Every finding on record at The Laurels of Galesburg

This citation pertains to intake 3052819.Based on interview and record review the facility failed to initiate cardiopulmonary resuscitation (CPR) and emergency medical services (EMS) for in 1 of 4 residents (R100) reviewed for acute change of condition, resulting in an Immediate Jeopardy, when on [DATE] R100 who was a full code, was found unresponsive and facility staff did not active EMS or initiate CPR. R100 subsequently was pronounce dead on [DATE] at 6:00am. Findings include:The facility failed to initiate CPR and EMS response for R100 who was a full code when found unresponsive on [DATE] at 5:50 AM. R100 was last seen on [DATE] at 4:45 AM when a breathing treatment was started and left during treatment. R100 was then not checked on again until 5:50 AM when she was found unresponsive and staff did not initiate CPR or EMS.The Immediate Jeopardy began on [DATE] when the facility failed to initiate CPR and call EMS on a resident with Full Code status. The Nursing Home Administrator was notified of the Immediate Jeopardy on [DATE] at 3:27 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and therefore past noncompliance was granted.According to R100's admission Record, the resident was admitted to the facility on [DATE] from an acute care hospital.Review of R100's medical records diagnoses included acute and chronic respiratory failure with hypoxia (lack of oxygen to body tissue and organs) and hypercapnia (excessive amount of carbon dioxide) and COPD (chronic obstructive pulmonary disease). Review of R100's Advance Directives dated [DATE] revealed, Full CodeReview of R100's Order Summary dated [DATE] revealed, Full CodeReview of R100's Medication/Treatment Administration Record (MAR/TAR) dated [DATE]-[DATE], revealed, Advance Directive: Full CodeReview of R100's Progress Note dated [DATE] at 4:14 PM, revealed, .she (R100) wants to continue being full code status.Review of R100's Progress Note dated [DATE] at 8:52 AM, revealed, At approximately 0550 I went into residents' room to check on her and to let her know it was the end of my shift. When entered resident's room I said (R100) and there was no response so I walked closer and touched her shoulder and said her name again still no response. I checked her radial pulse it was absent. I came to the hallway and seen (name of oncoming nurse) the first shift nurse that was taking over for me, I yelled her name she didn't hear me so I came closer and said (R100) is gone (name of oncoming nurse) grabbed her stethoscope, I then checked the MAR for the resident's code statues and went into room with (name of oncoming nurse) as she checked resident apical pulse, it was absent. (name of night nurse) another nurse was also present and assessed resident, absent of apical pulse was also confirmed. Time of death was pronounced at 0600. It was noted there was no documentation in the progress note of found code status or the attempt to begin CPR or call EMS.During an interview on [DATE] at 11:22 AM, Family Member (FM) C stated, My mother wanted to be a Full Code. She had signed paperwork at the facility stating her wishes. She was able to make her needs known. On [DATE] at 6:36 AM, I received a call from (Registered Nurse (RN) G), saying my mother had passed away. When I received the call (R100) was dead, my sister, wife, and my three daughters went immediately. My brother was on facetime with us when we got to (R100's room). I asked (RN G) why she did not do CPR for (R100) and she said it was her fault because she panicked. At that time another nurse was with (RN G) and I asked if anyone else could do CPR and the two nurses did not answer me. The other nurse, I think it was the Charge Nurse, told us not to touch (R100) until the Medical Examiner (ME) had come to examine (R100). I asked why no one did CPR on (R100) because she was full code and again, no one answered me and the two nurses left the room. My sister that was there is an RN and kept asking why CPR was not done because (R100) was a full code. We were later told the cause of death was natural causes. CPR was not performed, EMS not called, the ME was called to pronounce (R100's) death. The death certificate says (R100) was dead at 6:00 AM. During an interview and record review on [DATE] at 12:50 PM, Licensed Practical Nurse (LPN) J stated while reviewing R100's medical record, I was (R100) admitting nurse on [DATE]. She had been a resident for some time and was constantly going to the hospital for respiratory issues. I asked her and her family what she wanted her code status to be. (R100) stated she wanted to be Full Code. Her documentation from previous readmission dated [DATE] was reviewed and she said she that is what she wanted, Full Code.During an interview and record review on [DATE] at 1:00 PM, Director of Nursing (DON) B stated, (R100's) code status was Full Code. (RN G) found (R100) unresponsive on [DATE] at 5:50 AM and did not initiate CPR. (RN G) did not check for (R100's) code status right away either. There were two other nurses that were called to the resident's room, (RN H and LPN M), neither of them initiated CPR or checked for (R100's) code status.During an interview on [DATE] at 5:45 PM RN G stated, At the end of my shift on [DATE] at 5:50 AM I went to tell (R100) I was leaving. She had been anxious most of the night shift because she had been readmitted and was using her BiPAP all the time. I last saw (R100) at 4:45 AM when I started her nebulizer treatment. (Certified Nursing Assistant (CNA) O) was in with (R100) after me. When I got into her room I was calling out her name over and over and she did not respond. Her eyes were closed. I touched her on the arm and there was no response. I called out her name again. I checked her radial pulse (pulse at wrist) and there was nothing. I went out to the hall and called for the incoming nurse (RN H) saying (R100) is gone! (RN H) came to (R100's) room and I thought to myself Shoot, I forgot to check (R100's) code status. I went to the computer to look up (R100's) code status and found she was a full code. I went back to (R100) and by then the other night nurse (Licensed Practical Nurse (LPN) M) was in the room. (LPN M) said (R100) was dead. So I thought with an experienced nurse telling me (R100) was dead, I didn't think of doing CPR. I did not call EMS. I called the on-call manager (Assistant Director of Nursing (ADON) F) who told me to call (R100's) family, the police, the Medical Examiner (ME), and Medical Director (MD). I did receive education and training on Death of a Resident prior to this incident. I am certified in CPR and was before this incident. I panicked when I found (R100) and did not follow what I was trained for.During an interview on [DATE] at 12:23 PM, FM D stated, (RN G) told the family she panicked and didn't start CPR or call EMS. I'm so upset. I lost my mother. There were other nurses in that facility that could have started CPR, that could have called EMS.Review of facility policy, Death of a Resident dated [DATE], revealed, When the resident's spontaneous respiratory and circulatory functions have ceased.CPR attempts have been exhausted, an evaluation is made. This begins the process of pronouncing the death of the resident.Death is reported to the facility administrator and/or the director of nursing. One of these two individuals, or designee, reports the death to the local authorities and/or agencies, as appropriate.When a resident is found to be without heartbeat and respirations, the nurse on duty identifies the code status. If the resident is Full Code status, CPR is started and emergency 911 services are activated .The nurse on duty contacts the attending physician/NP (nurse practitioner)/PA (Physician Assistant) and communicates the clinical information.Based on clinical information communicated from the nurse, the physician/NP/PA decides to come to the facility to pronounce the death of the resident or decides to make a pronouncement over the phone. If death is pronounced, the physician/NP/PA gives authorization to remove the body of the deceased resident.The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions to remove the immediacy and correct the noncompliance:Medical Director was notified on [DATE].DON/designee educated Licensed Nurses on verifying code status when a resident is found without Vital Signs on [DATE].DON/designee provided education to all Licensed Nurses on [DATE] on Death of a Resident to include if resident is full code status, CPR is started and emergency 9-1-1 services are activated.Licensed Nurse who identified resident without VS was suspended immediately pending investigation on [DATE].100% audit of resident code status /supporting documentation was completed on [DATE]. Any concerns were addressed immediately. Code status was verified to be accurate and readily available on [DATE].DON/designee audited to ensure all Licensed Nurses were CPR certified with no expired licenses. 100% of Licensed Nurses were in compliance.DON/designee reviewed the crash cart, AED, and emergency management supplies on [DATE].NHA/DON reviewed advanced directive policy and death of a resident and deemed appropriate on [DATE].Ad-HOC QAPI was completed [DATE].The Licensed Nurse was reeducated one on one for responding to a resident without VS, how to verify code status, and notifying EMS on [DATE] prior to return to work. DON/Designee will complete Code Blue drills with varied shifts monthly for 90 days. DON will review audit findings in QAPI monthly for 90 days.

This citation pertains to intake 3052819.Based on interview and record review, the facility failed to monitor a nebulizer (medicated breathing treatment) treatment and ensure supplemental oxygen was continuously supplied to one resident (R100) of one resident reviewed for respiratory treatment and continuous oxygen use, resulting in decreased consciousness. Findings include:According to R100's admission Record the resident was admitted to the facility on [DATE].Review of R100's medical records diagnoses included acute and chronic respiratory failure with hypoxia (lack of oxygen to body tissue and organs) and hypercapnia (excessive amount of carbon dioxide) and COPD (chronic obstructive pulmonary disease). Review of R100's Order Summary, dated [DATE], included:- Ipratropium-Albuterol Inhalation Solution 0.5-25 (3) mg/ml.3ml inhale orally every 4 hours for COPD (administered by a nebulizer machine). - 02 Saturation monitoring four times a day for oxygen monitoring- BiPAP (Bilevel Positive Airway Pressure, a non-invasive type of ventilator that helps you breathe by pushing pressurized air into your airways through a mask and alternates between two pressures: a higher pressure when you inhale and a lower pressure when you exhale). Settings- 30%, 18/10 02 bleed in: 4L Mask size: Medium Mask Type: Full face as needed during naps and daytime, with exception to while eating- Settings (BiPAP) - 30%, 18/10 02 bleed in: 4L Mask size: Medium Mask Type: Full face at bedtime for COPD, HX of hypoxic Resp failure- Oxygen 4L via Nasal Canula while eating, resume BiPAP when finished eating with meals for oxygenation-Replace O2 bleed-in tubing as neededReview of R100's Medication/Treatment Administration Order dated [DATE]-[DATE], revealed, Ipratropium-Albuterol Inhalation Solution 0.5-25 (3) mg/ml.3ml inhale orally every 4 hours for COPD. Start date [DATE] at 4 PM Discontinue date [DATE] at 6:46 AM. It was noted on [DATE] the 0400 (4 AM) dose was administered.Review of R100's O2 Sats Summary revealed no oxygen saturation readings had been documented for the resident on this specific form.Further review of R100's Vital Signs document revealed no vital signs (VS: blood pressure, pulse, respirations, oxygen saturation) were documented on the forms for [DATE] or [DATE]. Review of R100 Care Plan, Special Instructions, revealed Describe breath sounds over all lung aspects (ie: wheezes, rales, rhonchi) vital signs with 02 sats and details of respirations, describe the effectiveness of any respiratory treatments given, (ie: nebulizers.other respiratory medications, oxygen, etc.) describe resident activity level and endurance, describe any changes in loc, anxiety or order mental status changes, objective signs of impaired respiratory status (ie cyanosis, sob, use of accessory muscles ,cough and sputum production.)During an interview [DATE] at 11:22 AM Family Member (FM) C stated, The facility told me (R100) called for a nebulizer treatment at 4:45 AM (on [DATE]). (Registered Nurse (RN) G) found (R100) unresponsive at 5:50 AM who called me at 6:36 AM and told my mother (R100) was dead. When me and my family came in, we saw (R100) had the BiPAP mask off to the side of her face. I'm wondering if the nurse gave (R100) her nebulizer treatment and did not put the oxygen and BiPAP back on her after the treatment was done. I thought the nurse had to watch while the nebulizer treatment was being given. Then that way the BiPAP mask would have been put back on her. Oxygen should have been running during the nebulizer treatment. The nebulizer treatment was started around 4:45 AM according to facility staff, then (RN G) came back in around 5:50 AM, about 1-1:05 hours later. Usually, a nebulizer treatment takes about 10 minutes to do. Something does not sound right. (R100) should have had a nurse with her during her nebulizer treatment. (R100) needed oxygen 24/7.During an interview on [DATE] at 5:45 PM, RN G stated, I started (R100's) nebulizer treatment around 4:45 AM on [DATE]. She had asked for one and had been using her BiPAP all night long whether she was awake or sleeping. When I started (R100's) nebulizer treatment I only stayed for a few minutes then I left because I had other things to do like starting morning medication pass. (CNA- Certified Nurse Aide O) put (R100's) BiPAP mask back on her after the nebulizer treatment was over. I did not verify (R100's) BiPAP or oxygen had been put back on her after the nebulizer was done. The BiPAP machine was still running at 5:50 AM when I found (R100) unresponsive. I called (CNA O) down to (R100's) room when I found (R100) unresponsive. (CNA O) took off (R100's) mask because she thought she was going to have to do post-mortem care. I do not know whether the mask (CNA O) took off was for the nebulizer treatment or the BiPAP machine. I don't know if (R100) was wearing oxygen during the nebulizer treatment. I have had training on how to administer a nebulizer treatment prior to this incident. CNAs take off the nebulizer mask and put oxygen back on all the time.During an interview on [DATE] at 8:26 AM, FM C stated, My mother (R100) had severe respiratory issues. She had them for a long time and needed a BiPAP machine to blow off the excess CO2. Anytime my mother was at a facility her PCO2 would increase because of her anxiety being at the facility with a different BiPAP machine. She was afraid the facility would not have the right one. When staff called me on [DATE] to tell me my mother had died I was in shock. She was fine the night before. She had been readmitted to the facility from the hospital and the Administrator (Nursing Home Administrator (NHA) A) had come up to the hospital to make sure my mother had the right mask to wear with the BiPAP machine the facility was providing for her. When my family went to the facility that morning ([DATE]) to see my mother she had the BiPAP mask lying on her chest. The top strap that went around her head was off of her head and the mask's bottom strap was still around her neck. My sister was there too; she is a nurse. She saw that the BiPAP machine reported the machine had been on for 12 hours and 22 minutes. That did not seem right because the machine was started at on [DATE] at 3:30 PM, shut off at around 4 AM to do the nebulizer treatment that only takes 10-15 minutes, and then should have been started again. If the BiPAP was started again after the nebulizer treatment and she was found unresponsive at 5:50 AM, that is more than 12 hours and 22 minutes. The times on the machine and what the facility told me and my family do not add up. The nurse did not have my mother's BiPAP machine back on after the nebulizer treatment was done sometime around 5:00 AM. (Name of oxygen supply company) keeps records on file for machine use.Review of R100's BiPAP Compliance Report dated [DATE]-[DATE], revealed, Total usage: 12 hours 22 minutes. Device used: 03:54 PM to 06:28 PM (2 hours and 34 minutes). Device used: 06:57 PM to 04:42 AM (9 hours and 45 minutes). Device used: 06:21 AM to 06:24 AM. It was noted R100's BiPAP machine was turned off at 4:42 AM and not started again until 6:21 AM and then only for 3 minutes which was a total of 12 hours and 22 minutes. During an interview on [DATE] at 8:40 AM, Certified Nursing Assistant (CNA) O stated, I was assigned to (R100) on [DATE] nights into [DATE] morning. I did not stop the nebulizer treatment. I did not put the BiPAP mask on her. That is not my job, that is the nurse's job and responsibility.During an interview on [DATE] at 10:50 AM, RN G stated, I did leave her during the nebulizer treatment I started it around 4:13 AM. My morning med pass starts at 5:00 AM. We were short CNAs, one had to leave, so I was answering call lights. (CNA O) took off the nebulizer treatment and BiPAP mask back on. She said (R100) was messing with the nebulizer mask so she put the BiPAP mask back on. I did not go back in and check on (R100) until I found her unresponsive at around 5:50 AM and pronounced her dead with two other facility nurses at 6:00 AM.During an interview on [DATE] at 7:23 AM, Assistant Director of Nursing (ADON)/Staff Education F stated, CNAs are not to apply or discontinue a nebulizer treatment or place a BiPAP back on. That is a nurse's duty. When I talked to some CNAs about this yesterday, I learned that many CNAs are being asked by nurses to remove the nebulizer treatment masks and start oxygen via CPAP/BiPAP machines. That is not a CNAs job. Only a nurse can do this.Review of the facility's procedure, Nebulizer Therapy no date available of facility review, revealed, .An established component of respiratory care, nebulizer therapy aids bronchial hygiene by hydrating dried and retained secretions, promoting expectoration of secretions, humidifying inspired oxygen, and delivering medications to the lower respiratory tract.Avoid distractions and interruptions when preparing and administering medication to prevent medication errors.Obtain the patient's (resident's) vital signs, assess the respiratory status.Remain with the patient and continue the treatment until the nebulizer begins to sputter.After treatment, obtain the patient's vital signs, assess the respiratory status.Document the procedure.

This citation pertains to Intake # 2792486 & 2793260.Based on interview, and record review, the facility failed to ensure a complete and accurate medical record in 1 of 13 residents (Resident #100) reviewed for comprehensive/accurate medical records, resulting in incomplete/missing charting related to resident behavioral concerns and skin alterations, the potential for additional behaviors to go unaddressed, and an inaccurate portrayal of resident status.Findings include:Resident #100Review of an admission Record revealed Resident #100 was a female, with pertinent diagnoses which included heart failure, insomnia, post-traumatic stress disorder, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss.Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 2/9/26, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, indicating she had severe cognitive impairment.In an interview on 3/25/26 at 3:54 PM, Certified Nursing Assistant (CNA) DD reported she assisted Resident #100 with incontinence care on 1/22/26, during the early morning hours (at approximately 3:00 AM), with the assistance of Licensed Practical Nurse (LPN) M. CNA DD reported they had approached Resident #100 to complete incontinence care several other times earlier in the shift, however, Resident #100 was combative and refused incontinence care during those previous attempts. CNA DD reported Resident #100 had not had her brief changed since around dinner time the evening prior due to the refusals/combative behaviors. CNA DD stated .We had to at least attempt to change her . CNA DD reported when she and LPN M went in to assist Resident #100 with incontinence care, LPN M pulled her covers back and Resident #100 started .trying to hit and kick . CNA DD reported LPN M held Resident #100's hands so they (CNA DD and LPN M) wouldn't get hit, and she changed Resident #100's wet brief. CNA DD reported after a few moments, Resident #100 stopped resisting care and said .OK I quit . and allowed CNA DD to complete the incontinence care.In an interview on 3/26/26 at 9:27 AM, Licensed Practical Nurse (LPN) R reported she was Resident #100's assigned nurse on 1/22/26 for day shift. LPN R reported she went into Resident #100's room on 1/22/26 in the morning to complete her rounds, and as LPN M walked by the door Resident #100 told LPN R to not let him (LPN M) in the room because LPN M had grabbed her arm. LPN R reported she observed a bruise on Resident #100's left arm. LPN R stated .She (Resident #100) was frightened .She is usually not afraid . LPN R reported Administrator A directed her to monitor the bruise on Resident #100's arm. LPN R reported she did not document her observation of the bruise on Resident #100's arm because .I didn't know what (Administrator A) wanted me to do .In an interview on 3/30/26 at 4:06 PM, LPN M reported he was Resident #100's assigned nurse from 1/21/26 to 1/22/26 on third shift. LPN M reported he did not receive any information in report regarding Resident #100 being combative or refusing care. LPN M reported as the shift progressed, the CNAs reported that Resident #100 was being combative and refusing to have her brief changed. LPN M reported they tried different caregivers and re-approaching her and stated .I couldn't just leave her like that . LPN M reported he went to the room to assist CNA DD with incontinence care later in the shift and attempted to softly wake Resident #100. LPN M reported CNA DD started to change Resident #100's wet brief and that is when Resident #100 became combative. LPN M reported he held Resident #100's hands/arms for a brief period of time to keep him and CNA DD from being struck, and once Resident #100 realized it was him (LPN M) she stopped resisting and allowed CNA DD to complete incontinence care. LPN M reported Resident #100 was .half-asleep . when they began attempting to change her wet brief. LPN M reported there were no further issues or complaints involving Resident #100 for the remainder of his shift. LPN M reported when residents refuse care, staff attempt to re-approach at a later time or get a different staff member to approach and offer care. LPN M reported he did not document the pattern of incontinence care refusals or the combative behaviors displayed by Resident #100 during that shift. LPN M reported he is now aware that he should have documented the refusals within Resident #100's electronic medical record.Review of the Progress Notes for Resident #100 revealed no documentation of her care refusals or combativeness with care on 1/21/26 and 1/22/26 (during third shift).In an interview on 3/31/26 at 10:43 AM, LPN Q reported she had worked with Resident #100 previously and indicated that when the resident refuses care and becomes combative, staff should give her space and re-approach at a later point in time. LPN Q stated .She might be nice as pie. You have to be cautious because she will just as quickly turn around and start screaming at you and hitting you . LPN Q reported when a resident refuses care or becomes combative during care, this behavior should be documented by the CNAs in the behavioral charting, and in a progress note if the nurses are aware.In an interview on 3/31/26 at 12:17 PM, Unit Manager D reported Resident #100 has a history of being combative with care. Unit Manager D reported she was notified on 1/22/26 that Resident #100 was complaining of pain in her arm. Unit Manager D reported she talked with Resident #100 and observed new bruising on one arm. Unit Manager D reported when asked what happened, Resident #100 reported staff changed (her brief) when she did not want to be changed. Unit Manager D reported when Resident #100 is resistant to care, staff have been instructed to get a second staff member for assistance. Unit Manager D reported if there is not an immediate safety risk and the resident is refusing care, staff should give her space and re-approach at a later point in time. Unit Manager D reported sometimes staff are able to distract Resident #100 with conversation or a snack. Unit Manager D reported after the incident involving Resident #100 on 1/22/26, staff were educated to re-approach when Resident #100 refuses care, offer the resident snacks, and make sure the resident is more fully awake before initiating care .because maybe that startled her . Unit Manager D reported CNAs should document behaviors (such as care refusals and combative behaviors) in the alert charting, and nursing should document behaviors and care refusals in the progress notes.In an interview on 1/31/26 at 2:33 PM, Assistant Director of Nursing (ADON) E reported on 1/22/26 Resident #100 complained of arm pain and alleged that a male staff member had hurt her arm. ADON E reported they obtained X-rays and the results were normal, with no fracture or soft tissue swelling identified. ADON E reported Resident #100 had bruising on her left forearm that was dark purple in color and complained of pain in her left arm. ADON E reported Resident #100 has a history of combative behaviors and resistance to care and gets bruises often due to flailing her arms and swinging at staff during care. ADON E stated .She can really be aggressive . ADON E reported after the incident/allegations on 1/22/26 involving Resident #100, staff were educated on resident rights, including the right to refuse care, and resident safety. ADON E reported when residents have these kinds of behaviors (combativeness/resistance to care) how staff approach them is important. ADON E reported staff were educated to have someone talk with the resident as a distraction while other staff provide care. ADON E stated .Don't just say this has got to be done . ADON E reported it was important to weigh the risks/benefits of each situation and determine .what keeps the patient the safest .If they tell you to leave, leave . ADON E reported behaviors such as combativeness and refusing care should be documented by the CNAs in the clinical alerts, and by nursing staff in the progress notes.In an interview on 3/31/26 at 3:17 PM, Social Worker RR reported Resident #100 has a history of combative behaviors and refusing care, and stated .despite her small size she is mighty . Social Worker RR reported these behaviors can be elevated when the resident is not familiar with a staff member. Social Worker RR reported after the incident on 1/22/26 involving Resident #100, staff were educated to give the resident space when she becomes combative, re-approach at a later point in time, and offer different caregivers. Social Worker RR stated .You have to allow her to de-escalate. You have to leave her alone . Social Worker RR reported these care refusals and aggressive behaviors are related to her mental health diagnoses and diagnosis of dementia. Social Worker RR reported she would expect to see documentation related to care refusals and combative behaviors within the electronic medical record by the nursing and CNA staff.Review of the policy/procedure Behavior Management, dated 4/20/23, revealed .The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors .The facility staff will utilize tasks in PCC (electronic medical record system) to document behaviors exhibited by the resident, including new, existing and escalating behaviors, as well as the effectiveness of interventions. Additional documentation may be needed in the IDT (Interdisciplinary Team) progress, behavior notes and at-risk notes regarding the behavior, interventions and changes to plan of care .Review of the policy/procedure Documentation Expectations, dated 6/21/23, revealed .Healthcare personnel will complete documentation requirements as outlined by the company and recorded in the medical record using accepted principles of documentation .Aspects of resident care such as observations and assessments, administration of medications, and services or treatments performed must be documented in the resident medical record according to company policy .Be Complete. All facts and pertinent information related to an event, course of treatment, resident condition, response to care, and deviation from standard treatment (including the reason for the deviation) must be documented .

This citation pertains to Intake # 2792486 & 2793260.Based on interview, and record review, the facility failed to ensure facility staff provided care that maintains the highest practicable physical and mental well-being for residents with dementia, cognitive deficit, and behaviors in 1 of 6 residents (Resident #100) reviewed for dementia care, resulting in agitation, distress, resistance to care, and the potential for additional care refusals.Findings include:Resident #100Review of an admission Record revealed Resident #100 was a female, with pertinent diagnoses which included heart failure, insomnia, post-traumatic stress disorder, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss.Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 2/9/26, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, indicating she had severe cognitive impairment.Review of a current Care Plan for Resident #100 revealed the need .has impaired communication r/t (related to) Hearing loss . revised 10/6/23, with interventions which included .Speak clearly and distinctly, adjusting volume and tone as needed . initiated 3/20/23.Review of a current Care Plan for Resident #100 revealed the need .at risk for decline in cognition and has impaired cognitive function or impaired thought processes R/T (related to): Dementia . revised 4/22/25, with interventions which included .Use communication techniques to enhance interaction: Allow adequate time to respond, Repeat as necessary, Do not rush, Request feedback, clarification from the resident, to ensure understanding, Face when speaking and make eye contact, Turn off TV/radio as needed to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and picture . and .Utilize approaches which allow resident to engage in activities such as limiting choices, cueing/reorientation, task segmentation, simple instructions/ activities that avoid overly demanding tasks, present one thought at a time, ask yes/no questions in order to determine resident's needs . both initiated 8/14/23.Review of a current Care Plan for Resident #100 revealed the need .has the potential for fluctuations in mood R/T: DX (Diagnosis): Bipolar DO (Disorder), Major Depression, Anxiety, Dementia becomes anxious and accusatory towards others i.e. forgets when she took pain medication and becomes accusatory (and) behavioral, unable to locate personal belongings and believes someone took them. Is profoundly hard of hearing (and) makes it difficult for her to understand when attempting to explain/redirect . revised 12/3/23, with interventions which included .Approach in a calm, quiet manner. Maintain appropriate body language during interactions such as maintaining eye contact and sitting in a relaxed position . initiated 4/17/23.In an interview on 3/25/26 at 3:54 PM, Certified Nursing Assistant (CNA) DD reported she assisted Resident #100 with incontinence care on 1/22/26, during the early morning hours (at approximately 3:00 AM), with the assistance of Licensed Practical Nurse (LPN) M. CNA DD reported they had approached Resident #100 to complete incontinence care several other times earlier in the shift, however, Resident #100 was combative and refused incontinence care during those previous attempts. CNA DD reported Resident #100 had not had her brief changed since around dinner time the evening prior due to the refusals/combative behaviors. CNA DD stated .We had to at least attempt to change her . CNA DD reported when she and LPN M went in to assist Resident #100 with incontinence care, LPN M pulled her covers back and Resident #100 started .trying to hit and kick . CNA DD reported LPN M held Resident #100's hands so they (CNA DD and LPN M) wouldn't get hit, and she changed Resident #100's wet brief. CNA DD reported after a few moments, Resident #100 stopped resisting care and said .OK I quit . and allowed CNA DD to complete the incontinence care.In an interview on 3/26/26 at 9:27 AM, Licensed Practical Nurse (LPN) R reported she was Resident #100's assigned nurse on 1/22/26 for day shift. LPN R reported she went into Resident #100's room on 1/22/26 in the morning to complete her rounds, and as LPN M walked by the door Resident #100 told LPN R to not let him (LPN M) in the room because LPN M had grabbed her arm. LPN R reported she observed a bruise on Resident #100's left arm. LPN R stated .She (Resident #100) was frightened .She is usually not afraid . LPN R reported Resident #100 has a history of refusing care, and if staff keep trying, she will often become more combative. LPN R reported when Resident #100 becomes combative, staff are to step away and give her space to calm down before re-approaching. LPN R stated .sometimes all it takes is a different person to approach her . and she will accept care. LPN R reported Resident #100 is not good at communicating her needs vocally and has impaired hearing. In an interview on 3/26/26 at 11:20 AM, CNA U reported she has worked with Resident #100 previously, and how staff approach her plays an important role in the way she reactions. CNA U reported sometimes Resident #100 will accept care and sometimes she .freaks out . CNA U reported when that happens, staff will give her space and re-approach at a different time.In an interview on 3/26/26 at 1:07 PM, CNA EE reported she has worked with Resident #100 previously, and reported Resident #100 can be resistant to care. CNA EE stated if Resident #100 doesn't want staff to change her, they give her space and re-approach at a different time, stating .I don't poke the bear . CNA EE reported she will sometimes try and find a different staff member who has known Resident #100 longer to re-approach and offer care. CNA EE reported they are usually able to find someone to calm Resident #100 down enough to allow care to be completed.In an interview on 3/26/26 at 4:27 PM, CNA GG reported she worked with Resident #100 on 1/21/26, and the resident had been refusing incontinence care throughout the evening. CNA GG reported when approached for incontinence care, Resident #100 began attempting to hit and swing at staff, so she left and re-approached later with another CNA. CNA GG reported those behaviors continued, so they decided to give the resident some space. CNA GG reported when third shift arrived, she notified CNA DD and LPN M that she was unable to change Resident #100's brief that evening and that Resident #100 was refusing care. CNA GG reported LPN M made a statement that Resident #100 had to be changed, and it didn't matter if she didn't want to. CNA GG reported she went into the room with CNA DD and LPN M and again, Resident #100 started kicking, swinging, and refusing incontinence care. CNA GG reported incontinence care was not provided at that time, and she completed her shift. CNA GG reported when she returned a few days later, she observed oval-shaped bruising on one of Resident #100's forearms.In an interview on 3/30/26 at 4:06 PM, LPN M reported he was Resident #100's assigned nurse from 1/21/26 to 1/22/26 on third shift. LPN M reported he did not receive any information in report regarding Resident #100 being combative or refusing care. LPN M reported as the shift progressed, the CNAs reported that Resident #100 was being combative and refusing to have her brief changed. LPN M reported they tried different caregivers and re-approaching her and stated .I couldn't just leave her like that . LPN M reported he went to the room to assist CNA DD with incontinence care later in the shift and attempted to softly wake Resident #100. LPN M reported CNA DD started to change Resident #100's wet brief and that is when Resident #100 became combative. LPN M reported he held Resident #100's hands/arms for a brief period of time to keep him and CNA DD from being struck, and once Resident #100 realized it was him (LPN M) she stopped resisting and allowed CNA DD to complete incontinence care. LPN M reported Resident #100 was .half-asleep . when they began attempting to change her wet brief. LPN M reported there were no further issues or complaints involving Resident #100 for the remainder of his shift. LPN M reported when residents refuse care, staff attempt to re-approach at a later time or get a different staff member to approach and offer care. LPN M reported he is now aware that when the resident became combative, he should not have intervened.In an interview on 3/31/26 at 10:43 AM, LPN Q reported she had worked with Resident #100 previously and indicated that when the resident refuses care and becomes combative, staff should give her space and re-approach at a later point in time. LPN Q stated .She might be nice as pie. You have to be cautious because she will just as quickly turn around and start screaming at you and hitting you .In an interview on 3/31/26 at 12:17 PM, Unit Manager D reported Resident #100 has a history of being combative with care. Unit Manager D reported she was notified on 1/22/26 that Resident #100 was complaining of pain in her arm. Unit Manager D reported she talked with Resident #100 and observed new bruising on one arm. Unit Manager D reported when asked what happened, Resident #100 reported staff changed (her brief) when she did not want to be changed. Unit Manager D reported when Resident #100 is resistant to care, staff have been instructed to get a second staff member for assistance. Unit Manager D reported if there is not an immediate safety risk and the resident is refusing care, staff should give her space and re-approach at a later point in time. Unit Manager D reported sometimes staff are able to distract Resident #100 with conversation or a snack. Unit Manager D reported after the incident involving Resident #100 on 1/22/26, staff were educated to re-approach when Resident #100 refuses care, offer the resident snacks, and make sure the resident is more fully awake before initiating care .because maybe that startled her .In an interview on 1/31/26 at 2:33 PM, Assistant Director of Nursing (ADON) E reported on 1/22/26 Resident #100 complained of arm pain and alleged that a male staff member had hurt her arm. ADON E reported they obtained X-rays and the results were normal, with no fracture or soft tissue swelling identified. ADON E reported Resident #100 had bruising on her left forearm that was dark purple in color and complained of pain in her left arm. ADON E reported Resident #100 has a history of combative behaviors and resistance to care and gets bruises often due to flailing her arms and swinging at staff during care. ADON E stated .She can really be aggressive . ADON E reported after the incident/allegations on 1/22/26 involving Resident #100, staff were educated on resident rights, including the right to refuse care, and resident safety. ADON E reported when residents have these kinds of behaviors (combativeness/resistance to care) how staff approach them is important. ADON E reported staff were educated to have someone talk with the resident as a distraction while other staff provide care. ADON E stated .Don't just say this has got to be done . ADON E reported it was important to weigh the risks/benefits of each situation and determine .what keeps the patient the safest .If they tell you to leave, leave .In an interview on 3/31/26 at 3:17 PM, Social Worker RR reported Resident #100 has a history of combative behaviors and refusing care, and stated .despite her small size she is mighty . Social Worker RR reported these behaviors can be elevated when the resident is not familiar with a staff member. Social Worker RR reported after the incident on 1/22/26 involving Resident #100, staff were educated to give the resident space when she becomes combative, re-approach at a later point in time, and offer different caregivers. Social Worker RR stated .You have to allow her to de-escalate. You have to leave her alone . Social Worker RR reported these care refusals and aggressive behaviors are related to her mental health diagnoses and diagnosis of dementia.Review of the policy/procedure Behavior Management, dated 4/20/23, revealed .The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors .It is essential that behaviors are recognized as a form of communication, rather than as a random, unpredictable or meaningless event. Attempting to identify causes of behaviors will assist with developing the appropriate plan, with appropriate interventions, to respond to these behaviors .Certain behavior may be anticipated and sometimes may be preventable based on understanding the underlying causes and possible triggers for each individual .The facility staff will utilize tasks in PCC (electronic medical record system) to document behaviors exhibited by the resident, including new, existing and escalating behaviors, as well as the effectiveness of interventions. Additional documentation may be needed in the IDT (Interdisciplinary Team) progress, behavior notes and at-risk notes regarding the behavior, interventions and changes to plan of care .Attempt to identify possible risk and causal/contributing factors for behaviors such as .Fatigue, lack of sleep or change in sleep patterns which may make the person more likely to misinterpret environmental cues resulting in anxiety, aggression or confusion .Sensory deficits (hearing, sight, smell) .The IDT will implement a care plan with the resident and/or resident representative or update existing care plan, with interventions that target behavioral symptoms, identified causes, resident specific goals and resident specific behaviors .Behavior care plans will be established for those with behaviors related to dementia, mental illness or other needs .Interventions will include specific non-pharmacological interventions and behavior management strategies developed specifically for the resident .During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included assessment of all residents and education on resident rights for refusal of care. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake #2735355Based on interview and record review, the facility failed to identify and thoroughly investigate situations involving potential abuse for 2 residents (Resident #107 and Resident #112) of 9 residents reviewed for abuse, resulting in the potential for ongoing abuse due to an incomplete investigation.Findings include:Resident #107Review of an admission Record revealed Resident #107 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (progressive disease that causes loss of cognitive abilities), moderate, with anxiety (persistent feelings of apprehension, dread and nervousness).Review of a Minimum Data Set (MDS) assessment for Resident #107 with a reference date of 11/17/25, revealed Section GG of the MDS revealed Resident #107 was independent (completed activity by themselves with a device) for walking.Review of a Care Plan for Resident #107 with a reference date of 11/11/25 revealed the following need/goal/interventions: (Resident #107) is at risk for fall related injury and falls R/T (related to) poor safety awareness. Goal: will be free from injury related to falls through the review date. Interventions: Educate.caregivers about safety reminders.keep resident's environment as safe as possible.remind resident to take her time when walking.Review of a Fall Report for Resident #107, dated 1/24/26 at 7:00pm, revealed Incident Description.Nurse was pushing medication cart and collided with resident. Fall was witnessed.complained of R (right) hip pain.Xray was ordered.results of Xray showed acute R femoral neck fracture (break in the narrow, upper part of the thigh bone, just below the ball of the hip joint, often caused by falls). Resident left via EMS (emergency medical services) .Review of a Post Fall Evaluation for Resident #107, with a reference date of 1/24/26, revealed Staff/witness present at/or observing resident after fall: ( Name omitted, Certified Nursing Assistant (CNA) II, CNA MM).Factors observed at time of fall.Environmental factors: Cart pushed in hall tripped resident.Re-Creation of Last 3 Hours Before Fall: the primary nursing assistant who observed the resident during the three hours prior to the fall was interviewed(print the name of the assistant): (Name Omitted, Laundry Aide (LA) BB).Root Cause of this Fall: .Environmental factors.Nurse Signature: (Name Omitted) Licensed Practical Nurse (LPN) K.In an interview on 3/31/26 at 7:54am, CNA MM reported she was not present on 1/24/26 when Resident #107 fell. CNA MM reported she saw Resident #107 later that evening before she was sent to the hospital. Of note, this contradicts the information LPN K documented in the Post Fall Evaluation.In an interview on 3/27/26 at 3:50, Laundry Aide (LA) BB reported she was on the memory care unit, in the hallway on 1/24/26 when Resident #107 fell and was injured. LA BB reported she was standing in the hallway, between rooms [ROOM NUMBERS] facing the west wall, looking at the name tag in a piece of personal laundry when out of her peripheral vision, she saw Resident #107 walking next to CNA VV as they walked toward here from the south. LA BB reported the resident fell and she saw LPN K, the medication cart, and CNA VV all right there together. LA BB reported she did not know if the cart hit the resident or not. LA BB reported she was never interviewed by Nursing Home Administrator (NHA) A regarding what she saw during the incident involving Resident #107 on 3/27/26.In an interview on 3/27/26 at 11:04am, former CNA VV reported she witnessed Resident #107's fall on 1/24/26 because the resident was next to her when she was hit by the cart. CNA VV reported she was pushing another resident in a wheelchair as Resident #107 walked next to her using her walker. CNA VV reported she and Resident #107 walked on the left side of the hall with Resident #107 on CNA VV's right side, near the middle of the hall. CNA VV heard LPN K sigh as she approached them from behind while pushing the medication cart. CNA VV reported it sounded like the medication cart was rapidly approaching them from behind and as she turned toward LPN K, she saw the LPN K quickly approaching with the medication cart, and one side began to swing toward Resident #107. CNA VV reported it looked like LPN K did not have control of the cart as one end of it swung toward them and hit the back of Resident #107's leg, causing the resident to fall to the floor. CNA VV reported she was concerned that LPN K was upset about an interaction the two of them had earlier in the day and was pushing the medication cart recklessly in frustration. When queried if she reported her concern to NHA A, CNA VV reported she told both NHA A and Director of Nursing (DON) WW in an 3-way telephone call on 1/24/26 that she felt Resident #107 had been injured as a result of the reckless actions of LPN K. CNA VV reported NHA A did not ask her for any additional information and disregarded her concerns. CNA VV reported she was never interviewed about the situation. Of note, CNA VV is not listed as a witness in the Post Fall Evaluation completed by LPN K.In an interview on 3/27/26 ay 11:45am, LPN K reported she was pushing the medication cart down the hall behind Resident #107 on 1/24/26 at approximately 6:45pm. When asked to describe what happened during the accident, LPN K stated She zigged when I zagged and she backed into the cart. LPN K confirmed that both she and Resident #107 were in motion when Resident #107 was knocked off balance by the medication cart. LPN K reported Resident #107 fell on the floor and was so dramatic as she lay on the floor yelling ohhhh. LPN K confirmed Resident #107 suffered a broken hip during the fall. LPN K confirmed she was not interviewed for additional information after she called NHA A on 1/24/26.Review of a soft file provided by NHA A revealed a summary which stated On 1/24/26, the Administrator received a phone call from (LPN K) regarding a witnessed fall.LPN K stated that she had been pushing the cart down the hallway and (Resident #107) was walking near her.LPN K saw her (Resident #107) and tried to be (sic) out of her way -she (Resident #107) stopped walking and backed up a step and clipped the corner of the cart; she lost her balance and fell to her buttocks.LPN K stated that it was an accident, and she didn't know (Resident #107) was so close to her. The document was signed by NHA A.In an interview on 3/31/26 at 2:00pm, NHA A reported on 1/24/26 LPN K called him to report that Resident #107 fell. NHA A reported it was his understanding that Resident #107 was startled by LPN K, lost her balance, and fell but he did not know if the resident was hit by the cart. NHA A reported he didn't have any red flags about the situation during which Resident #107 had a fall with major injury because LPN K called him. NHA A described the investigation of the incident as brief. When further queried, NHA A stated When an LPN calls and tells you exactly what happened, there was little need for an investigation. When asked if he spoke with CNA VV about her concerns, NHA A reported he could not recall what the CNA told him, but the CNA had mentioned a concern that the nurse may not have accurately reported what had happened. NHA A could not confirm speaking to any other witnesses, including LA BB. NHA A did not elaborate or look into whether any other interaction had occurred earlier in the day as reported by CNA VV that may have contributed to the incident.Resident #112Review of an admission Record revealed Resident #112 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: insomnia (a sleep disorder characterized by persistent difficulty falling asleep) and vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain, robbing brain cells of oxygen).Review of a Minimum Data Set (MDS) assessment for Resident#112 with a reference date of 1/30/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12/15, which indicated the resident was moderately cognitively impaired.Review of Physician Orders for Resident #112 with a reference date of 1/30/26 revealed a one-time order, diphenhydramine (an over-the-counter allergy medication known to cause drowsiness) HCI (hydrochloride) 25mg(milligrams), give 2 tablets by mouth one time only. No other orders for the use of diphenhydramine were present for Resident #112.In an interview on 3/31/26 at 11:34am, Resident #112 reported a male nurse had been giving him (brand name of diphenhydramine omitted) for at least a few weeks because it helped him sleep. Resident #112 reported he was recently told by a female nurse that the use of diphenhydramine was not recommended for those with dementia because it can worsen his cognitive skills. Resident #112 reported he had trouble sleeping for many years and prior to his admission, he used the medication nightly. When further queried about his concern with taking diphenhydramine at this time, Resident #112 stated I don't need anything to make my memory worse, so I don't want any more of that!In an interview on 3/27/26 at 11:45am, LPN K reported she was concerned LPN M was giving residents in memory care medications that he shouldn't. When asked to explain, LPN K reported she was concerned LPN M gave residents diphenhydramine, an over-the-counter allergy medication known to cause drowsiness, without a physician's order. LPN K reported a male resident (Resident #112) asked her several times for the medication and when she told him he didn't have an order for it, the resident said, the other nurse gives it to me. LPN K reported then she found an opened bottle of diphenhydramine HCI in the medication room on the memory care unit. LPN K reported it appeared that quite a bit of the medication was gone but none of the residents on the unit had an order for diphenhydramine HCI. LPN K reported LPN M recently stated to her We'll be ok tonight. I made sure everyone is going to sleep tonight. LPN K reported after her conversation with LPN M, she removed the open bottle of diphenhydramine from the medication storage room, but a new bottle was in its place the following night. LPN K reported she then told the supply clerk to take the medication out of the storage room and stop stocking it because she was concerned another nurse was giving it to residents without an order to do so. When queried, LPN K reported she did not report the concern to NHA A because she did not have proof of her allegation that residents were being wrongfully medicated. In an interview on 3/31/26 at 2:21pm, Nurse Practitioner (NP) XX reported none of the residents on the memory care unit had an order to receive diphenhydramine. NP XX reported the use of that medication for those with dementia created a higher risk for falls and had a sedating effect on the patient.In an interview on 3/27/26 NHA A reported the facility was aware of an allegation of misuse of diphenhydramine and an investigation was underway.Review of a soft file provided by NHA A related to improper administration of diphenhydramine to residents, revealed the facility interviewed 9 of 27 licensed nurses employed by the facility. No record of LPN K being interviewed was provided.In an interview on 3/31/26 NHA A reported he spoke with LPN K, and she expressed general concerns about finding diphenhydramine in the medication storage room on the memory care unit. When queried, NHA A denied that LPN K reported an allegation that LPN M was giving the medication to residents without a physician's order to make them sleep at night. NHA A confirmed this allegation would be investigated and reported.Review of the state agency Facility Reported Incidents data base of 4/1/26 at 3:45pm, revealed the facility had not submitted an investigation related to the accusation of a nurse giving residents diphenhydramine without an order.Review of a facility Abuse Prohibition Policy with a reference date of 9/9/22 revealed .It is the responsibility of all staff to provide a safe environment for the residents. Allegations of resident abuse.adverse event.mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies.

This citation pertains to intake #2792486,2735355 and #2793260.Based on interview, and record review, the facility failed to report allegations involving potential abuse, neglect, or mistreatment to the State Agency timely and accurately in 3 (Resident #107, #112, and #100) of 6 residents reviewed for reporting, including an alleged incident of mistreatment when Resident #107 was hit with a medication cart causing a fall with major injury, allegations of abuse (Resident #100 and Resident #112), resulting in the potential delay in actions to maintain the safety of facility residents and for allegations of abuse to not be reported timely and accurately. Findings include:Resident #107 Review of an admission Record revealed Resident #107 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (progressive disease that causes loss of cognitive abilities), moderate, with anxiety (persistent feelings of apprehension, dread and nervousness). Review of a Minimum Data Set (MDS) assessment for Resident #107 with a reference date of 11/17/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 11/15, which indicated the resident was moderately cognitively impaired. Section GG of the MDS revealed Resident #107 was independent (completed activity by themselves with a device) for walking. Section J revealed Resident #107 had a fall in the month prior to her admission to the facility. Review of a Care Plan for Resident #107 with a reference date of 11/11/25 revealed the following need/goal/interventions: (Resident #107) is at risk for fall related injury and falls R/T (related to) poor safety awareness. Goal: will be free from injury related to falls through the review date. Interventions: Educate.caregivers about safety reminders.keep resident's environment as safe as possible.remind resident to take her time when walking. Review of a Fall Report for Resident #107, dated 1/24/26 at 7:00pm, revealed Incident Description.Nurse was pushing medication cart and collided with resident. Fall was witnessed.complained of R (right) hip pain.Xray was ordered.results of Xray showed acute R femoral neck fracture (break in the narrow, upper part of the thigh bone, just below the ball of the hip joint, often caused by falls). Resident left via EMS (emergency medical services) . Review of a Post Fall Evaluation for Resident #107, with a reference date of 1/24/26, revealed Staff/witness present at/or observing resident after fall: ( Name omitted (Certified Nursing Assistant (CNA) II, CNA MM.Factors observed at time of fall.Environmental factors: Cart pushed in hall tripped resident.Re-Creation of Last 3 Hours Before Fall: the primary nursing assistant who observed the resident during the three hours prior to the fall was interviewed: (Name Omitted) Laundry Aide (LA) BB.Root Cause of this Fall: .Environmental factors.Nurse Signature: (Name Omitted) Licensed Practical Nurse (LPN) K. In an interview on 3/25/26 at 10:25am, CNA II reported she was at the nurse's station on 1/24/26 when she heard Resident #107 and LPN K begin to scream. She responded and saw Resident #107 on the floor on her back and LPN K reported she accidentally hit the resident with the medication cart. When queried regarding other staff that were present, CNA II reported former CNA VV was present when the accident occurred and (LA) BB was down the hall. In an interview on 3/31/26 at 7:54am, CNA MM reported she was not present on 1/24/26 when Resident #107 fell. CNA MM reported she saw Resident #107 later that evening before she was sent to the hospital. Of note, this contradicts the information LPN K documented in the Post Fall Evaluation. In an interview on 3/27/26 at 11:04am, former CNA VV reported she witnessed Resident #107's fall on 1/24/26 because the resident was next to her when she was hit by the cart. CNA VV reported she was pushing another resident in a wheelchair as Resident #107 walked next to her using her walker. CNA VV reported she and Resident #107 walked on the left side of the hall with Resident #107 on CNA VV's right side, near the middle of the hall. CNA VV heard LPN K sigh loudly as she approached them from behind while pushing the medication cart. CNA VV reported it sounded like the medication cart was rapidly approaching them from behind and as she turned toward LPN K, she saw the LPN K quickly approaching with the medication cart, and one side of the medication cart began to swing toward Resident #107. CNA VV reported it looked like LPN K did not have control of the cart as one end of it swung toward them and hit the back of Resident #107's leg, causing the resident to fall to the floor. CNA VV reported she was concerned that LPN K was upset about an interaction the two of them had earlier in the day and was pushing the medication cart recklessly in frustration. When queried if she reported her concern to Nursing Home Administrator (NHA) A, CNA VV confirmed she texted and called NHA A. CNA VV reported she left a voice mail message for NHA A who then called her back with a three-way call, that included former DON WW, about an hour later. CNA VV reported at that time she told both NHA A and DON WW she felt Resident #107 had been injured as a result of the reckless actions of LPN K. CNA VV reported NHA A did not ask her for any additional information and disregarded her concerns. CNA VV reported she was never interviewed about the situation. Of note, CNA VV is not listed as a witness in the Post Fall Evaluation completed by LPN K. In an interview on 3/27/26 ay 11:45am, LPN K reported she was pushing the medication cart down the hall behind Resident #107 on 1/24/26. When asked to describe what happened during the accident, LPN K stated She zigged when I zagged and she backed into the cart. LPN K confirmed that both she and Resident #107 were in motion when Resident #107 was knocked off balance by the medication cart. LPN K reported Resident #107 fell on the floor and was so dramatic as she lay on the floor yelling ohhhh. LPN K confirmed Resident #107 suffered a broken hip during the fall. LPN K confirmed she was not interviewed for additional information after she called NHA A on 1/24/26. In an interview on 3/31/26 at 2:00pm, NHA A reported on 1/24/26 LPN K called him to report that Resident #107 fell. NHA A reported it was his understanding that Resident #107 was startled by LPN K, lost her balance, and fell but was not hit by the medication cart. NHA A reported he didn't have any red flags about the situation during which Resident #107 had a fall with major injury because LPN K called him. When further queried, NHA A reported he did not think the nurse would have called him right away if she'd done something wrong, so he did not report or investigate the situation any further. When asked if he spoke with CNA VV about her concerns, NHA A reported he could not recall what the CNA told him, but the CNA had mentioned a concern that the nurse may not have accurately reported what had happened. Review of a QAPI (Quality Assurance Performance Improvement Review signed by NHA A revealed On 1/24/26 (Resident #107) the Administrator received a phone call from (LPN K).LPN K stated she had been pushing the cart down the hall and (Resident #107) was walking near her.(LPN K) tried to be (sic) out of her way-she (Resident #107) stopped walking and backed up a step and clipped the corner of the cart; she (Resident #107).fell on her buttocks.LPN K.didn't know (Resident #107) was so close to her.(LPN K) was verbally educated to pull her cart rather than pushing her cart to ensure no residents step in front of her while in mostion (sic) Review of the Facility Reported Incident database revealed the facility did not report any allegations of potential mistreatment for Resident #107. Resident #112 Review of an admission Record revealed Resident #112 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: insomnia (a sleep disorder characterized by persistent difficulty falling asleep) and vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain, robbing brain cells of oxygen). Review of a Minimum Data Set (MDS) assessment for Resident#112 with a reference date of 1/30/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12/15, which indicated the resident was moderately cognitively impaired. Review of Physician Orders for Resident #112 with a reference date of 1/30/26 revealed a one-time order, diphenhydramine (antihistamine that is used to help treat certain allergy or common cold symptoms, allergic reactions, trouble sleeping, motion sickness, or certain movement problems) HCI (hydrochloride) 25mg(milligrams), give 2 tablets by mouth one time only. No other orders for the use of diphenhydramine were present for Resident #112. In an interview on 3/31/26 at 11:34am, Resident #112 reported a male nurse had been giving him (brand name of diphenhydramine omitted) for at least a few weeks because it helped him sleep. Resident #112 reported he was recently told by a female nurse that the use of diphenhydramine was not recommended for those with dementia because it could worsen his cognitive skills. Resident #112 reported he had trouble sleeping for many years and prior to his admission, he used the medication nightly. When further queried about his concern with taking diphenhydramine at this time, Resident #112 stated I don't need anything to make my memory worse so I don't want anymore of that! In an interview on 3/27/26 at 11:45am, LPN K reported she was concerned LPN M was giving residents in memory care medications that he shouldn't. When asked to explain, LPN K reported she was concerned LPN M gave residents diphenhydramine, an over-the-counter allergy medication known to cause drowsiness, without a physician's order. LPN K reported a male resident (Resident #112) asked her several times for the medication and when she told him he didn't have an order for it, the resident said, the other nurse gives it to me. LPN K reported then she found an opened bottle of diphenhydramine HCI in the medication room on the memory care unit. LPN K reported it appeared that quite a bit of the medication was gone but none of the residents on the unit had an order for diphenhydramine HCI. LPN K reported LPN M recently stated to her We'll be ok tonight. I made sure everyone is going to sleep tonight. LPN K reported after her conversation with LPN M, she removed the open bottle of diphenhydramine from the medication storage room, but a new bottle was in its place the following night. LPN K reported she then told the supply clerk to take the medication out of the storage room and stop stocking it because she was concerned another nurse was giving it to residents without an order to do so. When queried, LPN K reported she did not report the concern to NHA A because she did not have proof of her allegation that residents were being wrongfully medicated. Attempts to interview LPN K for additional information were unsuccessful by the completion of the survey. Attempts to interview LPN M were unsuccessful by the completion of the survey. In an interview on 3/27/26 NHA A reported the facility was aware of an allegation of misuse of diphenhydramine and an investigation was underway. In an interview on 3/31/26 NHA A reported he spoke with LPN K and she expressed general concerns about finding diphenhydramine in the medication storage room on the memory care unit. When queried, NHA A denied that LPN K reported an allegation that LPN M was using the medication to make residents sleep at night. NHA A confirmed this allegation would be investigated and reported. In an interview on 3/31/26 at 2:21pm, Nurse Practitioner (NP) XX reported none of the residents on the memory care unit had an order to receive diphenhydramine. NP XX reported the use of that medication for those with dementia created a higher risk for falls and had a sedating effect on the patients. Review of the state agency Facility Reported Incidents data base of 4/1/26 at 3:45pm, revealed the facility had not submitted the allegation of potential mistreatment or abuse for Resident #112. Review of a facility Abuse Prohibition Policy with a reference date of 9/9/22 revealed .It is the responsibility of all staff to provide a safe environment for the residents. Allegations of resident abuse.adverse event.mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies. Definitions:.Neglect is the failure of employees to provide.services to a resident.to avoid physical harm, mental anguish or emotional distress.Misappropriation: means.deliberate misplacement.of a resident's belongings.Mistreatment means inappropriate treatment or exploitation of a guest/resident .Adverse event is an.undesirable.event that causes.serious injury.Reporting abuse and facility Response to the allegation.2. The Administrator or designee will notify.any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury) . Resident #100 Review of an admission Record revealed Resident #100 was a female, with pertinent diagnoses which included heart failure, insomnia, post-traumatic stress disorder, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 2/9/26, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, indicating she had severe cognitive impairment. In an interview on 3/26/26 at 9:27 AM, Licensed Practical Nurse (LPN) R reported she was Resident #100's assigned nurse on 1/22/26 for day shift. LPN R reported she went into Resident #100's room on 1/22/26 in the morning to complete her rounds, and as LPN M walked by the door Resident #100 told LPN R to not let him (LPN M) in the room because LPN M had grabbed her arm. LPN R reported she observed a bruise on Resident #100's left arm and notified Administrator A immediately of Resident #100's allegation of potential abuse. LPN R stated .She (Resident #100) was frightened .She is usually not afraid . LPN R reported Resident #100 made the allegation .early in the morning . around 6:30 AM-7:00 AM, and the administration was notified .right away . via phone. LPN R reported Administrator A directed her to monitor the bruise on Resident #100's arm, and he would report the allegation and handle the investigation. LPN R reported Resident #100 has a history of refusing care, and if staff keep trying, she will often become more combative. LPN R reported when Resident #100 becomes combative, staff are to step away and give her space to calm down before re-approaching. LPN R stated .sometimes all it takes is a different person to approach her . and she will accept care. LPN R reported Resident #100 is not good at communicating her needs vocally and has impaired hearing. LPN R reported she did not document her observation of the bruise on Resident #100's arm because .I didn't know what (Administrator A) wanted me to do . Review of an incident/accident report for Resident #100, dated 1/22/26 at 8:00 AM, revealed .Resident reported to nurse (LPN R) that during last rounds night shift nurse and (CNA) came into the room and changed her even though she verbalized that she was not wet and nurse (LPN M) held her wrists while CNA provided (incontinence) care .Resident Description: He grabbed my arms and twisted them, it hurt and I told him I was not very wet .Nurse assessed resident and observed a bruise on left arm. Nurse noted redness on the left arm, no other bruising noted .nursing immediately reported to (Administrator A), report filed with Michigan . Review of a Resident at Risk note for Resident #100, dated 1/22/26 at 9:30 AM, revealed .IDT (Interdisciplinary Team) met to discuss plan of care for resident who is long-term resident in the facility on hospice services, no plan to dc (discharge) home .Action Taken: Nursing assessed resident, bruise on left arm noted redness on right arm, pain managed with scheduled pain medications .Order for X-ray .Nursing to continue to monitor psychosocial status . Review of the MI-FRI System (a system for long-term care facilities to report Facility Reported Incidents) revealed the incident involving Resident #100 on 1/22/26 was reported to the State Agency via online submission on 1/22/26 at 11:40 AM (more than two hours after the allegation of abuse was made). Noted the documentation within the MI-FRI system indicated the incident was discovered (identified) at 10:00 AM despite being informed by LPN R of the concern between 6:30-7:00am that morning. In an interview on 3/31/26 at 3:37 PM, Administrator A reported he was notified of Resident #100's allegation involving a potential staff-resident abuse situation on 1/22/26 in the morning (on day shift). Administrator A reported Former Director of Nursing (DON) WW learned of the allegation from LPN R and came directly to his office to discuss the concern. Administrator A reported he did not recall receiving a phone call from LPN R prior to that point involving the allegation made by Resident #100. Administrator A reported Resident #100 told LPN R that LPN M had twisted her arm, and a bruise was noted on Resident #100's left arm. Administrator A indicated he reported the allegation of abuse involving Resident #100 to the State Agency, however, there was an issue with the MI-FRI system that day and he had to notify IT for additional assistance. Administrator A reported he was unsure when he first attempted to report the allegation of abuse to the State Agency on 1/22/26 and stated .I don't have a record of that . Administrator A reported that an allegation of abuse should be reported to the State Agency within two hours.

This citation pertains to intakes #2792486Based on interview and record review, the facility failed to ensure facility staff implement the facility abuse policy and procedure for 3 residents (Resident #112, Resident #104, and Resident #102) of 9 residents reviewed for abuse, resulting in incidents of potential abuse not being reported to the abuse coordinator immediately. Findings include:Resident #112Review of an admission Record revealed Resident #112 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: insomnia (a sleep disorder characterized by persistent difficulty falling asleep) and vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain, robbing brain cells of oxygen).Review of a Minimum Data Set (MDS) assessment for Resident#112 with a reference date of 1/30/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12/15, which indicated the resident was moderately cognitively impaired.Review of Physician Orders for Resident #112 with a reference date of 1/30/26 revealed a one-time order, diphenhydramine HCI (hydrochloride) 25mg(milligrams), give 2 tablets by mouth one time only. No other orders for the use of diphenhydramine were present for Resident #112.In an interview on 3/31/26 at 11:34am, Resident #112 reported a male nurse had been giving him (brand name of diphenhydramine omitted) for at least a few weeks because it helped him sleep. Resident #112 reported he was recently told by a female nurse that the use of diphenhydramine was not recommended for those with dementia because it worsen his cognitive skills. Resident #112 reported he had trouble sleeping for many years and prior to his admission, he used the medication nightly. When further queried about his concern with taking diphenhydramine at this time, Resident #112 stated I don't need anything to make my memory worse, so I don't want any more of that!In an interview on 3/27/26 at 11:45am, LPN K reported she was concerned LPN M was giving residents in memory care medications that he shouldn't. When asked to explain, LPN K reported she was concerned LPN M gave residents diphenhydramine, an over-the-counter allergy medication known to cause drowsiness, without a physician's order. LPN K reported a male resident asked her several times for the medication and when she told him he didn't have an order for it, the resident said, the other nurse gives it to me. LPN K reported then she found an opened bottle of diphenhydramine HCI in the medication room on the memory care unit. LPN K reported it appeared quite a bit of the medication was gone but none of the resident's on the unit had an order for diphenhydramine HCI. LPN K reported LPN M recently stated to her We'll be ok tonight. I made sure everyone is going to sleep tonight. LPN K reported after her conversation with LPN M, she removed the open bottle of diphenhydramine from the medication storage room, but a new bottle was in its place the following night. LPN K reported she then told the supply clerk to take the medication out of the storage room and stop stocking it because she was concerned another nurse was giving it to residents without an order to do so. When queried, LPN K reported she did not report the concern to (NHA) A because she did not have proof of her allegation that residents were being administered medication without a physician's order.In an interview on 3/27/26 at 2:43pm, Supply Clerk (SC) AA reported she stocked all the over-the-counter medications in each medication storage room throughout the facility. SC AA reported she did not keep a running total of the over-the counter medications she stocked, or the amount stored in the main stock room. SC AA reported all nurses have a key to the main stock room. SC AA reported she recently noticed a bottle of diphenhydramine was missing from the medication storage room on the memory care unit, so she restocked it with a new bottle. SC AA reported on 3/26/26, LPN K told her to stop stocking diphenhydramine in the memory care medication storage room because she was concerned another nurse was giving to residents without a physician's order. When queried, SC AA reported she did not tell NHA A about the allegation of resident's receiving medication without a physician's order.Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, lasting at least 6 months).Review of a Minimum Data Set (MDS) assessment for Resident #104 with a reference date of 1/28/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section D revealed Resident #104 reported he felt down, depressed, or hopeless several days during the 14-day assessment period. Section E revealed Resident #104 had no behaviors.Review of a Care Plan for Resident #104 with reference date of 11/19/25 revealed the following need/goal/interventions: (Resident #104) is at risk for adverse reactions and side effects r/t (related to) receiving an antidepressant. Goal: Will show decreased episodes of s/sx (signs and symptoms) of anxiety through the review date. Interventions. observe ongoing s/sx of depression.In an interview on 3/26/26 at 11:17am Resident #104 reported he told a staff member he thought two of his video games, valued at $160 dollars, had been stolen. Resident #104 reported he did not know the name or position of the staff member. Resident #104 reported the staff member told him the games were not on his inventory list and would not be replaced. Resident #104 reported he never told NHA A because he thought nothing could be done.In an interview on 3/31/26 at 4:22pm, NHA A reported staff never told him Resident #104 made an allegation of misappropriation of his video games. NHA A confirmed this allegation was never reported to the state agency and was never investigated.Resident #102Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (condition causing progressive loss of cognitive skills), bipolar disorder (chronic mental health condition causing extreme, disabling shifts in mood) and general anxiety disorder (mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday things).Review of a Minimum Data Set (MDS) assessment for Resident #102 with a reference date of 3/4/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 3/15, which indicated the resident was severely cognitively impaired. Section A of the MDS revealed Resident #102 had unclear speech and her ability to make herself understood was limited to concrete requests.Review of a Care Plan for Resident #102 with a reference date of 3/16/23 revealed the following need/goal/interventions: Need: (Resident #102) is at risk for impaired skin integrity.Goal: Minimize risk in effort to reduce likelihood of pressure injury.Interventions:.conduct weekly head to toe skin assessments, document and report abnormal findings to physician.follow facility policies.In an interview on 3/26/26 at 2:03pm, former Director of Nursing (DON) WW reported Resident #102 had a bruise of unknown origin on her forearm that was not immediately reported by floor staff. DON WW reported she realized the resident had an injury when she saw it documented on CNA alert charting a day after it was first identified.Review on an Incident Report for Resident #102 with a reference date of 1/19/26 revealed staff reported that the bruise was first noted on night shift by the assigned nurse on 1/18/26.In an interview on 3/26/26 at 12:44pm, CNA QQ reported on the morning of 1/19/26, at approximately 6:30am, she was told by a member of the off-going shift that Resident #102 had a bruise of unknown origin on her forearm. CNA QQ reported she knew the bruise should have been reported when it was identified so she alerted the Former DON WW. CNA QQ reported the bruise extended from the resident's wrist to the top of the forearm and covered most of the dorsal (top) surface of her forearm.Review of a Provider Progress Note for Resident #102 with a reference date of 1/19/26 at 8:00am revealed .New right forearm bruise.acute visit for new right forearm bruise.contusion(bruise) of right upper arm.right dorsal forearm bruise, unknown mechanism of injury.Review of a Nursing Progress Note for Resident #102 with a reference date of 1/19/26 at 9:08am revealed .skin issues note: bruised right forearm.Review of an Facility Reported Incident report for Resident #102, with a reference date of 1/19/26, revealed the information was submitted to the state agency at 1:48pm for the injury of unknown origin that was identified on 1/18/26. Of note, the report was not submitted with the required 2-hour time frame.In an interview on 3/31/26 at 4:22pm, NHA A reported it was the expectation that staff would report a concern of resident abuse to him immediately.Review of a facility Abuse Prohibition Policy with a reference date of 9/9/22 revealed .It is the responsibility of all staff to provide a safe environment for the residents. Definitions.f resident abuse.adverse event.mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies. Staff members.shall immediately report incidents of abuse and suspected abuse, . Definitions:.Neglect is the failure of employees to provide.services to a resident.to avoid physical harm, mental anguish or emotional distress.Misappropriation: means.deliberate misplacement.of a resident's belongings.Adverse event is an.undesirable.event that causes.serious injury.

Based on observation, interview, and record review, the facility failed to provide timely incontinence care in 1 of 4 residents (Resident #100) reviewed for dignity and timely response to resident needs, resulting in frustration and the potential for impaired dignity, infection, falls, and skin breakdown.Findings include:Resident #100Review of an admission Record revealed Resident #100 was a female, with pertinent diagnoses which included heart failure, insomnia, post-traumatic stress disorder, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss.Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 2/9/26, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, indicating she had severe cognitive impairment. Noted Resident #100 was frequently incontinent of urine and always incontinent of bowel.Review of a current Care Plan for Resident #100 revealed the need .risk for fall related injury and falls . revised 1/15/26, with interventions which included .Remind her frequently to use call light when assistance is needed . initiated 9/14/23.Review of a current Care Plan for Resident #100 revealed the need .at risk for impaired skin integrity/pressure injury . revised 10/6/23, with interventions which included .Complete hygiene care expeditiously and calmly to minimize duration of distress when the resident is uncooperative . initiated 1/29/26.In an observation on 3/31/26 at 11:02 AM, Resident #100 was noted in bed in her room. Observed that her call light was activated, with a light illuminated above her door frame. Observed Activity Assistant X respond to Resident #100's activated call light, and approach Resident #100 to identify what she needed. Observed Resident #100 request a brief change. Noted Activity Assistant X deactivated Resident #100's call light (with the need unmet) and informed Resident #100 she would need to get additional staff to help with the care. Activity Assistant X then exited Resident #100's room and continued down the hall. Observed Resident #100 appeared calm, with no negative mood or behaviors identified during this interaction.In an observation on 3/31/26 at 11:32 AM, Resident #100 was noted in bed in her room, lying on her right side with her hands folded under her head and her eyes closed. Noted that staff had not yet returned to Resident #100's room to assist with a brief change (per her request) since her call light was answered and deactivated at 11:02 AM (30 minutes prior).In an interview on 3/31/26 at 11:35 AM, Activity Assistant X reported when she responded to Resident #100's call light at 11:02 AM, the resident requested a brief change. Activity Assistant X reported she told the resident she would let someone (from nursing) know. Activity Assistant X reported she was not yet able to find a staff member to assist Resident #100 and had not yet communicated Resident #100's request to the nursing staff.In an observation and interview on 3/31/26 at 11:44 AM, Certified Nursing Assistant (CNA) EE entered Resident #100's room to deliver her lunch tray. Noted that when CNA EE arrived to Resident #100's room, the resident removed her soiled brief and threw it on the floor. Observed CNA EE prepare supplies and provide incontinence care for Resident #100 at this time. Observed Resident #100 appeared distressed and was moving around frequently in bed stating .diaper . repeatedly. CNA EE reported she was not assigned to Resident #100 and was not aware that Resident #100 had previously requested a brief change. Noted Resident #100 had been incontinent of bowel, and her linens were visibly soiled. Observed Resident #100 as she stated .my butt hurts . to CNA EE. Observed CNA EE provide incontinence care, and noted Resident #100 became agitated and aggressive several times during care. Noted dried bowel movement on Resident #100's bilateral buttocks that required additional soaking/washing to remove. Due to Resident #100's agitation/aggressive behaviors, Social Worker RR came to assist with redirecting Resident #100 and providing reassurance for the remainder of Resident #100's incontinence care.In an interview on 3/31/26 at 4:22 PM, Interim Director of Nursing (DON) B reported when responding to an activated call light, staff should leave the light on if the need is not able to be immediately addressed.Review of the policy/procedure Routine Resident Care, dated 3/12/25, revealed .Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene .Incontinence care is provided timely according to each resident's needs .Resident's call lights are answered timely and resident's requests are addressed, if permitted .Review of the policy/procedure Call Lights, dated 3/12/25, revealed .Call lights will be placed within the resident's reach and answered in a timely manner .Responding to a Call Light .Identify the location and answer the resident promptly .Knock on the door, identify yourself and ask the resident what you can help them with .Go to the location of the call light, and turn off the light if you are able to meet the resident request .Do what the resident requests of you, if permitted. If you are unsure go ask the charge nurse .When finished, turn the call light off and replace the call light within resident's reach .

Based on observation, interview and record review the facility failed to provide adequate supervision and implement interventions to prevent falls for 1 resident (Resident #7) of 6 residents, resulting in a fall, pain, and impaired functional ability due to amputation of right long finger and injury to right ring fingers. Findings include: Resident #7: Review of an admission Record revealed Resident #7 was a male with pertinent diagnoses which included dementia, history of falling, anxiety, adjustment disorder, hallucinations, legal blindness, hearing loss right ear, and restless leg syndrome (irresistible urge to move the legs). Review of current Care Plan for Resident #7, revised on 7/10/2018, revealed the focus, .(Resident #7) is at risk for fall related injury and falls R/T (related to): impaired gait, impaired mobility, muscle weakness, impaired vision and impaired hearing, resident has hallucinations. with the intervention .Anti roll backs to w/c (wheelchair) Initiated: 08/25/2022.Therapy to eval for wheelchair and safety evaluation.Date Initiated: 11/04/2024.AMBULATION/WALKING: Resident is unable to ambulate and requires max assistance with ambulation.Date Initiated: 02/24/2025.TRANSFER: Substantial/maximal assistance) with two helper(s).Date Initiated: 02/24/2025.Review of Progress Note dated 4/29/25 at 00:00 AM, revealed, .XXX[AGE] year-old male is seen today due to staff report that he had a fall. He was noted to have slid out of his wheelchair while sitting at the nurses station. He was not noted to have any injuries at this time.History is limited d/t patient mental status.ASSESSMENTS AND PLANS.New dycem (reusable non-slip material used to hold objects in firmly in place) has been placed in his wheelchair and therapy will assess for new cushion to encourage resident to sit back in his wheelchair.Review of Resident At Risk dated 4/29/2025 at 10:30 AM, revealed, .Reviewed Clinical Indicator: High risk for falls secondary to dementia, hallucinations, legally blind, HOH (hard of hearing), leans forward when propelling wheelchair and history of falls.Action Taken: New dycem placed in chair. OT (Occupational Therapy) to evaluate for wedge cushion in wheelchair.Response to Previous Actions Taken: Nursing to monitor effectiveness of new actions.Review of Physical Device Evaluation dated 6/13/25, revealed, .Type of Device: 2. Self-Releasing Belt.Does the device meet the following criteria: 1. It is attached or adjacent to the resident.2. Cannot be easily removed by the resident (cannot be removed intentionally).Met all 3 criteria, No. The device is an enabler.Reason for Enabler Device use: Repositioning/Support.Enable/Increase Bed Mobility.Enhance Mobility. Review of Nurses Notes dated 7/23/2025 at 11:15 AM, revealed, .(Specialty Care Unit) Nurse and UM were notified by PA (Physician Assistant) and CNAs (Certified Nursing Assistants) regarding (Resident #7)'s fall in the (Specialty Care Unit) Lounge. Upon assessment of the area, the table was turned over, and (Resident #7) was lying on his right side, responsive to verbal stimuli. VS (vital signs) 132/67, 62, 97.8, 14, 95%. Amputation of the 4th digit of his right hand, and skin removed on the 3rd digit. A pressure dressing was applied with moist gauze to the right digits and wrapped with Kerlex gauze. 911 was called to transfer (Resident #7) to (Local Hospital) . Review of Nurses Notes dated 7/23/2025 at 8:20 PM, revealed, .Res returned from (Local hospital). Res has an amp (amputation) of the right fingertip. New order for Keflex 500 mg 2 times a day for 7 days . Review of Care Plan dated 02/24/25, revealed, the focus .(Resident #7) has a functional ability deficit and requires assistance with self care/mobility . with the intervention .AMBULATION/WALKING: Resident is unable to ambulate and requires max assistance with ambulation. (Resident #7) will attempt to transfer himself.Revision on: 07/16/2024. Review of Incident Report dated 7/23/25, revealed, .Incident Description: Nursing Description: (Specialty Care Unit) Nurse and UM (Unit Manager) were notified by PA (Physician Assistant) and CNAs regarding (Resident)'s fall in the (Specialty Care Unit). Upon assessment of the area, the table was turned over, and (Resident #7) was lying on his right side, responsive to verbal stimuli. VS (vital signs) 132/67, 62, 97.8,14, 95% .Was this incident witnessed: N .Immediate Action Taken: Description: Amputation of the 4th digit of his right hand, and skin removed on the 3rd digit. A pressure dressing was applied with moist gauze to the right digits and wrapped with Kerlex (high absorbency, crinkle weave pattern cushions and protects wounds) gauze .911 was called to transfer (Resident #7) to (Local Hospital), wheelchair inspected, wheel cover ordered to cover wheels, seatbelt removed, care plan updated, guardian notified, provider bedside .Notes: Resident had amputation of 3rd & 4th digit of the right hand, bruising / redness of face, shoulders and lower extremities, and right hand .Injury Report Post Injury: Skin tear .27. Right hand (palm), Wheelchair brakes unlocked .Confused, Gait Imbalance .Ambulating without assistance . Review of summary of Staff Interviews revealed, .Certified Nursing Assistant (CNA) CC: Provided care for (Resident #7) at 650 AM, put seatbelt on, took to hallway at nurse's station. Resident placed in fish room (Resident Lounge) for meal unsupervised .Unit Manager (UM) C: notified by CNA that (Resident #7) had a fall in sensory/lounge. (Physician Assistant) was present, assessed resident. Noticed severed fingertip, on right finger, Right side and right ring finger skin tear. Sent to (Local Hospital) after first aide.Physician Assistant (PA) EEE: At around 10:15 AM, I was at nursing station and heard a noise, then the table turned over (Resident #7) laying on right side, head toward wall - wheelchair was turned opposite from resident, provided first aide and assessed resident, fingertip was behind the wheelchair.Licensed Practical Nurse (LPN) N: This morning at breakfast, CNA moved resident to lounge for breakfast, around 07:30 AM, At 10:15 AM (UM C) helped me restock narcotics when another nurse notified fall. Table was tipped over. Noticed fingertip was severed, provided assessment, LOC (level of consciousness) normal, provided first aide, call 911.CNA O: Took over at 08:30 AM care for (Resident #7), At 08:30 AM (Resident #7) was in lounge.(CNA CC) stated she had toileted him prior to leaving. The last time I checked on resident at 09:30 and he was sitting at table in the lounge. Was sitting charting at 10:15 AM, and (PA EEE) was standing in front of nurse station and informed about fall. Resident was laying on his side and table was flipped over. Resident was incontinent of diarrhea, was still having active BM (bowl movement) while on the floor. Nurse assessed/PA evaled, 911 called.Review of Physician Assistant Progress Note from (Local Hospital) dated 8/5/25, revealed, .Diagnosis: 1. Injury of finger of right hand, subsequent encounter.2. Laceration of right hand without foreign body, subsequent encounter.HPI: (Resident #7) is a 82 y.o. male with history of blindness and severe hearing loss who presents today for follow up of a right hand injury sustained 13 days ago when he fell out of his wheelchair and his long and ring fingers were caught in the wheelchair. Patient was evaluated at the ER where imaging showed a comminuted fracture of the distal fourth phalanx. He had a revision amputation with nail bed removal of right ring finger and I&D (Irrigation and Debridement) with repair of damaged fractures of right long finger by the ortho resident. He was placed in a cast last visit since he immediately began taking dressing off. He is accompanied by (Staff) from his LTC facility who helps provide history.Placed in three finger ulnar gutter cast (cast use to immobilize fractures) for protection .In an interview on 09/09/2025 at 11:33 AM, Licensed Practical Nurse (LPN) N reported she heard a loud noise, and Resident #7 had fallen out of his wheelchair and the table was turned on its side. LPN N demonstrated where the table was located midway along the wall on the right, the resident was lying on his right side near the table and the wheelchair was on the other side of the resident by his feet on the other side of the room. LPN N reported this event happened shortly after breakfast and he was in here eating his breakfast. LPN N reported at the time of the incident, he was ambulatory, up to the bathroom with assistance, no seatbelts anymore as a restraint, and he had occasions of restless and anxiousness. LPN N reported Resident #7 was unaware of his strength level. LPN N reported he does have periods of incontinence. LPN N reported the best guess was Resident #7 had a period of incontinence, went to stand up out of his wheelchair, had his fingers in the spokes of his wheelchair, the wheelchair rolled back and that was how the injury occurred. LPN N reported when she initially responded he was laying on his right side, wheelchair had rolled away, and he had a traumatic injury. In an interview on 09/09/2025 at 11:48 AM, Unit Manager (UM) C reported he was restocking in the (narcotic box) system and the door to the room was open. UM C reported there was a loud noise, one of the CNAs reported Resident #7 had fallen out of his chair. UM C reported himself and LPN N responded to the room (lounge) and he was lying on his right side, he was in a fetal position and portion of his finger lying on the floor. UM C reported LPN N went and retrieved a plastic bag and placed the finger on ice. UM C reported the table was upright, unsure of where the wheelchair was located, reported Resident #7 was facing the window at the back wall. UM C reported vitals signs were taken, first aide to his hand - placed moist gauze and kerlex to act as a kind of pressure bandage. UM C reported 911 had been called and the staff monitored his hand, reported Resident #7 was alert and talking to staff. UM C reported emergency services arrived and took him to the local hospital. UM C reported Resident #7 ended up having surgery where they removed more of his finger and closed the tip of it up. UM C reported the tip of Resident #7's finger was behind him and it was a ways from him. UM C reported Resident #7 could stand with direction and staff with him. UM C reported Resident #7 was able to walk to bathroom, 3-4 feet, prior to the fall. UM C reported the current chair Resident #7 had was prescribed by hospice as he was recently placed on hospice services. UM C reported it was a larger broda chair to accommodate Resident #7's size, reported the chair reduced his ability to self-propel. UM C reported Resident #7 wanted to always stand up. In an interview on 09/10/2025 at 9:20 AM, Activity Aide (AA) HH reported Resident #7 did attempt to get up from his wheelchair a lot. AA HH reported he was placed in the lounge to eat his breakfast as he kept pushing the dining room table in the dining room. In an interview on 09/10/2025 at 11:36 AM, CNA O reported she was sitting at the nurse's station on the computer charting on residents. CNA O reported she was informed he had been toileted prior to the aide leaving to go to another unit. CNA O reported the other aide had placed him in that room, to eat his breakfast there. CNA O reported she did not see what had happened but heard the noise, ran into the room, the table was flipped over, noticed he had a bowel movement, went to get clothing and other items to clean him up. CNA O reported Resident #7 was crying out, staff asked him if his finger hurt, and she placed a towel under his head. CNA O reported the nurse was assessing him and performing first aide on Resident #7. CNA O reported Resident #7 would stand up a lot and the seat belt was to remind him he couldn't stand up without it being unbuckled. CNA O reported Resident #7 was brought to the lounge to eat his breakfast and he did better sitting at the table in there as when he was in the dining room he would be reaching out to find items on the table and would touch other resident's food and other items and those residents would get upset. During an observation on 09/08/2025 at 1:03 PM, Resident #7 was observed in the hallway, his head was reclined back almost flat, approximately 20 degrees, the footrest was up at the level of his head, and his bottom was dipped down in the seat which did not allow Resident #7 to rise up from the chair on his own. Review of Therapy Note dated 7/30/2025 at 1:15 PM, revealed, .(Resident #7) was placed in a new 20-inch wheelchair with (B) spoke covers added to wheels, pressure reducing cushion with dycem on top, (B) rear anti-tippers, and anti-rollback self-locking brakes. In an interview on 09/09/25 at 11:44 AM, Rehab Manager JJ reported Resident #7 was assessed and started service on 5/12/25 and therapy trialed restraint reduction and Resident #7 needed all the interventions on his wheelchair; such as a cushion, anti-rollbacks, and anti-tippers. Rehab Manager JJ reported the seated belt notified the staff when Resident #7 was getting fidgety. Review of Nurses Notes dated 8/5/2025 at 12:22 PM, revealed, .Resident was restless and made multiple attempts at standing and exiting the wheelchair. LPN instructed CNA to please toilet the resident again to follow the care plan. Resident did not void and was becoming agitated in the bathroom and stated he did not have to void. Resident was returned to wheelchair and sat in front of the nurses station for monitoring. Non-pharm interventions for anxiety/agitation included a calm approach, providing a meal, toileting, conversation, and brief check. Review of Incident Report dated 8/6/25 at 11:30 AM, revealed, .CNAs (CNA P), (CNA CC) and (Unit Manager) were attempting to ambulate 3.5 feet to his toilet. We were able to assist (Resident #7) just in front of the toilet when he started collapsing, and he was lowered to the floor without hitting his head.This writer assessed (Resident #7) and he did not have any obvious injuries, and since it was witnessed, he was assisted to his feet and subsequently toileted.The addition of another CNA was needed to get (Resident #7) to his feet.Note: No immediate intervention was put in place to ensure safety immediately. Review of Care Plan for Resident #7 revised on 08/8/25, revealed the focus, .(Resident #7) is at risk for fall related injury and falls R/T (related to): impaired gait, impaired mobility, muscle weakness, impaired vision and impaired hearing, resident has hallucinations. with the intervention .Use bedside commode for safety. This writer had multiple observations of no commode present in Resident #7's room from 09/08/25 - 09/10/25. In an interview on 09/10/2025 1:06 PM, Director of Nursing (DON) B reported Resident #7 had a fall and amputated part of his finger. DON B reported Resident #7 was placed on hospice services after his return. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education to all staff, monitoring of the noncompliance that includes feedback from the Quality Assurance committee. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. Compliance date of 7-28-25.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.Findings include:On 9/8/25 starting at 9:55 AM, an initial tour of the kitchen found three dead end water lines that came from the floor and were not connected to anything. These were located at the hand sink on the cook line, the three compartment sink, and the single compartment preparation sink. Further review of the kitchen found that the hot water handle was not on the faucet, not allowing for use or easy flushing of the water line. On 9/8/25 at 2:05 PM, An observation of the central bath found a spa tub surrounded with resident equipment and used for the storage of items. When asked if the tub is used, Maintenance Director (MD) CCC stated he had only been in the facility a few weeks and was unsure. When asked if this was something that gets flushed regularly, he was unsure. On 9/8/25 at 2:12 PM, Observation of the Skilled Hall soiled utility room found a hopper with no running water from the hopper spray or the hot side of the overhead faucet. When asked if this was flushed, MD CCC was unsure. On 9/8/25 at 2:21 PM, Observation of the [NAME] Hall shower room found three showers with two of the showers set up with items stored in the stalls, appearing to not be regularly used. When asked if the two shower stalls with items in them were used or flushed, MD CCC was unsure. On 9/8/25 at 2:25 PM, Observation of the [NAME] Hall soiled utility room found that the hot water on the overhead faucet was not turned on, indicating a stagnant line. On 9/8/25 at 2:43 PM, Observation of the Birch Hall weight room found a shower stall in the back left corner. When asked if the shower spray is something that gets flushed regularly MD CCC was unsure. On 9/8/25 at 2:48 PM, Observation of the Birch Hall soiled utility room found that brown and discolored water came out of the hot water fixture of the over hopper faucet. Further review found that the spray to the hopper was not turned on, indicating a stagnant line.A review of the facility provided documents with details of their Water Management Plan, found meeting minutes where only the previous Maintenance staff was present and no risk assessment with a written or visual display showing a description of the buildings water systems. A record review of the facility provided document entitled Water Management Program, revised 2/1/2024, found that, The general principles of an effective water management program include.Preventing water stagnation. Further review found that, The assessment will include a description of the building water systems using text and flow diagrams for identification, and that, The water management program team will meet quarterly in conjunction with the infection control committee to validate and verify the water management program utilizing the meeting minutes for the water management program.

Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: On 9/8/25 at 10:07 AM, Observation of the of the two door [NAME] cooler found a tub of nourishment shakes and snacks used for tray line and dated for a week at a time. Further observation found half a dozen magic cups inside of the tub with manufacturer's directions that state the items need to be consumed within five days under refrigeration. On 9/8/25 at 10:50 AM, A tour of the activity rooms pantry refrigerator and resident refrigerator, with Dietary Manager (DM) KK, found the following items: two unopened yogurts with best by dates of 31 [DATE], an unopened manufactured container stating it was a chicken bowl with a best by date of [DATE], a container of vanilla pudding with a best by date of 15 [DATE], a Tupperware container of chili with no name and date of 8-26, three milk cartons with best by dates of 30 [DATE], and two ready whip containers with use by dates of July 17th 2025. At this time, an interview with DM KK found that the activities department takes care of the resident fridge and the kitchen staff stock and check the pantry fridge. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . On 9/8/25 at 10:19 AM, Observation of [NAME] DDD found that he was prepping raw chicken to be cooked for lunch. At this time, three sheet pans of chicken were laid out of the preparation table. After laying out the chicken, [NAME] DDD was observed adding spices to the chicken with the same gloves that were used to place the chicken on the sheet pans. The gloves were visibly wet and greasy from handling the raw chicken as [NAME] DDD started going through spices, picking up their original containers and spreading the spices over the chicken. When asked if he should be using the same gloves to handle raw chicken as he would to handle the spice containers, [NAME] DDD stopped what he was doing, discarded his gloves, and washed his hands. On 9/8/25 at 12:14 PM, Observation of [NAME] DDD on the serving line for lunch found he used his bare hands to grab a hamburger bun to make a cheeseburger for a resident. [NAME] DDD then put gloves on to grab a slice of cheese and add it to the cheeseburger. When asked if he normally wore gloves on the serving line to help complete task specific items, such as assembling a burger, [NAME] DDD stated that they have been informed to not wear gloves while serving on the line. According to the 2022 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:. (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; .(I) After engaging in other activities that contaminate the hands According to the 2022 FDA Food Code section 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12 (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. On 9/8/25 at 10:09 AM, Observation of the walk-in cooler found the back left rack showed increased accumulation of debris on the wire slats. An interview with DM KK found that they cleaned the racks recently but need to get that specific rack pulled out and power washed. Further observation found an accumulation of dirt and debris on the back floor juncture, in the corners, and near the legs of the storage racks. On 9/8/25 at 10:38 AM, An interview with DM KK found that Maintenance takes care of the ice machine cleanings and that a vendor had come in recently to go through both ice machines onsite. Observation of the kitchen ice machine found an accumulation of black debris on the corners of the inside plastic lip. When wiped with a clean paper towel, debris was evident and easily wiped off. Further review underneath and behind the kitchen ice machine and coffee area found an accumulation of dirt debris as well as plastic lids, plastic bags, and a nutritional cup (that requires refrigeration) underneath and against the wall.On 9/8/25 at 10:48 AM, Observation of the ice room outside of the kitchen found heavy accumulation of black spotted debris on the inside of the ice scoop holder. When shown to DM KK she stated she would get it cleaned. On 9/8/25 at 10:51 AM, Observation of the Activity fridge freezer found an increased accumulation of yellow debris and staining. Further observation of the Nourishment fridge found a heavy accumulation of dust and black spotted debris in the top gasket of the freezer and top portion of the refrigeration unit.On 9/8/25 at 11:04 AM, Observation of the dry storage room found increased accumulation of debris along the back floor and wall of the unit along with a handful of plastic spoons and a nutritional cup (that requires refrigeration). According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.

Based on observation and interview, the facility failed to provide an environment that promoted a dignified dining experience for 5 residents (R#35, #39, #42, #57, and #7) of 5 residents reviewed for dignity, resulting in feelings of disappointment with the dining experiences. Findings include: During an observation on 09/09/25 at 5:01 PM, Dinner was being served on the Specialty Care Unit (SCU). During an observation of the meal cart, there were no other meals on the cart and staff reported more meals needed to be brought by the dietary staff. During this time frame, Residents #35, #39, #42, #57, and #7 did not have a meal tray or had waited for staff to assist with their meal. During an observation on 09/09/25 at 5:15 PM, another cart was brought to the SCU by dietary staff and nursing staff distributed the meals to the remaining residents who hadn't received their meals. Resident #35: Review of an admission Record revealed Resident #35 was a female with pertinent diagnoses which included dementia, aphasia (language disorder that affects a person's ability to communicate), anxiety, and confusion. Review of Review of a Minimum Data Set (MDS) assessment for Resident #35, with a reference date of 8/6/25, revealed, .Section GG: Eating: the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.Supervision or touching assistance.During an observation on 09/09/25 at 5:01 PM, Activities Aide (AA) HH was feeding the resident at the table with Resident #35. The resident she was assisting with her meal was almost finished with her meal. Resident #35 was looking around the room, looked at staff members who were in the dining room to see if they had her meal tray. During an observation on 09/09/25 at 5:09 PM, Resident #35's table mate was eating her dessert. Resident #35 was still looking around the room at staff looked to see if they had her meal tray for her. At 5:17 PM, Resident #35 received her meal tray. Resident #39:Review of an admission Record revealed Resident #39 was a male with pertinent diagnoses which included anemia (blood doesn't have enough red blood cells), dementia, pot-traumatic stress disorder (PTSD), Vitamin D deficiency, and mixed irritable bowel syndrome (abdominal pain, bloating, diarrhea, and constipation. Resident #42:Review of an admission Record revealed Resident #42 was a male with pertinent diagnoses which included traumatic brain injury, dementia, mild intellectual disabilities, seizures, and signs and symptoms concerning food and fluid intake. During an observation on 09/09/25 at 5:05 PM, Residents #39, Resident #42, and Resident #47 were seated at a table together. Resident #47 had his meal tray but, Resident #39 and Resident #42 did not have their meal trays. When the second cart arrived, Resident #39 and Resident #42 received their meal trays at approximately 5:16 PM. Resident #57:Review of an admission Record revealed Resident #57 was a male with pertinent diagnoses which included diabetes, dementia, kidney disease, GERD, edema, stroke, and anxiety. During an observation on 09/09/25 at 5:01 PM, Resident #57 had not received his meal tray, but his table mate did, and she was being assisted by a staff member with her meal. During an observation on 09/09/25 at 5:03 PM, Resident #57 asked for his dinner as he saw other residents had received their meal trays as well. During an observation on 09/09/25 at 5:15 PM, Resident #57 received his meal tray. Resident #57 was visibly upset and reported to staff he did not like anything that was served to him, and he proceeded to leave the room.Resident #7: Review of an admission Record revealed Resident #7 was a male with pertinent diagnoses which included dementia, legal blindness and hearing loss. During an observation on 09/09/25 at 5:07 PM, Resident #7's meal tray was in his room placed on his nightstand. Resident #7 was lying with his head in the opposite direction, and his meal was at his feet. His meal tray had been delivered to his room approximately 5:04 PM. At 5:22 PM, Resident #7 was assisted by staff with his meal. Certified Nursing Assistant (CNA) T was assisting him with his meal, and he had finished three bowls of food at this point and was working on his dessert. CNA T reported Resident #7 told her he was hungry and he meant it. In an interview on 09/10/2025 at 12:41 PM, CNA GG reported when delivering trays, you would make sure each resident seated at the same table had their meals at the same time as it was a dignity concern if residents had food and other residents seated at the table did not. CN GG reported it would be upsetting for the resident who didn't have their food to watch someone else eat when you were hungry as well. In an interview on 09/10/25 at 12:55 PM Director of Nursing (DON) B reported there were no early meals in the SCU. DON B reported there should be no reason there were two separate carts brought to the unit at different times for meal service. DON B reported all residents seated at a table should be served their meals together as it was a dignity concern for others to be eating when another resident did not have their meal as well.

Based on observation, interview and record review, the facility failed to maintain a quiet homelike environment in resident areas at night as reported by 5 residents (Resident #15, Resident #54, Resident #33, Resident #79, Resident #20) of 18 residents reviewed for environment and as voiced in the confidential Resident Council Meeting resulting in resident dissatisfaction and frustration from constant noise levels.Findings include:Resident #15(R15) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R15 admitted to the facility on [DATE] with pertinent diagnoses including anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R15 was cognitively intact (13 to 15 cognitively intact). During an interview on 9/8/2025 at 10:50 AM, R15 stated that 3rd shift staff are loud and they don't care if they wake up residents. Resident #54 (R54) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R54 admitted to the facility on [DATE] with pertinent diagnoses including insomnia (sleep disorder characterized by difficulty falling or staying asleep). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R54 was cognitively intact (13 to 15 cognitively intact). During an interview on 9/8/2025 at 2:04 PM, R54 stated that 3rd shift staff are so inconsiderate since they slam doors and holler all night long. Resident #33 (R33) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R33 admitted to the facility on [DATE] with pertinent diagnoses including anxiety and insomnia (sleep disorder characterized by difficulty falling or staying asleep). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R33 was cognitively intact (13 to 15 cognitively intact). During an interview on 9/8/2025 at 11:51 AM, R33 stated that 3rd shift CNAs talk outside in the hall and are very loud and it disrupts his sleep. Review of Resident Council meeting notes dated 4/8/2025 revealed New business. night shift slamming doors. Review of Resident Council meeting notes dated 5/6/2025 revealed New business.3rd shift is slamming doors again. Review of Resident Council meeting notes dated 6/3/2025 revealed New business: 3rd shift slamming doors. During an interview on 9/9/2025 at 10:36 AM, Activity Director (AD) II said that she fills out any concern forms from resident council and gives them to Nursing Home Administrator (NHA) A to follow up on. During an interview on 9/9/2025 at 11:59 AM, NHA A stated that they are working hard on following up with concerns and looking at trends in their QAPI (Quality Assurance and Performance Improvement) meetings. NHA A said there were a few complaints about the noise levels a few months ago and he just received another concern form that morning regarding the noise levels on 3rd shift. Resident #79 Review of an admission Record revealed Resident #79 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: adjustment disorder and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #79, with a reference date of 7/29/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #79 was cognitively intact. In an interview on 9/8/25 at 9:45 AM., Resident #79 reported the staff was very loud during the night. Resident #79 reported it sounded like staff gathered outside of her door and talked and laughed while she was trying to sleep. Resident #79 reported she had difficulty sleeping and when the staff was loud at night, it made it harder. Resident #79 expressed that she was very tired this morning from being kept up last night because the staff was loud. Review of Care Plan for Resident #79 revealed Need/Goal/Interventions: . has alteration in sleeping pattern r/t (related to) dx (diagnosis) of insomnia (difficulty sleeping or staying asleep) . will obtain optimal amount of sleep.Attempt non-pharmacologic interventions to improve sleep patterns (Specify: create a quiet environment, comfortable temperatures.) With an initiated date of 1/24/2025. In an interview on 9/9/25 at 8:04 AM., Resident #79 reported she was woken up and kept up last night with the staff talking at the nurse's station again. Resident #79 reported it sounded like the staff was talking right outside of her door, it was very loud. It was noted that Resident #79's room was the closest room to the nurse's station. In an interview on 9/9/25 at 11:44 AM., Physical Therapy Assistant (PTA) VV reported Resident #79 had voiced concerns with staff being loud overnight and making it difficult for her to sleep. Resident #20 Review of an admission Record revealed Resident #20 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: obstructive sleep apnea (episodes of obstruction of the airway during sleep resulting in reduced or absent breathing), joint replacement surgery, and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 8/7/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #20 was cognitively intact. In an interview on 9/8/25 at 9:56 AM., Resident #20 reported third shift (staff) did not have consideration for the residents and they were loud. Resident #20 reported she heard the staff when they were talking and laughing at the nurse's station, and it woke her up. Resident #20 reported she was furious and told the staff to shut up. Resident #20 reported she told PTA VV about how loud the staff was during the night. In an interview on 9/9/25 at 11:44 AM., PTA VV reported Resident #20 had told her that the staff was loud at night and they kept her up. PTA VV reported she told Director of Rehab (DOR) WW and Social Services (SS) PP about Resident #20's complaint regarding the staff being too loud on third shift. In an interview on 9/9/25 at 11:55 AM., DOR WW reported PTA VV did inform her of Resident #20's concern regarding noisy staff and she informed the other managers. Review of Guest Assistance Form for Resident #20 dated 9/8/25 revealed .Sunday 9/7 A.M. Approximately 5 AM staff @ (at) nurses' station were laughing & carrying on loudly & woke me up. In an interview on 9/9/25 at 3:36 PM., SS PP reported she has handled noise complaints in the past for facility residents. SS PP reported interventions she had used were to provide residents with ear plugs, closing doors, room moves, and education of staff to keep the noise levels down. SS PP reported she was not aware of any current noise concerns from any residents.

Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record in 7 of 18 residents (Resident #47, #10, #69, #54, #9, #18, & #63) reviewed for comprehensive/accurate medical records, resulting in missing/inaccurate documentation and the potential for a deterioration in resident status. Findings include:Resident #47: Review of an admission Record revealed Resident #47 was a male with pertinent diagnoses which included Alzheimer's disease, dementia, psychotic disorder with hallucinations (mental illness causing a person to lose touch with reality, often perceiving this that aren't there), insomnia, altered mental status, and anxiety. Review of current Care Plan for Resident #47, revised on 6/2/25, revealed the focus, .(Resident #47) has a behavior program related to dementia diagnosis, history of hallucinations and delusions, has poor safety awareness, needs assistance with redirection at times . with the intervention .Assist resident to develop more appropriate methods of coping and interacting. Encourage resident to express feelings appropriately .Minimize potential for resident's disruptive behaviors by offering tasks which divert attention such as busy boards and snacks . Review of Resident #47's medical record from the period of 7/23/25 to 9/3/25 revealed multiple instances of undocumented observations of Resident #47 when he was assigned to be on one-to-one monitoring. On the dates, 7/25/25 - 7/26/25 the complete documentation for both days was missing from the record. In an interview on 09/10/2025 at 12:41 PM, Certified Nursing Assistant (CNA) GG reported it was important to complete the documentation for a one to one as the staff were assigned due to safety reasons to keep an eye on the resident. CNA GG reported you have to document and initial every 15 minutes on where the resident was located. In an interview on 09/10/2025 at 12:47 PM, Licensed Practical Nure (LPN) L reported when a resident was on one-to-one documentation it was the responsibility of the nurse to ensure the resident was being monitored and the nurse signed the document showing it was reviewed and completed. LPN L reported she maintained the 15-minute checklist with her at the cart or at the nurse's station. LPN L reported she was always walking up and down the hallways to deliver her medications or provide treatments and she would monitor residents as well. LPN L reported the report would need to be completed by the CNA assigned to him for that shift, by a CNA who monitored him while their CNA was on a break and by the nurse on the hallway. In an interview on 09/10/2025 at 1:01 PM, Director of Nursing (DON) B reported there should be no missing documentation for the 15-minute checklist and the nurse assigned to that resident should be double checking to ensure the staff were monitoring the resident and completing the checklist. DON B reported if the document was missing entries the facility can't ensure the resident's safety as not sure if the resident was monitored or was able to elope or had a fall. Review of Staff Meeting Script: Emphasizing Reporting and Documentation dated 5/30/25, revealed, .5. One to One Supervision: Purpose: The purpose of implementing one on one safety precautions is to ensure the safety of residents under our direct supervision. This involves preventing residents from making contact with or causing harm to others, as well as ensuring that they are not permitted to self-harm .Procedure: A resident will be assigned to a specific nursing staff member who will remain in proximity to the patient at all times. Documentation on the special precautions and observation log will be done every 15 minutes . Resident #10 Review of an admission Record revealed Resident #10 was a male, with pertinent diagnoses which included a stroke with left sided hemiplegia (paralysis), anxiety, major depression, chronic pain, and a stage 3 sacral pressure ulcer. Review of a Minimum Data Set (MDS) assessment for Resident #10, with a reference date of 8/15/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated he was cognitively intact. In an interview on 9/8/25 at 2:56 PM, Resident #10 reported his wound treatments were supposed to be changed by staff twice a day but were .not always . completed as ordered. Review of the Treatment Administration Record (TAR) for Resident #10, for September 2025, revealed the ordered treatment Apply zinc oxide to sacrum BID (twice a day) and prn (as needed) if incontinent two times a day for prevention/protection . had 2 missed entries (no documentation) for the scheduled treatments on 9/4/25 at 8:00 PM and 9/6/25 at 8:00 PM. Review of the Treatment Administration Record (TAR) for Resident #10, for September 2025, revealed the ordered treatment Cleanse (sacrococcygeal) wound with normal saline. Cover wound bed with (MediHoney) and collagen, cover with foam border dressing. Change BID and prn as (Resident #10) allows for soiling or dislodgement every day and night shift for treatment . had 6 missed entries (no documentation) for the scheduled treatments on 9/1/25 (AM and PM), 9/2/25 (PM), 9/4/25 (AM and PM), and 9/7/25 (PM). Review of the Treatment Administration Record (TAR) for Resident #10, for September 2025, revealed the ordered treatment L (left) Scapula: Cleanse with NS (normal saline), pat dry gently and apply Optilock (dressing) or superabsorber (dressing). change BID and PRN as (Resident #10) allows when soiled or dislodged, encourage use of roho cushion (an air-filled cushion that provides pressure relief) every day and night shift for Wound care . had 6 missed entries (no documentation) for the scheduled treatments on 9/1/25 (AM and PM), 9/2/25 (PM), 9/4/25 (AM and PM), and 9/7/25 (PM). Review of the Treatment Administration Record (TAR) for Resident #10, for August 2025, revealed the ordered treatment Apply zinc oxide to sacrum BID and prn if incontinent two times a day for prevention/protection . had 7 missed entries (no documentation) for the scheduled treatments on 8/23/25 at 8:00 AM and 8:00 PM, 8/24/25 at 8:00 AM and 8:00 PM, 8/26/25 at 8:00 AM, 8/27/25 at 8:00 PM, and 8/29/25 at 8:00 PM. Review of the Treatment Administration Record (TAR) for Resident #10, for August 2025, revealed the ordered treatment Cleanse (sacrococcygeal) wound with normal saline. Cover wound bed with (MediHoney) and collagen, cover with foam border dressing. Change BID and prn as (Resident #10) allows for soiling or dislodgement every day and night shift for treatment . had 10 missed entries (no documentation) for the scheduled treatments on 8/14/25 (PM), 8/17/25 (AM), 8/19/25 (PM), 8/23/25 (AM and PM), 8/24/25 (AM and PM), 8/26/25 (AM), 8/27/25 (PM), and 8/29/25 (PM). Review of the Treatment Administration Record (TAR) for Resident #10, for August 2025, revealed the ordered treatment L Scapula: Cleanse with NS, pat dry gently and apply Optilock (dressing) or superabsorber (dressing). change BID and PRN as (Resident #10) allows when soiled or dislodged, encourage use of roho cushion every day and night shift for Wound care . had 11 missed entries (no documentation) for the scheduled treatments on 8/14/25 (PM), 8/17/25 (AM), 8/19/25 (PM), 8/22/25 (AM), 8/23/25 (AM and PM), 8/24/25 (AM and PM), 8/26/25 (AM), 8/27/25 (PM), and 8/29/25 (PM). In an interview on 9/10/25 at 9:35 AM, Registered Nurse (RN) H reported Resident #10 was very particular with his care and who he would allow to complete wound treatments, often refusing ordered dressing changes. RN H reported his treatments were changed to twice a day in an attempt to increase compliance. RN H reported treatment refusals should be documented in the treatment record. In an interview on 9/10/25 at 1:07 PM, Unit Manager C reported Resident #10 often refused to allow nursing staff to complete his ordered wound treatments. Unit Manager C reported these refusals should be documented in the treatment record. Resident #69(R69) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R69's initial admission date to the facility was on 7/1/2020 with pertinent diagnoses including depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 11 out of 15 which indicated R69 had moderate cognitive impairment (8-12 moderate cognitive impairment). During an interview on 9/8/2025 at 11:15 AM, R69 was lying in bed and was unable to communicate clearly whether he had been receiving showers. Review of R69's shower schedule revealed he receives showers 2 times a week on Wednesdays and Saturdays in the afternoon. Review of R69's shower/bath 30-day lookback revealed that R69 refused 2 showers/baths and had 2 shower/baths. From 8/23/2025 to 9/6/2025 there was no documentation regarding if a shower had been given or refused. During an interview on 9/9/2025 at 3:14 PM, Licensed Practical Nurse (LPN) J that Certified Nursing Assistants (CNAs) should let the nurse know when a shower refusal occurs and document it. During an interview on 9/9/2025 at 3:20 PM, CNA U stated that R69 tends to refuse showers and likes a bed bath better. CNA U said that CNAs should document refusals. During an interview on 9/9/2025 at 4:41 PM, Director of Nursing (DON) B stated that CNAs use the electronic medical record to document showers/bed baths and refusals. When discussing R69's showers/bed baths, DON B said that R69 prefers a bed bath and she knew he had one between 8/23/2025 to 9/6/2025 but it wasn't documented. Resident #54 (R54) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R54 admitted to the facility on [DATE] with pertinent diagnoses including paraplegia (loss of motor and sensory functions in both lower limbs) and insomnia (sleep disorder characterized by difficulty falling or staying asleep). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R54 was cognitively intact (13 to 15 cognitively intact). During an interview on 9/9/2025 at 8:06 AM, R54 revealed that the CNAs don't try hard enough to give shower/bed baths and if he isn't in his room they don't come back and give him a shower later that day. Review of R54's shower schedule revealed he receives showers 2 times a week on Mondays and Thursdays in the afternoon. Review of R54's shower/bath lookback since admission on [DATE] revealed that he had 1 refusal and 1 day where he wasn't available. There were 2 days with no documentation. During an interview on 9/9/2025 at 3:14 PM, LPN J stated that CNAs should let the nurse know when a shower refusal occurs and document it. During an interview on 9/9/2025 at 3:20 PM, CNA U stated that R54 refuses a shower/bed bath at times and said that CNAs should document refusals. During an interview on 9/9/2025 at 4:41 PM, Director of Nursing (DON) B stated that CNAs use the electronic medical record to document showers/bed baths and refusals. When discussing R54, DON B said that she knows that R54 had received bed baths since admission but it wasn't documented. Resident #9 (R9) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R9's initial admission to the facility was 7/30/2018 and currently has pertinent diagnoses including hemiplegia and hemiparesis following cerebrovascular accident affecting right dominant side (paralysis on right side of body that can affect the arms, legs and facial muscles), insomnia (sleep disorder characterized by difficulty falling or staying asleep) and aphasia (difficulty communicating) . Brief Interview for Mental Status (BIMS) reflected a score of 8 out of 15 which indicated R9 had moderate cognitive impairment (8-12 moderate cognitive impairment). During an interview on 9/8/2025 at 12:26 PM, Family Member RR stated that R9 had eloped (leaving the facility without staff knowledge) from the facility a few times and he had a wander guard on after the first incident which she was happy about. Review of R9's current physician orders revealed that there was no order for the wander guard. Review of R9's July physician orders revealed Confirm placement of wander guard on resident wheelchair every shift, d/c date (discharge date -end date) 7/7/2025. Review of R18's care plan revealed (R9) is at risk for exit seeking and/or wandering. interventions: check for wander guard placement and functioning. Wander guard is located under his wheelchair due to resident removing the wander guard upon several attempts to place on his person. Date initiated 9/19/2024. Review of the Risk for Elopement form dated 7/18/2025 revealed a score of 13 which indicated R9 was at risk for elopement due to his history of trying to leave the facility. During an interview on 9/10/2025 at 7:54 AM, CNA O stated that she didn't think R9 had a wander guard on but they have been doing 15-minute checks on him. During an observation and interview on 9/10/2025 at 8:01 AM, LPN L showed this surveyor the wander guard underneath R9's wheelchair and stated that she checks the wander guard every shift she works and said there should be a physician order for it. When LPN L looked for the physician order in the chart, she couldn't find one and said that she knows to check for it even without the order since there used to be an order in R18's chart. LPN L said it probably wasn't put back in when he came back from the hospital in July. During an interview on 9/10/2025 at 10:21 AM, Social Services (SS) PP stated that R9 had a wander guard on due to his history of elopement and a physician order should be placed in the chart. During an interview on 9/10/2025 at 10:29 AM, DON B stated that R9 was doing better after signing onto Hospice in July and was coming out of his room more now. DON B said that wander guards are checked by nursing every shift and a physician order should be in the chart so the nursing staff know to look for it. DON B said that R9 went to the hospital in July and came back and was put on Hospice so the order must have been missed. DON B stated the physician order was just put in by LPN L that day and said, sorry it was missed. Resident #18 (R18) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R18's initial admission date to the facility was on 5/15/2020 with pertinent diagnoses including quadriplegia (loss of motor and sensory functions in all extremities), contracture of left and right elbow and contracture of left and right hand. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R18 was cognitively intact (13 to 15 cognitively intact). During an observation and interview on 9/8/2025 at 11:27 AM, R18 stated that he wants to have his splints put on after the CNAs stretch and do range of motion with him. He said they aren't putting the splints on. It was observed that both wrists were bent at a 90-degree angle. It was observed that R18 didn't have splints on during conversation.Further observations on 9/9/2025 and 9/10/2025, R18 did not have the splints on in the morning. Review of physician orders revealed (L) left elbow and (B) bilateral hand splints to be worn daily up to four hours as tolerated by resident in the morning for Restorative. Start date 3/18/2025. Review of R18's care plan revealed (R18) is at risk for a contracture development r/t (related to) spinal cord injury: C1 (fracture of the 1st cervical vertebrae) level of cervical spinal cord injury, contractures of bilateral hands and elbows. Date initiated 8/16/2022.interventions: L (left) elbow splints to be on for four hours daily as patient allows. Date initiated 9/18/2023. Review of R18's Kardex (CNAs follow it and it has resident specific information for all care areas on it) revealed Dressing/Splint Care: bilateral wrist, elbow splints to be on for 4 hours daily as patient allows. Review of August 2025 Treatment Administration Record (TAR) revealed (L) left elbow and (B) bilateral hand splints to be worn daily up to four hours as tolerated by resident in the morning for Restorative. Start date 3/18/2025. Hours 0600. There was no documentation for 4 days, 1 refusal and the other days had check marks indicating he wore it. Review of September 2025 TAR revealed (L) left elbow and (B) bilateral hand splints to be worn daily up to four hours as tolerated by resident in the morning for Restorative. Start date 3/18/2025. Hours 0600. From 9/1/2025 to 9/10/2025, 9/3/2025 had no documentation, 1 day had a refusal and the other days had check marks indicating he wore it. On 9/10/2025 R18 was documented as wearing the splint by LPN L. During an interview on 9/9/2025 at 4:11 PM, LPN L stated that R18 refuses to have the splint put on since it's painful for him. During an interview on 9/10/2025 at 7:55 AM, CNA O said she hadn't put the splint on R18 before but she said he doesn't have it on very often. During another interview on 9/10/2025 at 7:59 AM, LPN L was asked why she already marked R18 as wearing the splint and she stated that the CNAs would try to put it on later. During an interview on 9/10/2025 at 8:10 AM, Director of Therapy (DOR) AAA stated that therapy worked with R18 and the CNAs to make sure the splint was put on properly. DOR AAA said that R18 refuses to wear the splints at times. During an interview on 9/10/2025 at 10:48 A, CNA AA stated that R18 refuses to wear splints quite often. During an interview on 9/10/2025 at 10:37 AM, DON B stated that R18 refuses to have the splint put on. When asked about the documentation for the splints, DON B said that a 2 should be indicated when R18 refuses and a check mark means that he wore it. When looking at the documentation for 9/10/2025, DON B questioned why LPN L marked that R18 wore the splints when he didn't. Resident #63 Review of an admission Record revealed Resident #63 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left side weakness and paralysis following a stroke), contracture (shortening and hardening of muscles, tendons, or other tissues often leading to restricted joint mobility) left hand, and acquired absence of right toes (surgical removal of the toes). On 9/8/25 at 12:30 PM., Resident #63 was observed sitting in a wheelchair in her room, noted contracture of her left hand, no orthotic device was noted in her left hand. Orthosis/split (the shape of a carrot) device noted on top of the dresser in the corner of the room. Review of Order Summary for Resident #63 revealed (L) (left) Hand orthosis with Air Bladder donned with AM care, doffed with PM care as tolerated by pt. Skin to be monitored pre and post application for redness, skin break down and/or irritation. One time a day for place on resident with a start date of 8/7/2025. Review of Care Plan for Resident #63 revealed Need/Goal/Interventions: .is at risk for contracture development.will not develop any contractures.apply left hand air bladder as resident tolerates.initiated on 8/6/2025. In an interview on 9/8/25 at 2:12 PM., Certified Nurse Assistant (CNA) Z reported Resident #63 had a carrot for her left hand but she refused to wear it. CNA Z reported Resident #63 had not worn her carrot in a long time. CNA Z stated no means no; I can't put her carrot in her hand if she doesn't want me to. CNA Z reported she has not applied Resident #63's carrot in weeks. CNA Z reported there was no way for her to document when Resident #63 refused. On 9/9/2025 at 9:11 AM., 11:38 AM., and 3:12 PM, Resident #63's left hand orthosis with air bladder (carrot) was not in place in her left hand. Orthosis/split (the shape of a carrot) device noted on top of the dresser in the corner of the room. Review of Treatment Administration Record (TAR) for Resident #63 for the months of August and September 2025 revealed (L) Hand orthosis with Air Bladder donned with AM care, doffed with PM care as tolerated by pt. with blank/missing documentation for 8/24/25, 9/1/2025 and 9/3/2025; all other days from 8/7/2025 to 9/9/2025 had documentation of Resident #63 having her left hand orthosis (carrot) in place each day. In an interview on 9/9/25 at 4:40 PM., Registered Nurse (RN) G reported Resident #63 had a carrot for her left hand but did not like to wear it. RN G reported the nurse was responsible for documenting the carrot being in Resident #63's left hand. RN G reported she could document Resident #63's refusal to wear her carrot as a progress note or in the TAR. RN G reported she documented Resident #63's refusal to wear her carrot this shift after this surveyor asked if she was wearing it. In an interview on 9/10/25 at 9:17 AM., Director of Nursing (DON) B reported her expectations when a resident refused something was that staff circled back to try again and all refusals should be documented by the nurse. DON B reported documentation was a problem she was aware of. DON B reviewed Resident #63's TAR for the month of September 2025 and reported the blanks/missing documentation indicated something wasn't done, and the check mark indicated it was done. DON B confirmed the documentation for Resident #63's left-hand orthosis indicted it was applied every day between 8/7/25 and 9/9/25 except for 8/24/25, 9/1/25, and 9/3/25 which had no documentation noted. In an interview and observation on 9/10/25 at 9:28 AM., Resident #63 was in bed and did not have her left-hand orthosis in place. DON B verbalized confirmation that Resident #63 did not have her left-hand orthosis in place and was unable to locate it in the room. Review of Resident #63's medical record revealed no additional noted documentation of refusals to wear left-hand orthosis.

Based on observation, interview, and record review the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 9/8/25 at 2:11 PM, Observation of the central supply room found numerous items stored on the floor and underneath the storage racks. These items were personal hygiene products and care items for residents such as gauze and oxygen supplies. On 9/8/25 at 2:21 PM, Observation of the [NAME] Hall spa room found used gloves, a used razor, and a dozen used plastic razor guards, spread on the floor. Further review of the spa room found the underside of the shower bed with excess accumulation of what appeared to be, skin flakes, hair, bowel movement, and dirt debris. When asked about the shower bed Maintenance Director (MD) CCC, shook his head. On 9/8/25 at 2:40 PM, Observation of the Birch Hall spa room found eight washcloths laid out next to the sink. Further review found the shower call light cord was brown and black in sections with visible accumulation. Upon testing the call light in the shower area, it did not activate the call light or audible response in the hall when triggered. On 9/8/25 at 9:45 AM., the over the bed table in room [ROOM NUMBER] on the west hall was observed to be soiled with a spilled substance that was dry and appeared sticky. The floor was observed to be soiled with dirt, crumbs, brown spillage, and had visible trash present under and around the bed. On 9/8/25 at 9:56 AM, the floor in room [ROOM NUMBER] on the west hall was observed to be soiled with dirt, debris and had visible trash present on the floor. In an interview on 9/8/25 at 2:17 PM., Housekeeping Aide (HA) NN reported the facility was short a housekeeper and there was no one cleaning on the west hall. HA NN reported he was pulled to clean rooms after he finished cleaning the floors of the building. HA NN reported there were two full time and two part time housekeepers. HA NN reported the job he was hired for was floor technician. HA NN reported he would be able to clean about 3-4 rooms on the west hall before his shift ended. In an interview on 9/8/25 at 2:28 PM., HA NN reported there should be a housekeeper for each hall, but they do not have that kind of staff present. HA NN reported when they were short staffed the resident rooms only got the highlights of cleaning done. HA NN explained that got the highlights meant the housekeepers really only did the tables, and the trash unless there was visible soiled spot, then they would do that, but if the room looked clean, they don't worry about it. Only four rooms on the west hall were observed being cleaned on 9/8/2025. On 9/9/25 at 8:04 AM., the over the bed table in room [ROOM NUMBER] on the west hall was observed to be soiled with a spilled substance that was dry and appeared sticky. The floor was observed to be soiled with dirt, crumbs, spillage brown in color, and had visible trash present under and around the bed. On 9/9/25 at 8:15 AM, the floor in room [ROOM NUMBER] on the west hall was observed to be soiled with dirt, debris and had visible trash present on the floor. On 9/9/25 at 8:47 AM., there was observed light brown in color dried liquid spots on the floor beginning near the nurse's station and continuing ¾ of the way down the skilled hallway. In an interview on 9/9/25 at 10:53 AM., HA NN reported there were two housekeepers who called into work today and he was pulled to housekeeping to clean rooms instead of cleaning the floors. HA NN reported he was assigned all the rooms on the west hall and half of the rooms on the skilled hall to clean that shift. HA NN reported he would start with the rooms he did not get done yesterday and get as many done as he could. HA NN reported he was unsure if he would have time to do the floor of the building this shift. In an interview on 9/9/25 at 1:34 PM., Housekeeping Director (HD) QQ reported she was the interim housekeeping director, and she took over July 19, 2025. HD QQ reported she was the scheduler and was covering for payroll this week too. HD QQ reported every room should be cleaned daily and one or two rooms were scheduled for a deep clean daily. HD QQ reported a routine daily clean should include sweep and mop the floor, sanitize all the high touch surface areas, remove trash and clean the bathroom. HD QQ reported a deep clean included everything done daily and dusting, move the bed and clean the bed frame and mattress, the nightstand inside and out, and change the privacy curtain. HD QQ reported she rounded to check the deep cleaned rooms were completed. HD QQ reported she did not check the assigned deep cleaned rooms from yesterday, but she knew they did not get done. HD QQ reported the scheduled deep clean rooms were rescheduled for this upcoming weekend. HD QQ reported there were two call ins this morning, and there was no one to cover for them missing housekeepers other than HA NN. HD QQ confirmed that there was no housekeeper on the west hall yesterday and most of the rooms did not get cleaned as scheduled. In an interview on 9/9/25 at 1:57 PM., Nursing Home Administrator (NHA) A reported there was a problem with housekeeping and the facility had been without a director since March 2025. NHA A reported HD QQ had in the past taken to the floor to fill in and clean, but HD QQ did not do that yesterday. On 9/9/25 at 3:15 PM., NHA A reported he had instructed his management staff to assist with housekeeping in the facility. On 9/9/25 at 3:30 PM., HA NN reported he had cleaned 12 rooms today and had been told he was put on approved overtime to complete the cleaning of the remaining rooms. Review of Resident Council meeting notes dated 4/8/2025 revealed New business. room [ROOM NUMBER] is not getting cleaned. Review of Resident Council meeting notes dated 5/6/2025 revealed New business. Rooms are not being cleaned on a regular basis. Review of Resident Council meeting notes dated 6/3/2025 revealed .West Hall rooms not being cleaned regularly. Review of Resident Council meeting notes dated 8/5/2025 revealed Old business: Housekeeping.not mopping everytime or changing the trash everytime.

Based on observation and interviews, the facility failed to store trash and refuse containers covered and in a manner that maintains the area to prevent the harborage or feeding of pests.On 9/8/25 at 1:52 PM, Observation of the outside dumpsters, with Maintenance Director (MD) CCC, found the doors pushed open allowing for pests and precipitation to enter. An interview with MD CCC found that staff have a hard time tossing bags of trash into the dumpster unless the doors are opened. Further review of the dumpster area found excess trash, used gloves, and debris on the inside perimeter of the garbage area.

Based on observation, interview, and record review the facility failed to 1). develop a person-centered care plan for 1 resident (Resident #7) and 2). implement person-centered care plan interventions for 1 resident (Resident #63) of 18 residents reviewed for person-centered care plan development and intervention implementation, resulting in Resident #7 not having a care plan related to hospice services in place and Resident #63 having increased risk for skin breakdown due to not wearing prevalon boot (prevalon pressure-relieving heel protector boot designed to minimize pressure, friction, and shear on the feet, heels, and ankles of non-ambulatory (non-walking) patients). Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 1: Resident Assessment Instrument (RAI), revealed .The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that.(1) the assessment accurately reflects the resident's status.(2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals.(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. Resident #7: Review of an admission Record revealed Resident #7 was a male with pertinent diagnoses which included kidney disease, dementia, high blood pressure, prostate cancer, blocked and narrowed carotid artery (major arteries that run on either side of the neck supplying blood to the brain, face, and scalp), legal blindness and hearing loss. During an observation and interview on 09/08/2025 at 1:03 PM, Resident #7 was observed seated in his reclined Geri-chair across from the nurse's station along the wall to the dining room. CNA asked Resident #7 if he would like a shower and he replied he did. In an interview she indicated she was Hospice CNA BBB and had a trainee with her. Hospice CNA BBB reported she came to the facility a couple times a week to see Resident #7. Review of the medical record revealed there was no care plan for Resident #7 for Hospice services. In an interview on 09/10/2025 9:29 AM, MDS Coordinator E reviewed Resident #7's medical record and reported when an MDS was completed for hospice it would generate the care plan for hospice services. This had not yet been done. Resident #63 Review of an admission Record revealed Resident #63 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left side weakness and paralysis following a stroke), contracture (shortening and hardening of muscles, tendons, or other tissues often leading to restricted joint mobility) left hand, and acquired absence of right toes (surgical removal of the toes). On 9/8/25 at 12:30 PM., Resident #63 was observed sitting in a Broda wheelchair (specialized wheelchair with a high back, tilt -in-space positioning and comfortable for long-term sitting) in her room with her bare skin of her feet/legs resting directly against the wheelchair. Review of Order Summary for Resident #63 revealed Encourage (Resident #63) to wear pervalon boot to the left foot to off load pressure while in bed with a start date of 1/7/2024 and (L) (Left) Pressure Relief Ankle Foot Orthotics on with AM care and of with PM care, as patient allows with a start date of 8/27/2024. Review of Care Plan for Resident #63 revealed Need/Goal/Interventions: .is at risk for impaired skin integrity.will minimize risk in an effort to reduce likelihood of pressure injury development.left prevalon boot as tolerated initiated on 6/25/2024. In an interview on 9/8/25 at 2:12 PM., Certified Nurse Assistant (CNA) Z reported Resident #63 had a boot in the past for her left foot, but it was missing, and she did not wear it anymore. CNA Z reported that Resident #63 refused to wear her boot most of the time. CNA Z stated no means no; I can't force her to wear a boot she doesn't want to wear. CNA Z reported there was no way for her to document when a resident refused an assistive device, such as a prevalon boot. In an interview on 9/9/25 at 11:57 AM., Physical Therapist (PT) XX reported therapy recommended a soft boot for Resident #63 to protect her ankle from skin breakdown due to her continued crossing of her ankle over her leg. In an interview on 9/9/25 at 3:12 PM., CNA S reported she was not aware of any boot that Resident #63 should wear. During an observation on 9/9/25 at 3:21 PM., Resident #63 was in bed with her heel/feet/legs resting directly on the mattress. No prevalon boot was observed on Resident #63. The prevalon boot, light blue in color was observed in Resident #63's room closet, at the bottom, with other personal clothing items on top of it. During an observation on 9/10/2025 at 8:22 AM., Resident #63 was in bed with her heel/feet/legs resting directly on the mattress. No prevalon boot was observed on Resident #63. In an interview on 9/10/25 at 8:22 AM., CNA BB reported Resident #63 did not like to wear her boots and would refuse to wear them. In an interview on 9/10/25 at 9:17 AM., Director of Nursing (DON) B reported her expectations were that residents should wear any assistive devices ordered for them. DON B reported when a resident refused, her expectations were that staff circled back to try again and all refusals should be documented by the nurse. In an interview and observation on 9/10/25 at 9:28 AM., Resident #63 was in bed and not wearing a prevalon boot. DON B verbalized confirmation that Resident #63 did not have prevalon boot in place. Review of Resident #63's medical record revealed no noted documentation of refusals to wear prevalon boots.

Based on observation, interview, and record review the facility failed to ensure an orthosis device (a device designed to prevent or prevent the worsening of contractures (the shortening and hardening of muscles, tendons, or other tissues often leading to restricted joint mobility) was used as ordered in 1 (Resident #63) of 2 residents reviewed for mobility resulting in the potential for the worsening of contracture of Resident #63's left hand.Findings include:Resident #63Review of an admission Record revealed Resident #63 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left side weakness and paralysis following a stroke), contracture (shortening and hardening of muscles, tendons, or other tissues often leading to restricted joint mobility) left hand, and acquired absence of right toes (surgical removal of the toes). Review of a Minimum Data Set (MDS) assessment for Resident #63, with a reference date of 8/20/2025 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #63 was moderately cognitively impaired (BIMS score 8-12 indicates moderate cognitive impairment).Review of Order Summary for Resident #63 revealed (L) (left) Hand orthosis with Air Bladder donned with AM care, doffed with PM care as tolerated by pt. (patient) Skin to be monitored pre and post application for redness, skin break down and/or irritation. One time a day for place on resident with a start date of 8/7/2025.On 9/8/25 at 12:30 PM., Resident #63 was observed sitting in a wheelchair in her room, noted contracture of her left hand, no orthotic device was noted in her left hand. Orthosis/splint (the shape of a carrot) device noted on top of the dresser in the corner of the room.Review of Care Plan for Resident #63 revealed Need/Goal/Interventions: .is at risk for contracture development.will not develop any contractures.apply left hand air bladder as resident tolerates.initiated on 8/6/2025.In an interview on 9/8/25 at 2:12 PM., Certified Nurse Assistant (CNA) Z reported Resident #63 had a carrot for her left hand but she refused to wear it, and it had not been applied to Resident #63 left hand in weeks. CNA Z reported there was no way for her to document when Resident #63 refused.On 9/8/25 at 4:00 PM., Resident #63 was in bed, and no orthotic device was noted in her left hand.Review of the Treatment Administration Record (TAR) for Resident #63 for the months of August and September 2025 revealed (L) Hand orthosis with Air Bladder donned with AM care, doffed with PM care as tolerated by pt. with blank/missing documentation for 8/24/25, 9/1/2025 and 9/3/2025; all other days from 8/7/2025 to 9/9/2025 had documentation of Resident #63 having her left hand orthosis ( carrot) in place each day.During observations on 9/9/2025 at 9:11 AM., 11:38 AM., and 3:12 PM, Resident #63's left hand orthosis with air bladder ( carrot) was not in place in her left hand. Orthosis/split (the shape of a carrot) device noted on top of the dresser in the corner of the room.In an interview on 9/9/25 at 11:51 AM., Physical Therapy Assistant (PTA) VV reported Resident #63 had an air bladder orthosis device for her left hand. PTA VV reported nursing staff was responsible to apply Resident #63's orthosis.In an interview on 9/9/25 at 11:52 AM., Director of Rehab (DOR) WW reported Resident #63 was evaluated about a month ago for a split to try to lessen the contracture of her left hand. DOR WW reported the orthosis was referred to by the staff as a carrot due to the orthosis shape being like a carrot. DOR WW reported Resident #63's orthosis or carrot replaced a splint that was too painful for Resident #63 to tolerate.In an interview and observation on 9/9/25 at 3:12 PM., CNA S reported Resident #63 has a carrot for her left hand, but she was not wearing it. CNA S retrieved Resident #63's orthosis/splint ( carrot) from atop the dresser in Resident #63's room to demonstrate visualization to this surveyor.In an interview on 9/9/25 at 4:40 PM., Registered Nurse (RN) G reported Resident #63 had a carrot for her left hand and the nurse was responsible for verifying and documenting the carrot being in place in Resident #63's left hand. RN G reported she was able to document if Resident #63 refused to wear the carrot. RN G reported Resident #63 refused to wear her carrot today and she put in a progress note documenting Resident #63's refusal to wear her carrot. RN G reported she documented the refusal after this surveyor asked staff if she was wearing it. In an interview on 9/10/25 at 8:22 AM., CNA BB reported Resident #63 did not wear her carrot anymore.Further review of Resident #63's medical record revealed no additional noted documentation of refusals to wear left-hand orthosis/splint/carrot.In an interview on 9/10/25 at 9:17 AM., Director of Nursing (DON) B reported Resident #63 has a carrot for her left hand for her contracture and that she should be wearing it. DON B reported Resident #63 was a part of the restorative program; the program was new to the facility and part of the focus of the program was to prevent the worsening of contractures. DON B reported all the CNAs had been trained on restorative care with the training occurring in August 2024 and new hire staff being trained on restorative care during orientations. DON B reported the CNAs and nurses were responsible for the application of assistive devices such as Resident #63's carrot and nurses were responsible for charting regarding Residents wearing orthosis devices. DON B reported her expectations when a resident refused something was that staff circled back to try again and all refusals should be documented. DON B reported documentation was a problem she was aware of, and it was hard to get nurses to do their jobs. DON B reviewed Resident #63's TAR for the month of September 2025 and reported the blanks/missing documentation indicated something wasn't done, and the check mark indicated it was done. DON B confirmed the documentation for Resident #63's left-hand orthosis indicted it was applied every day between 8/7/25 and 9/9/25 except for 8/24/25, 9/1/25, and 9/3/25 which had no documentation noted. In an interview and observation on 9/10/25 at 9:28 AM., Resident #63 was in bed and did not have her carrot in her left hand. DON B verbalized confirmation that Resident #63 did not have her carrot in her left hand and DON B was unable to locate it in the room.Review of facility policy Restorative Nursing with a last revised date of 4/26/2024 revealed .A licensed nurse will help manage the restorative nursing process with assistance of nursing assistants trained in restorative care.3. Refer to specific restorative program procedures (s).Contracture Prevention and Management Program. 4. Determine resident willingness and ability to participate in a restorative program.5. If resident refuses to participate then care needs will be managed by nursing and other clinical staff.6. Document any refusals in the resident's medical record.

Based on interview and record review, the facility failed to track and offer the influenza and pneumococcal vaccines for 3 (Resident #9, #7, and #2) of 5 residents reviewed for immunizations, resulting in the failure to provide documentation of declination of immunizations and residents not being given the opportunity to receive or decline the influenza and/or pneumococcal vaccination. Findings include: According to the Centers for Disease Control and Prevention (CDC) PCV20 Vaccination for Adults 65 Years and Older dated 02/09/23, revealed, .Routine vaccination: Adults 65 years or older who have- Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose . www.cdc.gov/vaccines/hcp/admin/downloads/job-aid- SCDM-PCV20-508.pdf Resident #9:Review of an admission Record revealed Resident #9 was a male with pertinent diagnoses which included paralysis on his right side, stroke, seizures, asthma, and heart failure. During an observation and interview on 09/10/2025 at 10:46 AM, Infection Preventionist (IFP) D reviewed Resident #9's medical record, it revealed he was not offered the PCV 20 or PCV 15 in 2024 after he turned 65 and there was no signed consent or declination in the medical record. IFP D reported he should have been offered the PCV 20 then. IFP D reported Medical Records (MR) OO was preparing for the influenza season vaccinations and was creating packets to send out to the resident's representative. Resident #7: Review of an admission Record revealed Resident #7 was a male with pertinent diagnoses which included kidney disease, dementia, high blood pressure, prostate cancer, blocked and narrowed carotid artery (major arteries that run on either side of the neck supplying blood to the brain, face, and scalp). During an observation and interview on 09/10/2025 at 10:50 AM, IFP D reviewed Resident #7's medical record which revealed under immunizations Resident #7 had refused the PCV20 vaccine. IFP D reviewed the medical record and was unable to discover a signed declination in the record for the refusal. Resident #2: Review of an admission Record revealed Resident #2 was a male with pertinent diagnoses which included heart failure, kidney disease, respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), COPD, dependence on oxygen, diabetes, and stroke. During an observation and interview on 09/10/25 at 10:54 AM, IFP D reported Resident #2 refused the influenza and pneumococcal immunizations as documented in the medical record. IFP D reviewed Resident #2's medical record and a consent was located in the medical record dated 3/29/24 for him to receive the influenza vaccination. Resident #2 had not been immunized with the influenza vaccine per the medical record documentation.

Based on interview, and record review, the facility failed to address/implement dietitian recommendations for nutritional supplements in 1 of 7 residents (Resident #10) reviewed for nutrition, resulting in the potential for impaired wound healing. Findings include:Resident #10 Review of an admission Record revealed Resident #10 was a male, with pertinent diagnoses which included a stroke with left sided hemiplegia (paralysis), anxiety, major depression, chronic pain, and a stage 3 sacral pressure ulcer. Review of a current Care Plan Report for Resident #10 revealed the need (Resident #10) is at risk for alteration in nutrition and fluid status r/t (related to) Stage 3 skin pressure area, depression, anxiety . revised 8/17/25, with interventions which included Request Vitamin C, zinc to promote healing initiated 7/24/25. Review of a Nutritional Re-Evaluation assessment for Resident #10, dated 2/25/25, revealed .Resident with varied intake between 50-100% at meals. Resident doesn't always eat meals served and has his own frozen, prepackaged meals/snacks .Stage 3 pressure injury is reported (to be) deteriorating .recommend (vitamin) C and zinc supplementation .Nutrition Interventions .500 mg (milligrams) vitamin C daily x 10 days .Zinc Sulfate 220 mg x 10 days . Review of a Nutritional Evaluation assessment for Resident #10, dated 5/26/25, revealed .Resident has stage 3 pressure injury on sacrum and scapula .Nutrition Intervention .vitamin C 500 mg, and zinc sulfate 220 mg x 10 days to support micronutrient needs in wound healing . Review of a Nutritional Re-Evaluation assessment for Resident #10, dated 7/23/25, revealed .Stage 3 pressure injury is reported (to be) deteriorating .The previous RD (Registered Dietitian) recommended (vitamin) C and zinc supplementation. However, I see no order. Will request again .Nutrition Interventions .(Vitamin) C, zinc to assist with wound healing . Review of a Nutritional Re-Evaluation assessment for Resident #10, dated 8/17/25, revealed .Stage 3 pressure injury is reported (to be) deteriorating .The previous RD recommended (vitamin) C and zinc supplementation. However, I see no order. Will request again .Nutrition Interventions .Request (Vitamin) C, zinc to assist with wound healing . Review of an Order Summary Report for Resident #10 revealed no physician orders for Vitamin C or Zinc supplementation between February 2025 and September 2025. In an interview on 9/10/25 at 11:13 AM, Registered Dietitian (RD) SS reported she completed an evaluation of Resident #10's nutritional status in August 2025. RD SS reported she requested Vitamin C and Zinc to promote wound healing, and stated, I don't know if that was implemented yet . RD SS reported when she makes nutritional recommendations, she sends the list of recommendations to Director of Nursing (DON) B who then implements the recommendations. RD SS reported she is not sure why the recommendations from July 2025 to add Vitamin C and Zinc were not implemented for Resident #10. In an interview on 9/10/25 at 1:59 PM, DON B reported that when the RD completes nutritional assessments, she typically sends an email with a list of the recommendations and then will also ask for the orders to be put into the computer when she is onsite. DON B reported RD SS is new to the facility, and past RD's entered their own orders based on the dietary/nutritional recommendations. DON B stated in regard to the nutritional assessments completed in February 2025, May 2025, July 2025, and August 2025 and the lack of physician orders in the medical record related to Vitamin C and Zinc supplementation, .He (Resident #10) did not get the supplements that she had recommended .

This citation pertains to intake #MI00149391 Based on interview and record review the facility failed to ensure that residents were free from significant medication errors in 1 (Resident #100) of 2 residents reviewed for medication errors resulting in Resident #100 being transferred to an acute care hospital emergency room for treatment and admission to a medical intensive care unit. Findings include: Resident #100 Review of an Admission Record revealed Resident #100 had pertinent diagnoses which included: Cerebral infarction (Stroke), dysphagia (difficulty swallowing), acute respiratory failure with hypoxia (significantly difficult breathing, hypoxia- decreased oxygen in the body's blood) and pneumonitis due to inhalation of food and vomit (infection in the lungs related to inhaling food or vomit). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 1/5/2025 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated Resident #100 was severely cognitively impaired. Resident #102 - roommate of Resident #100 Review of an Admission Record revealed Resident #102 had pertinent diagnoses which included: Cerebral infarction (Stroke), abnormal posture, and pain. Review of Care Plan for Resident #100 revealed Need/Goal/Interventions/unable to tolerate nutritionally adequate food and/or fluids by mouth requiring the use of a feeding tube R/T (related to) dysphagia with G-tube (tube inserted into the stomach to be used for nutrition, hydration and medication administration) initiated 4/11/2023 .will remain free of side effects or complications related to tube feeding revised on 5/7/2024 .Will be free of aspiration (inhalation of food or fluid into the lungs) through the review date 5/7/24 . administer medications separately and flush between each medication 4/11/2023; administer tube feeding as ordered 4/11/2023; elevate the HOB (head of bed) 30 degrees while in bed 4/11/2023; observe for s/sx (signs and symptoms) of intolerance to the tube feeding such as Nausea, vomiting, abdominal discomfort, increased residual, abnormal lung sounds 4/11/2023; Observe/document/report to physician PRN (as needed) : Aspiration- fever. SOB (shortness of breath) tube dislodgement, infection at tube site, self extubation (removal of tube feeding) tube dysfunction, abnormal breath/lung sounds . initiated on 4/11/2023. Has a functional ability deficit and requires assistance with selfcare/mobility .total dependent in Broda chair (special high back padded wheelchair) for ambulation (movement) .bath shower total dependent, bed mobility total dependent, dressing total dependent, eating NPO (nothing by mouth) receives all nutrition and meds by peg tube (G-tube), total dependence 1/13/2025. Review of Medication Administration Record (MAR) for Resident #100 for January 2025 revealed Enteral Feed Order six times a day Bolus (a prescribed amount to be given at one time) tube feeding of 200 mL (milliliters) Jevity 1.5 for a total volume of 1200 mL daily/1800 kcal (calories) ordered at 0200 (2 am), 0600 (6 am), 1000 (10 am), 1400 (2 pm), 1800 (6 pm), and 2200 (10 pm). LPN O documented administration of bolus feeding for Resident #100 on 1/4/2025 at 2200 and 1/5/2025 at 0200. Review of Nurses Note for Resident #100 dated 1/5/25 at 8:18 PM authored by Licensed Practical Nurse (LPN) O revealed This nurse observed resident to be very drowsy with sound of increased secretions at hs (evening) med pass. VS (vital signs) obtained and were 96.9-(temperature)83-(pulse)14-(respirations)85/56-(blood pressure)92% RA (Pulse ox on room air) at this time. This nurse raised resident's head and repositioned resident upright in bed. Resident appeared to breathe easier. This nurse administered rx'd (prescribed) hs meds and feeding with no issues. This nurse continued to monitor resident. Upon doing next scheduled feeding, this nurse noticed increased congestion and decreased responsiveness at which vs were obtained and to be 97.5-116-28-124/84-65% RA. This nurse contacted provider for oxygen and nebulizer tx (treatment) orders. Oxygen @ (at) 2L via NC (nasal cannula) applied & O2 (oxygen) improved to 95%. This nurse contacted nurse on call. DON (Director of Nursing), on-call guardian after lvm (left voice mail) for assigned guardian. Provider gave orders to send resident for eval/tx of respiratory distress and unresponsiveness. On-call guardian gave okay to send to ER (emergency room ). Repeat vs after O2 administration and neb (nebulizer treatment) 97.5-115-32-96/67-91% via NC. EMS (emergency medical services) was called for transfer, paperwork prepared for EMS/hospital and monitored resident until EMS arrived. (Name Omitted) EMS transferred resident via stretcher out of facility to (Name Omitted) at 4:25 AM. Report called to (Name Omitted). Review of Compliance Summary provided by the facility revealed Details : Summary- (Name Omitted) ED physician stated on January 5, 2025, around 4:45 AM, (Resident #100) patient, had arrived at the emergency room for being unresponsive and having difficulty breathing. (Name Omitted) ED physician stated she had provided (Resident #100) with Narcan (an over-the counter medication that is used to treat opioid overdose) as if she had an opioid or narcotic overdose. (Name Omitted) ED physician stated after (Resident #100) was provided Narcan she made a full recovery. (Resident #100) received a drug test and tested positive for opioids. (Name Omitted) ED physician stated (Resident #100)'s medication chart does not say she was prescribed any opioid or narcotic medication. Review of ED Provider Notes for Resident #100 with a service date of 1/5/2025 at 5:08 AM., revealed .presenting for respiratory distress. Patient is somnolent (sleepy; drowsy) and not responding to any questions. Per EMS, the patient had worsening somnolence and respiratory distress since shift change last night. This acutely worsened with increased respiratory distress and hypoxia in the 60s (pulse ox readings, normal 88-100) around midnight. When they arrived, patient was gurgling and had copious secretions with concern for possible aspiration. At baseline, she has some aphasias (difficulty talking/forming words) but is able to complete conversations with simple short answers. After Narcan the patient is awake, alert, and answering limited questions. Review of MDM (Medical Decision Making) ED Notes for Resident #100 date of service 1/5/2025 at 7:46 AM., revealed .Patient was evaluated by respiratory therapy who recommended NP suctioning (Nasopharyngeal suctioning using the airway of the nose to suction secretions/phlegm). Patient was suctioned with copious (excessive) secretions. These looked creamy and white, similar to the tube feed in her G-tube . she also has pinpoint pupils and depressed respiratory status concerning for possible opiate overdose. Quick review of her medication list she does not have any opiate prescriptions. However, due to her clinical presentation, I did give her a dose of Narcan. She immediately became alert and responsive answering simple questions- confirming my suspicions of opiate overdose . UDS (urine drug screen) was positive for opiates and benzodiazepines .she has a prescription for lorazepam (a benzodiazepine) but does not have any opiate pain medications. This is very concerning as her somnolence and decreased respiratory drive likely contributed to her aspiration event and ultimately her respiratory distress . Of note, while awaiting hospitalist admission evaluation, the patient became more somnolent, hypotensive (low blood pressure) with decreased respiratory rate (slowed breathing). She was given an additional dose of Narcan with appropriate response. She had improvement of both her mentation as well as her blood pressure and respiratory status, so there is concern that she was possibly given a long-acting opiate . Narcan gtt (drip) initiated. Final diagnoses: hypoxia, opiate overdose, undetermined intent, aspiration pneumonitis. Review of Care Timeline for Resident #100 revealed 1/5/2025 admitted to (Name Omitted) medical intensive care unit from ED (emergency department) 0917 (9:17 AM). Review of Drug Screen 8 for Resident #100 dated 1/5/25 and 1/6/25, revealed urine collection at 5:21 am on 1/5/25 with results indicating opiate screen positive, detects morphine at concentration of 300 ng/mL (nanograms per milliliter) and higher. Urine collection at 7:41 am on 1/5/25 with results indicating opiate screen positive, detects morphine at concentration of 300ng/mL and higher. Urine collection at 13:26 (1:26 pm) on 1/6/25 with results indicating opiate screen positive, detects morphine at concentrations of 300ng/mL and higher. Review of Drug screen 8 for Resident #100 performed by additional non-local lab (Name Omitted) provided to the facility on [DATE] via fax revealed urine collection occurred on 1/5/2025 at 7:41 am. Opiate confirm urine, opiate interpretation positive, morphine count, 11,487 (normal range cutoff 25). Review of Physician Orders for Resident #100 reveal no order for an opioid narcotic, including morphine. In an interview on 1/27/25 9:58 Am., Resident #100 was sitting up in her Broda wheelchair, in her room, awake, and alert and able to answer simple questions. Resident #100 responded yes when queried about her recent hospital stay. Resident #100 did not provide any descriptions or details of her recent hospital stay. Resident #100 responded fine when she was asked how she was feeling. Resident #100 unable to continue to converse meaningfully with surveyor. In an interview on 1/27/25 at 10:01 LPN M reported Resident #100 was dependent on staff for all care and did not eat, drink or take any medications orally. Resident #100 received all her nutrition, hydration, and medications through her G-tube. LPN M reported Resident #100 was sent to the hospital on 1/5/25 for respiratory distress and unresponsiveness by the night shift nurse and Resident #100 was found to have a positive urine drug screen at the hospital. LPN M reported he cared for Resident #100 on Friday 1/3/25 and during his shift, she was at her baseline, alert, oriented to herself and responsive to conversations with one or two words. In an interview on 1/27/25 at 10:12 AM., LPN Q reported she did not directly care for Resident #100 prior to her transfer to the emergency department on 1/5/25. LPN Q reported Resident #100 was alert and oriented to herself and responded to conversations with one or two words and was confused at baseline. LPN Q reported Resident #100 could talk, not in complete sentences, but she could talk. In an interview on 1/27/25 at 10:24 AM., Registered Nurse (RN) K reported she cared for Resident #100 on 1/5/25, the shift prior to her transfer to the ED and did not recall anything out of the ordinary about Resident #100 that day. RN K reported that Resident #100 tested positive for opiates when she was in the hospital. RN K reported there was another resident, who used the same style Broda wheelchair as Resident #100, that did take opioid pain medications. RN K stated they (Resident #100 and the other resident) might even be in the same room. RN K reported DON B asked her if there was any way morphine concentrate could be mistaken as Tylenol. When queried, RN K reported that liquid Tylenol and morphine sulfate are similar in color. Review of Census for Resident #100 and Resident #102 revealed they were roommates on 1/5/2025. In an interview on 1/27/25 at 11:28 AM., Certified Nurse Assistant (CNA) E reported she was assigned to work with Resident #100 on 1/4/25 on the day shift. CNA E reported she recalled Resident #100 did not yell out for cares during that shift as she usually did. CNA E reported on first rounds and at 11:30 am when she went to provide care, Resident #100 was sleeping. CNA E reported at 11:30 am, Resident #100 was sleeping really hard. CNA E reported she had to do a sternal rub to wake Resident #100 up. CNA E reported when she provided care, Resident #100 was noodle like and limp when being turned or repositioned in the bed. CNA E reported she informed RN K who was Resident #100's assigned nurse that day, that Resident #100 was not herself and something was wrong. During an observation and interview on 1/27/25 at 11:38 AM., LPN M was observed preparing liquid acetaminophen, noted to be red in color for Resident #100. In a telephone interview on 1/28/25 at 8:25 AM LPN O reported she was the nurse who sent Resident #100 to the hospital on 1/5/25. LPN O reported Resident #100 was sleepy at the beginning of the shift which started at 6pm. LPN O reported when she administered Resident #100's evening medications, Tylenol and maybe another medication, Resident #100 was lethargic (drowsy) and not responding as she normally did. LPN O reported Resident #100 does not receive any narcotic medications during her shift. LPN O reported Resident #100 had a respiratory situation going on and she continued to decline during the shift. LPN O reported the reason Resident #100 was sent out to the hospital was for respiratory distress and unresponsiveness. LPN O reported she received the phone call from the ED, in the morning on 1/5/25, informing her that Resident #100 tested positive for opioids on a urine drug screen. LPN O confirmed that Resident #100 does not have any orders for, nor was she administered, opioid medications. LPN O was queried about possible medication error and LPN O stated I am not aware of any medication error I made. In a telephone interview on 1/28/25 at 10:01 AM., LPN J reported she was assigned to care for Resident #100 on 1/3/25 and Resident #100 was at her baseline; she responded, hi, when LPN J said hi to her before care. LPN J reported Resident #100 only gets Tylenol on my shift and that was given about 8:30 pm. LPN J stated DON B asked me if there was any way I had administered Resident #102's medication to Resident #100, I told her no. In an interview on 1/28/25 at 12:19 PM., DON B reported Resident #100 was transferred to the emergency roiagnom on [DATE] for respiratory distress and unresponsiveness. DON B reported she was included in a three-way phone call on the morning on 1/5/25 with the physician at the ED and the Nursing Home Administrator (NHA) A when she was made aware of Resident #100's signs and symptoms of a drug overdose and subsequent response to the administration of Narcan. DON B was made aware of Resident #100's positive urine drug screen in that phone call. DON B reported she requested a repeat urine drug screen test and DON B confirmed those test results were also positive and revealed significantly higher levels of concentrated morphine in Resident #100's system than the first test revealed. DON B reported she arrived at the facility on 1/5/25 and completed a full building narcotic count, and there were no discrepancies and no indication that the administration of an ordered narcotic medication to a resident was missed. When queried, DON B confirmed a narcotic medication administered to the wrong resident would not be reflected in the narcotic count. DON B confirmed Resident #100's urine drug screen was positive for the opioid morphine. DON B reported Resident #100's roommate (Resident #102) was administered two different types of morphine medications multiple times a day, and if Resident #102 had missed a dose of her scheduled morphine, it would have been reflected in her pain assessments. DON B reported she was unable to confirm that Resident #100 was administered any opioid narcotics prior to her transfer to the hospital on 1/5/25. Review of MAR for Resident #102 for January 2025 revealed Morphine Sulfate ER tablet extended release 30 MG (milligrams) Give 1 tablet by mouth three times a day for pain at 0800 (8am), 1200 (noon), and 2000 (8pm) with a start date of 10/22/2024. Documentation revealed Resident #102 was administered Morphine Sulfate ER tablet as scheduled on 1/3/25 and 1/4/25. Documented pain level for Resident #102 on 1/2/25 were 0 at 8am, 0 at 12pm, and 3 at 8pm; Pain level on 1/3/25 were 5 at 8am, 5 at 12pm, and 4 at 8pm; pain level on 1/4/25 were 3 at 8am, 4 at 12pm and 0 at 8pm. (pain level - 0 indicates no pain, and 10 indicates the worst pain). Morphine sulfate (concentrate) oral solution 20 mg/mL (morphine sulfate) give 1 ML by mouth every 2 hours for pain at 0000 (midnight), 0200 (2am), 0400 (4am), 0600 (6am), 0800 (8am), 1000 (10am) 1200 (noon), 1400 (2pm) 1600 (4pm), 1800 (6pm), 2000 (8pm), 2200 (10pm) with a start date of 12/13/24. Documentation revealed Resident #102 was administered morphine sulfate oral solution as scheduled on 1/3/2025 and 1/4/2025. Resident #102's documented pain level was rated a 5 for 10 of 12 doses of morphine concentrate, with a pain rating of 4 at 8pm and 0 pain at 10pm; and #102's documented pain level for morphine sulfate ER ranged from 0-4 on 1/4/2025. In an interview on 1/28/25 at 1:32 PM., NHA A reported the investigation completed by himself, DON, and conferred with medical director was unable to identify any deficient practices. NHA A confirmed that Resident #100 was sent to the hospital for respiratory distress and unresponsiveness on 1/5/25 and Resident #100 did have more than one urine drug screen that was positive for opioids after her transfer to the emergency department on 1/5/25. In a telephone interview on 1/28/25 at 2:02 PM., LPN P reported she was working on 1/5/25 when Resident #100 was sent to the emergency room . LPN P reported that LPN O requested she assess Resident #100 related to her respiratory distress and unresponsiveness. LPN P reported as soon as she saw Resident #100 sometime between 1 and 4 am on 1/5/25 she could see that she was struggling to breathe. LPN P reported Resident #100 sounded like she had fluid buildup on her lungs and LPN P thought maybe she has aspirated. LPN P reported Resident #100 was not responding, her eyes were rolling into the back of her head, she was really struggling to breath and was not able to focus with a sternal rub. LPN P stated I have never seen her (Resident #100) this bad, I was told it was a drug overdose, but she doesn't take anything for pain, she had no order for morphine. In an interview on 1/28/25 at 12:30 PM., DON B reported Narcan was available in the facility back up narcotic box. Review of Case Management Notes for Resident #100 dated 1/5/25 at 9:20 AM reveals .spoke to Admissions Coordinator (AC) C, she confirmed the facility self-reported to the state . 14:52 (2:52pm) Pt was hospitalized on [DATE] for PNA (pneumonia), hypoxia, and opiate overdose .1/6/2025 11:12 am (Name Omitted) Social Worker spoke with Resident #100's guardian, pt (patient) is alert and oriented to self at baseline and did not know how the pt received opiates .1/6/2025 12:04 pm (Name Omitted) Social Worker spoke with AC C from the facility, it is unknown what caused the positive opiate screen. She (AC C) indicated that there may be blood pressure medications that would cause a false positive, however the patient would not have responded to Narcan if this was the case . (Name Omitted) AC C indicated that it was unknown if this was a medication error. She (AC C) confirmed that pt would not have been able to obtain opiates and would not be able to take these medications . 1/6/2025 1:18 pm (Name Omitted) AC C was here to see patient States she (Resident #100) does not look good, (Name Omitted) AC C reports patient does not receive visits from anyone outside of the facility, and is dependent on staff for all ADLs (Activities of Daily Living) .

This citation contains 2 Deficiency Practice Statements, DPS #1 and #2. This citation pertains to intake number MI00142844 DPS#1 Based on interviews, and record review, the facility failed to protect the resident's right to be free from resident to resident verbal and physical abuse for 1 (Resident #100) of 4 Residents reviewed for abuse, resulting in Resident #100 experiencing fear, increased agitation, and requiring inpatient psychiatric hospitalization . Findings include: Review of an Admission Record with a reference date of 11/24/23 revealed Resident #100 was admitted to the facility with pertinent diagnoses that included: anxiety disorder, repeated falls, altered mental status, major depressive disorder. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 11/30/23 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #100 was severely cognitively impaired. Review of a Care Plan for Resident # 100, with a reference date of 12/11/23, revealed a focus/goal/interventions of: (Resident #100) has the potential for fluctuations in mood related to depression .anxiety. Goal: Mood will have minimal effect of daily life .Interventions .approach in calm, quiet manner .report changes in mood . Review of an Incident Report with a reference date of 1/15/24 revealed Resident #100 was found injured, laying on his bathroom floor at 1:30am. At that time, Resident #100 reported a man pushed him down. Resident #102, who shared the bathroom with Resident #100 but lived in the adjoining suite, reported he pushed Resident #100 because the resident exited the bathroom and entered his suite. In an interview on 3/19/24 at 1:12pm Competency Evaluated Nursing Assistant (CENA) M reported she cared for Resident #100 regularly prior to the incident on 1/15/24. CENA M reported Resident #100 was very sensitive to his environment and became very stressed by loud noises. CENA M reported she witnessed Resident #102 becoming verbally aggressive, yelling at Resident #100 several times and she made a point to provide Resident #100 with scheduled toileting assistance to decrease the likelihood of the resident attempting to go to the bathroom alone, and accidentally entering Resident #102's room. CENA M reported prior to the incident on 1/15/24 she could successfully assist Resident #100 with cares without him experiencing agitation, but after the incident he was not directable. In an interview on 3/19/24 at 10:16am, Licensed Practical Nurse (LPN) J reported she found Resident #100 on his bathroom floor at approximately 1:30am on 1/15/24. LPN J reported she began evaluating Resident #100 as he laid on the floor and he told her someone pushed him down. At that point, Resident #102 (Resident #100's suite mate), entered the bathroom and yelled I pushed him. Resident #102 said to Resident #100, You know why I pushed you. You kept coming in my room!. Resident #102 left the bathroom and slammed the door. When queried about Resident #100's injuries from the assault, LPN J reported Resident #100 had a hematoma on his forehead and complained of pain in his right elbow. LPN J reported she observed Resident #102 yelling at Resident #100 many times in the past when Resident #100 mistakenly entered Resident #102's room. LPN J reported Resident #102 used a loud, angry tone of voice during these interactions. In an interview on 3/20/24 at 9:03am, Competency Evaluated Nursing Assistant (CENA) L reported she heard a loud thud at approximately 1:30am on 1/15/24 and when she responded to the noise, she saw Resident #100 laying on his bathroom floor, LPN J was already present. CENA L reported she assisted Resident #100 off the floor, assisted him with toileting and then escorted him to a common area. CENA L reported Resident #100 appeared fearful and was visibly emotionally shaken up. As CENA L sat with Resident #100 he stated Why did that happen? We have to get along. CENA L reported Resident #100 complained of pain on his right side. Review of a Nurses Note entered at 4:40pm with a reference date of 1/15/24 revealed Resident #100 was evaluated with neuro checks (assessment of mental status, level of consciousness, pupillary response, motor strength, sensation, and gait) after the physical altercation and was sent to a local emergency department for further evaluation after he developed tremors and worsening balance. In an interview on 3/19/24 at 3:37pm, Competency Evaluated Nursing Assistant (CENA) D reported she witnessed Resident #102 yelling at Resident #100 many times prior to the incident that involved the physical altercation. CENA D reported Resident #100 took himself to the bathroom frequently but when he did so, he often mistakenly exited through the door that led directly into Resident #102's room. CENA D reported Resident #102 had threatened to hit Resident #100 and as a result, Resident #100 appeared scared to enter the bathroom he shared with Resident #102. In an interview on 3/20/24 at 11:34am Competency Evaluated Nursing Assistant (CENA) R reported she witnessed Resident #102 yelling at Resident #100 numerous times after Resident #100 mistakenly entered Resident #102's room from their shared bathroom. CENA R reported Resident #102 made threatening statements, saying he was going to get him. CENA R reported Resident #100 appeared scared to enter the bathroom and the facility should have taken action to resolve the situation. In an interview on 3/19/24 at 12:00pm, Licensed Practical Nurse (LPN) K reported Resident #102 had been verbally aggressive toward Resident #100 several times, and at one time had threatened to hit him. LPN K reported the facility had considered moving one of the residents to another room after Resident #102 threatened Resident #100, but no room moves had occurred. LPN K reported she cared for Resident #100 when he returned from the emergency room evaluation and at that time, he displayed almost constant symptoms of emotional distress and physical agitation. In an interview on 3/21/24 at 9:14am, Social Services Director (SSD) N she was aware that there was ongoing conflict involving Resident #100 inadvertently entering Resident #102's room, but neither had been offered the opportunity to move to another room until Resident #102 assaulted Resident #100. SSD N denied knowledge of Resident #102 yelling at Resident #100. In an interview on 3/21/24 at 3:30pm Nursing Home Administrator A reported staff were expected to report all potential resident abuse, including verbal or physical abuse immediately. When further queried, NHA A denied any reports of abuse involving Resident #100 prior to the physical assault on 1/15/24. NHA confirmed that verbal threats directed toward a resident and a resident putting hands on another in anger constitute abuse. Review of a History and Physical report from a local hospital revealed Resident #100 was evaluated for a traumatic brain injury, testing was negative, and he returned to the facility. Review of a Nurses Note entered at 6:30pm on 1/16/24 revealed a statement (Resident #100) has become more aggressive since fall on 1/15/24. Review of a Nurses Note entered at 6:00am on 1/17/24 revealed Resident #100 jolted awake, grabbed a staff members shirt and voiced he felt angry. Review of a Nurses Note entered at 5:00pm on 1/17/24 revealed Resident #100 was put on 1:1 supervision due to increased physical restlessness. Review of a Provider's Note with a reference date of 1/17/24 revealed Resident #100 began attempting to hit, push, and grab staff during cares and as a result was referred to an inpatient psychiatric hospital. Review of a Social Services Note entered at 2:51pm on 1/17/24 revealed Resident #100 was accepted for admission at an inpatient psychiatric hospital and left the facility at approximately 5:30pm. Using the reasonable person concept, though Resident #100 had decreased ability to verbally express his own thoughts due to his mental diagnoses, he was clearly fearful and angry following the verbal and physical abuse endured prior to and on 1/15/24. DPS #2 This citation pertains to intake # MI00142845 Based on interviews and record review the facility failed to protect the resident's right to be free from resident to resident physical abuse for 1 (Resident #102) of 4 residents reviewed for abuse, resulting in Resident #102 being punched in the face by another resident. Findings include: Review of an Admission Record with a reference date of 3/19/18 revealed Resident #102 was admitted to the facility with pertinent diagnoses that included: unspecified dementia with other behavioral disturbances, cognitive communication deficit, and mood disorder. Review of Minimum Data Set (MDS) assessment with a reference date of 2/26/24 revealed a Brief Inventory for Mental Status (BIMS) score of 5/15 which indicated Resident #102 was severely cognitively impaired. Section E of the MDS revealed Resident #102 had no behaviors directed at others in the last 7 days. Review of an Incident Report with a reference date of 1/20/24 revealed Resident #102 was struck in the face with a closed fist by Resident #101. In an interview on 3/20/24 at 2:18pm, Competency Evaluated Nursing Assistant (CENA) H reported 1/20/24 she heard residents yelling outside the activity room and ran to respond to the situation. CENA H reported as she ran up to the residents, she saw Resident #101 punch Resident #102 in the jaw with a closed fist. Resident #102 raised his arms in a defensive manner at which time Resident #101 struck Resident #102 in the arm with her hand. CENA H reported Resident #102 was visibly emotionally upset by Resident #101's actions and reported he just asked her to stop bumping into his wheelchair, but she got angry and hit him. In an interview on 3/20/24 at 3:56pm Licensed Practical Nurse (LPN) U reported she witnessed incidents in which Resident #101 became verbally and physically aggressive toward other residents, especially in the area outside the activities room. LPN U reported Resident #101 was easily over stimulated when she was in that area and other residents were nearby, as a result the staff tried to keep that area uncrowded and tried to keep Resident #101 away from others. LPN U reported Resident #101 was easily angered when asked to perform any action. In an interview on 3/21/24 at 8:54am, Resident #102 did not recall the altercation that took place on 1/20/24. In an interview on 3/21/24 at 9:42 Social Services Director (SSD) N reported Resident #101 had been physically aggressive toward other residents, primarily in the area outside the activities room. Review of a Behavior Monitoring Log with a reference date of January 2024, revealed Resident #101 demonstrated physically aggressive behavior on 1/16, 1/17, 1/18, 1/19 and 1/20. Review of a Abuse Prohibition policy with a reference date of 9/9/22 revealed a statement Abuse means the willful inflection of injury .intimidation .resulting in physical harm, pain or mental anguish .it includes verbal abuse .physical abuse .and mental abuse.

This citation pertains to MI00142844 Based on interview and record review the facility failed to initiate appropriate treatment measures for 1(Resident #100) of 4 residents reviewed for quality of care, resulting in a Resident #100 experiencing increased pain, developing an ankle abscess, sepsis, and requiring hospitalization . Findings include: Review of a facility policy titled Notification of Change with a reference date of 2/14/124 revealed: The facility must inform .the resident's practitioner when there is change in status .a change in status would include .a need to alter treatment .or to commence a new form of treatment . Review of an Admission Record with a reference date of 11/24/23 revealed Resident #100 was admitted to the facility with pertinent diagnoses that included: anxiety disorder, repeated falls, altered mental status, pain, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 11/30/23 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #100 was severely cognitively impaired. Section B of the MDS revealed Resident #100 had unclear speech, moderate difficulty hearing, usually made self understood, and sometimes understood what was being said to him. Section M revealed Resident #100 was deemed at risk for developing pressure ulcers/skin injuries. Review of a MDS assessment for Resident #100, with a reference date of 2/8/24 revealed Resident #100 returned to the facility following a hospitalization in a psychiatric hospital. Review of a MDS assessment for Resident #100, with a reference date of 2/21/24 revealed Resident #100 returned to the facility following an admission to a medical hospital. Review of a MDS assessment for Resident #100, with a reference date of 2/29/24, Section M revealed Resident #100 had an infection of the foot, a surgical wound that required wound care, dressings to his feet, started receiving an opioid, and had entered hospice (end of life) care. Review of a Nursing Comprehensive Evaluation dated 2/8/24, section K revealed Resident #100 had an actual impairment to his skin integrity (skin is compromised due to injuries like cuts, rashes, abrasions). The description of Resident #100's locations of impaired skin included: forehead scab, mid back skin tear, bilateral upper extremity discoloration, right lower extremity skin tear, left lower extremity scabs. Review of physician orders for Resident #100 with a reference date of 2/8-2/21/24 revealed no orders related to the treatment of skin tears or wounds. In an interview on 3/19/24 at 12:47pm Licensed Practical Nurse (LPN) J reported she completed the skin assessment portion of the comprehensive nursing evaluation for Resident #100 on 2/8/24. LPN J reported Resident #100 was readmitted that day with 4 skin integrity concerns, including a skin tear on his right lower leg. LPN J reported when a resident was admitted with a skin integrity concern, the Unit Manager would typically reach out to the physician for treatment orders. LPN J reported the facility no longer had a Unit Manager and as a result, getting treatment orders for Resident #100's skin issues slipped through the cracks. LPN J reported she wrapped Resident #100's wound in gauze but it did not stay in place. LPN J reported she did not reach out to the provider for treatment orders for Resident #100's skin tears. In an interview on 3/21/24 at 8:53am Licensed Practical Nurse (LPN) Q reported it was the responsibility of the nurse to notify the provider if a resident was admitted with a skin issue and there were no treatment orders in place. LPN Q reported if a skin tear was not properly cared for, there was potential for the injury to worsen and become infected. In an interview on 3/19/24 at 2:40pm LPN V reported if a resident was admitted with a skin tear the nurse should alert the provider and seek orders for treatment of the skin tear. Review of a Treatment Administration Record for Resident #100 revealed no orders for wound care until 2/22/24. In an interview on 3/20/24 at 11:23am, Wound Care Physician (MD) T reported he only evaluated residents when alerted by the nursing staff and had not evaluated Resident #100. MD T reported a skin tear required therapeutic intervention to avoid worsening of the injury and to reduce the potential for infection. MD T reported a nurse should contact the provider to seek orders for care of skin tears. When further queried, MD T reported if a resident developed a swollen, painful, reddened area with a loss of function, the nurse should contact the physician to rule out an infection. In an interview on 3/19/24 at 1:12pm, Competency Evaluated Nursing Assistant (CENA) P reported she knew Resident #100 well and noticed his right lower leg was swollen upon his return to the facility on [DATE]. CENA P reported Resident #100 winced in pain when she attempted to don a nonskid sock on his right foot. CENA P reported in the days prior to Resident #100 being hospitalized on [DATE], his oral intake was very poor and his functional abilities declined significantly. Review of an Amount Eaten record for Resident #100 revealed the resident did not eat on 2/10, 2/11, 2/12, 2/13 or 2/14/24. In an interview on 3/19/24 at 3:37pm, CENA D reported she noticed Resident #100's right leg was swollen when she cared for him on 2/9/24. CENA D reported when she touched the resident's leg he verbalized ouch! and she reported his complaint of pain to the nurse. CENA D reported Resident #100 was normally not painful. Review of a Pain level record for Resident #100 revealed his pain level was assessed at 0 on scale of 0-10 when he readmitted to the facility on [DATE]. On 2/11/24, Resident #100's pain level was assessed as a 3. On 2/13/24 Resident #100's pain level was assessed as a 4. On 2/14/24 Resident #100's pain level was assessed as an 8 on a scale of 0-10. In an interview on 3/20/24 at 9:03am, Competency Evaluated Nursing Assistant (CENA) R reported Resident #100 returned to the facility from an inpatient psychiatric hospitalization and at that time his leg appeared swollen. CENA R noticed that Resident #100 was primarily using a wheelchair and had previously been able to walk. CENA R reported she became concerned with the appearance of Resident #100's right lower leg, noticed a darkened area appeared on his foot, the swelling continued to worsen, then a wound opened and began draining. CENA R reported a nurse applied gauze around the resident's leg, but it did not stay on. In an interview on 3/20/24 at 3:37pm CENA O reported Resident #100 was not himself when he returned to the facility on [DATE]. CENA O reported Resident #100 was not walking well, his right lower leg was swollen, and he was not able to verbalize his thoughts. In an interview on 3/20/24 at 11:23am LPN C reported she worked on 2/9/24 was assigned to Resident #100's memory care unit but also to another area of the facility and it was hard to keep track of the resident's needs in memory care that day. LPN C did report Resident #100 had swelling in his right lower leg and would not allow anyone to touch it. LPN C reported she was not aware Resident #100 had skin tears and if he had treatments scheduled, they were not on her shift. LPN C was the nurse for Resident #100's unit on 2/10 and 2/11/24 as well. In an interview on 3/21/24 at 8:06am, LPN W reported a CENA asked her to come see Resident #100's ankle on 3/13/24. LPN W she looked at Resident #100's right lower leg, noted it was bright red, extremely swollen and appeared as though the skin was going to open around the area of his ankle. When queried about the appearance of Resident #100's leg, LPN W described it as festering as though it was infected. LPN W reported she asked Resident #100's nurse to evaluate his leg. No documentation of further evaluation was present. In an interview on 3/21/24 at 10:28am, Nurse Practitioner (NP) S reported she was usually made aware of skin tears and other skin conditions by the floor nurses. NP S reported to her knowledge, Resident #100 did not have a skin tear on his right lower leg, and she was unsure when he developed the wound on his ankle. When further queried about an appropriate course of treatment for a resident who developed redness, swelling, pain in an area near a skin tear, NP S reported she would start an antibiotic and order laboratory testing to evaluate for an infection. In an interview on 3/20/24 at 1:06pm, LPN K reported she was shocked at the appearance of Resident #100's right lower leg when she returned to work on 2/13/24. LPN K reported his leg was swollen, very red and she noticed a small blister forming that looked like an insect bite. LPN K reached out to the provider and an ultrasound was ordered to rule out a deep vein thrombosis (blood clot). LPN K reported by 2/14/24, Resident #100 had a large draining wound on his ankle, and she received orders to have the resident transferred to the hospital. The ultrasound was not completed prior to Resident #100 being admitted to the hospital on 2/14/24. Review of the Orthopedic Hospital Consult for Resident #100 dated 2/14/24 revealed, RLE (right lower extremity): Edema and erythema throughout the foot and ankle, Large bullous appearing lesion, approximately 10 cm, centered over the lateral malleolus, no active drainage; lesion is fluctuant with surrounding induration, A more proximal 4 cm lesion is present on the lateral aspect of the lower leg with overlying eschar, mild surrounding erythema, no active drainage or bleeding, no associated fluctuance. Patient withdrawing and kicking leg with any attempted exam, unable to thoroughly assess for subcutaneous emphysema. Review of a medical record revealed Resident #100 was admitted to a local medical hospital on 2/14/24 with pertinent diagnoses that included: sepsis from the skin and soft tissue of the ankle (serious condition resulting from the microorganisms in the blood or other tissues, potentially leading to malfunctioning of various organs, shock, and death), right ankle abscess, acute kidney injury, and acute toxic metabolic encephalopathy. Resident #100's white blood cell (WBC) count was 48.6 (normal 4.0-11.0) Further review revealed Resident #100 underwent 4 surgical interventions of his right foot/ankle, resulting in a wound that measured 13cm x 11cm. Resident #100 was discharged back to the facility on [DATE] on hospice. Review of the facility's Skin Management policy with a reference date of 12/15/22 revealed under a section titled Practice Guidelines: upon admission/re-admission all residents are evaluated for skin integrity .residents admitted with any skin impairment will have physician's orders for treatment .if a new skin impairment is identified .notify physician . The section titled Treatment of Skin Tears revealed: .all skin tears will be .treated based on physician's orders.

This intake pertains to intakes: MI00141760 & MI00141787. Based on interview and record review, the facility failed to safely utilize hoyer transfer lifts to ensure safety in 1 of 1 resident (Resident #101) reviewed for accidents and hazards, resulting in a leg fracture for Resident #101. Findings include: Review of an Admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: end stage renal/kidney disease, renal/kidney osteodystrophy (complication of chronic kidney disease that may weakens your bones). Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 1/4/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #101 was cognitively intact. In an interview on 1/18/24 at 8:55 AM., Confidential Informant (CI) R) reported (Resident #101) was transferred by staff a few weeks ago with a hoyer lift (a lift which has a cloth mesh sling which wraps around a resident, attached to a lift arm and then residents are lifted from a bed, wheelchair, floor etc .). (Resident #101's) was raised from his wheelchair to his bed after (Resident #101) returning to the facility for a medical appointment. CI R reported during the hoyer lift transfer the staff assisting (Resident #101) were rushing, and not paying attention to where (Resident #101's) legs were positioned on the lift. CI R reported (Resident #101) was talking to the staff who were lifting him up, and telling them to slow down, and lower him (Resident #101). CI R reported (Resident #101) was explaining to the staff that he was too high up, and his legs were not positioned correctly. CI R reported the staff did not follow the proper protocol and ensure safety for (Resident #101). CI R reported his (Resident #101's) legs were too high up, as well as not together. CI I reported (Resident #101's) legs were apart, and one leg was on one side of the lift frame (the pole-apparatus which raises the lift), and the other leg was on the other side of the frame. CI R reported the staff assisting (Resident #101) pushed his legs back (knee area) so that his legs would be able to be on the same side of the lift. CI R reported (Resident #101) asked multiple times for the staff to slow down and lower him so that the lift (sling area he was seated in) could be maneuvered to swing around properly, and his legs would not have to be pushed on. CI R reported (Resident #101) was fragile, and prone to fractures. CI R reported the staff are aware of his condition, but continued to do what they wanted instead of slowing down and listening to (Resident #101). CI R stated Instead of using handles to lower and pull (Resident #101) back staff members were pushing and pulling on legs and (Resident #101) now has a broken leg Review of Resident #101's Emergency Department Note revealed Encounter Date: 12/27/2023 Chief Complaint Patient (Resident #101) presents with Leg Pain Emergency Medical Support (EMS-ambulance): Coming from (Facility name omitted) Complaints of (C/O) right leg pain for two days. Known leg fracture lower. (Resident #101)Thinks he injured it from being transferred Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal In an interview on 1/18/24 at 12:48 PM., Interim-Director of Nursing (IDON) reported the Nursing Home Administrator (NHA A) was not in the facility due to being on vacation. IDON B reported she could not find any information regarding (Resident #101's) leg injury. IDON B reported (Resident #101) was currently wearing a leg brace for a fracture of his right leg. In an interview on 1/18/24 at 1:45 PM., Regional Clinical Consultant (RCC) F reported there was no incident-accident report completed by facility staff. RCC F reported at the time of the incident (Resident #101's) leg fracture the facility had an issue with having a full time Director of Nursing (DON). RCC F reported (Resident #101's) X-ray showed the fracture, and he had increased pain. RCC F reported (Resident #101) has a bone condition. RCC F reported when the orthopedic doctor came in due to (Resident #101's) pain (Resident #101) told him (the ortho doctor) that he broke his leg because of the transfer with a hoyer. In an interview on 1/18/24 at 4:30 PM., Resident #101 reported the staff that were assisting him from his wheelchair to his bed using the hoyer lift a few weeks ago. Resident #101 reported staff were pushing and pulling on his legs. Resident #101 reported they (staff) didn't listen to him when he was trying to tell them to slow down and lower the lift so his legs could be put together in order for them to swing him in the sling sideways. Resident #101 reported they continued to transfer him all the while, he knew being up so high in the lift that it was not a correct position for him to be in during the transfer. Resident #101 stated: I'm up in the air, they kept trying to turn the sling with me in it. I was all the way up to the top of the lift Resident #101 reported during the transfer the staff were saying . we have to get his feet over . Resident #101 reported he said to the staff . you're doing it wrong; I want to be lower I know my legs won't fit like that . Resident #101 reported they (staff) would not put him down. Resident #101 reported they kept me up there, and then forced my legs incorrectly to be on one side of the pole of the lift. Resident #101 reported they (staff) were both tugging on my legs, and disputing who was going to put the legs correct or which way to do it. Resident #101 stated another lady (staff member) came in and she started to try and help me. Resident #101 stated but it was like a game of tug of war, they kept tugging on me and wouldn't listen . Resident #101 reported a day or so later, the pain increased, and an X-ray was done, it showed the fracture. Resident #101 reported when the pain increased, he knew it was broken, it was so painful, they (staff) sent me to the hospital, but only after he (Resident #101) begged, and called family for help. Resident #101 reported he has had fractures in the past, and most staff are aware of that. Resident #101 stated . if staff are aware that I have had fractures in the past, and that I have weak bones, and stiffness, that should make them be even more careful than they are . Resident #101 reported the facility was so short staffed that all the cares that should be done for him are not completed daily. Resident #101 reported, if the staff didn't have to rush so much, he (Resident #101) would not have been injured. Resident #101 reported if the staff would have listened to the way I prefer and feel safest when transferring, slowed down to hear me this would not have happened. In an interview on 1/19/24 at 945 AM., Certified Nurse Aide (CNA) J reported the unit (Resident #101) residents on is a very heavy unit (high acuity) a lot of dependent residents who have 2-staff assists for cares. CNA J reported (Resident #101) is a fragile resident, staff needs to take their time and use caution when transferring him. CNA J reported he (Resident #101) will let you know how to maneuver him in the hoyer left, but some staff rush through it. CNA J reported many times staff are rushing because of acuity on the unit, and low staffing numbers. CNA J report most staff know (Resident #101) is fragile, but it is not listed on his CNA-Kardex (care guide specific to each resident). In an interview on 1/19/24 at 10:44 AM., Licensed Practical Nurse LPN K reported (Resident #101) is particular when he is being lifted in the hoyer. LPN K reported there are not enough staff, so it is very possible during (Resident #101's) transfer with the hoyer lift was rushed and most likely was the fact the staff not using the lift correctly, and not listening to (Resident #101's) needs during the transfer. Review of Resident #101's Care Plans revealed: No Focus areas addressing Resident #101's medical conditions needing extra caution, and proper placement when being assisted with any lifts/cares. Resident #101's Care Plan did not reveal any information for the staff referring to the Care Plan for Resident #101's specific care in regard to bone fragility, or at risk for fractures. Review of Resident #101's CNA Kardex revealed no mention of Resident #101's bone fragility, or take extra caution with transfers. Review of Resident #101's diagnoses listed in Resident #101's Electronic Medical Record (EMR) dated 1/10/23 revealed OTHER SPECIFIED DISORDERS OF DENSITY AND STRUCTURE, unspecified site .N/A not accepted as a Primary Diagnosis .1/10/2023 . diagnosis during stay (at facility).

Based on observation, interview, and record review the facility failed to 1.) provide adequate supervision to prevent falls with injury in 1 of 6 residents (Residents #63) and 2.) ensure safe transport of residents in a wheelchair with foot pedals in place in 2 of 9 residents (Resident #3 and #42) reviewed for accidents resulting in the potential of injury to residents. Findings include: Resident #63 Review of an Admission Record revealed Resident #63, a female, with pertinent diagnoses which included dementia. Review of a Minimum Data Set (MDS) assessment for Resident #63, with a reference date of 5/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #63 had severe cognitive impairment. A review of care plan record on 7/25/23 indicated that Resident #63's needs included . is at risk for falls related to injury and falls . date initiated 1/31/23 . Resident #63's goals include, will be free from injury related to falls Date initiated 1/31/23 . Resident #63's interventions include administer meds as ordered initiated 5/23/23 . anticipate and meet needs date initiated 5/6/23 . assess pain date initiated 6/23/23 .educate resident about safety reminders date initiated 6/9/23 . increase supervision while up in wheelchair date initiated 6/17/23 . A review of Nurses Notes dated 6/26/23 revealed . noted to be seen rising out of wheelchair, attempted to self-ambulate .lost balance, landed on buttock . A review of Nurses Notes dated 7/2/23 revealed . dime sized scabs to outer aspect of right knee . A review of Encounter dated 7/5/23 revealed . change in elevation encounter .Resident was found down. Trip and fall. Significant bleeding from 3cm head laceration . A review of Nurses Notes dated 7/5/23 revealed .returned to facility following ER visit at acute care facility (Name Omitted) . 7 staples on scalp . Hematoma also found on R hip. A review of Nurses Notes dated 7/7/23 revealed standing behind privacy curtain next to her roommate's bed . Right knee bleeding . noted blood in resident's hair . 3 cm laceration on scalp . A review of Resident at risk dated 7/11/23 revealed . resident has history of falls and impulsivity. Resident is non-compliant with safety interventions . Fall precautions reviewed . continue to follow care plan as written . This indicated there no changes were made to the care plan to prevent falls. A review of Nurses Notes dated 7/13/23 revealed Nurse found resident in lounge on floor on her right side. Resident unable to tell nurse what happened. Resident complains of cheek pain. Resident also has a skin tear on her right elbow . A review of Nurses Notes dated 7/15/23 revealed Resident observed on floor behind nurses stations attempting to get onto knees to stand up . A review of Nurses Notes dated 7/15/23 revealed Observed resident bruised right lower cheek related to fall. A review of Nurses Notes dated 7/21/23 revealed resident laying on her right side on the floor . A review of Minimum Data Set (MDS) falls worksheet on 7/25/23 revealed .has dementia with impaired cognition and wanders . has anxious behavior .unsteady on feet and needs supervision with locomotion . takes antianxiety medication that put resident at an increased risk for falls . A review of Care Plan on 7/25/23 revealed no resident specific intervention related to Resident #63's impulsivity or specific information related to increase supervision. During an interview on 7/26/23 at 10:22 AM, Registered Nurse (RN) E and Unit Manager (UM) D reported the responsibility of care plans is collaborative with the MDS nurse. RN E and UM D reported that the MDS nurse is the one that verifies a care plans accuracy. RN D reported the unit managers are responsible for the immediate baseline care plan creation.UM E reported that care plans can be updated as staff learns about the residents. UM E reported the care plan is not always updated after the comprehensive assessment is completed by nursing staff. During an interview on 7/26/23 at 1:30 PM, Minimum Data Set Registered Nurse (MDS/RN) F reported the MDS nurse does not create baseline care plans. MDS/RN F reported the MDS nurse reviews information and assigns other staff to complete their appropriate part. MDS/RN F reported information about a resident can be collected from resident's records, hospital discharge papers, family members, and staff. MDS/RN F reported that unit managers follow up for accuracy and completes a care plan for a resident. A review of facility policy Fall Management with effective date of 8/18/23 revealed .highest practical level of function by providing the guest resident adequate supervision . an evaluation to ensure that appropriate measures are in place to minimize the risk of future falls . 41424 Resident #3: Review of an Admission Record revealed Resident #3 was a female with pertinent diagnoses which included dementia with behavioral disturbance, anxiety, pain, PTSD, dysphagia (damage to the brain responsible for production and comprehension of speech), Parkinson's disease, falls, and insomnia. Review of current Care Plan for Resident #3, revised on 9/12/22, revealed the focus, .(Resident #3) is at risk for fall related injury and falls R/T: Parkinson's, tremor, impaired cognition, impulsiveness, vertigo, OP, decreased mobility, history of falls, Unaware of safety needs, Wandering . with the intervention .Keep resident's environment as safe as possible .Non skid strips on the floor beside the bed .Wheelchair with tilt feature .Encourage resident to participate to the fullest extent possible with each interaction .Locomotion: 1 assist in w/c (wheelchair) . During an observation on 07/24/23 at 10:11 AM, Activities Assistant (AA) CC was observed pushing Resident #3, who did not have her foot pedals on her wheelchair. AA She pushed her from halfway between day room and dining room into the dining room and sat her at the table just in the doorway on the left hand side. In an interview on 07/26/23 at 2:25 PM, Activities Assistant (AA) CC reported staff were supposed to walk next to them and hold their hands when the resident needs assistance to ambulate and does not have the foot pedals on for the wheelchair. Resident #42: Review of an Admission Record revealed Resident #42 was a female with pertinent diagnoses which included Alzheimer's disease, dementia, mood disorder with manic features, adjustment disorder mixed anxiety and depressed mood, dysphagia (damage to the brain responsible for production and comprehension of speech), and abnormal posture. Review of current Care Plan for Resident #42, revised on 5/25/23, revealed the focus, .Has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility . with the intervention .AMBULATION: Resident is non-ambulatory, is dependent with wheelchair . During an observation on 07/24/23 at 01:15 PM, CNA N was observed pushing Resident #42 down the hallway towards her room at rapid rate. CNA N realized, when she saw this writer, she did not have foot pedals on Resident #42's wheelchair and she stopped and stated, you can't push them without foot pedals. In an interview on 07/26/23 at 02:05 PM, CNA YY reported you would not push a resident without foot pedals on their wheelchair as they could put their feet down and you could cause injury to the resident. In an interview on 07/26/23 at 01:50 PM, Director of Nursing (DON) B reported the resident would not be pushed in a wheelchair without foot pedals as the staff could cause an injury and hurt the resident.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to activities of their choosing (smoking) in 5 of 20 residents who smoke (Residents #12, #22, #15, #46, and #11) reviewed for self-determination, resulting in a sustained increase in behaviors and anxiety for Resident #12, feelings of anger and increased behaviors for Resident #22, the potenial for decreased mood for Resident #15, feelings of anger for Resident #46, and increased agitation for Resident #11. Findings include: In an interview on [DATE] at 11:26 AM, CNA OO reported the residents would be happy about going out to smoke every day but I don't know how we are going to do it .we are already short on staffed and now this too .Plus we don't have any activities anymore they have left, just Activities Aide UU. During an interview on [DATE] at 3:15 PM LPN R stated, Residents can only smoke on Monday, Wednesday, and Friday. Activity staff take out residents to smoke. If Activities is not here to take out residents, then CNAs are put on the schedule. If staffing is short, then residents cannot go out to smoke. The facility has been wanting to make this a non-smoking building because of staffing. Residents want to smoke and cannot do it because of staffing. In an interview on [DATE] at 12:38 PM, Licensed Practical Nurse (LPN) R reported the facility had cut down on smoking breaks for residents because there was not enough staff to do more than that. In an interview on [DATE] at 8:26 AM, Previous Nursing Home Administrator (PNHA) FFF reported the facility cut down to 3 days per week with smoking breaks because it took one staff member to supervise the residents and one staff member to transport the residents to the smoking area and it was not feasible with staffing to continue to offer smoking breaks every day twice a day. In an interview on [DATE] at 9:34 AM, Social Worker (SW) BBB reported residents who smoked used to be able to go out every single day but when the facility was strapped with COVID-19, it was too difficult to give the residents smoking breaks every day, twice a day. In an interview on [DATE] at 11:02 AM, Former Activities Employee [NAME] JJJ reported the residents used to be able to smoke daily but the facility took weekends off the smoking schedule in [DATE] due to staffing and then the smoking breaks were further reduced down to M, W, F in [DATE], again due to staffing. Resident #12: Review of Admission Record revealed Resident #12 was a male with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nurse Notes dated [DATE] at 4:11 PM, revealed, .Guest had [CONDITION(S)] while out smoking .BP ,d+[DATE] . Review of the facility Smoking Data Collection & Assessment revised ,d+[DATE] revealed, The smoking assessment will be completed by a Licensed Nurse for all guests who wish to smoke . The assessment will be completed upon admission, quarterly, and with a change in condition if indicated. Review of Smoking Evaluation dated [DATE] completed by Former Activities Employee ([NAME]) JJJ revealed, Resident #12 had .Mental Status: Alert; Manual/Dexterity: 1. Gasps/Holds; Reflexes: Quick response; Speech: Clear, Understood; Vision: Adequate; Smokes only in designated area: Yes; Safely lights smoking materials: Yes; Follows smoking guidelines per policy: Yes; Able to call for emergency assistance: Yes; Returns smoking materials to nurse staff: Yes; Comments: Due to (Resident #12s) history of seizures while out smoking, he has been deemed as an unsafe smoker. He is unable to control when he has a [CONDITION(S)] but has been having a [CONDITION(S)] almost every time he goes outside to smoke. Nicotine patch offered to (Resident #12) . Review of Resident #12's Smoking Evaluation dated [DATE] reported the resident: -mental status: alert -manual dexterity: grasps/holds -reflexes: quick response -communication: speech clear, vision adequate -safely lights smoking materials: Yes - Holds smoking material safely: No (contradictory of above assessment) -safely extinguishes cigarettes : No -responds quickly to fallen ashes: Yes -follows smoking guidelines per policy: Yes -able to call for emergency assistance: Yes Summary Evaluation reported resident was 5. unsafe smoker. Additional summary options included R12 could have been assessed as: 1. supervised, 2. requires physical assistance, 3. requires smoking apron, 4. safe smoker, or 6, unsupervised. Comments included: Due to (Resident #12) history of seizures while out smoking, he has been deemed as an unsafe smoker. He is unable to control when he has a [CONDITION(S)] but has been having a [CONDITION(S)] almost every time he goes outside to smoke. Nicotine patch offered . There was no indication as to why Resident #12 was not observed by a licensed nurse and why Resident #12 was not assess as requires physical assistance or supervised. On [DATE] at 4:25 PM, Email from NHA A which reported the facility staff supervised all smoking at the facility currently. NHA A reported the residents are assessed for their safety to handle lit cigarettes and extinguish. If they are unable to handle a lit cigarette safely and extinguish safely, they would not be a safe smoker therefore assessed as dependent. In electronic communication from Previous NHA FFF on [DATE], the Smoking Evaluation from [DATE] was the last date Resident #12 was able to go to out to smoke at the facility. Review of the medical record revealed no documentation that specifically indicated R12 was having seizures specifically when going outside to smoke except on [DATE]. In an interview on [DATE] at 8:28 AM, Previous NHA FFF reported during a COVID outbreak in January, due to building logistics and staffing to take them out to smoke, we would not be able to watch all the residents while also taking out the smokers. Therefore, an extra resident council was conducted by the previous Activities Director to discuss the reduction in days for smoking. In an interview on [DATE] at 12:41 PM, revealed, .Resident Council President TTT and Resident #39 reported the facility previously allowed residents to smoke 7 days a week twice a day and then it went down to 5 days, and then down to 3 days. The resident council went along with the decision decided by facility administration to reduce the number of days for smoking due to the staffing issues with not having enough staff working in the facility. Resident #39 stated, .I did not agree (to the new policy) we were told that is what was going to happen .Not all smokers were present for the resident council meeting when this was discussed . Resident #39 stated, .I did not agree with it, that's for sure, we were told, we didn't have a choice . On [DATE] at 3:52 PM, received electronic correspondence from NHA A which indicated the smoking schedule as Monday, Wednesday, and Friday at 10:00 AM and 3:30 PM. Review of Activities Note dated [DATE] at 10:04 AM, revealed, .Resident got upset with AD (Activities Director) about smoke break and hit AD, He stated, Get your fat a** out of [MEDICATION(S)]. I'm going outside to smoke. AD explained that he is no longer a smoker here due to not being a safe smoker and he was upset. Resident then hit AD and then rolled away and went and sat out the front door to get fresh air . Review of Social Services Note dated [DATE] at 1:21 PM, revealed, .SSD (Social Services Director) received verbal consent for (Resident #12) to be transferred to the Specialty Care Unit . Review of Nurse Notes dated [DATE] at 2:31 PM, revealed, .Resident transferred to a room on SCU by SS via W/C. Staff offered education and orientation to the unit which was ineffective. He is voicing wanting to go smoke and wanting his coffee. He is requesting complaint forms and a writing utensil which was given to him . Review of eINTERACT SBAR Summary for Providers dated [DATE] at 4:02 PM, revealed, .Physical aggression danger to self or others .Resident was observed going to exit door to go outside to smoke .educate him on the directive from management of his smoking being ceases (sic) for his health and safety .became agitated with this nurse exhibited by hitting her and punching her. He was pulling on her clothing and arm in attempts to harm .Send to ER with petition . In an interview on [DATE] at 10:15 AM, Licensed Practical Nurse (LPN) O reported Resident #12 was moved to the SCU because he was highly agitated and attempting to harm others, throwing coffee at residents/staff. LPN O reported initially she was attempting for the first few hours after his transfer to deescalate the situation. LPN O reported she informed management if the situation escalated further, she would be calling for staff response. LPN O stated, .We were walking down the hallway, trying to talk to him and he was attempting to rip the phone off the wall .I was able to get the phone and took it to the nurse's station .He was talking about he was going to find a car .needed to go to the DMV .He was not making sense . LPN O reported Resident #12 cornered her, grabbed ahold of her arm, her clothing as he was hitting and punching her. LPN O reported she was able to get away from him and paged over the PA system for support on the unit. The Social Services Director was completing the petition to have the resident committed for inpatient hospitalization . Review of Social Services Note dated [DATE] at 4:13 PM, revealed, .Due to current behaviors and (Resident #12) attempting to harm staff threatening stating I will take out anyone young and old you just try me even if they are rolling in a wheelchair. SSD petitioned (Resident #12) for evaluation and possible admission to (local hospital ) psychiatric unit . Review of Petition for hospitalization dated [DATE], revealed, .4. The conclusions stated above are based on a. my personal observation of the person doing the following acts and saying the following things: Attempting to have physical contact with other residents, throwing hot liquids .b. the following conduct and statements that other have seen or heard and have told me about: Stating if he is not allowed to smoke he will harm anyone he has contact with . Review of Nursing Comprehensive assessment dated [DATE] revealed, .readmitted to facility on [DATE] at 2:25 PM .Does the resident smoke? 1. Yes .Does the resident have the desire to smoke during their stay? 1. Yes .Smoking Care Plan: Need: (Resident #12) wishes to use smoking products & has been assessed as being safe to smoke with supervision. Uses cigarettes . Review of Nursing Summary dated [DATE] at 11:55 AM, revealed, . He was per report sent to the hospital yesterday for a [CONDITION(S)]. Coming he is alert and oriented times one and requesting to smoke, staff has educated him on smoking . Review of Behavior Note dated [DATE] at 3:35 PM, revealed, .Resident at this time observed smokers going outside to smoke he was animate on going out to smoke. He became agitated and was becoming physically combative with this nurse. This nurse allowed him to go out while she remained with him. He was demanding a cigarette but was not given one. Upon return back into facility he returned without Incident. This was reported to management, Staff offered education on reasoning for his inability to smoke d/t (due to) his [CONDITION(S)] disorder. He is unable to retain this information d/t his cognitive inability and mental health status . Review of History and Physical dated [DATE] at 00:00 AM, revealed, . he is now returned for long term care .He is expressing frustration with not being able to smoke as he would like . Review of Behavior Note dated [DATE] at 5:44 PM, revealed, .Resident is observed exit seeking to all doors on the unit. He is expressing I want to go out to smoke. Staff has educated him on smoking policy of the facility. He was able to be redirected from the door. He Is now in his room resting in bed . Review of Care Plan for Resident #12, revised on [DATE], revealed the focus, .(Resident #12) has the potential to demonstrate physical and/or verbal aggression in regard to smoking . with the interventions .When (Resident #12) becomes agitated: due to not going outside to smoke Intervene before agitation escalates; Guide away from source of distress; Engage calmly and/or offer to talk resident on walk as needed . Review of Behavior Note dated [DATE] at 2:08 PM, revealed, .Resident observed agitated exhibited by pacing the hallways. Staring at staff and making demands to call (bank), an auto dealership, and demanding cigarettes to go outside and smoke. He Is demanding keys to open the med room door because he wants his cigarettes. He is breathing hard and fixated on staring at staff. His voice is raised. He is unable to be redirected from his fixation on smoking. He has since left the nurses station, but he keeps coming to the desk and making demands. Staff has let SS (social services) know of his behaviors . Review of Behavior Note dated [DATE] at 3:51 PM, revealed, .Resident has all his belongings packed in his room. Staff offered conversation to him about this to which he becomes aggressive with this nurse. He is noted again to be staring at nurse, teeth clenched, fist drawn. Staff has offered a goal-based approach to help him clean his room to which again agitates him. Staff is giving this resident space as any contact by this nurse is noted to increase his anxiety. Staff has notified SS (social worker) of this behavior . During an observation and interview on [DATE] at 3:43 PM, revealed, .Resident #12 was observed lying in his bed with his legs over the side of the bed and his head resting against the wall. Resident #12 stated, .They don't even allow me to smoke, they are not taking me out to smoke .I have a strong desire to go smoke .I have been pining (suffer a mental and physical decline) and waiting for a smoke .My mind is racing and I can't stop the thoughts .I have jitters in my hands, I want to take away the jitters in my hands .My brother was put in a placed like this and they killed him .Feel like I don't have anybody, anybody to help . In an interview on [DATE] at 2:36 PM, Guardian MMM reported Resident #12 had been a smoker for most of his life and He should be able to go out and smoke, he has that right. Guardian MMM reported staff at the facility informed her the doctor wrote an order preventing (Resident #12) to go out to smoke due to, as staff were telling me, he was having seizures when he smoked. Guardian MMM stated, .I have not seen the order though .I will be upset if I was lied to and there was no order .Daughter talked to me and was not sure why resident was no longer able to go out to smoke since he has been smoker his whole adult life and he was allowed to smoke since he has been there .His behaviors have most definitely increased due to not being able to smoke . In an observation and interview on [DATE] at 11:13 AM, Director of Nursing reviewed medical record for Resident #12 and stated, .There was no order for him to not smoke . When queried on why he was no longer able to go smoke since he was admitted as a smoker, DON reported she was not sure what had changed since admission as she did not do the assessment and the staff member who did, was no longer an employee. Also, there was no indication as to why R12 was not reassessed as a smoker. In an interview on [DATE] at 5:02 PM, Certified Nursing Assistant (CNA) RR reported Resident #12 doesn't like when he sees other residents go outside to smoke and he would have a big fit and would get very agitated and he would refuse all assistance. In an interview on [DATE] at 10:10 AM, Resident #12 stated, .I am shaking (resident held out his hands for this writer to observe the shaking of his hands) .I want a cigarette .Quitting is ungodly .I want to go outside .I have a million things going through my head and I can't control them .I am angry .I can't control them .Thinking about (a military based) and all those cancers they had their and my mom and she died of cancer .it surely was not the baby powder as we were there . CNA DD entered the room and Resident #12 was asking her about going out to smoke. CNA DD stated she was there to help get him cleaned up and dressed. In an interview on [DATE] at 1:34 PM, Resident #12 stated, .I missed three smoke breaks yesterday .I am pissed about, peeved about it .The pissed the hell out of him and he was trying to tell them .I am so agitated and irritated .Pisses the hell out of me and now I can't smoke today .Pisses the hell out of me that I missed those three smoke breaks yesterday and today we can't go out . In an interview on [DATE] at 1:43 PM, CNA CC stated, .Two week ago, (Resident #12) grabbed the cigarettes of other residents who were going out to smoke, and he was swinging at everyone who was trying to get them away from him. They finally got them away from him and locked them in the medication room . Note: This writer did to receive an incident report for this event, and it was not noted in the medical record. In an interview on [DATE] at 12:58 PM, CNA Y reported Resident #12 really loved his coffee and he would raid the coffee cart. Resident #12 was ready and waiting to go out for smoke break, pretty much for all smoke breaks, he would go out and smoke. He didn't care if it was extremely cold, he would smoke anyway. There was no diverting him from smoking. In an interview on [DATE] at 1:18 PM, Social Work Director BBB reported Resident #12 was threatening staff, young and old, didn't matter if they were rolling in a wheelchair. Resident #12 grabbed his cup that was closest to him, he was upset because he couldn't go out to smoke, and he wanted to smoke. SWD BBB reported she never observed him having a [CONDITION(S)] when he smoked, she was told he had seizures when he smoked. In an interview on [DATE] at 12:42 PM, CNA HH reported Resident #12 was .always up and about with his coffee and he loved his cigarettes. He was the first one right there at the door to go out to smoke . Yes, he did yell and cuss but that was how he was .he had always been appropriate in his interactions with me. In an interview on [DATE] at 3:34 PM, OTR Therapy UUU reported Resident #12 was on therapies service last month for physical therapy and occupational therapy. OTR UUU reported Resident #12 was an active participant in therapy and we knew not to schedule therapy for smoking times because he would go smoke and would get agitated if we tried to conduct therapy during smoking times. OTR UUU reported Resident #12 was stand by supervision for everything does not recommend no supervision. He also may still require more assistance .supervision fluctuated based on his cognition and his ability, if he was fatigued that day, would determine if he could actively participate. Review of the medical record for Resident #12 showed no order or documentation in progress notes by the provider which restricted Resident #12 from smoking due to seizures. Resident #22: Review of Admission Record revealed Resident #22 was a male with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Care Plan revision on [DATE], revealed the focus, .(Resident #22) wishes to smoke cigarettes & has been assessed as requiring a smoking apron and supervision . with the interventions .Assess (Resident #22)'s ability to smoke safely per facility policy .provide supervision during smoking activity. Requires a smoking apron . Review of Smoking Evaluation completed on [DATE], revealed, .Mental Status: Alert; Manual/Dexterity: 1. Gasps/Holds; Reflexes: Quick response; Speech: Clear, Understood; Vision: Adequate; Smokes only i1)n designated area: Yes; Safely lights smoking materials: no; Follows smoking guidelines per policy: Yes; Able to call for emergency assistance: Yes; Returns smoking materials to nurse staff: Yes; Summary of Evaluation: Supervised .Comments: (Resident #22) is unable to light his own cigarette he relies on staff to assist him . Smoking Evaluation completed on [DATE], revealed, .Mental Status: Alert; Manual/Dexterity: 2. Weak grasps/drops items; 1. Gasps/Holds; Reflexes: Diminished response; Speech: Clear, Understood; Vision: Adequate; Smokes only in designated area: Yes; Safely lights smoking materials: no; Follows smoking guidelines per policy: Yes; Able to call for emergency assistance: Yes; Returns smoking materials to nurse staff: Yes; Summary of Evaluation: Unsafe Smoker .Comments: (Resident #22) is being deemed an unsafe smoker due to not being able to light his own cigarette, hold a cigarette without dropping it, having delayed responses to fallen ashes, and not being able to extinguish cigarette safely. Nicotine patch offered to (Resident #22) . In an interview on [DATE] at 2:14 PM, Resident #22 reported he has only been allowed to smoke if his brother or his outside case worker comes to assist him with smoking. He reported the facility does not allow him to go out on smoking days and times with other residents. Resident #22 reported his niece bought him a lighter that senses his thumb, but it is too slippery at the top for him to open. Resident #22 reported the lighter has a sensor if he could get it open but it's just too slippery. Resident #22 reported he does wear a smoking apron (was placed on his chest/stomach area) when he goes out to smoke. Resident #22 reported he has tried another lighter but that one didn't work either. Resident #22 showed this writer his hand which was contracted but demonstrated that he was able to move his thumb across his index finger up and down, but he can't always move it enough or have enough strength to open the top of the lighter and activate the sensor on the lighter. Resident #22 reported he was very frustrated that he was not allowed to go out to smoke unless his brother drives all the way over from a neighboring town or his outside case worker comes to assist him. Resident #22 stated, .That's not right that my brother has to drive all the way over to take me out to smoke .It pisses me off more than anything he comes here twice a week, and my case worker comes on Wednesdays to help me .I am an anxious, jumpy person and not being able to smoke isn't right . In an interview on [DATE] at 12:23 PM, Ombudsman MM reported (Resident #22's) niece wants a handicap accessible lighter for the resident. Ombudsman MM reported Resident# 22 has a smoking apron that he wears when he smokes and indicated he has no problem wearing it. Ombudsman MM reported Resident #22 would slide his lighter a crossed the apron and attempt to hold his hand over the sensor to light the lighter. Ombudsman MM reported Resident #22 from what she could ascertain had never been assessed by the occupational therapist for his ability to smoke, he was his own person and has a BIMS of 14 capable of making his own decisions. Ombudsman MM stated, .I have had to deal with (Resident #22) calling my phone continuously and leaving messages about this type of situation. He was extremely agitated and frustrated by this decision . In an interview on [DATE] at 1:04 PM, Community Mental Health Nursing Home Monitor (CMHNHM) LLL reported she would see Resident #22 about ,d+[DATE] times per month. CMHNHM LLL reported she had gone to administration in the nursing home and spoke to the ombudsman about the restriction of his smoking privileges. Was told it is a safety hazard for him lighting the E lighter, holding his cigarette, and ability to put the cigarette out appropriately. CMHNHM LLL reported the final call had been made after several failed smoking safety assessments in the facility. CMHNHM LLL stated, .(Resident #22) was offered E cigarettes but prefers the old school smoking .(Resident #22) lost a lot of things in his life and smoking is a big issue because it provides him joy .Smoking brings some normalcy to his life, it was an activity he enjoyed doing, and it would get him outside .and with his [CONDITION(S)] that is a big thing .there has to be something adaptable so he would be able to smoke .He enjoys smoking it would make him content .I have been his case manager for ,d+[DATE] years and he has had the same range of motion in his arms .he does shake but that is due to his [CONDITION(S)] but it is not all the time .he definitely has had increased behaviors the last few months .More agitated, more hyper focused .It is a simple thing to assist him with . In an interview on [DATE] at 11:46 AM, Director of Nursing (DON) B reported nursing, social work, and activities were appropriate for conducting the smoking evaluations. DON B stated it is appropriate for him (Resident #22) to be evaluated by them, I don't see why it is any different than any other comorbidity . Review of the facility Smoking Data Collection & Assessment revised ,d+[DATE] revealed, The smoking assessment will be completed by a Licensed Nurse for all guests who wish to smoke . The assessment will be completed upon admission, quarterly, and with a change in condition if indicated. On [DATE], the Director of Nursing (DON) provided this writer was provided with an invoice of an adaptive device purchased for Resident #22. The devices Clip-On Ashtray with Remote tube holds a cigarette over an ash tray while a tube attaches to the cigarette. This tube runs up to the mouth to allow for remote smoking. This tube ensure that the cigarette is always over the ash tray . In an interview on [DATE] at 11:38 AM, Rehab Director SS stated, .I ordered it yesterday for him and they ordered 2 of them to have an extra one . Review of Admission Agreement received on [DATE], revealed, .V. RESIDENT RIGHTS: The Healthcare Center shall observe the rights of the Resident as established by local, state, and federal law . Review of Know Your Rights - Your Medicaid Care and Coverage in a Nursing Facility version DCH 0731 (,d+[DATE]) revealed, .Quality of Life in Your Nursing Home: You have a right to live in a safe, clean, comfortable, and home-like nursing home .You have a right to choose activities, schedules, and health care that meet your needs, interests and care plan. You have a right to take part in any social, religious, and community groups, both inside and outside the home .Quality of Your Medical Care: You have a right to receive necessary nursing, medical, and social services to reach and maintain the highest practicable physical, mental, and social well-being . R15 According to the Minimum Data Set (MDS) dated [DATE], R15 scored ,d+[DATE] (cognitively intact) on his BIMS (Brief Interview Status), required extensive assistance of two-person physical support for bed mobility, with no impairment in either arm or hand with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 2:55 PM R15 stated, I want to go out and smoke. Residents are allowed to go out to smoke only on Monday, Wednesday, and Friday. Today is Wednesday. I asked to go out today. An aide told me they would get my wheelchair for me that is kept out in the hall. I have not heard back from her yet. LPN Q stated I asked (R15's) CNA who told me the resident needed two-person assist into his wheelchair. R15 stated, Residents were told we could only go out and smoke on those three days because of not enough staff. R15 stated while shaking his head and sad expression stated, I want to go out and smoke. I like going out with others, visiting, and smoking gives me that. Staff tell me I can only go and smoke three days a week. Why? I guess because they do not have staff all the time. Review of R15's Care Plan revised [DATE] reported the resident preferred to engage in activities independently but was willing to attend programs as interested. R15 enjoyed going out to smoke and would socialize with other residents then. The goal for R15 was to have him participate in independent activities of choice daily (revision [DATE]). Interventions to reach this goal included was to introduce R15 to residents with similar interests and encourage/facilitate interaction ([DATE]). Review of R15's Care Plan Smoking Products dated [DATE] reported the resident wished to use smoking products and had been assessed as being safe to smoke with supervision. The goal was for R15 to be safe using smoking products and comply with facility smoking policy through the next review date. Interventions to meet this goal included assessing the resident's ability to smoke safely per facility policy. Review of R15's Care Plan dated [DATE] reported the resident is offered to go outside Monday, Wednesday, and Friday in the morning and the afternoon for smoking. R15 enjoys going out to smoke and is safely able to light/handle the lighter and cigarette, returning the smoking materials to staff after use. The goal was for the resident to attend smoking three times weekly at his leisure by next review date. The intervention to meet this goal was to offer R15 smoking three days a week M/W/F (Monday/Wednesday/Friday) in the morning and afternoon ([DATE]). Review of R15's Smoking Evaluation dated [DATE] (quarterly) reported the resident: -mental status: alert -manual dexterity: grasps/holds -safely lights and holds smoking materials -safely disposes of ashes in ashtray -safely extinguishes cigarette -responds quickly to fallen ashes -follows smoking guidelines per policy -able to call for emergency assistance Summary Evaluation reported resident was able to smoke while supervised. Review of R15's Smoking Evaluation dated [DATE] (admission) reported the resident: -mental status: alert -manual dexterity: grasps/holds -reflexes: quick responses -safely lights and holds smoking materials -disposes of ashes in ashtray -safely extinguishes cigarette -responds quickly to fallen ashes -follows smoking guidelines per policy -able to call for emergency assistance Summary Evaluation reported resident was a safe smoker and was able to smoke while supervised. Review of R15's Smoking Evaluation dated [DATE] (quarterly) reported the resident: -mental status: alert -manual dexterity: grasps/holds -reflexes: quick response -safely holds and lights smoking materials -disposes ashes in ashtray -safely extinguishes cigarettes -responds quickly to fallen ashes -follows smoking guidelines per policy -able to call for emergency assistance Summary Evaluation reported resident was a safe smoker and was able to smoke while supervised. R46 According to the Minimum Data Set (MDS) dated [DATE], R46 scored ,d+[DATE] on his BIMS (Brief Interview Mental Status), required extensive assistance of two-plus persons physical assist with bed mobility and locomotion on the unit, total dependence of two-plus person physical assist for transfers, supervision with set-up only for eating, impairment with his left arm, hand, and leg, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R46's Smoking Evaluation dated [DATE] (readmission) reported the resident: -me [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure adequate supervision for 7 of 8 residents (Resident #'s 23, 43, 52, 77, 13, 12, and 11) reviewed for supervision, resulting in: 1.) the potential for resident to resident abuse due to wandering in Residents #23, #43 and #52, 2.) falls with injury requiring outside intervention for Resident #77 and #13, 3.) falls without major injury for Resident #12, and 4.) an unsupervised elopement for Resident #11. Findings include: During an observation on 7/26/22 at 12:39 PM., 12 residents on the Specialty Care Unit (SCU-Locked dementia unit) eating lunch in the dining room with no staff present for approximately 6 minutes. Noted staff on the SCU passing trays on the hallway, and no nurse present on the unit at this time. Resident #23 Review of an Admission Record revealed Resident #23 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimers disease, [CONDITION(S)] and mood disorder with manic features. Review of a Minimum Data Set (MDS) assessment for Resident #23, with a reference date of 4/24/22 revealed a Brief Interview for Mental Status (BIMS) score of 03, out of a total possible score of 15, which indicated Resident #23 was severely cognitively impaired. Review of Resident #23 Care Plan revealed: NEED- (Resident #23) has the potential to demonstrate physical, verbal aggression R/T: Anger, History of: being combative with care, wandering in other Guests room to wake them by taping them resulting in other Guests being startled at times. INTERVENTIONS: Assess Resident #23 understanding of the situation. Allow time for the resident to express self and feelings towards the situation, including antecedents, effective calming strategies. Date Initiated: 03/18/2020 Created on: 03/18/2020 · Modify environment: Adjust room temperature to comfortable level, Reduce noise, dim lights, place familiar objects in room. Date Initiated: 03/18/2020 Created on: 03/18/2020 · Psychiatric consult as indicated. Date Initiated: 03/18/2020 . Resident #43 Review of an Admission Record revealed Resident #43 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia with behavioral disturbances. Review of a Minimum Data Set (MDS) assessment for Resident #43, with a reference date of 5/19/22 revealed a Brief Interview for Mental Status (BIMS) score of 04, out of a total possible score of 15, which indicated Resident #43 was severely cognitively impaired. During an observation on 7/26/22 at 10:49 AM., noted on the Specially Care Unit (SCU) no staff noted on the hallway (which was long/narrow with resident rooms on each side of the hallway) observed Resident #23 enter Resident #43's room. Resident #43 began yelling out help help help once Resident #23 approached Resident #43 and began touching Resident #43's wheelchair in which she (Resident #43) was seated in. Resident #23 began to self propel in her wheelchair near Resident #43's bedside table, nightstand and Resident #43 touching Resident #43 personal items. During an observation on 7/26/22 at 10:55 AM., Certified Nurse Aide (CNA) CC came into Resident #43's room after hearing Resident #43 hollering out help help help CNA CC redirected Resident #23 out of Resident #43's room into the dining room. During an interview on 7/26/22 at 10:57 AM., Resident #43 reported No when this surveyor asked if Resident #23 was her friend, and if she (Resident #43) welcomed into her (Resident #23) into the bedroom. During an interview on 7/26/22 at 11:02 AM., CNA CC reported Resident #23 wanders into other resident rooms quite often. CNA CC reported Resident #23 has been involved in Resident to Resident altercations. CNA CC reported there are usually 2 CNAs, a nurse an an Activity Aide (AA) on the unit. CNA CC reported it is very difficult to keep an eye on all 30-31 residents on the unit, especially when the CNA's are in other resident rooms, the nurse is passing medications, and the activity aide is (usually) in the dining room (dining room closed off by 1 doorway unable to observe unit from inside dining room) doing activities and keeping an eye on residents who like to spend their time in the dining area. During an observation on 7/28/22 at 1:10 PM., noticed Resident #23 self propelling down the hallway on the SCU back and forth the length of the hall, and side to side from one door to another. Resident #23 observed entering room 111 approximately 2 minutes passed before Activity Aide (AA) noticed. AA went into room 111 redirected Resident #23. Resident #23 continued self propelling up and down the hall holding onto the railings, fidgeting with them, and turning around to go back down the hall side to side. During an interview on 7/28/22 at 1:20 PM., AA UU reported Resident #23 is known to wander into other resident rooms and up and down the hallways. AA UU reported it is difficult for staff to be in 2 places at once AA UU reported for 30-32 residents on the SCU 2 CNA staff is not enough to adequately supervise and keep all the residents from wandering, falling and keep them entertained. AA UU reported during the hours of 2: 00 PM-6:00 PM many residents behaviors get worse around that time. AA UU reported with the amount of residents that can ambulate (walk-with or without walkers) and the size of the unit, it is very challenging to keep them away from one another, and eyes on everyone. AA UU reports if one of the residents on the 'SCU starts to have increased behaviors it becomes increasingly difficult due to the increase in stimulation, that it is not long before other resident start their own behaviors. AA UU reported some residents pace up and down the units hallway, self propel their wheelchairs, exit seek, and holler out. AA UU reported it would be beneficial to increase the staffing especially qualified staff (CNA's) on 1st and especially 2nd shifts. AA UU reported there would be a decrease in falls, and resident to resident altercations if there were at least 3 CNA's at all times on the unit, along with a nurse and an activity aide. Resident #52 Review of an Admission Record revealed Resident #52 was a [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia. Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 6/14/22 revealed a Brief Interview for Mental Status (BIMS) score of 02, out of a total possible score of 15, which indicated Resident #52 was severely cognitively impaired. During an observation/interview on 7/29/22 at 2:14 PM., observed Resident #23 entering Resident #52's bedroom. Resident #23 self-propelled her wheelchair towards Resident #52's bed. Resident #52 was observed laying asleep in her bed. Resident #23 approached Resident #52's bed, and began touching Resident #52's bedding, and covered legs as if she (Resident #23) were tucking her (Resident #52) in. Resident #23 then turned her wheelchair slightly around and began touching random personal belongs of Resident #52's which were on the nightstand and bedside table. At 2:19 PM., Certified Nurse Aide (CNA) X entered Resident #52's bedroom. Resident #52 woke up. CNA X tried to redirect Resident #23 away from Resident #52. Resident #23 was not easily redirectable and would not move from the area. Resident #52's eyes were opened and appeared to just watch Resident #23 and CNA X for a moment. CNA DD entered Resident #52's room. CNA DD attempted to redirect Resident #23 out of Resident #52's room and offered her a snack. Resident #23 would not move or self-propel her wheelchair from Resident #52's room. CNA DD then left the room and came back with foot pedals for Resident #23's wheelchair and Register Nurse (RN) I. RN I, CNA X and CNA DD then explained to Resident #23 that she needed let Resident #52 rest. CNA DD put the foot pedals on Resident #23's wheelchair and assisted her (Resident #23) out of Resident #52's room and down the hall to the dining room. During an interview on 7/29/22 at 2:35 PM., CNA X reported Resident #23 often wanders into other resident rooms. CNA X reported it is difficult to keep track of and monitor the residents on the specialty care unit (SCU) (locked dementia unit). CNA X reported Resident #23 is not always easy to redirect and has known behaviors of refusing care, lashing out, and resident to resident contact. CNA X reported it would be beneficial for the specialty care unit to have at least 3 CNA's at all time due to the number of wandering and behavior residents. CNA X reported the hours between about 2:00 PM-7:00 PM are extremely difficult because many of the residents residing on the SCU have sundowner's syndrome (sundown syndrome may include symptoms of [CONDITION(S)], anxiety, pacing, hallucinations, paranoia, and confusion). CNA X reported that is when a lot of resident-to-resident altercations, falls and behaviors increase. CNA X reported typically she has 15 residents on her assignment for the day, and it is not easy to keep an eye on all of her residents, especially when she (CNA X) is in a resident room doing cares, toileting, bathing, attending to behaviors or answering call lights. During an interview on 7/29/22 at 2:40 PM., CNA DD reported supervision of the residents on the SCU was challenging because a lot of times there are no eyes on what is happening in the hallway when CNA's (floor staff) are in other resident rooms, dining rooms or assisting with something off the unit (getting supplies, items from kitchen, or on break). CNA DD reported it is a very busy time and residents on the SCU have increased behaviors around mid afternoon until later in the evening. CNA DD reported Resident #23 has known behaviors of wandering in and out of other resident rooms, can be difficult to redirect, and can be combative. During an interview on 7/29/22 at 2:47 PM., Registered Nurse (RN) I reported Resident #23 wanders a lot into other resident rooms a lot. RN I reported there were not enough staff to adequately keep an eye on all the residents on the memory care unit. RN I reported there have been many resident-to-resident altercations, and an increase in falls on the SCU. RN I reported the facility recently lost quite a few activity staff, as well as if there call offs it was challenging to watch everyone while also trying to do care, pass meal trays, do treatments and medications. L RN I reported there should be 3 CNA at least on the SCU at all times to ensure the safety of all the resident residing on the unit. RN I reported sundowning residents become increasingly behavioral after lunch through dinner time. RN I reported if one incident occurs with a resident or 2, and the CNA's and nurse are attending to that situation it becomes like a [NAME] effect. RN I reported once that happens it is one incident after another and trying to keep eyes on all the residents becomes extremely hard. During an interview on 7/29/22 at 2:50 PM., Resident #52 reported she was unsure why that woman (Resident #23) came in her room. Resident #52 reported she was asleep until that happened. Resident #52 reported she just woke up when she heard people talking. Resident #52 reported she was not expecting visitors. Resident #77 Review of an Admission Record revealed Resident #77 was a [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia with behavioral disturbances. Review of a Minimum Data Set (MDS) assessment for Resident #77, with a reference date of 6/17/22 revealed a Brief Interview for Mental Status (BIMS) score of 04, out of a total possible score of 15, which indicated Resident #77 was cognitively impaired. Further review of Resident #77's MDS Functional Status Resident #77 was a 3. Extensive assistance - resident involved in activity, staff provide weight-bearing support. 2. One person physical assist. for toileting (bathroom assistance by staff). During an observation on 7/26/22 at 12:22 PM., Resident #77 was observed in the dining room walking with a 4-wheeled walker. Resident #77's gait (walk) was unsteady, and her (Resident #77's) walker was ahead of her while she (Resident #77) walked out of dining room into the hallway. LPN M was observed opening the shower room (with a bathroom/toilet) inside. LPN M prompted Resident #77 to use the toilet. Resident #77 entered the shower room alone as LPN Mwas observed to walk over to his medication cart approximately 4 feet away. LPN M continued to complete charting on the laptop on the medication cart. It was noted Resident #77 trying to open the shower room door from the inside. LPN M did not respond to the door immediately, LPN 'M responded once Resident #77 was heard making noise with her walker which was blocking the door from opening. LPN M then peeked around the corner, instructed Resident #77 to back up a bit, and then LPN M opened the shower room door for Resident #77. During an interview on 7/26/22 at 12:40 PM., LPN M reported (Resident #77) should have been supervised by him (LPN M) when she went into the shower room to use the bathroom. LPN M reported (Resident #77) is a high fall risk, and has had falls with injury. LPN M reported (Resident #77) reported he (LPN M) should have assisted with toileting (Resident #77). Review of Resident #77's Electronic Medical Record (EMR) revealed: 6/23/2022 12:10 Nurses Notes Late Entry: Note Text: (Resident #77) quickly got out of chair resulting left shoe with no sock on to fall off and (Resident #77) fell on to knees, chest, then forehead onto the ground. (Resident #77) was assessed by nurse resulting in bruise to left knee and left forehead . Review of Resident #77's EMR revealed: Progress Notes 6/26/2022 17:06 pm Nurses Notes Text: (Resident #77) observed on the floor in room 108 (room 108 was not Resident #77's room) .(Resident #77) found lying on her back head facing the window and feet towards the door with legs crossed, and hands over her chest. (Resident #77) unable to explain the reason for being in that room . Review of Resident # 77's EMR revealed: Progress Notes 7/4/2022 20:29 pm Nurses Notes Text: Patient (Resident #77) was found on floor in room 110 (room 110 was not Resident #77's room) Apparently she (Resident #77) had wandered in there and gone to the bathroom . Patient (Resident #77) was found with a laceration to back of head . Review of Resident # 77's EMR revealed: Physicians Notes 7/4/2022 00:00 am . CHIEF COMPLAINT Fall with head laceration General: (Resident #77) . seen due to fall with head laceration. (Resident #77) fell after using the bathroom (Resident #77) did hit her head. (Resident #77) sustained a laceration to the posterior head. Dressing was applied control bleeding however laceration is wide and will require repair Review of Resident #77's EMR revealed: Progress Notes 7/5/2022 04:34 am Nurses Notes Text: Patient (Resident #77) returned from hospital at 03:50 am. Patient (Resident #77) received 3 staples on back of head . During an interview on 7/28/22 at 2:10 PM., CNA KK reported if there were more staff working especially on the SCU there would be less falls, falls with injury and resident to resident altercations. CNA KK reported there are too many behavioral, and ambulatory (able to walk) residents to adequately keep them safe. During an observation on 7/28/22 at 3:58 PM., Resident #77 observed up walking with walker, walks quickly with 4 wheeled walker, somewhat unsteady gait .staff did no stand by, walked by her, went up to nurse towards exit door. Resident #77 observed exit seeking trying to get out to the main hall. During an observation on 7/29/22 at 2:11 PM, RN I had prepared to enter Resident #12's room and indicated she was going to get staff to assist the resident. During this time, Resident #77 had self-ambulated without her walker and was losing her balance by the double doors leading into the hallway. RN I ran to assist her prior to her losing her balance and falling. Certified Nursing Assistant (CNA) DD went to the resident's room to obtain her walker. Female resident resides more than halfway down the hallway on the Secure Care Unit (SCU). During an interview on 08/03/22 at 9:21 AM., Minimum Data Set (MDS) C nurse reported (Resident #77) was a 1 person physical assist for toileting. MDS nurse C reported staff should always assist (Resident #77) to the bathroom, and anticipate her needs before hand. Resident #13 Review of an Admission Record revealed Resident #13 was an [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 6/25/22 revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #13 was severely cognitively impaired. Review of a facility Post Fall Evaluation dated 6/25/22 at 2:40 PM., revealed: (Resident #13) walking around in dining room prior to fall Factors of the fall: lost strength/appeared weak .position observed: laying flat on the back. Review of Resident #13's Electronic Medical Record (EMR) revealed: Created By: (Licensed Practical Nurse (LPN) R) 6/25/2022 17:58 Nurses Note Text: (Resident #13) had unwitnessed fall in dining area. (Resident #13) unable to state what she was doing prior to incident Review of Resident #13's Electronic Medical Record (EMR) revealed: 6/25/2022 23:57 Nurses Notes Text: Throughout the evening (Resident #13) continued to exhibit signs and symptoms of pain including, guarding, yelling out, crying, and rubbing the painful area. She (Resident #13) was no longer moving her right leg and was keeping her leg in a bent position administered her scheduled Tylenol and it did not appear to be effective at all. Due to the increase in pain, inability to move the right leg, and inability to obtain an x-ray in house, (Resident #13) was sent to (emergency room ) for further evaluation and treatment . During an interview on 7/28/22 at 2:20 PM., CNA RR reported Resident #13 was unsteady on her feet but was able to walk with assist. CNA RR reported when (Resident #13) fell she was in the dining room, and she (CNA RR) heard her (Resident #13) cry out. CNA RR reported it is extremely difficult to keep an eye on all the residents on the Specialty Care Unit (SCU) due to behaviors, fall risks, wandering/exit seeking and only having 2 CNA's, 1 nurse, and 1 Activity Aide (AA) 1 year. CNA RR reported many residents wander into other resident rooms, and have behaviors such as lashing out, striking staff and other residents. CNA RR reported there should be at least 3 CNA on 1st and 2nd shift to prevent falls, wandering and resident to resident altercations. During an interview on 08/02/22 03:10 PM., LPN R reported Resident #13 fell on [DATE] and she was the assigned nurse on the SCU. LPN R reported at the time of her (Resident #13's) fall she (LPN R) was off the unit going on break. LPN R reported when she walked back onto the unit there were so many residents walking/wandering around it was absolute chaos LPN R reported it was extremely difficult to tend to Resident #13 to get her up of the floor to a safe place to accurately assess. LPN R reported on 1st and 2nd shift on the SCU there should always be 3 CNA's and if the nurse on duty goes on break, another nurse or manager should be covering the unit. LPN R reported there are too many residents that are high risk for falls, behaviors, resident to resident altercations and exit seeking to not have someone watching the hallway. LPN R reported without another set of eyes on the SCU unit, the falls, falls with injury and resident to resident altercation will continue. Review of Resident #13's Electronic Medical Record (EMR) revealed: 6/26/2022 05:49 Nurses Notes Text: Just spoke with the nurse at (hospital)and (Resident #13) is being admitted for a broken hip . Review of Resident #13's Electronic Medical Record (EMR) revealed: 6/30/2022 18:46 Nursing Summary Note Text: (Resident #13) returned to the facility at 1730 this evening. She (Resident #13) as 3 incisions to her (Resident #13) right lateral upper leg r/t (related to) surgical intervention. She (Resident #13) also has bruising to right leg from knee to hip She (Resident #13) is exhibiting signs of pain but is unable to state or rate her pain verbally . Resident #12: Review of Admission Record revealed Resident #12 was a male with pertinent diagnoses which included dementia with behavioral disturbance, ADHD, seizures, [CONDITION(S)] (wearing down of protective tissue at the ends of bones), muscle weakness, [MEDICATION(S)] (urinary tract infection), difficulty walking, [CONDITION(S)], cognitive communication deficit, and kidney failure. Review of falls Care Plan for Resident #12 revealed the focus, .(Resident #12) is at risk for fall related injury and falls . with the interventions .Bilat rear anti-tippers to w/c (wheelchair) created on 7/12/22 .Encourage the resident to wear appropriate footwear as needed created on 7/30/21 .Fall mat beside bed created on 4/13/22 .Check and change or offer toileting assistance about every 2 hours as tolerated created on 5/18/22 .have room cleaned at times when patient is participating in activities to allow floor time to dry revision on 1/1/22 .Keep the resident's environment as safe as possible .Avoid repositioning furniture and keep the bed in the appropriate position revision on 6/7/22 .place 4ww (wheeled walker) in cubby outside room when not ambulating with staff created on 7/22/22 .place personal items within reach while in bed created on 5/31/22 .Provide (Resident #12) with activities that minimize the potential for falls while providing diversion and distraction revision on 6/7/22 .Use w/c for toileting instead of 4 WW revision on 6/20/22 . Review of Incident and Accident Report dated 5/18/22, revealed, Patient found on floor next to bed. Fall was unwitnessed Patient stated trying to go to the bathroom .Interventions implemented: Labs and Q2 (every two hours) toileting program .Incontinent at the time of fall . Review of Progress Note dated 5/19/22 at 2:07 PM, revealed, .IDT met to review resident's fall from 5/18/2022. Resident was observed on the floor in his room stating he was trying to use his urinal .Action Taken: Immediate intervention is to obtain labs and Q2 (every 2 hours) toileting program . Review of Toilet Use and Continence' for previous 7 days revealed, .05:31 AM one person physical assist, 09:16 AM one person physical assist, 7:27 PM No set up or physical help from staff; 7/23/22: 00:04 AM, one person physical assist, 10:26 AM one person physical assist, 9:02 PM one person physical assist; 7/24/22 05:28 AM one person physical assist, 4:35 PM no setup or assist by staff; 7/25/22 05:15 AM, one person physical assist, 10:23 AM, one person physical assist, 3:28 PM one person physical assist; 7/26/22 05:59 AM, one person physical assist, 1:50 PM one person physical assist, 9:45 PM one person physical assist; 7/27/22 5:31 AM one person physical assist, 11:18 AM one person physical assist, 9:20 PM one person physical assist; 7/28/22 5:59 AM one person physical assist, 10:28 AM set up help only, 1:48 PM revealed no set up help by staff, 4:44 PM resident refused; 7/29/22 3:56 AM 2+person physical assist, 8:47 PM one person physical assist; 7/30/22 5:52 AM one person physical assist, 8:37 AM one person physical assist, 7:12 PM one person physical assist; 7/31/22 1:15 AM one person physical assist, 8:12 AM one person physical assist, 9:57 AM one person physical assist, 5:54 PM one person physical assist; 8/1/22 5:27 AM one person physical assist, 9:51 AM one person physical assist, 9:08 PM one person physical assist; 8/2/22 5:59 AM Resident refused, 12:28 PM one person physical assist, 8:01 PM one person physical assist . Review of Nurses Notes dated 5/31/22 at 2:01 AM, revealed, .Unwitnessed fall is on neurological checks per protocol .He was using his four wheeled walker at the time of fall. (Resident #12) is supposed to have staff assistance with transfers which he is resistant to and will regularly be observed ambulating with walker without staff assistance .Staff is performing 15 min checks throughout the night . Review of Nurses Notes dated 5/31/22 at 10:18 AM, revealed, .Resident was soiled and incontinent at the time of fall . Review of Incident and Accident Report dated 6/9/22, revealed, .Resident observed laying on floor flat on back hand behind his head . Review of Post Fall Evaluation dated 6/9/22, revealed, .What did the guest/resident say they were trying to do just before they fell ? .Said, WC (wheelchair) went out from under me.Fall Huddle: Faulty wheelchair .Another w/c provided . Review of Nurses Notes dated 6/9/22 at 6:38 PM, revealed, .Resident observed laying on the floor with legs out and hands behind head .Staff noted upon attempting to assist him to sit in his wheelchair that the breaks (sic) were faulty. Staff tagged the wheelchair and placed in (electronic maintenance report system) for repair . Review of Incident and Accident Report dated 6/20/22, revealed, .Resident was walking with CNA to bathroom and stated, I'm gonna fall. CNA lowered resident to the floor and onto his knees .Intervention implemented: W/C transfers instead of walker encouraged . Review of Post Fall Evaluation dated 7/1/22 at 4:05 PM, revealed, .Re-enactment of fall: Resident was using unlocked 4ww to transfer from w/c to bed. Lost balance and fell to floor .Tipped locked w/c backward but was not in w/c at that time .Resident not using 4ww appropriately (unable to state need of brakes use) . Review of Resident at Risk dated 7/12/22 at 1:38 PM, revealed, .Per nursing at 4:05 PM, resident was observed on the floor in his own room laying on his right side parallel to his bed on his fall mat .When asked what happened he said he was trying to transfer to his w/c with the use of his 4ww and fell .Staff examined resident and noted a new skin alteration of L sided redness to the torso .IDT reviewed the fall and determined an appropriate intervention of encouraging resident to not have 4ww at bedside and bilateral anti-tippers to w/c . Review of Order dated 7/12/22 revealed, .Antitippers to w/c bilat (bilaterally) . Review of Incident and Accident Report dated 7/21/22, revealed, .(Resident #12) was ambulating with 4ww unassisted and fell on to his left side .Hit head on floor .Only injury was slight redness to outer ankle .Interventions Implemented: [NAME] placed in cubby outside of room when not being assisted by staff . Review of Incident and Accident Report dated 7/22/22, revealed, .Resident was observed sitting upright held up by arm legs straight .He was in front of w/c on fall mat next to bed .Interventions implemented: Antitippers on w/c . Note: this is a repeat from the 7/12/22 order. Review of Post Fall Evaluation dated 7/22/22, revealed, .Time of fall: 0930 AM .Observed on floor (unwitnessed) .Resident brakes on w/c were not locked .No antitippers present & brakes not locked . Review of Resident at Risk dated 7/25/22 at 10:24 AM, revealed, .IDT reviewed the fall and determined an appropriate intervention of antitippers to w/c .Root cause analysis is that resident was attempting to self-transfer and fell . During an observation on 7/26/22 at 3:43 PM, Resident #12 was observed in his room lying on his bed with his legs over the side of the bed and his head resting on the wall next to his bed. During an observation on 7/28/22 at 11:09 AM, Resident #12 was observed self-ambulating in his room using his wheelchair handle and rolling bedside table for support. Resident was half way between his bed and the bathroom. During an observation on 7/29/22 at 10:06 AM, Resident #12 was observed walking in his room without his walker, which was in the room, or using his wheelchair to ambulate. Resident 12's wheelchair was located over by the entryway to the room. Resident #12's bed was located near the window on the other side of the room. Resident 12 would have to walk approximately 10 feet to reach his wheelchair. Resident #12's walker was located over the window halfway between his bed and the bathroom door. Resident #12's pants were completely soaked in the front covering his whole pelvic area and down his thighs almost reaching his knees. His pants in the back were soaked across the whole bottom and down the back of his legs to his knees. The blankets to his bed were on the floor at the foot of his bed where his rolling table was located placed in a horizontal position to the bed. During an observation on 7/29/22 at 1:11 PM, observed Resident #12 lying diagonally in his bed with his legs off the side of the bed. Resident did not have shoes on and had regular socks on his feet. Fall mat was not on the floor next to his bed. Resident #12's wheelchair was located across the room next to the dresser with the tv on it and out of resident's reach. During an observation on 7/29/22 at 2:05 PM, Resident #12 was observed seated in his wheelchair in his room and he wheeled over to his bed and self-transferred to his bed. No fall mat was located next to the resident's bed. Resident #12 locked the brakes on his wheelchair and it was next to his bed for easy access when attempting to transfer from his bed. During an observation on 7/29/22 at 2:11 PM, Resident #12 asked Registered Nurse (RN) I for a shoe lace for his shoe as it was missing. Resident #12's shoe was not observed to be very snug around resident's foot and could possibly fall off while resident was self-transferring or ambulating. During an observation on 7/29/22 at 2:58 PM, observed Resident #12 sitting on his bed with his table in front of him. No fall mat observed next to his bed. In an interview on 8/2/22 at 1:34 PM, Resident #12 reported he was upset about not being able to go outside to smoke and reported he just got his tennis shoes back as his neighbor stole his shoes not sure why this one has got no laces pointing to his left shoe. In an interview on 8/3/22 at 3:45 PM, LPN P reported Resident #12 had a higher incidence of falling with a shoe with no laces as he might trip or it could fall off and he would fall. LPN P reported Resident #12 was an increased fall risk and he left leg was just jumping earlier, she reported resident told her it was jumping all over the place. LPN P reported earlier when he was self-ambulating to get into the bed, I was worried he would fall if he couldn't make that step up to get on it (the fall mat) to get into bed. LPN P reported Resident #12 was supposed to have the fall mat in place anytime he is in the bed. In an interview on 8/3/22 at 12:29 PM, Resident #12 stated, .They won't let me walk .I have had 3 serious brain injuries from this place . Resident #12 was observed adjusting himself in the wheelchair. Resident #12's feet would get stuck under the wheelchair when he was attempting to self-propel down the hallway towards his room. He would propel a few feet and his feet would get stuck, stop reset himself and then self-propel an additional few feet. In an interview on 8/3/22 at 3:34 PM, OTR Therapy UUU reported Resident #12 was on therapy service last month for physical therapy and occupational therapy. OTR UUU reported Resident #12 was an active participant in therapy. OTR UUU reported Resident #12 was stand by supervision for everything does not recommend no [TRUNCATED]

This citation has 4 deficiency practice statements, A, B, and C. Deficiency Practice Statement A Based on observation, interview, and record review, the facility failed to: 1.) ensure staff use of personal protective equipment (PPE) to prevent the likelihood of the spread of communicable diseases ([MEDICAL CONDITION] -[MEDICAL CONDITION]) in 1 of 2 residents (Resident #4) reviewed [MEDICAL CONDITION] and, 2.) ensured facility staff identify and implement contact precautions to prevent the spread of infectious disease processes (crusted scabies) in 11 of 11 residents (Residents #45, #7, #8, #21, #44, #45, #57, #61, #65, #66, & #70) and 3.) ensure an effective infection control surveillance program for identifying, monitoring, and tracking potentially infectious diseases, resulting in an Immediate Jeopardy placing all residents at risk for the spread of communicable disease and infections. Finding include: Review of facility policy Infection Prevention and Control Program dated 11/16, revealed, Policy: The Infection Prevention and Control Program is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection to our guests, staff, volunteers, visitors, and other individuals providing services under contractual arrangements. The infection control process strives to improve the trends and patterns of significant infections. Purpose: The infection control program systems support the process to prevent, identify, report, investigate, and control infections and communicable diseases. The facility will use a coordinated process, which includes: 1. Guidelines from the Centers for Disease Control (CDC) two-tier isolation precautions systems: a. Standard Precautions b. Transmission-Based Precautions-contact, droplet, and airborne 2. Standards and procedures according to .CDC .5. Infection Surveillance System .Procedure: 2. Infection control in-service programs will be done annually and as needed for all staff. 3. Staff will follow Standard Precautions as observed daily during clinical rounds by DON/designee. 4. The following data collection will be used for infection surveillance: a. Clinical rounds b. 24-Hour Report .d. Medical records including physician progress notes [REDACTED]. Infection Report Worksheet .g. Infection control Surveillance and Monitoring Checklist .h. Random observations of staff practices .Responsibility: 1. The Administrator is responsible for the Infection Control Program 2. The DON/designee, as the delegated Infection Preventionist (IP), is to carry out the daily functions of the Infection Control Program 3. The Infection Control committee is a subcommittee of the Quality Assurance (QA) Committee and consists of the Administrator, Director of Nursing, Infection Preventionist, and the Medical Director. The Infection Control Committee meets monthly to provide direction for the Infection Control Program. The QA committee approves policies and procedures that relate to Infection Control .Reporting Mechanisms .4. Compliance with Infection Control Practices is measured and documented by a. Staff evaluation b. Observation of practices completed by the DON/designee, Infection Control Committee, or the delegates c. Monthly surveillance and monitoring Review of facility policy, Two-Tier Isolation Precautions revised 05/06, revealed, Policy: The facility will utilize the Two-tier Transmission Based Precautions as approved by the Centers for Disease control and Prevention (CDC). Purpose: There are two tiers Standard Precautions and Transmission-based Precautions. In the first and most important tier, are the precautions designed for care of all guests (residents) in the facility, regardless of their [DIAGNOSES REDACTED]. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infections. Transmission-based Precautions include Contact, Droplet, and Airborne and are designed for guests with suspicion of highly transmissible pathogens for which additional precautions are needed. When placing a guest in isolation, the nurse will utilize the clinical syndrome or condition table isolation precautions from the CDC to determine the type and duration of isolation. Isolation should be the least restrictive possible for the guest .Second Tier: Transmission-Based Precautions Contact Precautions Policy: Contact Precautions will be used (in addition to Standard Precautions) for specified guests known or suspected to be infected or colonized with epidemiological important microorganisms that can be transmitted by direct contact or indirect contact. Gloves and Hand Washing: 1. Wear gloves when entering the room. 2. Change gloves during the course of providing care, after having contact with infective material that may contain high concentrations of microorganisms .3. Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. Gowns: 1. Wear a gown (clean, non-sterile is adequate) when entering the room if you anticipate that your clothing will have substantial contact; a. with the guest b. with environmental surfaces or items in the guest room .1. Remove the gown before leaving the guest's environment and discard in appropriate container. Ensure that clothing does not contact potentially contaminated environmental surfaces after gown removal . Resident #4 Review of the Admission Record revealed Resident #4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 10/23/18 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #4 was cognitively intact. Review of the Order Summary Report dated 8/19, revealed Contact isolation during dressing changes r/t (related to)[MEDICAL CONDITION] in wound. Active 08/12/2019 Review of the Guest is on isolation precautions [MEDICAL CONDITION] in Wound Care Plan dated revision on 8/5/19, revealed Vancomyocin 1 mg everyday x 14 days (8/17/19) interventions ·Wound care as directed Date Initiated: 04/09/2019 During an observation on 08/13/19 at 2:10 PM, Registered Nurse (RN) T checked the wound care cart for supplies, then went to the medication supply storage room to get additional supplies- ([MEDICATION NAME]) a wound cleanser, ace bandage wrap, and (the Director of Nursing (DON) B gave her a container of bleach wipes). RN T entered Resident # 4's room placed instruction for the wound care and the bleach wipes on the over-the bed table. RN T then removed (tape, a marker, and a pair of scissors) from the shirt pocket of her uniform (did not clean the items) and placed them all on the top of the residents dresser along with the items for the dressing change. RN T went to the bathroom and cleaned her hands for less than 5 seconds and placed gloves on. RN T did not put on any additional personal protective equipment (PPE), she moved supplies needed for the dressing change (gauze, 4x4's, ace bandage, and xeroform) instructions and bleach wipes, to the over-the-bed table, washed hands for 6 seconds and put on clean gloves (wiped table with bleach wipe), put barrier towel on most of the over-the-bed table. (Supplies were on the far end of the table) RN T placed second towel under right leg prior to taking boot off, removed gloves and pulled up uniform pants, placed the items (gauze, 4/4's, xeroform) directly from the table onto the barrier, went to the bathroom washed hands with soap on them under running water for 6 seconds put on gloves, then re -turned to Resident #4 unwrapped the ace bandage from the right lower leg, and removed inner kerlix ( type of bandage) gauze, inner ankle 4x4 came off with wrap, slight redness noted wound approximately 0.5 x 0.5 inches noted, outer wound approximately 1 inch x 1.5 inch open area with dark wet healing tissue noted on ankle bone area and dry flaky skin noted going up 3.5 inch above ankle bone approximately 1 to 1.5 inches in width. Resident # 4 did not complain of any pain during the dressing removal. Padded 4x4 was over the outer ankle and old xeroform was noted 4x4 removed, gloves removed and hands washed for 6 seconds. When RN T came back from the bathroom after washing her hands she walked next to the resident and at 2:30 PM and the cloth key holder (lanyard) was hanging out of the right lower pant pocket approximately 6-8 inches dragging against the open area of the outer ankle wound as RN T walked by. RN T used [MEDICATION NAME] wound cleaner to spray both the inner and outer areas of the wound a 4 x 4 used to catch spray, then patted dry. RN T used alcohol wipes to clean the scissors then cut and placed xeroform over the 6 inch outer area of the ankle and the reddened area on the inner section, removed gloves and washed hands for 6 seconds, opened 4 x 4 fluff and placed them on the barrier where the dirty package had been placed when the barrier was set up. 4 x 4 fluff placed over the wound area, wrapped with kerlix, dated and signed and wrapped with ace bandage. Leg placed back in boot. Cleaned up trash and linen. Picked up alcohol wipes off floor and put in pocket of uniform top. During an interview on 08/13/19 at 3:00 PM, RN T was asked about the sign on Resident #4's door frame Please see Nurse before entering room and if she knew if Resident #4 was in contact precautions. RN T reported that she was not sure and it was not in the instructions she had printed out for wound care, but that she probably should have worn a gown when she did the dressing change. RN T was shown the cloth key chain (lanyard) hanging out of the right pant pocket and she stated I do not know what to do so I put it in my pocket and she placed her hand in her pocket, (no gloves - touching the lanyard) and stated I am going to talk to my infection control nurse. RN T reported that the infection control nurse was going to get her a key chain (lanyard). During an observation on 08/13/19 at 4:42 PM, RN T on hall passing medication with lanyard noted hanging 8 inches out of right leg pocket uniform. RN T reported that Licensed Practical Nurse (LPN) F Infection Control Nurse got her a new lanyard. RN T observed using key to open wound cart and get into both medication carts to place hand in and out of right lower pocket (which had been contaminated previously) then touch surfaces with hand. During an interview on 08/13/19 at 5:39 PM, Licensed Practical Nurse (LPN) F was asked, Did RN T wear PPE when she was in Resident #4's room?, No, Did the key chain (lanyard) touch the RN T's pants?, Yes, and the inside of the pocket, Yes, she has a new long fabric key chain (lanyard), Where is the new lanyard? In her pocket of her pants, what was the lanyard exposed to?[MEDICAL CONDITION], and what did it touch her pocket of her uniform pants. LPN F reported that they did not have RN T change her pants so the new lanyard was now contaminated, and that she will get her new pants and a new lanyard. Review of facility policy, Scabies dated 03/05, revealed, Policy: The facility will adequately treat cases of scabies and prevent the transmission to other guests (residents), staff, and visitors. The staff will follow contact precautions when caring for guests with scabies. General Information: Scabies is an infectious disease of the skin caused by Sarcoptes scabiei or itch mite. Transmission occurs most often by close personal contact, but prolonged casual contact also can result in transmission. Bedding and clothing (freshly contaminated) can sometimes be a source of transmission. Scabies begins with intense itching, popular eruptions, usually in the inter-digital spaces, but other areas can be involved. These areas may include the skin over the wrists, elbows, anterior axillary folds, belt line, thighs, nipples, abdomen, lower portion of the buttocks in women, and external genitalia in men. The scabies mite burrows under the skin and these burrows look like short, zigzag, grayish-white lines. The eruptions are caused by immature stages of the mites and/or sensitization to the protein produced by the mite. In persons without previous exposure, a brief period of 2-6 weeks usually elapses before the onset of the symptoms. Persons who previously have been infected develop symptoms 1-4 days after exposure. treatment of [REDACTED]. Scabies is almost always gone within 12 hours after the first treatment, but a second treatment repeated after 7 days may be recommended (follow manufacturer's directions) .To Avoid Re-infestation: .5. Confining the guest to the room [ROOM NUMBER]-24 hours after treatment is desirable if possible. 6. Contact precautions include gloves and gown if in close contact with infested persons or things (i.e. applying gloves, bedding, etc.) This is necessary both pre and post treatment for 12-24 hours after. According to the Centers for Disease Control regarding Scabies, Control measures for an outbreak involving one or more cases of crusted scabies should involve rapid and aggressive detection, diagnosis, infection control, and treatment measures because this form of scabies is so highly transmissible. Unrecognized crusted scabies often is the source of institutional outbreaks of scabies. Infection control personnel and dermatologists should be involved as soon as scabies is suspected in an institution. An institution-wide information program should be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread. Until successfully treated, patients with crusted scabies should be isolated from other patients who do not have crusted scabies. Assigning a cohort of caretakers to care only for patients with crusted scabies can reduce the potential for further transmission. Direct skin-to-skin contact between a patient with crusted scabies and his/her caretakers and visitors should be eliminated by following strict contact precautions, including the use of protective garments such as gowns, gloves, and shoe covers. The patient's room should be cleaned thoroughly. Bedding and clothing used by a person with scabies should be machine-laundered using the hot water and hot dryer cycles. Treatment should be strongly considered even in equivocal circumstances because of the complexity of controlling an institutional outbreak and the low risk associated with treatment. All suspected and confirmed cases, as well as all potentially exposed patients, staff, visitors, and family members should be treated at the same time to prevent re-exposure. Remember that symptoms of scabies can take weeks to appear the first time a person is infested; however, the person still can spread scabies during this asymptomatic period. Persons with crusted scabies generally require treatment at least twice, a week apart. Long-term surveillance for scabies is imperative to eradicate scabies from an institution. All new patients and staff should be screened and treated for [REDACTED]. The local health department and neighboring institutions should be notified of the outbreak and of any patients who may have been transferred to or of staff who may have worked in other institutions . Found at: https://www.cdc.gov/parasites/scabies/health_professionals/crusted.html Review of facility policy Hand Hygiene dated 11/16, revealed, Policy: The employee will perform hand hygiene as a primary means of preventing the spread of infection. WHEN TO WASH YOUR HANDS .4. Before and after entering isolation precaution settings . Review of facility Infection Control Log dated (MONTH) 2019, indicated Residents #7, #8, #21, #44, #45, #57, #61, #65, #66, & #70 were noted on 7/26/19 to have been identified with scabies and placed on contact isolation precautions. Residents #57, #61, & #70, were treated with [MEDICATION NAME] cream. Residents #7, #8, #21, #44, #45, #65, & #66 were treated with Stromectrol and [MEDICATION NAME] cream. On 8/10/19 all residents were documented to have been resolved of scabies. Resident #45 Review of a Face Sheet revealed Resident #45 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #45's physician progress notes [REDACTED].crusted scabies . Review of Resident #45's physician progress notes [REDACTED].f/u scabies .crusted scabies improving . The progress note did not indicate Resident #45's crusted scabies had been resolved. Review of Resident #45's MAR indicated [REDACTED]. by mouth one time only for scabies for 1 Day -Start Date-07/26/2019 with administration documented on 7/26/19. Review of Resident #45's MAR indicated [REDACTED]. During an observation and interview on 8/12/19 at 9:57 AM, Certified Nursing Assistant (CNA) M stated, (Resident #45) has scabies (indicating current infection). Some staff got them also. Nursing didn't know what it was at first that was bothering him. The staff tried changing laundry soaps and bath soap and that didn't help. (Resident #45) then went to a dermatologist. That is when it was found out he had scabies. Residents and staff started treatments about 3 weekends ago. Observed outside of room was a 3-drawer plastic container with PPE (Personal Protection Equipment). On Resident #45's door frame was a magnetic sign that indicated a nurse should be seen before entering the room. During an observation and interview on 8/12/19 at 10:59 AM, CNA M was noted to answer Resident #45's call light. Without donning PPE, CNA M entered Resident #45's room. CNA M stated, I was one of the staff that got scabies from Resident #45; it is a hazard of the job. I was treated twice for scabies with a cream. Some staff still do not feel comfortable going into his room without wearing the PPE. I don't know if he is still on contact precautions. I think the sign and gowns are still there for staff that want to wear them. During an interview on 8/12/19 at 11:08 AM, Licensed Practical Nurse (LPN) H stated, I don't know if (Resident #45) is still on contact precautions. I don't think it was mentioned in report this morning. I'll have to ask my UM (Unit Manager). Three minutes later, LPN H stated, He (referring to Resident #45) is being taken off contact precautions right now. During an interview on 8/13/19 at 7:14 PM UM F stated, The Infection Control Log says the 10 residents that were treated for [REDACTED]. I don't know if they were actually put on isolation because I wasn't here. During an interview on 8/13/19 at 7:16 PM, Director of Nursing (DON) B stated, I don't know if the 10 residents that were on the Infection Control Log being treated for [REDACTED]. I was not here. During an interview on 8/12/19 at 3:30 PM, UM F stated, As of today at 11:00 AM, I took (Resident #45) is off of contact precautions. I just haven't gotten everything done for it yet. Staff should have been doing the appropriate PPEs for it until it was discontinued. During an interview on 8/14/19 at 2:30 PM, Resident #45 stated, I felt like a piece a meat the way they (referring to the scabies) were chewing on me. It was horrible. I itched and hurt. They were all over me. I told the nurses I wanted a new doctor, not one that just stood at my doorway and told me everything was going to be okay. The doctor from here (referring to the facility medical director) never even came into my room to exam me. He just stood in the doorway. During an interview on 8/14/19 at 2:38 PM, Medical Director (MD) DDD stated, (Resident #45) has had a rash for a long time. He was treated with steroids and a cream. My NP (Nurse Practitioner) and I treated (Resident #45) and he would get better and the rash would almost be resolved. Usually a steroid won't treat scabies. I've been doing this, [MEDICATION NAME] medicine, for a long time and it didn't occur to me the rash to be scabies. 100% I did not think it was scabies. I've seen more scabies than most dermatologists. I told the nurses to assess all the residents in the entire building after (Resident #45's) [DIAGNOSES REDACTED]. The staff gave me a list of residents with a rash and I ordered them to treat them appropriately. I think the staff did everything appropriately after (Resident #45) was diagnosed . When a person has scabies they can develop contact [MEDICAL CONDITION] secondary because of the harshness of the scabies treatment. I have not seen (Resident #45) to reevaluate him. I don't know how the dermatologist will decide the scabies will be resolved. During an interview on 8/15/19 at 2:40 PM, Dermatologist Physician's Assistant (PA) WW stated, (Resident #45) was first seen 7/26/19 in our office for scabies. He had the rash on arms, chest, and legs. The rash was pink patches, with capular plaques an some crusting. He had a KOH prep (fungal test) that is a scrapping of a plaque and looked at under a microscope. The scraping was positive for mites and eggs. (Resident #45) had itching between digits (fingers and toes). The gold-standard of testing for scabies would be a skin scrapping. If there was itching between the digits along with areas on the genital or scrotum with patches, it would be the tell-tale of scabies. Anywhere else would need a confirmation of scrapping. ( Resident #45's) treatment was prescribed [MEDICATION NAME] cream. From his neck down; every piece of his entire body needed to be covered with the cream. The nurse was to cover everything on his body and leave on about 10 hours. The treatment needed to be repeated in 1 to 2 weeks. He had it bad enough to be put on oral ivermectrin. He must have been miserable. The treatment must be repeated in about 2 weeks. Scabies are a human parasite. It needs a host to survive. If it is not on a host for a couple of weeks it should die. The incubation period is typically around 1 week and is why the 2 dose treatment is necessary in case eggs hatch. But (Resident #45) had a very bad case. Again, the scrapping is necessary to diagnose the crusted scabies. (Resident #45) came in 8/8/19 for a re-check. He was still itchy and still getting rid of all the mites under his skin. The immune system needs to work to get rid of inflammation which takes about 6 weeks. The facility was able to kill the first round of scabies but not the second round of eggs that were under (Resident #45's) skin. By not doing the second dose of cream as the dermatologist prescribed, now the treatments have to start over again. It is important the full course of treatment is done. One round won't be enough. Scabies are very contagious. If you come in contact with it it will spread. The mite will travel; if you sit in a chair it will crawl on you and you will get it. Review of Resident #45's physician progress notes [REDACTED]. Crusted scabies. [MEDICATION NAME] cream apply neck down everywhere (groin/folds/digital spaces) at night q (every) 3 days x 1-2 weeks rinse off in am (morning) Ivermectin 6mg PO (by mouth) now repeat in 1 week wash EVERYTHING in hot H2O (water). Review of Resident #45's MAR indicated [REDACTED]. D/C Date 7/26/19 . [MEDICATION NAME] Cream 5% ([MEDICATION NAME]) Apply to rash topically one time only for scabies for 1 Day Start Date 7/26/19 with documentation the medication was administered 7/27/19 at 8:27 AM. The change in Resident #45's MAR indicated [REDACTED]. According to Scabies-Resources for Health Professionals - Medications - CDC at https://www.cdc.gov/parasites/scabies/health_professionals/meds.html, Topical [MEDICATION NAME] should be administered every 2-3 days for 1-2 weeks to treat crusted scabies. Review of Resident #45's physician progress notes [REDACTED].back still itches f/u scabies .back/chest/arms/hands pink pustules and papules .crusted scabies improving . The dermatologist did not indicate Resident #45's scabies had been resolved. Review of Resident #45's MAR indicated [REDACTED]. along with [MEDICATION NAME] Cream 5% Apply to whole body topically every day shift for suspected scabies for 1 Day Start Date 8/19/19 . indicating Resident #45 was still infected with crusted scabies. In an interview on 8/15/19 at 3:00 PM, Director of Nursing (DON) B stated, We, the nurses and I, were confused by the order from the dermatologist for (Resident #45). I wasn't sure why it would say every 3 days for 1 week. The numbers didn't make sense to me. I did not contact the office back to clarify the orders. I should have. (Resident #45) didn't get a second dose of the cream like the dermatologist wanted. Resident #44 Review of a Face Sheet revealed Resident #44 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #44, with a reference date of 6/13/19, revealed a Brief Interview for Mental Status (BIMS) score was unavailable which indicated Resident #44 was cognitively impaired. Review of Resident #44's MAR indicated [REDACTED]. with administration documented on 7/27/19. Resident #32 Review of a Face Sheet revealed Resident #32 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #32, with a reference date of 7/16/19, revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated Resident #32 was cognitively impaired. During an interview on 8/19/19 at 9:00 AM Resident #32 stated, I use the bathroom I share it with (Resident #45). During an interview on 8/19/19 at 9:05 AM, Resident #45 stated, I use the bathroom to brush my teeth, have a BM (Bowel Movement), wash my hands, and comb my hair in the mirror. Review of facility Nursing Care Card dated 8/16/19 indicated Resident #45 was on Contact Precautions and to use a commode while on contact precautions. Observed on 8/19/19 at 9:05 AM, Resident #45 did not have a commode in his room. During an interview on 8/19/19 at 9:10 AM, Resident #44 stated, I don't go to the bathroom in there but I will go in there to wash my hands. There are no wipes in there to clean the toilet or sink. Can you believe he (referring to Resident #45) and I have scabies again? Why couldn't they get rid of it the first time? Resident #7 Review of a Face Sheet revealed Resident #7 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 5/7/19, revealed a Brief Interview for Mental Status (BIMS) score was not available which indicated Resident #7 was unable to complete the interview. The MDS further indicated Resident #7 required extensive assistance of physical assistance for positioning, transfers, locomotion within the facility, ADLs (Activities of Daily Living) including personal hygiene, with functional limitation/impairment in range-of-motion of his upper extremities. Review of Resident #7's MAR (Medication Administration Record [REDACTED].with administration documented on 7/27/19. Resident #8 Review of a Face Sheet revealed Resident #8 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 4/21/19, revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated Resident #8 was moderately cognitively impaired. The MDS further indicated Resident #8 required supervision with positioning, transfers, dressing, and toileting with urinary intermittent catherization. Review of Resident #8's MAR (Medication Administration Record [REDACTED]. with administration documented on 7/27/19 Resident #21 Review of a Face Sheet revealed Resident #21 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #21, with a reference date of 5/16/19, revealed a Brief Interview for Mental Status (BIMS) score was not available, which indicated Resident #21 was unable to complete the interview. Attempts to interview Resident #21 by the surveyor were unsuccessful. Review of Resident #21's MAR indicated [REDACTED]. with administration documented on 7/27/19 Resident #57 Review of a Face Sheet revealed Resident #57 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #57, with a reference date of 7/12/19, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #57 was cognitively intact. Review of Resident #57's MAR indicated [REDACTED]. with administration documented on 7/27/19 Resident #61 Review of a Face Sheet revealed Resident #61 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #61, with a reference date of 7/14/19, revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #61 was moderately cognitively impaired. The MDS further indicated Resident #61 (TRUNCATED)

Based on interview and record review, the facility failed to prevent a facility acquired pressure ulcer for 1 (Resident #102) of 2 residents reviewed for pressure ulcers, resulting in the development of an avoidable pressure ulcer, the potential for the overall deterioration in health status. Findings include: Review of the Wound and Skin Management policy dated 6/11, reflected This manual has been established to address Pressure Ulcer prevention and treatment and the treatment of [REDACTED].Prevention - Prevention is defined as the priority for the elemental goal of wound and skin management. Prevention is the focus of the wound and skin management program. There is no better treatment for [REDACTED]. It is required that each guest who has a Braden Scale of 17 or below be on a pressure relieving/reducing mattress. The lower the Braden scale, the greater the need for higher quality pressure reducing mattress, e.g., alternating pressure, air fluidized, low air loss, etc Accurate assessment of each and every type of wound is critical to the healing process. A physician-directed multi-disciplinary team is the key to ensuring that each wound is assessed accurately and appropriately. In addition, administrative nurses, as well as staff nurses, are required to be knowledgeable regarding wound assessment, identifying types of wounds, and the correct modality of treatment based on established protocols. Review of a Admission Record revealed Resident #102 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 7/2/18 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated Resident #102 was severely cognitively impaired. Review of Verbal Order Summary Report dated 3/7/18, reflected Extra Protection Cream (EPC) to bottom for red sore area. every day and night shift. Review of Phone Order Summary Report dated 3/22/18, reflected Extra Protection Cream (EPC) to inner buttocks BID (twice a day). every day and night shift for excoriation. Review of Phone Order Summary Report dated 3/26/18, reflected Left glute (buttock) stage II: cleanse with normal saline, pat dry, apply skin prep to peri -wound bed, apply replicare (type of dressing) dressing. Change every other day and as needed till resolved every 24 hours as needed for stage II. Review of the Wound/Skin Healing Note dated 4/15/18 at 9:06 a.m., reflected Resident (#102) in room had a wound noted on 3/22/18. The wound is as follows:- Other (specify): Left inner butt: - excoriation: Length = 1, Width = 1, Depth = 0.1, healing well. The wound's progress is: Improved. The decision regarding the treatment is as follows: Continue Treatment. A care plan update was performed (nothing documented in the medical record), Dietary notified of area on, (nothing documented in the medical record), responsible party notified on (nothing documented in the medical record), physician notified (nothing documented in the medical record). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record regarding the above note was not provided as requested by the facility prior to exit. Review of the Wound/Skin Healing Note dated 4/13/18 at 8:00 a.m., reflected Resident #102 in room had a wound noted on 3/22/18. The wound is as follows:- Other (specify): Right inner butt: - Pressure: Length = 0.5, Width = 0.5, Depth = <0.1, Stage II .note, possible excoriation vs pressure. The wound's progress is Not Changed. The decision regarding the treatment is as follows: (nothing documented in medical record). A care plan update was preformed (Yes), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 4/13/18 at 8:00 a.m., reflected, Wound Findings 1. Date of Onset 3/22/18. Right inner Butt Pressure, Length = 0.5, Width = 0.5, Depth = 0.1, exudate - none, no odor, pink/beefy red, surrounding skin color - pink, continue treatment, care plan updated, pain related to wound, no. (sic) Review of the Wound/Skin Healing Note dated 4/13/18 at 9:06 a.m., reflected Resident #102 in room had a wound noted on 3/22/18. The wound is as follows:- Other (specify): Right inner butt: - Pressure: Length = 2.8, Width = 2.2, Depth = 0.1, Stage II .Biofilm noted, but removed easily. The wound's progress is Not Changed. The decision regarding the treatment is as follows: Continue Treatment. A care plan update was preformed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 4/13/18 at 9:06 a.m., reflected, Wound Findings 1. Date of Onset 3/22/18. Right inner Butt Pressure, Length = 2.8, Width = 2.2, Depth = 0.1, exudate - serous, small amount, no odor, granulation tissue, surrounding skin color - pink, pain related to wound, no. (sic) Review of Phone Order Summary Report dated 4/13/18, reflected Left inner buttock: cleanse with normal saline, pat dry, apply skin prep to peri-wound bed, apply replicare dressing. Change every 3rd and as needed till resolved every 24 hours as needed for stage II. Review of Verbal Order Summary Report dated 4/17/18, reflected Left inner buttock: cleanse with normal saline, pat dry, apply skin prep to peri-wound bed, apply medi-honey to wound bed, apply replicare dressing. Change every 3rd and as needed till resolved every 24 hours as needed for stage II. Review of the Wound/Skin Healing Note dated 4/19/18 at 9:06 a.m., reflected Resident #102 in room had a wound noted on 3/22/18. The wound is as follows:- Other (specify): Right inner butt: - Pressure: Length =Area healed. The wound's progress is (nothing documented). The decision regarding the treatment is as follows: (Nothing Documented). A care plan update was performed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 4/19/18 at 9:06 a.m., reflected, Wound Findings 1. Date of Onset 3/22/18. Right inner Butt Pressure, area healed (nothing else documented). (sic) Review of the Wound/Skin Healing Note dated 4/19/18 at 9:06 a.m., reflected Resident #102 in room had a wound noted on 3/22/18. The wound is as follows:- Other (specify): Left inner butt: - Pressure: Length = 2.4, Width = 1.5, Depth = 0.1, Stage II .Note: small amount of bioburden noted. The wound's progress is Improved. The decision regarding the treatment is as follows: Continue Treatment. A care plan update was preformed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 4/19/18 at 9:06 a.m., reflected, Wound Findings 1. Date of Onset 3/22/18. Left inner Butt, Pressure, Length = 2.4, Width = 1.5, Depth = 0.1, exudate - serous, small amount, no odor, granulation tissue, surrounding skin color - pink, progress - improved, pain related to wound, no. (sic) Review of the Skin01 Care Plan dated 4/14/2018, reflected NEED: Actual impaired skin integrity related to: Pressure injury, site/excoriation: Stage:II, site: Lt and right buttock Date Initiated: 04/13/2018 GOAL: Skin area will resolve. Date Initiated: 04/13/2018 Revision on: 04/26/2018 Target Date: 07/17/2018 INTERVENTIONS: Measure area weekly and document it's characteristics in skin log. Date Initiated: 04/13/2018. Obtain labs as ordered and review and report abnormals to physician Date Initiated: 04/13/2018 . When a guest chooses not to reposition as often as needed, explain consequences and continue to attempt to get to comply Date Initiated: 4/13/2018. Review of the Skin04 Care Plan date initiated 10/25/17, reflected NEED: Potential for impaired skin integrity related to: Impaired bed mobility, Incontinence of bowel and/or bladder, Impaired nutritional status chooses not to follow her diet at times , prefers not to shower or bathe. Dx. of DM (diabetes), [MEDICAL CONDITIONS](hypertention), [MEDICAL CONDITION] (congestive [MEDICAL CONDITIONS], hx. of skin breakdown. non-ambulatory. Date Initiated: 10/25/2017 Revision on: 04/26/2018 GOAL: · Skin will remain intact. Date Initiated: 10/25/2017 Target Date 7/7/2018 INTERVENTION: (have not changed since imitated 10/25/17) Review of Order Summary Report dated 4/26/18, reflected Left inner buttock: cleanse with normal saline, pat dry, apply skin prep to peri-wound bed, apply Z-Guard to wound bed, and cover with gauze and [MEDICATION NAME] clear dressing. Change every 3rd and as needed till resolved every night shift every 3 days for maceration. Review of Phone Order Summary Report dated 4/26/18, reflected Left inner buttock: cleanse with normal saline, pat dry, apply skin prep to peri-wound bed, apply Z-Guard to wound bed, and cover with gauze and [MEDICATION NAME] clear dressing. Change every 3rd and as needed till resolved every night shift every 3 days for stage II. Review of Phone Order Summary Report dated 5/1/18, reflected Left inner buttock: cleanse with normal saline, pat dry, apply skin prep to peri-wound bed, apply Z-Guard every shift and as needed every 24 hours as needed for Maceration discontinue order dated 8/9/2018. Review of the Wound/Skin Healing Note dated 5/3/18 at 1:06 p.m., reflected Resident #102 in room had a wound noted on 4/30/18. The wound is as follows:- Other (specify): Right inner butt: - Macerated: Length = 1.0, Width = 1.4, Depth = 0.1, -Note, area pink and healing. The wound's progress is Improved. The decision regarding the treatment is as follows: Continue Treatment. A care plan update was preformed (no), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 5/3/18 at 1:06 p.m., reflected, Wound Findings 1. Date of Onset 4/30/18. Right inner Butt Pressure, Length = 1.0, Width = 1.4, Depth = 0.1, macerated, Note area pink and healing. Exudate - none, no odor, pink/Beefy Red, surrounding skin color - pink, pain related to wound, no. (sic) Review of the Wound/Skin Healing Note dated 5/4/18 at 12:38 p.m., reflected Resident #102 in room had a wound noted on 3/22/18. The wound is as follows:- Other (specify): Left inner butt: - Pressure vs Maceration: Length = 3.0, Width = 1.9, Depth = unst, Stage-Unstageable Note: yellow/white/some black noted in base. The wound's progress is Not Changed. The decision regarding the treatment is as follows: Treatment Changed. A care plan update was preformed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 5/4/18 at 12:38 p.m., reflected, Wound Findings 1. Date of Onset 3/22/18. Left inner Butt Pressure, Length = 3.0, Width = 1.9, Depth = unstageable, pressure vs maceration Exudate - serous, scant amount, no odor, wound bed - slough, surrounding skin color - pink, surrounding tissue wound edges - peripheral tissue [MEDICAL CONDITION] and macerations, pain related to wound - no. (sic) Review of the Wound/Skin Healing Note dated 5/17/18 at 1:06 p.m., reflected Resident #102 in room had a wound noted on 3/22/18. The wound is as follows:- Other (specify): Left inner butt: - Pressure, Macerated: Length = 1.9, Width = 1.0, Depth = 0.2, Stage 2- The wound's progress is Not change. The decision regarding the treatment is as follows: Continue Treatment. A care plan update was preformed (no), Dietary notified of area on, (3/22/18), responsible party notified on (3/22/18), physician notified on (3/22/18). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 5/17/18, reflected was not provided per request by the facility upon exit. Review of the Wound/Skin Healing Note dated 6/13/18 at 6:20 p.m., reflected Resident #102 in room had a wound noted on 3/22/18. The wound is as follows:- Other (specify): Whole buttocks: - Other (specify): excoriation: Length = 10.0, Width = 8. The wound's progress is Improved. The decision regarding the treatment is as follows: Continue Treatment. A care plan update was preformed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 6/13/18 at 6:20 p.m., reflected, Wound Findings 1. Date of Onset 3/22/18. Whole buttocks, Length = 10, Width = 8, excoriation, pain related to wound - yes. (sic) Review of the Wound/Skin Healing Note dated 6/13/18 at 6:19 p.m., reflected Resident #102 in room had a wound noted on 3/22/18. The wound is as follows:- Other (specify): Left inner butt: - Other (specify): Excoriation: Length = 1.0, Width = 0.8, Depth = 0.1, The wound's progress is Improved. The decision regarding the treatment is as follows: Continue Treatment. A care plan update was preformed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 6/13/18 at 6:19 p.m., reflected, Wound Findings 1. Date of Onset 3/22/18. Left inner Buttocks, excoriation, Length = 1.0, Width = 0.8, Depth = 0.1, Exudate - (nothing documented), wound bed - (nothing documented), surrounding skin color - (nothing documented), surrounding tissue wound edges - (nothing documented), progress - improved, pain related to wound - yes. (sic) Review of the Behavior Care Solution Note dated 6/21/18, reflected Patients says her bottom hurts all the time as she wears depends. Review of the 7/1/18 Braden Assessment (tool used to assess skin), reflected Resident #102 was at moderate risk (score 14). Review of the Pain assessment dated [DATE], reflected Resident #102 has frequent pain located in wound/ulcer (buttocks) rated between 2-8/10, Timing and Contributing Factors - Repositioning and while sitting on buttocks .Review of System - Skin: admits buttock pain as lays on back side much of day. Review of the (MONTH) (YEAR) Progress Notes, reflected that there was no Wound/Skin Healing Notes. Review of the Periodic Care Observation dated 7/11/18 at 0:00 a.m., reflected Resident #102 VI. sleeps sound at night,VII. Pain- has excoriation pain in both buttocks, rest and re-positioning are used for pain interventions as well as Tylenol, XIII. Skin- skin turgor was good and free of open areas, excoriated both left and right buttock, treatment in place. Review of the Periodic Care Observation dated 7/18/18 at 0:00 a.m., reflected Resident #102 VI. sleeps sound at night,VII. Pain- general, [MEDICAL CONDITION], skin issues, turn, reposition, rest, Tylenol routine, XIII. Skin- skin turgor was fair and free of open areas, macerated. Review of Physician Phone Order dated 8/2/18, reflected [MEDICATION NAME] Ointment 0.44-20.6% Apply to buttocks and groin topically every day and night shift for excoriation. Review of the Wound/Skin Healing Note dated 8/8/18 at 1:34 p.m., reflected Resident #102 in room had a wound noted on 6/1/18. The wound is as follows:- Other (specify): Buttocks:-Other (specify): excoriation: Length = (not documented), Width = (not documented) , Depth = (not documented) , Stage-N/A, The wound's progress is (not documented) . The decision regarding the treatment is as follows: (not documented) . A care plan update was preformed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 8/8/18 at 1:34 p.m., reflected Wound Findings 1. Date of Onset 6/1/18. Buttocks, excoriation, Exudate - (nothing documented), wound bed - (nothing documented), surrounding skin color - (nothing documented), surrounding tissue wound edges - (nothing documented), progress - (nothing documented), pain related to wound - (nothing documented). (sic) Review of the Periodic Care Observation dated 8/14/18 at 6:42 p.m., reflected Resident #102 VI. sleeps sound at night,VII. Pain- none, XIII. Skin- skin turgor was fair and not free of open areas, pressure ulcers are present. Review of the Wound/Skin Healing Note dated 8/16/18 at 5:28 p.m., reflected Resident #102 in room had a wound noted on 8/9/18. The wound is as follows:- Other (specify): Left Buttock:-Other (specify): excoriation: Length = 6, Width = 2 , Depth = (not documented) , The wound's progress is Improved. The decision regarding the treatment is as follows: Continue Treatment . A care plan update was preformed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 8/16/18 at 5:22 p.m., reflected Wound Findings 1. Date of Onset 6/1/18. Left Buttocks, excoriation, Length = 6, Width = 2 , Depth = (not documented)- Exudate - (nothing documented), wound bed - (nothing documented), surrounding skin color - (nothing documented), surrounding tissue wound edges - (nothing documented), progress - improved, pain related to wound - (nothing documented). (sic) Review of the Periodic Care Observation dated 8/21/18 at 6:42 p.m., reflected Resident #102 VI. sleeps sound at night,VII. Pain- none, XIII. Skin- skin turgor was fair and not free of open areas, the following conditions are present, excoriated to buttock. Review of the Wound/Skin Healing Note dated 8/30/18 at 2:56 p.m., reflected Resident #102 in room had a wound noted on 8/9/18. The wound is as follows:- Other (specify): left buttocks:-Other (specify): excoriation: Length = 8, Width = 3.5 , Depth = (not documented), The wound's progress is Not changed. The decision regarding the treatment is as follows: Continue Treatment. A care plan update was preformed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 8/30/18 2:56 p.m., reflected Wound Findings 1. Date of Onset 8/9/18. Left Buttocks, excoriation, Length = 8, Width = 3.5 , Depth = (not documented)- Exudate - none, wound bed - none, surrounding skin color - normal for skin, surrounding tissue wound edges - normal for skin, progress - not changed, care plan updated: no, pain related to wound - Yes. (sic) Review of the Wound/Skin Healing Note dated 8/30/18 at 2:57 p.m., reflected Resident #102 in room had a wound noted on 8/23/18. The wound is as follows:- Other (specify): right buttocks:-Other (specify): excoriation: Length = 0.3, Width = 0.5 , Depth = (not documented), The wound's progress is (not documented). The decision regarding the treatment is as follows: Treatment changed. A care plan update was preformed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 8/30/18 at 2:57 p.m., reflected Wound Findings 1. Date of Onset 8/23/18. right Buttocks, excoriation, Length = 0.3, Width = 0.5 , Depth = (not documented)- Exudate - none, wound bed - none, surrounding skin color - normal for skin, surrounding tissue wound edges - normal for skin, progress - treatment changed, care plan updated: nothing documented, pain related to wound - (nothing documented). (sic) Review of the Wound/Skin Healing Note dated 8/30/18 at 2:54 p.m., reflected Resident #102 in room had a wound noted on 6/1/18. The wound is as follows:- Other (specify): whole buttocks:-Other (specify): excoriation: Length = (not documented), Width = (not documented) , Depth = (not documented), The wound's progress is not changed. The decision regarding the treatment is as follows: Continue Treatment. A care plan update was preformed (nothing documented), Dietary notified of area on, (nothing documented), responsible party notified on (nothing documented), physician notified on (nothing documented). See wound/skin healing record for further information. (sic) Review of the Wound/Skin Healing Record dated 8/30/18 at 2:54 p.m., reflected Wound Findings 1. Date of Onset 6/1/18. whole Buttocks, excoriation, Length = (not documented), Width = (not documented) , Depth = (not documented)- Exudate - none, wound bed - none, surrounding skin color - normal for skin, surrounding tissue wound edges - normal for skin, progress - not changed, care plan updated: no, pain related to wound - Yes. (sic) Review of the physician progress notes [REDACTED]. During an interview on 1/23/19 at 2:00 p.m. Certified Nursing Assistant (CNA) P reported that Resident #102's bottom may have had open areas, but they were small and the nurse put medication on it. CNA P reported that Resident #102 did not like to be turned she would lay in bed and not want to get moved. During an interview on 1/23/19 at 7:21 p.m., Registered Nurse (RN), Unit Manager (UM) M reported that the area to Resident #102's bottom was closed and doing well, then showed as pink and we started using Z-guard, but Resident #102 liked to lay on her bottom. UM M reported that they did not have a speciality mattress because she was improving, the Stage II areas were healed there was no open areas on her bottom. UM M reported that generally the physician come through bi-weekly and looks at the wounds even if the residents skin was just excoriated. During an interview on 1/24/18 at 2:56 p.m., Medical Doctor (MD) F reported that he did not recall Resident #102, and would look at wounds if there was a problem. MD F reported if there was a problem he would have written a statement. During an interview on 1/24/18 at 3:00 p.m., Nurse Practitioner (NP) C reported that if the nurses have a specific resident with wounds to round on he would, he could not recall Resident #102, the name was not familiar. NP C reported that he usually did not round on every resident who has wounds. During an interview on 1/24/19 at 4:13 p.m., Certified Nursing Assistant (CNA) H reported that if you turned Resident #102 she would hang on, her bottom was bad, the nurses got cream and powder they put on her. CNA H reported that she worked with Resident #102 and when she had a few days it was like we were never here, we would have to start all over working on Resident #102's bottom. CNA H reported that Resident #102 did not like covers and kept fan on her that the area to her bottom was open and bleeding, size of a soft ball more than one layer of skin missing, appeared like someone was not keeping her off her bottom at times. During an interview on 2/5/18 at 2:26 p.m., Licensed Practical Nurse (LPN) T reported that Resident #102 did not like to turn she would cry if staff would go to reposition her, staff would change her brief, but she was not teachable about the consequences of not repositioning. Review of the Emergency Department Records dated 9/2/18 at 8:57 p.m., reflected Skin: Diaphoretic. Hot to the touch. Large pressure ulcer on buttock.

This citation pertains to intake number MI 120 Based on interview, and record review, the facility failed to assess residents prior to [MEDICAL TREATMENT] in 2 of 3 sampled residents (Resident #103, Resident #104) reviewed for [MEDICAL TREATMENT] assessments, from a total sample of 4 residents, resulting in the lack of resident assessment, lack of the exchange of information necessary for the care of the resident, and hospitalization of Resident #103 for an infected graft site. Findings include: Review of the facility policy and procedure titled, [MEDICAL TREATMENT]-Coordination of Services revised 01/14, revealed, Purpose: To coordinate services and enhance communication between the . facility and the [MEDICAL TREATMENT] center. Procedure: 1. Upon receiving an order for [REDACTED].> - [MEDICAL TREATMENT] Guest Information Sheet - A copy of the current physician's orders, including [MEDICAL TREATMENT] orders - Current Care Plan - Blank Progress Notes - Blank Facility [MEDICAL TREATMENT] Communication - A copy of the guest's advanced directives 2. The Facility [MEDICAL TREATMENT] Communication form will be completed by the charge nurse to be sent with the guest to the [MEDICAL TREATMENT] center. 3. The Facility [MEDICAL TREATMENT] Communication form may contain the following information: - Changes in guest's physical assessment since last exam - Guest's mental/emotional state since last [MEDICAL TREATMENT] appointment - Oral intake since last appointment - Activity level since last appointment - New physician orders - New labs since last appointment - Most recent vital signs - Most recent weight if weighed between treatments - Guest's compliance with plan of care - Other appropriate comments 4. The communication notebook will be sent with the guest to the [MEDICAL TREATMENT] center . Resident #103 Review of an Admission Record revealed Resident #103 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #103 was cognitively intact. Review of the Care Plan RENAL dated 7/9/17 revealed, Resident #103 had End Stage [MEDICAL CONDITION] Requiring [MEDICAL TREATMENT]. The Care Plan, RENAL revealed Facility will utilize the [MEDICAL TREATMENT] Communication form to communicate with [MEDICAL TREATMENT] center. Send [MEDICAL TREATMENT] communication book to [MEDICAL TREATMENT] center with each appointment . Review of [MEDICAL TREATMENT] Communication forms for Resident #103 revealed 7 of 14 forms were not completed (6/29/17, 7/1/17, 7/13/17, 7/15/17, 7/18/17, 7/22/17, and 7/29/17). The uncompleted sections included, Vital Signs, Significant Changes Since Last [MEDICAL TREATMENT] Session, Labs Drawn Since Last [MEDICAL TREATMENT] Session, Physical Assessment, Diet/Fluid Order and Brief Summary of Intake, Activity Level, Compliance with Physician's Orders, Change in Medication Regimen Since Last visit, Signature, Title, and Phone Number, Date. Review of [MEDICAL TREATMENT] Communication dated 7/29/17 revealed section Completed by the facility was left blank. Review of [MEDICAL TREATMENT] Communication dated 7/29/17 under section Completed by the [MEDICAL TREATMENT] Provider revealed, On admit to clinic, patient present with chills, stating he feels cold .Temp of 100.0 degrees, pulse 102. Heart rate elevated from patient's normal .physician on call notified of slight altered mental status .Also noted, tunneled wound to right upper arm near axilla, draining white fluid. Patient sent to Borgess emergency room post treatment. Signed, Registered Nurse (RN) D. In a telephone interview on 8/15/17 at 3:40 p.m., RN D stated, Resident #103 was very, very sick. I was surprised they sent him (to [MEDICAL TREATMENT]) .(Resident #103) had rigors, chills, he was shaking. He was very slow to answer me. Resident #103 was not all there-just off. He told me he felt like[***] It was luck that I saw the wound .We finished his treatment. He didn't get worse or better (after his treatment). I called the facility to ask if they knew (Resident #103) was in this condition because they left the communication form blank, they said 'no'. Review of a hospital Hospitalist Progress Note dated 8/3/17 revealed, (Resident #103) was admitted to (Hospital Name) on July 29, 2017 with infection in his right arm with a draining wound. This was accompanied by fever, chills, weakness and drainage of purulent material from the wound on the medial aspect of his right arm. [MEDICAL TREATMENT] catheter has been removed and he underwent irrigation and debridement of the right uper extremity wound. The wound VAC (a vacuum dressing to promote healing) has been placed. The a culture of the wound revealed Resident #103 had E Coli in the wound. In an interview on 8/15/17 at 12:15 p.m., Unit Manager, RN C was shown the [MEDICAL TREATMENT] Communication form dated 7/29/17 for Resident #103 which revealed the entire section Completed by the facility was left blank. Unit Manager, RN stated, The least they could do is just fill out the form. Resident #104 Review of an Admission Record revealed Resident #104 was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #104 was cognitively intact. Review of the Care Plan RENAL dated 6/6/17 revealed, Resident #104 had End Stage [MEDICAL CONDITION] With [MEDICAL TREATMENT]. The Care Plan RENAL revealed, Facility will utilize the [MEDICAL TREATMENT] Communication form to communicate with [MEDICAL TREATMENT] center. Send [MEDICAL TREATMENT] communication book to [MEDICAL TREATMENT] center with each appointment . Review of [MEDICAL TREATMENT] Communication forms for Resident #104 revealed 9 of 20 forms were not completed on 6/29/17, 7/1/17, 7/4/17, 7/9/17, 7/18/17, 7/22/17, an undated form, 8/5/17, and 8/10/17. Uncompleted sections included, Vital Signs. In an interview on 8/15/17 at 2:13 p.m., Director of Nursing/RN B reported she would expect that the [MEDICAL TREATMENT] Communication forms to be filled out to show that a resident assessment was completed.

This citaiton pertains to intake number MI 176. Based on observation, interview, and record review, the facility failed to prevent the elopement and ensure the safety in 1 of 5 sampled residents (Resident #100) reviewed for safety, from a total sample of 5 residents, resulting in an Immediate Jeopardy (IJ) when Resident #100, who was identified as an elopement risk, exited the facility at approximately 10:00 a.m. on 1/1/17, unbeknownst to facility staff. Resident #100 was found when an unknown person from the community who delivered Resident #100 by car to the facility at 12:00 p.m. on 1/1/17, who reported they picked Resident #100 up walking on a 40 MPH two lane road down the road from the facility (approximately 6/10 of a mile (3168 feet). Findings include: Review of the Record of Admission and the Minimum Data Set (MDS), dated [DATE], revealed Resident #100 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #100 was moderately cognitively impaired for daily decision-making skills and expects to be discharged to the community. Review of the Incident Report dated 1/1/7 at 12:00 p.m., reflected Resident #100 left the building unattended. (Resident #100) was seen by a driver walking down (2 lane street in front of facility) and offered (Resident #100) a ride back to the building. The driver brought (Resident #100) back into the building around 12:00 p.m. and stated that he had seen (Resident #100) walking down the road and he stopped and asked him where he was headed. Resident then stated to the driver that he lived in the building up the hill. In an interview on 1/4/17 at 3:00 p.m., Resident #100 was sitting on the edge of his bed in his room, he reported that he exited the main door of the building after a guy to get some sunshine on his face, had a coat on, and was going to go to town. Resident #100 reported that he did not go to the gas station at the end of the road (approximately 8/10 of a mile away), because it was closed he turned (indicated left towards town), then was coming back and some guy stopped and ask if I wanted a ride and gave me a ride back. Resident #100 reported that he wants to go home but his son won't take him. In interviews on 1/4/17 at 3:15 p.m. and 1/5/17 at 11:55 a.m., Administrator A reported that he came in the facility on 1/1/17 at approximately 10:30 a.m. through the employee entrance, and about noon (2 hours from when Resident #100 was last seen by facility staff) someone from the community brought Resident #100 in the facility and asked if they belonged here. They were driving down the 40 MPH road down from the facility, saw him walking down the road, stopped and offered him a ride. He (citizen) reported that Resident #100 said he lived in the building up the hill and he just wanted to make sure this was where he lived. Administrator A reported that the person who brought Resident #100 back to the facility left after verifying he lived here stating he lived one town over. Administrator A reported that Resident #100 was picked up approximately a half a mile from the facility on the 40 MPH road. In an interview on 1/5/17 at 9:30 a.m., Certified Nursing Assistant (CNA) D reported that she verified Resident #100's wander guard (a safety device that alarms when leaving the building) was functioning at approximately 10:00 a.m. on 1/1/17 by pointing the wander guard tester at Resident #100's left ankle where the wander guard was, she did not visualize the wander guard just saw a lump under his sock. CNA D could not state if the wander guard band was in place at the time she verified functionality of the wander guard on Resident #100. CNA D reported that after 12:00 p.m. on 1/1/17 when Resident #100 was returned to his room, there was no wander guard found on him, but that the wander guard without the band was found in a cup in his dresser drawer. Review of the Physician Phone Order dated 10/25/16 at 2:00 p.m. reflected Resident #100 was to have a wander guard to left ankle, check placement every shift and check function every day. Review of the Care Area Assessment (CAA), dated 11/1/16, reflected Resident #100 demonstrates long and short term memory impairment, guest is ambulatory and has a wander guard in place and at times will think his car is outside in the parking lot and thinks he is still able to drive .Guest often will pack his belongings in his room and tell staff that his son and/or daughter in law will be here to take him home . Review of the Care Plan (Wander) dated 11/9/16, reflected Resident #100 was at risk for elopement related to wandering. Guest often will think his car is outside and request to leave and drive off. The Wander Care Plan goal reflected, Resident #100 will not leave facility unattended .Interventions *Ensure that wander guard is on each shift and working daily Review of the Behavior Care Solutions Progress Note dated 12/21/16 at 12:32 p.m., reflected Resident #100 wants to go home. In an interview on 1/5/17 at 9:45 a.m., CNA E reported that a couple months ago (maybe early November) she received a note that Resident #100's wander guard was missing and could not be found, so staff had replaced it. In an interview on 1/5/17 at 8:30 a.m., Registered Nurse (RN) G reported that the last time she saw Resident #100 on 1/1/17 was at 8:30 a.m. med pass and she had not visually noted his wander guard. RN G reported that when Resident #100 was returned to the facility on [DATE] at 12:00 p.m. she had not found a wander guard on him, but there was one without the band in his dresser drawer. RN G reported that she took the wander guard to get another band and when she returned to Resident #100's room she found another wander guard without a band in his sock. In an interview on 1/5/17 at 8:40 a.m., CNA H reported that he had last seen Resident #100 at about 9:00 a.m. when he picked up his breakfast tray. In an interview on 1/5/17 Licensed Practical Nurse (LPN) J reported that on 1/1/17 she saw Resident #100 by the nursing station about 10:00 a.m. On 1/5/17 at 12:37 p.m., Administrator A was notified of an Immediate Jeopardy that began on 1/1/17 at approximately 10:00 a.m., when the facility failed to prevent the elopement of Resident #100. On 1/5/17, this surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. Resident #100 was returned safely to the facility on [DATE] at 12:00 p.m. 2. Resident #100 was placed on 15 minute checks at 12:30 p.m. on 1/1/17 which will continue until a tamper proof wander guard arrives. 3. 21 of 27 licensed nurses, 28 of 37 certified nursing assistants, 6 of 12 therapy staff, 2 maintenance staff, 3 of 9 housekeeping/laundry staff 6 of 10 dietary staff, 4 of 4 administrative staff were in-serviced between 1/1/7 and 1/5/17 on ensuring visual placement of the wander guards. Education will continue until 100% reached and staff will not work until they have been in-services. 4. 17 of 17 residents with wander guards were visually verified for proper placement and function on 1/1/7 at 12:30 p.m. 5. On 1/1/7 wander guard system and all alarmed doors were checked for function, which will continue daily. 6. Continued compliance will be monitored daily, through daily clinical meeting, review of new order, 24 hour report, behavior management meetings, and quality assurance program. Although the Immediate Jeopardy was removed on 1/1/17, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency and all education had not yet been completed. #

This citation pertains to intake number MI 822. Based on observation, interview, and record review the facility failed to implement preventative measures to prevent the development of a pressure ulcer in 2 of 2 sampled residents (Resident #101 and Resident #103) reviewed for pressure ulcers, from a total sample of 9 residents, resulting in the delayed healing and the worsening of pressure ulcers. Findings include; Resident #101 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was an [AGE] year old female admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS revealed Resident #101's ability to make daily decisions was severely impaired and she was extensively dependent on one to two facility staff members for bed mobility, dressing, transfers, bathing, hygiene, and toilet use. Review of the Admission Care Plan dated 9/13/12 (DIC), Resident #101's individualized goals and approaches for pressure sores/skin care were "follow facility skin care protocol, turn every 2 hours and PRN (as needed), preventive measures: immediately report any redness or skin breakdown to charge nurse/physician, lift sheet for repositioning." Review of the Physician Admission Notes dated 9/17/13, revealed Resident #101 "does have a small abrasion on her left inner buttocks. They do have protective ointment on the above." Review of the Care Area Assessment (CAA) dated 10/15/13, revealed Resident #101's "skin is within normal limits at this time. She is at risk for breakdown due to a history of incontinence of bowel and bladder..." Review of the Skin 01 Care Plan dated 10/15/13, revealed Resident #101 had actual impaired skin integrity related to black nail on right second foot and abrasion on left inner buttock. Review of the Skin 04 Care Plan dated 10/15/13, revealed Resident #101 has the potential for impaired skin integrity. The Skin 04 Care Plan revealed the measurable goal was that there would be no avoidable pressure related skin issues by 1/13/14. Review of the Skin Care Plan dated 10/17/13, revealed Resident #101 had an actual alteration in skin integrity related to 2 pressure areas on the left heel, a Stage II blister on the left medial heel and an un-stageable area on the left lateral heel (presents as purple area). The Skin Care Plan revealed the goal was for the areas will resolve without sign/symptoms of infection by 1/15/14. The Skin Care Plan revealed approaches/interventions were to "Complete treatment as ordered. Observe, measure and record size and characteristics of areas weekly per protocol. Refer to skin risk and pain care plans for additional interventions. Float heels with heels up device while in bed (10/17/13) d/ced 11/5/13. ..Build-a-boots to both feet. may remove for care, bathing and observation (10/18/13). Utilize foot rests both when up in wheelchair (10/18/13)." Review of the Skin Care Plan dated 10/17/13, revealed Resident #101 had a problem documented on 10/18/13 concerning the right heel discoloration with slight blister formation. Review of the Skin Care Plan dated 10/17/13, revealed Resident #101 had a problem documented on 11/6/13 concerning "coccyx open area with reddened area surrounding." The Skin Care Plan revealed approaches/interventions were to "turn and reposition side to side while in bed. Air mattress". Review of the Skin Care Plan dated 10/17/13, revealed Resident #101 had a problem documented on 11/13/13 concerning "reddened area on left buttock where tape from OpSite was placed ." The Skin Care Plan revealed approaches/interventions were to "treatment changes to OpSite covering." Review of the Skin 04 Care Plan dated 1/31/04, revealed Resident #101 had the potential for impaired skin integrity related to history of dementia with communication problems, history of [MEDICAL CONDITIONS], scoliosis, kyphosis, and incontinence of bowel and bladder. The Skin 04 Care Plan revealed the measurable goal was that there would be no avoidable alterations in skin integrity. The Skin 04 Care Plan revealed approaches/interventions were "turn and reposition side to side only...Provide limited to extensive assistance to reposition every 2 hours and as needed... Assisted to reposition in chair as needed....Conduct weekly head to toe skin assessments, document and report abnormal findings to physician..." Review of the Admission Nursing assessment dated [DATE] at 12:00 p.m., revealed Resident #101's skin dry, pale, with no marks indicated on the body diagram. The Admission Nursing Assessment revealed the Bradon scale ( risk for pressure ulcers) was 16 (a total score of 17 or below deems resident at risk). Review of the Nurse Practitioner Progress Note dated 11/4/13, revealed Resident #101 was seen per request of nursing due to skin breakdown on heels and buttocks. The Nurse Practitioner Progress Note revealed un-stageable pressure ulcer on coccyx 1.7 cm x 0.6 cm x 0.2 cm and and un-stageable pressure ulcer to the left heel (no measurement noted). Review of the Physician's Progress Notes dated 11/5/13, revealed Resident #101 does wear protective boots due to the "unstageable on her heels." Review of the Nurse Practitioner Progress Note dated 11/7/13, revealed Resident #101 decub "red buttocks slightly to left Stage II small open area." Review of the Nurse Practitioner Progress Note dated 12/26/13, revealed Resident #101 was seen to evaluate coccyx wound due to nursing reports that wound was getting larger with a foul odor. The Nurse Practitioner Progress Note revealed a 1.0 cm x 1 cm round scabbed area on coccyx with no foul odor and scant drainage. Review of the Nurse Practitioner Progress Note dated 1/9/14, revealed Resident #101 was seen to evaluate coccyx wound due to no improvement. The Nurse Practitioner Progress Note revealed a Stage III decub/buttocks, 1.2 cm x 1.0 cm x 0.7 cm deep with 0.6 cm under lip at 12 o'clock, no surrounding redness, scant bloody yellow drainage. Review of the Report of Consultation dated 1/8/14, revealed Resident #101 had a Stage III pressure ulcer on her sacro-coccyx area, that measures 0.8 cm x 0.8 cm x 1 cm. The Report of Consultation revealed the treatment would change. Review of the Wound physician progress notes [REDACTED].#101's coccyx wound with no pus or foul odor, still tender, and measures 0.6 cm x 0.3 cm x 0.5 cm. Review of the Weekly Skin Assessments revealed that skin assessments prior to 10/4/13 were not conducted, and upon request, were not produced prior to the end of the survey. The Weekly Skin Assessments for 10/19/13,11/23/13, 11/30/13, 1/11/14,1/25/14, and 2/8/14 were not included in the records. Review of the Treatment Administration Record (TAR) dated 1/1/2014, revealed Resident #101 did not received 2 of 4 weekly scheduled skin assessments. Review of the Treatment Administration Record (TAR) dated 2/1/2014, revealed Resident #101 did not received 1 of 4 weekly scheduled skin assessments. In an observation on 2/27/13 at 8:30 a.m., Resident #101 was noted to be in her room bed, awake, and responded to the Surveyors knock on the door allowing her to enter the room, the head of the bed was elevated slightly and Resident #101 was laying on her back. At 9:40 a.m. Resident #101 was observed in a wheelchair in the activity/dining room coloring at a table with feet up on foot rests. Resident #101 continued to stay in the activity/dining room area until 1:10 p.m. when she was moved to her room in her wheelchair. Observed at 2:05 p.m. sitting in her wheelchair in her room looking in drawers. Resident #101 remained sitting in her wheelchair in her room at 2:30 p.m. At 3:15 p.m. she was eating a snack in her wheelchair in her room. At 4:40 p.m. Resident #101 was in the hallway in her wheelchair. There was no noted off loading of pressure sensitive areas by staff noted by this surveyor during the above observations. In an interview on 2/27/14 at 2:08 p.m., Certified Nursing Assistant (CNA) "D" reported that Resident #101 can inform staff when she has to go to the bathroom, and that she had not had to go today. CNA "D" reported that when she repositioned her she would reach down in her chair and move the cushion Resident #101 sits on. In an interview on 2/27/14 at 4:00 p.m., CNA "K" reported that he had just checked Resident #101 and she was dry and did not need to be toileted. In an interview on 2/27/14 at 12:00 p.m., Registered Nurse (RN) "A" reported that Resident #101's pressure wounds to her coccyx got better then worse, and due to the length of time, the facility brought in a wound specialist. Resident #103 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #103 was a [AGE] year old female admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]., depression, and failure to thrive. The MDS revealed Resident #103's ability to make daily decisions was severely impaired and she was extensively dependent on one to two facility staff members for bed mobility, dressing, eating, hygiene, bathing, and toilet use. Review of the Care Area assessment dated [DATE], revealed Resident #103 had a history of [REDACTED]. Review of the Shower/Skin Observation dated 1/14/14, revealed Resident #103 had a reddened area noted on her coccyx. Review of the Shower/Skin Observvation revealed no charge nurse signature. Review of the Shower/Skin Observation dated 1/17/14, revealed Resident #103 had a reddened area noted on her coccyx. Review of the Shower/Skin Observvation revealed no charge nurse signature or nursing assistant signature. Review of the Shower/Skin Observation dated 1/28/14, revealed Resident #103 had a reddened area noted on her coccyx. Review of the Shower/Skin Observvation revealed the charge nurse and nursing assistant had signed the observation sheets. Review of the Pressure Ulcer Record dated 2/4/14, revealed Resident #103 had a Stage III sacral wound that measured 0.5 cm x 0.2 cm with no odor, light pink, and light serous drainage. Review of the Pressure Ulcer Record dated 2/4/14, revealed Resident #103 had a Stage II upper sacral fluid filled blister that measured 3 cm x 2.5 cm, pink in color. Review of the Treatment Admission Record (TAR) dated 2/1/14, revealed Resident #103's weekly skin assessments were completed 2 of 4 times during the month. Review of the Facility Skin04 Care Plan dated 7/12/13, revealed Resident #103 had the potential for skin breakdown related to history of pressure ulcers, the measurable goal was that there would be no unavoidable pressure ulcers. The Skin04 Care Plan approaches/interventions were "...provide incontinent care with each episode and apply moisture barrier..." An observation and interview on 2/27/14 at 1:30 p.m., revealed CNA "A" remove Resident #103's brief. CNA "A" stated she thought it had been 2 1/2 hours since she had last changed Resident #103's brief. The Surveyor observed the brief to be saturated, dark yellow to tan in color, with nauseous, foul odor. In an interview on 3/3/14 at 10:30 a.m., Registered Nurse (RN) "A" reported the pressure ulcer was found on Resident #103's bottom on 2/4/14 as a blister and slowly progressed from there. #

This citation contains 4 Deficiency Practice Statements: A, B, C, D. A. Based on observation, interview and record review, the facility failed to ensure facility staff did not leave controlled substances unattended and in the open, where residents, facility staff, and/or visitor could consume or divert the medications/controlled substances for 4 of 18 sampled residents (Resident #12, #13, #14, and #15) reviewed for medications, from a total sample of 18 residents, resulting in an Immediate Jeopardy when, on 9/30/13 during a observed medication administration pass, Licensed Practical Nurse (LPN) "A" was observed to preset medications and then leave them unattended on top of a medication cart while administering medications in another residents room. This deficient practice placed all ambulatory residents at risk for serious harm, injury, and/or death. Findings include: In an observation on 9/30/13 at 4:00 p.m., LPN "A" was observed to have left the medication cart unattended to administer medications to another resident. Upon return to the cart with this surveyor, LPN "A" was found to have 4 medication cups sitting on top of the medication cart, each one with pills in them. The first cup had Norco (schedule III pain medication)10/325 milligrams (mg) scheduled to be administered to Resident #1) at 4:00 P.M. The second cup had Ultram (pain medication) 50 mg scheduled to be administered at to Resident #12 at 8:00 P.M., and Ativan (antianxiety medication-scheduled IV medication) 0.5 mg scheduled to be administered to Resident #12 at 4:00 P.M. The third medication cup had Norco 5/325 mg scheduled to be administered to Resident #14 at 6:00 P.M. The fourth medication cup had Sinemet (Parkinson medication) 25/100 scheduled to be given to Resident #15 at 9:00 P.M. and Remeron (antidepressant medication) 15 mg scheduled to be administered to Resident #15 at 8:00 P.M. Resident #12: Review of the Face Sheet reflected Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation on 9/30/13 at 4:20 P.M., of the medication cart revealed an unlabeled medication cup with 2 pills inside. Resident #13: Review of the Face Sheet reflected Resident #13 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation on 9/30/13 at 4:20 P.M., of the medication cart revealed an unlabeled mediation cup with 1 pill inside. Resident #14: Review of the Face Sheet reflected Resident #14 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation on 9/30/13 at 4:00 P.M., of the medication cart revealed an unlabeled medication cup with one pill inside. Resident #15: Review of the Face Sheet reflected Resident #15 was to be administered Sinemet 25/100 3 times a day at 8:00 A.M., 3:00 P.M., 9:00 P.M., and Remeron Soltab (dissolvable tablet) 15 (mg) daily at 9:00 P.M., for mood stabilization. The Medication Administration Record (MAR) reflected LPN "A" had already signed the 9:00 P.M., Sinemet dose as administered, well as the 8:00 P.M., as well as the dose of Remeron. An observation on 9/30/13 at 4:00 P.M., of the medication cart revealed an unlabeled medication cup with 3 pills inside. On 10/2/13 at 1:50 P.M., Regional Manager "VV" was notified of Immediate Jeopardy that began and was identified on 9/30/13 as result of the facility's failure to ensure residents were free from preset controlled substance medication with unlabeled medication left unattended on top of the medication cart. On 10/3/13 at 1:40 P.M., this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 9/30/13, LPN "A" was immediately counseled after the medication pass observation by the Unit Manager on the expectation of not pre-pouring medications, not leaving medications unattended on the top of the medication cart and securing medications. 2. ON 10/1/13, LPN "A" was again counseled by the DON prior to the beginning of her shift. 3. On 10/2/13, LPN "A" completed on-line education relating to medication pass standards, procedures and prevention of medication errors. 4. On 10/2/13, Residents #12, #13, #14, and #15 were evaluated by the DON. The attending physician was notified of the potential for medication errors for these 4 residents and will implement recommendations. The residents have not exhibited any negative outcomes to date. LPN "A" was suspended on 10/2/13 pending investigation of the incident. LPN "A" has not worked on the floor since 10/1/13. 5. On 10/2/13, 8 of 32 nurses have received the education as of 4:40 P.M. 32 of 32 Licensed Nurses will be in-serviced on the standards of practice for medication administration, securing of medications and documentation of medication administration after a medication has been administered before their next scheduled shift beginning on 10/2/13. 6. On 10/2/13, Licensed Nurses will be observed during medication passes to ensure understanding of medication administration, documentation standards, and securing medications when unattended. 7. On 10/2/13, effective immediately, all newly hired nurses will be observed during medication pass observation to ensure accuracy, proper medication pass techniques and documentation within the first 90 days of employment. 8. On 10/2/13, the Unit Managers, DON, and designees will conduct random observations of medication carts to ensure all medications are secured when the cart is unattended. Although the Immediate Jeopardy was removed on 10/3/2013, the facility remained out of compliance with a 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 yet been in-serviced and sustained compliance had not been verified by the State agency. B. Based on observation, interview and record review the facility failed to ensure wheelchair alarms were turned on and functioning in 2 of 18 sampled residents (Resident #5 and #12) reviewed for falls, from a total sample of 18 residents, resulting in the potential for injury. Findings include: Resident #12 Resident #12 was admitted to the facility 4/09 with a medical history according to the physician progress notes [REDACTED]. Review of the MDS (Minimum Data Set) dated 10/3/13 revealed Resident #12 was severely impaired with daily decision making skills, displayed no behaviors issues, required extensive two person assistance with transfers, toileting, was not steady and only able to stabilize with staff assistance moving from surface to surface or seated to standing position and was incontinent of both bowel and bladder. Resident #12 was observed on 9/30/13 at 2:45 PM sitting in a wheelchair in her room. When this surveyor sat down next to the resident an alarm was noted to be hanging in the back of the wheelchair with no light blinking. When the cord was disconnected no alarm rang and the on/off switch was noted to be in the "off" position. At 2:55 PM CNA "II" entered the room offering Resident #12 a drink, checked the alarm and turned the alarm to the "on" position. When asked if the alarm was just turned on CNA II replied "Yes, it was off. I just turned it on". Review of Resident #12's Medical Record revealed Physician orders [REDACTED]. Review of the Nursing Care Plan dated 3/13 titled "Falls" Intervention dated 5/8/13 "alarming sensor to wheelchair, pressure alarm to bed, wheelchair and recliner". Review of the Fall Risk assessment dated [DATE] revealed a score of "18" (any score above 10 represents high risk). Review of the CNA (certified nursing assistant) Care Card Section Fall Risk: Safety Equipment Sensor alarm to bed, wheelchair and recliner. ( ) Resident #5 According to the October 2013 Physician Orders, Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview and observation on 10/1/13 at approximately 3:15 PM, Resident #5 was observed to be sleeping in her wheelchair in the hallway next to her room. Observation of Resident #5's pressure alarm on her wheelchair revealed the horizontal light bar on the alarm box was not on or blinking. Licensed Practical Nurse (LPN) "A" was asked how to know if a pressure alarm was working, LPN "A" stated "it's suppose to be blinking." Certified Nursing Assistant (CNA) "HH" a CNA walking down the hallway was asked how often resident fall alarms are checked for operation, CNA "HH" reported that the staff are suppose to check to see if the light is flashing when they start their shift. CNA "II", the aide assisting Resident #5 on 10/1/13, reported the light on Resident #5's pressure alarm was flashing when she started her shift at 2:00 PM. When asked if the alarm gives any indication that the battery is going dead, CNA "II" stated "No". On 10/3/13 at approximately 10:50 AM, Assistant Director of Nursing (ADON) "G" was asked the expectation of staff for checking of alarms. ADON "G" reported that Central Supply Coordinator "GG" checks the alarms every day, the weekend manager will check the alarms on Saturday and Sunday, and all staff are to check alarms while in resident rooms doing care. When asked if the alarms notify staff when the battery is getting low, ADON "G" stated "I know of one kind that will beep when low battery". ADON "G" could not identify which alarm will make a beep noise when the battery was low. On 10/3/13 at approximately 11:00 AM, Central Supply Coordinator "GG" was asked about resident alarms. Central Supply Coordinator "GG" reported that the resident tab alarms do not notify if the battery is getting low. Central Supply Coordinator "GG" stated "the pressure alarms will emit a chirping noise when the battery is getting low." Central Supply Coordinator "GG" stated "the cordless alarms have a light that will blink when the battery gets low." Central Supply Coordinator "GG" reported that CNA's are suppose to check the alarm lights at the beginning of every shift, and everytime they transfer a resident. Central Supply Coordinator "GG" also explained that the tester ADON "G" was referring to was to check wanderguards only, and they get checked daily by Central Supply Coordinator "GG" and by weekend managers on the weekends. Resident #5's Fall Risk Assessment for 4/10/13 indicated Resident #5 was at a high risk for falls, assessment for 8/2/13 indicated Resident #5 was at a high risk for falls and the assessment for 9/8/13 did not have any parameters filled in, therefore no risk level was identified According to the Plan of Care for Resident #5 dated 09-21-13, titled: Falls, reflected "Resident is at risk for fall related injury related to: impaired vision, unsteady balance, impaired mobility, history of falls, impaired safety awareness, dementia, O/A, Hx of CVA, and Hx, left hip fx, Decreased ROM in the lower extremities." Under the title Interventions, the Plan of Care reflected: "Lock wheel on wheelchair prior to transfers. Pressure alarm on top of the w/c cushion, pressure alarm to the bed, check palcement (sic) and function q shift. start: 09-20-13." ( ) C. Based on observation and record review the facility failed to ensure a proper transfer according to the care plan in 1 of 18 sampled residents (Resident #12) reviewed for safe transfers, from a total sample of 18 residents, resulting in the potential for injury. Findings include: Resident #12 was observed on 10/2/13 at 1:15 PM by this surveyor being taken to her room returning from lunch in a wheelchair by an unidentified CNA. Upon entering the room the CNA removed the foot rests from the wheelchair, and using only one person (herself) transferred Resident #12 alone from the wheelchair to the recliner. The CNA did not check the care guide which was present inside the resident's closet door prior to the transfer. Review of the physician progress notes [REDACTED]. Review of the CNA care guide Section titled "Transfers: Level "E" (extensive) "Assist of 2" was checked. ( ) D. Based on observation, interview, and record review the facility failed to ensure adequate supervision was in place for 2 of 2 resident (Resident #2 and #17) reviewed for smoking, out of a total sample of 18 residents, resulting in the potential for injury. Findings include: Resident #2 Review of the Facility Smoking Policy dated August 17, 2012, revealed "Guests who would like to smoke should notify the charge nurse. All Guests are to be supervised while smoking unless the facility has determined the Guest is safe to smoke independently." Review of the Face Sheet revealed Resident #2 was a [AGE] year old male admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #2's [DIAGNOSES REDACTED]. The MDS revealed Resident #2's ability to make daily decision was moderately impaired. Review of the Facility Smoking Care Plan dated 2/19/13, revealed Resident #2 wished to smoke while in the facility. The Smoking Care Plan revealed the goal was that Resident #2 would comply with the Facility Smoking Policy. Review of the Nursing Progress Notes dated 9/29/13 at 2145 (9:45 PM), revealed "at approximately 1900 (7:00 PM) I saw this resident (Resident #2) at the end of skilled hall talking to ...(Resident #17)... I saw him then going outside with the other resident (Resident #17). When the aide to take him (Resident #2) out to smoke at 1930 (7:30 PM) was looking for him (Resident #2) I told them that he was probably outside. the aide then went outside to supervise him. The aide stated when she came back in that the resident (Resident #2) stated "Oh no, I'm going to be in big trouble aren't I?" The resident (Resident #2) was reminded again that he is not to go outside to smoke without a staff member or family present." Review of the Nursing Care Card (no date) revealed Resident #2 was not to be left outside unattended. In an interview on 10/1/13 at 1:40 PM, Registered Nurse (RN) "Y" reported Resident #2 did go outside unsupervised with Resident #17 who was an independent smoker. RN "Y" reported that when the Certified Nursing Assistant (CNA) (could not recall which one), came looking for Resident #2 at 7:30 PM to take him out to smoke she realized that Resident #2 must have gone outside with Resident #17. RN "Y" reported that at 7:00 PM 9/29/13 she observed Resident #17 who was an independent smoker and knows the exit code with Resident #2 near the exit door to the smoking area. RN "Y" reported that Resident #2 was outside approximately 25 minutes unsupervised and that she spoke with Resident #2 about not smoking without staff or family present. RN "Y" reported that Resident #17 was also spoke to about not letting Resident #2 out to smoke when he goes out. Resident #17 Review of the Face Sheet revealed Resident #17 was a [AGE] year old male readmitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #17's [DIAGNOSES REDACTED]. The MDS revealed Resident #17's ability to make daily decision was cognitively intact. Review of the Nursing Notes dated 10/3/13 at 10:10 AM, revealed late entry for 10/2/13 "This nurse spoke to resident (Resident #17) in regards to smoking policy. Reviewed policy with him. Notified him that due to the event on 9/29/13 a new smoking assessment would need to be initiated. He stated his understanding. Reviewed again that he is not to carry cigarettes and lighter and they are to be stored in the cart. he agreed. Discussed him having someone with him if he were to want to take a "walk" outside on unsteady ground. He stated understanding." In an interview and observation on 10/3/13 at 11:15 AM, Resident #17 reported that on 9/29/13 Resident #2 just followed him outside. Resident #17 reported that Resident #2 had a cigarette and lite it off one of his, he did not know where he got the cigarette from. Resident #17 reported that he knew Resident #2 was not suppose to be outside with him. Resident #17 reported that now the facility does not want him to smoke independently, he stated "I will not tell them how I know the code to get out the exit door" as he opened an went out with this Surveyor to the smoking area. Resident #17 reported that the facility are changing the rules from when he was admitted and he was considering leaving, he then pulled a lighter out of his pocket, picked a cigarette butt off the ground and attempted to light it. Resident #17 continued the interview and picked up a second cigarette butt off the ground, lite it, and started to smoke, an unidentified staff member came out to get him at this time. In an interview on 10/3/13 at 12:00 PM, Unit Manager Registered (RN) "C" reported that she was aware Resident #17 was carrying a lighter because he would not give it up and that he knew the exit code, he was not happy with the changes being implemented with his smoking and would not sign the new care plan. RN "C" reported Resident #17 was stating that he may go AMA and the facility was working with him on that. #

This Federal Tag contains 2 Deficiency Practice Statements, A and B. A. Based on observation, interview and record review, the facility failed to ensure residents were free from potential significant medication errors in 4 of 18 sampled residents (Resident #12, #13, #14, and #15) reviewed for medications, from a total sample of 18 residents, resulting in an Immediate Jeopardy when, on 9/30/13 on the 2nd shift, Licensed Practical Nurse (LPN) "A" preset medications and left them unattended on top of the medication cart which were due to be administered between 4:00 P.M., to 9:00 P.M., and then documented the medications were given on all Medication Administration Records (MAR) prior to the prescribed times. These deficient practices placed all residents who receive medication in the facility at risk for serious harm, injury and/or death. Findings include: In an observation on 9/30/13 beginning at 4:00 p.m., LPN "A"was observed to have left the medication cart unattended to administer medications to another resident. Upon return to the cart with this surveyor, LPN "A" was found to have 4 medication cups sitting on top of the medication cart, each one with pills in them. The first cup had [MEDICATION NAME] (schedule III pain medication)10/325 milligrams mg scheduled to be administered to Resident #13 at 4:00 P.M. The second cup had [MEDICATION NAME] (pain medication) 50 mg scheduled to be administered at to Resident #12 at 8:00 P.M., and [MEDICATION NAME] (antianxiety medication-scheduled IV medication) 0.5 mg scheduled to be administered to Resident #12 at 4:00 P.M. The third medication cup had [MEDICATION NAME] 5/325 mg scheduled to be administered to Resident #14 at 6:00 P.M. The fourth medication cup had [MEDICATION NAME] (Parkinson medication) 25/100 scheduled to be given to Resident #15 at 9:00 P.M. and [MEDICATION NAME] (antidepressant medication) 15 mg scheduled to be administered to Resident #15 at 8:00 P.M. LPN "A", when questioned about the medications being preset for residents, stated, " I know my doses and this is how my system is, it goes room by room, I know I shouldn't preset meds (medication), but I catch them (residents) as they come down the hall," Review of Resident #12, #13, #14, and #15's MAR'S for 9/2013 reflected all the above medication had been signed out as already administered by LPN "A". Resident #12: Review of the Face Sheet reflected Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation on 9/30/13 at 4:20 P.M., of the medication cart revealed an unlabeled medication cup with 2 pills inside. Review of the MAR indicated [REDACTED].M., 2:00 P.M., and 8:00 P.M. Resident #12 had also been prescribed [MEDICATION NAME] (scheduled IV medication) 0.5 mg was to be administered 2 times daily at 8:00 A.M., and 4:00 P.M. The MAR indicated had already signed the medication as administered for the 8:00 P.M., dose of [MEDICATION NAME] and the 4:00 P.M., dose of [MEDICATION NAME] prior to administration of either medication. Resident #13: Review of the Face Sheet reflected Resident #13 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation on 9/30/13 at 4:20 P.M., of the medication cart revealed an unlabeled mediation cup with 1 pill inside. Review of the MAR indicated [REDACTED].M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. The MAR indicated had already signed the medication as administered for the 4:00 P.M., which had not been administered and 8:00 P.M., doses. Resident #14: Review of the Face Sheet reflected Resident #14 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation on 9/30/13 at 4:00 P.M., of the medication cart revealed an unlabeled medication cup with one pill inside. Review of the MAR indicated [REDACTED].M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. The MAR indicated [REDACTED].M. dose. Resident #15: Review of the Face Sheet reflected Resident #15 was to be administered [MEDICATION NAME] 25/100 3 times a day at 8:00 A.M., 3:00 P.M., 9:00 P.M., and [MEDICATION NAME] (dissolvable tablet) 15 mg daily at 9:00 P.M., for mood stabilization. The MAR indicated had already signed the 9:00 P.M., [MEDICATION NAME] dose as administered, well as the 8:00 P.M., as well as the dose of [MEDICATION NAME]. An observation on 9/30/13 at 4:00 P.M., of the medication cart revealed an unlabeled medication cup with 3 pills inside. On 10/2/13 at 1:50 P.M., Regional Manager "VV" was notified of the Immediate Jeopardy that began on 9/30/2013, and identified on 9/30/13, due to the facility's failure to to ensure residents were free from potential significant medication errors when medications were preset and documented as admistered several hours prior to prescribed administration times. On 10/3/13 at 1:40 P.M., this surveyor verified the facility completed the following to removed the Immediate Jeopardy: 1. On 9/30/13, LPN "A" was immediately counseled after the medication pass observation by the Unit Manager on the expectation of not pre-pouring medications, not leaving medications unattended on the top of the medication cart and securing medications. 2. ON 10/1/13, LPN "A" was again counseled by the DON prior to the beginning of her shift. 3. On 10/2/13, LPN "A" completed on-line education relating to medication pass standards, procedures and prevention of medication errors. 4. On 10/2/13, Residents #12, #13, #14, and #15 were evaluated by the DON. The attending physician was notified of the potential for medication errors for these 4 residents and will implement recommendations. The residents have not exhibited any negative outcomes to date. LPN "A" was suspended on 10/2/13 pending investigation of the incident. LPN "A" has not worked on the floor since 10/1/13. 5. On 10/2/13, 8 of 32 nurses have received the education as of 4:40 P.M. 32 of 32 Licensed Nurses will be in-serviced on the standards of practice for medication administration, securing of medications and documentation of medication administration after a medication has been administered before their next scheduled shift beginning on 10/2/13. 6. On 10/2/13, Licensed Nurses will be observed during medication passes to ensure understanding of medication administration, documentation standards, and securing medications when unattended. 7. On 10/2/13, effective immediately, all newly hired nurses will be observed during medication pass observation to ensure accuracy, proper medication pass techniques and documentation within the first 90 days of employment. 8. On 10/2/13, the Unit Managers, DON, and designees will conduct random observations of medication carts to ensure all medications are secured when the cart is unattended. Although the Immediate Jeopardy was removed on 10/3/2013, the facility remained out of compliance with a 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 yet been in-serviced and sustained compliance had not been verified by the State agency. ( ) B. Based on observation, interview and record review, the facility failed to ensure medication was administered as prescribed for 1 of 25 observed medication administrations (Resident #25) reviewed for medication observations, from 18 total sampled residents, resulting in an inaccurate dose administered. Findings include: Resident #25: Review of the Monthly Physician Orders dated 10/1/13 to 10/31/13 reflected Resident #25 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an observation on 9/30/13 at 4:00 P.M., in the Birch Hallway LPN "A"was observed as she prepared the liquid antipsychotic medication [MEDICATION NAME], 2 milligrams (mg) for administration to Resident #25. LPN "A" was observed as she poured the liquid medication into the medication cup . The medication was poured to the 2.5 milliliter (ml) line. When questioned about accurate dosage, LPN "A" stated," I have checked this before and with the line it is very close, even though it seems like a small amount." LPN "A" was observed to administer the medication as Resident #25 accepted the liquid medication without any difficulty. LPN "A" was requested by this surveyor to re-pour the same amount into the medication cup and draw into a syringe. LPN "A" was observed as she re-poured the medication, drew the solution into a syringe and determined the amount of liquid withdrawn of the antipsychotic medication was [MEDICATION NAME] 2.4 ml., not the prescribed amount of 2.0 ml. The anti-psychotic medication, [MEDICATION NAME] was identified on the pharmacy label as [MEDICATION NAME] 1 mg per 1 milliliter ml. In an interview on 10/2/13 at 4:00 P.M., the Director of Nursing (DON) "F" reported LPN "A" had gone immediately to Unit Manager Registered Nurse (RN) "B" and had reported she felt she may be terminated as she had made some errors. DON "F" reported she had not been made aware of the antipsychotic medication dosage situation at that time. DON "F" reported no incident report had been made out and the situation had not been reported to the physician at that time. Review of the facility policy titled "Medication Administration" and dated 7/2010 reflected under preparation, item 3. "...When administering medications in liquid form, devices provided by the manufacturer or obtained from the provider pharmacy (such as oral syringes) are used to allow accurate measurement of doses.

Based on observation, interview, and record review, the facility failed to prevent the development of a Stage 4 pressure ulcer and prevent continued pressure in 1 of 2 sampled residents (Resident #9) reviewed for pressure ulcers, out of a total sample of 18, resulting in an Immediate Jeopardy for Resident #9, when on 8/15/2013, Resident #9 was identified to have "mushy" bilateral heels upon re-admission to the facility, and facility staffs did not monitor Resident #9's heels again until 9/5/13 after the Stage 4 ulcer was found on his left heel. These deficient practices places 61 residents, identified as at risk for skin breakdown, at risk for serious harm, and/or injury. Findings include: Review of facility Policy and Procedure titled, "Wound and Skin Management Program" dated 6/2011 revealed on page #22, under, "Monitoring Healing", "...If a wound does not show progress toward healing within a two week period, the guests treatment plan should be reviewed with the attending physician." On page #46, under, "Wound and Skin Condition Record", "All wound and skin conditions are to be documented on the Wound and Skin Condition Record weekly." Review of the Face Sheet revealed Resident #9 was an [AGE] year old male with [DIAGNOSES REDACTED]. The Face Sheet revealed Resident #9 was re-admitted to the facility on [DATE]. Review of the "Nursing Admission Assessment" dated 8/15/2013 revealed Resident #9 was assessed to have bilateral (both) "mushy" (soft) heels. Review of the Admission Physician order [REDACTED].#9's "mushy" heels. Review of a physician order [REDACTED]. Review of physician orders [REDACTED]. Review of physician "Progress Note" dated 8/19/13 and 8/26/2013 revealed no documentation from the physician in regards to Resident #9's heels. Review of an "Interdisciplinary Care Plan" dated 8/15/2013 revealed Resident #9 had bilateral "mushy" heels. The interventions were to float Resident #9's heels, pressure reduction mattress, medications as ordered, and treatment as ordered. Another care plan dated 8/15/2013 revealed a "Problem/Need" of, "DTI (deep tissue injury)" to left heel and stage 1 to right heel. The interventions included to notify the physician for worsening or no signs of healing. Review of facility "Shower/Skin Observation" records revealed that skin observation records were not started until 8/20/2013. On 8/20/2013 two observation records were completed and documented that Resident #9 had no abnormalities as well as on 8/28/13 or on 9/3/13. Furthermore, the dates of 9/6, 9/10, 9/13, and 9/17/2013 did not reveal any documentation of Resident #9's heels on the "Shower/Skin Observation" record. Review of "Wound and Skin Condition Log" dated 8/20, 8/27, and 9/3/2013 revealed no documentation of Resident #9's heels, and Resident #9's name was not written on the log. Review of "Pressure Ulcer Log" dated 8/20, 8/27, and 9/3/2013 reveal Resident #9 was not on the list of residents with pressure ulcers and therefore there was no documentation of Resident #9's heels. Review of a "Weekly Skin Assessment" record dated 9/1/2013 revealed no documentation of Resident #9's heels. Review of a "Nutritional Risk Score" record dated 8/28/2013 revealed documentation of Resident #9 not having any "skin conditions" concerns. Review of a "Nutritional Assessment" record dated 8/30/2013 revealed no documentation of Resident #9's heels. Review of nurses' notes dated 8/15 through 9/5/2013 revealed no documentation in regards to Resident #9's heels until 9/5/2013 (3 weeks after being admitted to the facility) when the notes revealed that Resident #9's left heel had an area of deep tissue injury. The note revealed that the physician was notified. Review of a "Pressure Ulcer Record" revealed that on 8/15/2013 Resident #9's heels were noted to be "mushy, soft reddened". No other measurements and/or assessments of Resident #9's heels were noted to be documented until 9/5/2013 when it was documented that Resident #9's left heel had a deep tissue injury, "converted to stage 4", measured 6 cm x 4 cm in length and depth, was dark black in color, and "mushy soft with a blood blister appearing." The record indicated that Resident #9's right heel was mushy and consisted of a 1 cm x 1 cm dark black area. Review of the physician "Progress notes" revealed that on 9/5/2013 the Nurse Practitioner (NP) noted Resident #9 had a "deep tissue injury" to his left heel, and noted that on 9/5/2013 Resident #9's left heel had a black blister and a lightly discolored smaller area to Resident #9's right heel. The progress note revealed that treatment was ordered on [DATE]. Review of the Physician orders [REDACTED]. Review of the care plan indicated "Problem/Need" - "DTI" dated 9/5/2013 revealed that Resident #9's left heel DTI had converted to a stage 4 pressure ulcer. A new intervention added was to float heels with heals up while in bed (previously ordered by the physician on 8/16/13). No other interventions were added. Review of the Nutritional "Progress Notes" dated 8/29/2013 revealed no documentation of Resident #9's heels, until 9/6/2013 when an increase in protein supplement was ordered. In an interview on 10/1/2013 at 1:15 PM, Unit Manager, Registered Nurse (RN) "B" stated that she did not know and "that's where the gap is" in regards to assessment, including documentation of Resident #9's heels. In an interview on 10/1/2013 at 1:55 PM, RN "C" said that she did not assess Resident #9's heels, she did not document any assessment, nor did she perform any treatment to Resident #9's heels. In an interview on 10/3/2013 at 11:15 AM, Certified Nurse Aid (CNA) "S", who provided showers to Resident #9, stated she was aware Resident #9 had problems with his heels. CNA "S" said she never really looks at Resident #9's heels but just washed them. CNA "S" said Resident #9 sat in a shower chair while she would wash him and stated that she did not lift Resident #9's feet high enough to visualize his heels. CNA "S" said she could feel Resident #9's heel were tender/mushy and stated Resident #9 wore a pink pad over his heel that she would place back on and put a sock over it. CNA "S" said no other dressing was on Resident #9's heel. In an interview on 10/3/2013 at 11:30 AM, CNA "EE" stated that Resident #9 would receive a full skin assessment twice a week during his shower time. CNA 'EE" ,who showered Resident #9 on 8/28/2013, stated that he did not see any abnormalities with Resident #9's heels and said that he was not aware of any pressure ulcers on Resident #9's heels. CNA "EE" said Resident #9 sat in a shower chair while receiving a shower and stated that he did not lift Resident #9's foot up in order to look under at his heels. CNA "EE" said Resident #9 was not able to lift his feet up too high and stated that he would turn Resident #9's foot side to side to visualize but did not look under Resident #9's foot to assess Resident #9's heels. In interviews conducted on 10/2/2013 at 11:58 AM and on 10/3/2013 at 3:28 PM, Nurse Practitioner (NP) "D" stated that she only knew that Resident #9's heels were "mushy" and then the next she knew Resident #9's left heel was a stage 4. NP "D" said she did not know Resident #9's left heel progressed so fast. NP "D" stated, on 10/3/2013, that she had just assessed Resident #9's heels and assessed Resident #9's left heal to have an un-stageable pressure ulcer. NP "D" said she was aware that Resident #9 sat in his wheelchair most of the day and stated that she would order blue boots (cushion) for him because she was not confident the pink pad eliminated all the pressure Resident #9 was putting on his heel on the floor. During observations conducted on 10/1/13 at 12:00 PM and 4:15 PM, on 10/2/13 at 3:35 PM, and on 10/3/13 at 11:45 AM, Resident #9 was noted to be sitting in a wheelchair with his feet solidly on the floor with grip socks on both feet. On 10/3/2013 at 4:40 PM, the Regional Operations Manager "VV" was notified of the Immediate Jeopardy that began on 8/15/2013, and identified on 10/2/2013, due to the facility's failure to prevent the development of a Stage 4 pressure ulcer to Resident #9's left heel and prevent continued pressure to Resident #9's heel when sitting in a wheelchair. On 10/4/2013 the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. Full in-house sweep will be initiated by the Unit Managers and designees on 10/3/2013 and completed by 10/4/2013 to ensure all pressure areas have been identified. 35 of 87 resident were completed on 10/3/2013. 2. Beginning 10/3/2013, any new pressure sores will be assessed, measured, and recorded on the pressure sore monitoring record. 3. Beginning 10/3/2013, the attending physician will be notified of identified skin areas, treatment orders obtained, treatments initiated, and pressure prevention interventions implemented. 4. Beginning 10/3/2013, all pressure areas will be assessed and measured by a licensed nurse at least weekly. Physician will be notified of any changes and treatments changed when indicated. 5. Beginning 10/3/2013, skin conditions will continue to be observed during care, during the weekly showers and new skin conditions will be reported to the charge nurses for further assessment, physician notification and intervention. 6. Beginning 10/3/2013, the charge nurses and Unit Managers will monitor the shower sheets daily to ensure all new skin areas have been reported to the nurse. 7. Beginning 10/3/2013, residents with pressure areas will be followed by the nutrition at risk committee. 8. Beginning 10/3/2013, identified residents will be referred to the dietician for recommendations. The RD has completed the assessment for Resident #9. 2 additional residents have been referred for further assessment and those will be completed on 10/4/2013. 9. Beginning 10/3/2013, all licensed nurses 32 of 32 will be in-serviced by the Director of Nursing and/or designee on identifying pressure areas, treatment of [REDACTED]. 7 of the 32 licensed staff were completed on 10/3/2013. 10. Beginning 10/3/2013, all nursing assistants will be in-serviced by the Director of Nursing and/or designee on the prevention of pressure ulcers and implementation of interventions prior to their next scheduled shift. 19 of the 50 nursing assistants were in-serviced on 10/3/2013. 11. Beginning 10/3/2013, the Administrative nurses and/or change nurses will observe the implementation of prevention interventions every shift. Any variances will be corrected at the time of the observation and additional education and/or disciplinary action initiated. 12. Beginning 10/3/2013, new pressure areas will be reviewed during the morning clinical meeting. The Unit Managers will ensure physician have been notified, assessment and measurements have been completed and treatments obtained, initiated and documented. Although the immediate Jeopardy was removed on 10/3/2013, the facility remained out of compliance with a 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 received the in-services for skin assessment and pressure ulcer prevention and sustained compliance had not been verified by the State agency. ( )

Based on interview and record review, the facility failed to ensure the Quality Assurance (QA) committee developed and implemented appropriate plans of action to monitor and prevent pressure ulcers in 1 of 2 residents (Resident #9) reviewed for pressure ulcers, from a total sample of 18 residents, resulting in Resident #9 developing a Stage 4 pressure ulcer and the potencial for all 35 residents, identified as at risk for skin breakdown/pressure ulcers, to have pressure ulcers that either develop and/or worsen. Findings include: Record review of the Face Sheet revealed Resident #9 was an [AGE] year old male with [DIAGNOSES REDACTED]. The Face Sheet revealed Resident #9 was re-admitted to the facility on [DATE]. Review of the "Nursing Admission Assessment" dated 8/15/2013 revealed Resident #9 was assessed to have bilateral "mushy" (soft) heels. Review of the admission physician orders [REDACTED].#9's "mushy" heels. Review of a physician order [REDACTED]. Review of physician orders [REDACTED]. Physician orders [REDACTED]. Review of physician "Progress Note" dated 8/19/13 and 8/26/2013 revealed no documentation from the physician in regards to Resident #9's heels. The Progress notes revealed that on 9/5/2013 the Nurse Practitioner (NP) noted Resident #9 had a "deep tissue injury" to his left heel, and noted that on 9/5/2013 Resident #9's left heel had a black blister and a lightly discolored smaller area to Resident #9's right heel. The progress note revealed that treatment was ordered on [DATE]. In an interview on 10/4/13 at 10:00 AM, Director of Nursing (DON) "F" reported that the QA committee met to discuss pressure ulcers on 8/19/13 and that the QA committee indicated that the pressure ulcer training and repositioning policy was revised on 7/13 to help prevent pressure ulcers and that the Unit Managers would review the Weekly Skin Assessment sheets to validate completion daily (M-F). In an interview on 10/4/13 at 11:20 AM, Unit Manager, Registered Nurse (RN) "C" stated, "They (weekly skin assessment sheets) were to be reviewed for completion, it would be impossible to recheck all residents for accuracy." Review of the training records for the policy change for pressure ulcers revealed all nursing staff had been educated by 8/9/13 regarding the revised pressure ulcer policy. ( )

This Citation pertains to intake numbers MI 766 and MI 246. Based on interview and record review, the facility failed to create individualized, comprehensive plans of care in 4 (Resident #101, Resident #103, Resident #104 and Resident #106), of 6 sampled residents reviewed for care plans, from a total of 6 sampled residents, resulting in lack of care to meet individualized needs of all 4 residents. Findings include: Resident #101 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed that Resident #101 no longer lived at the facility but was an [AGE] year old male admitted to the facility 3/14/13 with [DIAGNOSES REDACTED]. The MDS indicated that Resident #101 had clear speech, was understood, understands, had moderately impaired cognition, and required extensive assistance from 2 persons for transfers. Review of the hospital "Cardiac MD Discharge Orders" dated 3/14/13, revealed discharge [DIAGNOSES REDACTED]. Review of the "Plan of Care" dated 4/1/2013 for Resident #101 revealed there was no Care Plan in place for [MEDICAL CONDITION]. In an interview on 6/19/13 at 1:30 PM, Director of Nursing (DON) #2 stated the facility did not have any type of protocol to handle a resident diagnosed with [REDACTED]. A review of the "admission orders [REDACTED]. "There are an estimated 2 million people in the United States with heart failure, most of whom are elderly...One important prevention tool is weight monitoring. With your health care professional, you can develop a weight monitoring game plan ...If a patient is diagnosed with [REDACTED]." (<http://nursing.advanceweb.com/sharedresources/advancefornurses/resources/downloadableresources/nurseweightfeb18.pdf>). Review of the "Patient Transfer Form" dated 5/14/13, revealed Resident #101 was being transferred to another long term care facility. Review of hospital "History and Physical" dated 5/14/13, revealed that Resident #101 was being transferred from a nursing home for rehab to another nursing home for long-term care when the transfer team noticed that he was quite lethargic, his blood oxygenation was 70% (normal is greater than 95%) and was taken to the emergency room where he was admitted to the hospital with [REDACTED]. Review of hospital "History and Physical" dated 5/14/13, revealed that Resident #101 was admitted to the hospital with [REDACTED]. ( ) Resident #103 Review of the face sheet dated 3/30/10 and the most recent MDS dated [DATE] revealed Resident #103 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #103 had clear speech, was understood, understands, was continuously inattentive, had disorganized thinking, had severely impaired cognition, and required extensive assistance of 2 people for transfers. Review of the "Braden Scale for Predicting Pressure Sore Risk" dated 3/1/13 revealed Resident #103 scored a 13 (total score of 17 or less indicates that the individual is at risk.) Review of the "Potential for Skin Breakdown Plan of Care" dated 10/10/12 and updated 3/1/13 revealed the following interventions: "provide extensive assistance to reposition frequently and as needed...assist to reposition in chair as needed...conduct weekly head to toe assessments, document and report abnormal findings to physician". Review of the "Weekly Skin Assessment" dated 3/21/13, 3/28/13, 4/11/13, 4/25/13, 5/2/13, 5/16/13, 5/23/13, 5/30/13 and 6/4/13 revealed that on 4/25/13 Resident #103's skin was intact, and on 6/4/13, Resident #103 developed a stage 2 pressure ulcer to the right ischium. Review of the "Weekly Skin Assessment" form revealed that skin assessments for Resident #103 were not completed during the weeks of 3/31/13, 4/15/13 and 5/6/13. In an interview on 6/19 at 11:45 AM, when asked what "frequent" meant in regards to repositioning, MDS Coordinator/Registered Nurse (RN) #4 stated, "I wasn't about to put a time frame on how frequent to reposition...Not every intervention is on the care plans...I never put specifics on care plans, because everyone is different". ( ) Resident #104 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #104 was an [AGE] year old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing "Progress Notes" dated 3/3/13 through 6/19/13, revealed Resident #104 exhibited the behavior of "yelling out" almost daily. Review of the "Plan of Care" revealed there was not a "Behavior Problem Care Plan" in place until 6/4/13, six months after Resident #104 was admitted to the facility. In an interview on 6/26/13 at 2:08, Unit Manager/Registered Nurse (RN) #6 stated, "there was no rhyme or reason to the yelling (by Resident #104) " . In an interview on 6/25/13 at 3:16 PM, RN #16 stated, "Pretty much a daily occurrence (Resident #104 yelling out), would be a rarity when she (Resident #104) wouldn't yell...not as much yelling when the family was visiting". In an interview on 6/24/13 at 2:46 PM, Certified Nursing Assistant (CNA) #13 stated Resident #104 would yell out daily. CNA #13 stated, "(Resident #104) would scream for 4 reasons: had to go to the bathroom, was hungry, had pain, or if she was wet". In an interview on 6/26/13 at 9:10, Social Services Director (SSD) #25 stated Resident #104 would usually yell out every day. SSD #25 stated if Resident #104 was with an activities staff member, she would not yell out as much. SSD #25 stated, "There should have been a care plan in place for behaviors (prior to 6/4/13)". When asked why there was no care plan in place, SSD #25 stated, "I'm new, and trying to get caught up". In a telephone interview on 6/26/13 at 11:30 AM, CNA #19 stated she took care of Resident #104 regularly. CNA #19 stated Resident #104, "yelled daily, normally yelled because she was hungry, needed to be toileted or thirsty...normally would not yell out unless there was a problem. (Resident #104) did not yell out for no reason, was a way of communicating more so than anything". CNA #19 stated she tried to make it a point to let all the other staff know of the reasons why Resident #104 would yell. CNA #19 stated she did let Social Services know about the interventions that would decrease Resident #104's yelling out behaviors. In an interview on 6/28/13 at 11:10, off sample Resident #120 stated Resident #104 would yell out every day, "staff would just let her do it...only way (Resident #104) would calm down would be if someone talked to her". During the exit conference on 6/28/13 at 2:15, NHA #1 and Regional Quality Assurance Manager #22 agreed there should have been a care plan in place for Resident #104's behavior issues. ( ) Resident #106 According to the Face Sheet dated 4/24/13 and the most recent MDS dated [DATE] revealed, Resident #106 was a [AGE] year of male with [DIAGNOSES REDACTED]. Resident #106 had clear speech, was understood, usually understands, was continuously inattentive, had moderately impaired cognition and required extensive assistance of 2 persons for transfers. Review of the "Fall Risk Assessment" dated 5/10/13, revealed Resident #106 had a fall risk score of 27, and according to the document a total score of 10 or more represents high risk for falls. Review of the "Incident Report" dated 6/8/13 at 11:50 AM, revealed Resident #106 was "found on floor beside bed". The section "immediate intervention(s) to Prevent Recurrence" revealed "reassurance". Review of the "Incident Report" dated 6/11/13 at 12:50 AM, revealed Resident #106 was found on the floor in the resident's room. The section "immediate intervention(s) to Prevent Recurrence" revealed, "applied non-skid socks". Review of the "Incident Report" dated 6/12/13 at 3:50 AM, revealed Resident #106 was found on the floor. The section "immediate intervention(s) to Prevent Recurrence" revealed, "reapplied non-skid socks". Review of the "At risk for falls Care Plan" for Resident #106 dated 3/7/13 did not reflect any updates or additions after the falls on 6/8/13, 6/11/13 or 6/12/13. The care plan for Resident #106 was updated on 6/14/13 and included hipsters to be worn at all times, but non-skid socks was not added to the Care Plan. Review of the "Nursing Care Card" (no date) which indicated information for the CNA's regarding Resident #106's care did not reflect non-skid socks were to be worn. During an interview on 6/27/13 at 9:15 AM, Unit Manager, RN #6 stated, "Non-Slip socks is not on (Resident #106's) care guide, it is not updated yet...they are only updated periodically". ( )

This Citation pertains to intake numbers MI 766. Based on interview and record review, the facility failed to provide the necessary care according to professional standards of quality for one resident (Resident #101) in 1 of 3 sampled residents from a total of 6 sampled residents by not properly monitor a resident with severe [MEDICAL CONDITIONS], resulting in Resident #101 being hospitalized for [REDACTED]. Findings include: Nursing assessment is the "deliberate and systematic collection of data" of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According to the Clinical Process Guidelines: Process Guideline Heart Failure (October 9, 2007), "Overall goals for treating heart failure should be compatible with the individual ' s choices, values, overall condition, and prognosis...key goals of intervention for systolic dysfunction is to improve the heart's output during each contraction ...Making appropriate interventions consistently is most likely to produce desirable outcomes...Trying to manage heart failure without following a consistent process can contribute to avoidable adverse consequences such as decline in function and recurrent hospitalization , and may have a negative effect on function and quality of life...Monitoring should include (among other things) vital signs, responsiveness to treatment, overall functional status, status of related comorbid conditions, sense of well-being, and nutritional and fluid volume status ...More frequent monitoring may be needed if the individual is medically or functionally unstable...Key symptoms may include decreased activity level, shortness of breath, unexplained cough, unexpected or progressive weight gain associated with fluid retention, sleep disturbance, orthopnea (dyspnea while horizontal), or new or increasing lower-extremity swelling...Physical signs may include rales (sounds heard that indicate fluid) in the lungs, tachypnea (increased respiratory rate), [MEDICAL CONDITION](high heart rate) and [MEDICAL CONDITION] (swelling) ...additional symptoms of heart failure that may be confused with other physical and psychosocial concerns include: decreased food intake, decline in function, acute confusion, [MEDICAL CONDITION]" "There are an estimated 2 million people in the United States with heart failure, most of whom are elderly...One important prevention tool is weight monitoring. With your health care professional, you can develop a weight monitoring game plan ...If a patient is diagnosed with [REDACTED]." (<http://nursing.advanceweb.com/sharedresources/advancefornurses/resources/downloadableresources/nurseweightfeb18.pdf>). "BNP (B-type Natriuretic Peptide) is a substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens. The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable...In addition, BNP help the physician make decisions about hospitalization s, aggressive treatments, and future prognosis...BNP levels above 900 pg/mL indicate severe heart failure." (http://my.clevelandclinic.org/heart/services/tests/labtests/bnp.aspx) Review of the Face Sheet dated 3/14/13 and the most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #101 no longer lived at the facility. Resident #101 was an [AGE] year old male admitted to the facility 3/14/13 with [DIAGNOSES REDACTED]. Resident #101 had clear speech, was understood, understands, had moderately impaired cognition, and required extensive assistance from 2 persons for transfers. Review of the hospital "Cardiac MD Discharge Orders" dated 3/14/13, revealed discharge [DIAGNOSES REDACTED]. Review of the Plan of Care for Resident #101 revealed there was no Care Plan in place for [MEDICAL CONDITION]. Review of Resident #101's record failed to produce proof that Resident #101 was seen by the cardiologist for a follow up appointment. In an interview on 6/28/13 at 11:40 AM, NHA #1 stated, "I don't see where (Resident #101) went to see a cardiologist" as ordered. In an interview on 6/19/13 at 1:30 PM, DON #2 stated the facility did not have any type of protocol in place for [MEDICAL CONDITION]. DON #2 stated that the only way the facility would do anything different for a patient with [MEDICAL CONDITION] was if the admitting orders stated to do so, otherwise there would be no special care for a resident with [MEDICAL CONDITION]. In a telephone interview on 6/25 at 11:50 AM, Physician #14 stated, "...don't use ([MEDICAL CONDITION]) protocols for nursing home patients, residents are so different because of the variety". A review of the "admission orders [REDACTED]. Review of the "ADL Data Report" dated 3/14/13 through 5/14/13, revealed that urinary output for Resident #101 was not measured. In an interview on 6/19/13 at 1:30 PM, NHA #1 stated Resident #101's urine output was not measured. NHA #1 stated, Certified Nursing Assistants (CNAs) simply document when (Resident #101) voided. Review of the "Vital Signs and Weight Record" dated 3/14/13, revealed Resident #101 was not weighed daily. Review of the nursing "Progress Notes" dated 5/7/13 through 5/14/13, revealed there were no vital signs recorded for Resident #101. In an interview on 6/26/13 at 10:15 AM, Physician Assistant (PA) #17 stated, "we (physician services) only see patients once a month, we (physician services) rely on nursing staff for updates". In an interview on 6/17/13 at 2:00 PM, Licensed Practical Nurse (LPN) #3 stated Resident #101 "had a decline while he was here". In an interview on 6/18/13 at 2:05 PM, Registered Nurse (RN) #26 stated on the day of Resident #101's transfer, "(Resident #101) seemed to have a little congestion going on". In an interview on 6/19/13 at 10:15 AM, CNA #10 stated, "(Resident #101) always liked to be in his wheelchair...did notice a decline in health...when (Resident #101) was first admitted he could stand on his own, before he left he (Resident #101) was a 2 person assist". In an interview on 6/19/13 at 10:55 AM, CNA #11 stated, "(Resident #101)'s conditioned worsened why he was here...he was more together, his memory was better...he became very dependent, very confused...(Resident #101) was not in very good condition when he left...was very confused". Review of the "Patient Transfer Form" dated 5/14/14, revealed Resident #101 was being transferred to another long term care facility. Review of the "Interdisciplinary Discharge Summary" dated 5/14/13, revealed there were no vital signs recorded prior to Resident #101 being transferred. Review of hospital "History and Physical" dated 5/14/13, revealed that Resident #101 was being transferred from a nursing home for rehab to another nursing home for long-term care when the transfer team noticed that he was quite lethargic, his blood oxygenation was 70% (normal is greater than 92%) and was taken to the emergency room where he was admitted to the hospital with [REDACTED]. ( )

This Citation pertains to intake numbers MI 766. Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical well-being (properly monitor a resident with severe [MEDICAL CONDITIONS]) in 1 of 3 sampled residents (Resident #101) reviewed for [MEDICAL CONDITION], from a total of 6 sampled residents, resulting in Resident #101 being hospitalized for [REDACTED]. Findings include: Nursing assessment is the "deliberate and systematic collection of data" of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According to the Clinical Process Guidelines: Process Guideline Heart Failure (October 9, 2007), "Overall goals for treating heart failure should be compatible with the individual ' s choices, values, overall condition, and prognosis...key goals of intervention for systolic dysfunction is to improve the heart's output during each contraction ...Making appropriate interventions consistently is most likely to produce desirable outcomes...Trying to manage heart failure without following a consistent process can contribute to avoidable adverse consequences such as decline in function and recurrent hospitalization , and may have a negative effect on function and quality of life...Monitoring should include (among other things) vital signs, responsiveness to treatment, overall functional status, status of related comorbid conditions, sense of well-being, and nutritional and fluid volume status ...More frequent monitoring may be needed if the individual is medically or functionally unstable...Key symptoms may include decreased activity level, shortness of breath, unexplained cough, unexpected or progressive weight gain associated with fluid retention, sleep disturbance, orthopnea (dyspnea while horizontal), or new or increasing lower-extremity swelling...Physical signs may include rales (sounds heard that indicate fluid) in the lungs, tachypnea (increased respiratory rate), [MEDICAL CONDITION](high heart rate) and [MEDICAL CONDITION] (swelling) ...additional symptoms of heart failure that may be confused with other physical and psychosocial concerns include: decreased food intake, decline in function, acute confusion, [MEDICAL CONDITION]" "There are an estimated 2 million people in the United States with heart failure, most of whom are elderly...One important prevention tool is weight monitoring. With your health care professional, you can develop a weight monitoring game plan ...If a patient is diagnosed with [REDACTED]." (<http://nursing.advanceweb.com/sharedresources/advancefornurses/resources/downloadableresources/nurseweightfeb18.pdf>). "BNP (B-type Natriuretic Peptide) is a substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens. The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable...In addition, BNP help the physician make decisions about hospitalization s, aggressive treatments, and future prognosis...BNP levels above 900 pg/mL indicate severe heart failure." (http://my.clevelandclinic.org/heart/services/tests/labtests/bnp.aspx) Review of the Face Sheet dated 3/14/13 and the most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #101 no longer lived at the facility. Resident #101 was an [AGE] year old male admitted to the facility 3/14/13 with [DIAGNOSES REDACTED]. Resident #101 had clear speech, was understood, understands, had moderately impaired cognition, and required extensive assistance from 2 persons for transfers. Review of the hospital "Cardiac MD Discharge Orders" dated 3/14/13, revealed discharge [DIAGNOSES REDACTED]. Review of the Plan of Care for Resident #101 revealed there was no Care Plan in place for [MEDICAL CONDITION]. Review of Resident #101's record failed to produce proof that Resident #101 was seen by the cardiologist for a follow up appointment. In an interview on 6/28/13 at 11:40 AM, NHA #1 stated, "I don't see where (Resident #101) went to see a cardiologist" as ordered. In an interview on 6/19/13 at 1:30 PM, DON #2 stated the facility did not have any type of protocol in place for [MEDICAL CONDITION]. DON #2 stated that the only way the facility would do anything different for a patient with [MEDICAL CONDITION] was if the admitting orders stated to do so, otherwise there would be no special care for a resident with [MEDICAL CONDITION]. In a telephone interview on 6/25 at 11:50 AM, Physician #14 stated, "...don't use ([MEDICAL CONDITION]) protocols for nursing home patients, residents are so different because of the variety". A review of the "admission orders [REDACTED]. Review of the "ADL Data Report" dated 3/14/13 through 5/14/13, revealed that urinary output for Resident #101 was not measured. In an interview on 6/19/13 at 1:30 PM, NHA #1 stated Resident #101's urine output was not measured. NHA #1 stated, Certified Nursing Assistants (CNAs) simply document when (Resident #101) voided. Review of the "Vital Signs and Weight Record" dated 3/14/13, revealed Resident #101 was not weighed daily. Review of the nursing "Progress Notes" dated 5/7/13 through 5/14/13, revealed there were no vital signs recorded for Resident #101. In an interview on 6/26/13 at 10:15 AM, Physician Assistant (PA) #17 stated, "we (physician services) only see patients once a month, we (physician services) rely on nursing staff for updates". In an interview on 6/17/13 at 2:00 PM, Licensed Practical Nurse (LPN) #3 stated Resident #101 "had a decline while he was here". In an interview on 6/18/13 at 2:05 PM, Registered Nurse (RN) #26 stated on the day of Resident #101's transfer, "(Resident #101) seemed to have a little congestion going on". In an interview on 6/19/13 at 10:15 AM, CNA #10 stated, "(Resident #101) always liked to be in his wheelchair...did notice a decline in health...when (Resident #101) was first admitted he could stand on his own, before he left he (Resident #101) was a 2 person assist". In an interview on 6/19/13 at 10:55 AM, CNA #11 stated, "(Resident #101)'s conditioned worsened why he was here...he was more together, his memory was better...he became very dependent, very confused...(Resident #101) was not in very good condition when he left...was very confused". Review of the "Patient Transfer Form" dated 5/14/14, revealed Resident #101 was being transferred to another long term care facility. Review of the "Interdisciplinary Discharge Summary" dated 5/14/13, revealed there were no vital signs recorded prior to Resident #101 being transferred. Review of hospital "History and Physical" dated 5/14/13, revealed that Resident #101 was being transferred from a nursing home for rehab to another nursing home for long-term care when the transfer team noticed that he was quite lethargic, his blood oxygenation was 70% (normal is greater than 92%) and was taken to the emergency room where he was admitted to the hospital with [REDACTED]. ( )

This Citation pertains to intake MI 766. Based on interview and record review, the facility failed to develop and/or implement interventions to ensure repositioning and pressure relief to prevent the development of pressure sores for 2 of 3 sampled residents (#101 and #103) reviewed for pressure sores, from a total sample of 6 residents, resulting in Resident #101 developing potentially avoidable stage 3 pressure sore on his left ischium, a potentially avoidable stage 2 pressure sore on his right buttocks and potentially avoidable unstageable pressure sores on both the right and left heels, and Resident #103 developing a potentially avoidable stage 2 pressure sore on her right ischium Findings include: Resident #101 Review of the Face Sheet dated 3/14/13 and the most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #101 no longer lived at the facility. Resident #101 was an [AGE] year old male admitted to the facility 3/14/13 with [DIAGNOSES REDACTED]. Resident #101 had clear speech, was understood, understands, had moderately impaired cognition, and required extensive assistance from 2 persons for transfers. Review of hospital "History and Physical" dated 5/14/13 revealed that Resident #101 was being transferred from a nursing home for rehab to another nursing home for long-term care when the transfer team noticed that he was quite lethargic, his blood oxygenation was 70% (normal is greater than 92%) and was taken to the emergency room where he was admitted to the hospital with [REDACTED]. Review of the "Nursing Admission Assessment" form dated 3/14/13 revealed Resident #101 was free from pressure sores. Review of hospital "History and Physical" dated 5/14/13 revealed that Resident #101 was admitted to the hospital with [REDACTED]. Review of the hospital's Palliative Medicine Consultation dated 5/15/13 revealed Resident #101 had a stage 3 pressure ulcer on his left ischium, a stage 2 pressure ulcer on his right buttocks and unstageable decubitus pressure ulcers on both right and left heels. Review of the "Weekly Skin Assessment" form revealed that skin assessments were completed on 3/18/13, 4/8/13, 4/29/13, 5/12/13 and 5/13/13. The form revealed that on 3/18/13 Resident #101 was free from pressures sores. The form revealed that on 5/12/13 Resident #101 had 2 pressure sores on his backside, and pressure sores on each of his heels. Review of the potential for impaired skin integrity care plan dated 4/1/13 and updated on 5/13/13 revealed the following interventions: encourage to limit time sitting in chair, provide extensive assist of two to reposition frequently and as needed, conduct weekly head to toe skin assessments, document and report abnormal findings to physician and assist to reposition in chair as needed. Review of the "Weekly Skin Assessment" form revealed that assessments for Resident #101 were not completed during the weeks of 4/15/13, 4/22/13 and 5/6/13. In an interview on 6/19 at 11:45 AM, MDS Coordinator, RN #4 stated, "I don't know that they (care staff) do" know the limit of time resident should be in the chair. When asked what "frequent" meant, RN #4 stated, "I wasn't about to put a time frame on how frequent to reposition...Not every intervention is on the care plans...I never put specifics on care plans, because everyone is different". Review off the "Turning and Positioning" Policy dated 3/05, revealed "Guest will be encouraged and/or assisted to turn and reposition at least every two hours while in bed...Document in the progress notes: Turning and repositioning at least every two hours". Review of Resident #101's nursing "Progress Notes" dated 3/14/13 through 5/14/13 failed to reveal documentation of Resident #101 being repositioned at least every 2 hours. In an interview on 6/18 at 2:05 PM, Wound Nurse, RN #26 stated she was not made aware of Resident #101's pressure sores until after the resident was scheduled to transfer and that is why there was no "Wound and Skin Condition Record" of the new pressure sores. RN #26 stated that all nurses should start the "Wound and Skin Condition Record" upon assessment of a new wound, to include measuring the size of the wound. RN #26 agreed that Resident #101's skin assessments should not have indicated no alteration to the skin on 4/29/13 to having 3 separate stage 2 pressure ulcers on 5/12/13. ( ) Resident #103 Review of the face sheet dated 3/30/10 and the most recent MDS dated [DATE] revealed Resident #103 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #103 had clear speech, was understood, understands, was continuously inattentive, had disorganized thinking, had severely impaired cognition, and required extensive assistance of 2 people for transfers. Review of the "Weekly Skin Assessment" dated 3/21/13, 3/28/13, 4/11/13, 4/25/13, 5/2/13, 5/16/13, 5/23/13, 5/30/13 and 6/4/13 revealed that on 3/21/13 Resident #103's skin was intact, and on 6/4/13 Resident #103 had a stage 2 pressure ulcer to the right ischium. Review of the "Braden Scale for Predicting Pressure Sore Risk" dated 3/1/13 revealed Resident #103 scored a 13 (total score of 17 or less indicates that the individual is at risk.) Review of the "Potential for skin breakdown Plan of Care" dated 10/10/12 and updated 3/1/13 revealed the following interventions: provide extensive assistance to reposition frequently and as needed, assist to reposition in chair as needed, conduct weekly head to toe assessments, document and report abnormal findings to physician. In an interview on 6/19 at 11:45 AM, when asked what "frequent" meant, MDS Coordinator, RN #4 stated, "I wasn't about to put a time frame on how frequent to reposition...Not every intervention is on the care plans...I never put specifics on care plans, because everyone is different". Review of the "Weekly Skin Assessment" form revealed that assessments for Resident #103 were not completed during the weeks of 3/31/13, 4/15/13 and 5/6/13. Review of the "Nursing Care Card", undated revealed, Resident #103 was to be turned and repositioned every 2 hours. In an interview on 6/19/13 at 9:50 AM, Certified Nursing Assistant (CNA) #7 stated that staff should document when residents are turned, but sometime the "sheet" is not in the chart. In an interview on 6/19/13 at 10:04 AM, Unit Manager, RN #9 stated, she was not aware of where the CNAs should document that residents are repositioned. In an interview on 6/19/13 at 10:15 AM, Director of Nursing (DON) #2 stated that staff do not document when residents are repositioned, unless they are on a "restorative repositioning program". DON #2 stated that Resident #103 was not on a "restorative repositioning program". Review off the "Turning and Positioning" Policy dated 3/05, revealed "Guest will be encouraged and/or assisted to turn and reposition at least every two hours while in bed...Document in the progress notes: Turning and repositioning at least every two hours". ( )

This citation pertains to intake number MI 252. Based on observation, interviews, and record review, the facility failed to provide adequate supervision in 1 of 3 sampled residents (Resident #104), from a total sample of 10 residents, resulting in Resident #104 falling and fracturing her left hip and right rib. Findings Include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #104 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #104's ability to make daily decision was severely impaired, she was totally dependent on two staff members for transfers, and required extensive assistance of two staff members for personal hygiene. Review of the Incident Report dated 12/25/12 at 8:30 AM, revealed Resident #104 was found on the floor in the bathroom doorway in a great amount of pain, and the left hip appeared asymmetrical from the right. The Incident Report revealed Resident #104 was sent to the hospital. Review of the Incident Report/Registered Nurse (RN) Written Statement dated 12/26/12 (1350 or 1:50 PM), revealed Resident #104 was sent to the hospital after being found on her left side in the doorway of the bathroom in her room. The Incident Report/Registered Nurse (RN) Written Statement revealed Resident #104 was sent to the hospital and found to have a left hip fracture. Review of the physician progress notes [REDACTED]. The physician progress notes [REDACTED]. Review of the physician progress notes [REDACTED]. Review of the Falls Care Plan dated 2/21/12 and reviewed 10/8/12, revealed Resident #104 was at risk for falls, with interventions "...observe for fatigue and/or unsteadiness and encourage rest period...Pressure alarm to bed...Check placement and function every shift...Sensor pad alarm to wheelchair, check placement and function every shift...Encourage to wear non-skid socks...Often turns fall alarms off". In an interview on 3/11/13 at 8:47 AM, Certified Nursing Assistant (CNA) #24 reported that on 12/25/12 she heard Resident #104's bed alarm sounding and had taken her to the bathroom. CNA #24 reported that Resident #104 was a fall risk and she usually stays right outside the bathroom door or will leave it open if Resident #104 gives her permission, which she did on this day. CNA #24 reported that she cleared the bedside tray table and turned away from Resident #104 to walk about 7-8 feet to the doorway of the room to get her breakfast tray and by the time she turned back with the tray Resident #104 was already falling. CNA #24 reported calling for help and went to Resident #104. Observations during the on-site investigation 3/1/13, 3/4-7/13 revealed the Resident of Concern resting in bed with the Abduction Pillow in place, staff would reposition the Resident of Concern, but due to her non-healing fracture she would reposition herself and rotate her legs out of the desired position. Observations revealed the Resident of Concern was dressed appropriately for the day, clean, able to communicate her needs, and had a call light within reach. #

This citation pertains to intake number MI 268 Based on observation, interview, and record review, the facility failed to ensure the safety of 1 of 7 sampled residents (Resident #501) who required feeding assistance at meal times, out of a total sample of 7 sampled residents, resulting in an Immediate Jeopardy for Resident #501 when, on 8/1/2012 between 12:00 - 1:00 PM, Dietary Cook (DC) #1 broke three glasses of water that were prepared in a tray next to glasses of chocolate milk and on the food tray link waiting to be served. DC #1 did not discard the tray of filled water glasses or filled milk glasses and continued to serve the water and milk to residents during the lunch hour. A piece of glass was found in Resident #501's milk glass by Certified Nurse Aide (CNA) #2 while assisting her with her meal. This deficient practice placed an additional 22 residents, identified to receive water and/or milk after the glasses were broken, at high risk for injury, harm and/or death. Findings include: Per the facility Face Sheet, Resident #502 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Minimum Data Set" (MDS), dated [DATE], revealed Resident #501 rarely understood others, had highly impaired vision, severely impaired cognition, and required extensive assistance with eating. The MDS revealed that Resident #501 was on a mechanically altered diet (a change in the consistency of the food for safer swallowing purposes). Review of the "Nutrition" care plan, dated 4/16/2012, revealed Resident #501 was on a pureed diet (food that is ground up to make swallowing safer). The care plan revealed Resident #501 was required to be fed by staff. An attempt was made to interview Resident #501 on 8/23/2012 at 10:15 am, but was not successful because Resident #501 would not respond to questioning. In an interview on 8/23/2012 at 10:25 AM, CNA #2 stated that she was assisting Resident #501 to eat (did not know the date) when upon giving Resident about 200 cc (out of 240 cc) of chocolate milk she noticed a large piece of broken glass in the glass of chocolate milk. CNA #2 said she took the glass to Director of Nursing (DON) #4 and showed the glass to her. CNA #2 said DON #4 took the glass to the kitchen. CNA #2 said that neither she nor DON #4 immediately removed all glasses from residents in the dining room or elsewhere. CNA #2 said the residents in the dining room kept eating and drinking and that about 24 residents were in the dining room. CNA #2 said she tried to look into Resident #501's mouth when Resident #501 opened her mouth but stated that it was hard to see inside Resident #501's mouth. CNA #2 said that no nursing staff assessed Resident #501 after the incident. CNA #2 said Resident #501 had another glass of chocolate milk which she poured back in forth into an empty glass to check for more broken glass and then gave Resident #501 two sips before she decided to not give Resident #501 any more. CNA #2 said the piece of glass was about 2 inches in length and about 1/2 inch thick. Observation of the same type of glass that CNA #2 used to give Resident #501 a glass of chocolate milk was conducted with CNA #2 during the interview. The glass was identified by CNA #2 to have broken off at the base of the glass and it was observed to be consistent with approximately 1/2 inch in thickness. In an interview on 8/23/2012 at 11:28 AM, DON #4 said that she was paged into the dining room and CNA #2 showed her the broken glass. DON #4 said the piece of glass was about the size of her thumb. DON #4 said she took the glass to Certified Dietary Manager (CDM) #3. DON #4 said CDM #3 gave her a list of two other residents who had chocolate milk with their lunch. DON #4 said the two additional residents had drank all of the chocolate milk. DON #4 said that she learned from CDM #3 that DC #1 had broken a glass over the the top of glasses of water that were on the food line waiting to be served. DON #4 said that she was under the impression DC #1 had thrown out the glasses of water and replaced then with new glasses of water. DON #4 said that she had planned on assessing and monitoring residents herself by monitoring the 24 hour nursing report. DON #4 said she did not direct any nursing staff to assess residents for possible ingestion of glass or for injury. DON #4 said she did not make any of the resident's primary nurses know what had occurred or that they needed to assess and monitor residents. DON #4 said that no physician was notified of the incident. DON #4 said that no other residents were assessed after the incident. DON #4 stated that the incident occurred on 8/1/2012 but stated that no investigation or incident report was completed in regard to the incident. DON #4 said she did look into Resident #501's mouth for any bleeding but did not see any. In an interview on 8/23/2012 at 11:11 AM, CDM #3 said DON #4 had brought her the broken piece of glass about 1:00 PM. CDM #3 stated she learned that DC #1 had broken a glass. CDM #3 said 4 residents total had received chocolate milk and stated that she was under the impression that DC #1 had replaced all the glasses of water. CDM #3 said that no glasses of water or milk were immediately removed from residents in the dining room. CDM #3 said that she was not aware of a facility policy that directed staff on what should be done with any breakage of glass. CDM #3 said she told her staff that in the event of glass breakage above the waist it was proper to throw out the food and/or liquids in the vicinity of the break. In an interview on 8/23/2012 at 10:55 AM, DC #1 stated that she was working the tray line (did not know the date) when she had swung a glass over a tray of water glasses which resulted in her hitting and breaking approximately 3 glasses of water that sat on the water tray. DC #1 said 3 glasses had cracks and nicks in them. DC #1 said she had taken the broken glasses off the tray, but that she only checked for broken glass in the rest of them. DC #1 said she replaced the 3 broken glasses of water and sent the water out on resident food trays. DC #1 said she did not check any of the glasses of milk for broken glass. DC #1 said that after residents had been served their meals, CDM #3 had come to her and told her what had happened. DC #1 stated that CDM #3 told her that if this were to happen again, she was to throw all the glasses out and replace them. Observation of the tray line was conducted with DC #1 during the interview on 8/23/2012 at 10:55 AM. The tray of water glasses was observed to be in the same place that DC #1 reported they were on the day of the incident. The tray of water glasses was observed to be at the beginning of the tray line, on a tray where each glass sat in it's own section. The tray of glasses was observed to be right next to the tray line counter. DC #1 stated that two jugs of milk had been sitting next to the tray of water glasses and then next to the milk jugs were the glasses of chocolate milk. DC #1 said that she had no idea that a piece of glass had broken off and got into a glass of chocolate milk. On 8/23/2012 at 1:01 PM, DON #4 and CDM #3 confirmed that the incident occurred on 8/1/2012 between the hours of 12:00 PM and 1:00 PM. At 1:20 PM CDM #3 and DON #4 confirmed that 19 residents received water after the incident and 4 residents received chocolate milk. Review of facility policy and procedure titled "Dish Breakage" dated 4/2010, revealed, under #1, "Food exposed to broken dishware or glassware shall immediately be discarded." Another policy titled "China and Glassware Safety" dated 4/2012 revealed, under #2, "China and glassware that area chipped or cracked shall be discarded immediately." On 8/24/2012 at 3:33 PM, the Administrator was notified of the Immediate Jeopardy that began on 8/1/2012 and was identified on 8/23/2012 when DC #1 failed to discard glasses of water and milk which had been exposed to broken glass and continued to serve the glasses of water and milk to residents, resulting in Resident #501 receiving a glass of chocolate milk that contained an approximately 2 by 1/2 inch piece of broken glass. On 8/27/2012 the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. On 8/1/2012 resident #501's buccal cavity (mouth) was assessed for injury by the Director of Nursing. 2. On 8/24/2012 Resident #501's physician and legal representative were notified of the incident. 3. On 8/1/2012 three dietary staff were provided verbal education by the Certified Dietary Manager relating to the procedure to be implemented when there is a potential for contamination/injury from foreign objects/broken glass in food/fluid items. 4. Beginning 8/1/2012 the Director of Nursing monitored the 24 hour nursing reports to identify any resident changes in condition that may be indicative of bleeding. No entries had been identified for possible injury. 5. Beginning 8/23/2012 an all staff in-service was held regarding facility policy and procedure for foreign objects in food/drinks and what to do if discovered or identified. As of 8/27/2012 98 of 108 employees had been in-serviced. The remaining staff would not be allowed to work until they had completed the in-service. 6. On 8/23/2012 the 23 identified resident's vital signs were reviewed for the last 3 weeks (8/1 through 8/23/2012) to identify any potential injury or change in condition. Additionally the other 63 residents were also reviewed, and 2 of the 23 residents had been seen by the dentist which confirmed no injuries. 7. On 8/23/2012 the Administrator and Director of Nursing were in-serviced by the Regional Operations Manager on the requirement for reporting to Risk Management and investigation requirements which include complete documentation of investigation. 8. On 8/24/2012 the cook/dietary (DC #1) was suspended pending further investigation. 9. Beginning 8/23/2012 education relating to policies and procedures when there is a potential for contamination/injury from foreign objects/broken glass in food items will be included in new employee's orientation. 10. On 8/23/2012 the 4 residents who were sent to the hospital since 8/1/2012 had charts reviewed and hospitalization was not found to be related to the incident of 8/1/2012. Reasons for hospitalization included, 1 urinary tract infection, 1 fall, and 2 behavioral issues. 11. On 8/24/2012 the Medical Director was notified of the 8/1/2012 incident by the Director of Nursing. 12. On 8/24/2012 the Director of Nursing was educated by the Regional QA Manager on the need to direct staff to complete assessments and notify physicians after the incident on 8/1/2012 and similar incidents that may occur in the future. 13. On 8/23/2012 the facility policies concerning broken glass (dish Breakage) were reviewed by the Regional QA Manager and found to be adequate. Although the Immediate Jeopardy was removed on 8/24/2012, the facility remained out of compliance at a scope of isolated and severity of no actual harm but potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not received education and sustained compliance had not been verified by the State agency. ( )

This citation pertains to intake MI 699. Based on interview and record review, the facility failed to ensure adequate fluid intake to maintain hydration for 2 (#101 and #102) of 4 sampled residents, from a total sample of 4, resulting in Resident #101 being severely dehydrated, and Resident #102 being at risk for dehydration. Findings include: Resident #101: Review of Resident #101's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His Minimum Data Set ((MDS) dated [DATE] indicated he had severe cognitive impairment, required extensive assistance of two persons for transfers, eating, and toilet use, and had a history of [REDACTED]. Nutrition Care Plan dated [DATE] for Resident #101 indicated he was at risk due to Alzheimer's dementia with interventions listed to include observe for signs of dehydration such as dry mouth, poor skin turgor, lethargy, low blood pressure, to obtain labs per orders and report abnormal findings to physician, obtain weight at a minimum of monthly and report significant weight changes to physician and dietician, and an intervention added on [DATE] of encourage fluid intake. Review of Resident #101's nutritional assessment dated [DATE] revealed his calculated fluid requirement to be 2244 milliliters per day. According to the facility "Fluid Intake - Maintaining Adequate Hydration Status" Policy, provided to the surveyor by the facility Director of Nursing (DON) #1 on [DATE], the charge nurse is responsible for ensuring that each guest maintains adequate fluid intake, between 1500cc (cubic centimeters) and 2000cc each day unless the physician's orders [REDACTED]. Review of Resident #101's Intake/Output data collection sheets for [DATE] through [DATE] revealed Resident #101 received 500 cc's of fluid or less on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and no fluids on [DATE]. Resident #101 received 1000cc of fluid or less on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Resident #101 was a resident in the facility for 49 days and according to the Intake/Output data collect sheets, he received at least 1500 cc's of fluid (per facility policy) on only 4 days, [DATE], [DATE],, [DATE], and [DATE]. According http://medical-dictionary.thefreedictionary.com/p/osmolality, serum osmolality is "a measure of the number of dissolved particles per unit of water in serum... Measurement of the serum osmolality gives information about the hydration status within the cells because of the osmotic [MEDICATION NAME] that is constantly being maintained on either side of the cell membrane (homeostasis). Water moves freely back and forth across the membrane in response to the osmotic pressure being exerted by the molecules of solute in the intracellular and extracellular fluids. Serum osmolality reflects the status of hydration of the intracellular as well as the extracellular compartments and thus describes total body hydration". Normal adult blood osmolality is 285 to 296 mOsm/kg H2O with greater than 296 defined as dehydration. Serum Osmolality is calculated using the following formula: (2 x (NA) + (BUN/2.8) + (Glucose/18). The lab results from [DATE] for Resident #101 calculate his Serum Osmolality at 307, or dehydrated. Nurse's note for Resident #101 dated [DATE] indicated physician #6 was notified of abnormal lab values for Resident #101 and physician #6 stated he would see Resident #101 the next day. Review of physician orders [REDACTED]. The lab results from [DATE] for Resident #101 calculate his Serum Osmolality at 345, or severely dehydrated. physician progress notes [REDACTED].#101 had Dementia with increased agitation, and now with increased Sodium, with attempt to decrease with IVF (intravenous fluids - fluids given into a vein). physician's orders [REDACTED]. Nurse's note for Resident #101 dated [DATE] at 11:25 am, written by RN #12 indicated Resident #101 was running his wheelchair into people and objects, would not swallow his medications and new physician orders [REDACTED]. Nurse's note for Resident #101 dated [DATE] at 11:30 am, written by RN #12 indicated Resident #101's son was notified of am's events and new orders. Nurse's notes for Resident #101 dated [DATE] at 6:40 pm, written by RN/Unit Manager #3 (RN#3) indicated new orders were received for Resident #101 to receive IV fluids, unable to start due to increased psychomotor agitation, doctor aware, and new order was received to administer 0.25 milliliter of [MEDICATION NAME] every 2 hours as needed. Nurse's note for Resident #101 dated [DATE] at 8:30 am, written by RN #3 indicated RN #3 called pharmacy regarding [MEDICATION NAME] order, and pharmacy stated they never received order, which was re-faxed. Nurse's note for Resident #101 dated [DATE] at 4:05 pm indicated Resident #101 had a noted significant change, decline in most areas. Review of nurse's notes for Resident #101 revealed the first documentation of an attempt to communicate with Resident #101's family (Son and Power of Attorney) was [DATE] at 11:00 pm when nurse's notes for Resident #101 indicated his feet, knees and back were mottled (patchy blue color of the skin appearance indicates impending death), periods of apnea noted (not breathing) and Resident #101's son was called, a message was left regarding condition. Nurse's note for Resident #101 dated [DATE], indicated he was found with no respirations, no pulse, no blood pressure, with eyes fixed at 3:30 am. In an interview on [DATE] at 2:45 pm, RN #12 stated she called Resident #101's son on [DATE] to inform him of Resident #101 having a new order for a mattress on the floor and that he would not swallow his medications, so he had a new diet order. RN#12 stated she did not talk to Resident #101's son about Resident #101's labs. RN #12 stated she had heard Resident #101 had some bad labs, but did not see them because they were tucked away in the doctor's book. RN #12 stated when the Unit Manager, RN #3 came in, she said Resident #101 had some bad lab values and that Resident #101 was very dehydrated with an elevated BUN (blood urea nitrogen) and Sodium. RN #12 stated RN #3 was dealing with that. RN #12 stated that Resident #101 slept the entire first shift that day. In an interview on [DATE] at 12:55 pm, RN #3 stated Physician #6 wrote the order himself for the IV fluids and the mittens, for Resident #101. RN #3 stated the IV fluids were ordered because of Resident #101's bad labs, which indicated [MEDICAL CONDITION] (high sodium in the blood) and fluids needed to be started to avoid dehydration. RN #3 stated the mittens were to keep Resident #101 from pulling the IV out once it was started. When the surveyor asked if the IV line was ever started on Resident #101, RN #3 stated no, because Resident #101's arms were flailing. When the surveyor asked RN #3 if the [MEDICATION NAME] that had been ordered for Resident #101 had been given to him, RN #3 stated yes, but it only calmed him a little. The surveyor asked RN #3 if there was a reason why Resident #101 wasn't sent to the hospital for IV fluids at that time, and RN #3 stated no. RN #3 stated the mittens which had been ordered by Physician #6 were never used. In a telephone interview on [DATE] at 1:30 pm, the surveyor asked Physician #6 if he was aware that an IV line had never been started on Resident #101 and that Resident #101 had never received the 3 liters of IV fluids he (physician #6) had ordered, and Physician #6 stated no, he was not aware of this. When the surveyor asked Physician #6 why he did not transfer Resident #101 to the hospital, Physician #6 stated he is fully capable of treating elevated sodium at the facility with IV fluids. In an interview on [DATE] at 2:30 pm, Resident #101's son stated he thought his father might be dehydrated when he visited the last time because his dad's mouth was dry and "sticky". Resident #101's son also stated that his dad would hold an "imaginary cup" and pretend to drink from it. Resident #101's son stated the facility staff called him on the night of [DATE] at work, and stated his father's health had declined. Resident #101's son stated he came to the facility and about 5 hours later, his father died . Resident #102: Review of Resident #102's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His minimum data set (MDS), dated [DATE] indicated he was cognitively intact and required extensive assistance of one person for locomotion, dressing, eating, and personal hygiene. Resident #102's admission care plan (undated) identified him to be at risk for dehydration related to a [DIAGNOSES REDACTED]. According to the facility "Fluid Intake - Maintaining Adequate Hydration Status" Policy, provided to the surveyor by the facility Director of Nursing (DON) #1 on [DATE], the charge nurse is responsible for ensuring that each guest maintains adequate fluid intake, between 1500cc (cubic centimeters) and 2000cc each day unless the physician's orders [REDACTED]. Review of Resident #102's nutritional assessment dated [DATE] revealed his calculated fluid requirement to be 1505 milliliters per day. Review of Resident #102's Intake/Output data collection sheets for [DATE] through [DATE] revealed Resident #102 was a resident in the facility for 48 days and according to the Intake/Output data collect sheets, he only received at least 1500 cc's of fluid (per facility policy) on 14 of the 48 days. #

This citation pertains to intake MI 699. Based on interview and record review, the facility failed to notify the family in 1 (#101) of 4 sampled residents, from a total sample of 4 residents, of a significant change in condition and failed to notify resident #101's physician of a need to alter treatment for [REDACTED]. Findings include: Review of Resident #101's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His Minimum Data Set ((MDS) dated [DATE] indicated he had severe cognitive impairment, required extensive assistance of two persons for transfers, eating, and toilet use, and had a history of [REDACTED]. According http://medical-dictionary.thefreedictionary.com/p/osmolality, serum osmolality is "a measure of the number of dissolved particles per unit of water in serum... Measurement of the serum osmolality gives information about the hydration status within the cells because of the osmotic [MEDICATION NAME] that is constantly being maintained on either side of the cell membrane (homeostasis). Water moves freely back and forth across the membrane in response to the osmotic pressure being exerted by the molecules of solute in the intracellular and extracellular fluids. Serum osmolality reflects the status of hydration of the intracellular as well as the extracellular compartments and thus describes total body hydration". Normal adult blood osmolality is 285 to 296 mOsm/kg H2O with greater than 296 defined as dehydration. Serum Osmolality is calculated using the following formula: (2 x (NA) + (BUN/2.8) + (Glucose/18). The lab results from [DATE] for Resident #101 calculate his Serum Osmolality at 345, or severely dehydrated. physician progress notes [REDACTED].#101 had Dementia with increased agitation, and now with increased Sodium, with attempt to decrease with IVF (intravenous fluids - fluids given into a vein). physician's orders [REDACTED]. Nurse's note for Resident #101 dated [DATE] at 11:25 am, written by RN #12 indicated Resident #101 was running his wheelchair into people and objects, would not swallow his medications and new physician orders [REDACTED]. Nurse's note for Resident #101 dated [DATE] at 11:30 am, written by RN #12 indicated Resident #101's son was notified of am's events and new orders. Nurse's notes for Resident #101 dated [DATE] at 6:40 pm, written by RN/Unit Manager #3 (RN#3) indicated new orders were received for Resident #101 to receive IV fluids, unable to start due to increased psychomotor agitation, doctor aware, and new order was received to administer 0.25 milliliter of [MEDICATION NAME] every 2 hours as needed. Nurse's note for Resident #101 dated [DATE] at 8:30 am, written by RN #3 indicated RN #3 called pharmacy regarding [MEDICATION NAME] order, and pharmacy stated they never received order, which was re-faxed. Nurse's note for Resident #101 dated [DATE] at 4:05 pm indicated Resident #101 had a noted significant change, decline in most areas. Review of nurse's notes for Resident #101 revealed the first documentation of an attempt to communicate with Resident #101's family (Son and Power of Attorney) was [DATE] at 11:00 pm when nurse's notes for Resident #101 indicated his feet, knees and back were mottled (patchy blue color of the skin appearance indicates impending death), periods of apnea noted (not breathing) and Resident #101's son was called, a message was left regarding condition. Nurse's note for Resident #101 dated [DATE], indicated he was found with no respirations, no pulse, no blood pressure, with eyes fixed at 3:30 am. In an interview on [DATE] at 12:55 pm, RN #3 stated Physician #6 wrote the order himself for the IV fluids and the mittens, for Resident #101. RN #3 stated the IV fluids were ordered because of Resident #101's bad labs, which indicated [MEDICAL CONDITION] (high sodium in the blood) and fluids needed to be started to avoid dehydration. RN #3 stated the mittens were to keep Resident #101 from pulling the IV out once it was started. When the surveyor asked if the IV line was ever started on Resident #101, RN #3 stated no, because Resident #101's arms were flailing. When the surveyor asked RN #3 if the [MEDICATION NAME] that had been ordered for Resident #101 had been given to him, RN #3 stated yes, but it only calmed him a little. The surveyor asked RN #3 if there was a reason why Resident #101 wasn't sent to the hospital for IV fluids at that time, and RN #3 stated no. RN #3 stated the mittens which had been ordered by Physician #6 were never used. The surveyor asked RN #3 if Resident #101's family was every notified of Resident #101's laboratory values, physician's orders [REDACTED].#101 sent to the hospital. RN #3 stated Resident #101's wife was in the hospital at that time, but she (RN #3) had called Resident #101's son several times but had not heard back from him, and wasn't sure if the son had ever been reached. The surveyor asked RN #3 what the protocol was if Resident #101's son could not be reached to notify him of Resident #101's condition and RN #3 stated the facility would have to contact Resident #101's wife to get permission to send him to the hospital for treatment. The surveyor asked RN #3 if that was done and RN #3 stated she did not know. In a telephone interview on [DATE] at 1:30 pm, the surveyor asked Physician #6 if he was aware that an IV line had never been started on Resident #101 and that Resident #101 had never received the 3 liters of IV fluids he (physician #6) had ordered, and Physician #6 stated no, he was not aware of this. When the surveyor asked Physician #6 why he did not transfer Resident #101 to the hospital, Physician #6 stated he is fully capable of treating elevated sodium at the facility with IV fluids. In an interview on [DATE] at 2:00 pm, the surveyor asked the facility Director of Nursing (DON) #1 if the family of Resident #101 was ever notified of Resident #101's change in condition, his lab values, or the need for IV fluids, and DON #1 stated she did not know. The surveyor also asked DON #1 if the facility or the family had made the decision to make Resident #101 comfort care and DON #1 stated she did not know. In an interview on [DATE] at 2:20 pm, the surveyor asked RN #2 if she was the acting Director of Nursing at the time of Resident #101's change in condition, and RN #2 stated she was. RN #2 stated she did not get ahold of Resident #101's family regarding Resident #101's change in condition, his lab values or the physician's orders [REDACTED]. anything about who called the family and thought it was taken care of. In an interview on [DATE] at 2:30 pm, Resident #101's son stated he was not called by the facility regarding his father (resident #101) until 8:30 am on [DATE]. Resident #101's son stated his first message from the facility was at 8:30 am on [DATE] and he did not have any missed calls from the facility prior to that call. Resident #101's son stated when the facility staff called him they told him his father's health was declining and he should come to the facility because his father would probably not make it through the night. Resident #101's son stated the facility staff never said anything to him about labs, starting an IV (intravenous fluids), they never asked him if he wanted to send his father (resident #101) to the hospital, and no staff member ever talked to him about comfort care or hospice. Resident #101's son stated the facility staff called him and stated his father's health had declined, he came to the facility and about 5 hours later, his father died . In an interview on [DATE] at 3:05 pm, DON #1 stated the facility had "dropped the ball" with documentation of communication with the family. DON #1 stated Resident #101's son and Resident #101's wife both had Power of Attorney for Resident #101. DON #1 also stated that there was no documentation of any communication with Resident #101's family regarding his change in condition and the wishes of the family in the last three days of Resident #101's life. DON #1 stated it was not clear what the family's wishes were, whether to hospitalize Resident #101 or not, and there was no documentation that the facility reached the family of Resident #101 to ask them. #

This citation pertains to intake MI 699. Based on interview and record review, the facility failed to administer medications and Intravenous Fluids ordered by the physician in 1 (#101) of 4 sampled residents, from a total sample of 4 residents, resulting in Resident #101 being left untreated for [REDACTED]. Findings include: Medications: Review of Resident #101's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His Minimum Data Set ((MDS) dated [DATE] indicated he had severe cognitive impairment, required extensive assistance of two persons for transfers, eating, and toilet use, and had a history of [REDACTED]. Review of Resident #101's monthly physician orders [REDACTED]. The physician orders [REDACTED]. Resident care flow sheet for Resident #101 for May, 2012, indicated Resident #101 had no bowel movement 5/10/12 midnight shift until 5/16/12 on first shift, which was 19 total shifts with no bowel movement for Resident #101. Review of Resident #101's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. physician progress notes [REDACTED].#101 had episodes of increased agitation, anxiety and had constipation with questionable last bowel movement 6 shifts ago. The progress note stated Resident #101 needed Milk of Magnesia. A physician's orders [REDACTED].#101 was to receive Mag [MEDICATION NAME] 120 ml (milliliters) PO (by mouth) today for constipation. Review of Resident #101's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 6/21/12 at 11:10 am, the Surveyor requested a copy of the facility Bowel policy and/or protocol from DON #1. In an interview on 6/21/12 at 11:50 am, DON #1 stated the facility did not have a Bowel policy and handed the surveyor a piece of paper that was hand written and indicated, "Bowel process (no policy), Nurse to nurse instructions on the floor with new hires: If no BM x3 days, then MOM if already ordered. If not ordered, call MD with reques. If no BM x 4th day, same process for obtaining order [MEDICATION NAME] supp." Intravenous Fluids: physician progress notes [REDACTED].#101 had Dementia with increased agitation, and now with increased Sodium, with attempt to decrease with IVF (intravenous fluids - fluids given into a vein). physician's orders [REDACTED]. Nurse's notes for Resident #101 dated 6/13/12 at 6:40 pm, written by RN/Unit Manager #3 (RN#3) indicated new orders were received for Resident #101 to receive IV fluids, unable to start due to increased psychomotor agitation, doctor aware, and new order was received to administer 0.25 milliliter of [MEDICATION NAME] every 2 hours as needed. Nurse's note for Resident #101 dated 6/14/12 at 8:30 am, written by RN #3 indicated RN #3 called pharmacy regarding [MEDICATION NAME] order, and pharmacy stated they never received order, which was re-faxed. Nurse's note for Resident #101 dated 6/14/12 at 4:05 pm indicated Resident #101 had a noted significant change, decline in most areas. Review of nurse's notes for Resident #101 dated 6/14/12 at 11:00 pm revealed Resident #101's feet, knees and back were mottled (patchy blue color of the skin appearance indicates impending death), periods of apnea noted (not breathing) and Resident #101's son was called, a message was left regarding condition. Nurse's note for Resident #101 dated 6/15/12, indicated he was found with no respirations, no pulse, no blood pressure, with eyes fixed at 3:30 am. In an interview on 6/22/12 at 12:55 pm, RN #3 stated Physician #6 wrote the order himself for the IV fluids and the mittens, for Resident #101. RN #3 stated the IV fluids were ordered because of Resident #101's bad labs, which indicated [MEDICAL CONDITION] (high sodium in the blood) and fluids needed to be started to avoid dehydration. RN #3 stated the mittens were to keep Resident #101 from pulling the IV out once it was started. When the surveyor asked if the IV line was ever started on Resident #101, RN #3 stated no, because Resident #101's arms were flailing. When the surveyor asked RN #3 if the [MEDICATION NAME] that had been ordered for Resident #101 had been given to him, RN #3 stated yes, but it only calmed him a little. The surveyor asked RN #3 if there was a reason why Resident #101 wasn't sent to the hospital for IV fluids at that time, and RN #3 stated no. RN #3 stated the mittens which had been ordered by Physician #6 were never used. In a telephone interview on 6/22/12 at 1:30 pm, the surveyor asked Physician #6 if he was aware that an IV line had never been started on Resident #101 and that Resident #101 had never received the 3 liters of IV fluids he (physician #6) had ordered, and Physician #6 stated no, he was not aware of this. When the surveyor asked Physician #6 why he did not transfer Resident #101 to the hospital, Physician #6 stated he is fully capable of treating elevated sodium at the facility with IV fluids. In an interview on 6/22/12 at 2:00 pm, the surveyor asked the facility Director of Nursing (DON #1) if the IV Fluids which had been ordered by Resident #101's physician had ever been given to Resident #101, and DON #1 stated no, RN #3 never got the IV started. The nurse is obligated to follow the physician's orders [REDACTED]. (Fundamentals of Nursing Concepts, Process, and Practice. Mosby, Patricia A., Potter, Anne G., Perry, 1985). According to the Nursing's Social Policy Statement (American Nurses Association, 2003, pg. 2), "Society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality in performance is at the heart of this relationship." It goes on to state (pg. 11), "Professional nursing...is accountable for ensuring that its members act in the public interest in the course of providing the unique service society has entrusted to them." #

This citation pertains to intake number MI 954. Based on interview and record review the facility failed to ensure that safety measures (fall alarms) were on and in place in 1 of 7 sampled residents (Resident #500), out of a total sample of 7, resulting in a fall for Resident #500 and a sustained fracture of the right hip. Findings include: Per the facility face sheet Resident #500 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #500 no longer resided at the facility at the time of the investigation. Review of a "Minimum Data Set" ((MDS) dated [DATE] revealed Resident #500 required extensive assistance with transferring, and limited assistance with ambulation. Review of a care plan dated 4/6/2012 for "Falls" revealed Resident #500 was at risk for falls related to an unsteady gait (walking), impaired mobility, seizures, urinary tract infections, and medications. The interventions included that Resident #500 would have a pressure alarm (pad that the resident sits on and when pressure is released the alarm sounds) to her bed and wheelchair. Interventions also included supervise and limited assist with transfers. Review of an "Incident Report" dated 4/20/2012 revealed that at 4:45 PM Resident #500 was found lying of the floor in her room in front of her wheelchair. The report revealed Resident #500 had reported that she "bumped" her head on the door and had complaints of right hip pain. The report revealed, "Fall alarm was on w/c (wheelchair) but was not on at time of the fall." The "Post Fall Report" dated 4/20/2012 revealed "staff (did not acknowledge who) did not check for on/off" (speaking of the pressure alarm). The report revealed Resident #500 was transferred to the hospital. Review of a hospital "Patient Transfer Form" dated 4/20/2012 revealed Resident #500 was transferred to the hospital due to complaints of right hip pain upon movement of her right hip. Review of an x-ray dated 4/20/2012, that was taken while Resident #500 was at the facility, revealed a fracture of Resident #500's right femur (neck of the femur). Certified Nurse Aid (CNA) #1 was interviewed on 5/16/2012 at 2:35 PM. CNA #1 said Resident #500 had a pressure alarm on her bed and wheelchair. CNA #1 also stated Resident #500 had a tab alarm (an alarm that clips to the resident's clothing and sounds when disconnected). CNA #1 stated, "it's my fault". CNA #1 said Resident #500 had a procedure done on 4/20/2012 and stated that she had assisted Resident #500 to the bathroom to clean her up and then into her wheelchair and placed Resident #500 in front of her television in her room. CNA #1 said she forgot to attach the tab alarm to Resident #500, leaving the tab alarm on Resident #500's bed. CNA #1 also stated that she did not turn the pressure alarm on that was in Resident #500's chair. CNA #1 said she had heard Resident #500 yelling out and upon entering Resident #500's room found Resident #500 on the floor. CNA #1 said Resident #500 had complained of right hip pain. Registered Nurse (RN) #2 was interviewed on 5/16/2012 at 1:01 PM. RN #2 said on 4/20/2012 Resident #500 got up from her wheelchair and fell . RN #2 said the tab alarm was not attached to Resident #500 and also stated that the pressure alarm was turned off and therefore no alarm sounded when Resident #500 got up from her wheelchair. CNA #3 was interviewed on 5/16/2012 at 2:09 PM. CNA #3 said that she found Resident #500 on the floor around 5:30 PM on 4/20/2012. CNA #3 said she had heard a loud "bang" and then she found Resident #500 on the floor between her bed and the room closet. CNA #3 said she did not hear Resident #500's fall alarms sound and stated that she had gone into Resident #500's room because of the loud bang and she heard Resident #500 moaning. CNA #3 said Resident #500 was crying and stated that her right hip hurt bad. CNA #3 stated that she assisted CNA #1 to clean Resident #500 up and place her in her wheelchair, prior to Resident #500's fall. CNA #3 stated that she did not check Resident #500's fall alarms and stated that she left that up to CNA #1. Review of a "History and Physical" (H&P) dated 3/18/2012 prior to Resident #500's admission to the facility revealed no indication Resident #500 had a previous fracture of her right hip. The H&P, under past surgical history, revealed no indication of Resident #500 having hip surgery prior to her admission to the facility. Review of the hospital x-ray dated 4/20/2012 revealed a right hip fracture. Review of x-rays taken previous to Resident #500's admission to the facility beginning 3/11/2010 through 3/9/2012 revealed no evidence of a prior hip fracture until 4/20/2012 after Resident #500's fall at the facility. Review of a hospital "History and Physical" (H&P) dated 4/21/2012 revealed that an x-ray confirmed a right hip fracture. The report revealed that Resident #500 would be cleared to undergo surgery for [REDACTED]. ( )

THIS CITATION PERTAINS TO INTAKE MI 489. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE 1 OF 7 SAMPLED RESIDENTS (#101) WERE FREE FROM ABUSE, RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #101 HAD HER ARMS PHYSICALLY RESTRAINED WHILE HAVING HER FINGERNAILS CUT AGAINST HER WILL, SUSTAINING BRUISING TO BOTH ARMS AND HANDS, PAIN, AND EMOTIONAL DISTRESS, AND FEAR. THESE DEFICIENT PRACTICES PLACED ALL 85 RESIDENT IN THE FACILITY AT HIGH RISK FOR PHYSICAL HARM AND/OR INJURY. FINDINGS INCLUDE: REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #101'S CARE PLAN IDENTIFIED A PROBLEM WITH BEHAVIORS WITH INTERVENTIONS DATED 11/10/10 THAT INCLUDED: REASSURING RESIDENT #101 THAT SHE IS SAFE, THAT "YOU ARE HERE TO PROTECT HER AND KEEP HER SAFE", TO SIT AND TALK WITH RESIDENT #101 IN A QUIET, NON-THREATENING MANNER, DO NOT INVADE HER PERSONAL SPACE AND DO NOT ATTEMPT TO TOUCH HER (RESIDENT #101). THE FACILITY INCIDENT REPORT DATED 2/20/11 AT 4:00 AM, DOCUMENTED THAT RESIDENT #101 REFUSED CARE, WAS HITTING STAFF AND CAUSED INJURY TO A CNA (CERTIFIED NURSE AIDE) SECONDARY TO A JAGGED NAIL. THE INCIDENT REPORT DOCUMENTED THAT 2 STAFF COMPLETED NAIL CARE AND THAT DURING CARE, RESIDENT #101 BECAME COMBATIVE, "STAFF HELD HAND AND WRIST OF RESIDENT #101 AND BRUISING WAS NOTED AT 8:00 AM ON RIGHT HAND AND WRIST OF RESIDENT #101". THE INCIDENT REPORT DOCUMENTED BRUISES ON RESIDENT #101'S RIGHT FOREARM, THE TOP OF HER RIGHT HAND, AND ON HER RIGHT WRIST. THERE WERE NO SIZES DOCUMENTED. REVIEW OF THE FACILITY SHOWER/SKIN OBSERVATION SHEET FOR RESIDENT #101 DATED 2/17/11 SHOWED NO ABNORMALITIES ON RESIDENT #101'S SKIN. THE FACILITY SHOWER/SKIN OBSERVATION SHEET DATED 2/20/11 (THE DAY OF THE INCIDENT) SHOWED DOCUMENTED BRUISES TO RESIDENT #101'S RIGHT AND LEFT INNER ELBOW, RIGHT AND LEFT OUTER ELBOW, HER LEFT HAND, AND HER RIGHT FOREARM. THE FACILITY SHOWER/SKIN OBSERVATION SHEET DATED 2/24/11 REVEALED BRUISES REMAINED ON RESIDENT #101'S RIGHT AND LEFT INNER ELBOW, RIGHT AND LEFT OUTER ELBOW, HER LEFT HAND, AND RIGHT FOREARM. REVIEW OF THE FACILITY WOUND AND SKIN CONDITION RECORD DATED 2/20/11, PROVIDED TO THE SURVEYOR BY NURSE MANAGER #9, REVEALED THERE WAS BRUISING TO RESIDENT #101'S RIGHT HAND, RIGHT WRIST, RIGHT FOREARM AND LEFT HAND. IN AN INTERVIEW ON 3/9/11 AT 10:45 AM, AT THE NURSE'S STATION, NURSE MANAGER #9 OPENED HER WOUND DOCUMENTATION NOTEBOOK AND GAVE WOUND SHEETS DATED FOR 2/20/11 FOR RESIDENT #101 TO THE SURVEYOR. THE SURVEYOR ASKED NURSE MANAGER #9 IF THERE WERE ANY OTHER SHEETS WITH DOCUMENTATION OF WOUNDS FOR RESIDENT #101. NURSE MANAGER #9 STATED THERE WAS NO ADDITIONAL DOCUMENTATION OF WOUNDS FOR RESIDENT #101. NURSE MANAGER #9 STATED RESIDENT #101 DID NOT BRUISE EASILY AND THESE WERE THE FIRST BRUISES RESIDENT #101 HAD DEVELOPED IN OVER A YEAR. DURING AN OBSERVATION AND INTERVIEW ON 3/9/11 AT 10:48 AM, RESIDENT #101 STATED SHE REMEMBERED THE GIRLS (CNA #5 AND CNA #6) CUTTING HER NAILS. RESIDENT #101 STATED SHE TRIED TO TELL THEM THAT THE MANICURIST LADY WOULD TAKE CARE OF HER NAILS AND STRAIGHTEN THEM OUT, BUT THEY WOULDN'T LISTEN. RESIDENT #101 STATED THE TWO GIRLS HELD HER HANDS DOWN AND CUT HER NAILS. RESIDENT #101 DEMONSTRATED HOW HER HANDS WERE HELD TO THE SURVEYOR BY HOLDING HER ARMS CROSSED OVER AT THE WRIST. RESIDENT #101 STATED IT HURT WHEN THEY HELD HER ARMS DOWN LIKE THAT. WHEN ASKED BY THE SURVEYOR IF SHE COULD REMEMBER WHO DID THIS, RESIDENT #101 STATED IT WAS (CNA #5'S NAME) AND (CNA #6'S NAME). RESIDENT #101 TOLD THIS SURVEYOR THAT SHE HAD A MANICURIST THAT DID HER NAILS AND THE MANICURIST WAS SURPRISED THE CNA'S DID THAT TO HER. RESIDENT #101 WAS CRYING WHILE TELLING THIS SURVEYOR ABOUT THE INCIDENT. RESIDENT #101 STATED THE GIRLS DIDN'T EVEN FILE HER NAILS AND THAT THEY WERE ALL ROUGH WHEN THEY WERE DONE. RESIDENT #101 STATED THEY STARTED CLIPPING HER NAILS AND THAT ONE GIRL HELD HER HANDS AND ARMS WHILE THE OTHER GIRL CLIPPED HER NAILS. RESIDENT #101 STATED SHE WAS STILL UPSET ABOUT GETTING HER NAILS CUT AND DID NOT FEEL SAFE AT THE FACILITY BECAUSE "THE SAME GIRLS STILL TAKE CARE OF ME AND IT SCARES ME VERY MUCH BECAUSE THEY ARE SO MEAN TO ME". RESIDENT #101 WAS ABLE TO CORRECTLY IDENTIFY THE CURRENT YEAR, THE CURRENT PRESIDENT OF THE UNITED STATES, AND THE NAME OF THE FACILITY AT THE TIME OF THE INTERVIEW ON 3/9/11. IN AN INTERVIEW ON 3/9/11 AT 11:45 AM, CNA #6 STATED SHE WAS WORKING THE NIGHT SHIFT ON THE NIGHT RESIDENT #101 HAD HER NAILS CUT. CNA #6 STATED RESIDENT #101 HAD HIGH AGITATION LEVELS MOST OF THE NIGHT, AND HAD EARLIER REFUSED TO HAVE HER VITALS TAKEN AND REFUSED TO HAVE HER BED CHANGED AFTER BEING INCONTINENT. CNA #6 STATED WHEN RESIDENT #101 REFUSED TO HAVE HER BLOOD PRESSURE TAKEN, SHE (CNA #6 ) LEFT RESIDENT #101'S ROOM AND CAME BACK LATER. CNA #6 STATED WHEN SHE CAME BACK TO RESIDENT #101 TO GET HER BLOOD PRESSURE THE SECOND TIME, RESIDENT #101 ALLOWED HER TO GET HER BLOOD PRESSURE. CNA #6 STATED SHE HAD MADE MULTIPLE ATTEMPTS THROUGHOUT HER SHIFT TO PROVIDE INCONTINENCE CARE TO RESIDENT #101 AND THAT RESIDENT #101 KEPT REFUSING TO HAVE HER BED CHANGED. CNA #6 STATED AROUND 4:00 AM SHE (CNA #6 ) DECIDED TO CHANGE RESIDENT #101'S BEDDING BECAUSE IT WAS QUITE SOILED. CNA #6 STATED WHEN SHE TRIED TO TURN RESIDENT #101, THE RESIDENT STARTED SWINGING AND HIT HER (CNA #6), KNOCKED HER GLASSES OFF AND SCRATCHED HER (CNA #6). CNA #6 STATED SHE CONTINUED TRYING TO FINISH CHANGING RESIDENT #101 AND CNA #5 CAME IN THE ROOM TO ASSIST. CNA #6 STATED RESIDENT #101'S NAILS WERE LONG AND JAGGED AND CNA #5 WENT TO GET NAIL CLIPPERS FROM THE NURSE. CNA #6 STATED THAT RESIDENT #101 WAS STILL UPSET AT THAT TIME. CNA #6 STATED THAT CNA #5 RETURNED TO RESIDENT #101'S ROOM AND THAT SHE (CNA #6) AND CNA #5 HELD DOWN RESIDENT #101'S HANDS AND CLIPPED HER NAILS. CNA #6 STATED RESIDENT #101 WAS REAL UPSET ABOUT GETTING HER NAILS CUT AND KEPT MOVING HER ARMS AND STUFF. CNA #6 STATED THAT CNA #5 TOLD THE NURSE THAT THEY (CNA #5 AND CNA #6) HAD CUT RESIDENT #101'S NAILS AND THE NURSE TOLD CNA #5 TO MAKE SURE RESIDENT #101 DID NOT HAVE ANY BRUISING. CNA #6 STATED THAT WHEN RESIDENT #101 BECAME UPSET ABOUT HAVING HER NAILS CUT, SHE (CNA #6) DID NOT STOP. CNA #6 STATED, "WE DIDN'T MEAN TO LEAVE BRUISES ON HER". WHEN ASKED BY THE SURVEYOR IF SHE WOULD DO THIS AGAIN, CNA #6 STATED, "YES". IN AN INTERVIEW ON 3/9/11 AT 12:00 PM, CNA #5 STATED SHE USUALLY DIDN'T CARE FOR RESIDENT #101 BECAUSE RESIDENT #101 ACCUSED HER(CNA #5) OF SLEEPING WITH HER HUSBAND. CNA #5 STATED SHE HEARD CNA #6 YELLING, SO SHE WENT INTO RESIDENT #101'S ROOM TO ASSIST AND SAW THAT CNA #6 HAD A SCRATCH FROM RESIDENT #101. CNA #5 STATED RESIDENT #101'S NAILS LOOKED BAD, SO SHE WENT TO THE NURSE AND ASKED IF THEY (CNA #5 AND CNA #6) COULD CUT RESIDENT #101'S NAILS. CNA #5 REPORTED THE NURSE (LICENSED PRACTICAL NURSE #4 - LPN #4) GOT THE NAIL CLIPPERS FOR HER, SHE RETURNED TO RESIDENT #101'S ROOM, AND THAT SHE (CNA #5) AND CNA #6 HELD RESIDENT #101'S HANDS WHILE CNA #6 CUT RESIDENT #101'S NAILS. CNA #5 STATED THAT RESIDENT #101 STARTED ACTING CRAZY AND SHE HAD TO PUT "QUITE A GRIP ON HER". CNA #5 STATED THAT THEY (CNA #5 AND CNA #6) KNEW THAT RESIDENT #101 LIKED HER NAILS. CNA #5 STATED THAT RESIDENT #101 WAS FIGHTING AND CALLING THEM "[***] ING [***] ES" AND SWEARING. CNA #5 STATED THAT RESIDENT #101 WAS MAD AND DIDN'T WANT ANYONE NEAR HER. CNA #5 STATED SHE TOLD LPN #4 THEY HAD CUT ALL OF RESIDENT #101'S NAILS AND ASKED LPN #4 IF SHE HAD HEARD RESIDENT #101 SWEARING AT THEM. CNA #5 STATED LPN #4 ASKED HER WHY RESIDENT #101 WAS SWEARING. CNA #5 STATED SHE TOLD LPN #4 THAT RESIDENT #101 WAS "GOING NUTS". CNA #5 STATED LPN #4 TOLD HER TO CHECK RESIDENT #101 FOR BRUISES. CNA #5 STATED SHE TOLD LPN #4 TO HAVE CNA #6 DO IT, BECAUSE RESIDENT #101 WASN'T HER ASSIGNED RESIDENT. IN AN INTERVIEW ON 3/9/11 AT 11:10 AM, LPN #4 STATED SHE WAS THE NURSE CARING FOR RESIDENT #101 THE NIGHT RESIDENT #101 HAD HER NAILS CLIPPED. LPN #4 STATED THAT CNA #6 HAD CAME TO HER EARLY IN THE SHIFT AND REPORTED RESIDENT #101 HAD BEEN RESISTANT TO CARE AND THAT CNA #6 WAS GOING TO TRY TO RE-APPROACH RESIDENT #101 LATER, "BECAUSE WE KNOW THAT'S WHAT TO DO". LPN #4 STATED SHE TOLD CNA #6 IF SHE HAD ANY OTHER PROBLEMS TO COME AND GET HER. LPN #4 REPORTED THAT LATER IN THE SHIFT, CNA #5 CAME TO HER AND TOLD HER THAT RESIDENT #101 HAD LEFT A RED MARK ON CNA #6 AND HAD A SHARP NAIL. LPN #4 STATED CNA #5 NEVER TOLD HER THAT RESIDENT #101 WAS RESISTING CARE AT THAT TIME, JUST THAT RESIDENT #101 HAD A SHARP NAIL AND SHE (CNA #5) REQUESTED CLIPPERS TO TRIM THE NAIL. LPN #4 STATED SHE GAVE CLIPPERS TO CNA #5. LPN #4 STATED THE NEXT THING SHE KNEW STAFF #5 CAME TO HER AND TOLD HER THAT ALL OF RESIDENT #101'S NAILS HAD BEEN TRIMMED. LPN #4 STATED SHE ASKED CNA #5 WHY THEY HAD DONE THAT. LPN #4 SAID SHE TOLD CNA #5 TO GO BACK AND CHECK RESIDENT #101 FOR BRUISES. LPN #4 STATED SHE DID NOT HEAR ANYTHING BACK FROM CNA #5 OR CNA #6 AND DID NOT GO AN CHECK ON RESIDENT #101 AT THAT TIME. LPN #4 STATED AT THE END OF THE SHIFT, SHE ASSESSED CNA #6'S FACE AND SAW A RED MARK, BUT NO BREAK IN THE SKIN. LPN #4 STATED SHE HAD STAYED OVER ON THE DAY SHIFT TO HELP AND THAT LPN #3 CAME TO HER ASKING WHY RESIDENT #101 WAS SO UPSET. LPN #4 REPORTED THAT SHE TOLD LPN #3 THAT RESIDENT #101'S NAILS HAD BEEN TRIMMED. LPN #4 SAID LPN #3 REPORTED TO HER THAT RESIDENT #101'S WERE NOT TRIMMED, BUT THAT THEY HAD BEEN CUT. LPN #4 SAID SHE WENT WITH LPN #3 AND THE NURSE MANAGER #9 TO RESIDENT #101'S ROOM. LPN #4 STATED THAT RESIDENT #101 TOLD HER, LPN #3, AND NURSE MANAGER #9 THAT SHE WAS HELD DOWN AGAINST HER WILL AND HER NAILS WERE CUT. LPN #4 STATED SHE ASKED RESIDENT #101 IF SHE HAD HURT ANYONE OR HERSELF AND RESIDENT #101 STATED "NO, I WOULD HURT ANYONE" AND THAT RESIDENT #101 LOVED HER NAILS. LPN #4 REPORTED RESIDENT #101 WAS VERY UPSET AND SAD. IN AN INTERVIEW ON 3/9/11 AT 10:30 AM, LPN #3 STATED SHE WENT INTO RESIDENT #101'S ROOM AT THE BEGINNING OF HER SHIFT TO GIVE RESIDENT #101 MEDICATIONS AND FOUND RESIDENT #101 CRYING HEAVILY. LPN #3 SAID IT WAS NOT LIKE RESIDENT #101 TO CRY LIKE THAT AND ASKED RESIDENT #101 WHAT WAS WRONG. LPN #3 STATED RESIDENT #101 KEPT SAYING SHE "COULDN'T BELIEVE THEY DID THIS TO ME AND I CAN'T BELIEVE THEY CUT MY FINGERNAILS". LPN #3 ASKED RESIDENT #101 WHO CUT HER NAILS AND RESIDENT #101 REPORTED THE "GIRLS AT NIGHT DID IT" AND SHE DIDN'T KNOW WHY. LPN #3 SAID SHE IMMEDIATELY ASKED LPN #4 WHY RESIDENT #101'S NAILS WERE CUT. LPN #3 STATED CUTTING RESIDENT #101'S NAILS WAS A BIG DEAL BECAUSE HER (RESIDENT #101) NAILS WERE HER LIFE. LPN #3 STATED A MANICURIST TOOK CARE OF RESIDENT #101'S NAILS EVERY TWO WEEKS, AND THAT HER FINGERNAILS "WERE ALL SHE HAD". LPN #3 STATED THAT LPN #4 TOLD HER RESIDENT #101'S NAILS WERE CUT BECAUSE SHE SCRATCHED ONE THE STAFF MEMBERS. LPN #3 STATED SHE WENT BACK TO RESIDENT #101'S ROOM WITH LPN #4 AND NURSE MANAGER #9 AND FOUND RESIDENT #101 STILL UPSET AND CRYING. LPN #3 SAID RESIDENT #101 STATED SHE WAS HELD DOWN AND DIDN'T UNDERSTAND WHY, AND DEMONSTRATED HOW SHE WAS HELD DOWN (LPN #3 DEMONSTRATED HER ARMS BEING HELD WITH WRISTS CROSSED OVER EACH OTHER). LPN #3 REPORTED THAT RESIDENT #101 HAD BRUISES IN THE EXACT LOCATIONS THEY WOULD BE FROM BEING HELD DOWN AS RESIDENT #101 DESCRIBED. LPN #3 REPORTED THERE WERE BRUISES ON THE TOP AND UNDERSIDE OF BOTH OF RESIDENT #101'S FOREARMS, WRISTS, AND ONE THUMB. LPN #3 STATED RESIDENT #101'S NAILS "WERE HER WORLD" AND WHEN RESIDENT #101 DESCRIBED THE INCIDENT TO HER (LPN #3) SHE WAS "WITH IT" AND ALERT. IN AN INTERVIEW ON 3/15/11 AT 1:20 PM, NURSE MANAGER #9 STATED THAT WHEN SHE CAME IN TO WORK IN THE MORNING OF 2/20/11, LPN #4 ASKED HER TO COME AND SEE RESIDENT #101 WITH HER BECAUSE THEY CUT HER NAILS LAST NIGHT AND SHE WAS HAVING A FIT. NURSE MANAGER #9 SAID LPN #4 REPORTED THAT RESIDENT #101 HAD SCRATCHED CNA #6, SO CNA #5 AND CNA #6 CUT HER NAILS. NURSE MANAGER #9 SAID WHEN SHE ENTERED RESIDENT #101' ROOM SHE SAW BRUISES ON RESIDENT #101'S HANDS AND RESIDENT #101 WAS VERY UPSET. NURSE MANAGER #9 STATED RESIDENT #101 WAS CRYING AND KEPT SAYING THEY "CUT HER NAILS AND HELD ME DOWN LIKE THIS" (NURSE MANAGER #9 DEMONSTRATED HER ARMS CROSSED AT THE WRISTS). NURSE MANAGER #9 SAID RESIDENT #101'S BRUISES WERE EXACTLY WHERE THEY WOULD BE FROM HAVING HER ARMS HELD DOWN WITH HER WRISTS CROSSED. NURSE MANAGER #9 REPORTED BEING VERY UPSET ABOUT THE BRUISES ON RESIDENT #101 AND STATED, "WHAT DID THEY THINK THEY WERE DOING?" NURSE MANAGER #9 SAID SHE CALLED THE DIRECTOR OF NURSING (DON) WHO TOOK OVER FROM THERE. NURSE MANAGER #9 SAID SHE BELIEVED CNA #6 WAS ANGRY ABOUT BEING SCRATCHED BY RESIDENT #101 AND THAT IS WHY CNA #5 AND CNA #6 HELD RESIDENT #101 DOWN AND CUT HER NAILS. NURSE MANAGER #9 STATED SHE BELIEVED THIS TO BE ABUSE. IN AN INTERVIEW ON 3/9/11 AT 2:10 PM, THE DON STATED RESIDENT #101 TOLD HER SHE WAS HELD DOWN AND HER NAILS WERE CUT. THE DON STATED RESIDENT #101 KEPT DEMONSTRATING HOW HER HANDS WERE HELD DOWN. THE DON DEMONSTRATED AN ARMS CROSSED AT THE WRISTS POSITION FOR THE SURVEYOR. THE DON SAID RESIDENT #101 HAD BRUISING ON THE BACK OF HER HAND AND ON HER WRISTS. THIS SURVEYOR ASKED THE DON IF SHE BELIEVED THE BRUISING ON RESIDENT #101 CAME FROM CNA #5 AND CNA #6 HOLDING RESIDENT #101'S ARMS DOWN WHEN THEY CUT HER NAILS, THE DON STATED "YES". THE DON STATED CNA #5 DOES NOT USUALLY TAKE CARE OF RESIDENT #101 DUE TO RESIDENT #101 BELIEVING CNA #5 IS HAVING AN AFFAIR WITH HER HUSBAND. THE DON REPORTED CNA #6 WAS STILL ASSIGNED TO RESIDENT #101. IN AN INTERVIEW ON 3/15/11 AT 9:40 AM, NURSE CONSULTANT # 7 STATED THAT THE FACILITY KNEW THAT CNA #5 AND CNA #6 MADE A BAD DECISION WHEN CNA #5 AND CNA #6 HELD DOWN RESIDENT #101'S ARMS AND CUT HER NAILS. WHEN ASKED IF CNA #5 AND CNA #6 LEFT BRUISES ON RESIDENT #101 WHEN THEY HELD DOWN HER ARMS, NURSE CONSULTANT #7 STATED "YES". ON 3/9/11 AT 4:55 PM, THE REGIONAL OPERATOR AND CORPORATE DIRECTOR OF QUALITY ASSURANCE, THE DIRECTOR OF NURSING, AND NURSE CONSULTANT #7 WERE NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 2/20/11 WHEN RESIDENT #101 HAD HER ARMS PHYSICALLY RESTRAINED WHILE HAVING HER FINGERNAILS CUT AGAINST HER WILL, SUSTAINING BRUISING TO BOTH ARMS AND HANDS, PAIN, AND EMOTIONAL DISTRESS, AND FEAR. THESE DEFICIENT PRACTICES PLACED ALL 85 RESIDENTS IN THE FACILITY AT HIGH RISK FOR PHYSICAL HARM AND/OR INJURY. ON 3/16/11 AT 1:30 PM, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. CNA #5 AND CNA #6 WERE SUSPENDED FROM 2/20/11- 2/25/11, AND INSERVICED ON DEALING WITH DIFFICULT BEHAVIORS WHEN RESIDENTS REFUSE/RESIST CARE. ON 3/9/11 CNA #5 AND CNA #6 WERE RE-SUSPENDED AT 5:45 PM. 2. AS OF 2/20/11, CNA #6 HAS NOT PROVIDED CARE FOR RESIDENT #101. AS OF 2/28/11, CNA #5 HAS NOT PROVIDED CARE FOR RESIDENT #101. 3. ON 3/3/11, 47 OF 47 CNA'S AND 25 OF 25 LICENSED NURSES WERE RE-EDUCATED ON DEALING WITH RESIDENT WITH DIFFICULT BEHAVIORS. THE EDUCATION INCLUDED ON STOPPING CARE WHEN A RESIDENT REFUSES AND RE-APPROACHING AT A LATER TIME AND THAT THE CHARGE NURSE SHOULD BE NOTIFIED OF RESIDENTS WHO ARE REFUSING CARE. 4. ON 3/9/11, THE NEW ADMINISTRATOR AND DIRECTOR OF NURSING WERE EDUCATED BY THE REGIONAL OPERATOR AND CORPORATE DIRECTOR OF QUALITY ASSURANCE ON THE FACILITY ABUSE POLICY, METHODS OF INVESTIGATION, AND ADMINISTRATIVE ACTIONS RELATED TO THE OUTCOMES OF THE INVESTIGATION AS APPROPRIATE. 5. ON 3/3/11, THE FOLLOWING STAFF RECEIVED RE-EDUCATION ON THE FACILITY'S ABUSE POLICY AND THE NEED FOR IMMEDIATE REPORTING OF ABUSE: 6 OF 6 ADMINISTRATIVE STAFF, 12 OF 12 DIETARY STAFF, 11 OF 11 THERAPY STAFF, 5 OF 5 ACTIVITY STAFF, 12 OF 12 HOUSEKEEPING STAFF, 47 OF 47 CNA'S, AND 25 OF 25 LICENSED NURSING STAFF. 6. AS OF 3/9/11, THE ADMINISTRATOR WILL REVIEW ALL ABUSE ALLEGATIONS TO ENSURE APPROPRIATE ACTIONS WERE IMPLEMENTED AND ADMINISTRATIVE ACTION TAKEN WHEN INDICATED. THE ADMINISTRATOR WILL ENSURE ALL ALLEGATIONS ARE REPORTED TO THE STATE AGENCY AS REQUIRED. 7. THE INTERDISCIPLINARY TEAM REVIEWS ALL INCIDENTS DURING THE MORNING CLINICAL MEETING AND WILL ENSURE THAT ALL INJURIES HAVE BEEN INVESTIGATED TO DETERMINE IF ABUSE IS SUSPECTED AND APPROPRIATE ACTION TAKEN INCLUDING REPORTING TO THE STATE AGENCY. 8. BEGINNING 3/9/11, RANDOM RESIDENTS WHO ARE ABLE TO VERBALIZE THEIR NEEDS WILL BE INTERVIEWED THE THE ADMINISTRATIVE TEAM 3 TIMES PER WEEK TO ENSURE THEY FEEL SAFE IN THE FACILITY. ANY CONCERNS RELATED TO STAFF treatment of [REDACTED]. 9. BEGINNING 3/9/11, WEEKLY SKIN ASSESSMENTS AND SHOWER SHEETS ARE REVIEWED BY THE UNIT MANAGERS 5 DAYS A WEEK. ANY SUSPICION OF ABUSE WILL BE THOROUGHLY INVESTIGATED, ADMINISTRATIVE ACTION TAKEN, AND REPORTED TO THE STATE AGENCY. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 3/9/11, 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 NOT ALL FACILITY STAFF HAVE RECEIVED THE IN-SERVICE EDUCATION AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. #