Every finding on record at Stratford Pines Nursing and Rehabilitation Center

This citation is related to intake # 2676019Based on observation, interview, and record review, the facility failed to provide dignified care for 6 of 12 Confidential Resident Group Interview respondents and 3 residents (R36, R58, and R60) of 4 residents reviewed for dignity.Findings include: Resident #36 (R36) Review of an admission Record revealed R36 admitted to the facility on [DATE] with pertinent diagnoses which included weakness, overactive bladder, and difficulty walking. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R36, with a reference date of 1/22/2026 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12, out of a total possible score of 15, which indicated R36 was moderately cognitively impaired. Review of current activities of daily living Care Plan interventions for R36, initiated 1/6/2026, directed staff resident required assistance of one staff with ambulation and should assist when verbal or non-verbal indicators communicate toileting needs. In an interview on 3/30/2026 at 12:31 AM, R36 reported she waited up to 30 minutes for her call light to be answered, which sometimes caused her to soil herself. R36 stated soiling herself makes me feel terrible. R36 reported a few weeks ago she called 911 because no one answered her call light and they contacted the front desk. R36 stated, I have to scream to get help. Resident #58 (R58)Review of an admission Record reflects R58 admitted to the facility with diagnoses that included major depression, difficulty in walking and weakness. Review of a Minimum Data Set (MDS) assessment dated [DATE] reflects R58 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. R58 needed partial to moderate assistance with toilet transfers. Review of a Care Plan initiated 1/6/2026, revised 2/17/2026 reflected R58 needed assistance with Activities for Daily Living (ADLS), and required assistance with toileting before and after meals, HS (hour of sleep) and PRN (as needed). The care plan indicated R58 wears incontinence products check and change before and after meals, HS, with rounds and PRN. Assist when verbal or non-verbal indicators communicate toileting needs. Further review of the care plan indicated R58 had excoriation to peri area (initiated on 8/25/25, revised on 9/3/2025). During an observation beginning 3/31/2026 at 10:45 AM, the red call light over the door to room [ROOM NUMBER] was activated. Licensed Practical Nurse (LPN) D was standing at a medication cart a few feet away and did not respond to the call light. 2 unidentified Certified Nurse Aides (CNAs) were also on the unit. At 10:56 AM, the two unknown CNAs left the unit without answering the call light. LPN D moved the medication cart, placing it in front of the room across the hall and facing room [ROOM NUMBER] and did not respond to the call light activated over the door to room [ROOM NUMBER]. At 11:01, the CNAs returned to the unit with an open cart of meal trays, placing the cart directly outside room [ROOM NUMBER] and began passing the noon meals. Neither of the CNAs responded to the call light on outside room [ROOM NUMBER]. At 11:05 AM, one of the unknown CNAs entered room [ROOM NUMBER] and was overheard saying she could not assist the resident to the toilet because it was lunch time. The unknown CNA turned off the call light and left the room. A man's voice was overheard saying This is bulls***! This is unacceptable! . and the call light was again activated over the door to room [ROOM NUMBER]. During an interview and observation on 3/31/2026 at 11:07 AM, R58 was seated in a recliner chair in room [ROOM NUMBER]. Family Member (FM) H was standing next to R58 and was visibly upset. FM H reported R58's call light had been on since 10:30 AM that morning and that this isn't the first time staff take too long to answer R58's call light, sometimes taking up to an hour and a half before assistance is given. FM H also reported staff routinely shut off the call light without meeting R58's needs and said R58 would often skip breakfast because she did not want to eat while sitting in a wet brief. FM H also said that R58 did not like it when he complained about the long wait times because she would tell him she had to live here and did not want to upset staff or get on their bad side. When asked, R58 confirmed that the unknown CNA told her she could not be assisted to the bathroom because it was lunch time which R58 said made her feel very unimportant. R58 reported she was sitting in a soaking wet brief and had a rash in her groin area due to frequently being wet and/or soiled for extended periods of time. R58 also reported that when her assigned CNA goes on break, the other CNA on the hall will often tell her she has to wait until her assigned CNA returns from break before being assisted. Review of Interdisciplinary Documentation) dated 3/12/2026 reflected, Aide came to this nurse to notify her that (R58) has a (sic) open spot to labia and is having some bleeding in the brief. Aide also states that she is having a lot of redness bilateral thigh. Nurse evaluated and had aide place barrier cream to labia and bilateral thighs at this time. Notified provider in provider book to evaluate. Review of Interdisciplinary Documentation dated 3/13/2026 reflected Per the infection assessment (R58) meets Loeb criteria (minimum, evidence-based guidelines developed to assist clinicians in deciding when to initiate antibiotic therapy for nursing home residents) for skin and soft tissue infection. HCP (Healthcare Provider) diagnosis of intertrigo (an inflammatory skin rash caused by friction and moisture in skin folds) to periarea and groin. (R58) is incontinent of bowel and bladder. Encouragement provided to be toileted more frequently either before or after each meal as tolerated. (R58) states she has frequent bowel movements. Review of bathing in the past 2 weeks with 3/4 completed. STCP (Short Term Care Plan) made for further monitoring. CONFIDENTIAL GROUP INTERVIEWDuring a confidential resident group interview on 3/31/2026 at 1:30 PM, 6/12 residents reported they frequently experienced extended call light response times, ranging from 30 minutes to an hour and a half. The residents reported staff often shut the call light off before meeting their needs and promised to return, only to forget until the call light was activated again. One resident reported that twice in the last week they had to wait 45 minutes before they were assisted to the toilet, which caused pain, discomfort, and incontinence which made them feel lousy. Another resident reported that they feel the facility is not using the staff efficiently, especially during mealtimes. One resident reported that they frequently witnessed their roommate waiting a very long time for their call light to be answered which would make their roommate cry. During an interview on 4/01/2026 at 8:22 AM the Director of Nursing (DON) reported that all staff are to respond to call lights as soon as possible, ideally within 15 minutes. The DON said staff should not walk by call lights and should at least check in with the residents to find out what they needed. The DON said the call light is to be left on until the resident's needs are met. The DON said he was aware call light response time was a concern and did not know if it was because they needed more staff or better coordination of meal service so that more managers could help during these times. Resident #60 (R60) Review of the Electronic Medical Record (EMR) reflected R60 admitted to the facility with pertinent diagnoses that included Parkinson's Disease, Weakness, and Difficulty in Walking. Review of the Minimum Data Set (MDS, a tool to assess a resident's status) dated 1/7/2026 revealed a Brief Interview for Mental Status (BIMS, a tool to assess a resident's cognitive ability) score of 15 out of 15 which indicated the Resident was cognitively intact. Review of the Care Plan for R60 reflected the Resident required assistance of one staff member and a four-wheeled walker for transfers and ambulation. The Care Plan reflected R60 preferred to sleep in his recliner and was at risk for falls. On 3/30/2026 an interview was conducted with R60 in his room. R60 reported a complaint that he often had to wait too long for a response to his call light. R60 reported extended wait times had caused him to poop and pee myself. R60 reported incidents when he had waited 30 to 45 minutes for a response to his call light. R60 reported he was a fall hazard and I'm not supposed to get up by myself. R60 reported times when, unable to wait any longer, he had self-transferred into the bathroom stating I don't have time to walk over to my walker, only time to get myself into the bathroom . Sometimes they find me in the bathroom without my walker . I can't help it if I have to have bowel movements in the middle of the night or have to urinate. R60 reported that sometimes after waiting and urgency approached, he had banged on the wall next to his recliner. R60 reported I'm not deaf, I can hear them talking and laughing walking past my room. R60 pointed to the wall next to his recliner. Multiple marks were observed on the wall. The Resident demonstrated how he had struck the wall with the back of a closed fist when he had heard staff outside his room. R60 reported extended wait times occurred mostly at night but had also occurred during the day. R60 reported he had talked to the Director of Nursing (DON) and Social Worker (SW) L about this without resolution and reported this continued to be my biggest complaint. On 3/31/2026 at 11:56 AM the call light for R60 was observed to be on. -On 3/31/2026 at 12:01 PM an observation was noted that Certified Nurse Aide (CNA) K had entered the room of R60 with a lunch tray and the call light was turned off. Approximately on minute later CNA K left the room with the same lunch tray. -On 3/31/2026 at 12:04 PM R60 was interviewed and reported that he told CNA K that his girlfriend had already brought him lunch but that he needed to go to the bathroom. The Resident reported CNA K told him she would be back and then R60 stated, We'll see. -On 3/31/2026 at 12:06 PM CNA K and two other CNAs were observed delivering food trays to other resident rooms. -On 3/31/2026 at 12:09 PM multiple CNAs were observed walking back and forth in the hall with two CNAs talking about who was going to lunch. Also, during this time Registered Nurse (RN) M and Licensed Practical Nurse (LPN) O were observed as they left the alcove next to the room of R60. -On 3/31/2026 at 12:12 PM RN M and LPN O were observed as they returned to the alcove and LPN O left about one minute later walking past the room of R60 whose light remained off. RN M left the area walking the other direction. -On 3/31/2026 between 12:12 PM and 12:18 PM multiple care and non-care staff were observed walking in the hall past the room of R60. RN M had returned to the hall and was observed to respond to two call lights farther down the hall. -On 3/31/2026 at 12:25 the call light for the room of R60 was observed to illuminate. LPN O returned to the hall at this time and was observed to respond to the Resident's call light. -On 3/31/2026 at 12:35 PM an interview was conducted with LPN O who reported she had assisted R60 to the bathroom. LPN O reported that R60 had not been incontinent. On 4/1/2026 at 8:21 AM an interview was conducted with R60 in his room. When asked about the lunchtime call light wait of 3/31/2026 R60 reported he had waited a half hour for a response. R60 reported that CNA K did not return but that another staff member had taken him to the bathroom after he turned his light on again. R60 reported he had been incontinent in his brief by the time this staff member arrived. R60 stated I pee my pants, I poop my pants, it shouldn't be that way.

Based on interview and record review, the facility failed to inform residents of their right to maintain their current room or inform them of a room change prior to moving them for 4 Residents (R60, R101, R103 and R104) of 4 residents reviewed for notification of room change.Findings include: R60Review of R60's admission Record dated 5/12/26 revealed he was admitted to the facility on [DATE] and had diagnoses that included: Dysarthria (slow or slurred speech) and Anarthria (speech sound disorder resulting from a neurological injury), dysphonia (hoarseness of voice), Parkinson's disease, difficulty in walking and weakness. It also revealed he was his own responsible party.Review of R60's Brief Interview for Mental Status (BIMS), a cognitive assessment dated [DATE] revealed he scored 15/15 (normal cognition).R60 was interviewed in his room on 5/13/26 at 7:54 AM with Corporate Nurse (CN) C and the Director of Nursing (DON). R60 reported that when he had completed skill therapy facility staff informed him, he could no longer stay in the room he was admitted to because it was a Rehab (Rehabilitation) Unit. R60 said he did not want to move. He said, they just stuck me in this room. CN C said they were currently looking for a room to put him back on the Rehab Unit.During an interview with CN C on 5/13/26 at 8:30 AM, CN C confirmed residents can stay on the Rehab Unit even after they complete therapy. The policy for room change was requested and information on how residents know they have the right to stay in their room when the facility approach them to change rooms was requested.Review of R60's progress notes dated 4/22/26 at 13:20 (1:20 PM) revealed, SSD (Social Services Director) met with R60 to speak with him about moving rooms. R60 is LTC (Long Term Care) but has remain on the rehab wing unit a room opened up for him in LTC. (Name of R60) is agreeable to moving but expressed some displeasure with the potential of having a roommate. However, there was no indication that R60 was informed he could stay in his room. Not sure of the quote.On 5/13/26 at 11:00 AM the Nursing Home Administrator (NHA) reported they do not have any policy for room change notification and offered no additional information to confirm that residents that are moved are informed of their right to refuse the room change. R101Review of R101's admission Record dated 5/13/26 revealed she was admitted to the facility on [DATE] and had diagnoses that included: difficulty in walking, weakness, obesity, and stress incontinence. It also revealed R101 was her own responsible party.Review of R101 Brief Interview for Mental Status (BIMS) dated April 3, 2026, revealed she scored 15/15 (normal cognition).Review of R101's census report revealed that she was moved off the Rehab Unit on 1/12/26. During an interview with R101 in her room on 5/13/26 at 9:40 AM, R101 and her husband reported they were told when R101 completed therapy she had to move to a different room. They both reported she would never have moved from her original bed if they had been given a choice but now that she had settled into this room she did not want to move again.R101's concerns on being moved from the rehab unit when she completed therapy were shared with Corporate Nurse (CN) C and the DON on 5/13/26 at 9:50 AM. Documentation was requested that would indicate R101 was informed of her right to not be moved. Upon exit no information was provided to verify R101 was informed of her right to not be moved.R103Review of R103's admission Record dated 5/13/26 revealed he was admitted to the facility on [DATE] and he was not his own responsible party.Review of R103's census record revealed he was moved off the Rehab Unit on 4/6/26.Review of R103's progress notes from 4/2/26 to 4/9/26 revealed no indication of room change or notification of a room change.R104Review of R104's admission Record dated 5/13/26 revealed she was admitted to the facility on [DATE] and she was not her own responsible party.Review of R104's census record revealed she was moved off the Rehab Unit on 4/9/26.Review of R104's progress note dated 4/7/26 at 9:28 AM revealed, SSD called R104's husband and name of husband's friend to notify the of a room change for R104. SSD left message with name of R104 husband and spoke directly R104's husband's friend. [Name of husband] is R104's DPOA (Durable Power of Attorney) but he asked that [name of friend] was to be called when husband cannot be reached. [Name of friend] is content with this room change. He asked if R104 is getting worse. SSD explained that since R104 is LTC (Long term Care), she is being moved to the LTC side of the building, and it does not reflect a change in functioning. SSD also stated that her new room is more appropriate for her cognitive impairment. There was no indication the DPOA was provided with information that a room change could be declined.

Based on observation, interview and record review, the facility failed to ensure medications were labeled and dated correctly in 1 of 4 medication rooms. Findings include: During an observation on 4/1/2026 at 9:00 AM, a refrigerated vial of Tuberculin Purified Protein Derivative Diluted (a sterile solution used in a skin test to detect Mycobacterium tuberculosis (TB) infection) was open and without an opened on date. Review of the carton containing the vial of Tuberculin Purified Protein Derivative reflected Discard opened product after 30 days.During an interview on 4/1/2026 at 9:03 AM, Licensed Practical Nurse (LPN) I reported the vial should have been labeled with the date opened. LPN I looked at the vial and said it appeared almost full but said it would need to be thrown away because there was no way to tell how long it had been open.

Based on interview and record review, the facility failed to formulate and implement a person-centered comprehensive psychosocial Care Plan in accordance with facility policy for one resident (R95) of three residents reviewed for comprehensive Care Plans. Findings include:Review of the Minimum Data Set (MDS, a tool used to assess a resident status) with a reference date of 3/10/2026 reflected R95 admitted to the facility 3/3/2026 with pertinent diagnoses that included: Anxiety Disorder, Dementia, and Depression. Review of the MDS Brief Interview for Mental Status (BIMS, a tool used to assess cognitive status) revealed a score of 8 out of 15 which indicated that R95 was moderately cognitively impaired.Review of the Physicians Orders for R95 reflected the medication regimen included the psychoactive medications: Buspar (antianxiety medication) with a start date of 3/3/2026, Sertraline (antidepressant) with a start date of 3/4/2026 and Seroquel (atypical antipsychotic) with orders to monitor for the side effects of Antidepressant Medication and Antipsychotic Medication both with start dates of 3/10/2026.The policy provided by the facility titled Care Planning Process: Admission, Comprehensive and Short Term, last revised 11/2017 was reviewed. The policy reflected It is the policy of this facility to utilize the results of the MDS assessment to develop, review, and revise resident care plans. And Comprehensive:1. The interdisciplinary team will review the status in the Care Area Assessment (CAA) triggered areas [from the MDS] for making care plan determinations.The MDS Section V Care Area Assessment (CAA) Summary with a reference date of 3/10/2026 for R95 was reviewed. The review revealed trigger areas checked (yes) included, Cognitive Loss/Dementia, Behavioral Symptoms, Psychotropic Drug Use. However, the CAA Summary reflected that Psychosocial Well-Being Care Area and Psychosocial Care Planning Decision were not checked (No) and Not Assessed/ no information.Review of the Care Plan for R95 revealed a one psychosocial plan of care with a Focus of Resident has the potential for psychosocial distress related to: expressing sadness/ anger/empty feeling over lost roles and status initiated 3/6/2026. The two Goals established reflect adjustment to nursing home placement as evidenced by. socialization and stable BIMS, and The highest practicable level of communication, memory, judgement and orientation will be achieved with psychosocial needs met. Review of the Interventions or how will these goals be accomplished, included five interventions: two indicated monitoring (evaluate for changes and behavior monitoring) allow time to express feelings, acknowledgement of mood and behavior, and maintaining a calm environment. The Focus and all Interventions were initiated on 3/6/2026. Nowhere in this plan of care or in other areas of the Care Plan were the MDS diagnoses of depression or dementia recognized, personalized, or indicated that R95 was prescribed psychoactive medication that required monitoring were included.During an interview conducted 3/31/2026 at 4:19 PM, Social Worker (SW) L reported that a resident on psychoactive medications would not necessarily have a Care Plan for these medications. SW L reported a resident would be more more likely have a Care Plan if the resident had behaviors.

Based on observation, interview and record review, the facility failed to provide collaborative hospice care for 2 Residents (R78 and R92).Findings included: Review of R78's admission Record dated 5/12/26 revealed she was admitted to the facility on [DATE] and had diagnoses that included: vascular dementia- severe, anxiety disorder, depression, epilepsy, repeated falls, difficulty in walking and weakness. R78 was not her own responsible party.On 5/13/26 R78's bed was observed in the lowest position, and it was approximately 20 inches from the top of the mattress to the floor.During an interview with Corporate Nurse (CN) C on 5/13/26 at 11:19 AM the Surveyor questioned why R78 did not have a low bed as she had fallen out of bed on 5/7/26 and the progress notes indicated the facility had contacted hospice to provide a low bed for R78. There were no notes from hospice located in R78's Electronic Medical Record (EMR). No order for hospice services was currently in R78's Medical Record.Review of R78's physician orders revealed an ordered dated 5/12/26 for Admit to hospice 3/12/26. This order was obtained after the interview at on 5/12/26 at 11:19 AM.Review of R78's Kardex (nursing care instructions) dated 5/13/26 revealed, Fall/Behavior/Comfort Interventions: 5/7 - Hospice to provide bed that goes all the way to the floor with a mat next to bed.Review of R78's progress note dated 5/7/26 at 9:16 AM revealed, Resident was observed laying on her left side next to her bed curled up in a ball. Pt (patient) did strike her head has a laceration at the top inside her left ear area was cleaned off.(Name of Hospice) is ordering a bed that goes to the floor with a mat next to bed.There were no hospice notes located in R78's Electronic Medical Record (EMR).Review of the Care Plan for R78 did not reveal a Hospice Care plan had been formulated.Review of the EMR did not reflect documentation of Hospice services that had been provided to R78.R92Review of R92's admission Record dated 5/12/26 revealed he was admitted to the facility on [DATE] and had diagnoses that included: Aphasia (loss o ability to understand or express speech caused by brain damage), cerebral infarction (stroke), Parkinson's disease, and weakness. R92 was not his own responsible party.R92 was observed on 5/12/26 at 10:46 am sitting in the day room on his nursing unit. R92 had hair that was 3 to 4 inches long and it was not combed. R92 had facial hair that was approximately 1/4 inch long. R92 did not respond to his name or vocalize any words when asking him questions.Review of R92's picture on his admission Record dated 5/12/26 revealed his hair was short and combed and his facial hair was not present.During an interview with the Director of Nursing (DON) and Corporate Nurse (CN) C on 5/12/26 at 1:12 PM, R92's care plan and admission Record photo were reviewed. R92 Activities of Daily Living (ADL) care plan revealed he wanted to be shaved. The hospice book (not part of R92's medical record) was reviewed and revealed hospice was providing showers two times a week. There was no indication of R92 refusing shaving or any care. No hospice documentation was located in R92's Electronic Medical Record (EMR). The DON said the nurse should speak to the hospice staff and document care. The DON was not aware hospice notes had not been placed in R92's electronic medical record or reason why R92 had not had a haircut and had not been shaved.Review of R92's ADL (Activities of Daily Living) care plan dated 1/4/26 revealed, one intervention for hospice, Hospice, (name of hospice service) Nursing weekly; HHA (hospice health aide) 2 times a week, SW (social work) as needed. The care plan did not reflect any documented resident-centered goal or individualized interventions for hospice services. Review of R92's Electronic Medical Record (EMR) did not include any notes of services provided in the last two weeks.

Based on observation interview and record review, the facility failed to provide services to one Resident (R95) to maintain grooming standards. Findings include:Review of the admission Record reflected R95 admitted to the facility 3/3/2026 with diagnoses that included Parkinson's Disease, Difficulty in Walking and Weakness.On 3/30/2026 at 2:00 PM, an observation and interview were conducted in the room of R95 with the Resident and Family Member (FM) P. It was observed that R95 was unshaven. FM P reported that R95 was rubbing his face often as he was not used to having facial hair. FM P reported she was not sure if the facility would shave the Resident although a nurse did shave the Resident once. FM P reported R95 was scheduled for showers on Tuesdays and Saturdays. FM reported this past Saturday, though, she noted that R95 was unkempt but staff told her the Resident refused a shower earlier that day. FM P indicated she questioned the refusal but that R95 did get a shower after she asked staff to shower the Resident.On Tuesday, 3/31/2026 at 11:39 AM, an observation and interview were conducted with R95 in his room. R95 appeared to have been given a shower but had additional facial hair growth from the previous day. R95 reported he was not trying to grow a beard and had been wanting to get the facial hair mowed.On 3/31/2026 at 1:45 PM, at the room of R95, the Resident was observed in a wheelchair in the bathroom with FM P who was shaving him at the sink. FM P reported she asked staff to transfer the Resident to the wheelchair from the recliner so the Resident could be shaved.On 3/31/2026 at 2:24 PM, an interview was conducted with the Director of Nursing (DON) in his office. The DON reported residents were offered showers twice a week and were offered to be shaved on shower days. The DON reported that if a resident refused to shower, they were re-approached twice more then the nurse was to be informed of the refusal. The DON indicated refusals were documented. The DON reported that R95 is offered showers on Tuesday and Saturday and that R95 did get a shower this past Saturday. The DON was informed that the Resident got the shower because FM P requested this after staff claimed the Resident refused. The DON reported that R95 did get a shower on this day of this interview. The DON was informed that R95 was not shaved as it was indicated that this was to be offered on shower days and that FM P was observed shaving the Resident in his bathroom prior to this interview.

Based on observation, interview, and record review, the facility failed to provide services to gauge and ensure the activities of daily living (ADLs) did not diminish for one Resident (R95) of two residents reviewed for ADLs. Findings include.Review of the admission Record reflected R95 admitted to the facility 3/3/2026 with pertinent diagnoses that included Difficulty in Walking and Weakness. Review of the Minimum Data Set (MDS a tool used to assess a resident's status) Section A reflected R95 admitted from a hospital for short-term care with Section O, Special Treatments, Procedures, and Programs, reflected R95 was receiving physical and occupational therapy.On 3/30/2026 at 2:00 PM, an interview was conducted with Family Member (FM) P in the room of R95. FM P reported R95 was at the facility for therapy but had not progressed enough to go home. FM P reported therapy was going well but progress was slow. FM reported a second appeal had been filed to extend the stay of the Resident as the first appeal had been denied. FM P reported R95 had therapy every morning but would just sit in the recliner the rest of the day. FM M reported the only time staff had walked with R95 was to assist the Resident to the bathroom but no other time. FM P reported she had asked several staff if the family could walk the Resident in the hall during the day but were told no and that only a nurse could walk the Resident. FM P reported staff did not offer to ambulate R95 despite having been asked by family that R95 get up more during the day. FM P indicated she felt progress toward home discharge would improve if R95 did not spend so much of the day sedentary.Review of the Care plan for R95 reflected a Focus of Altered functional mobility and ADL's (Activities of Daily Living) related to Parkinson's Disease that caused unsteady gait, poor balance, Review of the interventions reflected, Resolved: Walking/Ambulation Therapy Only resolved on 3/10/2026. This indicated that after 3/10/2026 staff could walk with R95 as the Resident tolerated. R95 Current interventions for Transfer and Walking/Ambulation required One assist with 2WW (two wheeled walker). Also, that staff would assist with toileting before and after meals. Review of the Goal for Altered functional mobility plan of care for R95 reflected the only staff listed for the Goal was PT/OT (Physical Therapy/ Occupational Therapy) which indicated that nursing staff were not included in the plan of care for the Residents mobility. This Care Plan also reflected that R95 prefers to sleep in his recliner. This indicated that, outside of Therapy sessions and toileting, no plan was offered R95 for tolerable intermittent mobility for the Resident from his recliner.On 3/31/2026 at 11:39 PM, R95 was observed returning to his room with Occupational Therapist (OT) Q. R95 was wearing a gait let and was using a 2 wheeled walker as he was assisted by OT Q to the recliner in his room. OT Q reported that R95 continued to improve but had not yet reached his maximum potential yet. During a follow up interview conducted 4/1/2026 OT Q indicated that facility staff could walk the Resident if the precautions listed in the Care Plan were followed. The Care Plan was reviewed at this time and OT Q verified that there was nothing in the Plan of Care that prevented staff from ambulating with the Resident.On 3/31/2026 at 2:24 PM, an interview was conducted with the Director of Nursing (DON) in his office. The DON was informed that FM P was concerned that, outside of therapy, R95 was mostly sedentary sitting in his recliner but were told by staff the family could not ambulate the Resident. The DON was informed that despite family voicing this concern the facility staff did not offer to ambulate R95. The DON indicated that this concern had not been conveyed to him but that we could get him (R95) on a walking program. The DON reported that R95 was considered to be on the facility rehab (rehabilitation) side and not on the LTC (long-term care) side. The DON reported that the LTC side had a restorative program with range of motion being performed and walk to dine and walk to Activities was performed by floor staff for the residents on that side of the facility.

Based on observation, interview and record review, the facility failed to implement interventions to promote healing and prevent worsening of a facility acquired pressure ulcer for 1 resident (R7) out of 1 resident reviewed for pressure ulcers. Findings Include:Resident #7 (R7)Review of an admission Record reflected R7 admitted to the facility with diagnoses that included lumbar spina bifida without hydrocephalus, pressure ulcer of left heel stage 2 (partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister), pressure ulcer of left buttock, unstageable (a severe wound with full thickness tissue loss, fully covered by slough or eschar, making its true depth hidden).Review of a Physician Progress Note dated 2/2/2026 reflects Stage IV pressure injuries of left heel and left ischium . Plan: . Cleanse left heel wound with wound cleanser, normal saline, or soap and water and apply Medihoney, cover with Mepilex foam bordered dressing, and apply heel cushion boots every shift. Check skin daily. Continue position changes at least every 2 hours and pressure offloading measures. Encourage high protein diet, proper hygiene, and Foley catheter care to avoid skin breakdown and promote healing.Review of an order dated 12/12/2025 reflected apply heel cushioned boots to bilateral feet to offset pressure. remove boots check skin daily to heels, every shift for let inner heel wound.Review of a Care Plan initiated on 6/10/2024, revised 1/05/2026, indicated R7 had Actual skin impairment to left heel, blister. Interventions in the care plan did not include ensuring R7 wore protective heel cushion boots to relieve pressure on the feet and heels. During an observation on 3/31/2026 at 9:24 AM, R7 was seen in a Broda chair (a pressure relieving, tilt-in-space chair), both heels pressed on the straps of the chair, no heel cushion boots were in place. During an observation on 3/31/2026 at 11:18 AM, R7 was not in her room. Bilateral heel cushion boots were noted on the recliner chair. During an observation on 3/31/2026 at 11:20 AM, R7 was observed being assisted to eat in the main dining room. No heel cushion boots were observed on R7's feet. During an observation on 4/1/2026 at 8:36 AM, R7 was observed in a Broda chair in her room, heel cushion boots were not in place. The heel cushion boots were on the recliner chair in the resident's room. During an observation on 4/01/2026 at 10:15 AM, R7 was observed in a Broda chair in her room. Her feet/heels were resting on the straps of the chair; the heel cushion boots were not in place. The heel cushion boots meant to protect the resident's heels were on the recliner chair in the room.During an observation on 4/1/2026 at 11:18 AM, R7 was observed in a Broda chair in the dining room being assisted to eat lunch. R7 did not have heel cushion boots in place, her heels were resting on the straps of the Broda chair. Review of the March 2026 MAR-TAR for R7 reflected apply heel cushioned boots to bilateral feet to offset pressure. Remove boots check skin daily to heels, every shift for let inner heel wound. The intervention was documented as done during the day shift on 3/31/2026 despite the boots not being observed on R7 for the first several hours of the day. Review of the April 2026 MAR-TAR for R7 reflected apply heel cushioned boots to bilateral feet to offset pressure. remove boots check skin daily to heels, every shift for let inner heel wound. The intervention was documented as done, despite two observations on the morning of 4/1/2026 that the heel cushion boots were not in place. During an interview on 4/1/2026 at 11:30 AM, Licensed Practical Nurse (LPN) J reported that she documented R7's heel cushion boots were in place because she was sure she saw them on the resident first thing in the morning. LPN J did not know when or why the boots had been removed. During an interview on 4/1/2026 at 11:35 AM, the DON reported R7 should have the heel cushion boots in place while she was out of bed and said perhaps the order should be changed to every 4 hours so that there would be eyes on the resident more often to ensure the interventions remained in place. The DON was not aware that the intervention was not mentioned in the Care Plan.Review of a policy Skin at Risk Assessment Documentation, Staging & Treatment, revised 1/2020 reflected the purpose of the policy was To provide prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. To limit the development of avoidable pressure ulcers and provide evidence based guidance on effective strategies to promote pressure ulcer healing.

Based on observation, interview, and record review, the facility failed to ensure safe transfer practices for 1 resident (R92) of 1 resident reviewed for accidents.Findings include:Review of an admission Record revealed R92 admitted to the facility on [DATE] with pertinent diagnoses which included Parkinson's disease and weakness.Review of a current activities of daily living Care Plan intervention for R92, initiated 1/4/2026, revealed resident transferred with a rocking Broda wheelchair.In an observation and interview on 4/1/2026 at 7:44 AM in the dining hall, Licensed Practical Nurse (LPN) D pushed R92 to a dining table in his Broda wheelchair with both of his feet brushing the ground. R92 was not moving his feet to assist with movement. LPN D reported she was not sure where R92's wheelchair foot pedals were.In an interview on 4/1/2026 at 8:20 AM, Registered Nurse (RN) Clinical Care Coordinator (CCC) C reported resident's feet should not be in contact with the ground during wheelchair transfers unless they were moving and assisting the motion with their feet. RN CCC C reported resident's feet should either be elevated off the ground or resting on foot pedals to prevent injury during wheelchair transfers.

This citation is related to intake # 2804821 Based on interview and record review, the facility failed to follow standards of care for one of two resident's (Resident #102) reviewed for peripherally inserted central catheter care. Findings:Resident #102 (R102)Review of an admission Record revealed R102 was a [AGE] year-old female, admitted to the facility on [DATE] with pertinent diagnoses of a right hip fracture that required surgical repair and the use of a PICC line (peripherally inserted central catheter) to administer antibiotics for a urinary tract infection. Review of a nursing admission Assessment for R102 dated 02/26/26, revealed the notation .PICC line noted to the right upper arm. The assessment, completed by a licensed nurse, (a) did not specify the condition of the PICC line site and dressing (ie, was there any redness or swelling at the insertion site, was the dressing transparent (see through) and firmly attached to the skin), (b) did not specify the length of the catheter (necessary to be able to determine if the catheter gets pulled out or pushed in during care), (c) did not specify a measurement of the circumference of the arm just above the catheter insertion site, and (d) did not document the date the catheter and dressing were placed (the dressing must be changed at least every seven days, sooner if needed). Review of a nursing Skin Assessment for R102, dated 02/27/26, only noted .PICC line to right upper extremity. The assessment did not specify the condition of the PICC line insertion site, whether there were any signs or symptoms of infection, nor whether the dressing was intact. Review of a physician Progress Note for R102 reflected the physician saw R102 on 02/27/26 and made no mention of the resident having a PICC line, it's location, whether there were any signs or symptoms of infection at the site, or what the PICC line was being used for. Review of a nursing Skin Assessment for R102, dated 02/28/26, did not reveal the condition of the PICC line insertion site or if there were any signs or symptoms of infection noted. Review of a nursing Skin Assessment for R102, dated 03/01/26, only noted .PICC line to right upper extremity. The assessment did not specify the condition of the PICC line insertion site, whether there were any signs or symptoms of infection noted, nor whether the dressing was intact. Review of all Progress Notes for R102 revealed no documentation that the resident had a PICC line and that it was being monitored every shift. During an interview on 04/01/26 at 8:55 AM, the Director of Nursing (DON) stated that the expectation for caring for a resident with a PICC line included physician orders for (a) flushing the catheter before and after the administration of medications through the catheter and what type of solution used to flush the catheter, (b) monitoring the insertion site of the catheter every shift, (c) and checking the measurement of the catheter at admission and each time the dressing was changed. Review of an Electronic Treatment Administration Record (Etar) for R102, dated February 2026, reflected no physician orders for flushing the catheter before and after medication administration nor physician orders for monitoring the catheter insertion site every shift for signs and symptoms of infection. Review of an Electronic Treatment Administration Record (Etar) for R102, dated March 2026, reflected no physician orders for flushing the catheter before and after medication administration nor physician orders for monitoring the catheter insertion site every shift for signs and symptoms of infection. Review of Care Plans for R102 reflected that a specific care plan (a document used to identify the specific needs of a resident and and interventions that staff use to help the resident reach goals in their care) for the use and care of a PICC line had not been developed for R102 at the time of admission nor at anytime during her five day stay at the facility. Review of a ''Kardex (a quick reference care guide that direct care staff use to find important care and safety instructions specific to a resident) for R102 did not reflect instruction for blood pressure not to be taken in the right arm. Review of the EHR (electronic health record) revealed R102 was emergently transferred to the hospital on the morning of 03/02/26. Review of Hospital Records dated 03/02/26, revealed the following observations and treatments initiated for R102: (a) sepsis (infection) workup was initiated as the patient was hypotensive (low blood pressure), tachycardic (fast heart rate), and confused, (b) concerning inflammation (swelling) noted around the PICC line, (c) the PICC line was removed and the tip was sent for culture, and (d) the culture completed on the tip of the PICC line was positive for Candida albicans.

Based on observation and interview, the facility failed to maintain comfortable room temperatures for 2 Residents (R58 and R60) of 2 residents reviewed for comfortable room temperatures.Findings included: Review of R60's admission Recorded dated 5/12/26 revealed he was admitted to the facility on [DATE] and had diagnoses that included: Dysarthria (slow or slurred speech) and Anarthria (speech sound disorder resulting from a neurological injury), dysphonia (hoarseness of voice), Parkinson's disease, difficulty in walking and weakness. He was his own responsible party.Review of R60's Brief Interview for Mental Status (BIMS), a cognitive assessment dated [DATE] revealed he scored 15/15 (normal cognition).R60 was observed in his room on 5/12/26 at 9:31 AM, sitting in a recliner with a blanket over his head and body. When asked why he had a blanket over his head he responded because he was freezing cold. On 5/12/26 at 9:44 AM, Maintenance Worker (MW) J came to R60's room after he was notified by nursing that R60's room was cold. MW J used an ambient thermometer to take the temperature of the wall a few inches behind the chair R60 was sitting in and it read 68.2 degrees. There was no thermometer in R60's room to measure the room temperature. MW J said, they have difficulty maintaining room temperatures in this part of the facility because it has a wall radiator and ceiling vent heat. R60 said he turned on the ceiling heat system when he received the complaint about the room temperature. The ambient temperature of the heat vent was 105 degrees. He said it would not take long to get the room up to 72 degrees. R60 agreed 72 degrees would be comfortable. MW J denied any knowledge of R60 or other residents having concerns about room temperatures in this part of the building. He denied any ongoing monitoring of room temperatures in that part of the building.R58Review of R58's admission Record, dated 5/12/26 revealed she was admitted to the facility on [DATE] and had diagnoses that included: weakness and difficulty in walking. R58 was her own responsible party.Review of R58's Brief Interview for Mental Status (BIMS), a cognitive assessment dated [DATE] revealed she scored 15/15 (normal cognition).On 5/12/26 at 10:55 AM R58 was observed in her room sitting in room with her husband. R58 said she had been having problems with the room temperature. Her husband purchased 2 thermometers and put one on two walls toward the middle of the room. R58's husband said temperatures have gone down to 60 and 65 degrees at night. R58 was expressed the facility had indicated they had done everything they could do because it was an old heating system. R58 stated staff get her extra blankets but she would prefer a warmer room.During an interview with the Nursing Home Administrator (NHA) on 5/12/26 at 11:22 AM, he denied knowledge of R60's room temperature concerns and acknowledged he was aware R58 had room temperature concerns but believe he had resolved R60's room temperature concerns. A request was made for documentation related to room temperature concerns for the nursing unit where both R58 and R60 were located. (Both residents were located on the same unit a few rooms apart).Upon exit on 5/14/26 at 3:19 PM, the NHA emailed a copy of room temperatures taken for multiple rooms on R58 and R60's nursing unit. The temperatures were taken at night, and they were all above 72 degrees. No information was provided related to the when the NHA had become aware of the concern, any actions that were taken prior to the Surveyor informing him of the temperature concerns or ongoing efforts to ensure residents have comfortable room temperatures maintained.

Based on observation, interview, and record review, the facility failed to maintain clear and concise medical records for two residents (R78 and R9) of 20 residents whose records were reviewed.Findings include:Resident #78 (R78) Review of an admission Record revealed R78 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and depression. Review of R78's Physician's Orders revealed an order active 3/31/2026 to place a bordered foam dressing on her forehead every 7 days and PRN (as needed) if the bandage became soiled or loose until healed. In an observation on 3/31/2026 at 7:32 AM in the dining hall, R78 had a dressing on her right and central forehead dated 3/31/26. In an observation and interview on 3/31/2026 at 11:54 AM in the dining hall, R78 no longer had a dressing on her forehead, revealing two wounds that R78 was picking at. Registered Nurse (RN) E reported nursing staff sometimes replaced R78's dressing 10 times a day as she constantly removed the dressing. Review of R78's Electronic Medical Record (EMR) on 3/31/2026 at 3:31 PM revealed no documentation dressing changes had been completed in the month of March. In an interview on 3/31/2026 at 4:15 PM, RN E reported she had changed R78's forehead dressing 4 times already that day but had not documented any of these dressing changes. RN E reviewed the EMR to try to determine why the as needed dressing was not showing up for staff to document. In an interview on 4/1/2026 at 8:20 AM, RN Clinical Care Coordinator (CCC) C reviewed the EMR and reported R78 had a dressing order in place that was placed incorrectly so the dressing change did not generate as a task for nursing to complete. RN CCC C reported frequent as needed dressing changes were being completed but not documented for R78 in the month of March 2026. Resident #9 (R9)Review of an admission Record reflected R9 admitted to the facility with diagnoses that included fibromyalgia, dementia, depression and bipolar disorder. Review of Interdisciplinary Documentation dated 3/27/2026, reflected Spoke with DPOA (Durable Power of Attorney) regarding new abdominal x-ray orders and new medication from HCP (Heath Care Provider) visit on 3/26. (Name of DPOA) agrees with plan of care. No progress notes preceding or after the documentation on 3/27/2026 gave any indication R9 had been having difficulty, why an abdominal x-ray was ordered, or the results of the x-ray were found. Review of the Miscellaneous documents section of the Electronic Medical Record (EMR) did not reflect a recent HCP progress note that could account for the xray ordered or captured a HCP's visit with R9 on 3/26/2026. Review of Xray results reported on 3/30/26 indicated R9 did not have acute obstruction. The record indicated the indication for the x-ray was diarrhea. No further information related to R9's condition around this time was found in the EMR. During an interview on 4/01/2026 at 8:10 AM, the Director of Nursing (DON) reported that R9 will bring things up to the HCP sporadically without telling the nurse. The DON accessed a HCP progress note, dated 3/26/2026, from a system not accessible through the facility EMR. The DON reported R9 told the HCP she felt bloated, had large, hard bowel movements, and diarrhea. The DON said the HCP prescribed an anti-gas medication and abdominal x-ray for R9, despite a review of the EMR showing R9 did not meet criteria for the Bowel Protocol (a regimen implemented when a resident does not have a bowel movement for three days in a row). The DON said he would like to see the nurses document in the clinical record the reason why the resident was seen, as well as the outcome of the tests and medication change. The DON expected HCP progress notes to be accessed and attached to the resident's EMR withing 72 hours of being seen. The information you enter into a patient's individual medical record communicates within the patient's integrated health record the type and frequency of patient care delivered and provides accountability for the care you implemented. This information is then available for all members of the health care team in all settings to review. It is necessary to document all the nursing care you provide for each patient, including assessment data, nursing problems or diagnoses, interventions, and evaluation of patient responses, in the health record. Your data enable providers and outside reviewers of the medical record to track a patient's clinical course. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 365). Elsevier Health Sciences. Kindle Edition. The health care record provides a way for members of the interprofessional health care team to communicate about multiple aspects of patient care, including patient needs and response to care and therapies; clinical decision making; and the content and outcomes of consultations, patient education, and discharge planning. Information communicated in the health care record allows health care providers to know a patient thoroughly, facilitating safe, effective, timely, and patient-centered clinical decision making. The health care record is the most current and accurate, continuous source of information about a patient's health care status, allowing the plan of care to be clear to anyone who accesses the record. To enhance communication and promote safe patient care, you document assessment findings and patient information as soon as possible after you provide care (e.g., immediately after providing a nursing intervention or completing a patient assessment). The quality of patient care depends on your ability to communicate with other members of the health care team (see Chapter 24). When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur. The health record is an important means of communication because it is a confidential, permanent, legal documentation of information relevant to a patient's health care. The record is an ongoing current and accurate account of a patient's health care status and is available to all members of the health care team. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 366). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to revise the comprehensive care plan with updated interventions to prevent the development or worsening of a pressure ulcer for 1 resident (R7) out of 19 residents reviewed for care planning. Findings include: Resident #7 (R7)Review of an admission Record reflected R7 admitted to the facility with diagnoses that included lumbar spina bifida without hydrocephalus, pressure ulcer of left heel stage 2 (partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister), pressure ulcer of left buttock, unstageable (a severe wound with full thickness tissue loss, fully covered by slough or eschar, making its true depth hidden).Review of a Physician Progress Note dated 2/2/2026 reflects Stage IV pressure injuries of left heel and left ischium . Plan: . Cleanse left heel wound with wound cleanser, normal saline, or soap and water and apply Medihoney, cover with Mepilex foam bordered dressing, and apply heel cushion boots every shift. Check skin daily. Continue position changes at least every 2 hours and pressure offloading measures. Encourage high protein diet, proper hygiene, and Foley catheter care to avoid skin breakdown and promote healing.Review of an order dated 12/12/2025 reflected apply heel cushioned boots to bilateral feet to offset pressure. remove boots check skin daily to heels, every shift for let inner heel wound.Review of a Care Plan initiated on 6/10/2024, revised 1/05/2026, indicated R7 had Actual skin impairment to left heel, blister. Interventions in the care plan did not include ensuring R7 wore protective heel cushion boots to relieve pressure on the feet and heels. During an interview on 4/1/2026 at 11:35 AM, the DON reported R7 should have the heel cushion boots in place while she was out of bed and said perhaps the order should be changed to every 4 hours so that there would be eyes on the resident more often to ensure the interventions remained in place. The DON was not aware that the intervention was not mentioned in the Care Plan.Review of a policy Skin at Risk Assessment Documentation, Staging & Treatment, revised 1/2020 reflected the purpose of the policy was To provide prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. To limit the development of avoidable pressure ulcers and provide evidence-based guidance on effective strategies to promote pressure ulcer healing.

This citation pertains to intake number MI00151925 Falls Based on observation, interview and record review, the facility failed to provide adequate supervision, assistance and meaningful interventions to prevent falls for 2 residents (R1 & R6) of 4 residents reviewed for falls. Findings include: R1 Review of R1's admission record dated 5/8/25 revealed she was [AGE] years old, admitted to the facility on [DATE] and had diagnoses that included: Dementia, depression, difficulty in walking, and weaknesses. She was not her own responsible party. Review of R1's incident and accident report dated 1/21/25 at 23:00 (11:00 PM) revealed she had an unwitnessed fall. The description revealed, Called to room by CNA (Certified Nurse Aide), I observed R1 sitting on her bottom with her legs straight out in front of her. Her back was towards her bathroom door and her legs were facing her bed. R1 stated that she went to the bathroom and was trying to get back to her bed and she fell on her bottom. After Immediate Action Taken was Encourage resident to attend activities and come to common area for increased visibility. Staff interview revealed that R1 had been observed walking in her room at 10:30 PM and she was assisted to a chair, R1 refused assistance to the restroom. When that CNA returned, she found R1 scooting across the floor on her bottom. The root cause was increased confusion, self-ambulating from restroom to bed, without using call light or asking for staff assistance. No new intervention to prevent falls was located. Review of R1's incident and accident report dated 1/31/25 at 23:45 (11:45 PM) revealed she had an unwitnessed fall. The description revealed, Nurse made aware that resident had fall in room. Upon arrival, resident laying on floor by bed. When asked resident states I was seeing if I could walk. Interviews did not reveal any information about prior care or condition. It was unclear if she had been in bed, if she had slept or when she had last used the restroom. The immediate action taken revealed, touch pad call light added. The root cause was the resident room relocated x 3 over the last 2 weeks due to structural damage to facility, resulting in increased confusion to the resident. Review of R1's incident and accident report dated 2/5/25 at 6:15 AM, revealed she had an unwitnessed fall. The description revealed, Notified by CNA that R1 was observed on the floor in her room. Upon entering the room, observed R1 laying on her left side facing her bed with her lap blanket underneath her and her bed blanket on top of her. Her walker was to the left of her. I don't know what I was doing. I must have fallen from my bed. Immediate Action Taken revealed, Care plan reviewed and updated with pad alarm for immediate intervention as R1 does not use her call light and does not understand her limitations. The conclusion revealed, R1 was observed 15 minutes prior to the fall resting in her recliner, reading a book. She had been toileted less than 2 hours prior to the incident. The root cause was, R1 continues to be self-determined to transfer and ambulate. She is non-compliant with using call light for assistance. Resident was attempting to make her bed and her feet got caught in her blanket and she fell . The immediate intervention was the same as the fall on 1/31/25 which was to add a touch pad alarm. Review of R1's incident and accident report dated 2/6/25 at 9:20 AM revealed, Staff witnessed the resident tipping out of her wheelchair and yelled for help and ran to catch her. Staff managed to get a hand under her head but was not successful in preventing her head for striking the floor. The immediate action was to send R1 to the emergency room . The root cause was R1 was non-compliant with medication acceptance causing her to become hypotensive. No new intervention to prevent injury was located. Review of R1's incident and accident report dated 2/19/25 at 11:45 AM revealed, Resident was seated in the dining room as lunch was being served. This staff member was preparing meds (medications) at the med cart and heard a thunk sound and when I turned around, I observed this resident sitting on the floor next to her wheelchair in the dining room by the wall. Immediate action was to add a pad alarm to her wheelchair, bed and recliner. The root cause was R1 is self-determined. Review of R1's incident and accident report dated 3/14/25 at 19:15 (7:15 PM) revealed, Nurse was called to room R1's room where resident was observed laying on floor next to recliner head facing doorway, legs straight out towards the bed. The alarm pad was not in chair. Call light not on. Immediate action taken was reminders to put the alarm pad in place. The root cause was increased confusion related to UTI (urinary tract infection). Review of R1's incident and accident report dated 3/22/25 at 8:45 AM revealed, Resident was observed on the floor in front of her wheelchair in the dining room today. Staff heard a thud and turned to observe this resident on the floor. The resident appeared to be asleep in her wheelchair before the incident and could not tell us what had happened. The immediate action with to provide a different style wheelchair and having therapy evaluate positioning. The root cause was the resident was sleeping in her wheelchair, leaning forward and fell to the floor. During an interview with the Director of Nursing (DON) on 5/7/25 at 3:15 PM, R1's fall incident and accident reports were reviewed. The policy did not include doing an investigation or how to do a root cause. The DON was not always able to determine from the investigations what R1's behaviors were, or care was prior to her falls. Review of the falls and care plan revealed that R1 lacked safety awareness and required supervision during waking hours and needed to be in a supportive chair to prevent falling. The review of these records revealed some of the interventions were repeated at times, no new interventions were implemented at times and on one occasion an intervention that had been implemented was not in use. The DON did not know R1's wake or sleep patterns and was unaware of any structured activities or tolerance to being in areas where she could be observed when she was awake. When asked about meaningful interventions for each incident and how to prevent another fall, the DON could not elaborate the root cause and did not locate any interventions in R1's care plans to ensure R1 would be supervised when awake and anticipate her needs. R6 Review of R6's admission assessment dated [DATE] revealed she was [AGE] year-old, admitted to the facility on [DATE] and had diagnoses that included: epilepsy, dementia, depression, difficulty walking and weakness. R6 was not her own responsible party. R6 was observed in her nursing unit dining room on 5/6/25 at 12:00 noon. At approximately 12:20 PM, R6 wheeled herself out of the dining room to a restroom around the corner from the dining room. Four staff were in the dining room at that time assisting other residents eat at the far end of the dining room (they were not in eyesight when R6 left the dining room). R6 attempted to open the bathroom door and when she was not able to open it, she asked the housekeeper standing there with her cleaning cart for help to get into the bathroom. The housekeeper told her everyone is eating right now, and the housekeeper left the area without getting any staff to assist her. A few minutes later R1 asked the office staff sitting at the desk to help her get into the bathroom and that person said she could not help and left the area without getting R6 any help. R6 went back to her table to finish eating without getting any assistance to use the toilet. At approximately 12:30 PM, R6 wheeled herself over to the day room across from the dining room and transferred herself into a comfortable chair. R6 did not lock her wheelchair brakes and landed hard enough to make a thud when she landed in the chair. R6 had a strong urine smell that the Surveyor smelled from over 5 feet away when she was sitting in a comfortable chair. Review of R6's Activities of daily living (ADL) care plan dated revision on 12/18/24 revealed, R1 has altered functional mobility and ADL's related to advanced age with multiple comorbidities, decreased mobility and strength, recent illness, impaired cognition, high risk for falls and the need of staff assistance with transfers, mobility and toileting. It included the following interventions 1) initiated 6/22/22 able to leave on toilet: NO, 2) initiated 6/22/22 non-ambulatory, 3) transfer: Two assist (resident self-determines throughout the day; goals are to prevent injury. During an interview with the DON on 5/7/25 at 3:30 PM the observations of R6 not being within eyesight of staff while eating, leaving the dining room and attempting to get help to use the toilet were shared along with the unsafe transfer that was also unobserved by facility staff. R1 and R6 were both on the same nursing unit and the majority of the residents on that unit have dementia and lack safety awareness. The DON was disappointed that the staff R6 approached did not follow through with getting R6 help. The DON did not have any other information to add as to how the facility planned to ensure the residents on the Dementia unit would be provided with adequate supervision and assistance moving forward.

This citation pertains to intake number MI00151925 Based on observations, interviews and record review, the facility failed to respond timely to resident concerns for 2 Residents (R3 and R4) of 3 residents reviewed for concerns. Findings include: R4 Review of R4's admission assessment dated [DATE], revealed he was admitted to the facility on [DATE] and had diagnoses that included: traumatic subdural hemorrhage (brain injury) with loss of consciousness status unknown, cognitive communication deficit, difficulty walking, weakness, malaise (general feeling of discomfort, illness, or lack of well-being) and prostate cancer. During an interview with R4 and his wife on 5/7/25 at 1:15 AM they were concerned about meals, safety and lack of encouragement of activities since admission. R4 said he could not eat the food. He said he would not eat ground meat, the facility told him they did not have bacon, and the eggs were too dry. R4's wife brought him a cheeseburger, french fries and ice cream from a restaurant. R4's wife was very concerned because R4 had been in the hospital for the last 3 months and he had lost 50 pounds in the last year because he had cancer. R4's wife had been bringing snacks and meals every day because he would not eat the meat or most of the meals. R4 and his wife reported they had been complaining about the meals almost daily since admission. They did not recall seeing anyone from the dietary department since admission. They did not know how to file a concern form with the facility. R4 and his wife agreed to bring their concerns to management at this time. During an interview with the Dietary Manager (DM) E on 5/7/25 at 1:20 PM in R4's room, R4 and his wife reported the same concerns to DM E about the food and added that R4 wanted to be out of bed for breakfast and in the dining room for lunch and dinner. They added that R4 would not eat the food if it was cold. DM E explained that the food was served restaurant style in the dining room so the hot foods would be warmer than when he received them in his room. DM E said food preferences were to be completed on admission, and she did not have his food preferences. R4 and his wife said no one went over food preferences on admission. DM E found the food preferences paperwork on a table near the door in R4's room. When R4 complained about the ground meat she said she was following the Speech Therapist recommendations, and the Speech Therapist would have to evaluate him to change from ground meat to regular meat. During an interview with the Speech Therapist (ST) F on 5/7/25 at 1:50 PM in R4's room with R4 and his wife present, the ST F explained on admission she made his food orders as close to what she could do from his last hospitalization . ST F said the hospital had 7 different levels of diet and the facility only had 3. ST F saw R4 eat a french fry without any difficulty and saw that he had been eating a cheeseburger. She explained that based on his preferences she could change his diet. She saw the food preferences paperwork was still in his room and said normally she does complete that but for some reason she missed it. During an observation on 5/7/25 at 1:06 PM, R4 had lunch in his room on the bedside table. R4 was attempting to get into the bathroom and thought he had put the call light on, but the light was not on. The Surveyor assisted R4 with his call light. Certified Nurse Aide (CNA) G answered the call light. CNA G was asked if she had attempted to get R4 to the dining room for lunch and she said no he always ate in his room. (Request from 5/6/25 to eat in dining room for lunch and dinner was not communicated to the CNA). CNA G said R4 required the assistance of 2 people for transfers and left to get help. During an interview with the Director of Nursing (DON) on 5/8/25 at 11:00 AM, R4's food concerns, and desire for increased activity, food temperature, request to be up for meals and to the dining room were discussed. The DON said staff were aware of the need to complete concern forms and she was not aware of any concern forms for R4. She was not aware staff did not complete the food preferences or complete concern forms with R4 and his wife. R4 and his wife reported they had both made multiple complaints to staff about the food and wanted to be in the dining room for lunch and dinner. It was pointed out that after staff addressed the concerns on 5/7/25 they did not communicate to the Certified Nurse Aide that his preference was to eat in the dining room for lunch and dinner. No concern form was provided for the concerns made on 5/7/25 or previous complaints. R3 Review of R3's admission assessment dated [DATE] revealed she was admitted to the facility on [DATE] and had diagnoses that included: dementia, depression, and difficulty in walking. R3 was her own responsible party. During an interview with the DON on 5/8/25 at 10:28 AM, the surveyor asked the DON if she was aware of R3's requests to have family walk with her and have staff walk with her more. Record review revealed that R3 was discharged home with family on 4/11/25. The DON did not have personal knowledge of this request but was able to locate a care conference note dated 4/2/25 where the resident and family had requested to walk R3 to the bathroom daily instead of pushing her in the wheelchair. The note indicated the facility would not do this because they had determined it was not safe. The DON was not able to locate any reason why it was not safe for the Certified Nurse Aides (CNA's) to walk R3 to the bathroom as her care plan reflected. She only required 1 assist with a walker, family had been cleared to walk with her on 3/6/25 and the progress note dated 4/3/25 revealed she was able to walk 40 feet with contact guard assistance. The DON was not able to locate any risk/benefit information related to her request to be walked to the bathroom. Upon exit no information was located as to why the facility felt it was not safe for R3 to walk to the bathroom with the CNA's or any concern forms to address R3's concerns were provided. Review of R3's Activities of Daily Living (ADL) care plan dated 2/5/25 revealed, Ambulation: Therapy only resolved 2/14/25, 2/14/25 revealed, ambulation: one Assist with 2WW (two wheeled walker) follow with wheelchair. Review of R3's Interdisciplinary Documentation note dated 4/2/25 at 13:41 (1:41 PM) revealed, Resident and daughters state that Resident should be walked to the bathroom vs (verses) wheeled in wheelchair, and despite explanation as to why that would be unsafe daughter was talking over staff and was argumentative. Review of R3's Interdisciplinary Documentation note dated 4/3/25 at 10:56 AM revealed, Note Text: UR; (utilization review) PT/OT (Physical Therapy/Occupational Therapy), 1 PA (physical assistance with transfer with 2 WW (wheeled walker). Minimal assist with transfers. Ambulating max 40 ft (feet) CGA (contact guard assistance) with UB (upper body) ADL's (activities of daily living) Moderate assist with LB (lower body) ADL's.

This citation pertains to intake MI00151925 Based on observations, interviews and record review the facility failed to ensure that 1 Resident (R4) of 4 residents reviewed for accident hazards met the required bed rail and mattress hazards entrapment assessments. Findings include: Review of R4's admission assessment dated [DATE], revealed he was admitted to the facility on [DATE] had diagnoses that included: traumatic subdural hemorrhage (brain injury) with loss of consciousness status unknown, cognitive communication deficit, difficulty walking, weakness and malaise (general feeling of discomfort, illness, or lack of well-being. Review of the Michigan Department of Consumer and Industry Services Guidelines for Use of Bed Rails in Long Term Care Facilities, dated March 1, 2001, revealed, II. Properly Fitted Mattresses and Initial Bed Rail Installation. A. Since the size of the resident varies, a long-term care facility must document that the equipment chosen was assessed in relation to the specific resident for whom it is used to avoid the possibility of serious injury or death from entrapment or slipping through gaps created by body weight, body size, or bed, rail, mattress configurations. The maximum acceptable gap of the resident must be recorded in the medical record at the time the bed rail is installed for that resident. B. In an occupied bed, the space between bed rail and mattress and between the mattress and head or foot board can be no greater than 2.5 inches on any side. If the medical record indicates a smaller gap is required, the Department will require the long-term care facility to comply with the smaller measurement. C. Foam edges are acceptable to reduce gaps if they meet the fire safety standards and are not worn or otherwise rendered ineffective. D. The long-term care facility may consider placing Velcro or other anti-skid material between the mattress and mattress deck to reduce mattress movement. III. Proper Maintenance of Bed Rails. When bed rails are used, the long care facility must document that it has monitored and maintained the mattress and bed rails as follows: A. On each of the first 5 days following initial use, the resident, bed frame, bed rails and mattress must be monitored by each shift to document proper fit of and to ensure that the maximum distance between components for that resident, as recorded in the medical record, is not exceeded. The monitoring must ensure that the resident's weight, movement, or bed position is not exceeded. The monitoring must ensure that the resident's weight, movement, or bed position is not creating gaps that could potentially entrap the resident's head or other body parts. If gaps in excess of the maximums acceptable for the residents are being created, the record must document corrective actions taken. On 5/7/25 at 8:40 AM, R4 was observed sitting at the edge of his bed eating. The mattress at the foot of the bed had shifted and 6 inches of the metal bed frame was exposed. The mattress was a specialty mattress for pressure relief that was plugged into the wall which controlled air pressure. The bed had half rails on the top portion of the bed that covered most of the top section of the bed. R4 had a dressing over his left anterior lower leg and bruises on his right leg. R4 did not know where he got the bruises and injuries and reported he had short term memory loss after suffering a head injury from falling. The back of R4's thighs were resting on the metal bed frame. The gap between side rail and mattress with R4 in a sitting position was 5 inches. The mattress was compressed significantly. R4 said he could not stand without help. No staff were in the room at that time. During an interview with the Unit Manager (UM) C on 5/7/25 at 9:10 AM, the surveyor expressed concern about the R4's mattress sliding and concern that the gap between the mattress and rail could cause an entrapment issue. A request for the facility bed safety policy was requested along with all documents related to R4's assessments for bed safety. During an interview with the Maintenance Director (MD) D and the Nursing Home Administrator (NHA) on 5/7/25 at 11:25 AM, the Surveyor expressed concern for R4's bed safety and again requested the facility policy for bed safety. MD D had a form that he completes on residents with bedrails that indicated maximum gaps for residents' beds with rails. MD D keeps the forms in a book in his office. We went to R4's room, R4 was not in bed at that time. The mattress on the bed easily slid with light touch and when it was slid to the far-right position at the top it had a 2 3/4 inches gap and MD D reported his form allows for 2 3/8 inches (Michigan regulation is 2.5 inches). The resident was not in bed so the compressed measurement could not be accurately measured. However, the mattress was easily compressed with one hand to measure 3.5 inches at that same point. Review of R4's, Assessment/evaluation for conformance to FDA's bed system entrapment zones revealed the assessment was only evaluated on one day 4/29 (no year) or time of day. There was no indication if R4 was in bed at the time of the assessment. The form indicated the type of bed. For rail type Assist and Mattress/Overlay Type Air. All boxes were checked except the Zone 5 which did not apply to this bed. Zone 4 was the space/gap that forms between the mattress compressed by the patient, and the lowest portion of the rail, at the end of the rail. A dimensional limit of less than 2 3/8 inches measured between that mattress support platform and the lowest portion of the rail at the end to prevent neck entrapment. In addition, the V-shaped opening under the rails may present a risk of entrapment due to wedging. Nursing homes are to report entrapment events at this zone to the FDA. This form did not include the distance between the mattress and the rail as required by the State of Michigan. The maximum acceptable gap of the resident must be recorded in the medical record at the time the bed rail is installed for that resident. B. In an occupied bed, the space between bed rail and mattress and between the mattress and head or foot board can be no greater than 2.5 inches on any side. If the medical record indicates a smaller gap is required, the Department will require the long-term care facility to comply with the smaller measurement. Review of R4's medical record revealed one Restraint/Enabler assessment dated [DATE] at 9:23 AM (after the surveyor identified bed concerns). The Assessment revealed that R4 had bilateral assist rails to promote independent mobility. These are an assistive device. They do not restrict movement or his field of view. The assessment did not include any measurements or discussion of entrapment concerns. No other assessments, measurements or orders were located to assess R4's bed rail entrapment risk.

Based on observation, interview, and record review, the facility failed to ensure physical facilities and equipment were maintained in proper condition potentially affecting all residents that receive food and beverages from the kitchen. Findings include: On 1/29/25 between 8:45 AM and 10:30 AM the following concerns were observed during a tour of the kitchen and kitchenette: Observation of the kitchenette located outside the kitchen revealed the following concerns were shared with Dietary Manager (DM) L. Observation of the hand washing area revealed a missing employee hand washing reminder sign. Review of the FDA 2017 Food Code Section, 6-301.14 Handwashing Signage. Reflected the following, A sign or poster that notifies FOOD EMPLOYEES to wash their hands shall be provided at all HANDWASHING SINKS used by FOOD EMPLOYEES and shall be clearly visible to FOOD EMPLOYEES. Observation of two water filters (located on the wall that supplies water to the ice and water machines) were found undated/labeled. During the observation/interview with the DM L revealed she was unaware of when the filters were last changed and was unsure how long the filters were good for. DM L was asked to provide information regarding how long the filters were good for and when they were last replaced. The information was not received prior to the end of survey. Review of the FDA 2017 Food Code Section, 5-204.13 Conditioning Device, Location. Reflected the following, A water filter, screen, and other water conditioning device installed on water lines shall be located to facilitate disassembly for periodic servicing and cleaning. Review of the FDA 2017 Food Code Section, 5-205.13 Scheduling Inspection and Service for a Water System Device. A device such as a water treatment device or backflow preventer shall be scheduled for inspection and service, in accordance with manufacturer's instructions and as necessary to prevent device failure based on local water conditions, and records demonstrating inspection and service shall be maintained by the PERSON IN CHARGE. Further observation of this area revealed, two drain lines coming off the fresh water supply lines were discharging water directly onto the flooring beneath the ice machine (not into the drain) resulting in some standing water and a white substance coating the flooring beneath the ice machine and along the wall. Review of the FDA 2017 Food Code Section, 6-501.12 Cleaning, Frequency and Restrictions. Reflects the following, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. Observation of the kitchen revealed the coving (throughout the kitchen) had been removed from along the floor/wall junctures. Resulting in the area no longer being smooth, non- absorbent and easily cleanable. Review of the FDA 2017 Food Code Section, 6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. Reflected the following, (A) In FOOD ESTABLISHMENTS image cleaning methods other than water flushing are used for cleaning floors, the floor wall junctures shall be coved and closed to no longer than 1mm (one thirty-second inch). Further observation of the kitchen revealed the wall (located behind the steamer unit) needed repair due to visible wall joists resulting. The wall joists were visible because of missing and crumbling [NAME] board and missing coving along the floor/wall juncture. Review of the FDA 2017 Food Code Section, 6-501.11 Repairing. Reflected the following, PHYSICAL FACILITIES shall be maintained in good repair. Review of the FDA 2017 Food Code Section, 6-201.11 Floors, Walls, and Ceilings. Reflected the following, .floors, floor coverings walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE.

Based on observation, interview, and record review, the facility failed to follow policies and procedures for falls, implement meaningful care plan interventions, post fall neurological assessments, for two (R65 and R66), of three residents reviewed for accidents and supervision. Findings: R65 Review of the medical record reflected R65 admitted to the facility 7/30/24 with diagnoses that included Alzheimer's Disease and Parkinsons Disease. Review of the admission Minimum Data Set (MDS) dated [DATE] reflected the Resident was at risk for falls and had fallen twice since the admitted [DATE]. The cognitive evaluation conducted during the admission MDS of 8/6/24 for R65 reflected a Brief Interview for Mental Status (BIMS) score of 4. The following quarterly MDS of 11/5/24 reflected R65 was unable to complete the cognitive evaluation which indicated a cognitive decline since admission. On 1/29/24 at 9:44 AM, a request was submitted to the facility for the incident reports for R65 since 10/1/24. The facility provided documentation of ten incident reports of which nine were falls or suspected falls (10/21/24, 11/4/24, 12/1/24, 12/9/24,12/23/24, 12/27/24, 1/3/24, 1/4/24, 1/6/24), and one incident on 1/17/24 when R65 was found ambulating unsupervised. Review of the fall documentation of 12/27/24 at 9:00 AM reflected a staff member had just arrived at work and was putting away personal belongings. The staff member heard an audible alarm, came around a corner and observed R65 up walking, very unsteady on his feet and fell . The documentation reflected R65 was placed back into his chair, indicating that R65 was not supervised by staff prior to the arriving staff. Review of the incident documented 12/9/24 at 11:00 AM reflected staff identified a new bruise near the Resident's left eye measuring 2 centimeters (cm) x 4 cm, a reddened area on the top left of head, and a skin tear on the left shoulder. The documentation reflected R65 has been observed multiple times throughout the day attempting to self-ambulate. A Conclusion that an unwitnessed fall was suspected. The documentation reflected Neuros initiated (serial neurological evaluations) but no documentation of this was found in the EMR. The documentation reflected the Immediate Action was to have Therapy evaluate resident's ability to safely self-transfer from the floor to his bed/chair with no further documentation to indicate any immediate action was implemented to prevent future falls or increase supervision. The incident documented 12/27/24 at 9:00 AM revealed R65 had fallen while unsupervised. The Immediate Action documented reflected a referral was made to Therapy, the same as on 12/9/24. Review of the documentation of the falls R65 sustained on 10/21/24, 12/1/24, and 12/23/24 all revealed the same Immediate intervention to offer more activities and snacks (10/21/21 and 12/1/24), and encourage resident with activities (12/23/24). On 1/3/25 an unwitnessed fall was documented at 9:25 AM when R65 had slipped out of his chair in a common area. Following the fall the intervention implemented was to place a Dycem (a non-slip mat) in the Resident's chair to help prevent more falls. On 1/4/25 at 7:35 PM the fall documentation reflected R65 was observed slipping on to floor (sic). The documentation reflected, No Dycem in (R65's) chair at the time. Review of the non-fall incident documented on 1/17/24 at 3:30 AM reflected R65's Broda chair outside the Resident's bathroom door and he was standing in the bathroom. The documentation reflected R65 was .unattended, without his tab alarm attached to his shirt. The Resident was assessed and found to have a 2.4 cm x 4.2 cm abrasion on his right knee and an abrasion on his left knee. The documentation reflected R65 is severely cognitively impaired. Despite this and abrasions to the knees, staff accepted the Resident's explanation that I think I bumped it on the wall' (his knees) and that R65 said he did not fall. The documentation did not indicate why R65 was unsupervised in a Broda chair and not in his bed at 3:30 AM. Review of the medical record did not reflect that serial neurological checks were performed following this incident. On 1/30/25 at 1:19 PM an interview was conducted with the Director of Nursing (DON) in her office. The documentation of the incidents of R65 were reviewed. The DON was asked to provide any further information or documentation regarding these incidents. As of survey exit no additional information was provided. 37573 Review of a policy titled Accident/Incident Report Fall Management last revised 6/2018 revealed: Purpose: To establish a standard for accident/incident completion and to evaluate the facility responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and applying appropriate action. 5. The resident should not be moved until the initial evaluation is completed. If an injury is suspected, the resident should not be moved until Emergency Medical personnel arrive, unless prevention of such movement would result in increased risk for exacerbation of potential injury such as the case with a demented resident exhibiting behavior. d. the resident may be transferred via mechanical lift, backboard, or rolled onto a blanket and lifted by three or four caregivers to their bed. 6. It is recognized that not all falls can be prevented, the facility will utilize applicable elements of the systematic process of assessment, intervention, and monitoring to minimize fall risk and injury including: a. Fall risk screening b. Care plan interventions c. Evaluation of the response to interventions and balancing risk with the residents right to self-determination and independence d. Comfort Rounds and promotion of a culture of safety e. Assessment of sensory contributors f. Medication Review g. Orthostatic Hypotension h. Behavioral and Diagnosis risk factors i. History of falls with root cause analysis j. Pain management . 9. Following unusual occurrences, vital signs will be monitored as followed; a. Residents who have sustained a fall or resident observed on the floor resulting in no apparent injury will have their vitals taken immediately and as indicated by clinical assessment thereafter. b. A resident who sustains a head injury or suspected head injury will have the neurological assessment completed as indicated. c. Assessment will occur immediately and as indicated by the extend of the injury. Resident #66 (R66) Review of the Minimum Data Set (MDS) dated [DATE] for R66 revealed he admitted to the facility on [DATE] and is cognitively intact and has limited range of motion (LROM) on his upper extremity on one side. Review of the Electronic Medical Record (EMR) Diagnoses of weakness, difficulty walking, repeated falls, metabolic encephalopathy, orthostatic hypotension or metabolic encephalopathy, dementia, oxygen therapy, or fractures. Review of the Care Plan for R66 reveals no orthostatic hypotension or metabolic encephalopathy, dementia, oxygen therapy, or fractures. No transfers or mobility addressed before 1/2025. In an interview on 1/28/25 at 1:31 PM, the wife of R66 reported he had several falls at home and has had several falls here at the facility and broke some ribs. Review of the Incident/Accident Reports for R66 revealed the following unwitnessed falls: 9/6/24, 9/16/24, 9/28/24, 9/29/24, 10/8/24 at 4:25 AM, 10/15/24, 10/30/24, 11/7/24 at 11:00 AM, 11/7/24 at 10:30 PM, 11/12/24, 11/30/24, 12/4/24, and 1/12/25. Review of the Electronic Medical Record (EMR) for R66 revealed no post un-witnessed fall neurological checks for R66 for the following dates, 9/16/24, 9/29/24, 10/8/24, 11/7/24, 11/30/24, and 12/4/24. Review of the facility Neurological Assessment document revealed: FREQUENCY OF ASSESSMENT: Complete Neurological Assessment per facility policy. Use the following key for the frequency of neurological checks: Q [every] 15 minutes x 4 [hours]; Q 1hr [hour] x 4; Q 2hr x 8; Q 4hr x 6; Q 8hr x 3; then QD [every day] x4 (Total 7 days). Review of an Un-Witnessed Fall incident for R66 dated 9/6/24 at 6:45 PM revealed: Staff notified this nurse that resident was on the floor. Resident denied falling. Resident verbalized that he slipped out of his wheelchair. Root cause: [R66] denies falling, but rather slipping out of his wheelchair. [R66] has a Vitamin D deficiency identified in the hospital and was associated to recent falls. [R66] also has Orthostatic hypotension and metabolic encephalopathy. Resident is on Cholecalciferol for Vitamin D deficiency, midodrine for orthostatic hypotension. Conclusion: There is no violation of plan of care by staff. [R66] personal needs were met within one hour prior to the event. There is no allegation of abuse or neglect by [R66] or family. Care plan initiated for falls with interventions that included Encourage Non-skid Footwear shoes, Maintain personal items within reach, encourage to be in common areas between meals. Review of an Un-Witnessed Fall incident for R66 dated 9/16/24 at 1:45 PM revealed: . resident is on the floor between the toilet and the wheelchair, no shoes or socks on. [R66] stated he tripped transferring himself and lowered himself to the floor. Able to move all extremities on his own. Has scrape to left back. Root cause: Resident continues to self-transfer despite being a 1-assist with a 2-wheeled walker. [R66] was attempting to self-transfer in the bathroom without shoes or socks on, without using call light for assistance prior to ambulating, and slid down the wall and onto the floor. updated care plan for resident to be in common area between meals. Conclusion: There is no violation of plan of care by staff. Call light was in reach and wheelchair was functioning appropriately. [R66] personal needs were met within one hour prior to the event. There is no allegation of abuse or neglect by [R66] or family. Resident is receptive to interventions to decrease risk of injury yet continues to be self-determined to self-transfer. No new care plan interventions. Review of an Un-Witnessed Fall incident for R66 dated 9/28/24 at 8:00 PM revealed: During med pass this nurse heard a voice calling for help to get off the floor. This nurse ran to the room where the voice was coming from and found the resident sitting on the floor. Resident verbalized that he got up from his wheelchair to close the window shade and tripped over his wheelchair pedals and fell by his bed, then reached for the call light. Root cause: Continues to be self-determined and not use his call light and wait for assistance. Resident self-ambulated from his wheelchair and attempted to walk independently to the window to close the blind, and he tripped on his wheelchair pedals and fell on to the floor. Conclusion: There is no violation of plan of care by staff. [R66] personal needs were met within an hour prior to the event. There is no allegation of abuse or neglect by [R66] or family. Care plan interventions were: 9/28/24 [NAME] (sic) on wheelchair, Encourage toileting more frequently. Keep W/C (wheelchair) locked at bedside. Review of Un-Witnessed Fall incident for R66 dated 9/29/25 at 3:18 AM revealed: This nurse heard a voice screaming for help. I ran to the back hall and saw resident sitting in the doorway. He had a raised area and abrasion on his forehead, skin tear to his right nuckle (sic) and wrist. Resident verbalized that he was confused and didn't know where he was at the time. He got up out of bed to look for his wife and he hit his head on the floor. Root Cause: [R66] displayed increased confusion, Hospital Imaging results: CT head without contrast: Findings: Intracranial Hemorrhage . Small right frontal scalp contusion. Conclusion: There is no violation of plan of care by staff. [R66] personal needs were met within an hour prior to the event. There is no allegation of abuse or neglect by [R66] or family. No Care Plan interventions. Review of Un-Witnessed Fall incident for R66 dated 10/8/24 at 4:25 AM revealed: He stated he was attempting to transfer himself into his wheel chair (sic) from his bed to go to the bathroom but slipped and landed on the floor. He was able to reach his call-light to call for help. Root Cause: Resident is self determined and doesn't not (sic) use call light appropriately. Conclusion: New intervention is to keep wheelchair locked and at bedside and to encourage toileting more frequently. There is no violation of plan of care by staff. [R66] personal needs were met within an hour prior to the event. There is no allegation of abuse or neglect by [R66] or family. Intervention is already on the care plan from 9/28/24, no new intervention. Review of Un-Witnessed Fall incident for R66 dated 10/15/24 at 7:15 AM revealed: Root Cause: [R66] continues to be self-determined and was attempting to dress himself without asking staff for assistance. Resident states he was behind his wheelchair, attempting to change his shirt, and fell . Conclusion: There is no violation of plan of care by staff. [R66] personal needs were met within an hour prior to the event. There is no allegation of abuse or neglect by [R66] or family. Care plan interventions included: Reeducate resident regarding safety and the use of call light. Toilet riser with sides. Review of Un-Witnessed Fall incident for R66 dated 10/30/24 at 9:50 PM Staff notified this nurse that resident was on his knees by his bed. This nurse went to the room and saw resident on his knees. Call light was not on at the time of the fall. Residence (sic) verbalized that he was trying to get himself in to bed and he fell on his knees. Resident voiced that he does not need anyone's help to get in his bed. Root Cause: Resident continues to be self determined. Conclusion: There is no violation of plan of care by staff. [R66] personal needs were met within an hour prior to the event. There is no allegation of abuse or neglect by [R66] or family. Care Plan interventions included: Mattress on the floor by the bedside. Review of an Un-Witnessed Fall incident for R66 dated 11/7/24 at 11:00 AM revealed: Observed resident sitting on floor next to toilet and back resting on the wall. I was trying to go to the bathroom. Intervention: Frequent checks and offering toileting. Conclusion: There is no violation of plan of care by staff. [R66] personal needs were met within an hour prior to the event. There is no allegation of abuse or neglect by [R66] or family. The intervention is already on the care plan from 9/28/24. Review of an Un-Witnessed Fall incident for R66 dated 11/7/24 at 10:30 PM revealed: Staff notified this nurse that resident was on the floor in his room. Resident stated that he was trying to spread his blanket on his bed, and he fell out of his chair. Care plan was updated: Resident should not be left alone in room. Conclusion There is no violation of plan of care by staff. [R66] personal needs were met within an hour prior to the event. There is no allegation of abuse or neglect by [R66] or family. According to the care plan, his interventions dated 11/7/24 were: Resident should not be left alone by himself in the room. During this survey, R66 was observed alone in his room on 1/28/25 at 12:00 PM, 1/29/25 at 8:00 AM, 1/29/25 at 9:00 AM, 1/29/25 at 3:00 PM, and 1/30/25 at 11:00 AM. Resident was not observed outside his room in common areas with constant supervision. Review of an Un-Witnessed Fall incident for R66 dated 11/12/24 at 12:19 AM revealed: Resident observed on floor near recliner, yelling for help. Resident states he was going to the bathroom. Care Plan updated. Dycem (non-slip device) placed in recliner. Root Cause: Resident was attempting to self-ambulate from his recliner in the main living room to restroom without asking staff for assistance. [R66] does not recognize when his movements exceed his functional capabilities and attempts to self-transfer, despite being a 1-assist with a 2-wheeled walker for transfers and ambulation (not on care plan). Just prior to the event, [R66] was observed sleeping in his recliner by staff. Conclusion: There is no violation of plan of care by staff. [R66] personal needs were met within an hour prior to the event. Investigation does not include when his toileting needs were last met. The care plan intervention dated 11/11/24 (day before incident) included Dycem in recliner. Review of an Un-Witnessed Fall incident for R66 dated 11/30/24 at 2:36 AM revealed: Root cause: Resident has ulcerative colitis and had a flare up this morning. Resident had 5 watery stools. Resident was attempting to self-transfer to the toilet from his wheelchair and fell . He was attempting to provide care to self without using call light for staff assistance. Conclusion: There is no violation of plan of care by staff. [R66] personal needs were met within 30 minutes prior to the event. There was no care plan for ulcerative colitis and the previous care plan interventions were not followed. Review of an Un-Witnessed Fall incident for R66 dated 12/4/24 at 3:21 PM revealed: Root cause: [R66] was attempting to independently place his guitar into the guitar case that was on the floor in his room. He leaned forward in his wheelchair and fell forward onto the ground, resulting in abrasion to bilateral knees, right elbow skin tear, and abrasion to forehead. Care plan updated: If [R66] wants to play guitar, place case on bed for him to use contents without having to reach to the floor to not fall out of his wheelchair. This intervention is placed under Recreational Pursuits and was initiated on 11/19/24 by the social worker. Conclusion: There is no violation of plan of care by staff. [R66] personal needs were met within one hour prior to the event. Review of an Un-Witnessed Fall incident for R66 dated 1/12/25 at 8:13 PM, revealed: [R66] was heard by writer scream, Can somebody help me? . [R66] was found on all fours, hand and knees, kneeled in front of locked wheelchair (that had a Dycem pad securely flushed in wheelchair seat), with call light lying on the ground, next to the patient's hand . The writer kneeled down to help the patient and the patient arms gave out before she could reinforce the patients arms, and the patient hit his head approximately 2 from the ground on to the floor. Patient was then lowered to the ground . R66 had bruising on his forehead and wounds on his bilateral knees. Patient states, I was trying to pick things off the floor. I seen my remote and tried to grab it and slid out of my chair and I caught myself from hitting the floor. Care Plan updated to reinforce use of call light for staff assistance. Staff to continually re-educate. Conclusion: There is no violation of plan of care by staff. [R66] personal needs were met within one hour prior to the event. There is no allegation of abuse or neglect by resident or family. According to the Care plan, interventions on 1/13/25 included: Staff to continually reinforce call light use when resident needs assistance. Frequent rounding to offer resident assistance, reacher assistive device. Floor bed with high safety mattress. Anti-roll back to wheelchair. This was the last intervention that was revised on 1/28/25 during this survey. Review of a Physician Progress note dated 1/13/25 for R66 revealed: HPI (history of present illness): . history limited secondary to dementia. experiencing shortness of breath at times. Patient reports that oxygen is something new for him . patient also had a fall last night while sitting at the edge of the bed trying to grab something off the floor. Assessment/Plan: 1. Debility, 2. Orthostatic hypotension . 4. Anemia. Patient saturating well on 2 L (liters) O2 (oxygen) via nasal cannula, baseline does not require oxygen. Review of an Incident Report titled Other for R66 dated 1/16/25 at 2:57 PM revealed: Resident right rib pain to [Physician] on 1/14/25. X-ray on 1/15/25 shows acute nondisplaced fracture to right 10th rib. Review of a Physician Progress note dated 1/16/25 for R66 revealed: Assessment/Plan: 1. Debility, 2. Rib pain on right side, 3. Closed fracture of one rib of right side with routine healing, 4. History of fall, 5. Orthostatic hypotension. Review of the Care Plan for R66 revealed no specific fall care plan. The Activities of Daily Living (ADL) care plan revealed: FALL - RISK MANAGEMENT: Encourage Non-skid Footwear shoes, Maintain personal items within reach. encourage to be in common areas between meals. 9/28/24 [NAME] (sic) (Dycem-non-slip device) on wheelchair, Encourage toileting more frequently. Keep W/C locked at bedside. 10/15 Reeducate resident regarding safety and the use of call light. Toilet riser with sides. 10/30/24: Mattress on the floor by the bedside. 11/7/24: Resident should not be left alone by himself in the room. 11/11 Dycem in recliner 1/13: Staff to continually reinforce call light use when resident needs assistance. Frequent rounding to offer resident assistance, reacher assistive device. Floor bed with high safety mattress. Anti-roll back to wheelchair. Date Initiated: 09/06/2024. Revision on: 01/28/2025 No care plan interventions for falls on 9/16/24, 9/29/24, 10/8/24. In an interview on 1/30/25 at 9:37 AM, the Director of Nursing (DON) reported Staff know how to care for residents based on their care plans, which are inside the residents' closet doors in their rooms. When queried about the frequent falls R66 experienced, the lack of neurological checks after un-witnessed falls, the relevance of some interventions to fall prevention, and the repetitive copy-and-paste conclusions from the investigations stating There is no violation of plan of care by staff. [R66] personal needs were met within one hour prior to the event, the DON reported she did do a thorough investigation but may not be reflected in the reports provided. The DON reported she had more information in handwritten notes but were not available at this time or present in the EMR. She reported they addressed R66's falls in their interdisciplinary team (IDT) meetings. The DON acknowledged R66's care plan reflected frequent toileting, encourage to be in common areas, he is not to be left alone in his room, and encourage/educate call light use but these were not addressed in the investigation. The DON was informed that R66 was observed multiple times alone in his room and not in the common areas with supervision. The DON reported they are doing interventions but not always documenting it. When questioned about the call light intervention and the residents understanding of when or how to use it, the DON acknowledged the concern but did not have an answer. In an interview on 1/30/25 at 1:05 PM, the DON reported some of the falls that did not have neurological checks post un-witnessed falls had short term care plans in place where his vital signs and neurological assessments were done twice a day indicating the resident was being monitored, he just did not receive the frequent neurological checks. At the end that as of survey additional information was provided but did not address the concerns. Each patient has a different set of fall risk factors, so critical thinking must be applied during assessment to identify each patient's unique needs. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 415). Elsevier Health Sciences. Kindle Edition. Risk for falls. As you assess both a patient's health care and home environments, you simultaneously consider presence of fall risks. The identification of fall risks (e.g., impaired balance, reduced visual acuity) is essential to determine the targeted interventions needed to prevent falls. There are many fall risk-assessment instruments used by health care agencies. Most tools include risk categories based on age, fall history, elimination habits, high-risk medications, mobility, and cognition. Some include assessment for presence of patient care equipment (such as indwelling catheter or IV infusion) that makes mobility awkward. At a minimum the assessment needs to be completed on admission, following a change in a patient's condition, after a fall, and when the patient is transferred (AHRQ, 2018). Patients who are at risk for falling require ongoing assessments. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 420). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to inform the resident and/or the resident's responsible party, in advance of care, of the risks, benefits, and possible alternatives of treatment for the use of psychoactive medications for 1 of 1 resident (R71) reviewed for dementia care, resulting in the potential for the responsible party being uninformed of the resident's treatments and not able to choose to continue the treatments and/or choose an alternative preferred option. Findings include: A review of R71's Admission Record, dated 1/29/25, revealed R71 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, the Admission Record revealed multiple diagnoses that included Alzheimer's Disease, dementia with behaviors, depression, and anxiety. The Admission Record also revealed R71 had a Financial Power of Attorney (Durable Power of Attorney Q) and listed the resident and Durable Power of Attorney (DPOA) Q as the responsible parties. A review of R71's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 12/17/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed R71 was cognitively intact. A review of R71's Physician Determination of Decision Making Capability, dated 5/31/24, revealed R71 had been determined unable to make medical treatment decisions by their attending physician and a supporting physician/licensed psychologist. A review of R71's Specific Durable Power of Attorney for Personal and Medical Care, dated 1/17/23, revealed R71 had designated DPOA R and DPOA S (alternative) as the individuals who were to make medical decisions for R71 if they could no longer make medical decisions. A review of R71's Durable Power of Attorney form, dated 1/17/23, revealed R71 had designated DPOA S and DPOA Q (alternative) as the individuals who were to make financial decisions for R71 if they could no longer make financial decisions. A second review of R71's Admission Record, dated 1/29/25, failed to reveal any listing by name and/or contact information for DPOA R and/or DPOA S. A review of R71's January 2025 Medication Administration Record (MAR) revealed R71 was receiving Lexapro 20 milligrams (mg) for depression, Zyprexa 5 mg for delusions, and Ativan 0.5 mg for anxiety. A review of R71's Informed Consent for Medication for Lexapro, dated 8/12/24, revealed DPOA Q (R71's financial, not medical DPOA) had been informed on 8/8/24 of the reason for it's usage, the expected therapeutic goal, possible consequences of not taking the medication, the possible side effects of the medication's usage, and the ability to refuse to consent to R71 taking the medication at any time. A review of R71's Informed Consent for Medication for Zyprexa, dated 1/27/25, revealed DPOA Q (R71's financial, not medical DPOA) had been informed on 1/24/25 of the reason for it's usage, the expected therapeutic goal, possible consequences of not taking the medication, the possible side effects of the medication's usage, and the ability to refuse to consent to R71 taking the medication at any time. A review of R71's Informed Consent for Medication for Ativan, dated 1/27/25, revealed DPOA Q (R71's financial, not medical DPOA) had been informed on 1/24/25 of the reason for it's usage, the expected therapeutic goal, possible consequences of not taking the medication, the possible side effects of the medication's usage, and the ability to refuse to consent to R71 taking the medication at any time. A review of R71's progress notes, dated 3/14/24 to 1/30/25, failed to reveal any documentation that DPOA R and/or DPOA S had ever been contacted regarding R71's medical care/needs, including the risks, benefits, and possible alternatives of treatment for the use of psychoactive medications (medications that affect an individual's mental processes- e.g., antidepressants, anti-anxiety, and medications for delusions). In addition, R71's progress notes failed to reveal that the facility had ever talked to R71 specifically about the psychoactive medications she was taking. A review of R71's Interdisciplinary Documentation, dated 3/18/24, revealed R71's son (DPOA Q) informed the nurse that R71's other son (DPOA S- alternate medical decision maker) and his wife (DPOA R- primary medical decision maker) were R71's medical DPOA's. DPOA Q stated DPOA S had terminal cancer and could not make decisions for R71 anymore. The nurse told DPOA Q that she would relay the message to the social worker and have her call him. However, there was not any documentation that the message had been relayed to the social worker and/or that the social worker had followed up with DPOA Q regarding this information. During an interview on 1/29/25 at 1:40 PM, the Director of Nursing (DON) stated she called DPOA Q and he informed her that DPOA S passed away two days ago. She stated they do not have a phone number or contact information for DPOA R. The DON stated she was aware that DPOA Q had been notified every time that the facility needed medical decisions made, even though he was only listed as the Financial DPOA. The DON verified she could not find any documentation that DPOA R and/or DPOA S had participated in care conferences and/or been notified regarding making any medical decisions for R71, including the risks, benefits, and possible alternatives of treatment for the use of psychoactive medications.

Based on interview and record review, the facility failed to conduct a care conference timely for 1 of 18 sampled residents (R43), resulting in the potential for R43 and/or their responsible party not having an opportunity to participate in their person-centered plan of care and/or the planning process for their care. Findings include: A review of R43's Admission Record, dated 1/29/25, revealed R43 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R43's Admission Record revealed multiple diagnoses that included a cerebral infraction (stroke), dementia, and depression. A review of R43's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 11/12/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12 which revealed R43 was moderately cognitively intact. A review of R43's Physician Determination of Decision Making Capability, dated 8/16/24, revealed R43 had been determined to be unable to make medical treatment decisions by their attending physician and a supporting physician/licensed psychologist. A review of R43's electronic medical record, dated 8/8/24 to 1/30/24, revealed R43 had only one care conference on 8/12/24 (the Admission care conference). A review of R43's progress notes, dated 8/12/24 to 1/29/25, failed to reveal any attempts by the facility to schedule a care conference for R43 after the initial Admission care conference. During an interview on 01/30/25 at 11:50 AM, Social Services Director (SSD) F, confirmed R43 had not had a care conference where R43 and/or their responsible party would have an opportunity to participate in their person-centered plan of care and/or the planning process for their care since August 2024 (over 5 1/2 months ago). SSD F stated that they have not had one because R43 was going to court on 2/4/25 for guardianship and hopefully then we can finally get someone to come in to talk to about her care. SSD F further stated residents are supposed to have resident care conferences at least every 3 months, or sooner if the family requests one. A review of R43's Petition for Appointment of Guardian of Incapacitated Individual, dated 11/26/24, revealed the facility was petitioning the court to appoint a guardian because the current patient advocate is not acting consistent with the ward's (R43) best interests by not participating in care conferences. However, no care conferences had been scheduled, or attempted to be scheduled, since R43 was determined unable to make medical treatment decisions on 8/16/24. A review of R43's Notice of Hearing, dated 11/26/24, revealed R43 had a court date of 2/4/25 to petition for the appointment of a guardian. Therefore, according to SSD F, by the time the next care conference would be scheduled R43 would not have had a care conference in 6 months or more.

This citation pertains to intake # MI00148110 Based on interview and record review, the facility failed to provide increased supervision for 1 of 5 resident's (Resident #1) reviewed for falls, resulting in a fall with neck fractures and subsequent death. Findings: Resident #1 (R1) Review of an Admission Record revealed R1 was an [AGE] year-old male, admitted to the facility on [DATE], following a 13-day hospital stay for a left broken femur and multiple fractures of the pelvis. Other relevant diagnoses included highly impaired vision, hard of hearing, and chronic kidney disease. Review of R1's Hospital Discharge Summary dated [DATE] revealed, .Waxing and waning mentation, possible hospital delirium/sundowning: Issues with altered mental status possibly related to underlying dementia as well as need for pain medications with superimposed hospital delirium. Patient was alert and oriented x 3 upon evaluation during the day, difficulties happen at nighttime .Patient on day of discharge was doing very well. Alert and oriented x 3. Had no further issues with agitation at night. Pain was well controlled. Review of R1's Admission assessment dated [DATE] revealed R1 was alert and oriented to person, place, time, and situation .(R1) does have sundowners (confusion experienced in the evening through the night). Review of an Emar (electronic medication administration record) dated [DATE], revealed R1 was admitted to the facility and prescribed the following medications: Norco (an opiate pain reliever that causes sedation and confusion) ,d+[DATE] mg (milligrams) one tablet every 4 hours as needed, Robaxin (muscle relaxer that causes sedation) 500 mg one tablet by mouth four times a day, and Seroquel (an antipsychotic that causes sedation and confusion) 25 mg one tablet by mouth at night. The Seroquel had recently been prescribed and started while at the hospital due to possible hospital delirium/ sundowners. Review of a Provider Note dated [DATE] revealed, (R1) is at risk for falls due to medical condition and debility. Further review of the Emar, dated [DATE], reflected that R1 did not receive the prescribed pain medication Norco while at the facility until the morning of [DATE] at 7:49 AM. The last administered dose of Norco was given in the hospital, prior to R1's discharge to the facility, at 1:15 AM on [DATE], (R1 went greater than 2 days without prescribed pain medications). During an interview on [DATE] at 11:18 AM, Physical Therapist (PT) F reported that he assessed R1 on [DATE] following his admission. R1 was able to follow commands and stand but was unable to understand his weightbearing status and was made a hoyer lift transfer at that time. PT F reported that on [DATE] R1 was really confused and only bed mobility exercises were performed. During an interview on [DATE] at 9:42 AM, Nurse Practitioner (NP) D reported she had first assessed R1 on [DATE] and heard him moaning all day and visualized R1 throwing his legs over the bed and in constant motion which was likely indicative of pain. NP D reported that as she exited the facility on [DATE], she was notified by a licensed nurse that R1 was continuing to exhibit symptoms of pain and gave a verbal order to double the dose of Norco. NP D was not aware that the licensed nurses had not administered R1's Norco on [DATE] or [DATE]. During the same interview, NP D reported that she had ordered laboratory and diagnostic testing for R1 on [DATE] to ensure there was no other infectious process causing his agitation. NP D reported that she was not aware that when R1 admitted to the facility he was A&Ox,d+[DATE] and would have expected nursing staff to notify her of his change in mental status. NP D was not aware that the laboratory and diagnostic testing (chest x-ray) that were ordered on [DATE] had not been completed prior to R1's fall. Review of R1's Order Summary dated [DATE] revealed an increased order of Norco ,d+[DATE] mg two tablets by mouth every four hours as needed for pain. Review of R1's Care Conference Note dated [DATE] revealed, Resident was asleep and is currently in a mental state that prevents his participation .According to DPOA (durable power of attorney) A, resident was holding a conversation in the hospital and was very alert and oriented and had few memory issues .PT (physical therapist) F stated R1 had been unable to participate in therapy, and R1's decline has been very rapid . (There was no evidence that increased supervision/safety measures were implemented despite the Interdisciplinary Team noting a change in R1's cognitive status on [DATE]). Review of a Controlled Drug Receipt/Record/Disposition Form revealed that despite R1's acute change in cognition, R1 was given Norco ,d+[DATE] mg two tablets (the now ordered double dose) (a) on [DATE] at 7:49 AM and 4:00 PM, (b) on [DATE] at 3:12 AM, (c) on [DATE] at 3:37 AM and 7:55 PM, (d) on [DATE] at 1:04 AM, 7:10 AM, and 11:48 AM. Additionally on [DATE], R1 also received Robaxin 500 mg at 12:00 AM, 6:00 AM, and 12:00 PM. Both medications given during an acute change in condition, without increased supervision or safety measures put into place. Review of R1's Interdisciplinary Documentation dated [DATE] at 4:40 PM reflected that staff (a) heard a loud bang and entered R1's room, (b) found R1 laying on his left side on floor with feet still in the bed, (c) R1's face and head were reddened, (d) R1 had an abrasion to the top of the scalp, (e) moved R1 off the floor despite R1 not being able to answer any questions, and (f) received orders to send R1 to the emergency room . Review of R1's Hospital Documentation dated [DATE] revealed .Patient presenting as fall with multiple spinal fractures and with shock, suspect sepsis .It was reported that the patient was not at his typical neurologic (cognitive) baseline .septic shock, possibly secondary to sepsis due to pneumonia and urinary tract infection. Review of R1's Hospital Discharge Summary dated [DATE], revealed .Patient was noted to have injuries including C6 (sixth cervical vertebra) fracture, C7 fracture, possibly acute T1(first thoracic vertebra) and T2 compression fractures. Due to these injuries, the patient was admitted to the trauma service for admission .Discharge Condition: deceased . Review of R1's Death Certificate revealed the chain of events that directly caused the death .sudden death related to traumatic fall in adult resident facility. Spinal injuries include fractures, contusions, and compressions of the vertebral column, usually the result of trauma to the head or neck. The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage. Stabilization of the head and neck is done prior to moving the victim to prevent secondary injuries such as paralysis from destabilization of a cervical vertebrae fracture . (Diseases: Causes and Diagnosis Current Therapy Nursing Management (4th ed.). Pennsylvania: Springhouse.).

Based on observation, interview, and record review, the facility failed to monitor and prevent the development and worsening of pressure sores for one Resident (R39) of four reviewed for pressure sores, resulting in undocumented monitoring and worsening of pressure sores and increased pain. Findings: The Minimum Data Set (MDS) dated [DATE] reflected R39 admitted to the facility 10/12/23 with diagnoses that included Heart Failure and Renal Insufficiency. The MDS section M, Skin Conditions, reflected R39 was at risk for developing pressure sores but had no pressure sores at the time of admission. The Electronic Medical Record (EMR) document titled Wound Measurement dated 11/11/23 at 11:50 AM reflected that two new pressure wounds were identified on the right and left buttocks of R39. The documentation reflected a pressure wound on the Right buttock that measured 0.7 x 0.5 x 0.5 centimeters (cm) and was determined to be a Stage II ulcer. The documentation reflected another pressure wound on the left buttock that measured 0.7 x 0.4 x 0.1 cm and was also determined to be a Stage II ulcer. The document showed that the question #10, Is there tunneling or undermining? was answered Yes. However, no description of this was included. The narrative portion showed that R39 was known to refuse to lay down and spends her time in a recliner. The narrative reflected, Will meet with team and discuss preventative measures . Review of the EMR Treatment Administration Record (TAR) for November 2023 for R39 reflected treatment of the two pressure sores with the application a topical ointment twice a day began on 11/12/23. No cover dressing was ordered. Review of the EMR reflected a Short Term Care Plan Wound and Skin was initiated on 11/11/23. This Care Plan listed only the left pressure injury but identified the wound as a Sheer and not a pressure injury. The document reflected 9. Document compliance with (treatment and response to (treatment) (as needed). And 11. Weekly / (as needed) measurement of the area. The document did not reveal any repositioning guidelines. The Short-Term Care Plan did reflect that R39 was compliant 25 out of 28 entries for repositioning compliance. Review of the comprehensive Care Plan revealed a focus issue that R39 is at risk for impaired skin . The Goal of this issue reflected R39 will show improvement of impaired skin as evidence by .decreased measurements and/or prevention of avoidable impaired skin . Interventions for this Focus include: Measure open areas upon admission, weekly, and (as needed), Re-evaluate treatment and resident condition (as needed) with no improvement to wound appearance and/or measurements, Skin inspections with am/pm care and showering report abnormal (skin) to the charge nurse, and Assist with Repositioning ., Neither the comprehensive Care Plan nor the Short-Term Care Plan defined a repositioning frequency when R39 was At risk for impaired skin, or when impaired skin had been identified. Although the Wound Measurement documentation of 11/11/23 reflected that R39 was known to refuse off-loading of pressure areas the Short-Term Care plan documentation reflected that the Resident was largely compliant with repositioning measures. However, this Care plan did not give direction on repositioning frequency or that the team had formulated a plan. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention (EPUAP, NPIAP, PPPIA, 2019a). The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure (Maklebust and [NAME], 2016. A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominences (WOCN, 2016). [NAME], Review of the EMR Skin assessment dated [DATE] at 11:09 PM reflected only a surgical incision of the chest. The narrative portion of this Skin Assessment revealed no redness or open areas to body and did not include an assessment of the two Stage II pressure sores on the buttocks of R39. Review of the EMR Skin assessment dated [DATE] at 1:17 PM reflected Chest, Scar. The narrative portion of this Skin Assessment reflected (R39) has four small open areas on her left and right buttocks that have (ointment) being applied twice a day. She has preventative measures in place. The document did not reveal what these preventative or curative measures were. The document did not reflect any description of the status of the two pressure sores originally identified on 11/11/23 or any data of the two new additional areas as indicated by the narrative. Review of the EMR Skin assessment dated [DATE] did not identify any areas of concern but only a narrative review. The narrative review of the pressure wounds reflected identical wording as on 11/21/23 and the document did not include a description of the status of the four open areas indicated in the narrative. As of 11/30/23 the EMR did not reveal any documentation of measurements of the pressure sores since the areas were first identified on 11/11/23. On 11/30/23 at 9:29 AM an observation and interview were conducted in the room of R39 with the DON and Licensed Practical Nurse (LPN) B. During the encounter, during which the Doctor Ordered treatment was performed, R39 reported to the DON that her bottom hurts. R39 reported to the DON that she rated her pain at an 8 on the 1 to 10 pain scale with 10 being the worst pain. During the treatment the buttocks was exposed and revealed two areas of redness approximately 4 cm in diameter. Within these areas of redness were open areas that the DON measured. The DON reported that the open area on the right measured 3mm x 0.5 mm which reflected an increase of 2.3 mm in length. The area on the left measured 1mm x 0.5 mm which also reflected an increase of 0.3 mm. The DON reported that above the open area on the left was another open area that measured 0.5mm x 0.5 mm. The DON reported that a change in treatment was indicated. Review of the EMR Wound Measurement document dated 11/30/23 at 9:55 AM reflected the measurements of the three Stage II pressure injuries addressed by the DON had been documented in the EMR. Review of the EMR Doctor's Orders for R39 revealed a new Order for wound treatment dated 11/30/23 at 11:30 AM to include a dressing to the wounds on the buttocks.

This citation is related to intake # MI00- 7 Based on interview and record review, the facility failed to provide quality coordinated care to prevent a fall for 1 resident (Resident #117), resulting in bruising of the face, jaw, and neck and a left periorbital soft tissue hematoma ( a blood clot on the left side of the face, around the left eye) that required immediate emergency medical treatment and eventually required an incision and drainage (surgical procedure to remove the large blood clot and dead tissue). Findings: Resident #117 (R117) Review of an Admission Record revealed R117 was an [AGE] year old female, admitted to the facility the evening of Friday 1/19/21, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R117 had an appointed family member as durable power of attorney (DPOA) S. Review of an Admission Assessment, dated 01/19/21 at 6:30 P.M., and completed by Registered Nurse (RN) T, revealed the following information about R117 at the time of admission to the facility; (a) was alert and oriented x4 (A&O) and cognition was intact, (b) was oriented by staff to the room, call light system, location of bathroom and roommate, and verbalized understanding of the orientation given by staff, (c) was hard of hearing and used hearing aids, (d) received a copy of the 48 hour care plan that was initiated, (e) that DPOA S was not given a copy of the 48 hour care plan, and (f) had some bruising to the left shoulder and bilateral upper extremities from falls sustained at home. A review of R117's electronic medical records did not produce a copy of the 48 hour care plan initiated on 01/19/21. During an interview on 06/14/21 at 12:00 P.M., DPOA S stated the following: (a) several calls were made to the facility on the evening of Friday 01/19/21 and the morning of Saturday 01/20/21, to speak with someone about R117's short term care plans, (b) the phone calls were transferred to a nurses desk and then not answered, (c) reported being told, by a staff person over the phone on 01/20/21, that a copy of the care plan would be made available to the DPOA by 02/04/21, (d) received a care plan from the facility that was the care plan that had been used for R117 during a previous admission in August of 2020, and the care plan did not contain interventions or safety measures for falls or UTI's, and (e) was finally able to get a care conference set up for 01/21/21 so that concerns regarding R117's fall risk could be discussed with facility staff. Review of an Interdisciplinary Documentation note, dated 01/20/21 at 9:08 A.M., reflected that Family Member U had called the facility to express concerns about R117's recent falls (6 in the last month) and that all falls had occurred at night when R117 attempted to get up to the bathroom. Family Member U had also told facility staff that R117 had been reluctant to change a soiled brief because R117 was trying to save money. Family Member U felt that was a contributing factor to the UTI diagnoses. Review of an Interdisciplinary Documentation note, dated 01/20/21 at 4:32 P.M. revealed R117 is A&Ox 3 with periods of confusion. Review of an Interdisciplinary Documentation note, dated 01/21/21 at 6:34 A.M., revealed R117 is here for rehab (rehabilitation) following recurrent falls and UTI's, R117 is alert and oriented with confusion and forgetfulness. Review of an Interdisciplinary Care Conference Documentation note, dated 01/21/21 at 10:30 A.M., reflected that persons involved in the care conference were R117, DPOA S, and Social Worker (SW) D. The following information was noted, Discussion of increased supports at night took place during this meeting due to the increase of falls that (R117) has been having during the night. No documentation was located in the electronic medical record indicating that R117 received increased supports at night. No additional nursing or physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. on 01/22/21, describing the fall R117 sustained early that morning. Review of an Incident Report, dated 01/22/21 at 6:46 A.M. revealed the following: (a) R117 was observed by staff on the floor face down, the fall was not witnessed, (b) R117 reported attempting to go to the bathroom, (c) R117 was A&O x 1 at the time of the fall, and (d) no record of when R117 was last checked on by staff was noted. Review of an Ambulance Run Record, dated 01/22/21, revealed: Dispatched to (facility) .for a fall. [AGE] year old female, lying on the floor .staff at side and a large hematoma to the left eye. Staff stated they heard something from (R117's) room and found the resident on the floor. Staff state (R117) is supposed to be using a wheelchair and the resident wasn't using it. (R117) stated she got up to use the restroom. Staff could not tell (ambulance crew) what (R117's) normal mental status is because the staff members just got off vacation and did not know (R117). Resident does have slight bleeding and fluids leaking in the left eye. Resident's eye is already swollen shut. Review of an emergency room Physician note, dated 01/22/21, reflected: R117 had a fall early this morning. (R117) has a difficult time telling us the details. (R117) reported a fall from the sitting position while transferring to the wheelchair this morning, noting that (R117) struck her head. R117 has a large left periorbital soft tissue hematoma and is unable to open the left eye due to the swelling. Review of R117's care plans revealed the following notations and revisions: Focus: fall risk-potential for falls or injuries related to: (nothing was listed) date initiated 1/20/21. Focus: fall risk-R117 is at risk for falls related to: multiple falls in the past 30 days. Revised on 01/27/21. Focus: fall risk-R117 was diagnosed with acute UTI and [CONDITION(S)] resulting in confusion with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R117 has attempted surface to surface transfers in room and attempts to complete ADL's (activities of daily living) independent without prompting a caregiver for assistance which resulted in a fall. Other contributing factors include use of fall contributing medications, [CONDITION(S)], diabetes with polyneuropathy and history of falls. Staff continue to round in an effort to anticipate resident needs. Revised on 01/29/21. Review of an Interdisciplinary Documentation note, dated 01/29/21 at 3:31 P.M., reflected (facility staff and physician) were in to evaluate resident. R117 reported, I feel foggy. R117 fell on [DATE] and still has facial bruising and large hematoma to left forehead measuring 5cm x 4cm x 3cm tall. Review of an emergency room Physician note, dated 01/29/21, reflected the following information: Family and staff have noted confusion. Resident does have a hematoma over the left temple .it appears necrotic (dead tissue). (R117) does have a 10cm x 10 cm (centimeter) hematoma that is protruding about 6 cm over the left frontal scalp. There is bruising over the bilateral (both sides) frontal scalp down to the clavicles (collar bone). Review of emergency room photographs, taken 01/29/21, show R117 with bruising to 75% of the face and a one week old large hematoma over the left eye. Review of an emergency room Nursing note, dated 01/29/21 at 8:42 P.M. reflected: This nurse attempted to call report to (the facility) twice and was put on hold for the nurse each time for five minutes with no answer. Review of an After Visit Summary, dated 02/08/21, revealed the following from the plastic surgeon who had performed surgery on R117 earlier that day: Final diagnoses- evacuation of left forehead hematoma with sharp excisional debridement of necrotic skin and layered closure.

This citation pertains to intake number MI 824. Based on observation, interview and record review, the facility failed to prevent falls for 2 of 3 residents (Resident #1 and #3) reviewed for falls. This deficient practice resulted in Resident #1 sustaining bilateral leg fractures and Resident #3 sustaining avoidable falls. Findings include: Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 15 out of 15 which represents Resident #1 was cognitively intact. According to the incident report dated 10/30/19 at 5:00 PM, CNA A attempted to transfer Resident #1 with one assist from the bed to the wheelchair. The investigation portion of the report reflected that Resident #1 required the assistance of 2 staff to transfer and CNA A failed to follow the care plan. Resident #1 reported pain to bilateral legs, transferred to the emergency and required surgery to stabilize/repair the bilateral femur (leg) fractures. During an interview on 11/26/19 at 11:55 AM, Resident #1 reported that he recalled the events surrounding the fall on 10/30/19. Resident #1 stated, The CNA attempted to transfer me by himself. He should have had another person. Resident #1 showed this Surveyor his surgical repair incisions to both legs. During a telephone interview on 11/26/19 at 10:05 AM, CNA A stated that he attempted to stand and transfer Resident #1 with one assist (instead of 2 as he is care planned) when his legs gave out and he started to go to the floor. CNA A stated that he grabbed the gait belt and lifted him back to the bed. CNA A stated that Resident #1 complained that his knees hurt, and CNA A called for the nurse. CNA A stated that he reported to the nurse that he was attempting to position Resident #1 and prepare for transfer instead of telling the nurse that he was attempting to stand Resident #1 without a second person to assist. CNA A stated that he was scared to tell the truth at first because he didn't follow the care plan to have 2 people assist. CNA A stated that the DON suspended him a short time later after the hospital called and said Resident #1 broke both his legs during the incident. CNA A said the NHA interviewed him and that is when he told the truth about the circumstances of the fall. CNA A stated, I felt I was letting everyone down .It's not the facility's fault. I didn't follow the care plan. I don't think I can ever return to nursing knowing what I allowed that happen to him, when I didn't follow the care plan. CNA A stated that the facility terminated him from his position for not following the care plan which caused a serious injury. Resident #3 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 3 out of 15 which represents Resident #3 had severe cognitive impairment. The facility provided a list of falls from 10/1/19 - 11/25/19. The list reflected Resident #3 had fallen on 10/28/19 at 11:50 PM, 11/5/19 at 9:24 PM and 11/22/19 at 5:15 PM. An interview and record review was completed with the DON on 11/26/19 at 3:35 PM of the three falls and the findings are as follows: 10/28/19 at 11:50 PM, Resident had an unwitnessed fall, found on the floor next to the bed with the call light clipped to her gown. The call light was not activated. Resident states she was getting up for the day. The investigation reflected the root cause of the fall was resident attempting to ambulate without assistance and the facility implemented the intervention of remind to use call light and placed a winged mattress on her bed. According to the BIMS assessment the Resident had severe cognitive impairment and is not capable of remembering to use the call light for assistance. 11/5/19 at 9:24 PM, a nursing student was passing the Resident's room and from the hallway noticed that Resident had her feet hanging off the bed attempting to exit the bed. The nursing student called out for help, as the nursing student entered the room (along with CNA N) they observed the resident exiting the bed (feet off the bed on the floor) and assisted the resident to the floor. The resident stated that she was brushing crumbs from her bed. The DON stated that she didn't use her call light, so the facility replaced the call light with a soft touch call light. According to the BIMS assessment the Resident had severe cognitive impairment and is not capable of remembering to use the call light for assistance. 11/22/19 at 5:15 PM, Resident had an unwitnessed fall, the physician was passing by the resident's room when he observed her on the floor. The resident stated that she was trying to get up and go for walk. She sustained an abrasion to her right buttock. The root cause identified as self-transferring and forgets to use the call light. The facility placed a mat beside the bed to decrease the risk of injury. There was no intervention identified to prevent the reoccurrence of this type of fall. According to the nursing notes 11/14/19 Resident forgets she broke her leg, 11/23/19 Resident yells for help, and 11/26/19 Resident doesn't know why the mat is on the floor next to the bed. When asked how the current interventions will prevent the reoccurrence of falls for Resident #3, the DON stated, We operate on the resident's right, even though confused to self-determine things. When asked how the facility prevents falls for residents with severe cognitive impairment and poor safety awareness, the DON stated, I see what you are saying. She has a leg brace on and everything but still forgets she needs help.

Based on observation, interview, and record review, the facility failed to prevent a Stage 3 pressure ulcer (injury) for one Resident (#4) and failed to promote healing of a Stage 3 pressure ulcer for one Resident (#13), out of four residents reviewed for pressure ulcers, from a total sample of 41 residents. This deficient practice resulted in un healed Stage 3 pressure ulcers. Resident #4 According to the Minimum Data Set (MDS) assessment, dated 6/20/18, Resident #4 was admitted to the facility with multiple [DIAGNOSES REDACTED]. This same assessment indicated Resident #4 had upper and lower extremity impairment on one side, was dependant upon staff for transfers and bathing, and required maximum assistance with bed mobility, dressing and hygiene needs. Review of the Admission Assessment - Clinical 2.0 dated 9/13/17, Resident #4's admitted to the facility, reads, .Redness on his (Resident #4's) buttocks noted . Review of Resident #4's Potential for altered mobility and ADL's (activities of daily living) care plan, initiated date 9/13/17, had the following interventions : Skin: Apply barrier cream with incontinence care prn (as needed); inspect skin with bathing and care; report impaired skin integrity to charge nurse and Skin: Heels elevated in bed as tolerated; Inspect heels with care and report to charge nurse as indicated. Resident #4's Potential risk for impaired skin integrity related to: Poor nutritional intake, impaired functional mobility and or incontinence, dated 9/13/17, had the following intervention, .Skin inspections with am/pm (morning and evening) care and showering report abnormal to the charge nurse. There were no interventions to reposition Resident #4 every two hours or less. According to a progress note dated 10/5/17, Resident #4 had skin open on coccyx .L (length) 3.5 cm (centimeters) x (by) 2.5 cm. There were no updates made to Resident #4's Impaired Skin Integrity Care Plan on 10/5/17. A Short Term Care Plan Wound and Skin dated 10/5/17 was reviewed, Resident #4 was ordered to have [MEDICATION NAME] (a medication to promote wound healing) and dry gauze applied to the wound. Under Approach #12 Positioning guidelines/other indicated approaches for this resident, the care plan was blank indicating no additional positioning or approaches were put into place at this time. A skin assessment was completed on 10/13/17, the coccyx wound measured: Length 2.0 (no unit of measurement documented), Width: 1.0, Depth: 0.5, and staged at a 3. Resident #4's Impaired Skin Integrity Care Plan was updated 10/13/17 with the following interventions: .APM (Alternating Pressure Mattress) Mattress .Pressure reducing mattress .Consult RD (Registered Dietician)/CDM (Certified Dietary Manager) prn (as needed) to evaluate nutritional approaches i.e., enhanced foods, vitamin or protein supplements .Measure open areas upon admission, weekly, prn .Pressure reducing cushion to wheel chair .RE-evaluate treatment and resident condition prn with no improvement to wound appearance and/or measurements . There was no specific time frames documented for consultation with the RD, CDM, or doctor for recommendations to promote wound healing or change interventions. A wound tracking note on 10/23/17, 18 days after the wound was discovered, read, Location: Coccyx, Length: 5.0, Width: 1.5, Depth: 0.5, Stage: stage 3, Treatment: cleanse are apply [MEDICATION NAME] to dry gauze dressing daily and as needed another wound tracking note that same day indicated Resident #4 developed an additional pressure ulcer, read, Location: Left area next to coccyx, Length: 1.5, Width: 1.0, Depth: 0 . On 10/26/17, Resident #4 was transferred to the hospital and readmitted to the facility on [DATE]. A wound tracking note dated 11/6/17 read, Location: coccyx and surrounding tissue, Length: 7.0, Width: 8.0, Depth: 0.8, Stage: 3, Treatment: [MEDICATION NAME] gel to center slough area [MEDICATION NAME] to surrounding excoriated areas to be changed daily and as needed. Other: General outside excoriated area measures 7.0 x 8.0 center slough area measures 2.8 x 1.5 moderate amount of serosangenious drainage noted upon dressing change . According to the Timeline for (Resident #4), provided by the facility on 7/12/18 at 8:30 am, 11/9/17 HCP (Health Care Practitioner) note: Measurement 6.5 cm x 7.5 cm x 1.0 with thick fibrous slough; 3 cm x 2.5 cm. Santyl (medication to promote wound healing) dressing ordered. Unstageable. and 11/10/17 Care plan updated to assist to lie down between meals. This change in wound care orders were received over a month after the wound was discovered. On 11/30/17, Resident #4's coccyx wound was described as Stage 4 with palpable bone and deep red wound base. A wound vac was ordered at that time. Review of progress note dated 7/11/18, Resident #4's coccyx wound measured 1.3 cm x 1.0 cm x 0.1 cm and staged as a 4. Resident #4's coccyx dressing change was observed on 7/12/18, the wound bed was pink and surrounding skin was healthy and intact. Director of Nursing B was asked for a policy for wound care management and Resident #4's wound root cause analysis on 7/11/8 at 5:00 PM and again on 7/12/18 at 10:00 AM. DON B stated there wasn't a wound care managment policy and that they (the facility) just followed professional standards and that Resident #4 did not have a root cause analysis for his pressure ulcer. No additional documentation was provided by the end of this survey. Resident #13 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #13 was an [AGE] year old female initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. She required extensive assistance for activities of daily life (ADLs) and the Brief Interview for Mental Status (BIMs) assessment indicated Resident #13 was cognitively impaired. A review of Resident #13's care plan revealed the following interventions: SKIN .inspect skin with bathing and care; report impaired skin integrity to charge nurse, nutritional supplements per Dietary Assessment, Consult RD/CDM prn to evaluate nutritional approaches i.e., enhanced foods, vitamin or protein supplements. Review was completed of Resident #13's skin assessments, provided by the facility. The skin assessments were sporadically completed, and assessments were noted to be documented on 1/21/18, 2/4/18, 2/18/18, 3/18/18, 5/13/18, 6/27/18 and 7/1/18. Review of Resident #13 electronic medical record revealed upon readmission to the facility on [DATE] that she had a pressure ulcer of her coccyx. The facility provided Admission assessment dated [DATE] noted a skin issue of the coccyx but no further information regarding the size or stage of the wound was documented. The columns of type, length, width, depth and stage were all blank. A review of physician orders [REDACTED]. Per review of wound tracking documentation provided by the facility, the first measurement of the coccyx was completed on 3/14/18 at 16:03. There were two wounds noted, one on the left superior coccyx that measured 2.5x 1.0 cm with na for depth, and one on the right inferior coccyx that measured 1.0 cm x 0.7 cm and 0.3 cm depth. The stage was left blank. Wound tracking documentation revealed no staging until 6/21/18 where the stage was documented as 3. The most recent wound tracking assessment on 7/2/18 revealed 3 current wounds to the coccyx at 9:00 7:00 superior and 7:00 inferior. The wounds measured 3.0 x 2.2 cm with a depth of 0.1 cm, 1.0 x 1.0 cm with 0.1 cm depth and healed. A review of Resident #13's Treatment Administration Record (TAR) for (MONTH) revealed the order for cleanse wound bed to coccyx with NS. Apply [MEDICATION NAME] gel to wound bed and cover with dry gauze. Every day shift. The TAR revealed no documented treatments on 5/7/18, 5/22/18 and 5/29/18. A review of the TAR for (MONTH) revealed the order Cleanse wound bed to coccyx with NS. Fill with [MEDICATION NAME] silver and cover with dry dressing daily. Every day shift. The TAR revealed no documented treatments on 6/2/18, 6/6/18, 6/13/18, 6/16/18, 6/17/18, 6/20/18 and 6/25/18. Review of Resident #13's Nutritional Services Review revealed an admission assessment was completed by Dietary Manager (DM) Q on 3/15/2018. Resident #13's weight was noted as 169 lbs, with a usual weight of 170 lbs. Her estimated protein needs per the document are for 61-77 g protein/day the document notes protein intake as Normal 0.8-1.0 g/kg; Wound Care 1.2-1.5 g/kg. A pound is 2.2 kilograms, thus Resident #13 weighed 76.8 kilograms at the time of her assessment. Her protein intake would have been adequate for a normal resident, however with her current pressure ulcers her protein intake should have been estimated at 92-115 grams per day. The narrative in the nutrition assessment does not note that the resident has any current pressure ulcers. An additional annual Nutritional Services Review was completed by DM Q on 4/12/2018. Resident #13's weight was noted as 176 lbs, with a usual weight of 170 lbs. Her estimated protein needs per the document are for 64-80 g protein/day the document notes protein intake as Normal 0.8-1.0 g/kg; Wound Care 1.2-1.5 g/kg. A pound is 2.2 kilograms, thus Resident #28 weighed 80.0 kilograms at the time of her assessment. Her protein intake would have been adequate for a normal resident, however with her current pressure ulcers her protein intake should have been estimated at 96-120 grams per day. The narrative in the nutrition assessment does not note that the resident has any current pressure ulcers. An interview was completed with DM Q on 7/11/2018 at 11:55 AM. DM Q stated that he was not aware of any specific dietary needs or orders for residents that have pressure ulcers or are at risk for pressure ulcers. He stated that sometimes they will add a prostat (protein shake supplement) to a resident's diet if they need more protein. DM Q was asked if the prostat shake was part of Resident #13's dietary plan and he stated no DM Q was asked if any dietary changed were made to her nutrition plan due to her current pressure ulcers and DM Q stated she doesn't have any pressure ulcers. DM Q was informed Resident #13 has had pressure ulcers since (MONTH) and he stated he was not aware of that. DM Q admitted that I don't have a lot of experience with wounds and that it is not in his specific training. DM Q stated they have a consultant dietician that comes about once a month. DM Q stated the dietician has recently started coming every two weeks to consult but he could really use more support from the dietician on completing the nutrition assessments for residents.

This citation pertains to intake number MI 489. Based upon observation, interview, and record review, two of three sampled residents (residents #1, #2) failed to receive proper sling use with a mechanical lift, resulting in a preventable fall with a harmful fracture to resident #1, which required hospitalization and indeed severe pain. Findings include: From the review of the facility incident report, a witnessed fall occurred to resident #1 on June 23, 2016 at 7:20 a.m According to this report, resident #1 was being transferred on a mechanical lift. The lower sling loop detached from the lift and resident #1 was observed sliding out of the sling to the floor hitting the foot pedal on her right hip. Resident #1 complained of pain 10/10 (severe) to her right hip and lower extremity. EMS was notified immediately, and resident #1 exited the facility via EMS at 7:45 a.m There were two witnesses noted on this report, Certified Nursing Aids (CNA) (D) and (E). On July 12, 2016 at 11:00 a.m., CNA (D) was interviewed inside the facility conference room. CNA (D) stated that she was involved with the mechanical lift transfer of resident #1 on June 23, 2016 at 7:20 a.m CNA (D) stated that CNA (E) came to help with this transfer from another nursing station, and had placed the new sling under resident #1 prior to the transfer with the mechanical lift. CNA (D) stated that she had not received training with the use of this new sling, and she went to get the Hoyer lift from the doctors room in the nursing area. She stated that the new sling was crossed already as the previous slings were positioned prior to lifting the residents. Upon positioning resident #1 on the lift from the bed to wheelchair, the sling connections (2) came off the mechanical lift attachments and resident #1 slid off the sling and hit her bottom on the wheelchair foot pedals. CNA (D) stated that she did not know what sling attachment to use (there were four possibilities) for the four sling attachments to the mechanical lift. CNA (D) stated that after resident #1's fall, she received training on how to safely use the new slings. In addition, CNA (D) stated that the mechanical lift was removed from service because the hooks to attach the sling could not be closed due to the loop design of that lift. On July 12, 2016 at 3:35 p.m., CNA (E) was interviewed over the facility telephone inside the conference room. CNA (E) stated that she was assigned to the Meadowbrook nursing station the morning of June 23, 2016. She stated that she went to the Woodbridge nursing station to help CNA (D) transfer resident #1 with a mechanical lift from the bed to her wheelchair. CNA (E) stated that she prepared resident #1 for the transfer, and put the new sling under resident #1 prior to the lift, with the sling crossed just like the previous slings were positioned. As resident #1 was being transferred on the lift, the front straps came off of the mechanical lift and resident #1 fell off the sling to the floor. CNA (E) stated she had not been trained with the new sling prior to using it during the transfer of resident #1 on June 23, 2016. After resident #1 had fallen, she stated she was trained with the new sling by Facility Nurse (M). CNA (E) did not know what sling attachments to use on the lift (there were four different color codes). During an interview with the Facility Administrator (A) and Director of Nursing (B) on July 12, 2016 at 8:45 a.m. inside the conference room, Administrator (A) stated that new slings (Invacare) were distributed facility wide on June 22, 2016 and that Facility Nurse (M) was responsible to train staff and update care plans for all resident who required mechanical lifts for transfer. Facility Nurse (M) was not available to interview due to a hospitalization during the survey. At 9:30 a.m. on July 12, 2016 the Owner's Operator and Maintenance Manual for Invacare patient slings was reviewed. Under Accessories Warning Invacare products are specifically designed and manufactured for use in conjunction with Invacare accessories. Accessories designed by other manufacturers have not been tested by Invacare and are not recommended for use with Invacare products. Under General Guidelines Invacare slings are made specifically for use with Invacare lifts. For the safety of the patient DO NOT' intermix slings and lifts of different manufacturers. At 10:00 a.m. on July 12, 2016, Facility Maintenance Director (N) brought into the conference room from the garage the mechanical lift which was used to transfer resident #1 on June 23, 2016. This lift was observed to be a Hoyer HPL700 model manufactured by Linak Corporation from Denmark. Upon review if the HoyerHPL700 User Instruction Manual under WARNINGS, using other manufacturers' parts and accessories on Hoyer products is unsafe and may result in serious injury to patients and/or attendant. Use only Hoyer parts. Hoyer lifter parts are NOT interchangeable with other manufacturers' products. Thus, the facility failed to follow the accessory sling and lift manufacturers' warnings. In addition, the Owner's Operator and Maintenance Manuel for the new Invacare slings documents under General Guideline that users are to thoroughly read the instructions in this owner's manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several time with proper supervision and a capable individual acting as a patient. Again, the facility failed to follow the accessory sling manufacturers' warning. At 1:30 p.m. on July 12, 2016, Attending Physician (C) was visited inside his office in the facility. He showed the hospital x-ray results on resident #1 from his laptop computer. Dated 6/23/2016 at 9:44 a.m., the x-ray for resident #1's complete hip x-ray had findings associated with hip pain and injury that there is a transverse fracture through the proximal diaphysis of the right femur which is displaced laterally and overriding of fracture fragments with superior migration of the distal femur with respect to the proximal femur. There appears to be vertically oriented fracture through the greater trochanter and a small medial fragment from the lesser trochanter. Thus, resident #1 was harmed by this preventable fall from the mechanical lift with resulting severe pain. On July 12, 2016 at 2:04 p.m., resident #2 was observed sitting on his wheelchair inside his room with two visitors. Resident #2 was observed to have the new Invacare sling underneath him with a Liko UNO 100 mechanical lift inside his room outside of the bathroom door. Upon testing the two brakes of this Liko UNO 100 mechanical lift inside resident #2's room, the left brake was applied but did not hold the lift wheel so that the lift moved upon force. When this lift was taken into the hallway outside of resident #2's room, Facility Nurse Consultant (K) and CNA (I) were present. Attempting to lock the left brake of the Liko UNO 100 mechanical lift was not successful, and this lift was immediately taken out of service. CNA (I) stated that she had used the Liko UNO 100 mechanical lift for resident #2 that day, but was not aware of the faulty left brake. Also, according to the Invacare slings warnings as noted above, Accessories designed by other manufacturers have not been tested by Invacare and are not recommended for use with Invacare products. Under General Guidelines Invacare slings are made specifically for use with Invacare lifts. For the safety of the patient DO NOT' intermix slings and lifts of different manufacturers. On July 12, 2016 at 8:45 a.m. inside the facility conference room, Facility Administrator (A) requested that resident #1's fall with injury from the mechanical lift on June 23, 2016 would be found to be of past non-compliance under F323, because the incident was immediately investigated by him and the Director of Nursing (B). A root-cause was identified and corrective actions immediately implemented to prevent recurrence, which included: 1) Nurses and CNA's will be educated on the use of mechanical lift, mechanical lift guidance plan, and use of full body sling prior to working their next shift. 2) Residents with mechanical lift transfers will be assessed for the proper loop placement to ensure proper sling use and positioning during the transfer is achieved. 3)Mechanical lift guidance plans for loop color attachment are updated for each indicated resident. 4)Ongoing staff interview for concerns and recommendations in regards to loop placement and resident comfort. 5)DHCS will perform random audits x 2 months, 5-10 CNA's and nurses per week, to ensure guidelines and proper use of the mechanical lift is being consistently performed. 6)DHCS will report to QAPI committee x 2 months, the results of the audits and any injury that is a direct result of this PNC. This request of past noncompliance was denied in accordance with CMS S&C letter dated October 20, 2005 revised Guidance for citations of Past Noncompliance. Under Determining Citations of Past Noncompliance at the time of the Current Survey in a Nursing Home (Attachment 1) there was not sufficient evidence that the facility corrected the noncompliance. This was due to: 1) The facility's failure to follow Invacare's Owner's Operator and Maintenance Manuel for slings in use, Accessories designed by other manufacturers have not been tested by Invacare and are not recommended for use with Invacare products. Under General Guidelines Invacare slings are made specifically for use with Invacare lifts. For the safety of the patient DO NOT' intermix slings and lifts of different manufacturers. Also, Under General Guidelines Invacare slings are made specifically for use with Invacare lifts. For the safety of the patient DO NOT' intermix slings and lifts of different manufacturers. In addition users are to thoroughly read the instructions in this owner's manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several time with proper supervision and a capable individual acting as a patient. Interviews with the following CNA's confirmed that they had not physically demonstrated successful use of the Invacare sling as noted above: July 12, 2016 at 10:45 a.m. at the Meadowbrook nursing station CNA's (F), (G), (H). July 12, 2016 at 11:00 a.m. inside the conference room CNA (D). July 12, 2016 at 2:15 p.m. inside the Woodbridge nursing hallway CNA (I) July 12, 2016 at 3:35 p.m. over the facility telephone CNA (E). July 13, 2016 at 10:48 a.m. inside the Woodbridge nursing hallway CNA (J). ( )

This citation pertains to MI 222 Based on interview and record review, the facility failed to ensure an environment free of accident hazards and failed to ensure supervision by staff knowledgeable about care and safety interventions for 1 resident (#102), out of 7 residents reviewed for falls from a total sample of 7 residents, resulting in Resident #102 attempting to go to the bathroom unassisted and experiencing a fall with head lacerations that required a trip to the local hospital where Resident #102 received stitches, 3 pints of blood and 1 unit of plasma during his stay in the ICU (Intensive Care Unit). Findings include: Record review of Resident #102's Face Sheet documented Resident #102 was originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The diagnosis "post Subarachnoid Hemorrhage Poor Neurological Condition" was added upon Resident #102's readmission back into the facility on [DATE]. Resident #102's most recent Brief Interview of Mental Status (BIMS) documented on 05/28/2014 (prior to the fall that occurred on 07/06/14) showed Resident #102 had scored 12 out of a total possible of 15, meaning Resident #102 was moderately cognitively impaired. Record review of facility Variance Reports (11/01/2013 to 08/06/2014) documented Resident #102 had experienced falls at the facility on the following dates: 11/09/2013, 11/10/2013, 12/02/2013, 12/13/2013, and again on 12/13/2013, 01/08/2014, 01/01/2014, 01/04/2014 and 07/06/2014. According to documentation in the variance report for the incident that occurred on 07/06/14, Resident #102 was observed at 05:15 a.m., on the bathroom floor of his room, by Certified Nursing Assistant (CNA) staff member "D" who "called 911 (and) immediately began to apply pressure to back of head laceration." Continued documentation on the variance report read: "Monitored vitals and level of consciousness while waiting for EMS (Emergency Medical Service. Pt (patient) had bleed in brain, subarachnoid hemorrhage." The "Final Report" from the local hospital documented, on 07/06/2014, Resident #102 was admitted to the hospital with [REDACTED]. According to the facility's CNA Assignment Card for Resident #102 (dated 04/17/2014), the following was documented under the heading of "Problem (falls): Potential for Trauma-falls, injury": "(the resident is) impulsive and often will not wait for assist: answer call light and alarms promptly...Sensor alarms: bed and w/c (wheelchair tab, bed, w/c, and recliner pad alarm, motion detector at end of bed" and (highlighted in yellow under the heading "Equipment") documented: "* (asteric) when in recliner unplug recliner from wall." Record review of the CNA Bedside Care Plan, dated 08/2014 further documented (and again highlighted in yellow): "Off and on switch on electric cord on back of recliner - turn off when unattended in recliner." According to Resident #102's Care Plans, dated 03/08/2014 and 06/30/2014, and electronically printed on 07/11/2014, under the heading of "Falls", staff had documented: "Impulsive and forgetful...post CVA (Cerebral Vascular Accident) with left side weakness, poor safety awareness, attempts to self transfer self...refuses to wait for a second staff for transfers, impulsive, raises electric chair too high without waiting for staff." According to the facility "Variance/Incident Investigation Report" (no date) for the incident that occurred on 07/06/14, the brief explanation of the injury/incident that occurred on 07/06/14 at 5:15 a.m. was documented as: "CNA heard resident yell for help entered room and found resident laying with head by toilet and legs out of bathroom in room on floor." The investigative summary and conclusions documented, "Resident...has impulsiveness with poor safety awareness and judgment...has history of intentionally self-transferring from bed and recliner and removing alarms...does not wait for assistance...Resident has electric lift chair which is to be unplugged when unattended as resident will put chair up in high position to self transfer. Spouse had cord replaced on lift chair and requested an alternative to unplugging, facility supplied a toggle switch to turn chair on and off instead of unplugging on 07/03...Resident had removed tab alert which was found still attached to alarm. Alarm box found on wheelchair cord frayed...determine that Resident had attempted to self-transfer and...was unable to successfully ambulate and landed on floor...injury is not suspicious in nature and no abusive act occurred." On 08/07/2014 at approximately 11:20 a.m. staff member "D" was interviewed by phone from the conference room. During the interview staff "D" stated, "(The) sensor alarm was not connected, although the sensor pad to the recliner was on the seat of the recliner, the alarm box was not in the room...I thought I had the toggle switch in the off position, nobody showed me how to use the toggle switch, I just heard about it in report." When asked why he didn't correct the situation, staff "D" stated, "I never thought about it, I didn't realize it was supposed to be there." Staff "D" stated, after Resident #102's fall, they (the facility) reviewed all the care plans. Staff "D" was asked if the sensor pad was supposed to be on the recliner, staff "D" stated, "Yes, it was supposed to be on his recliner." Further documentation (untitled) in the form of papers filed with the facility investigation of Resident #102's fall investigation and dated 07/07/2014 documented: "Found recliner in high position toggle switch in between on and off, alarm box hanging on wheelchair with cord frayed, still functional. Per the Registered Nurse (staff member "M") responsible for Resident (#102's) care on the night of the fall, tab alert had been removed by resident and chair was up...she (staff "M") states that Resident didn't remember how they got to the bathroom. Staff member "D" stated he did an alarm check and Resident had tab alert on and he thought chair switch was in the off position. He states he didn't see the alarm box was on the wheelchair." Untitled facility investigation papers dated 07/08/2014, documented: "went to room - interventions added - put on and off stickers on toggle switch to indicate to staff when in those positions, replaced wheelchair alarm cord, placed tab alert on bed, recliner and wheelchair, placed alarm box on wheelchair, recliner and bed. On 07/08/2014 (while Resident #102 was in the hospital) at 6:00 p.m. (Staff member "G") re-interviewed (Staff "D"). (Staff "G") documented that (Staff "D") "was not to take care of (name of Resident #102) and that we would be placing him (Staff "D") on a different neighborhood." During the interview (staff "D") stated, "he only checked the tab alert on the recliner chair and the toggle switch looked like it was off. He did state that he had mentioned to the nurse that there was no motion sensor in the room. He states the cord for the chair alarm was hanging out of the pocket of the chair but no box was attached...when asked why he didn't look for the box during the alarm check he states, 'I didn't think to look, as he had his tab alert attached to his collar'...(staff "D") also stated he believed it was about 5 to 10 minutes since he (Resident #102) tried to get up and go to the bathroom." During interview and observations conducted at approximately 2:30 p.m. on 08/06/2014, the toggle switch the facility had provided Resident #102 for his recliner was evaluated with the Unit Manager, Registered Nurse (RN) staff member "G", in attendance. The toggle switch was an all white, two prong adapter, with a simple flat on and off switch. Staff "G" stated, "as part of our plan of correction we labeled the two sides of the On and Off switch to identify which was which." On the morning of Resident #102's fall, the switch had not been labeled. Staff "G" was asked how staff were to know which position was which, staff "G" stated, "right is on and left is off". This surveyor was noted to tell staff "G" that even this surveyor would not have been sure of that, and asked if staff were trained to use the toggle switch. Staff "G" stated she trained the staff; however, when asked if she had specifically trained staff "D" on how to use the switch, staff "G" said she could not recall. After further observation of the switch, staff "G" agreed that moving the switch into the middle position was not an easy task to do, since the switch would want to either click off or click on. It was found that the chair would not operate in the "middle position." RN staff member "G" was interviewed in the Director of Nursing (DON) office on 08/07/2014 at approximately 1:00 p.m. with staff member "A" in attendance. Staff "A" identified himself as the facility Administrator. Staff members "A" and "G" agreed that they would not be having this conversation today if just one of the safety measures had been into place. Staff "G" was asked why there was only 1 alarm box in Resident #102's room in which she replied, "I don't know, there should have been alarm boxes for all of his alarms." When asked if staff "G" assumed that the toggle switch in the middle position would operate the chair, she replied, "I don't know, I didn't check." When asked, both staff members "A" and "G" agreed, even if the recliner had been left in the "on" position and had the Resident attempt at a self transfer, the recliner sensor alarm would have sounded and alerted staff and could have possibly saved Resident #102 from experiencing this fall. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY ASSESS, MONITOR, DEVELOP AND IMPLEMENT PRESSURE RELIEVING INTERVENTIONS TO PREVENT DEVELOPMENT OF PRESSURE ULCERS FOR 1 OF 1 RESIDENTS (#13) REVIEWED FOR PRESSURE ULCERS FROM A TOTAL 16 SAMPLED RESIDENTS, RESULTING IN AN UNSTAGEABLE LEFT LATERAL ANKLE PRESSURE ULCER AND A STAGE 3 LEFT ISCHIAL PRESSURE ULCER WITH SIGNIFICANT PAIN. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET, UNDATED, RESIDENT #13 WAS A [AGE] year OLD MALE admitted to the facility on [DATE] FROM A LOCAL HOSPITAL WITH [DIAGNOSES REDACTED]. INITIAL WOUND ASSESSMENT NOTES DATED 10/5/12 REFLECTED RESIDENT #13 WAS admitted WITH THE FOLLOWING AREAS OF SKIN BREAKDOWN: 1) STAGE 2 (PARTIAL THICKNESS SKIN LOSS) RIGHT BUTTOCK PRESSURE ULCERS; 3 CM X 3.5 CM 2) WOUND TRAUMA LEFT LATERAL KNEE, 2 CM X 1.0 CM 3) WOUND TRAUMA LEFT SECOND TOE, 0.2 CM X 0.2 CM 4) UNSTAGEABLE (WOUND BED COVERED BY SLOUGH OR ESCHAR) LEFT LATERAL FOOT, 1.0 CM X 1.0 CM 5) UNSTAGEABLE LEFT LATERAL ANKLE, 1.0 CM X 0.5 CM THE MINIMUM DATA SET ((MDS) dated [DATE] RESIDENT #13 WAS AT RISK OF DEVELOPING PRESSURE ULCER AND HAD 1 STAGE 3 PRESSURE ULCER WITH MEASUREMENT OF 0.5 X 4.2 X 0.2 CM. HIS BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SCORE WAS NOT RECORDED, BUT HE HAD A SHORT TERM MEMORY LOSS AND HIS DECISION MAKING SKILLS WERE SEVERELY IMPAIRED. DESPITE THESE MULTIPLE WOUNDS THERE WAS NO CARE PLAN INITIATED, INCLUDING INTERVENTIONS TO PREVENT OR MONITOR THESE PRESSURE ULCERS UNTIL 4/4/13 AND THE INITIAL ASSESSMENT WAS NOT DONE 7 DAYS FROM THE ADMISSION (10/5/12). THE FACILITY FAILED TO CONSISTENTLY ASSESS THE WOUNDS. THE SECOND ENTRY WOUND CARE NOTES DATED 10/18/12 REFLECTED RESIDENT #13'S LEFT LATERAL FOOT AND LEFT LATERAL ANKLE WOUND WERE NOW CALLED DIABETIC ULCERS. HOWEVER, THE THIRD ENTRY WOUND CARE NOTES DATED 11/3/12 REFLECTED BOTH LEFT LATERAL FOOT AND LEFT LATERAL ANKLE WOUNDS WERE DEFINED AS STAGE 2 PRESSURE ULCERS. THE SUBSEQUENT WOUND CARE NOTES ENTRIES DATED 11/7/12 AND 11/9/12 REFLECTED LEFT LATERAL FOOT AND LEFT ANKLE BONY PROMINENCE WERE AGAIN CALLED AS DIABETIC ULCERS. THE WOUND CARE NOTES DATED 11/18/12, 11/27/12, 11/28/12 AND 11/30/12 REFLECTED RESIDENT #13 HAD A STAGE 3 (FULL THICKNESS SKIN LOSS) PRESSURE ULCER, MEASURING 2.2 CM X 2.2 CM. HOWEVER, THERE WAS NO BODY PART DOCUMENTED FOR THIS WOUND. THE WOUND CARE NOTES DATED 12/2/12 REFLECTED THE LEFT INNER ANKLE WAS AGAIN REFERRED TO PRESSURE ULCER. THE NOTE DATED 12/8/12 INDICATED THE RESIDENT WAS TREATED WITH ANTIBIOTIC FOR FOOT ULCER INFECTION. THE WOUND CARE NOTES DATED 12/29/12 REFLECTED RESIDENT #13 ' S LEFT LATERAL FOOT WAS A STAGE 2 ULCER AND MEASURED 2.0 CM X 1.4 CM X 0.2 CM. THE WOUND BED WAS COVERED WITH THIN LAYER OF SLOUGH AND THE SURROUNDING TISSUE WAS RED AND THE EDGES WERE MACERATED. THE WOUND DOCUMENTS WERE VERY CONFUSING AND INCONSISTENT IN TERMS OF LOCATION, STAGING AND THE TYPE. THE WOUND CARE NOTES DATED 1/1/13 REFLECTED RESIDENT #13 HAD A STAGE 2 PRESSURE ULCER ON HIS LEFT BUTTOCK MEASURING 0.6 CM X 1.6 CM X 0.1 CM. THE NOTE DATED 1/2/13 REFLECTED RESIDENT #13 HAD AN UNSTAGEABLE LEFT ISCHIAL PRESSURE ULCER MEASURING 1.5 CM X 0.3 CM X 0.1 CM. THE WOUND BED WAS COVERED WITH YELLOW SLOUGH THE SURROUNDING TISSUE HAD 5 CM X 2 CM BLANCHABLE RED AREA. ON 6/20/13 AT 11:00 A.M., THE UNIT MANAGER, (STAFF "A") STATED THESE TWO PRESSURE ULCERS WERE PROBABLY THE SAME LOCATION AND 1/1/13 WAS THE ONSET DATE OF THE CURRENT NON-HEALING LEFT ISCHIAL PRESSURE ULCER. THE WOUND CARE NOTES DATED 1/18/13 THROUGH 6/18/13 REFLECTED RESIDENT #13'S LEFT ISCHIAL PRESSURE ULCER HAD WORSENED IN SIZES AND CHARACTERISTICS AS FOLLOWS: 1/18/13 LEFT BUTTOCK SUPERIOR, 3.5 CM X 3.5 CM X 0.1 CM, SEROUS DRAINAGE WITH ODOR, STAGE 2 LEFT BUTTOCK INFERIOR, 1.5 CM X 1.5 CM X 0.1 CM, SANGUINOUS DRAINAGE WITH MODERATE ODOR, STAGE 2 1/28/13 LEFT BUTTOCK ISCHIAL, 4.0 CM X 3.0 CM X 0.2 CM, WOUND BED 50 % SLOUGH AND 50 % GRANULATION, STAGE 3 2/17/13 LEFT BUTTOCK, 4.7 CM X 2.5 CM X 0.1 CM, YELLOW SLOUGH NO WOUND MEASUREMENTS FOR NEARLY 2 MONTHS THEN, 4/1/13 LEFT ISCHIAL, 4.5 CM X 3.5 CM, WOUND BED COVERED WITH 100 % NECROTIC ESCHAR, UNSTAGEABLE 4/23/13 LEFT ISCHIAL, 2.7 X 2.7 X 0.2, WOUND BED NECROTIC 4/29/13 LEFT ISCHIAL, 3.5 X 2.7 X 0.3 5/6/13 LEFT ISCHIAL, 2.8 X 2.5 X 0.4, WOUND BED SLOUGH 5/13/13 LEFT ISCHIAL, 2.6 X 2.0 5/20/13 LEFT ISCHIAL, 1.8 X 2.0 X 1.4 5/27/13 LEFT ISCHIAL, 2.0 X 1.5, 50 % SLOUGH 6/4/13 LEFT ISCHIAL, 1.3 X 1.5 X 1.2 6/10/13 LEFT ISCHIAL, 1.2 X 1.0 X 1.2 6/18/13 LEFT ISCHIAL, 1.0 X 0.5 X 0.5, 100 % SLOUGH, UNSTAGEABLE THE WOUND CARE NOTES AGAIN HAD VERY CONFUSING AND INCONSISTENT DATA IN TERMS OF WOUND SIZES, LOCATION, STAGING AND CHARACTERISTICS. IN ADDITION, FREQUENT LONG PERIODS (UP TO 2 MONTH) OF LACK OF DOCUMENTATION REFLECTED A LACK OF WOUND PROGRESS. ON 6/20/13 AT 8:30 A.M., THE DIRECTOR OF NURSING STATED THE FACILITY IDENTIFIED WOUND DOCUMENTATION PROBLEM IN APRIL 2013 AND WAS IN THE PROCESS OF MAKING CHANGES TO REFLECT MORE ACCURATE, CONSISTENT DOCUMENTATION. THE CARE PLAN RELATED SKIN INTEGRITY AND PRESSURE ULCER DATED 4/4/13 REFLECTED RESIDENT #13 HAD LEFT ISCHIAL TUBEROSITY 100 % ESCHAR, SCROTUM 100 % ESCHAR, COCCYX 100 % SLOUGH, LEFT LATERAL [MEDICAL CONDITION] 100 % SLOUGH WITH [MEDICATION NAME] EXUDATE, PERI-FUNGAL REDNESS RELATED TO (4/4/13) URINE AND BOWEL INCONTINENCE, DIABETES, (5/9/13) ALTERED NUTRITIONAL STATE, IMMOBILITY, DECREASED SAFETY AWARENESS, DECREASED MOBILITY AND FRAGILE SKIN. THE INTERVENTIONS INCLUDED 1) ASSIST WITH HYGIENE AND GENERAL SKIN CARE, 2) REPOSITION EVERY 2 HOURS, 3) TURN SIDE TO SIDE EVERY 2 HOURS, 3) KEEP HEELS OFF BED WITH PILLOWS, 4) KEEP SKIN CLEAN AND DRY, 5) USE LIFT SHEET WHEN MOVING RESIDENT IN BED, 6) AIR MATTRESS, 7) INCONTINENCE PADS, 8) BARRIER CREAM TO PERI-AREA, 9) UP WITH HOYER, 10) HEEL PROTECTORS, 11) ASSESS SKIN DAILY, 12) LAY DOWN AFTER MEALS FOR MINIMUM OF 2 HOURS, 13) MEASURE AREA ON MONDAYS, 14) PROVIDE PAIN CONTROL TREATMENT, 15) PROVIDE FOOD SUPPLEMENT. ON 6/20/13 AT 11:00 A.M., THE UNIT MANAGER (STAFF "A") WAS ASKED WHETHER THERE WAS ANY PREVIOUS CARE PLAN (PRIOR TO 4/4/13) REGARDING PRESSURE ULCERS OR NOT. STAFF "A" SAID YES, BUT SHE WAS NOT ABLE TO PRODUCE ANY EVIDENCE THAT A CARE PLAN WITH INTERVENTIONS WAS DEVELOPED ON ADMISSION OR EVEN AFTER THE RESIDENT FIRST WAS IDENTIFIED WITH NEW PRESSURE ULCER ON 1/1/13 FOR SEVERAL MONTHS AND WHAT THE INTERVENTIONS WERE TO PREVENT SUCH ADVANCED STAGE OF PRESSURE ULCER. THE BRADEN SCALE, USED TO PREDICT RISK OF DEVELOPING PRESSURE ULCERS, DATED 9/28/12 REFLECTED RESIDENT #13 HAD A TOTAL SCORE OF 15 (LOWER THE SCORE, THE HIGHER THE RISK), NO TOTAL SCORE ON 10/10 12 (ONLY STATED " HIGH " ), A TOTAL SCORE OF 17 ON 11/3/12, NO TOTAL SCORE ON 2/12/13 (ONLY STATED " LOW), A TOTAL SCORE OF 11 ON 3/4/13 AND A TOTAL SCORE OF 12 ON 5/9/13. WITHOUT INDICATING EITHER THE SCALE OF RISK OR INTERPRETATION WHAT THE TOTAL SCORE MEANT DOES NOT REPRESENT CONSISTENT UNDERSTANDING OF PRESSURE ULCER RISK ASSESSMENT. THE NUTRITIONAL assessment dated [DATE] REFLECTED RESIDENT #13 WAS 69 INCHES TALL AND WEIGHED 154 POUNDS ON 9/29/12, 146 POUNDS ON 9/30/12 (8 POUND LOSS IN ONE DAY) AND 143 POUNDS ON 10/1/12 (ANOTHER 3 POUND LOSS IN ONE DAY). THE ASSESSMENT REFLECTED RESIDENT #13 HAD FAIR APPETITE, ATE OVER 50 % OF MEALS AND WAS DEPENDENT ON STAFF FOR FEEDING. THE UNINTENDED WEIGHT LOSS WAS DUE TO DYSPHAGIA (DIFFICULTY SWALLOWING) AND LESS THAN OPTIMAL ORAL INTAKE. HOWEVER, LOSING 10 POUNDS IN LESS THAN 3 DAYS COULD NOT BE EXPLAINED BY ONLY SUBOPTIMAL INTAKE. THERE WAS NO EVIDENCE THAT THE DIETITIAN HAD CONDUCTED A THOROUGH INVESTIGATION TO INCLUDE THE IMPACT OF WEIGHT AND NUTRITION WITH WOUND HEALING. THE FOLLOWING WEIGHT TRENDS FURTHER EXPLAINED A LACK OF THOROUGH INVESTIGATION REGARDING WEIGHT CHANGES; 10/13/12 146 POUNDS 10/24/12 138 POUNDS (8 POUND LOSS IN 11 DAYS) 12/13 12 133 POUNDS 1/13/13 127 POUNDS (6 POUND LOSS IN 30 DAYS) 1/16/13 135 POUNDS (8 POUND GAIN IN 3 DAYS) 1/23/13 128.5 POUNDS (7 POUND LOSS IN 7 DAYS) 2/6/13 128 POUNDS 4/17/13 119.4 POUNDS 5/1/13 111.2 POUNDS (8 POUND LOSS IN 14 DAYS) 5/8/13 116.2 POUNDS 6/5/13 115.6 POUNDS ALTHOUGH THE " WEIGHT IMBALANCES " POLICY DATED 7/2011 CALLED FOR REWEIGH OF RESIDENTS THE NEXT DAY WITH 3 POUNDS CHANGE, NO RE-WEIGHS WERE DONE WITH ANY OF THOSE SIGNIFICANT WEIGHT CHANGES. THE NUTRITIONAL assessment dated [DATE] REFLECTED RESIDENT HAD 26.2 POUNDS REPRESENTING 16.9 % UNPLANNED WEIGHT LOSS IN 180 DAYS. RESIDENT #13 WAS NOW admitted TO THE HOSPICE SERVICE. THE FOOD ACCEPTANCE RECORD DATED 1/1/13 THROUGH 6/20/13 REFLECTED RESIDENT #13 HAD FLUCTUATING ORAL INTAKE RANGING FROM 25 % TO 100 %, SNACKS AT 10 A, 2 P, AND BED TIME WERE DOCUMENTED AS CONSISTENTLY (95 % OF TIME) EITHER "DECLINED" OR "REFUSED." ON 6/19/13 AT 2:00 P.M., THE NURSE AIDE, (STAFF "I") STATED SHE HAD KNOWN THE RESIDENT FROM HIS ADMISSION DAY. STAFF 'I" SAID THE RESIDENT WOULD SPIT OUT OR REFUSED FOOD ON SOME DAYS, BUT HE WOULD EAT EVERYTHING ON SOME DAYS, DEPENDING ON HIS MOOD. STAFF "I" ADDED THE RESIDENT WAS ABLE TO FEED HIMSELF SOMEWHAT WHEN HE FIRST CAME, BUT HE WAS NOW A TOTAL FEED. THE NUTRITIONAL ASSESSMENT NOTE DATED 3/11/13 REFLECTED RESIDENT #13'S DIET WAS CHANGED TO DYSPHAGIA 1 WITH NECTAR THICKENED LIQUIDS. THE ASSESSMENT NOTE DATED 5/14/13 REFLECTED RESIDENT #13 MEAL INTAKE RANGED 50-75 %, CONSUMING 75-100 % SUPPLEMENTS. HOWEVER, RESIDENT #13 CONTINUED TO "LOST 12.6 % IN 6 MONTHS-DESPITE GOOD INTAKE." THERE WAS NO EVIDENCE THE DIETITIAN INVESTIGATED AS TO WHY THE RESIDENT WAS DOCUMENTED TO HAVE DECLINED OR REFUSED HIS SNACKS 95 % OF TIME. THE NUTRITIONAL RELATED LABORATORY VALUE DATED 9/20/12 (WHILE IN HOSPITAL) RESIDENT #13 HAD [MEDICATION NAME] LEVEL OF 4.0 G/DL (NORMAL RANGE: 3.5-5.0 G/DL), 2.6 G/DL ON 10/9/12, 3.1 G/DL ON 11/2/12 AND 3/4 G/DL ON 12/11/12. THE HEMOGLOBIN A 1 C LEVEL ON 11/2/12 WAS 6.9 % (NORMAL RANGE: < 6 % FOR NON-DIABETIC). THERE WAS NO FURTHER MONITORING OR EVALUATION OF BOTH [MEDICATION NAME] OR HEMOGLOBIN A 1 C LEVELS (PERTINENT TO WOUND HEALING). ON 6/20/13 AT 10:30 A.M., RESIDENT #13'S PRESSURE ULCER DRESSING CHANGE TO HIS LEFT ISCHIAL AND LEFT LATERAL/OUTER ANKLE WAS OBSERVED IN HIS ROOM. THE UNIT MANAGER, (STAFF ( "A") STATED THE RESIDENT WAS MEDICATED WITH NARCOTIC AROUND 8:30 A.M. AND AGAIN AROUND 9:30 A.M. (ADDITIONAL PAIN MEDICATION OBTAINED THROUGH HOSPICE CARE) DUE TO A LOT OF PAIN TODAY RELATED TO THE ULCERS. AS STAFF "A" REMOVED AN AIR BOOT FROM RESIDENT #13'S LEFT LEG AND UNTAPPED THE GAUGE ROLL FROM HIS LEFT LEG (RATHER THAN CUTTING THROUGH THE DRESSING WITH SCISSORS), RESIDENT SCREAMED IN PAIN. RESIDENT #13 CONTINUED TO MOAN AND GROAN AS STAFF "A" CLEANED AND APPLIED "[MEDICATION NAME]" GEL TO THE WOUND. THE LEFT LOWER BUTTOCK WOUND (LEFT ISCHIAL) HAD APPROXIMATELY 1 X 0.6 X 0.5 CM (QUOTED FROM WOUND NOTE) HOLE WITH MACERATED SURROUNDING SKIN EDGES. STAFF "A" APPLIED "[MEDICATION NAME]" GEL AND WRAPPED WITH KERLIX GAUZE DRESSING, ALTHOUGH THE ORDER WAS TO APPLY "WET TO DRY" GAUZE FOR DEBRIDEMENT. ( )

This citation pertains to intake number: MI 325 and MI 808 Based on observation, interview and record review, the facility failed to ensure the use of safety devices (fall alarms and wanderguard bracelet) for 2 of 4 sampled residents reviewed for safety (Resident #102 and Resident #104), from a total sample of 4 residents, resulting in a fall with a fractured foot for Resident #102, and an elopement from the facility with potential for injury for Resident #104 who did not have her care planned wanderguard device in place. Findings include: Resident #102 Review of Face Sheet and Minimum Data Set (MDS), dated [DATE] revealed Resident #102 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #102 had moderate cognitive impairment with a brief mental score (BIMS) of 8. Review of the fall risk scoring tool dated 6-7-12 revealed Resident #102 was at high risk for falls, fall risk scoring tool dated 8-18-12 revealed moderate risk, and fall risk scoring tool dated 12-6-12 revealed high risk of falls. Review of Resident Potential for Falls care plan dated 6-8-12 and Certified Nursing Assistant (CNA) Care Plan dated 6-8-12 revealed Resident #102 was to have a bed alarm and wheelchair alarm on; Resident #102 transferred, ambulated and toileted with 1 person assist; and the call light was to be within reach. Review of Care Area Assessment (CAA) dated 8-30-12 revealed Resident #102 required assist with ambulation, transferring and toileting. Review of the CAA dated 8-18-12 revealed safety needs to monitor frequently the bed alarm and wheelchair alarm. Review of the facility Fall Prevention and post follow up policy dated 11-1-11 revealed nursing was to create an appropriate care plan according to the fall risk assessment, that the need for continued or additional safety devices would be posted for the staff on care plans, and that staff are expected to maintain all alarms, motion detectors, sensors and other safety interventions in the "on" position, all alarms controls are to be placed out of the reach of residents whether in wheel chairs, beds, whenever possible. Review of the nurses notes dated 10-30-12 with a noted late entry for 10-28-12 revealed "Resident found on floor by bathroom door. Bed alarm unplugged, which is common for resident (Resident #102) to do herself and resident complained of mild pain in left foot but full active ROM (range of motion) noted." Review of the nurses notes dated 11-17-12 with a noted late entry for 10-28-12 revealed "At the start of shift approximately 5:30 pm, CNA notified nurse resident was complaining that left foot was hurting, nurse went to do assessment and noted left foot was slightly swollen and starting to bruise. Notified Doctor about resident foot, Doctor ordered x-ray of left foot, nurse called for x-ray of left foot." Review of an x-ray report dated 10-28-12 at 6:38 pm revealed that Resident #102 had a fracture of the left foot 2nd, 3rd and 5th metatarsal bone (bones in feet). In an observation and interview on 1-2-13 at 10:45 am, Resident #102 was lying in her bed. Resident #102 was alert but confused and disoriented. When questioned on how she broke her foot, Resident #102 stated "I don't remember." In an interview on 1-2-13 at 1:45 pm, Licensed Practical Nurse (LPN) #5 reported on 10-28-12 Resident #102 was found on the floor by the bathroom door in her room. LPN #5 reported that Resident #102 was supposed to have both pad alarm and tab alarm in place and that neither alarm went off at the time of the fall. LPN #5 reported the bed pad had been unplugged, and that Resident #102 had been known to remove the alarms in past. LPN #5 reported that the resident went out with the family after the fall, and when she came back from the outing LPN #5 had checked Resident #102's foot, it was red, not swollen. LPN #5 states she then gave report to the afternoon shift. In an interview on 1-2-13 at 2:00 pm, CNA #10 reported that on 10-28-12, LPN #5 had called for help, Resident #102 was lying on the floor by her bathroom door, one leg was under her and Resident #102 said her foot was hurting. CNA #10 reported she found a little bruise on the left foot before Resident #102 went out on an outing with her family. CNA #10 reported Resident #102 was to have a tab alert alarm, a bed and chair pad alarm on and at the time of the fall, the alarms were not on. CNA #10 reported that Resident #102 had been known to remove her alarms in the past, that CNA #10 would find the alarms unhooked during routine bed checks. CNA #10 reported that she could not remember if the call light had been on, the call light system is hooked up to a pager. Review of the facility Incident and Accident report titled Patient/visitor variance report and nurses notes dated 12-18-12 revealed Resident #102 had a fall on 12-18-12 in which Resident #102 fell out of bed and obtained a head injury in which she was sent to the emergency room to be evaluated due to change in condition, increased yelling out and increased confusion. The facility incident report dated 12-18-12 revealed "Bed alarm was unplugged, tab alert was off and it was placed across bedside table." Review of Resident #102's Potential for Falls care plan revealed there was no mention of Resident #102 being non-compliant with use of fall alarms, or unhooking or unplugging of fall alarms. Resident #104 Review of the Face Sheet and the Minimum Data Set (MDS), dated [DATE], revealed Resident #104 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #104 had severe cognitive impairment with a brief mental score (BIMS) of 6. Review of the Elopement Risk assessment dated [DATE] revealed Resident #104 was at high risk for elopement from the facility. Review of Resident #104's MDS dated [DATE] revealed Resident #104 was independent in transfers, ambulation and toileting. Review of Resident #104's Care Area Assessment (CAA's) undated revealed Resident #104 had poor safety awareness. Review of Resident #104's Potential for Elopement care plan dated 11-6-12 revealed Resident #104 was to have a wanderguard on at all times, staff was to check placement of wanderguard each shift, and that staff was to know the whereabouts of Resident #104. Review of the Incident and Accident report titled "Patient/visitor variance report" dated 12-7-12, revealed that Resident #104 "had went on leave of absence (LOA) on 12-7-12, came back and went into her room, left her room to look for her grandson, then walked out the main doors to look for her grandson, when she couldn't find him outside, she reentered the building where Social Worker #13 assisted her. Resident (#104) was found to not have a wanderguard bracelet on at the time she walked out of the main entrance." Review of the facility investigation report dated 12-7-12 revealed Visitor #15 had made a written statement that on 12-7-12 at 1:15 he had taken his grandma (Resident #104) out of the facility, they exited out the front doors and no alarms sounded. When they came back to the facility at approximately 3:00 pm, no alarms sounded and that he (Visitor #15) did not notice Resident #104 wearing anything on her wrist. Review of nurses notes dated 12-7-12 at 4:07 pm revealed Resident #104 was found walking back into the building by Social Worker #13. Resident #104's wanderguard did not alarm when she walked back into the facility, and it was noted that Resident #104 did not have the wanderguard on her at the time of elopement. In an interview on 1-3-13 at 2:00 pm, Clinical Support Technician #14 reported she was in the front admissions office with Social Worker #13 on 12-7-12, and saw Resident #104 out of the window, walking back into the facility through both double doors on her own. Clinical Support Technician #14 reported that the Resident #104 was not cold or in distress, and that she knew Resident #104 was not supposed to be outside on her own and no alarms went off when Resident #104 reentered the facility. Clinical Support Technician #14 reported that Social Worker #13 then went to check on Resident #104. In an interview on 1-3-13 at 2:15 pm, Social Worker #13 reported that on 12-7-12 she was in the front admission office which overlooks the front walk, she looked out the front window and saw Resident #104 walking back inside the facility, and that Resident #104 came back in to the facility on her own through both double doors and that no alarms went off. Social Worker #13 reported that Resident #104 stated that she was looking for her grandson whom had just brought her back from an outing. Social Worker #13 reported that when the wanderguard system alarms, it makes a loud noise. Social Worker #13 reported that Resident #104 did not have her wanderguard bracelet on when she reentered the facility. An observation was made on 1-2-13 at 12:30 pm of Resident #104 ambulating throughout the facility independently, her wanderguard bracelet was on her left wrist and tested to be working. Resident #104 was well groomed, pleasantly confused and wandering aimlessly around facility. On 1-4-13 at 10:00 am, Registered Nurse (RN) #4 accompanied surveyor to make rounds and together checked 18 of 18 residents for proper placement and working condition of all wanderguards. All 18 of 18 wanderguards were found to be in place on residents or their assistive devices (wheelchairs or walkers), and in working condition and 5 facility doors were checked for working wanderguard system. All 5 were found to be in proper working condition. Review of the facility's elopement policy dated 3-12 revealed: each resident identified as a wanderer is then required to wear a monitoring bracelet at all times and are monitored at least every shift or more frequently if needed by the staff; correctable risk factors are identified in the assessment process and addressed in and applied to the care plan. ( )

This citation pertains to intake numbers: MI 808, MI 357, MI 325. Based on interview and record review, the facility failed to develop comprehensive care plans based on resident assessments and staff observations in 3 of 4 residents (Resident #102, Resident #101 and Resident #104) reviewed for safety, from a total of 4 sampled residents, resulting in Resident #102 and Resident #101 having no safety devices (fall alarms) in place and both residents sustaining a fracture after a fall and Resident #104 not having a wanderguard on per the plan of care prior to an elopement for Resident #104. Findings include: Resident #102 Review of the Face Sheet and the Minimum Data Set (MDS), dated [DATE] revealed Resident #102 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #102 had moderate cognitive impairment with a brief mental score (BIMS) of 8. Review of the fall risk scoring tool dated 6-7-12 revealed that Resident #102 was at high risk for falls, fall risk scoring tool dated 8-18-12 revealed moderate risk, and fall risk scoring tool dated 12-6-12 revealed high risk of falls. Review of the Resident Potential for Falls care plan dated 6-8-12 and Certified Nursing Assistant (CNA) care plan dated 6-8-12 revealed Resident #102 was to have a bed alarm and wheelchair alarm on; Resident #102 transferred, ambulated and toileted with 1 person assist; and the call light was to be within reach. In an interview on 1-2-13 at 1:45 pm, Licensed Practical Nurse (LPN) #5 reported that on 10-28-12, Resident #102 was found on the floor by the bathroom door in her room. LPN #5 reported that Resident #102 was supposed to have both pad alarm and tab alarm in place and that neither alarm went off at the time of the fall. LPN #5 reported the bed pad had been unplugged, and that Resident #102 had been known to remove the alarms in past. LPN #5 reported she did not know if the past removal of alarms had been care planned. Review of an x-ray report dated 10-28-12 at 6:38 pm revealed that Resident #102 had a [MEDICAL CONDITION] foot 2nd, 3rd and 5th metatarsal bone (bones in feet). In an interview on 1-2-13 at 2:00 pm, CNA #10 reported that on 10-28-12, LPN #5 had called for help, Resident #102 was lying on the floor by her bathroom door, one leg was under her and Resident #102 said her foot was hurting. CNA #10 reported Resident #102 was to have a tab alert alarm, a bed and chair pad alarm on and at the time of the fall, the alarms were not on. CNA #10 reported that Resident #102 had been known to remove her alarms in the past, that CNA #10 would find the alarms unhooked during routine bed checks. Review of Resident #102's Potential for Falls care plan revealed there was no mention of Resident #102 being non-compliant with use of fall alarms, or unhooking or unplugging of fall alarms, which resulted in Resident #102 fall on 10-28-12 obtaining fractured bones in left foot. Resident #101 Review of the Face Sheet and the Minimum Data Set (MDS) dated ,[DATE], revealed Resident #101 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 had severe cognitive impairment with a brief mental score of 6. In an interview on 1-2-13 at 12:10 pm, Licensed Practical Nurse (LPN) #6 reported that on 9-1-12, Resident #101 had reported a fall in her room resulting in a fractured left wrist. LPN #6 reported that at the time of the reported fall, Resident #101's fall alarms never sounded, and no staff had observed Resident #101 on the floor at any time. LPN #6 reported that Resident #101 had a history of [REDACTED]." This Surveyor was unable to substantiate that the fall occurred, but did substantiate the wrist fracture occurred, and that Resident #101 has a history of removing her fall alarms and that risk factor was not found in Resident #101's Fall care plan. Review of Resident #101's Fall care plan dated 10-2-12 revealed Resident #101 was a high risk for falls, required assist for toileting and needed a bed alarm, but did not address non- compliance and known history of removing the fall alarms placing Resident #101 at an even higher risk of falls. Review of the facility Fall Prevention and post follow up policy dated 11/1/11 revealed nursing was to create an appropriate care plan according to the fall risk assessment, that the need for continued or additional safety devices would be posted for the staff on care plans, and that staff are expected to maintain all alarms, motion detectors, sensors and other safety interventions in the "on" position, all alarms controls are to be placed out of the reach of residents whether in wheel chairs, beds, whenever possible." Resident #104 Review of the Face Sheet and the Minimum Data Set (MDS), dated [DATE], revealed Resident #104 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #104 had severe cognitive impairment with a brief mental score (BIMS) of 6. Review of the Elopement Risk assessment dated [DATE] revealed Resident #104 was at high risk for elopement from the facility. Review of Resident #104's MDS dated [DATE] revealed Resident #104 was independent in transfers, ambulation and toileting. Review of nurses notes dated 12-7-12 at 4:07 pm revealed Resident #104 was found walking back into the building by Social Worker #13. Resident #104's wanderguard did not alarm when she walked back into the facility, and it was noted that Resident #104 did not have the wanderguard on her at the time of elopement. In an interview on 1-3-13 at 2:15 pm, Social Worker #13 reported that on 12-7-12 she was in the front admission office which overlooks the front walk, she looked out the front window and saw Resident #104 walking back inside the facility, and that Resident #104 came back in to the facility on her own through both double doors, no alarms went off, Resident #104 had her coat on. Social Worker #13 reported that Resident #104 stated that she was looking for her grandson whom had just brought her back from an outing. Social Worker #13 reported that when the wanderguard system alarms, it makes a loud noise. Social Worker #13 reported that Resident #104 did not have her wanderguard bracelet on when she reentered the facility and that on one other occasion Resident #104 had been known to cut off her wanderguard bracelet. In an interview on 1-4-13 at 11:00 am, Registered Nurse (RN) #4 reported that Resident #104 had one other instance that she knew of, in which Resident #104 had removed her wanderguard bracelet herself, and that Resident #104 had been asking visitors to borrow scissors, and staff now know not to give scissors to Resident #104. RN #14 reported she did not care plan any interventions regarding Resident #104's history of or desire to remove the wanderguard, therefore staff have no written direction as to not provide scissors to Resident #104 who is known to use scissors to cut off her wanderguard bracelet. Review of Resident #104's Care Area Assessment (CAA's), undated, revealed Resident #104 had poor safety awareness. The CAA's did not address any non-compliance or cutting off of the wanderguard bracelet. Review of Resident #104 Potential for Elopement care plan dated 11-6-12 revealed Resident #104 was to have a wanderguard on at all times, staff was to check placement of wanderguard each shift, and that staff was to know whereabouts of Resident #104. The Potential for Elopement care plan did not address the problem that staff had known that Resident #104 had been cutting off her wanderguard placing Resident #104 at risk of elopement from the facility. Review of the facility's elopement policy dated 3-12 revealed: each resident identified as a wanderer is then required to wear a monitoring bracelet at all times and are monitored at least every shift or more frequently if needed by the staff; correctable risk factors are identified in the assessment process and addressed in and applied to the care plan. ( )

This citation pertains to MI# 091 Based on observation, interview, and record review, the facility failed to: 1) provide adequate supervision and assistive devices to prevent a fall in 1 (#102) of 4 sampled residents, from a total sample of 4 residents, resulting in Resident #102 sustaining a fall with a fractured left hip, and 2) ensure that safety devices were in place and functioning in 2 (#103 and #104) of 4 sampled residents, from a total sample of 4 residents, resulting in the potential for harm, injury and/or death. Findings include: Resident #102: Record review of Resident #102's variance report dated 11/16/11 at 8:45 PM reflected that Resident #102 had [DIAGNOSES REDACTED]. Resident #102 was noted to be [AGE] years old at the time that the fall occurred. Resident #102's cognitive condition before the incident was noted as confused/disoriented intermittent. Record review of the fall variance sheet reflected that the fall was observed as fall from wheelchair. Resident #102 was noted to have a fall risk assessment prior to the fall and scored as high risk. The fall variance noted a history of falls and non-compliance with instructions. A description note at the bottom of the page reflected: Resident was watching TV in the front lobby sitting in his wheelchair. Two certified nurse assistants (CNA's) were present in the lobby area at the time of the fall. Resident #102 stood up from his wheelchair, took a step and fell towards his back and left side. The CNA reported to the nurse. The resident was noted to state his back and left leg hurt. Record review of the local hospital x-ray report dated 11/16/11 for resident #102 revealed impression of interrochanteric fracture of the left femur. Record review of Resident #102's minimum data set ((MDS) dated [DATE] reflected a [AGE] year old male with brief interview for mental status (BIM's) score of 5-severe impairment with disorganized thinking. Active [DIAGNOSES REDACTED]. History of falls was noted. MDS section G0300-balance during transitions and walking were noted to be not steady, and only to stabilize with human assistance. Record review of Resident #102's fall assessment dated [DATE] reflected a total score of 14, placing the resident as high risk for falls. Record review of Resident #102's fall care plan entry dated 8/13/11 reflected safety needs-monitor frequently, bed tab alert, silent alarm, wander guard. There was no mention of a chair/wheelchair alarm for safety noted to the care plan. In an interview on 2/13/12 at 12:30 PM, registered nurse (RN) unit manager #4 revealed that Resident #102 had a magnet tab alarm with a clip to his clothing. RN #4 stated that when Resident #102 stood up, the clip was not on. RN #4 stated "We don't know if Resident #102 pulled off the tab clip after nurse applied". Record review of the facility 'Fall Prevention & Post Fall Follow up' policy and procedure dated 7/11 reflected that under C.) Staff participation: Staff is expected to maintain all alarms......in the on position. All alarm controls are to be placed out of reach of residents whether in wheelchairs, beds, ect. whenever possible. Record review of facility 'Alarms, Personal' policy and procedure, dated 7/11 reflected to keep alarm control boxes out of reach of residents and alarms are to be left in the "on" position at all times. Record review of Resident #102's nurse note dated 11/16/11 at 10:25 PM reflected 'resident #102 was sitting in wheelchair next to the sofa watching the TV. The two CNA's who were in the lobby turned and saw Resident #102 during the fall as he sat to the floor. No alarms were sounding. However, the tab alert had just been checked during 8:30 PM med pass and was in place at that time. The chair alarm was not turned on. Record review of facility investigation staff statements dated 11/17/11 reflected interviews done with the staff involved. CNA # 8 was noted to state that she was sitting at the table by the camera, relieving the security guard and CNA #9 was standing behind her. It was noted that both CNA's #8 and #9 looked up and Resident #102 took a step away from his wheelchair. CNA #8 stated that registered nurse RN #10 had noticed that Resident #102's tab alert string was tangled around his arm and that sometimes he tries to take it off. It was noted that RN #10 untangled the tab alert string and clipped it to his shirt. It was noted that about 10 minutes after untangling the tab alarm string Resident #102 fell . Record review of facility investigation staff statement dated 11/17/11 reflected an interview done with certified nurse assistant CNA #9. CNA #9 was noted to state that she had come back from break and was looking at the camera behind CNA #8. CNA #8 was showing CNA #9 how it (the camera) worked. Resident #102 was noted as sitting in his wheelchair to the right of the couch when Resident #102 stood up and tried to take a step and fell and that no alarm had sounded. In an interview on 2/13/12 at 2:30 PM with CNA #9 reflected that she didn't actually see the fall, but stated that resident #102 stood up, took a step or fumbled 1 or 2 steps then fell backwards. The CNA stated that "No alarm sounded, we had no warning. CNA #8 was sitting at the camera screen, we were looking at the camera screen (together)......not paying attention to Resident #102, and all of a sudden he fell ". Record review of the facility investigation staff statement dated 11/17/11 reflected an interview done with RN #10. RN #10 was noted to state that she had seen Resident #102 about 15 minutes prior to his fall in the main lobby and that he had tangled his arm around the tab alert and that she (RN #10) untangled it and put the alert back on the back of his shirt. RN #10 was noted to state that after Resident #102 fell it was noted that the tab was still attached to the unit but not attached to Resident #102's shirt. Record review of Resident #102's certified nurse assistant (CNA) flow sheet charting for the month of 11/11 reflected that there were no alarm safety checks performed for Resident #102 until 11/29/11, thirteen days post fall. Record review of Resident #102's expiration form dated 1/8/12 reflected [DIAGNOSES REDACTED]. Resident #104: Observation on 2/12/12 at 7:45 AM with RN #6 of Resident #104 while Resident #104 was sitting up in her wheelchair revealed that there was a pressure pad alarm placed under Resident #104 but was not connected to an alarm box. It was also noted that Resident #104 did not have a bed alarm in place. The pressure pad alarm wire end was hanging freely to the floor. Resident #104 also had a string tab alarm attached to the back of the wheelchair but was not attached to the resident. In an interview on 2/12/12 at 7:45 AM with Resident #104 while observing her alarms revealed, "I'm suppose to have an alarm, it makes noise when I get out of my chair". Record review of Resident #104's bedside certified nurse assistant (CNA) care plan dated 2/5/12 reflected that Resident #104 was to have a pressure alarm to his bed and wheelchair. Resident #103: Observation during the entrance tour of room #114 revealed a tab alarm clipped to the back of a recliner, but there was no resident sitting in the chair. Observation made on 2/12/12 at 8:00 AM with RN unit manager #3, while auditing alarms, revealed that sampled Resident #103, who lived in room #114, was coming back from the dining room with a staff person when the state surveyor noted that Resident #103's alarm wire was cut/severed from the alarm box and dragging behind the resident's wheelchair. There was no string tab alarm noted to be attached to the chair or Resident #103. Resident #103 was seen during the entrance conference sitting in the dining room having her breakfast at a table with another resident. RN #3 had to find another staff member to assist with changing out the broken alarm with a new alarm. Record review of sampled resident #103's bedside certified nurse assistant (CNA) care plan dated 12/3/11 reflected that Resident #103 was to have a tab alert alarm, bed tab alert, wheelchair tab alert, bed alarm, wheelchair alarm and bedside chair alarm. In an interview on 1/12/12 at 9:50 AM, Resident #103 reported that she had a history of [REDACTED]. Record review of facility past non-compliance sheet dated 11/22/11 reflected a deficient practice of failure to maintain actively functioning chair alarm, with analysis of an unknown staff member deactivated chair alarm and that there was no check system in place to ensure activation of chair alarm per shift. (# )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO UTILIZE WHEELCHAIR FOOT PEDALS FOR TWO (#1 AND #13) OF SEVEN RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 16 RESIDENTS, RESULTING IN A PAINFUL LEG FRACTURE AND DECLINED FUNCTIONAL MOBILITY FOR RESIDENT #1 AND THE POTENTIAL FOR A FALL WITH INJURIES FOR RESIDENT #13. FINDINGS INCLUDE: DURING AN INTERVIEW ON 11/8/11 AT 12:50 P.M., RESIDENT #1 STATED THAT SHE WAS NOT DOING WELL. SHE STATED THAT SHE NOW HAD 59 STICHES IN HER RIGHT LEG BECAUSE A MALE FACILITY STAFF PERSON HAD WHEELED HER DOWN THE HALLWAY, ABOUT A WEEK AGO, AND HAD NOT PUT THE FOOT PEDALS ON HER WHEELCHAIR BEFORE TRANSPORTING HER. RESIDENT #1 STATED THAT HER RIGHT FOOT HAD DROPPED DOWN, BECOME CAUGHT IN THE RIGHT WHEEL OF HER WHEEL CHAIR, AND WAS TWISTED. THIS HAD RESULTED IN IMMEDIATE PAIN. RESIDENT #1 STATED THAT SHE HAD TOLD THIS STAFF PERSON TO PUT HER FOOT PEDALS ON, BUT THEY WERE ONLY GOING JUST A SHORT DISTANCE, SO HE DID NOT DO IT. RESIDENT #1 STATED THAT SHE HAD EXPERIENCED EXCRUCIATING PAIN, AS RECENTLY AS THE PREVIOUS NIGHT (11/7/11), EVEN WITH AN ICE PACK ON HER RIGHT KNEE AND EVEN WITH PAIN MEDICATIONS ADMINISTERED. DURING THE INTERVIEW, RESIDENT #1 WAS ASKED TO EXPLAIN WHERE THE FOOT PEDALS HAD BEEN AT THE TIME OF THE ACCIDENT, AND SHE STATED THAT THEY HAD BEEN IN A SATCHEL ON THE BACK OF HER WHEELCHAIR. RESIDENT #1 SAID SHE WAS TOLD THAT IT WAS FACILITY POLICY FOR FOOT PEDALS TO BE ON THE WHEELCHAIR WHEN THEY WERE PUSHING HER IN HER WHEEL CHAIR. BASED ON THE REVIEW OF THE FACILITY INVESTIGATION REPORT, DATED OCTOBER 30, 2011, RESIDENT #1 WAS BEING TRANSPORTED TO HER ROOM BY MEANS OF A WHEELCHAIR BY FACILITY NURSE AIDE "L" ON OCTOBER 29, 2011 AT 6:40 P.M., WHEN RESIDENT #1'S RIGHT FOOT WAS CAUGHT IN THE FRONT WHEEL OF HER CHAIR. ACCORDING TO THE REPORT, RESIDENT #1 HAD COMPLAINED OF DISCOMFORT TO HER ANKLE AND LEG. AN X-RAY WAS OBTAINED AT APPROXIMATELY 9:45 A.M. ON OCTOBER 30, 2011; THE RESULTS WERE CALLED TO FACILITY NURSE "H" AT 10:30 A.M. THAT SAME DAY. THE CONCLUSION WAS THAT THE RESIDENT HAD SUSTAINED A FRACTURE OF HER DISTAL FEMUR (THIGH BONE) JUST ABOVE HER RIGHT KNEE ARTHROPLASTY IMPLANT. A VIDEOTAPE OF THE 10/29/11 INCIDENT INVOLVING RESIDENT #1 WAS VIEWED IN THE DIRECTOR OF NURSING'S OFFICE ON NOVEMBER 8, 2011 AT 1:20 P.M.. THE DIRECTOR OF NURSING (DON) STATED THAT THE VIDEO HAD BEEN CAPTURED BY CAMERAS INSTALLED IN THE FACILITY. DURING THE VIDEO REPLAY, NURSE AIDE "L" WAS OBSERVED ON TAPE PUSHING RESIDENT #1'S WHEELCHAIR AROUND THE CORNER OF THE FACILITY'S FRONT HALLWAY AND DOWN THE MEADOW BROOK HALL FOR APPROXIMATELY THIRTY YARDS. THERE WERE NO FOOT PEDALS OBSERVED ON RESIDENT #1'S WHEEL CHAIR. WHEN RESIDENT #1'S WHEEL CHAIR STOPPED, NURSE AIDE "L" WAS OBSERVED TO MOVE TO THE FRONT OF RESIDENT #1'S WHEELCHAIR, BEND DOWN, AND LOOK AT THE RESIDENT'S RIGHT LEG. AFTER A PAUSE, NURSE AIDE "L" WAS OBSERVED GETTING FIRST THE RIGHT, AND THEN THE LEFT, WHEEL CHAIR FOOT PEDALS OUT OF THE SATCHEL ON THE BACK OF RESIDENT #1'S WHEELCHAIR AND PLACING THEM ON THE WHEEL CHAIR BEFORE PUSHING RESIDENT #1 FORWARD. AT THE END OF THE VIDEO REPLAY, THE DON WAS HEARD TO STATE NURSE AIDE "L" HAD NOT FOLLOWED THE GUIDELINE FOR USING FOOT PEDALS ON WHEEL CHAIRS WHILE TRANSPORTING A RESIDENT. DURING AN INTERVIEW ON NOVEMBER 9, 2011 AT 2:30 P.M. IN THE MEADOW BROOK DINNING ROOM, FACILITY PHYSICAL THERAPIST "F" WAS INTERVIEWED. HE STATED THAT RESIDENT #1 HAD BEEN admitted TO THE FACILITY AFTER AN ACCIDENT AT HOME WHERE SHE HAD HURT HER SHOULDERS. HE SAID THAT RESIDENT #1 HAD PARTICIPATED IN PHYSICAL THERAPY AND HAD PROGRESSED TO THE POINT OF BEING ABLE TO AMBULATE UP TO 200 FEET USING A FRONT WHEELED WALKER. IN FACT, RESIDENT #1 HAD BEEN discharged FROM PHYSICAL THERAPY, AND WAS READY TO GO HOME, WHEN THE ACCIDENT HAD OCCURRED ON OCTOBER 29, 2011. (BASED ON REVIEW OF THE RESIDENT'S RECORD, A physician's orders [REDACTED].) DURING THE 2:30 P.M. INTERVIEW, THERAPIST "F" STATED THAT, AFTER THE 10/29/11 INCIDENT, RESIDENT #1 HAD BECOME NON-WEIGHT BEARING ON HER RIGHT SIDE, AND SHE HAD TO HAVE A MECHANICAL LIFT IN ORDER TO TRANSFER BETWEEN SURFACES SUCH AS HER BED AND CHAIR. THERAPIST "F" STATED THAT RESIDENT #1 RETURNED TO PHYSICAL THERAPY AS A RESULT OF THE ACCIDENT THAT HAD OCCURRED ON OCTOBER 29, 2011. DURING A FOLLOW-UP INTERVIEW WITH RESIDENT #1, CONDUCTED ON NOVEMBER 9, 2011 AT 10:00 A.M., SHE STATED, AGAIN, THAT HER RIGHT KNEE WAS STILL HURTING "REAL BAD." A SIGN WAS OBSERVED ON THE BACK OF HER WHEEL CHAIR WHICH READ: "NO PEDALS NO PUSH." ( ) ACCORDING TO THE FACILITY ADMISSION INFORMATION SHEET DATED 5/5/09, RESIDENT #13 WAS admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. ON 11/9/11 AT AROUND 8:30 AM, RESIDENT #13 WAS OBSERVED IN HIS WHEEL CHAIR, SELF PROPELLING THE WHEELCHAIR WITH BOTH LEGS. THE WHEELCHAIR DID NOT HAVE FOOT PEDALS ATTACHED. AS RESIDENT #13 APPROACHED THE NURSES STATION WHERE THIS SURVEYOR WAS SITTING, A STAFF PERSON (UNIDENTIFIED AT THE TIME) CAME BEHIND RESIDENT #13 AND STARTED PUSHING HIM. RESIDENT #13 WAS JUST OUTSIDE HIS ROOM AND THE UNIDENTIFIED STAFF PERSON STOPPED PUSHING HIM, WENT INSIDE, AND CAME OUT WITH A SOFT KICK BALL WHICH RESIDENT #13 KICKED DOWN THE HALL. BY THE TIME THIS SURVEYOR HAD AN OPPORTUNITY TO TALK, THE UNIDENTIFIED STAFF PERSON HAD LEFT THE AREA. AS RESIDENT #13 WENT PAST THIS SURVEYOR, IT WAS NOTED THAT THERE WAS A WHITE TAPE ACROSS THE BACK OF THE WHEEL CHAIR WHICH STATED, "NO PEDALS NO PUSH ". ON 11/9/11 AT 2:20 P.M., THIS SURVEYOR ASKED THE CHARGE NURSE (STAFF "A") WHAT STAFF PERSON WOULD HAVE BEEN WITH RESIDENT #13 AT AROUND 8:30 A.M. THAT MORNING ASSISTING HIM WITH KICKING HIS SOFT KICK BALL AND SHE REPLIED MOST LIKELY IT WAS THE REHAB STAFF. ON 11/9/11 AT 3:25 PM, THIS SURVEYOR INTERVIEWED THE DIRECTOR OF NURSING (DON) AND ASKED HER ABOUT THE WHITE TAPE ON THE BACK OF THE WHEELCHAIRS. THE DON REPLIED THAT ALL WHEELCHAIRS HAVE THE TAPE ON THEM TO REMIND STAFF NOT TO PUSH RESIDENTS WHO DO NOT HAVE FOOT PEDALS ON THEIR WHEELCHAIR. THIS SURVEYOR EXPLAINED WHAT WAS OBSERVED AT AROUND 8:30 THAT MORNING ON CAMBRIDGE COURT INVOLVING RESIDENT #13. THE DON STATED ALL STAFF WERE INFORMED OF THE NEW POLICY AND THEY WERE TO NOTE THE TAPE ON THE BACK OF THE WHEELCHAIRS. THE DON STATED SHE WOULD TALK WITH THE REHAB STAFF AND GET BACK WITH MORE INFORMATION. AT AROUND 3:35 PM THE DON RETURNED AND SAID THAT THE PERSON WHO PUSHED RESIDENT #13 WAS AN ASSIGNED HOSPICE AIDE. THE DON SAID THAT SHE WAS UNDER THE IMPRESSION THEY KNEW NOT TO PUSH RESIDENTS WHO DID NOT HAVE PEDALS ON THEIR WHEELCHAIRS, BUT THAT SHE WOULD CALL THE HOSPICE AND INFORM THEM OF THE NEW POLICY. ( )

This citation pertains to MI# 786 Based on observation, interview and record review, the facility failed to provide supervision to prevent elopements for 2 (#103 & #105) of 9 sampled residents from a total of sample of 9 residents, resulting in Immediate Jeopardy for Residents #103 and #105 who were cognitively impaired and had a history of [REDACTED]. Resident #105, who had a history of [REDACTED]. Findings include: Resident #105: Record review of Resident #105's Minimum Data Set (MDS), dated [DATE], revealed that Resident #105 was an [AGE] year old female with a cognitive BIMs score of 5 (severe impairment), who rarely made decisions. The form noted that the resident had disorganized thinking that fluctuates (comes and goes, changes in severity). The resident was also noted to have physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing, abusing others) occuring 1 to 3 days in frequency. Record review of the facility variance report, dated 7/6/11, revealed that Resident #105, who was noted to be alert and oriented times two, was found outside in her wheelchair 20 feet from the building on 7/5/11 at 7:15 PM. Record review of Resident #105's elopement risk assessment, dated 6/14/11, revealed a score of 6. A score of 10 or more is at greater risk for elopement. Observation on 8/24/11 at 8:10 AM, of Resident #105 revealed that the resident was able to self propel her wheelchair throughout the facility. Record review of Resident #105's Social Service notes, dated 6/22/11 at 9:48 AM, revealed that on 6/17/11 it was reported that the resident's alarms were going off. Staff responded to the alarm and Resident #105 stated that she was going to go home. No elopement risk re-assessment was performed at that time nor was a wander guard alarm safety device was applied. Record review of Resident #105's social service note, dated 7/3/11 at 7:00 PM, revealed that Resident #105 was attempting to leave the facility and that she had packed her belongings. No elopement risk re-assessment was performed at that time nor was a wander guard alarm safety device applied. There were no social service notes related to the elopement on 7/5/11. In an interview on 8/25/11 at 2:40 PM, Social Service Staff #13 revealed that Resident #105 was confused and had a [DIAGNOSES REDACTED]. The social worker identified the BIMs score as 5 which meant severe impairment. The social worker stated that she was not aware that the resident had eloped from the building on 7/5/11 and that there was no social work note because she was not aware of the incident. Record review of nursing notes, dated 7/5/11, for all shifts revealed that there was no mention of the resident's elopement from the facility or if the resident was assessed for harm after being returned to the building. In an interview on 8/25/11 at 2:00 PM, Staff Nurse #10 revealed that he remembered Resident #105 sitting in the living room area of the Meadow Brook hall in her wheelchair at approximately 7:00 PM. Nurse #10 stated that he was passing medications and when he came out of a room, Resident #105 was outside on the sidewalk close to the parking lot. Nurse #10 stated that the living room area had a handicap push button door and that the resident must have exited through the door. Nurse #10 stated he did not see the resident exit the building, but that he found her outside the building. Nurse #10 stated that none of the staff , who were on duty during the shift, had seen Resident #105 leave. Nurse #10 stated that he charted the incident on an unusual occurrence report and that he told Nurse #6 about it the next day. Observation 8/26/11 at 12:00 PM, of the meadow brook handicap access door in the main living/TV room of the unit revealed a wander guard alarm system. The handicap automatic access door was timed at 30 seconds to completely open. Observation of the outside of the handicap access door revealed that the sidewalk lead into the front visitor parking lot. The side walk ran along the front of the building. There were also noted paved foot paths wide enough to accomidate a wheelchair which lead around the building noted. Record review of the facility 24/hour report, dated 7/5/11, noted that Resident #105 was found outside. In an interview on 8/26/11 at 11:46 AM, Resident #105 revealed that she recalled going out side to see the butterflies and stated that was a while ago and that a lot people went outside. She could not recall exiting the building alone on 7/5/11. Resident #105 was not re-assessed for elopement until 8/15/11 and scored 15 (an increase). The reassessment occurred after a second resident (#103) eloped from the building on 8/5/11. The incident involving Resident #105 was not reported to the state regulatory agency. # Resident #103: Record review of the facility 5-day investigation report, dated 8/11/11, revealed that on 8/5/11 Resident #103 was observed in the dining room at 6:05 PM. At 6:40 PM Resident #103 (35 minutes after last seen by staff) was observed by a visitor sitting outside in her wheelchair next to the front bench. The visitor notified Certified Nurse Assistant (CNA) #5. CNA #5 returned Resident #103 to the building and Licensed Practical Nurse (LPN) #21 was made aware and assessed. Resident #103 was noted to state to staff that she was waiting for her ride ([DIAGNOSES REDACTED]. Record review of Resident #103's Minimum Data Set (MDS), dated [DATE], revealed a [AGE] year old female with moderately impaired cognitive skills for daily decision making, who made poor decisions and needed cues and supervision. The form noted that an acute mental status change on assessment. [DIAGNOSES REDACTED]. Resident #103 was observed on 8/24/11 at 8:10 AM sitting in a recliner at her bedside. There was no WanderGuard on the resident's person, but one was observed on the empty wheelchair in the room. In an interview on 8/24/11 at 4:00 PM, Certified Nurse Assistant (CNA) #5 stated: "I was coming down the hallway to the center hallway, a couple of ladies walked up to me and stated to me that there was a woman sitting outside the front doors and that they didn't think that she was supposed to be there because she had a tab alarm on. I went outside to see who it was. It was (Resident #103). I asked her what she was doing. She stated that she was waiting for a ride. I told her it was hot outside and she could wait inside. I put on her foot pedals that were in the bag on the back of her chair and I pushed her down to the east Windsor unit and left her with her aide. I stopped and told nurse secretary #7 to place a WanderGuard on the resident. I went back to my unit (Meadow Brook) and told Nurse #21". CNA #5 did not know the identity of the ladies who approached her. CNA #5 stated that Resident #103 was seated at the end of the bench by the front door. In an interview on 8/24/11 at 3:53 PM, Licensed Practical Nurse (LPN) #21 stated that Resident #103 was found outside by visitors, who informed CNA #5. Nurse #21 stated that Resident #103 did not have a WanderGuard device at the time of the elopement. LPN #21 stated that a quick assessment was done and that a WanderGuard was applied to the resident's wheelchair. LPN #21 stated that Resident #103 was last seen at 6:05 PM leaving the main dining room and was brought back to the facility at 6:40 PM. (wear abouts un-known to facility staff for 35 minutes) Record review of Resident #103's care plan for compromised short term memory dated 10/21/09, revealed the resident was moderately impaired decision making. The care plan interventions noted to reorient/redirect and to offer verbal and non-verbal. Care plan for anxiety dated 11/9/09 revealed interventions to assist to activities. Care plan for safety awareness dated 11/9/09 through 11/19/09 did not list a WanderGuard device. Care plan for trauma/falls dated 10/7/09 through 6/16/11 revealed a history of falls and unsteady gait. Interventions noted to observe, record, and report all unsafe conditions and situations. There was no elopement risk care plan noted. Record review of Resident #103's CNA Care Plan Information form, dated 8/15/11, located on the resident's closet door, did list a WanderGuard device. Record review of facility WanderGuard policy, dated 7/09, revealed: Policy- To ensure all residents identified "at-risk" for wandering/elopement are protected by an alerting device and identification measures put into place for prevention. Procedure: 1.) Wander/Elopement Risk Assessment will be completed by nurse upon admission, re-admission, significant change and/or prn (as needed). 5.) Physician order [REDACTED]. This then initiates the" bid" (twice daily) checks for placement, operation and expiration date of device. Record review of Resident #103's elopement risk assessment, dated 11/10/09, revealed a score of 6. The resident did not have a documented elopement re-assessment until 8/10/11, 21 months since the last completed elopement assessment and after the elopement incident of of 8/5/11. Record review of Resident #103's nurses' notes, printed by the facility for the state surveyor on 8/25/11 at 10:08 AM, revealed that notes, dated 8/5/11 and 8/6/11, did not mention the incident of elopement. The Director of Nursing (DON) was notified on 8/26/11 at 4:40 PM of the Immediate Jeopardy that began on 8/5/11 at 6:05 PM, due to the facility's failures to provide supervision and prevent the elopements of Resident #103 and Resident #105. On 8/30/11 at 10: 45 AM, the state surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. On 8/11/11, the facility started elopement risk assessments on all 76 current residents and completed the assessments on 8/15/11. Seventy-six residents were assessed with [REDACTED]. There were 22 existing risks and 7 new risks. Residents, identified as an elopement risk, had their plans of care updated to reflect wander management system activation. 2. On 8/15/11, all 76 charts were audited for elopement risk assessments with 100% compliance. Thereafter, chart audits will be performed by neighborhood managers and results submitted to the Director of Nursing. 100% of charts will be audited quarterly until 100% compliance is achieved for 4 quarters. 3. On 8/12/11, guidelines were developed that states the MDS Nurse to perform elopement risk re-assessments quarterly. MDS Nurse to schedule with quarterly assessments. 4. On 8/12/11, Elopement/Wandering policy revision reflects that every shift checks on residents identified as elopement risks, or more frequently if indicated and all new residents will have a monitoring bracelet for the first fourteen days following admission. 5. On 8/12/11, staff placed at front living room to monitor entrance from 5:00 PM through 9:00 PM. This has been identified as the most opportune time that a resident could exit unobserved through the front doors. Staff to remain scheduled until MAG locks are installed, checked and working. Front living room is staffed during the day shift 8:00 AM-5:00 PM. 6. On 8/12/11, waiver submitted to the State of Michigan Fire Marshall with correct door heights. 7. On 8/26/11, CNA care plans revised to include wander management system (bracelet) location every shift and to notify nursing if location is not identified, effective 8/26/11. The charting will be in the CNA care plan in the electronic medical record. 8. On 8/26/11, monthly report for incomplete elopement assessments will be monitored by Director of Nursing. This will be reported in clinical management meeting monthly. 9. On 8/26/11, vendor on premises to assess current delayed egress (MAG) locks in five locations for re-activation. Equipment order placed by vendor with an expected delivery date of 9/2/11. 10. On 8/29/11, face-to-face education was initiated for all staff. Education included elopement risk assessment guidelines and the elopement/wandering policy. Staff will not be allowed to work until the education is completed. As of 8:30 AM on 8/30/11, 42 of 127 employees had been educated. 11. On 8/29/11, education began for certified nurse assistants and nursing staff on the CNA WanderGuard management system location every shift and notification to nursing if location is not identified. 42 of 127 employees were educated on 8/29/11. The employees will not be allowed to work until education is completed. 12. On 8/29/11, the front door was monitored for the additional hours of 9:00 PM-8:00 AM. The front door will be monitored 24 hours a day, 7 days a week effective 8/29/11 and, going forward, the monitoring will be documented to ensure compliance. This practice was to continue until the MAG locks were installed, checked and working. While the Immediate Jeopardy was removed on 8/29/11, the facility remained out of compliance at isolated scope and a severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to not all staff have been in-serviced and sustained compliance has not been verified by the state agency. #