Every finding on record at St. Joseph's, A Villa Center

Based on observation, interview, and record review, the facility failed to maintain accurate information in the medical record for one resident (R57) out of two reviewed for medical records. Findings include:On 3/24/2026 at 10:00 AM, R57 was observed sitting up in their wheelchair. R57 stated they were doing much better since they completed therapy and was looking to discharge home soon.A review of the medical record revealed R57 admitted into the facility on 1/16/2026 with the following medical diagnoses, Metabolic Encephalopathy and Obstructive and Reflux Uropathy. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental status (BIMS) score of 6/15, indicating an impaired cognition. R57 also required staff assistance with bed mobility and transfers. A review of the progress notes revealed the following provider note, Effective date: 3/18/2025 .PLAN: Obstructive Uropathy-(name of indwelling catheter) in place-Monitor closely for urinary retention-Patient will need outpatient follow up with urology .On 3/24/2026 at 12:57 PM, R57 reported they no longer had the indwelling catheter in place. R57 reported they were voiding well and did not believe they needed it put back in place. R57 reported they had not had the indwelling catheter in place for about 2 weeks now and they were using a urinal to void.On 3/25/2026 at 9:40 AM, an interview was conducted with Unit Manager (UM) B. UM B reported R57 removed (pull out) their indwelling catheter on 3/13/2026 and would not let the nurse reinsert it. UM B reported the physician was notified regarding R57 no longer having an indwelling catheter and they were unsure why it was documented in the medical record that R57 still had one inserted.On 3/26/2026 at 11:30 AM, an interview was conducted with the Director of Nursing (DON). The DON reported providers should be reviewing their notes for accuracy and R57 no longer has the indwelling catheter in place and will be following up with urology soon.A request for a facility policy related to accurate medical records was requested and not received by the end of survey.

Based on observation, interview, and record review, the facility failed to ensure one resident (R154) was free from unnecessary medications out of six reviewed for medications. Findings include:A review of the medical record showed R154 was admitted into the facility on 3/13/26 with diagnoses of heart failure, pulmonary hypertension, and acute respiratory failure with hypoxia (low oxygen levels). A review of the most recent MDS (minimum data set) of R154 showed a BIMS (brief interview for mental status) of 15/15, indicating fully intact cognition.A review of the medication orders of R154 revealed the following active orders:1.Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 MCG/ACT (microgram per actuation) (Fluticasone-Umeclidinium-Vilanterol) 1 puff inhale orally in the morning for SOB (shortness of breath)/Asthma. D/C (discontinue) Trelegy when Fluticasone/Salmetrol 100/50 mcg inhaler arrives.2. Advair Diskus Aerosol Powder Breath Activated 100-50 MCG/DOSE (Fluticasone-Salmeterol)1 inhalation inhale orally every 12 hours for Asthma.A review of the March 2026 MAR (medication administration record) for R154 showed both of these medications were administered from March 19th through March 25th.On 03/25/2026 at 9:27 AM, an interview was conducted with Unit Manager B. They stated Trelegy had been ordered for R154 as a therapeutic interchange until they were able to start taking Advair. Unit manager B confrimed the order indicated Trelegy should be stopped when Advair was started. Unit manager B opened the medication cart, and both inhalers were observed to be present for R154.On 03/25/2026 at 9:34 AM, an interview was conducted with RN (Registered Nurse) C and said they administered both inhalers to R154 that morning.A review of a facility policy titled, Medication Orders did not address unnecessary medications.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards for one (R58) out of four reviewed for accidents. Findings include:On 3/24/2026 at 10:40 AM, R58 was observed lying in bed in a low position. R58's right side of the bed was against the wall with the left side open to the room. Observed on the floor next to the bed was a floor mat that appeared to be torn in the middle and curled up towards the ends of the mat. A review of R58's medical record revealed, R58 was admitted to the facility on [DATE] with diagnosis of Dementia, severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance. A review of R58's Minimum Data Set (MDS) noted R58 with moderately impaired cognition and required some assistance with activities of daily living by staff. A review of R58's progress note, revealed the following, 1/27/2026 13:45 (1:45 PM) Incident/Accident: Writer observed resident on the floor in front of her wheelchair during rounds. Writer asked the resident where she had been trying to go; resident responded, I don't know.A review of R58's care plan noted, Focus: I had an actual fall d/t (due to) to my behaviors, impulsiveness, Poor Balance, Dementia, poor communication/comprehension, Psychoactive drug use, unsteady gait, Encephalopathy. Date Initiated: 02/13/2026 Goal: The resident's injuries will resolve without complication by review date. Date Initiated: 02/23/2024. Interventions: Landing mat implemented at bedside when in bed. Date Initiated: 02/23/2024.On 3/26/2026 at 12:37 PM, the Nursing Home Administrator was asked about the observation of R58's floor mat and reported the fall mats condition are to be checked daily.

Based on observation, interview, and record review, the facility failed to apply protective appliances for one resident (R79) out of one reviewed for quality of care. Findings include:A review of the physician's orders noted the following, Date:1/16/2026 .Out of bed daily in wheelchair to tolerance with padded boot on R (right) foot, as well as a leg rest pad to protect her RLE (right lower extremity) .Status: Active .On 3/25/2026 at 9:52 AM, R79 was observed up in their wheelchair. R79 reported they used to wear a boot on their right foot but had not worn them in quite some time. No padded boot was observed on the right foot, or leg rest pad to protect the RLE (right lower extremity). R79 reported they felt as though they still needed to wear the boot and leg rest pad. The medical record revealed R79 admitted into the facility on 1/12/2026 with the following medical diagnoses, Peripheral Vascular Disease and Polyneuropathy. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental (BIMS) status score of 12/15, indicating an impaired cognition. R79 also required staff assistance for bed mobility and transfers. On 3/25/2026 at 11:44 AM, R79 was observed in the therapy room and up in the wheelchair. No padded boot was observed on the right foot, or leg rest pad to protect the RLE.On 3/25/2026 at 12:58 PM, R79 was observed in the chair and eating lunch. R79 reported they would like to wear the boot and have the leg rest padding applied because they had been up for a while at this point and their foot was hurting. On 3/26/2026 at 9:28 AM, an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated when R79 admitted into the facility, they were in a different disposition than they are now and is doing much better. The DOR stated they would have to check into it (padded boot and leg rest pad).On 3/26/2026 at 11:41 AM, an interview was conducted with the Director of Nursing (DON). The DON reported R79 was evaluated by therapy, and the order was to remain active as R79 still needed the interventions in place.A facility policy related to application of protective appliances was requested and not received by the end of survey.

Based on interview and record review, the facility failed to timely submit MDS (Minimum Data Set, which is a resident assessment tool) assessment for two residents (R24 and R53) of three reviewed for resident assessment. Findings include: During the recertification survey the resident assessment task was triggered for MDS assessment being overdue 120 days. R24R24 was admitted to the facility on [DATE] with diagnosis of Intervertebral Disc disorder with Radiculopathy, [NAME] region. R24's Minimum Data Set (MDS) Medicare 5 day assessment dated [DATE] was marked Incomplete, Assessment was never added to a batch. The following assessments were submitted for R24:According to the tracking record A0410 was coded 3 which means the Unit is Medicare and/or Medicaid certified bed.No other assessments were submitted, all MDS assessments for R24 are missing. R53A review of R53's medical record revealed, R53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Chronic Kidney Disease. A review R53's census section (admission/discharge) revealed R53 as Hospital Unpaid Leave through 8/12/24. A review of R53's MDS list section noted incomplete assessment dated , 8/2/24 Discharge Return Anticipated/End of PPS (Prospective Payment System) Part A stay -Assessment was never added to a batch.The following assessments were submitted for R53:Entry Tracking record dated 05/18/2024 submitted and accepted on 05/31/2024.Combine MDS admission and 5-day PPS (Prospective Payment System) assessment with the target date 05/25/2024 was submitted and accepted on 06/07/2024. (this assessment had 3 warning for A0310A, A1010A, A1010C and A1600).PPS discharge assessment with the target date 06/06/2024 was submitted and accepted on 08/05/2024 (This assessment had warning for A2300- completed late more than 14 days after ARD) (Assessment Reference Date).SCSA (Significant Change in Status Assessment) with target date of 08/02/2024 was submitted and accepted on 08/09/2024.Discharge return anticipated with the target date of 08/02/2024 was submitted and accepted on 08/09/2024.Tracking record was submitted and accepted on 08/18/2024.SCSA with the target date of 08/02/2024 was submitted and accepted on 08/19/2024.Discharge return anticipated with the target date of 08/02/2024 was submitted and accepted on 08/19/2024.SCSA with the target date 08/21/2024 was submitted and accepted on 09/05/2024.Quarterly assessment with the target date of 11/21/2024 was submitted and accepted on 12/03/2024 (this assessment had 2 warning for A0500A and A0700).Quarterly assessment with the target date of 02/21/2025 was submitted and accepted on 03/12/2025 (this assessment had warning for A2300-Complete late more than 14 days after ARD).Quarterly assessment with the target date of 05/24/2025 was submitted and accepted on 06/14/2025 (this assessment had warning for A2300-complete late more than 14 days after ARD).Annual assessment with the target date of 08/22/2025 was submitted and accepted on 09/13/2025 (this assessment had warning for A2300-completed late more than 14 days after ARD)Quarterly assessment with the target date of 11/22/2025 was submitted and accepted on 12/14/2025 (this assessment had warning for A2300-completed late more than 14 days after ARD).Quarterly assessment with the target date of 02/22/2026 was submitted and accepted on 03/21/2026 (this assessment had warning for A2300-completed late more than 14 days after ARD).On 3/26/2026 at 1:36 PM, the MDS Nurse was asked about the late assessments and reported, both residents were Medicaid only and did not need the other assessments.

Based on observation and interview, the facility failed to provide 80 square feet per resident in multiple resident rooms, for 16 of 49 multiple resident rooms (#'s 112, 113, 114, 115, 116, 118, 119, 120, 122, 123, 124, 210, 213, 214, 215, and 216) resulting in, inadequate room space. Findings include:On 3/24/26 at 1:30 PM, observation of resident rooms and review of the facility bed count information revealed the following rooms that did not meet the minimum requirement of 80 square feet per resident: ROOM SQ. FT # OF BEDS112 282 4 113 282 4 114 282 4 115 282 4 116 282 4 118 282 4 119 282 4 120 282 4 122 282 4 123 282 4 124 282 4 210 282 4 213 282 4 214 286 4215 286 4 216 286 4On 3/25/26 at 2:45 PM, when asked about the insufficient square footage in some of the resident rooms, the Administrator stated there was a remodeling plan in process, and that in the interim, residents who express a concern are offered a larger room if available.

This citation pertains to Intake numbers MI00151424 and MI00152073. Based on observation, interview, and record review, the facility failed to provide adequate assessment, treatment and services to attain mental and psychosocial well-being for one resident (R502) of five residents reviewed for mental and psychosocial services. Findings include: R502 R502 was observed in bed in her room on 4/9/25 at 10:47 AM. R502 was crying with tears, stating they are not getting adequate mental health care and services that were appropriate for their health condition. R502 mentioned their diagnoses had crippled them and made them disabled. They also stated they used to walk, but now requires help. R502 expressed they are not getting any psychological services at the facility. R502's Electronic Medical Record (EMR) was reviewed on 4/9/25 at 4:00 PM. It revealed R502 was admitted on [DATE] with a diagnosis of Bipolar Disorder, current Episode Manic Severe with Psychotic features, Mood Disorder due to known physiological condition with manic features, Adjustment Disorder with mixed Anxiety and Depressed Mood, and Cerebral Palsy. R502's BIMS (Brief Mental Status) score was 15/15, assessed on January 10, 2025. A score of 15 means R502 is cognitively intact. According to the Minimum Data Set (MDS) Assessment Section GG, evaluated on January 17, 2025, the resident required substantial to maximum assistance with most of the Activities of Daily Living (ADLs), especially with showering, upper and lower body dressing, and personal hygiene. Dependent with transfers and did not ambulation not attempted due to medical condition on the date of assessment indicated above. A review of R502's Quarterly Evaluation progress notes was conducted on 4/9/25 at 1:10 PM, revealed: .Resident receives Antipsychotics/antidepressant medication . Another MDS Quarterly Evaluation Progress note entered on 4/9/25 at 1:09 PM revealed: .Resident has urinary incontinence. Resident S/S of incontinence is clothes or incontinence pad wet. Potential reversible causes for urinary incontinence is impaired mobility/ambulation. Other contributing diagnoses/medical condition: cerebral palsy. Receives Antidepressants/ Antipsychotics medication that may contribute to bladder dysfunction. Treatment plan is Check and Change. Receives Antidepressants/Antipsychotics medication that may contribute to bladder dysfunction. Treatment plan is Check and Change . A review of the medication prescribed for R502 was conducted on 4/9/25 at 3:30 PM and revealed: > Albuterol Sulfate Inhalation Nebulization Sodium. 1 application inhale orally via nebulizer every 6 hours as needed for shortness of breath (SOB) > Docusate Sodium Capsule 100 mg. Give 2 capsules by mouth at bedtime for constipation. > Guaifenesin Oral Liquid . Give 10 ml by mouth every 6 hours as needed for cough. > Pepcid Oral Tablet (Famotidine). Give 20 mg by mouth in the morning for acid reflux. > Vitamin D3 Oral Capsule 50 mcg (Cholecalciferol). Give 1 tablet by mouth one time a day for Vitamin D Deficiency. > Vitamin Deficiency System-B12 Injection Kit 1000 MCG/ML. (Cyanocobalamin). Inject 1000 mcg intramuscularly one time a day starting on the 13th and ending on the 13th every month for Vitamin Deficiency. Physician A was interviewed on 4/10/25 at 9:00 AM. Physician A indicated that although he was not R502's primary physician, he could answer questions regarding prescribed medications and their use. After Physician A reviewed R502's medication list, he revealed that none of the medications currently prescribed is for antidepressants or stabilizes R502's bipolar, mood, or manic condition. A Review of the Social Services Progress note written on January 21, 2025: Note Text: Quarterly Note: Resident remain stable. Resident remain full code status. Resident remain a&o3 she is able to make her needs known. Resident remain LTC r/t her needs for 24hr care. Resident remain total care with her ADL care. Resident have a DX: of Adjustment disorder with mixed anxiety and depressed mood. Resident continue to follow by psych service prn. Ancillary service remain in place. Resident continues to use her w/c for mobility. Resident code status and 37-78 was review. Resident interact with staff and her peer well. Resident have no family support. Resident is responsible for self. Continue with plan of care. According to the record review conducted on 4/9/25, it revealed, R502 did not receive any medications for the diagnosis of Adjustment Disorder with mixed anxiety and depressed mood. Psych services have not followed R502 since October 2024. According to the Director of Nursing (DON) interview on 4/10/25 at 1:11 PM, and confirmed that the nurse's assessment was inaccurate. No behavior was recorded or monitored in the Certified Nurse Assistant (CNA) documentation. The DON validated R502 was not in any psychotropic medication, mood stabilizers or antidepressants. The DON agreed R502 could benefit from psych therapy. The last time was on October 14, 2024. Social Services Progress Notes were reviewed on 4/9/25. The last Progress notes for R502 by Social Services was dated 1/21/25 at 10:23 AM-the purpose of the due to a quarterly evaluation. The Social Service Director was interviewed on 4/9/25 at 1:20 PM and confirmed R502 does not take any psychoactive medications and does not receive psychological therapy. The last visit with psychologist services was in October 2024 and had not received therapy because of refusal and did not have any behavior that triggered therapy or psychological services. No changes in R502's behavior were observed. The following behavior documentation found in progress notes was reviewed on 4/10/25 at 10:00 AM: -Dated 3/14/25, Progress Notes Text: Writer received a call from (name of local) police stating that resident was call stating that people are potentially being harmed and they needs help. Writer informed writer that SW would assess the situation. Writer and SW entered resident room and observed that resident was not in any respiratory or cardiac distress. Resident began yelling I feel sorry for you both for what you have been through in the past and many people are getting hurt and no one's doing anything about it. SW (name mentioned) if they was being abuse?, and resident stated NO, SW then asked if resident felt safe, resident stated yes. SW educated resident of risk vs. benefit of calling 911 for non emergent situations, resident acknowledged understanding. Resident sitting in bed. Safety maintained. Will continue with current POC. -Dated 3/20/25, Progress Notes Text: Resident refused all medication this shift. Resident also refused to get up in wheelchair (w/c) stating that their lungs are not working properly. The resident refused to have their vital signs taken. Resident became verbally aggressive during writers attempt to educated them about laying in the bed and refusing medication, the education attempted failed. Calm environment provided. Safety maintained. Will continue with current POC. -Dated 3/21/25, Progress Notes Text: Resident used personal cell phone to call 911. (name of local) police arrived. Writer escorted officer to resident room. Writer walked in resident room with police officers. Resident stated to police Abuse is going on everywhere and I want to go to the hospital. Police officer explained to resident they have to call Emergency Medical System (EMS) if they wants to go to hospital that is their right, and the benefit of calling 911 for non-emergent situations. (name of local) police cancelled the call. Resident always calls the police. The Administrator was interviewed on 4/9/25 at 4:00 PM. The Administrator stated R502 refused medications and does not take psychiatric meds. They are at baseline and did not need any referral to Behavior Care Services for therapy. The Nurse Practitioner (NP) was interviewed on 4/10/25 at 2:10 PM and explained the reason why he had not seen R502 since October 2024 (6+ months ago) was that he had not received any referral for R502 from the Social Worker and was waiting for referrals from the facility. The facility policy, Behavior Management Program, dated 11/28/2017, was reviewed on 4/10/25 at 1:30 PM. It indicated: Purpose: The purpose of the Behavior Management Program is to promote and provide the highest practicable quality of life and a safe environment for residents and staff .This facility will maintain a strong commitment to the safety and welfare of all residents under our care. We will assess residents for risk factors for the development of mood and behavior symptoms according to established guidelines. Ongoing evaluation of potential risks and care plan effectiveness is part of an overall treatment plan for all residents .2. Behavior and Psychotropic documentation in medical record system .Behavior Professional Service Recommended Referrals .

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all142 residents that consume food from the kitchen. Findings include: On 2/3/25 between 8:35 AM-8:50 AM, during an initial tour of the kitchen with [NAME] B, the following items were observed: The paper towel dispenser by the hand washing sink at the entrance to the kitchen was empty. According to the 2017 FDA Food Code section 6-301.12 Hand Drying Provision, Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels;. In the walk-in cooler, there was a pack of cheddar cheese with no date on it. [NAME] B discarded the cheddar cheese. The smaller cooler had a temperature of 49 degrees Fahrenheit. Three individual beverages were observed in the freezer with no labeling on the bottles. The [NAME] indicated that the beverages were most likely employee beverages that had been placed in the freezer. On 2/4/25 at 10:28 AM, Dietary Manager (DM) C was interviewed regarding lack of paper towel at the handwashing sink, the undated cheddar cheese, the temperature of the refrigerator, and the unlabeled beverages in the freezer. DM C indicated housekeeping was responsible for replacing the paper towel at the handwashing sink. Regarding the undated cheddar cheese, DM C stated, The label must have fallen off. DM C indicated the high refrigerator temperature was likely due to staff opening and closing the refrigerator frequently to place resident snacks in it. DM C confirmed the individual unlabeled beverages should not have been placed in the freezer. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on observation, interview, and record review the facility failed to provide timely Activities of Daily Living (ADLs) for one sampled resident (R140) of three reviewed for activities of daily living. Findings include: On 2/03/25 at 11:56 AM, R140 was observed with thick chin hair and with matted hair on the back of their head. On 2/04/25 at 4:08 PM, R140 was observed with a thick layer of chin hair and matted hair. R140 was asked about the chin hair. R140 was observed to grab their chin hair and pulled it away from their chin, then stated, I got a beard. R140 was asked if they preferred their hair this way and stated, No. It's out of control. R140 was asked if they had refused to get it cut and reported no they had not refused. R140 was admitted to the facility on [DATE] with diagnosis of Osteoarthritis. A review of R140's five day Minimum Data Set (MDS) assessment noted, R140 with an intact cognition. R140's Nursing assessment dated [DATE] revealed, R140 required assistance with ADLs. On 2/04/25 at 4:18 PM, the Unit Manager was asked about R140's bathing schedule and if chin hair would be address during that time. The Unit Manager reported that shaving should be addressed during the personal hygiene care. On 2/04/25 at 4:32 PM, R140's assigned Certified Nursing Assistant (CNA A) was asked about R140's chin hair. CNA A explained that she was an afternoon CNA and that she did not have R140 this morning. On 2/04/25 at 4:36 PM, the Unit Manager Nurse was asked if R140 refused if there would be a note that documented the refusal. The Unit Manager Nurse explained that there should be a refusal note. A review of R140's medical record did not reveal documentation regarding the refusal of chin hair to be cut. A review of the facility's policy titled, ADL (Activities of Daily Living), Functional Mobility & Resident Care, dated March 2017 revealed, Policy: Activities of Daily Living are routine activities that individuals normally complete daily without needing assistance . In long term care, we recognize that residents are admitted with physical and/or cognitive impairments that limit their ability to complete these tasks independently. Personal hygiene: . Shaves: Assure facial hair is removed safely, unless resident requests otherwise. Should this be so, notify the charge Nurse. Hair care: Wash and dry if needed, comb/brush and style. Check scalp for skin condition and report to the Charge Nurse as needed Refer to Activities/Social Worker for beauty/barber services if needed .

Based on observation, interview, and record review, the facility failed to provide a clean and homelike environment for residents in one (C-wing) of four nursing units. Findings include: On 02/04/25 at 2:00 PM, an observation was made of the C-wing medication storage room. The air vents in the room were noted to have layers of dirt and dust on it. Additionally an oberservation of a dried reddish stain on a light cover in the C-wing hallway was noted. On 02/04/25 at 2:10 PM, an interview occurred with the Maintenance Director D(MDD) to discuss the cleaning of the vents and light fixtures. The MMD stated, it must have been missed. On 02/04/25 at 2:20 PM, an interview was held with the Nursing Home Administrator (NHA) about the responsibility of cleaning the vents and cleaning light fixtures. The NHA stated that environmental services (housekeeping and maintenance) handle those services and should follow the cleaning policy. A review of the facility policy entitled Cleaning Procedures revealed, High Dust. Work your way clockwise around the the room (starting at the door and finishing at the door and dust all high surfaces. This includes, but is not limited to pictures, television, over bed lights, blinds, vents and all corners.

Based on observation, interview, and record review, the facility failed to provide 80 square feet per resident in multiple resident rooms, for 16 of 49 multiple resident rooms (#'s 112, 113, 114, 115, 116, 118, 119, 120, 122, 123, 124, 210, 213, 214, 215, and 216) resulting in, inadequate room space. Findings include: On 2/13/25 at 9:00 AM, observation of resident rooms and review of the facility bed count information revealed the following rooms that did not meet the minimum requirement of 80 square feet per resident: ROOM # SQ. FT # OF BEDS 112 282 4 113 282 4 114 282 4 115 282 4 116 282 4 118 282 4 119 282 4 120 282 4 122 282 4 123 282 4 124 282 4 210 282 4 213 282 4 214 286 4 215 286 4 216 286 4 On 2/3/25 at 4:34 PM, Maintenance Director (MD) D was interviewed about the rooms that provided less that 80 square feet of living space per resident. MD D indicated over the past year, A few rooms had been converted to three person rooms or less. On 2/4/25 at 11:30 AM, the Administrator (NHA) was interviewed about the lack of square footage in some of the rooms. The NHA indicated that the goal was to eliminate all four person rooms at the facility. The NHA further indicated that over the past year, six rooms had been converted to three person rooms or less and residents who were displeased with the lack of space in their rooms have been assisted with transferring to other facilities. A facility policy titled, Resident Rights with an, Effective Date of 11.28.2017, stated the following, Purpose: It is the practice of this facility to provide an environment in which residents may exercise their rights .Safe Environment: The right to a safe, .comfortable and homelike environment .

Based on observation, interview and record review the facility failed to ensure biologicals were labeled and dated when opened on the actual medication container in two of five medication carts reviewed, resulting in the potential for use of medications and biologicals past the expiration date and decreased efficacy of the medications and biologicals. Findings include: On 11/28/23 at 8:55 AM, the C wing medication cart was reviewed with Licensed Practical Nurse (LPN) A. A Dorzolamide,/Timolol eye drop vial for Resident R30 was not dated on the vial with the new expiration and or opened date, On 11/28/23 at 9:58 AM, the B wing second cart was reviewed with Registered Nurse (RN) B. The glucometer test strips were not dated with a date opened nor the new expiration date. A fluticasone/salmeterol 100/50 diskus inhaler for Resident R8, was not dated on the inhaler with the new expiration and or opened date, On 11/28/23 at 10:33 AM, Nursing Unit Manager C was queried about the labeling of medications and reported the open and or expiration date should be on the package and actual container/inhaler. A review of the facility policy titled, Medication Ordering and Receiving from Pharmacy dated April 2018 documented, Policy: Medications are labeled in accordance with facility requirements and state and federal laws . A review of the facility policy titled Medication Storage in the Facility dated April 2018, documented, D. When the original seal of a manufacturer's container of vial is initially broken the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration .

Based on observation, interview and record review, the facility failed to obtain a physician order in a timely manner for provided and implemented hand splints for one (R113) of three residents reviewed for hand splints. Findings include: Review of the facility record for R113 revealed an admitted [DATE] with diagnoses that included Cerebral Palsy, Muscle Wasting/Atrophy and Seizure Disorder. The Minimum Data Set (MDS) assessment dated [DATE] indicated R113 required total assistance for all activities of daily living. On 11/27/23 at 12:30 PM, R113 was observed laying in bed. The resident was not able to functionally communicate and both upper extremities appeared to be contracted. A right wrist/hand splint was observed to be in place in a loose and incorrect position. Additional review of the facility record for R113 revealed no physician order, care plan item or resident care Task item related to upper extremity splints. Review of R113's therapy record revealed an Occupational Therapy (OT) discharge summary dated 09/29/23 that indicated a left palmar guard splint had been implemented during the dates of service between 09/07/23 and 9/26/23. This discharge summary indicated that the long-term goal of R113 tolerating the left palmar guard for up to four hours had been met and exceeded as the Patient Progress statement in the summary stated Patient is able to tolerate palmar guard for more than four hours with checks for signs and symptoms of redness and skin breakdown. The Functional Maintenance section of the discharge summary included the statement Splint and brace program established and trained: Waiting on [right functional resting hand splint] to be delivered. Will provide education to staff for donning/doffing and wear schedule. Staff education provided for palm protector (palmar guard), skin checks and skin breakdown. On 11/28/23 at 4:07 PM, R113 was observed laying in bed. The right hand splint was not in place. The left palm protector was placed but was not positioned correctly and provided no barrier between the fingers and palm. On 11/29/23 at 11:05 AM, Licensed Practical Nurse (LPN) A reported that they were the charge nurse for R113's hall and that they were familiar with R113's care. LPN C reported that they were familiar with R113's hand splints and had received instruction from the therapy department regarding application and wearing schedule of the splints and stated that they were to be worn as tolerated. LPN C reported that the nurses aides (CNA's) had been instructed regarding R113's splinting program. On 11/29/23 at 11:20 AM, the facility Director of Rehab (DOR) D reported that splint-related orders and care plans are entered by the nursing staff. On 11/29/23 at 1:00 PM, the facility Director of Nursing (DON) reported that the expectation is that residents with hand splints will have the splint wearing instructions included in the Care Plan and in the Tasks resident care checklist. The DON reported that when nursing receives a splint recommendation/instructions from therapy they obtain the physician order and complete the care plan and Task updates. When asked about the physician order for R113's hand splints the DON stated There is no order. On 11/29/23 at 2:10 PM, the facility DOR D reported that no order or care plan was in place for R113's splints because they continued to be assessed for any further adjustments to the fit, wearing schedule, etc. prior to obtaining a physician order or including the application in the care plan and that they planned to include an order and a care plan at a later date. On 11/29/23 at 1:46 PM, a facility policy was requested from the Administrator (NHA) regarding physician's orders. At 3:05 PM, Corporate Director of Clinical Services E reported that there was no facility policy specific to physician's orders and that the issue of having orders present for resident treatments was considered a standard of practice.

Based on observation, interview, and record review the facility failed to provide a homelike environment for two residents (R24 and one confidential group resident) of seven residents reviewed for a homelike environment resulting in resident feelings of dissatisfaction with their living environment. Findings include: On 11/27/23 at 11:20 AM, during an initial tour of the facility R24 was interviewed regarding their satisfaction with care and services at the facility. R24 stated, There's not enough room. I don't feel comfortable in this room. R24 further indicated that their bed was too close to their roommate's bed. An observation of R24's room revealed that a total of four residents resided in the room and the distance between R24's bed and the resident's bed closest to them was less than one foot, with a privacy curtain hanging between the two beds. On 11/28/23 at 10:00 AM, a confidential group meeting was conducted with six confidential group members and the group was asked about their level of satisfaction with their living environment at the facility. One group member indicated that they resided in a room with three other residents and stated, It can get loud at night. They further indicated that their roommates get loud and play their television loudly at night when they are trying to sleep. On 11/28/23 at 3:46 PM, Social worker (SW) D was interviewed and asked about ways in which the facility attempted to maintain a homelike environment for their residents who reside in four bed rooms. SW D indicated that residents can request a room change and the facility will attempt to honor their request if possible. SW D was asked specifically about R24 and what they had done to ensure a homelike environment for R24. SW D indicated that [R24's Daughter] had contacted the facility and expressed dissatisfaction with [R24's] room. SW D stated, I spoke to [R24] about it and they indicated that they were fine with it. On 11/28/23 at 3:51 PM, R24 was further interviewed about their room and indicated that they would like to switch rooms if their certified nursing assistants (CNAs) and nurses could come with them. R24 stated, I love my CNAs. On 11/29/23 at 10:20 AM, Maintenance Director (MD) E was interviewed regarding any accommodations that were done to ensure a homelike environment was maintained in the facility's four person rooms. MD E stated, I know it's tight, there's not much we can do, it's an old building. If it was up to me all the residents would be in two person rooms. On 11/29/23 at 11:48 AM, R24 was observed sitting in the corner of their room in the dark. Loud snoring was heard coming from the bed next to R24's bed. R24 was further asked about their room and acknowledged that the room was tight and then shook their head. On 11/29/23 at 12:25 PM, the Administrator (NHA) was interviewed regarding attempts to address concerns regarding maintaining a homelike environment in the four person rooms. The NHA stated, We have tried to reduce the clutter, we ask those residents about concerns during weekly rounds, we try and move residents to a new room if we are able. We currently have no related complaints. We've only had one complaint from [R24's daughter] but [R24] had no complaints. On 11/29/23 at 12:41 PM, a review of R24's electronic medical record (EMR) revealed that R24 was admitted to the facility on [DATE] with diagnoses that included Anxiety disorder and Adult failure to thrive. R24's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R24 had a moderately impaired cognition. On 11/29/23 at 12:55 PM, a facility policy titled Accommodation of Needs and Preferences and Homelike Environment Guideline with no date was reviewed and stated the following, Policy: It is the practice of this facility to identify and provide reasonable accommodation of resident needs and preferences .This facility will provide a safe, clean, comfortable, and homelike environment .Guideline: The objective of the accommodation of resident needs and preferences is to create an individualized home-like environment to maintain and/or achieve independent functioning, dignity and well-being to the extent possible in accordance with the resident's own needs and preferences. Definitions: A homelike environment is one that de-emphasizes the institutional character of the setting .A determination of homelike should include the resident's opinion of the living environment.

Based on observation, interview, and record review, the facility failed to provide 80 square feet per resident in multiple resident rooms, for 12 of 49 multiple resident rooms (#'s 112, 113, 115, 116, 118, 119, 120, 122, 123, 124, 214, 215) resulting in, inadequate space and resident complaints. Findings include: On 11/27/22 at 9:00 AM, observation of resident rooms and review of the facility bed count information revealed the following rooms that did not meet the minimum requirement of 80 square feet per resident: ROOM # SQ. FT # OF BEDS 112 282 4 113 282 4 115 282 4 116 282 4 118 282 4 119 282 4 120 282 4 122 282 4 123 282 4 124 282 4 214 286 4 215 286 4 On 11/27/23 at 11:20 AM, residents in room [ROOM NUMBER] were interviewed regarding their room size, and R24 expressed concerns regarding their room being too crowded and their bed being too close to their roommate's bed.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner, resulting in the increased potential for cross contamination and the attraction of pests. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 9/11/22 between 8:30 AM- 9:00 AM, during an initial tour of the kitchen, the following items were observed: In the dry storage room, there was a buildup of food debris on the floor underneath the racks. In the walk-in cooler, there was food debris, a rotten cucumber and a juice container on the floor underneath the racks. In addition, there was an opened, undated 5 pound container of cottage cheese with a manufacturer's best by date of 9/6. The floor underneath the ice machine was coated with dust, debris and various items (lids, cups, bowls). The floor underneath the steamer, fryer and oven was observed with a heavy buildup of debris, grease and food. On 9/11/22 at 12:30 PM, Dietary Manager (DM) was queried and stated that the porter was responsible for cleaning the floors. DM added that they have not had a porter for a few days, because they have been short staffed. Review of the job duties for PM Porter noted: Sweep the floor and move the tables and kitchen equipment, if cook is busy wait until she is through to move stove, oven, fryer etc and you can mop just under equipment. The metal tracking on the ceiling, that holds the ceiling tiles in place, was observed with large clumps of dust accumulated on the surface. The metal sides of the ceiling fluorescent light fixtures were observed to be coated with dust. An electrical cord hanging down from the ceiling above the steam table, was observed with clumps of dust adhered to the cord surface. According to the 2013 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. The garbage grinder at the soiled side of the dish machine was observed to be rusted at the bottom, and was observed with a steady, slow leak of water. The floor underneath the garbage grinder was wet, with standing water pooled in between the grout lines of the floor tiles, and there was food debris on the floor underneath the garbage grinder. There were numerous gnats observed near the standing water and on the outside of the garbage grinder. According to the 2013 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.

Based on observation, interview, and record review the facility failed to serve meals in a palatable manner and at the preferred temperature for three sampled Residents (R12, R59 and R93) and one confidential group resident, of thirteen residents reviewed for food palatability, resulting in dissatisfaction during meals. Findings include: Resident #12 (R12) On 9/11/22 at 10:25 AM, during an initial tour of the facility R12 was interviewed about food palatability at the facility and stated, It is bland. On 9/11/22 at 11:00 AM, a review of R12's electronic medical record (EMR) revealed that R12 was admitted to the facility on [DATE] with diagnoses that included Dementia and [CONDITION(S)] ([CONDITION(S)]). A review of R12's most recent Minimum Data Set (MDS) assessment revealed that R12 had a moderately impaired cognition and required assistance of one to two people for all activities of daily living (ADLs) other than eating. Resident #59 (R59) On 9/11/22 at 11:29 AM, during an initial tour of the facility R59 was interviewed about food palatability at the facility and stated, Terrible, they give us too many potatoes, I'm sick of potatoes. On 9/11/22 at 11:44 AM, a review of R59's EMR revealed that R59 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] disease and Dementia. R59's most recent MDS dated [DATE] revealed that R59 had a moderately impaired cognition and was independent and/or required supervision for all ADLs. Resident #93 (R93) On 9/11/22 at 12:04 PM, during an initial tour of the facility R93 was interviewed about food palatability at the facility and stated, The food is cold. On 9/11/22 at 12:23 PM, a review of R93's EMR revealed that R93 was most recently admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes and Hypertension. R93's most recent MDS dated [DATE] revealed that R93 had a moderately impaired cognition and required extensive assistance of one person for all activities of daily living (ADLs) other than eating. On 9/12/22 at 10:09 AM, resident council meeting notes were reviewed for the months of June-August 2022 and revealed the following concerns regarding food palatability, Bland food, no seasoning or flavor. The residents want more food choices or alternatives. The residents want more fresh fruits such as strawberries, grapes, watermelon. On 9/12/22 at 10:37 AM, six confidential group residents were met with for a confidential group meeting. The group was asked about the palatability of the food at the facility and one of the confidential group resident's indicated that the food was cold and sometimes didn't taste good. On 9/12/22 at 12:00 PM, a food plate was pulled from a food cart on the unit and temperature tested by Food service manager (FSM) A and the results were the following: Salisbury steak with gravy: 112.5 degrees Fahrenheit; mashed potatoes: 114.8 degrees Fahrenheit; carrots: 95.6 degrees Fahrenheit. FSM A was interviewed and asked about the preferred serving temperature for hot food and stated, Food should be held at 135 degrees or greater, the serving temperature is all based upon resident preference. On 9/12/22 at 12:07 PM, the food was taste tested and revealed the following, the Salisbury steak with gravy tasted less than Luke warm and lacked a genuine meat like taste. The mashed potatoes tasted Luke warm and lacked taste and flavor. The carrots tasted Luke warm and lacked flavor. On 9/12/22 at 4:15 PM, a facility policy titled Food Temperatures-Monitoring Revised: 1/15/22 was reviewed and stated the following, Policy: It is the policy of the facility to maintain and monitor tray line holding temperatures of foods served during meal service .6 .Hot food items must be held on a heated device .at 135 degrees F [Fahrenheit] or higher. 10 .hot food temperatures should not be below 100 degrees F [Fahrenheit] at point of service .

Based on observation, interview and record review, the facility failed to provide ongoing behavioral health services, monitoring and follow-up after mental status change/decline for two sampled Residents (R93 and R35) of five sampled residents reviewed for psychiatric services, resulting in [CONDITION(S)] medication not being monitored, cognitive decline, ongoing distress, delusions, paranoia and the potential for an increase in psychiatric issues. Findings Include: Resident #93 (R93) On 9/12/22 at 1:18 PM, a review of R93's psychiatric care plan in their electronic medical record (EMR) revealed the following, Focus: Resident has impaired thought process r/t (related to) Dementia. Resident may exhibit behaviors or mood changes as a result. Date initiated: 10/12/2018. Goal: Resident will maintain current level of cognitive function through the review date. Date initiated: 3/30/2020 Target Date: 10/31/2022. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated: 10/12/2018. On 9/12/22 at 1:30 PM, a review of R93's orders in their EMR revealed an order dated 4/22/22 for Psych eval/treatment if indicated and a medication order dated 4/22/22 for Sertuline [[MEDICATION(S)]] HCI tablet 50 mg [milligrams] 0.5 tablet by mouth one time a day for antidepressant. On 9/12/22 at 1:47 PM, a review of psychiatric treatment documentation in R93's EMR revealed no documentation of a psychiatric evaluation being completed on R93. The most recent psychiatric services note reviewed in R93's EMR was dated 10/27/21. The psychiatric services consent form reviewed in R93's EMR was dated 11/8/19. On 9/12/22 at 2:27 PM, Social Services Director (SSD) B was interviewed regarding the documentation involving psychiatric/behavioral services in R93's EMR. SSD B indicated that they would contact the [Behavioral Health Service Provider] regarding this issue. On 9/12/22 at 2:30 PM, [Behavioral Health Service Provider] Psychiatric Nurse Practitioner (PNP) C was interviewed regarding psychiatric/behavioral health services currently being provided for R93. PNP C stated, I didn't know [R93] was on any antidepressant medication, sorry. PNP C was further interviewed and asked how frequently would they monitor a resident who was prescribed an antidepressant medication. PNP C stated, Typically we monitor our patients every three months. On 9/12/22 at 3:00 PM, the Assistant Director of Nursing (ADON) was interviewed regarding their expectations for monitoring residents who receive psychiatric medications. The ADON stated, Anyone prescribed psychiatric medications is followed by [Behavioral Services Provider]. The Director of Nursing (DON) was not available for an interview. On 9/12/22 at 3:40 PM, R93's EMR was reviewed and revealed that R93 was most recently admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R93's most recent Minimum Data Set assessment (MDS) dated [DATE] revealed that R93 had a moderately impaired cognition and required extensive assistance of one person for all activities of daily living (ADLs) other than eating. On 9/12/22 at 3:55 PM, a facility policy titled [CONDITION(S)] Medication Management Effective Date: 11.28.2017 was reviewed and stated the following, Purpose: .Residents prescribed psychoactive medications will receive adequate monitoring .Medication Classification: Psychoactive medication will be defined as any medication used for managing behavior, stabilizing mood, or treating a psychiatric disorder. Medication Review Procedure: 1. Psychoactive medication .will be routinely reviewed. 5. Medication will be reviewed quarterly at a minimum for progress towards therapeutic goals . Resident #35 (R35) On 9/11/2022 at 9:18 AM, an interview was conducted with R35 regarding their stay in the facility. R35 was observed to have thick chin hair, multiple layers of shirts and pants on. R35's breakfast tray was observed on the floor with the items spread across the room and R35 was heard talking to themselves. On 9/11/2022 at 12:00 PM, an interview was conducted with Nurse E regarding R35's behaviors. Nurse E stated that R35 refuses everything including medications, meals, and care. Nurse E states that R35 is physically and verbally abusive to staff, and it makes it impossible to care for them. A review of the medical record revealed that R35 admitted into the facility on [DATE] with the following diagnoses, [CONDITION(S)], [CONDITION(S)], and Selective Mutism. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6/15 indicating severely impaired cognition. R35 also required supervision with bed mobility and transfers. A review of a psychiatry note dated 7/12/2022 reflected the following, Patient is reported to have not received [their] monthly injection for month of July yet; has not been distributed to patient. Reported with increased behaviors, wearing multiple layers of clothing, including [their] long winter coat. Wandering the unit with difficulty being redirected, yelling out/screaming and talking outside [themselves]. Reported with paranoia, delusions, verbally aggressive, and poor sleep pattern .Considering patient has been on IM (intramuscular) injection for years and extended time between injections is not recommended and detriment to patient, will begin [MEDICATION(S)] 10 mg daily .until IM injection can be given. Recommended to send patient to ER (emergency room ) if symptoms are severe and IM can be delivered there. A review of the 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/12/2022 at 10:44 AM, R35 was observed in the hallway yelling and pointing at other residents. R35 was observed repeating the word shower while standing in the hallway. R35 was heard mumbling to themselves and speaking incoherently. Nurse E stated that R35 had not taken their medications for the morning and that this was typical behavior for them. Further review of a psychiatric note dated 9/6/2022 reflected the following, RN (Registered Nurse) reports patient has increased agitation since transition to oral medications while also having had difficulty with IM therapy. Previously well controlled when arrived to facility. Has had one order for ED (Emergency Department) visit for psychiatric evaluation without medication changes in the last two months. On 9/12/2022 at 2:35 PM, an interview was conducted with Physician F regarding R35's care. Physician F stated that they are aware R35 is not taking any medication and that they will be putting R35 back on the IM medication. Physician F stated that they will look and alter the medication until R35 is stable again. On 9/13/2022 at 12:30 PM, an interview was conducted with Social Worker (SW) B regarding R35 and their plan of care. SW B stated that they have psychiatric services following R35 and that they will exhaust everything they have at the facility before looking to see if there is a more appropriate setting. SW B stated that they did not know that R35 never received their [MEDICATION(S)] injections and that they will review it. A review of a facility policy titled, [CONDITION(S)] Medication Management and dated 11/28/2017, did not address behavior management.

This citation pertains to intake #'s: MI 408 and MI 368. Based on observation, interview, and record review, the facility failed to provide assistance to complete activities of daily living (ADL) care timely for two residents (Resident #7 and #55) of seven residents reviewed for activities of daily living care, resulting in poor hygiene and the potential for decreased body image and mental anguish. Findings include: Resident #55 (R55) On 9/11/2022 at 1:47 PM, R55 was interviewed regarding their stay in the facility. R55 stated that they wanted a peanut butter and jelly sandwich, as well as a shave. R55 was asked when was the last time they had a shower, and R55 stated that they could not remember. A review of the medical record revealed that R55 admitted into the facility with the following diagnoses, [CONDITION(S)], Muscle Wasting, and Abnormalities of Gait and Mobility. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 10/15 indicating a mildly impaired cognition. R55 also required supervision with set up for bed mobility and transfers. A review of the bathing task charting for the last thirty days revealed that R55 had only one documented shower on 9/12/2022. On 9/13/2022 at 12:52 PM, an interview was conducted with the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON). The ADON was queried regarding R55's showers. The ADON stated that sometimes R55 does refuse but that should be documented, and they would look further into it. No further information was provided prior to exit. Resident #7 (R7) A review of the intake revealed, Details: It was alleged the facility failed to ensure the resident was clean and well-groomed. Progress Note: 11/9/2021 21:33 (9:33 PM) Nursing Evaluation . The reason for the evaluation is Admission. admitted from: . Preferences: Bathing preference is a shower . A request was made via email for R7's shower documentation on 9/13/22 at 12:41 PM. On 9/13/22 at 2:24 PM, the Corporate staff reported that the facility was unable to locate any shower documentation for R7. At that time the Corporate staff was interviewed and asked what that meant for R7 receiving showers and explained, if there is no documentation then it is not done. Further review of R7's medical record did not reveal any documentation of R7's refusal of assistance with bathing/grooming. A review of R7's medical record noted, R7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R7's MDS assessment revealed, an impaired cognition and extensive assistance with activities of daily living. A review of R7's medical record revealed, Care plan: Resident have behavior problem r/t (related to) DX (diagnosis): of Dementia. Resident can be verbally and physically aggressive toward staff at time, and resident not easily redirected. Resident is seen by psych service prn (as needed) Resident legal guardian in place for decision making. Date Initiated: 07/18/2022. Canceled Date: 09/09/2022. A review of a facility policy titled, Activities of Daily Living and dated 5/07/2020 noted the following, In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our facility provides care and services for the following activities: Hygiene: Bathing/showers .

Based on observation, interview, and record review the facility failed to maintain a homelike environment, for Residents (R17 and R220) that lived in rooms with four beds, resulting in dissatisfaction of living environment. Resident #17 (R17) On 9/11/22 at 9:25 AM, R17's room was observed to have four residents that lived in the room. The room was observed to have limited space and residents' equipment next to the beds leaving no clear path out of bed. R17 was asked about the room and stated, It's too crowded. We have to share those small closet space. Observed between bed two and three were two wheelchairs, and an over bed table. Bed two had a tall walker, with an attached arm platform on the right side of the bed. Both sides of the bed were blocked with the resident's equipment. Between bed three and four, were two night stands back-to-back with TVs on it, next to that was an over bed table, and a chair. Resident #220 (R220) On 9/11/22 at 9:43 AM, room 216 was observed to have four residents in the room. R220 was asked about their stay at the facility and stated, There are too many people in this room. They took me off the first floor, it's nasty in here. The room was observed to have limited space and wheelchairs in the walking path. The two wardrobes that were observed in the room are shared by the four residents. R220 was asked if they felt they had enough privacy during conversations about care and stated, There is no privacy. I can't even watch TV without (resident in bed 3) looking all in my TV. After leaving the room from the residents, the resident in bed one and R220 was overheard having a back-and-forth disagreement about the interview that was held. On 9/13/22 at 12:55 PM, the Nursing Home Administrator (NHA) was interviewed and asked about the rooms with four residents. The NHA explained, that the facility's plan is to remove some beds offline, which then they would be able to space some residents out. The NHA was asked how staff maintain privacy during care or conversations about care. The NHA explained, We must speak in the lowest voice possible. Or we can use another area in the building. A review of the facility's policy titled, Accommodation of Needs and Preferences and Homelike Environment Guideline dated, 11/28/17, noted, Purpose: It is the practice of this facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Residents have the right to retain and use personal possessions to promote a homelike environment and to support each resident in maintaining their independence. The facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference . PROCEDURE: 1. The facility will assess and interview resident for the need to make reasonable accommodations such as: Room set-up, Placement of personal items and supplies Protection of resident's personal items and supplies from loss or theft Call light in reach for room and bathroom and the correct type for resident use Resident lighting to meet the resident's needs, Adaptive devices necessary to maintain/restore resident at their highest level of functioning . 7. The resident's environment will be maintained in a homelike manner to ensure: Appropriate housekeeping, Clean linens in good repair, Private closet space for each resident, Adequate and comfortable lighting, Comfortable and safe temperatures, Comfortable sound levels .

This citation pertains to intake MI 377 & MI 506. Based on interview and record review the facility failed to ensure one resident (#901) of three, reviewed for abuse, out of a total sample of five, was free from physical abuse, resulting in Resident #901 having multiple lacerations on his face and a [DIAGNOSES REDACTED]. Findings include: On 7/25/17 at 9:34 a.m., Resident #901's clinical medical record was reviewed and revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set, dated dated [DATE], indicated Resident 901's cognition was severely impaired and required extensive to total assistance from staff to complete all activities of living. Facility's summary of the incident revealed, On 6/23/17 Certified Nurse Assistant (CNA) reported to the nurse on duty that she observed resident in room with facial injuries and bleeding. CNA stated that she entered room to assist when she heard the resident yelling out for help. Resident identified CNA F as the perpetrator. Nurse immediately went to attend to resident and found resident with injuries. Resident reported that CNA F caused him to sustain injuries while he was providing care. Resident assessment revealed three scratches and laceration on his facial area. Resident indicated he received the injuries at the hands of CNA F. Per CNA F, resident injuries were from resident's head hitting the cabinet when he was turning him. Resident subsequently was discharged to the hospital to be assessed by physician. Resident returned to facility with [DIAGNOSES REDACTED]. Employee was immediately suspended pending an investigation. Incident was reported to the local police and the State of Michigan. Review of written statements from the roommates revealed, Bed-1 Resident could not see because the curtain was pulled. CNA F stated don't you kick me. Resident stated he heard CNA F hit Resident #901 and struggle. It got physical. Bed-4 agreed that there was a physical altercation between resident in bed-2. (Resident were unable to recall the incident during this survey) Written statement noted, When I came to work CNA F spoke to me by room [ROOM NUMBER] and Resident #901 was hollering come here he beat me up he had no cloths on and his face cut and bleeding and kept saying he beat me up. Incident and Accident Investigation dated 6/23/17 at 11:05 p.m. Description: Resident (901) presented with visible lacerations and bruises on face. Resident (#901) reported that CNA F inflicted the wounds . Investigation revealed that employee (CNA F) was in contact with resident at time injury was alleged to have taken place. Employee was immediately suspended and incident as reported to the police and state of Michigan. emergency room report dated 6/24/17 noted, Medically stable for transfer back to nursing home. diagnosed : Closed head injury. On 7/26/17 at 9:19 a.m., during an interview, the Administrator said, We suspended him right away and he never came back into the facility. The police said that they were going to proceed with the charges. Review Police Case report dated 6/24/17 noted . I spoke with Resident (#901), who stated that CNA F . An argument ensued, to which Resident #901 stated that CNA F punched him in the head/face with a closed fist at least three times. I observed a laceration on his left check, a laceration underneath his left eye, a laceration and bump between his eyebrows, and 2-3 bumps with lacerations on the top left of his forehead . Review of facility's email communication, addressed to Nurse Aides Registry dated 6/16/27, revealed detailed documents regarding the abuse was reported to the Registry. On 7/26/17 at 3:04 p.m., CNA D was contacted via phone, voice mail left. On 7/26/17 at 3:06 p.m., CNA F was contacted via phone, voice mail left. On 7/26/17 at 3:35 p.m., contact was attempt with the Police Officer, message left. On 7/26/17 at 4:00 p.m., during an interview, CNA G said, I work with Resident #901 often and he can sometimes be combative. CNA G was asked if Resident #901 had ever harmed himself, CNA G said, no. On 7/26/17 at 3:35 p.m., review of facility's policy titled Abuse,, Neglect, and Exploitation, March 2017 noted, Policy: Each resident has the right to be free from abuse, neglect, and misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff . 5. Physical Abuse includes, but not limited to hitting, slapping, pinching and kicking .

This citation pertains to intake MI 201. Based on interview and record review, the facility failed to provide on-going assessment when blood sugars results were unstable for one (#902) of three reviewed for assessments out of a total sample of five, resulting in the potential for life-threatening blood sugar levels. Findings include: On [DATE] at 9:30 a.m., during a phone interview, (Interested party) IP stated that Resident #902 had come to the facility after being in the hospital for a long stay and that Resident #902 was getting better. Her blood sugars had been fluctuating all week and we asked to have her sent to the hospital, but they said they could not send her, because they did not have an order to send her to the hospital. On [DATE] at 3:00 a.m., a review of the clinical record revealed that Resident #902 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set, dated dated [DATE], indicated Resident 902's cognition was intact and required extensive to total assistance from staff to complete all activities of living. A review of the physician orders, dated [DATE], revealed Resident #902 was to have her blood sugars checked before meals and at bedtime and to receive fast-acting insulin coverage (Humalog) based on the results (sliding scale). A review of the sliding scale on the Medication Record (MR), dated [DATE], documented that Resident #902 was to get the following units of insulin if the her blood sugar was as followed: ,[DATE] = 0 units, ,[DATE] = 2 units, ,[DATE] = 4 units, ,[DATE] = 6 units, ,[DATE] = 8 units, > (greater than) 401 = 10 units. However, there was no documentation insulin coverage was administered on [DATE] at 9:00 p.m. when Resident #902 had a blood sugar of 221. Further review of the clinical record revealed that Resident #902's blood sugar began unstable on [DATE]. The nursing notes documented the following: [DATE] at 5:00 p.m.: Resident alert and responsive able to make needs known. Blood Sugar (BS) down to 59 after lunch. Resident given [MEDICATION NAME] injection. Resident BS up 140. Resident BS 401 at 5:00 p.m., 10 units of Humalog given. Resident BS down 39. [MEDICATION NAME] injection given with insta-glucose. Resident BS up to 159. Resident alert and responsive able to make needs known. Denies any signs or symptoms of Hyper/[DIAGNOSES REDACTED]. Call light in reach . Nurse A However the nursing notes failed to document the signs or symptoms that caused the blood sugar to be checked outside of the physician's orders [REDACTED]. The notes failed to document physician and Director of Nursing notification. Additionally there was no documentation that Resident #902's blood sugars were monitored after the 9:00 p.m. check, blood sugar results of 221, which required 2 units, and was not given. There was no documentation for the rest of the night until Resident #902 was found unresponsive. On [DATE] at 3:13 p.m., review of the nurse's note dated [DATE] Resident found unresponsive during round at 1:20 a.m., CPR was initiated and ambulance called. Patient was last seen alive at 12 midnight sleeping in bed able to see chest rise and fall. After 30 minutes of CPR resident pronounced dead at 1:56 a.m . Nurse B. Physician's Recapitulation of Resident's Stay dated [DATE], Final Diagnosis: [REDACTED]. On [DATE] at 12:11 p.m., during an interview, Nurse A was about the events that she documented in Resident #902's medical chart on [DATE]. Nurse A said, I went on break and when I came back from break I was told by Nurse B what happened to Resident #902. Nurse A continued, I didn't give the insulin, Nurse B was taking care of here. Nurse A was asked if the physician had been notified of the change in condition with Resident #902. Nurse A said, the physician was called the first time and left a voice message. Nurse A said that her shift end around 7:00 p.m., and that she could not recall any additional information. On [DATE] at 12:57 p.m., 1:44 p.m., and 2:39 p.m., attempts were made to reach Nurse B, no message was able to be left due to voice mail being full. On [DATE] at 1:03 p.m. during an interview, the Director of Nursing (DON) was asked for documentation for monitoring of Resident #902 on [DATE]. The DON was unable to provide additional information. The DON said, It would either be on a nurse's note or on a nurse's assessment. No other assessments or documentation was found On [DATE] at 5:38 p.m., facility policy provided Nursing Care of the Adult Diabetic Mellitus Resident Purpose: The purpose of this guideline is: . 2. Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. 2. Recognize, assist and document the treatment of [REDACTED]. Documentation should reflect the carefully assessed diabetic resident and include the following: 1. Vital signs as ordered; 2. Level of consciousness; . 4. Accurate intake and output; 5. Percentage of meals consumed .

Based on observation, interview, and record review the facility failed to assess and implement treatment for [REDACTED].#511) of two residents reviewed for facility acquired pressure ulcers from a total of 24 sampled residents reviewed, resulting in the development of an unstageable plantar foot pressure ulcer and the potential for a delay in healing. Findings include: On 5/21/17 at 9:15 am, Resident #511 was observed in bed, on his back with the head of the bed up at a 30-40 degree angle. Bandages to Resident #511's right elbow and left foot were observed to be intact, slightly discolored with a grayish-colored substance around the edges, and dated 5/19/17 (day shift) 7 am-7pm. On 5/22/17 at 9:00 am, wound care was observed for Resident #511. Treatment Nurse U was observed to remove the bandage that was dated 5/20/17 from Resident #511's left foot and revealed an area that measured approximately 4.0 cm (centimeters) x 2.5 cm of eschar in the center of the wound bed. Treatment Nurse U explained that the dressing was noted to contain a moderate amount of serosanguinous drainage from the facility acquired unstageable pressure ulcer. At this time it was explained to Treatment Nurse U that on 5/21/17 the bandages to Resident #511 were dated 5/19/17. The Treatment Nurse explained that 5/19/17 was a Friday and I did the treatments that day. When asked why would the bandages that she applied on Friday would still be on Resident #511's left foot on Sunday morning, Treatment Nurse U acknowledged that the treatment was not performed as ordered and said that the bandages should be changed daily, That is what is ordered. An unstageable pressure ulcer is defined as the full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined (NPUAP, 2007). On 5/23/17 at 11:45 am, clinical record review revealed the following: Resident #511 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE], noted Resident #511 was in a comatose state and required one to two person total physical assistance with all activities of daily living which includes transfers and bed mobility. In addition, Resident #511 was at risk for the development of pressure ulcers but had no unstageable pressure ulcers at the time of assessment. However, the comprehensive MDS dated [DATE], indicated that Resident #511 had developed an unstageable pressure ulcer with eschar (dead tissue) while a resident at the facility. The Treatment Administration Record (TAR) for the Month of March 2017 documented, Cleanse Left Foot with wound cleanser and pat dry and apply Hydrogel impregnated over with abdominal dressing every day and as necessary to Resident #511's left foot wound. According to the TAR Resident #511 received this treatment on 3/9/17 and on 3/10/17. The treatment was documented as given and then the order was discontinued. However, review of the physician orders revealed there was no physician order to cleanse left foot with wound cleanser and pat dry and apply hydrogel impregnated over with abdominal dressing every day. There was no order that addressed Resident #511's left foot wound until 3/22/17. In addition, there was no order to discontinue the aforementioned treatment. Furthermore, there was no physician note nor were there any wound care notes that coincided with the treatment noted in the TAR. There was no description of the wound and no documented evidence of when the wound was discovered and that appropriate interventions were put into place at its discovery, to prevent further tissue damage and to promote healing. Further review there was no further treatment for [REDACTED]. The TAR documented, Clean left plantar foot with wound cleanser, pat dry, apply dry dressing every two days and as necessary. Review of the nurses notes/wound care notes revealed that on 3/15/17 there was no note regarding Resident #511's left foot wound. However, a subsequent nursing note dated 3/23/17 indicated that Resident #511's left plantar foot wound measured 8.5 cm (centimeters) x 4.8 cm (approximately 3 and a half inches long and 2 inches wide). Review of the treatment nurse notes dated 3/2/17, 3/8/17, and 3/15/17 indicated that Resident #511 was seen by the Wound Care Team. However, none of the notes documented that the Wound Care Team observed Resident #511's left foot and that no treatment was ordered to address Resident #511's left foot wound. A nurses note dated 3/23/17 documented that Resident #511 was seen by the Wound Care Team and the following was noted, Left plantar foot is an eschar and has received a status of not heeled. Measurements 8.5 cm x 4.8 cm. No drainage noted. Wound bed dry discolored base. A Wound Care Team note dated 3/22/17 noted that Resident #511 had a left plantar foot wound with eschar. However, a Wound Care Team noted dated 3/15/17 did not note a wound to Resident #511's left foot. A Braden Scale dated 2/20/17 revealed that Resident #511 was at a high risk for the development of pressure ulcers. There was no evidence that a Braden Scale assessment was performed at the onset of the Resident #511's facility acquired left foot pressure ulcer. Review of the Bath Sheets and Weekly Skin to Toe Assessments for the month of March 2017 indicated that there were no new skin issues for Resident #511. However, this contradicted the order that the previous Treatment Nurse CC transcribed and documented as given on 3/9/17 and on 3/10/17. On 5/23/17 at 3:30 pm, the Director of Nursing (DON) was queried regarding the absence of care to Resident #511's left foot and explained that she would have to look into the matter with the newly hired Treatment Nurse U. On 5/23/17 at 4:00 pm, the DON and Treatment Nurse U returned and were queried regarding the assessment and treatment of [REDACTED].#511's left foot. The DON explained that this was the main reason she had to fire the previous Treatment Nurse CC because She was not assessing the residents, She was not documenting correctly, and She was not doing the treatments. Treatment Nurse U added that she was not sure what previous Treatment Nurse CC had in place to treat the wound and stated, That is why when I saw the wound I covered it with the dry dressing. It was eschar. The Treatment Nurse held up her right pointer finger and thumb and used them to indicate approximately four to five inches in length and described the wound as an acquired unstageable pressure ulcer. When queried the DON and Treatment Nurse U were unable to explain or provide documented evidence of how or when the acquired unstageable pressure ulcer to Resident #511's left foot originated. On 5/23/17 at 5:00 pm, the facility policy titled, Skin Policy dated January 2017, was reviewed. The policy documented the following: A Braden Risk Assessment Scale will be performed upon the development of a pressure ulcer. Based on the total score for the resident a risk level is determined by the Braden Risk Assessment Scale. A Skin Assessment will be completed weekly utilizing the BATH and SKIN Report and the Nursing Weekly (Head to Toe) Skin Assessment. Pressure ulcers, as well as other significant wounds such as stasis ulcers, wounds etc, are to be inspected, measured and documented in the treatment record. Record measurements on the treatment record. Describe wound odor, color, etc. Weekly thereafter, pressure ulcers and wound are to be measured and documented in treatment record. The facility is expected to properly perform processes of assessment, problem identification, cause identification, management, monitoring, identification of complications, etc.

This citation has two deficient practice statements. Deficient Practice #1. This citation pertains to MI 353. Based on observation, interview, and record review the facility failed to appropriately assess; accurately obtain body temperature; and report an incident of suspected aspiration for one (#809) of two residents reviewed for significant change in status from a total sample of nine, resulting in hospitalization for diagnosed pneumonia and aspiration. Findings include: On 1/23/17 at 3:10 p.m., upon rounding Resident #809 was observed in his bed coughing. There was one identified Certified Nurse Assistant observed at the end of the hall assisting another resident. At 3:15 p.m., Resident #809 was observed again in his room, incessantly coughing. Upon entering Resident #809's room and closer observation, there was approximately 20 milliliters (ml) of a light brown colored, milk-like substance that had collected in the bottom of the oxygen mask that covered Resident #809's [MEDICAL CONDITION], with a one inch long and approximately two inch wide area on a white hand towel that had absorbed the light brown colored, milk-like substance, and the substance was visible on the outside of the [MEDICAL CONDITION]. With each expiration during the incessant coughing, the air (breath) which came out was observed to be malodorous. Resident #809 had a bottle of tube feeding ([MEDICATION NAME], a light brown colored milky substance, infusing at 80 mls per hour into Resident #809's gastrostomy (peg tube). At this time the surveyor exited the room and approached the nursing station with approximately 5 nursing staff present and summoned the nurse for Resident #809. Nurse 'A' and 'B' then entered the room where Resident #809 continued coughing. Nurse 'A' was asked about the substance around Resident #809's [MEDICAL CONDITION], that collected in the [MEDICAL CONDITION] and on the white hand towel that covered Resident #809's chest and area just below [MEDICAL CONDITION] stated, It is tube feeding. A [MEDICAL CONDITION] is surgically created opening in the resident's trachea which facilitates breathing. The artificial airway is an opening that allows direct access into the lungs. At that time Nurse 'A' turned off the tube feeding that was infusing into Resident #809's gastrostomy (PEG tube.) A gastrostomy is tube that is surgically inserted into the resident's stomach through the abdomen to provide nutrition. When asked if he checked Resident #809's stomach contents to ensure that the stomach was not full of tube feeding before starting the new bottle of [MEDICATION NAME], Nurse A', who started the tube feeding approximately 25 minutes earlier than ordered, explained that he checked for the stomach contents and It was zero. When asked if he knew why or how Resident #809 could have thrown up the tube feeding if he no stomach contents when he started the tube feeding, Nurse 'A' was unable to explain. Further query of Nurse 'A' revealed that tube feeding should not come out of the [MEDICAL CONDITION]. Nurse 'A' was asked if he smelled anything during Resident #809's exhalation and stated, I do not smell anything. On 1/23/17 at 4:00 p.m., the Director of Nursing (DON) and the Administrator were queried regarding the observations made at 3:15 p.m. along with Nurse 'A.' When asked if Nurse 'A' informed her that tube feeding was observed to come out of Resident #809's airway the DON stated that she was unaware of the incident and that she was only aware that Resident #809 had an emesis. At this time the DON, the Administrator, and the Nurse Consultant entered the room. Resident #809 was observed to be in the same position. The whites of Resident #809's eyes were reddened and his cheeks were also red in color. Nurse 'A' proceeded to take Resident #809's temperature by inserted the probe underneath his tongue and stated that the Resident's temperature was 98.9 while Resident #809's mouth remained opened. When queried if that was the best way to attain Resident #809's temperature Nurse 'A' explained that he always takes his temperature by placing the thermometer underneath his tongue and then stated, His mouth is closed. However, Resident #809's mouth remained opened and the facility's Nurse Consultant directed Nurse 'A' to take the temperature underneath Resident #809's arm (axillary) to obtain a more accurate body temperature. After taking Resident #809's temperature it read 103.1 (the average normal temperature is 98.7 degrees. The pulse registered at 119 (normal pulse is 60 - 100 beats per minute). Nurse 'A' then proceeded to suction the Resident's [MEDICAL CONDITION]. [MEDICAL CONDITION] was positioned onto Resident #809's right side of his chest. In [MEDICAL CONDITION] there was a small amount of a light-brown colored, milky substance. There was observed a different white towel covering Resident #809's chest and on the towel was a light-brown colored watery substance mixed with clear-colored mucous which lay right below the opening of the [MEDICAL CONDITION]. Nurse 'A' opened up two suctioning kits on Resident #809's chest/abdomen, while donning the gloves he broke sterile technique and proceeded to make 4 separate passes into Resident #809's [MEDICAL CONDITION]. Two times the end of the suction tube was observed to touch the milky mucous mixture prior to inserting it into Resident #809's [MEDICAL CONDITION]. Nurse 'A' performed the procedure without using sterile technique (set up the field on top of the resident and introduced the tubing after touching the mixture), performed 4 passes without results, and without the use of normal saline which could cause irritation. When queried Nurse 'A' stated, We are still trying to call (Physician 'B') and then suggested that he called several times and is still awaiting for his return phone call. At that time the Nurse Consultant asked, Did you call (Physician 'C')? Nurse 'A' stated, I don't have his number. At 4:15 p.m., upon leaving the unit, Nurse 'A' asked nursing staff at the desk if Physician 'B' returned the phone call. The DON explained that Physician 'B' wanted to send Resident #809 out to the hospital to rule out pneumonia and Nurse 'A' asked, Aspiration Pneumonia? Aspiration Pneumonia is when you inhale food, drink, vomit, or saliva into your lungs and is more common when something interferes with your normal gag reflex (mayoclinic.org). At 4:30 p.m., during further interview with the DON and the Administrator, the DON explained that the brown-colored milky substance could have been indicative of an infection and that the she also noted the odor that came from Resident #809's [MEDICAL CONDITION] and stated, When he coughs you can smell what smells like infection. The DON and the Administrator were also informed of the concerns observed during suctioning where the Nurse Consultant stated, We did some in-servicing on suctioning trach's (tracheostomies) after what I observed yesterday. At this time the DON acknowledged that in-servicing regarding suctioning trach's had begun to ensure that all nursing staff were competent in performing the procedure. When asked about taking temperatures correctly to ensure proper assessment so that resident needs are met, the DON explained that Nurse 'A' should have taken Resident #809's temperature axillary because for him the axillary temperature was more accurate and could then have been reported to Physician 'B' for necessary follow-up and intervention. On 1/24/17 at 11:00 am, Physician 'B' was interviewed via telephone. Physician 'B' stated, (Resident #809) was admitted (to the acute care facility) because he absolutely developed pneumonia. Physician 'B' explained that he reviewed the preliminary reports and that Resident #809's pneumonia was perhaps secondary to aspiration. When asked if he received several phone calls related to Resident #809, Physician 'B' stated, I got one call with a consensus from the nurses that he needed to be sent out (to an acute care facility.) Physician 'B' was unable to recall what time he was notified and explained that he was not informed that Resident #809 was found with emesis around his [MEDICAL CONDITION]. On 1/24/17 at 11:15 am, clinical record review revealed that Resident #809 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per the Minimum Data assessment dated [DATE] Resident #809 was in a persistent vegetative state and required one to two person physical assistance with all activities of daily living. According to the Physician Order Sheet signed 1/10/17, Elevate head 30 degrees, check peg tube placement and patency every shift, check gastric residual every shift, check SPO2 (pulse oxygen) every shift. Review of the care titled, Potential for aspiration related to resident receives tube feeding, nothing by mouth dated 12/14/16 noted, Check proper tube placement by aspirating or auscultation, observe for signs and symptoms of aspiration-increased respiratory effort, mental status changes, congestion, cough, check residual every shift for feeding tolerance. Review of the nurses notes dated 1/14/17 through 1/23/17 and the following was noted: 1/14/17 at 4:00 p.m., temperature 97.8 1/15/17 at 6:00 p.m., temperature = 97.1 1/17/17 at 5:00 p.m., temperature = 98.9. 1/18/17 at 6:30 p.m., temperature = 97.9. 1/19/17 (Midnight shift, 7 p.m. - 7 am), temperature = 98.2. 1/20/17 no temperature taken, 1/21/17 at 7:00 p.m., temperature = 98.3 1/22/17 at 5:45 a.m., temperature = 97.9 1/23/17 at 6:00 a.m., temperature = 98.3 1/23/17 at 4:00 p.m., temperature = 99.3 Though Resident #809's temperature was taken and found to be within normal limits, there was no evidence of how the temperature was taken and the nurses notes did not provide an explanation of how Resident #809 suddenly developed a temperature of 103. In addition, it should be noted that trach care or suction as needed was documented as performed in the above referenced nurses notes (with some days missing), however there is no documentation that described the color or consistency (assessment) of the secretions that were suctioned. Moreover, Nurse 'A' nursing note did not indicate if Resident #809's gastrostomy (PEG tube) was checked for placement. The SBAR Communication Form dated 1/23/16 indicated the following: Resident #809 had a pulse of 117 (normal for resident was between 80-90), temperature was 103 degrees taken axillary, Resident #809 had abnormal lung sounds, labored breathing and a productive cough, Resident #809 had experienced vomiting. Review of the facility transfer form dated 1/23/17 did not indicate the time in which the form was completed but was not completed by staff until after 5:15 p.m. as the form indicated that that was the last time vitals were taken and then recorded. (Per Surveyor observation, Resident #809 was observed to be in some respiratory distress at 3:15 p.m.) On 1/24/17 at 10:30 am, during an interview, the DON reported that Nurse 'A' was expected to have performed an accurate assessment and report to the nurse manager, the DON, and the physician in order to implement appropriate interventions in a timely manner for Resident #809. On 1/24/17 at 11:30 am, review of the facility policy titled, [MEDICAL CONDITION] Suction (undated) documented, To facilitate the removal of secretions from a resident's [MEDICAL CONDITION] or stoma and maintain an infection free (airway). The policy did not indicate how to set up a sterile field. (Nurse 'A' set up the sterile equipment on top of the resident's chest/abdomen and suctioned Resident #809 within a contaminated field.) The policy indicated to instill normal saline (to loosen secretions and provide lubrication for the suction tube), Nurse 'A' did not perform this step. The policy did not indicate the maximum number of times to insert the suction catheter into the [MEDICAL CONDITION] within getting any results. Nurse 'A' did four passes, without lubricating the tip of the catheter with saline and without any return. The policy also noted, Document color, consistency and amount of secretions in nurse's notes. ( ) This citation has two deficient practice statements. Deficient Practice #2. This citation pertains to intake number MI 351. Based on interview and record review the facility failed to manage pain for one (#806) of one sampled residents reviewed for pain, out of a total sample of nine, resulting in uncontrolled pain. Findings include: On 01/24/17 at 9:20 p.m., clinical record review revealed that Resident #806 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed the following: Order dated, 9/13/16 . Assess pain q (every) shift. [MEDICATION NAME] (Tylenol #3) 1 tab PO (by mouth) q 6 hrs prn, for pain. Medication Administration Record [REDACTED]. The order for pain assessment every shift was not listed on the MAR. On 1/24/17 at 2:54 p.m., the Administrator was queried about the administration of pain medication, and pain assessment. During the interview the Administrator stated, that we should follow the policy. On 1/24/17 at 3:18 p.m., during a interview, the Director of Nursing stated, that the resident should have a pain assessment every shift if that is the order. On 1/24/16 at 3:20 p.m., Review of the facility's policy titled, dated April 2016, Specific Medication Administration noted, After administration, return to cart, replace medication container, and document administration in the MAR indicated [REDACTED]. ( )

This citation pertains to intake MI 221. Based on interview and record review the facility failed to notify the attending physician of abnormally low pulse rates; medication not given; and, the refusal for an appointment with a cardiac specialist for 1 (#501) of 3 sampled residents reviewed for notification from a total sample of three, resulting in the need for emergency hospitalization for a sudden cardiac event. Findings include: On [DATE] at 9:15 a.m., during a conversation with Resident #501's daughter she said that a nurse from the facility called her on [DATE] (around lunch time) and informed her that (Resident #501) was found unresponsive; was transported to the local hospital; and died . On [DATE] at 9:45 a.m., review of a document titled Incident and Accident Report dated [DATE] documented, 12:30 p.m., Alarm sounding. Resident observed on the floor on the side of the bed face down. Unresponsive. Unable to obtain Vital signs (pulse, blood pressure and respiration rate). Injury to right side of forehead . On [DATE] at 10:00 a.m., record review revealed that Resident #501 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The purpose is to maintain an adequate heart rate, because the heart's natural pacemaker is not fast enough.). The Annual Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident's cognition was severely impaired and she required extensive assistance for all activities of daily living. A Social Service Assessment dated [DATE] documented, Resident needs a legal guardian due to Dementia. Resident presents confusion at times. The monthly physician orders for November, [DATE] and [DATE] revealed a physician's order for [MEDICATION NAME] (medication used for vasodilating effects, which in turns increases heart rate) 25 milligrams (mg) one tablet by mouth every 8 hours along with 50 mg (Total dose=75 mg). 6 AM, 2 PM and 10 PM. On [DATE] at 10:50 a.m., Certified Nurse Assistant (CNA) E was interviewed and indicated that she was the CNA assigned to (Resident #501) on [DATE]. CNA E said that around 12:30 p.m., she delivered a lunch tray and placed it on the over bed table located in front of (Resident #501) who was sitting up in the wheelchair. The CNA was asked if she remembers anyone else in the room at that time when the lunch tray was being delivered and stated, Yes. The resident in Bed One's son (Visitor D) comes and feeds her lunch every day, and he was here. I had just served her (Resident #501) her lunch tray and walked back out into the hallway when a few minutes later (Visitor D) ran out into the hallway and said that (Resident #501) needed some help. Me and (Staff Nurse J) came right away. When we entered the room we saw her (Resident #501) face down on the floor. During an interview with Visitor D at 11:15 a.m., he said he was in his mother's room (Roommate to Resident #501) feeding her lunch on [DATE]. He said he looked over and saw (Resident #501) shaking and then her head dropped down, hitting the over bed table on the right side. He stated It looked like she passed out and became unconscious. I got up right away and went to go get some help. The Nurse and CNA responded right away, but by the time we got back to the room I saw her on the floor. After that I stepped out of the room. On [DATE] at 11:25 a.m., during a phone interview, Staff Nurse J was asked about the events from [DATE]. Nurse J said that (Visitor D) came out of (Resident #501's) room and said that the resident needed some help. Nurse J said, I responded to the room and saw the resident laying face down on the floor. She (Resident #501) was unconscious. I called for additional assistance at this point, and right away a bunch nurses responded. Together we turned her over and placed her into bed that is when I saw a big knot on the right side of her forehead. She had no pulse or blood pressure so we started CPR (Cardiopulmonary Resuscitation). On [DATE] at 11:30 a.m., Attending Physician G was asked about the incident that occurred with Resident #501. Physician G indicated that he was aware of the event. Physician G stated, I have spoken to the emergency room Physician and I was told the resident had a 'sudden cardiac event'. The resident was cardiac stable prior to the event. Review of Resident #501's Pulse Rates (P) and Medication Administration Records (MAR) for the months of November and [DATE] and [DATE] revealed the following: [DATE]: ,[DATE]-P=58 (Average heart rate when sitting or resting during the day is about ,[DATE] beats per minute (bpm)). ,[DATE]-P=57 [DATE] MAR-[MEDICATION NAME] 75 mg three times a day was circled indicating medication was not given on both days ([DATE] and [DATE]-6 missed doses) with no documented evidence of why medication was not given or that attending physician was notified. [DATE]: ,[DATE]-P=52 ,[DATE]-P=50 ,[DATE]-P=51 ,[DATE]-P=57 ,[DATE]-P=50 ,[DATE]-P=46 ,[DATE]-P=52 ,[DATE]-P=48 ,[DATE]-P=36 ,[DATE]-P=49 ,[DATE]-P=51 ,[DATE]-P=36 ,[DATE]-P=50 ,[DATE]-P=49 ,[DATE]-P=42 ,[DATE]-P=41 ,[DATE]-P=52 ,[DATE]-P=34 ,[DATE]-P=55 ,[DATE]-P=54 ,[DATE]-P=55 [DATE] MAR-[MEDICATION NAME] 75 mg three times a day was circled indicating medication was not given on 26 days, 48 missed doses, with no documented evidence of why medication was not given or that attending physician was notified. [DATE]: ,[DATE]-P=58 ,[DATE]-P=50 ,[DATE]-P=54 ,[DATE]-P=54 ,[DATE]-P=50 ,[DATE]-P=56 ,[DATE]-P=56 ,[DATE]-P=56 ,[DATE]-P=45 January MAR-[MEDICATION NAME] 75 mg three times a day was circled indicating medication was not given on 8 days, 13 missed doses, with no documented evidence of why medication was not given or that attending physician was notified. There was no physician's order noted in the clinical record to hold the [MEDICATION NAME] if the pulse rate was below 60 bpm. A Nurse's progress note dated [DATE] documented, Nurse Practitioner notified of decreased pulse .Note new order for Cardiology Consult Indicated for Asymptomatic [MEDICAL CONDITION]. On [DATE] at 1:40 p.m. Ward Clerk (WC) H said during an interview that she was responsible for arranging appointments for Resident #501. WC H revealed a document titled Patient Appointment dated [DATE]. The document had Resident #501's name on with an appointment date of [DATE] at (Clinic location) with Patient Refused written on it. WC H was asked if Resident #501 was taken to the Cardiology appointment on [DATE] to which she replied, No. The patient refused. WC H could not remember if she reported this refusal to the assigned nurse that day. There was no documented evidence in the clinical record that the assigned Nurse, Nurse Practitioner or Attending Physician was made aware of the resident refusing the Cardiology appointment. On [DATE] at 5:19 p.m., along with the Director of Nursing (DON), a phone interview was conducted with Attending Physician G. Physician G' was asked if he was aware of Resident #501's low pulse rates and the [MEDICATION NAME] not being administered for approximately 5 weeks and stated, No. I was not aware. I would have wanted to been made aware anytime the pulse rate was below 60 bpm. I would have wanted her to have the [MEDICATION NAME] that medication was ordered for increasing the blood flow, pushing her heart rate up. On [DATE]/at 5:25 p.m., the DON stated The nurses should have notified the physician for his guidance with the low pulse rates and the medication administration. They should have documented on the back of the MAR indicated [REDACTED]. The DON was asked what the facility's policy was when a resident refuses a consultation appointment and stated, The nurse is to be notified. She then notifies the physician (or in this case the Nurse Practitioner) and the appointment is to be rescheduled. On [DATE] at 5:30 p.m., review of the facility's policy Physician Notification-Clinical Protocol dated [DATE] documented, The physician will help identify when a resident is receiving medications, or medication combinations associated with adverse drug reactions, that could lead to significant changes in condition .The nursing staff will contact the Physician based on the urgency of the situation .The Attending Physician will respond in a timely manner to notification of problem or changes in condition or status .The staff will notify the Medical Director for additional guidance and consultation if a timely response is not received. ( )

Based on observation, interview and record review, the facility failed to assess and implement interventions to manage chronic pain for one (#702) of eight sampled residents reviewed for pain from a total sample of 24, resulting in ongoing, unrelieved and debilitating pain. Findings include. On 3/18/14 at 9:15 am, Resident #702 was observed in bed, lying on her back. Resident #702 was grimacing. When interviewed, Resident #702 whispered, "My butt hurts. I have a sore on my butt. It is hurting." On 3/18/14 at 2:00 pm and at 3:15 pm, Resident #702 reported that she had received pain medication, but it only helped "a little." On 3/19/14 at 9:15 am, Resident #702's wound care was observed, provided by Wound Care Nurse 'D', Nurse 'O' and Wound Care Nurse 'P'. Resident #702 was observed to take hold of the grab bar and assist staff to reposition herself onto the right side. Three wounds were observed to be cleansed and dressed. With the first and second wound, Resident #702 verbalized discomfort by moaning when the soiled dressings were removed from the wounds and when the wounds were cleansed. When the third wound, that measured 2.0 cm (centimeters) x 2.0 cm x 3.5 cm with exposing bone was cleansed, Resident #702 yelled loudly, moaned, and contracted her buttocks. Resident #702 held on tightly to the grab bar and pulled herself toward the grab bar to move away from the hands of the treatment nurses. Resident #702 loudly moaned and yelled, "No. No. No. Hurry up!" Resident #702 then said that she wished for the nurses to complete the treatment. After Resident #702 was repositioned onto her back, tears were observed to well-up in her eyes and she began to frown. When queried, Resident #702 stated, "It (butt) hurts." On 3/19/14 at 9:40 am, Wound Care Nurse 'D' was queried regarding the pain experienced by Resident #702 during the treatment. Wound Care Nurse 'D' explained that Resident #702 had received a prn (as necessary) medication ([MEDICATION NAME]) for pain and a [MEDICATION NAME] (a narcotic [MEDICATION NAME]) approximately one hour prior to the start of wound care. Wound Care Nurse 'D' went on to say that Resident #702 received wound care daily and reported that Resident #702 would sometimes refuse to be repositioned or get up out of bed because of her pain. On 3/19/14 at 11:45 am, when queried about pain, Resident #702 explained that she used to get scheduled, regular pain medication because, "I have MS ([MEDICAL CONDITION])." Resident #702 expressed that she used to get up, sit in her wheelchair and get out of the room. Resident #702 reported that she has refused to be weighed (using a Hoyer sling) because "It hurts too much." When asked about repositioning, Resident #702 explained that sometimes repositioning helped with the pain on her buttocks, but that she had refused repositioning because "sometimes that (repositioning) hurts too much too." During this interview, Resident #702 grimaced and appeared tearful at times. On 3/19/14 at 10:30 am, Resident #702's clinical record was reviewed. According to the face sheet Resident #702 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS), dated [DATE] documented that Resident #702 had intact cognition. The admission "Nursing Comprehensive Evaluation" dated 2/20/14, documented that Resident #702 experienced pain upon admission that she rated at a "10" for the "worst pain gets" and an "8" for the best relief attained. According to the pain scale, a score of "8" and "10" indicated severe pain. Resident #702's goal for pain management was a "3." The initial care plan noted, "Make resident comfortable in environment. Monitor patient. Treat signs and symptoms of pain." There was a physician's orders [REDACTED].#702 would have to verbally ask staff for the medication). There was a physician's orders [REDACTED]. "Medication Administration Records" and "Narcotic Sheets" for the months of February and March 2014, documented that Resident #702 consistently requested pain medication one to three times each day. The Pain Assessment Interview with the reference date of 3/6/14 documented that Resident #702 experienced pain "almost constantly," with the pain intensity rated by Resident #702 at a "10," on a scale from 1 to 10, with '1' being minimal pain and '10' being most severe. There was a physician's orders [REDACTED]. On 3/19/14 at 9:40 am, when Wound Care Nurse 'D' was asked about efforts to address Resident 702's pain, she was not able to explain why, up until 3/18/14, Resident #702's pain had been treated only with an "as needed" medication when Resident #702 experienced severe pain on a daily basis. There was an "Activities Evaluation" dated 2/20/14, indicating that Resident #702's activity preference was to sit on the porch. An activity note, dated 2/22/14 documented, "(Resident #702) requires time in bed for relief off of pressure ulcers." There was a care plan with the most recent review date of 3/6/14 that had the goal, "Resident (#702) will confirm comfort and experience a sense of comfort, well being and increase mobility." The care plan also documented, "Monitor for signs and symptoms of discomfort (i.e., crying, grimacing, guarding...) and document, assess pain characteristics (i.e., location, duration, intensity, precipitating factors...) and document. Notify MD (Medical Doctor) if in need of an [MEDICATION NAME]." The Care Plan Conference Summary, dated 3/13/14, noted that on 3/6/14, a care conference took place at Resident #702's bedside. The "Summary Of Care Plan Conference Discussion" documented, "Resident (#702) had no concerns, only with her pain to her buttocks." On 3/19/14 at 11:00 am, Nurse 'R' was queried regarding the "Summary Of Care Plan Conference Discussion" that indicated that Resident #702's only concern was the pain to her buttocks. Nurse 'R' stated that she informed an unnamed nurse on the unit where Resident #702 lived about Resident #702's complaints of pain. Nurse 'R' stated that she did not document any pain concerns expressed by Resident #702 in the nurses' notes and that she did not take any additional actions to address Resident #702's complaints of pain. Review of the Physician Log Books from 10/3/13 through 3/11/14 revealed no entries related to Resident #702's concerns with pain. Review of the Nurses' Notes from 3/1/14 through 3/17/14 revealed no evidence that nursing staff addressed Resident #702's complaints of pain. On 3/21/14 at 11:00 am, the Director of Nursing (DON) was queried about Resident #702's complaints of pain. The DON explained that Resident #702 was less active since her most recent readmission and reported that, "If you ask (Resident #702) about pain (while laying still) she would always say no (deny pain)." When asked if Resident #702 was assessed for pain when being repositioned, being weighed (using a lift) or during dressing changes to deep wounds, the DON stated "No." The DON added that Resident #702 should have been assessed during movement or repositioning to get an understanding of the factors that caused her pain in order to provide appropriate pain interventions. The DON agreed that pain was the "sixth vital sign" and should be addressed as it is experienced by residents. However, the DON was unable to explain why Resident #702 was not provided with interventions to control her pain upon readmission when Resident #702 complained of pain levels at "10." The DON was unable to explain why Resident #702's complaints of pain were not addressed during or immediately following the Care Conference (3/6/13) when there were complaints of continued pain to the buttocks. The DON was unable to provide an explanation of why Resident #702's description of constant and unrelieved pain at a "10" was not addressed. On 3/20/14 at 2:00 pm, review of the facility's policy titled "Pain Management" (undated), documented that it is the facility's policy to "Provide treatment for [REDACTED]. Procedure: When assessing pain, be sure to provide ROM (Range of Motion) to resident and check all areas of resident's body, to identify other sources of pain. Determine and document the following: location, intensity of pain onset, duration and precipitating factors for pain. Determine and document the following: effects of pain on daily life and resident's goal for pain management...Please note, that all residents; receiving wound care treatments may be potentially subject to pain, and thus may require pain medication prior to treatment." ( ) ( )

This citation pertains to intakes #MI 237 and MI 326 Based on observation, interview, and record review, the facility failed to ensure that one (#701) of three sampled residents, all reviewed for accidents from a total sample of three, was properly transferred according to the plan of care, resulting in the resident being dropped during transfer and sustaining bilateral leg fractures. Findings include: Clinical record review on 1/22/14 at 10:00 a.m. revealed that Resident #701 was originally admitted into the facility on [DATE], and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. According to the most recent significant change Minimum Data Set, dated dated [DATE], Resident #701 had moderately impaired cognition, and was totally dependent upon staff for bed mobility and transfers. Review of a falls care plan for Resident #701, dated 4/22/13, noted that Resident #701 was non-ambulatory, and required a "Hoyer" lift for transfers, with the assistance of 2 staff members. Review of the nurse's notes for Resident #701 revealed the following: 12/24/13 at 06:30, "Resident (#701) c/o (complained of) pain to BLE (bilateral lower extremities). Upon talking with Resident, she stated she fell on yesterday (12/23/13)...Tylenol given for the pain. Will continue to monitor." 12/24/13 at 2:00 p.m., "Resident in bed...Resident states she fell , then says she didn't. Resident later reports she is in pain in her leg...Resident right knee appears swollen. Stat x-rays ordered on both legs." Review of the mobile x-ray results for Resident #701, dated 12/24/13, noted: (1) Exam date: 12/24/13 Reason: Pain Exam: Stat pelvis, left hip, femur, knee, tibia, fibula, ankle and foot x-ray. Impression: Osteopenia and arthritis diffuse in nature, with minimally angulated acute complete distal left femoral shaft fracture. (2) Exam date: 12/24/13 Reason: Pain Exam: Right hip, femur, knee, tibia, fibula, ankle and foot. Impression: There is evidence of a spiral oblique vertical essentially undisplaced fracture in the distal portion of the shaft of the right femur. A physician's orders [REDACTED]." Review of an Incident Report for Resident #701, dated 12/31/13, noted: Date of Occurrence: 12/24/13 (Date reported to nurse) "CNA (certified nurse assistant) reported to nurse that resident (#701) was having pain to the RLE (right lower extremity). Nurse checked resident, pain with movement...Resident stated I fell on my feet." On 1/22/14 at 11:00 a.m., Resident #701 was observed sitting up in a geriatric chair in the dining room. Resident #701 was queried regarding the fractures that were discovered on 12/24/13. Resident #701 stated, "She (CNA) dropped me." On 1/22/14 at 11:15 a.m., the Director of Nursing (DON) was queried regarding the bilateral femur fractures for Resident #701. The DON stated that she was notified by Nurse "E" on the morning of 12/24/13, that Resident #701 was complaining of pain to her bilateral lower extremities. The DON stated that she assessed Resident #701, and found that her right knee was swollen but non-painful, and that her left shin was painful to the touch. The DON further stated that Resident #701 told her she had been dropped on her feet. The DON stated that mobile x-rays were done, and showed that Resident #701 had bilateral femur fractures. The DON confirmed that Resident #701 was totally dependent on staff for transfers and bed mobility, and required a Hoyer lift for transfers, with the assistance of 2 staff. The DON stated that an investigation was initiated to determine the cause of the Resident #701's fractures. The DON stated that she reviewed the security tape footage from 12/23/13, and found that CNA "A" had entered the room of Resident #701 in the morning, by herself, and without a Hoyer lift. The DON stated that CNA "A" was then seen leaving the room, with Resident #701 up in a wheelchair. The DON stated that the facility concluded that CNA "A" had not utilized a Hoyer lift nor a 2 person assist for transferring Resident #701, as her care guide had instructed. The DON stated that CNA "A" was terminated for not following the resident's care guide, and for not following the facility's policy and procedures for safe transfers. During an interview with the Administrator on 1/22/14 at 3:30 p.m., it was found that the facility had identified a deficient practice on 12/24/13, and had implemented the following plan of correction, with a completion date of 01/06/2014: Plan of Correction: (1) Interviews were conducted with the nurses for all three shifts, and the CNA's assigned for all three shifts within 72 hours prior to 12/24/13. Interviews revealed no injuries or change in behavior were observed while Resident (#701) was in their care. The DON conducted an interview of the resident (#701) and revealed non-use of the Hoyer lift. (2) All residents utilizing mechanical lifts have been reviewed to ensure that appropriate lift is being used according to the resident's condition. Residents utilizing mechanical lifts plan of care have been reviewed and updated as deemed necessary. The care guides used by the CNA's have been reviewed and updated as deemed necessary. (3) The policy for Mechanical Lifts during transfers with Hoyer and Standing Lifts was reviewed and deemed appropriate. Zero Tolerance Lifting Policy was reviewed and deemed appropriate. The policy for 2-person transfers was reviewed and deemed appropriate. Nursing staff was in-serviced on the proper use of Hoyer and standing lifts, and on the proper 2 person transfer technique. Competency evaluations with return demonstrations were conducted for CNA's and Licensed Nurses. Maintenance checks for all mechanical lifts were reviewed. (4) The Licensed nurse management will monitor by observations of CNA transfers with mechanical lifts randomly weekly for four weeks and monthly thereafter to ensure staff is using the mechanical lifts according to care guide or care plan. The staff development nurse will monitor during routine rounds by observations and retrain as necessary. The QA Committee will monitor Incident and Accident reports monthly for on-going compliance. On 1/22/14, the Facility was found to be in substantial compliance with the regulatory requirements of F323. ( )

THIS CITATION PERTAINS TO INTAKE # MI 292 AND CONTAINS MULTIPLE DEFICIENT PRACTICE STATEMENTS. BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO ACCURATELY IDENTIFY INDIVIDUAL RISK OF AVOIDABLE ELOPEMENT, AND TO IMPLEMENT INTERVENTIONS CONSISTENT WITH ASSESSED NEEDS TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY FOR 1 (#101) OF 8 SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT RISK, FROM A TOTAL SAMPLE OF 9, RESULTING IN IMMEDIATE JEOPARDY WHEN RESIDENT #101 LEFT THE SAFETY OF THE FACILITY WITHOUT AUTHORIZATION AND/OR NECESSARY SUPERVISION ON SEPTEMBER 20, 2012 AT 3:00 P.M. WITHOUT STAFF KNOWLEDGE AND WITH THE POTENTIAL FOR SERIOUS INJURY, HARM, IMPAIRMENT AND/OR DEATH. AS A RESULT OF THIS DEFICIENT PRACTICE, 8 ADDITIONAL RESIDENTS, WHO WERE AT RISK FOR ELOPEMENT, WERE PUT AT HIGH RISK FOR ELOPEMENT, WHICH COULD RESULT IN PHYSICAL INJURY, HARM AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #101: ACCORDING TO THE FACILITY RECORDS, RESIDENT #101 WAS A COGNITIVELY IMPAIRED, [AGE] year-OLD MALE, WHO HAD [DIAGNOSES REDACTED]. ACCORDING TO THE HOSPITAL DISCHARGE SUMMARY, DATED SEPTEMBER 15, 2012, RESIDENT #101 HAD FALLEN PRIOR TO HIS HOSPITAL ADMISSION AND SUSTAINED A TRAUMATIC BRAIN INJURY INVOLVING BOTH THE TEMPORAL THE OCCIPITAL LOBES OF HIS BRAIN. THE SUMMARY WENT ON TO SAY THAT RESIDENT #101 WAS NOT ALWAYS ORIENTED AND NEEDED ASSISTANCE WITH DECISION MAKING. THE HOSPITAL PHYSICIAN SAID RESIDENT #101 WAS "...AWAKE BUT APPEARS TO BE CONFUSED AND THIS HAS BEEN THE CASE SINCE HIS FALL ..." ACCORDING TO THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 9/21/2012, RESIDENT #101 WAS RARELY-TO-NEVER UNDERSTANDABLE, SO AN INTERVIEW FOR DETERMINING MENTAL STATUS (BIMS) WAS NOT COMPLETED. ACCORDING TO THE MDS, RESIDENT #101 HAD IMPAIRED COGNITION, IMPAIRED SHORT TERM MEMORY, IMPAIRED LONG TERM MEMORY AND DISORGANIZED AND/OR INCOHERENT THINKING. ACCORDING TO THE MDS, RESIDENT #101 ALSO REQUIRED 1-PERSON ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. ACCORDING TO THE SOCIAL SERVICE PROGRESS NOTES, DATED 9/18/2012, RESIDENT #101 DISPLAYED "...PERSISTENT RESTLESSNESS, ANXIETY AND AGITATION. PRESENTS WITH IMPULSIVITY AND POOR SAFETY AWARENESS..." AND INDICATED THAT A FULL PSYCHIATRIC EVALUATION WAS NEEDED. ACCORDING TO THE SOCIAL SERVICE PROGRESS NOTES, RESIDENT #101 WAS CONFUSED AND HAD LIMITED-TO-POOR RECEPTIVE LANGUAGE, AND INSIGHT. RESIDENT #101 WAS "...LIKELY TO MISS SOME PART OF OR INTENT OF (THE) INTENDED MESSAGE..." ACCORDING TO THE REHABILITATION SCREENING, DATED 9/16/2012, RESIDENT #101 HAD IMPAIRED ORIENTATION, MEMORY AND SAFETY AWARENESS. ACCORDING TO RESIDENT #101'S ADVANCE DIRECTIVE, DATED 9/18/2012, RESIDENT #101 WAS UNABLE TO SPECIFY HIS NEEDS BECAUSE OF "...COGNITIVE DEFICITS..." DESPITE THESE CONSISTENT DOCUMENTED ASSESSMENTS OF RESIDENT #101'S COGNITIVE DEFICITS, THE FACILITY'S PHYSICIAN CHECKED A BOX ON THE HISTORY AND PHYSICAL THAT RESIDENT #101 MAINTAINED THE ABILITY TO MAKE DECISIONS FOR HIMSELF. HOWEVER, DESPITE THE FACILITY PHYSICIAN'S NOTE ON THE HISTORY AND PHYSICAL, RESIDENT #101'S ADMISSION SUMMARY SAID HIS DAUGHTER WAS RESPONSIBLE FOR RESIDENT #101'S DECISION MAKING. ACCORDING TO THE CARE PLAN, DATED 9/18/2012, RESIDENT #101 WANDERED THROUGHOUT THE FACILITY, WAS COMBATIVE DURING CARE AND WOULD REMOVE THE SAFETY DEVICES (I.E., A WHEELCHAIR ALARM) PLANNED TO ENSURE HIS SAFETY. RESIDENT #101 WAS DESCRIBED AS IMPULSIVE, WITH POOR SAFETY AWARENESS, BALANCE DEFICITS AND COGNITIVE DEFICITS. CARE PLAN APPROACHES INCLUDED "...APPLY WANDER GUARD (A DEVICE THAT TRANSMITS A SIGNAL WHICH ACTIVATES AN ALARM WHEN THE SIGNAL IS RECEIVED, USUALLY AT A DOORWAY) FOR RISK SCORE OF 10 OR GREATER..." RESIDENT #101'S NURSING COMPREHENSIVE EVALUATION, DATED 9/15/2012, INCLUDED A RISK FOR ELOPEMENT SECTION (SECTION "J"). ACCORDING TO THE EVALUATION, RESIDENT #101 SCORED 2 POINTS FOR BEING AMBULATORY, 3 POINTS FOR BEING COGNITIVELY IMPAIRED, 2 POINTS FOR MEDICATIONS TAKEN, AND 2 POINTS FOR BEING A NEW ADMISSION TO THE FACILITY, FOR A TOTAL OF 9 POINTS. THE PREDISPOSING DISEASE SECTION OF THE RISK FOR ELOPEMENT EVALUATION (WORTH 2 POINTS IN THE ASSESSMENT) WHICH GAVE EXAMPLES OF DEMENTIA, OBS (ORGANIC BRAI[DIAGNOSES REDACTED]), DEPRESSION, MENTAL ILLNESS, AND EXPRESSIVE LANGUAGE DEFICITS WAS MARKED AS "NONE PRESENT" DESPITE RESIDENT #101'S HISTORY OF TRAUMATIC BRAIN INJURY AND HIS ASSOCIATED ISSUES WITH MEMORY, SPEECH PERCEPTION, LANGUAGE EXPRESSION AND ABILITY TO RECOGNIZE AND RESPOND TO THE ENVIRONMENT. BECAUSE THE PREDISPOSING DISEASE SECTION OF THE RISK FOR ELOPEMENT EVALUATION WAS MARKED AS "NONE PRESENT", RESIDENT #101 SCORED A 9 INSTEAD OF AN 11, AND NO WANDER GUARD TRANSMITTER WAS IMPLEMENTED. ACCORDING TO THE INCIDENT AND ACCIDENT INVESTIGATION, DATED 9/20/2012 AT APPROXIMATELY 3:15 P.M., AN X-RAY TECHNICIAN ENTERED THE FACILITY THROUGH AN ALARMED AND LOCKED SIDE DOOR OF THE FACILITY. THE X-RAY TECHNICIAN SAW RESIDENT #101 SITTING IN A WHEELCHAIR BY THE DOOR. RESIDENT #101 TOLD THE X-RAY TECHNICIAN THAT HE (#101) WAS GOING OUTSIDE. THE X-RAY TECHNICIAN HELD THE DOOR OPEN FOR RESIDENT #101, AND HE (#101) PROCEEDED OUT OF THE BUILDING WHILE STILL IN HIS WHEELCHAIR. ACCORDING TO THE INCIDENT AND ACCIDENT INVESTIGATION, AT APPROXIMATELY 3:15 P.M., RESIDENT #101 WAS OBSERVED OUTSIDE THE FACILITY'S DELIVERY DOOR, SEATED ON THE GROUND. FACILITY STAFF RESPONDED TO THE LOCATION AND ASSISTED RESIDENT #101 BACK INSIDE THE FACILITY. ACCORDING TO THE INCIDENT AND ACCIDENT INVESTIGATION, AT APPROXIMATELY 3:15 P.M., THE DIRECTOR OF NURSING AND ADMINISTRATOR OF THE FACILITY WERE NOTIFIED OF THE INCIDENT. IN AN INTERVIEW ON 10/3/2012 AT 2:27 P.M., THE ADMINISTRATOR (NHA #1) WAS ASKED IF ALL THE EVENTS REFERENCED IN THE INCIDENT AND ACCIDENT REPORT OCCURRED AT EXACTLY 3:15 P.M., NHA #1 SAID, "...WELL, ALL CLOCKS ARE SET A LITTLE DIFFERENT..." NHA #1 SAID THAT ON AN UNKNOWN DATE, SHE REVIEWED A RECORDING OF THE VIDEO RECORDING OF THE DOORWAY THAT RESIDENT #101 EXITED THROUGH. NHA SAID SHE COULD NOT SEE RESIDENT #101 IN THE VIDEO, BUT THE VIDEO REVIEWED "...WAS CONSISTENT WITH STATEMENTS..." AND SAID THE X-RAY TECHNICIAN ENTERED THE FACILITY AT "...AROUND 3:15. WELL, IT COULD HAVE BEEN A LITTLE EARLIER..." WHEN NHA #1 WAS ASKED TO PROVIDE EVIDENCE OF WHEN THE X-RAY TECHNICIAN ENTERED THE FACILITY, NONE WAS PROVIDED. THE SURVEYOR REQUESTED TO VIEW A RECORDING OF THE ENTRANCE USED FOR VERIFICATION OF THE TIME FRAME IN QUESTION. NHA #1 SAID THERE WAS NO LONGER A RECORDED VIDEO. NHA # 1 SAID THE VIDEO TAPE USED WAS ONLY SAVED FOR 10 DAYS AND HAD BEEN ERASED. DURING AN INTERVIEW ON 10/3/2012 AT 3:15 P.M., THE X-RAY TECHNICIAN (RT #1) SAID THAT ON 9/20/2012, HE ENTERED THE FACILITY THROUGH AN ALARMED AND LOCKED SIDE DOOR OF THE FACILITY. RT #1 SAID THAT AS HE ENTERED, HE ENCOUNTERED AN INDIVIDUAL SITTING IN A WHEELCHAIR BY THE DOOR. RT #1 SAID THE PERSON IN THE WHEELCHAIR TOLD HIM HE WAS GOING OUTSIDE AND, WITHOUT ASKING QUESTIONS, RT #1 HELD THE DOOR OPEN FOR THE RESIDENT AS HE PROCEEDED OUTSIDE. RT #1 SAID HE (RT #1) WAS "...JUST BEING POLITE...WE HAVE NO WAY OF KNOWING WHO IS A RESIDENT AND WHO IS NOT ... " RT #1 WAS ASKED TO PROVIDE THE EXACT TIME HE ENTERED THE FACILITY. WHEN RT #1"...CHECKED HIS LOGS," HE FOUND HIS DOCUMENTATION THAT INDICATED THAT HE ENTERED THE FACILITY AT 3:00 P.M. IN AN INTERVIEW THAT OCCURRED ON 10/3/12, AT 2:12 P.M., CERTIFIED NURSE ASSISTANT (CNA #1) SAID THAT ON 9/20/2012 SHE GOT OFF WORK AT AROUND 3:15 P.M. CNA #1 SAID THAT AFTER SHE CLOCKED OUT AND EXITED THE BUILDING, SHE GOT INTO A CAR AND STARTED TO LEAVE THE FACILITY GROUNDS. CNA #1 SAID SHE LOOKED TO THE SIDE AND SAW RESIDENT #101 SITTING ON THE LAST BLOCK OF CONCRETE NEXT TO THE STREET. CNA #1 SAID SHE TOLD THE DRIVER TO STOP, AND WENT INTO THE BUILDING TO GET HELP. CNA #1 SAID THAT SHE TOLD THE CNA AND NURSE ON DUTY THAT RESIDENT #101 WAS UNSUPERVISED AND SITTING OUTSIDE, THE THREE OF THEM WENT TO RESIDENT #101, ASSISTED HIM INTO HIS WHEELCHAIR, WHICH HAD BEEN LEFT BETWEEN THE TWO SETS OF DOORS AND BROUGHT HIM BACK INSIDE THE FACILITY. ACCORDING TO THE INCIDENT AND ACCIDENT INVESTIGATION, DATED 9/20/2012, AT APPROXIMATELY 3:25 P.M., RESIDENT #101 WAS BROUGHT BACK INTO THE FACILITY. RESIDENT #101 ' S PHYSICIAN WAS NOTIFIED AND RESIDENT #101 WAS ASSESSED FOR INJURIES. ACCORDING TO THE INCIDENT AND ACCIDENT INVESTIGATION, RESIDENT #101 WAS FOUND TO BE FREE FROM INJURIES. ACCORDING TO THE FALLS CARE PLAN, RESIDENT #101'S WHEELCHAIR WAS TO BE EQUIPPED WITH A CHAIR ALARM, WHICH IT WAS ON THE DAY OF THE ELOPEMENT. HOWEVER, WHEN STAFF WERE INTERVIEWED ABOUT THE INCIDENT, INCLUDING CNA #1, NO ONE COULD STATE WHETHER OR NOT THE ALARM WAS FUNCTIONAL AND SOUNDING AT THE TIME RESIDENT #101 GOT OUT OF THE WHEELCHAIR AND ELOPED FROM THE FACILITY. IT WAS NOT CLEAR IF RESIDENT #101 HAD REMOVED THE ALARM. ON 10/5/2012 AT 11:26 A.M., THE SURVEYOR OBSERVED THE LOCATION WHERE RESIDENT #101 WAS FOUND. HE HAD BEEN SITTING ON A PIECE OF CONCRETE, WITH A ROCK-LIKE APPEARANCE, THAT WAS OBSERVED TO BE ABOUT 7 FEET FROM THE STREET AT THE ENTRANCE TO THE DELIVERY DRIVEWAY OF THE FACILITY. ACCORDING TO THE FACILITY'S TIME CLOCK EXEMPTION REPORT, CNA #1'S ACTUAL CLOCK OUT TIME ON 9/20/2012 WAS 3:20 P.M. BASED ON THE DOCUMENTATION PROVIDED BY RT #1 AND CNA #1'S TIME CARD, RESIDENT #101 WAS ALONE, OUTSIDE THE SAFETY OF THE FACILITY WITHOUT AUTHORIZATION AND/OR ANY NECESSARY SUPERVISION FOR APPROXIMATELY TWENTY MINUTES. DURING AN INTERVIEW ON 10/3/2012 AT 1:25 P.M., THE DIRECTOR OF NURSING (DON #1) REVIEWED RESIDENT #101'S CLINICAL RECORD AND SAID RESIDENT #101 SHOULD HAVE BEEN CONSIDERED AT RISK FOR ELOPEMENT, DUE TO HIS BRAIN INJURIES. DON #1 SAID IF RESIDENT #101 HAD BEEN CORRECTLY ASSESSED, HE WOULD HAVE BEEN REQUIRED TO WEAR A WANDER GUARD BRACELET AND THIS WOULD HAVE HELPED ENSURE HIS SAFETY. DON #1 THEN REVIEWED AN ELOPEMENT ASSESSMENT FOR RESIDENT #101, DATED 9/24/12, AFTER HE WAS FOUND OUTSIDE THE FACILITY WITHOUT SUPERVISION. ACCORDING TO DON #1, ON THIS LATER ASSESSMENT, STAFF DOCUMENTED THAT RESIDENT #101 HAD NO HISTORY OF ELOPEMENT (WORTH 10 POINTS). DON #1 SAID THAT THERE WERE "...OBVIOUSLY..." PROBLEMS WITH ASSESSMENTS BEING ACCURATE. IN AN INTERVIEW ON 10/3/2012 AT 1:05 P.M. NHA #1 SAID, "...THERE ARE SOME PROBLEMS WITH THE WHOLE ELOPEMENT PROCESS ESPECIALLY ASSESSMENT..." NHA #1 SAID THE PROBLEM WAS BEING LOOKED AT BY THE QUALITY ASSURANCE COMMITTEE. NHA #1 SAID, "...WE'RE LOOKING AT THE PROCESS, AND WE'RE TALKING TO CORPORATE...BUT NO ACTIONS HAVE BEEN TAKEN..." ON 10/8/2012 AT 4:18 P.M. AN IMMEDIATE JEOPARDY SITUATION WAS IDENTIFIED AT F-323. THE ADMINISTRATOR WAS INFORMED ON 10/9/2012, AT 11:23 A.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 9/20/2012 AT 3:00 P.M., AS A RESULT OF THE FACILITY'S FAILURE TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF RESIDENT #101, WHICH PLACED 8 ADDITIONAL RESIDENTS AT HIGH RISK FOR ELOPEMENT AND THE RISK OF SERIOUS HARM, INJURY AND/OR DEATH. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT RESIDENT #101 NO LONGER RESIDED IN THE FACILITY. 2. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 10/3/2012 FACILITY NURSING STAFF REVIEWED RESIDENTS' ELOPEMENT ASSESSMENTS AND IDENTIFIED THAT THERE WERE 8 RESIDENTS LIVING IN THE FACILITY WHO WERE ELOPEMENT RISKS ACCORDING TO THE ELOPEMENT ASSESSMENTS. 3. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 10/3/2012, LICENSED NURSE MANAGERS REVIEWED THE CHARTS OF 8 OF 8 RESIDENTS IDENTIFIED AT RISK FOR ELOPEMENT. CARE PLANS AND ASSESSMENTS WERE REVIEWED AND UPDATED AS NEEDED. 4. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 10/3/2012, WANDER GUARD TRANSMITTER CHECKS WERE CONDUCTED BY THE MAINTENANCE SUPERVISOR. ALL RESIDENTS CARE-PLANNED TO HAVE WANDER GUARD TRANSMITTERS WERE VERIFIED TO HAVE TRANSMITTERS IN PLACE AND WORKING PROPERLY. 5. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 10/3/2012, 14 OF 14 DOORS WERE CHECKED WERE CHECKED BY THE MAINTENANCE SUPERVISOR AND DOOR SYSTEMS WERE VERIFIED TO BE FUNCTIONING PROPERLY. 6. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT AS OF OCTOBER 3, 2012, MAINTENANCE AND/OR SECURITY WILL CONDUCT THE DAILY CHECKS OF THE WANDER GUARD BRACELETS UTILIZING THE TRANSMITTER TEST LOG. 7. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT BEGINNING OCTOBER 9, 2012, MAINTENANCE BEGAN CHECKING DOORS FIVE TIMES PER WEEK UTILIZING THE DOOR ALARM CHECK LOG TO ENSURE WANDER GUARD BRACELETS AND DOORS WERE FUNCTIONING PROPERLY. 8. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 9/25/2012, RT # 1 WAS IN-SERVICED ON THE ELOPEMENT POLICY AND PROCEDURE. 9. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 9/25/2012, THE ADMINISTRATOR IDENTIFIED THE VENDORS THAT UTILIZED THE BACK DELIVERY DOOR, TO PROVIDE SERVICES OR TO DELIVER GOODS. 10. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 9/25/2012, THE EMPLOYEES OF THE FACILITY'S CONTRACTED RADIOLOGY SERVICE IN-SERVICED THEIR EMPLOYEES ON THE ELOPEMENT POLICY AND PROCEDURE AND TO NOT ASSIST RESIDENTS WITH DOORS UNLESS ACCOMPANIED BY A FACILITY EMPLOYEE. 11. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 9/25/2012, THE FACILITY ADMINISTRATOR SENT A LETTER VIA E-MAIL TO LABORATORY AND AMBULANCE CONTRACTED VENDORS WHO UTILIZED THE DELIVERY DOOR, PERTAINING TO SAFETY MEASURES REQUIRED WHEN THEIR STAFF IS IN THE FACILITY. 12. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 10/9/2012, THE FACILITY ADMINISTRATOR SENT A LETTER VIA E-MAIL TO THE DURABLE MEDICAL EQUIPMENT VENDORS WHO UTILIZED THE DELIVERY DOOR, PERTAINING TO SAFETY MEASURES REQUIRED WHEN THEIR STAFF IS IN THE FACILITY. 13. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT SIGNS WERE POSTED AT THE BACK DELIVERY DOORS. SIGNS WERE VISIBLE WHEN ENTERING AND EXITING THE BUILDING. THE SIGNS READ, "PLEASE DO NOT HOLD THIS DOOR OPEN! THIS DOOR IS NOT AN EXIT FOR RESIDENTS (UNLESS ACCOMPANIED BY A (FACILITY) EMPLOYEE)." 14. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 10/3/2012, THE FACILITY'S INTERDISCIPLINARY TEAM REVIEWED THE ELOPEMENT AND ELOPEMENT ASSESSMENT POLICY AND PROCEDURE, WHICH INCLUDES CHECKING ALARMED DOORS AND DEEMED IT TO BE APPROPRIATE 15. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT ON 10/3/2012, THE FACILITY'S INTERDISCIPLINARY TEAM REVIEWED THE ELOPEMENT RISK ASSESSMENT AND WANDER GUARD BRACELET CHECK POLICIES AND PROCEDURES AND DEEMED THEM TO BE APPROPRIATE. 16. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT BEGINNING 10/9/2012, FACILITY STAFF WERE RE-EDUCATED ON THE ELOPEMENT POLICY AND PROCEDURE. 17. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT AS OF 10/9/2012, 71 OF 203 EMPLOYEES HAVE BEEN INSERVICED. ACCORDING TO POSTED FACILITY SIGNAGE, STAFF WILL NOT BE ALLOWED TO WORK UNTIL REEDUCATED ON POLICY AND PROCEDURES. 18. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT BEGINNING 10/9/2012, LICENSED NURSES WERE RE-EDUCATED ON THE ELOPEMENT ASSESSMENT POLICY AND PROCEDURE WITH EMPHASIS ON ADMISSION AT RISK ELOPEMENT ASSESSMENT. 19. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT AS OF 10/9/2012, 15 OF 39 NURSES HAVE BEEN INSERVICED. ACCORDING TO POSTED FACILITY SIGNAGE, STAFF WILL NOT BE ALLOWED TO WORK UNTIL REEDUCATED ON POLICY AND PROCEDURES. 20. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT FACILITY EDUCATION PLANNING INCLUDED THAT STAFF ARE TO BE RE-INSERVICED ON THE ELOPEMENT POLICY AND PROCEDURE QUARTERLY FOR THE NEXT 6 MONTHS, THEN A MINIMUM OF ANNUALLY. 21. ON 10/10/2012, THE SURVEYOR CONFIRMED THAT 8 OF 8 RESIDENTS IDENTIFIED AT RISK FOR ELOPEMENT WERE WEARING WANDER GUARD TRANSMITTERS THAT WERE FUNCTIONING PROPERLY. 22. ON 10/10/2012 THE SURVEYOR CONFIRMED THAT 14 OF 14 DOORS AND DOOR SYSTEMS WERE FUNCTIONING PROPERLY. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 10/9/2012, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY BECAUSE NOT ALL STAFF HAD BEEN EDUCATED ON THE PERTINENT POLICIES AND BECAUSE THE FACILITY'S SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( ) BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT WANDER GUARD BRACELET/ANKLET TRANSMITTERS WERE APPLIED AS DIRECTED BY PLANS OF CARE TO 3 (RESIDENTS #102, #103, AND #104) OF 8 SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT RISK FROM A TOTAL SAMPLE OF 9 RESIDENTS, RESULTING IN THE POTENTIAL FOR ELOPEMENT. FINDINGS INCLUDE: ON 10/3/2012 AT 11:10 A.M. THE SURVEYOR OBTAINED A LIST OF 9 RESIDENTS IN THE FACILITY WHO WERE REQUIRED TO WEAR WANDER GUARD BRACELETS OR ANKLETS FOR UNSAFE WANDERING AND RISK FOR ELOPEMENT PURPOSES. RESIDENT #102: ACCORDING TO THE FACILITY RECORDS, RESIDENT #102 WAS A COGNITIVELY IMPAIRED [AGE] year-OLD FEMALE, WHO HAD [DIAGNOSES REDACTED]. RESIDENT #102 WAS ONE OF THE 9 RESIDENTS IN THE FACILITY WHO WERE REQUIRED TO WEAR WANDER GUARD BRACELETS OR ANKLETS. ON 10/3/2012 AT 11:18 A.M. RESIDENT #102 WAS OBSERVED IN THE DINING ROOM WITH NO WANDER GUARD BRACELET OR ANKLET IN PLACE. THE LICENSED PRACTICAL NURSE (LPN #2) WAS ASKED ABOUT RESIDENT #102'S WANDER GUARD TRANSMITTER. LPN #2 SAID, "...IT fell OFF. I THINK IT WAS YESTERDAY, MAYBE. THEY WERE GOING TO GET A NEW ONE..." LPN #2 WAS UNABLE TO EXPLAIN WHO "THEY" WERE, THAT WERE GETTING THE NEW TRANSMITTER FOR RESIDENT #101 OR WHY "THEY" HAD NOT PLACED A NEW WANDER GUARD TRANSMITTER ON RESIDENT #102'S EXTREMITY. ON 10/3/2012, THE MAINTENANCE DIRECTOR (EVS #1) SAID THAT FACILITY STAFF MUST COME TO HIM TO GET NEW TRANSMITTERS. EVS #1 SAID HE WAS NEVER TOLD RESIDENT #102 NEEDED A NEW TRANSMITTER. EVS #1 SAID THAT HE USUALLY KEEPS "...A FEW (TRANSMITTERS) ON HAND, BUT IF IT HAPPENS AFTER 4 IN THE AFTERNOON WE DON'T FIND OUT. (THERE) USED TO BE ONE AT THE FRONT DESK, BUT NOT ANYMORE. IT TRIGGERED THE FRONT DOOR ..." EVS #1 CLARIFIED THAT THERE WAS NO LONGER A SPARE TRANSMITTER AVAILABLE FOR USE WHEN THE MAINTENANCE DEPARTMENT WAS CLOSED (OFF HOURS). ACCORDING TO EVS #1, IF STAFF NEEDED A TRANSMITTER, THEY (STAFF) NEEDED TO COME TO HIM TO GET A NEW ONE. EVS #1 AGAIN SAID HE WAS NEVER TOLD RESIDENT #102 NEEDED A NEW TRANSMITTER. (# ) RESIDENT #103: ACCORDING TO THE FACILITY RECORDS, RESIDENT #103 WAS A COGNITIVELY IMPAIRED [AGE] year-OLD FEMALE, WHO HAD [DIAGNOSES REDACTED]. RESIDENT #102 WAS ONE OF THE 9 RESIDENTS IN THE FACILITY WHO WERE REQUIRED TO WEAR WANDER GUARD BRACELETS OR ANKLETS. ON 10/3/2012 AT 11:21 A.M., RESIDENT #103 WAS OBSERVED IN THE BED WEARING AN ANKLE BRACELET, BUT WITHOUT THE WANDER GUARD TRANSMITTER. ON 10/3/2012 AT 11:21 A.M. THE CLINICAL CARE COORDINATOR (CCC #1) SEARCHED RESIDENT #103 AND RESIDENT #103'S BED, BUT WAS UNABLE TO FIND THE TRANSMITTER. CCC #1 SAID THE ANKLE BAND WAS IN PLACE, BUT NO TRANSMITTER WAS FOUND. NEITHER EVS #1 NOR CCC #1 WERE ABLE TO EXPLAIN HOW LONG THE TRANSMITTER WAS NOT IN PLACE ON RESIDENT #103'S ANKLE. (# ) RESIDENT #104: ACCORDING TO THE FACILITY RECORDS RESIDENT #104 WAS A COGNITIVELY IMPAIRED [AGE] year-OLD MALE, WHO HAD [DIAGNOSES REDACTED]. RESIDENT #104 WAS ONE OF THE 9 RESIDENTS IN THE FACILITY WHO WERE REQUIRED TO WEAR WANDER GUARD BRACELETS OR ANKLETS. ON 10/3/2012 AT 11:26 A.M. RESIDENT #104 WAS OBSERVED IN THE DINING ROOM WITH NO WANDER GUARD BRACELET OR ANKLET IN PLACE. RESIDENT #104 SAID, "...I DON'T WEAR NOTHING..." CCC #1 WAS ASKED IF SHE KNEW HOW LONG THE TRANSMITTERS WERE MISSING FOR RESIDENT #102, RESIDENT #103 AND RESIDENT #104. ON 10/3/2012 AT 11:28 CCC #1 SAID, "...SECURITY KEEPS THESE LOGS, WE DON'T GET THEM; OR THE INFORMATION..." (# ) BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO FOLLOW THE MANUFACTURER'S RECOMMENDATIONS AND FACILITY POLICIES FOR ENSURING THAT RESIDENTS' SAFETY DEVICES WERE BEING WORN AND WERE FUNCTIONAL FOR 5 (RESIDENTS #102, #103, #104, #108 AND #109) OF 8 SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT RISK FROM A TOTAL SAMPLE OF 9, AND FOR 4 (RESIDENTS #27, #75, #128, AND #129) OFF-SAMPLE RESIDENTS, RESULTING IN THE POTENTIAL FOR ELOPEMENT FROM THE FACILITY. FINDINGS INCLUDE: ACCORDING TO THE MANUFACTURER'S WANDER GUARD TRANSMITTER PRODUCT SHEET PROVIDED BY THE FACILITY, THE MANUFACTURER "...REQUIRES FACILITIES TO TEST THE TRANSMITTER FOR PROPER OPERATION ON A DAILY BASIS..." ACCORDING TO THE MANUFACTURER'S PRODUCT SHEET, EACH DAY THE AIDE RESPONSIBLE FOR THE CARE OF THE RESIDENTS UTILIZING THE SYSTEM MUST ENSURE (THAT THE) TRANSMITTER IS IN PLACE AND THAT THIS "...MUST BE DONE AT EACH SHIFT CHANGE...EACH TRANSMITTER SHOULD BE tested DAILY TO ENSURE THE TRANSMITTER IS WORKING PROPERLY...A DOCUMENTED TEST OF EACH ANKLE OR WRIST TRANSMITTER AT THE FACILITY MUST BE MADE EACH DAY." ACCORDING TO THE FACILITY'S POLICY, DATED JULY 2012, AND REVIEWED SEPTEMBER 28, 2012, THE WANDER GUARD TRANSMITTER "...WILL BE CHECKED ON A WEEKLY BASIS TO ENSURE FUNCTIONAL ACCURACY..." ACCORDING TO THE FACILITY'S POLICY, DATED AUGUST 29, 2012, TRANSMITTERS "...WILL BE CHECKED DAILY BY THE SECURITY STAFF WITHIN THE FIRST HOUR OF THE SHIFT TO ASSURE THEY ARE FUNCTIONING PROPERLY..." ON 10/3/2012 AT 11:10 A.M. THE SURVEYOR OBTAINED A LIST OF 9 RESIDENTS IN THE FACILITY WHO WERE REQUIRED TO WEAR WANDER GUARD BRACELETS OR ANKLETS FOR UNSAFE WANDERING AND RISK FOR ELOPEMENT PURPOSES. THIS LIST INCLUDED RESIDENT #102, RESIDENT #103, RESIDENT #104, RESIDENT #108, RESIDENT #109, RESIDENT #27, RESIDENT #75, RESIDENT #128 AND RESIDENT #129. THE SURVEYOR REQUESTED TO REVIEW THE DOCUMENTED DAILY TESTING OF EACH ANKLE OR WRIST TRANSMITTER'S FUNCTIONING. NONE WAS PROVIDED. THE SURVEYOR ASKED TO REVIEW THE DOCUMENTATION BY THOSE RESPONSIBLE FOR THE CARE OF THE RESIDENTS WHO ENSURE THE TRANSMITTERS WERE IN PLACE ON A SHIFT-TO-SHIFT BASIS. NONE WAS PROVIDED. THE SURVEYOR REQUESTED TO REVIEW THE DOCUMENTED WEEKLY TESTING OF EACH ANKLE OR WRIST TRANSMITTER FOR FUNCTIONAL ACCURACY. NONE WAS PROVIDED. IN AN INTERVIEW ON 10/3/2012 AT 10:25 A.M., CCC #1 SAID THERE WAS NO PROCESS BY WHICH THE TRANSMITTERS ARE tested , "...NOT DAILY OR AT ALL...THEY HAVE NOT BEEN tested SINCE THEY (TRANSMITTERS) WERE PLACED ..." ON THE RESIDENTS. IN AN INTERVIEW ON 10/3/2012 AT 11:07 A.M., EVS #1 SAID THERE WAS NO PROCESS BY WHICH THE TRANSMITTERS WERE tested on CE THEY ARE INSTALLED OR PLACED ON THE RESIDENTS. EVS #1 SAID HE HAD THE ONLY TRANSMITTER TESTER. EVS #1 SAID HE DID NOT TEST THE TRANSMITTERS AND NO OTHER STAFF COULD USE THE TESTER. DURING AN INTERVIEW ON 10/3/2012 AT 1:05 P.M., NHA #1 SAID THAT THE FACILITY SECURITY STAFF IS SUPPOSED TO MAKE SURE RESIDENTS ARE WEARING THE TRANSMITTERS, DAILY, ON THE NIGHT SHIFT. NHA #1 SAID THAT THE SECURITY STAFF DOES NOT EVER TEST TO ENSURE THE TRANSMITTERS FUNCTION PROPERLY. THE SURVEYOR REQUESTED A COPY OF ALL THE SECURITY LOGS FROM THE LAST 90 DAYS. ACCORDING TO THE LOGS PROVIDED BY THE FACILITY, NO EVIDENCE WAS FOUND THAT FACILITY SECURITY STAFF ENSURED THAT THE AT RISK RESIDENTS WERE WEARING TRANSMITTER BRACELETS ACCORDING TO FACILITY PRACTICE ON 25 OF THE 90 DAYS REVIEWED (THE EVENINGS OF 7/3/2012, 7/11/2012, 7/18/2012, 7/20/2012, 7/24/2012, 7/27/2012, 7/28/2012, 7/29/2012, 8/7/2012, 8/10/2012, 8/17/2012, 9/1/2012, 9/4/2012, 9/7/2012, 9/11/2012, 9/14/2012, 9/18/2012, 9/19/2012, 9/20/2012, 9/24/2012, 9/25/2012, 9/27/2012, 9/29/30, 10/1/2012 OR 10/2/2012). DURING AN INTERVIEW ON 10/3/2012 AT 2:00 P.M., NHA #1 REVIEWED THE POLICIES RELATED TO ENSURING TRANSMITTERS WERE IN PLACE AND FUNCTIONING AND WAS ASKED HOW SHE ENSURED THE FACILITY FOLLOWED THE MANUFACTURER'S RECOMMENDATIONS. NHA #1 SAID, "...WE CHOOSE TO FOLLOW A DIFFERENT POLICY," BUT SHE (NHA #1) COULD GIVE NO EVIDENCE TO INDICATE THAT ANY OF THE VARIED POLICIES OF THE FACILITY WERE FOLLOWED RELATED TO THE TESTING OF THE WANDER GUARD TRANSMITTERS. (# )

This Citation pertains to intake numbers MI 281, MI 420, and MI 430. Based on interview and record review the facility failed to use the proper transfer device for 1 of 3 sampled residents (Resident #102), from a total sample of 3 resident's, when Resident #102, who was totally dependent on facility staff for all Activities of Daily Living (ADL's) with a history of paralysis, contractures, inability to bear weight, and unable to use her upper extremities was transferred by a sit to stand mechanical device resulting in the fractures of both arms and both legs. Findings include: Resident #102 Resident #102 was not a resident at the facility at the time of the investigation. Resident #102 was admitted to the facility on [DATE] and according to the Face Sheet with a medical history of [REDACTED]. Review of the Facility Minimum Data Set ((MDS) dated [DATE], revealed Resident #102 was totally dependent on staff for all ADL's including bed mobility and transfers. The MDS indicated that the Resident #102 did not speak, was unable to make her needs known and was rarely understood but was able to understand others. Resident #102 was unable to swallow food or fluids and received total nutrition and fluids from a "[DEVICE]" (gastrostomy tube placed in stomach or bowel for nutrition). Review of the Care Assessment Area's (CAA) dated 1/23/12 under Functional/Rehabilitation Potential indicated Resident #102 had contractures to both her upper and lower extremities. Review of the undated facility CNA (certified nursing assistant) pictured care guide revealed "Mechanical Lift" checked with "2 person lift" with no type of lift specified. Review of the ADL care plan dated 1/23/11 revealed Resident #102 was unable to make her needs known, and required total care in all areas of function. Approaches included Resident #102 required a mechanical lift with 2 assist for all transfers. There was no type of mechanical lift specified on the care plan. Review of the Nursing Comprehensive Evaluation, dated 1/9/12, revealed the ADL status of Resident #102 was a total assist in all areas, was non-ambulatory, contractures of both the right and left hands, devices used for transfer had "Hoyer" checked. Review of the Occupational Therapy Evaluation and Initial Plan of Care, dated 2/1/12, revealed Resident #102 was a total assist with upright sitting and had contractures in her bilateral lower extremities which affected her ability to be positioned properly. Review of Physician orders [REDACTED]. Review of the Facility Incident and Accident Report dated 2/22/12 at 2:00 PM, revealed Date of Occurrence: 2/22/12 Other: observed BLE (bilateral lower extremities) looking swollen, bruised and dislocated. Observed bilateral knees swollen, red and right knee bruising. Physician Statement section: NP (Nurse Practitioner) wrote order for stat x-rays of bilateral hips, knees and tib/fib (tibia and fibula bones in lower legs). Review of the Facility Incident and Accident Report dated 2/24/12 at 10:45 AM Date of Occurrence: 2/21/12 "Other" "Resident's knees buckled and required additional assist, no known injury at this time. On 2/24/12 during investigation staff reported resident's knees buckled during EX lift transfer and resident had to be lifted by four staff members, observed resident resting in shower chair after reported" Review of the Facility Investigation Report (no date) revealed Resident #102 was transferred by CNA #3 on 2/21/12 at approximately 11:00 AM " using a sit to stand mechanical lift. During the transfer, Resident #102 ' s knees buckled and she began to slip downward. The treatment nurse and 2 restorative aides assisted to prevent Resident #102 ' s body from contacting the floor and the staff members lifted Resident #102 by the arms and legs (into the shower chair) " . The report indicated facility staff assessed Resident #102 on 2/22/12 at approximately 1:30 PM after it was discovered her knees were swollen and her bilateral lower extremities appeared dislocated by the Charge Nurse. X-rays were ordered and Resident #102 was found to have bilateral femur fractures. Resident #102 was transferred to the hospital. Review of the Facility Investigation Conclusion dated 2/26/12 revealed: "The investigation concluded the assigned CNA attempted to transfer Resident #102 without assistance using a sit to stand lift. The Residents' knees buckled. The CNA required assistance from 3 other staff members. While attempting to protect the resident's body from slipping further to the floor, the staff lifted her legs and arms, which is believed to have contributed to the humerus and femur fractures". Review of the X-ray report dated 2/22/12 revealed Resident #102 sustained an impacted supracondylar fracture of the right distal femur (upper leg) and a suspicious oblique fracture of the distal shaft of the left femur. Review of the hospital record x-ray report dated 2/23/12 at 3:22 AM, revealed Resident #102 had the following x-rays with results: bilateral shoulders: Right shoulder displaced fracture of the proximal right humerus (upper arm) below humeral head (at the shoulder joint); Left shoulder: Displaced comminuted fracture of the proximal humerus just distal to the humeral head with overlying soft tissue swelling bilaterally; Bilateral Femur x-rays: Displaced fractures of the distal femora with severe overlying soft tissue swelling. Resident #102 underwent open reduction with internal fixation of the left femur and the right femur fracture was treated with a brace/cast and both upper extremity fractures were not treated as of the resident's discharge to another facility on 2/29/2012. During an interview on 3/1/12 at 12:50 PM, Licensed Practical Nurse (LPN) #1 stated that during a transfer that a CNA attempted to transfer Resident #102 alone using the sit to stand device and during that transfer the resident's knees began to buckle and she began slipping down. LPN #1 stated, "3 people had to go in and help her lift the resident up using her arms and legs. We always are suppose to have 2 people present during transfer one doing the actual transfer with the device and one spotter. She had always been a total lift but don't think sit to stand was correct she needed the Hoyer (sling type transfer lift) I think restorative makes those decisions". During an interview on 3/1/12 at 1:05 PM, CNA #2 stated that Resident #102 was not her usual resident to care for and she was returning from lunch on 2/21/12 and was asked to go and assist CNA #3 to transfer Resident #102 for her shower. CNA #2 stated that upon entering the room she noticed that CNA #3 already had Resident #102 "hooked up with the harness around her chest it looked like she tried to lift her first without help and the resident started to slip out and she was not setting securely on the side of the bed. Her arms were lifted up and her legs were on the outside of the knee rest, split apart off the knee protector. I had no idea what I was walking into. I think (CNA #3) was impatient and didn't wait for help, she (Resident #102) was dead weight hanging there and the pressure on her legs probably broke them, the restorative CNA and treatment nurse came in to do what they needed to do and they helped get her to the shower chair, she (CNA #3) took her to the shower and the resident got her shower". During an interview on 3/1/12 at 2:10 PM, Treatment Nurse LPN #6 stated that on 2/21/12 she had entered the room to do the wound care treatments and noticed the resident sitting on the edge of the bed with the E-EZ stand sling behind her and the machine in front of her with 2 CNA's. LPN #6 stated that Resident 102's feet were on the foot rest but the knees were outside the knee guard, "I thought nothing unusual, 2 CNA's were in the room. She was contracted and wasn't holding on, her legs were bent at the knees, hanging there, so we lifted her to transfer her into the shower chair with the lift. I worked 3-11 PM on 2/21/12, that same day and when I checked her (Resident #102), I did not see any bruising, redness, abnormal positioning and did the routine skin assessment she was due for. I didn't notice any abnormal appearance to the legs, her arms were contracted and bilateral lower extremities were contracted but no deviation from the usual." During an interview on 3/1/12 at 2:45 PM, Physical Therapy Program Manager #2 reported that Resident #102 should have been transferred using a mechanical Hoyer sling lift due to her inability to bear weight, inability to follow commands, and an inability to hold onto the grab bars on the sit to stand mechanical lift. Physical Therapy Program Manager #2 stated, "The sit to stand was not an appropriate transfer device, she was totally dependent. The Hoyer lift was the appropriate device. You could tell that just by looking at her. Nursing appears to not have assessed the appropriateness of the device." Physical Therapy Program Manager #2 reported that therapy had not previously been involved with assessment for the use of the most appropriate transfer device for residents "but we are now". During a telephone interview on 3/2/12 at 12:20 PM, CNA #3 stated she was proceeding to get Resident #102 ready for her shower. CNA #3 stated that she had gotten the sling and sit to stand mechanical lift, but had not lifted the resident yet, when CNA #2 entered the room to help and then the Treatment Nurse LPN #6 and a Restorative aide to "do what they needed to do". When asked how long the sit to stand had been used to move Resident #102, CNA #3 responded "always, probably over a year I know when she (Resident #102) was on the 1st floor that's what was used, I admit I did not check the Care Guide it was bad judgement I can see now where the Hoyer should have been used, her legs buckled backwards and her arms just hung at her sides during transfers, I guess they left it up to the CNA's to determine which lift was good enough, the nurses knew about the sit to stand lift it has been the lift always used." When asked by this surveyor if she told anyone about Resident #102 slipping and buckling of her knees and that 4 people were needed to get her into the shower chair, CNA #3 replied, "It didn't seem anything unusual happened". When asked who completes the CNA Care guide and assesses resident's needs for the type of lift required CNA #3 replied "restorative aide and nurse, not the floor nurse, but that communication is not clear to the the CNA's". During an interview with Restorative Staffs CNA's #4-A, #4-B, #4-C, and Restorative Registered Nurse (RN) #5 on 3/2/12 at 1:30 PM, when asked who completes the CNA Care Guides on the units, the reply was "nurse on the unit, they do new admissions, readmits, reassessments we give input but the primary responsibility is the unit nurses. CNA #4-C stated that she had taken care of Resident #102 while she was on the 1st floor and the sit to stand was used when she was able to assist and was talking and able to use the lift back in 2010. She (Resident #102) could say certain things and respond slowly but did respond". Restorative RN #5 also stated that the care guides are done by nursing, "it was clear which device was correct we need to be more specific, I have also never seen a doctors order for any device that was to be used". During an interview on 3/2/12 at 10:15 AM, LPN #7 stated she worked 3-11 on 2/20/12 was off 2/21/12 and that on 2/22/12, after getting report, Resident #102 was the first person she went to. LPN #7 stated, "they told me about all the x-rays that were done stat (immediately). I saw the appearance of her legs, they looked different, shifted apart not normal. I saw a bruise on her right knee, her right leg was swollen and appeared dislocated, she was so contracted that now her legs were separated. I just can't believe that lift was used". During an interview on 3/2/12 at 10:25 AM, Unit Manager LPN #8 stated she was not sure how long the sit-to stand was being used and to her knowledge, the Hoyer lift was used. LPN #8 stated, "when I asked CNA #3 why she used that lift she replied she always did. I assumed that looking at the resident you could tell she needed the Hoyer, now we must be more specific. I got a call from the floor nurse to come and look right now at Resident 102's legs and something was not right. I believe the event occurred on 2/21/12 (Tuesday) and when I asked CNA #3 if anything unusual occurred on that shower day, she said nothing happened, the sit to stand lift was used to move her from bed to shower chair. The last time I myself saw her being transferred was sometime in December and the Hoyer was used." During an interview with Administrator #1 and Director of Nursing #2 on 3/2/12 at 2:40 PM, they stated that physician orders [REDACTED]. "It was probably left for the CNA to determine which device to use it was not specific enough on the CNA Care Guides and Care Plans and information was not conveyed to the CNA which device to use". ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO FOLLOW PHYSICIAN ORDERS [REDACTED]. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET, RESIDENT #507 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE INITIAL MINIMUM DATA SET (MDS), dated [DATE], INDICATED RESIDENT #507 HAD MODERATELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING, NEEDED PHYSICAL ASSISTANCE OF ONE STAFF FOR THE COMPLETION OF ALL ACTIVITIES OF DAILY LIVING AND HAD NO RANGE OF MOTION LIMITATIONS TO UPPER OR LOWER EXTREMITIES. ON 2/14/12 AT APPROXIMATELY 9:00 AM, RESIDENT #507 WAS OBSERVED SITTING UP IN BED AND THE RESIDENT'S LEFT HAND WAS CURLED UP IN A CONTRACTED POSITION WITH THE TIPS OF FINGERS RESTING ON THE PALMS OF THE HAND. RESIDENT #507 WAS OBSERVED AT THE FOLLOWING DATES AND TIMES: ON 2/14/12 AT 3:55 PM, ON 2/15/12 AT 8:58 AM, 12 AT 12:15 PM, AND ON 2/16/12 AT 8:15 AM. RESIDENT #507 WAS OBSERVED WITHOUT ANY TYPE OF DEVICE APPLIED TO THE LEFT HAND DURING ANY OF THESE OBSERVATIONS. THE RESIDENT'S LEFT HAND REMAINED CONTRACTED, WITHHIS FINGER TIPS RESTING ON HIS PALM. ON 2/15/12 AT 9:25 AM, OCCUPATIONAL THERAPIST (OT) "D" WAS OBSERVED ASSESSING RESIDENT #507'S RANGE OF MOTION. WHEN OT "D" ATTEMPTED TO STRAIGHTEN THE FINGERS OF RESIDENT #507'S LEFT HAND, THE RESIDENT GRIMACED AND YELLED OUT "OUCH!" THE RESIDENT WAS UNABLE TO STRAIGHTEN OUT THE FINGERS OF THE LEFT HAND EVEN WITH ASSISTANCE OF THE OCCUPATIONAL THERAPIST "D". ON 2/16/12 AT 9:50 AM, TEAM PROGRAM MANAGER EMPLOYEE "E" WAS INTERVIEWED REGARDING THE USE OF HAND SPLINTS AND THE CURRENT RANGE OF MOTION FOR RESIDENT #507. EMPLOYEE "E" REVEALED THAT UPON ADMISSION TO THE FACILITY, RESIDENT #507'S LEFT HAND WAS "FLACCID" AND EXPLAINED THIS MEANT THAT THERE WAS NO WEIGHT-BEARING ABILITY, BUT RESIDENT #507'S LEFT HAND WAS ABLE TO OPEN COMPLETELY AND THE RESIDENT HAD "FULL RANGE OF MOTION (ROM)". EMPLOYEE "E" WAS QUERIED AS TO WHAT THE INDICATIONS WOULD BE FOR THE USE OF A HAND SPLINT AND STATED, "IF THERE WAS A DECLINE NOTED OR INCREASED TONE (DECREASED FLEXION) THAT WOULD BE AN INDICATOR FOR THE USE OF A SPLINT." EMPLOYEE "E" REVEALED THAT UPON THE LAST RANGE OF MOTION ASSESSMENT, DATED 12/14/11, RESIDENT #507 SCORED A "4" INDICATING FULL RANGE OF MOTION (ROM) FULL FLEXION TO FULL EXTENSION OF ALL JOINTS ON ALL FINGERS." UPON THE ASSESSMENT, DATED 2/15/12, RESIDENT #507'S LEFT HAND SCORED A "2" WHICH INDICATED "MODERATE" ROM AT ONE OR MORE JOINTS OF ONE OR MORE FINGERS. THIS INDICATED A DECLINE IN RANGE OF MOTION. AT THIS TIME, TPM "E" WAS ALSO QUERIED ABOUT A NURSING NOTE DATED 12/19/11, WHICH STATED, "NEW ORDER: OBTAIN LEFT HAND SPLINT TO TREAT (TX) INCREASED TONE... TO BE WORN PER THERAPY UPON ARRIVAL." TPM "E" STATED, "THE PHYSICAL THERAPY DEPARTMENT WAS UNAWARE OF THE NURSING NOTE OR OF ANY PHYSICIAN ORDERS [REDACTED]." A REVIEW OF RESIDENT #507'S "RESIDENT CARE GUIDE" (THE GUIDE USED TO INSTRUCT CERTIFIED NURSE AIDES ON RESIDENT CARE NEEDS), INDICATED THAT THE RESIDENT HAD A LEFT LEG BRACE AND LEFT HAND SPLINT. PER THE "RESIDENT CARE GUIDE- ADDITIONAL COMMENTS", THE FOLLOWING INFORMATION WAS WRITTEN: "FYI: LEFT LEG BRACE TO BE WORN AT ALL TIMES WHILE IN BED PER THERAPY...LEFT SIDE WEAKNESS, LEFT HAND CONTRACTURES". THE "RESIDENT CARE GUIDE" DOCUMENTED NO SCHEDULED TIMES FOR THE USE OF THE LEFT HAND SPLINT. ON 2/16/12 AT 8:50 AM, TEAM PROGRAM MANAGER (TPM) "E" WAS SHOWN THE CERTIFIED NURSING ASSISTANT (CNA) "RESIDENT CARE GUIDE" WHICH INDICATED THE USE OF A HAND SPLINT FOR RESIDENT #507. AT THAT TIME TPM "E" STATED, "THE RESIDENT (#507) HAD BEEN REFERRED TO THE THE RESTORATIVE PROGRAM ON 1/03/12. RESTORATIVE AIDES WOULD BE RESPONSIBLE FOR FOLLOWING SPLINT WEARING SCHEDULES FOR RESIDENTS." ON 2/16/12 AT 9:05 AM, RESTORATIVE DIRECTOR "Q" WAS INTERVIEWED AND CONFIRMED THAT RESIDENT #507 WAS REFERRED TO THE RESTORATIVE PROGRAM. WHEN QUERIED ABOUT RESIDENT#507'S SPLINT WEARING SCHEDULE, RESTORATIVE DIRECTOR "Q" STATED, "THERAPY IS SUPPOSED TO PROVIDE A SPLINT WEARING SCHEDULE...I NEVER RECEIVED ONE FROM THEM." ON 2/16/12 AT 2:55 PM, THE MEDICAL DIRECTOR WAS INTERVIEWED REGARDING THE PHYSICIAN ORDER [REDACTED].#507. THE MEDICAL DIRECTOR STATED, "I WANTED THAT SPLINT IN PLACE TO PREVENT A DECLINE AND NOW THERE IS A DECLINE. IF AN ORDER IS PUT IN THE CHART, I EXPECT IT TO BE CARRIED OUT. THEY SHOULD HAVE CARRIED OUT THE ORDER." ON 2/16/12 AT 3:40 PM, THE REHABILITATION (REHAB) DIRECTOR "B" WAS INTERVIEWED REGARDING RESIDENT#507'S HAND SPLINT. REHAB DIRECTOR "B" STATED, "THE ORDER WAS NEVER BROUGHT TO THE ATTENTION OF THE PHYSICAL THERAPY DEPARTMENT." REVIEW OF THE FACILITY'S POLICY ENTITLED, "NURSING MAINTENANCE PHYSICAL FUNCTIONING" UNDATED, DOCUMENTED, "RESIDENTS WITHOUT LIMITED RANGE OF MOTION DO NOT EXPERIENCE REDUCTION IN RANGE OF MOTION UNLESS RESIDENT'S CONDITION DEMONSTRATES THAT A REDUCTION IS UNAVOIDABLE. RESIDENTS WITH LIMITED RANGE OF MOTION RECEIVE APPROPRIATE TREATMENT AND SERVICES TO INCREASE AND/OR PREVENT FURTHER DECREASE IN RANGE OF MOTION." REVIEW OF THE FACILITY'S POLICY ENTITLED, "RESTORATIVE AND ORTHOTIC DEVICES USE OF..." UNDATED, DOCUMENTED, "4. THE PHYSICIAN WRITES AN APPROPRIATE ORDER LISTING THE DEVICE, THE DURATION OF USE, ANY SPECIAL INSTRUCTIONS AND ANY SPECIAL MONITORING STEPS INDICATED. 5. THERAPIST AND/OR ALLIED HEALTH STAFF ASSISTS THE FACILITY IN LOCATING A VENDOR WHO CAN PROVIDE THE DEVICE, IF NOT A STOCK ITEM." ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PREVENTATIVE MEASURES FOR THE PREVENTION OF A PRESSURE ULCER FOR ONE (#721) OF FIVE RESIDENTS REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 25 , RESULTING IN THE DEVELOPMENT OF A FACILITY ACQUIRED PRESSURE ULCER. ADDITIONALLY, THE FACILITY FAILED TO FOLLOW physician's orders [REDACTED]. FINDINGS INCLUDE: ON 4/21/11 AT 12: 20 PM, RESIDENT #721 WAS OBSERVED IN THE HALLWAY IN A HIGH BACK RECLINER WITH LEGS BENT AT THE KNEE IN A LEFT SIDE LYING POSITION. BOTH FEET HAD PROTECTIVE BOOTS ON. AT 4/21/11 AT 2:00 P.M., THE RESIDENT REMAINED UP IN HIGH BACK CHAIR IN THE DAYROOM IN THE SAME POSITION. ON 4/22/11 AT 9:10 A.M., REVIEW OF RESIDENT #721'S ACTIVE CLINICAL RECORDS REVEALED THAT THE RESIDENT WAS admitted INto the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THE RESIDENT WAS SEVERELY COGNITIVELY IMPAIRED AND DEPENDED ON STAFF FOR REPOSITIONING. REVIEW OF THE BRADEN SKIN assessment dated [DATE] INDICATED THE RESIDENT HAD A SCORE OF 14, AT MODERATE RISK FOR SKIN BREAKDOWN. THE POTENTIAL FOR ALTERATION IN SKIN INTEGRITY RELATED TO TOTAL ASSIST, CARE PLAN DATED 9/29/10 INDICATED THE FOLLOWING GOAL/EXPECTED OUTCOME AND APPROACHES: "ALLOW STAFF TO ASSIST WITH TURNING AND REPOSITIONING EVERY 2 HOURS AND AS NEEDED TO HELP PREVENT BREAKDOWN". THERE WAS NO INDICATION TO FLOAT AND OR ELEVATE ( KEEP OF DEPENDENT SURFACES) RESIDENT #721'S FEET TO PREVENT SKIN BREAK DOWN. THERE WERE NO PROTECTIVE BOOTS ORDERED TO PREVENT SKIN BREAKDOWN. THE REVISED ALTERATION IN SKIN INTEGRITY CARE PLAN DATED 11/11/10 INDICATED RESIDENT #721 HAD THE FOLLOWING FACILITY ACQUIRED PRESSURE ULCERS: RIGHT LATERAL ANKLE, STAGE THREE ( III), RIGHT DORSAL FOOT ( NO STAGING), LEFT ANTERIOR ANKLE ( NO STAGING), LEFT HEEL ( NO STAGING) AND LEFT GLUTEAL , STAGE THREE (III). ON 4/22/11 AT 09:15 A.M., WOUND CARE WAS OBSERVED WITH TREATMENT NURSE "R". RESIDENT #721 WAS OBSERVED TO HAVE A RIGHT LATERAL ANKLE PRESSURE ULCER, MEASURING 2.0 CENTIMETER (CM) BY (X) 1.0 CM X 0.2 CENTIMETERS IN SIZE AND DEPTH. THE WOUND HAD A PINK TISSUE BASE WITH A SMALL AMOUNT OF DRAINAGE CONSISTING OF BLOOD. THE SURROUNDING TISSUE WAS DARK DEAD TISSUE AND THE EDGES OF THE WOUND WERE IRREGULAR. THE WOUND CARE CLINIC NOTE DATED 4/14/11 INDICATED THE FOLLOWING: LATERAL ANKLE 1.1 X 0.7 X 0.3 CM, PINK BASE, MODERATE SEROSANGUINOUS DRAINAGE (BLOOD TINGED) WITH IRREGULAR EDGES. RECOMMENDATIONS, ELEVATE BILATERAL LOWER EXTREMITIES (LEGS). TREATMENT NURSE "R" WAS QUERIED AS TO HOW THE RESIDENT DEVELOPED THE PRESSURE ULCER. THE TREATMENT NURSE STATED, "I'M NOT SURE". ON 4/22/11 AT 1:15 P.M., RESIDENT #721'S CLINICAL RECORD WAS REVIEWED WITH THE DIRECTOR OF NURSING (DON). THE DON WAS UNABLE TO EXPLAIN HOW THE RESIDENT ACQUIRED THE PRESSURE ULCER AT THE FACILITY AND WHY THERE WERE NO PREVENTIVE MEASURES IN PLACE FOR THE RESIDENT. THE DON REVIEWED THE RESIDENT'S CARE PLAN DATED 9/29/10 AND STATED " WE ALWAYS FLOAT THE HEELS FOR ANY RESIDENT AT RISK FOR SKIN BREAKDOWN, THAT IS OUR STANDARD OF PRACTICE. I DON'T KNOW WHY THIS RESIDENT DIDN'T HAVE THAT IN THE CARE PLAN . WE JUST GOT THOSE PROTECTIVE BOOTS IN THE LAST COUPLE OF MONTHS". ON 4/22/11 AT 1:45 P.M., REVIEW OF THE FACILITIES POLICY TITLED SKIN MANAGEMENT, DOCUMENTED, "IT IS THE POLICY OF THE FACILITY THAT A RESIDENT DOES NOT DEVELOP PRESSURE ULCERS UNLESS CLINICALLY UNAVOIDABLE . APPROPRIATE PREVENTATIVE MEASURE WILL BE IMPLEMENTED ON RESIDENTS IDENTIFIED AT RISK (SCORE OF 18 OR LESS ON THE BRADEN SCALE) AND THE INTERVENTIONS DOCUMENTED ON THE CARE PLAN . AN INITIAL CARE PLAN IS DEVELOPED UPON ADMISSION IF THE RESIDENT IS AT RISK OR HAS A PRESSURE ULCER AND THE COMPREHENSIVE CARE PLAN SHOULD ADDRESS ... PREVENTATIVE DEVICES, INCLUDING RECUMBENT AND SEATED SUPPORT SURFACES. POSITIONING REQUIREMENT." ( ) ON 4/19/11 AT 9:35 A.M., DURING THE INITIAL ROUNDS WITH THE FACILITY'S MINIMUM DATA SET (MDS) NURSE, RESIDENT #705 WAS OBSERVED LYING IN BED ASLEEP. THE MDS NURSE REPORTED THAT THE RESIDENT HAD PRESSURE ULCERS (PU), A [MEDICAL CONDITION], AND A SUPRAPUBIC CATHETER. ON 4/19/11 AT 1:45 P.M., RECORD REVIEW OF A FACE SHEET REVEALED THAT RESIDENT # 705 WAS admitted INto the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE ANNUAL MINIMUM DATA SET (MDS), dated [DATE], INDICATED THE RESIDENT HAD AN INDEPENDENT COGNITION AND REQUIRED EXTENSIVE ASSISTANCE TO COMPLETE CARE WITH ALL ACTIVITIES OF DAILY LIVING (ADL'S). ON 4/20/11 AT 9:50 A.M., THE FACILITY'S TREATMENT NURSE (NURSE "E") WAS OBSERVED TREATING RESIDENT #705'S RIGHT FLANK PRESSURE ULCER AND LEFT HIP PRESSURE ULCER. THE RIGHT FLANK PRESSURE ULCER OBSERVATION REVEALED THAT NURSE "E" REMOVED THE OLD DRESSING. A MODERATE AMOUNT OF YELLOW SLOUGH (DRAINAGE) WAS NOTED TO THE WOUND BED ALONG WITH SOME PINK TISSUE. THE WOUND WAS CLEANSED WITH WOUND CLEANSER AND SANTYL (AN ACTIVE ENZYMATIC THERAPY THAT CONTINUOUSLY REMOVES NECROTIC TISSUE FROM WOUNDS AT THE MICROSCOPIC LEVEL) AND CALCIUM ALGINATE PACKING (CALCIUM-ALGINATE DRESSING FORMS A SOFT GELL THAT ABSORBS WHEN IT COMES INTO CONTACT WITH WOUND EXUDATE) WERE APPLIED TO THE WOUND AND A DRY DRESSING WAS APPLIED. THE LEFT HIP: NURSE "E" REMOVED THE OLD DRESSING AND THE ULCER REVEALED PALE PINK TISSUE WITH SOME TUNNELING (DEPTH). THE WOUND WAS CLEANSED WITH WOUND CLEANSER. NURSE "E" APPLIED MEDI-HONEY PASTE (CLEANSES AND DEBRIDES)TO THE WOUND, PACKED WITH DRY GAUZE AND THEN APPLIED A DRY DRESSING. ON 4/20/11 AT 10:10 A.M., REVIEW OF THE "WOUND/SKIN HEALING RECORDS," DATED 4/14/11, REVEALED MEASUREMENTS AND DESCRIPTIONS OF THE TWO WOUNDS: 1. THE LEFT HIP PRESSURE ULCER WAS DESCRIBED AS A STAGE FOUR (IV) WOUND THAT MEASURED 0.9 CM (CENTIMETERS) X 0.6 CM, NO DEPTH, WITH SEROUS EXUDATE, AND PINK/BEEFY RED. 2. THE RIGHT FLANK PRESSURE ULCER WAS DESCRIBED AS A STAGE IV WOUND THAT MEASURED 4.5 CM X 3.8 CM, 2.4 CM DEPTH, WITH MODERATE SEROSANGUINEOUS EXUDATE, SLOUGH, AND WITH PINK SURROUNDING TISSUE. ON 4/20/11 AT 10:15 A.M., REVIEW OF THE CURRENT physician's orders [REDACTED]." DURING THE WOUND OBSERVATION, NURSE "E" USED THE SANTYL OINTMENT AND CALCIUM ALGINATE INSTEAD OF THE PRESCRIBED MEDI-HONEY PASTE. A physician's orders [REDACTED].) READ, "DISCONTINUE MEDI HONEY TO THE LEFT HIP...CLEANSE LEFT HIP WITH WOUND CLEANSER, APPLY SANTYL OINTMENT AND CALCIUM ALGINATE AND COVER WITH A DRY DRESSING." DURING THE WOUND OBSERVATION, NURSE "E" USED MEDI HONEY PASTE INSTEAD OF THE PRESCRIBED SANTYL AND THE CALCIUM ALGINATE. ON 4/20/11 AT 10:20 A.M., NURSE "E" WAS QUERIED REGARDING THE physician's orders [REDACTED]. NURSE "E" STATED, "I WROTE THOSE ORDERS WRONG. THE NURSE THAT WORKS WITH THE WOUND DOCTOR OFTEN MAKES MISTAKES LIKE THAT. I KNOW WHAT SHE MEANT." ON 4/20/11 AT 10:55 A.M., REVIEW OF THE "WOUND CARE CLINICS OF AMERICA" CONSULTATION, DATED 4/7/11, REVEALED UNDER THE SUBTITLE OF RECOMMENDATIONS, "1. CALCIUM ALGINATE TO LEFT HIP, 2. MEDI HONEY DAILY TO RIGHT FLANK..." ON 4/21/11 AT 8:35 A.M., RECORD REVIEW OF THE physician's orders [REDACTED]. THIS TIME THE ORDERS INDICATED THAT THEY WERE OBTAINED FROM THE RESIDENT'S ATTENDING PHYSICIAN (DR "I") INSTEAD OF THE WOUND PHYSICIAN OR WOUND CLINIC THAT READ: 1. "ORDER CLARIFICATION: CLEANSE RIGHT FLANK WITH WOUND CLEANSER, APPLY SANTYL OINTMENT WITH CALCIUM ALGINATE DAILY AND AS NECESSARY. COVER WITH A DRY DRESSING. DISCONTINUE MEDI HONEY TO RIGHT FLANK." 2. "ORDER CLARIFICATION: CLEANSE LEFT HIP WITH WOUND CLEANSER. APPLY MEDI HONEY PASTE AND COVER WITH A DRY DRESSING AND AS NECESSARY." ON 4/21/11 AT 8:45 A.M., RESIDENT #705'S ATTENDING PHYSICIAN (DR "I") WAS PRESENT AND WAS QUERIED REGARDING THE VERBAL ORDERS OBTAINED BY NURSE "E." DR "I" DENIED GIVING THE ORDERS BY WAY OF THE PHONE TO NURSE "E." DR. "I" FURTHER STATED, "I FOLLOW WHATEVER THE WOUND SPECIALISTS RECOMMEND. I DID NOT GET A CALL ON THOSE WOUND CLARIFICATION ORDERS. I NEVER GOT THAT CALL FOR WOUND CARE. I DON'T REMEMBER. I WAS OUT OF THE COUNTRY." ON 4/21/11 AT 8:55 A.M., NURSE "E" INSISTED ON OBTAINING THE WOUND ORDERS/CLARIFICATIONS FROM DR "I." ON 4/21/11 AT 9:10 A.M., THE WOUND PHYSICIAN (DR "F") WAS PRESENT AT THE NURSES' STATION AND WAS QUERIED REGARDING THE ORDERS FOR THE WOUNDS. DR "F" CONFIRMED THAT HE WANTED AND DID ORDER THE FOLLOWING: 1. CLEANSE THE RIGHT FLANK WITH WOUND CLEANSER, APPLY MEDI HONEY AND DRY DRESSING DAILY AND AS NECESSARY AFTER CLEANSING. 2. CLEANSE LEFT HIP WITH WOUND CLEANSER, APPLY SANTYL OINTMENT AND CALCIUM ALGINATE AND COVER WITH A DRY DRESSING. AT THIS TIME, DR "F" QUERIED NURSE "E" AS TO WHY SHE DID NOT CALL HIM OR HIS ASSISTANT INSTEAD OF THE ATTENDING PHYSICIAN FOR ORDER CLARIFICATIONS. NURSE "E" DID NOT PROVIDE AN EXPLANATION. DOCTOR "F" STATED, "IF THIS IS MY ORDER CALL ME FOR ANY CLARIFICATIONS." ON 4/21/11 AT 12:45 P.M., THE DIRECTOR OF NURSES (DON) WAS QUERIED REGARDING THE CLARIFICATION OF RESIDENT #705'S ORDERS FOR HIS WOUNDS. THE DON STATED, "FOR CLARIFICATIONS, NURSE "E" SHOULD HAVE CALLED THE PRESCRIBING DOCTOR." ( )