Every finding on record at The Laurels of Sandy Creek

This citation pertains to intakes 2738764 and 2707043Based on observation, interview, and record review the facility failed to maintain their roof in a safe, functional, and sanitary manner for 2 (Residents #112 and #113) of 4 residents reviewed for environment, resulting in dissatisfaction with living environment which affected all areas of the facility and an increased potential for contamination. Findings include:Resident #112: During an observation on 3/25/26 at 2:16 PM, in room [ROOM NUMBER] on the ceiling near the light fixture closest to the window there was a large, discolored orange stain that measured approximately 17 inches by 22 inches. The surface of the stain in many places appeared to have what looked like raised areas that indicated buildup of unknown material and/or deterioration of the ceiling. It was noted that a resident had belongings in this room but was out at the hospital. Review of Resident #112's brief interview for mental status, dated 2/12/26, was scored 15 which reflected he was cognitively intact. During an interview on 3/25/26 at 2:26 PM, Resident #112 reported he used to live in room [ROOM NUMBER] but had to move out of the room because of a ceiling leak that caused the light fixture to stop working. Resident #112 reported the leak caused him to have to move his bed and eventually had to move rooms. Resident #112 reported he liked his old room (room [ROOM NUMBER]) more and wanted to move back to it. Resident #112 reported his ceiling was leaking in December 2025 but reported it had started leaking prior to that. Resident #112 reported it had been an issue for over a year now. Review of Resident #112's Notice of Room Change, dated 12/17/2025, stated, This notice is to inform you that: We (The Facility) will be transferring you to another room.Current rooom (sic) 301B has a few leaks from roof, when able to be corrected resident wishes to return to room [ROOM NUMBER]B. Review of Resident #112's census report (shows room changes), undated, showed Resident #112 lived in room [ROOM NUMBER]B from 5/2024-12/17/25 and was moved to a different room on the 300s unit on 12/17/25. Review of the facility's Resident Council meeting minutes, dated 12/2/25, stated, Concerns: New: Leaks in rooms. Resident #113 Review of an admission Record revealed Resident #113 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic pain and depression. Review of a Minimum Data Set (MDS) assessment for Resident #113, with a reference date of 1/6/26 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #113 was moderately cognitively impaired. During an interview on 3/25/26 at 4:39 PM, Certified Nursing Assistant (CNA) K reported that she had concerns for staff and resident safety related to the facility's leaking roof. CNA K reported that the facility had to frequently move residents because water would leak all over the facility, including into resident rooms. CNA K reported that she felt it was unsafe because there were several residents that were unable to ambulate well and were at an increased risk of slipping and falling onto puddles that leaked throughout the facility. CNA K reported that at times, the roof was leaking water into the facility's shower rooms, and that there were times when residents were getting dripped on from the leaking roof when they were being showered. During an interview on 3/25/26 at 3:07 PM, Former Director of Nursing (DON) X reported that facility roof had been leaking for months, and it had become a safety risk for the staff and residents at the facility. Former (DON) X reported that multiple residents had to be moved from to different rooms because the roof was leaking onto the residents and their belongings. DON X reported she was aware of one Resident (Resident #113) sustaining a fall in the facility due to slipping on water that was leaking from the roof onto the floor in his room. During an interview on 3/26/26 at 11:18 AM, CNA Z reported that the facility's roof had been leaking for over a year, but the leaking seemed to increase this winter. CNA Z reported that anytime it rained or snowed, the facility would have several buckets around the facility to catch the water, and that the staff were frequently moving residents to other rooms because the roof was leaking into resident rooms. CNA Z voiced safety concerns for staff and residents due to the leaking roof. Review of Resident #113's Incident Report dated 2/17/26 and documented by Licensed Practical Nurse (LPN) Q revealed, Incident Description: Resident observed on the in front of his chest of drawers, sitting on top of wash basin, water on the floor. Wheelchair in front of his right side and bed to his left. Regular socks on. Call light within reach. Area free of clutter. (Resident #104) stated he slipped on water when transferring self from wheelchair to bed . During an interview on 3/25/26 at 3:26 PM, LPN Q reported that she was the nurse caring for Resident #113 on 2/17/26 when he slipped in fell on water leaking from the roof onto the floor of his room. LPN Q reported she found Resident #113 lying on his floor near his bed and observed water on the floor near him. LPNQ reported that the facility's roof had been leaking for quite some time, and several residents had to be moved because water was leaking into their rooms. During an interview on 3/25/26 at 4:29 PM, Resident #113 reported that he did fall on 2/17/26 in his room. Resident #113 reported he had slipped on water that was leaking from the roof onto his room floor. Resident #113 reported the roof had been leaking water into his room for quite some time. Resident #113 reported that he did experience some pain after his fall, but that the pain was resolved after a few days. On 3/25/26 at 8:15 AM, an interview with the Nursing Home Administrator (NHA) found that roof leaks had affected most of the facility as the snow melted on the roof from the winter. The NHA stated that over time, short term repairs were able to be put in place as issues arose (regarding the condition of the roof), but a full replacement is now scheduled for next week. On 3/25/26 starting at 9:23 AM, an initial tour of the East hall found the following observations: empty resident room [ROOM NUMBER] was observed with black staining on the ceiling, numerous stained and discolored ceiling tiles were observed walking down the hall to the East wing, East wing nurses station was observed with missing and discolored tiles with a system in place consisting of a plastic tarp funneling water into a five gallon bucket located on the desk of the East nurses station, East wing medication room was observed with bubbling and chipping surfaces on the back wall of the room indicating heavy moisture damage to the area. On 3/25/26 at 10:02 AM, an interview with Maintenance Director (MD) KK found that he has been employed with the facility for about four months and has been trying to stay on top of what he can. MD KK stated the roofing vendor had used 28 tubes of caulk since the snow had melted (to seal up holes until the roof could be fully redone). At this time, the surveyor and MD KK went on top of the roof to observe the current condition of the roof surface. The roof was observed with hundreds of caulk spots throughout with numerous areas circled or outlined to show larger issues within the roof's surface. At this time, contractors were also observed on the roof assessing the project for next week. On 3/25/26 at 12:50 PM, observation of the main middle hall near the middle back door observed numerous discolored and dried out ceiling tiles. On 3/25/26 starting at 12:52 PM, observation of the [NAME] hall found the following: discolored and brown ceiling tiles across from resident room [ROOM NUMBER], discoloration in the ceiling tiles at the North end of the [NAME] hall, two light fixtures leading to the South end of the [NAME] hall were found with rust accumulation indicating leaking into the light, Further down the South end of the [NAME] hall found numerous tiles discolored around the roof top unit, the South end [NAME] hall Spa was found with bubbling and brown areas of the ceiling, the west hall medication room was observed with heavy discoloration and sagging of the ceiling tiles, and the [NAME] hall day room was observed with black and brown discoloration coming from the ceiling.

This citation pertains to intake 2790806.Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of staff to resident abuse to other state agency according to state law in 1 (Resident #104) of 3 residents reviewed for abuse resulting in the nurse licensing department not being notified and officials being unaware of abuse allegations, and the potential for abuse to reoccur.Findings include: Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic pain, anxiety and dementia (a decline in mental ability in memory, reasoning, and communication). Review of Resident #104's facility reported incident (FRI) investigation summary revealed, . Date of event: Resident #104 was exhibiting agitation and increased pacing. Licensed Practical Nurse (LPN) CC requested Resident #104 go to her room and stay there as heard by witness. Resident #104 refused to go to her room. Resident #104 approached LPN CC attempting to strike her. LPN CC placed Resident #104's arms behind her back and physically assisted her to her room and closed the door. Resident #104 vocalized stop that hurts . In depth analysis of how deficiency occurred: LPN CC was not using skills of de-escalation. Her frustration perpetuated the situation to intensify, resulting in verbal and physical abuse to the resident . Disciplinary action to be taken: termination effective 2/16/26. Noted that the FRI summary did not include documentation of the facility reporting LPN CC to the State Bureau of Professional Licensing. During an interview on 3/24/26 at 1:25 PM, Nursing Home Administrator (NHA) A reported that she had substantiated that LPN CC had verbally and physically abused Resident #104 on 2/4/26 based on witness interviews. NHA A reported that she terminated LPN CC on 2/16/26. When this writer queried NHA A as to if she had reported LPN CC 's termination to the State Bureau of Professional Licensing, NHA A reported that she could not recall if she had reported LPN CC. In a follow up interview on 3/26/26 at 1:30 PM, NHA A confirmed that she had not reported LPN CC to the State Bureau of Professional Licensing. NHA A reported she had completed the form to send to report LPN CC but that she had somehow forgot to fax the report, and this was just missed. According to the Michigan Public Health Code MCL 333.20175: (10) A health facility or agency that employs, contracts with, or grants privileges to a health professional licensed or registered under article 15 shall report the following to the department not more than 30 days after it occurs: (a) Disciplinary action taken by the health facility or agency against a health professional licensed or registered under article 15 based on the licensee's or registrant's professional competence, disciplinary action that results in a change of employment status, or disciplinary action based on conduct that adversely affects the licensee's or registrant's clinical privileges for a period of more than 15 days. As used in this subdivision, adversely affects means the reduction, restriction, suspension, revocation, denial, or failure to renew the clinical privileges of a licensee or registrant by a health facility or agency. (b) Restriction or acceptance of the surrender of the clinical privileges of a licensee or registrant under either of the following circumstances: (i) The licensee or registrant is under investigation by the health facility or agency. (ii) There is an agreement in which the health facility or agency agrees not to conduct an investigation into the licensee's or registrant's alleged professional incompetence or improper professional conduct. (c) A case in which a health professional resigns or terminates a contract or whose contract is not renewed instead of the health facility or agency taking disciplinary action against the health professional.

Based on observation, interview, and record review, the facility failed to ensure adequate care for residents who received enteral nutrition (method of delivering nutrients directly into the gastrointestinal (GI) tract via tubes) in 1 (Resident #121) of 1 resident reviewed for enteral nutrition, resulting in the potential for aspiration pneumonia and spoiled tube feeding. Findings include: Resident #121Review of an admission Record revealed Resident #121 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic pain and dysphagia following cerebral infarction (difficulty swallowing following a stroke). Review of Resident #121's Orders revealed, Enteral Feed Order at bedtime Jevity1.5 (type of enteral nutrition formula) @80ml/hr (at milliliters per hour). Start date: 2/14/26 . Enteral Feed Order every shift Elevate head of bed at least 30 degrees during feeding. Start date: 1/21/26.Review of Resident #121's Care Plan revealed, Focus: (Resident #104) is unable to tolerate nutritionally adequate food and/or fluids by mouth requiring the use of a feeding tube R/T: dysphagia following cerebral infarction, moderate protein calorie malnutrition .Date initiated: 1/15/26 Goal: resident will remain free of aspiration . Interventions: resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Date Initiated: 01/15/2026.During an observation on 3/25/26 at 8:00 AM, Resident #121 was lying in her bed sleeping. Noted that Resident #121's room tray had two opened bottles of Jevity formula sitting on it. Both bottles were 1/4 full. One bottle was dated 3/24/26 and the other bottle was not dated. Resident #121's tube feed was running at 80 mL/hr. Noted that the bag of formula that was running was not labeled or dated to indicate when the formula was opened. Resident #121 was lying flat. In an observation and interview on 3/25/26 at 8:04 AM, Licensed Practical Nurse (LPN) I reported that he was the nurse caring for Resident #121 today, but that he had not been into Resident #121's room to see her yet. LPN I entered Resident #121's room with this writer and stated that Resident #121 was definitely lying way too flat and he re-positioned Resident #121's head of the bed to be elevated to 45 degrees. LPN I reported that he had no idea how long Resident #121 had been lying flat while her enteral feed was running. It was noted that LPN I did not provide further assessment of Resident #121. When this writer queried LPN I about the open Jevity containers in Resident #121's tray table, LPN I reported that they should have been discarded. LPN I reported that nurses were supposed to date enteral feeding formulas when they were opened with the date and time to ensure that the formula being administered was safe to use and not spoiled. During an observation on 3/25/26 at 9:38 AM, Resident #121 was lying in bed. It was noted that her enteral feed was still running at 80 mL/hr, and the formula bag remained undated/unlabeled. During an observation on 3/25/26 at 1:13 PM, Resident #121 was lying in bed. It was noted that her enteral feed was still running at 80 mL/hr, and the formula bag remained undated/unlabeled. During an observation on 3/26/26 at 7:58 AM, Resident #121 was lying in her bed with her tube feed running at 80 mL/hr. It was noted that the formula bag did not have a date on the formula bag to indicate when the formula was opened, or what time the enteral feeding was started. Resident #121's head of bed was not elevated to 30 degrees. During a care observation on 3/26/26 at 8:12 AM, LPN Y reported that she was caring for Resident #121 that day, and that she had been in her room shortly before to fix her tube feed. LPN Y entered Resident #121's room and adjusted Resident #121's head of the bed to 30 degrees. LPN Y confirmed that Resident #121's head of bed was not elevated to 30 degrees. Review of the facility's Enteral Feeding policy last revised 9/22/23 revealed, Policy: Residents maintain acceptable parameters of nutritional status . residents who are unable to feed themselves receive the necessary services to maintain good nutrition, including at times, enteral nutrition . Guidelines: 8. the resident should be in semi-Fowlers position (medical orientation where the patient lies on their back (supine) with the head of the bed elevated to a 30-45 degree angle) during administration and for 30 minutes to one hour after to prevent aspiration .

This citation pertains to intakes 2704281 and 2790806.Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse and/or physical abuse by staff for 2 (Residents #107 and 104) of 3 residents reviewed for abuse resulting in feelings of sadness and/or being handled in an undesirable way.Findings include:Resident #107: Review of Resident #107's Incident report (Facility Reported Incident; submitted to the state survey agency by the facility), dated 11/28/25, noted that Resident #107 had a brief interview for mental status (BIMS) score of 13 (which reflected he was cognitively intact), Cognitive Status: Independent, PERPETRATORS.Registered Nurse (RN) BB, Date/Time Incident Occurred: 11/27/2025 01:00 am, and Incident Summary: Resident, (Resident #107) reported.[physical descriptors of staff omitted] nurse (RN BB), told him (Curse word censored for report; F***) you, I hate you and gave him the middle finger. Roommate (Resident #114) heard the interaction.facility will suspend staff member (RN BB). Review of Resident #107's Facility Reported Incident form, dated 12/2/25, stated, .Date of Incident: 11/27/2025.Type of Incident: Allegation of Verbal Abuse.What allegedly occurred: Resident (Resident #107) reported (RN BB) told him, f*** you, I hate you. Stating he was frustrated with him about his oxygen.Who is the alleged perpetrator? .6p-6a (6PM-6AM) night shift Staff, (RN BB). Were there any witnesses: Yes.Resident: (Resident #114).Resident (Resident #107) stated it occurred 11/27 (2025) between 1-4am.Details from the witness: Resident (Resident #107) shares a room with another resident, (Resident #114) (BIM's (sic) of 13), Resident (Resident #114) was asked if he had heard anything transpire on the evening in question. (Resident #114) reported he heard his roommate (Resident #107) and the male nurse (RN BB) arguing. He stated he heard the nurse (RN BB) use a cuss word and tell him, I hate you. (RN BB) stated that he spoke sternly with (Resident #107).Based on the Resident (Resident #107) with the allegation and confirmation from his roommate (Resident #114) we determine that verbal abuse occurred from (RN BB). Review of the facility's complaint form submitted to the State's professional licensing intake section, undated, stated, Resident (Resident #107) alleged that Nurse (RN BB) told him, F*** you, I hate you. Another resident (Resident #114) confirmed allegation. Nurse (RN BB) terminated for verbal abuse. During an interview on 3/24/26 at 12:30 PM, Resident #107 was seated on his bed in his room and reported he had an incident with (RN BB) on a night shift at the end of November 2025 (11/26/27-11/27/25) where (RN BB) told him that he didn't need oxygen, told him F*** you, I hate you, and gave him the middle finger. Resident #107 stated the comments (RN BB) made to him that night upset me and it really bothered me a lot. Resident #107 reported that had been the first time (RN BB) had said f*** you to him but said there had been times prior that (RN BB) told him that he didn't like him. Resident #107 stated, What did I do to have him say that to me? What did I do to him? I never did anything to him for him to hate me. Resident #107 confirmed he first notified the facility about (RN BB) on 11/28/25 and had not on any day prior. During an interview on 3/24/26 at 12:40 PM, Resident #114 recalled the incident between Resident #107 and (RN BB) from the end of November 2025. Resident #114 reported the curtain was pulled halfway so he could only hear the two speaking but reported he remembered hearing (RN BB) say to Resident #114 I hate you, f*** (curse word) you, and what are you going to do about it?. Resident #114 reported this incident occurred some time ago but reported he remembered it well. Resident #114 reported (RN BB) had been verbally aggressive towards Resident #107 several times prior to the 11/26/25-11/27/25 incident but couldn't remember exact details or dates. During an interview on 3/24/26 at 12:57 PM, Licensed Practical Nurse T confirmed RN BB no longer worked at the facility and thought Residents #107 and #114 had the cognitive ability to be able to report an incident such as the one alleged between Resident #107 and RN BB. During an interview on 3/24/26 at 3:36 PM, Nursing Home Administrator (NHA) A reported both Residents #107 and #114's cognitive statuses indicated they should be accurate historians and were considered believable sources regarding their verbal abuse allegations reported on 11/28/25 against RN BB. During an interview on 3/25/26 at 11:07 AM, Social Worker (SW) F reported Resident #107 hadn't made any other allegations against staff for being verbally or physically abusive that she was aware of. SW F stated if something was happening Resident #107 would make it known. SW F reported Resident #114 didn't have a history of making false allegations against staff that she was aware of. Resident #104 Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic pain, anxiety and dementia (a decline in mental ability in memory, reasoning, and communication). Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 1/23/26 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #9 was moderately cognitively impaired. Review of Resident #104's Care Plan revealed, Focus:(Resident #104) has potential for impaired communication r/t (related to) Hx (history) of CVA (cerebrovascular accident-stroke), cognitive impairment with dementia diagnosis. Date initiated: 5/8/24. Interventions: Use communication techniques to enhance interaction: Allow adequate time to respond, Repeat as necessary, Do not rush, Request feedback, clarification from the resident, to ensure understanding, Face when speaking and make eye contact, Turn off TV/radio as needed to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communicationtools as needed, such as communication book/board, writing pad, gestures, signs, and pictures. Date initiated:5/8/24 .Focus: (Resident #104) has the potential to demonstrate verbal aggression r/t anger, dementia, depression, mental illness, poor impulse control. Date initiated:7/19/24. Interventions: COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . Date initiated: 8/13/24. Review of the facility reported incident (FRI) investigation summary revealed, . Date of event: Resident #104 was exhibiting agitation and increased pacing. Licensed Practical Nurse (LPN) CC requested Resident #104 go to her room and stay there as heard by witness. Resident #104 refused to go to her room. Resident #104 approached LPN CC attempting to strike her. LPN CC placed Resident #104's arms behind her back and physically assisted her to her room and closed the door. Resident #104 vocalized stop that hurts . In depth analysis of how deficiency occurred: LPN CC was not using skills of de-escalation. Her frustration perpetuated the situation to intensify, resulting in verbal and physical abuse to the resident . During an interview on 3/24/26 at 2:14 PM, LPN CC reported when she arrived to work her shift on 2/4/26 at 7:00 PM, that Resident #104 was already doing her pacing up and down the hallway like she always does and that Resident #104 was being aggressive towards other residents. LPN CC reported she started her medication pass when she noticed that Resident #104 was bothering the other nurse working at the facility. LPN CC reported LPN M asked her to come get Resident #104, so she went to the medication cart that LPN M and Resident #104 were standing at and asked Resident #104 to give LPN M some space. LPN CC reported in the past, Resident #104 had become triggered when asked to give space and since she knew that she politely put her hand on Resident #104's shoulder, but as she touched Resident #104's shoulder, she (Resident #104) turned around and started swinging on her. LPN CC reported she then got behind Resident #104 and guided (Resident #104) to her room with her hands around Resident #104's arms. LPN CC reported Resident #104 went into her room, and she told her to have a seat and stay in here for a minute. LPN CC reported Resident #104 was still pacing around her room and saying that she was going to leave. LPN CC reported Resident #104 went into her room on her own, but when she closed her room door, Resident #104 opened her door and came right back out. LPN CC reported she never yelled at Resident #104 and stated that she just had a loud voice. During an interview on 3/25/26 at 8:30 AM, Former CNA GG reported she had been working with LPN CC and LPN M on 2/4/26 and witnessed the physical interaction between LPN CC and Resident #104. Former CNA GG reported she had noticed earlier in the night that LPN CC had been a bit rude to Resident #104 when she was pacing the hallways and talking to other residents and staff. Former CNA GG reported she observed LPN CC go over to LPN M and Resident #104 and tell Resident #104 that she needed to leave LPN M alone and that she (Resident #104) was bothering her. Former CNA GG reported Resident #104 did not want to go to her room and told LPN CC that she was not going to go to her room which seemed to cause LPN CC to escalate. Former CNA GG reported she observed LPN CC grab both of Resident #104's wrists and placed them together behind her back and held Resident #104's arms up behind her back as she attempted to walk Resident #104 from the center hall area to her room. Former CNA GG reported that the position that LPN CC had placed Resident #104's arms in looked painful and Resident #104 was yelling ouch, that hurts and get off of me multiple times as she attempted to break free from the hold that LPN CC had her in. Former CNA GG reported that as LPN CC was continuing to take Resident #104 towards her room, she bashed Resident #104 into a utility closet. Former CNA GG reported that she was not sure if LPN CC intentionally bashed Resident #104 into the closet, or if it was because Resident #104 was trying to break free from LPN CC and LPN CC had to grab her even harder. Former CNA GG reported after LPN CC bashed Resident #104 into the utility closet, she continued to walk Resident #104 to her room, with her hands held behind her back, and Resident #104 continued to yell out that LPN CC was hurting her. Former CNA GG reported that she then watched LPN CC take Resident #104 into her room where she bashed her into the entrance area before entering Resident #104's room with her and slamming the door behind her. Former CNA GG reported that she could hear bashing around Resident #104's room and could hear Resident #104 screaming out Stop, I can't breathe. Former CNA GG reported that LPN CC opened Resident #104's door shortly after and walked out and slammed the door on Resident #104. Former CNA GG reported Resident #104 opened the door twice and tried to exit her room, and both times LPN CC slammed the door on her and screamed at her to stay in her room. Former CNA GG reported that after she slammed Resident #104's door on her the second time, LPN CC walked away and entered another resident room, and she went to get Resident #104. CNA GG reported Resident #104 was visibly shaken, crying, and her hair was messed up as if it had been pulled. Former CNA GG reported that Resident #104 told her that LPN CC choked her and threw her to the ground. Former CNA GG reported she felt like something had happened when LPN CC was in the room alone with Resident #104 because of all the bashing she heard. Former CNA GG reported that she had instructed Resident#104 to go to the dining room and stay with the receptionist as another staff member was reaching out to report the incident to Nursing Home Administrator (NHA) A. Former CNA GG reported that she did not intervene when LPN CC went after Resident #104 because was terrified for her own safety. Former CNA GG reported Resident #104 had behaviors, but she was typically very easy to redirect. Former CNA GG reported that as long Resident #104 was approached nicely, she would typically have a positive response and could be de-escalated pretty easily. During an interview on 3/25/26 at 9:11 AM, LPN M reported she had been working in the evening on 2/4/26 and had noticed that Resident #104 was pacing back and forth as she normally did. LPN M reported Resident #104 then approached her and was talking to her as she prepared medications at her medication cart. LPN M reported it was common for Resident #104 to stand by her as she prepared medications, and that Resident #104 liked to stand and chat, and it seemed to help calm her anxiety. LPN M reported Resident #104 was not being disruptive when LPN CC approached her and told Resident #104 the nurse doesn't want you bothering her, which LPN M reported that she did not say. LPN M reported that Resident #104 laughed at LPN CC and that seemed to escalate LPN CC and she then told Resident #104, I am being serious as she was getting louder in tone. LPN M reported Resident #104 told LPN CC that she was not going to go to her room and LPN CC then told her yes you are which triggered Resident #104 and she attempted to strike LPN CC who then grabbed Resident #104's arms and whipped them behind her back LPN CC then grabbed Resident#104 and began to walk Resident #104 to her room. LPN M reported that Resident #104 was yelling out that LPN CC was hurting her and she was trying to break free from LPN CC when LPN CC picked up Resident #104 and slammed her into the utility closet door. LPN M reported LPN CC then took Resident #104 around the corner towards her room and she could not see them at first so she thought that LPN CC had let Resident #104 go, but then she heard the loud bashing noises from Resident #104's room and Resident #104 yelling out that so she went towards the room and was told by Former CNA GG that LPN CC had taken Resident #104 into her room and slammed the door. LPN CC reported she instructed Former CNA GG to call NHA A immediately, as she observed LPN CC exit Resident #104's room and slam the door on her. LPN M reported Resident #104 attempted to exit her room twice and both times LPN CC slammed the door on her and yelled at her to stay in her room. LPN M reported that LPN CC then walked towards another resident room and stated, I am not dealing with this lady (Resident #104), I will fight her. LPN CC reported that she was shocked to see LPN CC act so aggressive and she was too scared to get in between her and Resident #104. LPN M reported she felt like LPN CC was watching her and Former CNA GG after the incident and she was scared that she was going to escalate again and go after her or another resident. LPN M reported that although Resident #104 had a history of behaviors, she was very easy to redirect. During an interview on 3/25/26 at 11:59 AM, Receptionist O reported that she had been working on 2/4/26 when Resident #104 came into the dining room speed walking, crying and saying that she had just gotten into a fight. Receptionist O reported that she thought that Resident #104 was possibly confused, so she offered to take Resident #104 to her room because she thought she might be getting overstimulated. Receptionist O reported that when she offered to take Resident #104 to her room, and they began walking when Resident #104 began to freak out and that she told her that she did not want to go down there (the hallway where LPN CC was) because she did not want to get into another fight. Receptionist O reported that as Resident #104 was crying in the hallway and saying she did not want to go to the hallway her room was on, a staff member walked by and told her that What Resident #104 is saying is true and that she needed to keep Resident #104 away from that area. Receptionist O reported that Resident #104's hair was messed up, and she seemed very shaken. Receptionist O reported that Resident #104 had told her that LPN CC had grabbed her by her shirt and threw her down. During an interview on 3/25/26 at 9:32 AM, Resident #104 reported that she did recall the incident with LPN CC on 2/24/26, but Resident #104 did not want to talk about the incident with this writer. Resident #104 reported, I am just glad she (LPN CC) is gone, and that is all that mattered. During an interview on 3/24/26 at 1:25 PM, Nursing Home Administrator (NHA) A reported that she had substantiated that LPN CC had verbally and physically abused Resident #104 on 2/4/256 based on witness interviews. NHA A reported that she terminated LPN CC on 2/16/26. Review of the facility's Abuse policy last revised 9/9/22 revealed, Policy: Each Guest shall be free from abuse . To assure guest/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 guest/residents . The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained all facility staff on abuse, police were notified on 2/4/26, LPN CC was terminated from the facility, Resident #104's care plan was reviewed and updated on 2/5/26, Social Services monitored Resident #104 for emotional concerns and potential psychosocial decline related to the incident, (Local Mental Health Provider) was consulted and collaborated with facility provider on behavior interventions and medication changes for Resident #104, All residents with a Brief Interview for Mental Status (BIMS) score of 10 or higher were interviewed to ensure there were no further complaints, and the facility conducted weekly abuse audits for 4 weeks and will continue monthly for 3 months.

Based on observation, interview, and record review, the facility failed to implement care plan interventions for 1 (Resident #111) of 9 residents reviewed for care plan implementation resulting in the potential for further skin breakdown and worsening of pressure ulcers. Findings include: Resident #111Review of an admission Record revealed Resident #111 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic pain and cerebral Infarction with expressive aphasia (stroke causing damage to the brain, resulting in non-fluent, effortful speech while comprehension remains relatively intact). Review of Resident #111's Orders revealed, WOUND CARE: Right elbow wound: cleanse with NS (normal saline)/wound cleanser. Apply Dakins (wound cleanser) solution moistened gauze to wound bed. Cover with silicone bordered dressing. every day shift. Start date: 3/17/26. WOUND CARE: Wounds to right plantar foot and heel: Paint areas with Iodine/betadine solution (topical antiseptic). every day shift. Start date: 3/24/26 .Review of Resident #111's Care Plan revealed, Focus: (Resident #111) has actual impairment to skin integrity r/t (related to) decreased mobility, medical device related pressure, bowel incontinence (the involuntary loss of stool), diarrhea, left hemiplegia following cerebral infarction (paralysis of the left side of the body resulting from a stroke), obesity, moderate protein calorie malnutrition Date initiated: 1/15/26. Interventions: pressure reducing boots to BLE (bilateral lower extremities) as tolerated by guest. Date initiated:1/28/26 .Soft pillow boot to right elbow. elbow. Date Initiated: 02/28/2026 .Treatment to skin impairment per order. Date Initiated: 01/16/2026 . Turn and Reposition q2h (every 2 hours) and PRN (as needed), as tolerated by resident. Date Initiated: 01/15/2026 .During an observation on 3/25/26 at 8:00 AM, Resident #111 was lying in bed on her back. Noted that Resident #111 was not wearing her pressure reducing boots on her feet, and they were sitting in her chair. During an observation on 3/25/26 at 9:38 AM, Resident #111 was lying in bed on her back in the same position as previous observation. It was noted that Resident #111's pressure reducing boots remained in her chair, and that Resident #111's feet were lying directly on the bed and not being floated over pillows or anything else to reduce pressure. During an interview on 3/25/26 at 1:13 PM, Certified Nursing Assistant (CNA) MM reported Resident #111 had multiple pressure ulcers, and that she was supposed to wear a pressure reducing pillow on her right arm and both feet at all times. CNA MM reported that Resident #111 tolerated the pressure reducing pillows well, and she had never witnessed kick her pressure reducing boots off. During an interview on 3/25/26 at 1:07 PM, Wound Care Nurse Practitioner (WCNP) DD reported he had been caring for Resident #111's pressure ulcers weekly for the last few months. WCNP DD reported that Resident #111 was high risk for worsening skin breakdown, and following pressure reducing interventions as ordered was crucial to prevent further skin breakdown. WCNP DD reported that Resident #111 was ordered to have a soft pillow boot on her right arm and pressure reducing boots to both feet at all times to help offload pressure. During a wound care observation and interview on 3/25/26 at 3:46 PM, Registered Nurse (RN) S had entered Resident #111's room to provide care to her wounds. RN S removed Resident #111's soft pillow on her right arm, Resident #111's right elbow wound was revealed to be open to air without any dressing on it. RN S looked around Resident #111's bed and floor to see if a bandage had fallen off and was not able to find a missing dressing. During an interview on 3/25/26 at 3:26 PM, LPN Q reported that the CNA's at the facility were not the best at communicating when they removed a soiled dressing or noticed the dressing had become dislodged if they were soiled or during care and not letting the nurse know so that they could apply a new dressing. Review of the facility's Care Planning policy last revised 6/24/21 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, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments and prepared for by the interdisciplinary team .

This citation pertains to intake # 2642001Based on interview, and record review, the facility failed to provide adequate supervision to prevent elopement and respond appropriately to an alarming exit door to ensure resident safety in 1 of 3 residents (Resident #101) reviewed for elopement/supervision, resulting in an Immediate Jeopardy when on 10/2/25 between 6:15 AM and 6:30 AM, Resident #101, who was an elopement risk, exited the facility, unbeknownst to facility staff, and was found by a Activities Director (AD) E approximately 50 yards away from the facility, in his wheelchair on the sidewalk of the road. This deficient practice placed all residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death.Findings include:The facility failed to provide adequate supervision to prevent elopement for an exit seeking resident, Resident #101, who was an elopement risk, and respond appropriately to an alarming exit door to ensure resident safety. Resident #101 eloped from the facility unbeknownst to staff on 10/2/25 between 6:15 AM-6:30 AM was found by off duty staff at approximately 6:40 AM, 50 yards from the facility on the sidewalk of a 25 MPH (miles per hour) road, ambulating in his wheelchair. The Immediate Jeopardy began on 10/2/25 when Resident #101 eloped from the facility unbeknownst to staff. The Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 10/21/25 at 10:20 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 10/2/25, and the deficient practice corrected on 10/7/25, prior to the start of the survey and was therefore past noncompliance.Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: severe depression with psychotic symptoms and anxiety. Review of Resident #101's Physician Orders indicated that a wanderguard (a wearable device that alerts staff when a resident is near an exit by activating the door alarm) was placed on his left ankle on 4/13/25.Review of Resident #101's Elopement Care Plan revealed, .at risk for elopement and/or wandering R/T (related to): history of attempts to leave facility unattended, impaired safety awareness. Date initiated 4/14/25 (no revisions). Interventions: Apply wanderguard per order. Check placement, function and expiration date per facility protocol. Wanderguard to LLE (left lower extremity) expires on 10/27 and wheelchair expires on 4/26. Date initiated: 4/14/25 Revision on 10/8/25, Approach in a slow, calm manner and redirect away from exit doors as needed. Date initiated: 4/14/25.Distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversation etc.Date initiated: 4/14/25.Resident is to be 1:1 observation at all times for elopement risk and behaviors. Date initiated: 10/2/25.Review of Resident #101's Fall Care Plan revealed, .at risk for fall related injury and falls R/T: history of falling, psychotropic medication use, impaired balance, moderate cognitive impairment, impaired vision. Date initiated: 1/21/25. Revised 7/29/25.Review of Resident #101's Behavior Note dated 9/16/25 at 10:07 AM revealed, .Stated he has a meeting with case manager on 9/18 and case manager is going to help him Get out of here or I'm busting out. Either way alive or dead. Stating (hospital) sent him here to the warden because he couldn't get his pants off. Reports the warden put the ball and chain on my leg.Review of Resident #101's Progress Note dated 9/30/25 at 12:16 PM revealed, Resident observed alarming east exit door.Review of Resident #101's Elopement Incident Report dated 10/2/25 at 6:40 AM revealed, Alerted by activity director that resident was outside near the (facility) sign. Activity director remained with resident keeping him in sight. Resident in W/C (wheelchair). Approached and able to redirect back into building. Resident indicated he wanted to get some fresh air.CNA let two residents out front door by putting in door code. Once she opened the door for the residents she left the area. (Resident #101) tailgated out the door following behind residents. Alarm did not sound off because code was entered to open for the other residents. This report was noted to conflict with witness interviews and door alarm observations. In an interview on 10/20/25 at 4:23 PM, Certified Nursing Assistant (CNA) M reported that she had been working on the hall on 10/2/25 and heard a door alarming in the dining room between 6:10 AM-6:30 AM. CNA M reported that she observed two residents that wore wanderguards in the area at the time but was not sure why the door was alarming. Resident #101 was near the door and the other resident was being assisted by Physical Therapy Assistant (PTA) H. CNA M reported that she peeked out the door, then deactivated the door alarm and went back to the hall. CNA M reported that Resident #101 had anger problems but seemed calm that morning. CNA M reported that minutes later the door was alarming again and Resident #101's whereabouts were unknown; CNA M assumed the resident was in his room. CNA M looked out the dining room windows and when she did not see anyone outside, she deactivated the door alarm and went back to the hall. When there was no explanation for the door alarming CNA M did not attempt to locate Resident #101 and did not call a code search to ensure that all residents were accounted for in the facility. CNA M reported that a few minutes later she opened the same door for two independent residents to go outside to smoke, and Resident #101 was not observed in the area at that time either. CNA M reported that when she went back to let the residents to back inside, they said there was a resident outside. CNA M reported that at that time she exited the building and saw Director of Nursing (DON) B and other staff outside with Resident #101.In an interview on 10/20/25 at 10:59 AM, PTA H reported that around 6:30 AM he went to the dining room to get a resident for therapy. PTA H reported that he saw CNA M in the dining room redirecting Resident #101 so that the door would stop alarming. PTA H reported that Resident #101 could walk independently but preferred to use a wheelchair most of the time.In an interview on 10/20/25 at 1:31 PM, AD E reported that when she went to pull into the facility parking lot at approximately 6:40 AM, she noticed Resident #101 was on the sidewalk, just off the property in his wheelchair. AD E stayed in her car, made a phone call to DON B, and kept Resident #101 in her sight until other staff arrived a few minutes later with a flashlight to escort Resident #101 back to the facility. AD E reported that Resident #101 didn't like being at the facility from day one when he admitted and would push on doors which made the alarms sound.In an interview on 10/20/25 at 3:21 PM, DON B reported that on 10/2/25 she was in her office near the dining room and had heard the door alarm multiple times between 6:00 AM-6:30 AM. DON B reported that she watched CNA M walk back and forth to deactivate the alarm and wanted to check to see what why the door had alarmed so many times, so she walked to the door. DON B deactivated the alarm herself and when she did not find an explanation for the door alarming, she returned to her office to announce a code search, and ensure all residents were accounted for. DON B reported that when she got back to her office to announce the code, she received a call from AD E who reported that Resident #101 was outside. DON B reported that she delegated the code search to another staff member and went outside to get Resident #101. DON B reported that it was dark outside and chilly that morning. DON B reported that when the door was alarming for an unknown reason, she should have walked outside first, to ensure that a resident had not exited through the door. In an interview on 10/20/25 at 11:30 AM, CNA G reported that Resident #101 was independent with ambulation in his wheelchair and had been observed heading to the dining room around 6:15 AM that day. CNA G reported that Resident #101's behaviors had been escalating the week prior to his elopement; he was angry, anxious and wanted to leave.In an interview on 10/21/25 at 11:21 AM, Licensed Practical Nurse (LPN) P reported that Resident #101 was very angry about having to live in the facility.In an interview on 10/20/25 at 4:53 PM, DON B reported that Resident #101 was declared incapacitated and unable to make his own decisions in March 2025 and a wanderguard was placed on his ankle in April 2025 due to concerns about him wanting to leave the facility. DON B reported that a second wanderguard was placed on his wheelchair in September 2025 as a precaution. DON B reported that Resident #101 had started to ramp up his behaviors in September after finding out that his guardian was not going to allow him to discharge from the facility.Review of Resident #101's Statement of Capacity dated 3/5/25 indicated that he was declared by two physicians, to be incapable and unable to make informed medical decisions.Review of Resident #101's Elopement Risk Assessment dated 4/13/25 and 7/20/25 both indicated that the resident was not verbalizing a desire to leave and was not at risk for elopement. This was noted to be an inaccurate reflection of the resident's status.In an interview on 10/21/25 at 1:45 PM, NHA A reported that residents don't have to say the words I want to leave, to be considered to have verbalized a desire to leave and therefore at risk for elopement. NHA A reported that Resident #101 was in fact at risk for elopement due to him constantly saying that he didn't want to be in the facility and calling the facility a jail. NHA A reported that following Resident #101's elopement on 10/2/25, she completed a new elopement risk assessment that indicated Resident #101 had expressed a desire a leave. NHA A reported that during their investigation they had discovered that elopement assessments were not being completed accurately. During an observation on 10/21/25 at 7:45 AM of the dining room door function, DON B opened the door by entering the code on the keypad and when a Wanderguard was near the door and/or passed through, the door started to alarm. The alarm continued to sound until the door was completely closed, the Wanderguard was approximately 4 feet from the area, and the code was re-entered. This observation provided clarity to the original incident report that concluded the door did not alarm when Resident #101 exited, because staff had entered the code to open the door. Regardless of the code being entered, the door alarm goes off when a Wanderguard is nearby.The Immediate Jeopardy that began on 10/2/25 was removed on 10/2/25 when the facility took the following actions to remove the immediacy. The deficient practice was corrected on 10/7/25 after the facility took the following steps to systemically correct the noncompliance prior to start of current survey. 1. Immediately upon notification DON and nurse assessed R101 in the parking lot and returned him to the facility. (10/2/2025 6:43 am). He had a Wanderguard in place. R101 responsible party was notified 10/2/2025 at 7:00A. On 10/2/25 7:00A, R101 was placed in dining room under supervision for breakfast. When he returned to his room placed on a 15-minute check, but within 10 minutes he broke lock on window and attempted to rip screen out, so he was immediately placed on 1:1 supervision until he was sent out to (psychiatric facility) on 10/9/25. His elopement risk assessment was updated, and his care plan and orders were reviewed. R101 Wanderguard was tested for function and placement on 10/2/2025 upon return to building at 6:50A. Verified Elopement books are all updated and in proper placement at the front desk and on each nurse's station on 10/2/25. 2. Housekeeping Supervisor and Maintenance Director inspected all emergency exits and completed a Wanderguard test on doors on 10/2/25. Secure Care was notified on 10/2/25 to have our doors validated for proper function. Maintenance spoke with (security company) and did an immediate review of main door for proper function. Maintenance returned to facility at 8:00P to check function of main entry door for proper alarm function when in alarm mode. No deficits noted. Secure Care came to the building on 10/3/25 to validate and cleared system functions per conversation with maintenance on 10/2/25, no deficits noted.3. On 10/2/25, all 74 residents were assessed for risk of elopement, 41 residents were determined to be at risk, and their care plans were reviewed for completeness. 11 of 41 residents determined to be at risk had Wanderguards in place.4. Maintenance Director or Housekeeping Supervisor/designee continues our ongoing process to check doors and document on a log seven days a week. Maintenance Director or Housekeeping Supervisor/designee checks and logs all exit doors for proper function and documents results 7 days a week results on the log. Administrator will review logs weekly to validate the process.5. The DON/designee education provided to staff in the building on October 2, 2025, regarding Elopement policy, when door alarm sounds staff respond immediately, exit building to outside where full view of exit area can be seen, use of light source for enhanced visibility during dawn or after dusk, when no one is observed call code search. Staff provided education between 10/2/25 and their next shift worked on Elopement policy. When door alarm sounds staff respond immediately, exit building to outside where full view of exit area can be seen, use of light source for enhanced visibility during dawn or after dusk, when no one is observed call code search. On 10/2/25, 88 out of 91 staff were educated, the remainder of employees were called for 1:1 education or educated upon arrival to work before reporting to their assignment. 6. Facility staff have been educated on our ongoing process regarding the Elopement Policy and procedure including residents who are at risk for exit seeking and have a Wanderguard. Resident are in the Missing Guest Book/Residents with Wanderguards kept at reception desk and each nursing station. Missing Guest Book/Residents with Wanderguards is updated minimally weekly and with any changes by the Interdisciplinary team for further interventions and update as needed.7. The DON/Designee reviewed all residents who are at risk for exit seeking and Wanderguards for elopement risk on 10/2/25. On 10/2/25 residents at risk for exit seeking were reassessed for elopement risk utilizing the evaluation tool in PCC. No deficits in care plan, orders, placement checks, or function checks were noted for residents at risk. The Nurses will continue the ongoing process of assessing residents for risk of Elopement upon Admission, quarterly and change of condition.8. On 10/2/25 the Administrator reviewed the investigation performed by the DON who began the investigation and interviewed all staff that worked the night shift and AM shift on 10/2/25. 9. The Administrator and QAPI (Quality Assurance and Performance Improvement) committee ad hoc (impromptu meeting) reviewed the missing guest policy and deemed it appropriate during the QAPI meeting 10/2/2025.10. Administrator audited the elopement books and deemed them to be up to date and accurate on 10/2/25.11. New employee orientation will continue to include the Elopement policy and procedure education.12. On 10/2/25 Maintenance Director/Designee checks the alarmed doors 7 days a week to ensure functioning properly, which has always been an ongoing aspect of the of Preventative Maintenance program. Any concerns will be addressed and findings submitted to QAPI committee for review and recommendations. The Administrator will review logs weekly to validate this process.13. Code search drills were held on 10/2/25 day shift, 10/7/25 second shift, 10/14/25 third shift. Facility will continue with an ongoing process of Code Search Drills performed once per shift weekly for 4 weeks and monthly thereafter. 14. Medical Director was made aware of the elopements on 10/2/25.15. Incident reviewed in an ad hoc QAPI meeting on 10/2/25 and at monthly QAPI on 10/16/25. At the Ad Hoc QAPI on 10/2/25 the root cause analysis (RCA) determined the cause of the incident was due to a deficient practice of not going outside for complete visualization and not calling a code search immediately when no one observed. The QAPI committee decided to complete all education and add a light source to reception desk for search. 16. At the Ad Hoc QAPI on 10/2/25, the decision was made to continue the education on elopement policy and response to all alarms immediately, complete visualization, and call code search. We will complete weekly drills to ensure proper response to alarms and procedure to eliminate alarm fatigue.17. The remaining 3 employees who were not completed on 10/2/25 have completed prior to their next shift worked.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education with all staff on proper response to door alarms, reviewing all residents at risk for elopement, and continued audits to ensure all residents were accurately assessed and monitoring was in place. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During a tour of the kitchen, at 8:10 AM on 5/19/25, observation of the clean utensil bins found that one of the bins was shown to have three utensils with stuck on and dried food debris. An interview with Dietary Manager T found that these containers get cleaned about weekly. Observation of the clean pots and pans at this time found one top with a faded date marking sticker labeled on the top. When asked if it should have come off when washed, DM T stated yes. Further review found a half pan with stuck on food debris on the side of the pan. Observation of large sheet pans stacked under the preparation table, at 8:13 AM on 5/19/25, found that most of the sheet pans were observed with encrusted grease caked on the inside corners of the pans. When asked if that is the cleanest the sheet pans get, DM T stated that staff tend to clean them in the dish machine and think that they need to scrub them by hand. During a tour of the East Pantry, at 8:50 AM on 5/19/25, it was observed that an ice chest was found stored in the room. When asked about the ice chest, DM T stated it was for water pass and the kitchen cleans it daily. Observation of the ice chest at this time found it full of ice and no way for water to drain as the ice melted. During a tour of the [NAME] Pantry, at 8:47 AM on 5/19/25, it was observed that the seal gasket of the refrigeration unit was found to be falling off and not connected properly in order to make a good seal. A revisit to the East Pantry, at 1:24 PM on 5/20/25, found the ice scoop stored right side up in the ice scoop holder. A revisits to the [NAME] Pantry, at 1:35 PM on 5/20/25, found the ice scoop stored right side up in the ice scoop holder. According to the 2022 FDA Food Code section 3-303.12 Storage or Display of Food in Contact with Water or Ice.(B) Except as specified in (C) and (D) of this section, unPACKAGED FOOD may not be stored in direct contact with undrained ice . According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles.(B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted . According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During an interview with DM T, at 8:22 AM on 5/19/25, it was found that the facility does not cool food regularly and that they don't log cooling for food saved from service. During an observation of the kitchen, at 8:28 AM on 5/19/25, it was observed that sausage patties from breakfast were placed in a gallon container with the top placed on it and left on the preparation table. A revisit to the kitchen, at 10:48 AM on 5/19/25, observed the container of sausage patties in the two door True cooler covered tightly with a lid with condensation found on the inside. The temperature of the product was taken and found to be 88F at this time. DM T stated that he will discard the food product. According to the 2022 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. During the initial tour of the kitchen, at 8:33 AM on 5/19/25, observation of the kitchen chemical closet found that the faucet had a four-way splitter that was closed on all ends. Further observation found the water handles left on and constant back pressure of water being applied to the faucets internal vacuum breaker. When asked if staff use this chemical closet, DM T stated yes. According to the 2022 FDA Food According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. During a tour of the dish machine area, at 8:36 AM on 5/19/25, it was observed that two spray bottles with bright red quaternary ammonium sanitizers were found in this area. After testing the concentration of the bottles, they were found to be around 500 parts per million. According to the 2022 FDA Food Code section 7-204.11 Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P, or (B) Meet the requirements as specified in 40 CFR 180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations.

Based on observation and interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living. Findings include: During a tour of the East Day room, at 9:43 AM on 5/19/25, it was observed that food crumbs, paper trash, and debris were found under and on the sides of seat cushions of two chairs and a love seat. During a tour of the East Hall Spa, at 9:53 AM on 5/19/25, it was observed that dried bowel movement was found stuck on the front bowl and seat of the commode. Further observation found an accumulation of dirt and debris behind the toilet in the back corner of the commode area and four wash cloths found stored on top of the paper towel holder next to the sink. During a tour of the [NAME] Hall spa room, at 10:42 AM on 5/19/25, it was observed that 12 wash cloths, four towels, and a box of gloves were stored on a shower chair next to the shower. Observation of the spa cabinet found a spray bottle of disinfectant stored over and next to clean and sanitary linens. During a revisit of the East Day room, at 9:04 AM on 5/20/25, observation of the chairs and love seat in this area found an accumulation of food crumbs, paper trash, and debris in the sides of the seat cushions. An interview with Laundry Director (LD) Q found that these areas should be cleaned daily. During a tour of the East side shower, at 9:09 AM on 5/20/25, observation of the commode found dried bowel movement on the front of the bowl and seat of the commode. Further observation found a stack of wash cloths stored on the paper towel holder. Observation of the cabinet found personal hygiene products stored with a bottle of cleaning disinfectant. When asked about items being stored together, LD Q stated that personal hygiene products should be stored in residents' rooms. During a tour of the [NAME] Shower room, at 9:21 AM on 5/20/25, it was observed that 14 towels and 12 wash cloths were found stored on a shower chair next to a shower. When asked if this is where clean linens are usually stored, LD Q stated no and that they should be stored in the cabinet to not get contaminated from residents showering. During a tour of the facility, starting at 1:35 PM on 5/20/25, observation of the following exit doors found gaps and spaces between the door, the door frame, and the installed weatherstripping. Doors noted with concern were the [NAME] hall North door (bottom), the [NAME] center South door (side), Center hall North courtyard door (bottom right), Dining Room exit door (left side), and the East hall North door (weatherstrip bent). These areas were found to allow the visible presence of light, air, and easy pest entry.

Based on observation, interview, and record review the facility failed to ensure adaptive dining equipment was provided for 1 (Resident #5) of 3 residents reviewed for adaptive dining equipment resulting in difficulty eating and the potential for weight loss. Findings include: During an observation and interview on 05/19/25 at 09:21 AM, Resident #5 was eating breakfast in bed independently in her room. The meal ticket stated, Alerts: .built up utensils and it was highlighted yellow. Resident #5 was served breakfast with regular dining utensils/silverware; no built up utensils were provided. Resident #5 reported she can't remember the last time she used or was provided with built up silverware. Resident #5 was observed awkwardly handling a spoon. Resident #5 reported her right arm (dominant arm/hand) is hard to use after she had a stroke. During an observation and interview on 05/20/25 at 09:33 AM, Resident #5 was eating breakfast in bed. Resident #5's meal ticket indicated she should have been provided with built up utensils/silverware, but she was provided regular handled silverware. Resident #5 stated, I can't grab things the same way as she used to be able to. Resident #5 confirmed her right arm/hand was her dominant side that she used to eat with. Resident #5 picked up a fork and her grip on the fork appeared insecure. Resident #5 reported it would be easier to eat if she had the built up utensils/silverware. Resident #5 stated, I have a hard time hanging on to this (fork) as she was holding the fork in what appeared to be an awkward and insecure grip. Resident #5 was holding the fork to her palm with only her pointer and middle finger. During an observation and interview on 05/20/25 at 12:34 PM, Certified Nurse Aide J delivered Resident #5's lunch to her room and helped set up the meal. Resident #5 was served her lunch meal with regular silverware but her meal ticket indicated to provide built up utensils. Resident #5 appeared to have a weak handle on the fork. Resident #5 was very slow with her eating movements and appeared to be having difficulty utilizing her utensils effectively such as needing multiple attempts to pick up food items off the plate. During an observation and interview on 05/21/25 at 08:03 AM, Resident #5 was eating her breakfast meal in her room independently. Resident #5 was provided regular utensils/silverware but no built up utensils were provided. Resident #5 reported it would be helpful if she could get her built up utensils/silverware. Resident #5's meal ticket indicated to provide built up utensils. During an interview on 05/21/25 at 09:32 AM, Dietary Manager T confirmed Resident #5 was supposed to have received built up utensils with her all meals as she was ordered to have them. Review of Resident #5's most recent brief interview for mental status, dated 4/27/25, score was 13 which indicated cognitively intact. Review of Resident #5's medical diagnoses included a diagnosis of history of transient ischemic attack (is like a temporary stroke) and cerebral infarction (stroke), dated 8/5/2022. Review of Resident #5's physician's orders included a diet order, revised 1/29/2025, that stated, Regular diet, chopped meat texture .built up utensils. Review of Resident #5's Nutritional Re-evaluation, dated 4/29/25, stated, .Adaptive Devices .foam built up utensils. Review of Resident #5's nutrition care plan included an intervention, revised 1/31/2025, that stated, Regular diet, Chopped Meat texture .built up utensils. Review of Resident #5's cognition care plan, revised 8/1/2024, stated, (Resident #5) is at risk for decline in cognition and has impaired cognitive function or impaired thought processes R/T: (related to) History of Stroke. Review of the facility's Adaptive Equipment (adaptive dining equipment) policy, revised 3/6/2024, stated, It is the policy of this facility to provide adaptive eating (dining) equipment for those residents who would benefit from their use .Culinary staff will place the adaptive equipment on each meal tray .

Based on interview and record review the facility failed to ensure residents received care in accordance with professional standards in 1 of 18 residents (Resident #37) reviewed for quality of care when nursing staff administered Lotrel (Medication used to treat hypertension) out of the physician ordered parameters resulting in the potential for adverse side effects. Findings include: Resident #37 Review of an Admission Record revealed Resident #37 was originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension (high blood pressure). Review of Resident #37's Orders revealed, Lotrel Oral Capsule 10-40 MG (Amlodipine Besylate-Benazepril HCl) Give 1 capsule by mouth one time a day for HTN Hold if Systolic (systolic blood pressure) <110/ HR (heart rate)<60 . Review of Resident #37's Pharmacy Consultation Report dated 3/6/25 revealed, (Resident #37) has an order for Lotrel that was administered outside of the parameters for which it was ordered. Specifically, on 3/3, 3/4 when SBP (systolic blood pressure) was below 110. Recommendation: Please remind staff of the importance of administering/holding medication within the parameters ordered . This recommendation was signed by Director of Nursing (DON) B on 3/18/25. Review of Resident #37's Medication Administration Record for March, April, and May 2025 revealed that staff had documented administering Lotrel to Resident #37 when his systolic blood pressure was below 110 on 3/3/25, 3/4/25, 3/15/25, 3/19/25, 5/9/25 and 5/11/25. It was noted that Licensed Practical Nurse (LPN) G had documented the administration of the medication for each date except for 5/11/25. In an interview on 5/21/25 at 12:22 PM, DON B reported that she did not recall the pharmacy recommendation that she had signed for Resident #37 on 3/18/25. DON B confirmed that she had not completed any follow up education with nursing staff on ensuring that they were administering medications within the parameter orders. This writer attempted to reach LPN G on 5/21/25 at 12:50 PM for an interview. LPN G was unable to be reached prior to survey exit. Review of the facility's Medication Administration policy dated 10/17/23 revealed, Resident medications are administered in an accurate, safe, timely, and sanitary matter . Physician's orders: Medications are administered in accordance with written orders of the attending physician . Procedure: .

Based on observation, interview, and record review the facility failed to ensure resident food and drink preferences were honored consistently for 8 (Residents #5, 8, 17, 31, 35, 51, 54, 74) of 8 residents reviewed for dining, resulting in feelings of anger and sadness and the potential for weight loss and/or dehydration. Findings include: Resident #51: During an observation and interview on 05/19/25 at 08:11 AM, Resident #51 was eating breakfast in her room independently. Resident #51 was served hot tea while her meal ticket stated, 8 fl oz (fluid ounces) coffee. Resident #51 was visibly upset and reported she didn't want tea and wanted coffee. Resident #51 was also served a sausage patty, but Resident #51's meal ticket indicated, Dislikes: .Sausage. Resident #51 confirmed she didn't like sausage and didn't want the sausage served to her. Resident #51 was visibly frustrated and stated, It pisses me off, they (the staff) know it regarding food preferences not being honored. Resident #51 reported it was common she was given items that weren't consistent with her food preferences on the meal ticket. Resident #8: During an observation and interview on 05/19/25 at 08:23 AM, Resident #8 was eating breakfast in her room independently. Resident #8 reported she liked eggs every day. Resident #8's meal ticket stated, Standing Orders: .Scrambled Eggs but no eggs were provided at that meal. Resident #8 reported she didn't get her three coffee creamers as the ticket indicated. The meal ticket stated, Standing Orders: 8 fl oz (fluid ounces) coffee (Creamer X (times) 3). Resident #8 stated, You have to eat what you don't want to eat and reported it made her feel sad when her food and drink preferences weren't honored. During an interview on 05/21/25 at 09:32 AM, Dietary Manager T confirmed eggs were available at the 05/19/2025 breakfast meal and should have been provided to Resident #8. Resident #5: During an observation and interview on 05/19/25 at 09:21 AM, Resident #5 was eating breakfast independently in her room. Resident #5 was served a sausage patty, but her meal ticket stated, Dislikes: .Sausage. Resident #5 stated, .I don't like sausage. Resident #74:During an observation on 05/19/25 at 09:43 AM, Resident #74's meal was served to the resident in her room. The meal ticket indicated she disliked eggs, but eggs were served to her. Resident #35: During an observation and interview on 05/19/25 at 11:53 AM, Resident #35 was served a black pepper condiment pack but her dislikes on her meal ticket stated black pepper. Resident #35 reported she often is served black pepper, she dislikes the black pepper, doesn't use it, and felt it was wasteful to keep providing the black pepper to her. Resident #31: During an observation and interview on 05/20/25 at 12:05 PM, Resident #31 was eating lunch independently in the main dining room. Resident #31's meal ticket stated, Dislikes .Carrots . Zucchini but he was served carrots and zucchini in his mixed vegetables. He left them uneaten on his plate. Resident #31 reported he doesn't like carrots or zucchini and would have preferred something else. Resident #17: During an observation and interview on 05/20/25 at 12:06 PM, Resident #17 was independently eating lunch in the main dining room. His meal ticket noted he disliked lima beans, but he was served lima beans. Resident #17 confirmed he doesn't like lima beans. During an interview on 05/21/25 at 09:32 AM, Dietary Manager T confirmed 05/20/2025's lunch had mixed vegetables which contained Carrots .zucchini .lima beans. Review of the facility's Food Preferences, revised 1/9/2025, stated, Food preferences will be identified on tray tickets to ensure residents are provided with appropriate food items. 46999 Resident #54 Review of a Nutritional Evaluation for Resident #54 with a reference date of 11/19/24 revealed Summary: .dx: COPD .regular diet .eat meals independently .ALLERGIC TO CUCUMBER AND PICKLES . In an interview on 5/19/25, at 10:04am, Resident #54 reported he was allergic to pickles and cucumbers and was concerned because although the facility was aware of his allergy, he recently received potato salad that contained pickles on his meal tray. Resident #54 reported he ate a few bites of potato salad before he realized it contained pickles. When further queried, Resident #54 reported in the past, he had become extremely nauseous and vomited violently for 30 minutes after he consumed pickles. Resident #54 reported in the past his body's reaction to eating pickles was exhausting to him, and he was worried that if he ate pickles now, in his state of worsened health, his body may not be able to tolerate it. Resident #54 reported I watch my food very carefully now because he was fearful about receiving pickles or cucumbers again in his meal. Review of a Kardex nursing care guide for Resident #54 with a reference date of 3/10/25 revealed Eating/Nutrition: Diet as ordered: regular diet, mechanical soft texture .easy to chew. Resident's food allergies were not listed. Review of the alert banner in Resident #54's medical record revealed Allergies . Cucumbers, Pickles. Review of a Meal Ticket for Resident #54 with a reference date of 5/20/25 revealed Allergies .pickles and cucumbers. During an observation on 5/20/25 at 12:33pm, Certified Nursing Assistant (CNA) J delivered Resident #54's lunch tray to him in his room. In an interview on 5/20/25 at 12:35pm, CNA J reported she regularly cared for Resident #54, and delivered his meals. CNA J reported was not aware the resident had any food allergies. In an interview on 5/20/25 at 1:59pm, CNA M reported Resident #54 watched his food very carefully because he was worried about mistakenly being served food that contained pickles or cucumbers again. Review of a Nurses Note for Resident #54 with a reference date of 4/19/25 revealed Resident has allergies to cucumbers/pickles. Resident (sic) reported that he noticed after a few bites of potato salad from dinner that there were pickles in it and immediately stopped eating and notified the nurse. Resident reported that mouth was slightly itchy .on call provider notified and ordered PRN (as needed) (name of antihistamine medication) and Ondansetron (anti-nausea) medication for 3 days. DON (Director of Nursing) and kitchen manager notified as well . Review of a Medication and Treatment Incident Report for Resident #54 with a reference date of 4/21/25 revealed Date of Incident: 4/19/25 .Route of Administration Involved: Pickles in potato salad .Description of Event: .resident took a couple of bites of potato salad .it had pickles .Resident c/o (complained of) itching in mouth . (antihistamine and anti-nausea medication) ordered. 2. Failure to Follow Procedure: allergy checking for meal ingredients .Corrective Action: Spoke with dietary manager . Efforts to contact the nurse who authored the Nurses Note and Medication and Treatment Incident Report where not successful at the time of the completion of the survey. In an interview on 5/21/25 at 9:30am, Dietary Manager (DM) T reported Resident #54 was mistakenly served potato salad that contained a known food allergen in April 2025. DM T reported the resident's food allergy was listed on his meal ticket at the time and the kitchen staff were expected to review the resident's food allergens as selected foods for the resident's meal tray. DM T reported the staff did not cross reference the ingredients list on the pre-made potato salad with Resident #54's food allergens on 4/19/25 when he was served food that contained pickles. DM T could not provide verification of any corrective action that was taken following the incident.

Based on observation, interview, and record review, the facility failed to ensure the use of person protective equipment (PPE) (gown and gloves) by staff during high contact care activities for 1 (Resident #27) of 18 residents reviewed for enhanced barrier precautions (EBP) resulting in the potential for the spread of infection, cross contamination, and disease transmission. Findings include: Review of a Minimum Data Set (MDS) assessment for Resident #27 with a reference date of 3/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #27 was moderately cognitively impaired. Section GG revealed Resident #27 was dependent (2 or more helpers required) to transfer from the wheelchair to the bed. Section K of the MDS revealed Resident #27 had an abdominal feeding tube. Review of a Care Plan for Resident # 27 with a reference date of 4/17/25, revealed a need/goal/interventions of: Need: Diet changed to pureed texture. Goal: Will maintain adequate nutrition and hydration .Interventions: .administer tube feeding as ordered .Enhanced Barrier Precautions . Review of Physician Orders for Resident #27 revealed 1. Enteral feed, every shift Flush Peg tube . 2. Cleanse peg tube site with wound cleanser and apply dry dressing, start date 4/15/25 .3. ENHANCED BARRIER PRECAUTIONS, 4/15/25. The status of the orders was Active. During an observation on 5/20/25 at 9:26am, Certified Nursing Assistants (CNAs) M and K transferred Resident #27 from his wheelchair to his bed. CNA K then assisted Resident #27 with rolling to his right side while in bed and as she evaluated Resident #27's incontinence brief to determine if it was soiled. Throughout the high contact cares of transferring Resident #27, assisting him with positioning, and checking his brief, CNA M and CNA K wore gloves but no gown. During an observation on 5/20/25 at 9:31am, signage on Resident #27's door stated, Enhanced Barrier Precautions .staff must .wear gloves and a gown for the following High-Contact Resident Care Activities .Transferring .providing hygiene .changing briefs . In an interview on 5/20/25, at 9:33am, CNA M reported the facility had provided training on the use of PPE for resident's in EBP, but she had forgotten Resident #27 had those precautions. CNA M reported she and CNA K should have worn gowns and gloves when they transferred and provided cares to Resident #27 on 5/20/25 at 9:26am. CNA M reported she sometimes felt confused about EBP and sometimes didn't notice the signage posted on resident doors. In an interview on 5/21/25 at 11:04am, Director of Nursing/Infection Preventionist (DON/IP) B reported Resident #27 was on EBP which required the staff to wear a gown and gloves during any high contact care, including transferring and checking the resident's brief. Review of an Enhanced Barrier Precautions policy with a reference date of 3/5/25 revealed Enhanced Barrier Precautions are indicated for residents with any of the following .a wound or indwelling device .Health care personnel caring for residents on Enhanced Barrier Precautions should wear gloves and gowns during high contact resident care. Examples of high contact resident care activities requiring gown and glove use: .transferring .providing hygiene .changing briefs .

Based on interview and record review, the facility failed to ensure 1 resident (Resident #6) of 24 residents received an accurate clinical assessment, reflective of the resident's status at the time of the assessment, resulting in inaccurate diagnosis of schizophrenia documented on MDS (Minimum Data Set) assessment. Findings include: Review of the MDS 3.0 RAI Manual v1.16, Chapter 1: Resident Assessment Instrument (RAI), revealed .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment . Resident #6 Review of an Admission Record revealed Resident #6 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: depression. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 3/14/25 revealed Active Medical Diagnosis of Schizophrenia. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 12/15/25 revealed Active Medical Diagnosis of Schizophrenia. Review of Resident #6's Electronic Health Record indicated no diagnosis of Schizophrenia, no documented behaviors, and no treatment orders related to Schizophrenia. Review of Resident #6's PASARR (Preadmission Screening and Resident Review) (an evaluation to determine if a resident has serious mental illness and/or intellectual disability) indicated no mental illness and dementia exempt. Review of Resident #6's Behavioral Care Services note dated 9/11/2024 revealed, Major depressive disorder, recurrent severe without psychotic features, Dementia .WITHOUT behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. In an interview on 05/21/25 at 10:32 AM, Director of Nursing (DON) B reported that Resident #6 does not have any orders for psychotropic medications and does not have any behaviors indicative of schizophrenia. In an interview on 05/21/25 at 10:34 AM, Minimum Data Set-Registered Nurse (MDS-RN) V reported that Resident #6 had never received treatment for schizophrenia or behaviors. MDS-RN V reported that the diagnosis of schizophrenia was documented in error on multiple MDS assessments; MDS-RN V will modify the assessments and resubmit them.

Based on interview and record review, the facility to follow advance directive wishes for 1 (Resident #278) of 24 residents reviewed for advance directives, resulting in Resident #278 receiving cardiopulmonary resuscitation (CPR) when Resident #278 had an Do Not Resuscitate (DNR) order in place. Findings include: Resident #278 Review of an Admission Record revealed Resident #278 was originally admitted to the facility on [DATE] with pertinent diagnoses which included shortness of breath. Review of Resident #278's Orders revealed, No CPR/DNR. Order Date: [DATE]. Review of Resident #278's DNR Order dated [DATE] revealed, Do-Not-Resuscitate Order. This do not resuscitate order is issued by (local physician), attending physician for (Resident #278). A. Declarant Consent- Resident is their own person. I have discussed my health status with my physician named above. I request that in the event my heart stopped beating and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. This order was signed by Resident #278 on [DATE] Review of Resident #278's Progress Notes dated [DATE] and documented by Licensed Practical Nurse (LPN) I revealed, At 6:50 PM this nurse heard a yell for help from CNA (Certified Nursing Assistant). This nurse reported to pt's (patient)(Resident #278) room where pt was in bed head back, eyes open, no respirations, circumoral cyanosis (blue discoloration around the mouth that can be caused by poor circulation or low oxygen levels in the blood), radial pulse absent, pt laid back and cartoid pulses absent, confirmed by two staff this nurse yelled for code status and initiated CPR as status was undetermined. multiple people responded and DNR confirmed. Est: (estimated) 45 seconds of compressions administered during that time faint pulse was felt this nurse immediately withdrew from compressions, pt began agonal breathing (abnormal and labored breathing), head of bed raised and pt began to take effective breaths. during this time DON (Director of Nursing) B and multiple staff present and using tactile stimuli pt began to respond to app (appropriately) EMS (emergency medical services) appropriately (sic). BS (blood sugar) 288. O2 (oxygen saturation) 80% oxygen placed 3L (liters) pt 88%. EMS arrived pt explained situation does not recall anything from incident, the pt denies chest pain, and refuses transfer to higher care. Order received to continue O2 for 24 hours titration of oxygen L to maintain 92% or higher. prior to episode per CNA pt was transferred to bed via hoyer (a lift that transfers patients with limited mobility) pt was talking during and then began saying I can't breathe I cant breathe the pts eyes then rolled back and went flaccid, per CNA this is when they yelled for help. Pt's family was called by DON. Will follow up as necessary. Review of Resident #278's EMS report dated [DATE] revealed, .Narrative: Per (facility) staff they were using the hoyer lift to move the pt (Resident #278) from his chair to bed when he became unresponsive, stopped breathing and they couldn't feel a pulse. Staff states they finished the transfer to bed and started chest compressions. Per staff before they were able to provide 60 compressions the pt was awake and moving their hands from his chest .Pt reported he was his own person and did not wish to be transported. Pt also reported he is a DNR and was not sure why CPR was every (sic) performed . In an interview on [DATE] at 8:39 AM, LPN I reported that she had just started her shift on [DATE] when she heard a CNA yelling for help in Resident #278's room, and stating that he was not responding. LPN I reported that when she went into Resident #278's room, she observed Resident #278 lying in bed unresponsive. LPN I reported that she felt for a pulse on Resident #278 and confirmed that he did not have a pulse. LPN I reported that she yelled for staff to tell her what his code status was, and she began CPR on Resident #278. LPN I reported that as she was doing compressions on Resident #278, several staff members began running in and yelling that Resident #278's code status was DNR. LPN I reported that she stopped compressions as soon as she found out that Resident #278 had a DNR order. LPN I reported that she noticed Resident #278 started to gasp, and then she felt a pulse on him, and placed on oxygen on him. LPN I reported that she acted as she would if she had found someone in the street and did not know their code status, because it was taking too long for staff to tell her what Resident #278's code status was. LPN I reported that she had voiced concerns with the facility before about needing resident code status to be in more places than just the computer, but the facility had not initiated any additional places to find resident code status. LPN I reported that she thought she had completed about 45 seconds of compressions on Resident #278. In an interview on [DATE] at 1:31 PM, CNA H reported that she was caring for Resident #278 on [DATE] when he went unresponsive. CNA H reported that her and CNA N were transferring Resident #278 from his chair to his bed with a hoyer lift when he began to say that he could not breathe. CNA H reported that they placed Resident #278 on his bed and sat the head of his bed up as they noticed that he went unresponsive. CNA H reported that she began yelling out for LPN I and as LPN H entered the room, she left to check to determine Resident #278's code status. CNA H reported that she ran out of the room and down to the nurses station to check the computer where she determined that Resident #278 had a DNR order. CNA H reported that she ran back to Resident #278's room and yelled that he had DNR, and then went to call 911. CNA H reported that she was the first staff member to tell LPN I that Resident #278 had a DNR order. In an interview on [DATE] at 2:05 PM, CNA N reported that she was caring for Resident #278 with CNA H on [DATE] when Resident #278 became unresponsive after they transferred Resident #278 from his chair to his bed. CNA N reported that as they laid Resident #278 in bed, he reported that he could not breathe and then went unresponsive. CNA N reported that she felt Resident #278's arm and could not find a pulse. CNA N reported that she and CNA H began yelling for help and LPN I entered Resident #278's room and also felt Resident #278's neck for a pulse, confirmed he did not have a pulse, and immediately began chest compressions on Resident #278. CNA N reported that after LPN I completed one round of compressions, LPN I checked Resident #278 for a pulse, and she reported that she felt a faint pulse. CNA N reported that she then checked Resident #278 and also felt a faint pulse on Resident #278. CNA N reported that as Resident #278 began to breathe again, several staff came in and reported that Resident #278 had a DNR order in place. In an interview on [DATE] at 1:11 PM, DON B reported that she was working on the evening of [DATE] and she ran to Resident #278's room when she heard staff yelling for help. DON B reported that when she went to Resident #278's room, she observed CNA H, CNA N, and LPN I' in Resident #278's room, and that Resident #278 was already beginning to wake up as she entered his room, and LPN I had already stopped performing CPR compressions on Resident #278. DON B confirmed that Resident #278 was unresponsive, did not have a pulse, and LPN I performed CPR on him, which did result in Resident #278 regaining a heartbeat. DON B reported that it was her expectation that staff would begin CPR on a resident until they verified the resident's code status. DON B confirmed that the facility did not complete an incident report, or initiate any further education after the incident with Resident #278 to improve the process of staff ensuring correct code status of residents in the event of emergencies. In an interview on [DATE] at 1:40 PM, Nursing Home Administrator (NHA) A reported that she was working on [DATE] when she had overheard a code blue being called for Resident #278. NHA A reported that she ran down to Resident #278's room and she saw LPN I, CNA N, and CNA H in Resident #278's room. NHA A reported that she ran to the nurses station and confirmed that Resident #278 had a DNR, and went back to Resident #278's room to report that he had a DNR, but that other staff were already there reporting his code status. NHA A reported that she had found out after the event that LPN I performed CPR on Resident #278 when he had an active DNR order in place. NHA A reported that the facility did not do an incident report after the event, but she thought that DON B had completed follow up education with staff. NHA A reported that she expected staff to confirm a resident's code status prior to initiating CPR. NHA A confirmed that Resident #278 was unresponsive, did not have a pulse, and LPN I performed CPR on him, which did result in Resident #278 regaining a heartbeat. Review of the Facility's CPR policy last reviewed [DATE] revealed, . Staff must maintain a current CPR certification for healthcare providers through a CPR provider whose training includes a hands on session in a physical instructor-led setting or a virtual instructor-led setting with hands-on demonstration in accordance with accepted national standards . 1. Validate the resident is full code and there is no DNR order .

Based on observation, interview, and record review the facility failed to perform a resident self-administration assessment and obtain a physician order for the self-administration of medication for 1 (Resident #5) of 18 residents reviewed for self-administration of medication, resulting in the potential for the mismanagement of medication and potential for adverse side effects. Findings include: During an observation and interview on 05/21/25 at 08:05 AM, Resident #5 had 8 pills/medications in a plastic disposable medication administration cup next to her meal on her meal tray in her room. Resident #5 was alone in her room and reported the medications were provided to her by a nurse before breakfast, but she just hadn't taken them yet. There was no facility staff in the room or in the hallway outside of the room. During an observation and interview on 05/21/25 at 08:31 AM, Licensed Practical Nurse (LPN) BB was preparing medications to be given to other residents at the opposite end of the hall past the nurse's station from Resident #5's room. LPN BB confirmed she provided Resident #5 medications earlier that morning and thought Resident #5 had taken her medications. LPN BB, stated, I don't know what happened this morning in regards to medications being left in Resident #5's room without staff present to ensure administration occurred. LPN BB walked down the hall to Resident #5's room and stated to Resident #5, I thought we took these (medications) this morning. LPN BB then removed the medication cup with the 8 pills/medications from Resident #5's room. LPN BB confirmed the 8 pills/medications that were left unattended in Resident #5's room were buspirone (anxiety medication), duloxetine (depression medication), ferrous gluconate (iron supplement), furosemide (Diuretic; lowers blood pressure and fluid retention), lisinopril (heart medication), metformin (diabetes (blood sugar) medication), metoprolol (hypertension medication) and Tylenol (pain reliever). LPN BB confirmed Resident #5 hadn't had a medication self-administration assessment completed so she wasn't supposed to have medications in her room without staff present. During an interview on 05/21/25 at 08:43 AM, Director of Nursing (DON) B reviewed Resident #5's record and confirmed Resident #5 hadn't had a medication self-administration evaluation and she would need one completed to self-administer medications. DON BB confirmed Resident #5 shouldn't have been left alone with medicatons on her meal tray in her room. Review of Resident #5's most recent brief interview for mental status score, dated 4/27/25, was 13 which indicated cognitively intact. Review of the facility's Medication Administration policy, revised 10/17/2023, stated, Authorized Personnel - Medications are .administered .only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications .Self-Administration - residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guideline for self-administration of medication. A self-administration evaluation will be completed prior to the resident starting the self-administering process. Self-administration of medication will be reflected in the resident care plan along with any special considerations .Observe that the resident swallows the oral medications. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication.

Based on interview and record review the facility failed to employ a full-time Registered Dietitian or a Certified Dietary Manager to provide an oversight of kitchen and clinical nutritional services. This deficient practice has the increased potential to result in food service sanitation failures, foodborne illness, or inadequate assessment of high-risk residents. Findings include: During the initial tour of the kitchen, starting at 7:50 AM on 5/19/25, it was found that Dietary Manager T still has a few more months to go until he completes his Certified Dietary Manger certification. When asked if he has been in the position for longer than a year, Dietary Manager T stated yes. When asked how often the dietitian comes to the facility, Dietary Manager T stated that the dietitian comes two days a week. When asked if he was aware that only one year was granted upon hire in the Dietary Manager / Food and Nutrition Supervisor role to obtain the Certified Dietary Manager certification, Dietary Manager T stated he thought he was allowed the length of the Certified Dietary Manager course, which is 18 months. A staff record review found no documentation that facility had a full time Certified Dietary Manager or full time Dietitian on staff.

This citation pertains to intake number MI00148293. Based on interview and record review, the facility failed to ensure staff had appropriate competencies and skills needed to provide care in a manner that supported their psychosocial wellness in 1 (Resident #102) of 6 residents reviewed for behavioral competency, resulting in inappropriate staff to resident interactions, inability of staff to appropriately address the psychological distress, unmet care needs, and resident not maintaining or achieving highest practical psycho-social well being. Findings include: Resident #102: Review of an Admission Record revealed Resident #102 was a female with pertinent diagnoses which included spina bifida (birth defect in which the spinal cord fails to develop properly), chiari syndrome (brain tissue extends into the spinal canal), anxiety, depression, homicidal ideations, premenstrual dysphoric disorder (severe form of premenstrual symptoms that includes physical and behavioral symptoms), hydrocephalus (build up of fluids in the cavities deep within the brain putting pressure on the brain and can cause brain damage), mood disorder, irritability and anger, seizures, mild intellectual disabilities, amputation of right lower leg, pain, and paralysis. Review of Care Plan revised on 1/2/25, revealed the focus, .(Resident #102) has the potential for fluctuations in mood R/T: Premenstrual dysphoric disorder, Depression, Mood disorder, Irritability and Anger, Mild Intellectual disabilities . with the intervention .Approach in a calm, quiet manner. Maintain appropriate body language during interactions such as maintaining eye contact and sitting in a relaxed position . Assist in developing or providing resident with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise, physical activity and socialization . Assist the resident to identify strengths, positive coping skills and reinforce these. Encourage resident to express feelings and provide time to talk as needed .Encourage family visits .Encourage participation in activities of preference .Encourage participation in ADL's .Observe and report to SW and/or physician prn acute changes in mood or behavior; feelings or sadness; increased anxiety/agitation, depression, withdrawal/loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills; how resident interacts with others .Observe and report to SW/physician as needed risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone . Review of Incident Investigation dated 11/17/24, revealed, .Type of Incident: Allegation of Verbal Abuse .Staff reported LPN (Licensed Practical Nurse) (LPN HH) was heard saying to (Resident #102) get your ass in your room, I'm not dealing with this.Where did the alleged incident occur: on 11/18/24 at [NAME] nursing station .Were there any witnesses .Yes .(Certified Nursing Assistant (CNA) II) and (CNA JJ) .Details from the witness: (CNA II) indicated that she was on the [NAME] unit when she heard (LPN HH) LPN telling (Resident #102) to get your ass to your room, I'm not dealing with this. (CNA JJ) indicated that (LPN HH) LPN came into work around 10 PM and was questioning (Resident #102) on why she was up. (CNA JJ) felt (LPN HH) tone was nasty. (Resident #102) was telling (LPN HH) she was waiting for 2 people to put her to bed .(LPN HH) then said you can go to bed, you should have been in bed. As they were discussing this with each other, I walked away to help another resident .Interview with affected resident: (Resident #102) indicated to DON (Director of Nursing) that she doesn't like (LPN HH). (Resident #102) was asked if she felt (LPN HH09 was mean or rude to her. (Resident #102) stated I don't like her. I really don't like her or (CNA II). I tell them that too .Interview with alleged perpetrator: I told (Resident #102) just get back to your room, get out of my face, just go back to your room and they will get back to you .(LPN HH) admits she may have stated get your ass back to your room, get out of my face .Summary Report of Facilities Conclusion: Allegation of Verbal abuse was alleged by a CNA regarding conversation between a resident and a nurse. Resident was displeased with the nurse and CNA on during the night shift and refused assistance. Resident became behavioral with escalating yelling and screaming. Resident was instructed to go to her room as this is care planned for quiet place to calm down. Resident continued with behaviors for more than 30 minutes and was told to go back to her room. Other staff who overheard the comment felt like the nurse was rude. Nurse indicate she may have stated get your ass back to your room, get out of my face.substantiate poor customer service and lack of recognition of need to remove self from an escalating situation if resident is safe . Review of Written Statement from CNA JJ revealed, .(LPN HH) came in around 10 PM questioning (Resident #102) why she was up w/a (with a) nasty tone. (Resident #102) told her she was waiting for 2 people to put her to bed .LPN HH) then said you can go to bed you should've been in bed. when they started to argue w/ each other I walked away to help another resident . This writer attempted to contact CNA II to discuss incident was unable to reach her. In an interview on 2/4/25 at 10:15 AM, Registered Nurse (RN) P reported she was in the break room and CNA II was eating her lunch and was venting to me about what happened earlier with Resident #102 and LPN HH. RN P reported CNA II reported she was disturbed by the comments the nurse was making to Resident #102. RN P reported she verified with her that she herself witnessed what was said and she said, yes. RN P informed the CNA this warranted a call to our administrator. RN P reported when the CNA was talking this hit my radar and what was said to the resident was inappropriate and the administrator needed to be called. Review of Nurses Note dated 1/26/25 at 2:59 PM, revealed, .Guest began to get frustrated with a dementia patient and started sighing. Writer informed staff and staff removed the dementia patient out of area. Another staff member attempted to take guest to her room and empty her catheter bag and she had an issue with that too, so staff member took her gloves off and walked away. Shortly after a guests family member came to facility and simply said hi to this guest and this guest replied, shut up. Staff member immediately attempted to put this guest into her room, and she started grabbing her door to not go into her room. Writer immediately went to help staff get guest into her room and guest began hitting, scratching and attempting to bite staff. Guest scratched guests neck and pulled name badge off writers shirt and broke holder to name badge. Writer has scratches on neck. Crisis center notified per orders and suggested guest get sent to (Local Hospital) for evaluation. Director of Nursing stated to have guest in facility at this time. Guest is in her room currently and staying calm at this time . In an interview on 2/4/25 at 3:14 PM, Certified Nursing Assistant (CNA) FF reported she had walked away from situation. CNA FF reported Resident #102 was originally at the nurse's station and followed her down the hallway towards the other unit. CNA FF reported we were in the hallway right outside of her room, another resident was with me as she was pushing her, bringing her to the other side of the building. CNA FF reported she asked Resident #102 if she could empty catheter bag really quick, she just huffs and puffs and acted frustrated, so she just stopped and continued on her way taking the other resident to the other unit. In an interview on 2/4/25 at 1:49 PM, Licensed Practical Nurse (LPN) Q reported she tried to take Resident #102 to her room after she was all huffy puffy. LPN Q reported when she (Resident #102) told the other resident's visitor to shut up, she (LPN Q) knew what was going to happen next, so she told the aide to get her and put her in her room. Resident #102 was fighting with the aide, so she went to help her, and she was yelling and attacking us, grabbed my shirt, trying to bite the CNA, she hit the CNA with a fist, and she was trying to grab her wheelchair wheels to get away from them. LPN Q reported this went on for approximately 5 minutes. Resident #102 bruised her breast, broke her name badge and scratched her neck. When queried if LPN Q attempted to redirect her, LPN Q responded can't do anything with her, and indicated she did not attempt to redirect her or remove herself from the situation. LPN Q reported when she gets like that you can't redirect her. This writer clarified the resident had huffed and puffed as she was agitated with another resident and had told a visitor to shut up and when queried whether LPN Q attempted to redirect her or to implement other interventions. LPN Q replied with no as she was going to escalate as that was how she was, and we had to get her into her room away from others. LPN Q reported the staff do not get training for her behaviors; we were told to not call 911 on her anymore as this would prevent her from going to an AFC (assisted living facility) home. LPN Q reported the staff do receive training in the (online learning program) but that was primarily for residents with dementia not for residents who have severe behavioral and mental health concerns. LPN Q reported the staff were not equipped to deal with a resident with her type of behaviors. In an interview on 2/4/25 at 09:53 AM, CNA G reported they were educated on abuse and neglect and they do not perform physical restraint and if a resident was placed in their room against their will that would be seclusion. In an interview on 2/4/25 at 9:53 AM, CNA H reported the training they received was specifically for residents with Dementia, Alzheimer's and PTSD. They had not received any training for residents who have schizophrenia and/or bipolar disorder. In an interview on 2/4/25 at 9:54 AM, CNA S reported for the interventions the staff would implement with a resident she would refer to the care plan for interventions after they initially tried to redirect the resident. CNA S reported the information was all in the computer and that was where they would find the specific interventions for a resident. CNA S reported the staff had not received any additional training to address those who may be having a mental health crisis and how to deal with it, if they were to perform a physical restraint it should be at the direction of the nurse. Note: All three CNAs reported the facility had a lot of resident who were younger with mental health concerns and they did not feel they had the education on how to deal with them. In an interview on 2/4/25 at 10:15 AM, Registered Nurse (RN) P reported the staff were educated yearly on abuse and neglect. RN P reported the staff received their education via the (online learning program) and at times they would receive additional training. RN P reported when a crisis situation would arise, we would implement the interventions in the care plan, and if necessary would transfer the resident out to the hospital. RN P reported the staff had not been educated on the performance of physical restraint and the facility does not use it. RN P reported resident had rights and the staff were educated on what their rights were. In an interview on 2/4/25 at 2:19 PM, Social Worker (SW) GG reported she does not work at the facility full time, she was filling in to help the facility out until they were able to hire a new social worker. SW GG reported she was unaware she was able to petition Resident #102 without guardian consent until last week. SW GG reported she would reach out the corporate social worker via emails since she was only working a few hours a week after hours and on the weekends. SW GG reported she had received education at the facility in regards to behavioral health education and had behavioral provider come to educate the staff on trauma informed care. SW GG reported the facility had more residents with behavioral health challenges now and the staff don't really get to know the residents and what triggers them and if the resident was set off, what works with each resident. SW GG reported if the staff don't understand and/or get to know the resident, they can set the residents off. In an interview on 2/5/25 at 8:36 AM, Activity Director (AD) BB reported she had been tracking the behaviors and held the behavioral health meetings. AD BB reported she had modified the behavior tracking for the CNAs as in the medical record they were not able to add additional information to the behavioral tracking. AD BB reported the behaviors for residents were documented on a sheet indicating what the behavior was, what intervention the staff tried and if it was successful. AD BB reported she does speak with the nursing staff to better understand the resident's behaviors, what behaviors changed, what's been documented in the record and she would also inform the staff of any behaviors they would need to monitor for when there were changes. AD BB reported they received education via the online training program. In an interview on 2/4/25 at 11:26 AM, Director of Nursing (DON) B reviewed Resident #102's medical record and when queried if the nursing staff had implemented person centered behavioral interventions on the resident's care plan when the incident occurred on 1/26/25 and DON B reported there were no documented attempted interventions in the record except moving her to a quiet place or her room. When queried if forcing Resident #102 into her room was part of her care plan, DON B reported it was not, they shouldn't have but she was care planned for removing her from the situation and have her go to a quiet place to calm down. When queried if the situation documented required the movement of Resident #102 to her room, DON B reported there was no way to know for sure what would happen next with Resident #102. DON B reported staff should have attempted to redirect her and implemented behavioral care interventions to address the situation. In an interview on 2/5/25 at 11:25 AM, Staff Development (SD) K reported the staff receive training monthly via the (online education program). SD K reported she monitored the completion of staff throughout the month and if they had not completed the trainings she would reach out to the supervisor, bring up during the morning meeting, and send out messages to try to get them to get it done. SD K reported she monitors staff implementation of behavioral training by watching and walking around, asks a lot of questions of staff, and if she was present during an incident she would provide one to one education to staff if it was needed. In an interview on 2/5/25 at 12:12 PM, Administrator A reported the staff had received multiple educations on de-escalation, trauma informed care, behavioral management, pain causing behaviors via a hospice presentation. Administrator A reported the facility had a population of residents who were younger and had more mental health concerns. Administrator A reported she walked the halls, does on the spot education with staff, received information from the behavioral management committee. Administrator A reported the staff had to realize the residents did not ask to be here, they were struggling with the age group and the behaviors, and she felt the staff allowed previous incidents influence/bias affect how they responded to a resident with behaviors. Administrator A reported she felt the facility was doing the best they could for all the people living at the facility.

Based on observation, interview and record review, the facility failed to prevent involuntary seclusion in 1 of 6 residents (Resident #102) reviewed for abuse, resulting in the potential for a decline in physical, mental, and psychosocial well-being. Findings include: Review of an Admission Record revealed Resident #102 was a female with pertinent diagnoses which included spina bifida (birth defect in which the spinal cord fails to develop properly), chiari syndrome (brain tissue extends into the spinal canal), anxiety, depression, homicidal ideations, premenstrual dysphoric disorder (severe form of premenstrual symptoms that includes physical and behavioral symptoms), hydrocephalus (buildup of fluids in the cavities deep within the brain putting pressure on the brain and can cause brain damage), mood disorder, irritability and anger, seizures, mild intellectual disabilities, amputation of right lower leg, pain, and paralysis. Review of Care Plan for Resident #102 revised on 12/29/24, revealed the focus, .(Resident #102) has experienced trauma at some point during the past .TRAUMA: Childhood abuse/neglect, Sexual violence, and Other: Worried about court dates, life changes, guilt for family relationships, and change in living situation (LTC vs AFC home) .TRIGGERS: Other residents dying can trigger resident to have increased anxiety, an emotional outburst, agitation, fear, and unwanted thoughts . with the intervention .Establish and maintain a trusting relationship .Maintain a calm non-threatening relationship by listening to the resident/guest .Move slowly and avoid sudden movements .Personal triggers: Being alone with males, loud noises, and fear of dying .provide reassurance to the resident/guest that he/she is safe and the facility is doing what is needed to maintain safety for all .Encourage resident/guest to talk about past trauma, as needed .Encourage resident/guest to talk about past trauma as needed .Encourage resident/guest to be involved in activities and be engaged with others as possible and desired . Review of Nurses Note dated 1/26/25 at 2:59 PM, revealed, .Guest began to get frustrated with a dementia patient and started sighing. Writer informed staff and staff removed the dementia patient out of area. Another staff member attempted to take guest to her room and empty her catheter bag and she had an issue with that too, so staff member took her gloves off and walked away. Shortly after a guests family member came to facility and simply said hi to this guest and this guest replied, shut up. Staff member immediately attempted to put this guest into her room, and she started grabbing her door to not go into her room. Writer immediately went to help staff get guest into her room and guest began hitting, scratching and attempting to bite staff. Guest scratched guests neck and pulled name badge off writers shirt and broke holder to name badge. Writer has scratches on neck. Crisis center notified per orders and suggested guest get sent to (Local Hospital) for evaluation. Director of Nursing stated to have guest in facility at this time. Guest is in her room currently and staying calm at this time . In an interview on 2/4/25 at 3:14 PM, Certified Nursing Assistant (CNA) FF reported she had walked away from situation. CNA FF reported Resident #102 was originally at the nurse's station and followed her down the hallway towards the other unit. CNA FF reported we were in the hallway right outside of her room, another resident was with me as she was pushing her, bringing her to the other side of the building. CNA FF reported she asked Resident #102 if she could empty catheter bag really quick, she just huffs and puffs and acted frustrated, so she just stopped and continued on her way taking the other resident to the other unit. In an interview on 2/4/25 at 1:49 PM, Licensed Practical Nurse (LPN) Q reported she tried to take Resident #102 to her room after she was all huffy puffy. LPN Q reported when she (Resident #102) told the other resident's visitor to shut up, she (LPN Q) knew what was going to happen next, so she told the aide to get her and put her in her room. Resident #102 was fighting with the aide, so she went to help her, and she was yelling and attacking us, grabbed my shirt, trying to bite the CNA, she hit the CNA with a fist, and she was trying to grab her wheelchair wheels to get away from them. LPN Q reported this went on for approximately 5 minutes. Resident #102 bruised her breast, broke her name badge and scratched her neck. When queried if LPN Q attempted to redirect her, LPN Q responded can't do anything with her, and indicated she did not attempt to redirect her or remove herself from the situation. LPN Q reported when she gets like that you can't redirect her. This writer clarified the resident had huffed and puffed as she was agitated with another resident and had told a visitor to shut up and when queried whether LPN Q attempted to redirect her or to implement other interventions. LPN Q replied with no as she was going to escalate as that was how she was, and we had to get her into her room away from others. LPN Q reported the staff do not get training for her behaviors; we were told to not call 911 on her anymore as this would prevent her from going to an AFC (assisted living facility) home. LPN Q reported the staff do receive training in the (online learning program) but that was primarily for residents with dementia not for residents who have severe behavioral and mental health concerns. LPN Q reported the staff were not equipped to deal with a resident with her type of behaviors. In an interview on 2/4/25 at 09:44 AM, CNA V reported she had not received any behavioral health training except for the (online learning program). CNA V indicated someone from the police department came and spoke to the staff about calling 911 for issues with residents and when to call them. CNA V reported if she suspected abuse she would go to the nurse and let them know, and then go to the administrator. When queried on abuse, CNA V reported the facility had not completed training with the staff on how to perform a physical restraint on a resident who was striking out and reported they should not be physically restraining a resident as it was a violation of their rights. In an interview on 2/4/25 at 09:53 AM, CNA G reported they were educated on abuse and neglect, and they do not perform physical restraint and if a resident was placed in their room against their will that would be seclusion. In an interview on 2/4/25 at 9:54 AM, CNA S reported for the interventions the staff would implement with a resident she would refer to the care plan for interventions after they initially tried to redirect the resident. CNA S reported the information was all in the computer and that was where they would find the specific interventions for a resident. CNA S reported the staff had not received any additional training to address those who may be having a mental health crisis and how to deal with it, if they were to perform a physical restraint it should be at the direction of the nurse. Note: Both CNAs reported the facility had a lot of resident who were younger with mental health concerns, and they did not feel they had the education on how to deal with them. In an interview on 2/4/25 at 10:15 AM, Registered Nurse (RN) P reported the staff were educated yearly on abuse and neglect. RN P reported the staff received their education via the (online learning program) and at times they would receive additional training. RN P reported when a crisis situation would arise, we would implement the interventions in the care plan, and if necessary, would transfer the resident out to the hospital. RN P reported the staff had not been educated on the performance of physical restraint and the facility does not use it. RN P reported resident had rights and the staff were educated on what their rights were. Review of Abuse Training dated 2/4/25, revealed, 51 out of 84 staff member had not completed the education for abuse. Review of policy, Abuse Prohibition Policy revised 9/9/2022, revealed, .5. The facility supervisory staff will integrate into the supervisory process monitoring the behavior of staff members and guests/residents that are indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression .

Based on interview and record review, the facility failed to ensure an infection control surveillance plan was in place and included an ongoing collection and interpretation of data for 4 (Resident #109, #112, #113, and #114) of 15 residents with the potential to affect all 78 residents who reside at the facility, resulting in the potential for the spread of infection without timely identification and response, and the development and spread of infection to a vulnerable population. Findings include: In an interview on 2/4/25 at 4:45 PM, Infection Preventionist (IP) K reported that the facility used a computer based program for infection control surveillance, that populates with residents automatically when a infection assessment confirms infection. IP K reported that she did not have a list of residents that were currently on antibiotics, and that she was not sure if they were included in the computer program. IP K reported that based on the list, there were currently 8 residents in the facility with infections, but that she had not collected all of their information yet. IP K reported that there were no residents currently with UTI's (urinary tract infection), and there was 1 resident with a suspected UTI. This surveyor requested that IP K update the report with real time data for review. Review of the Infection Control Surveillance Monthly Report dated February 2025 indicated, Resident #114 had completed Cephalexin (antibiotic) treatment for a UTI on 2/3/25, and Resident #109 had completed Cephalexin treatment for a UTI on 2/3/25. Resident #112 and #113 were not included on the report. This report was received on 2/5/25 at approximately 8:00 AM. Resident #109 Resident #109's Physician Orders indicated that Cephalexin had been discontinued on 1/31/25, Cipro (antibiotic) was prescribed on 1/31/25 and then discontinued on 2/1/25, and Macrobid (antibiotic) was prescribed on 2/1/25. Resident #109's was currently receiving Macrobid, with an end date of 2/8/25. The infection control report was not an accurate reflection of Resident #109's status. Resident #112 Resident #112's Nurses Note dated 1/31/25 at 9:26 AM revealed, Resident urine dark and foul smelling this morning. Per NP (Nurse Practitioner), dip (in-house test) urine. Known bladder mass. Urine dip performed. Results: positive for blood, protein, leukocytes (white blood cells, indicative of infection) . Resident #112's Physician Orders revealed, Obtain urine and send to lab for UA (urinalysis urine test) w/ (with) C&S (culture and sensitivity) if indicated. This was ordered on 1/31/25. Resident #113 Resident #113's Physician Orders indicated that Bactrim (antibiotic) had been prescribed for UTI on 2/1/25 until 2/10/25. Resident #113 was currently receiving Bactrim. Resident #114 Resident #114's Physician Orders indicated that Cephalexin had been prescribed on 1/29/25, with an end date of 2/8/25. Resident #114 was currently receiving Cephalexin. The infection control report was not an accurate reflection of Resident #114's status. In an interview on 2/5/25 at 8:53 AM, Director of Nursing (DON) B reported that infections and antibiotics are discussed every day in the morning meeting and should all have been included on the infection control surveillance report. DON B reported that Resident #112 and #113 should have been included on the report, and Resident #109 and #114 should not have been listed as resolved. In an interview on 2/5/25 at 1:30 PM, Nursing Home Administrator was notified that a past non-compliance for infection control would not be accepted due to current non-compliance.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration and documentation in 6 of 10 residents (Resident #7, #14, #22, #38, #39, and #50) reviewed for medication administration, resulting in the potential for medication errors. Findings include: During an observation on 05/09/24 at 09:10 AM of medication administration with Registered Nurse (RN) X and the east unit medication cart, RN X picked up 2 cups with multiple pills in each and 2 syringes of insulin (medication for blood sugar control) from the cart, locked the cart and proceeded to walk down the hall, enter a resident room and hand one cup to Resident #38 and the other cup to Resident #22. No observation of RN X confirming medications and/or identification of residents, and the medication cups were not labeled with the resident's name. During an observation and interview on 05/09/24 at 09:21 AM of medication administration, RN X documented administration of multiple medications for Resident #7, Resident #39, and Resident #50. RN X explained that Resident #7 had refused his medications before breakfast that day, Resident #39 had already gotten her medications earlier that day, and Resident #50 had received his medications from Licensed Practical Nurse (LPN) Z before she left that day. LPN Z had worked third shift. During an observation on 05/09/24 at 09:31 AM on east unit, RN X was preparing medications for Resident #14. RN X visualized Resident #14's orders on the computer, pulled Tylenol, Stool Softener, Fish Oil, Lasix (increases production of urine), and Finasteride (for urinary retention) from the cart, then closed the computer. RN X then opened another drawer, and grabbed Breo inhaler (for breathing). Then unlocked the narcotic box and pulled out Pregabalin (pain medication). RN X did not compare the medications with the physician orders, and did not check off the medications as they were pulled. RN X proceeded to administer the medications to Resident #14, then came back to the computer and checked off each medication and saved the record. In an interview on 05/09/24 at 09:55 AM, RN X reported that she did not know the facility policy related to the expectations for how and when to document medications in the record, and that she did not see any concern with giving medications to two residents at the same time. RN X reported that she should not have documented medications that she did not administer. An attempt was made on 05/09/24 at 01:52 PM to contact LPN Z to discuss why she did not sign out medications that were administered. Message was left, but no return call received. In an interview on 05/09/24 at 02:16 PM, Director of Nursing (DON) B reported that the expectation for medication administration was for nurses to compare each medication with the order in the computer, double check that the medication card matches the order, and then click off each medication on the Medication Administration Record (MAR) as they are pulled, then locked the computer screen, identify the resident, administer the medication, and lastly save the medication administration in the computer immediately following administration. DON B reported that preparing medications for two residents at the same time would risk administering the medications to the wrong resident, and was not facility procedure or policy. DON B reported that nursing staff were only authorized to sign medication administration for medications that they give, and should not sign out medications that were given by another nurse. Review of facility document, Medication Pass-Survey Preparedness revealed, .5. Identify guest by checking photo in med book and asking guest to state his or her name. 6. Verify medication and strength with order on MAR (3 times). 7. Pour meds immediately prior to administration, not before .10. Initial med sheet immediately after administration .

This citation pertains to intake: MI 333. Based on interview and record review, the facility failed to prevent the use of a physical restraint, utilized for the sole purpose of staff convenience, on 1 of 5 sampled residents (Resident #201) reviewed for physical restraints, resulting in an Immediate Jeopardy (IJ) when on 6/16/22 at approximately 8:15 PM, Resident #201, a cognitively impaired resident with known behaviors and a documented history of falls, was found sitting in their wheelchair with a gait belt applied around her waist and the back of the wheelchair such that Resident #201 could not get up. This deficient practice resulted in the potential for injury from attempts to free herself from the restraint, agitation and anxiety, panic, and dehumanization. Findings include: Review of a Face Sheet revealed Resident #201 was a female. Review of a Minimum Data Set (MDS) assessment for Resident #201, with a reference date of 5/16/22 revealed Resident #201 had 1.) a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #201 was severely cognitively impaired and 2.) active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #201's Care Plan revealed a focus of (Resident#201) is at risk for fall related injury and falls R/T (related to): history of falls, [CONDITION(S)] medication use Alzheimer's, frequent bladder incontinence and dementia . created on 5/10/22. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility incident report received by the state agency on 6/17/22 at 9:29 AM and investigation report received by the state agency on 6/25/22 at 11:47 AM revealed the incident occurred on 8/16/22 at 8:15 PM. Incident Summary Resident was sitting in wheelchair and it was noted that there was a gait belt around her waist attached to the chair .Investigation Summary On 6/16/22 (Activities Assistant (AA) D), activities assistant observed a gait around the waist of resident (Resident #201). The resident was sitting in the wheelchair and the gait belt was noted to be attached to the chair. (AA D) immediately informed (Registered Nurse (RN) G), who immediately went to the resident and removed the gait belt .Nurse then went and spoke to the aide (identified by facility as Certified Nursing Assistant (CNA) C) and the aide stated that she had put the gait belt on resident because the alarming seatbelt was going off and she needed to get other residents to bed . In an interview on 7/7/22 at 1:45 PM, Registered Nurse (RN) G reported had been Resident #201's nurse on 6/16/22 at 8:15 PM. RN G reported two Certified Nursing Assistants (CNA)s, CNA C and CNA E, were also on duty on Resident #201's hall on 6/16/22 at 8:15 PM. RN G reported that because Resident #201 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN G reported had been on another hall obtaining vitals on a male resident who had just returned from the emergency room when Activities Assistant (AA) D approached and reported that Resident #201 had been found seated at the nurses' station in her wheelchair with a gait belt around her waist and her wheelchair, rendering her unable to get up from the wheelchair. RN G reported when received that report, went directly to Resident #201, and found her sitting at the desk in her wheelchair with a gait belt applied around her waist and the wheelchair seat, with the buckle of the belt located in the back of the seat. RN G reported the gait belt was loose fitting but tight enough around the resident and the wheelchair with the buckle in the back, that it would not have been possible for Resident #201 to place it herself and that it would have had to have been placed by someone else. RN G reported Resident #201 would not have been able to remove the gait belt by herself either. RN G reported they (RN G) removed the gait belt immediately and ensured Resident #201's safety. RN G reported then requested CNA C to accompany them (RN G) to a private area and inquired if CNA C knew who put the gait belt on Resident #201. RN G reported CNA C had admitted that they had done so because they couldn't get the rest of the people to bed with Resident #201 setting off that alarm. RN G reported then called Director of Nursing (DON) B to report the incident and to let DON B know they had talked to CNA C who admitted they had placed the gait belt on Resident #201. RN G reported worked with CNA C and CNA E on Resident #201's hall for the remainder of their shift (which ended at 6:00 AM the next morning) without further incident. In an interview on 7/7/22 at 3:08 PM, Activities Assistant (AA) D reported was on duty on 6/16/22 at 8:15 PM. AA D reported had been passing out devotionals to the residents in their rooms and when walked past Resident #201 at the nurses' station, Resident #201 had indicated she wanted to go for a walk. AA D reported was getting ready to assist Resident #201 when noticed the wheelchair alarm belt was unlatched and open but was not sounding and was turned off. AA D reported then reached for the gait belt around Resident #201's waist to assist her up from the wheelchair but couldn't help her stand up and could not figure out why. AA D reported ran hands around the gait belt and noticed it was attached in the back of the wheelchair too. AA D reported didn't notice the gait belt around the back of the wheelchair right away because Resident #201's hoodie sweatshirt was hanging over the back of her chair, covering the gait belt. AA D stated, I just could not believe it. AA D reported immediately got RN G to report her findings and to have RN G verify the observation. In an interview on 7/7/22 at 4:03 PM, Certified Nursing Assistant (CNA) E reported had seen Resident #201 with a gait belt positioned around her waist and the back of her wheelchair and fastened in the back. CNA E reported it did not appear as though Resident #201 could have placed it on or removed it herself because it was tight enough that it could not have gone around the handles of the wheelchair and because the belt buckle was around the back of the seat. CNA E reported had asked CNA C if they put the belt on Resident #201 and that CNA C had said that they had because they were tired of Resident #201 getting up and that Resident #201 was not a one on one and they couldn't just sit there and watch her. CNA E reported when saw the gait belt around Resident #201, told CNA C to take it off and CNA C had said that they would. CNA E reported then got called away to answer a call light so didn't observe if CNA C had actually removed the gait belt from around Resident #201. CNA E reported didn't tell anyone about it because thought CNA C was kidding and was going to take it off because she knew better and kind of laughed about it. CNA E reported had later learned that RN G had removed the gait belt from Resident #201. CNA E reported worked the remainder of the shift with RN G and CNA C. In an interview on 7/8/22 at 2:42 PM, CNA C reported they had placed the gait belt on Resident #201 for safety reasons but did not put the gait belt around the wheelchair and stated, I don't know who did that. Review of a facility policy, Restraint Management last revised 10/1/19 revealed, .Overview Physical Restraints are not used for the purpose of discipline or convenience, but only as required to treat the guest's/resident's medical symptom. Definition Physical Restraints are defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the guest's/resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body .Also included as a restraint are facility practices that meet the definition of a restraint, such as .Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the guest/resident cannot remove and prevents the guest/resident from rising . Review of a facility policy, Abuse Prohibition Policy last revised 4/28/22 revealed, Policy Each guest/resident 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 convenience that are not required to treat the guest's/resident's medical symptoms . On 7/8/22 at 10:59 AM, Nursing Home Administrator (NHA) A was verbally notified and received writing notification of the Immediate Jeopardy that began on 6/16/22 and was identified on 7/8/22 due to the facility's failure to prevent the use of a physical restraint, utilized for the sole purpose of staff convenience, on Resident #201. A written plan for removal for the Immediate Jeopardy was received on 7/8/22 and the following was verified on 7/11/22: 1. Resident #201 had restraint removed at 8:15 pm on 6/16/22 and remains restraint free since that time. She shows no signs or symptoms of anxiety, agitation, panic or dehumanization. CNA C, an agency staff, has not worked at the facility since the incident and will not be returning. 2. Residents who reside in the facility who cannot communicate are at risk to be inappropriately restrained or abuse to occur. On 7/7/22 Twenty Nine residents were evaluated by the SW (Social Worker) and none were identified to be restrained and there had been a drop in behaviors overall, no evidence of abuse had occurred. At the time of the incident (the following morning) residents were interviewed to see if anyone had any abuse or care concerns and none were expressed. 3. On 7/8/22, the 34 remaining residents are being interviewed to inquire if anyone has any concerns related to restraints/abuse. Any concerns are being written on a concern sheet, followed up on, and reported if necessary per the policy. 4. Facility staff began to be educated on restraint policy, prohibition of all forms of inappropriate restraints and abuse prevention. Charge nurses and department heads have the authority to suspend an employee immediately for any allegation of abuse and ensure person centered interventions are in place. As of 7/8/22 at 12:00 noon, 55 employees have been educated so far at this time. Remaining employees will be educated before reporting for duty on the floor. 5. Administrator is responsible for the implementation of the above enumerated abatement plan. Although the Immediate Jeopardy was removed on 7/11/22, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm due to the fact that not all facility staff have received all education and sustained compliance has not been verified by the state agency.

This citation pertains to intake: MI 333. Based on interview and record review, the facility failed to prevent the likelihood for ongoing abuse for 1 resident (Resident #201) of 5 residents reviewed for abuse, resulting in an Immediate Jeopardy (IJ) that began on 6/16/22 at 8:15 PM when CNA C, after confirmation that CNA C had applied a physical restraint to Resident #201 for staff convenience, was permitted to remain at the facility, providing direct care to their assigned residents, including Resident #201, for the remainder of their shift (which ended at 6:00 AM the next morning). This deficient practice had the high likelihood to affect all vulnerable residents assigned to CNA C during that time. Findings include: Review of a Face Sheet revealed Resident #201 was a female. Review of a Minimum Data Set (MDS) assessment for Resident #201, with a reference date of 5/16/22 revealed Resident #201 had 1.) a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #201 was severely cognitively impaired and 2.) active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility incident report received by the state agency on 6/17/22 at 9:29 AM and investigation report received by the state agency on 6/25/22 at 11:47 AM revealed the incident occurred on 8/16/22 at 8:15 PM. Incident Summary Resident was sitting in wheelchair and it was noted that there was a gait belt around her waist attached to the chair .Investigation Summary On 6/16/22 (Activities Assistant (AA) D), activities assistant observed a gait (belt omitted) around the waist of resident (Resident #201). The resident was sitting in the wheelchair and the gait belt was noted to be attached to the chair. (AA D) immediately informed (Registered Nurse (RN) G), who immediately went to the resident and removed the gait belt .Nurse then went and spoke to the aide (identified by facility as Certified Nursing Assistant (CNA) C) and the aide stated that she had put the gait belt on resident because the alarming seatbelt was going off and she needed to get other residents to bed . In an interview on 7/7/22 at 1:45 PM, Registered Nurse (RN) G reported had been Resident #201's nurse on 6/16/22 at 8:15 PM. RN G reported had been on another hall obtaining vitals on a male resident who had just returned from the emergency room when Activities Assistant (AA) D approached and reported that Resident #201 had been found seated at the nurses' station in her wheelchair with a gait belt around her waist and her wheelchair, rendering her unable to get up from the wheelchair. RN G reported removed the gait belt immediately and ensured Resident #201's safety. RN G reported then requested CNA C to accompany them to a private area and inquired if CNA C knew who put the gait belt on Resident #201 when she was in the wheelchair to which CNA C reported they had done so because they couldn't get the rest of the people to bed with Resident #201 setting off that alarm. RN G reported then called Director of Nursing (DON) B to report the incident and to let DON B know they had talked to CNA C who admitted they had placed the gait belt on Resident #201. RN G reported CNA C had not been removed from her assignment and continued to work and provide care to assigned residents until the end of the shift at 6:00 AM the next morning. RN G reported DON B did not tell them (RN G) that CNA C had to be sent home. In an interview on 7/7/22 at 3:43 PM, Nursing Home Administrator (NHA) A reported that CNA C did finish their shift and was not immediately removed from their assignment but should have been. In an interview on 7/7/22 at 3:51 PM, DON B reported that RN G had contacted them (DON B) on 6/16/22 after it was discovered that CNA C had placed the gait belt on Resident #201 and around the wheelchair. DON B reported they (DON B) felt that RN G had done a good job in finding out what happened and had educated CNA C that it was not okay to physically restrain the resident. DON B reported had discussed with RN G Resident #201's state at the time she was found, and she appeared fine. DON B reported, given that information, felt that the residents would be safe, and had to consider that if sent CNA C home without staff to replace them, then the facility would not be meeting the rest of the residents' needs so it was decided that CNA C would stay and complete the shift. DON B reported in retrospect, should have sent CNA C home immediately pending further investigation of the reported incident. Review of a facility policy, Restraint Management last revised 10/1/19 revealed, .Overview Physical Restraints are not used for the purpose of discipline or convenience, but only as required to treat the guest's/resident's medical symptom. Definition Physical Restraints are defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the guest's/resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body .Also included as a restraint are facility practices that meet the definition of a restraint, such as .Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the guest/resident cannot remove and prevents the guest/resident from rising . Review of a facility policy, Abuse Prohibition Policy last revised 4/28/22 revealed, Policy Each guest/resident 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 convenience that are not required to treat the guest's/resident's medical symptoms .F. Protection of Guests/Residents during the Investigation 1. If the accused is an employee of the facility, he/she will be suspended until the investigation has been completed . On 7/8/22 at 10:59 AM, Nursing Home Administrator (NHA) A was verbally notified and received writing notification of the Immediate Jeopardy that began on 6/16/22 and was identified on 7/8/22 due to the facility's failure to prevent the likelihood for ongoing abuse to vulnerable residents after confirmation that CNA C had applied a physical restraint to Resident #201 for staff convenience and was permitted to remain at the facility, providing direct care to their assigned residents for the remainder of their shift (which ended at 6:00 AM the next morning). A written plan for removal for the Immediate Jeopardy was received on 7/8/22 and the following was verified on 7/11/22: 1. Resident #201 had restraint removed at 8:15 pm on 6/16/22 and remains restraint free since that time. She shows no signs or symptoms of anxiety, agitation, panic or dehumanization. CNA C, an agency staff, has not worked at the facility since the incident and will not be returning. 2. Residents who reside in the facility who cannot communicate are at risk to be inappropriately restrained or abuse to occur. On 7/7/22 Twenty Nine residents were evaluated by the SW (Social Worker) and none were identified to be restrained and there had been a drop in behaviors overall, no evidence of abuse had occurred. At the time of the incident (the following morning) residents were interviewed to see if anyone had any abuse or care concerns and none were expressed. 3. On 7/8/22, the 34 remaining residents are being interviewed to inquire if anyone has any concerns related to restraints/abuse. Any concerns are being written on a concern sheet, followed up on, and reported if necessary per the policy. 4. Facility staff began to be educated on restraint policy, prohibition of all forms of inappropriate restraints and abuse prevention. Charge nurses and department heads have the authority to suspend an employee immediately for any allegation of abuse and ensure person centered interventions are in place. As of 7/8/22 at 12:00 noon, 55 employees have been educated so far at this time. Remaining employees will be educated before reporting for duty on the floor. 5. Administrator is responsible for the implementation of the above enumerated abatement plan. Although the Immediate Jeopardy was removed on 7/11/22, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm due to the fact that not all facility staff have received all education and sustained compliance has not been verified by the state agency.

This citation pertains to intake #MI 724. Based on interview and record review, the facility failed to provide appropriate treatment and services for end of life care including notification of hospice in 1 of 2 residents (Resident #56) reviewed for hospice services, resulting in pain, anxiety, avoidable emotional distress during the last hours of Resident #56's life while in the active stages of dying. Findings include: Review of a Face Sheet revealed Resident #56 was admitted to the facility in 2017, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #56, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #56 was cognitively impaired. During a phone interview on [DATE] at 11:00 AM., Certified Nurse Aide (CNA) Y reported she worked the day shift (6:00 am-6:00 pm) on [DATE]. CNA Y reported on [DATE] when she arrived to work, she could hear Resident #56 calling out for help, and Resident #56's call light was on. CNA Y reported she was in the morning huddle for report from 3rd shift staff, and had heard that Resident #56 had had a tough night, calling out for help, and begging to go to the hospital. CNA Y reported after report, she went to Resident #56's room, and Resident #56 was diaphoretic (clammy/sweating), very pale in color and extremely anxious. CNA Y reported when she (CNA Y) went to comfort Resident #56, she (Resident #56) grabbed her arm, and would not let go. CNA Y reported Resident #56 was saying please, please help me, something is wrong, I am hurting, and something is wrong, I need to go to the hospital. CNA Y reported she told Resident #56, she would return with the nurse. CNA Y reported she left the call light on, went to the nurse who was assigned to Resident #56. CNA Y reported she told the agency nurse about Resident #56's condition, and how she wasn't doing very well. CNA Y reported she asked the agency nurse if she could go in and check on Resident #56. CNA Y reported the agency nurse said I can't right now, I'm doing medication pass, I gave her medications, there is nothing else I can do for her. CNA Y reported she went back to Resident #56's room to try and comfort her. CNA Y reported she turned off the call light, and told Resident #56 she would see what she could do. CNA Y reported she went to the CNA assigned to Resident #56 to inform of the situation. CNA Y stated I had to start getting my residents up and changed for breakfast, but the entire time I could hear her (Resident #56) hollering and crying out help me, help, something's wrong, I need to go to the hospital. Whenever I had a chance, I went back to her (Resident #56's) room to try to comfort her, it was breaking my heart, it was the worse cry I have ever heard in my life. I never want to experience that again. CNA Y reported for the next few hours she would continue to go into Resident #56's room. CNA Y reported her (Resident #56's) color was off, she (Resident #56) was completely pale, she (Resident #56) was crying out, she (Resident #56) was in a cold sweat. CNA Y reported (Resident #56) kept screaming help . help me, I cant feel my arms and legs, I need to get to the hospital. CNA Y reported she told (Resident #56) she would get the nurse, so CNA Y then went to another nurse who was a regularly employed charge nurse (Licensed Practical Nurse (LPN) I). CNA Y reported LPN I reported he was busy, but gave her (CNA Y) the phone number to hospice to give to the agency nurse assigned to Resident #56. CNA Y stated I told her (Resident #56) I would go get her nurse, we (myself and other CNA's) tried to get her nurse, but she was always busy. CNA Y reported the agency nurse said we have done everything we could do of her. CNA Y reported this was all happening for approximately 3 and a half hours. CNA Y stated I was still trying to get my other residents, I had left her (Resident #56's) call light on the entire time. I placed it in her hand, she was able to turn on, but was complaining as time went on, her arms, legs and fingers were going numb and she was in pain. CNA Y reported she was in the (Resident #56's room) very, very frequently, all the other aides were checking on her as well. CNA Y' stated she (Resident #56) was in extreme distress, in a panicked state. CNA Y reported she (Resident #56) said to me several times please don't leave me, please don't leave me, I'm begging, I'm scared, I want to go to the hospital. CNA Y reported during this time, Resident #56 was holding onto her hand/arm and wouldn't not let go. CNA Y reported she (Resident #56) was reaching out until she couldn't anymore, and then she (Resident #56) couldn't feel her arms and legs at that time she didn't reach out any longer. CNA Y stated I finally had enough, and I was going to get management. I went looking for managers, and couldn't find any. I found MDS/RN BB she went to Resident #56's room, I noticed the call light was shut off. CNA Y reported MDS/RN BB wasn't in Resident #56's room very long. CNA Y reported shortly after that (MDS/RN BBgoing into Resident #56's room) while during her rounds on assigned residents, she could hear Resident #56 moaning, and hollering out. CNA Y reported within an hour a housekeeper came to her and reported (Resident #56) had passed away. CNA Y stated She (Resident #56) died alone, afraid, in pain and in complete terror. CNA Y stated this situation was absolutely horrifying. I was feeling very powerless, I was tearful/crying .it was very traumatic .her (Resident #56's) screaming out, I'll never forget how that sounded. CNA Y reported the managers were all in a meeting practically the entire time this was going on. CNA Y reported managers typically start their meeting about 8:00 AM, or so. CNA Y reported she thinks Resident #56 passed away around 9:15 AM CNA Y reported the Director of Nursing (DON) B came down to the unit and asked how Resident #56 was doing, after she had already passed away. CNA Y reported AA H assisted CNA Y with organizing Resident #56's bed, and room prior to family arriving. CNA Y reported a short time after family arrived. CNA Y reported after family member came out of Resident #56's room, the family member was clearly upset, but also verbalized that hospice and family should have been notified earlier. During an interview on [DATE] at 11:35 AM., MDS/RN BB reported her duties are completing the MDS assessments on residents but she also works as a floor nurse, passing medications, and assisting where needed. MDS/RN BB reported she was familiar with Resident #56. MDS/RN BB reported Resident #56 had not been feeling well the week prior to her passing away on [DATE]. MDS/RN BB reported Resident #56 had been vomiting that week, and overall feeling nauseated. MDS/RN BB reported she had assessed Resident #56 a few times that week, and completed a significant change assessment, and progress note. MDS/RN BB reported on [DATE] CNA Y came to her (MDS/RN BB's) office and stated Resident #56 was not doing well at all. MDS/RN BB reported she went to Resident #56's room and noted was actively passing. Her (Resident #56) appearance was diaphoretic .sweaty, pale and was struggling to breathe. MDS/RN BB reported she appeared restless. MDS/RN BB stated, I felt she (Resident #56) needed something (roxinol and [MEDICATION(S)]) to make her (Resident #56) more comfortable and the nurse (agency) assigned to Resident #56 reported having given (Resident #56) her medications. MDS/RN BB reported she thinks the agency nurse at that time had said she contacted hospice and the family, or was in the process, the nurse was aware of Residents condition. MDS/RN BB reported the protocol for Resident #56's condition would have been to reach out to the affiliate hospice agency nurse, the facility physician and family. MDS/RN BB reported the hospice staff nurse would have immediately verbally ordered a medication to help Resident #56's pain and anxiety. MDS/RN BB reported there are always hospice medications in the back up boxes. MDS/RN BB reported when she saw her (Resident #56) she was only in Resident #56's room for a few minutes, and Resident #56 was uncomfortable. MDS/RN BB reported when she left Resident #56's room, she informed the agency nurse of Resident #56 condition and went to the morning meeting. MDS/RN BB reported she informed the Director of Nursing (DON) B of Resident #56's condition. MDS/RN BB reported Resident #56 passed during morning meeting Review of a Progress Note dated [DATE] at 16:15 MDS Note Text: (Resident #56) MDS Sig Change Interview, ARD [DATE]: Denies use of antianxiety and antipsychotic medication. Review of Resident #56's Hospice medications dated [DATE]: [MEDICATION(S)] 20 mg/ml give 0.25 ml every hour as needed for pain. & [DATE] [MEDICATION(S)] 0.4 mg every 4 hours (antinausea medication). Review of Residnet #56's Physicians Orders revealed: no roxinol or [MEDICATION(S)] ordered, no noted other pain medicaitons or anti-anxiety medicaions were ordered for Residnet #56 during the week of [DATE]-[DATE]. Review of Resident #56's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Meditation/Relaxation. 3) Positioning. 4) Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8)Social Interaction. as needed Document Non-Pharmacological interventions using the corresponding number.-Start Date-[DATE] -1739 PM . further review of this physician order, revealed on the MAR for the dates of [DATE]-[DATE] none of these interventions were checked in the box that the Physicians Order was provided. Review of Resident #56's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] =5 mg -Start Date- [DATE] 0257 (Discontinue)-D/C Date- [DATE]-1142 AM. further review of this physician order, revealed on the MAR for the dates of [DATE]-[DATE] .On [DATE] at 4:58 PM Resident #56 received MS 0.25 mg at 4:58 PM Resident did not receive another dose of MS 0.25 mg until nearly 24 hours later at 03:49 am. Resident #56 received another dose of MS 0.25 mg at 08:30 am. Review of Resident #56's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] &V (nausea-vomiting) -Start Date-[DATE] 2030 -D/C Date-[DATE] 1142 AM further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ., 4 mg of [MEDICATION(S)] . During an interview on [DATE] at 12:04 PM., Hospice Registered Nurse (H-RN) FF reported Resident #56 was admitted on [DATE] to Hospice. H-RN FF reported a notification came in on [DATE] in regards to Resident #56 passing away. H-RN FF reported the assigned hospice nurse went to the facility at approximately 10:30 AM., on [DATE]. H-RN FF reported their call log shows no incoming calls during the earlier hours. H-RN FF reported the last call to the hospice agency in regards to Resident #56 was placed on [DATE] which revealed a note reading: report a fall with no injuries transferring, she fell during reaching a call light. declined a visit. H-RN FF reported we like to make visits for any falls, but with Covid if no injuries or concern we do not go. H-RN FF reported we (hospice agency) should be called if anyone is in distress, that is what hospice is for. H-RN FF reported the pain medication should, and could have been given for every hour, we have nurses and on-call doctors can be called for anxiety. H-RN FF reported the Goal of hospice is to make sure the resident is comfortable, support staff, education, on call services for education, visits, medication, resources, help with the family. If someone is actively dying, we try to increase our visit at end of life. and checking in more. signs actively dying- determine when they are no longer talking, no eating, labored breathing, restlessness, terminal restlessness (some patients towards the end more distress, pain, breathing, their body fighting) if it is someone that can verbalize something going on. During an interview on [DATE] at 12:45 PM., Licensed Practical Nurse (LPN) I reported he worked the morning shift of [DATE] but was not assigned to Resident #56. LPN I reported he thinks it was an agency nurse. LPN I reported earlier in the week, and then again the day before ([DATE]) Resident #56 had been vomiting. LPN I reported he could at times hear Resident #56 crying out the morning of [DATE]. LPN I reported he was not on the unit Resident #56 was on, but down the hall. In an interview on [DATE] at 1:50 PM., Activity Aide (AA) H reported she was reported to work a little later that day. AA H reported she arrived at the facility after 9:,d+[DATE]:30 AM. AA H reported by the time she got into her office and set to do her morning duties, she was told Resident #56 had a rough night. AA H reported she was told by many staff that Resident #56 was crying out that morning for help. AA H reported once she was told Resident #56 had passed away, she (AA H) went to see what she could do to help. AA H reported she assisted CNA Y with getting Resident #56's room organized and things orderly for family. AA H reported when she arrived CNA Y was completing post-mortem care on Resident #56, so she waited until after that to assist with Resident #56's room. Resident #56 reported the morning of [DATE] after Resident #56 many staff were upset and reporting to me that they were concerned that Resident #56 was hollering out in pain, and crying for help. AA H reported many staff were visibly upset, crying as well as trying to maintain their composure while performing their daily work assignments. AA H reported Resident #56 had been sick earlier that week, and later in the day on [DATE] she had been turning her call light on and reporting she wanted to go to the hospital. AA H reported on [DATE] when Resident #56 requested to go to the hospital she (AA H) was getting to leave from her shift, the the nurse night shift (6:00 pm- 6:00 am) was in the room with Resident #56. AA H reported she is unsure what/if anything else happened throughout the night. AA H reported once she and CNA Y finished with Resident #56's room the morning of [DATE], Resident #56's family member came in. AA H reported she spoke with the family member briefly, and the family member was upset that no one had called her throughout the night or early morning hours of [DATE] when Resident #56 was crying out, and scared. During an interview on [DATE] at 2:48 PM., DON B reported she went to check on Resident #56 on [DATE] after 8:00 PM. DON B reported (Resident #56) stated I don't want the pain, I'm so confused.' DON B reported Resident #56 had been vomiting earlier in the week, and was having a [CONDITION(S)] (GI). DON B reported Resident #56 was having coffee ground emesiss (vomit that appears like coffee grounds-which is coagulated blood and stomach contents/secretions). DON B further reported Resident #56 repeated that she (Resident #56) doesn't want to be painful, her stomach was hurting. DON B reported Resident #56's appearance was pale, sweaty and fearful. DON B reported the morning of [DATE] she went to Resident #56's room and she had already passed away. DON B reported the hospice staff and family should have been contacted sooner, and Resident #56 could have been treated with other medications such as Roxinol and [MEDICATION(S)], to help make her more comfortable.

This citation has two (2) Deficiency Practice Statements (DPS) Deficient Practice Statement #1 Based on observation, interview, and record review, the facility failed to follow standard infection control practice per CDC (Centers for Disease Control) guidance for cohorting allowing for the spread of COVID-19 in 11 of 30 residents reviewed for infection control, resulting in an IJ (Immediate Jeopardy) when beginning on 5/15/2020 residents were improperly cohorted per CDC. In total, 25 residents tested positive for COVID-19 with three resident (3) deaths. This deficient practice placed all 69 residents residing in the facility at risk for serious harm and/or death. Findings include: On 1/14/2021 at 12:56 PM, the Corporate Clinical Consultant and Director of Nursing were notified verbally with the Nursing Home Administrator notified via email, of an Immediate Jeopardy that began on 5/15/2020 due to the facility's failure to effectively cohort per CDC guidance to prevent the spread of COVID-19. A written plan for removal for the immediate jeopardy was received on 1/14/2021 and the following was verified on 1/18/2021. 1. As of 1/15/2021, the roommates of positive guests (exposure/suspected guests) remain in 14-day contact and droplet isolation in their current rooms as to not further potentially expose any other guests by moving them throughout the facility. 2. Effective 1/8/2021, doors to COVID precaution rooms will remain closed unless there is a considerable safety risk for residents related to falls of which would be designated on the guest's care plan. 3. Beginning on 1/15/2021, suspected/presumptive guests will be isolated on the 100 center hall as a designated presumptive unit. This is where all new admission and readmissions will be until the central 300 Hall is no longer a Covid unit. The Covid 19 policy addresses placement of guests as new admission/readmissions, [MEDICAL TREATMENT], other outside visits. This policy was updated based on CDC and LARA guidance which allows for cohorting of guests if single rooms are not available. 4. The facility had one (1) guest on isolation/quarantine precautions due to being new or readmission to the facility. This one (1) guest remains asymptomatic and precautions are in place due to readmission status. 5. The facility has four (4) residents who are in isolation for [MEDICAL TREATMENT] and doctor appointments. Beginning 1/15/2021, these guests will be located in the 100 Center Hall, and all are free from Covid-19 symptoms, until the 300 Central Hall is no longer needed as a Covid-19 unit. 6. Currently no [MEDICAL TREATMENT], physician appointments or [MEDICAL CONDITION] persons are cohorting. 7. Beginning in April 2020 with frequent updates, residents are placed in rooms and cohorted, or not, based on the facility policy which follows CDC (Centers for Disease Control) and LARA (Licensing and Regulatory Affairs) guidance. 8. As of 11/10/2020, [MEDICAL TREATMENT] residents who go to the same clinic are cohorted, those who do not are left in rooms by themselves. Each situation is evaluated for risk and room placement is decided on the risk factors. 9. On 1/14/2021 by 8:00 PM, the remaining 29 guests in the facility that are not currently on the Covid-19 unit were evaluated by the nurses for signs/symptoms of COVID-19 with no noted symptomatic guests. If a guest shows any symptoms, a POC (point of care) test is done and if positive they are moved to the Covid-19 unit. If they have a roommate, the roommate remains in the room alone and is monitored tid (three times a day) for fourteen days. Testing continues per CMS (Centers for Medicaid and Medicare), CDC (Centers for Disease Control), and MDHHS (Michigan Department of Health and Human Services) guidance until 14-days have passed without any new positive cases. 10. On 1/18/2021 at midnight, all guests in the facility who are Covid-19 positive and not recovered or who have been exposed or who are in isolation have been placed on TID (three times a day) monitoring signs and symptoms of COVID-19, including vital signs, to increase monitoring of their status due to alleged potential for exposure. 11. On 1/15/2021, the DON (Director of Nursing) and QAPI (Quality, Assurance, Performance Improvement) team members reviewed the infection control policy regarding COVID-19 and Covid-19 today (1/18/2021) and deemed it appropriate, which included: (a) Droplet/contact isolation precautions (b) Dedicated units, isolation units, room placements based on CDC and LARA guidance (c) PPE (personal protection equipment) requirements and proper storage (d) Social distancing (e) Disinfection products (e) Mask use by housekeeping and others 12. On 1/15/2021 the DON and QAPI team members met and reviewed the Positive COVID-19 and Bed Management Decision Trees and deemed them to still be appropriate. The policy addresses the (quarantine) isolation (droplet/contact precautions), and monitoring guests for signs and symptoms of COVID-19 as identified by the CDC every day. The Medical Director was sent the information reviewed during the QAPI meeting via email. The room placement part of the Covid-19 policy was updated after LARA gave additional guidance November 2020. 13. On 1/14/21, the RCC (Regional Clinical Consultant) educated the DON, Administrator (by Phone) at the time the IJ (Immediate Jeopardy) was issued a. The quarantine/isolation policy for COVID positive guests, admissions/readmissions and those going out to appointments using the Covid-19 today tool, Covid-19 policy and BCHS/LARA Guidance issued on 11/10/2020. Although the immediate jeopardy was removed as of 1/15/2021, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because not all facility staff have received education and sustained compliance had not been verified by the State Agency. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance Preparing for COVID-19 in Nursing Homes, updated 11/20/20, revealed .Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 .As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP) .Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19 .Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing .Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them) .Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19 . Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility with dedicated HCP . Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Review of the Centers for Disease Control and Prevention (CDC) guidance Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/20, revealed .Resident Cohorting .Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 .Determine the location of the COVID-19 care unit before residents or HCP with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit .Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19 .Depending on facility capacity (e.g., staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms .Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19 . Resident with new-onset suspected or confirmed COVID-19 .Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing .Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit) .If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit .Maintain Transmission-Based Precautions for all residents on the unit at least until there are no additional clinical cases for 14 days after implementation of all recommended interventions . Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html Review of facility policy Novel Coronavirus Prevention and Response date reviewed/revised .12/20, revealed, Policy: This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of [MEDICAL CONDITION] .5. Interventions to prevent the introduction of respiratory germs into the facility .d. Consider designated wing/unit or a private room to accept new residents. Refer to the CDC guidance on observation for new admissions .7. Procedure when COVID-19 is suspected or confirmed .l. Minimize room transfers .11. Considerations for admitting residents with suspected or confirmed COVID-19, a. Maintain situational awareness of COVID-19 in the community and impact on hospital capacity. Prepare to create separate wings, units, or floors by moving current residents to handle hospital admissions, i. If there is no suspected or confirmed COVID-19 cases in the facility, do not admit until the resident has recovered, ii. If the facility currently has suspected or confirmed COVID-19 cases, admit to a private room on transmission-based precautions or cohort in rooms with other COVID-19 patients. Do not admit if the facility is unable to meet the level of care needs or the requirements for transmission-based precautions . During an interview on 1/13/2021 at 3:30 PM, Director of Nursing (DON) B stated, I have been in contact with our local health department ((LHD) V). When the facility put together the Covid-19 emergency plan, there was a virtual meeting with (LHD V, LHD Corporate supervisor W, the facility's interim NHA) and me. During that meeting (LHD W) said it was okay to co-hort residents with closet dates of suspected exposure. I did the initial Covid-19-unit set-up when the outbreak started. I could not get ahold of (LHD V) regarding co-horting so I went with facility's emergency plan. My last few contacts with the LHD were 1/8, 1/9, 1/10, and 1/13/2021. During an interview on 1/21/2021 at 8:12 AM Local Health Department (LHD) V stated, I am the CD (communicable disease) nurse for the health department. I believe I may have had a conversation with the DON at the beginning of Covid-19 and reviewed what the facility was doing to do if they had an outbreak. The facility had a plan and I thought it sounded good. I do not remember what the facility's plan was for cohorting. It was a brief call and thought it would be followed up on and maybe it was not. My co-worker is the one that talks to the facilities about setting up for Covid-19. She is out and will try to contact you. At the time of exit on 1/21/2021, further attempts to contact the LHD were made on 1/21/2021 at 9:00 AM with answer and no return call was made from the local health department. Resident #112 Review of a Face Sheet revealed Resident #112 was a [AGE] year-old female, readmitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Resident #113 Review of a Face Sheet revealed Resident #113 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an interview on 1/14/2021 at 11:15 AM, DON B stated, (Resident#112) was in isolation due to outside appointments with the wound clinic and (Resident #113) went outside the facility to [MEDICAL TREATMENT]. The two residents should not have been roomed together because (Resident #112's)[MEDICAL CONDITION] could be cross-contaminated to (Resident #113) by any type of infection control breech. Both residents were on transmission-based isolation precautions because they were to appointments outside of the facility. During an interview on 1/14/2021 at 12:30 PM DON B stated, (Resident #112) was moved to another room today because she has E.coli (bacterium) in her urine and her roommate is on [MEDICAL TREATMENT]. They are both on isolation. (Resident #112) went to outside appointments to the wound clinic and her roommate goes to [MEDICAL TREATMENT]. They were placed together and should not have been. During an interview on 1/14/2021 at 12:50 PM, Corporate Clinical Consultant (CCC) BB stated to DON B and surveyors, Corporate made it very clear to you that the isolation residents could not be co-horted; like the new admit and readmitted residents in with the appointment residents (referring to residents going to outside facility appointments). If new admit and re-admit residents were one-day apart coming into the facility, they could be co-horted. DON B stated, The facility was bed-locked, and the facility accepted re-admissions and new admissions. The facility had no other place to put them except together. CCC BB stated, Policy states you can only co-hort if admissions were one-day apart. Review of facility policy Pandemic Episode date 6/8/2020, revealed, .Management of Confirmed or Suspected Pandemic Illness in Resident/Guests .Containment .A private room is preferred whenever possible. If a private room is not available, cohort the resident/guest with a similar resident/guest. Consideration should be given to the length of time the confirmed pandemic illness resident/guest has been with their roommate. Relocation may not contain the exposure and could actually exacerbate the exposure . During an interview on 1/19/2021 at 4:45 PM Nursing Home Administrator (NHA) A stated, I was not involved with the bed assignments of co-horting new and re-admissions. That was the DON's decision. During an interview on 1/19/2021 at 5:00 PM DON B stated when asked why the new and re-admits were continued to be admitted while the facility was bed-locked, Before Covid-19 and during the facility's outbreak of Covid-19, beds and rooms were available to take in the admits on the isolation hall but no rooms were available in the general population. IDT (Interdisciplinary Team ) meets in the morning and consists of the heads of the clinical departments, Therapy, Admissions, DON, NHA, Activities, and Social Work. The Clinical department Heads discuss possible admits and where best to place them. If an admit comes to the facility with something we didn't know about the IDT will adjust the room placement. Sometimes the hospital is not completely honest about the resident and that initiates the room adjust when they arrive to the facility. On weekends and holidays there is a Weekend Manager that is on a rotating schedule. If there is an admit during that time, admissions, the manager, or the nurse will call be and we discuss the best room placement for the resident. Sometimes we ask the hospital to hold the resident until the next day. I am highly involved but not the only one that makes the bed placement decisions. The facility's Bed Management plan is a decision tree that the facility follows too place admits. It is in the Covid-19 policy. Review of the Covid-19 Bed Management Decision Tree dated 5/29/2020 revealed, .Guest/Resident Presentation New Admission/Readmission .New Admission/Readmission: The facility must consider all of the items below before making an admit/readmit decision: -The facility has sufficient PAR levels of PPE to place the new guest/resident in contact and droplet isolation for 14-days. (masks, gowns, eye protection, gloves) -The facility has sufficient staff to provide care and support services -Able to isolate the guest/resident appropriately . -There is an appropriate room for placement -Approval from the RDO/RCC (corporate) obtained by facility if admission/readmission is denied If the facility cannot take a readmission due to the above criteria, notify the referral source as to the reason why AND document the reason. Review documented reason during the facility's monthly QA (Quality Assurance) Meeting . Resident #110 Review of a Face Sheet revealed Resident #110 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 9/14/2020, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #110 was cognitively intact. Further review of the MDS indicated the resident required [MEDICAL CONDITION] care (a [MEDICAL CONDITION] is a surgical procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway in the trachea. A tube is placed in the trachea to allow the person to breathe). Resident #119 Review of a Face Sheet revealed Resident #119 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 5/7/2020 (Resident #110) had to be sent out to the ER to have his [MEDICAL CONDITION] (trach) put back in due to breathing problems and was re-admitted on [DATE]. He was placed in an isolation room for 14-days by himself. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 5/15/2020, (Resident #110) was moved in with (Resident #119) who was not on isolation precautions. (Resident #119's) guardian, stated it was okay for him to be roomed with (Resident #110) because she did not want (Resident #119) to be moved out of his room. The facility had to move (Resident #110) out of his room due to four (4) female residents needing his room and the attached suite room that shared a bathroom. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 5/15/2020, (Resident #110) was on his seventh (7th) day of his 14-day isolation. On (Resident #110's) 14th day of isolation he and (Resident #119) were taken off isolation. In hindsight (Resident #119) should have stayed in isolation for 14-days because he was presumptively exposed to (Resident #110). At that time, I was not the DON and do not know why the decision was made that way. Resident #114 Review of a Face Sheet revealed Resident #114 was a [AGE] year-old male, readmitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Resident #121 Review of a Face Sheet revealed Resident #121 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Resident #122 Review of a Face Sheet revealed Resident #122 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 6/30/2020 (Resident #110) was moved in with 3 other residents, (Residents #114, #121, and #122). None of the residents at that time, including (Resident #110) were on isolation precautions. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 8/27/2020 (Resident #110) went out of the facility to a dental appointment and returned to the same room with the same three (3) roommates. Since (Resident #110) had left the facility he was assumed presumptive and placed on isolation precautions. (Residents #114, #121, & #122) were presumptively exposed and placed on isolation precautions as well only due to their exposure to (Resident #110). At that time, the back hall was the facility's designated 14-day isolation hall and the only other residents to put (Resident #110) in with [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) infection in their wounds). During an interview on 1/20/2021 at 12:13 PM DON B stated, On 8/27/2020 the facility's census was 73 with 87 rooms. Eight (8) rooms were being painted and refurbished. There were 24 full rooms, five (5) that had resident with infections, two (2) rooms that had residents with behaviors that could not have a roommate. There was a room that an available be but there was a female resident occupying it and she was going out of the facility to appointments. The remaining beds/rooms were occupied by female residents, with one (1) bed available for a female resident. New female admissions were coming in the next few days and rooms were needed. I was the DON and in hindsight I should have held off on the new female admissions and moved one of the female residents to make room for (Resident #110). During an interview on 1/20/2021 at 12:13 PM DON B stated, On 9/10/2020, (Residents #110, #114, #121, & #122) were off the 14-day isolation precautions and moved together into a quad room that was off the isolation unit. Resident #130 Review of a Face Sheet revealed Resident #130 was a [AGE] year-old male, readmitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 9/14/2020 (Resident #114) went out of the facility for an appointment. Upon his return he was placed on 14-day isolation precautions and moved in with (Resident #130). (Resident #130) was admitted on [DATE], four (4) days prior and was on 14-day isolation precautions. (Resident #130) completed his 14-day isolation precautions on 9/24/2020. (Resident #130) should have been moved to another room to avoid extending isolation precautions due to being presumptively exposed by (Resident #110) who had had several appointments out of the facility during their time rooming together. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 9/24/2020 (Resident #110) went out of the facility for an appointment and placed back in with (Resident #130) who was no longer on isolation precautions causing him to be presumptively exposed. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 10/9/2020 (Resident #110) went out of the facility for an appointment and placed back in with (Resident #130) who was no longer on isolation precautions causing him to be presumptively exposed. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 10/11/2020 (Resident #110) went out of the facility for an appointment and placed back in with (Resident #130) causing (Resident #130) to be presumptively exposed. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 10/22/2020 (Resident #130) was sent to the hospital and re-admitted on [DATE] back in with (Resident #110). (Resident #110 and Resident #130) should not have been moved back in together because their 14-day isolation dates were not the same and they were presumptively re-exposing each other. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 10/30/2020 (Resident #110) went out of the facility for an appointment and placed back in with (Resident #130) causing (Resident #130) to be presumptively exposed. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 11/4/2020 (Resident #110) went out of the facility for an appointment and placed back in with (Resident #130) causing (Resident #130) to be presumptively exposed. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 11/9/2020 (Resident #130) was discharged from the facility. Resident #105 Review of a Face Sheet revealed Resident #105 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with pertinent [DIAGNOSES REDACTED]. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 11/16/2020 (Resident #105) was re-admiited from the hospital [MEDICAL CONDITION] and was placed in with (Resident #110). (Resident #105) prior to his hospitalization was on contact precautions [MEDICAL CONDITION] in wounds and came back on droplet and contact isolation precautions. (Resident #110) had [MEDICAL CONDITION] was on with (Resident #110) who had [MEDICAL CONDITION] it would made (Resident #110's)[MEDICAL CONDITION] susceptible to acquiring an infection. (Resident #110) stayed in room with (Resident #105) anticipating more appointments. Resident #131 Review of a Face Sheet revealed Resident #131 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. On 1/15/2021 the resident was diagnosed with [REDACTED]. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 12/1/2020 (Resident #105) moved in with (Resident #131) who was admitted [DATE]. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 12/10/2020 (Resident #110) went out of the facility for an appointment and came back to his room with no roommate. Resident #120 Review of a Face Sheet revealed Resident #120 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 12/16/2020 (Resident #120) went out of the facility for an appointment and moved in with (Resident #110) six (6) days into (Resident #110's) 14-day isolation precautions potentially re-exposing him. This room change happened because two (2) residents from the facility's assisted-living area moved into the facility due to positive COVID-19 results and the facility had to make a COVID-19 unit. This took rooms away from the long-term care residents. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 12/23/2020 (Resident #110) was sent to the ER and returned to room with (Resident #120) and re-exposing (Resident #120). The facility did not move either (Resident #110 or Resident #120) because the facility was still tight (referring to room availability) with two (2) assisted-living residents on the Covid-19 unit, residents going out of the facility for [MEDICAL TREATMENT] appointments, and rooms with just female residents who had outside appointments for [MEDICAL TREATMENT] or wound care. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 12/29/2020 (Resident #110) went out of the facility for an appointment and placed back in with (Resident #120) causing (Resident #120) to be presumptively exposed. The facility had empty rooms and there was no reason for (Resident #110) to go in with (Resident #120) and re-exposing him. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 1/5/2021 (Resident #105) was sent to ER and re-admitted on [DATE] on contact and droplet isolation precautions to a room with no roommate. During an interview on 1/20/2021 at 12:13 PM DON B stated, On 1/8/2021 (Resident #110) was moved in with (Resident #105). There was no reason for (Resident #105 and Resident #110) to be moved in together. Deficiency Statement #2: Based on interview, observation, and record review, the facility failed to adhere to professional standards to properly maintain infection control practices during a COVID-19 Focused Infection Control Survey related to proper 1) hand hygiene, 2) proper personal protective equipment use, 3) proper disposal of biohazard waste and linens, and 4) sanitization of shared equipment 5) appropriate concentration of disinfectant for 7 of 30 residents (Resident #105, #109, #110, #112, #117, #123, #127) reviewed for infection prevention, resulting in the increased potential for cross-contamination, bacterial harborage, and placing a vulnerable population at high risk for the transmission of COVID-19 and other pathogenic organisms. 1) Hand Hygiene: Review of policy Coronavirus (COVID 19) dated 10/6/2020 revealed, .Core Principles of COVID-19 Infection Prevention .Hand hygiene .cleaning and disinfecting high frequency touched surfaces in the facility often, and designated visitation areas after each visit .appropriate staff use of Personal Protective Equipment (PPE) .effective cohorting of guests/residents (e.g., separate areas dedicated COVID-19 care) . Review of policy, Hand Hygiene revised on 9/2019, revealed, .To decrease the risk of transmission of infection by appropriate hand hygiene .Hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections. According to the CDC (Centers for Disease Control), COVID-19 Healthcare Quality and Worker Safety Information, May 18, 2020, at https://www.cdc.gov/handhygiene/providers/index.html, revealed, Healthcare Providers . When and How to Perform Hand Hygiene . Multiple opportunities for hand hygiene may occur during a single care episode . Use an Alcohol-Based Hand Sanitizer immediately before touching a patient . before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, and after contact with blood, body fluids or contaminated surfaces. Wash with Soap and Water when hands are visibly soiled . Glove Use When and How to Wear Gloves Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. Change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs . Resident #109: Review of an Admission Record revealed Resident #109 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an ob (TRUNCATED)

This citation pertains to intake #: MI 982, MI 989, MI 999 Based on interview and record review, the facility failed to 1.) properly assess a resident with wound and identify a change in condition and 2.) notify the physician of an acute change in condtion for 1 of 8 residents (Resident #103) reviewed for quality of care, resulting in an immediate jeopardy when, beginning on 9/2/19, facility staff did not perform a comprehensive assessment on a wound and promptly notify the physician of an acute change in the wound. This deficient practice placed all residents at risk for serious harm, injury and/or death. On 12/11/19 the Administrator was verbally notified and received written notification of the immediate jeopardy that was identified on 12/11/19 due to the facility's failure to perform a comprehensive assessment on a wound and promptly notify the physician of an acute change in the wound. A written plan for removal for the immediate jeopardy was received on 12/11/19 and the following was verified on 12/11/19: The (facility) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy to resident health and safety identified by the survey team regarding the facility's alleged failure to adequately assess, document and identify critical changes to a vascular, diabetic wound for one resident. 1. Resident #103 no longer resides in the facility. 2. On 12-11-19 Director of Nursing/Designee assessed 9 out of 9 residents with wounds to ensure no acute change in condition occurred. Identified concerns were addressed immediately. 3. On 12-11-19 Director of Nursing/Designee began re-educating at 2:15pm with 5 out of 5 Licensed Nurses currently working, regarding Acute Change in Condition, Skin and Wound Program, Assessing wounds for change in condition, documentation and timely notification to medical provider and responsible party. The remaining 10 out of 15 Licensed Nurses will be re-educated by the Director of Nursing/Designee prior to the start of their next scheduled shift. 4. On 12-11-19, the QA reviewed the Skin and Wound Program, and the Acute Change of Condition Policy and they were deemed appropriate. 5. New Licensed Nurse orientation will continue to include Acute Change in Condition, Skin and Wound Program, Assessing wounds for change in condition, documentation and timely notification to medical provider and responsible party. 6. Director of Nursing/Designee will review guests with increase in pain, wounds that are not improving, any signs of change in condition for appropriate follow up during daily clinical meeting Monday through Friday. 7. Medical Director was notified of the Immediate Jeopardy F 684 by the Administrator on 12/11/19 at 2:50 pm with a discussion on the removal plan. An Adhoc QA meeting was held on 12/11/19 to discuss the Immediate Jeopardy and removal plan. 8. Director of Nursing/Designee will audit guests with wounds weekly times 4 weeks, then monthly times 3 months to ensure staff are following skin and wound program, identifying change of condition, appropriately documenting and physician/responsible party notification. 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 12/11/19, the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency. Findings include: Review of the facility policy, Change in status, identifying and communicating, long-term care last reviewed 6/14/19 revealed, Identify a suspected acute change in the resident. Review the resident's medical record, including .health history .Communicate the change in the resident's condition to the appropriate practioner. Notify the resident's family about the change in the resident's condition and the subsequent treatment plan. Implement the treatment plan or initiate the resident's transfer to another health care facility. Document the procedure. Review of Fundamentals of Nursing (Potter and Perry) revealed, Interdisciplinary communication among members of the health care team is essential, and the medical record is one tool that supports and facilitates that communication .To keep medical records accurate, any change in a patient's condition warrants immediate documentation about the event and the action that was taken to address the change. Potter, [NAME] [NAME]; Perry, Anne Griffin; Stockert, [NAME]; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing (Potter and Perry) revealed, Inspect the lower extremities for changes in color, temperature, and condition of the skin, indicating either arterial or venous alterations (Table 31-25). This is a good time to ask the patient about any history of pain in the legs. If an arterial occlusion is present, the patient has signs resulting from an absence of blood flow. Pain is distal to the occlusion. The five Ps- pain, pallor, pulselessness, paresthesias, and paralysis- characterize an occlusion. Potter, [NAME] [NAME]; Perry, Anne Griffin; Stockert, [NAME]; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #103 Review of a Face Sheet revealed Resident #103 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #103's Care Plan revealed, (Resident #103) has Venous/Stasis injury r/t (related to) [MEDICAL CONDITION] of top right foot Date Initiated: 08/26/2019 Created on: 08/26/2019 .Treatment to injury per physician's order. Date Initiated: 08/26/2019 Created on: 08/26/2019 .Observe and report to physician PRN (as needed) for s/sx (signs and symptoms) of infection: Green drainage, Foul odor, Redness and swelling, Red lines coming from the wound, Excessive pain, Fever. Date Initiated: 08/26/2019 Created on: 08/26/2019 .Evaluate wound for .infection, necrosis .gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. Date Initiated: 08/26/2019 Created on: 08/26/2019 Review of Resident #103's Care Plan revealed, (Resident #103) is at risk for fluctuation in blood sugar levels R/T: DM2 (diabetes type 2), requires insulin Date Initiated: 07/15/2019 Created on: 07/15/2019 Revision on: 07/15/2019 . Provide proper foot care as needed. Observe for changes in circulation. Observe for changes in skin integrity to the feet. Document findings and report and abnormal findings to the physician. Podiatry consult as needed. Date Initiated: 07/15/2019. Review of Resident #103's Care Plan revealed, (Resident #103) has [MEDICAL CONDITION] infection of the RLE (right lower extremity) Date Initiated: 07/23/2019 Created on: 07/23/2019 Revision on: 08/26/2019 [MEDICAL CONDITION] infection will resolve and skin heal by review date. Date Initiated: 07/23/2019 Created on: 07/23/2019 Revision on: 08/26/2019 Observe and document healing of the [MEDICAL CONDITION]. Any new or worsening symptoms identified report to the physician Date Initiated: 07/23/2019 Created on: 07/23/2019 Revision on: 08/26/2019 Observe affected area for increased Redness, swelling, warmth, tenderness/pain, hardness the area, and or foul drainage. Report abnormal findings to the physician. Date Initiated: 07/23/2019 Created on: 07/23/2019. Review of Resident #103's Skin & Wound Evaluation dated 8/5/19 revealed, 1. Type Blister .22. Location Dorsum Right Foot 23. Acquired: In-House Acquired 24. How long has the wound been present? Exact Date: 8/5/19 .2. Length 3.1 cm (centimeters) 3. Width 2.7 cm 4. Depth Not Applicable .10. Notes on Pain: guest noted to complain of 10/10 pain on consistant (sic) bases .Notifications: 5. (blank) Practitioner Notified 6. (blank) Resident/Responsible Party Notified: 7. (blank) Dietician Notified 8. (blank) Therapy (PT, OT, ST) Notified. This report did not indicate the status of Resident #103's pedal (foot) pulses. Review of Resident #103's Skin & Wound Evaluation dated 8/12/19 revealed, 1. Type Blister .22. Location Dorsum Right Foot 23. Acquired: In-House Acquired 24. How long has the wound been present? Exact Date: 8/5/19 .2. Length1.9 cm 3. Width 2.3 cm 4. Depth Not Applicable .10. Notes on Pain: Guest will c/o (complain of) pain on any body part barely touched .Notifications: 5. (blank) Practitioner Notified 6. (blank) Resident/Responsible Party Notified: 7. (blank) Dietician Notified 8. (blank) Therapy (PT, OT, ST) Notified. This report did not indicate the status of Resident #103's pedal pulses. Review of Resident #103's radiology exam Duplex Lower Extremity Arterial Unilateral dated 8/13/19 revealed, Reason for Study: [MEDICAL CONDITION] OF NATIVE ARTERIES OF EXTREMITIES WITH REST PAIN, RIGHT LEG .Conclusion: Moderate [MEDICAL CONDITION]. Review of Resident #103's Skin & Wound Evaluation dated 8/19/19 revealed, 1. Type Venous .22. Location Dorsum Right Foot 23. Acquired: In-House Acquired 24. How long has the wound been present? Exact Date: 8/5/19 .2. Length 6.7 cm 3. Width 4.4 cm 4. Depth Not Applicable .9. Pain Frequency: None .Progress: Improving .Notifications: 5. (blank) Practitioner Notified 6. (blank) Resident/Responsible Party Notified: 7. (blank) Dietician Notified 8. (blank) Therapy (PT, OT, ST) Notified. This report did not indicate the status of Resident #103's pedal pulses. Review of Resident #103's Skin & Wound Evaluation dated 8/26/19 revealed, 1. Type Venous .22. Location Dorsum Right Foot 23. Acquired: In-House Acquired 24. How long has the wound been present? Exact Date: 8/5/19 .2. Length 1.5 cm 3. Width 1.5 cm 4. Depth Not Applicable .Evidence of Infection: None .4. [MEDICAL CONDITION] 1. No swelling or [MEDICAL CONDITION] .6. Periwound Temperature Normal .Pain Frequency: Intermittent .Progress: Improving .2. Infection 1 MD/Provider diagnosed infection (blank) 2. Suspected Infection (blank) . Notifications: 5. (blank) Practitioner Notified 6. (blank) Resident/Responsible Party Notified: 7. (blank) Dietician Notified 8. (blank) Therapy (PT, OT, ST) Notified. This report did not indicate the status of Resident #103's pedal pulses. Review of Resident #103's physician progress notes [REDACTED]. And from the staff report there was a a large macerated area from her broken blister that covered half of her dorsal part of her foot and the tops of her toes. The majority of this is now a (sic) dryer. However, It is very red, warm, swollen, and painful. I will start her on antibiotics for [MEDICAL CONDITION] .Currently, her right foot is extremely painful .Seen today to assess right foot with increased pain and redness, and warmth. (sic) Review of Resident #103's Skin & Wound Evaluation dated 9/2/19 revealed, 1. Type Venous .22. Location Dorsum Right Foot 23. Acquired: In-House Acquired 24. How long has the wound been present? Exact Date: 8/5/19 .2. Length 12.1 cm 3. Width 6.7 cm 4. Depth Not Applicable .4. [MEDICAL CONDITION] 1. No swelling or [MEDICAL CONDITION] .6. Periwound Temperature Normal .Pain Frequency: At Dressing-and periodically throughout day or with ADLs (activities of daily living) Progress: Deteriorating .2. Infection 1 MD/Provider diagnosed infection (blank) 2. Suspected Infection (blank) . Notifications: 5. (blank) Practitioner Notified 6. (blank) Resident/Responsible Party Notified: 7. (blank) Dietician Notified 8. (blank) Therapy (PT, OT, ST) Notified. This report did not indicate the status of Resident #103's pedal pulses. Review of Resident #103's progress notes revealed no documentation that the provider was notified of the worsening of the wound. Review of Resident #103's Change in Condition Evaluation dated 9/3/19 revealed, 1. The change in condition, symptoms or signs I am calling about is/are: Other change in condition-family request .Since the change in condition occured have the symptoms or signs gotten-Stayed the same .Summarize your observations, evaluations and recommendations: none. Review of Resident #103's Transfer Notice dated 9/3/19 revealed, Reason for Transfer-family request for Rt (right) foot wound. Review of Resident #103's Progress Note dated 9/3/19 revealed, Guest sent out to hospital per guardians request, (ambulance service) picked up guest @ 315pm bring her to (name omitted) hospital. Review of Resident #103's Hospital Record dated 9/3/19 revealed, Chief Complaint: Foot Injury .ED (emergency department) Disposition-admitting [DIAGNOSES REDACTED].(Resident #103) has had worsening progression of the ulcers on her right foot with some associated necrotic appearance to the base of the foot with poor perfusion distally to the great toe .she has nonpalpable pulses clinically or by Doppler .She has new black scarring spots to her foot that developed about three days ago .Musculoskeletal: Positive for joint pain (right foot) and joint swelling (right foot). Skin: Positive for color change and new spots .Significant ulceration to right great toe approximately 2 cm x 3 cm covering full anterior first MT (metatarsal) joint to nail bed with blue discoloration of toe distally. A second ulcer that appears necrotic at the proximal base of 2nd toe that is approximately 2.5 cm x 1.5 cm with associated [MEDICAL CONDITION]. Both also have a necrotic base to them .was brought in today to the emergency department by family for right foot [MEDICAL CONDITION] and black discoloration.Vascular Surgery Brief Operative Note Date: 9/6/2019. Pre-Op Diagnosis: [REDACTED].Active Hospital Problems: Gangrene of right foot. Review of Resident #103's Hospital Wound Consult dated 9/4/19 revealed, Reason for Consult: Right foot gangrene .Painful, ischemic foot. During an interview on 12/10/2019 at 2:22 P.M., Family Member (FM) V reported that she was unaware of the worsening of Resident #103's wound. FM V reported that on 9/3/19 she could smell a foul odor coming from Resident #103 and upon further investigation found that Resident #103's right foot was oozing from the bandage. FM V removed the bandage and found it (right foot) black. FM V stated, We demanded (Resident #103) go to (the hospital) for treatment of [REDACTED]. During an interview on 12/12/2019 at 2:22 P.M., Licensed Practical Nurse (LPN) GG reported that if a wound worsens or there are any types of concerns with the wound, the physician should be notified immediately. LPN GG reported that a progress note is written after the physician is notified to ensure other facility staff are aware of the treatment plans and concerns. LPN GG reported that if she found that a wound worsened, there was a change in the color of the skin, and/or the resident did not have palpable pulse, she would notify the physician immediately. During an interview on 12/11/2019 at 9:48 [NAME]M., Assistant Director of Nursing (ADON) D reported that pedal pulses should have been assessed on the weekly wound assessments. ADON D reported that the expectation of the nursing staff in the facility was to notify the provider when there was a change in the condition of the wound. During an interview on 12/11/2019 at 9:51 [NAME]M., Nurse Practitioner (NP) DD reported that on her last observation of Resident #103's wound on 8/26/19, Resident #103's skin had redness surrounding the wound. NP DD started Resident #103 on an antibiotic for the appearance of an infection. NP DD and this writer reviewed the picture documentation of Resident #103's wound progression. NP DD reported that she could see a significant change from the wound picture on 8/26/19 and the picture on 9/2/19. NP DD reported that with the change in the appearance of the wound she would have expected a phone call/notification from facility staff on 9/2/19. NP DD reported she had not had any phone calls or concerns brought to her attention from facility staff regarding Resident #103's wound. NP DD reported that she had not been notified of any concerns until 9/3/19 when she received a phone call from facility staff that the guardian of Resident #103 was demanding that Resident #103 be sent to the emergency department for the evaluation of the wound on the right foot. NP DD reported that in order to perform her job she relies on staff to notify her of any changes in a resident's condition. NP DD reported that standard of practice for notification of change is the expectation for the licensed nursing staff in the facility.

This citation pertains to Intake # MI 574. Based on observation, interview, and record review, the facility failed to provide adequate supervision and complete 15-minute checks to prevent an elopement and ensure safety in 1 of 5 residents (Resident #101) reviewed for safety/supervision, from a total sample of 7, resulting in an Immediate Jeopardy when on 8/16/19 between 4:30 p.m. and 5:00 p.m., Resident #101 exited the facility, unbeknownst to facility staff, and was found by a community member approximately 1.1 miles away after sustaining a fall near the railroad tracks. The resident was returned to the facility via car by a community member at approximately 5:00 p.m. This deficient practice placed 14 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of a facility document titled Guest Location Visual Check/15 Minute, no date, revealed .Upon admission the licensed nurse completes a risk for elopement assessment to identify if guest is at risk. If it is determined that a guest is at risk, a wander guard will be placed on a guest as the guest will allow. A risk for elopement assessment is also completed quarterly with the Quarterly Nursing Comprehensive Evaluation .When a guest will not allow a wander guard to be placed, other interventions may be utilized such as Guest Location Visual Checks or monitoring .Guest Location Visual Checks are to be completed by the CNA (Certified Nursing Assistant) assigned to the guest. If the assigned CNA is unable to complete them, they are to notify the charge nurse, and insure (sic) that a fell ow co-worker can complete them .If a guest begins to show signs of exit seeking or wandering a Stop and Watch should be initiated and the licensed nurse is to be notified immediately . Review of an Admission Record 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 6/27/19, revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #101 had moderately impaired cognition. Review of a Care Plan for Resident #101, initiated 12/10/18, revealed .is at risk for exit seeking R/T (related to): Wandering, impaired cognition secondary to ETOH (alcohol use) with Wernicke's [MEDICAL CONDITION] (a neurological condition which can impair coordination and cause confusion), dementia, anxious/restless at times (Resident #101) will not allow wanderguard placement . Review of a Care Plan for Resident #101, initiated 12/17/18, revealed .has a actual behavior problem R/T: -Dx (diagnosis) of depression -Hx (history) of yelling at staff -Hx of becoming easily irritable -Hx of unplugging roommates belongings -Cognitive impairments -Hx of choosing to not follow plan of care -Hx of calling family repeatedly throughout the day . with interventions which included .15 minute checks . initiated 7/29/19. Review of a Nursing Comprehensive - Quarterly assessment for Resident #101, dated 6/11/19, revealed .Elopement Risk .Mobile with a device or Ambulatory .Placement Perception .Verbalizing desire to leave . Per the assessment, Resident #101 was identified as At Risk for elopement. Review of an Order Summary Report for Resident #101, revealed a physician order [REDACTED]. Review of a nursing Progress Note for Resident #101, dated 8/16/19 at 5:45 p.m., revealed .Guest returned to facility at 5pm, last seen 4:30pm. (Director of Nursing (DON) B) notified 5:05pm . Review of a nursing Progress Note for Resident #101, dated 8/16/19 at 7:39 p.m., revealed .At approximately 5:00pm on 8.16.2019 a male person brought (Resident #101) to the facility in his personal car. The male stated he observed (Resident #101) approximately 1.1 miles from the facility near the railroad tracks in (city facility located in) on the ground, he assisted (Resident #101) into his car and drove to the facility. He notified (Facility Name) staff and assisted (Licensed Practical Nurse (LPN) T), (Ancillary Clerk H) and (Certified Nursing Assistant (CNA) I) and (Unit Manager AA) with (Resident #101) out of his car. (Resident #101) was asked what he was doing, he stated he was going for a jog. (LPN T) asked him if he signed out and he state (sic) he didn't know if he signed out and says he thought someone did but didn't know. (Resident #101) was wearing athletic shorts, a t-shirt and his velcro tennis shoes. The temperature was approximately 78 degrees. (Resident #101) was placed on 1 on 1 supervision immediately upon return to the facility. A head to toe assessment was completed and documented in the electronic health record . Review of a nursing Progress Note for Resident #101, dated 8/16/19 at 5:15 p.m., revealed .Attempted to place wander guard, Guest became physically aggressive shaking fist in this nurses face . Review of a nursing Progress Note for Resident #101, dated 8/16/19 at 5:20 p.m., revealed .This nurse assessed head to toe, found multiple abrasions. No c/o (complaints of) pain at this time . Review of a Facility Past Non Compliance Report, dated 8/19/19, revealed .On 8.16.2019 (Resident #101) exited the facility via the main dining room door, facility staff missed 4:45pm guest location visual check .At approximately 5:00pm on 8.16.2019 a male from the community brought guest, (Resident #101), back to the facility. The man told the facility staff that he observed our guest, (Resident #101), approximately 1.1 miles from the facility near the railroad tracks in (city facility is located in). He (the community member) stated he saw him (Resident #101) jogging and then fell on the ground so he went to see if he needed help. The man then assisted (Resident #101) into his car and drove him back to the facility because he (Resident #101) stated that is where he lived. The man alerted staff that (Resident #101) was out in his car and they immediately responded to assist him back into the building .(Resident #101) was last seen in the facility that day at 4:30pm by (CNA S), resting comfortably in his bed .(Resident #101) was asked what he was doing and he stated he was going for a jog. (Resident #101) was assessed and found to be wearing athletic shorts, a t-shirt and his velcro tennis shoes. A head to toe assessment completed by (LPN T) and noted minor bruises and abrasion from the fall. The temperature outside was approximately 78 degrees. (Resident #101) was placed on 1 on 1 supervision immediately upon return to the facility .A facility head count was completed and all residents accounted for. Facility's investigation identified that staff did not follow residents care plan for every 15 minute visual checks . In an observation on 8/28/19 at 9:09 a.m., observed the main facility entrance door in the dining area near the front offices. Noted that the door was unlocked at this time. In an interview on 8/28/19 at 9:09 a.m., Maintenance Director C reported that the main facility entrance door is unlocked between 8:00 a.m. and 8:00 p.m. every day. In an interview on 8/28/19 at 9:09 a.m., DON B reported that the main facility entrance door has an alarm system in place which automatically locks the door when a resident with a wander guard bracelet approaches. In an interview on 8/28/19 at 10:29 a.m., CNA S reported that she was assigned to Resident #101 on 8/16/19 at the time of his elopement. CNA S reported that the last time she observed Resident #101 was at 4:30 p.m., at which time she noted he was in bed. CNA S reported that Resident #101 was on 15 minute checks, and that his next check was due at 4:45 p.m. CNA S reported that at approximately 4:40 p.m., LPN X requested her assistance with a resident who had just fallen. CNA S reported that after assisting with the fall, she helped a different resident off of the toilet, and stated .the next minute . she was contacted and told that (Resident #101) was coming back into the facility. Review of a Guest Location Visual Check form, dated 8/16/19, revealed Resident #101 was last observed at 4:30 p.m. in his room. Further review revealed a missing entry for the 8/16/19 visual check at 4:45 p.m. In an interview on 8/28/19 at 11:06 a.m., LPN X reported that on 8/16/19 at approximately 4:45 p.m. she had responded to a resident who had fallen in their room, and requested CNA S to assist her after the fall. LPN X reported that she and CNA S were in the room for approximately 5 minutes. In an interview on 8/28/19 at 12:12 p.m., CNA DD reported that she assisted Resident #101 out of the community member's car on 8/16/19 at approximately 5:00 p.m. CNA DD reported that Resident #101 said he was .jogging . CNA DD noted that upon his return to the facility on [DATE], Resident #101 had a .scuffed up knee . and was brought back into the facility via wheelchair. In an interview on 8/28/19 at 12:28 p.m., Ancillary Clerk H reported that she was in the front office at the time the incident occurred, and stated .I didn't see him at all .He's mobile, he's quick . Ancillary Clerk H reported that she was one of the first people to respond when Resident #101 was returned to the facility, and stated .he seemed more confused than usual . Ancillary Clerk H reported the community member who returned Resident #101 to the facility had observed the resident jogging and fall near the railroad tracks, so he stopped to help. In an interview on 8/28/19 at 12:51 p.m., Unit Manager AA reported that she was notified of Resident #101's elopement on 8/16/19 at approximately 5:00 p.m. Unit Manager AA reported that when she went outside Resident #101 was in the community member's car, and stated he seemed tired and .a little off . Unit Manager AA stated .when I asked him what was going on he told me he was going for a jog . Unit Manager AA reported that Resident #101 typically walks the halls at a fast pace. Unit Manager AA reported that Resident #101 had exit seeking behaviors over one year ago, and attempts to place a wander guard at that time were unsuccessful. Unit Manager AA stated .he (Resident #101) won't allow us to place one, he becomes agitated . Unit Manager AA reported that prior to the incident on 8/16/19, Resident #101 was on 15 minute checks. Unit Manager AA reported that immediately upon his return to the facility on [DATE], Resident #101 was placed on 1 on 1 supervision. In an interview on 8/28/19 at 1:09 p.m., DON B reported that the 15 minute checks for Resident #101 were initially started on 6/8/18, then discontinued on 2/13/19 due to no further statements about or attempts to exit. DON B reported the 15 minute checks for Resident #101 were restarted on 7/29/19 and continued until he was placed on 1 on 1 supervision on 8/16/19. DON B reported the 15 minute checks were restarted based on an interdisciplinary team decision on 7/29/19 due to increased requests by Resident #101 to go outside with activities and his impaired cognitive status. In an interview on 8/28/19 at 1:12 p.m., CNA Z reported that at approximately 5:00 p.m. on 8/16/19, she heard someone shout for a nurse in the lobby. CNA Z reported she went outside and Resident #101 was sitting in a car in the parking lot. CNA Z stated that Resident #101 .was tearful. He didn't say why .He looked upset . CNA Z reported that at the time of the incident on 8/16/19, Resident #101 was on 15 minute checks due to exit seeking behaviors. In an interview on 8/28/19 at 3:00 p.m., Administrator A reported that interventions for residents at risk of elopement are determined on a case by case basis, depending on the degree of exit seeking. Administrator A stated the staff would .at a minimum do the 15 minute visual checks . Administrator A reported Resident #101's 15 minute checks were implemented on 7/29/19 because he had been vocalizing how nice the weather was and looking out the windows, along with increased activity participation in outdoor activities. Administrator A reported that due to his impaired cognition, the 15 minute checks were started for safety. In an interview on 8/29/19 at 10:24 a.m., LPN T reported that she was notified of Resident #101's elopement on 8/16/19 at approximately 5:00 p.m. LPN T reported that when she went outside, Resident #101 .seemed a little disoriented .He had abrasions on his knees . LPN T reported that when asked what happened, Resident #101 told staff he went for a jog. LPN T reported that 15 minute checks were implemented recently due to increased signs of anxiety. LPN T stated .we attempted a wander guard and he wanted nothing to do with it .he would get hostile . LPN T reported that due to his refusal of the wander guard, 15 minute checks were implemented for safety on 7/29/19. LPN T reported that immediately after the incident on 8/16/19, Resident #101 was placed on 1 on 1 supervision until he was discharged from the facility. On 8/28/19, Administrator A was notified of an Immediate Jeopardy that began on 8/16/19 and was identified on 8/28/19 when Resident #101, who was identified as an elopement risk, eloped from the facility, unbeknownst to facility staff. On 8/28/19, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Immediately upon the return of Resident #101 on 8/16/19 to facility, staff assessed for injury and tried to place a wander guard on guests' ankle, but he became aggressive and refused. Resident #101 was placed on 1:1 supervision, Care plans and care card updated to reflect interventions. Resident #101 remained on 1:1 supervision until discharged from facility on 8/26/19. 2. On 8/16/19 Director of Nursing/Designee verified no other residents on 15-minute visual checks. 3. On 8/16/19 Director of Nursing/Designee began education with all staff, with 16 of 16 facility staff members, currently working, regarding Missing Guest Policy, guest location visual checks, and elopement risk of guests. The remaining staff members will be re-educated by the Director of Nursing/Designee prior to the start of their next scheduled shift. As of 8/19/19, 99 of 102 staff members have been re-educated. 4. On 8/16/19, Director of Nursing/Nurse Managers re-assessed the 11 current residents who trigger at risk for elopement including the placement and function of wanderguard, no issues identified. 5. On 8/16/19, the Administrator reviewed the facility Missing Guest Policy and it was deemed appropriate. 6. On 8/16/19, 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 per manufacturer guidelines. 7. On 8/18/19 Director of Nursing/Designee reassessed the other 64 current residents for potential elopement risk; with no concerns identified. 8. On 8/19/19 Director of Nursing reviewed the elopement books audited and confirmed they had current guest information. Medical Records will continue to update each book with any changes as needed per facility policy. 9. New employee orientation will continue to include Missing Person Policy and Procedures education. 10. Administrator/Director of Nursing/Designee will audit guests at risk for elopement weekly times 4 weeks, then monthly times 3 months to ensure staff are following facility's policy. Any concerns will be addressed immediately. Findings will be forwarded to QAPI Committee for further review and recommendations. 11. Maintenance Director/designee continues audits on secure doors with no concerns identified. Missing Guest drills being performed randomly by facility, no concerns identified. Director of Nursing has completed week 1 of audit for guests at risk for elopement with no concerns identified. The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the Missing Guest policy was reviewed and deemed appropriate, and the facility had achieved sustained compliance for F-689.

Based on observation, interview and record review the facility failed to prevent repeated occurrences of resident-to-resident abuse for three residents (Resident #703, Resident #704, and Resident #708) out of 10 residents reviewed for abuse, from a total sample of 10 residents, resulting in an immediate jeopardy when there was actual harm from resident-to-resident abuse for Resident #703 who was dragged across the floor by Resident #709; and when Resident #704 was pulled from her wheelchair onto the floor by Resident #707 on 8/19/15 and was then slapped by Resident #707 on 9/14/15; and when Resident #708 was pushed/shoved by Resident #707 on 7/15/15 and repeatedly hit by Resident #707 on 9/16/15. Findings include: Review of the facility's Abuse prohibition, investigation, and reporting policy, with a revision date of 5/12, defined physical abuse as hitting, slapping, pinching, kicking, etc. Further review of the facility's Abuse prohibition, investigation, and reporting policy reflected that Appropriate actions must be taken immediately to protect the guest and others who could be affected while the investigation is in progress. The policy also indicated that The Administrator is responsible for ensuring that allegations of abuse are reported to the State Licensing Agency, the Ombudsman, and/or other agencies as is required by state law. Resident #707 Review of a Record of Admission dated 9/1/15 indicated Resident #707 was a [AGE] year old man admitted the facility on 5/21/15. A Cumulative [DIAGNOSES REDACTED].#707 had [MEDICAL CONDITION], spinal stenosis, debility, agitation, hallucinations, combative behaviors, violent behaviors, impulse control disorder, anxiety and developmental delay. An MDS assessment dated [DATE] indicated Resident #707 was severely cognitively impaired and exhibited behaviors that were directed toward others causing a significant disruption to care and living environment. Review of a Plan of Care with an onset date of 2/4/15, last reviewed on 8/19/15 (the day Resident #707 pulled Resident #704 out of her wheelchair) indicated Resident #707 had an Actual Behavior Problem as evidenced by Yelling/screaming/cursing, grabbing out at others, attempting to throw things such as the computer and snack cart, incident with another resident on 2/2/15, incident with another resident on 2/3/15, scratching staff, digging fingernails into staff, flipping off staff, breaking things, 4/20/15 incident with another resident, making racial statements to staff, throwing snacks, broke phone at nurses desk, stating that he needs to break his legs to return to the hospital where the staff are cute, observed putting call light around his legs to try and 'break them' 7/30/15 struck another resident, 8/20/15 pulled another resident out of their wheelchair onto floor, 8/24/15 incident with another resident. Measurable goals (initiated on 2/4/15) for the Plan of Care were that Resident #707 would not harm himself or others during episodes of behavior. Interventions included: encourage activities as appropriate and desired for diversion. Activities has created a personalized calendar for resident with times and activities which he enjoys such as coloring, observe and record behaviors, provide the resident with as much control as possible in routines, activities, etc., provide a stable/supportive environment through consistency in daily routine, provide positive feedback when displaying positive behavior, provide resident with positive verbal cueing, administer medications and monitor effects, involve family/responsible party in plan of care. Family is very involved in his care. His parents visit often and are very active with his plan of care, discuss in behavior management, allow opportunity for guest to discuss mood, feelings, concerns, if unable to redirect behavior, assist guest to a quiet location. The following interventions were added to the plan of care on 4/27/15: 2 assist with all cares, 15 minute checks, private room, talk in calm low voice to help with anxiety, use the cordless phone at nurse's station when making phone calls. A notation on the care plan dated 7/30/15 indicated Resident #707 does enjoy sitting in social work office and interacting with social worker, does enjoy coloring pictures. On 8/20/15 the following intervention was added: eats meals in room with TV or radio on. No new interventions to keep Resident #707 from harming other residents or for increased supervision after resident to resident incidents beginning on 7/30/15 occurred. Resident #709 Resident #709 was a [AGE] year-old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. ( ) Review of the Plan of Care for Resident #709, with an onset date of 2-23-15 indicated that the resident Demonstrates cognitive impairment as evidenced by : Dementia, Inability to recall staff names/faces, short attention span, short term memory loss. Further review of the care plan revealed the resident is At risk for increased anxiety related to dx and history of delusion thought process along with cognitive impairment. ( ) Resident #704 Review of a facility Admission Summary (undated) indicated Resident #704 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #704 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 1/15, was independent with locomotion (how resident moves to and from distant areas on the floor) and exhibited wandering behavior daily. Review of a Behavior Documentation Record dated 7/21/15 indicated that Resident #704 .wanders in and out of people's rooms. (Resident #704) bumps into people in hallway and in dining room. On 11/10/15 (Resident #704) was in another resident's room and was trying to get her out, resident started to pinch my (the CNA's) arm and was kicking me then I asked another aide to help. She (Resident #704) is upsetting other residents and the other residents want her moved. The record also indicated that on 11/13/15 (Resident #704) is in and out of (other resident's) rooms all shift and takes things out of their rooms and the other residents are getting really upset about her being in (their rooms) and taking their things. Review of a Plan of Care initiated on 11/11/15 (four months after unsafe wandering behavior was first identified on the Behavior Documentation Record) indicated Resident #704 was at risk for elopement related to wandering. The goal of the care plan was only to prevent elopement with interventions which included Observe whereabouts frequently. No interventions on the care plan for keeping Resident #704 from wandering into other resident rooms or into unsafe situations in the facility were identified. Review of an Incident Report dated 8/19/15 timed 7:10 p.m. indicated Resident #704 was Self-propelling in hallway when she accidentally knocked over a resident's meal tray. This angered the resident (Resident #707) who grabbed (Resident #704's) wheelchair and tipped her out of her chair in the hallway. Superficial redness noted to upper back. (Resident #704) denies pain. Staff informed to keep resident on East hall. (Resident #704) independently propels in wheelchair. (Resident #707) to eat in day room to prevent this from happening again. Injuries noted at the time of the incident were Redness to back, redness to arms, and redness to left eye sclera. Review of a Nursing Note dated 8/19/15 indicated Resident #704 .noted to have bruises to left upper back, redness to bilateral upper arms, redness to sclera related to another guest grabbing wheelchair and brought her to the floor . Review of an Incident Report dated 9/14/15 timed 6:50 p.m. indicated Resident #704 was hit by (Resident #707) resulting in light bruising to right side of face. A statement written by Licensed Practical Nurse (LPN) D indicated At 6:50 p.m. (Resident #707) and (Resident #704) were at the nurse's station on the West Hall. (Resident #704) was talking to herself and (Resident #707) yelled at her to 'shut-up'. (Resident #707) thought she (Resident #704) yelled at him to 'shut-up'. (Resident #707) slapped (Resident #704) across her left side of face. No marks at that time. Interventions added after the abuse included closing center corridor double doors after dinner in attempt to keep residents from each other. During an observation on 11/16/15 at 9:28 a.m., Resident #704 was observed wandering into and back out of room [ROOM NUMBER]. No staff were present to redirect Resident #704. During an observation on 11/16/15 at 10:45 a.m., Resident #704 was observed unattended by staff wandering into room [ROOM NUMBER] and was yelled at by a resident in that room. Resident #704 did not respond to the shouts of the other resident and Licensed Practical Nurse (LPN) F got up from the nurse's station at the end of the hall and redirected Resident #704 into the hall. During an observation on 11/16/15 at 4:35 p.m., Resident #704 was observed wandering into room [ROOM NUMBER]. The resident who lived in room [ROOM NUMBER] bed 2 was overheard yelling at Resident #704 for over one minute before DON B noticed and redirected Resident #704 out of the room. Resident #703 Review of a Record of Admission dated 11/16/15 indicated Resident #703 was a [AGE] year old man admitted to the facility on [DATE]. A Cumulative [DIAGNOSES REDACTED].#703 had [MEDICAL CONDITION] and was legally blind and hard of hearing. An MDS assessment dated [DATE] indicated Resident #703 had short and long term memory impairments and exhibited wandering behaviors. Review of a Plan of Care initiated 11/11/15 (nearly 2 months after he was assessed to have wandering behaviors) indicated Resident #703 was at risk for elopement related to wandering with interventions to prevent leaving the facility that included observe whereabouts frequently. No interventions specific to keeping Resident #703 safe from hazards within the facility were mentioned. Review of an Incident Report indicated Resident #703 wandered into another resident's room. A statement attached to the Incident Report dated 9/18/15 reflected At approximately 1:25 p.m., I (Registered Nurse, RN G) responded to a CNA yelling for help .upon entering room (RN G) observed Resident #703 and another resident sitting on the floor facing each other. The other resident was yelling at the time (RN G) entered the room. (RN G) asked him what happened and he stated He (Resident #703) was in my room, he needs to get out NOW! (CNA H) stated that when she entered the room she observed the resident pulling Resident #703 across the floor by his shirt, which was around his neck at the time stating If he (Resident #703) comes in my room again, I'm going to kill him. During an interview on 11/17/15 at 3:15 p.m., NHA A was asked if she thought any additional interventions could have been implemented to safeguard other residents from Resident #707's violent outbursts. NHA A and the Director of Nursing (DON) B reiterated care plan interventions that had already been implemented. NHA A said she would have considered a 1:1 (one staff member to supervise Resident #707) if it was needed .if Resident #707 were more mobile . NHA A was asked if she thought confused residents who wandered throughout the facility should have been expected to know to avoid Resident #707 or Resident #709 and she said No. Resident #708: Resident #708 was an [AGE] year-old female, who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS), dated [DATE], for Resident #708 identified the resident's Brief Interview for Mental Status (BIMS) score as 0 out of a total possible score of 15, indicating severe cognitive impairment. Further review of the above MDS indicated that the mobility device normally used by Resident #708 was a wheelchair. Review of the Plan of Care for Resident #708 regarding pain, dated 10/14/2015, indicated that the resident Has no safety awareness. Interventions included, Provide for safety and Provide safe environment for wandering. Review of the Plan of Care for Resident #708 regarding wandering, dated 10/14/2015, indicated that the resident is at risk for elopement related to wandering. Interventions included, Observe whereabouts frequently. Review of the Plan of Care for Resident #708, dated 10/14/2015, reflected that the resident is At risk for injury due to dementia, poor safety awareness. No specific interventions were identified to keep resident safe from aggressive residents. Review of the Plan of Care for Resident #708, dated 10/14/2015, in regard to Activities reflected that the resident, Enjoys socializing with others and likes being up in her wheelchair self-propelling in the hallways throughout the day. Review of the Plan of Care for Resident #708, dated 11/16/2015, indicated an Actual Behavior Problem of wandering throughout facility. Interventions included, Provide a stable/supportive environment through consistency in daily routine .If unable to redirect behavior, assist guest to a quiet location .reassure guest of safety. Review of the facility's Behavior Documentation Record for Resident #708 indicated that on 8/23-24 the resident was trying to go in other residents' rooms. Tried redirecting, started hitting, screaming, and kicking multiple aides. Review of a facility Incident Report for Resident #708 identified a Guest to Guest incident on 7/15/2015 at 1:30 p.m. in the hallway. Review of a handwritten summary attached to the above incident report, dated 7/15/2015 and signed by the administrator, reflected that the incident was witnessed by another resident, who stated he saw (Resident #708) run into (Resident #707) with her wheelchair and (Resident #707) grabbed her arm to move her out of the way. Review of a facility Incident Report for Resident #707, dated 7/15/2015 at 1:30 p.m., identified an incident, with the Type of Occurrence classified as Other: Specify___. No further details were provided in this section indicating the Type of Occurrence. Review of a handwritten witness statement attached to the above incident report, dated 7/15/2015 included the statement, I seen (sic) (Resident #707) push/shove (Resident #708) after she ran into him with her wheelchair. (Resident #707) dropped his phone, was upset, and push/shoved (Resident #708). Review of a facility Incident Report for Resident #707 identified a Guest to Guest incident on 9/16/2015 at 7:30 p.m. in front of the nurses' station. A handwritten statement attached to the incident report included the statement, I observed (Resident #707) hit (Resident #708) . (Resident #707) reached out and struck (Resident #708) three times with an open hand. He hit her on the head, chest, and arm as she was trying to pass by. Review of Care Conference Minutes, dated 9/17/2015, for Resident #707, indicated a Care Plan Review was completed. Interventions were identified, including New activity schedule . Guests were immediately separated. Continue with activity schedule and redirect other guests out of (Resident #707's) space. Review of a typed summary, dated 9/17/2015, attached to the incident report for Resident #707, indicated the resident's father was notified .that interventions have been put into place and that resident is choosing to not want to do any of the interventions at this time .resident has had multiple incidents with others this week and for the safety of everyone, SW is following up on alternate placement options . The summary did not indicate whether any further interventions were attempted to protect other residents from Resident #707. On 11/19/15 at 11:44 a.m. the Administrator and Director of Nursing were informed of the Immediate Jeopardy that was identified on 11/17/15 and began on 7/15/15 for Resident #708, who was pushed/shoved by Resident #707 on 7/15/15 and was repeatedly hit by Resident #707 on 9/16/15 and for Resident #704 who was pulled out of her wheelchair by Resident #707 on 8/16/15 and who was slapped by Resident #707 on 9/14/15 and for Resident #703 who was dragged across the floor by Resident #709 on 9/18/15 as a result of the facility's failure to provide supervision to prevent resident to resident abuse. These deficient practices placed all residents who wandered and had cognitive impairment at risk for serious injury, harm and/or death. On 11/23/2015 the survey team confirmed the facility implemented the following to remove the Immediate Jeopardy: 1. Resident #707 was discharged from the facility on 9/18/15. 2. Resident # 704 continues to reside in the facility. The resident did not sustain any injuries relating to the incident on 8/19/15. The residents care plan has been updated to include diversional activities of rummage chest in activity room and also cubbies throughout facility to rummage through, provide purses/bags to rummage through, music in activity room. During episodes of increased wandering the staff will offer hand massages, music, coloring, singing to her, sitting with conversation, calling son 1:1 supervision when the resident is unable to be redirected and/or the facility will seek alternate placement if current interventions prove to be ineffective. 3. Resident #708 continues to reside in the facility. The resident did not sustain any injuries relating to Resident #707 grabbing Resident #708's arm to move her out of the way on 7/15/15. The immediate intervention was to relocate Resident #708 away from the area. Resident #708 did not sustain any injuries relating to the incident on 9/16/15. The immediate intervention was to remove Resident #708 from the immediate area. The Resident was and continues to be on every 15 minute checks. Resident #708's care plan has been updated to include ambulation three times a day to promote sleep at night, fluids throughout the day to prevent UTIs, and diversional activities of crafts in activity room, cook books to find a recipes, organize recipes, and/or increased supervision during episodes of increased wandering which typically follow episodes when the resident does not sleep at night and/or has a UTI. 4. Resident #703 did not sustain any injuries relating to the 9/18/15 incident. The Resident was moved to the other unit in the facility and there have been no further incidents. The resident requires assistance to and from activities relating to poor vision. The Administrative Nurses have reviewed the resident's care plan and made revisions when indicated on 11/19/15 to include redirect to activity room or cubbies where blocks are provided, provide guest with sock that provides comfort, ambulation three times a day. The other resident returned to his prior room and currently has a stop sign across his door. There have been no further incidents with this resident. His care plan was reviewed by the Administrative Nurses on 11/19/15 to ensure current interventions are identified and continue to be appropriate. 5. All residents in the facility were reviewed by the Administrative nurses on 11/19/15 for wandering and/or who exhibit aggressive behaviors. The facility has identified 12 residents who wander and 10 residents who exhibit aggressive behaviors. The facility has reviewed the care plans of the identified residents to ensure current interventions are appropriate and revised interventions when indicated. 6. 13 of 13 Licensed Nurses were in-serviced by the Administrative Nurses on the prevention of abuse for Residents who wander and protecting the identified residents from residents who have been identified to exhibit aggressive behaviors on 11/19/15. All other Licensed Nurses (10 of 23) will be in-serviced on the above prior to working their next scheduled shift. 7. 13 of 13 nursing assistants have been in-serviced by the Administrative Nurses on the prevention of abuse for Residents who wander and protecting the identified residents from residents who have been identified to exhibit aggressive behaviors on 11/19/15. All other nursing assistants (27 of 40) will be in-serviced on the above prior to working their next scheduled shift. 8. The Behavior Management Committee which consists of Social Services, Activity Director, and Unit Managers were in-serviced by the Regional Nurse on the need to identify risks associated with residents who wander including the potential for abuse relating to wandering, identifying appropriate interventions to prevent abuse, changing interventions that are ineffective and updating resident care plans with changes on 11/19/15. 9. The DON/Regional Nurse will attend the Behavior Management Meeting weekly for the next (4) four weeks to ensure behaviors are identified, interventions are identified and implemented and included in the plan of care. 10. The Behavior Management Committee and Administrative Nurses will monitor the identified residents to ensure interventions are implemented and effective. The Committee will revise interventions and the plan of care when indicated. Although the Immediate Jeopardy was removed on 11/19/15, the facility remained out of compliance at a scope of Pattern and a severity of Actual Harm that is not immediate jeopardy due to all staff had not been in-serviced and sustained compliance has not been verified by the state agency. ( )

Based on observation, interviews, and record review, the facility failed to provide adequate supervision to prevent repeated occurrences of resident-to-resident abuse for five residents, (Resident #703, Resident #704, Resident #707, Resident #708, and Resident #709) out of 10 residents reviewed for accident hazards and supervision from a total sample of 10 residents, resulting in immediate jeopardy when there was actual harm from a resident-to-resident abuse for Resident #703 who was dragged across the floor by Resident #709; and when Resident #704 was pulled from her wheelchair onto the floor by Resident #707 on 8/19/15 and was slapped by Resident #707 on 9/14/15; and when Resident #708 was pushed/shoved by Resident #707 on 7/15/15 and repeatedly hit by Resident #707 on 9/16/15. Findings include: Resident #707 Review of a Record of Admission dated 9/1/15 indicated Resident #707 was a [AGE] year old man admitted the facility on 5/21/15. A Cumulative [DIAGNOSES REDACTED].#707 had seizures, spinal stenosis, debility, agitation, hallucinations, combative behaviors, violent behaviors, impulse control disorder, anxiety and developmental delay. An MDS assessment dated [DATE] indicated Resident #707 was severely cognitively impaired and exhibited behaviors that were directed toward others causing a significant disruption to care and living environment. Review of a Plan of Care with an onset date of 2/4/15, last reviewed on 8/19/15 (the day Resident #707 pulled Resident #704 out of her wheelchair) indicated Resident #707 had an Actual Behavior Problem as evidenced by Yelling/screaming/cursing, grabbing out at others, attempting to throw things such as the computer and snack cart, incident with another resident on 2/2/15, incident with another resident on 2/3/15, scratching staff, digging fingernails into staff, flipping off staff, breaking things, 4/20/15 incident with another resident, making racial statements to staff, throwing snacks, broke phone at nurses desk, stating that he needs to break his legs to return to the hospital where the staff are cute, observed putting call light around his legs to try and 'break them' 7/30/15 struck another resident, 8/20/15 pulled another resident out of their wheelchair onto floor, 8/24/15 incident with another resident. Measurable goals (initiated on 2/4/15) for the Plan of Care were that Resident #707 would not harm himself or others during episodes of behavior. Interventions included: encourage activities as appropriate and desired for diversion. Activities has created a personalized calendar for resident with times and activities which he enjoys such as coloring, observe and record behaviors, provide the resident with as much control as possible in routines, activities, etc., provide a stable/supportive environment through consistency in daily routine, provide positive feedback when displaying positive behavior, provide resident with positive verbal cueing, administer medications and monitor effects, involve family/responsible party in plan of care. Family is very involved in his care. His parents visit often and are very active with his plan of care, discuss in behavior management, allow opportunity for guest to discuss mood, feelings, concerns, if unable to redirect behavior, assist guest to a quiet location. The following interventions were added to the plan of care on 4/27/15: 2 assist with all cares, 15 minute checks, private room, talk in calm low voice to help with anxiety, use the cordless phone at nurse ' s station when making phone calls. A notation on the care plan dated 7/30/15 indicated Resident #707 does enjoy sitting in social work office and interacting with social worker, does enjoy coloring pictures. On 8/20/15 the following intervention was added: eats meals in room with TV or radio on. No new interventions to keep Resident #707 from harming other residents or for increased supervision after resident to resident incidents was mentioned. During an interview on 11/19/15 at 2:00 p.m., Certified Nursing Assistant (CAN) K said that she knew Resident #707 was on 15 minute checks but wasn't ' sure if it was because of resident-to-resident checks or because he kept getting out of bed. Resident #709 Resident #709 was a [AGE] year-old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Plan of Care for Resident #709, with an onset date of 2-23-15 indicated that the resident Demonstrates cognitive impairment as evidenced by : Dementia, Inability to recall staff names/faces, short attention span, short term memory loss. Further review of the care plan revealed the resident is At risk for increased anxiety related to dx and history of delusion thought process along with cognitive impairment. ( ) Resident #704 Review of a facility Admission Summary (undated) indicated Resident #704 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #704 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 1/15, was independent with locomotion (how resident moves to and from distant areas on the floor) and exhibited wandering behavior daily. Review of a Behavior Documentation Record dated 7/21/15 indicated that Resident #704 .wanders in and out of people's rooms. (Resident #704) bumps into people in hallway and in dining room. On 11/10/15 (Resident #704) was in another resident's room and was trying to get her out, resident started to pinch my (the CNA's) arm and was kicking me then I asked another aide to help. She (Resident #704) is upsetting other residents and the other residents want her moved. The record also indicated that on 11/13/15 (Resident #704) is in and out of (other resident's) rooms all shift and takes things out of their rooms and the other residents are getting really upset about her being in (their rooms) and taking their things. Review of a Plan of Care initiated on 11/11/15 (four months after unsafe wandering behavior was first identified on the Behavior Documentation Record) indicated Resident #704 was at risk for elopement related to wandering. The goal of the care plan was only to prevent elopement with interventions which included Observe whereabouts frequently. No interventions on the care plan mentioned keeping Resident #704 from wandering into other resident rooms or into unsafe situations in the facility were identified. Review of an Incident Report dated 8/19/15 timed 7:10 p.m. indicated Resident #704 was Self-propelling in hallway when she accidentally knocked over a resident's meal tray. This angered the resident (Resident #707) who grabbed (Resident #704's) wheelchair and tipped her out of her chair in the hallway. Superficial redness noted to upper back. (Resident #704) denies pain. Staff informed to keep resident on East hall. (Resident #704) independently propels in wheelchair. (Resident #707) to eat in day room to prevent this from happening again. Injuries noted at the time of the incident were Redness to back, redness to arms, and redness to left eye sclera. Review of an Incident Report dated 9/14/15 timed 6:50 a.m. indicated Resident #704 was hit by (Resident #707) resulting in light bruising to right side of face. A statement written by Licensed Practical Nurse (LPN) D indicated At 6:50 p.m. (Resident #707) and (Resident #704) were at the nurse's station on the West Hall. (Resident #704) was talking to herself and (Resident #707) yelled at her to 'shut-up'. (Resident #707) thought she (Resident #704) yelled at him to 'shut-up'. (Resident #707) slapped (Resident #704) across her left side of face. No marks at that time. Interventions added after the abuse included closing center corridor double doors after dinner in attempt to keep residents from each other. During an observation on 11/16/15 at 9:28 a.m., Resident #704 was observed wandering into and back out of room 107. No staff were present to redirect Resident #704. During an observation on 11/16/15 at 10:45 a.m., Resident #704 was observed unattended by staff wandering into room 111 and was yelled at by a resident in that room. Resident #704 did not respond to the shouts of the other resident and Licensed Practical Nurse (LPN) F got up from the nurse's station at the end of the hall and redirected Resident #704 into the hall. During an observation on 11/16/15 at 4:35 p.m., Resident #704 was observed wandering into room 101. The resident who lived in room 101 bed 2 was overheard yelling at Resident #704 for over one minute before DON B noticed and redirected Resident #704 out of the room. Resident #703 Review of a Record of Admission dated 11/16/15 indicated Resident #703 was a [AGE] year old man admitted to the facility on [DATE]. A Cumulative [DIAGNOSES REDACTED].#703 had Downs syndrome and was legally blind and hard of hearing. An MDS assessment dated [DATE] indicated Resident #703 had short and long term memory impairments and exhibited wandering behaviors. Review of a Plan of Care initiated 11/11/15 (nearly 2 months after he was assessed to have wandering behaviors) indicated Resident #703 was at risk for elopement related to wandering with interventions to prevent leaving the facility that included observe whereabouts frequently. No interventions specific to keeping Resident #703 safe from hazards within the facility were mentioned. Review of an Incident Report indicated Resident #703 wandered into another resident's room. A statement attached to the Incident Report dated 9/18/15 reflected At approximately 1:25 p.m., I (Registered Nurse, RN G) responded to a CNA yelling for help .upon entering room (RN G) observed Resident #703 and another resident sitting on the floor facing each other. The other resident was yelling at the time (RN G) entered the room. (RN G) asked him what happened and he stated He (Resident #703) was in my room, he needs to get out NOW! (CNA H) stated that when she entered the room she observed the resident pulling Resident #703 across the floor by his shirt, which was around his neck at the time stating If he (Resident #703) comes in my room again, I'm going to kill him. During an interview on 11/17/15 at 3:15 p.m., NHA A was asked if she thought any additional interventions could have been implemented to safeguard other residents from Resident #707's violent outbursts. NHA A and the Director of Nursing (DON) B reiterated care plan interventions that had already been implemented. NHA A said she would have considered a 1:1 (one staff member to supervise Resident #707) if it was needed .if Resident #707 were more mobile . NHA A was asked if she thought confused residents who wandered throughout the facility should have been expected to know to avoid Resident #707 or Resident #709 and she said No. Resident #708: Resident #708 was an [AGE] year-old female, who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS), dated [DATE], for Resident #708 identified the resident ' s Brief Interview for Mental Status (BIMS) score as 0 out of a total possible score of 15, indicating severe cognitive impairment. Further review of the above MDS indicated that the mobility device normally used by Resident #708 was a wheelchair. Review of the Plan of Care for Resident #708 regarding pain, dated 10/14/2015, indicated that the resident Has no safety awareness. Interventions include, Provide for safety and Provide safe environment for wandering. Review of the Plan of Care for Resident #708 regarding wandering, dated 10/14/2015, indicated that the resident is at risk for elopement related to wandering. Interventions include, Observe whereabouts frequently. Review of the Plan of Care for Resident #708, dated 10/14/2015, reflected that the resident is At risk for injury due to dementia, poor safety awareness. No specific interventions were identified to keep resident safe from aggressive residents. Review of the Plan of Care for Resident #708, dated 10/14/2015,in regard to Activities reflected that the resident, Enjoys socializing with others and likes being up in her wheelchair self-propelling in the hallways throughout the day. Review of the Plan of Care for Resident #708, dated 11/16/2015, indicated an Actual Behavior Problem of wandering throughout facility. Interventions include, Provide a stable/supportive environment through consistency in daily routine .If unable to redirect behavior, assist guest to a quiet location .reassure guest of safety. Review of the facility ' s Behavior Documentation Record for Resident #708 indicated that on 8/23-24 the resident was trying to go in other residents ' rooms. Tried redirecting, started hitting, screaming, and kicking multiple aides. Review of a facility Incident Report for Resident #708 identified a Guest to Guest incident on 7/15/2015 at 1:30 p.m. in the hallway. Review of a handwritten summary attached to the above incident report, dated 7/15/2015 and signed by the administrator, reflected that the incident was witnessed by another resident, who stated he saw (Resident #708) run into (Resident #707) with her wheelchair and (Resident #707) grabbed her arm to move her out of the way. Review of a facility Incident Report for Resident #707, dated 7/15/2015 at 1:30 p.m., identified an incident, with the Type of Occurrence classified as Other: Specify___. No further details were provided in this section indicating the Type of Occurrence. Review of a handwritten witness statement attached to the above incident report, dated 7/15/2015 included the statement, I seen (sic) (Resident #707) push/shove (Resident #708) after she ran into him with her wheelchair. (Resident #707) dropped his phone, was upset, and push/shoved (Resident #708). Review of a facility Incident Report for Resident #707 identified a Guest to Guest incident on 9/16/2015 at 7:30 p.m. in front of the nurses ' station. A handwritten statement attached to the incident report included the statement, I observed (Resident #707) hit (Resident #708) . (Resident #707) reached out and struck (Resident #708) three times with an open hand. He hit her on the head, chest, and arm as she was trying to pass by. Review of Care Conference Minutes , dated 9/17/2015, for Resident #707, indicated a Care Plan Review was completed. Interventions were identified, including New activity schedule . Guests were immediately separated. Continue with activity schedule and redirect other guests out of (Resident #707 ' s) space. Review of a typed summary, dated 9/17/2015, attached to the incident report for Resident #707, indicated the resident ' s father was notified .that interventions have been put into place and that resident is choosing to not want to do any of the interventions at this time .resident has had multiple incidents with others this week and for the safety of everyone, SW is following up on alternate placement options . The summary did not indicate whether any further interventions were attempted to protect other residents from Resident #707. On 11/19/15 at 11:44 a.m. the Administrator and Director of Nursing were informed of the Immediate Jeopardy that was identified on 11/17/15 and began on 7/15/15 for Resident #708, who was pushed/shoved by Resident #707 on 7/15/15 and was repeatedly hit by Resident #707 on 9/16/15 and for Resident #704 who was pulled out of her wheelchair by Resident #707 on 8/16/15 and who was slapped by Resident #707 on 9/14/15 and for Resident #703 who was dragged across the floor by Resident #709 on 9/18/15 as a result of the facility ' s failure to provide supervision to prevent resident to resident abuse. These deficient practices placed all residents who wandered and had cognitive impairment at risk for serious injury, harm and/or death. On 11/23/2015 the survey team confirmed the facility implemented the following to remove the Immediate Jeopardy: 1. Resident #707 was discharged from the facility on 9/18/15. 2. Resident # 704 continues to reside in the facility. The resident did not sustain any injuries relating to the incident on 8/19/15. The residents care plan has been updated to include diversional activities of rummage chest in activity room and also cubbies throughout facility to rummage through, provide purses/bags to rummage through, music in activity room. During episodes of increased wandering the staff will offer hand massages, music, coloring, singing to her, sitting with conversation, calling son 1:1 supervision when the resident is unable to be redirected and/or the facility will seek alternate placement if current interventions prove to be ineffective. 3. Resident #708 continues to reside in the facility. The resident did not sustain any injuries relating to Resident #707 grabbing Resident #708 ' s arm to move her out of the way on 7/15/15. The immediate intervention was to relocate Resident #708 away from the area. Resident #708 did not sustain any injuries relating to the incident on 9/16/15. The immediate intervention was to remove Resident #708 from the immediate area. The Resident was and continues to be on every 15 minute checks. Resident #708 ' s care plan has been updated to include ambulation three times a day to promote sleep at night, fluids throughout the day to prevent UTIs, and diversional activities of crafts in activity room, cook books to find a recipes, organize recipes, and/or increased supervision during episodes of increased wandering which typically follow episodes when the resident does not sleep at night and/or has a UTI. 4. Resident #703 did not sustain any injuries relating to the 9/18/15 incident. The Resident was moved to the other unit in the facility and there have been no further incidents. The resident requires assistance to and from activities relating to poor vision. The Administrative Nurses have reviewed the resident ' s care plan and made revisions when indicated on 11/19/15 to include redirect to activity room or cubbies where blocks are provided, provide guest with sock that provides comfort, ambulation three times a day. The other resident returned to his prior room and currently has a stop sign across his door. There have been no further incidents with this resident. His care plan was reviewed by the Administrative Nurses on 11/19/15 to ensure current interventions are identified and continue to be appropriate. 5. All residents in the facility were reviewed by the Administrative nurses on 11/19/15 for wandering and/or who exhibit aggressive behaviors. The facility has identified 12 residents who wander and 10 residents who exhibit aggressive behaviors. The facility has reviewed the care plans of the identified residents to ensure current interventions are appropriate and revised interventions when indicated. 6. 13 of 13 Licensed Nurses were in-serviced by the Administrative Nurses on the prevention of abuse for Residents who wander and protecting the identified residents from residents who have been identified to exhibit aggressive behaviors on 11/19/15. All other Licensed Nurses (10 of 23) will be in-serviced on the above prior to working their next scheduled shift. 7. 13 of 13 nursing assistants have been in-serviced by the Administrative Nurses on the prevention of abuse for Residents who wander and protecting the identified residents from residents who have been identified to exhibit aggressive behaviors on 11/19/15. All other nursing assistants (27 of 40) will be in-serviced on the above prior to working their next scheduled shift. 8. The Behavior Management Committee which consists of Social Services, Activity Director, and Unit Managers were in-serviced by the Regional Nurse on the need to identify risks associated with residents who wander including the potential for abuse relating to wandering, identifying appropriate interventions to prevent abuse, changing interventions that are ineffective and updating resident care plans with changes on 11/19/15. 9. The DON/Regional Nurse will attend the Behavior Management Meeting weekly for the next (4) four weeks to ensure behaviors are identified, interventions are identified and implemented and included in the plan of care. 10. The Behavior Management Committee and Administrative Nurses will monitor the identified residents to ensure interventions are implemented and effective. The Committee will revise interventions and the plan of care when indicated. Although the Immediate Jeopardy was removed on 11/19/15, the facility remained out of compliance at a scope of Pattern and a severity of Actual Harm that is not immediate jeopardy due to all staff had not been in-serviced and sustained compliance has not been verified by the state agency. ( )

Based on observation, interview and record review the facility failed to fully implement its policy and procedure for abuse prevention, identification, and reporting for 5 residents (Resident #703, Resident #704, Resident #707, Resident #708 and Resident #709) out of 10 residents reviewed for abuse and neglect, from a total sample of 10 residents, resulting in the potential for abuse and neglect to continue to be unrecognized, not be reported or fully investigated. Findings: Review of the facility's Abuse prohibition, investigation, and reporting policy, with a revision date of 5/12, defined physical abuse as hitting, slapping, pinching, kicking, etc. Further review of the facility's Abuse prohibition, investigation, and reporting policy reflected that Appropriate actions must be taken immediately to protect the guest and others who could be affected while the investigation is in progress. The policy also indicated that The Administrator is responsible for ensuring that allegations of abuse are reported to the State Licensing Agency, the Ombudsperson, and/or other agencies as is required by state law. Resident #707 Review of a Record of Admission dated 9/1/15 indicated Resident #707 was a [AGE] year old man admitted the facility on 5/21/15. A Cumulative [DIAGNOSES REDACTED].#707 had [MEDICAL CONDITION], spinal stenosis, debility, agitation, hallucinations, combative behaviors, violent behaviors, impulse control disorder, anxiety and developmental delay. An MDS assessment dated [DATE] indicated Resident #707 was severely cognitively impaired and exhibited behaviors that were directed toward others causing a significant disruption to care and living environment. Review of a Plan of Care with an onset date of 2/4/15, last reviewed on 8/19/15 (the day Resident #707 pulled Resident #704 out of her wheelchair) indicated Resident #707 had an Actual Behavior Problem as evidenced by Yelling/screaming/cursing, grabbing out at others, attempting to throw things such as the computer and snack cart, incident with another resident on 2/2/15, incident with another resident on 2/3/15, scratching staff, digging fingernails into staff, flipping off staff, breaking things, 4/20/15 incident with another resident, making racial statements to staff, throwing snacks, broke phone at nurses desk, stating that he needs to break his legs to return to the hospital where the staff are cute, observed putting call light around his legs to try and 'break them' 7/30/15 struck another resident, 8/20/15 pulled another resident out of their wheelchair onto floor, 8/24/15 incident with another resident. Measureable goals (initiated on 2/4/15) for the Plan of Care were that Resident #707 would not harm himself or others during episodes of behavior. Interventions included: encourage activities as appropriate and desired for diversion. Activities has created a personalized calendar for resident with times and activities which he enjoys such as coloring, observe and record behaviors, provide the resident with as much control as possible in routines, activities, etc., provide a stable/supportive environment through consistency in daily routine, provide positive feedback when displaying positive behavior, provide resident with positive verbal cueing, administer medications and monitor effects, involve family/responsible party in plan of care. Family is very involved in his care. His parents visit often and are very active with his plan of care, discuss in behavior management, allow opportunity for guest to discuss mood, feelings, concerns, if unable to redirect behavior, assist guest to a quiet location. The following interventions were added to the plan of care on 4/27/15: 2 assist with all cares, 15 minute checks, private room, talk in calm low voice to help with anxiety, use the cordless phone at nurse's station when making phone calls. A notation on the care plan dated 7/30/15 indicated Resident #707 does enjoy sitting in social work office and interacting with social worker, does enjoy coloring pictures. On 8/20/15 the following intervention was added: eats meals in room with TV or radio on. No new interventions to keep Resident #707 from harming other residents or for increased supervision after resident to resident incidents was mentioned. Resident #709 Resident #709 was a [AGE] year-old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. ( ) Review of the Plan of Care for Resident #709, with an onset date of 2-23-15 indicated that the resident Demonstrates cognitive impairment as evidenced by : Dementia, Inability to recall staff names/faces, short attention span, short term memory loss. Further review of the care plan revealed the resident is At risk for increased anxiety related to dx and history of delusion thought process along with cognitive impairment. ( ) Resident #704 Review of a facility Admission Summary (undated) indicated Resident #704 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #704 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 1/15, was independent with locomotion (how resident moves to and from distant areas on the floor) and exhibited wandering behavior daily. Review of a Behavior Documentation Record dated 7/21/15 indicated that Resident #704 .wanders in and out of people's rooms. (Resident #704) bumps into people in hallway and in dining room. On 11/10/15 (Resident #704) was in another resident's room and was trying to get her out, resident started to pinch my (the CNA's) arm and was kicking me then I asked another aide to help. She (Resident #704) is upsetting other residents and the other residents want her moved. The record also indicated that on 11/13/15 (Resident #704) is in and out of (other resident's) rooms all shift and takes things out of their rooms and the other residents are getting really upset about her being in (their rooms) and taking their things. Review of a Plan of Care initiated on 11/11/15 (four months after unsafe wandering behavior was first identified on the Behavior Documentation Record) indicated Resident #704 was at risk for elopement related to wandering. The goal of the care plan was only to prevent elopement with interventions which included Observe whereabouts frequently. No interventions on the care plan mentioned keeping Resident #704 from wandering into other resident rooms or into unsafe situations in the facility were identified. Review of an Incident Report dated 8/19/15 timed 7:10 p.m. indicated Resident #704 was Self-propelling in hallway when she accidentally knocked over a resident's meal tray. This angered the resident (Resident #707) who grabbed (Resident #704's) wheelchair and tipped her out of her chair in the hallway. Superficial redness noted to upper back. (Resident #704) denies pain. Staff informed to keep resident on East hall. (Resident #704) independently propels in wheelchair. (Resident #707) to eat in day room to prevent this from happening again. Injuries noted at the time of the incident were Redness to back, redness to arms, and redness to left eye sclera. Review of a Nursing Note dated 8/19/15 indicated Resident #704 .noted to have bruises to left upper back, redness to bilateral upper arms, redness to sclera related to another guest grabbing wheelchair and brought her to the floor . Review of an Incident Report dated 9/14/15 timed 6:50 p.m. indicated Resident #704 was hit by (Resident #707) resulting in light bruising to right side of face. A statement written by Licensed Practical Nurse (LPN) D indicated At 6:50 p.m. (Resident #707) and (Resident #704) were at the nurse's station on the West Hall. (Resident #704) was talking to herself and (Resident #707) yelled at her to 'shut-up'. (Resident #707) thought she (Resident #704) yelled at him to 'shut-up'. (Resident #707) slapped (Resident #704) across her left side of face. No marks at that time. Interventions added after the abuse included closing center corridor double doors after dinner in attempt to keep residents from each other. During an observation on 11/16/15 at 9:28 a.m., Resident #704 was observed wandering into and back out of room [ROOM NUMBER]. No staff were present to redirect Resident #704. During an observation on 11/16/15 at 10:45 a.m., Resident #704 was observed unattended by staff wandering into room [ROOM NUMBER] and was yelled at by a resident in that room. Resident #704 did not respond to the shouts of the other resident and Licensed Practical Nurse (LPN) F got up from the nurse's station at the end of the hall and redirected Resident #704 into the hall. During an observation on 11/16/15 at 4:35 p.m., Resident #704 was observed wandering into room [ROOM NUMBER]. The resident who lived in room [ROOM NUMBER] bed 2 was overheard yelling at Resident #704 for over one minute before DON B noticed and redirected Resident #704 out of the room. Resident #703 Review of a Record of Admission dated 11/16/15 indicated Resident #703 was a [AGE] year old man admitted to the facility on [DATE]. A Cumulative [DIAGNOSES REDACTED].#703 had [MEDICAL CONDITION] and was legally blind and hard of hearing. An MDS assessment dated [DATE] indicated Resident #703 had short and long term memory impairments and exhibited wandering behaviors. Review of a Plan of Care initiated 11/11/15 (nearly 2 months after he was assessed to have wandering behaviors) indicated Resident #703 was at risk for elopement related to wandering with interventions to prevent leaving the facility that included observe whereabouts frequently. No interventions specific to keeping Resident #703 safe from hazards within the facility were mentioned. Review of an Incident Report indicated Resident #703 wandered into another resident's room. A statement attached to the Incident Report dated 9/18/15 reflected At approximately 1:25 p.m., I (Registered Nurse, RN G) responded to a CNA yelling for help .upon entering room (RN G) observed Resident #703 and another resident sitting on the floor facing each other. The other resident was yelling at the time (RN G) entered the room. (RN G) asked him what happened and he stated He (Resident #703) was in my room, he needs to get out NOW! (CNA H) stated that when she entered the room she observed the resident pulling Resident #703 across the floor by his shirt, which was around his neck at the time stating If he (Resident #703) comes in my room again, I'm going to kill him. During an interview on 11/17/15 at 3:15 p.m., NHA A was asked if she thought any additional interventions could have been implemented to safeguard other residents from Resident #707's violent outbursts. NHA A and the Director of Nursing (DON) B reiterated care plan interventions that had already been implemented. NHA A said she would have considered a 1:1 (one staff member to supervise Resident #707) if it was needed .if Resident #707 were more mobile . NHA A was asked if she thought confused residents who wandered throughout the facility should have been expected to know to avoid Resident #707 or Resident #709 and she said No. Resident #708: Resident #708 was an [AGE] year-old female, who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS), dated [DATE], for Resident #708 identified the resident's Brief Interview for Mental Status (BIMS) score as 0 out of a total possible score of 15, indicating severe cognitive impairment. Further review of the above MDS indicated that the mobility device normally used by Resident #708 was a wheelchair. Review of the Plan of Care for Resident #708 regarding pain, dated 10/14/2015, indicated that the resident Has no safety awareness. Interventions include, Provide for safety and Provide safe environment for wandering. Review of the Plan of Care for Resident #708 regarding wandering, dated 10/14/2015, indicated that the resident is at risk for elopement related to wandering.Interventions include, Observe whereabouts frequently. Review of the Plan of Care for Resident #708, dated 10/14/2015, reflected that the resident is At risk for injury due to dementia, poor safety awareness. No specific interventions were identified to keep resident safe from aggressive residents. Review of the Plan of Care for Resident #708, dated 10/14/2015,in regard to Activities reflected that the resident, Enjoys socializing with others and likes being up in her wheelchair self-propelling in the hallways throughout the day. Review of the Plan of Care for Resident #708, dated 11/16/2015, indicated an Actual Behavior Problem of wandering throughout facility. Interventions include, Provide a stable/supportive environment through consistency in daily routine .If unable to redirect behavior, assist guest to a quiet location .reassure guest of safety. Review of the facility's Behavior Documentation Record for Resident #708 indicated that on 8/23-24 the resident was trying to go in other residents' rooms. Tried redirecting, started hitting, screaming, and kicking multiple aides. Review of a facility Incident Report for Resident #708 identified a Guest to Guest incident on 7/15/2015 at 1:30 p.m. in the hallway. Review of a handwritten summary attached to the above incident report, dated 7/15/2015 and signed by the administrator, reflected that the incident was witnessed by another resident, who stated he saw (Resident #708) run into (Resident #707) with her wheelchair and (Resident #707) grabbed her arm to move her out of the way. Review of a facility Incident Report for Resident #707, dated 7/15/2015 at 1:30 p.m., identified an incident, with the Type of Occurrence classified as Other: Specify___. No further details were provided in this section indicating the Type of Occurrence. Review of a handwritten witness statement attached to the above incident report, dated 7/15/2015 included the statement, I seen (sic) (Resident #707) push/shove (Resident #708) after she ran into him with her wheelchair. (Resident #707) dropped his phone, was upset, and push/shoved (Resident #708). Review of a facility Incident Report for Resident #707 identified a Guest to Guest incident on 9/16/2015 at 7:30 p.m. in front of the nurses' station. A handwritten statement attached to the incident report included the statement, I observed (Resident #707) hit (Resident #708) . (Resident #707) reached out and struck (Resident #708) three times with an open hand. He hit her on the head, chest, and arm as she was trying to pass by. Review of Care Conference Minutes , dated 9/17/2015, for Resident #707, indicated a Care Plan Review was completed. Interventions were identified, including New activity schedule . Guests were immediately separated. Continue with activity schedule and redirect other guests out of (Resident #707's) space. Review of a typed summary, dated 9/17/2015, attached to the incident report for Resident #707, indicated the resident's father was notified .that interventions have been put into place and that resident is choosing to not want to do any of the interventions at this time .resident has had multiple incidents with others this week and for the safety of everyone, SW is following up on alternate placement options . The summary did not indicate whether any further interventions were attempted to protect other residents from Resident #707. ( )

This citation pertains to intake #MI 944 and MI 101. Based on interview and record review, the Facility failed to provide Cardiopulmonary Resuscitation (CPR) and activate Emergency Medical Services (EMS) per facility policy and the professional standards of care in 1 of 5 sampled Residents (#501), from a total sample of 5 residents, resulting in an Immediate Jeopardy when Resident #501, whose advance directives indicated she wanted CPR and emergency medical treatment in the event of respiratory or cardiac failure, was found by Licensed Practical Nurse (LPN) #3 on [DATE] at 3:45 PM with no pulse or respirations and CPR and EMS were not initiated. Resident #501 subsequently died . These deficient practices placed 23 additional residents, designated as full code, at risk for serious harm, injury and/or death. Findings include: Review of the Facility's Policy and Procedure titled, "Cardiopulmonary Resuscitation (Heartsaver CPR)- Indiana, Michigan, Ohio and Virginia" with a revised date of [DATE] revealed; "Policy: Guests experiencing a respiratory and/or [MEDICAL CONDITION] will be treated by a trained staff member following the procedure directed by the American Heart Association, per facility policy. Licensed nursing personnel employed over 90 days will have and maintain a current CPR certification. For Guests who have designated a Health Care Directive to indicate that they wish CPR as defined by the American Heart Association. Heartsaver CPR guidelines are as follows: Chest Compression-Airway-Breathing". Bullet #9 indicated, "Staff will continue compressions and rescue breaths until the guest begins to move/respond or EMS arrives." "Procedure: 1. Upon notification or observance of a guest in respiratory and/or [MEDICAL CONDITION], immediately validate the guest's code status. 2. If the Guest's code status directs resuscitation, commence Heartsaver CPR following the directions outlined by the American Heart Association (per facility policy), while alternate staff obtains the Emergency Cart. 3. While Heartsaver CPR continues, have another staff member notify the physician and the family immediately. 4. Have another staff member notify 911 immediately for emergency transport to an acute care setting. 5. Document in the Progress Notes: ? Date and time of respiratory and/or [MEDICAL CONDITION]. ? Guest's activity prior to the occurrence. ? Date and time of notification of the physician and his/her response. ? Date and time of notification of the physician and his/her response. ? Date and time of transport to an acute care setting. Note: If the guest does not respond, once CPR has been initiated it may only be stopped by emergency transport personnel at the direction of a physician." According to the Fundamentals of Nursing (Potter and Perry, 6th ed., 2005), "[MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that the client has had a [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) must be initiated. CPR is a basic emergency procedure of artificial respirations and manual external cardiac massage." Per the American Red Cross First Aid and Safety Handbook (2011), "A person in [MEDICAL CONDITION] is unconscious, not breathing, and has no heartbeat." The Handbook revealed that "a person in [MEDICAL CONDITION] will have the greatest chance of survival if there is: 1). Early access to the emergency medical services (EMS) system, 2). Early CPR, 3). Early defibrillation, and 4). Early advanced medical care." The Handbook also revealed that "without early CPR and defibrillation, the chance for survival is greatly reduced." According to the Handbook, "once you begin CPR, do not stop except in one of these situations ...another trained responder or EMS personnel take over." Review of the closed, clinical record revealed Resident #501 was an [AGE] year old female admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS), dated [DATE] revealed her [DIAGNOSES REDACTED]. Review of the Facility's Emergency Response Directive form for Resident #501 revealed the following; "The (named Facility), is committed to respecting and promoting the dignity of its residents. We seek to provide care in a [MEDICATION NAME] way that honors resident's wishes within the parameters of the accepted standards of practice. In the event of an emergency or critical situation where a decision about immediate medical intervention is required, appropriate clinical decisions will be made in light of the directive below which you have signed and dated: RESUSCITATION: I understand that if my heart stops or my breathing stops, cardiopulmonary resuscitation (CPR) will be attempted, with emergency transportation to the hospital where full life support measures may be undertaken." This form was signed by Resident #501, and signed and dated by the Facility's Medical Director (Resident #501's attending physician) (MD) #10, on [DATE]. Review of the Physician order [REDACTED]. Review of LPN #3's written statement (recorded on facility progress/nurse's notes and in Resident #501's clinical record on [DATE] at 1:40 PM), revealed LPN #3 documented that she checked Resident #501 at 2:45 PM and found her oxygen saturation was 85% and her pulse was 60 beats per minute. According to LPN #3's statement, Resident #501 was breathing and moved her head (there was no documentation of any additional assessment completed at that time). LPN #3 documented she started her medication pass for an hour, then returned and found Resident #501 "cool to touch, yellow/gray in color, without Blood Pressure, without pulse, oxygen on and started hard sternal rub followed by chest percussions, then stopped". LPN #3's statement indicated she then left the room, left Resident #501 alone, and went to a different unit to find Registered Nurse (RN) #5. The statement indicated the Director of Nursing (DON) #6 was called but did not instruct them to start CPR or call 911. Resident #501 was removed from the facility by a local Funeral Home at 8:40 PM. In an interview on [DATE] at 4:05 PM, LPN #3 said on [DATE], she had worked the East side but usually worked on the West side of the nursing Facility. LPN #3 said she received shift report from LPN #4 informing her that Resident #501's blood oxygen levels had been from 73% to 90%. LPN #3 said she checked on Resident #501 at 3:15 PM and noted Resident #501 was breathing and she moved her head, and that Resident #501's oxygen was on and her oxygen saturation level was 85% and her pulse was 60 beats per minute. LPN #3 reported she did not obtain a blood pressure, respiration count, take a temperature, or listen to lung sounds of Resident #501. LPN #3 reported she returned to Resident #501's room at 3:45 PM and noticed her color was grayish yellow and her oxygen was on. LPN #3 said she did not see Resident #501's chest moving and was not able to obtain a pulse. LPN #3 said Resident #501's skin was cool to touch and she tried to arouse her but there was no response so she did a sternal rub, but still got no response. LPN #3 stated, "I started chest percussions for a couple minutes but didn't know if she was a full code." LPN #3 reported that after she did chest percussions on Resident #501 for a "couple minutes" she went to the West unit and asked Registered Nurse (RN) #5 for help. LPN #3 said RN #5 came to Resident #501's room and checked for a pulse and said it looked like she had been dead awhile. RN #5 did not start CPR or assess any other vital signs. LPN #3 reported she went to call the Director of Nursing (DON) #6 who asked her what Resident #501's code status was. LPN #3 reported she did not know, so DON #6 instructed her to check the medical record. LPN #3 looked and informed DON #6 she was a "full code". LPN #3 reported that DON #6 asked her if she had done chest compressions, to which she responded, "I started them but stopped". LPN #3 reported that DON #6 stated, "Once you start CPR you are not suppose to stop". In an interview on [DATE] at 11:55 AM, RN #5 reported that on [DATE], "it was close to 4:00 PM, I was getting ready to do a medication pass and had started checking blood sugars when (LPN #3) came up and said she couldn't get a pulse ox (blood oxygen level) on (Resident #501) and that she couldn't wake her." RN #5 said she had an orientee with her and she had to take everything off the top of her medication cart and lock it in the cart before she left to help LPN #3. RN #5 said she asked LPN #3 if she assessed Resident #501 and was told "no". RN #5 said she went to Resident #501's room and found her yellow/gold in color, her tongue was dry, her pupils were fixed and dilated and her skin on her arms was cool to touch. LPN #3 was doing a sternal rub when she walked in the room but RN #5 said she did not initiate CPR, she did not call 911 and that nobody called 911. RN #5 said after she left the room and was at the nurse's station she heard LPN #3 say she didn't know her code status. When asked what the facility's protocol was for a full code resident RN #5 said, "you have to initiate CPR until paramedics take over." In an interview on [DATE] at 2:45 PM, Certified Nurse Aide (CNA) #8 said at about 2:00 PM, she helped an x-ray technician with Resident #501 and Resident #501 was screaming, hot and mumbling/grumbling. CNA #8 said she left the room as the x-ray technician was getting the x-ray. CNA #8 went to the nurse's station and asked LPN #3 what was wrong with Resident #501 and that she did not receive a response from LPN #3. CNA #8 reported she the left the nurses station to care for other Residents. At 3:50 PM on [DATE], CNA #8 said another CNA (CNA #15) came and told her something was wrong with Resident #501 so she went into the residents room and LPN #3 was already there. CNA #8 said, "(Resident #501) was already gone. (Resident #501) was starting to yellow, her mouth had saliva. (Resident #501) was still warm." CNA #8 said LPN #3 checked her pulse oximetry and it "was in the 80%". CNA #8 reported that RN #5 and an orientee (RN #16) walked in and RN #5 checked Resident #501's pulse, then left the room to check her code status. CNA #8 said she didn't know what to do, she had only worked at the Facility 3 weeks. Review of the written statement dated [DATE] at 5:00 PM revealed CNA #8 documented that she walked into Resident #501's room, "checked her pulse and pressed on her chest and got no response". CNA #8 documented, "(Resident #501) was already yellow and starting to turn cold". In an interview on [DATE] at 4:45 PM, CNA #15 reported that she worked [DATE] from 2:00 PM-10:00 PM, but did not have Resident #501. CNA #15 said, "at 3:50 PM I saw other nurses going in room so I went in. I saw (LPN #3) rub (Resident #501's) chest and then she left the room. (CNA #8) and I were alone in the room with (Resident #501), and we didn't know what to do, so we went out and asked if we should clean her up and (LPN #3)eventually said "yes". Review of the physician order [REDACTED].#3 revealed the following instructions were written; "Release remains to funeral home of choice." In an interview on [DATE] at 12:30 PM, when asked if he had signed Resident #501's Emergency Response Directive, Medical Director (MD) #10 said, "yes that's my signature. I was both the Medical Director and her attending Physician." MD #10 said he received a call about 4:30 PM on [DATE] regarding Resident #501 and was told she had passed away. When asked what instructions were provided to the nursing staff, MD #10 said he inquired as to her code status and was told she was a "full code". MD #10 asked why had the patient expired here as a full code? MD #10 said he was told at the time of the assessment Resident #501 had been already expired for "some time". When asked about CPR, MD #10 said, "I would have expected that to occur". MD #10 did not instruct staff to start CPR or call 911. In a telephone interview on [DATE] at 3:20 PM, Nurse Practitioner (NP) #13 said she received a voice message on [DATE] from LPN #4 who informed her Resident #501 was coughing and had respiratory difficulty and said not to bother calling back she would just get an x-ray. NP #13 said about an hour later LPN #4 called back and reported on voice mail that Resident #501 was having low oxygen saturation levels, and requested a [MEDICATION NAME] breathing treatment order. NP #13 said she called back at approximately 2:00 PM and LPN #3 said Resident #501 was fine, gave vital signs which were fine, so she gave an order for [REDACTED]." NP #13 reported in the next telephone call about 4:30 PM on [DATE], facility staff informed her that Resident #501 passed away. NP #13 asked what time and LPN #3 said about an hour ago. NP #13 instructed them to call MD #10, but did not give any further instructions. In an interview on [DATE] at 2:40 PM, DON #6 said she received a call from RN #5, on [DATE] at about 3:50 PM, who informed her Resident #501 was deceased . DON #6 asked how long ago and RN #5 told her a half hour ago. DON #6 asked what her code status was and RN #5 handed the phone to LPN #3 who told her she was a full code. DON #6 said she told LPN #3 she should be doing CPR while someone else called 911. In an interview on [DATE] at 3:50 PM, Administrator (Admin) #7 said she received a call from DON #6 on [DATE] at about 4:00 PM to inform her Resident #501 passed away. Admin #7 said she asked why Resident #501 wasn't sent out to the hospital and DON #6 said she was still looking into it. When asked what her response to LPN #3 finding Resident #501 unresponsive Admin#7 said she asked the question, "Why didn't she do CPR?" The Administrator was notified on [DATE] at 4:08 PM of an Immediate Jeopardy that began on [DATE] and was identified on [DATE] as a result of the facility's failure to provide CPR and activate EMS per facility policy and the professional standards of care resulting in Resident #501, whose advance directives indicated she wanted CPR and emergency medical treatment in the event of respiratory or cardiac failure, was found by on [DATE] at 3:45 PM with no pulse or respirations and CPR and EMS were not initiated. Resident #501 subsequently died . On [DATE] the surveyor confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. On [DATE], all 70 Residents emergency directives were reviewed to assure they were completed. 2. On [DATE], an audit of all 70 of 70 resident's records were completed to ensure the code status was identified with a code status sticker on the inside cover of the medical records. 3. An audit of all 70 of 70 medication records revealed they had the resident's code status per the facility's new policy titled, "Code Status Location" implemented on [DATE]. 4. On [DATE], 18 of 23 Licensed nurse employee files contained current CPR certifications. 5. On [DATE], 2 of 2 emergency crash carts were checked to ensure appropriate supplies were available. 6. Beginning [DATE] through [DATE], 14 of 14 Licensed Practical Nurses and on [DATE], 9 of 9 Registered Nurses were provided education regarding the facility policy on CPR. The following education was provided: A. If a resident is found unresponsive, attempt to arouse the individual. If the resident has no movement or response to stimuli, and no return of pulse and/or respirations, staff are to check the code status in the resident's chart and/or MAR and activate the facility's CPR policy. If the resident is a full code, a nurse will initiate CPR while another staff member calls 911, notifies the physician and the resident's legal representative. If CPR is initiated, it shall continue until care is transferred to EMS in accordance with the facility's CPR policy. B. Physician notification of Resident's Death C. SBAR guidelines for physician notification when there is a change in respiratory status. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the scope of pattern and severity of no actual harm with the potential for more than harm that is not Immediate Jeopardy due to all staff had not been in-serviced and sustained compliance had not yet been verified by the State Agency. #

This citation pertains to intake #MI 944 and MI 101. Based on interview and record review, the Facility failed to provide the necessary care and services to maintain the highest practicable physical and mental well-being by not assessing, monitoring, and providing prompt intervention for an acute change of condition in 1 of 5 sampled Residents (#501), from a total sample of 5 residents, resulting in an Immediate Jeopardy (IJ) when Resident #501 experienced respiratory distress beginning on the morning of [DATE], had a decreased oxygen level of 73% on [DATE] at 1:15 PM and was found unresponsive with no heartbeat and no respirations on [DATE] at 3:45 PM at which time facility staffs failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) and activate Emergency Medical Services (EMS), despite Resident #501's designation as a full code. These deficient practices placed all Residents, who have the potential for an acute change of condition, at risk for serious harm, injury and/or death. Findings include: Review of the closed, clinical record revealed Resident #501 was an [AGE] year old female admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS), dated [DATE] revealed her [DIAGNOSES REDACTED]. During interviews conducted on [DATE] at 1:55 PM and [DATE] at 10:50 AM, Certified Nurse Assistant (CNA) #1 said she worked on [DATE] from 6:00 AM until 2:00 PM and was assigned to care for Resident #501. CNA #1 said that on [DATE], Resident #501 was "especially real lethargic and yelled out help me a lot." CNA #1 said right before lunch "it took a turn" (for the worse, indicated CNA #1). CNA #1 said when she tried to dress Resident #501 it took 3 different attempts to stand her and normally it only took 1. CNA #1 reported that Resident #501 was unable to sit up in a wheelchair because she was so lethargic that she"leaned way over to the left side" over the armrest in the wheelchair. CNA #1 said she had to use a pillow to tilt/prop Resident #501 upright in the wheelchair, but then Resident #501 began to lean forward and "luckily" (CNA #2) was walking in the hallway and came "darting in the room to catch" Resident #501 from falling forward. CNA #1 said she was assisting Resident #501's roommate (#503), at the time and knew it was 10:00 AM because Resident #503 always gets up at 10:00 AM. CNA #1 said she and CNA #2 did not feel Resident #501 was safe in her wheelchair, so they (she and CNA #2) transferred Resident #501 back into the bed. CNA #1 stated, "that's when I noticed she had a lot of fluid on her lungs and was gurgling. She's been pneumonia on and off. So I told (LPN #4) about 10:45 AM about it." CNA #1 reported that a volunteer was sitting with Resident #501 and that "she (Resident #501) was really getting anxious, the 'help me's' had really escalated". In an interview on [DATE] at 11:35 AM, CNA #2 said on [DATE], she was walking down the hallway from the West end to the East and "I noticed out of the corner of my eye (Resident #501) was leaning forward". CNA #2 said she touched Resident #501 on the forehead and asked her if she wanted to lay down. CNA #2 said she then helped CNA #1 put Resident #501 back to bed. Review of the Physician order [REDACTED].#4 revealed, "CXR-Ap &lat today-cough/congestion and increased confusion" (chest x-ray-Apical and Lateral today-cough/congestion and increased confusion). Review of the Nurse's notes dated [DATE] at 1:30 PM, LPN #4 documented, "Resident (Resident #501) yelling out from room. Color pale, had removed oxygen, increased loose moist cough noted. Oxygen replaced. Head of bed elevated. BP ,[DATE] Pulse 78 respirations 24 temperature 98.4 (orally), pulse oximetry ranging from 73%-90%....Color improved with oxygen back on. Appetite poor. Restless in bed. (NP #13) notified of respiratory difficulties and pulse oximetry ,[DATE] (%). Chest x-ray ordered Ap & lat. x-ray here and notified. Resting quietly in bed now with oxygen on and Head of Bed elevated. Volunteer at bedside. (Guardian) notified of respiratory problems and chest x-ray ordered per answering machine. Chest x-ray taken at 1:30 PM." Nurse's notes (not dated and not timed) was written "Add on: Loose moist cough noted also." Review of the care plan for Resident #501 titled, "respiratory difficulty: potential for breathing difficulty related to [MEDICAL CONDITIONS] and oxygen dependant" and dated as last reviewed on [DATE] revealed instructions for nursing to "assess and document signs and symptoms of respiratory difficulty, report abnormal findings to physician". Review of the Physician order [REDACTED]. The order also instructed nursing staff to "administer oxygen at 3 liters per minute per nasal canula and check the pules oxymetry every shift and notify physician if less then 90%". In an interviews conducted on [DATE] at 3:37 PM and [DATE] at 11:35 PM, LPN #4 said she worked on [DATE] from 6:00 AM-2:00 PM and was the Charge Nurse for Resident #501. LPN #4 reported that CNA #1 did not notify her that Resident #501 was "gurgling and leaning" over, that she was unaware Resident #501 was "even up that day", or that she was lethargic. LPN #14 said she gave Resident #501 her medications about 7:30 AM and did not go into her room again until 1:15 PM. LPN #4 said that at 1:15 PM, CNA #9 told Resident #502 to get her because she needed to look at Resident #501. LPN #4 went to look at Resident #501 and saw her sitting on the edge of the bed so she laid her down. LPN #4 reported Resident #501's pulse oximetry (blood oxygen level) was at 73% (normal is greater than 95%) and her oxygen was off. LPN #4 reported she put her oxygen back on about 1:30 PM at 3 liters per minute and that Resident #501's pulse oximetry up to 75%. LPN #4 reported the next time she checked Resident #501's pulse oximetry, it was 78%. LPN #4 reported mobile x-ray was at the Facility for another resident she called Nurse Practitioner (NP) #13 and left a voice message saying she was obtaining a chest x-ray for Resident #501 and a second voice message stating her pulse oximetry was in the 70's%. LPN #4 reported she did not notify NP #13 that Resident #501's lungs sounds were "rattlely. I would tell her when she called back." LPN#4 said she gave report to LPN #3 at 1:45 PM but did not tell her about Resident #501's lung sounds. LPN #4 reported she did not send Resident #501 to the hospital because, "I thought she probably had pneumonia and to get a nebulizer treatment and that would take care of it." The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). The profession standard of quality for notifying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated [DATE]). Review of the Physician order [REDACTED].#3 revealed the following instructions were written; "[MEDICATION NAME] q 4 o while awake x 5 days" ([MEDICATION NAME] treatment every 4 hours while awake for 5 days). Review of the Nurse's note dated [DATE] at 2:20 PM, signed by LPN #3 was written, "new order per (NP #13), Duo Neb every 4 hours times 5 days while awake." There was no additional documentation regarding Resident #501's assessment or if Resident #501 had any additional monitoring for an acute change of condition such as lung sounds, temperature, pulse, respirations, or blood pressure. Review of the clinical record revealed there was no additional documentation in Resident #501's record to indicate facility staff had assessed and/or closely monitored Resident #501 on [DATE] after she was noted by CNA #1 to have a change in her condition at 10:00 AM and reported her findings to LPN #4 at 10:45 AM. In an interview on [DATE] at 4:05 PM, LPN #3 said her shift to work on [DATE] was from 2:00 PM until 10:00 PM. LPN #3 said on [DATE] she worked on the East side but usually worked on the West side of the Facility. LPN #3 said she received a report from LPN #4 informing her Resident #501's oxygen saturation blood levels were 73% to 90% and that she was supposed to be on oxygen. LPN #3 said she took the call when NP #13 called back at approximately 2:10 PM. LPN #3 said NP #13 ordered a [MEDICATION NAME] treatment 4 times a day. LPN #3 said the X-ray people were in the facility, and did an x-ray on Resident #501. LPN #3 said she checked on Resident #501 at 3:15 PM (1 hour and 15 minutes after her shift started) and noted Resident #501 was breathing, said "she moved her head", and her oxygen saturation level was 85% with a pulse was 60 beats per minute. LPN #3 reported she did not obtain a blood pressure, count the respirations, take a temperature, or listen to Resident #501's lung sounds. LPN #3 did not say if Resident #501 was awake and able to speak. LPN #3 reported she proceeded with her medication pass and at 3:45 PM, she returned to Resident #501's room and noticed her color was grayish/yellow and her oxygen was on. LPN #3 said she did not see Resident #501's chest moving and was not able to obtain a pulse. LPN #3 said Resident #501's skin was cool to touch and she tried to arouse her but there was no response so she did a sternal rub, still no response so, she stated, "I started chest percussions for a couple minutes but didn't know if she was a full code." LPN #3 reported that she asked Registered Nurse (RN) #5 and that RN #5 came to Resident #501's room and checked for a pulse and said it looked like she had been dead "awhile". In an interview on [DATE] at 11:55 AM, RN #5 said, "it was close to 4:00 PM and she was getting ready to do a medication pass when (LPN #3) came up to her and said she couldn't get a pulse ox (oximetry) on (Resident #501) and she couldn't wake her." RN #5 said she asked LPN #3 if she assessed Resident #501 and was told "no". RN #5 said she went to Resident #501's room and "she was like a yellow/gold color, her tongue was dry, her pupils were fixed and dilated (did not state how she checked Resident #501's pupils), and her skin on her arms was cool to touch." RN #5 said she left the room and was at the nurse's station when she heard LPN #3 say she didn't know her code status. Review of the Physician order [REDACTED].#3, revealed the following instructions were written; "Release remains to funeral home of choice." In an interview on [DATE] at 2:45 PM, CNA #8 said at approximately 2:00 PM, she helped an x-ray technician with Resident #501 and that Resident #501 was screaming, hot and mumbling/grumbling. CNA #8 reported she asked LPN #3 what was wrong with Resident #501 but did not receive a response from LPN #3, so she left to care for other Residents. At 3:50 PM on [DATE], CNA #8 said CNA #15 told her something was wrong with Resident #501 so she went into her room and LPN #3 was already in the room. CNA #8 said, "(Resident #501) was already gone and was starting to yellow, her mouth still had saliva, and was still warm." CNA #8 stated that (LPN#3) "was in the room" and did a pulse oximetry and that it "was in the 80%". CNA #8 reported that Resident #501 had oxygen on but said she tried to feel a pulse and checked both wrist, and could not feel one. CNA #8 reported that RN #5 walked in and, "checked the pulse I think and then left the room to check her code status". CNA #8 said she asked LPN #3 if they should "clean her up" and LPN #3 said "yeah". In an interview on [DATE] at 4:45 PM, CNA #15 reported that she worked [DATE] from 2:00 PM-10:00 PM, but did not have Resident #501. CNA #15 said, "at 3:50 PM I saw other nurses going in room so I went in. I saw (LPN #3) rub (Resident #501's) chest and then she left the room. (CNA #8) and I were alone in the room with (Resident #501), and we didn't know what to do, so we went out and asked if we should clean her up and (LPN #3)eventually said "yes". Review of the statement written completed by the Administrator (Admin) #7 on [DATE] (no time), as she interviewed volunteer (V) #18 regarding Resident #501 on [DATE] revealed V #18 told Admin #7 on [DATE] that he was at the Facility at 2:30 PM and that every time he passed by Resident #501's room she "was crying for help". V #18 went into her room and Resident #501 called him (a different man's first name), and said she loved him and asked him to help her. V #18 said she was "mentally distressed" and he held her hand. V #18 said a nurse came in and put her oxygen on and moved the head of her bed up. V #18 said Resident #501 "had a raspy, wet breathing. I tried to give her a drink and she spit it out." V #18 said he last checked on her (Resident #501) at 3:05 PM and she was "still breathing or sleeping". Review of the Facility's Emergency Response Directive form for Resident #501 revealed the following; "The (named Facility), is committed to respecting and promoting the dignity of its residents. We seek to provide care in a [MEDICATION NAME] way that honors resident's wishes within the parameters of the accepted standards of practice. In the event of an emergency or critical situation where a decision about immediate medical intervention is required, appropriate clinical decisions will be made in light of the directive below which you have signed and dated: RESUSCITATION: I understand that if my heart stops or my breathing stops, cardiopulmonary resuscitation (CPR) will be attempted, with emergency transportation to the hospital where full life support measures may be undertaken." This form was signed by Resident #501, and signed and dated by the Facility's Medical Director (Resident #501's attending physician - MD) #10, on [DATE]. In an interview on [DATE] at 12:30 PM, when asked if he had signed Resident #501's Emergency Response Directive, MD #10 said, "yes that's my signature. I was both the Medical Director and her attending Physician." MD #10 said he received a call about 4:30 PM on [DATE] regarding Resident #501 and was told she had passed away. In a telephone interview on [DATE] at 3:20 PM, NP #13 said she received a voice message on [DATE] from LPN #4 who informed her Resident #501 was coughing and had respiratory difficulty and said not to bother calling back she would just get an x-ray. NP #13 said about an hour later LPN #4 called back and left a message that Resident #501 was having low oxygen saturation levels, and could she order a [MEDICATION NAME] breathing treatment. NP #13 said she called back at approximately 2:00 PM and LPN #3 answered and said Resident #501 was fine, gave vital signs which were fine so she gave an order for [REDACTED].#13 said she got a call about 4:30 PM that Resident #501 passed away but did not give any information. NP#13 asked what time and LPN#3 said about an hour ago. Review of the chest x-ray done on [DATE] at 2:09 PM revealed Resident #501 had, "Cardiomegaly is noted with atheromatous changes and vascular graft in the descending aorta. Post surgical sternal sutures are noted in position. Compared to the previous examination of [DATE], there appears to be some accentuation of the [MEDICAL CONDITION] vasculature in both lower lung fields and early infiltrate in the right lung base. Clinical correlation is requested. The lung fields are otherwise essentially clear." In an interview on [DATE] at 10:40 AM, as MD #10 reviewed the chest x-ray for Resident #501 dated [DATE] and when asked what "clinical correlation is required" meant MD #10 said, "a hands on assessment is necessary or recommended." When asked if an assessment was suggested MD #10 said, "Yes, an assessment is suggested". Resident #503 was an [AGE] year old woman admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed her [DIAGNOSES REDACTED]. In an interview on [DATE] at 1:10 PM, Resident #503, (Resident #501's roommate), said Resident #501 came back from Bingo the other day and "looked kinda funny". Resident #503 said Resident #501 said "her tongue felt thick". Resident #503 said, "they didn't pay no attention to her". When asked who didn't pay any attention to Resident #501, staff? Resident #503 said, "yeah. Then she just never got better." Review of the Facility activity calendar for [DATE] revealed the last Bingo held prior to Resident #501's death was on [DATE] at 2:00 PM. In an interview on [DATE] at 2:40 PM, DON #6 said she received a call from RN #5 on [DATE] at about 3:50 PM, who informed her Resident #501 was deceased . DON #6 asked how long ago and RN #5 told her a half hour ago. DON #6 asked what her code status was and that RN #5 handed the phone to LPN #3 who told her she was a full code. DON #6 said reported that she told LPN #3 she should have been doing CPR while someone else called 911. DON #6 said she then told LPN #3 to make sure the staff clean Resident #501 up. In an interview on [DATE] at 3:50 PM, Admin #7 said she received a call from DON #6 on [DATE] at about 4:00 PM to inform her Resident #501 passed away. Admin #7 said she asked why Resident #501 wasn't sent out to the hospital and DON #6 said she was still looking into it. When asked what her response to LPN #3 finding Resident #501 unresponsive Admin#7 said she asked the question, "Why didn't she do CPR?" Admin #7 reported she called her corporate office and was asked why hadn't Resident #501 been sent out to the hospital. The Administrator was notified on [DATE] at 4:08 PM of an Immediate Jeopardy that began on [DATE] and was identified on [DATE] as a result of the facility's failure to provide the necessary care and services to maintain the highest practicable physical and mental well-being by not assessing, monitoring, and providing prompt intervention for an acute change of condition when Resident #501 experienced respiratory distress, had a decreased oxygen level, and was found unresponsive on [DATE] at 3:45 PM. On [DATE] the surveyor confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. On [DATE], all 70 Residents' emergency directives were reviewed to assure they were completed. 2. On [DATE], 21 of 23 Licensed Nurses were provided education, the 2 who were on vacation, will receive the education prior to returning to work. The education included: A. SBAR guidelines for physician notification when there is a change in respiratory status and the "Stop and Watch" process. B. When a resident exhibits an acute change in condition, the nurse will assess the resident, obtain vital signs, and utilize the clinical process guidelines as a resource and the SBAR algorithm. The physician will be notified and frequency of follow-up monitoring will be requested. In the absence of physician directed monitoring, the licensed nurse will complete follow-up monitoring/assessment every 15 minutes until the resident's vitals and/or condition are within the designated parameters or the resident has returned to baseline for 3 consecutive assessments. If the resident's condition or vitals worsen, the physician is to be notified. If the physician has not called back within 15 minutes the nurse has the authority to call 911 and transfer the resident to the hospital. C. Implemented and educated all nurses on Abnormal Pulse Oximetry Readings on [DATE]. 3. On [DATE], 26 of the 37 nursing assistants were re-educated on the SBAR Stop and Watch process when they notice a change in the resident's condition. The nursing assistants will complete a Stop and Watch form which should be given to the nurse upon completion. If the resident's change in condition is an emergent situation, such as difficulty breathing, complaints of chest pain, vomiting, bleeding, unresponsiveness, or change in cognition, the nursing assistant immediately notifies the nurse and the nurse will immediately assess the resident. A. When the nurse receives a Stop and Watch notification, the nurse will assess the resident and obtain vital signs, follow the Interact II algorithm, and notify the physician as indicated. If the resident has a significant or life threatening change in condition and the physician has not called within 15 minutes, the nurse has the authority to call 911. All other nursing assistants will be educated prior to their next shift Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the scope of widespread and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced and sustained compliance had not yet been verified by the State Agency. #

This citation pertains to intake #MI 944 and MI 101. Based on interview and record review, the Facility failed to notify the Physician in a timely manner of an acute change of condition in 1 of 5 sampled Residents (#501), from a total sample of 5 residents, resulting in Resident #501 who had lethargy, was pale in color, low blood oxygen levels, and a moist cough with respiratory difficulty, being found unresponsive with no heartbeat and no respirations and subsequently died . Findings include: The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). The profession standard of quality for notifying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated [DATE]). Review of the closed, clinical record revealed Resident #501 was an [AGE] year old woman who was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS), dated [DATE] revealed her [DIAGNOSES REDACTED]. During interviews conducted on [DATE] at 1:55 PM and [DATE] at 10:50 AM, Certified Nurse Assistant (CNA) #1 reported that she worked on [DATE] from 6:00 AM until 2:00 PM and was assigned to care for Resident #501. CNA #1 said that on [DATE], Resident #501 was "real lethargic and yelled out 'help me' a lot." CNA #1 said right before lunch "it took a turn (for the worse)". CNA #1 said when she tried to dress Resident #501 it took 3 different attempts to stand her and normally it only took 1 and that Resident #501 was not able to sit up in a wheelchair either because she was so lethargic, "she leaned way over to the left side" over the armrest in the wheelchair. CNA #1 said she used a pillow to tilt/prop Resident #501 upright in the wheelchair, but Resident #501 began to lean forward and that "luckily" CNA #2 was walking in the hallway and came "darting in the room to catch" Resident #501 as she was falling forward. CNA #1 said she was assisting Resident #501's roommate at the time, and knew it was 10:00 AM, because Resident #501's roommate always gets up at 10:00 AM. CNA #1 said she and CNA #2 did not feel Resident #501 was safe in her wheelchair and so they transferred Resident #501 back to her bed. CNA #1 stated, "that's when I noticed she had a lot of fluid on her lungs and was gurgling. She's been pneumonia on and off. So I told (Licensed Practical Nurse/LPN #4) about 10:45 AM about it." CNA #1 reported that a volunteer was sitting with Resident #501 and that "she (Resident #501) was really getting anxious, the 'help me's' had really escalated". Review of the Physician order [REDACTED].#4 revealed Resident #501 was ordered "CXR-Ap & lat today-cough/congestion and increased confusion (chest x-ray-today-front and side, cough/congestion and increased confusion). Review of the Nurse's Notes for Resident #501 on [DATE] at 1:40 PM, dated [DATE] at 1:30 PM and signed by LPN #4 was written, "Resident yelling out from room. Color pale, had removed oxygen, increased moist cough noted. Oxygen replaced. Head of bed elevated. BP ,[DATE] Pulse 78 respirations 24 temperature 98.4 (orally), pulse oximetry ranging from 73%-90%....Color improved with oxygen back on. Appetite poor. Restless in bed. Nurse Practitioner (NP) #13 notified of respiratory difficulties and pulse oximetry ,[DATE]. Chest x-ray ordered Ap & lat. x-ray here and notified. Resting quietly in bed now with oxygen on and Head of Bed elevated. Volunteer at bedside. (named guardian), notified of respiratory problems and chest x-ray ordered per answering machine. Chest x-ray taken at 1:30 PM." A Nurse's notes (not dated and not timed) was written "Add on: Loose moist cough notes also." There was no documentation of continued monitoring of Resident #501's blood oxygen level or continued status. Review of the physician order [REDACTED].#3, revealed Resident #501 had orders for, "[MEDICATION NAME] q 4 while awake x 5 days" ([MEDICATION NAME] treatment every 4 hours while awake for 5 days). Review of the Nurse's Notes dated [DATE] at 2:20 PM (1 hour and 10 minutes after last nursing note which indicated low oxygen levels), signed by LPN #3 was written, "new order per (NP #13), Duo Neb every 4 hours times 5 days while awake." There was no other documentation of any assessment or monitoring that had been done for Resident #501, such as lung sounds, temperature, pulse, respiration, or blood pressure. Review of the physician order [REDACTED].#3, revealed the following instructions were written for Resident #501; "Release remains to funeral home of choice." Review of the physician order [REDACTED].#4 revealed the following instructions were written for Resident #501; "code status" and an X next to "Resuscitate" was handwritten. The monthly physician order [REDACTED]. Review of the care plan for Resident #501 titled, "respiratory difficulty: potential for breathing difficulty related to [MEDICAL CONDITIONS] and oxygen dependant" and dated as last reviewed on [DATE] revealed instructions for nursing to "assess and document signs and symptoms of respiratory difficulty, report abnormal findings to physician." In an interview on [DATE] at 3:37 PM, LPN #4 said she worked on [DATE] during the day (6:00 AM-2:00 PM), and was the Charge Nurse for Resident #501. LPN #4 said at 1:15 PM, CNA #9 told another resident to come and get her because she needed to look at Resident #501. LPN #4 reported she went to look at Resident #501 and saw her sitting on the edge of the bed and helped her lay down. LPN #4 said Resident #501 had respiratory problems and didn't eat much. LPN #4 knew mobile x-ray was at the Facility for different resident and stated she called NP #13 and "left a voice message saying she was obtaining a chest x-ray for Resident #501 due to respiratory problems". LPN #4 said Resident #501's pulse oximetry reading dropped from 90% at 7:30 AM to 73%. LPN #4 said she left a second voice message at approximately 1:30 PM with NP #13 regarding Resident #501's low oxygen saturation levels. LPN #4 said she went back into Resident #501's room and her oxygen saturation level was low at 78%, then left to give end of shift report to LPN #3 at 1:45 PM. LPN #4 did not include, in report, the information regarding Resident #501's acute change in condition on [DATE] which included the symptoms of lethargy, loss of appetite, severe loss of balance, yelling out and whose oxygen saturation level dropped from 90% at 7:30 AM to 73% at approximately 1:30 PM and did not go above 78% at 1:45 PM. In an interview on [DATE] at 4:05 PM, LPN #3 said she received a report from LPN #4 informing her Resident #501's oxygen saturation blood levels were 73% to 90%. LPN #3 said NP #13 returned a call made be LPN #4, at was approximately 2:10 PM. LPN #3 said NP #13 told her it sounded like Resident #501 was blocked up and ordered a [MEDICATION NAME] treatment 4 times a day. LPN #3 said she checked on her at 3:15 PM and noted Resident #501 was breathing and she moved her head, but did not say Resident #501 was awake. LPN #3 said Resident #501's oxygen was on and her oxygen saturation level was 85% and her pulse was 60 beats per minute. LPN #3 did not obtain a blood pressure, count her respirations, nor did she take a temperature, or listen to Resident #501's lung sounds. At 3:45 PM, LPN #3 said she returned to Resident #501's room and noticed her color was grayish yellow and her oxygen was on. LPN #3 said she did not see Resident #501's chest moving and was not able to obtain a pulse. LPN #3 said Resident #501's skin was cool to touch and she tried to arouse her but there was no response so she did a sternal rub, still no response so, she stated, "I started chest percussions for a couple minutes but didn't know if she was a full code." Review of LPN #3's written statement (recorded on facility progress/nurse's notes and in Resident #501's clinical record on [DATE] at 1:40 PM), revealed LPN #3 wrote she checked Resident #501 at 2:45 PM and her oxygen saturation was 85% and her pulse was 60 beats per minute. According to her statement Resident #501 was breathing and moved her head. There was no documentation written regarding Resident #501's mental status, lung sounds or vital signs. LPN #3 wrote she started her medication pass for an hour, then returned and found Resident #501 "cool to touch, yellow/gray in color, without Blood Pressure, without pulse oxygen and started hard sternal rub followed by chest percussions, then stopped, walked out of the room, leaving Resident #501 alone and went to find Registered Nurse (RN) #5. LPN #3 documented that RN #5 instructed her to go back and "assess" Resident #501. LPN #3 did not document an assessment of Resident #501 in the nurses notes or in her statement written at 9:15 PM (5 and a half hours after she found Resident #501 without a Blood Pressure or pulse oxygen count). In an interview on [DATE] at 12:30 PM, Physician (MD) #10 reported that NP #13 had told him she received 2 calls from the Facility on [DATE] regarding Resident #501, however the first was regarding a chest x-ray and the second was the results of the x-ray and requesting a Nebulizer treatment. MD #10 said NP #13 did not inform him if she received notification from the Facility regarding Resident #501 being lethargic, having a severe balance problem and not being able to sit up in a chair, loss of appetite or yelling out during the day. In a telephone interview on [DATE] at 3:20 PM, NP #13 said she received a voice message on [DATE] from LPN #4 who had stated Resident #501 was coughing and had respiratory difficulty and said not to bother calling back she would just get an x-ray. NP #13 said about an hour later LPN #4 called back to voice mail and reported Resident #501 was having low oxygen saturation levels and requested an order for [REDACTED].#13 said she got a call about 4:30 PM that Resident #501 passed away "about an hour ago". NP #13 instructed LPN #3 to call MD #10. NP #13 did not give any other instructions. NP #13 reported she did not receive a call from LPN #3 regarding Resident #501's low blood oxygen level of 85% at 2:45 PM. NP #13 said she was not told that Resident #501 was lethargic, screaming out, or had been unable to sit in a wheelchair due to leaning on [DATE]. #

This citation pertains to intake #MI 944 and MI 101 Based on interview and record review, the Facility failed to allow a Resident to exercise their rights as a citizen of the Facility by following a signed Advanced Directive in 1 of 5 sampled Residents (#501), resulting in Cardio [MEDICAL CONDITION] Resuscitation (CPR) and Emergency Medical Services (EMS) not being immediately initiated when Resident #501 was found unresponsive with no heartbeat and no respirations on [DATE] at 3:45 PM despite her designation as a full code. Findings include: Review of the closed, clinical record revealed Resident #501 was an [AGE] year old woman who was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS), dated [DATE] revealed her [DIAGNOSES REDACTED]. Review of the Facility's Emergency Response Directive form revealed the following; "The (named Facility), is committed to respecting and promoting the dignity of its residents. We seek to provide care in a [MEDICATION NAME] way that honors resident's wishes within the parameters of the accepted standards of practice. In the event of an emergency or critical situation where a decision about immediate medical intervention is required, appropriate clinical decisions will be made in light of the directive below which you have signed and dated: RESUSCITATION: I understand that if my heart stops or my breathing stops, cardiopulmonary resuscitation (CPR) will be attempted, with emergency transportation to the hospital where full life support measures may be undertaken." This form was signed by Resident #501, and signed and dated by the Facility's Medical Director and Resident #501's attending physician (MD #10), on [DATE]. In an interview on [DATE] at 12:30 PM, when asked if he had signed Resident #501's Emergency Response Directive, MD #10 said, "yes that's my signature. I was both the Medical Director and her attending Physician." MD #10 said he received a call about 4:30 PM on [DATE] regarding Resident #501 and was told she had passed away. When asked what instructions he gave MD #10 said he inquired as to her code status and was told she was a "full code". MD #10 was asked why had the patient expired here as a full code? MD #10 said he was told at the time of the assessment Resident #501 had already expired for "some time". When asked about CPR, MD #10 said, "I would have expected that to occur". MD #10 did not instruct staff to start CPR and call 911. In an interview on [DATE] at 2:45 PM, Certified Nurse Aide (CNA) #8 said she worked on [DATE] from 2:00 PM-10:00 PM and at 3:50 PM on [DATE], CNA #8 said CNA #15 told her something was wrong with Resident #501. CNA #8 stated she went to Resident #501's room and Licensed Practical Nurse (LPN) #3 was already there. CNA #8 said, "(Resident #501) was already gone. (Resident #501) was starting to yellow, her mouth still had saliva". CNA #8 stated, "(LPN #3) was in the room" and that "(Resident #501) was still warm." CNA #8 said LPN #3 checked Resident #501's blood oxygen level and it "was in the 80%". CNA #8 stated that Resident #501 had oxygen on and she tried to feel a pulse and checked both wrist, but could not feel one. CNA #8 stated Registered Nurse (RN) #5 entered the room and that RN #5 checked the pulse "I think, and then left the room to check her code status". CNA #8 said she heard RN #5 say Resident #501 was a full code. CNA# 8 said that LPN #3 and RN #5 did not do CPR. In an interview on [DATE] at 4:45 PM, CNA #15 said she worked on [DATE] from 2:00 PM-10:00 PM but did not have Resident #501. CNA #15 said, "at 3:50 PM I saw other nurses going in room so I went in. I saw (LPN #3), rub (Resident #501's), chest and then she left the room. (CNA #8) and I were alone in the room with (Resident #501), and we didn't know what to do so we went out and asked if we should clean her up and (LPN #3) eventually said yes." In an interview on [DATE] at 4:05 PM, LPN #3 said she worked on [DATE] from 2:00 PM until 10:00 PM. LPN #3 said on [DATE], she had worked on the East side but usually worked on the West side. LPN #3 said she received a report from LPN #4 informing her Resident #501's oxygen saturation blood levels were 73% to 90%. At 3:45 PM, LPN#3 said she went to Resident #501's room and noticed her color was grayish yellow and her oxygen was on. LPN #3 said she did not see Resident #501's chest moving and was not able to obtain a pulse. LPN #3 said Resident #501's skin was cool to touch and she tried to arouse her but there was no response so she did a sternal rub, and still got no response so. LPN #3 stated, "I started chest percussions for a couple minutes but didn't know if she was a full code." LPN #3 said after she did chest percussions on Resident #501 for a couple minutes (did not know how long), she left Resident #501, alone, and went to the West unit and asked RN #5 to help her. LPN #3 said RN #5 came to Resident #501's room and checked for a pulse and said it looked like she had been dead awhile. LPN #3 stated RN #5 did not start CPR. LPN #3 said she left Resident #501 a second time and called the Director of Nursing (DON) #6 who asked what Resident #501's code status was. LPN #3 stated she did not know and that DON #6 instructed her to check the file. LPN #3 stated she checked the clinical record and informed DON #6 she was a "full code". LPN #3 stated DON #6 asked her if started compressions, and LPN #3 told her she started them but stopped and LPN #3 said DON #6 told her "once you start CPR you are not suppose to stop". In an interview on [DATE] at 11:55 AM, RN #5 said she worked on [DATE] from 6:AM-6:PM on the West side of the Facility. RN #5 said, "it was close to 4:00 PM and she was getting ready to do a medication pass and had started checking blood sugars when (LPN #3) came up to her and said she couldn't get a pulse ox (blood oxygen saturation reading) on (Resident #501) and she couldn't wake her." RN #5 said she had an orientee with her and she had to take everything off the top of her medication cart and lock it in the cart before she left to help LPN #3. RN #5 said she asked LPN #3 if she assessed Resident #501 and was told "no". RN #5 said she went to Resident #501's room and she was like a yellow/gold color, her tongue was dry, her pupils were fixed and dilated and her skin on her arms was cool to touch. LPN #3 was doing a sternal rub when she walked in the room, but RN #5 said she did not initiate CPR, she did not call 911 and that nobody called 911. When asked what the facility's protocol was for a full code resident RN #5 said, "you have to initiate CPR until paramedics take over." Review of LPN #3's written statement (recorded on facility progress/nurse's notes and in Resident #501's clinical record on [DATE] at 1:40 PM), revealed LPN #3 wrote she checked Resident #501 at 2:45 PM and found her oxygen saturation was 85% and her pulse was 60 beats per minute. According to LPN #3's statement, Resident #501 was breathing and moved her head. LPN #3 documented she started her medication pass for an hour, then returned and found Resident #501 "cool to touch, yellow/gray in color, without Blood Pressure, without pulse oxygen and started hard sternal rub followed by chest percussions, then stopped, walked out of the room, leaving Resident #501 alone and went to a different unit to find RN #5. The statement indicated DON #6 was called but did not instruct them to start CPR or call 911. Resident #501 was removed from the facility by a local Funeral Home at 8:40 PM In a telephone interview on [DATE] at 3:20 PM, Nurse Practitioner (NP) #13 said she got a call about 4:30 PM that Resident #501 passed away but did not give any information. NP #13 asked what time and LPN #3 said about an hour ago. NP #13 asked if they called MD #10, was told no, so she instructed them to call MD #10. NP #13 did not give any other instructions. In an interview on [DATE] at 2:40 PM, DON #6 said she received a call from RN #5, on [DATE] at about 3:50 PM, who informed her Resident #501 was deceased . DON #6 asked how long ago and RN #5 told her a half hour ago. DON #6 asked what her code status was and RN #5 handed the phone to LPN #3 who told her she was a full code. DON #6 said she told LPN #3 she should have been doing CPR while someone else called 911. DON #6 said LPN #3 told her she did a sternal rub and some chest percussions. When asked if she instructed LPN #3 to perform CPR on Resident #501, DON #6 responded, "CPR on a deceased person? You don't do CPR on a deceased person." DON #6 said she told LPN #3 to make sure the staff clean Resident #501 up. In an interview on [DATE] at 3:50 PM, Administrator (Admin) #7 said she received a call from DON #6 on [DATE] at about 4:00 PM to inform her Resident #501 passed away. Admin #7 said she asked why Resident #501 wasn't sent out to the hospital and DON #6 said she was still looking into it. Admin #7 said she asked the question, "Why didn't she do CPR?" (referring to LPN #3). #

Based on observation, interview, and record review, the facility failed to provide a safe environment per the care plan in 1 of 5 sampled residents (Resident #801), from a total sample of 5 residents, resulting in an Immediate Jeopardy when Resident #801, who had a known history of spilling hot coffee onto herself on 1/14/10 and had a care plan for coffee to be served at a temperature of less than 120 degrees Fahrenheit, spilled hot coffee onto her lap on 2/22/12 at 11:10 AM which was at a temperature greater than 140 degrees Fahrenheit, resulting in second degree burns to her groin. This deficient practice places all residents, who have been care planned for the potential to be burned from hot liquids, at risk for serious harm and/or injury. Findings include: Review of the Clinical Record revealed Resident #801 was a [AGE] year old woman admitted to the facility on [DATE]. Review of her cumulative [DIAGNOSES REDACTED]. Review of the nurse's notes, dated 1/14/10 at 6:00 PM, revealed Resident #801 was found in the dining room after she had spilled hot coffee on her legs. Resident #801 had two red burns on her legs from the spilled coffee. Review of Resident #801's Activities of Daily Living (ADL) care plan, with an onset date of 2/1/12 (no time), revealed instructions for "all Facility staff" to "Check temperature of coffee prior to giving to guest (temp to be less than 120 degrees F), start 2/1/12". Review of the Nutritional Care plan revealed on 2/22/12 (no time), Resident #801 was to have assistance of Certified Nurse Assistants (CNA's) with eating and/or drinking provided as needed. The Nutritional care plan also instructed CNA's, Dietary staff and Nurses to provide adaptive equipment PRN (as needed). Coffee cups with lids to help prevent spilling was started 2/22/12. Review of the Facility incident report, dated 2/22/12 at 11:10 AM, revealed Resident #801 was in the main dining room and spilled coffee on her lap. The emergency action revealed staff lifted Resident #801's pants and removed her from the dining room. Resident #801 was taken via wheelchair to her room. Review of the witness statement, dated 2/22/12 at 11:15 AM, revealed Activity Aide (AA) #1 poured coffee for Resident #801 out of her special coffee pot (white carafe) and then poured other residents' coffee and hot chocolate. AA#1 heard Resident #801 yell and ran over to her. A Nurse was paged to the dining room to assist. Review of the Facility's Food Temperature Record, dated 2/22/12, under "lunch coffee", revealed the temperature was measured and recorded at 172 degrees Fahrenheit, when tested prior to lunch. In a telephone interview on 2/29/12 at 11:10 AM, Dietary Aide (DA #8), said on 2/22/12 she poured Resident #801's coffee from the big machine (the same machine all the coffee comes from) in the kitchen into her white carafe and put ice in it, but someone put it out in the dining room and it had not been temped. An interview conducted on 2/28/12 at 8:45 AM and a review of the witness statement, dated 2/22/12, revealed Dietary Manager (DM) #4 took Resident #801's carafe of coffee back to the kitchen after Resident #801 spilled the coffee and measured the temperature as being 140 degrees Fahrenheit. DM #4 said Resident #801 had spilled coffee on the floor a couple of times during the prior week (2/15/12-2/21/12), and stated, "luckily not on herself". DM #4 said Resident #801's coffee was supposed to have been temped between 120-130 degrees Fahrenheit beginning in September 2011. DM #4 reported kitchen staff send the coffee out of the kitchen for Resident #801 if it's less than 160 degrees Fahrenheit, but that they did not actually record all the temperatures. According to the Michigan Department of Community Health: Scalding Injuries Caused By Excessive Hot Water, Food and Hot Beverage Temperatures (Revised August 5, 2008), it can take less then 1 second for a second degree burn to develop in water that is 150 degrees Fahrenheit. The elderly are particularly at increased risk because their skin tends to be less sensitive and reaction times are reduced, causing a tendency to not pull away from hot water quickly enough to avoid scalding. Their thinner skin also burns full depth more quickly. A Full thickness burn occurs in one second from liquids of 158 degrees Fahrenheit (Katcher, M. L. (1981). Scald burns from hot tap water. Jama, 246 p. 1219-1222.) An observation on 2/28/12 at 8:00 AM, revealed Resident #801 was sitting in a wheelchair, in the dining room eating breakfast and drinking coffee out of a purple and black travel mug with a lid on it. Resident #801 voiced no complaints. An observation on 2/28/12 at 9:45 AM, revealed Resident #801 was sitting in her wheelchair. Licensed Practical Nurse (LPN) #12 and Registered Nurse (RN) #10 pivot-transferred Resident #801, as she used only her left leg, from the wheelchair to the bed. Resident #801's thin, navy blue, pants were removed to observe the burns. Resident #801 was wearing no underwear or briefs and had no dressings on her wounds. The left side of Resident #801's inner thigh was light brown in color. LPN #12 said that it was scar tissue from her burn. The right inner thigh had an open, red and raw area, which measured 2.5 centimeters (cm) x 2 cm with surrounding red tissue that measured 4 cm x 4 cm. When asked why there wasn't a dressing on the open wound of Resident #801's inner thigh (groin area), LPN #12 said she did not put a dressing on it but did put Silvadene cream on it at 9:00 AM that morning. RN #10 did not respond to the question. In an interview on 2/28/12 at 9:44 AM, Resident #801 stated she could not remember how the burns on her inner thigh area occurred. In an interview on 2/28/12 at 9:20 AM, AA#1 said she was in the main dining room on 2/22/12 at 11:15 AM when the "hot cart" came out of the kitchen with Resident #801's coffee, which was in a white carafe. AA#1 said she poured a full cup of hot coffee in the green mug (a thermal mug without a lid). AA#1 said she left Resident #801 at the table with the coffee and began to pour coffee for other residents when she heard her yell "I burned my butt!". AA#1 reported she went to Resident #801, got a clothing protector (bib-like towel), and wiped the hot coffee that was on her lap and lifted her pants off the tops of her thighs. AA#1 demonstrated by lifting up the middle area of the top of her thighs on her own pants, as she sat in the chair. This action created a tenting effect that pulled the sides of her pants closer and tighter to her inner and outer skin of her thighs. AA#1 said she did not pour cool water on Resident #801 and said she had not received any emergency training for first aide of burns. AA#1 said she did not measure the temperature of the hot coffee for Resident #801 prior to pouring her coffee. AA #1 said a nurse was paged to the dining room and LPN #3 came into the dining room and pushed Resident #801 in a wheelchair, out of the dining room. AA#1 said she did not see anyone pour cool water on Resident #801's lap where the hot coffee had been spilled. In an interview on 2/28/12 at 10:30 AM, LPN #3 said she was completing a medication pass on 2/22/12 and was paged to the dining room. LPN #3 said she and Director of Nursing (DON) #6 went to the dining room, and took Resident #801 to her room. LPN #3 said she assessed and measured the burns which "already had blistered". LPN #3 said she did not put cool water on Resident #801's burns to lower the temperature and stop the tissue from burning. LPN #3 said the Nurse Practitioner (NP) #9, was at the Facility and assessed Resident #801 for second degree burns on both inner thighs and instructed LPN #3 and DON #6 by saying, "whenever hot liquid is spilled on anyone you should pour cool water on the area immediately!" In an interview on 2/29/12 at 10:33 AM, Nurse Practitioner (NP) #9 said she was at the Facility on 2/22/12 when lunch was starting. NP #9 said she was coming down the hall toward the dining room and saw a CNA bringing Resident #801 out of the dining room and someone was holding her pants off her legs. NP #9 said it was about a 30 second jaunt from the dining room to the resident's room. NP #9 said someone was putting Resident #801 in bed so she left and came back later approximately one minute. NP #9 said she assessed Resident #801's burns and documented in the progress notes. NP #9 said Resident #801 did not complain of pain. NP #9 said Resident #801 would probably not have sensation on her right leg, due to her [DIAGNOSES REDACTED].#6 that she should have poured cool water on Resident #801's lap and that DON #6 responded to her saying "OK". Review of the physician progress notes [REDACTED].#9, revealed Resident #801 was seen by NP #9 because she spilled coffee on her lap at lunch. NP #9 documented that Resident #801 had a history of [REDACTED]. NP #9 drew a picture with the pink area on both of the inner portion of Resident #801's thighs surrounding 3 blisters and documented "second degree burns-Silvadene, nursing to monitor for signs and symptoms of infection". Review of the physician progress notes [REDACTED].#11) assessed Resident #801's burns and documented "using capped coffee cup now and happy with plan". DO #11 drew a picture of the burned area and documented "minimal thigh burns in this noncompliant [AGE] year old status [REDACTED]. Review of the behavior logs for Resident #801 provided by the Facility on 3/5/12, revealed no documentation for behaviors on the behavior tracking logs from 7/17/06 until 2/29/12, when it was recorded Resident #801 removed the lid to her coffee mug and a second behavior recorded that she tried to take the lid off of her travel mug. No other behaviors were recorded for Resident #801 in the behavior log. In an interview on 2/28/12 at 9:59 AM, CNA #2 said she worked on 2/22/12 and was in the hallway, talking to other staff at approximately 11:15 AM when she heard someone "screaming loudly". CNA #2 said she went toward the sound and saw Resident #801 in the dining room patting her inner thighs. CNA #2 said she saw steam coming out of an open white carafe that was at Resident #801's place. CNA #2 said she grabbed a clothing protector and wiped the resident's pants because Resident #801 was yelling "OW, OW, OW, IT'S BURNING!" CNA #2 said, "I probably should have poured water. CNA #2 said, "later the Unit Manager told me I should have poured water". CNA #2 said she helped Resident #801 into bed, take her pants off and observed that "it was red in the inner right thigh and some of the skin peeled off". CNA #2 said she didn't see anyone there pour cool water on Resident #801. CNA #2 said when she is in the dining room taking care of Resident #801, she will pour the coffee and then remove the white carafe off of the table and take it away. CNA #2 said, "but I don't know the rules and regulations about her coffee. CNA #2 said Resident #801 does not have the steadiest of hands and she (CNA #2) was told Resident #801 had spilled coffee and burned herself before. Review of the Facility's Wound and Skin Condition Record, dated 2/22/12 and signed by LPN #3, revealed Resident #801 had a right groin open blister wound, which measured 1.5 cm x 1.0 cm and a left groin open blister wound, which measured 1 cm x 1 cm. LPN #3 said, in a second interview on 2/29/12 at 3:10 PM, the wounds were open but you could tell by the redness of the wound that blisters would form. When asked why Resident #801 didn't have a dressing over her wounds, LPN #3 said they don't have a protocol for burns but they have a dressing on her right side now. Review of the Physician Order, dated 2/24/12 at 2:18 PM, revealed instructions for an Occupational Therapy (OT) evaluation and treatment related to meals. Review of the OT evaluation, dated 2/28/12 at 4:38 PM, under "Plan of Treatment", revealed Resident #801 required "OT treatments 5 times a week for 2 weeks for improving a lack of coordination during meal times and to prevent spillage of drinks and food during meals." In an interview on 2/28/12 at 10:58 AM, DON #6 said the Facility had no policy, procedure or protocol for staff to follow in response to a burn from a hot liquid. In an interview on 2/28/12 at 11:06 AM, Administrator #5 confirmed that the Facility had no policy, procedure or protocol for burns and said the Nurses should have learned that response in nursing school. The Administrator was notified on 2/29/12 at 4:08 PM of an Immediate Jeopardy that began on 2/22/12 and was identified on 2/28/12 as a result of the facility's failure to provide a safe environment for Resident #801, who had a known history of spilling hot coffee onto herself, spilled hot coffee onto her lap on 2/22/12 at 11:10 AM which was at a temperature greater than 140 degrees Fahrenheit, resulting in second degree burns to her groin. On 3/5/12 the surveyor confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. Resident #801 was provided a travel mug with lid for hot liquids on 2/22/12 prior to her supper meal. Resident #801's Nutritional care plan, with an onset date of 2/22/12 (no time), was updated to include the use of adaptive equipment- coffee mug with a lid due to Closed Head injury, Seizure Disorder and Dementia. Resident #801's Care Card had instructions written (no date or time), for nursing to "serve coffee in a travel mug/encourage use". 2. Resident #801 was evaluated by Occupational Therapy (OT) on 2/28/12 and determined to require skilled OT services to "minimize safety hazards/barriers". 3. 81 out of 81 Residents were observed while eating and drinking by Licensed Administrative Nurses on 2/22/12 and 2/23/12 to determine if they were at risk for spilling hot liquids. 6 Residents were fed by staff who handled the hot liquids and 1 Resident did not like hot liquids. The care plans were reviewed and there were no other Residents found by the Nurses who had a care plan for specific temps of their hot liquids. The Facility had 4 admissions 1 on 2/22/12, 1 on 2/23/12, 1 on 3/1/12 and 1 on 3/2/12 and all had OT evals done on 3/5/12 regarding their ADL abilities to determine if they were safe to handle hot liquids. All 4 were determined to be independent with feeding with set up provided for 3 of the Residents. 4. 13 of 13 Dietary Staff signed an in-service record dated 2/22/12 which included a training on the new policy, "Recording Temperatures for Guests". The training was done by the Dietary Manager to ensure Resident #801's coffee temps are delivered to her at less than 120 degrees Farenheit prior to leaving the kitchen. 5. As of 2/22/12, the Dietary Staff monitored and recorded Resident #801's coffee temperatures at every meal. Coffee that exceeds the required temperature was cooled to less than 120 degrees F. The temperature logs from 2/22/12 until 3/5/12 were completed. 6. 114 employees out of 127 employees had been provided education beginning 3/1/12 through 3/4/12 relating to emergency action in the event of a potential/actual burn. The Facility will provide an in-service on a yearly basis on emergency action in the event of a burn. New staff will be in-serviced during orientation on the emergency action in the event of a burn. Although the Immediate jeopardy was removed on 3/1/12, the facility remained out of compliance at the scope of "Isolated" and a severity of "Actual harm that is not Immediate Jeopardy", due to all of the staff had not been in-serviced and sustained compliance had not been verified by the state agency. #

This citation pertains to intake number MI 263. Based on observation, interview, and record review, the Facility failed to meet professional standards of practice following a burn (adequate emergency treatment) in 1 of 5 sampled residents (Resident #801), from a total sample of 5 residents, resulting in a delay of treatment, after Resident #801 spilled hot coffee on her lap and sustained second [MEDICAL CONDITION] both inner thighs. Findings include: According to the Burn Institute under the section titled; "First Aide for Burns"...What you do in the first few minutes after it occurs CAN make a difference in the severity of the injury. Children and Older Adults, because they have thinner skin, get [MEDICAL CONDITION] lower temperatures and in less time than an adult. Exposure for thus, three seconds to water which is 140 degrees F. can result in a full thickness or third degree burn on a child or an older adult. Safety Tips: 1. STOP THE BURNING PROCESS. 2. Remove all burned clothing...may keep in the heat and cause a deeper injury. If clothing sticks to skin-cool the material or tear around to preserve good skin tissue. 3. POUR COOL WATER OVER BURNED AREA. Keep pouring the cool water for at least 3-5 minutes. Never put ice or cold water on a burn as it lowers body temperature and can make the burn worse. 6. Cover [MEDICAL CONDITION] a soft clean, dry dressing bandage or sheet (burninstitute.org). A Full thickness burn occurs in one second from liquids of 158 degrees Fahrenheit (Katcher, M. L. (1981). [MEDICAL CONDITION] hot tap water. Jama, 246 p. 1219-1222.) Review of the Clinical Record revealed Resident #801 was a [AGE] year old woman admitted to the facility on [DATE]. Review of her cumulative [DIAGNOSES REDACTED]. An observation on 2/28/12 at 9:45 AM, revealed Resident #801 was seated in her wheelchair in her room. Licensed Practical Nurse (LPN) #12 and Registered Nurse (RN) #10 pivot-transferred Resident #801, as she used only her left leg, from the wheelchair to the bed. Resident #801's navy blue pants were removed to observe the burns. Resident #801 had no underwear or briefs on. There were no dressings on her wounds. The left side of Resident #801's inner thigh was light brown in color. LPN #12 said that it was scar tissue from her burn. Resident #801's right inner thigh had a burn that measured 2.5 cm (centimeters) x 2 cm that was open (no dressing), red and raw and the surrounding tissue had a 4 cm x 4 cm reddened area. When asked why there wasn't a dressing on the open wound of Resident #801's inner thigh (groin area), LPN #12 said she did not put a dressing on it but did put [MEDICATION NAME] cream on it at 9:00 AM that morning. RN #10 did not respond to the question. Review of the Facility incident report, dated 2/22/12 at 11:10 AM, revealed Resident #801 was in the main dining room and spilled coffee on her lap. The emergency action section revealed staff lifted Resident #801's pants and removed her from the dining room via wheelchair to her room. Review of the witness statement, dated 2/22/12 at 11:15 AM, revealed Activity Aide (AA) #1 poured coffee for Resident #801 out of her special coffee pot (white carafe) and then went and poured other residents' coffee and hot chocolate. AA#1 heard Resident #801 yell and ran over to her. A Nurse was paged to the dining room to assist. In an interview on 2/28/12 at 9:20 AM, AA#1 reported she was in the main dining room on 2/22/12 at 11:15 AM when the "hot cart" came out of the kitchen with Resident #801's coffee, which was in a white carafe. AA#1 said she poured a full cup of hot coffee in the green mug (thermal mug without a lid). AA#1 said, in an interview at 1:50 PM on 2/29/12, the cup held 180 cc of hot liquid. AA#1 said she left Resident #801 at the table with the coffee and began to pour coffee for other residents, when she heard Resident #801 yell "I burned my butt!" AA#1 reported she went to Resident #801 and got a clothing protector (bib-like towel), and wiped the hot coffee that was on her lap and lifted her pants off the tops of her thighs. AA#1 demonstrated by lifting the middle area of the top of her thighs on her own pants up, as she sat in the chair. This action created a tenting effect that pulled the sides of her pants closer and tighter to her inner and outer skin of her thighs. AA#1 reported that she did not pour cool water on Resident #801 and that she had not received any emergency training for the first aid of burns. AA#1 said she did not measure the temperature of the hot coffee for Resident #801. AA#1 said a nurse was paged to the dining room and that LPN #3 came into the dining room and pushed Resident #801, in a wheelchair, out of the dining room. AA#1 said she did not see anyone pour cool water on Resident #801's lap where the hot coffee had been spilled. In an interview on 2/28/12 at 10:30 AM, LPN #3 stated she was completing a medication pass on 2/22/12 and was paged to the dining room. LPN #3 said she and the Director of Nursing (DON) #6 went to the dining room and took Resident #801 to her room. LPN #3 said she assessed and measured [MEDICAL CONDITION] "already had blistered". LPN #3 said she did not put cool water on Resident #801'[MEDICAL CONDITION] lower the temperature and stop the tissue from burning. LPN #3 said Nurse Practitioner (NP) #9, was at the Facility and assessed Resident #801 for second [MEDICAL CONDITION] both inner thighs and instructed LPN #3 and DON #6 by saying, "whenever hot liquid is spilled on anyone you should pour cool water on the area immediately!" In an interview on 2/29/12 at 10:33 AM, NP #9 said she was at the Facility on 2/22/12 when lunch was starting. NP #9 said she was coming down the hall toward the dining room and saw a CNA bringing Resident #801 out of the dining room and someone was holding her pants off her legs. NP #9 said it was about a 30 second jaunt from the dining room to the resident's room. NP #9 said someone was putting Resident #801 to bed so she left and came back in about a minute. NP #9 said she assessed Resident #801'[MEDICAL CONDITION] documented in the progress notes. NP #9 said Resident #801 would probably not have sensation on her right leg due to her [DIAGNOSES REDACTED].#6 that she should have poured cool water on Resident #801 and that DON #6 responded to her saying "OK". Review of the physician progress notes [REDACTED].#9, revealed Resident #801 was seen by NP #9 because she spilled coffee on her lap at lunch. NP #9 documented that Resident #801 had a history of [REDACTED]. NP #9 drew a picture with the pink area on both of the inner portion of Resident #801's thighs surrounding 3 blisters and documented second degree burns-[MEDICATION NAME], nursing to monitor for signs and symptoms of infection. Review of the physician progress notes [REDACTED].#11 assessed Resident #801'[MEDICAL CONDITION] documented "using capped coffee cup now and happy with plan." DO #11 drew a picture of the burned area and documented "minimal [MEDICAL CONDITION] this noncompliant [AGE] year old status [REDACTED]. An interview conducted on 2/28/12 at 8:45 AM, and review of the witness statement, dated 2/22/12, revealed Dietary Manager (DM) #4 took Resident #801's carafe of coffee back to the kitchen, after Resident #801 spilled coffee onto her lap. DM #4 measured the temperature of the coffee to be 140 degrees Fahrenheit. DM #4 reported that Resident #801 had spilled coffee on the floor a couple of times during the prior week (2/15/12-2/21/12), and said, "luckily not on herself". DM #4 reported that Resident #801's coffee had been designated to be between 120-130 degrees Fahrenheit since September 2011. DM #4 reported kitchen staff would send the coffee out of the kitchen for Resident #801 "if it's less than 160 degrees Fahrenheit", but that they did not actually record all the temperatures. In an interview on 2/28/12 at 9:59 AM, Certified Nurse Aide (CNA) #2 said, she worked on 2/22/12 and was in the hallway, talking to other staff at about 11:15 AM when she heard someone "screaming loudly". CNA #2 said she went toward the sound and saw Resident #801, in the dining room, patting her inner thighs. CNA #2 said she saw steam coming out of an open white carafe that was at Resident #801's place. CNA #2 said she grabbed a clothing protector and wiped her pants because Resident #801 was yelling "OW, OW, OW, IT'S BURNING!" CNA #2 said, "I probably should have poured water". CNA #2 said, "later the Unit Manager told me I should have poured water". CNA #2 said she helped Resident #801 into bed, take her pants off, and stated, "it was red in the inner right thigh and some of the skin peeled off". CNA #2 said NP #9 came in so she left the room. CNA #2 said, "but I don't know the rules and regulations about her coffee". CNA #2 said Resident #801 does not have the steadiest of hands and she was told she spilled coffee and burned herself before. CNA #2 said she wrote a witness statement the same day (2/22/12) and gave it to Administrator #5. Review of the Wound and Skin Condition Record, dated 2/22/12 and signed by LPN #3, revealed Resident #801 had a right groin open blister wound which measured 1.5 cm x 1.0 cm and left groin open blister wound which measured 1 cm x 1 cm. In a second interview on 2/29/12 at 3:10 PM, LPN #3 said she could tell by the redness of the wound that blisters would form. When asked why Resident #801 didn't have a dressing over her wounds, LPN #3 said they don't have a protocol [MEDICAL CONDITION] they have a dressing on her right side now. In an interview on 2/28/12 at 10:58 AM, DON #6 said the Facility had no policy, procedure or protocol for staff to follow in the event of a burn from a hot liquid. In an interview on 2/28/12 at 11:06 AM, Administrator #5 confirmed the Facility had no policy, procedure or protocol [MEDICAL CONDITION] said the Nurses should have learned that response in nursing school. #

THIS CITATION PERTAINS TO MI 743 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO 1.) DOCUMENT NOTIFICATION OF AN ABNORMAL CHEST X-RAY TO A PHYSICIAN AND 2.) ASSESS AND MONITOR SIGNS AND SYMPTOMS OF PNEUMONIA FOR 1 OF 6 SAMPLED RESIDENTS (#501) FROM A TOTAL SAMPLE OF 6 RESIDENTS, RESULTING IN RESIDENT #501 NOT HAVING PROPER RESPIRATORY TREATMENT AND WAS SENT TO THE HOSPITAL WHERE RESIDENT #501 EXPIRED. FINDINGS INCLUDE: ACCORDING TO THE FUNDAMENTALS OF NURSING (POTTER AND PERRY, 6 th EDITION, 2005), "TO LIMIT NURSING LIABILITY, NURSING DOCUMENTATION MUST CLEARLY INDICATE THAT INDIVIDUALIZED, GOAL-DIRECTED NURSING CARE WAS PROVIDED TO A CLIENT BASED ON THE NURSING ASSESSMENT. THE RECORD NEEDS TO DESCRIBE EXACTLY WHAT HAPPENED TO A CLIENT. EVEN THOUGH NURSING MAY HAVE BEEN EXCELLENT, IN A COURT OF LAW CARE NOT DOCUMENTED IS CARE NOT PROVIDED. NURSES NEED TO INDICATE ALL ASSESSMENTS, INTERVENTIONS, CLIENT RESPONSES, INSTRUCTIONS, AND REFERRALS IN THE MEDICAL RECORD. NURSES INFORM PHYSICIANS OF CHANGES IN A CLIENT'S CONDITION AND COMMUNICATE INFORMATION TO OTHER NURSES. TO DOCUMENT A PHONE CALL, THE NURSE INCLUDES WHEN THE CALL WAS MADE, WHO MADE IT, WHO WAS CALLED, TO WHO INFORMATION WAS GIVEN, WHAT INFORMATION WAS GIVEN, AND WHAT INFORMATION WAS RECEIVED." ACCORDING TO MEDICAL SURGICAL NURSING (IGNATAVICIUS AND WORKMAN, 4 TH EDITION, 2002), SIGNS AND SYMPTOMS OF PNEUMONIA ARE CHILLS, FEVER, PERSISTENT COUGH, DYSPNEA, WHEEZING, HEMOPTYSIS, INCREASED SPUTUM PRODUCTION, CHEST DISCOMFORT, INCREASING FATIGUE, DIAPHORESIS, CYANOSIS, TACHYPNEA, [MEDICAL CONDITION] ABNORMAL BREATH SOUNDS, AND WEAKNESS. "IN THE OLDER ADULT, THE CHEST X-RAY FILM IS ESSENTIAL FOR EARLY [DIAGNOSES REDACTED]." INTERVENTIONS FOR RESIDENTS WITH PNEUMONIA INCLUDE: -MONITOR CLIENT'S ABILITY TO COUGH EFFECTIVELY; -ENCOURAGE CLIENT TO PERFORM DEEP BREATHING, COUGHING, AND TURNING; -ENCOURAGE USE OF INCENTIVE SPIROMETRY, AS APPROPRIATE; -INSTITUTE RESPIRATORY THERAPY TREATMENTS (E.G., NEBULIZER) AND ANTIBIOTICS IF NECESSARY; -AUSCULTATE LUNG SOUNDS AFTER TREATMENTS TO NOTE RESULTS. REVIEW OF THE FACE SHEET REVEALED RESIDENT #501 WAS A [AGE] year OLD MALE admitted to the facility on [DATE]. REVIEW OF THE CUMULATIVE [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS) dated [DATE], REVEALED RESIDENT #501 HAD MODERATE COGNITIVE IMPAIRMENTS AND REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF THE MEDICATION RECORD FOR [DATE], REVEALED RESIDENT #501 REQUIRED OXYGEN AT 2 LITERS/MINUTE VIA NASAL CANNULA TO MAINTAIN A PULSE OXYGEN LEVEL ABOVE 90%. REVIEW OF A NURSE'S NOTE DATED [DATE] AT 10:00 PM, REVEALED RESIDENT #501'S VITAL SIGNS WERE AS FOLLOWED: TEMPERATURE-101 DEGREES FARENHEIT TAKEN UNDER THE ARM (NORMAL RANGE: 96XXX,[DATE].4 DEGREES FARENHEIT); HEART RATE-104 BEATS PER MINUTE (NORMAL RANGE: ,[DATE] BEATS PER MINUTE); RESPIRATIONS- 28 BREATHS PER MINUTE (NORMAL RANGE: ,[DATE] BREATHS PER MINUTE); BLOOD PRESSURE- ,[DATE] (NORMAL RANGE: ,[DATE]); PULSE OXYGEN LEVEL-87% ON 3 LITERS OF OXYGEN (,[DATE]% ON ROOM AIR). THE NOTE REVEALED RESIDENT #501 REFUSED TO GO TO THE HOSPITAL AND THE PHYSICIAN AND FAMILY WERE NOTIFIED. THE NOTE REVEALED "A COOL CLOTH KEPT ON FOREHEAD, REMOVED SOME CLOTHING" FOR RESIDENT #501. REVIEW OF THE physician's orders [REDACTED].#501 DUE TO EMESIS (VOMITING), FEVER, DECREASED PULSE OXYGEN LEVELS, AND POSSIBLE ASPIRATION. REVIEW OF A CHEST X-RAY DATED [DATE], REVEALED RESIDENT #501 HAD MILD [MEDICAL CONDITION] VASCULAR CONGESTION (EXCESSIVE ACCUMULATION OF FLUID IN THE LUNGS) IN BOTH LOWER LUNG FIELDS WITH POSSIBLE INFILTRATE (BODILY FLUID) IN THE RIGHT LUNG BASE. THE CHEST X-RAY REVEALED A PHYSICIAN SIGNED THE DOCUMENT ON [DATE], BUT DID NOT HAVE ANY ORDERS OR COMMENTS ON THE CHEST X-RAY DOCUMENT. REVIEW OF THE NURSE'S NOTE DATED [DATE] AT 2:25 AM AND WRITTEN BY REGISTERED NURSE (RN) #7,REVEALED RESIDENT #501'S VITAL SIGNS WERE WITHIN NORMAL LIMITS AND LUNG SOUNDS WERE CLEAR TO AUSCULTATION BUT DIMINISHED IN THE BASES. REVIEW OF THE NURSE'S NOTE DATED [DATE] AT 3:00 PM AND WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #3, REVEALED RESIDENT #501 HAD LUNG SOUNDS THAT WERE DIMINISHED. REVIEW OF A NURSE'S NOTE DATED [DATE] AT 4:55 AM AND WRITTEN BY RN #7, REVEALED RESIDENT #501'S CHEST X-RAY WAS NOTED, HOWEVER, IT DID NOT REVEAL WHETHER THE PHYSICIAN WAS NOTIFIED OF THE CHEST X-RAY RESULTS ON [DATE]. THE NOTE REVEALED RESIDENT #501 HAD SHORTNESS OF BREATH UPON EXERTION. THERE WAS NO DOCUMENTATION OF RESIDENT #501'S LUNG SOUNDS. REVIEW OF THE NURSE'S NOTES REVEALED THERE WAS NO DOCUMENTATION OF ASSESSMENT FOR RESIDENT #501 ON [DATE]. IN AN INTERVIEW ON [DATE] AT 3:00 PM, RN #7 REPORTED SHE COULD NOT REMEMBER IF SHE NOTIFIED THE PHYSICIAN ON [DATE], CONCERNING RESIDENT #501'S ABNORMAL CHEST X-RAY. IN AN INTERVIEW ON [DATE] AT 3:23 PM, RN #13 REPORTED SHE COULD NOT REMEMBER IF SHE NOTIFIED THE PHYSICIAN OR WAS AWARE OF RESIDENT #501'S ABNORMAL CHEST X-RAY RESULTS. REVIEW OF THE NURSE'S NOTES AND 24-HOUR REPORTS FROM [DATE] THROUGH [DATE] AND PHYSICIAN'S PROGRESS NOTES FROM [DATE], REVEALED THE PHYSICIAN WAS NOT NOTIFIED OF RESIDENT #501'S CHEST X-RAY RESULTS. REVIEW OF physician's orders [REDACTED].#501. REVIEW OF A NURSE'S NOTES DATED [DATE] AT 7:40 AM AND WRITTEN BY RN #13, REVEALED RESIDENT #501 HAD A DUSKY APPEARANCE AND A PULSE OXYGEN LEVEL OF 62% ON 2 LITERS NASAL CANNULA. THE NOTE REVEALED RESIDENT #501'S OXYGEN WAS INCREASED TO 3 LITERS. REVIEW OF A NURSE'S NOTE DATED [DATE] WITH NO TIME AND WRITTEN BY LPN #3, REVEALED RESIDENT #501 CONTINUED WITH LOW PULSE OXYGEN LEVELS "IN THE 80'S." THE NOTE REVEALED THE PHYSICIAN WAS NOTIFIED AND NEBULIZER TREATMENTS WERE ORDERED. THE NOTE REVEALED THE NEBULIZER TREATMENTS WERE INEFFECTIVE IN INCREASING RESIDENT #501'S PULSE OXYGEN LEVELS AND HE WAS SENT TO THE HOSPITAL AT 7:40 AM FOR FURTHER EVALUATION. REVIEW OF THE AMBULANCE REPORT DATED [DATE] AT 7:42 AM, REVEALED "WHEEZING THROUGHOUT UPPER AND LOWER LUNG FIELDS" WERE NOTED UPON ASCULTATION OF RESIDENT #501'S LUNGS. REVIEW OF THE HOSPITAL RECORD DATED [DATE] AT 8:21 AM, REVEALED RESIDENT #501'S VITAL SIGNS WERE AS FOLLOWED: -BLOOD PRESSURE: ,[DATE] -PULSE: 142 BEATS PER MINUTE -RESPIRATIONS: 36 BREATHS PER MINUTE -TEMPERATURE: 100 DEGREES FARENHEIT TAKEN BY MOUTH -PULSE OXYGEN LEVEL: 93% ON A NON-REBREATHER MASK (DEVICE USED TO TREAT [MEDICAL CONDITION] (OXYGEN DEFICIENCY) WITH A HIGHER CONCENTRATION OF OXYGEN). THE NOTE REVEALED RESIDENT #501 HAD SHORTNESS OF BREATH, A PRODUCTIVE COUGH, AND CHILLS. REVIEW OF THE HOSPITAL'S CHEST X-RAY REPORT DATED [DATE], REVEALED RESIDENT #501 HAD "EXTENSIVE INFILTRATES THROUGHOUT THE RIGHT LUNG AND IN THE LEFT LUNG BASE ARE NONSPECIFIC BUT PNEUMONIA IS LIKELY." REVIEW OF THE HOSPITAL RECORD DATED [DATE], REVEALED RESIDENT #501 "WAS NOTED TO BE FEBRILE WITH A TEMPERATURE OF 100.8 DEGREES FARENHEIT, [MEDICAL CONDITION] (HIGH PULSE RATE) WITH A PULSE OF 140, TACHYPENIC (HIGH RESPIRATORY RATE) WITH A RESPIRATORY RATE OF 36 AND HYPOXIC WITH OXYGEN SATURATION OF 93% ON 100% VIA NON-REBREATHER MASK. A CHEST X-RAY IDENTIFIED EXTENSIVE RIGHT-SIDED AND TO A LESSER EXTENT LEFT-SIDED INFILTRATE. THE RECORD REVEALED RESIDENT #501 HAD HEALTH CARE ACQUIRED PNEUMONIA WITH A CONCERN FOR ASPIRATION PNEUMONIA [MEDICAL CONDITION] SYNDROME (A SYSTEMIC [MEDICAL CONDITION] RESPONSE TO AN INFECTION). THE RECORD REVEALED RESIDENT #501 RECEIVED ANTIBIOTICS TO TREAT HIS PNEUMONIA. REVIEW OF THE HOSPITAL RECORD DATED [DATE], REVEALED RESIDENT #501 CONTINUED TO BE DYSPNEIC (DIFFICULTY IN BREATHING). THE RECORD REVEALED RESIDENT #501 WAS FOUND UNRESPONSIVE "WITHOUT ANY PALPABLE PULSE OR ANY RESPIRATORY EFFORT" AND WAS PRONOUNCED DEAD. THE RECORD REVEALED RESIDENT #501 expired on [DATE]. ( )

Findings Include: Based on observation, interview and record review, the facility failed ensure a safe environment in 4 of 7 sampled residents (#600, #601, #602, and #603) from a total of 7 sampled residents, resulting in falls with injury that required hospital evaluation for Resident #601 and #603 and hospital evaluation and treatment for [REDACTED]. Resident #600 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #600 was an [AGE] year old female originally admitted to the facility on [DATE] and re-admitted on [DATE]. The MDS revealed Resident #600's ability to make decision for daily living was moderately impaired, she required extensive assistance with transfers, dressing, toilet use, personal hygiene, and bathing, required oxygen therapy, and had a history of [REDACTED]. Review of the Fall Risk assessment dated ,[DATE] (no year) obtained from the current floor chart, revealed Resident #600 had a fall score was 19. The Fall Risk Assessment reflected that "Total Score of 10 or more represents HIGH RISK". Review of the Fall Care Plan dated 1/3/2011 revealed Resident #600 was at risk for injury from falls. Interventions in place 6/23/11, on the Fall Care Plan was an alarming self releasing seat belt, while Resident #600 was in the wheelchair, related to decreased safety awareness. Review of the Nursing Progress Notes dated 12/21/11 at 1:15 a.m. revealed "nursing called to (Resident #600's) room per Certified Nursing Assistant (CENA) and noted (Resident #600) in the bathroom, eyes open and unresponsive to verbal tactile stimuli....CENA and nursing kept talking to (Resident #600) and rubbing her arms. (Resident #600) started responding slowly after 2 minutes. Nurse Practitioner paged. (Resident #600) to wheelchair with extensive assist of 2 then to bed. Will continue to monitor". Review of the Nursing Progress Notes dated 12/21/11 at 11:55 p.m., revealed that Resident #600 became unresponsive while on toilet, fell face forward onto floor, hitting forehead above right eye and hit right cheekbone. Resident #600 remained unresponsive for approximately 15 seconds, then began moving arms, did not respond to questions. "After 15 seconds Resident #600 stated she wanted to get up, rolled her onto right side with assist of Resident #600 and CENA, then got her into sitting position. Had glasses on when she fell , and there was small laceration on bridge of nose...Admits to pain in forehead in bruised area and in back of right leg". Review of the Nursing Progress Notes dated 12/22/11 at 3:00 a.m., Resident #600 up to the bathroom with 2 CENA's and "had another unresponsive episode...Transported to and from the bathroom with wheelchair and 2 CENA's with Resident #600 at all times when up... answering questions appropriately within 5 seconds of episode". Review of the Incident Report dated 12/22/11 at 10:40 a.m., revealed Resident #600 was "lying face down with blood coming from face, laceration noted to forehead. CENA with Resident #600 at the time of fall. CENA states Resident #600 fell from sitting in wheelchair to floor landing on face. Resident #600's seat safety belt was off. Resident #600 was transported to the hospital via ambulance". Review of the Hospital Emergency and Pre-Hospital Documentation dated 12/22/11 (no time), revealed that Resident #600 had a nasal bone fracture. The Hospital Transfer Documentation dated 12/23/11 (no time) revealed that laboratory studies noted Resident #600's sodium level was low at 115 (normal 134-146), potassium was low at 2 (normal 3.4-5.0) and chloride was low at 64 (normal 98-112). Review of Nursing Progress Notes dated 12/22/11 at 11:30 a.m., revealed that at approximately 10:40 a.m. Resident #600 "fell face forward in her room, nurse was called into room, Resident #600 was face down on the floor, blood on her head, laceration noted to forehead, pressure and ice applied, CENA #3 was in the room at the time of fall while CENA #3 reached for clothes out of the closet Resident #600 fell forward"... In an interview on 1/3/12 at 3:05 p.m., Administrator #1 and Regional Quality Assurance Manager (QA) #1 stated Resident #600 had episodes of syncope (fainting) prior to her falling out of her wheelchair on 12/22/11 and going to the hospital. The QA Manager #1 stated that after the syncope episode prior to her fall on 12/22/11 at 10:40 a.m., Resident #600's was to be a 2 person assist in the bathroom. In interviews on 1/4/12 at 8:35 and 10:30 a.m., Physician #1 stated Resident #600 was having exasperation of Congestive Heart Failure (weak heart) so diuretics were ordered, which caused electrolyte (sodium, potassium..) levels to decrease, that she was definitely having syncope problems prior to the fall on 12/22/11, and that Resident #600 probably would not have "gone down if we had put 2 staff on her at all times". An interview and observation on 1/4/12 at 9:45 a.m., revealed Resident #600 was in her room with her legs up on a pillow in a lounge chair, oxygen on, dressed appropriately for the day, and with noted bruising to her cheeks and a healing wound in the center of her forehead. Resident #600 stated that she did not recall the fall on 12/22/11. In an interview on 1/5/11 at 10:15 a.m., CENA #3 stated he assisted Resident #600 from her lounge chair to her wheelchair without a gait belt to go to the bathroom. CENA #3 stated that since Resident #600 was going to the bathroom it was a good time to get her dressed. CENA #3 stated that he turned away from Resident #600 to get clothing from her closet, looked back to verify the correct clothing was obtained, and CENA #3 saw Resident #600 falling forward out of her wheelchair. CENA #3 stated Resident #600 did not have her self releasing seat belt on and "there was no stopping her" from falling. CENA #3 stated there was no other staff in the room to assist Resident #600 and that when transporting a resident to the bathroom in a wheelchair CENA #3 does not normally put the self releasing seat belt on residents. CENA #3 stated that the prior shift reported that during the night Resident #600 had a fall. Review of the Gait Belt Policy dated 3/05, revealed that "a gait belt is utilized for safety in the transfer and ambulation of an unstable or non-weight bearing guest". Resident #601 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed that Resident #601 was a [AGE] year old female originally admitted to the facility on [DATE] and re-admitted on [DATE]. The MDS revealed that Resident #601's ability to make decision for daily living was moderately impaired, she required extensive assistance with transfers, dressing, toilet use, personal hygiene, and bathing and required oxygen therapy. The MDS revealed that [DIAGNOSES REDACTED]. The Communication Care Area Assessment (CAA) of the MDS dated [DATE] revealed that Resident #601 did not use her call light and "will transfer herself from the wheelchair to bed without asking for assistance". The Activities of Daily Living CAA of the MDS dated [DATE], revealed that that Resident #601 required assistance with her cares, transfers, and toileting, Resident #601 "is very impulsive and does not call for assistance. She has alarms on for safety". Review of the Incident Report dated 11/16/11 at 8:15 p.m., revealed Licensed Practical Nurse (LPN) #1 was called STAT (immediately) into Resident #601's room by another nurse. LPN #1 observed Resident #601 face down on floor next to her bed with some frothy emesis around her mouth and a hematoma (a collection of pooled blood) on her right forehead. LPN #1 stated Resident #601 was taken to the hospital by ambulance. In an interview on 1/4/12 at 2:50 p.m., LPN #1 stated that the she entered Resident #601's room she was face down by the bed, the chair alarm was going off, and a cut was noted above Resident #601's eye (did not recall which eye). LPN #1 reported Resident #601 is usually pretty good at not getting up, but she forgets and staff hear the alarm go off. LPN #1 stated Resident #601 was not safe to be up in her room by herself. In an interview on 1/5/11 at 9:45 a.m., LPN #3 stated that a CENA (not sure which one) found Resident #601 and another un-named CENA came to get her. Resident #601 was found lying face down on the floor with one hand under her chin. LPN #3 stated Resident #601 was non-compliant with use of the call light to call for assistance to transfer into bed or the bathroom. LPN #3 stated that it is difficult to tell where a fall alarm is going off and staff "just run down the hall until they find the room with the fall alarm sounding". In in interview on 1/4/12 at 2:40 p.m., CENA #1 stated being in the hallway when Resident #601's roommate came to the door of their room and "hollered (Resident #601) needs help, (twice)". CENA #1 stated he went in the room and found Resident #601 face down on the floor with her face next to the dresser laying parallel with the bed, a small amount of blood was noted on the floor, but CENA #1 stated he could not tell where the blood was coming from. CENA #1 stated Resident #601 had a tendency to loose her balance and had an alarm on her wheelchair. CENA #1 stated on the day of the fall he was working in a room 2 doors away from Resident #601's room and did not hear the fall alarm sounding, but stated the wheelchair alarm was sounding when he entered the room. CENA #1 stated that it is hard to tell where an alarm is going off and staff just have to go down the hall towards the sound until the fall alarm is found. In an interview on 1/3/12 at 2:35 p.m., Resident #601 stated that "they said I fell " (the ambulance driver), but that she did not recall the fall. In an interview on 1/3/12 at 2:39 p.m., the roommate of Resident #601 stated she heard a drop and move, but the curtain was closed between her and Resident #601 so she did not witness her fall. The roommate of Resident #601 stated she called out to Resident #601 and after awhile thought to get a better look, saw Resident #601 had fallen, and alerted the staff. The roommate of Resident #601 stated she did not recall hearing a fall alarm sounding. Review of the Falls Care Plan dated 7/28/11 revealed Resident #601 was at risk for fall and the intervention put in place was a sensor pad to bed and wheelchair, with placement and function checked every shift. Resident #602 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed that Resident #602 was an [AGE] year old female originally admitted to the facility on [DATE]. The MDS revealed that Resident #602's ability to make decision for daily living was cognitively intact, she required extensive assistance with transfers, ambulation, dressing, toilet use, personal hygiene, bathing, and had a history of [REDACTED]. The Activities of Daily Living,Urinary Incontinence and Falls, Care Area Assessment (CAA) of the MDS dated [DATE], indicated Resident #602 requires assistance with her cares, transfers, and toileting. The Urinary Incontinence and Falls CAA of the MDS dated [DATE], indicated Resident #602 had a history of [REDACTED]. The Falls CAA of the MDS dated [DATE], indicated Resident #602 was aware of her falls and she will not get up without calling for assistance. "She does have some vision problem in the one eye she had a corneal transplant in". Review of the Nursing Admission assessment dated [DATE] (no time), revealed Resident #602 had a fall score was 14. The Fall Risk Assessment reflected a "Total Score of 10 or more represents HIGH RISK". Review of the Physical Therapy Evaluation dated 11/4/11, revealed Resident #602's current level of function for transfers was a maximum assist. The Physical Therapy Daily/weekly documentation for Resident #602 revealed, for the week of 11/11/11-11/17/11 she required assistance with walking and transfers. Review of the Occupational Therapy Daily/Weekly Documentation dated 11/12/11-11/18/11, revealed that on 11/15/11 Resident #602 required maximum assist with floor to chair transfers and would benefit from left lower leg strengthening to aid with pull up to seat and difficulties with getting to knees. Review of the History and Physical (H&P) dated 11/2/11, revealed that the admission [DIAGNOSES REDACTED]. frequent falls. The H&P revealed Resident #602 had been experiencing frequent falls for the past two months. Resident #602 states "she had a right eye corneal transplant in may and since that time she has had some difficulty with her balance, but over the past two months it has gotten much worse" Review of the Incident Report dated 11/19/11 at 10:10 p.m., revealed that the location of the Incident was at bedside, LPN #3 was called per CENA to the room and noted Resident #602 on the floor on her back at the bedside with bright red bleeding from a laceration above her right eye and the back of her head. Resident #602 was sent to the hospital. Review of the Nursing Progress Notes dated 11/20/11 at 930 a.m., revealed that when Resident #601 returned to the facility from the hospital she had a dressing just above the eyebrow and had 4 sutures. An interview and observation on 1/3/12 at 2:45 p.m., Resident #602 stated that she slipped on something and fell back against her bed and her walker fell on her, she had 4 stitches over her right eye and a bump on the back of her head. Resident #602 stated she laid on the floor about a half hour before anyone came to the room after her fall. Resident #602 was dressed appropriately for the day and she stated she did not like the fall alarm or to have to use the call light, because it is always at least 15-20 minutes before someone answered the call light. Resident #602 stated that after the fall she had been incontinent and pooped her pants waiting for assistance to the bathroom, and had a bladder infection. In an interview on 1/5/11 at 9:45 a.m., LPN #3 stated Resident #602 was admitted with a history of falls, and when she first came to the facility she was shaky. LPN #3 stated Resident #602 was close to the nursing station and normally used her call light but LPN #3 had CENA's check on Resident #602 often. LPN #3 stated that on the night Resident #602 fell she did not use her call light to get a CENA to assist her and that the roommate had put her call light on to alert staff to Resident #602's fall. LPN #3 stated that Resident #602 did not like to bother the staff. Resident #603 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #603 was a [AGE] year old female originally admitted to the facility on ,[DATE] and re-admitted on [DATE]. The MDS revealed Resident #603's ability to make decision for daily living was cognitively intact, she required extensive assistance with transfers, dressing, toilet use, personal hygiene, and bathing. The MDS revealed [DIAGNOSES REDACTED]. Review of Fall Risk assessment dated [DATE], (no time), revealed Resident #603 had a fall score was 16. The Fall Risk Assessment indicated a "Total Score of 10 or more represents HIGH RISK". Review of the Incident Report dated 12/10/11 at 4:15 p.m., revealed Resident #603 was observed laying on her abdomen with her head against the foot board of the bed opposite hers, and a laceration 1 cm x 0.3 cm noted behind her left ear. Resident #603 was sent to the hospital. The Incident Investigation Questionnaire reflected Resident #603 "had a history of [REDACTED]. LPN #2's own words regarding the injury involving Resident #603 was documented as "self transferring from bed; Resident #603 attempted to climb over foot pedals of wheelchair and tripped and fell ". In an interview on 1/5/12 at 12:50 p.m., LPN #2 stated that she heard Resident #603 yell out, went to her room, and found her laying with her head at the foot of there bed across from her bed with her legs stretched out towards her bed. LPN #2 stated after doing an assessment, it was determined that Resident #603 should be sent to the hospital for evaluation. LPN #2 stated Resident #603 did not have fall alarms except to use as a call light. LPN #2 stated Resident #603 normally does get up and go through her closet, and if staff see her up alone in her room they go in and stand by her. LPN #2 stated that Resident #603 is not safe to be up alone. LPN #2 stated an intervention put in place after the fall on 12/10/11 was to have CENA staff take wheelchair leg extensions off the wheelchair when it was not in use. Review of the Nursing Care Card (no date) specific to the care required by CENA's for Resident #603, revealed that when "wheelchair foot rests not in use place in bag on wheelchair". Review of the Post Fall Evaluation dated 12/10/11, revealed that Resident #603 did not have fall alarms in place. In an interview on 1/4/12 at 4:20 p.m. CNA #2 stated that Resident #603 does self transfer even though she is not suppose to and that is why foot rests would be left on the wheelchair when Resident #603 was in bed. Observations by this surveyor on 1/4/11 at 12:50 and 3:55 p.m., revealed Resident #603 was laying in bed with her eyes closed. Resident #603's wheelchair was by closet (to the right of the head of the bed) with the foot rests in place on the wheelchair. In an interview on 1/4/12 at 4:27 p.m., Registered Nurse Unit Manager (RNUM) #1 stated that Resident #603 was crawling out of her bed over her wheelchair to get to her closet when she fell . When asked what prevented Resident #603 from falling over the foot rests of the wheelchair again, RNUM #1 stated that the foot rests were to be placed in the bag on the back of the wheelchair when not in use. RNUM #1 walked with this surveyor to Resident #603 room and noted that Resident #603 was in bed and the foot rests were on the wheelchair, RNUM #1 removed the foot rests and put them in the bag on the back of the wheelchair.

THIS CITATION PERTAINS TO MI 743 & MI 942 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO: 1.) PROVIDE SUPERVISION TO PREVENT SELF-HARM IN 1 OF 5 SAMPLED RESIDENTS (RESIDENT #502), FROM A TOTAL SAMPLE OF 5 RESIDENTS, RESULTING IN RESIDENT #502 , WHO had a history of [REDACTED].) UTILIZE SAFETY DEVICES FOR 1 OF 5 RESIDENTS (#505), FROM A TOTAL SAMPLE OF 5 RESIDENTS, RESULTING IN ACTUAL HARM WHEN RESIDENT #505 fell IN THE BATHROOM AND SUSTAINED A RIGHT PARIETAL NON-DEPRESSED SKULL FRACTURE. FINDINGS INCLUDE: RESIDENT #502 REVIEW OF THE FACE SHEET FROM THE MEDICAL RECORD DATED [DATE], REVEALED RESIDENT #502 WAS A [AGE] year OLD FEMALE AND WAS admitted to the facility on [DATE] AND REadmitted on [DATE] AND [DATE]. REVIEW OF THE CUMULATIVE [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE], REVEALED RESIDENT #502 DID NOT HAVE ANY COGNITIVE IMPAIRMENTS. REVIEW OF A SOCIAL SERVICES NOTE DATED [DATE] AND WRITTEN BY SOCIAL WORKER #10, REVEALED ON [DATE], RESIDENT #502 WAS IN HER WHEELCHAIR HITTING HER HEAD ON THE DOOR STATING SHE WANTED TO DIE. THE NOTE REVEALED RESIDENT #502 DID NOT HAVE PLAN ON HOW TO HARM HERSELF. REVIEW OF A SOCIAL SERVICES NOTE DATED [DATE] AND WRITTEN BY SOCIAL WORKER #10, REVEALED ON [DATE], RESIDENT #502 "STATED SHE WANTED TO DIE AND PLANNED TO KILL HERSELF" AND "PLANNED TO WRAP A CORD AROUND HER NECK." THE NOTE REVEALED RESIDENT #502 "REFUSED TO DO A VERBAL CONTRACT TO NOT HARM HERSELF" WITH PSYCHOLOGIST #12. REVIEW OF THE PATIENT TRANSFER FORM DATED [DATE], REVEALED RESIDENT #502 WAS SENT TO THE HOSPITAL DUE TO SUICIDAL IDEATION WITH PLANS. REVIEW OF A NURSE'S NOTE DATED [DATE], REVEALED RESIDENT #502 RETURNED TO THE FACILITY. REVIEW OF A MOOD CARE PLAN DATED [DATE], REVEALED RESIDENT #502 had a history of [REDACTED]. THE CARE PLAN REVEALED RESIDENT #502'S INTERVENTIONS TO REMAIN SAFE FROM SELF-HARM INCLUDED: -IF RESIDENT #502 EXPRESSED DESIRE TO HARM SELF, THEN STAFF WOULD REMAIN ONE TO ONE WITH RESIDENT #502 UNTIL CRISIS WAS RESOLVED; -RESIDENT #502 WOULD BE CHECKED ON EVERY 15 MINUTES FROM [DATE] TO [DATE]; -RESIDENT #502 WOULD BE CHECKED ON EVERY 30 MINUTES FROM [DATE] TO [DATE]; -THE PHYSICIAN MUST BE NOTIFIED IF RESIDENT #502 EXPRESSED INTENT TO HARM HERSELF; -MAKE SURE NO CHEMICALS WERE LEFT IN ROOM SUCH AS MOUTHWASH, BODY SPRAY, SHAMPOO FOR RESIDENT #502 AND HER ROOMMATE; -PLACED A PAD BETWEEN THE WALL AND BED TO PREVENT INJURY IF RESIDENT #502 STARTED TO STRIKE HEAD ON THE WALL. -REPLACED CALL LIGHT WITH HAND HELD BELL; -ENSURED THAT NO POTENTIAL DANGEROUS OBJECTS WERE LEFT IN THE ROOM, SUCH AS SCISSORS, METAL HANGERS, TRASH BAGS, AND TOOTHPICKS. REVIEW OF NURSE'S NOTES FROM [DATE] TO [DATE], REVEALED RESIDENT #502 WAS "PLEASANT", "COOPERATIVE," AND "HAPPY." THE NOTES INDICATED RESIDENT #502 HAD NO SUICIDAL THOUGHTS. REVIEW OF INCIDENT/ACCIDENT REPORT DATED [DATE] REVEALED RESIDENT #502 fell OUT OF HER WHEELCHAIR WHILE TRYING TO REACH HER CALL LIGHT. THE REPORT REVEALED FACILITY STAFF PLACED RESIDENT #502'S CALL LIGHT (NOT HAND BELL PREVIOUS CARE PLANNED) WITHIN REACH TO PREVENT FURTHER RECURRENCE. REVIEW OF OF NURSE'S NOTE DATED [DATE], REVEALED RESIDENT #502'S "CALL LIGHT CORD WAS UNATTACHED FROM BASE OF BED SO THAT CALL LIGHT MAY BE CLIPPED TO RESIDENT'S CLOTHING." IN AN INTERVIEW ON [DATE] AT 3:15 PM, ADMINISTRATOR #1 REPORTED THE FACILITY STAFF FELT IT WAS SAFE FOR RESIDENT #502 TO HAVE HER CALL LIGHT CORD BACK BECAUSE SHE WAS NOT DISPLAYING ANY SIGNS OR SYMPTOMS OF WANTING TO HARM HERSELF. IN AN INTERVIEW ON [DATE] AT 11:30 AM, PHYSICIAN #14 REPORTED RESIDENT #502 WAS ABLE TO HAVE HER CALL LIGHT CORD BECAUSE SHE WAS NOT HAVING ANY SUICIDAL IDEATION SINCE SHE WAS REadmitted to the facility on [DATE]. PHYSICIAN #14 REPORTED IT WAS A JUDGEMENT CALL AND A DIGNITY ISSUE IN GIVING BACK RESIDENT #502'S CALL LIGHT CORD. IN AN INTERVIEW ON [DATE] AT 10:00 AM, PSYCHOLOGIST #12 REPORTED RESIDENT #502 HAD A FIXATION WITH CORDS AND HE WAS NOT AWARE THAT SHE RECEIVED HER CALL LIGHT CORD BACK. IN AN INTERVIEW ON [DATE] AT 9:30 AM, SOCIAL WORKER #10 REPORTED SHE WAS NOT AWARE THAT RESIDENT #502 HAD RECEIVED BACK HER CALL LIGHT CORD. REVIEW OF A PSYCHOLOGIST NOTE DATED [DATE] AND WRITTEN BY PSYCHOLOGIST #12, REVEALED RESIDENT #502 "CONTINUED AS IMPROVED IN THINKING WITHOUT PSYCHOSIS/DELIRIUM/DELUSIONS, HOWEVER, SHE CONTINUES AS DEPRESSED. THOUGH SHE DENIED HAVING ANY ACTIVE THOUGHTS OF SUICIDE, SHE SAID THAT THERE WERE NO REASONS FOR HER TO GO ON LIVING." REVIEW OF A BEHAVIOR DOCUMENTATION RECORD DATED [DATE] AT 5:25 PM, REVEALED RESIDENT #502 WAS "HITTING HER HEAD AGAINST THE WALL, HAD A PILLOW OVER FACE AND CALL LIGHT (CORD) WRAPPED AROUND HER NECK." IN AN INTERVIEW ON [DATE] AT 11:10 AM, LICENSED PRACTICAL NURSE (LPN) #11 REPORTED ON [DATE], THE CALL LIGHT CORD WAS WRAPPED LOOSELY AROUND RESIDENT #502'S NECK. LPN #11 REPORTED SHE ASSESSED RESIDENT #502 AND NOTED THERE WERE NO INJURIES. REVIEW OF A NURSE'S NOTE DATED [DATE], REVEALED RESIDENT #502 WAS TRANSFERRED TO THE HOSPITAL DUE TO SUICIDAL COMMENTS AND ACTIONS. REVIEW OF THE NURSE'S NOTE DATED [DATE], REVEALED RESIDENT #502 RETURNED TO THE FACILITY. IN AN INTERVIEW ON [DATE] AT 9:55 AM, RESIDENT #502 REPORTED SHE WAS FEELING BETTER AND WAS NOT HAVING ANY THOUGHTS OF HARMING HERSELF. IN AN OBSERVATION ON [DATE] AT 9:55 AM, RESIDENT #502 WAS SITTING IN HER WHEELCHAIR IN HER ROOM. THERE WERE NO BAGS, CORDS, OR SHARP OBJECTS PRESENT IN THE ROOM. THERE WAS A PAD BETWEEN THE WALL AND BED AND A LANDING STRIP POSITIONED ON THE FLOOR BY HER BED. IN AN OBSERVATION ON [DATE] AT 11:30 AM, RESIDENT #502 WAS IN HER WHEELCHAIR IN THE MAIN DINING ROOM CONVERSING WITH OTHER RESIDENTS AT THE TABLE. RESIDENT #502 WAS SMILING AND APPEARED WELL-GROOMED. ( ) RESIDENT #505 RESIDENT #505 NO LONGER LIVED AT THE FACILITY AT THE TIME OF THE INVESTIGATION CONDUCTED FROM [DATE] TO [DATE]. REVIEW OF THE FACE SHEET DATED [DATE], REVEALED RESIDENT #505 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE]. REVIEW OF THE admission orders [REDACTED]. REVIEW OF THE HOSPITAL RECORD DATED [DATE], REVEALED RESIDENT #505 fell AT HOME FIVE DAYS AGO ([DATE]) AND SUSTAINED A RIGHT ELBOW FRACTURE AND A RIGHT RIB FRACTURE. REVIEW OF THE NURSING ADMISSION assessment dated [DATE], REVEALED RESIDENT #505 WAS ALERT AND ORIENTED TO PLACE AND PERSON. THE ASSESSMENT REVEALED RESIDENT #505 DISPLAYED CONFUSION AND SHORT AND LONG TERM MEMORY PROBLEMS. THE ASSESSMENT REVEALED RESIDENT #505 NEEDED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S) AND THAT RESIDENT #505 WAS AT RISK FOR FALLS WITH A TOTAL FALL SCORE OF 24 (A TOTAL SCORE OF 10 OR ABOVE DEEMED THE RESIDENT AT RISK FOR FALLS). REVIEW OF A PHYSICAL THERAPY EVALUATION DATED [DATE] REVEALED RESIDENT #505 REQUIRED MODERATE ASSISTANCE (REQUIRES 50% OF MANUAL ASSISTANCE) WITH 1 PERSON AND A FOUR WHEELED WALKER. THE EVALUATION REVEALED RESIDENT #505 HAD POOR STANDING BALANCE AND HAD A TENDENCY TO FALL DUE TO UNSTEADY GAIT. REVIEW OF A PHYSICAL THERAPY DAILY/WEEKLY DOCUMENTATION NOTE DATED [DATE] THROUGH [DATE], REVEALED RESIDENT #505 HAD AN INCREASED RISK FOR FALLS. THE NOTE REVEALED ON [DATE], RESIDENT #505 WAS A CONTACT GUARD ASSIST (REQUIRES HANDS ON, MANUAL ASSIST FOR BALANCE OR SAFETY ISSUES) WITH A FOUR WHEELED WALKER. THE NOTE REVEALED ON [DATE], RESIDENT #505'S STANDING BALANCE WAS FAIR AND UNSUPPORTED WITH NO ASSISTIVE DEVICES. REVIEW OF AN OCCUPATIONAL THERAPY DAILY/WEEKLY DOCUMENTATION NOTE DATED [DATE] THROUGH [DATE], REVEALED ON [DATE], RESIDENT #505 NEEDED CONTACT GUARD ASSIST WITH TOILET TRANSFERS. REVIEW OF REHABILITATION DEPARTMENT'S POLICY AND PROCEDURE FOR GUEST SAFETY DURING TREATMENT DATED ,[DATE], REVEALED "GAIT BELTS SHOULD BE USED BY STAFF WHEN TRANSFERRING AND/OR AMBULATING GUESTS." REVIEW OF THE REHABILITATION DEPARTMENT'S POLICY AND PROCEDURE FOR USE OF GAIT BELT DATED ,[DATE], REVEALED "A GAIT BELT IS UTILIZED FOR SAFETY IN THE TRANSFER AND AMBULATION OF AN UNSTABLE OR NON-WEIGHTBEARING GUEST." REVIEW OF NURSING'S POLICY AND PROCEDURE FOR AMBULATION OF GUEST WITH ASSISTANCE DATED ,[DATE], REVEALED GUEST REQUIRING ASSISTANCE WILL BE AMBULATED WITH THE ASSISTANCE OF ONE OR TWO PERSONS AND A GAIT BELT. REVIEW OF NURSING ASSISTANT DOCUMENTATION DATED [DATE] THROUGH [DATE] REVEALED RESIDENT #505 REQUIRED LIMITED (PHYSICAL HELP IN GUIDED MANEUVERING OF LIMBS) TO EXTENSIVE (WEIGHT BEARING ASSISTANCE) ASSIST WITH TRANSFERS AND TOILETING. REVIEW OF THE NURSE'S NOTE DATED [DATE] AT 10:30 PM, REVEALED "AIDES WERE GETTING CLIENT (RESIDENT #505) UP FOR DINNER, UPON SITTING HER IN WHEELCHAIR CLIENT HAD VERY TIGHT GRIP (BILATERAL) TO WHEELCHAIR. CLIENTS HEAD TILTED BACK, EYES WERE IN BLANK STARE. NO RESPONSE TO VERBAL OR TOUCH. CLIENT REMAINED IN THIS STATE FOR 30 SEC (SECONDS)-1 MIN (MINUTE)." REVIEW OF NURSE'S NOTED DATED [DATE] (LATE ENTRY FOR [DATE] AT 10:30 PM), REVEALED THE PHYSICIAN WAS NOTIFIED OF RESIDENT #505'S UNRESPONSIVE EPISODE AND INSTRUCTIONS WERE MADE TO MONITOR RESIDENT #505. REVIEW OF INCIDENT REPORT DATED [DATE] AT 11:30 AM WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #11, REVEALED "THERAPY INTO RES. (RESIDENT #505) ROOM TO WORK WITH HER. SHE (RESIDENT #505) HAD TO USE THE BR (BATHROOM). RES. REFUSED TO WEAR SHOES AND REFUSED ASSISTANCE TO GO INTO THE BR WITH HER. THERAPY HEARD A NOISE AND OPENED BR DOOR, OBSERVED RES. ON THE FLOOR." IN AN INTERVIEW ON [DATE] AT 10:45 AM AND A WRITTEN STATEMENT DATED [DATE], PHYSICAL THERAPY ASSISTANT (PTA) #18 REPORTED ON [DATE] AT APPROXIMATELY 11:20 AM, RESIDENT #505 REFUSED TO PUT HER SHOES ON AND PROCEEDED TO THE BATHROOM. PTA #18 REPORTED SHE FOLLOWED RESIDENT #505 TO THE BATHROOM AND ENSURED SHE ON WAS ON TOILET. PTA #18 REPORTED RESIDENT #505 DID NOT USE HER WALKER AND COULD NOT REMEMBER IF SHE USED HER GAIT BELT ON RESIDENT #505. PTA #18 REPORTED SHE CHECKED ON RESIDENT #505 AND CHANGED HER BRIEF AND RESIDENT #505 STATED SHE WAS ALMOST DONE AND DID NOT NEED HELP. PTA #18 REPORTED SHE CHECKED ON RESIDENT #505 AGAIN AND AS RESIDENT #505 WAS WALKING TOWARDS THE BATHROOM DOOR, SHE TOLD RESIDENT #505 TO FLUSH THE TOILET. PTA #18 REPORTED RESIDENT #505 CLOSED THE BATHROOM DOOR AND THEN SHE HEARD A "HARD THUMP." PTA #18 REPORTED SHE WENT INTO THE BATHROOM AND SAW RESIDENT #505 ON THE FLOOR, FLAT ON HER BACK. PTA #18 REPORTED SHE HAD FAMILY MEMBER #19 STAY WITH RESIDENT #505 AND IMMEDIATELY NOTIFIED DIRECTOR OF NURSING (DON) #2. IN AN INTERVIEW ON [DATE] AT 9:07 AM, FAMILY MEMBER #19 REPORTED SHE WAS IN THE ROOM WITH RESIDENT #505 AND PTA#18. FAMILY MEMBER #19 REPORTED RESIDENT #505 NEEDED TO USE BATHROOM BUT REFUSED TO HAVE PTA #18 PUT HER SHOES ON. FAMILY MEMBER #19 REPORTED SHE WITNESSED RESIDENT #505 WALK BY HERSELF TO THE BATHROOM WITHOUT ANY ASSISTANCE FROM PTA#18. FAMILY MEMBER #19 REPORTED PTA #18 STOOD BY RESIDENT #505'S BED. FAMILY MEMBER #19 REPORTED PTA #19 DID CHECK ON RESIDENT #505 A COUPLE OF TIMES BUT PTA #18 DID NOT STAY IN THE BATHROOM WITH RESIDENT #505. IN AN INTERVIEW ON [DATE] AT 10:40 AM AND REVIEW OF A WRITTEN STATEMENT DATED [DATE], DON #2 REPORTED RESIDENT #505 WAS ON THE BATHROOM FLOOR, LYING ON HER BACK IN A STIFF POSITION AND WAS UNRESPONSIVE. DON #2 REPORTED RESIDENT #505'S PUPILS WERE FIXED AND DILATED, ARMS WERE STRAIGHT OUT, HANDS WERE IN A FIST POSITION, AND LEGS WERE STRAIGHT WITH TOES POINTING DOWN. REVIEW OF A PATIENT TRANSFER FORM, DATED [DATE], REVEALED RESIDENT #505 WAS TRANSFERRED TO THE HOSPITAL. REVIEW OF A HOSPITAL RECORD DATED [DATE] REVEALED RESIDENT #505 SUSTAINED A RIGHT PARIETAL (BONE THAT FORMS THE BACK AND SIDES OF THE SKULL) NON-DEPRESSED SKULL FRACTURE WITH ASSOCIATED PNEUMOCEPHALUS (GAS OR AIR IN THE CAVITY OF THE BRAIN), TRAUMATIC SUBARACHNOID HEMORRHAGE (BLEEDING BETWEEN THE BRAIN AND BRAIN TISSUES), INTRAVENTRICULAR HEMORRHAGE (BLEEDING INTO THE VENTRICLES OF THE BRAIN), HEMORRHAGIC (BLEEDING) CONTUSION TO THE RIGHT FRONTAL AREA OF THE BRAIN, SUBDURAL HEMATOMA (BLEEDING BETWEEN THE TISSUES THAT COVER THE BRAIN), AND CEREBRAL EDEMA (SWELLING OF THE BRAIN). THE RECORD REVEALED RESIDENT #505 WAS AWAKE AND ALERT, BUT DID NOT FOLLOW COMMANDS, AND RESIDENT #505'S SPEECH WAS INCOMPREHENSIBLE. THE RECORD REVEALED RESIDENT #505 EYE'S WERE DEVIATED TO THE LEFT. THE RECORD REVEALED RESIDENT #505'S "GAZE AND HEAD TYPICALLY DIRECTED TO THE LEFT AND IT LOOKS AS IF THE PATIENT IS STARING OFF INTO SPACE." aCCORDING TO pUBmED HEALTH Subdural hematomas are usually the result of a serious head injury. When one occurs in this way, it is called an "acute" subdural hematoma. Acute subdural hematomas are among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death. (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 32/) REVIEW OF A HOSPITAL RECORD DATED [DATE], REVEALED RESIDENT #505 "REMAINED OBTUNDED (HAVING DIMINISHED AROUSAL AND AWARENESS) WITH INTERMITTENT RESPONSE TO PAINFUL STIMULI AND MOVING OF THE EXTREMITIES. HER MENTAL STATUS WAS LABILE, BUT 1 DAY PATIENT WAS OBTUNDED AND NOT RESPONSIVE, AND THE FOLLOWING DAY PATIENT WAS MINIMALLY RESPONSIVE." THE REPORT REVEALED THE FAMILY DESIRED TO MAKE RESIDENT #505 "COMFORTABLE AND DO COMFORT CARE ORDERS." THE REPORT REVEALED RESIDENT #505 WAS discharged FROM THE HOSPITAL ON [DATE] TO A DIFFERENT FACILITY. IN AN INTERVIEW ON [DATE] AT 9:07 AM, FAMILY MEMBER #19 REPORTED RESIDENT #505 expired on [DATE]. ( )

This citation pertains to Intake Number MI 439 Based on observation, interview, and record review, the facility failed to provide sufficient fluids to 1 of 4 sampled residents (Resident #103) resulting in dehydration and hospitalization . Findings include: Review of the Face Sheet and the Minimum Data Set ((MDS) dated [DATE], reflected that Resident #103 was a [AGE] year old male admitted to the facility on [DATE]. Resident #103's daily decision making skills were moderately impaired and his ability to make himself understood was limited. Resident #103 required extensive assistance of two persons for transfers, bathing, and toilet use. Resident #103 required extensive assistance of one person for personal hygiene which includes brushing teeth. Resident #103's MDS skin assessment revealed (1) Stage 1 (intact skin non blanchable) and (4) Stage 2 (partial thickness skin loss) pressure ulcers. The Care Area Assessment (CAA) of the MDS revealed that Resident #103 had a history of [REDACTED]. Review of the Hospital emergency room History and Physical dated 2/28/11, revealed that Resident #103's family noted that Resident #103 had been complaining that his throat was very sore, and he was having difficulty swallowing things. The Physical Exam revealed that Resident #103's general appearance was "difficult to assess,... appeared weak and hypovolemic" (body fluid loss). The mouth assessment revealed "a black tongue, with several patches of white plaque that scrape with tongue depressor. His mouth appears very sore. Holding ice in his mouth then spitting it out to help relieve the pain". Resident #103 was given two units of blood and intravenous (in veins) fluids. The Assessment revealed that Resident #103 had oral candidiasis (infection on the mucous membranes in the mouth). Laboratory results revealed a Blood Urea Nitrogen (BUN) of 129 (normal 7 - 18 ), creatinine of 3.4 (normal 0.8 - 1.3), Review of the Dietian Progress Notes dated 2/4/11, revealed that Resident #103's estimated daily fluids were 1980 milliliters (unit of measure 1 ounce is equivalent to approximately 30 milliliters) (mL) due to varied intake and multiple pressure areas. Review of Nutritional assessment dated [DATE], revealed Fluid Requirements for Resident #103 as 1240 - 1550 milliliters of fluid a day. In an interview on 4/20/11 at 10:40 a.m. the Dietary Manager (DM) reported that Argiment has 26.9 grams of protein per packet, and would be mixed with 240 milliliters (mL) of water. The DM reported that Argiment was obtained from the pharmacy after an order was written and that Argiment was a protein powder used if wounds were not healing. The DM was shown the Food Acceptance Record and requested to calculate the amount of fluid Resident #103 had consumed 2/23/11-2/26-11. The DM calculations reported; 2/23/11 - 690 milliliters 2/24/11 - 630 milliliters 2/25/11 - 930 milliliters 2/26/11 - 990 milliliters, noting that family usually provided dinner and that the Certified Nursing Staff (CNA) did not record this meal in the Food Acceptance Record. The DM reported that she was not aware Resident #103 was having loose stools. The DM reported that the hydration sheet noted in the Medication Record was part of the Food Acceptance Record. The DM was given a copy of the February Medical Administration Report (MAR) and reported that according to the MAR indicated [REDACTED]. The DM could not determine why the Argiment had not been started on 2/4/11 and administered per the Registered Dietian's order. Review of Nursing Progress Notes dated 2/4/11 at 6 p.m. for Resident #103 revealed, "new dietary orders in physician's telephone order sheet, [MEDICATION NAME] lab to evaluate protein status, add 1 packet of Argiment (protein supplement) BID (twice a day) - multiple pressure ulcers". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #103's MAR indicated [REDACTED]. The Liquid Protein was to be given at 8 a.m., 2 p.m., and 8 p.m. with the percentage consumed by Resident #103 recorded in the MAR. Resident #103's MAR indicated [REDACTED] 2/14/11 - at 8 a.m. nurse initial circled (means not given) (no notation as to why liquid protein was not given reported in the Nurse Medication Notes), 2 p.m. nurse initial circled (no notation as to why liquid protein not given reported in the Nurse Medication Notes), and 8 p.m. 100 % taken 2/15/11 - blank record nothing recorded at any of the administration times 2/16/11 - all three time frames initialed by nurse and circled (the Nurse Medication Notes dated 2/16/11 at 8 a.m. reflected "liquid protein unable to administer supplier notified of need") (no notation was made at 2 p.m. or 8 p.m. as to why the liquid protein was not administered) 2/17/11 - all three time frames initialed by nurse and circled (no notation as to why liquid protein was not given reported in the Nurse Medication Notes) 2/18/11 - 8 a.m. and 2 p.m. dose initialed by nurse and circled (no notation as to why liquid protein was not given reported in the Nurse Medication Notes), the 8 p.m. dose reflected 100 % taken 2/19, 20, 22-24, 26/11 - 8 a.m. and 2 p.m. dose given, no percentage taken by Resident #103 was recorded 2/19-26/11 - 8 p.m. dose reflected 100 % taken 2/21/11 - 8 a.m. dose given, no percentage taken by Resident #103 was recorded, 2 p.m. record blank 2/25/11 - 8 a.m. and 2 p.m. record blank. The Argiment, 1 packet twice daily dated 2/4/11, which would have also given Resident #103 480 mL of fluid was blank for the 8 a.m. dose from 2/4-27/11. The 8 p.m. dose was blank for the month of February, except on 2/11/11, the nurse had initialed and circle the initials, (no notation as to why the Argiment was not given per Dietician Order was noted in the Nurse Medication Notes for any day of February). Review of the Food Acceptance Record dated 2/2011, reflected that fluid consumption was recorded as; 2/14/11 - Total 26 ounces x 30 mL = 780 mL 2/15/11 - Total 28 ounces x 30 mL = 840 mL 2/16/11 - Total 36 ounces x 30 mL = 1080 mL 2/17/11 - Total 14 ounces x 30 mL = 420 mL 2/18/11 - Total 24 ounces x 30 mL = 720 mL 2/19/11 - Total 10 ounces x 30 mL = 300 mL 2/20/11 - Total 14 ounces x 30 mL = 420 mL 2/21/11 - Total 26 ounces x 30 mL = 780 mL 2/22/11 - Total 18 ounces x 30 mL = 540 mL 2/23/11 - Total 26 ounces x 30 mL = 780 mL 2/24/11 - Total 18 ounces x 30 mL = 540 mL 2/25/11 - Total 32 ounces x 30 mL = 960 mL 2/26/11 - Total 30 ounces x 30 mL = 900 mL 2/27/11 - Total 8 ounces x 30 mL = 240 mL Review of the Nurse Progress Notes dated 2/27/11 at 2:35 a.m., reflected Resident #103 had a "large brownish emesis (vomit) x 1..." (no quantity recorded). Review of the Nursing Progress Notes for February 2011, reflected that Resident #103 had a large emesis (no quantity recorded) on 2/15/11 of undigested food. No other notations of emesis were noted in the February 2011 Nursing Progress Notes. In an interview on 4/20/11 at 9:55 a.m., Licensed Practical Nurse (LPN) #1 reported that Resident #103 had a loose stool. In an interview on 4/20/11 at 11:45 a.m., CNA #4 reported that Resident #103 was "not his normal self", did not respond well, needed to be fed, and was not talking. CNA #4 reported that Resident #103 had a stool on 2/26/11 during the day shift, but did not recall color or size. CNA #4 reported that Resident #103 was voiding less than normal. CNA #4 reported that she informed LPN #4 about the changes she was noting in Resident #103. In an interview on 4/20/11 at 12:00 p.m., CNA #9 reported that on 2/22/11 she recalled informing the nurse that Resident #103 was not eating, he was staying in bed, and had to be fed. CNA #9 reported that a couple of days prior to Resident #103 falling out of bed on 2/27/11 she noted that he looked grey and had quit eating. CNA #9 reported that she informed the nurse (did not recall nurse) of these changes and that Resident #103 was complaining of pain, CNA #9 could not recall the nurse she spoke with. CNA #9 reported that on 2/26/11, Resident #103 was "not talking very much", and she swabbed his mouth after noting his tongue was black and that Resident #103 would not eat or drink which was "not normal". CNA #9 reported informing the nurse (unable to recall which nurse) of Resident #103's black tongue. In an interview on 4/20/11 at 2:52 p.m., LPN #2 reported that she did recall Resident #103 had a black tongue, but did not know it was a change in condition for him. LPN #2 denies that any CNA reported that Resident #103 was not himself, but did recall staff CNA trying to get him to eat or drink. Review of Nursing Progress notes dated 2/26/11 at 10 p.m., revealed Resident #103 with increased weakness with transfers, also noted by staff to have black tongue. In an interview on 4/27/11 at 7:25 a.m., CNA #5 reported that after Resident #103 fell out of bed at 1:35 a.m. on 2/27/11 he had a small "dark" bowel movement, and vomited (no measured), CNA #5 reported that LPN #5 stated that the vomit "looked like medicine". In an interview on 4/20/11 at 3:10 p.m., Family Member #1 reported that later in the week of 2/21/11 when Family Member #2 was visiting they noted that Resident #103 had a black tongue and reported it to the staff. Family Member #1 reported that the staff member (did not recall who) told Family Member #2 that Resident #103's tongue was black, "because he had been eating oreo cookies". Family Member #1 reported that Resident #103's mouth was hurting, he was spitting food out in napkins, and was not eating. In an interview on 4/27/11 at 10:20 a.m., LPN #3 reported that Family Member #1 did call with concerns about Resident #103 not eating or talking. LPN #3 reported that she spoke with the Speech Therapist (SP)she said that possibly the texture of the ham on the egg mcmuffin was too hard to chew, but LPN #3 did not recall if the ST looked at Resident #103. In an interview on 4/27/11 at 12:15 p.m., CNA #7 reported that the week before 2/27/11, she noticed Resident #103 was "on the call light" a lot more, to get up to bathroom, but did not void much, and that he wanted his brief changed for just a little bit of stool "from passing gas and had a little color in brief" of soft brownish stool. CNA #7 reported that she informed the nurse (did not recall which nurse) about Resident !03's urge to void with not much result. In an interview on 4/27/11 at 11:15 a.m., LPN #4 reported that she never received any report from CNA's about Resident #103's decline. LPN #4 reported that vomiting and the black tongue were new changes for Resident #103. In an interview on 4/20/11 at 7:50 a.m., Physician #1 reported that he was not aware that Resident #103 had vomited on 2/27/11 at 2:35 a.m. after the fall out of bed. Physician #1 reported that he was not aware Resident #103 had been having loose stools, was not eating well, and had a black tongue. Physician #1 reported that he should have been notified of any change of condition in Resident #103. Observations by surveyor on 4/18/11 from 11:30 a.m. to 1:00 p.m.., 4/19/11 after 4:30 p.m., and 4/20/11 6:20 a.m. - 6:35 a.m. and 7:10 a.m. - 7:35 a.m. revealed like residents eating and drinking with and without assistance by staff. Observations were conducted during the meal hours in the main dining room and residents rooms. The surveyor observed water being passed and snacks offered and consumed by residents when the surveyor was on the resident hallways during the investigation.

This citation pertains to Intake Number MI 439 Based on observation, interview, and record review, the facility failed to provide adequate and appropriate nutrition in 1 of 4 sampled residents (Resident #103) resulting in significant weight loss, non-healing pressure ulcers, and hospitalization . Findings include: Review of the Face Sheet and the Minimum Data Set ((MDS) dated [DATE], reflected that Resident #103 was a [AGE] year old male admitted to the facility on [DATE]. Resident #103's daily decision making skills were moderately impaired and his ability to make himself understood was limited. Resident #103 required extensive assistance of two persons for transfers, bathing, and toilet use. Resident #103 required extensive assistance of one person for personal hygiene which includes brushing teeth. Resident #103's MDS skin assessment revealed (1) Stage 1 (intact skin non blanchable) and (4) Stage 2 (partial thickness skin loss) pressure ulcers. The Care Area Assessment (CAA) of the MDS revealed that Resident #103 had a history of [REDACTED]. Review of the Hospital emergency room History and Physical dated 2/28/11, revealed that Resident #103's family noted that Resident #103 had been complaining that his throat was very sore, and he was having difficulty swallowing things. The Physical Exam revealed that Resident #103's general appearance was "difficult to assess,... appeared weak and hypovolemic" (body fluid loss). The mouth assessment revealed "a black tongue, with several patches of white plaque that scrape with tongue depressor. His mouth appears very sore. Holding ice in his mouth then spitting it out to help relieve the pain". Resident #103 was given two units of blood and intravenous (in veins) fluids. The Assessment revealed that Resident #103 had oral candidiasis (infection on the mucous membranes in the mouth). Laboratory results revealed a Blood Urea Nitrogen (BUN) of 129 (normal 7 - 18 ), creatinine of 3.4 (normal 0.8 - 1.3). Review of the Hospital laboratory results dated [DATE] collected at 2:22 p.m., revealed that Resident #103's hematocrit was 19.0% (normal 41%- 51%) and [MEDICATION NAME] of 2.7 (normal 3.5 - 5.1). According to Laboratory and Diagnostic Tests with Nursing Implications. Sixth Edition. (2002), a hematocrit of less than 15% is a panic value. The clinical problems related to a decreased level included, "...protein [MEDICAL CONDITION]". [MEDICATION NAME] is "a compound of proteins" with clinical problems related to a decreased level that include "...severe [MEDICAL CONDITION]". Review of Nutritional assessment dated [DATE], and signed by the Dietary Manager (DM) revealed Resident #103's Estimated Protein Needs (EPN) were 74 grams of protein a day. Review of Nursing Progress Notes dated 2/4/11 at 6 p.m. for Resident #103 revealed, "new dietary orders in physician's telephone order sheet, [MEDICATION NAME] lab to evaluate protein status, add 1 packet of Argiment (protein supplement) BID (twice a day) - multiple pressure ulcers". Review of the Registered Dietitian (RD) Progress Notes dated 2/4/11, revealed that Resident #103 has a Stage I pressure ulcer on his bilateral buttock and 4-5 Stage II pressure ulcers on his right buttock. The RD estimated Resident #103's daily nutritional needs as 79.2 - 85.5 grams of protein and 1980 milliliters (unit of measure - 1 ounce is equivalent to approximately 30 milliliters) (mL) of fluid daily due to varied intake and multiple pressure areas. The Progress Notes recommended 1 packet of Argiment (protein supplement) twice a day for Resident #103. Review of the Dietary Manager Progress Notes dated 2/9/11, reflected Resident #103 current weight was 137 pounds,a 6.1 % weight loss in one month and 10.3 % weight loss in 3 months. The Dietary Manager (DM) recommended putting Resident #103 on a Super Nutrition Program (SNP) and to continue monitoring weights and food acceptance. The DM Progress Notes reflected that a SNP provides 3454 calories and 110 grams of protein. The DM Progress Notes reflected that Resident #103 currently has Stage II pressure ulcers on bilateral buttocks. The DM also noted that the Registered Dietician reviewed Resident #103's record on 2/4/11, recommended 1 packet Argiment twice a day, order written 2/4/11, related to significant weight loss, fair oral intake of food, altered skin integrity, and abnormal labs. In an interview on 4/20/11 at 10:40 a.m. the Dietary Manager (DM) reported that Argiment has 26.9 grams of protein per packet. The DM reported that Argiment was obtained from the pharmacy after an order was written and that Argiment was a protein powder used if wounds were not healing. The DM could was unable to tell the surveyor why Resident #103 had not received any Argiment as ordered by the Registered Dietitian on 2/4/11. The DM was shown the Food Acceptance Record noting that family usually provided dinner and that the Certified Nursing Staff (CNA) did not record this meal in the Food Acceptance Record. Review of Nursing Progress Notes dated 2/16/11 at 3:48 p.m. for Resident #103 revealed, " order clarification received and faxed to pharmacy: Argiment one packet twice daily, start when available". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #103's MAR indicated [REDACTED]. The Liquid Protein was to be given at 8 a.m., 2 p.m., and 8 p.m. with the percentage consumed by Resident #103 recorded in the MAR. Resident #103's MAR indicated [REDACTED] 2/14/11 - at 8 a.m. nurse initial circled (means not given) (no notation as to why liquid protein not given reported in the Nurse Medication Notes), 2 p.m. nurse initial circled (no notation as to why liquid protein not given reported in the Nurse Medication Notes), and 8 p.m. 100 % taken 2/15/11 - blank record nothing recorded at any of the administration times 2/16/11 - all three time frames initialed by nurse and circled (the Nurse Medication Notes dated 2/16/11 at 8 a.m. reflected "liquid protein unable to administer supplier notified of need") (no notation was made at 2 p.m. or 8 p.m. as to why the liquid protein was not administered) 2/17/11 - all three time frames initialed by nurse and circled (no notation as to why liquid protein was not given reported in the Nurse Medication Notes) 2/18/11 - 8 a.m. and 2 p.m. dose initialed by nurse and circled (no notation as to why liquid protein was not given reported in the Nurse Medication Notes), the 8 p.m. dose reflected 100 % taken 2/19, 20, 22-24, 26/11 - 8 a.m. and 2 p.m. dose given, no percentage taken by Resident #103 was recorded 2/19-26/11 - 8 p.m. dose reflected 100 % taken 2/21/11 - 8 a.m. dose given, no percentage taken by Resident #103 was recorded, 2 p.m. record blank 2/25/11 - 8 a.m. and 2 p.m. record blank. The Argiment 1 packet twice daily dated 2/4/11, was blank 8 a.m. 2/4-27/11, the 8 p.m. dose was blank except on 2/11/11, the nurse initialed and circle, no notation as to why the Argiment was not given per Dietician Order was noted in the Nurse Medication Notes for any day of February. Review of the Nursing Care Card for Resident #103 reflected that the Intake and Output were to be recorded. Review of the Food Acceptance Record dated 2/2011, reflected that meal consumption was recorded on the record as; (1) = 75-100%, (2) = 50-74%l, (3) = 25-49%, (4) = 0-24%, and Refused (R) for the amount of food Resident #103 consumed for breakfast (B), lunch (L), and dinner (D) each day. Review of the Food Acceptance Record for; 2/14/11 - B = 2, L = 3, and D = R 2/15/11 - B = 1, L = R, and D = family 2/16/11 - B = 1, L = 3, and D = 4 2/17/11 - B = 3, L = R, D = family 2/18/11 - B = 3, L = (not recorded), D = family 2/19/11 - B = family, L = R, D = family 2/20/11 - B = 1, L = R, D = family 2/21/11 - B = 2, L = 3, D = 3 2/22/11 - B = 2, L = 4, D = 3 2/23/11 - B = 2, L = 3, D = family 2/24/11 - B = 2, L = 4, D = family 2/25/11 - B = 3, L = R. D = 3 2/26/11 - B = 2, L = R, D = 3 2/27/11 - B = 4, L = R, D = (at hospital). In an interview on 4/20/11 at 11:45 a.m., Certified Nursing Assistant (CNA) #4 reported that Resident #103 was not his normal self, CNA #4 went to get CNA #9, because she was more familiar with Resident #103. CNA #4 reported that Resident #103 did not respond well, needed to be fed, which was not normal for him. In an interview on 4/20/11 at 12:00 p.m., CNA #9 reported that on 2/22/11 she recalled informing the nurse that Resident #103 was not eating, he was staying in bed, and had to be fed. CNA #9 reported that a couple of days prior to Resident #103 falling out of bed on 2/27/11 she noted that he looked grey and had quit eating. CNA 39 reported that she informed the nurse of these changes and that Resident #103 was complaining of pain, CNA #9 could not recall the nurse she spoke with. In an interview on 4/20/11 at 2:52 p.m., Licensed Practical Nurse (LPN) #2 reported that she did recall Resident #103 had a black tongue, but did not know it was a change in condition for him, so she did not notify the physician. LPN #2 denies that any CNA reported that Resident #103 was not himself, but did recall staff CNA trying to get him to eat or drink. Review of Nursing Progress notes dated 2/26/11 at 10 p.m. and signed by LPN #2, revealed Resident #103 with increased weakness with transfers, also noted by staff to have black tongue. In an interview on 4/20/11 at 3:10 p.m., Resident #103's Family Member #1 reported that on 2/19/11 they brought Resident #103 an egg mcmuffin which was his favorite breakfast and he could not eat it, Resident #103 could not state why. Family Member #1 reported calling the facility on 2/21/11 to report Resident #103 not eating the egg mcmuffin on 2/19/11. Family Member #1 reported that she spoke with LPN #3, and she (LPN #3) said she would have the Speech Therapist look at Resident #103. Family Member #1 reported that later in the week of 2/21/11 when Family Member #2 was visiting they noted that Resident #103 had a black tongue and reported it to the staff. Family Member #1 reported that the staff member (did not recall who) told Family Member #2 that Resident #103's tongue was black, "because he had been eating oreo cookies". Family Member #1 reported that Resident #103's mouth was hurting, he was spitting food out in napkins, and was not eating. In an interview on 4/27/11 at 10:20 a.m., LPN #3 reported that Family Member #1 did call with concerns about Resident #103 not eating or talking. LPN #3 reported that she spoke with the Speech Therapist (SP)she said that possibly the texture of the ham on the egg mcmuffin was too hard to chew, but LPN #3 did not recall if the ST looked at Resident #103. In an interview on 4/28/11 at 5:46 p.m., CNA #12 reported that Resident #103 was "going downhill, not independent, not eating well and we had to feed him" the week prior to his fall out of bed on 2/27/11. In an interview on 4/20/11 at 7:50 a.m., Physician #1 reported that he was not aware that Resident #103 had vomited on 2/27/11 at 2:35 a.m. after the fall out of bed. Physician #1 reported that he was not aware Resident #103 had been having loose stools, was not eating well, and had a black tongue. Physician #1 reported that he should have been notified of any change of condition in Resident #103. Observations by surveyor on 4/18/11 from 11:30 a.m. to 1:00 p.m.., 4/19/11 after 4:30 p.m., and 4/20/11 6:20 a.m. - 6:35 a.m. and 7:10 a.m. - 7:35 a.m. revealed like residents eating with and without assistance by staff. The surveyor observed water being passed and snacks offered and consumed by residents when the surveyor was on the resident hallways during the investigation.

This citation pertains to Intake Number MI 499 and MI 439 Based on observation, interview, and record review, the facility failed to prevent falls and ensure a safe environment in 2 of 4 sampled residents (Resident #102) who fell from a wheelchair resulting in a fracture of her left hip femoral neck, her right hip, and had pubic rami fractures and (Resident #103) who fell from a wheelchair resulting in a fractured right clavicle. Findings include: Resident #102: Review of the Face Sheet and the Minimum Data Set ((MDS) dated [DATE], reflected that Resident #102 was a [AGE] year old female admitted to the facility on [DATE]. Resident #102's daily decision making skills were moderately impaired, required extensive assistance of one person for transfers, locomotion on the unit, dressing, personal hygiene, bathing, and toilet use. Resident #102's functional status reflected that she was not steady without human assistance during transition and walking. The Care Area Assessment (CAA) of the MDS revealed that Resident #102 had a history of [REDACTED]. The prime admit [DIAGNOSES REDACTED]. Review of the Incident Report dated [DATE] at 6:50 a.m., reflected that LPN #4 was paged to the main dining room, Certified Nursing Assistant (CNA) #12 found Resident #102 "on floor lying on right side fetal position (body is curled with the head and limbs drawn in). Resident #102 crying out loud that her right hip was very painful, stated her shoulder and head was hit hard. No visible injury". No first aid was administered, Resident #102 was taken by ambulance to the hospital at 7:20 a.m.. Resident #102's condition before the incident is documented as disoriented. In an interview on [DATE] at 5:46 p.m., CNA #12 reported that she was taking residents to the dining room and found Resident #102 on the floor calling for help. CNA #12 reported that Resident #102 was not at the place she usually sits for her meals. CNA #12 reported that Resident #102 had been ill and was not herself since her husband died . CNA #12 reported that Resident #102 was not responsive to her when CNA #12 found her on the floor, Resident #102 "mumbled" a lot, and did not state how she fell . CNA #12 reported that LPN #4 came and took over and then the ambulance crew came. Review of the Post Fall Evaluation dated [DATE] at 9:35 a.m., reflected that Resident #102 was in a wheelchair with footrests. Review of the Ambulance Emergency Run Sheet dated [DATE] on scene at 7:11 a.m., reflected that Resident #102 "fell from standing position. Found laying on right side, fetal position. Patient cries and state right hip pain...Patient also complains thoracic back pain. Patient mildly confused, normal for her". Review of the Hospital Emergency Department Records dated [DATE] at 8:45 a.m., reflected that Resident #102 presents after an unwitnessed fall in the nursing home. Radiological studies showed an equivocal fracture of her left femoral and a fracture of her right hip. Family understand that even if they choose to repair of femoral neck fracture, Resident #102 will likely be in pain from the pubic rami fractures. Further imaging studies were declined since the family was not interested in acute interventions. Review of the Interdisciplinary Care Plan dated [DATE] and evaluated [DATE], reflected that Resident #102's Problem / Need is documented as; risk for falls - fell at home - had right hip pain - negative for fracture - ...fall risk 28 (score greater than 10 is HIGH RISK)...The Fall Care Plan Interventions are documented as ...supervise / assist with activities of daily living... - monitor for fatigue and/or unsteadiness and encourage rest periods.... Review of the Social Worker Progress Notes dated [DATE] reflected that staff report Resident #102 is very restless and fretful today. Resident #102 is tearful stating she doesn't know what to do. Resident #102 repeatedly taking off her clothes, attempting to stand and resisting assistance.... In an interview on [DATE] at 1:50 p.m., CNA #1 reported that Resident #102 was assisted to the dining room by the CNA's as she was unable to propel herself in her wheelchair all the way to the dining room. CNA #1 reported that she did not take Resident #102 to the dining room until she heard the overhead call for all staff to dining room because Resident #102 would try to get out of her wheelchair and CNA #1 did not feel safe leaving Resident #102 alone in the dining room without staff. In an interview on [DATE] at 4:40 p.m., the Social Worker reported that after Resident #102's husband passed there were days Resident #102 didn't know where she was. In an interview on [DATE] at 6:35 a.m., Licensed Practical Nurse (LPN) #5 reported that before her fall on [DATE] Resident #102 could use her feet a little to propel herself in the wheelchair, but could not have moved herself to the dining room. In an interview on [DATE] at 8:40 a.m., CNA #3 reported that Resident #102 was not alert, kept taking off her clothes, and attempted to stand from the wheelchair. CNA #3 reported that Resident #102 was not safe to be left alone. In an interview on [DATE] at 11:45 a.m., CNA #4 reported that 3rd shift who left at 6:00 a.m. had gotten Resident #102 up on [DATE]. CNA #4 reported seeing Resident #102 in the dining room at the table where she usually had her meal about 10 minutes prior to the fall. CNA #4 reported that Resident #102 looked tired, and in hindsight she (CNA #4) should probably should have taken Resident #102 back to the Nurses Station. In an interview on [DATE] at 12:00 a.m., CNA #9 reported that prior to Resident #102's fall on [DATE] she was not eating well, and would take her clothes off a lot, while in her wheelchair. CNA #9 reported that Resident #102 was not safe to be left in her wheelchair, in the dining room alone. In an interview on [DATE] at 10:55 a.m., LPN #3 reported that Resident #102 was a fall risk, had pressure alarms, and at times would attempt to get up out of the wheelchair. In an interview on [DATE]/ at 11:15 a.m., LPN #4 reported that Resident #102 was taken to the dining room by a CNA (unable to recall which CNA), and that it was a little early for Resident #102 to be in the dining room. In an interview on [DATE] at 12:02 p.m., CNA #6 reported that Resident #102 was not safe to be left alone in her wheelchair, because she would try and get up. CNA #6 reported that Resident #102 was "out of it" after her husband died . CNA #6 reported taking care of Resident #102 at the 5:00 p.m. meal and that Resident #102 would not have been safe left alone in the dining room at that time. In an interview on [DATE] at 1:45 p.m., CNA #10 reported that before the fall on [DATE] Resident #102 was very "antsy" and would not stay in bed. CNA #10 reported that Resident #102 was not safe alone in her wheelchair, because she would try to get up. Resident #103: Review of the Face Sheet and the Minimum Data Set ((MDS) dated [DATE], reflected that Resident #103 was a [AGE] year old male admitted to the facility on [DATE]. Resident #103's daily decision making skills were moderately impaired and his ability to make himself understood was limited. Resident #103 required extensive assistance of two persons for transfers, bathing, and toilet use. Resident #103 required extensive assistance of one person for personal hygiene which includes brushing teeth. Resident #103's MDS skin assessment revealed (1) Stage 1 (intact skin non blanchable) and (4) Stage 2 (partial thickness skin loss) pressure ulcers. The Care Area Assessment (CAA) of the MDS revealed that Resident #103 had a history of [REDACTED]. Review of the Incident Reported dated [DATE] at 10:20 p.m., reflected Resident #103 was found on his back laying on the floor in his room. Resident #103 stated "I fell asleep in my chair". Review of physician progress notes [REDACTED]. Review of the Plan of Care dated [DATE], reviewed [DATE] reflected that Resident #103's Problems/Conclusions were documented as "Falls 02: At risk for fall related injury secondary to history of falls and psychotropic drug use". The Plan of Care documented Approaches/Interventions as: [DATE] Assistive devices as ordered [DATE] Supervise and assist with transfers as needed [DATE] Torso Support - encourage Resident #103 to wear while up in wheelchair [DATE] Encourage Resident #103 to continue use of torso support for improved safety [DATE] Sensor pad to bed and wheelchair In an interview on [DATE] at 12:10 p.m., LPN #5 reported that Resident #103 had a torso support that would hold him upright in his wheelchair, but Resident #103 was known to unsnap the torso support. LPN #5 reported that staff was to check the torso support every shift or when Resident #103 was up in his wheelchair. LPN #5 reported that Resident #103 was known to sleep in his wheelchair. LPN #5 reported that Resident #103 had the torso support since November of 2010, that staff knew he unsnapped the torso support, and were to check on Resident #103 more often when he was up in his wheelchair. Review of physician progress notes [REDACTED]. Review of the Fall Risk assessment dated [DATE], reflected that Resident #103 total score was 22 (a total score of 10 or more represents HIGH RISK). Review of Physical Therapy Evaluation and Plan of Treatment dated [DATE], reflected that Resident #103's reason for referral was that Resident #103 fell and fractured right shoulder and has declined substantially since ,[DATE] and worse since right shoulder fracture. Observations by surveyor on [DATE] at 9:40 a.m. and 3:45 p.m., [DATE] at 2:05 p.m., and [DATE] 6:20 a.m. - 6:35 a.m. and 7:10 a.m. - 7:35 a.m. revealed other like residents in wheelchairs, up with walkers, or resting in bed in their rooms, chair or bed alarms observed, were in place and functioning, and residents were being assisted by Physical Therapist or CNA's. Residents in the dining room on [DATE] at 6:30 a.m. were able to self propel their wheelchair. CNA staff were not observed bringing any residents who were cognitively impaired to the dining room until after 7:00 a.m., when there were more staff present. The surveyor did not observe any residents sleeping in their wheelchairs during this observation time.

This citation pertains to intake number MI 545. Based on interview and record review the facility failed to provide the necessary care and services by not administering physician ordered routine medication (Potassium) to one of six sampled residents (Resident #103) resulting in Immediate Jeopardy for Resident #103 who did not receive her Potassium for 69 days (from [DATE]-[DATE]). Resident #103 died on [DATE]. This deficient practice places 87 other residents who were ordered to receive routine medications on a daily basis, at high risk for serious harm, injury, or death. Findings Include: Resident #103 Per Resident #103's face sheet, she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Per Resident #103's MDS (Minimum Data Set), dated [DATE], she had diagnoses of diabetes, cardiac [MEDICAL CONDITION], hypertension, dementia, depression and [MEDICATION NAME] degeneration, had moderately impaired cognitive skills for daily decision making and no oral or nutritional problems. Per nursing Progress Notes, dated [DATE] at 6:00 AM, "Resident (#103) has been up since 4:00 AM in wheel chair in corridor...Yesterday at HS (hour of sleep), resident (#103) was reading "(name of a magazine)"..." Per nursing Progress Notes, dated [DATE] at 7:00 AM, "At 6:50 AM called to resident's side while she was sitting in wheel chair at the end of center hall ...Resident nonresponsive..." Per Resident #103's death certificate, dated [DATE], "Actual or presumed time of death: 11:45 AM" and reason for death: "a. Cardiac [MEDICAL CONDITION]; b. Hypokalemia (low potassium)". According to Mosby's Manual of Diagnostic and Laboratory Tests, 2002, page 373: "...Because the serum (blood) concentration of potassium is so small, minor changes in concentration have significant consequences...Therefore, if potassium is not adequately supplied in the diet (or by IV administration in the patient who is unable to eat), serum potassium levels can drop rapidly...This electrolyte (potassium) has profound effects on the heart rate and contractility (ability to beat) ...Drugs that may cause decreased levels include ...diuretics (potassium wasting) ...insulin ..." Per Resident #103's "physician's orders [REDACTED]. Resident #103's MARs reflected that she received the ordered doses of Insulin. Per Resident #103's "physician's orders [REDACTED]. resident #103's MARs reflected that she received 28 of the 31 daily doses prescribed in July, 2010 and 17 of the 18 daily doses, before her death, in August, 2010. Laboratory abnormalities related to the administration of [MEDICATION NAME] include hypokalemia in 14.7% of those taking the medication. "Serum potassium should be measured periodically and potassium supplements or potassium-sparing diuretics added if necessary".(http://www.rxlist.com/[MEDICATION NAME]-drug.htm). Per nursing "Progress Notes", dated [DATE], "Resident having difficulty swallow (potassium) tabs, changed to liquid equivalent due to critically low lab results of 2.4 (normal 3XXX,[DATE].3 mmol/L)". Per Resident #103's laboratory reports: [DATE] - Potassium 3.0 mmol/L (signed by physician-date illegible) [DATE] - Potassium 2.4 mmol/L (signed by physician-date illegible) [DATE] - Potassium 3.0 mmol/L (signed by physician-date illegible) [DATE] - Potassium 2.2 mmol/L (signed as reported to physician by nurse #39-not dated) Per Resident #103's nursing Progress Notes, there was no note written to indicate that a physician had been notified about the [DATE] Potassium laboratory value. Per Resident #103's nursing Progress Notes, dated [DATE], "Resident having difficulty swallow (Potassium) tabs, changed to liquid equivalent due to critically low lab results of 2.4". Per Resident #103's nursing Progress Notes, dated [DATE], "(Physician #21) in - labs reviewed - order for labs on [DATE] noted". Per Resident #103's nursing Progress Notes, dated [DATE], "...continues to refuse her medication periodically". Per Resident #103's nursing Progress Notes, there was no note written that would suggest that the physician had been notified about the [DATE] Potassium laboratory value. On [DATE], per Resident #103's nursing Progress Notes, "(Physician #21) in today. No new orders". Per Resident #103's nursing Progress Notes, dated [DATE], "Critical labs reported to (physician #21). Order to increase Potassium 40 meq to BID ( two times per day) and recheck next lab day", was signed by nurse #39. Review of Resident #3's MARs (Medication Administration Records), between [DATE]-[DATE], nursing recorded Resident #103 had received all scheduled doses. However, review of Resident #103's MARs (Medication Administration Records) showed potassium was not administered on [DATE], [DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE], [DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE]-[DATE], [DATE], [DATE], ,[DATE]-[DATE], [DATE], [DATE], [DATE]-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]-[DATE], [DATE] and [DATE]. Nursing staff did not record any: 1.) repeated attempts to get resident to accept potassium medication (except on [DATE]) 2.) education given to resident regarding the ill effects of refusing potassium supplementation 3.) follow-up with physician regarding refusal of potassium medication 4.) follow-up with the family regarding refusal of potassium medication 5.) Refusal of Treatment forms Review of Resident #103's nursing "Progress Notes" from [DATE]-[DATE] showed no evidence that nursing notified physician #21 that Resident #103 had refused the Potassium during that time frame. Per the facility's "Refusal of Treatment" policy, dated ,[DATE], "...If a guest refuses treatment, it will be documented in his/her medical record using the "Refusal of Treatment (form)...A guest who refuses treatment will be informed of the following: a. The reason for the recommended treatment, b. alternatives to the recommended treatment, c. Implications of refusal of treatment...Procedure: 1. Nursing and/or the guest's physician will explain the benefits of treatment, including alternatives and risks, to the guest and/or his/her legal representative. 2. Nursing will notify the physician regarding the Refusal of Treatment if he/she is not present when the refusal is made. 3. If the guest refuses the treatment, a Refusal of Treatment (form) is to be completed and signed and dated by the guest or his/her legal representative and a facility representative. 4. The Refusal of Treatment form will be filed int he guest's medical record under the "Miscellaneous" tab. Review of Resident #103's medical record showed no evidence that the family was notified by nursing services, social services, any member of the Interdisciplinary Team or a physician of Resident #103's low potassium levels or of Resident #103 not receiving the potassium medication. In an interview with administrator #1 and director of nursing #2 on [DATE] at 11:27, they were unable to account for why the family had not been notified by facility staff about resident #103's critical lab values, not having Resident #103's low potassium care planned, or Resident #103 not having interventions in place to correct the low Potassium levels. Administrator #1 stated that Potassium could have been administered by an intravenous route if she had been gone to a hospital. Per "Emergency Response Directive" for Resident #103, dated [DATE], Resident #103's Power of Attorney was Resident #103's daughter #37. Per Resident #103's daughter #37, in a telephone interview on [DATE] at 2:19 PM, and resident #103's daughter #38, in a telephone interview on [DATE] at 2:30 PM, no one at the facility told them about their mother's low potassium levels until her death was eminent on [DATE], at which time physician #21 encouraged them to change their mother's code status to "Do Not Resuscitate". Both daughters said they would have promoted interventions to correct the low potassium if they would have known. Per review of Resident #103's physician's orders [REDACTED].#21 (Resident #103's attending physician/Medical Director): [DATE] - "Change Potassium to liquid equivalent. 40 meq every day due to difficulty swallowing pills". [DATE] - "Potassium oral solution 20 meq by P.O. (by mouth) two times a day (8:00 AM and 8:00 PM)". [DATE] - "DC (discontinue) Potassium order on [DATE]. Continue Potassium oral solution 40 meq/15 ml P.O. every day (8:00 AM)". [DATE] - "Increase Potassium to bid (two times per day). Recheck next lab day". On [DATE], the Surveyor found most of physician #21's "Progress Notes" for Resident #103 to be illegible. On [DATE], at 3:40 PM, the administrator #1, told Surveyor that physician #21 wanted to speak with Surveyor. In the phone conversation with physician #21, Surveyor informed physician #21 that his notes were "very important" to the case regarding Resident #3. In the phone conversation, [MEDICATION NAME] approximately seven minutes, physician #21 angrily, repeatedly demanded to know why Surveyor and facility staff were unable to decipher his writing but finally agreed to complete the transcription of his notes. Surveyor decided that questioning physician #21 regarding the circumstances of Resident #3's death would be disadvantageous, in light of physician #21's anger. On [DATE], the administrator #1 conveyed that physician #21 came to the facility and transcribed his original "Progress Notes" for Resident #103 (from [DATE], [DATE], [DATE] and [DATE]) for Resident #103, on the evening of [DATE]. Review of physician #21's signed transcribed "Progress Notes" for Resident #103 revealed no [DIAGNOSES REDACTED]. Review of Resident #103's medical record showed no indication that the pharmacist had monitored Resident #103's critical laboratory values or made pharmacological recommendations to restore Resident #103's potassium levels. In an interview with the administrator, on [DATE] at 10:20, she stated the pharmacy was supposed to review resident #103's labs and do a full monthly medication reviews but that this had not been being done. Per the dietary manager #16, in an interview on [DATE] at 3:50 PM, she told Surveyor she had been the facility's dietary manager for the last 10 months. Surveyor asked dietary manager #16 to explain what role potassium played in the human body. Dietary manager #16 responded, "...Honestly, I'm drawing a blank". Dietary manager #16 was unable to produce evidence that the abnormal potassium levels for Resident #103 were ever reviewed at the Nutrition Risk Committee. Dietary manager #16 said she looked at laboratory values only when it was time for her to fill out her section of the MDS (Minimum Data Set) and only if she saw abnormal labs, did she refer those residents to the consultant dietitian (there was no evidence in Resident #103's medical record that a consultant dietitian had reviewed Resident # 103's labs or made dietary recommendations to help correct hypokalemia). Dietary manager #16 admitted she had not done a nutritional assessment for Resident #103's MDS with an Assessment Reference Date of [DATE] because no one told her to. RAPs (Resident Assessment Protocols), dated [DATE], showed "Nutritional Status" section was not signed, even though "Section R: Assessment Information, 2 -Signature of the Person Coordinating the Assessment" was "signed as complete" by nurse # 17, dated [DATE]. Per the "Job Description Dietary Manager", "Job Functions: Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. the omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position". Per the administrator #1, in an interview on [DATE] at 11:27 AM, she said dietary manager #16 should have been monitoring Resident #103's labs and reporting the abnormal labs to the consultant dietitian. Administrator #1 stated, "It is her (dietary manager # 16's) responsibility to monitor labs as they are drawn". Review of Resident #103's "Plan of Care" revealed there was no "Plan of Care" initiated for Resident #103 in regards to low potassium. Per nursing "Progress Notes", dated [DATE], "At 6:50 PM, called to resident's side while she was sitting in WC (wheel chair) at the end of center hall by CENA (nurse aide). Resident unresponsive. Respirations shallow and 10 (breaths/minute). taken to room with bed and placed sitting on edge of bed. resident responding more with eyes open, would say her name. Refused to lay down. Complaint of nausea. did have small emesis. Temperature 96.8 axillary, BS (blood sugar) 286, O2 saturation 88%, pulse 48, respirations 18, B/P (blood pressure) ,[DATE]. Call placed to (nurse practitioner #40)...7:30 PM. (Nurse Practioner #40) returned call. report of what happen given. Resident more responsive and talking, could say what her name is and stated she didn't feel well. CBC (complete blood count) and CMP (comprehensive metabolic panel laboratory test) if possible ordered...9:00 PM. Daughter in at 8:00 PM. Gave report of what happened to her. Daughter sitting with her. resident sleeping but does respond when touched and name spoken". Per nursing "Progress Notes", dated [DATE], "While care given at 3:45 AM, resident (#103) became unresponsive for ,[DATE] seconds then became responsive. Had small emesis. Care given and put in chair. 5:00 AM. Had medium yellow phlegm emesis...At 11:40 AM, observed resident (#103) in room. No breaths, no pulse, no blood pressure. Family at bedside. (Physician #21) in to see..." On [DATE] at 11:25 AM, the administrator was notified of the Immediate Jeopardy that resulted from multiple system errors, culminating on [DATE], when Resident #103 began rapidly declining in health. On [DATE], Surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1). On [DATE], an audit of all current resident charts was conducted to identify critically abnormal lab values and that notification of the physician and responsible party was completed and documented. 2). On [DATE], training was provided to all 20 facility nurses regarding documented notification of the responsible party and the physician upon receipt of critical lab values. On [DATE], pocket cards were provided to all on-duty nurses, and a notice was posted for all oncoming nurses to take a copy of the pocket card outlining the steps to take with medication and treatment refusals. 3). On [DATE], the Certified Dietary Manager was inserviced on the role of potassium in the body, the laboratory values to be followed by the Dietary Manager and on signing of RAPs. 4). On [DATE], a new consulting pharmacist was assigned to the facility and found no critical laboratory values or conditions in the facility audit. 5). On [DATE], the attending physician (Medical Director) was advised of the requirement for legible and complete documentation, including documentation of discussions/notifications of responsible parties when critical labs and critical conditions exist and the dates of those discussions. 6). On [DATE], the MDS Coordinators were inserviced on assuring that all required assessments (including nutritional assessments) are done by the appropriate staff by making sure their corresponding signatures are present on required RAPs and MDSs prior to signing that the MDS is complete. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of no actual harm but potential for more than minimal harm not immediate jeopardy because sustained compliance had not been verified by the state agency.( )

This citation pertains to intake number MI 545. Based on interviews and records review, the facility failed to immediately inform one of a total of 6 sampled residents (Resident #103) legal representative/interested family member of critical abnormal laboratory values and potential interventions to prevent a sudden unresponsive state and ultimately her death death (on 8/19/10). Findings Include: Resident #103 Per Resident #103's face sheet, she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Per Resident #103's MDS (Minimum Data Set), dated 7/20/10, she had diagnoses of diabetes, cardiac [MEDICAL CONDITION], hypertension, dementia, depression and [MEDICATION NAME] degeneration, had moderately impaired cognitive skills for daily decision making and no oral or nutritional problems. Per nursing Progress Notes, dated 8/18/10 at 6:00 AM, "Resident (#103) has been up since 4:00 AM in wheel chair in corridor...Yesterday at HS (hour of sleep), resident (#103) was reading "(name of a magazine)"..." Per nursing Progress Notes, dated 8/18/10 at 7:00 AM, "At 6:50 AM called to resident's side while she was sitting in wheel chair at the end of center hall ...Resident nonresponsive..." Per Resident #103's death certificate, dated 8/19/10, "Actual or presumed time of death: 11:45 AM" and reason for death: "a. Cardiac [MEDICAL CONDITION]; b. Hypokalemia (low potassium)". According to Mosby's Manual of Diagnostic and Laboratory Tests, 2002, page 373: "...Because the serum (blood) concentration of potassium is so small, minor changes in concentration have significant consequences...Therefore, if potassium is not adequately supplied in the diet (or by IV administration in the patient who is unable to eat), serum potassium levels can drop rapidly...This electrolyte (potassium) has profound effects on the heart rate and contractility (ability to beat) ...Drugs that may cause decreased levels include ...diuretics (potassium wasting) ...insulin ..." Per Resident #103's "physician's orders [REDACTED]. Resident #103's MARs reflected that she received the ordered doses of Insulin. Per Resident #103's "physician's orders [REDACTED]. resident #103's MARs reflected that she received 28 of the 31 daily doses prescribed in July, 2010 and 17 of the 18 daily doses, before her death, in August, 2010. Laboratory abnormalities related to the administration of [MEDICATION NAME] include hypokalemia in 14.7% of those taking the medication. "Serum potassium should be measured periodically and potassium supplements or potassium-sparing diuretics added if necessary".(http://www.rxlist.com/[MEDICATION NAME]-drug.htm). Per nursing "Progress Notes", dated 6/22/10, "Resident having difficulty swallow (potassium) tabs, changed to liquid equivalent due to critically low lab results of 2.4 (normal 3.5-5.3 mmol/L)". Per Resident #103's laboratory reports: 6/01/10 - Potassium 3.0 mmol/L (signed by physician-date illegible) 6/22/10 - Potassium 2.4 mmol/L (signed by physician-date illegible) 7/06/10 - Potassium 3.0 mmol/L (signed by physician-date illegible) 8/17/10 - Potassium 2.2 mmol/L (signed as reported to physician by nurse #39-not dated) Per Resident #103's nursing Progress Notes, there was no note written to indicate that a physician had been notified about the 6/01/10 Potassium laboratory value. Per Resident #103's nursing Progress Notes, dated 6/22/10, "Resident having difficulty swallow (Potassium) tabs, changed to liquid equivalent due to critically low lab results of 2.4". Per Resident #103's nursing Progress Notes, dated 6/30/10, "(Physician #21) in - labs reviewed - order for labs on 7/06/10 noted". Per Resident #103's nursing Progress Notes, dated 7/02/10, "...continues to refuse her medication periodically". Per Resident #103's nursing Progress Notes, there was no note written that would suggest that the physician had been notified about the 7/06/10 Potassium laboratory value. On 7/7/10, per Resident #103's nursing Progress Notes, "(Physician #21) in today. No new orders". Per Resident #103's nursing Progress Notes, dated 8/17/10, "Critical labs reported to (physician #21). Order to increase Potassium 40 meq to BID ( two times per day) and recheck next lab day", was signed by nurse #39. Review of Resident #3's MARs (Medication Administration Records), between 1/01/10-5/3/10, nursing recorded Resident #103 had received all scheduled doses. However, review of Resident #103's MARs (Medication Administration Records) showed potassium was not administered on 5/4/10, 5/05/10, 5/8/10-5/16/10, 5/19/10-5/21/10, 5/24/10, 5/25/10, 5/28/10-5/31/10, 6/01/10-6/05/10, 6/07/10, 6/08/10, 6/10/10, 6/11/10, 6/13/10-6/16/10, 6/20/10, 6/21/10, 6/23-6/25/10, 6/28/10, 6/30/10, 7/01/10-7/04/10, 7/07/10, 7/08/10, 7/11/10, 7/12/10, 7/15/10-7/18/10, 7/21/10-7/24/10, 7/26/10, 7/29/10, 8/01/10, 8/04/10, 8/05/10, 8/09/10, 8/12/10-8/16/10, 8/17/10 and 8/18/10. Nursing staff did not record any: 1.) repeated attempts to get resident to accept potassium medication (except on 8/17/10) 2.) education given to resident regarding the ill effects of refusing potassium supplementation 3.) follow-up with physician regarding refusal of potassium medication 4.) follow-up with the family regarding refusal of potassium medication 5.) Refusal of Treatment forms Review of Resident #103's nursing "Progress Notes" from 5/04/10-8/18/10 showed no evidence that nursing notified physician #21 that Resident #103 had refused the Potassium during that time frame. Per the facility's "Refusal of Treatment" policy, dated 12/04, "...If a guest refuses treatment, it will be documented in his/her medical record using the "Refusal of Treatment (form)...A guest who refuses treatment will be informed of the following: a. The reason for the recommended treatment, b. alternatives to the recommended treatment, c. Implications of refusal of treatment...Procedure: 1. Nursing and/or the guest's physician will explain the benefits of treatment, including alternatives and risks, to the guest and/or his/her legal representative. 2. Nursing will notify the physician regarding the Refusal of Treatment if he/she is not present when the refusal is made. 3. If the guest refuses the treatment, a Refusal of Treatment (form) is to be completed and signed and dated by the guest or his/her legal representative and a facility representative. 4. The Refusal of Treatment form will be filed int he guest's medical record under the "Miscellaneous" tab. Review of Resident #103's medical record showed no evidence that the family was notified by nursing services, social services, any member of the Interdisciplinary Team or a physician of Resident #103's low potassium levels or of Resident #103 not receiving the potassium medication. In an interview with administrator #1 and director of nursing #2 on 10/01/10 at 11:27, they were unable to account for why the family had not been notified by facility staff about resident #103's critical lab values, not having Resident #103's low potassium care planned, or Resident #103 not having interventions in place to correct the low Potassium levels. Administrator #1 stated that Potassium could have been administered by an intravenous route if Resident #103 had been gone to a hospital. Per review of Resident #103's physician's orders [REDACTED].#21 (Resident #103's attending physician/Medical Director): 6/22/10 - "Change Potassium to liquid equivalent. 40 meq every day due to difficulty swallowing pills". 6/29/10 - "Potassium oral solution 20 meq by P.O. (by mouth) two times a day (8:00 AM and 8:00 PM)". 6/29/10 - "DC (discontinue) Potassium order on 6/29/10. Continue Potassium oral solution 40 meq/15 ml P.O. every day (8:00 AM)". 8/17/10 - "Increase Potassium to bid (two times per day). Recheck next lab day". On 9/30/10, the Surveyor found most of physician #21's "Progress Notes" for Resident #103 to be illegible. On 9/30/10, at 3:40 PM, the administrator #1, told Surveyor that physician #21 wanted to speak with Surveyor. In the phone conversation with physician #21, Surveyor informed physician #21 that his notes were "very important" to the case regarding Resident #3. In the phone conversation, [MEDICATION NAME] approximately seven minutes, physician #21 angrily, repeatedly demanded to know why Surveyor and facility staff were unable to decipher his writing but finally agreed to complete the transcription of his notes. Surveyor decided that questioning physician #21 regarding the circumstances of Resident #3's death would be disadvantageous, in light of physician #21's anger. On 10/01/10, the administrator #1 conveyed that physician #21 came to the facility and transcribed his original "Progress Notes" for Resident #103 (from 6/09/10, 7/07/10, 8/04/10 and 8/18/10) for Resident #103, on the evening of 9/30/10. Review of physician #21's signed transcribed "Progress Notes" for Resident #103 revealed no [DIAGNOSES REDACTED]. Review of Resident #103's medical record showed no indication that the pharmacist had monitored Resident #103's critical laboratory values or made pharmacological recommendations to restore Resident #103's potassium levels. In an interview with the administrator, on 10/01/10 at 10:20, she stated the pharmacy was supposed to review resident #103's labs and do a full monthly medication reviews but that this had not been being done. Per the dietary manager #16, in an interview on 9/30/10 at 3:50 PM, she told Surveyor she had been the facility's dietary manager for the last 10 months. Surveyor asked dietary manager #16 to explain what role potassium played in the human body. Dietary manager #16 responded, "...Honestly, I'm drawing a blank". Dietary manager #16 was unable to produce evidence that the abnormal potassium levels for Resident #103 were ever reviewed at the Nutrition Risk Committee. Dietary manager #16 said she looked at laboratory values only when it was time for her to fill out her section of the MDS (Minimum Data Set) and only if she saw abnormal labs, did she refer those residents to the consultant dietitian (there was no evidence in Resident #103's medical record that a consultant dietitian had reviewed Resident # 103's labs or made dietary recommendations to help correct hypokalemia). Dietary manager #16 admitted she had not done a nutritional assessment for Resident #103's MDS with an Assessment Reference Date of 7/20/10 because no one told her to. RAPs (Resident Assessment Protocols), dated 7/20/10, showed "Nutritional Status" section was not signed, even though "Section R: Assessment Information, 2 -Signature of the Person Coordinating the Assessment" was "signed as complete" by nurse # 17, dated 8/11/10. Per the "Job Description Dietary Manager", "Job Functions: Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. the omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position". Per the administrator #1, in an interview on 10/01/10 at 11:27 AM, she said dietary manager #16 should have been monitoring Resident #103's labs and reporting the abnormal labs to the consultant dietitian. Administrator #1 stated, "It is her (dietary manager # 16's) responsibility to monitor labs as they are drawn". Review of Resident #103's "Plan of Care" revealed there was no "Plan of Care" initiated for Resident #103 in regards to low potassium. Per nursing "Progress Notes", dated 8/18/10, "At 6:50 PM, called to resident's side while she was sitting in WC (wheel chair) at the end of center hall by CENA (nurse aide). Resident unresponsive. Respirations shallow and 10 (breaths/minute). taken to room with bed and placed sitting on edge of bed. resident responding more with eyes open, would say her name. Refused to lay down. Complaint of nausea. did have small emesis. Temperature 96.8 axillary, BS (blood sugar) 286, O2 saturation 88%, pulse 48, respirations 18, B/P (blood pressure) 126/62. Call placed to (nurse practitioner #40)...7:30 PM. (Nurse Practioner #40) returned call. report of what happen given. Resident more responsive and talking, could say what her name is and stated she didn't feel well. CBC (complete blood count) and CMP (comprehensive metabolic panel laboratory test) if possible ordered...9:00 PM. Daughter in at 8:00 PM. Gave report of what happened to her. Daughter sitting with her. resident sleeping but does respond when touched and name spoken". Per nursing "Progress Notes", dated 8/19/10, "While care given at 3:45 AM, resident (#103) became unresponsive for 5-10 seconds then became responsive. Had small emesis. Care given and put in chair. 5:00 AM. Had medium yellow phlegm emesis...At 11:40 AM, observed resident (#103) in room. No breaths, no pulse, no blood pressure. Family at bedside. (Physician #21) in to see..." On 10/04/10 at 11:25 AM, the administrator was notified of the Immediate Jeopardy that resulted from multiple system errors, culminating on 8/17/10, when Resident #103 began rapidly declining in health. Per "Emergency Response Directive" for Resident #103, dated 11/23/09, Resident #103's Power of Attorney was Resident #103's daughter #37. Per Resident #103's daughter #37, in a telephone interview on 9/20/10 at 2:19 PM, and resident #103's daughter #38, in a telephone interview on 9/20/10 at 2:30 PM, no one at the facility told them about their mother's low potassium levels until her death was eminent on 8/19/10, at which time physician #21 encouraged them to change their mother's code status to "Do Not Resuscitate". Both daughters said they would have promoted interventions to correct the low potassium if they would have known.

This citation pertains to intake number MI 545. Based on interviews and records review, the facility failed to assess and coordinate care to improve medical status of one of six sampled residents (Resident #103), who did not receive physician ordered Potassium for 69 days (from 5/01/10-8/18/10), did not receive a monthly medication review by the pharmacist, and the dietary manager did not follow through in reporting Resident #103's critical laboratory values (Potassium levels) to the dietitian contributing in sudden unresponsive state and ultimately to her death (on 8/19/10), and placing 87 other residents who were ordered to receive routine medications on a daily basis, to have a monthly medication review by the pharmacist, and to have the dietary manager report all abnormal laboratory values to the dietitian at risk for serious harm. Findings Include: Resident #103 Per Resident #103's face sheet, she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Per Resident #103's MDS (Minimum Data Set), dated 7/20/10, she had diagnoses of diabetes, cardiac [MEDICAL CONDITION], hypertension, dementia, depression and [MEDICATION NAME] degeneration, had moderately impaired cognitive skills for daily decision making and no oral or nutritional problems. Per nursing Progress Notes, dated 8/18/10 at 6:00 AM, "Resident (#103) has been up since 4:00 AM in wheel chair in corridor...Yesterday at HS (hour of sleep), resident (#103) was reading "(name of a magazine)"..." Per nursing Progress Notes, dated 8/18/10 at 7:00 AM, "At 6:50 AM called to resident's side while she was sitting in wheel chair at the end of center hall ...Resident nonresponsive..." Per Resident #103's death certificate, dated 8/19/10, "Actual or presumed time of death: 11:45 AM" and reason for death: "a. Cardiac [MEDICAL CONDITION]; b. Hypokalemia (low potassium)". According to Mosby's Manual of Diagnostic and Laboratory Tests, 2002, page 373: "...Because the serum (blood) concentration of potassium is so small, minor changes in concentration have significant consequences...Therefore, if potassium is not adequately supplied in the diet (or by IV administration in the patient who is unable to eat), serum potassium levels can drop rapidly...This electrolyte (potassium) has profound effects on the heart rate and contractility (ability to beat) ...Drugs that may cause decreased levels include ...diuretics (potassium wasting) ...insulin ..." Per Resident #103's "physician's orders [REDACTED]. Resident #103's MARs reflected that she received the ordered doses of Insulin. Per Resident #103's "physician's orders [REDACTED]. resident #103's MARs reflected that she received 28 of the 31 daily doses prescribed in July, 2010 and 17 of the 18 daily doses, before her death, in August, 2010. Laboratory abnormalities related to the administration of [MEDICATION NAME] include hypokalemia in 14.7% of those taking the medication. "Serum potassium should be measured periodically and potassium supplements or potassium-sparing diuretics added if necessary".(http://www.rxlist.com/[MEDICATION NAME]-drug.htm). Per nursing "Progress Notes", dated 6/22/10, "Resident having difficulty swallow (potassium) tabs, changed to liquid equivalent due to critically low lab results of 2.4 (normal 3.5-5.3 mmol/L)". Per Resident #103's laboratory reports: 6/01/10 - Potassium 3.0 mmol/L (signed by physician-date illegible) 6/22/10 - Potassium 2.4 mmol/L (signed by physician-date illegible) 7/06/10 - Potassium 3.0 mmol/L (signed by physician-date illegible) 8/17/10 - Potassium 2.2 mmol/L (signed as reported to physician by nurse #39-not dated) Per Resident #103's nursing Progress Notes, there was no note written to indicate that a physician had been notified about the 6/01/10 Potassium laboratory value. Per Resident #103's nursing Progress Notes, dated 6/22/10, "Resident having difficulty swallow (Potassium) tabs, changed to liquid equivalent due to critically low lab results of 2.4". Per Resident #103's nursing Progress Notes, dated 6/30/10, "(Physician #21) in - labs reviewed - order for labs on 7/06/10 noted". Per Resident #103's nursing Progress Notes, dated 7/02/10, "...continues to refuse her medication periodically". Per Resident #103's nursing Progress Notes, there was no note written that would suggest that the physician had been notified about the 7/06/10 Potassium laboratory value. On 7/7/10, per Resident #103's nursing Progress Notes, "(Physician #21) in today. No new orders". Per Resident #103's nursing Progress Notes, dated 8/17/10, "Critical labs reported to (physician #21). Order to increase Potassium 40 meq to BID ( two times per day) and recheck next lab day", was signed by nurse #39. Review of Resident #3's MARs (Medication Administration Records), between 1/01/10-5/3/10, nursing recorded Resident #103 had received all scheduled doses. However, review of Resident #103's MARs (Medication Administration Records) showed potassium was not administered on 5/4/10, 5/05/10, 5/8/10-5/16/10, 5/19/10-5/21/10, 5/24/10, 5/25/10, 5/28/10-5/31/10, 6/01/10-6/05/10, 6/07/10, 6/08/10, 6/10/10, 6/11/10, 6/13/10-6/16/10, 6/20/10, 6/21/10, 6/23-6/25/10, 6/28/10, 6/30/10, 7/01/10-7/04/10, 7/07/10, 7/08/10, 7/11/10, 7/12/10, 7/15/10-7/18/10, 7/21/10-7/24/10, 7/26/10, 7/29/10, 8/01/10, 8/04/10, 8/05/10, 8/09/10, 8/12/10-8/16/10, 8/17/10 and 8/18/10. Nursing staff did not record any: 1.) repeated attempts to get resident to accept potassium medication (except on 8/17/10) 2.) education given to resident regarding the ill effects of refusing potassium supplementation 3.) follow-up with physician regarding refusal of potassium medication 4.) follow-up with the family regarding refusal of potassium medication 5.) Refusal of Treatment forms Review of Resident #103's nursing "Progress Notes" from 5/04/10-8/18/10 showed no evidence that nursing notified physician #21 that Resident #103 had refused the Potassium during that time frame. Per the facility's "Refusal of Treatment" policy, dated 12/04, "...If a guest refuses treatment, it will be documented in his/her medical record using the "Refusal of Treatment (form)...A guest who refuses treatment will be informed of the following: a. The reason for the recommended treatment, b. alternatives to the recommended treatment, c. Implications of refusal of treatment...Procedure: 1. Nursing and/or the guest's physician will explain the benefits of treatment, including alternatives and risks, to the guest and/or his/her legal representative. 2. Nursing will notify the physician regarding the Refusal of Treatment if he/she is not present when the refusal is made. 3. If the guest refuses the treatment, a Refusal of Treatment (form) is to be completed and signed and dated by the guest or his/her legal representative and a facility representative. 4. The Refusal of Treatment form will be filed int he guest's medical record under the "Miscellaneous" tab. Review of Resident #103's medical record showed no evidence that the family was notified by nursing services, social services, any member of the Interdisciplinary Team or a physician of Resident #103's low potassium levels or of Resident #103 not receiving the potassium medication. In an interview with administrator #1 and director of nursing #2 on 10/01/10 at 11:27, they were unable to account for why the family had not been notified by facility staff about resident #103's critical lab values, not having Resident #103's low potassium care planned, or Resident #103 not having interventions in place to correct the low Potassium levels. Administrator #1 stated that Potassium could have been administered by an intravenous route if she had been gone to a hospital. Per "Emergency Response Directive" for Resident #103, dated 11/23/09, Resident #103's Power of Attorney was Resident #103's daughter #37. Per Resident #103's daughter #37, in a telephone interview on 9/20/10 at 2:19 PM, and resident #103's daughter #38, in a telephone interview on 9/20/10 at 2:30 PM, no one at the facility told them about their mother's low potassium levels until her death was eminent on 8/19/10, at which time physician #21 encouraged them to change their mother's code status to "Do Not Resuscitate". Both daughters said they would have promoted interventions to correct the low potassium if they would have known. Per review of Resident #103's physician's orders [REDACTED].#21 (Resident #103's attending physician/Medical Director): 6/22/10 - "Change Potassium to liquid equivalent. 40 meq every day due to difficulty swallowing pills". 6/29/10 - "Potassium oral solution 20 meq by P.O. (by mouth) two times a day (8:00 AM and 8:00 PM)". 6/29/10 - "DC (discontinue) Potassium order on 6/29/10. Continue Potassium oral solution 40 meq/15 ml P.O. every day (8:00 AM)". 8/17/10 - "Increase Potassium to bid (two times per day). Recheck next lab day". On 9/30/10, the Surveyor found most of physician #21's "Progress Notes" for Resident #103 to be illegible. On 9/30/10, at 3:40 PM, the administrator #1, told Surveyor that physician #21 wanted to speak with Surveyor. In the phone conversation with physician #21, Surveyor informed physician #21 that his notes were "very important" to the case regarding Resident #3. In the phone conversation, [MEDICATION NAME] approximately seven minutes, physician #21 angrily, repeatedly demanded to know why Surveyor and facility staff were unable to decipher his writing but finally agreed to complete the transcription of his notes. Surveyor decided that questioning physician #21 regarding the circumstances of Resident #3's death would be disadvantageous, in light of physician #21's anger. On 10/01/10, the administrator #1 conveyed that physician #21 came to the facility and transcribed his original "Progress Notes" for Resident #103 (from 6/09/10, 7/07/10, 8/04/10 and 8/18/10) for Resident #103, on the evening of 9/30/10. Review of physician #21's signed transcribed "Progress Notes" for Resident #103 revealed no [DIAGNOSES REDACTED]. Review of Resident #103's medical record showed no indication that the pharmacist had monitored Resident #103's critical laboratory values or made pharmacological recommendations to restore Resident #103's potassium levels. In an interview with the administrator, on 10/01/10 at 10:20, she stated the pharmacy was supposed to review resident #103's labs and do a full monthly medication reviews but that this had not been being done. Per the dietary manager #16, in an interview on 9/30/10 at 3:50 PM, she told Surveyor she had been the facility's dietary manager for the last 10 months. Surveyor asked dietary manager #16 to explain what role potassium played in the human body. Dietary manager #16 responded, "...Honestly, I'm drawing a blank". Dietary manager #16 was unable to produce evidence that the abnormal potassium levels for Resident #103 were ever reviewed at the Nutrition Risk Committee. Dietary manager #16 said she looked at laboratory values only when it was time for her to fill out her section of the MDS (Minimum Data Set) and only if she saw abnormal labs, did she refer those residents to the consultant dietitian (there was no evidence in Resident #103's medical record that a consultant dietitian had reviewed Resident # 103's labs or made dietary recommendations to help correct hypokalemia). Dietary manager #16 admitted she had not done a nutritional assessment for Resident #103's MDS with an Assessment Reference Date of 7/20/10 because no one told her to. RAPs (Resident Assessment Protocols), dated 7/20/10, showed "Nutritional Status" section was not signed, even though "Section R: Assessment Information, 2 -Signature of the Person Coordinating the Assessment" was "signed as complete" by nurse # 17, dated 8/11/10. Per the "Job Description Dietary Manager", "Job Functions: Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. the omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position". Per the administrator #1, in an interview on 10/01/10 at 11:27 AM, she said dietary manager #16 should have been monitoring Resident #103's labs and reporting the abnormal labs to the consultant dietitian. Administrator #1 stated, "It is her (dietary manager # 16's) responsibility to monitor labs as they are drawn". Review of Resident #103's "Plan of Care" revealed there was no "Plan of Care" initiated for Resident #103 in regards to low potassium. Per nursing "Progress Notes", dated 8/18/10, "At 6:50 PM, called to resident's side while she was sitting in WC (wheel chair) at the end of center hall by CENA (nurse aide). Resident unresponsive. Respirations shallow and 10 (breaths/minute). taken to room with bed and placed sitting on edge of bed. resident responding more with eyes open, would say her name. Refused to lay down. Complaint of nausea. did have small emesis. Temperature 96.8 axillary, BS (blood sugar) 286, O2 saturation 88%, pulse 48, respirations 18, B/P (blood pressure) 126/62. Call placed to (nurse practitioner #40)...7:30 PM. (Nurse Practioner #40) returned call. report of what happen given. Resident more responsive and talking, could say what her name is and stated she didn't feel well. CBC (complete blood count) and CMP (comprehensive metabolic panel laboratory test) if possible ordered...9:00 PM. Daughter in at 8:00 PM. Gave report of what happened to her. Daughter sitting with her. resident sleeping but does respond when touched and name spoken". Per nursing "Progress Notes", dated 8/19/10, "While care given at 3:45 AM, resident (#103) became unresponsive for 5-10 seconds then became responsive. Had small emesis. Care given and put in chair. 5:00 AM. Had medium yellow phlegm emesis...At 11:40 AM, observed resident (#103) in room. No breaths, no pulse, no blood pressure. Family at bedside. (Physician #21) in to see..."

This citation pertains to intake number MI 545. Based on interviews and records review, the facility failed to properly administer critical medication for one of a total of six sampled residents (Resident#103) resulting in a sudden unresponsive state and ultimately to her death (on 8/19/10), and placed all 87 residents, who were ordered to receive routine medications on a daily basis, at risk for serious harm and/or death by not ensuring staff followed appropriate follow-up procedures when residents refused or were not administered medications. Findings Include: Resident #103 Review of Resident #3's MARs (Medication Administration Records), showed she had potassium medication ordered since her admission. From 1/01/10-5/3/10, she had received all scheduled doses. However, review of Resident #103's MARs (Medication Administration Records) showed potassium was not administered on 5/4/10, 5/05/10, 5/8/10-5/16/10, 5/19/10-5/21/10, 5/24/10, 5/25/10, 5/28/10-5/31/10, 6/01/10-6/05/10, 6/07/10, 6/08/10, 6/10/10, 6/11/10, 6/13/10-6/16/10, 6/20/10, 6/21/10, 6/23-6/25/10, 6/28/10, 6/30/10, 7/01/10-7/04/10, 7/07/10, 7/08/10, 7/11/10, 7/12/10, 7/15/10-7/18/10, 7/21/10-7/24/10, 7/26/10, 7/29/10, 8/01/10, 8/04/10, 8/05/10, 8/09/10, 8/12/10-8/16/10, 8/17/10 and 8/18/10. Nursing staff did not record any: 1.) repeated attempts to get resident to accept potassium medication (except on 8/17/10) 2.) education given to resident regarding the ill effects of refusing potassium supplementation 3.) follow-up with physician regarding refusal of potassium medication 4.) follow-up with the family regarding refusal of potassium medication 5.) Refusal of Treatment forms Per the facility's "Refusal of Treatment" policy, dated 12/04, "...If a guest refuses treatment, it will be documented in his/her medical record using the "Refusal of Treatment (form)...A guest who refuses treatment will be informed of the following: a. The reason for the recommended treatment, b. alternatives to the recommended treatment, c. Implications of refusal of treatment...Procedure: 1. Nursing and/or the guest's physician will explain the benefits of treatment, including alternatives and risks, to the guest and/or his/her legal representative. 2. Nursing will notify the physician regarding the Refusal of Treatment if he/she is not present when the refusal is made. 3. If the guest refuses the treatment, a Refusal of Treatment (form) is to be completed and signed and dated by the guest or his/her legal representative and a facility representative. 4. The Refusal of Treatment form will be filed int he guest's medical record under the "Miscellaneous" tab. Per Resident #103's death certificate, dated 8/19/10, reason for death: "a. Cardiac [MEDICAL CONDITION]; b. Hypokalemia (low potassium)". According to Mosby's Manual of Diagnostic and Laboratory Tests, 2002, page 373: "...Because the serum (blood) concentration of potassium is so small, minor changes in concentration have significant consequences...Therefore, if potassium is not adequately supplied in the diet (or by IV administration in the patient who is unable to eat), serum potassium levels can drop rapidly...This electrolyte (potassium) has profound effects on the heart rate and contractility (ability to beat) ...Drugs that may cause decreased levels include ...diuretics (potassium wasting) ...insulin ...". Per "Emergency Response Directive" for Resident #103, dated 11/23/09, Resident #103's Power of Attorney was Resident #103's daughter #37. Per Resident #103's daughter #37, in a telephone interview on 9/20/10 at 2:19 PM, and resident #103's daughter #38, in a telephone interview on 9/20/10 at 2:30 PM, no one at the facility told them about their mother's low potassium levels until her death was eminent on 8/19/10, at which time physician #21 encouraged them to change their mother's code status to "Do Not Resuscitate". Both daughters said they would have promoted interventions to correct the low potassium if they would have known. Review of Resident #103's medical record showed no evidence that the family was notified by nursing services, social services, any member of the Interdisciplinary Team or a physician of Resident #103's low potassium levels or of Resident #103 not receiving the potassium medication. Review of Resident #103's medical record showed no indication that the pharmacist had monitored Resident #103's critical laboratory values or made pharmacological recommendations to restore Resident #103's potassium levels. On 9/30/10, the Surveyor found most of physician #21's "Progress Notes" for Resident #103 to be illegible. On 10/01/10, the administrator #1 conveyed that physician #21 transcribed his original "Progress Notes" for Resident #103 (from 6/09/10, 7/07/10, 8/04/10 and 8/18/10) for Resident #103, on the evening of 9/30/10. Review of physician #21's transcribed Progress Notes revealed no [DIAGNOSES REDACTED].

This citation pertains to intake number MI 545. Based on interviews and records review, the facility's pharmacist failed failed to monitor critical laboratory values and make pharmacological recommendations to the physician and director of nursing to prevent the sudden unresponsive state and ultimately death (on 8/19/10) of one of a total of six sampled residents (Resident#103). Findings Include: Resident #103 Per Resident #103's face sheet, she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Per Resident #103's MDS (Minimum Data Set), dated 7/20/10, she had diagnoses of diabetes, cardiac dysrhythmias, hypertension, dementia, depression and macular degeneration, had moderately impaired cognitive skills for daily decision making and no oral or nutritional problems. Per nursing Progress Notes, dated 8/18/10 at 6:00 AM, "Resident (#103) has been up since 4:00 AM in wheel chair in corridor...Yesterday at HS (hour of sleep), resident (#103) was reading "(name of a magazine)"..." Per nursing Progress Notes, dated 8/18/10 at 7:00 AM, "At 6:50 AM called to resident's side while she was sitting in wheel chair at the end of center hall ...Resident nonresponsive..." Per Resident #103's death certificate, dated 8/19/10, "Actual or presumed time of death: 11:45 AM" and reason for death: "a. Cardiac Dysrhythmia; b. Hypokalemia (low potassium)". According to Mosby's Manual of Diagnostic and Laboratory Tests, 2002, page 373: "...Because the serum (blood) concentration of potassium is so small, minor changes in concentration have significant consequences...Therefore, if potassium is not adequately supplied in the diet (or by IV administration in the patient who is unable to eat), serum potassium levels can drop rapidly...This electrolyte (potassium) has profound effects on the heart rate and contractility (ability to beat) ...Drugs that may cause decreased levels include ...diuretics (potassium wasting) ...(and) insulin ...". Per Resident #103's "physician's orders [REDACTED]. Resident #103's MARs reflected that she received the ordered doses of Insulin. Per Resident #103's "physician's orders [REDACTED]. resident #103's MARs reflected that she received 28 of the 31 daily doses prescribed in July, 2010 and 17 of the 18 daily doses, before her death, in August, 2010. Laboratory abnormalities related to the administration of Bumex include hypokalemia in 14.7% of those taking the medication. "Serum potassium should be measured periodically and potassium supplements or potassium-sparing diuretics added if necessary".(http://www.rxlist.com/bumex-drug.htm). Per nursing "Progress Notes", dated 6/22/10, "Resident having difficulty swallow (potassium) tabs, changed to liquid equivalent due to critically low lab results of 2.4 (normal 3.5-5.3 mmol/L)". Per Resident #103's laboratory reports: 6/01/10 - Potassium 3.0 mmol/L (signed by physician-date illegible) 6/22/10 - Potassium 2.4 mmol/L (signed by physician-date illegible) 7/06/10 - Potassium 3.0 mmol/L (signed by physician-date illegible) 8/17/10 - Potassium 2.2 mmol/L (signed as reported to physician by nurse #39-not dated) Per Resident #103's nursing Progress Notes, there was no note written to indicate that a physician had been notified about the 6/01/10 Potassium laboratory value. Per Resident #103's nursing Progress Notes, dated 6/22/10, "Resident having difficulty swallow (Potassium) tabs, changed to liquid equivalent due to critically low lab results of 2.4". Per Resident #103's nursing Progress Notes, dated 6/30/10, "(Physician #21) in - labs reviewed - order for labs on 7/06/10 noted". Per Resident #103's nursing Progress Notes, dated 7/02/10, "...continues to refuse her medication periodically". Per Resident #103's nursing Progress Notes, there was no note written that would suggest that the physician had been notified about the 7/06/10 Potassium laboratory value. On 7/7/10, per Resident #103's nursing Progress Notes, "(Physician #21) in today. No new orders". Per Resident #103's nursing Progress Notes, dated 8/17/10, "Critical labs reported to (physician #21). Order to increase Potassium 40 meq to BID ( two times per day) and recheck next lab day", was signed by nurse #39. Review of Resident #3's MARs (Medication Administration Records), between 1/01/10-5/3/10, nursing recorded Resident #103 had received all scheduled doses. However, review of Resident #103's MARs (Medication Administration Records) showed potassium was not administered on 5/4/10, 5/05/10, 5/8/10-5/16/10, 5/19/10-5/21/10, 5/24/10, 5/25/10, 5/28/10-5/31/10, 6/01/10-6/05/10, 6/07/10, 6/08/10, 6/10/10, 6/11/10, 6/13/10-6/16/10, 6/20/10, 6/21/10, 6/23-6/25/10, 6/28/10, 6/30/10, 7/01/10-7/04/10, 7/07/10, 7/08/10, 7/11/10, 7/12/10, 7/15/10-7/18/10, 7/21/10-7/24/10, 7/26/10, 7/29/10, 8/01/10, 8/04/10, 8/05/10, 8/09/10, 8/12/10-8/16/10, 8/17/10 and 8/18/10. Nursing staff did not record any: 1.) repeated attempts to get resident to accept potassium medication (except on 8/17/10) 2.) education given to resident regarding the ill effects of refusing potassium supplementation 3.) follow-up with physician regarding refusal of potassium medication 4.) follow-up with the family regarding refusal of potassium medication 5.) Refusal of Treatment forms Review of Resident #103's nursing "Progress Notes" from 5/04/10-8/18/10 showed no evidence that nursing notified physician #21 that Resident #103 had refused the Potassium during that time frame. Per the facility's "Refusal of Treatment" policy, dated 12/04, "...If a guest refuses treatment, it will be documented in his/her medical record using the "Refusal of Treatment (form)...A guest who refuses treatment will be informed of the following: a. The reason for the recommended treatment, b. alternatives to the recommended treatment, c. Implications of refusal of treatment...Procedure: 1. Nursing and/or the guest's physician will explain the benefits of treatment, including alternatives and risks, to the guest and/or his/her legal representative. 2. Nursing will notify the physician regarding the Refusal of Treatment if he/she is not present when the refusal is made. 3. If the guest refuses the treatment, a Refusal of Treatment (form) is to be completed and signed and dated by the guest or his/her legal representative and a facility representative. 4. The Refusal of Treatment form will be filed int he guest's medical record under the "Miscellaneous" tab. Review of Resident #103's medical record showed no evidence that the family was notified by nursing services, social services, any member of the Interdisciplinary Team or a physician of Resident #103's low potassium levels or of Resident #103 not receiving the potassium medication. In an interview with administrator #1 and director of nursing #2 on 10/01/10 at 11:27, they were unable to account for why the family had not been notified by facility staff about resident #103's critical lab values, not having Resident #103's low potassium care planned, or Resident #103 not having interventions in place to correct the low Potassium levels. Administrator #1 stated that Potassium could have been administered by an intravenous route if she had been gone to a hospital. Per review of Resident #103's physician's orders [REDACTED].#21 (Resident #103's attending physician/Medical Director): 6/22/10 - "Change Potassium to liquid equivalent. 40 meq every day due to difficulty swallowing pills". 6/29/10 - "Potassium oral solution 20 meq by P.O. (by mouth) two times a day (8:00 AM and 8:00 PM)". 6/29/10 - "DC (discontinue) Potassium order on 6/29/10. Continue Potassium oral solution 40 meq/15 ml P.O. every day (8:00 AM)". 8/17/10 - "Increase Potassium to bid (two times per day). Recheck next lab day". On 9/30/10, the Surveyor found most of physician #21's "Progress Notes" for Resident #103 to be illegible. On 9/30/10, at 3:40 PM, the administrator #1, told Surveyor that physician #21 wanted to speak with Surveyor. In the phone conversation with physician #21, Surveyor informed physician #21 that his notes were "very important" to the case regarding Resident #3. In the phone conversation, lasting approximately seven minutes, physician #21 angrily, repeatedly demanded to know why Surveyor and facility staff were unable to decipher his writing but finally agreed to complete the transcription of his notes. Surveyor decided that questioning physician #21 regarding the circumstances of Resident #3's death would be disadvantageous, in light of physician #21's anger. On 10/01/10, the administrator #1 conveyed that physician #21 came to the facility and transcribed his original "Progress Notes" for Resident #103 (from 6/09/10, 7/07/10, 8/04/10 and 8/18/10) for Resident #103, on the evening of 9/30/10. Review of physician #21's signed transcribed "Progress Notes" for Resident #103 revealed no [DIAGNOSES REDACTED]. Review of Resident #103's medical record showed no indication that the pharmacist had monitored Resident #103's critical laboratory values or made pharmacological recommendations to restore Resident #103's potassium levels. In an interview with the administrator, on 10/01/10 at 10:20, she stated the pharmacy was supposed to review resident #103's labs and do a full monthly medication reviews but that this had not been being done. Review of Resident #103's "Plan of Care" revealed there was no "Plan of Care" initiated for Resident #103 in regards to low potassium. Per nursing "Progress Notes", dated 8/18/10, "At 6:50 PM, called to resident's side while she was sitting in WC (wheel chair) at the end of center hall by CENA (nurse aide). Resident unresponsive. Respirations shallow and 10 (breaths/minute). taken to room with bed and placed sitting on edge of bed. resident responding more with eyes open, would say her name. Refused to lay down. Complaint of nausea. did have small emesis. Temperature 96.8 axillary, BS (blood sugar) 286, O2 saturation 88%, pulse 48, respirations 18, B/P (blood pressure) 126/62. Call placed to (nurse practitioner #40)...7:30 PM. (Nurse Practioner #40) returned call. report of what happen given. Resident more responsive and talking, could say what her name is and stated she didn't feel well. CBC (complete blood count) and CMP (comprehensive metabolic panel laboratory test) if possible ordered...9:00 PM. Daughter in at 8:00 PM. Gave report of what happened to her. Daughter sitting with her. resident sleeping but does respond when touched and name spoken". Per nursing "Progress Notes", dated 8/19/10, "While care given at 3:45 AM, resident (#103) became unresponsive for 5-10 seconds then became responsive. Had small emesis. Care given and put in chair. 5:00 AM. Had medium yellow phlegm emesis...At 11:40 AM, observed resident (#103) in room. No breaths, no pulse, no blood pressure. Family at bedside. (Physician #21) in to see..." Per "Emergency Response Directive" for Resident #103, dated 11/23/09, Resident #103's Power of Attorney was Resident #103's daughter #37. Per Resident #103's daughter #37, in a telephone interview on 9/20/10 at 2:19 PM, and resident #103's daughter #38, in a telephone interview on 9/20/10 at 2:30 PM, no one at the facility told them about their mother's low potassium levels until her death was eminent on 8/19/10, at which time physician #21 encouraged them to change their mother's code status to "Do Not Resuscitate". Both daughters said they would have promoted interventions to correct the low potassium if they would have known.

This citation pertains to intake number MI 545. Based on interviews and records review, the facility failed to enforce the facility's policies related to assessing critical laboratory values and the administration of medications resulting in sudden unresponsiveness and ultimately the death (on 8/19/10), of one of six sampled residents (Resident#103) and placed all 87 residents at risk for serious harm and/or death. Findings Include: Per Resident #103's face sheet, she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Per Resident #103's MDS (Minimum Data Set), dated 7/20/10, she had diagnoses of diabetes, cardiac [MEDICAL CONDITION], hypertension, dementia, depression and [MEDICATION NAME] degeneration, had moderately impaired cognitive skills for daily decision making and no oral or nutritional problems. Per nursing Progress Notes, dated 8/18/10 at 6:00 AM, "Resident (#103) has been up since 4:00 AM in wheel chair in corridor...Yesterday at HS (hour of sleep), resident (#103) was reading "(name of a magazine)"..." Per nursing Progress Notes, dated 8/18/10 at 7:00 AM, "At 6:50 AM called to resident's side while she was sitting in wheel chair at the end of center hall ...Resident nonresponsive..." Per Resident #103's death certificate, dated 8/19/10, "Actual or presumed time of death: 11:45 AM" and reason for death: "a. Cardiac [MEDICAL CONDITION]; b. Hypokalemia (low potassium)". According to Mosby's Manual of Diagnostic and Laboratory Tests, 2002, page 373: "...Because the serum (blood) concentration of potassium is so small, minor changes in concentration have significant consequences...Therefore, if potassium is not adequately supplied in the diet (or by IV administration in the patient who is unable to eat), serum potassium levels can drop rapidly...This electrolyte (potassium) has profound effects on the heart rate and contractility (ability to beat) ...Drugs that may cause decreased levels include ...diuretics (potassium wasting) ...insulin ...". Per Resident #103's "physician's orders [REDACTED]. Resident #103's MARs reflected that she received the ordered doses of Insulin. Per Resident #103's "physician's orders [REDACTED]. resident #103's MARs reflected that she received 28 of the 31 daily doses prescribed in July, 2010 and 17 of the 18 daily doses, before her death, in August, 2010. Laboratory abnormalities related to the administration of [MEDICATION NAME] include hypokalemia in 14.7% of those taking the medication. "Serum potassium should be measured periodically and potassium supplements or potassium-sparing diuretics added if necessary".(http://www.rxlist.com/[MEDICATION NAME]-drug.htm). Per nursing "Progress Notes", dated 6/22/10, "Resident having difficulty swallow (potassium) tabs, changed to liquid equivalent due to critically low lab results of 2.4 (normal 3.5-5.3 mmol/L)". Per Resident #103's laboratory reports: 6/01/10 - Potassium 3.0 mmol/L (signed by physician-date illegible) 6/22/10 - Potassium 2.4 mmol/L (signed by physician-date illegible) 7/06/10 - Potassium 3.0 mmol/L (signed by physician-date illegible) 8/17/10 - Potassium 2.2 mmol/L (signed as reported to physician by nurse #39-not dated) Per Resident #103's nursing Progress Notes, there was no note written to indicate that a physician had been notified about the 6/01/10 Potassium laboratory value. Per Resident #103's nursing Progress Notes, dated 6/22/10, "Resident having difficulty swallow (Potassium) tabs, changed to liquid equivalent due to critically low lab results of 2.4". Per Resident #103's nursing Progress Notes, dated 6/30/10, "(Physician #21) in - labs reviewed - order for labs on 7/06/10 noted". Per Resident #103's nursing Progress Notes, dated 7/02/10, "...continues to refuse her medication periodically". Per Resident #103's nursing Progress Notes, there was no note written that would suggest that the physician had been notified about the 7/06/10 Potassium laboratory value. On 7/7/10, per Resident #103's nursing Progress Notes, "(Physician #21) in today. No new orders". Per Resident #103's nursing Progress Notes, dated 8/17/10, "Critical labs reported to (physician #21). Order to increase Potassium 40 meq to BID ( two times per day) and recheck next lab day", was signed by nurse #39. Review of Resident #3's MARs (Medication Administration Records), between 1/01/10-5/3/10, nursing recorded Resident #103 had received all scheduled doses. However, review of Resident #103's MARs (Medication Administration Records) showed potassium was not administered on 5/4/10, 5/05/10, 5/8/10-5/16/10, 5/19/10-5/21/10, 5/24/10, 5/25/10, 5/28/10-5/31/10, 6/01/10-6/05/10, 6/07/10, 6/08/10, 6/10/10, 6/11/10, 6/13/10-6/16/10, 6/20/10, 6/21/10, 6/23-6/25/10, 6/28/10, 6/30/10, 7/01/10-7/04/10, 7/07/10, 7/08/10, 7/11/10, 7/12/10, 7/15/10-7/18/10, 7/21/10-7/24/10, 7/26/10, 7/29/10, 8/01/10, 8/04/10, 8/05/10, 8/09/10, 8/12/10-8/16/10, 8/17/10 and 8/18/10. Nursing staff did not record any: 1.) repeated attempts to get resident to accept potassium medication (except on 8/17/10) 2.) education given to resident regarding the ill effects of refusing potassium supplementation 3.) follow-up with physician regarding refusal of potassium medication 4.) follow-up with the family regarding refusal of potassium medication 5.) Refusal of Treatment forms Review of Resident #103's nursing "Progress Notes" from 5/04/10-8/18/10 showed no evidence that nursing notified physician #21 that Resident #103 had refused the Potassium during that time frame. Per the facility's "Refusal of Treatment" policy, dated 12/04, "...If a guest refuses treatment, it will be documented in his/her medical record using the "Refusal of Treatment (form)...A guest who refuses treatment will be informed of the following: a. The reason for the recommended treatment, b. alternatives to the recommended treatment, c. Implications of refusal of treatment...Procedure: 1. Nursing and/or the guest's physician will explain the benefits of treatment, including alternatives and risks, to the guest and/or his/her legal representative. 2. Nursing will notify the physician regarding the Refusal of Treatment if he/she is not present when the refusal is made. 3. If the guest refuses the treatment, a Refusal of Treatment (form) is to be completed and signed and dated by the guest or his/her legal representative and a facility representative. 4. The Refusal of Treatment form will be filed int he guest's medical record under the "Miscellaneous" tab. Review of Resident #103's medical record showed no evidence that the family was notified by nursing services, social services, any member of the Interdisciplinary Team or a physician of Resident #103's low potassium levels or of Resident #103 not receiving the potassium medication. In an interview with administrator #1 and director of nursing #2 on 10/01/10 at 11:27, they were unable to account for why the family had not been notified by facility staff about resident #103's critical lab values, not having Resident #103's low potassium care planned, or Resident #103 not having interventions in place to correct the low Potassium levels. Administrator #1 stated that Potassium could have been administered by an intravenous route if Resident #103 had been gone to a hospital. Per "Emergency Response Directive" for Resident #103, dated 11/23/09, Resident #103's Power of Attorney was Resident #103's daughter #37. Per Resident #103's daughter #37, in a telephone interview on 9/20/10 at 2:19 PM, and resident #103's daughter #38, in a telephone interview on 9/20/10 at 2:30 PM, no one at the facility told them about their mother's low potassium levels until her death was eminent on 8/19/10, at which time physician #21 encouraged them to change their mother's code status to "Do Not Resuscitate". Both daughters said they would have promoted interventions to correct the low potassium if they would have known. Per review of Resident #103's physician's orders [REDACTED].#21 (Resident #103's attending physician/Medical Director): 6/22/10 - "Change Potassium to liquid equivalent. 40 meq every day due to difficulty swallowing pills". 6/29/10 - "Potassium oral solution 20 meq by P.O. (by mouth) two times a day (8:00 AM and 8:00 PM)". 6/29/10 - "DC (discontinue) Potassium order on 6/29/10. Continue Potassium oral solution 40 meq/15 ml P.O. every day (8:00 AM)". 8/17/10 - "Increase Potassium to bid (two times per day). Recheck next lab day". On 9/30/10, the Surveyor found most of physician #21's "Progress Notes" for Resident #103 to be illegible. On 9/30/10, at 3:40 PM, the administrator #1, told Surveyor that physician #21 wanted to speak with Surveyor. In the phone conversation with physician #21, Surveyor informed physician #21 that his notes were "very important" to the case regarding Resident #3. In the phone conversation, [MEDICATION NAME] approximately seven minutes, physician #21 angrily, repeatedly demanded to know why Surveyor and facility staff were unable to decipher his writing but finally agreed to complete the transcription of his notes. Surveyor decided that questioning physician #21 regarding the circumstances of Resident #3's death would be disadvantageous, in light of physician #21's anger. On 10/01/10, the administrator #1 conveyed that physician #21 came to the facility and transcribed his original "Progress Notes" for Resident #103 (from 6/09/10, 7/07/10, 8/04/10 and 8/18/10) for Resident #103, on the evening of 9/30/10. Review of physician #21's signed transcribed "Progress Notes" for Resident #103 revealed no [DIAGNOSES REDACTED]. Review of Resident #103's medical record showed no indication that the pharmacist had monitored Resident #103's critical laboratory values or made pharmacological recommendations to restore Resident #103's potassium levels. In an interview with the administrator, on 10/01/10 at 10:20, she stated the pharmacy was supposed to review resident #103's labs and do a full monthly medication reviews but that this had not been being done. Per the dietary manager #16, in an interview on 9/30/10 at 3:50 PM, she told Surveyor she had been the facility's dietary manager for the last 10 months. Surveyor asked dietary manager #16 to explain what role potassium played in the human body. Dietary manager #16 responded, "...Honestly, I'm drawing a blank". Dietary manager #16 was unable to produce evidence that the abnormal potassium levels for Resident #103 were ever reviewed at the Nutrition Risk Committee. Dietary manager #16 said she looked at laboratory values only when it was time for her to fill out her section of the MDS (Minimum Data Set) and only if she saw abnormal labs, did she refer those residents to the consultant dietitian (there was no evidence in Resident #103's medical record that a consultant dietitian had reviewed Resident # 103's labs or made dietary recommendations to help correct hypokalemia). Dietary manager #16 admitted she had not done a nutritional assessment for Resident #103's MDS with an Assessment Reference Date of 7/20/10 because no one told her to. RAPs (Resident Assessment Protocols), dated 7/20/10, showed "Nutritional Status" section was not signed, even though "Section R: Assessment Information, 2 -Signature of the Person Coordinating the Assessment" was "signed as complete" by nurse # 17, dated 8/11/10. Per the "Job Description Dietary Manager", "Job Functions: Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. the omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position". Per the administrator #1, in an interview on 10/01/10 at 11:27 AM, she said dietary manager #16 should have been monitoring Resident #103's labs and reporting the abnormal labs to the consultant dietitian. Administrator #1 stated, "It is her (dietary manager # 16's) responsibility to monitor labs as they are drawn". Review of Resident #103's "Plan of Care" revealed there was no "Plan of Care" initiated for Resident #103 in regards to low potassium. Per nursing "Progress Notes", dated 8/18/10, "At 6:50 PM, called to resident's side while she was sitting in WC (wheel chair) at the end of center hall by CENA (nurse aide). Resident unresponsive. Respirations shallow and 10 (breaths/minute). taken to room with bed and placed sitting on edge of bed. resident responding more with eyes open, would say her name. Refused to lay down. Complaint of nausea. did have small emesis. Temperature 96.8 axillary, BS (blood sugar) 286, O2 saturation 88%, pulse 48, respirations 18, B/P (blood pressure) 126/62. Call placed to (nurse practitioner #40)...7:30 PM. (Nurse Practioner #40) returned call. report of what happen given. Resident more responsive and talking, could say what her name is and stated she didn't feel well. CBC (complete blood count) and CMP (comprehensive metabolic panel laboratory test) if possible ordered...9:00 PM. Daughter in at 8:00 PM. Gave report of what happened to her. Daughter sitting with her. resident sleeping but does respond when touched and name spoken". Per nursing "Progress Notes", dated 8/19/10, "While care given at 3:45 AM, resident (#103) became unresponsive for 5-10 seconds then became responsive. Had small emesis. Care given and put in chair. 5:00 AM. Had medium yellow phlegm emesis...At 11:40 AM, observed resident (#103) in room. No breaths, no pulse, no blood pressure. Family at bedside. (Physician #21) in to see..."