Every finding on record at The Neighborhoods of White Lake

This citation pertains to intake #3020495 Based on observation, interview, and record review the facility failed to ensure adequate staffing to meet resident's needs for 13 residents (R#'s 10, 46, 32, 50, 23, 31, 8, 49, 38, 2, 18, 21, and 8) of 13 residents reviewed for staffing, resulting in verbalized complaints and frustration with receiving timely care. This deficient practice had the potential to affect all 39 residents residing in the facility. Findings include: On 7/27/26 at 9:24 AM, an interview was conducted with R10, who had intact cognition. They were asked about their stay in the facility and said the facility was short of staff on the unit saying, There is the bare minimum for staff. They were asked what types of things made them believe the facility was short of staff and said they experienced long wait times when requesting assistance. They further reported most of the time there was only one staff member (either a nurse or an aide) on their unit. When asked how long they had to wait they said a couple of times it was more than 45 minutes. On 7/27/26 at 9:30 AM, an interview was conducted with R46, who had intact cognition. They were asked if they had any concerns about their stay in the facility and said, They are short of staff. When asked what made them believe the facility was short of staff, they said they had to wait up to an hour for someone to answer their call light and experienced delays getting assistance to get out of bed. They further said they noticed the nursing staff passing and cleaning up trays for the meal services and during those times staff could not help the residents. On 7/27/26 at 9:36 AM, an interview was conducted with R32, who had intact cognition. R32 was asked about their stay in the facility and complained about staffing on the night shift and meals being delivered late. R32 was asked what things made them believe there were not enough staff and said; a while ago (they did not recall the exact date) the resident next door (R50) fell and could be heard by R32 verbally calling out for help. When asked how long they heard R50 calling out for help, they said 30 to 40 minutes before staff were available to help them. They were asked about the late meals and said they did not think there were enough staff to care for the residents and serve the meals timely because the nursing staff had to perform dining duties, and care for residents. On 7/27/26 at 9:44 AM, an interview was conducted with R23, who had intact cognition. They said they had been in the facility for three weeks. They were asked about their stay and said they experienced long wait times to go to the bathroom. They further said the facility would frequently send one of the two aides from the second-floor home. They were asked how they knew the facility sent an aide home and said the remaining aide would tell them they sent the other aide home, their wait times were longer, and when they received care, the aide would tell them they had to come from another area of the building to answer their light. On 7/27/26 at 10:38 AM, an interview was conducted with R49, who had intact cognition. They were asked about their stay in the building and said the meals were frequently served late. They were asked if they knew why and said it was because there were not enough staff. They said the aides and the nurse on the unit were responsible for passing and cleaning up meal trays, but if they also had to answer call lights and tend to resident needs, the meals were delayed. On 7/27/26 at 1:14 PM, during an initial interview with R31, a cognitively intact resident who required minimal care from staff, frustratedly voiced concern there were some residents who required more care from a CNA (Certfifed Nurse Aide) and there are times when there were not enough CNAs to assist. Per R31, the facility would send CNA's home, So they can save money. On 7/27/26 at 2:54 PM, R8 was observed with two CNA's transferring them from their wheelchair into bed via a mechanical transfer lift device. R8, a cognitively intact resident, voiced concern questioning when there were two CNA's helping them, who provided care for the other residents? When asked why they questioned this, R8 said there were times when they noticed the CNA's are short staffed and said they were concerned for the other residents who can't speak for themselves. On 7/28/26 at 8:28 AM, Licensed Practical Nurse (LPN) C confirmed they were the nurse for the entire first floor and usually had two CNAs. LPN C said there was a problem with staffing for the CNA's when the census on the second floor was decreased, a CNA would be sent home. They further reported that instead of sending a CNA home, they often could use them for assistance on the first floor. When asked if they get assistance from other nurses or managers when needed, LPN C had no comment. On 7/28/26 at 8:40 AM, R49 and R23 were observed in the dining area on the East Lake Unit awaiting the breakfast meal. There were no staff present and R23 remarked, We are still here waiting. R38 and R50 joined R23 and R49 in the dining room and staff started to appear. At 8:46 AM, Dietary Staff 'I' began building the meal trays from the serving station on the unit. The observation of the dining area and room tray pass was concluded at 9:30 AM, and it was not observed R32 received their meal tray. On 7/28/26 at 10:15 AM, a review of the facility provided resident council meeting minutes was conducted and revealed that in the meeting on 2/23/26 the residents complained of long call light response times, it was noted there was no facility follow-up response documented. Continued review of the minutes revealed that in the meeting on 6/29/26 the residents complained about the wait times for lunch and dinner, however; the response provided only addressed concerns with food temperatures, not the long wait times for the meal. On 7/28/26 at 10:30 AM, a resident council meeting with the State Agency was conducted. There were four attendees (R#'s 2, 18, 31, and 8) who were cognitively intact and regularly participated in the facility resident council meetings. The meeting began with an open-ended question asking if the attendees had any concerns about their stay at the facility. The question was met with all attendees expressing complaints about facility staffing. They said staff are busy and can't answer the call lights and they must wait for extended periods to have their needs met. When asked what needs, they indicated they had to wait for assistance out of bed and to use the bathroom. One attendee said the CNA's both answer call lights and serve the meals and this results in either late meals, or call lights not being answered timely during a meal service. They further reported they were aware the facility would sometimes send one of the CNA's home leaving three for the building. The residents further opined the facility was trying to, save money by not providing enough staff to meet their needs. On 7/28/26 at 12:30 PM, an interview was conducted with CNA 'J'. They were asked about their role with meal service. They explained they set up the trays with the cups and utensils, and dietary staff plated the meals. After the meals were plated, they were responsible for serving residents in the dining room and delivering room trays. They were asked what happened if a call light went off when they were serving meals, they said they would answer the call light, and the nurse would take over serving. They were further asked what happened if the nurse was busy and not able to deliver trays and they said the meal service stopped until someone was available to resume serving. They were asked if any other staff such as managers came out to help and said, Sometimes, not often. CNA 'J' was then asked about staffing in general and said each of the two units upstairs had one nurse and one CNA, and the two units downstairs shared a nurse and had one CNA per unit. They further said sometimes the facility would send one of the four CNA's home leaving three CNA's for four units on two floors requiring a CNA to have residents assigned both upstairs and downstairs. When asked if they were able to get all their work done when a CNA had been sent home, they said, We could use more help. On 7/29/26 At 9:14 AM, an interview was conducted with Nurse 'K'. They were asked about staffing and said sometimes they send a CNA home leaving three aides for four units requiring one aide to split upstairs and downstairs making it an issue to meet all the resident's needs in a timely manner. On 7/29/26 at 9:22 AM, an interview was conducted with Nurse Unit Manager 'M'. They were asked about the facility's staffing and said when the census was lower, they would send one CNA home leaving three for the building and one CNA would have resident's assigned on both the first and second floors. They were asked what happened if it were mealtime, the CNA assigned to both floors was on the first floor providing care and both nurses upstairs were busy, what happened with the meal service; and they said the meal service would stop until the nurses and the CNA's were available to resume. On 7/29/26 at 8:50 AM, an interview was conducted with CNA 'L'. They were asked about staffing and said sometimes they would send one CNA home leaving three in the building with one having to split residents on the first and second floor. They were asked if it was difficult to meet the resident's needs with that assignment and said it was. On 7/29/26 at 10:03 AM, an interview was conducted with the facility's Director of Nursing (DON), and they were asked about staffing. They acknowledged that sometimes the facility sent a CNA home leaving three in the building requiring one to split residents on the first and second floors. They were asked if they had identified any concerns with staffing and having a CNA cover both floors and said they met the, Required staffing numbers. On 7/29/26 at approximately 12:40 PM, a Quality Assessment and Assurance (QAA) interview was conducted with the Administrator. The Administrator was queried about the QA committees Performance Improvement Project(s). They reported they had been working on staffing, specifically call light response and noted they received multiple grievances starting in January 2026 that noted nursing staff were not responding timely to resident's call lights. They indicated that they initially saw some improvement, but again in March 2026 they noted a decline and continued to work on decreasing the resident's wait time. The facility reported via e-mail on 7/29/26 at 12:39 PM, they did not have a specific policy for staffing beyond what was kept in the facility assessment. A review of the facility provided assessment was conducted and read, .The facility provides person centered, competent care that helps each person served to live their life as they wish. The services and care provided assist people to reach their highest level of practicable potential and maintain their ability to participate in life activities as long as they are able.Resident Care and Services based on the needs of our resident population. The facility provides care and services based on the needs of our resident population.

This citation pertains to Intake Number: MI00149932 and MI00150088. Based on interview and record review, the facility failed to ensure physical restraints were not used for staff convenience for one (R702) of two residents reviewed for abuse, resulting in staff tying the resident's drawstring pants in the back so that he could not remove them. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 1/21/25 that noted R702 expressed a grievance on 1/16/25 regarding a concern they had with bed positioning during a brief change while being assisted by Certified Nursing Assistant (CNA) 'A'. An unannounced, onsite investigated was conducted on 2/27/25. A review of R702's clinical record revealed R702 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included: cerebral infarction, hemiplegia affecting right dominant side, prostate cancer, and dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R702 had severely impaired cognition, no behaviors, was frequently incontinent of urine, and did not use restraints. A review of R702's nursing progress notes revealed R702 was continent of urine, but wore a brief. On 12/25/24, R702 was observed on the floor with a soiled brief next to him. On 1/7/25, Resident was observed with brief balled up and thrown off the bed. Pad rolled up and noted on floor next to resident. Resident wearing only t-shirt, blanket soiled with urine . A review of an investigation conducted by the facility in regards to R702's grievance against CNA 'A' revealed the following: An .Investigation Summary . documented, On 1/16/2025 (R702) reported concern to Nurse .regarding being changed on the previous midnight shift. Resident said the CNA kept moving him from side to side when she was changing him . A Staff Interview Summary indicated CNA 'A' was interviewed on 1/21/25. The summary of the statement/interview included the following: .(CNA 'A') indicated (R702) was not wet but when she began changing him he started going (urine) .Resident stated, 'I'm not playing with myself' as his pants were down partially per CNA when she came into room. (CNA 'A') .did indicate when putting PJ's on (drawstring in back) he raised his arm .(CNA 'A') indicated (R702) said, 'I don't want them tight' referring to his pajamas. (CNA 'A') states she told (Registered Nurse - RN 'C') about the interaction . On 2/27/25 at 10:58 AM, an interview was conducted with CNA 'A' via the telephone. CNA 'A' indicated they worked at the facility but they were terminated from employment on 1/27/25. When queried about what occurred with R702 on 1/16/25, CNA 'A' reported the resident said they tried to roll him off the bed and then tried to hit CNA 'A' because he thought he was going to fall. CNA 'A' further explained R702 became anxious and said I can't breathe! when CNA 'A was putting the resident's pajama pants back on after a brief change. According to CNA 'A', R702 said he did not want the pajamas tied too tight and CNA 'A' assured him that they would be loose enough. CNA 'A' explained they tied the drawstring to R702's pajamas pants in the back instead of the front that night because that was what the other CNAs had been doing. CNA 'A' reported she previously notified RN 'C' about the other CNAs tying R702's pants in the back and RN 'C' said she was aware. CNA 'A' reported it was the first time that she tied the pants in the back that night (1/16/25) and since the nurse was aware she did not think it was a problem. When queried about why R702's pants were being tied in the back instead of the front, CNA 'A' stated, He kept stripping and peeing all over himself and the bedding. It slows him down and he wasn't getting them off like that. CNA 'A' reported she first found out about tying R702's pants in the back from CNA 'E' who said they had been doing that with R702 to prevent him from taking his pants off. On 2/27/25 at 12:43 PM, a telephone interview was attempted with RN 'C'. RN 'C' was not available prior to the end of the survey. On 2/27/25 at 2:16 PM, a telephone interview was attempted with CNA 'E'. CNA 'E' was not available prior to the end of the survey. A review of CNA 'A's personnel file revealed a document titled, Termination dated 1/16/25. The Corrective Action reason was Policy Violation. The following was documented, For resident 1 person assist did not use gait belt and did not follow the proper procedure as well as resident restraint. On 2/27/25 at 1:30 PM, an interview was conducted with the Administrator who was the designated Abuse Coordinator for the facility. When queried about the investigation conducted by the facility in regards to R702's grievance about the care provided by CNA 'A', the Administrator reported R702 said CNA 'A' 'turned him from side to side when giving care' and he did not feel like she needed to do that. The Administrator reported CNA 'A' was immediately removed from R702's care and the concern was reported to the State Agency as an allegation of abuse. When queried about why turning the resident from side to side was considered abuse and was there anything else that was concerning, the Administrator stated, There was also something about her (CNA 'A') putting his (R702) pants on incorrectly. When queried about what happened with R702's pants, the Administrator reviewed the facility's investigation and stated, Never mind. There is nothing about the pants. When queried about the Termination document in CNA 'A's personnel file that documented resident restraint as part of the reason they were terminated from employment, the Administrator stated, There were no restraints. When queried about tying a resident's pants in the back so that they were unable to remove them, the Administrator reported that would be considered a restraint. On 2/27/25 at approximately 1:45 PM, an interview was conducted with the Regional Human Resources Director, HR 'D' and the Administrator. HR 'D' reported CNA 'A' was terminated for not using a gait belt with another resident. When queried about why it was documented that CNA 'A' was also terminated for resident restraint, HR 'D' reported CNA 'A' told them that she tied R702's pants backwards and R702 had already been discharged from the facility. When queried about what was done to ensure not other staff were restraining residents this way, the Administrator reported CNA 'A' just reported it during an interview and no other action was taken to ensure other residents were not being restrained. A review of a facility policy titled, Restraint Free Environment dated May 2008 revealed, It is the intention and goal of this community to strive to be a restraint free community. To provide the elder/resident with the choices, dignity and independence that they deserve living in this community as they would from their individual home .

This citation pertains to Intake #MI00149932 Based on observation, interview and record review the facility failed to ensure residents were transferred with a gait belt per facility protocol for one (R701) of two residents reviewed for care. Findings include: A FRI (facility reported incident) was submitted to the State Agency (SA) that reported R701 alleged that they were treated roughly by CNA (certified nursing assistant) A. A review of the intake provided to the SA and accompanied investigation forms documented, in part, the following: .Grievance reported by another resident .When social worker interviewed like resident on 1/20/25, R701 indicated that CNA A is rough with transfers placing her hard on toilet seat and wheelchair .CNA remains suspended pending further investigation .Conclusion: Based on investigation and interview the facility cannot substantiate abuse or neglect .Staff Interview Summary .Do you recall if she landed hard in her wheelchair or on toilet? I can remember a few times she landed hard in her wheelchair. I just guide her when transferring .I did not use a gait belt because I just guide her . A Summary of Investigation and findings noted the following: . Resident transfers to wheelchair likely resulted in resident sitting down hard .only guiding resident. Staff correction action related to use of gait belt for all transfers with residents . On 2/27/25 at 10:58 AM, an interview was conducted with CNA 'A' via the telephone. CNA 'A' indicated they worked at the facility but they were terminated from employment on 1/27/25. CNA A was queried as to allegations made by R701 and why they were terminated from the facility. CNA A reported they were interviewed about how they provided care for R701. CNA A explained they were told they did not use a gait belt during a transfer. CNA A reported that they did not understand why they were terminated for failing to use a gait belt as other staff did not use a gait belt and they felt the resident just needed supervision. On 2/27/25 at approximately 1:05 PM, R701 was observed sitting in their room in their wheelchair. The resident was asked how staff helped them get from their bed to their wheelchair and they stated that staff will put their hands on their chair and then staff will say, one, two, three and then lift them up under their arms. When asked if a gait belt was used, they indicated no. CNA F who was assigned to R701 was interviewed in R701's room. CNA F was asked how they transferred R701 and reported that they use their gait belt. During the interview, again R701 noted that they did not believe staff used a gait belt to transfer them. A review of R701's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: peripheral vascular disease, type II diabetes, and unsteadiness on feet. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 14/15 (intact cognition). On 2/27/25 at approximately 1:30 PM, the Administrator/Abuse coordinator was interviewed regarding the FRI that was submitted based on R701's allegation of rough treatment by CNA A. The Administrator reported that R701 made allegations that they were treated roughly by CNA 'A specifically when being placed on the toilet. They indicated that following an interview with CNA A they determined that CNA A was not using a gait belt per facility policy and that could have contributed to R701's allegation. A review of the facility policy titled, Safe Lifting/Handling/Repositioning of Resident (11/2022) documented, in part, .To provide a safe working environment focused on associate safety, resident safety and overall injury protection .Employees are required to successfully complete appropriate training use .equipment when necessary .2. Gait Belts: To be used with residents who need assistance with transfers/standing/walking or balances .The gait belt provides a secure firm hold to help stabilize and handle residents during ambulation and transfer .

This citation pertains to Intake Number: MI00150088. Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse for one ( R702) of two residents reviewed for abuse. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 1/21/25 that noted R702 expressed a grievance on 1/16/25 regarding a concern they had with bed positioning during a brief change while being assisted by Certified Nursing Assistant (CNA) 'A'. An unannounced, onsite investigated was conducted on 2/27/25. A review of R702's clinical record revealed R702 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included: cerebral infarction, hemiplegia affecting right dominant side, prostate cancer, and dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R702 had severely impaired cognition, no behaviors, was frequently incontinent of urine, and did not use restraints. A review of an investigation conducted by the facility in regards to R702's grievance against CNA 'A' revealed the following: An .Investigation Summary . documented, On 1/16/2025 (R702) reported concern to Nurse .regarding being changed on the previous midnight shift. Resident said the CNA kept moving him from side to side when she was changing him . It was further documented that R702 put his arm up and the CNA (CNA 'A') said, You don't have the authority to touch me. The summary noted, During interview with (CNA 'A') .she recalled caring for (R702) .Resident was noted to have a pull up on at the time. (CNA 'A') indicated he was not soiled but was going to put a brief on. Resident's pants were partially pulled down and resident indicated, 'I am not playing with myself'. (CNA 'A') indicated that resident assisted in rolling from side to side to place the brief. CNA indicated that when rolling putting his pajamas back on the resident raised his arm. CNA indicated she thought the resident was attempting to strike her and said, 'You don't touch me'. (CNA 'A') indicated the resident then said, 'I don't want them tight', referring to his pajama bottoms . A Staff Interview Summary indicated CNA 'A' was interviewed on 1/21/25. The summary of the statement/interview included the following: .(CNA 'A') indicated (R702) was not wet but when she began changing him he started going (urine) .Resident stated, 'I'm not playing with myself' as his pants were down partially per CNA when she came into room. (CNA 'A') .did indicate when putting PJ's on (drawstring in back) he raised his arm .(CNA 'A') indicated (R702) said, 'I don't want them tight' referring to his pajamas. (CNA 'A') states she told (Registered Nurse - RN 'C') about the interaction . It should be noted that CNA 'A' statement about putting R702's pajamas on with the drawstring in the back was not included in the investigation summary provided to the State Agency and there was no additional documented investigation provided regarding why R702's pajama pants were tied in the back or if other staff were doing that as well. On 2/27/25 at 10:58 AM, an interview was conducted with CNA 'A' via the telephone. CNA 'A' indicated they worked at the facility but they were terminated from employment on 1/27/25. When queried about what occurred with R702 on 1/16/25, CNA 'A' reported the resident said they tried to roll him off the bed and then tried to hit CNA 'A' because he thought he was going to fall. CNA 'A' further explained R702 became anxious and said I can't breathe! when CNA 'A was putting the resident's pajama pants back on after a brief change. According to CNA 'A', R702 said he did not want the pajamas tied too tight and CNA 'A' assured him that they would be loose enough. CNA 'A' explained they tied the drawstring to R702's pajamas pants in the back instead of the front that night because that was what the other CNAs had been doing. CNA 'A' reported she previously notified RN 'C' about the other CNAs tying R702's pants in the back and RN 'C' said she was aware. CNA 'A' reported it was the first time that she tied the pants in the back that night (1/16/25) and since the nurse was aware she did not think it was a problem. When queried about why R702's pants were being tied in the back instead of the front, CNA 'A' stated, He kept stripping and peeing all over himself and the bedding. It slows him down and he wasn't getting them off like that. CNA 'A' reported she first found out about tying R702's pants in the back from CNA 'E' who said they had been doing that with R702 to prevent him from taking his pants off. On 2/27/25 at 12:43 PM, a telephone interview was attempted with RN 'C'. RN 'C' was not available prior to the end of the survey. On 2/27/25 at 2:16 PM, a telephone interview was attempted with CNA 'E'. CNA 'E' was not available prior to the end of the survey. A review of CNA 'A's personnel file revealed a document titled, Termination dated 1/16/25. The Corrective Action reason was Policy Violation. The following was documented, For resident 1 person assist did not use gait belt and did not follow the proper procedure as well as resident restraint. On 2/27/25 at 1:30 PM, an interview was conducted with the Administrator who was the designated Abuse Coordinator for the facility. When queried about the investigation conducted by the facility in regards to R702's grievance about the care provided by CNA 'A', the Administrator reported R702 said CNA 'A' 'turned him from side to side when giving care' and he did not feel like she needed to do that. The Administrator reported CNA 'A' was immediately removed from R702's care and the concern was reported to the State Agency as an allegation of abuse. When queried about why turning the resident from side to side was considered abuse and was there anything else that was concerning, the Administrator stated, There was also something about her (CNA 'A') putting his (R702) pants on incorrectly. When queried about what happened with R702's pants, the Administrator reviewed the facility's investigation and stated, Never mind. There is nothing about the pants. When queried about the Termination document in CNA 'A's personnel file that documented resident restraint as part of the reason they were terminated from employment, the Administrator stated, There were no restraints. When queried about tying a resident's pants in the back so that they were unable to remove them, the Administrator reported that would be considered a restraint. On 2/27/25 at approximately 1:45 PM, an interview was conducted with the Regional Human Resources Director, HR 'D' and the Administrator. HR 'D' reported CNA 'A' was terminated for not using a gait belt with another resident. When queried about why it was documented that CNA 'A' was also terminated for resident restraint, HR 'D' reported CNA 'A' told them that she tied R702's pants backwards. When queried about what was done to investigate CNA 'A' restricting R702's access to his body by restraining him by tying his pants in the back, the Administrator and HR 'D' reported they only found out about it because CNA 'A' told them she tied the pants in the back and at the time, R702 was already discharged from the facility and when he was interviewed about the original grievance he never mentioned it. When queried about what was done to ensure no other staff were restraining any other residents that way and what was done to find out why CNA 'A' restrained R702, the Administrator reported CNA 'A' just reported it during an interview, no additional questions were asked, and no other action was taken to ensure other residents were not being restrained. When queried about why the information about R702 being restrained was not included in the investigation summary submitted to the State Agency, the Administrator reported she did not find out until the investigation was complete. It should be noted that CNA 'A' was interviewed on 1/21/25 and the investigation was submitted to the State Agency on 1/27/25.

This citation pertains to intake #MI00137907. Based on interview and record review, the facility failed to obtain consent and authorization prior to ancillary provider consultation and treatment provision for one (R701) of two residents reviewed for resident rights. This deficient practice has the potential to affect all residents that reside within the facility. Findings include: Review of a complaint filed with the State Agency included an allegation that the resident's legal representative/patient advocate was not consulted prior to optometry evaluations and subsequent provision of glasses. It was further reported that had they been consulted, they would not have given consent/authorization due to the resident's severe visual impairment and severe cognitive impairment. Review of the clinical record revealed R701 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia in other diseases classified elsewhere without behavioral disturbance, psychotic disturbances, mood disturbance, and anxiety, and unspecified macular degeneration. According to the Minimum Data Set (MDS) assessment dated [DATE], the status was still in progress and not yet completed. The MDS assessment dated [DATE] documented R701 had highly impaired vision with no corrective lenses, and had severe cognitive impairment. Review of a vision care plan initiated on 8/7/17 documented, Resident's ability to see in adequate light is Highly Impaired secondary to her hx/dx (history/diagnosis) of Macular Degeneration. Resident's daughter/POA (Power of Attorney) refuses for resident to have vision exams, so her care plan goal will be based upon maintenance. Review of the clinical record revealed R701 had a health care power of attorney dated 6/24/2016 which identified a legal representative/patient advocate. R701 had been declared unable to participate in medical treatment decisions secondary to dementia on 7/3/18 and 7/6/18, which activated the role of the patient advocate. Additionally, R701's payor status was identified as MEDICAID as the primary payor source. Review of a progress note dated 9/17/18 read, Daughter/POA signed consent for eyecare on 8/15/17, however now do not wish for her mother to be seen by facility group. Resident daughter will take her out. On 1/29/24 at 9:18 AM, an interview was conducted with Certified Nursing Assistant (CNA 'C') who was assigned to R701. When asked if the resident wore any glasses, CNA 'C' reported they didn't wear any glasses as they were legally blind. On 1/29/24 at 10:55 AM, the Administrator reported they had recently had a change in Social Work staff and that they had been acting in that role for a short time, but had recently hired a new Social Worker. When asked about R701's eyecare consultations, the Administrator reported the family had signed a consent that indicated they did not want any eyecare consultations. The Administrator was requested to provide any documentation of consents/declinations for ancillary services for R701. On 1/29/24 at 11:02 AM, an interview was conducted with the Director of Nursing (DON) who reported they had been in that role since May 2023. When asked to explain their discussion with R701's patient advocate regarding their concerns that R701 had seen optometry without their consent, the DON reported they could only recall that R701 had been seen by an optometrist and glasses were ordered. When asked who coordinated ancillary services, the DON reported that would've been the Social Worker (SW 'E') who was no longer employed at the facility. On 1/29/24 at 12:15 PM, the Administrator provided documentation which included one consent form with the current ancillary service provider dated 9/18/23 in which R701's patient advocate placed an X through the NO option for vision and audiology. There were no prior consent/declinations provided for review. The only consent available for review in the resident's electronic health record was from a previous ancillary provider from 2017. The Administrator further reported they were no sure how R701 would've been seen if there was no prior consent. The Administrator was informed that the interview with the DON confirmed R701 had been seen by the ancillary provider's optometrist and glasses were ordered. The Administrator was requested to have the current ancillary company provide any consultations/exams from services provided and they reported they would follow-up. Review of the documentation provided by the facility for consultations/exams provided by the current ancillary provider included several consultations in which R701 had been seen multiple times from December 2022 to June 2023 at the request of the physician, and without the prior consent/authorization from their legal representative/patient advocate. On 1/29/24 at 12:42 PM, a phone interview was conducted with the SW 'E'. They reported they had worked at the facility for about a year and a half and their last day worked was 11/13/23. When asked if they could recall any details or discussion with R701's patient advocate regarding concerns about R701 being seen by ancillary services without their consent, SW 'E' reported they were not able to recall any specific details. When asked who would've initiated referrals to the ancillary provider, SW 'E' reported usually nursing would initiate and social would follow-up. SW 'E' further explained there was a list generated by the ancillary provider which usually had all long-term care residents on the list, and if there was anyone who was not already on the list or needed to come off, SW would notify them about that. When asked who obtained the consents for treatment and services with the ancillary provider, SW 'E' reported that would be Social Work. They were unable to recall any specific details regarding consents or declinations for R701. On 1/29/24 at 1:00 PM, a phone interview was conducted with the ancillary provider coordinator (Coordinator 'F'). When asked about their process for providing ancillary services to residents in the facility, they reported the residents that were on Medicaid status did not require a consent, and were able to be seen Just on the Doctor's order. They further reported their process was they send a list to the facility about three weeks ahead of time for the facility to review if anyone new needed to be added, or if anyone needed to come off. Coordinator 'F' further reported they received R701's physician order on 5/24/23, and now that they received the consent (in September 2023) R701 was taken off of any future vision visits. When asked to explain more about the physician orders, Coordinator 'F' reported the initial order was good for as long as the resident doesn't change primary care physicians. Coordinator 'F' was requested to provide R701's consent provided prior September 2023 and they reported they would look for the original order as the one scanned was difficult to read and call back. On 1/29/24 at 1:22 PM, Coordinator 'F' called back and reported R701's initial physician order to be seen was on 3/24/22. They further reported their company first started providing ancillary services at the facility on 12/20/21, and the order on 3/24/22 began the resident's first visit with them. When asked when the resident was seen in 2023 as there was no documentation in the electronic health record, Coordinator 'F' reported the resident was seen on 6/6/23, their provider ordered the glasses on 6/8/23, and it usually took 10-14 business days to deliver the glasses but did not have access to the tracking number for when they were delivered to the facility. On 1/29/24 at 1:51 PM, Physician 'G' was attempted to be contacted by phone, but there was no return call by the end of the survey. On 1/29/24 at 2:15 PM, the Administrator provided additional documentation which included a list of residents that were to be seen by the ancillary provider with Physician 'G's signature dated 3/24/22. This documenation included R701 as well as 20 other residents with a check mark next to YES for Oral Health Eval (evaluation) and TX (treatment) for optometry, podiatry, dental, and audiology services. The Administrator reported that most of the long-term care residents were automatically referred for ancillary services including vision, dental and podiatry unless there were those exceptions who didn't want services and they now were aware R701 should not be seen by the vision services. When asked about the facility's process with lack of obtaining consent and authorization prior to treatments with the ancillary provider, and the process of only requiring a physician order to arrange treatment for residents, especially those that were considered long-term or Medicaid status, the Administrator was unable to offer any further explanation, but indicated consent should be obtained regardless of the resident's payor source and prior to any treatment provided.

Based on observation, interview and record review the facility failed to ensure a resident's medications were appropriately reconciled by a physician upon admission for one (R186) of one resident reviewed for physician services. Findings include: On 2/28/23 at 9:55 AM, R186 was observed lying in bed. R186 was asked about the care in the facility. R186 explained he had been taking Lyrica for several years due to pain from his neuropathy, but he was not getting it at the facility and did not know why. Review of the clinical record revealed R186 was admitted into the facility on [DATE] with diagnoses that included: fracture of left leg, fracture of left arm and neuropathy. According to the Minimum Data Set Assessment (MDS) dated [DATE], R186 was cognitively intact and required the assistance of staff for activities of daily living (ADL's). Review of R186's February 2023 Medication Administration Record (MAR) revealed no current or discontinued order for Lyrica. Review of R186's hospital discharge paperwork revealed a list of medications that included Pregabalin (Lyrica). On 3/1/23 at 2:23 PM, the Director of Nursing (DON) was interviewed and asked why R186 had not been getting Lyrica when it was on his hospital discharge paperwork. The DON explained he would have to look into the issue. On 3/1/23 at approximately 3:30 PM, the DON explained when R186 was admitted , there was not a prescription for Lyrica sent by the hospital, so Lyrica was not able to be ordered from the pharmacy until the physician reviewed R186's medications. Review of a Medication Reconciliation Worksheet for Post-Hospital Care dated 2/14/23 at 9:28 PM by Licensed Practical Nurse (LPN) K read in part, .Hospital Recommended Medications Needing Clarification . lyrica . no prescription . MD (Medical Doctor) to review . On 3/2/23 at 9:03 AM, LPN H was interviewed and asked how medications were reconciled and ordered for new admissions. LPN H explained she went over the medication list with the resident first, then would call the doctor and go over all the medications, then would put the orders into the computer for the pharmacy. LPN H was asked about controlled substance medications, including Lyrica. LPN H explained sometimes the hospital would send prescriptions for the controlled substances, then they would fax the prescription to the pharmacy. When asked what happened when there was no prescription, LPN H explained they had to call the pharmacy, and the pharmacy would call the doctor to get a controlled substance order. On 3/2/23 at 11:34 AM, LPN K was interviewed by phone and asked about R186's admission on 2/14/23 and his Lyrica. LPN K explained the hospital had not sent a prescription for Lyrica, it was on the medication list, but there was no dosage or frequency on the list. When asked if she call the doctor, LPN K explained she called the on-call doctor to go over the medications and put it on the medication reconciliation form so the doctor could review the medication the next day and address the Lyrica order with the resident. On 3/2/23 at 1:22 PM, Dr. L, R186's attending physician, was interviewed by phone and asked about R186's admission and his Lyrica. Dr. L explained when a resident was admitted to the facility, the nurse would call and go over the resident's medications and he would give verbal orders for the medications. When asked about controlled substances like Lyrica, Dr. L explained the pharmacy would call him to get an emergency supply until a prescription could be written. Dr. L was asked why R186's Lyrica had not been ordered. Dr. L explained he did not know what he had written in his progress note when he saw R186, and did not remember anything about Lyrica needing clarification. Review of a facility provided History and Physical note by Dr. L dated 2/16/23 read in part, .I have restarted his home meds (medications) after reviewing them with him . On 3/2/23 at 2:49 PM, Dr. M, who was the on-call physician on 2/14/23, was called and a message left. No return call was received prior to the end of the survey.

Based on observation, interview and record review, the facility failed to ensure Insulin was prepared and administered per professional standards for one (R13) of four residents reviewed for medication administration. Findings include: On 3/1/23 at 11:51 PM, Licensed Practical Nurse (LPN) C was observed preparing R13's Insulin as part of a medication administration. LPN C was observed to remove an Aspart FlexPen (Insulin pen) from R13's medication cabinet, then remove the cap, wipe the top with an alcohol pad and attach a needle to the pen. LPN C was then observed to dial the pen to 6 (6 Units), prepare R13's abdomen and injected the Insulin into R13's abdomen. LPN C was asked about why she did not prime the Insulin pen prior to giving the 6 Units. LPN C explained she thought she only had to prime the Insulin pen the first time it was used. Review of the clinical record revealed R13 was admitted into the facility on [DATE] with diagnoses that included: diabetes, kidney disease and depression. According to the Minimum Data Set (MDS) assessment dated [DATE], R13 had moderately impaired cognition. On 3/1/23 at 2:23 PM, the Director of Nursing (DON) was asked should Insulin pens be primed before use. The DON explained an Insulin pen should be primed before every use. Review of the manufacture package insert for NovoLog Aspart FlexPen read in part, .Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units . F. Hold your NovoLog FlexPen with the needle pointing up . G. Keep the needle pointing upwards, press the push-button all the way in . A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of Insulin after 6 times, do not use the NovoLog FlexPen .

Based on observation, interview and record review, the facility failed to ensure meals were served at a preferred palatable temperature for four anonymous residents who attended a Group Interview and all residents who consumed room food trays. Findings include: On 1/5/22 at 10:00 AM a Group Interview was conducted with five residents who asked to remain anonymous. When asked about concerns in the facility, the residents reported that often they would receive their meals and they would be cold. One resident reported that residents who ate in the dining area received their food first and then trays were delivered to the rooms. When that happened, the food was often cold. Another two residents stated that every time soup is served it is cold and has to be reheated. A resident who attended Resident Council meetings in the past reported that the concern about cold food has been discussed at other meetings. A review of Resident Council notes was conducted. A note dated 9/15/21 read, in part, the following: Department: Dietary - Issue identified by Residents: Food is sometimes cold. Department Response: .I spoke with the servers to make sure the food on room trays is properly covered. We take temperatures on the units before service. If the food is not at the correct temperature it is returned to the kitchen for correction. It should be noted that there were no notes for the month of November and December 2021. On 1/05/22 at approximately 12:30 PM a dining observation was made on the East Wood Unit. Dietary Staff E was serving the lunch meal from warming trays. Staff E reported that the two residents sitting in the dining area would receive their food first and then the seven other residents who eat in their room would receive their trays after. At no time during the observation was the temperature of the food taken on the unit before served. The last tray served on the East Wood Hall was obtained to be used as a test tray. The tray was to be served to R14, a cognitively impaired resident. The following temperatures were obtained using a probe thermometer: Turkey with gray: 50.1 ºF (Fahrenheit) Bread stuffing: 46.9 ºF Green Beans: 34.1 ºF On 1/5/22 at approximately 1:18 PM, an interview was conducted with Director of Dining F. When questioned as to temping the food on the unit kitchens and palatability of food for the residents, Staff F reported that the temperatures are taken in the kitchen that resides in the basement prior to being transferred to the units. Staff 'F reported that food can be re-heated upon request. A review of the facility policy titled, Food Temperature and Taste read in part, Description: Food temperatures are taken using a probe thermometer throughout the production process, prior to serving food and is maintained in Hot or Cold holding equipment .It is also important to check food temperatures when removing item from .and warmer for service .

Based on interview, and record review, the facility failed to thoroughly assess for advance directives and end of life wishes upon admission for one resident (R30), of three residents reviewed for advanced directives, resulting in the potential for residents end of life wishes to not be honored. Findings include: A review of a facility provided policy titled, Admitting Process and Advance Directives dated [DATE] was conducted and read, 1. Residents will be asked during the admission process if they have an Advance Directive. The responses will be recorded in the medical record by admissions or designee. 2. If the resident has an Advance Directive, the resident will be asked for a copy of the document for the resident's record by admissions or designee . On [DATE] at 2:19 PM, a review of R30's electronic medical record was conducted and revealed R30 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R30's Minimum Data Set assessment dated [DATE] revealed R30 had intact cognition and required extensive assistance from one staff member for most activities of daily living. A review of R30's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a document titled TREATMENT PREFERENCES AND DETERMINATION OF RESIDENT'S WISHES in R30's paper clinical record was conducted and revealed R30 was a Code A-Full Resuscitation and life-sustaining treatment. On [DATE] at 4:10 PM, R30 was observed seated in their wheelchair in their room. At that time, an interview was conducted with R30 regarding whether they facility had asked them about any of their end of life wishes such as whether they had an advance directive or whether they wanted CPR if they were found unresponsive with no heartbeat or respirations. R30 denied facility staff had a conversation with them and said they would not want, anything dramatic. R30 went on to say all of their end of life wishes were outlined in their trust. R30 was asked if the facility requested a copy of their trust and said they had not. R30 was asked if they were aware what type of services would be provided if they were found without a heartbeat or respirations and said they did not know. On [DATE] at 9:40 AM, an interview was conducted with Social Worker 'I' regarding the facility's process and policy for assessing for advance directives, code status, and end of life wishes. Social Worker 'I' said residents were given a packet upon admission that explained advance directives and they were assessed by the person admitting them for a code status. At that time, Social Worker 'I' was asked if they had assessed R30 for their end of life wishes and if they could provide documented evidence of the assessment. Social Worker 'I' said they would follow-up if they had any evidence; but did not provide any additional information by the end of the survey. On [DATE] at 2:40 PM, an interview was conducted with the facility's Administrator regarding the facility's policy for assessing for advance directives, code status, and end of life wishes. The Administrator explained the admitting nurse could obtain a code status until the Social Worker was able to see the new admission. The Administrator continued to explain the Social Worker was responsible for assessing for advance directives, giving residents all their different options, obtaining copies of any advance directives, and documenting in the record the conversation and the resident's responses and choices. On [DATE] at 4:10 PM, the facility's Administrator reported they personally visited R30 and performed an assessment for advance directives, code status, and end of life wishes and said R30 did have a living will, but they did not know what the living will contained. The Administrator further reported that after having all the options explained to them, R30 changed their code status from Code-A (full resuscitation) to Code-B, on the TREATMENT PREFERENCES AND DETERMINATION OF RESIDENT'S WISHES form that read, .Code B- I want all my illnesses treated aggressively, including full hospitalization . This includes hospitalization for routine and emergency treatment. However, I DO NOT want cardiopulmonary resuscitation (CPR) .

Based on observation, interview and record review, the facility failed to operationalize its policy to report an injury of unknown origin for one (R#5) of one resident reviewed for abuse, resulting in the facility not identifying an injury of unknown origin, or investigation into the circumstances of the injury, and not reporting to the facility Abuse Coordinator or State Agency, which has the potential for abuse to go undetected, and injuries to continue. Findings include: On 1/27/20 at 8:57 AM, R#5 was observed seated in a wheelchair next to the bed. A large red/blue colored bruise (approximately 2 inches by 3 inches) was observed above R#5's right eye on the forehead. R#5 was asked about the bruise and how it occurred, but was unable to provide any explanation due to significant cognitive impairment. A review of the clinical record revealed R#5 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Det (MDS) assessment dated [DATE] documented R#5 had severely impaired cognition, no behavior concerns, required extensive assistance of one person for bed mobility, transfer, locomotion off unit, dressing, and toilet use, was occasionally incontinent of urine, always continent of bowel, and had two falls since previous assessment with no injury. A review of the progress notes revealed a recent fall on 1/25/20 (in which R#5 was lying on the floor face down and explained the bruising to the forehead). However, further review of the progress notes identified R#5 with change in condition first documented as identified on 1/3/20 and there was no documentation that the Administrator (also the facility's Abuse Coordinator) had been informed of R#5's change in condition and injury of unknown origin. Documentation in R#5's progress notes from 1/3/20 to 1/28/20 included: On 1/03/20 at 11:32 AM, Resident was guarding her right elbow this am, no bruise, no swelling noted, no injury reported, Tylenol for discomfort administered, resident was able to lift her arm and bend it, (name of Nurse Practitioner/NP [NAME] redacted) is aware, XRay right elbow was ordered, will monitor. On 1/06/20 at 9:05 AM, .Informed by CNA (certified nursing assistant) resident c/o pain in (R) wrist area, Noted red in color slightly swollen. Tylenol given for discomfort . There was no documentation that the Administrator had been informed of the resident's guarding of the elbow. On 1/07/20 at 10:21 AM, Resident's right elbow and right wrist hand remain swollen, redden and painful to touch. Resident guarding right arm, flinches when right arm is touched . On 1/07/20 at 11:21 AM, x ray results of right hand and wrist - negative for fx (fracture)/dislocation . On 1/10/20 at 11:19 AM, Resident was to have a Doppler of her right upper arm. She would not let the tech do it. She was yelling no (sic) and know one could calm her down enough to let him do the Doppler. On 1/18/20 at 10:56 AM, Swelling to right antecubital (elbow) area improving, denies pain, NP is aware of her condition . On 1/21/20 at 10:23 AM, XRay of right arm completed, waiting for results . On 1/29/20 at 1:20 PM, an interview and record review was conducted with the Director of Nursing (DON). Upon review of the incident reports provided by the facility, there was no accident/incident report or investigation provided regarding R#5's change in condition/right arm/elbow/wrist. When asked about whether the facility had conducted an investigation into this, the DON reported, No. Because nothing was visible. Nothing happened. Cause (R#5) was guarding, got an x-ray. Why would we do that when there's no visible concern other than the guarding? When asked if there was any further investigation upon continued changes as documented on 1/7/20, the DON reviewed the staff's documentation and offered no response. When asked if there was any investigation that may have been identified or initiated at that time, the DON reported No. When asked if the DON had been informed of R#5's change in condition, the DON was unable to offer any clear response. When asked if there was an injury of unknown origin, what was the facility's procedure, the DON reported, We investigate it and report. The DON reported the facility's Abuse Coordinator was the Administrator. On 1/29/20 at 2:58 PM, the DON reported, I do recall the arm thing. He (Physician) feels it's related to a blood draw. A review of R#5's available laboratory results revealed R#5 had multiple lab draws in (MONTH) 2019. However, there was no lab draw done between 12/9/19 and 1/8/20. The resident's first documented observation of guarding of the right arm was on 1/3/20. The DON was informed of the lab result findings and was unable to offer any further explanation. When asked if the facility should have initiated an investigation to rule out possibility of abuse, the DON reported, I could've done better investigation with this. What more do you want me to say? On 1/29/20 at 3:27 PM, an interview was conducted with the Administrator who confirmed she was also the facility's Abuse Coordinator. When asked what the facility's process was when there was an injury to a resident, or injury of unknown origin, the Administrator reported, If there was an injury or if it was unknown I would have been notified. When asked if she had been notified of R#5's injury of unknown origin and/or change in condition, the Administrator reported, I don't recall this particular incident. A review of the facility's policy Accidents - Incidents Unplanned Occurrence Reports dated May, (YEAR) documented, in part: .An unusual occurrence, including injuries of unknown source, must be reported to the supervisor as soon as such occurrence is discovered or when information is learned .An occurrence report must be completed for all reported accident/ incident or unusual occurrences .Procedures governing the reporting and investigation of abuse, neglect . are located in our facility's abuse prevention policy . A review of the facility's policy Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition dated December, 2019 documented, in part: .Injuries of Unknown Source are classified as such when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of the extent of the injury or the location of the injury .or the number of injuries observed at one particular point in time or the incidence of injuries over time .Identification of injuries of unknown origin/source .Incidents and/or alleged violations involving abuse, neglect .including injuries of unknown source .are reported immediately to the Administrator/designee, but not later than 2 hours after the allegation is made .The Administrator or his/her designee will notify the State Agency of alleged violations involving abuse, neglect .and injuries of unknown source as soon as possible, but not later than 2 hours after the allegation is made .or not later than 24 hours if the events .do not result in serious injury. The results of the investigation will be reported to the Administrator, and a final report will be submitted to the state agency after the investigation is completed, but no later than five (5) working days after the discovery of the incident .In follow-up to the identification of Injury of Uknown Source .Evaluate and make necessary changes in resident's care plan to protect against the occurrence of another similar injury .

Based on observation, interview and record review, the facility failed to provide adequate supervision and interventions to prevent falls, and thorough investigation into the causes of the falls/accidents for one (R#5) of three residents reviewed for accidents, resulting in R#5 sustaining multiple falls with injury, and the increased potential for serious harm and injury. Findings include: On 1/27/20 at 8:57 AM, R#5 was observed seated in a wheelchair next to the bed. A large red/blue colored bruise (approximately 2 inches by 3 inches) was observed above R#5 right eye on the forehead. R#5 was asked about the bruise and how it occurred, but was unable to provide any explanation due to significant cognitive impairment. A review of the clinical record revealed R#5 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#5 had severely impaired cognition, no behavior concerns, required extensive assistance of one person for bed mobility, transfer, locomotion off unit, dressing, and toilet use, was occasionally incontinent of urine, always continent of bowel, and had two falls since previous assessment with no injury. A review of the admission MDS assessment dated [DATE] documented R#5 had severely impaired cognition, no behavior concerns, required extensive assistance of one person for bed mobility, dressing, limited assistance of one person for transfer, eating, toilet use, was occasionally incontinent of urine, always continent of bowel, had a fall in the last month prior to admission, had a fall in the last 2-6 months, and had one fall with injury (not major) since admission or the previous assessment. A review of the care plans included a Potential for injury associated with falls R/T (related to) decreased mobility/unsteady gait, on [MEDICAL CONDITION] medication. which had been initiated on 10/19/19. Interventions were documented as: Orient me to surroundings & introduce to other residents. (Initiated 10/19/19) Maintain clutter free environment. (Initiated 10/19/19) Keep call light within reach. (Initiated 10/19/19) Offer resident a snack and or beverage at the counter prior to dinner. (Initiated 10/19/19) Offer resident to sit at the counter with a beverage in the early morning after toileting. (Initiated 11/1/19) Offer to close blinds after dinner, when resident goes back to her room. (Initiated 1/25/20) A review of the progress notes revealed multiple entries from staff of R#5 exhibiting restless behaviors of attempted and actually getting up unassisted from the wheelchair, both in the room and in common areas, as well as episodes of difficulty being able to redirect at times. Documented progress notes from 1/28/20 to 10/19/19 included: On 1/28/20 at 10:22 PM .resident remain very forgetfull <sic>, she was observed this afternoon toileting herself alone without requesting for help . On 1/25/20 at 8:00 PM, Informed by CNA (Certified Nursing Assistant) resident was on floor in room. Nurse went to room observed resident lying floor face down in front of w/ch (wheelchair) <sic> near window area .Noted a bruise to (R) (right) forehead, Ice pack applied, Noted small skin tear between 3rd and 4th finger on (R) hand cleaned .Resident not able to verbalize, what she was doing to be on floor . On 11/22/19 at 11:03 AM, Resident was noted by nurse standing without any pulls <sic> up, no pants, walking around her room, she already unpacket <sic> her closet laundry, all doors at her TV stands are open, gait unsteady .reorientated .call light within reach. On 11/13/19 at 2:15 PM, Resident wandering, combative and resistant to care .Resident daughter has made herself available has <sic> part of the plan of care when resident becomes disruptive. Resident is alert to name only and may get confused when she doesn't see her daughter or granddaughter . On 11/12/19 at 4:21 PM, Very confused & forgetful, requires continuous watching, she forgets to ask for or to request for assistance, locomotion via W/C (wheelchair), she tend to get out from W/C alone, gait not steady, requires one person limited assist with her ADLS, transfer, toileting & bed mobility .call light within reach. On 11/11/19 at 7:13 PM, Resident wanders a lot . On 11/01/19 at 8:34 AM, At approximately 6:30 AM, CNA alerted nurse that resident was found on the entryway floor, going into her bathroom .Intervention for future prevention is to offer resident to sit at the counter with a beverage, after toileting in the early morning hours . On 10/29/19 at 8:56 PM, .when she was getting agitated & wanted to wander, staff approached her on the soft voice & engaged her into exercising activity .staff supervised her all the time, toileted . On 10/28/19 at 12:29 AM, Resident get out of bed without any assistance .she requires assistance with ambulation redirected, but due to her condition not affective .she was brought to the living room area & supervised . On 10/27/19 at 9:32 PM, .She was very combative at dinner time when this writer tried to move her away from a Resident that felt uncomfortable with her. She stood up, grabbed my arm and pinched as hard as she could. She is yelling and cussing at Residents and cannot be redirected. She get very angry if you try to redirect her at all. On 10/27/19 at 10:48 AM, A & Ox1, very confused & forgetfull, wonders <sic> a lot in & out from her room . On 10/25/19 at 9:55 AM, Resident alert & verbal with confusion & forgetfulness, multiple attempts to get out of bed reported during the night & beginning of the morning, resident does not use the call light due to her forgetfulness, also does not request for help . On 10/24/19 at 10:50 PM, Recv'd (received) up I n <sic> wh/c .Noted confusion and agitation. Spit out prn (as needed) meds x 2. Kept attempting yo <sic> amb. (ambulate) without assistance .Nurse called daughter (name redacted) informed of behaviors, daughter came and sat with resident after dinner . On 10/23/19 at 3:16 PM, Res. alert with confusion/restlessness .Res. freq. restless and motoring self in WC . On 10/22/19 at 10:24 PM, Resident presenting with uncontrollable anger. Hitting and kicking. Yelling at staff, cussing a lot. Staff trying to get her to stay seated, afraid she will fall, She is not stable when she stands up. Can not <sic> redirect her . On 10/20/19 at 3:20 PM, Res. alert with confusion / restlessness .Res. freq. (frequently) restless and motoring self in WC - attempting to stand freq. and required redirection from staff . On 10/19/19 at 10:53 PM, 4:30 PM - Nurse came to room after hearing CNA call for help, Observed resident on floor lying on left side .Noted skin tear to Left arm/elbow area . On 10/19/19 at 4:34 PM, .Oriented to person only .Res. had a fall on 10/15 and had right knee abrasion and right flank bruise. hospitalized on ,[DATE] R/T fall with ST's (skin tears) right elbow, wrist and thumb, bruise right orbital area and dislocated right 5th digit . On 1/29/20 at 1:20 PM, an interview and record review was conducted with the Director of Nursing (DON) to review R#5's falls since admission on 10/19/19. At that time, the DON was unable to recall the specific interventions and deferred to the facility's fall documents. The DON was able to confirm that R#5 had been identified as a high fall risk upon both admissions into the facility. Upon review of the fall documentation, the DON reported R#5's falls were unwitnessed. When asked how the facility had determined the potential root cause of the fall given the falls were unwitnessed and there were no staff interviews conducted as part of the facility's investigation, the DON reported they try to re-enact the circumstances and implement interventions from there. The DON was asked about whether the facility had considered R#5's need for increased supervision due to R#5's significant cognitive impairment which was known prior to and upon admission as well as the multiple documented entries from nursing staff of R#5's restlessness, wandering behaviors and difficulty redirecting at times. The DON reported, We don't provide one to one here. We don't have the staff for that. When asked about the lack of statements from other staff that may have been able to provide additional information such as when the resident was last seen, toileted, or last offered a drink or snack, the DON offered no further explanation. When asked about the interventions to Orient me to surroundings and Keep call light within reach were appropriate for a confused resident and the lack of identification of increased supervision as an intervention, the DON offered no further response. On 1/29/20 at 3:52 PM, a phone interview was conducted with R#5's responsible party (RP B). When asked about R#5's fall occurrences and interventions provided by the facility, RP B reported concerns with the frequency of monitoring and availability of staff to provide adequate supervision. RP B stated, When I walked in on Saturday night (1/25/20) she was sleeping and I went out to go find a CNA and there was no one there. When she was in assisted living (on campus) and fell , found out she had another UTI (urinary tract infection) which makes her restless. I told them (facility) she needs to be watched more often. They told me that they don't have the staff to do that, they don't have a one to one .I feel one CNA on a neighborhood is not enough .The very first day she was there (10/19/19) me and my daughter left to go get lunch and the hour we were gone, she fell .I don't feel they (facility) are attentive enough. A review of the facility's policy Falls Management dated December, (YEAR) documented, in part: .A resident's care plan is evaluated and revised based on the resident's response, outcomes, and needs .Communities will evaluate resident falls and determine appropriate interventions to prevent future falls .

Based on observation, interview and record review, the facility failed to ensure the survey binder was easily accessible to residents, and inform residents, families, and visitors of the location of the facility's most recent survey results for seven of seven residents who attended a confidential Resident Council meeting, resulting in the potential for all residents, families, and visitors to be uninformed of the facility's deficient practices. Findings Include: On 1/28/20 at 10:00 a.m., a confidential Resident Council meeting was conducted. Seven of seven residents who attended the meeting verbalized that they were unaware of the location of the facility's most recent State Agency survey results. On 1/28/20 at 10:55 a.m., an observation was made of the facility's survey binder that was on top of a mantle in the lobby near the front entrance. The mantle was not visible to residents that used wheelchairs. On 1/28/20 at 11:50 a.m., during an interview, when asked about the State Agency inspection results for residents' view, Registered Nurse (RN) 'F' on the Eastlake Unit stated, I thought that it was downstairs. I don't know that we have it up here, but if someone was to ask for it, I would surely get it for them. On 1/28/20 at 12:07 p.m., Certified Nursing Assistant (CNA) 'G' stated, I believe it's downstairs by the conference room. On 1/28/20 at 12:18 p.m., an interview was conducted with Activities Director 'H' who reported that Resident Council meetings are usually the first Friday of each month in the activities room. When asked where the State Survey Results were posted, Activities Director 'H' reported the survey results are on the mantel in the front lobby. Activities Director 'H' was asked if residents were able to come down to the front lobby to read the survey results. Activities Director 'H' stated, Only the ones that can self-propel usually come down here. The rest of them usually stay in their rooms, or the common area unless we take them somewhere. When queried how residents know where to find the State Agency survey results, Activities Director 'H' stated, I guess we would have to take them there (front lobby). When asked if they ever talked about the survey results during the Resident Council meetings, Activities Director 'H' stated, Not usually. Activities Director 'H' was asked what they discussed at the Resident Council meetings with the residents, and stated, I usually talk about the building, and any departments (Nursing, CNAs, Therapy, Environment, and Dietary). On 1/28/20 at 2:20 p.m., during an interview, when asked if residents were made aware of the State Agency survey results, the Director of Nursing (DON) stated, I can't say that I have personally made residents aware of where it is. On 1/28/20 at approximately 2:52 p.m., the facility Administrator was queried about the posting of the State Agency survey results being readily accessible to residents, families, and visitors. The Administrator reported that the survey results and all public information were usually on a lower table in the lobby that was being repaired, and residents should have known how to access it. A document provided by the facility titled Know Your Rights-- revealed the following: . You have a right to review the last survey of the nursing home conducted by the State Survey Agency or federal surveyors. This survey and any plan of correction currently in place for your home must be easily available for your review. You may also ask the staff for any inspection reports done by the state during the past five years .

This citation pertains to intake numbers: MI 787 Based on interview and record review, the facility failed to update and complete a comprehensive facility wide assessment that included the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, Equipment (medical and non-medical) and physical environment, services and physical plant considerations that are necessary to care for the facilities population, resulting in the potential for unidentified resources necessary to provide care and services to the 38 residents that reside at the facility. Findings include: On 9/16/19 at 4:01 PM, the facility's assessment was reviewed and revealed a facility assessment that was not updated to reflect the current resident census and facility's capacity. On 9/16/19 at 4:35 PM, when queried the Regional Vice President (RVP) A reviewed the facility assessment and removed the facility assessment from the facility assessment binder and stated, This is old, she probably has the updated one in her office somewhere let me go and check. On 9/16/19 at 5:16 PM, the Director of Nursing (DON) returned with a typed Facility Assessment Tool containing partially handwritten information. The provided documents was reviewed and revealed numerous required components of the facility assessment missing such as: the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, Equipment (medical and non-medical) and physical environment, services and physical plant considerations that are necessary to care for the facilities population. At that time the DON was queried on the missing components and acknowledged that they were unsure on what the facility assessment should contain. The Administrator was not present on this survey date. On 9/16/19 at 5:30 PM, the RVP A was queried on the facility assessment and provided no further explanation or documentation by the exit of survey. A facility policy titled Facility assessment dated (MONTH) (YEAR) documented in part, The facility assessment will contain information regarding the resident population . The average daily census, the care the facility is capable of providing to the resident population considering the types of diseases, conditions, physical and cognitive, disabilities, and overall acuity . The physical environment, equipment, services, and other physical plant considerations . The facility assessment will contain information regarding the facility resources including . Equipment (medical and non-medical) . The facility must also review and update the assessment whenever there is, or the facility plans for a change that would require a substantial modification to any part of the assessment .

This citation pertains to intake numbers: MI 787, MI 138 Based on observation, interview and record review, the facility failed to provide adequate staffing to meet residents needs for three (R#s: 703, 704 and 706) of five sampled residents reviewed for sufficient staffing, resulting in complaints of prolonged response times from staff and inadequate ADL (Activities of Daily Living) care related to staffing. Findings include: Resident #703 Review of complaint allegations submitted to the State Agency included concerns that there was not enough staff to monitor, provide safe transfers or provide proper care to the residents. On 9/16/19 at 10:59 AM, an interview was conducted with R#703. When asked if they had any concerns regarding their care at the facility R#703 stated, It takes forever for the staff to come. you can scream for twenty minutes and no one will show up on night shift and early mornings. R#703 was admitted into the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#703 had intact cognition. Resident #704 On 9/16/19 at 11:05 a.m., R#704 was observed sitting in a wheelchair in their room. When asked about their care at the facility and if there was enough staff to care for all of their needs, R#704 stated, They were using a sliding board and it wasn't working for me. I can't move the right leg and sometimes the left one doesn't work. I slid to the floor. They lifted me up under the arms to get me in the chair. That's how they were trying to transfer me on the board and the board did not work . When asked about the staff at the facility, R#704 stated, . I think they could use more. Sometimes there is only one girl (aides) . I have a little problem with the night shift. They can take quite a while. Sometimes it takes an hour. I know they have to work the other side and sometimes it takes a while for them to get back here. A review of the clinical record revealed R#704 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment dated [DATE] revealed R#704 had a BIMS (Brief Interview for Mental Status) score of 15 out 15 that indicated intact cognition for decision-making, and required extensive assistance with one to two-person physical assist with activities of daily living. On 9/16/19 at 11:16 a.m., when asked if there was enough staff to care for the residents, Certified Nurse Assistant (CNA) 'E' stated, According to their (facility) ratio, I'm told with the nurses it is . When asked if the nurses help with resident care, CNA 'E' stated, My only complaint is the nurses don't help . It's the acuity of the person. It's very difficult to depend on the other person (CNA) who is on the other end being so far away . On 9/16/19 at 11:34 a.m., during an interview, when queried if residents had complaints regarding staffing and call lights, Registered Nurse (RN) 'G' stated, Rarely on the day shift. I heard some complaints about the afternoon or midnights, but midnights don't have the same amount of staff as the day shift. If there is acuity and two lights are on at the same time . Resident #706 On 9/16/19 at 3:44 PM, an interview was conducted with R#706. When asked if they had any concerns regarding their care at the facility R#706 stated, I have to sit in my bowel movement for an hour because those aides are washing dishes, it should be about patient care first and it's not here. It's terrible. I am speaking for all the residents that can't speak for themselves. R#706 was admitted into the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. On 9/16/19 at 12:20 PM, CNA A was interviewed regarding staffing and stated, Yes, I've worked short staffed. It's not a bad place to work at but they can improve with the staffing. Since they decreased the census, we would usually work with two CNA's on each floor with an additional CNA that would rotate between the two floors to help out so that we all have 6 rooms a piece to do. Lately, we haven't had that additional CNA to help out. They have been sending people home due to the low census. On 9/16/19 at 12:41 PM, CNA B was interviewed regarding staffing and stated, According to them (the facility administration) we aren't short staffed, but we are. On 9/16/19 at 12:50 PM, CNA C was interviewed regarding staffing and stated, Yes, it's a bit overwhelming. There are a lot of behaviors and two people assist and we don't have enough staff to help. We use to have to wait for other staff members and there were times that I had to do it by myself, now we can grab anybody. Now anyone from any department can spot us while we use the hoyer. On 9/16/19 at 1:50 PM, CNA D was interviewed regarding staffing and stated, I've had to work by myself sometimes; the nurse will help if they can. Now they have someone spot us when using the hoyer. A lot of us are getting hurt because we are always working short staffed. A review of the facility's resident council minutes dated 7/3/19 at 10:36 AM, documented in part, Nursing: love nurses, some longer waits for CNAs (night). On 9/16/19 at 12:08 PM, the Director of Nursing (DON) was queried regarding staffing and stated, We staff based off the census. On 9/16/19 at 4:55 PM, the DON was asked to provide the facility's policy on staffing and shortly returned with a policy titled, Posting of Direct Care Daily Staffing dated (MONTH) 2008. The policy was reviewed and contained no pertinent information to reflect the above deficient practice.

This citation refers to Intake Number MI 840. Based on interview and record review, the facility failed to report allegations of employee to resident abuse to the State Agency for one (#803) of three residents reviewed for abuse, resulting in the potential for undetected or continued abuse. Findings include: On 3/18/19, R#803's clinical record was reviewed and revealed the following: R#803 was admitted into the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#803 had intact cognition. A progress note dated 3/14/19 noted concerns were being followed up as part of the grievance process. Grievance forms, Incident Reports, and Investigations for R#803 were requested from the Administrator. A Grievance/Complaint Report form dated 3/11/19 was reviewed on 3/19/19. The grievance was reported to the Administrator by R#803's family member. The form was completed by the Director of Nursing (DON) and it documented the following: .finger stick .pill throwing . It was documented that the DON was assigned to follow up and was assigned on 3/11/19 and the grievance was to be resolved by 3/12/19. It documented that the grievance was resolved and noted, Unable to substantiate .Pill throwing not substantiated. Finger stick not substantiated . A second Grievance/Complaint Report dated 3/10/19 contained the content from an email sent to the Administrator by R#803's family member. It documented, .AFTERNOON and OVERNIGHT STAFF .Downright nasty (throwing pills at my father after he asked for, and waited several hours) .One nurse kept pricking my dad's finger and he explained that he doesn't have diabetes. She demanded she do it and that it was ordered. After we asked the next morning - there's NOTHING in his record for a finger prick .My dad felt like it was just to be mean as it was the same nurse who threw his pill at him . A Resident Interview Summary dated 3/11/19 completed by the DON documented, .Re: finger sticks. Resident states a certain nurse does an accucheck (blood sugar check) on him when she works. Happened a few times . There was no further documentation of how the allegations of the finger prick or pills being thrown was investigated. On 3/19/19 at 4:11 P.M., the Administrator (who also functioned as the facility's Abuse Coordinator) was asked if there was any additional information besides that which was provided on 3/18/19 regarding any grievances, incident reports, or investigations for R#803. The Administrator stated, That's everything for (R#803). On 3/19/19 at 4:45 P.M., the Administrator and DON were interviewed. When asked about how the grievance received from R#803's family member on 3/10/19 was handled, the Administrator reported she received it in an email, started investigating, had a conference call with the family member, and spoke with the resident. The Administrator reported that showers were checked into, the food concerns were checked into, housekeeping records were reviewed, and an observation of the resident's room was conducted. When queried about whether or not the allegations of a nurse throwing pills at R#803 and pricking his finger without a physician's orders [REDACTED]. The Administrator and DON both reported they spoke with the resident on 3/11/19. When queried about how the allegation of the nurse pricking R#803's finger was unsubstantiated when R#803 told the DON (and the DON documented) that it happened, the DON and Administrator did not offer a response. The Administrator was asked when allegations of abuse would be reported to the State Agency. The Administrator stated, We have 24 hours to report if there's no serious injury. The facility's policy was reviewed with the Administrator and DON at that time and it read, .Reporting/Response .Timing: The Administrator or his/her designee will notify the State Agency of alleged violations involving abuse, neglect, exploitation, or mistreatment .as soon as possible, 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 . When queried about why the allegations of abuse toward R#803 were not reported to the State Agency, the DON stated, I had no reason to think it happened after talking to the resident. The Administrator reported the family member sent the email on 3/10/19, but she did not read it until 3/11/19. The Administrator reported she spoke with the resident right away, but did not have documented evidence of the conversation (only the documented interview conducted by the DON which was reported to have been done at a later time). There was no documented evidence of an investigation, interviews with staff, or attempts to look into who was sticking R#803's finger unnecessarily (who was allegedly the same nurse who allegedly threw pills at R#803 to show definitively that it did not happen.

This citation refers to Intake Number: MI 9. Based on interview and record review, the facility failed to administer as needed pain medications after a complaint of pain for one (#801) of three residents reviewed for pain, resulting in increased pain and a delay in the ability to participate in therapy. Findings include: A complaint was submitted to the State Agency that alleged R#801 had to wait until the next day after admission to receive pain medications due to them not being available at the facility. On 3/18/19, R#801's clinical record was reviewed and revealed the following: R#801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#801 had intact cognition and daily complaints of pain. An admission progress note dated 12/18/18 documented, .received 12:08 P.M. from hospital via family car. AOx3 (alert and oriented to person, place, and time) .Incision on mid lwr (lower) back 4.5cm long with 11 sutures .c/o (complaints of) pain with PRN (as needed) medications ordered. Medications reviewed with family and approved by PA . There were no additional progress notes on 12/18/18. A physician progress notes [REDACTED].M. documented, .recent laminectomy and discectomy (a surgery to relieve pressure on the nerves in the lower back). Presents here for postoperative physical therapy and pain control .Unfortunately last night there was a problem with the pharmacy drop and patient missed a dose of (narcotic pain medication) and is now behind the pain. She is doing a bit better with the doses given this morning but I expect she will improve more over the next 24 hours with scheduled dosing .We'll restart physical therapy tomorrow and see how she does .Assessment and Plan: status [REDACTED]. Patient did not get her (narcotic pain medication) last night secondary to missed pharmacy drop. We'll schedule (narcotic pain medication) for 2 days to catch up to her acute pain then resume when necessary schedule . physician's orders [REDACTED]. An order dated 12/18/18 for a narcotic medication to treat moderate to severe pain) 10 milligrams (mg) every 6 hours as needed. The above order was changed on 12/19/18 to be given every 6 hours (scheduled). R#801's Medication Administration Record [REDACTED]. The 10mg dose of narcotic pain medication was not administered to R#801 on 12/18/18 (the admission note documented R#801 complained of pain). R#801 received the 10mg dose of narcotic pain medication on 12/19/18 at 7:53 A.M. and the results were documented as No Relief. As needed [MEDICATION NAME] (a non-narcotic pain medication ordered by the physician on 12/18/18) was not administered on 12/18/18. R#801's Non-PRN Treatment Notes documented R#801 had a pain level of 6 (on a scale of one to 10 with 10 being the worst pain) on the midnight shift. On 12/19/18 on the day shift, R#801's pain level was documented as 9. On 3/18/19 at 1:55 P.M., Nurse A (the admitting nurse on 12/18/18) was interviewed via the telephone. Nurse A reported that she thought she remembered being the admitting nurse, but was not sure if she was the nurse who entered the medications into the system for pharmacy. Nurse A stated, They (pharmacy) only have two shipment times. They are supposed to drop ship if the medications is not in the back up box, but that doesn't always happen. When queried about what was done to address R#801's pain, Nurse A reported she did not remember. When queried about what was done when medications were not available for administration, Nurse A stated, We call pharmacy for an authorization to pull from back up. Nurse A did not remember what was done on 12/18/18. On 3/18/19 at 1:30 P.M., the Director of Nursing (DON) was interviewed. When asked what the facility did to ensure resident had medications available to them upon admission into the facility, the DON stated, There's no guarantee. We get notification, get a brief synopsis from hospital. Pharmacy delivery is twice a day (3pm and after midnight around 1am). If it's a later admission, the meds would have to come with the 1am delivery. We could ask for a drop ship, but it doesn't make much of a difference. When asked what should be done if a medications is not available, the DON stated, The physician is called because it's a doctors' order. If we can't give it we want to ask what they want to do. Most times they will say to give it when available. When queried about pain medication, the DON stated, We would need to get an auth to pull from back up, but that rarely happens. The DON was asked why R#801 did not receive PRN narcotic pain medication upon admission after she complained of pain. The DON stated, The physician should have been notified and would have been called to verify the orders. The DON verified that the narcotic pain medication prescribed to R#801 was available in the back up box. When asked why R#801 did not receive the narcotic pain medication from the back up box, the DON stated, She didn't ask for it. When asked if a resident new to the facility would know to ask for the medication when she just arrived, the DON did not offer a response. The DON provided the controlled substance proof of use sheet which documented, the narcotic pain medication was given at 8:00 A.M. on 12/19/18 (approximately 20 hours after she was admitted ). A review of the hospital discharge records revealed R#801 received the narcotic pain medication at 3:26 A.M. on 12/18/18. A facility policy regarding pain management was requested from the DON. The DON reported the facility did not have a policy.

Based on observation, interview and record review the Facility failed to implement and ensure sufficient fall interventions were in place to prevent falls for two (#19 and #44) of three residents reviewed for falls/accidents resulting in R#19 sustaining an injury/fracture to the left knee, a decline in mobility and pain and the likelihood of both R#19 and R#44 sustaining additional falls with injury. Findings include: Resident #19 On 10/29/18 at approximately 9:00 AM, R #19 was observed sitting in a wheelchair. R #19's left leg was wrapped with a full leg immobilizer from the top of the hip to the ankle. R#19 also had a large bruise on the right wrist. When queried as to what happened to the left leg, R#19 reported that she fell , but was not able to explain how, when or where the fall occurred. When asked if the leg hurt, R#19 stated, Yes. R#19's call light was observed hanging over the bed opposite of the resident and out of reach of the resident. On 10/29/18 at 3:00 PM, a review of R#19's clinical record documented that the Resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#19's Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5/15 (severe cognitively impaired) and required limited one person assist for transfers and was able to walk using a walker and needed transfer with limited one person assist. A progress note dated 7/13/18 read, in part, Patient observed on the floor by the toilet sitting on her buttocks at approx. 4:30 pm no pain observed .Dr. (name redacted) notified . A progress note dated 10/17/18 read, in part, During walk around nurse observed R#19 grimacing in pain and rubbing left knee while sitting on the side of the bed, when asked if in pain resident answered yes and that she fell on her knee, but resident could not tell when or where. Upon assessment resident's left knee appeared swollen and bruised, purple color and warm to the touch. Physician contacted, left knee x-ray ordered . A progress note dated 10/21/18 read, in part, Resident observed on the floor in a semi-upright position .partial ROM (range of motion) on LLE (left lower extremity) Hoyer lift to bed. LLE [MEDICAL CONDITION] was present prior to observation on the floor .Dr. (name redacted) notified . Have a x-ray of the knee with 2 views, venous duplex ultrasound done and start Neurochecks . A progress note dated 10/22/18 read, in part, IDT (interdisciplinary) met and reviewed post fall. This is a long term resident who has an unsteady gait, muscle weakness and Alzheimer's. Her call light was not on and she will forget to use her light and forgets to ask for assist. She was attempting to transfer herself into bed. A progress note dated 10/23/18 read, in part, Seeing patient today for recent falls which occurred on 10-17 and 10-21 .Patient complained of left knee pain shortly after the first fall and has been noted to have decreased level of functioning, not wanting to get out of bed secondary to the pain . On 10/23/18 R#19 left the Facility for an appointment. A Care Plan Report for Falls (effective 7/9/18) documented, in part, the following: Problems: Potential for injury associated with falls R/T unsteady gait .Interventions: Orient me to surroundings & introduce to other residents (effective 7/9/18); Maintain clutter free environment (effective 7/9/18); Keep call light within reach (effective 7/9/18); Monitor resident while in the bathroom, on toilet as tolerated (effective 7/16/18); Educate resident to use call lite <sic> to ask for assistance with transfer (effective 10/17/18) and offer to assist resident to bed after dinner (effective 10/21/18). Two fall assessments were provided by the Facility and documented, in part, as follows: Assessment Date (7/9/18): . Fall Scale: Total = BLANK No risk 0-24, Low risk 25-50 and high risk greater or equal to 51. Assessment Date (10/30/18): .Fall Scale: Total = 75, High Risk. No additional fall assessments were provided by the end of the survey. A request for Investigation and Accident ( I & A) reports and investigation documents pertaining to R#19 was initiated on 10/29/18 at 4:30 PM and reviewed on 10/30/18 at approximately 10:00 AM and documented, in part, as follows: Current Summary (Fall Event) 7/12/18 .Details of the Event .Specific Event Type: From chair/gerichair/stool .Injury Incurred? NO .Brief Factual Description: Patient was observed on the floor sitting on her buttocks in front of the toilet. Preventative measures .patient will be monitored while in bathroom and or on the toilet as tolerated .transfer status 1 assist .person witnessed .blank Current Summary (Fall Event) 10/17/18 .Details of the Event .Specific Event Type: from chair, gerichair/stool. Reported by p/t(patient)/family/representative .Injury Incurred? YES Type of Fall .Accidental Fall .Brief Factual Description .swollen, bruised and painful left knee. Resident states she fell but did not know when .Preventative Measures and/or corrective actions taken: Reeducate resident on the use of call light, to call for assistance at all times even at time of fall .transfer status .walker .x-ray results: Pending . Current Summary (Fall Event) 10/21/18 .Details of the Event .Specific Event Type: From chair/gerchair/stool .Injury Incurred? UNKNOWN .Type of Fall .Accidental Fall .Brief Factual Description .Resident was observed in semi upright position on the floor, next to bed .Preventative Measures and/or corrective actions taken: Offer to assist resident to bed after dinner .Transfer status: 1 assist .Does the resident have a history of falls or multiple falls: YES .Does the resident have an unsteady gait? YES .Does the resident have reduced or lost use of a limb (arm or leg) NO. On 10/30/18 at approximately 8:30 AM an interview and record review was conducted with the Director of Nursing (DON) pertaining to R#19. The DON was queried as to R#19's falls and the fall prevention implementations made by the Facility. With respect to R#19 the DON reported that after the first fall in (MONTH) (YEAR), the Facility continued with the initial fall plan of a clutter free environment and the use of call lights and added monitoring for toileting of the resident. After the second fall on 10/17/18, that resulted in an injury to the resident, the DON reported the intervention implemented for R#19 was the re-educated on the use of the call light. After the third fall on 10/21/18 with possible further injury of the knee and hip, the DON reported the careplan was updated to add assistance to bed following dinner. When queried as to the intervention made after the second fall that included the re-education of the use of a call light for a severely cognitively impaired resident and an initial observation of the resident's call light out of reach, the DON stated, We do continue to re-educate even those resident's who are cognitively impaired. When queried as to further interventions that could be implemented the DON reported that the Facility does not use fall alarms and with respect to R#19, fall mats were not implemented. When queried as to R#19's injury(s) sustained as a result of the falls on 10/17/18 and 10/21/18, the DON reported the initial x-ray obtained after the 10/17/18 fall indicated no fracture. With respect to the x-rays obtained after the 10/21/18 fall, the DON reported that she was still reviewing documentation and investigating, but believed that R#19 did not have a fracture following 10/17/18. With respect to the fall on 10/21/18 the DON reported that a finding of a [MEDICAL CONDITION] was noted to be not acute. The DON was asked to provide x-ray results and hospital records pertaining to the injury(s) sustained from the falls. On 10/30/18 at approximately 3:20 PM, R#19 was observed sitting in her wheelchair. Her left leg with the imobilizer was extended out. The resident's call light was observed lying on the floor. When queried as to how R#19 receives help with care, R#19 stated, I don't know. When asked about how a call light is used, R#19 stated, I don't know. No staff were observed in R#19's unit. At approximately 3:30 PM, Activity Directory L entered R#19's room and placed the call light within reach. On 10/30/18 at 03:35 PM an interview was conducted with Occupation Therapist (OT)/Director K pertaining to R#19. OT K reported that R#19 received therapy services upon admission and was doing well, and stated, She could ambulate with assistance and a walker. We did stop services. We were asked to assist her after the fall on 10/17/18 as she was non-ambulatory and non-weight baring at the time. On 10/30/18 at approximately 3:00 PM a review of the (name redacted) X-ray mobile services findings was conducted and documented, in part, the following: October 17, (YEAR) (R#19) findings: Left knee .Minimal spur formation appears to be present along the medial border of the tibial plateaul . no evidence of fracture or dislocation or loose bodies in the joint space of the left knee. October 22, (YEAR) (R#19) Left Knee Technique: two views in one view there is a suspicious vertical linear lucency in the lower portion of the patella .if symptoms persist a follow-up examination is suggested. Impression: [MEDICAL CONDITION] arthritic changes with no recent fracture or dislocation. October 22, (YEAR) (R#19) Left lower extremity venous duplex study .History of falls 2 days ago with bruising around the left knee and swelling .Impression: there is no definite evidence to suggest presence of [MEDICAL CONDITION] . October 23, (YEAR) (R#19) Right Hip and Left Knee: Findings: .Right and left hip joints hip .No evidence of fracture or dislocation on either side (hip) .there is evidence of an oblique fracture in the anterior aspect of the patella (knee) . On 10/30/18 at 4:39 PM a phone call was made to the mobile x-ray/radiologist service to discuss the findings documented above. (Name redacted) informed the surveyor a message would be left with the Radiologist. No return phone call was received prior to the end of the survey, On 10/31/18 at approximately 9:00 AM, Hospital (name redacted) records provided by the Facility were reviewed and documented, in part, .10/24/18 .admitted through the ED (emergency department) last night after presenting with cardiac arrhythmia .reported she had a fall recently and on her way to orthopedic evaluation transported via EMS (emergency medical services) . she has a history of dementia and unable to give complete history 10/24/18 00:42 .Exam: CT(computed tomography scan/sophisticated x-ray device) .Findings: There is an incomplete [MEDICATION NAME] patellar pole .moderate degree of soft tissue swelling .to the patella . Hospital (name redacted) PT (physical therapy) Initial Evaluation (10/25/18) documented, in part, Reason for Referral .decreased mobility .Past medical and surgical history .admitted .fall -fx (fracture) patella .dementia .general rehab comment: left knee immobilizer .CT of left knee shows [MEDICATION NAME] inferior patellar pole .primary pain: acute .Therapeutic Activity Performed: PT limited with activities and needed max assistance due to increase LLE pain with minimal movement initiated sit to stand x2 for positioning and hygiene purpose unable to tolerate standing with increase time .Assessment problem list .Ambulation deficits, balance deficits, bed mobility deficits, decreased functional mobility, decreased independence with transfers. Range of motion deficits On 10/31/18 at 11:43 AM a follow-up interview with the DON was conducted pertaining to R#19 and observations of a call light use and placement for R#19. The DON reported that she would still continue to educate on the use of the call light along with further interventions. Resident #44 On 10/29/18 at approximately 9:40 a.m., R#44 was observed in their wheelchair in their common room. R#44 was queried if they have had any falls the nursing home and they nodded their head yes. On 10/30/18 at approximately 3:38 p.m., R#44 was observed in their room lying in their bed. R#44 was observed to be lying in their bed without a wing tipped mattress. Staff member M was queried if they observed R#44 without a wing tipped matted and they stated that they did. Staff member M was queried if R#44 should have a wing tipped mattress to sleep on in their room and they stated, I don't know lets look at the care plan. On 10/30/18 the medical record for R#44 was reviewed and revealed the following: R#44 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#44's MDS (minimum data set) with an ARD (assessment reference date) of 8/16/18 revealed R#44 needed extensive assistance from facility staff with most of their activities of daily living. R#44's BIMS score (brief interview of mental status) was three indicating severe cognitive impairment. A review of R#44's current care plan revealed the following: Problem-Potential for injury associated with falls R/T (related to) generalized weakness and confusion .Goal-Resident risks for injury related to falls will be minimized though next review Interventions Administer medications as ordered. Notify physician of adverse effects and obtain orders as needed Complete fall risk assessment and modify care plan as needed .Use assistive devices as described on resident summary for mobility and ADL tasks .Change mattress to a wing tip Mattress. A fall event report dated 10-3-18 revealed the following: Details of the Event: Specific Event Type-From Bed .Type of Fall-Accidental Fall .Brief Factual Description-pt (patient) observed on the floor at approx. (approximately) 0750 (military time). When asked pt stated that she must have rolled out of bed while she was sleeping. No c/o (complaints of) (grammar) or visible injury noted except for a sore back from falling to the floor .Preventative Measures and/or corrective actions taken: Changed mattress to winged tip mattress. A clinical note dated 10-3-18 revealed the following: IDT (interdisciplinary team) met and reviewed post fall. No injury noted. Resident is Ox1 (orientation to self only) with confusion noted and poor safety awareness. This resident has a history of falls and also among her [DIAGNOSES REDACTED]. She is (age of #44) and has a BIMS of three. It is noted that she rolled out of bed. A wing tipped mattress was applied her parameters. On 10/30/18 at approximately 3:40 p.m., R#44's resident care summary and care plan was reviewed with staff member M. Staff member M was queried if R#44 should have had a wing tipped mattress when they were in her room lying in their bed and they stated, yeah, she need one. It's in the care plan. Staff member M was queried if R#44 is a fall risk and they indicated that they were. Staff member M was queried why R#44 didn't have a wing tipped mattress in place and they indicated that they had a room change and the mattress wasn't transferred with them. On 10/30/18 at approximately 1:00 p.m., during a conversation with the Director of Nursing (DON) the DON was queried if it was their expectation that fall interventions indicated on the plan of care should be applied and in place and they said that it was. On 10/31/18 at approximately 2:30 PM a review of the Facility's Policy titled Fall Managemetn (Date: (MONTH) (YEAR)) documented, in part: Purpose: to prevent and/or reduce the number of falls by providing an individualized, person centered care approach with Communities managing fall risk through the process of assessment, planning, implementation, and evaluation .General Guidelines .Falls and fall risk will be managed through the process of assessment, planning, implementation, and evaluation .process/procedure 1. upon admission, quarterly and with any significant change in conditons residents will be screened for fall risk. 2. Residnet who are at risk for falls will have an individualized care plan developed which identifies interventions to reduce fall risk. 3. The community will incorporate a resident's choices into the plan of care. This can help the facility balance interventions to reduce the risk of an accident, while honoring the resident's autonomy. 4. A resident's care plan is evaluated and revised based on the resident's response, outcomes and needs. 5. Communities will evaluate resident falls and determine appropriate interventions to prevent future falls.

Based on interview, and record review the facility failed to ensure recommendations made by the consulting pharmacist during the monthly medication regimen review were documented and that a physician response to pharmacist recommendations were documented in the resident's clinical record for five (#'s 12, 26, 31, 44, 47) of five residents reviewed for a medication regimen review, resulting in the likelihood for the continuance of unnecessary medications and lack of communication of recommended medication changes. Findings include: Resident #12 A record review was conducted on 10/30/18. During that review it was discovered R#12 was originally admitted to the facility on [DATE] with a readmission of 7/15/18 with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/28/18, R#12 scored 15/15 on the Brief Interview of Mental Status (BIMS) exam indicating intact cognition. A further review of R#12's clinical record revealed monthly progress notes by the pharmacist that read, .Potential irregularity noted - see report . dated 9/5/18, 8/1/18, 7/9/18 and 6/6/18. Documentation of the identfied irregularity on the pharmacist's report and the physician's response to the recommendation was not present in the record. Resident #31 A record review was conducted on 10/30/18. During that review it was discovered R#31 was originally admitted to the facility on [DATE] with a readmission of 8/21/18 with [DIAGNOSES REDACTED]. According to the most recent MDS assessment with an ARD of 9/4/18, R#31 scored a 15/15 on the BIMS exam indicating intact cognition. A further review of R#31's clinical record revealed monthly progress notes by the pharmacist that read, Potential irregularity noted - see report dated 9/5/18. Documentation of the identified irregularity on the pharmacist's report and the physician's response to the recommendation was not present in the record. Resident #47 A record review was conducted on 10/10/18. During that review it was discovered R#47 was originally admitted to the facility on [DATE] with a readmission of 2/17/18 with [DIAGNOSES REDACTED]. According to the annual MDS assessment with an ARD of 9/7/18, R#47 scored a 2/15 on the BIMS exam indicating severe cognitive impairment. A further review of R#47's clinical record revealed monthly progress notes by the pharmacist that read, Potential irregularity noted - see report dated 9/5/18. Documentation of the identified irregularity on the pharmacist's report and the physician's response to the recommendation was not present in the record. R#26 On 10/31/18 at 10:07 AM, a review of R#26's clinical record was conduced and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R#26's MDS assessment dated [DATE] indicated intact cognition and extensive assistance of one staff member for daily living. A review of R#26's monthly pharmacist recommendation notes for July, August, and (MONTH) (YEAR) were reviewed. Each note indicated the pharmacist noted a Potential irregularity for those months, however; the notes did not indicate what irregularity the pharmacist identified. On 10/30/18 at 11:10 AM and 4:30 PM and 10/31/18 at 11:20 AM the facility was requested to provide the recommendations of the pharmacist (for the months of July, August, and (MONTH) (YEAR)) and evidence of whether the attending physician accepted, declined, or modified the pharmacist's recommendations. The recommendations and evidence of the physician's response was not received by the end of the survey. Resident #44 On 10/31/18 at 10:15 AM, a review of R#44's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R#44's Most recent MDS assessment indicated severely impaired cognition and extensive assistance of one to two staff members for most activities of daily living. A review R#44's monthly pharmacist recommendation notes for (MONTH) and (MONTH) (YEAR) were reviewed and each note indicated the pharmacist identified a potential irregularity for those months, however; the notes did not indicate with type of irregularity the pharmacist identified. On 10/31/18 at 10:45 AM and 3:00 PM, the facility was requested to provide the pharmacist recommendations and the physician's response to the recommendations for R#44 for the months of (MONTH) and (MONTH) (YEAR). The recommendations and evidence of the physician's knowledge of the recommendations were not received by the end of the survey. 10/31/18 at 2:14 PM, an interview was conducted with the facility's Director of Nursing (DON) and Clinical Care Coordinator 'O'. During the interview, the DON explained the facility had recently switched pharmacy companies and she was aware of the concern that the recommendations and physician's response to the recommendations for R#26 and R#44 could not be located. On 10/31/18 at approximately 3:20 PM, a review of the facility provided policy was conducted. It was noted the effective date of the policy was 11/28/16. The policy titled, Medication Regimen Review was reviewed and read, .6 Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRRs. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR .to act upon the recommendations contained in the MRR. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained with the MRR, or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure medications were appropriately stored in one of three medication room refrigerators, resulting in the likelihood for administration of expired flu vaccinations. Findings include: On [DATE] at 2:10 PM, a review of one of the two medication storage areas on the second floor was conducted with Registered Nurse (RN) 'D'. The refrigerator in the storage area was observed to contain 5 unopened vials and one opened vial dated [DATE] of flu vaccine that read, (YEAR)-2018 Formula. All of the vials were observed to have an expiration date of [DATE]. At that time, RN 'D' was queried about the vial that was opened with the date [DATE]. RN 'D' said, I didn't give it, but someone probably did. On [DATE] at 2:44 PM, an interview with the facility's Director of Nursing (DON) was conducted. During the interview, the DON indicated that the expired flu vaccine should not have been kept in the refrigerator. On [DATE] at approximately 3:00 PM, a review of the facility's Policy titled Medication Storage dated ,[DATE] was reviewed and read, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations .14. Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock, and disposed of according to procedures . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

Based on interview and record review the facility failed to implement an immunization program per facility policy for four residents (#'s 1, 18, 31, 36) who were able to sign their own consents of ten residents reviewed for vaccinations, resulting in the likelihood for lack of education regarding risks and benefits of administration of the vaccination to the resident. Findings include: On 10/30/18 a review of the facility's immunization records revealed no documentation of signed consents for the Influenza vaccine for the (MONTH) 1, (YEAR) - (MONTH) 31, 2019 Influenza season. On 10/30/18 at approximately 1:00 PM Clinical Care Coordinator 'A' was asked to provide the documentation of signed consents for the Influenza vaccine for Resident's #1,18, 31 and 36. On 10/30/18 at 3:50 PM an interview with Clinical Care Coordinator 'A' was conducted. During that interview Clinical Care Coordinator 'A' stated, We do not have the (YEAR) immunizations done yet, we hope to have them done by the first week in November. When asked if the consents had been obtained from the residents, Clinical Care Coordinator 'A' replied, We are trying to get the consents from the families (of the residents). On 10/31/18 at 8:45 AM an interview with the Director of Nursing (DON) was conducted. During that interview the DON was queried as to the Influenza consents. The DON stated the consents had been mailed to the families of the the residents, and they were waiting for them to be returned. A review of the facility's undated policy titled Influenza (Flu) Vaccination of Residents read .Current and newly admitted residents, all staff, and volunteers will be offered the influenza vaccine from (MONTH) of each year through the end of (MONTH) the following year .

Based on observation, interview and record review the facility failed to ensure a resident was maintained in a safe position while providing care based on their assessed needs one resident (R#901) of two residents reviewed for falls of a total sample of five resulting in R#901 sustaining a preventable fall resulting in a fractured femur, laceration to head and Minimally displaced [MEDICAL CONDITION] and inferior left pubic rami that required emergency hospital care. Findings include: On 4/11/18 at approx. 1:30 p.m. R#901 was observed in their room lying in their bed. Sutures (staples) were observed in R#901's head. R#901 was queried if they had a fall and they stated yes. R#901 was queried regarding the details of their fall and they stated I don't know. On 4/11/18 at approx. 2:02 p.m., the medical record for R#901 was reviewed and revealed the following: R#901 was initially admitted to the facility on [DATE] and was readmitted from the hospital on [DATE]. R#901 had [DIAGNOSES REDACTED]. R#901's MDS (Minimum Data Set) with an ARD (assessment reference date) of 1/19/18 indicated R#901 required extensive assistance from facility staff with bed mobility, transfers, dressing, personal hygiene and bathing. R#901 was coded as always incontinent and R#901's BIMS score (brief interview of mental status) was 3 indicating severely impaired cognition. A nursing progress addendum note dated 3/28/18 for an initial nursing progress note dated 3/26/18 stated the following: Res was lying on her side being changed by the CNA- CNA turned to grab towel and res. rolled off the side of the bed. Res has approx 5cm long abrasion on upper forehead which was bleeding - area cleansed with NS (normal saline) and pressure dressing applied with Kerlix wrap. Res did not lose consciousness-alert and answering questions. ROM X4 with some c/o (complaint of) knee pain- when asked about pain res. states she had it before her fall. Daughter notified. (Attending Physician) reached at 2:30 pm and order received to send to ( hospital name) ER for sutures. DON (Director of Nursing) notified. Neurochecks in progress with no change in L[NAME]. (Ambulance Company Name) took res. to ER at 3PM. A hospital CT exam (special X-ray tests that produce cross-sectional images of the body using X-rays and a computer.) of the left lower extremity (left leg) dated 3/26/18 revealed the following: There is acute displaced comminuted fracture (broken bone) in the distal left femur (thigh bone) with approximately 1.2 cm medial displacement of the distal fracture fragment. Impression- 1. Acute displaced comminuted [MEDICAL CONDITION] left femur , extending into the femoral component of the left total knee arthroplasty. A hospital CT exam of the pelvis dated 3/26/18 revealed the following: Extremely osteopenis bones. A thin lucent line is demonstrated in the left anterior acetabulum (concave surface of the pelvis) and left superior pubic ramus (a part of the pubic bone) concerning for an acute nondisplaced fracture. A hospital X-ray of the pelvis dated 3/26/18 revealed the following: Impression- 1. Minimally displaced [MEDICAL CONDITION] and inferior left pubic rami. A hospital surgical note dated 3/28/18 reveled the following: [AGE] year-old non-ambulating female . who fell out of her bed at her nursing home directly onto her face and knees. Patient had immediate pain and swelling her left knee and also sustained a laceration to her forehead. Presented to the ER where the laceration as managed. She was also found to have a far distal supracondylar periprosthetic femur fracture. Orthopedics was consulted. On exam the patient had extreme pain with any motion of her left lower extremity . A nursing note dated 3/30/18 revealed the following: Res. admitted per gurney from hospital. Alert X 2 and in no apparent discomfort Laceration on forehead with 11 staples in place. Leg immobilizer in place on left leg. Incision left upper thigh with 3 staples in place-no drainage. Large central incision above left knee with 24 staples in place- oozing small amt. serosanguinous fluid. Two incisions on either side of central incision with 4 staples in place- no drng . A Physician evaluation dated 4/3/18 revealed the following: Patient is seen post hospitalization for fractured femur laceration of the forehead she appears to be in significant pain and I loosened her immobilizer. We will plan increasing to 5 mg [MEDICATION NAME] On 4/11/18 at approx. 2:30 p.m., the facility investigative file regarding R#901's fall on 3/26/18 was reviewed and revealed the following: A facility document signed by staff member A and the Director of Nursing (DON) which was dated 3/27/18 titled One on One Education stated the following: Education Objective: Resident Safety. Summary of Content: - Gather all supplies before starting care. -Call for additional assistance via call light if needed. -Keep resident in safest position. -Review resident care summary. -Ensure all safety precautions are in place. A facility document titled Corrective Action Notice which was signed by staff member A and the DON revealed the following: Violation of TSLC policy 3.4. This policy outlines unacceptable behaviors and actions. This corrective action addresses specifically #26. Failure to perform duties according to established standards for quality, performance and quantity. On 3/26/18 colleague failed to provide safe resident care. On 4/11/18 at approx. 2:46 p.m., Staff member A was queried regarding R#901's fall on 3/26/18. Staff member A stated the following: I was in the room changing the brief providing incontinence care for her. I used the draw sheet to roll her on her side. She had a bowel movement so I went to the bathroom to get a towel. She was still on her side when I was in the bathroom and when I was in the bathroom grabbing the towel I hear the resident fall and she shouted ouch. I came out of the bathroom and she was bleeding and I told another aide to get the nurse. Staff member A was queried if it was standard to practice to leave a resident on their side unattended while they gather additional supplies and staff member A stated no, I should have called for help. I shouldn't have left her. I also should have brought enough supplies with me so I wouldn't have to get anymore. Staff member A was queried if they had remained at R#901's bedside would R#901 have fallen and she stated no, I would have been able to get her. Staff member A was queried about the corrective action notice they received and they stated I got it because I left her unattended and didn't bring enough supplies. It was due to the residents safety. It was my mistake. On 4/11/18 at approx. 3:45 p.m., the Director of Nursing (DON) was queried regarding the investigation for R#901's fall on 3/26/18. The DON was queried why the facility gave staff member A one to one education and issued a corrective action and they stated that it was due to the severity of the fall and the injuries sustained by the resident. The DON was queried what staff member A should have done that may have prevented the the fall and they stated make sure the resident was in the safest position and they have all their supplies. She should have used the call light to get help. We inserviced all the staff on making sure they have all their supplies and use the call light for help. On 4/12/18 at approx. 10:29 a.m., staff member B was queried how to give appropriate incontinence care for R#901. Staff member B was queried if it was acceptable to leave a resident on their side and unattended to go gather more supplies in the bathroom and they stated no, I would call for help. Staff member B was queried if facility nursing aides should have all the supplies for incotinence care at the bedside prior to providing the care and they stated that they should. On 4/11/18 at approx. 11:08 a.m., a facility document titled Falls Management dated (MONTH) (YEAR) was reviewed and revealed the following: Purpose To prevent and/or reduce the number of fall by providing an individualized, person-centered care approach with communities managing fall risk though the process of assessment, planning, implementation and evaluation A facility document titled Perineal care of the female patient revised (MONTH) 17, (YEAR) for which the DON provided when queried for an incontinence care policy was reviewed and revealed the following: Implementation: Gather and prepare the equipment at the patient's bedside.

Based on observation, interview and record review, the facility failed to position the resident during care based on his assessed needs that led to a preventable fall for one sampled Resident (#707) out of five residents reviewed for falls out of a total sample of 17, resulting in a laceration to the forehead and left elbow skin tear that required emergency hospital care. Findings include: On 8/15/17 at 10:45 AM, an observation of Resident #707 was made. Resident #707 was seated in his wheelchair in his room and noted to have an approximate 1 inch semi-closed laceration to the left forehead. When the resident was queried regarding the laceration, Resident #707 appeared confused and had garbled speech. A review of Resident #707's clinical record was conducted on 8/15/17 at 11:15 AM, and revealed that Resident #707 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #707's quarterly minimum data set (MDS) assessment dated [DATE] documented that the resident had a 6 out of 15 BIMS (brief interview of mental status) score which indicated severely impaired cognitively and required extensive to total assistance of 1-2 person (s) for activities of daily living. A review of a clinical note for Resident #707 and documented by Nurse 'I' dated 8/5/17 was conducted on 8/15/17 at 11:30 AM. Nurse 'I' documented: Resident #707 had a fall at 8:20 this am. The resident sustained [REDACTED]. Emergency medical service (EMS) was called and patient was transferred to hospital for evaluation. treatment for [REDACTED]. The left elbow was wrapped in kerlix and the patient received a tetanus shot. A review of the incident and accident (I/A) reports titled: Unplanned Occurrence Report, dated 8/5/17 and 6/29/17, for Resident #707 was conducted on 8/15/17 at 12:15 PM. The incident and accident reports revealed in part: I/A dated 8/5/17 and timed at 8:20 AM, was completed by Nurse 'I' and documented: Location of incident: Resident's Room. Briefly describe occurrence. Facility Aide got resident up to get dressed. Resident was sitting on the side of the bed with bed in the lowest position. The Aide was picking up the Resident's shoe as the Resident leaned forward and fell on to the floor. Name of Witness: Aide 'H'. First aid administered: Compress Dressing to head. Resident transferred to hospital . Preventative measures and/or corrective actions taken: Put shoes on resident when lying in bed. I/A dated 6/29/17 and timed 0718 AM, documented: Location of incident: On his bed. Briefly describe occurrence. While getting resident dressed with resident sitting on side of bed, resident fell forward on to the floor. Preventative measures and/or corrective actions taken: Resident to remain lying in Bed while getting dressed and not sitting on edge of Bed. On 8/15/17 at 1:30 PM, a review of the facility's fall risk assessments dated 7/29/17 titled: Morse Fall Scale and Tug Mobility Test was performed. The Morse Fall Scale and Tug Mobility Test total score for Resident #707 was 60 and the ledger documented: Morse Fall Risk Level- High Risk greater than or equal to 51. A review of Resident #707's care plan, with an effective date of 7/29/2017, was conducted on 8/15/17 at 2:00 PM. The Care Plan documented: Problems- Potential for injury associated with falls R/T (related to) generalized weakness, unsteadiness, H/O (history of) falls, decreased safety awareness. Goals- Residents risks for injury related to falls will be minimized through next review. Intervention dated 6/30/17- Resident to remain lying in bed while dressing and until ready to be transferred by the stand assist lift device (a stand assist lift is used to transfer a patient between seated surfaces). An interview was conducted with the Nurse 'I' on 8/15/17 at 3:20 PM. When queried regarding Resident #707's fall with injury on 8/5/17 and care planned intervention not followed after fall on 6/29/17, Nurse 'I' indicated that she had not witnessed the fall. Nurse 'I stated: The Aide (referring to Aide 'H') was with Resident #707. She (referring to Aide 'H') had him on the side of the bed getting him dressed. She went to reach for a shoe and Resident #707 fell on the floor hitting left side of forehead. I think he had a left elbow skin tear. I observed resident on the floor. Pressure was applied to the forehead, vital signs were taken and EMS called. An interview was conducted with Aide 'H' on 8/16/17 at 9:25 AM. When queried regarding Resident #707's fall with injury on 8/5/17 and care planned intervention not followed after previous fall of 6/29/17, Aide 'H' stated: I was getting him dressed. Resident #707 was sitting at edge of bed. I was putting Resident #707's shoes on. Resident #707's shoes were on the wheelchair and the wheelchair was in reach so I didn't have to turn my back or anything. As I went to grab the shoe, I saw Resident #707 leaning forward and tried to catch him but Resident #707 was too fast and heavy. Aide 'H' indicated that Resident #707's head hit the corner of the dresser in the room which was located next to the bed. Aide 'H' stated: There wasn't anything to my knowledge that said he could not be seated on the side of the bed, but after the fall, I had a one on one with my Director of Nursing (DON) and Assistant Director of Nursing (ADON) and they told me I cannot dress him or put Resident #707's shoes on unless he is lying down because he is too unstable to be sitting. The ambulance was called because he was bleeding. The cut was about an inch (referring to forehead). Apparently Resident #707 had something on left elbow so they wrapped it. On 8/16/17 at 11:00 AM, a review of Resident #707's hospital emergency department (ED) Triage and Assessment as well as the Cat-Scan (CT Scan) result dated 8/5/17 was conducted. The ED Triage and Assessment documented: Chief Complaint Description: slip and fall getting out of bed ., 3 cm (centimeter) lac (laceration) to forehead, 3 cm skin tear left upper arm. The CT result documented: Findings: Soft tissue hematoma overlies the left frontal bone. An interview was conducted with the DON on 8/16/17 at 4:45 PM, When queried regarding Resident #707's fall with injury on 8/5/17 and previous fall of 6/29/17, the DON indicated that Aide 'H' did not follow the care plan for Resident #707 and stated: We would dress him as much as we can in bed. A review of the facility policy and procedure titled Falls Management- Date: December, 2015 was conducted on 8/16/17 at 5:00 PM and documented: Purpose: To prevent and/or reduce the number of falls by providing an individualized, person centered care approach with Communities managing fall risk through the process of assessment, planning, implementation and evaluation (APIE). Process/Procedure 2. Residents who are at risk for falls will have an individualized care plan developed which identifies interventions to reduce fall risk. 4. A resident's care plan is evaluated and revised based on the resident's response, outcomes, and needs. 5. Communities will evaluate resident falls and determine appropriate interventions to prevent future falls.

This Citation refers to Intake #M 0487 Based on interview and record review the facility failed to assess a resident displaying respiratory distress and provide cardiopulmonary resuscitation (CPR) for a resident with an Advanced Directive that indicated Full Code Status and was found without vital signs for one (#501) of four resident's reviewed for code status out of a total sample of five residents, resulting in an Immediate Jeopardy when Resident #501 was found expired. This had the potential for further harm, serious injury and/or death to other residents. The Immediate Jeopardy was identified at 1:25 p.m. on [DATE]. The administrator was notified of the Immediate Jeopardy on [DATE] at 3:35 p.m. and a plan of correction was requested to remove the immediacy. The IJ was removed on [DATE] at 9:00 a.m., when the facility submitted the acceptable plan of correction that was implemented and verified on site by the survey team. Although the IJ was removed, the facility ' s deficient practice was not corrected and remained isolated with the potential for more than minimal harm that is not an immediate jeopardy. Findings include: On [DATE] at 12:30 p.m. the Facility Administrator provided several documents pertaining to an investigation of the death of Resident #501 on [DATE]. All documents provided were reviewed during the survey and included the following: Resident #501 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident's Minimum Data Set ((MDS) dated [DATE] revealed that the Resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intake). Further review of the Resident's clinical record revealed an Advanced Directive dated [DATE] indicating that Resident #501 was a FULL CODE. Further review of the Resident's clinical record revealed, in part, the following notes: Clinical Note (author by the social worker (SW) B dated [DATE]: .Resident is a pleasant male .who presents to our community for short term rehab s/p (since being) hospitalization for right humerus fracture He reports that his discharge goal is to return home with his wife.resident has signed himself as FULL CODE (emphasis added) and reports his plan to return home. Clinical Note (authored by Nurse A ) Late Entry dated [DATE] at 2200: I placed [MEDICAL CONDITION] (continuous positive airway pressure/ a treatment that uses mild air pressure to keep the airways open- typically used by those with breathing problems) machine on pt (patient). I checked his SPO2 - 93%. He stated that was good for him. I told him I would see him throughout the night. Call light within reach. Clinical Note titled : Change in Condition (authored by Nurse A) Late entry dated [DATE] at 0550, I entered patients room to administer medications he was not breathing very pale he did not have pulse. I called 911 . A review of Facility's investigation documentation included the following: Staff Interview Summary(s): Title: CNA (Certified Nursing Assistant) C Date of Interview: 6.29.16 Who conducted interview: DON (Director of Nursing) Summary of statement: Q. On [DATE] did you take care of Resident #501? A. Yes Q. Did you take off the bi-pap? A. Yes, I took it off and put on the nasal canula and the oxygen on the wall was already on 9L (liters) of 02. at 3:30 a.m. that's when he told me he had to go to the bathroom . so CNA D and I transferred him to the chair. At this time he is having a hard time breathing so we used the resident's personal pulse-ox to see what his oxygen was and it was 70%. We let him sit for a minute and get his oxygen at least 90%, his baseline is 90% Q. Can we go back to the 70% O2 level ? Was that reported to the nurse? A. Yes, right after we finished taking him to the bathroom and back to bed. Q. Anything abnormal that you can report? A. No, I passed fresh water at 5:00 a.m. and saw that Resident #501 was breathing. Then at 5:50 a.m. the Nurse found him. The Nurse was calling his name. She called his name 3 times and the nurse ran out and told me he passed away. Nurse was kind of freaking out On [DATE] at 11:28 a.m., a phone interview was conducted with CNA C regarding the incident that occurred with Resident #501 and the statement signed on [DATE]. CNA C was queried as to whether she informed Nurse A that Resident 501's pulse-ox was 70%. CNA C stated, I told Nurse A after we took him to the bathroom. I let her know that his pulse-ox was 70% and that we put on his 02. I also told her that after a few breaths it was back at 91%. Nurse A said that was okay. Staff Interview Summary ([DATE]) Title/Position: CNA D Summary of Statement: Call light 3:00 a.m., Resident #501. CNA C and I .addressed Resident and inquired his needs; requested to use the bathroom. He had [MEDICAL CONDITION] on and CNA C detached oxygen tubing from [MEDICAL CONDITION] and applied to nasal canula .assisted Resident to bathroom . let resident know to put on call light .after five minutes .assisted off the toilet. Resident became labored in breathing and asked if he needed a few minutes to catch his breath .we stood with him and he caught his breath . wheeled him back toward bed. Begin to exhibit labored breathing again, took bedside pulse-ox and read 78. We ensured he was raised to 90 degree angle .We went to put the [MEDICAL CONDITION] on and resident said he did not want it on .I left to speak with Nurse A and told her resident did not want [MEDICAL CONDITION] on anymore. Nurse said if pulse ox greater than 90 it was ok. Reported previous pulse-ox at 78. We left room On [DATE] at 4:15 p.m., a phone interview was conducted with CNA D regarding the incident involving Resident #501 and the statement provided on [DATE]. CNA D responded, I helped CNA C that evening around 3:00 a.m., as the Resident was a two person assist. I remember that his pulse-ox was low around 78% . we got it back to about 91% and told Nurse A that it was low and he refused to have his [MEDICAL CONDITION] put on. He did have his O2 on around 6:00 a.m., CNA C told me that he had passed away. Staff Interview Summary -[DATE] Title/Position: LPN Nurse Manager A Q. Why didn't you start CPR? A. I was told it was the policy that if someone was clearly dead that we don't start CPR. On [DATE] at 5:10 p.m. and phone interview was conducted with Nurse A regarding the incident that occurred on [DATE] and was queried as to her statement provided to the Facility as referenced above. Nurse A stated I did not give CPR to Resident #501. I followed the Facility's policy that I learned in training, it informed us that CPR does not have to be performed if the Resident was not breathing. When further queried as to whether she was informed by a CNA(s) that Resident #501's pulse-ox was at 70% around 3:30 a.m Nurse A stated, I do not recall if they told me or not. On [DATE] at 4:10 p.m., an interview was conducted with the Director of Education, Nurse E regarding CPR training for all nursing staff. Nurse E responded, I train all staff that if there is a Code A (Full Code) CPR should be performed. Nurse E was queried as to whether there is a difference between witnessed and non-witnessed cessation of vitals. Nurse E stated, I would do always have done CPR if the Resident was a FULL CODE. There may have been some confusion with Nurse A because of our old policy. When asked if that policy was provided to staff during training, Nurse E stated, I read them the policy during training, I don't give them a copy. On [DATE] at 12:30 p.m., an interview was conducted with the DON. The DON was queried as to the incident regarding Resident #501 and the Facility's policy pertaining to CPR. The DON stated, I never read the original CPR policy. It was given to me in a packet when I was hired (approximately 2 months ago). In the situation involving Resident #501, I was surprised that Nurse A did not attempt CPR. I would have. When queried as to why Nurse A did not assess Resident #501 after CNA C reported that the resident's pulse-ox had dropped in the 70s, the DON stated, I believe Nurse A stated that she was never told. The DON was informed that there was no documentation provided in the investigation packet that revealed that Nurse A was not informed by the CNA. The DON stated, OK, if it's not there I guess it's not there. If the CNA(s) told her there was a decline Nurse A should have assessed the Resident. The DON was also queried as to whether Resident #501 had a careplan for his [MEDICAL CONDITION]. The DON stated, No, I do not believe so. On [DATE] at 9:40 AM, the Medical Director was interviewed via phone regarding a chart review completed following the death of Resident #501. The Medical Director stated Resident #501 was changed to a full code upon admission to Facility. The Medical Director further stated nurse A found Resident #501 expired. Resident #501 was a full code and Nurse A did not initiate CPR. On [DATE] at 12:30 PM, an interview was conducted with the Administrator regarding the incident pertaining to Resident #501. The Administrator was queried about the investigation and responded, We interviewed the staff involved and determined that CPR should have been performed as Resident #501 was a FULL CODE. We revised our policy and in-serviced staff. We will continue to audit to ensure this does not occur again. On [DATE] at 11:00 a.m., a review of the Facility's policy, in place at the time of the event referenced above and titled Cardiopulmonry Resuscitation CPR dated [DATE] revealed the following: Purpose: In the event of a witnessed cessation of vital signs, residents with a full code status will have CPR efforts and 911 will be called. 1. Witnessed cessation of vital signs: A. Cessation of vital signs and / or respirations occurs in the presence of another person/staff member B. Full Code status is determined by method of validation (wristband, Code status document in chart C. A Full Code is called and initiated (may call a code Blue) D. Initiate CPR (cardiopulmonary resuscitation) E. Call 911 2. Resident is found with absent vital signs/respiration and unwitnessed arrest/cessation: A. Determine status; pupils fixed and dilated, femoral and carotid pulses absent and absent vital signs/respirations, cyanotic extremities. B. According to individual state rules the resident is pronounced deceased by the registered nurse and/or physician is contacted related to findings and the physician pronounces the resident deceased based on clinical findings (absence of vital signs, pupils fixed and dilated). C. Notify family and funeral home (physician if not already contacted). 3. A physicians order is obtained on admission as well as the resident ' s wishes or POA (Power of Attorney). The policy of this community is explained to the resident upon admission and with each review of CPR-Code/No Code Status. This process will be clearly identified in the residents chart. 4. This process and the meaning of this process will be explained to the family and or resident with regards to CPR initiation and when CPR will be initiate. , The facility submitted the following IJ removal plan on [DATE]: · On [DATE] Education of licensed nurses began immediately regarding proper CPR protocols including their role in an event of cessation of vital signs in residents with a full code status. · On afternoon shift of [DATE] the licensed nurses, (Nurse 1), was interviewed and 1:1 education was provided on clarification of CPR policy. Nurse 1, successfully completed CPR post-test and verbally reiterated necessary steps in the event of a cessation of vital signs, residents with a full code status. · The CNA's taking care of (Resident #501) the early morning of [DATE] were interview on their next schedule shift. Around 1:30 am on [DATE] (Nurse 2) was interviewed by administrator and DON. Around 2:00 am on [DATE] (CNA 1)was interviewed by administrator and DON. CNA 1's interview determined she witnessed him sleeping at 5 am with O2 on. · As of [DATE] no licensed nurses were allowed to work on the floor until education received. All 38 licensed nurses have been re-educated on the CPR process and have successfully completed the post-test. (There are 2 nurses on Leave of Absence). There are 2 nurses on leave of absence. Education will ensue with post-test prior to their first shift of work. · On [DATE] CPR certification status of all licensed nurses was reviewed and found to be current and at 100% compliance prior to the incident involving Mr. Mason. · On [DATE] all licensed nurses employee files were verified with current CPR cards. · On [DATE] all like residents that are Code A had audit conducted to ensure Code status order matched the resident advanced directives. · On [DATE] the CPR policy was reviewed and found to meet the intent of the regulation. · To ensure ongoing compliance, mock codes will be randomly conducted on all shifts. Evidence of ongoing compliance includes the successful mock codes completed on [DATE] at 1:05 pm and [DATE] at 3:45 pm. The community will continue to do random mock codes with findings reported monthly to the DON and trends to the Mission Driven Quality Improvement committee monthly for review and recommendation.