+ (normal is negative) -Protein 30 (normal is negative) -Leukocyte Esterase 1+ (present of leukocytes - type of White Blood Cell which may indicate inflammation or infection; normal is negative) -RBC (Red Blood Cells) 3-10 (normal is 0-2) -WBC (White Blood Cells) > 50 (normal is 0-2) -Casts, Hyaline (usually caused by dehydration) 3-5 (normal is 0-2) -Bacteria 2+ (normal is negative) The associated Culture and Sensitivity result report which specifies the causative microorganism of the infection and details the susceptibility and resistance of the organism to medications was dated 6/6/20 at 8:52 PM. Review of Resident #703's progress note documentation revealed the following: -5/26/20 at 10:58 PM: Medical . Reason for Visit: Confused, Hallucinating . Assessment Acute AMS (Acute Mental Status change) . -5/28/20 at 12:02 AM: Nursing . u/a (urinalysis) c&s (culture and sensitivity) obtained via straight cath, tolerated well. Dark cloudy urine obtained. placed in (facility) fridge, lab called for pick up . -5/28/20 at 11:44 PM: Nursing . Spoke with lab r/t (related to) u/a results. states they are backed up will have it ran in am. -6/5/20 at 1:41 AM: Nursing . Abnormal Lab Results Reviewed and Logged. Lab Test: UA. (Healthcare Provider) will be in to review. -6/5/20 at 12:34 PM: Physician Extender . Chief Complaint . Patient with UA (urinalysis) drawn due to AMS (Acute Mental Status change)/Confusion, Lethargy . Results suspicious for UTI . Assessment: Suspect Acute/Subacute UTI . Empiric treatment with [MEDICATION NAME] (antibiotic), Await Culture Results . -6/10/20 at 5:18 PM: Nursing . Resident refused all scheduled medications and accu-checks, was sent out 911 today around 12:23 PM, DX (Diagnosis) mental status change . Review of Resident #703's Medication Administration Record [REDACTED]. On 6/8/20 at 5:11 PM, [MEDICATION NAME] was discontinued and [MEDICATION NAME] (different oral antibiotic) was started. An interview was conducted with the Director of Nursing (DON) and Registered Nurse (RN) B on 7/9/20 at 11:30 AM. When queried regarding Resident #703's UA order on 5/26/20 and no results in the medical record until 6/4/20, the DON and RN B reviewed the Resident's medical record and revealed they were not able to locate the results. The DON and RN B indicated they would look into it. On 7/9/20 at 1:10 PM, an interview was completed with the DON and RN B. When queried regarding Resident #703's UA, the DON stated, It was collected on the 27th. When asked if the results dated 6/4/20 were from the urine sample collected from the Resident on 5/27/20, the DON and RN B both revealed they were not sure. The DON then stated, Maybe another urine sample was collected on 6/4. When asked why there was not a note indicating a urine sample was obtained on that date if one was obtained, the DON was unable to provide an explanation. When queried regarding facility policy/procedure pertaining to obtaining/collecting and sending specimens to the laboratory for diagnostic testing, the DON revealed facility staff collect specimens and then contact the laboratory for the specimen to be picked up at the facility. The DON was then asked about facility policy/procedure related to storage of urine specimens while waiting for pick up and replied, There is one fridge to put samples in. When queried if the refrigerator is checked/monitored to ensure samples are picked up, the DON indicated there is not as all samples are placed in the fridge and laboratory staff pick up the specimens from there. The DON and RN B were then asked if the urinalysis was completed on urine obtained eight days prior to testing, RN B stated, I will check the (order) requisition numbers with the lab. An interview was conducted with the DON and RN B on 7/9/20 at 2:15 PM regarding Resident #703's UA and verification of sample dates with the laboratory. RN B stated, I verified the requisition number (UA ordered on 5/26) and it's the only one. When asked if they were saying the UA ordered and the sample obtained on 5/28/20 was the same sample that was tested at the lab on 6/4/20, RN B and the DON both revealed it was. When queried why the sample was not sent to the lab after it was collected and why facility staff did not identify the delay in obtaining the results, RN B stated, Well, (Resident #703) had blood work completed so we were monitoring them. When asked if blood work will reflect if an individual has a UTI, RN B revealed it would not but that the blood work indicated the Resident did not have a (systemic) infection. When asked if an untreated UTI could lead to Urosepsis (systemic infection throughout body- diagnostic blood work with aid in [DIAGNOSES REDACTED]. The DON and RN B were then asked how blood work is able to identify a UTI prior to progression to urosepsis and did not provide a response. When queried regarding the delay in treatment of [REDACTED].#703 had a UTI, and antibiotic treatment not being started until 6/6/20, the DON and RN B were unable to provide an explanation. A policy/procedure related to laboratory and diagnostic testing was requested at this time. An interview was conducted with the facility Administrator and DON on 7/9/20 at 3:20 PM. When queried regarding the delay in care for Resident #703, the Administrator did not provide further explanation. Review of facility provided Laboratory Services Under Arrangement Agreement (Dated 9/10/18) revealed, (Laboratory Name) Responsibilities: 1. Provide requested laboratory services and provide a phlebotomist to obtain specimens on an agreed . schedule outlined on Laboratory Services Addendum . 2. Send laboratory reports to Facility . Laboratory Services Addendum . 1. Routine Laboratory Draw Day (s) . Monday, Tuesday, Thursday, Saturday, and legal holidays . 5. Non-Routine Courier Services: A. Any courier services in excess of the agreed upon pick-ups, Twice Daily .

This citation pertains to intake # Based on interview and record review, the facility failed to assess, document, and intervene appropriately and timely for the treatment of [REDACTED].#702) of 1 resident reviewed for the assessment of [MEDICAL CONDITION] from a total sample of three, resulting in discomfort and death. Findings include: On [DATE] at 9:35 AM, a telephone interview was completed with Confidential Witness A. According to Confidential Witness A, She had last visited Resident #702 on [DATE] and stated, I was going on a little weekend get away so I went to see her before I left, I knew she didn't look good, she was blown up like a balloon. I told her I was worried about her and she told me not to worry about her, that was the last time I seen her! She was only [AGE] years old . On [DATE] at 9:55 AM, a review of the face sheet and Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #702 was admitted into the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the MDS, Resident #702 had a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognition. On [DATE] at 10:37 AM, a record review was completed of the Physician order [REDACTED]. [DATE] 7:40 AM Weight one time [DATE] 12:31 AM Weight daily after first urination and before breakfast. Notify Doctor if weight increase of 3# (pounds) in one day, or 5 # in 5 days . [DATE] 12:26 AM Monitor weight one time related to 40# weight change [DATE] [MEDICATION NAME] 40 mg (milligrams) by mouth daily [DATE] Weight daily x2, then weekly x4, then monthly On [DATE] at 11:39 AM, a review of Resident # 702 weights during the stay at the facility revealed the following: [DATE] 250 pounds (#) (initial weight) [DATE] 251 # [DATE] 293 # [DATE] 284 # [DATE] 279 # [DATE] 277 # [DATE] 275 # On [DATE] at 11:44 AM, a review of Progress Notes for Resident #702 revealed the following: [DATE]: Initial Nursing Admission Assessment - No [MEDICAL CONDITION] present. [DATE]: 10:39 PM Nurses Note: Resident noted with bilateral lower extremity swelling. Contacted Doctor (Dr. B), Dr. stated he will be in to see her (Resident #702) tomorrow. [DATE]: 2:24 PM Doctor Progress Note authored by Dr. B: Pt (patient/Resident #702) was seen for [MEDICAL CONDITION] and SOB (shortness of breath), meds, VS (vital signs), Wt. (weight) and labs reviewed. Pt c/o (complains of) swelling in her lower extremities and mild SOB. No fever or chills and pain is well controlled .Extremities ++ [MEDICAL CONDITION]. Assessment and Plan-[MEDICAL CONDITION] and fluid overload. R/o (rule out) [MEDICAL CONDITION] exacerbation, was started today on PO (by mouth) [MEDICATION NAME] (water pill) and [MEDICAL CONDITION] Protocol. [DATE]: 2:43 PM Nurses Note: Writer entered room to administer (blood thinner) injection after therapy session, writer started to gather supplies to pack resident's incision and resident stated, 'I'm tired right now, just let me catch my breath' . [DATE] : Nurses Note: Writer called down to residents room by CNA (Certified Nurse Assistant) at approximately 2155 (9:55 PM). Resident noted unresponsive at that time. No pulse noted by writer or supervisor. [DATE] called and CPR (Cardio [MEDICAL CONDITION] Resuscitation) initiated. Resident discharged to (hospital). On [DATE] at 12:30 PM, an interview was completed with Dr.B. During the interview, Dr. B reviewed his Progress Notes. Dr. B stated, I saw her twice. She did not have a history of [MEDICAL CONDITION]. I realized she had fluid overload so I put her on oral [MEDICATION NAME]. Dr. B was queried in regards to his choice of using oral [MEDICATION NAME] verses a more aggressive dose or route of medication (medications given through intravenous or muscular injection absorb in the body more quickly). Dr. B stated, I did not feel it was severe enough, in the same visit I ordered to remove the PICC line (Peripheral Inserted Central Catheter-giving intravenous access), if I felt it was severe enough, I would have ordered [MEDICATION NAME] IV (intravenous). I put her on [MEDICAL CONDITION] protocol. Dr. B was queried regarding the facility's [MEDICAL CONDITION] protocol and stated, It is daily weights, more monitoring and kidney monitoring because of the [MEDICATION NAME]. Dr. B was queried if he was aware of the amount of weight gain of Resident #702, Dr. B did not provide an answer. On [DATE] at 12:50 PM, a policy on the management of [MEDICAL CONDITION] and the [MEDICAL CONDITION] protocol was requested, and according to the Director of Nursing (DON), there was not a policy on [MEDICAL CONDITION] but a protocol template was received and reviewed with the DON. According to the DON, the template is what is in the electronic medical record (EMR) once someone is placed on the [MEDICAL CONDITION] Protocol. The DON was queried in regards to the [MEDICAL CONDITION] protocol that Dr. B put Resident #702 on. The DON stated, If someone comes in with [MEDICAL CONDITION], they go on the protocol. She (Resident #702) did not come in with it ([MEDICAL CONDITION]). The DON was asked if a resident develops [MEDICAL CONDITION] during the facility stay, can they be placed on the [MEDICAL CONDITION] protocol, the DON replied, Yes, they can. A review of the template for the [MEDICAL CONDITION] Protocol titled, Daily Nursing Shift Progress Report: [MEDICAL CONDITION] the following: All [MEDICAL CONDITION] patient need this charting. Orders to trend. On the template, vital signs, weights were measured, as well as lung sounds and [MEDICAL CONDITION] (in detail) were monitored. On the bottom of the template was a place to document shortness of breath and other symptoms the resident may have been experiencing. The DON was queried as to why the template was not started for Resident #702. The DON stated, Well it depends if the doctor orders it or not. The DON was reminded of the progress note dated [DATE] that Dr. B wrote that stated, [MEDICAL CONDITION] Protocol started and stated, It can go on as an alert for the nurses, I am not sure why it didn't in this case. The DON was also queried about the the orders written on [DATE], three days after Resident #702 was seen by Dr. B that had initiated partial orders that mimicked the [MEDICAL CONDITION] Protocol according to the template,(VS and daily weights), the DON did not have an explanation as to why the orders were started. The DON was also queried to where the daily documentation of SOB and [MEDICAL CONDITION] for Resident #702 was, but did not offer an explanation. A request to interview the staff nurse that wrote the orders on [DATE] was made but the DON had stated that the nurse had no longer worked at the facility. On [DATE] at 1:05 PM, a record review of the Physical Therapy (PT) Notes was completed for Resident #702 and revealed the following: Initial PT Evaluation [MEDICAL CONDITION]-None present [DATE]: Pt. educated on positioning of her LES (lower extremities) while supine in bed to promote reduced [MEDICAL CONDITION], including the need to elevate LES with use of pillows and with bed controller to elevate FOB (foot of bed). Pt. also instructed in active exercises i.e. ankle pumps, to promote decreased [MEDICAL CONDITION]. Pt's performance is currently limited due to c/o bilateral foot pain and significant LE [MEDICAL CONDITION]. On [DATE] at 1:55 PM, a review of the death certificate dated [DATE] for Resident #702 stated the following: .chain of events-diseases, injuries or complications-that directly caused the death a. [MEDICAL CONDITION] There were no other comorbidities listed. On [DATE] at 2:00 PM, a review of the Cardiac care plans for Resident #702 was completed, but did not make any reference to the new onset of [MEDICAL CONDITION]. On [DATE] at 2:25 PM, an interview was completed with the Administrator in regards to the [MEDICAL CONDITION] Protocol being started per Dr. B's Progress Note on [DATE]. The Administrator stated, The Dr. said that just because he wrote that, doesn't mean it was the part of an order. The Administrator did not have an explanation as to why the [MEDICAL CONDITION] Protocol was not carried through.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS, COORDINATE CARE AND SERVICES, AND IMPLEMENT INTERVENTIONS FOR treatment of [REDACTED].#512) OF TEN SAMPLED RESIDENTS REVIEWED FOR WOUNDS FROM A TOTAL OF 26, RESULTING IN THE DEVELOPMENT OF PRESSURE SORES, WORSENING OF EXISTING PRESSURE SORES. FINDINGS INCLUDE: ON 3/12/13 AT 3:50 P.M., DURING AN INTERVIEW WITH RESIDENT #512'S WIFE, SHE STATED THAT RESIDENT #512 DEVELOPED A "SORE ON HIS BOTTOM FROM SITTING ON THE BEDPAN." OBSERVATION REVEALED THE RESIDENT SITTING IN BED IN A SEMI-FOWLER'S POSITION (SEMI SITTING POSITION). THE RESIDENT STATED, "I GOT A SORE FROM SITTING ON THE BED PAN. I WAS CONSTIPATED WHEN I FIRST GOT HERE." RECORD REVIEW REVEALED THAT RESIDENT #512 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #512'S ADMISSION MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] INDICATED THE RESIDENT'S COGNITION WAS INTACT AND REQUIRED EXTENSIVE ASSISTANCE FROM STAFF FOR BED MOBILITY, TRANSFERS AND TOILETING. THE MDS DID NOT INDICATE THAT THE RESIDENT HAD A PRESSURE SORE. REVIEW OF THE NURSING ADMISSION ASSESSMENT, DATED 2/18/13 INDICATED NO SKIN ULCERS. THE NURSING ADMISSION ASSESSMENT ALSO HAD THE FOLLOWING QUESTIONS ADDRESSED UNDER THE SECTION TITLED, "IDENTIFYING RISK FACTORS" : -"IS RESIDENT IMMOBILE? ANSWER: NO -EVEN THOUGH THE RESIDENT CURRENTLY DOES NOT HAVE AN ULCER, IS HE/SHE AT HIGHER RISK OF DEVELOPING ULCERS OR COMPLICATE TREATMENT? ANSWER: NO -IS THE DEVELOPMENT OF AN ULCER PROBABLE GIVEN THE RESIDENT'S DISEASE AND TREATMENT? ANSWER: NO." TWO BRADEN SCALES (A SCALE TO PREDICT PRESSURE SORE RISK) DATED 2/18/13 AND 2/25/13 SCORED RESIDENT #512'S RISK FOR DEVELOPING A PRESSURE SORE AT A "20-LOW RISK". THE ADMISSION CARE PLAN TITLED "POTENTIAL FOR IMPAIRED SKIN INTEGRITY", DATED 2/18/13 HAD INTERVENTIONS OF "SKIN ASSESSMENTS UPON ADMISSION, WEEKLY, AND PRN (AS NEEDED)". TREATMENT RECORDS DATED 2/18/13 DOCUMENTED NO AREA OF CONCERN ON THE BUTTOCKS REGION. TREATMENT RECORDS DATED 2/20/13 DOCUMENTED, "BUTTOCKS REDDENED AND BLANCHABLE TO TOUCH." TREATMENT RECORDS DATED 2/27/13 DOCUMENTED, "STAGE 2 ULCER WITH NECROTIC (DEAD) TISSUE. TREATMENT WITH ALLEVYN (WOUND TREATMENT DRESSING) APPLIED." A DRESSING CHANGE AND WOUND CARE OBSERVATION WAS CONDUCTED ON 3/14/13 AT 8:45 A.M. WITH STAFF NURSE "S". IT WAS OBSERVED THAT RESIDENT #512 HAD A STAGE II (PARTIAL THICKNESS LOSS OF SKIN PRESENTING AS A SHALLOW OPEN ULCER WITH A PINK WOUND BED), PECAN SHAPED WOUND ON THE RIGHT BUTTOCKS MEASURING 4.3 CENTIMETERS (CM) X 2.2 CM. ON 3/14/13 AT 9:00 A.M., CERTIFIED NURSE ASSISTANT (CNA) "D", WHO WAS THE CNA REGULARLY ASSIGNED TO RESIDENT #512, WAS QUERIED REGARDING THE TOILETING OF THE RESIDENT. CNA "D" STATED, "HE USE TO USE THE BED PAN. BUT NOW HE GOES IN HIS BRIEF, BECAUSE HE GOT A BED SORE FROM THE BEDPAN." ON 3/14/13 AT 10:20 A.M., WOUND CARE NURSE "E" WAS INTERVIEWED REGARDING THE ACQUIRED PRESSURE ULCER FOR RESIDENT #512. NURSE "E" SAID THAT THE RESIDENT WAS HAVING ISSUES WITH PAIN AND WOULD NOT MOVE SELF IN THE BED WHEN HE WAS FIRST admitted INTO THE FACILITY, AND WOULD NOT TAKE NARCOTICS BECAUSE IT CAUSED CONSTIPATION. SHE WENT ON TO SAY THAT AFTER THE REDNESS WAS NOTED ON THE BUTTOCKS ON 2/20/13, MOBILITY BARS WERE APPLIED TO THE BED. THE NUTRITIONAL assessment dated [DATE] DOCUMENTED, "[MEDICATION NAME] 2.7 (LOW)"- NORMAL RANGE 3.5-5.4. "RESIDENT WITH GOOD APPETITE AND DOES NOT APPEAR TO BE MALNOURISHED, WILL CONTINUE TO MONITOR LABS FOR IMPROVEMENT." ON 3/15/13 AT 11:35 A.M., THE DIRECTOR OF NURSING (DON) AND UNIT MANAGER (UM) "C" WERE INTERVIEWED REGARDING THE ACQUIRED PRESSURE ULCER FOR RESIDENT #512. UM "C" STATED "I WAS SHOCKED WHEN I FOUND OUT HE HAD A SORE. HE (RESIDENT #512) USES THE CALL LIGHT." THE DON SAID, EVERYONE THAT COMES IN HERE (TO THE FACILITY) IS ON A EVERY TWO HOUR TURNING SCHEDULE AND THAT SKIN CHECKS WERE BEING DONE NIGHTLY. THE DOCUMENT TITLED "RESIDENT TREATMENT ADMINISTRATION RECORD" DOCUMENTED "DAILY HEEL AND SACRUM CHECK", WAS SIGNED AS BEING DONE FROM 2/18/13 THRU 2/28/13. THE DON WAS ASKED HOW A RESIDENT THAT WAS AT LOW RISK FOR PRESSURE ULCERS, AND WAS BEING TURNED EVERY TWO HOURS, AND HAD SKIN CHECKS BEING PERFORMED DAILY COULD HAVE BROKEN DOWN, SHE WAS UNABLE TO EXPLAIN HOW. ( ) ON 3/12/13 AT 12:40 PM, A REVIEW OF RESIDENT #505'S CLINICAL RECORD WITH NURSE UNIT MANAGER 'H' REVEALED: THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS ALSO NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, WAS TOTALLY DEPENDENT ON STAFF FOR ACTIVITIES OF DAILY LIVING, AND HAD TWO, STAGE III (FULL THICKNESS SKIN LOSS) PRESSURE SORES. THE RESIDENT RECEIVED HOSPICE SERVICES BEGINNING 12/16/11 PER REVIEW OF A HOSPICE CARE PLAN WRITTEN BY THE FACILITY DATED 12/16/11 THRU 9/6/12, WITH A TERMINAL [DIAGNOSES REDACTED]." THE RESIDENT'S PRESSURE ULCER RISK SCORES ON 4/17/12, 10/23/12, AND 1/21/13="HIGH RISK" AND "VERY HIGH RISK." REVIEW OF WOUND TREATMENT RECORDS DATED 4/1/12 THRU 3/10/13 FOR RESIDENT #505 NOTED THAT STAGE III PRESSURE SORES ON THE BILATERAL HIPS HAD PURULENT (PUS) DRAINAGE AND FROM 9/15/12 THRU 2/24/13, CRUSHED [MEDICATION NAME] (ANTIBIOTIC) WAS APPLIED TO THE WOUNDS "FOR ODOR CONTROL." A NEW [MEDICATION NAME] AGENT WAS STARTED FOR THE WOUNDS ON 2/25/13 PER THE TREATMENT RECORDS. WHEN ASKED ABOUT THE NEW TREATMENT, THE FACILITY'S WOUND CARE NURSE, NURSE 'E', STATED, "THE WOUNDS WERE GETTING LARGER AND THEY (FACILITY STAFF) CALLED ME." NURSE 'E' STATED THAT SHE ASSESSED THE WOUNDS ON 2/25/13 WHEN THE NEW TREATMENT STARTED. THERE WAS NO DOCUMENTED EVIDENCE THAT SHE HAD ASSESSED THE WOUNDS SINCE LAST SURVEY ON 3/16/12 AND DID NOT PROVIDE THIS INFORMATION BY THE END OF THE CURRENT SURVEY AS REQUESTED WHEN QUERIED REGARDING THE DRAINAGE AND ODOR ON 3/12/13 AT 1:45 PM AND 3/13/13 AT 11:30 AM RESPECTFULLY, THE FACILITY'S MEDICAL DIRECTOR AND THE RESIDENT'S PHYSICIAN ('J) DID NOT RESPOND WHY THERE WAS NO DOCUMENTED CULTURE TAKEN OF THE WOUND TO DETERMINE THE CAUSE OF THE PURULENCE AND ODOR. THEY STATED THAT THE RESIDENT WAS BEING SEEN BY THE FACILITY'S WOUND CARE SPECIALIST. THEY WERE UNABLE TO RESPOND WHEN INFORMED THAT THERE WERE NO DOCUMENTED VISITS BY THE WOUND SPECIALIST. ON 3/12/13 AT 2 PM, THE MEDICAL DIRECTOR STATED, "I STAND CORRECTED, (THE RESIDENT) IS NOT BEING CURRENTLY SEEN BY (THE WOUND SPECIALIST)." WHEN IT WAS REITERATED THAT THE RESIDENT HAD NOT BEEN SEEN, THE MEDICAL DIRECTOR SAID, "OH. THAT WAS NOT MY UNDERSTANDING. I WILL HAVE TO LOOK INTO IT." MONTHLY PROGRESS NOTES BY PHYSICIAN 'J' DATED 4/7/12, 5/5/12, 6/29/12, 7/28/12, 9/5/12, 10/8/12, 10/30/12, 11/29/12, 12/28/12, AND 1/28/13 NOTED: "FOLLOW-UP WITH THE WOUND CARE NURSE" AND "CONSIDER WOUND CONSULT TO EVALUATE MULTIPLE WOUNDS." ON 3/13/13 AT 10:35 AM, NURSES 'K', 'O', AND FACILITY WOUND CARE NURSE 'E' WERE OBSERVED PROVIDING WOUND CARE FOR THE STAGE III PRESSURE SORES ON RESIDENT #505'S BILATERAL HIPS IN ADDITION TO TWO STAGE II (PARTIAL THICKNESS SKIN LOSS) PRESSURE SORES ON THE BILATERAL HEELS. THE RESIDENT WAS BLIND, CONFUSED, IMMOBILE, AND HAD SEVERE LEG CONTRACTURES THAT RESULTED IN THE RESIDENT'S KNEES DRAWN UP TO THE CHEST AND THE HEELS PRESSED INTO THE REGION BELOW THE BUTTOCKS (ISCHIUM) BILATERALLY. NURSE 'O' REMOVED AN UNDATED DRESSING ON THE RIGHT HIP SATURATED WITH SEROUS (RED) DRAINAGE. NURSE 'E' MEASURED A PRESSURE SORE, WHICH WAS 4.5 X 3.5 X 0.7 CENTIMETERS (CM) IN DIAMETER AND DEPTH. THE WOUND HAD UNDERMINING (WAS LARGER IN DIAMETER UNDERNEATH THE OUTER OPENING), BUT THERE WAS NO MENTION OR MEASUREMENTS OF THE UNDERMINING BY NURSE 'E', WHO THEN HAD TO BE ASKED TO CONDUCT THE MEASUREMENT. WHEN ASKED WHAT THE MEASUREMENT WAS, NURSE 'E' IMPROPERLY ADDED THIS MEASUREMENT TO THE OUTER WOUND OPENING MEASUREMENT AND SAID THAT THE UNDERMINING PORTION OF THE WOUND MEASURED "6 CM." WHEN QUERIED FURTHER, THE NURSE RE-MEASURED THE UNDERMINING AND SAID IT WAS "0.5 CM." SECTIONS OF THE UNDERMINING MEASURED 0.7 CM, AND 0.6 CM IN TWO OTHER AREAS OF THE WOUND, BUT NURSE 'E' COULD NOT PROPERLY IDENTIFY THE LOCATIONS OF THESE MEASUREMENTS IN THE WOUND WHEN ASKED. NURSE 'O' REMOVED A THIN, UNDATED DRESSING FROM THE RIGHT HEEL THAT WAS SATURATED WITH BROWN DRAINAGE. THE RESIDENT HAD A PARTIALLY NECROTIC (DEAD TISSUE) PRESSURE SORE THAT MEASURED 2.0 X 3.0 CM. WHEN ASKED ABOUT THIS WOUND, NURSE 'E' STATED, "THIS WOUND WAS NOT OPEN THE LAST TIME I SAW IT (ON 2/25/13 PER NURSE 'E')." WHEN QUERIED, NURSE 'E' SAID THAT SHE WAS NOT TOLD ABOUT THE WOUND BY STAFF, BUT SHOULD HAVE. NURSE 'K' CLEANED THE RIGHT HEEL AND APPLIED THE SAME TYPE OF THIN DRESSING, WHICH ACCORDING TO NURSE 'E', WAS CHANGED EVERY THREE DAYS. WHEN ASKED ABOUT A TREATMENT, EXTRA PADDING, AND THE FREQUENCY OF THE DRESSING CHANGES FOR THE WOUND, NURSE 'E' STATED THAT THERE WAS NO TREATMENT ORDERED AND WOULD HAVE TO CALL THE PHYSICIAN. NURSE 'O' REMOVED A DRESSING FROM RESIDENT #505'S LEFT HIP THAT WAS SATURATED WITH YELLOW DRAINAGE. NURSE 'K' WASHED HANDS, DONNED NEW GLOVES, AND CLEANED A PRESSURE SORE, WHICH MEASURED 5.5 X 4.5 CM WITH UNDERMINING MEASURING 0.5 AND 0.8 CM. NURSE 'K' THEN APPLIED THE WOUND TREATMENT AND A NEW DRESSING WITHOUT WASHING HER HANDS BETWEEN CLEANING THE WOUND AND APPLYING THE NEW DRESSING. THE RESIDENT'S LEFT HEEL WAS FIRMLY PRESSING ON THE LEFT ISCHIUM. NURSE 'E' WAS ASKED TO OBSERVE THE HEEL THAT HAD NO DRESSING OR PADDING. THE HEEL HAD A SMALL OPEN AREA THAT MEASURED 0.3 X 0.3 CM. NURSE 'E' STATED THAT THIS WAS A NEW OPEN AREA. THERE WAS NO PROTECTIVE DRESSING APPLIED TO THE SORE. NURSE 'E' STATED THAT THE RESIDENT HAD THE HIP WOUNDS "FOR YEARS," BUT THE HIP WOUNDS LOOKED BETTER SINCE THE [MEDICATION NAME] TREATMENT WAS STARTED ON 2/25/13. WHEN ASKED WHY THE TREATMENT WAS NOT STARTED SOONER, NURSE 'E' STATED THAT SHE WAS NOT AWARE OF THAT TYPE OF TREATMENT UNTIL THEN AFTER HEARING ABOUT THE TREATMENT FROM THE FACILITY'S WOUND CARE SPECIALIST, WHO HAD FREQUENTLY USED THE TREATMENT ON OTHERS WITH SUCCESSFUL RESULTS. THE TREATMENT WAS DESIGNED FOR USE ON WOUNDS THAT WERE DIFFICULT TO HEAL THAT HAD LARGE AMOUNTS OF DRAINAGE. ON 3/13/13 AT 1:30 PM AND ON 3/14/13 AT 2:45 PM RESPECTFULLY, HOSPICE NURSE 'A' AND THE DIRECTOR OF NURSING (DON) WERE QUERIED ABOUT THE FOLLOWING: LACK OF WOUND ASSESSMENTS AND IMPROPER WOUND MEASUREMENTS BY NURSE 'E', LACK OF HAND WASHING DURING WOUND CARE BY NURSE 'K', INTERVENTIONS TO PROMOTE WOUND HEALING, SUCH AS A WOUND CULTURE AND WOUND SPECIALIST CONSULT. THEY DID NOT RESPOND WHY THERE WERE DEFICIENCIES IN THESE AREAS. REVIEW OF THE FACILITY'S "SKIN CARE GUIDELINES" POLICY, DATED 4/2011 AND "ROUTINE HANDWASHING" POLICY DATED 6/2012: -THE NURSE WILL DO WEEKLY SKIN ASSESSMENTS AND THE RESIDENT'S CARE PLAN WILL BE REVIEWED AND REVISED, IS NECESSARY, SPECIFIC TO WOUND CARE TREATMENT AND RISK FACTORS. -PERSONNEL SHOULD WASH HANDS BEFORE PERFORMING AN INVASIVE PROCEDURE, OR WHEN CONTACT WITH MUCOUS MEMBRANES, OR NON-INTACT SKIN, AFTER HANDLING CONTAMINATED ITEMS, OR AFTER CONTACT WITH BLOOD OR BODY FLUIDS. -HANDS MUST BE WASHED WHEN GLOVES ARE USED. ( )

REFER TO INTAKE MI 928 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE PRESCRIBED THERAPEUTIC DIET TO ONE RESIDENT OF THE FOUR RESIDENTS (RESIDENT #101) REVIEWED FOR CHOKING IN A TOTAL SAMPLE OF 8 RESIDENTS, RESULTING IN RESIDENT #101 CHOKING. FINDINGS INCLUDE: RESIDENT #101 A REVIEW OF THE ADMISSION RECORD OF RESIDENT #101, REVEALED A [AGE] year OLD WOMAN RE-admitted to the facility on [DATE]. THE HISTORY AND PHYSICAL DATED 1/1/2012 REVEALED [DIAGNOSES REDACTED]. THE DIET PRESCRIBED AT THE TIME OF ADMISSION WAS MECHANICAL SOFT WITH THIN LIQUIDS. ON 1/24/2012 THE DIET ORDER WAS CHANGED TO NECTAR THICK LIQUIDS, HOWEVER, THE CONSISTENCY OF THE THE SOLID FOODS REMAINED THE SAME. ON 2/22/2012 AT 2:30 PM, DURING A TELEPHONE INTERVIEW WITH CNA #24, ASSIGNED TO THE DINING ROOM ON THE DAY OF THE INCIDENT, CNA #24 SAID SHE DID NOT CHECK THE MEAL TICKET OF RESIDENT #101 WHEN SHE GAVE HER THE TRAY. SHE SAID THE RESIDENT'S MEAL INCLUDED A GRILLED HAM AND CHEESE SANDWICH, WHICH SHE CUT INTO SMALL PIECES. SHE SAID RESIDENT #101 ATE 5 SMALL PIECES WITHOUT DIFFICULTY. ON THE 6TH BITE SHE BEGAN TO CHOKE. THE AIDE #24 CALLED FOR HELP AND PERFORMED THE [MEDICATION NAME] MANEUVER WITHOUT SUCCESS. ADDITIONAL STAFF ARRIVED AND TOOK OVER THE CARE OF THE RESIDENT. RESIDENT #101 WAS RUSHED TO HER ROOM. SHE SAID SHE HEARD LICENSED PRACTICAL NURSE (LPN) #13 SAY, "OH, I THINK I BROKE A RIB." ON 2/22/2012 AT 10:35 AM DURING AN INTERVIEW WITH CNA #23 REGARDING THE INCIDENT WITH RESIDENT #101 CHOKING, SHE SAID THAT SHE WAS ASSIGNED TO THE DINING ROOM THE DAY OF THE INCIDENT. SHE SAID HER ASSIGNED RESIDENTS HAD EATEN AND SHE ALREADY LEFT THE DINING ROOM. SHE RAN TO THE ROOM WHEN SHE HEARD OVER THE PUBLIC ADDRESS SYSTEM, "STAT ALL AVAILABLE NURSES TO THE SUNSHINE DINING ROOM." SHE OBSERVED NURSE AIDE #24 WITH HER ARMS AROUND THE RESIDENT AND THEN LPN #13 CAME AND STARTED DOING THE [MEDICATION NAME] MANEUVER ON RESIDENT #101. OTHER NURSE AIDES AND LPN #18 RESPONDED TO THE ROOM. SHE SAID THERE WERE 3 RESIDENTS IN THE ROOM WHEN SHE ENTERED, ALL WERE SEATED AT THE SAME TABLE. THE TRAY IN FRONT OF RESIDENT #101 HAD A CUT UP GRILLED HAM AND CHEESE SANDWICH ON THE PLATE. SHE REMOVED THE TRAY TO THE CART AFTER THE RESIDENT WAS MOVED FROM THE ROOM. A COPY OF THE MEAL TICKET DATED 2/2/2012 FOR RESIDENT #101, PROVIDED WITH THE INVESTIGATION REPORT BY THE FACILITY, INDICATED THAT THE ENTREE WAS A FISH SANDWICH. A LARGE C WITH THE WORD CHOPPED BENEATH WAS NOTED AT THE TOP RIGHT HAND CORNER OF THIS DOCUMENT, AND NECTAR THICK LIQUIDS WRITTEN AT THE BOTTOM. A REVIEW OF THE INTERDISCIPLINARY PROGRESS NOTES DATED 2/2/2012 AT 2:05 PM WRITTEN BY LPN #13, DOCUMENTED HE WAS "CALLED TO THE UNIT DINING ROOM BY CERTIFIED NURSE ASSISTANT (CNA) #24, DUE TO RESIDENT #101 CHOKING ON LUNCH. RESIDENT #101 WAS STRUGGLING TO BREATHE WITH A PULSE RATE OF 60, R (RESPIRATIONS) NOT DISCERNABLE. ATTEMPTS MADE TO CLEAR HER MOUTH WERE UNSUCCESSFUL AND RESIDENT WENT LIMP. THE [MEDICATION NAME] MANEUVER WAS PERFORMED 3 TIMES AND RESIDENT BEGAN TO SNORT. THE RESIDENT WAS THEN RETURNED TO HER ROOM, BACK BLOWS AND MOUTH SWEEP WERE PERFORMED, AND FOOD [MEDICATION NAME] WAS REMOVED FROM HER MOUTH. THE COLOR RETURNED TO HER FACE AND RESPIRATIONS RESUMED. THE RESIDENT'S VITAL SIGNS AFTER THE EVENT INCLUDED BLOOD PRESSURE OF 180/60, (NORMAL 120-140/60-80) PULSE RATE OF 99,(NORMAL 60-100) RESPIRATIONS OF 22 (NORMAL 18-22) AND SPO2 OF 95% (OXYGEN LEVEL MEASUREMENT- NORMAL 92-100%). THE EMERGENCY SERVICES (EMS) ARRIVED AND TRANSPORTED THE RESIDENT TO A LOCAL HOSPITAL." ACCORDING TO NURSING PROGRESS NOTES DATED 2/2/2012, RESIDENT#101 RETURNED TO THE FACILITY AT 8:30 PM. SHE WAS ALERT AND RESPONDED TO HER NAME BY NODDING, WHICH WAS HER BASELINE. NURSING PROGRESS NOTES DATED 2/3/2012 AT 2 PM, DOCUMENTED THE HOSPITAL CALLED AND REPORTED AN X-RAY DONE THERE REVEALED THAT RESIDENT#101 HAD FRACTURED RIBS 4 AND 5 ON THE RIGHT SIDE. A REVIEW OF THE MENUS PROVIDED BY THE ADMINISTRATOR FOR FALL AND WINTER 2012, FOR RESIDENTS PRESCRIBED A MECHANICAL SOFT DIET, INDICATED THAT ALL MEAT ITEMS WERE TO BE GROUND-UP EXCEPT BAKED FISH OR TUNA FISH SALAD. DURING AN INTERVIEW ON 2/22/2012 AT 10:50 AM WITH THE REGISTERED DIETITIAN #21 (RD) WHEN ASKED HOW HE THOUGHT THE INCIDENT WITH RESIDENT #101 HAPPENED, HE SAID HE SUSPECTED THAT THE WRONG ENTREE WAS ON RESIDENT #101'S TRAY. HE SAID HE CONDUCTED AN INVESTIGATION IN HIS AREA AND PUT INTERVENTIONS IN PLACE TO PREVENT THIS TYPE OF ERROR FROM OCCURRING IN THE FUTURE.

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS, MONITOR AND TREAT ONE (#721) OF 27 SAMPLED RESIDENTS WITH AN ELEVATED BLOOD PRESSURE OF ,[DATE] WHO HAD COMPLAINTS OF NAUSEA AND VOMITING, AND FAILED TO NOTIFY THE PHYSICIAN OF THESE POTENTIALLY LIFE THREATENING ACUTE CHANGES IN CONDITION FOR THIS RESIDENT DURING ADMINISTRATION OF A RESPIRATORY NEBULIZER treatment for [REDACTED].#721) BEING FOUND UNRESPONSIVE WITH NO PALPABLE BLOOD PRESSURE READING AND A HEART RATE OF 154. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON [DATE] AT 2:00 PM. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON [DATE] AT 4:59 PM. THE IJ WAS REMOVED ON [DATE] BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON [DATE] AS VERIFIED ONSITE ON [DATE], DURING THE COMPLETION OF THE EXTENDED SURVEY. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS ISOLATED WITH ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY. IN ADDITION, THE FACILITY FAILED TO ASSESS THE PAIN STATUS OF ONE (# 702) OF 27 SAMPLED RESIDENTS, RESULTING IN UNMET PAIN MANAGEMENT, AND FAILED TO MONITOR AND TREAT A HEAD WOUND FOR ONE (# 709) OF 28 SAMPLED RESIDENTS, RESULTING IN AN INFECTION. FINDINGS INCLUDE: ON [DATE] AT 1:15 PM, RECORD REVIEW REVEALED THAT RESIDENT #721 WAS AN [AGE] year old FEMALE ORIGINALLY admitted INto the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE Minimum Data Set, dated dated [DATE] INDICATED RESIDENT #721 COGNITION WAS INDEPENDENT. THE RESIDENT REQUIRED TOTAL ASSISTANCE FROM STAFF FOR ALL ACTIVITIES FOR DAILY LIVING INCLUDING BED MOBILITY AND TRANSFERS. ON [DATE] AT 12:45 P.M., REVIEW OF NURSING NOTES DATED [DATE] THROUGH [DATE] THAT ON [DATE] AT 5:00 AM , RESIDENT # 721 BLOOD PRESSURE WAS ,[DATE] AND THE RESIDENT COMPLAINED OF NAUSEA AND VOMITED A MODERATE AMOUNT OF GREEN PARTICLES WITH FLUID. THE PHYSICIAN WAS NOTIFIED. THERE WAS NO DOCUMENTED EVIDENCE OF NEW ORDERS FOR COMPLAINTS OF [MEDICAL CONDITION] DISTRESS OR ADJUSTMENT IN MEDICATION ORDERS. ON [DATE] AT 6:45 AM, RESIDENT # 721 HAD A SECOND VOMITING EPISODE AND THE RESIDENT'S BLOOD PRESSURE WAS NOW ,[DATE]. THE PHYSICIAN WAS AGAIN NOTIFIED. THERE WAS NO DOCUMENTED EVIDENCE OF NEW ORDERS FOR THE VOMITING EPISODES OR ADJUSTMENT IN MEDICATIONS TO DECEASE THE RESIDENT'S BLOOD PRESSURE. PER NURSES NOTE DATED [DATE] AT 3:40 PM, "RESIDENT ( # 721) COMPLAINED OF [MEDICAL CONDITION] UPSET IN EARLY AM" (TIME NOT DOCUMENTED). THERE WAS NO DOCUMENTED EVIDENCE THAT THE PHYSICIAN WAS NOTIFIED. PER NURSE'S NOTE DATED [DATE] (NO TIME DOCUMENTED), RESIDENT (# 721) STATED, "STOMACH HURTING". BLOOD PRESSURE WAS ,[DATE] AND TYLENOL WAS GIVEN FOR PAIN. " THERE WAS NO DOCUMENTED EVIDENCE THAT THE PHYSICIAN WAS NOTIFIED REGARDING THE RESIDENT'S COMPLAINT'S OF [MEDICAL CONDITION] DISTRESS AND THE ELEVATION OF THE RESIDENT'S BLOOD PRESSURE. THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORD THAT INDICATED THAT RESIDENT # 721'S CARDIAC AND [MEDICAL CONDITION] STATUS WAS ASSESSED AND MONITORED. THERE WAS NO DOCUMENTED EVIDENCE THAT THE RESIDENT'S BLOOD PRESSURE AND VITAL SIGNS WERE REASSESSED. THERE WAS NO DOCUMENTED EVIDENCE THAT A PHYSICIAN ASSESSED THE RESIDENT'S HIGH BLOOD PRESSURE. PER NURSE'S NOTE DATED [DATE] AT 10:30 PM, (LATE ENTRY) RESIDENT'S SON ARRIVED, STATED, "MY MOTHER CALLED ME AT 9:00 PM AND SOUNDED CONFUSED. SHE SAID THAT SHE WASN'T SURE WHERE SHE WAS AND SHE WAS FEARFUL FOR THE PEOPLE AROUND HER, TO GET THERE AS QUICKLY AS HE COULD". PER NURSE'S NOTE DATED [DATE] AT 9:15 PM, "WENT INTO RESIDENT'S (# 721) ROOM TO REMOVE A NEBULIZER (BREATHING TREATMENT) THAT WAS INITIATED AT 6:00 PM ON [DATE]. NOTICED RESIDENTS ( # 721) FACE PALE AND THE RESIDENT WAS TAKING LONG BREATHS WITH GURGLING SOUNDS. CALLED FOR HELP AND REQUESTED 911." AT 9:17 PM, BEGAN CARDIOPULMONARY RESUSCITATION (CPR). UNABLE TO OBTAIN BLOOD PRESSURE, PULSE OXIMETRY (OXYGEN LEVEL IN THE BLOOD) WAS 83 PERCENT (% ) (NORMAL RANGE 93% OR GREATER), PULSE WAS 154. CPR CONTINUED. AT 9:20 PM, RESIDENT HAD A FAINT PULSE AND CPR CONTINUED. AT 9:23 PM, EMERGENCY RESPONSE STAFF ARRIVED AND TOOK OVER THE CPR. AT 9:25 PM, FIRE AND POLICE ARRIVED AND THE CPR CONTINUED VIA EMS STAFF. AT 9:45 PM, CPR WAS STOPPED PER A HOSPITAL PHYSICIAN THAT THE EMERGENCY RESPONSE STAFF WERE COMMUNICATING WITH." THERE WERE NO DOCUMENTED EVIDENCE THAT THE FACILITY ATTEMPTED TO TRANSPORT THE RESIDENT TO THE HOSPITAL BEFORE STOPPING CPR. REVIEW OF RESIDENT # 721 ADVANCE DIRECTIVE DATED [DATE] INDICATED " FULL RESUSCITATION". ON [DATE] AT 1:50 PM THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING THE INCIDENTS THAT OCCURRED ON [DATE] - [DATE] TO RESIDENT #721. THE DON STATED, "THE NURSE WHO WAS ON DUTY ON [DATE] WAS A POOL (AGENCY ) NURSE WHO NO LONGER WORKED AT THE FACILITY." THE DON WAS ALSO INTERVIEWED REGARDING THE FACILITY'S POLICY ON ELEVATED VITAL SIGNS AND NAUSEA AND VOMITING. THE DON STATED, " WE HAVE STANDING ORDERS". ON [DATE] AT APPROXIMATELY 2:30 PM NURSE SUPERVISOR (O ) WAS INTERVIEWED REGARDING THE FACILITY'S POLICY ON ELEVATED VITAL SIGNS AND [MEDICAL CONDITION] DISTRESS FOR A RESIDENT WITH [MEDICAL CONDITION]. NURSE SUPERVISOR "O" STATED, "I WAS NOT ON DUTY ON [DATE], BUT IF I WAS MADE AWARE OF THE RESIDENT'S BLOOD PRESSURE OF ,[DATE], I WOULD HAVE NOTIFIED THE PHYSICIAN." ON [DATE] AT 3:15 PM, RESIDENT #721'S MEDICATION ADMINISTRATION RECORD (MAR) AND physician's orders [REDACTED]. NURSE SUPERVISOR "O" WAS UNABLE TO EXPLAIN, WHY THE RESIDENT'S BLOOD PRESSURE WAS NOT RECHECKED AFTER THE [DATE] READING OF ,[DATE] AND WHY THE PHYSICIAN WAS NOT NOTIFIED OF THE ELEVATED BLOOD PRESSURE; WHY THE PHYSICIAN WAS NOT NOTIFIED OF THE RESIDENTS COMPLAINT OF [MEDICAL CONDITION] PAIN; WHY THE NEBULIZER TREATMENT WAS INITIATED ON [DATE] AT 6:00 PM AND WAS STILL RUNNING AT 9:15 PM.; WHY STAFF WAS NOT PRESENT DURING THE ADMINISTRATION OF THE NEBULIZER TREATMENT, AND WHY THE RESIDENT'S PHYSICIAN WAS NOT NOTIFIED OF THE ACUTE CHANGE IN CONDITION WHEN THE RESIDENT WAS FOUND PALE, TAKING LONG BREATHS AND WAS UNRESPONSIVE. THERE WERE NO DOCUMENTED EVIDENCE THAT THE FACILITY POLICIES WERE REVISED OR REVIEWED AND NO DOCUMENTED EVIDENCE THAT THE FACILITY PROVIDED INSERVICES TO CLINICAL STAFF ON ASSESSMENTS/MONITORING OF RESIDENTS WITH AN ACUTE CHANGE IN CONDITION. ON [DATE] AT 2:00 PM, REVIEW OF WEBSITE DRUGS. COM, THE SIDE EFFECTS OF [MEDICATION NAME]/[MEDICATION NAME] ARE ," FAST OR IRREGULAR HEARTBEAT; NEW OR WORSENING BREATHING PROBLEMS". ON [DATE] AT 2:15 PM, REVIEW OF WEBSITE: NATIONAL HEART, LUNG, AND BLOOD INSTITUTE, TITLED, "WOMEN AND [MEDICAL CONDITION]", DOCUMENTED, "MANY [MEDICAL CONDITION] START SLOWLY. WARNING SIGNS INCLUDES SWEAT AND NAUSEA." ON [DATE] AT 8:30 AM, REVIEW OF WEBSITE: AMERICAN HEART ASSOCIATION, TITLED, "[MEDICAL CONDITION] SYMPTOMS AND WARNING SIGNS", DOCUMENTED, "WOMEN ARE SOMEWHAT MORE LIKELY THAN MEN TO EXPERIENCE SOME OF THE OTHER COMMON SYMPTOMS, PARTICULARLY SHORTNESS OF BREATH, NAUSEA AND VOMITING, AND BACK OR JAW PAIN." ON [DATE] AT 4:00 PM, REVIEW OF THE FACILITY'S POLICY, TITLED " STANDING ORDERS" DATED ,[DATE] DOCUMENTED, "NOTIFY PHYSICIAN IMMEDIATELY FOR SYSTOLIC BLOOD PRESSURE GREATER THAN 160 OR LESS THAN 100 WITH SYMPTOMS. FOR NAUSEA WITH OR WITHOUT VOMITING, REPORT IMMEDIATELY TO THE PHYSICIAN IF ACCOMPANIED BY ABDOMINAL PAIN OR CHANGES IN VITAL SIGNS. FOR [MEDICAL CONDITION] UPSET GIVE 4 TEASPOONS OF [MEDICATION NAME] EVERY 2 HOURS AS NEEDED AND NOTIFY THE PHYSICIAN IF NO RELIEF IN 24 HOURS. ALL STANDING DOCTOR'S ORDERS FOR MEDICATION MUST BE WRITTEN IN THE DOCTOR'S ORDER SHEET BEFORE IMPLEMENTING THEM." THERE WERE NO DOCUMENTED NOR SIGNED MEDICATION STANDING ORDERS IN THE CLINICAL RECORD FOR RESIDENT #721. ON [DATE] AT 4:15 PM, REVIEW OF THE FACILITY'S POLICY, TITLED CPR-911 DATED ,[DATE] DOCUMENTED, "FOR THOSE RESIDENTS WHERE CPR WAS INITIATED BY FACILITY STAFF, 911 SHALL BE CONTACTED FOR CONTINUATION OF EMERGENCY CARE AND TRANSPORTATION TO THE HOSPITAL. THE FACILITY'S SUBMITTED A PLAN OF CORRECTION DATED [DATE] WHICH DOCUMENTED THE FOLLOWING: 1. RESIDENT #721 IS NO LONGER A RESIDENT. 2. ALL IN-HOUSE RESIDENTS RECEIVED COMPLETE PHYSICAL ASSESSMENTS INCLUDING TEMPERATURE, RESPIRATORY RATE, LUNG SOUNDS, APICAL HEART RATE, AND BLOOD PRESSURE, PAIN SCALE ,[DATE] WITH LOCATION, AND ANY SIGNS AND SYMPTOMS OF ACUTE RESPIRATORY/CARDIAC DISTRESS. THE ASSESSMENT TOOL WAS CREATED BY THE MEDICAL DIRECTOR. ALL RESIDENTS (170) RECEIVED THIS ASSESSMENT ON [DATE]. EACH COMPLETE PHYSICAL ASSESSMENT WAS COMPLETED BY DIRECTOR OF NURSING, UNIT MANAGERS AND NURSING CONSULTANTS WHICH INCLUDED RN/LPN. AT THAT TIME ALL FINDINGS WERE REVIEWED BY THE DIRECTOR OF NURSING, ANY ACUTE CHANGE IN CONDITION CONCERNS WERE REPORTED TO THE ATTENDING PHYSICIAN. THE MEDICAL DIRECTOR REVIEWED ALL COMPLETE PHYSICIAN ASSESSMENTS. RESIDENTS ARE CURRENTLY STABLE AND NOT IN IMMEDIATE JEOPARDY. 3. THE STANDING ORDER POLICY WAS REVISED. THE NEW POLICY FOR CONDITION CHANGE TO REPORT TO PHYSICIAN/ NURSING RESPONSIBILITY FOR CONDITION CHANGE WERE IMPLEMENTED. POLICIES APPROVED BY MEDICAL DIRECTOR. NURSING STAFF HAVE BEEN EDUCATED ON (A) THE IMPORTANCE OF ASSESSING AND REPORTING ABNORMAL VITAL SIGNS ESPECIALLY THOSE THAT ARE ACCOMPANIED WITH ADDITIONAL SYMPTOMS OF DISTRESS; AND (B) RECOGNIZING AND REACTING TO ACUTE CONDITION CHANGES REQUIRING FURTHER ASSESSMENT AND PHYSICIAN REPORTING. 78 RN/LPN OUT OF 80 EMPLOYED RN/LPN HAS BEEN EDUCATED. NO AGENCY NURSING STAFF IS WORKING AT SHOREPOINTE NURSING CENTER. IF NEED ARISES, THE AGENCY NURSING STAFF WILL RECEIVE THE REQUIRED EDUCATION ABOVE PRIOR TO WORKING IN THE FACILITY. WE HAVE EDUCATED ABOVE PRIOR TO WORKING IN THE FACILITY. WE EDUCATED 85 OUT OF 100 C.N.A.S. 4. RESIDENTS WHO DISPLAY ACUTE CONDITION CHANGES WILL BE LOGGED ON THE 24 HOUR REPORT FOR SHIFT-TO-SHIFT FOLLOW THROUGH. THE NURSING DESIGNEE WILL REVIEW THE 24 HOUR REPORT DAILY FOR APPROPRIATE ASSESSMENT, TREATMENT AND FOLLOW-UP. THE UNIT MANAGER OR NURSING DESIGNEE WILL CONDUCT 15 RANDOM MEDICAL CHART AUDITS DAILY TO ASSESS FOR ACUTE CONDITION CHANGES AND/OR ABNORMAL VITAL SIGNS. THE UNIT MANAGER OR DESIGNEE WILL REPORT THEIR DAILY FINDINGS TO THE DIRECTOR OF NURSING. ALL FINDINGS WILL BE REPORTED QUARTERLY TO THE QUALITY ASSURANCE COMMITTEE UNTIL THE QUALITY ASSURANCE COMMITTEE DISCONTINUES THE REVIEW AND/OR MONITORING PROCESS. THE DIRECTOR OF NURSING WILL BE RESPONSIBLE FOR COMPLIANCE. ( ) ( ) ( ) ( ) ( ) ( ) ( ) RESIDENT #709 WAS OBSERVED THROUGHOUT EACH DAY OF THE SURVEY PROPELLING HERSELF IN A WHEELCHAIR. THE RESIDENT WAS CONFUSED AND NON-VERBAL. ON [DATE] AT 10:30 AM, THE CLINICAL RECORD AND AN INCIDENT/ACCIDENT (I/A) REPORT FOR RESIDENT #709 WAS REVIEWED WITH THE ASSISTANT DIRECTOR OF NURSING(ADON 'B') WHOM THE DIRECTOR OF NURSING DEFERRED TO FOR INFORMATION REGARDING INCIDENTS INVOLVING THIS RESIDENT. RESIDENT #709 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS NOTED THAT THE RESIDENT WAS NON-AMBULATORY, HAD MODERATELY SEVERE COGNITIVE IMPAIRMENT, AND REQUIRED EXTENSIVE ASSISTANCE FROM STAFF FOR TRANSFERS AND MOBILITY. A REVIEW OF AN I/A REPORT NOTED THE FOLLOWING: ON [DATE], RESIDENT #709 WAS FOUND ON THE FLOOR IN THE HALLWAY BY THE ELEVATOR BY A VISITOR WHO SUMMONED STAFF. THE RESIDENT WAS BLEEDING FROM THE FOREHEAD. RESIDENT #709 SUSTAINED THREE SKIN TEARS TO THE LEFT FOREHEAD. ONE MEASURED 7 CENTIMETER (CM) X 3.5 CM AND THE OTHER TWO MEASURED 1 CM EACH. SHE WAS TRANSFERRED TO THE HOSPITAL emergency roiagnom on [DATE] AND RETURNED to the facility on [DATE] WITH A DRESSING ON THE FOREHEAD. THE LARGER HEAD WOUND SUBSEQUENTLY BECAME INFECTED AND DID NOT HEAL UNTIL [DATE] PER THE FOLLOWING DETAILS: NURSES NOTED THAT THE RESIDENT RETURNED FROM THE HOSPITAL WITH A DRESSING TO THE FOREHEAD ON [DATE]. THE RESIDENT WAS PRESCRIBED DAILY CLEANING OF THE AREA WITH NORMAL SALINE, APPLY TRIPLE ANTIBIOTIC OINTMENT, AND APPLY A TELPHA DRESSING UNTIL HEALED. PER NURSES NOTES ON [DATE], THE DRESSING WAS DRY AND INTACT. ON [DATE], THE RESIDENT WAS NOTED TO HAVE "PERIORBITAL DARKENING." ON [DATE], A BRUISE REMAINED TO THE FOREHEAD AND "SKIN TEAR LEFT FOREHEAD IS SCABBED OVER AND ECCHYMOSIS (BRUISING)" TO FOREHEAD. ON [DATE], THE DRESSING AND treatment for [REDACTED]." THERE WERE NO DOCUMENTED physician progress notes [REDACTED]. ON [DATE], NURSES NOTED: "RESIDENT WENT TO BEAUTY SHOP TODAY....AND THE BEAUTICIAN SAID HER (RESIDENT #709'S) HEAD HAD PUS COMING OUT OF OLD INJURY FROM FALL. NURSE PRACTITIONER (NP 'E') CALLED TO SEE THEM. ONE IN MIDDLE OF HEAD....LAYERS OF SKIN GONE IS ,[DATE] CM WIDE AND 1 CM LONG....ONE ON LEFT SIDE OF HEAD IS A LARGE SCAB....3 CM X 3 CM. IT IS ROUND." ON [DATE], NP 'E' NOTED: "PER HAIRSTYLIST AND REGISTERED NURSE (RN), PATIENT WITH SOME ACTIVE DRAINAGE PER OLD FOREHEAD WOUND....POSITIVE [DIAGNOSES REDACTED] (REDNESS) SURROUNDING, 3 X 2 CM, RAISED, SCALY WOUND....WOUND [MEDICAL CONDITION]." THE RESIDENT WAS PRESCRIBED KEFLEX (ANTIBIOTIC) THREE TIMES A DAY FOR SEVEN DAYS. THERE WAS NO ORDER FOR CLEANING, PROVIDING WOUND CARE, OR DRESSING THE WOUND. THERE WAS NO MENTION OF THE HEAD WOUND ON SKIN INTEGRITY CARE PLANS UNTIL [DATE] AND NO MENTION ON FALL CARE PLANS. RESIDENT #709 HAD DOCUMENTED NURSES NOTES ALMOST DAILY AND NOTES WERE FREQUENTLY DOCUMENTED UP TO THREE TIMES A DAY. WHEN QUERIED, NURSE MANAGER 'A' WAS UNABLE TO EXPLAIN WHY THERE WERE NO NURSES NOTES FROM [DATE] UNTIL [DATE], WHEN THE WOUND WAS NOTED TO BE DRAINING IN THE BEAUTY SHOP. SHE WAS UNABLE TO RESPOND WHY, IF THE RESIDENT WAS BEING WASHED AND OBSERVED EVERYDAY BY STAFF, NO ONE SAW SOME SIGN OF INFECTION (REDNESS, [MEDICAL CONDITION]) TO THE FOREHEAD PRIOR TO [DATE]. REVIEW OF THE FACILITY'S "SKIN CARE GUIDELINES" DATED [DATE]: "NURSES MUST DO WEEKLY SKIN ASSESSMENTS AND REVIEW/REVISE THE RESIDENT'S CARE PLAN. THE NURSE MANAGER MUST REVIEW ALL SKIN ASSESSMENTS. WORSENING OF PREVIOUS AREAS MUST BE REPORTED TO THE PHYSICIAN AND DOCUMENTED IN PROGRESS NOTES BY NURSING." FROM [DATE] THRU [DATE], NURSES NOTED THAT THE WOUND HAD A SCAB AND WAS CLOSED, DRY, AND INTACT. ON [DATE], AN ORDER WAS WRITTEN TO CLEAN THE WOUND WITH SALINE AND APPLY TRIPLE ANTIBIOTIC OINTMENT TO "SKIN SURROUNDING THE SCAB DAILY UNTIL HEALED" OR FOR 14 DAYS. PER THE TREATMENT RECORD, THE WOUND CARE BEGAN ON [DATE] AND ENDED [DATE]. ( ) ON [DATE] AT 1:00 PM, RECORD REVIEW REVEALED THAT RESIDENT #702 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], DOCUMENTED RESIDENT #702 AS REQUIRING EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING, had a history of [REDACTED]. THE MDS DOCUMENTED RESIDENT #702 HAD "POOR GENERAL AWARENESS AND JUDGEMENT FOR SAFETY." THE "RESIDENT SAFETY ASSESSMENT" DATED [DATE] SCORED RESIDENT #702 AT ,[DATE] IN WHICH THE SCALE WAS: LOW-LESS THAN OR EQUAL TO 14 AND HIGH WAS GREATER THAN OR EQUALED TO 15. ON [DATE] AT 9:30 A.M., THE INCIDENTS AND ACCIDENTS FOR RESIDENT #702 WERE REVIEWED WITH PART OF "THE FACILITY'S SAFETY TEAM", STAFF MEMBERS "M", "N", "B" AND THE DIRECTOR OF NURSING (DON). THE INCIDENT AND ACCIDENT DATED [DATE] AT 7:15 P.M. DOCUMENTED RESIDENT #702 WAS "OBSERVED" ON THE FLOOR "ON HIS FACE....VERBALIZED PAIN TO RIGHT LEG AND NON-VERBAL GUARDING ON MOVEMENT." AN ABRASION 1.5 CENTIMETERS BY 1.0 CENTIMETERS WAS OBSERVED TO RIGHT KNEE. ON [DATE] AT 9:00 A.M., REVIEW OF RESIDENT # 702'S "RESIDENT ADL RECORD AND IMPLEMENTATION OF CARE PLAN' DOCUMENT [DATE] "REFUSED SHOWER DUE TO HIS RIGHT LEG HURTING AND REFUSED LUNCH." FURTHER REVIEW OF RESIDENT #702'S X-RAY FOR [DATE] AFTER A FALL DOCUMENTS "A PROGRESS STUDY IS SUGGESTED TO COMPLETELY EXCLUDE AN IMPACTED FRACTURE." FURTHER REVIEW OF THE PHYSICIAN'S NOTES DATED [DATE], [DATE] AND [DATE] DOES NOT INDICATE "A PROGRESS STUDY IS SUGGESTED TO COMPLETELY EXCLUDE AN IMPACTED FRACTURE." THE physician progress notes [REDACTED]." ON [DATE] AT 12:00 P.M., THE DON WAS QUERIED REGARDING THE LACK OF "A PROGRESS STUDY" TO EXCLUDE AN IMPACTED FRACTURE. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS, AND IMPLEMENT CONSISTENT AND EFFECTIVE SUPERVISION AFTER EACH FALL AND CHANGE IN BEHAVIOR FOR ONE (#707) OF 11 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 27 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY TO THE RESIDENT'S HEALTH AND SAFETY AS EVIDENCED BY MULTIPLE FALLS, INJURIES, AND NUMEROUS PSYCHOTIC EPISODES OF RESTLESSNESS, AGITATION, AND EMOTIONAL DISTRESS. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 4/4/11 AT 3:00 PM. THE ADMINISTRATION WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 4/6/11 AT 4:30 PM. THE IJ WAS REMOVED ON 4/6/11 BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 4/6/11 , AS VERIFIED ONSITE ON 4/8/11 , DURING THE COMPLETION OF THE EXTENDED SURVEY. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS PATTERN. ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY. IN ADDITION, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION, SAFELY OPERATE RESIDENT CARE EQUIPMENT, AND IMPLEMENT SAFETY DEVICES/INTERVENTIONS FOR FIVE (#'S 702, 704, 705, 709, AND 717) OF 11 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 27, RESULTING IN A ABRASION TO THE BUTTOCKS, HEMATOMA TO THE FOREHEAD, SKIN TEARS TO THE FOREHEAD AND FOREARM; INGESTION OF HAND SANITIZER; LACERATION TO INNER RIGHT TOE; AND SEPARATION OF BABY TOE FROM FOURTH TOE BY A WHEELCHAIR AND NUMEROUS FALLS. FINDINGS INCLUDE: ON 3/30/11 AT 12:30 P.M., RESIDENT #707'S BEHAVIOR LOGS, MEDICATION ADMINISTRATION RECORDS (MAR), AND CLINICAL RECORDS WERE REVIEWED WITH THE SOCIAL WORKER "J". ON 3/31/11 AT 1:00 P.M., RESIDENT #707'S CLINICAL RECORD AND FACILITY INCIDENT AND ACCIDENT (I&A) REPORTS FOR RESIDENT #707 WERE REVIEWED WITH MEMBERS OF THE FACILITY SAFETY TEAM, PHYSICAL THERAPIST (PT) "N", OCCUPATIONAL THERAPY SENIOR CLINICAL SPECIALIST (OT) "M", AND THE ASSISTANT DIRECTOR OF NURSING (ADON) "B". PER THE ADMISSION FACE SHEET/[DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET ASSESSMENTS ((MDS) dated [DATE] AND 12/17/10, RESIDENT #707 HAD MODERATELY IMPAIRED COGNITION, NEEDED STAFF ASSISTANCE FOR TRANSFERS TO THE WHEELCHAIR AND AMBULATION, AND had a history of [REDACTED].#707 EXHIBITED PHYSICALLY ABUSIVE BEHAVIORS THAT WERE EASILY ALTERED. THE 12/17/10 MDS DOCUMENTED THAT NO UNDESIRABLE BEHAVIORS HAD OCCURRED. REVIEW OF THE PHYSICIANS MEDICATION ORDERS SUMMARY SHEET FOR 8/1/10 THROUGH 8/31/10 REVEALED THE FOLLOWING ORDERS: - 3/7/10 ORDER FOR SEROQUEL (AN ANTIPSYCHOTIC) 25 MILLIGRAMS (MG) DAILY (QD) AT BEDTIME, -3/31/10 ORDER FOR CELEXA (ANTIDEPRESSANT), 10 MG Q A.M. -7/26/10 ORDER FOR LORAZEPAM 1 MG INTRAMUSCULAR INJECTION (IM), AS NEEDED. A FALLS RISK SCORE DATED 7/20/10 DOCUMENTED THAT RESIDENT #707 WAS AT HIGH RISK FOR FALLS. RESIDENT #707'S NURSING CARE PLANS INCLUDED THE FOLLOWING: A. "RISK FOR FALLS", DATED 5/6/10, INCLUDED THE FOLLOWING INTERVENTIONS: "KEEP BED AT LOWEST LEVEL WHEN NOT ADMINISTERING CARE", " USE CALM APPROACH WHEN REDIRECTING, AND OFFER REASSURANCE. B. "RISK FOR GAIT DISTURBANCE DUE TO ANTI DEPRESSANT AND ANTI PSYCHOTIC MEDICATION" DATED 5/14/10, REVIEWED 7/20/10, INCLUDED THE FOLLOWING INTERVENTION: " ASSESS ANY BEHAVIOR/MOOD CHANGES". C. "BEHAVIOR", DATED 5/3/10, (NO REVIEW DATES NOTED) INCLUDED THE FOLLOWING INTERVENTIONS: "PROVIDE FREQUENT VISUAL CHECKS WHEN UP IN WHEELCHAIR ON UNIT", AND "IF PATIENT REFUSES, RETURN LATER AND TRY AGAIN". D. "MOOD", DATED 2/9/10 (NO REVIEW DATES NOTED), INCLUDED THE FOLLOWING INTERVENTIONS: "MONITOR FOR CHANGES IN MOOD AND BEHAVIOR AND REPORT TO SOCIAL WORK", "OFFER ACTIVITIES THAT PROMOTE USEFULNESS", AND "OBSERVE RESIDENT'S WHEREABOUTS WHEN OUT OF HER ROOM AND PROVIDE FREQUENT VISUAL CHECKS." ACCORDING TO NURSES NOTES DATED 7/15/10 THROUGH 10/29/10, RESIDENT #707 EXHIBITED EPISODES OF AGITATION, COMBATIVENESS, RESISTANCE TO CARE, AND EXHIBITED NUMEROUS ATTEMPTS TO SELF TRANSFER WITHOUT STAFF ASSISTANCE ON NUMEROUS OCCASIONS. THREE I/A REPORTS FOR RESIDENT #707 NOTED THE FOLLOWING: #1. ON 7/26/10 AT 12:30 A.M.., THE RESIDENT WAS FOUND ON THE FLOOR IN HER ROOM AFTER ATTEMPTING A SELF TRANSFER. THERE WAS NO INJURY NOTED. WHEN QUERIED, THE SAFETY TEAM REPORTED THAT RESIDENT #707 HAD SUFFERED MULTIPLE FALLS IN THE FACILITY PRIOR TO 7/26/10, BUT STATED THAT THE RESIDENT DID NOT HAVE SAFETY MATS OR A LOW BED POSITION. THEY WERE UNABLE TO EXPLAIN WHY THE BED WAS NOT IN LOW POSITION WHEN THE CARE PLAN LISTED IT AS AN INTERVENTION. THERE WERE NO NEW CORRECTIVE ACTIONS TO PREVENT REOCCURRENCE. NURSES NOTED THAT THE RESIDENT WAS AGITATED AND COMBATIVE WITH STAFF AFTER THE FALL, NOTING "YELLING ANXIOUSLY...., SWINGING AT STAFF, REFUSING TO HAVE VITALS TAKEN." WHEN THE PSYCHIATRIST EVALUATED RESIDENT #707 ON 8/4/10, THERE WAS NO MENTION THAT HE WAS MADE AWARE OF AGITATION, COMBATIVE BEHAVIORS OR RESISTANCE TO CARE. HE NOTED: "I SPOKE WITH STAFF. ACCORDING TO STAFF SHE IS MORE CONFUSED RECENTLY. SHE IS NOT SHOWING ANY MAJOR BEHAVIORAL PROBLEMS." THERE WERE NO SOCIAL SERVICE INTERVENTIONS, AND NO DOCUMENTATION OF BEHAVIORS FOR RESIDENT #707 IN BEHAVIOR LOGS FOR THE DATE OF THE FALL. NURSING NOTES AND BEHAVIOR LOGS FROM 9/1/10 THRU 9/7/10 NOTED NUMEROUS EPISODES OF VERBAL ABUSE, COMBATIVENESS WITH STAFF, RESISTANCE TO CARE, PARANOIA, AND ANXIETY. #2. ON 9/7/10 AT 6:30 AM, THE RESIDENT fell WHILE ATTENDED BY NURSE AIDE "W" AND NURSE "X". THE STAFF STATEMENT DOCUMENTED, "ATTEMPTS MADE TO TOILET RESIDENT, COMBATIVE (KICKING YELLING, HITTING) WITH CARE AND STAFF, STOOD AND LOST BALANCE, THEN fell on LEFT HIP." A "PATIENT TRANSFER FORM" DATED 9/7/10 DOCUMENTED THAT RESIDENT #707 WAS TRANSFERRED TO ACUTE CARE ON 9/7/10 (NO TIME NOTED) FOR "[DIAGNOSES REDACTED].M., REVEALED: "status [REDACTED]." WHEN QUERIED, THE SAFETY TEAM REPORTED THAT RESIDENT #707 STILL DID NOT HAVE A LOW BED OR SAFETY MATS IN PLACE ON 9/7/10, DESPITE THESE INTERVENTIONS BEING CARE PLANNED AND THE HISTORY OF PREVIOUS FALLS. THE SAFETY TEAM WAS UNABLE TO CONFIRM WHETHER STAFF "W" AND "X" FOLLOWED CARE PLAN INTERVENTIONS TO "REASSURE AND REDIRECT" AND TO "RETURN LATER AND TRY AGAIN". EMPLOYEES "W" AND "X" WERE NO LONGER EMPLOYED BY THE FACILITY AND UNAVAILABLE FOR COMMENT. THE SAFETY TEAM WAS UNABLE TO EXPLAIN HOW THE RESIDENT fell AND BROKE A HIP WHILE TWO STAFF WERE IN ATTENDANCE TO KEEP HER SAFE. A FACE SHEET DOCUMENTED RESIDENT #707 WAS readmitted TO THE FACILITY ON 9/15/10 WITH A [DIAGNOSES REDACTED]. RESIDENT #707'S REadmission orders [REDACTED]. AN "AT RISK FOR FALLS" CARE PLAN DATED 9/18/10 INCLUDED INTERVENTIONS: KEEP BED AT LOWEST LEVEL WHEN NOT ADMINISTERING CARE, "CONCAVE MATTRESS", AND "CONSULT WITH RECREATIONAL THERAPY TO FIND DIVERSIONAL ACTIVITIES IN WHICH THE RESIDENT WILL PARTICIPATE." PER A PSYCHIATRIST EVALUATION DATED 9/19/10: "SHE IS NOT SHOWING ANY BEHAVIORAL PROBLEMS." THERE WAS NO INDICATION THE PSYCHIATRIST WAS INFORMED OF THE AGITATION, COMBATIVENESS, OR RESISTANCE TO CARE DOCUMENTED IN THE NURSING NOTES, ON THE BEHAVIOR LOGS, AND IN THE INCIDENT AND ACCIDENT REPORTS. #3. ON 9/30/10, THE RESIDENT WAS ON THE FLOOR IN HER ROOM. THE CORRECTIVE ACTION: "NEEDS CONCAVE MATTRESS WITH LOW BED." A PATIENT TRANSFER FORM DATED 9/30/10 INDICATED RESIDENT #707 WAS TRANSFERRED TO ACUTE CARE ON 9/30/10 FOR [DIAGNOSES REDACTED]. AN ACUTE CARE X RAY REPORT DATED 10/01/10 REVEALED: THERE WAS "A SLIGHT DEGREE OF DISPLACEMENT" OF THE DEVICE THAT WAS IMPLANTED DURING SURGICAL REPAIR FOR THE HIP FRACTURE. WHEN QUERIED, THE SAFETY TEAM REPORTED THAT RESIDENT #707'S BED DID NOT HAVE A LOW BED OR BEDSIDE SAFETY MATS ON 9/30/10. WHEN ASKED WHY, OT "M" STATED THAT SAFETY MATS COULD NOT BE USED UNLESS THE BED WAS IN A LOW POSITION AND THAT THE RESIDENT'S BED COULD NOT BE PLACED IN LOW POSITION BECAUSE SHE WAS ON "HIP PRECAUTIONS" AFTER THE HIP SURGERY MAKING A LOW BED CONTRAINDICATED. HOWEVER, THE RESIDENT'S CLINICAL RECORD CONTRADICTED THIS CLAIM. A FACILITY "THERAPY DEMOGRAPHIC & PRIOR LEVEL OF FUNCTION" FORM BY THE OT DEPARTMENT ON 9/16/10, NOTED THE RESIDENT DID NOT NEED "HIP PRECAUTIONS." A CARE PLAN FOR RESIDENT #707, TITLED "RISK FOR FALLS" DATED 9/18/10, NOTED: "KEEP BED AT LOWEST LEVEL WHEN NOT ADMINISTERING CARE" AND "LOW BED WITH MATS TO RIGHT AND LEFT SIDE OF BED." THE SAFETY TEAM COULD NOT EXPLAIN WHY THESE INTERVENTIONS WERE LISTED ON THE CARE PLAN IF NOT IMPLEMENTED. "BEHAVIOR MANAGEMENT TRACKING" RECORDS FOR RESIDENT #707 FROM 10/14/10 AND 10/20/10 REVEALED 21 EPISODES OF AGITATION AND RESTLESSNESS, AND THE SHE HAD RECEIVED NUMEROUS DOSES OF ATIVAN WITHOUT EFFECT. RESIDENT #707 CONTINUED TO HAVE FALLS. PER I/A REPORTS, THE FOLLOWING 22 FALLS OCCURRED, 21 OF THE FALLS OCCURRING BETWEEN THE DATES OF 10/2/10 THRU 12/23/10: #4. ON 10/2/10 AT 1 PM, THE RESIDENT WAS ON THE FLOOR IN THE "TV ROOM." THERE WAS NO NOTED INJURY. PER THERAPY NOTES DATED 10/2/10, THE RESIDENT WAS OBSERVED ATTEMPTING TO REMOVE HER WHEELCHAIR FOOTRESTS. THE CORRECTIVE MEASURE TO PREVENT REOCCURRENCE: CHANGE THE TYPE OF WHEELCHAIR. #5, #6, AND #7. ON 10/3/10, THE RESIDENT WAS ON THE FLOOR IN HER ROOM AT 6 PM, 8 PM, AND 9:55 PM. THERE WERE NO NOTED INJURIES OR CORRECTIVE ACTIONS. HOWEVER, ON 10/4/10, THERE WAS A HOSPITAL HISTORY AND PHYSICAL DATED 10/4/10 FOR THE RESIDENT THAT NOTED: THE RESIDENT RECENTLY STARTED TO HAVE "DRAMATIC CHANGES IN HER BEHAVIOR AND ATTITUDE," "HAD MORE THAN SEVEN FALLS IN ONE DAY," WAS "VERY AGITATED," AND "HARD TO CONTROL;" HER FAMILY AND STAFF DECIDED TO SEND HER TO THE HOSPITAL. REVIEW OF A FACILITY "TRANSFER FORM" REVEALED THAT RESIDENT #707 WAS TRANSFERRED TO ACUTE CARE ON 10/3/10 FOR, "MULTIPLE FALLS THIS EVENING, VERY RESTLESS AND AGITATED, RECEIVED ATIVAN IM AT 5:00 P.M., CONTINUES TO BE RESTLESS AND AGITATED." REVIEW OF A NURSING NOTE DATED 10/3/10 REVEALED THERE WAS NO DOCUMENTATION OF SUPERVISION PROVIDED FOR RESIDENT #707, AND NO EXPLANATION OF WHY THE RESIDENT WAS LEFT IN THE ROOM WITHOUT SUPERVISION EACH TIME AFTER A FALL, RESULTING IN THREE FALLS ON THE SAME SHIFT. THE RESIDENT WAS NOTED TO BE AGITATED AND ATTEMPTING TO GET OUT OF BED. DOCUMENTATION ON 10/3/10 AT 8 P.M., INCLUDED THE NOTATION, " (RESIDENT #707'S SON) STATED, "SO YOU CAN'T HANDLE HER, WHAT ARE YOU GOING TO DO? DUMP HER AT THE HOSPITAL? THERE WAS A FACE SHEET DOCUMENTING READMISSION to the facility on [DATE]. [DIAGNOSES REDACTED]. #8, #9, AND #10. ON 10/9/10, THE RESIDENT WAS ON THE FLOOR AT 11:45 AM IN THE HALLWAY, AT 2:55 PM IN HER ROOM, AND AT 3 PM IN HER ROOM. THERE WERE NO NOTED INJURIES. THE CORRECTIVE MEASURES: EVALUATE THE FUNCTION OF THE WHEELCHAIR, CHANGE THE WHEELCHAIR, AND REVIEW HER MEDICATIONS. THERE WAS ANOTHER FACE SHEET DOCUMENTING READMISSION to the facility on [DATE]. [DIAGNOSES REDACTED]. A PHYSICIAN'S DISCHARGE SUMMARY FOR AN ACUTE CARE STAY FROM 10/9/10 TO 10/13/10, SIGNED ON 10/18/10, NOTED THE FOLLOWING, "TRANSFERRED TO ER (emergency room ) DUE TO SIGNIFICANT WEAKNESS, CONFUSION AND AGITATION. PATIENT fell TWICE PRIOR TO HER TRANSFER." A NURSE'S NOTE AND BEHAVIOR LOG ENTRY DATED 10/26/10 DOCUMENTED , "RESIDENT ATTEMPTING MULTIPLE TIMES TO SCOOT OUT OF CHAIR, RESIDENT KEPT AT NURSE'S STATION FOR CLOSE OBSERVATION. RESIDENT IS NOT ABLE TO BE REDIRECTED." #11 AND #12. ON 10/27/10, THE RESIDENT WAS ON THE FLOOR IN HER ROOM AT 6:55 AM AND IN FRONT OF THE NURSES STATION AT 7:30 PM. THERE WERE NO NOTED INJURIES. STAFF WERE NEAR THE NURSES STATION BUT DID NOT WITNESS THE FALL. THE CORRECTIVE MEASURES: INSTRUCTED TO USE CALL LIGHT AFTER THE FIRST FALL AND "ONE TO ONE" SUPERVISION AFTER THE SECOND FALL. A NURSE'S NOTE DATED 10/27/10 AT 7 A.M., DOCUMENTED RESIDENT #707 HAD FALLEN FROM BED. THERE IS NO DOCUMENTATION REGARDING HOW RESIDENT #707 WAS BEING SUPERVISED AFTER LEAVING THE NURSING STATION. A NURSING NOTE DATED 10/27/10 AT 1:15 P.M., DOCUMENTED RESIDENT #707 WAS AGITATED, "ALERT WITH CONFUSION RESTLESS AND FIDGETS. RESIDENT AT 1200 TAKING CLOTHES OFF AND NOT ALLOWING STAFF TO REDRESS HER." #13 AND #14. ON 10/29/10, THE RESIDENT WAS ON THE FLOOR AT 5:25 PM AT THE NURSES STATION AND AT 6 PM IN HER ROOM. THERE WERE NO NOTED INJURIES OR CORRECTIVE MEASURES. REVIEW OF NURSING NOTES DATED 10/29/10 AT 8:30 A.M. AND AT 10:30 A.M., DOCUMENTED THAT RESIDENT #707 WAS AGITATED AND TRYING TO GET OUT OF THE CHAIR. REVIEW OF A NURSING NOTE DATED 10/29/10 REVEALED NO DOCUMENTATION OF HOW RESIDENT #707 WAS BEING SUPERVISED AFTER THE AGITATION WAS NOTICED. THERE WAS NO EXPLANATION OF WHY RESIDENT #707 WAS NOT SUPERVISED DESPITE DOCUMENTATION OF AGITATION IN THE NURSING NOTES IN MULTIPLE ENTRIES THROUGHOUT THE DAY, AT 8:30 A.M., 9 A.M., 10:30 A.M., AND 11:00 P.M. (AT START OF SHIFT, I.E. 3:00 P.M.) #15 AND #16. ON 10/30/10, THE RESIDENT WAS ON THE FLOOR AT 8:15 AM IN HER ROOM AND IN FRONT OF THE NURSES STATION AT 4:50 PM. THERE WERE NO NOTED INJURIES. THE CORRECTIVE MEASURES: PLACE IN FRONT OF THE NURSES STATION. REVIEW OF BEHAVIOR LOGS FOR 11/2010 FOR RESIDENT #707 REVEALED NUMEROUS DOSES OF ATIVAN WERE GIVEN FOR AGITATION WITHOUT EFFECT. #17. ON 11/17/10 AT 8:30 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM. THERE WERE NO NOTED INJURIES. THE CORRECTIVE MEASURE: PLACE IN FRONT OF THE NURSES STATION. A physician's orders [REDACTED].#707, AND GIVE HALDOL (AN ANTI PSYCHOTIC) AS NEEDED INSTEAD. WHEN QUERIED ABOUT THIS ON 3/30/11, EMPLOYEE "A" REPORTED THAT THE ATIVAN WAS DISCONTINUED BY THE PHYSICIAN BECAUSE IT WAS INEFFECTIVE FOR TREATING RESIDENT #707'S AGITATION. #18. ON 12/1/10 AT 5:30 AM, THE RESIDENT WAS ON THE FLOOR BY THE BATHROOM IN HER ROOM. THE ALARM DID NOT SOUND. NURSE AIDE "W" NOTED ON 12/1/10: "LAST TIME SEEN WAS AT 5:15 A.M., ON THE FLOOR. FIRST TIME SEEING HER WAS AT 11:30 PM (THE PREVIOUS NIGHT), SHE WAS SLEEPING IN BED." A STATEMENT BY CHARGE NURSE "BB" DATED 12/1/10 NOTED THE FOLLOWING, "RESIDENT OBSERVED WITH BED WET. URINE TO FITTED SHEET, (URINE) SOAKED PAD AND BRIEF (WHICH RESIDENT TOOK OFF)." THE CORRECTIVE MEASURE: PLACE IN A GERI-CHAIR AT THE NURSES STATION. WHEN QUERIED, THE SAFETY TEAM WAS UNABLE TO EXPLAIN WHY RESIDENT #707 HAD NOT BEEN CHECKED OR HAD HER BRIEF CHANGED BETWEEN 11:30 P.M. AND 5:15 A.M., WHEN HER NURSING CARE PLAN ENTITLED "AT RISK FOR FALLS" AS WELL AS HER URINARY CARE PLAN STATED "TOILET AND OR CHECK BRIEF FOR WETNESS EVERY 2 HOURS." NURSE AIDE "W" WAS UNAVAILABLE FOR INTERVIEW AS SHE WAS NO LONGER EMPLOYED BY THE FACILITY. #19. ON 12/2/10 AT 7:40 PM, THE RESIDENT WAS ON THE FLOOR IN ANOTHER RESIDENT'S ROOM. THE ALARM DID NOT SOUND. THE CORRECTIVE MEASURE: THE RESIDENT WAS TAKEN TO HER ROOM AND PLACED IN A GERI-CHAIR. #20. ON 12/6/10 AT 1:45 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM. THE ALARM DID NOT SOUND. THERE WAS NO NOTED INJURY. THE CORRECTIVE MEASURE: "NEW BATTERY WAS PLACED IN ALARM (CONTROL) BOX." #21. ON 12/8/10 AT 11:40 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM. THERE WAS NO NOTED INJURY. THE CORRECTIVE MEASURE: PLACE THE RESIDENT IN A VISIBLE AREA. #22. ON 12/9/10 AT 2:30 PM, THE RESIDENT WAS ON THE FLOOR IN THE HALLWAY. THERE WAS NO NOTED INJURY. THE CORRECTIVE MEASURE: PLACE THE RESIDENT CLOSER TO THE NURSES STATION. #23. ON 12/14/10 AT 5 PM, THE RESIDENT WAS ON THE FLOOR AT THE "FRONT DESK." THE RESIDENT WAS POINTING TO THE LEFT SIDE OF HER HEAD AND INDICATED THAT THERE WAS PAIN. THERE WAS NO CORRECTIVE MEASURE. REVIEW OF A FACILITY RESIDENT FALLS ASSESSMENT TOOL FOR RESIDENT #707, DATED 12/14/10, REVEALED A NEW INTERVENTION HAD BEEN ADDED, "SEAT BELT TRIAL". #24. ON 12/23/10 AT 11:30 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM. THERE WAS NO NOTED INJURY. THE CORRECTIVE MEASURE: PLACED IN A WHEELCHAIR WITH A SELF-RELEASING SEATBELT AND BROUGHT TO THE NURSES STATION. WHEN QUERIED WHY THE 12/17/10 MDS HAD CODED RESIDENT #707 AS HAVING NO PROBLEM BEHAVIORS, SOCIAL WORKER "J" REPORTED SHE WAS UNAWARE RESIDENT #707 HAD BEEN HAVING PROBLEM BEHAVIORS. EMPLOYEE "J" THEN STATED THAT THERE WERE NON CHEMICAL INTERVENTIONS THAT WERE SUCCESSFUL IN CALMING RESIDENT #707'S AGITATION. EMPLOYEE "J" STATED THAT THE RESIDENT HAD HAND HELD "TOYS" THAT SHE ENJOYED MANIPULATING THAT KEPT HER BUSY AND THAT FOLDING TOWELS WERE ALSO SUCCESSFUL TO PREVENT THE RESTLESSNESS AND AGITATION. EMPLOYEE "J" STATED THE ACTIVITIES DEPARTMENT HAD CARE PLANNED ACTIVITIES FOR RESIDENT #707, AS BOREDOM COULD LEAD TO AGITATION. REVIEW OF RECREATIONAL THERAPY ATTENDANCE RECORDS REVEALED RESIDENT #707 HAD RECEIVED FOUR ACTIVITY DEPARTMENT INTERACTIONS OR GROUP ACTIVITIES IN FEBRUARY 2011, AND 10 IN JANUARY 2011. ON 4/1/11 AT 11:30 A.M., THE ACTIVITY DEPARTMENT COORDINATOR REPORTED THAT SHE DID NOT KNOW WHAT HAPPENED TO RESIDENT #707'S TOYS. WHEN QUERIED, THE SAFETY TEAM REPORTED THAT NO ONE FROM THE ACTIVITY DEPARTMENT ATTENDED FALLS COMMITTEE MEETINGS. #25. ON 2/23/11 AT 9:20 PM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM. THERE WAS NO NOTED INJURY. THE CORRECTIVE MEASURE: PLACE IN A GERI-CHAIR. A RESIDENT FALLS ASSESSMENT FORM FOR RESIDENT #707, DATED 2/23/11 DOCUMENTED A NEW SAFETY INTERVENTION HAD BEEN ADDED, "BED ALARM ADDED TO FOOT OF BED.". WHEN QUERIED, THE SAFETY COMMITTEE WAS UNABLE TO EXPLAIN WHY RESIDENT #707 CONTINUED TO BE LEFT WITHOUT SUPERVISION AFTER 25 FALLS. THE SAFETY COMMITTEE WAS ALSO UNABLE TO EXPLAIN WHAT WAS DONE TO ENSURE THAT SAFETY EQUIPMENT WAS FUNCTIONING PROPERLY BEFORE LEAVING THE RESIDENT WITHOUT SUPERVISION. ON 3/29/11 AT VARIOUS TIMES THROUGHOUT THE DAY, RESIDENT #707 WAS OBSERVED ASLEEP IN A GERI CHAIR (ROLLING RECLINER) IN THE HALLWAY, WITH A PERSONAL SAFETY ALARM ATTACHED. ON 3/30/11 THROUGH 4/1/11 AT VARIOUS TIMES THROUGHOUT THE DAY, RESIDENT #707 WAS OBSERVED IN THE HALLWAY BY THE NURSING STATION, SEATED IN A GERI CHAIR. THE RESIDENT WAS ALERT BUT CONFUSED, AND DID NOT RESPOND TO QUESTIONING. THE RESIDENT REPEATEDLY ATTEMPTED TO CLIMB OUT OF THE GERI CHAIR, CAUSING THE SAFETY ALARM TO SOUND AND STAFF TO INTERVENE. THE RESIDENT WAS REDIRECTED TO REMAIN IN THE CHAIR EACH TIME STAFF INTERVENED, BUT RE-ATTEMPTED TO EXIT THE GERI CHAIR AGAIN WITHIN 5 TO 15 MINUTES. ON 3/30/11 AT 11:00 A.M., REVIEW OF FACILITY ACCIDENT AND INCIDENT (I&A) REPORTS WITH THE SAFETY TEAM REVEALED THAT RESIDENT #707 HAD SUFFERED 25 FALLS IN THE FACILITY SINCE MAY 2010, INCLUDING A FALL WITH FRACTURE WHICH REQUIRED TRANSFER TO ACUTE CARE FOR AN ORIF (OPEN REDUCTION INTERNAL FIXATION) (SURGICAL REPAIR), AND A FALL RESULTING IN DISPLACEMENT OF THE ORIF REPAIR, WHICH RESULTED IN ANOTHER TRANSFER TO ACUTE CARE. THE FACILITY SUBMITTED A PLAN OF CORRECTION (POC) DATED 4/7/11 THAT INDICATED: 1. RESIDENT # 707 REMAINS AT SPNC. RESIDENT HAS BEEN RE-ASSESSED BY HER PRIMARY PHYSICIAN. ALL CURRENT MEDICATIONS HAVE BEEN REVIEWED. HOSPICE SERVICES REMAIN ACTIVE IN HER CARE INCLUDING NURSING, REGISTERED DIETICIAN SERVICES, SOCIAL SERVICES AND CHAPLAIN SERVICES. RESIDENT # 707 WAS EVALUATED BY HOSPICE PHYSICIAN ON 4/6/11. RESIDENT IS STABLE SHOWING NO SIGNS OR SYMPTOMS OF PSYCHOTIC EPISODES, RESTLESSNESS, AGITATION OR EMOTIONAL DISTRESS AND REMAINS FREE OF INJURIES AT THE PRESENT TIME. 2. ALL IN HOUSE RESIDENTS WHO HAVE HAD A FALL RELATED INCIDENT AT SPNC WERE RE-assessed with [REDACTED]. THE ASSESSMENT TOOL WAS APPROVED TO USE FOR THE RE-EVALUATION PROCESS BY THE MEDICAL DIRECTOR. ALL CURRENT IN-HOUSE RESIDENTS (57) WHO SUSTAINED A FALL HAVE RECEIVED THIS ASSESSMENT ON APRIL 6, 2011. FALLS RISK ASSESSMENTS WERE COMPLETED BY DIRECTOR OF NURSING, UNIT MANAGERS, AND NURSING CONSULTANTS, WHICH INCLUDED RN/LPN AND OCCUPATIONAL THERAPIST. ALL CURRENT IN-HOUSE RESIDENTS ON ANTI-PSYCHOTIC MEDICATION AND THOSE RESIDENTS IDENTIFIED WITH A CHANGE IN BEHAVIOR WERE RE-ASSESSED BY LICENSED SOCIAL WORKERS FOR APPROPRIATE USE OF MEDICATION AND REFERRED TO PHYSICIAN SERVICES FOR APPROPRIATE FOLLOW UP IF NEEDED. AT THIS TIME, ALL FINDINGS FROM THE FALL RISK ASSESSMENT AND THE SOCIAL WORKER ASSESSMENTS WERE REVIEWED BY THE DIRECTOR OF NURSING AND CARE PLANS WERE UPDATED. THE MEDICAL DIRECTOR WAS CONSULTED. RESIDENTS ARE CURRENTLY STABLE AND NOT IN IMMEDIATE JEOPARDY. 3. THE MEDICAL DIRECTOR WAS INVOLVED WITH THE REVIEW AND REVISION WITH THE FOLLOWING POLICY CHANGES. THE FALL RISK ASSESSMENT WAS REVIEWED. THE 72 HOUR FALL RISK FOLLOW-UP ASSESSMENT WAS MODIFIED TO INCLUDE CHANGE IN BEHAVIOR MONITORING POST FALL. THE PROCESS FOR IMPLEMENTING APPROPRIATE INTERVENTIONS WAS CHANGED AND EACH RESIDENT WILL BE ASSESSED AFTER A FALL BY THE CHARGE NURSE. THE CHARGE NURSE WILL IMMEDIATELY PLACE APPROPRIATE INTERVENTIONS TO PREVENT FALLS. WITHIN A 24 HOUR PERIOD THE INTERVENTIONS PUT IN PLACE BY THE CHARGE NURSE WILL BR RE-EVALUATED BY THE UNIT MANAGER FOR APPROPRIATENESS. THESE FINDINGS WILL BE SUBMITTED WEEKLY TO THE QA FALLS SUB-COMMITTEE FOR FURTHER RECOMMENDATIONS IF NEEDED. NURSING STAFF HAVE BEEN EDUCATED ON (a) THE IMPORTANCE OF IMPLEMENTING APPROPRIATE INTERVENTIONS POST FALL AND CARE PLAN UPDATING AND (b) THE IMPORTANCE OF NOTIFYING SOCIAL SERVICES IF A RESIDENT HAS A CHANGE IN BEHAVIOR POST FALL. EACH NURSING STAFF MEMBER HAS BEEN PROVIDED A REFERENCE TOOL TO GUIDE THEM IN SELECTING APPROPRIATE INTERVENTIONS TO PREVENT FALLS. 46 OUT OF 80 EMPLOYED RN/LPN HAVE BEEN EDUCATED. 4. THE NURSING DESIGNEE WILL REVIEW ALL FALLS WITHIN 24 HOURS. THE AUDIT WILL CONSIST OF REVIEWING THE INTERVENTIONS LISTED TO DETERMINE APPROPRIATENESS AND TO DETERMINE IF SOCIAL SERVICES HAS BEEN NOTIFIED OF ANY BEHAVIOR CHANGES POST FALLS. ALL FALLS WILL BE REVIEWED WEEKLY BY THE QA SUBCOMMITTEE WITH THE MEDICAL DIRECTOR PRESENT. A BEHAVIOR MANAGEMENT MEETING WILL BE HELD MONTHLY WITH THE MEDICAL DIRECTOR TO REVIEW THE USE OF ANTIPSYCHOTIC MEDICATIONS AND/OR BEHAVIOR CHANGES. THE UNIT MANAGER OR DESIGNEE WILL REPORT THEIR DAILY FINDINGS TO THE DIRECTOR OF NURSING. ALL FINDINGS WILL BE REPORTED QUARTERLY TO THE QUALITY ASSURANCE COMMITTEE UNTIL THE QUALITY ASSURANCE COMMITTEE DISCONTINUES THE REVIEW AND/OR MONITORING PROCESS. THE DIRECTOR OF NURSING WILL BE RESPONSIBLE FOR COMPLIANCE. ( / / / / / / ) RESIDENT #709 WAS OBSERVED THROUGHOUT EACH DAY OF THE SURVEY PROPELLING HERSELF IN A WHEELCHAIR. THE RESIDENT WAS CONFUSED, NON-VERBAL, AND HAD A SAFETY ALARM ON HER BED AND AN ALARMING SELF RELEASING SEATBELT ATTACHED TO THE WHEELCHAIR TO ALERT STAFF OF UNASSISTED TRANSFERS. ON 4/1/11 AT 10:30 AM, THE CLINICAL RECORD AND INCIDENT/ACCIDENT (I/A) REPORTS FOR RESIDENT #709 WERE REVIEWED WITH THE ASSISTANT DIRECTOR OF NURSING (ADON 'B') WHOM THE DIRECTOR OF NURSING DEFERRED TO FOR INFORMATION REGARDING INCIDENTS INVOLVING THIS RESIDENT. RESIDENT #709 WAS admitted on [DATE] WITH Diagnoses: [REDACTED]. THE MDS NOTED THAT THE RESIDENT WAS NON-AMBULATORY, HAD MODERATELY SEVERE COGNITIVE IMPAIRMENT, AND REQUIRED EXTENSIVE ASSISTANCE FROM STAFF FOR TRANSFERS AND MOBILITY. FALL RISK ASSESSMENTS DATED 4/22/10, 5/24/10, AND 6/30/10 FOR RESIDENT #709 INDICATED THAT THE RESIDENT WAS AT HIGH RISK FOR FALLS. ACCORDING TO RESIDENT #709'S "RISK FOR FALLS" AND "NEED FOR ALARM TO PROMOTE RESIDENT SAFETY" CARE PLANS DATED 11/30/09 THRU 3/10/11, INTERVENTIONS INCLUDED: "BED/CHAIR ALARMS, APPLY THE ALARM AND CHECK FOR PROPER FUNCTIONING. CHECK ALARM FUNCTION EVERY SHIFT. IMPLEMENT ALL SAFETY INTERVENTIONS. KEEP ENVIRONMENT FREE OF HAZARDOUS OBJECTS." THE CARE PLANS DID NOT INCLUDE AN INTERVENTION TO PROVIDE ADEQUATE STAFF SUPERVISION. RESIDENT #709 HAD NUMEROUS INCIDENTS PER THE FOLLOWING DETAILS: 1. ON 5/24/10, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH PANTS DOWN TO THE KNEES. SHE SUSTAINED AN "ABRASION" ON THE BUTTOCKS. ACCORDING TO A POST-FALL ASSESSMENT TOOL, NARRATIVE SUMMARY, AND NURSES NOTES: THE ALARM WAS IN PLACE AT THE TIME OF THE FALL BUT DID NOT SOUND. THE CORRECTIVE ACTION TO PREVENT REOCCURRENCE: THE FACILITY "REINFORCED" AND "SPOKE" TO A NURSE AIDE ABOUT THE IMPORTANCE OF CHECKING THE FUNCTIONING OF THE ALARM. 2. ON 6/30/10, THE RESIDENT WAS FOUND ON THE FALL SAFETY MAT IN HER ROOM WITH THE ALARM SOUNDING. THERE WAS NO NOTED INJURY. 3. ON 7/1/10, THE RESIDENT WAS FOUND ON THE FLOOR BY CONSTRUCTION WORKERS WHO SUMMONED STAFF. THE THE SEATBELT WAS UNFASTENED AND THE ALARM DID NOT SOUND. THE resident sustained [REDACTED]. THE CORRECTIVE ACTION: "CONTINUE TO TEACH ALL STAFF REGARDING THE MECHANICS OF HOW THE SEATBELT WORKS." ADON 'B' WAS UNABLE TO EXPLAIN WHY CONSTRUCTION WORKERS HAD TO NOTIFY STAFF OF THE RESIDENT'S FALL. 4. ON 9/6/10, THE RESIDENT WAS FOUND ON THE FLOOR MAT IN HER ROOM. THE ALARM DID NOT SOUND. THERE WAS NO NOTED INJURY. THE ALARM CONTROL BOX WIRE "WAS NOT ATTACHED TO THE ALARM BOX." THE CORRECTIVE ACTION: OBTAIN THE "CORRECT" ALARM BOX AND OBTAIN A "NEW" BOX. 5. ON 9/24/10, RESIDENT #709 WAS FOUND ON THE FLOOR IN THE HALLWAY BY THE ELEVATOR BY A VISITOR WHO SUMMONED STAFF. THE RESIDENT WAS BLEEDING FROM THE FOREHEAD. THE ALARM WAS ATTACHED TO THE RESIDENT, WAS IN WORKING ORDER, BUT THERE WAS NO MENTION THAT THE ALARM SOUNDED. THE FALL ASSESSMENT TOOL ASKED THE QUESTION "DID THE ALARM WORK PROPERLY?" THERE WAS NO RESPONSE TO THE QUESTION. THE I/A REPORT QUESTIONED WHETHER THE ALARM SOUNDED. THE RESPONSE: THE ALARMING BELT WAS ON (THE RESIDENT) AND IT WORKED, BUT DID NOT ANSWER WHETHER IT SOUNDED OR NOT. THE POST-FALL NARRATIVE SUMMARY NOTED THAT THE ALARM BOX WAS "CHANGED" AFTER THE FALL. ADON 'B' WAS UNABLE TO EXPLAIN WHY A VISITOR HAD TO NOTIFY STAFF THAT THE RESIDENT HAD FALLEN. RESIDENT #709 SUSTAINED THREE SKIN TEARS TO THE LEFT FOREHEAD. ONE MEASURED 7 CM X 3.5 CM AND THE OTHER TWO MEASURED 1 CM EACH. SHE WAS TRANSFERRED TO THE HOSPITAL emergency roiagnom on [DATE] AND RETURNED to the facility on [DATE] WITH A DRESSING ON THE FOREHEAD. THE LARGER HEAD WOUND SUBSEQUENTLY BECAME INFECTED AND DID NOT HEAL UNTIL DECEMBER 2010. 6. ON 9/30/10, THREE DAYS AFTER hospitalization , RESIDENT #709 WAS ON THE FLOOR IN THE DINING ROOM. THE ALARM DID NOT SOUND. A POST-FALL "STATEMENT OF EVENT" ASKED THE QUESTION "WAS ALARM IN PLACE? FUNCTIONING?" THE ANSWER WAS "YES." THE I/A REPORT ASKED IF THE ALARM SOUNDED. THE ANSWER WAS "NO." THE CORRECTIVE MEASURE: "STAFF EDUCATED ON SELF RELEASE BELT USE" AND THE NURSE AND NURSE AIDE WERE TO "CHECK ALL SAFETY EQUIPMENT...." THERE WAS NO NOTED INJURY. ON 11/4/10, RESIDENT #709 YELLED AT A MALE RESIDENT (WHO HAD SINCE BEEN discharged ) AND HIT HIM ON THE BACK OF THE HEAD TWICE. SHE SUSTAINED A SKIN TEAR ON THE LEFT FOREARM. THE RESIDENTS HAD TO BE SEPARATED. THIS INCIDENT WAS REPORTED TO THE STATE AGENCY, INVESTIGATED, AND CLEARED ON 11/18/10. HOWEVER, INCIDENTS TOWARD THE MALE RESIDENT CONTINUED WITH THE POTENTIAL FOR SERIOUS HARM. ON 11/11/10 RESIDENT #709 WAS OBSERVED BECOMING IRATE, MAKING THREATENING MOTIONS, AND SEEKING ATTENTION FROM THE SAME MALE RESIDENT WHEN SHE OBSERVED HIM TALKING TO ANOTHER FEMALE. ON 11/12/10, RESIDENT #709 HAD A "VERBAL EXCHANGE" WITH THE MALE RESIDENT, CALLED HIM "MY HUSBAND," FOLLOWED HIM IN HER WHEELCHAIR, AND DISPLAYED "AGGRESSIVE BEHAVIOR" PER NURSES NOTES. SHE HAD TO BE GIVEN AN ANTI-ANXIETY MEDICATION (XANAX) AND DISTRACTED FROM THE AREA. 7. ON 11/14/10, RESIDENT #709 CONTINUED TO DISPLAY AGGRESSIVE BEHAVIOR TOWARD THE MALE RESIDENT. PER THE I/A REPORT, SHE "FOLLOWED CLOSELY BEHIND" HIM, "YELLING AND TAUNTING" HIM. PER SOCIAL SERVICE NOTES (NOT DATED UNTIL 2/26/11), RESIDENT #709 WAS "CONTINUOUSLY GETTING AGITATED" WITH THE MALE RESIDENT, "WOULD ATTEMPT TO HIT" HIM, AND WAS VERBALLY AGGRESSIVE. SHE HAD TO BE TRANSFERRED TO ANOTHER FLOOR, HOWEVER, THE RESIDENT WAS NOT TRANSFERRED TO UNTIL 11/18/10. WHEN QUERIED, ADON 'B' WAS UNABLE TO EXPLAIN WHY RESIDENT #709 WAS NOT PROMPTLY TRANSFERRED AND WAS ALLOWED CONTINUED ACCESS TO THE MALE RESIDENT FROM 11/4/10 THRU 11/18/10. 8. ON 2/14/11, RESIDENT #709, WHO LIVED ON THE SECOND FLOOR, WAS FOUND IN THE MAIN DINING ROOM ON THE FIRST FLOOR BY THE ICE CREAM PARLOR WITH A HAND SANITIZER PUMP IN HER HAND "PUMPING IT IN HER MOUTH" PER THE I/A/ REPORT. THE REPORT NOTED, "SHE HAD A FAIR AMOUNT ON HER MOUTH AND ON THE FRONT OF HER." THE FACILITY HAD TO CALL THE POISON CONTROL AGENCY FOR INSTRUCTIONS AND MONITOR THE RESIDENT EVERY HOUR. THE I/A REPORT ASKED THE QUESTION, "WERE THERE ANY ENVIRONMENTAL FACTORS THAT MAY HAVE CONTRIBUTED TO THE INCIDENT?" THE QUESTION WAS NOT ANSWERED. WHEN QUERIED, ADON 'B' WAS UNABLE TO EXPLAIN WHY THE RESIDENT WAS IN THE DINING ROOM ON THE FIRST FLOOR, WHETHER OR NOT SHE WAS ALONE, AND WHY SHE WAS NOT BEING SUPERVISED. THE ADON COULD NOT EXPLAIN WHERE AND HOW THE RESIDENT OBTAINED THE HAND SANITIZER. PER THE ACTIVITY CALENDAR FOR FEBRUARY 2011, THE LAST ACTIVITY (BINGO) IN THE MAIN FIRST FLOOR DINING ROOM ON 2/14/11, WAS SCHEDULED AT 2:30 PM. ALSO, ADON 'B' WAS UNABLE TO EXPLAIN WHY THE SAFETY ALARMS FOR RESIDENT #709 WERE NOT IMPLEMENTED ON 5/24/10, 7/1/10, 9/6/10, 9/24/10, AND 9/30/10. IN ADDITION, DURING THE SURVEY, ON 3/31/11 AT 9:05 AM, RESIDENT #709 WAS OBSERVED SEATED IN THE WHEELCHAIR, ALONE IN HER ROOM. ADON 'B' WAS ASKED TO OBSERVE THE RESIDENT'S ALARMING SEATBELT AND TO ACTIVATE IT. WHEN ADON 'B' UNFASTENED THE SEATBELT, THE ALARM DID NOT SOUND. THE ALARM CONTROL BOX WAS NOT ATTACHED. ADON 'B' LOOKED UNDERNEATH THE RESIDENT'S WHEELCHAIR, AROUND THE BED, ON THE FLOOR, AND IN THE NIGHT STAND DRAWERS BUT THERE WAS NO BOX IN THE ROOM. THE ADON WAS UNABLE TO EXPLAIN WHY AND SAID, "I'M FLABBERGASTED" AND LEFT THE ROOM TO RETRIEVE A CONTROL BOX. WHEN QUERIED ABOUT THE MISSING BOX, THE RESIDENT'S ASSIGNED NURSE AIDE ('D'), WHO PLACED HER IN THE WHEELCHAIR THAT MORNING, RESPONDED, "SHE HAD ONE (CONTROL BOX) YESTERDAY" AND COULD NOT EXPLAIN WHY SHE DID NOT HAVE ONE THAT DAY. ( ) INCIDENT #1 ON 3/29/11 AT 11:20 A.M., DURING AN INTERVIEW WITH RESIDENT #705, HE STATED, "I HURT MY FOOT DOWNSTAIRS IN THERAPY." WHEN ASKED WHAT HAPPENED, THE RESIDENT STATED, "I DON'T KNOW WHAT HAPPENED, ALL I KNOW IS IT HURT LIKE HELL." ON 3/29/11 AT 11:40 A.M., REVIEW OF RESIDENT #705 ' S MEDICAL RECORD FACE SHEET REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] AND RE-admitted on [DATE]. RESIDENT #705'S [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #705'S MINIMUM DATA SET (MDS), dated [DATE] INDICATED THE RESIDENT'S COGNITION WAS MODERATELY IMPAIRED. THE MDS ALSO INDICATED THAT RESIDENT #705 REQUIRED ASSISTANCE WITH TRANSFER, DRESSING, EATING, HYGIENE AND MOBILITY. REVIEW OF RESIDENT#705'S RESIDENT CARE AREA assessment dated [DATE] DOCUMENTED, "THE RESIDENT NEEDS MAXIMUM ASSIST FOR TRANSFERS AND BED MOBILITY AND NEEDS TWO PERSON ASSISTANCE...HIS GATE IS UNSTEADY AND HAS FAIR SAFETY AWARENESS. " REVIEW OF THE WOUND ASSESSMENT RECORD DATED 12/2/10 DOCUMENTED, "ON 11/11/10 PATIENT (#705) HAD ACCIDENT IN PHYSICAL THERAPY." ON 3/30/11 AT 10:16 A.M., REVIEW OF THE "NON FALL RELATED TEAM REPORT " DATED 11/11/10 DOCUMENTED: "WHILE IN THERAPY A BAR fell DOWN AND HIT HIS (#705) RIGHT TOE, SKIN SPLIT PROXIMAL TO RIGHT GREAT TOE NAIL. BLEEDING AND SWELLING NOTED. DISCOLORATION AND BRUISING TO TOE. LATERAL ASPECT OF RIGHT GREAT TOE NAIL PRESSING ON SKIN APPEAR TO BE 2ND DEGREE SWELLING. SKIN SPLIT PROXIMAL TO RIGHT GREAT TOE NAIL. BLEEDING AND SWELLING NOTED. DISCOLORATION AND BRUISING TO TOE. LACERATION/OPEN AREA MEASUREMENTS WERE 3 CENTIMETERS (CM) BY 1.5 CM BY 0.5 CM. " REVIEW OF THE " PHYSICAL THERAPY ADDENDUM NOTE " DATED 11/11/10 DOCUMENTED: " A TECH (PHYSICAL THERAPY TECHNICIAN) SHOWED UP ...AND MOVED THE HANDLE THAT MOVE THE STANDING FRAME DOWN SUDDENLY SO THE STANDING FRAM

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR, IMPLEMENT TIMELY INTERVENTIONS, AND VERIFY WEIGHT CHANGES FOR THREE ( #'S 701, 704, AND 719) SAMPLED RESIDENTS OF 13 RESIDENTS REVIEWED FOR WEIGHT CONCERNS, FROM A TOTAL OF 27 SAMPLED RESIDENTS, RESULTING IN WEIGHT LOSS. FINDINGS INCLUDE: REVIEW OF THE CLINICAL RECORD AND FACE SHEET ON 3/30/11, AT 1:00 PM, REVEALED, RESIDENT #704 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS), WITH ASSESSMENT REFERENCE DATE OF 2/12/11, IDENTIFIED THE RESIDENT AS SEVERELY COGNITIVELY IMPAIRED REQUIRING MEAL SET-UP AND SUPERVISION WITH EATING. ON 3/29/11 AT 2:30 PM, REVIEW OF RESIDENT #704'S WEIGHT RECORD REVEALED THE RESIDENT'S WEIGHT FLUCTUATED BY SIGNIFICANT AMOUNTS THAT INDICATED THE RESIDENT HAD A 33 PERCENT WEIGHT LOSS BETWEEN 12/1/10 AND 1/12/11, WITH NO EVIDENCE THAT THE WEIGHT CHANGES WERE INVESTIGATED. THE FOLLOWING DEMONSTRATES THESE CHANGES: 11/29/10 = 153.6 POUNDS 12/1/10 = 145.0 POUNDS (BLANK) = 141.2 POUNDS 1/12/11 = 104.6 POUNDS 1/13/11 = 109.7 POUNDS 1/19/11 = 108.2 POUNDS 1/26/11 = 108.6 POUNDS 2/2/11 = 107.2 POUNDS 2/16/11 = 103.1 POUNDS 3/1/11 = 101.8 POUNDS A REVIEW OF THE NUTRITION assessment dated [DATE] REFLECTED THAT RESIDENT #704 WAS 5 FEET 5 INCHES TALL AND WEIGHED 153.6 POUNDS. HER IDEAL BODY WEIGHT WAS 125 POUNDS (PLUS OR MINUS 10 PERCENT). BASED ON THE NUTRITIONAL SCREEN, RESIDENT #704 REQUIRED " FURTHER ASSESSMENT OF HER NUTRITIONAL NEEDS. THE RECOMMENDATIONS WERE TO MONITOR ORAL INTAKE PRIOR TO SUPPLEMENTS." A REVIEW OF THE NUTRITION SUMMARY AND RECOMMENDATIONS DATED 12/16/10 REVEALED THE FOLLOWING: THERE WAS NO ADVANCE DIRECTIVE RELATED TO TUBE FEEDING SUPPORT NOR WAS THERE EVIDENCE OF A PLANNED WEIGHT LOSS. THE SUMMARY ALSO REFLECTED THAT RESIDENT #704 HAD DECLINED IN WEIGHT. HER WEIGHT LOSS WAS DOCUMENTED AT 5 PERCENT IN ONE WEEK. HER ORAL INTAKE WAS POOR. HER DIET WAS CHANGED TO ADVANCED PUREED (PUDDING LIKE)/THINNED LIQUIDS. RECOMMENDATIONS WERE FOR THE STAFF TO "FEED HER AND STOP AFTER A FEW SPOONFULS, TO ALLOW THE RESIDENT REST". DIET CHANGED TO REGULAR ADVANCED PUREED (NEARLY REGULAR TEXTURES WITH EXCEPTION OF HARD, STICKY OR CHEWY FOOD). WHOLE MILK WAS RECOMMENDED THREE TIMES PER DAY, FORTIFIED CEREAL AND MED PASS SUPPLEMENT (PROVIDES ADDITIONAL CALORIES). ON 3/29/11 AT 12:15 PM, RESIDENT #704 WAS OBSERVED IN HER WHEELCHAIR IN THE DINING ROOM BEING FED BY STAFF. SHE HAD EATEN ALL OF HER POTATOES, 1/2 OF HER MEAT PORTION, 1/2 OF HER SOUP WHILE BEING FED BY STAFF. ON 3/30/11 AT 9:00 AM, RESIDENT #704 WAS OBSERVED IN BED WITH HER EYES CLOSED. A BREAKFAST TRAY, WAS IN FRONT OF THE RESIDENT THERE WAS A BOWL OF OATMEAL, TOAST WITH JELLY, EGGS AN UNOPENED CARTON OF SKIM MILK, AND A GLASS OF CRANBERRY JUICE. NO STAFF WERE OBSERVED IN THE RESIDENT'S ROOM PROVIDING MEAL ASSISTANCE. THE RESIDENT SHOULD HAVE HAD WHOLE MILK. ON 3/30/11 AT 9:10 AM, WHEN ASKED UNIT MANAGER "T" STATED SHE WOULD LOOK FOR THE CERTIFIED NURSE ASSISTANT (CNA) TO ASSIST THE RESIDENT WITH EATING. ON 3/30/11 AT 9:15 AM, UPON RETURN TO RESIDENT #704'S ROOM THE BREAKFAST MEAL TRAY WAS GONE. IT WAS UNCLEAR WHAT HAPPENED WITH THE BREAKFAST TRAY. ON 3/30/11 AT 12:30 PM, RESIDENT #704 WAS OBSERVED IN BED WHEN ASKED IF SHE ATE LUNCH SHE STATED "I DID NOT WANT TO EAT LUNCH WHEN THEY BROUGHT IT IN". ON 3/30/11 AT 12:40 PM UNIT MANAGER "T" INTERVIEWED REGARDING RESIDENT #704 LUNCH REFUSAL SHE SAID " SHE REFUSES TO EAT HER HER MEALS OFTEN . WHEN FURTHER QUERIED UNIT MANAGER "T" WAS UNABLE TO EXPLAIN IF THERE WAS A REASON THE RESIDENT DID NOT WANT TO EAT, OR IF THE RESIDENT ATE HER BREAKFAST THIS MORNING WHEN SHE WENT TO LOOK FOR THE CNA. ON 3/31/11 AT 9:05 AM, RESIDENT #704 WAS OBSERVED BEING FED BY UNIT MANAGER "T". THE RESIDENT HAD EATEN ALL OF HER SCRAMBLED EGGS, A PEACH HALF, 1/2 PORTION OF COFFEE CAKE, FEW TEASPOONS OF OATMEAL, 1/2 GLASS OF JUICE. ON 3/31/11 AT 12:15 PM, RESIDENT #704 WAS OBSERVED IN BED. HER EYES WERE CLOSED HER LUNCH TRAY WAS UNTOUCHED. THERE WAS NO STAFF OBSERVED IN HER ROOM TO ASSIST WITH FEEDING. ON 3/31/11 AT 3:00 PM, RESIDENT #704 WAS OBSERVED IN BED WHEN ASKED IF SHE WAS HUNGRY SHE STATED "I AM THIRSTY I WANT SOME WATER. A FOAM CUP WAS ON HER NIGHTSTAND, OUT OF REACH FOR THE RESIDENT. ON 4/1/11 AT 12:20 PM, RESIDENT #704 WAS OBSERVED IN BED. A LUNCH TRAY WAS IN FRONT OF HER. THE RESIDENT HAD A BOWL OF CHICKEN NOODLE SOUP, AN UNOPENED CARTON OF SKIM MILK( SHOUD HAVE WHOLE MILK), A GLASS OF CRANBERRY JUICE AND AN UNTOUCHED ENTREE. NO STAFF WERE PRESENT TO ASSIST WITH FEEDING. THROUGHOUT THE SURVEY WHEN RESIDENT #704 WAS OBSERVED WITH STAFF ASSISTANCE DURING MEALS HER INTAKE WAS GREATER THAN 50 PERCENT, WHEREAS WHEN SHE WAS OBSERVED WITHOUT STAFF PRESENCE HER INTAKE WAS POOR, OR SHE REFUSED MEALS. REVIEW OF DIETARY PROGRESS NOTES ON 3/30/11 AT 1:00 PM, DATED 1/7/11 THROUGH 1/28/11 REFLECTED THE RESIDENT HAD SIGNIFICANT WEIGHT LOSS FROM HER ADMISSION WEIGHT OF 153 POUNDS. A PROGRESS NOTE DATED 1/17/11 REFLECTED RESIDENT #704'S WEIGHT AT 110 POUNDS, A SIGNIFICANT WEIGHT CHANGE OF 35 POUNDS FOR ONE MONTH. HER [MEDICATION NAME] ( USED TO MEASURE BLOOD PROTEIN LEVELS) WAS LOW AT 2.9 (NORMAL RANGE 3.5-4.9) WITH THE PLAN TO DISCUSS WITH CARE TEAM FURTHER INTERVENTIONS FOR WEIGHT LOSS. A PROGRESS NOTE DATED 1/28/11 REFLECTED WEIGHT HOLDING AT 108 POUNDS, GOAL TO PREVENT ANY FURTHER WEIGHT LOSS. ON 4/1/11 AT 9:00 AM, THE RECORD WAS REVIEWED WITH DIETITIAN "K" REGARDING RESIDENT #704'S WEIGHT LOSS. HE STATED, " THE RESIDENT'S WEIGHT HAD DROPPED SINCE ADMISSION, BUT I WAS NOT SURE IF THE RESIDENT'S WEIGHT ON ADMISSION ON 11/29/10 OF 153 POUNDS WAS CORRECT OR IF THE WEIGHT THE SECOND DAY FOLLOWING ADMISSION ON 12/1/10 OF 145 POUNDS WAS CORRECT SINCE THE RESIDENT WAS admitted WITH PEDAL [MEDICAL CONDITION] AND WAS ON A DIURETIC." DIETITIAN "K" WAS UNABLE TO EXPLAIN WHY RESIDENT #704 WAS NOT WEIGHED WEEKLY, NOR MONITORED WEEKLY AS PER THE FACILITY'S POLICY FOR PREVENTING WEIGHT LOSS FOR NUTRITIONALLY AT RISK RESIDENTS. DIETITIAN "K" WAS UNABLE TO EXPLAIN WHY RESIDENT #704 WAS NOT ON A CALORIE COUNT AS PER THE FACILITY'S POLICY. DIETITIAN "K" DID NOT KNOW IF RESIDENT #704 WAS OFFERED FOOD SUBSTITUTES WHEN SHE REFUSED TO EAT AND DIETITIAN "K" REPORTED RESIDENT #704 WAS NOT ON THE FACILITY'S SNACK LIST.. ON 4/1/11 AT 3:00 PM, DURING RECORD REVIEW WITH UNIT MANAGER "T" OF RESIDENT #704'S FOOD ACCEPTANCE LOGS IT WAS CONFIRMED THAT FOOD SUBSTITUTES WERE NOT OFFERED WHEN THE RESIDENT REFUSED TO EAT NOR DOCUMENTED ON THE FOOD ACCEPTANCE LOGS AS BEING OFFERED ACCORDING TO THE FACILITY'S POLICY. REVIEW OF THE FACILITY'S POLICY TITLED "WEIGHT LOSS QUALITY ASSURANCE COMMITTEE" DATED 11/1/08 IT WAS REVEALED: 1. "ALL RESIDENTS WILL BE WEIGHED ON THE ADMISSION AND THE DAY AFTER ADMISSION. BOTH WEIGHTS WILL BE RECORDED ON THE VITAL FLOW SHEET....AS PER CURRENT STANDARDS OF PRACTICE, AFTER ADMISSION THE RESIDENT WILL BE WEIGHED WEEKLY FOR FOUR WEEKS...". 4. "NURSE MANAGERS WILL BE RESPONSIBLE FOR OBTAINING WEIGHTS..NURSE MANAGERS WILL PROVIDE THE DIETITIAN WITH WEIGHTS FOR ALL RESIDENTS BY THE SEVENTH OF EACH MONTH. 9. "THE DIETITIAN AND THE DOCTOR WILL DOCUMENT ON THE WEIGHT LOSS/GAIN RECOMMENDATIONS SHEETS OR IN THE PROGRESS NOTES OF THE RESIDENT'S CHART INFORMATION RELEVANT TO: A. REASONS FOR WEIGHT CHANGE; B. FUTURE RISK FACTORS; C. INTERVENTIONS WHICH MAY INCLUDE: DIET CHANGE/CONSISTENCY CHANGE, ADDITION/DELETION/CHANGES OF SUPPLEMENTATION, CHANGES IN FREQUENCY OF WEIGHT, FOOD PREFERENCE UPDATES, CALORIE COUNTS, PHYSICIAN TO REVIEW THE USE OF ANY ANOREXIGENIC, MEDICATION. IF THERE IS ANOTHER OBVIOUS CAUSE FOR THE WEIGHT LOSS HE/SHE SHOULD INDICATE THAT IS THE REASON WHY THE ANOREXIGENIC MEDICATION WERE NOT ADDRESSED, MOOD ISSUES/CHANGES IN MEDICATION (I.E.ANTIDEPRESSANTS- APPETITE STIMULANTS),FICATION OF ADVANCED DIRECTIVES RELATED TO ENTERAL AND [MEDICATION NAME] NUTRITION D.) CHANGES IN THE PLAN OF CARE 10. THE WEIGHT COMMITTEE WILL MEET ONCE MONTHLY TO DISCUSS WEIGHT CHANGES AND INTERVENTIONS. ( ) ON 3/30/11 AT APPROXIMATELY 12:30 PM, RESIDENT #719 WAS OBSERVED IN THE DINING ROOM BEING FED BY HER RELATIVE. THE RESIDENT WAS THIN, WEAK, AND CONFUSED. ON 3/31/11 AT 12:15 PM, THE RESIDENT, WHO LIVED ON THE 2ND FLOOR, WAS BROUGHT TO THE 2ND FLOOR DINING ROOM BY A NURSE AIDE AND PLACED AT A TABLE. THE RESIDENT SAT WHILE OTHER RESIDENTS ATE THEIR LUNCH. AT 1 PM, THE RESIDENT HAD BEEN TAKEN TO THE 1ST FLOOR DINING ROOM (ATRIUM). HER RELATIVE WAS OBSERVED TAKING HER LUNCH TRAY FROM THE 2ND FLOOR DOWN TO THE 1ST FLOOR DINING ROOM. WHEN QUERIED, HE (HER SON)SAID, "SHE LIKES IT DOWN THERE. I AM GOING TO FEED HER THERE." AT 2 PM, THE CLINICAL RECORD FOR RESIDENT #719 WAS REVIEWED. THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. PER THE MDS (MINIMUM DATA SET) DATED 11/15/10, THE RESIDENT REQUIRED SUPERVISION ONLY DURING MEALS. THE MDS dated [DATE] NOTED THAT THE RESIDENT REQUIRED STAFF ASSISTANCE FOR EATING ON A LIMITED BASIS. THE RESIDENT WAS 4 FEET 9 INCHES IN HEIGHT. RESIDENT #719'S WEIGHTS ON THE VITAL SIGN FLOW SHEET WERE AS FOLLOWS: 6/10/10=91.6 POUNDS. 8/5/10=103.4 POUNDS. 9/8/10=84 POUNDS. 10/6/10=85.3 POUNDS. 12/2/10=82.6 POUNDS. 12/15/10=77.8 POUNDS. 1/1/11=77 POUNDS. ON 12/14/10, WEEKLY WEIGHTS WERE RECOMMENDED FOR 4 WEEKS FOR RESIDENT #719. ON 1/12/11, THE O.T. (OCCUPATIONAL THERAPY) DEPARTMENT RECOMMENDED: A PLATE GUARD (RIM AROUND THE PLATE) DURING MEALS TO INCREASE THE ABILITY TO SCOOP UP FOOD AND FEED HERSELF; A RIGHT SIDE LATERAL SUPPORT TO THE WHEELCHAIR TO PREVENT THE TRUNK OF HER BODY FROM LEANING TO THE RIGHT. ON 1/17/11, THE R.D. (REGISTERED DIETITIAN) RECOMMENDED A NUTRITIONAL SUPPLEMENT TWICE A DAY TO BE GIVEN DURING MEDICATION PASS AND TO WEIGH THE RESIDENT WEEKLY FOR 4 MORE WEEKS. THE R.D. NOTED THAT THERE WAS "A 5% WEIGHT DISCREPANCY SINCE LAST MONTHS WEIGHT, HAS LOST 7% (BODY WEIGHT) IN PAST 30 DAYS. WEIGHT NOW 77 POUNDS." THE FOLLOWING NOTATIONS WERE REVIEWED ON RESIDENT #719'S "RESIDENT DIETARY PROFILE" (A WEIGHT HISTORY FOR THE PAST 180 DAYS FROM 10/3/2010). 10/12/10-85 POUNDS-"ALERT:LOSS OF 10.2% IN 154 DAYS." 11/11/10-88 POUNDS. 12/6/10-83 POUNDS-"NEW 180 DAY LOW-ALERT: LOSS OF 5.7% IN 25 DAYS." 1/8/11-77 POUNDS-"NEW 180 DAY LOW-ALERT: LOSS OF 12.5% IN 58 DAYS." 2/7/11-78 POUNDS.-"ALERT: LOSS OF 11.4% IN 88 DAYS." 3/8/11-75 POUNDS-"NEW 180 DAY LOW-ALERT: LOSS OF 9.6% IN 92 DAYS." ON 4/1/11 AT 8:35 AM, RESIDENT #719 WAS OBSERVED IN BED WITH HER BREAKFAST TRAY IN FRONT OF HER ON AN OVER-BED TABLE. SHE WAS LEANING BACK, AWAY FROM THE TABLE. THE RESIDENT HAD A BOWL OF OATMEAL. SHE WAS OBSERVED FOR 10 MINUTES ATTEMPTING TO LIFT A SPOONFUL OF OATMEAL FROM THE BOWL TO HER MOUTH. EACH TIME SHE TRIED TO MOVE THE SPOON AWAY FROM THE BOWL, SHE WAS TOO WEAK TO LIFT IT BEYOND THE EDGE OF THE TABLE TO HER MOUTH. SHE REPEATEDLY HAD TO STOP, PUT THE SPOON BACK IN THE BOWL, AND TAKE DEEP BREATHS. STAFF WERE OBSERVED GOING IN AND OUT OF OTHER ROOMS AND CONDUCTING THEIR DUTIES, BUT NO ONE STOPPED TO ASSIST THE RESIDENT. AT 8:45 AM, ADON (ASSISTANT DIRECTOR OF NURSING) 'B' WAS ASKED TO OBSERVED RESIDENT #719 ATTEMPTING TO FEED HERSELF. SHE SAW THE RESIDENT LIFTING THE SPOON, GIVING UP, AND PUTTING THE SPOON BACK IN THE BOWL. ADON 'B' WAS ASKED WHY THE RESIDENT WAS IN BED AND NOT UP IN THE WHEELCHAIR FOR A MORE UPRIGHT POSITION AND PROPER BODY ALIGNMENT TO FACILITATE EATING. SHE WAS ASKED WHY OTHER RESIDENTS ON THE UNIT, WHO REQUIRED EXTENSIVE ASSISTANCE FROM STAFF, WERE OBSERVED UP, OUT OF BED, AND DRESSED, BUT NOT RESIDENT #719. SHE WAS ALSO ASKED WHY STAFF WAS NOT ASSISTING AND/OR FEEDING THE RESIDENT AND WHY THE RESIDENT WAS NOT IN THE DINING ROOM FOR CLOSER SUPERVISION. ADON 'B' WAS UNABLE TO RESPOND TO ANY OF THE QUESTIONS. SHE IMMEDIATELY ASKED A NURSE AIDE TO COME TO THE RESIDENT'S ROOM TO FEED HER. AT 11:40 AM, RESIDENT #719'S CLINICAL RECORD WAS REVIEWED WITH THE R.D. THERE WERE NO DOCUMENTED WEEKLY WEIGHTS FOR THE RESIDENT FOR DECEMBER 2010 THRU FEBRUARY 2011 AS RECOMMENDED. WHEN QUERIED, HE SAID, "I USUALLY GET THEM AND PLACE THEM IN MY BOOK. I DON'T HAVE THEM." HE SAID, "I GUESS THEY WERE NOT DONE." HE WAS UNABLE TO EXPLAIN WHY HE DID NOT FOLLOW-UP WITH NURSING STAFF, WHO WAS RESPONSIBLE FOR OBTAINING THE WEIGHTS, TO ENSURE THAT THEY WERE BEING DONE. WHEN ASKED, THE R.D. STATED THAT THE RESIDENT WAS NO LONGER ON WEEKLY WEIGHTS AND WAS UNABLE TO EXPLAIN WHY IN LIEU OF THE CONTINUED WEIGHT LOSS. HE SAID, "WE DISCUSS HER REGULARLY IN OUR WEIGHT COMMITTEE MEETINGS" AND STATED THAT NOTES FROM THE MEETINGS WERE AVAILABLE. THE NOTES WERE REQUESTED BUT NOT PROVIDED BY THE END OF THE SURVEY. ON 4/1/11 AT 11:45 AM, THE R.D. WAS ASKED TO HAVE RESIDENT #719 WEIGHED. THE R.D. SUMMONED AN AIDE WHO USUALLY WEIGHED THE RESIDENTS. THE AIDE REPORTED THAT RESIDENT #719 WAS USUALLY WEIGHED ON THE SAME SIT-DOWN TYPE SCALE EACH TIME (FOR CONSISTENCY) BUT COULD NOT BE WEIGHED ON THE SAME SCALE BECAUSE THE WAS INOPERABLE. A "NUTRITION" CARE PLAN FOR RESIDENT #719 DATED 2/7/11, NOTED THAT THE RESIDENT'S USUAL ADULT BODY WEIGHT WAS 90 POUNDS. THE CARE PLAN DID NOT MENTION WEEKLY WEIGHTS AS AN INTERVENTION OR THE O.T. RECOMMENDATIONS TO SEAT THE RESIDENT UPRIGHT IN A WHEELCHAIR DURING MEALS. THE CARE PLAN HOWEVER, NOTED INTERVENTIONS: -"ENCOURAGE RESIDENT TO BE IN THE SMALL DINING ROOM FOR BREAKFAST AND LUNCH. -"PROVIDE EXTENSIVE ASSISTANCE WITH ALL MEALS." -"OBTAIN AND FOLLOW WEIGHT AS ORDERED." THROUGHOUT EACH DAY OF THE SURVEY, RESIDENT #701 WAS OBSERVED TO HAVE A [MEDICAL CONDITION] FEEDING TUBE. SHE WAS WEAK AND REQUIRED ASSISTANCE FROM STAFF FOR ALL ACTIVITIES OF DAILY LIVING. THE CLINICAL RECORD WAS REVIEWED ON 3/29/11 AT 2 PM. THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. SHE WAS PRESCRIBED A TUBE FEEDING FORMULA AT 55 ML (MILLILITERS) PER HOUR TO RUN FOR 20 HOURS A DAY. NURSES NOTES, DATED 3/8/11 DOCUMENTED THAT THE RESIDENT "CONTINUES TO HAVE LIQUID BROWN STOOLS." THERE WAS NO DOCUMENTED ADMISSION WEIGHT FOR THE RESIDENT. THE RESIDENT'S WEIGHTS SINCE ADMISSION, WERE REQUESTED FROM THE R.D. WHICH REVEALED THAT THE RESIDENT'S FIRST WEIGHT WAS OBTAINED ON 3/9/11, FIVE DAYS AFTER ADMISSION. THE R.D. WAS UNABLE TO EXPLAIN WHY THE RESIDENT, WHO WAS HAVING DIARRHEA AND RECEIVING TUBE FEEDINGS, DID NOT HAVE A BASELINE WEIGHT OBTAINED FOR PROPER MANAGEMENT OF NUTRITIONAL PARAMETERS. PER THE FACILITY'S "WEIGHT LOSS QUALITY ASSURANCE COMMITTEE" POLICY DATED 11/1/08: -THE PURPOSE OF THE POLICY: "TO BE BOTH PROACTIVE AND REACTIVE IN PREVENTING WEIGHT LOSS OF NUTRITIONALLY "AT RISK" RESIDENTS." -"ALL RESIDENTS WILL BE WEIGHED ON THE DAY OF ADMISSION AND THE DAY AFTER ADMISSION....IF THERE IS A DISCREPANCY OF GREATER THAN FIVE POUNDS, A THIRD WEIGHT WILL BE OBTAINED." -"WEEKLY WEIGHTS WILL BE MONITORED WEEKLY BY THE DIETITIAN." -THE WEIGHT COMMITTEE MUST MEET MONTHLY TO DISCUSS WEIGHT CHANGES AND INTERVENTIONS. FOLLOWING THE MEETING, THE DIETITIAN IS RESPONSIBLE FOR DOCUMENTATION OF COMMITTEE RECOMMENDATIONS. -"IT WILL BE THE RESPONSIBILITY OF NURSE MANAGERS TO SEE THAT RECOMMENDATIONS REGARDING NURSING CARE(MORE ASSISTANCE DURING MEALS, CHANGE IN DINING LOCATION) ARE IMPLEMENTED" AND THAT THE INTERVENTIONS ARE REFLECTED ON THE CARE PLAN. ( )