Every finding on record at The Lodge at Taylor

This citation pertains to intake 2602236.Based on observation, interview and record review the facility failed to ensure safe maintenance of shower gurneys, as four out five were observed to be missing safety pins required to secure the side rails.Findings include:On 9/9/25 at 12:14 PM, the shower room in Hall C was observed to contain a shower gurney missing all required safety pins to secure the side railings.On 9/9/25 at 12:16 PM, the shower room in Hall B was observed to have two shower gurneys missing all pins to secure the side rails.On 9/9/25 at 12:20 PM, the shower room on Hall E was observed to contain a shower gurney missing two of the four required safety pins to secure side rails.Record review of maintenance logs revealed no evidence that shower gurneys were routinely assessed for safety. In addition, there were no documented requests to replace the missing safety pins. Lastly, review of Certified Nursing Assistant Competency form indicated no education related to the use of the shower gurneys.On 9/9/25 at 1:00 PM, an interview was conducted with the Nursing Home Administrator, who reported that all shower gurneys should be safely maintained and that staff are expected to report equipment in need of repair in a timely manner to prevent accidents. Furthermore, nursing staff should be in serviced on using the shower gurneys. Record review of policy Physical Environment: Electrical Equipment revised 1/1/22 documented, The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Based on observation, interview, and record review, the facility failed to ensure that a call button was within reach for one resident (R102) reviewed for call light access. Findings include:During an observation on 8/21/25 at 8:46 AM, R102 was observed awake and lying in bed. R102 was receiving breakfast meal assistance from a staff member. R102's call button was observed on the floor at the head of the bed. During an interview on 8/21/25 at 8:51 AM, Non-Certified Nurse Aide E said she had been in R102's room assisting him with the breakfast meal. During an observation and interview on 8/21/25 at 8:56 AM, Licensed Practical Nurse (LPN) B noted R102's call light on the floor and said that the resident could not reach it. LPN B indicated that R102 had the capacity to use the call button. A review of the clinical record for R102 documented an admission date of 7/24/25 with diagnoses that included atrial fibrillation, morbid obesity, and hemiplegia/hemiparesis following cerebral infarction affecting right dominant side. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and no impairment of the upper extremities. A review of R102's care plans documented in part the following:- Resident has an ADL (activity of daily living) self-care performance deficit related to Congestive Heart Failure (CHF), generalized weakness, obesity, impaired mobility. Initiated: 7/24/25. Interventions included: Encourage resident to use call light when assistance is needed. Initiated 7/24/25 - Resident is at risk for falls/injury related to bladder incontinence, bowel incontinence, generalized weakness, needs assistance with ADLs, obesity, psychoactive medication use. Initiated 7/25/25. Interventions included: Encourage resident to use call light. Initiates 7/25/25. On 8/21/25 at 1:46 PM, the Director of Nursing (DON) said resident's call lights should be within reach. A review of the facility policy titled, Call Light: Accessibility and Timely Response, dated 12/28/23, revealed in part the following:- The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance.- Residents are educated on how to call for help by using the resident call system. On 8/21/25 at 2:45 PM during the exit conference the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was none.

Based on observation, interview, and record review, the facility failed to demonstrate professional standards of practice by not securing a physician's order and properly documenting wound care for one resident (R102) out of three residents reviewed for wound care. Findings include: During an observation on 8/21/25 at 8:24 AM, R102 was observed awake and lying in bed. A wound patch was observed on R102's right arm dated 8/16/25. During an observation and interview on 8/21/25 at 8:56 AM, Licensed Practical Nurse (LPN) B noted the patch on R102's right arm and stated, (R102) should have an order for the patch. LPN B reviewed R102's electronic health record (EHR) and confirmed there was no physician's order to apply a wound patch to R102's right arm or nursing note regarding the wound patch dated 8/16/25. A review of R102's EHR documented an admission date of 7/24/25 with diagnoses that included atrial fibrillation, morbid obesity, and hemiplegia/hemiparesis following cerebral infarction affecting right dominant side. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. R102's care plans were reviewed, and the following care plan focus areas were revised on 8/21/25:- Resident is at risk for impaired skin integrity related to incontinent of bladder, incontinent of bowel, obesity, impaired mobility, history of cellulitis, has history of picking at skin.- Resident has impaired skin integrity as evidenced by: Abrasion to right elbow, arterial wound to right lateral malleolus, cellulitis to RUE (right upper extremity) (resolved); Abrasion to sternum (resolved) present upon admission. During an interview on 8/21/25 at 1:46 PM, the Director of Nursing (DON) said R102 had a scab on his right arm and the nurse put a dressing on it. The DON stated, There should have been a physician's order for that. The DON said the physician should have been made aware of what was going on with the resident and to also direct the nurse to implement the proper wound treatment. The DON acknowledged there was no note written regarding the wound and treatment provided. The DON added that whatever treatments are done for the residents should be documented. A review of the facility policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, dated 3/20/24, documented in part the following: The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. On 8/21/25 at 2:45 PM during the exit conference the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was none.

This citation pertains to MI000151505. Based on observation, interview, and record review the facility failed to implement adequate interventions and supervision to prevent multiple falls for one (R103) of three residents reviewed for accidents, resulting in injuries and hospital visits. Findings include: On 5/6/25 at 1:30 p.m. R103 was observed in an activity room. The resident was observed attempting to propel herself in the wheelchair to exit the area. Unit Manager A was observed redirecting R103 multiple times by grabbing of the wheelchair and placing the resident back in the area. R103 was also observed motioning to UM A to move away from her when redirected by staff. R103 was non-interviewable due to cognitive impairment. On 5/6/25 at 2:20 p.m. R103's roommate was interviewed and stated, She is up all night, standing up by herself, and falls. She does not listen to anyone. Review of the electronic medical record (EMR) documented R103 was initially admitted into the facility on [DATE] with a readmission from the hospital (after a fall) on 3/14/25 with diagnoses that included impulsiveness, metabolic encephalopathy, seizure disorder, muscle weakness, bipolar disorder, generalized anxiety disorder, impulse disorder, and unspecified falls. According to the admission Minimum Data Set assessment dated [DATE], R103 had severe cognitive impairment (BIMS-2) and required extensive one-person assistance with activities of daily living. Review of the Fall care plan initially dated 2/4/25, with the last revision date of 4/30/25 documented in part the following: Resident is at risk for falls/injury related to weakness and foot drop, history of falls, attempting to ambulate without assistance, placing self on floor, cognition, behaviors, and unable to be re-directed. Goal: Reduce the risk of injury through the next review. Interventions: Keep resident in common area when awake (2/10/25). Structured activities to meet resident's needs (2/19/25). Ensure the resident's room is free from accidents and hazards (2/4/25). Mat to floor next to bed (left side) (3/19/25). Low bed (2/5/25). There was no admission Fall Assessment for R103. Review of the Nursing Admission Evaluation dated 2/4/25 documented in the Safety section the following: Unsafe behaviors present: Attempts to climb over bed rails and/or get out of bed independently when they require assistance. Mobility: Unsafe wheelchair seating. The readmission Fall Risk Evaluation dated 5/1/25 documented in part the following: History of falls- During the last 90 days has the resident experienced a fall? Yes Comments- Resident continues to have multiple falls in facility due to behavior and cognition. Review of the nurse's progress notes in part documented the following falls: 2/4/25 20:53 (10:53 pm)- Writer was notified resident had fallen in room while walking unsupervised in room, fall was witnessed by roommate . R103' care plan was reviewed/updated on 2/4/25 and 2/5/25. 2/9/25 19:39 (7:39 pm)- Resident roommate turned call light on. Writer answered call light and observed resident on floor. Resident was sitting on her bottom. Resident roommate stated the resident got up out of her bed and was walking and then proceeded to fall. 2/10/2025 10:48 (10:48 am) - Writer witnessed blood on resident's left eyebrow. Resident's roommate stated resident had fallen and hit head on bed .sent resident out to the hospital . R103's care plan was reviewed/updated on 2/10/25. 2/11/2025 00:08 (12:08 am) - Resident arrived back from hospital at 2045. No new orders. Resident has 3 stitches on her left eyebrow. Bruises on left side of the body. 2/15/2025 08:12 (8:12 am) - On the morning of 2/15/25 the resident was observed sitting on bed. Writer was passing medication to the residents in (XX) resident was observed sitting on the bed with a bloody face. Writer immediately cleaned resident's face and noticed a large gash above residents left eye. Writer called 911, the resident was transported via EMS. R103's care plan was reviewed/updated on 2/19/25. 3/19/25 01:18 (1:18 am) - Resident was observed coming down the hall with laceration in the middle of her forehead . Resident sent out. Incident occurred on 3/18/25 (times not indicated). R103's care plan was reviewed/updated on 3/19/25. 3/20/2025 23:28 (11:28 pm) - Patient attempted to get out of her chair and was observed on the floor. Patient was assessed, and no injuries were observed MD notified. However, there was no documented evidence the care plan was updated or revised at this time. 3/22/2025 06:55 (6:55 am) - The resident was observed by nursing staff sitting on the mat (near bedside) with blood coming from her suture site (mid forehead). However, there was no documented evidence the care plan was updated or revised at this time. 3/22/2025 23:41 (11:41 pm) - Prior to fall resident was sitting at nurse's station not in distress. At around 9:30 pm, was observed resident on the floor lying on the right side. Skin assessed. Skin redness noted at right cheek. However, there was no documented evidence the care plan was updated or revised at this time. 3/31/2025 05:34 (5:34 am) - Writer observes resident standing at desk at 5:15am writer comes to resident to assist back in chair, writer observes blood coming from forehead of patient, writer assist resident into chair, resident's wheelchair in room, writer observes a blood trail leading from resident's room to nursing station, two Cena's arrive to assist with wet towels as writer grabs supplies to tend to wound on forehead. Resident had prior stitches that have opened, resident having blood scattered over her face with blood clots . resident appears to have knot on forehead, injury to lip, and blood coming from nose with a scratch on nose . ambulance arrived for pick up. Resident leaving out at 5:40am. However, there was no documented evidence the care plan was updated or revised at this time. 4/6/2025 02:50 (2:50 am) - Prior to fall resident was observed in bed resting with no signs of distress or pain. Upon rounds Cena observed resident on bed with her previous injury on forehead bleeding and a new laceration on the bridge of her nose bleeding . However, there was no documented evidence the care plan was updated or revised at this time. 4/7/2025 09:21 - IDT Team met to discuss unwitnessed fall that occurred in resident room. Staff observed resident on her bed, bleeding from face with laceration to bridge of nose. Prior to that, the resident was sleeping in bed. Resident unable to state what occurred. Nurse assessed. Laceration cleansed. MD notified. Care Plan reviewed. Fall mat in place. Team will evaluate for bolster mattress. 4/14/2025 19:26 (7:26 pm) Resident was observed attempting to walk and fell forward onto a nurse. The nurse then slid down to floor . However, there was no documented evidence the care plan was updated or revised at this time. 4/15/2025 9:27 - IDT Team met to discuss incident with the resident. Resident got out of her wheelchair and was trying to walk. Staff member caught resident before she fell . Lowered to the ground . Care Plan reviewed. Resident is not able to be educated r/t impaired cognition and behaviors. However, there was no documented evidence the fall care plan was updated or revised at this time. 4/19/2025 21:00 (9:00 pm) - Resident was observed with swelling and bleeding to her forehead. Resident was sitting at the nurse's station when she inflicted harm to herself when she hit her head on desk . Writer notified Dr and was ordered to send resident out to the hospital. Resident was transferred by two paramedics via ambulance . 4/29/2025 00:00 (12:00 am) - Resident observed placing self onto floor several times throughout the shift . 4/29/2025 19:51 (7:51 pm) - Patient continues to place herself onto floor and show signs of being combative and resistant to redirection for safety. Patient attempted continually to get up and threw herself onto the ground on her face Patient observed bleeding from her mouth and nose . Patient being sent out to hospital per unit manager. Care plan was reviewed/revised on 4/30/25. 5/2/2025 22:32 (11:32 pm) - While heading towards resident, observed resident stand up from wheelchair and sit down onto floor while at nursing station . However, there was no documented evidence the fall care plan was updated or revised at this time. On 5/7/25 at 1:30 p.m. the Nursing Home Administrator (NHA) was interviewed regarding R103 having multiple falls. The NHA stated, We have done everything. I don't know what to do to keep her from falling. We discussed it in the IDT meetings and talked about getting a wheelchair seat belt, but because she can't release the wheelchair seat belt, it would probably be a form of a restraint. On 5/8/25 at 11:30 a.m. Unit Manager (UM) A was asked about interventions for R103 falls that occurs during the evening/night time and UM A reported there were none for the evening and the focus was for day time. UM A added, Maybe she should have some (activities) during the night as an intervention for when she tries to get out of bed or some activities like music to help keep her calm and something to do. I think that would have helped her from so many falls. Review of the care plans revealed there was no facility follow up for bolsters for the bed documented in the nurse's progress notes or on the care plan. There were no additional interventions implemented after 3/19/25. On 5/8/25 at 1:38 p.m. the Director of Nursing (DON) presented a Structure Day Program and said the facility have currently started using the program for R103's falls. The DON stated, I think it will be helpful in preventing the residents from falling. Eleven falls is a lot and hopefully the program will be effective. Review of the facility's policy titled Fall Prevention Program dated 10/26/23 documented the following in part: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk . When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program . Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The care plan will be revised as needed .

Based on observation and interview, the facility failed to maintain the over-bed tables in 7 resident rooms (#'s B4, C2, E4, G2, I11, I12, and J9). Findings include: On 12/10/24 between 2:00 pm-2:30 PM, in resident rooms B4,C2, E4, G2, J9, I2, I11 and I12, there were over-bed tables observed with missing edging, peeling surface veneer and rough, exposed particle board. The tables were no longer smooth and easily cleanable. During an interview on 12/10/24 at 3:15 PM, Maintenance Director K stated that he relies on staff to let him know when a table needs to be replaced. When shown the over-bed table in room C2 (the whole top surface was lifted away from the particle board) Maintenance Director K stated, It's water warped. It needs to be replaced.

Based on observation, interview and record review, the facility failed to act promptly on a consistent grievance received from residents at ten consecutive monthly Resident Council Meetings resulting in residents not having water passed to them on a regular basis and feelings of frustration due to not having their needs met. Findings include: On 12/10/24 at 1:44 PM R9 was observed in bed without water or water cup on their bedside or over-the-bed table. There was no type of hydration visible in the resident's room. R9 could not say if there had been water available to them at their bedside earlier. On 12/11/24 at 9:03 AM R9 was observed in bed without water or water cup on their bedside or over-bed table. There was no visible hydration in the resident's room. R9 was asked if water was offered to them earlier. R9 was unable to be meaningfully interviewed due to cognition impairment, but did ask for a drink of water. According to R9's Electronic Health Record (EHR) the resident had resided at the facility since 2011 and had severe cognition impairment with a Brief Interview for Mental Status (BIMS) Score of 4/15. On 12/11/24 at approximately 9:35 AM R57 was observed in her room without a water cup on her over-bed table. R57 said that residents had been complaining of not receiving water pass on a regular basis for months now. R57 said, We bring it up in every resident council meeting, but it never gets fixed. Sometimes we get water, sometimes were don't. I can ask for it, but others can't. According to R57's EHR the resident had resided at the facility since 7/7/22. The Minimum Data Set (MDS) dated [DATE] indicated the resident had a BIMS score of 15/15 (intact cognition.) On 12/11/24 at 9:37 AM R64 was observed without water or a water cup at bedside. R64 said that concerns have been brought up at the council meeting regularly. The resident stated, Some staff remember to bring us water, and some don't. R64 said they were independent and able to walk to the kitchen and ask for water. According to R64's EHR the resident admitted to the facility on [DATE]. The MDS indicated the resident had a BIMS score of 15/15. On 12/11/24 at approximately 9:45 AM Certified Nursing Assistant (CNA) M, who was the assigned CNA for R9, R57 and R64, was interviewed. CNA M said they had not passed water to any residents yet because they thought the midnight shift had done it before they left. A review of the facility's Resident Council Meeting (RCM) minutes from 2/6/24 - 11/12/24 included the following resident's concerns: 2/6/24; no water or ice being passed, mostly on the afternoon shift. 3/1/24; no water being passed. 4/9/24; water pass is not consistent, not getting water on the midnight shift. 5/7/24; water pass is still not getting passed on the midnight shift. 6/12/24; water pass getting better, but not on the week-ends. 7/11/24; no water pass on the week-end is on new business. 8/13/24; old business section reports ' no water pass'. There is no resolution reported. 9/10/24; no water pass - it depends on who is working. 10/8/24; no water pass on the afternoon shift. 11/12/24; unresolved old business; no water pass. On 12/11/24 at 11:37 AM during an interview with the Nursing Home Administrator (NHA) the RCM notes from 2/6/24 - 11/12/24 were reviewed. The NHA acknowledged that residents had concerns regarding not getting water pass on certain shifts at every RCM since 2/6/24. The NHA said that staff had received in-services in October and water was getting passed to residents. The NHA said, We did an education and then audits to check if water pass had been done in October and it showed that resident's were getting water. Then staff changes occurred and water pass wasn't being done consistently. We need to start monitoring it again. The NHA presented the in-services and audits for water pass dated 10/14/24, 10/16/24 and 10/17/24. The NHA was asked if anything had been done to resolve the concerns for water pass prior to October 2024 and replied no. The NHA could not explain why no resolutions had occurred regarding water pass since February 2024. On 12/11/24 at 11:42 AM the Director of Nursing (DON) reviewed the audits for water pass on 10/16/24 and 10/17/24 and acknowledged that some residents had still not received water pass even after in-services had been provided to staff. The DON said, Some of our staff has changed since then and we need to complete another in-service for water pass to residents. The DON said she had only been in the this position for a short time and could not provide any documented in-services or audits for water pass prior to 10/16/24. The DON acknowledged that residents had been expressing their concerns with lack of water pass since 2/11/24. According to the facility's policy for Resident Hydration last revised on 1/1/2022 in part reads; 7. Residents will be provided fluids on a daily and routine basis as part of daily care

Based on observation, interview and record review the facility failed to apply a barrier while administering medications for one resident (R15) out of four residents reviewed for medication administration. Findings include: On 12/11/24 at 9:00 AM, Licensed Practical Nurse (LPN) J was observed with two pre-filled syringes containing a long-acting insulin (Glargine) and one syringe containing a short acting insulin (Flasp). LPN J entered R15's room and laid all three syringes on the resident's bedside table with no barrier. R15's bedside table had multiple items and debris scattered on surface. LPN J then proceeded to administer the medications. A record review of R15's electronic medical record (EMR) disclosed their admission to the facility on [DATE], with a diagnosis of type two diabetes mellitus without complications. Review of R15's Minimum Data Set (MDS) dated [DATE], R15 required supervision for most activities of daily living (ADLS). Review of R15's Brief Interview for Mental Status (BIMS) revealed impaired cognition, with a score of 10 out of 15 (impaired cognition.) On 12/11/24 at 1:42 PM, LPN J was interviewed. It was reported that R15's medication should not have been placed directly on the bedside table due to the potential for contamination. On 12/11/24 at 2:26 PM, an interview was conducted with the Director of Nursing (DON). It was reported that nurses should not place resident medications on surfaces without the use of a barrier to prevent contamination and infection from concealed body fluids and other unknown contaminants. Review of facility policy Medication Administration revised 1/17/2023 documented, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observation, interview, and record review the facility failed to ensure a bathroom call light was in working order for one (R1) of two residents reviewed for environment resulting in call light not answered in a timely manner, unmet care needs, and the potential delay in responding to emergency situations. Findings include: On 12/10/24 at 10:57 a.m. R1 was observed in the bathroom located in the room. R1 was sitting in a wheelchair attempting to come out of the bathroom. The resident said the staff do not answer the call light. R1 stated angrily, I had to go to the bathroom really bad and couldn't wait for staff to help me, so I got on the toilet myself. I turned on the call light to get help getting off, but no one came so I got off by myself. The resident said they require assistance with going to the bathroom and shouldn't self-transfer to the toilet because of epilepsy, I realize I could have fell . The resident was not sure how long the call light was not working because they usually receive assistance from staff, except today. The bathroom light indicator was activated, however the indicator outside the door was not. When the call light is activated, a blue light illuminates outside of the room that can be seen by in the hall. Unit Manager H overheard talk about the call light and instructed R1 not to use the bathroom call light until it was repaired. On 12/11/24 at 11:41 a.m. review of the electronic medical record documented R1 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, epilepsy, convulsions, restless legs syndrome, and dementia. According to the annual Minimum Data Set assessment dated [DATE], R1 was cognitively intact (BIMS=15), and required substantial/maximal assistance with toileting. Review of the activities of daily living care plan dated 6/7/24 documented in part: Resident has an activities of daily living self-care performance deficit related to anxiety, behaviors, cerebral palsy, cognitive impairment, dementia, depression, generalized weakness, impaired vision, poor balance, poor coordination, seizures generalized weakness, and history of falls. Intervention: Toileting: 1 person assist. On 12/17/24 at 2:05 p.m. Maintenance Director I was interviewed and queried about call light functioning and monitoring. Maintenance Director I said monthly call light audits are completed. Each room and bathroom's call light functioning are checked. The Maintenance Director said they were not aware R1's bathroom call light was not working. Staff are to use the electronic repair order system to inform when something needs repair.

Based on interview and record review the facility failed to effectively communicate with a dialysis provider for one resident (R250) out of three residents requiring dialysis services, resulting in seven doses of antibiotics that were not administered as ordered by a physician. Findings include: On 12/10/24 at 10:41 AM, during an interview with R250, it was reported that intravenous antibiotics were not administered during dialysis. A record review of R250's electronic medical record (EMR) disclosed their admission to the facility on [DATE], with a diagnosis of end stage renal failure and osteomyelitis (infection of bone) of left foot and ankle. Review of R250's Minimum Data Set (MDS) dated [DATE], R250 required partial/moderate assist for most activities of daily living (ADLS). Review of R250's Brief Interview for Mental Status (BIMS) dated 11/29/24 revealed intact cognition, with a score of 15 out of 15 (intact cognition.) Record review of physician orders documented that R250 was to receive Cefepime HCL (antibiotics) . should be administered intravenously once daily on Mondays, Wednesdays, and Fridays until 12/29/24, after completing hemodialysis (HD). Furthermore, it was revealed that Vancomycin HCL (antibiotic) was prescribed for osteomyelitis. The order indicated that 500 mg(milligrams) of Vancomycin HCL administered intravenously daily on Mondays, Wednesdays, and Fridays until December 29, 2024. Administer post (after) HD. Review of the Medication Administration Record (MAR) for December 2024 disclosed that Vancomycin was not administered on December 2, 4, 6, and 9. Furthermore, Cefepime was not administered on December 4, 6, and 9. Review of Communication Report from dialysis provider on 12/2/24, it was documented under Antibiotics Given- 0. On 12/4/24,12/6/24 and 12/9/24 under Antibiotics Given there was no documentation. On 12/11/24 at 4:00 PM, an interview was conducted with the Director of Nursing (DON), it was confirmed that R250 had missed four doses of Vancomycin and three doses of Cefepime. When asked about how the antibiotics should have been administered, DON reported that the antibiotics should have been taken to dialysis to be administered and when the antibiotics were not available, nursing staff should have informed the physician. On 12/12/24 at 11:15 AM, a follow-up interview was conducted with the DON. When queried about the communication with the dialysis provider, DON reported that the dialysis staff and nursing staff should have made the DON or the UM aware that antibiotics were not given. It was further reported that communication with dialysis needs to be addressed. Review of facility policy Care Planning Special Needs-Dialysis dated 12/28/23 documented the following: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving dialysis. Further review of policy documented, 4.Nursing staff will provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day, and as needed. 5. If no written report is received upon return from dialysis, nursing staff will call the dialysis provider to receive a report.

Based on observation, interview and record review the facility failed to provide adequate foot care for one resident (R32) out of four residents reviewed for Activities of Daily Living (ADLS). Findings include: On 12/10/24 at 10:16 AM, R32's feet were observed to have long, jagged, thick, greenish/black-toe nails. Additionally, R32's feet had white patches of dry skin and moist debris encrusted between toes. During an interview, R32 expressed a desire for podiatry services due to the inability to provide nail care independently. A review of the electronic medical records (EMR) revealed that R32 was admitted to the facility on [DATE] with a diagnosis of morbid obesity, type two diabetes, and end stage renal failure. Review of R32's Brief Interview for Mental Status (BIMS) dated 9/20/24 indicated that R32 scored 15 out of 15 (intact cognition). Review of R32's Minimum Data Set (MDS) dated [DATE], it was noted that R32 exhibited dependency with most ADLs. Upon further review of R32's EMR it was discovered that R32 had not been registered or received podiatry care. Additionally, care plans reviewed did not contain any specific interventions for foot care. On 12/11/24 at 11:27 AM, R32's feet were observed and remained in the same condition as the previous day. On 12/11/24 at 2:36 P.M., an interview was conducted with the Director of Nursing (DON) following the observation of R32's feet. It was reported that podiatry services should have been provided, even if the resident did not have a diabetic diagnosis related to the resident's current comorbidities (multiple medical conditions). On 12/11/24 at 2:39 PM, an interview was conducted with the Social Worker (SW) G, regarding the registration of R32's podiatry services. It was reported that R32 was not registered for podiatry services at that time, and the staff member that assists with setting up these services had not done it in a timely manner. On 12/11/24 at 3:10 PM, an interview was conducted with Nursing Home Administrator (NHA), it was reported that residents should be provided with foot care by staff and podiatry services should be provided if residents need that specific service. Review of policy Nail Care dated 8/2024 documented the following: .1. Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care, if possible. a. Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g., curling, color changes, separation from the nailbed, redness, bleeding, pain, odor, infection, etc.). b. Obtain history and preferences regarding podiatrist. 2. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing Basis. 3. Routine nail care, to include trimming and filing, will be provided on a regular basis and as the need arises. 4. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only podiatrists, physician/practitioners, or licensed nurse shall trim toenails for residents with diabetes or circulation problems .

Based on interview and record review, the facility failed to administer medications as ordered and failed to notify the physician of missed doses for one resident (R250) out of five residents reviewed for medications. Findings include: On 12/10/24 at 10:41 AM, during an interview with R250, it was reported that intravenous antibiotics were not administered during dialysis. A record review of R250's electronic medical record (EMR) disclosed their admission to the facility on [DATE], with a diagnosis of end stage renal failure and osteomyelitis (infection of bone) of left foot and ankle. Review of R250's Minimum Data Set (MDS) dated [DATE], R250 required partial/moderate assist for most activities of daily living (ADLS). Review of R250's Brief Interview for Mental Status (BIMS) dated 11/29/24 revealed intact cognition, with a score of 15 out of 15. Record review of physician orders documented that R250 was to receive Cefepime HCL (antibiotics) . should be administered intravenously once daily on Mondays, Wednesdays, and Fridays until 12/29/24, after completing hemodialysis (HD). Furthermore, it was revealed that Vancomycin HCL (antibiotic) was prescribed for osteomyelitis. The order indicated that 500 mg(milligrams) of Vancomycin HCL should be administered intravenously daily on Mondays, Wednesdays, and Fridays until December 29, 2024. Administer post (after) HD. Review of the Medication Administration Record (MAR) for December 2024 disclosed that Vancomycin was not administered on December 2, 4, 6, and 9. Furthermore, Cefepime was not administered on December 4, 6, and 9. Review of Progress Notes dated 12/4/24, Licensed Practical Nurse (LPN) E documented Pt (patient) in dialysis. No documentation related to administration of antibiotics or that the physician was informed of the missed doses. Review of Progress Notes dated 12/6/24 at 2:12 PM, LPN D documented dialysis to administer to patient for both antibiotics. No documentation related to administration of antibiotics or that the physician was informed of the missed doses. Review of Progress Notes dated 12/9/24. Registered Nurse (RN) F documented both antibiotics were on order. No documentation indicated that the physician was made aware of the missed doses. Review of Communication Report from dialysis provider on 12/2/24, it was documented under Antibiotics Given- 0. On 12/4/24,12/6/24 and 12/9/24 under Antibiotics Given there was no documentation. On 12/10/24 at 10:50 AM, an interview was conducted with Unit Manager (UM) H. At this time UMH was informed that R250 had reported not receiving antibiotics that were ordered to be given at dialysis. UMH reported not being aware of the missed doses and would look into it. On 12/11/24 at 4:00 PM, an interview was conducted with the Director of Nursing (DON), it was confirmed that R250 had missed four doses of Vancomycin and three doses of Cefepime. When questioned about how the antibiotics should have been administered, DON reported that the antibiotics should have been taken to dialysis to be administered and when the antibiotics were not available, nursing staff should have informed the physician. On 12/11/24 at 4:20 PM, an interview was conducted with Physician L, it was reported that nursing staff did not report the missing doses of antibiotics until 12/10/24. On 12/12/24 at 10:02 AM an interview was conducted with LPN E, it was reported that the physician was not informed of the missed doses of antibiotics. On 12/12/24 at 10:15 AM, an interview was conducted with LPN D, It was reported that the physician was not informed of the missed doses of antibiotics. On 12/12/24 at 10:35 AM, an interview was conducted with RN F, it was reported that the physician was not informed of the missed doses of antibiotics. On 12/12/24 at 11:15 AM, a follow-up interview was conducted with DON. When asked the reason that the antibiotics were not available. The DON reported that either the antibiotics were not available in the facility or could not be found. When queried about the communication with the dialysis provider, DON reported that the dialysis staff and nursing staff should have made the DON or the UM aware that antibiotics were not given. Review of facility policy Medication Administration dated 1/17/23, documented, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .

Based on interview and record review the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and/or DCH-3878 documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for mental illness needs upon admission for two (R44 and R86) of four residents reviewed for PAS/ARRs, resulting in the potential for residents not to receive care and services appropriate to their mental health needs. Findings include: R86 On 12/10/24 at 2:51 p.m. review of the electronic medical record documented R86 was initially admitted into the facility on [DATE] and readmitted on [DATE] from the hospital with diagnoses that included paranoid schizophrenia, anoxic brain damage, cocaine abuse, and adjustment disorder. According to quarterly Minimum Data Set assessment dated [DATE], R86 had no speech, severely impaired cognition and dependent with all activities of daily living. Review of the Preadmission Screening (Level I Screen, 3877) dated 9/12/24, documented R86 had mental illness and receiving antidepressant/antipsychotic indicated by a checked yes. Review of the Mental Illness/Intellectual Disability/ Related Condition Exemption Criteria Certification (3878) dated 9/12/24, documented R86 had Dementia Exemption checked yes. The 3877 and 3878 were completed by hospital staff on the day of discharge to the facility. Review of hospital records, face sheet, and psychiatric progress note dated 11/6/24 did not document R86 had a diagnosis of dementia. On 12/11/24 at 1:43 p.m. Social Worker (SW)G was interviewed and queried about the 3877/3878 and was a Level II evaluation request sent to the local mental health agency. SW G stated, This was confusing because of the dementia exemption. I don't know why dementia was not put on 3877. It came from another facility. I typically review them (PASARR) upon admission, but I can't remember what happened with this one. A request for a Level II evaluation was not submitted to the local mental health agency based on the 3877 and other pertinent information not reviewed. 22349 R44 According to Electronic Health Record (EHR) R44 admitted to the facility on [DATE] with diagnoses that included unspecified psychosis and metabolic encephalopathy (broad term for a brain disease that alters brain function.) The MDS dated [DATE] indicated the resident had severe cognition impairment and was non-verbal. R44 was prescribed a psychoactive medication; Risperdal 0.5 milligrams every day for paranoia. Review of the Preadmission Screening (Level I Screen, DCH-3877) dated 12/23/2023, documented R44 had mental illness and receiving antidepressant/antipsychotic checked yes. There was no DCH-3877 form completed upon admission to the facility and no Level II Screen, DCH-3878 assessment. On 12/11/24 at 3:49 PM during an interview regarding R44, SW G said that the resident did not have a PASARR assessment completed since admitting to the facility. SW G said, The resident came from another facility and it was missed. We should have reviewed it and updated it. The resident will most likely be exempt for a level II, but we should have done a PASARR. Review of the facility's policy titled, Resident Assessment Coordination with PASARR Program dated 10/23 documented in part: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening . PASARR Level I - initial pre-screening that is completed prior to admission . PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority(cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs . If a resident who was not screened due to an exception and the resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state designated authority for Level II PASARR evaluation and determination . The Social Services Director shall be responsible for keeping track of each resident's PASARR condition.

Based on observation, interview and record review the facility failed to perform proper hand hygiene and gloving during wound care for one resident (R205) out of three residents reviewed for infection control practices. Findings include: On 11/6/24 at 10:40 AM Licensed Practical Nurse (LPN) A was observed performing wound care for R205. LPN A entered the resident's room and did not perform hand hygiene. A hand sink was located inside of the room. LPN A proceeded to apply two pairs of gloves to each hand and removed the soiled dressings. All gloves were removed, and hand hygiene was not performed. LPN A then applied two more pairs of gloves to each hand and completed wound care. R205 was observed to have an approximately two-centimeter by three-centimeter open cancer lesion on side of the left breast. LPN A removed all gloves and hand hygiene was not performed. LPN A applied another pair of gloves and proceeded to assist with further care. On 11/6/24 at 11:02 AM, during an interview with LPN A, it was reported that hand hygiene should have been performed when moving from Dirty to clean dressings. It was further reported, I did not wash hands because I doubled gloved. An interview on 11/6/24 at 12:30 PM with the Director of Nursing (DON), it was reported that before starting wound care that hand hygiene should be performed, then hand hygiene should be performed after removing soiled dressing and before applying clean dressings, and then after administration of that treatment. The DON further reported double gloving should not be substituted for hand hygiene. Review of R205's electronic medical record revealed admission into the facility on [DATE] with a diagnosis of malignant neoplasm (cancer) of right female breast and need for assistance with personal care. According to Brief Interview for Mental Status dated 8/13/24, R205 had scored 13 out of 15 (intact cognition). Review of policy Hand Hygiene dated 12/13/23, documented, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. It was further documented in the policy, 6 a. - The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (applying) gloves, and immediately after removing gloves.

This citation pertains to intake number MI00145631. Based on observation, interview, and record review the facility failed to include one resident (R501) on the podiatrist list out of three residents reviewed for Activities of Daily Living (ADLS), resulting in R501 having overgrown toenails and resident dissatisfaction with foot care. Findings include: On 10/2/24 at 11:10 AM R501 reported that he was not seen by the foot doctor to have his nails trimmed and that he had to make his own outside appointment in August because the facility didn't put him on the podiatry list. An observation of bilateral feet revealed resident's great toenails had grown passed the end of toes. R501 further reported, I like my toenails kept short. Review of R501's Electronic Health Record (EHR) revealed admitted to the facility on [DATE] with pertinent diagnosis which included cerebral infarction, hemiplegia affecting left dominant side, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed R501 had intact cognition and required set up for personal hygiene. Further review of R501's EHR revealed no podiatry consults since admission or documentation of nail care being administered. On 10/2/24 at 11:55 AM Social Worker (SW) E was interviewed and said the previous social worker did not send a complete referral to the podiatry group. R501 should have been seen by the podiatrist in August. On 10/2/24 at 4:00 PM the Director of Nursing (DON) was interviewed and did not provide any documentation of nail care for R501. The DON agreed the referral for podiatry should have been made. Review of the facility policy titled Nail Care revised 8/20/24 revealed in part .The purpose of this procedure is to provide guidelines for the care of a resident's nails for good grooming and health. 1. Assessment of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care, if possible. Obtain history and preferences regarding podiatrist. Identify conditions that increase risk for foot or nail problems such as stroke. Routine nail care, to include trimming and filing, will be provided on a regular basis and as the need arises.

This citation pertains to intake MI00145907 and MI00146790. Based on observation, interview, and record review, the facility failed to ensure tube feeding (liquid nutrition) was administered in accordance to physician's orders for one (R510) of four residents reviewed for tube feeding resulting in R510's tube feeding being on hold for an undetermined amount of time, the amount of tube feeding administered being less than prescribed, and the potential for the resident to have insufficient nutrition, hydration, and weight loss. Findings include: On 10/2/24 at approximately 9:00 AM, R510 was observed laying in her bed with a tube feeding pump that was audibly alarming. The display screen on the tube feeding pump indicated the tube feeding was on hold. The display screen did not indicate how long the feeding had been on hold or how much tube feeding had been administered. R510 was unable to be interviewed due to severely impaired cognition and non-verbal status. The tube feeding bottle was identified as Jevity 1.5 Cal, 1,500 milliliter (ml) bottle and had the following documentation written on it; hung on 10/1/24 at 9:00 PM, rate = 73 ml/hr (73 milliliters per hour). The 1,500 ml bottle had approximately 550 ml of feeding infused. A review of R510's Electronic Health Record (EHR) indicated the resident had diagnoses that included anoxic brain injury (brain cell death due to oxygen deprivation) and required a feeding tube (a tube surgically inserted through the wall of the abdomen into the stomach to deliver liquid nutrition, hydration, and medication). On the 5/10/24, the physician ordered the following tube feeding orders; Jevity 1.5 Cal at 73 ml/hour to go up at 12:00 PM and run until 1,314 ml had been infused. A care plan for Enteral Feeding (tube feeding) revised on 1/22/24 included the following interventions: Administer enteral nutrition per orders. A care plan for Risk of altered Nutrition revised on 8/25/24 included the following interventions: Administer enteral nutrition per orders. On 10/2/24 at approximately 9:20 AM the Director of Nursing (DON) and R510's nurse, Licensed Practical Nurse (LPN) B were at R510's bedside and asked about R510's tube feeding. Neither LPN B or the DON could determine how long the resident's tube feeding was on hold or how much tube feeding (Jevity 1.5 Cal) had been infused over a 24-hour period. The DON said, The tube feeding bottle has documentation on it to indicate it was hung at 9:00 PM. The order is for 73 ml per hour. If the tube had been properly infusing for 12 hours, then about 876 milliliter should have been given to the resident by now. The bottle currently only has 550 ml infused, so the resident is about 300 ml short at this time. I will notify the physician and dietitian to determine how to correct this. The DON had reviewed R510's order and could not explain why the tube feeding was hung at 9:00 PM instead of at 12:00 PM in accordance with the physician's orders. On 10/2/24 at approximately 2:00 PM the DON reported that the physician had been notified that R510's tube feeding and hydration amount had not been met for this 24- hour period. The DON said that both nutrition and water boluses (large dose of formula infused over a short period of time) had been prescribed to the resident and the tube feeding infusion will be restarted the next day at 12:00 PM per the physician's original order. According to the facility's Feeding Tube policy revised on 6/30/22 in part reads; Feeding tubes will be used only as necessary to address malnutrition and dehydration, or when the resident's clinical condition deems this intervention medically necessary to maintain acceptable parameters of nutrition and hydration. Feeding tubes will be maintained in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible 7. Feeding tubes will be utilized according to physician's orders 11. e. Ensure that the administration of enteral nutrition is consistent with and follows the physician's orders 12. c. Periodic evaluation of the amount of feeding being administered for consistency with physician's orders.

This citation pertains to intake MI00146210. Based on observation, interview, and record review, the facility failed to ensure appropriate tracheostomy (surgical opening created in the front of the neck into the trachea to help oxygen reach the lungs) care was provided to one of three residents (R510) reviewed for tracheostomy care resulting in R510 not receiving the prescribed amount of humidified oxygen due to unaddressed malfunctioning humidification equipment with the potential for respiratory complications. Findings include: On 10/2/24 at approximately 9:00 AM, R510 was observed laying in her bed with a tracheostomy covered with a trach collar (soft plastic mask that fits over the trach to deliver humidified oxygen). The trach collar tubing was connected to a compressor (machine that delivers humidification to oxygen) that was set on 0% (zero) humidification. The oxygen concentrator (machine that delivers oxygen) was set at 5 liters. The compressor's water bottle was leaking water and dripping down the outside of the trach tubing and trach collection bag. The trach collection bag and some of the trach collar tubing was lying in approximately 2 inches of water inside a plastic wash basin. The plastic wash basin was set in the lower drawer of the resident's bedside dresser. R510 was unable to be interviewed due to severely impaired cognition and non-verbal status. R510 did not appear to be in any distress. A review of R510's Electronic Health Record (EHR) indicated the resident had diagnoses that included anoxic brain injury (brain cell death due to oxygen deprivation) and required a tracheostomy for adequate oxygenation. According to the physician's orders dated 5/10/24, R510's trach collar orders were 5 L/ 28%. A care plan for Impaired Pulmonary/respiratory status related to tracheostomy initiated on 5/11/24 include the following interventions; Tracheostomy care per orders and as needed. On 10/2/24 at approximately 9:30 AM the Director of Nursing (DON) and Respiratory Therapist (RT) C were at R510's bedside and asked about the trach tubing lying in 2 inches of water in the plastic wash basin in the resident's bedside dresser. RT C said, It's not supposed to be like that. I don't know what happened. I did trach care earlier, and it wasn't leaking like this. Upon inspection of the resident's trach equipment RT C said the humidification setting was incorrect. RT C adjusted the humidification setting, re-adjusted the water bottle on the concentrator to stop the water from leaking out of the connection site and removed the plastic wash basin from the resident's dresser. R510's pulse oximetry was assessed and read 94 % (normal reading is 90-100%). R510 was not in any apparent respiratory distress. The DON said that if R510's trach equipment was leaking water the RT should have been notified immediately. The staff should not have just set the trach equipment inside a wash basin and let it continue to leak. It should have been addressed differently. We will be having an education immediately. According to the facility's policy for Tracheostomy Care last reviewed on 10/26/23 in part reads: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Compliance Guidelines: 1.The facility, in collaboration with the attending practitioner, must perform a comprehensive assessment of the resident's respiratory needs 3.Tracheostomy care will be provided according to the physician's orders, comprehensive assessment and individualized care plan such as monitoring for resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate 5. The facility will ensure staff responsible for providing tracheostomy care including suctioning are trained and competent according to professional standards of practice.

This citation pertains to Intake number MI00145631. Based on interview and record review the facility failed to provide Occupational Therapy (OT) sessions as ordered for one (R501) of three residents reviewed for physical rehab, resulting in missed therapy sessions and resident dissatisfaction. Findings include: On 10/2/24 at 11:10 AM R501 was observed sitting in his wheelchair in his room wearing a left palm protector. When R501 was questioned about his care in the facility R501 stated I didn't get all my OT sessions. I had surgery on my left forearm to lengthen the tendons going to my hand so that I could open my hand better. My hand isn't any better, about the same as before the surgery. R501 removed the left palm protector and demonstrated his left hand in a flexion contracture. R501 further stated I'm going to get therapy outside of this facility because they didn't do enough. Review of R501's Electronic Health Record (EHR) revealed admitted to the facility on [DATE] with pertinent diagnosis which included cerebral infarction, hemiplegia affecting left dominant side, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R501 had intact cognition. Review of R501's physician orders revealed Effective 5/16/24 OT 3-5x/week for 30 days. Review of the R501's OT evaluation revealed Frequency 3 to 5 times/week Duration 30 days Intensity Daily Cert period 5/16/24 -6/14/2024. Clinical impression/reason for skilled services: Patient recently had a surgery to fractionally lengthen his tendons on LUE (left upper extremity) 4/6/24. Patient requires PROM (passive range of motion) to stretch tendons to increase ROM and decrease risk of contractures. Patient demonstrates good rehab potential. Review of R501's OT service log revealed OT therapy provided one OT session for the week of 6/2/24 with no missed visits documented. Week of 6/9/24 resident unavailable 6/10/24, refused 6/11/24, OT provided on 6/2/24 and resident refused on 6/14/24. One session of OT was performed for the week of 6/9/24. On 10/2/24 at 12:30 PM Occupational Therapist D was interviewed and said R501 should have been seen by OT at least three times a week and there isn't a documented reason why R501 was only seen once a week. On 10/2/24 at 4:00 PM the Director of Nursing (DON) was interviewed and said therapy should be performed per orders and therapist plan of care. Review of the facility policy titled Rehabilitation Therapy and Services reviewed 1/1/22 revealed in part: . The facility is committed to providing quality therapy services .be pursuant to physician orders .be reasonable and necessary to improve a resident's current condition, to maintain the residents' current condition or to prevent or slow further deterioration of the resident's condition.

This citation pertains to intake MI00145597. Based on interview and record review, the facility failed to implement interventions for a hypoglycemia (blood glucose/sugar) for one resident (R103) out of three residents reviewed for change in condition, resulting in R103 being hospitalized for hypoglycemia. Findings include: Review of an Admission Record revealed, R103 admitted to the facility on [DATE] and discharged [DATE] with pertinent diagnosis which included End Stage Renal and Type 2 Diabetes. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R103 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15. Review of a progress note with a date of [DATE] at 2:07 p.m. revealed, At 8:05 am Resident was found by another staff member to be unresponsive. code blue started. Team started performing CPR immediately. 911 was contacted. CPR continued for about 15 minutes until EMS arrived. EMS continued CPR for about 15 minutes. resident regained the pulse. EMS transported resident to hospital. DON and unit manager made aware.MD notified. family member made aware (sic). Review of vital signs revealed, R103 had a blood glucose of 35 on [DATE] at 8:10 a.m. Review of Physician orders revealed R103 had the following orders: If blood sugar less than (70) administer OJ, Food or glucose gel per manufacturer recommendation. Recheck in 15 minutes if no improvement notify MD as needed. May obtain blood glucose as needed if symptoms of hypo/hyperglycemia & notify MD as needed Notify MD if BS less than 70 or 250 or greater. Observe resident closely for signs & symptoms of hypoglycemia and hyperglycemia Hypoglycemia Symptoms: Confusion; Dizziness; Feeling shaky; Hunger; Headaches; Irritability; Pounding heart; Racing pulse; Pale skin; Sweating; Trembling; Weakness; Anxiety Hyperglycemia Symptoms: Increased thirst; Headaches; Trouble concentrating; Blurred vision; Frequent urination; Fatigue; Weight loss. Every shift. Insulin Glargine Solution 100 UNIT/ML Inject 20 unit subcutaneously two times a day for diabetes. Review of a July Medication Administration Record (MAR) revealed R103 received Insulin Glargine 20 units given at 6:00 a.m. on [DATE]. There was no documentation for Glucagon (medication to increase blood glucose levels) administration. In an interview on [DATE] at 10:16 a.m. Registered Nurse (RN) B reported arriving to work at 7:00 a.m. on [DATE]. RN B reported R103 was found unconscious and had a low blood glucose level. RN B reported she did not give R103 any morning medications and that R103 received insulin at 5:00 a.m. from another nurse. RN B then reported they started CPR, EMS arrived and R103's pulse returned. R103 was then sent to ER. In an interview on [DATE] at 10:21 a.m., the Director of Nursing (DON) confirmed R103 had a blood sugar of 35 and received 20 units of Lantus at 6:00 a.m. The DON then reported Licensed Practical Nurse (LPN) C was the night nurse who administered the Lantus to R103 at 6:00 a.m. In an interview on [DATE] at 12:32 p.m., the DON reported the facility has a best practice medication guide that includes hypoglycemia. The DON then reported R103's blood glucose of 35 was documented at 8:10 a.m. and the EMS arrived at 8:20 a.m. The DON was asked if the nurse administered Glucagon per the diabetic protocol. The DON stated, I don't see where we gave it to her. I don't know if they had time before EMS arrived. In an observation on [DATE] at 12:34 p.m., the backup medication list was reviewed with the DON. The list revealed 2 vials of Glucagon was included in the backup medication system. In an interview on [DATE] at 12:37 p.m., RN B reported they were about to give R103 Glucagon, but EMS arrived. When asked if the Glucagon was pulled from the backup system RN B stated, No. In an interview on [DATE] at 1:19 p.m., the DON was asked about expectations for administering Glucagon for blood glucose under 70. The staff should give Glucagon if EMS has not arrived. The DON then reported the EMS usually has arrived by then. The DON reported it takes 15 minutes for Glucagon to work and stated, It probably would not have helped. Review of Hospital records dated [DATE] at 8:44 a.m. revealed, R103 arrived at the ER with a chief complaint of cardiac arrest. EMS arrived at the facility and found R103 to be hypoglycemic. Labs revealed a glucose level of 13. Review of a Diabetic Protocol with no date documented the following: If the blood glucose reading is 70 mg/dl or below, the nurse should utilize the hypoglycemic protocol per the practitioner's orders. Treatment of hypoglycemia should not be delayed before notifying the practitioner. Blood glucose (BG) less than 70 and resident is unable or unwilling to take nutrition orally, immediate action/treatment give glucagon 1mg subcutaneously, 3 mg intranasal or 1 mg intermuscular.

This citation pertains to intake MI00145283. Based on interview and record review, the facility failed to provide accurate resident identifying documents and medical records upon emergent transfer to the hospital for one resident (R101) of three residents reviewed for emergency transfer, resulting in resident identification and medical information not being sent with EMS (Emergency Medical Service) personnel to the hospital and the potential for unmet care needs upon transfer. Findings include: Review of an Admission Record revealed, R101 readmitted to the facility on [DATE] and discharged [DATE] with pertinent diagnosis which included End Stage Renal, Type 2 Diabetes and Dysphagia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R101 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 9 out of 15. Review of a SBAR Communication Form and progress note dated 6/9/24 revealed, R101 was transferred to the hospital by EMS due to mental status change and blood pressure monitoring. In an interview on 7/18/24 at 9:49 a.m., Licensed Practical Nurse (LPN) A reported when a resident is discharged to the hospital; the physician is called to get an order, SBAR is completed, the SBAR and face sheet are sent to the hospital with the resident. In an interview on 7/18/24 at 10:31a.m., the Director of Nursing (DON) reported there was a concern with R101's discharge. The DON reported two nurses worked together to send R101 to the hospital. The DON then reported one of the nurses printed out the wrong paperwork and gave it to EMS. The hospital called hours later and informed the facility that the paperwork they received had another resident's information and not R101's. In an interview on 7/18/24 at 11:23 a.m., the Nursing Home Administrator (NHA) reported a past noncompliance was completed for the incident involving R101. The NHA reported incorrect paperwork was sent to the hospital for R101. The NHA reported the paperwork went through the facility, EMS and the hospital before the incorrect information was noticed. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1. Two nurses to verify the correct paperwork, nurses to initial and a copy of the paperwork to be placed in the unit managers mailbox. 2. Face sheet with photo to be sent with transfer paperwork. 3. Charge nurse to call ER prior to transfer to give report. 4. Charge nurse to contact DON/On-Call Manger to notify of transfer. 5. All resident EMR to be reviewed to ensure a current photo is in place, as resident allows. 6. DON/Designee will audit discharge to ensure substantial compliance. Results of these Audits will be brought to the QAPI Committee for review monthly. 7. Nursing staff educated on the new process. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake number MI00144256. Based on interview and record review, the facility failed to immediately report an allegation of sexual abuse for two residents (R601and R603) of three residents reviewed for abuse, resulting in unreported allegations of abuse and the potential for further allegations of abuse to go unreported. Findings include: R601 Review of an Admission Record revealed, R601 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included anxiety, bipolar disorder, and paranoid schizophrenia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R601 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15. Review of a progress note with a date of 4/18/24 at 9:34 a.m. revealed, Writer notified that it was an reported incident from 4/17/24. Incident reported was resident was in another resident room last night around 9pm and other resident was touching her under shirt (R603) . R603 Review of an Admission Record revealed, R603 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included legal blindness, depressed mood, and adjustment disorder with mixed anxiety. Review of a MDS assessment dated [DATE] revealed R603 had no cognitive impairment with a BIMS score of 15 out of 15. The incident was reported to the SA on 4/22/24 by the Nursing Home Administrator (NHA). In an interview on 6/6/24 at 1:48 p.m. the NHA reported the incident between R601 and R603 was not reported to the SA on the day it happened because she did not feel it was not an allegation of abuse. In an interview on 6/6/24 at 2:41 p.m., the NHA reported allegations of abuse should be reported within two hours of notification. Review of an Abuse, Neglect and Exploitation policy revised 1/10/24 documented, . Reporting/Response . a. immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

This citation pertains to Intake MI00143341. Based on interview and record review, the facility failed to implement adequate interventions in a timely manner for one resident (R103) deemed to be at very high risk for pressure ulcers out of five residents reviewed for wound care, resulting in the worsening of an existing stage 4 pressure ulcer. Findings include: It was reported to the State Agency that a resident was not receiving appropriate wound care treatment. On 3/27/24 at 11:08 AM, a Concerned Family Member for Resident #103 (R103) said R103 passed away on 1/31/24 because he was not receiving adequate wound care in the facility. A copy of R103's death certificate was provided. A review of the clinical record for R103 revealed an admission into the facility on [DATE] and discharged from the facility on 1/18/24. R103's diagnoses included gastrostomy status (feeding tube), tracheostomy, end stage renal disease, local infection of the skin and subcutaneous tissue, anoxic brain damage, resistance to multiple antimicrobial drugs (MRSA), and stage 4 pressure ulcer of sacral region. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A facility document titled, Nursing Admission Evaluation, dated 1/10/24 revealed R103 was dependent upon staff for bed mobility and toileting, 2+ persons assist for transfers, and was unable to follow commands and cooperate with transfers. Further review of R103's clinical record documented the following: 1. Braden Scale for Predicting Pressure Sore Risk, dated 1/11/24, score: 8.0 - Very High Risk (score of 9 or below). Moisture: constantly moist. (Interpretation: skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.) 2. R103's hospital discharge summary dated 1/10/24 revealed the following: Wound Care Instructions: Sacrum-cleanse wound, apply skin protectant to peri wound, pack wound with Vashe (wound cleanser) moist gauze, cover with sacral adhesive foam. Change BID (twice daily) and prn (as needed). 3. R103's Skin and Wound Evaluation dated 1/10/24 revealed in part the following: Type: pressure Stage: 4: full-thickness skin and tissue loss Location: Sacrum Present on Admission Wound measurements. Length: 7.4 cm (centimeter) Width: 5.2 cm Depth: 4.5 cm % Slough: 50 % of wound filled Exudate: Moderate amount of serosanguineous Secondary dressing was to include dry dressing and silicone. A review of R103's Skin and Wound Evaluation dated 1/17/24 documented a significant increase in the size of the resident's sacral wound in seven days. 4. R103's Skin and Wound Evaluation dated 1/17/24 revealed in part the following: Type: pressure Stage: 4: full-thickness skin and tissue loss Location: Sacrum Present on Admission Wound measurements: Length: 12.3 cm Width: 13.1 cm Depth: 5.2 cm % Slough: 60 % of wound filled Exudate: Moderate amount of serosanguineous Secondary dressing was to include foam dressing and silicone. Review of R103's care plans documented in part the following: 1. Focus: Resident has episodes of bowel incontinence related to generalized weakness, impaired mobility, depression, diabetes, diuretic use, functional incontinence, unable to feel urge to have BM (bowel movement), unable to verbalize need to toilet. Date Initiated: 1/12/2024. Interventions: Administer medication as ordered. Assist resident with toileting needs. Check at regular intervals and change as needed. Initiated 1/12/24. Resident's family request that his brief be open and not fastened while in bed. Initiated 1/18/24. 2. Focus: Resident is at risk for impaired skin integrity related to confined to a bed all or most of the time, diabetes, impaired cognition, incontinent of bowel, needs assistance with Activities of Daily Living, receiving dialysis, requires staff assistance to reposition, cancer diagnosis, chronic end-stage renal disease, depression, edema, uses devices that can cause pressure (oxygen/trach tubing, indwelling catheter tubing, feeding tube). Date Initiated: 1/11/2024. Interventions: Apply protective barrier cream after incontinent episodes. Administer medications as ordered. Assist resident with turning and repositioning as needed. Initiated 1/11/24. 3. Focus: Resident has impaired skin integrity as evidenced by: (Stage 4 to sacrum present upon admission) related to confined to a bed all or most of the time, diabetes, impaired cognition, incontinent of bowel, needs assistance with Activities of Daily Living, receiving dialysis, requires staff assistance to reposition, cancer diagnosis, chronic end-stage renal disease, depression, edema, uses devices that can cause pressure (oxygen/trach tubing, indwelling catheter tubing, feeding tube). Date Initiated: 1/11/2024. Interventions: Administer treatment(s) per orders. Apply protective barrier cream after incontinent episodes. Assist resident with turning and repositioning as needed. Initiated 1/11/24. Low air loss mattress. Initiated 1/12/24. During an interview and record review on 3/27/24 at 2:45 PM, Wound Care Nurse, Licensed Practical Nurse (LPN) C said R103 was admitted with a sacrum wound. LPN C stated, The family was very intent on the wound being cleaned and remaining clean. We treated his sacral wound as we would normally do. I spoke with the family a lot while he was here. LPN C added if anything was wrong with the dressing integrity after a resident with a sacral wound had a bowel movement the dressing needed to be changed. The following documents for R103 were reviewed with LPN C: January 2024 Medication Administration Record (MAR), January 2024 Treatment Administration Record (TAR), nursing progress notes, and Certified Nurse Aide (CNA) documentation of R103's bowel movements. A review of the January 2024 MAR documented the following orders: 1. Dakins (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) (a wound care solution). Apply to sacrum topically one time a day for wound care. Start date: 1/11/24. Discontinue date: 1/17/24. This sacral dressing change was administered at 9:00 AM on the following dates: 1/11/24, 1/12/24, 1/13/24, 1/14/24, 1/15/24, 1/16/24, and 1/17/24. None of these scheduled dressing changes were documented as administered by Wound Care Nurse, LPN C. 2. Dakins (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite). Apply to sacrum topically one time a day for wound care cleanse with wound cleanser pat dry apply iodosorb gel (an antimicrobial gel) to peri wound and pack Dakins soaked gauze into wound in a wet to dry manner cover with silicone border. Start date: 1/18/24. Discontinue date 1/19/24. This sacral dressing change was administered at 1:30 PM on 1/18/24. A review of R103's nursing progress notes documented additional dressing changes occurred on the following dates and times: 1/11/24 at 7:39 PM, 1/13/24 at 3:38 PM, 1/14/24 at 8:22 AM, 1/15/24 at 12:45 AM, 1/15/24 at 6:50 AM, 1/16/24 at 9:10 AM, and 1/16/24 at 5:58 PM. Through review of documentation the dressing changes on 1/13/24 and 1/14/24 were not performed by the wound care nurse. According to LPN C, the prn dressing changes should have been documented on the TAR or MAR and they were not. According to CNA documentation, R103 had a diarrheal bowel movement on 1/12/24 at 2:54 PM. LPN C stated, We don't have any documentation to support that his dressing was changed at that time. As a wound care nurse, I would expect his dressing to be changed because of the watery diarrhea. I'm 100% sure that his dressing was changed. I know it wasn't documented. It needed to be documented. A medium size bowel movement was recorded on 1/18/24 at 1:57 AM. The only dressing change recorded on 1/18/24 was at 1:30 PM. LPN C said the silicone foam was a waterproof bandage, and the integrity of the bandage would remain intact even if the resident experienced diarrhea. LPN C said she always used the silicone foam when she changed R103's dressing even if it was not on the wound care order. The addition of the silicone foam was not added to R103's orders until 1/18/24. An interview and record review were conducted with the Director of Nursing (DON) and LPN C on 3/28/24 at 11:17 AM. A review of R103's hospital discharged orders included: Sacrum-cleanse wound, apply skin protectant to peri wound, pack wound with vashe moist gauze, cover with sacral adhesive foam. Change BID and prn. LPN C indicated that Dakins and vashe are similar and sacral adhesive foam was a silicone foam. LPN C stated, Our first (wound care) order was incomplete because it left off the (silicone adhesive) barrier. The packaging for the silicone foam dressing was reviewed and indicated it was for the management of exuding wounds (wounds leaking fluid). On 3/28/24 at 11:40 AM, when Physician M was queried why R103's wound care order was changed from twice daily to once daily, he stated, I usually don't change the order on wound care (from the hospital). Physician M added it might have been a default order. On 3/28/24 at 12:51 PM, the DON provided documentation that indicated a silicone dressing was used as a treatment for R103 on 1/17/24. The DON acknowledged that the silicone dressing was not added to R103's wound care order until 1/18/24. The DON said the wound care nurse did not complete all R103's dressing changes. On 3/27/24 at 12:30 PM, a document titled, Certification of Vital Record and Certificate of Death, dated 2/8/24 was reviewed and revealed in part the following: -Decedent's Name: (R103) -date of death : 1/31/24 -Enter the chain of events - diseases, injuries, or complications - that directly caused the death: (a.) Septic Shock - Approximate interval between onset and death: days (b.) Infected Sacral Decubitus Ulcer - Approximate interval between onset and death: 14 days -Manner of death: Natural The Death Certificate designated the approximate beginning of the chain of events that led to R103's death as 1/17/24. A review of the facility policy titled Pressure Injury Prevention and Management, dated 1/1/22, documented in part the following: - The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. - Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). On 3/28/24 at 1:00 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

This citation pertains to intake MI000132679 and MI00136138. Based on interview and record review the facility failed to assess, monitor abnormal skin condition, and implement interventions to prevent the development and worsening of pressure ulcers for two (R411 and R421) of six residents reviewed resulting in R411 developing a Stage 3 pressure ulcer {Full-thickness loss of skin, in which adipose/fat is visible in the ulcer and granulation tissue and rolled wound edges are often present with visible slough (wet/filmy yellow dead cells/tissue) and/or eschar (dry black dead cells/tissue)} that required hospitalization and R421 developing an infected and worsening unstageable sacral wound. Findings include: R411 The State Agency received a complaint that the resident developed a pressure ulcer of the coccyx/sacrum that required hospitalization while residing in the facility for Covid-19 management. According to R411's closed Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included Covid-19 virus. A Braden Scale assessment on 10/7/22 identified R411 as being 'at risk' for developing pressure ulcers. On 10/8/22, R411's initial skin assessment documented 'yes' to a skin condition of the 'coccyx' area. No other description of the skin condition was provided on the skin assessment form. A progress note dated 10/8/22 indicated there was 'redness' to the coccyx area. No measurements were documented. The Minimum Data Set (MDS) dated [DATE] indicated R411 did not have any pressure ulcers. On 10/10/22 a Pressure Ulcer care plan was initiated and included the following interventions: monitor/document/report PRN any change in skin status; appearance, color, wound healing, s/sx signs/symptoms) of infection, wound size (length x width x depth), stage, and skin inspections by CNA (certified nurse assistant) during cares and showers/baths. Report changes to licensed nurse immediately. On 10/14/22 a weekly skin assessment form documented an 'abnormal area' to the skin with no further description. There was no documentation to indicate the Physician was notified of the 'abnormal area'. The Nurse Practitioner's Progress notes dated 10/13/22 and 10/17/22 indicated there were no skin concerns or skin treatments prescribed to R411's coccyx area. On 10/19/22 the Wound Care Physician's note indicated R411 had a Stage 3 pressure ulcer on the sacral area that measured: 3.2cm (centimeter) x 5.3 cm x 0.2 cm. Skin treatments were prescribed daily and as needed (prn) and a Low-Air-Loss (LAL) mattress was recommended. There was no additional documentation to support that the LAL Mattress was applied to the resident's bed. The Treatment Administration Record (TAR) documented the prescribed skin treatments were administered daily. There were no revised interventions to the care plan to include the LAL mattress application. On 10/26/22 the Wound Care Physician's note indicated R411's sacral pressure ulcer changed to a Deep Tissue Pressure Injury and measured: 9.0cm x 6.5 cm x Indeterminate depth with 80 % necrotic (blackened/dead) tissue. New skin treatments were prescribed, and a LAL mattress was recommended. There was no additional documentation to support that the LAL Mattress was applied to the resident's bed. The TAR documented the prescribed skin treatments were administered daily. On 10/29/22 a progress note indicated R411 was transferred to the hospital for 'necrotic wound' on his sacral area. On 8/23/23 at 1:30 PM the facility's Wound Care nurse, Licensed Practical Nurse (LPN) A reviewed R411's EHR and said the resident's coccyx/sacral area was compromised upon admission but acknowledged there was no description of the area or preventative skin treatments prescribed for the area until 10/19/22 (12 days after admission). LPN A could not provide any documentation to support the Wound Care team had been notified of R411's 'abnormal area' on 10/14/22 or if the LAL mattress had ever been applied to R411's bed. LPN A said if a LAL mattress was ordered it would be on the TELS system (software/management platform for maintenance orders). On 8/23/23 at 4:10 PM LPN A said she reviewed the TELS orders for this time frame and could not produce any order or documentation to support that R411 to had a LAL mattress. 34901 R421 It was reported to the State Agency that a resident did not receive appropriate care resulting in worsening of a bedsore. A review of the clinical record documented Resident #421 (R421) was initially admitted to the facility on [DATE]. During the current year, 2023, R421 had the following discharges and readmissions: readmit 1/28/23 - discharge 3/5/23; readmit 3/11/23 - discharge 3/17/23; readmit 3/20/23 - discharge 5/3/23; readmit 5/8/23 and final discharge 7/21/23. R421's diagnoses included Parkinson's Disease and hemiplegia/hemiparesis. A MDS assessment dated [DATE] documented severe cognitive impairment and total dependence on 2+ persons for bed mobility and transfers. A wound note of 3/23/23 documented MASD (moisture-associated skin damage: skin erosion caused by prolonged exposure to a source of moisture such as urine, stool perspiration) left buttock. Size: 1.2 cm x 0.9 cm x 0. Responsible party notified. Additional wound notes documented the following: 7/5/23: MASD sacrum: Area (A) 4.5 cm x Length (L) 2.41 cm x Width (W) 2.47 cm x Depth (D) 0.3 cm. 7/12/23: MASD sacrum: A 3.32 x L 2.16 x W 2.2 x D 1.5. 7/18/23: Infection of intervertebral disc (pyogenic) sacral and sacrococcygeal region noted. 7/19/23: pressure injury unstageable sacrum: A 3.91 cm x L 1.8 cm x W 2.67 cm x D 1.6 cm. Max undermining 4.5 cm. A review of R421's July 2023 Treatment Administration Record (TAR) revealed wound care for R421's buttock/sacrum wound stopped on 7/12/23 and was resumed on 7/20/23. - Cleanse area with normal saline. Pat dry. Apply Dermseptin every shift and prn (as needed) to sacrum, cover with bordered foam one time a day for wound care. End date 7/12/23. - Cleanse with wound cleanser. Pat dry. Apply medihoney (wound care dressing) and dermablue with silver (a wound care dressing) as directed to left/right buttock wound. Skin barrier wipe to peri wound. Cover with bordered foam one time a day for wound care. End date 7/12/23. - Sacrum and Coccyx 3 views ** Sent for Imaging 7/18/23 5:11 PM ET ** one time only related to Infection of intervertebral disc (pyogenic), sacral and sacrococcygeal region (M46.38) rule out possible infection to sacrum area. Start date 7/18/23. The TAR did not document that this dressing was provided. - Cleanse with wound cleanser. Pat dry. Apply collagen wound filler at base pack with Calcium Alginate rope and Medihoney as directed to Sacrum. Skin barrier wipe to peri wound. Cover with bordered foam as needed for wound care. Administer PRN. Start date 7/19/23. The TAR did not document that this dressing was provided. - Cleanse with wound cleanser. Pat dry. Apply collagen wound filler at base pack with Calcium Alginate rope and Medihoney as directed to Sacrum. Skin barrier wipe to peri wound. Cover with bordered foam one time a day for wound care. Start date 7/20/23. During an interview and record review on 8/24/23 at 1:53 PM, the Director of Nursing (DON) said dermatitis (MASD) can eventually break the surface of the skin. According to the facility's policy 'Pressure Injury Prevention and Management' revised on 1/1/2022 revealed in part the following; the facility is committed to the prevention of avoidable pressure injuries and the promotion of existing pressure injuries 3. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment, using the [NAME] or Braden tool on all residents upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly. b. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. c. Assessments of pressure injuries will be performed by a licensed nurse, and documented in the medical record. d. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after task. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. iii. Provide appropriate, pressure-redistributing, support surfaces. iv. Maintain or improve nutrition and hydration status, where feasible f. Interventions will be documented in the care plan and communicated to all relevant staff.

This citation pertains to intake MI 6730. Based on observation, interview and record review the facility failed to provide adequate supervision during resident's smoking sessions, affecting one resident (R#1) out of three residents reviewed for smoking session protocols, resulting in R#1 acquiring a second degree burn to forehead. Findings Include: On 2/23/21, record review revealed R#1 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE], R#1 had intact cognition and was extensive assist with Activities of Daily Living (ADLS). Record review of facility's Past Non-Compliance Checklist documented Receptionist took the residents out to smoke at their scheduled time. The phone rang. Receptionist handed resident R#9 the lighter. Resident lit R#1's cigarette. R#1's hair was up; however, she had a couple of loose strands hanging down. As the cigarette was being lit wind blew the loose strands of hair into the flame of the lighter, catching them on fire. The flames were quickly extinguished. R#1 sustained two [MEDICAL CONDITION] her forehead. Record review of smoking care plan intervention initiated on 1/20/16 documents R#1 requires supervision while smoking. Review of Statement of Witness by R#9 documents Receptionist A gave me the lighter and I lit R#1's cigarette. When I lit it, wind blew, and blew her hair into the lighter. Review of NP/PA Progress Notes dated 2/24/21 documented . Second degree burn site evaluated right forehead. On 2/23/21 at 1:30 pm. R#1 observed with a second degree (partial thickness) burn to forehead. During interview with R#1 when asked if R#9 had lit her cigarette, R#1 nodded yes. When asked if Receptionist A had left to answer the phone, R#1 nodded yes. When asked did your hair catch on fire, R#1 nodded yes. When asked if that was the reason there was a burn on forehead, she nodded yes. On 2/24/21 at 9:30 am, during interview with Administrator (ADM), when asked during smoking sessions should there always be direct supervision provided. ADM stated, Yes. When asked during smoke sessions should supervision leave to answer a phone, ADM stated, No. When asked if other residents should light each other's cigarettes, ADM stated, No. When asked of R#1 received a burn to right forehead, ADM stated Yes. On 2/24/21, record review of Smoking Policy- Smoking Campus- Residents revised 10/30/20 documented It is the policy of this facility to establish and maintain safe resident smoking practices. This policy also includes electronic cigarettes. This policy is used to educate residents and representatives. Smoking Times- 1. The facility shall provide reasonable means (i.e., assigned smoking times) for the provision of direct supervision to those residents wishing to smoke.

This citation pertains to intake number MI 402. Based on interview and record review, the facility failed to care plan and ensure respiratory equipment was in use for one (#301) of three sampled residents reviewed for respiratory care, resulting in development of respiratory distress, and exacerbation of [MEDICAL CONDITION] and [MEDICAL CONDITION] due to [MEDICAL CONDITION] (low oxygen level) requiring emergency hospital treatment and admission. Findings include: The complainant reported to the State agency that resident #301 was not provided oxygen resulting in respiratory compromise and hospitalization . On 1/15/20 at 1:30 PM, clinical records were reviewed for resident #301 as follows: The resident was admitted into the facility on [DATE] following hospitalization since 10/9/19 for acute [MEDICAL CONDITION]. Other [DIAGNOSES REDACTED]. The resident's hospital History and Physical noted the resident had arrived there with severe shortness of breath. He was placed on a [MEDICAL CONDITION] machine (a device that delivers pressurized air through a mask into the airway to keep the throat muscles from collapsing and obstructing the airway) in the Intensive Care Unit for exacerbation of [MEDICAL CONDITION]. The Continuing Patient Care Transfer Record, which was faxed to the facility on [DATE] by the hospital Case Manager before the resident's arrival, listed the resident's discharge medications and plan of care including: oxygen 4 liters nasal cannula (prongs inserted just inside the nostrils), [MEDICAL CONDITION] at (nighttime). Per the facility Nurse Admission assessment dated [DATE], the resident was alert, oriented to person, place, time and situation and receiving nasal oxygen with no respiratory distress noted. At 3:48 PM that day, the resident's oxygen level was 94% (normal range=95-100%) on nasal oxygen and a pulse of 94. On 10/24/19 at 5:33 AM, the level was recorded at 95% on oxygen and pulse of 88. According to the resident's medication record, a scheduled [MEDICATION NAME] breathing treatment was given at 6 AM on 10/24/19. At 8:28 AM, per a SBAR (acute change in condition) Communication Form: The resident had a decreased oxygen level of 74% while noted to be on oxygen at 4 liters, pulse 114, shortness of breath and appeared more confused; Wheezing noted Scheduled breathing treatment administered prior to shift change. 911 called. The fire department (EMS) arrived and noted in their Patient Care record (run sheet) at 8:50 AM: Primary Impression-Acute respiratory distress (dyspnea), pulse 118, 85% oxygen level. Upon arrival his oxygen was not turned on. At 8:52 AM, an oxygen mask was applied and run at 10 liters. The oxygen level was then 94% and pulse increased to 120. The resident's skin appeared cyanotic (blue-ish discoloration due to low oxygen) and rales (rattling) present to lungs. Per hospital emergency department (ED) notes: EMS reports that upon their arrival, patient had nasal cannula in his nose but that 'it was not hooked up.' Patient normally wears 3 liters at home; Upon arrival patient is wheezing bilaterally, tachypneic (rapid respiratory rate), using accessory muscles (muscles contributing to breathing, typically used only during respiratory dysfunction). He is placed on [MEDICAL CONDITION]. The resident was noted as being oxygen dependent by history. An Internal Medicine specialist wrote: Patient was discharged yesterday from hospital, went to the nursing home. They did not have him on [MEDICAL CONDITION]. Patient came back very short of breath, hypoxic, was started on [MEDICAL CONDITION]. An Infectious Disease specialist saw the resident in the ED and noted: Rhonchi (continuous rattling lung sound), shortness of breath most likely a combination of [MEDICAL CONDITION] exacerbation/Pulmonary vascular congestion, doubt pneumonia after review of chest X-ray results and antibiotics to treat pneumonia were discontinued. The [MEDICAL CONDITION] specialist noted: This patient came into the hospital with [MEDICAL CONDITION], distress and congestion and [MEDICAL CONDITION] In the nursing home, they had no equipment for him. They just had oxygen. They did not have any [MEDICAL CONDITION] machine Patient had a high lactic acid level (a buildup when there is not enough oxygen in muscles) when he came in, but it is normal now. Past medical history included, [MEDICAL CONDITIONS] and oxygen dependence. [MEDICAL CONDITION], was the resident's [DIAGNOSES REDACTED]. At 2:30 PM, the hospital Case Manager was queried by phone and said, I faxed the paperwork (Transfer Record) to the nursing home with info about the [MEDICAL CONDITION] machine. I spoke to (a former admission employee) and she said she got the fax and to send him over because she was ordering it and it would be there for when he was ready to use it that night. She said, I called and found out from her that the (medical equipment) supplier didn't deliver it and he was sent back to the hospital. I called their corporate (office) and complained and spoke to (the facility liaison). They told me he was okay to send. At 3 PM, the Admission Director said, I ordered the [MEDICAL CONDITION] (the morning of 10/23/19). It didn't come in. She said there was usually a four hour turnaround time for delivery and the supplier did not give an explanation why the device did not come. She said, It was supposed to be here for that night. At 3:40 PM, the resident's clinical record was then reviewed with the Director of Nursing (DON). When asked to see the orders for the oxygen and [MEDICAL CONDITION], the DON looked for it and said, I don't see it. There's no settings for the [MEDICAL CONDITION]. She saw nasal oxygen at 4 liters and [MEDICAL CONDITION] at night in the hospital Continuing Care Transfer Record and said, The orders should have been followed. When asked to see a care plan that addressed oxygen and [MEDICAL CONDITION] use, the DON looked at all the care plans and found two titled, Shortness of Breath and Altered Respiratory Status/Difficulty Breathing both initiated 10/23/19, however, they did not mention oxygen and [MEDICAL CONDITION] as interventions. The DON said, It should have been on the care plan. She said that she was not on staff at the facility when the situation occurred. I heard about (the missing [MEDICAL CONDITION]) from (the Admissions Director) but I didn't hear about the oxygen not being on. On 1/15/20 at 5 PM, per review of the facility's Oxygen Administration policy dated 7/2013: Verify that there is a physician's order Review the resident's care plan Before administering oxygen, and while the resident is receiving oxygen therapy, verify the physician order requirements Check the tubing connected to the oxygen cylinder or concentrator to assure that it is free of kinks. Turn on the oxygen Place the appropriate oxygen device on the resident (i.e., mask, nasal cannula ). The facility's [MEDICAL CONDITION]/[MEDICAL CONDITION] policy dated 3/22/11 noted: Purpose-To provide the spontaneously breathing resident with continuous positive airway pressure with or without oxygen. To improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. To promote resident comfort and safety Review the physician's order

Based on observations, interviews, and record review the facility failed to provide care and services according to standard of practice for one of six residents (#63) reviewed for indwelling urinary catheters resulting in R#63 not having a physician's order for an indwelling catheter, not receiving appropriate care for the catheter, developing a urinary tract infection [MEDICAL CONDITION], and not receiving the prescribed treatment for [REDACTED]. During an observation on 8/20/18 at 12:20 PM, R#63 was resting in bed with an indwelling urinary catheter (foley) that was not secured or anchored to the resident's upper thigh area. The urine in the collection bag was cloudy dark amber. The resident complained of back pain and requested a pain medication from Nurse 'C'. Nurse 'C' was asked about the foley not being anchored to the resident thigh. Nurse 'C' said that it should be secured and will obtain a leg strap. A medical record review is conducted and reveals that R#63 admitted to the facility on [DATE]. The Minimum Data Set ((MDS) dated [DATE] indicates that the resident is always incontinent of urine, and does not have a foley catheter. A 'discharge assessment' MDS, dated [DATE] indicated that R#63 had a foley catheter. A review of the medical record did not reveal a physician's order for the foley catheter, nor was there a care plan. A review of the treatment administration record (TAR) from, revealed there was no documentation to support that any care had been provided for the resident's foley catheter. The review of R#63's progress notes are as follows: - 7/9/2018 at 8:16 PM Nurses' Notes Text: 14fr (french) foley placed per wound care doctor, to decrease the urine in the wounds. There was no corresponding physician's order. - 7/22/18 at a urinalysis reports positive for bacteria in R#63's urine. There is no corresponding physician's order for the urine sample. There was no documentation to support the physician was notified of the results. - 7/26/18 at 5:58 PM, new 16 french foley placed, small clot noted in foley catheter line, so entire circuit was changed. Urine is draining yellow. There is no corresponding physician's order. - 7/27/18 at 4:27 PM; bloody urine in Foley bag, physician notified, ordered to flush until clear. There was no corresponding physician's order, or additional documentation by the physician, or the physician extender. - 8/3/18 at 2:07 PM; Pertinent Charting-Infections/Signs Symptoms Note Text: Site of originally identified infection: UT/sepsis. [MEDICATION NAME] (antibiotic) 750 mg qod (every other day) until 8-7-18. Keflex (antibiotic) 500 milligrams bid (twice a day) x 10 days (for 10 straight days). - 8/13/18 at 10:32 AM transcribed by Nurse Practitioner; urine is 'milky in appearance'. There was no follow-up documentation. A review of the Medication Administration Record [REDACTED]. The resident only received three of the 20 doses prescribed (8/3/18 at 9:00 AM and 9:00 PM, and 8/13/18 at 9:00 PM) On 8/21/18 at 8:08 AM, R#63 is laying in high fowlers, the foley catheter does not have anchor securing it to his thigh. Nurse 'F' is asked about the foley not being secured/anchored to the resident's upper thigh area. Nurse 'F' said that the foley should be secured and will obtain a leg strap. On 8/21/18 at 1:53 PM, The Assistant Director of Nursing (ADON) confirms that there is no physician's order for R#63's foley, and no care plan. On 8/21/18 at 3:12 PM, the ADON confirmed that R#63 had a urinalysis on 7/22/18 that indicated the resident was positive for a UTI, but no antibiotics were prescribed for the UTI until 8/3/18. The ADON also confirmed that the antibiotic that was prescribed was given incorrectly. The resident only received three of the prescribed 20 doses. The ADON said the Physician was notified and a second urinalysis was obtained today, and the resident's temperature was being monitored for fever. During an interview on 8/22/18 at 10:32 AM, the physician said the antibiotic prescription was for 10 consecutive days. The Physician said the antibiotic was not administered according to 'standard of practice'. According to the facility's 'Indwelling catheter insertion, female resident policy, the only policy regarding indwelling catheters provided to the survey team, by the ADON on 8/22/18 at 1:24 PM reads as follows: - 1. verify there is a physician's order for this procedure. The order should include,,routine care of the catheter, and orders for changing. -2. review the resident's care plan. -48 tape catheter to the inner thigh or secure with leg strap.

Based on interview and record review the facility failed to timely implement Contact Precautions (Transmission based measure implemented to a resident known or suspected to be infected with a microorganism that can be transmitted by direct contact with other residents or indirect contact with environmental surfaces) for one sampled resident (#505) with a [DIAGNOSES REDACTED]. Findings include: R#505. Record review revealed that R#505 was admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented the residents cognition was severely impaired and required extensive two person staff assistance for all activities of daily living. Review of a skilled daily note dated 5/27/18 documented, Bowel/Gastrointestinal (GI). Bowel sounds present, diarrhea. Need a stool specimen for c.diff the next time patient has a bowel movement (bm). Review of a laboratory result dated 5/27/18 (13 days after re-admission back in to the facility) documented, Specimen Description Result; C.difficile [MEDICATION NAME] Positive, Toxin Positive. [DIAGNOSES REDACTED]icile present, toxin present. A physician's orders [REDACTED]. diff. test results) documented, Isolation precautions for all encounters with patient due to positive [DIAGNOSES REDACTED]. diagnoses. R#510. Record review revealed that R#510 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] documented the residents cognition was intact and required extensive two person staff assistance for all activities of daily living. R#510 resided in the room directly adjacent to R#505. Review of a document titled, Evaluation of Bowel assessment dated [DATE] (7 days after admission in to the facility) documented, [DIAGNOSES REDACTED]. Review of a laboratory result for [DIAGNOSES REDACTED] with a collection dated 5/28/18 and reported results 5/29/18 (2 days after R#505 was [DIAGNOSES REDACTED]. diff. A physician's orders [REDACTED].#510's contact precautions were implemented (1 day after [DIAGNOSES REDACTED]. specimen was collected not on first symptomatic day). R#509. Record review revealed that R#509 was admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] documented the residents cognition was intact and required extensive one person staff assistance for all activities of daily living. R#509 resided in the room next to R#505. Review of a laboratory result for [DIAGNOSES REDACTED] with a collection dated of 5/29/18 and reported results dated 5/30/18 (3 days after R#505 was [DIAGNOSES REDACTED]. diff. Toxin Positive. A physician's orders [REDACTED].#509's contact precautions were implemented (1 day after [DIAGNOSES REDACTED]. specimen was collected not on first symptomatic day). On 5/6/18 at 11:30 AM, the Infection Control (IC) Nurse F was queried regarding the [DIAGNOSES REDACTED] for R#'s 505, 509 and 510. Along with Nurse F, a document titled, Line listing of Resident infections for (MONTH) (YEAR) was reviewed. Nurse F stated, I believe (R#505 had a Urinary tract infection [MEDICAL CONDITION] and was on an antibiotic for a long time. Being on an antibiotic will kill off normal flora (bacteria) in the intestinal system and makes the resident more susceptible to [DIAGNOSES REDACTED]. Nurse F was asked about the facility's policy and procedure on Contact precautions and [DIAGNOSES REDACTED]. Nurse F stated that when a resident is suspected (example: having loose, watery stools) to have [DIAGNOSES REDACTED] the nurse should implement transmission based precautions (isolation) right away to keep the potential infection from spreading. Nurse F could not explain why R#505 was not placed in to contact isolation until 3 days after symptoms of diarrhea were identified. The IC nurse also said that R#509 is R#505's wife and that they share an adjoining room and have been in contact with each other during this time period. When asked about R#510, Nurse F stated, He in the same hallway in an adjacent room. I'm sure all these [DIAGNOSES REDACTED] infections are linked. On 5/6/18 at 11:40 AM -during an interview with the facility's Director of Nursing (DON), she was asked about the procedure when a resident displayed symptoms of [DIAGNOSES REDACTED]. The DON said the nurse should contact the doctor and get an order to test the stool for [DIAGNOSES REDACTED] and obtain a contact precaution order as a precautionary measure until the test results are confirmed. Review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions dated 2/22/11 documented, In addition to Standard Precautions (overall approach to preventing transmission of communicable diseases), implement Contact Precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Examples of infections requiring Contact Precautions include, but are not limited to: .(2) Diarrhea associated with [MEDICAL CONDITION].

Based on interview and record review, the facility failed to provide adequate supervision for one (#801) of four residents reviewed for falls, resulting in a displaced right femoral fracture . Findings Include: On 4/26/18 at 12:30 P.M., A review of the Facility's Incident Report/ Investigation Report documented on (MONTH) 3, (YEAR) at 7:30 P.M. R#801 was found on the floor in front of her wheelchair. The report indicated R#801 had sustained an unwitnessed fall in the Dining Room. Resident #801 complained of upper right thigh pain and was given two Extra Strength Tylenol. At 8:45 P.M. The physician was notified and a stat x-ray of the resident's hip and right knee were ordered. On (MONTH) 4, (YEAR) the local hospital informed the facility R#801 had sustained a mildly displaced femoral fracture. According to the Investigation, which was completed by Nurse D, R#801 was sitting upright on the floor with her back against the front of the wheelchair. The Fall Summary indicated the resident was found on the floor in the Dining Room. under the #6 Question, the investigation stated, R#801 was alone and unattended. ( Not Supervised). Review of the Admission Record for resident #801 documented the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], R#801 had severely impaired cognition and required extensive assistance with one person physical assist. Review of the care plan dated 1/18/2016, documented The resident is at risk for falls related to unaware of safety needs, poor communication/comprehension, wandering, history of falls. Interventions R#801 needs a safe environment with even floors free from spills and/or clutter: adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach *Provide activities of interest * The resident needs activities that minimize the potential for falls while providing diversion and distraction (has an activity bag for recreational distraction). There was no further interventions addressing the safety and supervision of the resident. Review of the Statement of Witness dated 4/3/18, indicated kitchen staff were present at the time of the incident cleaning the dining room, however the identity of these individuals were not documented. Nursing Staff and Administrative Staff involved in the investigation and witness of the incident were not available or made available for interview. On 4/26/18 at 6:40 P.M., the current Director of Nursing had no information to offer regarding R#801's fracture.

This citation refers to intake #s MI 708 and MI 350. Based on observation, interview and record review the facility failed to implement supervision and safety devices to prevent falls for five sampled residents (#'s 603, 610, 611, 621, and 625) out of 12 residents reviewed for falls from a total sample of 26, resulting in multiple resident falls and falls with major injury (fractured ribs, hip and finger). Findings include: Resident #610 On 7/11/17 at 2:30 p.m., R#610 was observed in a wheel chair in the hallway outside of her room. At this time R#610 was asked if she had any falls while residing in the facility. The resident responded by saying that she get weak and dizzy when she try's to stand up, but she could not remember having any falls. On 7/11/17 at 4:20 p.m., record review revealed that R#610 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was moderately impaired and required limited, one person assistance for transfers. The Fall Risk Evaluation dated 4/3/17 scored R#610 at a 14-Interventions Required. Review of the Fall care plan dated 5/12/16 had interventions of; bed in low position at all times, call light within reach at all times, non-skid socks/shoes, bed side mat to left side of bed, when in bed, keep resident in common area when unattended by staff, as tolerated, anti-tipper to wheel chair, Bedside mat to left side of bed, when in bed . Review of incident and accident reports: - 3/5/17 documented, Patient went to sit back in wheel chair after standing at bedside folding cover back on bed, wheel chair unlocked and rolled from under resident, sat on floor. Root cause: Patient forgetting to lock wheel chair prior to standing, unsteady gait and balance due to right sided weakness. Interventions: Remind patient to lock wheel chair before rise/transfers call for assistance with making bed. Education provided to ask for assistance, lock wheel chair. Fall care plan intervention added; anti roll back to wheel chair. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Physical Therapy (PT) approved days for PT 3 times a week for 12 weeks. - 4/3/17 documented, Bruise noted to right knee. When asked resident what happened she stated that she fell a couple of days ago going to the bank. Root Cause: Transferring self without assistance from staff. Interventions: Educate patient to use call light and get assistance from staff before transferring self. Fall care plan interventions added; No new safety interventions were added to the care plan. - 4/4/17 documented, Resident noted laying on floor on left side stated she fell . Noted lump on back of head, left lateral side. Resident alert .Unaware she was lying on floor. Root cause: Resident attempting to self transfer and lost balance and fell to floor. Interventions: Resident educated on use of call light and one person assist from nursing staff .Resident is spontaneous, unpredictable, impulsive with poor safety awareness. Often will not allow assistance with activities of daily living (ADL's). Send to hospital due to mental status changes. Upon return add wheel chair alarm. Review of the hospital record document titled, CT Thorax final results: #2. Acute appearing fractures involving the anterior right fourth through seventh ribs and anterolateral left fourth through sixth ribs . On 7/12/17 at 4:23 p.m., the facility's Director of Nursing (DON) along with Unit Manager (Nurse B) and was asked about the falls and safety interventions for R#610. The DON said that she investigated the incident on 4/3/17 and determined (R#610) bumped her knee on the bed (despite the resident stating fell a couple of days ago going to the bank) and no new interventions were added to the fall care plan. Nurse B was asked how a resident with a [DIAGNOSES REDACTED]. I must have thought education was an appropriative intervention. I see now that she was confused and may not have been able to retain that information. Resident #625 On 7/14/17 at 10:20 a.m., record review revealed that R#625 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was severely impaired and required limited, one person assistance for transfers. The Fall Risk Evaluation dated 6/1/16 scored R#625 at a 14-10 or higher is at risk. Review of the Fall care plan dated 6/2/16 had interventions of; bed in low position when not providing care, left bed against wall per resident request, resident call light within reach and encourage the resident to use it for assistance as needed . Review of incident/accident and investigation reports: -10/6/16 documented, Patient observed on floor laying on right side in doorway of bathroom. Patient stated 'I got dizzy and fell down'. Fall care plan interventions added; 3 day bladder tracking. Results; The resident has occasional bladder incontinence. No bladder program needed at this time. Further investigation revealed; 10/7/16 Pelvic x-ray results, No evidence for an acute fracture, dislocation, or acute osseous abnormality in the pelvis. 10/10/16 Nurses note documented resident complained of left knee pain and unable to bear weight on left side. X-ray of left knee negative. 10/13/16 upon assessment nurse noted resident to have increased pain. Resident verbalized left hip pain guarding left hip. New left hip x-rays ordered. Left hip x-ray results; new mildly displaced fracture involving the left superior and left inferior pubic rami (part of the pelvis), sent out to hospital for orthopedic evaluation. Review of hospital records dated 10/14/16 revealed a new [DIAGNOSES REDACTED]. Review of Interdisciplinary team notes dated 10/21/16 documented, Closed nondisplaced fracture of left ischium .3 day bladder tracking initiated upon return . Fall care plan intervention added after discovery of fracture of ischium; (a second) 3 day bladder tracking. 15 days after first 3 day bladder tracking which determined no bladder program was needed. No other safety interventions were added to the care plan. -4/21/17 documented, Resident said she fell out of wheelchair trying to get her shoe from under her bed. Resident did not acquire assistance before attempting to help self. Nurse note dated 4/23/17 Resident complained of left hand pain. Left hand swollen and discoloration to ring finger. X-ray left hand results; Fifth metacarpal (finger) representing a fracture. On 7/14/17 at 1:36 p.m., the Director of Nursing (DON) was asked about safety interventions for R#625. The DON was not able to explain why a repeat 3 day bladder tracking program was the only new intervention that was added to the Fall care plan from October 2016 to April 2017 to keep the resident safe from further falls with major injuries. Resident #611- The complainant reported in writing to the State agency that facility staff failed to secure the resident during a transfer via mechanical lift and that the resident slipped out landing on the floor. On 7/11/17 at 12:30 PM, the complainant was observed feeding the resident. The resident was alert, confused, unable to effectively communicate and was seated in a reclining wheelchair. The complainant said that the resident was being transported by one employee to bed via mechanical lift a few months ago and went straight down (fell to the floor) from the lift landing on her buttocks, which was witnessed by a family member. The resident was transported to the hospital for X-rays, which were negative for fractures and that the resident developed bruising to the lower back and tailbone area. At 3 PM, per review of the resident's clinical record and an incident report: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) completed 1/24/17 indicated that the resident had severe cognitive impairment, was non-ambulatory and required total two-person assistance for transfers. A Mechanical Lift Evaluation dated 1/8/17 noted: Two staff assistance for transfers. An Activities of Daily Living care plan revised on 8/6/16 noted an intervention: mechanical lift for transfers by two people. The incident report dated 4/1/17 noted that on 4/1/17, a nurse aide used a mechanical lift to transfer the resident from wheelchair to bed, without staff assistance and that while suspended in air, the resident fell from the body lift sling. The incident investigation noted that upon inspection, there was no malfunction of the mechanical lift. The investigation revealed a statement from the nurse aide who was present during the fall: The aide said she felt pressured and intimated by the family member to rush and transfer the resident to bed without waiting for staff assistance and that while suspended in air, the resident began to slip out of the side of the sling. The root cause of the fall was noted as: visiting with family, who was in a hurry, family insistent upon transfer to bed prior to leaving. (Nurse aide) stated she would have assistance in 5 minutes, family (member) insisted she would help as she did not have 5 minutes to wait for the 2 staff required. The (aide) relented to family's insistence and allowed family to assist. The resident became agitated during descent to bed and slid from sling to floor on to buttocks. The initial root cause of the fall: agitation. Initial interventions to prevent future falls: Perhaps a different sling style with sides to prevent movement to cause fall. On 7/13/17 at 10:15 AM, when asked about the fall during the one-person staff transfer via mechanical lift, the Director of Nursing (DON) did not respond why the transfer did not occur until two staff were present. There was no documented disciplinary action or staff education for the nurse aide involved. The DON did not respond when asked why the root cause indicated that the resident and/or family member were responsible for the fall. Resident #603 On 7/12/17 at 9:00 a.m., review of the clinical record revealed R#603 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/14/17, R#603 was had some cognitive impairment (scored 11/15 on brief mental status exam), required extensive assistance of one person for most activities of daily living (ADLs) and transfers, and had one fall since the prior MDS assessment with no injury. Review of the Resident's care plans included a fall care plan initiated 1/29/16, revised 5/15/17 which read, The resident is at risk for falls r/t (related to) hemiparesis second to CVA, Gait/balance problems, medication use. Interventions included, Determine causative factors of fall and resolve or minimize 5-15-17 maintenance tag to address locks on wc; Date initiated: 01/29/2016; Revision on: 05/16/2017. Review of the incident reports provided by the facility included: On 1/18/17 at 5:00 p.m. resident was noted to be having CVA (cerebrovascular accident/stroke) s/s (signs and symptoms) - was placed in bed and while staff was calling 911 res. rolled from bed to floor . The investigation following this fall noted the Resident did not sustain injury, however was sent to the hospital for s/s of CVA. The facility did not identify whether there was any other staff present in the room (which could have prevented the Resident's fall during a change in medical status). On 5/15/17 at 3:30 a.m., Res. observed sitting upright on floor next to bed - was attempting to self transfer and states the w/c (wheelchair) slipped out from under him . The investigation following this fall noted the Resident did not sustain injury, however it was identified that the w/c had not been locked properly due to malfunctioning w/c breaks. Review of the IDT-Interdisciplinary Progress Note included: On 5/16/2017 8:44 AM, IDT met to discuss I/a .resident was attempting to self transfer from bed to wc and slipped to floor, he states his wc slid from beneath him, upon investigation it was noted his wc brakes don't completely lock on wc, a repair ticket was written for maintenance . On 5/18/17 9:07 AM, IDT met to review I/a .resident fell to floor during attempted self transfer, wc locks did not completely lock causing wc to slid from beneath res. when he attempted to sit in wc, repair tag was submitted for wc. On 7/13/17 at 12:25 p.m., Nurse Manager U was asked to review the Resident's incidents. At that time, when asked about the fall on 1/18/17 and why the Resident had been left unattended/unsupervised during a change in medical condition and subsequent fall from bed, Nurse Manager U was unable to offer any further explanation. When asked about the fall on 5/15/17, Nurse Manager U reported it was due to a faulty wheelchair brake, and was unable to offer any further explanation when asked if anyone had reported the need for repair prior to the Resident's fall. On 7/13/17 at 5:00 p.m., Maintenance Director (Staff E) was asked who monitored Resident equipment such as wheelchairs to make sure they were in safe, working condition and responded, That's a good question. If there's a problem, they should put in TELS (an internal computerized communication system). We also do rounds. At that time, Staff E was asked to provide any further documentation such as audits of rounds specific to Resident care equipment, however there was no such documentation provided by the end of the survey. Staff E did provide a TELS Work Order System which read, wc brakes don't lock right please fix . The form identified Opened Date: May 16, 2017 at 7:12 AM CT and Status: Closed. There was no date included of when this had been closed. Resident #621 On 7/12/17 at 1:20 p.m., and 7/13/17 at 8:18 a.m., R#621 was observed seated in a wheelchair at a table in the main dining room. At each observation, the Resident was seated on top of a thick wheelchair cushion, which prevented the Resident's bottom from being positioned in a negative pitch (as identified as an interventions following a fall on 5/25/17). On 7/13/17 at 1:15 p.m., Therapy Manager (Staff Q) was asked to evaluate R#621's wheelchair for the negative pitch. At that time, Staff Q reported, It's almost as if there is no pitch with the cushion. Will need to try to adjust. See that chair (another Resident's wheelchair with a noticeable decline in the wheelchair seat towards the back of the wheelchair), that's a negative pitch. On 7/12/17 at 4:30 p.m., review of the clinical record revealed R#621 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment with an ARD of 6/14/17, R#621 had severe cognitive impairment (scored 3/15 on brief mental status exam), required extensive assistance of one person for bed mobility, transfers, and ADLs, and had two falls since the previous MDS assessment with no injuries. Review of R#621's fall care plan initiated 2/23/16, revised 6/23/17 identified, (name of Resident) is at risk for falls r/t .Resident does not always use his call light or ask staff for assistance. Interventions included, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of R#621's multiple incident reports provided by the facility since September 2016 included: On 11/28/16 at 10:00 p.m., Patient had w/c a side of bed in lowest position and wanted to get to his w/c but slid onto floor . Intervention identified by the facility was res. educated to call light. On 12/24/16 at 3:15 p.m., With rounds, staff heard a sound coming from (room #), walked in room, observed resident sitting in front of bathroom toilet, and unlocked w/c at doorway of bathroom . Intervention identified by the facility was therapy referral and anti roll back to w/c. On 3/11/17 at 1:30 a.m., Res. self transferred self to toilet and when transferring off toilet to w/c res. states he fell to floor . Intervention identified by the facility was Res. to use call light for nsg staff assist and wear non skid socks when in bed. On 5/25/17 at 6:15 a.m., Obs. Resident lying on the floor next to his wheelchair at the dining room. Resident stated, I fell asleep and slid off at the wheelchair . Interventions identified by the facility included, Res. referred to therapy for w/c positioning and negative pitch to w/c (so that the Resident's bottom is positioned further back preventing the Resident from sliding forward). On 6/11/17 at 4:15 a.m., Obs. Sitting on floor next to bathroom at 4:15 am - Res. stated I want to go the bathroom . Interventions identified by the facility was Anti tippers added to back of w/c. (This intervention had already been identified following the fall on 12/24/16 and should have been in place at the time of this fall.) On 6/19/17 at 5:30 p.m., Pt. trying to self transfer from bed to chair and fell and hit right side of head (small laceration) . Interventions identified by the facility was Bed alarm placed on bed to alert staff of self transfer attempts. Further documentation included a statement of witness from Certified Nursing Assistant (CNA V) which read, I (name of CNA V), the CNA for E hall afternoons went to R#621's room to wake him up for dinner. I woke him up and he sat on the edge of the bed. I then went to go assist (roommate's name). As I was assisting (roommate's name) I heard a thud from behind me. I observed that R#621 had fallen to the floor . (The facility's fall investigation did not identify whether education had been provided to the staff that left the Resident unattended at the side of the bed while caring for the roommate, which may have prevented the Resident from falling and sustaining an injury.) On 7/13/17 at 12:00 p.m., an interview and record review was conducted with Nurse Manager B. Upon review of the multiple incident reports for R#621, Nurse Manager B confirmed the Resident had poor cognition and safety awareness. When asked about the facility's interventions which included reorienting the Resident to use the call light for assistance, Nurse Manager B acknowledged the intervention was not appropriate and when asked about why the Resident had been left unattended while seated at the side of the bed by staff, Nurse Manager B reported that should not have occurred. When asked about the duplicate intervention identified on 6/11/17 to add anti-tippers to the wheelchair when this intervention had already been identified following a fall on 12/24/16, Nurse Manager B was unable to offer any explanation. On 7/14/17 at 1:30 p.m., review of the facility's Falls-Clinical Protocol policy dated 2/2013 documented, Based on the assessment an initial plan of care will be developed and implemented to address identified risk. This will be revised as necessary .Interventions should be developed and implemented per the assessed needs .the staff will monitor and document the individual's response to interventions intended to reduce falling or the consequence of falling residents will be reviewed through standards of care at a determined time frame after new interventions are implemented to determine if effective or revision is necessary .if interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention (for example, dizziness or musculoskeletal pain) has resolved.

This citation has two deficient practices. Deficient practice #1 Based on observation, interview and record review, the facility failed to ensure a safe environment during a shower for one (#709) of seven sampled Residents reviewed for falls in a total sample of 24, resulting in a preventable fall, a skin tear to the left elbow, hospitalization for complaints of pain to the hip, ankle and wrist, significant emotional distress (expressions of fear to re-enter the shower room), and refusals of showers since the fall on 5/5/16. Findings include: On 8/29/16 at 12:00 p.m., Resident #709 was observed lying in bed and upon approach agreed to participate in an interview. When asked about whether staff have ever harmed her, the Resident stated, I fell in the shower a few months ago. I was reaching for the grab bar to turn on my side and the whole bed tipped over and I landed on the floor of the shower. See my scar (pointed to a cicatrix/scar on the left elbow)? I had to go to the hospital and I was there for two days (5/5 - 5/6/15). Thankfully I didn't break anything. But I am terrified to go back in there. I haven't been in there since. I told em only bed baths. When prompted for further details, Resident #709 reported Certified Nursing Assistant (CNA D) was the staff person who provided the shower on the day of the fall. The Resident stated, That was CNA Ds first and only time giving me a shower. I won't go back in there ever! On 8/30/16 at 2:35 p.m., an interview was conducted with CNA D who was assigned to Resident #709. When asked about the fall that occurred with Resident #709 during the shower, CNA D reported, There was an incident where she fell out (off the shower bed). She's (Resident #709) gonna tell you she only wants a bed bath now. When you ask her for a shower, she'll tell you No. When I put her in the shower she grabbed and the whole shower bed fell over when she was reaching and she went down. Even the wheels were locked and it went over. Since then, they (facility) changed policy to use two people but she still only wants bed baths. At that time, CNA D was requested to observe the shower room where Resident #709 fell . Upon observation of the A hall shower room, there were two shower areas, one was a single shower with a flat (level) floor, the other had two showers and the tile floor for both shower drains were significantly dipped down (uneven surface) towards the floor drains. At that time, CNA D proceeded to provide a visual re-enactment of the Resident's fall. Review of the facility's incident report dated 5/6/16 and subsequent investigation failed to identify any documented evidence regarding environmental hazards (utilization of a shower room with uneven surfaces and a shower bed) which contributed to the fall when the Resident attempted to reach for the shower bars. The section of the investigation titled, Environmental factors was left blank. The documentation included: Writer called to shower room by CNA observed resident lying on left side facing wall with shower bed on side. Resident stated she reached for bar on wall with both hands causing fall .skin tear noted to left elbow, Resident complained of pain, transferred to the hospital for further evaluation. Further review of the clinical record revealed Resident #709 initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #709 was cognitively intact (scored 15/15 on mental status exam), exhibited episodes of feeling tired or having little energy, poor appetite or overeating, had no behavior concerns, and required total assistance of one person for bathing. Review of the fall care plan initiated and revised on 2/16/16 included interventions which documented: The resident needs a safe environment with even floors . 5/6/16 two staff to provide shower Review of the ADL (Activities of Daily Living) care plan initiated and revised on 2/16/16 included interventions which documented: Resident prefers Shower 2x/week The resident requires assistance of 1 staff with bathing/showering 2 x's/week and as necessary On 8/30/16 at 3:30 p.m., an interview and record review was conducted with the Administrator. When asked about Resident #709's fall on 5/5/16 in the shower room, the Administrator reported The Resident won't go back into the shower. The two stalls are dipped (at the floor drains). It wasn't a default on part of the equipment, the fall could've been prevented. The gurney (shower bed) should've been used in the single shower stall. Made it be that if anyone has a gurney there would be two people to assist. At that time, a request was made for the facility's policy regarding shower care, however there was no further documentation provided by the end of the survey. ( ) Deficient practice #2 Based on observation, interview, and record review, the facility failed to ensure that oxygen tanks were stored in a secure manner in two storage closets across from two of three nurse's stations located on the C and I unit hallways and ensure that electrical extension cords were not plugged into each other on the A unit hallway affecting all 37 Residents on the A, C, and I unit hallways resulting in an increased risks of explosion and fire. Findings include: During the environmental tour of the facility, on 8/29/16 between 12:30 p.m. and 4:00 p.m., an extension cord was observed plugged into a second extension cord in the room that Resident #s 2, 4, and 709 resided in. The second extension cord was plugged into a third extension cord that was plugged into a wall outlet. A tube feeding pump was plugged into the end of the extension cord chain. The Maintenance Director was asked about the use of the extension cords and responded, They shouldn't be using extension cords at all, and indicated that he did not know they were in the room. During the environmental tour of the facility, on 8/29/16 between 12:30 p.m. and 4:00 p.m., three unrestrained oxygen tanks were observed in the storage room located on the C unit hallway and one unrestrained oxygen tank was observed in the storage room on the I unit hallway. The Maintenance Director, present during the tour, offered no explanation for the unrestrained oxygen tanks. During an interview, on 8/31/16 at 11:00 a.m., the Administrator indicated that their was no formal policy for the use of extension cords, however, they were not to be used in the facility except for in the office areas. Review, on 8/31/16 at 11:00 a.m., of the facility's policy titled, Oxygen Administration did not address storage of oxygen tanks when not in use. ( )

Based on observation, interview, and record review, the facility failed to utilize all the safety straps on a mechanical lift and have two staff persons provide assistance during operation of the lift when transferring one (#501)of three sampled Residents (#501) reviewed for transfers with a mechanical lift, from a total sample of three, resulting in Resident #501 slipping from the lift during a transfer off the toilet, falling back onto the toilet seat and fracturing the upper neck of her left humerus (shoulder area). Findings include: According to the occurrence report dated 7/28/15 at 5:00 p.m., Resident #501 was being toileted with the use of a mechanical 'sit-to-stand' lift. Certified Nursing Assistant ( CNA 'F') transferred the R#501 to the toilet, utilizing the lift, without incident. After R#501 was finished using the toilet, CNA 'F' attempted to use the mechanical lift by herself, and did not use the safety straps designed to go across R#501's legs and waist/chest area. R#501 'passed out' and slid back down onto the toilet. R#501 was transferred out to the hospital for low blood pressure and left shoulder pain. R#501 was treated at the hospital for blood pressure concerns, but no surgical intervention was recommended or performed for the left upper humerus fracture. During a medical record review conducted on 8/24/15 at 11:00 a.m., it was determined that R#501 was admitted to the facility with multiple [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified R#501 as requiring total assistance from staff for transfers, toileting, and hygiene. According to the 'Resident lifting, transferring, and repositioning data collection' form dated 3/11/15, R#501 was assessed to require the use of a mechanical 'sit-to-stand' lift and two person assist. R#501's weight was documented at 258 pounds and a height of 67 inches. A care plan for ADL/Mobility care dated 6/19/14 indicated that two staff persons and a mechanical 'sit-to-stand' lift were required to transfer R#501. During an interview on 8/24/15 at 10:00 a.m., the Director of Nursing (DON) said that CNA 'F' was terminated from employment at the facility because she violated a safety policy. CNA 'F' did not utilize a second staff member during a transfer using a lift, and did not apply the velcro safety straps across R#501's leg or chest/waist area. During the transfer from the toilet back to the wheelchair, R#501 passed out and slid back down onto the toilet seat, injuring her left humerus. The DON said that R#501's left side was flaccid and was placed over the bar of the mechanical lift and had abruptly fallen down when R#501 slid back onto the toilet. The DON said that the Resident's left humerus will not be surgically repaired because the Resident's left arm has been flaccid and unable to be moved voluntarily or rehabilitated. During an interview on 8/24/15 at 11:00 a.m., R#501 was observed seated in her wheelchair, in her room watching TV, with a soft sling on her left arm. R#501 said that when she was being toileted on 7/28/15, only one CNA was helping her and she told the CNA, I'm going down and then 'passed out'. R#501 said that the CNA did not reapply the velcro safety straps across her chest or legs and when she fell back onto the toilet she thinks her left arm flopped back down so hard that she broke it. During a telephone interview on 8/24/15 at noon, CNA 'F' said that there was nothing more to say regarding the incident with R#501 on 7/28/15. CNA 'F' said she lost her job over it and that was it. CNA 'F' did confirm that she did assist R#501 with the mechanical lift alone, and did not reapply the safety straps because R#501 doesn't like the straps on. CNA 'F' could not explain how R#501's left arm became fractured. According to the facility's policy, 'Safe lifting and Movement of Residents', revised on 4/2015, step 3 reads as follows; Two staff shall be present to assist during all patient transfers utilizing a mechanical lift. ( )

This citation pertains to intake MI 846 Based on interview and record review, the facility failed to implement a fall prevention intervention that was identified on the care plan, and provide safe supervision and assistance for one (#501) of four sampled residents residents reviewed for falls, out of a total of four, resulting in a fall from bed that resulted in a large subacute right subdural hematoma (brain bleed), a secondary [DIAGNOSES REDACTED] (brain swelling caused from increased fluid), and a craniotomy (surgery to relieve pressure from increased fluid). Findings include: On 2/26/15 at 9:35 a.m. Resident #501's closed medical record was reviewed and according to Resident #501's face sheet, the resident was initially admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 10/17/14 described Resident #501 was described to have severely impaired cognition; required extensive assistance with all activities of daily living (ADLs), totally dependent upon others for bathing; and required extensive assistance with bed mobility with the assistance of two people. Bed mobility was defined per the MDS as: how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Review of an Occurrence Report, dated 1/5/15 at 6:05 a.m., for Resident #501 revealed the following documentation: Writer called to room by CNA (Certified Nursing Assistant), observed pt (patient) on mat in supine position. No noted injuries.CNA stated during personal care she turned res (resident) on left side and while holding on resident's pants, turned to grab wash cloth and resident grabbed on to the side of the bed and pulled herself to the floor landing on floor mat in supine position (lying face upward). The witness statement written by the assigned CNA (N), dated 1/5/15 at 6:00 a.m., revealed the following documentation: I had (Resident #501) on her side trying to change her and get her dressed. I had my hand on her pants and turned to grab a towel and she grabbed the side of the bed and pulled herself off. She hit the back of her head on the floor mat. I immediately checked for bleeding and there was none. The witness statement written by the assigned Nurse (O), dated 1/5/15 at 6:00 a.m., revealed the following documentation: Writer called into room by CNA. Writer observed pt (patient) lying on back on floor mat.writer educated CNA on being fully prepared when performing ADL care. CNA verbalized understanding. On 2/26/15 at 12:30 p.m., CNA N was interviewed by way of phone regarding the incident. CNA N stated, I had her on her left side. She was facing away from me. She grabbed the mattress while hanging on the side of the bed, then she pulled herself off the bed while using her right hand. I was the only one in the room with her. She was a one person assist with baths and turns. Sometimes it required two people at a time to care for her because she is so stiff. On 2/26/15 at 3:00 p.m., the Director of Nursing (DON) was queried regarding the assistance required when caring for Resident #501 while in bed and how Resident #501 was positioned during the time of the fall incident. The DON stated, I don't think the fact she was turned away from the CNA contributed to the cause of her fall. Resident #501's quarterly MDS assessment, dated 10/17/14, was then reviewed with the DON. The bed mobility assessment section was reviewed with the DON where it indicated Resident #501 required extensive assistance with the assistance of two plus persons for physical assistance. The DON stated, I will have to further review it and get back with you. On 2/26/15 at 3:25 p.m., Resident #501's current Fall/Injury Assessment: Prevention and Management Plan of Care (care plan) was reviewed. Interventions on the care plan included: -Matt to floor -Bed next to wall -Perimeter mattress -Chair and bed alarms -Lock bed wheels, etc. On 2/27/15 at 9:20 a.m., the DON was queried regarding the incident and the position of the bed. The DON stated, I don't know how the bed was positioned. I know the resident's back was to the CNA. It was ok that the resident was turned away from the CNA. On 2/27/15 at 9:35 a.m., the facility's MDS nurse (Nurse P) was interviewed regarding the quarterly Minimum Data Set (MDS) assessment, dated 10/17/15, section for mobility, for Resident #501. Nurse P reported that she reviewed what the CNA's chart in caretracker (system with resident care information) regarding the amount of assistance required for Resident #501. Based on what the CNAs entered, that is what is coded on the MDS for mobility, even if Resident required the assistance of two people one time during the time period of MDS assessment. Yet, review of Resident #501's current ADL/Mobility Plan of care indicated that she required only the assistance of one person. On 2/27/15 at 2:45 p.m., CNA N was called again for additional information regarding the incident. Particularly regarding the location and positioning of Resident #501's bed. CNA N reported the bed was not against the wall. CNA N stated, She (#501) was positioned on her left side. Resident #501's right hand grabbed the left side of the mattress which caused her to roll out of bed. I was on the right side of the bed. She (#501) landed on her right side. Her head hit the mat. There was no explanation provided as to why the bed was not against the wall as indicated on the care plan for falls. On 2/27/15 at 2:50 p.m., Resident #501's head cat scan, dated 2/6/15, was reviewed and revealed the following: Large subacute right subdural hematoma with associated acute component. There is effacement of the right cerebral sulci as a result. There is significant associated mass effect with subfalcine herniation of midline structures to the left a distance of approximately 17 cm (centimeters). There is secondary [DIAGNOSES REDACTED] of the left ventricle. Also, effacement of. Per the Administrator and the DON, the only traumatic fall/incident Resident #501 had was the fall on 1/5/15 (fall from bed). On 2/27/15 at 2:55 p.m., review of the facility's policy titled, Turning and Positioning, dated March 2007, revealed the following documentation: Residents will be turned and positioned according to their co-morbidities and individual abilities. ( ) This citation pertains to intakes: MI 894, and MI 928. Based on interviews and record reviews the facility failed to provide adequate supervision during toileting for one of four residents, (#502) reviewed for fall risk, from a total sample of four, resulting in Resident #502, being placed in the bathroom by the day shift staff and found on the bathroom floor by the afternoon shift staff. Findings include: According to the facility's Occurrence Report dated 2/15/15 at 3:00 p.m., LPN 'B' was called to Resident #502's bathroom by Certified Nursing Assistant (CNA) 'C' and found the Resident on the bathroom floor, laying on her right side. CNA 'E' had placed Resident #502 in the bathroom for toileting, CNA 'C' found the Resident on the bathroom floor. Resident #502 did not sustain any visible injury. During an interview on 2/26/15 at 3:15 p.m., LPN 'B' said that on 2/15/15 at approximately 3:00 p.m., the afternoon shift CNA 'C' yelled out to her that Resident #502 was on the bathroom floor. LPN 'B' said she was unsure of what had happened, but thought the day shift CNA 'E' put the Resident in the bathroom and left. Then the afternoon shift CNA 'C' found the Resident during her rounds. LPN 'B' said that Resident #502 was,' kind of out of it', but not completely unresponsive, and 'within 30 minutes, she was back to normal'. LPN 'B' said that Resident #502 did not sustain any injury and the neurological assessments indicate any changes from the Resident's baseline. During a telephone interview on 2/26/15 at 12:15 p.m., CNA 'C' said that on 2/15/15 at approximately 3:00 p.m., she answered the call light for Resident #502's neighbor (R#504, is a Resident who shares a dorm style bathroom with Resident #502) and was told that Resident #502 was on the floor in the bathroom for over an hour. CNA 'C' said that she called for a nurse, and immediately assisted the Resident up with the help of LPN 'B'. CNA 'C' said she did not put the Resident in the bathroom and could not say how long that Resident #502 was in the bathroom, or for how long she was on the floor because she had just started her afternoon shift. CNA 'C' did say that Resident's who were 'fall risks' should not be left on the toilet without assistance. During a telephone interview on 2/26/15 at 1:30 p.m., CNA 'E' said that on 2/15/15 at approximately 2:30 p.m., she put Resident #502 in the bathroom for a bowel movement and went outside the bathroom, to give the Resident privacy. CNA 'E' said she had to leave early that day and reported to another (unnamed) CNA that Resident #502 was still on the toilet, and she left. CNA 'E' said she was unaware that Resident #502 had five previous falls while at the facility. A review of CNA 'E's time and attendance record revealed that on 2/15/15 she punched out at 2:50 p.m. During an interview on 2/26/15 at 10:30 a.m., Resident #504 said that on 2/15/15 at approximately 2:00 p.m., she heard someone talking with Resident #502 while in the bathroom, and then within a few minutes she heard a 'thump' and Resident #502 was moaning. Resident #504 said she put her call light on, and yelled out to passing staff on several occasions, but no one answered her light for over an hour. At about 3:15 p.m., the afternoon CNA came in and she told her (the CNA), that Resident #502 was in the bathroom for over an hour, and possibly fell . Resident #504 said that the CNA went outside the door, and into Resident #502's room. She could hear the CNA through the bathroom door, yelling for help and then another person asking Resident #502 if she was 'O.K.'. During an interview on 2/27/15 at 1:45 p.m., LPN 'I' said that she was working on 2/15/15 during that time Resident #502 was found on the floor. LPN 'I' sais that the CNA should have never left the Resident unattended in the bathroom because the Resident was a known fall risk, with a cast on her right hand, and a large slippery dressing on her left foot. A review or the medical record conducted on 2/26/15 at noon revealed that Resident #502 was admitted to the facility on [DATE] for multiple [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified Resident #502 as having a BIMS score (brief interview for mental status) of 5/15. Resident #502 was documented to have disorganized thinking and unclear thought processes. Resident #502 was documented to have the following five falls prior to her sixth fall on 2/15/15; 11/26/15 at 3:00 p.m., 12/19/14 at midnight, 1/27/15 at 1:00 p.m., 1/27/15 at 10:00 p.m., 2/6/15 at 6:00 p.m. Resident #502 had a cast on her lower right arm and hand, and a dressing to her left foot. A care plan for fall prevention was initiated upon admission and identified several interventions which included a low bed, and personal alarms to the resident's bed and wheelchair. ( ) According to the facility's policy for, ' Fall/Injury Management-Post Fall or Injury', revised on 11/2013; proper action following a fall includes.determining what may have caused or contributed to the fall is necessary to provide consistent interventions to help prevent future occurrences.

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 870 AND MI 187. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND FAILED TO IMPLEMENT EFFECTIVE INTERVENTIONS TO PREVENT FALLS FOR ONE (RESIDENT #503) OF TWO RESIDENTS REVIEWED FOR FALLS FROM A TOTAL OF TWELVE SAMPLED RESIDENTS RESULTING IN MULTIPLE FALLS AND A FALL WITH SUBSEQUENT FRACTURE. FINDINGS INCLUDE: A COMPLAINT AND FACILITY REPORTED INCIDENT ON FILE REPORTED THAT RESIDENT #503 HAD SUSTAINED A FALL WITH INJURY. ON 4/1/13 AT 10:55 A.M., RESIDENT #503 WAS OBSERVED SEATED IN A WHEELCHAIR BEING PUSHED BY A HOSPICE SOCIAL WORKER. RESIDENT #503 WAS OBSERVED WITH A CAST ON HER RIGHT ARM WHICH WAS RESTING ON A TRAY ATTACHED TO HER WHEELCHAIR. AN ALARM WAS OBSERVED ON THE BACK OF THE WHEELCHAIR. WHEN ADDRESSED, RESIDENT #503 OFFERED NO VERBAL RESPONSE, BUT DID GIVE MOMENTARY EYE CONTACT. ACCORDING TO THE CLINICAL RECORD, RESIDENT #503 WAS AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE CLINICAL RECORD ALSO INDICATED THAT RESIDENT #503 WAS UNDER THE CARE OF HOSPICE SERVICES. THE MOST RECENT COMPREHENSIVE MINIMUM DATA SET (MDS) assessment dated [DATE] DOCUMENTED THAT RESIDENT #503 REQUIRED SUPERVISION TO EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, AMBULATION, HYGIENE, BATHING AND TOILETING. THE MDS ALSO DOCUMENTED THAT RESIDENT #503 HAD AN UNSTEADY GAIT, WAS UNSTEADY WHEN TRANSFERRING FROM SURFACE TO SURFACE AND USED A WHEELCHAIR FOR MOBILITY. ON 4/1/13 DURING AN INTERVIEW WITH ASSISTANT DIRECTOR OF NURSING (ADON) #1 WITH THE DIRECTOR OF NURSING (DON) IN ATTENDANCE, ADON #1WAS QUERIED ABOUT RESIDENT #503'S FALL HISTORY WHILE RESIDING AT THE FACILITY. THE ADON REPORTED, "...SHE (RESIDENT #503) FRACTURED HER RIGHT ARM. SHE'S A HOSPICE PATIENT AND THE FALL WAS UNAVOIDABLE RELATED TO HER MENTAL STATUS. SHE (RESIDENT #503) STILL THINKS SHE CAN GET UP AND WALK WITHOUT ASSISTANCE. SHE HAS HAD OTHER FALLS HERE AT THE FACILITY AND INITIALLY HAD NO INTERVENTIONS OTHER THAN THE STANDARD LOW BED. SINCE HER FALLS, WE'VE ADDED A SENSOR ALARM, A FLOOR MAT AND A CHAIR ALARM. WE ASSIGNED ONE TO ONE SUPERVISION SEVERAL WEEKS AFTER HER FALL, RELATED TO HER ALTERED MENTATION..." WHEN ASKED ABOUT RESIDENT #503'S PRIOR FALLS, ADON #1 REPORTED, "...SHE (RESIDENT #503) HAS A HISTORY OF UNASSISTED TRANSFERS DUE TO HER HISTORY OF NONCOMPLIANCE WITH USE OF THE CALL LIGHT. SHE WAS INITIALLY admitted TO THE FACILITY DUE TO TOO MANY FALLS AT HOME. SHE WAS admitted [DATE] AND HAD TWO FALLS IN THE LAST THREE MONTHS..." THE ADON FURTHER REPORTED, "...SHE HAD FALLS ON 2/10/11, 6/11/12, 12/26/12, 1/9/13 AND 1/22/13. WHEN SHE WAS FIRST admitted , SHE AMBULATED WITH A WALKER. WE SAW THE SLOW DECLINE. SHE WAS NO LONGER SAFE TO USE THE WALKER DUE TO HER DECREASED COGNITION SO WE SENT HER WALKER HOME AND INSTRUCTED HER TO USE THE CALL LIGHT. WE ADDED A BED ALARM AND FLOOR MAT ON 1/9/13 AND A CHAIR ALARM ON 1/21/13..." WHEN RESIDENT #503'S FALLS RISK ASSESSMENT WAS REQUESTED FOR REVIEW, ADON #1 REPORTED, "...WE DON'T DO FALLS RISK ASSESSMENTS..." REVIEW OF THE FACILITY'S "FACILITY INCIDENT REPORT - 24 HOURS" DATED 1/18/13, DISCOVERED/REPORTED AT 4:30 P.M. REVEALED, "...1/18/13 AT 8:15 A.M., RESIDENT COMPLAINED OF PAIN IN RIGHT ARM TO HOSPICE AID. HOSPICE AID REPORTED TO NURSE (LICENSED PRACTICAL NURSE/LPN #6) ON STAFF ASSIGNED TO RESIDENT. NURSE NOTIFIED MD (DOCTOR), ORDER OBTAINED FOR X-RAY. X-RAY COMPLETED AND RESULTS SHOW ACUTE RIGHT DISTAL RADIUS FRACTURE. UPON INTERVIEW OF THE NURSE (LPN #6), NURSE STATED THAT RESIDENT HAD A FALL AT APPROXIMATELY 8:15 ON 1/18/13..." ADON #1 DID NOT MENTION THAT RESIDENT #503 HAD A FALL ON 1/18/13 THAT RESULTED IN THE MENTIONED FRACTURE WHEN SHE REPORTED THE OTHER FALL INCIDENTS. A REVIEW OF THE FACILITY'S "RESIDENT INCIDENT" FORM DATED 1/18/13 REVEALED, "...FALL: 1/18/13 8:30 P.M., (RESIDENT #503) OBSERVED ON FLOOR. RESIDENT (#503) SEATED IN WHEELCHAIR. ASSIGNED CNA (CERTIFIED NURSE AIDE) LEFT (RESIDENT #503'S) ROOM TO DISPOSE OF SOILED LINEN. ASSIGNED CNA HEARD A CALL FOR HELP FROM (RESIDENT #503'S) ROOMMATE. (RESIDENT #503) ON FLOOR IN FRONT OF HER WHEELCHAIR, STATED WAS TRYING TO GET UP. C/O (COMPLAINED OF) PAIN TO RIGHT WRIST AND FOREARM. RESIDENT (#503) HOLDING RIGHT FOREARM AND WRIST GRIMACING. ACTIVITY PRIOR TO INCIDENT: SITTING IN WHEELCHAIR. WAS RESIDENT (#503) TOTALLY DEPENDENT ON CENTER STAFF FOR THEIR CARE? YES. IS THERE A HISTORY OF FALLS? YES. X-RAYS ORDERED. RESIDENT (#503) SENT TO HOSPITAL FOR TREATMENT. CHAIR ALARM INITIATED. RESIDENT (#503) NONCOMPLIANT WITH CALL LIGHT USE. RESIDENT HAS FALLEN IN THE PAST..." RESIDENT #503 HAD BEEN LEFT IN HER WHEELCHAIR, UNATTENDED AND UNSUPERVISED, WITH NO ALARMS IN PLACE TO HER CHAIR, AS STAFF TENDED TO OTHER RESIDENTS. ADON #1 DID NOT EXPLAIN WHY STAFF HAD LEFT RESIDENT #503 UNATTENDED AND UNSUPERVISED IN LIGHT OF HER HISTORY OF NONCOMPLIANCE, DECLINE IN COGNITION AND UNASSISTED TRANSFERS, AS admitted BY ADON #1. THE RADIOLOGY REPORT DATED 1/18/13 DOCUMENTED, "...RIGHT FOREARM AND WRIST, ACUTE RIGHT DISTAL RADIUS FRACTURE..." REVIEW OF THE RESIDENT INCIDENT FORMS IN THE CLINICAL RECORD REVEALED THE FOLLOWING FOR RESIDENT #503: "...12/21/12, 2:35 A.M., FALL: LAYING FLAT ON HER BACK NEXT TO ROOMMATES BED. RESIDENT #503 WAS WALKING TO BATHROOM WITH CANE WHEN SHE LOST HER BALANCE AND fell BUTT FIRST ON FLOOR. COMPLAINED OF (C/O) RIGHT HIP AND MID BACK PAIN. ABRASION TO LEFT MID BACK. DUE TO MUSCLE WEAKNESS USE HER WALKER INSTEAD OF CANE. USE CALL LIGHT. CARE PLAN (CP) REVISED. ALERT, CONFUSED..." A "PROGRESS NOTE DATED 1/6/13 REVEALED, "...INCREASED ANXIETY NOTED. REMAINS CONFUSED WITH INCREASED RISK FOR FALL..." A PROGRESS NOTE DATED 1/7/13 REVEALED, "...CONFUSION NOTED..." "...1/9/13 10:30 A.M., FALL: CNA (CERTIFIED NURSING ASSISTANT) HELPING IN ANOTHER ROOM WHEN HEARD CALLS FOR HELP IN THE HALL. OBSERVED (RESIDENT #503) LYING ON HER SIDE ON FLOOR NEXT TO ANOTHER RESIDENT'S BED. C/O PAIN TO LEFT SHOULDER. X-RAYS ORDERED FOR LEFT SHOULDER, LEFT HIP AND SKULL. FLOOR MATT AND BED ALARM AND ENCOURAGE CALL LIGHT..." THE "RADIOLOGY REPORT" DATED 1/9/13 REVEALED "...NO DEFINITE RADIOGRAPHIC EVIDENCE OF ACUTE FRACTURE OR DISLOCATION..." A "PROGRESS NOTE DATED 1/9/13 REVEALED, "...INCREASED AGITATION NOTED. REMAINS CONFUSED WITH INCREASED RISK FOR FALL..." THERE WAS NO DOCUMENTED EVIDENCE THAT RESIDENT #503 HAD BEEN ASSIGNED TO ONE TO ONE SUPERVISION OR THAT FACILITY STAFF INCREASED THE FREQUENCY OF ROUNDS IN LIGHT OF HER INCREASED AGITATION AND INCREASED RISK FOR FALLS. A PROGRESS NOTE DATED 1/10/13 REVEALED, "...INCREASED ANXIETY. REMAINS CONFUSED WITH INCREASED RISK FOR FALL..." A PROGRESS NOTE DATED 1/19/13 REVEALED, "...PATIENT NON WEIGHT BEARING LEFT LEG. TURNED AND REPOSITION Q2H (EVERY 2 HOURS) AND AS NEEDED WITH TWO PERSON ASSIST..." A PROGRESS NOTE DATED 1/20/13 REVEALED, "...SPECIAL BED AND MATTRESS AND FLOOR MATTS DELIVERED AT 2120 (9:30 P.M.) AFTER BEING ORDERED BY THE HOSPICE NURSE. REMAINS CONFUSED WITH INCREASED RISK FOR FALL..." "...1/22/13 5:00 P.M., FALL: STAFF HEARD BED ALARM GOING OFF, ON REACHING (RESIDENT #503'S) ROOM, WAS FALLING ON THE FLOOR. NURSE OBSERVED (RESIDENT #503) LYING ON HER BACK. ROOMMATE SAYS (RESIDENT #503) GOT UP OFF THE BED, LOST BALANCE AND fell . C/O PAIN RIGHT HIP AND LOWER BACK. IS THERE A KNOWN OR SUSPECTED INJURY? YES. DESCRIBE: HAS A KNOWN RIGHT WRIST AND LEFT HIP FRACTURE. X-RAY BILATERAL HIP, PELVIS AND LEFT SHOULDER. RESIDENT (RESIDENT #503) NONCOMPLIANT WITH THE CALL LIGHT. RESIDENT HAS FALLEN IN THE PAST. CP REVISION. RESIDENT PLACED ON 1:1 (ONE TO ONE SUPERVISION). ALERT, CONFUSED..." THE RADIOLOGY REPORT DATED 1/22/13 REVEALED, "...THERE IS NO RADIOGRAPHIC EVIDENCE OF ACUTE FRACTURE OR DISLOCATION..." THERE WAS NO DOCUMENTED EVIDENCE THAT FACILITY STAFF INCREASED ROUNDS OR ADDED 1:1 SUPERVISION PRIOR TO THIS FALL. A PROGRESS NOTE DATED 1/23/13 REVEALED, "...PATIENT (#503) PLACED ON CONSTANT MONITORING; ONE TO ONE (1:1) AS OF NOW..." THERE WAS NO DOCUMENTED EVIDENCE THAT 1:1 SUPERVISION OR "CONSTANT MONITORING" WAS IN PLACE PRIOR TO RESIDENT #503'S FALLS, IN LIGHT OF RESIDENT #503'S HISTORY OF UNASSISTED TRANSFERS, NONCOMPLIANCE WITH USE OF CALL LIGHT AND DECLINE IN COGNITION, AGITATION AND INCREASED CONFUSION. A PROGRESS NOTE DATED 3/8/13 REVEALED, "...ONE ON ONE DISCONTINUED..." A PROGRESS NOTE DATED 3/15/13 REVEALED, "...REMAINS CONFUSED WITH INCREASED RISK FOR FALL. SEVERAL ATTEMPTS TO GET OUT OF BED AND WHEELCHAIR..." PROGRESS NOTES DATED 3/28/13 AND 3/29/13 BOTH DOCUMENT, "...REMAINS CONFUSED WITH INCREASED RISK FOR FALL..." "...3/30/13 5:00 A.M., FALL: RESIDENT #503 OBSERVED ON HER KNEES AT END OF HER BED. RESIDENT #503 STATED HER BACK HURTS. NO REDNESS OR SWELLING NOTED. BOLSTERS TO BED TO PREVENT FURTHER UNASSISTED TRANSFERS. ALERT, ORIENTED TO PERSON, CONFUSED..." A REVIEW OF THE FACILITY'S "RISK REDUCTION: FALLS AND INJURIES PROGRAM" POLICY REVISED APRIL 2012 REVEALED: "...THE USE OF TOOLS OR ITEMS SUCH AS PERSONAL ALARMS CAN HELP MONITOR RESIDENT'S ACTIVITIES BUT DOES NOT ELIMINATE THE NEED FOR STAFF VIGILANCE AND ARE NOT TO BE UTILIZED IN LIEU OF SUPERVISION..." "...ASSESS RESIDENT'S ABILITY TO UTILIZE THE CALL LIGHT OR BELL..." "...IMPLEMENT INTERVENTIONS TO REDUCE RISK IN RESIDENTS WITH CONFUSION. INTERVENTIONS MAY INCLUDE, BUT ARE NOT LIMITED TO: ANTICIPATE NEEDS, FREQUENTLY ORIENT TO CALL BELL..." "...1:1 IF INDICATED..." THE FACILITY'S POLICY DID NOT ADDRESS INCREASING THE FREQUENCY OF STAFF ROUNDS IN ORDER TO ENSURE RESIDENT SAFETY.

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 870 AND MI 187. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE POST FALL CARE AND TREATMENT BY NOT PROVIDING AN IMMEDIATE POST FALL ASSESSMENT; BY NOT ENSURING THAT THE RESIDENT WAS IMMOBILIZED; AND BY NOT ASSESSING AND MANAGING COMPLAINTS OF PAIN FOR ONE (RESIDENT #503) OF TWO SAMPLED RESIDENTS REVIEWED FOR FALLS FROM A TOTAL OF TWELVE SAMPLED RESIDENTS, RESULTING IN UNRELIEVED PAIN, DELAY IN THE IDENTIFICATION AND treatment of [REDACTED]. FINDINGS INCLUDE: ON 4/1/13 AT 10:55 A.M., DURING A TOUR OF THE FACILITY, RESIDENT #503 WAS OBSERVED SEATED IN HER WHEELCHAIR BEING PUSHED BY A SOCIAL WORKER. WHEN ADDRESSED, RESIDENT #503 OFFERED NO VERBAL RESPONSE. RESIDENT #503'S RIGHT ARM WAS OBSERVED IN A CAST AND WAS RESTING ON A TRAY ATTACHED TO THE WHEELCHAIR. AN ALARM WAS OBSERVED ATTACHED TO RESIDENT #503'S WHEELCHAIR. A REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #503 WAS AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE CLINICAL RECORD FURTHER REVEALED THAT RESIDENT #503 WAS UNDER HOSPICE CARE. THE MOST RECENT COMPREHENSIVE MINIMUM DATA SET (MDS) assessment dated [DATE] DOCUMENTED THAT RESIDENT #503 REQUIRED SUPERVISION TO EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, AMBULATION, HYGIENE, BATHING AND TOILETING. A REVIEW OF THE FACILITY'S "RESIDENT INCIDENT" FORM DATED 1/18/13 REVEALED, "...FALL: 1/18/13 8:30 P.M., (RESIDENT #503) OBSERVED ON FLOOR. RESIDENT (#503) SEATED IN WHEELCHAIR. ASSIGNED CNA (CERTIFIED NURSE AIDE) LEFT (RESIDENT #503'S) ROOM TO DISPOSE OF SOILED LINEN. ASSIGNED CNA HEARD A CALL FOR HELP FROM (RESIDENT #503'S) ROOMMATE. (RESIDENT #503) ON FLOOR IN FRONT OF HER WHEELCHAIR, STATED WAS TRYING TO GET UP. C/O (COMPLAINED OF) PAIN TO RIGHT WRIST AND FOREARM. RESIDENT (#503) HOLDING RIGHT FOREARM AND WRIST GRIMACING. ACTIVITY PRIOR TO INCIDENT: SITTING IN WHEELCHAIR. WAS RESIDENT (#503) TOTALLY DEPENDENT ON CENTER STAFF FOR THEIR CARE? YES. IS THERE A HISTORY OF FALLS? YES. X-RAYS ORDERED. RESIDENT (#503) SENT TO HOSPITAL FOR TREATMENT. CHAIR ALARM INITIATED. RESIDENT (#503) NONCOMPLIANT WITH CALL LIGHT USE. RESIDENT HAS FALLEN IN THE PAST..." REVIEW OF THE FACILITY'S "FACILITY INCIDENT REPORT - 24 HOURS" DATED 1/18/13 REVEALED, "DATE/TIME DISCOVERED OR REPORTED? 1/18/13 4:30 P.M. RESIDENT (#503) COMPLAINED OF PAIN IN RIGHT ARM TO HOSPICE AIDE. HOSPICE AIDE REPORTED TO NURSE ON STAFF ASSIGNED TO RESIDENT. NURSE NOTIFIED MD (DOCTOR), ORDER OBTAINED FOR X-RAY. X-RAY COMPLETED AND RESULTS SHOW ACUTE RIGHT DISTAL RADIUS FRACTURE. UPON INTERVIEW OF THE NURSE, NURSE STATED THAT RESIDENT (RESIDENT #503) HAD A FALL AT APPROXIMATELY 8:15 A.M. ON 1/18/13..." ON 4/1/13 AT 2:05 P.M., DURING A RECORD REVIEW OF THE FALLS RESIDENT #503 HAD DURING HER STAY AT THE FACILITY, IT WAS DISCOVERED THAT THE FACILITY'S 5-DAY REPORT AND SUMMARY OF INVESTIGATION WAS NOT IN THE FILE. WHEN THIS REPORT AND SUMMARY WAS REQUESTED, THE DIRECTOR OF NURSING (DON) REPORTED, "...I'LL GET IT FOR YOU. I'M SORRY. I WAS REVIEWING AND CORRECTING THE DOCUMENTATION IN THE REPORT TO REFLECT THAT THE RESIDENT (#503) ACTUALLY fell THE MORNING OF 1/18/13 AND WASN'T ADDRESSED BY THE NURSE UNTIL LATER THAT EVENING..." WHEN ASKED TO CLARIFY HER STATEMENT, THE DON REPORTED, "...THE NURSE (LICENSED PRACTICAL NURSE/LPN #6) FAILED TO ASSESS (RESIDENT #503) AFTER BEING NOTIFIED OF (RESIDENT #503'S) FALL. THIS WAS THE FALL THAT RESULTED IN (RESIDENT #503'S) RIGHT ARM FRACTURE...SHE (LPN #6) DIDN'T ASSESS THE PATIENT (RESIDENT #503), THAT SHOULD HAVE BEEN DONE IMMEDIATELY. SHE DIDN'T NOTIFY THE FAMILY, AND WHEN SHE SPOKE WITH THE DOCTOR, SHE (LPN #6) SAID THERE WAS NO FALL..." A REVIEW OF THE FACILITY'S "FACILITY INVESTIGATION REPORT - 5 WORKING DAYS" AND THE SUMMARY OF INVESTIGATION/RECAPITULATION REVEALED "...ON 1/18/13 AT APPROXIMATELY 8:15 A.M., (RESIDENT #503) WAS OBSERVED ON THE FLOOR IN HER ROOM BY CNAS (#6) AND (#7). THE FALL WAS WITNESSED BY HER ROOMMATE WHO STATED THAT THE RESIDENT STOOD UP AND BEGAN WALKING TOWARD HER BED. THE ROOMMATE STATED THAT (RESIDENT #503) BECAME UNSTEADY, LOST HER BALANCE AND fell on HER RIGHT SIDE. THE ROOMMATE STATED THAT SHE CALLED FOR HELP AND (CNA #7) CAME INTO ROOM WITH (CNA #6). PER (CNA #7'S) STATEMENT, SHE (#7) HAD PROVIDED A.M. (MORNING) CARE TO (RESIDENT #503) AND ASSISTED HER TO HER WHEELCHAIR AND LEFT THE ROOM TO TAKE CARE OF THE SOILED LINEN. (CNA #7) HEARD SOMEONE YELL FOR HELP WHEN SHE CAME OUT OF THE SOILED UTILITY ROOM AND ENTERED (RESIDENT #503'S) ROOM AND OBSERVED HER ON THE FLOOR BY THE MAT. (CNA #7) STATED THAT SHE STAYED WITH (RESIDENT #503) AND SENT (CNA #6) TO GO GET THE NURSE. (CNA #6) STATED THAT SHE REPORTED THE FALL TO (LPN #6) AND THEN THE TWO CNAS TRANSFERRED (RESIDENT #503) OFF OF THE FLOOR WITH THE LIFT BEFORE (LPN #6) CAME TO ASSESS (RESIDENT #503). (LPN #6) STATED THAT SHE WAS NOTIFIED OF THE FALL WHEN SHE WAS IN THE DINING ROOM. (LPN #6) DID NOT ASSESS (RESIDENT #503). LATER IN THE DAY, THE HOSPICE CNA CAME TO (LPN #6) TO REPORT THAT THE RESIDENT (#503) WAS COMPLAINING OF PAIN TO HER RIGHT ARM AND THAT SHE WAS HAVING DIFFICULTY WITH ROM (RANGE OF MOTION) AND ADLS (ACTIVITIES OF DAILY LIVING). (LPN #6) CONTACTED THE PHYSICIAN AND RECEIVED an order for [REDACTED]. X-RAY RESULTS SHOWED A DISTAL RADIUS [MEDICAL CONDITION] ARM. (RESIDENT #503) WAS TRANSFERRED TO THE ER (emergency room ). RESIDENT (#503) RETURNED TO THE CENTER WITH A CAST..." THE SUMMARY FURTHER DOCUMENTED "...(LPN #6) DID NOT IMMEDIATELY ASSESS (RESIDENT #503) AFTER SHE (#6) WAS INFORMED THAT SHE (#503) WAS OBSERVED ON THE FLOOR. (LPN #6) DID NOT COMPLETE THE INCIDENT/ACCIDENT REPORT WHEN THE FALL OCCURRED. (LPN #6) DID NOT REPORT THE FALL TO HER MANAGER, FAMILY OR PHYSICIAN. (LPN #6) CALLED THE PHYSICIAN MUCH LATER IN THE SHIFT TO REPORT THAT THE RESIDENT HAD PAIN IN THE RIGHT ARM AND RECEIVED an order for [REDACTED]. THE CNAS (#6, #7) admitted THAT THE RESIDENT HAD A FALL WHEN QUESTIONED BY THE ASSISTANT DIRECTOR OF NURSING (ADON/RN #3) AND THIS IS HOW THE CENTER BECAME AWARE OF THE FALL. THE CNAS DID NOT FOLLOW POLICY AND PROCEDURE AND TRANSFERRED THE RESIDENT OFF OF THE FLOOR BEFORE THE NURSE ASSESSED..." SEVERAL UNSUCCESSFUL ATTEMPTS WERE MADE TO CONTACT CNA #6, CNA #7 AND LPN #6 FOR INTERVIEWS. WRITTEN STATEMENTS ON FILE SUBMITTED BY THE ABOVE MENTIONED STAFF WERE REVIEWED AND FOUND TO BE CONSISTENT WITH THE ABOVE DOCUMENTATION. A REVIEW OF RESIDENT #503'S X-RAY REPORT TAKING WHILE AT THE FACILITY, DATED 1/18/13 REVEALED "...THE RIGHT FOREARM DEMONSTRATES A [MEDICAL CONDITION] RADIUS WITH NO DISPLACEMENT. ACUTE RIGHT DISTAL RADIUS FRACTURE..." A REVIEW OF THE HOSPITAL "RADIOLOGICAL REPORT" DATED 1/18/13 REVEALED, "...ARRIVAL TIME 9:41 P.M., FRACTURED RIGHT ARM FROM FACILITY WITH FALL THIS MORNING. X-RAY VERIFIED..." ANOTHER HOSPITAL RADIOLOGY REPORT DATED 1/18/13 REVEALED, "...status [REDACTED]. A NONDISPLACED [MEDICAL CONDITION] LEFT FEMUR CANNOT BE EXCLUDED. CT (COMPUTED TOMOGRAPHY) SCAN RECOMMENDED..." THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORD THAT THE FACILITY FOLLOWED THE RECOMMENDATIONS OF THE RADIOLOGIST TO OBTAIN A CT TO VERIFY OR RULE OUT A POSSIBLE FRACTURED FEMUR. A physician's orders [REDACTED]. OF THE MEDICATION OBSERVATION RECORD (MORS) FOR JANUARY 2013 REVEALED THAT RESIDENT #503 RECEIVED HER PRESCRIBED PAIN MEDICATION ON 1/18/13 AT 12:00 A.M., 6:00 A.M. AND 12:00 P.M. DESPITE THE ADMINISTRATION OF NARCOTIC PAIN MEDICATION, RESIDENT #503 CONTINUED TO COMPLAIN OF UNRELIEVED PAIN TO HER RIGHT FOREARM, AND REPORTED IT TO THE HOSPICE CNA WHO THEN REPORTED THE INFORMATION TO LPN #6. THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORD THAT LPN #6 ASSESSED RESIDENT #503'S PAIN LEVEL ONCE NOTIFIED OF HER FALL ON THE MORNING OF 1/18/13 AT 8:15 A.M. RESIDENT #503 HAD NOT BEEN ASSESSED FOR PAIN PRIOR TO HER COMPLAINT OF RIGHT FOREARM PAIN, WHICH SHE REPORTED TO THE HOSPICE AIDE WHO WAS PROVIDING CARE AT THE TIME. FURTHER REVIEW OF THE CLINICAL RECORD REVEALED NO DOCUMENTED EVIDENCE THAT THE PHYSICIAN OR FAMILY HAD BEEN NOTIFIED OF RESIDENT #503'S FALL ON THE MORNING OF 1/18/13 AT 8:15 A.M. A REVIEW OF THE FACILITY'S FALL POLICY, REVISED JULY 2012, REVEALED THE FOLLOWING: "...ASSESS THE RESIDENT AND IMPLEMENT APPROPRIATE MEASURES TO PROVIDE IMMEDIATE CARE AFTER A FALL/INJURY..." "...INITIATE AND COMPLETE THE ACCIDENT/INCIDENT PROCESS..." THE FACILITY'S FALL POLICY DID NOT ADDRESS NOTIFICATION OF THE PHYSICIAN OR THE RESIDENT'S FAMILY OF A FALL WITH INJURY. FURTHER, THE FACILITY'S FALL POLICY DID NOT ADDRESS IMMOBILIZATION OF A RESIDENT POST FALL, WHICH SPEAKS TO NOT MOVING THE RESIDENT PRIOR TO BEING ASSESSED BY LICENSED MEDICAL STAFF, IN ORDER TO AVOID THE POTENTIAL FOR FURTHER INJURY.

THIS CITATION REFERS TO INTAKE NUMBER MI 860. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT A SIGNIFICANT MEDICATION ERROR REGARDING [MEDICATION NAME] (BLOOD THINNER MEDICATION) FOR ONE (RESIDENT #101) OF 5 SAMPLED RESIDENTS REVIEWED FOR [MEDICATION NAME] ADMINISTRATION, FROM A TOTAL SAMPLE OF 8 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHEN SHE RECEIVED THE [MEDICATION NAME] THAT HAD BEEN ORDERED FOR ANOTHER RESIDENT. RESIDENT #101 SUBSEQUENTLY died . THIS DEFICIENT PRACTICE PLACED RESIDENT #101 AT HIGH RISK FOR SERIOUS HARM, INJURY OR DEATH. AS A RESULT OF THE FACILITY'S FAILURE TO ADMINISTER MEDICATIONS IN AN ACCURATE MANNER, 24 OTHER RESIDENTS WITH PHYSICIANS' ORDERS TO RECEIVE [MEDICATION NAME] WERE PLACED AT HIGH RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: ACCORDING TO THE FACILITY INVESTIGATIVE REPORT, DATED [DATE], RESIDENT #101 WAS NOTED TO HAVE A SMALL AMOUNT OF RECTAL BLEEDING AND BRUISING ON HER UPPER AND LOWER EXTREMITIES ON [DATE]. THE PHYSICIAN REVIEWED THE CLINICAL RECORD ON [DATE] AND DETERMINED THAT RESIDENT #101 HAD RECEIVED A MEDICATION WHICH HAD NEVER BEEN ORDERED. THE MEDICATION WAS [MEDICATION NAME] (A BLOOD THINNER). RESIDENT #101 HAD RECEIVED 4 MG OF [MEDICATION NAME] DAILY, FROM [DATE] TO [DATE]. THE PHYSICIAN DISCONTINUED THE [MEDICATION NAME] AND ORDERED BOTH A [MEDICATION NAME] ANTIDOTE (VITAMIN K) AND LABORATORY TESTS TO DETECT ABNORMAL BLEEDING. LABORATORY TEST RESULTS REVEALED THAT RESIDENT #101 HAD A CRITICALLY ELEVATED BLEEDING RATE ([MEDICATION NAME] TIME (PT) OF 129.8 AND INTERNATIONAL NORMALIZED RATIO (INR) OF 12.6). AFTER RECEIVING THE LABORATORY TEST RESULTS ON [DATE], RESIDENT #101 WAS TRANSFERRED TO THE HOSPITAL FOR FURTHER EVALUATION AND TREATMENT. ACCORDING TO "CLINICAL MEDICAL-SURGICAL NURSING, A DECISION-MAKING REFERENCE," PUBLISHED IN 2002, BY GEORGE-GAY AND CHERNECKY, PAGE 326, FOR AN INDIVIDUAL RECEIVING [MEDICATION NAME], THE TARGET INR SHOULD BE BETWEEN 2.0 AND 3.0. AN UNANNOUNCED COMPLAINT INVESTIGATION WAS BEGUN ON [DATE]. THE PROTOCOL FOR THE ABBREVIATED SURVEY WAS FOLLOWED IN CONDUCTING THE INVESTIGATION. RESIDENT #101 WAS AN [AGE] year-OLD WOMAN, WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT HAD BEEN RECEIVING HOSPICE CARE SINCE [DATE]. RESIDENT #101 EXPIRED AT THE HOSPITAL ON [DATE] AT 3:30 PM, WITH THE CAUSE OF DEATH LISTED AS [MEDICAL CONDITION], CARDIOGENIC SHOCK, SEVERE [MEDICAL CONDITIONS] AND [DIAGNOSES REDACTED] (ENLARGED HEART). ACCORDING TO RESIDENT #101'S MEDICATION ADMINISTRATION RECORD (MAR), DATED [DATE] TO [DATE], [MEDICATION NAME] 4 MG WAS GIVEN DAILY FROM [DATE] TO [DATE]. A TOTAL OF 16 DOSES WERE RECORDED ON THE MAR. DURING AN INTERVIEW ON [DATE], AT 2:40 PM, DIRECTOR OF NURSING (DON) #1 STATED THAT ON [DATE], LICENSED PRACTICAL NURSE (LPN) #9 ERRONEOUSLY WROTE A VERBAL ORDER TO "DECREASE [MEDICATION NAME] TO 4 MG DAILY" FOR RESIDENT #101. THE ORDER WAS INTENDED FOR ANOTHER RESIDENT, RESIDENT #104. THE ERRONEOUS ORDER FOR RESIDENT #101 WAS FAXED TO THE PHARMACY. THE PHARMACY ENTERED THE [MEDICATION NAME] ORDER ON RESIDENT #101'S MEDICATION PROFILE. AS A RESULT, THE [MEDICATION NAME] FIRST APPEARED ON THE [DATE] MONTHLY PRESCRIPTION RENEWAL ORDERS FOR RESIDENT #101. THE ORDER FOR [MEDICATION NAME] WAS NOT ON RESIDENT #101'S [DATE] OR [DATE] PRESCRIPTION RENEWAL ORDERS, NOR ON ANY INTERIM ORDER IN THE RESIDENT'S CHART. THE DON SAID THAT THE ORDER SLIP WAS RETRIEVED FROM THE PHARMACY, IDENTIFYING THE ERROR. ON [DATE] AT 5:00 PM DURING A TELEPHONE INTERVIEW THE ATTENDING PHYSICIAN #7 SAID THAT HE WAS NOT SURE OF THE DATE THAT HE SIGNED THE [DATE] TO [DATE] MONTHLY RENEWAL ORDER FORM (SIGNATURE WAS PRESENT, BUT WAS NOT DATED). PHYSICIAN #7 STATED THAT HE WAS NOT AWARE THAT THE [MEDICATION NAME] HAD BEEN ADDED TO THE ORDERS IN ERROR, UNTIL [DATE], WHEN HE WAS NOTIFIED THAT RESIDENT #101 HAD RECTAL BLEEDING. AT THAT TIME HE GAVE A VERBAL ORDER TO DISCONTINUE [MEDICATION NAME] AND GIVE 10 MG OF VITAMIN K (A [MEDICATION NAME] ANTIDOTE), AND LABORATORY TESTS TO MEASURE PT/INR, HEMOGLOBIN AND HEMATOCRIT (TESTS TO DETERMINE THE AMOUNT OF BLOOD LOSS). THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL AFTER THE TEST RESULTS WERE RECEIVED BY HIM ON [DATE]. DURING AN INTERVIEW ON [DATE] AT 5:45 PM, REGISTERED NURSE (RN) #5 SAID THAT SHE DID NOT CHECK FOR A PT/INR LEVEL, PRIOR TO ADMINISTERING [MEDICATION NAME] TO RESIDENT #101 ON [DATE] AND ON [DATE], AS REQUIRED BY FACILITY POLICY. RN #8 WAS INTERVIEWED ON [DATE] AT 6:00 PM. RN #8 SAID THAT SHE NORMALLY WOULD CHECK THE INR LEVEL PRIOR TO GIVING [MEDICATION NAME] TO A RESIDENT. SHE REVIEWED THE MEDICATION ADMINISTRATION RECORD (MAR) FOR RESIDENT #101 AND DETERMINED THAT SHE SIGNED FOR A DOSE OF [MEDICATION NAME] FOR RESIDENT #101 ON [DATE]. SHE REVIEWED THE CHART AND CONFIRMED THAT THERE WERE NO INR RESULTS AVAILABLE PRIOR TO [DATE]. RN #8 SAID, "I GUESS I DIDN'T CHECK THE LEVEL BEFORE GIVING THAT DOSE." ON [DATE] LPN #11WAS INTERVIEWED AT 9:40 AM BY TELEPHONE. HE SAID HE WAS CALLED BY THE ADMINISTRATOR ON [DATE] AND MADE AWARE OF THE INCIDENT. LPN#11 SAID THAT HE HAD CHECKED THE [DATE] RENEWAL ORDERS AGAINST THE [DATE] ORDERS AND ALL INTERIM ORDERS PRIOR TO [DATE] BEFORE SIGNING THE BOTTOM OF THE ORDERS. LPN#11 SAID THAT HE WROTE ON THE ORDER FORM NEXT TO THE [MEDICATION NAME] ORDER THE PHRASE "NOT PREVIOUSLY ORDERED." LPN #11 STATED THAT ON THE MEDICATION ADMINISTRATION RECORD HE WROTE, "0 (ZERO WITH A LINE THROUGH IT) ORDER." LPN #11 WENT ON TO SAY THAT THE MIDNIGHT NURSE WAS TO CHECK ALL THE RENEWALS FOR THE UNIT AND THAT THE UNIT MANAGER WAS TO DOUBLE CHECK THE ORDERS SO HE (LPN #11) WAS NOT SURE WHY THE ERROR WAS NOT CAUGHT. RN UNIT MANAGER #10 WAS INTERVIEWED BY TELEPHONE ON [DATE] AT 11:00 AM. RN #10 SAID HE WORKED THE 7 AM TO 3:30 PM SHIFT AND HAD 48 CHARTS TO CHECK. HE SAID THAT HE RECALLED THE NIGHT HE CHECKED CHARTS, BECAUSE IT TOOK HIM UNTIL 1 AM TO COMPLETE THE TASK. HE SAID THAT NORMALLY THE CHARTS ARE PRINTED ON THE 20TH OF EACH MONTH AND THAT THE UNIT MANAGERS HAVE TO TAKE TIME OUT OF THEIR DAY TO CHECK THEM ALL. HE SAID THAT HE CHECKED THE "D" HALLWAY LAST AND HE WAS STRUGGLING TO STAY AWAKE. RN UNIT MANAGER #10 STATED THAT HE WAS NO LONGER EMPLOYED BY THE FACILITY. ON [DATE] AT 3:05 PM, DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN) #9 SAID THAT HE WAS NOT AWARE THAT HE HAD MADE A MISTAKE WITH RESIDENT #101'S MEDICATIONS UNTIL HE WAS NOTIFIED BY DON #1. LPN #9 SAID HE WAS REALLY NOT SURE OF EXACTLY WHAT HAPPENED. HE SAID HE TOOK A PHONE ORDER TO DECREASE THE [MEDICATION NAME] FOR RESIDENT #104, BUT THAT HE MUST HAVE WROTE THE ORDER ON RESIDENT #101'S CHART. LPN #9 SAID THAT HE MUST HAVE FAXED THE ORDER FOR RESIDENT #101 TO THE PHARMACY. THEN, AT A LATER TIME, HE CHECKED RESIDENT #104'S CHART AND WHEN HE DID NOT SEE THE [MEDICATION NAME] ORDER, HE ENTERED an order for [REDACTED]. WHEN ASKED IF HE REMOVED THE ERRONEOUS ORDER FROM THE CHART OF RESIDENT #101, LPN #9 SAID HE DID NOT REMOVE IT AND COULD NOT SAY WHO WOULD HAVE REMOVED IT. LPN #9 SAID HE WAS NOT SURE WHY THE NURSE WHO RECEIVED THE [MEDICATION NAME] DELIVERY THE NEXT DAY ([DATE]) DID NOT QUESTION THE ORDER, SINCE RESIDENT #101 HAD NEVER HAD [MEDICATION NAME] PRESCRIBED. A REVIEW OF RESIDENT #104'S CLINICAL RECORD INDICATED THE [MEDICATION NAME] ORDER ON [DATE] FOR "DECREASE [MEDICATION NAME] TO 4 MG DAILY." THE MEDICATION ADMINISTRATION RECORD INDICATED RESIDENT #104 RECEIVED THE CORRECT DOSES OF [MEDICATION NAME]. AT 3:30 PM ON [DATE], DURING AN INTERVIEW WITH THE DON #1 AND REGIONAL DIRECTOR OF CLINICAL OPERATIONS (RDC) #6, RDC #6 SAID THAT THE MEDICATION CART WAS IMMEDIATELY CHECKED ON [DATE]. THERE WAS ONLY ONE BLISTER PACK OF [MEDICATION NAME] FOR RESIDENT #101 WITH 14 PILLS MISSING (16 DOSES WERE SIGNED AS GIVEN ON THE MEDICATION ADMINISTRATION RECORD). RDC #6 SAID THAT [MEDICATION NAME] DOSES CHANGE FREQUENTLY, SO IT WAS NOT ON A CYCLE REFILL. THE DON #1 WAS UNABLE TO EXPLAIN WHY THE NURSE, WHO RECEIVED THE DELIVERY ON [DATE], DID NOT IDENTIFY THAT THE RESIDENT WAS NOT ON [MEDICATION NAME]. ACCORDING TO DON #1, THE FACILITY HAD 24 RESIDENTS WITH ORDERS FOR [MEDICATION NAME], AND THEIR ORDERS WERE ALL CHECKED. [MEDICATION NAME] ADMINISTRATION REEDUCATION BEGAN ON [DATE], CONTINUING THROUGH TO [DATE]. ALL LICENSED STAFF WERE IN-SERVICED ON THE HIGH RISK MEDICATION POLICY, INCLUDING THE IMPORTANCE OF PT/INR MONITORING, CHECKING THE RESULT PRIOR TO ADMINISTERING THE DOSE TO THE RESIDENT, ROUTINE TIMING OF LABORATORY DRAWS AND RESULTS, AND PROPER CHECKING OF ALL RENEWAL ORDERS. THOSE STAFF MEMBERS ON LEAVE OF ABSENCE (LOA) AND/OR VACATION WERE TO BE IN-SERVICED PRIOR TO THEIR FIRST RETURN SHIFT. ON [DATE] AT 12:10 PM, DURING A PHONE INTERVIEW LPN #24 SAID SHE WAS A NEW NURSE AND DID NOT KNOW ANYTHING ABOUT [MEDICATION NAME]. SHE SAID SHE CHECKED HER OTHER PATIENT LIVING ON THE "D" HALLWAY, WHO WAS ON [MEDICATION NAME], FOR THE PT/INR ON MONDAYS WHEN THE RESULTS WERE REPORTED. SHE DID NOT SEE ANY LABORATORY RESULT FOR RESIDENT #101 AND DID NOT LOOK FOR ONE PRIOR TO ADMINISTERING THE DOSE OF [MEDICATION NAME]. SHE SAID THAT SHE GOT A DISCIPLINE AND AN IN-SERVICE AND NOW SHE CHECKS DAILY AND INITIALS IT ON THE [MEDICATION NAME] LOG. ON [DATE], DON #1 PROVIDED DOCUMENTATION OF DISCIPLINARY ACTION FOR THE NURSES INVOLVED IN THE ERRONEOUS ORDER, FOR MONTHLY RENEWAL CHECKS, AND THOSE THAT ADMINISTERED A DOSE WITHOUT FIRST VERIFYING THE PT/INR RESULT. ON [DATE] AT 11:40 AM, A MEETING WAS HELD WITH REGISTERED PHARMACIST (RPH) #20, WHO WAS THE GENERAL MANAGER AND REGIONAL CLINICAL MANAGER #13, OF THE PROVIDING PHARMACY, WITH DON #1 AND RDC #6 PRESENT. RPH #20 SAID THAT THE PHARMACY SERVICE, UPON NOTIFICATION OF THE ERROR, BEGAN AN INTERNAL INVESTIGATION AND DETERMINED THAT THE PHARMACIST IN THE CLINICAL OFFICE FAILED TO COMPLETE A PROFILE REVIEW AND DID AN "OVERRIDE" FOR BOTH THE ORDER CHANGE AND DRUG INTERACTION, WHEN ENTERING THE [MEDICATION NAME] ORDER ON RESIDENT #101'S PROFILE. THE PROVIDING PHARMACY BEGAN A ONE-TO-ONE EDUCATIONAL INTERVENTION TO THE PRIMARY OFFENDER AND THE ENTIRE CLINICAL STAFF (26 ADDITIONAL PHARMACISTS). ON [DATE] AT 10:30 A.M., THE ADMINISTRATOR WAS INFORMED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AS A RESULT OF THE FACILITY'S FAILURE TO ADMINISTER MEDICATIONS ([MEDICATION NAME]) IN AN ACCURATE MANNER, AND WHICH PLACED AN ADDITIONAL 24 RESIDENTS AT HIGH RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #101 RECEIVED VITAMIN K 10MG P.O. ON [DATE] AT APPROXIMATELY 4PM. 2. AN IMMEDIATE PT/INR WAS ORDERED ON [DATE]. 3. RESULTS OF THE PT/INR WERE RECEIVED ON [DATE] AT APPROXIMATELY 2:45AM AND WERE IMMEDIATELY REPORTED TO THE PHYSICIAN, WHO ORDERED RESIDENT #101 TO BE discharged TO THE HOSPITAL FOR FURTHER EVALUATION AND TREATMENT. THE RESULTS WERE: PT 129.8 AND INR 12.6 4. ON [DATE], AN AUDIT OF ALL RESIDENTS RECEIVING [MEDICATION NAME] WAS COMPLETED. THESE AUDITS WERE COMPLETED BY THE UNIT MANAGERS AND THE THREE ASSISTANT DIRECTORS OF NURSING (ADONS). THESE AUDITS INCLUDED CORRECT ORDERS, CORRECT TRANSCRIPTION AND LABORATORY ORDERS FOR MONITORING THE PT/INRS. AN ADDITIONAL AUDIT WAS COMPLETED ON [DATE] BY THE UNIT MANAGERS AND ADONS COMPARING TO THE PHARMACY ANTICOAGULANT LIST. A TOTAL OF 47 CHARTS WERE COMPLETED. 5. ON [DATE], ALL MEDICATION CARTS WERE AUDITED BY THE UNIT MANAGERS, ADONS, CORPORATE SUPPORT NURSE AND THE DON. 11 OUT OF 11 MEDICATION CARTS WERE AUDITED. NO EXTRA [MEDICATION NAME] MEDICATIONS OR INCORRECT [MEDICATION NAME] MEDICATIONS WERE PRESENT. ALL MEDICATION CARTS CONTAINED THE CORRECT DOSES FOR [MEDICATION NAME] MEDICATIONS ACCORDING TO THE physician's orders [REDACTED]. 6. ON [DATE] THE FACILITY INITIATED A PRACTICE TO REVIEW DAILY MONDAY THROUGH FRIDAY ALL NEW [MEDICATION NAME] ORDERS IN THE TRIAGE MEETINGS WITH ALL DEPARTMENT HEADS. THE ADONS WILL BRING ALL NEW ORDERS FOR REVIEW. 7. ON [DATE], WEEKLY [MEDICATION NAME] AUDITS FORMS WERE INITIATED BY THE UNIT MANAGERS AND ADONS AND WILL BE FORWARDED TO THE QUALITY IMPROVEMENT PROCESS COMMITTEE MEMBERS FOR REVIEW. THESE AUDITS WILL INCLUDE: ORDER TRANSCRIPTIONS/CORRECT ORDERS; MEDICATION CART AUDITS; RESULTS OF THE PT/INRS; ANTIBIOTIC ORDERS WITH [MEDICATION NAME] ORDERS; LABORATORY RESULTS/NOTIFYING PHYSICIAN; CARE PLANNING; ALERT STICKERS; AND RESIDENT CARE GUIDE UPDATES (CNA CARE PLANS). 8. A QUALITY IMPROVEMENT PROCESS COMMITTEE MEETING WAS HELD ON [DATE] WITH THE MEDICAL DIRECTOR TO REVIEW PRACTICES ON PT/INR MONITORING, PLAN OF CORRECTION, EDUCATION AND ROLES OF MEDICAL STAFF REGARDING [MEDICATION NAME]. 9. ALL LICENSED NURSES WERE EDUCATED ON: THE PRACTICE FOR LABORATORY TESTING/NOTIFYING THE PHYSICIAN; MUST CHECK LAST PT/INR PRIOR TO ADMINISTERING [MEDICATION NAME]; ENSURING THERE IS A physician's orders [REDACTED]. RENEWAL ORDERS. ALL EDUCATION WAS COMPLETED BETWEEN [DATE] THROUGH [DATE]. 55 OF THE 58 LICENSED NURSES EMPLOYED AT THE FACILITY RECEIVED THE EDUCATION. THE 3 REMAINING NURSES ARE ON A MEDICAL LEAVE OF ABSENCE AND WILL BE EDUCATED PRIOR TO RETURNING TO WORK. 10. LICENSED NURSES INVOLVED IN THE [MEDICATION NAME] ERROR FOR THIS RESIDENT WERE INTERVIEWED AND RECEIVED DISCIPLINARY ACTION BASED ON THEIR INVOLVEMENT IN THE OFFENSE. THE [MEDICATION NAME] WAS ADMINISTERED 16 TIMES BETWEEN [DATE] AND [DATE] BY 8 DIFFERENT NURSES. THE RESIDENT DID NOT RECEIVE [MEDICATION NAME] PRIOR TO THIS TIMEFRAME. ALL 8 NURSES WERE DISCIPLINED BETWEEN [DATE] THROUGH [DATE]. SOME OF THESE NURSES WERE ON HOLIDAY AND RECEIVED DISCIPLINE UPON RETURNING. 11. ON [DATE], A MONTHLY CLINICAL SYSTEMS AUDIT WAS COMPLETED BY UNIT MANAGERS AND ADONS THAT INCLUDED WOUND CARE AND CONTRAINDICATIONS FOR THE USE OF [MEDICATION NAME] THAT WILL BE FORWARDED TO THE QUALITY IMPROVEMENT PROCESS COMMITTEE FOR REVIEW. 12. THE PHARMACY MANAGER WAS NOTIFIED ON [DATE] REGARDING THE [MEDICATION NAME]. EDUCATION FOR THE PHARMACISTS REGARDING THE PHARMACY'S POLICY FOR HIGH RISK DRUGS INCLUDING [MEDICATION NAME] BEGAN ON [DATE]. AS OF [DATE], 5 OUT OF 13 PHARMACISTS HAVE BEEN EDUCATED. PER THE PHARMACY MANGER, THE OTHER 8 PHARMACISTS WERE CURRENTLY ON A LOA OR VACATION. THE PHARMACISTS WILL BE EDUCATED UPON RETURN TO WORK TO THE PHARMACY. THE PHARMACIST THAT WAS DIRECTLY INVOLVED IN THE INCIDENT WILL BE EDUCATED UPON HIS RETURN TO WORK ON [DATE]. 13. ON [DATE], THE MEDICAL DIRECTOR REVIEWED THE IMPORTANCE OF REVIEWING THE ORDERS FOR ACCURACY INCLUDING THE MONTHLY PHYSICIAN ORDER [REDACTED]. THE SAME EDUCATION WAS PROVIDED THROUGH A LETTER FROM THE MEDICAL DIRECTOR TO ALL THE ADDITIONAL 13 ATTENDING PHYSICIANS AT THE CENTER, MAILED ON [DATE]. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON [DATE] WAS REMOVED ON [DATE]. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED.

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 699 AND MI 864 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE A SAFE ENVIRONMENT TO PREVENT A FALL (RESIDENT WAS ROLLED OUT OF BED TO FLOOR BY STAFF, DURING REPOSITIONING) AND FAILED TO PROVIDE A BED ALARM PER THE CARE PLAN, FOR 1 (#106) OF 6 SAMPLED RESIDENTS REVIEWED FOR SAFETY, FROM A TOTAL SAMPLE OF 9 RESIDENTS, RESULTING IN A CLOSED HEAD INJURY, WRIST AND KNEE PAIN AND PERSISTENT PSYCHOLOGICAL DISTRESS (FEAR OF FALLING). FINDINGS INCLUDE: RESIDENT #106 WAS AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. RESIDENT #106'S [DIAGNOSES REDACTED]. PER THE MDS (MINIMUM DATA SET) assessment dated [DATE], RESIDENT #106 WAS ALERT AND ORIENTED, COGNITIVELY INTACT AND ABLE TO MAKE HERSELF UNDERSTOOD AND UNDERSTAND OTHERS. SHE REQUIRED EXTENSIVE TO TOTAL CARE FOR BED MOBILITY AND TRANSFER. FURTHER REVIEW OF RESIDENT #106'S CLINICAL RECORD REVEALED A FALL/INJURY ASSESSMENT, PREVENTION AND MANAGEMENT CARE PLAN DATED 2/1/12 WITH INTERVENTIONS WHICH INCLUDED 2 PERSON ASSIST FOR TRANSFER WITH MECHANICAL LIFT, LOW BED, BED AND CHAIR ALARMS, FLOOR MAT ON EACH SIDE OF BED, AND NIGHT LIGHT. THE CARE PLAN WAS UPDATED ON 3/13/12, ADDING BILATERAL MOBILITY BARS, AND WEAR WRIST SPLINT & ACE (BANDAGE) TO KNEE. AN ADL (ACTIVITIES OF DAILY LIVING) CARE PLAN DATED 2/1/12 DOCUMENTED, "TWO STAFF TO BE PRESENT AT ALL TIMES DURING CARE." ON 3/28/12, AT 9:40 A.M. DURING THE INITIAL TOUR, OBSERVATIONS WERE MADE OF RESIDENT #106 IN HER ROOM AT THE FACILITY. SHE WAS ASLEEP IN A LOW BED WITH A PERIMETER MATTRESS. THE CALL LIGHT WAS ATTACHED TO THE FRONT OF HER GOWN, BILATERAL ASSIST BARS WERE IN PLACE AND SHE WAS HOLDING ON TO THE LEFT ASSIST BAR. BILATERAL FLOOR MATS WERE IN PLACE ON THE FLOOR. NO ALARMS WERE OBSERVED ON RESIDENT #106'S BED. ON 3/28/12 AT 2:10 P.M. THE SURVEYOR ENTERED RESIDENT #106'S ROOM WITH CNA (CERTIFIED NURSING ASSISTANT) #2 AND CNA #17. NO ALARMS WERE OBSERVED ON THE BED. THE SURVEYOR MADE INTRODUCTIONS AND ASKED RESIDENT #106 IF SHE (#106) WOULD ALLOW THE SURVEYOR TO MAKE AN OBSERVATION OF HER CARE AND SHE (#106) AGREED. THE TWO CNAS (#2 AND #17) INFORMED THE RESIDENT OF WHAT THEY WERE GOING TO DO AND RESIDENT #106 SAID, "I'M SCARED." WHEN ASKED BY THE SURVEYOR TO EXPLAIN HER STATEMENT, RESIDENT #106 SAID, "BECAUSE I fell TWO TIMES. THIS BED IS TOO SMALL." CNAS #2 AND #17 PROVIDED CARE TO RESIDENT #106 AND EACH TIME SHE WAS ASSISTED WITH TURNING SHE COMPLAINED SHE WAS "TOO CLOSE TO THE EDGE AND AFRAID." ON 3/28/12 AT 3:00 P.M., THE SURVEYOR INTERVIEWED RESIDENT #106 IN HER ROOM, WHILE SHE WAS LYING IN BED. RESIDENT #106 SAID THAT ON THE DAY SHE fell , SHE HAD USED THE CALL LIGHT TWO TIMES TO CALL FOR ASSISTANCE RELATED TO INCONTINENCE. WHEN THE CNA CAME IN THE SECOND TIME, SHE (THE CNA) TOLD RESIDENT #106 TO "ROLL OVER, AND SHE ROLLED ME BEFORE I COULD TURN OR GRAB THE RAIL. I fell on THE FLOOR ON THE RIGHT SIDE...I LANDED ON MY RIGHT SIDE, MY LEG STILL HURTS....I CAN'T TURN OVER I'M SCARED. I'M AFRAID I'M GOING TO FALL AND I SLEEP HANGING ONTO THIS (RESIDENT #106 GRABBED THE ASSIST BAR)...I DON'T FEEL SAFE TURNING MYSELF, BUT WITH 2 PEOPLE, IT IS OK." PER THE FACILITY "ACCIDENT/INCIDENT REPORT," DATED 3/12/12 AT 5:48 P.M., RESIDENT #106 WAS OBSERVED ON THE FLOOR (IN HER ROOM) BETWEEN THE BED AND TV, WITH RIGHT HIP, ARM, FACE/HEAD ON FLOOR. RESIDENT #106 WAS ASSESSED AND FOUND TO HAVE COMPLAINTS OF PAIN IN RIGHT ARM (SHOULDER & ELBOW), HAND (WRIST & FINGERS) RIGHT LEG (HIP & KNEE). THE REPORT DOCUMENTED THE RESIDENT KNEW THE CAUSE OF THE INCIDENT, HOWEVER, THE SECTION TITLED "REASON" WAS BLANK. THE "WITNESS INVESTIGATION STATEMENT" WRITTEN BY CNA #11 ON 3/12/12 READ, "AS I WAS CHANGING (NAME OF RESIDENT #106) SHE WENT TO ROLL FOR ME AS SHE ALWAYS DOES AND GRABBED THE BAR ON THE RIGHT SIDE OF THE BED, SHE LIFTED HER LEFT LEG AND ROLLED TOO FAR, AND ROLLED OFF THE BED... IN THE CARE PLAN IT STATES SHE IS A 2 (PERSON) ASSIST, BUT (RESIDENT #106) YELLED AT THE OTHER AIDE WHEN I BROUGHT THEM IN, SO BEING THAT SHE ALWAYS ASSISTED ME WITH ROLLING HERSELF OVER AND FEELS UNCOMFORTABLE WITH OTHER PEOPLE BEING THERE, I DID HER AS A ONE PERSON ASSIST FOR HER PRIVACY AND CONVENIENCE." ON 3/29/12 AT 12:10 P.M. CNA #11 WAS INTERVIEWED BY PHONE REGARDING THE INCIDENT. SHE STATED SHE HAD BEEN PROVIDING CARE FOR ANOTHER RESIDENT AND WAS INFORMED BY CNA #12 THAT SHE (#12) HAD CHANGED RESIDENT #106. CNA #12 THEN INFORMED HER (#11) THAT RESIDENT #106 NEEDED TO CHANGED AGAIN. CNA #11 STATED SHE TOLD CNA #12 SHE (#11) "COULD HANDLE IT." CNA #11 THEN TOLD THE SURVEYOR HOW THE RESIDENT HAD ROLLED OVER FOR HER AND ROLLED OUT OF BED. CNA #11 SAID RESIDENT #106 SAID, "NOT AGAIN." CNA #11 SAID SHE WAS NEVER TOLD THAT RESIDENT #106 WAS A 2 PERSON ASSIST, BUT ADDED SHE "HAD NOT CHECKED THE CARE GUIDE FOR A LONG TIME." CNA #11 SAID THAT RESIDENT #106 WAS ALWAYS ONLY A 1 PERSON ASSIST FOR CARE AND NEEDED 2 PERSONS FOR TRANSFERS ONLY. SHE SAID "LOOK AT THE CNA DOCUMENTATION IN THE COMPUTER, IT WILL SHOW EVERYONE PROVIDED HER CARE WITH 1 ASSIST." CNA #11 SAID AFTER THE FALL, NURSE LPN (LICENSED PRACTICAL NURSE ) #13 CALLED HER TO THE ROOM AND SHOWED HER THE CARE GUIDE WHICH SAID RESIDENT #106 WAS A 2 PERSON ASSIST. CNA #11 SAID SHE WAS SENT HOME THEN LATER TERMINATED. THE WITNESS INVESTIGATION STATEMENT WRITTEN BY CNA #12 ON 3/12/12 READ, "I WAS FIRST IN THE ROOM WITH (NAME OF RESIDENT # 106) TO ANSWER HER CALL LIGHT, WHEN CNA #11 CAME IN AND TOLD ME IT WAS HER ROOM AND THAT (RESIDENT #106) WOULD FEEL MORE COMFORTABLE WITH JUST HER (CNA #11)...SO I LEFT THE ROOM." ON 3/29/12 AT 1:15 P.M., CNA #12 WAS INTERVIEWED BY PHONE REGARDING THE INCIDENT. SHE STATED SHE WAS OFF THE UNIT WHEN RESIDENT #106 fell . SHE SAID BEFORE HER BREAK SHE HAD ANSWERED RESIDENT #106'S CALL LIGHT AND SHE HAD REQUESTED TO BE CHANGED. CNA #12 STATED SHE WAS NOT FAMILIAR WITH THE RESIDENT AND ASKED ANOTHER CNA FOR ASSISTANCE (SHE WAS UNABLE TO RECALL THE OTHER CNA'S NAME). CNA #12 SAID THE CALL LIGHT SOUNDED AGAIN A LITTLE LATTER AND SHE WENT IN TO ANSWER IT. WHILE IN THE ROOM CNA #11 ENTERED AND SAID SHE WOULD TAKE CARE OF RESIDENT #106. CNA #12 SAID SHE OFFERED TWICE TO ASSIST AND WAS TOLD BY CNA #11 THAT SHE (#12) WAS NOT NEEDED. ON 3/29/12 AT 1:30 P.M., LPN #13 WAS INTERVIEWED PER PHONE AND SAID THAT ON 3/12/12, SHE WAS IN THE HALL PASSING MEDICATIONS WHEN CNA #11 OPENED RESIDENT #106'S DOOR AND INFORMED HER THE RESIDENT WAS ON THE FLOOR. SHE SAID WHEN SHE ENTERED, RESIDENT #106 WAS ON THE FLOOR ON THE RIGHT SIDE OF THE BED. ACCORDING TO LPN #12, "SHE (#106) WAS YELLING AND CRYING IN PAIN AND SAYING SHE WAS IN PAIN...AND SAID IT HURT ALL OVER." LPN #13 SAID AFTER ASSESSING THE RESIDENT AND GETTING HER BACK IN BED, SHE LOOKED AT RESIDENT #106'S CARE GUIDE WHERE IT WAS DOCUMENTED THAT RESIDENT #106 WAS A 2 PERSON ASSIST. LPN #13 SAID THAT WHEN SHE ASKED CNA #11 ABOUT IT, CNA #11 TOLD HER SHE KNEW THAT SHE (#106) WAS A 2 PERSON ASSIST, BUT THAT RESIDENT #106 DID NOT WANT THE OTHER CNA IN THE ROOM. A REVIEW OF THE OF THE CNA ADL (ACTIVITIES OF DAILY LIVING) DETAILED REPORT DATED 3/1/12 TO 3/13/12, REVEALED 15 DIFFERENT CNAS DOCUMENTED PROVIDING ONE- PERSON ASSISTANCE AND 2 CNAS DOCUMENTED TWO-PERSON ASSISTANCE TO RESIDENT #106 FOR BED MOBILITY. FROM 3/14/12 TO 3/28/12 CNAS DOCUMENTED 20 TIMES PROVIDING A ONE-PERSON ASSIST, AND 26 TIMES PROVIDING A TWO-PERSON ASSIST WITH BED MOBILITY FOR RESIDENT #106. ON 3/30/12 AT 12:05 P.M. THE FACILITY SOCIAL WORKER #9 WAS INTERVIEWED. SOCIAL WORKER #9 SAID SHE HAD VISITED RESIDENT #106 AFTER THE FALL AND THAT RESIDENT #106 HAD VERBALIZED TO HER (SOCIAL WORKER #9) THAT SHE (#106) WAS AFRAID THAT SHE WOULD FALL AGAIN. THE SOCIAL WORKER SAID THAT RESIDENT #106 WANTED FULL SIDE RAILS ON HER BED AND SHE HAD INFORMED HER THAT PER RESTORATIVE NURSING, THE FACILITY DID NOT HAVE FULL SIDE RAILS. THE SOCIAL WORKER SAID THAT THE FACILITY WAS WORKING ON GETTING RESIDENT #106 A LARGER BED. ON 3/28/12 AT 4:25 P.M. AND 4:30 P.M. RESPECTIVELY, CNA #6 AND LPN (LICENSED PRACTICAL NURSE) #7, WERE SHOWN RESIDENT #106'S CARE GUIDE AND ASKED IF THE ALARMS DOCUMENTED ON THE CARE GUIDE WERE IN PLACE. THE CNA, THE LPN AND THE SURVEYOR OBSERVED RESIDENT #106 AND FOUND NO ALARMS IN PLACE. LPN # 7 IMMEDIATELY RETRIEVED A SENSOR ALARM AND PLACED IT RESIDENT #106'S BED. ON 3/29/12 AT 10:00 A.M. CNA #2, WHO HAD BEEN ASSIGNED TO RESIDENT #106 ON 3/28/12, WAS QUERIED REGARDING RESIDENT #106'S ALARM. SHE SAID SHE WAS NOT AWARE THAT RESIDENT #106 WAS TO HAVE AN ALARM. CNA #2 STATED, "I AM NOT GOING TO LIE. I DID NOT CHECK THE CARE GUIDE." CNA #2 SAID THE CARE GUIDE IS NOT ALWAYS ON THE UNIT AND IS SOMETIMES IN SOMEONE'S OFFICE. A REVIEW OF THE HOSPITAL DISCHARGE INSTRUCTIONS DATED 3/13/12 AT 0:01 A.M., DOCUMENTED RESIDENT #106 WAS RETURNED TO THE FACILITY WITH A DISCHARGE [DIAGNOSES REDACTED]." INSTRUCTIONS INCLUDED CARE FOR ABRASIONS AND SPRAINS. ON 3/29/12 AT 10:15 A.M. AND 3/30 12 AT 11:15 A.M. THE DON (DIRECTOR OF NURSING) WAS INTERVIEWED. ON 3/29/12 SHE WAS INFORMED OF THE SURVEYOR'S FINDING REGARDING RESIDENT #106'S ALARM NOT BEING IN PLACE ON DAY SHIFT ON 3/28/12. SHE STATED, "THEN I GUESS WE'LL HAVE TO FIRE MORE PEOPLE." THE DON INFORMED THE SURVEYOR THAT STAFF WERE DOING A COMPLETE AUDIT OF THE BUILDING TO ASSESS COMPLIANCE WITH RESIDENT CARE PLANS AND CARE GUIDES. ON 3/30/12 SHE SAID AT THE TIME OF RESIDENT #106'S FALL, SHE (THE DON) WAS INFORMED BY THE SUPERVISOR OF THE INCIDENT. THE DON SAID IT WAS DETERMINED THAT CNA #11 HAD NOT FOLLOWED THE CARE GUIDE AND WAS SUSPENDED UNTIL THE INCIDENT WAS INVESTIGATED AND WAS THEN TERMINATED. A REVIEW OF CNA #11'S PERSONNEL FILE REVEALED A LETTER OF TERMINATION DATED 3/13/12. A REVIEW OF CNA #11'S IN-SERVICE TRAINING DOCUMENTED SHE HAD BEEN IN-SERVICED REGARDING TRANSFERS, BED MOBILITY AND CARE GUIDE DELIVERY ON HIRE IN 8/11 AND ON 2/10/12. ( )( )

BASED ON RECORD REVIEW AND INTERVIEW THE FACILITY FAILED TO PROVIDE SUFFICIENT AMOUNTS OF ORAL FLUIDS FOR ONE (#404) OF 24 SAMPLED RESIDENTS RESULTING IN hospitalization FOR DEHYDRATION. FINDINGS INCLUDE: ON 11/06/11 AT 3:30 P.M., RESIDENT #404'S CLINICAL RECORD WAS REVIEWED. PER THE FACE SHEET, RESIDENT #404 WAS admitted to the facility on [DATE]. THE [DIAGNOSES REDACTED]. PER THE INITIAL MINIMUM DATA SET (MDS) UNDATED, RESIDENT #404 WAS CODED AS BEING "COGNITIVELY INTACT" AND HAD THE ABILITY TO UNDERSTAND OTHERS AS WELL AS BEING ABLE TO MAKE HERSELF UNDERSTOOD. THE RESIDENT WAS IDENTIFIED AS HAVING DYSPHAGIA (DIFFICULTY AND PAIN ON SWALLOWING), AND REQUIRED A MECHANICALLY ALTERED DIET (CHANGE IN FOOD TEXTURE) TO ASSIST WITH SWALLOWING AND RESIDENT #404 REQUIRED EXTENSIVE ASSISTANCE FROM STAFF TO EAT. THE "NURSING COMPREHENSIVE ADMISSION DATA COLLECTION AND ASSESSMENT," DATED 10/24/11, DESCRIBED RESIDENT #404'S LIPS AS BEING "ROUGH" AND HER SKIN WAS "DRY". THERE WAS NO FURTHER ASSESSMENT. THE DATA COLLECTION TOOL DID NOT ASSESS EATING ABILITY. THE FACILITY DOCUMENT ENTITLED "NUTRITION RISK DATA COLLECTION AND ASSESSMENT," DATED 10/26/11, DOCUMENTED THE FOLLOWING: "INADEQUATE INTAKE SECONDARY TO ALTERED TEXTURE DIET AS EVIDENCED BY RESIDENT CONSUMING 25% OF MEALS. REFERRED TO SLP (SPEECH LANGUAGE PATHOLOGY) TO CONFIRM APPROPRIATE DIET....MONITOR PO (BY MOUTH) INTAKE, LABS AS AVAILABLE, WEEKLY WEIGHTS." IN ADDITION, THE NUTRITION ASSESSMENT REVEALED THAT THE RESIDENT HAD DIFFICULTY SWALLOWING, REQUIRED ASSISTANCE WITH FEEDING AND HAD A BLOOD UREA NITROGEN (BUN) OF 29. (A HIGH BUN IS AN INDICATOR OF DEHYDRATION--THE NORMAL REFERENCE RANGE OF BUN WAS 7-25 MILLIGRAMS PER DECILITER). A DYSPHAGIA (LEVEL ONE) DIET WITH NECTAR THICKENED LIQUIDS WAS RECOMMENDED FOR RESIDENT #404. THE ESTIMATED FLUID NEEDS FOR RESIDENT #404 WAS 1700 CC'S AND THE ESTIMATED NUMBER OF CALORIES REQUIRED WAS 1273 TO 1655 CALORIES (ESTIMATED TO MEET HER DIETARY NEEDS). FURTHER REVIEW OF THE CLINICAL RECORD REVEALED THERE WAS NO HYDRATION OR NUTRITION CARE PLAN DEVELOPED. NURSES NOTES REVEALED THE FOLLOWING: 1. 10/24/11 "CERTIFIED NURSE ASSISTANT (CNA) ASSISTED WITH FEEDING. 2. 10/26/11 "RESIDENT CONFUSED" 3. 10/26/11 "POOR APPETITE AT DINNER" 4. 10/27/11 "INCREASED CONFUSION" 10/28/11 "PATIENT IS CONFUSED" 5. 10/30/11 "ATE 25% DINNER IN THE ROOM BEING FED BY STAFF. FAMILY ATTEMPTED TO GIVE THIN LIQUIDS...REMAINS CONFUSED" 6. 10/31/11 "REMAINS CONFUSED...RESIDENT REFUSES NECTAR THICK LIQUIDS, MED PASS SUPPLEMENT AND MEALS BREAKFAST AND LUNCH". 7. 11/2/11 "POOR PO (ORAL) INTAKE, CONTINUES TO REFUSE THICKENED LIQUIDS. VERY LETHARGIC. PHYSICIAN IN TO SEE RESIDENT THIS MORNING AND WANTS RESIDENT TRANSFERRED TO emergency room ... EVALUATE AND TREAT FOR ACUTE [MEDICAL CONDITION] AND DEHYDRATION". REVIEW OF THE "MEAL AND FLUIDS CHART DETAIL REPORT" FOR RESIDENT #404 REVEALED STAFF DOCUMENTED THE RESIDENT CONSUMED "NO" FLUIDS THE EVENING OF 10/24/11 AND A TOTAL OF 270 CC'S OF FLUID ( 30 CC'S EQUALS ONE OUNCE) ON 10/25/11, THEREFORE, RESIDENT #404 CONSUMED APPROXIMATELY 9 1/2 OUNCES OF FLUID ON 10/25/11. DOCUMENTATION FOR SUBSEQUENT DAYS WAS AS FOLLOWS: 10/26/11--A TOTAL OF 180 CC'S OF FLUID (APPROXIMATELY 6 OUNCES) WAS CONSUMED. 10/27/11--A TOTAL OF 630 CC'S OF FLUID (APPROXIMATELY 21 OUNCES) WAS CONSUMED. ON 10/28/11--A TOTAL OF 720 CC'S OF FLUID (APPROXIMATELY 24 OUNCES) WAS CONSUMED. ON 10/29/11--A TOTAL OF 120 CC'S OF FLUID (APPROXIMATELY 4 OUNCES) WAS CONSUMED. ON 10/30/11--A TOTAL OF 300 CC'S OF FLUID (APPROXIMATELY 10 OUNCES) WAS CONSUMED. ON 10/31/11--A TOTAL OF 748 CC'S OF FLUID (APPROXIMATELY 25 OUNCES) WAS CONSUMED. ON 11/01/11--A TOTAL OF 150 CC'S OF FLUID (APPROXIMATELY 5 OUNCES) WAS CONSUMED. REVIEW OF A LABORATORY REPORT, DATED 11/01/11, REVEALED RESIDENT #404'S BUN WAS 82 (REFERENCE RANGE 7-25MG/DL) AND [MEDICATION NAME] LEVEL WAS 1.73 (REFERENCE RANGE 0.62 TO 1.22 MG/DL--CREATININE IS A SUBSTANCE FILTERED OUT OF THE BLOOD BY THE KIDNEYS. MEASUREMENT OF CREATININE IS IMPORTANT TO ASSESS KIDNEY FUNCTION AND AFFECTS SYSTEMS FUNCTIONING IN THE BODY). THE PHYSICIAN ORDERED "HYPODERMOCLYSIS NS (NORMAL SALINE 0.9% AT 75 ML (MILLILITERS) PER HOUR TIMES 24 HOURS" (Hypodermoclysis IS A TECHNIQUE FOR TREATING DEHYDRATION AND WATER-ELECTROLYTE IMBALANCE BY INFUSING FLUID, ALSO CALLED REHYDRATING SOLUTION, SUBCUTANEOUSLY (IN THE ABDOMEN). REVIEW OF A physician progress notes [REDACTED]." THE PHYSICIAN ORDERED FOR RESIDENT #404 TO BE "TRANSFERRED TO emergency room . EVALUATION AND TREATMENT. DEHYDRATION AND ACUTE [MEDICAL CONDITION]." ON 11/06/11 AT 3:45 P.M., NURSE 'W' WAS QUERIED REGARDING HOW SHE MONITORED RESIDENT #404'S ORAL/FLUID INTAKE PRIOR TO hospitalization on [DATE]. NURSE 'W' STATED, "I NOTICED THAT SHE WAS TAKING IN ABOUT 50 PERCENT OF HER MEALS BEFORE SHE WAS SENT OUT." NURSE 'W' WAS UNABLE TO EXPLAIN "HOW" FLUID ACCEPTANCE WAS MONITORED. ON 11/8/11 AT 8:45 A.M., CERTIFIED NURSE ASSISTANT (CNA) 'M' WAS QUERIED REGARDING "HOW" SHE MONITORED THE ORAL/FLUID INTAKE OF RESIDENT #404. CNA 'M ' STATED, "IF THE RESIDENT ATE LESS THAN 50 PERCENT--WE REPORT THAT TO THE NURSE." CNA 'M' INDICATED SHE DID NOT REPORT A DECLINE IN FLUID INTAKE TO THE NURSE. A DOCUMENT ENTITLED, "POST ACUTE/CHANGE OF CONDITION MONITORING RECORD," DATED 10/24/11 - 10/28/11, WAS "BLANK" AND THERE WERE NO CARDIAC, BREATHING, HYDRATION PROBLEMS IDENTIFIED. ON 11/9/11 AT 12:45 P.M., THE DIRECTOR OF NURSING (DON) AND THE ADMINISTRATOR WERE QUERIED VIA TELEPHONE REGARDING RESIDENT #404'S HYDRATION. THE DON WAS ASKED WHAT INTERVENTIONS WERE IMPLEMENTED AFTER THE NURSING STAFF INDICATED RESIDENT #404 HAD DECREASED ORAL/FLUID INTAKE ON ADMISSION AND AN ELEVATED BUN OF 29 ON ADMISSION (10/24/11). THE DON STATED, "WE WERE TRYING TO HYDRATE HER ORALLY." THE DON WAS ASKED TO PROVIDE DOCUMENTATION OR EVIDENCE OF STAFF ATTEMPTS TO ORALLY HYDRATE RESIDENT #404. NO WRITTEN DOCUMENTATION, OTHER THAN THE ADMINISTRATION OF MED PASS SUPPLEMENT, IMPLEMENTED ON 10/26/11, WAS PROVIDED. THE DON WAS ASKED IF ANY ADDITIONAL INTERVENTIONS WERE IMPLEMENTED TO PREVENT RESIDENT #404 FROM BECOMING DEHYDRATED SINCE THE RESIDENT CONTINUED WITH DOCUMENTED DECREASED ORAL FLUID INTAKE. THE DON AND THE ADMINISTRATOR WERE UNABLE TO EXPLAIN. THE "MEAL AND FLUIDS CHART DETAIL REPORT" WAS REVIEWED WITH THE DON AND THE ADMINISTRATOR. RESIDENT #404 AVERAGED FLUID INTAKE FROM 10/24 TO 11/01/11 WAS 263 CC'S EACH DAY. AS INDICATED IN THE NUTRITIONAL ASSESSMENT, DATED 10/26/11, RESIDENT #404 REQUIRED 1704 CC'S PER DAY ACCORDING TO HER WEIGHT. IN ADDITION, THE "CHART" REVEALED THAT RESIDENT #404 REFUSED ALL OR MOST OF HER MEALS (APPROXIMATELY 29 TIMES) PRIOR TO THE RESIDENT BEING hospitalized for [REDACTED].#404 FROM BECOMING DEHYDRATED. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT WATER TEMPERATURES AT HANDWASHING AND LAVATORY SINKS ON THE NORTH UNIT WERE AT A SAFE RANGE FOR FIVE (#'S 401, 416, 424, 425, AND 426) OF 27 SAMPLED RESIDENTS AND TWO OFF-SAMPLED RESIDENTS (#108 AND #122). THE HOT WATER TEMPERATURES MEASURED BETWEEN 120.4 TO 131.7 DEGREES FAHRENHEIT (F), RESULTING IN AN IMMEDIATE JEOPARDY (IJ) CAUSED BY THE POTENTIAL FOR SERIOUS BURNS. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 1/25/11 AT 12:55 PM. THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY ON 1/25/11 AT 4:45 PM. THE IJ WAS REMOVED ON 1/26/11 WHEN A PLAN OF CORRECTION (POC) WAS SUBMITTED BY THE FACILITY. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS ISOLATED, NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 1/25/11 AT 10:30 AM, DURING A TOUR OF THE FACILITY WITH THE MAINTENANCE ASSISTANT, HOT WATER TEMPERATURES OF 120.3 DEGREES F. WERE MEASURED IN RESIDENT #108'S HAND SINK AND 120.4 DEGREES F. IN RESIDENT #122'S HAND SINK. WHEN THESE TEMPERATURES WERE OBTAINED, THE MAINTENANCE ASSISTANT ATTEMPTED TO ADJUST THE TEMPERATURES BUT COULD NOT DO SO. HE REPLIED, "I NEED AN ALLEN WRENCH FROM THE TOOL KIT." ON 1/25/11 AT 12:55 PM, THE HOT WATER TEMPERATURES STILL HAD NOT BEEN ADJUSTED. THE MAINTENANCE STAFF WERE UNABLE TO STATE WHY. THE TEMPERATURES WERE THEN MEASURED TO RANGE FROM 121.6 TO 131.7, IN ROOMS OF RESIDENT #'S 401, 416, 424, 425, 426, AND FOR RESIDENT #108 (WHEN CHECKED THE SECOND TIME). RESIDENT #401=121.6 DEGREES F. (FAHRENHEIT) IN THE HAND SINK (LOCATED DIRECTLY IN THE ROOM). RESIDENT #416=127 DEGREES F. IN THE HAND SINK. RESIDENT #424=123 DEGREES F. IN THE LAVATORY SINK AND 124.5 DEGREES F. IN THE HAND SINK. RESIDENT #425=131.7 DEGREES F. IN THE HAND SINK. RESIDENT #426=124.7 DEGREES F. IN THE HAND SINK. RESIDENT #108=120.3 DEGREES F. AND 121.8 DEGREES F. IN THE HAND SINK. RESIDENT #122=120.4 DEGREES F. IN THE HAND SINK. RESIDENT #401 WAS OBSERVED TO BE COMPLETELY IMMOBILE AND NON-VERBAL. THE RESIDENT REQUIRED TOTAL CARE FROM STAFF FOR ALL ACTIVITIES OF DAILY LIVING, THUS UNABLE TO USE THE HAND SINK. RESIDENTS #'S 424, 426, AND 108 STATED THAT THEY USED THE HAND SINKS IN THEIR ROOMS TO PERFORM PERSONAL HYGIENE, WHEN QUERIED. RESIDENT #'S 416 AND 425 WERE ABLE TO USE THE SINKS FOR HANDWASHING AND TO PERFORM PERSONAL CARE WITH MINIMAL ASSISTANCE, ACCORDING TO STAFF; RESIDENT #416 HAD PERIODS OF CONFUSION AND RESIDENT #425 WAS [AGE] years OLD WITH THIN AND FRAGILE SKIN. ON 1/26/11 AT 10 A.M., MAINTENANCE SUPERVISOR 'K' WAS QUERIED REGARDING THE FREQUENCY OF CHECKING THE FACILITY'S HOT WATER TEMPERATURES. SUPERVISOR 'K' STATED THAT HOT WATER TEMPERATURES WERE CHECKED ONCE A MONTH. PREVENTATIVE MAINTENANCE LOG SHEETS WERE OBSERVED TO BE FILLED OUT FOR OCTOBER, NOVEMBER, AND DECEMBER (2010). HOWEVER, THE SAME ROOMS WERE CHECKED EACH MONTH, NONE OF WHICH WERE THE AFFECTED ROOMS. THIS WAS INSUFFICIENT SINCE ROOMS ON THE NORTH UNIT WERE PART OF A NEWER ADDITION WHICH HAD MIXING VALVES FOR EACH LAVATORY IN EACH BED ROOM AND TOILET ROOM. REVIEW OF THE FACILITY'S IMMEDIATE PLAN OF CORRECTION (POC) REVEALED THE FOLLOWING INTERVENTIONS: 1. WATER TEMPERATURES WERE MONITORED AND RECORDED FOR SINKS ON THE NORTH UNIT EVERY TWO HOURS; RESIDENTS WERE TO BE REMOVED FROM ROOMS AND MIXING VALVES ADJUSTED FOR TEMPERATURES ABOVE A SAFE RANGE. 2. STAFF PRESENT IN THE BUILDING BETWEEN 5 PM AND 7 PM ON 1/25/11, WERE IN-SERVICED AS TO RECOGNITION OF APPROPRIATE WATER TEMPERATURES AND REPORTING PROCEDURES. IN-SERVICING CONTINUED THROUGHOUT THE NIGHT FOR THE MIDNIGHT SHIFT ON 1/25/11 AND FOR ON-COMING DAY AND AFTERNOON STAFF ON 1/26/11. ALL STAFF WILL BE INSERVICED BEFORE RETURNING TO WORK. 3. MAINTENANCE AND ADMINISTRATIVE STAFF WERE ASSIGNED TO TAKE WATER TEMPERATURES EVERY TWO HOURS FOR THE NEXT 24-HOURS (5 PM ON 1/25/11 TO 5 PM ON 1/26/11) IN ALL RESIDENT ROOMS ON THE NORTH UNIT. RESIDENTS WERE TO BE REMOVED FROM ROOMS AND MIXING VALVES ADJUSTED IF TEMPERATURES WERE ABOVE AN ACCEPTABLE RANGE. THE RESULTS OF THE TEMPERATURE MONITORING WAS REPORTED TO THE ADMINISTRATOR, WHO WILL BE RESPONSIBLE FOR CONTINUED COMPLIANCE. ( ) ( ) ( ) ( ) ( ) ( ) ( )