Every finding on record at The Laurels of Kent

Based on observation, interview, and record review, the facility failed to keep the dish machine in a state of repair that would allow for the machine's operational requirements to be met.Findings Include:On 2/22/26 at 10:00 AM, observation of the kitchen dish machine found that it was not reaching proper temperature or pressure for the wash and rinse cycles. A review of the machines' data plate (that shows the minimum requirements) found that the Wash temperature should be 150F - 160F, Rinse temperature should be 180F from the manifold (for a contact of 160F), and the final rinse pressure should be 20 pounds per square inch (psi). At this time, five cycles of the dish machine were run with the following characteristics observed: The wash cycle gauge showed between 140F-146F, the rinse pressure gauge showed between 35-50 psi, and the dish plate thermometer, which tracks the contact temperatures, showed contact temperatures of 137F-150F. A record review of the document entitled Dishmachine Temperature / Sanitizer Log, dated [DATE], found that the morning rinse temperature was recorded low on the log with no corrective action noted. Further review of the log found eight recorded hot water sanitizing rinse temperatures below the required 180F from the manifold. On 2/22/26 at 11:15 AM, a follow up tour of the kitchen found that the dish machine was still not reaching the minimum manufactures requirements. Certified Dietary Manager (CDM) QQ ran a thermo-tape test strip through, and it did not trigger the 160F contact temperature required. CDM QQ stated they would have to use the three-compartment sink and get someone to come check on the unit.

Based on observation, interview, and record review the facility failed to consistently honor food preferences for 5 (Residents #106, 91, 31, 5, and 42) of 11 residents reviewed for dining resulting in being served disliked foods, frustration, decreased meal enjoyment, and the potential for unintended weight loss due to decreased oral intake.Findings include:Resident #106: Review of Resident #106's Brief Interview for Mental Status, dated 2/20/26, revealed a score of 15 which indicated she was cognitively intact. During an observation and interview on 02/22/2026 at 11:26 AM, Resident #106 was in her bed eating lunch. Resident #106 was served a salad that contained iceberg lettuce and tomatoes. On Resident #106's tray was a meal ticket (A slip of paper that noted the residents' diet order, likes, dislikes, and other meal information) that stated, .Only veggies (vegetables) preferred is (sic) broccoli, green beans and carrots. Resident #106 reported she hated tomatoes and didn't care for iceberg lettuce. Resident #106 confirmed the facility had taken down her preferences and they were accurate on the meal ticket. During an observation and interview on 02/23/2026 at 11:30 AM, Resident #106 was in her bed eating lunch. On Resident #106's tray was a meal ticket that stated, Dislikes: [NAME] bread and Only veggies (vegetables) preferred is (sic) broccoli, green beans and carrots. Resident #106 was served an open-faced turkey sandwich on white bread and mixed vegetables (which contained peas, corn, green beans, carrots, and lima beans). Resident #106 was observed pushing the lima beans off to the side of the plate. Resident #106 stated she gets a bit frustrated when she was served food items that were on her dislike list. Resident #91: Review of Resident #91's Brief Interview for Mental Status, dated 1/12/26, revealed a score of 12 which indicated moderate cognitive impairment. During an observation and interview on 02/23/2026 at 11:36 AM, Resident #91 was eating lunch in the main dining room. Resident #91 was served mixed vegetables (peas, corn, green beans, carrots, and lima beans) and her meal ticket stated, Dislikes: [NAME] peas .carrots .Beans. Resident #91 reported it makes her sick when she is given food on her dislikes list. Resident #91 proceeded to eat none of the mixed vegetables and pushed the bowl containing them away on the table with a grimace on her face. Review of Resident #91's nutrition care plan revealed an intervention, dated 5/28/2019, which stated, Provide diet preferences and offer substitutes as needed. Resident #31: During an observation and interview on 02/23/2026 at 11:41 AM, Resident #31 was eating lunch in the main dining room. Resident #31 was served mixed vegetables (peas, corn, green beans, carrots, and lima beans). Resident #31's meal ticket on the table stated, Dislikes: .Green Beans. Resident #31 reported she wouldn't eat them and left them untouched on her plate. Review of Resident #31's nutrition care plan revealed an intervention, dated 5/6/2025, which stated, Provide diet preferences and offer substitutes as needed.Resident #5: During an observation and interview on 02/23/2026 at 11:46 AM, Resident #5 was eating lunch in the main dining room. Resident #5 was served mixed vegetables (peas, corn, green beans, carrots, and lima beans). Resident #5's meal ticket on the table stated, Dislikes: .Green Peas. Resident #5 stated, I hate green peas .since I was 6 years old and reported it felt like nobody listens when asked how it made him feel to be served food on his dislike list. Resident #5 ate none of the mixed vegetables and left them untouched. Review of Resident #5's nutrition care plan revealed an intervention, dated 10/25/2025, which stated, Provide diet preferences and offer substitutes as needed. Review of the facility's Food Preferences policy, dated 1/9/25, stated, Food preferences will be identified on tray tickets to ensure residents are provided with appropriate food items. Resident #42 Review of an admission Record revealed Resident #42 was a female, with pertinent diagnoses which included depression and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 12/11/25, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated she was cognitively intact. In an interview on 2/22/26 at 10:16 AM, Resident #42 reported concerns with the food served at the facility. Resident #42 reported some of the meals served are terrible due to the combinations of foods served and being served items that she dislikes. Resident #42 reported when this happens, she will not eat her meal and wait for the next meal to be served. Review of a current Care Plan for Resident #42 revealed the focus .at nutritional and/or dehydration risk R/T (related to): allergic to oranges, leaves over 25% of food uneaten at (mealtimes) . revised 12/6/25, with interventions which included .Provide diet preferences and offer substitutes as needed . initiated 8/9/20. Review of a Diet History/Food Preferences assessment for Resident #42, dated 12/11/25, revealed dislikes which included gravy and lima beans. Review of a Diet History/Food Preferences assessment for Resident #42, dated 9/12/25, revealed dislikes which included corn and lima beans. In an observation and interview on 2/23/26 at 10:51 AM, Resident #42 was served her lunch tray in her room. Noted Resident #42 was served an open-faced turkey sandwich, with mashed potatoes and gravy, along with mixed vegetables (a combination of peas, corn, green beans, carrots, and lima beans). Resident #42 stated .I won't eat it . and reported she did not like gravy or when food items are .all mixed up . Noted Resident #42's tray ticket listed multiple dislikes which included both gravy and mixed vegetables. In an observation and interview on 2/24/26 at 11:18 AM, Resident #42 was served her lunch tray in her room. Noted Resident #42 was served a beef taco with cheese and tomato, Spanish rice, and refried beans. Resident #42 referred to the Spanish rice and refried beans and stated .I don't like them . Noted Resident #42's tray ticket had a note which stated .no beans of any kind . In an interview on 2/24/26 at 1:44 PM, Dietary Manager QQ reported dietary preferences are assessed quarterly, with changes to preferences modified more frequently as needed. Dietary Manager QQ reported when meals are served, the cook would be responsible to reference the tray ticket (which lists diet orders, allergies, likes, and dislikes) for each resident prior to plating the meal to ensure residents are served items consistent with their diet and preferences.

Based on interview and record review, the facility failed to ensure that irregularities identified by the pharmacist were acted upon for 1 resident (Resident #2) of 5 residents, reviewed for unnecessary medications resulting in Resident #2 receiving an excessive dose of Escitalopram (antidepressant medication) and the potential for medication side effects including life threatening effects from QT (a measurement that shows the heart's electrical activity) prolongation (when the electrical system in your heart takes too long to recharge).Findings include:Review of an admission Record revealed Resident #2 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: schizophrenia (a serious mental health condition that results in a mix of hallucinations, delusions, and disorganized thinking and behavior) and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme high episode to a low depressive episode). Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 2/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #2 was cognitively intact. During an interview and observation on 02/22/2026 at 11:53 AM Resident #2 was in his room sitting in his wheelchair and refused to speak with this surveyor. In a subsequent interview on 02/23/2026 at 9:00 AM, Resident #2 willingly verbalized frustration with having to reside in the facility and that they (unknown people) were treating him wrong.In an interview on 02/24/2026 @ 12:44 PM, Social Worker (SW) D reported that she did not have any record of Resident #2's MRR (medication regimen review) by the pharmacist and was confident that Resident #2's medication had not been changed and there were no recommendations to be changed. SW D reported the BCS (behavioral care services) provider documents all changes in medications in a visit note and then usually sends an email to explain any changes. SW D reported that Resident #2's behaviors still vary and he continued to be hyper focused on his medications. SW D reported that she would not recommend any adjustments being made to his medications and trusted the BCS providers.In an interview on 02/24/2026 at 2:02 PM, Director of Nursing (DON) B reported that she had located Resident #2's Medication Regimen Review (MRR) report from December 2025 but was not able to find the corresponding irregularities report.Review of Resident #2's Medication Regimen Review (MRR) dated 12/16/25 indicated that there was a report attached that explained irregularities and/or recommendations.In a subsequent interview on 02/24/2026 at 2:27 PM, DON B reported that she had located the December MRR recommendations from the pharmacist, which were to decrease Resident #2's Escitalopram from 20 mg to 10 mg. DON B reported that the facility provider had not acknowledged the recommendations but that the BCS provider notes indicated that Resident #2 had been receiving an incorrect dose of Escitalopram while in the hospital in November 2025 and that it was continued when the resident returned to the facility. DON B further reported that Resident #2's current physician orders for Escitalopram were still 20 mg and had not changed since he returned from the hospital on [DATE]. Review of Resident #2's Note to Attending Physician/Prescriber dated 12/16/25 revealed, (Resident #2) is receiving Lexapro (Escitalopram) 20 mg daily, which exceeds the maximum recommended daily dose of Escitalopram 10 mg daily in those over [AGE] years of age. Recommendation: Please decrease to 10 mg daily, while concurrently monitoring for reemergence of depression and/or withdrawal symptoms. If symptoms emerge, alternative therapy may be warranted. Rationale for recommendation: Due to the risk of QT prolongation, Escitalopram 10 mg per day is the maximum recommended dose for individuals who are older than [AGE] years of age. If Escitalopram is to continue at this dose, it is recommended that the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual . This document did not include a physician/provider response. Review of Resident #2's current Medication Orders revealed, Escitalopram Oxalate Oral Tablet 10 mg, give 2 tablets by mouth on time a day for Bipolar, Active 11/10/2025 at 4:00 AM.

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for Medicare Part A services in 2 residents (Resident #73 and #92) of 3 residents, reviewed for timely provision of notifications, resulting in the potential for the resident or resident representative to be unaware of changes regarding financial liability, frustration, and a delay in the ability to file an appeal. Findings include: Review of an admission Record revealed Resident #73 was originally admitted to the facility on [DATE].Review of Resident #73's SNF (skilled nursing facility) Beneficiary Protection Notification Review revealed, .Last covered day of Part A Service: 11/12/25 .The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted .1. Was a SNF ABN, Form CMS-10055 provided to the resident? .No - if no, explain why the form was not provided: (no explanation recorded) .Review of an admission Record revealed Resident #92 was originally admitted to the facility on [DATE]. Review of Resident #92's SNF Beneficiary Protection Notification Review revealed, .Last covered day of Part A Service: 2/19/26 .The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted .1. Was a SNF ABN, Form CMS-10055 provided to the resident? .No - if no, explain why the form was not provided: (no explanation recorded) . In an interview on 02/23/2026 at 1:38 PM, Nursing Home Administrator (NHA) A reported that the above documents were accurate, and Resident #73 and #92 had not received the required ABN notifications. NHA A reported that the facility had recently hired a new Business Office Manager (BOM) that was responsible for providing notifications to residents when there was a change in their insurance benefits. In an interview on 02/24/2026 at 11:52 AM, BOM X reported that she had forgotten to issue ABN notifications when Resident #73 and #92 had a change in their benefits.

This citation pertains to intake #2713932Based on interview and record review, the facility failed to ensure accurate documentation in a medical record for 2 (Resident #29 and #2) of 18 residents reviewed for accurate medical records, resulting in inaccurate documentation of the services provided and inaccurate physician notes. Findings include:Resident #29 Review of an admission Record revealed Resident #29 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: pain in the right knee and chronic pain. Review of a Minimum Data Set (MDS) assessment for Resident #29, with a reference date of 1/20/2026 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #29 was cognitively intact. Review of section J: Health Conditions Pain Management for Resident #29 revealed a scheduled pain medication regimen, no PRN (as needed) pain medication use, with occasional pain occurring, the worst being scored a 6 of 10 (10 being the worst pain ever experienced) in the previous 5 days of the assessment. Review of Physician Orders for Resident #29 revealed Oxycodone HCl (hydrochloride) Oral Tablet 10 mg (Milligram) give 10 mg by mouth at bedtime for chronic pain was originally started on 1/31/2025 at the time of admission and had been a continuous order throughout her stay in the facility for pain management, with the most recent renewal of the order on 2/5/26. In an interview on 2/22/26 at 2:39 PM, Resident #29 reported the facility did not have her medication in the building, the pharmacy would not send it, and for a few days in January 2026 and staff were retrieving her pain medication from the backup supply box. Resident #29 reported there was one night she did not get her pain medication at all. Review of the Medication Administration Record (MAR) for January 2026 for Resident #29 revealed 10 mg oxycodone was documented held/see nurse's note by Licensed Practical Nurse (LPN) O on 1/8/26. Review of eMar-Medication Administration Note (electronic medication administration record) dated 1/8/26 at 23:47 (11:47 PM), authored by Licensed Practical Nurse (LPN) O for Resident #29 revealed . needs new script (prescription). Physician aware. In a telephone interview on 2/24/26 at 2:05 PM, LPN O reported she recalled when Resident #29's oxycodone ran out and she had to call the on-call provider to get a new script. She did not recall the exact date but remembered she had gotten a 3-day supply called into pharmacy. When queried, LPN O reported she probably documented the mediation was on hold on 1/8/26 because it was not available and then when she was able to pull it out of backup, she just gave it to her. LPN O reported she should have struck out the documentation that the medication was on hold and documented a late entry that it was given, and it was late. LPN O reported she did not document that she had given Resident #29 her pain medication, 10 mg oxycodone, on 1/8/26, but she knew she gave it to her late after she pulled it out of the backup box. Review of the MAR for Resident #29 revealed documentation on 1/11/26 by LPN V that indicated resident #29 received her ordered oxycodone 10 mg tablet at bedtime. Review of Transactions by Patient ID for the back-up medication box at the facility for Resident #29 revealed oxycodone IR (Immediate Release) 10 mg was pulled from backup for Resident #29 on 1/9/26 at 1:55 am and no tablet was pulled for administration on 1/11/26. Multiple attempts to contact LPN V were unsuccessful, and no interview was conducted by the time of survey exit. Review of Packing Slip revealed (Name Redacted) pharmacy delivered 15 tablets of Oxycodone 10 mg for Resident #29 on 1/13/26. In an interview on 2/24/26 at 10:53 AM Director of Nursing (DON) B confirmed that Resident #29 was given the last tablet of her oxycodone 10 mg supply on 1/6/26, documentation indicated that Resident #29's oxycodone 10 mg was held (not given) on 1/8/26, no documentation was noted indicating Resident #29 received a dose of 10 mg oxycodone late on 1/8/26. DON B reported documentation indicated that Resident #29 was given her scheduled dose of oxycodone 10 mg on 1/11/26, but DON B was unable to determine where the medication tablet came from. DON B reported one dose pulled on 1/9/26 was most likely the late administered dose that was not documented by LPN O. DON B stated It appears Resident #29 did not get a dose on 1/11/26, even though it was documented she did. DON B confirmed that the documentation was inaccurate. Review of an admission Record revealed Resident #2 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: schizophrenia (a serious mental health condition that results in a mix of hallucinations, delusions, and disorganized thinking and behavior) and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme high episode to a low depressive episode). Review of Resident #2's current Physician Orders revealed, Escitalopram Oxalate (antidepressant medication) Oral Tablet 10 mg, give 2 tablets (total of 20 mg) by mouth one time a day for Bipolar, Active 11/10/2025 at 4:00 AM. In an interview on 02/24/2026 at 2:27 PM, Director of Nursing (DON) B reported that Resident #2's current physician orders for Escitalopram were for two 10 mg pills (20 mg total) and had not changed since he returned from the hospital on [DATE]. DON B reported that prior to Resident #2's hospitalization he had been taking 10 mg of Escitalopram. Review of Resident #2's Provider Visit notes from 11/9/25 to the most recent visit on 2/19/2026 related to the management of his Escitalopram revealed, . Medication list: .Escitalopram oxalate oral tablet 10 mg, give 1 tablet (total of 10 mg) by mouth one time a day for bipolar disorder .Active 3/20/25 This medication list, including dose and frequency, is taken from the facility where patient resides and reflects the best information available at the time of the encounter .Patient is seen today by provider for chronic condition management review f/u (follow up). Detailed chart review, medication review, labs, vital signs, nursing notes, IDT (intradisciplinary) notes reviewed. Nursing denies any concerns at this time .Schizoaffective disorder, bipolar type . It was noted that this information was inconsistent with Resident #2's current physician orders for Escitalopram.

This citation pertains to intake #2713932.Based on interview and record review, the facility failed to ensure residents were free from significant medication errors in 1 (Resident #29) of 3 residents reviewed for pain management services, resulting in Resident #29 missing a dose of scheduled pain medication and experienced pain, frustration and difficulty sleeping. Findings include:Resident #29Review of an admission Record revealed Resident #29 had pertinent diagnoses which included: pain in the right knee and chronic pain.Review of a Minimum Data Set (MDS) assessment for Resident #29, with a reference date of 1/20/2026 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #29 was cognitively intact. Review of section J: Health Conditions Pain Management for Resident #29 revealed a scheduled pain medication regimen, no PRN (as needed) pain medication use, with occasional pain occurring, and the worst being scored a 6 of 10 (10 being the worst pain ever experienced) in the previous 5 days of the assessment.Review of Physician Orders for Resident #29 revealed Oxycodone HCl (hydrochloride) (potent medication used to treat pain) Oral Tablet 10 mg (milligrams) give 10 mg by mouth at bedtime for chronic pain was originally started on 1/31/2025 at the time of admission and had been a continuous order throughout her stay in the facility for pain management, with the most recent renewal of the order on 2/5/26.In an interview on 2/22/26 at 12:07 PM, Resident #29 reported she had severe chronic pain in her back, and it was managed with 10 mg oxycodone at night. Resident #29 reported the pain would be very bad if she didn't have her pain medication as it was scheduled. Resident #29 reported she took one pain pill a day at bedtime.In an interview on 2/22/26 at 2:39 PM, Resident #29 reported there was a situation with her pain medication in January 2026. Resident #29 reported they did not have her medication in the building, the pharmacy would not send it, and the nursing staff was retrieving her pain medication from the backup supply box. Resident #29 reported there was one night, she did not get her pain medication at all and the pain that night escalated to a 10, was unbearable and she did not get much sleep because of it. Review of the Medication Administration Record (MAR) for January 2026 for Resident #29 revealed 10 mg oxycodone was documented held/see nurse's note by Licensed Practical Nurse (LPN) O on 1/8/26.Review of eMar-Medication Administration Note (electronic medication administration record) dated 1/8/26 at 23:47 (11:47 PM), authored by LPN O for Resident #29 revealed . needs new script (prescription). Physician aware.In an interview on 2/24/26 at 1:30 PM, Registered Nurse/ Nurse Manager (RN/NM) R reported Resident #29 told her about her problems with the pharmacy providing her pain medication to the facility, the difficulties the staff had getting the medication out of the backup box, and that she had missed a dose of her oxycodone 10 mg. Review of Controlled Drug Receipt/Record/Disposition Form for Resident #29 dated received 12/23/25 indicated Oxycodone IR (immediate release) Tab 10 mg, included 14 tablets and the last recorded tablet was given to Resident #29 on 1/6/26 and there were no more tablets available.Review of Transactions by Patient ID (Identification) for the backup medication box at the facility for Resident #29 revealed oxycodone IR 10 mg was pulled from back up for Resident #29 on 1/7/26, twice on 1/9/26, 1/10/26, and 1/12/26. No tablet was pulled for Resident #29 on 1/8/26 or 1/11/26.Review of the MAR (Medication administration record) for Resident #29 revealed documentation on 1/11/26 by LPN V that indicated resident #29 received her ordered oxycodone 10 mg tablet at bedtime.In a telephone interview on 2/24/26 at 2:05 PM, LPN O reported she recalled when Resident #29's oxycodone ran out and she had to call the on-call provider to get a new script. She did not recall the exact date but remembered she had gotten a 3-day supply called into pharmacy. LPN O reported that Resident #29 could not go without her pain medication, her pain was too intense if she missed a dose. When queried, LPN O reported she probably documented the mediation was on hold on 1/8/26 because it was not available and then when she was able to pull it out of backup, she just gave it to her. LPN O reported she should have struck out the documentation that the medication was on hold and documented a late entry that it was given, but it was late. LPN O reported she did not document that she had given Resident #29 her pain medication, 10 mg oxycodone, on 1/8/26, but she knew she gave it to her late after she pulled it out of the backup box.Review of Packing Slip revealed on 1/13/26, (Name Redacted) pharmacy delivered 15 tablets of Oxycodone 10 mg for Resident #29.In an interview on 2/24/26 at 10:53 AM Director of Nursing (DON) B reported she didn't know what happened and confirmed that Resident #29 was given the last tablet of her oxycodone 10 mg supply on 1/6/26, back-up supply was used for doses on 1/7/26, 1/9/26, 1/10/26, and 1/12/26 and received her next supply on 1/14/26. DON B reported one dose pulled on 1/9/26 was most likely the late administered dose that was not documented by LPN O. DON B was unable to determine where the documented dose of 10 mg oxycodone that was administered on 1/11/26 for Resident #29 came from. DON B stated It appears Resident #29 did not get a dose that night even though it was documented she did.Multiple attempts to contact LPN V were unsuccessful, and no interview was conducted by the time of survey exit.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 (Resident #5) of 5 residents reviewed for accidents and falls, resulting in the potential for injury.Findings include:Resident #5Review of an admission Record revealed Resident #5 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: mild cognitive impairment of uncertain or unknown etiology (source) and history of falling.Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 1/15/2026 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #5 was moderately cognitively impaired (8-12 moderate cognitive impairment). Review of section J: Health Conditions Falls- indicated that Resident #5 had experienced falls since admission.Review of Care Plan for Resident #5 revealed Resident #5 is at risk for fall related injury and falls R/T (related to): Deconditioning, fear of falling, gait/balance problems, unsteady, impaired, history of falling. with interventions of encourage proper foot wear, keep resident's environment as safe as possible, provide activities that minimize the potential for falls while providing diversion and distractions, and call light within reach all initiated on 10/24/25. Care Plan was updated to include interventions of grippy socks to be worn as allowed and offer toileting before and after melas were added on 11/11/25. The last intervention added on 12/22/25 was to add a sign to Resident #5's walker to remind him to use it when ambulating (walking). Resident #5 had functional ability deficit and request assistance with self-care/mobility with interventions for transfers as resident requires supervision/touching assist with one helper initiated 11/3/25 and ambulation/walking resident requires supervision/touch assistance with 1 helper and a 4ww (4 wheeled walker) initiated on 2/18/26.Review of Kardex (a collection of interventions from the care plan in one location for ease of access by staff) accessed on 2/24/26 for Resident #5 revealed transferring resident requires supervision/touching assist with one helper, ambulation/walking resident requires supervision/touching assistance with one helper, 4WW resident continues to ambulate without assistance.On 2/22/26 at 9:45 AM Resident #5 was observed standing at the foot of his bed in his room and was manipulating the handles of his 4WW from the side as it was parked at the foot of the bed, while standing between the foot rests that were attached to his wheelchair as the urine collection bag connected to his catheter (a tube inserted into the bladder to drain urine) was still hanging from the bottom side of the wheelchair. There were unknown staff members present in the hallway, walking past his room with the door open and noted to be looking into the room as they passed. No staff members entered his room or acknowledged him. Resident sat down in his wheelchair after several minutes of standing. On 2/22/26 at 10:23 AM, Resident #5 was observed standing between the footrests on his wheelchair, in the doorway of his room, holding his urine collection bag in both hands. Resident #5 was noted to be unsteady, turning in circles, and at one point observed to be off balance and grabbed for the handrail attached to the wall outside of the room to steady himself. During this observation, an unknown staff member was observed sitting at the nurses' station at the end of the hallway and appeared to be observing Resident #5 while he was standing in the hallway. At 10:26 AM Licensed Practical Nurse (LPN) W was observed walking around and sitting at the nurse's station and looking down the hallway at Resident #5 who was still standing between the footrests on his wheelchair in the doorway to his room. Certified Nurse Assistant (CNA) II was observed walking around the nurse's station, stopping, turning to observe the hallway, and then continued to walk behind the nurse's station. Resident #5 was still standing in the hallway. None of the staff members attempted to intervene in any way with Resident #5 while he was standing in the hallway. Resident #5 sat in his wheelchair at 10:27 AM while still holding his urine collection bag.In a telephone interview on 2/22/26 at 11:25 AM, Family Member MM stated Resident #5 had several falls since he was admitted to the facility.Review of Resident #5's medical record indicated he had 5 documented falls since admission.In an interview on 2/23/26 at 1:24 PM, CNA II reported Resident #5 was independent for transfers and ambulation. CNA II reported sometimes he needed a little help, but not all the time. CNA II reported Resident #5 was a fall risk.In an interview on 2/23/26 at 1:42 PM, Unit Manager (UM) M reported Resident #5 had an unsteady gait, shuffles his feet sometimes when he walks and was a fall risk. UM M reported Resident #5 needed the assistance of one person for cares, but he could independently transfer. UM M reported sometimes Resident #5 would get stuck when transferring and he was unable to get his feet to keep moving in the direction his body was going. UM M reported Resident #5 was independent in his room with transfers and ambulation.In an interview on 2/24/26 at 8:42 AM, Occupational Therapist (OT) OO reported Resident #5 has a shuffling gait and had experienced a decline since December. OT OO reported Resident #5 was unsafe to transfer or ambulate independently and that was why he was on physical therapy services. OT OO reported if nursing staff says he can transfer and walk independently, they are wrong. He was a fall risk and requires touching when transferring and walking. In an interview on 2/24/26 at 10:49 AM LPN J reported Resident #5 had an unsteady gait, had falls in the past, was a fall risk, and needed standby/contact guard assistance. LPN J reported Resident #5 needed increased supervision as had recently declined in his ability to safety do things independently. In an interview on 2/24/26 at 1:30 PM, Physical Therapy Assistant (PTA) PP reported Resident #5 should not be up by himself, he was a fall risk, and that he was a one assist with a four wheeled walker with transfers and ambulation. PTA PP reported when Resident #5 was in his room he forgot he needed help, was impulsive, would not remember he needed to ask assistance and needed increased supervision related to safety. PTA PP reported Resident #5 definitely needed someone touching him when he was transferring or walking.In an interview on 2/24/26 at 1:55 PM, CNA I and CNA T reported Resident #5 had to have hands on assistance if he was doing any kind of transfer or walking. CNA T reported Resident #5 had a very unsteady gait and was very wobbly when standing.On 2/24/26 at 1:57 PM, CNA T retrieved a binder at the nurse's station and indicated it was a care plan update book. CNA T reported the binder was how the changes in a care plan for a resident was communicated to the staff. CNA T opened the book to a page for Resident #5 that was dated 2/18/26 and noted to have green highlighted marks emphasizing (when) ambulation/walking - Resident requires supervision/touch assistance with one helper, 4ww; Resident continues to ambulate without assistance.

This citation pertains to Intake 1326155.Based on observation, interview, and record review the facility failed to have sufficient staffing to ensure resident care needs were responded to timely for 5 (Residents #1, 2, 6, 7, and 8) of 7 residents reviewed for sufficient staffing, and the potential to affect all those living at the facility of the facility census of 97 resulting in feelings of anger, frustration, and/or embarrassment.Findings include:Resident #1:During an interview on 8/26/25 at 11:51 AM, Resident #1 reported she had feelings of frustration when she had to wait prolonged times to receive staff assistance getting from her bed to her power chair. Resident #1 reported call light times are often not good (long and reported an example of waiting approximately one and a half hours. Resident #1 reported call light wait times are longest when she wanted to get up out of bed and into her power chair around lunch time.During observations and interviews starting on 8/27/25 at 9:18 AM, the call light monitor behind the nurses' station at the end of the 200s hall and call lights above the door in view of all in the hall were watched. At 9:18 AM, the call light monitor at the nurses' station was lit up (activated/turned on) for Resident #1's room and room [ROOM NUMBER] and the call lights above Resident #1's room and room [ROOM NUMBER] were lit up (activated/turned on). room [ROOM NUMBER]'s call light was turned off/responded to at 9:18 AM, and Resident #1's call light remained on (resident awaiting staff response to a care need). The surveyor then proceeded down to Resident #1's room. Resident #1 was lying on her back in her bed, the call light remained on, and she reported she had put on her call light at 9 AM and was waiting for staff to get her out of bed and into her power chair. Resident #1 confirmed she is unable to transfer independently from bed to chair without staff's assistance but wanted to get up so she could take herself down to the beautician to get her hair colored. Resident #1 reported she was concerned because the beautician only comes one day a week every other week and needed the service while the beautician was available. Resident #1 reported it was after breakfast and in-between meals, so she didn't know what was taking so long. Resident #1 appeared visibly frustrated. Resident #1 reported she felt the staffing levels were low and waited longer than 15 minutes for her call light to be answered four times each week on average. The surveyor waited with the resident until the call light was answered. At 9:41 AM, Beautician K entered Resident #1's room to get the resident for hair care. Beautician K reported that she was with Resident #1 when the call light was put on at 9 AM, or no later than 9:05 AM, so that she could get to the Beautician's room. No other person came into Resident #1's room or addressed Resident #1 until 9:44 AM when Certified Nurse Aide J entered Resident #1's room. CNA J and M got Resident #1 up into her power chair, and Resident #1 began to independently use her power chair to exit her room and start heading down the hall to the Beautician's room at 10:03 AM.During an interview on 8/27/25 at 9:44 AM, Certified Nurse Aide (CNA) J reported the CNA's working the 200 hall was herself (CNA J), CNA L, and CNA M was split working both the 100 and 200 halls. CNA J reported the expectation was 5 minutes to answer a call light. CNA J confirmed there was no significant event that would have created a delay to answer Resident #1's call light and they had been providing routine/normal daily cares for residents. CNA J reported she felt they had enough staff to meet care needs on the day shift this day but reported often when working a later shift there was often no CNA working on the 500 hall and that it was frustrating. (The 500 hall was separated from the 100/200 halls requiring staff to walk down a hallway to access the 500 hall rooms.) CNA J reported she felt 2nds and thirds (evenings and nights) shifts struggle with staffing levels and meeting resident care needs/call lights.During an interview on 8/27/25 at 9:58 AM, Certified Nurse Aide (CNA) F was asked what the facility's call light response time was expected to be. CNA F reported realistically 5-7 minutes. CNA F reported second shift staffing levels suffer/not always having enough staff.During an interview on 8/27/25 at 10:03 AM, Certified Nurse Aide (CNA) M stated, Not on a regular basis when she was asked if the facility is staffed enough to allow time to meet resident needs timely. CNA M confirmed she was working rooms on both the 200s hall and the 100s hall, she hadn't seen Resident #1's call light on as she had been on the 100s hall at the time, and nothing happened this morning out of the ordinary that would have prevented staff from meeting call lights (resident care needs) timely. CNA M reported she felt they were adequately staffed today for the day shift.During an observation and interview on 8/27/25 at 10:44 AM, Resident #1's hair care was completed by the beautician, she was seated upright in her wheelchair in her room, and reported when she had to wait that long, like she did that morning 9 AM-9:44 AM for her call light to be answered, she stated she doesn't yell but I get frustrated and angry. If it had got to 1 hour I may have yelled.Review of Resident #1's care plan, revised 5/20/25, stated, (Resident #1) has a functional ability deficit and requires assistance with self care/mobility R/T (related to): Activity Intolerance, Fatigue/Weakness, Impaired Balance, Impaired Mobility, Pain in back, bilateral (left and right) knees, obesity (excess body fat), hx (history) of falls .Encourage resident (Resident #1) to use bell/call light to call for assistance .AMBULATION/WALKING: Resident (Resident #1) is unable to ambulate and requires a power wheelchair for locomotion .Dependent (transfers) [Brand Name; mechanical/powered lift transfer devices] with two helpers .DRESSING: Resident (Resident #1) requires Substantial/Maximum assist (upper body) Dependent (lower body, footwear) with two or more helper(s) .Anticipate and meet resident's needs. Review of Resident #1's brief interview for mental status, dated 7/24/25, had a score of 15 which indicated she was cognitively intact. During an interview on 8/28/25 at 8:28 AM, Director of Nursing (DON) B reported the only time the facility has issues with staffing is 6-10 PM when A-Side (100/200 halls) has to send someone over. DON B reported they were fully staffed yesterday (8/27/25) and 44 minutes was unacceptable, regarding the staff's call light response time to Resident #1's call light. DON B reported they discuss call wait times at all staff meetings across all shifts and small huddles to go over call light response times. Resident #2:During an interview on 8/26/25 at 10:03 AM, Resident #2 reported on 5/31/25 the facility was short staffed, wasn't responsive to his call light, and reported staff working that day had told him they were short staffed.During an observation and interview on 8/27/25 at 3:59 PM, Scheduling staff Q reported on 5/31/25 there was one time slot not covered/staffed. Staff Q reported on that day they had two orientees shadowing but could assist but reported with counting the orientees there was still one night shift slot that wasn't filled. Staff Q confirmed the facility had some low Certified Nurse Aide (CNA) staffing in the past week or so. Staff Q stated, second shift was rough yesterday (8/26/25) and was unable to get someone to fill in/cover staffing from 6-10PM. Staff Q confirmed this 6-10 PM slot that wasn't covered meant there was no CNA on the 500 hall. Staff Q stated staff from the A side (100/200 halls) would monitor 500 hall. When asked how staff on the 100 and 200 halls would know if call lights were on or going off Staff Q reported staff would periodically come over to the 500s hall and check. Per direct observation at that time, 8/27/25 at 3:59 PM, the 500s hall was a distinctly separate unit and separated from the other units. The 100 and 200 halls were separated from the 500s unit by a hallway and was away and out of sight from someone on the 100 and 200 halls.During an interview on 8/28/25 at 9:06 AM, Scheduling staff Q went over the schedules of the past week. Staff Q confirmed that on 8/24/25 from 6-10 PM they were short staff and on 8/27/25 Staff Q confirmed the 500 hall 6-10 PM staff slot for a CNA was not filled.Review of Resident #2's brief interview for mental status score, dated 5/29/25, was scored 15 which reflected intact cognition.Resident #6:During an observation and interview on 8/27/25 at 3:40 PM, Resident #6 presented a grievance/concern form he recently submitted with the facility, but it only contained the front side (the back side of the facility grievance form would address upcoming follow-up/resolution). The grievance indicated CNA C would come into his room and turn his call light off without needs being met. Resident #6 stated, They're so short staffed it's ridiculous.Review of Resident #6's Resident, Family, Employee, and Visitor Assistance Form, dated 8/23/25, stated, What is your concern about? .(CNA C) keeps coming into my room (Resident #6's) and shutting my call light off without my needs being met. Also while I was on the toilet I put the call light on.Shut it off.How can we address your issues? .Have (Nursing Home Administrator A) speak to me.and this is still an ongoing issue.Is this an ongoing problem? .Yes.If Yes, for how long? .Months.Have you contacted us in the past about this Issue? .Yes.Review of Resident #6's functional ability plan, revised 5/21/25, stated, (Resident #6) has a functional ability deficit and requires assistance with self care/mobility R/T (related to): Impaired Mobility, Activity Intolerance, Fatigue/Weakness, Pain, SOB (Shortness of Breath) with exertion .TRANSFER: Resident (Resident #6) requires Dependent assist with 2 helpers SIT 2STAND (device to assist an individual from sitting to standing) .TOILET HYGIENE: Resident (Resident #6) is Dependent with one helper(s) .TOILET TRANSFER: Resident requires Dependent assist with 2 helpers Sit 2 Stand .Provide assistive devices as needed .electric w/c (wheelchair). Resident #6's care plan included a diagnosis list which included, IRRITANT CONTACT DERMATITIS DUE TO FECAL, URINARY OR DUAL INCONTINENCE .IRRITABLE BOWEL SYNDROME. Review of Resident #6's brief interview for mental status, dated 7/24/25, had a score of 15 which indicated he was cognitively intact. Resident #7:Review of Resident #7's Resident, Family, Employee, and Visitor Assistance Form (concern form), dated 7/16/25, stated, What is your concern about? .My light stays on forever. No one answers it and that is why I have to start yelling and getting mad for help.Is this an ongoing problem? .Yes.Review of Resident #7's brief interview for mental status score, dated 6/30/25, was scored 14 which reflected intact cognition.Review of Resident #7's functional ability care plan, revised 7/2/25, stated, .requires assistance with self care/mobility R/T (related to): recent right femur fracture-only able to toe touch. and included an intervention of Encourage resident to use bell/call light to call for assistance.Resident #8:During an interview on 8/28/25 at 9:55 AM, Resident #8 reported the night shift is when he experiences his longest call light wait times. Resident #8 reported call light response times can be anywhere from 20 minutes to an hour and a half. Resident #8 reported he felt the night shift was understaffed. Resident #8 reported he has had many accidents with both bowel/bladder (feces/urine) and is the main reason he uses his call light to get to the bathroom. Resident #8 reported he hits his call light before he has had the accident, but while waiting he soils himself. Resident #8 reported he felt embarrassed and bad when he has a bowel and/or bladder accident waiting for his call light to be responded to. Resident #8 reported he must wear briefs (disposable adult briefs) because he had a cast on his right ankle and can't walk or transfer to the toilet himself.Review of Resident #8's brief interview for mental status, dated 8/10/25, had a score of 15 which indicated he was cognitively intact. Review of Resident #8's impaired skin care plan, dated 7/5/25, stated, (Resident #8) is incontinent of bladder (urine) & bowel (feces) R/T (related to): obesity (excess body fat), muscle weakness .ankle fracture .Resident uses disposable briefs .Check q (every) 2 hr (hours) and prn (as needed) for incontinence. During an interview on 8/28/25 at 10:28 AM, Ombudsman R reported over the past quarter she had received four concerns regarding long call light wait times, staff telling residents somebody called off (as a response to why call lights weren't being responded to timely), and/or staff telling residents they don't have enough time (to meet care needs/call lights timely). Review of the facility's resident council minutes, dated 7/15/25, stated, .New Business.Call lights not being answered 500 Hall (wait over 1 hour)-concern form filled.Review of the facility's resident council minutes, dated 8/19/25, stated, Group Concerns: 200-500 halls lights not being answered, have to wait 45 minutes to an hour .New Business .200 hall lights not being answered - (Resident #1) stated wait 45 min. (minutes)-1 hour (Told (staff first name) 6 weeks ago) .500 hall no aides after 6 pm - not answering call lights anytime .Old Business (list follow-up from last month's minutes). Issues not resolved move to new business .500 call lights - (still not being answered).Review of the facility's Nursing Staffing policy, approved 11/4/2024, stated, The nursing services department provides 24-hour nursing services. The facility ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident .Nursing service is provided by number and type of personnel to ensure that each resident: .Receives proper care to maintain their highest level of functioning .The facility will staff to meet the needs of the residents at the facility . Review of the facility's Call Lights policy, revised 3/12/2025, stated, 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 .

This citation pertains to intake MI00152092. Based on interview and record review, the facility failed to monitor and prevent resident to resident sexual abuse for 4 of 6 residents (Resident #101, #102, #104, and #105) reviewed for abuse, resulting in the potential for a decline in physical, mental, and psychosocial well-being. Findings include: Resident #101 Review of an Admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included personal history of traumatic brain injury and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #101 was severely cognitively impaired. Review of Resident #101's Letter of Guardianship dated 12/18/24 indicated that Resident #101 was totally without the capacity to care for herself, and the court had granted Resident #101 a full guardian. Resident #102 Review of an Admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included cognitive communication deficit and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/24/25 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #102 was severely cognitively impaired. Review of the Facility Reported Incident (FRI) dated 4/8/25 revealed, On 4/8/25 at 10:00 pm, Registered Nurse (RN) N observed (Resident #101) resident laying on (Resident #102's) bed with (Resident #102) in between (Resident #101) legs. (Resident #101) pants were off one leg and around her other ankle and (Resident #102) had his pajama and underpants down to his knees, his penis was not fully exposed. (Registered Nurse (RN) ) F immediately intervened and assisted (Resident #101) back to her room. (RN F) did not witness any intercourse but it appeared that (Resident #102) was fondling (Resident #101) . In an interview on 4/15/25 at 1:32 PM, RN F reported that on 4/8/25 she had completed report with the oncoming shift when she was notified by Certified Nursing Assistant (CNA) H that Resident #101 was not in her room. RN F reported that she began to look for Resident #101 and the first place that she went was Resident #102's room. RN F reported that she went to Resident #102's room because she had seen Resident #101 and Resident #102 together in the hallway earlier that evening. RN F reported that she entered Resident #102's room and turned on the light to observe Resident #102 sitting at the end of his bed with his legs dangling over the side of his bed and Resident #101 was laying on Resident #102's bed with her legs over Resident #102's lap. RN F confirmed that Resident #101's pants were down to her ankles, and she did not have on underwear or a brief. RN F reported that Resident #102's pants and underwear were also down, but his penis was not fully exposed. RN F confirmed that she observed Resident #102 fondling Resident #101's vagina area, but she did not see Resident #102 penetrating Resident #101 with his fingers. RN F reported that the first time that she had observed Resident #101 and Resident #102 spending time together was earlier that night. RN F reported that she saw the residents holding hands in the hallway and thought that is interesting but she did not think much else of that at the time. RN F confirmed that staff had to redirect Resident #101 away from Resident #102's room earlier that evening. RN F reported that after she separated the residents, she contacted the charge nurse and the Nursing Home Administrator (NHA) A. In an interview on 4/15/25 at 12:41 PM, CNA H reported that she came to the facility to start her shift around 9:45 PM, and after getting report she began making rounds to check on her assigned residents when she noted that Resident #101 was not in her room. CNA H reported that she immediately told RN F that Resident #101 was missing and RN F said she might be with Resident #102 and went towards his room. CNA H reported that she followed behind RN F and entered Resident #102's room shortly after RN F. CNA H reported that when she entered Resident #102's room RN F had already turned the lights on, and she observed Resident #101 lying on Resident #102's bed with her pants off. CNA H confirmed that Resident #102's pants were also off, but that she did not observe his penis. CNA H reported that Resident #102 was sitting at the end of the bed when she entered the room. CNA H reported that she did not see interaction between Resident #101 and Resident #102, but that she had entered after RN F who had already begun separating the residents. CNA H reported that she had been told in report from the off going shift that Resident #101 and Resident #102 had been hanging around each other and that Resident #101 had to be redirected from Resident #102's room earlier that evening. In an interview on 4/15/25 at 7:45 AM, NHA A reported that she contacted Resident #101's guardian on 4/9/25 and made her aware of the incident between Resident #101 and Resident #102 on 4/8/25, and obtained consent for sexual intercourse to continue. NHA A reported that she contacted Resident #102's guardian on 4/8/25 at 10:15 PM, and obtained consent for sexual intercourse. NHA A confirmed that the facility had not reached out to the guardians before the incident to determine consent for the relationship between Resident #101 and Resident #102. Resident #103 Review of an Admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and adult failure to thrive. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 4/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #103 was severely cognitively impaired. Review of Resident #103's Letters of Guardianship dated 6/5/24 revealed that Resident #103 had been appointed a full guardian. Resident #104 Review of an Admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included cognitive communication deficit and depression. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 3/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated Resident #104 was severely cognitively impaired. Review of Resident #104's Appointment of Guardian of Incapacitated Individual dated 9/11/24 revealed that Resident #104 was totally unable to care for herself and was appointed a full guardian. In an interview on 4/15/25 at 1:32 PM, RN F reported that she was aware of a relationship between Resident #103 and Resident #104. RN F reported that on 4/3/25 or 4/4/25, she observed Resident #103 and Resident #104 in the lounge together. RN F reported that Resident #103 was groping Resident #104's breasts over her shirt. RN F reported that she did not document this incident or report it to the abuse coordinator. RN F confirmed that she did not know if Resident #103 and Resident #104's guardian's had consented to them having sexual interactions. Review of Resident #103's Nurses Notes dated 2/8/25 and documented by Licensed Practical Nurse (LPN) G revealed, (Resident #103) was in the middle of the hall massaging (Resident #104) breast; educated that he could not be doing that out in the hall, in public. He stated she (Resident #104) was doing it to him, but his statement was not witnessed. (Resident #104) did not look upset or in any distress. Separated residents and he went into the shower. In an interview on 4/16/25 at 3:50 PM, LPN G reported that she did recall witnessing Resident #103 fondling Resident #104's breast in the hallway. LPN G reported that she did not know if Resident #103 and Resident #104 had consent from their guardians for their relationship. LPN G reported that she did not report witnessing Resident #103 massaging Resident #104's breast to the facility's abuse coordinator. In an interview on 4/16/25 at 8:53 AM, Social Worker (SW) K reported that she was aware that Resident #103 and Resident #104 were spending a lot of time together, and they had been observed by staff holding hands on several occasions. SW K reported that she was not aware that Resident #103 and Resident #104 had passed the boundary of holding hands. SW K reported that she had a conversation with Resident #104's guardian about Resident #103 and Resident #104's relationship, and obtained consent for the relationship. SW K reported that she had documented the conversation she had with Resident #104's guardian on her Care Conference Note dated 1/9/25. SW K confirmed that when she spoke with Resident #104's guardian, she did not clarify with Resident #104's guardian if she gave consent for sexual intercourse, or anything beyond holding hands. SW K reported that she had not talked to Resident #103's guardian, and she could not recall who had obtained consent from Resident #103's guardian to have a relationship with Resident #104. Review of Resident #103's Progress Notes dated 7/8/24 revealed, Writer was reported that Resident #103 was engaging in a relationship with (initials of name redacted). Resident #103 reported that he is in interest of this relationship and does not feel threaten by it. Resident #103 was explained he needs to wait until his guardian reports what kind of relationship he can engage with female resident. Review of Resident #103's Progress Notes dated 7/16/24 revealed, Received a phone call from (Resident #103) guardian saying that she talked to the resident's family, and they were okay with (Resident #103) having a relationship as long as the resident do it appropriately. Incoming nurse informed. Noted that the progress notes dated 7/8/24 and 7/16/24 were before Resident #104 was admitted to the facility, and the consent that the facility obtained for this relationship was not for Resident #103's relationship with Resident #104. It is also noted that the facility did not document what kind of boundaries Resident #103's guardian had in place, and if a sexual relationship was allowed. Review of Resident #104's Care Conference Note dated 1/9/25 revealed, .Care Plan Review: .She (Resident #104's guardian) is not worried about (Resident #104) holding hands with her new male friend. (Resident #104's guardian) reports her friend looks a lot like her dad and can see how she feels like wanting to be by him . Noted that Resident #104's Care Conference Note dated 1/9/25 did not indicate if Resident #104's guardian had provided consent for anything further than Resident #104 holding hands with Resident #103. In an interview on 4/16/25 at 10:13 AM, Director of Nursing (DON) B reported that she was present for Resident #104's Care Conference on 1/9/25 and she recalled SW K asking Resident #104's guardian about consent for her relationship with Resident #103. DON B reviewed Resident #104's Care Conference note dated 1/9/25 and confirmed that the documentation did not indicate if Resident #104's guardian had consented to anything more than Resident #104 holding hands with Resident #103. DON B was unable to find documentation of consent from Resident #103's guardian for his relationship with Resident #104. In an interview on 4/16/25 at 11:27 AM, NHA A reported that she was not involved in obtaining consent from Resident #104's guardian and her relationship with Resident #103. NHA A reviewed Resident #104's Care Conferencenote dated 1/9/25 and confirmed that the documentation did not indicate if Resident #104's guardian had consented to anything more than Resident #104 holding hands with Resident #103. NHA A reported that she was not aware of the incident between Resident #103 and Resident #104 on 2/8/25 where Resident #103 was witnessed massaging Resident #104's breasts. Resident #105 Review of an Admission Record revealed Resident # 105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia and depression. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 1/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #105 was moderately cognitively impaired. Review of Resident #105's Letters of Guardianship dated 6/15/22 revealed that Resident #105 was designated two full co-guardians. Resident #106 Review of a Admission Record revealed Resident #106 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 3/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident # 106 was severely cognitively impaired. Review of Resident #106's Letter of Guardianship dated 9/9/21 revealed that Resident #106 had been appointed a full guardian. Review of Resident #106's Nurses Notes dated 6/10/24 and documented by RN C revealed, (Resident #106) came into another resident's room and was caught by an aid doing sexual interaction with a male resident (Resident #105). Unit Manager informed of this incident and DON B notified Review of Resident #105's Social Services Note dated 7/18/24 revealed, Writer contacted (Resident #105) guardian ( Guardian BB) to report relationship between (Resident #105) and female resident (Resident #106), often known to be of sexual interaction. This relationship is consensual from both residents. When (Resident #105) was interviewed; he stated he likes the female resident (Resident #106), does not feel obligated or in stress, and wish to continue to have this relationship with her. (Guardian BB) stated he will (sic) like to talk to (co-guardian) before a decision is made about situation. In an interview on 4/16/25 at 8:19 AM, RN C reported that she did recall the incident between Resident #105 and Resident #106 on 6/10/24. RN C reported that she could not recall which CNA told her that they had found Resident #105 and Resident #106, but that she remembered that the CNA told her it was a sexual interaction, so she reported it to the Unit Manager. RN C could not recall what the sexual interaction between Resident #105 and Resident #106 entailed. In an interview on 4/16/25 at 12:36 PM, Former Unit Manager (UM) DD reported that she did recall being informed of Resident #106 being found in Resident #105's room. UM DD could not recall which CNA had witnessed Resident #105 and Resident #106, but she did recall that Resident #106 was observed performing oral sex on Resident #105. UM DD reported that she contacted Resident #105 and Resident #106's guardians to inform of the incident, and she also notified DON B. UM DD reported that Resident #106's guardian did not have any concerns with the sexual interaction between Resident #105 and Resident #106, but Resident #105's guardian did. UM DD reported that she recalled that Resident #105's guardian was not thrilled and wanted the facility to keep Resident #105 and Resident #106 from having any further sexual interactions. In an interview on 4/16/25 at 2:10 PM, CNA R reported that Resident #105 and Resident #106 had been in a relationship for a long time, CNA R reported that she was not sure if Resident #105 and Resident #106's guardians had consented to a sexual relationship. CNA R reported that Resident #106 used to go to Resident #105's room all the time in the past, and she had observed Resident #105's hands up Resident #106's pants before. CNA R could not recall the date when she had made that observation, and reported that it was a very long time ago. In an interview on 4/16/25 at 8:53 AM, SW K reported that she knew Resident #105 and Resident #106 had been in a relationship together for quite some time. SW K reported that Resident #105 and Resident #106 did go into each other's rooms, but the staff try to separate them. SW K reported that Resident #105 and Resident #106's guardians had consented to the residents having a sexual relationship. This writer reviewed the note that SW K documented in Resident #105's chart that indicated that Guardian BB needed to discuss the relationship and boundaries and had not yet given consent. SW K reported that Guardian BB did give consent for sexual interaction. SW K was not able to provide further documentation to verify that Guardian BB had consented to sexual interactions. In an interview on 4/16/25 at 8:29 AM, Resident #105's Guardian (Guardian BB) reported that he had been made aware of Resident #105's relationship with Resident #106. Guardian BB reported that the facility had contacted him in June 2024 after the incident occurred between Resident #105 and Resident #106, and in July 2024 and asked for consent for the relationship, and what kind of boundaries Guardian BB was comfortable with. Guardian BB reported that he had informed the facility that he was okay with Resident #105 and Resident #106 spending time together, holding hands, and kissing, but he was not comfortable with Resident #105 having a sexual relationship. In an interview on 4/16/25 at 10:13 AM, DON B reported that she knew that Resident #106's guardian had given consent for Resident #106 to have a sexual relationship, but she did not know if Resident #105's guardian had given consent for a sexual relationship. DON B reported that she had been made aware of the incident between Resident #105 and Resident #106 on 6/10/24. DON B confirmed that she did not report the incident, and the facility did not do any follow up with Resident #105 and Resident #106 after the incident. In an interview on 4/16/25 at 11:27 AM, NHA A reported that she was unaware of the incident between Resident #105 and Resident #106 on 6/10/24. NHA A confirmed that if she had been made aware of the incident, she would have reported it to the state agency and completed an investigation. NHA A confirmed that the facility had never obtained consent for Resident #105 to participate in a sexual relationship. In a follow up interview on 4/16/25 at 4:15 PM, NHAA reported that she had contacted Guardian BBand confirmed that he did not consent to Resident #105 having a sexual relationship. Review of the facility's Abuse Prohibition Policy last revised 9/19/22 revealed, Policy: Each guest shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse .To assure guests/residents are free from abuse, neglect, or mistreatment, the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guest/residents .Definitions: . Sexual Abuse: is non-consensual sexual contact of any type with guest/resident. Sexual abuse is defined as non-consensual sexual contact of any type with a guest/resident. Sexual abuse includes, but is not limited to: unwanted intimate touching of any kind especially of breasts or perineal area; all types of sexual assault or battery, such as rape, sodomy, fondling and/or intercourse or coerced nudity;forced observation of masturbation and/or pornography; and taking sexually explicit photographs and/or audio/video recordings of a guest/resident and maintaining and/or distributing them (e.g. posting on social media). Guests/residents have the right to engage in sexual activity. If at anytime the facility has reason to suspect the guest/resident does not have the capacity to consent to the sexual activity the facility should evaluate whether the guest/resident has the capacity to consent

Based on interview and record review, the facility failed to ensure staff implemented the abuse policy by immediately reporting an allegation of abuse to the abuse coordinator for 4 of 6 residents (Resident #103, #104, #105 and #106) reviewed for abuse, resulting in a resident to resident allegation of sexual abuse not being reported immediately to the facility Abuse Coordinator and the potential for additional allegations of abuse to go unreported. Findings include: Resident #103 Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 4/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #103 was severely cognitively impaired. Review of Resident #103's Letters of Guardianship dated 6/5/24 revealed that Resident #103 had been appointed a full guardian. Resident #104 Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 3/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated Resident #104 was severely cognitively impaired. Review of Resident #104's Appointment of Guardian of Incapacitated Individual dated 9/11/24 revealed that Resident #104 was totally unable to care for herself and was appointed a full guardian. In an interview on 4/15/25 at 1:32 PM, RN F reported that she was aware of a relationship between Resident #103 and Resident #104. RN F reported that on April 3rd or April 4th, she had observed Resident #103 and Resident #104 in the lounge together. RN F reported that Resident #103 was groping Resident #104's chest over her shirt. RN F reported that she did not document this incident or report it to the abuse coordinator. RN F confirmed that she did not know if Resident #103 and Resident #104's guardian's had consented to them having sexual interactions. RN F reported that she did not know that she should have reported this incident to the abuse coordinator (Nursing Home Administrator (NHA) A. In an interview on 4/16/25 at 3:50 PM, LPN G reported that she did recall witnessing Resident #103 fondling Resident #104's breast in the hallway. LPN G reported that she did not know if Resident #103 and Resident #104 had consent from their guardians for their relationship. LPN G reported that she did not report witnessing Resident #103 massaging Resident #104's breast to the facility's abuse coordinator. LPN G reported that she did not think she needed to report this incident to the abuse coordinator because the facility reads all the nursing notes every morning. In an interview on 4/16/25 at 11:27 AM, NHA A reported that she was not aware of the incident between Resident #103 and Resident #104 on 2/8/25 where Resident #103 was witnessed massaging Resident #104's breasts. Resident #105 Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 1/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #105 was moderately cognitively impaired. Review of Resident #105's Letters of Guardianship dated 6/15/22 revealed that Resident #105 was designated two full co-guardians. Resident #106 Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 3/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident # 106 was severely cognitively impaired. Review of Resident #106's Letter of Guardianship dated 9/9/21 revealed that Resident #106 had been appointed a full guardian. Review of Resident #106's Nurses Notes dated 6/10/24 and documented by RN C revealed, (Resident #106) came into another resident's room and was caught by an aid doing sexual interaction with a male resident (Resident #105). Unit Manager informed of this incident and DON B notified In an interview on 4/16/25 at 8:19 AM, RN C reported that she did recall the incident between Resident #105 and Resident #106 on 6/10/24. RN C reported that she could not recall which CNA told her that they had found Resident #105 and Resident #106, but that she remembered that the CNA told her it was a sexual interaction, so she reported it to the Unit Manager. RN C could not recall what the sexual interaction between Resident #105 and Resident #106 entailed. In an interview on 4/16/25 at 12:36 PM, Former Unit Manager (UM) DD reported that she did recall being informed of Resident #106 being found in Resident #105's room. UM DD could not recall which CNA had witnessed Resident #105 and Resident #106, but she did recall that Resident #106 was observed performing oral sex on Resident #105. UM DD reported that she contacted Resident #105 and Resident #106's guardians to inform of the incident, and she also notified DON B. UM DD reported that she did not report this incident to the abuse coordinator because she thought that DON B was going to. In an interview on 4/16/25 at 2:10 PM, CNA R reported that Resident #105 and Resident #106 had been in a relationship for a long time, CNA R reported that she was not sure if Resident #105 and Resident #106's guardians had consented to a sexual relationship. CNA R reported that Resident #106 used to go to Resident #105's room all the time in the past, and she had observed Resident #105's hands up Resident #106's pants before. CNA R could not recall the date when she had made that observation, and reported that it was a very long time ago. CNA R reported that she did not report this incident to the abuse coordinator. In an interview on 4/16/25 at 10:13 AM, DON B reported that she had been made aware of the incident between Resident #105 and Resident #106 on 6/10/24. DON B confirmed that she did not report the incident, and the facility did not do any follow up with Resident #105 and Resident #106 after the incident. DON B reported that she did not report this incident because Resident #105 and Resident #106 had been in a relationship for a very long time, and this was not a new situation. In an interview on 4/16/25 at 11:27 AM, NHA A reported that she was unaware of the incident between Resident #105 and Resident #106 on 6/10/24. NHA A confirmed that if she had been made aware of the incident, she would have reported it to the state agency and completed an investigation. NHA A confirmed that the facility had never obtained consent for Resident #105 to participate in a sexual relationship. Review of the facility's Abuse Prohibition Policy last revised 9/19/22 revealed, Policy: Each guest shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convince that are not required to treat the guest/resident's medical symptoms .To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents .Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative. The subject of abuse should be routinely and openly discussed. Guests/residents will be educated concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse incidents on admission and at least annually thereafter. Staff members, volunteers, family members, and others shall immediately report incidents of abuse and suspected abuse, and should be assured that they will be protected against repercussions. Abuse can be guest/resident-to-guest/resident, staff-to-guest/resident, family-to-guest/resident, visitor-to-guest/resident, etc . Definitions: Sexual Abuse is non-consensual sexual contact of any type with a guest/resident. Sexual abuse is defined as non-consensual sexual contact of any type with a guest/resident. Sexual abuse includes, but is not limited to: unwanted intimate touching of any kind especially of breasts or perineal area; all types of sexual assault or battery, such as rape, sodomy, fondling and/or intercourse or coerced nudity; forced observation of masturbation and/or pornography; and taking sexually explicit photographs and/or audio/video recordings of a guest/resident(s) and maintaining and/or distributing them (e.g. posting on social media). Guests/residents have the right to engage in consensual sexual activity. If at anytime the facility has reason to suspect the guest/resident does not have the capacity to consent to sexual activity the facility should evaluate whether the guest/resident has the capacity to consent . Investigation: 1. Allegations by anyone who becomes aware of verbal, physical, mental, sexual or emotional abuse and mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must immediately report it to his/her Administrator .

Based on interview and record review, the facility failed to develop and implement comprehensive, person centered care plans for 4 residents (Resident #102, #103, #104 and #105) of 6 residents reviewed, resulting in unmet care needs and the potential for negative physical, mental and psychosocial outcomes. Findings include: Resident #102 Review of an Admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included cognitive communication deficit and major depressive disorder. Review of the Facility Reported Incident (FRI) dated [DATE] revealed, On [DATE] at 10:00 PM, (Registered Nurse- RN) N observed (Resident #101) resident laying on (Resident #102's) bed with (Resident #2) in between (Resident #101) legs. (Resident #101) pants were off one leg and around her other ankle and (Resident #102) had his pajama and underpants down to his knees, his penis was not fully exposed. (Registered Nurse (RN) ) F immediately intervened and assisted (Resident #101) back to her room. (RN F) did not witness any intercourse but it appeared that (Resident #102) was fondling (Resident #101). Actions taken by the facility: . H. Care plans have been updated . Review of Resident #102's Care Plan revealed, (Resident #102) is experiencing episodes of hypersexuality. Sexual behavior in an appropriate setting. Date Initiated: [DATE]. Goals: Will have no episodes of inappropriate sexual behavior through the review date. Date Initiated: [DATE]. Interventions: Allow resident to express feelings, concerns or questions related to sexuality. Date Initiated: [DATE]. Discuss possible alternatives for intimacy within setting as needed. Date Initiated: [DATE]. Psych consult as needed. Date Initiated: [DATE]. Set limits/guidelines for behaviors as needed. Date Initiated: [DATE]. It was noted that Resident #102's Care Plan had not been updated until [DATE], and the care plan did not address Resident #102's relationship with Resident #101, and what boundaries were in place for this relationship. In an interview on [DATE] at 11:16 AM, Social Worker (SW) K reported that she had forgotten to update Resident #102's Care Plan after the incident between Resident #101 and Resident #102, and that she had just created the Care Plan for Resident #102 that morning. SW K confirmed that Resident #102's Care Plan did not include what boundaries were in place for his relationship with Resident #101. Resident #103 Review of a Admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and adult failure to thrive. Review of Resident #103's Care Plan revealed, (Resident #103) enjoys spending time with female residents, holding hands, sitting and talking with them. He is appropriate and kind. He does not initiate this interaction, but is approached by specific female residents. Date Initiated: [DATE]. Goal: (Resident #103) will stop interacting with any resident that he is not comfortable with and be accepting of staff intervention when needed. Date Initiated: [DATE]. Intervention: Check in with (Resident #103) to ensure his comfort with other residents. Intervene as needed. Date Initiated: [DATE]. (Resident #103) is experiencing episodes of hypersexuality with a female resident from 100 hall Sexual behavior in an appropriate setting. Date Initiated: [DATE]. Goals: Will have no episodes of inappropriate sexual behavior through the review date. Date Initiated: [DATE]. Interventions: Allow resident to express feelings, concerns or questions related to sexuality. Date Initiated: [DATE]. Discuss possible alternatives for intimacy within setting as needed. Date Initiated: [DATE]. Provide time and an environment for privacy as needed/available. Date Initiated: [DATE]. Psych consult as needed. Date Initiated: [DATE]. Set limits/guidelines for behaviors as needed. Resident is not allowed into female room Date Initiated: [DATE] . It was noted that Resident #103's Care Plan did not address his relationship with Resident #104, or what boundaries were in place for their relationship. Resident #103's Care Plan addressed previous relationships he had with other residents in the facility. Resident #104 Review of a Admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included cognitive communication deficit and depression. Review of Resident #104's Care Plan revealed, (Resident #104) likes to hold hands with a male resident. (Resident #104's guardian) reports her friend looks a lot like her dad and can see how she feels like wanting to be by him and gives consent as long as both of them are comfortable and is consensual. Date Initiated: [DATE]. Goals: Will have no episodes of inappropriate sexual behavior through the review date. Date Initiated: [DATE]. Interventions: Encourage participation in diversional activities of interest. Date Initiated: [DATE]. Psych consult as needed. Date Initiated: [DATE]. Set limits/guidelines for behaviors as needed. Date Initiated: [DATE]. In an interview on [DATE] at 1:32 PM, Registered Nurse (RN) F reported that she was aware of a relationship between Resident #103 and Resident #104. RN F reported that on [DATE]rd or [DATE]th, she had observed Resident #103 and Resident #104 in the lounge together. RN F reported that Resident #103 was groping Resident #104's chest over her shirt. RN F reported that she was unaware of what boundaries were in place for Resident #103 and Resident #104. Review of Resident #103's Nurses Notes dated [DATE] and documented by Licensed Practical Nurse (LPN) G revealed, (Resident #103) was in the middle of the hall massaging (Resident #104) breast; educated that he could not be doing that out in the hall, in public. He stated she (Resident #104) was doing it to him, but his statement was not witnessed. (Resident #104) did not look upset or in any distress. Separated residents and he went into the shower. In an interview on [DATE] at 3:50 PM, Licensed Practical Nurse (LPN) G reported that she did recall witnessing Resident #103 fondling Resident #104's breast in the hallway. LPN G reported that she did not know if Resident #103 and Resident #104 had any boundaries in place for their relationship. In an interview on [DATE] at 8:53 AM, SW K reported that she was aware that Resident #103 and Resident #104 were spending a lot of time together, and they had been observed by staff holding hands on several occasions. SW K reported that she was not aware that Resident #103 and Resident #104 had passed the boundary of holding hands. SW K confirmed that she did not create Care Plans for Resident #103, and had just initiated a Care Plan for Resident #104 the day prior to address the relationship between Resident #103 and Resident #104. SW K confirmed that Resident #104's Care Plan did not address what boundaries were in place for Resident #103 and Resident #104's relationship. SW K reported that she had just forgotten to update Resident #104's Care Plan. Resident #105 Review of an Admission Record revealed Resident # 105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia and depression. Review of Resident #105's Care Plan revealed, (Resident #105) likes to spend time with a female resident that often rubs his back and call girlfriend. Date Initiated: [DATE] . It was noted that Resident #105's Care Plan related to his relationship with Resident #106 was not initiated until [DATE], and did not include interventions to discuss what boundaries were in place for the relationship. Resident #106 Review of an Admission Record revealed Resident #106 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and cognitive communication deficit. Review of Resident #106's Care Plan revealed, (Resident #106) enjoys to engage (sic) in kissing and physical behaviors with other male residents at the facility. Guardian is aware. Date Initiated: [DATE]. Goals: Appropriate boundaries will be identified and implemented during these times, as needed. Date Initiated: [DATE]. Interventions: Allow resident to express feelings, concerns or questions related to sexuality. Date Initiated: [DATE]. Encourage participation in diversional activities of interest. Date Initiated: [DATE]. Set limits/guidelines for behaviors as needed. Date Initiated: [DATE]. (Resident #106) has a history of experiencing a budding relationship with a resident .Discusses relationship boundaries. this guest has agreed and verbalized understanding to only holding hands and kissing with resident and speaking in common areas. This resident expired. However, (Resident #106) currently holds a romantic relationship with a new resident. Date Initiated: [DATE]. Goal: Will have no episodes of inappropriate sexual behavior through the review date. Date Initiated: [DATE]. Interventions: Psych consult as needed. Date Initiated: [DATE]. set limits and guidelines as needed Date Initiated: [DATE] . Review of Resident #106's Nurses Notes dated [DATE] and documented by RN C revealed, (Resident #106) came into another resident's room and was caught by an aid doing sexual interaction with a male resident (Resident #105). Unit Manager informed of this incident and DON B notified Review of Resident #105's Social Services Note dated [DATE] revealed, Writer contacted (Resident #105) guardian ( Guardian BB) to report relationship between (Resident #105) and female resident (Resident #106), often known to be of sexual interaction. This relationship is consensual from both residents. When (Resident #105) was interviewed; he stated he likes the female resident (Resident #106), does not feel obligated or in stress, and wish to continue to have this relationship with her. (Guardian BB) stated he will like to talk to (co-guardian) before a decision is made about situation. In an interview on [DATE] at 8:19 AM, RN C reported that she did recall the incident between Resident #105 and Resident #106 on [DATE]. RN C reported that she could not recall which CNA told her that they had found Resident #105 and Resident #106, but that she remembered that the CNA told her it was a sexual interaction, so she reported it to the Unit Manager. RN C could not recall what the sexual interaction between Resident #105 and Resident #106 entailed. RN C was not aware what boundaries were in place for the relationship between Resident #105 and Resident #106. In an interview on [DATE] at 2:10 PM, Certified Nursing Assistant (CNA) R reported that Resident #105 and Resident #106 had been in a relationship for a long time, CNA R reported that she was not sure if Resident #105 and Resident #106's guardians had consented to a sexual relationship. CNA R was not aware what boundaries were in place for the relationship between Resident #105 and Resident #106. In an interview on [DATE] at 8:53 AM, SW K reported that she had Resident #105 and Resident #106 had been in a relationship together for quite some time. SW K reported that Resident #105 and Resident #106 did go into each other's rooms, but the staff try to separate them. SW K confirmed that she had not updated Resident #105 until [DATE] and had not updated Resident #106's Care Plan related to the relationship between the residents. SW K confirmed that Resident #105 and Resident #106's Care Plans did not address what boundaries were in place for Resident 3105 and Resident #106's relationship. SW K reported that she had just missed this. In an interview on [DATE] at 1:58 PM, CNA T reported that she was not aware what boundaries were in place for Resident #103 and Resident #104's relationship, or Resident #105 and Resident #106's relationship. CNA T reported that CNA's should have that information available in the resident care plan, but that the facility was not good at keeping up on that and communicating those type of things in the care plans. In an interview on [DATE] at 10:13 AM, DON B reported that staff utilized the resident's Care Plan to know what boundaries were in place for residents that had romantic relationships in the facility. DON B confirmed that the facility had not ensured that care plans were initiated following the discovery of the relationships between Resident #103 and Resident #104 and between Resident #105 and Resident #106. Review of the facility's Care Planning policy dated [DATE] revealed, Purpose: Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights Additional resources will also be utilized to ensure that any additional needs or risk areas are identified . Procedure: .7. The care plan must be specific, resident centered, individualized and unique to each resident and may include: It should be oriented toward preventing avoidable declines, How to manage risk factors . involve and communicate the needs of the resident with direct care staff .

This citation pertains to intake MI00151467. Based on interview and record review the facility failed to implement interventions, treatment, and monitoring for the prevention of pressure ulcers, prevent the development of pressure ulcers, implement monitoring to prevent the worsening of pressure ulcers, and implement treatment(s) to promote healing of pressure ulcers in 1 of 3 residents (Resident #3) reviewed for pressure ulcers, resulting in Resident #3 developing an unstageable pressure ulcer on the sacrum (tailbone) and an unstageable pressure ulcer on the right ear requiring hospitalization for a wound infection that lead to osteomyelitis (bone infection), gangrene (death of body tissue due to lack of blood flow or a serious bacterial infection) and ultimately the need for surgical intervention. Findings include: Resident #3 Review of an Admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and diabetes mellitus. Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 2/21/25 revealed Section GG- Functional Abilities and Goals indicated that Resident #3 was dependent and required assistance for toileting, and showers/bathing. Section M: Skin Conditions indicated that Resident #3 was at risk for developing pressure ulcers, and that Resident #3 did not have one or more unhealed pressure ulcers stage 1 or higher. Review of Resident #3's Care Plan revealed, (Resident #3) is at risk for impaired skin integrity/pressure injury R/T (related to) decreased mobility, Impaired Bed Mobility, Impaired Nutritional Status,Incontinence bowel and bladder, Psychotropic drug use, history of falls. Start Date: 2/16/25. Interventions: Braden scale per protocol Date Initiated: 2/16/2025. Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Date Initiated: 02/16/2025. Cue to reposition self as needed. Date Initiated: 2/16/2025. Turn/reposition resident every 2 hours and PRN (as needed).Date Initiated: 3/18/2025 . Review of Resident #3's Total Body Skin assessment dated [DATE] indicated that Resident #3's did not have any wounds. Review of Resident #3 Nurses Note dated 3/5/25 and documented by Licensed Practical Nurse (LPN) E revealed, (Resident #3 ) right ear has redness, swelling, and some skin breakdown. Skin prep (skin protectant) applied. (Resident #3) lays with the right side of her head on the pillow often. (Resident #3) also has an open area on her coccyx (tailbone/sacrum area and used interchangeably in hospital and facility documentation), cream and bandage applied. It was noted the facility did not initiate any treatment orders for Resident #3's right ear or coccyx on on 3/5/25. Treatment orders were initiated for Resident #3's coccyx wound on 3/15/25 and her right ear wound on 3/20/25. Review of Resident #3's Total Body Skin assessment dated [DATE] and documented by Licensed Practical Nurse E indicated that Resident #3 did not have any new wounds. Review of Resident #3 's Nurses Notes dated 3/11/25 at 6:38 AM and documented by Registered Nurse (RN) R revealed, (Resident #3) having chills and skin is warm to touch. Checked temp (temperature), 100.4. PRN (as needed) Tylenol PO (by mouth) given. TSB (Tepid Sponge Bath: A method used to cool down or provide comfort to patients during fever) done. Rechecked temp after 1 hour, 99.8. Left a note for NP (Nurse Practitioner) for further assessment and to assess sore in the coccyx area. Review of Resident #3's Nurses Notes dated 3/11/25 at 7:35 AM and documented by RN M revealed, (Resident #3) presented with fever and tachycardia (a condition where the heart rate exceeds 100 beats per minute when at rest) not controlled with Tylenol. (Resident #3) sent to (local hospital) for possible sepsis . Review of Resident #3's Hospital Records dated 3/11/25 revealed, . Upon arrival to the emergency department, (Resident #3) was hemodynamically unstable (unstable movement of blood that results in inadequate blood flow), tachycardic to 136, tachypneic (fast, shallow breathing) at 22 .Physical exam is notable for skin that is hot to touch diffusely, dry oral mucosa (inside the mouth), disoriented and unable to provide much history .Patient meets SIRS criteria (series of objective physical and laboratory findings indicative of infection) for sepsis . Assessment and Plan: Sepsis-likely secondary to UTI (urinary tract infection) and possible pneumonia .WOC (Wound, Ostomy, and Continence)Nursing note: . WOC consulted for sacrum, R (right) ear . Sacrum. Measurement: Approx 4 x 2 x 0.2 cm, grossly oval, with devitalized (tissue that has lost it's blood supply and is no longer viable) purple/black, moist bed with faint slough (dead tissue within the wound) centrally. Moderate serous (clear to yellow fluid) drainage. Erthyematic (redness) periwound. No induration, fluctuance. (tense area of skin with a wave-like or boggy feeling upon palpation). No purulence (pus) observed. Impression: Deep tissue injury (DTI) Right Ear: Eschar (dead tissue that sheds or falls off from the skin) covered wound medially and lateral with pale central tissue. Serous exudate (fluid) is scant. Periwound erythema. Impression: Evolving DTI . It was noted that Resident #3 was hospitalized from 3/11/25- 3/14/25 and then returned to the facility on [DATE]. Review of Resident #3's Orders revealed, Sacrum to brown eschar area cleanse with wound cleanser, pat dry, apply optifoam (type of dressing) daily and PRN. every day shift for sacral wound. Start date: 3/15/2025 .Right ear - unstageable pressure injury: Cleanse wound with wound cleanser. Apply medi-honey gel to wound, cover with small foam pad. Change daily. every day shift. Start date: 3/20/25 . It was noted that Resident #3's right ear wound care treatment order was not initiated upon re-admission to the facility on [DATE], and began on 3/20/25. Review of Resident #3's Nurses Note dated 3/17/2025, revealed sacral wound odorous. no drainage. surrounding tissue red. cleansed with wound cleanser, optifoam applied as per order Review of Resident #3's Progress Note dated 3/17/25 and documented by Nurse Practitioner (NP) CC revealed, .Will continue to be followed by the wound team for open wounds on right ear and sacrum . It was noted that NP CC did not assess Resident #3's wounds or initiate new treatment orders. Review of Resident #3's Initial Consult dated 3/18/25 and documented by Wound Care NP (WC-NP) DD revealed, . (Resident #3) is seen today for wounds to her sacral area and right ear secondary to pressure. Staff notes she was sent out to acute care last week with blanchable (the ability for the skin to turn white or pale in appearance when pressed and then return to its original color) redness to the sacral area and then returned with an unstageable pressure injury. Right ear wound secondary to positioning as (Resident #3) favors to lean on her right side . She does verbalize some pain to the sacral wound area . Review of Resident #3's Orders revealed, Sacrum, unstageable pressure injury: Cleanse wound with wound cleanser. Cover wound bed with gauze soaked with Dakins (topical antiseptic used as a wound cleanser). Cover with super absorbent dressing. Change daily. every day shift. Start Date: 3/20/2025. It was noted that this treatment was documented as See nurses note on 3/21/25 by LPN T. The nurses note did not indicate if the treatment was completed as ordered. Review of Resident #3's Nurses Note dated 3/23/25 revealed, Transferring (Resident #3) to (local hospital) for eval (evaluation) and treatment/NG (naso gastric- tube inserted through the nose and down the throat into the stomach to deliver fluids, nutrients, and medications) tube replacement. Continues to be tachycardic with some tremors to right hand developing . Review of Resident #'s Hospital Records dated 3/23/25 revealed, (Resident # 3) . with a history of diabetes, hypertension, chronic sacral wound presenting from outside facility with concerns sepsis .On arrival to the emergency department patient nonacute distress, vital signs significant for tachycardia at rate of 149, blood pressure of 182/84, tachypnea at a rate of 26, temp of 39.3 C. (102.7 F) .On examination of the patient's sacral wound she appears to have dressings have been soaked with purulent discharge. And wound appears to be mildly erythematous at the edges, appears to have a necrotic center . did review patient's emergency department discharge note from 3/14/2025 which reports that she was initially admitted on [DATE] with the findings consistent with sepsis. On time of admission it appeared that patient had x-ray findings suspicious for pneumonia along with urine cultures that grew positive for polymicrobial infection .This time patient appears to be sirs positive with source likely sacral wound . Hospital course: .During this hospital stay, plastic surgery was consulted for the sacral wound debridement. Patient was taken to the OR on 03/25. Bone cultures from this showed sacral osteomyelitis .Colorectal surgery was consulted regarding a diverting colostomy (surgical opening in the abdomen called a stoma that allows waste to pass out of the body) . Patient and mother were agreeable to diverting colostomy and patient was transferred to (local hospital) on 03/30 to facilitate .Colorectal surgery performed diverting colostomy without complication on 4/1 without complications .Tissue Pathology dated 3/28/25: Result: Bone and soft tissue, sacrum, biopsy: Gangrene with focal acute osteomyelitis . During an interview on 4/8/25 at 1:59 PM, LPN V reported that she cared for Resident #3 frequently, and that she never refused care or treatment, including being repositioned. LPN V reported that she could not recall what Resident #3's wound on her sacrum area looked like, but she thought it was just a small area that needed a dressing. When this writer queried about LPN V 's documentation on 3/21/25 for Resident #3's wound care treatment, LPN V reported that she did not complete the treatment that day, so she documented it to pass to the next shift. LPN V confirmed that the note the had entered did not indicate that she had not completed the wound care treatment, but did remove it from the tasks list to complete. During an interview on 4/8/25 at 2:21 PM, Director of Nursing (DON) B reported that she assisted the wound care provider weekly with wound rounds. DON B confirmed that Resident #3 was first assessed by the wound care provider on 3/18/25. DON B reported that she was unaware that LPN E had found an open area on Resident #3's coccyx area, and she had not seen the note that he entered regarding this. DON B reported that the facility nurses knew to report any new skin conditions to her and the provider, and she did not know why LPN E did not follow the facility's process. DON B reported that she was first made aware of Resident #3's coccyx wound on 3/11/25, but she did not assess it because Resident #3 was sent to the hospital before she could. DON B confirmed that the facility did not have a treatment order in place, and the facility provider and wound care provider did not assess and begin to treat Resident #3's wound on her ear or coccyx area until she returned from the hospital on 3/15/25. DON B reviewed Resident #3's Total Body Skin assessment dated [DATE] which was documented by LPN E and confirmed that LPN E did not note Resident #3's open area on her coccyx as a new wound. DON B confirmed that an open area on the coccyx would have been considered a new wound. DON B reported that she was not sure that the area on Resident #3's coccyx was open, or if LPN E had made an error in his documentation. DON B confirmed that she did not review Resident #3's hospital records, and did not know what Resident #3's wounds looked like upon admission at the hospital. DON B reported that when Resident #3 returned to the facility on [DATE], she was assessed by LPN X, who received verbal orders for wound care to begin on 3/15/25. DON confirmed that Resident #3's wound were first assessed by a provider on 3/18/25 and updated treatment orders were initiated for Resident #3's coccyx wound on 3/20/25. This writer attempted to reach LPN E via telephone on 4/8/25 at 2:11 PM and 4/9/25 at 7:51 AM. LPN E did not return calls prior to survey exit. During an interview on 4/9/25 at 8:11 AM, Certified Nursing Assistant (CNA) U reported that she frequently cared for Resident #3. CNA U reported that on 3/6/25 she had noticed that Resident #3's coccyx area was reddened and it looked like the top layer of skin was totally gone, it almost looked like her bottom had been scraped across something and there was an open area. CNA U reported that she had reported this finding to LPN X but she did not know if LPN X assessed Resident #3. CNA U reported that Resident #3 did not usually refuse cares or treatments. This writer attempted to reach LPN X via telephone on 4/9/25 at 9:17 AM. LPN X did not return call prior to survey exit. During an interview on 4/9/25 at 9:53 AM, CNA G reported that she had cared for Resident #3 on 3/7/25 and recalled finding the large wound on Resident #3's coccyx area when she was assisting Resident #3 in the shower. CNA G reported that she had not cared for Resident #3 in awhile, and she had not gotten in report that Resident #3 had a wound, so she was surprised when she saw it. CNA G reported that the wound was very large, around the size of a golf ball, and that the skin was black. CNA G reported that someone had lathered a lot of some kind of cream on the wound, so she left the wound alone, took Resident #3 to her bed, and then went and informed LPN E. CNA G reported that LPN E was unaware that Resident #3 had a large wound, and she recalled him grabbing a dressing and that she had to tell him you will need a much bigger dressing than that. During an interview on 4/9/25 at 8:46 AM, CNA D reported that she had cared for Resident #3 on 3/10/25. CNA D reported that when she completed her first brief change for Resident #3 that night she was shocked to see that Resident #3 had a very large open wound on her bottom (coccyx) area. CNA D she was shocked because she had not gotten in report that Resident #3 had a wound, and the wound was as big as a softball, red in color around the open area. CNA D reported that there was no bandage or any type of cream on the wound. CNA D reported that she also noticed that Resident #3 was shaky, sweaty, and running a fever, so she immediately reported her concern to RN R. CNA D reported that RN R was also unaware that Resident #3 had a wound on her bottom. During an interview on 4/9/25 at 9:04 AM, RN R reported that she had been made aware on 3/10/25 that Resident #3 had a wound on her coccyx area. RN R reported that she went into Resident #3's room when staff were completing incontinence care on her to look at the wound. RN R reported that she could not recall if the wound had a bandage on it. RN R reported that she did not know what size the open area was because the wound was covered with stool, and she did not wait for staff to finish cleaning the stool off of Resident #3 so she could finish assessing the wound. RN R confirmed that she would normally not leave an open wound without doing any kind of treatment, but since it was time for her to go home, she did. RN R reported that she did leave a note for the NP to assess the wound, but she could not recall if she had informed the oncoming nurse that she left without measuring the wound and completing an accurate assessment of the wound. During a follow up interview on 4/9/25, DON B reported that she was unable to explain why the facility had not started treatment orders for Resident #3's right ear wound until 3/20/25 when the wound was noted on 3/14/25 when Resident #3 was readmitted to the facility. During an interview on 4/9/25 at 11:40 AM, Unit Manager (UM) EE confirmed that she was unaware of Resident #3's wounds on her ear and coccyx until 3/11/25. UM EE confirmed that she had not observed Resident #3's wounds. UM EE reported that she was one of the staff members responsible for reviewing documentation, and that nursing progress notes were reviewed in the morning interdisciplinary (IDT) meetings every day. UM EE confirmed that the IDT team did not discuss the note placed by LPN E on 3/5/25 regarding Resident #3's ear and open wound on her coccyx. UM EE reported that LPN E should have notified the facility's provider and DON B about the wounds that he found on Resident #3 so the facility could have started treatment for them. Review of the facility's Skin Management policy dated 9/19/24 revealed, Policy: It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Overview: Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes. Practice Guidelines: . 4. Residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing. A physician's order for treatment, and Skin impairment location, measurements and characteristics documented .12.If a new area of skin impairment is identified, notify the resident, responsible party, practitioner, DON/designee and treatment team, if applicable .

Based on observation, interview, and record review the facility failed to ensure dignified verbal interactions between staff and resident for 1 (Resident #9) of 4 residents reviewed for dignity and respect resulting in negative emotional feelings and the potential for decreased self-worth or self-esteem. Findings include: Resident #9: Review of Resident #9's medical diagnoses, print date 4/9/25, included diagnoses of down syndrome and unspecified dementia. Review of Resident #9's brief interview for mental status score, dated 3/26/25, was scored 2 which indicated severe cognitive impairment. During an observation on 4/9/25 at 8:47 AM, Resident #9 was seated in her wheelchair in her room and was observed calling out verbally, moaning, crying, and stated, Ow, it hurts. Housekeeping staff F entered Resident #9's room as this was happening. Staff F asked what resident #9 needed and Resident #9 was unable to clearly state a care need to Staff F. Staff F then stated, We're not just gonna (going to) sit and cry, told Resident #9 to not call out and to use her call light, and exited the room approximately one to two minutes after entering. There were no other staff or residents in the area at that time and staff F didn't offer any diversional interventions/activities. No television was observed to be on in the room at the time and staff F wasn't observed to go get someone from the nursing staff to assist Resident #9. During an observation and interview on 4/9/25 at 9:06 AM, Resident #9 seated in her wheelchair in her room continued to call out, moaned, and cried with her eyes closed. Resident #9 stated, Not good when asked how housekeeping staff F's interaction with her made her feel. Resident #9 stated, Yes when asked if housekeeping staff F had spoken to her like that before. During an interview on 4/9/25 at 9:10 AM, Registered Nurse (RN) Y reported Resident #9 had lived at an assisted living facility prior to admission at this facility and there was alleged abuse that occurred towards Resident #9. RN Y reported Resident #9 has called out off and on since admission to the facility. RN Y reported she would remove a staff member from a resident room if she heard a staff member say, We're not just gonna (going to) sit and cry to a resident, take that staff member to the Director of Nursing's office and then check back on the resident to see if they were okay. During an interview on 4/9/25 at 9:18 AM, housekeeping staff F reported Resident #9 likes to sit and cry because she wants attention. Staff F confirmed she said to Resident #9, We're not just gonna (going to) sit and cry. Staff F stated, I know it sounds harsh, but it was better than straight up yelling. Staff F reported she has heard, but not seen, other staff get over stimulated and sound harsh with their tone with Resident #9 when she called out a lot. Staff F noted she only heard these interactions but didn't see them. Staff F was unable to recall staff names or details of these observations but reported they (unknown facility staff) get a little loud and harsh and if you walked by while they interacted with Resident #9 you'd think it's yelling. Staff F reported she has a loud tone and had told Resident #9 that if she doesn't use her call light or just sit there and not want help, there isn't much anyone is going to be able to do. Staff F reported Resident #9 came from a living environment with more one to one care and Resident #9 isn't used to not being the center of attention. Staff F reported when staff go in to Resident #9's room she'll stop calling out, but as soon as staff leaves, she starts back up. During an interview on 4/9/25 at 9:24 AM, the Director of Nursing (DON) B reported housekeeping staff F recently had in-service on customer service and training on how to speak to residents at an all-staff meeting. DON B confirmed no staff should say what housekeeping staff F said (We're not just gonna (going to) sit and cry) to Resident #9 or any other resident. During an interview on 4/9/25 at 9:54 AM, the Nursing Home Administrator (NHA) A reported they don't tolerate talk like that in regards to the way in which housekeeping staff F spoke to Resident #9. During an interview on 4/9/25 at 11:02 AM, NHA A confirmed and showed in-service records that showed housekeeping staff F was educated on 4/1/25 on appropriate ways to speak to residents. Review of Resident #9's behavior problem care plan, dated 3/25/25, stated, (Resident #9) has an actual behavior problem R/T (related to): yelling and screaming for attention . This behavior care plan had an intervention, dated 3/25/25, that stated, Resident prefers the following diversional activities: Coloring with staff, likes watching [NAME] (animals) on tv (television), likes to spend time with staff. Review of Resident #9's activities care plan, revised 12/31/2024, stated, Interests include: coloring, tv (television), word puzzles, bingo, football, news with intervention of Ensure tv (television) remote available (likes football, news, Christmas movies, scooby doo, action, variety) and Provide encouragement and reassurance. Review of Resident #9's psychiatry initial evaluation, stated, (Resident #9) has a history of suffering sexual, emotional, and physical abuse as an adult .Patient has Down syndrome which may contribute to her cognitive and physical presentation and behavioral issues including yelling, crying .Continue with supportive care, encouraged diversional activities, and provide nonpharmacologic behavior management interventions when needed. Review of the facility's dignity policy, revised 3/28/2024, stated, The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality .Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth .Care for residents in a manner that maintains dignity and individuality . Applying the reasonable person concept, one would not want to be told We're not just gonna (going to) sit and cry while crying alone in their room, but would prefer supportive responses and/or diversional activity.

Based on interview, and record review, the facility failed to timely report an injury of unknown origin to the State Agency in 1 of 1 resident (Resident #94) reviewed for abuse, resulting in the potential for a delayed/incomplete investigation. Findings include: In an interview on 12/18/24 at 4:43 PM, Family Member L reported a concern involving a bruise on Resident #94's right inner thigh. Family Member L reported they noticed the bruise during a visit while Resident #94 was in the bathroom. Family Member L described the bruise as .huge . and reported when they asked the nurse what happened the facility had no explanation. Family Member L reported they were concerned that the large bruise to Resident #94's right inner thigh was not reported or investigated. Review of an Admission Record revealed Resident #94 was a female, with pertinent diagnoses which included severe dementia with agitation, depression, anxiety, high blood pressure, heart disease, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #94, with a reference date of 9/24/24, revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated moderate cognitive impairment. Review of a Progress Note for Resident #94, dated 10/28/24 at 9:26 PM, revealed .Resident is very agitated and swearing. She agreed to speak to (Family Member L). This nurse also spoke to (Family Member L). (Family Member L) reports that (they were) here yesterday and noted a large bruise to (Resident #94's) inner right thigh near the groin. (Family Member L) reports that (they) told the nurse on duty and was wondering what had been done about it . Review of a Progress Note for Resident #94, dated 10/28/24 at 10:12 PM, revealed .With the assistance of a (Certified Nursing Assistant) I observed the bruise to the right inner thigh. It is purple/red in color and about the size of a soft ball. It is mid way between the knee and the groin. Resident has no idea when or how it occurred . Review of a Progress Note for Resident #94, dated 10/29/24 at 9:27 AM, revealed .Guest did have a fall and was on the floor recently looking for her remote to her bed. The remote issue was resolved. The bruise to her right inner thigh very well could be resulted from the fall . No other notes or assessments noted related to the bruise on Resident #94's right inner thigh. In an interview on 12/20/24 at 9:09 AM, Administrator A reported the bruise noted to Resident #94's right inner thigh on 10/28/24 was not reported to the State Survey Agency. In an interview on 12/20/24 at 9:37 AM, Director of Nursing (DON) B reported she met with Family Member L about the bruise noted to Resident #94's right inner thigh on 10/28/24. DON B reported Resident #94 had a fall a few days prior, and stated .we thought the bruise was from that . DON B stated .(Resident #94) self-transfers, she puts herself on the floor .That is what we believed the bruise was from . Review of an Incident/Accident report for Resident #94, dated 10/23/24 at 3:00 PM, revealed .Resident noted to be sitting cross legged on the floor in front of her bed after sliding to the floor. She did not hit her head . Per the report, no injuries were observed at the time of the incident. Note this incident occurred five days prior to identifying the bruise on Resident #94's right inner thigh. No other Incident/Accident reports noted between 10/23/24 and 10/28/24, the date the bruise was identified on Resident #94's right inner thigh. Review of a Total Body Skin Assessment for Resident #94, dated 10/25/24 at 10:32 AM, revealed no new skin issues. In an interview on 12/20/24 at 2:26 PM, Registered Nurse (RN) G reported for any new injury/bruise with unknown origin, an incident report should be completed. RN G reported management would be responsible for the investigation. Review of all Incident/Accident Reports for Resident #94 revealed no Incident/Accident Report or investigation related to the bruise noted on her right inner thigh on 10/28/24.

Based on interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin in 1 of 1 resident (Resident #94) reviewed for abuse, resulting in an incomplete facility investigation. Findings include: In an interview on 12/18/24 at 4:43 PM, Family Member L reported a concern involving a bruise on Resident #94's right inner thigh. Family Member L reported they noticed the bruise during a visit while Resident #94 was in the bathroom. Family Member L described the bruise as .huge . and reported when they asked the nurse what happened the facility had no explanation. Family Member L reported they were concerned that the large bruise to Resident #94's right inner thigh was not reported or investigated. Review of an Admission Record revealed Resident #94 was a female, with pertinent diagnoses which included severe dementia with agitation, depression, anxiety, high blood pressure, heart disease, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #94, with a reference date of 9/24/24, revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated moderate cognitive impairment. Review of a Progress Note for Resident #94, dated 10/28/24 at 9:26 PM, revealed .Resident is very agitated and swearing. She agreed to speak to (Family Member L). This nurse also spoke to (Family Member L). (Family Member L) reports that (they were) here yesterday and noted a large bruise to (Resident #94's) inner right thigh near the groin. (Family Member L) reports that (they) told the nurse on duty and was wondering what had been done about it . Review of a Progress Note for Resident #94, dated 10/28/24 at 10:12 PM, revealed .With the assistance of a (Certified Nursing Assistant) I observed the bruise to the right inner thigh. It is purple/red in color and about the size of a soft ball. It is mid way between the knee and the groin. Resident has no idea when or how it occurred . Review of a Progress Note for Resident #94, dated 10/29/24 at 9:27 AM, revealed .Guest did have a fall and was on the floor recently looking for her remote to her bed. The remote issue was resolved. The bruise to her right inner thigh very well could be resulted from the fall . No other notes or assessments noted related to the bruise on Resident #94's right inner thigh. In an interview on 12/20/24 at 9:37 AM, Director of Nursing (DON) B reported she met with Family Member L about the bruise noted to Resident #94's right inner thigh on 10/28/24. DON B reported Resident #94 had a fall a few days prior, and stated .we thought the bruise was from that . DON B stated .(Resident #94) self-transfers, she puts herself on the floor .That is what we believed the bruise was from . Review of an Incident/Accident report for Resident #94, dated 10/23/24 at 3:00 PM, revealed .Resident noted to be sitting cross legged on the floor in front of her bed after sliding to the floor. She did not hit her head . Per the report, no injuries were observed at the time of the incident. Note this incident occurred five days prior to identifying the bruise on Resident #94's right inner thigh. No other Incident/Accident reports noted between 10/23/24 and 10/28/24, the date the bruise was identified on Resident #94's right inner thigh. Review of a Total Body Skin Assessment for Resident #94, dated 10/25/24 at 10:32 AM, revealed no new skin issues. In an interview on 12/20/24 at 2:26 PM, Registered Nurse (RN) G reported for any new injury/bruise with unknown origin, an incident report should be completed. RN G reported management would be responsible for the investigation. Review of all Incident/Accident Reports for Resident #94 revealed no Incident/Accident Report or investigation related to the bruise noted on her right inner thigh on 10/28/24.

Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for 2 (Resident #14 and #94) of 20 residents reviewed for medical records, resulting in an inaccurate reflection of personal hygiene acceptance, lack of nursing assessment documentation, and the potential for facility staff and providers not having all of the pertinent information to care for residents. Findings include: Resident #14 During an observation on 12/18/24 at 10:02 AM Resident #14 was lying in bed, his nails were very long, his facial hair was overgrown and the hair on his head was greasy and disheveled (messy). During an observation on 12/19/24 at 09:29 AM Resident #14 was lying in bed, his nails were long and dirty, and his facial hair had food substance in it. In an interview on 12/19/24 at 02:08 PM, Certified Nursing Assistant (CNA) I reported that Resident #14 refused grooming of his hair and nails, and did not like to be touched. CNA I reported that Resident #14 verbalized no when staff offer to assist with hair and nails. In an interview on 12/20/24 at 09:16 AM, Social Worker (SW) Y reported that she checked the medical record dashboard to know if residents are refusing care. SW Y had not been told that Resident #14 was refusing care, and he had not refusals on on the dashboard. SW Y reported that when residents refuse care, she would try to encourage a different time, evaluate if there was a reason for the refusals, and/or contact family. Review of Resident #14's Personal Hygiene task record indicated no refusals of care from the past 30 days, and every day indicated that the task had been completed by staff. This documentation was inconsistent with the interview from CNA I. Review of Resident #14's ADL (activities of daily living) Care statement task record indicated yes to the past 30 days of the following statement, Have you provided routine standard care which includes evaluating skin daily and reporting changes, shaving and nail care as needed, turning and repositioning, oral care, washing face and hands, hair care, clean clothes and linens . There were no days marked as resident refused. Resident #94 In an interview on 12/18/24 at 04:43 PM, Family Member (FM) L reported that Resident #94 was supposed to see a dentist for a broken tooth, but she had not heard anything about it. Review of Resident #94's Nurses Notes dated 11/27/2024 revealed, Resident's daughter (name excluded) in and informed this writer that resident has a broken tooth on the bottom right that was not broken last Thursday when she was here. DON (Director of Nursing) B informed. In an interview on 12/20/24 at 09:31 AM, Nursing Home Administrator (NHA) A reported that the dentist is scheduled to come in next week, but that Resident #94 was not on the list. NHA A was not informed by DON B that the resident needed to see the dentist. In an interview on 12/20/24 at 09:42 AM, DON B reported that she spoke with Resident #94's family about her broken tooth, and talked to staff about it also. DON B reported that she assessed Resident #94's tooth and the resident did not have any issues with pain or eating. DON B reported that she did not refer the resident to the dentist and did not document her findings.

Based on observation, interview, and record review, the facility failed to post required nurse staffing information on a daily basis, for all 98 residents in the facility, resulting in a lack of available staffing information for residents and visitors. Findings include: In an observation and review of the posting Report of Nursing Staff Directly Responsible for Patient Care document, in the main entryway of the facility on 12/18/24 and 12/19/24, revealed no information recorded in the total hours columns of the document. In an interview on 12/19/24 at 09:53 AM, Medical Records/Scheduler (MRS) JJ reported that she was responsible for posting the daily staffing report. MRS JJ reported that she only recorded the number of staff, and did not know to include how many hours they were working on that day. In an interview on 12/20/24 at 12:31 PM, Nursing Home Administrator (NHA) A reported that she did not know to the nursing hours needed to be reflected on the posting.

This citation pertains to intake #MI00144277. Based on interview, and record review, the facility failed to provide adequate supervision and accurately implement the elopement policy in 3 of 5 residents (Resident #203, #208, & #209), reviewed for safety and monitoring, resulting in the potential for injury. Findings include: Review of the facility document Elopement Residents indicated 17 residents that were at risk for elopement and were currently wearing wanderguard bracelets. Resident #203, #208, and #209 were included on the list. Resident #203 Review of an Admission Record revealed Resident #203 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke and seizure disorder. Review of a Minimum Data Set (MDS) assessment for Resident #203, with a reference date of 4/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #203 was cognitively impaired. Review of the Functional Abilities revealed that Resident #203 could walk independently. Review of Resident #203's Incident Report dated 4/22/24 at 2:00 PM revealed, .Resident was seen outside by another staff member coming into work. A staff member came outside to get him and bring him back inside. The resident had gone to the front desk and asked to go outside for a walk. The staff member at the front desk thought the resident was allowed to go outside the facility independently and helped him get out the front door. Resident cooperated coming back inside without an issue but did wonder why he wasn't allowed to go out and walk. Resident Description: He wanted to walk down the street and see if he could get more cigarettes since he had run out of them . In an interview on 5/15/24 at 10:45 AM, Receptionist (REC) O reported that on 4/22/24 Resident #203 had came to the window and said that he was all set to go outside for a walk, and had appeared to be signing himself out. REC O reported that when Resident #203 tried to open the door, it alarmed and locked and stated, .I reset the alarm and let him out the door . REC O reported that she had been confused about the door alarms and the wanderguard system, and believed Resident #203 when he said that he was all set to go out. REC O reported that she was newly hired to the facility on [DATE], had only received one day of orientation, and had not been shown the Elopement Binder that identified all residents that were at risk for elopement. In an interview on 5/16/24 at 8:47 AM, Certified Nursing Assistant (CNA) W reported that she noticed Resident #203 walking on sidewalk about a block away from the facility when she was driving to work on 4/22/24 at about 1:45 PM, and she knew that he was not supposed to be by himself, but was not sure what to do. CNA W reported that when she pulled into the parking lot of the facility, she alerted another staff member (Director of Marketing (DOM) K) that had been in the parking lot at the time. CNA W reported that DOM K immediately went running down the sidewalk, and CNA W entered that facility and notified Nursing Home Administrator (NHA) A of the elopement. CNA W reported that the first time she had seen Resident #203 in the facility, she was not familiar with his exit seeking, thought that he was a visitor and almost let him out the door. CNA W reported that she knew that there was a binder at the nurse's station that has pictures of all the resident's that are at risk for elopement. In an interview on 5/15/24 at 11:10 AM, DOM K reported that she had been in the parking lot on 4/22/24 when CNA W drove in and yelled to her that there was a resident on the sidewalk down the road. DOM K reported that she immediately went running, and at first could not see the resident because the road curved, but then saw Resident #203 walking on the sidewalk on the other side of the first cross street. DOM K reported that Resident #203 stopped when she called his name and was easily redirected to walk back to the facility. Review of Resident #203's Elopement Risk assessment dated [DATE] revealed that the resident was at no risk for elopement. Review of Resident #203's Elopement Risk assessment dated [DATE] revealed that the resident was at risk for elopement, and expressed desire to leave the facility. Review of Resident #203's Elopement Risk assessment dated [DATE] revealed that the resident was at no risk for elopement, did not verbalize a desire to leave, had no history of elopement, and had been in the facility for greater than 30 days. This assessment was not accurate. Review of Resident #203's current Physician Orders indicated that an order for a Wanderguard bracelet was in place since 4/5/24. There was no documentation justifying why the resident had orders for a wanderguard bracelet in place upon admission. Review of Resident #203's Elopement Care Plan revealed, Need: .at risk for elopement r/t (related to) new setting, going out to smoke, confusion. Date initiated 4/22/24. Goal: .will not exit the building without staff present through the next review. Date initiated: 4/22/24. Interventions: .Wander guard to right wrist, check placement and function as ordered. Date initiated 4/22/24. The resident's Functional Abilities Care Plan revealed, Need: .functional ability deficit and requires assistance with self care/mobility r/t impaired cognition, epilepsy, hx (history) of stroke. Date initiated: 4/8/24 .Interventions: .Wander guard to right wrist. Date initiated: 4/8/24. Ambulation/Walking: Resident is independent . The at risk for elopement care plan was initiated after the resident's elopement on 4/22/24. Review of the facility document Past Non-Compliance dated 4/22/24 revealed, .disarming secure care alarm system for a resident with a wanderguard on and resident exited the facility, was identified by staff member coming into work, and staff member in parking lot retrieved resident and returned to the facility without incident .Corrective actions taken for deficient practice: Receptionist was re-educated .Current staff in the building were re-educated .Risk for elopement assessment was completed for all current residents, those identified at risk have appropriate wander guard in place and care plans reflecting risk .Date of completion of plan of correction: 4/23/24. In an interview on 5/15/24 at 3:49 PM, Director of Nursing (DON) B reported that Resident #203's elopement assessments were inconsistent and were not accurately documented. DON B reported that for a wanderguard to be ordered, the elopement assessment should reflect a risk of elopement, and/or the record should include why the decision was made to order a wanderguard upon admission on 4/5/24, and Resident #203's record did not reveal . DON B reported that Resident #203 had in fact remained at risk for elopement since he admitted on [DATE], and most certainly following his actual elopement on 4/22/24. In a subsequent interview on 5/16/24 at 10:28 AM, DON B reporting that on 5/16/24 the facility had reviewed all residents that were listed on their previous Elopement Risk list, and had determined that 9 of those residents were not at risk and therefore their wanderguards were removed. DON B reported that on 5/16/24 the facility had reviewed Elopement Risk assessments from new admissions for the past 30 days, and 12 of those were inaccurately documented. In an interview on 5/16/24 at 11:41 AM, Licensed Practical Nurse/Unit Manager (LPN-UM) M reported that upon admission, Resident #203 was considered an elopement risk because he had verbalized a desire to leave the facility unsupervised, and was very confused about why he wasn't able to do that. LPN-UM M reported the Elopement Assessment record was completed inaccurately on 4/5/24 and on 4/30/24. Resident #208 Review of Resident #208's the current Physician Orders revealed that the resident had orders for wanderguard to be on place since 11/30/23. Review of Resident #208's Elopement Assessments dated 5/11/18, 7/9/20, 4/23/24, and 5/16/24, all indicate that the resident was at no risk for elopement. Review of Resident #208's Progress Note dated 5/16/24 revealed, .(Resident #208) does wander through the building, but with purpose. She has never attempted to exit the building as of this time.Risk for elopement was redone and resident is not at risk for elopement. Resident #209 Review of Resident #209's the current Physician Orders indicated that the resident had orders for wanderguard to be on place since 11/16/23. Review of Resident #209's Elopement Assessments dated 4/7/22, 4/14/22, 4/21/22, 4/28/22, 4/23/24, and 5/16/24, all indicate that the resident was at no risk for elopement. Review of Resident #209's Progress Note dated 5/16/24 revealed, .reassessed for risk for elopement as she had an order for wanderguard. Risk assessment indicates not at risk. Resident has declined in w/c (wheelchair) mobility, no longer ambulates and therefor is not considered at risk or requiring of a wanderguard. Review of the facility policy Elopement dated 4/26/22 revealed, .It is the responsibility of all personnel to report any guest/resident attempting to leave the premises, or suspected of being missing, to the licensed nurse and to document the occurrence .1. The facility will evaluate guest's/resident's risk for elopement upon admission, weekly x 4 .2. After the Risk for Elopement is completed, and a guest/resident is deemed at risk for elopement, the licensed nurse will: .c. Verification of the placement of the wandering device will be done on each shift and documented on the MAR (Medication Administration Record) by the licensed nurse. d. The Social Worker/designee will create and maintain a current log for all guests/residents that are at risk for elopement. Minimally, this log will be kept at the nursing station, reception desk and/or additional locations as deemed appropriate by the facility's interdisciplinary team .If an employee observes a guest/resident attempting to leave the facility .e. Review the current Elopement Risks and re-evaluate .

Based on interview and record review, the facility failed to ensure COVID-19 immunization were offered to 2 (Resident #54 and #6) out of 5 residents, reviewed for COVID-19 immunizations, resulting in the increased likelihood of severe infection and complications/death related to COVID-19. Findings include: In an interview on [DATE] at 12:33 PM, NHA reported that the facility currently had 18 residents that were positive for COVID-19, and in droplet isolation. NHA reported that a COVID-19 outbreak began on [DATE], and a total of 56 residents have tested positive since then, with the most recent on [DATE]. NHA reported that two residents have died from COVID-19, Resident #54 and #6. Resident #6 Review of an Admission Record revealed Resident #6 was originally admitted to the facility on [DATE]. Review of Resident #6's Admission assessment dated [DATE] indicated that she had not received any doses of COVID-19 vaccine. Review of Resident #6's COVID-19 Vaccine consent revealed no consent or education. In an interview on [DATE] at 01:46 PM, IP C reported that Resident #6 did not have any consent forms in her record for COVID-19, and there were no COVID-19 immunizations included in her immunization records. Review of Resident #6's COVID-19 results indicated that the resident tested positive for COVID-19 on [DATE]. In an interview on [DATE] at 02:05 PM, IP C reported that she has not completed an audit of the residents in the facility to ensure that they have been offered and educated on COVID-19 vaccines. In an interview on [DATE] at 09:22 AM, DON B reported that the facility had not completed an audit to ensure that residents were offered and educated on the COVID-19 vaccine and stated, .we have done influenza and pneumococcal audits . Review of the hospital records dated [DATE] revealed Resident #6 was admitted to the hospital where she died on [DATE] at 1:50 pm with the Preliminary cause of death: COVID-19 pneumonia. Resident #54 Review of an Admission Record revealed Resident #54 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral infarction (stroke). Review of Resident #54's Immunizations indicated that she had received SARS-COV-2 (COVID-19) Dose 2 on [DATE], and COVID-19 Dose 1 on [DATE]. There were no booster doses documented. In an interview on [DATE] at 01:39 PM, Infection Preventionist (IP) C reported that residents should be offered and receive consent forms for COVID-19 upon admission. IP C reported that upon admission, Resident #54 indicated that she wanted COVID-19 vaccination, but did not know if she had received her first dose already. IP C reported that the facility obtained Resident #54's immunization records which revealed that she had received the first 2 primary doses and stated, .we should have contacted the guardian at that time to offer the booster . Review of Resident #54's COVID-19 results indicated that the resident tested positive for COVID-19 on [DATE]. In an interview on [DATE] at 1:45 PM, Director of Nursing (DON) B reported Resident #54 tested positive for COVID-19 on [DATE], was found unresponsive on [DATE] and stated, .not sure what she died from .she had heart problems and possibly related to having COVID . Review of the hospital record dated [DATE] revealed Resident #54 died on [DATE] at 4:25 am with cause of death being cardiac arrest. Review of a facility policy Resident COVID-19 Vaccination last revised [DATE] revealed, .3. All new residents and resident representatives will be provided with education on COVID-19 vaccination .4. The facility will obtain a signed consent form for the administration of the COVID-19 vaccine .A declination will be signed if consent is not given .8. The facility will track consents and declinations of all residents in the immunizations section of the medical record. 9. All new and re-admissions will be evaluated by the nurse and/or physician for previous immunization and will be offered the vaccine if appropriate and available .Procedure for Additional Doses: 1. The vaccine administrator will identify residents that would qualify to receive the additional dose or booster dose of COVID-19 vaccine based on CDC recommendations .2. Educate resident or responsible party on additional dose of COVID-19 vaccine .

This citation has 2 DPS statements, #1 and #2. DPS #1 Based on interview and record review, the facility failed to maintain professional standards when responding to an acute change in condition in 1 of 19 residents (Resident #54 ) reviewed for quality of care, when facility staff failed to ensure a physician was notified of Resident #54's extreme elevation in heart rate (pulse) and respirations, and adequately monitor and assess Resident #54 for further decline in health status, resulting in a delay in treatment and ultimately Resident #54 being found unresponsive, without an audible BP (blood pressure) or palpable pulse, and was transferred to the hospital via EMS (emergency medical services), where she later died . Findings include: Resident #54 Review of an Admission Record revealed Resident #54 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral infarction (stroke). Review of Resident #54's Advance Directive indicated to perform CPR (cardiopulmonary resuscitation) and transfer to the hospital where full life support measure are to be taken. In an interview on [DATE] at 08:51 AM, Licensed Practical Nurse (LPN) H reported that a Certified Nursing Assistant (CNA) had reported abnormal vital signs for Resident #54 on [DATE] around 6:45 PM, and LPN H rechecked the vital signs and got the same readings; Respirations 32, Pulse (heart rate) 114. LPN H reported that she sent a text message to the on-call provider regarding Resident #54's abnormal vital signs and stated, .(Resident #54) was not showing any signs of distress .all they (on-call provider) said was to continue to monitor and just to keep an eye on her . LPN H reported that she was not familiar with how Resident #54 was at baseline (normal), because she did not normally work that hall. LPN H reported that she did not go back into Resident #54's room that night, did not recheck her vital signs and stated, .I could see her from the hallway when I walked by .she was laying in bed watching TV . LPN H reported that she had worked 6:00 PM-10:00 PM on [DATE]. Review of Resident #54's Progress Notes revealed no entries from LPN H on [DATE], and/or related to Resident #54's change of condition on [DATE]. In an interview on [DATE] at 12:53 PM, LPN R reported that when she started her shift on [DATE] at 10:00 PM she had received report from LPN H regarding Resident #54's condition. LPN R reported that LPN H told her that Resident #54 had an elevated pulse and respirations, and that LPN H had sent a message to the on-call physician, but had not heard back yet. LPN R reported that she (LPN R) did not try to call the on-call physician and did not immediately assess Resident #54 and stated, .I was busy .I had pill counts to do . LPN R reported that she went into Resident #54's room at approximately 11:00 PM, and that Resident #54 verbalized to her that she did not feel good and stated, .that was all she said . LPN R reported that she checked Resident #54's vital signs at 11:00 PM and stated, .there was nothing alarming .her respirations were pretty normal .I can't remember what her vitals were .I can't remember if I called the doctor . LPN R reported that she did not document Resident #54's assessment and/or vital signs in the health record. LPN R reported that a little while after 1:00 AM on [DATE] (approximately 2 hours later) CNA AA and/or CNA KK had informed her that Resident #54 was unresponsive and that they were not able to obtain vital signs. LPN R reported that at that time Resident #54 would not speak, move, or open her eyes, and LPN R could not obtain a blood pressure or feel a pulse, but that Resident #54's respirations were 24 and the oxygen saturation device was picking up a pulse. LPN R reported that she called the on-call provider (Nurse Practitioner (NP) I) to get authorization to send Resident #54 to the emergency room and then called 911 and waited for the ambulance to arrive. LPN R's interview was not consistent with what LPN H reported regarding having spoke to the on-call provider. An attempt was made on [DATE] at 01:10 PM to interview CNA AA by phone, but there was no return call. An attempt was made on [DATE] at 01:12 PM to interview CNA KK by phone, but there was no return call. Review of Resident #54's Progress Notes provided by DON revealed the following text messages between the facility and the physician on-call services regarding Resident #54: -On [DATE] at 6:47 PM written by LPN H, Patient tested positive with covid on ,d+[DATE], had round of Paxlovid (antiviral medication) which is completed. Her vitals now are ,d+[DATE] (blood pressure), 114 (heart rate), 97.6 (temperature), 32 (respirations), 94% (oxygen level in blood) RA (room air). Her Respirations and heart rate are both elevated. She doesn't seem like she's in distress, laying in bed watching television. -On [DATE] at 1:17 AM written by LPN R, Resident is currently with a BS (blood sugar) of 473, she is cold, unresponsive, BP (blood pressure) is very hard to get, unable to obtain with machine, the best I can get is a guess of ,d+[DATE], but again I do not trust that. Pulse is 60, respirations 24, and her O2 (oxygen level) RA is ,d+[DATE]%, getting a concentrator, but her extremities are so cold I'm not sure this is accurate for the O2. -On [DATE] at 1:19 AM written by LPN R, Looks as though the only injectable insulin is Trulicity (medication for blood sugar). -On [DATE] at 1:28 AM written by NP I, Spoke to you on phone-Thank you. In an interview on [DATE] at 08:19 AM, NP I reported that she was not on-call until 7:00 PM on [DATE] and was not aware of the text message regarding Resident #54, that was sent at 6:47 PM by LPN H. NP I reported that LPN R called her on [DATE] before NP I even got the text that was sent at 1:17 AM, and reported the resident's poor condition and NP I offered a telehealth (virtual) visit, but LPN R felt that Resident #54 needed to go to the hospital. NP I reported that she had no further information regarding Resident #54. In an interview on [DATE] at 01:46 PM, Physician Assistant (PA) J reported that he was the on-call provider on [DATE] until 7:00 PM, but that he had not received any text message regarding Resident #54. PA J reported that the staff have to specifically include him in the text messages, otherwise he would not have gotten the text message. PA J reported that if he had received notification that a resident had a heart rate of 114 and respirations of 32, he would have ordered labs, completed a telemed (virtual) visit, had nursing closely monitor and recheck vital signs to ensure that they return to normal, at the very least. PA J was the provider on-call at the time LPN H discovered Resident #54's abnormal vital signs, and PA J did not speak with LPN H as reported in LPN H's interview. In an interview on [DATE] at 09:05 AM, DON reported that LPN H sent the initial text message to the on-call provider on [DATE] at 6:47 PM and stated, .they must have spoken on the phone because there is no response from the provider in the text thread record . DON reported that she (DON) was also included on that text message thread for Resident #54, but that she was off work at the time so she did not see it. DON reported that the expectation for nursing staff would be to closely monitor Resident #54, rechecking vital signs and contacting the provider ASAP. DON reported that LPN H did not document her assessment findings, and there was no record of LPN H speaking with the on-call provider. In an interview on [DATE] at 1:00 PM, Regional Nurse (RN) SS reported that PA J was on-call [DATE] until 7:00 PM, but that PA J was not listed on the text message thread for Resident #54, therefore PA J would not have gotten the message, and the others on the thread would not have responded because it was after hours and they were not on-call. Concluding that the initial text message sent to on-call providers related to Resident #54's vital signs at 6:45 PM, was not ever received or addressed by a provider. In an interview on [DATE] at 10:23 AM, CNA G reported that on [DATE] she had noticed Resident #54 was very out of it and stated, .she was zonked out, wouldn't open her eyes, not responding to us, looked like she was sleeping . CNA G reported that Resident #54's respirations and pulse were very high for her, and CNA G reported that she immediately notified LPN H and explained that Resident #54 was not normally like that. CNA G reported that LPN H rechecked the vital signs and got the same results, but did not do anything else. CNA G reported that Resident #54 was in isolation for COVID-19 therefore her room door was shut that night and stated, .I did not recheck her vitals .I opened the door and checked in on her around 9:30 PM before I left .and she was still zonked out and unresponsive . CNA G reported that she reported off to CNA AA and CNA KK around 10:00 PM and made sure that they both knew to keep an eye on Resident #54. Review of Resident #54's Ambulance Report indicated that the inital call to dispatch was received on [DATE] at 1:39 AM and EMA arrived at the facility at 1:48 AM and revealed, .upon arrival staff states patient was last seen at 10 PM; Patient appeared to be at her baseline then with slight wealness and tachypnea (elevated heart rate) per staff however staff did not think it was a concern at that time; patient was now found by staff unresponsive with tachypnea and cold extremities; .patient noted to normally be awake and talking; patient also noted to test positive for covid recently per staff .patient noted to be full code; staff had no other information for EMS. Assessment: upon arrival patient was found unresponsive .breathing noted to be rapid .carotid pulse felt on initial assessment .EMS unable to get BP in facility. however noted to have a carotid pulse. later found to be ,d+[DATE] and then decline from there . Review of Resident #54's Hospital Records revealed, .Arrived in ED (emergency department) [DATE] at 2:42 AM .presented to the emergency department unresponsive. She was found down at her living facility. No clear exact down time. Patient was recently diagnosed with COVID. Reportedly at 10:00 p.m. patient was having some symptoms of worsening respiratory function .She has a history of diabetes and was recently positive for COVID 2 days ago .EMS (emergency medical service) was concerned that patient may not have had a pulse on arrival. On arrival patient has evidence of agonal (gasping for air) breathing but does not have any pain response to upper lower extremities. Pupils are dilated and nonreactive .Initial blood pressure showed ,d+[DATE] however she appears cyanotic (blue skin), cool to touch and poorly perfused. We continued multiple blood pressure checks which showed evidence of worsening hypotension (low blood pressure) .Patient was considered full code according to her living facility documents so we started chest compressions .Three rounds of CPR were performed and DPOA (durable power of attorney) who is the patient's niece arrived in the emergency department Just before intubation (a tube inserted down the throat to breath) patient's family said they do not want her to be on a ventilator at all cost and did not want any further compressions. At this time we confirmed the patient's wishes with the DPOA and the decision was made to stop the code. Initially did not have any pulses after we stopped chest compressions. Over the next few minutes we monitored for pulses and I performed a bedside ultrasound which showed some cardiac activity. A few minutes after stopping compressions she seemed to regain pulses .We discussed the situation with family .They request that we do not perform CPR any further if we lose pulses. Comfort care measures were started and patient was placed on supplemental oxygen and monitored for discomfort .Patient eventually had loss of pulses and time of death was declared at 4:25 a.m .Diagnosis at time of Disposition (discharge) Cardiac Arrest (heart attack) . Review of Resident #54's Blood Work Results from the emergency roiagnom on [DATE] at 3:11 AM indicated that the Troponin (protein found in heart muscle) level was abnormally high (101), with the normal reference value indicated as <14, and further revealed, There are a variety of reasons Troponin may be elevated, including: Coronary artery disease with atherosclerotic plaque disruption/thrombosis (blood clot), Oxygen Supply/Demand mismatch causing ischemia (inadequate blood flow to heart) .Other conditions causing myocardial (heart muscles) injury . Review of Resident #54's Progress Notes dated [DATE] (no time) by NP I revealed, Nurse called to report patient recently tested positive for COVID on ,d+[DATE]. Tonight, blood sugar is 473 & resident is non-responsive, concern for DKA (diabetic ketoacidosis: life threatening complication related to high blood sugar), nursing reports they only check her sugars once weekly. Also nursing reported unable to get a reading for BP on machine and tried manually but could not hear well but thought was ,d+[DATE], HR 114, with RR (respiration rate) 32 and O2 ,d+[DATE]% on RZ. Concern for possible pneumonia vs PE (pulmonary embolism: blood clot in lungs) as well with recent COVID. offered telehealth visit prior to sending to ER but nursing declined. resident sent to ER. Review of Resident #54's Vital Signs Record indicated at 6:43 AM on [DATE] a pulse of 68 bpm (beats per minute) and then at 6:45 PM on [DATE] a pulse of 114 bpm. These were the last 2 entries. Review of Resident #54's Vital Signs Record indicated at 6:43 AM on [DATE] respirations were 15 breaths/min (minute) and then on [DATE] at 6:45 PM respirations were 32 breaths/min. These were the last 2 entries. 47659 DPS #2 Based on observation, interview, and record review, the facility failed to assess and notify the physician of a skin condition for 1 resident (Resident # 24) of 19 residents reviewed for quality of care, resulting in delayed treatment of a skin condition and resident discomfort, with the potential for worsening skin condition. Findings include: Review of an Admission Record revealed Resident #24, was originally admitted to the facility on [DATE] with pertinent diagnoses which included anxiety and venous insufficiency (improper functioning of the vein [NAME] in the leg, causing swelling and skin changes). Review of a Minimum Data Set (MDS) assessment for Resident #24, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score revealed Resident #24 was cognitively intact. During an interview on [DATE] at 11:26 AM, Resident #24 reported that she had a concern with the condition of the skin on her legs. Resident #24 reported that her legs were constantly itchy, dry, and flaky which was caused her discomfort. Resident #24 reported that she had been dealing with the itchy skin for several weeks. Resident #24 reported that some nurses would occasionally put lotion on her legs, but this was not helping with the itching. Resident #24's skin on her right and left legs were red and irritated with several scabs and dry skin flakes noted. The size of the irritated skin was approximately half of the surface area of each shin. On [DATE] 03:49 PM, this surveyor conducted a review of Resident #24's orders, and found no orders for treating Resident #24's skin condition on her legs. Review of Resident #24's Progress Notes revealed that Resident #24's skin condition on her legs was not addressed by the provider during visits on the following dates: [DATE], [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 3:21 PM, Registered Nurse (RN) T reported that Resident #24 had received several treatments in the past for skin issues on her legs. RN T reported that Resident #24 did not have any current orders for treatment for the skin condition on her legs. RN T reported that she was unaware that Resident #24 was experiencing frequent itching and discomfort in her legs, but that she would let the provider know right away. During an interview on [DATE] at 10:41 AM, Nurse Practitioner (NP) VV reported that she was unaware that Resident #24 had current complaints of frequent itching and discomfort related to the condition of her skin on her legs. NP VV reported that she had not been contacted by nursing staff regarding this concern, and if she had been made aware, she could have ordered a cream to help decrease the itching on her legs. Review of Resident' #24's Total Body Skin assessment dated [DATE] and documented by Licensed Practical Nurse (LPN) Q revealed, .Skin condition: Normal. Number of new skin conditions: 0. During an interview on [DATE] at 2:21 PM, LPN Q reported that he had completed a skin assessment on Resident #24 earlier in the day. LPN Q reported that he had noted discoloration on Resident #24's legs, but that he did not note any new skin conditions in the skin assessment because he did not see any skin conditions that were new. LPN Q reported that he was unaware that Resident #24 had concerns with the redness, irritation, and itching on both of her legs. During an interview on [DATE] at 2:44 PM, Resident #24 reported that RN T did not assess the skin on her legs on [DATE], and that she did not have a skin assessment completed on [DATE] by LPN Q. Resident #24 reported that if nursing staff had completed a skin assessment, she would have mentioned her concerns regarding the skin condition on her legs at that time. Review of Resident #24'sProgress Notes dated [DATE] at 2:55 PM and documented by LPN Q revealed, Resident mentioned to this nurse that she is worried about how long it is taking for her legs to heal. Resident had a venous ulcer (wound caused by abnormal or damaged veins) on RLE (right lower extremity) and venous stasis (conditions in which blood pools, or stands in the large veins of legs) on BLE (Bilateral lower extremity). Staff is currently putting lotion on the legs to help with dry skin. Tiger text sent to provider asking if there is anything that can be ordered for treatment .

Based on observation, interview, and record review, the facility failed to ensure residents received incontinence and wound care consistent with professional standards, and ensure timely communication of alterations of skin integrity/abnormal findings in 1 of 21 residents (#66) reviewed for quality of care, resulting in extreme pain due to worsening of non-pressure wounds, a decrease in ADL's (activities of daily living), lack of assessment, monitoring, and documentation, and the potential for a decline in psychological wellbeing. Findings include: Review of an Admission Record revealed Resident #66 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #66, with a reference date of 8/19/22 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #66 was cognitively impaired. Review of the Functional Status revealed that Resident #66 required extensive assistance of 2 people for mobility in bed. Review of Resident #66's Incontinence Care Plan revealed, .incontinent of bowel r/t (related to) weakness, decreased mobility, and dementia Date Initiated: 02/22/2020 .INTERVENTIONS: Check frequently for incontinence. Wash, rinse and dry perineum. Change clothing after incontinence care as needed Date Initiated: 07/28/2022 . Review of Resident #66's Skin Care Plan revealed, .at risk for impaired skin integrity/pressure injury .Date Initiated: 07/28/2022 .INTERVENTIONS: Assist to reposition frequently as guest allows. Date Initiated: 02/22/2020 .Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Date Initiated: 02/22/2020, Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] & repositioning, Roho (pressure reducing) Cushion to wheelchair Date Initiated: 10/26/2022. During an observation and interview on 11/29/22 at 11:18 A.M. Resident #66 was lying in bed on his back with the HOB (head of bed) at approximately 30 degrees. Resident #66 reported that he had wounds on both sides of his butt from sitting in his own feces for so long and stated, .I have not been changed yet today . During an observation and interview on 11/30/22 at 01:22 P.M. Resident #66 was lying in bed on his back and reported that he was supposed to see the wound doctor that day, but had not. Resident #66 also reported that he had not received incontinence care yet that day. During an observation on 12/01/22 at 09:25 A.M. Resident #66 was lying in bed on his back with the at HOB 45 degrees. In an interview on 12/01/22 at 10:15 A.M., Certified Nursing Assistant (CNA) HH' reported that Resident #66 refused breakfast that morning and said that he couldn't sit up because his butt hurt. In an interview on 12/01/22 11:54 A.M., CNA KK reported that Resident #66 received incontinence care around 6:00 A.M. this morning and stated, .we will do him again before we leave, around 2:00 P.M .his bottom is really bad .he refuses a lot because of how much it hurts . During an observation and interview on 12/01/22 at 01:45 P.M. in Resident #66's room Certified Nursing Assistant (CNA) GG and CNA KK were preparing to perform incontinence care. CNA GG reported (Resident #66's) buttocks were in really bad shape and incontinence care was very painful for the resident. Resident #66 asked the CNA's if he could get up into his chair. CNA KK reported that she did not think it was a good idea in fear that the hoyer sling would cause further pain and injury to the skin on Resident #66's buttocks. Resident #66 was rolled onto his left side and was crying out in pain as his buttocks were separated from the sheet below him. The entire surface area of Resident #66's buttocks was completely denuded (loss of epidermis caused by exposure to urine, feces, bodily fluids, friction, or wound drainage), and actively bleeding. There was no sign of residual barrier cream observed on Resident #66's buttocks. Resident #66 was moaning, crying out and flinching in response to the pain as CNA KK was washing overtop of the buttocks with a soapy washcloth. This surveyor requested that Unit Manager (UM) O was notified immediately. UM O entered the room a few minutes later and reported that she had no idea that Resident #66's wound on his buttocks had gotten that bad and stated, .I did not get any messages about him . CNA GG reported that Resident #66's buttocks had been in that condition since 11/24/22, and also had a stinky green drainage and stated, .I notified the nurse last week . UM O reported that she would immediately call the wound provider. In an interview on 12/01/22 at 2:30 P.M. Licensed Practical Nurse (LPN) OO reported that she had not done any treatments or observed Resident #66's buttock wounds that day. LPN OO was the day shift (6:00 A.M.-2:30 P.M.) nurse and reported that she was not aware of any concerns with Resident #66's bottom. In an interview on 12/01/22 at 03:51 P.M., UM O reported that Resident #66 had been on weekly wound rounds, but was not seen on rounds yesterday, because they only had time to see resident's with pressure ulcers. UM O reported that Resident #66 should have been getting frequent incontinence care and repositioning for comfort. UM O reported that Resident #66 was not receiving any pain management for his wounds, but was currently receiving Tylenol 650 mg every 8 hours for general pain. UM O reported that Resident #66 also had orders for a topical treatment to be applied once every 8 hours, but that he did not have orders for anything to be used between treatments, or after incontinent episodes. UM O reported that she had instructed LPN OO to complete Resident #66's wound treatment after the previous observation. UM O also reported that Resident #66's treatment orders were not accurate and stated that there were currently 3 orders for the same treatment, and the correct one was the most recent ordered treatment on 11/23/22 and stated, .it's confusing .when the new orders were put in, the old one's did not get discontinued . Review of Resident #66's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for a pain level of 0/10. Review of Resident #66's Treatment Administration Record (TAR) revealed, buttock-Cleanse area with NS (normal saline). Apply Triad (wound paste) mixed with house antifungal cream. Apply with every shift. Active 11/23/2022 Scheduled Day, Evening, and Night. There was no record of administration on 12/1/22. This was the current order per UM O. Review of Resident #66's TAR revealed, Triad Hydrophilic (protective) Wound Dress Paste (Wound Dressings) Apply to buttocks topically every shift for MASD (moisture associated skin damage) mix spoonful of triad paste with small amount of [MEDICATION(S)] powder (used to treat fungal infections) & apply generously to buttocks after episodes of incontinence. Do not scrub off. -Start Date- 08/18/2022. Scheduled Day, Evening, and Night. Review of Resident #66's TAR revealed, [MEDICATION(S)] Powder 0 UNIT/GM Apply to buttocks topically every shift for MASD sprinkle small amount of powder into spoonful of Triad paste & apply generously to buttocks after episodes of incontinence. Do not scrub off. -Start Date- 09/05/2022. Scheduled Day, Evening, and Night shift. There was no record of administration on 12/1/22. This surveyor requested all wound progress notes, and assessments for the wound on Resident #66's buttocks. Review of Resident #66's Skin & Wound Evaluations received from NHA indicated that the wound on Resident #66's buttocks (coccyx) was first assessed on 8/23/22, it was facility acquired, present for 1 month, the type of wound was MASD, 2.1 cm x 1.5 cm, bleeding was noted, the surrounding skin was excoriated (superficial loss of tissue) and fragile, there was no pain, the treatment was hydrocoloid (protective) dressing, the wound was healable, and it was noted as resolved. The subsequent assessments were as follows: 9/16/22: MASD, coccyx, present for 1 month, 10 cm x 3.9 cm, bleeding noted, surrounding skin was fragile, no pain, healable, [MEDICATION(S)] dressing, and it was noted as improving. 9/26/22: MASD, coccyx, present for 1 month, 7.3 cm x 1.4 cm, no bleeding, surrounding skin was normal, no pain, [MEDICATION(S)] dressing, and it was noted as improving. 10/5/22: MASD, coccyx, present for 1 month, 3.1 cm x 0.9 cm, no bleeding, surrounding skin was intact, no pain, [MEDICATION(S)] dressing, and it was noted as improving. 10/12/22: MASD, coccyx, present for 1-3 months, 7.4 cm x 3.7 cm, wound bed 50% epithelial covered and 50% granulation filled, bleeding, light exudate (drainage), sanguineous/bloody, surrounding skin denuded, excoriated, and fragile, intermittent pain 3/10, healable, treatment (other), and it was noted as deteriorating. 10/17/22: MASD, coccyx, present for 1 month, 1.7 cm x 0.9 cm, wound bed (no documented), bleeding, no exudate, surrounding skin dry/flaky and excoriated, no pain, healable, [MEDICATION(S)] dressing, and it was noted as stable. 10/26/22: MASD, coccyx, present for 1 month, 8.7 cm x 5.6 cm, wound bed no documented, bleeding, surrounding tissue fragile, no pain, healable, hydroicolloid dressing, it was noted as deteriorating, noted diagnosed as infection, [MEDICATION(S)] (used for fungal infections) added x 3 days. 11/2/22: MASD, coccyx, present for 1 month, 1.8 cm x 0.6 cm, wound bed 50% granulation, bleeding, surrounding skin excoriated, no pain, healable, [MEDICATION(S)] dressing, and noted that it was stable. 11/9/22: MASD, coccyx, present for 1 month, 5.8 cm x 3.0 cm, healable, there was no further description of the wound, and no treatment noted. 11/16/22: MASD, coccyx, present for 1 month, there was no further description of the wound, and no treatment noted. 11/23/22: MASD, coccyx, 1 month, 9.9 cm x 7.0 cm, there was no further description of the wound, and no treatment noted. Review of Resident #66's Total Body Skin Assessments completed weekly from 8/26/22-11/30/22 indicated no new skin conditions.

This citation pertains to intake MI 334 and an FIC survey. Based on observation, interviews and record review, the facility failed to provide adequate supervision to prevent accident for 1 (Resident #121) of 6 residents reviewed at risk for falls, resulting in an immediate jeopardy on [DATE] at 12:45 A.M., when Resident #121 was left unattended after being observed in a restless state, resulting in a unwitnessed fall, where she sustained multiple facial fractures and 2 days later died in the hospital due to complications from the fall. This deficient practice placed all residents requiring supervision at risk. Findings include: On [DATE], Nursing Home Administrator was notified of an Immediate Jeopardy that began on [DATE] when Resident #121, had an unwitnessed fall that resulted in her death 2 days later. On [DATE] surveyors verified the facility completed the following to remove the Immediate Jeopardy. 1. As of [DATE] as of 6:30 pm, 13 of 88 residents fall risk assessment, fall care plans and cardex were reviewed and updated as needed. 2. As of [DATE] as of 10:00 pm, 32 of 95 staff members were educated on fall management policy. The remaining staff members will be educated prior to the start of their next scheduled shift. Those on leave or vacation will be in-served prior to the start of their next scheduled shift. 3. [DATE] as of 6:30 pm, staffing was reviewed to ensure appropriate coverage for resident care needs. Information was pulled from MDS (minimum data set), resident acuity (assistance needed with activities of daily living and transfers) and discussions with staff members. 4. As of [DATE] as of 10:00 pm, 15 nursing staff were educated on sign in/out for breaks to ensure communicate when leaving the unit to ensure that appropriate amount staff is available. Information was pulled from MDS, resident acuity (assistance needed with activities of daily living and transfers) and discussions with staff members to determine that staffing was appropriate and staff are able to breaks. 5. While staff are on break the staff remaining on the unit will round on the unit to ensure resident safety, the staff working the Covid unit will utilize the break room on that unit. Staff on the unit will prioritized the resident's needs and request the staff come off break as needed. 6. As of [DATE] at 4:00 pm, rounds of unit were completed to ensure that resident are being adequately supervised for safety. Observations were conducted to monitor timeliness of answering calls, appropriate amount of staff was present on the hall to meeting residents needs by the information obtained from MDS and discussions with staff members. 7. Administrator is responsible for the implementation of the above enumerated abatement plan. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance with 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 all staff had not received education and sustained compliance had not yet been verified by the state agency. Resident #121 Review of an Admission Record revealed Resident #121 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: COVID-19, lack of coordination, and abdominal aortic aneursym (without rupture). Review of a Minimum Data Set (MDS) assessment for Resident #121, with a reference date of [DATE] revealed a Staff Assessment for Mental Status indicating that Resident #121 was severely impaired. Review of the Functional Status revealed that Resident #121 required extensive assistance of 2 people for transfers and toileting, extensive assistance of 1 person for bed mobility (how resident moves to and from a lying position), and walking did not occur. Review of Resident #121's Care Plan revealed, (Resident #121) is at risk for fall related injury and falls related to: Alzheimer's, Extrapyramidal (involuntary movements) and movement disorder, confusion, poor communication, comprehension, anxiety, history of falls .She often transfers from her bed and ambulates without walker to hallway revision on: [DATE]. INTERVENTIONS: .anticipate and meet needs PRN (as needed). Date initiated: [DATE] .Encourage guest to use her walker when ambulating. Date initiated: [DATE] . Review of a Resident #121's Care Plan revealed, (Resident #121) has an (Activities of Daily Living) ADL Self Care Performance Deficit and requires extensive assistance with dressing, personal hygiene, toileting, and bathing .INTERVENTIONS: BED MOBILITY .Check and make sure guest is fully in bed. She tends to fall asleep with her legs off the bed. Revision on: [DATE] .Resident is independent with transfers. Revision on: [DATE] .Resident does ambulate at times to hallway from bed and uses w/c (wheelchair) .Revision on: [DATE] . Review of a Facility Reported Incident (FRI) submitted [DATE] at 11:10 A.M. revealed, On [DATE] at 10:35 am, (Durable Power of Attorney) of (Resident #121) notified the facility that she had a nose fracture and 14 stitches. On [DATE] at 12:45 am, (Resident #121) was observed on the floor in her room. She was noted to have a laceration to her forehead. Pressure was applied and she was sent to ER for evaluation. (Resident #121) is able to sit her self on the side of the bed independently. Interview with (Licensed Practical Nurse (LPN) X) by (NHA): I had observed (Resident #121) in her bed at 12:30 am when I was going down the hallway to go on break (breakroom is on the hallway). At 12:45 am, (Certified Nursing Assistant (CNA) KK) came and got me due to (Resident #121) being on the floor . Review of Resident #121's Hospital Records revealed, .fell out of wheelchair onto floor, 2 lacerations to forehead with significant blood loss and well as bleeding from nose .Assessment/Plan: .Abdominal aortic aneurysm (AAA) .Closed fracture of nasal bone .Closed fracture of maxilla (jaw) .Hospital Course: .patient had an unwitnessed ground level fall from her wheelchair. She was found lying in a pool of blood due to this she was urgently brought to the emergency room where she was initially quite agitated. She required multiple IV (intravenous) medications for agitation .She had significant findings of multiple facial fractures. She also had a CT (detailed image) of her thorax (chest), abdomen, pelvis. The CT of her abdomen found that her known AAA had enlarged from approximately 5.3 cm to now almost 9 cm in diameter and had signs that were concerning for pending rupture. She was started on comfort care measures while in the emergency room and is resting comfortably now .On ,d+[DATE] at 9:38 a.m., patient was placed on hospice . Patient remained on hospice with both hospice and hospitalist team following until 1321(1:21 P.M.) on [DATE] when this provider was called to bedside to evaluate patient. Patient had died in her sleep with grandson at bedside .Cause of death traumatic from accident and fall complication facial fractures Review of Resident #121's Death Certificate revealed, .Cause of death: Medical complications of facial fractures .Manner of death: Accident .Date of Injury: [DATE] .Describe how injury occurred: deceased fell and fractured bones of the face During an interview on [DATE] at 8:21 A.M., Medical Examiner (ME) PP reported that according to the medical exam performed following Resident #121's death, it was determined that the rapid decline in health status over a 48 hour period was a direct result of the significant fractures that Resident #121 sustained during her fall in the facility 2 days prior. ME PP reported that there was no indication that Resident #104's aortic abdominal aneurysm had ruptured. During an interview on [DATE] at 10:05 A.M., LPN X reported that on [DATE] she was assigned to the COVID-19 hall and the 200 hall and stated, .it was exhausting . LPN X reported that Resident #121 was observed on [DATE] at 12:30 A.M. awake, sitting in her bed, making da-da-da noises and stated, .I did not go in her room .that was normal for her .she gets very restless at night . LPN X reported that she left the hall for break at 12:30 A.M., and then at about 12:45 A.M. CNA KK came and told her that Resident #121 had been found laying on the floor in a pool of blood. LPN X reported that when she arrived at Resident #121 room, she observed more blood than she had ever seen in her life and stated, .there was so much blood .huge clots of blood on the floor . LPN X reported that 911 was called immediately. LPN X reported that Resident #121 gets restless and attempts to get out of bed and into her chair during the night, but is too weak and has fallen several times. LPN X reported that it is very difficult for 1 CNA to monitor all the residents on the COVID-19 hall and stated, .with constant call lights going off .most need 2 people for cares .I always tell them that I need more help . During an interview on [DATE] at 12:51 P.M., CNA KK reported that on [DATE] she was the only CNA working the COVID-19 hall and stated, I was so stressed out .there was close to 30 people .I was so busy .lights were going off like crazy .a lot of wandering people .constantly redirecting people that were trying to leave the hall .a lot of check and changes . CNA KK reported that she had asked CNA BB (who was assigned to 300 hall) to help her try to get caught up, and that CNA BB had been the first to find Resident #121 after her fall. CNA KK reported that she had observed Resident #121 prior to the fall laying sideways in her bed with her legs dangling off the edge and making noises and stated, .when she makes those noises she is agitated .she has to pee .we know to go in and take her to the toilet .she is really hard to transfer .she is a 2 person . Review of the Resident Roster for the COVID-19 hall on [DATE]-[DATE] during the time of Resident #121's fall, provided by NHA, indicated that there were 25 residents on the hall. NHA also indicated that there were four residents with known fall risk, three residents that were known wanderers, and 4 residents that required assistance of 2 people for cares. During an interview on [DATE] at 8:13 A.M., LPN OO reported that she was sitting at the nurses station on 300 hall on [DATE], when CNA KK came running from the COVID-19 hall and yelling for help, saying it was really bad. LPN OO reported that when she arrived in Resident #121's room, she was laying on the floor and there was blood everywhere around her and stated, .I wrapped her head .I couldn't tell where the wounds were . LPN OO reported that she instructed CNA KK to go get LPN X from the breakroom on 300 hall. LPN OO reported that CNA KK was the only CNA assigned to the hall that night and stated, .she needed more help .all the residents were COVID positive and on isolation .she was in rooms for long amounts of time it was an unsafe situation . LPN OO reported that it was her understanding that Resident #121 was independent and stated, .I did not know of her to need extra supervision .I didn't know she was a fall risk or had prior incidents . Attempts to interview CNA BB by phone were made on [DATE], [DATE] & [DATE], with no return call. During an interview on [DATE] at 10:45 A.M., Registered Nurse (RN) HH reported that Resident #121 could transfer herself into her chair or into bed, but not safely. RN HH reported that staff would do frequent checks to ensure she was not attempting to self ambulate. RN HH reported that staff that are not familiar with a resident's care needs would need to look at the care guide in the binder on the hall. Review of Resident #121's Care Guide indicated under the fall risk box bed against wall and in the transfer box independent was selected. Review of Resident #121's Fall Report dated [DATE] at 12:45 A.M. revealed, .Pt (patient) observed on the floor next to her room .Injuries: left waist top buttocks large bruise noted .Describe initial intervention to prevent further falls: frequent toileting, call light within reach, PT (physical therapy) recommended wheelchair instead of walker, but patient walks better with walker, while the wheelchair she constantly forgets and walks without using it. Recommend PT to evaluate for use of walker During an interview on [DATE] at 12:15 P.M., Occupational Therapist (OT) P reported that Resident #121 had been walking prior to multiple falls recently, but recently declined and did not have the cognitive ability to transfer to her walker or wheelchair safely anymore. OT P reported that a couple years ago, therapy had transitioned Resident #121 from her walker to a wheelchair and the last time she was evaluated for transfers was [DATE], and at that time she required 1:1 assistance for transfers. OT P reported that Resident #121 was not evaluated for transfers or ambulation after her fall on [DATE]. Reviewing Resident #121's Care Plan which indicated that she was independent for transfers, OT P reported that Resident #121 could physically stand on her own, but as far as safety goes was not independent due to the risk of falling. OT P reported that she completes a form for the nursing staff and the nurses update care plans. During an interview on [DATE] at 3:45 P.M., DON reported that Resident #121 would frequently sit up in bed and stated, .but if she started talking jibber jabber, then that's when it started to escalate and we would try to intervene before she tried to self-ambulate . DON reported that after Resident #121's fall on [DATE] there were no new interventions put in place. Review of a facility policy Fall Management dated [DATE] revealed, The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Each guest/resident is assisted in attaining/maintaining his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Guests/residents Will be evaluated by the inter-disciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of nursing/designee is responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk evaluation, treatment, evaluation, and monitor of guest/resident falls .

This citation pertains to intake #MI 134. Based on interview and record review the facility failed to provide quality care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of an Admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 6/29/22 at 7:42 A.M., Family Member (FM) VV reported that Resident #104 passed away on 12/21/21 due to a severe infection that she acquired in a wound while residing in the facility. During an interview on 6/29/22 at 8:32 A.M. Hospice Nurse (HN) III reported that hospice had been managing Resident #104's wound care and dressing changes until she admitted to the facility. HN III reported that when Resident #104 admitted to the facility the wound on her coccyx was doing very good and was a Stage 3 pressure ulcer. During an interview on 6/29/22 at 10:39 A.M., Registered Nurse (RN) HH reported that Resident #104 had a wound on her coccyx, Resident #104 did not refuse wound dressing changes, but went on to say that often times wound dressings were not completed as ordered. RN HH reported that the nursing staff had been known to sign off in the record, but not actually perform the treatment and stated, .I know because I have found the dressings I did, still on residents days later . RN HH reported that the concern has been brought to the attention of the DON. During an interview on 6/29/22 at 11:29 P.M., DON reported that she was not aware of a concern with nursing staff completing wound treatments. During an interview on 6/30/22 at 7:39 A.M., Nurse Practitioner (NP) UU reported that Resident #104's wound was deteriorating due to the dying process, but the infection was not expected. NP UU reported that she completed Resident #104's wound evaluations weekly along side of the DON and stated, .when I see a wound declining I do ask questions .I don't review the treatment records, the DON would do that .I was not aware of any missed treatments . NP UU was no longer treating residents at the facility and did not have access to Resident #104's medical record at that time. Review of Resident #104's Death Certificate indicated 3 causes of death, 1). Alzheimer's disease with early onset, 2). [CONDITION(S)] secondary to wound infection, and 3). Pressure Ulcer on Coccyx. Review of Resident #104's Wound Evaluation dated 11/10/21 revealed, Pressure: Kennedy terminal ulcer .Unstageable .Location: coccyx .5.6 cm length x 1.0 cm width . Review of the attached picture revealed a clean, narrow linear wound, with slough (dead tissue) covering the wound bed. Review of Resident #104's Wound Evaluation dated 12/1/21 revealed, Pressure: Kennedy terminal ulcer .Unstageable .Location: coccyx .3.2 cm length x 1.9 cm width .Slough: 50% . Review of the attached picture revealed a round wound with slough and eschar (dry black dead tissue) noted in wound bed. Review of Resident #104's Wound Evaluation dated 12/8/21 revealed, Pressure: Kennedy terminal ulcer .Unstageable .Location: coccyx .7.7 cm length x 2.7 cm width .Slough: 20%, Eschar: 50% .Exudate: light . The wound had doubled in size. Review of the attached picture revealed an obvious decline in the wound size and depth. The entire wound was covered in a crusted eschar and slough. Review of Resident #104's Provider Visit Note dated 12/8/21 revealed, .Wound on buttocks appears to be changing to a deeper wound with slough and eschar present and 3 cm depth to coccyx. Will continue treatments .Staff encouraged to irrigate wound well with dressing changes due to small amount of stool noted in wound . Review of Resident #104's Treatment Administration Record (TAR) for November/December of 2021 revealed, Please cleanse coccyx wound with wound cleanser and pat dry. Apply [MEDICATION(S)] (topical to aid in wound healing) sheet or gel to slough areas and cover with coccyx [MEDICATION(S)] (bandage) and change daily and as needed. Start date 11/11/21 End date 12/15/21 This record indicated that Resident #104 missed 7 of 35 opportunities for the treatment, including 12/4/21, 12/5/21, 12/7/21 and 12/10/21. It was noted that Resident #104's wound significantly worsened on 12/8/21, evidenced by the wound evaluation and provider note. Review of Resident #104's Wound Evaluation dated 12/15/21 revealed, Pressure: Kennedy terminal ulcer .Unstageable .Location: coccyx .3.9 cm length x 2.5 cm width .Slough: 40%, Eschar: 60% .Signs of infection: increase in drainage .Exudate: Moderate, Odor: faint . Review of the attached picture revealed an obvious decline in the wound. The black eschar was more prominent and the surrounding tissue was fragile. Review of Resident #104's Provider Visit Note dated 12/15/21 revealed, .Wound on buttocks appears to be changing to a deeper wound with slough and eschar present and 4 cm depth to coccyx. Will adjust treatments . Review of Resident #104's TAR indicated a change in wound treatment orders, Please cleanse coccyx wound with wound cleanser and pat dry. Pack with Dakins (antimicrobial) full strength soaked gauze, and cover with coccyx [MEDICATION(S)] .BID (two times a day) .Start date 12/15/22 at 8:00 P.M. The record indicated that Resident #104 missed 1 of 10 opportunities for that treatment. Review of Hospice Visit Note dated 12/16/22 revealed, .notified facility RN that the patients wound had significantly deteriorated and seemed infected at this time .Facility RN to address decline in wound status at tomorrows wound care meeting . Review of Resident #104's Provider Visit Note dated 12/17/21 revealed, .Noted with low grade fever and does appear more fatigued. Wound noted with purulent drainage and will start antibiotics to help and monitor . Review of Resident #104's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M.

This citation refers to intake MI# 221 Based on interview and record review, the facility failed to thoroughly assess for signs of life (respirations and pulse) and provide life sustaining Cardiopulmonary Resuscitation (CPR) for a full code resident in 1 of 1 sampled resident (Resident #2) reviewed for CPR, from a total sample of 12 residents, resulting in an Immediate Jeopardy when on [DATE] at approximately 6:00 pm, Resident #2 who had elected to be a full code, was found by RN A to be unresponsive, with no pulse, no respirations, and no CPR was initiated. Resident #2 was eventually transferred to the hospital where he was diagnosed with [CONDITION(S)] and expired with acute [CONDITION(S)] as his cause of death. Findings include: The IJ notification was sent via email and communicated verbally on [DATE] at 2:15 p.m., to the Administrator due to Resident #2 not receiving CPR per his advanced directive. On [DATE] at approximately 1:00 p.m., this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On [DATE], Director of Nursing/Designee began re-education at 3:00 pm with 7 out of 8 Licensed Nurses currently working, regarding Acute Change in Condition, code status, medical emergencies and initiation of CPR. The remaining 19 out of 26 Licensed Nurses will be re-educated by the Director of Nursing/Designee prior to the start of their next scheduled shift. 2. On [DATE], Director of Nursing/Designee assessed 111 residents to ensure a code status was listed on the first page of Point Click Care. Any concerns were addressed immediately. 3. On [DATE], Director of Nursing/Designee completed 1:1 training and completed competency with RN nurse. 4. Beginning [DATE], Facility will complete Code Blue drills quarterly on all shifts. 5. On [DATE], the QA committee reviewed the Medical Emergency policy, Acute Change of Condition policy and CPR policy and they were deemed appropriate. 6. New Licensed Nurse orientation will continue to include Acute Change in Condition, CPR skills, code documentation form, assessing residents for change in condition, and documentation. 7. On [DATE], Director of Nursing/Designee reviewed 26 out of 26 Licensed Nurses' BLS certifications. Any concerns were addressed immediately. 8. On [DATE], Medical Director was notified of the Immediate Jeopardy F678 by the Administrator. An Adhoc QA meeting will be held on [DATE] to discuss the Immediate Jeopardy and removal plan. 9. Director of Nursing/Designee will audit 24 hour report for any codes or change in conditions weekly times 4 weeks, then monthly times 3 months to ensure staff are following assessment and documentation requirements, identifying change of condition, and responding appropriately. Any concerns will be addressed immediately. Findings will be forwarded to the QAPI Committee for further review and recommendations. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance as scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the fact that not all staff had received education and the sustained compliance could not yet be verified by the State Agency. A review of Resident #2's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was transferred to the hospital via EMS on [DATE]. A review of the [DATE] Annual Minimum Data Set (MDS) assessment revealed he scored ,d+[DATE] on the Brief Interview for Metal Status (BIMS) assessment indicating intact cognition A review of Resident #2's advanced directives revealed he was signed a full code by his responsible party on [DATE]. A review of a facility progress note for Resident #2 dated [DATE] revealed, Notified by nursing via phone that patient had collapsed at bedside and was unresponsive to verbal or tactile stimuli. Patient sent to hospital via 911. There were no other nursing notes describing what had taken place prior to Resident #2 being transferred to the hospital. A review of a hospital note for Resident #2 titled, ED (Emergency Department) to Hosp-Admission and dated [DATE] revealed, Patient arrive from (Name of Facility) for chief complaint of [CONDITION(S)] that was first notice by EMS at 6:10 p.m. The patient had approximately 50 minutes - 1 hour of PEA (pulseless electrical activity) arrest . Per EMS, the nursing staff was walking with the patient . he collapsed at 6:02 p.m. At the time when they (Facility staff) called, he had pulses and was breathing however was unresponsive. When EMS arrived he was not breathing and did not have pulses . He is ill-appearing and toxic-appearing . A review of a hospital note for Resident #2 titled, History and Physical dated [DATE] revealed, I did call (Name of Facility) multiple times and was unable to speak with anybody who had information related to this event . A review of a hospital note for Resident #2 titled, discharged as deceased Summary dated [DATE] revealed, date of death : [DATE]. Time of Death: 8:23 AM. Preliminary Cause of Death: Acute [CONDITION(S)] with [CONDITION(S)] (HCC). A review of the EMS Patient Care Report dated [DATE] for Resident #2 revealed, . Circulation: Pulses - carotid - absent. External/skin: cyanotic. Breathing: absent . Mental status: unresponsive . CPR provided prior to EMS care: No . Patient was walking back in his room when he collapsed. Per staff they state he was breathing at the time and they placed him on a nasal cannula and did a nebulizer. They state his sats dropped drastically and did not physically check a pulse but he has a pulse on the pulse ox machine. Upon EMS arrival, pt lying on the floor. Pt is cyanotic, pulseless and apneic . Further review of this document provided the following timeline per EMS: 6:02 p.m. EMS received call. 6:02 p.m. EMS dispatched. 6:13 p.m. EMS at scene. 6:15 p.m. EMS at patient. 6:58 p.m. EMS in transport. 7:16 p.m. EMS arrived at hospital. On [DATE] at 8:34 a.m., an interview was conducted with the Director of Nursing (DON) regarding the events that occurred with Resident #2 on [DATE]. The DON stated, I only know what I've been told. I wasn't here (when the event occurred). When it happened (LPN B) had called me about the incident with (Resident #2). I was told that two of them (staff) had saw him going down. That (RN A) had went into the room. Like he was falling. That (RN A) said he had a pulse and was still breathing. That there was no need for them to call a Code Blue. When asked if she had any concerns about how Registered Nurse (RN) A had acted during the event, the DON stated, (RN A) is an RN and is very experienced. She reacts well. And when it looked like he wasn't coming around they called 911. When asked about the lack of documentation in the medical record about the event, the DON stated, We go over documentation (in training's). I'm just shocked that there is no documentation. On [DATE] at 8:54 a.m., a telephone interview was conducted with Licensed Practical Nurse (LPN) B who was on the unit taking care of Resident #2 at the time of the incident. LPN B stated, So (RN A) had just gotten on to the unit, towards the end of my shift. My shift is done at 6. One of the aides (CNA's), I'm not sure which, called attention to us that he had fallen. (RN A) went in, and I notified the doctor. He didn't talk. He was breathing. I had worked with him over the weekend on breathing and constipation. Over the weekend I watched closely. He looked worn out and tired when he fell . So I got on the computer and did a . text to the Physician. I was dealing with that part and she was in the room. When asked if she had witnessed RN A take Resident #2's vitals, LPN B stated, Yeah, the machine (pulse oximeter) was in the room. When asked if she had witnessed RN A take Resident #2's pulse manually, LPN B stated, I don't recall that. When asked if 911 was called and by who, LPN B stated, I did. I said that he wasn't responding, and I needed them to come and get him. LPN B was asked how much time lapsed between when the Resident became unconscious and when she called 911, and stated, Maybe ten minutes? When EMS arrived I wasn't in the room, I was at the desk charting. Some other nurses came down. We were waiting. Because of the weekend and the way he was breathing I was concerned he might need oxygen and that he might take a turn. I grabbed the crash cart, but I realized we didn't have a part of it, so I sent a CNA down to get it from another unit and other nurses came down. They were all congregated outside the room. Two other nurses bent down by him and said he wasn't breathing. I believe I went back to the phone to find out what was going on (with the EMS). When asked which nurses she had witnessed saying that Resident #2 wasn't breathing, LPN B stated, (RN A) and um (LPN C) and (LPN E). Or maybe they said that they couldn't find a pulse. On [DATE] at 9:02 a.m., a telephone interview was conducted with RN A. When asked about the events of Resident #2 being sent out on [DATE] revealed, I've been very busy. I've been there the last 4 nights and my recall is not good. He fell , actually he was walking in his room. He went down at the end of his bed . in a sitting up position. I was with him. And (LPN B) went and called the doctor and the ambulance . I had him, I was supporting his back and I believe two aides were with me. We put the oxygen sat on (pulse oximeter) . I believe he had oxygen in the room . I hadn't seen him in like two weeks . We gave him oxygen. His O2 (oxygen) was on the lower side and the pulse rate was first I believe tachy and then it stabled off in the 70's. I may have given him a breathing treatment, to make sure there wasn't any secretions . His O2 went down to the 80's or 90's, and then the 70's and started dropping. When asked if she taken Resident #2's pulse manually, RN A stated, No, because I was supporting him. But we had the (pulse oximeter) on him. When asked how Resident #2 appeared, RN A stated, . When we set him up and put the oxygen on his color appeared better . his breathing would have been shallow. I was holding him up and holding the neb mask on his face. RN A stated,On the pulse ox it at first it was like 130 (pulse), it was up there. Then it started to decrease, in the 40's. I believe actually that was right before the ambulance came. He essentially had a pulse rate on the (pulse oximeter). When asked if any other nurses had been in the room, RN A stated, No, not at that time. In the period of ,d+[DATE] minutes I was in there giving him the breathing treatment. No one came in. When asked what happened when the other nurses did show up, RN A stated, It seemed like everybody came at once. All I know is that I was there with him holding his back and I was patting his back. When asked if any other nurses had come in and assessed Resident #2 to have no pulse, RN A stated, I'm trying to remember. They weren't there the whole time. If she (LPN E) saw that (Resident #2) didn't have a pulse then she should have called a code. I was more focused on him. When his pulse went down into the 40's I went and got the board, the crash board. And then he was layed down on the ground. Then the EMS was there, all at about the same time. When asked who RN A left to watch Resident #2 while she left the room, RN A stated, I have no idea. I cannot say. When asked if she left Resident #2 alone, RN A stated, I don't think so. So I grabbed the backboard so we could start CPR. When asked if Resident #2 had ever stopped breathing or had no pulse, RN A stated, I don't think he would have considering I was monitoring the machine. When asked if EMS was with the Resident when she came back to the room, RN A stated, I can't say. I can't say they were there at that exact moment. When asked if at that time Resident #2 was without a pulse or not breathing, RN A stated, I would say no, but I can't say that he had no pulse. When asked if she observed any staff attempt CPR, RN A reported she had not. When asked if a code blue was called, RN A reported it had not. RN A reported that she called the DON to inform her of the events that had transpired. On [DATE]/21 at 10:58 a.m., a telephone interview was conducted with the Manager of the EMS company/EMS G. EMS G was asked about the concerns that were reported from the EMS H form the run on [DATE] to transfer Resident #2 to the hospital. EMS G stated, (EMS H) is on vacation right now, but this is a call that I talked to her about afterwards. She had concerns when they arrived. They had received a call for a nonresponsive. She said (when they arrived) there were no staff around to let them in. When they got to the patient he was laying in bed, cyanotic with a non-rebreather mask on, which just blows oxygen. She said there was just one staff waiting in the room. When she (EMS H) told the staff that it didn't appear that he (Resident #2) had a pulse the staff told them that he had had a pulse when they put the mask on him, and that it had been on for 'a while'. They couldn't give a timeline to EMS H about what had happened. She said that the staff were very frustrated with her questioning them, and that the nurse on the hall kept leaving. The biggest issues were the unknown down time, and that staff had been there most of the time and hadn't checked manually for a pulse or given CPR. On [DATE] at 11:25 a.m., a telephone interview was conducted with LPN E. When asked what she recalled from the event on [DATE] with Resident #2, LPN E stated, Basically I was not on that hall. It was the end of the shift. Another nurse came to take over for me. We were doing report and someone came down the hall, a CNA or two and somebody asked about a crash cart. The nurse coming on for report asked what happened, and they said that (Resident #2) . that something was wrong. That was the point where (LPN C) and I went to she what was going on . We went down to the room. He was sitting on the floor in a seated position with a CNA behind him holding him upright. (RN A) was in the room . They had hooked him to a nebulizer, and at this time he had a pulse ox on his finger, but it wasn't on all the way. I tried to find a pulse and couldn't find one. (LPN C) also went to try and find a pulse. I called out for a stethoscope because there wasn't one in the room. At that point (LPN C) called yelled that she can't find a pulse. (RN A) was saying that he had a pulse and that she had assessed him. I said, 'has anyone called 911?' Someone at that point was in the process. There was a big debate about initiating CPR. At that point (LPN B) came into the room . I don't remember her being in the room too much. At this point (LPN C) and I left the room, since the ambulance was coming and they felt that he had a pulse. As I was walking back to my unit that was when I left the EMS come in. When asked how Resident #2 had looked physically at this time, LPN E stated, He was limp. He had an off color. Grayish blue color to him. When asked if she had witnessed Resident #2 breathing, LPNE stated, No. That was the problem. That was why I was upset. I didn't even know that a code was happening. I guess they didn't feel it was an actual code. On [DATE] at 11:33 a.m., a telephone interview was conducted with LPN C regarding the events of [DATE]. LPN C stated, When I came in I noticed the crash cart. One CNA ran over for an ambubag (device to provide breathing assistance). We went to see what was going on. They had the gentleman (Resident #2) hooked up to a breathing treatment. (RN A) was the one taking care of him. When asked if she found Resident #2 with a pulse or breathing, LPN C stated, I didn't think so, but (RN A) said that he did (have a pulse). I went to the door to let the EMS in. LPN C confirmed that she witnessed no staff attempt CPR and that a Code Blue had not been called. On [DATE] at 12:00 p.m., a follow up telephone interview was conducted with LPN B. When asked about what time they had witnessed Resident #2 falling unresponsive, LPN B reported it was towards the end of her shift, and likely around 5:,d+[DATE]:50 p.m. When asked if she witnessed anyone other than EMS attempt CPR, LPN B stated, No. When asked if she had discussed calling a Code Blue with RN A, LPN B stated, No, because nothing was said about him not breathing or having a pulse. It just looked like he needed to go out. When asked why then she had gone to get the crash cart, LPN B stated, When he first fell I put it over there because he'd been sick over the weekend. When asked what she had done when she heard LPN C and LPN E state that Resident #2 had no pulse, LPN B stated, I just froze, and I went to call (The DON) and find out what was supposed to happen in that situation. On [DATE] at 12:32 p.m., a telephone interview was conducted with CNA K about the events that occurred with Resident #2 on [DATE]. CNA K stated, Yes I was on that hall. It was a scary time, overwhelming for me and the (other) CNA's. I don't think the proper procedures were taking place. It was (RN A) and (LPN B) was the nursing getting ready to come off the unit. It was (RN A) I think that told me (Resident #2) needed to be cleaned up because he (defecated). I went in the room with the wash clothes. I seen him walking with the walker in the room while I was getting the wash cloth wet. He almost got to the other side and collapsed, and I was like 'Oh my . Help! Help! Somebody!' I eased him down and everyone came rushing in. (RN A) had me get a glove with water in it. A blue glove. I don't know why (she asked me to do that). I assumed the nurse (RN A) would give CPR. I was the one sitting behind him, holding him up with the vital machine hooked up. I said (to RN A) 'you need to do CPR his head is falling over' but she said that he had a pulse. We were trying to find a pulse (manually) but we didn't find a pulse, but per the machine he had a pulse. She (RN A) was pounding on his chest and back and yelling '(name of Resident #2)!' I kept telling her to do something. LPN B popped her head in (the room). I think she thought that (RN A) was doing CPR. The crash cart came in at some point. (LPN C) and (LPN E) came in . they were asking why she (RN A) didn't do CPR. When asked if RN A left her alone in the room with Resident #2, CNA K stated, I think she did. I was with the Resident (#2) when she left to try to get the board. Some of the other CNA's were in there with me. I was with him (when the EMS arrived). I remember them coming in, hooking him up, laying him flat, and starting CPR . I've been a CNA for [AGE] years and I know what should be done (in that type of event). On [DATE] at 1:50 p.m., a telephone interview was conducted with CNA L regarding the events on [DATE] with Resident #2. CNA L stated, I knew (CNA K) was going to come over (to relieve me). I waited ,d+[DATE] minutes, and then I went over there. I was asking for (CNA K) and they said that she was in with (Resident #2) . (RN A) was working and she was rushing everywhere. She (CNA K) said 'He's not breathing' and that (RN A) said to put the medicine mask on (Resident #2). I said 'If he's not breathing we need to call a code blue' and she (CNA K) stated, 'no, she told me not to do that.' CNA L reported she saw no staff attempting to give Resident #2 CPR and that no Code Blue was called. On [DATE] at approximately 2:00 p.m., the Administrator and the DON were asked about the situation and reported that they had not been aware that Resident #2 had been found without a pulse. The DON and Administrator reported that they were not aware that the policy had not been followed. A review of a facility policy titled, Medical Emergency Management dated ,d+[DATE] revealed, . 4. Once a medical emergency is identified, qualified staff evaluates the guest/resident, initiates the appropriate emergency procedure(s), and calls Emergency services 911. The staff continues to provide care and monitor the guest/resident until the emergency personnel arrive. A review of the facility policy titled, Cardiopulmonary Resuscitation (CPR), Two Person dated [DATE] revealed, . Assess the patient to determine unresponsiveness . If the patient is unresponsive shout for nearby help and activate the emergency response system . Check to see whether the patient is apneic or only gasping (as opposed to regular breathing) and, if able, check simultaneously for a pulse to minimize delay in detecting [CONDITION(S)] and initiating CPR. To do this, place your index and middle fingers in the groove between the patient's trachea and the stenoclediomastoid muscle (as shown before) . If the patient is breathing normally and has a pulse, monitor closely until until the emergency response team arrives .

This pertains to intake number (s) MI 619, MI 620, MI 356 and MI 348. Based on observation, interview and record review the facility failed to prevent elopement and ensure safety in 2 of 17 residents (Resident #111 and #112) reviewed for safety/supervision, resulting in an Immediate Jeopardy when 1). on 7/8/20, Resident #111 (with a known elopement risk) exited the facility unbeknown to facility staff, and was found approximately 5 hours later lying in tall grass approximately 25 yards from the facility, and 2). on 7/4/20 at approximately 11:45 A.M., Resident #112 (with a known elopement risk) exited the facility unbeknownst to facility staff, and was found by a member of the community approximately 30 minutes later. This deficient practice placed 14 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. On 7/29/20 at 2:16 P.M., NHA A was notified and received written notification of the immediate jeopardy that began on 7/4/20 due to the facility's failure to implement safety measures to prevent the elopement of and ensure residents at risk for elopement (Resident #111 and #112) were safely returned to the facility after an elopement. On 8/6/20, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Immediately upon arrival back to the facility after being assessed at the hospital (Resident #112) was returned to the facility. (7/4/20 1700) Her wander- guard remains on her and is functioning properly. She remained on bedrest the remainder of the evening. On 7/5/20 at 7 am upon rising (Resident #112) was put on 15 minute checks until it was discontinued on 7/7/20 upon discussion by the IDT (interdisciplinary team) and NP (nurse practitioner) as the resident was not exhibiting exit seeking behaviors. However, on 7/13/2020 she began to exhibiting exit seeking behaviors once again and was put back on 15 minute checks and her care plan was updated. The wander- guard was added to the care plan and her face sheet and photo was added to the elopement book on 7/6/20 Monday. Elopement books are kept at the front office and on each nurse's station. 2. On 7/8/20 The Nurse completed an assessment Immediately upon returning into the facility for Resident #111. The Nurse completed a more complete head to toe assessment of (Resident #111) in the shower room. His VS were stable neuro checks were normal. Wander guard was functioning properly and 15 minute checks initiated on 7/8/20 and are ongoing due to continuing to exit seek. 3. CNA NN checked on 7/4/20 all the exit doors and all residents who have wander guards on and all were functioning properly. This was in addition to our policy in which the nurses check wander-guards for functionality daily and placement every shift 4. CNA NN checked on 7/4/20 all windows and all were functioning properly - all [MEDICATION NAME] were in place. 5. Housekeeping supervisor finished an inspection of all windows [MEDICATION NAME] on 7/9/2020 to ensure windows and [MEDICATION NAME] are functioning properly. Audits are being completed weekly. As of 7/9/2020 NHA A checked on 7/8/20 all the exit doors which were functioning properly upon her arrival to the facility at 12:30 am 6. The DON (Director of Nursing) on 7/6/20 verified that no other residents were on 15 minute checks. Then (Resident #111) was placed on 15 minute checks on 7/8/20. 7. The ADON (Assistant Director of Nursing) began education for all staff on Elopement policy which includes when to call a code search or W, what to do when an alarms door goes off, what to do when a guest is exhibiting exit seeking behavior. On 7/9/20, 63 out of 119, staff were educated the remainder of employees will be reeducated upon arrival to work before reporting to their assignment. On 7/24/20 113 out of 119, staff have been educated, the remaining 6 are either on FMLA (family medical leave act) or PRN (as needed) and will be educated upon the first day they work. 8. Per Elopement policy, which was educated with all staff, residents who are actively exit seeking are to have an incident report completed with exit seeking. Wander guard to be applied, added to Missing Guest Book and reviewed by Interdisciplinary team for further interventions and update of care plan to reflect intervention. 9. The DON/ Designee reviewed all guests for elopement risk on 7/7/20 during the morning stand up. The IDT did not identify any other guests at risk for elopement, just the original 15 with (Resident #112) added to the list. On 7/9/20 all 106 residents were reassessed for elopement risk utilizing the evaluation tool in (electronic health record). 10. The Administrator and QA (Quality Assurance) committee reviewed the missing guest policy and deemed it appropriate during the QA meeting 7/24/20. 11. SW (Social Worker) audited the elopement books and deemed them to be updated and accurate on 7/6/20 and 7/9/20. They are reviewed weekly at clin-ops meeting and as needed. 12. New employee orientation will continue to include the missing guest policy and procedure education 13. Starting 7/9/20, Administrator and DON will audit guests at risk for elopement weekly times 4 weeks then monthly times 3 months to ensure staff are following the policy. Any concerns will be addressed immediately. Findings will be forwarded to the QAPI committee for further review and recommendations. 14. Maintenance Director/Designee checks the all alarmed doors 7 days a week to ensure functioning properly which has always been part of Preventative Maintenance program. Any concerns will be addressed and findings submitted to QAPI committee for review and recommendations. 15. Code search drills were held on 7/10/20, 7/14/20 and 7/20/20. 16. Door screener was relocated to facing the front entrance door, able to see down the road on 7/9/20. 17. Medical Director made aware of the elopements on 7/7/20. 18. Incidents reviewed in QAPI meeting on 7/24/20 but were reviewed with IDT on 7/6/20 and 7/8/20. 19. The Department Heads under the direction of the DON began re-education on 7/31/20 for all staff on Exit seeking behaviors and what to do who to notify etc. which includes when to call a code search or W, what to do when an alarms door goes off, what to do when a guest is exhibiting exit seeking behavior. New education began on 7/31/20 on abuse and reporting immediately to the administrator all verbal and physical allegations of abuse, neglect, misappropriation and the policy was re-shared, the importance of not moving a resident before assessed by a licensed nurse and if unable to assess then call emergency services, discussion on importance of knowing where your residents are at all times and visualize them at beginning of shift, end of shift and at least every two hours provide care per the CP (care plan). The Social Media Policy was also reviewed. On 7/31/20, 38 staff out of 114, staff were educated the remainder of employees will be reeducated upon arrival to work before reporting to their assignment. Although the immediate jeopardy was removed on 7/31/20, the facility remained out of compliance with 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 all staff had not received the inservice education and sustained compliance had not yet been verified by the state agency. Findings include: Review of a facility document Elopement policy Revised 8/2019 revealed, It is the policy of this facility to the extent reasonably possible, the elopement of guests/residents from the facility .It is the responsibility of all personnel to report any guest/resident attempting to leave the premises, or suspected of being missing, to the licensed nurse and to document the occurrence . Procedure: .8. Rounds of all guests/residents are made at the beginning of the shift, at meal times, and at the end of the shift at a minimum by direct care staff and licensed nurses. CNA (Certified Nursing Assistant) .or nurse can achieve this through the medication administration pass, meal time passes, and during care rounds. Alarm activation: 1. if an employee here's a door alarm, he or she should: a. Immediately go to the side of the alarm; b. If a guest/resident is observed attempting to exit the facility, follow the steps outlined below for attempts to leave the facility; c. If no guest/resident is found to be exiting the facility, the employee should walk outside; conduct a visual observation of the immediate area to ensure that a guest/resident has not already exited the facility. If no guest/resident is observed, then the staff member will return into the building; 2. In situations where the alarm sounds and a guest/resident is not found to have exited: a. Notify the licensed nurse immediately, and b. Ensure that a headcount is completed to ensure that all guests/residence are accounted for. Guest/resident attempts to leave the facility: 1. If an employee observes a guest/resident attempting to leave the facility, he or she should: a. Be courteous and preventing the departure and assist in returning the guest/resident to the facility; b. Obtain assistance from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the licensed nurse or director of nursing services that a guest/resident is attempting to leave the facility and/or the guest/resident has left the facility. c. Complete an incident report. E. Review the current elopement risk and reevaluate if needed. 2. If a guest/resident leaves the facility, upon return the director of nursing or licensed nurse should: a. Notify the administrator; B. Examine the guest/resident for injuries . Resident #111 Review of an Admission Record revealed Resident #111 was a 78 -year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]., delusional disorder, visual hallucinations and [MEDICAL CONDITIONS]. Review of a Minimum Data Set (MDS) assessment for Resident #111, with a reference date of 6/24/20 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #111 was severely cognitively impaired. Review of the Functional Status revealed that Resident #111 required supervision and 1 person physical assist for transfers and walking, required extensive assistance of 1 person physical assist for toileting and personal hygiene, and his balance was not steady during transitions and walking with an assistive device walker. Review of a Care Plan revealed, NEED: (Resident #111) is at risk for fall related injury and falls R/T (related to): [MEDICAL CONDITIONS] and collapse, repeated falls, muscle weakness, [MEDICAL CONDITION], dementia, hx (history) of falls, impaired vision, unsteady gait, potential medication side effects, hallucinations and delusions, lack of coordination, abnormalities of gait and mobility, [MEDICAL CONDITION] and [MEDICAL CONDITION], incontinence . (Resident #111) has been known to sleep walk .Date Initiated: 06/27/2019 . INTERVENTIONS: .Increased supervision, Neuro's (neurological assessment) Date Initiated: 12/05/2019 .Keep the resident's environment as safe as possible with: even floors .adequate lighting; .Date Initiated: 06/27/2019 .Remind to always use walker Date Initiated: 02/14/2020 .To have guest in populated area and floor clear of clutter. Date Initiated: 02/17/2020. Review of a Care Plan revealed, NEED: (Resident #111) is at risk for Exit seeking R/T: confusion secondary to dementia .Date Initiated: 07/01/2019 .INTERVENTIONS: 7/8/20 15 minute checks initiated. Date Initiated: 07/09/2020 .Apply wanderguard (a bracelet worn that triggers an alarm to sound at exit doors) per order. Check placement, function and expiration date per facility protocol. Date Initiated: 07/01/2019 .Approach in a slow, calm manner and redirect away from exit doors as needed. Date Initiated: 07/01/2019 .Assess for fall risk per facility policy. Date Initiated: 07/01/2019. Distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversation etc .Date Initiated: 07/01/2019 . Provide reassurance/Redirect as needed when in an area resident should not be in. Use a calm approach. Date Initiated: 07/01/2019 .Provide structured activities, toileting, walking inside and outside with supervision as needed. Date Initiated: 07/01/2019. Review of an Incident Report completed by Registered Nurse (RN) G on 7/8/20 at 12:20 A.M. revealed, (Resident #111) .Type of Occurrence: Elopement .Injury: Abrasions .Location: Outside of building .Caregiver: (Certified Nursing Assistant (CNA) D). It was noted that the report did not accurately reflect the day and time of Resident #111's elopement, but instead indicated the day and time that Resident #111 was found and returned to the facility. Review of Facility Reported Incident (FRI)/5 Day Investigation Report submitted on 7/15/20 revealed, .On 7/8/20 at 12:00 A.M. a code search was called .Resident #111 was located at 12:20 A.M .The facility is able to substantiate that (Resident # 111) had exited the facility without staff's knowledge. Upon staff identifying that (Resident # 111) was not in the building, a code search was called at 12:00 AM and he was located at 12:20 AM on the east side of the building over the fence. He was located lying on the ground. Upon reentry into the building, it was noted that his wanderguard did set the alarm off. RN G did complete a head to toe assessment and observed several abrasions to his right knee, left shoulder and on top of his head. (Resident # 111) did report that he had fall (sic) and that it was a robbery and they threw him over the fence . The facility was not able to identify how (Resident #111) exited the facility, per investigation no staff members on the 300 hall had heard or turned off the alarm door by the B-side nurses. It was noted that the nurse did not complete an assessment of any kind, prior to Resident #111 being transferred into his wheelchair and returned to the facility. During an observation on 7/28/20 at 4:26 P.M., Resident #111 observed in hall near exit door attempting to exit the facility, and being redirected by Assistant Director of Nursing (ADON) I and CNA E. During an observation on 7/30/20 at 1:04 P.M., Resident #111 was walking, unsteady and slow in the hall with a walker. Observed wanderguard bracelet on Resident #111's right wrist. During an interview on 7/29/20 at 9:08 A.M., Nursing Home Administrator (NHA) A reported that staff realized that Resident #111 had exited the facility at approximately 12:00 A.M. on 7/8/20 when CNA E noticed his unattended walker by an exit door. NHA A reported that a resident search was started immediately and stated, .at 12:20 A.M. (Resident #111 ) was found outside .25 yards from smoke door on other side of white fence .he was lying on the ground .we do not know how long he was outside .(RN G) did an assessment and there was no reason to send him to the hospital for an evaluation . NHA A reported that Resident #111 had a functioning wanderguard at the time of elopement and staff were all aware that he was an elopement risk. NHA A stated, .staff said that they did not hear a door alarm or turn one off . NHA A concluded that she did not know what procedure failed with this elopement or how Resident #111 exited the facility without staff knowing. During an interview and observation of the door alarms on 7/29/20 at 10:00 A.M., Maintenance Director (MTD) OO tested the alarm on exit door #7 on 300 hall by B nurse's station (this was where Resident #111's walker was found unattended the day he eloped). This surveyor observed an audible alarm at the door and at the nurse's station. This surveyor did not observed an audible alarm when present half way down 300 hall. MTD OO stated, this door only alarms at this nurse's station .if you are in a resident's room, the alarm is not audible .the staff would not hear it . During an interview on 7/30/20 at 2:04 P.M., CNA D reported that she had worked 7/7/20 from 2:00-10:30 P.M. and was assigned as Resident #111's caregiver on 300 hall. CNA D reported that Resident #111 had tried to exit the facility about 5 times that day, and that he was very agitated. CNA D stated, .the last time that I saw him was about 8:00 P.M .when I tried to change him, but he was agitated, therefore I decided to reapproach at a later time . CNA D reported that Resident #111 was her last person to put to bed at 9:00 P.M. and stated, .when I didn't see him at 9:00 P.M., I just thought he was wandering around and calming down .I did not try to find him .I did not have time to get to (Resident #111) . CNA D reported that she reported off to RN G at shift change, but did not inform RN G that Resident #111 had not be provided care during her shift. CNA D reported that she did not provide any water, snacks, toileting or incontinence care to Resident #111 during her shift. During an interview on 7/30/20 at 3:18 P.M., Confidential Informant PP stated, .the day that (Resident #111) got out .I noticed his walker at the door between 7:00-7:30 P.M .I assumed he had left it there . During an interview on 7/29/20 at 3:36 P.M., CNA E reported that she arrived on 300 hall to cover CNA F for a break at about 12:05 A.M. on 7/8/20 and noticed Resident #111 was not in his room and his walker was parked near the exit door on 300 hall by the nurse's station. CNA E reported that the staff assigned to 300 hall were CNA F and RN G and when asked could not indicate Resident #111's whereabouts. CNA E reported that she went outside to search for Resident #111 and stated .I called out loudly for him .I heard him moaning in the distance .I found him laying in the tall weeds about 10 feet from the fence .no one would have ever seen him .he was not moving .he was covered in grass and prickers .he couldn't stand .his head was bleeding .he had one shoe on .his clothes were soaked with urine . CNA E reported that CNA E and CNA F waited by Resident #111, while RN G when to retrieve a wheelchair, but that it was taking too long, therefore CNA E and CNA F picked Resident #111 up by his arms and legs and carried him towards the sidewalk, where they were met by RN G with a wheelchair. CNA E reported that RN G did not visualize Resident #111 prior to him being transferred into the wheelchair. During an interview on 7/30/20 at 11:59 A.M., CNA F reported that she was working 300 hall by herself and she was assigned to Resident #111's care during the time that he was determined to be missing on 7/7/20 between 11:30 P.M-12:00 A.M. CNA F reported that she arrived to work that day at 6:00 P.M. and stated, .(Resident #111) wasn't in the hall when I went on break at 9:00 P.M I am assuming that he was already outside at that time . CNA F reported that she was not aware that Resident #111 was at risk for elopement and was not aware that he was wearing a wanderguard. CNA F stated, .I don't usually worry about elopements .unless I hear a door alarm .I would just have assumed that he was in bed sleeping . CNA F reported that she was not made aware that Resident #111 had not received care that evening. CNA F reported that she was doing her rounds and had not made it to care for Resident #111 before CNA E asked about his whereabouts just before 12:00 A.M. CNA F reported that she and CNA E searched outside for Resident #111 and stated, .we followed his voice and found him .he had somehow gotten over the fence and was lying in the weeds .his shoes were off .he couldn't move himself .he had a scrape on his head .he kept saying that he was afraid .we rolled him over and arm and legged him to get him out of there . During an interview on 7/30/20 at 4:01 P.M., RN G reported that she was not aware that Resident #111 was exit seeking on 7/7/20 during 2nd shift. RN G stated, .I had heard door alarms constantly that night .I had given (Resident #111) medicine at the beginning of the shift around 7:00 P.M he was sitting by the nurse's station .he was wet and I had asked (CNA D) to change him .she later told me that he was resistant .I did not see him at all after that .there was no reason for me to think he was exit seeking . RN G reported that she did not follow up with CNA D nor did she ensure that Resident #111 had been provided incontinence care. RN G reported that CNA E asked about Resident #111's whereabouts around 12:00 A.M. and that was when a search was started. RN G reported that she initially went outside and didn't see Resident #111, but then later went outside again with CNA E and CNAF and they were able to determine that Resident #111 was somewhere on the other side of the fence in the tall weeds. RN G stated, .as soon as (Resident #111) answered us, I went inside to get a flashlight and a wheelchair .I couldn't see him .it was too dark back there .by the time I got back with the wheelchair the CNA's had found him, and had carried him to the sidewalk .he was disoriented .we brought him right to the shower .I didn't know about his abrasions on head and shoulder until we got him cleaned up . RN G stated, .there was no way for me to assess him in the weeds . RN G reported that she was not sure if Resident #111 had hit his head or how he had gotten the abrasions on his head. RN G reported that she was concerned about Resident #111's hydration because it was hot outside and she didn't know how long he had been outside and without fluids. RN G reported that she paged the on call physician group, but did not hear back from them. RN G stated, .I don't remember if I called them again .I had other duties that night . RN G reported that she did not find a reason to send Resident #111 to the hospital for evaluation. During an interview on 7/30/20 at 12:45 P.M., regarding Resident #111's elopement, NHA A reported that RN G should have taken the responsibility to supervise an exit seeking resident and stated, .she did not do that .I don't know what she did or tried to put in place .I haven't asked her . NHA A reported that staffing at the time of Resident #111's elopement was not sufficient to provide 1:1 supervision to a resident that is exit seeking. NHA A reported that she is aware that there are staffing issues in the facility and stated, .staffing could have contributed to Resident #111's elopement . Resident #112 Review of an Admission Record revealed Resident #112 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 #112, with a reference date of 5/23/20 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #112 was cognitively impaired. Review of the Functional Status revealed that Resident #112 was independent with transfers, walking and locomotion on and off the unit. Review of a Care Plan revealed, NEED: (Resident #112) is at risk for fall related injury and falls R/T: dementia,[MEDICAL CONDITION](high blood pressure), DM2 (diabetes), dizziness and giddiness, abnormalities of gait and mobility, chronic pai[DIAGNOSES REDACTED], OA ([MEDICAL CONDITION]), sleep apnea, muscle weakness, difficulty walking, alzheimer's Date Initiated: 06/27/2019 INTERVENTIONS: Keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position Date Initiated: 06/27/2019. Review of a Care Plan revealed, NEED: (Resident #112) has a dx (diagnosis) of major [MEDICAL CONDITION]. She has a hx of expressing [MEDICAL CONDITION], ie doesn't want to live anymore, wishes she could fall asleep and not wake up, feels she has no purpose now. Has voiced having no plan to harm self or take her own life .Date Initiated: 07/01/2019 INTERVENTIONS: Should resident be expressing a desire to harm self or others provide 1:1 monitoring, follow suicide protocol and report to physician immediately. Date Initiated: 07/01/2019. Review of an Incident Report completed by Licensed Practical Nurse (LPN) QQ on 7/4/20 revealed, Location: family room .Elopement .Activity before: ambulation .(Resident #112) exited the building via the window .CENA (certified nursing assistant) assigned: CNA P . Multiple attempts were made to contact CNA P for an interview, all were unsuccessful. Review of FRI 5 Day Investigation Report submitted on 7/13/20 revealed, .Elopement .On 7/4/20 at around 12:15 PM, the facility was notified by the police that (Resident #112), was out of the facility and an ambulance has been called .Wander guard was applied at 10:30 AM prior to the elopement due to exit seeking. (Resident #112) was located by a neighbor who contacted the police .Review of environment and surroundings-the facility did identify that the window in the family room was fully open, screen was sitting on the floor and the [MEDICATION NAME] was sitting on the windowsill .(Resident #112) was located .5 miles from the facility .Conclusion: the facility is able to substantiate that (Resident #112) eloped from the building without staff aware. Staff had been redirecting her from exit doors in the morning and a wander guard was applied at 10:30 AM to the right ankle. The last time that staff observed (Resident #112) was at 11:45 AM which was confirmed by (CNA RR), who redirected her from the front door. At 11:45 AM (Housekeeper (HSK) CC) brought a chair into the family room and noticed the window was open all the way, screen was sitting on the ground and [MEDICATION NAME] was sitting on the windowsill. HSK CC did notify LPN QQ who instructed her to put it back in .Per interview with (neighbor), the facility was able to identify that (Resident #112) walked down (road) which dead ends into the facility. (Resident #112) did not need to cross in front of any window and would not be visible by any staff members due to it was lunchtime and they were feeding and passing out lunch trays . The facility is able to substantiate that no code search was called per the elopement policy. LPN QQ was terminated due to not following policies and procedures for elopement. The facility is able to substantiate that (Resident #112) did leave the building without staff knowing. During an observation and interview on 7/29/20 at 12:36 P.M., Resident #112 was lying in her bed with her eyes open. Resident #112 pleasantly reported that she doesn't use her call light and prefers to stay in her room. During an interview on 7/30/20 at 2:45 P.M., NHA A reported that prior to Resident #112's elopement on 7/4/20, LPN QQ was aware that Resident #112 was actively exit seeking and had threatened to harm herself. NHA A reported that LPN QQ failed to ensure that Resident #112 was closely monitored and that LPN QQ had been terminated from employment as a result. During an interview and observation on 7/29/20 at 10:39 A.M., Maintenance Director (MTD) OO reported that Resident #112 had disassembled the lock and exited through a window in the family room on 7/4/20. Observation of the said window to be approximately 24 inches from the ground which was covered with rocks and lead to a driveway approximately 10 feet from the window. During an interview on 7/29/20 at 12:44 P.M., Housekeeping Staff (HSK) CC reported that on 7/4/20 at approximately 11:45 A.M. she had noticed that it was very humid in the family room, noting that the window and screen had both been removed from the window. HSK CC stated, .I reported it to the nurse (LPN QQ) .I told (LPN QQ) that the screen was out .he was on the phone and mumbled something about (Resident #112) trying to get out .then told me to put the window back together . HSK CC reported that LPN QQ did not ask about Resident #112, nor did he observe the window. HSK CC stated, .it never occurred to me that (Resident #112) would have gone out through the window .I thought she had just been messing with stuff .I did not call a code or search for residents . Review of a Statement written by LPN QQ revealed, On 7/4/20, (Resident #112) began exit seeking early and tried all exit doors. I alerted staff to this and applied a wander guard to her right ankle. After (Resident #112) made a statement to staff about harming herself, I called the (NHA A). On completion of the call, staff informed me the police was (sic) calling about (Resident #112) being at another location and they had call (sic) an ambulance for her. When the ambulance brought her here, I asked them to transport her to the (hospital). Multiple attempts were made to contact LPN QQ for an interview, all were unsuccessful. Review of a Statement written by CNA RR revealed, (Resident #112) came up to the door and I had to redirect her 3 to 4 times. At around 10:30 AM, (Resident #112) made a comment about harming herself and me. I let (LPN QQ) know. The last time that I observed (Resident #112) was at 11:45 AM, I had to redirect her from the door. Multiple attempts were made to contact CNA RR for an interview, all were unsuccessful. Review of a Statement written by NHA A revealed, This writer was contacted on 7/20/20 at 12:10 PM by LPN QQ regarding the comment that (Resident #112) made about harming herself and (CNA RR). This writer instructed (LPN QQ) to make sure that we know where she is located at all times and utilize plastic silverware for meals (due to she stated she was going to slit her throat). At 12:17 PM (LPN QQ) contacted this writer to notify me that the police just called and were with (Resident #112) about two blocks away from the facility. He stated that an ambulance was called and taking her to (hospital).

This pertains to intake number (s) MI 619, MI 230, MI 356 and MI 348. Based on interview and record review, the facility failed to ensure facility staff followed professional standards of care for patient care for 1 of 17 residents (Resident #111) reviewed for quality of care, resulting in an immediate jeopardy when, 1.) on 7/7/20, facility staff did not provide care and expected monitoring from 7:00 pm-10:30 pm of Resident #111 who was actively exit seeking and who eloped from the building and 2.) licensed nursing staff did not assess Resident #111 and did not prohibit other facility staff from moving Resident #111, after a fall that occurred during an elopement. Licensed nursing staff did not contact emergency services or immediately assess Resident #111, who exited the facility unbeknownst to facility staff, had a fall with injuries and was found approximately 5 hours later. This deficient practice placed all 107 residents at risk for serious harm, injury and/or death. On 7/31/20 at 10:30 A.M., DON B and Regional Clinical Consultant (RCC) C were notified and received written notification of the immediate jeopardy that began on 7/7/20 due to the facility's failure to ensure facility staff followed professional standards of care for Resident #111, who was not monitored for 3 1/2 hours, was not assessed by licensed nursing staff prior to being moved after a elopement with fall, and emergency services were not contacted to assess Resident #111 after being unattended and outside for approximately 5 hours. On 8/6/20, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 7/8/20 the Nurse completed an assessment immediately upon returning the resident into the facility. The Nurse completed a more complete head to toe assessment of Resident #111 in the shower room. His VS (vital signs) were stable neuro (neurological)checks were normal. Wander guard was functioning properly and 15 minute checks initiated on 7/8/20 and are ongoing due to continuing to exit seek. 2. NHA A checked on 7/8/20 all the exit doors which were functioning properly upon her arrival to the facility at 12:30 am 3. The Resident was placed on 15 minute checks on 7/8/20 and continues on 15 minute checks 4. The CNA who was assigned to the resident is no longer employed by the facility. Last date worked 7/22/20. 5. The Nurse involved received one on one education about staff not moving a resident until assessed and if unable to assess without moving call emergency services on 7/31/20. 6. The Department Heads under the direction of the DON began re-education on 7/31/20 for all staff on Exit seeking behaviors and what to do who to notify etc. which includes when to call a code search or W, what to do when an alarms door goes off, what to do when a guest is exhibiting exit seeking behavior. New education began on 7/31/20 on abuse and reporting immediately to the administrator all verbal and physical allegations of abuse, neglect, misappropriation and the policy was re-shared, the importance of not moving a resident before assessed by a licensed nurse and if unable to assess then call emergency services, discussion on importance of knowing where your residents are at all times and visualize them at beginning of shift, end of shift and at least every two hours provide care per the CP (care plan). The Social Media Policy was also reviewed. On 7/31/20, 38 staff out of 114, staff were educated the remainder of employees will be reeducated upon arrival to work before reporting to their assignment. On 8/1/20, 62 staff out of 114 staff, were educated and on 8/2/20 74 out of 114 staff, were educated. 7. Per Elopement policy, which was educated with all staff, residents who are actively exit seeking are to have an incident report completed with exit seeking. Wander guard to be applied, added to Missing Guest Book and reviewed by Interdisciplinary team for further interventions and update of care plan to reflect intervention. Per the facility policy all residents with wander guards are checked for placement every shift and functionality daily by the nurse. 8. Daily Monday through Friday at Clinical Ops (operations) meeting the clinical team will review all resident incidents to ensure that policies and procedures have been followed and implemented related to falls elopements and monitoring. Any concerns will be addressed immediately and the Administrator and Regional Clinical Coordinator notified of any concerns. Any issues related to the safety of residents in the last 30 days will be thoroughly reviewed on 8/3/20 to ensure everything was done per quality of care standards. 9. Medical Director made aware of the IJ on 7/31/20 while in the facility. 10. Starting 8/4/20, Administrator and DON will audit guests with incident reports and high risk notes to ensure all appropriate measures were taken per the standards of practice weekly times 4 weeks then monthly times 3 months to ensure staff are following the standards of practice related to incidents, reporting, assessing and following the plan of care. Any concerns will be addressed immediately. Findings will be forwarded to the QAPI committee for further review and recommendations. 11. Starting 8/4/20 The ADON will run monthly reports for compliance to (company name) training Each Department Director will ensure that their staff has completed the required trainings. If they are not completed corrective action will occur. Although the immediate jeopardy was removed on 8/4/20 the facility remained out of compliance as a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to not all staff have received education and sustained compliance had not yet been verified by the state agency. Findings include: Review of Job Description Certified Nursing Assistant revealed, The primary purpose of your position is to provide your assigned guests with routine daily nursing care in accordance with our established nursing care procedures, and as may be directed by your supervisors .Report all changes in the guest's condition to the charge nurse immediately .Assist guests with bowel and bladder function (i.e., Take to bathroom, offer bedpan/urinal, portable commode, etc.). Keep incontinent guests clean and dry . Check guests routinely to assure that their personal care needs are being met .Notify the charge nurse of any guest leaving/missing from the facility . According to American Journal of Nursing November 2007, Volume :107 Number 11, When a fall occurs: Step one: assessment. When a patient falls, don't assume that no injury has occurred-this can be a devastating mistake. Before moving the patient, ask him what he thinks caused the fall and assess any associated symptoms. Then conduct a comprehensive assessment . Review of a facility document Elopement policy Revised 8/2019 revealed, It is the policy of this facility to the extent reasonably possible, the elopement of guests/residents from the facility .It is the responsibility of all personnel to report any guest/resident attempting to leave the premises, or suspected of being missing, to the licensed nurse and to document the occurrence . Procedure: .8. Rounds of all guests/residents are made at the beginning of the shift, at meal times, and at the end of the shift at a minimum by direct care staff and licensed nurses. CNA (Certified Nursing Assistant) .or nurse can achieve this through the medication administration pass, meal time passes, and during care rounds . Guest/resident attempts to leave the facility: 1. If an employee observes a guest/resident attempting to leave the facility, he or she should: a. Be courteous and preventing the departure and assist in returning the guest/resident to the facility; b. Obtain assistance from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the licensed nurse or director of nursing services that a guest/resident is attempting to leave the facility and/or the guest/resident has left the facility . 2. If a guest/resident leaves the facility, upon return the director of nursing or licensed nurse should: a. Notify the administrator; B. Examine the guest/resident for injuries . Review of the Fall Management Policy with a revised date of 10/2019 revealed, 3. When a fall occurrs, the licensed nurse will evaluate the guest/resident for injury. *Do not move the individual until he/she has been examined by a nurse. Review of an Admission Record revealed Resident #111 was a 78 -year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]., delusional disorder, visual hallucinations and [MEDICAL CONDITIONS]. Review of a Minimum Data Set (MDS) assessment for Resident #111, with a reference date of 6/24/20 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #111 was severely cognitively impaired. Review of the Functional Status revealed that Resident #111 required supervision and 1 person physical assist for transfers and walking, required extensive assistance of 1 person physical assist for toileting and personal hygiene, and his balance was not steady during transitions and walking with an assistive device walker. Review of a Care Plan revealed, NEED: (Resident #111) has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility r/t (related to): potential medication side effects, [MEDICAL CONDITION], abdominal hernia hallucinations and delusions, lack of coordination, abnormalities of gait and mobility, [MEDICAL CONDITION] and [MEDICAL CONDITION], incontinence, history of falling .history of closed head injury. Date Initiated: 06/28/2019. INTERVENTIONS: .TOILET USE: Resident requires extensive assistance of one staff to use toilet. Date Initiated: 06/28/2019. PERSONAL HYGIENE/ORAL CARE: Resident requires extensive assistance with personal hygiene and oral care. Date Initiated: 06/28/2019. Review of a Care Plan revealed, NEED: (Resident #111) is at risk for fall related injury and falls R/T (related to): [MEDICAL CONDITIONS] and collapse, repeated falls, muscle weakness, [MEDICAL CONDITION], dementia, hx (history) of falls, impaired vision, unsteady gait, potential medication side effects, hallucinations and delusions, lack of coordination, abnormalities of gait and mobility, [MEDICAL CONDITION] and [MEDICAL CONDITION], incontinence .Date Initiated: 06/27/2019 . INTERVENTIONS: .Increased supervision, Neuro's (neurological assessment) Date Initiated: 12/05/2019 .Keep the resident's environment as safe as possible with: even floors .adequate lighting; .Date Initiated: 06/27/2019 .Remind to always use walker Date Initiated: 02/14/2020 .To have guest in populated area and floor clear of clutter. Date Initiated: 02/17/2020. Review of a Care Plan revealed, NEED: (Resident #111) is at risk for Exit seeking R/T: confusion secondary to dementia .Date Initiated: 07/01/2019 .INTERVENTIONS: .Apply wanderguard (a bracelet worn that triggers an alarm to sound at exit doors) per order .Date Initiated: 07/01/2019 .Approach in a slow, calm manner and redirect away from exit doors as needed. Date Initiated: 07/01/2019 .Distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversation etc .Date Initiated: 07/01/2019 . Provide reassurance/Redirect as needed when in an area resident should not be in. Use a calm approach. Date Initiated: 07/01/2019 .Provide structured activities, toileting, walking inside and outside with supervision as needed. Date Initiated: 07/01/2019. Review of an Incident Report completed by Registered Nurse (RN) G on 7/8/20 at 12:20 A.M. revealed, (Resident #111) .Type of Occurrence: Elopement .Injury: Abrasions .Location: Outside of building .Caregiver: (Certified Nursing Assistant (CNA) D). It was noted that the report did not accurately reflect the day and time of Resident #111's elopement, but instead indicated the day and time that Resident #111 was found and returned to the facility. Review of Facility Reported Incident (FRI) 5 Day Investigation Report submitted on 7/15/20 revealed, .On 7/8/20 at 12:00 A.M. a code search was called .Resident #111 was located at 12:20 A.M .The facility is able to substantiate that (Resident # 111) had exited the facility without staff's knowledge. Upon staff identifying that (Resident # 111) was not in the building, a code search was called at 12:00 AM and he was located at 12:20 AM on the east side of the building over the fence. He was located lying on the ground .RN G did complete a head to toe assessment and observed several abrasions to his right knee, left shoulder and on top of his head . The facility was not able to identify how (Resident #111) exited the facility, per investigation no staff members on the 300 hall had heard or turned off the alarm door by the B-side nurses. It was noted that the nurse did not complete an assessment of any kind, prior to Resident #111 being transferred into his wheelchair and returned to the facility. During an observation on 7/28/20 at 4:26 P.M., Resident #111 observed in hall near exit door attempting to exit the facility, and being redirected by Assistant Director of Nursing (ADON) I and CNA E. During an observation on 7/30/20 at 1:04 P.M., Resident #111 was walking, unsteady and slow in the hall with a walker. Observed wanderguard bracelet on Resident #111's right wrist. During an interview on 7/29/20 at 9:08 A.M., Nursing Home Administrator (NHA) A reported that staff realized that Resident #111 had exited the facility at approximately 12:00 A.M. on 7/8/20 when CNA E noticed his unattended walker by an exit door. NHA A stated, .at 12:20 A.M. (Resident #111 ) was found outside .25 yards from smoke door on other side of white fence .he was lying on the ground .we do not know how long he was outside .(RN G) did an assessment and there was no reason to send him to the hospital for an evaluation . During an interview on 7/30/20 at 2:04 P.M., CNA D reported that she had worked on 7/7/20 from 2:00 P.M.-10:30 P.M. and was assigned as Resident #111's caregiver on 300 hall. CNA D reported that Resident #111 had tried to exit the facility about 5 times that day, and that he was very agitated. CNA D stated, .the last time that I saw him was about 8:00 P.M .when I tried to change him .you could tell he was wet, but he was agitated, therefore I decided to reapproach at a later time . CNA D stated, .I did not try to change him again .I knew that he needed to be changed . CNA D reported that Resident #111 was her last person to put to bed at 9:00 P.M. and stated, .when I didn't see him at 9:00 P.M., I just thought he was wandering around and calming down .I did not try to find him .I did not have time to get to (Resident #111) . CNA D reported that she reported off to RN G at shift change, but did not inform RN G that Resident #111 had not be provided care during her shift. CNA D reported that she did not provide any water, snacks, toileting or incontinence care to Resident #111 during her entire shift. During an interview on 7/29/20 at 3:36 P.M., CNA E reported that she arrived on 300 hall to cover CNA F for a break at about 12:05 A.M. on 7/8/20 and noticed Resident #111 was not in his room and his walker was parked near the exit door on 300 hall by the nurse's station. CNA E reported that the staff assigned to 300 hall were CNA F and RN G and when asked could not indicate Resident #111's whereabouts. CNA E reported that she went outside to search for Resident #111 and stated .I called out loudly for him .I heard him moaning in the distance .I found him laying in the tall weeds about 10 feet from the fence .no one would have ever seen him .he was not moving .he was covered in grass and prickers .he couldn't stand .his head was bleeding .he had one shoe on .his clothes were soaked with urine . CNA E reported that CNA E and CNA F waited by Resident #111, while RN G when to retrieve a wheelchair, but that it was taking too long, therefore CNA E and CNA F picked Resident #111 up by his arms and legs and carried him towards the sidewalk, where they were then met by RN G with a wheelchair. CNA E reported that RN G did not visualize Resident #111 prior to him being transferred into the wheelchair. During an interview on 7/30/20 at 11:59 A.M., CNA F reported that she was working 300 hall by herself and she was assigned to Resident #111's care during the time that he was determined to be missing on 7/7/20 between 11:30 P.M-12:00 A.M. CNA F reported that she arrived to work that day at 6:00 P.M. and stated, .(Resident #111) wasn't in the hall when I went on break at 9:00 P.M I am assuming that he was already outside at that time . CNA F reported that she was not aware that Resident #111 was at risk for elopement and was not aware that he was wearing a wanderguard. CNA F stated, .I don't usually worry about elopements .unless I hear a door alarm .I would just have assumed that he was in bed sleeping . CNA F reported that she was not made aware that Resident #111 had not received care that evening. CNA F reported that she was doing her rounds and had not made it to care for Resident #111 before CNA E asked about his whereabouts just before 12:00 A.M. CNA F reported that she and CNA E searched outside for Resident #111 and stated, .we followed his voice and found him .he had somehow gotten over the fence and was lying in the weeds .his shoes were off .he couldn't move himself .he had a scrape on his head .he kept saying that he was afraid .we rolled him over and arm and legged him to get him out of there . During an interview on 7/30/20 at 4:01 P.M., RN G reported that she was not aware that Resident #111 was exit seeking on 7/7/20 during 2nd shift. RN G stated, .I had heard door alarms constantly that night .I had given (Resident #111) medicine at the beginning of the shift around 7:00 P.M he was sitting by the nurse's station .he was wet and I had asked (CNA D) to change him .she later told me that he was resistant .I did not see him at all after that .there was no reason for me to think he was exit seeking . RN G reported that CNA E asked about Resident #111's whereabouts around 12:00 A.M. and that was when a search was started. RN G reported that she initially went outside and didn't see Resident #111, but then later went outside again with CNA E and CNAF and they were able to determine that Resident #111 was somewhere on the other side of the fence in the tall weeds. RN G stated, .as soon as (Resident #111) answered us, I went inside to get a flashlight and a wheelchair .I couldn't see him .it was too dark back there .by the time I got back with the wheelchair the CNA's had found him, and had carried him to the sidewalk .he was disoriented .we brought him right to the shower .I didn't know about his abrasions on head and shoulder until we got him cleaned up . RN G stated, .there was no way for me to assess him in the weeds . RN G reported that she was not sure if Resident #111 had hit his head or how he had gotten the abrasions on his head. RN G reported that she was concerned about Resident #111's hydration because it was hot outside and she didn't know how long he had been outside and without fluids. RN G reported that she paged the on call physician group, but did not hear back from them. RN G stated, .I don't remember if I called them again .I had other duties that night . RN G reported that she did not find a reason to send Resident #111 to the hospital for evaluation.

This citation pertains to intake number MI 502 Based on observation, interview, and record review the facility failed to ensure a resident was free of significant medication errors, for 1 of 17 residents (Resident #110), reviewed for medication reconciliation, resulting in the ingestion of a non-prescribed drug causing an overdose that lead to a significant change in condition. Findings include: .[MEDICATION NAME] is an opioid medication .[MEDICATION NAME] is used as a pain reliever and as part of drug addiction detoxification and maintenance programs .Misuse of [MEDICATION NAME] can cause addiction, overdose, or death .Opioid medicine can slow or stop your breathing, and death may occur .you should seek emergency medical attention if you have slow breathing with long pauses, blue colored lips, or if you are hard to wake up .nausea or vomiting .You should not use [MEDICATION NAME] . if you have: .breathing problems .heart problems .kidney disease . problems with your .[MEDICAL CONDITION] .Serious side effects may be more likely in older adult and those who are malnourished or debilitated . use [MEDICAL CONDITION] medications .opioid medication ([MEDICATION NAME]) can interact with many other drugs .other narcotic medication .antidepressant or antipsychotic medicine . (drugs.com/[MEDICATION NAME]/html) .Developing tolerance to [MEDICATION NAME] plays a role in the quantities which provoke and overdose. The official lethal dose for [MEDICATION NAME] is 25 mg for a non tolerant adult. A 200 mg does may be fatal for a regular user .[MEDICATION NAME] carries more risks than other painkillers because it tends to build up in the body and can disrupt a person's breathing or heart rhythm . Because the exceptionally prolonged duration of action with half life averaging 25 hours, [MEDICATION NAME] overdose can be fatal, especially if taken with other narcotic medications . Overdose symptoms may include: apnea (long pauses in breathing) .coma .confusion .extreme drowsiness and sleepiness .fatigue .pinpoint pupils .shallow breathing .vomiting . Overdose symptoms occur up to 10 hours after overdose . (prescription-drug.addictionblog.org) Review of a facility Admissions Record revealed Resident #110 was an [AGE] year-old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #110's Minimum Data Set ((MDS) dated [DATE], revealed, Resident #110 required set up assistance for eating; limited assistance for ambulation, dressing, and hygiene: and extensive assistance with some transfers, toileting, and bathing. Brief Interview for Mental Status (BIMS), on 6/15/20, revealed Resident #110 was cognitively intact, with a BIMS score of 15 out of 15. Review of Resident #110's hospital records, dated 7/1/20, revealed Chief Complaint: Altered mental status .suspected toxic metabolic [MEDICAL CONDITION] ([MEDICAL CONDITION] characterized by mental status changes, lethargy, confusion, difficulty speech or movement due to illness, infection, or exposure to toxic substances or drugs), nausea with vomiting .suspected aspiration pneumonia (lung infection due to substances from the mouth or stomach entering the lungs by inhaling food or vomit) . (Resident #110) was admitted for Stroke code. Upon work up of her mental status changes found to have positive for [MEDICATION NAME], mild pyuria (mild infection in urine), CXR with possible right basilar infiltrate (chest x-ray with possible fluid in lungs suggesting pneumonia) .She was hypoxemic (low levels of oxygen in the blood) on arrival and unresponsive to verbal stimuli . The patient's daughtyer visited her yesterday and thought she was a little off at that time. The patient did not wake up this morning for breakfast as per usual. Staff went to check on patient and noted she was minimally responsive, did not arouse to verbal stimuli but moaned with sternal rubbing. The patient was nonverbal and vomited twice. Review of the hospital Inpatient Progress Note dated 7/2/20, Assessment/Plan: Urine drug screen is positive for [MEDICATION NAME] patient is not on any medications to explain this. Review of Resident #110's Medication Administration Records (MAR) for June and July of 2020, revealed no physician order for [REDACTED]. Review of Resident #110's reentry form the hospital Minimum Data Set ((MDS) dated [DATE], revealed, Resident #110 had a significant change in condition. Little to no data was documented for assistance with activities of daily living. Brief Interview for Mental Status (BIMS), on 7/14/20, revealed Resident #110 was now moderately cognitively impaired, with a BIMS score of 9 out of 15, which indicated a significant cognitive decline from 6/14/20 BIMS score. During an observation and interview on 7/31/20 at 9:30 AM, Resident #110 was lying in bed in her room. Resident #110 was slow to respond and provided slurred one-word answers to Licensed Practical Nurse JJ (LPN). LPN JJ indicated Resident #110 has changed physically and cognitively after her last hospital admission (7/1/20 - 7/8/20). LPN JJ indicated prior to hospitalization Resident #110 required limited assistance with care and self-propel in her wheelchair to dining and activities. LPN JJ indicated Resident #110 was pleasantly confused but could carrying on a simple conversation and make her needs known. LPN JJ indicated after the return from the hospital Resident #110 was more lethargic, more confused, dependent for care, and rarely got out of bed. LPN JJ indicated Resident #110 was also just admitted to hospice services after her last hospital admission. LPN JJ indicated was unaware Resident #110 had tested positive for [MEDICATION NAME] when admitted to the hospital on [DATE]. In an interview on 7/31/20 at 10:00 AM, Director of Nursing B (DON) indicated was not directly informed that Resident #110 had tested positive for [MEDICATION NAME] upon admission to the hospital on [DATE]. DON B indicated overheard Nursing Home Administrator A (NHA) and Unit Manager II (UM) discussing Resident #110's [MEDICATION NAME] ingestion. DON B indicated was not asked to investigate and assumed NHA A and UM II were looking into the matter. In an interview on 7/31/20 at 1:30 PM, UM II indicated Resident #110 was found lethargic, only responsive to a sternal rub, and vomiting in her room on 7/1/20. UM II indicated Resident #110 was sent to the hospital for evaluation and was alerted by the hospital that Resident #110 had tested positive for [MEDICATION NAME]. UM II indicated was doubtful Resident #110 could have found the [MEDICATION NAME] or was given the [MEDICATION NAME] by a visitor. UM II indicated at the time of the medication overdose, the facility was not accepting visitors and residents had very restricted movement through the building due to COVID 19 mandates. UM II indicated the [MEDICATION NAME] found in Resident #110's system was mostly likely a medication error. UM #110 indicated prior to the episode on 7/1/20, Resident #110 preferred sitting in her wheelchair; was typically alert and oriented; and was impulsive attempting to stand or walk from her wheelchair. UM II indicated when Resident #110 returned from the hospital she had a significant change in condition from the ingestion of the [MEDICATION NAME]; she was not alert or oriented and was dependent for all cares. UM II indicated Resident #110 was also admitted to hospice since her return. In an interview on 8/4/20 at 1:30 PM, NHA A indicated was aware Resident #110 had received [MEDICATION NAME] and went out to the hospital for complications related to the ingestion. NHA A indicated does not know how Resident #110 could have gotten the [MEDICATION NAME]. NHA A indicated they checked the medication carts and Resident #110's physcian orders but did not interview any nurse or other resident regarding the error. NHA A indicated no investigation was documented into the medication error.

This citation pertains to intake #'s MI 209 and MI 374 Based on observation, interview, and record review, the facility failed to prevent facility acquired pressure ulcers and provide pressure ulcer preventative care consistent with professional standards of practice for 2 out of 6 residents (Resident #105 and #101) reviewed for the risk of and/or the development of pressure injuries, resulting in the development of a Stage III avoidable pressure ulcer for Resident #105 and the potential for skin breakdown and overall deterioration in health status for Resident #101. Findings include: Review of the facility policy, Pressure injury management, long-term care last revised 8/17/18 revealed, Pressure injury management calls for a multidisciplinary approach. A registered nurse specially trained in wound care typically leads the team. A certified nursing assistant implements measures to prevent pressure injury formation and reports signs of skin breakdown to the registered nurse. Review of the Fundamentals of Nursing revealed, Consider repositioning the patient at least every 2 hours if allowed by his or her overall condition .For patients at risk for skin breakdown who are able to sit in a chair, limit the amount of time they sit to 2 hours or less at any given time. In the sitting position the pressure on the ischial tuberosities is greater than in the supine position. In addition, teach the patient to shift weight every 15 minutes while sitting. Potter, [NAME] [NAME]; Perry, Anne Griffin; Stockert, [NAME]; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #105 Review of a Face Sheet revealed Resident #105 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 #105, with a reference date of 6/19/19 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated Resident #105 was severely cognitively impaired. Review of the Functional Status revealed that Resident #105 required extensive two person physical assistance for bed mobility, transferring, dressing, toileting, and personal hygiene. Review of Resident #105's care plan created on 6/25/19 revealed, Potential impairment to skin integrity r/t: Impaired bed mobility, Incont B/B (incontinent of bowel and bladder), DM2 (type 2 diabetes), muscle weakness, abnormal posture,[MEDICAL CONDITION](stroke), TIA ([MEDICAL CONDITION]/mini stroke) .Cue to reposition self as needed .Provide ext assistance to reposition frequently & as needed. Review of Resident #105's Braden Scale dated 7/21/19 revealed a score of 12 indicating Resident #105 was a high risk for a pressure ulcer. Review of Resident #105's Skin & Wound note dated 6/2/19 revealed Resident #105 had no skin conditions/alteration of skin integrity. Review of Resident #105's Skin & Wound note dated 6/13/19 revealed Date of Onset 06/07/2019 .Site Coccyx Type Pressure Length 1.5(cm) Width 1.5(cm) Depth 0.2(cm) Stage II 3. Tunneling/Undermining-none 4. Exudate Type-serosanguinous 5. Exudate amount-moderate 6. Odor-none 7. Wound Bed-Pink/Beefy Red .Slough 8. Surrounding Skin Color-Normal for Skin 9. Surrounding Tissue Wound Edges-Normal for Skin 10. Progress (blank) .12. Care Plan Updated-No .Notified Responsible Party 06/13/2019. Review of Resident #105's Skin & Wound note dated 6/19/19 revealed Date of Onset 06/07/2019 .Site Coccyx Type Pressure Length 2(cm) Width 2.6(cm) Depth 0.2(cm) Stage II 3. Tunneling/Undermining-none 4. Exudate Type-none 5. Exudate amount-none 6. Odor-none 7. Wound Bed-Pink/Beefy Red. 8. Surrounding Skin Color-Pink 9. Surrounding Tissue Wound Edges-Normal for Skin 10. Progress-not changed 12. Care Plan Updated-No. Review of Resident #105's Skin & Wound note dated 6/26/19 revealed Date of Onset 06/07/2019 .Site Coccyx Type Pressure Length 2(cm) Width 0.1(cm) Depth 0.1(cm) Stage II 3. Tunneling/Undermining-None 4. Exudate Type-Serosanguinous 5. Exudate amount-scant 6. Odor-none 7. Wound Bed-Pink/Beefy Red Granulation Tissue. 8. Surrounding Skin Color-Normal for Skin 9. Surrounding Tissue Wound Edges-Normal for Skin 10. Progress-Improved .12. Care Plan Updated-No. Review of Resident #105's Skin & Wound note dated 7/3/19 revealed Date of Onset 06/06/2019 .Site Coccyx Type Pressure Length 2(cm) Width 1(cm) Depth 0.2(cm) Stage II 3. Tunneling/Undermining-none 4. Exudate Type-Serosanguinous 5. Exudate amount-small 6. Odor-none 7. Wound Bed-Granulation Tissue. 8. Surrounding Skin Color-Normal for Skin 9. Surrounding Tissue Wound Edges-Maceration 10. Progress-not changed 12. Care Plan Updated-No. Review of Resident #105's Skin & Wound Evaluation note dated 7/10/19 revealed, 1. Type-Pressure .Stage 2: Partial-Thickness skin loss with exposed dermis .22. Location-Coccyx .Acquired: In-House Acquired .Wound Measurements .Length 1.7cm .Width 1.3cm .Depth 0.3cm Undermining-Not Applicable .Tunneling-Not Applicable .Surrounding Tissue .Denuded-loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate or friction .Cleansing Solution-Generic wound cleanser .Primary Dressing: 9. Foam .Secondary Dressing: 9. No secondary dressing .Additional Care 3. Cushion .Nutrition/Dietary supplementation (Turning/repositioning program was not chosen) .Wound Pain .None. Review of Resident #105's Skin & Wound Evaluation note dated 7/17/19 revealed, 1. Type-Pressure .Stage 2: Partial-Thickness skin loss with exposed dermis .22. Location-Coccyx .Acquired: In-House Acquired .Wound Measurements .Length 2.3cm .Width 2.8cm .Depth 0.2cm Undermining-Not Applicable .Tunneling-Not Applicable .Surrounding Tissue .Denuded-loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate or friction .Additional Care 3. Air Flow Pad .Incontinence management .Moisture barrier .Nutrition/Dietary supplementation (Turning/repositioning program was not chosen) .PAIN AD Score 4 (Indicating a worsening in pain and increase in size). Review of Resident #105's Skin & Wound Evaluation note dated 7/23/19 revealed, 1. Type-Pressure .Stage 2: Partial-Thickness skin loss with exposed dermis .22. Location-Coccyx .Acquired: In-House Acquired .Wound Measurements .Length 2.5cm .Width 3.0cm .Depth 0.4cm Undermining-Not Applicable .Tunneling-Not Applicable .Surrounding Tissue .Macerated: Wet, white, waterlogged tissue .Additional Care 3. Air Flow Pad .Incontinence management .Moisture barrier .Nutrition/Dietary supplementation (Turning/repositioning program was not chosen) .PAIN AD Score 6 (Indicating a worsening in pain and increase in size). Review of Resident #105's nurse practitioner note dated 7/30/19 revealed, The patient's medications and labs were reviewed. He has also been followed in regards to a coccyx wound that has been progressively worsening. Slowly getting bigger in size .Stage 3 noted to coccyx with slough at base but no surrounding [DIAGNOSES REDACTED] mild induration surrounding wound edges. Review of Resident #105's Skin & Wound Evaluation note dated 8/1/19 revealed, 1. Type-Pressure .Stage 2: Partial-Thickness skin loss with exposed dermis .22. Location-Coccyx .Acquired: In-House Acquired .Wound Measurements .Length 4.0cm .Width 1.8cm .Depth 2.6cm Undermining-Not Applicable .Tunneling-Not Applicable .Odor note after cleansing-None .Induration (Abnormal hardening of the tissue which may be a sign of underlying infection)-None present .Additional Care 3. Air Flow Pad .cushion .Incontinence management .Turning/repositioning program .Progress .Deteriorating. Review of Resident #105's physician order dated 8/5/19 revealed, (name omitted) wound clinic consult for decub coccyx ulcer. Review of the Wound Healing Center's progress note dated 8/7/19 revealed, INTEGUMENTARY .Wound foul smelling, with dark gray firmly adherent slough to wound bed. No granulation tissue present. Wound edges indurated and firm with some callous and maceration .Assessment-Pressure ulcer of sacral region, unstageable .Procedure .There was a Selective/Open Wound Non-Viable Tissue Debridement with a total area of 6 sq cm performed by (name omitted) .Post Debridement Measurements: 3.2cm length x 2.1cm width x 2.6cm depth; 13.722cm(3) volume. Post debridement Stage note as Unstageable/Unclassified. Character of Wound/Ulcer Post Debridement requires further debridement .culture obtained instead due to foul odor and other signs of infection. Review of Resident #105's x-ray of his sacrum and coccyx dated 8/7/19 revealed, Relative demineralization of the coccyx. This could be a reflection of osteo[DIAGNOSES REDACTED] (infection in the bone which can be caused by a pressure ulcer). Review of Resident #105's Wound Healing Center progress notes dated 8/8/19 revealed, [MEDICAL CONDITION] markers significantly elevated, which may be due infection (sic). WBC's (White Blood Count indicates infection) also elevated. Review of Resident #105's emergency room notes dated 8/8/19 revealed, Diagnosis 1.[MEDICAL CONDITION], due to unspecified organism .Acute. 2. Skin ulcer of sacrum, unspecified ulcer stage .Patient is brought in with concerns for a worsening sacral wound. On exam he has a deep tunneling ulceration in the sacral region Patient's labs are remarkable for leukocytosis with all elevated [MEDICAL CONDITION] markers .CT (scan) was obtained to further evaluate his sacral wound which shows no definite bony involvement, however there is a deep tunneling wound which includes some rectal inflammation .Patient will be admitted to the hospital [MEDICAL CONDITION] secondary to his sacral wound Sacral unstageable tunneling decubitus ulcer with necrotic tissue within wound. During an interview on 08/14/2019 at 1:23 P.M., Social Worker (SW) H reported that Resident #105 did not have behaviors. SW H reported that he would become tearful but not aggressive. Review of Resident #105's psychiatric progress note dated 2/19/19 revealed, He currently denies that he is sad or anxious and no notes by staff stating so. Staff states that he can become tearful at times and can sundown (confusion at night) but overall doing well. Review of Resident #105's psychiatric progress note dated 7/16/19 revealed, Complaint: episodic tearfulness .Staff states that he continues (sic) to have episodes of tearfulness .Overall staff states that he does well, gets up daily, allows them to do ADLs. Review of Resident #105's nursing progress note dated 7/6/2019 revealed, No behavior or mood changes noted. Calm and cooperative with cares. Review of Resident #105's nursing progress note dated 7/7/2019 revealed, No aggressive behaviors noted with care or otherwise. Will continue to monitor. Review of Resident #105's nursing progress note dated 7/7/2019 revealed, No behaviors noted. Review of Resident #105's nursing progress note dated 7/10/2019 revealed, No aggressive behaviors noted, however, guest was observed crying at approximately 4 pm. Review of Resident #105's nursing progress note dated 7/10/2019 revealed, No aggressive behaviors with cares or otherwise noted. Will continue to monitor. Review of Resident #105's nursing progress note dated 7/13/19 revealed, no behaviors noted at this time will continue to monitor. Review of Resident #105's nursing progress note dated 7/24/2019 revealed, Cooperative with care. Review of Resident #105's nursing progress note dated 8/1/19 revealed, No mood or behavior changes noted this shift. No c/o pain or discomfort voiced. Cooperative with care. Review of Resident #105's nursing progress note dated 8/5/19 revealed, no behaviors noted at this time. Review of Resident #105's nursing progress note dated 8/6/19 revealed, No mood or behaviors noted thus far in shift, will continue to monitor. Review of the medical record revealed no documentation to indicate Resident #105 refused repositioning. During an interview on 08/12/2019 at 2:55 P.M., Licensed Practical Nurse (LPN) C reported that at times the Certified Nursing Assistants (CNA) do not reposition residents timely due the high acuity of the residents and the lack of staff. During an interview 08/14/2019 at 1:25 P.M., CNA [NAME] reported that residents who are dependent on care are to be repositioned every 2 hours. During an interview 08/14/2019 at 1:28 P.M., CNA F and CNA G reported that residents who are dependent on care are to be repositioned every 2 hours. Resident #101 Review of a Face Sheet revealed Resident #101 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 #101, with a reference date of 6/20/19 revealed a Staff Assessment for Mental Status which revealed Cognitive Skills for Daily Decision Making .3. Severely impaired. Review of the Functional Status revealed that Resident #101 required extensive assistance of two persons for bed mobility, dressing, toileting, and personal hygiene. Review of Resident #101's care plan revised 4/1/19 revealed, (Resident #101) is at risk for impaired skin integrity/pressure injury R/T (related to): dependence on staff for assistance with adls (activities of daily living) and near comatose state. Bilateral AKA (above knee amputation). HX (history) of 12 minutes of [MEDICAL CONDITION] and subsequently an [MEDICAL CONDITIONS] .Turn/reposition resident frequently and PRN (as needed) Date Initiated: 04/01/2019 Review of Resident #101's Braden Scale (assesses risk of pressure ulcer) dated 3/15/19 revealed a score of 7 indicating Resident #101 was at a very high risk of a pressure ulcer. Review of Resident #101's Braden Scale (assesses risk of pressure ulcer) dated 5/9/19 revealed a score of 11 indicating Resident #101 was at a high risk of a pressure ulcer. During an observation on 08/12/2019 at 12:48 P.M., Resident #101 was in his bed with a pillow behind his left side. During an observation on 08/12/2019 at 2:48 P.M., Resident #101 was in his bed with a pillow behind his left side. During an observation on 08/12/2019 at 2:56 P.M., Resident #101 was in his bed with a pillow behind his left side. During an observation on 08/12/2019 at 3:09 P.M., Resident #101 was in his bed with a pillow behind his left side. During an observation on 08/12/2019 at 3:45 P.M., Resident #101 was in his bed with a pillow behind his left side. During an interview on 08/12/2019 at 3:47 P.M., CNA D reported that Resident #101 should be repositioned every 2 hours. CNA D stated, I'm a little behind with repositioning Resident #101.

This citation pertains to intake numbers MI 410 and MI 508. Based on observation, interview, and record review, the facility failed to ensure the safety and prevent two elopements for 1 of 5 sampled residents (Resident #100) reviewed for safety/elopements, from a total sample of 10 residents, resulting in an immediate jeopardy when Resident #100, who was identified as an elopement risk and had a wanderguard in place to prevent elopement, eloped on 5/6/18 and again on 5/10/18, unbeknownst to facility staff. This deficient practice placed 15 residents, identified as risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of a Face Sheet revealed Resident #100 was a 66 -year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident # 100, with a reference date of 4/12/18 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #100 was severely cognitively impaired. Review of Resident #100's MDS, on 5/6/18, Resident #100 was independently mobile in the facility without direct supervision Review of the Physician order [REDACTED].#100 had an order for [REDACTED]. Review of the Care Plan for Wandering used prior to the elopement on 5/6/18 revealed, Wander: Exit seeking R/T (related to): Wandering, impaired cognition. 3/28/18 2 wandergards (sic)-1 on right wrist per preference, and one on right front of w/c. Interventions: Approach in a slow, calming manner when redirecting away from doors, ensure that wandergaurd (sic) is on each shift and functioning daily. Observe whereabouts frequently, redirect away from exit doors as needed. Redirect to activities as able .created on 1/28/18. According to the facility investigation, the front door alarm by the office was sounding on 5/6/18 at 7:30 P.M. Resident #100 was believed to have exited the facility, unbeknownst to facility staff, and was observed by Licensed Practical Nurse (LPN) F and Certified Nurse Assistant (CNA) G approximately 0.25 miles away on a residential area road after crossing two intersections. Resident #100 was returned to the facility by facility staff at 7:33 P.M. Resident #100 did not have the wander-guard on his right wrist or on his wheelchair when he returned to the facility. In an interview on 5/23/18 at 3:32 P.M., CNA D reported that on 5/6/18 she was working on Resident #100's unit and had seen him off and on and had observed him last during dinner. Dinner service begins at 5:00 P.M. CNA D was unable to give specific time for her last observation of Resident #100. CNA D reported that Resident #100 took his wander guard off of his right wrist and his wheelchair (front right) and eloped from the facility. CNA D reported that Resident #100 was found on a heavily trafficked road with a speed limit of 45 MPH. This path led Resident #100 to cross a busy intersection. CNA D reported Resident #100 has a history of attempting to remove his wander-guards. Review of the Care Plans for Wandering revealed it was not updated after the elopement on 5/6/18. Review of the Guest Location Visual Check revealed 15-minute checks were initiated on 5/6/18 at 7:30 P.M. In an interview on 05/25/2018 at 1:51 P.M. CNA L reported that on 5/10/18, CNA L was returning from bringing a resident to an appointment and observed Resident #100 in his wheelchair in the road. CNA L stated, I have no idea the last person who saw him last or what time he was seen. In an interview on 05/25/2018 at 2:00 P.M., CNA E reported that on 5/10/18, prior to the second elopement, I wasn't technically with him. He (Resident #100) was at the nurses' station waiting for (nurse). I took him to the family room and turned the TV on for him. He got up and sat on the couch. CNA E reported that she last observed Resident #100 on 5/10/18 at 6:15 P.M. CNA E reported that she was not assigned to Resident #100's unit that shift. CNA E stated, I honestly don't know how he got out. I heard the Code W (overhead announcement that a resident is missing) and found out it was (Resident #100). I was not told that I was supposed to watch him. CNA E reported that when a resident is on 15 minute checks there is No designated checker. All of us check on him. Pretty much everyone has the responsibility (to perform the 15 minute checks). Review of the Facility Guest Location Visual Check revealed 5/10/18 at 6:15 P.M., Initials (CNA E) documented Resident #100's location as Family Room. In an interview on 5/23/18 at 2:22 p.m., Accounts Payable Coordinator C reported that on 5/10/18 another facility resident was leaving the facility via ambulance and was wearing a Wander-guard. AP Coordinator C reported that Resident #100 was able to elope without notice because the facility staff believed that the resident that was taken by ambulance was the only resident that had set off the Wander-guard alarm. AP Coordinator C reported that she found Resident #100 at 6:33 P.M. approximately 0.25 miles away after crossing a busy intersection. Accounts Payable Coordinator C reported that Resident #100 did not use the sidewalk but instead used the right shoulder of the road. In an interview on 05/25/2018 at 2:17 P.M., LPN I reported that she last observed Resident #100 on 5/10/18 at right about the 6 P.M. mark. LPN I reported that around the time of Resident #100's elopement, there was a resident being transported via ambulance to the hospital that had a Wander-guard on. LPN I stated, I think staff thought it was the resident being sent out that set it off (the wander-guard alarm). LPN I reported that she does not know what door Resident #100 exited from. LPN I stated that when a resident is on 15 minutes checks, We all pitch in for the 15 minutes checks. There is no designated person (to complete the 15 minute checks). In an interview on 5/23/18 3:00 P.M., Administrator A reported that she was unable to conclude which door Resident #100 eloped from. Administrator A reported that she contacted the Ambulance service to conclude the time that Resident #100 likely eloped. The ambulance service reported that the Ambulance employees radioed dispatch at 6:21 P.M. to notify dispatch of their departure from the facility. Administrator A reported that when Resident #100 returned to the facility his Wander-guards were in place and functional. Review of the Care Plan for Wandering revealed the care plan was revised on 5/15/18. 1:1 initiated 5/10/18 while guest is awake. Initiated 5/10/18, 15-minute checks while guest is sleeping. During an observation on 5/23/18 at 1:04 P.M., a facility resident exited the facility to the courtyard through Door #9. Her Wander-guard set off the alarm. The resident was able to stand up out of her wheelchair, open the door, exit the facility, and reenter before a staff member assisted her at 1:07 P.M. During an observation on 5/23/18 at 1:16 P.M., a facility resident exited the facility to the courtyard through Door #9. Her Wander-guard set off the alarm. Staff arrived to assist the resident at 1:18 P.M On 5/24/18, Administrator A was notified of an immediate jeopardy that began on 5/6/18 when Resident #100, who was an elopement risk, eloped from the facility unbeknownst to facility staff. On 5/25/18, the following was verified to remove the immediate jeopardy: 1. As of 5/11/18, Resident #100 has 1:1 supervision when awake and 15 minute checks when sleeping. He continues to wear wanderguard to his right wrist and attached to the right side of wheelchair. 2. As of 5/23/18, Wanderguard was placed in the wheelchair bag that is located on the back of the resident's wheelchair due to he will remove wanderguards of his arm and wheelchair without staff knowledge. Wanderguard was assessed to ensure that it would function proper when in the bag on the back of the wheelchair - wanderguard did function properly. 3. On 5/11/18, Nurse Managers re-assessed the 16 current residents who have a wanderguard devices. As of 5/11/18, all 16 current residents remain at risk for elopement and a wanderguard device remains in place. Nurse Managers also reassessed the other 99 current residents for elopement risk; no other residents were identified as a risk. 4. On 5/11/18, the Director of Nursing & Unit Managers audited the 16 current residents with wanderguards to ensure placement and proper functioning were documented in each residents Treatment Administration Record. Licensed Nurses continue to check for placement every shift and functionality daily and document on the Treatment Administration record per facility's policy. 5. On 5/11/18, the Administrator reviewed the facility Missing Guest policy and it was deemed appropriate. 6. On 5/11/18, the Maintenance Director and/or designee validated that all Secure Care doors throughout the facility were functioning properly. The Maintenance Director and/or designee will continue checking all Secure Care doors for proper functioning on a daily basis per facility policy and document findings daily. 7. On 5/11/18 Social Service reviewed the elopement books and they were found to be up-to-date. Social service will update each book with any changes as needed the per facility policy. 5/23/18, Missing Guest books (elopement books) reviewed and current. 8. On 5/11/18, Staff Development Director/designee educated 105 of 136 facility staff members regarding missing guest policy. The remaining staff members will be educated by the Staff Development Director and Nurse Managers prior to the start of their next scheduled shift. 9. As of 5/18/18, 130 facility staff members have been in-service with 6 remaining staff member on leave or vacation who will be in-service prior to the start of their next scheduled shift. 10. New employee orientation will include Missing Person Policy and Procedures education. 5/16/18 -general orientation and education completed. 5/24/18 - general orientation and education completed. 11. On 5/23/18, Maintenance Supervisor audited annunciators at each nurses' station and they are at appropriate volume. Secure Care has been contacted to assess if we can change the sound of the doors alarms to the courtyard. 12. As of 5/23/18, a Receptionist to be a front office 7 days a week from 9 am to 9 pm to monitor courtyard door and front office exit door. 13. On 5/23/18, Maintenance Director re-educated on completing Code W (missing guest) drills at need to be completed odd hours and on all three shifts. 5/24/18 Code W drill completed and staff responded appropriately. Although the immediate jeopardy was removed on 5/24/18, 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 staff had received education and the State Agency had not verified sustained compliance.

This Citation Pertains to Intake MI 618. Based on interview, and record review, the facility failed to provide an environment free from verbal abuse for one (#1) of two total sampled residents reviewed for abuse, resulting the resident being frightened of a staff member and to ask for assistance for her care needs. Findings include: Review of the facility's ABUSE PROHIBITION, INVESTIGATION, AND REPORTING policy revised 4/2017 revealed, The facility shall not allow verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, or exploitation .Verbal abuse is defined as any use of oral, written, or gestured language that includes disparaging and derogatory terms to guests or their families, or within hearing distance, to describe guests, regardless of their age, ability to comprehend, or disability .Mental abuse is defined as, but not limited to, harassment, threats of punishment, coercion, intimidation . Further review of the policy revealed that the facility will, Train employees through orientation, annually, and ongoing sessions on issues related to abuse prohibition such as: Dementia management and resident abuse prevention. Review of the Record of Admission and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was a [AGE] year old female resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #1 had clear speech, understood, understands was moderately impaired cognitively and required extensive assistance of 1-2 staff for Activities of Daily Living (ADLs). Review of the facility's 5 day investigation, undated, revealed, On 9/24/17 at 4:45 a.m., (Resident #1), resident reported to (Licensed Practical Nurse (LPN) D) that (Resident #1) didn't like the 'black girl' (Certified Nursing Assistant (CNA) E) working today. (LPN D) asked why and (Resident #1) reported that 'I told her I was going to kick her and she (CNA E) said, 'I'll show you what this back [***] can really do if you kick me.' Review of the facility's Payroll Authorization Form dated 9/29/17 revealed that CNA E was terminated on 9/24/17 for Allegation of verbal abuse. During an interview on 10/12/17 at 10:20 a.m., Resident #1 stated that she did remember the incident with CNA E. During a follow up interview at 12:44 p.m. Resident #1 stated that CNA E did scare her and that she was still scared of her, I don't want her around me, I told (Nursing Home Administrator (NHA) A) that I don't want her around me. Review of a hand written statement by LPN D, undated, revealed, I brought (Resident #1) her meds (medications) approx (approximately) 4:45 a.m, and she immediately told me that she didn't like the 'black girl' working today. I asked her why (Resident #1) told me 'she threatened me'. I asked (Resident #1) to explain to me, (Resident #1) said 'I told her I was going to kick her and (CNA E) said I'll show you what this black [***] can really do if you kick me.' .I asked (CNA E) what happened and (CNA E) told me '(Resident #1) called me a black [***] and told me she was going to kick me so I told her I love my job but not that much and if she kicked me I'd show her what a black [***] can really do.' (CNA E) said she finished care and walked out. I went back to (Resident #1's) room, I asked (Resident #1) if she would like to report the situation - (Resident #1) told me yes but asked me to wait until (CNA E) was gone in fear of retaliation. During a telephone interview on 10/12/17 at 3:15 p.m., when asked about the incident between Resident #1 and CNA E, LPN D confirmed her written statement. LPN D further stated that she felt what CNA E did was verbal abuse, Yes, that is why I called (Nursing Home Administrator (NHA) A). LPN D further stated, When I asked (CNA E) about it, she said 'Yup, I said it, I don't have anything to lose. During this same interview, when asked if Resident #1 was scared, LPN D stated, Yes, when I went and talked to (Resident #1) she said she didn't want to say anything until (CNA E) left because she was scared of her. Review of an undated, hand written statement by CNA F, the CNA that was with CNA E while providing cares to Resident #1 revealed, On [DATE]th 2017 at around 3:30 a.m. (CNA E) an aide, asked me if I would help her change (Resident #1). While we were changing (Resident #1) she was very rude to (CNA E) and called her a black [***] and threatened to kick (CNA E). (CNA E) then proceeded to tell (Resident #1) 'go ahead and kick me and I will show you what black [***] es do.' (CNA E) also said that if (Resident #1) kicked her, it would take a group of people to get her off (Resident #1's) head. We finished changing (Resident #1) and left the room. During a telephone interview on 10/12/17 at 12:05 p.m., CNA F confirmed her statement regarding the incident between Resident #1 and CNA E. CNA F further stated, (CNA E) said (to Resident #1), 'I'll show you what this black [***] can really do if you kick me', and she kept saying it over and over. When asked if she felt it was verbal abuse, CNA F stated, Yes. When asked if the facility had provided training to the CNAs regarding caring for residents with this type of behavior, CNA F stated, Yes, remain calm, and if you can't then you should walk out of the room and have another staff member help them, you shouldn't cuss and swear at them. In this same interview, when asked if Resident #1 was scared during this incident, CNA F stated, I know that (Resident #1) was afraid of (CNA E), she told the nurse that.

Based on obervation, interview and record review the facility failed to provide appropriate assistance to prevent a serious injury from a fall for 1 resident (Resident #3) out of 1 resident reviewed for falls from a total sample of 3 residents resulting in bilateral lower leg fractures when a nursing assistant did not use a gait belt while transferring a resident known to have weakness and difficulty walking. Findings include: According to the State Operations Manual, a Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Review of a facility policy for Gait Belt use dated 3/2005 reflected A gait belt is utilized for safety in the transfer and ambulation of an unstable or non-weight bearing guest. Review of a Face Sheet dated 10/10/17 and a Minimum Data Set quarterly assessment dated [DATE] reflected Resident #3 was an [AGE] year old woman originally admited to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS reflected Resident #3 was cognitively intact and needed extensive assistance from two people and a walker for transfer and ambulation. Review of a care plan for ADL's (activities for daily living) reflected that Resident #3 Requires supervision to extensive assistance depending on specific activity of daily living related to: tube feedings, weakness, and decreased visual function, initiated on 10/19/16 and last updated 7/17/17, reflected The GOAL of the care plan was that Resident #3 will be able to perform ADL's with limited to extensive assistance daily with interventions that included: Provide assistance with ADL's only to the extent required; encorage her to be independent every day; observe for changes in functional level and report; May walk independently with walker in room or in hallways--may require assistance at times. Review of a care plan for Falls reflected Resident #3 was At risk for fall related injury related to history of falls, requires assist with toileting, dressing initiated on 10/19/16 and last updated on 7/17/17 reflected the GOAL of the care plan was that Resident #3 Will be free from falls and injury daily with interventions that included Monitor for fatigue and/or unsteadiness and encourage rest periods due to muscle weakness; One supervised or limited assistance with transfers, ambulation and toileting as needed; remind resident to feel for chair at back of legs before sitting. Also feel for both sides of chair before sitting. During an observation on 10/10/17 at 11:20 a.m., Resident #3 was found in the physical therapy department, seated in her wheelchair, wearing a gait belt, positioned between parallel bars, with black lower leg boot/braces in place. Physical Therapy Assistant (PTA) C and PTA D had finished working with Resident #3 for that day and explained that she was able to stand briefly with assistance between the parallel bars. Resident #3 was asked what had happened and she said My knees gave out and I've got two broken legs. I'm so weak now, this is the first time I've been able to stand since it happened. Review of an Incident Report indicated that on 9/8/17 at 12:00 p.m., Resident #3's knees buckled while standing with injuries described as pain in bilateral ankles, worse pain in right (ankle). The incident report was completed by Director of Nursing (DON) B and listed herself as witness and/or caregiver. Immediate interventions to prevent reoccurrance noted on the report indicated Resident #3 was assisted back to chair, pain medication given, ice applied. No witness statements or identification of staff assigned to care for Resident #3 at the time of the incident were noted. During an interview on 10/10/17 at 2:59 p.m., DON B explained she was not present at the time of the incident and completed the incident report on behalf of the nurse working at the time who was too busy to complete it. DON B could not readily identify what staff were involved in the incident. Review of Progress Notes dated 9/8/17 at 3:01 p.m. reflected Licensed Practical Nurse (LPN) I was on duty at the time of the incident and documented .(Resident #3) states knees buckled when CNA was transferring resident. Resident did not fall, CNA assisted resident into chair and obtained another CNA to assist with transferring resident. This nurse administered tylenol as ordered. Elevated resident's bilateral lower extremities (BLE) and applied ice packs. Resident resident in bed with eyes closed at this time, call light in reach. Will continue to monitor. During a telephone interview on 10/10/17 at 4:06 p.m., LPN I reported she was told about the incident on 9/8/17 but couldn't recall what time it was. LPN I said she wasn't sure whether an incident report needed to be made out or not because it wasn't a fall. When asked what a fall was, LPN I said a fall was an unexpected change in elevation and she would expect to be told immediately so she could assess the resident. LPN I said CNA H and CNA J were involved in the incident and did not come to her immediately. LPN I said she did not perform a complete physical exam but did ask Resident #3 if she was in pain. LPN I said she did not think x-rays should be ordered because Resident #3 did not fall . During a telephone interview on 10/10/17 at 3:50 p.m., Certified Nurse Aide (CNA) H explained that on 9/8/17 at approximately 9:30 a.m., she was assisting Resident #3 to transfer from her bed to her wheelchair with the use of a walker when Resident #3's knees just buckled as she was backing up to the wheelchair and she slipped off the chair. CNA H said Resident #3 was almost on her knees on the floor with her feet under her and she was unable to stand to sit in the wheelchair. CNA H left the room to get CNA J to help complete the transfer. CNA H said she had not used a gait belt and that CNA J applied one once he got to the room. CNA H recalled Resident #3 saying Just get me off the ground! and afterward, complaining of ankle pain. CNA H said she didn't usually use a gait belt with Resident #3 becuase she could transfer herself. During an interview on 10/11/17 at 8:40 a.m., CNA J reported he was called to assist CNA H with Resident #3. CNA J said when he entered the room it looked like Resident #3 was seated on the very edge of her wheelchair with her feet planted on the ground below the wheelchair. CNA J applied a gait belt and both he and CNA H assisted Resident #3 into the chair. CNA H said he knew CNA J was going to take Resident #3 to the shower room and wasn't going to let her try and transfer Resident #3 alone, so he accompanied them into the shower room to assist with transferring Resident #3 into the shower chair. CNA J said he and CNA H did have Resident #3 attempt to stand for the transfer but were unsuccessful. She was dead weight so we sat her (Resident #3) back down and brought her back to her room and put her in bed. CNA J said Resident #3 complained of leg and ankle pain, the nurse was notified. CNA J said Resident #3 never got back out of bed again. During an interview on 10/10/17 at 4:30 p.m., Resident #3 was asked to clarify the incident that occurred on 9/8/17. Resident #3 said she was standing with her walker and her knee buckled while she was backing up to her wheelchair. Resident #3 said CNA H did not tell her to feel for her chair at the back of her legs before sitting or cue her to feel for both sides of her chair before sitting, I know I wasn't there yet (at the chair), my knees buckled before I could get there! Resident #3 said CNA H had not used a gait belt and she found herself in a squatting position while CNA H ran for help, and couldn't be sure if it was her bottom or her back resting against the edge of the wheelchair. Resident #3 recalled telling CNA H to hurry, and said Oh it hurt so bad!. Resident #3 said CNA J came and helped her into her chair and then CNA H and CNA J took her to the shower room. Resident #3 reported she told the aides she Just couldn't do it (shower) but they did have her try to stand. Review of Progress Notes dated 9/10/17 at 6:15 a.m. reflected LPN G documented Physician ordered x-ray of left and right ankle on 9/9/17 related to increased complaint of ankle/foot pain and swelling to right ankle. Physician aware of results. Reordered left ankle x-ray to rule out fracture. Vital signs stable, resident stated scheduled pain meds help with the pain. Review of Progress Notes dated 9/11/17 at 6:36 a.m., documented by LPN G refelcted Second left ankle x-ray results reported to (Medical Doctor (MD) M). New order to send resident to (name of hospital) urgent care this morning to be evaluated. Paperwork filled out and given to first shift nurse to send resident out with . Review of a Radiology Results Report for x-rays obtained on 9/9/17 at 22:30 (10:30 p.m.) reflected Resident #3 had a suspected distal left fibula fracture (left lower leg) fracture with a recommendation for a repeat x-ray. The right ankle x-ray revealed swelling but no fracture was identified. A repeat x-ray of the left ankle on 9/10/17 at 11:50 p.m. confirmed Resident #3 had a non-displaced distal fibula fracture. A repeat x-ray of the right ankle was not completed. Review of a Diagnostic Radiology Report from Resident #3's follow up appointment at a local hospital urgent care on 9/11/17 at 11:08 a.m. reflected Resident #3 had a left lateral malleolus fracture and a suspected right lateral malleolus fracture. During a telephone interview on 10/11/17 at 11:50 a.m., MD M reported he could not recall exactly what time of day he was contacted by DON B about the incident on 9/8/17. MD M said (Resident #3) said she stood at the bedside and her legs gave way. MD M said he did not order any x-rays becuase her was not told she fell and there was no report of impact or trauma and that he ordered the x-rays after Resident #3 complained of persistant pain. During an interview on 10/11/17 at 9:15 a.m., Director of Nursing (DON) B said it was her expectation that if a person requires 1 person to assist (with transfers/ambulation) or you have to make contact with that person than you have to use a gait belt. Review of an Employee Disciplinary Record dated 10/11/17 reflected Assistant Director of Nursing (ADON) P gave a final written warning to CNA H related to Gait Belt Use and directed CNA H You must utilize your gait belt for safety purposes and follow procedure; next time (CNA H fails to use her gait belt) will be termination. CNA H was also educated on Incident Reporting, directing CNA H to ensure you will report to nurse immediately with any incident and provide nurse with accurate information of occurrence.

This citation pertains to intake number MI 619. Based on interview and record review the facility failed to provide supervision and interventions, and determine root cause to prevent falls for 1 (Resident #22) of 1 resident reviewed for falls, from a total sample of 24 residents, resulting in Resident #22 sustaining three falls, two of which were in a 90 minute time frame, not being properly assessed after the falls, and was found to have a right hip fracture. Findings Include: Review of the Record of Admission and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #22 had unclear speech, sometimes understood other, sometimes understands, had inattentive behavior, disorganized thinking and was severely impaired cognitively. Further review of the MDS revealed that Resident #22 required extensive assistance with bed mobility, transfers and activities of daily living. Review of the facility's Incident Report dated 9/19/16 at 3:00 p.m. revealed Resident #22 was found on the floor next to his wheelchair and sustained a laceration to his head. Further review of the report failed to reveal the root cause of the fall, and failed to provide any new interventions to prevent the resident from sustaining further falls. Review of the Witness Statement dated 9/19/16 revealed that Resident #22 had sustained a, Deep laceration to right side of scalp. Review of the Post-Incident Analysis form dated 9/19/16 revealed that Resident #22 was, Sent to hospital for further eval (evaluation). Review of the hospital Emergency Department Discharge Instructions dated 9/19/16 revealed that Resident #22 received staples to his scalp laceration. Review of the Post-Fall Report dated 9/19/16 revealed that Resident #22 stated he was trying to change the channel on the TV when he fell . Review of the Inter-Facility Continuity of Care Report dated 9/30/16 revealed that Resident #22 was being transferred to the hospital for, Acute displaced and angulated and rotated Fracture in the subcapital region of the neck of right hip femur (with) deformity. Review of the facility's Incident Report dated 9/28/16 at 4:00 p.m. revealed Resident #22, Tipped in wheelchair on knees. Further review of the report failed to reveal the root cause of the fall, and the intervention to prevent further recurrence of falls was, redirected to ask for help if needed. During an interview on 10/18/16 at 1:45 p.m., when asked if Resident #22 would understand that he needed to ask for help when he needed it, Certified Nursing Assistant (CNA) F stated, No, he was very frigidity, his mind wasn't there, he couldn't understand why we kept telling him to stay seated .No, he would not understand the using of the call light to get assistance. During an interview on 10/19/16 at 1:35 p.m. with the nurse that cared for Resident #22 on 9/28/16, when asked about Resident #22's falls, RN S stated, The first fall was in the hallway, there was a lot of people, and all of a sudden his fall alarm was going off, and he was still in his wheelchair, but it was flipped over and on he was on his knees, so me and another staff member kind of flipped him back into his chair. I looked him over, and he was able to move everything. When asked if an assessment was done prior to putting him in his wheelchair, RN S stated, No. Review of the facility's Incident Report dated 9/28/16 at 5:30 p.m. revealed that Resident #22 was found on the floor of his room. Review of the x-ray results dated 9/29/16 revealed Resident #22 had an, acute displaced and angulated and rotated fracture in the subcapital region of the neck of the right hip femur (hip) with deformity. Review of the Witness Statement dated 9/28/16 at 5:30 p.m., written by CNA F revealed, .heard an alarm going off. I ran out into the hall and followed the sound to (Resident #22's) room where I observed him on the floor by his roommate's bed The nurse and I put a gait belt onto resident and put him into his wheelchair. Review of the physician order [REDACTED].#22 was to a Safet Mat at bedside. Review of the nurses note dated 9/28/16 at 5:30 p.m. written by Registered Nurse (RN) S revealed, CNA alert nurse that (Resident #22) was on floor near edge of floor mattress went in with CNA helped him into wheelchair. Eval (evaluation) completed 0 (no) new bruises or opened areas. (Resident #22) was in low bed with mattress on floor, said he climbed out of bed and crawled off mattress . Review of Resident #22's Falls/Safety/Elopement Risks care plan dated 9/15/16 revealed the intervention of Safety MAT by Bed. Further review of the care plan revealed that only new interventions that were put into place were on 9/20/16, and was visitors to make staff aware when leaving. There were no new interventions that were put into place that would prevent the resident from falling from his wheelchair. During an interview on 10/19/16 at 1:35 p.m., when asked about Resident #22's second fall on 9/28/16, RN S stated, At some point he was put back to bed, he was found by the CNA on the floor touching the edge of the mattress (that was on the floor), he told the CNA that he fell . The arms he could move ok, he was able to stand up and get him back in the wheelchair and then he was able to move his legs. When asked about the mattress being at Resident #22's bedside, RN S stated, He couldn't stand on the mattress, if he tried to stand on that mattress, he would have fell . During an interview on 10/19/16 at 9:05 a.m., when asked what the intervention of Safet MAT by bed was, Registered Nurse L stated, it is a thin grey mat. During an interview on 10/18/16 at 1:45 p.m., when asked if there was a thin grey mat next to Resident #22's bed, when he was found on the floor of his room, CNA F stated no, He had a mattress on the floor, it could have had some input into his fall, he was very unstable. During an interview on 10/19/16 at 10:25 a.m., when asked if Resident #22 had a safet mat at his bedside, CNA P stated, He had a mattress on the floor. When asked if it was a regular bed mattress, CNA P stated, Yes. During an interview on 10/19/16 at 9:15 a.m., when asked if Resident #22 had a Safet mat at his bedside, CNA M stated, He had a regular mattress with a fitted sheet. When asked what the difference between a SafeT mat and a mattress was, CNA M stated, The SafeT mat or a falls mat is a thin grey mat, but he (Resident #22) had a regular mattress. During an interview on 10/19/16 at 1:35 p.m. with the nurse that cared for Resident #22 on 9/28/16, when asked if you updated Resident #22's care plan after the the two falls on 9/28/16, RN S stated, No. During this investigation, after talking with the nurse and the aides that assisted with Resident #22 after his falls on 9/28/16, and reviewing the medical chart, there was no indication that a full range of motion assessment was completed after Resident #22's falls. After both falls, Resident #22 was put back into his wheelchair before a complete assessment was completed. During an interview on 10/19/16 at 10:30 a.m., when asked if there were any documented complete post fall assessments for Resident #22's two falls on 9/28/16, Regional Quality Assurance Manger, RN C stated, I thought there was, I can look. Later on 10/19/16 at 12:00 p.m., RN C stated to me, There were no post fall assessments for (Resident #22). Yes, there should be post fall assessments completed. ( )

Based on observation, interviews, and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident resulting in residents not having accurate advanced directives or properly identified decision makers, abuse not being prevented, investigated and reported to the State Agency, not administering medications and treatments as ordered, not preventing weight loss, not administering vaccinations, not properly administering and documenting [MEDICAL CONDITION] Skin tests, not providing a safe and sanitary kitchen, not properly inservicing nurse aides, not properly training staff on the use of the electronic medical record, not maintaining clinical records with accepted professional standards and the potential for all 107 residents not to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings Include: Based on interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place and ensure a primary decision maker was identified for 4 of 5 (#3, #8, #13 and #14) residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), from a total sample of 20 residents, resulting in the potential for a resident's preferences for medical care to not be followed by the facility. Resident #3 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Face Sheet revealed Resident #3's son was her financial and medical responsible party. Review of the Letters of Guardianship revealed Resident #3's son as her guardian and reflected an expiration date of [DATE]. Review of Resident #3's Admission Agreement, revealed Resident #3's son signed as her representative, but the sections titled capacity or capacities in which you are signing (pease check all that apply) and Financial Responsible Party were not completed. Review of Resident #3's Emergency Response Directive, revealed Resident #3's son signed for Resuscitation (cardiopulmonary resuscitation/CPR) on [DATE] (11 months after the guardianship expired). In an interview on [DATE] at 11:10 am, Social Worker (SW) D reported she was not aware Resident #3's Letter of Guardianship was expired. SW D reported she should be responsible for tracking expiration dates of guardianships. ( ) Resident #8 Resident #8 was a [AGE] year old female admitted to the facility [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed Resident #8 had a BIMS score of 3 which indicated the Resident was severely cognitively impaired. Review of the medical record Face Sheet for Resident #8 revealed no Advance Directive was in place. The Face Sheet indicated Friend P was the first contact but had no financial or medical responsibility. Review of the medical record for Resident #8 did not reveal a guardian or patient advocate had been assigned, requested or accepted by Resident #8. The medical record did not reveal a Power of Attorney (POA). The medical record did not reveal documentation Resident #8 had been deemed mentally incompetent by medical providers. Review of the medical record revealed the facility form, Consent to Treat, dated [DATE]. The form, signed by Friend P, indicated, .constitutes . agreement to permit the rendering of health care services to Resident #8. Review of the medical record did not reveal documentation that granted the authority to Friend P to give this consent on the behalf of Resident #8. Review of the facility document, Advance Directive Notification/Acknowledgement, dated [DATE], indicated Resident #8 had executed an Advance Medical Directive and was signed by Friend P. Review of the medical record did not reveal documentation that granted the authority to Friend P to give this acknowledgement on the behalf of Resident #8. Review of the facility document dated [DATE], for, Emergency Response Directive for (Resident #8), addressed what medical actions were Resuscitation, where full life support measures may be undertaken. And 2) No Resuscitation, this means that the facility's staff will not attempt to artificially maintain my heartbeat and/or respiration. The form revealed both sections had been signed by Friend P with the Authority of a Power of Attorney. Based on interview and record review the facility failed to notify one guardian of a pressure ulcer (#2) and failed to update legal representatives of 3 residents (#2,#3 and #14) of 5 residents sampled for advanced directives, of a total sample of 20 residents, resulting in one legal representatives not being notified of a change in condition and the potential for other legal representative not to be contacted when there was a change in medical condition. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Face Sheet revealed Resident #3's son was her financial and medical responsible party. Review of the Letters of Guardianship revealed Resident #3's son as her guardian and reflected an expiration date of [DATE]. The Letter of Guardianship revealed a different address for Resident #3's son than the Face Sheet indicated. In an interview on [DATE] at 11:10 am, Social Worker (SW) D reported she was not aware Resident #3's Letter of Guardianship was expired. SW D reported she should be responsible for tracking expiration dates of guardianships. ( ) Based on interview, and record review, the facility failed to prevent an incident of verbal abuse in 1 (#15) of 3 sampled residents reviewed for abuse, from a total of 20 residents, resulting in the resident crying, weeping and becoming very anxious. Findings include: Review of the facility's Abuse Prohibition, Investigation and Reporting policy revised ,[DATE] revealed, It is the policy of the facility to prohibit mistreatment, neglect, and abuse of guests/residents .The facility shall not allow verbal, mental, sexual, or physical abuse .The facility will not condone guest abuse by anyone .The facility will screen prospective employees in order to not employ individuals who have been found guilty of abusing, neglecting, mistreating .of residents .At least two (2) employment reference checks are to be completed on all applicants prior to employment. Negative findings regarding abuse, neglect, or mistreatment eliminate the applicant from being considered for employment .A review of the applicant's past history must be considered prior to hiring and reasonable efforts must be made to uncover information about any past history .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #15 had clear speech, understood, usually understands was severely impaired cognitively, required extensive assistance of staff for Activities of Daily Living and was frequently incontinent of bowel. Review of the Facility Investigation Summary submitted to the State Agency dated, [DATE] revealed, On [DATE] A staff member passed (Resident #15's) open door way and heard (Certified Nursing Assistant (CNA) O) ask (Resident #15) if she shit on the floor. Later when asked, (Resident #15) confirmed that the nurse aide asked the question. (Resident #15) did become tearful when she was asked to confirm the situation. During an interview on [DATE] at 12:18 p.m., when asked to describe Resident #15's demeanor when asking about the incident, Assistant Director of Nursing (ADON) C stated, She did become quite tearful. I sat with her quite a while, she was weeping and crying, she was very anxious. Review of the Payroll Authorization Form dated [DATE] revealed that CNA O was terminated on [DATE] for, Violation of the Abuse policy. Review of CNA O's personnel record revealed that CNA O's employment from the facility was previously terminated just six months prior, on [DATE], for a neglectful act; however CNA O was rehired on [DATE]. Review of the Employee Disciplinary Record dated [DATE] revealed CNA O was terminated on [DATE] related to an incident in which, There was a guest complaint that (CNA O) answered a call light, stated it was the other CNAs job and left the room resulting in the guest being incontinent. When (CNA O) was asked to perform a care for a guest you blew it off and stated you had charting to do. Review of the Payroll Authorization Form dated [DATE] revealed that CNA O was terminated from employment and was not eligible for re-hire. In an interview on [DATE] at 12:18 p.m., when asked if telling a resident that they would not assist a resident to be toileted, and it resulted in that resident being incontinent, would be considered neglect and should be reported as such, ADON C stated, Yes, I would call that neglect. During an interview on [DATE] at 8:25 a.m., when asked why CNA O was re-hired, Nursing Home Administrator (NHA) A stated, The DON (Director of Nursing) re-hired her, the former DON. I think we did have a conversation, but I don't remember (the former DON's) response. I know it was not a good idea. NHA A reviewed the Employment Disciplinary Record dated [DATE], and was asked if he was familiar with the circumstances surrounding CNA O being terminated the first time in May of 2015, NHA A replied, No, I can't remember exactly. ( ) Based on interview, and record review, the facility failed to prevent an incident of neglect in 1 unidentified resident (#21) of 3 sampled residents reviewed for neglect, from a total sample of 20 residents, resulting in the resident being incontinent and the potential for mental anguish. Findings include: Review of the facility's Abuse Prohibition, Investigation and Reporting policy revised ,[DATE] revealed, It is the policy of the facility to prohibit mistreatment, neglect, and abuse of guests/residents .The facility shall not allow verbal, mental, sexual, or physical abuse .The facility will not condone guest abuse by anyone .The facility will screen prospective employees in order to not employ individuals who have been found guilty of abusing, neglecting, mistreating .of residents .At least two (2) employment reference checks are to be completed on all applicants prior to employment. Negative findings regarding abuse, neglect, or mistreatment eliminate the applicant from being considered for employment .A review of the applicant's past history must be considered prior to hiring and reasonable efforts must be made to uncover information about any past history .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Review of the Employee Disciplinary Record dated [DATE] revealed CNA O was terminated on [DATE] related to an incident in which, 1. There was a guest (Unidentified Resident #21) complaint that (CNA O) answered a call light, stated (to the resident that) it was the other CNAs job and left the room resulting in the guest being incontinent. 2. When (CNA O) was asked to perform a care for a guest you blew it off and stated you had charting to do. Review of the Payroll Authorization Form dated [DATE] revealed that CNA O was terminated from employment and was not eligible for re-hire. In an interview on [DATE] at 12:18 p.m., when asked if telling a resident that they would not assist a resident to be toileted, and it resulted in that resident being incontinent, would be considered neglect and should be reported as such, Assistant Director of Nursing (ADON) C stated, Yes, I would call that neglect. During an interview on [DATE], when asked if this incident was reported and investigated as neglect, Nursing Home Administrator (NHA) A stated, No, it was not reported, it wasn't reported to me. I didn't even know about it until we looked at her (CNA O's) personnel record. When asked if it was known who the resident was, NHA A stated, No. The Director of Nursing (DON) and the ADON at the time of this incident no longer worked at the facility, and therefore were not available for an interview. ( ) Based on interview and record review, the facility failed to report to the Nursing Home Administrator, and the state agency an allegation of abuse and neglect in 1 resident (Unknown Resident #21) of 3 sampled residents reviewed for abuse and neglect from a total sample of 20, resulting in a neglectful act not being investigated, reported to the state agency, and a staff member further abusing/neglecting residents (Resident #15). Findings include: Review of the facility's Abuse Prohibition, Investigation and Reporting policy revised ,[DATE] revealed, It is the policy of the facility to prohibit mistreatment, neglect, and abuse of guests/residents .The facility shall not allow verbal, mental, sexual, or physical abuse .The facility will not condone guest abuse by anyone .The facility will screen prospective employees in order to not employ individuals who have been found guilty of abusing, neglecting, mistreating .of residents .At least two (2) employment reference checks are to be completed on all applicants prior to employment. Negative findings regarding abuse, neglect, or mistreatment eliminate the applicant from being considered for employment .A review of the applicant's past history must be considered prior to hiring and reasonable efforts must be made to uncover information about any past history .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .All allegations of abuse must be reported immediately to the Administrator .The Administrator is responsible for ensuring that allegations of abuse are reported to the State Licensing Agency, the Ombudperson, and/or other agencies as required by law. This includes the initial 24-hour and five (5) day reports. Review of the Employee Disciplinary Record dated [DATE] revealed CNA O was terminated on [DATE] related to an incident in which, 1. There was a guest (Unidentified Resident #21) complaint that (CNA O) answered a call light, stated (to the resident that) it was the other CNAs job and left the room resulting in the guest being incontinent. 2. When (CNA O) was asked to perform a care for a guest you blew it off and stated you had charting to do. Review of the Payroll Authorization Form dated [DATE] revealed that CNA O was terminated from employment and was not eligible for re-hire. In an interview on [DATE] at 12:18 p.m., when asked if telling a resident that they would not assist a resident to be toileted, and it resulted in that resident being incontinent, would be considered neglect and should be reported as such, Assistant Director of Nursing (ADON) C stated, Yes, I would call that neglect. During an interview on [DATE], when asked if this incident was reported and investigated as neglect, Nursing Home Administrator (NHA) A stated, No, it was not reported, it wasn't reported to me. I didn't even know about it until we looked at her (CNA O's) personnel record. When asked if it was known who the resident was, NHA A stated, No. The Director of Nursing (DON) and the ADON at the time of this incident no longer worked at the facility, and therefore were not available for an interview. According to the personnell record, CNA O was terminated from employment on [DATE] after neglecting an unknown resident. On [DATE], even though the Payroll Authorization Form dated [DATE] revealed that CNA O was not eligible for re-hire, CNA O was rehired to the facility. On [DATE] the following incident took place in the facility, in which CNA O was once again terminated for, Violation of the Abuse Policy: Review of the Facility Investigation Summary submitted to the State Agency dated, [DATE] revealed, On [DATE] A staff member passed (Resident #15's) open door way and heard (Certified Nursing Assistant (CNA) O) ask (Resident #15) if she shit on the floor. Later when asked, (Resident #15) confirmed that the nurse aide asked the question. (Resident #15) did become tearful when she was asked to confirm the situation. Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #15 had clear speech, understood, usually understands was severely impaired cognitively, required extensive assistance of staff for Activities of Daily Living and was frequently incontinent of bowel. During an interview on [DATE] at 12:18 p.m., when asked to describe Resident #15's demeanor when asking about the incident, Assistant Director of Nursing (ADON) C stated, She did become quite tearful. I sat with her quite a while, she was weeping and crying, she was very anxious. During an interview on [DATE] at 8:25 a.m., when asked why CNA O was re-hired, Nursing Home Administrator (NHA) A stated, The DON (Director of Nursing) re-hired her, the former DON. I think we did have a conversation, but I don't remember (the former DON's) response. I know it was not a good idea. NHA A reviewed the Employment Disciplinary Record dated [DATE], and was asked if he was familiar with the circumstances surrounding CNA O being terminated the first time in May of 2015, NHA A replied, No, I can't remember exactly. ( ) Based on interview and record review, the facility failed to operationalize its policy and procedures for reporting an allegation of abuse, in 1 resident (Unknown Resident #21) of 3 sampled residents reviewed for abuse and neglect from a total sample of 20 and screening of employees prior to hiring in 1 staff member (Certified Nursing Assistant (CNA) O), and the protection of residents, resulting in a neglectful act not being investigated, reported to the state agency, and a staff member being inappropriately re-hired and further abusing/neglecting residents (Resident #15). Findings include: Review of the facility's Abuse Prohibition, Investigation and Reporting policy revised ,[DATE] revealed, It is the policy of the facility to prohibit mistreatment, neglect, and abuse of guests/residents .The facility shall not allow verbal, mental, sexual, or physical abuse .The facility will not condone guest abuse by anyone .The facility will screen prospective employees in order to not employ individuals who have been found guilty of abusing, neglecting, mistreating .of residents .At least two (2) employment reference checks are to be completed on all applicants prior to employment. Negative findings regarding abuse, neglect, or mistreatment eliminate the applicant from being considered for employment .A review of the applicant's past history must be considered prior to hiring and reasonable efforts must be made to uncover information about any past history .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .All allegations of abuse must be reported immediately to the Administrator .The Administrator is responsible for ensuring that allegations of abuse are reported to the State Licensing Agency, the Ombudperson, and/or other agencies as required by law. This includes the initial 24-hour and five (5) day reports. Review of the Employee Disciplinary Record dated [DATE] revealed CNA O was terminated on [DATE] related to an incident in which, 1. There was a guest (Unidentified Resident #21) complaint that (CNA O) answered a call light, stated (to the resident that) it was the other CNAs job and left the room resulting in the guest being incontinent. 2. When (CNA O) was asked to perform a care for a guest you blew it off and stated you had charting to do. Review of the Payroll Authorization Form dated [DATE] revealed that CNA O was terminated from employment and was not eligible for re-hire. In an interview on [DATE] at 12:18 p.m., when asked if telling a resident that they would not assist a resident to be toileted, and it resulted in that resident being incontinent, would be considered neglect and should be reported as such, Assistant Director of Nursing (ADON) C stated, Yes, I would call that neglect. During an interview on [DATE], when asked if this incident was reported and investigated as neglect, Nursing Home Administrator (NHA) A stated, No, it was not reported, it wasn't reported to me. I didn't even know about it until we looked at her (CNA O's) personnel record. When asked if it was known who the resident was, NHA A stated, No. The Director of Nursing (DON) and the ADON at the time of this incident no longer worked at the facility, and therefore were not available for an interview. In summary, CNA O was terminated from employment on [DATE] after neglecting an unknown resident. On [DATE], even though the Payroll Authorization Form dated [DATE] revealed that CNA O was not eligible for re-hire, CNA O was rehired to the facility. On [DATE] the following incident took place in the facility, in which CNA O was once again terminated for, Violation of the Abuse Policy: Review of the Facility Investigation Summary submitted to the State Agency dated, [DATE] revealed, On [DATE] A staff member passed (Resident #15's) open door way and heard (Certified Nursing Assistant (CNA) O) ask (Resident #15) if she shit on the floor. Later when asked, (Resident #15) confirmed that the nurse aide asked the question. (Resident #15) did become tearful when she was asked to confirm the situation. Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #15 had clear speech, understood, usually understands was severely impaired cognitively, required extensive assistance of staff for Activities of Daily Living and was frequently incontinent of bowel. During an interview on [DATE] at 12:18 p.m., when asked to describe Resident #15's demeanor when asking about the incident, Assistant Director of Nursing (ADON) C stated, She did become quite tearful. I sat with her quite a while, she was weeping and crying, she was very anxious. During an interview on [DATE] at 8:25 a.m., when asked why CNA O was re-hired, Nursing Home Administrator (NHA) A stated, The DON (Director of Nursing) re-hired her, the former DON. I think we did have a conversation, but I don't remember (the former DON's) response. I know it was not a good idea. NHA A reviewed the Employment Disciplinary Record dated [DATE], and was asked if he was familiar with the circumstances surrounding CNA O being terminated the first time in May of 2015, NHA A replied, No, I can't remember exactly. ( ) Based on interview and record review, the facility failed to provide timely medically related social services for 6 of 6 Residents (#2, #3, #8, #13, #14 and #15) reviewed for social services, from a total of 20 sampled residents, resulting in residents not having accurate advance directives, residents not having social services follow up visits after being abused and the the potential for residents not being able to maintain her highest physical, mental and psychosocial well being. Findings include: Review of the facility's Advanced Directives Policy and Procedure, undated, revealed, In the State of Michigan, a person of sound mind may create an advance directive appointing another individual, a patient advocate, to make decisions concerning his/her care, custody and medical treatment in the event that the person is unable to participate in such decisions .In case of a resident adjudicated incompetent (unable to make their own decisions) under the laws of Michigan by a court of competent jurisdiction, the right of the resident are exercised by the person appointed under Michigan law to act on the resident's behalf (a guardian) .At the time each individual is admitted as a resident, the resident shall be provided with a copy of the attached information regarding advance directives .The facility shall inquire of each resident, at the time of admission and periodically thereafter, whether or not the resident has executed an advance directive, a living will, or has otherwise made his/her treatment wishes known. The facility shall document in the clinical record. During an interview on [DATE] at 12:25 p.m., when asked when residents are asked to provide guardianship paperwork or advance directives, Admissions Director (Staff F) stated, upon admission the admission packet is reviewed and signed with the resident, If they say they have a DPOA (Durable Power of Attorney) or guardian, I will mark yes and then ask them to give that paperwork to the Social Worker during their first care conference. When asked when the first care conference was usually held, Staff F stated, We like to have them within 72 hours of admission. When asked if any type of advance directive paperwork was provided to the resident upon admission, Staff F stated, no, do not give out any information. Staff F further stated that it was the Social Worker's responsibility to collect guardianship paperwork and advance directive paperwork during the first care conference. Resident #13 Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #13 was a [AGE] year old female resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #13 had clear speech, was moderately impaired cognitively and required staff assistance for Activities of Daily Living. During an interview on [DATE] at 11:45 a.m., when asked who Resident #13's responsible party was, and who was contacted to make medical decisions, Social Worker (SW) D stated, It is the niece. Review of a Social Work note for Resident #13, dated [DATE] revealed, Resident's niece remains as POA (Power of Attorney) and makes all medical and financial decisions. However review of the medical chart failed to reveal that Resident #13's niece was the actual POA or guardian. Review of Resident #13's face sheet did reveal that Resident #13's niece was listed as the 1st Contact but was not listed as the responsible party. Further review of Resident #13's medical record revealed a very confusing trail of paperwork regarding Resident #13's guardian. First, was a Letters of Guardianship dated [DATE] naming Resident #13's niece as the guardian. Second was a Letters of Guardianship dated [DATE] naming Guardian N as Resident #13's guardian, however these letters expired on [DATE]. Further review of Resident #13's medical record failed to reveal any updated information regarding who Resident #13's responsible party was. During an interview on [DATE] at 11:45 a.m., when shown the expired guardianship letters for Resident #13, SW D stated, The niece is the guardian, I will call her and have her send me an updated one. When asked if she was aware of the guardianship letters being expired, SW D stated, No., yet the Letters of Guardianship had been expired for over 3 years. During an interview on [DATE] at 1:15 p.m., this surveyor asked SW D if up to date guardianship paperwork for Resident #13 had been received yet, SW D stated no. This surveyor then requested that SW D call the County Office to determine who Resident #13's actual guardian was. On [DATE] at approximately 2:00 p.m., SW D provided this surveyor with Letters of Guardianship dated [DATE] with an Expiration Dated Extended To of [DATE] naming Guardian N Resident #13's legal guardian, not Resident #13's niece. Resident #14 Review of the face sheet an most recent Minimum Data Set assessment dated [DATE] revealed Resident #14 was a [AGE] year old female resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #14 had clear speech, was understood, understands and required assistance of staff for Activities of Daily Living. Review of the face sheet revealed that a guardian was listed for Resident #14 as being the responsible party, however review of the Letters of Guardianship dated [DATE] revealed that the guardianship expired on [DATE]. During an interview on [DATE] at 11:45 SW D stated that she was aware of the Letters of Guardianship being expired, but thought there were updated letters stating, I will have to check and see. SW D failed to provide this surveyor with any updated information regarding Resident #14's legal guardianship status prior to exit. Review of the admission contract paperwork revealed that on [DATE] a form titled Advance Directive Notification/Acknowledgement was signed by the resident, however nothing on the form was checked, and therefore there was no indication as to whether or not Resident #14 had any type of advance directive or was provided any information regarding advance directives. Review of Resident #14's medical record failed to reveal any type of advance directives. Resident #15 Review of the facility's Abuse Prohibition, Investigation and Reporting policy revised ,[DATE] revealed, Upon receiving information concerning an allegation of abuse, neglect, mistreatment, or misappropriation, the Director of Nursing of Administrator will request that a representative of the Social Services Department monitor the guest's feeling concerning the incident, as well as the guest's reactions to his or her involvement . Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #15 had clear speech, understood, usually understands was severely impaired cognitively, required extensive assistance of staff for Activities of Daily Living and was frequently incontinent of bowel. Review of the Facility Investigation Summary submitted to the State Agency dated, [DATE] revealed, On [DATE] A staff member passed (Resident #15's) open door way and heard (Certified Nursing Assistant (CNA) O) ask (Resident #15) if she shit on the floor. Later when asked, (Resident #15) confirmed that the nurse aide asked the question. (Resident #15) did become tearful when she was asked to confirm the situation. During an interview on [DATE] at 12:18 p.m., when asked to describe Resident #15's demeanor when asking about the incident, Assistant Director of Nursing (ADON) C stated, She did become quite tearful. I sat with her quite a while, she was weeping and crying, she was very anxious. Review of the complete medical record failed to reveal that there was any type of social services monitoring of Resident #15's feelings or reactions after the verbal abuse incident. During an interview on [DATE] at 11:45 a.m., Social Worker (SW) D was asked to provide any docum

This citation pertains to intake number MI 857 Based on interview, and record review, the facility failed to prevent an incident of verbal abuse in 1 (#15) of 3 sampled residents reviewed for abuse, from a total of 20 residents, resulting in the resident crying, weeping and becoming very anxious. Findings include: Review of the facility's Abuse Prohibition, Investigation and Reporting policy revised 12/2009 revealed, It is the policy of the facility to prohibit mistreatment, neglect, and abuse of guests/residents .The facility shall not allow verbal, mental, sexual, or physical abuse .The facility will not condone guest abuse by anyone .The facility will screen prospective employees in order to not employ individuals who have been found guilty of abusing, neglecting, mistreating .of residents .At least two (2) employment reference checks are to be completed on all applicants prior to employment. Negative findings regarding abuse, neglect, or mistreatment eliminate the applicant from being considered for employment .A review of the applicant's past history must be considered prior to hiring and reasonable efforts must be made to uncover information about any past history .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #15 had clear speech, understood, usually understands was severely impaired cognitively, required extensive assistance of staff for Activities of Daily Living and was frequently incontinent of bowel. Review of the Facility Investigation Summary submitted to the State Agency dated, 5/21/16 revealed, On 5/20/16 A staff member passed (Resident #15's) open door way and heard (Certified Nursing Assistant (CNA) O) ask (Resident #15) if she shit on the floor. Later when asked, (Resident #15) confirmed that the nurse aide asked the question. (Resident #15) did become tearful when she was asked to confirm the situation. During an interview on 6/8/15 at 12:18 p.m., when asked to describe Resident #15's demeanor when asking about the incident, Assistant Director of Nursing (ADON) C stated, She did become quite tearful. I sat with her quite a while, she was weeping and crying, she was very anxious. Review of the Payroll Authorization Form dated 5/24/16 revealed that CNA O was terminated on 5/20/16 for, Violation of the Abuse policy. Review of CNA O's personnel record revealed that CNA O's employment from the facility was previously terminated just six months prior, on 10/13/15, for a neglectful act; however CNA O was rehired on 12/15/15. Review of the Employee Disciplinary Record dated 10/7/15 revealed CNA O was terminated on 10/7/15 related to an incident in which, There was a guest complaint that (CNA O) answered a call light, stated it was the other CNAs job and left the room resulting in the guest being incontinent. When (CNA O) was asked to perform a care for a guest you blew it off and stated you had charting to do. Review of the Payroll Authorization Form dated 10/13/15 revealed that CNA O was terminated from employment and was not eligible for re-hire. In an interview on 6/8/16 at 12:18 p.m., when asked if telling a resident that they would not assist a resident to be toileted, and it resulted in that resident being incontinent, would be considered neglect and should be reported as such, ADON C stated, Yes, I would call that neglect. During an interview on 6/8/16 at 8:25 a.m., when asked why CNA O was re-hired, Nursing Home Administrator (NHA) A stated, The DON (Director of Nursing) re-hired her, the former DON. I think we did have a conversation, but I don't remember (the former DON's) response. I know it was not a good idea. NHA A reviewed the Employment Disciplinary Record dated 10/7/15, and was asked if he was familiar with the circumstances surrounding CNA O being terminated the first time in May of 2015, NHA A replied, No, I can't remember exactly. ( )

This citation pertains to MI 246 This case was discussed with CMS in Chicago prior to calling Immediate Jeopardy. Based on observation, interview, and record review, the facility failed to ensure a safe environment and provide adequate supervision for 1 of 7 sampled residents (Resident #101) reviewed for safety, from a total sample of 7 residents, resulting in an Immediate Jeopardy when, on 1/15/16, Resident #101 eloped from the facility unbeknownst to staff, without winter clothing for an undetermined amount of time, then fell into the snow and was unable to get up. Resident #101 sustained hypothermia (dangerously low body temperature). This deficient practice placed 18 additional residents, who were assessed as risk of elopement, at a high risk of serious injury, harm, impairment, or death. Findings include: Resident #101 Review of the Record of admitted d 5/15/15, revealed Resident #101 was a [AGE] year-old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 needed limited assist with 1 (one) staff assist for: transfers, walking, and eating. A Staff Assessment for Mental Status from the MDS assessment reflected Resident #101's cognitive status was moderately impaired. Review of Resident #101's Care Plan titled Wander and dated 8/17/15 indicated Resident #101: WANDER: At risk for elopement related to wandering; poor insight into boundaries of peers, and has wandered into peers rooms. Further review of Care Plan revealed : Goals: Will not leave facility unattended. Approaches/Interventions: Redirect away from exit doors as needed, Observe whereabouts frequently. On 6/4/15 an update to Care Plan revealed : Behaviors related to Dementia: Guest will often times, wander in hallway and into other guest rooms. Review of a facility Incident Report for Resident #101 dated 1/15/16 at 8:30 p.m. Type of occurrence: Elopement , Type of injury: Other- Cold, Red buttock & feet, Location: Courtyard. Review of the Post Incident Analysis not dated report revealed area listed as Reporting-Is this reportable to the Licensing Entity? yes/no box was unchecked. There were no signatures on the incident report from the facility Director of Nursing (DON) J, Nursing Home Administrator (NHA) J, and Medical Director. Review of a facility Witness Statement dated 1/15/16 (no time noted) indicated Certified Nurse Aide (CNA) E documented Another resident rushed over to 400 hall and yelled, 'A lady is laying in the snow'. I ran full speed outside the lady (Resident #101) was sitting in the snow. I dropped down behind her, wrapped my arms and body around her to give her my body heat. Review of a facility Witness Statement dated 1/15/16 (no time noted) indicated Licensed Practical Nurse (LPN) B was assigned to Resident #101. LPN B documented, I heard (CNA E) say 'Someone is laying in the snow, in the courtyard'. I ran to courtyard where I saw (Resident #101) lying in the snow from waist down, on right elbow. I told (CNA E) to stay with (Resident #101). I ran inside and paged for more help. Further review of witness statement revealed area on document asks What did resident say happened? LPN B documented Resident #101 didn't, unable to understand, self talk. LPN B documented assessment after incident Brought (Resident #101) inside, placed in bed, removed all wet clothing- buttock very red, feet red, skin cold. Review of a facility Witness Statement dated 1/15/16 (no time noted) indicated CNA C was assigned to Resident #101. CNA C last observed Resident #101 in the diversional room (dining room b) at 7:45 p.m. Further review of document revealed the detailed description of what CNA C observed : I observed her (Resident #101) sitting in the snow with another (CNA E) holding her at 8:30 p.m. Review of a Nursing Note dated 1/16/16 at 1:03 a.m. indicated Resident #101 was found in snow, brought inside and placed in bed. Removed wet clothing and warm blankets applied. Temp = 94.5. Pulse = 72. Respiratory = 20. Blood Pressure = 122/64. Buttocks dark red, feet red, and skin cold. Nursing note written by LPN B. Review of a facility Elopement Assessment dated 12/12 indicated Resident #101 was at risk for elopement, further review revealed To be completed by Licensed Nurse or Social Worker quarterly, or significant change in condition. The revised/reviewed dates noted on Resident #101's Elopement Assessment revealed the assessment was revised/reviewed on dates 6/15/13 and not again until 1/15/16 was a revised/reviewed date noted on the assessment, over 2 1/2 (two and a half) years later. Review of a Physicians Note signed by Physician D on 1/21/16 at 1:44 p.m. revealed The patient (Resident #101) was seen in her room (on 1/15/16). The patient was seen to follow up on multiple concerns. The patient (Resident #101) had sustained an unwitnessed fall in the backyard at the facility with an unknown downtime and estimated to be around 20 minutes. The patient (Resident #101) was lying in the snow until the staff discovered her and brought her to her room. General Appearance: (Resident #101) is in no apparent distress other than saying that she is cold and wanted to be covered. Skin examination reveals multiple areas of redness on the back and the buttocks. Further review revealed Assessment&Plan : 1. Fall likely due to mechanical fall and possible slipping on the snow. 2. Hypothermia: Temperature is 94.8. During an interview and observation on 1/19/16 at 2:00 p.m. in Resident #101's bedroom, Resident #101 stated One week ago today, 2 men pulled me out of the snowy, watery ditch. I thought I was about to freeze to death, my left hand still isn't working right, it's a weird feeling, feels numb and tingly. During an interview on 1/19/16 at 2:55 p.m., Director of Nursing (DON) J stated that Resident #101 was found outside in the snow by another resident who had gone outside to the facility courtyard to smoke on 1/15/16 at approximately 8:30 p.m. On 1/15/16 at approximately 8:35 p.m. the DON J returned to the facility from the parking lot once DON was notified (DON was working late the evening of 1/15/16, and just about to leave for the night) of the incident by LPN B to assist with the assessment and treatment for [REDACTED]. DON J stated Intravenous fluids (IV) were initiated by Emergency Medical Personal (Ambulance) for treatment of [REDACTED]. The physician took a tympanic (in the ear) temperature with a result of 94.8. When asked if the DON J was aware of the outside air temperature on 1/15/15, DON J stated I don't know what it was. When asked how long it takes for an elderly person to become hypothermic (hypothermia-low body temperature) the DON J stated it's a matter of minutes. When asked by this surveyor if she or anyone reported Resident #101 being found outside in the snow in the courtyard, by another resident to the State Agency (SA), the DON J stated No, because she was found on the premises. The outside air temperature on 1/15/16 at approximately 8:10 p.m. was 34 degrees Fahrenheit (F), wind chill factor 25 degrees (F), a west wind at 12.7 miles per hour with approximately 4 inches of snow on the ground. http://www.wunderground.com/history Hypothermia is defined as A potentially fatal condition, occurs when body temperature falls below 95 degrees Fahrenheit (F). (Normal body temperature range is 98.6 degrees Fahrenheit). www.medical-dictionary.com <http://www.medical-dictionary.com>. · Hypothermia: Cold-Blooded Killer When your body temperature sinks below 96°F, you have hypothermia. Prolonged exposure to temperatures as warm as 60°F, particularly in water, can trigger hypothermia if you aren't properly dressed. Of the 28,000 people hypothermia kills yearly, most are seniors, according to the National Institute of Aging, but some are children and young adults. Everyone needs to be careful. Some medicines, problems with circulation, and certain illnesses may reduce your ability to resist hypothermia. As you age, your body becomes less efficient at letting you know when you are too cold. In addition, older people tend not to shiver effectively, one of the ways the body warms itself up. http://www.nws.noaa.gov/om/winter/cold.shtml (National Oceanic and Atmospheric Administration <http://www.noaa.gov>National Weather Service <http://www.weather.gov>) During an interview on 1/19/16 at 3:50 p.m., CNA C indicated she was assigned to Resident #101 on 1/15/16 and last observed her in the dining room (b) at approximately 7:45 p.m. CNA C stated I had forgotten to check on (Resident #101's Wander Care Plan intervention observe resident frequently) (Resident #101) after 7:45 p.m. because I was assisting another staff member with cares for another resident. The door that Resident #101 went through was unlocked, it typically has a key up on the frame in a magnetic box, the door is supposed to be locked. I am unsure how it got unlocked or who would have checked it last to see if it was locked. CNA C reported when she heard Resident #101 was found outside lying in the snow, CNA C ran to get blankets and went outside to help. CNA C stated, (Resident #101) appeared very cold, (Resident #101) was wearing pants, a short sleeve shirt, and tennis shoes. (Resident #101) was confused, staff assisted (Resident #101) back into the facility and into her bed, (Resident #101's) temperature was taken. CNA C was asked what Resident #101's temperature was, and which route was used, CNA C stated (Resident #101's) temperature was tympanic and 92.8 degrees. The oral (by mouth) would not work. During an interview on 1/19/16 at 4:05 p.m., CNA E indicated she heard a male resident who was at the end of the hall near a courtyard door where residents who smoke meet, yelling there is a lady laying in the snow. CNA E reported she ran to the courtyard, Resident #101 was next to her walker and had fallen in the snow. Resident #101 was cold and shivering and was wearing a short sleeve shirt, pants, no jacket and black shoes. Staff came after LPN B had went back inside and called for help, (Resident #101) was taken back to her room, wet clothes were removed. During an interview on 1/19/15 at 4:45 p.m., Nursing Home Administrator (NHA) J indicated the door to an outside courtyard was not locked at the time Resident #101 exited through it on 1/15/16. During an interview on 1/20/16 at 10:00 a.m., when asked why Intervenous fluids (IV) were started on Resident #101, DON J stated to increase Resident #101's core temperature. I had initially tried before the ambulance arrived to start the IV but I blew the vein. When asked why Resident #101 was not sent to the Emergency Department (ED), DON J reported the on-site physician D decided to treat Resident #101 at the facility for hypothermia. During an interview on 1/20/16 at 3:20 p.m., Physician D stated On 1/15/16 sometime after 8:30 p.m. I was called into (Resident #101's) room and informed Resident #101 was found lying outside in the snow, upon assessment Resident #101 was shivering, her back, and buttocks were red. I initiated an order for [REDACTED].#101's) temperature and prevent dehydration due to shivering, passive warming was done as well through the use of blankets. During an interview on 1/20/16 at 4:55 p.m. with the facility NHA I, DON J and Corporate- Quality Assurance (QA) H, this surveyor asked why the exit door in which Resident #101 was able to gain unsupervised access to the outside courtyard was not locked, alarmed for wander guards, alarmed with a key pad alarm system and/or any other alarming device, NHA J said I don't know, I just don't know. During a telephone interview on 1/25/16 at 4:10 p.m., LPN B indicated on 1/15/16 at approximately 8:30 p.m. she heard commotion down the hall as she was passing medications, LPN B heard a male yelling someone is laying in the snow in the courtyard. LPN B reported she took off running down the hall to the outside courtyard, when she approached Resident #101 CNA E was with Resident #101 attempting to warm her up. Resident #101 was confused and talking about Jesus at initial assessment. LPN B and CNA E attempted to stand Resident #101 unsuccessfully, LPN B ran back inside to get help. Staff came and assisted Resident #101 into a wheelchair and to her bedroom. Resident #101 was taken out of wet clothing and warmed with blankets. LPN B stated Resident #101's buttocks was beet red LPN B went on to reveal the DON J and Physician D were in the facility. an order for [REDACTED].#101 was assessed by him. When asked when the last time LPN B observed Resident #101 LPN B stated before 7:55 p.m. because at that time I was out of the building smoking a cigarette, and then I came back inside, I have low blood sugar and had to have a snack. Further questioning revealed LPN B was assigned to Resident #101 as charge nurse/supervisor on Resident #101's unit. Review of employee files on 1/25/16 revealed LPN B had 6 (six) Employee Disciplinary Records from 2/24/15-11/18/15 in which the 6 th resulted in the following communication between the DON and LPN B and which indicated LPN B Refused to sign the disciplinary communication revealed : November 18, 2015 Subject: work performance (LPN B) your responsibilities as a charge nurse include multitasking, medication administration, and knowing or being familiar with company policies, and prioritizing. As a licensed nurse you are required to provide supervision in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the DON or RN Charge Nurse/Supervisor to ensure that the highest degree of quality care is maintained at all times. We have had several discussions over the past few weeks about prioritizing .Given the continuance of performance issues, I am giving you a Final written warning. Your performance must improve immediately, or further disciplinary action, up to an including discharge will result. On 1/20/16 at 4:55 p.m., the facility Nursing Home Administrator, and Director of Nursing were notified of the Immediate Jeopardy that was identified on 1/19/16 and began on 1/15/16 due to the facility failure to ensure a safe environment and provide adequate supervision to prevent Resident #101, who was a known elopement risk, from getting out a door that is normally locked, falling in the snow for an unidentified amount of time, being found by another resident who happened to go out doors to smoke, and required treatment for [REDACTED]. On 1/21/16 at 2:00 p.m. this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Exit door in dining room b to the outside courtyard had been alarmed and locked. 2. All staff were in-serviced on resident safety, accidents and hazards by the Nursing Home Administrator (NHA) and Director of Nursing (DON) starting on 1/15/16-1/21/16, staff will not be allowed to work their shift until in-serviced at next scheduled work day. 3. All staff were in-serviced on supervision of residents by the Nursing Home Administrator and Director of Nursing starting on 1/21/16-1/25/16, any staff not present will not be allowed to work their scheduled shift until in-serviced by the NHA/DON or Assistant Director of Nursing. Although the facility removed the Immediate Jeopardy on 1/21/16, 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 all facility staff have not yet been educated and the State Agency had not yet verified sustained compliance.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO REPOSITION TO RELIEVE PRESSURE, MONITOR THE CONDITION OF A PRESSURE RELIEVING CUSHION, AND MAINTAIN THE CUSHION IN A MANNER THAT WOULD MINIMIZE THE RISK OF PRESSURE ULCERS FOR 1 RESIDENT (#2), AND FAILED TO PROVIDE A PRESSURE RELIEVING DEVICE FOR A SECOND RESIDENT (#3), OUT OF 3 RESIDENTS REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN THE DEVELOPMENT OF AN AVOIDABLE STAGE 3 PRESSURE ULCER FOR RESIDENT #2 AND A STAGE 2 PRESSURE ULCER FOR RESIDENT #3. FINDINGS INCLUDE: ACCORDING TO THE physician's orders [REDACTED]. ACCORDING TO THE DOCUMENT TITLED, "MICHIGAN DEPARTMENT OF COMMUNITY HEALTH COMPREHENSIVE LEVEL II EVALUATION", DATED 8/17/12, RESIDENT #2 HAD A PRIMARY [DIAGNOSES REDACTED]. RESIDENT #2 WAS ASSESSED AS HAVING COGNITIVE ABILITIES COMPARABLE TO A 4-YEAR OLD; HER SPEECH WAS GARBLED WITH THE ABILITY TO STILL USE SOME WORDS, AND SHE USED GESTURES TO ASSIST IN MAKING HER NEEDS KNOWN. ACCORDING TO THE RESIDENT ASSESSMENT INSTRUMENT, DATED 7/2/12, RESIDENT #2 REQUIRED A LIFT DEVICE FOR TRANSFERS, EXTENSIVE ASSIST OF TWO STAFF IN ORDER TO REPOSITION IN BED, EXTENSIVE ASSIST OF ONE STAFF FOR DRESSING, HYGIENE, BATHING AND PUSHING HER WHEELCHAIR, AND WAS CODED AS "ALWAYS INCONTINENT OF BOWEL AND BLADDER." RESIDENT #2 WAS ASSESSED AS SEVERELY COGNITIVELY IMPAIRED ON THE "BRIEF INTERVIEW FOR MENTAL STATUS", AND SHE HAD MODERATELY IMPAIRED MEMORY, INATTENTION AND DISORGANIZED THINKING. BEHAVIORS LISTED FOR RESIDENT #2 INCLUDED: SELF HARM, HITTING AT OTHERS, AND THROWING HERSELF OUT OF BED WHEN FRUSTRATED WITH STAFF. ACCORDING TO PHYSICIAN'S PROGRESS NOTES FOR THE PERIOD NOVEMBER THROUGH DECEMBER, 2012, THE FOLLOWING WERE REFLECTED FOR RESIDENT #2: -ON 11/10/12: "DEVELOPED AN AREA OF MACERATION (SOFTENING/TEARING OF SKIN DUE TO PROLONGED EXPOSURE TO MOISTURE) AT THE SUPERIOR INTERGLUTEAL CREASE AND RIGHT THIGH (THE AREA OF THE RESIDENT'S BOTTOM IN CONTACT WITH HER WHEEL CHAIR CUSHION) THIS WEEK." UNDER PHYSICAL EXAMINATION: "INTERGLUTEAL CREASE 0.5 X 1.5 CM (CENTIMETER) 2ND-DEGREE OPEN AREA." -ON 11/16/12: "WOUND WORSENED AND LOOKED A BIT NECROTIC IN THE ULCER BED." -ON 12/7/12: "...RIGHT VISUAL ISCHIAL (BONY PROMINENCE) SORE. IT WAS INITIALLY JUST A MACERATED AREA 4 WEEKS AGO. EVENTUALLY, IT WAS FOUND THAT HER WHEELCHAIR PAD HAD ITS INTEGRITY COMPROMISED. IT HAD BEEN WET AND HAD GOTTEN VERY HARD AND CRACKED WITH SOME FOLDS UNDER THE INTACT-APPEARING LINER. IT HAS SINCE BEEN CHANGED. IN THE MEANTIME, SHE GOT AN OPEN AREA, WHICH BROKE DOWN..." DURING AN INTERVIEW ON 2/28/13 AT APPROXIMATELY 10:00 AM, WHEN ASKED TO PROVIDE EVIDENCE OF FACILITY INVESTIGATION INTO THE MACERATED AREA DESCRIBED BY THE PHYSICIAN, THE ASSISTANT DIRECTOR OF NURSES (ADON) NURSE "H" WAS UNABLE TO PROVIDE PROGRESS NOTES OR PRESSURE ULCER RECORDS DESCRIBING A MACERATED AREA ON RESIDENT #2'S RIGHT BUTTOCK. ACCORDING TO THE FACILITY DOCUMENT TITLED, "PRESSURE ULCER RECORD", THE FOLLOWING WAS REFLECTED: -ON 11/8 (2012), STAGE 2 (PARTIAL THICKNESS LOSS OF SKIN), OPEN AREA. -ON 11/16/12, UNSTAGEABLE (EXTENT OF THE DAMAGE COULD NOT BE VISUALIZED) 5 X 3 X 0.1, NECROTIC (DEAD) TISSUE. -ON 11/27/12. UNSTAGEABLE, 5.3 X 2.5 X 1.6, SLOUGH (DEAD TISSUE) IN WOUND, LOOSENING. -ON 12/4.12, U (UNSTAGEABLE), 5.8 X 6.4 X 2.4. -ON 12/11/12, STAGE 3 (FULL THICKNESS LOSS OF SKIN, DEEP CRATER EXPOSING SUBCUTANEOUS TISSUE), 2.5 X 1.5 X 2. A REVIEW OF RESIDENT #2'S CARE PLAN (DATED 11/16/12) REFLECTED NO NEW INTERVENTIONS ENTERED ON 11/8/12, AND THERE WERE NO INTERVENTIONS FOR INSPECTING/CLEANING RESIDENT #2'S WHEEL CHAIR CUSHION ADDED TO THE CARE PLAN IN ORDER TO PREVENT FURTHER MACERATION OF HER BOTTOM. ON 2/26/13 AT 12:05 AM, RESIDENT #2 WAS OBSERVED IN THE DINING ROOM SITTING IN A HIGH BACK WHEEL CHAIR, WEARING A CLOTHING PROTECTOR, AND HER 3-COMPARTMENT PLATE WAS RESTING ON HER CLOTHING PROTECTOR WHICH WAS RESTING ON THE WOODEN TRAY ATTACHED TO HER WHEEL CHAIR. AS RESIDENT #2 WAS OBSERVED, SHE FED HER SELF WITH A SPOON, BUT LARGE AMOUNTS OF FOOD fell OFF THE SPOON AND OUT OF HER MOUTH, TO LAND ON THE CLOTHING PROTECTOR OR FALL FURTHER DOWN THE SIDE OF HER BODY TO REST ON THE WHEEL CHAIR CUSHION. ON 2/27/13 AT 9:00 AM, RESIDENT #2 WAS OBSERVED IN BED IN HER ROOM, WITH THE HEAD OF HER BED ELEVATED, WITH HER EYES CLOSED. RESIDENT #2 HAD EATEN BREAKFAST, AND ONE SIDE OF THE TOP OF RESIDENT #2'S GOWN WAS WET. DURING THAT SAME OBSERVATION, SPLASHES WERE OBSERVED ON RESIDENT #2'S WHEEL CHAIR CUSHION AND A DRY, SHINY CIRCULAR AREA WAS OBSERVED ON THE BACK HALF OF THE CUSHION. DURING AN INTERVIEW AT APPROXIMATELY 9:15 AM THAT MORNING, THE DIRECTOR OF NURSE'S STATED THE UNIDENTIFIED SHINY, CIRCULAR AREA ON THE CUSHION WOULD NOT WASH OFF. ON 2/27/13 AT 9:45 AM, CERTIFIED NURSE ASSISTANT (CNA) "P" WAS OBSERVED IN RESIDENT #2'S ROOM, AS SHE PROVIDED MORNING CARE FOR RESIDENT #2. WHEN ASKED, CNA "P" STATED THAT RESIDENT #2 DID NOT LIKE TO LIE DOWN AND PREFERRED TO BE UP AND AROUND THE FACILITY IN HER WHEEL CHAIR. CNA "P" STATED, "IT'S VERY DIFFICULT TO HAVE HER LIE DOWN DURING THE DAY." ON 2/27/13 AT 10:20 AM, REGISTERED NURSE (RN) "U" WAS OBSERVED AS SHE CHANGED RESIDENT # 2'S PRESSURE ULCER DRESSING. AFTER REMOVAL OF THE DRESSING AND PACKING, THE RESIDENT'S WOUND WAS RINSED WITH APPROXIMATELY 10 MILLILITERS OF STERILE NORMAL SALINE, AND PATTED DRY WITH A CLEAN GAUZE. THE WOUND WAS OBSERVED TO BE APPROXIMATELY 2.5 BY 1-2 CENTIMETERS IN SIZE, APPEARED TO BE AT LEAST 1.5 CM IN DEPTH, AND THE MARGINS OF THE WOUND WERE PINK. RN "U" WAS OBSERVED TO PACK THE WOUND WITH A LENGTH OF GAUZE (TREATED WITH MEDICATION TO KEEP SLOUGH FROM FORMING) AND COVERED THE PRESSURE ULCER WITH AN ADHERENT DRESSING. ON 2/28/13 AT 11:50 AM, RESIDENT #2 WAS OBSERVED IN THE DINING ROOM, IN HER WHEEL CHAIR WITH THE WOODEN TRAY ATTACHED, DRINKING APPROXIMATELY 8-12 OUNCES OF A WHITE, THICKENED LIQUID FROM A CLEAR PLASTIC GLASS. RESIDENT #2 POSITIONED THE OPENING OF THE GLASS IN HER MOUTH WITH THE TOP OF THE RIM RESTING AGAINST THE BRIDGE OF HER NOSE. RESIDENT #2 TILTED HER HEAD BACK, AND DRANK THE ENTIRE GLASS IN A FEW, HUGE GULPS, WHILE THE LIQUID RAN DOWN BOTH SIDES OF HER MOUTH, CHIN AND CLOTHING PROTECTOR, AND SPLASHED ON HER WHEEL CHAIR ARMS AND SEAT CUSHION, MISSING THE WOODEN TRAY. ON 2/28/12, RESIDENT #2 WAS OBSERVED AT TIMES INCLUDING, BUT NOT LIMITED TO 1:00 PM, 2:15 PM, 3:30 PM AND 4:00 PM, BUT WAS NOT OBSERVED ASSISTED OUT OF HER WHEEL CHAIR AT ANY OF THOSE TIMES IN ORDER TO REMOVE PRESSURE FROM HER BOTTOM. ACCORDING TO RESIDENT #2'S CARE PLAN TITLED "ACTUAL SKIN BREAKDOWN" ("ONSET" DATE OF 1/16/13), AN INTERVENTION (ALSO DATED 1/16/13) DIRECTED: "RESIDENT NOT TO BE UP FOR MORE THAN TWO HOURS AT A TIME." THE CARE PLAN DOCUMENTED THAT RESIDENT #2 HAD "...AN UNSTAGEABLE (ULCER) ON 11/16/12 AND (ON) 12/25/12 ESCHAR REMOVED AND CURRENTLY A STAGE 3 TO RIGHT ISCH (ISCHIUM) RELATED TO INCONTINENCE." ON 3/1/13 AT 11:40 AM, OCCUPATIONAL THERAPIST (OT) "O" WAS INTERVIEWED IN THE THERAPY ROOM. WHEN ASKED ABOUT THE PHYSICIAN'S DOCUMENTATION FROM 11/10/12 (REGARDING A MACERATED AREA ON RESIDENT #2'S BUTTOCK) AND THE 12/7/12 DOCUMENTATION (REGARDING THE COMPROMISED CONDITION OF RESIDENT #2'S WHEEL CHAIR CUSHION), OT "O" RESPONDED, "THE OLD CUSHION WAS FUNCTIONAL, BUT MISUSED, NOT OVERUSED". WHEN ASKED TO EXPLAIN WHAT THE DIFFERENCE WAS, OT "O" SAID THAT "MISUSED" MEANT NOT MONITORED, AS OPPOSED TO "OVERUSED", WHICH MEANT USED BEYOND THE INTENDED LIFESPAN OF THE CUSHION. WHEN ASKED IF "MISUSED" INCLUDED NOT CLEANING THE CUSHION, OT "O" NODDED AND SAID, "YES". OT "O" STATED THAT RESIDENT #2 WAS GIVEN A NEW WHEEL CHAIR CUSHION ON 12/17/12. WHEN THE OBSERVATIONS OF RESIDENT #2 FEEDING HERSELF ON 2/28/13 AT 11:50 AM WERE DESCRIBED TO OT "O", OT "O" SAID THAT RESIDENT #2 TOOK HUGE BITES, AND FOOD WOULD ESCAPE FROM THE SIDES OF HER MOUTH. HOWEVER, THERE WAS NO EVIDENCE PROVIDED TO SHOW THAT THE FACILITY HAD DEVELOPED INTERVENTIONS TO PROTECT THE WHEEL CHAIR CUSHION FROM ACCUMULATING SPILLS, OR FROM BECOMING WET AND CONTAMINATED. ( ) ACCORDING TO PHYSICIAN RECORDS DATED 2/1/13 TO 2/28/13, RESIDENT (#3) WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. BASED ON REVIEW OF THE NURSING ADMISSION ASSESSMENT, DATED 1/11/13, RESIDENT (#3'S) SKIN WAS INTACT. ACCORDING TO THE PRESSURE ULCER RECORD, DATED 1/29/13, RESIDENT (#3) DEVELOPED A STAGE 2 PRESSURE WOUND TO THE COCCYX (TAILBONE) THAT WAS 2 CENTIMETERS (CM) IN LENGTH BY 0.8 (CM) IN WIDTH WITH NO DEPTH. RESIDENT (#3'S) PLAN OF CARE, DATED 1/30/13, INCLUDED AN INTERVENTION FOR A PRESSURE REDUCTION SURFACE TO CHAIR AT ALL TIMES AND PRESSURE REDUCTION MATTRESS TO BED. DURING AN INTERVIEW ON 2/27/13 AT 11:30 A.M., UNIT MANAGER "A" SAID THAT RESIDENT (#3) HAD BEEN IDENTIFIED AT THE TIME OF ADMISSION AS FREQUENTLY REFUSING TO LAY ON HER SIDE RELATED TO RECENT HIP SURGERY. UNIT MANAGER "A" SAID, AS SOON AS THE PRESSURE WOUND WAS IDENTIFIED, A SPECIAL PRESSURE RELIEF MATTRESS WAS PLACED ON RESIDENT (#3'S) BED (CONFIRMING THAT THE INTERVENTION WAS ADDED AFTER, NOT BEFORE, THE WOUND DEVELOPED). UNIT MANAGER "A" WAS NOT AWARE IF THE FACILITY'S PHYSICAL THERAPY DEPARTMENT HAD ASSESSED RESIDENT (#3) FOR PRESSURE RELIEF FOR HER WHEELCHAIR, OR IF A PRESSURE RELIEF INTERVENTION FOR THE WHEELCHAIR WAS USED AT THE TIME OF RESIDENT (#3'S) ADMISSION. RESIDENT (#3) WAS OBSERVED ON 2/27/13 AT 12:15 P.M., SITTING ON A CHAIR LOCATED IN THE "A" WING DINING ROOM, WITHOUT PRESSURE RELIEF TO HER BUTTOCKS. RESIDENT (#3) WAS OBSERVED ON 2/28/13 AT 12:45 P.M., SITTING IN HER ROOM AT THE BEDSIDE IN A CHAIR, WITHOUT PRESSURE RELIEF TO HER BUTTOCKS. RESIDENT (#3'S) PRESSURE ULCER WOUND WAS OBSERVED ON 3/1/13 AT 10:00 A.M. THE WOUND WAS LOCATED ON THE COCCYX AREA. THE AREA WAS OBSERVED TO BE CLOSED WITH A SMALL WHITE PATCH OF THICKENED SKIN. ACCORDING TO NURSES' PROGRESS NOTES DATED 2/3/13, RESIDENT (#3) WAS COGNITIVELY "A & O X 3" (ALERT AND ORIENTED TO PERSON, PLACE AND TIME). RESIDENT (#3) WAS INTERVIEWED ON 3/1/13 AT 10:30 A.M. IN HER ROOM. AND WAS ASKED ABOUT PRESSURE RELIEF TO HER BEDSIDE CHAIR, DINING ROOM CHAIR AND WHEELCHAIR. RESIDENT (#3) SAID SHE HAD NEVER SET ON ANYTHING WITH ADDED CUSHIONS SINCE SHE HAD BEEN AT THE FACILITY, BUT DID STATE THAT SHE HAD RECEIVED A NEW MATTRESS SINCE SHE HAD BEEN THERE. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND INTERVENTIONS TO PREVENT FALLS FOR 3 RESIDENTS ( #5, #14, AND #29) OF 6 RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 24 RESIDENTS AND FAILED TO CONDUCT AN ACCURATE ASSESSMENT TO PREVENT FALLS FOR 1 RESIDENT (#5) OF 6 RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 24 RESIDENTS. IN ADDITION THE FACILITY, FAILED TO ENSURE THE SECURITY OF HAZARDOUS CHEMICALS IN 4 OF 4 HOUSEKEEPING CARTS, RESULTING IN A FRACTURED WRIST IN THREE PLACES AND A HEAD INJURY FOR RESIDENT #5, AND THE POTENTIAL FOR INJURY DUE TO MULTIPLE FALLS FOR RESIDENT #14, AND #29, AND THE POTENTIAL EXPOSURE TO HAZARDOUS CHEMICALS FOR (80 DEMENTIA ? MENTAL ILLNESS OUT OF CENSUS OF 125) RESPECTIVELY. FINDINGS INCLUDE: RESIDENT #5 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. UPON REVIEW OF THE FACILITY'S DOCUMENT, TITLED "INCIDENT REPORT" DATED 4/17/12. RESIDENT#5 WAS OBSERVED ON THE FLOOR IN HER ROOM AT 12:30 A.M. A HEMATOMA WAS NOTED ON LEFT SIDE OF FOREHEAD AND SWELLING TO LEFT WRIST. XRAY OF 4/17/12 REFLECTED NO FRACTURE TO LEFT WRIST OR FINGERS. ON 4/24/12 ANOTHER XRAY WAS COMPLETED DUE TO RESIDENT CONTINUED COMPLAINT OF PAIN, SWELLING, BRUISING, AND DECREASED MOBILITY IN LEFT WRIST. AN XRAY TAKEN ON 4/24/12 OF THE LEFT WRIST READ 2 FRACTURES OF THE RADIUS, AND A SUSPICIOUS FX OF THE ULNAR. ON 4/26/12 AT 3:30 P.M. AN INTERVIEW VIA TELEPHONE WITH CHARGE NURSE "Y" WAS CONDUCTED. STAFF "Y" INDICATED THAT JUST PRIOR TO FALL ON 4/17/12 RESIDENT #5 HAD TURNED ON THE CALLIGHT, NURSE "Y" HAD HELPED RESIDENT # 5 TO BATHROOM AND HAD LEFT RESIDENT #5 ALONE ON TOILET WHILE STAFF "Y" ASSISTED ANOTHER RESIDENT IN A ROOM ACROSS FROM RESIDENT #5'S ROOM. STAFF "Y" HEARD RESIDENT #5 YELL FOR HELP AND UPON STAFF "Y" RETURNING TO THE ROOM RESIDENT #5 WAS OBSERVED ON THE FLOOR. STAFF "F" REPORTED THAT SHE LEFT RESIDENT UNATTENDED IN THE BATHROOM AS RESIDENT #5 SHOWED NO INDICATION OF FALLS AND WAS NOT NOTED TO BE AT HIGH RISK FOR FALLS. UPON REVIEW OF RESIDENT #5'S MEDICAL RECORD THE FACILITY'S DOCUMENT TITLED "NURSING ADMISSION ASSESSMENT" DATED 4/12/12 REFLECTED A SCORE FOR FALL RISK AS A 3 (LOW RISK), AND A SCORE OF 10 OR ABOVE WOULD INDICATE THAT A RESIDENT MAY BE A HIGH RISK FOR FALLS. UPON REVIEW OF THE FACILITY'S DOCUMENT TITLED "OCCUPATIONAL THERAPY EVALUATION AND PLAN OF TREATMENT RECORD" DATED 4/12/12 FOR RESIDENT #5, REFLECTED, "......PRESENTS VERY DECONDITIONED WITH GENERALIZED WEAKNESS AND DECREASED ADL'S (ACTIVITIES OF DAILY LIVING)......RISK FACTORS: DUE TO THE DOCUMENTED PHYSICAL IMPAIRMENTS AND ASSOCIATED FUNCTIONAL DEFICITS, THE PATIENT IS AT RISK FOR: FALLS......". THE FACILITY'S DOCUMENT TITLED "PHYSICAL THERAPY AND PLAN OF TREATMENT RECORD" DATED 4/13/12 FOR RESIDENT #5 REFLECTED, ".....PATIENT DEMONSTRATED SIGNIFICANT DECLINE IN BED MOBILITY AND TRANSFER.....DECREASED GAIT FUNCTION USING STANDARD CANE ON EVEN SURFACES.....DEMONSTRATED DECREASE BILATERAL LOWER EXTREMITY STRENGTH......RISK FACTORS: DUE TO THE DOCUMENTED PHYSICAL IMPAIRMENTS AND ASSOCIATED FUNCTIONAL DEFICITS THE PATIENT IS AT RISK FOR:......FALLS". ON 4/26/12 AT 11:30 A.M. AN INTERVIEW WAS CONDUCTED IN THE THERAPY DIRECTORS OFFICE WITH STAFF "S" THERAPY DIRECTOR, STAFF "V", PHYSICAL THERAPIST, AND STAFF "W", OCCUPATIONAL THERAPIST STAFF "S" STATED AND STAFF "V" AND "W" VERBALIZED AGREEMENT THAT ON RESIDENT #5'S ADMISSION TO FACILITY ON 4/12/12 RESIDENT #5 DEMONSTRATED UNSTEADY GAIT, BALANCE PROBLEMS WITH DYNAMIC STANDING ALONG WITH AMBULATION AND DEMONSTRATED CONFUSION "FUZZINESS". STAFF "S",STATED AND STAFF "V" AND "W" VERBALIZED AGREEMENT THAT RESIDENT #5 WAS AT A HIGH RISK FOR FALLS UPON ADMISSION (4/12/12). STAFF "S" INDICATED PER FACILITY PROTOCOL, THAT A COMMUNICATION FORM WAS USED TO COMMUNICATE TRANSFER STATUS AND SAFETY ISSUES TO NURSING STAFF OF NEW INTERVENTIONS FOR RESIDENTS. A COPY OF THE COMMUNICATION FORM FOR RESIDENT #5 FROM DATE OF ADMISSION (4/12/12) WAS REQUESTED FROM STAFF "S" AND UNIT MANAGER NURSE STAFF "T" AND WAS NOT PROVIDED BEFORE END OF SURVEY. ON 4/26/12 AT 1:30 P.M. IN THE MDS OFFICE AN INTERVIEW WAS CONDUCTED WITH UNIT MANAGER STAFF "T" SHE REPORTED THAT RESIDENT #5 ON ADMISSION HAD POOR JUDGEMENT, NEEDED REMINDERS AND WAS NOTED TO BE IMPULSIVE. STAFF "T" INDICATED THAT RESIDENT # 5 HAD BEEN admitted TO FACILITY IN THE FALL OF 2011 WITH A PELVIC FRACTURE AND WAS AT HIGH RISK FOR FALLS AT THAT TIME, AND WAS NOT ASSESSED TO BE AT HIGH RISK FOR FALLS UPON ADMISSION ON 4/12/12. STAFF MEMBER "T" REPORTED SHE WAS UNAWARE THERAPY HAD IDENTIFIED RESIDENT # 5 TO BE AT HIGH RISK FOR FALLS. ON 4/26/12 AT 3:15 P.M. AN INTERVIEW VIA TELEPHONE WITH CHARGE NURSE "X" WAS CONDUCTED. STAFF "X" INDICATED RESIDENT#5 WAS ALERT AND ORIENTED TO PERSON, PLACE, AND TIME BUT DID DEMONSTRATE SOME INTERMITTENT CONFUSION UPON ADMISSION. STAFF "X" ASSISTED RESIDENT #5 TO BATHROOM ON 4/12/12 AND RESIDENT #5 DEMONSTRATED A SLOW SHUFFLED GAIT, HUNCHED OVER AND GUARDING HER ABDOMINAL AREA. STAFF "X" REPORTED SHE DID NOT FEEL RESIDENT #5 WAS AT HIGH RISK FOR FALLS AT THAT TIME. UPON REVIEW OF RESIDENT #5'S MEDICAL RECORD, THE DOCUMENT TITLED "ADMISSION CARE PLAN" DATED 4/12/12 AND DOCUMENT TITLED " NURSING CARE GUIDE", UNDATED, DID NOT REFLECT THERAPY'S INDICATION OF HIGH FALL RISK FOR RESIDENT #5 UPON COMPLETION OF PHYSICAL AND OCCUPATIONAL THERAPY EVALUATIONS. ON 4/26/12 AT 4:00 P.M. IN THE CONFERENCE ROOM THE DON REPORTED THAT PER THE FACILITY'S POLICY AND PROCEDURE "FALL AWARENESS PROGRAM" RESIDENTS ARE ASSESSED FOR FALLS UPON ADMISSION AND THEN QUARTERLY. DON ALSO REPORTED THAT SHE WAS UNAWARE THAT BOTH OCCUPATIONAL AND PHYSICAL THERAPY DOCUMENTED RESIDENT #5 WAS AT THE RISK FOR FALLS ON THEIR EVALUATIONS, AND THAT THIS INFORMATION HAD NOT BEEN REPORTED TO HER. THE PHYSICIAN TELEPHONE ORDERS DATED 4/15/12 REFLECTED RESIDENT #5 HAD A CHANGE IN MEDICATION FROM ALPRAZOLAM (XANAX) FOR ANXIETY 0.5 MILLIGRAMS (MG) TWICE A DAY TO LORAZEPAM (ATIVAN) FOR ANXIETY 0.5 MG TWICE A DAY. THE PHYSICIAN ORDERS [REDACTED]. RESIDENT #5'S RECORD DID NOT REFLECT WHY THE CHANGES OR INCREASE IN MEDICATION WERE COMPLETED. THE MEDICATION ADMINISTRATION RECORD DATED 4/2012, RESIDENT #5 ON 4/16/12 AT 9:00 P.M. RECEIVED LORAZEPAM (ATIVAN) 0.5 MG AND TRAZODONE 50 MG. DURING AN INTERVIEW WITH UNIT MANAGER "T" ON 4/26/12 AT 1:30 P.M. IN THE MDS OFFICE UNIT MANAGER "T" REPORTED SHE WAS UNSURE WHY RESIDENT # 5'S LORAZEPAM OR TRAZODONE WAS CHANGED. ON 4/26/12 AT 3:30 P.M. UNIT MANAGER "T" CONFIRMED THAT NO REASON FOR LORAZEPAM OR TRAZODONE MEDICATIONS WAS NOTED IN THE RECORD AND THAT UNIT MANAGER "T" REMAINED UNSURE WHY THE CHANGES WERE MADE. ( / ) BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONDUCT AN ACCURATE ASSESSMENT TO PREVENT FALL FOR 1 RESIDENT (#5) OF 24 RESIDENTS REVIEWED FOR ACCURATE ASSESSMENT OUT OF A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN A FRACTURED WRIST IN THREE PLACES AND A HEAD INJURY FOR RESIDENT #5. FINDINGS INCLUDE: ACCORDING TO THE FACILITIES DOCUMENT TITLED "CLINICAL DEPARTURE SUMMARY" DATED 4/12/12 , RESIDENT #5 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. UPON REVIEW OF THE FACILITY'S DOCUMENT, TITLED "INCIDENT REPORT" DATED 4/17/12. RESIDENT#5 WAS OBSERVED ON THE FLOOR IN HER ROOM AT 12:30 A.M. A HEMATOMA WAS NOTED ON LEFT SIDE OF FOREHEAD AND SWELLING TO LEFT WRIST. XRAY OF 4/17/12 REFLECTED NO FRACTURE TO LEFT WRIST OR FINGERS. ON 4/24/12 ANOTHER XRAY WAS COMPLETED DUE TO RESIDENT CONTINUED COMPLAINT OF PAIN, SWELLING, BRUISING, AND DECREASED MOBILITY IN LEFT WRIST. AN XRAY TAKEN ON 4/24/12 OF THE LEFT WRIST READ 2 FRACTURES OF THE RADIUS, AND A SUSPICIOUS FX OF THE ULNAR. ON 4/26/12 AT 3:30 P.M. AN INTERVIEW VIA TELEPHONE WITH CHARGE NURSE "Y" WAS CONDUCTED. STAFF "Y" INDICATED THAT JUST PRIOR TO FALL ON 4/17/12 RESIDENT #5 HAD TURNED ON CALLIGHT, NURSE "Y" HAD HELPED RESIDENT # 5 TO BATHROOM AND HAD LEFT RESIDENT #5 ALONE ON TOILET WHILE STAFF "Y" ASSISTED ANOTHER RESIDENT IN A ROOM ACROSS ACROSS THE HALL FROM RESIDENT #5'S ROOM. STAFF "Y" HEARD RESIDENT #5 YELL FOR HELP AND UPON STAFF "Y" RETURNING TO THE ROOM RESIDENT #5 WAS OBSERVED ON THE FLOOR. STAFF "F" REPORTED THAT SHE LEFT RESIDENT UNATTENDED IN THE BATHROOM AS RESIDENT #5 SHOWED NO INDICATION OF FALLS AND WAS NOT NOTED TO BE AT HIGH RISK FOR FALLS. UPON REVIEW OF RESIDENT #5'S MEDICAL RECORD THE FACILITY'S DOCUMENT TITLED "NURSING ADMISSION ASSESSMENT" DATED 4/12/12 REFLECTED A SCORE FOR FALL RISK AS A 3 (LOW RISK), AND A SCORE OF 10 OR ABOVE WOULD INDICATE THAT A RESIDENT MAY BE A HIGH RISK FOR FALLS. UPON REVIEW OF THE FACILITY'S DOCUMENT TITLED "OCCUPATIONAL THERAPY EVALUATION AND PLAN OF TREATMENT RECORD" DATED 4/12/12 FOR RESIDENT #5, REFLECTED, "......PRESENTS VERY DECONDITIONED WITH GENERALIZED WEAKNESS AND DECREASED ADL'S (ACTIVITIES OF DAILY LIVING)......RISK FACTORS: DUE TO THE DOCUMENTED PHYSICAL IMPAIRMENTS AND ASSOCIATED FUNCTIONAL DEFICITS, THE PATIENT IS AT RISK FOR: FALLS......". THE FACILITY'S DOCUMENT TITLED "PHYSICAL THERAPY AND PLAN OF TREATMENT RECORD" DATED 4/13/12 FOR RESIDENT #5 REFLECTED, ".....PATIENT DEMONSTRATED SIGNIFICANT DECLINE IN BED MOBILITY AND TRANSFER.....DECREASED GAIT FUNCTION USING STANDARD CANE ON EVEN SURFACES.....DEMONSTRATED DECREASE BILATERAL LOWER EXTREMITY STRENGTH......RISK FACTORS: DUE TO THE DOCUMENTED PHYSICAL IMPAIRMENTS AND ASSOCIATED FUNCTIONAL DEFICITS THE PATIENT IS AT RISK FOR:......FALLS". ON 4/26/12 AT 11:30 A.M. AN INTERVIEW WAS CONDUCTED IN THE THERAPY DIRECTORS OFFICE WITH STAFF "S" THERAPY DIRECTOR, STAFF "V", PHYSICAL THERAPIST, AND STAFF "W", OCCUPATIONAL THERAPIST STAFF "S" STATED AND STAFF "V" AND "W" VERBALIZED AGREEMENT THAT ON RESIDENT #5'S ADMISSION TO FACILITY ON 4/12/12 RESIDENT #5 DEMONSTRATED UNSTEADY GAIT, BALANCE PROBLEMS WITH DYNAMIC STANDING ALONG WITH AMBULATION AND DEMONSTRATED CONFUSION "FUZZINESS". STAFF "S",STATED AND STAFF "V" AND "W" VERBALIZED AGREEMENT THAT RESIDENT #5 WAS AT A HIGH RISK FOR FALLS UPON ADMISSION (4/12/12). STAFF "S" INDICATED PER FACILITY PROTOCOL, THAT A COMMUNICATION FORM WAS USED TO COMMUNICATE TRANSFER STATUS AND SAFETY ISSUES TO NURSING STAFF OF NEW INTERVENTIONS FOR RESIDENTS. A COPY OF THE COMMUNICATION FORM FOR RESIDENT #5 FROM DATE OF ADMISSION (4/12/12) WAS REQUESTED FROM STAFF "S" AND UNIT MANAGER NURSE STAFF "T" AND WAS NOT PROVIDED BEFORE END OF SURVEY. ON 4/26/12 AT 1:30 P.M. IN THE MDS OFFICE AN INTERVIEW WAS CONDUCTED WITH UNIT MANAGER STAFF "T" SHE REPORTED THAT RESIDENT #5 ON ADMISSION HAD POOR JUDGEMENT, NEEDED REMINDERS AND WAS NOTED TO BE IMPULSIVE. STAFF "T" INDICATED THAT RESIDENT #5 HAD BEEN admitted TO FACILITY IN THE FALL OF 2011 WITH A PELVIC FRACTURE AND WAS AT HIGH RISK FOR FALLS AT THAT TIME, AND WAS NOT ASSESSED TO BE AT HIGH RISK FOR FALLS UPON ADMISSION ON 4/12/12. STAFF MEMBER "T" REPORTED SHE WAS UNAWARE THERAPY HAD IDENTIFIED RESIDENT # 5 TO BE AT HIGH RISK FOR FALLS. ON 4/26/12 AT 3:15 P.M. AN INTERVIEW VIA TELEPHONE WITH CHARGE NURSE "X" WAS CONDUCTED. STAFF "X" INDICATED RESIDENT#5 WAS ALERT AND ORIENTED TO PERSON, PLACE, AND TIME BUT DID DEMONSTRATE UPON ADMISSION SOME INTERMITTENT CONFUSION. STAFF "X" ASSISTED RESIDENT #5 TO BATHROOM ON 4/12/12 AND RESIDENT #5 DEMONSTRATED A SLOW SHUFFLED GAIT, HUNCHED OVER AND GUARDING HER ABDOMINAL AREA. STAFF "X" REPORTED SHE DID NOT FEEL RESIDENT #5 WAS AT HIGH RISK FOR FALLS AT THAT TIME. UPON REVIEW OF RESIDENT #5'S MEDICAL RECORD, THE DOCUMENT TITLED "ADMISSION CARE PLAN" DATED 4/12/12 AND DOCUMENT TITLED " NURSING CARE GUIDE", UNDATED, DID NOT REFLECT THERAPY'S INDICATION OF HIGH FALL RISK FOR RESIDENT #5 UPON COMPLETION OF PHYSICAL AND OCCUPATIONAL THERAPY EVALUATIONS. ON 4/26/12 AT 4:00 P.M. IN THE CONFERENCE ROOM THE DON REPORTED THAT PER THE FACILITY'S POLICY AND PROCEDURE "FALL AWARENESS PROGRAM" DATED OCTOBER 2010, RESIDENTS ARE ASSESSED FOR FALLS UPON ADMISSION AND THEN QUARTERLY. DON ALSO REPORTED THAT SHE WAS UNAWARE THAT BOTH OCCUPATIONAL AND PHYSICAL THERAPY DOCUMENTED RESIDENT #5 WAS AT THE RISK FOR FALLS ON THEIR EVALUATIONS, AND THAT THIS INFORMATION HAD NOT BEEN REPORTED TO HER. THE PHYSICIAN TELEPHONE ORDERS DATED 4/15/12 REFLECTED RESIDENT #5 HAD A CHANGE IN MEDICATION FROM ALPRAZOLAM (XANAX) FOR ANXIETY 0.5 MILLIGRAMS (MG) TWICE A DAY TO LORAZEPAM (ATIVAN) FOR ANXIETY 0.5 MG TWICE A DAY. THE PHYSICIAN ORDERS [REDACTED]. THE MEDICATION ADMINISTRATION RECORD DATED 4/2012, RESIDENT #5 ON 4/16/12 AT 9:00 P.M. RECEIVED LORAZEPAM (ATIVAN) 0.5 MG AND TRAZODONE 50 MG. DURING AN INTERVIEW WITH UNIT MANAGER "T" ON 4/26/12 AT 1:30 P.M. IN THE MDS OFFICE UNIT MANAGER "T" REPORTED SHE WAS UNSURE WHY RESIDENT # 5'S LORAZEPAM OR TRAZODONE WAS CHANGED. ON 4/26/12 AT 3:30 P.M. UNIT MANAGER "T" CONFIRMED THAT NO REASON FOR LORAZEPAM OR TRAZODONE MEDICATIONS WAS NOTED IN THE RECORD AND THAT UNIT MANAGER "T" REMAINED UNSURE WHY THE CHANGES WERE MADE. ( / ) ON 4/26/2012 AT 3:15 P.M. DURING THE ENVIRONMENTAL TOUR WITH THE MAINTENANCE DIRECTOR, STAFF "R" AND THE HOUSEKEEPING DIRECTOR, STAFF "Q" A HOUSEKEEPING CART WAS OBSERVED IN THE HALL OUTSIDE OF RESIDENT ROOM #112 UNLOCKED AND UNATTENDED. THERE WERE FIVE BOTTLES OF CHEMICALS NOTED IN THE UNLOCKED CART: 1) THE CHEMICAL "CLEAN ON THE GO SMOKE & ODOR ELIMINATOR" AND ACCORDING TO THE MSDS (MATERIAL SAFETY DATA SHEET) THIS CHEMICAL CAUSES EYE IRRITATION, SKIN IRRITATION, HARMFUL IF SWALLOWED, AND INHALATION MAY CAUSE RESPIRATORY IRRITATION; 2)THE CHEMICAL "CLEAN ON THE GO CLEAN BY PEROXY" AND ACCORDING TO THE MSDS (MATERIAL SAFETY DATA SHEET) THIS CHEMICAL CAUSES EYE IRRITATION, SKIN IRRITATION, HARMFUL IF SWALLOWED, AND INHALATION MAY CAUSE RESPIRATORY IRRITATION, AND IF INGESTED MAY RESULT IN DISTENTION OF THE ESOPHAGUS AND STOMACH; 3) THE CHEMICAL "CLEAN ON THE GO BIORENEWABLES GLASS CLEANER" AND ACCORDING TO THE MSDS (MATERIAL SAFETY DATA SHEET) THIS CHEMICAL CAUSES EYE IRRITATION, SKIN IRRITATION, HARMFUL IF SWALLOWED, AND INHALATION MAY CAUSE RESPIRATORY IRRITATION; 4) THE CHEMICAL "CLEAN ON THE GO AIRLIFT TROPICAL" AND ACCORDING TO THE MSDS TO CAUSE EYE IRRITATION, SKIN IRRITATION, HARMFUL IF SWALLOWED, AND INHALATION MAY CAUSE RESPIRATORY IRRITATION; 5) THE CHEMICAL "CLEAN ON THE GO ACID BATHROOM AND SHOWER CLEANER" AND ACCORDING TO THE MSDS TO BE CORROSIVE CAUSING SEVERE EYE DAMAGE, SEVERE SKIN DAMAGE AND IRRITATION, HARMFUL OR FATAL IF SWALLOWED, AND HARMFUL IF INHALED. ON 4/26/2012 AT 3:15 P.M. AN INTERVIEW WITH THE HOUSEKEEPING DIRECTOR, STAFF "Q" WAS CONDUCTED IN THE HALL AT THE HOUSEKEEPING CART LOCATED OUTSIDE OF RESIDENT ROOM #112. STAFF "Q" INDICATED THE HOUSEKEEPING CART DID NOT HAVE A KEY AND THAT WAS WHY THE CART WAS TURNED TOWARD THE RESIDENT'S ROOM WHEN THE HOUSEKEEPER WAS CLEANING AND/OR MAY NEED TO LEAVE THE CART. ON 4/26/2012 AT 3:20 P.M. AN INTERVIEW WITH A HOUSEKEEPER, STAFF "FF" THAT WALKED UP TO THE CART FROM INSIDE ROOM #112 WAS CONDUCTED. STAFF "FF" INDICATED THERE WERE NO KEYS TO THE HOUSEKEEPING CARTS. THEN CONTINUED TO STATE THERE WERE 4 CARTS IN USE DURING THE DAY AND ONE CART LOCKED UP AS A BACK-UP CART IF NEEDED. STAFF "FF" STATED SHE HAD USED ALL THE CARTS AND NONE OF THEM HAD KEYS OR WERE LOCKED FOR THE PAST YEAR IN WHICH SHE HAD WORKED AT THE FACILITY. ( ) ACCORDING TO THE MONTHLY physician's orders [REDACTED]. ACCORDING TO THE FALLS CARE PLAN, INITIATED ON 5/17/11, RESIDENT #14 WAS "AT RISK FOR FALL RELATED INJURY SECONDARY TO HISTORY OF FALLS." THE INCIDENT REPORT DATED 11/13/11 AT 1:15 PM, RELFECTED "AIDE HEARD ALARM, WENT INTO ROOM AND OBSERVED RES. (RESIDENT) ON FLOOR WITH HEAD AGAINST WALL, LYING ON SIDE." THE INCIDENT REPORT REFLECTED THIS INCIDENT OCCURRED IN RESIDENT #14'S ROOM. THE SECTION "TYPE OF INJURY" REFLECTED "RED AREA ON L (LEFT) BACK OF HEAD." THE SECTION "POST-INCIDENT FOLLOW-UP" REFLECTED "RESIDENT IS NOT TO BE LEFT IN ROOM ALONE. MUST BE IN HALLWAY AS TO BE SUPERVISED." THE INTERVENTION "TAKE RES. IN HALLWAY WHEN IN W/C (WHEELCHAIR) WHEN EVER LEAVING ROOM" WAS ADDED TO RESIDENT #14'S FALLS CARE PLAN ON 11/14/11. THE INTERVENTION "RESIDENT TO BE IN OPEN AREA, WHEN IN W/C (NEAR STAFF)" HAD ALREADY BEEN ADDED TO THE FALLS CARE PLAN ON 6/9/11, 5 MONTHS BEFORE THE FALL. THE INTERVENTION "RES. OUT IN HALLWAY IF STAFF NOT IN ROOM AND UP IN W/C" HAD BEEN ADDED TO THE FALLS CARE PLAN ON 8/30/11, OVER 2 MONTHS BEFORE THE FALL. THE INCIDENT REPORT, DATED 11/15/11 AT 3:30 PM, REFLECTED "RES. ATTEMPTED TO SELF TRANSFER FROM W/C TO BED, ALARM SOUNDED, WITNESSED SLIDING TO FLOOR ON BUTT." THE INCIDENT REPORT REFLECTED THIS INCIDENT OCCURRED IN RESIDENT #14'S ROOM. THE SECTION "ACTION PLAN" REFLECTED "EDUCATE CENA'S (CERTIFIED NURSE'S AIDE) NOT TO PLACE RESIDENT IN ROOM UNSUPERVISED WHILE IN W/C." THIS INTERVENTION HAD ALREADY BEEN PUT IN PLACE AFTER RESIDENT #14'S PREVIOUS FALL ON 11/13/11. THE INTERVENTION "RE-EDUCATE CENA'S NOT TO LEAVE RES. IN ROOM WHILE IN W/C UNSUPERVISED" HAD BEEN ADDED TO RESIDENT #14'S FALLS CARE PLAN ON 11/15/11. THE INCIDENT REPORT DATED 12/3/11 AT 12:45 PM, REFLECTED "FOUND ON FLOOR IN ROOM." THE SECTION "ACTION PLAN" REFLECTED "BED IMMEDIATELY AFTER MEALS." THE INTERVENTION "PUT RESIDENT TO BED ASAP (AS SOON AS POSSIBLE) MEAL IS DONE" WAS PLACED ON RESIDENT #14'S CARE PLAN ON 12/3/11. THE INTERVENTION "PUT RESIDENT TO BED BETWEEN MEALS" HAD ALREADY BEEN ADDED TO RESIDENT #14'S FALLS CARE PLAN ON 7/29/11. THE INCIDENT REPORT DATED 12/9/11 AT 9:50 AM, REFLECTED "RES. APPARENTLY TRIED TO STAND FROM W/C AND fell on HER BOTTOM. (HOUSEKEEPER'S NAME) OBSERVED HER SITTING ON FLOOR AND ALERTED NURSE AND CENA." THE SECTION "ACTION PLAN" REFLECTED "GUEST SUPERVISION WAS MODIFIED." THE INTERVENTION ADDED TO RESIDENT #14'S CARE PLAN ON 12/9/11 WAS "OBSERVE IF RESIDENT APPEARS/STATES SHE IS TIRED, LAY DOWN FOR NAP/REST." THE INTERVENTION "MONITOR FOR FATIGUE AND/OR UNSTEADINESS AND ENCOURAGE REST PERIODS" WAS ALREADY PRESENT ON RESIDENT #14'S FALLS CARE PLAN DATED 5/17/11. THE INCIDENT REPORT DATED 1/3/12 AT 4:15 PM, REFLECTED "AIDE CALLED THIS NURSE INTO ROOM TO ASSESS AND ASSIST WITH RESIDENT WHO WAS SITTING ON FLOOR. AIDE STATED SHE LOWERED RES TO FLOOR AS SHE SLIPPED IN SOME SPILLED THICKENED WATER." THE SECTION "ACTION PLAN" REFLECTED "RES TO WEAR GRIPPY SOCKS AAT (AT ALL TIMES)." THE INTERVENTION "ENSURE WEARING APPOPRIATE FOOTWEAR FOR TRANSFERS AND AMBULATION" WAS ALREADY PRESENT ON RESIDENT #14'S FALLS CARE PLAN DATED 5/17/11. IN AN INTERVIEW IN "DAY ROOM 3" ON 4/27/12, AT 10:45 AM, THE UNIT MANAGER, REGISTERED NURSE (RN) "D", STATED "IT DOESN'T LOOK LIKE WE CHANGED IT" REFERRING TO RESIDENT #14'S FALLS CARE PLAN, IN REGARDS TO THE FALL ON 1/3/12. THE INCIDENT REPORT DATED 2/1/12 AT 8:00 PM, REFLECTED "YELLING HEARD AND ALARM SOUNDING. RES FOUND LAYING ON FLOOR ON L (LEFT) SIDE WITH BROKEN BEDSIDE TABLE ON TOP OF HER. BRUISE NOTED TO L CHEEK AND L ELBOW." THE SECTION "ACTION PLAN" REFLECTED "TOILETING PLAN INITIATED." THE INTERVENTION "RESTORATIVE TOILETING PROGRAM" WAS ALREADY PRESENT ON RESIDENT #14'S CARE PLAN, DATED 5/17/11. THE INCIDENT REPORT DATED 3/18/12 AT 10:00 AM, REFLECTED "FOUND ON FLOOR" WITH THE LOCATION SECTION MARKED "CORRIDOR." THE SECTION "ACTION PLAN" REFLECTED "RES. KEPT NEAR NURSES CARD (SIC), REINFORCE PREVIOUS INTERVENTIONS." THE INTERVENTION "RESIDENT TO BE IN OPEN AREA, WHEN IN W/C (NEAR STAFF)" HAD ALREADY BEEN IMPLEMENTED ON RESIDENT #14'S FALLS CARE PLAN ON 6/9/11. IN AN INTERVIEW IN "DAY ROOM 3" ON 4/27/12, AT 10:45 AM, RN "D", STATED "I DON'T SEE AN UPDATE FOR THAT FALL ON THE CARE PLAN" REFERRING TO RESIDENT #14'S FALL THAT OCCURRED ON 3/18/12. RESIDENT #14'S MINIMUM DATA SET (MDS), WITH AN ASSESSMENT REFERENCE DATE OF 11/14/11, REFLECTED FOR TRANSFERS, RESIDENT #14 REQUIRED "EXTENSIVE ASSISTANCE" WITH "TWO + PERSONS PHYSICAL ASSIST", AND THAT RESIDENT #14'S MOBILITY DEVICE WAS A "WHEELCHAIR." RESIDENT #14'S FALLS CARE PLAN DATED 5/17/11 REFLECTED "RESIDENT WILL SAFELY TRANSFER INDEPENDENTLY DAILY." IN AN INTERVIEW IN "DAY ROOM 3" ON 4/27/12, AT 10:45 AM, RN "D", STATED THAT RESIDENT #14 "NEEDS A GAIT BELT AND AN AIDE FOR TRANFSERS." RESIDENT #14'S ADL (ACTIVITIES OF DAILY LIVING) CARE PLAN LAST REVIEWED ON 2/13/12, REFLECTED "RESIDENT INDEPENDENT WITH TRANSFERS, ENCOURAGE USE OF 4WW (4 WHEELED WALKER)." NO UPDATE TO RESIDENT # 14'S TRANSFER ABILITY WAS SEEN ON HER FALLS CARE PLAN, OR HER ADL CARE PLAN, BOTH WITH A REVIEW DATE OF 2/12/12. THE FALL ASSESSMENT COMPLETED ON 2/13/12 FOR RESIDENT #14 REFLECTED A SCORE OF "17", A SCORE GREATER THAN 10 INDICATED A RISK. THE FACILITY'S POLICY "FALLS AWARENESS PROGRAM" DATED OCTOBER 2010, REFLECTED "5. THE FALLS AWARENESS PROGRAM IS OVERSEEN BY THE BEHAVIOR MANAGEMENT COMMITTEE. OCCURRENCES RELATED TO FALLS ARE REVIEWED BY THE COMMITTEE. CARE PLANS WILL BE REVIEWED WITH APPROPRIATE UPDATE OF INTERVENTIONS WITHIN 24-72 HOURS OF EACH NEW OCCURRENCE. 6. THE GUEST WILL BE REassessed with [REDACTED]. THE BEHAVIOR MANAGEMENT COMMITTEE WILL RE-EVALUATE THE GUEST'S RISK AND OCCURRENCES. A DETERMINATION WILL BE MADE TO EITHER CONTINUE THE GUEST IN THE FALLS AWARENESS PROGRAM OR TO DISCONTINUE THE GUEST FROM THE PROGRAM. CARE PLANS WILL BE UPDATED ACCORDINGLY." ACCORDING TO THE physician's orders [REDACTED]. THE "FALL RISK ASSESSMENT" WITH DATES INCLUDING 10/23/11, 1/23/12, AND 4/12/12, REFLECTED THAT RESIDENT #29 WAS AT A HIGH RISK FOR FALLS AS EVIDENCED BY SCORES OF 22, 24 AND 25 ("IF THE SCORE IS TEN OR GREATER, THE GUEST SHOULD BE CONSIDERED AT RISK FOR POTENTIAL FALLS."). THE INCIDENT REPORT DATED 7/14/11, REFLECTED "RES. WAS REACHING FOR BAG WHILE IN W/C, SLID OUT OF CHAIR AND LANDED ON BUTT." THE ACTION PLAN REFLECTED "CALL LITE (SIC) MAKE AVAILABLE AND AND ADVISE RESIDENT TO USE/MAKE BAG MORE ACCESSIBLE." THE INCIDENT REPORT DATED 8/1/11, REFLECTED "RES SLID OFF EDGE OF BED WHILE AIDE WAS GETTING CLOTHES OUT OF CLOSET. AIDE COULD NOT CATCH HER BEFORE HITTING THE FLOOR. RIGHT SHOULDER IS RED." THE SECTION "ACTION PLAN" REFLECTED "CENA EDUCATION: DO NOT SIT RESIDENT UP BEFORE READY TO TRANSFER." THE INCIDENT REPORT DATED 9/10/11, REFLECTED "RES SLID FROM W/C ONTO FLOOR. RES FOUND BY STAFF RESPONDING TO SOUNDING FALL ALARM." THE SECTION "POST-INCIDENT FOLLOW-UP" REFLECTED "DYCEM (ITEM PLACED ON WHEEL CHAIR TO PREVENT SLIDING) WAS NOT ON SEAT OF W/C, RES IS SUPPOSED TO HAVE THIS TO PREVENT SLIPPING (CARE PLANNED). DYCEM PLACED TO ENSURE RES DOES NOT SLIDE OUT OF OR OFF OF SEAT OF W/C." THE INCIDENT REPORT DATED 11/10/11, REFLECTED "FOUND RESIDENT ON FLOOR. RESIDENT WAS REACHING FOR SOMETHING AND SLID OF (SIC) W/C." THE SECTION "TYPE OF INJURY" REFLECTED "HEMATOMA/BRUISE L HEAD". THE SECTION "ALARM/RESTRAINT USE" REFLECTED THAT THE BATTERIES IN RESIDENT #29'S CHAIR ALARM WERE NOT WORKING. THE SECTION "ACTION PLAN" REFLECTED "STAFF INSERVICES WERE HELD. MAKING SURE BATTERIES WORK" AND MAKE SURE STAFF IS KEEPING REACHER IN SIGHT AND IN REACH." RESIDENT #29'S FALLS CARE PLAN DATED 2/16/11, REFLECTED THE INTERVENTION "SENSOR TO WHEELCHAIR - CHECK PLACEMENT AND RUNCTION (SIC) EVERY SHIFT, TAB ALARM TYPE." ON 4/27/12, AT 10:55 AM, RESIDENT #29 WAS OBSERVED PROPELLING HERSELF IN HER WHEELCHAIR PAST THE CONFERENCE ROOM. RESIDENT #29 WAS SITTING ON THE FRONT HALF OF THE SEAT, LEANING FORWARD. NO TAB ALARM WAS OBSERVED ON HER WHEELCHAIR OR CONNECTED TO THE BACK OF HER SHIRT. CENA "Z" WAS INTERVIEWED IN "NURSES STATION B" ON 4/27/12 AT 11:10 AM. CENA "Z" IDENTIFIED HERSELF AS IN CHARGE OF TAKING CARE OF RESIDENT #29 FOR THE DAY SHIFT ON 4/27/12. CENA "Z" COULD NOT EXPLAIN WHY RESIDENT #29'S TAB ALARM WAS NOT IN PLACE WHILE SHE WAS PROPELLING HERSELF BY THE CONFERENCE ROOM THAT MORNING. CENA "Z" WAS AKSED IF RESIDENT #29 IS ABLE TO REMOVE THE ALARM, AND SHE RESPONDED "I DON'T SEE HOW SHE COULD TAKE IT OFF HERSELF." THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT FALLS FOR BOTH RESIDENT #14 AND #29, AND FAILED TO CONTINUOUSLY IMPLEMENT, REVIEW, AND REVISE INTERVENTIONS TO PREVENT FALLS FOR BOTH RESIDENTS. ( )

This citation pertains to MI# 670 Based on interview and record review, the facility staff failed to follow physician orders [REDACTED].#101 and subsequent death. Findings include: Record review of resident #101's re-admission physician progress notes [REDACTED]. Record review of physician order [REDACTED]. Nurse note dated [DATE] at 10:15 AM revealed: 'Resident in bed resting with head of bed elevated, oxygen at 3 liters, oxygen saturation 83%, lung sounds coarse bilateral, increased anxiety this shift, yelling whenever up in wheelchair. Staff tried to comfort resident without much success. Continue to monitor. Nebulizer treatment was given. Nurse note dated [DATE] at 10:45 AM revealed that the unit manager RN #3 left a message for a daughter to call the facility regarding the resident not eating well. There was no mention of increased anxiety or decreased oxygen saturation. Record review of 'Physician Order's Via Fax' form dated [DATE] at 11:45 AM for resident #101 revealed nurse #15 notified the physician of decreased oxygen levels of 83% on 2 liters, lung sounds coarse sound wet. Resident is extremely anxious, and no longer had an order for [REDACTED]. Nurse noted dated [DATE] at 2:15 PM revealed that the unit manager wrote she had spoken with daughter regarding resident not eating well and discussed the possibility of re-starting [MEDICATION NAME] (antianxiety medication) due to increased shortness of breath, yelling out and increased anxiety. No noted difference in mood since starting antidepressant. In agreement to try [MEDICATION NAME]. I will attempt to feed in room where less stimulation. Daughter requested a phone call tomorrow with update. Will continue to monitor. In an interview on [DATE] at 12:40 PM, Licensed Practical Nurse (LPN) #15, while reviewing Resident #101's closed medical record, revealed that on [DATE] she went into Resident #101's room to do respiratory assessment at the start of her shift (day shift 6:00 AM). Nurse #15 stated that Resident #101 was 77% saturation on 1.5 liters nasal cannula and that she raised the head of the bed, checked the tubing and tank which were fine, she increased the oxygen to 2 liters and saturation came up to 80%. At 11:45 AM nurse #15 stated that she faxed the physician's office her assessment, and called the office to have the office nurse get his attention to the fax. Record review of physician order [REDACTED]. Continued interview on [DATE] at 12:40 PM, with LPN #15, revealed that she was aware of strict orders not to raise resident #101's oxygen above 1XXX,[DATE] liters, because the resident could not blow off the carbon, stating it was like poison to the resident. LPN #15 stated that on [DATE] Resident #101 was yelling out, very restless, wanting up in her wheelchair then in bed and then back into wheelchair, and taking her oxygen off. LPN #15 stated that she received a call from the physician and an order to increase the oxygen level to ,[DATE] liters to goal saturation of 88%. LPN #15 stated that she went to the unit manager RN #3 with concerns about the order increase of oxygen to ,[DATE] liters and to seek what to do. LPN stated, "I didn't make the decision by myself, I went to my unit manager (RN #3) for decision. We (LPN #15 and RN #3) did not raise the oxygen level; it would poison her, carbon retainer". LPN #15 stated, "RN #3 only said 'doesn't he know we have an order not to raise her oxygen", so we did not increase the oxygen flow". During the interview, LPN #15 was asked why Resident #101 was not transferred to the hospital when there was a noted change/decrease in oxygen levels at the beginning of the shift and LPN #15 stated that the physician did not mention sending the resident out and that she needed a physician order [REDACTED]. In an interview on [DATE] at 11:03 AM via phone, LPN #7 (who was on duty when the Resident #101 was transferred to the hospital), stated that her assessment at 3:00 PM revealed Resident #101's oxygen saturation was 83%, she knew parameters of 88%-94% were the resident's goal. LPN #7 stated that Resident #101 had an ongoing issue with her oxygen saturation levels decreasing, and that over the last couple of weeks the resident's behaviors of shouting out had increased. LPN #7 stated that she received shift report from LPN #15 and that LPN #15 was aware of decreased oxygenation and had faxed the physician. The state surveyor asked LPN #7 if she increased resident #101's oxygen flow stating "No, I didn't change her oxygen level, ask LPN #15 she took the doctors order". Record review of resident #101's 'Patient Transfer Form' dated [DATE] reflected that the resident's (Resident #101's) oxygen saturation had been down to 83%, it was currently noted staying at 69%, has confusion and increased lethargy. Resident is on 3 liters of oxygen at this time. Record review of resident #101's nurse note dated [DATE] at 6:10 PM reflected that the resident's oxygen saturation was at 83% AT 3:00 PM (oxygen liters were not documented). Resident has been yelling out. Resident family arrived around 5:30 PM. Resident oxygen saturation at this time dropped to 70% on 2.5 liters. Vital signs ,[DATE], 98.9, 26 respirations. Resident's daughter wanted resident to go to emergency room . Physician was contacted and resident is being sent out to hospital. Resident is confused and increased lethargy. Resident was noted to have left the facility at 6:30 PM via ambulance. Record review of emergency room record dated [DATE] reflected that the resident presented to the emergency room with [MEDICAL CONDITION] and [MEDICAL CONDITION]. emergency room course and treatment plan revealed that the resident had significant respiratory distress and lethargic. The resident was noted to be a no code although the emergency room physician did ask the resident if she wanted to be intubated and was noted to state yes. The resident was intubated and ventilated and admitted to the ICU and later died . Record review of facility 'Guest Care General Policies' dated ,[DATE] from the administrative policy manual revealed that on page 3, heading 'Nursing policies and procedures address the total needs of the guest and include at least the following: #7.) Medications and treatments administered in accordance with physician orders [REDACTED]. #11.) Ensuring delivery of nursing services in accordance with physician orders, nursing directed care plan, and the facility policies and procedures. According to the Michigan Licensed Practical Nurses Association (www.michgancenterfor nursing.org/mimages/clark.pdf) 'Licensed Practical Nurse Scope of Practice Michigan' form (undated) Public Health Code 1978 PA 368, as amended: R 333XXX Nursing "Practice of Nursing as a Licensed Practical Nurse" or "LPN" means the practice of nursing is based on less comprehensive knowledge and skill than that of a registered professional nurse and performed under the supervision of a registered nurse, physician......." #

This citation pertains to MI# 670 Based on interview and record review, the facility failed to maintain the highest practical well-being for 1 (#101) of 4 sampled residents, resulting in resident #101 experiencing a change in condition of increased confusion, increased anxiety and decreased oxygenation saturation levels and being sent to the emergency room at family request for a change in condition. Findings include: impaired Record review of Resident #101's minimum data set ((MDS) dated [DATE] for re-admission from acute hospital, reflected a [AGE] year old female with brief interview of mental status score of 9 (8-12: Moderately impaired) with [DIAGNOSES REDACTED]. The resident was noted to have shortness of breath (SOB) with exertion and required oxygen therapy. Record review of the physician order [REDACTED]. Record review of Resident #101's nurse notes dated 2/26/12 at 11:00 AM revealed that the resident had course lung sounds, wet cough on 3 liters (oxygen) still between 82%-88% O2 (oxygen saturation). Physician was notified and medication was ordered 5 days of steroid medication. Nurse note dated 2/27/12 at 9:00 PM revealed that Resident #101 complained of shortness of breath O2 saturation 81% nebulizer treatment given, O2 sat at 89% within 15 minutes, is calm and resting with oxygen at 3 liters/NC (nasal cannula). There were no further assessments noted or re-check of oxygenation levels noted. Nurse note dated 2/28/12 at 4:00 AM revealed temperature of 97.6, oxygen 87% (did not document the oxygen liters in use), resident anxious this shift repeating "Help me, help me". When assured staffs are there to help resident uneasy and continues to repeat "Help me, help me". Nebulizer treatment given as ordered, HOB (head of bed) elevated for comfort, denied pain or discomfort. Nurse note dated 2/28/12 at 10:15 AM revealed: 'Resident in bed resting with head of bed elevated, oxygen at 3 liters, oxygen saturation 83%, lung sounds coarse bilateral, increased anxiety this shift, yelling whenever up in wheelchair. Staff tried to comfort resident without much success. Continue to monitor. Nebulizer treatment was given. There was no post nebulizer treatment assessment noted. Nurse note dated 2/28/12 at 10:45 AM revealed that the unit manager RN #3 left a message for a daughter to call the facility regarding the resident not eating well. There was no mention of increased anxiety or decreased oxygen saturation. Record review of 'Physician Order's Via Fax' form dated 2/28/12 at 11:45 AM for Resident #101 revealed LPN #15 notified the physician of decreased oxygen levels of 83% on 2 liters, lung sounds coarse sound wet. Resident is extremely anxious, and no longer had an order for [REDACTED]. Nurse note dated 2/28/12 at 2:15 PM revealed that the unit manager wrote she had spoken with daughter regarding resident not eating well and discussed the possibility of re-starting [MEDICATION NAME] (antianxiety medication) due to increased shortness of breath, yelling out and increased anxiety. No noted difference in mood since starting antidepressant. In agreement to try [MEDICATION NAME]. I will attempt to feed in room where less stimulation. Daughter request a phone call tomorrow with update. Will continue to monitor. In an interview on 3/23/12 at 11:10 AM, Certified Nurse Assistant (CNA) #5 revealed that she did work the 200 hall on the day shift and was familiar with Resident #101. CNA #5 stated that on the residents last day in the facility she gave the resident a shower and got her dressed for the day. CNA #5 stated that Resident #101 went to the dining room for breakfast and lunch, but at dinner time Resident #101 looked tired and didn't want to eat. CNA #5 stated that a family member came in and said that Resident #101 didn't look right, checked her oxygen saturation at 82% on 2 liters oxygen. In an interview on 3/26/12 at 12:40 PM, LPN #15, while reviewing Resident #101's closed medical record, revealed that on 2/28/12 she went into Resident #101's room to do a respiratory assessment at the start of her shift (day shift 6:00 AM). LPN #15 stated that Resident #101 had an oxygen saturation of 77% on 1.5 liters nasal cannula and that she raised the head of the bed, checked the tubing and tank which were fine, she increased the oxygen to 2 liters and saturation came up to 80%. At 11:45 AM LPN #15 stated that she faxed the physician's office her assessment, and called the office to have the office nurse get his attention to the fax. LPN #15 stated that the last couple of days Resident #101 was at the facility she was "so confused, different-pleasantly confused, but different, a change from her usual". Record review of physician order [REDACTED]. Continued interview on 3/26/12 at 12:40 PM with LPN #15 revealed that she was aware of strict orders not to raise Resident #101's oxygen above 1.5-2 liters, because the resident could not blow off the carbon, stating it was like poison to the resident. LPN #15 stated that on 2/28/12 Resident #101 was yelling out, very restless, wanting up in her wheelchair then in bed and then back into wheelchair, and taking her oxygen off. LPN #15 stated that she received a call from the physician and an order to increase the oxygen level to 3-5 liters to goal saturation of 88%. LPN #15 stated that she went to the unit manager RN #3 with concerns about the order increase of oxygen to 3-5 liters and to seek what to do. LPN #15 stated, "I didn't make the decision by myself, I went to my unit manager (RN #3) for decision. We (LPN #15 and RN #3) did not raise the oxygen level; it would poison her, carbon retainer". LPN #15 stated, "RN #3 only said 'doesn't he know we have an order not to raise her oxygen", so we did not increase the oxygen flow". During the interview LPN #15 was asked why Resident #101 was not transferred to the hospital when there was a noted change/decrease in oxygen levels at the beginning of the shift and LPN #15 stated that the physician did not mention sending the resident out and that she needed a physician order [REDACTED]. In a telephone interview on 3/26/12 at 11:03 AM, LPN #7 (who was on duty when the resident was transferred to the hospital) revealed, her assessment at 3:00 PM oxygen saturation was 83%, she knew parameters of 88%-94% were the resident's goal. LPN #7 stated that Resident #101 had an ongoing issue with her oxygen saturation levels decreasing, and that over the last couple of weeks the resident's behaviors of shouting out had increased. LPN #7 stated that she received shift report from LPN #15 and that LPN #15 was aware of decreased oxygenation and had faxed the physician. The state surveyor asked LPN #7 if she increased resident #101's oxygen flow stating "No, I didn't change her oxygen level, ask LPN #15 she took the doctors order". Record review of Resident #101's 'Patient Transfer Form' dated 2/28/12 reflected that the resident oxygen saturation had been down to 83%, it was currently noted staying at 69%, has confusion and increased lethargy. Resident is on 3 liters of oxygen at this time. Record review of Resident #101's closed medical record revealed that on 2/28/12 after receiving a physician order [REDACTED]. Record review of the physician progress notes [REDACTED].#101) she started going downhill 2 days ago with increased hypoxemia and less alertness. She was confused and agitated with 86% oxygen saturation on 4 liters. She was already on 20 milligrams [MEDICATION NAME] daily. I increased her [MEDICATION NAME] to 60 mg daily and ordered a chest x-ray which showed no acute pneumonia. She was not much different the next day, still de-saturated with any exertion. Today she was more agitated and anxious, yelling out. I Okayed her to use [MEDICATION NAME] 0.5 mg every 8 hours as needed- I am not sure if she ever got any. She was not eating well. The decision was made by one of the family members to send her to the hospital. #

This citation pertains to intake numbers MI 599 and MI 625. Based on observation, interview, and record review, the facility failed to ensure the Medical Director was responsible for the implementation of the resident care policy for pressure ulcers and ensure the coordination for the care and services regarding pressure ulcers in the facility in 5 of 11 sampled residents (Resident #105, Resident #108, Resident #110, Resident #112, and Resident #114), and the potential for the development of impaired skin impairments, a delay, inadequate or inappropriate treatment of [REDACTED]. Findings Include: An unannounced survey was conducted [DATE]-[DATE]. During the investigation, avoidable, undocumented pressure ulcers or worsening of existing, documented, avoidable pressure ulcers were observed on 5 of 11 sampled residents (Resident #105, Resident #108, Resident #110, Resident #112, and Resident #114). According to the "Clinical Process Guidelines: Prevention and Management of Pressure Ulcers", "...Staff should describe and document pressure ulcer's key characteristics including size, location, depth and state, the presence or absence of necrosis and slough, tunneling or sinus tract(s), and exudate. Staff also should comment on the condition of wound bed including evidence of healing such as granulation (where visible) the presence of eschar, and the status of surrounding skin...Staff should document findings that support the conclusion that an ulcer is not pressure-related)...a physician or other health care practitioner should also evaluate the evidence..". (MDCH - Clinical Process Guidelines, 2003). Per the corporate "Medical Director Agreement", signed on [DATE] by facility Medical Director #28, "The Medical Director is responsible for (A) implementation of resident care policies; and (B) the coordination of medical care in the facility..." On [DATE], at 1:20 PM, Surveyor # requested the facility's Policy and Procedures regarding wound care. The Administrator #3 stated she "wasn't clinical (not educated in patient care)" and asked the Regional Quality Assurance Manager #1 to assist Surveyor # . Regional Quality Assurance Manager #1 pointed to a binder stating it was their "Wound Management Program". The first page in the large binder was a "Reviewed" date page that was signed and dated by the Administrator for the past 3 years. When Surveyor # asked Administrator #3 what "Reviewed" meant, she stated it meant that she had made sure all updates to the "Wound Management Program" had been placed into the binder. The "Wound Management Program" documents in the binder were dated ",[DATE]". Surveyor # requested evidence that the Medical Director had reviewed the "Wound Management Program". In an interview, on [DATE] at 10:35 AM the Medical Director #28 stated he did not examine residents' skin unless asked to do so by nursing and said the, "(DON #2) does wound rounds...because, "It's hard to look at them when they (facility physicians) need to". The Medical Director #28 stated there were, "...some wound I may never see...I don't do wound rounds". Medical Director #28 stated he had not reviewed the 1997 "Wound Management Program" in over 2 years. When Medical Director #28 was asked if he believed the 1997 "Wound Management Program" was still current he replied, "Yes". In an interview on [DATE] at 1:00 PM the Vice President of Quality Assurance #36 stated she had "no idea" why the Administrator #3 and the Regional Quality Assurance Manager #1 had been using the "old", "Wound Management Program" from 1997 and said, "That has expired." Vice President of Quality Assurance #36 said the "Wound Management Program" had been updated a "few years ago" because of changes in staging pressure ulcers (the addition of the definition of "Deep Tissue Injury" by NPUAP (National Pressure Ulcer Advisory Panel - 2007) and because the corporation had adopted the use of a certain brand name products for the treatment of [REDACTED]. The Vice President of Quality Assurance #36 explained that the corporation had a Corporate Medical Director that reviewed the policies and procedures for the entire corporation but there was no evidence that he had reviewed patient care policies, including the "Wound Management Program" policy and procedure. She stated he was no longer with the company, and that the facility Medical Director #28 had been responsible for reviewing policies ever since. Vice President of Quality Assurance #36 stated there was no evidence that the former Corporate Medical Director had reviewed the new "Wound Management Program". The revision date on the new "Wound Management Program" was ,[DATE]. Resident #105 Per Resident #105's MDS' (Minimum Data Set), dated [DATE] and [DATE], he had [DIAGNOSES REDACTED]. Per the "Pressure Ulcer Record" for Resident #105, dated [DATE], "Left buttock. Area scab, rough dry looking skin no depth. Stage II. 2 x 1 cm surface. 1st layer of skin off". On [DATE] at 10:50 AM, in the presence of Licensed Practical Nurse (LPN) #21 and nurse aide #22, this surveyor observed Resident #105 lying in feces on his back. Nurse aide #22 turned Resident #105 and surveyor # observed an open wound (Stage II pressure ulcer-shallow crater with loss of outer skin) on Resident #105's left buttock. The wound, measured by LPN #21 was 2 cm x 3 cm, the tissue inside was raw looking and pale pink in color, and the wound edge was surrounded by white tissue. LPN #21 stated, "It looks a lot better. It's not pink around it (the open area) any more", indicating the wound was had existed prior, and was now improving The Physician's "Progress Notes" for Resident #105 dated [DATE] and [DATE], and signed by Physician Assistant #24, both stated, "Diagnosis...Decubitus Ulcer. No further information regarding the condition of ulcer or the treatment provided was recorded in these physician "Progress Notes". Resident #108 Per the Face Sheet, the Medical Director #28 was the attending physician for Resident #108. Per Resident #108's MDS, dated [DATE], she did not walk in her room or corridor but needed no assistance with locomotion on unit, was incontinent of bowel and bladder, had [DIAGNOSES REDACTED]. Per Resident #108's MDS, dated [DATE], she had no pressure ulcers and no healed pressure ulcers. Per Resident #108's "Weekly Skin Assessment", dated [DATE] and [DATE] showed "excoriated" coccyx, and on [DATE], (signed by LPN #20), there was an "open" wound on Resident #108's buttocks. There was no measurement or further description of location or appearance of the open wound. On [DATE] at 11:02 AM, in the presence of LPN #19 and nurse aide #18, this surveyor observed a dark pinkish red 3.2 cm x 1 cm Stage II pressure ulcer containing a scant amount of granulation tissue (tissue formed in a healing wound), on the left buttocks of Resident #108. When asked to describe the wound, LPN #19 stated, "Open, nonblanchable (does not return to normal color), surrounding tissue pink, no tunneling (does not extend below). Minimal amount of sero-sanguinous (blood tinged) drainage". There was no mention of Resident #108's "excoriated" coccyx or "open" wound on her buttocks in the Medical Director's "physician progress notes [REDACTED]. Resident #110 Per Resident #110's MDS, dated [DATE], Resident #110 was admitted to the facility on [DATE], had modified (difficulty in new situations only) cognitive skills for daily decision making, needed extensive assistance with walking in his room, bed mobility and personal hygiene, and had no pressure ulcers and no history of pressure ulcers. Per a "physician's orders [REDACTED].#110) has unstageable opening on buttocks..." Per Resident #110's "physician progress notes [REDACTED]. Prognosis fair". There was no documentation regarding the "unstageable opening on buttocks" during 2011 in Resident #110's "physician progress notes [REDACTED]. Resident #112 Resident #112's TARs dated, [DATE]-[DATE], stated, "Excoriation right lower buttock..." but did not contain measurements, surrounding skin condition, drainage or progression of the wounds. On [DATE] at 1:55 PM, in the presence of nurse aide #43, surveyor # observed Resident #112 lying on her back in bed. Nurse aide #43 turned Resident #112 to her side, exposed Resident #112's buttocks and described the condition of Resident #112's skin, saying, "It's a little slightly (open) right here. Surveyor # observed a Stage II pressure ulcer with small amount of serosanguinous (bloody) drainage. There was no mention of the condition of the skin on Resident #112's buttock in the "physician progress notes [REDACTED]. Resident #114 Per Resident #114's "Weekly Skin Assessment", documented by licensed nursing staff, Resident #114 had an "open" area on his coccyx (tailbone) on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no mention of Resident #114's coccyx wound (measurements, color, temperature, drainage, surrounding tissue condition, etc.) or any skin assessment in the "physician progress notes [REDACTED]. ( )

This citation pertains to intake numbers MI 599 and MI 625. Based on observation, interview, and record review, the facility failed to ensure residents who did not have pressure ulcers, did not develop them and failed to promote the healing of pressure ulcers that were present in 5 of 11 sampled residents (Resident #105, Resident #108, Resident #110, Resident #112, and Resident #114), resulting in a delay in treatment and increased potential for deterioration in health status and well-being. Findings include: Per the "Intake Information", dated 3/01/11, Registered Nurse (RN) #30 stated, Resident #105 had a wound for his coccyx that (Director of Nursing - DON #2) is documenting as excoriation". On 3/22/11 at 10:20 AM, Administrator #3 stated there was no definition of "excoriation" in their "Wound Management Program", "because it was a common term". In an interview, on 3/14/11 at 1:30 PM, Unit Manager #5 stated "excoriation" could be a Stage I pressure ulcer and said, "I don't do the staging. The (DON #2) stages them". According to the "Clinical Process Guidelines: Prevention and Management of Pressure Ulcers", "...Staff should describe and document pressure ulcer's key characteristics including size, location, depth and state, the presence or absence of necrosis and slough, tunneling or sinus tract(s), and exudate. Staff also should comment on the condition of wound bed including evidence of healing such as granulation (where visible) the presence of eschar, and the status of surrounding skin...Staff should document findings that support the conclusion that an ulcer is not pressure-related)...a physician or other health care practitioner should also evaluate the evidence..For a resident with a pressure ulcer or who is at risk for pressure ulceration, staff should turn and reposition the resident approximately every two hours while in bed and reposition the resident approximately hourly while seated". (MDCH - Clinical Process Guidelines, 2003). According to the facility "Wound and Skin Management Program" page 9: "Treatment...program is designed for adherence to current practice standards and guidelines...These protocols include: a. wound management with the incontinent guest, b. skin conditions such a as skin tears, fungal infections, and excoriation, c. pressure ulcers, 3. surgical wounds... Documentation of wounds will be individualized, accurate, appropriate, and consistent. a. Braden Scale, b. Shower/skin Observation sheet, c. Weekly Skin Evaluation, d. Pressure Ulcer Record, e. Pressure Ulcer Log, f. Wound and skin Condition Log, g. Care Plan - the care plans should be written so that they almost write the progress note themselves...It is important to have continual, frequent inservices to staff regarding wound prevention..." And, from page 14: "Required documentation: Initiate weekly documentation using the Weekly Skin Evaluation and Nurses Progress Notes. The Wound and Skin Condition Log for non-pressure related areas (i.e., surgical wounds, lacerations, bruises, excortication, venous stasis ulcers, etc.) and the Pressure Ulcer Log for all pressure related areas, must also be completed based upon the type of wound. A summary of each log which stems from your weekly skin assessment team meeting must also be completed..." The required documentation listed on pages 9 and 14 did not include the Wound and Skin Condition Record. The required documentation on page 14 did not include the Pressure Ulcer Record. In a telephone interview, on 3/22/11 at 11:10 AM, the corporate Director of Quality Assurance #34 stated she did not know why the "Pressure Ulcer Record" and "Wound and Skin Condition Record" were not mentioned in the "Wound and Skin Management Program" policy and said, "They should be...don't know why it's not spelled out... I can put them in right now". The corporate Director of Quality Assurance #34 stated the "Wound and Skin Condition Record" was last updated in 2001 but it is "certainly" taught and it is required that the facilities use it and the "Pressure Ulcer Record". She said it was the DON #2's responsibility to make sure the forms are taught to facility staff and were being used. In an interview, on 3/15/11 at 12:43 PM, DON #2 stated she was the facility's "wound nurse" and completed and documented all wound assessments and measurements. DON #2 stated she "did not trust" the nursing staff to document on and classify wounds; that nurses were to call her at any time of the day or night if they found a skin condition that needed attention. DON #2 stated, "They (nursing staff) all know to call me and I will come right in (immediately to the facility)". DON #2 stated she did weekly wound rounds. In a second interview, on 3/16/11 at 11:15 AM, DON #2 stated she maintained and kept the the resident "Wound and Skin Condition Record" and "Pressure Ulcer Record" in a "Wound Book" in her office. DON #2 stated, "We do not measure or describe residents' skin conditions such as excoriation, bruises, skin tears, abrasions, rashes or other skin impairments". In an interview, on 3/17/11 at 2:40 PM, LPN #15 stated she had never been instructed to call the DON #2 at home when she found a skin condition such as a pressure ulcer, rather she was instructed to put a note in her (DON#2) mail box. When asked if she measured wounds she replied, "That's something the DON does". LPN #15 stated that nurses were not allowed to measure or describe [MEDICAL CONDITION] (tissue swelling) either. LPN #15 stated she had worked at the facility for one year but, "Never saw a "Pressure Ulcer Records or Wound and Skin condition Records before" and stated she did not know if there were any facility "standing orders" for wound treatments and stated she was "allowed to" write orders for topical antifungal ointments. When asked how she knew if a resident had a skin condition, such as a pressure ulcer, LPN #15 stated, "It gets passed on in report between shifts". In an interview 3/17/11 at 3:13 PM, Administrator #3 stated that DON #2 was not a certified wound specialist or a nurse practitioner. On 3/16/11 at 12:25 PM, Unit Manager/RN #5 stated, "We (nursing staff) are not to chart any open areas". Resident #105 Per Resident #105's MDS' (Minimum Data Set), dated 9/27/10 and 3/14/11, he had [DIAGNOSES REDACTED]. Physician's "Progress Notes" since dated 2/17/11 and 2/24/11, and signed by Physician Assistant #24, both stated, "Diagnosis...Decubitus (pressure) Ulcer. No other description of skin condition was recorded in these physician "Progress Notes". Per the "Pressure Ulcer Record" for Resident #105, dated 3/14/11, "Left buttock. Area scab, rough dry looking skin no depth. Stage II. 2 x 1 cm surface. 1st layer of skin off". On 3/16/11 at 10:50 AM, in the presence of LPN #21 and nurse aide #22, this surveyor observed Resident #105 lying in feces on his back. Nurse aide #22 turned Resident #105 and surveyor # observed an open wound (Stage II pressure ulcer-shallow crater with loss of outer skin) on Resident #105's left buttock. The wound, measured by LPN #21 was 2 cm x 3 cm, the tissue inside was raw looking and pale pink in color, and the wound edge was surrounded by white tissue. LPN #21 stated, "It looks a lot better. It's not pink around it (the open area) any more". Per Resident #105's "Plan of Care", dated 1/09/11, "Potential for skin breakdown related to [MEDICAL CONDITION] and decline in mobility ... "1/09/11, Excoriated area. Cleanse coccyx..." There was no documentation of an open wound, pressure ulcer or healed pressure ulcer. No skin impairments were documented for Resident #105's buttocks on "Shower/Skin Observation" records and "Weekly Skin Assessments" from 2/01/11-3/13/11. There was no "Wound and Skin Condition Record" for Resident #105 in his medical record. The "Nurses "Progress Notes", "Plan of Care" or TAR did not did not contain documentation of the description of the wound on Resident #105's buttocks. The "Wound and Skin Condition Log" and the "Pressure Ulcer Log" had not been completed in regards to Resident #105. Resident #108 Per Resident #108's MDS, dated [DATE], she did not walk in her room or corridor but needed no assistance with locomotion on unit, was incontinent of bowel and bladder, had [DIAGNOSES REDACTED]. Per Resident #108's MDS, dated [DATE], she had no pressure ulcers and no history of healed pressure ulcers. Per Resident #108's "Weekly Skin Assessment", dated 2/15/11 and 2/21/11 showed "excoriated" coccyx, and on 3/14/11, (signed by LPN #20), there was an "open" wound on Resident #108's buttocks. There was no measurement or further description of location or appearance of the open wound. On 3/16/11 at 11:02 AM, in the presence of LPN #19 and nurse aide #18, this surveyor observed a dark pinkish red 3.2 cm x 1 cm Stage II pressure ulcer containing a scant amount of granulation tissue (tissue formed in a healing wound), on the left buttock of Resident #108. When asked to describe the wound, LPN #19 stated, "Open, nonblanchable (does not return to normal color), surrounding tissue pink, no tunneling (does not extend below). Minimal amount of sero-sanguinous (blood tinged) drainage". On 3/16/11 at 11:07 AM, Unit Manager #5 entered Resident #108's room and observed the wound on Resident # 108's buttocks and stated,"This is the first time I've seen it". In an interview, on 3/16/11 at 11:15 AM, DON #2 stated she had not seen the ulcer on Resident #108's buttocks and said, "I was not told of (Resident #108's pressure ulcer). How can I know if no one tells me". She further stated, "The nurses are not using wound sheets ("Wound and Skin Condition Records")... they should be kept in the TAR (Treatment Administration Record) book". A "Plan of Care...Actual skin breakdown related to decreased mobility, urinary incontinence, and need for extensive assistance with bed mobility" for Resident #108 was dated 3/16/11 at 12:11 PM (after Surveyor # observed Resident #108's Stage II ulcer on her left buttock). There was no "Pressure Ulcer Record" or "Wound and Skin Condition Record" in Resident #108's medical record, the "Wound Book", or the TAR book. Nurses "Progress Notes", "Plan of Care" and TARs for Resident #108 did not did not contain documentation of Resident #108's Stage II left buttock pressure ulcer. The "Wound and Skin Condition Log and the Pressure Ulcer Log had not been completed in regards to Resident #108. On 3/21/11, surveyor # observed Resident #108 sitting up in bed at a 90 degree angle, with her legs outstretched, at 10:20 AM, and sitting in her wheel chair at 11:50 AM, 1:12 PM, 2:40 PM, 3:20 PM, and at 4:52 PM, placing pressure on Resident #108's wounds. In an interview on 3/16/11 at 2:21 PM, Dietary Manager #42 stated she did not know about the Stage II pressure ulcer on Resident #108's buttocks and said, "Usually the (DON #2) lets me know (if there is any pressure ulcers)". Resident #110 Per Resident #110's MDS, dated [DATE], Resident #110 was admitted to the facility on [DATE], had modified (difficulty in new situations only) cognitive skills for daily decision making, needed extensive assistance with walking in his room, bed mobility and personal hygiene, and had no pressure ulcers and no history of pressure ulcers. Per a "physician's orders [REDACTED].#110) has unstageable opening on buttocks..." Per Resident #110's "physician progress notes [REDACTED].#110's "physician progress notes [REDACTED]. On 3/16/11 at 1:05 PM, in the presence of DON #2, surveyor # observed a Stage II pressure ulcer on Resident #110's buttock and asked the DON #2 to measure and describe the area. DON #2 measured the pressure ulcer on Resident #110's right hip, near the gluteal fold, to be 5 cm x 4.5 cm; it was pale inside and the right outer edge contained dark red tissue. DON #2 reported yellow exudate (drainage) and slough (dead tissue) in the center of the pressure ulcer. There was a pressure ulcer that measured 1.5 cm x 1 cm below the larger one which DON #2 described as "denuded" (loss of outer layer of skin) and defined it as a "Stage I pressure ulcer". According to DON #2, the wounds were contained inside an area on Resident #110's buttocks that measured 14 cm x 11 cm of "[DIAGNOSES REDACTED]". Surveyor # observed that skin DON#2 described as "[DIAGNOSES REDACTED]" to be dark purple in color. Per a "Pressure Ulcer Record" for Resident #110, dated 2/25/11, "Resident has red excoriation. Right buttock. Dark eschar with [DIAGNOSES REDACTED]. Stage: U (unstageable/covered with eschar), 4 cm x 5 cm. On 3/01/11, documentation on the "Pressure Ulcer Record" indicated, "eschar 3 cm x 3 cm". The final entry on Resident #110's "Pressure Ulcer Record" was on 3/08/11 and it stated, "Stage II...4 x 3 (cm)...no drainage...area has red granulation tissue with yellow slough". There was no mention of the Stage I pressure ulcer that measured 1.5 cm x 1 cm or the area on Resident #110's buttocks that measured 14 cm x 11 cm of dark purple skin DON #2 had called "[DIAGNOSES REDACTED]". "Weekly Skin Evaluations" dated 2/15/11, 2/18/11, and 2/22/11 indicated that Resident #110 had "excoriated" buttocks. The "Nurses "Progress Notes", "Plan of Care", or TAR's did not contain documentation or description of Resident #110's "excoriation" or pressure ulcers. There was no "Wound and Skin Condition Record" in Resident #110's medical record, the "Wound Book", or the TAR book. On 3/21/11, surveyor # observed Resident #110 lying flat on his back in bed at 1:12 PM, 2:40 PM and 3:20 PM, placing pressure on his buttocks. On 3/22/11, surveyor # observed Resident #110 lying flat on his back in bed at 9:18 AM, 10:02 AM and at 3:22 PM, placing pressure on his buttocks. Resident #112 Per Resident #112's MDS, dated [DATE], she had no pressure ulcers or healed pressure ulcers, was frequently incontinent of bowel and bladder, needed human assistance for walking, turning and moving on and off toilet, and had [DIAGNOSES REDACTED]. On 3/17/11 at 1:55 PM, in the presence of nurse aide #43, surveyor # observed Resident #112 lying on her back in bed. Nurse aide #43 turned Resident #112 to her side and surveyor # observed a Stage II pressure ulcer with small amount of serosanguinous (bloody) drainage. At 2:00 PM, in the presence of LPN #32, Surveyor # observed Resident #112's pressure ulcer and asked LPN #32 to describe the open area on Resident #112's left buttock. LPN #32 stated Resident #112 had a 1 cm red, tender, "excoriated" area that "looks like a thin layer of skin is gone" surrounded by a red area that measured 3 cm round. LPN #32 said there was a 4 inch by 1/2 inch wide reddened area on the right buttock also. When LPN #32 touched the areas, Resident #112 said, "That hurts". Review of the TAR's dated 1/25/11-2/28/11 indicated Resident #112 had "Excoriation right lower buttock...". There was no documentation of measurements, surrounding skin condition, drainage, or progression of the Resident #112's pressure ulcers. The "Nurses Progress Notes" and "Plan of Care" did not did not contain documentation of the description of Resident #112's pressure ulcer or any "excoriation". There was no "Pressure Ulcer Record" or "Wound and Skin Condition Record" in Resident #112's medical record, the "Wound Book", or the TAR book. Neither the"Wound and Skin Condition Log" nor the "Pressure Ulcer Log" had been completed in regards to Resident #112. Per a "Physician's Telephone Order" for Resident #112, signed and dated 1/28/11 by LPN #47 and signed (not dated), by Physician #46, "Alternating pressure to bed". On 3/22 11 at 9:20 AM, Surveyor # observed Resident #112's mattress. It was a "Air Pro Elite" which was set at 3.8 Normal Pressure and not alternating pressure. On 3/22/11, Surveyor # observed Resident #112 sitting in her wheel chair at 9:20 AM, 10:00 AM, 1:40 PM, and 3:21 PM, placing pressure on Resident #112's wounds. Resident #114 Per Resident #114's MDS, dated [DATE], Resident #114 was admitted to the facility on [DATE], did not walk in room or corridor, had [DIAGNOSES REDACTED]. Per Resident #114's "Nursing Admission Assessment", dated 12/24/10, Resident #114 had 1.) an open area on his coccyx, 2.) upper/inner right thigh, and...a scab on his left knee, a bruise on his left lower leg, and his heels were dry and soft. Under "Comments" was written, "Areas to bottom 1.) 0.5 x 0.5, no drainage, redness around areas; 2.) 1.0 x 1.0 reddened area...Scab present on left knee. Bilateral (both) feet dry, flaked, heels soft". On 3/17/11 at 4:00 PM, in the presence of RN #14 and nurse aide #10, surveyor # observed a black eschar (thick black dead tissue/unstageable pressure ulcer) that measured 2.25 cm x 2 cm on the right heel of Resident #114. When asked how long the eschar had been present, nurse aide #14 stated, "I'm not sure...for a while. Last week he (Resident #114) got a waffle boot (light weight boot filled with air used to heal and/or prevent the formation of heel pressure ulcers) that we're supposed to put on him. I don't know where it is". LPN #14 stated she had no knowledge of how long the eschar had been on Resident #114's right heel and stated, "There was a waffle boot here somewhere". Resident #114 was lying on his back in bed and his heels were resting directly on the mattress of the bed. On 3/21/11 at 4:50 PM, in the presence of LPN (Licensed Practical Nurse) #17 and nurse aide #7, surveyor # observed the black eschar 2.25 cm x 2 cm on the right heel of Resident #114. LPN #17 stated that the eschar was present on Resident #114's right heel when she worked, "...the weekend before last" (9 days prior). Resident #114 was lying on his back in bed and his heels were resting directly on the mattress of the bed. On 3/22/11 at 1:30 PM, in the presence of RN #25, surveyor # observed black eschar on Resident #114's right heel that was soft on palpation and when touched, Resident #114 cried out, grimaced and started moaning. RN# 25 stated Resident #114's doctor (Physician #23) had not seen the eschar yet. On 3/21/11 at 1:12 PM and 2:40 PM, Resident #114 was lying on his back in bed and his heels were resting directly on the mattress of the bed. On 3/23/11 at 9:25 AM, Resident #114 was on his back in bed with 1 flat pillow under his lower legs. Resident #114's heels were laying on the mattress. On 3/21/11, surveyor # observed Resident #114 lying in bed with his heels directly touching the mattress at 1:12 PM, 2:40 PM, 3:20 PM and 4:50 PM. On 3/22/11 at 9:38 AM , nurse aide #27 stated, "He (Resident #114) had waffle boots for his heels because he has soft heels. I came in one day and his waffle boots were gone..." On 3/22/11 at 9:16 AM , surveyor # observed Resident #114 lying in bed on his back with his heels "floating" off the mattress by the use of a pillow under the calves of his legs. On 3/22/11 at 10:07 AM, 12:50, and 3:17 PM, Resident #114 was observed lying in bed on his back with his heels directly touching the mattress of the bed; a flat pillow was under the calves of his legs and his heels were directly touching the mattress. Per Resident #114's "Plan of Care", dated 1/03/11, " Problem...Skin 01: actual skin breakdown (type of skin breakdown and location of skin breakdown not noted) related to decreased mobility ...Conduct weekly head to toe skin assessments and report abnormal finding to physician and chart in nurses notes". The black eschar on Resident #114's right heel and open area on coccyx were not documented on the "Plan of Care". There was no intervention listed to "float heels" or use waffle boots documented under "Problem...actual skin breakdown" area. Per Resident #114's "Plan of Care", dated 1/03/11, "Problem...Skin: Risk for alteration in skin integrity related to incontinence, gastrostomy (stomach) tube, decreased mobility, dementia diagnosis, [MEDICAL CONDITION], diabetes mellitus...Turn and reposition every 2 hour and prn (as needed)...Diabetic foot checks every evening...Weekly skin assessments to be performed by the nurse." There was an intervention listed to "Float heels while in bed", dated 1/03/11, but the use waffle boots was not documented under ""Problem...Risk for alteration in skin integrity" area. There was a discrepancy between Resident #114's "Plan(s) of Care" and his "Nursing Care Card" (nurse aide care guide). Per Resident #114's "Nursing Care Card", "Turning and Positioning Schedule: every 1 hours and prn (as needed)..." (Resident #114's "Plan of Care" said "every 2 hours). Per Resident #114's TAR's dated 1/25/11-3/15/11, "Diabetic Foot checks once a day at bedtime" was initialed by nursing every day at 8:00 PM (indicating nurses had performed a visual inspection of the feet for impaired skin integrity). There was no documentation of any foot skin impairments (including eschar on Resident #114's right heel) noted on the TAR's. There was no "Pressure Ulcer Record" for Resident #114 in his medical record, the "Wound Book" or the TAR book. The "Wound and Skin Condition Log" and the Pressure Ulcer Log had not been completed in regards to Resident #114. Review of Resident #114's nursing "Progress Notes" between 1/01/11-3/17/11 revealed no mention of diabetic foot exams, the black eschar on Resident #114's right heel, or the skin condition of Resident #114's buttock/coccyx area. Review Resident #114's "physician progress notes [REDACTED].#114's skin condition or that nursing had reported the eschar on Resident #114's heel to the physician. Per a "Nutrition at Risk Monitoring Record", dated 2/23/11 and signed by Dietary Manager #42, "Stable weights. RD (Registered Dietitian) follows monthly as needed". In a telephone interview, on 3/30/11 at 2:15 PM, Registered Dietitian #44 stated she came back to work at the facility the week before, after being gone for over a year. Registered Dietitian #44 stated she reviewed Resident #114's laboratory values from a blood sample collected 3/21/11, showing low protein levels and stated the previous dietitian put Resident #114 on a partial-protein but Resident #114 should have had a complete protein tube feeding formula. ( ) ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 799 BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEW, THE FACILITY FAILED TO MEET THE PROFESSIONAL STANDARDS OF QUALITY REGARDING THE ASSESSMENT OF PAIN IN ONE (#501) OF FOUR SAMPLED RESULTING IN RESIDENT #501 NOT RECEIVING MEDICAL ATTENTION WHEN SHE COMPLAINED OF PAIN. FINDINGS INCLUDE: ACCORDING TO RESIDENT #501'S RECORD OF ADMISSION, RESIDENT #501 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE PHYSICIAN'S HISTORY AND PHYSICAL DATED 10/7/10, RESIDENT #501 HAD [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE], INDICATED THAT RESIDENT #501 REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, DRESSING TOILETING, PERSONAL HYGIENE, AND BATHING. THE MDS FURTHER INDICATED THAT RESIDENT #501 USED A WHEELCHAIR AS A MOBILITY DEVICE. ACCORDING TO RESIDENT #501'S NURSING ADMISSION assessment dated [DATE], RESIDENT #501 HAD INDEPENDENT COGNITION AND WAS ORIENTED TO TIME, PLACE AND PERSON. THE FACILITY'S INCIDENT REPORT DATED 1/7/11, DOCUMENTED THAT ON THE MORNING OF "...CNAS (CERTIFIED NURSING ASSISTANTS) WERE PROVIDING MORNING CARE TO RESIDENT #501. WHEN THE CNA'S ROLLED HER (#501) OVER, RESIDENT #501 YELLED OUT. RESIDENT #501 STATED THAT CNA #1 WAS PUSHING HER DOWN THE HALL IN HER WHEELCHAIR, AND HER (#501) FOOT fell OFF THE FOOT PEDAL AND GOT STUCK UNDER THE RUG AT THE FRONT OFFICE THE DAY BEFORE..." "...ORTHOPEDIC SURGEON CONTACTED ON 1/7/11, ORDER FROM ORTHOPEDIC TO SEND RESIDENT #501 TO NEARBY CARE FACILITY FOR EVALUATION AND TREATMENT..." "...RESIDENT #501 WAS treated for [REDACTED]. A REVIEW OF RESIDENT #501'S X-RAY REPORT DATED 1/6/11, REVEALED: "...FINDINGS: EXAMINATION REVEALS SOFT TISSUE SWELLING WITH A VERTICAL [MEDICAL CONDITION] MALLEOLUS AND A SLIGHTLY OBLIQUE [MEDICAL CONDITION] FIBULA WITH NO SIGNIFICANT DISPLACEMENT..." ON 1/27/11 AT 10:00 A.M., DURING AN INTERVIEW, THE ADMINISTRATOR REPORTED THAT "...ON THURSDAY EVENING, RESIDENT #501 WANTED FAST FOOD AND WAS IN A HURRY TO GET MONEY FROM THE BUSINESS OFFICE, SO CNA #1 PUSHED HER (#501)TO THE BUSINESS OFFICE TO EXPEDITE THINGS. HER (#501) FOOT GOT CAUGHT UNDER THE RUG. IT WAS A DIFFERENT RUG. WE CHANGED IT. CNA #1 KNEW HER (#501) FOOT DROPPED OFF THE FOOT PEDAL, BUT RESIDENT #501 MADE NO RESPONSE. SHE (#501) MAY HAVE SAID "OUCH"..." DURING A TOUR OF THE FACILITY ON 1/27/11 AT 10:40 A.M., RESIDENT #501 WAS OBSERVED IN THE HALLWAY SEATED IN HER WHEELCHAIR WITH AN IMMOBILIZER ON HER LOWER LEFT LEG. WHEN ASKED TO RECALL WHAT HAPPENED RESULTING IN THE FRACTURE TO HER LEFT ANKLE, RESIDENT #501 REPORTED THE FOLLOWING: "...I WAS TRYING TO GET SOME MONEY FROM THE FRONT OFFICE SO I COULD GET SOMETHING FROM THE FAST FOOD PLACE. CNA #1 WAS PUSHING ME. MY LEFT FOOT SLIPPED OFF AND GOT CAUGHT UNDER THE RUG. I WAS HOLLERING SO LOUD..." "...WHEN ASKED WHAT CNA #1 DID TO ASSIST HER, RESIDENT #501 SAID "THERE WAS ONLY SO MUCH SHE COULD DO". ON 1/27/11 AT 11:11 A.M., AN INTERVIEW WITH CNA #1 WAS CONDUCTED. WHEN QUERIED ABOUT RESIDENT #501'S COGNITION AND ABILITY TO RECALL INFORMATION, CNA #1 SAID: "...SHE'S THERE. SHE'S VERY APPROPRIATE WITH HER ANSWERS AND HER REQUESTS. SHE SEEMS TO BE WITH IT MOST OF THE TIME. SHE'S WITTY AND HAS A GREAT SENSE OF HUMOR. I'VE WORKED WITH HER A LOT..." WHEN ASKED TO RECALL THE EVENTS THAT TRANSPIRED ON THE DAY RESIDENT #501 WAS INJURED, CNA #1 REPORTED THE FOLLOWING: "...BETWEEN 4:00 P.M AND 5:00 P.M., , SHE (#501) CAME AND FOUND ME TO TAKE HER TO THE FRONT OFFICE FOR FAST FOOD. SHE (#501) PROPELLED HERSELF TO THE 400 HALL TO FIND ME, BUT I (CNA #1) TURNED HER AROUND AND BROUGHT HER UP TO THE BUSINESS OFFICE..." "...SHE (#501) CAN USUALLY PROPEL HERSELF, BUT I (CNA #1) PUSHED HER (#501) THIS TIME SO WE COULD GET THERE FASTER..." "...THERE WAS A VERY LARGE BLACK MATT THAT EXTENDED PAST THE BUSINESS OFFICE DOORS AND WHEN WE GOT TO THE MATT, SHE (#501) YELLED OUT "OUCH, MY FOOT"..." "...SHE (#501) SAID "MY FOOT IS OFF THE PEDAL". I STOPPED THE CHAIR AND WENT AROUND THE FROM OF THE CHAIR TO SEE HER LEFT FOOT WAS ON THE FLOOR..." WHEN ASKED IF RESIDENT #501'S LEFT FOOT/ANKLE WAS TWISTED IN ANY WAY, CNA #1 SAID "NO." CNA #1 FURTHER STATED THAT WHENEVER RESIDENT #501 BECAME ANXIOUS, SHE WOULD ROCK AND MOVE IN HER WHEELCHAIR AND "...SHE ROCKS THAT FOOT RIGHT OFF THAT PEDAL..." WHEN ASKED IF THERE WAS A STRAP ON THE LEG OF RESIDENT #501'S WHEELCHAIR TO SECURE HER LEFT LEG AND PREVENT IT FROM SLIPPING OFF THE FOOT PEDAL/LEG REST, CNA #1 SAID "NO". WHEN ASKED WHY THERE WAS NO STRAP TO SECURE RESIDENT #501'S LEG IN THE EVENT IT SHOULD SLIP OFF THE LEG REST/FOOT PEDAL, SEEING AS IT HAD HAPPENED BEFORE, CNA #1 SAID "...I DON'T KNOW, BUT THERE'S ONE ON THERE NOW...". WHEN ASKED WHAT MEASURES SHE TOOK AFTER RESIDENT #501'S LEFT LEG SLIPPED OFF OF HER LEG REST/FOOT PEDAL, CNA #1 SAID "...I PICKED HER FOOT UP AND PUT IT BACK ON THE PEDAL..." "...I WENT ON TO GET HER MONEY AND I GOT HER FAST FOOD AND BROUGHT IT BACK TO HER AND SHE (#501) ATE IT IN HER ROOM..." WHEN ASKED IF SHE (CNA #1) REPORTED THE INJURY TO THE NURSE, CNA #1 SAID "...I DID NOT TELL THE NURSE THAT HER FOOT SLIPPED OFF OR THAT SHE CRIED OUT. WE WENT ON ABOUT OUR NIGHT BECAUSE SHE (#501) DIDN'T APPEAR TO BE IN ANY DISTRESS..." ADDITIONALLY, CNA #1 REPORTED THAT SHE (CNA #1) RECEIVED A CALL AT HOME FROM FACILITY STAFF, ASKING HER ABOUT WHAT HAPPENED TO RESIDENT #501'S ANKLE/FOOT..." CNA #1 STATED THAT "...IT HAPPENED ON TUESDAY JANUARY 4, 2011 AND THEY (FACILITY STAFF) CALLED ME ON FRIDAY, JANUARY 7, 2011 TO ASK ME ABOUT IT..." ON 1/27/11 AT 12:15 P.M., AN INTERVIEW WAS CONDUCTED WITH THE PHYSICAL THERAPIST (PT) WHO REPORTED THE FOLLOWING: "...SHE (#501) HAS A LEFT FOOT REST DUE TO AN OLD STROKE AND SHE HAS LEFT SIDED [MEDICAL CONDITION] (PARALYSIS). SHE HAS A ONE ARM DRIVE WHEELCHAIR TO ENABLE HER TO MANEUVER THE CHAIR INDEPENDENTLY AND A FOOT REST/PEDAL ON THE LEFT SIDE DUE TO HER STROKE..." THE PT STATED THAT THERE IS NOW A "...CUFF (CUSHIONED DEVICE WITH RAISED AREAS ON EACH SIDE TO PREVENT EXTREMITY FROM ROLLING BACK AND FORTH) ON RESIDENT #501'S FOOT REST TO HELP SUPPORT THE EXTRA WEIGHT OF THE IMMOBILIZER AND TO KEEP HER LEFT FOOT IN PLACE..." THE PT FURTHER STATED THAT "...WITH A REGULAR FOOT REST, YOUR FOOT WOULD SLIDE OFF..." WHEN ASKED WHEN RESIDENT #501'S CUFF WAS APPLIED TO HER WHEELCHAIR, THE PT SAID "...AFTER THE FRACTURE SHE HAD..." ADDITIONALLY, THE PT SAID "...FROM TIME TO TIME, YOU NOTICE HER (#501) FOOT NOT ON THE FOOT PEDAL..." WHEN ASKED IF RESIDENT #501 COULD HAVE BENEFITED FROM HAVING A CUFF APPLIED TO HER WHEELCHAIR FOOT REST/PEDAL PRIOR TO HER INJURY, THE PT SAID "...HER (#501) FOOT WOULDN'T HAVE SLIPPED OFF IF SHE'D HAD A CUFF OR OTHER DEVICE TO IMMOBILIZE THE LEG AND KEEP IT IN PLACE..." WHEN ASKED WHY RESIDENT #501 WAS NOT ASSESSED AS HAVING A NEED FOR A CUFF OR OTHER DEVICE TO PREVENT HER (#501) LEG/FOOT FROM ROLLING OFF OF HER FOOT/LEG REST, THE PT SAID THAT IT WAS THE RESPONSIBILITY OF THE OCCUPATIONAL THERAPY DEPARTMENT TO PERFORM THIS ASSESSMENT IF NEEDED. THE PHYSICAL THERAPIST COULD NOT EXPLAIN WHY RESIDENT #501 HAD NOT BEEN ASSESSED AS HAVING A NEED FOR A CUFF OR OTHER GUARDING DEVICES TO PREVENT RESIDENT #501'S LEG/FOOT FROM ROLLING OFF OF HER LEG/FOOT REST. RESIDENT #501'S PHYSICAL THERAPY (PT) AND OCCUPATIONAL THERAPY (OT) ASSESSMENT AND NOTES WERE REQUESTED BUT NOT PROVIDED TO THE SURVEYOR AT THE TIME OF THE INVESTIGATION. ON 1/27/11 AT 12:46 P.M., AN INTERVIEW WAS CONDUCTED WITH LPN #1 WHO REPORTED THE FOLLOWING: "...I CAME BACK FROM MY DAYS OFF AND I WAS TOLD BY LPN #2 DURING MORNING REPORT AT 6:00 A.M. THAT SHE (#501) HAD BEEN COMPLAINING OF LEG PAIN AND THAT HE (LPN #2) DIDN'T HAVE A CHANCE TO ASSESS HER BECAUSE IT WAS AT THE END OF HIS SHIFT..." WHEN ASKED IF SHE WENT TO ASSESS RESIDENT #501 UPON LEARNING OF HER COMPLAINTS OF LEG PAIN, LPN #1 SAID "NO". "...I STARTED PREPARING FOR MY MORNING MEDS WHICH WERE DUE AT 8:00 A.M.. THEN ONE OF THE AIDES CAME AND ASKED ME FOR HELP TO CLEAN HER (#501) UP. WHEN I WENT IN THERE WE NOTICED BRUISING TO HER LEFT ANKLE AND POSTERIOR CALF AREA. WHEN ASKED WHY SHE (LPN #1) FAILED TO ASSESS RESIDENT #501'S COMPLAINTS OF LEG PAIN AT THE START OF HER SHIFT, LPN #2 OFFERED NO EXPLANATION. ACCORDING TO THE FACILITY'S INCIDENT REPORT, LPN #1 ASSESSED RESIDENT #501 AT 8:00 A.M. AND DISCOVERED SWELLING AND BRUISING TO RESIDENT #501'S LEFT ANKLE AND POSTERIOR CALF. THIS TIME WAS TWO HOURS AFTER THE START OF LPN #1'S SHIFT. ON 1/27/11 AT 1:02 P.M., DURING A TELEPHONE INTERVIEW, CNA #2 REPORTED "...SHE (#501) WASN'T MY RESIDENT BUT I HEARD HER YELLING "MY FOOT, MY FOOT" FROM ANOTHER ROOM. I CAME IN TO HELP GET HER UP AND THAT'S WHEN SHE (#501) TOLD ME SHE HURT HER FOOT THE DAY BEFORE AND THAT SOMEONE WAS PUSHING HER (#501) AND HER FOOT GOT RAN OVER BY THE FOOT PEDAL..." CNA #2 FURTHER STATED "...WE WENT AND GOT LPN #1 AND THAT'S WHEN I SAW SWELLING AND A BRUISE ON HER LEFT ANKLE..." ON 1/27/11 AT 1:30 P.M., THE DIRECTOR OF NURSING (DON) REPORTED, "...THERE IS NO EXPLANATION OF WHY THE NURSES DID NOT INFORM PT OR OT THAT HER (#501) LEG KEPT ROLLING OFF THE FOOT/LEG REST. FURTHER, THERE WAS NO DOCUMENTED EVIDENCE THAT THE CONCERN OF RESIDENT #501'S LEG ROLLING OFF THE FOOT/LEG REST HAD BEEN ADDRESSED. ADDITIONALLY, THE DON SAID "...CNA #1 SHOULD'VE TOLD THE NURSE AT THE TIME THE INJURY HAPPENED AND LPN #2 SHOULD'VE ASSESSED HER (#501) PRIOR TO LEAVING..." "...WHEN I ASKED HIM (LPN #2) WHY HE DIDN'T ASSESS HER (#501), HE (LPN #2) SAID "THEY TOLD ME ABOUT IT AND I PASSED IT ON IN REPORT"..." ON 1/27/11 AT 3:53 P.M., DURING A TELEPHONE CONVERSATION WITH LPN #2, HE REPORTED THE FOLLOWING: "...I WAS COMPLETING MY MORNING MEDICATION PASS AND THE AIDS TOLD ME THAT RESIDENT #501 HAD PAIN TO HER ANKLE. THE AIDES WEREN'T SURE IF IT WAS SWOLLEN AND I WAS ALREADY IN THE PROCESS OF GIVING REPORT SO I JUST MADE A NOTE TO PASS IT ON TO THE NEXT NURSE (LPN #1)..." WHEN ASKED WHY HE (LPN #2) DIDN'T ASSESS RESIDENT #501 FOR COMPLAINTS OF PAIN TO HER LEG, LPN #2 SAID "...BECAUSE I WAS GETTING READY TO GIVE REPORT TO LPN #1..." LPN #2 FURTHER STATED: "...SHE (#501) COMPLAINS A LOT. IF I GO IN HER ROOM FOR EVERY SINGLE COMPLAINT, I'D BE IN THERE ALL NIGHT...". "ACCURATE PAIN ASSESSMENT IS ESSENTIAL FOR EFFECTIVE PAIN MANAGEMENT." (FUNDAMENTALS OF NURSING, KOZIER, B., ERB, G., BERMAN, A., SNYDER, S., 2004). "...I RELY ON THE AIDES TO BE MY EYES AND EARS WHEN I'M DOING OTHER ROUNDS..." "...I DIDN'T ASSESS HER BECAUSE IT WAS MINUTES FROM ME GIVING REPORT. IN HIND SIGHT, I SHOULD HAVE ASSESSED HER (#501)..." ADDITIONALLY, LPN #2 STATED THE FOLLOWING: "...THE NIGHT WAS TYPICAL IN THAT SHE ALWAYS COMPLAINED OF ACHES AND PAINS..." THE FACILITY STAFF WAS UNABLE TO EXPLAIN WHY RESIDENT #501 WAS NOT PROVIDED WITH THE NECESSARY DEVICES TO PREVENT HER LEG FROM ROLLING OFF THE WHEELCHAIR FOOT REST AND WHY FACILITY STAFF FAILED TO PROPERLY ASSESS RESIDENT #501 WHEN SHE COMPLAINED OF LEFT LEG/ANKLE PAIN WHICH WAS DISCOVERED TO BE A FRACTURE.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 799 BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS AND IMPLEMENT INTERVENTIONS TO PREVENT AN INJURY FOR ONE (#501) OF FOUR SAMPLED RESIDENTS RESULTING IN RESIDENT #501'S FOOT SLIPPING OFF OF HER WHEELCHAIR REST AND GETTING STUCK UNDER A RUG RESULTING IN A FRACTURE. FINDINGS INCLUDE: ACCORDING TO RESIDENT #501'S RECORD OF ADMISSION, RESIDENT #501 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE PHYSICIAN'S HISTORY AND PHYSICAL DATED 10/7/10, RESIDENT #501 HAD [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE], INDICATED THAT RESIDENT #501 REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, DRESSING TOILETING, PERSON HYGIENE AND BATHING. THE MDS FURTHER INDICATED THAT RESIDENT #501 USED A WHEELCHAIR AS A MOBILITY DEVICE. ACCORDING TO RESIDENT #501'S NURSING ADMISSION assessment dated [DATE], RESIDENT #501 HAD INDEPENDENT COGNITION AND WAS ORIENTED TO TIME, PLACE AND PERSON. THE FACILITY'S INCIDENT REPORT DATED 1/7/11, DOCUMENTED THAT ON THE MORNING OF "...CNAS (CERTIFIED NURSING ASSISTANTS WERE PROVIDING MORNING CARE TO RESIDENT #501. WHEN CNAS ROLLED HER (#501) OVER, RESIDENT #501 YELLED OUT. RESIDENT #501 STATED THAT CNA #1 WAS PUSHING HER DOWN THE HALL IN HER WHEELCHAIR, AND HER (#501) FOOT fell OFF THE FOOT PEDAL AND GOT STUCK UNDER THE RUG AT THE FRONT OFFICE THE DAY BEFORE..." "...ORTHOPEDIC SURGEON CONTACTED ON 1/7/11, ORDER FROM ORTHOPEDIC TO SEND RESIDENT #501 TO NEARBY CARE FACILITY FOR EVALUATION AND TREATMENT..." "...RESIDENT #501 WAS treated for [REDACTED]. A REVIEW OF RESIDENT #501'S X-RAY REPORT DATED 1/6/11, REVEALED: "...FINDINGS: EXAMINATION REVEALS SOFT TISSUE SWELLING WITH A VERTICAL FRACTURE OF THE MEDIAL MALLEOLUS AND A SLIGHTLY OBLIQUE FRACTURE OF THE DISTAL FIBULA WITH NO SIGNIFICANT DISPLACEMENT..." ON 1/27/11 AT 10:00 A.M., DURING AN INTERVIEW, THE ADMINISTRATOR REPORTED THAT "...ON THURSDAY EVENING, RESIDENT #501 WANTED FAST FOOD AND WAS IN A HURRY TO GET MONEY FROM THE BUSINESS OFFICE, SO CNA #1 PUSHED HER (#501)TO THE BUSINESS TO EXPEDITE THINGS. HER (#501) FOOT GOT CAUGHT UNDER THE RUG. IT WAS A DIFFERENT RUG. WE CHANGED IT. CNA #1 KNEW HER (#501) FOOT DROPPED OFF THE FOOT PEDAL, BUT RESIDENT #501 MADE NO RESPONSE. SHE (#501) MAY HAVE SAID "OUCH"..." DURING A TOUR OF THE FACILITY ON 1/27/11 AT 10:40 A.M., RESIDENT #501 WAS OBSERVED IN THE HALLWAY SEATED IN HER WHEELCHAIR WITH AN IMMOBILIZER ON HER LOWER LEFT LEG. WHEN ASKED TO RECALL WHAT HAPPENED THAT RESULTED IN THE FRACTURE TO HER LEFT ANKLE, RESIDENT #501 REPORTED THE FOLLOWING: "...I WAS TRYING TO GET SOME MONEY FROM THE FRONT OFFICE SO I COULD GET SOMETHING FROM THE FAST FOOD PLACE. CNA #1 WAS PUSHING ME. MY LEFT FOOT SLIPPED OFF AND GOT CAUGHT UNDER THE RUG. I WAS HOLLERING SO LOUD..." "...WHEN ASKED WHAT CNA #1 DID TO ASSIST HER, RESIDENT #501 SAID "THERE WAS ONLY SO MUCH SHE COULD DO". ON 1/27/11 AT 11:11 A.M., AN INTERVIEW WITH CNA #1 WAS CONDUCTED. WHEN QUERIED ABOUT RESIDENT #501'S COGNITION AND ABILITY TO RECALL INFORMATION, CNA #1 SAID: "...SHE'S THERE. SHE'S VERY APPROPRIATE WITH HER ANSWERS AND HER REQUESTS. SHE SEEMS TO BE WITH IT MOST OF THE TIME. SHE'S WITTY AND HAS A GREAT SENSE OF HUMOR. I'VE WORKED WITH HER A LOT..." WHEN ASKED TO RECALL THE EVENTS THAT TRANSPIRED ON THE DAY RESIDENT #501 WAS INJURED, CNA #1 REPORTED THE FOLLOWING: "...BETWEEN 4:00 P.M AND 5:00 P.M., , SHE (#501) CAME AND FOUND ME TO TAKE HER TO THE FRONT OFFICE FOR FAST FOOD. SHE (#501) PROPELLED HERSELF TO THE 400 HALL TO FIND ME, BUT I (CNA #1) TURNED HER AROUND AND BROUGHT HER UP TO THE BUSINESS OFFICE..." "...SHE (#501) CAN USUALLY PROPEL HERSELF, BUT I (CNA #1) PUSHED HER (#501) THIS TIME SO WE COULD GET THERE FASTER..." "...THERE WAS A VERY LARGE BLACK MATT THAT EXTENDED PAST THE BUSINESS OFFICE DOORS AND WHEN WE GOT TO THE MATT, SHE (#501) YELLED OUT "OUCH, MY FOOT"..." "...SHE (#501) SAID "MY FOOT IS OFF THE PEDAL". I STOPPED THE CHAIR AND WENT AROUND THE FROM OF THE CHAIR TO SEE HER LEFT FOOT WAS ON THE FLOOR..." WHEN ASKED IF RESIDENT #501'S LEFT FOOT/ANKLE;E WAS TWISTED IN ANY WAY, CNA #1 SAID "NO." CNA #1 FURTHER STATED THAT WHENEVER RESIDENT #501 BECAME ANXIOUS, SHE WOULD ROCK AND MOVE IN HER WHEELCHAIR AND "...SHE ROCKS THAT FOOT RIGHT OFF THAT PEDAL..." WHEN ASKED IF THERE WAS A STRAP ON THE LEG OF RESIDENT #501'S WHEELCHAIR TO SECURE HER LEFT LEG AND PREVENT IT FROM SLIPPING OFF THE FOOT PEDAL/LEG REST, CNA #1 SAID "NO". WHEN ASKED WHY THERE WAS NO STRAP TO SECURE RESIDENT #501'S LEG IN THE EVENT IT SHOULD SLIP OFF THE LEG REST/FOOT PEDAL, SEEING AS IT HAD HAPPENED BEFORE, CNA #1 SAID "...I DON'T KNOW, BUT THERE'S ONE ON THERE NOW...". WHEN ASKED WHAT MEASURES SHE TOOK AFTER RESIDENT #501'S LEFT LEG SLIPPED OFF OF HER LEG REST/FOOT PEDAL, CNA #1 SAID "...I PICKED HER FOOT UP AND PUT IT BACK ON THE PEDAL..." "...I WENT ON TO GET HER MONEY AND I GOT HER FAST FOOT AND BROUGHT IT BACK TO HER AND SHE (#501) ATE IT IN HER ROOM..." WHEN ASKED IF SHE (CNA #1) REPORTED THE INJURY TO THE NURSE, CNA #1 SAID "...I DID NOT TELL THE NURSE THAT HER FOOT SLIPPED OFF OR THAT SHE CRIED OUT. WE WENT ON ABOUT OUR NIGHT BECAUSE SHE (#501) DIDN'T APPEAR TO BE IN ANY DISTRESS..." ADDITIONALLY, CNA #1 REPORTED THAT SHE (CNA #1) RECEIVED A CALL AT HOME FROM FACILITY STAFF, ASKING HER ABOUT WHAT HAPPENED TO RESIDENT #501'S ANKLE/FOOT..." CNA #1 STATED THAT "...IT HAPPENED ON TUESDAY JANUARY 4, 2011 AND THEY (FACILITY STAFF) CALLED ME ON FRIDAY, JANUARY 7, 2011 TO ASK ME ABOUT IT..." ON 1/27/11 AT 12:15 P.M., AN INTERVIEW WAS CONDUCTED WITH THE PHYSICAL THERAPIST (PT) WHO REPORTED THE FOLLOWING: "...SHE (#501) HAS A LEFT FOOT REST DUE TO AN OLD STROKE AND SHE HAS LEFT SIDED [DIAGNOSES REDACTED] (PARALYSIS). SHE HAS A ONE ARM DRIVE WHEELCHAIR TO ENABLE HER TO MANEUVER THE CHAIR INDEPENDENTLY AND A FOOT REST/PEDAL ON THE LEFT SIDE DUE TO HER STROKE..." THE PT STATED THAT THERE IS NOW A "...CUFF (CUSHIONED DEVICE WITH RAISED AREAS ON EACH SIDE TO PREVENT EXTREMITY FROM ROLLING BACK AND FORTH) ON RESIDENT #501'S FOOT REST TO HELP SUPPORT THE EXTRA WEIGHT OF THE IMMOBILIZER AND TO KEEP HER LEFT FOOT IN PLACE..." THE PT FURTHER STATED THAT "...WITH A REGULAR FOOT REST, YOUR FOOT WOULD SLIDE OFF..." WHEN ASKED WHEN RESIDENT #501'S CUFF WAS APPLIED TO HER WHEELCHAIR, THE PT SAID "...AFTER THE FRACTURE SHE HAD..." ADDITIONALLY, THE PT SAID "...FROM TIME TO TIME, YOU NOTICE HER (#501) FOOT NOT ON THE FOOT PEDAL..." WHEN ASKED IF RESIDENT #501 COULD HAVE BENEFITED FROM HAVING A CUFF APPLIED TO HER WHEELCHAIR FOOT REST/PEDAL PRIOR TO HER INJURY, THE PT SAID "...HER (#501) FOOT WOULDN'T HAVE SLIPPED OFF IF SHE'D HAD A CUFF OR OTHER DEVICE TO IMMOBILIZE THE LEG AND KEEP IT IN PLACE..." WHEN ASKED WHY RESIDENT #501 WAS NOT ASSESSED AS HAVING A NEED FOR A CUFF OR OTHER DEVICE TO PREVENT HER (#501) LEG/FOOT FROM ROLLING OFF OF HER FOOT/LEG REST, THE PT SAID THAT IT WAS THE RESPONSIBILITY OF THE OCCUPATIONAL THERAPY DEPARTMENT TO PERFORM THIS ASSESSMENT IF NEEDED. THE PHYSICAL THERAPIST COULD NOT EXPLAIN WHY RESIDENT #501 HAD NOT BEEN ASSESSED AS HAVING A NEED FOR A CUFF OR OTHER GUARDING DEVICES TO PREVENT RESIDENT #501'S LEG/FOOT FROM ROLLING OFF OF HER LEG/FOOT REST. RESIDENT #501'S PHYSICAL THERAPY (PT) AND OCCUPATIONAL THERAPY (OT) ASSESSMENT AND NOTES WERE REQUESTED BUT NOT PROVIDED TO THE SURVEYOR AT THE TIME OF THE INVESTIGATION. ON 1/27/11 AT 1:30 P.M., THE DON REPORTED, "...THERE IS NO EXPLANATION OF WHY THE NURSES DID NOT INFORM PT OR OT THAT HER (#501) LEG KEPT ROLLING OFF THE FOOT/LEG REST.