Every finding on record at The Laurels of Coldwater

This citation pertains to intake #3051218Based on observations, interviews, record review, the facility failed to protect the resident's right to be free from physical abuse by a resident.Findings Include:Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/18/26, reflected R3 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R4 was admitted to the facility on [DATE], with diagnosis that included Vascular dementia, moderate, with agitation and irritability and anger. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/8/26, reflected R4 scored 3 out of 15 (severe cognitively impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 7/29/26 at 3:20 pm, R3 was observed in her room, seated in a wheelchair, and reading a book. R3 recollected previous encounters with R4. R3 stated that she has never spoke to him before, however, R4 would enter R3's room uninvited on several occasions. On 6/8/26 around midnight, R4 entered R3's room and stepped over to her bedside. R3 told R4 that he needed to leave. R4 refused. R3 repeatedly told R4 to leave or she was going to call the police. R4 told R3 that he did not care of she called the police. Staff arrived to assist and removed R4 from the room. R3 stated that there had been several encounters similar to this which occurred on and off all day and all night. R3 reported feeling afraid, and therefore, filled out a Grievances form to express her concern regarding R4 entering her room without permission. R3 went on to explain that one day, on 6/14/26, R4 came into R3's room without permission, yet again. R3 told R4 that he needed to leave. R4 responded by repeatedly calling R3 a b*tch and an as*hole, R4 approached R3 and lifted his cane to hit R3/ R3 stated she put her arm up to avoid being hit in the face, resulting in R4's cane striking R3 on the outer portion of her palm. R3 stated that staff intervened and after a few moments of coaxing R4 to leave the room, R4 finally exited R3's room. R3 presented a photograph of her hand which had a deep purple bruise on the outer part of her hand and knuckle. R3 reported that after the incident, R4's room was moved to the front of the hall as opposed to the end which reduced the number of times that R4 was walking past her room. R3 stated that she felt relieved because she was getting more and more afraid for R4. When asked if there any interventions in place to keep R4 from entering her room, R3 stated she had a stop sign set across her doorway however, the time of the incident, she did not observe the sign in place across her doorway. R4 also stated that her stop sign was removed two or three days ago and a staff member put it back up today.Review of a handwritten Grievance form completed by R3 stated the guy that wanders came into my room Monday night 6/8/26. Was at end of curtains by bathroom and was walking up toward bed. Very scary. He did this 2-3 times. I called for help both times. The came and took him out. He is very scary. In the section which states who else knows about the problem or incident, R3's handwritten response stated man in charge of nurses . In the section that states how can we address your issues?, R3's handwritten response stated he is very scary. has been walking in hall most of day looking in rooms .I kept telling him to leave. He wouldn't. Called me names. On the Grievance form, R3 indicated that this was an ongoing problem, stating, about a week, off and on all day sometimes PM (night). Review of a Facility reported incident report dated 6/14/26 stated that on 6/14/26 at 3:20 PM, R4 entered R3's room and when R3 told R4 to leave, R4 made contact with R3 using a walking cane. According to the same report, Licensed Practical Nurse (LPN) C was interviewed LPN C stated I heard yelling down the hall. the CNA (certified nursing assistant) and I entered the room and [R4] sat down on B bed facing [R3]. [R4] said she's a b*tch. Why didn't she just say it was her room. [R3] said I came out of the bathroom and saw saw him and told him to leave now. He starting walking toward me swinging his cane. I put my hand up and he hit my hand with the cane. A staff interview conducted with CNA D stated I heard [R3] screaming, get out. When i entered the room, [R3] was at the end of her bed. [R4] was yelling, why bitch?. LPN C' took [R4] out of the room. R3 was rubbing her hand and I noticed a bruise. [R3] stated he was swinging his cane and I put my hand up and the cane hit my hand. Review of a Nurses Note dated 12/16/25 stated Due to increased aggression towards staff with cane, cane has been removed from residents room. A walker has been provided. Resident has not used the cane consistently and ambulates frequently without it . Review of a Behavior Note dated 1/27/26 stated Resident attempted to enter female's room x 2. The first time he said he was lost. The second time he said she was his ex girlfriend . Review of a Progress Note dated 1/30/26 stated Nurse reports that his behaviors continue on second shift. He is still getting agitated with female residents and staff. He has been taking away food from other residents. When he is corrected or redirected, he gets verbally aggressive. Review of a Progress note dated 5/31/2026 revealed resident [R4] standing in the hallway arguing with [another resident], who accused him of being in her room. He said he did not know it was her room and [other resident] stated that he hit her in the left arm. He said that her would hit her again if she did not shut up. This nurse stepped between them and told him to go to his room . A nurses note dated 6/4/26 stated Guest [R4] came out of his room agitated that his roommate is accusing him of taking his stuff. Guest stated that he wanted a room change and he was done being blamed for everything going missing in that room. Guest also stated that if something does not change and his room mate goes off on him again he will hit him with his cane. DON (Director of Nursing) was called about situation. DON stated just to keep an eye on them and he will figure something out when he gets to facility. The follow up to the situation was to relocate R4 to a different room, at the end of the hallway. Review of the Care plan, Kardax, and Nurses Progress Notes revealed no indication of how R4 regained access to his cane that was removed from his possession in December 2025 or mention of any cane in any documentation. Review of a social services note dated 6/4/26 stated Resident wandering hallway and into other residents rooms throughout day. Resident easily redirected. Review of R4's Care plan revealed an absence of any Care Plan or any interventions related to R4's entering other residents' rooms. On 6/14/26, a nurses note stated At [3:20 PM] writer and CNA heard yelling down south hall. Writer and CNA entered [R3's room] and observed resident in front of TV (television) walking towards bed A, resident sat down on edge of bed facing female resident. Female resident observed sitting on the edge of her bed. [R4] stated She is mean, she is a b*tch. Writer and CNA encouraged resident to leave room that is not his. Resident stated why didn't she just say it was her room? Resident then began stating b*tch while pointing cane at female resident. Resident exited room with writer, writer escorted resident to his room. Resident then walked down south hall stating f*cking b*tch to writer. Resident placed on 1:1. Female resident stated I came out of the bathroom and saw him. I told him to leave now. He said no. I told him to leave and leave now or I was going to call the police. He said call them, call them now and started walking towards me swinging his cane. I put my hand up and he hit me with his cane right here. Purple bruise noted to female residents right hand. R4 was placed on one-to-one observation following the incident. Review of an Encounter note completed by a Physician dated 7/3/26 stated Resident (R4) reviewed regarding 1:1 status ? [sic] resident apparently has had some wandering tight [sic] behaviors and is going into other residence [sic] rooms. He has become aggressive with staff when attempted to be redirected. Healso [sic] had a physical altercation with another resident. He was placed on 1:1 observation and since then seems to have done reasonably well as he is able to be immediately redirected instead of after he becomes involved with other residents. At this time, I do not think discontinuing one: one observation would be appropriate.In an interview on 7/30/28 at 11:09 AM, CNA D confirmed she was working the day of the incident between R3 and R4. CNA D stated she hard another resident yell [R3] needs help. CNA D went down to R3's room and observed R4 calling R3 a b*tch repeatedly. CNA D stated R4 sat on the roommates bed in R3's room and continued to state that R3 was a b*tich, After some coaxing, staff were able to convince R4 to leave R3's room. In an interview on 7/30/26 at 11:18 am, LPN C stated that R4 is very forgetful, to the point that he will exit his room and immediately forget where his room is. LPN C stated she knew R3 was complaining prior to the incident between R3 and R4 regarding how R4 made her feel afraid. LPN C stated that R4's room was located at the end of the hall so despite having a sign on his door identifying R4's room as his room, R4 walked past several other rooms in the meantime and consistently attempted to enter them because he did not see the sign indicating which room was his until he got to the very end of the hallway and was able to locate his room. LPN C stated hat on the day of the incident between R3 and R4, she heard yelling coming from R3's room and responded. R4 was observed seated on the roommates bed, calling names to R3. R4 stated that he was in his room.In an interview on 7/30/26 at 11:55 am, Resident #6 (R6) was interviewed regarding R4. R6 resided on the same hallway as R3 and R4. R6 stated that R4 had wandered into her room several times. During on occasion, R4 was aggressive and told R4 that he owns this building, so she needed to get out. R6 responded by telling R4 that she pays rent and had no intentions of leaving. R4 proceeded to bawl his fists up and call R6 a b*tch. R6 reported the incidents as scary and felt disrespected. Per R6, this was reported to the DON who took down the information. and told R6 that this was an ongoing issue with R4. R6 stated that staff placed a stop sign across her doorway however, it had been removed and she was not sure why. In an interview on 7/30/26 at 12:30 pm, Social Worker (SW) J stated that she spoke with R3 regarding the grievance she filed. The solution was to put a stop sign across R3's door. In an interview on 7/30/26 at 12:42 PM, Unit Manager (UM) E stated that R4 used to reside on her unit. When residing on that unit, R4 entered other residents rooms. When asked about the walking cane, UM E stated that it was removed and could not locate any information regarding a cane on R4's care plan, only ambulation using a walker. In an interview on 7/30/26 at 1:29 PM, DON B stated that he was aware of R4's cane being removed, however, was not sure how he regained access to the walking cane. After the first incident when R4 allegedly entered a room and struck a resident, he was moved to another unit. DON B stated that R4's room was moved to the front of the hall but acknowledged that was an intervention that was taken after the incident with R3 occurred. DON B could not speak much to interventions in place to eliminate R4 entering other residents' rooms.On 7/30/26 at 2:33 pm Nursing Home Administrator (NHA) A stated that abuse is described as any willful verbal and/or physical act. NHA A acknowledged that swinging a cane to hit another resident was a willful act.

This citation pertains to intake #3051218 Based on observation, interview, and record review the facility failed to develop an individualized care plan addressing behaviors and approrpiate ambulatory device for one (Resident #4) out of 6 reviewed for care plans. Finding include:Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/18/26, reflected R3 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R4 was admitted to the facility on [DATE], with diagnosis that included Vascular dementia, moderate, with agitation and irritability and anger. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/8/26, reflected R4 scored 3 out of 15 (severe cognitively impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 7/29/26 at 3:20 pm, R3 was observed in her room, seated in a wheelchair, and reading a book. R3 recollected previous encounters with R4. R3 stated that she has never spoke to him before, however, R4 would enter R3's room uninvited on several occasions. On 6/8/26 around midnight, R4 entered R3's room and stepped over to her bedside. R3 told R4 that he needed to leave. R4 refused. R3 repeatedly told R4 to leave or she was going to call the police. R4 told R3 that he did not care of she called the police. Staff arrived to assist and removed R4 from the room. R3 stated that there had been several encounters similar to this which occurred on and off all day and all night. R3 reported feeling afraid, and therefore, filled out a Grievances form to express her concern regarding R4 entering her room without permission. R3 went on to explain that one day, on 6/14/26, R4 came into R3's room without permission, yet again. R3 told R4 that he needed to leave. R4 responded by repeatedly calling R3 a b*tch and an as*hole, R4 approached R3 and lifted his cane to hit R3/ R3 stated she put her arm up to avoid being hit in the face, resulting in R4's cane striking R3 on the outer portion of her palm. R3 stated that staff intervened and after a few moments of coaxing R4 to leave the room, R4 finally exited R3's room. R3 presented a photograph of her hand which had a deep purple bruise on the outer part of her hand and knuckle. R3 reported that after the incident, R4's room was moved to the front of the hall as opposed to the end which reduced the number of times that R4 was walking past her room. R3 stated that she felt relieved because she was getting more and more afraid for R4. When asked if there any interventions in place to keep R4 from entering her room, R3 stated she had a stop sign set across her doorway however, the time of the incident, she did not observe the sign in place across her doorway. R4 also stated that her stop sign was removed two or three days ago and a staff member put it back up today.Review of a handwritten Grievance form completed by R3 stated the guy that wanders came into my room Monday night 6/8/26. Was at end of curtains by bathroom and was walking up toward bed. Very scary. He did this 2-3 times. I called for help both times. The came and took him out. He is very scary. In the section which states who else knows about the problem or incident, R3's handwritten response stated man in charge of nurses . In the section that states how can we address your issues?, R3's handwritten response stated he is very scary. has been walking in hall most of day looking in rooms .I kept telling him to leave. He wouldn't. Called me names. On the Grievance form, R3 indicated that this was an ongoing problem, stating, about a week, off and on all day sometimes PM (night). Review of a Facility reported incident report dated 6/14/26 stated that on 6/14/26 at 3:20 PM, R4 entered R3's room and when R3 told R4 to leave, R4 made contact with R3 using a walking cane. According to the same report, Licensed Practical Nurse (LPN) C was interviewed LPN C stated I heard yelling down the hall. the CNA (certified nursing assistant) and I entered the room and [R4] sat down on B bed facing [R3]. [R4] said she's a b*tch. Why didn't she just say it was her room. [R3] said I came out of the bathroom and saw saw him and told him to leave now. He starting walking toward me swinging his cane. I put my hand up and he hit my hand with the cane. A staff interview conducted with CNA D stated I heard [R3] screaming, get out. When i entered the room, [R3] was at the end of her bed. [R4] was yelling, why bitch?. LPN C' took [R4] out of the room. R3 was rubbing her hand and I noticed a bruise. [R3] stated he was swinging his cane and I put my hand up and the cane hit my hand. Review of a Nurses Note dated 12/16/25 stated Due to increased aggression towards staff with cane, cane has been removed from residents room. A walker has been provided. Resident has not used the cane consistently and ambulates frequently without it . Review of a Behavior Note dated 1/27/26 stated Resident attempted to enter female's room x 2. The first time he said he was lost. The second time he said she was his ex girlfriend . Review of a Progress Note dated 1/30/26 stated Nurse reports that his behaviors continue on second shift. He is still getting agitated with female residents and staff. He has been taking away food from other residents. When he is corrected or redirected, he gets verbally aggressive. Review of a Progress note dated 5/31/2026 revealed resident [R4] standing in the hallway arguing with [another resident], who accused him of being in her room. He said he did not know it was her room and [other resident] stated that he hit her in the left arm. He said that her would hit her again if she did not shut up. This nurse stepped between them and told him to go to his room . A nurses note dated 6/4/26 stated Guest [R4] came out of his room agitated that his roommate is accusing him of taking his stuff. Guest stated that he wanted a room change and he was done being blamed for everything going missing in that room. Guest also stated that if something does not change and his room mate goes off on him again he will hit him with his cane. DON (Director of Nursing) was called about situation. DON stated just to keep an eye on them and he will figure something out when he gets to facility. The follow up to the situation was to relocate R4 to a different room, at the end of the hallway. Review of the Care plan, Kardax, and Nurses Progress Notes revealed no indication of how R4 regained access to his cane that was removed from his possession in December 2025 or mention of any cane in any documentation. Review of a social services note dated 6/4/26 stated Resident wandering hallway and into other residents rooms throughout day. Resident easily redirected. Review of R4's Care plan revealed an absence of any Care Plan or any interventions related to R4's entering other residents' rooms. R4's Care plan spoke to using a walker for ambulation, however, nothing was noted on his Care Plan about using a walking cane. In an interview on 7/30/26 at 11:55 am, Resident #6 (R6) was interviewed regarding R4. R6 resided on the same hallway as R3 and R4. R6 stated that R4 had wandered into her room several times. During on occasion, R4 was aggressive and told R4 that he owns this building, so she needed to get out. R6 responded by telling R4 that she pays rent and had no intentions of leaving. R4 proceeded to bawl his fists up and call R6 a b*tch. R6 reported the incidents as scary and felt disrespected. Per R6, this was reported to the DON who took down the information. and told R6 that this was an ongoing issue with R4. R6 stated that staff placed a stop sign across her doorway however, it had been removed and she was not sure why. In an interview on 7/30/26 at 12:42 PM, Unit Manager (UM) E stated that R4 used to reside on her unit. When residing on that unit, R4 entered other residents' rooms. When asked about the walking cane, UM E stated that it was removed and could not locate any information regarding a cane on R4's care plan, only ambulation using a walker. UM E denied seeing any interventions regarding entering other residents' rooms. In an interview on 7/30/26 at 1:29 PM, DON B stated that he was aware of R4's cane being removed, however, was not sure how he regained access to the walking cane. After the first incident when R4 allegedly entered a room and struck a resident, he was moved to another unit. DON B stated that R4's room was moved to the front of the hall but acknowledged that was an intervention that was taken after the incident with R3 occurred. DON B could not speak much to interventions in place to eliminate R4 entering other residents' rooms or notifiying staff that he was not to have access to a cane.

This citation pertains to intake 3072680. Based on observation, interview and record review, the facility failed to ensure adequate blood glucose (sugar) monitoring for one (R2) of three reviewed. Findings include: Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included type 1 diabetes mellitus with ketoacidosis, without coma. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/9/26, reflected R2 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 7/29/26 at 3:20 PM, R2 was observed in bed. R2 reported the amount of insulin that had been ordered for them was too high and had been decreased.On 7/30/26 at 10:35 AM, R2 was observed in bed. R2 reported monitoring their own blood glucose multiple times daily, at home. R2 reported their blood glucose was not being monitored daily at the facility. A Physician History and Physical Progress Note, dated 7/3/26, reflected R2 was seen for an admission visit, after hospitalization for hyperglycemia (high blood sugar). According to the note, R2 had a history of poorly controlled type one diabetes. R2's medical record reflected a Physician Order, dated 7/2/26 to 7/9/26, for nine units of insulin glargine (long-acting insulin to help maintain stable blood glucose levels) to be administered twice daily. R2's medical record reflected a Physician Order, dated 7/10/26 to 7/20/26, for 15 units of insulin glargine to be administered daily. R2's medical record reflected a Physician Order, with a start date of 7/22/26, for 10 units of Lantus (long-acting insulin) to be administered daily. R2's medical record did not reflect routine monitoring of blood glucose levels. A Physician Order, with a start date of 7/5/26, reflected R2 was to have a FreeStyle Libre device (blood glucose monitor with a sensor that is placed in the arm, which can monitor blood glucose levels continuously) that was to be changed every 14 days. The July 2026 Medication Administration Record (MAR) reflected FreeStyle Libre device changes were ordered for 7/5/26 and 7/19/26 but were not documentation as being administered. Documentation for 7/5/26 reflected the device was not placed/changed due to R2 being absent from the facility. A Medication Administration Progress Note for 7/19/26 reflected the FreeStyle Libre device was on order. R2's July MAR reflected their blood glucose was documented as being checked on 7/4/26, 7/6/26, 7/7/26, 7/8/26, 7/16/26, and 7/19/26.The vital signs section of R2's medical record reflected additional documentation which included blood glucose checks on 7/3/26, 7/4/26, 7/6/26, 7/7/26, 7/8/26, 7/9/26, 7/16/26, 7/19/26 and 7/25/26. On 7/4/26, R2's blood glucose levels were documented ten times, with results ranging from 39 mg/dL (milligrams per deciliter/unit of measurement) to 273 mg/dL. A Progress Note for 7/5/26 at 9:32 AM reflected R2 was transferred to the emergency room after being observed in bed, unresponsive to verbal stimuli. R2's oxygen saturation level was 70 percent, and their blood glucose level was 40 mg/dL. A Progress Note for 7/5/26 at 6:29 PM reflected R2 returned to the facility. A Progress Note for 7/16/26 reflected a nurse entered R2's room and noted that R2 appeared unresponsive and was snoring loudly. R2's blood glucose was 53 mg/dL at that time. A Glucagon injection (medication used for emergency treatment of low blood sugar) was administered. Recheck blood glucose levels were 63 mg/dL and 120 mg/dL. In an interview on 7/30/26 at 11:18 PM, Licensed Practical Nurse (LPN) C reported residents that were receiving long-acting did not typically have their blood glucose levels checked after they were deemed stable. After they were deemed stable, blood glucose levels were checked if a resident exhibited signs of hypoglycemia (low blood sugar).In an interview on 7/30/26 at 1:29 PM, Director of Nursing (DON) B reported if a resident was on long-acting insulin, they typically did not monitor blood glucose levels. DON B reported if there were complications with blood glucose or they had to send a resident to the hospital, they may monitor blood glucose for residents receiving long-acting insulin. DON B reported R2 had a FreeStyle Libre device. After discussion pertaining to FreeStyle Libre documentation for R2, DON B then stated he did not know if R2 had a FreeStyle Libre device. DON B reported if R2 did not have a FreeStyle Libre device, the expectation was that R2's blood glucose would be monitored daily while on Lantus insulin. R2's medical record, including the 7/2026 MAR, Progress Notes and vital signs documentation did not reflect daily blood glucose level monitoring.

This citation pertains to intake 3026546. Based on observation, interview and record review, the facility failed to report an allegation of resident-to-resident sexual abuse to the State Agency timely for two (R3 and R4) of three reviewed. Findings include:R3:Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included bilateral primary osteoarthritis of knee, anxiety, major depressive disorder ([DATE]) and suicidal ideations ([DATE]). The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and 11 out of 27 (moderate depression) on the Patient Health Questionnaire (PHQ-9/tool for screening and measuring depression severity).R4:Review of the medical record reflected R4 admitted to the facility on [DATE], with diagnoses that included vascular dementia and other sexual disorders ([DATE]). The admission MDS, with an ARD of [DATE], reflected R4 scored seven out of 15 (severe cognitive impairment) on the BIMS. R4 died in the facility on [DATE]. On [DATE] at 11:24 AM, R3 was observed lying in bed. R3 reported, on Monday, [DATE], around 4:20 AM, R4 entered his room and pulled her pants and brief down, fully exposing the lower half of her body. R3 alleged R4 grabbed his blanket and stated, just lay there, men don't know how to do it. R3 described that he attempted to use his reacher to push the emergency call button on the wall, but R4 had his reacher. R3 stated he pressed his call light and told R4 someone was going to come and see what she was doing. R3 reported R4 then pulled her pants up and exited the room. R3 stated R4 went to a room across the hall and got in an empty bed. Approximately 20 to 25 minutes later, staff responded. After taking R4 to her room, staff entered R3's room, and he explained what occurred. R3 stated he reported the incident to Licensed Practical Nurse (LPN) D around 6:00 AM the same day. R3 stated LPN D notified him she had to report the incident as sexual assault. R3 reported he sent an email to the Business Office Manager (BOM K) the same day ([DATE]), which included information about the incident. R3 stated Director of Nursing (DON) B came to speak with him about the incident shortly after he sent the email. In an interview on [DATE] at 1:20 PM, Nursing Home Administrator (NHA) A stated R3 reported a resident went into his room and started to take off her clothes. R3 said he understood the female resident was confused, that he was able to redirect her with his reacher, and she never touched him. NHA A said facility staff spoke to R3 right after the incident, and R3 reported he was not offended by it. NHA A indicated after R3 changed his story to a clear allegation of abuse (on [DATE]), the facility reported it to the State Agency. In a phone interview on [DATE] at 2:27 PM, Certified Nurse Aide (CNA) I reported R4 would enter the rooms of other residents at night. CNA I stated one night, R4 went into R3's room. CNA I could not recall if R4 said what she was doing in R3's room at the time. CNA I stated R4 made a comment that seemed sexual in nature. In a phone interview on [DATE] at 2:49 PM, CNA J reported R4 wandered on third shift, sometimes into other resident rooms to talk. CNA J described staff went looking for R4 (on [DATE]), as she was not in her room. CNA J reported R4 was observed in a bed, in another resident's room (across the hall from R3). CNA J stated when R3 and his roommate heard staff (redirecting R4), they reported R4 had been in their room, before going across the hall. CNA J stated R3 reported R4 said something sexually explicit and started taking her pants off, while in their room. CNA J stated they reported the incident to the nurse. In an interview on [DATE] at 9:02 AM, DON B reported being notified of the incident by BOM K and immediately going to speak with R3. R3 reported that R4 entered his room. DON B described that R3 told R4 no and to leave his room. R3 used his reacher to ward R4 off. According to DON B, R4 made a statement to R3 about men can't do something, and R3 got her to leave the room. DON B denied that R3 mentioned R4 removing any clothing or touching him in any way. DON B stated, when talking to R3, he did not mention anything about assault or being touched. DON B stated R3 was calm and not under duress, which was why the incident was not reported. DON B reported last week ([DATE]), R3 made statements that R4 touched him and pulled her pants down (on [DATE]). In an interview on [DATE] at 9:45 AM, LPN D reported while giving morning medications (on [DATE]), R3 said a confused woman took her pants off and got into bed with him. R3 told her she was in the wrong room and needed to leave, which she did. When clarifying if R3 stated R4 tried to get in bed with him, LPN D stated she was not sure if R4 attempted to get in bed with R3. LPN D reported asking R3 if he felt threatened, felt safe or sexually assaulted, and he said he was fine. LPN D stated she reported it immediately. On [DATE] at 10:49 AM, R3 was observed lying in bed. R3 reported, at the time, the interaction with R4 scared him. R3 perceived her comment to him as though she was going to have some type of sexual activity with him. In an interview on [DATE] at 11:12 AM, NHA A described that when speaking to R3 last week ([DATE]), R3 gave the same story as he had previously, except on [DATE], R3 used terminology that he was sexually assaulted. NHA A stated R3 never used that wording when DON B spoke with him (on [DATE]). NHA A indicated when R3 mentioned sexual assault, he reported the allegation to the State Agency.

This citation pertains to intake 3026546. Based on observation, interview and record review, the facility failed to investigate an allegation of resident-to-resident sexual abuse timely for two (R3 and R4) of three reviewed. Findings include: R3:Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included bilateral primary osteoarthritis of knee, anxiety, major depressive disorder ([DATE]) and suicidal ideations ([DATE]). The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and 11 out of 27 (moderate depression) on the Patient Health Questionnaire (PHQ-9/tool for screening and measuring depression severity).R4:Review of the medical record reflected R4 admitted to the facility on [DATE], with diagnoses that included vascular dementia and other sexual disorders ([DATE]). The admission MDS, with an ARD of [DATE], reflected R4 scored seven out of 15 (severe cognitive impairment) on the BIMS. R4 died in the facility on [DATE]. On [DATE] at 11:24 AM, R3 was observed lying in bed. R3 reported that on the Monday, [DATE], around 4:20 AM, R4 entered his room and pulled her pants and brief down, fully exposing the lower half of her body. R3 alleged that R4 grabbed his blanket and stated, just lay there, men don't know how to do it. R3 described that he attempted to use his reacher to push the emergency call button on the wall, but R4 had his reacher. R3 stated he pressed his call light and told R4 someone was going to come and see what she was doing. R3 reported R4 then pulled her pants up and exited the room. R3 stated R4 went to a room across the hall and got in an empty bed. Approximately 20 to 25 minutes later, staff responded. After taking R4 to her room, staff entered R3's room, and he explained what occurred. R3 stated he reported the incident to Licensed Practical Nurse (LPN) D around 6:00 AM the same day. R3 stated LPN D notified him that she had to report the incident as sexual assault. R3 reported he sent an email to the Business Office Manager (BOM K) the same day ([DATE]), which included information about the incident. R3 stated Director of Nursing (DON) B came to speak with him about the incident shortly after he sent the email. In an interview on [DATE] at 1:20 PM, Nursing Home Administrator (NHA) A stated R3 reported that a resident went into his room and started to take off her clothes. R3 said he understood the female resident was confused, that he was able to redirect her with his reacher, and she never touched him. NHA A said facility staff spoke to R3 right after the incident, and R3 reported he was not offended by it. NHA A indicated after R3 changed his story to a clear allegation of abuse (on [DATE]), the facility reported it to the State Agency. In a phone interview on [DATE] at 2:27 PM, Certified Nurse Aide (CNA) I reported R4 would enter the rooms of other residents at night. CNA I stated one night, R4 went into R3's room. CNA I could not recall if R4 said what she was doing in R3's room at the time. CNA I stated R4 made a comment that seemed sexual in nature. In a phone interview on [DATE] at 2:49 PM, CNA J reported R4 wandered on third shift, sometimes into other resident rooms to talk. CNA J described that staff went looking for R4 (on [DATE]), as she was not in her room. CNA J reported R4 was observed in a bed, in another resident's room (across the hall from R3). CNA J stated when R3 and his roommate heard staff (redirecting R4), they reported that R4 had been in their room, before going across the hall. CNA J stated R3 reported that R4 said something sexually explicit and started taking her pants off, while in their room. CNA J stated they reported the incident to the nurse, and that was the last she heard about it. In an interview on [DATE] at 9:02 AM, DON B reported being notified of the incident by BOM K and immediately going to speak with R3. R3 reported that R4 entered his room. DON B described that R3 told R4 no and to leave his room. R3 used his reacher to ward R4 off. According to DON B, R4 made a statement to R3 about men can't do something, and R3 got her to leave the room. DON B denied that R3 mentioned R4 removing any clothing or touching him in any way. DON B stated, when talking to R3, he did not mention anything about assault or being touched. DON B stated R3 was calm and not under duress, which was why the incident was not reported. DON B reported last week ([DATE]), R3 made statements that R4 touched him and pulled her pants down (on [DATE]). In an interview on [DATE] at 9:45 AM, LPN D reported while giving morning medications (on [DATE]), R3 said a confused woman took her pants off and got into bed with him. R3 told her she was in the wrong room and needed to leave, which she did. When clarifying if R3 stated R4 tried to get in bed with him, LPN D stated she was not sure if R4 attempted to get in bed with R3. LPN D reported asking R3 if he felt threatened, felt safe or sexually assaulted, and he said he was fine. LPN D stated she reported it immediately. On [DATE] at 10:49 AM, R3 was observed lying in bed. R3 reported, at the time, the interaction with R4 scared him. R3 perceived her comment to him as though she was going to have some type of sexual activity with him. In an interview on [DATE] at 11:12 AM, NHA A described that when speaking to R3 last week ([DATE]), R3 gave the same story as he had previously, except on [DATE], R3 used terminology that he was sexually assaulted. NHA A stated R3 never used that wording when DON B spoke with him (on [DATE]). NHA A indicated when R3 mentioned sexual assault, he reported the allegation to the State Agency and initiated an investigation. R3's medical record did not reflect documentation of the alleged incident from [DATE], until [DATE].

This citation pertains to intake 3015141. Based on observation, interview and record review, the facility failed to revise the Care Plan for one (R2) of three reviewed. Findings include:Review of the medical record reflected R2 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction (stroke) due to unspecified occlusion (blockage) or stenosis (narrowing) of the right middle cerebral artery, dysphagia (difficulty swallowing) following cerebral infarction, unspecified protein-calorie malnutrition (5/15/26) and gastrostomy (surgical opening through the abdomen, into the stomach) status (5/15/26). The Admission/5-day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/4/26, reflected R2 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received a mechanically altered diet.R2's medical record reflected they discharged to the hospital on 5/8/26. R2 readmitted to the facility on [DATE], with a feeding tube in place. On 6/2/26 at 9:40 AM, R2 was observed lying in bed, with their eyes closed. The head of the bed was slightly elevated. A tube feeding pump was observed at the left bedside, with tube feeding formula and a water flush hanging. On 6/3/26 at 8:47 AM, R2 was observed lying in bed, awake, with the head of the bed slightly elevated. Osmolite 1.5 Cal tube feeding formula and a water flush bag were hanging from a tube feeding pole at the bedside. The tube feeding pump was set for a tube feed infusion rate of 65 milliliters (mL) per hour. The water flush rate was set for an infusion of 250 mL every four hours. A Physician Order, dated 5/15/26, reflected, Nothing By Mouth diet Nothing By Mouth texture, Nothing By Mouth consistency. A Care Plan intervention, dated 5/1/26, reflected, Provide diet as ordered- Pureed [diet texture], nectar thick [liquid consistency]. An intervention, dated 5/1/26, reflected to assist the resident with meals as needed. An intervention, dated 5/6/26, reflected to provide diet as ordered, observe and document food acceptance and offer substitutes as needed. An intervention, dated 5/6/26, reflected to encourage fluid as tolerated. R2's Kardex (Certified Nurse Aide Care Guide) was noted to include the same interventions. In an interview on 6/4/26 at 9:02 AM, Director of Nursing (DON) B reported, at the time of readmission, it was the responsibility of the floor nurse to update the Care Plan. DON B reported the Interdisciplinary Team reviewed new orders and the hospital course upon readmission. At that time, they would also review the Care Plan. DON B acknowledged R2's Care Plan had not been revised and continued to reflect a pureed diet texture and nectar thick liquid consistency.

This citation pertains to intake 3026546. Based on observation, interview and record review, the facility failed to ensure timely mental and psychosocial evaluation or continued psychosocial support after a resident-to-resident sexual abuse allegation for one (R3) of three reviewed. Findings include: R3:Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included bilateral primary osteoarthritis of knee, anxiety, major depressive disorder (5/21/25) and suicidal ideations (8/8/25). The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/23/26, reflected R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and 11 out of 27 (moderate depression) on the Patient Health Questionnaire (PHQ-9/tool for screening and measuring depression severity).On 6/2/26 at 11:24 AM, R3 was observed lying in bed. R3 reported, on Monday, 4/13/26, around 4:20 AM, R4 entered his room and pulled her pants and brief down, fully exposing the lower half of her body. R3 alleged R4 grabbed his blanket and stated, just lay there, men don't know how to do it. R3 described, he attempted to use his reacher to push the emergency call button on the wall, but R4 had his reacher. R3 stated he pressed his call light and told R4 someone was going to come and see what she was doing. R3 reported R4 then pulled her pants up and exited the room. R3 stated R4 went to a room across the hall and got in an empty bed. Approximately 20 to 25 minutes later, staff responded. After taking R4 to her room, staff entered R3's room, and he explained what occurred. R3 reported he sent an email to the Business Office Manager (BOM K) the same day (4/13/26), which included information about the incident. R3 stated Director of Nursing (DON) B came to speak with him about the incident shortly after he sent the email. In an interview on 6/4/26 at 9:02 AM, DON B reported being notified of the incident by BOM K and immediately going to speak with R3. R3 reported that R4 entered his room. DON B described, R3 told R4 no and to leave his room. R3 used his reacher to ward R4 off. According to DON B, R4 made a statement to R3 about men can't do something, and R3 got her to leave the room. DON B denied R3 mentioned R4 removing any clothing or touching him in any way. DON B stated, when talking to R3, he did not mention anything about assault or being touched. DON B stated, R3 was calm and not under duress. DON B reported last week (5/27/26), R3 made statements that R4 touched him and pulled her pants down (on 4/13/26). In an interview on 6/4/26 at 9:45 AM, LPN D reported while giving morning medications (on 4/13/26), R3 said a confused woman took her pants off and got into bed with him. R3 told her she was in the wrong room and needed to leave, which she did. When clarifying if R3 stated R4 tried to get in bed with him, LPN D stated she was not sure if R4 attempted to get in bed with R3. LPN D reported asking R3 if he felt threatened, felt safe or sexually assaulted, and he said he was fine. On 6/4/26 at 10:49 AM, R3 was observed lying in bed. R3 reported, at the time, the interaction with R4 scared him. R3 perceived her comment to him as though she was going to have some type of sexual activity with him. In an interview on 6/2/26 at 2:07 PM, Social Worker (SW) C reported following up with R3 last week (5/27/26), after R3 reported he was sexually assaulted back in April. SW C reported R3 emailed the BOM about the incident at the time, but she had not been made aware of that (sexual in nature incident). SW C reported she had not followed up with R3 since 5/27/26. SW C acknowledged R3 had a history of depression and suicidal ideations. SW C reported she would typically follow up with a wellness check but could not speak to why she had not done that. R3's medical record did not reflect documentation regarding the alleged incident on 4/13/26, until 5/27/26.

Based on observation, interview, and record review the facility failed to follow up on resident grievances for one (resident 1) of one reviewed.Findings include:On 4/10/26 at 12:13 PM, during an observation and interview, R1 was observed lying in bed, on her back. R1 reported that a friend of hers was able to review her electronic medical record and discovered there was an order for restorative therapy and it was believed to have been set to start January 1, 2026. R1 further stated that she had received this service 5 times total since January 1st and had been told by staff that they didn't have anyone to run the program. R1 reported that she filed a grievance related to not receiving the ordered restorative therapy and to date had not received any follow up by facility staff. R1 provided a photo of the grievance that was submitted. Review of the photo of R1's Grievance form revealed the following: the form was signed and dated by the resident on 3/25/2026, What is your concern about? Restorative therapy-Per my chart on December 31st, 2025, I was to start therapy on January 1st, 2026. This still hasn't happened. This is important to my physical health., Who else knows about your issues? I have shared in recent care meeting, with nurses, CNA's (certified nursing assistants) and (name redacted) PA, plus (name redacted) in physical therapy., How can we address your issues? My suggestion is-Bring in 1 or 2 CNA's to do the therapy and once they complete therapy for the day, then they could float and help where needed. There is always need for an extra hand. The facility was unable to locate/provide a copy of R1's grievance prior to survey exit.Review of the clinical record revealed R1 was admitted into the facility on 8/28/2025 with diagnoses that included: chronic inflammatory demyelinating polyneuritis (a rare, long-term autoimmune disease where the immune system attacks the protective covering of peripheral nerves which causes progressive muscle weakness, numbness/tingling in hands and feet) and bradycardia (slow heart rate). According to the Minimum Data Set (MDS) assessment dated [DATE], R1 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). Review of section GG-Functional Abilities revealed R1 required substantial/maximal assistance for lying to sitting on side of bed and was dependent for lower body dressing.Review of R1's Restorative Initial Evaluation dated 12/24/2025, revealed Upon assessment the guest/resident is noted to have functional deficits in: independent ROM (range of motion) in bilat (bilateral) ankles and repositioning from supine to upright seating positioning at the edge of bed.The following restorative program(s) would prevent a decline or possibly improve the guest's abilities to: increase ROM in bilat ankles; reposition in bed.A review of R1's physician orders revealed an active order for restorative program, May participate in nursing restorative programs. Resident to participate in passive ROM of bilateral ankles and/or progress to positional changes of supine to sitting on edge of bed for 15 minutes per 24 hours with staff and/or supervision of visiting guests, document daily. A review of R1's Task log for Nursing Rehab: Passive ROM: 10 repetitions per ankle revealed that during the 30 day look back period (3/12/2026-4/10/2026) this service was documented as being provided a total of 6 times, a response of Not Applicable was documented 49 times, and a response of Resident Refused was documented 8 times.A review of R1's Task log for Nursing Rehab: Bed Mobility: supine to sitting with assistance for 15 minutes on edge of bed revealed that during the 30 day look back period (3/12/2026-4/10/2026) this service was documented as being provided a total of 3 times, a response of Not Applicable was documented 53 times, and a response of Resident Refused was documented 9 times.On 4/10/2026 at 3:09 PM, during an interview with Environmental Manager I, it was reported that she is responsible for overseeing the facilities grievances/concerns. When asked if they keep a log of grievances filed, she reported that she did not but could check with the administrator to see if he did (no monthly grievance log was provided prior to survey exit). When asked specifically about R1's grievance that was filed on 3/25/26, she confirmed that it was not included in the paper copies of grievances (for the last 3 months) which were provided for review. Environmental Manager I reported that she would check in another location and provide the requested grievance if located, no facility copy of R1's grievance was provided prior to survey exit. Environmental Manager further reported that their goal is to get a resolution to concerns as soon as possible and that she believed the policy stated within 5-7 days. On 4/10/2026 at 4:20 PM, during an interview with Nursing Home Administrator (NHA) A, it was reported that grievances are logged into [NAME] (program used to track concerns) electronically once they have been resolved. A review of the facilities policy titled Facility Compliance Program, documented in part Upon discovering an issue, problem, or event where non-compliance is reasonably suspected, the individual must report such concern to the Facility Compliance Officer (FCO). Failure to report may result in progressive disciplinary action or termination.The concerns will be communicated as soon as discovered to the FCO for investigation. Concerns will be triaged according to the Priority Table below.ACTION Within 5 working days of receipt of the complaint when there is a potential for a negative outcome. Some examples for this category may include but may not be limited to: .Services not provided by a vendor-i.e. therapy, physician services etc.The Facility Compliance Officer will track all concerns reported through the Compliance Program.The FCO will create a summary each month using the data from [NAME] .print to include in QAPI (Quality Assurance and Performance Improvement ) meetings.It should be noted that R1 is alert and oriented with a BIMS of 14/15, is bedbound and provided a photographed copy of the grievance she filed with facility staff and her concern related to not receiving restorative therapy was substantiated.

This citation pertains to intake 2961814. Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for two (R3 & R5) of three reviewed. Findings include:Resident #3 (R3) Review of the medical record reflected that R3 was admitted to the facility on [DATE]. Diagnoses of cellulitis in both lower legs, chronic obstructive pulmonary disease, heart failure, dementia, difficulty walking and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2026 revealed R3 had a Brief Interview of Mental Status (BIMS) of 7 (severely impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R3 was assist with set up with eating, partial to moderate assistance toileting, showering, dressing lower body. During an observation and interview on 04/10/2026 at 2:15 PM, R3 stated she kept her cigarettes and lighter with her. R3 stated she keeps them in her purse or carries them with her. When R3 was asked if the staff ever put them in the medication cart or locked up in the medication room, or the lockers they provide out in the smoking area, R3 stated no. During an interview on 04/10/2026 at 2:25 PM, Licensed Practical Nurse (LPN) C was asked if she had any of the resident's smoking devices in the medication administration cart, she stated no she did not. LPN C stated the residents are supposed to use the lockers out in the smoking area but they don't use them. LPN C stated they do not keep extra smoking devices in the medication room. Record review revealed R3 was listed on the smoking list but did not have a smoking evaluation completed on admission. R3 did not have smoking listed on her care plan. During an interview on 04/10/26 at 3:50 PM, DON B stated he didn't know who developed the smoking care plan for residents. DON B also stated he was unaware of residents having their smoking devices on them. DON B added it wasn't brought to his attention. When asked who did the smoking assessment, DON B stated it varied because some residents come from the hospital and say they are not going to smoke and then they change their mind, they would do one then. DON B was asked if R3 was on the smoking list, DON B stated yes, her name was on the list. Review of the complaint received by the State Agency revealed Multiple residents have lighters and cigarettes in their rooms. I am concerned about fires and smoking in rooms. Lots of residents are using oxygen. Review of the list of smokers provided by the facility revealed 16 independent smokers and one dependent smoker. The independent smoker list included R3 and R5. Review of the medical record revealed R5 was admitted to the facility on [DATE] with a diagnosis of paraplegia. The Minimum Data Set (MDS) with and Assessment Reference (ARD) of 1/22/26 revealed R5 scored 15 out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Nursing Summary dated 4/6/26 revealed Chooses to smoke while in facility and follows smoking rules and procedures appropriately. Review of R5's Smoking Evaluation dated 4/7/26 revealed yes was marked for Follows smoking/vaping guidelines per policy (smokes/vapes in designated area, returns smoking/vaping paraphernalia to appropriate person/location, etc.). The Smoking Evaluation revealed R5 was a safe smoker-Resident may opt to smoke independently. On 4/10/26 at 11:33 AM, R5 was observed in his wheelchair in his room. R5 reported he was a smoker and kept his cigarettes and lighter in his room inside the fanny pack which was in his lap. R5 reported he was able to go outside and independently smoke at any time he wanted to and did not lock up or return his smoking paraphernalia to staff. On 4/10/26 at 12:21 PM, R5 was observed self-propelling their wheelchair down the hall and outside to the smoking area with his fanny pack. On 4/10/26 at 12:25 PM, R5 was observed smoking outside in the designated smoking area with three other residents. Review of R5's smoking care plan revealed interventions that included staff members will maintain all smoking paraphernalia for all unsafe and safe smokers; e.g., cigarettes, cigars, pipes, lighters, lighter fluid, tobacco, spit container, or any other matter or substance that contains a tobacco product. Review of the facility's Smoking Policy scanned into R5's medical record and signed by R5 on 7/12/25 revealed Guests are not permitted to have cigarettes, tobacco products, marijuana, or other smoking products OR lighters in their room or on their person at any time other than designated smoking times. All smoking paraphernalia will be turned into the nurse or supervising staff when the resident is done smoking. In an interview on 4/10/26 at 12:21 PM, Licensed Practical Nurse (LPN) C reported the facility's policy was that residents were to have their smoking paraphernalia outside in the designated lock boxes. LPN C reported most of the residents were independent with smoking and were responsible for placing their own cigarettes in the lock boxes outside. When asked if there were any residents who did not use the lockboxes, LPN C stated, Yes, all of them don't use the lockbox because they don't want to. LPN C reported all the residents kept their smoking paraphernalia in their rooms. In an interview on 4/10/26 at 12:30 PM, Director of Nursing (DON) B reported residents who smoked had their choice on where to store smoking paraphernalia which included in the lockers provided in the designated smoking area or turn the paraphernalia into the nurses for storage in the medication room. DON B reported storing smoking paraphernalia in the resident's room was not allowed per policy. On 4/10/26 at 3:49 PM, DON B reported they were unsure who developed smoking care plans and reported he would assume a resident who smoked had a smoking care plan in place. DON B reported he was unaware that R5 kept their smoking paraphernalia in their room. Review of the facility's Smoking Policy effective 6/17/25 revealed Staff members maintain all smoking paraphernalia for all unsafe and safe smokers; e.g., cigarettes, e-cigarettes, vaping devices, cigars, pipes, lighters, lighter fluid, or any other matter or substance that contains a tobacco product. Staff members distribute smoking materials to resident's that are unsafe to smoke at the designated smoking times, and to residents that are deemed safe to smoke and may smoke independently, at their request. Smoking paraphernalia will be retrieved by staff when smoking activity is concluded.

Based on observation, interview, and record review, the facility failed to provide restorative therapy as ordered for two (resident 1 and resident 4) of three reviewed. Findings include:R1On 4/10/26 at 12:13 PM, during an observation and interview, R1 was observed lying in bed, on her back. R1 reported that a friend of hers was able to review her electronic medical record and discovered there was an order for restorative therapy and it was believed to have been set to start January 1, 2026. R1 further stated that she had received this service 5 times total since January 1st and had been told by staff that they didn't have anyone to run the program. R1 reported that she filed a grievance related to not receiving the ordered restorative therapy and to date had not received any follow up. R1 reported that the only time she had been offered and refused restorative therapy was on February 23rd when she had a urinary tract infection, felt dizzy and didn't feel it was safe to sit at the edge of the bed. R1 adamantly denied any other refusals of restorative services. R1 provided a photo of the grievance that was submitted. A review of the photo of R1's Grievance form revealed the following: the form was signed and dated by the resident on 3/25/2026, What is your concern about? Restorative therapy-Per my chart on December 31st, 2025, I was to start therapy on January 1st, 2026. This still hasn't happened. This is important to my physical health., Who else knows about your issues? I have shared recent care meeting, with nurses, CNA's (certified nursing assistants) and (name redacted) PA, plus (name redacted) in physical therapy., How can we address your issues? My suggestion is-Bring in 1 or 2 CNA's to do the therapy and once they complete therapy for the day, then they could float and help where needed. There is always need for an extra hand. Facility was unable to locate/provide a copy of R1's grievance prior to survey exit.A review of the clinical record revealed R1 was admitted into the facility on 8/28/2025 with diagnoses that included: chronic inflammatory demyelinating polyneuritis (a rare, long-term autoimmune disease where the immune system attacks the protective covering of peripheral nerves which causes progressive muscle weakness, numbness/tingling in hands and feet) and bradycardia (slow heart rate). According to the Minimum Data Set (MDS) assessment dated [DATE], R1 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). Review of section GG-Functional Abilities revealed R1 required substantial/maximal assistance for lying to sitting on side of bed and was dependent for lower body dressing.A review of R1's Restorative Initial Evaluation dated 12/24/2025, revealed Upon assessment the guest/resident is noted to have functional deficits in: independent ROM (range of motion) in bilat (bilateral) ankles and repositioning from supine to upright seating positioning at the edge of bed.The following restorative program(s) would prevent a decline or possibly improve the guest's abilities to: increase ROM in bilat ankles; reposition in bed.A review of R1's physician orders revealed an active order for restorative program, May participate in nursing restorative programs. Resident to participate in passive ROM of bilateral ankles and/or progress to positional changes of supine to sitting on edge of bed for 15 minutes per 24 hours with staff and/or supervision of visiting guests, document daily. A review of R1's Task log for Nursing Rehab: Passive ROM: 10 repetitions per ankle revealed that during the 30 day look back period (3/12/2026-4/10/2026) this service was documented as being provided a total of 6 times, a response of Not Applicable was documented 49 times, and a response of Resident Refused was documented 8 times.A review of R1's Task log for Nursing Rehab: Bed Mobility: supine to sitting with assistance for 15 minutes on edge of bed revealed that during the 30 day look back period (3/12/2026-4/10/2026) this service was documented as being provided a total of 3 times, a response of Not Applicable was documented 53 times, and a response of Resident Refused was documented 9 times. R4On 4/10/2026 at 11:42 AM, R4 was observed lying in her bed on her back. She was observed to be well-groomed.A review of the clinical record revealed R#4 was admitted into the facility on 8/11/2023 with diagnoses that included: malignant neuroleptic syndrome (a rare, severe reaction to antipsychotic medications which causes extreme muscle stiffness) and catatonic schizophrenia. According to the Minimum Data Set (MDS) assessment dated [DATE], R4 scored 7/15 on the Brief Interview for Mental Status exam (which indicated severely impaired cognition). A review of section GG-Functional Abilities revealed R4 was dependent for personal hygiene.A review of R4's physician orders revealed an active restorative order May participate in nursing restorative program for 15 minutes daily for 7 days a week to assist staff with performing hand over hand grooming adls (activities of daily living).A review of R4's Task log for Nursing Rehab: Dressing/grooming: Hand over hand assistance with hair brushing/combing, teeth brushing, and face washing revealed that during the 30 day look back period (3/12/2026-4/10/2026) 7 days had no documentation of this service being provided or refused, 19 days the 15 minute goal was not met, and Not Applicable was documented 47 times. On 4/10/2026 at 3:55 PM, during an interview with Assistant director of Nursing (ADON) H, it was reported that she was currently responsible for overseeing the Restorative program and the previous Restorative nurse had quit a few weeks ago. It was reported that the CNA's are responsible for completing and documenting restorative therapy each shift. ADON H was asked to review the Task log for R1, she confirmed that the documentation showed that R1 was not regularly receiving restorative nursing as ordered. ADON also reported that any refusals of care should be reported to the nurse and documented in a progress note and that there was no circumstance where not applicable would be appropriate to document.A review of the facilities policy titled Restorative Nursing updated 4/26/2024, documented in part The facility strives to enable the resident to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being.A licensed nurse will help manage the restorative nursing process with assistance of nursing assistants trained in restorative care.Nursing Restorative is available up to 6-7 times per week and is provided for residents meeting restorative criteria.Daily documentation of minutes and initials by nursing assistants (on days' program is delivered).

This citation pertains to intake 2690644.Based on observation, interview and record review, the facility failed to ensure a licensed medical provider (Physician, Nurse Practitioner, Physician Assistant) routinely examined pressure ulcers for one (R4) of three reviewed.Findings include: R4's medical record reflected they admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included osteomyelitis (infection in a bone) of vertebra, sacral and sacrococcygeal region and stage 4 pressure ulcers (wound that penetrates all three layers of skin, exposing muscles, tendons and bones) of the sacral region, right buttock and left buttock. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/3/26, reflected R4 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded as having four stage 4 pressure ulcers. Two of the four pressure ulcers were coded as being present on admission/entry or reentry to the facility.On 3/12/26 at 11:52 AM, R4 was observed lying in bed, verbalizing ow and ouch. A specialty air mattress pump was hanging on the footboard of the bed. R4 stated they were doing terrible because of a bleeding tooth. On 3/13/26 at 1:22 PM, R4 was observed seated in a Broda chair, near a nursing station. A Physician Order, dated 10/6/26, reflected to cleanse R4's left ischium (lower/back part of hip bone) wound with wound cleanser, pat dry, pack the wound with a plain packing strip and cover with a bordered foam dressing, daily and as needed. An assessment of R4's left ischium stage four pressure ulcer, dated 3/11/26, reflected the wound had been present since admission [DATE]), and wound progress was stalled/previously improving wound characteristics were plateaued. The wound measured 2.49 centimeters (cm) in length by 1.86 cm in width and one cm in depth. Undermining (tissue destruction extending under the skin edges, making the ulcer larger at the base than at skin surface) of 0.5 cm in length from 11:00 to 4:00 positions was documented. A Physician Order, dated 3/27/25, reflected to cleanse R4's right ischium wound with wound cleanser, pat dry, apply Dakins full strength moistened gauze to the wound and cover with a foam dressing, daily and as needed. An assessment of R4's right ischium stage four pressure ulcer, dated 3/11/26, reflected the wound was present on admission, and wound progress was improving. The wound measured 1.48 cm in length by 1.49 cm in width by 0.5 cm in depth. Undermining of one cm in length from 10:00 to 1:00 positions was documented.A Physician Order, dated 3/27/25, reflected to cleanse R4's sacrum (bone below the lumbar vertebrae/bones in lower spine) wound with wound cleanser, pat dry, apply Dakins full strength moistened gauze to the wound and cover with a foam dressing, daily and as needed.An assessment of R4's sacrum stage four pressure ulcer, dated 3/11/26, reflected the wound was facility-acquired on 11/17/23, and wound progress was improving. The wound measured 2.73 cm in length by 4.19 cm in width by 0.5 cm in depth. Undermining of 2.5 cm in length from 9:00 to 4:00 positions was documented. A Physician Order, dated 3/27/25, reflected to cleanse R4's left rear hip wound with wound cleanser, pat dry, apply Dakins full strength moistened gauze to the wound and cover with a foam dressing, daily and as needed. An assessment of R4's left rear hip stage four pressure ulcer, dated 3/11/26, reflected the wound was facility-acquired on 3/1/24, and wound progress was stalled/previously improving wound characteristics were plateaued. The wound measured 1.06 cm in length by 0.39 cm in width by 0.3 cm in depth. Tunneling (passageway of tissue destruction under the surface of the skin with an opening at skin level from the wound edge) of 4.5 cm in length at the 3:00 position was documented. In an interview on 3/12/26 at 2:37 PM, Licensed Practical Nurse (LPN) F reported being the facility's wound care nurse. LPN F reported R4 received hospice services, and wound treatments were directed by hospice. According to LPN F, R4's wound treatments were more directed towards comfort versus wound healing, and they were working towards keeping the wounds clean and free of infection. During the onsite survey, review of R4's Progress Notes from 5/1/25 to the most recent 3/12/26 at 12:19 PM did not reflect that a provider had examined R4's stage four pressure ulcers. On 3/13/26 at 11:00 AM, a verbal request was made to Nursing Home Administrator (NHA) A, for the most recent date that a provider had evaluated R4's pressure ulcers. A Physician Progress Note, dated 6/26/25 and provided by the facility, reflected R4 had a past medical history which included decubitus ulcers (pressure ulcers), was enrolled in hospice and continued to receive care for their sacral wound. The note reflected extensive sacral ulcerations were reported. The documentation did not reflect that R4's pressure ulcers were examined during the visit. In an interview on 3/13/26 at 1:40 PM, Director of Nursing (DON) B reported hospice conducted face-to-face evaluations, and the facility had meetings with hospice for care coordination. When asked if the provider would evaluate wounds during the face-to-face encounter, DON B reported that was the expectation. A hospice Nurse Practitioner (NP) face-to-face encounter, dated 2/28/26 and provided by the facility, reflected the presence of non-healing stage four pressure ulcers. Documentation did not reflect that R4's pressure ulcers were examined during the encounter.

Based on interview and record review the facility failed to ensure care plans were reviewed and revised for four out of 11 residents (Resident #2, 6, 7, & 9).This citation pertains to intake numbers 2527031, 2669486, and 2656254.Resident #2 (R2):Per the facility electronic medical record (EMR) R2 was admitted to the facility on [DATE]. Record review of a facility incident report revealed that on 9/10/2025 R2 had an altercation with his roommate. R2 began to yell at his roommate to shut the mother f**king door to the bathroom because his roommate had turned the light on. The report revealed R2 yelled to his roommate to come over to him so he could slap him. Review of R2's progress notes dated 9/10/2025 revealed a notation that R2 threatened to physically harm his roommate because he had the bathroom door open. The note revealed R2' roommate growled at him then R2 began to get up, told him to shut the door, and he was going to beat him. The progress note revealed that the intervention was that R2 was moved to another room, which was a shared room. Review of R2's care plans revealed a care plan in place that stated (R2) has the potential for fluctuations in mood R/T (related to): unspecified psychosis, insomnia, major depression disorder with treatment in place., initiated on 2/17/2022, and last revised on 2/10/2025. Review of the interventions revealed none of the interventions were revised as a result of R2's aggression towards his roommate on 9/10/2025, nor where there any new interventions that identified and addressed R2's aggression towards other residents. The last revised intervention was dated 8/23/2023. No other care plan was found in R2's EMR that addressed his known aggression towards other residents nor interventions for prevention. R6 and R7:Review of a facility incident report dated 10/15/2025 revealed that about 6:30 AM R6 & R7 got into a disagreement because R6 turned on a light in the room, and then both residents made physical contact with each other. The incident report revealed R6 & 7 were heard by staff arguing and witnessed to have shove and swat at each other. The incident report revealed approximately 90 minutes after the light was turned on R7 confronted R6 by standing close to him and yelling. The report revealed R6 asked R7 to leave him alone and his stuff, but R7 then pushed R6, and then both residents began to strike each other with closed fists. R6 was moved to another room.Review of R6's care plans revealed a care plan that R6 had the potential for fluctuations in mood related to his diagnosis of depression, which was initiated on 6/16/2025 and last revised on 6/16/2025. Review of the care plan interventions revealed no interventions that address R6's aggression towards other residents after the incident. The last revised intervention was dated 5/18/2025. There were also no new interventions added to R6's plan of care post incident knowing aggression towards other resident occurred. No other care plan was noted to be on R6's EMR that address R6's aggression towards another resident with the potential for further aggression to occur, Review of R7's care plan revealed R6 was care planned for a potential for fluctuations in mood related to his diagnosis of dementia, depression, hallucinations, delusions. The care plan was initiated on 9/9/2024 with the last revision dated 9/10/2025. Review of the interventions revealed no interventions that addressed R7's aggression that occurred on 10/15/2025, no interventions were added to prevent further aggression towards other residents, and the last revised intervention was dated 3/25/2025.R9:Review of an incident report dated 10/30/2025 revealed R9 was found to be pushing his wife in her wheelchair, who was also a resident at the facility (R8), into their room and R9 attempted to use R8's arm and torso to turn the wheelchair when the wheelchair would not turn. The incident report revealed that a staff member heard R9 shouting at R8 and upon going in their room to assist the staff member saw R9 behind R8 yelling at her and grabbing her shoulder. R9 was heard by the staff member to call R8 an idiot. R8 was heard repeatedly to say to R9 to stop touching her, but then R9 struck R8 with an open hand in the shoulder/neck area and clutched R8's forearm. R8 was moved to another room. Review of R9s care plans revealed no care plan was put into place post incident for R9's aggression towards his wife R8, and no care plan was put into place for the fact that R9's wife was moved to another room, nor able to live in the same room as him for the time.In an interview on 12/17/2025 at 9:31 AM Director of Nursing (DON) B stated when an incident occurs, we have an Interdisciplinary Team (IDT) meeting to talk about the incident. DON B said the process for updating care plans was that during the IDT meeting the Social Worker had the computer up and would update care plans as the team discussed resident changes in their plan of care. DON B said that his expectation was, regarding the above incidents, that the resident's care plan be updated. DON B said he could not state why R2, 6. 7., & 9's care plan were not updated after each of the incident of aggression towards other residents, especially that the incidents were newly identified behaviors.In an interview on 12/17/2025 at 12:48 PM, Social Services (SS) H stated that every morning there were stand up meetings; then stated after that IDT meeting were held. SS H said everyone in the IDT meeting would have a computer and the discipline that the update pertained to would updated the care plan for that area, such as nursing, dietary, therapy etc SS H reviewed R2, 6, 7, & 9's care plans and stated she was not sure if the residents care plans just got missed, and she did not know why the care plans were not updated.

Based on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by staff.Findings Included:This citation pertains to intake number 2622835.Per the facility Electronic Medical Record (EMR) Resident #3 (R3) was admitted to the facility on [DATE]. Diagnoses included post-traumatic stress disorder (PTSD), anxiety, and history of physical abuse.Review of a Minimum Data Set, dated [DATE] revealed R3 had a Brief Interview for Mental Status score of 15 out of 15 which indicated she R3 had no cognitive deficit. Review of a facility incident and investigation report revealed that on 9/5/2025 Certified Nurse Aid (CNA) D used abusive language towards R3 causing R3 emotional distress. The report revealed R3 overheard two CNA's, CNA C and CNA D talking, and she heard CNA C tell CNA D that R3 was faking her incontinence. R3 then turned on her call light and CNA D responded. R3 asked CNA D for a grievance form and CNA D told her that she did not need one. The report revealed R3 asked CNA D for her name and CNA D refused to tell R3 her name, and upon R3 persisting CNA D began to swear at her and raise her voice, then stated to R3 that she did not have to give R3 her F**king name. The report revealed that the facility found that verbal abuse occurred from CNA D towards R3, and CNA D was terminated from her employment at the facility. In an interview on 12/16/2025 at1:28 PM, R3 stated that it was at the shift change when (CNA) C told CNA D, who was the oncoming CNA that she was incontinent and that she [NAME] being incontinent. R3 said she put on her CL, CNA D answered her call light, and she told CNA D that she does need help and was not faking it. R3 said she then went out to the hallway and got a grievance form to fill out for regarding CNA C making the comment that she faked being incontinent. R3 said when she was out in the hallway, she approached CNA D and asked her what her name was, and CNA D responded by saying that she did not have to tell me her F**king name was. R3 said that the Registered Nurse (RN) E took herself and CNA D into a conference room, and she tried to tell RN E what happened but said when she spoke CNA D kept saying I didn't do that b*tch. R3 said she would state to CNA D that it was her turn to talk, but CNA D would just say, no it is my turn b*tch. R3 said the only intervention RN E immediately did was tell CNA D to be quiet.In an interview on 12/16/2025 at 11:25 AM, RN E said R3 complained about CNA D not wanting to help change her from being incontinent. RN E said she took them R3 and CNA D into the conference room to see what happened. RN E said R3 was very upset. RN E said she called the manager on call, who was the Assistant Director of Nursing (ADON) F, and reported her that R3 was very upset, angry and did not want CNA D to care for her anymore. In an interview on 12/16/2025 at 12:18 PM, ADON F said CNA D had called her and told her what happened, but she got a different story. ADON F said R11, who is another resident, heard CNA D say to R3 that she did not give a sh*t about the form (grievance form), and that she was not going to give her F**king name to her. ADON F said both R3 and R11's statements of what CNA D said were the same. ADON F said R3 did fill out a grievance form and was upset that CNA D would not sign the grievance form. In an interview on 12/16/2025 at 1:55 PM, CNA D said her and CNA C were walking room to room giving report for shift change and said when they got the R3's room CNA C said R3 had fallen and was needing assistance. CNA D said R3 then put her call light on and said to her that she heard herself and CNA C said that she did not want to do anything for herself, and she wanted a grievance form. CNA D said R3 told her she was going to sign it. CNA D said she got R3 a grievance form. CNA D said RN F took herself and R3 into the conference room. CNA D said R3 went off. CNA D said she was never able to talk in the conference room, because R3 would not stop talking. CNA D said R3 did ask what her name was and said she just told R3 her name. In an interview on 12/16/2025 at 11:42 AM, CNA G said that R3 thought that when she had given CNA D report she had made a statement to CNA D that R3 was faking her incontinence. CNA G said R3 and CNA D got into an arguing match, and R3 was upset and angry.In an interview on 12/16/2025 at 1:46 PM, R11 stated that he heard CNA C say to CNA D that R3 was faking her incontinence. R11 said R3 wanted to fill out a grievance form and wanted to know CNA D's name but when she asked CNA D her name, CNA D said that she did not have to tell R3 her F**king name. Review of CNA D's education that the facility provided revealed that on 7/6/2025 CNA D received 0.75 hours of education on Abuse, Neglect, and Exploitation, and was graded a 100%. CNA D was also noted to have received education on the Elder Abuse: The Elder Justice Act Self-Paced on 9/1/2025 where she received 0.5 hours of educational time and was graded an 80%. Of note, CNA D received training in elder abuse on 9/1/2025 which was only four days prior to the verbal abuse and argument she was involved with regarding R3.

This citation pertains to Intake 2604669 Based on observation, interview, and record review, the facility failed to ensure one resident (R1) of three reviewed was free from the use of a physical restraint. Findings include:Review of the facility reported incident revealed staff applied a sheet to [R1's] wheelchair (restraint) putting resident at risk for potential harm. Review of the medical record revealed R1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included alcohol dependence with alcohol induced persisting dementia, pathological fracture of pelvis, wedge compression fracture of vertebra, and anxiety disorder. Review of the Brief Interview for Mental Status (BIMS-a cognitive screening tool) dated 8/22/25 revealed R1 scored 7 out of 15 indicating severe cognitive impairment. R1 sustained multiple falls while in the facility. On 8/29/25 at 9:52 AM, R1 was observed in bed with a staff member providing one on one supervision. In a telephone interview on 8/28/25 at 10:32 AM, Certified Nursing Assistant (CNA) E reported during the night shift on 8/18/25 into the morning of 8/19/25, they observed R1 halfway out of bed and had to assist R1 into their wheelchair and out to the nurses' station for supervision. CNA E reported around 2:00 AM, they heard Licensed Practical Nurse (LPN) H yell for help because R1 was close to falling out of their wheelchair. CNA E reported R1's body was slumped over with their head past their knees. CNA E reported it appeared R1 did not have any upper body control. CNA E reported they suggested supporting R1's upper body with a sheet to prevent R1 from slumping over. CNA E reported LPN H agreed so they proceeded to wrap a sheet around R1 with the ends of the sheet under R1's arms and then tied the sheet to the back handles of the wheelchair to prevent R1 from falling. CNA E reported at that time they did not think about the laws and rules that it's a restraint. In a telephone interview on 8/28/25 at 10:52 AM, CNA D reported during the night shift of 8/18/25 into the morning of 8/19/25, R1 was very agitated and wanted to get out of bed and into their wheelchair multiple times that night, which they assisted with doing. CNA D reported at one point; they came back to the nurses' station and R1 was sitting in their wheelchair while CNA E and LPN H were tying [R1] to the wheelchair with a bedsheet. CNA D stated, it was a restraint. She [R1] couldn't get out of it. CNA D reported they were not aware of how long R1 had the sheet tied around them but guessed approximately 15 minutes. In a telephone interview on 8/28/25 at 11:02 AM, (LPN) H reported R1 had just returned from the hospital after being one on one supervision in the hospital. LPN H reported R1 would not stay put no matter what they did with her. LPN H reported by 10:30 to 11:00 PM, R1 was exhausted and would not stay still. LPN H reported R1 was in the wheelchair with their head almost under the chair and hands on the floor. LPN H reported R1 did not have any core strength to hold herself up. LPN H reported CNA E suggesting using a sheet to assist with holding R1 in the chair. LPN H stated technically we aren't supposed to use a restraint, but they did not want R1 to fall. LPN H stated so I let [CNA E] put a sheet around [R1} and she tied it to the handles of the wheelchair. LPN H reported they got R1 sitting up enough, put a pillow in front of her and covered her with a blanket. LPN H reported R1 fell asleep after approximately 15 minutes and then was put back in bed. LPN H reported R1 was in bed all night after this until about 5:00 AM when it was discovered she fell in the doorway of her room. In an interview on 8/28/25 at 1:04 PM, Nursing Home Administrator (NHA) A reported R1 their investigation showed R1 was restrained to the wheelchair with a bedsheet on 8/19/25 at approximately 3:00 AM. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: R1 placed on one on one for observation, investigation, review of the Abuse Prohibition Policy, staff education on the Abuse Prohibition Policy with the focus on identifying a physical restraint and reporting, and audits pf staff knowledge of abuse policy, restraints, and reporting. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 130 residents, resulting in the increased likelihood for cross contamination and bacterial harborage.Findings include: On 07/23/2025 at 10:05 A.M., A common area environmental tour was conducted with Environmental Services Director (ESD) M. The following issues were noted: A-Hall Nursing Station: Two 12-inch-wide by 12-inch-long vinyl flooring tiles were observed (etched, scored, particulate). The concrete flooring sub-surface was also observed exposed through the worn vinyl tiles. (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. Restroom: The hand sink faucet assembly was observed loose-to-mount. (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. Lounge: The courtyard entrance/exit door threshold was observed with an air gap. The gap between the metal threshold plate and door slab measured approximately 0.5 - 1.0-inches-deep by 36-inches-long. The metal door frame and slab face were also observed (etched, scored, particulate, corroded). (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. B-Hall Nursing Station: The countertop Formica edge was observed missing. The damaged area measured approximately 1-inch-wide by 6-feet-long. (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. Restroom: The commode base caulking was observed (etched, scored, stained, particulate). Lounge: Both sides of the entrance door were observed (etched, scored, particulate). The damaged area measured approximately 36-inches-wide by 36-inches-long respectively. The exterior entrance/exit courtyard (smoking area) door and metal support frame were also observed (etched, scored, corroded, particulate). (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. The hallway corridor entrance double-door assembly was observed to not completely close upon opening. The double-door assembly was also observed requiring manual assist to completely close and reset the alarmed door code assembly. (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. Occupational/Physical Therapy: The hand sink faucet assembly was observed loose-to-mount. (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. C-Unit Soiled Linen/Biohazard Room: The Formica laminate countertop edge was observed missing. The missing countertop edge measured approximately 2-inches-wide by 18-inches-long. (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. On 07/23/2025 at 3:05 P.M., An environmental tour of sampled resident rooms was conducted with Environmental Services Director (ESD) M. The following items were noted: 101: The drywall surface was observed (etched, scored, particulate), adjacent to Bed A. The damaged drywall surface measured approximately 4-feet-wide by 6-feet-long. 102: The restroom commode base caulking was observed (etched, scored, stained, particulate). 104: The drywall surface was observed (etched, scored, particulate), adjacent to Bed A and Bed B. The damaged drywall surface measured approximately 4-feet-wide by 20-feet-long. The privacy curtain between Bed A and Bed B was also observed soiled with accumulated and encrusted food debris. 105: The drywall surface was observed (etched, scored, particulate), adjacent to the Bed B headboard. The damaged drywall surface measured approximately 4-inches-wide by 24-inches-long. The drywall surface was also observed (etched, scored, particulate), adjacent to the Bed A footboard. The damaged drywall surface measured approximately 18-inches-wide by 24-inches-long. 106: The privacy curtain between Bed A and Bed B was observed heavily soiled with accumulated and encrusted food residue. The drywall surface was also observed (etched, scored, particulate), adjacent to the Bed A headboard. The damaged drywall surface measured approximately 24-inches-wide by 18-inches-long. One carpenter ant was additionally observed foraging between Bed A and Bed B. The flooring surface was further observed soiled with accumulated and encrusted dust/dirt and food debris. 108: The drywall surface was observed (etched, scored, particulate), adjacent to Bed B. The damaged drywall surface measured approximately 24-inches-wide by 30-inches-long. The restroom commode base caulking was also observed (etched, scored, stained, particulate). 127: The drywall surface was observed (etched, scored, particulate), adjacent to Bed A. The damaged drywall surface measured approximately 4-feet-wide by 10-feet-long. 132: The drywall surface was observed (etched, scored, particulate), adjacent to Bed A. The damaged drywall surface measured approximately 20-inches-wide by 60-inches-long. 133: The restroom commode support was observed loose-to-mount. The restroom commode support could be moved from side-to-side approximately 4-6-inches. 134: The restroom commode support was observed loose-to-mount. The restroom commode support could be moved from side-to-side approximately 4-6-inches. 135: The drywall surface was observed (etched, scored, particulate), adjacent to Bed A. The damaged drywall surface measured approximately 24-inches-wide by 30-inches-long. The drywall surface was also observed (etched, scored, particulate), adjacent to Bed B. The damaged drywall surface measured approximately 30-inches-wide by 36-inches-long. 136: The drywall surface was observed (etched, scored, particulate), adjacent to Bed A. The damaged drywall surface measured approximately 4-feet-wide by 15-feet-long. 216: The restroom commode support was observed loose-to-mount. The restroom commode support could be moved from side-to-side approximately 10-12-inches. The restroom commode base caulking was also observed (etched, scored, particulate). 222: The restroom commode base caulking was observed (etched, scored, particulate). 340: The drywall surface was observed (etched, scored, particulate), adjacent to Bed A and Bed B headboards. The damaged drywall surface measured approximately 3-feet-wide by 3-feet-long respectively. 345: The drywall surface was observed (etched, scored, particulate), adjacent to the Bed A headboard. The damaged drywall surface measured approximately 3-feet-wide by 4-feet-long. The drywall surface was also observed (etched, scored, particulate), adjacent to the sitting chair. The damaged drywall surface measured approximately 6-inches-wide by 24-inches-long. 352: The drywall surface was observed (etched, scored, particulate), adjacent to the Bed A and Bed B headboards. The damaged drywall surface measured approximately 4-inches-wide by 36-inches-long respectively. 354: The restroom commode base caulking was observed (etched, scored, particulate). 359: The drywall surface was observed (etched, scored, particulate), adjacent to the Bed A headboard. The damaged drywall surface measured approximately 3-feet-wide by 5-feet-long. The restroom commode support was also observed loose-to-mount. The restroom commode support could be moved from side-to-side approximately 6-8-inches. 361: The restroom commode support was observed loose-to-mount. The restroom commode support could be moved from side-to-side approximately 8-10 inches. On 07/23/25 at 05:15 P.M., An interview was conducted with Environmental Services Director (ESD) M regarding the facility maintenance work order system. (ESD) M stated: We have the TELS system. On 07/25/25 at 09:00 A.M., Record review of the Policy/Procedure entitled: Housekeeping Services dated 7/8/2025 revealed under Policy: To promote a sanitary environment. (II) Routine Cleaning of Horizontal Surfaces (A) In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. On 07/25/25 at 09:15 A.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observations, interviews, record reviews, and 6 (9, 23, 52, 57, 82, 124) of 26 sampled residents, the facility failed to provide palatable food products effecting 126 residents who consume food, resulting in the increased potential for resident decreased food acceptance and nutritional decline. Findings include:R57: Review of the medical record reflected R57 admitted to the facility on [DATE], with diagnoses that included muscle weakness and moderate protein-calorie malnutrition. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/14/25, reflected 57 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 07/22/2025 at 9:48 AM, R57 was observed in bed, eating a bowl of cereal. R57 reported the facility's food was not good, and they had not had a hot meal or cold glass of milk since admitting to the facility. R82: Review of the medical record reflected R82 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included type 2 diabetes, unspecified protein-calorie malnutrition, schizoaffective disorder, major depressive disorder and anxiety. The Quarterly MDS, with an ARD of 7/8/25, reflected R82 scored 15 out of 15 (cognitively intact) on the BIMS. On 07/22/2025 at 10:15 AM, R82 reported the facility's food was horrible, and they would not eat it. R82 stated they had to go to the store to get their own food, such as peanut butter and jelly. According to R82, food was often served cold. R9: Review of the medical record reflected R9 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included Multiple Sclerosis. The Quarterly MDS, with an ARD of 6/27/25, reflected R9 scored 15 out of 15 (cognitively intact) on the BIMS. On 07/22/2025 at 11:26 AM, R9 described the facility's food as nasty. On 07/22/2025 at 1:12 PM, a palatability test was conducted on a lunch tray, consisting of a breaded chicken patty, mashed potatoes and gravy, a dinner roll, spinach and cherry pie. The tray was lukewarm and lacked flavor. Resident #52 (R52) Review of the medical record revealed R52 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/30/25 revealed R52 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 07/22/2025 at 9:34 AM, R52 was observed sitting on the edge of their bed. R52 reported they ate all meals in their room and that the food was cold and the milk was hot. R52 reported this had been reported to staff multiple times, but that staff don't seem to care. On 07/22/2025 at 1:14 PM, a lunch test tray revealed the breaded chicken patty was bland and lukewarm. The mashed potatoes were lukewarm and had an unpleasant taste Resident #124 On 7/21/2025 at 11:39 AM, R124 was observed in his room. R124 reported that the food is terrible. Resident #23 On 7/21/2025 at 12:06 PM, R23 stated that the food is shi*ty. On 7/22/2025 at 1:15 PM, the lunch meal was sampled. The breaded chicken was lukewarm and bland. The mashed potato with gravy tastes like starch water. On 07/22/2025 at 11:25 A.M., An interview was conducted with R124 regarding facility food products. R124 stated: The food is terrible. R124 also stated: I don't know what is wrong with it. R124 further stated: The food is ice cold when they hand it out. On 07/22/2025 at 12:47 P.M., Food product temperatures were monitored utilizing a ThermoWorks Superfast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident 57's lunch meal: Chef Salad - 54.2 degrees Fahrenheit* Hot Dog - 109.8 degrees Fahrenheit* Beverage (Coffee) - 128.5 degrees Fahrenheit* (*) The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained:(1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5°C (41°F) or less. On 07/22/2025 at 12:54 P.M., Food product temperatures were monitored utilizing a ThermoWorks Superfast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident 82's lunch meal: Chef Salad - 55.7 degrees Fahrenheit* Hot Dog - 122.6 degrees Fahrenheit* Beverage (2% Milk) - 54.2 degrees Fahrenheit* (*) The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5°C (41°F) or less. On 07/22/2025 at 1:35 P.M., A lunch meal food palatability test was conducted by this surveyor. The mashed potatoes and gravy were observed to be bland, flavorless, and grainy. The chicken patty was also observed to be unappetizing, chalky, and bland. The spinach was additionally observed to be slushy, bland, and overcooked. The cherry pie was further observed to be granular and insipid. On 07/23/2025 at 12:57 P.M., An interview was conducted with R52 regarding facility food products. R52 stated: The food is always cold. R52 also stated: The food sucks. R52 additionally stated: The food is disgusting. R52 further stated: When I eat in my room the food is always cold. R52 was queried regarding his lunch meal today. R52 stated: I ate the food and it was cold. R52 also stated: The potato soup was cold today. R52 further stated: My chocolate milk cup was also dirty today. On 07/25/25 at 08:00 A.M., Record review of the Policy/Procedure entitled: Meal Service dated 1/9/25 revealed under Policy: It is the policy of this facility to provide a dining experience that is conducive to meal acceptance, which includes a quiet, pleasant room, positive staff attitudes, and attractive meal presentation. On 07/25/25 at 08:15 A.M., Record review of the Policy/Procedure entitled: Food Temperatures dated 1/9/2025 revealed under Policy: Foods will be maintained at proper temperature to ensure food safety. Record review of the Policy/Procedure entitled: Food Temperatures dated 1/9/2025 further revealed under Procedures: (5) Test trays will be conducted periodically and the food temperatures, as served to the resident, will be monitored by the Nutrition Professional.

Based on interview and record review the facility failed to ensure advanced directives were listed correctly on one (R44) of one resident investigated for advanced directives.Findings Include:Resident #44 (R44)Review of the medical record reflected that R44 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Diagnoses of respiratory failure, dementia, lung cancer, chronic obstructive pulmonary disease, anxiety, depression and psychosis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/2025 revealed R44 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R44 is independent for care and needs minimal assistant with set up.On 07/21/2025 at 3:21 PM, R44 had a DNR in her electronic Medical Record (EMR) signed and dated 11/23/24. The face sheet also called the banner did not reveal R44 as a DNR, it had full code for advanced directives. Record review revealed a DNR signed 11/23/24 with 2 witnesses. During an interview on 07/22/2025 at 1:11 PM, Social Service Worker (SW) H stated R44 had a full code on her banner. SW H then added she should have been a DNR. SW H stated she returned from the hospital 5 days ago and it didn't get updated.Record review revealed the full code status for R44 had been switched during the onsite survey to DNR late afternoon of 07/22/2025, following the interview with SW H.

Based on observation, interview and record review the facility failed to ensure appropriate monitoring for two residents (R7, R82) receiving psychotropic medications. Findings include:Review of the medical record reflected R7 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included vascular dementia and hypotension due to drugs. Review of the Physician orders revealed an active order for Seroquel Oral Tablet (an antipsychotic), give 25 milligrams by mouth one time a day for Dementia with mood disturbance. Review of Physician orders revealed an active order which stated to monitor for psychotropic medication side effects, including orthostatic hypotension (sudden drop of blood pressure with position change). Review of the Physician order revealed no order for orthostatic blood pressure readings. Review of the vitals tab on the electronic medical record revealed no orthostatic blood pressures had been documented. In an interview on 7/24/2025 at 10:22 AM, Director of Nursing (DON) B stated that the expectation would be to monitor and document orthostatic blood pressures. According to the National Alliance on Mental Illness, a common side effect of Seroquel is orthostatic hypotension (a drop in blood pressure when standing up from sitting or lying down), increased heart rate, drowsiness, headache, agitation, dizziness, fatigue, extrapyramidal symptoms, weight gain, cholesterol abnormalities, increased glucose, dry mouth, increased appetite, constipation, increased blood pressure (pediatrics). R82: Review of the medical record reflected R82 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included type 2 diabetes, unspecified protein-calorie malnutrition, schizoaffective disorder, major depressive disorder and anxiety. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/8/25, reflected R82 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). A Physician's Order, dated 4/2/25, reflected R82 received 5 milligrams (mg) of Abilify (antipsychotic medication) by mouth, at bedtime, for antidepressant. A Physician's Order, dated 7/31/23, reflected to monitor for side effects related to antipsychotic medication use, including orthostatic hypotension (blood pressure drop when standing, after sitting or lying down). In an interview on 07/24/2025 at 10:22 AM, Director of Nursing (DON) B reported orthostatic blood pressures would have been documented in the vital signs section of the medical record or in the Progress Notes. R82's medical record did not reflect evidence of routine orthostatic blood pressure monitoring.

Based on interview, and record review the facility failed to ensure one out of 26 residents (Resident #130) care plan was revised. Findings Included:Per the facility face sheet Resident #130 (R130) was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Physician's orders revealed an order for, [NAME] boot (boots that are puffed up to prevent heels from coming in touch with the bed surface) to bilateral (both) feet while guest is in bed, every shift for Skin integrity., dated 2/11/2025.Review of R130's care plans revealed a care plan in place for, (R130) at risk for impaired skin integrity/pressure injury R/T (related to): decreased mobility, Dx (diagnoses): Alzheimer's Dementia, Anemia, DM (diabetes), HTN (high blood pressure), Bipolar, Mood d/o (disorder), Impaired cognition, Incontinence bladder and bowel, Psychotropic drug use, and protein calorie malnutrition. The care plan was created on 10/14/2021, initiated on 9/17/23, and revised on 2/11/25, however, the [NAME] boots were not added to R130's plan of care when the care plan was revised. Review of R130's Kardex (Certified Nurse Aid plan of care) revealed the [NAME] boots were not documented on the CNAs Kardex either.Record review of R130's treatment administration record for the month of July 2025 revealed the order for R130 to wear the [NAME] boots to bilateral feet while in bed, every shift for skin integrity, dated 2/11/2025.In an interview on 7/24/2025 at 10:48 AM, Director of Nursing (DON) B stated that he did not see the [NAME] boots on R130's care plan but stated he could see the boots were ordered. DON B said he did not see the boots listed on the CNA Kardex for R130's plan of care and, stated that his expectation was that if there was a Physician's order then the boots were to be added to R130's care plan, and also on R130's Kardex plan of care.

Based on interview and record review, the facility failed to ensure follow-up on monthly pharmacy medication regimen reviews for one (R82) of five reviewed.Findings include: Review of the medical record reflected R82 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included type 2 diabetes, unspecified protein-calorie malnutrition, schizoaffective disorder, major depressive disorder and anxiety. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/8/25, reflected R82 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R82's monthly pharmacy medication regimen reviews reflected to see the report for any noted irregularities and/or recommendations for 1/31/25. Upon further review of R82's medical record, their pharmacy review report for 1/31/25 was not noted. An email was sent to Nursing Home Administrator (NHA) A on 07/23/2025 at 4:03 PM, to request R82's pharmacy review report for 1/31/25. On 07/24/2025 at 8:51 AM, Director of Nursing (DON) B reported R82's pharmacy recommendation for 1/31/25 was blank (had a recommendation but had not been followed up on). Review of R82's pharmacy Consultation Report, dated 1/31/25, reflected R82 was being treated for hypertension (high blood pressure) and received loratadine-D, which could worsen hypertension. The recommendation was to consider discontinuing loratadine-D. If antihistamine therapy was indicated, the recommendation was to consider alternative therapy with loratadine 10 milligrams daily (without decongestant). The Physician's response to the recommendation was not marked. The recommendation did not include signatures of the physician or DON. In an interview on 07/24/2025 at 10:22 AM, DON B reported they had received the blank pharmacy recommendation for 1/31/25 from their provider group the day prior. DON B reported he would have followed up on the pharmacy recommendation, had he received it (prior).

This Citation Pertains to Intake #MI 574 and Intake # MI 791 This citations has two deficient practice statements. DPS 1 and DPS 2. DPS 1) Based on observation, interview and record review, the facility failed to prevent falls for 4 of 7 residents (Resident #62, #121, #117 and #41) reviewed for falls resulting in resident #121 falling from a mechanical lift during staff transfer and sustaining a [CONDITION(S)] and the potential for injuries for Resident #41, #62, and #117 and decreased quality of life. Finding include: Resident #121 (R121) On 06/07/22 at 12:20 PM R121's visitor reported he fell out of the mechanical lift and broke a hip. On 06/08/22 at 4:15 PM, R121's family member stated Of course, I had concerns, they dropped him and fractured his hip, that should have not happened. The nurse said the strap broke and he slid on the floor. But I heard the CNA [Certified Nursing Assistant] tell her relief that the strap was not completely over the hook. The strap slipped and he fell . I am not sure how to feel about this. I am sad for [R121] who has considerably declined since it happened. On 06/09/22 at 8:55 AM Certified Nursing Assistant (CNA) NN stated, So basically, I asked one of the co-workers to come and spot me, I hooked up one (left) side and she [Non-Certified Aide OO] hooked the other (right) side. Once we got him strapped in, I started raising the lift, and then R121 was up in the air and the right side back strap came off the lift, and R121 fell to the floor. We pushed the call light/emergency light, and the nurses came in to assist. Once we assessed his body and laid him on his back and 4 people lifted him in a sheet and put him in bed. They did not have me fill out an incident report, which I was surprised. LPN's I and C were the nurses working that day, contacted the DON B. CNA PP to do a demo on proper transfers with mechanical lifts. On 06/09/22 at 09:35 AM CNA PP stated, DON B asked me to observe CNA NN and CNA OO do a demo on use of a mechanical lift after R121 fell from the lift. I made sure they knew the importance of making sure the strap was latched in there since the one used was not hooked in properly. When asked about the loops being attached properly on the one previously used, They told me it was not hooked properly. When asked about both CNAs NN and OO being certified nursing assistants. CNA PP reported that CNA NN was certified but OO was a hospitality aide. When asked about her job description, CNA PP reported she was allowed to do anything nonresident related, such as take in water, answer the call lights and tell the other CNAs what those resident needs. Review of Non-Certified Aide OO's personnel file revealed they were a hospitality aide, with a job description dated 5/26/21. Temporary nurse aide skills competency checklist was completed documenting 1) Preventing Infection While Providing Personal Care. 2) Personal safety and emergency care, 3) Documentation and Core nursing Skills, 4) Positioning, moving and restorative care, 5) Nutrition and Elimination, 6) Advanced and Specialty care environment, 7) Comfort care and end of life and 8) Ethics and the Law in LTC. This checklist had employee's initials and observer initials with no sign off signature or date completed. The job description in this personal file is for a hospitality aide, not a certified nursing assistant. In an interview on 06/09/22 at 10:39 AM, Director of Nursing (DON) B reported she did not obtain statements from the staff involved in R121's fall since it was a witnessed incident. DON B reported she was not able to determine the cause of the fall. DON B reported that Scheduler/CNA PP did a training with the staff after the incident. On 06/09/22 at 11:15AM DON B reported I cannot find the education sheet on the demo use of the lift, but I am still looking. We determined it was operator error, it wasn't the equipment or the sling, that's why we did the education. In a telephone interview on 6/9/22 at 1:33 PM, Non-Certified Aide OO reported they thought they put the loop of the sling over the ring, but it slipped out. Non-Certified Aide OO reported they were on R121's left side and CNA NN operated the lift while Non-Certified Aide OO guided R121. On 06/10/22 at 0820 LPN I was asked about the fall on 5/25/22 with R121. LPN I stated, I was the first nurse that came in, 3 straps were hooked and 1 was hanging off the hook, I called daughter regarding incident. I filled out an incident report and put in a nurses note. Record review reflected that R121 had an increase in his pain management following this accident on 05/25/22. [MEDICATION(S)] patch 75mcg/hr. was increased to [MEDICATION(S)] 100 mcg/hr. for pain relief. [MEDICATION(S)] concentrate 100mg/5 ml (20mg/ml) ordered to give 0.5ml every hour as needed for severe pain, restlessness or dyspnea (shortness of breath). On 06/10/22 at 1:00 PM DON B was still unable to produce the education document on the mechanical lift following the accident of R121 falling from a lift. Resident #117 (R117): Per the facility face sheet R117 was admitted to the facility on [DATE]. Diagnoses included [CONDITION(S)] (a progressive breakdown of nerve cells in the brain), and right and left foot drop (feet drop forward with the loss of ability to correct the position). Review of an Incident Report, dated 5/29/2022, revealed R117 had fallen out of her Broda chair (high back style wheelchair that tilts back), and was found face down on the floor. The Post Fall Report, which was part of the Incident Report revealed R117 was to be in a common area while up in her wheelchair. Review of a progress note dated, 5/29/2022, revealed R117 was found on the floor in her room face down next to her wheel chair. The progress note also revealed R117 should not be left alone in her room when up in her chair, and needed to be in a common area up by the nurses' station. Record review of a care plan, dated 3/31/2022, and revised on 4/18/2022, titled (R117) is at risk for fall related injury and falls R/T (related too): DX (diagnoses): [CONDITION(S)] (a progressive breakdown of nerve cells in the brain) dx, Gait (walking)/balance problems: non-ambulatory, Incontinence: bowel, bladder, Poor communication/comprehension, Psychoactive drug use, Unaware of safety. Review of the interventions in place on the same care plan revealed no intervention that R117 needed to be in a common area up by the nurses' station, and not left in her room while up in her Broda chair after her fall on 5/29/2022. Record review a care plan, dated 3/31/2022, and last revised on 4/18/2022, titled (R117) has an ADL (activities of daily living) Self Care Performance Deficit and requires assistance with ADL's and mobility r/t: Disease Process: [CONDITION(S)] dx, Malnutrition, Limited Mobility. The care plan revealed the intervention that R117 was to Broda chair for and assistive device, dated 4/4/2022, and revised on 4/18/2022, however the care plan did include the intervention that R117 was to be in a common area up by the nurses' station while up in her wheelchair. In an observation on 6/09/2022, at 1:05 PM, R117 was observed sitting in her Broda chair inside of her room, and not in the common area by the nurses' station, until 2:03 PM when R117 was observed to be taken to an activity in the B-hall dining room. In another observation on 6/09/2022, at 4:10 PM, R117 was observed back in her room up in her Broda chair, and not in a common area by the nurses' station. In an interview on 6/10/2022, at 8:43 AM, Director of Nursing (DON) B that all resident falls were reviewed within 48 hours of the fall. DON B said all departments had the responsibility for resident care plans and revision of care plans. Resident #62 (R62) On 6/08/22 at 9:19 AM, R62 was observed sitting in a wheelchair in her room. R62's Minimum Data Set (MDS) with an assessment reference date of 5/22/22, indicated her Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents score was 12 (08-12 Moderately Impaired). R62's same MDS assessment indicated she required extensive assistance for transfers with two plus persons providing physical assist. In review of R62's risk for falls care plan, revised 11/29/21, she was at risk for falls due to diagnoses of heart failure, high blood pressure, gait and balance deficits, psychoactive drug use, hearing deficits, and was non-ambulatory. In review of R62's nurses notes, she fell on [DATE]. An Incident Report was requested from the Director of Nursing. Incident Report dated 3/27/22 at 7:00 AM, R62 was found on the floor in her room. Immediate interventions included increased monitoring. In review of R62's fall risk care plan, increased monitoring was not added to the care plan. On 6/08/22 at 4:25 PM Director of Nursing (DON) B was interviewed and stated she just signed the Incident Report for R62 from 3/27/22 because she found it on the unit managers desk and had not seen it prior to the date of this interview. DON B stated in the same interview, increased monitoring probably meant the staff were going to monitor her while parked at the nurse's station. DON B confirmed the interdisciplinary team (IDT) did not review R62's fall, it was missed completely. Incident Report dated 4/06/22 at 1:45 AM indicated R62 rolled from her bed onto the floor mat. DPS 2) Based on observation, interview and record review, the facility failed to implement interventions to prevent elopement for one resident (#41) of one reviewed for elopement, resulting in R41 having eloped for an 11 hour period. Findings include: According to the clinical record including the Minimum Data Set (MDS) with an assessment reference date of 3/24/22 reflected Resident # 41 (R41) was admitted to the facility on [DATE] with diagnosis of dementia. Review of the MDS reflected R41 scored 11 out of 15 (moderate cognitive impairment) and that R41 had wandered. R41 was admitted to the non-secured. Review of the facility reported incident reflected R41 eloped on 05/09/2022 at approximately 8:00pm, a search began at that time along with notification to Nursing Home Administrator (NHA) A, Director of Nursing (DON) DON B the Physician, guardian/wife JJ and local Police Department were notified. R41 was observed on 5/10/2022 at approximately 10:00am in the parking lot of a fast food restaurant by an off duty employee who had an appointment at a building next to the restaurant. Of note the restaurant was located across the main road. Upon R41's return to the facility he was placed in the facility's secured dementia unit. Review of the facility elopement risk assessments dated 3/24 3/31, 4/7 and 5/12 all reflected R41 was at High risk for elopement, the 4/14 assessment revealed R41 scored 1 point below being High risk. Review of R41's progress notes dated 3/17, 3/19 and 4/17 reflected he was angry and threatened to elope. An interdisciplinary team progress note dated 5/06/2022 reflected R41 kept removing his wanderguard bracelet and due to this behavior he was put on 15 minute checks for 7 days and had no incidents, thus the wanderguard was discontinued at that time. Further record review failed to identify any additional interventions or safety measures to prevent elopement. On 06/07/22 at 01:49 PM, during a phone interview with legal guardian/ wife ,JJ she reported R41's main reason for admission to the facility was because he continuously eloped from home The police department knew us well, he got out from house a lot. Oh my goodness he would take off quite often. Id ask where he was going and he'd say it was absolutely non of my business. When queried if the facility was aware of R41's behavior at home, legal guardian/ wife ,JJ responded Absolutely they knew, I told them all he eloped from home, he is going to try it there . He is definitely a flight risk Legal guardian/ wife ,JJ reported she had been legal guardian for nearly a year and over the last 2 years R41's confusion and increased along with the constant bouts of elopement. On 06/07/22 02:23 PM R41 was observed sitting in chair in main area of the secured dementia unit. He reported he once jumped over the fence, it happened. it was a breeze. I only jumped it once. R41 was unable to articulate where he slept or spent the night 5/9/22 but stated he had to go and get points and pay his wife. On 06/07/22 03:54 PM during an interview with Certified Nursing Assistant (CNA) II reported R41 did talk about leaving the facility at times and would talk a lot about his wife. CNA II further stated on the evening of 5/9 he was angry at his wife because she dropped off some items for him but didn't come in the building to see him. During an interview with Licensed Practical Nurse (LPN) HH on 06/07 4:03pm she reported she was assigned to R41 the evening he eloped. LPN HH stated she went to pass his medications and discovered he was gone at approximately 8:00PM on 5/9/22, elaborated that R41 always talked about leaving and getting out of the facility, that he had to go drive to Traverse City or other random cities that he would name. LPN HH stated she reported and requested management From the get go that R41 be moved off her unit and onto the secured dementia unit. LPN HH stated facility Social Worker (SW) W refused to have R41 move because he smoked and it would be too much on the staff to take R41 on and off the dementia unit several times a day to go and smoke. On 06/07/22 at 4:24PM, during an interview with Registered Nurse/ Unit Manager (RN/UM) K reported she recalled R41 complaining the facility felt like a prison. When queried if she was aware of R41's history of elopement from home and floor staff voicing concern/request for R41's safety to be moved to secure unit prior to the elopement, RN/UM K stated she was aware. When queried why R41 was not place in the secure unit prior to the elopement. RN/UM K replied Because he was a smoker and he was too high functioning. On the afternoon of 6/09/22 during a phone interview with SW W he reported his last day of full time employment at the facility was last week, he now works on an as needed basis and had no recollection on R41 or the overnight elopement from 1 month ago. On 06/10/22 at 10:04 AM , during an interview with DON B she reported R41 didn't want to be at the facility but was doing ok. DON B elaborated that the alarm bracelet was discontinued because R41 kept cutting it off, DON B stated the facility did 15 minute checks for 7 days and since he didn't try to elope in that 7 day time frame those were stopped. When queried what was put in place to prevent elopement a that time, DON B said nothing, We didn't think this would happen. DON B acknowledge she was aware of the reasoning for long term care placement was elopement. When queried why R41 was not on the secured dementia unit given his history and DON Bstated he didn't qualify because he was to high functioning. Of note, further record review revealed there was one assessment/evaluation for placement for the secured unit, which was dated after his successful elopement attempt.

This Citation Pertains To Intake MI 371 Based on interview and record review the facility failed to ensure one out of six residents (Resident #1) received appropriate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Left facility via Emergency Medical Services for emergency care. Review of R1's medication orders revealed R1 was to receive the following medication to treat Type 2 diabetes mellitus, [MEDICATION(S)] Solution (insulin Glargina) 100 units/milliliter (ml) 110 units subcutaneously two times per day (started 12/10/2021) and Insulin [MEDICATION(S)] Solution 100 units/ml give 10 units subcutaneously before meals (started 12/10/2021). Record review of progress notes dated 12/12/2021 at 09:50 a.m. revealed R1 was non-responsive to verbal and physical touch stimulation. Pupils where equal and reactive. His blood sugar was checked and found to be 38 milligram (mg)/deciliter (dl). [MEDICATION(S)] 1milligram (mg) was injected into R1's right deltoid at 10:00 a.m. His blood sugar was checked again and found to be 70mg/dl. Two packets of instant Glucose Gel were given at 10:34 a.m.(route by mouth per MAR) Per R1's progress notes on 12/12/2021 at 11:10 a.m. R1's blood sugar was recorded at 77mg/dl and the primary care physician (PCP) was notified. The progress notes revealed that the PCP placed [MEDICATION(S)] Solution 100 units/ml 10 units subcutaneously on hold until seen by the PCP. Record review of R1's medication administration record (MAR) for December 2021 revealed R1 was to receive [MEDICATION(S)] Solution (insulin Glargina) 100 units/milliliter (ml) 110 units subcutaneously HS (at bedtime), however was placed on hold 12/12/2021. R1's MAR for December 2021 revealed R1's Insulin [MEDICATION(S)] Solution 100 units/ml 10 units subcutaneously before meals was placed on hold that evening. Record review of R1's progress notes 12/12/2021 at 02:04 p.m. revealed R1'sblood sugar was 117 mg/dl and R1 was awake, watching tv, and that his speech was clear. Record review of R1's progress notes 12/13/2021 at 7:00 a.m. R1 was nonresponsive. His blood sugar was recorded in progress notes to be 70mg/dl. R1 was given [MEDICATION(S)] gel and his blood sugar was re-checked and recorded in the progress notes to be 48mg/dl. The PCP ordered one time [MEDICATION(S)] injection. His blood sugar was re-checked and recorded in the progress notes to be 120 mg/dl. After administration It was documented in the progress notes that R1 was observed sitting up and responding. It was also documented in the progress notes that R1 ate some of his breakfast. Review of Record review of R1's MAR December 2021 revealed that the 12/13/2021 a.m. dose of [MEDICATION(S)] Solution (insulin Glargina) 100 units/milliliter (ml) give 110 units subcutaneously was not given. Further review of the MAR demonstrated that [MEDICATION(S)] Solution (insulin Glargina) 100 units/milliliter (ml) give 110 units subcutaneously was discontinued and changed to [MEDICATION(S)] Solution (insulin Glargina) 100 units/milliliter (ml) give 70 units subcutaneously tow times per day. The MAR also revealed that R1 received Insulin [MEDICATION(S)] Solution 100 units/ml 10 units subcutaneously at 4:30 p.m. with a blood sugar of 171 mg/dl. Record review of R1's progress notes revealed that on 12/13/2021 at 7:29 p.m. R1's blood glucose level registered HI(great that 600 mg/dl) and received [MEDICATION(S)] Solution (insulin Glargina) 100 units/milliliter (ml) 70 units subcutaneously was administered. Record review of R1's MAR December 2021 revealed [MEDICATION(S)] Solution (insulin Glargina) 100 units/milliliter (ml) 70 units subcutaneously was administered on 12/14/2021 at 8:09 a.m. Record review of R1's progress notes, dated 12/14/2021, revealed no documentation that R1's blood glucose level was checked prior to the administration of the [MEDICATION(S)] insulin. Further review of R1's progress notes, dated 12/14/2021, at 09:17 a.m, revealed Licensed Practical Nurse (LPN) J documented, At approximately 0845 am attempted several times to wake resident up for breakfast and medications, using sternal rub after no success. Resident would not wake up. Checked blood sugar, was at 194. Vital signs were T 98.2 P65 RR 16 BP 151/85 Spo2 96%. The progress notes further revealed that Physician Assistant (PA) K had placed Insulin [MEDICATION(S)] Solution 100 units/ml give 10 units subcutaneously before meals on hold. (LPN) J documented in R1's progress notes dated 12/14/2021 at 1:26 p.m., Attempted to wake resident up for lunch, after no success, attempted sternal rub (technique is performed by rubbing the knuckles of a closed fist firmly and vigorously on the sternum, the stimulus is applied to the core of the body, it is referred to as a central painful stimulus). Resident continued to sleep. Blood sugar was at 117. Vital signs T 97.2 P84 RR 18 BP 127/76 SPO2 97 . Gave glucose gel as allowed. It was also noted in the progress note that PA K was made aware of resident's condition. Record review of R1's progress notes revealed PA K entered a progress note, which was signed on 12/14/2021 at 1:07 p.m., entitled FU (Follow up) after admission. In the section history of present illness it was documented patient has been having very low blood sugars. Yesterday, his long-acting insulin was adjusted to 70 units twice daily from 110 units twice daily . Patient was sleeping this morning, and I was unable to arouse him. Vital signs otherwise have been stable. PA K further documented in section medications that the resident was given Glucose gel 40% 12/13/21 December 12, 2021 . [MEDICATION(S)] Emergency Kit 1mg: Inject 1 dose December 12, 2021 to [DATE]. Glucose Gel 40% to keep blood 100, December 12, 2021. No further documentation noted by PA K regarding interventions for R1's unresponsiveness as demonstrated by sternal rub. Record review of R1's progress notes revealed that on 12/14/2021 at 05:38 p.m., Resident continues to sleep, current blood sugar is 52, (noted that PA K was on call and notified). At 05:41 p.m. glucose gel 40% was given to R1. No record of blood R1's glucose level, after giving glucose gel 40% was found in the medical record. Record review of R1's progress notes revealed that on 12/14/2021 at 06:00 p.m. Registered Nursing (RN) L completed a Situation-Background-Assessment-Recommendation (SBAR) which revealed R1 was unresponsive and code status was full resuscitation. RN L documented on 12/14/2021 at 06:15 p.m. Order rec'd to start D5W (water and [MEDICATION(S)]) at 75/hr. Started via PICC (peripherally inserted central catheter) line. After an hour checked sugar 152. Still not responding. At 7pm new provider on. Gave her update. Blood sugar checked again at 8 pm per her request 253. D5W taken down. Remains unresponsive, to pain, even. Pupils are equal and reactive, eyes are deviated to the R as is tongue. He has snoring respirations. Ordre rec'd (received) to send pt. out. It was also noted in the progress note that when Emergency Medical Services arrived that R'1s blood sugar was 450. It was also documented on 12/14/2021 at 06:15 p.m. R1 was received in the emergency department, Remains unresponsive and they report that blood sugar was 23 when pt. arrived to their ER. During interview on 12/27/2021 at 10:00 a.m. with LPN J she was asked if it was practice at the facility to obtain blood glucose levels prior to administration of insulin. LPN J explain that it was her practice to obtain blood glucose levels prior to administration of insulin. When asked where those would be documented, LPN J explained sometimes in the MAR and sometimes in the progress notes. When asked if LPN J could recount what she told PA K regarding R1's hypoglycemic events she explained that she could not recall the conversation and would need to refer to the Tiger Text (a form of Point Click Care Communication sent to the providers) that would have been relayed to the physician assistant. She was unaware if those conversation were retrievable within the medical record and would have to ask the Director of Nursing (DON) B. LPN J was asked if she thought it would have been necessary sooner to transfer R1 to the emergency department related to his unresponsiveness following a sternal rub on two occasions on 12/14/2021. LPN J explained that she would need Physician's approval to send a resident to the hospital. When LPN J was asked if she had requested R'1 be sent to the hospital she explained she could not remember and would have to refer to the Tiger Text. LPN J did not return to provide answer regarding being able to review Tiger Text. During interview on 12/27/2021 at 10:30 a.m. with PA K explained that they should have been having glucometer readings since the time of admission. When asked to review the medical record she was unable to locate a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . PA K was asked to review the events of 12/14/2021 for R1. She was also asked if she was aware that R1 could not be aroused even after a sternal rub on at least two occasions. PA K explained that she was aware and said she could not wake R1 when she examined R1 on 12/14/2021. When asked if this caused her concern PA K explained that she had reviewed his medical records and he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When this surveyor requested PA K to demonstrate the order or results in the medical record she was unable to locate orders or results. When this surveyor questioned the process of orders or results PA K explained that she must have given a verbal order through the tiger text system and not written the order herself. PA K explained that she did not know how to refer to that Tiger Text history of conversations. During interview on 12/27/2021 at 11:56 a.m. the Director of Nursing (DON) B informed this surveyor that Tiger Text system could not retrieve text conversations past 7 days from when the text are entered. During telephone interview on 12/27/2021 at 02:19 p.m. Physician M was asked to review the R1's most recent stay at the facility. Physician M explained that he remembered being contacted by PA K on 12/14/2021 about R1's hypoglycemic events. He also explained that R1 could not be waken during these events and recalled that R1's vitals were stable. This surveyor asked physician M if he was aware that R1 could not be aroused even with a sternal rub? Physician M explained he was not. Physician M explained that if it had been reported to him R1 was not arousable with a sternal rub he would have given order to transfer R1 to the emergency department for evaluation. Recorded review of hospital records dated 12/16/2021 revealed R1 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 12/28/2021 R1 was in the hospital in an intensive care unit, on mechanical ventilation.

This Citation Pertains To MI 446 Based on observation, interview and record review the facility failed to prevent a fall for 1 resident (#2) of 2 reviewed for falls, resulting in a left nondisplaced fractured femur that required surgical repair and a fractured great left toe. Findings include; According to the clinical record, Resident #2 (R2) was admitted to the facility on [DATE], review of R2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/21 revealed R2 required extensive assistance for toileting, bed mobility and hygiene from 2 staff persons. Review of the activity of daily living care plan initiated and currently in place was dated 4/14/20 and reflected R2 required extensive assistance with bed mobility, transfers, and toileting. Resident was observed and determined not to be interviewable during the survey. Review of the facility's incident and accident report dated 8/16/2021 reflected R2 was observed on the floor by Certified Nursing Assistant (CNA) C, R2 was assessed by Nursing staff whom observed R2's left leg was shortened and rotated outward, the immediate intervention was to transferred R2 to the hospital, further review of the incident and accident report reflected CNA C was educated to follow R2's care plan. Review of hospital records reflected R2 required surgical intervention to repair the left femur on 8/18/21. On 12/27/2021 at 12:45 pm, during an interview with Director of Nursing (DON) B, she reported R2 was supposed to have 2 staff persons during the care provided on 8/16/2021 at the time of the fall. DON B further reported CNA C was no longer employed at the facility and was given a written warning as a result of R2's injury and lack of following the care plan. Review of CNA C's documented verbal warning reflected CNA C did not follow a care plan which resulted in an injury for a resident that occurred on 8/16/2021, the verbal warning form was issued on 8/17/21 and signed by CNA C. On 12/27/21 at 1:53pm during a phone interview with former employee CNA C, she stated she was providing incontinence care to R2 on 8/16/21 and left R2 in bed on her side for a minute, I went to go get a brief or pad or something, and when I came back she was on the floor. CNA C stated she had heard of other CNA's changing R2 without assistance so she thought she could do the same. CNA C further stated she was aware of how to check the care plan and CNA care guide, and offered no explanation as why she did not ask or solicit help as directed in R2's care plan.

This citation pertains to MI 5831. Based on interview and record review, the facility failed to readmit one of one residents reviewed for return to facility (involving Resident #5 and Resident #3), resulting in Resident #5 not being allowed to return to his home and being transferred to a facility far away from the residents family and in another state, and the potential for other residents to be denied their right for reentry. Findings include: Upon entrance to the facility on [DATE] at 12:00 PM, Surveyor was informed there were no active Covid-19 cases in the facility. Review of R5's Discharge Return Anticipated Minimum Data Set (MDS), dated [DATE], he was admitted to the facility on [DATE], was severely cognitively impaired, wandered daily and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R5's Care Plan, dated 1/17/2020, (R5) requires 24-hour care/LTC (long term care) placement at this time related to dx (diagnosis) of dementia. Legal decision maker has verbalized acceptance of plan to remain in the facility. According to R5's Care Plan, dated 12/28/2019, (R5) is at risk for wandering d/t (due to) Dx (diagnosis) of dementia. In an interview, on 3/16/21 at 9:10 AM, Ombudsman H reported R5 had severe dementia and had been residing in the Dementia Unit at the facility. Ombudsman H said, (R5) didn't injure any residents . (the facility) sent him out to get him stable for behaviors towards staff. Complainant H stated R5 had been at a psychiatric hospital and once he had no behaviors, he R5 contracted Covid-19 and had to stay longer. However, when R5 had recovered from Covid, (The facility) refused to take him back. Complainant H said, We tried to find placement everywhere . (Daughter/POA/Power of Attorney Q) was distraught and beside herself. According to Ombudsman H, the facility did not give Daughter Q an Involuntary Discharge notice. Ombudsman H stated she told Administrator R5 was stable and without behaviors but Administrator A told her his boss told him he didn't care if he received a Federal citation, that he was not going to take R5 back due to his past behaviors. In an interview, on 3/16/21 at 10:13 AM, Psychiatric Hospital Social Service Coordinator O reported, (R5) was with us for so long - 150 days roughly. (R5) had come from (facility) and we had him ready to return a couple of times, but behaviors hindered us from sending us back but then they called us and said they had COVID in the facility and could not accept him. It is Covid world. Is realistic it could have happened. My theory was to give them a day to do Covid management. At that time, (R5) was negative or Covid with us and they disagreed with his readmission until they were (Covid-19) negative free. We kept calling them and got no response. (R5's) family wanted him back there. He had been there for quite some time. Then, they finally (the facilty) told us he had been discharged from their facility. They told us they would work with us with a sister facility but never gave us that information to make that transfer happen. We had to place him in (a different state) facility on 2/15/21. (R5) ran out of lifetime reserve psychiatric days. In an interview, on 3/17/21 at 8:30 AM, Daughter Q said (R5) would get ornery and they would send him out to get his medications adjusted. The last time, when they were ready to send him back, (the facility) refused to take him back. They said he could not come back due to Covid even though he already had Covid. They told me there was COVID-19 in the nursing home. They told (the psychiatric hospital) it didn't' matter about Covid - they weren't taking him back. They never gave me a reason other than Covid. I spoke with Social Work and Admissions (at the facility). I spoke with them a couple of different times. One time they told me they didn't have room for him. He was there for 2-3 weeks . I received nothing in the mail from them (the facility). I am his POA for medical and financial. (Currently) (R5) is doing good. They got his medications straightened out . (The psychiatric hospital) said I had to come and get him because he had been there almost 150 days, but I told them there was no way I could take care of him. Then, I called (Ombudsman H) again. Then, all of a sudden, (the psychiatric hospital) called and (a facility in a different state approximately 60 miles from the facility) said they would take him - he's been there a couple of months . (R5) had been (at the facility) for one and a half years and they were good with him. In an interview, on 3/17/21 at 8:45 AM, the facility's Director of Marketing M said, When (R5) was hospitalized , we sent him to (the psychiatric hospital). Then, when he was ready to come back, we were Covid positive and we were not taking admissions. We weren't taking anyone during that time. Our criteria is they must follow isolation precautions and he was not able to do that. We did work with the family to look for alternate placement for him at that time. We faxed his referral to multiple skilled nursing facilities and sister facilities, but they had the same criteria and could not take him. I have a list of places we tried. It was really difficult at that time . We were not able to meet his needs medically because he could not even stay in the room. He was exit seeking and a wanderer. Our new admissions must be able to follow the isolation requirements. Someone who is not redirectable we are not taking since we have had the new admission criteria. Most facilities I reached out at the time were closed to admissions. When interviewed as to whether they would accept R5 now since they no longer had active Covid cases Director of Marketing M said, we would have to see what his current conditions are . Review of R5's psychiatric hospital Social Service note, dated 10/29/20 at 12:55 PM, revealed, (Director of Marketing M) called and stated (R5) is able to return but they cannot and will not take him back on Friday; 'we will take on Monday 11/02/20'. Review of R5's psychiatric hospital Social Service note, dated 11/04/20 at 1:19 PM, revealed, Contacted (Director of Marketing M) and stated we are ready for discharge tomorrow 11/05(20). (Director of Marketing M) stated, 'at this time we have Covid in our facility and we are not accepting new patients. Staff replied with, '(R5) is not a new patient; he is an existing patient .Staff stated we have to have a discharge plan and we need to discharge him tomorrow. (Director of Marketing M) stated they will reach out to sister facilities about accepting him. Review of R5's psychiatric hospital Social Service note, dated 11/04/20 at 3:29 PM, revealed, Called (Daughter Q) . said when she called, she stated, 'I told them I want hm to return (to the facility) and contact Hospice; they stated, 'Okay'. Review of R5's psychiatric hospital Social Service note, dated 11/04/20 at 3:31 PM, Contacted (Director of Marketing M) to discuss (Daughter Q's conversation regarding it be up to her if (R5) return(ed). (Director of Marketing M) stated, 'at this time, my Administrator is saying we aren't taking anyone into our facility. Review of R5's psychiatric hospital Social Service note, dated 12/02/20 at 12:10 PM, revealed, The Social Worker (R) spoke with (facility Social Worker/SW P). (SW P) informed the (SW R) that R5 is still unable to return to them even though he is not Covid positive and their original reasoning for postponing his discharge was the fact that they have Covid at their facility . Review of R5's psychiatric hospital Social Service note, dated 12/20/20 at 2:10 PM, . Social Worker (SW R) and CEO (Chief Executive Officer of the psychiatric hospital) have left at least eight messages there over the last ten days. (Daughter Q) was told by Director of Marketing M) at the (facility) that they still have not found alternate placement for (R5) . In an interview, on 3/17/21 at 2:50 PM, Administrator A said, . It is my understanding (R5) did not meet readmission criteria because he could not follow the guidelines to protect the others. He was a risk to the safety and well bearing of others because he could not follow the guidelines . If someone has covid they were put on the covid unit . The CDC (Centers for Disease Control) guidelines changed so often . A list of other residents not allowed to the facility after hospitalization due to wandering was requested. On 3/17/2021 5:18 PM, the facility provided evidence they sent referrals to seven facilities on behalf of R5 on 11/05/20, but none before or after 11/05/20. According to the facility Referral Log, R5's case was opened on 9/17/20 and closed on 11/02/20. In a second interview with psychiatric hospital Social Service Coordinator O, on 3/17/21 at 4:11 PM, Our legal team sent an Email to the facility on [DATE] stating (R5) was on day 20. (R5's) Power of Attorney (POA) had been paying for his bed hold. His actual discharge from our facility was on 2/15/21 - 149 days . On day (44) 11/02/20, they were prepared to receive him. When I talked to (the facility's Director of Marketing M) she said they had Covid there and couldn't accept him. After that, they stopped responding to our calls. Finally, they said they had discharged him. We went back and forth with our attorney and had our corporate reach out . We sent out over 121 referrals for him in Michigan . Our discharge plan became home health care and sending him home with his (family). We finally found placement in (another state). In an interview, on 3/17/21 at 11:50 AM, facility SW P reported, Before, (R5) was sent out (to the psychiatric hospital) and came back. The last time when the (psychiatric) hospital was ready to send (R5) back, we could not accept admissions due to Covid. We weren't taking any admissions. I believe that decision was from corporate. Whenever we had a Covid patient in the building, we could not admit . No, there is no documentation in the chart. 9/17/20 (the day of his discharge) is the last (progress) note. It was not an involuntary discharge because POA was aware he was sent to the hospital and agreed to it. When we did not accept (R5) back it was not an involuntary discharge. I'm not sure about the Bed Hold policy. I don't know who handles that. I did attempt to reach out to other facilities and faxed referrals. When he could come back, the hospital would call and give an update and say no he's not coming due to x, y and z. and they found alternative placement. Review of R5's Medical Record revealed no physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The last Nurse Practitioner Progress Note was dated 9/15/20 (one day prior to the last discharge) and revealed, .(R5) was transferred to (Psychiatric Hospital) and returned back to us on 8/21/20 with the only medication change being the addition of an [MEDICATION(S)] patch (Central Nervous System Depressant) . Review of R5's Psychiatric Hospital Progress Note, dated 10/28/21 AM (not timed), revealed, .No anger or aggression. No [NAME] (no sexual acting out), and on 10/28/21 at 1:00 PM, No PA/VA (no physical aggression/verbal aggression). No acute behaviors . Review of the facility infection line listing revealed no active Covid-19 cases in [DATE], [DATE] or March 2021; the line listings for the months 9/20 - 12/20, requested on 3/18/2021 8:52 AM, were not supplied by time of exit. In an interview, on 3/17/21 at 5:09 PM, Director of Nursing (DON) B stated, On day 44 we were unable to maintain isolation . (The psychiatric hospital) cancelled his return because he was not stable and when they were ready to send him back, we made the assumption he was not stable. We had far too many patients with Covid and we were not able to maintain isolation .I dispute this being his home. He was not here that long . R5 was admitted to the facility on [DATE]. Review of MDS data revealed the facility permitted other residents that wandered, were allowed reentry to the facility: According to the MDS, dated [DATE], Resident #3 (R3) was severely cognitively impaired and wandered; she was discharged to the hospital on 11/11/20 with return anticipated and reentered the facility on 11/13/20.

This citation has two deficient practice statements (A and B) A) Based on observation, interview and record review, the facility failed to follow and implement infection control practices per the Centers for Disease Control (CDC) guidelines to prevent the spread of COVID-19 for nine residents (Resident #5, #6, #7, #8, #9, #10, #12, #13, and #15) resulting in Immediate Jeopardy when the facility failed to 1) immediately isolate symptomatic residents, 2) clearly post isolation signage, 3) perform proper hand hygiene, 4) ensure appropriate Personal Protective Equipment (PPE) utilization and proper storage, 5) maintain physical distancing of residents and encourage proper mask use, 6) utilize EPA registered disinfectant products with the appropriate contact time, and 7) operationalize policies and procedures related to COVID-19. These deficient practices resulted in the likelihood for further cross contamination of COVID-19 to other residents residing in the facility, thereby putting all 134 facility residents at risk for infection, hospitalization and/or death. Findings include: On 9/23/20, as requested upon entrance, the facility provided the surveyors with a list of positive COVID-19 and suspected positive residents. The list included eight residents; two of which were positive (Resident #6 and Resident #7) and six of which were suspected positive (Resident #8, #9, #11, #12, #13, and #15). On 9/23/20 at 8:40 AM, the Director of Nursing (DON) B reported the facility had two residents who were currently positive for COVID-19 and those two residents were in a room with a plastic barrier in the doorway. During an observation on 9/23/2020 at 9:31 AM, Hospitality Aide (HA) O was observed on the A Wing hallway with a cart that had a cooler and a towel on it. HA O was observed exiting room [ROOM NUMBER] and placing beverage mugs on the towel, then refilling the mugs with ice. After finishing with room [ROOM NUMBER], HA O proceeded to room [ROOM NUMBER], without performing hand hygiene between rooms. HA O placed the beverage mugs from room [ROOM NUMBER] on the cart and refilled them with ice. After finishing with room [ROOM NUMBER], HA O proceeded to grab a beverage mug from a resident in Resident #10's room, without performing hand hygiene between rooms. On 9/23/2020 at 9:37 AM, Resident #5 (R5) was observed from the hallway, in their room alone, with the door open. R5 was seated at the edge of their bed. A sign was posted on the exterior of the room door, reflecting contact/droplet isolation. A cart was observed outside the room door for storage of Personal Protective Equipment (PPE). During an interview on 9/23/2020 at 9:59 AM, HA O reported they passed ice water (to residents). HA O reported they only sanitized their hands after every two to three residents. HA O reported they did not sanitize their hands between each resident or between each room. On 9/23/2020 at 10:33 AM, Housekeeping Aide (HSK) G was observed wearing a surgical mask and gloves while sweeping a resident room. HSK G reported they used HDQ Neutral to mop the rooms. When asked what the contact time was for the product, HSK G reported they were supposed to spray the product, then wipe it down and let it air dry. When asked how long they waited before wiping the product, HSK G reported about one minute, maybe not even that long. HSK G also reported they used HDQ Neutral on a rag to wipe the bed frame, tables, night stands and call lights. HSK G reported that when they went into isolation rooms, they wore a gown, gloves, face shield and a second mask. HSK G reported the second mask was also a surgical mask. The Environmental Protection Agency (EPA) number on the HDQ Neutral bottle reflected -130-5741. According to, https://www.epa.gov/pesticide-registration/list-n-advanced-search-page-disinfectants-coronavirus-covid-19, List N Advanced Search Page: Disinfectants for Coronavirus (COVID-19), the contact time was 10 minutes. On 9/23/2020 at approximately 11:18 AM, Resident #12 (R12) and Resident #13's (R13) room door (R12 and R13 were roommates) was observed to have signs posted to see the nurse before entering and for contact/droplet isolation precautions. The room door was observed to be open, and a PPE storage cart was outside the room door. On 9/23/2020 at 11:25 AM, the door for R12 and R13's room remained open, and a stop sign was observed across the doorway. On 9/23/2020 at 3:02 PM, the door for R12 and R13's room was observed to be approximately 50 percent open with a privacy curtain drawn around Bed A. According to a facility list of residents that were positive and suspected of having COVID-19, R12 and R13 were on the list as being suspected of having COVID-19. On 9/24/2020 at 9:25 AM, Transport Driver (TD) P was observed seated at the nurse's station near the 200 and 300 rooms. TD P's KN95 mask was at his chin, with his mouth and nose exposed as he was talking. When TD P turned and saw the surveyor, he pulled his mask up over his mouth and nose. Resident #10 (R10) Review of the medical record reflected that R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/2020, reflected that R10 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R10's laboratory results reflected that a COVID-19 test was collected on 9/8/2020 at 8:58 AM. That same test reflected it was positive, with a result date of 9/13/2020 at 2:08 AM. R10's Physician's Orders reflected that contact and droplet isolation transmission-based precautions related to COVID-19 were initiated on 9/14/2020 and discontinued on 9/18/2020. A Progress Note by Nurse Practitioner (NP) M on 9/15/2020 with a time of 00:00 (midnight) reflected, .being seen today due to positive covid test on routine screening. Reportedly, he has been asymptomatic (no symptoms) .Pt (patient) has not had known exposure at this time, but has been out to specialist appointments (reportedly maintaining facemask in place). Has not had non-staff member inside facility to visit in at least the past 2 weeks . A Progress Note by NP M on 9/22/2020 with a time of 00:00 reflected, .Reportedly, he has been asymptomatic .Loose-sounding cough .ICD Codes: .Lab test positive for detection of COVID-19 virus (sic) Most recent test in chart is positive. Asymptomatic with the exception of cough .Cough Acute. Frequent, loose .Continue enhanced droplet isolation . R10's Physician's Orders did not reflect that transmission-based precautions (isolation) were in place on 9/22/2020, nor were they re-ordered after NP M's visit on 9/22/2020. On 9/23/2020 at 9:31 AM, R10's room was not observed to have transmission-based precautions in place. On 9/24/2020 at 11:25 AM, R10's room was not observed to have transmission-based precautions in place. On 9/24/2020 at 11:32 AM, Certified Nurse Aide (CNA) Q reported that R10 did not have any transmission-based precautions in place. In an interview on 9/24/2020 at 12:32 PM, NP M reported that even after R10's positive COVID-19 test, he did not have any symptoms, not that he has reported to me. NP M confirmed that she visited R10 on 9/22/2020. When asked if R10 had any new symptoms, NP M reported that R10 had a loose-sounding cough, but that was it. NP M reported that R10 had chronic lung conditions. When asked if she had any recommendations for R10 at the time of her visit on 9/22/2020, NP M reported, .continue isolation per policy, if it falls into their policy . When asked if R10 should have been in isolation or put back in isolation on that date (9/22/2020), NP M reported the last thing she knew was that R10 was positive on that date. NP M reported that as far as R10's symptoms were concerned, she thought it would have been extreme to keep R10 in isolation if he had a negative test. NP M then stated she didn't see a test more recent than the 8th (9/8/2020) in R10's chart. When NP M was asked if by looking at her visit note (for 9/22/2020), would her recommendation be that R10 was in droplet isolation? NP M stated by her note and data in the chart, the recommendation would be that R10 stayed in enhanced isolation. NP M stated she thought R10 was in precautions that day (on 9/22/2020). NP M stated she said to continue enhanced droplet isolation. When asked how long she would anticipate the precautions to continue for, NP M reported at least 14 days after the positive test (for COVID-19). NP M stated that it was debatable if R10 really showed symptoms given his chronic lung conditions. In an interview on 9/24/2020 at 3:16 PM, Infection Preventionist (IP) I reported that if a resident tested positive for COVID-19, they would not be tested again for eight weeks. IP I reported there were exceptions, such as if the individual became symptomatic in that timeframe. They would then retest. When discussing when precautions would be put back in place for an individual that developed symptoms of COVID-19, after they were COVID-19 positive and previously asymptomatic, IP I stated they would be put back in precautions at that time, if they developed symptoms. When discussing NP M's progress note for R10 on 9/22/2020, IP I stated that it didn't clearly spell out to her that it (cough) was new onset. IP I reported she would have liked to clarify with NP M. According to IP I, if NP M truly felt it (cough) was new onset, R10 should have been isolated and retested . IP I reported that R10 was not isolated or retested for COVID-19. According to IP I, R10's transmission-based precautions were discontinued on 9/18/2020. In a separate interview on 9/25/2020 at 3:16 PM, IP I reported that when someone was placed on transmission-based precautions, it was put in as an order (in the medical record). During an interview on 9/29/2020 at 2:59 PM IP I was asked if residents were placed in transmission-based precautions when they were readmitted to the facility. IP I reported that if they were gone overnight, they would start the whole 14 day isolation over again. According to IP I, residents were not always placed on transmission-based precautions after returning from outside provider appointments, [MEDICAL TREATMENT] or visits to the emergency room , unless they were to return to the facility without a mask on. Observations on 9/23/20 at 9:20 AM revealed the facility had numerous residents on isolation throughout the facility. Staff were observed coming out of isolation rooms without wearing their face shields. At 9:27 AM, Certified Nursing Assistant (CNA) J was observed donning PPE to go into an isolation room. When asked about face shields, CNA J reported each staff member had a different face shield for each isolation room and the face shields were stored in plastic bags, inside the isolation room. On 9/23/20 at 9:46 AM, the Specialty Care Unit (SCU)/dementia unit was observed. There were residents sitting in the main area and included two residents sitting on the couch together. Neither resident was wearing a mask. Staff were not observed encouraging either resident to wear a mask. Resident #6 and Resident #7 (COVID-19 positive) were observed in the same room with a plastic zippered barrier in their doorway and a PPE cart in the hallway. There was no isolation signage. Their room was on the same hall/in the same area as other residents on the unit. Resident #8 and Resident #9 (suspected COVID-19 positive) were observed in the next room. Their door had isolation signage and a PPE cart in the hallway. There were three face shields observed sitting on the handrails outside of these two rooms. A staff member came by, collected the face shields, and placed them in a plastic bag. The handrail was not observed to be sanitized after this. These two rooms were the only rooms on isolation; therefore, they were the only rooms on the unit in which staff wore PPE during resident care. There were eight empty resident rooms at the end of the other hallway on the Specialty Care Unit. At 9:54 AM, an exercise activity was observed in the SCU dining room. There were 11 residents observed in the dining room. Two of the residents were not wearing a mask and two other residents were seated within three feet of each other. Activities Director (AD) K was observed rubbing a resident's back. AD K then went to the sink and washed her hands for five seconds. AD K then again rubbed the residents back and then washed her hands for 13 seconds before continuing to other tasks. At 10:00 AM, two residents were observed sitting across from each other at a table that measured approximately four feet by four feet. One of the residents was not wearing a mask. A staff member was sitting at the side of the table, between the residents. At 10:09 AM, three residents were observed seated at another table and not distanced six feet apart. One resident at another table was observed with his mask on his forehead while he stacked blocks. Another resident wearing a mask that was not covering his nose, was transported in his wheelchair to this same table and sat right next to the resident with a mask on his forehead. At 10:23 AM, there were now four residents observed at the table with the stacking blocks. The residents were not six feet apart. One resident was observed pulling on her mask and removing it numerous times, one resident was wearing a mask appropriately, one with the mask on his forehead, and one with the mask under his nose. Staff were in and out of the dining room and joked about the resident wearing his mask as a headband. On 9/23/20 at 10:35 AM, two residents were observed seated in wheelchairs in the common area of the SCU. One resident's mask was not covering his nose and the residents were seated approximately three feet apart. Staff were walking through but did not encourage proper mask wear or physical distancing. At 10:36 AM, the four residents seated at the dining room table were observed again. The resident with the mask on his forehead and the resident with his nose exposed were speaking to each other with their faces approximately two feet apart. One resident had his hand on the other resident's forearm. Two staff members were present but did not encourage proper mask wear or physical distancing. According to The Centers For Disease Control and Prevention's (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Source control refers to use of cloth face coverings or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. Patients and visitors should, ideally, wear their own cloth face covering (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth face covering, as supplies allow. Patients may remove their cloth face covering when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room .Respirators with an exhalation valve are not recommended for source control, as they allow unfiltered exhaled breath to escape .Encourage Physical Distancing .Healthcare delivery requires close physical contact between patients and HCP (Healthcare Personnel). However, when possible, physical distancing (maintaining 6 feet between people) is an important strategy to prevent [DIAGNOSES REDACTED]-CoV-2 transmission. Examples of how physical distancing can be implemented for patients include: · Limiting visitors to the facility to those essential for the patient's physical or emotional well-being and care (e.g., care partner, parent). Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets. · Scheduling appointments to limit the number of patients in waiting rooms. · Arranging seating in waiting rooms so patients can sit at least 6 feet apart. · Modifying in-person group healthcare activities (e.g., group therapy, recreational activities) by implementing virtual methods (e.g., video format for group therapy) or scheduling smaller in-person group sessions while having patients sit at least 6 feet apart. In some circumstances, such as higher levels of community transmission or numbers of patients with COVID-19 being cared for at the facility, and when healthcare-associated transmission is occurring, facilities might cancel in-person group activities in favor of an exclusively virtual format. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#adhere) According to The Guideline for Hand Hygiene in Healthcare Settings, CDC recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. (https://www.cdc.gov/handhygiene/providers/index.html) On 9/23/20 at 10:27 AM, Housekeeper E was observed working on the SCU where two COVID-19 positive and two suspected COVID-19 positive residents resided. When asked about disinfectant products used, Housekeeper E reported she used HDQ 99.9% disinfectant and the isolation rooms also had Clorox wipes. When asked how the HDQ was used, Housekeeper E stated we spray everything down, let it sit for ten minutes, and then it's automatically disinfected. When asked what is done if the product dries before ten minutes, Housekeeper E reported the surface was automatically disinfected. Housekeeper E then pulled a rag out of her bucket to demonstrate sanitizing the handrail in the hallway. Housekeeper E wiped down the handrail and reported it took ten minutes to dry. After five minutes, the surveyor felt the handrail to be dry. When asked what PPE she wore into an isolation room, Housekeeper E reported she wore gowns, gloves, double mask (two surgical masks), and a face shield. Housekeeper E reported face shields were stored in plastic bags inside of the isolation room and labeled with staff names. Review of the Super HDQ Neutral Efficacy Bulletin revealed: [DIAGNOSES REDACTED] Associated Coronavirus had a 10-minute wet contact time utilizing 0.5 ounces of Super HDQ Neutral concentrate per gallon of water. The Environmental Protection Agency (EPA) number on the HDQ Neutral bottle reflected -130-5741. According to, https://www.epa.gov/pesticide-registration/list-n-advanced-search-page-disinfectants-coronavirus-covid-19, List N Advanced Search Page: Disinfectants for Coronavirus (COVID-19), the contact time was 10 minutes. Review of the CDC's Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19 revealed, Facilities should plan to dedicate space to care for residents with COVID-19 even before they have an active case. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19 and would have dedicated HCP to deliver care within this space. Another consideration is how to manage new admissions or readmissions when COVID-19 status is unknown. Options may include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Residents could be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their exposure (or admission). Testing at the end of this period could be considered to increase certainty that the resident is not infected. If an observation area has been created, residents in the facility who develop symptoms consistent with COVID-19 could be moved from their rooms to a single room in this area pending results of [DIAGNOSES REDACTED]-CoV-2 testing .Disinfectants used at a facility should be EPA-registered, hospital-grade disinfectants with an emerging [MEDICAL CONDITION] pathogens claim against [DIAGNOSES REDACTED]-CoV-2. List N on the EPA website lists products that meet EPA's criteria for use against [DIAGNOSES REDACTED]-CoV-2 (https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-[DIAGNOSES REDACTED]-cov-2) .All EPA-registered, hospital-grade disinfectants have a contact time which is required to kill or inactivate pathogens. Environmental surfaces must remain wet with the product for the entire contact time duration to work appropriately. Contact times range from 30 seconds to 10 minutes. Keeping a surface wet for 10 minutes is seldom accomplished with a single application. It is important for facilities to know that their product is appropriate (List N as above) and is being used for the entire contact time. Also, it is helpful for the facility to assign responsibility for cleaning and disinfection of specific surfaces and equipment (who cleans what). (https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp/assessment-tool-nursing-homes.pdf) According to the EPA'S Frequent Questions about Disinfectants and Coronavirus (COVID-19), How does EPA know that the products on List N work on [DIAGNOSES REDACTED]-CoV-2? EPA expects the products on List N to kill [DIAGNOSES REDACTED]-CoV-2, the coronavirus that causes COVID-19, because they: · Demonstrate efficacy against the coronavirus [DIAGNOSES REDACTED]-CoV-2 (COVID-19); · Demonstrate efficacy against a pathogen that is harder to kill than [DIAGNOSES REDACTED]-CoV-2 (COVID-19); or · Demonstrate efficacy against a different human coronavirus similar to [DIAGNOSES REDACTED]-CoV-2 (COVID-19). (https://www.epa.gov/coronavirus/frequent-questions-about-disinfectants-and-coronavirus-covid-19) and What does the column Follow the disinfection directions and preparation for the following virus mean? Why [MEDICAL CONDITION] other than the human coronavirus listed in that column? This column shows the harder-to-[MEDICAL CONDITION] pathogens than the human coronavirus. Products qualify for the emerging [MEDICAL CONDITION] pathogen claim by showing that it works against the listed harder-to-[MEDICAL CONDITION] pathogen. Therefore, if the contact time for this harder-to-[MEDICAL CONDITION] is followed, EPA expects the product to be effective against [DIAGNOSES REDACTED]-CoV-2 (the coronavirus that causes COVID-19) on surfaces. You can also find this information on the product label. It's important to note that EPA expects that all products on the list will be effective against [DIAGNOSES REDACTED]-CoV-2 (COVID-19). According to Centers For Medicare and Medicaid Services' (CMS) COVID-19 Focused Infection Control Survey Pathway dated 8/25/20, For a resident with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available. A facemask is an acceptable alternative if a respirator is not available. When COVID-19 is identified in the facility, staff wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability) .Objects and environmental surfaces that are touched frequently and in close proximity to the resident (e.g., bed rails, over-bed table, bedside commode, lavatory surfaces in resident bathrooms) are cleaned and disinfected with an EPA-registered disinfectant for healthcare setting (effective against the organism identified if known) at least daily and when visibly soiled. According to the CDC, HCP should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) Resident #6 (R6) Review of the medical record and Minimum Data Set ((MDS) dated [DATE] revealed R6 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The MDS revealed R6 scored 0 out of 15 (severe cognitive impairment) on the Brief Interview Mental Status (BIMS). Review of the Nurse Practitioner Progress Notes dated 9/14/20 revealed Chief Complaint / Nature of Presenting Problem: Lethargic, diarrhea .Patient is being seen today at the request of nursing for acute, mild lethargy and frequent diarrhea .Associated symptoms include sleepiness, loose stools occurring more than 3 times daily, foul-smelling stools . Review of R6's COVID-19 test results dated 9/14/20 and conducted as part of the facility's weekly routine testing, revealed the test was collected on 9/14/20 and results were reported as positive on 9/19/20 (5 days later). Review of the Physician's Note dated 9/18/20 revealed .Diarrhea Acute, no discernible etiology at this time and GI exam negative. [MEDICAL CONDITION] negative. Reportedly decreased in frequency . Review of the Nurse's Note dated 9/19/2020 revealed R6 tested positive for COVID-19 and was moved to a neighboring room and placed in contact/droplet isolation. According to the Centers for Disease Control and Prevention (CDC), People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19. (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html) In an interview on 9/24/20 at 3:16 PM, Infection Preventionist (IP) I reported the facility was monitoring residents for signs and symptoms of COVID-19. When asked if there were a specific number of symptoms needed to suspect COVID-19, IP I reported any number of symptoms would be of concern. When asked about R6 being documented as lethargic and having diarrhea on 9/14/20, IP I reported R6 should have been isolated on 9/14/20 and reported she was not aware of the documented symptoms. Resident #7 (R7) Review of the medical record and MDS dated [DATE] revealed R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed R7 scored 0 out of 15 (severe cognitive impairment) on the BIMS. Review of R7's COVID-19 test results dated 9/14/20 and conducted as part of the facility's weekly routine testing, revealed the test was collected on 9/14/20 and results were reported as positive on 9/19/20 (5 days later). Review of the Nurse's Note dated 9/19/20 revealed R7 tested positive for COVID-19 and was placed in contact/droplet isolation. R7 remained in her same room, which is the room R6 was transferred to. Resident #8 (R8) Review of the medical record and MDS dated [DATE] revealed R8 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS revealed R8 scored 0 out of 15 (severely cognitively impaired) on the BIMS. Review of R8's COVID-19 test results dated 9/14/20 and conducted as part of the facility's weekly routine testing, revealed the test was collected on 9/14/20 and results were reported as negative on 9/18/20 (4 days later). Review of the Nurse's Note dated 9/19/20 revealed Resident exposed to roommate who tested positive for Covid-19. (R8) placed in contact/droplet isolation for 14 days . The medical record revealed R8 moved to R6's old room, into R6's previous bed on 9/19/20. This was the same day R6's COVID-19 test results came back as positive. Resident #9 (R9) Review of the medical record and the MDS dated [DATE] revealed R9 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The MDS revealed R9 scored 0 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status. Review of R9's COVID-19 test results dated 9/14/20 and conducted as part of the facility's weekly routine testing, revealed the test was collected on 9/14/20 and results were reported as negative on 9/18/20 (4 days later). Review of the Nurse's Note dated 9/19/20 revealed Resident exposed to roommate who tested positive for Covid-19. (R9) placed in contact/droplet isolation for 14 days . The medical record revealed R9 stayed in her same room and now shared a room with R8. According to the CDC, Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) According to the facility's 672 Census & Condition, the census on 9/23/20 was 134 residents. The facility's bed capacity was 169. In an interview on 9/23/20 at 11:51 AM, IP I reported at the time COVID-19 test results were received, R6 and R7's rooms were next to each other and they each had a roommate (R8 and R9). IP I reported once positive results were received, the facility swapped R6 and R8 so that the two positive residents (R6 and R7) were together in one room and the two exposed residents (R8 and R9) were in the same room. IP I reported the facility put up a plastic barrier to form a containment over R6 and R7's doorway. IP I reported the facility previously had an area dedicated for positive COVID-19, but that area had been taken down once all those residents recovered. When asked when the room swap happened, IP I stated It was short .within a half hour of receiving the COVID-19 test results. IP I reported she told housekeeping to do a deep clean on the room where a positive resident was moved out of and a negative resident was moved into. When asked if there was a certain timeframe after cleaning and disinfecting and before moving a resident into a room where a COVID-19 positive resident previously resided, IP I stated Normally yes. Normally it's the deep clean and it's usually about a day. I know that wasn't the case, but I felt it was more important to get those two away from each other and isolated from the rest. Review of the facility's Coronavirus (COVID 19) policy dated 9/5/20 revealed Place a guest/resident with a suspected or confirmed COVID 19 [DIAGNOSES REDACTED].If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have teste (TRUNCATED)

Based on interview and record review, the facility failed to ensure the one of one residents reviewed for quality of care (R138) received treatment and care that was in accordance with professional standards of practice, their comprehensive, person centered care plan, and the resident's choice, resulting in or contributing to her death. Findings include: According to the Minimum Data Set (MDS), dated [DATE], R138 was a [AGE] year-old who scored 15 out of 15 on the Brief Interview for Mental Status (cognitively intact), did not reject care, needed extensive assistance with transfers, did not walk, did not have of a condition or chronic disease that may result in a life expectancy of less than six months (per physician documentation), and had [DIAGNOSES REDACTED]. According to additional MDS data R138 had been discharged from the facility (with return anticipated) on [DATE], [DATE], [DATE] and [DATE]. According to the Assistant Director of Nursing (ADON) C in an email, dated [DATE] at 12:46 PM, After looking in PCC (R138's electronic medical record) it appears that the discharges on [DATE] and [DATE] were directly from [MEDICAL TREATMENT] to the hospital and the discharges on [DATE] were from the facility per patient request and on [DATE] from the facility d/t pt c/o SOB (due to R138 complaint of shortness of breath). Review of R138's medical record revealed it was her choice to be a full code (all life-saving efforts). R138 resided on A-wing on [DATE]. Review of R138's Care Plans revealed, Date Initiated: [DATE], CARDIAC: At risk for decreased Cardiac Output R/T (related to):[MEDICAL CONDITION](high blood pressure), HLD (high cholesterol), A-Fib (rapid heartbeat), [MEDICAL CONDITIONS], HX.[MEDICAL CONDITION]& [MEDICAL CONDITION] (history of stroke and [MEDICAL CONDITION], [MEDICAL CONDITIONS]; Date Initiated: [DATE], Potential Difficulty Breathing R/T: SOB (shortness of breath), Abnormal respiration, Abnormal lung sounds, Abnormal pulse oximetry, Cough, anxiety. R/T: [MEDICAL CONDITIONS], Narcotic use, (HX/history of fluid overload, & HX. URI/Upper respiratory infection); and, Date Initiated: [DATE], (R138) will not have complications from choosing not to follow treatment regimen daily with: Diet, Devices, Treatments, Medications. Review of Nursing Notes, documented by Licensed Practical Nurse (LPN) R , dated [DATE] at 00:53 (53 minutes after midnight) on [DATE], revealed in its entirety, Cena (Nurse Aide L) entered room at 2300 (11:00 PM - in contrast to the time (11:40 PM) documented in the Emergency Medical Response report below), called nurse (LPN R), res (R138) had no vs (vital signs) present, no pulse, no resp (respirations), no bp (blood pressure). CPR (cardiopulmonary resuscitation) started, (Emergency Medical Services) notified. (Emergency Medical Services) here to take over cpr, unable to obtain a pulse. Death called at 0020 (12:20 AM). Message left with son (R138's son DD) to call. Message left in the doctor's book. (Assistant Director of Nursing (ADON) C) and (RN U/On-Call Supervisor) here. (Funeral home) notified (sic). Staff interviews (see below) confirmed there was no facility record keeper during the facility's resuscitation efforts. According to the Death Certificate (Certifying Physician/Medical Director O), R138 died on [DATE] at 12:21 AM from 1. [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) with HD ([MEDICAL TREATMENT]), 2. Diabetes II (Insulin Dependent), and 3. [MEDICAL CONDITION]. Review of the Emergency Medical Response Billing Review, received by facility on [DATE] at 4:41 PM (day 4 of the survey) per fax information, revealed EMS (Emergency Medical Response) received a call from the facility on [DATE] at 11:42 PM and arrived at the facility on [DATE] at 11:57 PM; the estimated time of arrest was 10:30 PM. According to the Narrative History Text, Arrived to find (R138) lying in bed with staff doing CPR. The staff stated that the PT (R138), was c/o (complaining of) diff (difficulty breathing) at 10:30 (PM) and she asked to go to the hospital. The staff checked on her at 11:40 (PM) and found her not breathing. CPR was started. Than (then) CREW (emergency medical team) arrived with MFR's (medical first responders) and moved the PT from the bed to the floor. The PT was placed onto the LUCA S (see below). An AIRE (airway) was secured. An IV was placed with meds (medications) as noted. Above CREW noted wet sloshy lungs sounds on the left (lungs). (Clear lung sounds) on the right. The PT was cold to the touch with mottling to her extremities. The staff stated that the PT missed her [MEDICAL TREATMENT] the day before . TOD (time of death) was called at 00:22 (22 minutes after midnight) (sic). (According to LUCUS Chest Compression System, 2019, The LUCAS device delivers safe and effective chest compressions. <https://www.lucas-cpr.com/clinical_evidence/#quality_cpr>) The complaint of difficult breathing and request to go to the hospital at 10:30 PM was not documented in Nursing Progress Notes (see below). Review of R138's Nursing Notes revealed the last time R138 refused to go to [MEDICAL TREATMENT] was on [DATE] and she was subsequently transferred to the hospital on [DATE]. Review of R138's Nursing Notes revealed there were no Nursing Progress Notes documented [DATE] - [DATE], [DATE] - [DATE], or [DATE] - [DATE]. Review of a chest x-ray for R138, dated [DATE] at 4:45 PM, revealed, . no evidence of pneumonia or [MEDICAL CONDITIONS] . Review of laboratory data revealed R138 had a urinalysis done on [DATE] (not timed) that showed lactobacillus (normal organism inhabiting the bladder) present. There was no documentation in Nursing Progress Notes regarding why a urinalysis was done. Review of R138's Nursing Progress notes documented on [DATE] revealed only three entries: 1.) LPN R documented on [DATE] at 06:33 AM - Nurses Notes Note Text: (R138) refused to go to [MEDICAL TREATMENT], states she doesn't feel well. Res has productive cough of tan green mucus, LS (lung sounds) are very congested with crackles and wheezes. HOB (head of bed) elevated, O2 (oxygen) on, nmts (breathing treatments) as ordered. 2.) LPN S documented on [DATE] at 7:40 PM - Nurses Notes Note Text: (R138) requesting to go to hospital, stating not feeling well. staff talked to (R138) and informed (R138) that cxr was negative, but labs were possitive (positive) for UA (urinalysis). staff in formed (informed) (R138) DR (doctor). would be called and ATB (antibiotic) possibly started. (R138) lso (also) given anxiety meds (medication) per (R138) request. (Medical Director O) called and message left about lab (laboratory data) and cxr (chest x-ray) as well as V.S (vital signs) and request for ATB (antibiotic). staff awaiting call back from (Medical Director O) at this time (sic). 3.) LPN S documented on [DATE] at 8:42 PM - Nurses Notes Note Text: (Medical Director O) called back new V.S given. no new orders at this time. Review of R138's Nursing Progress Notes revealed there were seven Late Entries created on [DATE]: 1.) Created By: LPN S on [DATE] at 5:25 PM - [DATE] at 6:30 PM - Nurses Notes Late Entry: Note Text: After evening meal (R138) stated that she was not feeling well. This nurse informed the in house nurse manager (RN U/On-Call Supervisor) who then went to speak with (R138). This nurse reviewed her UA results along with chest xray and notified (R138) that the chest xray was negative, and of the UA results and that the WBC were too many to count and that I would be contacting the physician and requesting ATB. After (R138) spoke to nurse manager (RN U/On-Call Supervisor) (R138) had requested her scheduled 2000 medications (including antianxiety medication [MEDICATION NAME] 0.25 mg scheduled for 8:00 PM) which she did receive. Breathing treatment given which (R138) stated did help her. Vitals at this time-BP ,[DATE]. At this time (R138) is s/s (signs and symptoms) of anxiousness and requested someone to sit and chat with her which (CNA EE) did do for approximately 20 minutes at which time CNA EE) left (sic). 2.) Created By: RN U/On-Call Supervisor on [DATE] at 5:54 PM - [DATE] at 6:45 PM - Nurses Notes Late Entry: Note Text: At approximately (6:45 PM) This nurse was notified that (R138) was not feeling well and stated she wanted to go to the hospital. This writer went to see (R138) and assess. (R138) stated that she was not feeling well and that she felt like she had pneumonia. This nurse assured (R138) of in house treatment such as x rays and labs. She informed me that she had a chest x ray earlier in the day. This nurse suggested that I take a look at the results. I asked if (R138) was ok for the moment while I went to check and would be back to tell (R138) the results. 3.) Created By: RN U/On-Call Supervisor on [DATE] at 5:56 PM - [DATE] at 7:00 PM - Nurses Notes Late Entry: Note Text: This nurse notified DON (B) of (R138) complaint of not feeling well and stating (R138) wanted to go to the hospital and current vitals that were reported to this nurse. DON (B) instructed this nurse that when the physician is notified to request IM [MEDICATION NAME] ([MEDICATION NAME] - antibiotic) and labs related to [MEDICAL CONDITION]. (According to Wikipedia Online Dictionary, 2019, [MEDICATION NAME], sold under the trade name [MEDICATION NAME], is an antibiotic used for the treatment of [REDACTED]. These include middle ear infections, endocarditis, meningitis, pneumonia, bone and joint infections, intra-abdominal infections, skin infections, urinary tract infections, gonorrhea, and pelvic [MEDICAL CONDITION] disease. <https://en.wikipedia.org/wiki/[MEDICATION NAME]>) 4.) Created by LPN S on [DATE] at 5:29 PM - [DATE] at 7:00 PM - Nurses Notes Late Entry: Note Text: this nurse assisted (R138) in re-positioning and noted that her anxiety level had decreased and she thanked this nurse and appeared comfortable, no further complaints at this time. 5.) Created by RN U/On-Call Supervisor on [DATE] at 5:58 PM - [DATE] at 7:15 PM - Nurses Notes Late Entry: Note Text: Returned to speak to (R138) about the results. Discussed that she is negative for pneumonia and [MEDICAL CONDITIONS] and that her UA stated that her WBC (white blood cells) were high which could be infection. (R138) insisted that she had pneumonia and this nurse reassured her that she did not and reminded her that she did not go to [MEDICAL TREATMENT] earlier that day and she may be feeling this way due to her not attending. This nurse validated her s/s (signs and symptoms) of anxiety. This nurse offered assistance to (R138) and asked if there was anything I can do to help her feel more comfortable. I notified (R138) of the facilities intention of notifying the physician asap (as soon as possible) and requesting an ABX for the U[NAME] This nurse offered for (R138) to take her scheduled meds which included her antianxiety medication which (R138) did agree to. (R138) stated that she would feel better after taking her 2000 (8:00 PM) medications and the physician was notified of the test results. This nurse exited room and notified her floor nurse of request of scheduled medications and the need to notify the physician of the results of the UA and chest x ray. (According to MedStar Health, (YEAR), Outpatient Management of Patients with Community Acquired Pneumonia . A negative chest X-ray does not completely rule out pneumonia. False negative chest xrays may be seen in very early pneumonia, [DIAGNOSES REDACTED], dehydration or Pneumocystis Jirovecii Pneumonia. <https://ct1.medstarhealth.org/content/uploads/sites/[DATE]/Community-Acquired-Pneumonia-Adults-Guideline-Sept-2017.pdf>) (According to the Rhode Island Medical Journal, ,[DATE], False-Negative Chest Radiographs in Emergency Department [DIAGNOSES REDACTED]. Infiltrates consistent with pneumonia may be missed by CXR alone in a significant minority of ED patients. In the appropriate clinical context, clinicians should consider advanced imaging in patients with negative CXR. <http://rimed.org/rimedicaljournal/[DATE]-,[DATE]-cont-maughan.pdf>) 6.) Created by LPN S on [DATE] at 5:34 PM - 2019 at 8:42 - Nurses Notes Late Entry: Note Text: (Medical Director O) returned call and he was informed of (R138) test (UA chest x ray) results. Informed (Medical Director O) of (R138) BP (blood pressure) ,[DATE]. This nurse requested ATB (antibiotic) which he declined. No new orders. (R138) informed of (Medical Director O) decision, resident verbalized understanding. 7.) Created by LPN S on [DATE] at 5:41 PM - [DATE] at 9:30 PM - Nurses Notes Late Entry: Note Text: (R138) requested assistance with re positioning and looping her oxygen tubing onto her ear. This is normal for her several times during the shift. this nurse assisted (R138) with securing call light and bed control per her request. (Requests from R138 to be transferred to the hospital on [DATE], appear in the above Nursing Progress Note documentation at 6:45 PM, 7:00 PM, 7:40 PM and 10:30 PM.) According to the Director of Nursing (DON B), per an email timeline dated [DATE] at 3:14 PM, the only documented vital signs by Nursing staff for R138 on [DATE] were as follows: 5:29 AM: BP - (blood pressure) ,[DATE] (per vital signs log). 9:43 AM: BP - ,[DATE], temperature 98.1 (Fahrenheit), pulse 71, respirations 19, SPO2 (oxygen level) 92%. (per Medication Administration Notes) 2:55 PM: BP - ,[DATE] (per vital signs log). 3:35 PM: BP - ,[DATE] (per Medication Administration Notes). 6:30 PM: BP - ,[DATE] (per Nursing Progress Notes and documented at 7:35 PM in vital signs log; 8:42 PM: BP - ,[DATE] reported to physician/documented Nursing Progress Notes). There were no lung sounds documented after 6:33 AM, no assessments for fluid overload, and temperature was only documented once by Nursing staff on [DATE]. According to Physician Assistant (PA) P Progress Notes, received via fax to the facility on [DATE] at 11:10 AM, and dictated on [DATE] at 3:14 PM (time of visit not documented), R138's vital signs were: temperature - 99 (degrees Fahrenheit), pulse - 74, respirations - 20, O2 - 92 %, B/P - ,[DATE], Pain scale - 4 out of 10. In a telephone interview, on [DATE] at 11:17 AM, PA P reported he examined R138 and took her vital signs himself somewhere between 9:00 AM - 9:30 AM but did not speak with the nurse on duty or share the vital signs he took. PA P stated he usually just put his findings in his dictated notes. PA P stated he did not give orders for Nursing staff to monitor R138 because she appeared she was in her usual state. PA P stated he was not told that earlier in the day R138 stated she did not feel well and was found to have a productive cough with tan green mucus and lungs congested with crackles and wheezes. PA P also reported, When a resident or the family wants the resident to go to the hospital, I send them. I wouldn't never keep them back from their wishes. In an interview, on [DATE] at 10:40 AM, A-wing Unit Manager Registered Nurse/RN F, stated, Yes, (R138) was a full code, and no there was no investigation (following her death). After the fact, I met with (Medical Director O). I was on call and they called and told me she wasn't feeling well and refused [MEDICAL TREATMENT] and had a productive cough. Throughout the day, (R138) was not feeling well. (RN U/On-Call Supervisor) at 6:30 PM spoke with (R138) and explained the results: Urinalysis showed White blood cells too many to count and she would request antibiotic. A breathing treatment was given. (R138) was anxious and wanted someone to sit with her and (CNA/nurse aide EE) did sit with her. (R138) wanted to go to the hospital because she felt like she had pneumonia. (Medical Director O) notified regarding the test results lactobacillus was the organism . Culture came in on [DATE]. He said no antibiotic was needed. I think I talked to him and said (R138) needed [MEDICAL TREATMENT] or if I discussed it with (Medical Director O) after she died . I didn't document. I don't go to QA (Quality Assurance) meeting; I don't know how that goes. DON (B) and NHA (Nursing Home Administrator A) were aware of the death and that (R138) was a full code. (ADON C) and (RN U/On-Call Supervisor) were here at the time of (R138's) death. (R138) was not on hospice and it was not an expected event. I planned on coming in in the morning ([DATE]) to call [MEDICAL TREATMENT] to see if we could squeeze her in. We were told by the (Medical Director O) she did not need to go to the hospital. I don't know if they do [MEDICAL TREATMENT] at the hospital. On [DATE] at 12:36 PM, RN U/On-Call Supervisor reported, I was here working (on [DATE]) and was On-call manager that night. (LPN S) was the floor nurse that night. (LPN S) came to see me I assessed (R138) and speak with her. I wrote my note (timed 18:45 PM) after that. (LPN S) told me (R138) was not feeling well and wanted to go to the hospital. (R138) told me she thought she had pneumonia and we talked about that and talked to her about what we could do for her in-house such as labs and an x-ray and (R138) said she already had one that day. I asked (R138) if she wanted me to take a peek at the x-ray and she said she would like to know the results. I went to look for her results, I called DON (B) to let her know that (R138) was not feeling well and (R138) stated she wanted to go to the hospital. I gave (DON B) the VS given by the nurse on the floor; some were not within normal limits. I can't recall what they were or when they were taken. I observed her. I did not listen to her lung sounds. When I went back in she seemed more anxious because she felt sick. I discussed the results of her x-ray not showing pneumonia, but she was still concerned about pneumonia. (R138) chose not to go to [MEDICAL TREATMENT]. We discussed that she refused [MEDICAL TREATMENT]. I did not ask her if she wanted to reschedule [MEDICAL TREATMENT] and I did not call [MEDICAL TREATMENT] that day. (R138) didn't feel well and thought she had pneumonia because that is how she felt when she had pneumonia earlier (in the past). I don't recall I asking (R138) if she had pain while breathing. I could see she was anxious and asked her if she would like her anxiety med (medication) and she said yes. At the time, I was not aware of the earlier assessment of crackles, wheezes, etc. We do use SBAR (see below). I did not initiate it. (LPN S) and I were in communication. SBAR is used to see how the patient is doing, what changes are made. No SBAR was done for (R138) on [DATE]. A Change in Status form is required when a resident is sent to the hospital. Sure, SBAR guides you to that decision (whether to send to hospital). I was not present when (LPN S) called (Medical Director O). Also discussed UA (urinalysis) results with (R138). I had no other interaction with (R138) that night. I told (R138) I would have someone talk to the doctor about her WBC (white blood) count and getting an ABX (antibiotic) if he wanted to order that. The antianxiety meds and getting ahold of the doc (doctor) to see if the doc wanted to look at her lab results. Before I went back in, I called the (DON B) and told her (R138) wasn't feeling well and (R138) stated wanted to go to the hospital and gave her the vs. I don't have them. (DON B) asked about her vs. and mentioned [MEDICAL CONDITION] (see below) due to her vs. I did not speak to (Medical Director O). I was here when (R138) passed (died ) and in the room during CPR (cardiopulmonary resuscitation). I didn't find her. (ADON C) came back to me (came and told me). I was still on-call manager. I observed CPR. I asked one of the CNAs (unknown) what happened, but she did not give me any details. I don't know who found her. I was the one on call. (ADON C) was working in her office that night. I didn't get to the room until EMS was there. They didn't notify me because I wasn't really working patient care; they didn't know I was here. I did not have a phone call about (R138) from the staff. With changes, I should have been notified. No Incident Report or Witness Statement was asked of me. There was no Incident Report. SBAR should have been initiated. RN U/On-Call Supervisor reported she did not educate the resident that early phase pneumonia may not show on the x-ray. SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition. <http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx>), In an interview, on [DATE] at 2:10 PM, CNA M stated she worked 2nd shift 2:00 PM - 10:00 PM on [DATE]. CNA M said, I remember going in to see (R138) during rounds she was doing good. No concerns. (R138) ate her dinner. I did not do her VS and was not asked to do her VS. During report s(R138) had been herself and was not needing anything. Was not told (R138) had an elevated temp or that (R138) had requested to go to the hospital. I saw her often normally because she would have her light on, but she didn't that night, so I checked on her every 2 hours to see if she needed anything. Sometimes that night (R138) told me she wasn't feeling good and I would report it to my nurse. (R138) had a stomach-ache and a headache. I didn't see her coughing, but she had oxygen on. (R138) was laying down with her head at 90 degrees and sleeping. I last saw her right before I left at 10:00 PM; I told her have a good night and she said thank you and went back to sleep. (R138) was sleeping more than usual. I let the nurse know. In report, I told the oncoming nurse aid (R138) hadn't been feeling good all night and was sleeping which was unusual for her. CAN stated she did not know what SBAR or Stop and Alert was but said I talked to the nurse a couple of times about (R138) that night. In an interview, on [DATE] at 2:47 PM, DON B said, I was called by (RN U/On-Call Supervisor) and told (R138) had a change of condition, was anxious and had had a chest x-ray and UA (urinalysis) pending. I recall vital signs were indicative of, positive, [MEDICAL CONDITION] (see below) and that we could suggest to (Medical Director O) [MEDICAL CONDITION]. 1st call (RN U/On-Call Supervisor) made to me, she said there was change of condition at least two vital signs were out of whack for me to consider it [MEDICAL CONDITION]. The second time (RN U/On-Call Supervisor) called me to tell me the chest x-ray and UA results. DON B stated she did not record the conversations, or the vital signs presented to her during the phone conversations with RN U/On-Call Supervisor on [DATE]. According to Mayo Clinic, [DATE],[MEDICAL CONDITION] is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in older adults . <https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc- 214>) In an interview, on [DATE] at 2:58 PM, (LPN S) reported, When I came on my shift (at 2:00 PM), nothing out of the ordinary was reported for (R138). Throughout the shift, (R138) presented with URI (upper respiratory infection) which was normal for her; she would have this often. (R138) said it was bothering her that day. At supper time she said, I think I should go to the hospital (RN U/On-Call Supervisor) was in the building. I let (RN U/On-Call Supervisor) know (R138) wanted to go to the hospital. (RN U/On-Call Supervisor) went and talked to (R138) said (R138) agreed to stay. we got some orders, ended up not sure if we did a Significant Change in Status. I called the doc. with (R138's) BP, vitals, and the way she was acting. I wanted an antibiotic thinking (R138) was sick or possibly septic. I wanted to talk to him. I waited and waited for him to return the call. I retook his BP and read it to him. I asked him, 'Are you going to give me an abx or anything?'. When I called him, I left a voice message saying (R138) was requesting to go to the hospital. The vital signs should be in my charting. No physician examined her that day. I don't recall if it was on the 24-hour report. I relayed everything (LPN R) who I gave report to at 6:00 PM but (LPN R) didn't take over my assignment until 10:00 PM -10:30 PM. Yes, gave another report at 10:30. I told (LPN R) (R138) was sleeping but if (R138) wanted to go to the hospital, I had all the paperwork ready to go. He did not order her to go to the hospital. (R138) agreed to stay after (RN U/On-Call Supervisor) talked to her. I took the VS because I have to give her BP pill. I don't think she had a temp (fever). I don't think I took her temp. I can't remember. I don't think I called (DON B). I think (RN U/On-Call Supervisor) did, she was on call. (R138) was sleeping (R138) was breathing. (R138) was upright and I was watching her breathe. I didn't want to bother (R138) so I left. (R138) didn't complain after she talked to (RN U/On-Call Supervisor). If I knew she had chest congestion and productive cough of tan green I would look to see if she had a high fever, able to clear her airways, any lower congestion, hard time breathing, lethargic, not able to talk to me. BP was taken some time between 2:00 PM - 4:00 PM and then again somewhere between 7:00 PM and - 9:00 PM. The SBAR, I believe, is something the Aides fill that out, if they see a change. No one handed me one that night. In an interview, on [DATE] at 3:52 PM, DON B said, I looked at it (R138's death) afterwards, didn't see any educational opportunities. No, we do not review deaths in the facility that were full codes. They do shift report. One event cough was reported to (LPN S). (LPN S) should know what an SBAR is.[MEDICAL CONDITION] and elevated temp are not used with SBAR. It is a tool to gather information before notifying a physician. It is in PCC (electronic medical record). There is a Stop and Watch can be filled out by several disciplines, such as nurse aides. Change of Condition is the E-interact; (LPN S) would know what you are talking about. We have no policy that they have to fill that out. It is a tool in PCC. There is no Policy on how to use it. It's only a tool to gather information to present to the Physician. In an interview, on [DATE] at 9:48 AM, LPN T reported she was the nurse assigned to R138 on day shift on [DATE]. LPN T said, I did not know (R138) had not been feeling well and refused [MEDICAL TREATMENT] that particular morning. I leave at 2:00 PM. Sounds like she got a fever at some point. 24-hour report gets passed from nurse to nurse, shift to shift. It is a communication form to communicate with the Unit Manager, not to the doctor; that would have been verbal. (On [DATE]), (R138) was in bed watching TV. (R138) did have a little congestion going on she had a chronic cough. LPN T reported she did not listen to lung sounds and did not remember what she told the oncoming nurse (LPN S) in report about R138. LPN T reported e-Interact is used when there is a change of condition, when it is first noticed by the nurse. Probably should have been started by (LPN R), she is the one who first observed it. The nurse who finds it fills it out and it is not continued by the next nurse. We used to have a paper one that was given to the next nurse (for continuity) but since we went to computer, we don't have it. I liked paper better, we don't lose it and the system doesn't break down. Parameters for doing vital signs would be with the e-Interact. According to the website INTERACT®, (Interventions to Reduce Acute Care Transfers) (2019) INTERACT is a quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in everyday practice in long-term care facilities. <http://www.pathway-interact.com/> Review of the 24-hr report for [DATE] (not timed), revealed LPN T documented: (R138) Chest x-ray ordered, chest congestion, SOB (shortness of breath) . In an interview, on [DATE] at 10:45 AM, regarding R138, (LPN R) /third shift nurse reported, We took VS (on [DATE] around 6:30 AM). I take them before (R138) goes to [MEDICAL TREATMENT]. They should be on the sheet . A paper in (R138's) book, not the electronic medical record. [NAME] (electronic)-INTERACT? I've never heard of that. 24-hour report? We use that to pass things along to our Unit Manager. At 10:00 PM we start a new one and the old one goes to the manager's office. While in use, it usually stays on the med cart. We have little reports we pass between nurses. I know she had a chest x-ray. I told (LPN T) that (R138) wasn't feeling well, lungs were congested. I listened to (R138) with stethoscope. (R138) always had O2. Refused [MEDICAL TREATMENT] about one or two weeks ago, then she made it to the next [MEDICAL TREATMENT] or was sent to the hospital. Regarding the evening or [DATE], LPN R said, No, one recorded what happened during the code. (CNA L) went to get her VS, stepped out and I knew right away, grabbed the crash cart. Nurse from B wing came right away (RN X). (CNA L) was getting VS on her because we always check her stats and she hadn't been feeling well. (LPN S) told me no change, still congested, x-ray was done was clear; I did not know (R138) requested to go to the hospital at that time. If a resident requested to go to the hospital, I call the doc to get the ok to send them. I don't know what e-Interact is. Our communication between nurses is a paper with residents' names on it so we can write stuff on it for the next person to know. No Policy and Procedure, it's just something we do to help ourselves on A-wing. I don't know if the other wings do it. (RN X) and (RN W) B-wing nurses started the code. I did the paperwork called (EMS/Emergency Medical Services), not sure if I called the doc. Tried calling the (R138's) son (EE) and couldn't get an answer. I remember I never got ahold of the son (EE). (EMS) may have called her death. We are all trained on CPR. No, we don't have a recorder. Lifecare does that, but we don't. It took 5 minutes at the most before they got there. They did CPR for quite a while (over 30 min) and got no pulse. In an email, dated [DATE] at 10:49 AM, DON B returned a request for the facility's Policy and Procedure for Cardiopulmonary Resuscitation. In her reply, DON B documented, We have a DNR (do not resuscitate) policy. But what I gave you is our only policy on CPR. The information provided was a procedural excerpt on how to perform CPR from a professional journal, (Lippincott) dated [DATE]. There was no facility Policy for CPR initiation, documentation, or quality review following adverse event. In an interview, on [DATE] at 12:22 PM, CNA N/R138's day shift CNA reported she had worked at the facility for [AGE] years and said, Stop and Watch is something you can fill out. I'm not sure if it is required. It is a little form that you fill out. Honestly, I haven't seen one for a couple of years. If they are on A-wing, I don't know where they are. I don't remember doing one on (R138). In a telephone interview regarding R138, on [DATE] at 12:45 PM, (Medical Director O) said, They had called, and I called back, I called and called and called, ended up calling (RN F) and told her no one was picking up. They relayed that the chest x-ray was normal, and they wanted and antibiotic for a UTI (urinary tract infection) but (R138) was afebrile and the count showed no reason to place her on an antibiotic. No, they did not tell me she wanted to go to the hospital. If she or any resident wanted, 100% of the time I would send them out. (R138) didn't go to [MEDICAL TREATMENT] t

This citation pertain to Compliant Intakes: MI 911 and MI 530. Based on observation, interview, and record review, the facility failed to provide adequate supervision (Resident #4) and implement therapy recommendations (Resident #4 & #10) to prevent falls in 2 of 4 residents reviewed for falls, resulting in fractures (Resident #4) and pain (Resident #4 & #10), resulting in an Immediate Jeopardy for Resident #4 when on [DATE] Resident #4 had a fall that resulted in a neck fracture ultimately contributing to his death on [DATE], placing 69 other residents who were identified to be at risk for falls, at a high risk for injury, harm, and/or death. Findings include: Resident #10 Resident #10 was observed on [DATE] at 9:25 AM sitting in her wheelchair in her room. Resident #10 stated on the same date and time that she had waited a long period of time for staff assistance, sitting on a commode with her call light on, usually 20 minutes or longer for assistance on multiple occasions. On [DATE] at 11:15 AM, During interview Resident #10's family member I stated he was concerned Resident #10 had had 2 falls since she was admitted to the facility; and one time she was left on the commode so long that she couldn't stand up. Admission Record dated [DATE] revealed Resident #10 was admitted to the facility on [DATE]. Resident #10 Minimum Data Set (MDS) 3.0, with an Assessment Reference Date (ARD) of [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 15 (Scale: ,[DATE] Cognitively Intact). Resident #10's Admission MDS assessment with an ARD of [DATE], revealed Resident #10 required extensive physical assistance of two plus persons to walk in her room. The most recent MDS assessment with an ARD of [DATE], revealed Resident #10 was walking in her room less, that the activity occurred only once or twice with the assistance to two plus persons. Restorative Program Therapy to Nursing Communication dated [DATE] and retrieved as a scanned document from the electronic medical record, revealed interventions needed to reach Resident #10's restorative program goals were to (1) encourage Resident #10 to walk in her room with her oxygen on 5 liters, then turn back down to 4 liters after increased activity per doctors orders, (2) Place commode in the bathroom and have Resident #10 walk with staff with contact guard assistance (have one or two hands on body to help with balance), (3) walk Resident #10 with contact guard assistance, oxygen on at all times, and with wheelchair to follow, (4) Encourage morning stretch and Resident #10 to perform her therapeutic exercises given to her by therapy to help Resident #10 maintain her current level of function, (4) encourage Resident #10 to use her toileting aid to assist in her own hygiene. Nursing Care Card (Nurse Assistant Care Plan) dated [DATE] revealed Resident #10 used a wheelchair for locomotion and there was no mention of ambulation or any of the above recommended therapy interventions to reach restorative goals. Resident #10's fall prevention care plan, initiated on [DATE] was reviewed and there was no mention of ambulation or any of the above recommended therapy interventions to reach restorative goals. Incident Report dated [DATE] at 1:10 PM revealed Resident #10 fell in her room during a transfer with and sustained a hematoma/bruise. There was no mention on the same report of the location of the hematoma/bruise. Progress Notes dated [DATE] at 5:38 PM indicated Resident #10 had complained of right leg pain from just below the knee to the ankle. Certified Nurse Assistant (CNA) F was interviewed on [DATE] at 9:10 AM and stated she answered Resident #10's call light prior to the fall on [DATE] and was sitting on a commode next to her bed for 15 minutes or so. During the same interview, CNA F stated she had asked Resident #10 if she could transfer from the commode to her bed because she knew she had sat on the commode a long time, but they decided to continue on with the transfer. CNA F stated Resident #10 stood up, reached for the side-rail on her bed, but missed it and fell to the floor. On [DATE] at 10:00 AM CNA L stated Resident #10 was her usual assignment and did not recall doing any stretching exercises, ambulation with her walker or using a toileting hygiene aid for Resident #10 in (MONTH) (YEAR). CNA L was not aware of Resident #10's restorative plan in (MONTH) (YEAR). On [DATE] at 11:34 AM, Rehabilation Manager K stated Restorative Program Therapy to Nursing Communication forms were given to the nurse and unit manager; and were also discussed in the facility morning meetings. Resident #4 Per the facility face sheet Resident #4 was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS), dated [DATE] revealed Resident #4 had disorganized thinking, and difficulty focusing attention. The MDS also revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated a severe cognitive ability. The MDS revealed Resident #4 required extensive assistance with transfers, and limited assistance with ambulation. Another MDS dated [DATE] revealed Resident #4 had 1 fall without injury, and 1 fall with injury. Record review of an incident report dated [DATE] revealed Resident #4 was found on the floor at the end of the hall on the C-wing with a minor abrasion to the left side of his forehead. Another incident report dated [DATE] revealed Resident #4 was found with his body on the floor and his feet up at the head of the bed. An incident report dated [DATE] revealed Resident #4 was observed to walk into the corner of a wall, which caused a scratch in the center of his forehead. The report revealed Resident #4 was assisted to bed, but only stayed a few minutes before getting back up again. The report revealed Resident #4 was noted to not sleep well, and the intervention was to perform a sleep log for 4 days. Another incident report dated [DATE] revealed Resident #4 was found, at approximately 6:40 AM, on the floor in the hallway. The report revealed Resident #4 had sustained a fracture of his left hip, and was transferred to the hospital. Another incident report, dated [DATE], revealed Resident #4 was found on the floor, in front of the nurses' station. The report revealed Resident #4 was sitting in a wheelchair at the nurses' station when Visitor E witnessed his fall. The report revealed the Visitor E had walked out of her husbands room when she observed Resident #4 attempt to stand up from his wheelchair, lost his balance, struck his head on the a treatment cart, and fell to the floor. The report revealed Visitor E notified staff, and upon assessment Resident #4 was found on his left side with 4 to 5 quarter size blood droplets next to his head, a laceration approximately 3 cm on the top of his forehead and was grabbing his left hip. The report revealed an ambulance was called, and upon arrival a C-collar (collar placed on the neck to support neck in the case of injury) and was transferred to the hospital. The report revealed Resident #4 was receiving therapy services related to his [MEDICAL CONDITION] repair. Record review of a care plan titled, Behaviors, dated [DATE], revealed Resident #4 had behaviors that included physical and verbal aggression, not following treatment plan, and walking around without socks on. The care plan revealed, under interventions, Resident #4 would sit on the floor at times, and choose to sleep on the floor, although did not reveal any interventions to address Resident #4 sitting or sleeping on the floor. The care plan was last updated on [DATE]. Review of a care plan titled, Falls, dated [DATE] revealed Resident #4 was at risk for falls related to the use of [MEDICAL CONDITION] medications, and episodes of tiredness. Review of another care plan titled, Falls, dated [DATE] revealed Resident #4 was at risk for a fall related injury due to [MEDICAL CONDITION] drug use, history of falls, and [DIAGNOSES REDACTED].#4 had a fall on [DATE], and was lowered to the floor, and on [DATE] had rolled out of bed. The care plan was last updated on [DATE]. No interventions related to Resident #4's falls was noted for increased supervision. An additional care plan titled, Falls, dated [DATE], and initiated on [DATE] revealed Resident #45 was at risk for a fall related injury related to the use of [MEDICAL CONDITION] medication use, and increased tiredness. The care plan did not reveal any interventions for increased supervision, nor any additional interventions after the date of [DATE]. Record review of a hospital Operative Note dated [DATE] revealed Resident #4 had surgery to repair his left [MEDICAL CONDITION]. Review of a hospital Consultation note, dated [DATE], revealed Resident #4 had sustained a C-1 fracture (neck fracture) that was unstable, and a dislocation of his left hip repair. The note revealed Resident #4 was not responsive. In an interview on [DATE] at 10:26 AM, Certified Nurse Aid (CNA) P, who worked on the B-hall, stated Resident #4 was a one person assist, but a 2 person if there were problems, and as far as she knew he was a 2 person assist. CNA P stated Resident #4 would not allow staff to hold onto him while he ambulated, and stated the only 1:1 supervision she knew of was for his behaviors. CNA P said Resident #4 did not understand how to use his call light, and she heard he had fallen a few times while he resided on the C-hall. CNA P said she could not recall when Resident #4 was moved to the B-hall. CNA P said she was never instructed to increase supervision of Resident #4 based on his history of falls, and stated after Resident #4's return to the facility form his [MEDICAL CONDITION] repair he would not follow directions, and would stand up on his own. CNA P stated Resident #4 was taken to the nurses' station area, or in bed for supervision. In an interview on [DATE] at 11:26 AM, CNA G stated regarding the residents last fall on [DATE], that she had taken Resident #4 to the nurses' station in his wheelchair so if he attempted to stand up someone would see him. CNA G said she left him there to go get an oxygen tank, and when she returned he was on the floor. CNA G said she thought there were nurses' at the nursing station, but could not say who. CNA G said she did not review Resident #4's care card before she got him up, and was never instructed to keep him in a common area for supervision when he was up out of bed, and stated she did not know he would get up on his own. CNA G said she did not tell any staff member Resident #4 was at the nurses' station when she left him there, and was not ever told she needed to let a staff member know he was there before she left him alone. In an interview on [DATE] at 12:51 PM, Visitor E stated on [DATE] there were no staff members in the hall when she walked into the hallway and observed Resident #4 fall. Visitor E stated she had observed Resident #4 attempt to get up all day on his own. Visitor E said there were no staff in view of Resident #4 and she was about 10 feet away from him, and said she was not able to get to him in time to prevent his fall. Visitor E said she observed Resident #4 stand up, spin to his left, and fall forward. Visitor E said Resident #4 may have hit his head on the wall handrail, the treatment cart, and was bleeding at his hair line. Visitor E said she went to Resident #4 after about 30 seconds, and then had to yell for staff to come help. Visitor E said she had to really scream to get any of the staff's attention to come help him, and took about 30 seconds for staff to arrive. Visitor E said anytime she was at the facility and observed Resident #4 sitting at the nurses' station he would attempt to get up on his own, and stated he had been attempting to get up on his own all day. Visitor E stated Resident #4 could not hold a conversation, and said the staff would sit him back down and tell him not to get up. In an interview on [DATE] at 3:00 PM, Resident #4's Guardian H stated she had requested Resident #4's death certificate, as he had passed away at the hospital after his fall that resulted in a neck fracture. Guardian H said Resident #4 had a hip repair at the hospital from a fall at the facility on [DATE]. Guardian H said Resident #4 went back to the facility and fell again. Guardian H stated Resident #4 dislocated his hip again, had a laceration to his forehead, and broke his neck. Guardian H said she did not recall who told her, at the hosptial, but stated she was told if Resident #4 moved it could kill him immediately. Guardian H said it was impossible to keep Resident #4 still, and was told by the physician they could not keep him still, and said even after repair of his dislocated hip it popped out again. Guardian H said the physician told her they would sedate him and keep him comfortable, but stated Resident #4 had passed away. In an interview on [DATE] at 4:07 PM, Orthopedic Surgeon, Physician Q stated Resident #4 had a fall that resulted in a C-1 fracture in his neck. Physician Q stated that if Resident #4 made one slight move it would sever his C-spine and cause him to stop breathing, and stated that was most likely what occurred. Physician Q said he had not completed Resident #4's death certificate, but stated he was putting the cause of death on the death certificate of complications from a C-1 fracture. In an interview on [DATE] at 8:41 PM, Licensed Practical Nurse (LPN) M, who was the Unit Manager of the B-hall, stated Resident #4 was able to ambulate on his own before he broke his hip, and stated after his return from the hospital for his hip repair his status had changed from ambulation to wheelchair. LPN M said Resident #4 did not follow directions, and was slightly bent over when he walked. LPN M said, when asked what interventions were put in place for supervision related to falls, That was why he was at the nurses' station when he fell for increased supervision. LPN M said Resident #4 was unpredictable and staff had to constantly tell him to sit down, and that was why a cushion was placed in his wheelchair seat, and antilock breaks on his wheelchair. LPN M said she was not sure if staff were at the nurses' station when Resident #4 fell on [DATE], but stated he was at the nurses' station for oversight, and stated everyone (staff) knew he was there (at the nurses' station). LPN M said Resident #4 was not in view of any staff when he fell on [DATE], and stated his fall was not witnessed by staff. LPN M said the CNAs were to review a resident's care card before caring for the resident, and stated she did not believe Resident #4 had adequate supervision at the time of his fall on [DATE], and stated it was unfortunate that no one was out there (at the nurses' station) when Resident #4 fell . LPN M said Resident #4 would not stay in one place long and would wander. In an interview on [DATE] at 11:38 AM, Registered Nurse (RN) R, who was Resident #4's nurse at the time of his fall on [DATE], stated Resident #4 would attempt to stand up on his own a lot, and stated she had to tell him twice to sit back down in his wheelchair. RN R said when Resident #4 fell on [DATE] she did not witness his fall. RN R said Resident #4 was put at the nurses' station for increased supervision, and said she knew he was there when she went into another resident's room. RN R said Resident #4 was not on 1:1 supervision, and stated that she could not answer if Resident 34 needed increased supervision. RN R said Resident #4 was in his wheelchair across from the nurses' station and by her treatment cart. RN R said a visitor had yelled for help. In an interview on [DATE] at 10:25 AM, Director of Nursing (DON) B stated she was not aware of any fall Resident #4 had prior to his [MEDICAL CONDITION] from a fall on [DATE]. DON B said Resident #4 was weight bearing at the time of his fall on [DATE], but stated she preferred he not ambulate, and was not one 1:1 supervision. DON B was asked how it was implemented that Resident #4 was being supervised while he was up in his wheelchair, and DON B stated that would be a 1:1 supervision. DON B said Resident #4 did not follow directions. In an interview on [DATE] at 12:18 PM, Physical Therapist (PT) S stated she had worked with Resident #4 while he resided on both B and C-hall, and stated Resident #4 would attempt to get up on his own 2 days after his return from the hospital for his hip surgery. PT S stated she and other staff had to constantly tell Resident #4 to sit back down, and stated she would turn her back and he would attempt to stand up on his own. PT S said Resident #4 was unsteady due to his [MEDICAL CONDITION], and would hold onto staff tight when standing up. PT S said Resident #4 could not remember directions, and did not follow directions when told to sit back down. PT S stated she had told all the nurses' and CNAs on both the B and C-hall Resident #4 needed to be supervised at all times while up in his wheelchair. PT S said Resident #4 was ok to ambulate on his own up until he fractured his hip on [DATE]. PT S stated that she had also instructed nursing staff Resident #4 needed increased supervision, and that was why he needed to be at the nurses' station. On [DATE] at 4:40 PM the Administrator was notified of the Immediate Jeopardy that was identified on [DATE], and began on [DATE] when Resident #4, who had a known history of falls with major injury, was left unsupervised at the nurses' station, stood up from his wheelchair unbeknownst to staff, and fell that resulted in dislocation of his recent left [MEDICAL CONDITION], and fracture of his C-1 vertebrae in his neck that ultimately contributing in Resident #4's death. On [DATE] the surveyor verified the facility had implemented the following interventions to remove the Immediate Jeopardy: 1). Beginning [DATE] an inservice for all nursing staff was initiated that included providing increased supervision, assessing, and providing to the needs of fall risk resident that are displaying restlessness and attempts to self-transfer. 2). As of [DATE] 92 out of 97 staff members (36 licensed nurses and 61 Certified Nurse Aids) had been educated. 3). Beginning [DATE] a complete audit of all current residents who may display signs and/or symptoms of impulsiveness will begin supervision immediately. 4). On [DATE], 69 out of 69 residents determined to be at risk for falls were reviewed to ensure risk assessments continued to be appropriate. 5). On [DATE], 69 out of 69 residents determined to be at risk for falls were reviewed by administrative nurses and the Interdisciplinary Team (IDT) for fall care plan interventions, physician orders, and care card to ensure correlation with the fall care plans. 6). The remaining current 54 residents will be reviewed for fall risks by Administrative nurses by [DATE] to ensure risk assessment continue to be appropriate. 7). The medical records of the remaining 54 residents will be reviewed by administrative nurses and the IDT team by [DATE] to determine appropriate interventions, review of physician orders, and care cards to ensure correlation with the fall care plan. 8). Continued compliance will be monitored daily through interdisciplinary resident review during the morning clinical meeting, review of all new admission, fall risk assessments, and care plan interventions, and through the facility's quality assurance program, Additional education and monitoring will be initiated for any identified concerns. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not yet been verified by the state agency.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 3 residents reviewed for elopement, from a total of 7 sampled residents, resulting in Resident #3 eloping from the facility with a resultant fall, and the potential for significant injury and death. Findings include: According to the Minimum Data Set, dated dated [DATE], and Face Sheet, dated 3/07/17, Resident #3 was a [AGE] year old woman, who was admitted on [DATE], had severe cognitive impairment, and [DIAGNOSES REDACTED]. According to Resident #3's Nursing Progress Notes, dated 03/06/17, Resident wanting to leave this morning to go to school or go out of the building to look for spouse resident was found in the parking lot .was found on her knees. Incident report dated 03/06/17 reflected resident exited front door. According to Resident #3's Nursing Admission Assessment, dated 2/02/17, she was at high risk for wandering, and was to wear a (wanderguard) bracelet. In a telephone interview, on 3/07/17 at 3:33 PM, LPN I reported she was assigned to Resident #3 on 3/06/17 at the time of the incident. LPN I reported she was not aware the front entrance door was alarming when Resident #3 apparently exited that door because the North A - Wing door was alarming at the same time, and she was busy trying to locate the code to shut if it off. LPN I reported she was aware Resident #3 wore an alarm bracelet, and she witnessed her setting off the North A - Wing door alarm. LPN I said, (Resident #3) wanders into others' rooms. When I didn't see her, I didn't know the entrance door alarm was shut off. LPN I said Resident #3 was saying she needed to go to school. After I found the code and shut off the North A-Wing door alarm, I didn't see (Resident #3). A CNA/Nurse Aide found her on the ground. It was about 5:20 AM. I later checked, and she had abrasions on her knee. LPN I reported Resident #3 had been agitated during the night, but she had not placed her on 1:1 observation. LPN I said, I was trying to keep an eye on her . Usually, she stayed close to a staff member. LPN I reported she had seen Resident #3 at the Nurses' Station approximately 5 minutes before she was discovered outside unattended. According to Wunderground.com, 2017, the temperature (in the city where the facility was located) on 3/06/17 at 5:15 AM was 50 degrees Fahrenheit. <https://www.wunderground.com/history/airport/KOEB/2017/3/6/DailyHistory.html?req_city=Coldwater&req_state=MI&req_statename=&reqdb.zip= &reqdb.magic=1&reqdb.wmo= In a telephone interview, on 3/07/17 at 4:08 PM, Housekeeper/Floor Technician J reported he heard door alarms start sounding at around 5:00 AM, but he did not immediately go an investigate. Housekeeper J said the alarms were sounding for a solid 7 minutes .I had to shut off North Hall door because the nurse (LPN I) didn't know how to shut it off. Housekeeper J said after he shut the North Hall door alarm off, he could hear the Front Entrance door alarm, so he went and shut it off, looked out the window and saw no one. Housekeeper J said when he went back the to Unit, LPN I said 'Have you seen (Resident #3)?'. Housekeeper J said, I (then) went out the front door and went outside and saw (Resident #3) by the bus. She was half way in her wheelchair like she was getting ready to stand up. I went back inside to find a CNA. An observation of the facility parking lot and bus location revealed it was approximately 30 yards from the front entrance and another approximate 30 yards from a city street. On 3/08/17 at 12:26 PM, in lieu of the Administrator's absence, DON/Director of Nursing B was presented with Immediate Jeopardy at F-323 for the facility's failure to prevent the elopement of Resident #3 for between 5 - 20 minutes on 3-6-17, which resulted in a fall with knee abrasions, and had the potential to cause serious physical injury and the potential for death. It was determined the facility had put the following interventions in place: · On 3/06/17, Resident #3 was assessed by LPN I, and found to have a minor injury to her knee. · On 3/06/17, Resident #3's room was relocated to the secured unit with approval of her Responsible Party U. · On 3/06/17, all facility doors' wanderguard systems were checked and found to be functioning properly. · On 3/06/17, all 9 residents' wearing wanderguard bracelets were reassessed for risk of elopement, (with no changes) and their Care Plans and Care Cards were reviewed. · On 3/06/17, of the additional 127 facility residents, 41 resided on the locked unit and were assessed as not needing a wanderguard bracelet, and the 86 remaining facility residents were assessed, and found not to be at risk for elopement. · On 3/06/17, Housekeeper/Floor Technician J and LPN/Licensed Practical Nurse I received individual reeducation on Missing Guest Policy and Procedure. · On 3/06/17, inservicing on the Missing Guest Policy and Procedure (including disalarming doors and going outdoors to check for residents when door alarms sound), and Missing Resident drills was initiated by Administrator A. · On 3/07/17, over 50% of facility staff (118 out of 188) had been re-educated on the Missing Guest Policy, and the remaining staff will not be allowed to work until they have received the education. It was determined the facility removed the immediacy on 3/07/17 however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy as sustained compliance could not be verified by the state agency.

This citation pertains to MI 552. Based on observation, interview, and record review, the facility failed to provide care according to professional standards (obtain and administer narcotic pain medication) for 1 of 3 residents reviewed for narcotic pain medication administration (Resident #5), from a total of 8 sampled residents, resulting in unnecessary severe pain, and psychosocial harm. Findings include: According to Pain Management Nursing, 2000, The newly approved Joint Commission on Accreditation of Healthcare Organizations (JCAHO) pain management standards present an important opportunity for widespread and sustainable improvement in pain assessment and management. Unrelieved pain is a major, yet avoidable, public health problem. Despite [AGE] years of work by educators, clinicians, and professional organizations and the publication of clinical practice guidelines, there have been, at best, modest improvements in pain management practices. Multiple barriers found in the health care system, and among health care professionals .continue to impede progress. <http://www.painmanagementnursing.org/article/S1524-9042(00) -2/abstract> According to the facility's Medication Administration Policy and Procedure, dated 7/09, .Record any omissions including date, time, and reason on the back of the Medication Administration Record (MAR) . The Policy and Procedure did not include a procedure to reorder narcotic pain medications. On 3/08/17 at 1:20 PM, DON/Director of Nursing B reported the facility's did not have a narcotic pain medication policy and procedure, and there were no Medication Error Reports for Resident #5 in March, 2017. According to the facility's Medication Errors and Drug Reactions Policy and Procedure, dated 8/14, .The charge nurse is responsible for completing an Incident Report .The Incident Report should be logged on a separate Incident Report Log designated for medication errors only .Documentation in the Progress Notes: The medication(s) given .An analysis of Adverse Medication Event will be completed by a member of the Quality Assurance Committee. The occurrence will also be reviewed at the facility's next Quality Assurance meeting . The Policy and Procedure did not mention errors due to omitted doses, nor the procedure to assure prescriptions for narcotics are available in a manner that would not impede appropriate treatment. According to Intake Information, received 3/06/17 (not timed), The (anonymous) complainant (F) alleges that the resident (Resident #5) did not receive pain medication ([MEDICATION NAME]/narcotic 5 mg every 4 hours) on Saturday, March 4th, 2017 and Sunday, March 5th, 2017 until 2 p.m. due to the medication not being re-ordered. The resident was observed to be suffering by the complainant, not eating, tearful, and in pain . According to the MDS/Minimum Data Set, dated dated [DATE], Resident #5 was a [AGE] year old woman, who was admitted to the facility on [DATE], was cognitively intact, and had [DIAGNOSES REDACTED]. According to Resident #5's Pain Care Plan, dated 1/10/17, Actual Pain related to .pain to right leg, buttock, arm. Guest states acceptable level of pain is: 4 .Encourage to request pain medication at onset of pain; Observe and report decreased function and decreased quality of life such as change in sleep pattern, appetite, physical function, relationships with others Irritability, disruptive behavior), emotions (Crying anger, altered concentration) and limitations in ADL/Activities of Daily Living .Observe and report patterns of pain and possible contributing factors .Evaluate characteristics of pain: on scale of 0 - 10. Resident #5's MAR/Medication Administration Record and Nursing Progress Notes revealed she reported severe pain and was being administered [MEDICATION NAME] (narcotic pain medication) 5 mg, 2 tablets per physician's prn/as needed order. It was documented she received this dosage 4 times on 3/02/17: · 4:46 AM (pain level - 9) · 10:31 AM (pain level - 8) · 4:02 PM for (pain level - 8) · 8:21 PM for (pain level - 7) Resident #5 received this dosage 3 times on 3/03/17: · 6:30 AM (pain level - 8) · 12:40 PM (pain level - 8) · 7:05 PM (pain level - 9) Resident #5's received only 2 dosages 2 on 3/04/17: 9:01 AM (pain level - 7) 3:28 PM (pain level - 8) And, according to Resident #5's MAR/Medication Administration Record, she did not receive Oxydodone again until 3/05/17 at 2:03 PM (23 hours since her last dose). In an interview/observation, on 3/07/17 at 11:25 AM, Resident #5 was asked if she received her prn/as needed narcotic pain medication when she requested it, and she replied, .I ask, and I get forgotten. Sometimes, I forget to ask or I forget when I last had it. It takes 45 minutes to an hour to get a pain med (pill) .This past weekend, I went with no pain meds ([MEDICATION NAME]). The nurses on 1st, 2nd, and 3rd shift told me they had to call the pharmacy or the doctor. I was in pain all weekend. (Resident #5 pointed at her left foot. It was observed to have a gauze dressing and her leg was darkly discolored to mid calf). My left heel, toes and top of my foot is black, bleeds, and hurts really bad. When I got back from [MEDICAL TREATMENT] on Monday, I asked for my pain medication and they said, 'Yes, you can have your Oxy. My pain was a 9 all weekend, and I had trouble eating and sleeping. I couldn't do anything. I couldn't go to Bingo. They kept telling me, 'We don't have anything we can give you'. Review of Nursing Progress Notes and MARs revealed no documentation of Resident #5's requests for her prn Oxy pain medication between 3/04/17 at 3:28 PM and 3/05/17 at 2:03 PM. Review of Resident #5's Controlled Substances Proof of Use form, revealed the last 2 doses were administered on 3/04/17 at 3:30 PM by LPN/Licensed Practical Nurse G. In an interview, on 3/07/17 at 2:15 PM, LPN G reported she worked from 6:00 PM - 10:00 PM and was assigned to Resident #5 on Saturday, 3/04/17, and she was the facility's Staff Development Nurse. When asked whether she made sure there was [MEDICATION NAME] available for Resident #5 after she administered the last 2 tablets, she replied, The sticker was already gone to order it. I assumed it would come in the night time tote .I didn't look at the zero, which means we need a reauthorization. I gave report to (LPN Q at 6:00 PM). She sent a request to pull 6 tablets from back-up. (While reviewing the form LPN Q said, 'It was faxed to pharmacy at 6:38 PM on Saturday.) When asked why Resident #5 did not receive Oxy until Sunday at 2:03 PM, LPN G replied, Maybe they needed a new script. The On-call Nurse Practioner should get from the doctor. We should be able to get a script within an hour or so. In a telephone interview, on 3/07/17 at 2:31 PM, LPN H reported she was assigned to Resident #5 the night shift on 3/04/17 at 10:00 PM - 7:00 AM 3/05/17. LPN H said (Resident #5's) husband called around 11:00 PM and said something about pain meds .I gave report to (LPN N) Sunday (3/05/17) morning. LPN H denied Resident #5 made any requests for pain medications to her on her shift. In an interview, on 3/08/17 at 12:45 PM, Nurse Aide K reported she was assigned to Resident #5 on Sunday, 3/05/17 and said, (Resident #5) was upset because she had no pain medication. she said she was in a lot of pain and they didn't have any. She didn't have any when I left at 2:00 PM. (Resident #5's) husband was here and was upset about it around noon. I told (LPN N) and she said she was trying to get her some, but there wasn't any .(Resident #5) got up in the morning, but went back to bed after breakfast .She didn't go to Bingo, she just lain in bed on her side . In a telephone interview, on 3/08/17 at 1:59 PM, LPN N reported she was assigned to Resident #5 on 3/05/17 and said LPN H told her in morning report that she had tried On-call for a new prescription. It sounded like (Resident #5) had been painful all night and was asking for it . When asked if she or anyone else had documented the omissions on a Medication Error report or told the DON (B), Administrator (A), or the Medical Director (T), she replied, Not that I know of . LPN O was trying to call (Resident #5's) doctor (Physician S) and she talked to the DON (B). When asked if she thought there had been a violation of professional standards related to Resident #5 being in severe pain, and nursing staff not obtaining it for her, she replied, Not for the lack of trying. LPN N was asked if she had ever received an in-service on obtaining narcotic medication appropriately, and she said she had not. In an interview, on 3/08/17 at 2:54 PM, DON B stated the facility had no Policy and Procedure on obtaining narcotic medications. DON B reported she was unaware Resident #5 had requested prn [MEDICATION NAME] on 3/04/16 and 3/05/17, but was not administered this medication for pain relief. DON B was asked if Professional Standards were violated regarding the issue and she replied, Yes, no resident should have untreated pain. They could have called me, or the Medical Director, or the Administrator. The medication should have been reordered when the (medication) card was half full. When asked if licensed nurses had been educated on when to obtain narcotic medication refill authorization, DON B said they had not been formally educated, but agreed it was a professional standard to make sure there was enough medication available, and to administer ordered pain medications to relieve pain. DON B said a Medication Error Report should have been made out and if one had been done, it would have gone to the Medical Director and to the Quality Assurance Committee. DON B also said documentation for pain medication omissions should have been recorded on the MAR and in Nursing Notes, and the complaint made by Resident #5's husband should have been documented and reported to her or the Administrator A. In an interview, on 3/08/17 at 4:05 PM, Resident #5 stated she had requested pain medication from the LPN G the evening of 3/04/17. Resident #5 was asked what her pain level was at that time, and she said, Yes, and my pain level was 9. When asked if she had requested pain medication from LPN H during the midnight shift, she replied, Yes, I did and she told me I didn't have any .my pain was a 9. When asked if she had requested pain medication form LPN N on Sunday morning, she replied, Yes, at 7:00 AM. My pain was 9. In an interview, on 3/08/17 at 4:08 PM, LPN G confirmed Resident #5 had requested Oxy on 3/04/17 at approximately 8:30 PM.

This citation pertains to MI 705. Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain the highest practical physical level of well being (recognize, assess, monitor, and treat infections, pain, wounds (surgical and arterial ulcer), central line, and a Peripherally Inserted Central Catheter (PICC). A PICC line is a thin, soft, long catheter tube that is inserted into a vein in adult's arm, leg or neck) in 2 of 24 sampled residents (Resident #3 and #18) reviewed for admission orders [REDACTED]. Findings include: Resident #18 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #18 was a [AGE] year of male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #18 had a BIMS/Brief Interview for Mental Status (assessment tool) score of 14, which indicated his ability to make daily decisions was cognitively intact, and he required two person physical assist with transfers, toileting, dressing, hygiene, bathing and one person physical assist with locomotion on the unit with use of wheelchair. The MDS reflected Resident #18 had constant pain and used as need pain medications for pain relief. During a Medication Administration Observation on 2/13/17 at 4:05 p.m., LPN (Licensed Practical Nurse) AA reported she was unable to locate Resident #18's Cefpodoxine (antibiotic) for the [MEDICAL CONDITION] in the medication cart. Upon further review it was determined that Resident #18 did not receive the ordered antibiotic and the resident did not receive PICC maintenance on the first 3 days at the facility (2/9/17, 2/10/17, 2/11/17) as per hospital physician transfer orders. (A PICC line is a thin, soft, long catheter tube that is inserted into a vein in adult's arm, leg or neck.) In a telephone interview on 2/15/17 at 3:48 p.m., LPN Z reported she was assigned to Resident #18 on 2/11/17 and on that day she identified missing admission medications and treatments from 2/9/17 that had been on the hospital discharge orders but not transcribed correctly at the facility on admission. LPN Z reported LPN BB helped complete the medication error documents for the missing medication that included: [MEDICATION NAME] (antibiotic) 100 mg twice orally daily, Potassium 20 mEq four times daily orally, Zinc 220 mg daily, urea 40% cream to left lower leg for 3 days, normal saline (salt water) flush daily for PICC maintenance, and [MEDICATION NAME] (anticoagulant) flush daily for PICC maintenance. LPN Z reported the admission nurse DD was new and did not complete the required documents according to the admission check list (including the Admission Skin Assessment and Initial Care Plans). Review of the 6 facility documents labeled, Analysis of Adverse Medication Event, all dated 2/11/17, provided by Director of Nursing B, revealed Resident #18 had 6 transcription medication error on 2/9/17 that were identified on 2/11/17 by LPN BB. The documents reflected Resident #18 did not receive prescribed medications; [MEDICATION NAME], Potassium (four times daily), Zinc, Urea cream, normal saline and [MEDICATION NAME] for PICC maintenance. The documents reflected the errors were discovered during an admission check 2 days after the admit and reflected the wrong hospital admission orders [REDACTED] In a second interview on 2/16/17 at 10:20 a.m., LPN Z reported she had been assigned to Resident #18 on 2/11/17 and 2/12/17 and was unaware of any open wounds. At this time, LPN Z was observed reviewing the Skin Assessment book on B hall and there were no wound sheets for Resident #18. Together LPN Z and this Surveyor entered Resident #18's room, LPN Z removed Resident #18's sock from the left foot and revealed a gauze dressing over the toe area. Resident #18 reported only his wife had done the dressing changes since the admission on 2/9/17 because staff had not performed them. LPN Z removed the blood soaked dressing. Resident #18 had 7 sutures noted on the medial left great toe area, a dime sized open area on the ball of the foot and a moderate amount of dried thick flaky skin with dark pink to red discoloration noted to the left lower leg. Resident #18 stated, this is the first time a nurse has looked at my foot since I got here. Upon review of the (now completed) Nursing Admission Assessment form that was signed and dated 2/09/17 by Registered Nurse DD LPN Z reported when she worked on 2/11/17 the skin assessment portion, signature and date was blank. LPN Z said, someone must have told her (nurse DD) to go back and complete that. LPN Z reported on 2/11/17 Resident #18's family member KK asked if the PICC line was being used and LPN Z reported she was unaware Resident #18 had a PICC line. LPN Z reported again that Registered Nurse(RN) DD admitted Resident #18 on 2/9/17 was new and did not complete the admission skin assessment, the initial care plans, nor the immunization record, or skin sheets. LPN Z reported the facility policy and procedure for a new admission is to complete the Admission assessment, have resident sign consents, verify hospital discharge orders and transcribe orders including diet and code status into the computer before the end of the shift and report to next shift anything from admission check list not completed. In an interview on 2/22/17 at 11:42 a.m. LPN BB reported she worked on B wing on 2/11/17 and helped LPN Z complete the 6 medication error event documents for Resident #18 related to the transcription errors from 2/9/17 admission. LPN BB reported she contacted DON B immediately on 2/11/17 and reported medication errors. LPN BB reported DON B advised LPN BB to educate RN DD on the next shift. LPN BB reported she called and notified the B wing unit manager N as well on 2/11/17. LPN BB reported she educated RN DD on 2/11/17 when RN DD arrived to the facility for the next shift related to the incomplete admission skin assessment (including the missing PICC flushes and dressing changes), missing initial care plans, and medication transcription errors reports. LPN BB reported she told RN DD to clarify the zinc order from 2/9/17. LPN BB did not return to work until 2/16/17 and the zinc order still was not in the system. LPN BB reported she notified the doctor and spoke with DON B and Administrator A on 2/16/17. LPN BB reported DON B said, 'you should have followed up or verified order was completed'. LPN BB reported she corrected Resident #18's zinc order on 2/16/17 and stated, I had never cared for (named Resident #18) since he has been here. Review of the Hospital Discharge Instructions, dated 2/9/17, revealed [MEDICATION NAME] Proxetil([MEDICATION NAME]) 100 mg twice daily and an order that revealed, Keep PICC Line, PICC line care and flushes per protocol. The Discharge orders revealed, dressing change to foot-xeroform, gauze and wrap daily after saline wash, and orders for Potassium Chloride 20 meq four times daily by mouth, Urea 142 gm cream daily for 3 days, zinc 220 mg daily, [MEDICATION NAME] 7.5/325 every 6 hours PRN pain, normal saline IV flush and [MEDICATION NAME] IV flush. Review of the Physician Orders, dated 2/9/17 though 2/10/17, for Resident #18, revealed no orders for code status, PICC maintenance, [MEDICATION NAME], Zinc, or Potassium Chloride. The Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The TAR reflected 6 missed physician ordered wound/surgical dressing changes related to Resident #18's left foot. Review of the Nursing Progress Note, signed and dated by RN DD on 2/9/17 at 10:10 p.m., reflected, Narcotic script was faxed to the pharmacy along with an off the pull form. Pharmacy called to inform that script was not filled out properly and it can not be filled. They stated it is missing the DEA number. Resident stated he feels he needs pain medicine soon as his foot is starting to hurt . Review of the Nursing Progress Note, signed and dated by RN DD on 2/10/17 at 1:58 a.m., reflected, resident had no complaints at this time but did state that his pain is in his left foot; 3 toes were just amputated .Pain Description 1: Sharp, Pain Score: 5 (Moderate) . Review of Nursing Progress Notes, dated 2/10/17, reflected the next pain assessment occurred at 9:09 p.m. Resident #18 rated pain at 8/10 and was give first dose of [MEDICATION NAME] 7.5/325 . On 2/16/17 at 11:30 a.m., Review of Resident #18's medical record reflected no physician progress notes [REDACTED]. According to the facilities admission orders [REDACTED].These orders will be processed by a licensed nurse in a timely manner following the guest's admission to the facility . In an interview on 2/16/17 at 2:00 p.m. Unit Manager N reported the facility policy for new admissions required the unit managers to do a chart check within 24 hours of a new admission. Unit Manager N reported Resident #18 was admitted to the facility on [DATE] at around 4:30 p.m. and 2/10/17 the floor was short a nurse so Unit Manager N worked the floor that day providing direct resident care and was not able to review Resident #18's admission. Unit Manager N reported he did not check Resident #18's chart until 2/13/17. Unit Manager N reported he was unsure why he did not notice the missing wound care orders. Unit Manager N reported Resident #18 should have had wound sheets, all hospital orders in computer, PICC maintained and wound care done starting 2/9/17 upon admission. LPN (BB): Interviewed on 2/17/17 at 1557: Revealed that new admits primarily come on the B wing. Sometimes I am given notice of admissions, and sometimes I don't know I have an admission until the resident shows up and the then the hospital packet 10 minutes later, and I don't have time to prepare for the admission. When an admission comes, I have to stop what I'm doing, orient the resident to the facility, their room, the staff, and call light so that they feel comfortable. Then I try to finish task I was doing prior to them arriving. LPN BB was asked when was she able to do the admission assessment. She replied, Whenever I can fit it in and whatever I can get done. LPN BB was asked if she had any issue completing admissions recently. LPN BB stated, about 1 month ago 3 admits together. We were short on nurses and we got 2 of the 3 admissions done 100%. The 3rd one we got his name and medications in the system, and passed it on to the next shift for completion but it was never done by the nurse. The DON comes to us the next morning complaining of the third admission not being done. The prior nurse did nothing. In an interview on 2/22/17 at 12:45 p.m. DON B reported it was her expectation that the nurse on duty when a new admission arrives orient the resident to the room and bed, perform a head to toe assessment, review hospital discharge orders, call the physician, document on the admission form and the electronic medical record and transcribe the orders into the the computer system within 2 hours of the new admission. DON B reported if the new admission arrives close to the shift change the nurse should clearly communicate with the next shift nurse the admission tasks that still need to be done and document on the 24 hour report. In a telephone interview on 2/22/17 at 4:00 p.m. RN DD reported she had worked with the facility about 1 month and was the admitting nurse for Resident #18 on 2/9/17 around 5:00 p.m. RN DD reported on 2/9/17 she worked the B wing from 2:00 p.m. through 3:00 a.m. on 2/10/17. RN DD reported she worked in a hospital setting prior to the facility and was new to the long term care admission process. RN DD reported the other nurse on B wing also received a new admission that evening and he had been with the facility for less than a month. RN DD reported she performed an assessment of Resident #18 upon arrival and was aware of the PICC and the recent left 3 toe amputations and reported the dressing was dry and intact to the left foot and reported she did not remove the dressing from the left foot. RN DD reported she completed the admission assessment document, consents, admission note in the computer and transcribed medications into the computer from the hospital discharge orders the narcotic script was attached to. RN DD reported it was later brought to her attention that there was more than 1 set of admission orders [REDACTED]. RN DD reported she did not enter an order for [REDACTED].>In an interview on 2/22/17 at 4:45 p.m. Resident #18 family member KK reported she talked to Resident #18's nurse on 2/9/17 about the dressing on the right foot. Resident #18's family KK reported when she arrived in the evening on 2/10/17 she spoke with Resident #18's LPN XY at around 8:00 p.m. related Resident #18's unchanged left foot dressing. Resident #18's family KK reported LPN XY provided Resident #18's family KK with the wound dressing materials needed, including [MEDICATION NAME] AG, from the treatment cart and Resident #18's family KK performed the dressing 2/10/17 through 2/16/17 daily. Resident #18 along with Resident #18's family KK denied being informed by the facility related to the delay in treatment for [REDACTED]. Resident #3 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #3 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED].#3 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with transfers, toileting, dressing, hygiene, bathing and one person physical assist with locomotion on the unit with use of wheelchair. The MDS reflected Resident #3 had frequent pain and used schedule and as need pain medications for pain relief. According to the facility, Pain Management Program policy and procedure, dated 3/05, reflected, The Pain Management Program will be used by nursing staff to evaluate, provide appropriate interventions, and monitor the effectiveness of the pain regimen for guests experiencing acute and/or chronic pain, in order to promote comfort and the ability to reach their highest functional level .Situations when guests may be evaluated for pain include, but not limited to: .c. Guest exhibits depressed or withdrawn symptoms, d. Guest verbalize pain and/or requests pain medication, e. Guest exhibits non-verbal cues, i.e., grimacing, wringing of hands, f. Guest receives regular use of pain medications (routine or PRN). g. Guest has pressure ulcers, surgical wounds, casts, splints etc .l. Examples of Chronic Illness or injury include, but not limited to .7. Surgery ( .phantom limb pain) 8. Vascular Disorders ([MEDICAL CONDITION], claudication, ischemia) .Evaluation of Pain Regimen: 1. The licensed nurse is responsible for summarizing the guest's response (progress or decline) in regard to the care plan at least monthly, and revising the pain regimen with the interdisciplinary team if necessary. 2. The interdisciplinary care conference team will evaluate the care plan in conjunction with the pain assessment and pharmacist recommendations .4. the guest will be discharged from the Pain Management Program when the pain is effectively managed (0-2 on the pain scale) by the current pain regimen. In an interview on 2/14/17 at 10:05 a.m. Resident #3 reported she was unhappy with care she had received at the facility. Resident #3 reported she was currently having a lot of pain in her foot and had talked with several staff on several occasions about the increased pain. Resident #3 reported she had attended 2 care conferences along with her family and had requested a different doctor because she was not happy the current doctor Za related to concerns that included refusing to adjust pain medications. Resident #3 was noted to be very upset when discussing the subject and began crying. Resident #3 reported difficulty sleeping related to the uncontrolled pain level. In a second interview on 2/15/17 at 9:55 a.m. Resident #3 was noted to be in bed and upset related to the [MEDICAL TREATMENT] center sending her back to the facility related to a fever. Resident #3 reported the facility wanted to transfer her to the hospital but she refused to go. Resident #3 reported she had requested a new doctor soon after doctor Za had first seen her but was unsure who she spoke with. However, Resident #3 reported she had attended 2 care conferences that her family and had requested a different doctor because she was not happy the current doctor Za related to concerns that included refusing to adjust pain medications. Resident #3 reported the people present at the care conference included her husband, son, unit manager N, Certified Nurse Aide(CNA) PP and herself. Resident #3 also reported she requested to have [MEDICATION NAME] dose restarted because after she had gone into the hospital someone had taken it away. Resident #3's husband reported they were told in the care conference that Resident #3 would have to be seen by the by Psychologist related to that, however, Resident #3 reported she had not seen anyone yet. According to the Care Conference Minutes, dated 1/6/17 and 1/24/17, reflected no mention of Resident #3 request for a new doctor or request for psychologist evaluation. The Care Conference Minutes had notes form individual departments related to current resident status. No discussion was noted on the minutes about what took place during the meeting. The care conferences were attended by Resident #3 and family, several staff including CNA PP. In an interview on 2/15/17 at 11:50 a.m. at the B hall nurses station CNA PP reported she did attend a care conference meeting for Resident #3 on 1/24/17. CNA PP reported Resident #3 and family talked about care concerns related to call light response times and CNA discussed options that have worked to resolve the concerns with 3rd shift. Unit Manager N, who was also present at the B hall nurse station, reported he was present at the care conference for Resident #3 and recalls a discussion about Resident #3 requesting a new physician. Unit Manager N reported that he recalls being told that the other facility physician was not excepting new residents though. Unit Manager N reported Social Worker(SW) MM should know more about that. Review of the Hospital Discharge Orders, dated 12/22/16, Resident #3 had an orders that included [MEDICATION NAME] 2 g intravenously(IV) every 12 hours(antibiotic), [MEDICATION NAME] 2000mg IV every 12 hours(antibiotic), routine central line care and an order for [REDACTED]. Review of the Medication Administration Record(MAR), dated 12/22/16 through 12/31/16, revealed Resident #3 had 3 missed doses of [MEDICATION NAME] 2 gm IV on 2/23/16 through 12/24/16 and 1 missed dose of [MEDICATION NAME] 2 gm IV on 12/24/16 and no documented central line normal saline or [MEDICATION NAME] flushes for 4 days. Review of the Physician Orders, dated 12/22/16 through 12/27/16, reflected no central line normal saline flushes/[MEDICATION NAME] flushes until 12/27/16(Resident #3 was admitted with central line catheter on 12/22/16). The Physician included an order for [REDACTED]. Review of the facility, Pain Assessment document, dated 12/22/16, reflected Resident #3 was alert and oriented and complained of 6/10 pain on a scale to the left lower leg. The assessment reflected Resident #3 would express pain with verbal complaints or facial/non-verbal gestures. Review of the MAR, dated 12/22/16 through 2/15/17, reflected Resident #3 had received 77 doses of as needed [MEDICATION NAME] 10mg for pain levels greater than 7/10. The MAR indicated [REDACTED]. Review of the physician progress notes [REDACTED]. Review of the Nursing Progress Notes, dated 12/22/16 through 2/16/17, reflected no mention of facility staff contacting the physician related to change in Resident #3's pain regimen or to report routine use of as needed pain medication. Review of the Pain Care Plans, dated 1/10/17, reflected Resident #3's acceptable level of pain was 4/10 with a goal that Resident #3 will state relief of pain daily. The care plan interventions included, encourage to request pain medications at onset of pain, observe and report decreased function and decreased quality of life such as change in sleep patterns, appetite, physical function, relationships with others, emotions. In an interview on 1/16/17 at 11:25 a.m. Social Worker (SW) MM reported she had been working with the facility for 3 weeks and was new to long term care. SW MM reported she first met with Resident #3 on 2/14/17 after receiving a request by staff related to resident being upset and request for [MEDICATION NAME]. SW MM reported she met with Resident #3 on 2/14/17 and Resident #3 appeared calm and appropriate and denied any concerns or needs. SW DD did not mention to Resident #3 that she was seeing her related to staff request related to resident request to see psychiatrist about getting a script for [MEDICATION NAME]. SW DD reported she did not document in Resident #3's medical record only on scratch paper for her record and was not aware of her role to discuss and arrange psychiatrist visits. In a second interview on 2/23/17 at 10:50 a.m. SW MM reported she was told by facility Nurse Consultant Bb that the resident must personally fire the physician themselves if the resident is unhappy with the care. In an interview on 2/23/17 at 11:00 p.m. Nurse Consultant Bb reported the facility policy for residents that want a different physician was that the resident must fire the doctor on their own. Nurse Consultant Bb stated, they do not get involved with the process. Nurse Consultant Bb reported physicians are assigned to residents by facility admission staff upon admission. On 2/16/17 at approximately 6:15 p.m., the Administrator was notified of the Immediate Jeopardy that began on 2/16/17 and was identified on 2/16/17 at 2:30 p.m., when the facility failed to recognize, assess, monitor, and treat Resident #18's infection, wounds, and a PICC. On 2/21/17, the survey team confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. Resident #18 surgical wound was assessed, measured and documented on 2/16/17. The treatment order was obtained by the physician and the treatment was completed per physician's orders [REDACTED]. 2. Nurse Practitioner for Dr. in to see guest on 2/171.7 and has documented guest doing well with no negative consequence since admission to facility. 3. Resident #18 PICC line was discontinued per physician's orders [REDACTED]. 4. Resident #18 continues to receive oral antibiotic twice a day per physician's orders [REDACTED].>5. In-servicing education was initiated on 2/16/17 by the Director of Nursing/designee to licensed nurses to include review of policies for Admission of Guest, Admission Orders, Medication Administration, Dressing Change, Wound and Skin Condition Record, Weekly Skin Assessment, Maintaining the Peripherally Inserted Central Catheter and Changing the PICC Dressing and education is continuing until 100% reached and all licensed nurses will receive education prior to their next scheduled work. 6. Licensed Nurses assigned to the care of Resident #18 received individual counseling on 2/17/17 by the Director of Nursing/Designee regarding requirements to administer Resident medications as ordered, to complete Resident treatments to surgical wounds as ordered, and to maintain Residents PICC line catheter per physician's orders [REDACTED]. 7. The Administrative Nurse assigned to complete new admission chart review for Resident #18 received individual counseling by the Director of Nursing on 2/17/17. 8. 20 out of 41 Licensed Nurses were re-educated by the Director of Nursing/designee between 2/16/17 and 2/17/17 related to the admission process, medication and treatment administration and care and maintenance of a PICC line. 9. The medical records of 19 out of 19 Residents admitted since 2/1/17 were reviewed by Administrative Nurses on 2/17/17 to ensure appropriate follow up related to the admission process, medication and treatment administration and care and maintenance of PICC lines. 10. 3 out of 3 current Residents with surgical wounds were reviewed on 2/17/17 by Administrative Nurses to ensure treatment administration is being completed as ordered. 11. 3 out of 3 current Residents with PICC line catheters were reviewed on 2/17/17 by Administrative Nurses to ensure maintenance care has been provided according to obtained physician's orders [REDACTED]. 12. 14 out of 14 current Residents receiving antibiotics were reviewed on 2/17/17 by Administrative Nurses to ensure antibiotic is being administered as ordered. 13. Continued compliance will be monitored daily through interdisciplinary Resident review during the morning clinical meeting, review of all new admissions and new orders, review of 24 hour report, review of Medication Administration Records, review of wound and skin conditions and through the facility's quality assurance program. Additional education and monitoring will be initiated for any identified concerns. Although the Immediate Jeopardy was removed on 2/17/17, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not been verified by the State Agency.

Based on observation, interview, and record review, the facility failed to fully assess, accurately/consistently monitor/document, and prevent development of and/or worsening of pressure ulcers for 3 of 5 residents reviewed for pressure ulcers (Residents #2, #5, and #16), from a total of 24 sampled residents, resulting in pain and discomfort, and the potential for further deterioration in health status and the potential for psychosocial damage. Findings include: Resident #16 According to the MDS, dated [DATE], Resident #16 was readmitted to the facility on [DATE], had a BIMs of 10 (Brief Interview for Mental Status/moderate cognitive impairment), needed assistance with bed mobility, and he had [DIAGNOSES REDACTED]. On 2/15/17 at 9:40 AM, Resident #16 was observed laying on his back in bed at a 60 degree angle. Resident #16 said, I'm in terrible pain in my back, right above my kicker. Review of Shower/Skin Observation Records for Resident #16 revealed no skin issued in November and December 2016, and no skin issues in January 2017. Resident #16's Shower/Skin Observation Record, dated 2/03/17, revealed a skin impairment on his buttocks (circled/area not specified). Review of a Weekly Skin Assessment for Resident #16, dated 2/11/16, revealed, Has existing wound condition and there were 3 circled areas - 1 circle on each buttock and 1 on the left lower back (none on coccyx or heels). During an observation on 2/15/17 at 9:40 AM, Resident #16 was laying in bed on his back with 2 pillows under his head, and one pillow sitting in a wheelchair at bedside. There was a turning schedule clock on an 8 inch x 11 inch sheet of paper on the wall above the head of his bed. The turning schedule clock indicated Resident #16 was to be turned: 12 - 2 (o'clock): back; 2 -4: left; 4 - 6: right; 6 - 8: back; 8 - 10: left; 10 - 12: right. In an interview, on 2/15/17 at 10:05 AM, RN/Registered Nurse R said he had worked at the facility for about a month, and he knew Weekly Skin Assessments were done on the weekend, but he didn't know who was assigned to do them. RN R went to a binder and copied all of the wound/pressure ulcer flow sheet for Resident #16 and gave them to Surveyor. There were 3 Pressure Ulcer Records for Resident #16 (right buttocks, left hip, and coccyx, but not left gluteal fold/crease between the buttocks, or left heel): 1.) Initial Wound Description: 2/03/17: R (right) buttocks open area (red) area around, blanches well, Stage II, 2 cm x 3 cm (no depth documented); 2.) Initial Wound Description: 2/03/17, left hip/lower back, pin point small open area, Stage II 0.5 cm x 0.5 cm (no depth documented); 3.) Initial Wound Description: 2/02/17, Coccyx - red open area on coccyx, open ulcer, blanches well, Stage II, 5 cm x 3 cm (no depth documented), red .2/12/(17) Stage II 0.6 cm x 0.4 cm x 0.1 cm .pink. Review of Resident #16's Nursing Progress Notes revealed only 2 entries (2/08/17 at 4:56 AM and 2/10/17 at 6:18 AM) and of those 2 notes, only 1 contained documentation regarding regarding Resident #16's skin condition, but it was incomplete/inaccurate information; per the note in its entirety on 2/10/17: (Skin Changes) Skin Changes Since Last Assessment: Yes .Skin Notes: Reddened area to coccyx .refusal to be turned .SKIN .(Skin) Skin Warm/Dry .(Skin Issues) Skin Issues Discoloration .Skin Issues Mucous Membranes: Moist .Skin Issues Notes: reddened area to coccyx .(Wound) Wound: No. On 2/15/17 at 10:15 AM, Surveyor observed RN/Registered Nurse R prepare for a dressing change and then enter directly into Resident #16's room. RN R then began removing the covers off of Resident #16, who was laying on his back at a 40 degree angle (according to the turning schedule, Resident #16 should have been on his right side at this time). Resident #16's heels were directly resting on the mattress. RN R tugged on the incontinence pad under Resident #16 to turn him to his side (likely causing friction/shearing to Resident #16's skin). RN R said Resident #16 was difficult to turn and said, I should have gotten someone to help me turn him. RN R stated there were no dressings on Resident #16's skin, and said, Usually, there would be one on. RN R described the following 3 areas as he performed the dressing changes (right buttock, left inner gluteal fold, and right upper back, but not coccyx): 1.) Right buttock/gluteal fold - open .1 cm x 5 cm x surface, no drainage or odor. 2.) Left inner gluteal fold - 4 cm x 2 cm, not open (healed); 3.) Right upper buttock/back - open, 0.5 cm x 2 cm x surface -skin off the top of it. RN R then turned Resident #16 to his other side by tugging on the incontinence pad again and positioned Resident #16 on his back again with 2 pillows under his head, creating a 40 degree angle. Surveyor asked to see Resident #16's heels, and RN R looked at the left heel and said, red, blanches and then looked at the left heel where a dark gray spot was observed, and said, dark area, does not blanch - 1 cm x 1 cm. RN R then placed put the pillow from the wheelchair under Resident #16's calves. Review of Physician order [REDACTED]./17, but no orders for right buttock or right gluteal fold, left inner gluteal fold, or heels. Review of Wound NP/Nurse Practitioner WW's Progress Notes, dated 2/13/17, revealed: Wound #2 Right Buttock has a Primary Etiology of pressure ulcer and is a Stage 2 Pressure Injury .Wound #3 Left Buttock has a Primary Etiology of pressure ulcer and is a State 2 Pressure Injury .Wound #4 Left Lower Back has a Primary Etiology of pressure ulcer and is a State 2 Pressure Injury .Change (Three) times per/week .Follow Facility Pressure Ulcer Prevention Policy/Protocol. There was no mention of the condition of Resident #16's coccyx, heels or Resident #16's skin tolerance (the amount of time a resident's skin can tolerate pressure). (A NP WW documented Progress Note, dated 11/21/17, revealed Wound #1 was Left Buttock .Stage 1 Pressure Injury Pressure Ulcer and has received an outcome of Resolved). According to the Turning and Positioning Policy and Procedure, dated 3/13, Guests will be . assisted to turn and reposition at least every two hours while in bed . Request the appropriate number of staff members necessary to turn and reposition the guest .Float heels off the bed . In an interview, on 2/15/17 at 10:55 AM, Nurse Aide S reported he worked full time and was always assigned to Resident #16. Nurse Aide S said he did not change Resident #16's brief earlier that day until around 9:30 AM, and at that time, there were no dressings on Resident #16's wounds. Nurse Aide S said Resident #16' confusion getting worse for the past month, that he could not sit up very well, and could not reposition himself in bed, that Resident #16 at all of his meals, but wasn't drinking as well as he used to. According to Resident #16's MARs/Medication Administration Records, [MEDICATION NAME] (antipsychotic medication/see below) 0.5 mg one tab at bedtime was ordered started on 1/20/17 (about a month ago). According to Rx.com, 2017, side effects of [MEDICATION NAME] included, Drowsiness, dizziness, lightheadedness .tiredness .To reduce the risk of dizziness and lightheadedness, get up slowly when rising from a sitting or lying position. <http://www.rxlist.com/[MEDICATION NAME]-drug/consumer-side-effects-precautions.htm> On 2/15/17 at 1:05 PM, Resident #16 was observed still laying on his back at a 40 degree angle. In a subsequent interview, on 2/15/17 at 3:51 PM, Nurse Aide S was asked how many times Resident #16 had been turned and repositioned that day, and he responded, He wasn't. There is no use trying. On 2/15/17 at 4:39 PM, Resident #16 was observed still laying on his back at a 40 degree angle (according to the turning schedule, Resident #16 should have been on his right side at this time). In an interview, on 2/16 17 at 11:44 PM, Nurse Aide W reported (Resident #16) was wet when he got up around 7:00 AM - 7:30 AM and she had only changed him that one time so far that day. When asked if she had changed Resident #16's position since she got him into the wheelchair at around 7:00 AM, she replied, No, he hasn't asked to go back to bed. On 2/16/17 Resident #16 was observed sitting continuously in his wheelchair in his room at 8:30 AM, 10:00 AM, and 11:40 AM. On 2/16/17 Resident #16 was observed sitting continuously in his wheelchair in his room at at 12:20 PM, 12:50 PM, 1:00 PM, 1:20 PM, 3:10 PM, and at 5:50 PM. (Resident #16 had been sitting upright in his wheelchair for over 10 hours.) In an interview, on 2/16/17 at approximately 3:00 PM, when asked about Resident #16's open areas, LPN OP said, There were 2 little open areas on his bony area/iliac crest on Resident #16's lower back. I found them during a shower assessment. He has 2 open areas now on his bottom. They are all from pressure, laying in bed. He doesn't like to stay on his side. LPN OP was asked if NP WW was aware Resident #16 refused to turn, and asked what devices were used for postponing Resident #16 to prevent pressure ulcers, and LPN OP replied, I honestly don't know. That probably wasn't discussed with (NP WW) when she was here. LPN OP reported she had never checked Resident #16's heels for signs of tissue injury. In an interview, on 2/22/17 at 4:30 PM, Dietary Clinical Manager reported after reviewing his records, there was no dietary reason for Resident #16 to develop pressure ulcers. In an interview, on 2/23/17 at 10:30 AM, DON B was asked how a resident should be treated if they wanted to be awake at night and sleep during the day, and she said staff should accommodate the resident's schedule, not the other way around. When asked, What about meals?, DON B replied, We can keep their meals in the refrigerator and heat them up when they want to eat. In a telephone interview, on 2/23/17 at 2:25 PM, Physician JJ reported she was unaware Resident #16 had developed pressure ulcers on 2/03/17. Review of Resident #16's Skin Care Plans, revealed a Care Plan entitled Actual impaired skin integrity - pressure injury site: right and left buttock, left lower back - all are Stage 2 was developed 2/09/17 (6 days after the Initial documentation above). The Interventions included: When guest chooses not follow recommended turning & repositioning, explain consequences and continue to attempt to get guest to turn & reposition ., but there was no intervention to elevate heels, perform tissue tolerance, devices to use for positioning, potential encouragement/involvement of family members regarding refusals to turn, or conforming to Resident's sleep/wake schedule to increase cooperation. Resident #2 Based on the Minimum Data Set assessment, dated 12/31/16, Resident #2 was a [AGE] year old minimally cognitively impaired female whose [DIAGNOSES REDACTED]. Based on the Brief Interview for Mental Status Resident #2 scored 11/15 indicating minimal cognitive impairment. Based on the Record of Admission to (facility name) form Resident #2 was admitted to the facility on [DATE]. The care plan Actual impaired skin integrity for Resident #2, dated 1/12/17, included the following interventions; observe for signs and symptoms of infections related to area, measure area weekly and document it's characteristics in skin record, refer to potential for skin impairment care plan for interventions. The Potential for impaired skin integrity care plan included the following interventions; assist to reposition in chair as needed-observe for sliding down, provide extensive assist to reposition frequency and as needed, pressure reduction mattress and wheelchair cushion, float heels while in bed and conduct weekly head to toe assessments and document/report abnormal findings. There were no interventions addressing how long Resident #5 should be up in the wheelchair putting pressure on the coccyx wound. The Nursing Care Card used by staff for resident care, dated 1/22/17, reflected the intervention lay down following meals as allowed r/t (related to) falls (fall 1/22/17). Wound measurements from the hospital Wound Care Assessment for Resident #2, dated 12/23/16, reflected the stage 4 sacral/coccyx wound measured 10 cm long by 8 cm wide and 4 cm deep with 2 cm undermining (wound continues under the top layer of tissue) at 10-12 o'clock. The wound bed had 90% granulation tissue and 5% slough (dead tissue) with the coccyx bone exposed. The left heel stage 4 wound measured 5 cm by 4 cm by 0.5 cm with 0.5 cm undermining at 12 o'clock. The wound bed was 95% granulation tissue and the heel bone was exposed. No facility wound measurements or assessments of the wounds were provided as of 5:00 PM on 2/23/17 except the wound clinic Nurse Practitioner (NP) WW's assessment dated [DATE], 8 weeks after the resident was admitted . The comments section of the Administration Record (AR), dated 12/1/16-12/31/16, reflected on 1/11/17 at 3:35 PM Dressing done. Per (NP WWs name) at Wound Center, okay to use [MEDICATION NAME] AG (silver) sheets until rope available. There was no documentation of the assessment of the wound during the clinic visit on 1/11/17. On 2/23/27 at 3:00 PM NP WW confirmed the 2/13/17 documentation of Resident #2's wounds was the only documentation provided to the facility. On 2/13/17 NP WW documented the wounds as follows; 1) sacral stage 4 pressure injury measuring 8.8 cm by 8.8 cm by 2.7 cm with no undermining and exposed bone. The wound bed had 25% slough and 76-100% bright red granulation, a large amount of serosanguinous (blood and serum) drainage and a mild odor. Debridement of the slough was performed with no change in the wound measurements. 2) The left heel wound was classified as a stage 3 pressure injury measuring 3.7 cm by 3.1 cm by 0.1 cm with no undermining. The wound bed had 1-25% yellow slough and 51-75% pink granulation with moderate serosanguinous drainage. Both wounds were smaller than when last measured at the hospital on [DATE]. On 2/15/17 at 11:30 AM dressing change and wound observations were made of the coccyx and left heel for Resident #2 in her room with Licensed Practical Nurse (LPN) OP and Certified Nursing Aide (CNA) Cc. The left heel wound was triangle shaped and the wound bed was approximately 75% covered with yellow slough and 25 % red tissue. The coccyx wound bed was beefy red with exposed bone visible. Resident #2's right heel had a small dark blue/purple area approximately 0.5 cm by 1.0 cm surrounded by dry scaly skin. CNA Cc stated he had not seen the dry skin on the heel when he cared for the Resident in the past. LPN OP stated she had not worked the B Unit in 2 months and was not aware of any right heel issue for Resident #2. The admission physician orders [REDACTED]. The AR, dated 12/1/16-12/31/16, reflected the coccyx dressing was documented as completed twice daily starting 11:13 PM on 12/24/16 through the evening shift on 12/31/16 except the evenings of 12/25/16 and 12/29/16 where there was no documentation the treatment was completed. The the wet to dry coccyx dressing continued until 1/9/17 when it was changed to packing with [MEDICATION NAME] AG and an occlusive cover with Allevyn every other day, based on the AR dated 1/1/7-1/31/17. There was no documentation the coccyx dressing was done on the evening shift on 1/7/17 and 1/8/17, the day and evening shift on 1/9/17 and 1/13/17. In addition, the coccyx dressing was completed a day late on 1/30/17, when it should have been done on 1/29/17. The treatment was again a day late on 2/6/17 and 2/13/17 based on the AR dated 2/1/17-2/28/17. There was no explanation on the AR as to why the treatments were not done according to the physician orders. The AR, dated 1/1/7-1/31/17, reflected the left heel wound treatment was changed on 1/9/17 to [MEDICATION NAME] AG to the wound bed with an Allevyn occlusive cover 3 times a week. Resident #5 Based on the Minimum Data Set (MDS) assessment, dated 11/17/16, Resident #5 was a [AGE] year old moderately cognitively impaired female whose [DIAGNOSES REDACTED]. with behavior disturbance, paranoid delusions, history of a stroke with leg weakness, a heart rhythm disturbance [MEDICAL CONDITION], anxiety and depression. Based on the Brief Interview for Mental Status (BIMS) in the above MDS Resident #5 scored 8/15 indicating moderate cognitive impairment. The Braden pressure wound risk assessments, dated 10/19/16, 12/27/16 and 1/16/17, were scored at 15, 14, 15 respectively indicating a moderate risk for pressure wound development for Resident #5. Review of the nutritional assessments and serial weights reflected Resident #5 had not been eating well and had a slow/steady weight loss from 118 pounds in 3/2016 to 106.4 pounds in 10/2016 and 100 pounds in 1/2017 despite the use of protein and calorie supplements. laboratory results dated [DATE] reflected decreased total protein level of 5.9 gm/ml (normal range 6.4-8.3 gm/ml) and an [MEDICATION NAME] (a protein) level of 3.2 gm/ml (normal range 3.4-5.0 gm/ml). Protein is required to maintain skin integrity and heal wounds. On 2/15/17 at 10:00 AM Resident #5's left heel wound was observed during a dressing change performed by Licensed Practical Nurse (LPN) MN. The wound was approximately 4.0 cm by 3.5 cm by 0.1 cm with a clean wound bed. The upper 1/3 was pink and the lower 2/3s was pale pink. There was no drainage or odor. Resident #5 stated there was pain in the heel depending on how she lay in the bed but the pain medication was effective. On 2/16/17 at 4:20 PM a superficial stage 2 wound was observed on the upper left buttock to the left of the coccyx (tail bone) approximately 0.5 cm by 0.8 cm with no depth. There was no dressing on the wound. Based on the nursing progress note dated 2/16/17 Resident #5 had declined to have the duoderm ([MEDICATION NAME] adhesive/protective dressing) dressing applied. A duoderm dressing had been observed over the wound on 2/15/17 at 9:45 AM. No excoriation (red with small open areas) on the buttocks was observed. The care plan related to the potential for skin breakdown for Resident #5, dated 6/6/16 and reviewed 9/8/16, reflected the intervention conduct weekly head to toe skin assessments, document and report abnormal findings to physician (6/6/12) and Heelift boot to LLE (left lower extremity) at all times (12/21/16). The care plan actual impaired skin integrity related to bilateral pressure ulcers on heels, dated 10/27/16, reflected the intervention Measure area weekly and document it's characteristics in skin log. Based on the Weekly Skin Assessment documentation completed by a nurse Resident #5 did not have any issues identified with her heels on 10/9/16, 10/16/16 and 10/30/16. The entries dated 11/6/16 and 11/13/16 had the box for Has existing checked and both heels and the right calf were circled on the body picture. There was no additional documented skin assessment until 11/27/16 (2 weeks later) where only the left heel was circled as an existing issue. The left heel was also documented as existing on 12/22/16, 12/25/16 and 1/8/17. However, Resident #5 was in the hospital from 12/23/16-12/27/16. There was no Wound and Skin Condition Record provided For Resident #5 prior to 12/27/16. The first description of Resident #5's heel issues was by Nurse Practitioner (NP) WW on 10/20/16 in the Visit Report where the right heel was described as a stage 1 (intact skin with non-blanchable (pressure on an area does not cause the area to turn white and returns to normal when the pressure is released indicating decreased circulation) redness of a localized area) pressure wound measuring 0.3 cm long by 0.3 cm wide. The left heel was also described as a stage 1 pressure wound measuring 1.3 cm long by 2.7 cm wide. A border foam dressing was prescribed for both heels and was to be changed 3 times a week. In addition, an air mattress, heel protectors (not a pressure relieving product) and elevating heels off the bed was also prescribed. The next documentation of the heel wounds was on 11/14/16, five weeks later, by NP WW in the Visit Report. The right heel condition has declined to a stage 2 open wound measuring 0.6 cm long by 0.7 cm wide by 0.1 deep with 76-100% yellow slough (dead tissue). The left heel condition has declined to a stage 2 open wound measuring 1.9 cm long by 2.5 cm wide by 0.1 deep with 76-100% yellow slough (dead tissue). The treatment and interventions remained the same. The next documentation was 2 weeks later on 11/28/16 by NP WW in the Visit Notes. The left heel wound was slightly larger measuring 1.8 cm by 3.1 cm by 0.1 cm with 1-25% of the area covered with slough and the remainder of the wound had bright red granulation tissue which indicated healing. The treatment was changed to applying collagen (a moisturizer) to the wound bed and covering it with a foam dressing 3 times a week. There was no documentation related to the right heel. No documentation of the wound was found for another 21 days until NP WW assessed the wound on 12/19/16 in the Visit Report. The left heel wound had worsened and measured larger at 3.0 cm by 3.2 cm by 0.1 cm with 51-75% coverage with black eschar (hard dead tissue) and 1-25% yellow slough. The wound bed was not visible. The treatment was changed to Iodosorb (an anti bacterial gauze) to the wound and a gauze wrap. A Heelift boot (foam boot with the heel area open to reduce pressure on the wound) to the left foot was provided on 12/21/16. There was no documentation related to the right heel wound. There was no additional documentation of either heel wound until 12/27/16 when Resident #5 returned from a 4 day hospital stay (12/23/16-12/27/16). The Nursing Admission Assessment and the Wound and Skin Condition Record, dated 12/27/16 and signed by Registered Nurse (RN)Aa, reflected the left heel wound was larger and measured 3.0 cm by 4.0 cm with 75% coverage with dark tissue and 25% red wound bed. The same documents reflected the right heel had a yellow crusty area measuring 2.5 cm by 2.0 cm. The buttocks were noted to be excoriated. NP WW evaluated the left heel on 12/29/16 based on the Visit Report. The left heel wound measured 2.1 cm by 2.4 cm by 0.1 cm (smaller) and 51-75% pink granulation tissue. The new treatment ordered was Xeroform (an antibacterial gauze) to the wound bed and cover with gauze. The difference in the size of the wound from 12/27/16 to 12/29/16 could be explained by 2 different nurses measuring the wound, the wound care NP WW and facility RN Aa. The Wound and Skin Condition Record reflected the left heel measurements were the same on 12/31/16 then increased to 4.0 cm by 3.0 cm by 0.1 cm on 1/7/17 as measured by LPN TT. The wound bed was described as yellow (slough). Resident #5 was admitted to Hospice care on 1/5/17 and the Wound Clinic services were discontinued. Based on the Wound and Skin Condition Record wound measurements by the facility staff continued every 3-10 days (1/16/17, 1/23/17, 1/30/17, 2/5/17, 2/15/17 and 2/18/17) with the wound remaining relatively the same size until 2/18/17 when it measured smaller at 3.6 cm by 3.5 cm (no depth was measured). The wound bed progressed from yellow to pink on 2/15/17 and 2/18/17. No description of the wound was documented on 1/23/17 and 2/5/17. There was no facility assessment of the right and left heel pressure wounds for Resident #5 prior to NP WW's assessment on 10/20/16. NP WW did not see the wounds again until five weeks later on 11/14/16 when the condition of both heels had declined from intact non-blanchable skin to open wounds. There was no documentation provided of the condition of the heels within those 5 weeks. The next two assessments by NP WW were 2 and 3 weeks apart with no facility documentation between the visits. The right heel wound was not documented after 11/14/16. There was no documentation related to the buttocks excoriation after it was identified on 12/17/16. The care plan for Resident #5 was not followed. There was no evidence the facility investigated the potential cause of the heel injury to prevent further injury. On 2/16/17 at 3:20 PM Unit Manager LPN N stated he thought Resident #5's heel wounds had been related to ill-fitting shoes but there was no documentation of this issue and the care plan did not address the use of shoes.

This citation pertains to MI 4705. Based on observation, interview and record review the facility failed to ensure that neuro checks and orthostatic blood pressure were assessed after a fall for 1 resident (#9), the storage and use of the wheelchair passenger safety restraints were used to secure a wheelchair in the facility van according to manufacturer's recommendations and proper assessment and treatment of [REDACTED].#21), and documentation was provided that falls were thoroughly investigated, root cause determined and the care plan updated for 1 resident (#5) and out of 9 evaluated for falls from a total sample of 24 resulting in multiple injuries, failure to determine the root cause and the potential for death. Findings include: Resident #9 According to, Long Term Care Clinical Pearls, Powered by HCPro's Long-Term Care Nursing Library, [DATE], 3. Perform frequent neurologic assessments every: 15 minutes for two hours, 30 minutes for two hours, 60 minutes for four hours, eight hours for 16 hours, eight hours until at least 72 hours have elapsed and resident is stable. 4. Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength. According to the facility's Identification Summary, Resident #9 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (resident assessment, dated [DATE], reflected that Resident #9 had some memory problems, required the assist of 2 staff persons for bed mobility, transfers and toileting; 1 staff person for walking with her walker, dressing, eating, hygiene and bathing, had a urinary catheter and was frequently incontinent of bowel. According to a facility incident report, dated [DATE] at 10:30 p.m., Resident #9 was heard calling for help and observed on the floor near her bathroom. Resident #9 was documented as stating she was, going to the restroom and became dizzy. Despite this, no orthostatic blood pressure was checked. The incident report records failed to reflect whether Resident #9 hit her head, but Regional Nurse Consultant Bb was unable to locate documentation that neuro checks were completed after the fall. I recall they were done, Nurse Bb said. It was eventually determined that Resident #9 fractured her left hip when she fell . Resident #21 According to, Diseases: Causes and [DIAGNOSES REDACTED]. The real danger lies in possible spinal cord damage .The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage. According to, Diseases: Causes and [DIAGNOSES REDACTED]. The real danger lies in possible spinal cord damage .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. According to the facility's Identification Summary, Resident #21 was a female in her eighties, admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. According to the Minimum Data Set (resident assessment), dated [DATE], Resident #21 had good memory, made her own decisions, required the assist of 1 staff person for dressing, set up of meals and hygiene; the assist of 2 staff persons for transfers, bed mobility, bathing and toileting; propelled her personal power wheelchair; had decreased strength and movement of both arms and legs and contractures of both hands. According to the facility's incident report, dated [DATE], at approximately 3:00 p.m. Resident #21, flipped over in chair in van on her way to a doctor's appointment. The report reflected that the wheelchair seat belt was fastened, the wheelchair, itself, was locked in position, and the safety belts in the van was secured to the wheelchair. The van driver reported that he was turning into another road when the chair tipped over and Resident #21 fell out. When asked, Resident #21 said that she was OK. The report reflected that the driver assisted Resident #21 back into her chair. The physician, with whom Resident #21 had the appointment, assessed and had her injuries dressed. Upon return to the facility, Resident #21 was noted to have a hematoma to the right and left forehead, a skin tear to the right forearm and wrist and bruising to the right elbow. According to an unsigned, undated document in the incident report packet, I got the chair from underneath her. Rolled her over. Notice a skin tear (unknown word) the right forearm. Went into her Doctors office and had them help me get her Back into her chair .The chair was lock down properly. Had to unstrap the chair before I moved it. The intervention was to transport Resident #21 in the van in a manual wheelchair, which she refused to do. According to a nurse's note, dated [DATE], the wheelchair was, again, documented as flipping over in the van. On [DATE] at 8:30 a.m., Van Driver SS was interviewed and an observation of the demonstrated reenactment of the safety belts used in the facility van was made. The back of the van had 2 areas for wheelchairs. Eight seat belts were observed lying on the floor, and 2 chest/lab belts, similar in design to those used in the front seat of a car were hanging on the back doors and on the floor of the van. In demonstration, Driver SS showed how the four belts were wrapped/fastened to the areas beneath the seat of Resident #21's power wheelchair. When asked about the chest/lap belts on the back doors of the van, Driver SS said he was told by the previous bus driver, who no longer worked at the facility, that those particular safety belts were not needed if the resident wore a fastened lap belt in their wheelchair. When asked to describe what happened that day, Driver SS said that he had to swerve into another lane because another driver suddenly changed lanes in front him. Resident #21 fell over the armrests of her wheelchair to the floor of the van. The wheelchair remained right there in the restraints, Driver SS said. I asked her if she hurt anywhere and she said no. I made sure she didn't have a broken neck and placed a blanket under her head to make her as comfortable as possible. I called the nursing home and they said to continue on to the doctor's appointment. A tech met me in the parking lot and they helped get her back into the wheelchair. When asked how he made sure there was no head injury, Driver SS said that he checked her pupils. When asked what that meant, he said he checked that they were the same size and that she could follow his moving finger with her eyes. When asked how he ensured that she did not have a broken neck, Driver SS said that she denied pain. When asked if he placed a cervical collar on her, Driver SS said that he did not. When asked if he was, now, using the chest/lap belts hanging from the back of the van doors, Driver SS said that he was not because they had decided the reason she fell was because Resident #21 sat up so high in her power wheelchair; she used 2 wheelchair cushions in the seat of her power wheelchair and was top heavy. They wanted her to use a manual wheelchair in the van, but she refused. When asked, Driver SS said that his nurse's aide certification was up to date. A review of the, User Instructions for the restraints in the facility van, reflected the following: A. Secure Wheelchair. B. Secure Passenger. 1. Attache Lap Belt. 2. Attach Shoulder Belt. Under, Warning: Never rely on wheelchair's lapbelt or a postural support belt unless properly approved & crash tested . Under Maintenance & Care, Always keep belts clean and off the floor by using a storage device . On [DATE] at approximately 5:00 p.m., Administrator A was advised of this surveyor's concerns. When asked if she read the manufacturer's instructions on the seat belt usage in the facility van, Administrator A said that she had not. Resident #5 Based on the Minimum Data Set (MDS) assessment, dated [DATE], Resident #5 was a [AGE] year old moderately cognitively impaired female whose [DIAGNOSES REDACTED]. Based on the Brief Interview for Mental Status (BIMS) in the above MDS Resident #5 scored ,[DATE] indicating moderate cognitive impairment. According to the above MDS Resident #5 required staff assistance with transfers, toileting, bathing, dressing and propelling in her wheelchair. Based on the above MDS and fall risk assessments dated [DATE] and [DATE] Resident #5 had a history of [REDACTED].=10 or greater) on both dates. Resident #5's care plan related to fall risk, dated [DATE] and last reviewed [DATE], reflected the following interventions; lock wheelchair prior to transfers ([DATE]), bed against the wall for safety and mobility ([DATE]), bed alarm ([DATE]), chair alarm ([DATE]) and extensive/maximum assist ,[DATE] staff for transfers ([DATE], also on Activity of Daily Living care plan since [DATE]). Review of the Nursing Care Card, used by staff when giving care and kept inside the closet door in the resident's room, dated [DATE], updated [DATE] and [DATE] and in use on [DATE], reflected the following interventions; bed and chair alarms and ,[DATE] person assists for transfers and wheelchair movement. The interventions When up in w/c (wheelchair), Pt (patient) to be in common areas, not alone in room and Dycem (non-skid fabric) to w/c seat were undated and the updated date on the right side of the card of [DATE] matched the two interventions added to the fall risk care plan on [DATE]. It was unclear when the two interventions were added to the Nursing Care Card, dated [DATE]. The facility Incident Report for Resident #5, dated [DATE] at 7:30 AM, reflected the Resident was found on the floor next to her bed without injury and the wheelchair alarm sounding. When asked what she (Resident #5) was trying to do she stated What does it look like? The incident was reviewed by Unit Manager (UM) Licensed Practical Nurse (LPN) N on [DATE] and the new intervention was to place Resident #5 in common areas where she would be visible to staff when she was in her wheelchair. Review of Resident #5's care plan related to fall risk, dated [DATE] and last reviewed [DATE], reflected the interventions When up in w/c (wheelchair), guest to be in common areas, not to be left in room alone and Dycem to wheelchair were dated [DATE]. Resident #5 was admitted to the hospital from [DATE] - [DATE] for treatment of [REDACTED]. Based on the nursing progress note in the electronic medical record, dated [DATE] at 1:39 PM Resident #5 was found on the floor at 9:30 AM without injury. There was no Incident Report or investigation available during the survey related to this fall. On [DATE] at 9:00 AM Director of Nursing (DON) B stated the Incident Report and investigation could not be found. DON B stated the fall had been investigated and discussed at the morning Interdisciplinary Team meeting and recorded on the Incident Monitoring form. Review of the Incident Monitoring form for Resident #5 reflected the first entry was [DATE] 7:30 AM Room. There was no indication what the incident was or what the intervention was to be if any. The next entry was [DATE] 7:15 PM Room take to common area when up in w/c. There was no Incident Report, nursing note or investigation for that date/time. The entry for [DATE] reflected Room with no time, description of the incident or interventions. The 24-hour Report Follow-Up form for Unit C where Resident #5 resided, dated [DATE], reflected fell yest (yesterday) with no additional information related to the fall. On [DATE] at 9:37 AM LPN TT stated that on [DATE] Resident #5 was found on the floor in her room sitting on her bottom facing the bed with her wheelchair behind her. LPN TT stated their was no injury observed for Resident #5 and the Resident had been in the hallway outside her room before being found on the floor in her room. LPN TT stated she had completed an Incident Report on the same date and put it in UM LPN N's mailbox on the wall of the Unit C nursing station. On [DATE] at 9:37 AM LPN TT stated that on [DATE] the most recent date on the Nursing Care Card for Resident #5 was [DATE] and there was no instruction to keep Resident #5 in common areas where she was visible to staff when she was in her wheelchair. LPN TT stated she had not received any verbal communication related to the above intervention before [DATE]. At 9:50 AM and 10:10 AM on the the same day Certified Nursing Aides (CNA) UU and VV respectively confirmed LPN TT's statement related to the date and interventions on the Nursing Care Card for Resident #5. On [DATE] at 10:10 AM CNA VV stated that on [DATE] after breakfast Resident #5 was seated in her wheelchair in the hallway facing the doorway of her room when the Resident's vital signs (blood pressure, pulse, respirations and temperature) were obtained by CNA VV. CNA VV stated she then went across the hall to get vital signs from another resident and told Resident #5 she would be back to help her to bed even though Resident #5 had not asked to go to bed. CNA VV stated while she was obtaining the vital signs of the resident across the hall she heard an alarm and saw Resident #5's empty wheelchair slowly rolling away from the Resident's bed and observed her on the floor in front of the bed when she (CNA VV) entered the room. CNA VV stated she looked at the Resident's Nursing Care Card after the fall and the last date on it was [DATE] with no instructions to leave Resident #5 in a common area visible to staff when she was in her wheelchair. On [DATE] at 9:50 AM CNA UU stated that on [DATE] after breakfast Resident #5 had asked a Hospice Aide to take her to her room but CNA UU had instructed the Hospice Aide to leave Resident #5 in the hallway. CNA UU stated when she told Resident #5 she would be back to help her after she completed a task (didn't recall what it was or how long she was gone) the Resident was facing the doorway to her room with the foot pedals of the wheelchair at the doorframe. CNA UU stated when she returned she was told Resident #5 was on the floor in her room then observed Resident #5 sitting on the floor facing her bed. CNA UU stated Resident #5 told her I was going to bed. CNA UU stated she wrote a statement as did CNA VV and LPN TT then all three staff were disciplined for not following the Nursing Care Card instructions to keep Resident #5 in a common area visible to staff when she was in her wheelchair. CNA UU stated the Nursing Care Card in use on [DATE] was dated [DATE] with no instructions to leave Resident #5 in a common area visible to staff when she was in her wheelchair. Based on the above interviews Resident #5's Nursing Care Card had not been updated to reflect the need for increase supervision while up in the wheelchair as prescribed after her fall on [DATE]. In addition, the same Nursing Care Card, dated [DATE], was in use on her readmission on [DATE] following her hospitalization for stroke-like symptoms and pneumonia.

Based on observation, interview and record review, the facility failed to assure 4 of 7 residents reviewed for unnecessary medications were free from potentially unnecessary antipsychotics (Resident #5, 16, 17, 33), from a total of 24 sampled residents and 13 supplemental residents, resulting in increased risk of physical and psychosocial harm. Findings include: Resident #16 According to the MDS, dated [DATE], Resident #16 was readmitted to the facility on [DATE], had a BIMs of 10 (Brief Interview for Mental Status/moderate cognitive impairment), needed assistance with bed mobility, and he had diagnosed including: [DIAGNOSES REDACTED]. On 2/15/17 at 9:40 AM, Resident #16 was observed alert, laying on his back in bed with a flat affect on his face. In an interview, on 2/15/17 at 10:55 AM, Nurse Aide S reported he worked full time and was always assigned to Resident #16. Nurse Aide S said Resident #16's confusion getting worse for the past month), that he could not sit up very well, and could not reposition himself in bed, that Resident #16 at all of his meals, but wasn't drinking as well as he used to. Review of Resident #16's MARs/Medication Administration Records, [MEDICATION NAME] (antipsychotic medication - see below) 0.5 mg one tab at bedtime was ordered started on 1/20/17, and had not been discontinued as of 2/15/17. According to Rx.com, 2017, side effects of [MEDICATION NAME] include, Drowsiness, dizziness, lightheadedness, drooling, nausea, weight gain, or tiredness may occur .To reduce the risk of dizziness and lightheadedness, get up slowly when rising from a sitting or lying position .Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects .Tell your doctor right away if you have any serious side effects, including: difficulty swallowing, muscle spasms, shaking (tremor), mental/mood changes (such as anxiety, restlessness), signs of infection (such as fever, persistent sore throat) .This medication may infrequently make your blood sugar level rise, which can cause or worsen diabetes. Tell your doctor immediately if you develop symptoms of high blood sugar, such as increased thirst and urination. If you already have diabetes, be sure to check your blood sugars regularly. Your doctor may need to adjust your diabetes medication, exercise program, or diet .This drug may also cause significant weight gain and a rise in your blood cholesterol (or triglyceride) levels. These effects, along with diabetes, may increase your risk for developing [MEDICAL CONDITION]. Discuss the risks and benefits of treatment with your doctor .[MEDICATION NAME] ([MEDICATION NAME]) may rarely cause a condition known as tardive dyskinesia. In some cases, this condition may be permanent. Tell your doctor immediately if you develop any unusual/uncontrolled movements (especially of the face, lips, mouth, tongue, arms or legs). <http://www.rxlist.com/[MEDICATION NAME]-drug/consumer-side-effects-precautions.htm> On 2/22/17 at 4:15 PM, Surveyor requested from DON/Director of Nursing B, for all behavior documentation, signed informed consent, risk benefit analysis, and physician progress notes [REDACTED]. On 2/23/17 at 9:10 AM, DON B reported informed consent for [MEDICATION NAME] was not obtained from Resident #16, who was his own responsible party, and his Primary Contact, had not been contacted regarding the administration of the antipsychotic medication. DON B stated [MEDICATION NAME] was ordered because of yelling and resisting care, but there was no documentation of this behavior in Resident #16's medical record, nor any documentation of trials of non-pharmacological interventions. DON B said, The only documentation of behaviors is in physician progress notes [REDACTED]. When asked why Resident #16 was placed on [MEDICATION NAME] if he there were no documented behaviors, DON B replied, I know. I agree .last night (2/22/17) at 4:00 PM, LPN T called Granddaughter FF and told her what happened. Surveyor asked if Physician JJ had been notified of the medication errors, and lack of documented evidence for the use of [MEDICATION NAME], and requested LPN T's documentation from 2/22/17. DON B said, I don't know what (LPN T) told the doctor .I don't think she wrote any (Nursing Progress) notes. Review of Physician JJ's Progress Notes, dated 1/20/17, revealed, Pt (Resident #16) noted to have some hallucinations per roommate. Physician JJ did not document the Risk verses Benefit of having Resident #1 take an antipsychotic, nor any discussion with Resident #16 regarding such. According to the MDS, dated [DATE], Resident #32 (Resident #16's roommate) scored 15 out of 15 (no cognitive impairment) on the BIMs and had no psychiatric diagnoses. On 2/23/17 at 9:30 AM, Resident #32 was asked if he had any knowledge of Resident #16 seeing things that were not present, and he replied, Sometimes, when he's dreaming, he thinks he's back at the store, and he yells out, but he's just dreaming. He's okay when he wakes up a little. I'm much more worried about the spells he's been having. His eyes roll back, and he passes out. That's happened a couple of times lately. Its really scary. Review of a Nursing Progress Notes, dated 1/19/17 at 11:52 revealed, .non responsive episode in the am, d/c'd (discontinued) losartan (blood pressure medication) due to consistent low blood pressures .101/67 . Review of Resident #16's Blood Pressure Log and MARs/Medication Administration Records revealed no entries between 1/20/17 - 2/19/17. Blood Pressure documentation in the Nursing Progress Notes was done on only 3 times in the next 30 days after Losartan was discontinued (1/27/17, 2/02/17, 2/10/17). A blood pressure reading documented on the Blood Pressure Log on 2/21/17 was 95/56. In an interview, on 2/23/17 at 9:50 AM, RN R, who was assigned to Resident #16 reported he had never seen Resident #16 hallucinate, and he worked full time, assigned to Resident #16 since 1/25/17. When asked if he monitored Resident #16 for antipsychotic side effects or if the monitoring of side effects was listed on the Treatment Record, RN R said, No, but that's a good idea. On 2/23/17 at 10:01 AM, Surveyor unsuccessfully attempted to reach Granddaughter FF via phone. On 2/23/17 at 10:08 AM, Surveyor interviewed LPN T via phone. LPN T reported she called Physician JJ on 2/22/17 and, She said to continue to monitor. Upon further inquiry, LPN T revealed she just made sure the medication ([MEDICATION NAME]) was in the (medication cart) drawer, and did not tell Physician JJ there was no documentation or signed informed consent to support the use of [MEDICATION NAME] for Resident #16. When asked if she knew of any behaviors, LPN T said she never documented any behaviors, and said, He is just defiant with the girls sometimes when they want to transfer him .He was staying up all night long. Yes, he refused to get up because he was tired. As long as he's up for meals, he can sleep if he wants to. [MEDICATION NAME] was given so he would sleep at night. I think he has sundowners (see below), and wants to stay awake at night, and sleep during the day. When asked if she had any knowledge of Resident #16 experiencing bad dreams, she replied, Yes, he living in them like it's real. No hallucinations that I'm aware of. He's okay when he comes to (wakes up). According to WebMD, 2017, When you are with someone who has [MEDICAL CONDITION], you may notice big changes in how they act in the late afternoon or early evening. Doctors call it sundowning, or sundow[DIAGNOSES REDACTED]. <http://www.webmd.com/alzheimers/guide/manage-sundowning#1> In an interview, on 2/23/17 at 10:30 AM, DON B was asked how a resident should be treated if they wanted to be awake at night and sleep during the day, and she said staff should accommodate the resident's schedule, not the other way around. When asked, What about meals?, DON B replied, We can keep their meals in the refrigerator and heat them up when they want to eat. Review of Resident #16's Behavior Data and Analysis showed only former SW/Social Worker HH made an entries in December 2016 and January 2017. On 12/21/17, SW's HH notes revealed No documented behaviors. On 2/15/17, SW MM documented No documented behaviors. Review of all of Resident #16's Nursing Progress Notes since 12/01/16 revealed no documented behaviors. According to a Behavioral Health physician progress notes [REDACTED].There are no recent documented mood or behavioral disturbances .His demeanor is cooperative and pleasant .He presents non-distressing delusional material. He presents a calm and euthymic (normal, non-depressed, pleasant) mood. It is noted that PCP (Physician JJ) started [MEDICATION NAME] on 1/20/17 for hallucinations .Number of psychiatric hospitalization s: 0 .[MEDICAL CONDITION] with behavioral disturbance .Risk vs. Benefit Analysis. The risks of [MEDICATION NAME] therapy include risks for cardiovascular and [MEDICAL CONDITION] events, EPS symptoms, and mortality. However, the medication benefits such as improved quality of life by a decrease in distressing delusions, anger and agitation outweigh any of the aforementioned risks .Continue to monitor for medication side effects. Continue to monitor and document behavioral disturbances and mood problems . In a telephone interview, on 2/23/17 at 11:26 AM, NP GG was asked if she had noted any behaviors for Resident #16 to justify the risk of the use of [MEDICATION NAME], and she replied, It's a difficult job. I do the best I can. I only see a resident every 2 or 3 months, there are so many. It takes me 2 hours and 15 minutes to (travel) there (to the facility). Everything I do is so criticized and monitored. There are no documented behaviors. The Optimum System (EMR/Electronic Medical Record) system (the facility's EMR) takes me hours to find an individual behavior. There is such a high turn over of Social Workers and Unit Managers, the ones there are all brand new (making it difficult to obtain accurate information about residents). The things I have tried to implement don't get done. I've asked many times to have more increase in behavior log entries - they are quite often empty, or to put behavior charting under Behavior Monitoring in (EMR) rather than mixed in a Nursing Note. Its also difficult when more than one person is ordering psych meds. I think its better for one person to do it, then have a team meeting to see if there is enough data to justify the medication. When asked why she continued or did not recommend stopping the [MEDICATION NAME] for Resident #16, NP GG replied, I trust (Physician JJ's) judgement. In a telephone interview, on 2/23/17 at 2:25 PM, Physician JJ was asked why she documented on 1/20/17 that Resident #16 was having hallucinations, what non-pharmacological approaches had been attempted, and why [MEDICATION NAME] was ordered. Physician JJ' did not answer the questions presented and said, I don't know. I haven't been there for a couple of weeks. He was difficult. I will look at it next week. It's hard to find vital signs and labs. I have to get someone to help me - get someone to pull it up (from EMR). Physician JJ stated he was unaware Resident #16 was his own responsible party, unaware he had been awake at night which may have caused resistance to getting out of bed during the day, and was unaware Resident #16 had developed pressure ulcers on 2/03/17. According to the FDA/US Federal Food and Drug Administration, 2013, FDA is requiring the manufacturers of conventional antipsychotic drugs to add a Boxed Warning and Warning to the drugs' prescribing information about the risk of mortality in elderly patients treated for [REDACTED]. Antipsychotic drugs are not approved for the treatment of [REDACTED].Physicians who prescribe antipsychotics to elderly patients with dementia-related [MEDICAL CONDITION] should discuss this risk of increased mortality with their patients, patients' families, and caregivers . <https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm 0.htm> Resident #17 and #33 According to the MDS, dated [DATE], Resident #17 was admitted to the facility on [DATE] and had moderate cognitive impairment, and diagnosed including: [DIAGNOSES REDACTED]. According to the MDS, dated Resident #33 was admitted to the facility on [DATE], and had diagnoses of [MEDICAL CONDITION], urinary tract infection, and [MEDICAL CONDITION]. On 2/23/17 at 11:45 AM, SW/Social Workers LL and MM presented a list of residents currently taking antipsychotic medications (32 of the facility's 26 residents with a [DIAGNOSES REDACTED].#17 (ordered on [DATE] by Physician/Medical Director XX), and [MEDICATION NAME] (antipsychotic medication) for Resident #33 (ordered by Physician XX on 1/26/17). These medications may have been declined, and deemed unnecessary medications by the responsible parties. Resident #5 Based on the Minimum Data Set (MDS) assessment, dated 11/17/16, Resident #5 was a [AGE] year old moderately cognitively impaired female whose diagnoses included Alzheimer's dementia with behavior disturbance, paranoid delusions, history of a stroke with leg weakness, a heart rhythm disturbance [MEDICAL CONDITION], anxiety and depression. Based on the Brief Interview for Mental Status (BIMS) in the above MDS Resident #5 scored 8/15 indicating moderate cognitive impairment. Based on the Medication Administration Record [REDACTED]. According to the same MAR indicated [REDACTED]. Review of Psychiatric Nurse Practitioner (PNP) GG's progress notes dated 6/29/16, 7/1/16, 7/15/16, 7/22/16, 8/1/16, 8/19/16, 9/23/16, 11/6/16 and 1/16/17 reflected the following diagnoses for Resident #5; Alzheimer's dementia with behavioral disturbances, paranoid delusions, depression, anxiety, [MEDICAL CONDITIONS], stomach acid reflux, difficulty swallowing and muscle weakness. There was no documentation of the [DIAGNOSES REDACTED]. Review of the Cumulative [DIAGNOSES REDACTED]. The physician Progress Note, dated 12/20/16, reflected a diagnoses of psychiatric disorder and cognitive deficits. The History and Physical, dated 1/3/17, reflected the [DIAGNOSES REDACTED]. Pharmacist QQ's Consultation Report, dated 11/18/16, reflected Comment: (Resident #5's name) receives an antipsychotic, [MEDICATION NAME], currently listed in (pharmacy provider name) for 'agitation'. Federal nursing facility regulations require that antipsychotic agents be used only with one or more of the following conditions: 1) conditions other than dementia:-[MEDICAL CONDITION], schizo-affective or schizophreniform disorder-delusional disorder-hiccups-[MEDICAL CONDITION]'s Disorder-[MEDICAL CONDITION]-[MEDICAL CONDITION] in the absence of dementia-nausea/vomiting [MEDICAL CONDITION] or its therapy-drug related [MEDICAL CONDITION]/mania (e.g., steroids)-mood disorders (e.g. [MEDICAL CONDITION] disorder, severe refractory depression and/or with psychotic features)-medical illnesses with psychotic symptoms (e.g., neoplastic disease or [MEDICAL CONDITION]) 2) Behavioral or psychological symptoms of dementia (BPSD) 3) Symptoms or behaviors MUST present DANGER to the resident or others AND one or both of the following; a) symptoms are due [MEDICAL CONDITIONS] (auditory, visual, or other hallucination; delusions, paranoia or grandiosity); OR b) care-planned interventions have been attempted, except in an emergency. Recommendation: If current therapy is to be continued, please indicate: 1) The specific diagnosis/indication requiring treatment (listed as 1 or 2 above), AND 2) The symptom criteria or behavior (listed under 3 above) .Physician's Response: the requested documentation has been provided below, please update records accordingly. Documentation: [DIAGNOSES REDACTED]. The form was signed by Resident #5's attending Physician/Medical Director XX on 12/21/16 and no symptoms or behaviors were listed. On 2/16/17 at 3:20 PM Unit Manager (UM) Licensed Practical Nurse (LPN) N stated he thought the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. When asked how a new [DIAGNOSES REDACTED].#5 who had Alzheimer's dementia UM LPN N stated he did not know. Review of the MARs for 12/2016 and 1/2017 reflected Resident #5 was prescribed and received the following antibiotics; [MEDICATION NAME] 1 gm intramuscularly daily from 12/14/16-12/23/16 for a urinary tract infection [MEDICAL CONDITION], [MEDICATION NAME] 50 mg four times daily from 12/20/16-12/23/16 and 12/27/17-1/2/17 [MEDICATION NAME] (irritation of the bladder wall), [MEDICATION NAME] 500 mg daily from 12/27/16-12/31/16 for pneumonia, [MEDICATION NAME] 500 mg on 1/4/17 then 250 mg from 1/5/17-1/8/17 except on 1/7/17 with no [DIAGNOSES REDACTED]. Review of the nursing assessment dated [DATE] at 10:18 AM reflected no urinary complaints and a normal temperature of 97.7 degrees Fahrenheit (F). The assessment at 9:59 PM reflected a normal temperature of 98.2 degrees F and a urinary complaint of frequency of urination. The nursing note dated 12/14/16 at 2:47 PM reflected an order from Physician XX for the antibiotic [MEDICATION NAME] IM for a UTI that was to start the same day and be given for 10 days. The next the nursing note was not until 12/17/16 at 11:32 PM and reflected no urinary pain or burning with urination. Review of laboratory results for a urinalysis completed on 12/11/16 reflected 3+ leukocyte esterase (normal=negative), greater than 100,000 cfu/ml white blood cells (normal=0-3000) and many bacteria (normal=none). The culture and sensitivity results reflected the bacteria escherichia coli at greater than 100,000 cfu/ml and sensitivity (antibiotic would be effective to kill the bacteria) to [MEDICATION NAME]. On 2/23/17 at 4:07 PM the Director of Nursing (DON) B stated there was no infection tracking documentation related to any signs and symptoms of a UTI for Resident #5. The physician progress notes [REDACTED].#5 had .recently been treated for [REDACTED]. The McGeer's Criteria (2012) for [DIAGNOSES REDACTED]. acute pain or difficulty urinating, b. fever or elevated blood white blood count (>14,000 leukocytes or >6% bands or 1500 bands/mm3) and at least 1 of the following urinary tract subcriteria, i. acute side pain or tenderness, ii. suprapubic pain, iii. gross blood in the urine, iv. new or marked increase in incontinence, v. new or marked increase in urgency, vi. new or marked increase in frequency. c. in the absence of fever or elevated blood white blood count, then 2 or more of the following localizing urinary tract subcriteria, i. suprapubic pain, ii. gross blood in the urine iii. new or marked increase in incontinence, iv. new or marked increase in urgency, v. new or marked increase in frequency. 2) One of the following microbiologic subcriteria, a. at least 100,000 cfu/ml of no more than 2 microorganisms in a voided sample, b. at least 100,000 cfu/ml of any number of organisms collected by in-and-out catheter. Resident #5 did not meet the criteria for [DIAGNOSES REDACTED]. Beginning on 12/20/16 at 5:00 AM antibiotic treatment was initiated with [MEDICATION NAME] (Nitrofuradantin) 50 mg four times daily for a UTI and continued for 13 doses according to the MAR, dated 12/1/16-12/31/16. There was no evidence provided of any signs or symptoms exhibited by Resident #5 related to a UTI. In addition, according to the manufacturer in Specialized Long-Term Care Nursing Drug Handbook, 2008, pages 717-719, therapeutic concentrations of [MEDICATION NAME] are not attained in urine of residents with a creatinine clearance of less than 60 ml/min (a measure of kidney function). The manufacturer states the drug is contraindicated for residents with a creatinine clearance of less than 60 ml/min. On 12/19/16 the pharmacy provider calculated Resident #5's creatinine clearance as less than 30 ml/min and stated [MEDICATION NAME] was not recommended for the Resident. Resident #5 received an antibiotic that was not effective in treating the bacteria and was contraindicated based on her kidney function and without evidence of infection. On 12/23/16 a urinalysis performed on a catheterized specimen in the hospital showed no UTI was present. Resident #5 was hospitalized from [DATE]-12/27/16 and treated for [REDACTED]. The discharge physician orders [REDACTED]. Resident #5 received all 5 doses from 12/27/16-12/31/16 based on the MAR indicated [REDACTED]. According to the manufacturer in Specialized Long-Term Care Nursing Drug Handbook, 2008, pages 577-580, dosage adjustments are required for residents with a creatinine clearance of less than 50 ml/min. The manufacturer recommendation for Resident #5's creatinine clearance of less than 30 ml/min is an initial dose of 500 mg daily then 250 mg daily. Based on the physician orders, dated 12/27/16 [MEDICATION NAME] 50 mg four times daily for 7 days for [MEDICATION NAME] was prescribed for Resident #5 on her readmission from the hospital. Based on the MARs dated 12/1/16/-12/31/16 and 1/1/7-1/31/17 Resident #5 received 25 of the 28 doses ordered (1 refusal) between 12/27/16-1/2/17. There was no evidence the facility had addressed the need for a dose reduction of either antibiotic for Resident #5 based on her kidney function. Based on the Creatinine Clearance Calculator Report dated 2/22/17 by DON B Resident #5's creatinine clearance was 33.8 ml/min. Based on the MAR indicated [REDACTED]. There was no [DIAGNOSES REDACTED].early interstitial infiltrates in the right lung base which is consistent with a [DIAGNOSES REDACTED]. Based on the MAR indicated [REDACTED]. Review of the physician order [REDACTED]. The initial [DIAGNOSES REDACTED]. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated 1/25/17, reflected in the client orders section .1/24/16 Hospice Physician Verbal Order Add Bactrim 500 mg tab BID (twice daily) Z (sic, times) 7 days for probable UTI, signs and symptoms of confusion, paranoia, agitation, dark urine and 1/25/17 DC (discontinue) Bactrim order add [MEDICATION NAME] 100 mg bid X (times) 7 days due to sulfa allergy . The 2/1/17 progress notes from two different providers (unreadable signatures) did not address the use of the [MEDICATION NAME] or urinary symptoms for Resident #5. On 2/23/17 at 4:07 PM the DON stated there was no evidence of tracking of signs and symptoms of a UTI for Resident #5. There was no evidence a urinalysis or culture and sensitivity had been done to identify an infection. Resident #5 returned from the hospital 12/27/16 with an indwelling urinary catheter related to [MEDICAL CONDITION]. The McGeer's Criteria (2012) for [DIAGNOSES REDACTED]. At least 1 of the following sign or symptom subcriteria, a. fever, b. either acute change in mental status or acute functional decline, with no alternate [DIAGNOSES REDACTED]. new-onset suprapubic pain or side pain or tenderness, d. purulent (pus) discharge from around the catheter. There was no evidence Resident #5 met the criteria for the [DIAGNOSES REDACTED]. In addition to the issued described above the use of multiple antibiotics put Resident #5 at risk for the development of antibiotic resistance (antibiotics not being effective) and super infections such as [MEDICAL CONDITION] (an intestinal infection causing inflammation of the bowel and severe diarrhea).

Based on interview and record review the facility failed to ensure that 4 of 14 residents reviewed for medications (#2, 3, 16 and 18) from a total of 24 sampled residents were free of significant medication errors resulting in Resident #2 not receiving intravenous (IV) antibiotics as ordered for three doses, Resident #3 not receiving two IV antibiotics as ordered and appropriate care for a central line IV catheter, Resident #16 not receiving 8 doses of an antipsychotic, and not receiving an antibiotic as ordered, and Resident #18 not receiving antibiotics as ordered for three doses, blood pressure and wound treatment medications and appropriate care for a central line IV catheter creating the potential for infection, central line failure, development of medical issues and behaviors related to missed medications. Findings include: Resident #2 Based on the Minimum Data Set assessment, dated 12/31/16, Resident #2 was a [AGE] year old minimally cognitively impaired female whose [DIAGNOSES REDACTED]. Based on the Brief Interview for Mental Status Resident #2 scored 11 out of 15 indicating minimal cognitive impairment. Based on the Record of Admission to (facility name) form Resident #2 was admitted to the facility on [DATE]. Based on the admission physician orders, dated 12/24/16 at 6:46 PM, Resident #2 was to receive the antibiotic [MEDICATION NAME] 600 mg IV every 8 hours for 42 days for treatment of [REDACTED]. Based on the hospital discharge summary and orders dated 12/24/16 the antibiotic had been started in the hospital and was to continue at the facility. The manufacturer recommendation in Specialized Long Term Care Nursing Daily Handbook 2008, pages 216-218, is to give the antibiotic in equally divided doses over a 24 hour period to maintain a steady concentration of the antibiotic in the blood stream for the most effective treatment of [REDACTED]. Based on the Medication Administration Record [REDACTED]. Review of the same MAR indicated [REDACTED]drop ship (send in a delivery before the scheduled evening regular delivery) the medication. There was no documentation on the MAR indicated [REDACTED]. Based on the documentation by Licensed Practical Nurse ST at 1:54 PM on 12/25/16, spoke with pharmacy and on the way stat (immediately), the 1:00 PM dose was not available in the facility, There was no evidence the 1:00 PM dose was given. The scheduled 9:00 PM dose for 12/25/16 was documented as given at 10:38 PM, more than 24 hours after admission to the facility. Resident #2 was placed at risk for worsening of her infection and a delay in wound heeling of her stage 4 left heel and coccyx wounds. Resident #16 According to the MDS, dated [DATE], Resident #16 was readmitted to the facility on [DATE], had a BIMs of 10 out of 15 (Brief Interview for Mental Status/moderate cognitive impairment), needed assistance with bed mobility, and he had [DIAGNOSES REDACTED]. In an interview, on 2/15/17 at 10:55 AM, Nurse Aide S reported he worked full time and was always assigned to Resident #16. Nurse Aide S said Resident #16's confusion getting worse for the past month, that he could not sit up very well, and could not reposition himself in bed, that Resident #16 ate all of his meals, but wasn't drinking as well as he used to. Review of Resident #16's MARs/Medication Administration Records revealed [MEDICATION NAME] (antipsychotic medication - see below) 0.5 mg one tab at bedtime was ordered started on 1/20/17 (about 1 month ago). According to Rx.com, 2017, side effects of [MEDICATION NAME] include, Drowsiness, dizziness, lightheadedness, drooling, nausea, weight gain, or tiredness may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly .To reduce the risk of dizziness and lightheadedness, get up slowly when rising from a sitting or lying position .Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects .Tell your doctor right away if you have any serious side effects, including: difficulty swallowing, muscle spasms, shaking (tremor), mental/mood changes (such as anxiety, restlessness), signs of infection (such as fever, persistent sore throat) .This medication may infrequently make your blood sugar level rise, which can cause or worsen diabetes. Tell your doctor immediately if you develop symptoms of high blood sugar, such as increased thirst and urination. If you already have diabetes, be sure to check your blood sugars regularly. Your doctor may need to adjust your diabetes medication, exercise program, or diet .This drug may also cause significant weight gain and a rise in your blood cholesterol (or triglyceride) levels. These effects, along with diabetes, may increase your risk for developing [MEDICAL CONDITION]. Discuss the risks and benefits of treatment with your doctor .[MEDICATION NAME] may rarely cause a condition known as tardive dyskinesia. In some cases, this condition may be permanent. Tell your doctor immediately if you develop any unusual/uncontrolled movements (especially of the face, lips, mouth, tongue, arms or legs). <http://www.rxlist.com/[MEDICATION NAME]-drug/consumer-side-effects-precautions.htm> While reviewing Resident #16's MARs/Medication Administration Records on 2/22/17 at 4:00 PM, it was revealed: [MEDICATION NAME] (antipsychotic medication) 0.5 mg one tab at bedtime; oral for dementia w (with)/hallucinations. Stated 01/20/17 at 10:41 AM was documented as not administered on 1/20/17, 1/21/17, 1/23/17, 1/24/17, 1/25/17, 1/28/17, 1/29/17, and 1/30/17 (8 doses). On 2/22/17 at 4:15 PM, Surveyor requested from DON/Director of Nursing B, for all Medication Error Reports for Resident #16 since the beginning of 2017. Review of Resident #16's January, 2017 MAR indicated [REDACTED] 1/20/17 - not available 1/21/17 - not available will call pharmacy 1/22/17 - (no note/documented as given on MAR) 1/23/17 - not available 1/24/17 - not available 1/25/17 - called pharmacy, they sent out a 30 day supply on the 20th of jan (sic) 1/26/17 - (no note/documented as given on MAR) 1/27/17 - given 1/28/17 - held, not available 1/29/17 - not available 1/30/17 - held not available Review of Resident #16's February, 2017 MAR indicated [REDACTED]. On 2/23/17 at 9:10 AM, DON B reported informed consent for [MEDICATION NAME] was not obtained from Resident #16, who was his own responsible party, and his Primary Contact, had not been contacted regarding the omissions of administration of the antipsychotic medication. DON B reported there were no Medication Error reports for the omitted doses of [MEDICATION NAME]. On 2/23/17 at 10:08 AM, Surveyor interviewed LPN T via phone. LPN T reported she thought the omitted doses of [MEDICATION NAME] for Resident #16 happened, because insurance won't cover it until the doctor signs the order for it. In a telephone interview, on 2/23/17 at 2:25 PM, Physician JJ stated she was unaware Resident #16 did not receive [MEDICATION NAME] according to his orders. Further review of Resident #16's MARs revealed, [MEDICATION NAME] (antibiotic) 1 gm vial one gm once per day; intramuscular for urinary tract infection was ordered to be started 1/26/17, but was not administered until 1/29/17. Resident #18 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #18 was a [AGE] year of male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #18 had a BIM (assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact, and he required two person physical assist with transfers, toileting, dressing, hygiene, bathing and one person physical assist with locomotion on the unit with use of wheelchair. The MDS reflected Resident #18 had constant pain and used as need pain medications for pain relief. During a Medication Administration Observation on 2/13/17 at 4:05 p.m., LPN (Licensed Practical Nurse) AA reported she was unable to locate Resident #18's Cefpodoxine (antibiotic) for the [MEDICAL CONDITION] in the medication cart. Upon further review it was determined that Resident #18 did not receive the ordered antibiotic and the resident did not receive PICC maintenance on the first 3 days at the facility (2/9/17, 2/10/17, 2/11/17) as per hospital physician transfer orders. In a telephone interview on 2/15/17 at 3:48 p.m. LPN Z reported she cared for Resident #18 on 2/11/17 and identified missing admission medications and treatments from 2/9/17 that had been on the hospital discharge orders but not transcribed correctly at the facility on admission. LPN Z reported LPN BB helped complete the medication error documents for the missing medication that included: [MEDICATION NAME] 100 mg twice daily orally (antibiotic), Potassium 20 meq four times daily orally, Zinc 220 mg daily, urea 40% cream to left lower leg for 3 days, normal saline flush daily for PICC maintenance, and [MEDICATION NAME] flush daily for PICC maintenance. LPN Z reported the admission nurse was new and did not complete the required documents according to the admission check list including no documentation present on the skin assessment (body) including the PICC and reported no care plans competed. Review of the 6 facility documents labeled, Analysis of Adverse Medication Event, dated 2/11/17, provided by Director of Nursing B, revealed Resident #18 had 6 transcription medication errors on 2/9/17 and identified on 2/11/17 by LPN BB. The documents reflected Resident #18 did not receive prescribed medications; [MEDICATION NAME], Potassium (four times daily), Zinc, Urea cream, normal saline and [MEDICATION NAME] for PICC maintenance. The documents reflected the errors were discovered during an admission orders [REDACTED] In an interview on 2/22/17 at 11:42 a.m. LPN BB reported she worked on B wing on 2/11/17 and helped LPN Z complete the 6 medication error event documents for Resident #18 related to the transcription errors from 2/9/17 admission. LPN BB reported she contacted DON B immediately on 2/11/17 and reported medication errors. LPN BB reported DON B advised LPN BB to educate RN DD on the next shift. LPN BB reported DON B stated, teach her in a kind and respectful manor. LPN BB reported she called and notified the B wing unit manager N as well on 2/11/17. LPN BB reported she educated RN DD on 2/11/17 when RN DD arrived to the facility for the next shift related to the incomplete admission skin assessment (including missing PICC), missing care plans, medication transcription errors reports. LPN BB reported she educated RN DD to clarify the zinc order from 2/9/17 and did not returned to work until 2/16/17 and the zinc order still was not in the system. LPN BB reported on 2/16/17 she notified the doctor and spoke with DON B and Administrator A and was told by DON B, you should have followed up or verified order was completed. LPN BB reported she corrected Resident #18's zinc order on 2/16/17 and stated, I had never cared for (named Resident #18) since he has been here. According to the Hospital Discharge Instructions, dated 2/9/17, revealed [MEDICATION NAME] Proxetil ([MEDICATION NAME]) 100 mg twice daily and an order that revealed, Keep PICC Line, PICC line care and flushes per protocol. The Discharge orders revealed, dressing change to foot-xeroform, gauze and wrap daily after saline wash. Upon further review of the hospital discharge orders revealed orders for Potassium Chloride 20 meq four times daily by mouth, Urea 142 gm cream daily for 3 days, zinc 220 mg daily, [MEDICATION NAME] 7.5/325 every 6 hours PRN pain, normal saline IV flush and [MEDICATION NAME] IV flush. According to the Physician Orders, dated 2/9/17 though 2/10/17, for Resident #18, revealed no orders for code status, PICC maintenance (normal saline/[MEDICATION NAME] flushes), [MEDICATION NAME] (antibiotic), Zinc, and revealed Potassium Chloride 20 meq 3 times daily. The Physician order [REDACTED]. According to the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The TAR reflected 6 missed physician ordered wound/surgical dressing changes related to Resident #18's left foot. According to the facilities admission orders [REDACTED].These orders will be processed by a licensed nurse in a timely manner following the guest's admission to the facility . Resident #3 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #3 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED].#3 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with transfers, toileting, dressing, hygiene, bathing and one person physical assist with locomotion on the unit with use of wheelchair. The MDS reflected Resident #3 had frequent pain and used schedule and as need pain medications for pain relief. Review of the Hospital Discharge Orders, dated 12/22/16, Resident #3 had an orders that included [MEDICATION NAME] 2 g intravenously (IV) every 12 hours (antibiotic), [MEDICATION NAME] 2000mg IV every 12 hours (antibiotic), routine central line care and an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Physician Orders, dated 12/22/16 through 12/27/16, reflected no central line normal saline flushes/[MEDICATION NAME] flushes until 12/27/16 (Resident #3 was admitted with central line catheter on 12/22/16). The Physician included an order for [REDACTED].

This citaion pertains to intakes: MI 479, MI 156, MI 953 and MI 207 Based on observation interview and record review the facility failed to assess, supervise, thoroughly investigate, determine root cause and update plan of care to prevent further accidents for 1 resident (#42) of 1 reviewed for a burn, 2 residents (#37, and 38) of 8 reviewed for resident to resident altercations and 4 residents (#36, 43, 45 and 46) of 6 reviewed for falls from a total sample of 40, resulting in a 2nd degree burn, potential for resident to resident injury and potential for increased falls and related injuries. Findings Include: Resident #42 According to the facility Admission Record, dated 9/27/16 and the MDS (minimum data set- an assessment) dated 9/5/16, Resident #42 was a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. Resident #42 was able to understand and could be understood, had a BIMS (brief interview of mental status- a cognitive test) score of 10/15 indicating Resident #42 was mildly impaired cognitively. Resident #42 required extensive assist of one staff member for transfer, dressing, personal hygiene and toileting needs. Resident #42 required supervision with meals. Review of the incident report, dated 9/9/16 at 1530 (3:30 p.m.) Type of Occurrence: .11. Other: injury .Type of Injury: F. Burn .Location: 10. nurses station . Review of the facility 5 day investigation, undated, refected on 9/9/16 Resident #42 spilled coffee on himself causing a 1st burn on his left lateral thigh and 2nd degree on left posterior thigh. The 2nd degree burn measured 3 x 3 inches with blisters .(Resident #2) obtained this coffee from the B wing nourishment room. He had his coffee in his personal mug with a lid in which he placed the mug between his left leg and wheelchair. When (Resident #42) moved his left leg the coffee tipped over in his lap . During an interview on 9/27/16 at 10:30 a.m., Resident #42 was observed in a high back wheelchair with a left arm support and foot pedal on left side of wheelchair. Resident #42 was unable to use left arm, hand or leg. When Resident #42 was asked stated I had got coffee from someone on B hall, I placed my cup in the left side of my wheelchair because my cup holder was broke at the time, I was heading back to my room and it tipped over. It felt like an electric shock .it was boiling .I got a burn to my left leg and hurts like h***. During an interview with unit manager Licensed Practical Nurse (LPN) P, on 9/27/16 at 11:00 a.m., when asked about coffee spill and burn for Resident #42 stated he really likes his coffee and we had a coffee pot in the B hall nourishment room that was used for employees and at night for residents after the kitchen was closed. He (Resident #42) likes to carry his cup between his legs and will refuse to use the cup holder, the cup tipped over when he adjusted his left leg. He uses a travel mug with a straw thru the lid. LPN P stated the coffee pot was immediately removed from B hall nourishment room. When asked if resident were periodically assessed for safe handling of hot liquids to prevent burns stated No, I don't think so. At 11:45 a.m. during an interview with Director of Nursing (DON) B when asked stated all residents are assessed for hot liquid safety on admission and reviewed quarterly by nurse on unit and screened quarterly by therapy. Review of therapy screen for Resident #42 dated 9/6/16, did not include any assessment of resident ability to handle hot liquids safely. Facility did not provide any documentation of quarterly review by nursing prior to exit. Review of Resident #42's care plans, refusal was not documented. The facility provided a refusal of treatment document, that reflected Resident #42 refused to be supervised with all hot liquids, dated 9/27/16. During an interview with Certified Dietary Manager (CDM) F on 9/27/16 at 12:00 p.m., when asked stated that temperatures of the coffee in the kitchen was not monitored on daily basis nor was the coffee in the B hall nourishment room before it was removed after Resident #42 sustained a burn. I was not aware there was a coffee maker in the B Hall nourishment room before the incident with (Resident #42). I know that we have not been consistently checking and recording temperatures of coffee in the kitchen. During an interview with unit manager Licensed Practical Nurse (LPN) L on 9/27/16 at 3:00 p.m. stated (Resident #42) did not have a cup holder on his wheelchair at the time (of the burn), maintenance was attempting to get a new one. LPN L stated there was not an alternative used until replacement could be obtained. LPN L confirmed the facility did not monitor the temperature of the coffee in B hall Nourishment room to ensure it was served to residents at a safe temperature. On 9/28/16 at 11:05 a.m. with LPN N, during an observation of dressing change, Resident #42 complained of pain during removal and cleaning of the wound. The wound was approximately 5 cm (centimeters) x 4 cm, the center of the wound had a yellow film. The wound edges were beefy red. Resident #42's travel mug was observed sitting on the bedside stand it was a 20 ounce cup with a screw on top and closable opening with straw placed in opening. Liquid would easily spill out if tipped. Review of the Medication Administration Record (MAR) for September 2016 reflected Resident #42 had Keflex 500 milligrams twice a day ordered 9/17/16 to 9/23/16 for treatment of [REDACTED]. Review of the Treatment Administration Record (TAR) for September 2016 reflected Resident #42 received treatment to left thigh wound of a debriding agent to clean wound of dead tissue. Review of the medical record resident #42 was seen by wound care specialist Nurse Practitioner (NP) O for treatment of [REDACTED]. ( ) On 9/29/16 at 9:10 a.m. on the C hall unit, while at the nurses station an alarm sounded, sound was coming form room 475 on the north hall. The only staff observed in the hallway at the time was Licensed Practical Nurse (LPN) N on the south hall about 3/4 of the way down the hall at the medication cart. LPN N was observed to look towards the sound of the alarm but did not investigate. Alarm stopped sounding as resident in room 475 moved in her wheelchair. An unidentified resident was observed to removed the stop sign attached with Velcro across the doorway of room 475 and enter the room walked into the bathroom turned around and exited the room. Again, no staff was observed be in hallway except LPN N on the south unit. No staff supervision was observed. Resident #37 According to the facility Admission Record, dated 9/15/16 and the MDS (minimum data set- an assessment) dated 7/14/16, Resident #37 was a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. Resident #37 was able to be understood and understand others, had a BIMS (brief interview of mental status- a cognitive test) score of 3/15 indicating Resident #37 was severely impaired cognitively. Resident #37 required extensive assist of one staff members for dressing, toileting and personal hygiene. Limited assist of one staff member for bed mobility. Resident #37 required supervision with transfer, ambulating on and off unit, in and out of his room, and eating. Resident #37 had physical behavioral symptoms directed towards others and wandering. Review of the incident reports for Resident #37 for July 2016 to September 2016. Resident #37 had 2 incidents of resident to resident altercations. Resident #38 According to the facility Admission Record, dated 8/29/16 and the MDS (minimum data set- an assessment) dated 8/21/16, Resident #38 was a [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. Resident #38 was sometimes able to be understood and usually understood others, had a BIMS (brief interview of mental status- a cognitive test) score of 3/15 indicating Resident #38 was severely impaired cognitively. Resident #38 required extensive assist of one staff members for bed mobility, dressing, and personal hygiene. Limited assist of one staff member for toilet use. Resident #38 required supervision with transfer, ambulating on and off unit, in and out of his room, and eating. Review of the incident reports for Resident #38 for July 2016 to September 2016, Resident #38 had 2 incidents of resident to resident altercations in which residents wandered into Resident #38's room when she was in the room. During an interview with Registered Nurse (RN) S, on 9/29/16 when asked stated both Resident #37 and #38 have personal space issues. Resident #37 was often intrusive into others personal space and was unable to understand how his actions affected others. Resident #38 was the opposite she did not like anyone in her personal space especially men. We have to keep a close eye on both (Resident #37 and #38) sometimes we can't get to them in time. When asked what interventions were used to monitor to prevent resident to resident altercations with residents on unit stated we use stop signs on the doorways and close supervision. During an interview with Certified Nurse Aide (CNA) T on 9/29/16 at 3:00 p.m. when asked what the facility had in place to prevent resident to resident altercations for Resident's #37 an #38 We use a stop sign across (Resident #38's) door, but she often removes it to get in and out and (Resident #37) can remove it if he wants to. During an interview with CNA D on 9/30/16 at 3:55 p.m. stated her primary assignment was on the C Hall unit, locked dementia unit, when asked stated all residents require supervision due to dementia, sometimes it is hard to keep an eye on everyone especially around break times and meals. Review of care plans for Resident #38, dated 6/8/16 did not reflect that Resident #38 had personal space issues and how staff was to ensure wandering residents did not invade her space. Review of Behavior Documentation Record Resident #38, undated, reflected Resident #38 behaviors were only At times places self on floor. Review of Nursing Care Card for Resident #38, undated, reflected Guest is very territorial, does not like others in her room, stop sign on doorway. During an interview with the DONB on 9/28/16 stated the facility staffs per resident numbers and not based on acuity. During an interview with CNA D a full time employee for hall C on 9/30/16 at 4:00 p.m., when asked stated There are usually 4 CNA's on the shift but whith breaks sometimes it's 2 on the unit and the nurse. ( ) According to the the Incident Report Procedure, undated, gave nursing staff directions on how to proceed when an incident occurs, stated When an incident occurs, please follow this guideline: 1. Call the nurse manager on call and inform her of the incident, 2. Briefly note the incident in the residents chart in the nurses notes. 3. Fill out the incident report form completely. 4. Fill out the post fall incident report completely. 5. Draw map of incident. 6. All staff on the wing fill out the employee written statement on separate sheers of paper. 7. The morning after an incident occurred, the nurse and the staff member who witnessed the incident, will call the unit manager or her back up for the wing, between 8:00 and 8:30 a.m. Monday Trough Friday for the post-incident quality assurance interview. 8. If the incident occurs on the weekend the nurse and staff member must call on Monday. 9. The unit manager will fill out the post incident quality assurance interview form. 10. The unit manager will bring the incident folder, chart and care card and master assignment sheet to the morning meeting. 11. The incident will be discussed at morning clinical. 12. The unit manager will fill out the post- incident analysis form. 13. The IDT (interdisciplinary team will agree on the intervention and sign the care plan meeting document. 14. The unit manager will update the care plan, care card and nurses aide assignment sheets. 15. The unit manager will leave all documents in the folder for the medical director's signature. 16. The director of nursing will receive the entire completed folder and will enter the incident on the incident report log and place all documents in the incident binder. According to the facility Falls Awareness Program, dated 10/10, under Policy: Guests at risk for falls will be monitored by staff. Purpose: to promptly identify guests at risk for falls. Equipment: Green or clear identifier tag for wheelchair or walker. Procedure: 1. The Nursing Admission Assessment, including the Risk for Falls section, will be completed upon admission. 2. If the guest is determined to not be at risk for falls, a clear identifier tag will be placed on his/her assistive device (walker, wheelchair, etc.) as appropriate. 4. Each fall will be assessed by completing the Post Fall Evaluation. The Incident/Accident policy and procedure will be followed. 5. The Falls Awareness program is overseen by the Behavior Management Committee. Occurrences related to falls are reviewed by the committee. Care plans will be reviewed with appropriate update of interventions within 24-72 hours of each new occurrence. 6. The guest will be reassessed with [REDACTED]. The Behavior Management Committee will re-evaluate the guest's risk and occurrences. A determination will be made to either continue the guest in the Falls Awareness Program or to discontinue the guest from the program. Care plans will be updated according. 7. If the guest is determined not to be at risk for falling, the green identifying tag will be removed and a clear tag will be placed on his/her wheelchair or walker as appropriate. 8. Each guest will continue to be evaluated for risk factors quarterly. Resident #43 According to the facility Admission Record, dated 11/5/15 and the MDS (minimum data set- an assessment) dated 8/22/16, Resident #43 was a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. Resident #43 was sometimes able to be understood and usually was able to understand others, had a BIMS (brief interview of mental status- a cognitive test) score of 3/15 indicating Resident #43 was severely impaired cognitively. Resident #43 required extensive assist of two staff members for bed mobility, transfer and toilet use. Extensive assist of one staff member for dressing and personal hygiene. Resident #43 required supervision locomotion on and off unit. Ambulation in room and corridor did not occur. On 9/27/16 at 4:50 p.m., Resident #43 was observed in his room. Resident #43's room was at the end of the south hall on the C unit, furthest from the nurses station. Resident #43 was observed to be standing at the side of his bed reaching for the curtain in the window, Resident #43's alarm on bed was not sounding. Staff was notified and CNA I assisted Resident #43 back to the edge of the bed. Review of Incident Reports for Resident #43 had 2 falls, 8/18/16 and 8/21/16. Per the Incident Report, dated 8/18/16 at 3:30 p.m., Resident #43 was found on the floor in his room with out injury. Immediate interventions put in place to prevent recurrence: up in wheelchair at nurses station, snack offered then dinner, redirected and monitored. Review of the Post-Fall Report, dated 8/18/16 at 3:30 p.m., stated Resident #43 wanted to get up to go shopping Review of the Nurses Notes Resident #43 was later sent to emergency room for treatment of [REDACTED]. Review of the Post Incident Analysis, dated 8/30/16, under Post-Incident Follow-up/Action Plan, The following measures have been implemented to prevent occurrence or recurrence: guest supervision modified. Review of the Summary of Clinical Event (S.O.C.E.), completed by LPN L and signed by Director of Nursing (DON) B 8/31/16, under Summary of Investigation: (Include x-ray/lab results, intervention changes, current guest/visitor status, and care plan):, stated CNA observed guest on floor in room. Nurse notified skin assessment completed. No injury or discolorations noted. Guest assisted up from floor to wheelchair and snack given, placed at nurses station. Guest stated I got to go shopping. MD (physician) and guardian notified. Intervention: guest supervision modified. Under Resolution obtained: yes or no neither was checked. Date resolved was blank. Under Care Plan Updated: neither yes or no was checked. Review of the Falls Care Plan dated 12/16/15 was not updated. Per the Incident Report, dated 8/21/16 at 9:20 a.m., Resident #43 was found on the floor in his room with out injury. Immediate interventions put in place to prevent recurrence: Will transfer to bed when finished with breakfast. Review of the Post-Fall Report, dated 8/21/16 at 9:20 a.m., stated Resident #43 will transfer self regardless and doesn't respond to alarm noise. He does what he wants. Review of the Post Incident Analysis, dated 8/30/16, under Post-Incident Follow-up/Action Plan, The following measures have been implemented to prevent occurrence or recurrence: lay down after meals. Review of the Summary of Clinical Event (S.O.C.E.), completed by LPN L and signed by Director of Nursing (DON) B 8/31/16, under Summary of Investigation: (Include x-ray/lab results, intervention changes, current guest/visitor status, and care plan):, stated housekeeping observed guest on floor, notified CNA's and nurses. Nurse entered room to guest laying on the floor with feet under roommates bed. Guest stated I'm not bleeding. Guest was assisted up from floor to bed, nurse completed skin assessment no injury or discolorations noted. MD and guardian notified. Interventions: lay down after meals. Under Resolution obtained: yes or no neither was checked. Date resolved was blank. Under Care Plan Updated: neither yes or no was checked. Review of the Falls Care Plan dated 12/16/15 was not updated. Review of the Nursing Care Card (the way the facility communicates resident care needs to CNA'S) did not reflect dates of when intervention where changed or modified to prevent further occurrences of falls. Resident #45 According to the facility Admission Record, dated 6/13/16 and the MDS (minimum data set- an assessment) dated 9/2/16, Resident #45 was a [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. Resident #45 was sometimes able to be understood and usually was able to understand others, had a BIMS (brief interview of mental status- a cognitive test) score of 3/15 indicating Resident #45 was severely impaired cognitively. Resident #45 required extensive assist of two staff members for transfer and toilet use. Extensive assist of one staff member for bed mobility, locomotion on and off unit, dressing and personal hygiene. Resident #45 required supervision with eating. Ambulating in room or corridor did not occur. Review of Incident Reports for Resident #45 had 2 falls, 8/19/16 and 9/15/16. Per the Incident Report, dated 8/19/16 at 9:30 p.m., Resident #45 was found on the floor in her room with out injury. Immediate interventions put in place to prevent recurrence: toileted, in bed- repositioned. Review of the Post-Fall Report, dated 8/19/16 at 9:15 p.m., stated Resident #45 was rising to Go get bubbles. Resident #45 had night time care provided and was in bed. Resident #45's brief was wet and was toileted after fall. Review of the Post Incident Analysis, dated 8/30/16 10 days after incident, under Post-Incident Follow-up/Action Plan, The following measures have been implemented to prevent occurrence or recurrence: Toileting plan imitated/modified. Review of the Summary of Clinical Event (S.O.C.E.), completed by LPN P signed and by Director of Nursing (DON) B 8/31/16, under Summary of Investigation: (Include x-ray/lab results, intervention changes, current guest/visitor status, and care plan): stated CNA observed guest sitting on floor next to bed. Nurse notified skin assessment completed. No injury or discolorations noted. Guest stated 'Going to her bubbles', guest was assisted up from floor and into bed. MD and family notified. Neuro checks started, no complaint of pain/discomfort. Resident toileted and repositioned in bed. Intervention: toileting plan intimated. Under Resolution obtained: yes or no neither was checked. Date resolved was blank. Under Care Plan Updated: neither yes or no was checked. Review of the Falls Care Plan dated 3/22/16 was not updated. Facility did not provide documentation that toileting program was completed. During an interview with CNA D a full time employee for hall C on 9/30/16 at 4:00 p.m., when asked stated I don't remember doing a bowel and bladder tracker on (Resident #45). Per the Incident Report, dated 9/15/16 at 4:00 p.m., Resident #45 was found on the floor in her room with hematoma (goose egg) to left forehead. Immediate interventions put in place to prevent recurrence: Resident #45 was transferred to local emergency room . Review of the Post-Fall Report, dated 9/15/16 at 4:00 p.m., stated Resident #45 was reaching in wheelchair bending over to pick up what wasn't there, Resident #45 thought there was something on the floor. Review of the Post Incident Analysis, dated 9/20/16, under Post-Incident Follow-up/Action Plan, The following measures have been implemented to prevent occurrence or recurrence: Seatbelt to wheelchair. Review of the Summary of Clinical Event (S.O.C.E.), completed by LPN P and unsigned and by Director of Nursing (DON) B, under Summary of Investigation: (Include x-ray/lab results, intervention changes, current guest/visitor status, and care plan): stated Nurse entered room guest laying on floor. Nurse completed skin assessment noting left forehead hematomas, 2 lacerations with slight bleeding noted. Ice applied to forehead. MD and family notified. Call made to (Ambulance service) per MD order to send to (local emergency room ) for evaluation and treatment .Intervention: Seatbelt added to wheelchair. Under Resolution obtained: yes or no neither was checked. Date resolved was blank. Under Care Plan Updated: neither yes or no was checked. Review of the Falls Care Plan dated 3/22/16 was not updated until 9/19/16. Review of the Nursing Care Card reflected the care card had not been updated since 8/11/16. Resident #46 According to the facility Admission Record, dated 9/7/16 and the MDS (minimum data set- an assessment) dated 9/5/16, Resident #46 was a [AGE] year old male admitted to the facility, 8/23/16, with [DIAGNOSES REDACTED]. Resident #46 was sometimes able to be understood and usually was able to understand others, had a BIMS (brief interview of mental status- a cognitive test) score of 2/15 indicating Resident #46 was severely impaired cognitively. Resident #46 required extensive assist of two staff members for bed mobility, transfer, dressing, toilet use and personal hygiene. Extensive assist of one staff member for locomotion on and off unit, and eating. Resident #46 ambulating in room or corridor did not occur. Review of the Admission Care Plan , dated 8/23/16, reflected Resident #46 was assessed to be at high fall risk and the following interventions were began: Evaluate for unsteady gait, Ambulation devices as necessary, Instruct guest on appropriate safety measures, Observe cognitive status for ability to ask for assist, Observe guest footwear for fit and non-skid soles, alarms and type: As ordered Review of the Nursing Admission Assessment, dated 8/23/16, reflected Resident #46 had fall risk total score of 24 the instructions reflected Total Score of 10 above deems Guest at risk; initiate care plan. Review of Incident Reports for Resident #46 had 4 falls from 8/25/16 to 8/26/16, with 3 occurring on 8/26/16. Per the Incident Report, dated Thursday 8/25/16 at 9:00 p.m., Resident #46 was witnessed to fall in corridor receiving a laceration to unidentified part of body. Immediate interventions put in place to prevent recurrence was 24 hour emergency lap buddy (a soft device across front of wheelchair). Facility did not provide documentation of Post-fall Report, or map of the incident. Review of the Post Incident Quality Assurance Interview, dated Tuesday 8/30/16, completed by unit manager Licensed Practical Nurse (LPN) L, who interviewed the LPN on duty at the time of incident did not reflect investigation of what was happening prior to fall. Only one witness statement was completed. Review of the Post Incident Analysis, dated 8/30/16, under Post-Incident Follow-up/Action Plan, The following measures have been implemented to prevent occurrence or recurrence: guest supervision modified and use of assistive devices was modified. Review of the Summary of Clinical Event (S.O.C.E.), completed by LPN L and signed by Director of Nursing (DON) B 8/31/16, under Summary of Investigation: (Include x-ray/lab results, intervention changes, current guest/visitor status, and care plan):, stated Guest observed on floor with small laceration to forehead. Guest was assisted back to wheelchair, cut to forehead cleansed and dressed. Guest has had numerous episodes of getting up with out assistance or attempting to. Guest has no regard for safety or personal alarms. Resident had recently been toileted and did not want to lay down to go to bed. Will fit wheelchair for lap buddy pad to try deter resident from getting up without assistance and reduce the risk of recurrent falls. Under Resolution obtained: yes or no neither was checked. Date resolved was blank. Under Care Plan Updated: neither yes or no was checked. Review of the Admission Care Plan dated 8/23/16 was not updated. Per the Incident Report, dated Friday 8/26/16, at 9:40 a.m., Resident #46 was witnessed to fall in dining room from his wheelchair. No injuries were identified. Immediate interventions put in place to prevent recurrence: extensive assist to wheelchair and applied lap buddy. Review of the Post-Fall Report, dated 8/26/16 at 10:00 a.m., reflected Resident #46 was in the dining room and was rising from wheelchair oversight at the time was noted dementia/Parkinson's and resident new to facility. There was not a map of incident provided by the facility. Review of the Post Incident Analysis, dated 8/30/16, under Post-Incident Follow-up/Action Plan, The following measures have been implemented to prevent occurrence or recurrence: guest supervision modified and use of assistive devices was modified, the environment modified. Review of the Summary of Clinical Event (S.O.C.E.), completed by LPN L and signed by Director of Nursing (DON) B 8/31/16, under Summary of Investigation: (Include x-ray/lab results, intervention changes, current guest/visitor status, and care plan):, stated Guest with witnessed fall in dining room. Guest with poor self awareness of safety, disregard for alarms or other safety interventions. Lap buddy applied. Under Family concerns, was blank Resolution obtained: yes or no neither was checked. Date resolved was blank. Under Care Plan Updated: neither yes or no was checked. Review of the Admission Care Plan dated 8/23/16 was not updated. Per the Incident Report, dated Friday 8/26/16, at 6:30 p.m., Resident #46 was witnessed to push self forward out of chair and landed on hands and knees. No injuries were identified. Immediate interventions put in place to prevent recurrence: Switched his wheelchair with one that the lap buddy would fit snuggly in fit properly. Review of the Post-Fall Report, dated 8/26/16 at 8:00 p.m., reflected Resident #46 was at the nurses station and threw himself forward from wheelchair and onto hand and knees. Certified nurse aide was 4-5- feet away at time. Lap buddy was not fitting wheelchair properly. Review of the Post Incident Analysis, dated 8/30/16, under Post-Incident Follow-up/Action Plan, The following measures have been implemented to prevent occurrence or recurrence: supervision modified. Review of the Summary of Clinical Event (S.O.C.E.), completed by LPN L and signed by Director of Nursing (DON) B 8/31/16, under Summary of Investigation: (Include x-ray/lab results, intervention changes, current guest/visitor status, and care plan):, stated Guest with continued disregard for personal safety. Removing his lap buddy frequently, does not leave it in place. Removed his lap buddy again and fell on to floor. No injury received. Staff to keep patient with in eyesight to help decrease risk of falls. Under Family concerns, was blank Resolution obtained: yes or no neither was checked. Date resolved was blank. Under Care Plan Updated: neither yes or no was checked. Review of the Admission Care Plan dated 8/23/16 was not updated. Per the Incident Report, dated Thursday 8/26/16 at , Resident #46 was witnessed to push self forward out of wheelchair and landed on hands and knees. No injury was noted. Immediate interventions put in place to prevent recurrence: had staff sit within arms reach and be looking at resident at all times. Facility did not provide documentation of Post-fall Report. Review of the Post Incident Quality Assurance Interview, dated Tuesday 8/30/16, completed by unit manager Licensed Practical Nurse (LPN) L, who interviewed the LPN on duty at the time of incident did not reflect investigation of what was happening prior to fall. Review of the Post Incident Analysis, dated 8/30/16, under Post-Incident Follow-up/Action Plan, The following measures have been implemented to prevent occurrence or recurrence: guest supervision modified, use of assistive devices was modified, Physician contacted to evaluate clinical status (e.g. labs, tests, etc), referral to physical therapy for seat belt. Review of the Summary of Clinical Event (S.O.C.E.), completed by LPN L and signed by Director of Nursing (DON) B 8/31/16, under Summary of Investigation: (Include x-ray/lab results, intervention changes, current guest/visitor status, and care plan):, stated Guest with recurrent falls over 36 hour time period. No regard for personal safety or employed safety devices. fell on floor out of wheelchair after removing lap buddy put in place and thrusting himself on to floor. No injuries received. Guest's wife is concerned by the number of falls that are happening. Will check urine to rule out UTI (urinary tract infection), labs to be obtained, will have physical therapy evaluate for seatbelt to ensure safety. Wife is supportive of all these interventions- brought up the seat belt intervention herself with staff. Under Resolution obtained: yes or no neither was checked. Date resolved was blank. Under Care Plan Updated: neither yes or no was checked. Review of the Admission Care Plan dated 8/23/16 was not updated. Review of the Nursing Care Card (the way the facility communicates resident care needs to CNA'S) did not reflect dates of when intervention where changed or modified to prevent further occurrences of falls. Review the Incident Reports for falls from 7/16 to 9/30/16, the facility had 89 reported falls. July-18, August-32, and September- 39. During an interview with the Director of Nursing (DON) B and Hall C unit manager Licensed Practical Nurse (LPN) L on 9/28/16 at 11:00 a.m. stated the process for monitoring and reviewing falls initial investigation and implementation of interventions is completed by the nurses, I follow up and ensure the paperwork is completed. Once it is done I give to the DON. When asked, LPN L was not aware of how many falls had occurred on c hall unit but it was a lot. DON B stated that she completes a tracking tool but does not trend per shift or assess for patterns such as staffing with each fall. When asked if there had been any recent training on fall prevention DON B said no. ( )

The citation is related to Intake MI 008. Based on interview and record review the facility failed to A) assess and ensure that oxygen saturations was monitored upon admission and with a known history of [MEDICAL CONDITION] requiring continuous oxygen, B) failed to asses respiratory status and oxygen saturation with changing of shift, C) D) failed to document resident care, resident status and notify physician with concerns of Bi-pap and possible change of condition, for 1 of a total of 40 sampled and supplemental residents (Resident #31), resulting in the potential for oxygen depravation, [MEDICAL CONDITION], and respiratory distress. Findings include: According to Status Report dated [DATE] Resident (R) #31 was a newly admitted resident, who had a Bi-pap ordered and was listed to have Oxygen (O2) at 3 liters (L). The back of the sheet reflected R31 was documented to have [MEDICATION NAME] (diuretic) for Heart Failure (HF), used Bi-Pap at night, and 3L of O2 related to wheezing and coarse lung sounds. The Electronic Medical Record (EMR) reflected R31's primary [DIAGNOSES REDACTED]. The Nursing Admission assessment dated [DATE] completed by Licensed Practical Nurse (LPN W), reflected, R31 was admitted to the facility at 4:10 PM. The assessment did not list any diagnoses, or a respiratory assessment of any kind. Also, the Progress Note documented by LPN W reflected R31 arrived at the facility at 4:10 PM via transport from a local hospital. The first Progress Note reflected LPN W completed an Admission Oversedation for R31 at 8:43 PM. The Admission Observation reflected the following: Respiratory: R31 was having difficulty breathing and was Short Of Breath (SOB) with sitting and with exertion. R31's left/right lung sounds exhibited wheezing with expiration and throughout. Mental Status/Cognition: R31 was documented as having a new onset of mental status changes with confusion, disorientation, yelling, rambling and being disruptive to other resident since her admission. Mood and Behavioral/Psycho/Spiritual: Her mood was anxious, with chronic disruptive behavior, and slept intermittently. The 2016 Mayo Foundation for Medical Education and Research on-line reference defined Wheezing: Wheezing is a high-pitched [MEDICATION NAME] sound made while breathing. Most commonly wheezing occurs during breathing out (expiration), but it can sometimes be related to breathing in (inspiration). Causes: Wheezing results from a narrowing of the airways and typically indicates some difficulty breathing. The narrowing of the airways can be caused by inflammation from asthma, an infection, an allergic reaction, or by a physical obstruction, such as a tumor or a foreign object that's been inhaled. The second Progress Note timed 9:46 PM by LPN W reflected Vital Signs (VS): Radial pulse normal, heart rate 97, respirations 20, blood pressure ,[DATE], with no documented results for the pulse ox (oxygen) source. The VS and Weight Record sheet dated [DATE] reflected R31's name, room number, height: 5 feet 2 inches, and weight: 271.6 pounds. Yet, there was not a column for oxygen saturation results listed on the sheet. The last Progress Note timed 1:27 PM by LPN (X) reflected, Reported from third shift nurse that guest would not keep [MEDICAL CONDITION] machine on. Staff was putting it back on several time (sic) through out the night. Guest was hollering out from her room. She was checked on several times. At 7:36 I went in to give her medications and found her unresponsive. I called out in to the hallway to call the code. We began CPR at 7:40a. EMT's arrived at 7:45 AM. Time of death 8:12 AM . Facility staffing sheet dated [DATE] reflected LPN (Y) was the third shift nurse who worked after LPN W and before LPN X. The [DATE] Medication Administration Record [REDACTED] medications: [REDACTED]. Duodneb 0.5 milligrams (mg)-3 mg/milliliters solution one unit dose three times daily for SOB. [MEDICATION NAME] Diskus 50 mc one puff twice daily for [MEDICAL CONDITION]. Treatments: [MEDICAL CONDITION] at bedtime for spontaneous. Bi-pap (Bilevel positive air pressure). The Alaskan Sleep Education Center on-line reference defined a Bi-pap as a non-invasive form of therapy for patients suffering from sleep apnea. The air pressure keeps the throat muscles from collapsing and reducing obstructions by acting as a splint. Oxygen: humidified via nasal cannula continuous for 3L/minute. A work order from a local medical equipment company reflected a [MEDICAL CONDITION] and NH humidifier: Mask full face was delivered to the facility for R31 on [DATE]. The admitting respiratory care plan reflected the facility staff were to monitor R31's oxygen therapy, oxygen saturation, observe endurance and report complications. LPN W was interviewed by phone [DATE] at 2:42 PM, and was asked to recall the admission of R31 on [DATE]. LPN W revealed, When she was admitted I remember her having erratic behavior. When I was doing her assessment she was yelling odd things. The guy who admitted her from transport stated she was acting funny. She was yelling things out. Other residents were wondering what was going on with her. I had called my unit manager and the doctor. The doctor agreed, that was the behavior she exhibited at the hospital. The doctor stated he would be coming in a couple days to see her. Staff were trying to get sensors alarms for her bed and chair because of her erratic behavior and for her fall risk. I went back down there to check on her at 9:00 PM or 9:30 PM and she was sleeping. My shift had ended at 6:00 pm, but I stayed to do her orders and finish her paperwork. I gave report to LPN Y, she was there when I talked to the doctor. When asked who obtained R31's vital signs LPN W stated, the nursing assistants. When asked if R31 received oxygen LPN W stated, Yes ,[DATE] liters. That is what made me call the doctor, because she jerked her oxygen out of her nose like the exorcist. She (R31) said, They are coming to get me. LPN W was asked if R31 oxygen saturation was checked. She replied, That was part of what should have been checked. We have to have to their orthostatic blood pressures done also. That would be in the comprehensive assessment and the sheet the aides fill out. Lastly, LPN W was asked with shift change when should the oncoming nurse do an assessment. LPN W replied, I would say it should be every shift. She was pretty erratic. Record review revealed, no hard copy or EMR documentation was available to reflect LPN W had notified any physician related to R31. The nurse manager for the R31's hall that day was RN Z, who was interviewed on [DATE] at 12:19 PM. RN Z was given a brief summary of R31's documented admission records and behavior obtained by the writer, with no documentation of oxygen saturation with a know history of RF, SOB, [MEDICAL CONDITION] and continuous oxygen use. RN Z was then given the admission assessment and progress notes to view. Upon reading the documents RN Z stated, I don't see her pulse ox here. I see no documentation of oxygen at all. RN Z stated that R31's behavior and respiratory signs/symptoms were indicative of oxygen deficiency. LPN Y was interviewed by phone on [DATE] at 1:41 PM. She was asked to recall caring for R31 on [DATE] - [DATE]. LPN Y stated, She was very confused. She was yelling out and I gave her night-time medications and she went to sleep that night. That morning she was awake and there was nothing out of the ordinary. I did not do her admission. LPN Y revealed, that she had received report that R31 was confused and needed a lot of help. When asked if she assessed R31 LPN Y replied, Yes I'm sure, it would be in the computer. LPN Y revealed R31's breathing was okay, her oxygen was on, and that R31 was not SOB. All of her vital signs were normal. She was awake off/on and confused throughout the night, and that R31 not keeping her oxygen on, may have caused her to act erratic and confused. When asked how often are you to document on a new admit. LPN Y replied, I recalled checking on her frequently during the night. The resident was still alive when I gave report. There was no documentation available in the hard chart and/or EMR by LPN Y related to R31, during her shift after LPN W's last note [DATE] at 9:46 PM or up until the first note documented on [DATE] at 1:27 PM by LPN Y who found R31 unresponsive, specifically the following: -no assessment. -no oxygen saturation results. -no vital signs documented (other than vital signs obtained by LPN W at 9:46 PM on [DATE]). -no documentation reflecting visual checking on R31 occurred. -no documentation that R31 was confused or having behaviors. -no depigmentation that R31 would not keep her [MEDICAL CONDITION] on. -no documentation of any doctor being notified of R31's change in behavior and/or complications. -no documentation of lung sound assessment. ( )

This citation has 2 Deficiency Practice Statements, A and B Deficiency Practice Statement A Based on observation interview and record review, the facility failed to initiate physicians orders in a timely manner, transcribe physician orders [REDACTED].#9, Resident #11, and Resident #14) reviewed for skin care, from a total sample of 24 residents, resulting in delay in treatment, non-resolving skin irritation, and delayed healing. Findings include: Resident #9 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #9 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS reflected that Resident #9's ability to make daily decisions was cognitively intact and he currently required the assistance of one staff members for toileting, hygiene, and bathing. Review of the Consult Physician Note dated 1/14/16 reflected, Resident #9 had complaints of a rash on his dorsal arms, neck and some patches on the scalp. we will start him a [MEDICATION NAME] 0.1% ointment twice a day, good skin care, and lubrication. If this takes care of his [MEDICAL CONDITION], the [MEDICATION NAME] should be cut back, and then stopped. The lubrication and gentle skin care, with mild soaps and avoidance of hot water should continue. Review of the Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. In an observation and interview on 1/27/16 at 9:25 a.m. in Resident #9's room, Resident #9 reported that the rash noted on both arms (red bumps the size of an eraser and smaller from the upper arm towards the hands, covering a good portions of the surface) was being treated with a cream to stop the itching. Resident #9 opened the top drawer of his small dresser on the wall to the right when entering the room and pulled out a tube of [MEDICATION NAME] cream. Resident #9 reported that the [MEDICATION NAME] cream stopped the itching for about 2 hours and that a nurse gave it to him to use as needed. In an interview on 1/28/16 at 8:30 a.m., Licensed Practical Nurse (LPN) Unit Manager (UM) C reported that the order for Resident #9's skin treatment did not define where to apply the ointment. LPN C reported that she was not aware Resident #9 was self treating the rash with [MEDICATION NAME] cream. In an interview on 1/28/16 at 8:35 a.m., LPN U reported that she was taking care of Resident #9 and was not aware he was self treating his rash with [MEDICATION NAME] cream. LPN U reported that family brings in things at times and staff watch for it, but were not aware of the [MEDICATION NAME] cream. Resident #11 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #11 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS reflected that Resident #11's ability to make daily decisions was cognitively intact and she currently required the assistance of one to two staff members for toileting, hygiene, and bathing. Review of the Skin 01 Care Plan dated 11/6/15, reflected Actual impaired skin integrity related to psoriasis/red rash to trunk area, bilateral arms, bilateral legs .Measurable Foals: area of skin breakdown will be free of signs and symptoms of infections. Approaches/Interventions: Measure area weekly and document it's characteristics in skin log. Conduct weekly head to toe skin assessment and report abnormal finding to physician and chart in nurses notes. Treatment as ordered Review of the Physician Phone Orders dated 7/1/15 (no time), reflected Resident #11 was ordered [MEDICATION NAME] 0.1% ointment; Apply to bilateral lower extremities and abdomen twice a day (BID) for 2 weeks then 3 days per week. Review of the Consultation Report dated 7/1/15, reflected severe [MEDICAL CONDITION]-legs/abdomen. [MEDICATION NAME] 0.1% ointment to be applied by staff BID for 2 weeks then 3 days per week to legs and abdomen. Review of the Nursing Notes dated 7/2/15 at 2:23 a.m., reflected Resident #11's assessment Skin .Skin is very rough and dry, Resident is always scratching. Resident scratches until she has open area . Review of the Medication Administration Record [REDACTED]. The 7/1/15 MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. The 7/1/15 MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the Nursing Notes dated 7/23/15 at 3:23 a.m., reflected Resident #11's assessment Skin .Skin Issues Notes: Resident skin is very dry, has many areas that she has scratched open, scaley and very thick Review of the Nursing Notes dated 7/30/15 at 4:00 a.m., reflected Resident #11's assessment Skin .Skin Issues Notes: Generalized inflammation present . Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the Nursing Notes dated 8/6/15 at 2:00 a.m., reflected Resident #11's assessment Skin .Skin Issues Rash .generalized [MEDICAL CONDITION]-treated per orders with lachydrin. Review of the Nursing Notes dated 8/20/15 at 1:09 a.m., reflected Resident #11's assessment Skin .Skin Issues Notes: Resident continues to have redness noted to bilateral upper extremities and bilateral lower extremities (BLE), trunk, under abdomen. Treatment applied as ordered. Resident noted to scratch BLE several times per shift but denies doing so even when witnessed by staff. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the Nursing Notes dated 9/3/15 at 12:56 a.m., reflected Resident #11's assessment Skin .Skin Issues Notes: Resident skin is very thick, rough, Resident scratches until there are open areas. Review of the Nursing Notes dated 9/3/15 at 12:56 a.m., reflected Resident #11's assessment Skin .Skin Issues Notes: Resident skin is very thick, scaley and rough, Resident scratches until skin is open and bleeding. Review of the MAR indicated [REDACTED]. The [MEDICATION NAME] 0.1% ointment was not reflected on the 10/2015 MAR. Review of the Weekly Skin assessment dated [DATE], 12/18/15. 12/25/15, 1/1/16, 1/8/16, 1/15/16, and 1/22/16 reflected that Resident #11 had skin conditions on her lower extremities, her back hip areas, across her bottom, and abdominal area. The Weekly Skin assessment dated [DATE] and 1/22/16, reflected that treatment was in place. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the Physicians Phone Orders dated 11/2/15, reflected start [MEDICATION NAME] cream + zinc + [MEDICATION NAME] 2.5% + [MEDICATION NAME] 1% 1:1:1:1 apply to bilateral lower extremities and thighs BID till clear. In an interview on 1/27/16 at 5:45 p.m., Licensed Practical Nurse (LPN) V reported that she had taken the order for [MEDICATION NAME] cream + zinc + [MEDICATION NAME] 2.5% + [MEDICATION NAME] 1% 1:1:1:1 apply to bilateral lower extremities and thighs BID till clear, and checked there system for the cream. LPN V reported that the cream was not in the system and the Nurse Practitioner that wrote the order was not available so she passed the information on to the next shift and flagged the order in Resident #11's chart. LPN V reported that when she worked with Resident #11 next, the order was still flagged so she called pharmacy and was informed how to proceed to obtain the physician's orders [REDACTED].>Review of the MAR indicated [REDACTED]topically for redness. Review of the MAR indicated [REDACTED]topically for redness. The MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]topically for redness. Review of the Shower/Skin Observation dated 1/20/16, reported Reddened area, scabbed area, rash, and raw areas all over from scratching. In an observation during tour on 1/26/16 at 9:40 a.m., Resident #11 was sitting on the side of the bed her feet were dry, red and [MEDICAL CONDITION], her ankles were dry and appeared to be peeling skin in 1 inch lateral areas. Resident #11 had body odor that was eye watering and was noted scratching at her right abdominal area and hips. In an observation and interview on 1/27/16 at 7:20 a.m. and 1:30 p.m., Resident #11 was laying in her bed scratching her left hip, red welts were noted on her left hip and thigh. An unidentified Certified Nursing Assistant was informed she was itching and informed Licensed Practical Nurse (LPN) Q who reported that she had been informed Resident #11 was complaining of itching and that she had completed her skin treatment at 8:00 a.m LPN Q reported that the skin treatment of [REDACTED].#11 was red, on her abdomen, buttock, hips, and lower extremities. In an observation on 1/27/16 at 9:55 a.m., Certified Nursing Assistant (CNA) T assisted Resident #11 from her bed to the shower. The bed pad had several area of dried blood at approximately back/hip placement the size of a quarter and a patch of smeared brown/red at the right upper thigh area the Resident was scratching at 7:20 a.m. CNA T helped Resident #11 disrobe for the shower raised red and inflamed areas were noted across the left side of her abdomen from the middle of the abdominal area to the hip, large raised areas with redness and dry, scaly skin were noted on the right and left buttock, the right hip down to the thigh was scratched and raw with some dry skin noted, the lower legs were thick, dry, red in areas to her toes on both feet. A clump of skin was peeling away around her ankles. CNA T assisted Resident #11 with non slip socks and dressing. In an observation on 1/27/16 ay 10:50 a.m., Licensed Practical Nurse (LPN) R placed her gloves on and put [MEDICATION NAME] cream + zinc + [MEDICATION NAME] 2.5% + [MEDICATION NAME] 1% 1:1:1:1 to Resident #11's lower extremities from mid thigh to ankles. LPN R did not remove the socks and put any cream on Resident #11's ankles, no cream was applied to the upper thigh. In an interview on 1/27/16 at 10:30 a.m., Resident #11 reported that no one had given her a treatment for [REDACTED]. Review of the MAR indicated [REDACTED] In an interview on 1/28/16 at 1:00 p.m., Nurse Practitioner (NP) Gg reported that Resident #11 was on her list to see today for the first time. NP Gg reported that the original order as written ([MEDICATION NAME] cream + zinc + [MEDICATION NAME] 2.5% + [MEDICATION NAME] 1% 1:1:1:1 apply to bilateral lower extremities and thighs BID) would include the feet, but not the abdomen and back of hip, an order would have been needed to treat those areas. # Deficient Practice Statement B Based on observation, interview and record review the facility failed to ensure that bowel movements were tracked and lack of bowel movements assessed and treated for [REDACTED]. Findings include: According to the identification summary, [DIAGNOSES REDACTED].#14 was an [AGE] year old male admitted to the facility for [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, resident assessment), dated 11/10/15, Resident #14 had significant memory impairment, was sometimes understood and sometimes understood others, exhibited disorganized thinking, inattention, almost daily wandering, and behaviors of going in other resident's rooms, disrobing, urinating in inappropriate places and touching/handling other residents and their possessions. Resident #14 was continent of bladder, always incontinent of bowel, required the assist of 2 staff for dressing, hygiene and bathing, and assist of 1 staff for bed mobility, transfers and eating. According to the bowel care plan, dated 9/18/15, Resident #14 had the following interventions: Observe and record frequency/characteristics of bowel movements (BM). Provide diet as ordered and encourage fluid intake as needed. Encourage to report any feelings of constipation or abdominal pressure. Administer medications as ordered. Instruct to avoid straining during bowel expulsion. Observe for signs of constipation .Offer prunes or prune juice as appropriate. Encourage to participate in exercise as able. Encourage fiber in diet. Provide extensive assist to the bathroom as needed. According to physician's orders [REDACTED]. Resident #14 was prescribed polyethylene [MEDICATION NAME] dissolved in water once daily to prevent constipation, and could have MOM every 2 days for no BM for 2 days, [MEDICATION NAME] rectal suppositories once daily for no BM for 3 days. Lastly, family could supply Ex-Lax for Resident #14 to take every other day for constipation, and he received this every other day from 11/1/15 through 11/15/16. On 1/28/16 at 11:45 a.m., Licensed Practical Nurse (LPN) Ee was interviewed. When asked how bowel movements were monitored, LPN Ee said the the night shift nurses make a list that includes all residents without a BM for 2 or 3 days. Then, LPN Ee stated that she wanted to locate a written protocol, as this was not included in physician's standing orders. LPN Ee provided a document titled Bowel Regime, revised on 8/26/04, which read as follows: 1. All residents not medically prohibited, will be offered and encouraged to drink prune or apple juice and adequate fluids of choice. 2. If a resident has not had a bowel movement in the past 48 hours (2 days), the resident is to receive M.O.M. (Milk of Magnesia) per the physician order [REDACTED]. 3. If there are no results from the M.O.M. by the following day, then the resident is to receive a suppository by a licensed nurse in accordance with the written physician order [REDACTED]. A digital rectal exam is required before insertion of the suppository. If no stool is present then the suppository is not to be given. 4. If bowel movement still has not occurred by the 2 pm to 10 pm shift, then licensed nurse is to give the resident an enema in accordance with written physician order. A rectal examination is necessary before giving the enema. A review of bowel movement electronic tracker records and medication administration records reflected the following: -No BM documented for at least 5 days, 11/1/15 through 11/5/15. Ex-Lax was given every other day. -No BM documented for 11 days, 11/7/15 through 11/17/15. Ex-Lax was given every other day through 11/15/15, after which the family did not bring any more in. MOM was given on the 17th. -Resident #14 had a BM on 11/18, 22 and 26. -No BM documented for 8 days, from 11/27/15 through 12/4/15, and nothing was given. -No BM documented for 9 days, from 12/6/15 through 12/14/15, and nothing was given. -No BM documented for 7 days 12/16/15 through 12/22/15, and nothing was given. -No BM documented for 10 days, from 12/24/15 through 1/2/16, and nothing was given. -No BM documented for 21 days, from 1/4/16 through 1/23/16, and nothing was given According to nurse's electronic progress notes, no abdominal assessments or rectal examinations, related to constipation, were documented between 11/1/2015 through 1/31//2016. On 1/27/16 at 6:00 p.m., Family #1 was interviewed via phone. Family #1 expressed concern about Resident #14 being constipated. He always had to have a bowel movement before leaving the house for work, she said, If he didn't, his work day didn't go right. Family #1 mentioned that she was giving Resident #14 chocolate-flavored Ex-lax when she thought he needed it. When asked if she inquired about his BM regularity, Family #1 said that she had not, and was not aware that BM's were to be tracked. When asked, Family #1 was not aware that Resident #14 was incontinent of bowel, and was surprised to hear it. On 1/28/16 at 11:50 a.m., Unit Manager E could not explain why no bowel movements were documented, nor treatment given to Resident #14. On 1/28/16 at 11:50 a.m., when asked, Director of Nurses B said that she didn't know what to say, but she knew there was a problem when she printed Resident #14's bowel tracker records. ( )

This portion of the citation pertains to intake number MI 033. Based on observation, interview, and record review, the facility failed to (1) provide staff assistance and (2) assess skin and/or wound in 3 of 5 sampled residents (#100, #109, and #108) reviewed for ADL (activities of daily living) and skin care from a total sample of 11 residents, resulting in (1) the development of a fungal skin infection, pain, and the potential for infections and (2) the development of an infection of a surgical wound and delay in treatment. Findings include: Resident #100 Review of the Face Sheet and MDS dated [DATE], revealed Resident #100 was a [AGE] year old female re-admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS reflected that Resident #100's ability to make daily decisions was cognitively intact and she required the assistant of one to two staff members for transfers, dressing, toilet use, hygiene and bathing. Review of the Incident Report dated 7/9/15 at 2-10 p.m., reflected that Resident #100, had an injury to her right inner ankle that included a hematoma/bruise and swelling. Review of the physician progress notes [REDACTED].#100 was seen for an evaluation There is increased [MEDICAL CONDITION] in the right medial aspect of the ankle .I will have nursing keep her back in bed with the lower extremity elevated which might improve her lower extremity [MEDICAL CONDITION] and we will put her in bed as much as tolerated .Report any acute changes. Review of the Physician Phone Orders and the Treatment Administration Record (TAR) dated 7/10/15, reflected that there was no order from the 7/10/15 physician progress notes [REDACTED].>Review of the Admission Care Plan dated 5/22/15, reflected that Resident #100 was on anticoagulant (prevents clotting) and the goal were .observe for signs and symptoms of bleeding, report as indicated, protect from injury. Review of the Care Plans, reflected that there was no Anticoagulant Care Plan after the admission care plan. In an interview on 9/21/15 at 3:30 p.m., Administrator A reported that there was no care plan for an anticoagulant except for the Admission Care Plan. Review of the Shower/Skin Observation dated 7/9/15 (no time), reflected that Resident #100 had a bump on her right ankle. Review of the Interdisciplinary Narrative Notes dated 7/9/15 -7/12/13, reflected no documentation about Resident #100's right ankle. Review of the Treatment Administration Record (TAR) dated 7/1/15, reflected 5/25/2015 Bilateral lower extremities: elevate three times a day for 30 min,The TAR was documented as completed by nursing staff from 7/9/15 - 7/14/15,1 except one opportunity. 5/27/15 Bilateral legs: apply lotion one time a day, The TAR was documented as completed by nursing staff from 7/9/15 - 7/14/15, 5/27/15 Bilateral lower extremities: apply compression stockings 15-20 mmhg thin, on in AM, off at bedtime. The TAR was documented as completed by nursing staff from 7/9/15 - 7/14/15. Review of the Interdisciplinary Narrative Notes dated 7/13/15 at 2:52 p.m., reflected that physician was in to see Resident #100. New order for X-ray right foot and ankle due to pain, bruising. Review of the Interdisciplinary Narrative Notes dated 7/14/15 at 10:53 a.m., reflected Resident #100 Noted large increase in [MEDICAL CONDITION] and bruising right ankle since nurse observed at 7 AM. Nurse practitioner notified with orders to send to ER for evaluation. Review of the physician progress notes [REDACTED].#100 was seen for an ongoing [DIAGNOSES REDACTED]. She states that there was some irritation secondary to hitting her wheelchair. She has a hematoma on the ankle at this time. She does have pain and swelling to the area. There is the potential that if it does continue to swell she might have to have this opened from the hematoma Skin: The hematoma is soft and painful at the present time. It does not look to be bleeding any further. She does have pain and tenderness in the ankle. The hematoma is present with swelling and redness, and again is extremely painful. In an interview on 9/21/15 at 12:00 p.m., Director of Nursing (DON) Registered Nurse (RN) B reported that she did investigation after Resident #100's family reported the bump on her right ankle and that staff would continue to monitor bump. DON B reported that there was no documentation on the TAR to continue to monitor bump to Resident #100's right ankle. In an interview on 9/21/15 at 1:45 p.m., Licensed Practical Nurse (LPN) EE reported that she worked on 7/12/15 and that initials on the TAR indicated that she applied lotion to Resident #100's legs, but could not recall what her right ankle looked like. In an interview on 9/21/15 at 5:04 p.m., LPN AA reported that family of Resident #100 called on 7/9/15 to ask what we were doing about the right ankle, which family stated had been bumped a few days prior. LPN AA reported that the area on the right ankle of Resident #100 looked like a blood blister, but she pressed on it to see if the blood was movable and it was not. LPN AA reported that she would have verbally passed on to the next shift the bump on Resident #100's right ankle so that it could be monitored. LPN AA reported that if NP II wanted to have Resident #100's legs elevated and her in bed as much as tolerated it should have been written in the TAR. In an interview on 9/21/15 at 1:58 p.m., Registered Nurse (RN) FF reported that staff informed her the family of Resident #100 called on 7/9/15 to ask what was being done for the bump on Resident #100's right ankle that had been hit by her foot peddle on the wheelchair. RN FF reported that an incident report was started and she assessed the ankle and documented the bump to right ankle as a hematoma/bruise with swelling and put Resident #100 on the list to have the nurse practitioner look at her on his next visit. RN FF reported that an x-ray was order after the nurse practitioner looked at Resident #100 on 7/10/15 and that came back negative. In an interview on 9/21/15 at 2:10 p.m., LPN CC reported that she did the treatment on Resident #100's leg (applied lotion) on 7/13/15 at about 11:30 a.m., but did not take care of Resident #100 but a couple of times and does not recall anything out of the ordinary. In an interview on 9/21/15 at 2:15 p.m., LPN DD reported that if there was not an order to look for changes in Resident #100's right ankle she may not have looked at the ankle. In an interview on 9/21/15 at 3:15 p.m., Nurse Practitioner (NP) II reported that after his assessment of Resident #100's right ankle on 7/10/15 he would expect nurses to check ankle. In an interview on 9/21/15 at 4:00 p.m., Physician JJ reported that he was called to examine Resident #100's right ankle on 7/13/15 just as he was leaving, tests were ordered to check the clotting factors and her blood count, but he did not feel the hematoma was bad enough to send Resident #100 to the hospital. Physician JJ reported that the test results were monitoring of the right ankle and that staff found the increase in the hematoma on 7/14/15 and sent her out. Review of the Inter-Facility Continuity of Care Report dated 7/14/15 (no time), reflected that Resident #100's reason for transfer bruising, increased [MEDICAL CONDITION] right ankle. Review of the Operative Note dated 7/14/15 (no time), reflected that Resident #100's Indication for Surgery: This is a [AGE] year-old lady who presented with expanding mass in the right lower extremity .When I saw her the lower extremity below the knee was quite tense and hard and very painful. I was not sure whether patient has a [DIAGNOSES REDACTED] also from the bleeding. In the interim apparently the skin spontaneously ruptured and she bled almost 2,000 mL of blood. The patient has been taking [MEDICATION NAME] (an anticoagulant) at the (facility) 6 mg daily and also [MEDICATION NAME] 80 mg twice a day. The blood was not clotting. We gave her a couple units of fresh frozen plasma and blood and we proceeded to the operating room. In an interview and observation on 7/16/15 at 1:20 p.m., Resident #100 was up in a wheelchair with her right leg bent down and foot sitting on the foot peddle. The right leg had a dressing on it, Resident #100 stated that she had been bumped on the right ankle by the foot peddle and about 2 weeks after it happened the bump increased and got hard like a ball, she went to the hospital and it broke open, and she has been going to the wound clinic once a week since and having the dressing changed daily. Resident #109 Review of the Face Sheet and MDS dated [DATE], revealed Resident #109 was a [AGE] year old female re-admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS reflected that Resident #109's ability to make daily decisions was cognitively intact and she required the assistant of one to two staff members for transfers, dressing, toilet use, hygiene and bathing. In an observation on 9/17/15 at 11:30 a.m., Certified Nursing Assistant (CNA) O and CNA R did perineal (peri) care for Resident #100. The brief was loosed and revealed a large soft stool which had oozed forward in the vaginal area. CNA R used a wash cloth with soap was used to remove the stool and clean from the back to the front of the vaginal area, a wet wash cloth was used to rinse the vaginal area from back to front and the area was dried with a wash cloth from back to front Resident 100 yelled ouch ouch easy that is sore, CNA O stated I can see why it hurts the vaginal area was bright red spreading outward to the tops of her thighs on both sides of the labia. A clean brief was placed on Resident #100 with no barrier cream to the vaginal area. CNA R and CNA O assisted to dress and transfer Resident #100 to her wheelchair with Resident #100 voicing that it was painful to her neck during dressing. CNA R and CNA O pushed Resident #100 past Registered Nurse (RN) KK. In an interview on 9/22/15 at 11:15 a.m., RN KK reported that on the day Resident #100 was re-admitted on [DATE] and she had a small red area above her labia in the vaginal area. RN KK reported that staff did not inform her that Resident #100 was complaining of pain during cleaning of her vagina on 9/17/15, they just said she complained a lot. RN KK reported that if the CNA saw reddness to the vaginal area during care she would have expected them to notify her. Review of the current CNA Nursing Care Card, reflected no special treatments for bowel and bladder care. Review of the Nursing Admission assessment dated [DATE] (no time), reflected Resident #109 had sligh redness in peri area. Review of the Physician Phone Orders dated 9/16/15 - 9/22/15, reflected that no order for vaginal cream was documented. In an interview on 9/22/15 at 11:05 a.m., Resident #109 reported that her vagina area hurts when they clean her. # This citation pertains to MI 148 Resident #108 According to a facility face sheet dated 8/24/15 at 1:52 p.m., Resident #108 was a [AGE] year old female admitted into the facility on [DATE] at 3:00 p.m. with the [DIAGNOSES REDACTED]. A facility document titled, admission orders [REDACTED]. According to a Nursing Admission Assessment dated 8/1715 (no time noted), reflected, Integumentary (skin): 1) 40 by (unable to read) area (area noted is right abdomen. 2) 10 x 5 cm (centimeter) scabbed area (area noted is left ball of foot), 3) boot with pins ([DEVICE]) (left ankle area is noted). 4) Incision (no measurements, left ankle area is noted). An acute care facility discharge instruction dated 8/17/15 reflected that Resident #108 was discharged on [DATE] to a skilled nursing facility and required wound care to her left lower leg/ankle. A facility physician order [REDACTED]. apply xeroform to base of each pin, weave Kerlix fluff throughout pins. cover with egg crate foam, light wrap with age wrap daily. According to a facility document titled, Nursing Care Card (no date noted) for Resident #108, Resident #108 required, Extensive assistance bathing for a shower or a bed bath. An Admission Minimum Data Set for Resident #108 dated 8/24/15 reflected for Personal hygiene (how a resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands), Resident #108 required, extensive assistance of one person. Bathing, Resident #108, activity did not occur in past 7 days. A facility policy titled, Shower/Skin Observation dated revised 6/2011 reflected, The nursing assistant is to complete the Shower/Skin Observation form with each shower, whirlpool, or complete bed bath for each guest twice weekly. The nursing assistant is to check the appropriate area(s) on the form and note the location of any abnormalities by placing an X on the body diagram. The nursing assistant is to describe these areas as bruise, abrasion, skin tear, reddened area, scabbed area, rash, or other to the best of his/her understanding .the nursing assistant will then sign and date the form. The nursing assistant is to notify the charge nurse and obtain the charge nurses signature and date. The charge nurse will read the information on the form and follow up on any reported areas. If the nursing assistant has reported any abnormalities, the licensed nurse must observe the areas. The charge nurse will chart any abnormalities int he guest's medical record .the Director of Nursing or his/her designee will check the Shower Book daily. A facility document titled, Weekly Skin Assessment no date noted for Resident #108 was shown to UM G. UM G was asked what this form was. UM G stated it was a skin assessment that was completed weekly by the nurses. Resident #108's weekly skin assessment to be completed by had not been done during her stay from 8/17/15 to 9/9/15. A facility document titled, Wound and Skin Condition dated, first observed 8/19/15, site: left lower extremity, category: wound, type: 2 surgical, treatment: TAO (treatment as ordered). On 8/19/15 (no time noted) wound status is noted to be PTW (Partial Thickness Wound), 13.5 cm length (no width or depth noted). No odor. No drainage. Color Pink. Comments: 10 pins [DEVICE]. Staff initialed this. On 8/26/15 (no time noted), wound status is noted to be, 2 (surgical). Length of wound is 13.5 with no width or depth noted. No odor, No drainage, Color pink. Comments: sutures intact, no signs or symptoms infections, no drainage from pins. Staff initialed this. On 9/2/15 (no time noted), the assessment notation was, out on appointment to surgeon. Staff initialed this. A Report of Consultation dated 9/2/15 (no time noted) by Resident #108's consulting surgeon reflected, Macerated pin sites, redness consistent with [MEDICAL CONDITION] (infection of the skin) around the pins. x rays look good. Diagnosis: [REDACTED]. Recommendations: Pin care 50% normal saline 50 (%) hydrogen peroxide tid (three times a day). Start [MEDICATION NAME] (an antibiotic for the [MEDICAL CONDITION]) bid (twice a day), leave open to air after pin care, no xeroform or gauze, re check in 1 week. No weight bearing left lower extremity. There was no measurement or in depth assessment of the wound noted by the physician. On 9/9/15 (no time noted), the assessment notation was, LOA (leave of absence) to ortho appointment. Staples out 9/2/15. Staff initialed this. Review of a facility policy titled, Dressing Change, Clean Technique dated revised 3/2010 reflected, Document appearance of the wound on the Wound and Skin Condition Record .Document measurements, appearance, peri wound, and drainage on the appropriate record. This policy does not define frequency of this needed documentation. According to Nursingtimes.net, there is information required to assess a wound. The assessment process, which can be assisted by the use of a wound assessment tool, should help identify: the number and location of wounds, the grade of the wound/s - color and or/numerical grading tools may be used, the size of the wound - dimensions (length, and breadth or width) .nature of any wound fluid - is it exudate (slough), serous fluid (clear fluid), or pus (infected fluid), the cause, nature and severity of any pain related to the wound .Assessment of the surrounding skin. Assessment should identify whether the skin is [DIAGNOSES REDACTED]tous (red and warm), excoriated (stripping of the top layer of skin), indurated (a change in skin temperature) or macerated (excessive moisture) .Documentation. This essential, both as a record of best practice at the time it was written and as a vital communication tool that should be accessible to all professionals involved in the management of the patients wound. (http://www.nursingtimes.net/Journals/2012/10/05/y/v/c/ 1The-elements-of-wound-assessment.pdf) An interview on 9/18/15 at 11:00 a.m. by phone, Resident #108 revealed that when she got to the emergency room , staff said she had a bad fungal infection in her abdominal folds. Resident #108 stated she wasn't aware of the infection. It wasn't bothering me. Resident #108 required assistance with bathing and wasn't able to accomplish the task herself adequately. Skin folds were not assessed by facility staff, both certified nurses aides and nursing and a resulting fungal infection occurred. There was no staff written assessment of the surgical wound since 8/26/15. Resident #108 was hosptalized on [DATE] to treat [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staph aureus, a skin bacteria that is resistant to many antibiotics) in her surgical ankle wound. Acute Care hospitalization Acute Plan of Care notes dated 9/10/15 (no time noted) reflect, MRSA, wound. Patient admitted with infection of [DEVICE]s of her left lower leg. A request for all skin documentation was made to Director of Nursing B. Skin assessments that were given are as documented in this citation. No further skin documentation was made available before survey exit on 9/21/15. ( )

This Citation pertains to MI 924 Based on interview and record review the facility failed to monitor a resident timely in 1 of 5 sampled residents (#105) reviewed for acute change of condition, from a total sample of 5 residents, resulting in Resident #105 being found blue/purple in color, cold to the touch and unresponsive. Findings include: According to the Legal and Ethical Issues in Nursing, fourth edition, by Guido (2006), standards of care must have and use the knowledge and skill ordinarily possessed and used by nurses actively [MEDICATION NAME] in the nurse's specialty area. According to the Code of Ethic for Nurses (American Nurses Association, 2001, p. 14), the nurse's primary commitment is to the health, well-being, and safety of the patient. The nurse must take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team. The Code of Ethics for Nurses (p. 17) goes on to state the nurse is accountable to the quality of nursing care given to patients and the delegation of nursing care activities of other health care workers. The nurse is responsible for monitoring the activities of these individuals and evaluating the quality of the care provided. The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). Resident #105 was admitted to the facility on [DATE] and died on [DATE] with a medical history according to the facility face sheet and hospital records which included left hip replacement surgery, diabetes, depression, coronary [MEDICAL CONDITION] and sleep apnea. Review of the Nursing Admission assessment dated [DATE] revealed Resident #105 was admitted at 2 PM. Resident #105 was cognitively intact for daily decision making skills. Review of the facility Nursing Care dated [DATE] titled Admission Care Plan (Initial Care Plan used on new admissions) Admission Diagnosis: [REDACTED]. Circle the title of each applicable care plan problem, 2. Indicate each approach that will be used. 3. Individualize goals and approaches as appropriate. During a telephone interview on [DATE] at 3:45 PM, Family Member J reported they got to the facility about 5 PM (on [DATE]) and she (Resident #105) was so sleepy and while talking would doze off. Family Member J stated, As we were getting ready to leave, she hollered she was going to be sick and throw up. So I grabbed the papercan and she threw up black stuff. A lot of liquid, black chunks. It was 6:20 PM. I looked at the clock. The nurse came in and we left. During an interview on [DATE] at 1:50 PM, Certified Nurse Aide (CNA) F reported that she worked on ,[DATE] the 2 PM-10 PM shift and had helped Resident #105 get ready for bed on [DATE] and that two family members had told her that Resident #105 had a black liquidly emesis grayish-black approximately 120 cc. CNA F stated, The resident had me call her daughter and I told her it probably wasn't anything to worry about, but I would let my nurse know. So I cleaned her up, but without thinking I threw it away. The family had given her the papercan to vomit in and I did it without thinking. I took her vital signs like I was told, wrote them on the sheet and the nurses transcribe them onto the record. I didn't know she was a Diabetic. At 9 PM when I checked on her, she said she felt better but was really tired. My shift ended at 10 PM and I went home after I did my hand-off to the next shift. I did tell them about her vomiting but don't remember if I told them about the color. During an interview on [DATE] at 2:15 PM, Licensed Practical Nurse (LPN) G reported that she worked on [DATE] on the ,[DATE] PM shift. LPN G reported that the CNA did tell her about the emesis and she had the CNA get vital signs. When asked to locate the documentation regarding the emesis and assessment of Resident #105 related to the emesis, LPN G replied, It's not there. I didn't document that and I didn't call the doctor. It was a one time event. Review of the document titled Observations To Report To The Physician Rev ,[DATE] Policy: The licensed nurse will report changes in the guest condition due to illness, exacerbation of existing condition or accidents and incidents to the physician as soon as possible, but no later than one hour after the observation of a significant or life threatening change in condition, and four hours for an observed change in condition. Procedure: 1. Notify the physician of a change in the guest's condition. 2. Document the time and date that the physician was notified. the physician's response, and any treatment ordered in the Progress Notes. Section titled Nausea and Vomiting report as self-induced by resident; projectile (with force) describe color (bloody, coffee-ground, greenish) consistency (liquid or undigested food). Review of Resident #105's Medical Record dated [DATE] 9:21 AM upon entering room at 8:45 AM (5 ,[DATE] hours after resident was last seen by facility staff) resident was found in bed unresponsive with no pulse or respirations noted. Resident is a full code and initiated CPR at 8:48 AM. EMS arrived and took over CPR but were unsuccessful. Time of death at 9:12 AM. Attempted to contact family. Left message to have family return call, Doctor notified of events. Review of the EMS Prehospital Care Report Summary dated [DATE] at 8:53 AM Clinical: [MEDICAL CONDITION] Breathing: Apneic (no breathing) Skin Temperature: Cold Left and Right Eye Not reactive. Cardiac Rhythm: Asystole (no heartbeat) Blood Sugar 107 Narrative History: Staff relates patient was last seen 6 hours ago. Very cold apneic and pulseless. AED (automatic external defibrillator) advised no shock. Pt. very cold, dry. Dr. called after 18 minutes stated to stop resuscitation. Time of death 09:12 AM. In an interview conducted on [DATE] at 11:05 AM, LPN D reported she was the nurse on duty on [DATE] beginning at 6 AM and reported she (Resident #105) was last on the list to do accu-checks. LPN D stated, I went into the room and called her name with no response. I checked her, then called a code. She was cold, pale with a purplish blue color. No CNA's had seen her from 6 AM until I entered the room at 8:45 AM. She possibly wasn't checked since the night before. When I asked the CNA (CNA O) on the previous night (10 PM-6 AM) shift when had she seen (Resident #105) last, she told me she saw her at the start of her shift (10 PM) and she was OK. When I called the code we started chest compressions and giving breaths, 2 other nurses came to help, the paramedics came in to relieve us, I tried to call the family, but the family came in 15 minutes after we called the code, I informed the family of the events, called the coroner, gave information to the family about an autopsy, body was released, I called the attending physician, and the body was released to the funeral home. In a second telephone interview on [DATE] at 10:48 AM, LPN D reported that when she entered Resident 105's room on the morning of [DATE] that she had no C-Pap on. She had been dead for awhile. We used the Ambu bag, did chest compressions the call lite was attached to her bed within reach. Review of the facility provided document titled Job Description: Certified Nursing Assistant Revised ,[DATE] Section 3 Personnel Functions - check Guests routinely to assure that their personal care needs are being met. During an interview on [DATE] at 12:15 PM CNA M reported that she worked the 6 AM to 6 PM on [DATE] and had arrived an hour late. CNA M stated, A CNA stayed over the hour until I got to work at 7 AM. I got report from her. She told me she did a walk through with the midnight person at 6 AM, gave me a run down and then she left. I continued with resident care and taking residents to the dining room. Next thing I know nurses are doing CPR. I didn't see or speak to her (Resident #105) that morning (from 7:00 AM to 8:45 AM when Resident #105 was found by LPN D). I was busy getting residents to the dining room. During an interview on [DATE] at 3:10 PM CNA O reported that on [DATE] I assisted her to the bathroom, it was a busy night. I remember I did a bed check the door was open the TV and lights were on. I think it must have been about 2 AM when my co-worker took her to the bathroom I think the last time I saw her was between ,[DATE]:30 AM. We do last bed check about 3 AM and then start getting stuff around for AM care. My co-worker told me she had took her to the bathroom (in the middle of the night). We start report at 6:15 AM. I know the 3rd shift CNA stayed over. I tried to give report at 6 AM but they disappeared so I left. CNA O had not observed or checked on Resident #105 from approximately 3:30 AM until the time she left at approximately 6:15 AM. Multiple telephone calls/messages were placed by this surveyor during the investigation in an attempt to interview the 2nd CNA assigned to the hall on [DATE] 10 PM- 6 AM shift with no calls returned. During a telephone interview on [DATE] at 2:45 PM Registered Nurse (RN) N reported that he worked the 10 PM-6 AM on [DATE]. RN N stated, When I come on at 10 PM, we get report, at midnight pass any medications. If I remember that resident had no medications scheduled at midnight. I make at least hourly rounds to check if resident's are in bed, peek in on them with a flashlight. I can't pinpoint the exact times. I don't recall the last time I saw her. I don't recall if during report there was any mention of an emesis. During an interview on [DATE] at 9:55 AM Director of Nurses (DON) A reported that We don't have a policy about checking resident's. They answer call lights, give medications, take vital signs and assist residents to the bathroom, but nothing such as a Policy and Procedure. In a telephone interview on [DATE] at 8:50 AM, Physician P, who performed the autopsy on Resident #105, reported that there was dark green liquid in the stomach of undigested gastric contents. Physician P reported, There was pathology of an enlarged left ventricle with moderate 50% occulusion of 2 vessels, advanced [MEDICAL CONDITION] but will not be sure until the microscopic slides of tissue are returned to me to be sure of cause of death. I believe this may have been a cardiac event. ( )

This Citation pertains to MI 591 Based on observation, interview and record review the facility failed to ensure the safety and adequate transfers to prevent falls in 3 of 11 sampled residents (Resident #3, Resident #6, and Resident #4) reviewed for falls, from a total of 24 sampled residents, resulting in a fall with neck and facial fractures for Resident #3, a fall with the potential for undetected head injury for Resident #6, and the potential for a fall with injury for Resident #4. Findings include: Resident #3 Resident #3 was observed during initial tour on 1/26/15 at 9:30 AM in bed in her room, wearing a neck brace with two blankets rolled next to her head. Both eyes were purplish, blue from mid temple to cheeks across both cheeks in a "lone ranger mask" configuration. When tour guide # C was asked how the resident sustained [REDACTED].?" "yes". According to the Minimum Data Set (MDS) dated ,[DATE], Resident #3 was admitted to the facility 7/8/2013 with a medical history which included high blood pressure, diabetes, dementia, depression, stroke and fall history. The MDS dated ,[DATE] revealed Resident #3 was sometimes able to makes herself understood and usually had the ability to understand others, was severely cognitively impaired for daily decision making skills, required extensive one person assistance with transfers, walking in the room and corridor, moving about the unit, dressing, eating, toileting, personal hygiene. Resident #3 was totally dependent on staff for bathing, was incontinent of both bowel and bladder, and was only able to stabilize with staff and not steady while walking, moving from seated to standing position, turning around to face the opposite direction, moving on and off the toilet and transferring from surface to surface such as bed and chair. Review of the Fall Risk assessment dated [DATE] revealed Resident #3 had a total score of 15 were as a total score of 10 or more represented a "High Risk" for falls. Resident #3's total score dated 10/14 was 17. Review of the "Nursing care card" (directions for Certified Nurse Aides (CNA's) to provide care) dated 8/8/14 revealed in the section "dressing: "shoes on when up" was documented. Review of the Plan of Care for Falls dated 7/11/14 revealed Resident #3 was "at risk for fall related injury related to unsteady gait, impaired mobility, psychotropic drug use, dementia. Goal: free from major injury through next review 1/11/15. Interventions: keep items of frequent use within reach, administer med's as ordered, monitor for fatigue and unsteadiness encourage rest periods, keep bed in low position, supervise and assisted with transfers, orient to surroundings as needed, complete fall risk per protocol, ambulate with one assist and walker (dated 9/29)." The care plan had an update on 8/8/14 which indicated Resident #3 was to have "shoes when up" and "gripper socks while in bed". On 8/6/14, Resident #3 was to have, "Dycem to floor in front of bed and chair." Review of the Incident report dated 6/18/14 at 8 PM revealed Resident #3 sustained a 8 cm X 2 cm bruise to the left hip area. Review of a written staff statement revealed, "I was changing her brief and she fell . I had caught her from falling down." The Investigation note dated 6/18/14 revealed Resident #3 "plopped down" in her bedside chair landing with her left side against the arm of the chair. An intervention put in place included a pillow was placed in the chair on the left side. Review of the report dated 6/22/14 at 4 PM revealed Resident #3 was, "Found on floor" in her room. The Post Fall report revealed circumstances of the fall indicated "transferring" as guest activity. The section Guest oversight/supervision at time of incident revealed, "Sensor pads to bed and chair at all times, fall mat at bedside". The report indicated the alarm was sounding. Review of the Nurses Note dated 6/22/14 at 7:21 PM revealed, "Resident (Resident #3) found on floor at 4 PM, asked about event resident smiled, no complaints of pain assisted back to chair X 2 assist. No obvious signs of injury". Review of the Incident report dated 8/5/14 at 4:50 PM revealed Resident #3 was, "found on floor in room." Review of the written staff witness statements revealed, "Passing med's, CNA's came and got me. I saw her sitting directly in front of her personal recliner, on the mat. Wondered if she tried to transfer self to bed from recliner. Both bed and chair alarms were going off arms and hands were not touching bed when I entered room." Review of the fall summary revealed, "Observed (Resident #3) sitting on floor, directly in front of personal recliner. Seated on floor mat, alarms were sounding. Observed that sensor pad was forward in chair. In conjunction with position on floor, leads to conclusion she slid out of chair as she attempted a self transfer. Dycem applied to top and bottom of sensor pad in recliner". (Dycem anti-slip material). Review of the Incident report dated 8/7/14 at 6:15 PM revealed Resident #3 was, "Found on floor in room. Skin tear and bruise." The diagram on report indicated Resident #3 had a skin tear 0.5 cm on head and hematoma 3.5 cm X 4 cm on head. Review of the written staff statements revealed, "Was walking down hall, opened door at 6:30 PM heard alarm going off. Resident (Resident #3) on floor, over on roommates side of room, head leaning on foot board of bed. Last seen sitting in recliner. Sustained hematoma to right forehead, skin tear on bridge of nose, to ER for CT scan, she is to wear shoes when walking." Review of the Incident report dated 1/19/15 at 5:45 PM revealed Resident #3 had a "Fall in dining room" Type of injury "laceration, bruise, swelling middle of forehead 6 X 7 cm. to ER at 6 PM. Review of post fall report from 1/19/15 circumstances of fall "ambulating". Review of the Post fall summary dated 1/20/15 revealed "at approximately 5:45 PM (Resident #3) was observed by Certified Nurse Aide (CNA) as she tripped and fell face first onto the dining room floor. She was observed at 5:35 PM sitting at the table she eats meals at (no alarms were present). She was not seated in her usual seat, rather opposite seat normally at. CNA left the dining room to assist another caregiver (leaving Resident #3 unattended) and returned approximately 10 minutes later. As CNA re-entered dinning room observed resident ambulating from northeast section of dining room toward her usual dining table. CNA observed her take step, trip and fall landing on her face. She was assisted to sit up. Extremities evaluated no sign of injury, lifted into wheelchair taken to her room, 911 was called, sent to ER, left facility at 6:30 PM." During an interview on 1/28/15 at 3:50 PM, CNA "I" reported she was present in the dining room setting up coffee and beverages for residents. CNA "I" stated, "I had all my resident's in the dining room. My hall partner came and got me and we went down the hall 2 doors to help her transfer a resident into the wheelchair. As I got (back) to the small door in the dining room, I saw (Resident #3) trip and fall. She was not sitting at her normal table there had been an activity prior and they (activity personnel) had left at approximately 5 PM. The resident's (in the dining room) were left alone because we had to bring other resident's in. (Resident #3) required supervision. When we only have 4 CNA's, there is no one in the dining room, but if we have 5 CNA's it sure is better when there is. Resident #3 is suppose to have supervision when she was up, there was no supervision in the dining room when she fell . I was coming back into the dining room, I saw her fall face first with no attempt to break her fall. She had grippy socks on, she didn't have shoes on". During an interview on 1/28/15 at 4:12 PM, CNA "J" reported she was assigned to Resident #3 the night of the fall. CNA "J" reported she had seen Resident #3 sitting in a chair across from the nurses station at approximately 2:10 PM with other residents. Both she and CNA "I" had their breaks and began getting residents ready for dinner. CNA "J" stated, "I needed help, so I went and got (CNA "I"). We transferred another one of my residents and (CNA "I") left to go back to the dining room. When I had brought my resident to the dining room (Resident #3) had already fallen. CNA "J" stated, "She had slippy socks on. I had no idea she had to have shoes on. Every time I saw her she had socks on. I usually do check my care guides, but not that night." In an interview on 1/28/15 at 3:10 PM, Registered Nurse (RN) "H" reported that she didn't hear the fall, but heard someone say there was a fall, "so I went into the dining room. The other nurse on the other hall dealt with her head. I saw blood coming from her nose, we logged rolled her. (Resident #3) kept trying to move her head all over. We tried to stabilize her head. I checked her legs there was no pain, same length, she flexed her hips no pain, legs and arms were ok. I checked with my flashlight her ears and eyes her mouth was open she was gagging. I could see she had a broken nose, it looked like to me she had blood on the side of her mouth. She started gurgling, we had to immediately save her life. She was swallowing blood. We cleaned her airway out so she could breath, elevated her head 30 degrees. All the while the other nurse was holding onto her head with her hands around her neck. You could see she had obvious orbital fractures (bones around eyes), but she was OK. So 5 staff picked her up and lifted her carefully into the wheelchair, she was stiff and erect. She was non-compliant with alarms. She had socks on, no shoes. She does require supervision as she was constantly needing to be brought back. She was unsteady on her feet. She did require increased supervision from previous falls. The ambulance came and she was gone by 6:30 PM to the ER". Review of hospital radiology/emergency room reports dated 1/19/15 revealed Resident #3 sustained "fractures involving the C1 and C2 (vertebrae in the neck) unstable fracture with displacement, closed head injury with subdural bleed (blood on the brain), nasal fracture, superficial laceration to face over bridge of nose, superficial abrasion to face, multiple contusions with soft tissue hematoma, and abrasion to head and face (SEVERE)." ( ) Resident #6 According to the facility identification summary, Resident #6 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), dated [DATE], Resident #6 was moderately cognitively impaired, required assist of 1 staff for bathing, required assist of 2 staff for bed mobility, hygiene, dressing, toileting and a mechanical lift for transfers and was always incontinent of bowel and bladder. According to 1/2015 physician's orders [REDACTED]. According to the Fall Risk Assessment, dated 10/10/14, Resident #6 scored a 17 (10 or more represents high risk). Care plan interventions to prevent falls for Resident #6 were, bed in low position, half rails and 1 hour checks by aides was noted on the nursing care card. According to the Michigan Department of Community Health's "Falls/Fall Risk Process Guidelines", 2001, "Residents who have fallen are at risk for delayed consequences which may occur within several days after the fall; occasionally they can occur several weeks later. According to the Michigan Department of Community Health Clinical Advisory Panel's, "Clinical Process Guideline: Evaluation of Falls/Fall Risk Memorandum", dated 2/13/04, "The professional standard of quality for analyzing falls is the facility's staff and practitioners attempt to identify causes of the condition or problem...The facility's staff and practitioners use the information to decide how to best manage a resident's condition, symptom, or situation". According to the Incident report dated 11/3/14 at 3:30 p.m., Resident #6 had an unwitnessed fall and was found on the floor next to her bed. When asked what happened, Resident #6 said, "I was rolling over in bed and fell out". The report revealed that Resident #6 had been reminded several times to keep her legs in the bed as she was observed hanging her lower legs over the side. The report also revealed that 2 aides had repositioned her 30 minutes prior the fall, but there was no information about whether Resident #6 was repositioned in the middle of her bed or near an edge. The incident report failed to address whether or not Resident #6 hit her head when she fell . On the post-fall report, side rails were not checked, even though Resident #6 had them on her bed. The question, "Was height of bed adjustable?" was answered as not applicable. Documentation of neuro checks after the fall were requested, but not provided by exit at 5:00 p.m. on 1/30/15. On 1/27/15 at 11:40 a.m., Registered Nurse (RN)/Unit Manager "C" was interviewed about Resident #6's fall on 11/3/15. RN "C" understood how determining the root cause of a fall would drive planning interventions to prevent falls. RN "C" said that Resident #6 did have a bariatric (bigger) mattress prior to this fall, and confirmed that neuro checks were not done following the fall. She agreed that neuro checks should have been done. ( ) Resident #4 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #4 was an [AGE] year old male with [DIAGNOSES REDACTED].(narrowing of the arteries in heart), history of heart attack, chronic obstructive pulmonary disease (inflammation lung disease), congestive heart disease (decrease heart function), chronic kidney disease (decreased kidney function). The MDS reflected Resident #4 had a BIM (assessment tool) score of 10 which indicated his ability to make daily decisions was moderately impaired, and he required two person extensive physical assist with transfers, dressing, toileting, hygiene, locomotion on unit and total dependence with bathing and eating. According to the Facility Hydraulic Lift policy and procedure, dated November 2008, under "Policy: A hydraulic lift may be used at the direction of a physician's orders [REDACTED]. At least two staff members are to be present and assist in the use of the hydraulic lift when transferring a guest. Procedure:...5. Follow the manufacturer's guidelines regarding the operation of and procedure for guest transfer for the specific model of hydraulic lift..." According to the Owner's Operator and Maintenance Manual for the Manual/Electric Portable Patient Lift provided by the facility, dated 2011, under "Section 1, General Guidelines...Lifting the Patient. When using an adjustable base lift, the legs MUST be in a maximum Opened/Locked position before lifting the patient..." In an observation on 1/28/15 at 12:00 p.m. Resident #4 was observed being transferred from bed to geri chair with use of electric mechanical lift with assistance of Certified Nurse Aide (CNA) "O" and CNA "P". Lift sling was positioned under Resident #4. CNA "O" donned clean gloves and positioned mechanical lift legs under bed in closed position. Resident #4's lift sling was attached to lift and CNA "O" elevated Resident #4 off bed with support of CNA "P". CNA "O" rolled mechanical lift out from under bed. CNA "O" changed position of mechanical lift legs to open and positioned Resident #4 over geri chair from side and CNA "O" lowered Resident #4 into chair with assistance of CNA "P". ( )

This Citation pertains to MI 854 Based on observation, interview and record review the facility failed to notify the durable power of attorney (family member) and the attending physician in 1 of 9 sampled residents (#101) reviewed for notification following an abuse, from a total of 9 sampled residents, resulting in an Immediate Jeopardy when, beginning 7/14/13, Resident #101 was subjected to multiple sexual abuses from Resident #102 and facility staffs did not inform the physician or Durable Power of Attorney (DPOA) for further guidance and means to prevent additional incidences from occurring. This deficient practice placed all residents in the facility, who have been deemed mentally incompetent and may be subjected to resident to resident abuse, at risk for serious harm, injury, and/or mental anguish. Findings include: Review of the Facility Policy and Procedure titled "Abuse Prohibition, Investigation and Reporting" dated Rev 02/09 revealed "Policy: It is the policy of this facility to prohibit mistreatment, neglect and abuse of guests/residents and/or misappropriation of guest/resident property or resources. The facility shall not allow verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and all facility personnel will promptly report any incident or suspected incident of guest mistreatment, injuries of unknown source or misappropriation of property/resources. Reports of alleged abuse and/or misappropriation will be immediately reported to the Administrator and thoroughly investigated. Allegation of abuse/misappropriation and the investigative conclusion will be reported to the appropriate State regulatory agency, Law Enforcement agency, licensing and/or certification board as required by State and Federal law. Standard: The facility will not condone guest abuse by anyone, including staff members, other guests, consultants, volunteers, and staff of other agencies serving the guest, family members, legal guardian, sponsors, friends or other individuals. Section II: Identification: c: Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Section III: 1. The person(s) observing an incident of guest abuse or suspecting guest abuse must immediately report such incidents/suspicions to the Administrator. If the Administrator is not immediately available, the allegation should be reported to a charge nurse, social worker, nursing administration to ensure that the guest is safe. The supervisor/management person in charge will then immediately notify the Administrator. When an incident of guest abuse is alleged, the incident must be reported to the charge nurse regardless of the time lapse since the incident occurred. 4. The Administrator will appoint a representative to investigate the incident. The Administrator will initiate the Investigation of Alleged Abuse, Mistreatment, or Misappropriation (form #ADMIN009) and make the appropriate notifications as outlined on the form. 15. The Director of Nursing will inform the guest's attending physician and facility Medical Director of the investigation findings and corrective actions." Review of ADMIN 009 Form Contents revealed: "Intake information name of guest, nature of allegation, resident (s) involved reported to, date, time, who reported the alleged incident, initial details of allegation, action taken pending investigation. Notifications: MANDATORY: 1. Physician 2. Family 3. Corporate Representative. As Appropriate: 4. Adult Protective Services 5. Ombudsman 6. Local Police 7. Appropriate State Agency Date/Time Reported To: Name/Title and Comment Section were present on the form. Guest/Staff Member #1 Interviewed: Date/time Interviewee's written statement attached to incident report Yes/No What Happened?" Resident #101 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] and 2/25/14, and Physician ' s Progress Note, dated 4/1/14, revealed that Resident #101 had [DIAGNOSES REDACTED]. The MDS indicated Resident #101 required the extensive assistance of one person for locomotion and transfers, had no history of behaviors, and was unable to complete the Brief Interview for Mental Status (BIMS). Facility staff determined that Resident #101 had memory problems and was moderately cognitively impaired (decisions poor; cues/supervision required). Review of the facility document titled "Medical Condition/Rehabilitation Potential" dated 7/11/12, revealed Resident #101 had been deemed unable to make her own medical or financial decisions by two physicians. Review of the Care Plan titled "Cognitio" and dated 3/6/14, revealed Resident #101 had "impaired decision making related to [DIAGNOSES REDACTED]." Review of the Care Plan, titled "ADL" (Activities of Daily Living), revealed that Resident #101 required extensive assistance due to a "history of rotator cuff repair and muscle weakness and fatigue". Interventions included but were not limited to "encourage her to participate in care, set up supplies and instruct to wash face and hands". In an observation and interview on 5/5/14 at 12 PM, Resident #101 was observed in her room. Present at the doorway was a mesh Velcro entrance stop sign on the door frame with an alarm on the right side and Velcro attached to the left side holding it in place. Resident #101 was noted to be sitting in a wheelchair beside the bed bent over from the waist rubbing her legs. Resident #101's hands and arms were noted to be shaking. Resident #101's hair was unkempt with her clothing clean and shirt buttons/button holes mismatched. When asked by this surveyor how she felt Resident #101 replied "it's best not to say anything around here" and exited the room self propelling out of the room going under the stop sign at the doorway. Resident #101 went down the hallway into the main dining room and wheeled herself over to the table and waited for lunch. Resident #101 passed several other residents and did not acknowledge any resident while passing. Resident #102 Review of the facility MDS (minimum data set an assessment tool) dated 4/16/14 revealed Resident #102's BIMS score was 9 which indicated he was moderately impaired for daily decision making skills, required extensive two person assistance with transfers, required set-up supervision and was self-sufficient when in a wheelchair, required extensive one person assistance with dressing, personal hygiene and bathing, was frequently incontinent of urine and occasionally incontinent of bowel. Review of the Care Plan, titled "Behave 2" dated 8/2/13, revealed Resident #102 "has shown to have an actual behavior problem AEB (as evidenced by) yelling/screaming/cursing, history of being non-compliant with treatment, noted to be sexually inappropriate verbally during time of care being provided" and on 10/18/13 that "(Resident #102) at times has been noted to wander into others rooms uninvited i.e. opening closed doors." Interventions listed included but not limited to, "Reassure of safety, encourage diversional activity, observe and record behaviors, redirect behavior-be firm but supportive, provide a stable/supportive environment through consistency in daily routine, investigate each concern, staff should document fixations, interventions and outcomes." The care plan had an update on 12/11/13 which indicated, "Encourage resident to socialize on south hall (hall Resident #102 resided on) & by nurses station." Review of Resident #102's Behavior Log, dated 7/14/13 at 10:00 am, revealed Resident #102 was found in Resident #101's room. The log documented that Resident #101 was "scared" and told the facility staff member that Resident #102 was "going against her and putting his hands in her shirt and doing inappropriate things." There was no documentation in the medical record to indicate the DPOA or the attending physician had been notified of the incident that occurred on 7/14/13. Review of the Progress Notes, dated 8/13/13 at 2:45 PM, revealed the Certified Nurse Aides (CNA's) notified the nurse that Resident #102 was found in Resident #101's room rubbing her breasts. Resident #102 was escorted out of Resident #101's room and was placed on 15 minute checks. The note indicated per CNA, Resident #101 had her shirt pulled up for resident to rub her breasts. The note indicated the unit manager (Registered Nurse (RN)/Unit Manager #7) was notified. There was no documentation that Resident #101's DPOA or attending physician had been notified. Review of the Behavior log, dated 8/27 (year not designated) at 9:30 (am/pm not designated), revealed Resident #102 took down the stop sign and was found in Resident #101's room kissing her. The log indicated that Resident #102 "knew he wasn't supposed to be in there but he needed to see her. He knows how to take the stop sign down without setting the alarm." There was no documentation in the medical record to indicate the DPOA or the attending physician had been notified of the incident. Review of the Behavior log, dated 9/11/13 at 10:15 am, revealed Resident #102 was found in Resident #101's room with both residents "backs to the door. I could see his hands in front of her massaging her. He told me not to tell." Resident #102 was removed from the room and his actions were reported to the nurse. In an interview on 5/7/14 at 10:40 am, Certified Nurse Aide (CNA) #1 reported that on 9/11/13 when she found Resident #102 in Resident #101's room, Resident #102 had his hand on Resident #101's breast and was rubbing it. CNA #1 stated she got in trouble with the Director of Nursing (DON) #8 and Administrator #9 for documenting Resident #102's behavior. CNA #1 reported that she has been told by DON #8, Administrator #9, and the Unit Manager (Registered Nurse (RN) #7) not to document the behaviors "because if the State sees that, it will look like we're not doing our job." There was no documentation in the medical record to indicate the DPOA or the attending physician had been notified of the incident. Review of the Behavior log, dated 9/24/13 at 3:15 PM, revealed Resident #102 was found on the North hall at the end doors kissing Resident #101 on the mouth. In an interview on 5/7/14 at 11:00 am, CNA #5 reported after reviewing the behavior log that she found Resident #102 kissing Resident #101 on the mouth on 9/24/13. CNA #5 said, "Both residents were sitting in wheelchairs and he was leaning over into her kissing her. She was not leaning into him. I was told by the Social Worker that he (Resident #102) was not to be down the North Hall. I told the nurses that he wasn't allowed down there but they said they didn't know anything about it." Upon review of the CNA Care Kardex which indicated Resident #101 was alert to person, place and time, CNA #5 reported that Resident #101's care Kardex needed to be updated because she was no longer as alert as it indicated. CNA #5 reported that the Behavior Logs used to have information on what to do about Resident #102's behaviors, but the one she documented on did not have any interventions listed. CNA #5 agreed that Resident #102's care Kardex did not have instructions for 15 minute checks. There was no documentation in the medical record to indicate the DPOA or the attending physician had been notified of the incident. Review of the Behavior log,dated 10/28/13 at 11:15 am, revealed Resident #102 was found kissing Resident #101. There was no documentation in the medical record to indicate the DPOA or the attending physician had been notified of the incident. Review of the Behavior log, dated 5/2/14 at 10:10 am, revealed Resident #102 was found in Resident #101's room with "his hand down her pants touching her. She was moaning and making noises." At 10:20 AM the log indicated Resident #102 was "sitting at the nurse's station telling us he will go down the north hall as many times as he wants and there is nothing anybody can do about it." CNA #2 notified the nurse of the incident. In an interview on 5/6/14 at 1:50 PM Licensed Practical Nurse (LPN) #6 said, "After the incident, I called the DON and was told the social worker (SW #3) would come down and take care of it. I called her again and was told to not document anything that happened between (Resident #101 and Resident #102). I'm going to have him (SW#3) do it, he did the investigation, it's up to him to document." LPN #6 reported she assessed Resident #101 3-4 minutes maybe longer after she was notified about the incident and found no scratches, bruises or anything, but only assessed from the waist up. LPN #6 reported that Resident #101 could not recall the incident. LPN #6 reported that SW #3 came down to the unit on 5/2/14 and when she told him what happened, he responded, "Oh good, it means she's not upset." Review of the Social Worker type-written investigation (no date) revealed CNA #2 told Social Worker (SW) #3 that she was "charting at the nurse's station and (Resident #102) was noted to be halfway down the hall (south hall) talking to other residents. The next thing I see he was gone; it may have been 4-5 minutes from the last time I saw him. I tiptoed down to (Resident #101's) room because I've been told not to assume things are happening so I wanted to catch him. She had her hands on her pants exposing herself and his hands down her pants. (Resident #101) seemed to enjoy the interaction. She was smiling, I told (Resident #102) to leave and he did." There was no documentation to indicated the attending physician or Resident #101's DPOA were notified of the incident. In an interview on 5/7/14 at 10:08 AM CNA #2 was asked to review the type-written investigation for accuracy. CNA #2 documented and stated, "(Resident #101's) hands were down in the area but not sure if she was helping or not. I took (Resident #102) to the nurses station when I left the room". Review of the Psychiatrist Progress Notes, dated 7/10/13 through 3/19/14, revealed no documentation regarding any of Resident #102's behaviors. In an interview on 5/6/14 at 12:10 PM, SW #3 reported that Resident #101 and #102 "seek each other out often, but no actual touch. He (Resident #102) seeks friendship. We put (Resident #102) on 15 minute checks, a stop sign on both residents doors, and allow them to visit at the nurses station and look out the north hall windows and chat." SW #3 reported after the incident on 5/2/14, he visited Resident #101 and found her to have no problems. SW #3 stated, "I would not have called that incident a sexual assault because she did not say 'no'." When asked if Resident #101 could agree to have sexual encounters, SW #3 stated, "she didn't disagree, she didn't say no. She can make her needs known. She denied when I asked her that he was even in the room." SW #3 reported that the DPOA of Resident #101 had not been notified or asked if a relationship of any kind was permissible. When asked if Resident #101's DPOA had been told about a sexual relationship, SW #3 stated, "No, this was a consensual relationship" and Resident #101 had "no negative outcome" related to the incident. Social Worker #3 reported that on 5/2/14 he was notified by (DON #8) that a report was called to the DON by the staff nurse that Resident #102 was observed by a CNA with his hands inside Resident #101's pants with his hands inside her vagina. Social Worker #3 reported he went down to the unit (Unit C locked dementia unit) to check on Resident #101 and that Resident #101 was smiling and in no distress. SW #3 stated, "I wouldn't call that sexual assault, sexual assault is when someone says no". When asked if Resident #101 was clinically able to make her own decisions? Social Worker #3 replied "no". When asked if Resident #101 could agree to have sex, SW #3 stated, "she can make her needs known, she didn't disagree she didn't say no, she denied when I asked her that he was even in the room". When asked if the DPOA been called to give permission for Resident #101 to have sexual relations with Resident #102, SW #3 replied, "No". Review of the facility progress notes dated 5/2/14 at 12:06 PM, revealed "reported to Social Services that (Resident #102) was visiting with another resident in her room, pants open resident exposed. Social Services visited with Resident #101 and she states he has not been in here at all today and everything is fine." Review of the facility progress notes dated 5/7/14 at 10:40 AM entered by Registered Nurse (RN)/Unit Manager #7 "Nursing: spoke with (DPOA) on phone concerning his mother & (Resident #102). (DPOA) states he is well aware of his mother & (Resident #102). States his mother has behaviors & a temper to go with it. Review of the facility progress notes dated 5/7/14 at 10:40 AM entered by Unit Manager #7 "Nursing: spoke with family member #14 on phone concerning his mother and resident #102. Family member #14 states he is well aware of his mother and resident #102. States his mother has behaviors and a temper to go with it, very supportive family". Very supportive family. ' During a telephone interview on 5/7/14 at 5:05 PM, DPOA #14 (Resident #101's DPOA) reported that he was called by "someone this morning (5/7/14) about a relationship that had developed between his family member and another resident I think is name is (Resident #102)". DPOA #14 reported that she (Resident #101) had been seeing this resident sitting at the table, drinking coffee, looking out the window and there had been a question if Resident #101 had her blouse unbuttoned. DPOA #14 stated, "I don't care about them holding hands kissing and having coffee, but if anything goes beyond that that's a different story, I have been led to believe that I do not have the right to say no to the relationship, but anything that is physical or mental harm or fondling is not ok". DPOA #14 was asked by this surveyor if he was aware of an event which occurred on 5/2/14 in which a male resident was found with his hands inside (Resident #101's) pants. DPOA #14 replied "no that's not OK, no one told me about that. No that's just not OK". During an interview on 5/7/14 at 4:05 PM, RN #7 reported that she had spoken to Resident #101's DPOA on "numerous times" about the relationship between Resident #101 and Resident #102. When asked to locate the documentation in the medical record that showed those conversations, RN #7 was unable to locate the documentation. RN #7 stated, "I never thought I would have to document every conversation I have with everyone. I know if it's not documented it's not done". During an interview on 5/8/14 at 11:55 AM, Nurse Practitioner (NP) #12 reported she was not made aware of an incident which occurred on 5/2/14 involving Resident #101 and Resident #102, NP #12 reported that no information had been relayed to her involving either resident. During a telephone interview on 5/8/14 at 3:15 PM Attending Physician #13 (attending physician for Resident #101 and #102) reported being unaware of any behaviors involving Resident #102, any encounters between Resident #101 and Resident #102 including the incident on 5/2/14 where Resident #102's hand was observed down Resident #101's pants "until my Nurse Practitioner told me this morning". On 5/8/14 at 1:00 p.m., Administrator #9 was notified of an Immediate Jeopardy that began on 7/14/13 after Resident #101 was subjected to multiple sexual abuses from Resident #102 and facility staffs did not inform the physician or Durable Power of Attorney (DPOA) for further guidance and means to prevent additional incidences from occurring. On 5/12-13/14, this Surveyor confirmed that facility staff implemented the following to remove the Immediate Jeopardy: 1. On 5/8/14, Resident #102 was immediately put on 1:1. 2. On 5/8/14, the attending physician and Nurse Practitioner were notified. 3. On 5/7/14, Resident #101 was referred to the psychologist and seen. 4. On 5/7/14, Resident #102 was referred to the psychologist and seen. 5. On 5/8/14 the Director of Nursing, Social Services Director, Regional Nurse, and Nursing Administrative Staff reviewed all incident reports for the past 2 months; behavior logs for the past 6 months for residents on the secured unit; and the past 30 days of the facility 24 hour reports, to ensure that no other residents have been affected by inappropriate sexual behaviors. 6. On 5/8/14, the Administrator and Director of Nursing were re-educated by the Regional Quality Assurance Nurse and Regional Operator on the facility's policy and the federal regulations regarding notification of Family/Responsible party and physician. 7. On 5/8/14, 16 of 46 Licensed Nurses' were re-educated by the Staff Development Coordinator and Director of Nursing regarding the facility's abuse policy, prevention of abuse, notification of physicians and legal representatives of abuse, investigation, documentation of behaviors and ensuring interventions are implemented as identified in the plan of care. Licensed Nurses' will be in-serviced prior to assuming their work duties. 8. On 5/8/14, 2 of 2 Social Workers were re-educated by the Regional Quality Assurance Nurse on the facility's abuse policy, prevention of abuse, notification of physicians and legal representatives of abuse, investigation, documentation of behaviors and ensuring interventions are implemented as identified in the plan of care. Although the Immediate Jeopardy was removed on 5/8/14, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not yet been verified by the State Agency.

This Citation pertains to MI 854 Based on observation, interview, and record review, the facility failed to ensure the safety and prevent multiple resident-to-resident sexual abuses in 1 of 9 sampled residents (Resident #101), reviewed for abuse, from a total sample of 9 residents, resulting in Immediate Jeopardy when, beginning on 7/14/13, Resident #101 was subjected to repeated sexual abuses by Resident #102, and facility staffs did not prevent subsequent recurrences. This placed 31 additional female residents who resided on the locked dementia unit at risk for serious harm, mental anguish, and/or injury. Findings include: Resident #101 Review of the Face Sheet and Minimum Data Sets (MDS), dated [DATE] and 2/25/14, and Physician's Progress Note, dated 4/1/14, revealed that Resident #101 had [DIAGNOSES REDACTED]. The MDS indicated Resident #101 required the extensive assistance of one person for locomotion and transfers, had no history of behaviors, and was unable to complete the Brief Interview for Mental Status (BIMS). Facility staff determined that Resident #101 had memory problems and was moderately cognitively impaired (decisions poor; cues/supervision required). Review of the facility document titled "Medical Condition/Rehabilitation Potential" dated 7/11/12, revealed Resident #101 had been deemed unable to make her own medical or financial decisions by two physicians. Review of the Care Plan titled "Cognitio" and dated 3/6/14, revealed Resident #101 had "impaired decision making related to [DIAGNOSES REDACTED]. "Interventions included, but were not limited to, "help make decisions and advise of available options as needed, encourage to talk about safety decisions, help to explore options and understand ramifications of decisions." Review of the Care Plan, titled "ADL" (activities of daily living), revealed that Resident #101 required extensive assistance due to a "history of rotator cuff repair and muscle weakness and fatigue". Interventions included but were not limited to "encourage her to participate in care, set up supplies and instruct to wash face and hands." Resident #101 was observed/interviewed on 5/5/14 at 12 p.m., present at the doorway was a mesh Velcro entrance stop sign on the door frame with an alarm on the right side and Velcro attached to the left side holding it in place. Resident #101 was noted to be sitting in a wheelchair beside the bed bent over from the waist rubbing her legs. Resident #101's hands and arms were noted to be shaking. Resident #101's hair was unkempt with notable bad breath, clothing clean with shirt buttons/button holes mismatched, and no body odor was noted. When asked by this Surveyor how she felt, Resident #101 replied that her legs hurt but "it's best not to say anything around here" and exited the room self propelling out of the room going under the stop sign at the doorway. Resident #101 wheeled down to the dining room and waited for lunch. Resident #101 past several other residents and did not acknowledge any resident while passing. Resident #102 Review of the Face Sheet and Minimum Data Sets (MDS), dated [DATE] and 4/16/14 and the physician progress notes [REDACTED].#102 had [DIAGNOSES REDACTED]. The MDS revealed Resident #102 ' s BIMS score was a 9, indicating he was moderately cognitively impaired, had no history of behaviors, required oversight and set up for locomotion on the unit via wheelchair, and did not go off the unit. Review of the Medical Condition/Rehabilitation Potential, dated 6/4/13 and 6/12/13, revealed Resident #102 had been deemed unable to make his own medical or financial decisions by two physicians. Review of the Care Plan titled "Cognit02", dated 8/2/13, revealed Resident #102 "has shown to at times have impaired decision making related to current events likely r/t (related to) current medical condition along with dx (diagnosis) dementia. "The interventions listed included, "Help (Resident #102) explore options and understand ramifications of decisions, encourage to express and vent feeling as needed, observe for changes in moods and behaviors and notify physicians as needed, refer to psych services as needed." Review of the Care Plan, titled "Behave 2" dated 8/2/13, revealed Resident #102 "has shown to have an actual behavior problem AEB (as evidenced by) yelling/screaming/cursing, history of being non-compliant with treatment, noted to be sexually inappropriate verbally during time of care being provided" and on 10/18/13 that "(Resident #102) at times has been noted to wander into others rooms uninvited i.e. opening closed doors." Interventions listed included but not limited to, "Reassure (Resident #102) of safety, encourage diversional activity, observe and record behaviors, redirect behavior-be firm but supportive, provide a stable/supportive environment through consistency in daily routine, investigate each concern, staff should document fixations, interventions and outcomes. The care plan had an update on 12/11/13 which indicated "Encourage resident to socialize on south hall & by nurses station." Review of Resident #102's Behavior Log, dated 7/14/13 at 10:00 a.m., revealed Resident #102 was found in Resident #101's room. The log documented that Resident #101 was "scared" and told the facility staff member that Resident #102 was "going against her and putting his hands in her shirt and doing inappropriate things." Review of the Progress Notes, dated 8/13/13 at 2:45 p.m., revealed the Certified Nurse Aide (CNA) notified the nurse that Resident #102 was found in Resident #101's room rubbing her breasts. Resident #102 was escorted out of Resident #101's room and was placed on 15 minute checks. The note indicated per CNA, Resident #101 had her shirt pulled up for resident to rub her breasts. The note indicated the unit manager was notified. Review of the Behavior log, dated 8/22/13 at 11:00 (a.m./p.m. not designated), revealed Resident #102 was found by facility staff in Resident #101's room unbuttoning her shirt. The log documented that Resident #102 stated, "Oh don't report this or tell anyone. I am just having a little fun. I notified the nurse and minutes later he was caught in that room again." Review of the Behavior log, dated 8/27 (year not designated) at 9:30 (a.m./p.m. not designated), revealed Resident #102 took down the stop sign and was found in Resident #101's room kissing her. The log indicated that Resident #102 "knew he wasn't supposed to be in there but he needed to see her. He knows how to take the stop sign down without setting the alarm." Review of Resident #102's Behavior Log, dated 8/30/13 at 9:45 a.m., revealed Resident #102 was found on the North hall (where Resident #101 resides) upsetting (Resident #101) and "hollering at staff telling us to leave him and her alone ... She didn't want him down there ...He wouldn't leave her alone." Review of the Behavior log, dated 8/31/13 at 10:55 a.m., revealed Resident #102 was found going into Resident #101's room and was redirected out of the room. The log indicated, "by the time the nurse made it back to the nurses station, (Resident #102) was back in room [ROOM NUMBER] (Resident #101's room) and had to be removed again." Review of the Behavior log, dated 9/11/13 at 10:15 a.m., revealed Resident #102 was found in Resident #101's room with both residents "backs to the door. I could see his hands in front of her massaging her. He told me not to tell." Resident #102 was removed from the room and his actions were reported to the nurse. In an interview on 5/7/14 at 10:40 a.m., CNA #1 reported that on 9/11/13 when she found Resident #102 in Resident #101's room, Resident #102 had his hand on Resident #101's breast and was rubbing it. CNA #1 stated she got in trouble with the Director of Nursing (DON) #8 and Administrator #9 for documenting Resident #102's behavior. CNA #1 reported that she has been told by DON #8, Administrator #9, and the Unit Manager not to document the behaviors "because if the State sees that, it will look like we're not doing our job." Review of the Behavior log, dated 9/24/13 at 3:15 p.m., revealed Resident #102 was found on the North hall at the end doors kissing Resident #101 on the mouth. In an interview on 5/7/14 at 11:00 a.m., CNA #5 reported after reviewing the behavior log that she found Resident #102 kissing Resident #101 on the mouth on 9/24/13. CNA #5 said, "Both residents were sitting in wheelchairs and he was leaning over into her kissing her. She was not leaning into him. I was told by the Social Worker that he (Resident #102) was not to be down the North Hall. I told the nurses that he wasn't allowed down there but they said they didn't know anything about it." Upon review of the CNA Care Kardex which indicated Resident #101 was alert to person, place and time, CNA #5 reported that Resident #101's Care Kardex needed to be updated because she was no longer as alert as it indicated. CNA #5 reported that the Behavior Logs used to have information on what to do about Resident #102's behaviors, but the one she documented on did not have any interventions listed. CNA #5 agreed that Resident #102's Care Kardex did not have instructions for 15 minute checks even though her understanding was that Resident #102 was on 15 minute checks and had consistently documented them. Review of the Behavior log, dated 10/28/13 at 11:15 a.m., revealed Resident #102 was found kissing Resident #101. Review of the Facility Progress notes dated 11/24/13 "Resident (Resident #101) refused to come to dining room for lunch stated "didn't feel well". Resident from room [ROOM NUMBER]B (Resident #102's room) observed in her room after lunch. He dropped his electric cigarette on the floor and then told her to pick it up. She was in bed and attempted to lean over the side and was close to falling on the floor when CNA prevented this from occurring. Male resident removed from the room without problems." Review of the Facility Progress notes dated 2/22/14 at 10:09 p.m. "(Resident #102) was in the doorway of resident in room [ROOM NUMBER]B. refused to leave after female resident was yelling at him, tried to return to female resident's room and was redirected at 19:45 p.m. (7:45 p.m.). Review of the Behavior log, dated 5/2/14 at 10:10 a.m., revealed Resident #102 was found in Resident #101's room with "his hand down her pants touching her. She was moaning and making noises. CNA #2 notified the nurse of the incident." At 10:20 a.m. the log indicated Resident #102 was "sitting at the nurse's station telling us he will go down the north hall as many times as he wants and there is nothing anybody can do about it." Review of the Nursing Progress notes dated 5/2/14, revealed no documentation was present on the medical record regarding skin assessment completed for Resident #101 after the incident occurred. In a telephone interview on 5/6/14 at 1:50 p.m., Licensed Practical Nurse (LPN) #6 said, "After the incident, I called the DON (#8) and was told the social worker (SW #3) would come down and take care of it. I called her again and was told to not document anything that happened between (Resident #101 and Resident #102). I'm going to have him (SW#3) do it, he did the investigation, it's up to him to document." LPN #6 stated, "When I entered the room, (Resident #101) was sitting in her wheelchair leaning forward bent down I asked if she could tell me what had happened, she did not have any recollection of what had happened. I saw no bruises or scratches. I only pulled her brief out which was rumbled, but no I did not check between her legs. I only did a skin assessment top up, not waist down." LPN #6 reported that after she checked Resident #101 over she placed a second call to the DON to report there were no scratches or bruises. LPN #6 stated, "I was told that the Social Worker would come down and take care of it. That's when she (DON) told me make sure you don't document anything that happened between (Resident #101 and Resident #102), you can do a skin assessment he can't. When SW (#3) came down to the unit on 5/2/14 and I told him what happened (that Resident #101 did not recall the incident), he responded, 'Oh good, it means she's not upset'. I thought that a very strange remark. He talked with the CNA, I didn't see him talk to anyone else." LPN #6 reported that she often saw Resident #102 seek Resident #101 but not visa versa. LPN #6 stated, "I have even had to separate them. I saw (Resident #102) try to 'visit' (Resident #101). At some points (Resident #101) seemed afraid to go out of her room, she would say 'that man is out there'." Review of the Social Worker (SW) #3's type-written investigation (no date), revealed CNA #2 told SW#3 that she was "charting at the nurse's station and (Resident #102) was noted to be halfway down the hall (south hall) talking to other residents. The next thing I see he was gone; it may have been 4-5 minutes from the last time I saw him. I tiptoed down to (Resident #101's) room because I've been told not to assume things are happening so I wanted to catch him. She had her hands on her pants exposing herself and his hands down her pants. (Resident #101) seemed to enjoy the interaction. She was smiling. I told (Resident #102) to leave and he did." In an interview on 5/7/14 at 10:08 a.m., CNA #2 was asked to review the type-written SW investigation for accuracy. CNA #2 documented and stated, "(Resident #101's) hands were down in the area but not sure if she was helping or not. I took (Resident #102) to the nurses station when I left the room." Review of the Facility Progress Notes dated 5/5/14 at 12:08 p.m. "SS (Social Services/SW #3) spoke to (Resident #102) and he said he had no trouble over the weekend and that everything is fine. (Resident #102) made good eye contact during the visit, he was up in wheelchair waiting for breakfast." Review of Facility Progress Notes dated 5/5/14 at 12:14 p.m. "SS (#3) spoke to (Resident #101) and she said she had no trouble over the weekend and that everything is fine. (Resident #101) made good eye contact during the visit, she was up in wheelchair waiting for breakfast down north hall." In an interview on 5/6/14 at 12:10 p.m., SW #3 reported that Resident #101 and #102 "seek each other out often, but no actual touch. He (Resident #102) seeks friendship. We put (Resident #102) on 15 minute checks (did not indicate when), put a stop sign on both residents doors, and allow them to visit at the nurses station." SW #3 reported after the incident on 5/2/14, he visited Resident #101 and found her to have no problems. SW #3 stated, "I would not have called that incident a sexual assault because she did not say 'no." When asked if Resident #101 could agree to to sexual encounters, SW #3 stated, "she didn't disagree, she didn't say 'no'. (Resident #101) can make her needs known. She (Resident #101) denied when I asked her that he was even in the room." SW #3 reported that the DPOA of Resident #101 had not been notified or even asked if a relationship of any kind was permissible. SW #3 reported Resident #101 had "no negative outcome" related to the incident During a telephone interview on 5/12/14 at 1:42 p.m., Psychiatrist #16 reported that during the care conferences held monthly Resident 102's, behaviors were discussed and documented. Psychiatrist #16 stated that she sought outside consultation with a geriatric psychiatrist "because the case was so complicated I wanted to be sure we were doing things appropriately". When asked if she was aware of Resident 102's behavior prior to the incident on 5/2/14 Psychiatrist #16 stated, "Yes, I was aware of them. We had talked". When asked to identify who "we" was, Psychiatrist #16 replied, "the Unit Manager (RN #7) and Social Worker (SW #3)". When asked what behaviors were being discussed and of concern, Psychiatrist #16 stated, "The behaviors that Resident #102 displayed. No aggression. It would be a violation of his civil rights to stop a relationship which was voluntary and consensual. The Resident (#102) was always supervised and we had a grey area and not sure what to do." Psychiatrist #16 also reported that she had read and reviewed the Behavior Logs related to Resident #102 at the monthly care conferences attended by RN #7, SW #3 and herself. Psychiatrist #16 reported that she had never spoken to either Resident #102 or Resident #101's (there was no documentation present that Psychiatrist #16 had ever seen Resident #101 prior to 5/7/14) DPOA's about any behaviors, concerns, treatment plans, medication changes. Psychiatrist #16 stated, "The staff at the facility, the Social Worker does that. I don't speak to families usually, they (facility staff) do it". When asked why no behaviors were documented on the physician progress notes [REDACTED].#16 stated, "I am certain that I have documented about behaviors and again at the monthly care conferences it had been documented". When asked if she was aware of Resident #102 fondling Resident #101's breasts in the past and the sexual assault which occurred on 5/2/14, Psychiatrist #16 replied, "Yes I was aware of it when I wrote the Progress Note (on 5/7/14)." Review of the Progress Note dated 5/7/14, authored by the attending Psychiatrist #16 on Resident 102's medical record revealed, "patient currently evidences stable clinical status regarding psychopharmacologic schedule, no side effects of medications evidenced. Discussed with Interdisciplinary Staff that the patient has voluntarily had physical contact with another patient, as will voluntary on her part, and this has been by mutual choice therefore no evidence of harm to either. Staff is aware of this shared affection with other patient and will observe for any changes affecting both patients well being. No need for medication intervention required so as to not violate civil rights. I will continue to follow-up, Stable mood reported." Review of all provided Psychiatrist Progress Notes dated 7/10/13 through 3/19/14, revealed no documentation regarding any of Resident #102's specific behaviors. Review of the facility documents titled "Behavior Data and Analysis" for Resident #102, dated 3/6/13, 4/3, 5/1, 6/12, 7/10, 7/19, 8/6, 8/21, 9/10, 10/17, 11/6, 12/11, 1/5/14, 2/12, 3/19, 4/15, revealed the same words "new onset behaviors-severe anxiety and [MEDICAL CONDITION]. Mood and behaviors stable, will continue to observe" were documented. No other behavior information was documented. In an interview on 5/6/14 at 11:15 a.m., Unit Manager/RN #7 reported that Resident #102 did not score high and was basically not cognitively intact "depends on the day." When asked why the stop sign was across both Resident #101 and Resident #102's doorway it was to be able to "watch him and afford him privacy." When asked to review the unit's 24 hour shift-shift logs (report given to pass information between nurses) dated 5/2/14 on the 10 PM-6 AM shift was blank, 6 am-2 p.m. was blank, in the 2 PM-10 PM section "Resident #102" was named specifically for Resident #101's section. In Resident #102's section of the 24 hour log "behaviors 2-10" was written but without specificity. RN #7 reported that Resident #102 was "argumentative, upsets easily but behaviors have improved with medications, has a dry sense of humor, he goes on outings, has care plans to do gardening in the patio, and is seen quarterly by psychiatric services, incontinent of urine he waits too long and requires 2 person assistance if he does wet himself he places wash cloths inside his brief, but he has no other behaviors." RN #7 stated Resident #101 "is friendly likes to talk, she can stand to pivot, requires 2 assist, her cognition she knows her room and family she has a nice understanding family, requires supervision at meals, needs to be reminded to go to the bathroom but has no behaviors." When asked about the 24 hour log report documentation dated 5/3/14 for Resident #101 for the 10 PM-6 am shift "behaviors" was written, the 6 am -2 p.m. was blank and 2 p.m.-10 p.m. had documented "(Resident #102) not allowed off south hall OK" entered on the 24 hour shift-shift for 5/3/14 on 10 p.m.-6 a.m. shift "behaviors 2-10" meant, RN #7 stated, "he (Resident #102) is allowed on the south hall. He has no other behaviors. I don't know what that means." During a second interview/document review on 5/7/14 at 6:38 p.m., RN #7 was asked who was responsible to document on the Facility Behavior Logs, Progress Notes, Monthly Care Conferences, and Nursing Care Plans. RN #7 stated, "both myself and the Social Worker are. I update the Nursing Care Plans and CNA Care Guide and document the care conferences, SW (#3) writes the interventions related to the behaviors on the Behavior Log." When asked to locate documentation on any of the facility Behavior Logs, Progress Notes, Nursing Care Plans, Monthly Care Conferences with SW #3, Psychiatrist #16 and herself in attendance for accuracy in describing behaviors related to Resident #102 and why the information was not on the Behavior Logs, why the behavior logs and interventions for the CNA's to know how to deal with situations involving both Resident #101 and #102, and behavior data and analysis section were blank and not filled out, or on the care conferences in which the documentation was written by RN #7, RN #7 stated, "We have discussed it I don't know why it's not there". When asked why the behavior logs were not kept as part of the medical record, RN #7 stated, "The social worker takes them out. I tell my staff to document what you see not what you hear." Location of the facility record behavior logs, including the incident on 5/2/14, were not located in the active medical record but were located in the thinned chart in medical records. Review of the Facility Policy and Procedure titled "Abuse Prohibition, Investigation and Reporting" dated Rev 02/09 revealed "Policy: It is the policy of this facility to prohibit mistreatment, neglect and abuse of guests/residents and/or misappropriation of guest/resident property or resources. The facility shall not allow verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and all facility personnel will promptly report any incident or suspected incident of guest mistreatment, injuries of unknown source or misappropriation of property/resources. Reports of alleged abuse and/or misappropriation will be immediately reported to the Administrator and thoroughly investigated. Allegation of abuse/misappropriation and the investigative conclusion will be reported to the appropriate State regulatory agency, Law Enforcement agency, licensing and/or certification board as required by State and Federal law. Standard: The facility will not condone guest abuse by anyone, including staff members, other guests, consultants, volunteers, and staff of other agencies serving the guest, family members, legal guardian, sponsors, friends or other individuals. Section II: Identification: c: Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Section III: 1. The person(s) observing an incident of guest abuse or suspecting guest abuse must immediately report such incidents/suspicions to the Administrator. If the Administrator is not immediately available, the allegation should be reported to a charge nurse, social worker, nursing administration to ensure that the guest is safe. The supervisor/management person in charge will then immediately notify the Administrator. When an incident of guest abuse is alleged, the incident must be reported to the charge nurse regardless of the time lapse since the incident occurred. 2. Upon receiving a report of abuse, the charge nurse will immediately examine the guest. If any injuries are identified, the charge nurse will notify the physician and administer treatment as ordered. The findings of the examination will be recorded in the medical record. (The physician is to be notified timely even if no injuries are observed). 3. Appropriate actions must be taken immediately to protect the guest and others who could be affected while the investigation is in progress. Accused individuals will be denied unsupervised access to the guest. 4. The Administrator will appoint a representative to investigate the incident. The Administrator will initiate the Investigation of Alleged Abuse, Mistreatment, or Misappropriation (form #ADMIN009) and make the appropriate notifications as outlined on the form. 6. The charge nurse will complete the Incident Report (#Admin 005). 7. A completed copy of the Incident Report will be provided to the Administrator within 24 hours of the occurrence of the incident. IV. Reporting: 10. All allegations of abuse must be reported immediately to the Administrator. 13. The Administrator is responsible for ensuring that allegations of abuse are reported to the State Licensing Agency, Ombudsperson, and/or other agencies as is required by state law. This includes the initial 24 hour and 5 day reports. 15. The Director of Nursing will inform the guest's attending physician and facility Medical Director of the investigation findings and corrective actions." Review of ADMIN 009 Form Contents revealed: "Intake information name of guest, nature of allegation, resident (s) involved reported to, date, time, who reported the alleged incident, initial details of allegation, action taken pending investigation. Notifications: MANDATORY: 1. Physician 2. Family 3. Corporate Representative. As Appropriate: 4. Adult Protective Services 5. Ombudsman 6. Local Police 7. Appropriate State Agency Date/Time Reported To: Name/Title and Comment Section were present on the form. Guest/Staff Member #1 Interviewed: Date/time Interviewee's written statement attached to incident report Yes/No What Happened?" On 5/8/14 at 1:00 p.m., Administrator #9 was notified of an Immediate Jeopardy that began on 7/14/13 after Resident #101 was subjected to repeated sexual abuses by Resident #102, and facility staffs did not prevent recurrence. On 5/12-13/14 this Surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. On 5/8/14, Resident #102 was immediately put on 1:1. 2. On 5/7/14, Resident #101 was referred to the psychologist. 3. On 5/7/14, Resident #102 was referred to the psychologist. 4. On 5/8/14, the Facility Abuse Policy was reviewed and revised to reflect the State Operations Manual regulatory language. 5. On 5/8/14, the Nurse Practitioner conducted a complete examination of Resident #101 and she was sent to the hospital per DPOA request for a evaluation and examination of possible sexual assault. 6. Beginning 5/7/14, all residents behavior records, 24 hour reports and incident reports for the past 30 days were reviewed by the Director of Nursing, Unit Managers and Social Services to identify any situation/ event, or occurrence that might indicate inappropriate sexual behavior. 7. On 5/8/14, the Administrator and Director of Nursing (DON) were re-educated by the Regional Quality Assurance Nurse and Regional Operator on the facility's policy for the prevention of abuse which includes but not limited to: prevention, identification, investigation and reporting. 8. On 5/8/14, 16 of 46 Licensed Nurses' were re-educated by the Nurse Managers and designees on the facility's abuse policy, prevention of abuse, notification of physicians and legal representatives of abuse, investigation, documentation of behaviors and ensuring interventions are implemented as identified in the plan of care. No licensed nurses will be allowed to work prior to receiving the information. 9. On 5/8/14, the Social Workers, Administrator, and DON (4 of 4) were re-educated by the Regional Quality Assurance Nurse on the facility's abuse policy, prevention of abuse, notification of physicians and legal representatives of abuse, investigation, documentation of behaviors and ensuring interventions are implemented as identified in the plan of care. 10. On 5/8/14, the Social Workers (2 of 2) were re-educated by the Regional Quality Assurance Nurse on the need to identify when residents are forming relationships, whether the residents are capable of making independent decisions regarding the relationship, the relationship is consensual, and in the circumstance where the residents have been identified to be incapable of making appropriate decisions and/or deemed mentally incapacitated, the legal representative is aware of the relationship and consulted as to boundaries for the relationship. 11. On 5/8/14, 38 of 70 Certified Nursing Assistants (CNA's) were re-educated on the facility's abuse policy. No CNA's will be allowed to work prior to receiving the information. 12. Beginning 5/8/14, the Administrator and Director of Nursing will report all allegations of abuse, neglect, misappropriation of property and mistreatment per the Elder Justice Act and SOM regulatory language to the State Agency. The Administrator and DON will report the same allegations to the Regional Quality Assurance Nurse/Regional Operator for the next (3) three months to ensure incidents have been thoroughly investigated, legal representatives have been notified and reported to the State Agency as required. Although the Immediate Jeopardy was removed on 5/8/14, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency

This Citation pertains to MI 854 Based on observation, interview, and record review, the facility failed to initiate a thorough investigation and report to the State and local law enforcement authorities incidents of abuse per facility policy in 1 of 9 sampled residents (Resident #101), reviewed for allegations of abuse, from a total sample of 9 residents, resulting in an Immediate Jeopardy when, beginning 7/14/13, Resident #101 was subjected to repeated sexual abuse by Resident #102 and facility staffs did not thoroughly investigate or report any incidents to the State or law enforcement agency to prevent subsequent recurrences. This placed 31 additional female residents, who resided on the locked dementia unit, at risk for serious harm, mental anguish, and/or injury. Findings include: Review of the Facility Policy and Procedure titled "Abuse Prohibition, Investigation and Reporting" dated Rev 02/09 revealed "Policy: It is the policy of this facility to prohibit mistreatment, neglect and abuse of guests/residents and/or misappropriation of guest/resident property or resources. The facility shall not allow verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and all facility personnel will promptly report any incident or suspected incident of guest mistreatment, injuries of unknown source or misappropriation of property/resources. Reports of alleged abuse and/or misappropriation will be immediately reported to the Administrator and thoroughly investigated. Allegation of abuse/misappropriation and the investigative conclusion will be reported to the appropriate State regulatory agency, Law Enforcement agency, licensing and/or certification board as required by State and Federal law. Standard: The facility will not condone guest abuse by anyone, including staff members, other guests, consultants, volunteers, and staff of other agencies serving the guest, family members, legal guardian, sponsors, friends or other individuals. Section II: Identification: c: Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Section III: 1. The person(s) observing an incident of guest abuse or suspecting guest abuse must immediately report such incidents/suspicions to the Administrator. If the Administrator is not immediately available, the allegation should be reported to a charge nurse, social worker, nursing administration to ensure that the guest is safe. The supervisor/management person in charge will then immediately notify the Administrator. When an incident of guest abuse is alleged, the incident must be reported to the charge nurse regardless of the time lapse since the incident occurred. 4. The Administrator will appoint a representative to investigate the incident. The Administrator will initiate the Investigation of Alleged Abuse, Mistreatment, or Misappropriation (form #ADMIN009) and make the appropriate notifications as outlined on the form. 6. The charge nurse will complete the Incident Report (#Admin 005). 7. A completed copy of the Incident Report will be provided to the Administrator within 24 hours of the occurrence of the incident. IV. Reporting: 10. All allegations of abuse must be reported immediately to the Administrator. 13. The Administrator is responsible for ensuring that allegations of abuse are reported to the State Licensing Agency, Ombudsperson, and/or other agencies as is required by state law. This includes the initial 24 hour and 5 day reports. 15. The Director of Nursing will inform the guest's attending physician and facility Medical Director of the investigation findings and corrective actions." Review of ADMIN 009 Form Contents revealed: "Notifications: MANDATORY: 1. Physician 2. Family 3. Corporate Representative. As Appropriate: 4. Adult Protective Services 5. Ombudsman 6. Local Police 7. Appropriate State Agency Date/Time Reported To: Name/Title and Comment Section were present on the form. Guest/Staff Member #1 Interviewed: Date/time Interviewee's written statement attached to incident report Yes/No What Happened?" Resident #101 Review of the Face Sheet and Minimum Data Sets (MDS), dated [DATE] and 2/25/14, and Physician's Progress Note, dated 4/1/14, revealed that Resident #101 had [DIAGNOSES REDACTED]. The MDS indicated Resident #101 required the extensive assistance of one person for locomotion and transfers, had no history of behaviors, and was unable to complete the Brief Interview for Mental Status (BIMS). Facility staff determined that Resident #101 had memory problems and was moderately cognitively impaired (decisions poor; cues/supervision required). Review of the facility document titled "Medical Condition/Rehabilitation Potential" dated 7/11/12, revealed Resident #101 had been deemed unable to make her own medical or financial decisions by two physicians. Review of the Care Plan titled "Cognitio" and dated 3/6/14, revealed Resident #101 had "impaired decision making related to [DIAGNOSES REDACTED]." Interventions included, but were not limited to, "help make decisions and advise of available options as needed, encourage to talk about safety decisions, help to explore options and understand ramifications of decisions." Review of the Care Plan, titled "ADL" (Activities of Daily Living), revealed that Resident #101 required extensive assistance due to a "history of rotator cuff repair and muscle weakness and fatigue". Interventions included but were not limited to "encourage her to participate in care, set up supplies and instruct to wash face and hands". Resident #101 was observed on 5/5/14 at 12 PM present at the doorway was a mesh Velcro entrance stop sign on the door frame with an alarm on the right side and Velcro attached to the left side holding it in place. Resident #101 was noted to be sitting in a wheelchair beside the bed bent over from the waist rubbing her legs. Resident #101's hands and arms were noted to be shaking. Resident #101's hair was unkempt with notable bad breath, clothing clean with shirt buttons/button holes mismatched, no body odor was noted . When asked by this surveyor how she felt Resident #101 replied when asked that her legs hurt but "it's best not to say anything around here" and exited the room self propelling out of the room going under the stop sign at the doorway. Resident #102 Review of the Face Sheet and Minimum Data Sets (MDS), dated [DATE] and 4/16/14 and the physician progress notes [REDACTED].#102 had [DIAGNOSES REDACTED]. The MDS revealed Resident #102 ' s BIMS score was a 9, indicating he was moderately cognitively impaired, had no history of behaviors, required oversight and set up for locomotion on the unit via wheelchair, and did not go off the unit. Review of the Medical Condition/Rehabilitation Potential, dated 6/4/13 and 6/12/13, revealed Resident #102 had been deemed unable to make his own medical or financial decisions by two physicians. Review of Resident #102's Behavior Log, dated 7/14/13 at 10:00 a.m., revealed Resident #102 was found in Resident #101's room. The log documented that Resident #101 was "scared" and told the facility staff member that Resident #102 was "going against her and putting his hands in her shirt and doing inappropriate things." Review of the Progress Notes, dated 8/13/13 at 2:45 p.m., revealed the Certified Nurse Aide (CNA) notified the nurse that Resident #102 was found in Resident #101's room rubbing her breasts. Resident #102 was escorted out of Resident #101's room and was placed on 15 minute checks. The note indicated per CNA, Resident #101 had her shirt pulled up for resident to rub her breasts. The note indicated the unit manager was notified. Review of the Behavior log, dated 8/22/13 at 11:00 (a.m./p.m. not designated), revealed Resident #102 was found by facility staff in Resident #101's room unbuttoning her shirt. The log documented that Resident #102 stated, "Oh don't report this or tell anyone. I am just having a little fun. I notified the nurse and minutes later he was caught in that room again." Review of the Behavior log, dated 8/27 (year not designated) at 9:30 (a.m./p.m. not designated), revealed Resident #102 took down the stop sign and was found in Resident #101's room kissing her. The log indicated that Resident #102 "knew he wasn't supposed to be in there but he needed to see her. He knows how to take the stop sign down without setting the alarm." Review of Resident #102's Behavior Log, dated 8/30/13 at 9:45 a.m., revealed Resident #102 was found on the North hall (where Resident #101 resides) upsetting (Resident #101) and "hollering at staff telling us to leave him and her alone ... She didn't want him down there ...He wouldn't leave her alone." Review of the Behavior log, dated 8/31/13 at 10:55 a.m., revealed Resident #102 was found going into Resident #101's room and was redirected out of the room. The log indicated, "by the time the nurse made it back to the nurses station, (Resident #102) was back in room [ROOM NUMBER] (Resident #101's room) and had to be removed again." Review of the Behavior log, dated 9/11/13 at 10:15 a.m., revealed Resident #102 was found in Resident #101's room with both residents "backs to the door. I could see his hands in front of her massaging her. He told me not to tell." Resident #102 was removed from the room and his actions were reported to the nurse. In an interview on 5/7/14 at 10:40 a.m., CNA #1 reported that on 9/11/13 when she found Resident #102 in Resident #101's room, Resident #102 had his hand on Resident #101's breast and was rubbing it. CNA #1 reported that she has been told by DON #8, Administrator #9, and the Unit Manager (#7) not to document the behaviors "because if the State sees that, it will look like we're not doing our job." Review of the Behavior log, dated 9/24/13 at 3:15 p.m., revealed Resident #102 was found on the North hall at the end doors kissing Resident #101 on the mouth. In an interview on 5/7/14 at 11:00 a.m., CNA #5 reported after reviewing the behavior log that she found Resident #102 kissing Resident #101 on the mouth on 9/24/13. CNA #5 said, "Both residents were sitting in wheelchairs and he was leaning over into her kissing her. She was not leaning into him. I was told by the Social Worker that he (Resident #102) was not to be down the North Hall. I told the nurses that he wasn't allowed down there but they said they didn't know anything about it." Review of the Behavior log, dated 10/28/13 at 11:15 a.m., revealed Resident #102 was found kissing Resident #101. Review of the Behavior log, dated 5/2/14 at 10:10 a.m., revealed Resident #102 was found in Resident #101's room with "his hand down her pants touching her. She was moaning and making noises. CNA #2 notified the nurse of the incident." At 10:20 a.m. the log indicated Resident #102 was "sitting at the nurse's station telling us he will go down the north hall as many times as he wants and there is nothing anybody can do about it." During a telephone interview on 5/5/14 at 7:17 PM, Licensed Practical Nurse (LPN) #6 reported that she was not a witness to the event but "the CNA came up to me and told me she saw Resident #102's hands inside the pants of Resident #101. I called the DON and told her what happened, she told me do a skin assessment to check for bruises. When I called her back she told me 'I didn't see anything, so I wouldn't write it up' and that the Social Worker would document and investigate. She specifically told me not to document, she was placing the blame on the CNA's for not doing 15 minute checks. No, I did not check the vaginal area. I pulled her pants away and looked and could only see the top of the perineal area." LPN #6 reported that Resident #101 could not recall the incident. LPN #6 reported that SW #3 came down to the unit on 5/2/14 and when she told him what happened, he responded, "Oh good, it means she's not upset." In a second telephone interview on 5/6/14 at 1:50 p.m., LPN #6 said, "After the incident, I called the DON (#8) and was told the social worker (SW #3) would come down and take care of it." LPN #6 stated, "When I entered the room, (Resident #101) was sitting in her wheelchair leaning forward bent down I asked if she could tell me what had happened, she did not have any recollection of what had happened. I saw no bruises or scratches. I only pulled her brief out which was rumbled, but no I did not check between her legs. I only did a skin assessment top up, not waist down." LPN #6 reported that after she checked Resident #101 over she placed a second call to the DON to report there were no scratches or bruises. LPN #6 stated, "I was told that the Social Worker would come down and take care of it. That's when she (DON) told me make sure you don't document anything that happened between (Resident #101 and Resident #102), you can do a skin assessment he can't. LPN #6 reported that she often saw Resident #102 seek Resident #101 but not visa versa. LPN #6 stated, "I have even had to separate them. I saw (Resident #102) try to 'visit' (Resident #101). At some points (Resident #101) seemed afraid to go out of her room, she would say 'that man is out there'." In an interview on 5/6/14 at 12:10 PM, SW #3 reported that Resident #101 and #102 "seek each other out often, but no actual touch. He (Resident #102) seeks friendship. We put (Resident #102) on 15 minute checks, a stop sign on both residents doors, and allow them to visit at the nurses station and look out the north hall windows and chat." SW #3 reported after the incident on 5/2/14, he visited Resident #101 and found her to have no problems. SW #3 stated, "I would not have called that incident a sexual assault because she did not say 'no'." SW #3 reported the DPOA of Resident #101 had not been notified or asked if a relationship of any kind was permissible. When asked if Resident #101's POA had been told about a sexual relationship, SW #3 stated, "No, this was a consensual relationship". SW #3 reported Resident #101 had "no negative outcome" related to the incidents. During a second interview on 5/7/14 at 5:55 PM, SW #3 reported that on 5/2/14 he was notified by the Director of Nurses (DON) #8 that a report was called to the DON by the staff nurse that Resident #102 was observed by a CNA with his hands inside Resident #101's pants with his hands inside her (Resident #101) vagina. SW #3 reported he went down to the unit (Unit C locked dementia unit) to check on Resident #101 and that Resident #101 was smiling and in no distress. SW#3 stated, "I wouldn't call that sexual assault, sexual assault is when someone says no." When asked if any incident report had been written regarding any sexual allegation/staff witness from 7/14/13 (when Resident #102 had been transferred to the locked dementia unit) to 5/2/14, SW #3 replied "no". SW #3 reported that Resident #101 denied that Resident #102 was in the room and "When I asked (CNA #2) what happened, I wrote it down on my notes". SW #3 was asked if Resident #101's DPOA (Durable Power of Attorney) had been notified of the incident on 5/2/14. SW #3 replied, "No I have not". When asked if the DPOA for Resident #101 been made aware of the sexual relationship between Resident #101 and Resident #102, SW #3 replied, "No." SW #3 also reported he did not have CNA #2 write out her statement or proof-read for accuracy the information during his investigation. SW #3 asked if Administrator #9 and DON #8 thought this was a reportable event, SW #3 replied "no." SW #3 reported that the discussion between he, Administrator #9 and DON #8 regarding Resident #102 fondling Resident #101's breasts determined that the incidents were "consensual". When asked who the Abuse Coordinator for the facility was SW #3 reported it was Administrator #9. During a telephone interview with CNA #2 on 5/6/14 at 3:40 PM she reported that she had been at the nurses station doing charting at approximately 10 AM on 5/2/14, when Resident #102 rolled past both herself and the nurse on duty. As she turned around she noticed that Resident #102 was no where to be seen, "I knew exactly where he was so I went down to Resident 101's room, as I tiptoed into the room, the door was partly open, the privacy curtain pulled 1/2 way across the room, I saw both resident's in their wheelchair, Resident #101 was facing the bed with Resident #102 sitting beside/behind angled toward the bed with his back facing the door. I saw his hand inside her pants moving his hand rapidly, she was moaning. I can't describe it, but when I approached them he jerked his hand out. I took him out of the room to the nurses station and told my nurse what had just happened. We are always told when we see what he's doing that we are assuming too much and if we didn't see him do anything not to document anything. I can tell you I have seen him fondling her breasts, unbuttoning her blouse and massaging her breasts more than once. When I take him (Resident #102) out of the room (Resident #101's room) and go tell the nurses by the time they get to her she doesn't even remember anything. She is really confused so they don't do anything. Later that day I heard him (Resident #102) tell my nurse she was a liar and making stuff up about him and nothing was going to stop him from seeing her (Resident #101). Review of the SW #3's type-written investigation (no date) revealed CNA #2 told SW #3 that she was "charting at the nurse's station and (Resident #102) was noted to be halfway down the hall (south hall) talking to other residents. The next thing I see he was gone; it may have been 4-5 minutes from the last time I saw him. I tiptoed down to (Resident #101's) room because I've been told not to assume things are happening so I wanted to catch him. She had her hands on her pants exposing herself and his hands down her pants. (Resident #101) seemed to enjoy the interaction. She was smiling, I told (Resident #102) to leave and he did. " In a second interview on 5/7/14 at 10:08 am CNA #2 was asked to review the type-written investigation for accuracy. CNA # 2 documented and stated, "(Resident #101's) hands were down in the area but not sure if she was helping or not. I took (Resident #102) to the nurses station when I left the room". During a interview on 5/7/14 at 2:55 PM Administrator #9 and DON #8 stated that it was a basic human right to touch, and a stop sign had been placed on the resident's doors. Administrator #9 stated, "We have determined its willful". When asked if any incident reports had been completed regarding the multiple events/behaviors related to #102's sexual abuses toward Resident #101, DON #8 replied "No." When why this was not reported to the State Agency and law enforcement, Administrator #9 and DON #8 reported that it was a consensual relationship and that even though Resident #101 had been deemed mentally incapacitated, the DPOA is in place to only make medical decision, not to decide what type of relationships Resident #101 could have, therefore, it was not reportable. Administrator #9 stated, "If we keep him (Resident #102) away from her (Resident #101), we are violating his civil rights by separating him or confining him against his will. Then we would have to report that." On 5/8/14 at 1:00 p.m., Administrator #9 was notified of an Immediate Jeopardy that began on 7/14/13 after Resident #101 was subjected to repeated sexual abuse by Resident #102 and facility staffs did not thoroughly investigate to prevent recurrence or report any incidents to the State or law enforcement agency. On 5/12-13/14 this Surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. On 5/8/14, Resident #102 was immediately put on 1:1. 2. On 5/7/14, Resident #101 was referred to the psychologist. 3. On 5/7/14, Resident #102 was referred to the psychologist. 4. On 5/8/14, all residents with the potential and/or exhibiting behaviors were reviewed by the Director of Nursing, Unit Managers, and Social Services to ensure appropriate interventions are identified, interventions are being implemented and attending physicians and legal representatives being notified of any incidents. 5. On 5/8/14, the Director of Nursing and Regional Nurse review all incident reports and behavior records for the past (6) six months to ensure that no other resident have been affected by inappropriate sexual behaviors. 6. On 5/8/14, the Administrator and DON were re-educated by the Regional Quality Assurance Nurse and Regional Operator on the facility's policy for the prevention of abuse which includes but not limited to: prevention, identification, investigation and reporting. 7. On 5/8/14, the two Social Workers, Administrator, and DON (4 of 4) were re-educated by the Regional Quality Assurance Nurse on the facility's abuse policy, prevention of abuse, notification of physicians and legal representatives of abuse, investigation, documentation of behaviors and ensuring interventions are implemented as identified in the plan of care. 8. On 5/8/14 the Social Workers (2 of 2) were re-educated by the Regional Quality Assurance Nurse on the need to identify when residents are forming relationships, whether the residents are capable of making independent decisions regarding the relationship, the relationship is consensual, and in the circumstance where the residents have been identified to be incapable of making appropriate decisions and/or deemed mentally incapacitated, the legal representative is aware of the relationship and consulted as to boundaries for the relationship. 9. Beginning 5/8/14, the Administrator and Director of Nursing will report all allegations of abuse, neglect, misappropriation of property and mistreatment per the Elder Justice Act and SOM regulatory language to the State Agency. The Administrator and DON will report the same allegations to the Regional Quality Assurance Nurse/Regional Operator for the next (3) three months to ensure incidents have been thoroughly investigated, legal representatives have been notified and reported to the State Agency as required. Although the Immediate Jeopardy was removed on 5/8/14, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

This Citation pertains to MI 854 Based on observation, interview, and record review, the facility failed to: 1.) ensure the facility abuse policy followed SOM (State Operations Manual) regulatory language and the Elder Justice Act of 2010, and 2.) implement the facility policy regarding abuse by documenting reported incidents, notification of incidents to interested parties, thoroughly investigate and report allegations and/or incidences of abuse to the State Agency in 1 of 9 sampled residents (Resident #101), reviewed for incidents of abuse, from a total sample of 9 residents, resulting in Immediate Jeopardy when Resident #101 was subjected to repeated sexual abuse by Resident #102 and facility staffs did not thoroughly investigate or report any incidents to the State or law enforcement agency to prevent subsequent recurrences. This placed 31 additional female residents who resided on the locked dementia unit at risk for serious harm, mental anguish, and/or injury. Findings include: Review of the Facility Policy and Procedure titled "Abuse Prohibition, Investigation and Reporting" dated Rev 02/09 revealed "Policy: It is the policy of this facility to prohibit mistreatment, neglect and abuse of guests/residents and/or misappropriation of guest/resident property or resources. The facility shall not allow verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and all facility personnel will promptly report any incident or suspected incident of guest mistreatment, injuries of unknown source or misappropriation of property/resources. Reports of alleged abuse and/or misappropriation will be immediately reported to the Administrator and thoroughly investigated. Allegation of abuse/misappropriation and the investigative conclusion will be reported to the appropriate State regulatory agency, Law Enforcement agency, licensing and/or certification board as required by State and Federal law. Standard: The facility will not condone guest abuse by anyone, including staff members, other guests, consultants, volunteers, and staff of other agencies serving the guest, family members, legal guardian, sponsors, friends or other individuals. Section II: Identification: c: Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Section III: 1. The person(s) observing an incident of guest abuse or suspecting guest abuse must immediately report such incidents/suspicions to the Administrator. If the Administrator is not immediately available, the allegation should be reported to a charge nurse, social worker, nursing administration to ensure that the guest is safe. The supervisor/management person in charge will then immediately notify the Administrator. When an incident of guest abuse is alleged, the incident must be reported to the charge nurse regardless of the time lapse since the incident occurred. 4. The Administrator will appoint a representative to investigate the incident. The Administrator will initiate the Investigation of Alleged Abuse, Mistreatment, or Misappropriation (form #ADMIN009) and make the appropriate notifications as outlined on the form. 6. The charge nurse will complete the Incident Report (#Admin 005). 7. A completed copy of the Incident Report will be provided to the Administrator within 24 hours of the occurrence of the incident. IV. Reporting: 10. All allegations of abuse must be reported immediately to the Administrator. 13. The Administrator is responsible for ensuring that allegations of abuse are reported to the State Licensing Agency, Ombudsperson, and/or other agencies as is required by state law. This includes the initial 24 hour and 5 day reports. 15. The Director of Nursing will inform the guest's attending physician and facility Medical Director of the investigation findings and corrective actions." Review of ADMIN 009 Form Contents revealed: "Notifications: MANDATORY: 1. Physician 2. Family 3. Corporate Representative. As Appropriate: 4. Adult Protective Services 5. Ombudsman 6. Local Police 7. Appropriate State Agency Date/Time Reported To: Name/Title and Comment Section were present on the form. Guest/Staff Member #1 Interviewed: Date/time Interviewee's written statement attached to incident report Yes/No What Happened?" According to the "Center for Medicaid, CHIP, and Survey & Certification/Survey & Certification Group" letter dated 6/17/11 (Ref: S&C 11-3-NH, Revised 01/20/12) for "reporting reasonable suspicion of a crime in a Long-term-Care Facility (LTC)" "effective implementation of Section 1150 B of the Act may promote a timely response to potential crimes, thereby protecting residents of such facilities. The statute required that: "covered individuals (employees) timely report any reasonable suspicion of a crime against a resident of, or who is receiving care from a LTC, (Long Term Care) if the events that cause the reasonable suspicion result in serious bodily injury, the report must be made immediately after forming the suspicion (but not later that two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion. The LTC facility's responsibilities under exiting CMS (Centers for Medicare & Medicaid Services) conditions and requirements are to report incidents, prevent abuse or neglect, provide quality care and a safe environment, train staff, and similar duties of direct relevance to safety and quality of care". The State Operations Manual reflected under F-226, Intent 483.13 (c) (1) (iii) and 483.13 (c) (4) the facility have procedures to "report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required..." Resident #101 Review of the Face Sheet and Minimum Data Sets (MDS), dated [DATE] and 2/25/14, and Physician's Progress Note, dated 4/1/14, revealed that Resident #101 had [DIAGNOSES REDACTED]. The MDS indicated Resident #101 required the extensive assistance of one person for locomotion and transfers, had no history of behaviors, and was unable to complete the Brief Interview for Mental Status (BIMS). Facility staff determined that Resident #101 had memory problems and was moderately cognitively impaired (decisions poor; cues/supervision required). Review of the facility document titled "Medical Condition/Rehabilitation Potential" dated 7/11/12, revealed Resident #101 had been deemed unable to make her own medical or financial decisions by two physicians. Review of the Care Plan titled "Cognitio" and dated 3/6/14, revealed Resident #101 had "impaired decision making related to [DIAGNOSES REDACTED]." Interventions included, but were not limited to, "help make decisions and advise of available options as needed, encourage to talk about safety decisions, help to explore options and understand ramifications of decisions." Review of the Care Plan, titled "ADL" (Activities of Daily Living), revealed that Resident #101 required extensive assistance due to a "history of rotator cuff repair and muscle weakness and fatigue". Interventions included but were not limited to "encourage her to participate in care, set up supplies and instruct to wash face and hands". Resident #101 was observed on 5/5/14 at 12 PM present at the doorway was a mesh Velcro entrance stop sign on the door frame with an alarm on the right side and Velcro attached to the left side holding it in place. Resident #101 was noted to be sitting in a wheelchair beside the bed bent over from the waist rubbing her legs. Resident #101's hands and arms were noted to be shaking. Resident #101's hair was unkempt with notable bad breath, clothing clean with shirt buttons/button holes mismatched, no body odor was noted . When asked by this surveyor how she felt Resident #101 replied when asked that her legs hurt but "it's best not to say anything around here" and exited the room self propelling out of the room going under the stop sign at the doorway. Resident #102 Review of the Face Sheet and Minimum Data Sets (MDS), dated [DATE] and 4/16/14 and the physician progress notes [REDACTED].#102 had [DIAGNOSES REDACTED]. The MDS revealed Resident #102 ' s BIMS score was a 9, indicating he was moderately cognitively impaired, had no history of behaviors, required oversight and set up for locomotion on the unit via wheelchair, and did not go off the unit. Review of the Medical Condition/Rehabilitation Potential, dated 6/4/13 and 6/12/13, revealed Resident #102 had been deemed unable to make his own medical or financial decisions by two physicians. Review of Resident #102's Behavior Log, dated 7/14/13 at 10:00 a.m., revealed Resident #102 was found in Resident #101's room. The log documented that Resident #101 was "scared" and told the facility staff member that Resident #102 was "going against her and putting his hands in her shirt and doing inappropriate things." Review of the Progress Notes, dated 8/13/13 at 2:45 p.m., revealed the Certified Nurse Aide (CNA) notified the nurse that Resident #102 was found in Resident #101's room rubbing her breasts. Resident #102 was escorted out of Resident #101's room and was placed on 15 minute checks. The note indicated per CNA, Resident #101 had her shirt pulled up for resident to rub her breasts. The note indicated the unit manager was notified. Review of the Behavior log, dated 8/22/13 at 11:00 (a.m./p.m. not designated), revealed Resident #102 was found by facility staff in Resident #101's room unbuttoning her shirt. The log documented that Resident #102 stated, "Oh don't report this or tell anyone. I am just having a little fun. I notified the nurse and minutes later he was caught in that room again." Review of the Behavior log, dated 8/27 (year not designated) at 9:30 (a.m./p.m. not designated), revealed Resident #102 took down the stop sign and was found in Resident #101's room kissing her. The log indicated that Resident #102 "knew he wasn't supposed to be in there but he needed to see her. He knows how to take the stop sign down without setting the alarm." Review of Resident #102's Behavior Log, dated 8/30/13 at 9:45 a.m., revealed Resident #102 was found on the North hall (where Resident #101 resides) upsetting (Resident #101) and "hollering at staff telling us to leave him and her alone ... She didn't want him down there ...He wouldn't leave her alone." Review of the Behavior log, dated 8/31/13 at 10:55 a.m., revealed Resident #102 was found going into Resident #101's room and was redirected out of the room. The log indicated, "by the time the nurse made it back to the nurses station, (Resident #102) was back in room [ROOM NUMBER] (Resident #101's room) and had to be removed again." Review of the Behavior log, dated 9/11/13 at 10:15 a.m., revealed Resident #102 was found in Resident #101's room with both residents "backs to the door. I could see his hands in front of her massaging her. He told me not to tell." Resident #102 was removed from the room and his actions were reported to the nurse. In an interview on 5/7/14 at 10:40 AM, CNA #1 reported that on 9/11/13 when she found Resident #102 in Resident #101's room . Resident #102 had his hand on Resident #101's breast and was rubbing it. CNA #1 stated she got in trouble with the Director of Nursing (DON) #8 and Administrator #9 for documenting Resident #102 's behavior. CNA #1 reported that she has been told by DON #8, Administrator #9, and Unit Manager #7 not to document the behaviors "because if the State sees that, it will look like we're not doing our job." Review of the Behavior log, dated 9/24/13 at 3:15 p.m., revealed Resident #102 was found on the North hall at the end doors kissing Resident #101 on the mouth. In an interview on 5/7/14 at 11:00 a.m., CNA #5 reported after reviewing the behavior log that she found Resident #102 kissing Resident #101 on the mouth on 9/24/13. CNA #5 said, "Both residents were sitting in wheelchairs and he was leaning over into her kissing her. She was not leaning into him. I was told by the Social Worker that he (Resident #102) was not to be down the North Hall. I told the nurses that he wasn't allowed down there but they said they didn't know anything about it." Review of the Behavior log, dated 10/28/13 at 11:15 a.m., revealed Resident #102 was found kissing Resident #101. Review of the Behavior log, dated 5/2/14 at 10:10 a.m., revealed Resident #102 was found in Resident #101's room with "his hand down her pants touching her. She was moaning and making noises. CNA #2 notified the nurse of the incident." At 10:20 a.m. the log indicated Resident #102 was "sitting at the nurse's station telling us he will go down the north hall as many times as he wants and there is nothing anybody can do about it." During a telephone interview on 5/5/14 at 7:17 PM, Licensed Practical Nurse (LPN) #6 reported that she was not a witness to the event but "the CNA came up to me and told me she saw Resident #102's hands inside the pants of Resident #101. I called the DON and told her what happened, she told me do a skin assessment to check for bruises. When I called her back she told me 'I didn't see anything, so I wouldn't write it up' and that the Social Worker would document and investigate. She specifically told me not to document, she was placing the blame on the CNA's for not doing 15 minute checks. No, I did not check the vaginal area. I pulled her pants away and looked and could only see the top of the perineal area." LPN #6 reported that Resident #101 could not recall the incident. LPN #6 reported that SW #3 came down to the unit on 5/2/14 and when she told him what happened, he responded, "Oh good, it means she's not upset." In a second telephone interview on 5/6/14 at 1:50 p.m., LPN #6 said, "After the incident, I called the DON (#8) and was told the social worker (SW #3) would come down and take care of it." LPN #6 stated, "When I entered the room, (Resident #101) was sitting in her wheelchair leaning forward bent down I asked if she could tell me what had happened, she did not have any recollection of what had happened. I saw no bruises or scratches. I only pulled her brief out which was rumbled, but no I did not check between her legs. I only did a skin assessment top up, not waist down." LPN #6 reported that after she checked Resident #101 over she placed a second call to the DON to report there were no scratches or bruises. LPN #6 stated, "I was told that the Social Worker would come down and take care of it. That's when she (DON) told me make sure you don't document anything that happened between (Resident #101 and Resident #102), you can do a skin assessment he can't. LPN #6 reported that she often saw Resident #102 seek Resident #101 but not visa versa. LPN #6 stated, "I have even had to separate them. I saw (Resident #102) try to 'visit' (Resident #101). At some points (Resident #101) seemed afraid to go out of her room, she would say 'that man is out there'." Review of the Nursing Progress Notes dated 5/2/14 to 5/5/14 revealed no documentation present on the medical record related to a physical assessment completed for Resident #101. In an interview on 5/6/14 at 12:10 PM, SW #3 reported that Resident #101 and #102 "seek each other out often, but no actual touch. He (Resident #102) seeks friendship. We put (Resident #102) on 15 minute checks, a stop sign on both residents doors, and allow them to visit at the nurses station and look out the north hall windows and chat." SW #3 reported after the incident on 5/2/14, he visited Resident #101 and found her to have no problems. SW #3 stated, "I would not have called that incident a sexual assault because she did not say 'no'." SW #3 reported the DPOA of Resident #101 had not been notified or asked if a relationship of any kind was permissible. When asked if Resident #101's POA had been told about a sexual relationship, SW #3 stated, "No, this was a consensual relationship". SW #3 reported Resident #101 had "no negative outcome" related to the incidents. During a second interview on 5/7/14 at 5:55 PM, SW #3 reported that on 5/2/14 he was notified by the Director of Nurses (DON) #8 that a report was called to the DON by the staff nurse that Resident #102 was observed by a CNA with his hands inside Resident #101's pants with his hands inside her (Resident #101) vagina. SW #3 reported he went down to the unit (Unit C locked dementia unit) to check on Resident #101 and that Resident #101 was smiling and in no distress. SW#3 stated, "I wouldn't call that sexual assault, sexual assault is when someone says no." When asked if any incident report had been written regarding any sexual allegation/staff witness from 7/14/13 (when Resident #102 had been transferred to the locked dementia unit) to 5/2/14, SW #3 replied "no". SW #3 reported that Resident #101 denied that Resident #102 was in the room and "When I asked (CNA #2) what happened, I wrote it down on my notes". SW #3 was asked if Resident #101's DPOA (Durable Power of Attorney) had been notified of the incident on 5/2/14. SW #3 replied, "No I have not". When asked if the DPOA for Resident #101 been made aware of the sexual relationship between Resident #101 and Resident #102, SW #3 replied, "No." SW #3 also reported he did not have CNA #2 write out her statement or proof-read for accuracy the information during his investigation. SW #3 asked if Administrator #9 and DON #8 thought this was a reportable event, SW #3 replied "no." SW #3 reported that the discussion between he, Administrator #9 and DON #8 regarding Resident #102 fondling Resident #101's breasts determined that the incidents were "consensual". When asked who the Abuse Coordinator for the facility was SW #3 reported it was Administrator #9. During a telephone interview with CNA #2 on 5/6/14 at 3:40 PM she reported that she had been at the nurses station doing charting at approximately 10 AM on 5/2/14, when Resident #102 rolled past both herself and the nurse on duty. As she turned around she noticed that Resident #102 was no where to be seen, "I knew exactly where he was so I went down to Resident 101's room, as I tiptoed into the room, the door was partly open, the privacy curtain pulled 1/2 way across the room, I saw both resident's in their wheelchair, Resident #101 was facing the bed with Resident #102 sitting beside/behind angled toward the bed with his back facing the door. I saw his hand inside her pants moving his hand rapidly, she was moaning. I can't describe it, but when I approached them he jerked his hand out. I took him out of the room to the nurses station and told my nurse what had just happened. We are always told when we see what he's doing that we are assuming too much and if we didn't see him do anything not to document anything. I can tell you I have seen him fondling her breasts, unbuttoning her blouse and massaging her breasts more than once. When I take him (Resident #102) out of the room (Resident #101's room) and go tell the nurses by the time they get to her she doesn't even remember anything. She is really confused so they don't do anything. Later that day I heard him (Resident #102) tell my nurse she was a liar and making stuff up about him and nothing was going to stop him from seeing her (Resident #101). Review of the SW #3's type-written investigation (no date) revealed CNA #2 told SW #3 that she was "charting at the nurse's station and (Resident #102) was noted to be halfway down the hall (south hall) talking to other residents. The next thing I see he was gone; it may have been 4-5 minutes from the last time I saw him. I tiptoed down to (Resident #101's) room because I've been told not to assume things are happening so I wanted to catch him. She had her hands on her pants exposing herself and his hands down her pants. (Resident #101) seemed to enjoy the interaction. She was smiling, I told (Resident #102) to leave and he did. " In a second interview on 5/7/14 at 10:08 am CNA #2 was asked to review the type-written investigation for accuracy. CNA # 2 documented and stated, "(Resident #101's) hands were down in the area but not sure if she was helping or not. I took (Resident #102) to the nurses station when I left the room". During an interview on 5/7/14 at 4:05 PM, Unit Manager/Registered Nurse (RN) #7 reported that she had spoken to Resident #101's DPOA on "numerous times" about the relationship between Resident #101 and Resident #102. When asked to locate the documentation in the medical record documenting those conversations, RN #7 was unable to locate the documentation. RN #7 stated, "I never thought I would have to document every conversation I have with everyone. I know if it's not documented it's not done". RN #7 was asked to locate in the medical record documentation regarding the sexual abuse Resident #102 committed against Resident #101 and to locate incident reports after each incidence of abuse that had occurred. RN #7 was unable to locate the information in the medical record and stated, "No incident reports were done. I have told staff to document what they see" During a interview on 5/7/14 at 2:55 PM Administrator #9 and DON #8 stated that it was a basic human right to touch, and a stop sign had been placed on the resident's doors. Administrator #9 stated, "We have determined its willful". When asked if any incident reports had been completed regarding the multiple events/behaviors related to #102's sexual abuses toward Resident #101, DON #8 replied "No." When why this was not reported to the State Agency and law enforcement, Administrator #9 and DON #8 reported that it was a consensual relationship and that even though Resident #101 had been deemed mentally incapacitated, the DPOA is in place to only make medical decision, not to decide what type of relationships Resident #101 could have, therefore, it was not reportable. Administrator #9 stated, "If we keep him (Resident #102) away from her (Resident #101), we are violating his civil rights by separating him or confining him against his will. Then we would have to report that." On 5/8/14 at 1:00 p.m., Administrator #9 was notified of an Immediate Jeopardy that began on 7/14/13 due to the facility's failure to ensure the facility abuse policy followed State Operations Manual regulatory language and the Elder Justice Act of 2010, and implement the facility policy regarding abuse after Resident #101 was subjected to repeated sexual abuse by Resident #102 and facility staffs did not implement their own policy to prevent recurrence On 5/12-13/14 this Surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. On 5/8/14, Resident #102 was immediately put on 1:1 supervision. 2. On 5/7/14, Resident #101 was referred to the psychologist and seen. 3. On 5/7/14, Resident #102 was referred to the psychologist and seen. 4. On 5/8/14, the abuse policy was reviewed and revised to reflect the State Operations Manual regulatory language. 5. On 5/8/14, the Administrator and Director of Nursing (DON) were re-educated by the Regional Quality Assurance Nurse and Regional Operator on the facility's policy for the prevention of abuse which includes but not limited to: prevention, identification, investigation and reporting immediately to the state agency. 6. On 5/8/14, 16 of 46 Licensed Nurses' were re-educated by the Nurse Managers and designees on the facility's abuse policy, prevention of abuse, notification of physicians and legal representatives of abuse, investigation, documentation of behaviors and ensuring interventions are implemented as identified in the plan of care. Remaining licensed staff will be re-educated prior to assuming their next shift. 7. On 5/8/14, 2 of 2 Social Workers were re-educated by the Regional Quality Assurance Nurse on the facility's abuse policy, prevention of abuse, notification of physicians and legal representatives of abuse, investigation, documentation of behaviors and ensuring interventions are implemented as identified in the plan of care. 8. On 5/8/14, 38 of 70 CNA's were re-educated on the facility's abuse policy. The remainder of CNA's will be re-educated on the facility's abuse policy prior to working their next scheduled shift. 9. Beginning 5/8/14, the Administrator and Director of Nursing will report all allegations of abuse, neglect, misappropriation of property and mistreatment per the Elder Justice Act and SOM regulatory language to the State Agency. The Administrator and DON will report the same allegations to the Regional Quality Assurance Nurse/Regional Operator for the next (3) three months to ensure incidents have been thoroughly investigated, legal representatives have been notified and reported to the State Agency as required. Although the Immediate Jeopardy was removed on 5/8/14, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

This Citation pertains to MI 854 Based on observation, interview, and record review, the facility Administration failed to administer the building to ensure the highest practicable physical, mental, and psychosocial well-being of each resident by: 1.) prevent repeated resident to resident sexual abuse, 2.) document and initiate a thorough investigation of incidents of resident to resident sexual abuse, 3.) report incidents of sexual abuse to State and local law enforcement agencies, 4.) implement the facility policy and procedure regarding abuse, 5.) ensure the safety and protection of a resident after all incidents of sexual abuse occurred, 7.) put interventions in place to prevent resident to resident sexual abuse, 8.) ensure a complete physical assessment and/or hospitalization for sexual assault examination was completed timely after multiple resident to resident sexual abuses, and 10.) ensure notification of a Durable Power of Attorney (DPOA) and the attending physician of sexual abuse in 1 of 9 sampled residents (Resident #101), reviewed for allegations of abuse, from a total sample of 9 residents, resulting in Immediate Jeopardy when, after 7/14/13, Resident #101 was subjected to repeated sexual abuses by Resident #102 and facility Management, who was fully aware, did not stop nor prevent additional occurrences. This deficient practice placed all residents in the facility, who have been deemed mentally incompetent and may be subjected to resident to resident sexual abuse, at risk for serious harm, mental anguish and/or injury. Findings include: Review of the Facility Policy and Procedure titled "Abuse Prohibition, Investigation and Reporting" dated Rev 02/09 Policy: It is the policy of this facility to prohibit mistreatment, neglect and abuse of guests/residents and/or misappropriation of guest/resident property or resources. The facility shall not allow verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and all facility personnel will promptly report any incident or suspected incident of guest mistreatment, injuries of unknown source or misappropriation of property/resources. Reports of alleged abuse and/or misappropriation will be immediately reported to the Administrator and thoroughly investigated. Allegation of abuse/misappropriation and the investigative conclusion will be reported to the appropriate State regulatory agency, Law Enforcement agency, licensing and/or certification board as required by State and Federal law. Standard: The facility will not condone guest abuse by anyone, including staff members, other guests, consultants, volunteers, and staff of other agencies serving the guest, family members, legal guardian, sponsors, friends or other individuals. Section II: Identification: c: Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Section III: 1. The person(s) observing an incident of guest abuse or suspecting guest abuse must immediately report such incidents/suspicions to the Administrator. If the Administrator is not immediately available, the allegation should be reported to a charge nurse, social worker, nursing administration to ensure that the guest is safe. The supervisor/management person in charge will then immediately notify the Administrator. When an incident of guest abuse is alleged, the incident must be reported to the charge nurse regardless of the time lapse since the incident occurred. 2. Upon receiving a report of abuse, the charge nurse will immediately examine the guest. If any injuries are identified, the charge nurse will notify the physician and administer treatment as ordered. The findings of the examination will be recorded in the medical record. (The physician is to be notified timely even if no injuries are observed). 3. Appropriate actions must be taken immediately to protect the guest and others who could be affected while the investigation is in progress. Accused individuals will be denied unsupervised access to the guest. 4. The Administrator will appoint a representative to investigate the incident. The Administrator will initiate the Investigation of Alleged Abuse, Mistreatment, or Misappropriation (form #ADMIN009) and make the appropriate notifications as outlined on the form. 6. The charge nurse will complete the Incident Report (#Admin 005). 7. A completed copy of the Incident Report will be provided to the Administrator within 24 hours of the occurrence of the incident. IV. Reporting: 10. All allegations of abuse must be reported immediately to the Administrator. 13. The Administrator is responsible for ensuring that allegations of abuse are reported to the State Licensing Agency, Ombudsperson, and/or other agencies as is required by state law. This includes the initial 24 hour and 5 day reports. 15. The Director of Nursing will inform the guest's attending physician and facility Medical Director of the investigation findings and corrective actions. Review of ADMIN 009 Form Contents revealed: intake information name of guest, nature of allegation, resident (s) involved reported to, date, time, who reported the alleged incident, initial details of allegation, action taken pending investigation. Notifications: MANDATORY: 1. Physician 2. Family 3. Corporate Representative. As Appropriate: 4. Adult Protective Services 5. Ombudsman 6. Local Police 7. Appropriate State Agency Date/Time Reported To: Name/Title and Comment Section were present on the form. Guest/Staff Member #1 Interviewed: Date/time Interviewee's written statement attached to incident report Yes/No What Happened? Resident #101 Review of the Face Sheet and Minimum Data Sets (MDS), dated [DATE] and 2/25/14, and Physician's Progress Note, dated 4/1/14, revealed that Resident #101 had [DIAGNOSES REDACTED]. The MDS indicated Resident #101 required the extensive assistance of one person for locomotion and transfers, had no history of behaviors, and was unable to complete the Brief Interview for Mental Status (BIMS). Facility staff determined that Resident #101 had memory problems and was moderately cognitively impaired (decisions poor; cues/supervision required). Review of the facility document titled "Medical Condition/Rehabilitation Potential" dated 7/11/12, revealed Resident #101 had been deemed unable to make her own medical or financial decisions by two physicians. Review of the Care Plan titled "Cognitio" dated 3/6/14, revealed Resident #101 had "impaired decision making related to [DIAGNOSES REDACTED]." Interventions included, but were not limited to, "help make decisions and advise of available options as needed, encourage to talk about safety decisions, help to explore options and understand ramifications of decisions." Review of the Care Plan, titled "ADL" (activities of daily living), revealed that Resident #101 required extensive assistance due to a "history of rotator cuff repair and muscle weakness and fatigue". Interventions included but were not limited to "encourage her to participate in care, set up supplies and instruct to wash face and hands." Resident #101 was observed on 5/5/14 at 12 PM present at the doorway was a mesh Velcro entrance stop sign on the door frame with an alarm on the right side and Velcro attached to the left side holding it in place. Resident #101 was noted to be sitting in a wheelchair beside the bed bent over from the waist rubbing her legs. Resident #101's hands and arms were noted to be shaking. Resident #101's hair was unkept with notable bad breath, clothing clean with shirt buttons/button holes mismatched, no body odor was noted . When asked by this surveyor how she felt Resident #101 replied when asked that her legs hurt but "it's best not to say anything around here" and exited the room self propelling out of the room going under the stop sign at the doorway. Resident #102 Review of the Face Sheet and Minimum Data Sets (MDS), dated [DATE] and 4/16/14 and the physician progress notes [REDACTED].#102 had [DIAGNOSES REDACTED]. The MDS revealed Resident #102 ' s BIMS score was a 9, indicating he was moderately cognitively impaired, had no history of behaviors, required oversight and set up for locomotion on the unit via wheelchair, and did not go off the unit. Review of the Medical Condition/Rehabilitation Potential, dated 6/4/13 and 6/12/13, revealed Resident #102 had been deemed unable to make his own medical or financial decisions by two physicians. Review of Resident #102's Behavior Log, dated 7/14/13 at 10:00 AM, revealed Resident #102 was found in Resident #101's room. The log documented that Resident #101 was "scared" and told the facility staff member that Resident #102 was "going against her and putting his hands in her shirt and doing inappropriate things." Review of the Progress Notes, dated 8/13/13 at 2:45 PM, revealed the Certified Nurse Aides (CNA) notified the nurse that Resident #102 was found in Resident #101 's room rubbing her breasts. Resident #102 was escorted out of Resident #101's room and was placed on 15 minute checks. The note indicated per CNA, Resident #101 had her shirt pulled up for resident to rub her breasts. The note indicated the unit manager was notified. Review of the Behavior log, dated 8/22/13 at 11:00 (am/pm not designated), revealed Resident #102 was found by facility staff in Resident #101's room unbuttoning her shirt. The log documented that Resident #102 stated, "Oh don't report this or tell anyone. I am just having a little fun. I notified the nurse and minutes later he was caught in that room again. " Review of the Behavior log, dated 8/27 (year not designated) at 9:30 (am/pm not designated), revealed Resident #102 took down the stop sign and was found in Resident #101's room kissing her. The log indicated that Resident #102 "knew he wasn't supposed to be in there but he needed to see her. He knows how to take the stop sign down without setting the alarm. " Review of Resident #102's Behavior Log, dated 8/30/13 at 9:45 am, revealed Resident #102 was found on the North hall (where Resident #101 resides) upsetting (Resident #101) and " hollering at staff telling us to leave him and her alone ... She didn't want him down there ...He wouldn't leave her alone. " Review of the Behavior log, dated 8/31/13 at 10:55 am, revealed Resident #102 was found going into Resident #101's room and was redirected out of the room. The log indicated, "by the time the nurse made it back to the nurses station, (Resident #102) was back in room [ROOM NUMBER] (Resident #101 's room) and had to be removed again. " Review of the Behavior log, dated 9/11/13 at 10:15 am, revealed Resident #102 was found in Resident #101's with both residents "backs to the door. I could see his hands in front of her massaging her. He told me not to tell. "Resident #102 was removed from the room and his actions were reported to the nurse". In an interview on 5/7/14 at 10:40 am, CNA #1 reported that on 9/11/13 when she found Resident #102 in Resident #101's room . Resident #102 had his hand on Resident #101's breast and was rubbing it. CNA #1 stated she got in trouble with the Director of Nursing (DON) #8 and Administrator #9 for documenting Resident #102 's behavior. CNA #1 reported that she has been told by DON #8, Administrator #9, and the Unit Manager not to document the behaviors "because if the State sees that, it will look like we're not doing our job." Review of the Behavior log, dated 9/24/13 at 3:15 PM, revealed Resident #102 was found on the North hall at the end doors kissing Resident #101 on the mouth. In an interview on 5/7/14 at 11:00 am, CNA #5 reported after reviewing the behavior log that she found Resident #102 kissing Resident #101 on the mouth on 9/24/13. CNA #5 said, "Both residents were sitting in wheelchairs and he was leaning over into her kissing her. She was not leaning into him. I was told by the Social Worker that he (Resident #102) was not to be down the North Hall. I told the nurses that he wasn't allowed down there but they said they didn't know anything about it." Upon review of the CNA Care Kardex which indicated Resident #101 was alert to person, place and time, CNA #5 reported that Resident #101 ' s care Kardex needed to be updated because she was no longer as alert as it indicated. CNA #5 reported that the Behavior Logs used to have information on what to do about Resident #102's behaviors, but the one she documented on did not have any interventions listed. CNA #5 agreed that Resident #102's care Kardex did not have instructions for 15 minute checks. Review of the Behavior log, dated 10/28/13 at 11:15 am, revealed Resident #102 was found kissing Resident #101. Review of the Facility Progress notes dated 11/24/13 "Resident (#101) refused to come to dining room for lunch stated "didn't feel well". Resident from room [ROOM NUMBER] B (Resident 102's room) observed in her room after lunch. He dropped his electric cigarette on the floor and then told her to pick it up. She was in bed and attempted to lean over the side and was close to falling on the floor when CNA prevented this from occurring. Male resident removed from the room without problems". Review of the Behavior log, dated 5/2/14 at 10:10 am, revealed Resident #102 was found in Resident #101's room with "his hand down her pants touching her. She was moaning and making noises." At 10:20 am the log indicated Resident #102 was "sitting at the nurse's station telling us he will go down the north hall as many times as he wants and there is nothing anybody can do about it." CNA #2 notified the nurse of the incident. In an telephone interview on 5/6/14 at 1:50 PM Licensed Practical Nurse (LPN) #6 said, "After the incident, I called the DON and was told the social worker (SW #3) would come down and take care of it. I called her again and was told to not document anything that happened between (Resident #101 and Resident #102). I'm going to have him (SW #3) do it, he did the investigation, it's up to him to document." LPN #6 reported that after she was told by the CNA about the incident she called the DON to report the incident. LPN #6 stated, "I maybe took a few minutes not sure how long. When I entered the room Resident #101 was sitting in her wheelchair leaning forward bent down. I asked if she could tell me what had happened, she did not have any recollection of what had happened. I saw no bruises or scratches. I only pulled her brief out which was rumbled, but no I did not check between her legs. I only did a skin assessment top up, not waist down. When I talked with her she could not recall the incident." LPN #6 reported that after she checked Resident #101 over she placed a second call to the DON to report there were no scratches or bruises. LPN #6 stated, "I was told that the social worker would come down and take care of it. That's when she (DON) told me make sure you don't document anything that happened between (Resident #101 and Resident #102), you can do a skin assessment he can't. When (SW #3) came to the unit on 5/2/14, I told him what happened that the resident (#101) didn't recall the incident, he responded, 'Oh good, it means she's not upset'. I thought that very strange remark." LPN #6 reported that she often saw Resident #102 seek Resident #101 out. LPN #5 stated, "I see her in her room, doesn't seem to look for him. He approach's her. I have even had to separate them. I saw (Resident #102) try to 'visit' (Resident #101). At some points (Resident #101) seemed afraid to go out of her room she would say 'that man is out there'." Review of the Nursing Progress notes dated 5/2/14 revealed no documentation was present on the medical record regarding physical/skin assessment was completed on Resident #101. Review of the Social Worker #3's (SW) type-written investigation (no date) revealed CNA #2 told Social Worker #3 that she was "charting at the nurse's station and (Resident #102) was noted to be halfway down the hall (south hall) talking to other residents. The next thing I see he was gone; it may have been 4-5 minutes from the last time I saw him. I tiptoed down to (Resident #101's) room because I've been told not to assume things are happening so I wanted to catch him. She had her hands on her pants exposing herself and his hands down her pants. (Resident #101) seemed to enjoy the interaction. She was smiling, I told (Resident #102) to leave and he did. " In an interview on 5/7/14 at 10:08 am CNA #2 was asked to review the type-written investigation for accuracy. CNA #2 documented and stated, "(Resident #101's) hands were down in the area but not sure if she was helping or not. I took (Resident #102) to the nurses station when I left the room". In an interview on 5/6/14 at 12:10 PM SW #3 reported that Resident #101 and #102 "seek each other out often, but no actual touch. He (Resident #102) seeks friendship. We put (Resident #102) on 15 minute checks, a stop sign on both residents doors, and allow them to visit at the nurses station." SW #3 reported after the incident on 5/2/14, he visited Resident #101 and found her to have no problems. SW #3 stated, "I would not have called that incident a sexual assault because she did not say 'no'." When asked if Resident #101 could agree to sexual encounters, SW #3 stated, "she didn't disagree, she didn't say no. She can make her needs known. She denied when I asked her that he (Resident #102) was even in the room." SW #3 reported that Resident #101's DPOA had not been notified or asked if a relationship of any kind was permissible. SW #3 reported Resident #101 had "no negative outcome" related to the incident. During a telephone interview with the attending Psychiatrist #16 on 5/12/14 at 1:42 PM she reported that during the care conferences held monthly Resident #102's behaviors were discussed and documented. She also noted that she sought outside consultation with a geriatric psychiatrist "because the case was so complicated I wanted to be sure we were doing things appropriately." When asked if she was aware of Resident 102's behavior prior to the incident on 5/2/14 she reported "yes I was aware of them we had talked" when asked who "we" was Psychiatrist #16 replied "the unit manager and social worker". When asked what behaviors were being discussed and of concern, Psychiatrist #16 stated, "The behaviors was that Resident #102 displayed. It would be a violation of his civil rights to stop a relationship which was voluntary and consensual. The resident (#102) was always supervised and we had a grey area and not sure what to do." Psychiatrist #16 reported that she had read and reviewed the behavior logs related to Resident #102 at the monthly care conferences attended by the unit manager and social worker and herself. Psychiatrist #16 reported she had never been asked not to document on the medical record about Resident #102's behaviors, "I would never do that". Psychiatrist #16 also reported that she had never spoken to either Resident #102 or Resident #101's (no documentation was present that Psychiatrist #16 had seen Resident #101 prior to 5/7/14) DPOA's about any behaviors, concerns, treatment plans, or medication changes indicating "the staff at the facility, the social worker, does that. I don't speak to families. They (facility staff) do it." When asked why no behaviors were documented on the physician progress notes [REDACTED]. Psychiatrist #16 stated, "I am certain that I have documented about behaviors and again at the monthly care conferences it had been documented." When asked if she was aware of Resident #102's history of fondling Resident #101's breasts, and the sexual assault of Resident #101 that occurred on 5/2/14, Psychiatrist #16 replied "Yes, I was aware of it when I wrote the progress note." Review of the Progress note dated 5/7/14, authored by the attending Psychiatrist #16 on Resident 102's medical record revealed, "patient currently evidences stable clinical status regarding psychopharmacologic schedule, no side effects of medications evidenced. Discussed with Interdisciplinary staff that the patient has voluntarily had physical contact with another patient, as will voluntary on her part, and this has been by mutual choice therefore no evidence of harm to either. Staff is aware of this shared affection with other patient and will observe for any changes affecting both patients well being. No need for medication intervention required so as to not violate civil rights. I will continue to follow-up. Stable mood reported". Review of the Psychiatrist Progress Notes, dated 7/10/13 through 3/19/14, revealed no documentation regarding any of Resident #102's specific behaviors. Review of the facility documents titled "Behavior Data and Analysis" dated 3/6/13, 4/3, 5/1, 6/12, 7/10, 7/19, 8/6, 8/21, 9/10, 10/17, 11/6, 12/11, 1/5/14, 2/12, 3/19, 4/15, revealed documentation "new onset behaviors-severe anxiety and [MEDICAL CONDITION]. Mood and behaviors stable, will continue to observe". No other behavior information was documented. During an interviews on 5/6/14 at 11:15 AM, Unit Manager/Registered Nurse (RN) #7 reported that Resident #102 did not score high and was basically not cognitively intact "depends on the day". When asked why the stop sign was across both Resident #101 and Resident #102's doorway it was to be able to "watch him and afford him privacy". When asked to review the unit's 24 hour shift-shift logs (report given to pass information between nurses) dated 5/2/14 the 10 PM-6 AM shift was blank, 6 am-2 pm was blank, in the 2 PM-10 PM section (Resident #102) was named specifically for Resident #101's section. In Resident #102's section of the 24 hour log "behaviors 2-10" was written,. RN #7 reported that Resident #102 is "argumentative, upsets easily but behaviors have improved with medications, has a dry sense of humor, he goes on outings, has care plans to do gardening in the patio, and is seen quarterly by psychiatric services, incontinent of urine he waits too long and requires 2 person assistance. If he does wet himself, he places wash cloths inside his brief, but he has no other behaviors". RN #7 reported Resident #101,"is friendly likes to talk, she can stand to pivot, requires 2 assist, her cognition she knows her room and family she has a nice understanding family, requires supervision at meals, needs to be reminded to go to the bathroom but has no behaviors". When asked about the 24 hour log report documentation dated 5/3/14 for Resident #101 for the 10 PM-6 am shift "behaviors" was written, the 6 am -2 pm was blank and 2 pm-10 pm "(Resident #102) not allowed off south hall OK", RN #7 replied, "he is allowed the south hall. He has no other behaviors, I don't know what that means". During a second interview/document review on 5/7/14 at 6:38 PM, when asked who was responsible to document on the facility behavior logs, progress notes and monthly care conferences and nursing care plans RN #7 replied, "both myself and the social worker are. I update the nursing care plans and CNA care guide and document the care conferences, the SW (#3) writes the interventions related to the behaviors on the behavior log." When asked to locate documentation on any of the facility behavior logs, progress notes, nursing care plans, monthly care conferences, why the information was not on the behavior logs, why the behavior logs and interventions were not documented for the CNA's to know how to deal with situations involving both Resident #101 and #102, and behavior data and analysis section were blank and not filled out, RN #7 stated, "We have discussed it. I don't know why it's not there". When asked why the behavior logs were not kept as part of the medical record RN #7 replied, "the social worker takes them out. I tell my staff to document what you see not what you hear." Location of the facility behavior logs were not located on the medical record and were located in the thinned chart in medical records by facility staffs upon request. No incident/accident reports were provided by the facility when requested by this surveyor regarding each documented incident that occurred between Resident #101 and Resident #102. During a interview on 5/7/14 at 2:55 PM Administrator #9 and DON #8 stated that it was a basic human right to touch, and a stop sign had been placed on the resident's doors. Administrator #9 stated, "We have determined its willful". When asked if any incident reports had been completed regarding the multiple events/behaviors related to #102's sexual abuses toward Resident #101, DON #8 replied "No." When why this was not reported to the State Agency and law enforcement, Administrator #9 and DON #8 reported that it was a consensual relationship and that even though Resident #101 had been deemed mentally incapacitated, the DPOA is in place to only make medical decision, not to decide what type of relationships Resident #101 could have, therefore, it was not reportable. Administrator #9 stated, "If we keep him (Resident #102) away from her (Resident #101), we are violating his civil rights by separating him or confining him against his will. Then we would have to report that." On 5/8/14 at 1:00 p.m., Administrator #9 was notified of an Immediate Jeopardy that began on 7/14/13 due to the facility's failure to ensure the highest practicable physical, mental, and psychosocial well-being of each resident by implementing their own abuse policy and ensure the safety of Resident #101. On 5/12-13/14 this Surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. Beginning 5/8/14, the Administrator and Director of Nursing will report all allegations of abuse, neglect, misappropriation of property and mistreatment per the Elder Justice Act and SOM regulatory language to the State Agency. The Administrator and DON will report the same allegations to the Regional Quality Assurance Nurse/Regional Operator for the next (3) three months to ensure incidents have been thoroughly investigated, legal representatives have been notified and reported to the State Agency as required. 2. On 5/8/14, the Administrator has re-educated the Social Services Director regarding his expectations for the SS Director to review the behavior documentation records and report any unusual events to the Administrator immediately. 3. On 5/8/14, the Administrator had ensured that staff re-education was initiated. 4. On 5/8/14, the Administrator instructed the Staff Development Coordinator to ensure new hires receive education on the revised policy for abuse, neglect, misappropriation of property and mistreatment. Although the Immediate Jeopardy was removed on 5/8/14, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

Based on observation, interview, and record review the facility failed to prevent pressure ulcers in 1 of 1 sampled resident (Resident #14) reviewed for pressure ulcers, from a total sample of 24 residents, resulting in new area of skin breakdown on left buttocks and potential for additional undetected areas of skin breakdown. Findings include: According to the facility Identification Summary, dated 3/28/13, Resident #14 was a [AGE] year old female, readmitted to the facility 2/19/13. Review of the documents "Cumulative [DIAGNOSES REDACTED].#14 had [DIAGNOSES REDACTED]. According to the "Minimum Data Set" ((MDS) dated [DATE], Resident #14 had long and short term memory loss and severely impaired cognition-never or rarely made decisions. The MDS indicated Resident #14 required extensive/dependent assistance of 2 staff members for turning and repositioning, bathing, dressing, and toilet needs and that Resident #14 had an indwelling foley catheter (tube inserted into the bladder to drain urine). Review of the "Braden Scale for Predicting Pressure Sore Risk" dated 5/1/13, reflected that Resident #14 had a total Braden Scale score of 11. A total score of 17 or less indicated that the resident was at risk for skin breakdown. Review of the "Weekly Skin Assessment" dated 12/18/13 and signed by the C-Hall Unit Manager, Registered Nurse (RN) "C" indicated that Resident #14 had an existing wound on left buttock, no new areas were noted. Resident #14 was observed on initial tour 12/16/13 at 5:30 am in bed on her back with arms folded over her chest. Resident #14's knees were observed to be bent and both heels were on the mattress. Resident #14 was observed 12/17/13 at 8:35 am in her room in bed, Resident #14 was observed to be on her back and her heels were noted to be on the bed. On 12/17/13 at 10:45 am, Resident #14 was observed in her room and still remained on her back with both heels on the mattress. On 12/19/13 at 10:30 am, with Registered Nurse (RN) "H" and Licensed Practical Nurse (LPN) "AA", an observation of the dressing change to the existing pressure ulcer on Resident #14's left buttock was conducted. Upon entering the room room Resident #14 was laying on her back both heels on the mattress. Resident #14 was assisted by LPN "AA" to her right side. No drawsheet was used to help reduce pulling on Resident #14's skin with repositioning. An observation of a second area of breakdown was noted to be above and to the left of the wound area where the dressing was being applied. The area of breakdown was approximately the size of a nickle with a yellow center. RN "H" stated that the area had not been there on Monday 12/16/13 when she did Resident #14's dressing change but that Resident #14 had been turned the other way. No measurements of the wound was taken at the time of this observation and no treatment was applied to area. RN "H" said that the Nurse Practitioner was to be in that day and she would have him look at the area. After the dressing change Resident #14 was placed back onto her back. On 12/19/13 at 1:00 pm RN "C" was interviewed about the skin assessment for Resident #14 she had completed on 12/18/13. RN "C" revealed that she had not looked specifically at Resident #14's bottom with that assessment and had not turned Resident #14 completely to get a good look at Resident #14 left buttock. In an interview on 12/17/13 at 1:45 pm Certified Nurse Aide (CNA) "D", assigned to Resident #14 that day, stated that the only care that she had provided for Resident #14 that day had been to wash her face and hands, as 3rd shift (10 pm to 6 am) CNA had dressed Resident #14 for the day before CNA "D" had arrived to work. CNA "D" stated that her shift started at 6 am and ended at 2 pm. Review of Resident #14's, undated,"Nursing care Card" (a document that the CNA's use to know how to care for the residents), under "Bed Mobility/Skin Care" it reflected that Resident #14 was dependent and required staff assistance with turning and repositioning every 2 hours and that heels were to be floated (elevated off the bed). Review of Resident #14's "Plan of Care" onset date of 2/11/13 under "Approaches/Interventions" it was indicated that staff was to use a drawsheet for turning and repositioning while in bed. Review of the facilities "Wound and Skin Management Program" under "Prevention" it identified that the facility will assess and identify risk factors, assist with mobility, and provide support surfaces to prevent breakdown. ( )

This citation pertains to MI 357 Based on observation, interview, and record review, the facility failed to ensure sufficient fluid intake and monitor hydration status for 1 of 5 residents reviewed for hydration (Resident #105), from a total sample of 8 residents, resulting in severe dehydration for Resident #105. Findings include: Review of the Face Sheet and Minimum Data Sets ((MDS) dated [DATE] and 2/6/13, revealed Resident #105 was an [AGE] year old male, originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], revealed Resident #105 had moderately impaired cognitive skills for daily decision making. The MDS dated [DATE], revealed Resident #105 required extensive assistance for eating, did not display any behavioral symptoms, and did not reject care. Review of the Nutrition Care Plan dated 1/15/13, revealed Resident #105 was at risk for dehydration, refused to eat, and required assistance to eat. The Care Plan revealed staff was to "observe for signs and symptoms of dehydration such as dry mouth, poor skin turgor, lethargy, low blood pressure, etc..." and "provide assist with eating and/or drinking as needed". There was not an intervention to encourage fluids. Review of the Nutritional assessment dated [DATE], revealed Resident #105's fluid requirement was 2400 mL (milliliters). During an interview on 3/14/13 at 2:15 PM, Dietary Manager #28 reported the fluid requirement is the intake amount required by Resident #105. Dietary Manager #28 reported she would monitor fluid intake, and if intake was low, she notified the dietician. Dietary Manager #28 could not specifically remember if she had reported Resident #105's intake to the Registered Dietician. During a telephone interview on 3/14/13 at 3:45 PM, Registered Dietician (RD) #31 stated the fluid requirement is what Resident #105 needed daily "to maintain hydration and body function". Review of the Intake/Output Data Collection Sheet dated 1/9/13 through 2/6/13, revealed Resident #105 had the following daily fluid intake: 800 mL on 1/9/13, 1200 mL on 1/10/13, 780 mL on 1/11/13, 720 mL on 1/12/13, 540 mL on 1/13/13, 480 mL on 1/14/13, 1680 mL on 1/15/13, 840 mL on 1/16/13, 1200 mL on 1/17/13, 780 mL on 1/18/13, 720 mL on 1/19/13, 1320 mL on 1/20/13, 960 mL on 1/21/13 was, 800 mL on 1/22/13, 1320 mL on 1/23/13, 1440 mL on 1/24/13, 540 mL on 1/25/13, 1080 mL on 1/26/13, 1080 mL on 1/27/13, 1320 mL on 1/28/13, 720 mL on 1/29/13, 660 mL on 1/30/13, 300 mL on 1/31/13, 120 mL on 2/1/13, 360 mL on 2/2/13, 60 mL on 2/3/13, 240 mL on 2/4/13, 120 mL and sips of fluid on 2/5/13, and 10 mL on 2/6/13. Total fluid need was 67,200 mL for 28 days and Resident #105 received 22,190 mL which was a fluid deficit of 45,010 mL over a 28 day period. During an interview on 3/15/13 at 2:50 PM, Registered Nurse (RN)/Unit Manager #35 reported that the Intake/Output Data Collection Sheets included all the fluids for the day, including what is consumed at meals. During an interview on 3/13/13 at 2:37 PM, Certified Nursing Assistant (CNA) #9 reported that in general low fluid intake amounts are reported to the nurse. CNA #9 could not remember if she reported Resident #105's low intake to the nurse. During an interview on 3/13/13 at 3:30 PM, Registered Nurse (RN) #19 reported hydration status is monitored by intake and output records, skin moisture, skin turgor, and urine color. During an interview on 3/14/13 at 9:20 AM, Licensed Practical Nurse (LPN) #21 reported if fluid intake was low for a resident, an assessment would be done and the physician would be notified. LPN #21 reported if staff encouraged fluids, it would "usually be in the nurse's notes". During a telephone interview on 3/14/13 at 11:04 AM, CNA #25 reported Resident #105 "asked for water a lot...towards the end, he (Resident #105) needed a lot of encouragement and reminders to drink". Review of the Nurse's Notes dated 1/8/13 through 2/4/13, revealed no documentation that Resident #105 refused fluids or that fluids were encouraged, and no documentation regarding skin turgor or mucous membranes. Review of the Nurse Practitioner (NP) progress note dated 1/17/13, revealed Resident #105 was "well hydrated" Review of the Nurse Practitioner (NP) #22 progress note dated 2/1/13, revealed "He (Resident #105) appears rather dry. He has decreased skin turgor (a reflection of the skin's elasticity, measured by monitoring the time it takes for the skin to return to position after it is lightly pinched between the examiner's thumb and forefinger) and his mucous membranes are mildly dry..." Signs and symptoms of fluid volume deficit (dehydration) include dry mucous membranes and poor skin turgor (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). During a telephone interview on 3/14/13 at 9:48 AM, NP #22 reported based on his assessment on 2/1/13, fluids would be encouraged. When queried as to why labwork to check hydration status was not ordered, NP #22 stated "they certainly could have been drawn, but I'm not sure why they were not ordered". Review of the physician's orders [REDACTED].#105 regarding labwork or hydration status. Review of the Nutrition Care Plan dated 1/15/13, revealed no new interventions were initiated for dehydration for Resident #105. The Clinical Process Guidelines for Maintaining Hydration and Electrolyte Balance indicate clinical observation of hydration status--unlike nutritional status--may not suffice, and adequate recognition of hydration management may require lab tests...The staff and practitioner should consider fluid and electrolyte imbalance when a significant condition change occurred that could not be readily explained by another cause. The practitioner should order appropriate laboratory evaluation, including BUN, creatinine, electrolytes and other relevant tests...Lab testing may be helpful, in addition to other approaches to try and clarify current hydration status. (MDCH, 11/8/05) Review of Resident #105's laboratory reports, revealed the last laboratory results were from 1/7/13 and showed sodium level of 138 (normal range 135-148) and blood urea nitrogen (BUN) level of 24 (normal range 7-22). During a telephone interview on 3/14/13 at 3:45, when queried about how hydration status is monitored, RD #31 reported she looked at the intake records and at labwork, but stated, "I hate to wait for labs because I can catch it (dehydration)". RD #31 reported she would notify the physician if fluid intake was not meeting the estimated fluid requirements. RD #31 stated "they (staff) should have been encouraging intake all along" and that the care plan should say encourage fluids. RD #31 reported she would be in the facility on 3/15/13 and would look at Resident #105's chart with this surveyor. This surveyor requested that RD #31 provide documentation that the physician was notified regarding Resident #105's low fluid intake. During an interview on 3/15/13 at 2:10 PM, RD #31 sat down with this surveyor and went through Resident #105's chart. RD #31 was unable to provide documentation that the physician was notified regarding Resident #105's low fluid intake. RD #31 stated "I had him as eating fine...with 75% intake he probably was meeting fluid needs". Review of Resident #105's Nutrition Progress Notes dated 1/22/13, revealed "meeting assessed needs". There were no further Nutrition Progress Notes and no documentation to indicate the physican was notified that Resident #105 was not meeting the estimated fluid requirements. During a telephone interview on 3/14/13 at 10:00 AM, Family Member #23 reported Resident #105 had water in his room, but she never saw him drink it on his own. Family Member #23 reported she did not witness staff offer water or encourage Resident #105 to drink. Review of the Nurse's Notes dated 2/6/13, revealed Resident #105 was "unresponsive to verbal stimuli or touch...mottling up to knees" and he was transferred to the hospital. Review of the Hospital Records dated 2/6/13, revealed Resident #105 had bloodwork done at 6:08 PM which revealed Resident #105 had a sodium of 160 (normal range 135-148) and blood urea nitrogen (BUN) of 91 (normal range 7-22). The Hospital Records indicated Resident #015 had a "poor prognosis for survival" and a clinical impression of "sepsis with altered mental status and shock, severe dehydration, moderate [MEDICAL CONDITION], severe [MEDICAL CONDITION] (high sodium in blood), and acute urinary tract infection". An elevated blood urea nitrogen (BUN) and sodium level could be an indication of dehydration. (Kee, J.L. (2002) Laboratory and Diagnostic Tests with Nursing Implications (6th ed.). Upper Saddle River, NJ: Pearson Education). Review of Resident #105's Certificate of Death revealed he was pronounced dead on 2/7/13 at 10:35 AM as a result of [MEDICAL CONDITIONS] (kidney and blood infection). During a telephone interview on 3/14/13 at 10:00 AM, Family Member #23 stated "If I would have known what was wrong, I would have sent him (Resident #105) to the hospital sooner"..."we had no idea what was going on. They never once suggested we send him to the hospital until that night (2/6/13). Family Member #23 reported that dehydration was never mentioned by the facility. During a telephone interview on 3/14/13 at 12:30 PM, this surveyor read Resident #105's hospital laboratory results to Physician #29, who then stated "He (Resident #105) was dry". Physician #29 was queried as to why laboratory results were not ordered prior to 2/4/13 and Physician #29 stated "having the lab values would have helped obviously. Would an IV had prolonged his life if started sooner? Probably". When queried if the laboratory results presented as dehydration, Physician #29 stated "Oh of course with a sodium that high and BUN that high". Observations during the onsite investigation revealed residents had fluids available in their rooms, but this surveyor did not witness staff assisting residents with drinking, except at meal times. ( )

This citation pertains to MI 877. Based on interview and record review, the facility failed to maintain the highest practicable physical well-being (provide CardioPulmonary Resuscitation (CPR) and activate Emergency Medical Services (EMS) per facility policy) in 1 of 8 sampled residents (Resident #106) reviewed for Code status, from a total of 8 sampled residents, resulting in an Immediate Jeopardy when Resident #106, who was a full code, was found by Licensed Practical Nurse (LPN) #13 and LPN #14 on [DATE] at 6:08 AM with no pulse or respirations and CPR and EMS were not initiated. Resident #106 subsequently died . This deficient practice placed 55 additional residents, designated as having a full code status, at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet and the Minimum Data Set (MDS), dated [DATE], revealed Resident #106 was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #106 had a Brief Interview for Mental Status (BIMS) score of ,[DATE] (indicating severe cognitive impairment), and was on oxygen therapy. Resident #106 had a Guardian (Representative #15) in place who was activated on [DATE]. Review of the Emergency Response Directive/Advanced Directive Form, dated [DATE], revealed Resident #106's Representative #15 signed a request which indicated that, in the event her "heart stops or breathing stops, Cardio-Pulmonary Resuscitation (CPR) will be attempted, with emergency transportation to the hospital where full life support measures may be undertaken". This form was signed by Medical Director #17 (no date). Review of Resident #106's Progress Notes, dated [DATE] at 3:00 AM, revealed "VS (vital signs) - T (temperature) 97.9, P (pulse) -111, BP (blood pressure) ,[DATE], R (respirations) 28, O2 Sat (oxygen in blood) before (nebulizer medication/mist treatment) 78%; after (treatment) 91%. (Resident #106) responds to verbal stimuli. Opens eye. Speech clear; soft. Skin color pale. SOB (shortness of breath) when lying flat in bed. HOB (head of bed) ... LS (lung sounds) with few scattered crackles all fields. O2 (oxygen) on at 3 LPM (liters per minutes)." Per Resident #106's Progress Notes dated [DATE] at 6:30 AM, LPN #13 wrote, "This nurse entered (Resident #106's) room after (Certified Nursing Assistant/CNA) request et (sic) observed (Resident #106) without pulse or resp (respirations) noted; fell ow nurse (LPN #14) entered room et (sic) observed no pulse at 6:08 AM. This nurse (LPN #13) called to notify (Resident #106's) guardian. (LPN #14) notified (NP/Nurse Practitioner #16) on call for (Physician #17); family to return call with funeral home information." In an interview on [DATE] at 2:21 PM, in the presence of facility Regional Quality Assurance Manager #29, Director of Nursing (DON) #5 stated "(LPN #13 and LPN #14) found (Resident #106) clinically dead/without signs of life". When asked why CPR was not initiated, DON #5 stated, "(Resident #106) was alert and oriented, made her needs known. It was not an emergent situation because they found (Resident #106) cold and her mucus membranes were dry." When asked how much time had passed since Resident #106 was without vital signs, DON #5 stated, "I had not asked that". In an interview on [DATE] at 4:28 PM, LPN #13 identified herself as the nurse coming on duty on [DATE] at 6:00 AM. LPN #13 stated she was at the nurse's station when she heard two CNAs calling, "We need a nurse!" LPN #13 stated, "I entered (Resident #106's) room, LPN #14 (the nurse assigned to Resident #106 from [DATE]-[DATE] midnight shift) was right behind me. We checked (Resident #106) out. She was gone, gone. She was cold." When asked what assessments she and LPN #14 performed to assess Resident #106's condition, LPN #13 stated, "Nothing really. We checked for a pulse; she was cold." In an interview on [DATE] at 4:50 PM, Administrator #9 was asked if LPN #13 and LPN #14 followed the facility policy regarding the initiation of CPR in regards to Resident #106, and Administrator #9 stated, "I don't know the facility Policy and Procedure according to Michigan law. I do know a Registered Nurse can pronounce a death. The nurses (LPN #13 and LPN #14) noted she (Resident #106) was gone, gone. I don't know if they should start CPR." Review of the facility CardioPulmonary Resuscitation (CPR) - (Heartsaver CPR) Policy with a revised date of ,[DATE] revealed, "...Licensed nursing personnel employed over 90 days will have and maintain a current CPR certification...For guests with a designated healthcare directive to indicate they wish CPR, to be performed, or in the absence of a healthcare directive, the facility will initiate CPR at the level of Heartsaver CPR as defined by the American Heart Association. Heartsaver CPR guidelines are as follows: chest compression-airway-breathing. Procedure: Upon notification or observance of a guest in respiratory or [MEDICAL CONDITION], immediately validate the guest code status. If the guest code status directs resuscitation, commence Heartsaver CPR following the directions outlined by the American Heart Association (per facility policy), while alternate staff obtains the Emergency Cart. While Heartsaver CPR continues, have another staff member notify the physician and the family immediately. Have another staff member notify 911 immediately for emergency transport to and acute care setting." The policy indicated under #6, "The facility will maintain on duty 24 hours a day a trained staff member capable of providing Heartsaver CPR with current certification from a provider that adheres to the standards and guidelines of the American Heart Association." In an interview on [DATE] at 8:30 AM, LPN #14 stated, "At 4:00 AM, (Resident #106) was alert and able to make her needs known. I did not check on her again after that." When asked by this surveyor why she did not perform CPR on Resident #106 when she was observed unresponsive, LPN #14 stated, "I did not do CPR because she had a mucus film on her eyes and it had been over 2 hours since she was last observed. The policy says to start CPR. I did not do that because it was a mute point." LPN #14 reported she did not check on Resident #106's code status because "she had been DNR in the hospital" and "did not check her chart" at the facility when Resident #106 was found unresponsive. In an interview on [DATE] at 2:26 PM, CNA #39 stated she remembered the night that Resident #106 expired. CNA #39 said, "I remember that. (Resident #106) was one sick lady. I checked her at 5:30 (AM) and at 6:00 (AM) she was gone. It was an expected one. We were surprised she made it to 5:30 (AM). We washed her up and repositioned her at 5:30 (AM). The nurse (LPN #14) talked to us during the night and told us her death was expected. At 5:30 (AM) she was rattily, labored (breathing)". In a telephone interview on [DATE] at 9:45 AM, Nurse Practitioner (NP) #16 said he did not ask what the resident's (Resident #106) Code status was when a facility nurse called and told him a resident had expired. NP #16 said, "I ask if it (death) was expected" and "If they (a resident) were cold, breathless and pulseless, from my estimation, even in that situation, to maintain dignity, if there were no spontaneous respirations, fixed pupils, to start CPR would not be appropriate at that point." NP #16 stated he had never been told that LPN's were not allowed to pronounce death in Michigan and said, "In general a Full Code would be extremely useless if they are found to be cold and pulseless...I don't know their (the facility's) specific policy. I never received a policy". NP #16 stated he had not received any education from Medical Director #17 regarding the facility's CPR Policy and Procedure. In a telephone interview on [DATE] at 10:44 AM, Representative #15 stated Resident #106 was a full code and that it was Resident #106's wish to be a full code, "I was trying to fulfill her wishes." Representative #15 stated that the facility called her "a bit" after 6:00 AM and informed her that Resident #106 had passed and was told by LPN #13 that Resident #106's respirations "had become less and less and further apart during the night." Representative #15 stated the facility did not call during the night to inform her that Resident #106's condition was deteriorating. Representative #15 reported that she was a nurse and that Resident #106 had [MEDICAL CONDITION] and "thought she needed to be in a controlled setting so it could be watched. I thought it may improve her breathing if she were in a controlled setting." In a telephone interview on [DATE] at 12:40 PM, Medical Director #17 stated to Surveyor # , "I am a certified Medical Director, am certified in Geriatrics (care focused on the elderly). This is what I do". When asked if he were familiar with the facility's policies and procedures regarding the initiation of CPR on residents with a Full Code status, Medical Director #17 stated, "If a resident is a Full Code, obviously you want to do CPR, but each case has to have an individual response. I understand (Resident #106) was found cold, no pulse, and no respirations. I absolutely have no trouble with the staff not doing CPR even though she was a Full Code. I respect the wishes of a resident, but if they are brain dead, and heart dead, I do not feel CPR should be done. If she were my mother that is the standard I am going by. Each case is individual and has to be realized..." When asked what instruction he had given to NP #16 regarding the initiation of CPR for residents found without pulse or respirations that had a Full Code designation, Medical Director #17 stated, "Each case has to be individual. Medicine is not a cook book. Each case develops individually". When asked if Resident #106 was in the process of actively dying on [DATE], Medical Director #17 said, "I have no idea...I don't think I went against the facility (CPR) policy. I realize the facility (CPR) policy says Full Code...but CPR on a dead body, I think it's wrong medically to do it. Each case has to be taken individually. You have to adjust your policies. They are not black and white". On [DATE] at 12:41 PM, Unit Manager/Wound Nurse/Infection Control Nurse/Staffing Coordinator (UM) #1 provided copies of the licensed nurses with current CPR cards; 19 of the 37 licensed facility nurses had current CPR certification. UM #1 reported at the time Resident #106 was found unresponsive, there were 4 licensed nurses certified in CPR available to perform a code if called upon. Review of LPN #13 and LPN #14's personnel files revealed that LPN #13 or LPN #14 did not have current CPR certifications. The Administrator was notified on [DATE] at 3:30 PM of an Immediate Jeopardy that began on [DATE] as a result of the facility's failure to provide CardioPulmonary Resuscitation (CPR) and activate Emergency Medical Services (EMS) per facility policy and the professional standards of care for Resident #106, who was found without a pulse and without respirations, and CPR and EMS were not initiated. On [DATE] the Surveyors confirmed that the Facility staffs completed the following to remove the Immediate Jeopardy: 1. On [DATE], all current residents' (149 of 149) Emergency Directives (Advanced Directives) were reviewed to ensure their Emergency Directive was completed; all Emergency Directives were current as of [DATE], and each resident's Code status was recorded in each resident's Medication Administration records (MAR's) and with a red sticker on the inside cover of their Medical Records. 2. On [DATE], all 37 licensed nurses' employee files were reviewed to determine each nurse's CPR certification status (24 of 37 had current CPR as of [DATE]); re-education of the remaining 19 facility licensed nurses has been scheduled for completion on [DATE]. 3. Beginning [DATE], the Unit Manager/Wound Nurse/Infection Control Nurse/Staffing Coordinator #1 will ensure a CPR certified nurse is scheduled on each shift until 100 % of the facility licensed nurses are certified. 4. On [DATE], all 3 emergency crash carts were checked to ensure appropriate supplies were available. 5. On [DATE], (14 of 25) LPN's and (9 of 12) RN's were provided education and (11 of 11) remaining LPN's will be educated prior to their next scheduled shift. The following education was provided: A). If a resident is found unresponsive, attempt to arouse the individual. If the resident has no movement or response to stimuli, and no return of pulse and/or respirations staff is to check the Code status in the resident's chart and/or MAR and activate the facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure. (If the resident is a Full code, a licensed nurse will initiate CPR while another staff member calls 911, notifies the physician and the residents ' legal representative. If CPR is initiated, it shall continue until care is transferred to EMS). B). Physician Notification of Resident's Death. C). SBAR/Situation, Background, Assessment, Recommendations guidelines for physician notification where there is a change in respiratory status. 6. On [DATE], LPN #13 and LPN #14 were provided 1:1 education relating to residents' Code status initiation of CPR for any resident identified with a Full Code status, and accurate and timely documentation. 7. On [DATE], the Administrator #9, Medical Director #17, and his extenders (including NP #16) were provided additional education relating the facility's CPR Policy and Procedure and The Michigan Death Act (which identifies that only an RN may pronounce death). Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced and sustained compliance had not yet been verified by the State Agency. ( and )

This citation pertains to MI 877. Based on interview and record review, the facility failed to ensure a resident was allowed to exercise her right as a citizen (follow a signed Advance Directive) in 1 of 8 residents (Resident #106), reviewed for Code status, from a total of 8 sampled residents, resulting in CardioPulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) not being immediately initiated when Resident #106 was found unresponsive with no pulse and no respirations on [DATE], despite her designation as a full code. Findings include: Per the facility Residents Rights document (not dated) provided to Surveyor # on [DATE] at 1:32 PM, and identified by Unit Manger #1 as the document given to residents upon admission, "...Each resident in a nursing facility has a right ...To make choices concerning personal privileges..." Review of the Face Sheet and the Minimum Data Set (MDS), dated [DATE], revealed Resident #106 was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #106 had a Brief Interview for Mental Status (BIMS) score of ,[DATE] (indicating severe cognitive impairment). Resident #106 had a Guardian (Representative #15) in place that was activated on [DATE]. Review of the Emergency Response Directive/Advanced Directive Form dated [DATE] revealed Resident #106's Representative #15 signed a request which indicated that in the event her heart stops or breathing stops, Cardiopulmonary Resuscitation (CPR) would be attempted, with emergency transportation to the hospital where full life support measures may be undertaken. Review of the facility CardioPulmonary Resuscitation (CPR) - (Heartsaver CPR) Policy with a revised date of ,[DATE] revealed, "For guests with a designated healthcare directive to indicate they wish CPR, to be performed, or in the absence of a healthcare directive, the facility will initiate CPR at the level of Heartsaver CPR as defined by the American Heart Association. Heartsaver CPR guidelines are as follows: chest compression-airway-breathing. Procedure: Upon notification or observance of a guest in respiratory or [MEDICAL CONDITION], immediately validate the guest code status. If the guest code status directs resuscitation, commence Heartsaver CPR following the directions outlined by the American Heart Association (per facility policy), while alternate staff obtains the Emergency Cart. While Heartsaver CPR continues, have another staff member notify the physician and the family immediately. Have another staff member notify 911 immediately for emergency transport to and acute care setting." Per Resident #106's Progress Notes, dated [DATE] at 6:30 AM, Licensed Practical Nurse (LPN) #13 documented, "This nurse entered (Resident #106's) room after (nurse aide) request et (sic) observed (Resident #106) without pulse or resp (respirations) noted; fell ow nurse (LPN #14) entered room et (sic) observed no pulse at 6:08 AM. This nurse (LPN #13) called to notify (Resident #106's) guardian. (LPN #14) notified (NP/Nurse Practitioner #16) on-call for (Physician #17); family to return call with funeral home information." In an interview, on [DATE] at 4:28 PM, LPN #13 identified herself as the nurse coming on duty on [DATE] at 6:00 AM. LPN #13 stated she was at the nurse's station when she heard two nurse aides calling, "We need a nurse!" LPN #13 stated, "I entered (Resident #106's) room, LPN #14 (the nurse assigned to Resident #106 on [DATE]-[DATE] midnight shift) was right behind me. We checked (Resident #106) out. She was gone, gone. She was cold." When asked what assessments were performed to assess Resident #106's condition, LPN #13 stated, "Nothing really. We checked for a pulse; she was cold." In an interview on [DATE] at 10:44 AM, Representative #15 stated Resident #106 was a full code and that it was Resident #106's wish to be a full code, "I was trying to fulfill her wishes." Representative #15 stated that the facility called her "a bit" after 6:00 AM and informed her that Resident #106 had passed and was told by LPN #13 that Resident #106's respirations "had become less and less and further apart during the night." Representative #15 stated the facility did not call during the night to inform her that Resident #106's condition was deteriorating. In an interview on [DATE] at 4:50 PM, Administrator #9 was asked if LPN #13 and LPN #14 followed the facility policy regarding the initiation of CPR in regards to Resident #106, and Administrator #9 stated, "I don't know the facility Policy and Procedure according to Michigan law. I do know a Registered Nurse can pronounce a death. The nurses (LPN #13 and LPN #14) noted she (Resident #106) was gone, gone. I don't know if they should start CPR". In a telephone interview on [DATE] at 12:40 PM, Medical Director #17 stated to Surveyor # , "I am a certified Medical Director, am certified in Geriatrics (care focused on elderly people). This is what I do". When asked if he were familiar with the facility's policies and procedures regarding the initiation of CPR on residents with a Full Code status, Medical Director #17 stated, "If a resident is a Full Code, obviously you want to do CPR, but each case has to have an individual response. I understand (Resident #106) was found cold, no pulse, and no respirations. I absolutely have no trouble with the staff not doing CPR even though she was a Full Code. I respect the wishes of a resident, but if they are brain dead, and heart dead, I do not feel CPR should be done. If she were my mother, that is the standard I am going by. Each case is individual and has to be realized..." When asked what instruction he had given to NP #16 regarding the initiation of CPR for residents found without pulse or respirations that had a Full Code designation, Medical Director #17 stated, "Each case has to be individual. Medicine is not a cook book. Each case develops individually". When asked if Resident #106 was in the process of actively dying on [DATE], Medical Director #17 said, "I have no idea...I don't think I went against the facility (CPR) policy. I realize the facility (CPR) policy says Full Code...but CPR on a dead body, I think its wrong medically to do it. Each case has to be taken individually. You have to adjust your policies. they are not black and white". ( and )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED ENSURE RESIDENTS RECEIVED PROPER RESPIRATORY CARE AND TREATMENT IN 1 (# 8) OF 8 RESIDENTS REVIEWED WITH OXYGEN IN A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN RESIDENT #8 EXPERIENCING SEVERE RESPIRATORY DISTRESS REQUIRING TRANSFER TO THE emergency room (ER) AND ADMISSION TO THE HOSPITAL. FINDINGS INCLUDE: ACCORDING TO "MEDICAL history and physical examination [REDACTED]. RESIDENT #8 ALSO had a history of [REDACTED]. ACCORDING TO THE RESPIRATORY DIFFICULTY BREATHING PLAN OF CARE, DATED 4/24/12, RESIDENT #8 SLEEPS IN A RECLINER CHAIR DUE TO SOB WHEN LYING FLAT. ACCORDING TO THE MINIMUM DATA SET (MDS) ASSESSMENT OF 4/22/12, RESIDENT #8 WAS RE-admitted to the facility on [DATE]. RESIDENT #8 HAD A BRIEF INTERVIEW OF MENTAL STATUS (BIMS) OF 11 OUT OF 15, INDICATING A MODERATELY IMPAIRED COGNITIVE STATUS. ACCORDING TO THE MDS ASSESSMENT OF 10/26/10, RESIDENT #8 WAS A LONG TERM RESIDENT AT THIS FACILITY, ORIGINALLY admitted on [DATE]. ON 4/25/12 AT 10:40 AM, RESIDENT #8 WAS OBSERVED SITTING IN HER ROOM IN HER WHEELCHAIR AND APPEARED TO BE IN RESPIRATORY DISTRESS. RESIDENT #8 WAS OBSERVED WITHOUT OXYGEN ON. A NEBULIZER MASK WAS NOTED ON HER FOREHEAD. THE OXYGEN CONCENTRATOR WAS SET AT 2 L WITH THE OXYGEN TUBING DISCONNECTED FROM THE MASK AND THE OXYGEN TUBING WAS OBSERVED LAYING ON THE FLOOR. ADDITIONALLY, THE OXYGEN TANK ON THE BACK OF THE WHEELCHAIR WAS NOT IS USE AS THE TANK WAS TURNED OFF AND HAD NO OXYGEN TUBING ATTACHED. CENA "B" CAME INTO RESIDENT #8'S ROOM TO PICK UP THE RESIDENTS BREAKFAST TRAY. THE CENA DID NOT ADDRESS THE FACT THAT RESIDENT #8 WAS NOT RECEIVING OXYGEN AND WAS WEARING AN OXYGEN MASK ON HER FOREHEAD. ACCORDING TO STATE AGENCY CLINICAL PROCESS GUIDELINES FOR ACUTE CHANGE OF CONDITION (ACOC), THE NURSING ASSISTANT HAS A RESPONSIBILITY TO RECOGNIZE AND REPORT CONDITION CHANGES, MAKE FREQUENT OBSERVATIONS OF THE PATIENT'S CONDITION AND SYMPTOMS. AT THIS TIME A NURSE WAS REQUESTED BY THE SURVEYOR TO OBTAIN AN O2 PULSE OXIMETRY SATURATION (A NON-INVASIVE TECHNIQUE USED TO DETERMINE OXYGEN SATURATION LEVEL IN ORDER TO MEASURE BENEFITS OF SUPPLEMENTAL OXYGEN) FOR RESIDENT #8. AT APPROXIMATELY 10:43 AM, REGISTERED NURSE "D" RESPONDED. NURSE "D" TOOK AN INITIAL O2 SAT OF 68%, RE-POSITIONED THE PROBE AND RECEIVED ANOTHER READING OF 62%. NURSE "D" STATED THAT SHE BELIEVED THE PULSE OXIMETRY MACHINE MUST NOT BE WORKING PROPERLY. NURSE "D" THEN DISCOVERED THAT THE OXYGEN TUBING WAS NOT CONNECTED TO THE RESIDENTS MASK AND STATED, "YOUR OXYGEN IS NOT ON!" THE PULSE OXIMETRY TAKEN AT THIS TIME WAS 58%. NURSE "D" THEN PLACED A NASAL CANNULA ON RESIDENT #8 AT 2 L. AND LEFT THE RESIDENTS ROOM MOMENTARILY. NURSE "D" RETURNED TO THE RESIDENTS ROOM AND OBTAINED ANOTHER 02 SAT WHICH WAS 85-86% . DURING THIS TIME RESIDENT #8 WAS OBSERVED TO BE GRAY IN COLOR, SOB, LEANING FORWARD WITH AUDIBLE WHEEZING. RESIDENT #8 HAD A NON-PRODUCTIVE CONGESTED COUGH. STAFF "D" ADMINISTERED A NEBULIZER TREATMENT AT APPROXIMATELY 10:47 AM. THERE WAS NOT ANY DOCUMENTATION FOUND IN THE MEDICAL RECORD THAT RESIDENT #8'S RESPIRATORY RATE WAS MONITORED BEFORE AND DURING THE NEBULIZER TREATMENT. AT 11:00 AM, LICENSED PRACTICAL NURSE "C", RETURNED FROM LUNCH, RECEIVED REPORT IN RESIDENT #8'S ROOM FROM NURSE "D", AND TOOK OVER CARE OF RESIDENT #8. STAFF "C", STATED THAT SHE GAVE RESIDENT #8 A BREATHING TREATMENT AT 7:00 AM AND 9:00 AM AND THE MASK WAS PUT ON BECAUSE RESIDENT #8 WAS MOUTH BREATHING. AT APPROXIMATELY 11:06 AM, NURSE "C" INSTRUCTED NURSE AIDES"B" AND "F" TO STAY WITH RESIDENT #8 AND MONITOR O2 SAT'S WHILE SHE LEFT TO CALL THE PHYSICIAN. O2 SAT WAS OBSERVED AT 76%. ON 4/25/12 AT 11:10, STAFF "B" STATED THAT EARLIER THIS MORNING SHE APPLIED A MASK AT 9:30 AM PER NURSE "C" INSTRUCTIONS AND THE O2 SAT WAS 85% AT THAT TIME. VITAL SIGNS WERE NOT OBSERVED AS OBTAINED BY THE NURSE ASSISTANTS "B" AND "F" BEFORE OR DURING THIS OBSERVATION. THE FIRST RESPIRATION RATE VITAL SIGN WAS TAKEN AT 11:20 AM. ON 4/25/12 AT APPROXIMATELY 11:23 AM, RESIDENT #8'S OXYGEN WAS INCREASED FROM 2 L TO 3 L BY STAFF "C". RESIDENT #8 CONTINUED WITH RESPIRATORY DISTRESS AND WAS LEANING FORWARD IN HER WHEELCHAIR AND HER O2 SAT WAS 78%. ON 4/25/12 AT 11:31 AM, RESIDENT #8'S WAS TRANSFERRED TO THE ER PER PHYSICIAN ORDERS [REDACTED]. RECORD REVIEW REFLECTED THAT RESIDENT #8 HAD CONTINUED RESPIRATORY DECLINE WHICH BEGAN DAYS EARLIER. ON 4/22/12 AT 3:30 AM, THE NURSES "PROGRESS NOTES" REFLECTED THAT RESIDENT #8 O2 SAT WAS 67%, AND ORDERS WERE RECEIVED FOR A CHEST X-RAY AND ONE ADDITIONAL NEBULIZER TREATMENT. AT 2:45 PM, ORDERS WERE RECEIVED FOR [MEDICATION NAME] 400 MILLIGRAMS (MG) FOR 10 DAYS. THE CHEST X-RAY, DATED 4/22/12 FOUND AN AREA OF INFILTRATE (FLUID IN AIRSPACE) IN THE LEFT LUNG BASE. ON 4/24/12 AT 10:45 AM, DURING THE INIAL TOUR WITH THE MDS COORDINATOR NURSE STAFF "N", RESIDENT #8 WAS OBSERVED SITTING IN HER ROOM IN HER WHEELCHAIR. RESIDENT STATED THAT SHE COULD NOT BREATH AND THAT SHE NEEDED TO GO TO THE HOSPITAL. ACCORDING TO THE NURSES "PROGRESS NOTES" ON 4/24/12 AT 1:00 PM, RESIDENT OXYGEN SATURATION (O2 SAT) LEVELS WERE 81-85% AND 91% FOLLOWING SCHEDULED NEBULIZER (NEB) TREATMENTS (AEROSOL RESPIRATORY TREATMENT). SOB WAS NOTED WITH EXERTION AND AT REST. RESIDENT #8'S SKIN COLOR WAS PALE. THE NURSES PROGRESS NOTE DID NOT INDICATE THAT THE PHYSICIAN WAS NOTIFIED PER THE "PULSE OXIMETRY" POLICY DATED 12/02 WHICH STATES, "THE PHYSICIAN MUST BE CONTACTED FOR OXYGEN SATURATIONS BELOW 90%". ON 4/24/12 AT 6:00 PM, THE NURSES "PROGRESS NOTES" REFLECTED THAT RESIDENT #8 WAS ALERT WITH CONFUSION AND COMPLAINED THAT SHE DID NOT "...FEEL GOOD AT ALL...". SKIN WAS PALE AND SOB WAS NOTED WITH EXERTION. RESIDENT #8 VOMITED A SMALL AMOUNT AND an order for [REDACTED]. ACCORDING TO THE NURSES "PROGRESS NOTES", ON 4/25/12 AT 6:30 AM, RESIDENT #8 COMPLAINED OF SHORTNESS OF BREATH AND DID NOT WANT TO GO TO THE DINING ROOM FOR BREAKFAST. PER THE NURSING NOTE AT 9:00 AM, RESIDENT #8 WAS SOB AT REST AND O2 SAT WAS 85%. ORDERS WERE RECEIVED TO INCREASE THE OXYGEN FROM 2 LITERS (L) TO 3 L. FOLLOWING ANOTHER NEB TREATMENT WAS ADMINISTERED INCREASING THE O2 SAT TO 90%. AT 10:25 AM, THE NURSE DOCUMENTED THAT RESIDENT #8'S O2 SAT WAS 87% AND THE NURSE ASSISTANT (CENA) CHANGED THE O2 MASK. ACCORDING TO THE MEDICATION RECORD (MAR) FOR APRIL 2012, RESIDENT #8 WAS SCHEDULED TO RECEIVE [MEDICATION NAME] 0.083%, 1 VIAL PER NEB TREATMENT THREE TIMES A DAY AT 7:00 AM, 11:00 AM, AND 4:00 PM. 2 ADDITIONAL TREATMENTS WERE NOTED ON THAT MAR indicated [REDACTED]. THESE ADDITIONAL NEB TREATMENTS WERE WRITTEN NEXT TO AN ORDER OBTAINED ON 4/22/12 FOR AN ADDITIONAL [MEDICATION NAME] 0.83%, ONE VIAL, ONE DOSE ONLY. THAT ONE EXTRA DOSE WAS GIVEN ON 4/22/12 AT 4:00 AM. ACCORDING TO THE RESPIRATORY DIFFICULTY BREATHING PLAN OF CARE, DATED 4/24/12, EDUCATION REGARDING COUGHING & DEEP BREATHING (TO IMPROVE [MEDICAL CONDITION] GAS EXCHANGE) AND PURSED LIP BREATHING (TO CONTROL SOB) SHOULD BE PROVIDED STARTING 4/24/12. DOCUMENTATION THAT EDUCATION WAS PROVIDED AND ENCOURAGED WAS NOT FOUND ANYWHERE IN THE MEDICAL RECORD. ACCORDING TO THE "ER PHYSICIAN NOTE" DATED 4/25/12 AND OBTAINED FROM THE FACILITY ON 4/30/12 AT 11:05 AM, RESIDENT #8'S CHIEF COMPLAINT WAS SEVERE DYSPNEA THAT STARTED THE PREVIOUS NIGHT AND WAS WORSENING. THE CLINICAL IMPRESSION INCLUDED ACUTE [MEDICAL CONDITION], ACUTE EXACERBATION OF [MEDICAL CONDITION], AND MODERATE DEHYDRATION. THE FACILITIES FAILURE TO ENSURE THAT OXYGEN WAS ADMINISTERED TO RESIDENT #8 PER THE PHYSICIAN ORDER [REDACTED]. ( )

Complaint Intake Number: MI- 358 Based on interviews and records review, the facility failed to provide adequate supervision to prevent elopement for 1 of 7 residents in the sample who were identified as at risk of elopement (#101), resulting in immediate jeopardy when resident #101 exited the facility through an alarmed door and someone silenced the alarm without determining who set off the alarm and was found by the police at a store 0.6 miles from the facility along the most direct street route which placed him at high risk for serious harm or injury and placed other elopement risk residents at high risk for serious harm or injury due to silencing a door alarm without discovering if a resident had left the facility. Findings include: Per the Nurses' Notes dated 8/8/10 at 15:35 (3:35 p.m.) Nurse #27 was informed by Nurse Aide #82 that Resident #101 was not in the facility. A search of the inside of the facility and the perimeter was done and Resident #101 was not found. The Police were notified and at 16:23 (4:23 p.m.) Resident #101 was returned to the Facility by the Police. Per the Nurses' Notes dated 8/8/10 at "about 14:20" (2:20 p.m.) Nurse #34 wrote that she saw Resident #101 "at the Nurses' Station and at 14:30 (2:30 p.m.) he "went to south door of B-wing, opened door and went outside." Nurse #34 "assisted other nurse to get resident back in building. 15-minute checks were being done by staff." Nurse #34 wrote that she was informed at 15:35 that Resident #101 was missing and she and other staff conducted a search of the inside of the facility and the grounds. Nurse #34 wrote that she called the police and at 16:23 the police returned Resident #101 to the facility. Per the Police Report dated 8/8/10 Resident #101 was found "by (name of store)." Per the odometer on the State of Michigan car driven by this Surveyor on 10/26/10 at 10:10 a.m. the direct route was 0.6 miles from the parking lot of the store to the facility was via 2 busy streets (multi-lane with red-green-yellow traffic lights). It was unknown what route Resident #101 took (such as on side streets or cross lots). Per the Minimum (MDS) data set [DATE] Resident #101 was a [AGE] year old male who was diagnosed with [REDACTED]. Per the Activity of Daily Living Functioning Summary dated 8/3/10 Resident #101 did not recognize his wife or the staff and staff tried to put a pajama top on him for a shirt to help identify him as a resident as his appearance was such that he could be mistaken for a visitor. Per the Admission Nursing assessment dated [DATE] Resident #101 was identified as at risk for elopement and did not know his name. Per a care plan dated 7/20/10 staff were instructed to apply a Wander Guard elopement risk alarm bracelet and a pajama top. Resident #101 made multiple attempts prior to the date in question to exit the facility as evidenced by Nurses' Notes such as: 7/21/10 "Notified wife of (Resident #101) leaving building from south door and about his many attempts to leave building." and 7/23/10 "Resident exited building with staff following behind." Per the Nurses' Notes dated 8/7/10 Resident #101 had a "steady gait" and "ambulated about the wing." In a telephone interview on 10/27/10 at 4:00 p.m. Nurse #27 said Resident #101 was a known elopement risk, wore a Wander Guard elopement alert alarm bracelet and was on 15 minute checks on 8/8/10. Nurse #27 said she saw Resident #101 at the Nurses' Station "a couple of minutes before." Nurse #27 described the interior and exterior searches done on 8/8/10 and stated she was outside when she saw a police cruiser and flagged the patrolman down and reported Resident #101 missing. Nurse #27 said "the police picked him up" and brought Resident #101 back to the facility. Nurse #27 said she was later told that Nurse Aide #30 heard a door alarm sound just before Resident #101 was discovered missing. In an interview on 10/28/10 at 4:31 p.m. Nurse #34 described the search for Resident #101 on 8/8/10 and stated she did a "head-to-toe" skin check upon his return and found no evidence of injury. The Director of Nursing stated in the entrance interview on 10/26/10 at 10:15 a.m. that she conducted an investigation and no one admitted to silencing the door alarm on 8/8/10 when Resident #101 exited the facility. The Director of Nursing stated all the exit doors were equipped with the Wander Guard alarm and all door alarms were checked and found in working order after the incident. The Director of Nursing stated Resident #101's alarm bracelet was checked after the incident and found in working order. Thus an unknown person had to have silenced the door alarm. It was unknown if the person who silenced the door alarm looked out to see who had set it off. The Director of Nursing stated on 8/10/10 she found a note in her mailbox from Nurse Aide #30. The Director of Nursing produced the note which said Nurse Aide #30 "heard a faint alarm" and "looked out" and "saw no one." In a telephone interview on 10/27/10 at 5:32 p.m. Nurse Aide #30 said she "heard a faint alarm from a distance away." Nurse Aide #30 denied silencing the door alarm. Resident #101 was discharged to another health care facility on 10/22/10. The Administrator was notified on 10/28/10 at 3:20 p.m. of the Immediate Jeopardy that began on 8/8/10 as a result of failure to adequately supervise Resident #101, who was a known elopement risk, and its failure to follow standards of practice to determine who set off the door alarm and the whereabouts of the person(s) who activated the door alarm. This deficient practice places all residents who are identified as being at risk for elopement, at high risk for possible physical harm, injury and death. On 10/28/10, the Surveyor confirmed that the facility staff completed the following to remove Immediate Jeopardy: 1. On 8/8/10, Resident #101 was returned uninjured to the facility, reassessed for elopement risk, he was relocated to a secured unit and 1:1 supervision was initiated. 2. On 8/9/10, 16 of 16 residents who wore the Wander Guard bracelet were assessed for bracelet placement and function. 3. On 8/9/10, all exit door alarms were tested and found in working order. 4. On 10/27/10 a policy and procedure "Unwitnessed Alarming Door" was written. 5. On 10/28/10 the policies and procedures "Wander Guard-Secure Care Device Assessment" (Rev. 3/05) and "Missing Guests" (03/05) were reviewed and deemed adequate and appropriate to meet the needs of the residents. 6. On 8/10/10-198 of 198 employees were in-serviced on the "Wander Guard-Secure Care Device Assessment" (Rev. 3/05) and "Missing Guests" policies and procedures. 7. on 10/28/10-159 of 189 employees were in-serviced on the new policy and procedure "Unwitnessed Alarming Door" dated 10/27/10. 8. On 10/28/10-7 of 7 department heads were provided in-service materials and sign-in logs and were instructed to provide in-service education to their staff who had not yet received the in-service on "Unwitnessed Alarming Door" prior to staff assuming their next work assignment. 9. On 10/27/10 a monitoring program was developed and implemented to log unwitnessed door alarm events in a notebook kept at the nurses' stations. 10. On 10/28/10-159 of 189 employees were in-serviced to report to the charge nurse all unwitnessed door alarm events. Remaining employees will be in-serviced prior to their next shift. 11. On 10/28/10-22 of 35 charge nurses received in-service training to complete the monitoring log in the notebook at the nurses' stations. 12. On 10/28/10 the Director of Nursing and the Assistant Director of Nursing were given the responsibility to review the Alarm Notebook five times a week to ensure staff compliance with the "Unwitnessed Alarming Door" (10/27/10) policy and resident tracking and trending. Immediate Jeopardy was removed on 10/28/10 at 5:00 p.m. The facility remained out of compliance at a scope and severity of pattern with no actual harm but potential for more than minimal harm but not immediate jeopardy due to not all staff in-service training was completed and sustained compliance had not been verified by the State Agency. ( )