Every finding on record at The Orchards at Armada

Based on observation, interview, and record review, the facility failed to ensure the call light was kept within reach for one (R15) of four residents reviewed for call light access. Findings include:On 07/28/2026 at 10:20 AM, R15 was observed lying in bed. The call light was observed hanging over the top left edge of the head of the bed and clipped onto itself at the side of the mattress out of view and reach. R15 was asked how they contact staff if they need assistance and they couldn't provide a response. When asked if they use a call light, they stated yes. When asked if they knew where their call light was, they stated, Sometimes it's right here with me but not always.A review of R15's electronic medical record (EMR) revealed they were admitted to the facility on [DATE] with diagnoses including Right Femur Fracture and Anxiety Disorder. The Minimum Data Set (MDS) assessment dated [DATE] indicated R15 has moderate cognitive impairment and requires maximum assistance with most self-care tasks. R15's activities of daily living (ADLs) care plan included the intervention Encourage me to use my call light, keep it within my reach.On 07/29/2026 at 9:51 AM, R15's call light was observed to be clipped onto itself on the left side of the mattress at the head of the bed, out of the resident's view and reach. R15 was asked if they knew where their call light was and they reported they did not. R15 was asked if they would prefer to be able to reach and use their call light and they stated, Of course I would.On 07/30/2026 at 8:38 AM, R15 was observed lying in bed eating breakfast. The call light was observed clipped on the left side of the mattress at the head of the bed as previously observed. R15 was asked if they were able to reach their call light or if they knew where it was and they stated No, I'm not sure where it is. When asked if they would like to be able to see and reach the call light they stated Oh, yes I would.On 07/30/2026 at 10:00 AM, Unit Manager (UM) B was interviewed and asked their expectation regarding resident's access to their call light and said, The goal is for residents to have their call light within reach.On 07/30/2026 at 11:25 AM, The facility Director of Nursing (DON) was interviewed and confirmed call lights are to be kept within resident's reach.A review of the undated facility policy titled Unit Rounds (describing the Standard Operating Procedure (SOP) for daily unit rounds) revealed the item Call light placed appropriately on a list of items to check in resident rooms.

Based on observation, interview, and record review, the facility failed to ensure restorative services were provided timely for one resident (R902) of four reviewed for range of motion (ROM) and mobility. Findings include: On 05/06/26 at 9:50 AM, R902 was observed laying on their back in bed saying they entered the facility to learn how to walk and could not currently walk and was not in therapy. R902 reported they had been in therapy while at the facility but did not recall why they were discharged from therapy and required assistance to get out of bed. On 05/06/26 at 12:50 PM, R902's information was reviewed with Physical Therapist (PT) A. PT A reported R902 was on the therapy caseload from 02/25/26 to 04/03/26 and was discharged due to R902 reaching their highest practicable level. Bed mobility at discharge was supervision (just standby resident) and was supervision for walking 50-100 feet with a walker. PT A reported R902 as able to get up and walk without physical assistance. PT A reported R902 was discharged to restorative therapy and referred 04/06/26 for sessions 3-5 times a week. On 05/06/25 at 2:15 PM, Restorative Certified Nursing Assistant (CNA) B reported they had worked with R902 prior to 2/25/26 but had not received anything after R902's 04/03/26 discharge. CNA B reported R902 had a decline previous to the most recent therapy session and could not work with R902 as they had become a two person assist. CNA B reported were the only restorative CNA and they were only allowed six or seven residents to work with at any one time and R902 was not currently on their restorative program caseload. A review of the medical records for R902 reveal R902 was admitted into the facility on [DATE]. Diagnoses included Anxiety, Heart Attack and Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 14/15 Brief Interview for Mental Status (BIMS) score and the need for substantial/maximal for lower body dressing and toileting hygiene and partial/moderate assistance for sitting to lying, sitting to standing and transfers. A review of the active care plan initiated 08/29/25 revealed, occasionally incontinent of bowel . I am on restorative nursing .revised 04/06/26 .up to 20 minutes on scifit (bike), ambulate with 2WW (two wheeled walker) A PA (one person assist) assist with WC (wheelchair) follow left knee brace, 3-5x a week . The need assistance with my ADLs (activities of daily living) care plan revised 02/09/25 documented R902 as a two person assist for bed mobility, personal hygiene and dressing.A review of the referral from Physical therapy dated 04/03/26 documented R902 was referred to restorative nursing services for 3-5x a week, ambulate with 2WW (wheeled walker) PA (partial assist) assist with WC (wheelchair) follow left knee brace, goal to maintain current functional ability with therapy. This referral to restorative therapy had yet to be provided. On 05/06/26 at 4:16 PM, the Director of Nursing (DON) reported the process for restorative services was to give the referral to nurse management, who would put in the care plan and add it to the tasks and then hand it to the restorative CNA. The DON did not have an explanation as to why the referral did not make it to the restorative CNA. A review of the undated policy titled, Rehabilitation-Transition Process revealed, Purpose: To provide communication regarding resident care and services needed to maximize physical function . All appropriate disciplines will assist in the implementation and coordination of all rehabilitation programs .

This citation pertains to Intake 2786506.Based on interview and record review, the facility failed to ensure a wound status condition update to specialist for one resident (R901) of three residents reviewed for wounds. Findings Include:A complaint called into the State Agency indicated, Neither (name of consulting physician) and/or myself or my family members-who were visited daily- were never notified that there was an infection going on with (name of R901's) leg. (Name of consulting physician) sent (name of R901) to emergency immediately .Review of the clinical record revealed R901 was admitted to the facility on [DATE]. R901's diagnoses included Chronic ulcer of the right ankle (open wound right lower leg) and Varicose veins of Right lower extremity (RLE) with ulcer. The record revealed the resident was to have a wound vac (a vacuum dressing over a wound to promote healing) as ordered by a Wound Care Clinic Consulting Specialist (WCCCS). R901 had a follow-up visit on 12/4/2025 with the WCCCS where the wound vac was removed with an Unna boot (dressing and wrap used to heal wounds) was ordered. Review of the clinical record revealed on 12/10/25, the wounds demonstrated increasing edema (swelling) and redness, pending Primary Medical Doctor (PMD) C contact and evaluation.Further review of the record documented on 12/11/25, PMD C was notified of swelling, redness, and warmth of the right foot and R901's white blood count (indicating infection) was 11.6 (normal range is 5 - 10). PMD C's documentation revealed they have spoken with the WCCCS regarding the plan of care. The plan of care included a change in the antibiotics in addition to cleanse with acetic acid, normal saline rinse, pat dry, betadine wipe to peri-wound (around wound), apply nickel thick layer of wound debriding ointment (removal of unhealthy tissue), normal saline moist gauze, covered by dry gauze covered with thicker pads and wrapped with gauze wrapping to be secured with self-adherent bandage from metatarsal heads (mid foot) to just below the knee and recommended a consult with the wound care doctor. There is no documentation indicating the WCCCS was consulted.A progress note dated 12/12/25, by Rehabilitation Nurse Practitioner (RNP) D revealed R901 stated increasing RLE pain, edema, warmth, drainage, and erythema (redness). RNP D further documented to still followed with wound care. R901 also revealed they were not sleeping well so did not want to attend therapy that day. There is no documentation indicating the WCCCS was consulted.Further review revealed on 12/16/25, R901 was complaining of throbbing of the wound. Documentation revealed under the heading Skin: Wound Vac off, wound right lower extremity with slough, yellowish drainage, foul-smelling, saturated gauze and redness surrounding warmth, looks like cellulitis with wound infection. There is no documentation indicating the WCCCS was consulted.A Wound Care Nurse (WCN) A progress note dated 12/17/25 documented, Increased ulceration, slough/necrosis, edema, heavy drainage.additional new ulcerations 100% necrotic (dead tissue), slough is holding drainage, serous drainage, purulent drainage both observed. Upon light pressure to sloughed areas with cleansing, moderate bright yellow thick purulence expressed. Slough has membrane like appearance and both types of drainage can be distinctly seen.wound bed and edges assessed with increased erythema and edema.New lateral right lower extremity calf observed with intact purple fluid filled lesion, peri-wound erythema and pain. Wound care NP notified. There is no documentation indicating the WCCCS was consulted.On 12/18/25, R901 went for a subsequent follow-up visit with the WCCCS and was sent to the emergency room (ER) for a wound infection.Further review of the clinical record does not indicate the WCCCS was consulted regarding the deterioration of R901's wound during the seven days after PMD C contacted them on 12/11/25.A review of R901's Treatment Administration Record (TAR) for December revealed no documentation regarding the completion of any wound treatment. On 2/25/2026 at 12:01, an interview with WCN A revealed when the wound care treatment changed to the Unna boot dressing, the wound began to deteriorate. At 2:19 PM, PMD C was interviewed. PMD C was asked if an outside provider was directing the care of a resident under their care, and a wound showed evidence of deterioration would they contact that provider. PMD C stated No. PMD C further revealed that for wounds, it would be the WCN or WCNP who would make that call.At 2:42 PM, Wound Care Nurse Practitioner (WCNP) B was interviewed and asked if they were responsible for wound care at the facility when there is an outside provider and said, as a courtesy they may get involved as a second pair of eyes, but that normally they would not be involved. WCNP B confirmed they looked at the wounds and discussed with PMD C but did not document any involvement. WCNP B further revealed it was the responsibility of the facility to contact the outside consulting provider with questions or wound deterioration. A review of the undated policy Skin Management Facility Guidelines was reviewed. The guidelines indicate: residents admitted with skin impairments will have .-that wound location and characteristics documented; Identify any physical, functional, and/or psychological complications related to an existing ulcer, for example, pain, cellulitis, osteomyelitis, or social isolation. The guidelines also revealed the Licensed Nurse is to complete an appropriate skin form which includes a description of the ulcer as follows: Non-Pressure Skin Condition Report for all identified non-pressure skin alterations. The policies for Wound Care and Communication with Outside Consulting Physicians was requested but not received by end of survey.

Based on observation, interview and record review the facility failed to ensure Peripherally Inserted Central Catheter (PICC) line care infection control measures and hand hygiene during meal assistance was performed for two residents (R42 and R15) of three residents reviewed for infection prevention. Findings include: R42 On 06/09/25 at 2:19 PM, IV medication administration for R42 was observed with Registered Nurse (RN)A and Licensed Practical Nurse (LPN) B. RN A was observed to complete hand hygiene on the way into the room. A sign on the wall at the right side of the doorway indicated enhanced barrier precautions were required and a gown and gloves were to be used when providing care via a central line such as the PICC line. A cart with the appropriate Personal Protective Equipment (PPE) was at the right hand side of the doorway. RN A entered the room without a gown on and proceeded to hang the IV bag on the IV pole. RN A handed the IV administration tubing to LPN B. RN A then reached into their left pants pocket and removed a pair of gloves and donned them. The IV line was observed to have air bubbles and RN A subsequently left the room to get another tubing set. Upon return to the room RN A donned a second pair of gloves from their pocket and had not donned a gown prior to completing the IV administration. RN A was asked about the gloves pulled from the pocket and acknowledged this it was an old habit. A review of the record for R42 revealed R42 was admitted into the facility 03/07/2025. Diagnoses included, Osteomyelitis (Bone infection), Discitis (vertebral disc infection) and Hepatitis C. On 06/10/25 at 12:02 PM, the Director of Nursing (DON) reported and the Infection Control Nurse confirmed gloves should not be storred in the staffs pocket and a gown and gloves should be worn for the IV administration via a central line for a resident on enhanced barrier precautions. R15 Review of the facility record for R15 revealed an admission date of 12/18/23 with diagnoses including Dementia and Dysphagia (swallowing difficulty). R15's physician orders included an active order dated 12/21/23 stating 1:1 feeding, aspiration precautions, keep upright in chair while feeding. On 06/09/25 at 12:14 PM, during an observation of the lunch service in the memory care unit dining room, Volunteer C was observed providing one to one feeding assistance to R15. On two occasions Volunteer C was observed to set down R15's utensil and reach over to assist with something on another residents meal tray, then return to assisting R15 without completing hand hygiene in between. On 06/10/25 at 10:54 AM, the Director of Nursing (DON) was interviewed and reported the expectation is staff providing one to one feeding assistance would ideally not simultaneously assist other residents, however, if assisting another resident is indicated then hand hygiene should be completed in between assisting the residents. A review of the undated policy titled, IV Therapy revealed, Purpose: Preventative measures for controlling common infections are a critical component of the overall plan of care for resident requiring IV therapy . A review of the undated policy titled, Enhanced Barrier Precautions (EBP) revealed, It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug resistant organisms . All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions . High contact resident care activities . g. Device care or use: central line . 5. Continue enhanced barrier precautions until the qualifying condition or indwelling device is still active or in use. Review of the undated facility policy Hand Hygiene revealed the Policy Statement Hand hygiene shall be regarded by this organization as the single most important means of preventing the spread of infections. The Procedure portion of the policy included item 4. Appropriate hand hygiene must be performed under the following conditions: f. Before and after assisting a resident with meals (hand washing with soap and water).

Based on observation, interview, and record review, the facility failed to provide feeding assistance in a dignified manner for one (R15) of six residents reviewed for dignity. Findings include: On 06/09/25 at 12:14 PM, during an observation of the lunch service in the memory care unit dining room, Volunteer C was observed providing feeding assistance to R15 who was sitting up in a chair. Throughout the observation Volunteer C was in a standing position adjacent to the resident and was observed intermittently attending to another resident. On 06/10/25 at 10:54 AM, the facility Director of Nursing (DON) was interviewed and reported the expectation is that staff providing one to one feeding assistance should not do so in a standing position and that ideally, they would not assist more than one resident at a time in order to maintain resident dignity. Review of the facility record for R15 revealed an admission date of 12/18/23 with diagnoses including Dementia and Dysphagia (swallowing difficulty). R15's physician orders included an active order dated 12/21/23 stating 1:1 feeding, aspiration (choking) precautions, keep upright in chair while feeding. Review of R15's Nutritional Risk Care Plan revealed intervention item 1 to 1 assist with my meals. Review of the undated facility policy Resident Assistance to Eat revealed the following Procedure item: .10. Assist the resident as necessary. If the resident needs to be fed, do not stand but sit with the resident.

Based on observation, interview, and record review, the facility failed to ensure Peripherally Inserted Central Catheter (PICC) line care was performed consistant with professional standards of practice for one resident R42 of one whose Intravenous (IV) medication administration was observed. Findings include: On 06/08/25 at 3:56 PM, R42 was observed to be in bed with their head resting on their left hand and forearm. The PICC line dressing was observed to have a folded white gauze approximately two inches by two inches under a transparent dressing covering the insertion site, dated 06/01/25. R42 confirmed the dressing was being changed weekly and was receiving an IV antibiotic daily. A review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) for June 2025 documented the PICC line was last changed 06/01/25 and the IV antibiotic was infused daily. On 06/09/25 at 2:19 PM, IV medication administration for R42 was observed with Registered Nurse (RN)A and Licensed Practical Nurse (LPN) B. RN A donned gloves, cleaned the hub of the PICC line and flushed the line with normal saline. RN A then connected the IV tubing to the bag and primed the tubing. RN A then cleansed the hub again and went to connect line. The line was observed to have greater than ten air bubbles approximately 1/16 inch to an 1/8 inch long along approximately two feet of the distal end of the line. RN A then noted the air bubbles and subsequently left the room to get another tubing set and completed the IV administration. On 06/10/25 at 12:02 PM, the Director of Nursing (DON) reported a PICC line dressing with gauze should be changed within 48 hours and any air bubbles drained out prior to connection of the IV tubing to the resident. The DON also acknowledged the PICC insertion site could not be directly assessed for signs and symptoms of infection when a gauze dressing was in place. A review of the record for R42 revealed R42 was admitted into the facility 03/07/2025. Diagnoses included, Osteomyelitis (Bone infection) and Discitis (vertebral disc infection). A review of the undated policy titled, IV Therapy revealed .15. Manage Central Venous Catheters as follows: Use a sterile transparent or gauze dressing over all central lines. [NAME] the dressing with date and initials when the site care is performed. Visually assess the site every day for signs of complications or infection. Perform site care every 72 hours and as necessary. Change the dressing .

Based on observation, interview, and record review, the facility failed to ensure opened food items were dated and discarded when expired, and failed to maintain the filter for the ice machine. This deficient practice had the potential to affect all residents that consume food. Findings include: On [DATE] between 8:30 AM-9:00 AM, during a tour of the kitchen with Dietary Manager (DM) L, the following items were observed: In the Blue Air reach-in cooler, there was an opened package of deli turkey dated ,d+[DATE], and an opened, undated package of salami. DM L stated both items would be discarded. In the Traulsen reach-in cooler, there was an opened 1 gallon container of Caesar dressing dated ,d+[DATE], and an opened container of Enchilada sauce dated ,d+[DATE]. DML stated they should be discarded 30 days after opening. According to the 2017 FDA Food Code section ,d+[DATE].17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. In the dry storage room, there was an unlabeled bin of white powder. DM L confirmed the powder was thickener and that it should be labeled. According to the 2017 FDA Food Code ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. The ice machine filter was dated ,d+[DATE]-,d+[DATE]. DM L stated Maintenance was responsible for changing the filter. In the resident refrigerator located in the Activity room/Dining room, there was a container of cut pineapple with a use-by date of ,d+[DATE], and an undated container of chicken soup. Review of the undated policy Safe Storage and Handling of Outside Food noted: Any food which is not going to be consumed immediately must be covered and labeled with the resident's name and date the food was brought into the facility and placed into the unit refrigerator. The activity cabinet located next to the resident refrigerator was observed with numerous ants crawling about on the top surface. Activity staff stated she would let Maintenance know.

This citation pertains to Intakes MI00142869 and MI00143155. Based on observation, interview, and record review, the facility failed to provide timely assistance to meet the needs of residents for four residents (R367, R33, R17, R6) of five whose care needs were reviewed. Findings include: On 05/21/24 at 9:21 AM, R6 reported they have two or three times a week when staff take an hour or more to assist them when the call light is turned on. On 05/21/24 at 4:18 PM, a visitor reported they visit the facility every day and the facility staffing levels are short very often and have is a great concern. There are more staff than normal here today. Weekends are the worst. There are times when there is only one aide. I struggle with this, it is hard when you don't have family to help with visits. I sometimes wonder if they fill water cups on Saturday and Sunday. I have been thinking of moving (my family member) for this reason. On 05/22/24 at 10:08 AM, the call light for R367 was observed activated. At 10:13 AM, the call station monitor was observed and the call light had been on for 14 minutes and 48 seconds. At this time a staff member entered room [ROOM NUMBER] and noted a resident was visibly diaphoretic (sweating beaded) and reported the nurse would be in when had time. At 10:14 AM, the call light for R33 was observed to be activated. At 10:16 AM, Licensed Practical Nurse (LPN) Hpoked their head into the cracked doorway of R367 asked what R367 needed then entered the room and asked R367 number one or two. The call light was on around 18 minutes for R367. LPN G then stepped back out, left the call light on and certified nursing assistant (CNA) I walked down the hall and entered the room of R367. At 10:18 AM LPN H had returned to the medication cart. CNA I aide poked their head out of R367's room, then stepped out, went into room [ROOM NUMBER] and then to the room of R33. R33 noted they had wanted to get up in their wheelchair. On 05/22/24 at 11:05 AM, R33 was observed to be supine in bed. R33 reported they had asked staff to get up into their wheelchair around 10:00 AM. R33 was able to discern time from the clock on the wall at the foot of the bed. R33 required a mechanical lift and two persons to transfer into their wheelchair. On 05/22/24 at 12:11 PM, five call lights were observed to be activated. Staff were in room [ROOM NUMBER]. The call station kiosk indicated room [ROOM NUMBER]-1 had been activated for 23 minutes and 12 seconds, R367 had been activated for 25 minutes and 52 seconds; R17's call light had been activated for 12 minutes and 10 seconds. At 12:13 PM R367 increased to 27 minutes and 27 seconds. Room117-2 room was observed activated and answered. Staff with a sling on their arm entered 109, for a wait time of 25 minutes. At 12:16 PM, Staff entered R367's room exited and then went to R33's and R17's room and exited. At 05/22/24 at 12:22 PM, R367 reported they needed to pee and have bowel movement. The flow of a urinary catheter appeared restricted as it was under the resident's leg and tight between the brief and the thigh. Occupational Therapy Assistant (COTA) K entered R367's room noted upon exit that R367 needed a bed pan, and was not able to do it alone. R367 reported they were uncomfortable. R367 had waited over 29 minutes for assistance. R367 was dependent on staff for bed mobility and toileting. On 05/22/24 at 12:27 PM, R17's reactivated their call light and one of the staff from R367's room went to check on R17. At 12:36 PM, R17 rolled out of their room seated in their wheelchair. R17 had wanted to get up. R17 asked the nurse who helped them get up and the nurse reported it was the nurse. R17 required one person assistance for transfer into their wheelchair. On 05/22/24 at 12:37 PM, LPN H checked on R367. R367 remained on the bed pan. On 05/22/24 at 12:48 PM, CNA J was asked about they're assignment and reported they had 23 residents on their set and they were managing. At 12:52 PM, CNA I reported they had 22 residents. CNA I reported that a month ago they had three CNAs a couple times to work the set but lately there had been only two CNAs to cover all 45 patients. CNA I noted they had worked with three only a couple of times and it goes much smoother with three. On 05/22/24 at 8:19 AM, R6 was observed to be in bed and reported they hoped breakfast will be in soon and reported it was usually around 8:30 and and maybe 9 AM if the staff are busy. R6 required one person assistance. On 05/23/24 at 8:30 AM, the identified concerns were reviewed with the Director of Nursing (DON) and reported that needs should be met as soon as possible and unless there was an extenuating circumstance it should not be more than twenty minutes. A review of a complaint to the State Agency reported the weekend of 03/01/24 to 03/03/24. revealed, Today the facility had one CNA for both sides!! 46 patients on long term and also18 patients for memory care! .My mom should not have to deal with this! No care, call light on, and at least an hour wait every time we ring for assistance. A review of the schedule and time punch data documented the facility had a census of 59: -On 3/1/24 two CNA's and three nurse for the day shift. Three afternoon CNAs worked a double to cover the next 16 hours. One of the three CNA's did not clock in unitl 6:29 PM. -On 03/02/24 four CNA's worked on the day shift until 2:30 PM, a fifth until 11 AM. Three nurses were on for the day and nights shift-They worked 12 hour shifts. Four CNAs were on for the afternoon shift: two started at 2:30 PM; two started at 6:30 PM. Three of those CNAs were on for the night shifts. -On 03/03/24 three nurses were on for each shift and three CNA's covered each shift. Two of those worked the afternoon and night shift. A policy related to call light response time and timing for completion of resident request/care needs met once reported to staff were requested on 05/23/24 at 11:28 AM but not received prior to survey exit.

Based on observation, interview and record review, the facility failed to apply heel protecters and lids to drinks per physician orders for one resident (R5) out of one reviewed for physician orders. Findings include: On 5/21/2024 at 10:00 AM, R5 was observed in bed. R5 stated they had just started to eat breakfast because they were waiting on their coffee to come. R5 stated they had just received their coffee and was now about to eat breakfast. R5's coffee cup was observed to not have a lid on it. R5 was asked if they like to get out of bed often. R5 stated that get out the bed when they feel like it. R5 was noted to not have anything on their heels and their heels were resting on the mattress. A review of the medical record revealed that R5 admitted into the facility on [DATE] with the following diagnoses, Muscle Weakness and Difficulty in Walking. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15 indicating an impaired cognition. R5 also required assistance with bed mobility and transfer. Further review of active physician orders revealed the following orders, Start Date: 6/22/2023. Order: Verify heel protectors are in place when pt (patient) in bed. Start Date: 6/27/2023. Directions: handled mug with lid for all drinks at all meals. On 5/21/2024 at 12:50 PM, R5 was observed in bed with two coffees with no lid, as well as a cranberry juice with no handle or lid. R5 was also observed with their heels resting on the mattress, no heel protectors in place. On 5/22/2024 at 9:06 AM and 12:54 AM, R5 was observed with a beverage (chocolate milk and cranberry juice) in a no handles cup and no lid. R5 was also noted to have their heels on the mattress, no heel protectors in place. On 5/23/2024 at 9:44 AM, R5 was observed laying in bed with their heels on the mattress, no heel protectors were in place. On 5/23/2024 at 9:49 AM, an interview was conducted with Licensed Practical Nurse (LPN) A. LPN A stated they have not tried to put on boots for R5 yet because R5 was eating breakfast when they went in there. LPN A stated R5 does refuse to wear them a lot. On 5/23/2024 at 10:25 AM, an interview was conducted with the Director of Nursing (DON). The DON stated R5 does refuse to wear the heel protectors, but it should be documented if they refuse. The DON stated the staff have been educated regarding ensuring liquids, especially coffee has lids, and they keep them on top of the cart. A request for a policy related to following physician orders was requested on 5/23/2024 at 10:23 AM, to which facility stated it was standard practice and no policy was available.

This citation pertains to Intake MI00143588. Based on observation, interview, and record review, the facility failed to ensure food items were provided in a puree consistency per the diet order for one resident (R53) of two whose diets were reviewed. Findings include: On 05/22/24 at 9:37 AM, R53 was observed to be in bed, the torso curved down away from head of bed so the top of head pointed toward the left side of the bed. Three clear plastic cups of orange juice, milk and a pink liquid were observed with lids off and appeared filled. Scrambled eggs and a bowl of oatmeal had not been touched nor appeared to have been eaten. A regular size bag of hard pretzels was open next to the food tray. On 05/22/24 at 9:58 AM, R53 had been sat up slightly more upright in the bed. The meal tray and pretzels remained. On 05/22/24 at 1:55 PM, R53 was observed to be in bed. A pureed, entree had been served with a regular cubed piece of frosted cake. No items had been eaten. No liquids appeared to have been drank. On 05/23/24 at 8:30 AM, care concerns were reviewed with the Director of Nursing (DON). The DON was asked about the diet and reported the dietitian was at the facility and they would reach out to hospice for additional interventions for the diet. On 05/23/24 at 10:47 AM, the Registered Dietitician (RD) was asked about the regular cake and hard pretzels and reported they were not part of a pureed diet. A review of the record for R53 revealed R53 was admitted into the facility on [DATE]. Diagnoses included Need for Assistance with Personal Care, Pressure Ulcer of Left Lower Back and Severe Protein Calorie Malnutrition. The diet order dated 05/03/24 documented Regular Diet, pureed texture, thin liquid consistency. A review of the undated policy/standard operating procedure titled, Resident Assistance to Eat revealed, Purpose: To assist the resident to eat, and to provide nutrition for residents needing assistance with eating. Procedure: .3. Identify the resident and verify that the diet served is correct. 4. Arrange food on the table in front of the resident .

Based on observation, interview, and record review, the facility failed to wear proper personal protective equipment (PPE) for one resident (R24) out of one reviewed for Enhanced Barrier Precautions (EBP). Findings Include: On 5/21/2024 at 9:50 AM, Registered Nurse (RN) E was observed in front of R24's door grabbing gloves. RN E stated they were going into the room to finish performing care on R24. An EBP sign and cart was noted to be in front of the door. On 5/21/2024 at 9:55 AM, RN E was observed coming out of R24's room. RN E was queried as to why R24 was on EBP. RN E stated they thought that they were on EBP because R24 has chronic urinary tract infections. A review of the medical record revealed that R24 admitted into the facility on [DATE] with the following diagnoses, Personal History of Urinary Tract Infections and Muscle Weakness. Further review of the medical record revealed a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. R24 also required assistance with bed mobility and transfers. Further review of the physician orders noted the following, Ordered: 4/10/2024. Order: Maintain EBP r/t (related to) urine. 4/5/2024. Status: Active. On 5/21/2024 at 2:46 PM, the Infection Control Task was completed with Infection Control Preventionist (ICP) F. ICP F stated that EBP is in place to protect the residents, as well as the staff. ICP F stated that R24 is on EBP and that all staff had been educated on what to wear when a resident is on EBP. A review of a facility policy titled, Enhanced Barrier Precautions noted the following, Policy: It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms.

Based on observation, interview, and record review, the facility failed to ensure an indwelling catheter (tube inserted into the bladder to drain urine) leg strap/band was in place and tubing positioned to allow for urine to drain for one resident (R367) of one reviewed for catheters. Findings include: On 05/21/24 at 9:59 AM, R367 was observed to be supine in bed and dressed in a hospital style gown. The connection point for the urinary catheter and drainage bag tubing was visible on the left leg and no strap was observed to prevent tension on the insertion site/urethra was in place. R367 was asked about the urinary catheter and leg strap and commented that it (the catheter) may be removed the next day. R367 reported they had been in the facility a few days. On 05/21/24 at 1:35 PM, rehab staff were in the residents room with resident. The urinary catheter drainage tubing was looped and on the floor. On 05/21/24 at 1:56 PM, rehab staff had exited the room. The urinary catheter drainage tubing remained looped and on the floor. The connection point was visible with no leg strap. On 05/21/24 at 4:50 PM, R367 was observed to be supine in bed. An incontinence brief was in place, The urinary catheter was observed to exit the left side of the brief and run under the left leg. The drainage tubing was looped down onto the floor at the left side of bed. No leg strap was visible. On 05/22/24 at 8:17 AM, R367 was observed to be supine in bed. The urinary catheter drainage tubing was looped down on the left side of bed. On 05/22/24 at 9:53 AM, R367 was observed to be supine in bed. The urinary catheter was present and the tubing was under the left leg and looped down along the left side of the bed. On 05/22/24 at 12:22 PM, R367 was asked how things were going and reported they needed to pee and have a bowel movement. The brief appeared tight and stretched at the crease between the leg and the pelvis. The tubing for the urinary catheter was under the left leg, with the connection point to the drainage tubing visible at the lateral edge of the left thigh. On 05/22/24 at 12:27 PM, Licensed Practical Nurse (LPN) H was queried about the positioning of the urinary catheter and a leg strap. LPN H confirmed no securement device was in place and the urinary catheter tubing was under R367's leg. On 05/23/24 at 8:07 AM, R367 was supine in bed, uncovered, the urinary catheter connection was visible without a leg strap in placed. A review of the progress notes indicated the urinary drainage bag had been replaced on the night shift. On 05/23/24 at 8:30 AM, the identified concerns were reviewed with the Director of Nursing (DON)and they reported they would have put on a leg strap and repositoned the catheter. The DON also noted they would have made a nurse note and reviewed the care plan and updated it as needed. A review of the facility record for R367 revealed: R367 was admitted into the facility on [DATE]. Diagnoses included Dysfunction of the Bladder, Arthritis and Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and R367 was dependent on staff for toileting, dressing, rolling left to right/right to left, transfer and personal hygiene. The MDS also noted the presence of an indwelling urinary catheter. A review of the facility policy titled, Indwelling Catheter Care revealed, Purpose: Routine catheter care helps prevent infections and other complications, and is usually performed daily. This can be performed by a Certified Nurse Assistant (CNA) Fundamental Information. Maintenance: Inspect the catheter and tubing periodically to detect compression or kinking that could obstruct urine flow. Keep the drainage tube and collection bag lower than bladder at all times .Inspect catheter for any problems . 7. Inspect outside of catheter where it enters urinary meatus and tissue around meatus. 8. Remove leg band used to secure catheter to thigh. 9. Inspect the area for signs of irritation . 12. Reapply leg band used to secure catheter to outer thigh. 13. Remove gloves and re-tape catheter or reapply leg band to other thigh. 14. Provide enough slack before securing catheter to prevent tension on tubing .

Based on observation, interview, and record review, the facility failed to ensure medications were administered per manufactures recommendations and per physician order for one resident (R54) of four observed for the medication pass, resulting in a med error rate of 7.89 percent. Findings include: On 05/22/24 at 9:07 AM, A medication pass observation was conducted with Licensed Practical Nurse (LPN) A for R54. R54 was provided cholestyramine (a cholesterol binding agent) 4 gm (gram) in liquid form with calcium acetate 667 mg (milligram) two tablets, calcitriol 0.5 mcg (microgram) one tablet, fludrocortisone 0.1 mg one tablet constipation refused, Omeprazole 20 mg one tablet, Rifaximin 550 mg one tablet, Velphoro 500 mg (sucroferric oxyhydroxide) one tablet, Lexapro 5 mg one tablet, and Norco/hydrocodone 5 mg/325 mg one tablet. LPN A was queried about the administration of the cholestyramine with the other medications and proceeded to provide R54 with the medication. R54 was also prescribed: Doptelet 20 mg (avatrombopag) Give 40 mg by mouth one time a day. This was not given and was noted to be on order as of 05/19/24. Further review indicated the medication was to be provided by family. The May 2024 medication administration record documented the medication had not been given in the month of May. R54 was also prescribed: Lidoderm Patch 5% Lidocaine apply to right knee topically in the morning for right knee pain. A 5% Menthol Patch was pulled from the medication cart and dated for 5/22 by LPN A. The order for a Lidocaine 5% patch was confirmed with LPN A. LPN A reported they did not have any Lidoderm patches and reported they believed that is what was normally given. LPN A asked the Director of Nursing (DON) and supply room staff member, and the supply staff member confrimed they only have the menthol patch in supply. The DON reported they usually interchange for the Menthol for the Lidoderm and would get an order for the change. On 05/23/24 at 8:30 AM and 1:47 PM, the idenitified medication concerns were reviewed with the DON. The orders for the cholestyramine, Lidocaine patch and Doptelet/avatrombopag were reviewed and the DON reported the doptolet was addressed and noted R54's spouse was to get it and followed a specific schedule for the administration. Clarification of the order indicated it was to be given every other week. The DON confrimed the difference in the Menthol and Lidocaine patch and reported they had called the physician and received an order to change the lidocaine patch to the menthol patch. The DON also reported the physician changed the cholestyramine to two hours before or two hours after the other medications given by mouth. A review of the URL www.drugs.com/mtm/cholestyramine.html revealed, .Cholestyramine resin may delay or reduce the absorption of concomitant oral medication .Avoid taking other medications at the same time you take cholestyramine. Wait at least 1 hour before or 4 to 6 hours after taking cholestyramine before you take any other medications. A policy or protocol from the physician and pharmacy related to the cholestyramine were requested at the time of the interview and on 05/21/24 at 11:28 AM, but not received prior to survey exit.

Based on observation, interview, and record review, the facility failed to revise a care plan for one resident (R56) out of one reviewed for care plans. Findings Include: On 5/21/2024 at 9:46 AM, R56 was observed in their bed with a breakfast tray in front of them. R56 was observed attempting to eat some of their applesauce. R56 was noted to have pureed textured food. A review of the tray ticket stated R56 was supposed to be a 1:1 assist with feeding, no one was noted to be in the room. A review of the medical record revealed R56 admitted into the facility on [DATE] with the following diagnoses, Dysphagia following Cerebral Infarction and Aphasia. Further review of the medical record revealed a Brief Interview for Mental Status score of 2/15 indicating an impaired cognition. R56 also required assistance with bed mobility and transfers. Further review of the care plan revealed the following intervention, No straws and no fluids at bedside. On 5/21/2024 at 9:49 AM, 9:50 AM, 5/21/2023 at 12:04 PM, 12:59 PM, 5/22/2024 at 8:58 AM, 5/22/2024 at 12:59 PM, and 5/23/2024 at 9:54 AM, R56 was observed in the room with fluids at their bedside, including water with a straw. On 5/23/2024 at 10:25 AM, an interview was conducted with Registered Dietitian (RD) B. RD B stated R56 was changed to thin liquids and can have liquids at bedside. RD B states the care plan was not updated to reflect the change. A review of a facility policy titled, Comprehensive Plan of Care noted the following, 13. Re-evaluate and modify care plans: as necessary to reflect changes in care, service and treatment.

Based on observation, interview, and record review, the facility failed to ensure meal assistance and positioning were provided for two residents (R53, R56) of five whose care needs and activities of daily living (ADLs) were reviewed. Findings include: R53 On 05/21/24 at 9:41 AM, R53 was observed to be supine in bed. Three pillows were stacked behind the shoulders and head. R53 appeared frail with decreased muscle mass and visible bony prominences in the face, shoulders and arms. R53 leaned over toward the left side of the bed. The head of the bed was up around 45 degrees. The breakfast of scrambled eggs had not been touched. R53 was asked if they needed help to eat and said yes and appeared to fall asleep. On 05/21/24 at 11:54 AM, R54 was observed to be supine in bed, the head of bed up around 45 degrees, leaned over toward the left side of the bed and appeared asleep. The breakfast tray previously observed had not been eaten. On 05/21/24 at 1:03 PM and 1:14 PM, R53 was observed to be hunched down in the bed and leaned over toward the left side. R53 appeared asleep. The lunch tray had not been eaten. Three clear plastic cups of fluids were observed with lids on them. Staff walked by the room, looked in but did not stop. A staff member was asked if R53 could eat on their own and reported R53 could, but needs encouragement. On 05/21/24 at 1:17 PM, staff picked up the uneaten food tray, R53 remained in a similar position. On 05/22/24 at 9:37 AM, R53 was observed to be in bed, the torso curved down away from head of bed so the top of head pointed toward the left side of the bed. The head of the bed was up around 30-45 degrees and R53 appeared asleep. Three clear plastic cups of orange juice, milk and a pink liquid were observed with lids off and observed full. Scrambled eggs and a bowl of oatmeal had not been touched. A large bag of hard pretzels was open next to the food tray. On 05/22/24 at 9:58 AM, R53 had been sat up slightly more upright in the bed. The meal tray and pretzels remained untouched. On 05/22/24 at 1:55 PM, R53 was observed to be in bed, leaned over toward the left, propped on pillows, eyes closed, oxygen on and appeared asleep. A pureed, food entree had been served with a piece of frosted cake. No items had been eaten. No liquids appeared to have been drank. On 05/23/24 at 8:30 AM, R53's care concerns were reviewed with the Director of Nursing (DON). The DON was asked about the diet and reported the dietitian was at the facility and they would reach out to hospice for additional interventions and would also go in to see if R53 needed assistance to eat and update the care plan as needed. On 05/23/24 at 10:06 AM, Certified Nursing Assistant (CNA) I reported they cared for R53 two times a week, R53 was more spontaneously talking when admitted but less so lately, R53 was independent with eating and they encouraged R53 to eat and checked on R53 to see if they need help. On 05/23/24 at 10:47 AM, the Registered Dietitian (RD) reported R53 had entered the facility frail and underweight and was therefore started on health shakes. The RD reported they had been alerted that morning that R53 needed more assistance to eat. A review of the record for R53 revealed R53 was admitted into the facility on [DATE]. Diagnoses included Need for Assistance with Personal Care, Pressure Ulcer of Left Lower Back and Severe Protein Calorie Malnutrition. The diet order dated 05/03/24 documented Regular Diet, pureed texture, thin liquid consistency. An order for hospice was dated for 05/13/24. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and the need for partial/moderate assistance for upper body dressing and personal hygiene, substantial/maximal assistance to roll left and right and setup for eating. A nursing care plan documented, I need assistance with my (activities of daily living) ADLS .Eating: I need '(specify what assistance)' by staff to eat . (It did not specify what assistance was needed.) The Kardex (CNA care guide) documented, .Anticipate and meet my needs .Assist me with my meals. Please assist me with my meals . A review of the task record documentation from 05/03/24 to 05/22/22 revealed 13 meals were documented as zero to 25% eaten and 13 meals 26% to 50% eaten. Three meals had been documented as refused. 44750 R56 On 5/21/2024 at 9:46 AM, R56 was observed in their bed with a breakfast tray in front of them. R56 was observed attempting to eat some of their applesauce. R56 was noted to have pureed food. A review of the tray ticket stated R56 was supposed to be a 1:1 assist with feeding, no one was noted to be in the room. A review of the medical record revealed that R56 admitted into the facility on [DATE] with the following diagnoses, Dysphagia following Cerebral Infarction and Aphasia. Further review of the medical record revealed a Brief Interview for Mental Status score of 2/15 indicating an impaired cognition. R56 also required assistance with bed mobility and transfers. Further review of the diet order noted the following: Start:5/6/2024. Directions: 1:1 feed with slow rate and small bites for diet. Status: Active. A review of a barium swallow study dated 4/1/2024 recommended 1:1 feed for R56. On 5/21/2024 at 12:59 PM and 5/22/2024 at 8:58 AM, R56 was observed in their bed with their food tray in front of them. No one was noted to be in the room assisting with feeding. On 5/23/2024 at 10:11 AM, an interview was conducted with Director of Rehabilitation (DOR) C. DOR C stated R56 refuses to allow anyone to feed them, and that Occupational Therapy has been working with R56. DOR C was queried regarding who is responsible for entering diet orders and recommendations and said, the Speech Therapist writes the order and gives it to the nurse for any changes. On 5/23/2024 at 10:18 AM, an interview was conducted with Certified Occupational Therapy Assistant (COTA) D. COTA D stated R56 can self feed and drink with cues and sometimes hand over hand (technique that physically guides someones hand movements to help develop motor skills). COTA B stated R56 is a 1:1 due to them still needing cueing and guiding. On 5/23/2024 at 10:47 AM, an interview was conducted with the Registered Dietitian (RD) B. RD B stated R56 was able to feed themselves, however the orders have not been updated yet. RD B stated that R56 refuses if someone tries to feed them. A review of the undated policy/standard operating procedure titled, Resident Assistance to Eat revealed, Purpose: To assist the resident to eat, and to provide nutrition for residents needing assistance with eating. Procedure: 1. Inform the resident that it is mealtime. 2. Obtain the resident's meal. 3. Identify the resident and verify that the diet served is correct. 4. Arrange food on the table in front of the resident. 5. Remove food covers, prepare, and arrange the food, as necessary, for the resident. 6. Protect the resident's clothing with a clothing protector or napkin if resident desires. 7. Wash your hands if you will be assisting the resident to eat. 8. Encourage the resident to feed himself/herself as much as possible, using self -help aids for eating. 9. Identify food and location on the tray for residents with visual problems. 10. Assist the resident as necessary. If the resident needs to be fed, do not stand but sit with the resident. 11. Notify charge nurse if resident refuses meal. 12. Note food and fluid intake when needed. 13. Remove protective coverings from the resident and wash resident ' s face and hands after meal if needed or requested. 14. For residents with room trays: If resident has a room tray, position resident in an upright, secure position in a chair (if applicable) or in a upright position using support pillows if unable to sit. Adjust tray table to comfortable eating position. Monitor the resident periodically to determine if assistance is needed. Remove tray from room soon after resident completes meal . A review of the undated policy/standard operating procedure titled, Baseline Interim Plan of Care revealed, Each resident will have a baseline care plan developed and implemented within 48 hours of admission to the facility which includes the instructions needed to provide effective and patient centered care that meets the professional standards of quality care. Each resident readmitted to the facility will have the previous care plans evaluated for appropriateness of goals and interventions within 48 hours of admission . A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. A review of the undated policy/standard operating procedure titled, Comprehensive Plan of Care revealed, Each resident will have a comprehensive care plan developed within 7 days after the the completion of a comprehensive or quarterly assessment .Address the resident ' s individual needs, strengths, and preferences .The comprehensive care plan must be patient centered .Be periodically reviewed and revised by the interdisciplinary team as changes in the resident ' s care and treatment occur .Care plans must be fully developed within 7 days after completing the comprehensive assessment (MDS) . A review of the undated policy/standard operating procedure titled, Skin Management Guidelines revealed, .The facility is committed to providing care and services to residents to prevent the development of skin breakdown. The following guidelines are in place to reach this goal: .Residents admitted with skin impairments will have .Appropriate interventions implemented to promote healing .

This citation pertains to Intake M100141494. Based on interview, and record review, the facility failed to prevent an elopement for one resident (R701) who had severe cognitive impairment, a high risk for falls, a known elopement risk, and demonstrated multiple attempts to exit the facility shortly before the elopement occurred. R701 eloped from the facility on 11/06/23 between 7:30 PM and 8 PM through the South exit door, without triggering the door alarm and unwitnessed by staff. In response to R701's repeated attempts to exit the South exit door, a staff member (Certified Nurse Assistant -CNA C) placed a geri-chair in front of the door to discourage R701 from approaching the door. CNA C exited another resident's room after providing care, and noticed the geri-chair had been moved and did not see R701. CNA C notified staff (Licensed Practical Nurse -LPN B) on the unit and they went out the South exit door and R701 was located sitting in the driver's seat of a facility van in the parking lot. R701, had barricaded the outside of the South exit door with their wheelchair and ambulated to the parking lot without any assistive devices. Staff reported they located R701 sitting in the van saying I'm going home. This non-complaince makes serious injury, harm impairment or death likely to occure for R701. Immediate Jeopardy: The Immediate Jeopardy (IJ) started on 11/06/23 and the immediacy was removed on 11/07/23 per review of the facility's responding interventions as verified on 12/19/23. The IJ was identified on 12/19/23 during an abbreviated survey. The facility was notified of the IJ on 12/19/23 at 3:12 PM and was asked for a removal plan. The IJ was removed on 11/07/23, based on the facility's implementation of the removal plan as verified onsite on 12/19/23. Findings include: Review of the facility record for R701 revealed an admitted [DATE] with diagnoses that included Vascular Dementia, Epilepsy and Difficulty in Walking. The Minimum Data Set (MDS) assessment dated [DATE] indicated that R701's ability to complete car transfers or to walk 50 feet were not attempted due to medical and or safety concerns. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] was scored 3/15 indicating severe cognitive impairment. Review of R701's facility Care Plan dated 10/27/23 revealed the Focus statement I am an elopement risk. I have periods of high confusion with exit seeking behavior. I do get upset when my wife leaves because she does not take me with her. This focus area included the Goal statements I will not leave the facility unattended and My safety will be maintained. This focus area also included the Interventions statement Observe me for my whereabouts frequently. The Care Plan also included the focus statement I have a history of falls related to disease process. An additional focus statement declared I have limited physical mobility related to stroke and included the intervention statement Ambulation: I am able to ambulate with a two-wheeled walker within the facility with one staff member and wheelchair to follow. Further review of R701's facility assessments revealed an Elopement assessment dated [DATE] that indicated R701 was considered At risk to wander. A Fall assessment dated [DATE] indicated R701 was considered High risk for falling. Additional review of R701's medical record revealed the following notes: A Nurse's note by Licensed Practical Nurse (LPN) B, documented 11/06/23 23:16 (11:16 PM) Resident was wandering up and down hallway in wheelchair stating [R701] was going home. [R701] had set the door alarm off, which had been reset. CNA had placed a geri-chair (lounge style reclining chair) in front of the exit door to discourage resident from setting the alarm off again. When CNA returned to the nurse's station from another resident's room, [they] noticed the geri-chair was moved away from the exit door. All staff immediately began to look for resident. Resident out in parking lot sitting inside white minivan. Resident returned to the building without incident. POA (Power of Attorney) and DON (Director of Nursing) notified. On 12/18/23 at 12:40 PM, LPN B was interviewed in person and reported that they were working during the shift when R701 exited the building. LPN B reported that R701 had been exit seeking at the South exit door and that CNA C had moved a geri-chair in front of the door after redirecting R701 away from the door multiple times. LPN B reported that they were working at their medication cart when CNA C returned from another resident's room and noticed that the geri-chair had been moved and they did not see R701. LPN B reported that they began searching for R701 and when they went out the South exit door they were able to see R701 sitting in the driver's seat of an unlocked facility van because the van door was open and the dome light was on. LPN B reported the door alarm was not sounding just prior to or during the time that staff realized R701 was missing. On 12/18/23 at 1:20 PM, CNA C was interviewed via phone and reported that they did recall the incident of R701 being found outside the building on the evening of 11/06/23. CNA C reported that R701 had attempted to exit the South door repetitively setting off the door alarm. CNA C stated that they had been in another resident's room providing care and when they left that room they noticed R701 was missing. CNA C reported that they notified other staff on the unit and began searching for the resident proceeded to the South exit where they located R701 in the parking lot sitting in the facility van. CNA C reported that they could not recall for sure whether or not the door alarm was sounding when they realized R701 was missing. On 12/18/23 at 2:20 PM, the facility Maintenance Director (MD) reported that they were aware of the incident involving R701 exiting the building on 11/06/23. The MD reported that their understanding of the situation was that the door alarm did not sound when the resident exited .The MD reported that when the door alarm is triggered and sounds staff can enter the code at the door to silence the door alarm but also have to enter the code at the nurses station to silence the overhead alarm that sounds when the door opens after being pushed for 15 seconds. The MD reported that proper protocol is that once the alarms are silenced the door should be checked by pushing enough to hear the initial alarm sound which ensures the alarm is active. On 12/18/23 at 3:49 PM, the facility Administrator (NHA) was interviewed and reported that they became aware of R701 having exited the facility the following morning. The NHA reported that they and the staff were not able to identify why the door had not alarmed when the resident exited the building. On 12/18/23 at 4:13 PM, the facility Director of Nursing (DON) reported that they became aware of R701 having exited the facility at approximately 8 PM on 11/06/23 when they were called by LPN G to report the situation. On 12/19/23 at 11:15 AM, the MD reported that, considering that a geri-chair had been placed in front of the South exit door, it was a possibility that if the chair contacted the door and prevented it from closing completely, it could have disarmed the door alarm. The MD demonstrated that if there is a small gap in the door closure (small enough that the door appears to be closed) the alarm is not activated. Review of the undated facility policy titled Elopement, Potential Resident revealed the policy statement It is the policy of this facility to provide residents with a safe and secure environment and identify residents who may be at risk for unobserved exit from the facility. The Procedure section of the policy includes the following entries: 7. If the resident exits the facility without authorization and there is no witness and is located: e. Complete an Unusual Occurrence Report. f. Assess/investigate why and how the elopement attempt was made. Identify necessary steps to prevent future attempts and document steps taken in the Unusual Occurrence Investigation. The facilities removal plan: Residents residing in the facility have the potential to be affected. A census check was completed and all 66 residents were accounted for. Doors and alarms were checked immediately by staff, to ensure the safety of other residents. Residents were assessed for elopement risk, and care plans were reviewed by DON (Director of Nursing) or designee and revised as needed. Elopement Books located at each nurse's station were reviewed/revised as needed by the Social Worker. The Maintenance Director did a check on the door alarms with no concerns noted. The Elopement Policy was reviewed and deemed appropriate. Staff were re-educated on the elopement policy with an emphasis on ensuring doors are re-alarmed when closed. Staff that are not present or on leave will be educated upon return to work. The push bar mechanism was engaged on OV door 3 to ensure it is locked from the outside, and staff were notified to not utilize OV door 3 as an entrance. An additional alarm on the door was also set to sound when opened. The Maintenance Director will conduct monthly elopement drills and daily testing of the operation of all exit doors and locks for sustained compliance. Date of Compliance: 11/7/2023 During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included The Elopement Policy was reviewed and deemed appropriate. Staff were re-educated on the elopement policy with an emphasis on ensuring doors are re-alarmed when closed. Staff that are not present or on leave will be educated upon return to work. The push bar mechanism was engaged on OV door 3 to ensure it is locked from the outside, and staff were notified to not utilize OV door 3 as an entrance. An additional alarm on the door was also set to sound when opened. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intake MI00137215. Based on interview and record review the facility failed to ensure bathing was documented and or provided per the plan of care for one resident (R901) of three reviewed for shower/baths resulting in the potential for the resident to not have been bathed regularly. Findings include: A review of the Intake revealed, Complainant states the resident only received two showers in 24 days. The complainant states the only reason the resident received the 2nd shower is because (R901) told facility staff that if they didn't give the resident a shower, (R901) was going to do it (themselves). The intake further noted times when R901 was found in a soiled brief and not assisted to the bathroom. A review of the record for R901 revealed R901 was admitted into the facility on [DATE] and discharged [DATE]. Diagnoses included Paralysis of the Left Non-Dominant side, Difficulty Walking and Heart Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition and the need for extensive assistance of one or two persons for bed mobility, transfer, personal hygiene, dressing and toilet use. The bathing task indicated the Activity itself did not occur in the entire period. An I need extensive assistance with my (activities of daily living) ADLs care plan initiated 05/01/23 documented, Bathing/Showering: I need extensive assistance by one staff member. A review of the tasks for R901 revealed, ADL - Bathing Monday, Friday afternoons. A review of the task documentation report for May 2023 revealed no showers were documented as completed in the electronic medical record for R901. A request for shower documentation revealed three skin sheets. Skin sheets are reported to have been done when a shower was given and then signed by the Certified Nursing Assistant (CNA) and nurse. One sheet dated 05/08/23 and on dated 05/22/23 documented a shower was provided. One sheet dated 05/18/23 documented bathing as refused as it was too late at 8:30 PM. The 05/08/23 and 05/22/23 skin sheets were not signed by a nurse-the signature line was blank. Per the schedule R901 could have received a shower/bath on 05/01/23, 05/05/23, 05/08/23, 05/12/23, 05/15/23, 05/19/23 and 05/22/23. On 07/05/23 at 12:18 PM CNA A was asked about showers and staffing and reported that staff work together to get the care for residents done and some CNA's are better at asking for help and working together to get care done when down a staff member. On 07/05/23 at 2:00 PM, CNA B reported that staff can get resident care done but it is a challenge. On 07/05/23 at 5:20 PM, the Director of Nursing (DON) reported there were only three skin/shower sheets which were dated 05/08/23, 05/18/23 and 05/22/23. The DON reported there was no additional documentation of any showers given to R901. A review of the undated facility policy Tub Bath or Shower revealed, Tub baths and or showers are used to cleanse the body, stimulate circulation and condition and assist debriding skin. The policy did not indicate the need to document the bath or shower.

This citation pertains to Intakes MI00130612, MI00133804, and MI00135872. Based on observation, interview, and record review, the facility failed to provide timely ADL (activities of daily living) care for three residents (R3, R35, and R167) of four reviewed, resulting in unmet care needs and the potential for skin breakdown. Findings include: On 5/7/23 at 10:08 AM, 10:10 AM, and 10:12 AM, R3 could be heard calling out for water from their room. An overwhelming smell of stool was noted upon entering the room and the temperature was noted to be uncomfortably warm. R3 was observed lying in their bed and continued to ask for water. R167, who shared the room with R3, was observed lying in their bed as well. R3 stated it was hot in the room and also indicated that they needed to be changed. R3 stated that they told staff, A long time ago .An hour ago that they, Pooped [their] diaper. R3 expressed feeling as though staff knew their brief was soiled but just did not want to help them. R3 was observed wearing a hospital-type gown and disposable brief. Stool was noted on the outside of the brief and the brief appeared full. Stool was also noted on R3's legs and their bed sheets. At 10:19 AM, R3 found their call light and pressed it. At 10:25 AM, R3 pressed on their call light button again (despite the call light still being on) and stated, The girls here don't like taking care of me, they don't come. That's the thing. Agency Certified Nursing Assistant (CNA) A entered the room without knocking or announcing who they were to R3 and R167. CNA A was then asked if she had made it into this room yet on her shift to provide morning care to R3 and R167. CNA A responded, No, and R3 also stated, No. R3 stated that staff on the previous shift had been in to provide care around 5 AM and that was the last time they were changed. CNA A indicated that she did not receive report at shift change. R3 was noted without any hydration near/at the bedside and told CNA A that they were thirsty. R167 was noted to be lying on top of a cloth bed (chux) pad and wearing a hospital-type gown. R167 was observed to be sitting in a large amount of stool on the bed pad. R167's appeared to have been soiled for some time, due to dried brown staining around the stool on the pad. At 10:35 AM, an attempt to interview R167 further was unsuccessful as the resident appeared confused and was unaware of having had a bowel movement. CNA A attempted to provide incontinence care to R167 but the resident became irritated and had difficulty being moved in bed. At 10:46 AM, CNA A left the room to find some assistance (CNA B) with R167. R3 stated that they were still waiting for water. While providing incontinence care to R167, CNA B indicated she had been in the room to feed R167 breakfast but had not checked the resident's brief. R167's gown was also soiled with stool. At 10:59 AM, CNA A and CNA B were interviewed after providing care to R167. CNA A prepared to provide morning care to R3. CNA B commented that she has just been trying to get done what she can, but it has been difficult with the amount of residents she is assigned to care for. CNA A indicated that the aides still had residents that had not yet been changed or provided care yet this morning, because she and CNA B had to help feed some residents breakfast. At 12:24 PM, R35 was observed sitting up in their wheelchair in the hallway. R35 asked Registered Nurse (RN) D to help put them back into bed. RN D asked R35 if they would be okay with sitting up for lunch before being put back into bed. R35 agreed. At 1:21 PM, R35 was observed sitting up in their wheelchair in the hallway. R35 commented that they were still waiting to be put back into bed and indicated they had already eaten lunch. At 1:30 PM, R35 was observed sitting up in their wheelchair in the hallway. R35 asked if this surveyor was able to help get them back into bed. At 1:46 PM, R35 was observed sitting up in their wheelchair in the hallway. At 1:53 PM, R35 wheeled themselves up to the nurses' station in their wheelchair. At 2:25 PM, R35 was observed sitting up in a shower chair and was taken down to the shower room by Certified Nursing Assistant (CNA) C. At 3:06 PM, R35 was observed in bed with a towel over their hair. R35 appeared tired but indicated that they had been happy to get a shower. A review of R3's record revealed that the resident was initially admitted into the facility on [DATE] with a most recent admitted [DATE] with medical diagnoses of Cerebral Infarction, Diabetes, COPD (Chronic Obstructive Pulmonary Disease), Anxiety, and Diffuse Traumatic Brain Injury. Further review revealed that the resident is moderately cognitively impaired and requires limited to extensive assistance from staff for most activities of daily living (ADLs). A review of R3's care plan revealed: -Keep me as clean and dry as possible .Date Initiated: 05/04/2022. -I need assistance with my ADLs r/t (related to) weakness Date Initiated: 05/03/2022. -PERSONAL HYGIENE: I need assistance of 1 from you with personal hygiene and oral care. Date Initiated: 05/04/2022. A review of R35's record revealed that the resident was initially admitted into the facility on [DATE] with a most recent admitted [DATE] with medical diagnoses of Metabolic Encephalopathy, Femur Fracture, Traumatic Brain Bleed, Heart Disease, Anxiety, and Alzheimer's Disease with Late Onset. Further review revealed that the resident is severely cognitively impaired and requires extensive assistance from staff for most activities of daily living (ADLs). A review of R167's record revealed that the resident was admitted into the facility on [DATE] with medical diagnoses of Femur Fracture, Anxiety, and Dementia. Further review revealed that the resident is severely cognitively impaired and requires extensive assistance from staff for most activities of daily living (ADLs). On 5/9/23 at 8:51 AM, the Director of Nursing (DON) was interviewed regarding the delayed care noted on 5/7/23 (Sunday) and indicated that she felt the facility was adequately staffed that day and therefore, had no explanation for why the care was delayed. A review of facility-provided policies and procedures did not specify timeframe for provision of care.

This citation pertains to Intake MI00130612. Based on observation, interview, and record review, the facility failed to ensure hydration was readily available, affecting one resident (R3) and resulting in prolonged thirst and discomfort. Findings include: On 5/7/23 at 10:08 AM, 10:10 AM, and 10:12 AM, R3 could be heard calling out for water from their room. An overwhelming smell of stool was noted upon entering the room and the temperature was noted to be uncomfortably warm. R3 was observed lying in their bed and continued to ask for water. R3 also commented on how warm it felt in her room and said, They took [my] water .That's why I'm begging for water my mouth is so dry I can't even talk .Boy, my mouth is so dry. No hydration liquid was noted near R3 or on their side of the room. R3's bedside table was next to their bed with nothing on it. On 5/7/23 at 10:19 AM, R3 pressed their call light. At 10:25 AM, Agency Certified Nursing Assistant (CNA) A entered the room without knocking or announcing who they were to the residents. CNA A was interviewed and indicated she had not yet made it into the room to provide care to the residents this morning. R3 expressed how thirsty they were to CNA A. CNA A gathered up supplies to provide morning care to R3 and their roommate, however, no water was brought to R3. On 5/7/23 at 10:46 AM, CNA A provided care to R3's roommate and CNA B was brought in to assist. The dial thermostat on the wall was noted to be in a plastic lock-box, and indicated that the temperature in the room was 80 degrees Fahrenheit (F). R3 stated that they were still waiting for water. On 5/7/23 at 11:21 AM, multiple temperatures were taken in R3's room via infrared thermometer. The temperature range in the room was 79-83 degrees (F). R3 was observed still in bed, with no water or other hydration near them or on their side of the room. R3's bedside table remained empty. On 5/7/23 at 12:23 PM, CNA A was observed coming out of R3's room. R3 indicated that some guy brought them juice and that CNA A had just brought them the water they had been requesting. On 5/9/23 at 8:51 AM, the Director of Nursing (DON) was interviewed and asked when fresh water/hydration is expected to be available to residents. The DON indicated that fresh water is to be passed by the aides either at shift change or right after breakfast, i.e. at least 3 times in 24 hours. The DON added that if a resident is requesting water, staff is expected to get them some water. A review of R3's record revealed that the resident was initially admitted into the facility on [DATE] with a most recent admitted [DATE] with medical diagnoses of Cerebral Infarction, Diabetes, COPD (Chronic Obstructive Pulmonary Disease), Anxiety, and Diffuse Traumatic Brain Injury. Further review revealed that the resident is moderately cognitively impaired and requires limited to extensive assistance from staff for most activities of daily living (ADLs). A review of the facility's hydration policy dated 9/1/21 revealed, Residents' hydration needs are met throughout the day from various sources.

This citation pertains to MI00131083. Based on interview and record review, the facility failed to ensure wound treatments and interventions were completed and or documented as completed for one sampled resident (R905) of three reviewed for pressure ulcer care, resulting in the potential for prolonged wound healing. Findings include: A review of an Intake called into the State Agency revealed: (R905) has developed wounds on the left heel and coccyx from being left in bed for 10 days. A review of the record for R905 revealed: R905 was admitted into the facility on [DATE]. Diagnoses included Pressure Ulcer of left heel, Diabetes, Alzheimer's and Dementia. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition and the need for the extensive assistance of two persons for bed mobility, transfer and dressing. A skin/wound note dated 06/21/22 documented, .open areas to left buttock . A Weekly Wound Healing Record dated 08/10/22 documented, Location .Left Heel .Acquired .Date Acquired: 08/07/2022 .Type: Pressure .(Suspected Deep Tissue Injury) .Length 1.5 (centimeters) cm, Width 1.5 cm . A second Weekly Wound Healing Record dated 08/10/22 documented, Location .Coccyx .Acquired .Date Acquired: 08/03/2022 .Type; Pressure .Length 1.0 (centimeters) cm, Width 1.5 cm, Depth 0.1 cm . A Weekly Wound Healing Record dated 09/21/22 documented, Location .Left Heel .Acquired .Date Acquired: 08/07/2022 .Type: Pressure .Pressure Ulcer Stage: 2 .Length 1.0 (centimeters) cm, Width 1.0 cm, Depth 0.1 cm . A Weekly Wound Healing Record dated 11/03/22 documented, Location .Left Heel .Acquired .Date Acquired: 09/22/2022 .Type: Pressure .Pressure Ulcer Stage: (Suspected Deep Tissue Injury) .Length 1.5 (centimeters) cm, Width 1.0 cm .deteriorating . R905 discharged to another facility on 11/11/22. A review of the Treatment Administration Record (TAR) for September 2022 revealed no documentation of a left heel wound treatment on 9/28. A review of the October 2022 TAR revealed missing documentation for the left heel wound treatment on 10/3, 10/8, 10/11, 10/12, 10/15-10/18, 10/20, 10/21 and 10/25. A progress note dated 10/12/22 documented the left heel wound as healed. A nurse progress noted dated 10/14/22 indicated the left heel wound was not healed and had been documented as healed in error. The wound care team documented care on 10/14 and 10/19. On 10/24/22 the infectious disease practitioner documented .Patient does report tenderness to palpation and is seen with just socks on (their) feet, laying in bed .offload left heel at all times . The heel lift boots were not documented on the October TAR as in place on 10/23, 10/24 or 10/25 on the second shift. On 04/12/23 at 12:06 PM the wound care nurse was asked about R905 and reported the left heel wound was acquired at the facility and heel lift boots were used as an intervention to heal the wound. On 04/12/23 at 1:36 PM, on review of the missing documentation for the left heel wound the Administrator confirmed nurses are to document the completed treatments. On 04/12/23 at 1:40 PM, the TAR's for September and October 2022 were reviewed with the Director of Nursing (DON) who confirmed the expectation is for nurses to document completion of the wound treatments. A review of the undated facility policy titled, Pressure Ulcer and Skin Care Management revealed, .The licensed nurse implements the wound care treatment procedures in accordance with current standards of practice .

This citation pertains to intake: MI 945. Based on observation, interview, and record review the facility failed to provide adequate monitoring and supervision to prevent elopement from the facility for one sampled Resident (R27) who had a known history of elopement attempts (the prior day) and was severely cognitively impaired with the [DIAGNOSES REDACTED]. R27 eloped out of the malfunctioning alarmed don the Dementia Unit (that did not alarm) on 2/22/21 for an unknown amount of time. It was documented on 2/21/21, R27 set off the door alarm five times throughout the night to look for (R27's) son. Re-assurance was provided, drinks, snacks, TV offered with short term effectiveness noted. On 2/22/21, R27 left out of the locked Dementia Unit at approximately 8:30 AM. Staff were unaware that the resident had exited the building until Certified Nurse Assistant A (CNA A) observed R27 outside walking without a coat. On that day the low temperature was 28 degrees, this deficient practice resulted in an Immediate Jeopardy and the likelihood for serious injury, harm, and/or death. The Immediate Jeopardy (IJ) started on 2/22/2021 and was identified on 3/1/2021. The Nursing Home Director of Nursing was notified of the Immediate Jeopardy on 3/1/2021 at 4:00 PM and was asked for a plan to remove the immediacy. The IJ was removed on 3/1/2021, based on the facility's implementation of the removal plan as verified onsite on 3/2/2021. Although the immediacy was removed, the facility's deficient practice remained isolated with actual harm that is not immediate jeopardy. Findings include: A review of facility incident report revealed, Online submission on: 2/22/21, 2:09 PM, Summary resident (R27) was observed outside the building walking on the sidewalk . On 3/01/21 at 12:03 PM, R27 was observed in the dining room with a staff member. On 3/01/21 at 2:35 PM, R27 was observed in the dining room with a staff member. On 3/01/21 at 2:41 PM, the Life Enrichment Director was asked about R27's one to one assignment and stated, (R27) has been on a one to one since Saturday (February 26th). (R27) is on for exit seeking and getting out two times. The first time we had some door malfunctions. This time it worked (the door alarm) and they got to R27 right away. A review of the facility's incident report noted, Date of Incident 2/22/21. Time of incident 8:45 AM. (R27). Condition prior to incident Alert/Confused/Disoriented. Location: Hallway/Outside. Type of incident: Elopement. Brief Description: Resident observed by floor CNA (CNA A') to be outside of facility. CNA (CNA A) immediately went out and redirected resident back into facility. Resident on one to one then 15 minute checks meds (medication) reviewed staff education started . A review of the facility Progress notes revealed, 2/21/2021 06:53 (6:53 AM) Behavior Note Text: resident set off door alarms 5 times throughout night to look for (R27's) son. Re-assurance provided. Drinks, snacks, TV offered with short term effectiveness noted. Daughter and Dr. notified. Resident currently in bed quiet at this time. On 3/01/21 at 3:00 PM, the Director of Nursing (DON) was asked about R27's progress note that revealed R27 had set the door alarm off five times. The DON stated, That was on Sunday (February 21st) (R27) set the door off five times. The DON was asked if the facility implemented interventions after the five attempts to leave the building. The DON stated, We redirected (R27) and offered snacks. The DON asked if the facility did any other interventions and stated, Nothing else put in place at that time. The DON was asked about the day February 22nd, when R27 eloped and if it was the same door R27 set the alarm off five times the day before. The DON explained, R27 left out on February 22nd around 8:30 AM and that it was the same door, but the alarm did not go off. The DON continued and stated, The aide was (CNA A) and agency Nurse B that day. We don't know what was going on with the door. (R27) was then put on 15 minute checks and one to one. We thought (R27) was doing better three to four days later and put (R27) on 30 minute checks. We had an alarm tech to come in and check the doors and put new alarms on the doors. The DON was then asked how R27 eloped a second time out of the building on February the 26th. The DON explained that (R27) walked out the same door on that day. R27 was moved to the other unit, because R27 was too close to the door. The DON was asked if R27 was on a one to one at the time of the second elopement on February 26th and stated, No (R27) was on 30 minute checks. On 3/02/21 at 9:57 AM, an observation of the facility doors was made with the Maintenance Director (MD) that stated, The new sounders were put on the doors on Friday (February 26th). The MD was asked about the report that the door alarm was not working on the day R27 eloped the first time from the facility. The MD stated, I do test every day and they worked. The MD was asked to explain how the door alarm system worked prior to new alarms that were added. The MD explained that staff could turn the alarm off at the nurses station and it did not require for a person to physically get up and go to the sounding door to turn the alarm off. To lock the door back and rearm the door it did require someone to go to the door. The MD was asked the process to rearm the door and stated, Staff would have to go and push the door open, let it close, wait about 3 seconds and it locks back. The MD was asked if those steps were not done would the door stay unlocked and unactive. The MD stated, Yes. The alarm would not be on and the door would be unlocked. Friday we added the extra alarm that someone would have to get up and go to the door to disarm the alarm. The MD was asked if the secured Dementia unit door alarms were connected to the rest of the facility alarms. The MD stated, No. On 3/02/21 at 1:01 PM, CNA A was asked about the day she found R27 outside of the facility. CNA A explained, It was around 8:15 AM or 8:20 AM (R27) was walking and pacing in the hallway towards the door, I redirected (R27). (R27) was not acting right, after redirecting (R27) I went to report to the Nurse about how (R27) was acting. When I was walking back, I saw (R27) outside. CNA A was asked the time they saw (R27) walking outside, and stated, I brought (R27) back in around 8:30 AM. CNA A continued and stated, The door did not alarm. I then told them (R27) is outside, and I went out to get (R27). CNA A was asked if the door alarmed when they went outside to bring R27 back into the facility. CNA A stated, No. CNA A was asked if the previous shift reported that R27 had set the door alarm off five times attempting to leave the building. CNA A explained, that there was no report of R27 setting the door alarm off or trying to leave the building. CNA A was asked if they had observed R27 wandering or attempting to leave the facility before. CNA A stated, No. I don't usually work that unit. I know (R27) got out again another day after that at like 9:00 PM and that is why they moved (R27) to the other unit. CNA A was asked, how many staff were on the Dementia unit and residents did she have assigned for that day. CNA A stated, 18 residents. Me and a Nurse. On 3/02/21 at 8:50 AM, R27 was observed in their room with an activities aide in the room and a staff person sitting right outside of the door to the room. On 3/02/21 at 10:48 AM, R27 was observed in the dining room with sitter. On 3/02/21 at 1:27 PM, Nurse C was interviewed via phone and asked about R27's exit seeking behavior during her shift. Nurse C stated, It was Saturday into Sunday early morning (R27) was setting off the door alarm. (R27) never went out the door. On 3/02/21 at 3:31 PM, CNA D was asked via phone about R27's exit seeking behavior and stated, (R27) would stand at the door, reading the door sign, but had never went out the door. On 3/03/21 at 12:57 PM, Licsened Practial Nurse (LPN E) was asked about R27's exit seeking behavior, and stated, (R27) and another resident would walk the halls together and sometimes become confused and have sundowners (A symptom of [MEDICAL CONDITION] and other forms of dementia. It's also known as late-day confusion) and they would often need to be redirected away from the door. It seems that (R27's) confusion was becoming worse in the last month or so. A review of the facility's documents regarding R27's elopement noted the following: Alarm system company document dated 2/22/2021, noted: 1) Troubleshoot how resident was able to exit from door w/o (without) setting off alarm. -when door alarm is set off and door isn't physically open & (and) closed the door doesn't lock back down as indicated by no green light present @ (at) nurses keypad. 2) Recommend installing key switch resets at door to force employees to reset each occurrence. Written statement noted, I was heading down the Hall of (Dementia Unit) and I witnessed resident outside of facility as (R27) passed by the window and no alarm had been set off or was sounding at that time I immediately called for help and went out to redirect (R27) back into the building. (R27) stated (R27) was looking for (R27's) son. I was able to get (R27) back in the building. signed (CNA A). Written statement noted, I was in room (another residents room) performing a treatment when the MDS (Minimum Data Set) nurse came into the room and informed me that resident from room (R27) had eloped, but was now back in safely. I went and assessed resident taking vitals and performing a skin inspection management was notified of the occurrence and interventions are being put in place. (Registerd Nurse F) 2/22/21. A review of the facility's incident reported noted, Date of Incident 2/26/21. Time of incident 2100 PM (9:00 PM). (R27). Condition prior to incident Alert. Location: blank. Type of incident: Elopement. Brief Description: prior to elopement resident's plan of care in progress resident on 30 minute visual check. Resident last approx. (approximately) 2055 (10:55 PM) in (R27) bedroom writer + (plus) CNA separating resident from room (another resident) resident last seen in (R27's) room with door closed at 1200 alarm sounded writer /CNA was able to assist resident back inside building . Progress note: 2/27/2021 0327 (3:27 AM) Nurses Note Text: Prior to incident residence plan of care was in progress. At approximately 2100 (9:00 PM) writer was alerted that an exit door had been touched or opened by alarm on unit going off, writer immediately ran back exit door near residents room. Head account was done on unit. Writer running to back door exit on low Hall when noted that resident was not in room, alarm code was working, writer could see resident through window on second door outside trying to put on coat, by this time CNA had came out of room (another resident) assisted with door code. Writer was able to assist resident back to building before (R27) was able to take second step onto parking lot time note it was 2114 (9:14 PM) when resident was assisted back to unit. Further review of R27's medical record revealed that R27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment noted R27 with an impaired cognition and idependent with ADLs (activities of daily living). A review of R27's Elopement assessments noted the following: 10/2/2020. High risk to Wander 12.0 (score), 11/5/2020. High risk to Wander 12.0, 12/31/2020. At Risk to Wander 9.0, 1/12/2021. High risk to Wander 12.0, 2/21/2021. High risk to Wander 13.0, 2/22/2021. High risk to Wander 17.0, 2/26/2021. High risk to Wander 15.0. A review of R27's care plan noted, Focus: I am an elopement risk I have periods of high confusion with 'exit seeking' behavior, I have verbally expressed the need to leave. I have dreams where I feel someone is after my Son, and I awake frightened. Date Initiated: 10/12/2020. Revision on: 02/25/2021. Goals: My safety will be maintained Date Initiated: 10/12/2020. Revision on: 02/22/2021. I will not leave the facility unattended Date Initiated: 10/12/2020. Revision on: 02/22/2021. Intervention: Distract me from exit seeking by offering me snacks-cookies, beverages and 1-1 conversation. I love watching outdoors and talking about my Family. Date Initiated: 10/12/2020. Revision on: 02/25/2021. Keep my picture in the Elopement book so all are aware Date Initiated: 10/12/2020. Revision on: 02/22/2021. Since I am an elopement risk - Observe my mood and listen for me saying such things as 'I want to go home' or 'I want to leave' Date Initiated: 10/12/2020. Revision on: 02/22/2021. A review of R27's medical record noted, the following progress notes: 2/19/20 18:12:00 (6:12 PM) res (resident) stating until dinner meal (R27) has packed all (R27) belongings and will be leaving tomorrow. nurse educated to resident this was (R27) home now. res slightly agitated. will report to oncoming nurse. 2/19/2020 15:27 (3:27 PM) Behavior Note Text: res pleasant and coop ( ) with staff, occ requesting to talk with staff. res stating to nurse that (R27) needs pack up belongings, states (R27) is leaving tomorrow. res observed to have some anxiety, e.g., (example) rubbing hands of face, occ taking deep breaths. res comes to DR (dinning room) and then returns to room and looks through belongings. smiling with other residents . no neg (negative) beh (behaviors) or statements this shift. will monitor. 9/21/2020 18:22 (6:22 PM) Behavior Note Text: Resident was anxious during dinner time. Resident stated (R27) wanted to have (R27) family come pick (R27) up and leave because (R27) does not feel safe here. Writer reassured resident that (R27) was safe here. Resident calmed down and ate (R27) dinner. After dinner, resident approached writer at nurses station and told writer (R27) wanted to leave tonight. Writer redirected resident by telling (R27) it was late and (R27) had a bed to sleep in here tonight. Resident called writer a liar. Resident did not make any physical attempt to leave the unit/building. Resident did not verbalize a plan on how (R27) was going to leave. Resident redirected by life enrichment staff to play trivia; effective. 11/28/2020 13:49 (1:49 PM) Behavior Note Text: Resident extremely anxious this morning, asking to call daughter to see what time (R27) was picking (R27) up. Explained to resident multiple times that (R27) would be staying here. Asked to call daughter. Spoke with son in law briefly then hung up phone after yelling at him. Resident with unsteady gait and looking faint. Assisted (R27) back to room after (R27) refused to sit in hall chair. Spoke with (staff) and order for [MEDICATION NAME] 0.5mg (milligrams) twice daily renewed x (times) 14 days. Med (Medication) administered at 0905 (9:05 AM) and effective. No further behaviors noted thus far. 12/16/2020 19:00 (7:00 PM) Behavior Note Text: Resident confused this shift, thought (R27) was going to be picked up for a job interview then later thought (R27) family was coming to get (R27). 1:1 effective in redirecting/reorienting resident. 12/18/2020 19:23 (7:23 PM) Behavior Note Text: Resident anxious this evening, stating that (R27) needed to meet someone and asking when (R27) is going home. Angry with staff when 1:1 given. [MEDICATION NAME] 0.5mg order reinstated by PA (Physician Assistant) and administered at 1900 (7:00 PM). 12/20/2020 17:57 (5:57 PM) Behavior Note Text: Resident exhibiting anxiousness at approx. (approximately) 1330 (1:00 PM). Resident was worried about having a ride to go home. PRN (as needed) [MEDICATION NAME] given and effective. Resident also spoke with (R27's) daughter . on the phone and was told (R27) would be staying here tonight by daughter. PRN [MEDICATION NAME] was effective. At approx. 1800 (6:00 PM) resident asking writer x2 where all (R27's) stolen clothing went. Writer explained to resident that (R27) clothing went to laundry and they would be returned in the morning. Resident did not exhibit any exit seeking behaviors this shift. No [MEDICAL CONDITION] or verbalizations of self harm were noted this shift. 12/22/2020 14:01 (2:01 PM) Behavior Note Text: Resident anxious on and off throughout the day, 1:1 somewhat effective at times. Confused about (R27) stay here and wondering why no one is picking (R27) up and saying at times that (R27) is waiting for (R27) daughter. Resident tearful and asking to call (R27's) daughter at 1330 (1:30 PM). Spoke with daughter and somewhat calmer. PRN [MEDICATION NAME] administered. 12/25/2020 18:59 (6:59 PM) Behavior Note Text: Resident upset with staff wanting to go home. Calling daughter several times throughout the shift. Lifted up cover to fire alarm setting it off. Redirected back to (R27) room several times. 12/26/2020 02:08 (2:08 AM) Behavior Note Text: Resident mentioned wanting to go home a few times through out shift. Resident resting comfortably at this time. 12/27/2020 17:42 (5:42 PM) Behavior Note Text: Resident anxious at times throughout the shift. Confused and asking about leaving and (R27's) family coming to get (R27). 1:1 somewhat effective, resident calmer and smiling later in the shift after 1:1 by several staff members. 1/24/2021 17:10 (5:10 PM) Behavior Note Text: Was anxious around lunchtime. Was asking staff if anyone could give (R27) a ride home or if (R27) could rent a car to get home. Scheduled [MEDICATION NAME] given and was effective. 2/6/2021 19:04 (7:04 PM) Behavior Note Text: Activity aid observed resident in room (another residents room) removing things from closet. Angry when redirected, confused when talking to this writer and believed that (R27) was in (R27) room. 2/8/2021 22:26 (10:26 PM) Social Services Text: Social Services Annual Note: Met with resident in the dining room, and we visited in the sitting room. Resident has [DIAGNOSES REDACTED]. Resident is alert with orientation to self, is able to make needs known. Due to impaired cognition, (R27) is unable to make daily decisions as it relates to care and safety. Resident's daughter is POA (Power of Attorney), . Resident needs minimal assistance, guidance with ADL's and ambulates independently. Resident is an elopement risk AEB (as evidence by) setting off door alarms and saying, 'I am going home.' Resident has a history of saying 'I want to die' or I wish I was dead' . has made medication changes to address anxiety, will continue to monitor. Family is supportive with visits on hold at this time. Resident does not remember Family calling (R27) on the phone, and (R27) will make comments of, 'I wish my Family would call or remember I am here ' A review of the facility policy undated, titled, Elopement, Potential Resident noted, Policy: It is this policy of this facility to provide residents with a safe and secure environment and identify residents who may be at risk for unobserved exit from the facility . Fundamental information residents who entered the facility may display behaviors that are unsafe particularly since they are entering an environment that is unfamiliar. Residents with cognitive loss or impaired judgment may attempt to leave the premises, known as exit seeking behavior. Residents are most vulnerable in the early admission., however residents with progressive cognitive disorders can begin to displaying Exit Seeking Behaviors at any time . Procedure: . 6. If the resident exits the facility without authorization and there is no witness and is located: . f. Assess f investigate why and how the elopment attempt was made. Identifying necessary steps to prevent further attempts and document steps taken in the unusual occurrence investigation. G. Implement strategies to minimize recurrence of elopement attempts . k. Update the residents care plan with preventative measures for elopement .

This citation pertains to intake 8. Based on interview and record review, the facility failed to provide ongoing behavioral health services and follow-up after mental status change/decline for one sampled resident (R900), who was suspected to have resolving [MEDICAL CONDITION] upon admission to the facility, resulting in the resident experiencing cognitive decline, hallucinations, and ongoing distress without psychiatric assessment/treatment prior to discharge. Findings include: On 1/14/2021 at 11:00 AM, Confidential Witness A was interviewed regarding R900's care while in the facility. Witness A stated, (R900) came home in worse condition than when they went into that facility. (R900) was no longer able to hold (their) head up, was crying and in pain. They did change (R900's) medications, kept saying they were doing pain management. (R900) was screaming when (they) got home. We did a tele-visit and the doctor said to put (R900) in an ambulance and take (them) to the hospital. Witness A indicated R900 had an increase in behaviors and stated, How can you discharge someone like that? Kicking, spitting, hitting. It was awful and it wasn't (like them). Witness A stated that from around 9/7 to the date the resident was discharged from the facility, (R900) didn't even know who I was, (they were) screaming at me, confused. Witness A stated that R900 was, discharged from facility on 9/18/2020, later taken to the hospital where it was discovered that (they) had a fracture to (the) upper back, was inpatient for two weeks with [MEDICAL CONDITION] and extreme pain, and passed away on 10/6/2020. A review of R900's Minimum Data Set (MDS) assessments dated 8/8/2020 and 9/18/2020 were reviewed and revealed that the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. The resident was discharged to the community on 9/18/2020. Further review of the 8/8/2020 MDS assessment revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment, with no hallucinations, delusions, or behaviors noted. The 8/8/2020 MDS also indicated that the resident was occasionally incontinent of bowel and had a catheter upon admission. Review of the resident's 9/18/2020 MDS assessment revealed a BIMS score of 8, indicating a moderate-to-severe cognitive impairment, and indicated Yes, for hallucinations, verbal behavioral symptoms, and wandering. The 9/18/2020 MDS indicated that the resident was now frequently incontinent of bowel and bladder. A review of R900's medical record indicated that psychiatric services had seen the resident upon admission into the facility, with a note dated 8/5/2020 which included the following: Complaint: evaluate mood/cognition/behavior for intervention planning .Resident was cooperative with encounter .laughing and smiling and did not appear to be in any acute distress .[MEDICAL CONDITION] without behavioral disturbance - Plan: rule out whether behavioral disturbance is consistently present versus whether current behaviors are attributable to resolving [MEDICAL CONDITION] .Disposition: Resident seen .has dementia and suspect (they) may have resolving [MEDICAL CONDITION] as well at this time .was impulsive on exam and not interacting meaningfully during encounter. Will continue to monitor, and if there are specific psychological/behavioral issues that need to be addressed during (their) stay, we can address them at that time . The assessment indicated the resident was confused with concrete thinking, with some remote memory intact. No hallucinations/delusions were noted. Further review revealed a psychiatric services note dated 8/7/2020 which included the following: Resident has history of depression. Hx (history) of use of [MEDICATION NAME] (antidepressant) with s/e (side effects) of hallucinations and was given dose in the hospital. No current [MEDICAL CONDITION] medications. Staff report resident's mood has been stable with no recent mood or behavior concerns documented. Today resident is alert, seen in bed .Resident is irritable today. Does not want to answer mood questions .Appetite and sleep are okay .pain is controlled .Resident ends visit. No acute distress noted .Perceptual Disturbances: None observed on exam .Plan: Monitor mood and behavior. Document concerns. Notify service of any changes . No further psychiatric services notes were found in R900's record. A review of R900's Medication Administration Record [REDACTED]. The resident began receiving [MEDICATION NAME] 50 MG (opioid-like medication) two times a day for pain beginning on 8/19/2020. Further review of the MAR indicated [REDACTED]. A pharmacy medication regimen review was noted to be completed for the resident on 8/5/2020 but no further reviews were found. A review of R900's progress notes and therapy notes revealed the following: SLP (Speech Language Pathology) Evaluation and Plan of Treatment, Start of Care: 8/4/2020 .Patient Goals: Pt (patient) stated a goal of being able to communicate without difficulty with unknown people (staff, etc) as well as returning home. Potential for Achieving Rehab Goals: Patient demonstrates good rehab potential as evidenced by ability to follow 1-step directions, active participation in skilled treatment and attentive to tasks. Focus of Plan of Treatment. Signed by Speech Language Pathologist (SLP) J (SLP J was on leave and not at facility during survey time period). 8/7/2020 16:25 (4:25 PM) Social Services Initial Note: (R900) admitted .from hospital on [DATE] .Resident is alert and oriented x2, is able to make needs known .consent for (psychiatric services completed). Family does not want psychiatric medications .Social Services will continue to monitor, provide support and initiate discharge planning. Date of Service 8/11/2020 .Skilled ST (Speech Therapy) services provided to treat cognitive-communication deficits. Pt alert, cooperative, and seated upright in wheelchair for therapeutic intervention .Pt was able to self-correct language errors when provided visual cues .after initial training (pt) was able to communicate effectively with 100% accuracy given min (minimal) cues. Signed by SLP J. Date of Service 8/13/2020 .Skilled ST services provided to treat cognitive-communication deficits. Pt alert, cooperative, and seated upright in wheelchair in therapy gym. Pt reported being happy to be off contact precautions and in the gym .significant improvement in function compared to previous sessions. Signed by SLP J. 8/15/2020 07:17 (AM) Skilled .Cognition/Behavior/Alertness/Speech/Understanding: Alert and oriented to self, pleasantly confused, able to make needs known. Speech is clear but not always correct to situation. Able to follow simple directions. Date of Service 8/21/2020 .Skilled ST services provided to treat cognitive-communication deficits .completed cognitive-communication tasks requiring (pt) to recall new information and communicate effectively .No significant word retrieval or expressive language deficits noted during structured cognitive-communication tasks. This is a significant improvement in function compared to previous sessions. Signed by SLP J. Date of Service 8/31/2020 .Skilled ST services provided to treat cognitive-communication deficits .Pt demonstrated increased confusion compared to previous sessions. (Nurse) and physician aware 8/31/2020 12:25 (PM) Behavior Note .resident has increased confusion and having hallucinations. Resident states (they are) seeing a lady and a litle (sic) child walking in the hallway outside (their) room. Resident went in to other resident's rooms thinking (their spouse) was in those beds. Resident stated to nurse I am so confused and burst into tears. 9/2/2020 12:01 (PM) Nurses Note .CNA (Certified Nursing Assistant) reported to this RN (Registered Nurse) that resident thought (they were) holding (a) baby. No baby present. SW (Social Worker) aware; UA C&S (urinalysis, culture and sensitivity) pending. Resident redirected successfully. 9/6/2020 05:30 (AM) Behavior Note .Resident difficult with medication administration attempting to hit writer and to hit medication out of writer's hand. Resident refused to transfer into wheel chair and also refused to lay down in bed. Resident refusing incontinent care from staff hitting staff and attempting to kick staff. Resident able to be redirected and able to be calmed down once in wheel chair and at nurse's station. Warm blanket and fluids offered, resident accepted and became pleasant. Took medication without further difficulty. 9/8/2020 02:57 (AM) Behavior Note .Resident awake throughout night hallucinating seeing children running around resident stated, I was tied up at a Chinese restaurant on 15 mile road.Resident up at nurse's station with staff throughout night, refused 2AM [MEDICATION NAME] (tylenol) X3 attempts. Date of Service 9/8/2020 .Pt demonstrate intermittant confusion during therapy session including requesting (their) mother and hallucinating children. Nursing aware of mental status changes. Pt recently finished antibiotic treatment for [REDACTED]. Signed by SLP J. Date of Service 9/9/2020 .Pt demonstrated disorientation to time and familiar persons (daughter, therapist, etc) .discharge planning initiated. Signed by SLP J. Date of Service 9/10/2020 .Pt alert, confused, and seated upright in chair in dining room. Pt was disoriented to time and benefited from verbal/visual cues from SLP to be reoriented. Pt tearful and demonstrated difficulty communicating feelings and pain . Signed by SLP J. 9/10/2020 12:42 (PM) Skilled .Cognition/Behavior/Alertness/Speech/Understanding: .Resident crying at times throughout the shift, upset and asking to go home . Date of Service 9/11/2020 .Pt had difficulty expressing wants, needs, and thoughts effectively. This is a decline in pt's functional communication skills compared to previous sessions . Signed by SLP J. 9/11/2020 14:20 (2:20 PM) Behavior Note Note Text: Resident felt that nurse and CNA who were assisting resident in the next bed were being mean by laying the resident in bed. Resident then began crying. Signed by Licensed Practical Nurse (LPN) H. 9/12/2020 18:25 (6:25 PM) Behavior Note Note Text: Resident was confused several times this shift. Resident able to answer simple questions appropriately. Date of Service 9/14/2020 .Pt continues to present with confusion regarding time, place, and situation . Signed by SLP J. Date of Service 9/15/2020 .Pt seated upright in wheelchair for therapeutic intervention in room. The BIMS was administered to compare current cognitive functioning compared to previous reporting periods .received a score of 7/15 on the BIMS . Signed by SLP J. 9/15/2020 10:33 (AM) Skilled .Cognition/Behavior/Alertness/Speech/Understanding: Alert with confusion. Calling out at times throughout shift for (family members). Date of Service 9/16/2020 .Pt lethargic but awake. Pt disoriented to time, place, and situation. Visual aids uneffectively to improve orientation .Spoke with pt's nurse regarding decline in cognitive functioning and changes in mental status. Spoke with pt's (family) regarding discharge planning. Date of Service 9/17/2020 .Caregiver trainig (sic) completed with patient and patient (family). Patient was initially not cooperative and refusing to do any tasks, however after max encouragement .patient was agreeable . Signed by Physical Therapy Assistant (PTA) E. On 1/19/2021 at 12:02 PM, Certified Occupational Therapy Assistant (COTA) I was interviewed and queried regarding working with R900. COTA I indicated that R900 had been showing signs of confusion since admission to the facility on [DATE], but stated, (R900) started getting better at first, then declined again. It was cognitively (that they) declined. We had (R900's family member) come in to see how (R900) transferred (prior to discharge). (R900) was very angry (towards the family member) .and wouldn't work (with them). R900 was tearful some days then some days great, it fluctuated .The longer (R900) stayed, the more angry (they) became. On 1/19/2021 at 12:19 PM, Certified Nursing Assistant (CNA) K was interviewed regarding R900's mental status while they were in the facility. CNA K stated, (R900) became more confused the longer (they were) here. Towards the end (they) wouldn't even acknowledge (their spouse, they were) very foul and cursing (the spouse). (R900) was fine towards (their spouse) at the beginning then started cursing (them) out. (R900) started just 'going off' towards the end (of their stay). On 1/19/2021 at 1:07 PM, Physician C was called for interview and left a voicemail for call back, however a call back was not received prior to survey exit. On 1/19/2021 at 1:37 PM, PTA E was interviewed and queried regarding working with R900. PTA E indicated they had recalled R900 being, Pleasantly confused when (they) first got here. PTA E was queried regarding R900's mental state during their stay at the facility and responded that, Towards the end of (R900's) stay, (they were) still confused but more agitated .The day we did the caregiver training with (family), (R900) was confused and agitated. I remember that (R900) was agitated on this last day, we setup to do caregiver training with (family). (R900) was not going to cooperate and was refusing to do anything .I would have to say the mental state got slightly worse or stayed the same .(R900) was pleasantly confused at first but then towards the end started to get agitated and confused. At the beginning (R900) would agree to do things with us and towards the end (they were) refusing some partial treatments. On 1/19/2021 at 1:55 PM, LPN H was queried regarding the note she had written about R900 on 9/11/2020. LPN H stated, The resident was confused, would cry a lot off and on. When queried regarding receipt of any training or knowledge of protocols for mental status change assessments or [MEDICAL CONDITION] assessments, LPN H stated, No, not from here. Never had any training like that before. A review of R900's care plan and psychosocial well-being/mood care plan (COVID-19) revealed an update on 8/27/2020 that read, (underlined) I have the potential to experience a decline in in my psychosocial well-being and/or mood state. As evidenced by: (blank). Related to: Restricted visitation from my friends and family secondary to COVID-19 .I will not show a decline in my psychosocial well-being through next review . No further care plan updates or behavior/mood/mental status focus areas, goals, or interventions were noted. On 1/19/2021 at 2:22 PM, the Social Services Director (SSD) was interviewed and queried as to when R900 was seen by psychiatric services while in the facility. The SSD indicated that the resident was seen on 8/5/2020 and 8/7/2020 and stated, It might just be those two (visits). When queried regarding R900 having hallucinations, and if psychiatric services had seen the resident after that, the SSD stated, I don't know what you're .(R900) had hallucinations and stuff when (they) came in. (R900's) cognition fluctuated, it was poor when (they) came in. The SSD was then queried regarding the psych services note dated 8/5/2020 that mentioned concern for resolving [MEDICAL CONDITION], and asked if psych was consulted again after that. The SSD stated, I think it was just those two times (8/5 and 8/7). (R900) was having [MEDICAL CONDITION], and thought (their) room was (their) living room. When queried regarding any documentation present from her (the SSD), psychiatric services, or the physician related to the change in R900's mental status and hallucinations that began towards the end of August and beginning of September 2020, the SSD stated, Oh, I see where you're seeing hallucinations. When asked if the SSD had documented on anything for R900 after her admission note on 8/7/2020, and/or if psych services had seen the resident after 8/7/2020, the SSD stated, No, I don't think so, and added, The physician ordered labs and stuff. When queried regarding the pain medication changes made for R900, the SSD stated, The family thought that could have been some of the issue. I thought they had decreased the pain medications per family's request. When queried regarding who was doing medication reviews for the resident, the SSD stated, I did a lot of that and went over that with the (family), (who) made a comment about the [MEDICATION NAME]. Felt it was too much and that the resident was not used to having that kind of stuff ordered. When queried regarding mental status assessments/[MEDICAL CONDITION] assessments, the SSD did not provide an answer. The SSD indicated that the resident had come to the facility as pleasantly confused and became worse around the time of the UTI diagnosis. The SSD also indicated that the hallucinations R900 was experiencing in September 2020 were, Something that would be followed up on normally (by) all of us .Psych, social work, all of us. On 1/19/2021 at 3:00 PM, after requesting a policy/procedure regarding [MEDICAL CONDITION] and/or change in mental status, the Director of Nursing (DON) stated that the facility's Acute Change in Condition policy covered [MEDICAL CONDITION], and It would be (discussed) through clinical (meetings) in the morning. When queried regarding protocol for mental status assessments/[MEDICAL CONDITION] assessments and/or who usually follows up on mental status changes such as increased agitation, crying, and/or hallucinations, the DON stated, Psych and (Physician C) follow up on these mental status changes. When queried if he would have expected psych services to have seen R900 after experiencing hallucinations, the DON stated, I would expect so. I thought I recall that (they) did. On 1/19/2021 at 3:30 PM, the DON brought the psych services note dated 8/5/2020 and stated, It talked about [MEDICAL CONDITION]. When asked who continues to monitor possible resolving [MEDICAL CONDITION], the DON stated, Nurses do, put it in the progress notes, the doctor would. The DON stated he did not see the follow-up in the resident's chart upon looking. When queried regarding R900's care plan, the DON indicated he did not know why the psychosocial care plan area was on paper and not in the electronic medical record and provided no further information. A review of the facility's Acute Change in Condition policy, undated, revealed: An Acute Change of Condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. 'Clinically important' means a deviation that, without intervention, may result in complications or death .Residents are assessed upon admission to establish 'Baseline Data' .Utilize care paths, document findings, assessments, and interventions on the CHANGE OF CONDITION A change in a resident's status that affect the problem(s)/goal(s) or approach(es) on his/her care plan are documented as revisions and communicated to the interdisciplinary team .The following symptoms may suggest ACOC or require additional assessment: .Level of consciousness should be distinguished from aspects of cognition such as orientation and memory, level of consciousness is the degree of awakeness, i.e alert, drowsy/lethargic .a reduction of one level or more in level of consciousness, i.e from alert to lethargic .sudden or persistent decline in function .significant change in nature or pattern of usual behavior, new onset of resistance to care, abrupt onset or progression of significant agitation or combative behavior, significant change in affect or mood, violent/destructive behaviors directed at self or others .Abrupt onset of, or increase in, confusion, onset of hallucinations, delusions or paranoia, significant fluctuations in level of confusion during the day or over several days .

Based on observation, interview and record review, the facility failed to mitigate the spread of COVID-19 (a highly contagious respiratory infection) by not completing thorough contact tracing after an employee tested positive for [MEDICAL CONDITION], resulting in 14 staff members and 28 residents becoming infected with [MEDICAL CONDITION], causing illness, discomfort, hospitalization s and death. Findings include: The Immediate Jeopardy (IJ) started on 10/10/2020 and was identified on 11/18/2020. The acting Administrator was notified of the Immediate Jeopardy on 11/18/2020 at 4:30 PM and was asked for a plan to remove the immediacy. The IJ was removed on 11/18/2020, based on the facility's implementation of the removal plan as verified onsite on 11/19/2020. Although the immediacy was removed, the facility's deficient practice remained widespread with actual harm that is not immediate jeopardy. On 11/18/2020 at 8:05 AM, during a partial tour of the facility, the Director of Nursing (DON) explained that the facility had an outbreak of COVID-19 recently, resulting in the opening of a COVID-19 unit to house the positive cases within the building. According to the DON, there were 11 positive residents residing on the unit. The DON also noted that the current building census was 50. On 11/18/2020 at 8:25 AM, the transitional unit was observed during meal time. The hallway had a tarped entrance separating this unit from the rest of the facility. Most residents on the unit had a sign next to their doors indicating droplet precautions were required before entering the rooms. There were Personal Protective Equipment (PPE) stations set up before entering the resident rooms. On 11/18/2020 at 9:05 AM, the COVID-19 unit was observed. The unit was also separated by a tarped entrance with immediate access to a donning and doffing area. Upon entering the unit, the unit was observed to be almost at full capacity. There were two staff members present on the unit (a Certified Nursing Assistant/CNA and a nurse). According to the Infection Control Preventionist (ICP A), the residents were mostly long term care residents that had acquired [MEDICAL CONDITION] within in the facility. On 11/18/2020 at 10:24 AM, an interview was conducted with the DON and ICP A. According to ICP A, one of two ICP nurses, ICP A is in charge of handling the COVID-19 aspect of infection control. The DON had explained that the facility had not had a positive resident or staff member since June (2020). Since the positive COVID test result on 10/10/2020, the facility had seen an increase in COVID+ cases within both staff and residents throughout the building, with the exception of the memory care unit. The memory care unit requires a code entry through double doors and has dedicated staff. The DON confirmed several staff and residents required hospitalization related to COVID-19. The ICP A was asked if they had any residents pass away from [MEDICAL CONDITION], the ICP A indicated that they had a couple residents who did not make it back to us (from the hospital due to expiring within the hospital). A record review of the COVID-19 line listing for October and November revealed the following: Staff 10/10/2020-One staff member tested positive (Activity Aide B) 10/20/2020-One staff member tested positive 10/21/2020-Two staff members tested positive 10/22/2020-One staff member tested positive 11/2/2020-One staff member tested positive 11/7/2020-One staff member tested positive 11/8/2020-Two staff members tested positive 11/9/2020-Two staff members tested positive 11/10/2020-One staff member tested positive 11/13/2020-One staff member tested positive 11/16/2020-One staff member tested positive Residents 10/12/2020-One resident tested positive 10/19/2020-One resident tested positive 10/20/2020-One resident tested positive 10/21/2020-One resident tested positive 10/26/2020-One resident tested positive 11/2/2020-Six residents tested positive 11/3/2020-One resident tested positive 11/4/2020-One resident tested positive 11/5/2020-One resident tested positive 11/7/2020-Three residents tested positive 11/8/2020-Three residents tested positive 11/9/2020-Three residents tested positive 11/12/2020-Two residents tested positive 11/13/2020-One resident tested positive 11/16/2020-Two residents tested positive On 11/18/2020 at 1:01 PM, an interview was completed with the ICP A. ICP A was asked what might have caused the COVID-19 outbreak within the building. ICP A explained that it may have started with Activity Aide B. ICP A stated that Activity Aide B had no specific assignment and was able to go throughout the building to engage all the residents. On 11/18/2020 at 1:32 PM, an interview was completed with Activity Aide B. Activity Aide B was asked about her workday on 10/10/2020. Activity Aide B described coming to work as scheduled and then receiving a message regarding a personal external exposure to a confirmed COVID-19 positive person. The Activity Aide B informed the applicable work supervisor and was tested at the nursing home, and tested positive. Following the positive test results, Activity Aide B was instructed to immediately exit the building and to quarantine. Activity Aide B was asked to detail duties that day but generally described going all over the building that day. The Activity Aide B was asked if she had symptoms of COVID-19 on 10/10/2020, and stated, I thought I had allergies [REDACTED]. I take stuff for allergies [REDACTED]. On 11/18/2020 at 2:09 PM, an interview was completed with the ICP A. ICP A was asked what steps were taken once Activity Aide B tested positive. ICP A stated that Activity Aide B tested (positive) after a known exposure and sent home. Monday (10/12/2020) all residents were tested , with one positive result. This resident was sent to an approved COVID nursing home. ICP A confirmed that the nursing home did not have a COVID isolation unit at the time, so any COVID+ resident was sent either to the hospital or a COVID approved nursing home. On 10/22/2020, another activity aide tested positive. Several additional residents tested positive on 11/2/2020. A COVID unit was then opened as other COVID approved nursing homes were full. The ICP A was asked what had been done as a result of the outbreak and stated, We offered the staff to wear a better mask (beside surgical) throughout the building and offered them face shields. We tested the staff and residents twice per week because of the county's infection rate. On 11/19/2020 at 10:05 AM, an interview was completed with the DON and the ICP A. The DON and ICP A were asked if contact tracing had been completed on 10/10/2020 once Activity Aide B had turned up positive with COVID-19. The DON explained they did not feel the need to do contact tracing since residents and staff were being monitoring for signs and symptoms of COVID-19 twice per day. The DON and ICP A were asked if any resident had been placed in isolation and appropriate transmission based precautions as a result of known contact with Activity Aide B and lessen the exposure risk to other residents and staff. Both the ICP A and DON confirmed that no other actions were taken other than initial transfer of COVID+ residents and monitoring and testing of residents and staff alike, but no in-depth contact tracing (investigation to trace who Activity Aide B had come in contact with on 10/10/2020) or facility wide implementation of appropriate transmission-based precautions as required by the facility's own policies and procedures as well as CMS (Centers for Medicare and Medicaid Services) regulations to prevent the spread of infection. The Administrator was out on a leave during the survey. A review of the COVID-19 Focused Survey for Nursing Homes issued by the Centers for Medicare and Medicaid Services (CMS) dated 08/25/2020 revealed the following: .If staff develop symptoms at work .does the facility .Inform the facility's infection preventionist and include information on individuals, equipment, and locations the person came in contact with . A review of the facility policy titled, Management of Outbreak of Communicable Diseases (COVID-19) (no date) revealed the following: Guideline: Outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled .How it is spread: COVID-19 is primarily spread through droplets, which means to become infected, people generally must be within six feet of someone who is contagious and come into contact with these droplets, which means to become infected, people generally must be within six feet of someone who is contagious and come into contact with these droplets. It may be possible that a person can get COVID-19 by touching a surface or object that has [MEDICAL CONDITION] on it and then touching their own mouth, nose, or possibly eyes. Symptoms of COVID-19 appear within two to 14 days .Prevention: The best way to prevent illness to avoid being exposed to this virus .Procedure .1. When a potential outbreak of a communicable disease arises, the Infection Prevention and Control Nurse should take aggressive steps to contain the disease and prevent spreading .3. Symptomatic residents and employees are to be considered potentially infected and are to be isolated .8. It is the responsibility of all employees to: Report illness to their supervisor .General Facility Guidance .If COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 [DIAGNOSES REDACTED]. F880 ABATEMENT PLAN Line listing was reviewed immediately to identify staff that were tested positive for Covid-19 in the last 48 hours. Base on record review, o One COVID-19 positive staff member was identified on 11/16/2020 as being in contact with residents in the last 48 hours. This named staff identified 21 residents and five staff members in our Autumn Ridge Unit. o 21 Identified residents and five staff were in contact with COVID positive staff member on the 11/16/2020 that the staff member tested positive. o 21 Identified residents and five staff were all tested for Covid-19 according to state and local health department guidance, turn-up with NEGATIVE results. o 21 identified residents and five staff do not have any signs and symptoms of Covid-19 to date. Identified residents and staff will continue to be monitored for signs and symptoms of COVID-19. Twice weekly Covid-19 testing for all staff and residents per guideline. Continue daily review and updates of the line listing to identify any staff and residents with signs and symptoms of Covid-19 and/or positive of Covid-19, and communication to the local health department. Compliance Date: 11/18/2020

Pertains to intake 2 Based on observation, interview and record review the facility failed to ensure proper incontinence care was completed on and or prevent a facility acquired urinary tract infection [MEDICAL CONDITION] for three sampled residents (R901, R902, R903) of three residents reviewed for incontinence care and UTI resulting in resulting in urinary tract infections [MEDICAL CONDITION] from feces borne organisms, mental status changes and discomfort. Findings include: R901 On 11/06/20 at 2:00 PM, Nurse A was asked about R901. Nurse A reported R901 was alert to self and incontinent of urine and stool. At 2:14 PM, incontinence care for R901 was observed. Nurse A and Certified Nurse Assistant (CNA) B put on disposable gloves and positioned R901 on their back in bed. CNA B was observed to open the brief of R901. CNA B cleaned the vaginal area with disposable wipes. R901 was turned onto their left side toward CNA B. Nurse A reported some rough areas to the buttocks of R901 and used multiple wipes and removed some dried stool. The white disposable wipes appeared with a brown colored substance after wiping the buttocks of the resident. Nurse A then wiped the vaginal area from behind as they noted some drainage. The resident was then placed onto their back and Nurse A then wiped the vaginal area with three wipes. Nurse A did not change their gloves and did not perform hand hygiene prior to wiping the frontal labial (vaginal) area of R901. Nurse A was asked about the concern of cleaning the stool from the buttocks of R901 then proceeding to return to the frontal area without changing gloves and stated, I know better. Nurse A confirmed additional gloves were present in the bathroom. A review of the medical record for R901 revealed: R901 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. A lab result dated collected 08/07/20 and received 08/11/20 documented many bacteria present. The organism was Proteus Mirabilis. A review of the progress notes documented multiple refusals of the antibiotics for the UTI. The August 2020 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A Nurse Practitioner note dated 10/20/20 at 2:00 PM revealed, Initial evaluation for antibiotic management .female long term resident .started on [MEDICATION NAME] for suspected bacterial vaginosis. Staff report that patient has had increasing vaginal discharge and complains of vaginal discomfort during peri-care .has a history of dementia and is incontinent of bowel and bladder. It is difficult to discern if there is an odor from the discharge because the patient ' s urine odor is strong. Discharge documented as grayish white and thick .has had a recent fall with a history of frequent falls. Unknown prior history of vaginal infections. Plan: 1. Continue [MEDICATION NAME](anti fungal), but increase dose to 500 (milligrams) mg (twice a day) bid for 7 days total 2. Gentle but thorough perineal cleansing . R902 A review of the medical record for R902 revealed: R902 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The nursing care plan revealed R902 had two UTIs: Resolved: I am on antibiotic therapy (related to) r/t a UTI, Date Initiated: 08/13/2020. I will be free of signs/symptoms of my infection by the review date. Maintain universal precautions when providing my care. Follow your policy and procedures for line listing, summarizing and reporting infections. Monitor/document/report to my doctor if I have s/sx of [MEDICAL CONDITION]: Changes in behavior, Altered mental status, Wide variation in cognitive function throughout the day, Communication decline, Disorientation, Periods of lethargy, Restlessness and agitation, Altered sleep cycle. Provide me my antibiotic per my doctor's orders. The second UTI care plan revealed: Resolved: I am on (antibiotic) ABT (related to) r/t UTI, Date Initiated: 09/09/2019. I will be free of signs & symptoms of UTI by next review date. Administer my ABT as order. R903 A review of the medical record for R903 revealed: R903 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. R903 discharged on [DATE]. A review of the nursing care plan revealed: I am incontinent of Bowel and Bladder occasionally. Date Initiated: 08/03/2020, I will be free of (sign and symptoms) s/s of a UTI by review date, Keep me as clean and dry as possible .I need assistance with my (activitie of daily living) ADL's (related to) r/t weakness. Date Initiated: 08/03/2020. I need assistance of (one)1 by you for toileting A review of the progress notes revealed: 9/16/2020 (6:26 PM), Health Status Note Note Text: Resident very lethargic this shift .Dr. made aware via phone. New orders: Stat Chest X-Ray and (urinalysis) UA. 9/16/2020 (9:30 PM),) Nurses Note Note Text: 2000: X-ray tech in to complete Stat (chest x ray) CXR. Awaiting results .In house urine dip obtained via clean catch, urine dark yellow/hazy with foul odor, in house urine dip positive, urine obtained for lab pick up .(Blood draw person) Phleb in to draw Stat labs as ordered, awaiting results. A lab result for urine dated collected 09/16/20, received 09/17/20 and reported 09/20/20 revealed, Bacteria Many and the organism to be greater than 100,000 and E-Coli. On 11/06/20 at 3:37 PM, the medical record for R903 was reviewed with the (Minimum Data Set) MDS Nurse C. Nurse C reported a UTI was not a skilled need that related to the admitting [DIAGNOSES REDACTED]. The facility therefore, would not keep the resident at the facility. Nurse C acknowledged the results from the urine culture for R903 had not come back from the lab before R903 discharged . Nurse C further reported it typically takes 14 days for one to recover from a UTI. On 11/06/20 at 3:50 PM, a review of concerns was conducted with the Director of Nursing (DON) and Infection Control Preventionist (ICP) D. The DON recalled R903 was getting discharged and was lethargic. The DON was asked about R903 not getting an antibiotic prior to discharge and the DON reported R903 was discharged prior to when the urine culture came back therefore was not started on antibiotics. ICP D reported the same. The DON acknowledged the change in condition for R903, but noted UTIs can be treated from home and was not a skilled need. The DON was then asked about R901 and the observation of incontinence care. The DON reported cleaning of a resident during incontinence care should be from clean to dirty and front to back. The DON was asked about the need to change gloves after wiping stool off the buttocks of R901 and reported the gloves should have been changed prior to wiping the frontal (vaginal) area of R901. On 11/06/20 at 4:05 PM, facility urinary tract infections documented on the facility line listing were reviewed with ICP E. On the August 2020 line listing for infections R902 was documented with a UTI on 08/10. The organism was ESBL (extended-spectrum beta-lactamases which include E-Coli from the gastrointestinal tract) an antibiotic resistant organism per the Center for Disease Control (CDC) at (www.cdc.gov/hai/organisms/ESBL.html). R901 was documented with a UTI on 08/11. The organism was Proteus Mirabilis (found in soil, wastewater and the gastrointestinal tract). R903 was documented with a UTI on 08/30. The organism was [MEDICATION NAME] faecalis (from the gastrointestinal tract). Three additional facility acquired UTIs were documented (two were E-Coli). The September 2020 line listing documented five facility acquired UTIs and the October line listing documented six facility acquired UTIs (all without a urinary catheter). The ICP was asked about training related to the number of facility acquired urinary tract infections and reported that they had a discussion with staff back in August or September where the aides were told slow down with incontinence care and to make sure the residents were clean. The concern related to not changing gloves after cleaning stool before going to a clean area was acknowledge ICP E and reported cleaning should always be from clean to dirty. A review of the facility policy Perineal Care (undated) revealed, Perineal Care(area between the anus and the scrotum in the male and between the anus and the labial opening to the vagina) in the female) Care is provided to promote cleanliness, prevent infection and remove irritating and odorous secretions that collect under the foreskin of the penis and on the inner surface of the labia .2. Cleanse, rinse and dry perineal area, starting at posterior vaginal vault and wiping front to back . A review of the facility Hand Hygiene operating procedure (undated), revealed: Hand hygiene shall be regarded by this organisation as the single most improtant means of preventing the spread of infections .4 Appropriate hand hygiene must be performed under the following conditions .b. When hand ar visibly soiled; Before and after direct resident contact .g. Before and after assisting a resident with personal care .m. Before and after assisting a resident with toileting;

This Citation Pertains to Intake Number MI 781. Based on observation, interview and record review, the facility failed to provide monitoring and supervision to prevent elopement from the front door of the facility at approximately 8:00 PM on 4/12/20 for one (#702) of five Residents reviewed for elopement. An Immediate Jeopardy (IJ) was identified when Resident #702 eloped from the facility, after being assessed as an elopement risk and two prior elopement attempts on 4/12/20 before exiting the facility without staff knowledge of the exit and/or their whereabouts in their wheelchair. Resident #702 was found outside of the facility, with their wheelchair on top of them, resulting in the potential for serious harm, injury, or death. The Administrator was notified of the Immediate Jeopardy on 6/30/20 at 3:35 PM. A plan to remove the immediacy was requested. The IJ was removed on 4/13/20 based on the facility's implementation of the plan removal as verified onsite on 7/1/20. Although the IJ was removed, the facility's deficient practice remained at isolated. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: An interview was conducted with the facility Administrator on 6/30/20 at 9:15 AM. When queried regarding an elopement at the facility, the Administrator indicated they would provide the investigation completed by the facility. With further inquiry regarding the Resident and what had occurred, the Administrator detailed Resident #702 had exited the facility through the front doors and was found, after they had fallen and tipped over in their wheelchair by a Nursing Assistant returning to work after a break. When asked, the Administrator specified that, since Covid, all staff have to enter/reenter the facility through the main doors to have temperature screening completed. At this time, the Administrator provided a tour of the doors and outside area where Resident #702 was found after exiting the facility without staff knowledge. Resident #702 exited through the main, alarmed, door of the facility which lead into a lobby area. The Resident then exited the lobby exit door to the outside of the facility. The outside lobby door opened to a sideway and a parking lot. Directly across from the parking lot a deep ditch with a large metal culvert was noted. When asked where the Resident was found by staff, the Administrator indicated the Resident was found just off the sidewalk. When queried regarding Resident #702's cognition, the Administrator revealed the Resident was severely cognitively impaired. When asked if the Resident's room was in the facilities locked Dementia/Memory unit, the Administrator replied, No, but they will be. Review of facility provided Incident and Accident Report for Resident #702, dated 4/12/20 at 8:15 PM, revealed, Incident Type . Fall . Brief Description: At approximately 2015 (8:15 PM) this Resident had demonstrated 3 different episodes of exit -seeking behavior, such as making statements such as 'I want to see my Mom' and going towards the main entrance and touching the push-bar (on main exit door). Resident was re-directed each time back to the nursing station around other staff. Each time the Resident pushed the push-bar it would make a loud 'beep' sound; one time the Resident managed to push the door open and set the alarm off. The system was re-set and the light on the panel had indicated the system was on and working. The Resident then made their way back towards the door and somehow managed to open the door without setting the alarm off, and then opened the external door. The Resident was observed on the ground by a CNA (Nursing Assistant) who then ran in the facility to alert other staff that the Resident was outside, on the ground. The Resident had two small skin tears to their left elbow and an abrasion to their left great toe. No other injuries were observed . The Incident and Accident Report further revealed Resident #702 was Confused/Disorientated prior to the incident and receiving three psychoactive medications including [MEDICATION NAME] (anti-anxiety medication), [MEDICATION NAME] (medication used to treat Alzheimer's/ Dementia), and [MEDICATION NAME] (antidepressant medication). Report did not detail Resident clothing at time of elopement. Review of facility provided investigation documentation pertaining to Resident #702's elopement from the facility included: Incident and Accident Report (detailed above) Post Fall Investigation Form. The form included, CNA (Nursing Assistant) had re-directed Resident multiple times back to nursing station; Resident kept wheeling away . Elopement Timeline Staff Interviews conducted by the Director of Nursing (DON). The question listed on the interview statement forms was: Please tell me in your own words what you witnessed r/t (related to) the incident? The following interview statements were reviewed: -Registered Nurse (RN) A statement dated 4/13/20. The statement detailed, I was passing medication from the start of my shift at 1900 (7:00 PM). During that time, the Resident was retrieved at least three times propelling down the hallway towards the front door. (Resident #702) made it to the door and set off the beeping of the door and set off the alarm once. I reset the alarm at the desk. (Question: Did anyone reset the door alarm?) Yes, (Nursing Assistant D) stated they reset it. I heard (Agency Nursing Assistant I) calling for help and ran down to the front entrance about 2015 (8:15 PM) and observed Resident laying on side outside . -Nursing Assistant D statement dated 4/13/20. The statement revealed, During shift, the Resident seemed to get more agitated . I was alerted that (the Resident) wheeled down the hallway and was asked to redirect and bring them back which I did. Then the Resident went back down the hallway and set off 'beeping' of the bar and on the door and brought back again . The last time I saw (Resident #702) was approx. 2000 (8:00 PM). I heard the call for help when I was in (room number) and exited the building to help . I had to punch in the code to exit (door). I observed the Resident on the ground with their legs up in the wheelchair . -Nursing Assistant J statement dated 4/13/20. The statement detailed, The Resident at approx. 1745 (5:45 PM) was having dinner . mood became very agitated stating, 'I want to go home and see my Mom and crying.' (Resident #702) started heading down the hall towards the front door several times and the nurse asked us to bring them back . During that time, I did not hear any alarms going off . The statement also revealed Nursing Assistant J responded to Agency Nursing Assistant I's call for assistance upon finding the Resident outside. Per the statement, I observed the Resident on their back, their body was on the ground in the parking lot and wheelchair was on the sidewalk . When we got (Resident #702) up . they opened their eyes and stated, 'I am sorry, I was just trying to go home'. -Agency Nursing Assistant I statement dated 4/15/20. The statement revealed, During the afternoon shift, (Resident #702) was very irritable During the day shift, the nurse kept (Resident #702) behind the desk where they were still behavioral. During the early evening prior to my lunch break, I witness the Resident wheeling to the front door at least two times and another CNA retrieve them. I do not remember any alarms going off at that time. I went on my lunch break at 1945 (7:45 PM) . then I exited the break room door . Approximately 8:10 -8:15 (PM), I came to the front entrance to temp in and observed the Resident lying on their back in the parking lot . -Licensed Practical Nurse (LPN) C statement dated 4/13/20. The statement included, Resident was very agitated at nurses' station upon start of shift . Yelling, 'I want to see my Mom' . Resident started wheeling around . staff would redirect and bring back to nurses station. This happened at least three times that the Resident propelled towards the front door. (Resident #702) set the beeper on the door off once and returned to the nurses' station. The second time, set off the alarm and was reset by another nurse and CNA . A staff schedule and/or assignment sheet for the date of the incident was not included in the provided documentation. The actual staff schedule/assignment was requested on 6/30/20 at 12:47 PM. Review of Resident #702's medical record revealed the Resident was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, displayed behavior symptoms that interfered with the provision of care, and required limited to extensive assistance to perform Activities of Daily Living (ADLs) with the exception of supervision for eating. The medical record further revealed Resident #702 was admitted to Hospice services on 6/25/20. Review of Resident #702's care plans revealed, I am an elopement risk I am exhibiting exit seeking behavior, I have periods of high confusion with 'exit seeking' behavior (Initiated: 3/25/20; Revised: 6/25/20). Care plan interventions included: -Encourage me to attend activities of choice to promote happiness (Initiated: 3/25/20; Revised: 4/7/20) -I have snacks available in the SW (Social Work) office and in my room, these work well for redirection as my Family supplies them. (Initiated: 4/13/20) -Keep my picture in the Elopement book so all are aware (Initiated: 3/25/20; Revised: 4/7/20) -Since I am an elopement risk - Observe my mood and listen for me saying such things as 'I want to go home' or 'I want to leave' (Initiated: 3/25/20; Revised: 4/7/20) -Utilize distraction & re-direction such as from exit seeking by offering me snacks, beverages, activities, toileting, & conversation and I enjoy Music and Memory (Initiated: 4/13/20; Revised: 4/19/20) The care plan also included the Resolved (discontinued) intervention, Observe me for my whereabouts frequently (Initiated: 3/25/20). Review of Resident #702's Elopement Assessment documentation in the Electronic Medical Record (EMR) revealed Elopement Assessments were completed on 1/3/20, 3/6/20, and 6/18/20. All assessments indicated the Resident was a High Risk to Wander. On 6/30/20 at 12:05 PM, Resident #702 was observed in the hall of the Transition Unit of the facility in a wheelchair. Dark black and purple colored bruising was noted around the bottom and top of the Resident's right eye. Resident #702 had slipper socks in place on their feet. The non-slip gripper on the left foot was observed to be positioned on the top of the Resident's foot. An interview was conducted at this time. Resident #702 was noted to be pleasantly confused. When queried regarding the bruise on their eye, Resident #702 was unable to recall what occurred. When asked if it hurt, Resident #702 replied, Well yeah. Resident #702 was observed self-propelling and moving themselves in their wheelchair utilizing their feet. Record review of Resident #702's progress note documentation in the EMR revealed the following: -1/17/20: Social Services Note . Resident needs assistance with ADLs and is able to propel self in w/c (wheelchair) and is monitored. Resident is an elopement risk AEB (As Evidenced By) behavior . -2/21/20: Senior Wellness Note . Staff report and documentation states resident has periods of confusion, anxiousness, agitation, wandering, exit seeking . -2/23/20: Behavior Note . Resident kept going from door to door and even setting off exit door alarms twice . -3/27/20: Senior Wellness Note . Resident has history of confusion, anxiousness, agitation, yelling out, irritability, aggression, wandering, exit seeking, and combativeness . -4/2/20: Social Services Note . Resident needs assistance with ADLs and is able to propel self in w/c . Resident is an elopement risk AEB behavior . Resident prefers to sit in the hallway during activities . is in contact precautions at this time as (Resident) went to Hospital after a fall for stitches . -4/4/20: Behavior Note . Resident began wondering the halls and unable to be redirected despite multiple staff encouragement. Wondering in others rooms and towards exit doors . -4/7/20: Behavior Note . Resident at exit door, redirected mult times . (Resident) was combative when was redirected away from door . -4/13/20 at 2:30 AM: Unusual Occurrence . At approximately 2015 (8:15 PM), this resident had demonstrated 3 different episodes of exit-seeking behavior, such as making statements such as 'I want to see my mom' and going towards the Main Entrance and touching the push-bar. Resident was re-directed each time back to the nursing station around other staff. Each time the resident pushed the push bar it would make the loud 'beep' sound; one time the resident managed to push the door open and set the alarm off. The system was re-set and the light on the panel had indicated the system was on and working. The resident then made their way back towards the door and somehow managed to open the door without setting the alarm off, and then opened the external door. The resident was observed on the ground by a CNA who then ran in the facility to alert other staff that the resident was outside, on the ground. The resident had two small skin tears to left elbow and an abrasion to left great toe. No other injuries . New intervention: Distract me from exit-seeking behavior by offering me sugar-free snacks . -4/17/20: Senior Wellness Note . Since last visit [MEDICATION NAME] scheduled on 4/13. Staff report and documentation states resident has periods of agitation, anxiousness, tearfulness, combativeness, exit seeking . Resident is drowsy . Prescriptions: Reduce [MEDICATION NAME] to 0.125 mg (milligrams) BID (twice a day) and 0.125 mg BID PRN (as needed) x 14 days d/t (due to) drowsiness noted . On 6/30/20 at 12:30 PM, an interview was completed with Registered Nurse (RN) G and Licensed Practical Nurse (LPN) H. When queried regarding facility policy/procedure pertaining to door alarms, both RN G and LPN H indicated the alarm will beep if the handle is pushed without entering the code but the alarm does not actually go off unless the door is opened. When asked if nursing staff is responsible to reset the door alarm after the alarm has gone off, both nurses indicated they are. When asked how the door alarm is reset, RN G and LPN H detailed that a code has to be entered into the control box on the wall and LPN H gestured toward a white colored control box on the wall of the nurses station. RN G and LPN H were then asked if anything needed to be completed at the exit door to reset the alarm system after the alarm had been triggered and both replied, No. An interview was conducted with the Director of Nursing (DON) on 6/30/20 at 1:00 PM. When queried regarding Resident #702's elopement from the facility on 4/12/20 and what staff were working, the DON stated, It would have been the night shift nurse and the afternoon CNA (Certified Nursing Assistant). The DON elaborated that nursing staff work 12 hour shifts and Nursing Assistant staff work eight hour shifts at the facility. When asked what had occurred, the DON stated, (Agency CNA I) went on break and came back around to the front door to enter (facility) and that's when they found (Resident #702). The DON reviewed the facility provided investigation documentation at this time and revealed Resident #702 had tried to exit the facility twice through the same door on 4/12/20 prior to exiting and had caused the door alarm to beep. When asked if the door alarm had been disengaged when Resident #702 pushed on the door causing it to beep, the DON replied, My understanding is that it (alarm) didn't go off but it made the long beeping sound. The DON was then asked if the door alarm needed to be reset after making a long beeping sound and did not provide a response. When queried if there was a problem identified with the exit door alarm, the DON stated, It was difficult because I asked the CNAs. One of the CNAs told me they had to punch the code to go outside. The DON was then asked if the entry code would have to be entered to exit/enter the facility if the door alarm had been triggered and not reset, and replied, We don't know. When queried if the facility had cameras and/or video footage of the hall and main door, the DON replied, No, no cameras. When queried regarding the Resident having an unwitnessed fall outside of the facility with subsequent abrasions and skin tears and documentation of treatment provided, the DON reviewed the Resident's medical record and indicated they were unable to locate orders and/or treatment documentation. When queried regarding facility policy/procedure pertaining to assessment following an unwitnessed fall, the DON revealed neuro-checks should be completed. When asked if neurochecks were completed for Resident #702, the DON stated, No, we did not. It was a newer nurse, but we implemented that. The DON was then asked about Agency Nursing Assistants working in the facility when Resident #702 exited the facility and stated, We had two agency CNAs but one was on a different unit. When asked if staffing levels were sufficient to monitor Residents, the DON indicated the facility brought in agency staff as needed. When queried why Resident #702's elopement care plan was initiated on 3/25/20 when the Resident's elopement assessment in January 2020 identified them as a high risk for elopement, the DON reviewed the Resident's medical record and indicated they were unsure why the Resident's care plan was not initiated until March 2020. On 6/30/20 at 1:44 PM, an interview was conducted with Agency Nursing Assistant I. When queried regarding Resident #702's elopement from the facility on 4/12/20, Agency Nursing Assistant I revealed they found Resident #702 when they were reentering the facility after their break. Agency Nursing Assistant I stated, They (facility) have a protocol that we had to come back in through the front door. I seen a wheelchair flipped over and a Resident was under it yelling for help. I ran in and everybody ran to help. When asked if they exited the building through the same door when they left for their break, Agency Nursing Assistant I indicated they exited through a different door but had to go back in that door to get temp checked. With further inquiry regarding Resident #702, Agency Nursing Assistant I stated, Previously before that, (Resident #702) had made it down (to the door) and set the alarm off. The nurse had went down there (to the door) but I don't know if they reset it (alarm). Agency Nursing Assistant I further detailed, I worked 16 hours that day and (Resident #702) was all worked up. They keep trying to get out of the wheelchair and get out (of the facility). (Resident #702) kept saying they were leaving. When asked what interventions were implemented, Agency Nursing Assistant I revealed staff just kept getting the Resident and bringing them back up by the nurses' station. Agency Nursing Assistant I further stated, During the day shift, the nurse kept (Resident #702) behind the nurses' station. When asked if there was sufficient staffing to monitor the Residents, Agency Nursing Assistant I replied, They are always short there. The staffing is definitely a issue. An interview was conducted with Nursing Assistant D on 6/30/20 at 2:00 PM. When queried, Nursing Assistant D revealed they were working on 4/12/20 when Resident #702 eloped from the facility. When queried what occurred, Nursing Assistant D stated, It was like the alarm system failed. Nursing Assistant D further revealed they had to enter the (door code) to go out to assist when Resident #702 was found. When asked if Resident #702 had attempted to exit through the main door previously that day, Nursing Assistant D revealed the Resident had and that staff had brought the Resident back. Nursing Assistant D stated, There was a slew of incidences that happened with other Residents that night too. When queried regarding staffing, Nursing Assistant D indicated the facility had been using agency staff at that time to fill shortages. On 6/30/20 at 2:25 PM, an interview was completed with Maintenance Director F. When queried regarding the door alarm system functionality including how the alarm is reset, Maintenance Director F stated, You have to reset the panel (at the nurses station) and type in the code at the door (where alarm was triggered). Maintenance Director F was then asked about the door alarm not sounding when Resident #702 exited the building and revealed they were unsure why the door alarms did not activate. Maintenance Director F further stated, We (maintenance staff) were checking the door alarms daily before (Resident #702's elopement). With further inquiry, Maintenance Director F revealed door alarm checks were completed by maintenance staff on weekdays. When asked, Maintenance Director F denied any concerns during routine door alarm checks. An interview was conducted with the Administrator on 6/30/20 at 2:45 PM. When queried regarding RN G and LPN H statements related to only having to reset the exit door alarm at the nurses station and not at the doors, the Administrator stated, They have all received training. The Administrator then revealed that RN G was new to the facility and was not employed when staff received education following Resident #702's elopement. When queried regarding door alarm training and education being provided in New Employee Orientation (NEO), the Administrator stated, It should be included. An interview was conducted with Nurse A on 6/30/20 at 3:55 PM. When queried regarding Resident #702's elopement from the facility, Nurse A revealed they were the Resident's assigned nurse when the incident occurred. When asked about the incident, Nurse A stated, It was a crazy night. It was awful. When asked what was crazy and awful, Nurse A revealed they needed to administer medications at that time and stated, All the patients conjugate at the nurses' station. I'm a nurse, not a babysitter. That is the busiest time of the night for us (for medication administration). When asked if Resident #702 had made attempts to exit the facility prior to being found outside, Nurse A stated, Yes, (Resident #702) tried to get out previously that night. When asked, Nurse A revealed Resident #702 had pushed on the door exit and caused the door alarm to beep. Nurse A was asked if the door alarm had to be reset after the door alarm beeped and replied, I didn't have to reset the alarm that time. Nurse A revealed the door alarm beeps if it is pressed but only needs to be reset when the actual alarm is triggered which occurs when the door bar is pressed and then opened. With further inquiry regarding Resident #702 on 4/12/20, Nurse A stated, They kept wheeling down that hall (towards door). When queried if the alarm went off when Resident #702 exited the building, Nurse A replied, No. We were all shocked. We were like how did (Resident #702) get outside. Nurse A proceeded to state, Then I had to reset the alarm. Nurse A was then queried regarding facility policy/procedure pertaining to resetting the door exit alarms and stated, Have to enter the code three times until there is a green check mark and then have to do it at the door too. When queried regarding Resident #702 being located outside by staff, Nurse A revealed (Agency Nursing Assistant I) found the Resident outside, yelled for help and they responded. Nurse A indicated the Resident was assessed and assisted off the ground and back into the facility by staff. When queried regarding injuries, Nurse A stated, (Resident #702) scraped their toe. I cleaned it and put a band aid on it. With further inquiry regarding staff and what staff were doing at the time the incident occurred, Nurse A replied, (Agency Nursing Assistant I) was on break. I think someone else was on break too, but I can't remember who but (Nurse C) and I were like where is everybody because we can't just be sitting there when we have meds to pass. Nurse A further specified that staff members are not supposed to take their breaks at the same time. Review of facility policy/procedure entitled, Elopement Book (No Date) revealed, It is the policy of this facility to coordinate and help identity Residents with cognitive loss that have been assessed and identified as being at risk for unobserved exit from the facility . Elopement occurs when a Resident leaves the facility or a safe area without authorization and/or any necessary supervision to do so . 5. If the resident attempts to leave the facility without authorization and there is a witness: a. Assist the resident and redirect to a safe area . d. Complete an Unusual Occurrence report. e. Determine what additional interventions are needed to minimize another attempt at an unauthorized leave. f. Update the resident's care plane with additional preventative measures for elopement. g. The nurse will document in the nurses' notes . 6. If the resident exits the facility without authorizations and there is no witness and is located: a. Redirect the resident to a safe area . d. Upon return to facility, examine the resident for injuries. e. Complete an Unusual Occurrence Report . k. Update the resident's care plan with preventative measures for elopement . Review of facility policy/procedure entitled, Elopement, Potential Resident (Revised July 2013) revealed, It is the policy of this facility to provide residents with a safe and secure environment and identify residents who may be at risk for unobserved exit from the facility Residents with cognitive loss or impaired judgement may attempt to leave the premises, known as Exit Seeking Behavior . Procedure . 4. If a resident is identified as being at risk for elopement, which is if the resident scores a 9/10 or higher on the risk tool, the following interventions will be put into place. a. Care plan developed that identified the specific risk factors displayed by the residents . e. A wander alarm device will be placed on the resident based on the type of system used by the facility . Review of facility policy/procedure entitled, Behavior Management Program (No Date) did not include information directly pertaining to elopement and/or elopement risk. Review of facility policy/procedure entitled, Unusual Occurrences (Updated 4/12/18) revealed, The facility will take measure necessary to provide residents . with a safe and incident free environment. If an incident or unusual occurrence takes place, the facility will provide the intervention and documentation necessary to address the incident and prevent future reoccurrence . Examples of Unusual Occurrences include but are not limited to . Elopements . Process . 2. If safety needs are identified, interventions will be put into place and care plans will be updated to minimize risk factors . Removal Plan: Resident #702 continue to reside in the facility. Background: Resident#702 exited the building in her wheelchair through the front door. She was observed on the sidewalk at the parking lot edge for a short period of time. Outside weather was dry and temperature was 50 - 55 degrees. The R#702 was wearing pants, sweater, and grippy socks. - The staff immediately assessed R#702 head to toe at the site and transferred her back into her wheelchair, took her to her room, transferred her to bed and performed a head to toe assessment. - Vital signs were checked and they're all recorded and within normal limits. - Family was notified. - Physician was notified and evaluated #702 - Resident was monitored Q30 minutes and as needed for 24 hours by Nursing with no elopement related problems identified. - Door alarms were checked immediately and they're activated and without any issues. - Door alarm company was contacted. The door alarm situation was reviewed with the company by the Maintenance Director and no visit was recommended. - Social work evaluated resident for psychosocial welfare and noted no changes in her psychological status. - Senior Wellness was contacted and evaluated the R#702 Total of 59 residents that reside in the facility were assessed for Elopement. 14 residents were identified as high risk for elopement and have the potential to be affected. - An audit of a total of 59 residents residing in the facility was completed and 14 residents identified that were high risk for elopement; their care plans were updated as needed. - The Elopement policy and the Behavioral management policy were reviewed and deemed appropriate. - Elopement books are located at each nurses station and in the front office and have been reviewed and updated. - All staff has been re-educated immediately on the following: Staff that are not available will be re-educated on or before returning to work. Elopement policy Location of Elopement books Reset door alarm Elopement and Exit Seeking Behavior of residents Maintenance department checks door alarms Monday through Friday and the Manager on Duty checks door alarms on the weekend. - AdHoc QAPI meeting was held on 4/15/2020 to analyze the incident and to ensure that the elopement prevention processes are being implemented. - Elopement drills for all staff have been done by the Maintenance Director covering all shifts. The DON or designee will audit residents at risk for elopement daily x 5 days to ensure care plans are updated, weekly x 4 weeks and then monthly for 3 months to ensure the proper plan of care is in place. Corrective action will be implemented immediately as necessary. AdHoc QAPI meeting was held on 4/15/19 to analyze the incident, determine cause and implement corrections. Monthly QAPI will be completed to discuss concerns and continued compliance. The DON or designee is responsible for compliance; effective date immediately. Effective date of compliance 4/13/20

This Citation Pertains to Intake MI 490. Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure the provision and implementation of adequate and necessary supervision, monitoring, and provide requested Activity of Daily Living (ADL) care assistance for one (# 701) of three Residents reviewed, resulting Resident #701 not receiving care as requested, attempting to use the restroom unassisted, and experiencing a fall with physical injury requiring emergency medical treatment, surgery, unnecessary pain, and the likelihood of decline in overall health and well-being. Findings include: An interview was conducted with the facility Administrator on 6/30/20 at 9:15 AM. When queried regarding Resident #701's fall with injury in the facility, the Administrator revealed the Resident was currently in the facility in the locked memory care/dementia unit. With further inquiry regarding the fall, the Administrator indicated they would provide the facility investigation folder. Review of facility provided investigation documentation for Resident #701 included an Incident and Accident form, a Post Fall Investigation form, Sleep Study documentation (dated 4/14/20 to 4/16/20) and progress note documentation. Detailed review of provided documentation revealed the following: -Incident and Accident form: Date: 5/18/20 . 5:00 AM . Brief Description: Resident up in Geri- Chair (wheeled, padded, reclining chair for medical use) was just toileted at 0435 (4:35 AM) and returned to chair. A loud scream heard for help. Staff observed Resident on floor near chair, physical assessment c/o (complain of) pain to L (left) hip, no weight bearing to L leg . Injury Type . Pain L hip/leg . Treatment . X-Ray ordered . -Post Fall Investigation: Statements: What was Resident doing immediately prior to the fall: sleeping in hallway. Resident's statement: I was trying to go to bathroom . Current Interventions in place per CP (Care Plan): Will assist with toileting immediately upon request even when previously just toileted . New Intervention: Assist with toilet immediately upon request . Call light: N/A . An observation of Resident #701's room in the facility occurred on 6/30/20 at 11:15 AM. The Resident's room was located at the very end of the hall, the furthest from the nurses' station, within the secured dementia/memory care unit of the facility. Resident #701 was not present in their room at this time. Resident #701's bed was noted to have a regular mattress. On 6/30/20 at 11:30 AM, Resident #701 was observed in the central dining/activity area of the locked memory care unit of the facility. The Resident was sitting in a wheelchair at a table with their eyes closed. An interview was conducted at this time. Resident #701 made eye contact, was pleasantly confused, but was unable to provide meaningful answers to questions when asked. An interview was completed with Nursing Assistant B on 6/30/20 at 11:35 AM. When queried regarding Resident #701, Nursing Assistant B stated, They will try to get up on their own. (Resident #701) is like a flash. When asked for clarification, Nursing Assistant B explained that Resident #701 will get out of their wheelchair and walk towards their room before staff are aware or able to get to them. When asked if Resident #701 requires assistance to ambulate, Nursing Assistant B indicated they did. When queried if they were working when the Resident fell and broke their hip, Nursing Assistant B revealed they were not. When asked if the resident had a history of [REDACTED].#701 had fallen a lot. Nursing Assistant B then stated, Resident #701 goes back to bed and then tries to get right back up. When asked about Resident #701's room placement and fall risk, Nursing Assistant B indicated they were unsure why the Resident's room was so far from the nurses' station. Nursing Assistant B further revealed the Resident sleeps in a Geri chair near the nurses' station so that staff are able to keep a closer eye on them. With further inquiry, Nursing Assistant B stated, It's hard. Over the weekend, I was the only CNA (Nursing Assistant) here (in locked memory/dementia unit) with a nurse. Nursing Assistant B was asked how many Residents there were in the unit and replied, 16 down here. We have six or seven Hoyers (mechanical lift to transfer Residents- require two staff to operate) plus five or six (Residents) who are two person assists. When asked how many Residents on the unit were high fall risks, Nursing Assistant B did not provide a number but indicated there were multiple at-risk Residents. When queried regarding monitoring of high fall risk Residents with the majority of Residents on the unit requiring two staff members to transfer and provide care, Nursing Assistant B revealed they do as much as they can before having to transfer a Resident and then they put on the call light and wait for the nurse (to assist). Nursing Assistant B elaborated, That means nobody is watching anybody else (Residents) down here unless it is after 9:00 AM and Activities (staff) is here. Nursing Assistant B was asked for clarification regarding Activities staff and revealed there is a dedicated Activities staff member who works in the locked memory/dementia care unit of the facility and starts at 9:00 AM during the week. Nursing Assistant B further revealed the Activities staff stay in the central dining/activity area of the unit. When asked, Nursing Assistant B revealed that it is very common to only have one Nursing Assistant and one nurse on the unit during the day/afternoon shift and that is what is always scheduled on night shift. At 11:47 AM on 6/30/20, an interview was conducted with Licensed Practical Nurse (LPN) K. LPN K was asked if they were working on 5/18/20 when Resident #701 fell resulting in a [MEDICAL CONDITION] and replied, No. When queried if the Resident had been a fall risk prior to the fall with fracture, LPN K indicated they had and revealed the Resident had multiple falls. Record review revealed Resident #701 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required extensive assistance to perform Activities of Daily Living (ADLs). The Resident's face sheet also revealed a [DIAGNOSES REDACTED]. Onset Date: 5/23/20. Review of Resident #701's current/active care plans revealed a care plan titled, I have a history of falls r/t (related to) dementia (Initiated: 6/5/20). The care plan included the interventions: - 30-minute checks on resident location to increase observation (Initiated: 6/5/20) - Be sure my touch pad call light is within reach and encourage me to use it for assistance as needed (Initiated: 6/5/20) - Bilateral floor mats to exit sides of bed (Initiated: 6/5/20) - Ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair) (Initiated: 6/5/20) Review of Resident #701's progress note documentation revealed the following: -5/18/20 at 5:00 AM: Incident Note . Resident was resting quietly in geri-chair, a loud scream heard by staff. Staff observed resident on floor near chair, during physical assessment resident states was trying to go to bathroom . pain to left hip no swelling redness noted at this time. Resident is unable to bear weight to left leg at this time . -5/18/20 at 7:38 AM: Incident Note . Resident remain at nurses' station . Resident is awaiting x-ray at this time. -5/18/20 at 10:11 AM: Incident Note . new intervention: assist with toileting immediately upon request. -5/18/20 at 1:41 PM: physician progress notes [REDACTED]. Fall this a.m. Left hip pain. Waiting on x-ray. Will transfer (to) hospital for evaluation . -5/18/20 at 4:14 PM: Interdisciplinary Note: (Physician) in, Res transferred Hospital for L hip X-ray to r/o (rule out) FX (fracture). (Mobile Diagnostic Company) unable to obtain x-ray stat today . Resident medicated with [MEDICATION NAME] (prescription pain medication) for pain this shift. L hip area swollen and painful with movement. Review of Resident #701's Change in Condition Evaluation assessment, dated 5/18/20 at 2:16 PM, revealed the following abnormal skin assessment: -Left trochanter (hip) . swollen . -Left lower leg (rear) . elongated bruise noted . -Right lower leg (rear) . painful enlargement . Resident #701's medical record documentation further revealed the Resident returned to the facility, after having surgery in the hospital to repair their left [MEDICAL CONDITION] on 5/23/20. Review of Resident #701's Incident and Accident reports revealed the Resident had seven falls at the facility since November 2019. Review reviewed the following: -6/23/20 at 7:25 PM: Location: Resident Room . Fall . Brief Description: Writer heard Resident yelling out . Resident sitting on floor mat on buttocks facing the door . New Action Taken to Prevent Reoccurrence . Care plan updated . -6/5/20 at 7:07 PM: Location: Resident Room . Fall . Brief Description: Observed Resident sitting on floor on right side of body on window side of bed. Redness noted to bilat knees and small abrasion to right knee . New Action Taken to Prevent Reoccurrence . Care plan updated . Bilat floor mats . -1/27/20 at 8:30 PM: Location: Resident Room . Brief Description: Resident observed sitting with legs out on floor . suspected self-transfer . New Action Taken to Prevent Reoccurrence . Care plan updated . Resident moved near nurses' station. Redirect Resident to area of higher supervision . New intervention not noted on care plan. -12/7/19 at 9:15 PM: Location: Dining Room . Fall . Brief Description: Was sitting up in chair in dining room when last seen. A few minutes later, CNA noticed Resident sitting on backside with back to wall . New Action Taken to Prevent Reoccurrence . Care plan updated . Anti-roll back brakes repaired . I cannot be left alone in dining room . -11/11/19 at 7:00 AM: Location: Shower Room . Fall . Brief Description . Resident noted sitting on butt in doorway with door partially open . When asked Resident stated 'I don't know' to what happened or what was doing in there . New Action Taken to Prevent Reoccurrence . Care plan updated . I use a wheelchair . need supervision so my whereabouts are known . -11/3/19 at 8:50 AM: Location: Dining Room . Fall . Brief Description: Resident observed lying on the dining room floor on right side . New Action Taken to Prevent Reoccurrence . Staff Re-education . Care plan updated . Encourage me to lay down after meals to rest . Review of requested facility staffing documentation for 5/18/20 revealed two staff Agency LPN L and Nursing Assistant M were working in the memory/dementia care unit of the facility when Resident #701 fell and fractured their hip. Review of Resident #701's closed care plans revealed a care plan entitled, I am at risk for falls r/t weakness, lack of safety awareness (Initiated: 5/23/20; care plan close date: 6/2/20). The care plan included the interventions: -I must be supervised when in a dining room chair (Initiated: 12/9/19) - I cannot be left alone in dining room (Initiated: 12/9/19) -I use a wheelchair for locomotion and need supervision so my whereabouts are known (Initiated: 11/11/19) - If resident is sleeping in chair put resident to bed (Initiated: 10/28/19) An interview was conducted with the Administrator on 7/1/20 at 9:30 AM. When queried regarding Resident #701's falls in the facility and care plan interventions to prevent falls including supervision and staffing on the memory care/dementia unit, the Administrator indicated facility staff have IDT (Interdisciplinary Team) meetings after a Resident fall to discuss methods to prevent future falls. An interview was completed with Registered Nurse (RN) N on 7/1/20 at 9:45 AM. When queried regarding Resident #701's x-ray completion on 5/18/20 following their fall, RN N stated, I remember there were issues with getting the X-ray. There were issues with the X-ray company coming in. It was ordered STAT so the Doctor just decided to send (Resident #701) out. An interview was conducted with the Director of Nursing (DON) on 7/1/20 at 12:25 PM. When queried regarding Resident #701's fall with fracture on 5/18/20 and interventions in place, including supervision, the DON indicated the ADON (Assistant Director of Nursing) had updated the Resident's care plan and spoke to staff pertaining to the fall and to speak to them. When asked about staffing on the memory care/dementia unit, the DON stated, There are two people at night. When asked about the Residents on the unit requiring supervision and assistance of two staff members, the DON revealed the nurse and Nursing Assistant on the unit work together. When queried regarding the STAT x-ray ordered for Resident #701 following the fall on 5/18/20 not being completed, the DON revealed STAT orders should be completed within four hours but was unable to provide further explanation concerning why the x-ray was not completed. A policy/procedure pertaining to STAT orders was requested at this time. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/1/20 at 12:30 PM. When queried regarding Resident #701's fall with fracture and care plan interventions, the ADON stated, I talked to Nursing Assistant M and they said (Resident #701) had asked to go to the bathroom but they were helping another Resident. When queried regarding the care plan intervention indicating the Resident was not to left alone and unsupervised in the dining room, the ADON reviewed Resident #701's Incident and Accident Report and medical record and stated, I can't understand why. It probably wasn't worded very well. After further review of the medical record, the ADON stated, It was probably a night thing. When asked, the ADON indicated activity staff are not present in the dining/activity room of the facility later in the evening. When queried if the Resident needed to be supervised while in their Geri-chair in the hallway between the nurses' station and the activity/dining room, the ADON did not provide an explanation. An interview was conducted with Nursing Assistant M on 7/1/20 at 2:10 PM. When queried if they were working when Resident #701 fell on [DATE], Nursing Assistant M revealed they were. When queried regarding what occurred, Nursing Assistant M revealed they were working with Agency LPN L and that staff work together on the unit. When asked what occurred when Resident #701 fell , Nursing Assistant M revealed they had recently taken the Resident to the bathroom and were going to help another Resident when Resident #701 said they had to go again and had to have a BM (bowel movement). Nursing Assistant M indicated they told the Resident they would help them after providing care to another Resident as they had just gone to the bathroom. Nursing Assistant M then revealed they heard the Resident yelling while in a room with LPN L and then they found the Resident on the floor. When asked about the Resident being in the Geri-chair at that time, Nursing Assistant M stated, (Resident #701) kept getting out of bed so they sleep in the chair so we can watch them. When asked if the Resident was supposed to be supervised and/or monitored at all times, Nursing Assistant M replied, They were where we could see them when we came out of a room. It's hard with only two people down there (working on unit). An interview was completed with Agency LPN L on 7/1/20 at 3:20 PM. When queried regarding Resident #701's fall on 5/18/20, LPN L stated, About 4:30 AM, the Aide took (Resident #701) to the bathroom kitty corner from the nurses' station. Then about 5:00 AM, we heard a scream. (Resident #701) was on the floor, primarily on their left side. When asked about the Resident's injuries, LPN L stated, They didn't have any pain at first, swelling initially. (Resident #701) couldn't bear weight on their left leg so I called the doctor and got an order for [REDACTED].#701's) pain and swelling increased. When queried where the Resident was at the time of the fall, LPN L revealed Resident #701 sleeps in a Geri-chair near the nurses' station and not in their room. LPN L indicated the Geri-chair was in the hall between the dining room and the nurses' station. With further inquiry regarding the intervention of assisting the Resident to use the restroom immediately when asked, LPN L stated, (Resident #701) had said they had to have a BM (bowel movement) after they just went to the bathroom and they did because I could smell it (after fall). When queried who was working in the memory care/dementia unit when the fall occurred, LPN L indicated there were working with Nursing Assistant M and stated, It was just the two of us. When asked if Resident #701 was supposed to be supervised while up in central areas of the unit and while in their Geri-chair, LPN L replied, Yes, definitely. I think that is the reason they were put in the Geri-chair so we could watch them. With further inquiry regarding Resident #701's care plan intervention related to supervision while in the dining room, LPN L stated, I didn't know the care plan said that. With further inquiry, LPN L stated, It sounds to me like (Resident #701) should have been supervised at all times when up in the chair. When queried regarding monitoring Residents when they were assisting the Nursing Assistant with care, LPN L stated, Absolutely no one. LPN L then stated, One other person (staff) would have prevented it. It is very unsafe to only have two people working on that unit. Review of facility policy/procedure entitled, Fall Management Guidelines (no date) revealed, Each Resident is assisted with attaining/ maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls . A plan of care is developed and implemented on this evaluation with ongoing review . A policy/procedure pertaining to STAT orders/diagnostics was requested but not recieved by the conclusion of the survey.

This Citation Pertains to Intake MI 310 Based on observation, interview and record review, the facility failed to ensure assessment of mobility and level of assistance for ambulation, per professional standards of practice, for one (#400) of three Residents reviewed for falls resulting in a change in a Resident's transfer and ambulation assistance level by a Physical Therapy Assistant, without Physical Therapist documentation, and a subsequent fall with fracture and considerable, unnecessary pain. Findings include: Record review on 8/28/19 revealed Resident #400 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADLs). Additional review revealed the Resident was transferred from the facility to the hospital on [DATE] after a fall with fracture and returned to the the facility on 8/8/19. Review of Resident #400's care plan revealed a care plan entitled, I am at risk for falls r/t (related to) [MEDICAL CONDITION] (Initiated: 8/5/19). The care plan included the interventions: -Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility (Initiated: 5/3/19) -Ensure my glasses are clean and in good repair (Initiated: 5/3/19) -I use a wheelchair and need assistance with locomotion. Place dycem on top of the w/c (wheelchair) cushion (Initiated: 5/3/19) Review of Resident #400's progress notes in the medical record revealed the following: -8/4/19: Unusual Occurrence Note: Alerted to room by CNA (Nursing Assistant) yelling for help. Upon entry resident was on the bathroom floor laying on left side with a puddle of blood under left elbow, wheelchair was in the bathroom doorway, and 2 ww (wheeled walker) was folded up behind room door. Resident was laid on back and left leg was assessed. Able to move left leg and denied pain. Denied hitting head. Assisted back into the wheelchair and transferred back to bed to get a better assessment. Asked resident what happened and resident stated I went to the bathroom without using my walker. When asked why (Resident) stated I haven't used it all day yesterday either. While assessing resident then complained of pain in the left groin and inner thigh area while lifting leg. Resident then stated that they hit the back of their head when falling. No bumps or stiffness to the neck noted. Neuro checks done and within normal range. Left elbow cleaned, laceration noted approximately 1 cm (centimeter) long and down to the bone. Wrapped and the on call Dr notified . Order to send to hospital . -8/20/19: Team Health Progress Notes . Patient is being evaluated per nursing request due to left leg pain and [MEDICAL CONDITION]. Patient recently had a fall sustained fracture underwent open reduction internal fixation -left femoral. The patient reports that leg has increased pain. Patient also has a hemoglobin of 7.3 (decreased red blood cells) . does have a follow-up appointment with Ortho (Physician) on 8/26. I did take the patient into the restroom to look at leg and (Resident #400) had episodes of confusion not realizing that she had recent surgery . -8/8/19: Admission Note: Resident . is back from hospital following a left ORIF (surgical hip repair) . -8/9/19: TEAM HEALTH H&P . Patient sent to hospital after left hip pain after fall, found to have acute impacted subcapital fracture of left femoral neck. Patient underwent ORIF (hip surgery) . on 8-5-19. Now here for PT/OT and possibly long term care . -8/14/19: MDS Note: (Resident #400) state has frequent pain in left leg and at times has difficulty falling asleep due to the pain . On 8/28/19 at 1:15 PM, Resident #400 was observed in their room. The Resident was sitting in their wheelchair and visible tears were noted running down the Resident's cheeks. When asked why they were crying, Resident #400 stated, My leg hurts so bad (Resident #400 was observed rubbing their left thigh). I hate to complain but the pain is so bad. Record review of facility provided Incident and Accident Report and investigation for Resident #400 on 8/28/19 revealed the following: -8/4/19: Time of Incident: 1315 (1:15 PM) . Resident states they were getting off the toilet to pull up pants and fell on their left side . Type of Injury: L (left) elbow . bleeding . laceration . New Action Taken to Prevent Reoccurrence . Resident Education . Treatment . Sent to Hospital . First Aid Left elbow . Current Care Plan Interventions In Place: (MONTH) ambulate to bathroom by self with 2 ww (wheeled walker) during day . An interview was completed with the Director of Nursing (DON) on 8/28/19 at 1:30 PM. When queried regarding the names of the CNA's working when Resident #400 fell , the DON indicated, (Nursing Assistant B) and (Nursing Assistant C). An interview was conducted with Nurse A on 8/28/19 at 1:40 PM. When queried regarding Resident #400's fall in the facility on 8/4/19 and who was working, Nurse A stated, I know (Nursing Assistant B) was working that day because they yelled down the hall. (Resident #400) was laying on the ground in blood when I got in there. We got (the Resident) back in their chair. When asked where the Resident's walker was in the room at that time, Nurse A stated, (Resident #400's) walker was behind the (room) door, against the wall. (The Resident) said they hadn't been using it for a couple days. When asked how the Resident would have been able to access their walker if it was folded behind the door, Nurse A replied, (Resident #400) only used the walker to use the bathroom. When asked about the Resident's injury and assessment following the fall, Nurse A stated, (Resident #400) said they couldn't even lift their leg up and it was hurting. On 8/28/19 at 1:49 PM, Nursing Assistant C was contacted via telephone. A message was left with return phone number. An interview was completed with Nursing Assistant B on 8/28/19 at 1:50 PM. When queried regarding Resident #400 and their fall in the facility on 8/4/19, Nursing Assistant B stated, (Resident #400) told me they were going to the bathroom. (The Resident) was independent (level of assistance) at the time so they could do that. I was walking down the hall to go to the bathroom myself and I thought I heard someone yelling. I went in (Resident #400's) room and (Resident #400) was on the floor. When asked where the Resident's walker was located in the room at the time of the fall, Nursing Assistant B stated, (Resident #400's) walker is normally behind the door. (The Resident) only used to the walker to get out of the bed or go to the bathroom. With further inquiry, Nursing Assistant B indicated the Resident used a wheelchair for all other activities. Nursing Assistant B then stated, )Resident #400) was actually very hesitant to get up by themselves. (The Resident) couldn't actually get out of bed by themselves because they couldn't stand up by themselves. With further inquiry regarding why the Resident's activity level was independent if they were unable to get out of bed by themselves and couldn't stand alone, Nursing Assistant B replied, Therapy changed (Resident #400), you would have to ask them. Record review of Resident #400's ambulation/assistance orders on 8/28/19 revealed the following: -7/18/19: Pt. may ambulate to bathroom with a 2 wheeled walker independently. The order was entered by by Occupational Therapy Assistant Therapy Manager E -7/30/19: Pt. may ambulate to bathroom with a 2 wheeled walker independently during day shift. Assist of 1 with 2 ww (wheeled walker) at night. Order entered by the Assistant Director of Nursing (ADON). On 8/28/19 at 2:05 PM, an interview was conducted with Speech Therapist D. When asked who the Therapy staff that had worked with Resident #400 before their fall on 8/8/19, Therapy Manager [NAME] approached the desk and stated, You can talk to me. When asked, Manager [NAME] replied, (Physical Therapy Assistant F) and Physical Therapist G would have seen (the Resident). Phone numbers for Physical Therapy Assistant F and Physical Therapist G were requested from Manager [NAME] at this time. When asked if they were familiar with the Resident, Manager [NAME] indicated they were. When queried why Resident #400's ambulation assistance was changed on 7/18/19 and on 7/30/19 when Physical Therapy's last treatment/certification period ended on 6/7/19, Manager [NAME] indicated the Resident was screened by therapy services. Upon request, Manager [NAME] provided a Therapy Screen assessment dated [DATE]. The Therapy Screen Assessment was signed and completed by Physical Therapy Assistant F. Review of the Therapy Screen Assessment revealed, Screen completed secondary to patients request to ambulate in room to/from bathroom. Pt. observed for 3 days ambulating to/from bathroom with good safety sequencing and technique. Pt. at baseline for other functional mobility. When queried by the screen did not include use of a walker and type of walker, Therapy Manager [NAME] stated, It doesn't matter. It is in the order. When asked if Physical Therapy Assistant F completed the assessment to change Resident #400's ambulation status to independent from having assistance, Therapy Manager [NAME] stated, Yes. When asked if Physical Therapy Assistants and/or Occupational Therapy Assistants are allowed to change a Resident's plan of care and treatment, Therapy Manager F replied, Well, they can enter orders (in the computer system). When asked if the role and scope of practice of Physical Therapy Assistant and/or Occupational Therapy Assistant is to to carry out treatments and interventions implemented by the Physical Therapist, Therapy Manager [NAME] replied, Well, yes. When asked if it is within a Physical Therapy Assistant or Occupational Therapy Assistants Scope of practice to complete an assessment and change a Resident's plan of care or treatment plan, Therapy Manager [NAME] revealed it was not. With further inquiry regarding Resident #400's assessment to change their status being completed by a Physical Therapy Assistant and if the Physical Therapist reviews and co-signs the assessments before prior to a change being made in a a Resident's plan of care, Physical Therapy Manager [NAME] replied, It isn't documented. Yes, there should be something (documented). When asked why the Physical Therapy Assistant changed Resident #400's plan of care and treatment and why the order on 7/18/19 was entered by an Occupational Therapy Assistant if that is not within the scope of their practice to assess and make significant changes, Therapy Manager [NAME] did not provide an explanation. On 8/28/19 at 2:16 PM, a phone interview was attempted to be completed with Physical Therapy Assistant F. A message was left with return number. On 8/28/19 at 2:18 PM, a phone interview was attempted to be completed with Physical Therapist G. A message was left with return number. An interview was completed with the ADON on 8/28/19 on 2:25 PM. When queried regarding Resident #400's ambulation order change on 7/30/19, the ADON indicated the Resident had expressed concerns related to not having assistance when ambulated so they had changed to order so they would have assistance at night. On 8/28/19 at 3:00 PM, an interview was conducted with the facility Administrator and Director of Nursing (DON). When queried regarding the role scope of a Physical Therapy Assistant, the Administrator stated, I would assume they carry out treatments, do what the Physical Therapist ordered. When queried regarding Physical Therapy Assistant F changing Resident #400's ambulation order to independent without documentation of a Physical Therapist assessment or agreement and the Resident falling and fracturing their hip, the Administrator stated, I don't know their policies. Did the Doctor sign it? At this time the DON stated, The Doctor would not assess that, they are a general practitioner. This is ridiculous. No further explanation was provided. Upon request for facility policy/procedure pertaining to Therapy Services, the following was received and reviewed on 8/28/19: -Licensed Physical Therapy Assistant Job Description (no date), Provides Therapy services to resident under the direct supervision of the Physical Therapist . Provides treatment in accordance with established standards of practice . Review of facility policy/procedure entitled, Fall Management Guidelines (p. 76, no date) revealed, Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review . Return phone calls were not received from Nursing Assistant C, Physical Therapy Assistant F and Physical Therapy G by the conclusion of the survey.

This Citation Pertains to Intake # Based on observation, interview and record review, the facility failed to operationalize their Fall Managment Policy to ensure reassessment was completed after a fall and interventions were enacted to prevent future falls with serious injury for 2 (#'s 701 and 702) of 3 residents sampled for falls from a total sample of 3, resulting in both residents experiencing repeated falls; Resident #701 sustained a clavicle (shoulder bone) fracture and Resident #702 a [MEDICAL CONDITION] after falling. Findings Include: Resident #701 A record review on 12/26/17 at 10:35 am, revealed Resident #701 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 4/15 with severe cognitive impairment and needed extensive 2 person assistance with transfers and extensive 1 person assistance with toileting. The resident did not walk per the MDS. An Activities of Daily Living (ADL) Care Plan dated 3/16/17 indicated- Transfers, I need assist x1 with gait belt PRN (as needed) assist x2 with gait belt when difficult to transfer. Resolved 11/15/17, with no new indication of how the resident transferred until 12/10/17, Transfer Status .assist of two with gait belt for all transfers, Toileting .2 assist to transfer with gait belt. Dated 12/10/17. On 12/26/17 at 10:39 am, a record review revealed the following: An Incident Note dated 10/4/17 at 10:00 am- CNA (Certified Nursing Assistant) found Resident lying on (their) back on the floor between the beds . An Incident and Accident Report, dated 12/4/17 at 8:45 am- CNA found resident lying on bedroom floor on is back, small 1 cm laceration on left side top of head. Complains of left shoulder pain. The resident described the incident as follows- .was getting out of bed to go to the bathroom and slipped and fell . The last time the resident Toileted or brief changed - 6:30 am. On 12/26/17 at 11:37 am, an interview with Nurse F provided, The CNA came and got me. (Resident #701) was lying on the floor. Me and another nurse assessed him and he was complaining about his shoulder. I called the doctor and he ordered a STAT (as soon as possible) x-ray. It took way too long to get here, around dinner time. It needs to be addressed. The results came within an hour and it showed a clavicle fracture. (The resident) was sent to the hospital and is supposed to wear a sling. When Nurse F was queried on what Fall Prevention measures were in place for the resident prior to the fall with a clavicle fracture, she replied, There were no fall alarms at that time. We try to keep an eye on him. An interview with the Director of Nursing (DON), on 12/26/17 at 11:50 am, revealed, I can't find the Incident Reports or investigations from (Resident #701's) last 2 falls. I'm trying to put an investigation together. The Assistant Director of Nursing was also in the office looking through a large stack of Incident and Accident reports. The DON was queried how she knew the resident fell if there was no Incident report and stated, I saw it in the progress notes in the chart. The DON indicated Resident #701 had fallen and broken their clavicle on 12/4/17 and had 2 prior falls on 11/4/17 and 11/15/17. At 12:00 pm, Resident #701 was observed in the dining room sleeping in a wheelchair, with a chair alarm attached. A bedside table held the lunch meal. No one was assisting. On 12/26/17 at 1:00 pm the following record review occurred: A Fall Care Plan, dated 3/16/17 with Interventions Revised 11/4/17 Falling Star Program, and several times after 12/4/17, including bed and chair alarms on 12/5/17. There were no updated Interventions after Resident #701 fell on [DATE]. Fall Assessments dated 9/8/17 with a score of 41 (Moderate Risk for falls) and 12/4/17-score 75 (High Risk for falls) were reviewed. There were no Fall Re-Assessments completed after the resident fell on [DATE] or 11/15/17. Resident #702 On 12/26/17 at 12:01 pm, Resident #702 was observed in the dining room in a high back wheelchair sleeping. A chair alarm was attached. The lunch meal was sitting in front of the resident. There were 4 Residents sitting at the table and 1 CNA to assist with eating. No one was assisting Resident #702. A record review on 12/26/17 at 12:25 pm revealed the following: Resident #702 was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had severe cognitive impairment (BIMS 3/15) and needed total 1-2 person assistance with all care. A review of the Incident and Accident reports revealed Resident #702 fell on [DATE], while in the shower, 12/3/17 at 3:45am, in room between the beds and 12/3/17 at 12:30 pm, in the dining room. 11/23/17 8:35 pm, Fall: Alerted by CNA that resident was sitting on floor in shower room. CNA stated that she had just completed resident's shower and resident was standing up on dry part of floor . and was holding onto door knob. CNA turned to grab bottle of cleaner and when she turned back around resident was sitting on the floor .No gait belt was used .Resident complained of elbow hurting, x-ray ordered . 12/3/17 at 3:45 am, Fall: Found on floor between the beds sitting upright. Found by CNA K .Resident states, I fell . Alarm was going off, but while in room stopped working, (Action Taken) Check 9 volt battery on alarm every month. 12/3/17 at 12:30 pm, Fall: EVS (Environmental services) worker called for help in Dining Room, writer (Nurse M) responded to observe Resident laying on floor on Right side, Resident assessed. Helped back into wheelchair, vitals obtained Resident taken to bed for further assessment, No Evidence of external Injury Resident having pain in right leg and hip, x-ray ordered .Alarm, did not go off .no CNA or Nurse in area at time . A Written statement dated 12/3/17, from EVS worker L- I was working in the hallway cleaning. Then I looked up and saw (Resident #702) walking .and looked like she lost her balance and fell down on her right side. I could not get to her fast enough to stop or help her. She did not have her walker with her. Care Plans: Fall Care Plan, initiated 7/14/16, Interventions, I am to wear a gait belt while up due to self- transfers, unsteady gait, initiated 7/31/17, To have tab alarm on any chair I am sitting in, dated 8/7/17 . ambulate with a weighted rolling walker and gait belt, contact guard, assist of one . dated, 5/10/17, Falling Star Program 5/9/17. There was no mention of checking the alarm battery to ensure it was functional. The Care Plan was not updated after the fall on 11/23/17 or after the fall on 12/3/17 at 3:45 am. Resident #702 fell again on 12/3/17 at 12:30 pm, while ambulating unsupervised in the dining room and fractured her right hip. Fall Assessments: 9/29/17, score 80 (High Risk for falls), 12/9/17, score 65 (High Risk for falls). There was no Fall Risk Re-assessment after Resident #702 fell on [DATE] or 12/3/17 at 3:45 am, until after the resident fell and fracture their right hip on 12/3/17 at 12:30 pm. An interview with MDS Nurses B and C, on 12/26/17 at 1:10 pm provided, We update the Care Plans that day or the next day, as soon as we know about it (a fall). When queried why the Care Plans were not updated with interventions to aid in preventing additional falls for Resident's # 701 and 702, they replied, I'm not sure if we did anything after that. Nurse E replied, I don't remember anything being added at that time (after Resident #701 fell on [DATE] and Resident #702 fell on [DATE]). An Interview with the ADON on 12/26/17 at 2:30 pm, revealed The Falling Star program is an old program. There are supposed to be Star stickers on the doors to alert staff to the resident's fall risk. The DON and ADON were queried on why the Care Plans were not updated or Fall Risk reassessed for Residents #701 and #702, after the resident's prior falls and the ADON stated, I know we need interventions. The DON stated, I don't know. I haven't had a chance to review all of the policies. On 12/26/17 at 2:35 pm, an observation outside both Resident #701 and #702's bedroom doors, indicated there were no Star stickers on the resident's doors or next to their name tags outside their doors. On 12/26/17 at 2:40 pm, CNA's D and E were queried how they would know that Residents #701 and #702 were at risk for falls and stated, Looking at their names you would not know they were a fall risk. There is no star. At 2:45 pm on 12/26/17, a review of the facility policy titled Fall Management Guidelines, dated January 2011, revealed Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices .as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation .The licensed nurse will document the incident on .Post Fall Interdisciplinary (IDT) Assessment (if the incident is a fall) .update the care plan .The IDT will review all resident falls at the next morning meeting to evaluate/investigate .the IDT will review/modify the plan of care to minimize the risk of repeat falls .The IDT will complete the Interdisciplinary Post -Fall Assessment .

Based on interview and record review, the facility failed to provide restorative nursing services to 1 sampled resident (#704) of 15 sampled residents of a total sample of 15 residents, resulting in Resident #704 experiencing a decline in the ability to ambulate or reach their highest practible level of physical and psychosocial well being. Findings include: A record review indicated Resident #704 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) dated 8/2/2016 indicated that she needed total assistance with transfers and extensive assistance with ambulation. On 9/8/2016 at 0950, Resident #704's family member was interviewed. The family member indicated that their mother (Resident #704) was becoming weaker and had more difficulty with transfers and walking. The family member stated, I wish she would have more exercise and get around better. When the family member was queried about Resident #704 receiving restorative nursing services for transfers and walking, he stated, What is that? On 9/8/2016, the MDS dated [DATE] was reviewed and it indicated that Resident #704 received Restorative nursing services 1 day out of the past 7 days. On 9/8/2016 1140 the physician orders [REDACTED]. On 9/8/2016, the Care Plans dated 7/20/2016, for Resident #704, were reveiwed and indicated, I need assistance with ADL's related to Dementia. I am on a Restorative Nursing Program, Interventions: Nursing Rehab/Restorative:Ambulation. On 9/8/2016 at 1145 MDS nurse E was interviewed and queried to the location of September 2016 restorative nursing notes for Resident #704. MDS E was unable to locate any and stated, There aren't any for September. The DON (Director of Nursing) was queried as to the location of the restorative nursing notes for Resident #704. The DON provided Restorative notes for June 2016 with 4 entries dated 6/24/16, 6/17/16, 6/10/16 and 6/3/16. All entries indicated Resident #704 ambulated 40-50 feet with a rolling walker and was advancing the walker on her own, July 2016 restorative notes with 6 entries dated 7/5/16, 7/8/16, 7/12/16, 7/15/16, 7/18/16 and 7/22/16, ambulatory ability was 5-50 feet, August 2016 restorative notes indicated 2 entries dated 8/15/16 and 8/18/16, both indicated ambulation of 50 feet. There was no further documentation for restorative nursing services after 8/18/2016. A note by the restorative RN dated 8/2/2016 read, .resident ambulates 20 feet with rolling walker when she is not emotional or crying. This is a decrease in mobility. Will discuss with therapy. Continue restorative program. On 9/8/2016 at 1030, the DON stated, I haven't had a restorative nurse aide for several weeks. I have placed an ad to hire someone new. The previous retorative aide left in August. ( ) ( )

THIS CITATION PERTAINS TO INTAKE #MI 404. BASED ON INTERVIEW AND RECORDS REVIEW, THE FACILITY FAILED TO DISPENSE AND ADMINISTER [MEDICATION NAME] (AN ANTICOAGULANT MEDICATION, ALSO CALLED A BLOOD THINNER) IN ADEQUATE DOSES ACCORDING TO A CURRENT physician's orders [REDACTED].#105, #106 AND #108) OF 6 SAMPLED RESIDENTS RECEIVING [MEDICATION NAME] FROM A TOTAL SAMPLE OF 9 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101, WHEN FOR TWO DAYS, NURSING STAFF FAILED TO ADMINISTER THE INCREASED DOSAGE OF [MEDICATION NAME] AS ORDERED BY HER PHYSICIAN, AND SHE SUBSEQUENTLY DEVELOPED DECREASED BLOOD CLOTTING TIME; THE FORMATION OF INTRAVASCULAR BLOOD CLOTS; AND, COMPLETE VASCULAR OCCLUSION WITH TISSUE DEATH IN BOTH OF HER LOWER EXTREMITIES. RESIDENT #101 SUBSEQUENTLY died . THE FACILITY ALSO FAILED TO DOCUMENT THE ADMINISTRATION OF ORDERED [MEDICATION NAME] FOR RESIDENT #105, PROVIDED INACCURATE [MEDICATION NAME] DRUG DOSING INFORMATION FOR RESIDENT #106 TO THE ORDERING PHYSICIAN AND DOCUMENTED THAT [MEDICATION NAME] WAS ADMINISTERED TWICE IN ONE DAY WITHOUT A physician's order [REDACTED]. THESE DEFICIENT PRACTICES PLACED 6 RESIDENTS RESIDING AT THE FACILITY AND WHO ARE RECEIVING [MEDICATION NAME] THERAPY AT HIGH RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #101: REVIEW OF THE FACE SHEET, DATED [DATE], REVEALED THAT RESIDENT #101 WAS A [AGE] year-OLD FEMALE, WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE Minimum Data Set, dated dated [DATE], REVEALED RESIDENT #101 HAD MODERATELY IMPAIRED DECISION MAKING WITH MEMORY LOSS, REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING, AND RECEIVED [MEDICATION NAME] DAILY. REVIEW OF THE HOSPITAL DISCHARGE SUMMARY FOUND IN RESIDENT #101'S CLINICAL RECORD, DATED [DATE], REVEALED RESIDENT #101 WAS REQUIRED TO TAKE HER [MEDICATION NAME] "EXACTLY AS DIRECTED." REVIEW OF admission orders [REDACTED]. THE PHYSICIAN ORDERED 2.5 MGS (MILLIGRAMS) OF [MEDICATION NAME] DAILY, WITH WEEKLY INTERNATIONAL NORMALIZED RATIO (INR) TESTS USED TO MONITOR HER CLOTTING TIMES AND GUIDE [MEDICATION NAME] DOSE ADJUSTMENTS MADE BY HER PHYSICIAN. REVIEW OF INR TEST RESULTS, DATED [DATE], REVEALED RESIDENT #101 HAD A SUB-THERAPEUTIC INR OF 1.8 SECONDS. ACCORDING TO "CLINICAL MEDICAL-SURGICAL NURSING, A DECISION-MAKING REFERENCE," PUBLISHED IN 2002, BY GEORGE-GAY AND CHERNECKY, PAGE 326, FOR AN INDIVIDUAL RECEIVING [MEDICATION NAME], THE TARGET INR SHOULD BE BETWEEN 2.0 AND 3.0 SECONDS. REVIEW OF ORDERS, DATED [DATE], REVEALED THE PHYSICIAN RESPONDED TO THE SUB-THERAPEUTIC INR LEVEL BY ORDERING STAFF TO ADMINISTER AN ADDITIONAL 0.5 MGS OF [MEDICATION NAME] EVERY OTHER DAY. REVIEW OF THE PHYSICIAN'S PROGRESS NOTES, DATED [DATE], REVEALED RESIDENT #101 HAD NO SWELLING OR PAIN IN HER EXTREMITIES WHEN EXAMINED. REVIEW OF THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. STAFF DOCUMENTED RESIDENT #101 CONTINUED TO RECEIVE ONLY 2.5 MGS OF [MEDICATION NAME] ON BOTH [DATE] AND [DATE]. REVIEW OF NURSING NOTES, DATED [DATE] AT 10:55 P.M., REVEALED THAT RESIDENT #101 HAD "COOL" AND "PALE" LOWER LEGS AFTER SITTING UPRIGHT FOR FIVE HOURS. STAFF DOCUMENTED RESIDENT #101 WAS PLACED IN BED AND THROUGHOUT THE NIGHT COMPLAINED OF PROGRESSIVE RIGHT LEG, FOOT, AND GREAT TOE PAIN, BEFORE THE PHYSICIAN WAS NOTIFIED AT 8:00 A.M. REVIEW OF ORDERS, DATED [DATE], REVEALED THE PHYSICIAN REQUESTED RESIDENT #101 BE SENT TO A LOCAL AREA HOSPITAL. REVIEW OF HOSPITAL RECORDS FOR RESIDENT #101, DATED [DATE] AT 11:29 A.M., REVEALED THAT WHEN RESIDENT #101 ARRIVED AT THE EMERGENCY DEPARTMENT, HER RIGHT FOOT WAS WHITE AND PAINFUL. REVIEW OF LAB TESTS OBTAINED AT THE HOSPITAL, DATED [DATE] AT 12:05 P.M., REVEALED RESIDENT #101 HAD A CONTINUED, PRONOUNCED SUB-THERAPEUTIC INR LEVEL OF 1.23 SECONDS. REVIEW OF AN ULTRASOUND OBTAINED AT THE HOSPITAL, DATED [DATE] AT 1:22 P.M., REVEALED "CRITICAL ISCHEMIA (LACK OF OXYGEN TO) BOTH LOWER EXTREMITIES WORSE IN THE LEFT LOWER EXTREMITY THAN THE RIGHT." REVIEW OF THE PHYSICIAN'S HOSPITAL ADMISSION HISTORY AND PHYSICAL REVEALED THAT RESIDENT #101 WAS admitted TO HOSPICE WITH AN ISCHEMIA RIGHT LEG AND SUBSEQUENTLY died on [DATE] AT 8:54 P.M. REVIEW OF THE DEATH CERTIFICATE PROVIDED BY FAMILY ON [DATE], DATED [DATE], REVEALED RESIDENT #101 died OF "VASCULAR INSUFFICIENCY, CARDIOPULMONARY ARREST, (AND) [MEDICAL CONDITION] FIBRILLATION." DURING AN INTERVIEW [DATE] AT 3:15 P.M., DIRECTOR OF NURSING (DON) #1 SAID THAT A SUB-THERAPEUTIC INR RESULT CAME BACK FOR RESIDENT #101 ON [DATE]. DON #1 SAID THE PHYSICIAN RESPONDED TO THE BLOOD TEST BY INCREASING THE DAILY DOSE OF [MEDICATION NAME] BY 0.5 MGS EVERY OTHER DAY. HOWEVER, SHE SAID THAT FACILITY STAFF NEVER TRANSCRIBED THE NEW [MEDICATION NAME] ORDER, AND ON [DATE] AND [DATE], NEVER DISPENSED OR ADMINISTERED THE INCREASED DOSE OF [MEDICATION NAME] TO RESIDENT #101. DON #1 SAID ON [DATE] RESIDENT #101 WAS TAKEN TO A LOCAL AREA HOSPITAL WITH SIGNS OF BLOOD CLOT FORMATION IN HER LOWER RIGHT LEG. RESIDENT #105: REVIEW OF THE FACE SHEET, DATED [DATE], REVEALED RESIDENT #105 WAS A [AGE] year-OLD FEMALE, WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE Minimum Data Set, dated dated [DATE], REVEALED RESIDENT #105 HAD IMPAIRED COGNITION, DID NOT WALK, REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING, AND RECEIVED [MEDICATION NAME] DAILY. REVIEW OF PHYSICIAN ORDERS, DATED [DATE], REVEALED RESIDENT #105 REQUIRED DAILY [MEDICATION NAME] DOSING, WITH 0.5 MGS GIVEN ON MONDAYS, WEDNESDAY, FRIDAYS, SUNDAYS, AND 1 MG GIVEN TUESDAY, THURSDAY, AND SATURDAYS. REVIEW OF INR RESULTS, DATED [DATE], REVEALED RESIDENT #105 HAD A SUPRA-THERAPEUTIC (ELEVATED) INR OF 3.5 SECONDS. REVIEW OF physician's orders [REDACTED]. REVIEW OF THE INR RESULTS, DATED [DATE], REVEALED RESIDENT #105 CONTINUED TO HAVE A SUPRA-THERAPEUTIC INR OF 3.1 SECONDS. REVIEW OF ORDERS, DATED [DATE], REVEALED THE [MEDICATION NAME] DOSE WAS AGAIN TO BE HELD FOR TWO DAYS BEFORE A REPEAT INR TEST WAS CONDUCTED (ON [DATE]). REVIEW OF THE INR RESULTS, DATED [DATE], REVEALED RESIDENT #105 HAD A SUPRA-THERAPEUTIC INR OF 3.3 SECONDS. REVIEW OF ORDERS, DATED [DATE], REVEALED THE [MEDICATION NAME] DOSE WAS AGAIN TO BE HELD FOR TWO DAYS BEFORE A REPEAT INR TEST WAS CONDUCTED (ON [DATE]). REVIEW OF THE INR RESULTS, DATED [DATE], REVEALED RESIDENT #105 HAD AN INR OF 2.8 SECONDS. REVIEW OF ORDERS, DATED [DATE], REVEALED THE [MEDICATION NAME] WAS TO BE RESTARTED WITH THE ADMINISTRATION OF 0.5 MGS ON MONDAYS, WEDNESDAYS, FRIDAYS, AND SUNDAYS AND WITH 1 MG GIVEN TUESDAY, THURSDAY, AND SATURDAYS. REVIEW OF THE Medication Administration Record, [REDACTED]. DURING AN INTERVIEW [DATE] AT 12:45 P.M., DON #1 HAD THE OPPORTUNITY TO REVIEW THE MEDICAL RECORD AND WAS UNABLE TO EXPLAIN WHY NURSING FAILED TO DOCUMENT THE ADMINISTRATION OF RESIDENT #105'S ORDERED [MEDICATION NAME] FOR [DATE]. DON #1 SAID SHE DID NOT KNOW IF THE MEDICATION HAD BEEN GIVEN. RESIDENT #106: REVIEW OF THE FACE SHEET, DATED [DATE], REVEALED RESIDENT #106 WAS AN [AGE] year-OLD MALE, WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA, SET DATED [DATE], REVEALED RESIDENT #106 HAD IMPAIRED COGNITION WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. RESIDENT #106 REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL ACTIVITIES OF DAILY LIVING, AND RECEIVED DAILY [MEDICATION NAME]. REVIEW OF THE ORDER SET, DATED [DATE], REVEALED RESIDENT #106 REQUIRED ALTERNATING DAILY DOSES OF [MEDICATION NAME], WITH 3 MGS GIVEN ONE DAY AND THEN 3.5 MGS GIVEN THE NEXT. REVIEW OF INR TEST RESULTS, DATED [DATE], REVEALED RESIDENT #106 HAD A SUB-THERAPEUTIC INR OF 1.8 SECONDS. REVIEW OF ORDERS, DATED [DATE], REVEALED THE PHYSICIAN RESPONDED TO THE SUB-THERAPEUTIC INR AND INCREASED THE [MEDICATION NAME] DOSE TO 3.5 MGS DAILY. REVIEW OF THE MAR indicated [REDACTED] REVIEW OF INR TEST RESULTS, DATED [DATE], REVEALED RESIDENT #106 HAD AN INR OF 2.0 SECONDS. FURTHER REVIEW REVEALED THAT, ON THE BOTTOM OF THE PAGE, WAS THE HANDWRITTEN INR RESULT FROM [DATE] OF 1.8 SECONDS, AND THE COMMENT "ON [MEDICATION NAME] 3 MG ALT (ALTERNATING) WITH 3.5 (MGS)." THE FORM WAS SIGNED BY THE PRACTITIONER, WHO REVIEWED THE INFORMATION AND, IN RETURN, DOCUMENTED "0 (NO) CHANGE." REVIEW OF THE RESIDENT #106'S ANTICOAGULATION LOG SHEET, DATED [DATE], REVEALED HE HAD AN INR RESULT OF 2.0 SECONDS. AGAIN, STAFF INACCURATELY DOCUMENTED THAT HE TOOK ALTERNATING DOSES OF [MEDICATION NAME], 3 MGS ONE DAY AND 3.5 MGS THE NEXT. NURSING STAFF DOCUMENTED ON THE LOG SHEET THAT RESIDENT #106'S PHYSICIAN TOLD THEM THAT NO DOSE CHANGE FOR THE [MEDICATION NAME] WAS REQUIRED. REVIEW OF THE Medication Administration Record, [REDACTED]. REVIEW OF THE MEDICAL RECORD FAILED TO PROVIDE ANY EVIDENCE TO SUGGEST THE DESIRED DOSE OF [MEDICATION NAME] WAS EVER CLARIFIED WITH THE PHYSICIAN. DURING AN INTERVIEW [DATE] AT 12:50 P.M., DON #1 SAID THE PURPOSE OF THE HANDWRITTEN INFORMATION, THAT NURSING STAFF HAD PLACED AT THE BOTTOM OF EACH INR REPORT, WAS TO PROVIDE THE PHYSICIAN WITH A FAST AND ACCURATE REFERENCE FOR RECENT INR RESULTS AND CURRENT [MEDICATION NAME] DOSING. DON #1 SAID THE PHYSICIAN USED THIS INFORMATION TO MAKE [MEDICATION NAME] ADJUSTMENTS. DON #1 THEN REVIEWED THE MEDICAL RECORD AND SAID THE PHYSICIAN WAS NOT ABLE TO MAKE AN INFORMED DECISION FOR [MEDICATION NAME] DOSING BECAUSE HE WAS NOT PROVIDED WITH ACCURATE DOSING INFORMATION. WITH FURTHER REVIEW OF THE RECORD, DON #1 SAID WITHOUT PHYSICIAN CLARIFICATION, IT WAS NOT POSSIBLE TO KNOW WHAT DOSE OF [MEDICATION NAME] THE PHYSICIAN ACTUALLY WANTED RESIDENT #106 TO RECEIVE. DON #1 DID NOT PROVIDE ANY DOCUMENTED EVIDENCE TO SUGGEST THE ORDER WAS EVER CLARIFIED. RESIDENT #108: REVIEW OF THE FACE SHEET, DATED [DATE], REVEALED RESIDENT #108 WAS AN [AGE] year-OLD FEMALE, WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE Minimum Data Set, dated dated [DATE], REVEALED RESIDENT #108 WAS ABLE TO MAKE HER OWN DECISIONS, REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING, AND RECEIVED DAILY [MEDICATION NAME]. REVIEW OF PHYSICIAN ORDERS, DATED [DATE], REVEALED RESIDENT #108 WAS TO RECEIVE 3 MGS OF [MEDICATION NAME] DAILY. REVIEW OF INR RESULTS, DATED [DATE], REVEALED RESIDENT #108 HAD A SUB-THERAPEUTIC INR RESULT OF 1.1 SECONDS. REVIEW OF ORDERS, DATED [DATE], REVEALED THE PHYSICIAN RESPONDED TO THE SUB-THERAPEUTIC [MEDICATION NAME] LEVEL BY INCREASING THE DOSE OF [MEDICATION NAME] EVERY OTHER DAY. RESIDENT #108 WAS TO RECEIVE 3 MGS ONE DAY, ALTERNATING WITH 3.5 MGS THE NEXT DAY. REVIEW OF THE MAR, DATED [DATE], REVEALED NURSING STAFF DOCUMENTED [MEDICATION NAME] WAS ADMINISTERED TWICE ON THAT DAY ([DATE]). STAFF DOCUMENTED THAT THE PRIOR ORDER FOR 3 MGS OF [MEDICATION NAME] HAD BEEN ADMINISTERED AND THE NEW ORDER FOR 3.5 MGS EVERY OTHER DAY HAD ALSO BEEN ADMINISTERED. DURING AN INTERVIEW [DATE] AT 11:00 A.M., DON #1 SAID THAT EVEN THOUGH SHE FELT BOTH DOSES OF [MEDICATION NAME] DOCUMENTED [DATE] HAD NOT BEEN GIVEN TO RESIDENT #108, AND THAT IT HAD BEEN A DOCUMENTATION ERROR, SHE HAD NO PROOF TO SUPPORT HER CONCLUSION. DURING AN INTERVIEW [DATE] AT 3:20 P.M., ADMINISTRATOR (ADM) #1 SAID THE FACILITY SELF-REPORTED THEIR FAILURE TO TRANSCRIBE, DISPENSE, AND ADMINISTER, RESIDENT #101'S INCREASED DOSE OF [MEDICATION NAME] AS ORDERED [DATE], RESULTING IN hospitalization . DURING A TELEPHONE CONFERENCE [DATE] AT 1:52 P.M., THE ADMINISTRATOR AND DON WERE BOTH INFORMED OF THE IMMEDIATE JEOPARDY THAT BEGAN [DATE], WHEN FOR TWO DAYS THE FACILITY FAILED TO DISPENSE AND ADMINISTER THE ORDERED DOSE OF [MEDICATION NAME] REQUIRED BY RESIDENT #101, RESULTING IN THE SUB-THERAPEUTIC LEVEL OF MEDICATION: THE SUBSEQUENT DECREASED BLOOD CLOTTING TIME; THE FORMATION OF INTRAVASCULAR BLOOD CLOTS; AND, COMPLETE VASCULAR OCCLUSION WITH TISSUE DEATH IN BOTH OF HER LOWER EXTREMITIES. THIS DEFICIENT PRACTICE PLACED SIX (6) OTHER RESIDENTS RECEIVING [MEDICATION NAME] THERAPY AT HIGH RISK FOR SERIOUS HARM, INJURY, OR DEATH. ON [DATE], THE SURVEYOR DETERMINED THROUGH INTERVIEW AND RECORDS REVIEW, THAT THE FOLLOWING MEASURES HAD BEEN IMPLEMENTED BY [DATE], TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #101 WAS discharged [DATE] AND NO LONGER LIVED AT THE FACILITY. 2. THERE WERE 6 RESIDENTS AT THE FACILITY, WHO WERE IDENTIFIED TO HAVE SIMILAR RISK BECAUSE THEY RECEIVED [MEDICATION NAME] THERAPY (RESIDENTS #104, #105, #106, #107, #108 AND #109). 3. 6 OF 6 RESIDENT RECORD REVIEWS VERIFIED WEEKLY INR TEST FOR [DATE] WERE ACCURATELY ORDERED, RESULTED, RECORDED ON INDIVIDUAL ANTICOAGULANT LOG SHEETS, AND CALLED TO THE PHYSICIAN THE SAME DAY. 4. 6 OF 6 RESIDENT RECORDS REVEALED AS OF [DATE] PHYSICIAN ORDERS [REDACTED]. 5. MEDICAL RECORD REVIEW FOR RESIDENT #104, #107 AND #109 REVEALED NO DEFICIENT PRACTICE. 6. MEDICAL RECORDS REVIEWED FOR RESIDENT #105 REVEALED STAFF FAILED TO DOCUMENT HER [MEDICATION NAME] ADMINISTRATION ON [DATE] AND IN RESPONSE THE FACILITY A) PROVIDED 1:1 NURSING EDUCATION AND DISCIPLINE TO THE NURSE INVOLVED; AND VERIFIED B) A COMPLETED INR TEST DATED [DATE]; C) THAT PHYSICIAN NOTIFICATION OCCURRED THE DAY THE INR RESULTS WERE AVAILABLE; D) THAT PHYSICIAN ORDERS [REDACTED]. 7. MEDICAL RECORDS REVIEWED FOR RESIDENT #106 REVEALED STAFF INACCURATELY CONVEYED CURRENT [MEDICATION NAME] DOSING TO THE PHYSICIAN WHEN PRESENTING THE INR RESULTS FOR [MEDICATION NAME] ORDERS ON [DATE] AND IN RESPONSE THE FACILITY VERIFIED A) THE INR FOR [DATE] WAS COMPLETED AS ORDERED; B) THE PHYSICIAN RECEIVED THE INR RESULTS THE SAME DAY THEY WERE AVAILABLE; C) PHYSICIAN ORDERS [REDACTED]. 8. MEDICAL RECORDS REVIEWED FOR RESIDENT #108 REVEALED [MEDICATION NAME] WAS ADMINISTERED TWICE ON [DATE] AND IN RESPONSE THE FACILITY A) PROVIDED 1:1 NURSING EDUCATION AND DISCIPLINE TO THE NURSE INVOLVED; AND VERIFIED B) COMPLETED INR TEST DATED [DATE]; C) PHYSICIAN NOTIFICATION OCCURRED THE DAY THE INR RESULTS WERE AVAILABLE; D) PHYSICIAN ORDERS [REDACTED]. 9. MEDICATION ADMINISTRATION RECORDS, DATED [DATE], REVEALED ALL 6 OF 6 RESIDENTS RECEIVED ACCURATE DOSES OF [MEDICATION NAME] BASED ON CURRENT PHYSICIAN ORDERS. 10. THE FOLLOWING POLICIES WERE REVIEWED ON [DATE] BY THE ADMINISTRATOR, DON, AND ASSISTANT DON, AND DEEMED APPROPRIATE; A) MEDICATION ADMINISTRATION; B) MEDICATION ERROR REPORTING; C) PHYSICIAN ORDER [REDACTED]. 11. AN AD HOC QUALITY ASSURANCE MEETING OCCURRED ON [DATE]. THE DON SAID THAT THE ADMINISTRATOR, ASSISTANT DON, MEDICAL DIRECTOR AND HERSELF WERE PRESENT. AT THIS MEETING, THE FACILITY'S [MEDICATION NAME] THERAPY POLICY WAS REVIEWED, REVISED, APPROVED AND IMPLEMENTED. 12. ON [DATE], 12 OF 25 NURSES DOCUMENTED RECEIVING THE MANDATORY EDUCATION REQUIRED BY ALL LICENSED NURSES AT THE FACILITY BEFORE RETURNING TO ACTIVE DUTY. THE EDUCATION CONSISTED OF A) PHYSICIAN ORDER [REDACTED]. 13. AUDITS INITIATED [DATE] FOUND NO DEFICIENT PRACTICE. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON [DATE] WAS REMOVED ON [DATE]. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "PATTERN" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL ALL APPLICABLE FACILITY STAFF COMPLETED EDUCATION AND SUSTAINED COMPLIANCE CAN BE VERIFIED BY THE STATE AGENCY. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 260. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT EACH RESIDENT RECEIVES ADEQUATE SUPERVISION TO PREVENT ACCIDENTS DURING RESIDENT TRANSFERS IN 1 OF 4 SAMPLED RESIDENTS (# 101) RESULTING IN RESIDENT # 101 ' S BRUISE ON THE LEFT SIDE OF THE BACK AND CHEST, AND RESIDENT # 101 ' S LEFT CLAVICLE FRACTURE WITH ASSOCIATED PAIN AND RESULTING IN THE POTENTIAL FOR FUTURE INJURY. FINDINGS INCLUDE: RESIDENT # 101: ACCORDING TO THE FACESHEET DATED 1/18/2011, RESIDENT # 101 HAS LIVED IN THE FACILITY SINCE 5/5/2006. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT # 101 WAS A [AGE] year OLD ALERT FEMALE THAT REQUIRED EXTENSIVE ASSISTANCE WITH ALL TRANSFERS. SHE HAD SEVERAL [DIAGNOSES REDACTED]. THE CARE PLAN DATED 1/30/2010, IDENTIFIED FALLS AS AN AREA OF CONCERN AND INDICATED RESIDENT #101 REQUIRED THE ASSISTANCE OF 2 WITH ALL TRANSFERS. ACCORDING TO NURSE ' S NOTES DATED 1/27/2011 A SKIN ASSESSMENT REVEALED BRUISING ON RESIDENT # 101'S BACK. ACCORDING TO NURSE ' S NOTES DATED 1/30/2011 RESIDENT # 101 COMPLAINED OF LEFT SHOULDER PAIN. RADIOLOGY REPORTS DATED 2/3/2011 REVEALED "FINDINGS SUGGESTIVE OF A RECENT FRACTURE OF THE DISTAL CLAVICLE" (FRONT PART OF THE SHOULDER JOINT) ON 2/18/2011 AT 11:30 AM THE DIRECTOR OF REHAB SAID THAT THE THERAPY DEPARTMENT IN SERVICES ALL CERTIFIED NURSE ASSISTANTS (CNA). THEY ARE TAUGHT NOT TO LIFT RESIDENTS UNDER THE ARMS BECAUSE IT COULD CAUSE SHOULDER OR ARM INJURIES SUCH AS FRACTURES OF THE DISTAL CLAVICLE. THE DIRECTOR OF REHAB SAID RESIDENT # 101 REQUIRED A 2 PERSON PIVOT TRANSFER WITH THE USE OF A GAIT BELT. ON 2/23/2011 AT 10:50 AM THE ASSISTANT DIRECTOR OF NURSING (ADON) SAID THAT ALL CNA STAFF MUST PROVE PROOF OF COMPETENCY IN TRANSFERRING RESIDENTS IN ACCORDANCE WITH FACILITY POLICY BEFORE LEAVING THE ORIENTATION PROCESS. THE ADON SAID ALL STAFF MEMBERS ARE TOLD DURING ORIENTATION THAT FAILURE TO TRANSFER RESIDENTS APPROPRIATELY COULD LEAD TO SUBSTANTIAL INJURY. THE ADON SAID THEY ARE SPECIFICALLY TOLD NOT TO EVER PICK UP RESIDENTS UNDER THE ARMS, BECAUSE IT CAN AND WILL CAUSE SHOULDER INJURIES. ON 2/18/2011 AT 11:40 AM CNA #1 SAID SHE CARED FOR RESIDENT # 101 REGULARLY. CNA # 1 SAID THAT THEY WOULD NORMALLY TRANSFER RESIDENT # 101 BY PLACING RESIDENT # 101 BETWEEN 2 CNAS, REACHING UNDER RESIDENT # 101 ARM (IN THE ARMPIT) WITH ONE ARM AND GRABBING THE GAIT BELT WITH THE OTHER HAND AND LIFTING. CNA # 1 SAID FACILITY STAFF USED TO LIFT ALL RESIDENTS THAT WAY, BUT WERE TAUGHT NOT TO DO SO IN ORIENTATION. ON 2/18/2011 AT 11:40 AM CNA #2 SAID SHE CARED FOR RESIDENT # 101 REGULARLY. CNA # 2 SAID THAT CNA STAFF WOULD NORMALLY TRANSFER RESIDENT # 101 BY PLACING RESIDENT # 101 BETWEEN 2 CNAS, REACHING UNDER RESIDENT # 101 ARM (IN THE ARMPIT) WITH ONE ARM AND GRABBING THE GAIT BELT WITH THE OTHER HAND AND LIFTING. CNA # 2 SAID THAT IN ORIENTATION STAFF WERE TAUGHT NOT TO DO THAT. ON 2/23/2011 AT 9:55 AM THE DIRECTOR OF NURSING SAID SHE WAS IN CHARGE OF INVESTIGATING THE CAUSE OF THE BRUISING AND FRACTURE. THE DIRECTOR OF NURSING SAID THAT SHE WAS UNABLE TO FIND A DEFINITE SINGLE TRANSFER THAT WAS THE CAUSE THE INCIDENT, BUT THAT ACCORDING TO HER INVESTIGATION RESIDENT # 101 ' S BRUISING AND FRACTURE WAS MOST REASONABLY THE DIRECT RESULT OF SEVERAL CNA'S PERFORMING AN INAPPROPRIATE AND UNSAFE TRANSFER. ( )