Every finding on record at The Orchards at Canterbury on the Lake

This citation pertains to Intake 2698293Based on interview and record review, the facility failed to ensure proper positioning and to maintain proper bed mobility for one (R701) of two residents reviewed for accidents resulting in R701 falling out of bed during activity of daily living [ADL] care and being transferred to the hospital. Findings include:A complaint was filed with the State Agency [SA] that alleged in part, .Monday morning, 12-15-2025, [R701] called. and stated that he had soiled himself and couldn't any [sic] help. Minutes later he called. and stated that he was on the floor, hurt his right foot and that the aide was just standing there. the aide lowered the bed and told him he could crawl up into bed himself, which he did. he had rolled out of the bed and fell on the floor while the aide was providing care. He stated that he told her that he was falling and she did nothing.Review of the closed record revealed R701 was admitted into the facility on [DATE] with diagnoses that included: nondisplaced trimalleolar [ankle] fracture of right lower leg, fracture of shaft of right fibula [lower leg] and anxiety disorder. According to a Brief Interview for Mental Status [BIMS] exam dated 12/13/25, (R701) scored 10/15 indicating moderately impaired cognition.Review of R701's ADL care plan initiated 12/13/25 revealed an intervention that read, BED MOBILITY: I require 1 person extensive (assistance) by staff to turn and reposition me frequently while in bed.Review of R701's progress notes revealed a Nurses Note dated 12/15/25 at 8:24 AM by Licensed Practical Nurse [LPN] 'A' that read in part, Resident stated that during ADL care, Cena [Certified Nursing Assistant] asked him to roll over to his left side and in doing he slid to the floor while still on top of his mattress. Resident continued stating that he assisted himself off the floor and back onto the bed. Cena verified. called EMS [Emergency Medical [NAME]] to transfer him to the hospital. Verbal education was reinforced to Cena on proper positioning and safety when providing ADL care.On 1/20/26 at 9:26 AM, LPN 'A' was interviewed via phone and asked about R701 falling out of bed. LPN 'A' explained CNA 'B' came and told him R701 had slid out of bed when she was trying to change him. when he got to R701's room, he was half in and half out of the bed, he tried to help him, but R701 told him he could do it himself. LPN 'A' was asked if he had asked R701 what had happened. LPN 'A' explained R701 said CNA 'B' did not help him when he was sliding out of the bed or on the floor.On 1/20/26 at 9:46 AM, CNA 'B' was called and a voicemail left. At 12:50 PM, the Administrator was asked to help in contacting CNA 'B'. At approximately 1:0 PM, the Administrator explained both she and the Director of Nursing [DON] had left voicemails for CNA 'B'. No return call was made prior to the end of the survey. On 1/20/26 at 11:35 PM, the Administrator and the DON were interviewed and asked about R701's fall. The Administrator explained they had investigated the incident and determined it resulted from improper bed mobility technique and insufficient positioning safeguards at the time of care. The Administrator further explained CNA 'B' had received 1:1 education.Review of a Work Performance/Work Rules Disciplinary Action Record dated 12/15/25 revealed CNA 'B' received a Written Warning #1 for Staff received education regarding safe bed mobility. Refused to sign was written on the line for Employee's Signature [CNA 'B'] and was signed by the DON on 12/15/25.Review of a facility policy titled Bed Mobility undated, read in part, .Fundamental Information: Guidelines for instructing the resident: Give clean and concise directions. Use short, direct sentences.; Movements should be performed slowly to allow the resident to optimally assist in the activity.; Slow, small movements help prevent injury to the resident and the staff member's back.; Be consistent. Consistent performance of an activity helps avoid confusion, facilitates the resident's learning, and allows the resident to maximally assist with the activity.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included staff re-education, equipment review, and enhanced monitoring. Systemic changes were put in place to mitigate risk and prevent recurrence for residents during an Ad Hoc Quality Assurance and Performance Improvement [QAPI] meeting. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Complaint #2649498Based on interview and record review, the facility failed to notify the resident's responsible party of a change of condition after a fall and a subsequent emergent transfer to the hospital for one (R801) of one resident reviewed for notification of changes. Findings include:A review of a complaint submitted to the State Agency revealed an allegation that R801 fell in the early morning of [DATE] and was taken to the local hospital via ambulance. R801's responsible party alleged they were unaware of the fall or hospital transfer until 3:45 PM when the emergency room (ER) physician contacted them to say R801 sustained a Dense fracture of the C-2 Vertebrae.On [DATE], an onsite investigation was conducted.A review of R801's clinical record revealed R801 was admitted into the facility on [DATE], discharged to the hospital on [DATE] and [DATE], and expired in the facility on [DATE]. R801's diagnoses included: chronic obstructive pulmonary disease (COPD), Alzheimer's Disease, and a neck fracture (as of [DATE]). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had moderately impaired cognition. There was documentation that R801's family member was her legal decision maker and R801 was deemed unable to make her own medical decisions on [DATE].A review of R801's progress notes revealed on [DATE], Licensed Practical Nurse (LPN) 'A' wrote a Nurses Note that documented, Nurse was notified by assigned CNA (Certified Nursing Assistant) that the resident had an audible fall heard from the hallway.Resident reported severe head pain with facial grimacing.MD (medical doctor) notified; order received to transfer resident to (local hospital). EMS (Emergency Medical Services) arrived and resident was transferred via stretcher to (local hospital. There was no documentation that R801's responsible party was notified.A review of a Social Services progress note dated [DATE] revealed documentation that R801's responsible party expressed some frustrations regarding residents d/c (discharge) to the hospital.and requested to speak with someone to provide answers to her questions.A review of a Concern Form dated [DATE] revealed R801's responsible party had the following concern: Nurse did not call to inform her mother was sent out to hospital on [DATE]. The Administrator was interviewed and identified the nurse as LPN 'A'.A review of a Work Performance/Work Rules Disciplinary Action Record for LPN 'A' revealed she received a Written warning for [DATE] because she failed to notify residents daughter (POA - Power of Attorney/decision maker) of a fall that occurred on [DATE]. It was documented LPN 'A' received one to one education by telephone regarding contacting residents' POA, family, and/ or emergency contact for any falls, change of condition, or new orders. The form was signed by a supervisor and the administrator but was not signed by LPN 'A'.On [DATE] at 1:10 PM, an interview was conducted with LPN 'A' via the telephone. When queried about whether she contacted R801's responsible party on [DATE] after she fell and was transferred to the hospital, LPN 'A' reported it was her best practice to call. LPN 'A' did not give a clear answer on whether she called R801's responsible party on [DATE] or if it was for a second fall on [DATE]. When queried about any education provided regarding contacting residents' POA, family, and/or emergency contact, LPN 'A' did not recall if she received education regarding that and stated, They call you all the time about stuff and did not recall receiving any disciplinary action (written warning).A review of an undated document that was provided as a facility policy titled, Fall Management Guidelines, revealed, in part, the following, .As soon as practicable, communicate the fall to the attending physician and the resident's responsible party/legal representative and document in the medical record.

This citation pertains to intake 2643927Based on observation, interview and record review, the facility failed to ensure medications were available to administer per the Physician's orders for two residents (R901 and R902) of two residents reviewed for medication administration. Findings include:On 10/21/25 a concern submitted to the State Agency was reviewed which alleged R901 did not have their medication available for administration upon being admitted to the facility.R901On 10/21/25 at approximately 11:05 a.m., R901 was observed in their room, up in their wheelchair. R901 was queried regarding their IV ABT (intravenous antibiotics) and they reported they had a PICC line (PICC-peripherally inserted central catheter) in their upper left arm. R901 was queried if they had any concerns regarding their antibiotics that had been administered via the PICC line, and they reported that they did not get them the night they were admitted due the facility because the facility did order them in time. R901 reported they did not receive any ABT until the following day. R901 was queried if the Nursing staff had been donning personal protective equipment (PPE) including gowns when providing care to them, and they reported that nobody was wearing any gowns.On 10/21/25 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE], last readmitted on [DATE] and had diagnoses including Urinary tract infection, Extended Spectrum Beta Lactamase (ESBL) Resistance and Iron deficiency-Anemia. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 9/19/25 revealed R901 needed assistance from facility staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was 15 indicating intact cognition. A faxed hospital prescription dated 10/13/25 revealed the following: ertapenem 1 g (gram) in sodium chloride 0.9 % 50 mL (milliliters) IVPB (intravenous piggyback) 1 each START-10/13/2025 END-10/20/2025 Route: Infuse 1 g (gram) into a venous catheter 1 (one) time each day at the same time for 7 days. End date 10/20/2025A facility Admissions Notice revealed the following: Return .admit date : [DATE] .Transport Time: 3:00 PM .Immediate Equipment/Intervention Needs .IV/Pump/Supplies .Important Details: Pt (patient) is on IV Ertapenem 1 G for seven days. Start date 10.13. End date 10.20.25. Pt must have IV at 6pm today. A review of R901's hospital discharge instructions with a printed date of 10/14/25 revealed the following: 1 g in sodium chloride 0.9 % 50 mL (milliliters) IVPB (piggyback) 3 START Infuse 1 g into a venous catheter 1 (one) time each day at the same time for 7 days. End date 10/20/2025 .Last time this was given: October 13, 2025 5:27. A review of R901's Physician orders while at the facility revealed the following: Start Date: 10/15/25 Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium) Use 1 gram intravenously one time a day for UTI until 10/21/2025 14:00 Administer with 50 mL IVPG of 0.9 sodium chloride.A review of R901's October 2025 Medication Administration Record (MAR) revealed R901 was not administered their Entrapenem on 10/14/25 and did not receive a Dose at the facility until the following day on 10/15/25.R902On 10/21/25 the medical record for R902 was reviewed and revealed the following: R902 was initially admitted to the facility on [DATE] and had diagnoses including Chronic kidney disease and Dementia.A review of R902's Physician orders revealed the following: 1. Potassium Chloride Oral Packet 20 MEQ (milliequivalent) (Potassium Chloride) Give 1 packet by mouth one time a day for hypokalemia and 2. Metoprolol Succinate ER (extended release) Oral Tablet Extended Release 24 Hour 50 MG (milligram)) (Metoprolol Succinate) Give 1 tablet by mouth one time a day for hypertension.A review of R902's October 2025 MAR revealed the following medications that were documented as not being administered: Potassium Chloride Oral Packet 20 MEQ: 10/14, 10/17, 10/18, 10/19 10/21. Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG: 10/17 and 10/21.A review of R902's progress notes revealed the following EMAR notes pertaining to the dates in which R902's medications were not administered: 10/14/25-Potassium Chloride Oral Packet .Give 1 packet by mouth one time a day for hypokalemia-Medication not available awaiting delivery from pharmacy 10/17/25-Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day for hypertension-medication not available Potassium Chloride Oral Packet 20 MEQ Give 1 packet by mouth one time a day for hypokalemia-medication not available. 10/18/25-Potassium Chloride Oral Packet 20 MEQ Give 1 packet by mouth one time a day for hypokalemia-ON ORDER 10/19/25-Potassium Chloride Oral Packet 20 MEQ Give 1 packet by mouth one time a day for hypokalemia-on order 10/21/25-Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day for hypertension- medication not available Potassium Chloride Oral Packet 20 MEQ Give 1 packet by mouth one time a day for hypokalemia-medication not availableOn 10/21/25 at approximately 12:43 p.m., The Director of Nursing (DON) was queried regarding the missed dosage of R901's antibiotic on the evening of 10/14/25. The DON indicated that they were aware that R901 was supposed to have his ABT administered that evening but that they did not have it in stock. The DON indicated that they had previously looked into the issue and that the Nurse was taken off the schedule and Nursing staff had been re-educated on ensuring medications were available for new admissions and how to order medications for STAT delivery (as soon as possible) as well as checking the backup supply. The DON indicated that the floor Nurse should have reached out to other staff to help in how to secure the medications for administration that day so R901 could have gotten their medication that day even if they arrived at the facility without their medications with them. The DON reported that they had to start R901's IV ABT the next day on 10/15/25 as a result. The DON was queried on the process of ordering and reordering medications, and they reported that the Nurse should be ordering them in a timely manner to ensure administration and then following up with pharmacy and administration if there are issues. On 10/21/25 at approximately 4:10 p.m., during a conversation with Nurse Manger A (NM A), NM A was queried regarding the medications for R902 that were documented as being unavailable for administration. NM A indicated that the medications were available and that R902's potassium chloride was in the medication cart, but the Nurses did not look hard enough to find it. NM A indicated that R902's metoprolol was located in the backup supply of medications, and the Nursing staff should have gone to the backup supply to pull it for it to be administered as ordered. A facility document titled Medication Administration and General guidelines was reviewed and revealed the following: Policy-Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in LinkRx otherwise authorized personnel should refer to Drug Reference material provided by facility .

This citation pertains to intake 2643927Based on observation interview and record review, the facility failed to ensure sufficient staffing was provided to meet resident needs for two residents (R901 and R903) of three residents reviewed for staffing. Findings include:On 10/21/25 a concern submitted to the State Agency was reviewed which alleged the facility did not have enough staff to meet resident needs.R901On 10/21/25 at approximately 11:05 a.m., R901 was observed in their room, up in their wheelchair. R901 was queried regarding the staffing levels in the facility and they reported that the facility is often short of staff and they have had to wait long wait times for their call button (a device used to notify staff of the need for assistance) to be answered resulting in significant delays in getting their needs met. On 10/21/25 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE], last readmitted on [DATE] and had diagnoses including Urinary tract infection, Extended Spectrum Beta Lactamase (ESBL) Resistance and Iron deficiency-Anemia. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 9/19/25 revealed R901 needed assistance from facility staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was 15 indicating intact cognition.R903On 10/21/25 at approximately 2:51 p.m., visitor F reported that the facility had an issue with staffing in the building and that on 10/19/25 there was only one CNA (Certified Nursing Assistant) caring for resident on the first floor and that R903 was left wet for multiple hours during the day shift and they could not get their brief changed. Visitor F reported R903 was dependent on the Nursing staff to get changed and that the facility does not have enough staff to do it without waiting long periods of time. On 10/21/25 the medical record for R903 was reviewed and revealed the following: R903 was initially admitted to the facility on [DATE] and had diagnoses including Hemiplegia and hemiparesis following cerebral infarction (stroke) and Dementia. On 10/21/25 a review of the staffing sheets for the facility for 10/19/25 revealed two CNA's (Certified Nurse Assistant) were scheduled to work the first floor at 7:00 AM-3:00 PM shift and another CNA was scheduled to come in at 10:00 AM.On 10/21/25 at approximately 3:41 p.m., CNA D was queried regarding working the day shift on the first floor on 10/19/25 and they reported they were the only CNA on the floor for approximately 4-5 hours and were not provided any assistance until after lunch at approximately 1:30 pm. CNA D indicated that visitor F was upset that R903 had not been changed and was left wet so another CNA came to help at that time. CNA D reported that another CNA did not work the set that morning and they were not replaced, and they were doing the best they could to change all the residents on the first floor because the Nurse was busy with giving medications. CNA D was queried how the staffing shortage affected the residents on the floor, and they indicated that call lights were answered late and nobody got any bathing that morning and that some residents were wet longer than they should have been. On 10/21/25 at approximately 3:25 p.m., Staffing Coordinator C (SC C) was queried regarding the staffing shortage during the morning of 10/19/25 on the first floor. SC C indicated that they had a call off on the floor in which one CNA did not work and another that was supposed to come in at 10:00 AM to help. SC C reported that CNA B was supposed to go to the first floor to help CNA D with the resident's care. On 10/21/25 at approximately 3:51 p.m., Nurse E was queried regarding the staffing levels on the first floor on the morning of 10/19/25. Nurse E reported they were only provided one CNA for all the residents on the floor and the residents experienced delays in their care due to the shortage. Nurse E indicated that they did not receive any additional assistance until after lunch when another CNA came down to help them. On 10/21/25 at approximately 3:54 p.m., CNA B was queried regarding the staffing shortage on the first floor on 10/19/25. They indicated that they were unaware of the staffing shortage until they were instructed to go down to the first floor after lunch (around 1pm-1:30pm). CNA B reported when they arrived on the floor, CNA D was the only CNA on the floor and a lot of residents were wet (with urine) and needed to be changed. CNA B was queried why did they not assist CNA D earlier in the morning, and they reported they did not know they were supposed to go to the first floor until someone told them after lunch was finished. On 10/21/25 a facility document titled Staffing and Scheduling was reviewed and revealed the following: Purpose-To assure adequate, competent staff is available to provide care for the residents .Fundamental information-Staffing for acuity involved understanding the needs of residents and staffing accordingly to assure care can be provided to address resident needs. The DON (Director of Nursing) should work closely with the staffing coordinator to identify nursing staffing needs and hire nursing staff accordingly .

This citation pertains to intake 2643927Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions were provided for one resident (R901) of two residents reviewed for infection control. Findings include: On 10/21/25 a concern submitted to the State Agency was reviewed which alleged R901 was not provided adequate protections to prevent infection. On 10/21/25 at approximately 11:05 a.m., R901 was observed in their room, up in their wheelchair. R901 was queried regarding their IV ABT (intravenous antibiotics) and they indicated that they had a line (PICC-peripherally inserted central catheter) in their upper left arm. R901 was queried if they had any concerns regarding their antibiotics and they reported that they did not get them the night they were admitted , because the facility did not order them in time. R901 was queried if the Nursing staff were donning personal protective equipment (PPE) including gowns when providing care, and they reported that nobody was wearing any gowns. At that time, an observation of R901's room revealed no signage indicating staff were to be donning PPE when providing care. No gowns were observed in the vicinity of R901's room indicating that staff were to don PPE when providing care to R901. An observation of R901's upper left arm was conducted and revealed a dressing covering the PICC line with dried blood underneath it. On 10/21/25 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE], last readmitted on [DATE] and had diagnoses including Urinary tract infection (UTI), Extended Spectrum Beta Lactamase (ESBL) Resistance and Iron deficiency-Anemia. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 9/19/25 revealed R901 needed assistance from facility staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was 15 indicating intact cognition. A review of R901's careplan revealed the following: Focus-I am on antibiotic therapy r/t (related to) a UTI (Urinary tract infection) Date Initiated: 09/28/2025 .A review of R901's Physician orders revealed the following: Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium) Use 1 gram intravenouslyone time a day for UTI until 10/21/2025 23:59 .Further review of R901's Physician orders and careplans did not reveal any orders/instructions for enhanced barrier precautions or any other type of transmission based precautions. On 10/21/25 at approximately 12:32 p.m., during a conversation with facility Infection Control Preventionist H (ICP H), ICP H was queried if R901 should be provided transmission precautions since they had an infection and a PICC line in their arm and were receiving ABT. ICP H indicated that R901 should be on contact precautions due to the EBSL (Extended-Spectrum Beta-Lactamase) infection they had and the PICC line in their arm. ICP H was informed of the observations of R901 not having any precautions provided to them or any Physician orders/careplans in their medical record and they indicated they would implement the precautions immediately and that for some reason R901 was missed when they review who should have been provided precautions upon admission to the facility. On 10/21/25 at approximately 2:27 p.m., during a conversation with the Director of Nursing (DON) the DON was queried regarding the lack of transmission based precautions provided to R901 since they were re-admitted to the facility with a PICC line and they indicated they were aware of the issue and it had been corrected with orders put in place and appropriate signage on R901's door and PPE by the room entrance. On 10/21/25 a secondary review of the medical record was reviewed with an updated Physician order dated 10/21/25 at 12:45 p.m., that documented the following: Contact Precautions for ESBL in urine: Practice hand hygiene and put on gown, mask, and gloves. Wear eye protection (goggles) for splash potential high contactcare. Remove/dispose of used PPE prior to exiting resident's room. Practice hand hygiene. PPE found at nurses' station or Clean Utility room. two times a day forprecautions.On 10/21/25 a facility document titled Transmission Precautions: Contact: was reviewed and revealed the following: Purpose-In addition to Standard Precautions, Precautions are used for residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident, or indirect contact (touching) with environmental surfaces or resident care items in the resident's environment .3. Gowns-Wear a clean, non-sterile gown upon entering the resident's room if you anticipate substantial contact between your clothing and the resident, environmental surfaces or items in the room .

This citation pertains to Intake Number MI001227212. This citation has two deficient practice statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to assess a new skin impairment and implement treatments in a timely manner and according to physician's orders for two (R55 and R49) of four reviewed for non-pressure skin impairments, resulting in a wound to R55's arm becoming infected with delayed healing. Findings include: R55 On 7/29/25 at 10:45 AM, R55 was observed in bed. A dressing dated 7/29/25 was observed on R55's right forearm. When queried about what happened to his arm, R55 stated, She burnt it. R55 appeared fully able to understand the questions being asked but had trouble finding words and explained that sometimes the words he wants to say, do not come out correctly or he could not say the word (aphasia). R55 explained the wound on his arm has been present for a long time and was not healing. On 7/30/25 at approximately 1:00 PM, R55 was observed eating lunch. A dressing dated 7/29/25 was observed on R55's right forearm. On 7/31/25 at 9:53 AM, R55 was observed lying in bed. R55's right forearm was observed with a discoloration approximately 3.8 centimeters in diameter with a raised center approximately 1.25 centimeters x 2.4 cm that had two small black scab-like areas with a skin bridge between the scabs. R55 was asked about the wound. R55 explained he was burned in therapy and said the therapist placed a device on his arm, walked away and was on her computer. R55 said it hurt really bad, and he felt pain shooting up his arm. A review of R55's clinical record revealed R55 was admitted into the facility on 2/11/25 with diagnoses that included: cerebral ischemia (stroke). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R55 had intact cognition and was dependent on staff assistance for activities of daily living (ADLs) other than eating and required substantial/maximal assistance for bed mobility and transfers. R55 had one-sided impairment to his lower and upper extremities. The MDS noted R55 had a skin tear. A review of an admission MDS dated [DATE] revealed R55 did not have any skin impairments. A review of R55's Weekly Head-To-Toe Assessment (skin assessments) revealed the following: On 4/4/25, it was documented R55 had a scab discolored area to the right lower arm. The assessment was signed and locked on 5/23/25, 49 days later. On 4/8/25, a skin assessment was started, but was never completed, signed or locked and as of 7/30/25, it was in progress. There were no weekly skin assessments in the clinical record between 4/4/25 and 5/20/25. On 5/20/25, it was documented on a skin assessment that R55 had small size bruising on bilateral arms skin fragile and did not document any open areas. A review of a Physical Medicine and Rehabilitation (PM&R) progress note dated 4/7/25 revealed documentation that included, .4/7/25: .Per COTA (Certified Occupational Therapist Assistant), pt (patient) has been tolerating estim (electrical stimulation therapy), but on Friday she noted new skin issues following removal of the estim pads (electrodes) - nursing was notified and estim was removed from his tx (treatment) plan . A review of a (PM&R) progress note dated 4/16/25 revealed documentation that included, .4/7/25: Agree with d/c (discontinue) of estim due to skin intolerance following removal of the pads on 4/4. Discussed with DOR (Director of Rehab) to have the estim unit calibrated ASAP (as soon as possible) . Further review of R55's clinical record revealed no documentation of the new skin issues identified by the COTA after using the estim machine were assessed or evaluated by a nurse of medical provider other than the skin assessment dated [DATE] (locked on 5/23/25) that noted a scab and discoloration. A review of R55's Skin/Wound progress notes revealed the following: A note written on 5/19/25 documented, .Wound Rounds .Seen on wound rounds re (regarding) area on right arm .Seen (regarding) open ulcer to right posterior forearm. Patient states it started as a skin tear. Base with mix of granular tissue (new connective tissue that forms during wound healing) and yellow slough (necrotic tissue) with slightly raised darker discolored rim surrounding. Entire area 2 x 3 cm (centimeters). With erythema (redness), induration (thickening and hardening of the skin) and tenderness to touch. Mild serosanguinous (a mixture of clear, thin, watery drainage and blood). (Treat) with xeroform (a sterile occlusive petroleum-based wound dressing) and cover with bordered gauze. Change daily and PRN (as needed). Will start doxycycline (an antibiotic medication used to treat infection) .10 days for cellulitis (bacterial tissue/skin infection) . There was no documentation present in R55's clinical record that indicated any change to R55's right arm after it was noted in the PM&R notes that the resident had a skin impairment after use of the estim machine on 4/4/25 and the skin assessment dated [DATE] and locked on 5/23/25 that documented a scab and discoloration. A review of R55's Physician's Orders revealed an order dated 5/20/25 with a discontinue date of 6/9/25 to Cleanse forearm wound with NS (normal saline) and pat dry. Apply xeroform and cover with dry dressing. A review of R55's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2025 and June 2025 revealed the above order was not added to the MAR or TAR which would alert the nurse to administer the treatment and sign off when it was completed. Further review of R55's Physician's Orders revealed a new order dated 6/12/25 with a discontinue date of 6/30/25 to Cleanse right forearm wound with NS and pat dry. Apply xeroform and cover with foam dressing every day shift every Mon (Monday), Thu (Thursday) for wound care. A review of R55's MAR and TAR for June 2025 revealed the 6/12/25-6/30/25 physician's order was on the TAR. However, treatments were not administered (as evidenced by no nurse's signature) on 6/12/25, 6/16/25, and 6/19/25. The first treatment that was signed off as administered was on 6/23/25. It should be noted that according to the PM&R progress notes, the skin impairment was first identified during therapy on 4/4/25, approximately two and a half months earlier and after the wound was discovered to be infected, there was no wound treatment completed between 5/20/25 and 6/23/25, other than oral antibiotics. A review of R55's care plans revealed a care plan was initiated on 5/27/25 in regard to an actual impairment to skin integrity of the Right arm, r/t (related to) open ulcer, fragile skin, decreased mobility, right side weakness. It should be noted that the skin impairment to R55's right arm was first identified in therapy on 4/4/25.The interventions included encouraging R55 not to pick his skin, to avoid scratching, to turn and reposition, and observe for side effects of the antibiotics. There was no mention of the electrical stimulation machine. Further review of R55's clinical record revealed R55 was evaluated by the wound care provider on 7/14/25. A review of a Skin/Wound Note dated 7/14/25 revealed documentation that the area on R55's right forearm was resolved. The note documented the treatment was to be discontinued and the area left open to air. It should be noted that upon observation of R55 on 7/29/25, there was a dressing applied dated 7/29/25. A review of R55's Physician's Orders revealed the treatment to R55's arm was not discontinued as recommended by the wound provider and the TAR indicated nurses had completed treatment to the area on 7/14/25, 7/17/25, 7/21/25 and 7/28/25. On 7/30/25 at 1:30 PM, an interview was conducted with the Wound Nurse, Licensed Practical Nurse (LPN) 'Y'. When asked if an observation of R55's right arm could be conducted LPN 'Y' reported the treatment was discontinued and there was nothing there anymore. When queried about the dressing dated 7/29/25, LPN 'Y' said it was discontinued a couple weeks ago. At that time, LPN 'Y' instructed LPN 'Z' to remove the dressing on R55's arm and LPN 'Y' discontinued the treatment order without looking at R55's arm. An observation of R55's arm was conducted with LPN 'Z'. LPN 'Z' removed the dressing dated 7/29/25. A scant amount of brown drainage was observed on the dressing. R55's right arm was observed with a discolored area with two small open areas in the center. R55 attempted to explain what happened to his arm and repeated that she burned it. R55 explained there was a computer and he was burned and the wound has taken a long time to heal. On 7/31/25 at approximately 8:30 AM, further review of R55's clinical record revealed no progress note regarding the open areas present during the wound observation with LPN 'Z' on 7/30/25. On 7/31/25 at 9:17 AM, a follow-up interview was conducted with LPN 'Y'. When queried about what a resolved wound would look like, LPN 'Y' said there would be no drainage and no open area. The observations from 7/30/25 of drainage on the dressing and open areas on R55's arm was discussed. LPN 'Y' reported she was not notified by LPN 'Z' or anyone else about the skin impairment. When queried about what happened to R55's arm, LPN 'Y' said there were allegations that R55 was burned in therapy. LPN 'Y' further explained that R55 received electrical stimulation therapy and when the therapist removed the pads with the electrodes, R55 had a skin impairment that was not there prior to applying the pads. LPN 'Y further reported that R55 was adamant that he was burned during therapy. LPN 'Y' said she was contacted and she assessed the wound within the next day or two, but it was just a scab. When queried about how R55's arm would form a scab during the electrical stimulation treatment, LPN 'Y' reported that she questioned if he was burned. When queried about where LPN 'Y's assessment was documented, LPN 'Y' did not offer a response. (It should be noted that there was no documented assessment from LPN 'Y' in the clinical record on or around 4/4/25). LPN 'Y' reported they started treatments right away, the scab came off, the wound became an open area, and it was not resolved. LPN 'Y' said they were looking into whether it was skin cancer since the wound was not healing, but R55 did not wish to see a dermatologist. At that time, LPN 'Y' was asked to provide information about what interventions and treatment were put in place after the initial skin impairment was identified by the therapist. On 7/31/25 at 12:05 PM, an interview was conducted with COTA 'DD'. When queried about what happened with R55's right arm, COTA 'DD' reported back in April he received electrical stimulation therapy. COTA 'DD' did not see any skin integrity issues prior to applying the pads, but when she took them off he had skin integrity issues. When queried about what R55's skin looked like after the pads were removed, COTA 'DD' reported it looked like a scab, a dark area and R55 said he was fine. COTA 'DD explained she reported the skin integrity issue to the nurse, the Certified Nursing Assistant (CNA), and management and also documented it in her notes. A review of medical provider progress notes for R55 revealed R55 was seen by Nurse Practitioner (NP) 'EE' on 4/9/25 and 4/25/25. However, there was no documentation of any skin changes to R55's right arm. R55 was seen by NP 'EE' on 5/28/25. At that time, the wound to R55's right arm was documented, but he was already on antibiotics and the wound had already worsened. A review of a progress note written by Physician 'FF' on 7/2/25 revealed documentation that included, .Pt has skin lesion on his right upper extremity, open wound/open ulceration .stated that the wound had been there for a long period of time .he denies scratching it .The chronic nature of the wound make it suspicious for skin cancer .Other possibility wound be venous stasis ulcer . On 7/31/25 at 12:55pm, an interview was conducted with Physician 'FF' via the telephone. Physician 'FF' reported he was not informed that R55 reported being burned by the electrical stimulation machine and was not aware that treatment was not started for over two months, but that he would make the same recommendations that were documented in his progress note on 7/2/25. On 7/31/25 at 12:13 PM, LPN 'Y' followed up and reported no treatment was implemented on 4/4/25 because it was just a scab. LPN 'Y' said treatment was ordered on 5/20/25 when herself and the wound provider assessed the area and it had worsened. When queried about how a scab formed on intact skin on 4/4/25 within 15-20 minutes while receiving the electrical stimulation treatment, LPN 'Y' said it was more likely from the electrical stimulation machine and not a scab. When queried about whether anyone identified the area worsening prior to it being infected and requiring antibiotics, LPN 'Y' did not offer a response. LPN 'Y' reported she would look into it. A review of an incident report dated 4/4/25 completed by LPN 'C' revealed the following documentation, Writer was notified by CNA that resident had blisters on right arm. Upon assessment writer observed 2 scabbed discolored areas on resident right arm .Resident unable to explain to writer what happened . It was documented that the incident was not witnessed and the wound care nurse and NP were notified on 4/4/25. On 7/31/25 at 1:11 PM, an interview was conducted with LPN 'C'. When queried about the incident report regarding R55's arm on 4/4/25, LPN 'C' reported CNA 'CC' reported that R55 had blisters on his arm. LPN 'C' assessed R55 and explained they were not blisters; they were flat. LPN 'C' said they looked like old scabs and there was an indentation. According to LPN 'C', R55 did not know what happened. When queried about what was done after R55 was identified to have a new skin impairment, LPN 'C' said she notified LPN 'Y' and logged it for the doctor. LPN 'C' reported that she did not complete the incident report until much later (in May) when management asked her to complete one. LPN 'C' said she did not know she had to complete an incident report. When queried about whether she documented her assessment of R55's arm on 4/4/25 and she reported she did not. On 7/31/25 at 1:49pm, an interview was conducted with CNA 'CC'. When queried about the skin impairment she reported to LPN 'C' on 4/4/25, CNA 'CC' stated, It wasn't blistered or anything. It's hard to describe. It wasn't bruised. It just wasn't there before. There was one major area that really stuck out. CNA 'CC' said R55 said it happened at therapy and he was upset about it. CNA 'CC' said she told LPN 'C' but did not remember if she told her what R55 said. When queried about whether LPN 'C' assessed R55, CNA 'CC' said she thought she did, but did not remember. On 7/31/25 at 2:32 PM, LPN 'Y' followed up. At that time, R55's clinical record was reviewed and LPN 'Y' confirmed the treatment that was supposed to start on 5/20/25 was not on the MAR or TAR. LPN 'Y' also confirmed the order that was started on 6/12/25 had several missed treatments. LPN 'Y' reported she was unaware of that and it was not identified when the incident was investigated. On 7/31/25 at 3:40 PM, an interview was conducted with the DON. When queried about R55's going without treatment to the skin impairment to his right arm until 6/23/25, the DON reported she was unaware. When queried about whether the wound care coordinator was responsible to ensure treatments were implemented and administered according to physician's orders, the DON reported they were. R49 On 7/29/25 at 10:11 AM, R49 was observed in their room in their wheelchair. R49's right pant leg was pulled up to their knee and their right shin was observed to have tight, shiny, reddened skin with diffuse areas of blistering and serous drainage. On 7/29/2025 at 1:00 PM, R49 was observed in their wheelchair propelling towards the dining room. R49's right pant leg was again observed pulled up to their knee and their right shin continued to be observed with tight, shiny, reddened skin with diffuse blistering and serous drainage. On 7/29/25 at approximately 2:30 PM, a review of R49's physician orders was conducted and did not reveal any treatment orders for their right leg. On 7/30/2025 at 12:35 PM, R49 was observed in their wheelchair with their right pant leg pulled up to their knee. At that time, their right leg was observed to be wrapped in bulky gauze. On 7/30/2025 at 1:22 PM, a second review of R49's physician's orders was conducted and revealed an order dated 7/30/25 that indicated R49's right leg was to be cleansed with normal saline, covered in a large pad, and wrapped with bulky dressing. On 7/31/2025 at 2:53 PM, an interview was conducted with the facility's Director of Nursing, and they were asked when a treatment should be initiated after the identification of a wound or skin impairment. They indicated it should be implemented, Immediately. Deficient Practice #2 Based on observation, interview, and record review, the facility failed to ensure medications were pulled from the back-up medication supply and administered for one resident (R139), of three residents reviewed for medication administration, resulting in verbalized complaints, frustration, and the potential for complications from not receiving scheduled medications. Findings include: On 7/29/25 at 10:51 AM, R139 was observed in their room. They were asked about their stay in the facility and verbalized some concerns regarding their medications. They said they did not think they received all their cardiac medications prescribed after their discharge from the hospital when they first admitted to the facility and they were concerned about their cardiac condition. On 7/30/2025 at 12:02 PM, a review of R139's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: a heart attack, heart disease, high blood pressure, and presence of a heart bypass graft. R139's physician's orders and Medication Administration Record (MAR) were reviewed and revealed the following: An order for clopidigrel (a medication to prevent blood clots) 75 milligrams (mg) scheduled for 9 AM on 7/25/24 coded as a 9 (indicating the medication was held) with an accompanying progress note that read, New admission medication not available waiting for pharmacy to deliver. An order for Isosorbide Mononitrate (a medication for chest pain) 30 mg scheduled for 9 AM on 7/25/25 coded as a 9 with an accompanying progress note that read, New admission medication not available waiting for pharmacy to deliver. An order for Amiodarone (a medication for irregular heartbeat) 200 mg scheduled for 9 AM on 7/25/25 coded as a 9 with an accompanying progress note that read, New admission medication not available waiting for pharmacy to deliver. On 7/31/25 at 9:08 AM, a review of the facility's back-up medication supply was conducted and revealed the facility stocked Clopidigrel 75 mg, Isosorbide Mononitrate 30 mg, and Amiodarone 200 mg in their back-up medication supply. On 7/31/25 at a 2:53 PM, an interview was conducted with the facility's Director of Nursing, and they indicated the missed medications could have been pulled from the back-up medication supply for administration to R139. A review of a facility provided policy titled, Medication Administration and General Guidelines was reviewed; however, the policy did not address removing medications from the back-up medication supply for administration.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 7/29/25 during an initial observation of the kitchen between 8:40 AM-9:30 AM, the following items were observed: There was a wet wiping rag lying on the counter and not stored inside the sanitizer bucket. Food Service Manager JJ confirmed the rag should be stored inside the sanitizer solution. According to the 2022 FDA Food Code section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114; The vent grates on the vent hood were observed with a buildup of grease and debris. Food Service Manager JJ stated the vent hood is cleaned quarterly.According to the 2022 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.The interior of the microwave was soiled with dried on food debris.The ice machine filters were observed to be dusty, and the top exterior of the ice machine was observed with a thick lime scale. In addition, the flooring underneath the ice machine was observed to be wet with a black, slimy film.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.The Atmospheric Vacuum Breaker near the hose sprayer in the dish machine room was observed to be missing the top cap.According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to law; P and(B) Maintained in good repair.On 7/29/25 at 9:45 AM, the 1st floor resident refrigerator was observed with the following undated items: An Arby's roast beef sandwich, a container of soup, a container of chicken, a bag of chopped salad, a plastic bag with a container of fish and a bowl of soup, 5 containers of various food items labeled with a resident's name but no date, 3 containers of various food items that were undated, 2 food containers dated 7/2/25. When queried, Food Service Manager JJ confirmed all items should be dated. In addition to the undated food items, the interior of the resident refrigerator was observed to be soiled with spills and dried on food debris. In the Hoshizaki cooler located in the 1st floor kitchenette, there was an opened, undated container of thick and easy liquid (the manufacturer's label stated to use by 4 days after opening). On 7/29/25 at 10:00 AM, in the 2nd floor kitchenette Hoshizaki cooler, there was an opened, undated container of ready care thickened dairy drink. According to the undated facility policy Safe Storage & Handling of Outside Food, 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 .All food that is stored in the refrigerator and not consumed within 3 days will be discarded by facility staff daily.

Based on observation, interview and record review the facility Quality Assurance and Quality Improvement (QAPI) program failed to identify and implement plans to address systemic issues regarding Infection Control and Pest Control which had the ability to affect the health, safety and quality of life for all residents who resided in the facility. Findings include: A recertification survey was conducted 7/29/25 through 7/31/25 and systemic concerns were identified in Infection Control and Pest Control.On 7/31/25 at 3:16 PM, a meeting was held with the Administrator to discuss the priority and ongoing issues that the Quality Assurance (QA) committee had identified and were working on to improve the facility. The Administrator explained areas of concern the QA committee were currently working on; however, Infection Control and Pest Control were not identified as areas of concern. The Administrator was asked about the lack of infection surveillance for legionella and failure to follow the county's health department guidance. The Administrator was informed that throughout the survey, observations of flying insects were made on all three floors residents resided on, and that the most recent pest control documentation was from 3/17/25. The Administrator acknowledged the concerns, and explained neither issue had a current QAPI plan. Review of a facility policy titled, Quality Assurance Performance Improvement Procedure Manual undated read in part, .QAPI committee responsibilities include identifying and responding to quality deficiencies throughout the facility, and oversight of the facility'[s QAPI program. The committee must develop and implement corrective action and monitor those actions to ensure performance goals or benchmarks are achieved. It also determines what performance measures will be monitored, the schedule or frequency for monitoring this data, identified opportunities for improvement and prioritizes issues by their size of impact.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program by eliminating harborage conditions and provision of routine and/or as needed pest control which had the potential to affect all residents (including R8) in the facility. Findings include:Observations during the recertification survey from 7/29/25 - 7/31/25 revealed flying insects were observed in multiple locations including the conference room (utilized by residents, visitors, and staff), throughout the hallways and resident rooms on first, second, and third floors, and in the resident dining areas on the second and third floor.The facility's main elevator was observed from 7/29/25 - 7/31/25 to have multiple dead insects inside the elevator's ceiling light cover.Additionally, just prior to the start of this survey, a resident was identified with maggots in a wound.On 7/29/25 at 10:10 AM, observation of the third floor dining room revealed five tables that had meal trays with uncovered food items. Additionally there was a small pushcart that contained several meal trays with uncovered food items. Flying insects were observed throughout the dining room and kitchenette area.On 7/29/25 at 10:50 AM, an interview was conducted with R8's Legal Guardian (LG) who was seated in a wheelchair next to the resident who was lying in bed. Throughout this interview there were several flying insects observed throughout the resident's room. When asked about the flying insects, the LG confirmed the same observation and reported when they complained about it a while ago, one of the nurses gave them this (pointed to a small red apple container on the resident's bedside dresser which was a vinegar gnat bait). When asked if anyone had been back to check the trap, the LG reported no one had followed up and they further reported they thought the problem was the staff let the food sit out too long in the rooms and dining room before they clear it.On 7/29/25 at 11:38 AM, the facility was requested to provide pest control logs since January 2025.Review of pest control documentation provided by the Administrator revealed the most recent visit was on 3/17/25 which did not include any specific details of findings. The documentation labelled April 2025 was actually from April 2024 and 2023. There was no documentation that routine pest control had been provided since March 2025.On 7/31/25 at 8:32 AM, the facility was requested to provide any additional documentation since March 2025 and informed the April documentation was from 2024 and to confirm if that was accurate.On 7/31/25 at 8:39 AM, the Administrator reported they would follow-up.On 7/31/25 at 9:10 AM, an interview and observation of the third floor was conducted with the Maintenance Director (Staff ‘R') who reported they worked at the facility for about four years and in the Director role for about four months.When asked about the facility's pest control, they reported they weren't responsible for that, but if staff saw anything, they might call them or put it in a work order. They were not aware of any staff concerns regarding flies and gnats.On 7/31/25 at 9:15 AM, while walking throughout the facility from the first floor to the third floor, multiple flying insects were observed throughout the hallways.When asked about R8's room, Staff ‘R' reported they were not aware the vinegar bait had been given to them. When asked if they were made aware of any concerns with flying insects, they reported they were not. When asked who was responsible for monitoring the facility's pest control, Staff ‘R' reported they weren't sure, but it was not them.On 7/31/25 at 1:30 PM, the Administrator reported the pest control contact had not returned their call as of now. When asked if they had any documentation of staff reporting concerns with flying insects, they reported they didn't have any formal documentation. There was no further documentation of pest control provided by the end of the survey.According to the facility's Standards of Practice (SOP) titled, Pest Control dated March 2019: .It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents .Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats) .Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated .According to the 2022 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: 4. (D) Eliminating harborage conditions.

Based on observation, interview and record review, the facility failed to ensure safe and appropriate storage for three medication (med) carts and one medication (med) storage room of four med carts and two med storage rooms that were reviewed for medication storage and labeling. Findings include:On [DATE] at approximately 12:43 p.m., a medication cart on the second floor (med cart one) was reviewed with Nurse Z and revealed an insulin kwickpen that had an opened date of [DATE] with an expiration date of [DATE]. Nurse Z was interviewed pertaining to the expired insulin pen and they reported they would have to discard it due to it being past the expiration date. On [DATE] at approximately 12:49 p.m., Medication cart 3 (med cart 3) was reviewed with Nurse HH on second floor. An opened vial of multidose insulin was observed to have an expiration date of [DATE]. Nurse HH was interviewed pertaining to the expired insulin vial and reported it would have to be thrown away and a new one had to be opened. On [DATE] at approximately 1:03 p.m., the medication cart located on the third floor was reviewed with Nurse II. The cart was observed to have dust located in the bottom of the drawer along with multiple opened bottles of supplements that contained dried, sticky residues on their tops/sides along with sticky handles. Nurse II was interviewed regarding the sticky residues on the bottles, and the dust particles in the drawer and the reported that the carts should be cleaned out each day. On [DATE] at approximately 2:48 p.m., the medication storage room on the third floor was reviewed which contained an opened bottle of liquid pain relief that had an expiration date of 06/25. On [DATE] at approximately 3:02 p.m., Nurse II was shown the bottle of liquid pain relief with the expiration date of 06/25 and they indicated they would have to throw it away. On [DATE] a facility document titled Medication Storage in the Facility was reviewed and revealed the following: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exits. 14. Medication storage areas are kept clean, well lit, and free of clutter .

Based on observation, interview and record reviews the facility failed to ensure infection control standards, practices and protocols were followed consistently, failed to ensure an effective infection control surveillance program and failed to follow the county's health department guidance regarding the monitoring of legionella that included seven (R's 57, 5, 34, 142, 143, 63 & 144) of seven residents reviewed. Findings include: On 7/30/25 at 8:35 AM, observation of a medication administration for a resident in Contact Precautions revealed Licensed Practical Nurse (LPN) “F” was observed to put on an isolation gown, a simple mask and put on gloves from an isolation cart outside a room. LPN “F” entered the room, took the residents’ vitals, then walked back out of the room to stand at the medication cart in the hallway. LPN “F” then prepared the residents’ medications continuing to wear the same isolation gown and simple mask. After exiting the room, for the second time with the same gown and mask, LPN “F” removed the gown, mask and gloves and washed her hands. LPN “F” was asked about keeping the gown and mask on after exiting the room after she took the vitals. LPN “F” explained she thought since it was right outside of the room, she could keep the gown on. On 7/31/25 at 8:38 AM, IP “T” was interviewed and asked if staff could keep an isolation gown on after being in a Contact Precaution room. IP “T” explained all personal protection equipment (PPE) should be removed before leaving a Contact Precaution room, it should never be taken outside a room. Review of a facility policy titled, “Transmission Precautions: Contact” undated read in part, “…In addition to Standard Precautions, Contact Precautions are used for residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident, or indirect contact (touching) with environmental surfaces or resident care items in the resident’s environment…” A review of a letter attached to an email sent to the facility’s Administrator by the county’s Epidemiologist dated 3/14/25, documented in part “… Re: Legionellosis Investigation… One healthcare-associated case who resided at your facility during their incubation period in 2023. Several positive sampling locations in the case’s path, combined with a review of medical records, implicate your facility as the likely exposure location for this case… After initial results identified multiple legionella-positive sampling sites… These results are routinely positive for legionella bacteria at a majority of sampling locations, in both swab and bulk sample types…” On 7/31/25 at 11:52 AM, a telephone interview was conducted with the County’s Epidemiologist (CE) “X”. The above letter was discussed and CE “X” was asked if the facility was provided guidance clinically to follow to ensure the safety of the facility’s residents. CE “X” stated the facility’s Administration team was provided the following guidance, “… We have not been made aware of a case with an exposure at the facility in well over six months, but we recommended the enhanced testing because of environmental sampling results… Clinical symptoms of pneumonia may vary but must include acute onset of lower respiratory illness with fever and/or cough. Additional symptoms could include myalgia, shortness of breath, headache, malaise, chest discomfort, confusion, nausea, diarrhea, or abdominal pain…” CE “X” documented in part “… Note that this definition includes a fever or cough. Including only fever would not meet our recommendation. A review of the facility’s Infection Surveillance Program revealed multiple residents that met the requirements for the enhanced legionella testing, which was not identified or conducted by the facility staff. A small sample was identified to establish a pattern of the facility’s deficient practices. A review of the “Infection Control Line Listing” revealed the following: January 2025- documented- shortness of breath and cough for R63. February 2025- documented cough and congestion for R’s 143 and 142. May 2025- documented shortness of breath and cough for R144. June 2025- documented cough, shortness of breath and pain for R5. July 2025- documented cough and positive for pneumonia for R34. A review of R57’s progress note dated 6/30/25 at 3:02 PM, documented in part “levofloxacin Oral Tablet… Give 500mg by mouth one time a day for pneumonia for 7 days…” This was not identified and/or recorded on June 2025 infection surveillance log. Further review of the Infection Surveillance Program and resident medical records revealed enhanced testing for legionella was not performed for residents that met the criteria provided by the County’s health department. This indicated the facility failed to follow the guidance of the County’s health department and failed to ensure an effective Infection Control Surveillance Program. On 7/31/25 at approximately 11:11 AM, the Infection Preventionist (IP) “T” and Director of Nursing (DON) was interviewed and asked about their collaborative plan with the health department in monitoring the residents for legionella. The DON stated they did not have communication with the health department. The DON stated the Administration team at the facility implemented a criteria to test any resident with a fever of 102 degrees or above. On 7/31/25 at 1:49 PM, the IP “T”, DON and Administrator was interviewed together and the guidance provided by the County’s Epidemiologist was discussed. IP “T”, the DON and Administrator was asked why the facility was not following the County’s Epidemiologist guidance clinically for residents that exhibited signs and symptoms noted on the guidance from the health department. An explanation was not provided. No additional information or documentation was provided by the end of the survey.

Based on interview and record reviews the facility failed to ensure an effective system to monitor antibiotic use in the facility for four (R's 145, 14, 8 & 126) of four residents reviewed. Findings include:A review of the facility's Infection Control Logs and the monitoring of antibiotics revealed multiple residents identified to have potentially been prescribed an unnecessary antibiotic. A small sample was identified for review: April 2025- 4/20/25- R8 confusion, urgency, freq (frequency). Incont (incontinence). + dipstick UA (urinalysis). Macrobid.A review of a Nursing note dated 4/2025 at 5:59 PM, documented in part . writer observed resident with confusion. vitals are within normal limits. collected UA by straight cath. positive for leukocytes. Called on call and was given an order to start resident on Macrobid 100mg two times a day for 5 days. Sample was collected at 5:40 PM and placed in the 1st floor refrigerator.The medical record did not identify urgency, frequency or incontinence of urine. Further review of the medical record revealed no documentation of results from a urinalysis or sensitivity and urine culture. May 2025-5/23/25- R126 urgency, freq, incont. + UA.Review of R126's medical record revealed no identification or documentation of the resident to have urgency, frequent and incontinence of urine. Further review of the medical record revealed no results of a culture and sensitivity test to have been conducted. June 2025-Upon admission [DATE]) R145 was documented to have been prescribed metronidazole. There was no documentation of the antibiotic to have been reviewed for appropriateness. July 2025-7/29/25- R14 was prescribed Macrobid 100mg twice a day for 5 days for an asymptomatic urinary tract infection (uti). A review of the medical record revealed no identification or documentation of signs or symptoms of a uti.Review of the Infection control logs and resident medical records revealed no documentation of the review of appropriateness of the antibiotics prescribed to the above residents. On 7/31/25 at approximately 11:11 AM, the Director of Nursing (DON) and Infection Preventionist (IP) T was interviewed and asked about the oversight of antibiotic use in the facility and the reviewal of appropriateness of the antibiotics prescribed. The IP T explained they were newly hired into the role of the IP. IP T stated they would input the data for the resident into the computerized McGeer checklist to see if it met criteria. IP T stated they would review referrals, labs, and results. When asked if they consulted with the Physician regarding the appropriateness (risks/benefits) of the antibiotic usage, IP T stated they were not. The DON and IP T was asked about the review of the appropriateness of antibiotics prescribed to R's 8, 126, 145 and 14. The DON and IP T stated they would look into it and follow back up. At approximately 1:52 PM, the DON and IP T returned and stated they were discussing the appropriateness of the antibiotic for R14. No further explanation or documentation was provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure two (R55 and R30) of three residents reviewed for Advance Directives were educated and given the opportunity to formulate an advance directive for their health care wishes. Findings include:R55 On 7/29/25 at 10:45 AM, R55 was observed in bed. R55 had difficulty speaking at times, but appeared to clearly understand the questions being asked. At times, R55 had difficulty verbalizing a word, but explained he understood and knew what to say, but the words did not come out properly (aphasia). On 7/30/25 at 8:25 AM, R55 expressed concerns he had with the care in the facility. R55 said he got out of bed to go to therapy, but otherwise preferred to stay in his room. A review of R55's clinical record revealed R55 was admitted into the facility on 2/11/25 with diagnoses that included: cerebral ischemia (stroke). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R55 had clear speech, with distinct intelligible words, mad himself understood, and had intact cognition. A review of R55's Physician's Orders revealed an order dated 2/11/25, discontinued on 2/23/25 for Full Code (all life-saving measures will be attempted if the heart stops beating or the person stops breathing) by default. An active order with a start date of 2/23/25 documented, Full Code. A review of a Code Status/'Do Not Resuscitate' Directive form revealed R55's signature and a family member's signature dated 211/25 that indicated R55 was a Full Code. A review of a SW (Social Work) Initial Assessment and Discharge Plan progress note dated 2/21/25 revealed documentation that included.able to make needs known .demonstrating moderate cognitive impairment .SW is working in conjunction with IDT (interdisciplinary team) to address cognition with a goal of improvement throughout stay and SW initiated formal Capacity (evaluation). Safety awareness and impulsivity seem to be intact and no concerns at this time .Referral for psych services is indicated at this time for a capacity (evaluation) .Social Work has reviewed Advance Directive and current code status which are appropriate at this time. Resident wishes for code status to remain FULL code . It should be noted that after review of R55's complete clinical record, there was no evidence of a documented Advance Directive. A review of a Physician/Psychologist Determination of Decision Making Capacity form indicated R55 Lacks the capacity to make informed medical decisions independently. The form was signed by a physician on 3/6/25 and a psychologist on 3/5/25. A review of a Social Services note dated 7/22/25, written by Social Services Coordinator (SSC) 'AA' revealed the following documentation, SW notified that resident is in need of establishing a guardian (a person appointed by a judge to make all decisions when the person is deemed incompetent to make their own decisions). SW contacted (guardianship company) to submit referral. (Guardianship company) accepted referral and needed information sent to facility attorney to begin guardianship petition. On 7/30/25 at approximately 1:15 PM, an interview was conducted with R55. When queried about whether anyone had a conversation with him about developing an advance directive that would designate someone to make decisions for him in the event he was unable to, R55 reported he was able to make his own decisions at that time, but (R55's son's name) was the person he designated to make decisions for him if he were unable to. R55 reported he had two other sons and referred to them by name, but clearly explained the first son he mentioned was the person who he wanted involved in his treatment decisions. When queried about any conversations the facility staff had with him regarding his code status or what his treatment wishes were in the event that his heart stopped beating, R55 reported nobody in the facility had a meaningful conversation with him about that. R55 said he did not think he would want to be resuscitated but wanted to have a conversation regarding it before making any definitive decision. On 7/30/25 at approximately 2:00 PM, an interview was conducted with SSC 'AA'. When queried about the social services department's responsibility in regard to discussing formulating advance directives with residents, SSC 'AA' reported advance directives were discussed at every care conference and/or quarterly and code status was also discussed with the resident or their legal representative. When queried about who was responsible to explain the residents' rights for decision making and for designating someone to make decisions on their behalf if they became unable to, SSC 'AA' stated, Anyone could talk to them about formulating an advance directive. When queried about who was permitted to make a decision regarding code status for a resident, SSC 'AA' reported a resident signed their own code status form if they were competent to do so, otherwise their Durable Power of Attorney for Heath Care (DPOA - a legal document that designates another person to make decisions on your behalf if you are unable to make your own decisions) or legal guardian would decide and sign the form. SSC 'AA' reported the DPOA became active only when a resident was deemed incapacitated. When queried about whether a resident would be included in any conversations about their treatment wishes even if they had a legal guardian or DPOA, SSC 'AA' reported it depended on whether the legal guardian wished for the resident to be included in the conversation. When queried about the facility's process for determining whether a resident was competent to make their own medical decisions, SSC 'AA' reported the resident was evaluated by a physician and psychologist who determined their competency. SSC 'AA' was asked to explain the process for obtaining a legal guardian for a resident who did not have a DPOA. SSC 'AA' reported it depended on whether the resident had family who were active in their care and if so, the facility would encourage family to file for guardianship. Otherwise, if family was not involved or did not wish to file for guardianship, the facility used their attorney to assist with filing for guardianship through the court. At that time, SSC 'AA' was asked if R55 made his own medical decisions. SSC 'AA' reported he did not and was deemed incapacitated to make medical decisions in March 2025. When queried about who made decisions for R55, SSC 'AA' reported R55 could still assist with decision making and one of R55's son's was active in his care, but Business Office Manager (BOM) 'BB' told SSC 'AA' R55 was in need of a legal guardian and they would utilize the facility's attorney to facilitate that process. When queried about the progress note that documented the facility contacted a guardianship company to facilitate pursuing guardianship for R55 and did not note anything about discussing guardianship with R55's family, SSC 'AA' reported R55's son was supposed to pursue guardianship and never did so they had to move on to the next step. When queried about whether R55 needed a legal guardian as he appeared able to clearly understand others and whether formulating an advance directive (DPOA) was discussed with R55 before going forward with legal guardianship, SSC 'A' reported once R55 was deemed unable to make medical decisions on 3/5/25, he was no longer able to designate a DPOA. SSC 'A' reported R55 did designate his son as his DPOA but the paperwork because null and void because R55 was already deemed incompetent. When queried about any discussion that was had with R55 and his family prior to moving forward with pursuing guardianship as documented on 7/22/25, SSC 'AA' reported the facility only had an umbrella discussion and said she was positive R55 would say he wanted his son (R55's son's name) to make decisions for him. SSC 'A' further reported the facility wanted to get legal guardianship for R55 because R55 needed assistance with completion of the Medicaid application and the son did not provide all the information. On 7/30/25 at 2:50 PM, an interview was conducted with the Administrator. When queried about the facility's protocol on assisting residents with formulating advance directives, the Administrator reported on admission, the social services staff interviewed the residents or if the resident was unable to be interviewed, they would talk to the responsible party or legal guardian. When queried about what was included in the discussion, the Administrator stated, They talk about whether they want to be a full code. The Administrator further explained that the resident was included in a discussion regarding appointing a decision maker if they became unable to make decisions on their own. If the resident was not about to make their own decisions, the facility would verify if they had a financial or medical decision maker in place and if not, legal guardianship would be explored. When queried about how it was determined that a resident was unable to make their own decisions, the Administrator reported it would be discussed by the IDT and then SW would facilitate a competency evaluation by a physician and psychologist. When queried about the facility's process when it was believed a resident needed a legal guardian, the Administrator reported they would first meet with the resident's family to discuss the need for guardianship and to see if the resident had a DPOA already in place. If the resident did not have a DPOA, then the family was strongly encouraged to file for legal guardianship. When queried about whether the resident could designate a DPOA at that time, if they were able to participate in the conversation, the Administrator reported if the facility physician and psychologist already deemed them incompetent to make decisions then they could not choose a DPOA. The Administrator reported all conversations regarding advance directives, guardianship, and steps taken were expected to be documented in the resident's clinical record At that time, the Administrator was asked about R55 and whether he was able to make his own decisions. The Administrator stated, He is about to make his own decisions. When queried about the progress note that documented the facility contacting a guardianship company and their attorney to file for legal guardianship, the Administrator stated, He owes us a lot of money. The Administrator reported the facility was trying to get R55 a conservator to handle the financial end of things. The Administrator reported R55's son was approached about getting documents in order to apply for Medicaid, but he did not get what they needed. The Administrator reported they were only trying to get help with the financial side of things and not medical. It should be noted that there was no documentation of the above in R55's clinical record. When queried about her comment that R55 was able to make his own decisions and why R55 was deemed incompetent, the Administrator reported R55 presented differently on admission, but although he had some challenges with verbal communication, he appeared to understand others. The Administrator explained R55's competency should have been reviewed. On 7/31/25 at 8:22 AM, an interview was conducted with R55's son. When queried about any conversations the facility had with him regarding advance directives or obtaining legal guardianship, R55's son said when R55 was admitted the facility talked to him about formulating DPOA paperwork. R55's son said R55 designated him as his DPOA in May 2025, and they had the paperwork developed which designated R55's son as his decision maker in the event he was unable to make decisions for himself. When queried about whether the paperwork was on file at the facility, R55's son said the facility said they no longer needed the DPOA paperwork. R55's son said about two months ago, BOM 'BB' talked to him about applying for Medicaid and requested financial documents which were provided via email. R55's son instructed BOM 'BB' to talk to R55 directly about any life insurance that he had. R55 did not hear anything since then. R55 reported the facility did not inform him of any plans to file for legal guardianship. On 7/31/25 at 9:06 AM, an interview was conducted with BOM 'BB' via the telephone. When queried about contacting SSC 'AA' in regards to R55 needing a legal guardian and what led to that decision, BOM 'BB' said it was determined R55 had to stay for long term care and therefore needed to apply for Medicaid. When queried about any conversation that was had with R55 and his son, BOM 'BB' reported R55's son was helping me to a point but at some point got frustrated with the financial documentation and said to ask (R55) .I asked (R55) and he looked at me bewildered (It should be noted that R55 has aphasia and needs time to process and formulate a response) . BOM 'BB' reported she told R55's son that she needed the paperwork. BOM 'BB' reported the facility needed a conservator in order to get the financial paperwork in order. Further review of R55's medical record revealed no documentation of only needing assistance with financial matters. A review of an undated policy provided by the facility titled, Advance Directives Policy, revealed, in part, the following, .A resident or a person claiming to responsible for a resident will be asked during the admission process if the resident has an Advance Directive .All Advance Directives .will be reviewed by the Admissions Department when received prior to or on admission. The Social Serivces Department upon admission and at least annually will review the advanced directives .If the advance directive document is found to be insufficient, the resident, responsible party and/or the party claiming to be a healthcare legal decision maker will be notified and the document will be placed on file and the medical record noted that the advance directive was not sufficient .Capacitated/Competent resident who wish to execute a DPOA-HC (Health Care) upon admission will be assisted by the Social Worker or Designee. Competent residents, who wish to execute a DPOA-HC after admission will be assisted by the Social Services Department .A competent resident must have the ability to understand and to communicate both the decision to execute a Durable Power of Attorney for Healthcare and/or a Resident Code Status and understand the effect of any of these documents. An individual's competence may vary from time to time, and even within the same day. Mental illness or a diagnosis of dementia alone, even having a legal guardian, does not necessarily mean that the resident is not 'of sound mind' or not 'competent' for the purposes of executing an Advance Directive . R30 On 7/29/25 at 11:17 AM, R30 was observed lying down on their back in bed. A brief interview was conducted with the resident at that time. A review of the medical record revealed R30 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia (difficulty speaking) and an anxiety disorder. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13 (which indicated intact cognition). The resident was noted to be their own responsible party for all clinical and financial decisions. A review of the medical record revealed no documentation of the resident to have been educated and offered to formulate an advance directive. A review of a facility policy titled “Advance Directives Policy” dated “Nov.1991” documented in part, “… Regardless of previously executed Advance Directives, information on resident rights concerning Advance Directives will be provided to each competent adult resident by the Admissions Department at the time of resident admission, or by the Social Worker following admission and documented in the Social Services progress notes…” On 7/30/25 at 2:22 PM, the admission Coordinator (AC) “A” was interviewed and asked their role in educating and offering residents to formulate or decline to formulate an advance directive. AC “A” responded they completed the initial tours of the facility and admission documents with the residents and/or resident representatives and the social workers and nursing was responsible for the advance directives portion. On 7/31/25 at 8:34 AM, the Director of Social Work (DSW) “B” was interviewed and asked their role in the education and offering to residents and/or resident representatives to formulate an advance directive. DSW “B” responded they will talk to the residents/resident representatives and discuss code status. DSW “B” stated they ask if they have an advance directive and will note it in their progress notes and ensure the documents are scanned in the medical record. When asked if the residents/resident representatives don’t have an advance directive upon admission if the social workers are educating and offering the residents/resident representatives on advance directives, DSW “B” stated “… We don’t necessarily have this conversation with everyone…” When asked why not, DSW “B” stated most residents are admitted and discharged so fast in the facility. DSW “B” was asked to review the record of R30 and provide any documentation of the resident to have been educated and offered to formulate an advance directive. On 7/31/25 at 8:40 AM, the Director of Nursing (DON) was interviewed and asked the facility’s nursing role in the educating and offering to formulate and/or decline to formulate an advance directive for the residents. The DON stated the nurses would ask on admission if they have an advance directive but they don’t educate the residents/resident representatives. On 7/31/25 at 9:18 AM, DSW “B” followed up and stated they were unable to find documentation of R30 to have been educated or offered to formulate an advance directive. No additional information or documentation was provided by the end of the survey.

Based on observations, interview and record review the facility failed to protect the resident's right to be free from neglect for one (R141) of five residents reviewed for abuse resulting in R141 being left on a bedpan for four hours. Findings include: On 7/29/25 at 9:56 AM, R141 was observed lying in bed. R141 was asked about care at the facility. R141 explained a couple nights before he had to go to the bathroom during the night. the aide put him on a bedpan. she did not come back, he was on the bedpan for four hours, his bottom was hurting bad, his legs and heels still hurt from being on the bedpan that long. then when the aide finally came back, she took the bedpan to the bathroom, he thought she was going to clean him up, but she walked out of the room. he waited to see if she was going to get supplies, but she did not come back, so he pushed his call light again after about 15-20 minutes. the aide came back and asked what he needed, he asked if she was going to clean him up, she told him she had forgotten and would get the supplies. she never came back. the day shift aide was the one who finally cleaned him up. R141 was asked if he had told anyone at the facility about what happened. R141 explained he told the Social Worker about it the next day.Review of the clinical record revealed R141 was admitted into the facility on 7/26/25 with diagnoses that included: traumatic subdural hemorrhage, repeated falls and Parkinson's Disease. According to a Brief Interview for Mental Status (BIMS) exam dated 7/28/25, R141 scored 15/15 indicating intact cognition.Review of a Concern Form dated 7/28/25 for R141 read in part, .Resident stated call light was answered but task [sic] were not complete. Aide left him on bedside commode (commode was crossed out) bedpan for 2 hours, when taken off bedpan was not properly cleaned. 7/27/25. PM shift.On 7/30/25 at 4:35 PM, R141 was asked if he was placed on the bedpan on the afternoon shift or the midnight shift. R141 explained it was at 1:00 AM, and he was on it for four hours and then had to wait for the day shift to get cleaned up. On 7/31/25 at 8:56 AM, Certified Nursing Assistant (CNA) K was interviewed by phone and asked if she knew anything about R141 being on a bedpan on the night of 7/27/25. CNA K explained she had not worked on 7/27/25, but did have R141 on the midnight shift on 7/28/25 and R141 had told her about being left on the bedpan was very upset about it, and that his bottom and legs were still hurting.On 7/31/25 at 9:15 AM, CNA M, who was R141's assigned midnight shift CNA on 7/28/25, was called and a message left. No return call was received. It should be noted that on 7/31/25 at 10:40 AM, the Administrator emailed she had contacted CNA M to return the call, and on 7/31/25 at 12:57 PM, the Director of Nursing (DON) also contacted CNA M to return the call.On 7/31/25 at 12:01 PM, CNA L, who was R141's assigned day shift CNA on 7/28/25, was interviewed and asked if she knew anything about R141 being on a bedpan during the night. CNA L explained R141 was very upset, the midnight CNA had left him on the bedpan for four hours. she started to clean him up and could still see the ring around his bottom from the bedpan. there was dried feces on his skin she had to wash off. CNA L was asked who had been R141's midnight CNA. CNA L explained she had not received any report when she started her shift, so she did not know who it was.On 7/31/25 at 12:57 PM, the DON was interviewed and asked how long a resident should be left on a bedpan. The DON explained after putting a resident on a bedpan, privacy should be given, but they should be checked on in approximately five minutes. The DON was asked about R141 being left on a bedpan for four hours. The DON explained they had provided education to the CNA. The DON was asked to verify who the CNA was. The DON explained it was CNA L. The DON was asked if a resident should be cleaned up after using a bedpan. The DON explained it was expected that a resident was always cleaned after using a bedpan. On 7/31/25 at 2:00 PM, the Administrator was interviewed and asked if leaving a resident on a bedpan and not cleaning them up after taking them off could be considered neglect, the Administrator acknowledged the concern.Review of a facility policy titled, Abuse & Elder Justice Act Policy dated 1/18/24 read in part, .Neglect: means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (There is a presumption that neglect has occurred whenever a facility or individual fails to provide a treatment or services to a resident which is necessary for a resident's health or safety, and the failure to provide that treatment or service results in a deterioration of the resident's physical, mental, or emotional condition).

Based on observation, interview and record review, the facility failed to ensure resident equipment was maintained in good repair for one (R8) of three residents reviewed for a homelike environment. Findings include:On 7/29/25 at 10:50 AM, an interview was conducted with R8's Legal Guardian (LG) who was seated in a wheelchair next to the resident who was lying in bed. The wheelchair was observed to have a missing left armrest, and the wheels had no treads and were very worn. When asked about whether that had been provided by the facility or brought in from home, the LG reported that was provided by the facility. When asked how long the wheelchair had been in that condition and if anyone had identified a need to replace or repair the wheelchair, the LG reported the wheelchair had been a wreck for a while and no one from the facility had ever asked about it before.On 7/31/25 at 9:10 AM, an interview and observation of the third floor was conducted with the Maintenance Director (Staff ‘R') who has worked at the facility for about four years and in the Director role for about four months.When asked about the facility's process for reporting items that needed to be repaired or replaced, Maintenance Director reported staff usually placed outside their office with a note or verbally told them. When asked if the facility utilized an electronic reporting, they reported they did but most staff told them verbally.On 7/31/25 at 9:15 AM, Staff ‘R' confirmed the same observation of R8's wheelchair and reported they were not aware of that before now and would follow-up.Review of the documentation provided of the electronic reporting for items that needed maintenance and had already been addressed did not include R8's wheelchair.According to the facility's undated Standards of Practice titled, Equipment Repair or Replacement: .When a repair or replacement need is identified, the employee should enter the information into the TELs system (an electronic work order reporting system), which will communicate with the Maintenance staff .Log repairs into the TELs system.

Based on observation, interview and record review the facility failed to protect a resident from exploitation for one (R124) of five residents reviewed for abuse. Findings include: On 7/29/25 at 11:13 AM, R124 was observed sitting in a wheelchair in his room. R124 was asked if he was able to take himself to the bathroom. R124 explained he needed staff assistance.Review of the clinical record revealed R124 was admitted into the facility on 6/25/25 with diagnoses that included: metabolic encephalopathy, multiple fractures of ribs and diabetes. According to the Minimum Data Set (MDS) assessment dated [DATE], R124 had moderately impaired cognition.On 7/31/25 at 12:01 PM, Certified Nursing Assistant (CNA) L was interviewed about a concern with R124's roommate. During this interview, CNA L was asked if on the morning of 7/28/25 R124 and his bed were left wet. CNA L explained when she started her shift that morning, she had been given no report and both R124 and his roommate needed to be cleaned up. CNA L then explained she had taken a picture. CNA L proceeded to take out her personal phone and explained she had hundreds of pictures. CNA L produced a picture that showed a person sitting on a bed, the face was not visible, but the image was identifiable as R124. The picture showed the blue pad top of the fitted sheet, and the fitted sheet were wet. CNA L was asked why she had pictures of residents on her personal phone. CNA L explained she took the pictures so she could defend herself.On 7/31/25 at 2:30 PM, the Administrator was interviewed and asked if employees were allowed to take pictures of residents on their personal phones. The Administrator explained employees were not allowed to take pictures of residents, it was in their Employee Handbook, as well as in the Abuse Policy.Review of CNA L's employee file revealed documentation of CNA L receiving an Employee Handbook as well as a checklist of items in the Employee Handbook.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two residents (R#'s 49 and 20), of two residents reviewed for accommodation of needs, resulting in the potential for delayed attention to resident care needs. Findings include:On 7/29/25 at 10:11 AM, R49's room was observed with the right side of their bed against the wall. R49 was in their wheelchair on the left side of the bed and it appeared their foot was wedged between the wheelchair pedal and the bottom of the bed rails. R49 asked for assistance to have their foot unstuck from under the bed. They were asked to activate their call light for staff assistance, and said they did not have their call light. At that time, the call light was observed hanging down from the call light box on the right side of the bed against the wall, not within reach of R49. On 7/29/25 at 10:18 AM, R20's room was observed with the left side of the bed against the wall. R20 was in their wheelchair on the right side of the bed at the foot. An oxygen concentrator was placed on the right side of the bed at the head. At that time, R20 requested assistance to use the restroom. R20 was asked to activate the call light and said, I can't reach it. At that time, the call light was observed to be at the head of the bed clipped onto the bed linens behind the concentrator, approximately five foot away from R20's reach. On 7/29/25 at 10:19 AM, Nurse 'C' was made aware R20 requested assistance and their call light was out of their reach. Nurse 'C' said it should have been within reach and went to assist R20. A review of a facility provided policy titled, Call Light Policy was reviewed; however, the policy did not address ensuring call lights were kept within resident reach.

Based on observation, interview and record reviews the facility failed to ensure a dignified dining experience for one (R14) of one resident reviewed for dining, which had the ability to affect multiple residents who dined in the second floor dining room. Findings include: On 7/29/25 at 11:50 AM, an observation of the second floor lunch meal was conducted in the dining room area. Initially, 16 residents were observed in the dining room waiting to be served. At 12:20 PM, the first tray was observed being served. Flies were observed flying around the dining room. The first, second, third, fourth and fifth table were observed to have been provided their lunch meals, with the exception of two residents at the second table and R14 from the third table. The two residents from the second table and R14 were observed with no lunch meals to have been provided. At 12:37 PM, the two residents from the second table was provided their meal. One resident was observed to require the assistance of staff to be fed. At 12:39 PM, R14 was observed looking down, while the rest of the residents at table three were almost completed and/or finished with their lunch. At 12:46 PM, R14 was served a bacon cheeseburger. On 7/30/25 at 2:43 PM, the Administrator and Director of Nursing (DON) were interviewed regarding the observations made of the lunch meal on the second floor on 7/29/25. The Administrator and DON stated they were informed of the observations. Education had been provided to the staff and they were hoping for a better experience moving forward.No further explanation or documentation was provided by the end of the survey.

Based on interview and record review, the facility failed to ensure a stop-date for a PRN (as needed) order for anti-anxiety medication for one resident (R120), of five residents reviewed for unnecessary medications. Findings include: On 7/31/2025 at 11:02 AM, a review of R120's clinical record revealed they most recently re-admitted to the facility on [DATE] with diagnoses that included: heart disease, protein calorie malnutrition, adjustment disorder, anxiety disorder, falls, delirium, depression, and dementia with behaviors. R120's physician orders were reviewed and revealed a current, active order originating 12/20/24 for Ativan 0.5 mg (milligrams) to be given every four hours as needed. It was noted the medication had been re-ordered on 3/13/25 and 6/9/25 with the same instructions, to be given every four hours as needed with no duration of time for use defined. A review of R120's monthly medication regimen review reports prepared by the facility's pharmacist and reviewed and signed by the attending physician was conducted and revealed the following: A report dated 1/28/25 that indicated R120's PRN Ativan (anti-anxiety medication) order should include a duration of time for use. The report was signed by the physician and a box was checked that read, Continue with the above (Ativan) PRN order for #30 days. Rationale: Hospice patient. A report dated 2/27/25 that indicated R120's PRN Ativan order should include a duration of time for use. The report was signed by the physician and box was checked that read, Continue with the above (Ativan) PRN order for #14 days. Rationale: Hospice and is in need d/t (due to) anxiety. A report dated 3/29/25 that indicated R120's PRN Ativan order should include a duration of time for use. The report was signed by the physician and box was checked that read, Continue with the above (Ativan) PRN order for #14 days. Rationale: Hospice patient, Benefit > Risk. On 7/31/25 at 11:27 AM and 1:00 PM, a request for monthly medication regimen reviews for 4/28/25 and 5/21/25 was made. On 7/31/25 at 3:35 PM, an interview was conducted with the facility's Director of Nursing. They said they could not find the monthly medication regimen reviews for April and May. During the interview it was brought to their attention that in January, February, and March the Pharmacist recommended a duration of use for the Ativan, the Physician put a duration of time for use on the form, but the order had never been changed and still as of the survey remained the original order (dated 12/20/24) for the medication to be given every four hours as needed. They said if the physician signed the form and put a duration of time for use, the physician would be the one responsible for changing the order in the computer system. A review of a facility provided policy titled, Drug Regimen Review was conducted; however, the policy did not address changing the orders based on the Pharmacist's recommendation and the Physician's response to the recommendation.

This citation pertains to intake #1227216 Based on interview and record review the facility failed to report an allegation of neglect and an injury of unknown origin to the State Agency for two residents (R138 and R141) of five residents reviewed for abuse, neglect and mistreatment. Findings include: On 7/29/25 a complaint that was submitted to the State Agency was reviewed that alleged R138 had a head wound from an unknown origin. On 7/29/25 the medical record for R138 was reviewed and revealed the following: R138 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Brief Psychotic disorder and was discharged to the hospital on 6/16/25. A review of R138’s MDS (minimum data set) with an ARD (assessment reference date) of 6/5/25 revealed R138 needed supervision from facility staff with most of their activities of daily living. A review of R138's progress notes revealed the following: 6/14/2025- Noted new skin issue observed by CNA (Certified Nursing Assistant). Resident observed with discoloration to forehead. Tx (treatment) order noted in place and provided. Noted notification of MD (Medical Doctor), wound care and family. 6/13/2025- Physician Progress Notes- Date: 6/13/2025 .CHIEF COMPLAINT .PRESENT ILLNESS WITH ASSESSMENT AND PLAN: .evaluated at the bedside on June 13, 2025 overall comfortable with no acute distress. Patient later in the day according to the staff and per imaging noted to have infection burn on his forehead. Patient according to the staff did not sustain a fall. Otherwise with no fever or chills .Patient with history of advanced dementia and behavioral disturbances with frequent falls requires frequent redirection and safety measures. According to the staff he did not have a fall at this event we will monitor any changes Patient to continue on current supportive care .Monitor for any bleed with friction rub around his forehead and above his left eyebrow. 6/13/2025- Nurses Note- Writer alerted by CNA that resident had red discoloration to his forehead. Residents skin was assessed. Nurse caring for resident made aware, MD notified, Wife notified. Logged for Wound care. Treatment ordered for TAO (triple antibiotic ointment) daily for one week. A review of the MIFRI (Michigan reporting system) revealed no submitted investigation for R138's wound/burn on their forehead as indicated by the Physican on 6/13/25 was present in the system. On 7/30/2025 at approximately 2:08 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding R138's forehead wound/burn documented by the Physican on 6/13/25 and they reported that they were never made aware of it but would have to check their documentation to see if any investigations had been completed. On 7/30/2025 at approximately 2:37 p.m., the facility Administrator and DON were queried regarding R138's wound/burn on their forehead. The Administrator indicated they were never made aware of the injury and no investigation or reporting to the State Agency was done due to them not being aware. The DON was queried if they knew how R138's sustained a wound/burn on their forehead and they reported the injury origin was unknown. The Administrator was queried if they should have been made aware of the injury if its origin was unknown, and they indicated that they should have, and they would have started their process for reporting and investigating an injury of unknown origin. On 7/30/25 a facility document pertaining titled Abuse and Elder Justice Act Policy was reviewed and revealed the following: Component 7: Reporting/Response The facility shall: a. Immediately report (within 24 hours) to the State of Michigan b. Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation On 7/29/25 at 9:56 AM, R141 was observed lying in bed. R141 was asked about care at the facility. R141 explained a couple nights before he had to go to the bathroom during the night… the aide put him on a bedpan at 1:00 AM… she did not come back, he was on the bedpan for four hours, his bottom was hurting bad, his legs and heels still hurt from being on the bedpan that long… then when the aide finally came back, she took the bedpan to the bathroom, he thought she was going to clean him up, but she walked out of the room… he waited to see if she was going to get supplies, but she did not come back, so he pushed his call light again after about 15-20 minutes… the aide came back and asked what he needed, he asked if she was going to clean him up, she told him she had forgotten and would get the supplies… she never came back… the day shift aide was the one who finally clean him up. R141 was asked if he had told anyone at the facility about what happened. R141 explained he told the Social Worker about it the next day. Review of the clinical record revealed R141 was admitted into the facility on 7/26/25 with diagnoses that included: traumatic subdural hemorrhage, repeated falls and Parkinson’s Disease. According to a Brief Interview for Mental Status (BIMS) exam dated 7/28/25, R141 scored 15/15 indicating intact cognition. Review of a “Concern Form” dated 7/28/25 for R141 read in part, “…Resident stated call light was answered but task [sic] were not complete. Aide left him on bedside commode (commode was crossed out) bedpan for 2 hours, when taken off bedpan was not properly cleaned… 7/27/25… PM shift…” On 7/31/25 at 12:57 PM, the DON was interviewed and asked how long a resident should be left on a bedpan. The DON explained after putting a resident on a bedpan, privacy should be given, but they should be checked on in approximately five minutes. The DON was asked if a resident should be cleaned up after using a bedpan. The DON explained it was expected that a resident was always cleaned after using a bedpan. When asked if leaving a resident on a bedpan for four hours and not cleaning them up could be considered neglect, the DON acknowledged the concern. On 7/31/25 at 2:00 PM, the Administrator was interviewed and asked if she had reported to the SA that R141 had been left on a bedpan for four hours and not cleaned up after until the next shift. The Administrator explained she had not, but when put like that, she should have.

This citation pertains to intake #'s MI00147613 and MI00147486. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by Certified Nursing Assistant C (CNA C) for one resident (R901) of two residents reviewed for abuse/neglect/mistreatment, resulting in R901 being in pain from being punched, kicked and the target of derogatory language. Findings include: On 10/28/24 a complaint submitted to the State Agency (SA) was reviewed that alleged R901 was physically and verbally abused by CNA C on 10/12/24. On 10/28/24 at approximately 8:57 a.m., during a conversation with the facility Administrator (who is also the abuse coordinator), the Administrator was queried pertaining to the allegation of physical and verbal abuse perpetrated by CNA C against R901 on 10/12/24 and the Administrator indicated that it did happen and was witnessed by Nurse D. The Administrator indicated the following: The event occurred on Saturday October 12th 2024 during the early morning and they were initially called on the phone by CNA C who informed them that Nurse D would be calling them about trying to get their glasses back from R901. A few minutes later, the Administrator reported receiving a phone call from Nurse D who indicated they were trying to have CNA C leave the facility but they would not leave. The Administrator then reported that they could hear CNA C yelling in the background and the Administrator informed Nurse D that if CNA C would not leave then to call the police. The Administrator then reported that Nurse D informed them that CNA C was being aggressive with staff but did not initially disclose the incident of abuse pertaining to R901. The Administrator indicated that they instructed Nurse D to write a statement pertaining to CNA C's behavior but that a few hours later, the Administrator received a phone call from the Director of Nursing (DON) that indicated abuse had occurred and at that time, the police department was notified. The Administrator reported that CNA C was arrested but that they were currently released from jail and that they had implemented a past-noncompliance procedure which included reeducating all staff on abuse/neglect/mistreatment and dealing with residents who display challenging behaviors. On 10/28/24 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 9/18/24 revealed R901 needed supervision from facility staff with personal hygiene. R901's BIMS score (brief interview for mental status) was 10 indicating moderately impaired cognition. A Nursing progress note dated 10/12/24 at 8:26 a.m., revealed the following: [CNA C] Asked me my name. she then asked what should she do if a resident has her glasses. I asked her which resident was she referring to she stated [R901]. I then entered the room and asked [R901] could I see her glasses she told me no that the doctor had prescribed them for her reading. before I could say the resident's name again [CNA C] ran up on [R901] grabbed her by the neck grabbed the glasses off of [R901] face swung on [R901] and kicked her leg and called her a [b****}. [R901] started swinging in defense I pulled them apart and told [CNA C] to leave immediately. I than proceeded to call [Administrator] I was told to walk her out of the building and to call the police if she did not leave. I then called the DON and was told police and state is being notified. Assessments are being completed. I came and asked to watch the floor while I reported the incident she then told [CNA B] she from zone eight and she will knock her out. A Vitals and Pain only note dated 10/12/2024 at 8:53 a.m., revealed the following: .Pain: Over the past 5 days, how often have you limited your day-to-day activities(excluding rehabilitation therapy sessions) because of pain: Rarely or not at all. Pain intensity: 3 Please rate the intensity of your worst pain over the last 5 days: Mild. Indicators of pain: Vocal complaints of pain. resident complained of being sore . A Nursing note dated 10/12/2024 at 9:16 a.m., revealed the following: Received report from MN (midnight) nurse shift. Police officers arrived. Face sheet of resident provided. MN nurse provided witness statement. EMS (Emergency Medical Services) arrived, assessed resident and reported to writer that resident did not want to go to hospital at this time A Nursing note dated 10/12/2024 at 2:12 p.m., revealed the following:Resident's daughter/guardian, [Name of daughter] visiting this afternoon. Daughter requests that the resident get checked out further in the emergency room . Resident gave verbal consent as well A Nursing note dated 10/12/2024 at 8:59 p.m., revealed the following: Resident returned from hospital via ambulance, on stretcher with 2 attendants. Awake and alert and talking with staff. Assisted in to room and declined wanting to go to her bed. Up with RW (rolling walker) and in to the bathroom. She states she is hungry and CNA warmed her meal tray up, which had been saved for her. Resident stated she feels ok and is not having any extra pain right now. She says she hurt some at the hospital but they 'fixed her up' and she is only having a little bit of leg pain now . A copy of R901's hospital documentation on 10/12/24 revealed the following: radiology Orders: XR (x-ray) Chest 1 View Portable 10/12/24. Reason: Patient assaulted, punched/beat on chest .XR elbow Complete 3+ views Left 10/12/24-Reason: Patient assaulting, complaining of left hand pain, swelling. XR Hand Complete 3+ views Left 10/12/24-Reason: Patient assaulting, complaining of left arm pain, swelling. A Speech therapy (ST) evaluation dated with an onset date of 10/12/24 and start of care date of 10/15/24 revealed the following: Reason for referral: .was referred to a skilled ST evaluation following discharge from the hospital with complaints of pain during swallow. Pt (patient) presented to the hospital secondary to an incident resulting injury to her neck, complaints of pain and dysphagia upon hospitalization pt agreeable to remaining on ST caseload to treat and follow for pain during swallow and continued changes to diet orders. St educated pt guardian on results of evaluation and risks and benefits for MBSS (modified barium swallow study) to visualize swallow for potential dysphagia secondary to assault trauma . On 10/28/24 at approximately 11:01 a.m., the DON was queried regarding the abuse allegation pertaining to R901 and CNA C on 10/12/24 and they indicated that they had first talked to Nurse D on the phone at around 7:30 a.m., that day and that Nurse D had informed them of what had happened between R901 and CNA C that included CNA C punching, kicking, grabbing the neck and calling R901 at b****. The DON indicated that Nurse D had broken up the fight and told CNA C to leave the facility. The DON indicated by the time they had spoken with Nurse D, CNA C had left the building and after they got off the phone with Nurse D, they called the Administrator and informed them of the abuse committed by CNA C and the police were notified. On 10/28/24 at approximately 11:33 a.m., R901 was observed in their room, laying on their bed and dressed appropriately. R901 was queried if they remembered the incident with CNA C being physical with them and they indicated they did remember it. R901 indicated that CNA C thought they had their glasses and that they came into their room with the Nurse. R901 then reported that CNA C started to attack them including being punched and kicked and that CNA C also grabbed their neck. R901 indicated they were trying to fight back with their reacher device. R901 further reported that the other staff person (Nurse D) had to get CNA C off of them and get them out of the room. R901 was queried how they felt about the incident afterward and they reported they did not feel good. R901 was queried if they felt safe in the facility and they reported they did not but that they had not seen CNA C since the incident. R901 indicated they were glad CNA C was gone and if they ever saw her again, they would try to whoop her. R901 was queried if they were hurt and they indicated they were and that they were punched in the chest and kicked in the leg and they hurt their arm when CNA C was grabbing them. On 10/28/24 at approximately 12:30 p.m., Nurse D was queried regarding their observations of the incident between R901 and CNA C on 10/12/24. Nurse D indicated that the incident started by CNA C asking them what to do if a resident has their glasses and they asked C who the resident was and they Indicated it was R901. Nurse D then reported going to R901's room and CNA C followed them behind. Nurse D queried R901 if they had CNA C's glasses and at that time, CNA C jumped in front of them and then punched and kicked R901 along with grabbing their neck and calling them a b**** to their face. Nurse D reported they had to get CNA C off of R901 and then removed them from R901's room and told CNA C to leave the building, but CNA C would not go and was still across the hall agitated. Nurse D then indicated they went and got help from another CNA to watch the floor and protect R901 from CNA C while they went to another floor to call the Administrator and get help to remove CNA C from the facility. Nurse D reported they called the Administrator and informed them of what happened and that in return the Administrator instructed them to call the police if CNA C still refused to leave the facility. Nurse D was queried if they informed the Administrator of the witnessed abuse from CNA C towards R901 and they indicated that they did and that the Administrator told them not to call police at that time. Nurse D also reported they had called the DON but there was no answer so they left a voicemail. Nurse D Stated that they got help from another Nurse aide to go back to the unit where CNA C was to remove them from the building and CNA C was overheard threatening the other aide who was watching the floor and protecting R901. Nurse D then indicated that CNA C ended up getting their belongings shortly after and left the facility. Nurse D was queried if they ever notified the police department of the witnessed abuse and they indicated they did not because CNA C had left the facility. Nurse D was queried regarding R901's status after CNA C left and they indicated they were nervous/anxious about the incident but that it was expected. Nurse D was queried what time the abuse occurred at and they reported it was sometime between 4:00 AM. and 5:00 AM. On 10/28/24, the facility investigation pertaining to R901's abuse allegation perpetrated by CNA C on 10/12/24 was reviewed and revealed the following: [R901] five day report .On Saturday October [no date] [CNA C] called [Administrator], the Administrator/Abuse Coordinator at 5:11 a.m. [CNA C] reported to this writer that [R901] had taken her glasses and that she had gone into [R901]'s room to attempt to remove her glasses from [R901]'s face and that the Nurse would be calling this writer. At 5:15 a.m., [Nurse D] LPN (Licensed Practical Nurse), called this writer to inform me that [CNA C] was being loud and was aggressive to the staff and that [Nurse D] had asked [CNA C] to leave the building, but [CNA C] would not leave. This writer advised [Nurse D] to tell [CNA C] to leave and if she did not to call the police. [CNA C] has been suspended pending investigation. On October 15, 2024 [CNA C]'s employment was terminated. This writer told [Nurse D] to write her statement, to complete an incident report and a pain and skin assessment and give it to [DON} Director of Nursing. At approximately 7:42 am. [DON], Director of Nursing call this writer and informed this writer of the content of [Nurse D]'s statement. The statement read, '[CNA C] asked what should she do if a resident has her glasses. I asked her which resident and [CNA C] said [R901]. I entered [R901]'s room and asked [R901] could I see the glasses. [R901] stated, no those glasses was given to her by her doctor. I then tried to respond to [R901], but before I could call her name again, [CNA C] grabbed [R901] by her neck, swung on [R901], kicked her and called her a b***. [R901] was swinging back and had a grabber swinging it for defense. I separated [CNA C] and [R901] and told [CNA C] that she had to leave immediately and I then called [Administrator], the Abuse Coordinator.' Upon hearing this from [DON], this writer instructed [DON] to call the police and to notify the State of Michigan. The [Local Police Department] arrived at the the community with EMS-Case Number [Case Number] [Name of Local Police Officer]. They wanted to take [R901] to the hospital for evaluation but [R901] refused. The Police Officer was provided with information regarding [CNA C]-Date of birth, address, phone number etc .On Saturday October 12, 2024 at 2pm, the Administrator checked on [R901] and spoke to her daughter. Her daughter identified that [R901] was able to recall the event and that she was tearful and shaky but in good spirits. [R901]'s daughter confirmed that the police had contacted her and she stated that she is pressing charges against [CNA C]. [R901]'s daughter was able to convince [R901] to go to the hospital for evaluation on Saturday afternoon. [R901] was evaluated at [Name of local hospital]. Results were resident was complaining of Dysphagia, left hand pain and left arm pain. Resident was returned to the community following the evaluation. Resident is receiving pain medication and is being evaluated by Speech Therapy for Dysphagia On Monday October 14, 2024, Social Worker [Social Worker E] interviewed [R901]. [R901] stated, 'The staff member came into my room and had an actual fight with me. The girl came in and told me that those are my glasses and snatched them off my face. The girl hit and punched me and took my walker away and threw stuff around in there room. I told her that I was going to call the police. I went out to the hospital because of it. My neck, face and right leg hurts. The Doctor prescribed me something for pain. I feel safe in the facility and I am glad that the staff member is out of the building. I was told me that the staff member had been arrested so that makes me feel better .On Monday October 14, 2024 Detective F interviewed this writer, [DON] and [R901]. He stated that he is pursing Elder Abuse Charges for this event Based on this investigation, [CNA C] did grab [R901]'s throat hit her and called her a b**** . A Citizen Statement form from the local police department that documented Nurse D's statement was reviewed and revealed the following: [CNA C] asked what should she do if a resident has her glasses. I asked her which resident she said [R901]. I entered [R901]'s room and asked her could I see the glasses. [R901] stated no those glasses was given to her by her Doctor. I then tried to say [R901] but before I could call her name again [CNA C] had grabbed [R901] by the neck swung on [R901] kicked her and called her a b****. [R901] was swinging back and had a grabber swinging it for defense. I separated them and told her she had to leave immediately. I then called the abuse coordinator [Administrator]. A typed witness statement from CNA B that was signed on 10/17/24 was reviewed and revealed the following: Nurse came in room [ROOM NUMBER] where I was rendered <sic> came hysterically and told me that CENA beat a resident up, choked kicked her and call her names. Nurse said can you watch up here until I come back. After finishing care to the resident, I went around to [R901]'s room. Went to [R901] room and consoled resident she was shaking. I hugged her and told her I love her. [CNA C] ran into [R901]'s room and said 'you took my f***** glasses and you know you did. You bitch' I turned around and told [CNA C] to leave while standing in front of [R901] blocking [CNA C] from her and demanded that she get out and leave now. [CNA C] left out and went to desk, I went to edge of door and [CNA C] screamed at me that she was going to bust you up [CNA B]. She said you say something again I'm going to bust you up. Another CENA [CNA A] came up there saying what happen. I don't believe you did that. [CNA C] was saying I want my glasses. [CNA A] said I was supposed to be walking you out. [CNA C] continued packing back and forth A termination letter dated 10/15/24 for CNA C revealed the following: This letter serves to inform you that your employment at [Name of facility] has been terminated effective October 15, 2024, related to the incident that occurred on October 12, 2024, which have been documented and deemed detrimental to the safety and well-being of our staff and residents . On 10/28/24 a facility document titled [Facility] Abuse&Elder Justice Act Policy: was reviewed and revealed the following: Policy-It is our policy to maintain an environment free of abuse, neglect, exploitation, mistreatment and misappropriation of resident property. The resident has the right to be free from verbal , sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants, clinicians, volunteers, staff or other agencies servicing the resident family members or legal guardians, friends or other individuals .

This citation pertains to Intake#: MI00138928 Based on interviews and record review, the facility failed to (1) consistently monitor the change in condition for a Resident (R905) with Congestive Heart Failure (CHF - inability of the heart to pump blood efficiently, causing shortness of breath, fatigue, leg and foot swelling, and weakness) and transfer to hospital per advance directives and (2) failed to communicate/coordinate and follow up on the orders by the specialist (cardiologist) timely, resulting in a 9.4 lb.(pound) weight gain (in 4 days), difficulty breathing, discomfort, and death in the facility. Findings include: R905 R905 was admitted to the facility on [DATE] after hospitalization . R905 was living at home with their family prior to hospitalization . R905's was not returning to the community, and they were staying as a long-term resident in the facility. R905 was admitted to the hospital on [DATE] with a heart attack and was discharged to the facility on [DATE]. R905's other admitting diagnoses included congestive heart failure (CHF), hypertension (high blood pressure), and bipolar disorder. R905's Brief Interview for Mental Status (BIMS) score was ,d+[DATE], indicative of severe cognitive impairment. R905 had a family member appointed as their guardian. Based on the Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], R905 needed extensive staff assistance with their mobility and Activities of Daily Living (ADL - mobility in bed, transfers, toileting, etc.). A review of the complaint received by the State Agency revealed that R905 had a change in their condition during their stay. According to the complaint, the facility failed to monitor, follow up timely, and transfer R905 to the hospital. The report also revealed that the facility failed to communicate the change in condition and test results with the guardian which resulted in not providing them an opportunity to decide about R905's medical care and timely transfer to hospital. A review of R905's Electronic Medical Record (EMR) revealed an admission order dated [DATE] that read, AD (Advance Directive): Full Code by default. R905's wishes were to receive all resuscitation measures to keep them alive if their heart stopped beating and/or they stopped breathing. Another admission order dated [DATE] read, Weekly weight every day shift every Monday. A review of the progress notes revealed a clinical admission evaluation dated [DATE]. The admission evaluation read in part, O2 (oxygen) sats (saturation): O2 96% --Method: Room Air Cardio-Vascular: .No edema (swelling) present. Respiratory: Lungs clear throughout bilaterally. No difficulty breathing. No cough noted. Utilizing oxygen: No. A review of the admission History and Physical note by the provider dated [DATE] read in part, Respiratory: clear to auscultation, no respiratory distress, or use of accessory muscles (muscles other than the diaphragm and rib-cage muscles that may be used for labored breathing). Cardiovascular: Regular rhythm .Edema/varicosities (twisted, enlarged veins at the skin surface) of extremities: No edema or varicosities. Record review revealed that R905 did not have any edema in their legs, and they were not receiving oxygen when admitted to the facility. A review of R905's weight report revealed an admission weight of 281.0 lbs. dated [DATE]. Further review of EMR revealed a social work progress note dated [DATE]. The progress note read in part, .Resident presents as pleasant and motivated in therapy at this time .social work has reviewed advance directive and code status which are appropriate at this time. Patient/family would like the code status to remain FULL code, son is filing for guardianship. A wound care practitioner note dated [DATE], read in part, LE (Lower Extremities - legs): with bilateral (both) pitting edema. It must be noted that R905 did not have any edema on their lower extremities (legs) when they were admitted to the facility. A progress note dated [DATE] at 15:09 read, PA (Physician Assistant) notified, no new orders at this time, continue to encourage fluids. A review of orders for laboratory tests revealed a lab order dated [DATE] that read, CMP (comprehensive metabolic panel), CBC (complete blood count), ,d+[DATE] Dx (diagnoses). Anemia, elevated BUN (Blood Urea Nitrogen), elevated alkaline phosphatase one time only for 6 days. Copies of the laboratory test reports, and radiology reports were not accessible on EMR. All laboratory test and radiology reports for R905 were requested and they were provided via e-mail. A review of the lab results from the order revealed that R905 had abnormal (higher) results for BUN, 54.9 (previous BUN was 38.0 on [DATE]) in addition with other abnormal lab values. The laboratory note dated [DATE], signed by the practitioner read I ordered BMP (Basic Metabolic Panel - a laboratory test) and encourage fluids. Review of the practitioner note dated [DATE], revealed that R905 was seen for abnormal lab values and a fall, and the above recommendations for to add 8 oz. of water with meals to promote hydration. The practitioner visit note also revealed that R905 had pitting edema (swelling) on both of their legs. R905 also had an order dated [DATE] that read BMP (basic metabolic panel) one time only until [DATE] - 23:59. There was no documented evidence in EMR that this test was completed and no results for this test were provided by the facility via e-mail. Further review of orders read another laboratory test order dated [DATE] that read, BMP one time only until [DATE] - 23:59. There was no documented evidence on the EMR that this test was completed, and no results were provided by the facility via e-mail. Further review of R905's EMR revealed a cardiology (heart specialist) consult dated [DATE]. The cardiology note revealed that R905 had 3+ bilateral pitting edema on their legs. The assessment section of the note acute on chronic systolic and diastolic heart failure listed as the first diagnosis. The plan section of the note read continue diuretics (medicines that help reduce fluid buildup in the body) as the first plan for R905. It must be noted that R905 was not receiving any diuretics prior to the consult. A review of R905's orders and Medication Administration Record (MAR) did not reveal that R905 was started on diuretics timely after the cardiology consult on [DATE]. A review of R905's weight report revealed that weekly weights were not completed as ordered by the physician, from [DATE]. The order was changed to monthly weights on [DATE] and it was changed back to weekly weights every Friday on [DATE]. The weight report had the following entries: [DATE] - 293.1 lbs. [DATE] - 293.1 lbs. [DATE] - 292.6 lbs. (9.4 lbs. weight gain in 4 days) [DATE] - 283.2 lbs. [DATE] - 283.0 lbs. [DATE] - 283.0 lbs. [DATE] - 282.3 lbs. [DATE] - 281.0 lbs. There was no documented evidence of communication with the physician or practitioner on R905's significant weight gain of 9.4 lbs. in 4 days. A nursing progress note dated [DATE] at 18:24 read, patient was complaining of shortness of breath (SOB), nurse gave PRN (as needed) inhaler. Patient was sating at 90%. Nurse put on 2 L (liters) NC (nasal cannula). Pt. sating at 98% . A practitioner note dated [DATE], read in part, Patient seen and examined for concern of SOB .Patient states she has cough, shortness of breath, that began on ,d+[DATE] and collecting in BLE (Bilateral Lower Extremities) and has history of CHF. Plan section revealed that they ordered a Stat (immediately/urgent) chest x-ray, O2 (oxygen) at 2 Liters via nasal cannula and nebulizer treatment. It must be noted that during this time R905 was still not receiving their diuretics as recommended by the cardiologist for CHF. The x-ray results revealed a suspicion for pulmonary edema (abnormal fluid buildup in lungs), pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity); and severe cardiomegaly (enlarged heart). Further review of the orders revealed an order for diuretic that read furosemide 20 mg.(milligrams) once a day for CHF), ordered on [DATE], and R905 received their first dose on [DATE]. On [DATE], R905 had 9.4 lbs. weight gain in 4 days. There was no documented evidence that the physician or practitioner was made aware of the significant weight gain. There was no timely follow up physician or practitioner visit that addressed the significant weight in 4 days. The order for diuretic dosage was changed on [DATE], increased Furosemide 20 mg one time a day to two times a day. A weight warning note dated [DATE] (15 days after 9.4 lbs. weight gain in 4 days) read in part, weight gain possible d/t physical inactivity, good appetite, and or food choices. Skin intact. No edema noted, furosemide in place. Wt. changes possible d/t fluid fluctuations . R905 was recovering from a recent heart attack and there was no documented evidence that R905 had any tests done to monitor their heart function with their change in condition. A review of the hospital discharge summary revealed that R905 was receiving diuretics during their stay at the hospital, and they were discontinued prior to discharge. There was no documented evidence a medication reconciliation or follow up with R905's guardian or their primary care physician. A review of progress notes dated [DATE] at 4:36 AM read in part, At approximately 24:22 assigned CNA (Certified Nursing Assistant) informed writer that patient was not responding during her routine rounds. Full code status confirmed, and code blue called .Emergency response arrived and continued with CPR at 24:38, staff continued to assist. Patient pronounced at 01:23 by physician. An interview was completed with the R905's guardian on [DATE] at approximately 10:15 AM. R905's guardian reported that they were visiting their family member regularly at the facility. The guardian reported that they had usually visited after work and R905's brother visited during the day. They had reported that R905's breathing was getting worse, and they had reported their concerns to the facility staff and unit manager. The guardian also reported that they were not aware that R905 was not getting their diuretics and that R905 had heart failure and they had been on diuretic medications for a long time due to heart failure. The guardian also reported that on [DATE] they had received three phone calls from R905's phone requesting the guardian to come. During the visit R905 reported that they were not feeling well and had trouble breathing. The guardian reported that they had alerted the staff members who were on duty. The guardian also reported that on [DATE] they had visited R905 multiple times at the facility. The guardian reported that after they reported to the facility staff, staff followed up and obtained an order for oxygen. A chest x-ray was ordered after that. They did not receive any call from the facility on the x-ray results. The guardian reported that they had called the facility and spoke with the unit manager. The guardian reported they were not notified of the findings the chest x-ray during their conversation with the unit manager. The guardian also reported that they were notified that there were no concerns with the chest x-ray results. The guardian added that they would have called the ambulance themselves and transferred R905 to hospital had they been notified of the findings from the chest x-ray. An interview with practitioner A was completed on [DATE], at approximately 12:20 PM. Practitioner A reported that they did not have to access to records. Practitioner A was queried on the medication reconciliation process on the new residents admitted to the facility. The practitioner reported that initial medication reconciliation was completed by the physician who during the initial history and physical visit, was to make sure that residents were receiving the right medications. If the Resident was not able to provide the information they would follow up with the family member. The practitioner was queried specifically on R905 and the cardiologist recommendations to continue the diuretics and why they were not started timely. Practitioner A reported that the facility staff were not notifying them of any consultations or recommendations from the specialist. If they were notified of the recommendations timely they would have followed up and ordered the medications. An interview was completed with the Registered Dietician (RD - staff member B) on [DATE] at approximately 1 PM. Staff member B was queried about the weekly weight process. Staff member reported that if a Resident had an order for weekly weights, nursing team would complete the weights and input in EMR. If they were missed on the due date RD would alert the nursing team to complete them. If a resident had a weight change of 5 lbs. or more a reweight was completed to ensure accuracy and documented on the EMR within five days. The EMR system triggered an alert when there were 5 lbs. or more change in weight. Queried on R905 and the weight gain with no re-weight. Staff member B agreed that there should have been a re-weight and RD who followed up on R905 no longer works at the facility. An interview was completed with former unit manager (staff member D) on [DATE] at approximately 2:15 PM. Staff member confirmed that they were the unit manager during October - [DATE]. Staff member was queried about the R905. Staff member reported that they remembered the Resident. Staff member was queried about the weight monitoring process. Staff member reported that of there was a significant change in weight RD would alert the nursing team and nursing team followed up with physician or practitioner. When queried specifically on R905's significant weight gain and no follow up, they reported that they would have followed if it was brought to their attention, and they would have documented. An interview was completed with the Director of Nursing (DON) on [DATE] at approximately 1:20 PM. The DON was queried on the facility's medication reconciliation process. The DON reported that upon admission or readmission the nursing staff followed up with the physician on the resident diagnoses and their medications from the discharge summary and the physician gave the orders to continue, change doses or discontinue medications based on admitting diagnoses. The Physician followed up during their initial visit. If the admitted residents were long term residents, the team would review the EMR prior to admission from the hospital to ensure that residents were receiving all their medications. If they were short-term residents, the medication reconciliation was completed during the first interdisciplinary team meeting that was typically held within ,d+[DATE] hours with residents and families. The DON was queried on the weekly weight and reweight process and confirmed weekly weights were completed as ordered and the RD would alert nursing staff if there was a difference in 5 lbs. from the previous weight. The nursing team completed the re-weight and followed up with the physician or practitioner for further orders. The DON agreed that staff should have followed up with the physician on R905's significant weight gain. The DON was queried on the cardiology consult on [DATE] and why the orders were not followed up timely. DON reported that the cardiologist visited the Residents at the facility, and they had access to the EMR. The visit was completed on [DATE] and the facility received the completed notes several days later and agreed there was a process break down that led to the delay in following up on the orders. A facility provided document titled Change in a Resident's Condition or Status read in part, Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical condition and/or status (e.g., changes in level of care, billing/payments, resident rights etc.) The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. Accident or incident involving the resident. b. Discover of injuries of an unknown source c. Adverse reaction to medication d. Significant change of resident's physical/emotional/medical condition e. Need to alter the resident's treatment significantly. f. Refusal of treatment or medication two or more consecutive times g. Need to transfer the resident to a hospital/treatment center .

This citation pertains to intake: MI00137797. Based on interview and record review the facility failed to ensure a fall risk assessment was completed accurately, ensure a comprehensive assessment and evaluation was completed to implement the safest and most appropriate transfer device for R808, the facility failed to follow their policy on mechanical lifts and failed to ensure the proper education, training and competency was conducted with every staff member before the use of the mechanical device for one (R808) of one resident reviewed for accidents, resulting in the resident to have excruciating pain and the need to transfer the resident to the hospital for a higher level of care. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . I was contacted by a nurse from (facility name) that told me (R808) was being transferred on a [NAME] steady (transfer machine) when her knees buckled, and she was lowered to the floor . When I spoke to (R808) she immediately began to say she was in pain, and did I know that they (facility staff) had dropped her? . was in severe pain and could barely move and was in excruciating pain . We requested to have (R808) sent to the emergency room due to the amount of pain she was experiencing . on 6/12/2023 . diagnosed with a T12 vertebral fracture . remains hospitalized as of June 14th, 2023 . Review of the medical record revealed R808 was admitted to the facility on [DATE] and transferred to the hospital on 6/12/23. R808 admitted with diagnoses that included: nondisplaced fracture of coronoid process of right ulna, muscle weakness, lack of coordination, abnormalities of gait and mobility, history of fall, cardiac implants, chronic kidney disease, syncope and collapse and orthostatic hypotension. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status score of 12 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of the preadmission paperwork provided to the facility on R808's admission documented the following in part . right coronoid ulna fracture s/p (status post) fall . had several syncopal episodes r/t (related to) Orthostatic Hypotension . Patient requires . assist of 2 (two people) for transfers . Safety Concerns- Client had had several syncopal episodes which increase client's risk for falls . Further review of the admission paperwork provided to the facility documented the following in part . The patient will continue the splint to the right upper extremity and coordinate the care with orthopedic surgery. The patient is on non-weight bearing status on the right upper extremity . Per the complainant R808 had an orthopedic follow up appointment scheduled for 6/12/23, until that time, R808 was non-weight bearing to their right arm. Review of the admission fall assessment completed on 6/1/23 at 3:35 AM, documented in part . Has the Resident ever fallen before? No . Does the resident have more than one diagnosis on the chart? No . These two questions were inaccurate which resulted in a fall score of 36, categorizing the resident as Moderate Risk for Falling. This indicated the facility failed to complete the admission fall assessment accurately. Review of an Admission Evaluation note dated 6/1/23 at 1:16 AM, documented in part . Safety concerns . Falls, unsteady gait . admitting diagnosis of right coronoid ulna fracture . some episodes of confusion . is an assist x2 (two people) for transfers . Review of a Nursing Progress Note dated 6/11/23 at 5:20 PM, documented in part . writer called to the room by CNA (Certified Nursing Assistant). Observed pt (patient) lying on her back next to bed. CNA was attempting to transfer pt via required [NAME] steady. While standing with [NAME] steady. CNA slightly pulled [NAME] steady away from bed when pt knees buckled. CNA guided pt to the floor . The CNA was later identified as an agency CNA B. Review of a facility incident report dated 6/11/23 at 4:48 PM, documented in part . Verbal CNA education provided on proper technique use of [NAME] Steady <sic>. CNA should lower seating behind pt prior to moving [NAME] Steady <sic>. CNA verbalized understanding . Review of a transfer form dated 6/12/23 at 10:00 AM, documented R808 was transferred to the hospital due to the Fall. Review of a Discharge Note dated 6/12/23 at 6:18 PM, documented in part . had indication of pain but could not explain where she was having pain. She stated that she had a fall the previous day and she was in a lot of pain . During transferring, she appeared to be extremely sore. The resident was transferred to the hospital and did not return back to the facility. On 6/27/23 an interview was conducted with the complainant who stated R808 was just discharged from the hospital yesterday on 6/26/23 to another facility. The complainant stated R808 was diagnosed with a T12 vertebral fracture. Review of an initial Occupational Therapy (OT) encounter summary note dated 6/1/23, documented in part . Evaluation and assessment included examinations of body systems using standardized tests and measure of 4 elements including body structures and functions, activity limitations, and/or participation restrictions. Patient assessment identified . performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions. Clinical Presentation: Evolving clinical presentation Complexity of clinical decision making related to assessment and creation of plan of care: Med complexity . This note was documented by OT C. Review of a Therapy orders implemented by OT C on 6/1/23, documented the following in part . TRANSFER STATUS . [NAME] Steady . ADL'S . Bathing - Extensive, Toileting - Total . Ambulation - Extensive, Bed Mobility - Extensive, Transfers - Extensive . Extensive = Mod/Max (Moderate/Maximum assistance) . Review of a care plan titled . ADL Self Care Performance Deficit related to decreased functional mobility . documented the following intervention . TRANSFERS: [NAME] STEADY <sic> X1 PERSON ASSIST . Initiated: 06/01/2023 . Review of a Physical Therapist (PT) encounter summary note dated 6/2/23, documented in part . past medical history of multiple falls . pt (patient) sustained a fall onto RUE (right upper extremity). Imaging indicated nondisplaced fx (fracture) of coronoid process ulna In the hospital pt was dx (diagnosed ) encephalopathy and acute renal impairment. Pt demonstrates decline in function since fall episode and hospitalization . Pt approached in room and was alert, O (orientated) to self, and answering basic questions . Pt presents with impaired strength, balance, and functional activity tolerance in sitting and standing. Pt unable to sit up on the EOB (edge of bed) due to c/o (complaints of) weakness and stomach pain. Pt requires max A+ (maximum assistance) for rolling and supine . sit. Pt refused to get OOB (out of bed) at this time requiring max education on importance of sitting on the EOB and participating in PT. Pt is not expected to spontaneously recover as she requires skilled PT services to improve her physical impairments and attain her highest functioning level with reduced risk for falls . This note was documented by PT D. Review of a Physician Progress Note dated 6/1/23 at 1:08 PM, documented in part . recurrent falls, and orthostatic hypotension . hospitalization ,d+[DATE] (secondary to) fall with history of recent fall associated with ulnar fracture with altered mental status. X-rays revealed right coracoid ulnar fracture and patient was placed in a splint . Patient endorses feeling very weak and tired . reports she is having moderate pain to her RUE. RUE splint in place . right ankle fracture with pins . NWB (non-weight bearing) to RUE until seen by ortho . Chronic orthostatic hypotension . Encourage patient to change positions slowly . Review of an OT encounter note dated 6/2/23, documented in part . Pt demonstrating max bed mobility with poor activity tolerance and endurance to complete unsupported sitting EOB safety . Review of a PT encounter note dated 6/4/23, documented in part . Pt in bed in supine, willing to participate. Bed mob training to improve safety and independence, Max A, cues for sequencing, pt confused, difficulty following directions . Max+A, via stand pivot transfer . maintaining NWB RUE. Pt was provided extended time to complete the task due to confusion and difficulty following directions . Review of an OT encounter note dated 6/4/23, documented in part . Pt supine in bed at start of session. Bed mobility to sit EOB requiring max A . Stand pivot . to w/c (wheelchair) requiring max A (maximum assistance) c (with) max vc (voice commands) on hand placement and sequencing . Review of a PT encounter note dated 6/6/23, documented in part . pt in bed in supine, will to participate with max encouragement. Bed mob (mobility) training to improve safety and independence, Max A, cueing for sequencing . max cueing for w/c, hands, and feet placement. Pt confused during treatment session, nonverbal, difficulty following directions, requiring extended time to complete the tasks . This pm discussed with pt's daughter over the phone d/c (discharge) planning and lack of progress with PT . informed pt's daughter about the need to start d/c planning due to lack of progress with therapy . Review of a PT encounter note dated 6/7/23, documented in part . Pt in bed supine, willing to participate with max encouragement . sitting EOB, pt became dizzy, lightheaded, unable to maintain seated position, requesting to be back in supine . Pt refused to sit up again or perform any other activities . Due to muscle atrophy and muscle wasting pt is unable to make own positional changes . On 6/27/23 at 1:22 PM, the facility's Administrator was asked to provide the manufacturer's manual for the [NAME] steady transfer device. Review of the Instructions for use [NAME] Steady . [NAME] Steady Compact . dated 03/2020 documented in part . It is recommended that facilities establish regular assessment routines to make sure that caregivers are assessing each patient/residents prior to use. Before use, the caregiver should always consider the patient's/resident's medical condition as well as physical and mental capabilities. In addition, the patient/resident must . have the ability to stand unaided or stand with minimal assistance . be able to sit on the edge of the bed . WARNING: To avoid injury, a full clinical assessment of the patient's condition and suitability must be carried out by qualified personnel before attempting to use [NAME] Steady . This mobile patient lift must be used by a caregiver trained with these instructions . Failure to comply may result in a patient fall . Review of the facility's policy titled Lifting Machine, Using a Mechanical which is the same policy all staff was educated on (6/14/23) after R808's fall, documented in part . The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device . At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Mechanical lifts may be used for tasks that require: Lifting a resident from the floor; Transferring a resident from bed to chair; Lateral transfers; Lifting limbs; Toileting or bathing; or Repositioning . Type of lifts that may be available in the facility are . Floor-based full body sling lifts . Overhead full body sling lifts . Sit-to-stand lifts . Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility . This indicated after review of the resident medical history, physical and mental capabilities the resident was not a good candidate for the [NAME] Steady transfer device per the manufacturer's instruction book. The facility staff also failed to follow their own policy in ensuring that two staff members utilized the mechanical lift device. On 6/27/23 at 1:46 PM, CNA (agency) B was interviewed via telephone when asked about the fall with R808 on 6/11/23, CNA B stated they were told by the facility staff that R808 needed to get up to have their weight taken and that R808 was a one person with the [NAME] Steady lift. CNA B stated they put the [NAME] steady in front of R808's wheelchair and the resident put both of their arms on the bar. CNA B stated they pulled the [NAME] steady from the wheelchair but did not put the seat down for R808 to sit on it as they pulled the [NAME] steady from R808's wheelchair. When asked, CNA B stated R808 stated they were about to sit down because they couldn't hold on anymore. CNA B stated, they pulled the device away from the wheelchair to put the seat of the mechanical device behind the resident, but it was too late. CNA B stated they assisted R808 to the floor. When asked if they received education and was trained to use the [NAME] steady by the facility staff, CNA B stated . they did provide the education to me after the fact . CNA B stated they were not trained or educated on how to use the [NAME] steady prior to using it with R808. When asked if they were aware that R808 was not supposed to use their right arm, CNA B stated in part . No, I didn't know about (R808)'s arm at all . it would have been helpful to know about (R808)'s arm because the hoyer would have been safer to use on her . When asked if R808 had a sling or any device in place to their right arm, CNA B stated no. This revealed the facility failed to train, educate, and ensure CNA B (agency) competency before using the [NAME] steady device. On 6/27/23 at 12:08 PM, the Therapy Director (TD) E and OT C were interviewed together. OT C was asked considering R808's medical history and current condition, physical and mental capabilities how did they come to the conclusion that R808 was an appropriate candidate for the [NAME] Steady device. OT C stated based off their initial evaluation with the resident they thought the [NAME] Steady was the most appropriate device. OT C initial evaluation was reviewed and revealed no documentation of the resident to have been an appropriate candidate for the [NAME] Steady device. OT C was informed of the manufacturers' instructions on what the resident must have the ability to do with the consideration of the resident's medical condition, physical and mental capabilities, OT C stated if the staff used the [NAME] Steady the correct way, there is no way R808 would have fell from the device. TD E and OT C was asked if either observed R808 with the [NAME] Steady device, to ensure the transfer device was safe and appropriate for R808, both stated no. TD E and OT C was then asked if either trained the staff on how to use the [NAME] Steady device with R808, both stated no. OT C stated the nursing staff is responsible to train their staff on the use of the [NAME] Steady device. TD E stated if the nursing request additional training the therapy department will conduct those trainings. TD E and OT C was asked if the recommendation to use the [NAME] Steady was discussed amongst the Interdisciplinary team to discuss the safest and most appropriate transfer method for the resident, OT C replied they understood there is a discrepancy between their initial evaluation compared to the PT's initial evaluation, however they based their recommendation on what they saw. On 6/27/23 at 1:00 PM, the DON (Director of Nursing) was asked to provide the training, education, and competency that CNA B received on the [NAME] Steady device. The DON was asked why they recommended R808 back to therapy services to re-evaluate the transfer status if the fall occurred because of the staff error and the DON replied in part . because the rational was that (R808) might not be appropriate for the [NAME] Steady . (R808) had an injury to the arm . and (R808) couldn't reach up and hold on to the [NAME] Steady and the resident stated that (they were unable to use it), so I was like, she can't use this . On 6/28/23 at 8:44 AM, TD E was interviewed and asked how it was possible that the therapy team was/is writing orders for staff to utilize the [NAME] Steady with one staff member if the facility's policy documents at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift? TD E replied they were unaware of the facility policy and would follow up with the Administrator. On 6/28/23 at 8:53 AM, the DON returned and stated they were unable to provide the training, education, and competency for CNA B regarding the use of the [NAME] Steady because the facility's educator was on vacation and not answering their phone. The DON stated that all agency staff is given a packet upon working. The DON was asked how they are implementing interventions for only one staff member to utilize the [NAME] Steady device if the facility policy and the education that they provided to all of the nursing staff after R808 fall document the device should be utilized by two staff members for safety? The DON replied they were not aware that one person could not use it and the therapy department are the one's that wrote the order. On 6/28/23 at 9:36 AM, TD E returned and stated they talked to the Administrator and reviewed the policy. TD E stated they are in the process of modifying and updating the policy. No further explanation or documentation was provided before the end of survey.

This citation pertains to intake(s): MI00137776, MI00137797 & MI00137902. Based on observation, interview, and record reviews the facility failed to maintain an active water management plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) and failed to maintain a consistent and effective infection surveillance program resulting in water borne pathogens to exist and spread in the facility's plumbing system and resulting in R810 to be diagnosed with presumptive healthcare associated Legionellosis, R811 to not have been identified with signs/symptoms/diagnosis to fit the criteria for testing of Legionellosis and the increased risk of respiratory infection for all residents that resided in the facility. Findings include: Review of multiple complaints submitted to the State Agency (SA) reported concerns of Legionellosis in the facility's water system. WATER MANAGEMENT PLAN Review of a Centers For Medicare & Medicaid Services (CMS) memo (Ref: QSO-17-30) Dated 6/2/17 and revised on 7/6/18, documented in part . The bacterium Legionella can cause a serious type of pneumonia . in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains . Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella . In a recent review of LD (legionellosis/Legionella) outbreaks occurring from 2000-2014 in the U.S., 19% were associated with long-term care facilities . On 6/27/23 at 8:30 AM, the Director of Nursing (DON) was asked to provide the facility's Infection Control Surveillance program for the last year. At 1:18 PM, the DON was asked the status of the requested surveillance program. At 2:22 PM, the facility's Infection Control Nurse (ICN A) who also serves as the facility's Infection Control Preventionist, provided a couple of months of the infection surveillance logs. Review of the facility's Infection Control Surveillance log program for May 2023 and June 2023, revealed no documentation of a resident diagnosed with Legionellosis. Further review of the Surveillance documentation revealed no investigation of an identified case of Legionellosis. On 6/28/23 at 10:47 AM, an interview was conducted with ICN A. ICN A was asked for the monthly analyzation, mapping, tracking and antibiotic stewardship data, which was not included in the documentation provided for the Infection Surveillance Program. ICN A stated they would provide it. ICN A was then asked about the resident (later identified as R810) who was diagnosed with Legionellosis. ICN A stated R810's name. When asked why that information was not documented and included in the facility's infection surveillance program, ICN A stated the resident was transferred to the hospital and diagnosed with it and the county health department reached out to the facility to inform them of the diagnosis. ICN A then went on to state because the resident was not in the facility, their status was not logged on the facility's infection control surveillance log. ICN A was asked if the county health department notified the facility of a resident who was transferred from the facility and diagnosed with a legionellosis, a presumptive healthcare-associated Legionnaires' case, why would that not be included in the facility's program? ICN A did not have a reply. ICN A was asked if an investigation was completed regarding the Legionellosis diagnosis of R810 and ICN A stated there was an investigation completed. ICN A was asked to provide the investigation at this time. Review of R810's medical record documented R810 was admitted to the facility on [DATE] and remained in the facility until 5/30/23 when the resident was transferred to the hospital. R810 was admitted with diagnoses that included: dementia, chronic obstructive pulmonary disease, right bundle branch block, thrombocytosis, atrial fibrillation, atherosclerotic heart disease, chronic kidney disease, Stage 3B, and hypertension. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of a Nursing Progress Note dated 5/30/23 at 8:19 PM, documented in part . Resident complained of sob (shortness of breath). Writer checked spo2 and it was 86%. 2 liters of 02 (oxygen) nc (nasal cannula) was place <sic> on resident. 02 went up to 96% then dropped down to 81%. On call physician notified. Ordered to send resident out . Review of the facility's water management plan revealed the facility failed to develop a water management plan that specified testing protocols, acceptable ranges for control measures, effective surveillance process and failed to contain any documentation or results of testing and corrective actions taken when control limits are not maintained. Further review of the facility's water management plan documented the following in part, . The water management team consists of the following representatives . Infection Control Practitioner, Facilities Director, Medical Director, Facility Administrator/Executive Director, Local Water Department Representative, water Maintenance Contractor Representative . Surveillance Process . Engaged (third party water management company name) to help identify environmental controls (with monitoring and a water flow diagram . The plan did not document the names and roles of the water management team and the third-party water management company named in the surveillance section was no longer utilized by the facility. The last documentation provided by the facility with the third-party water management company that was named in the surveillance section was a comprehensive proposal plan completed on 2/1/2019. On 6/28/23 at 3:43 PM, the Director of Nursing (DON) and Infection Control Nurse (ICN) A (who also served as the facility's Infection Control Preventionist) was interviewed and asked who each member of the water management team was and what their roles were, neither could answer. The DON and ICN A was asked the last time the water management team met to review the water management plan, and both stated they had not attended a water management meeting since they were employed at the facility. On 6/29/23 at 9:14 AM, an interview was conducted with the Epidemiologist of the County's Health Department, Epidemiologist F. Epidemiologist F was asked about their interactions with the facility regarding R810, Epidemiologist F replied the county received the case three weeks ago. (R810) had presumptive healthcare-associated Legionnaires'. Epidemiologist F explained multiple samples were collected from the facility and a few tested positive for three locations throughout the facility for Legionella. Epidemiologist F stated directive was given to the facility on what to implement moving forward and that the facility will be monitored for the next six months. Epidemiologist F stated the facility was instructed to test anyone within the last two months with pneumonia like symptoms with a urine antigen test and sputum test. Epidemiologist F explained the facility will roughly sample 20 locations every two weeks for the first three months then monthly (totaling the six months observation). Epidemiologist F stated when they entered the facility, the facility staff was very straightforward that they needed to update their water management plan and they would be working with a third-party water management company to get a better plan in place. Epidemiologist F stated the chlorine and water ph levels needed to go up on a few of the locations that were sampled at the facility and the facility would be following up with the third-party water management company. An email was obtained from Epidemiologist F regarding the directive given to the facility since 6/5/23 when the facility was first notified by phone and from 6/6/23 after a virtual meeting was conducted with the facility staff. Review of the facility' Legionella testing results collected on 6/9/23, documented Legionella was found on a first-floor pod 1 sink and in two-bathroom sinks located in two different rooms, a total of three areas identified in the facility. On 6/29/23 at 9:48 AM, the Maintenance Manager (MM) G was interviewed and when asked what they had been recently educated on by the facility regarding their water management plan and MM G stated they were not testing for Legionella specifically and they learned that the facility needed to have a better plan moving forward. When asked MM G stated the facility had not discussed or reviewed the water management plan for some time now. MM G was then asked about each documented member of the water team on the facility's water management plan and their role, MM G was unable to answer this question. When asked if the facility had experienced changes in the facility's water quality prior to the resident being diagnosed with legionellosis and MM G stated the facility had a water main break a couple of months ago. MM G was asked to provide documentation of the water main break and the documentation of what the facility implemented and monitored following the water main break. MM G was asked had the water management team met since the presumptive healthcare-associated Legionnaires' case and MM G stated they had not had an official meeting, but the facility administration team met to follow up on the health department directives. No documentation of the water main break or the follow up of the water main break was provided by the end of the survey. INFECTION SURVEILLANCE Review of the June 2023 Infection Control Surveillance log documented on 6/6/23, documented R811 was diagnosed with a Lower Resp (respiratory) infection. There were no sign or symptoms listed on the surveillance log. Review of a Nursing progress note dated 6/5/23 at 12:46 PM, documented in part . resident presented with SOB (shortness of breath), and productive cough with yellow tinged sputum. 02 @ (at) 85% oxygen via nasal cannula was administered. Residents current 02 @95% on 3 L (liters) of oxygen via nasal cannula . STAT (immediate) chest x-ray ordered . Review of a Physician progress note dated 6/5/23 at 12:38 PM, documented in part . c/o (complaints of) . cough and hypoxia. Per nurse, patient has pulse ox of 85% on room air and he has productive cough of yellow sputum. Patient is seen and evaluated and reports he has had cough for the last 2-3 days and feels mildly SOB today . Lungs with wheezing bilaterally. Oxygen 3 L applied per nurse via NC (nasal cannula) . Review of a Physician progress note dated 6/6/23 at 4:44 PM, documented in part . evaluation of his mild hypoxia and cough that started yesterday 6/5/23 CXR (chest X-ray) results appreciated which revealed pneumonia with possible pleural effusion. Patient was started on Levaquin 500 mg (milligram) . Review of the facility Legionella investigation and the facility LEGIONELLA TESTING POLICY documented the following in part . during the 6-month surveillance from June 6 - December 6, 2023 . Residents will be evaluated by the Nurses through regular rounds to determine if residents have symptoms of Legionella . The symptoms identified that will require testing will be as follows . 1. Resident has a diagnosis of pneumonia . A urine test will be obtained and a sputum if possible . Further review of the Legionella investigation contained a facility Nursing Protocol for Suspected Legionnaires' Disease that documented in part . Nursing staff should identify residents who are at risk of developing Legionnaires' disease . recent exposure to cooling towers, air conditioners, or residents that have exhibited Legionnaires' disease signs and symptoms in the last 2 months . Nursing staff should perform a thorough assessment of the resident's symptoms, including . cough, shortness of breath . if exhibited , or if resident has a complaint of signs and symptoms in the last 2 months, test resident for Legionella antigen . Review of the residents who were tested for Legionella was completed, however R811 was not identified by the nursing staff or by the ICN A and was not tested for Legionella. This revealed the facility did not consistently follow the directive of Epidemiologist F and the facility's Infection Surveillance system was not effective in identifying, intervening, and ensuring timely testing was completed for R811. An additional review of the facility's Legionella investigation revealed an audit was completed on 6/8/23 and R811 was documented as N (No) to not have symptoms that included cough . shortness of breath, despite R811's medical record to have contained documentation that R811 still required the supplemental oxygen at the time of survey, due to their oxygen levels at 88% on room air and the 02 (oxygen) to have been reapplied at 3 L, per the nursing note dated 6/27/23 at 6:29 PM. On 6/29/23 at 10:39 AM, the DON and ICN A was interviewed and asked about the Legionella investigation. The DON explained they completed the investigation. ICN A stated they corresponded with the Health department and Epidemiologist F who informed them what symptoms to look out for and instructed them to look back for the last two months and to test those who had symptoms, pneumonia or was prescribed an antibiotic for an actual respiratory infection. The DON and ICN A was asked why R811 was not tested , due to meeting the criteria set forth by the county health department to be tested and by the facility's policy. ICN A confirmed that R811 was not tested but would look into it. Shortly after, ICN A returned and stated Legionella testing has now been ordered for R811 and their roommate. Review of an email dated 6/29/23 at 9:42 AM, sent by Epidemiologist F to the surveyor documented in part, . Below is the exact language we sent the facility on 6/6 after a virtual meeting with them (they were notified by phone on 6/5) . While the investigation and environmental sampling are pending, the Health Division is making the following restrictions . immediately begin surveillance - order the urinary antigen test and a respiratory sputum panel with legionella culture if the clinical presentation is consistent with pneumonia . Do urine antigen testing on all pneumonia or pneumonia like presentations from the past 2 months for current residents and report results to the Health Division . No further explanation or documentation was provided by the end of the survey.

This citation has two deficient practices. Citation #1 This citation pertains to Intake #MI00135116 Based on interview and record review the facility failed to ensure a safe transfer was performed for one (R703) out of three residents reviewed for falls, resulting in the resident sustaining a fall with fracture to their right clavicle, a trip to the hospital and pain. Findings include: A Facility Reported Incident (FRI) was reported to the State Agency (SA) that indicated R703 sustained a fall with injury on or about 3/3/23. Additional investigation information noted that a CNA failed to follow proper facility protocol during the resident's transfer and as such the resident fell and sustained a fracture to their right clavicle. Review of the facility policy titled, Resident Transfer Lift Policy (2/4/19) documented, in part: Policy: .Lifting devices are utilized whenever a resident is not independently mobile .All centers are designated as minimal lift centers, which require staff to use the resident handling devices as assessed for each resident .Team members who do not use the lifting device(s) identified for a resident are subject to one-on-one retraining and disciplinary action . A review of R703's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: type II diabetes, chronic respirator failure and urinary retention. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 12/15 (moderately intact) and required extensive one person assistance for transfers. Continued review of R703's clinical record, documented, in part, the following: Nursing Progress Note (3/2/22) authored by Nurse B: Approximately 1000 (10 AM) writer is walking down hall and heard a loud noise. As writer entered room resident observed on floor lying on their back. Writer called out to resident, and they took a few minutes to respond. When resident responded they stated, I hit my head a (sic) heard a crunch when I hit the floor .Resident is complaining of right shoulder and neck pain .STAT X-ray 2 views of right shoulder and neck . Nursing Progress Note (3/3/23) authored by the Director of Nursing (DON): .Stated last night their pain was a 10 on scale 1-10 . A physician progress (3/3/23) .Patient seen and examined as follow up ER (emergency room ) visit for right clavicular fracture. Patient experienced a fall from standing up from the toilet yesterday, and c/o (complaint of) knee pair and R shoulder pain, x-rays performed showed R clavicular fx .Pt stated that they hit their head .Patient went to ER for further evaluation .admits to pain with movement of the RUE (right upper extremity) . A review of R703's Care Plan noted, in part, the following: Problem .R703 has an ADL Self Care Performance Deficit .TRANSFERS: [NAME] STEADY x 1 PERSON ASSIST . On 3/16/23 at approximately 11:51 AM, an interview was conducted with Certified Nursing Assistant (CNA) A. CNA A reported working for the facility for two years. When asked as to the incident that occurred on 3/2/23, CNA A reported that they were assigned to R703 for the day shift. R703 needed to use the bathroom and instead of using the lift (hereinafter [NAME] STEADY) that they were care planned for, they used a mechanical lift ([NAME] 3000) that required a two person assist. CNA A noted that as they were trying to get the resident back in bed, R703 slipped out of the sling, they tried to catch them, but they fell to the ground and bumped their head. CNA A reported that they went to get Nurse B who did a full assessment, and the resident was sent to the hospital. The resident was later found to have a fracture to their right clavicle. When asked as to why they did not use the lift that was care planned for the resident, CNA A reported that they wanted to get R703 to the bathroom and could not locate the [NAME] STEADY lift and did not ask for assistance with the mechanical lift. CNA A reported that they were suspended and upon return received additional training on the proper way to transfer residents. An attempt to contact Nurse B via phone was done on 3/16/23 at approximately 12:00 PM. No return call was made prior to the end of the Survey. On 3/16/23 at approximately 3:16 PM, an interview was conducted with the DON. When queried as to the incident that occurred the DON reported that CNA A transferred R703 using a two person lift on their own, even though R703 was care planned as a one-person transfer. The DON indicated that CNA A reported that they knew that they should not have used the two person ([NAME] 3000) on their own and either should have asked for assistance or made an attempt to locate the proper one person assist lift. Citation #2 This citation pertaining to Intake #MI00135160 Based on observation, interview and record review the facility failed to ensure one (R705) did not elope from the facility out of five residents reviewed for elopement/accidents. Findings include: A FRI was reported to the SA that indicated that on 2/24/22, R705 eloped from the facility and was found outside the facility on the ground. A facility policy titled, Elopement (revised 1/10/13) was reviewed and revealed the following: Policy Statement .It is the policy of this facility to prevent to the extent possible, the elopement of the residents from the facility .Elopement occurs when a resident who needs supervision leaves a safe area without authorization .and/or necessary supervision to do so . Review of R705's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses that included, in part: malignant brain tumor, repeated falls and anxiety. A review of the residents MDS (2/16/23) noted the resident had a BIMS score of 4/15 (severally impaired cognition) and required extensive one to two person assist for most ADLs. The MDS noted that the resident suffered from hallucinations. Continued review of the resident's record documented, in part, the following: 2/22/23 Nursing Progress Note (10:29 AM): .Primary mode of transportation w/c (wheelchair) . 2/22/23 Nursing Progress Note (12:29 PM): .R705 administered a Rapid Nasal COVID-19 test on 2/22/23 .Results: Positive . 2/22/23 Nursing Progress Note (2:55 PM): .Emergency contact notified of R705's positive result . Contact/Droplet precautions .Room transfer . 2/22/23 Post Fall Evaluation (8:43 PM): .5:00 PM Fall was witnessed . Ambulating without assistance .Abrasion of left arm .Contributing factors: Recent change in environment: YES . 2/23/23 IDT Note (12:24 PM): .reviewed incident on 2/22/23 Root cause self-ambulating without assistance .recently room change to (number redacted) due to newly diagnosed with COVID . 2/24/23 Nursing Progress Note (8:19 AM): .Writer (Nurse D) made aware resident wasn't in room at 6:45 AM on 2/24/23 .Writer immediately started searching all rooms and bathrooms .At about 655 am writer approached incoming staff asking if they seen male outdoors with staff stating yes. Writer ran to back exit door went out of door with no sounding alarm when exiting. Writer walked around parking lot did not see resident. Writer entered the loading dock doors and resident was sitting on bench accompanied by other employees . A review of the Incident/Accident (IA) report revealed, in part the following: Incident Summary: R705 was located outside the building about 20 feet from the set doors .Witness Statement Form .Name: Contracted Staff C .Time: 6:35 -6:45 AM .Location: Near employee parking lot .Upon arriving at work I saw what appeared as a pile of something as passing it was determined to be a person .he stuck his hand up. I instructed the Uber driver to stop and go back to help .assisted the guy (hereinafter R705) up on their feet and into the Uber car, drove up to the door and brought the guy in and called for help. 2 housekeepers help open door and lead us to bench .the guy was asking for water .called my boss to inform her of what had happened .Description of Accident .called security phone to let me (Security Staff F) to let me know one of our .Staff had helped an elderly man that she found outside .into our building and they were in front of the beauty salon .the man was alert but seemed shaken .could not tell us his full name .I asked how did he get outside .replied I walked past a gas tank . On 3/15/23 at approximately 9:25 AM, an interview and limited tour of the facility was conducted with Maintenance Supervisor (MS) E. MS E reported that the facility lost power 2/23/23 through 2/25/23 and while they had a generator, it was not able to ensure the heat system was fully working. MS E noted that the facility utilized a contract service to ensure the facility was a minimum partially heated. The service brought in supplemental heat sources that were placed outside the facility and utilized ducts through the door and windows to bring the heat into the building. MS E pointed out the door that R705 eloped from and reported that the as the ducts were coming through the door, one of the doors was open and covered with a thick like plastic and the exit door was not closed and therefore the alarm did not sound when R705 exited. On 3/15/23 at approximately 3:23 PM, a phone interview was conducted with Staff C. Staff C reported that they were employed by a contracted food service as a dietary aide and worked at the Assisted Living Facility (ALF) connected to the Skilled Living Campus where R705 resided. Staff C reported that on 2/24/23 they were being dropped off to work by an Uber Driver at approximately 6:30 AM. Staff C noted that it was dark outside and as they started to approach the ALF door, they noticed what they initially thought was a big pile. They then saw a hand waving. Staff C had the Uber Driver pull over and observed R705 lying on the ground in a fetal position. R705 was wearing pajama bottoms, a long sleeve shirt and slippers, but no socks. Staff C reported that the resident was shaking, very cold to the touch and was covered with icicles. Staff C stated the resident was not steady on their feet and they, along with the Uber Driver lifted the resident into the car and drove them over to the loading dock entrance and placed R705 on a bench. Staff C further noted that at the time, several staff members were there to assess the resident. When asked if any staff were noted to be outside looking for the resident, they replied that to their recollection they did not see anyone else. *It should be noted that weather temperature estimates on 2/24/23 ranged from 19.4 degrees to 21.4 degrees Fahrenheit. On 3/16/23 at approximately 9:52 AM, a phone interview was conducted with Nurse D. Nurse D reported that they were not directly employed by the facility. When queried as to the elopement incident on 2/24/23, Nurse D reported that it was the first time they had been assigned to R705 and noted that that they had last seen the resident when they passed medication at or around 5:30 AM. They recalled that the resident was in bed and on precautions due to COVID-19. They reported that a Certified Nursing Assistant (CNA) notified them around 6:45 am that the resident was not in the room. They further reported that they started to ask staff if they had seen the resident and did not get a response. In addition, they did not hear an alarm sound. They then walked around the facility near the resident's room and observed that the exit door was open due to the power outage. Nurse D was then notified that the resident was found outside and was placed on a bench near the docking unit. On 3/16/23 at approximately 10:20 AM, a phone interview was conducted with Security Staff F. Security Staff F reported they have been employed by the facility for approximately five years and usually work the midnight shift. When queried as to the elopement incident (2/24/23) involving R705, they recalled that Staff C had brought the resident in from outside and reported to them that they found the resident outside on the ground in a fetal position and brought them in through the loading dock entrance. Staff F noted that after the incident they did an inspection of the area and noted that they could see tracks in the snow near the door and observed that the plastic covering the door was torn. Staff F reported that facility staff were notified that they should be watching the open doors as they would not alarm if anyone exited the doors.

This citation pertains to Intake #'s MI 423 and MI 399 DPS #1 Based on observation, interview and record review the facility failed to ensure a resident was transferred per the plan of care for one (R89) of five residents reviewed for accidents, resulting in R89 sustaining a left tibial plateau (knee) fracture. Findings include: On 9/7/22 at 3:25 PM, R89 was observed lying in bed with a brace on her left leg. R89 was asked about the brace on her leg. R89 explained she had been sitting in her wheelchair and the CNA (Certified Nursing Assistant) was going to transfer her to the bed . she told the CNA that she needed a Hoyer (mechanical lift), but the CNA thought she could do it herself and lifted her up under the arms and put her on the bed, but her leg dragged and it twisted and broke. When asked if she went to the hospital, R89 explained she had wanted to go to the hospital immediately, but they did not send her for two days. Review of the clinical record revealed R89 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: displaced bicondylar fracture of left tibia, heart failure and diabetes. According to the Minimum Data Set (MDS) assessment dated [DATE], R89 was cognitively intact and required the extensive assistance of staff for all activities of daily living (ADL's), including transfers. Review of R89's Safe Transfer Practices care plan revealed an intervention revised 5/26/22 that read, .TRANSFERS; MAXI MOVE (hoyer lift) X2 PERSON ASSIST. Review of R89's progress notes revealed: A nursing note by Licensed Practical Nurse (LPN) C dated 8/2/22 at 2:12 AM read in part, Resident stated 'the CENA that put me in the bed did not use the lift and she twisted my left knee when she pick [sic] me up to put me in the bed, now it keeps hurting', writer text (Doctor) . A nursing note by LPN C dated 8/2/22 at 7:09 AM read, Writer sill have not received a return call from (Doctor), to report resident c/o knee pain from being transferred to bed without the use of lift, resident sated 'the CENA twisted my knee when putting me in the bed without the lift', resident also stated 'I told her to get help', staff was already gone home when complaint was made and resident requested pain medication x2 during night shift. A nursing note dated 8/3/22 at 5:09 PM read in part, resident states she's having pain in her left leg when she's being moved around such as being changed, resident states she doesn't get any relief for the pain medication and would like to go to the hospital to have a CAT (computerized tomography) scan . A radiology note dated 8/4/22 at 10:00 AM read in part, .Resident continues to have complaint of increased pain in left leg. P.A. (physician assistant) informed or [sic] resident's complaints. New order to send resident to (hospital) to rule out fracture in left leg . Review of R89's hospital paperwork dated 8/9/22 revealed diagnoses that included: Closed fracture of left tibial plateau and acute pain of left knee. On 9/8/22 at 8:05 AM, Certified Nursing Assistant (CNA) B was interviewed by phone and asked if she had transferred R89 by herself on 8/1/22. CNA B explained she had worked the afternoon shift (3:00 PM-11:00 PM) that day, and was getting R89 ready for bed . R89 told her she was a mechanical lift, but she did not see anyone to help her, so she placed the wheelchair next to the bed, picked R89 up and did a pivot and put her in the bed. CNA B was asked if she had access to R89's plan of care and transfer requirements. CNA B explained they had given her computer access, but it did not work. When asked why she did not use a lift when R89 had told her she needed one, CNA B explained R89 had said her bottom was hurting, so she wanted to get her out of the wheelchair and did not see anyone to help her, so she thought she could do it. CNA B was asked if there was a lift available. CNA B explained there was a lift in the hall. When asked if R89 had yelled out when she transferred her, CNA B explained R89 did not make any noise, but after she was in the bed told her she had twisted her leg. When asked what she did when R89 said she had twisted her knee, CNA B explained she went to tell the nurse that R89 said she had twisted her knee, and that she needed something for pain, but could not find the nurse. On 9/8/22 at 8:22 AM, LPN C was interviewed by phone and asked when she knew about R89's knee pain. LPN C explained she had not known anything about it until the CNA on the midnight shift (11:00 PM-7:00 AM) told her R89 said the afternoon CNA had twisted her leg and that it hurt. When asked what she did when told about R89, LPN C explained she immediately went and assessed R89, called the doctor, and gave R89 pain medication. LPN C was asked if CNA B had told her that R89 said she had twisted her knee. LPN C explained CNA B never told her anything about it, it was CNA E, the midnight CNA, that told her. On 9/8/22 at 8:32 AM, CNA E was interviewed by phone and asked about R89. CNA E explained he was doing his initial rounds when R89 told him that CNA B had twisted her leg when she put her to bed, and that R89 said she told CNA B she was a lift but she did not use one. CNA E was asked what he did when R89 told him about her leg. CNA E explained he went and told the nurse. When asked if CNA B had told him about R89 when she gave him report, CNA E said she did not. On 9/8/22 at 1:27 PM, Therapy Director X was interviewed and asked about R89's transfer status. Therapy Director X explained the only safe way to transfer R89 was with a Maxi Move lift. On 9/13/22 at 12:00 PM, the Director of Nursing (DON) was interviewed and asked how residents should be safely transferred. The DON explained all residents should be transferred per there plan of care. The DON was asked even if CNA B did not have access to R89's care plan, when R89 told her she was a mechanical lift, how should she have transferred her. The DON explained if the CNA did not know how to transfer a resident, they should ask the nurse before they transfer them. Review of a facility policy titled, Lifting Machine, using a Mechanical revised 7/1/17 read in part, .The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device . Mechanical lifts may be used for tasks that require: .b. Transferring a resident from bed to chair; c. Lateral transfers . DPS #2 Based on observation, interview and record review the facility failed to ensure adequate supervision for one (R807) of five residents reviewed for accidents, resulting in R807 opening an exit door into a stairwell and falling down the stairs in a wheelchair sustaining a left frontal subarachnoid hemorrhage (brain bleed). Findings include: Review of a complaint filed with the State Agency read in part, .(R807) fell down the stairs in her wheelchair . when (R807) opened the door to the stairwell, it sounded an alarm but staff didn't respond and the resident fell and sustained serious injuries . the resident isn't monitored appropriately . Review of the clinical record revealed R807 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included: traumatic subarachnoid hemorrhage, dementia, and [CONDITION(S)]. According to the Minimum Data Set (MDS) assessment dated [DATE], R807 had moderately impaired cognition and required the assistance of staff for activities of daily living (ADL's). Review of R807's progress notes revealed a nursing note by licensed Practical Nurse (LPN) D dated 8/15/22 at 6:07 PM that read in part, writer had just seen pt (patient) at (4:40 PM) in the wheelchair coming out of her room . wheeled herself to the dining room . nurse was summoned to the back stairwell by the fire door exit, patient was laying on the floor at the bottom of the stair laying on her right side. blood was coming from the pt right arm, and pt was yelling help me, 'resident stated 'I don't want to go back in there' 'I want to go home'. 'I have pain in my arm' . pt had a skin tear and blood on her right arm by her elbow . was sent to the ER for further assessing. Review of R807 hospital paperwork dated 8/15/22 read in part, .CT (computerized tomography) Head: Acute, localized, posttraumatic subarachnoid hemorrhage over the left dorsal frontal lobe . Review of R807's physician orders revealed an order dated 8/22/22 that read, May have wanderguard device. Review of R807's elopement risk/wandering care plan revealed an intervention initiated 8/23/22 that read, .Monitor location throughout the shift. Document [sic] wandering behavior and attempted divisional interventions. It should be noted there was no intervention that included a wanderguard. Review of R807's Treatment Administration Record (TAR) revealed no documentation of a wanderguard placed, checked, or ensuring continued placement. On 9/7/22 at 3:10 PM, R807 was observed sitting in a wheelchair watching television in a common area, a dressing was observed on R807's right elbow. R807 was asked how her elbow was injured. R807 explained she did not know. When asked if she had fallen down the stairs, R807 first said I did? Then said, I think I did. R807 was asked how it happened. R807 explained she did not remember. On 9/7/22 at 3:15 PM, LPN A, who was R807's assigned nurse, was asked if R807 had a wanderguard. LPN A explained it was on her wheelchair as R807 would take it off. When asked where it was documented that R807 had a wanderguard, LPN A looked at the TAR and could not find a check to be done and explained she would put it into the care plan. Additional review of R807's elopement risk/wandering care plan revealed an intervention initiated 9/7/22 that read, Wanderguard to wheel chair. On 9/8/22 at 8:56 AM, LPN D was interviewed by phone and asked about R807. LPN D explained she had seen R807 approximately 20 minutes before she fell down the stairs, R807 was propelling herself toward the dining room. LPN D was asked if she ever saw R807 going toward the exit door. LPN D explained she never saw R807 trying to leave, or get out the door . the Certified Nursing Assistant (CNA) never told her she had tried to get out before, or she would have watched R807 closely. When asked if she had heard the exit door alarming, LPN D explained she did not hear the alarm. LPN D was asked how she found out R807 had fallen down the stairs. LPN D explained the Unit Manager was calling for help that R807 had fallen down the stairs, R807 was on the landing, the wheelchair had been on top of her, but it had already been removed and R807 was curled into a fetal position on her right side on the landing. On 9/8/22 at 9:22 AM, Utility Technician G was interviewed and asked about R807 falling down the stairs. Utility Technician G explained he had gone on the unit to pull garbage and heard the door alarm going off when he was getting off the elevator . he had to go down the hall and turn a corner to get to the hall where the door was alarming and saw R807 moving herself towards the door . R807 got to the door first and opened the door . no one else was in the hall . stopped R807 and told her she could not go in there, that was stairs . R807 said she was tired of hearing the noise and wanted it to stop . a CNA came and she started to push R807 down the hall, but R807 yelled at her and the CNA stopped pushing her and walked away . had his big black garbage bin and followed behind R807 down the hall until they were in the area by the nurse station and there were other people present so he left to take the garbage out . was coming back to clean carpets when he heard several door alarms and received a call that R807 had fallen down the stairs. On 9/8/22 at 9:45 AM, CNA F was interviewed by phone and asked about R807. CNA F explained that afternoon, R807 had kept going toward the exit door and saying she was looking for her kids . kept moving her back, away from the stairs . was in a room when the alarm went off . went and opened the door and looked down the stairs, but did not see anyone . thought it might have been staff that had set it off . went to the nurse to ask how to turn off the alarm, the nurse did not know . was looking for someone else to turn off the alarm . saw R807 in the hall . saw a maintenance man come off the elevator . asked him to turn off the alarm . he turn it off . tried to push R807 away from the door again, she was swatting and swearing at her . went into dining room to help pass dinner trays . then told someone had fallen down the stairs, hoped it was not R807, but it was. On 9/8/22 at 10:15 AM, Maintenance Supervisor S was interviewed and asked about the exit door alarms. Maintenance Supervisor S explained there were two alarms that would go off when an exit door was opened. When asked do demonstrate when the alarms sounded and where they sounded, Maintenance Supervisor S demonstrated opening an exit door with the door R807 had used. Upon pushing in the crash bar, an alarm sounded at the door, then in 15 seconds, the door opened and a magnet alarm went off at the top of the door. Maintenance Supervisor S explained the alarm also sounded at the nurse station, and to reset the alarms required a key and a code to enter. It was verified that the alarm was sounding at the nurse station, which is situated directly across from the dining room. On 9/13/22 at 11:15 AM, the facility's elopement books were reviewed at each nurse station. All books were identical in content, but R807's name and picture were not in any of the books. On 9/13/22 at 11:40 AM, Social Work (SW) Director CC was interviewed and asked about the elopement books. SW CC explained she received a report from nursing on who should be in the elopement book and she had updated the books after R807 had fallen down the stairs. When informed R807 was not in the books, SW CC' appeared shocked and attempted to find an old copy of the elopement book, but was unable to find any documentation that R807 had ever been listed in the elopement book. On 9/13/22 at 12:00 PM, the Director of Nursing (DON) was interviewed and asked if R807 had received adequate supervision before she fell down the stairs. The DON explained multiple staff had redirected R807 that day, but at the time of the incident, most of the staff were in the dining room because it was dinner time and they did not hear the alarm. When told the alarm was verified as sounding loudly at the nurse station, directly across from the dining room, the DON had no answer. The DON was told of R807 not being listed in any elopement books. The DON had no reply. Review of a facility policy titled, Elopement - Elopement Alert dated 8/16/21 read in part, . 1. Wandering is random or repetitive locomotion/ambulation. This movement may be goal directed or may be non-goal directed or aimless. 2. Elopement occurs when a resident needing supervision leaves a safe area without authorization and/or any necessary supervision to do so . Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing.

This citation pertains to intakes MI 851 and MI 284. Based on interview and record review the facility failed to ensure ongoing, detailed, accurate skin assessments and ongoing wound care consultant visits to ensure appropriate treatments were in place for one resident, (R317) of two residents revealed for pressure ulcers, resulting in the development of a heel Deep Tissue Injury, and the worsening of a pressure ulcer to a stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present, often includes undermining or tunneling). Findings include: On [DATE] at 8:07 AM, A review of R317's closed clinical record was conducted and revealed they admitted to the facility on [DATE] discharged to the hospital on [DATE], readmitted on [DATE], discharged again to the hospital on [DATE] and readmitted on [DATE], and then discharged to the hospital on [DATE] where they expired shortly upon their admission. R317's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R317's hospital admission record dated [DATE] revealed a wound assessment that indicated they admitted from the facility to the hospital with a stage 3 pressure injury (full-thickness loss of skin in which fat is visible and slough or eschar may be visible) to their sacrum and a deep tissue injury to their right heel. The Wound Summary assessment dated [DATE] in the hospital records read, .Sacrum-Stage 3 pressure injury, present on admission. Appears to be an evolved deep tissue injury. Peri wound is open, pink, moist, sloughing yellow. Peri wound is red blanching in areas, but also areas of burgundy and purple. Small amount of drainage, serosanguineous and yellow. Minimal odor. Wound is very painful to patient .Right heel-deep tissue injury, present on admission. Closed wound. Burgundy, purple base of wound . A review of R317's hospital admission record dated [DATE] revealed R317 admitted to the hospital with a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present, often includes undermining or tunneling). the records read, .Wound Summary Assessment: Coccyx stage 4 chronic pressure injury, beige, brown tissue in base, undermining pocket .small foul serosanguineous drainage, partially nonblanchable [CONDITION(S)] erosion and cluster of wound with slough in base at peri-wound . Continued review of R317's hospital records revealed they expired on [DATE] and the first listed cause of death read, [CONDITION(S)]. A review of F317's skin assessments, wound care consults, and progress notes in the facility's medical record revealed the following: A wound care consult from Dr. 'J' on [DATE] that read, .Noted with a rash to the coccyx and adjoining buttocks related to MASD (moisture-associated skin damage) . A document titled, 2018 Visual Skin Evaluation that documented R317 had a Reddened area on their Coccyx on [DATE] A wound care consult from Dr. 'J' on [DATE] that read, .Rash to coccyx and adjoining buttocks related to MASD much improved . A nursing note dated [DATE] by Licensed Practical Nurse (LPN) 'L' that read, .buttocks area is clean but she arrived with 2 patches on the middle buttocks . A wound care consult from Dr. 'J' dated [DATE] that read, .readmitted with area of dark discoloration to coccyx and adjoining buttocks related to DTPI (Deep tissue pressure injury, a serious form of pressure injury). 8 x 6 cm (centimeters). Partially ulcerated in the middle .Rx (treatment) with Triad paste q (every) shift and prn (as needed) and monitor . The documentation did not describe the ulceration or give a pressure ulcer stage. A Wound assessment dated [DATE], completed by Registered Nurse (RN) 'K' that indicated R317 had a deep tissue pressure injury (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister) with an accompanying Wound Note that read, readmitted with an area of dark discoloration to coccyx and adjoining buttocks related to DTPI. Partially ulcerated in the middle . A wound care consult from NP (Nurse Practitioner) 'M' dated [DATE] that read, .area of dark discoloration to coccyx and adjoining buttocks related to DTPI. 7.5 x 6 cm. Partially ulcerated in the middle. No drainage. Continue Rx (treatment) with Triad paste q shift (every shift), prn (as needed), and monitor . A wound assessment dated [DATE] completed by RN 'K' with an accompanying wound note that read, Area of dark discoloration to coccyx and adjoining buttocks related to DTPI. Partially ulcerated in the middle. It was noted this was the last documented wound assessment by facility staff in R317's record. A wound care consult from Dr. 'J' dated [DATE] that read, .Area of dark discoloration to coccyx and adjoining buttocks related to DTPI. Improving/fading. 7.6 cm x 6 cm. Partially ulcerated in in the middle. No drainage. Continue Rx with Triad paste q shift, prn, and monitor . A wound care consult from Dr. 'J' dated [DATE] that read, .Partially ulcerated area of dark discoloration to coccyx and adjoining buttocks related to DTPI. Improving/fading. 6.8 x 5.8 cm .Continue Rx with Triad paste q shift, prn, and monitor . A review of R317's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Instructions: Cleanse coccyx with normal saline, apply [MEDICATION(S)] to wound bed, cover with gauze daily and prn . It was noted there was no documentation in the record that indicated either Dr. 'J' or NP 'M' had seen R317. It was further noted there was no description of any type of wounds or why R317's treatment had been changed from the last documented assessment of an Improving/fading DTPI on [DATE]. A review of a progress note entered into the record by RN 'O' on [DATE] read, .Continue medi-honey treatment to coccyx per (NP 'M') via telehealth video call assessment . It was noted there was no documentation by NP 'M' that indicated they assessed R317 on, or around [DATE]. Due to the lack of information in the record (no wound care consult or weekly skin/wound assessments) it could not be determined the condition of R317's skin or wounds. Continued review of R317's progress notes revealed the following: A note dated [DATE] from Registered Dietician 'N' that read, .unstageable to coccyx without improvement at this time . It is unclear where RD 'N' obtained that information as there were no wound care consults or weekly wound care assessments that gave any indication about any wounds R317 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] A note entered into the record by RN 'O' on [DATE] that read, .Wound of coccyx, treatment as ordered, logged for wound care team reassessment <sic> .approx. (approximately) 1400 (2:00 PM) resident c/o (complaint of) ,d+[DATE] pain of sacral area . A note entered into the record by RN 'O' on [DATE] that read, .Wound care team assessed sacral/coccyx wound . Evidence of the wound care team assessing R317 on [DATE] was not present in the record. Continued review of R317's record revealed they readmitted to the facility on [DATE]. A note entered into the record by LPN 'P' on [DATE] read, .open area to coccyx .logged into doctors log, and wound log . There was no admission skin assessment or any other documentation that described the wound on R317's coccyx. A wound care consult note dated [DATE] by Dr. 'J' was reviewed and read, .admitted with an unstageable (obscured full-thickness tissue loss) ulcer to the sacro-coccyx and adjoining buttocks. With necrotic eschar in the middle. Surrounding skin dark and with partial ulceration. 12.1 x 14.9 cm. Scant serosanguineous drainage. Rx to the necrotic area with Medhoney <sic>, apply triad paste to the surrounding skin and cover . On [DATE] at 12:31 PM, the facility Administrator was requested to provide any additional documentation regarding R317's skin or wounds including any assessments, and missing wound care consults, specifically from [DATE] (where the treatment was changed to [MEDICATION(S)]), [DATE] where it was documented NP 'M' performed an assessment, and [DATE] where it was documented the wound care team performed an assessment. At 1:53 PM, the facility's Administrator reported there was no additional documentation to be provided regarding R317's pressure ulcer or skin conditions. On [DATE] at 12:45 PM, a review of R317's facility provided care plans were conducted and a Problem initiated [DATE] read, .(R317) has impaired skin integrity unstageable to coccyx upon admission .Interventions: .Document size, site, amount of drainage, amount of healing, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:00 PM, the Director of Nursing (DON) was asked about R317's pressure ulcer and said they were not the facility's Director of Nursing at the time of R317's stay in the facility. A review of a facility provided policy titled, Skin Assessments dated [DATE] was conducted and read, Policy: To Assess and appropriately respond to a resident's skin concerns. Procedures: Upon admission, readmission, PRN, and with all skin status changes, or when assigned by a Supervisor, each resident will be observed and assessed for skin concerns. 1. A licensed nurse shall perform a skin assessment using a skin Assessment form and update the Braden Scale. 2. The caregiver shall look at the resident's skin for any and all concerns on an ongoing basis during a resident's routing scheduled shower, personal care needs, while dressing, and undressing. Any concerns are to be reported to the Charge Nurse immediately. 3. Completion of the skin check done during the resident's routine scheduled shower/bath will be documented by the caregiver on the Shower sheet. This documentation will be reviewed by the Nurse and by the Nurse Supervisor on a weekly basis. 4. When a skin concern is found, findings shall be reported to the resident's physician and the resident's responsible party. 5. Any resident noticed to have any pressure or stasis ulcers shall have a completed skin assessment done on a weekly basis until the pressure or stasis ulcers are healed. 6. Any pressure or stasis ulcers identified will be reported to the wound nurse.

This citation pertains to intake: MI 851 and contains two Deficient Practice Statements. Deficient Practice #1 Based on observation, interview and record review the facility failed to identify the root cause of falls and implement effective interventions to prevent further falls for two (R's 18 and 319) of seven residents reviewed for accidents. Findings include: Review of a fall policy titled Falls - Clinical Protocol dated March 2018, documented in part .The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable .Based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified and also reconsider the current interventions . R18 Review of the clinical record revealed R18 was admitted to the facility on [DATE] with a readmitted d of 1/3/2022 and diagnoses that included: Dementia. A MDS assessment dated [DATE] documented a Brief Interview for Mental Status score of 00, indicating severely impaired cognition and required staff assistance for all ADLs. On 6/22/22 at 9:56 AM, incident reports for falls were requested for R18 from October 2021 to current from the Administrator. Shortly after the Administrator provided one fall incident reported dated 2/19/22. Review of a facility incident report date 2/19/22, documented in part .Resident stated that she got up to look for her address book but lost balance and fell down to the floor. Noted a non-straight (displaced) left middle finger, open skin on her left cheek and abrasion on her right knee. Resident was lying flat in her bed apparently she got up by herself and transfer by herself back to bed .IMMEDIATE INTERVENTION (PREVENT REOCCURANCE): Redirection provided to resident to use the call light when she needs any assistance. Transferred to w/c (wheelchair) and propelled to the hallway <sic> front of the station .Root Cause identified- Resident got up without assistance to look for her address book . Review of a Nursing Note dated 2/19/22 at 4:34 PM, documented in part .Today at 2 pm when this writer came to resident's room to give her due medications found resident lying on her back in her bed but noticed some blood on her face and right lower leg, noted an expression of pain on her face, immediately resident was assessed and noted her left middle finger non straight and displaced, also noted an small skin tear on her left cheek, right knee superficial abrasion and right knee slight redness, called (physician name) and reported the incident and injuries, he ordered Stat (immediate) X Ray to left middle finger . Review of a Nursing Note dated 2/19/22 at 7:37 PM, documented in part .Called (physician name) to report resident's left middle finger X Ray result which is dislocation to the finger . On 6/23/22 at 3:19 PM, the Administrator and Director Of Nursing (DON) was asked to provide a copy of the hand x-ray results from February 2022, however no results were provided by the end of survey. Further review of the Nursing Notes documented another fall on 12/29/21 at 9:01 PM, which documented in part .Resident was observed by this writer in bed with blanket over her and resting with eyes close <sic>. While speaking to Resident a darkening around residents eye was noted, This writer turned on more lightening .periorbital bruising with slight swelling to right outer brow. Resident was asked by this writer what happened (resident name) stated I fell over there on the rocks, while pointing towards the restroom door and trash can. Resident was assisted to restroom for skin assessment. Resident was asked to point out the area where she fell .again stated I fell right there Resident pointed to the trash can near the bathroom door. Resident had no complaint <sic> at this time or during transfer to toilet. There is swelling <sic> was noted to the right elbow, a few small red bruises right forearm and a small abrasion noted below right knee. During skin assessment resident complained of pain with movement of right leg. Injuries are noted predominately on right side of residents body. PA (Physician Assistant) was notified order received for xrays of right side of her body . On 6/23/22 at approximately 12:00 PM, the Administrator was asked about R18's December 2021 fall and a second request was asked for all incident reports that pertained to falls from October 2021 to current. Shortly after, the Administrator provided a fall incident reported dated 12/29/21. Review of the 12/29/21 fall incident report dated 12/29/21 at 3:40 PM, documented in part .Writer observed residents right eye bruised. Resident stated she fell by the trash can next to restroom door. It's believed resident was attempting to go to the restroom but fell before she opened the door. Bathroom door alarm functioning and in place. Resident possibly hit the trash can when she fell .IMMEDIATE INTERVENTION .Refer to Therapy to eval/treat after result's .Resident needs to be transferred to (Room number) for closer monitoring .Resident got herself back in bed and didn't alert the staff. Resident has a hx (history) of previous falls that she reported at later dates .Root Cause identified Resident has a hx of ambulating in her room and noncompliance with using call bell for assistance . Review of a pelvis radiology report dated 12/29/21 at 11:27 PM, documented in part .IMPRESSIONS .There is a transverse, impacted right femoral neck fracture which should be considered acute until proven otherwise . Review of hospital History and Physical report dated 12/30/21 at 6:44 PM, documented in part .Chief Complaint- Pt (patient) c/o (complaints of) right hip fx (fracture) .female with .dementia who presents to ED (Emergency Department) from nursing home with chief complaint of R (right) hip pain. Nursing home staff that <sic> patient had unwitnessed fall at approximately 1300, after which patient was nonambulatory .XR (x-ray) skull showed possible orbital fracture, and patient was sent ED with concern for hip fracture .has history of frequent falls with prior L (left) left fracture .Imaging Results CT (Cat Scan) Hip w/o (without) Contrast Right .Nondisplaced right femoral subcapital neck fracture .CT Maxillofacial w/o Contrast .Subcutaneous soft tissue hematomas of the right periorbital, premaxillary and nasal subcutaneous tissues .Assessment/Plan .Fracture of unspecified part of neck of right femur, initial encounter for closed fracture, Hip fracture, right, Frequent falls, Hip pain-swelling, Traumatic ecchymosis of orbital rim . Review of a hospital Surgical Documentation dated 12/30/21 at 7:00 PM, documented in part .Procedure .Percutaneous Fixation Right Femoral Neck Fracture .Patient is only to self and is otherwise confused and is a poor historian .the patient sustained an unwitnessed fall sometime in the early morning of 12/30/2021. Patient did strike her face as well as complaining of right hip pain which did not allow her to walk. Patient was previously ambulatory in some capacity. Patient was seen and evaluated by orthopedics team after a right valgus impacted femoral neck fracture was noted on x-rays. This was further confirmed on CT imaging. Patient has a DPOA appointed to her and after discussing her injuries with him, he expressed his wishes to move forward with operative fixation of her right femoral neck . The operation was noted to be completed with no complications. Review of the last completed fall risk assessment dated [DATE], documented a score of 105. A High Risk score was classified as equaled to or more than 51. Review of the facility's current Electronic Medical Record (EMR) system contained no fall care plan for R18. The facility changed medical record systems in March 2022 per the Administration staff. On 6/23/22 at 1:17 PM, the Administrator was asked to provide a copy of the resident's care plans located in their hard copy chart on the unit. At 1:23 PM, the Administrator informed the surveyor that there were no care plans in the resident's chart. A request was made for the Administrator to provide the care plans that was located from the facility's previous EMR system. Review of the care plans previously implemented (prior to the MARCH 2022 EMR system switch) revealed a care plan titled (Resident name) is at risk for falls r/t (related to) unsteady gait, weakness, polypharmacy as well as dementia and .psychotic behaviors. Fall prior to admission which resulted in facial laceration and contusion .EFFECTIVE: 7/2/2018 - PRESENT . The care plan documented a Therapy to evaluate/treat intervention (implemented on 12/29/2021). The care plan documented an intervention that was implemented in 2018 which documented Restorative Nursing program for lower extremity strengthening and fall prevention that was implemented. The care plan did not have an intervention implemented after the February 2022 fall. At the time of survey, the resident's clinical record did not contain a fall care plan, despite being a high fall risk resident with a recent history of falls with major injury. On 6/23/22 at 2:27 PM, the DON was asked why the root cause analysis of the December 2021 and February 2022 falls were not investigated and identified, why ineffective interventions were implemented for a resident with dementia and why the facility did not implement a current fall care plan for a resident that recently had a major injury from a fall. The DON stated they would look into it. At 3:53 PM, the DON stated they could not provide any additional explanation or documentation. No further documentation was provided by the end of survey. R319 On 6/21/22 at 10:09 AM, R319 was observed in their room up in their wheelchair. R319 was observed to have an undated foam adherent dressing to their left elbow. At that time, R319 was asked what happened to their elbow and said, I fell . On 6/21/22 at 12:48 PM, a review of a progress note entered into the record by Licensed Practical Nurse (LPN) 'H' on 6/16/22 at 9:23 PM was conducted and read, .writer notified by CNA (certified nurse aide) that resident was on the floor in her bathroom. Writer entered room and saw resident on the floor. writer asked the resident what happened, resident stated I just fell . writer performed range of motion on all extremities. skin assessment performed with a skin tear to left elbow noted. skin tear cleaned with normal saline and steri strips applied On 6/22/22 at 11:45 AM, a review of R319's record revealed and admitted [DATE], and a readmitted [DATE]. R319's diagnoses included: [CONDITION(S)] and collapse, concussion with loss of consciousness, [CONDITION(S)], and dementia. R319's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated they had severe cognitive impairment, were non-ambulatory and required extensive assistance from one staff member for most activities of daily living. The MDS also indicated R319 had a triggered care area assessment for falls. A review of R319's MORSE FALL-Senior Living assessment on 5/27/22 revealed R319 was a High Risk for Falling. A review of R319's care plans was conducted and despite being admitted with a diagnoses of [CONDITION(S)] and collapse, a high risk for falling score, a triggered care area assessment for falls and a fall on 6/16/22, R319 did not have a care plan for falls implemented until 6/22/22. On 6/22/22 11:55 AM, a second review of R319's progress notes was conducted and revealed a note dated 6/22/22 at 10:08 AM that read, .IDT team met to review incident from 6/16/22. Resident educated on using proper transfer techniques and utilizing call button to ask for assistance. Care plan updated . 06/22/22 at 12:06 PM, the facility's Administrator reported they had no incident/accident reports or investigations for R319. On 6/22/22 at 2:00 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding falls, specifically R319's fall. The DON said they did have an incident/accident report for R319's fall and provided a document titled, Incident Audit Report. A review of the report was conducted at that time and indicated the incident was In Progress. Continued review of the document repeated the nursing progress note by LPN 'H' on 6/16/22. It was noted the report did not include any investigation into the root cause of R319's fall, no statements from staff, or resident specific appropriate interventions implemented to prevent future falls. Deficient Practice #2 Based on observation, interview and record review the facility failed to ensure a safe transfer when using a lift for two residents (R17 and R89) out of seven residents reviewed for falls, resulting in R17 sustaining bruises on the back of their right hand, redness and swelling to the right knee and pain and R89 sustaining a knee fracture. Findings include: R17 On 6/21/22 at approximately 10:00 AM, R17 was observed lying in bed in their room. The resident was alert, but not able to most questions asked. A review of R17's clinical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that included: dementia, kidney failure, and [CONDITION(S)]. A review of the resident's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 3/15 (cognitively impaired) and required an extensive two person assist for transfers. Continued review of R17's record documented in part, the following: Nursing Progress Note (3/30/22): .The nurse was notified by the day shift nurse, about the incident. The resident was picked up from the floor in the bathroom by 3 staff with the Hoyer machine .On skin assessment the resident has some bruises on the back of her right hand with <sic> bluish in color, and redness on both knees. The right knee was swelling, warm to touch and red, when touch resident c/o (complained of) pain in the area, the leg was repositioned with little effect and the resident continued to c/o pain .The STAT X-RAY on the right knee was done . (Authored by Nurse AA). IDT (interdisciplinary team) Note (4/4/22): IDT team met and reviewed 3/29/30. Agency CNA (certified nursing assistant) educated on proper use of (name of sit-to-stand aid) and not able to return to facility . (Authored by Nurse LL). A review of the facility's Incident and Accident form documented, in part: .Incident Date: 3/29/22 at 7:30 PM .The nurse was called by the day shift nurse of the identified fall .The nurse asked what happened and the resident couldn't explain herself .The CNA said she took the resident to the bathroom with the (name of sit-to-stand aid) and .while trying to get the resident in bed, the resident was not able to stand, so she let her go on her knees to look for help .resident c/o of pain at the right knee .The CNA was instructed to always look for a second person when using any of the machines . A review of R17's care plan documented the following: The resident has an ADL Self Care Performance Deficit. Limited Mobility (Date initiated 3/30/22) .Intervention: Transfers (name of sit-to-stand aid) x2 PERSON ASSIST (Date initiated 3/30/22). *It should be noted that there was no intervention in place prior to 3/30/22. On 6/22/22 at approximately 5:25 PM, an interview was conducted via phone with Nurse AA. Nurse AA reported that she was aware of the incident and stated that she had informed CNA that she needed two people when lifting R17 and the CNA told her that she knew what she was doing, but later reported to her that she needed help as R17 was on the floor. Further to her knowledge, the CNA no longer worked at the facility. Nurse AA did not recall the name of the CNA. On 6/23/22 at approximately 9:22 AM, an interview was conducted with the Director of Nursing (DON). The DON was able to identify the CNA as CNA EEE. When queried about the incident, the DON stated she was aware of the situation and reported that on the day of the incident, Nurse .noted that she observed CNA EEE entering into R17's room with the lift and then the Nurse told her not to do it on her own and CNA EEE told Nurse AA that she knew what to do. Shortly after CNA EEE reported that the resident could not stand and had to be lowered to the floor. The DON further reported that the CNA EEE was terminated as it was the facility's policy that all transfers using the (name of sit-to-stand aid) need to be completed by two staff to ensure the resident's safety. R89 On 6/21/22 at 10:54 a.m., R89 was observed in bed. When asked about their care at the facility, R89 stated they had a fall about two months ago when they were on one of those machines, a (3000 Unit Lift). R89 further stated, I told the girl (aide - Certified Nurse Assistant- CNA) that I was going to fall because it was slippery, and she said, 'We don't have that far to go, and then I fell . I was in such pain, for a long time for over a month . R89 further stated, I kept complaining about the pain and my daughter told me to tell the doctor to do a CAT (Computerized Axial Tomography Scan - medical imaging technique used in radiology to obtain detailed internal images). R89 explained that the facility sent them to get a CAT Scan and it showed they had a fracture in their knee, and the hospital put a soft brace around their knee. R89 stated before the incident, they were able to stand on that leg/knee, but now they cannot. When asked if it was one or two-staff who assisted them with the transfer using the lift, R89 stated, One. When asked if they remembered who it was, R89 reported No. She was from the Agency. Review of the electronic clinical record revealed R89 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included in part: [CONDITION(S)] Accident ([CONDITION(S)] -Stroke), Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), Tremor, and Heart Failure. According to the quarterly MDS assessment dated [DATE], R89 had a BIMS exam score of 15 indicating intact cognition and required extensive assistance with two-person physical assist for transfer. It was noted that R89's transfer status was two-person assist prior to the incident. Review of the Incident Audit Report dated 3/28/22 at 10:38 (AM) documented in part the following: Incident Details/Description: Cena (CNA) assigned called the writer to resident's room and observed resident's <sic> on (name of sit-to-stand aid) standing with right foot stuck between leg of lift . Reported by LPN 'III' Resident Description: My foot got caught. Description of Action Taken: Assisted resident out of (name of sit-to-stand aid) with cena (Certified Nursing Assistant). Assess for injury, pain and vital sign . Resident transferred from floor to bed PRN (as needed) pain medication given. X-ray of back, right hip and femur, lumbar ordered . Level of Pain: 8 . Factors: Equipment Related: Y (Yes) During Transfer: Y Witnesses: Was this incident witnessed: Y Progress Notes dated 4/8/22 at 12:06 (AM) documented the following: Incident Note Resident was being transferred from w/c (wheelchair) to bed by CNA with sit-to-stand machine. When CNA stared <sic> raising the machine up the resident let go and fell on her back toward her right side. CNA called for help and writer plus 1 CNA went to assist. Upon assessment writer noted redness to residents back but <sic> with no skin tears noted. Resident c/o (complaint of) lower back pain and right leg pain. Resident assisted back into bed with maxi lift with the assistance of 2 CNA's and 1 nurse. Vitals WNL (within normal limits). Resident given PRN (as needed) pain medication and tolerated well. MD notified and ordered X-ray of lumbar, right hip and femur. Family and manager notified. Report by LPN 'JJJ'. On 6/22/22 at 5:15 p.m., during an interview, Nurse Manager 'LL' stated, All lifts require two-person assist. On 6/23/22 from 12:34 to 12:45 p.m., calls were placed to LPN 'III', LPN 'JJJ', and CNA 'KKK' and a message was left on the voice mail with no return calls. On 6/23/22 at 12:50 p.m., an interview was conducted with the DON regarding safe transfer for residents. The DON stated, Any mechanical lift with a motor, must have two people. One person to operate the machinery and the second person is hands on the patient, guiding them. A review of the facility policy titled, Lifting Machine, Using a Mechanical (Revised July 2017) documented, in part: Purpose: The purpose of this procedure is to establish general principals of safe lifting using a mechanical lifting device . General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift .Types of lifts that may be available in the facility are . c. Sit-to-stand lifts .

Based on observation, interview, and record review the facility failed to ensure a resident was free from avoidable accidents for one (R#75) of two residents reviewed for accidents, resulting in the resident being hit on the head by a reacher device (an assistive device with a claw-like end used to grab items) and sustaining a bruise under the right eye and a knot to the forehead. Findings include: On 3/16/21 at 9:06AM, R#75 was observed in their room, and was observed to have a slight bruise present under the resident's right eye. The resident was queried in regard to the bruise and explained it had occurred with an aide and a reacher resident has sight bruise under the resident's right eye said occurred with aide with a reacher. A reacher device was observed to be present on R#75's bed. On 3/16/21 at 2:50PM, R#75 was further queried in regard to the incident and explained, in part, she didn't do what she was supposed to, you don't go over a person's head. The resident explained it had been an aide and did not know the employee's name. R#75 explained they had a big bump there for a long time. Review of a progress note dated 1/9/21 at 6:35AM documented, in part, Upon doing AM medications, resident stated that while the CNA (Certified Nursing Assistant) was providing care, the reacher fell and hit resident in head. Resident states the reacher is normally another way while in bed. Resident states could not recall what CNA was doing when the reacher fell . Resident has purple discoloration under R (right) eye and knot to R lateral forehead. On call Dr (doctor) notified and ordered to monitor patient and to contact Dr back if resident has complaints of headache or emesis . Review of an IDT (interdisciplinary team) note effective date 1/15/21 at 3:30PM documented, in part, Resident reviewed for incident on 01/09/2021. Resident was observed to have a bruise under her right eye and on the right lateral side of her forehead. Resident stated that a staff member grabbed her reacher to turn her call light off and accidentally dropped the reacher and hit her in the face .Education was done with all staff on the floor inregards <sic> to using objects to turn off resident call lights and the importance of maintaining resident safety. Review of an incident and accident (I/A) report for the resident dated 1/9/21 at 6:00 AM in regard to the incident documented the following injuries: knot to R (right) lateral forehead and red circular area under R eye. On 3/17/21 at 3:43PM, the facility's Director of Nursing (DON) was queried in regard to the situation and explained that everyone had been educated as a specific individual did not admit to the situation. The DON also acknowledged staff should not be using a reacher to turn off call lights.

Based on observation, interview and record review the facility failed to consistently investigate the root cause analysis of falls and implement/modify interventions to prevent further falls for two (R#'s 702 and 705) of three residents reviewed for falls, resulting in unknown causes of repetitive falls, care plan interventions not modified to prevent further falls and R# 705 to have sustain a left femoral neck fracture requiring hospitalization and left hip hemiarthroplasty (a surgical procedure that replaces one half of the hip joint with a prosthetic). Findings include: R# 702 A facility reported incident dated 2/18/20 at 10:38 am, documented in part . found to have a bruise on face, sacrum and right leg. Investigation initiated . A review of the clinical record revealed R# 702 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 out of 15 (indicating severely impaired cognition) and was dependent on staff for all Activities of Daily Living (ADL's). A facility Event Report form dated 2/17/20 at 8:05 am documented in part, . CNA (Certified Nursing Assistant) notice pt (patient) had a bruise to her left lower cheek as she was sitting at the dining room table. When pt was asked about how she got the bruise resident stated, I don't know. When asked if it hurted <sic> when touched/pressed pt stated, no. When asked by unit manager pt stated, I fell and crawled to the chair. bruise greenish purple around purple/red area size of a quarter 2 x 2 cm (centimeters) . What Action Nurse initiated immediately in response to this Event to prevent a reoccurrence: Resident is no <sic> compliance with asking for assistance and does everything for herself. Door is always open when resident is in room . Root Cause Determination by Charge Nurse at the time of the event: It's possible she could have caused irritation and bruising by picking and pulling out her facial hairs. Pt also taking ASA (aspirin), which makes her prone for bruising . The Investigation Summary was not completed and left blank on this form. A fall risk assessment dated [DATE] at 13:21 (1:21 pm) documented a total fall risk score of 80, indicating High Risk which then directs the staff to Implement High Risk Fall Prevention Intervention. A Radiology Report dated 2/17/20 at 2:47 pm, documented in part . Reason for Exam: swelling bruising on right side of face . Conclusion: Unremarkable facial bones . A facility Even Report form dated 2/17/20 at 16:00 (4 pm) documented in part, . Resident said she fell but doesn't know when. CNA showered the resident and additional bruises were observed 2 dark purple bruises- 6cm x 6cm on her R (right) left and one same description on the sacrum . What Action Nurse initiated immediately in response to this Event to prevent a reoccurrence: Son encouraged his mother to not ambulate without supervision . Root Cause Determination by Charge Nurse at the time of the event: See original incident report . The Investigation Summary was not completed and left blank on this form. On 7/22/20 at 9:55 am, R# 702's reports on falls were requested from the Administrator for review. The Administrator provided the following: On 11/23/19 at 4:25 pm, an Event Report form documented in part . Resident was ambulating in hallway pushing w/c (wheelchair) resident was standing in front of patio window stepped to the side + lost her balance fell to her knees then over onto her right side resting on her right arm . c/o (complaints of) mild discomfort (R) (right) thigh . What Action Nurse initiated immediately in response to this Event to prevent a reoccurrence: Referred to therapy, staff to continue to redirect resident to use her walker for ambulation around and not push w/c . Root Cause Determination by Charge Nurse at the time of the event: Resident has poor safety awareness has a hx (history) of noncompliance with using walker and w/c . The Investigation Summary was not completed and left blank on this form. On 12/22/19 at 2:30 pm, an Event Report form documented in part . Resident stated she fell in her room when CENA (Certified Nursing Assistant) asked her why she was breathing to <sic> hard, Resident reported to this writer she was walking in her room and lost her footing and fell next to the bed . Resident stated she was having some discomfort in her (L) (left) hip . What Action Nurse initiated immediately in response to this Event to prevent a reoccurrence: Door of room (room number redacted) was left open while resident was in room. Refer to therapy . Root Cause Determination by Charge Nurse at the time of the event: Resident has poor safety awareness, has a hx of noncompliance with use of w/c and walker. Resident is non-compliant with using call light/ or asking for assistance . The Investigation Summary was not completed and left blank on this form. On 1/17/20 at 11:30 pm, an Event Report form documented in part . Resident was cleaning/organizing her closet and states she fell on her bottom out of her w/c . Res (resident) was observed sitting on the floor in her room, on her buttocks with feet/legs in front of her, and w/c directly behind her . small ping pong sized <sic> red blanchable area on the back of the upper L (left) thigh . What Action Nurse initiated immediately in response to this Event to prevent a reoccurrence: Put resident's items back where she wanted them, assisted her to the toilet, and back to bed. Door left open . Root Cause Determination by Charge Nurse at the time of the event: Poor safety awareness. Non-compliant with safety interventions that are in place . The Investigation Summary was not completed and left blank on this form. On 2/23/20 at 10:50 pm, an Event Report form documented in part . Resident states she was trying to go to the bathroom with her w/c & fell off of the bed . observed resident sitting on the floor with bedside, on buttocks, back against the bed with w/c out in front of her . Red/pink blanchable area to L shoulder blade area where resident was leaning against bed . What Action Nurse initiated immediately in response to this Event to prevent a reoccurrence: Assisted resident to bed, placed w/c next to bed, locked, positioned call light where resident requested- asked resident to demonstrate call light use & asked her to please use it. Room door left open . Root Cause Determination by Charge Nurse at the time of the event: Resident has poor safety awareness & continues to use her w/c as a walker regardless of frequent reminders & instructions . The Investigation Summary was not completed and left blank on this form. On 2/25/20 at 10:20 am, an Event Report form documented in part . Resident observed by staff sitting on the floor resting against restroom door frame, bathroom door was closed, w/c facing resident . resident bruised from previous falls . Restorative exchanged w/c for a lower and shorter w/c seating, dyson applied to cushion, current cushion changed to wedge cushion. Bathroom alarm, and N.O. (new orders) received for labs . resident is not to be in room by herself unless in bed . Root Cause Determination by Charge Nurse at the time of the event: Resident has a hx (history) of poor safety awareness and not alerting staff for assistance. Resident also has a hx of sitting on the edge of her w/c despite staff cues and redirection . The Investigation Summary was not completed and left blank on this form. On 4/3/20 at 7:00 pm, an Event Report form documented in part . Resident said <sic> was trying to open her dresser, but lost balance and fell to the floor . What Action Nurse initiated immediately in response to this Event to prevent a reoccurrence: Safety measures taken and explained resident's CNA to keep residents room always open to prevent new incidents . Root Cause Determination by Charge Nurse at the time of the event: Resident was in her room with the door closed and when she got up from her w/c to try to open the dresser, lost her balance and fell to the floor . Investigation Summary: Resident was trying to open dresser & lost balance IDT (Interdisciplinary team) believes w/c moved, antiroll backs ordered for wheelchair . A care plan titled (R# 702's name) is at risk a <sic> self-care deficit: bed mobility, transfers, hygiene, dressing, grooming, feeding, toileting, locomotion on/off unit (no date) documented in part, . Often refuses showers on shower days or help from staff. Will not lock wheelchair. Gets mad and defensive if help is offered. Wants door to room closed. Heightened Supervision every 30 minutes for safety . A care plan titled (R# 702's name) is at risk for falls as r/t (related to) decreased mobility and dementia . Refer to therapy for evaluation and treatment as needed, refer to therapy for evaluation and treatment as needed, Encourage or remind to use assistive devices daily: walker when ambulating, transfer bars in bathroom and handrails in hallways, continue to maintain observation by keeping her door open while she is in the room, shave resident facial hair on shower days if needed, monitor for facial bruising and notify physician of any changes, medication review, assist with activities as needed, bed in lowest position, check on resident at least every 2-3 hours to identify and meet needs as well as note location and safety status. Keep in view as much as possible as indicated . Risk Committee to review all falls per policy and provide appropriate interventions as indicated . On 7/22/20 at 11:02 am, the Administrator provided education and training on Incident reminder check off list, post fall investigation, event report, 72-hour neuro-check sheet and CNA post incident reporting. On 7/22/20 at 11:03 am, the Administrator acknowledged the concerns and stated that they identified I & A (Incident and Accident) report's not being completed and the facility is currently trying to rectify this. The Administrator stated the team is discussing it in QA (Quality Assurance). On 7/22/20 at 2:07 pm the Administrator and Director of Nursing (DON) were queried on the multiple documented falls, the IDT findings on root cause analysis of falls, the repetitive implemented interventions, the lack of Investigation Summary documentation and the documented heightened supervision for the resident and stated in part . no follow up investigation or interventions were implemented in the past. We are meeting as a team and doing post falls constantly, discussing it at QA. We are still trying to tighten that process and making sure their following the resident's interventions. A lot of this wasn't done before with the prior Administration . R# 705 A facility reported incident was reported to the State Agency on 3/9/20 at 4:41 pm, which documented in part . sent to the ER (emergency room ) on 3/7 due to increased complaints of pain <sic> her left hip. Reports from the hospital were just received and it has been determined that she has an acute impacted fx (fracture) of left femoral neck . On 7/22/20 at 1:30 pm, R# 705 was observed lying in bed on their back, their eyes was closed and their mouth was observed open. The resident did not respond to verbal stimuli. A review of the clinical record revealed R# 705 was admitted into the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 out of 15 (indicating severely impaired cognition). R# 705 was dependent on staff for all ADL's. A facility Event Report dated 2/23/20 at 5:10 pm, documented in part . describe what happened: unable to say what happened . in middle of hallway . small superficial abrasion on L (left) forehead . What Action Nurse initiated immediately in response to this Event to prevent a reoccurrence: Resident opted to eat in her room, then brought out by Nurse's station . The Root Cause Determination by Charge Nurse at the time of the event and the Investigation Summary portion of this form was left blank and not completed. A facility Event Report dated 2/27/20 at 7:40 pm, documented in part . Resident said she bent over to check on her shoes . No injury sustained . What Action Nurse initiated immediately in response to this Event to prevent a reoccurrence: Re-educated resident regarding staying safe while on the w/c (wheelchair). Resident reminded not to bend over to pick up anything from the floor. Always to ask for help . The Root Cause Determination by Charge Nurse at the time of the event and the Investigation Summary portion of this form was left blank and not completed. A facility Event Report dated 2/29/20 at 6:40 pm, documented in part . Resident was observed on her bottom on the floor between the wheelchair and her bed. She is unable to describe what happened . Typically resident is within eyesight of nurse's station . Resident put in bed. Will keep resident within eyesight of nurse's station whenever possible . Root Cause Determination by Charge Nurse at the time of the event: resident wanted to go to bed . Investigation Summary: Resident wanted to go to bed . A review of the Event Report's and clincial record revealed the facility failed to consistently determine the root cause analysis of the resident falls, complete a thorough investigation for all of the falls and consistently implement new and/or modify interventions to prevent further falls. A Nursing Note dated 3/7/20 at 10:41 am, documented in part . At the start of this shift 7p-7a, this nurse witnessed this resident ambulating in her room pushing her w/c. This nurse approached the resident and assisted the resident to sit down in her w/c . The resident c/o (complaints of) pain to her left hip at this time. The resident was given PRN (as needed) Tylenol . Approx. 45 minuets after the med was given, the resident admitted relief from the prn pain med (medication) . The CNA (Certified Nursing Assistant) care giver explained to this nurse that the resident stood and transferred into bed with c/o left leg pain but only c/o pain momentarily . This nurse was doing skin tx's (treatments) per the doctor's orders. The resident c/o pain to the left hip area. The resident was given Tylenol per the prn order at 0539 (5:39 am). The resident admitted relief from the Tylenol . The therapist . came to the nurses during report and explained that the resident is having pain to the left hip that is keeping the resident from doing her exercises, which is new . The nurse assessed the resident's left hip. The resident continues to have slight [MEDICAL CONDITION] to the left hip . This nursed ordered a STAT (immediate) left hip xray . No fall noted . During the whole 7p- 7am shift after the resident went to bed at approx 2030 (8:30 pm), the resident did not get OOB (out of bed) for the rest of the noc (night shift) . A Radiology Report dated 3/7/20 at 2:39 pm, documented in part . Reason for exam: pain in left hip . Conclusion: Acute left femoral neck fracture . Documented on that report (by staff) noted in part NP (Nurse Practitioner) notified asked to send resident out . (out to the hospital). A hospital physician consultation report dated 3/7/20 at 21:18 (9:18 pm), documented in part . Chief complaint: left hip pain . Per nursing home report, patient started complaining of left hip pain early this AM while trying to get out of bed. No witnessed falls. Patient normally ambulates independently at baseline with a walker . She has a history of right [MEDICAL CONDITION] s/p (status [REDACTED]. Radiographs demonstrated left subcapital displaced femoral neck fracture . Patient admitted to (unit name redacted) with orthopedic surgery consult . A hospital Radiology report dated 3/7/20 at 19:20 (7:20 pm) documented in part, . Impression: Acute impacted fracture left femoral neck the superior/cranial displacement of distal fracture component by 2.5 cm (centimeters) . A hospital physician consultation report dated 3/11/20 at 1602 (4:02 pm) documented in part, . Patient was taken to the OR (Operating Room) on 3/10/2020 for a left hip [MEDICAL CONDITION] hemiarthroplasty . On 7/22/20 at 11:03 am, the Administrator acknowledged the concerns and stated that they identified I & A (Incident and Accident) report's not being completed and the facility is currently trying to rectify this. The Administrator stated the team is discussing it in QA (Quality Assurance). On 7/22/20 at 2:07 pm the Administrator and Director of Nursing (DON) was queried on the multiple documented falls, the IDT findings on root cause analysis of falls, the repetitive implemented interventions, the lack of Investigation Summary documentation and stated in part . no follow up investigation or interventions implemented in the past. We are meeting as a team and doing post falls constantly, discussing it at QA. We are still trying to tighten that process and making sure their following the resident's interventions. A lot of this wasn't done before with the prior Administration . The fall risk assessment, falls, Incident and Accident policies were requested at this time. A facility policy titled Fall Prevention (7/14/20) was provided and documented in part . The goal of this policy/ procedure is to promote a safe environment and reduce the number of falls and severity of injuries related to fall and other incidents . Necessary fall precautions will be implemented: Place call light within resident's reach at all times, Encourage resident to request assistance before attempting to transfer/ ambulate, Orient/ reorient resident to new surroundings, Staff to assist with toileting and transfers when appropriate, staff to assess gait and balance . With the occurrence of a fall . an Incident/ Accident report will be completed by the nurse on duty . These reports will be reviewed at an interdisciplinary team meeting for further intervention of safety needs . The Interdisciplinary team includes the Director of Nursing, the Patient Care Coordinator, the Director of Staff Development, as well as representatives from Physical Therapy, Social Services, MDS, Dietary, and the Activities Department. It will meet to review all falls/ incidents and amend the resident's care plan and resident's summary as needed . The Charge nurse will initiate the Post Fall Investigation. Then Nurse Manager to review for completion . Care plans for those residents at risk for falls will be initiated upon admission and updated as needed . The Nurse Manager will pick up the incident reports from the units prior to morning meeting. The incidents will be discussed at the morning meeting with the Interdisciplinary Team. The report will be completed by the Unit Manager and reviewed by the DON, the Administrator, and the Medical Director .Any injury of unknown cause will also be documented on an Incident/ Accident report. The report will be initiated by the nurse on duty. If further investigation is necessary, an Abuse Investigation Report will be initiated by the nurse and then given to the Administrator who is the Canterbury Abuse Coordinator. An incident/ accident summary report will be completed by the nurse manager. Appropriate in-services and interventions will be implemented according to the summary's findings of any trends, patterns, or safety issues. These results and interventions will also be included in the facility's QAPI process. A facility policy titled Incidents & Accidents- Investigating and Reporting (dated: 8/1/19) was provided and documented in part . All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator . The Charge Nurse or supervisor shall promptly initiate and document investigation of the accident or incident . The Charge Nurse or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Nurse Supervisor/Director of Nursing within 24 hours of the incident or accident. All Incident and Accident reports are reviewed in the morning meeting . the Director of Nursing will be notified immediately. All incident and accident reports and investigations shall be completed in 5 working days .

This citation pertains to MI 741, MI 661, and MI 043: Based on interview and record review, the facility failed to provide thorough and accurate assessments, and implement appropriate treatments and interventions for pressure ulcers for one resident (R#814) of two residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar), the development of signs and symptoms of infection, and a transfer to the hospital for treatment of [REDACTED]. On 2/11/20 at 9:20 AM, a review of R#814's closed clinical record was conducted. R#814 was admitted to the facility on [DATE] for rehabilitation after hip surgery, and was discharged on [DATE] to the emergency room . R#814's [DIAGNOSES REDACTED]. A review of R#814's Minimum Data Set (MDS) assessment dated [DATE] indicated R#814 had intact cognition, was non-ambulatory, required extensive to total assistance with activities of daily living, and had an indwelling urinary catheter. A review of Section M. for skin conditions in R#814's MDS assessment indicated R#814 had an unstageable pressure ulcer. A review of R#814's nursing admission assessment titled, Nursing Evaluation dated 6/4/19 by Licensed Practical Nurse (LPN) 'P' was reviewed and indicated R#814 admitted to the facility with a wound on their left, right, lateral, and medial coccyx. The appearance of the wound was documented as, Appearance: Blanchable (when skin loses redness with pressure, but redness returns after pressure is relieved) Reddened. It is noted that a Stage I pressure ulcer is defined by the National Pressure Injury Advisory Panel as intact skin with non-blanchable redness. It was further noted the sections for the wound measurement were left blank. Continued review of the assessment indicated that R#814 had continued use of indwelling catheter related to contamination of stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer) or stage 4 (full thickness skin loss exposing underlying muscle, tendon, cartilage or bone) pressure sore with urine, though the initial nursing assessment only documented Blanchable Redness. A review of R#814's admission Braden Score (a tool used to determine pressure ulcer risk) calculated by LPN 'P' on 6/4/19 indicated R#814 was At Risk for the development of pressure ulcers. A review of R#814's admission note by LPN 'P' was reviewed and did not make any mention of R#814 having a pressure ulcer. A review of a note also dated 6/4/19 from LPN 'Q' was reviewed and read, .PU (pressure ulcer) to coccyx . It was noted that neither of these progress notes documented any description of the pressure ulcer such as it's appearance, measurements, or whether there was any drainage or odor. A review of R#814's admission orders [REDACTED]. Continued review of R#814's record revealed a Wound assessment dated [DATE] that indicated R#814 admitted to the facility with a pressure ulcer. The document indicated R#814 had been seen by wound care on 6/10/19. The wound was documented as an unstageable pressure ulcer measuring 8.5 cm (centimeters) in length and 13.5 cm in width. The depth was not measured, and No was indicated on the assessment for the presence of infection or odor. The note included in the assessment read, Area identified on admission. Wound is on coccyx and buttock. Treatment changed to (Name Brand) (a sterile, enzymatic [MEDICATION NAME] ointment) and CDD (cover with dry dressing) daily d/t (due to) wound being necrotic in appearance. A review of R#811's wound progress note from Nurse Practitioner (NP) 'L' dated 6/10/19 was reviewed and read, .Large unstageable ulcer to sacrococcyx extending to b/l (bilateral) buttocks. Right buttock covered with necrotic eshar <sic> and left buttock covered with thick yellow eschar . It was noted no measurements were included in the progress note. A review of the only weekly skin assessment note for R#814's stay in the facility (6/4/19-6/24/19) was conducted. The skin assessment was dated 6/15/19 and indicated R#814 had pressure ulcers on their right and left buttock that had both slough and eschar. A review of a progress note documented on 6/16/19 was reviewed and read, .PRN (as needed) tx (treatment) completed to coccyx wound. Blackened center with reddened borders, odors present . NP 'L's note for the visit on 6/17/19 was reviewed and read the exact same as the note on 6/10/19, Large unstageable ulcer to sacrococcyx extending to b/l (bilateral) buttocks. Right buttock covered with necrotic eshar <sic> and left buttock covered with thick yellow eschar . It was noted no measurements were included in the wound care consultant's notes. Continued review of R#814's progress notes was conducted and the following was revealed: 6/22/19 .has a necrotic pressure ulcer at the buttocks and coccyx, draining much fluid, she is going to the hospital for further treatment . 6/23/19 Dressing to right buttock done today. Observed was a large amount of thick white pus draining from wound. The wound also is foul smelling . 6/24/19 (Dr. 'O') in to see resident earlier this am (morning) in regards to decubitis ulcer at Buttocks. Order received to transfer resident to hospital. Open area continues to be necrotic with yellow slough covering majority of wound bed with large area of tunneling at upper aspect of wound. Large amt (amount) of greenish drainage observed .very foul odor present . A review of Dr. 'O's progress note dated 6/24/19 was conducted and read, .Plan: Will send her to hospital for better wound care and ABX (antibiotic) therapy . A review of R#814's care plans was conducted and it was noted the only care plan that addressed anything about R#814 having a pressure ulcer was a dietary care plan. It was further noted there were no progress notes in R#814's record, or evidence that indicated a specialized wound care practitioner had seen the resident. On 2/11/20 at approximately 10:45 AM, an interview with Unit Manager 'G' was conducted regarding documentation of wounds upon admission. During the interview, Unit Manager 'G' explained that all wounds should be described and measured in the assessment and in the progress notes. Unit Manager 'G' also indicated the physician should be made aware of the wound so they can order the appropriate treatments and consult wound care if needed. On 2/12/19 at 11:15 AM, an interview with the facility's Director of Nursing (DON) was conducted regarding pressure ulcers, documentation, and assessment. The DON indicated skin assessments should be done weekly. When asked about how nurses should document skin integrity concerns upon admission, the DON explained they should document accurately and in detail any concerns with skin, and that should be communicated to the doctor so an appropriate treatment can be ordered. When queried about R#814's initial skin assessment being documented as a Blanchable Reddened area on 6/4/19 and then deteriorating to a 8.5 cm x 13.5 cm unstageable pressure ulcer with slough and eschar by 6/10/19, the DON indicated the wound deterioration did appear to have happened while R#814 was in the facility based upon the documentation in the record. The DON was then asked if R#814 should have had a care plan for pressure ulcers and indicated they should have. The DON also indicated she recognized issues with the facility's pressure ulcer management and had been working on a new facility protocol. A review of a facility policy titled, Pressure Ulcer Treatment dated 12/28/15 was reviewed and read, The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. 1. Review the resident's care plan to assess for any special needs of the resident .1. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s) .c. Pressure ulcer care .Pressure ulcer treatment requires a comprehensive approach, including: 1. Debridement 2. Managing Infections .4. Maximizing the potential for healing . The facility was asked if they had any additional information to provide regarding the concern; none was provided by the end of the survey.

This citation refers to intake number(s): MI 170, MI 172, and MI 180. Based on observations, interviews, and record review, the facility failed to ensure two residents with severe cognitive impairment (R#801 and R#802) of six residents reviewed for accidents, did not exit the facility without knowledge of the staff on at least four occasions within one month, resulting in an immediate jeopardy (IJ) when R#801 who was exhibiting exit seeking behaviors left the building from the same emergency exit door on the unit on two separate occasions without knowledge of the staff, and R#802 who was a fall risk and deemed incompetent to make his own decisions, drove a motorized wheelchair a half mile down the main road without the knowledge of the staff and was found by an off duty staff member and was subsequently allowed to leave the facility unaccompanied by staff or family members. This put the residents at risk for serious injury, serious harm, and/or death. Findings include: The IJ began on 7/4/19. The IJ was identified on 8/7/19 at 3:45 P.M. and the Executive Director was notified and a plan to remove the immediacy was requested. The immediacy was removed on 8/8/19 at approximatley 3:30 P.M. based on the facility's implementation of an acceptable plan of removal verified on-site by the surveyor. Three anonymous complaints were submitted to the State Agency. One alleged R#801 eloped from the facility on 7/4/19 and a second time on 7/23 or 7/24 through an emergency door that has no alarm to indicate the door is open. The first complaint also alleged the staff were instructed not to document the incidents because neither was considered an elopement. The second complaint alleged R#802 left the faciity on or about 7/24 or 7/25 and was seen by a staff member down the street. It was alleged management told staff the resident had the right to leave and was over 21. The complaint documented R#802 had cognitive impairment and that this was the third incident in less than a month. The third complaint alleged R#801 eloped twice through a broken emergency exit door and R#802 was found down the road. It was alleged that management instructed staff that the residents involved were adults and can leave when they want and instructed them that they were not elopements and were intimidating staff not to call it an elopement. The complaint documented R#801 and R#802 had difficulty finding their rooms at times. An unannounced onsite abbreviated survey was conducted from 8/6/19 through 8/8/19. R#801 R#801's clinical record was reviewed on 8/6/19 and it revealed the following: R#801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#801 had severely impaired cognition (indicated by a Brief Interview of Mental Status - BIMS score of 5 out of 15 in which a score of 0-7 indicated severe cognitive impairment), no behaviors including wandering, and required supervision and set up only to walk in the room, and supervision from one staff member to walk in the corridor of the facility. R#801 required limited assistance for bed mobility and transfers. A progress note dated 6/21/19 at 3:53 A.M. documented, .Resident keep wandering around,having short period of sleep . A progress note dated 7/4/19 at 10:05 P.M. documented, Son called this writer to help with resident who was combative. Outside of doorway resident was swinging his arms at son. Redirected resident to couch and TV. Resident and this writer walked down to Pod 3 while son and wife left floor. Resident walked slowly to door and stated. 'I'm leaving' and attempted to open exit door. Door alarm sounded. CENA (Certified Nursing Assistant - CNA) redirected resident and walked him to his room. CENA alerted this writer that he had just viewed resident thru (another resident's room number) window. This writer and CENA exited Pod 3 emergency exit and reached resident and attempted to redirect resident. Exit door Pod 4, alarm sounded and noted by maintenance. This writer sent CENA for security. This writer attempted to redirect resident towards Pavilion. Resident entered doorway of apartments (another building). Inner door locked. Resident became more agitated and combative. Swinging arms, smacking this writer on face. This writer yelled for help multiple times. This writer remained with resident between locked door and outside door unable to redirect resident. Maintenance and CENA arrived. Maintenance took lead in redirecting resident to outside and towards Pavilion. Resident became verbally louder and 911 called at aprox (6:05 P.M.). (City name redacted) police attempted do <sic> de-escalate situation. Police spoke with wife on phone. Wife waiting at front of building for son to pick her up in car. Wife came to back of building attempt to convince resident to settle down. Wife stated resident was admitted to this facility for combative behavior. (City name redacted) Fire transferred resident by stretcher without further incident. Wife and son informed that resident would be going to (hospital name redacted) for evaluation. Son informed this writer that resident became upset earlier because he wanted 'to go home.' Through out this incident resident repeatedly stated to Fire, staff and police that he 'wanted to go home.' MD informed. DON (Director of Nursing) and admin (Administrator) aware. A progress note dated 7/5/19 documented, .Resident arrived at facility 1:45am .(brand name wandering management system bracelet) intact to Left ankle will continue to monitor . A progress note dated 7/6/19 documented, Resident observed walking down hallway half dressed pretending that he had a gun in his hand shooting staff and other residents. Nurse asked resident if he would like to come down to his room to get dressed resident pretended to shoot nurse. Resident was wandering down hallways trying to enter into other residents room. Staff informed resident that he could not go into other peoples rooms he then kicked the door and stated that the room needed to be cleared from all threats. Other staff tried to calm resident down and he would swing at the staff but never did come in contact with anyone. 911 called to transport resident to hospital. DON notified .Resident left at 6:05pm via ambulance .(brand name wandering management system bracelet) removed by nurse . A progress note dated 7/6/19 documented R#801 returned to the facility from the hospital and a (wandering management system bracelet) was applied to the resident's left ankle. A progress note dated 7/9/19 documented, .He was worried about his wife and he wanted to leave the facility before bed time . A progress note dated 7/14/19 documented, .Up in w/c self propelling in halls. Ambulating unassisted, requires staff redirection . A progress note dated 7/14/19 documented, Resident wandering this afternoon. Multiple self transfer and unassisted ambulation attempts. Resident confused on place and time. Thinking he is at work 'in the factory' and working on the 'batteries and boxes' and waiting for 'his boss'. After dinner resident attempted to exit emergency door on pod #2 (a unit on the opposite side of the first floor on the opposite side of the nurses station) near oxygen room. Alarm sounding and staff responded appropriately. Easy to redirect. Remains confused although pleasant. No combative behaviors. Sitting 1:1 with this nurse at this time. A progress note dated 7/15/19 documented, Resident's family came for visit this evening after resident's family left resident he started to expressed <sic> the need to leave the building and find his car. PRN (as needed) (brand name of medication used to treat anxiety) was given with a slight improvement in behavior. Resident was sitting in common area by dining room when he got up from his w/c (wheelchair) and fell to his knees. Resident was able to get himself up from the floor without assistance from staff. He obtained a dime size abrasion on his RLE (right lower extremity) . A progress note dated 7/19/19 documented, Resident very confused today. In the AM he refused all medication. At lunch time he refused his accu checks. After lunch when all the resident were coming out of the dining room resident sat in his WC and blocked the other resident and would not let them around him. Resident was observed multiple times throughout shift up walking. Resident was not easily redirected back to WC. Resident observed in another resident's room transferring them from their WC to bed. Resident brought back out to common area. Resident in hallway self propelling himself up and down hallway. A progress note dated 7/20/19 documented, .Resident was wandering during the night shift with some behavior and anxiousness noticed . A progress note dated 7/25/19 written by Nurse U documented, Resident's room changed to (room number on the second floor) . There was no explanation documented of why R#801's room was changed. A Care Plan Report was reviewed for R#801's admitted through 8/6/19 to include all changes to the care plans. A care plan created and effective on 7/5/19 documented R#801 was At risk for elopement. Will try to follow family . Interventions on 7/5/19 included in part, the following: wandering management system bracelet, Check on resident at least every ___ (blank) hours to identify and meet needs as well as note location and safety status. Keep in view as much as possible as indicated (the care plan did not specify how often to check on the resident), Look for these precursors to elopement: _____________________(blank)Redirect or bring to supervised area during these times (the care plan did not specify any individualized precursors), Place resident near nurses area in order to be under closer observation, psychiatric consult as needed, Keep door alarm on at all times. Respond promptly to alarm, All staff to be aware of (R#801's) tendency to wander, including front office ., Bedside monitor in room. There were no further interventions implemented after 7/5/19. On 8/6/19 between 9:15 A.M. and 9:25 A.M. an observation of the first floor exit doors was conducted with the campus Maintenance Director (CMD) B. The Piccadilly Unit (also referred to as Pod 4 by facility staff) was observed to have a glass double door that was labeled Emergency Exit Only Alarm will Sound that led to the outside of the facility (a sidewalk led to a road within the facility campus and then a parking lot and wooded area was further across the road). CMD B reported that particular door was different than the rest of the exit doors in the facility and did not previously alarm when opened. A second exit door was observed on the Piccadilly Unit that alarmed loudly when opened and led to a stairwell and another door that led outside of the facility. According to CMD B, all doors are checked weekly for functioning alarms and functioning (brand name for wandering management system). CMD B reported no issues were reported to him in the past month. CMD B provided logs from the above inspections for (MONTH) 2019 and they revealed no issues on the first floor. There were no logs that addressed the door alarms, only the wandering management system. The dates tested were 7/5/19, 7/12/19, 7/19/19, and 7/26/19. On 8/6/19 at 11:00 A.M., R#801 was observed lying on the couch on the unit watching television. When spoken to, R#801 closed his eyes. On 8/6/19 at 11:11 A.M., R#801's emergency contact (family member) was contacted via the telephone. The family member reported he was unable to talk at that time. On 8/6/19 at 11:30 A.M., all incident and accident reports (I&As) were requested from the DON for R#801. On 8/6/19 at 11:35 A.M., Unit Clerk S was interviewed. When queried about how it was known which residents could safely leave the unit or building unsupervised, Unit Clerk S referred to the Elopement Risk Book and reported all residents in the book were at risk of elopement and wore wandering management system bracelets. R#801 was in the elopement risk book with a wandering management system bracelet check dated 6/14/19. On 8/6/19 at 1:25 P.M., Nurse U was interviewed. When queried about why R#801 was moved to a room on the second floor on 7/25/19, Nurse U stated, He was going to go up there anyway for long term, but he went out the door so he had to go up there for safety. Nurse U reported she was with another resident when R#801 exited the facility and it was brought to her attention that Physical Therapist (PT) V was leaving and found R#801 outside of the building. Nurse U reported she was unaware of any exit seeking behaviors from R#801 and thought the resident had a wandering management system bracelet on at that time. Nurse U reported she did not complete an I&A on 7/25/19 because the DON knew before Nurse U did so she was already involved. On 8/6/19 at 1:30 P.M., PT V was interviewed. When queried about R#801 exiting the facility on 7/25/19, PT V reported he left for the day through the front lobby and when he got around the building by the parking lot, I saw him outside of the exit door. He said he was looking for his car. PT V reported he was on the sidewalk, outside the door, by the trees. PT V reported that an activities staff member came to the door and had to let R#801 back inside. PT V was asked what time he left the faciity on [DATE] and reported that he would check his schedule. PT V reported he left between 10:00 and 11:00 A.M. on 7/25/19. On 8/6/19 at 1:40 P.M., an observation of the Pod 4 emergency exit (the glass double doors leading directly outside) was made with CMD B and the wandering management system was demonstrated. CMD B demonstrated how if the door was opened without a wandering management system bracelet in the vicinity, you could open the door. The door was very difficult to open and required a lot of force to open it. When opened, the door triggered a loud alarm. CMD B demonstrated (by holding a wandering management system device) that if a wandering management system device is within a certain range of the sensor on the door, the door will lock. CMD B explained that if a resident with a wandering management system device exited the door behind someone else, it would trigger the wandering system alarm which was demonstrated. The wandering system alarm was a beeping noise that was not audible unless you were directly in the vicinity of the door. On 8/6/19 at 2:00 P.M., I&As for R#801 were reviewed and revealed a fall in the dining room on 6/14/19 and a fall in the common area by the dining room on 7/15/19. An I&A dated 7/4/19 at 7:30 P.M. documented, See nursing notes and documented the DON was notified and R#801 was sent to the hospital for eval. Attempt to help (R#801) adjust to living here. There was a typed page by the social worker indicated she talked with the resident upon returning to the facility on [DATE] and another typed page that was a copy of the nurse's note in the clinical record written by Nurse D. There was no documentation of any interviews with staff, any inspection of the door, or if R#801 had a wandering management system bracelet on at the time and/or if it was functioning. On 8/6/19 at 2:25 P.M., Nurse D was interviewed via the telephone. When queried about R#801 being found outside of the facility on 7/5/19, Nurse D stated, The resident was in the room with son and wife. He (R#801) was hitting the son because he told him he was leaving. The resident said he was leaving and ran out of the room. I redirected him. Talked to the son and told him I would take the resident for a walk to the end of the hall and to just leave when we get down there. We got about half way and then the wife was walking down the hall. Nurse D further stated, We were about two feet from the exit door and he (R#801) went right for the door. The CNA (CNA Q) tried to redirect him and got him into his room. Then I went to get a blood sugar and (CNA Q) went to pass trays. Then (CNA Q) came running saying 'He's gone! He's outside!' and ran toward Pod 3 (Penny Lane Unit). (CNA Q) saw (R#801) from another resident's window walking outside. We crashed through the emergency door and it alarmed, but I was confused why we didn't hear any alarm when R#801 was outside. Nurse D reported R#801 was very difficult to redirect when outside and that staff from maintenance arrived because they were alerted due to Nurse D and CNA Q going through the alarming door. R#801 entered the doors leading to the apartments (a separate building) but they were locked. Nurse D stated, He lost it when he realized he couldn't get inside. Finally maintenance was able to redirect him and we called 911. It took them a long time to calm him down and then took him to the hospital. All he wanted to do was go home. Nurse D reported that she thought R#801 had a wandering management system bracelet at that time and did not know how he got out of the door. Nurse D stated, Maintenance Staff checked the (wander alert system) and it just beeped. You would never hear that if you weren't standing right by the door. When queried about whether or not R#801 had ever gotten out of the facility any other times, Nurse D stated, I heard he got outside, but I wasn't on duty. I don't know why they don't fix the door! I'm glad (R#801) didn't get any further by the swampy pond. On 8/6/19 at 3:00 P.M., an attempt to interview CNA Q via the telephone was made. A message was left. CNA Q was not available for interview prior to the end of the survey. On 8/6/19 at 3:20 P.M., an I&A for R#801 dated 7/25/19 (that was not in the folder of I&As upon first review as noted above) completed by the Assistant Director of Nursing (ADON). The I&A did not indicate a time of the incident and documented, See report. Witnesses were documented as Activities and Therapy but did not document the staff members names. The location of the occurrence documented, Pod 4 door. The action immediately initiated was Explain to (R#801) that his car is not outside, it is @ his home. A typed summary signed by the DON documented R#801 was with his wife in the common area asking about his car. The wife said it was safe outside in the parking lot and R#801 then exited through the door on the unit and the door alarm sounded. It was documented therapy staff found R#801 outside and redirected him back in and an activities staff member let R#801 back inside. It was documented R#801 was moved to a room on the second floor for safety. An interview with activities staff was typed and unsigned and did not include the staff member's name. The summary did not include how the information typed was obtained and from whom. There was no documentation in the clinical record of R#801 exiting the building on 7/25/19. The summary did not include any interviews with the staff who were assigned to R#801 at the time of his unsupervised exit from the building. Visitor Sign In Sheets from 7/25/19 documented R#801's wife did not arrive to the facility until 11:10 A.M. (PT V who found R#801 outside of the facility left the facility between 10:00 and 11:00 A.M.) Progress notes were reviewed since admission and there were no social services notes regarding R#801's exit seeking behaviors. On 8/7/19 at 12:30 P.M., the ADON was interviewed regarding the I&A for R#801 on 7/25/19. The ADON reported completing an I&A was standard protocol for any incidents. When queried about the lack of documentation in the clinical record regarding R#801's exit from the building on 7/25/19, the ADON stated, I ended up just getting statements from staff and typing it up. When asked about the time R#801 exited the building, the ADON stated, Maybe around 10 or 11 A.M. I don't really know. The ADON reported that the incident was investigated by herself, the DON, and the Administrator. The ADON reported it was not necessary to document because His wife was here and he usually rolls around. When asked what doors he went out of, the ADON stated, The hospice doors (which were explained to be the Pod 4 double glass emergency exit doors). The ADON did not know the time R#801 exited or was brought back in and stated, He was brought back in immediately. The ADON did not offer an explanation of how R#801 was able to exit through a door that was equipped with a wandering management system. On 8/7/19 at 1:07 P.M., the DON was interviewed. When queried about the facility's protocol when residents were actively exhibiting exit seeking behaviors, the DON stated, Monitor them, try to keep them in visible sight in common areas and redirecting. When asked if R#801 should have been left unsupervised in his room after opening an exit door and verbalizing the desire to leave the facility on 7/4/19, the DON stated, He was redirected to his room. I don't believe he was at his aggravation point yet. The DON reported R#801 received a wandering management system bracelet at the end of June. When queried about how R#801 was able to exit through a door equipped with a wandering system sensor if he had a wandering bracelet on 7/4/19, the DON stated, That is a door that is used as an exit door by people. It's not an emergency exit. I have no idea if he followed someone out or something. The DON was asked to clarify which door R#801 exited on 7/4/19 and reported it was the double glass doors on Pod 4. The DON reported R#801 received a wandering alert bracelet in (MONTH) 2019 due to the elopement risk assessment asking if he was confused. The DON was further interviewed about R#801's second unsupervised exit from the facility on 7/25/19. The DON stated, He just rolled up to the door and opened it. The DON did not offer an explanation of why R#801 was found by an off duty staff member (PT V) outside of the facility on the sidewalk. When queried about the I&A that said see report completed by the ADON and the time of the incident, the DON stated, I don't know, maybe around 1 or 2 P.M. When asked why it wasn't part of the investigation, the DON stated, It wasn't on my mind to find out. The DON reported that after R#801 exited the Pod 4 emergency exit on 7/25/19, she had CMD B add a wireless alert to the door that would alert nurses' pagers and would sound a louder alarm when opened. The DON reported that no education was provided to staff after R#801 exited the facility unsupervised on two occasions because it didn't fit the definition of elopement. The DON defined elopement as Somebody that is voicing to leave the facility and not come back. On 8/7/19 at approximately 1:45 P.M., Nurse F was interviewed about the Pod 4 emergency exit doors. Nurse F reported that staff did not ever use those doors to exit the building. Further review of R#801's clinical record revealed the following: A Statement of Competency signed by a Psychologist on 6/18/19 and a Physician on 6/21/19 documented R#801 was incompetent to make his own medical decisions and unable to understand and express his end of life care choices. A Wander Data Collection Tool documented on 7/5/19, R#801 was reassessed by Social Service Manager (SSM) R. The assessment documented R#801 did not wander and wandering did not place resident at risk of getting to a potentially dangerous place such as outside the facility (despite documentation of wandering and exiting the facility unattended without the knowledge of the staff on 7/4/19). Fall Risk Assessments completed on 7/15/19 and 7/22/19 indicated R#801 was at high risk for falls. An Elopement Risk Evaluation completed on 6/14/19 indicated R#801 had confusion and cognitive impairment and no wandering behaviors. R#801 was not reassessed after exhibiting wandering behaviors according to the nursing progress notes on 6/21/19. On 8/8/19 at approximately 9:00 A.M., CMD B was further interviewed and reported the loud alarm that was currently present on the Pod 4 double glass emergency exit door was not installed until 7/25/19, after R#801 exited through that door a second time. CMD B reported that a nurse call system was also installed at that time that would alert their pagers. When queried about how a resident with a wandering management system bracelet would be able to exit that door since it locked when the bracelet was within range of the sensor, CMD B stated, Either they followed someone out or the door was not completely locked and/or misaligned. If the wind was holding it open or something, the magnetic lock would not engage, it would just alarm (the quiet beeping explained above). On 8/8/19 at approximately 9:15 A.M., the Administrator and the DON were interviewed. The Administrator reported being aware that the Pod 4 door did not function like the other doors on the units (did not have a key and did not alarm). The Administrator reported that years ago it was a hospice unit and that door was used to go in and out of. The Administrator reported prior to 7/25/19, you could go in and out of the door and it would only activate an alert if a resident had a wandering management system bracelet. The DON reported she asked CMD B to add an alarm after R#801 exited through that door a second time because you could not hear the wander alert unless you were in close proximity to the door. R#802 R#802's clinical record was reviewed and revealed R#802 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R#802 had severely impaired cognition (BIMS score of 5 out of 15), no behaviors including wandering, required extensive one to two person assist for bed mobility and transfers, required limited assistance for locomotion on the unit and that locomotion off the unit only occurred once or twice. According to the MDS, R#802 had two or more falls during the quarterly assessment period. A progress note written by Nurse T on 7/26/19 documented, Resident has been educated on not leaving the building on his own without making staff aware. Daughter was made aware that her father went outside without staff with him. A progress note written by Nurse D on 7/28/19 at 7:00 P.M. documented, Informed DON that resident left building without signing out in LOA (Leave of Absence) log book. Instructed resident to inform staff when he is leaving floor. Verbalized understanding of such. Resident informed this writer that he will do so in the future. Resident was unable to find his room. This writer directed him to his room. Will continue to monitor. A Care Plan Report for R#802 that included all changes made since his admission on 1/31/19 was reviewed on 8/6/19 at approximately 10:25 A.M. and revealed the following: An Active care plan created by Nurse Z and effective on 7/28/19 documented, Resident is not signing out in LOA log book when he leaves building may be at risk for wandering. (The DON provided a printed care plan on 8/8/19 that documented the same as above but replaced the word wandering with elopement and explained that it was created on 7/28/19). Active care plans created by SSM R on 7/28/18 and changed on 8/6/19 at 10:07 A.M. documented, Resident is not signing out in LOA log book when he leaves building. An intervention created on 7/28/19 documented, (R#802) will return without injury or harm to this facility. All other interventions were created on 8/6/19 (11 days after it was first documented R#802 left the facility without notifying staff). An Active care plan created and effective on 4/21/19 created by SSM R documented, Cognitive skills for daily decision making impaired .demonstrates difficulty in new situations, alert and oriented to person and situation. (R#802) has had a significant decline. He was deemed incompetent to make his own medical decisions. He is alert and oriented to person and situation with forgetfulness. A Statement of Competency signed by a Psychologist on 4/30/19 and a Physician on 5/3/19 documented R#802 was incompetent to make medical decisions and unable to understand end of life care choices. On 8/6/19 at 11:00 A.M., R#802 was observed sleeping. On 8/6/19 at 1:10 P.M., R#802 was observed lying in bed. R#802 reported he went out by the main road once and they didn't like it. On 8/6/19 at 11:07 A.M., Receptionist I was interviewed. When queried about whether or not she had a list of residents who were not supposed to leave the building unattended, Receptionist I stated, No. I know the residents or I just call the floor. I get to know them. On 8/6/19 at 11:35 A.M., Unit Clerk S was interviewed. When queried about how it was known which residents could safely leave the unit or building unsupervised, Unit Clerk S referred to the Elopement Risk Book and reported all residents in the book were at risk of elopement and wore wandering management system bracelets. R#802 was not in the elopement risk book. On 8/6/19 at 11:30 A.M., all incident and accident reports (I&As) were requested from the DON for R#802. There were no I&As provided for R#802 for the dates of 7/26/19 and 7/28/19. There was an I&A dated 4/30/19 that documented R#802 lost his balance reaching for a shirt and on 4/7/19 used the recliner remote incorrectly and slid off the chair onto the floor. On 8/6/19 at 2:25 P.M., Nurse D was interviewed regarding R#802. Nurse D reported R#802 left the facility unsupervised two times and stated, The first time I was not here, but I was here during the second time. I heard he got out Friday (7/26/19) and then he got out on me when I worked on Sunday (7/28/19). Apparently he was supposed to sign out in the log book, but that doesn't make sense to have someone with dementia sign out. He can sometimes make sense, but to sign a log book doesn't seem safe .When the DON was called, we were told he was over [AGE] years of age so he can sign out if he wants to and if it's care planned we don't have to document it because it's not an elopement. Nurse D reported that she heard R#802 was found down by the school on 7/26/19. Nurse D reported that Staff O would know all the details from 7/26/19. On 8/6/19 at 3:00 P.M., Staff N was interviewed. Staff N reported on 7/26/19, R#802 was seen by the school (located approximately one half mile down the main road from the facility) when she was driving after leaving the facility after work. Staff N stated, He goes outside all the time. This time he got turned around. The managers told me he was allowed to go out whenever he wanted. Staff N reported that she called the nurse who went to get Staff O. On 8/6/19 at 3:10 P.M., Staff O was contacted via the telephone but did not answer. A second attempt was made on 8/7/19 at 9:10 A.M. Staff O was not available for interview prior to the end of the survey. On 8/6/19 at approximately 3:15 P.M., Staff AA was interviewed. Staff AA reported staff were afraid to talk because they were told they would lose their jobs. Staff AA stated, Anything could have happened to him (referring to R#802), hit by a car, heat stroke, a fall! If nobody found him, the door locks at 8:00 P.M. They are writing it off like it was no big deal. I would lose my job if anyone knew I was saying this to you. Staff AA reported Staff O had all of the details. On 8/6/19 at 4:10 P.M., the sign out log located on the second floor, where R#802 resided, was reviewed and revealed R#802 had never signed out to leave the unit or building. Nurse T reported that R#802 was allowed to sign himself out unsupervised. On 8/6/19 at 4:25 P.M., Social Services Coordinator (SSC) P was interviewed. SSC reported R#802 was deemed incompetent to make decisions. On 8/7/19 at 9:00 A.M., Physician K (R#802's attending physician) was contacted via the telephone and a message was left. No return call was received prior to the end of the survey. On 8/7/19 at 9:05 A.M., Nurse Practitioner (NP) L was interviewed via the telephone. NP L reported R#802 was independent in driving a motorized wheelchair. NP L reported that if R#802 were

This citation refers to Intake Number MI 087. Based on interview an record review, the facility failed to lock the wheels of the bed during resident care for one (#801) of three residents reviewed for accidents, resulting in the resident falling face down on the floor and sustaining a 12 centimeter [MEDICAL CONDITION] that required an emergency hospital transfer, and facial bruising and swelling. Findings include: On 6/4/19, R#801's clinical record was reviewed and revealed the following: R#801 was admitted into the facility on [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#801 had severely impaired cognition and required extensive two person assistance for bed mobility and transfers. A Nursing Note dated 1/17/19 at 7:44 A.M. documented, CNA (Certified Nursing Assistant) came running down hall and said she needed help that the resident fell to the floor .Nurse (name redacted) said to get to the room right away .blood on the floor. Called to (name redacted) to call 911. Observed resident on floor at 5:25 A.M Bed was away from the wall and close to her night stand. Face down on stomach with blood from the head .Staff applied pressure to her forehead to try to stop bleeding .Vitals were not able to be obtain due to the resident in possible shock .The nurse asked the CNA (CNA A) what happened. The CNA told the nurse she was perfoming ADL (Activities of Daily Living) care, emptied her (indwelling urinary catheter), she was changing her brief and turn her to left side and resident said wait my arm. The resident grabbed her arm and began falling off the bed . A Nursing Note dated 1/17/19 at 2:49 P.M. documented, Resident arrived via EMS at 10:08am .Resident has a laceration to the forehead, beginning in the middle of the forehead and ending right before left temple, measured approximately 12cm (centimeters) in length, resident left eye is swollen, resident forehead has bruising under laceration. A Nursing Note dated 1/18/19 at 8:27 A.M. documented, .@ 8pm (on 1/17/19) .Left upper face swelling and dried blood noted, incision intact, left eye swollen .asked if she was in pain - stated I don't know .Neuro checks continue . On 6/4/19 at 11:00 A.M., an Event Report (Incident and Accident Report - I&A) for R#801 was reviewed and documented on 1/17/19 at 5:25 A.M., R#801 fell off the bed during ADL care and landed face first on her stomach and had blood coming from her forehead. The I&A documented R$801 was transferred to the hospital. The action initiated immediately to prevent a reoccurrence was documented as, always have two people during incontinent care and transfers. The I&A documented that the care plan was followed and the root cause documented, Resident on the edge of bed during care moved arm and rolled out of bed . A Post Incident Team Review documented the immediate intervention used as Two staff for repositioning. A CNA Post Incident Report completed by CNA A documented, I arrived in (R#801) room at 5:!5am to start AM care. I gathered her clothes, [NAME] hose, socks, brief, towels and wipes. I emptied her (indwelling urinary catheter) bag, put on her [NAME] hose, socks and pants. I turned her over to her left side and began changing her brief. I told her I'm going to now turn her over towards me. She said wait my arm and moved her arm closer to the bed as she tugged her arm she began falling off the bed. I yelled for help. Nurses and CNA's arrived in the room. We moved the bed and noticed it was blood coming from somewhere. Nurses yelled to another nurse to call 911. We all worked together to cover her up, and hold a towel to stop bleeding . An Investigation Summary dated 1/17/19 documented, In 1/17/19 at 525am CNA was in the room with (R#801) and preforming <sic> ADL care .positioned her on her left side in the bed to clean her up and change her brief .told (R#801) that she was going to turn her back on her back. CNA stated (R#801) said 'my arm' and moved/tugged her arm and as she did this she rolled toward the wall and the bed started moving away from the wall and (R#801) was falling. CNA states she tried to hold onto (R#801) and started yelling for help. Nursing staff entered room to observe (R#801) laying face down on the floor between the bed and the wall .Initial nurse in room noted that head of bed was away from the wall and foot of bed was close to wall and (R#801) was on the floor between the bed and the wall. This was verified by the assigned nurse. During investigation writer talked with all staff on the floor. CNA providing care stated that she locked the foot of the bed when asked about locking the bed and positioning of bed during ADL care. Writer asked CNA is she locked the head of the bed and she state, 'no' .(R#801) returned to the facility at 10:08am .Laceration to forehead measures 12cm and was sutured, no glue used .care plan updated, (R#801) is to be a two person assist with repositioning in bed, including brief changes .In my professional opinion the CNA did not ensure the head of the bed was locked and when (R#801) was on her left side and repositioned her arm it caused her body to move forward towards the wall and her body weight against the wall and the head of the bed not locked caused the bed to move and (R#801) to gall. I believe the laceration was caused by the wheel and brake system of the bed . A written and signed statement by Nurse B documented, This is my statement of events .The CENA that was caring for the resident ran to the area where I was passing meds .and stated I need help (R#801) fell on the floor .Upon entering the room I noted resident was lying face down on the left side of bed. She was between the bed & wall I also noticed the blankets on the floor under the wheels at the end of the bed. I also noted resident was tangled in the O2 (oxygen) tubing, (catheter) tubing, telephone line .I gave instructions to move the bed to the hallway so that we could have enough space to work. As I got near the resident I saw a very large amount of blood, resident was crying out and remained alert .there was a large laceration to the forehead .Prior to the bed being moved I noted that part of the bed was locked, the top front was unlocked & the foot was locked & the bed had a space between the bed & wall . On 6/4/19 at 12:10 P.M., CNA A's personnel file was reviewed and revealed CNA A was no longer an employee at the facility. At that time, a phone interview was attempted. A voice message was left. CNA A was unavailable for interview prior to the end of the survey. On 6/4/19 at 12:15 P.M., Nurse B was contacted via the telephone. Nurse B was unavailable for interview prior to the end of the survey. On 6/4/19 at 3:00 P.M., the Director of Nursing (DON) was interviewed. The DON was not an employee at the facility at the time of the incident. When queried about where CNAs would find the required level of assistance for care of a resident, the DON stated, Care plans or resident summary. A Resident Summary for R#801 dated 1/17/19 and 11/2018 documented R#801 required Extensive Assist x1. R#801's ADL care plan documented R#801 required extensive assist x 2 for bed mobility, initiated on 2/1/19 (after R#802 was discharged from the facility). As mentioned above, R#801's MDS assessment documented R#801 required extensive two person assistance for bed mobility during the 10/23/18 assessment period. Further review of R#801's clinical record revealed a Physical Therapy Discharge Summary dated 10/20/19 that documented R#801 required maximum assist with bed mobility. On 6/4/19 at 5:00 P.M., the MDS coordinator was interviewed. The MDS coordinator reported that she collected data from nurses, nurse aides, and therapy to determine the level of assistance required by a resident. The MDS coordinator reported that the MDS assessment data would carry over to a care plan and resident summary and the CNA documentation was reviewed for the assessment period. The CNA documentation for bed mobility for (MONTH) 2019 was reviewed with the MDS coordinator and revealed multiple days prior to 1/17/19 that R#801 required two person assistance for bed mobility. When asked why the MDS level of assistance did not carry over to the care plan or resident summary, the MDS coordinator said she would have to look into it.

Based on observation, interview, and record review, the facility failed to ensure interventions were identified to transfer one (R#701) according to the plan of care out of six residents reviewed for falls/accidents, resulting in R#701 receiving a fractured femur and pain. Findings Include: On 1/17/19 at 11:30 a.m., a record review of the electronic clinical record revealed R#701 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed R#701 had moderately impaired cognition and required extensive assistance with two-person physical assist for transfer. Review of the facility care plans created 9/18/15 revealed the following: Problems: (Name) R#701 is at risk for falls r/t (related/to) general weakness, requires assist with transfers and currently non-ambulatory . 11/15/18 lowered to floor during transfer - fracture to right distal femur osteopenia . Interventions: Identify resident specific intervention of falls and communicate intervention via the resident summary and nursing report sheet . Created 2/13/18 Disciplines: Certified Nursing Assistant / Skilled Nursing A review of the Clinical Notes Report revealed . Observed the resident sitting on the bathroom floor facing the toilet. CNA stated that as resident was being transferred from toilet her legs gave out and she was lowered to the store (floor). Resident was assisted into bed by CNA staff using the Maxie move . Resident c/o (complain of) pain to right leg . Further review of the radiology report dated 11/15/18 revealed the results as Acute fracture distal femur. Knee joint replacement. Osteopenia with [MEDICAL CONDITION] change. Conclusion: Acute distal femur fracture. Slight distraction. A review of the hospital discharge summary revealed the following: Admitting Diagnoses: [REDACTED]. Traumatic Right Femoral Fracture 2. Right lower extremity [MEDICAL CONDITION] 3. Acute pain secondary to #1 . Discharge Diagnoses: [REDACTED]. Traumatic right femoral fracture s/p (status [REDACTED]. On 1/17/19 at 11:55 a.m., R#701 was observed in the room seated in a wheelchair with anti-tip rear wheels. R#701 was hard of hearing but answered questions adequately. When asked if she had a fall, R#701 stated, Yes, I fell in the bathroom. The two girls (Certified Nurse Assistants - CNAs) help me out of bed. I told them to get the lift and they didn't. They tried to put me on the toilet themselves, and it just wasn't right. It was when I got off the toilet my leg hurt me. I kind of fell down . I told them my leg was hurting. When asked what the girls did after that, R#701 stated, They left. R#701 further stated, It happened a couple of months ago. I had to get surgery on it (pointing toward her right leg). A review of the facility's resident statement revealed the following: She didn't know what happened. CENA stated that resident's legs gave out while being transferred from toilet. Describe Environment . Resident was in the bathroom sitting on the floor facing the toilet. Describe Injury . 0 Apparent Injury, resident c/o (complain of) pain R (Right) leg pain Point out to MD . What action nurse initiated . Resident was put in bed, x-rays were obtained, resident remained in bed until completed and results received. Licensed Practical Nurse (LPN) 'A' Medication factors - All Events taking [MEDICATION NAME] Taking [MEDICATION NAME] Fall Score: 35 Was the care plan followed: X No Did you care plan this incident: X Yes Root cause determination by charge nurse: When she stood legs buckled and she had to be lowered to the floor . Outcome: Fracture Care Plan Implemented as Written: No Disposition: ER Visit Return From Hospital: 11/19/18 (Evening) Transfer status was changed to Maxi Move for all transfers. Education Inservice (Name) - CNA 'B' topic: Lifts / Care Plans CNA 'B' used a Sara Steady to transfer (Name) R#701. R#701 is a Sara 3000 w(with)/green sling. R#701 had to be lowered to the floor during transfer. Desired Outcome: Follow care plan to prevent incident. On 1/17/18 at 4:12 p.m., during a telephone interview, when queried about the incident that occurred with R#701, CNA 'B' stated, I was going to reposition her (R#701), because I was trying to adjust her brief. She said her legs were giving out. Another aide (CNA 'C') came in to help. R#701 said it wasn't going to work. So, we lowered her down to the floor. When asked how R#701 was transferred, CNA 'B' stated, I was told to use the Sara Steady. When asked about other ways to find out a resident's transfer status, CNA 'B' stated, I could have looked on the computer or we have papers, but they are not always up-to-date. When asked what kind of papers, CNA 'B' stated, I'm not for sure what they are called, but we all get a daily paper. When asked if she got the daily paper that day, CNA 'B' stated, I don't think I got it because I got (name) R#701 when I first got to work. When queried how and when she knew about R#701's transfer status, CNA 'B' stated, I found out a day or so later when they (facility) called me. CNA 'B' further stated, I had (Name) R#701 5-6 times before the incident, and I was told to use the Sara Steady with (Name) R#701. A review of the facility investigation revealed a statement by CNA 'B' written as follow: On Thursday Nov. 15 I toilette (Name) R#701 after lunch upon standing after getting her buttocks wiped (Name) was asked to stand again to get her brief put on, to put the other side down on the on the Sara Steady due to the cramp space I wasn't able to do so, so I had to pull it a little away from the toilet, she had to stand again so I could readjust her brief, as she was standing I notice her feet weren't position properly so that's when I asked her to move them back so she could be secure, as I was adjusting her; her legs gave away, CNA 'C' walked in to see if I needed assistance, assist me, (Name) legs weren't proper so we tried to aide her in the right position. (Name) stated, she couldn't, we notice her legs were going back instead and we decided to lower her down to the ground ., that's when we got additional assistance. Further review of the Education Inservice revealed the following: Topic: Lifts / Care Plans (Name) CNA 'B' used a Sara Steady to transfer (Name) R#701. R#701 is a Sara 3000 w/green sling/ R#701 had to be lowered to the floor during transfer. Desire Outcome: Follow care plan to prevent incident. During an interview with Clinical Manager 'D' on 1/17/19 at 5:00 p.m., when asked to explain the difference between the Sara Steady and Sara 3000 lifts, Clinical Manager 'D' stated, the Sara Steady has a bar for residents to hold on to. They (residents) have to be able to bare weight to their feet and able to stand up. The Sara 3000 have two handles. The residents still have to be able to bare weight. It also locks their feet in a strap that goes behind each leg. There is a sling that goes around the body and underneath the arms that fasten to the machine. The machine is added to assist in lifting. When asked which lift should have been used to transfer R#701, Clinical Manager 'D' stated, As far as I know, (Name) R#701 has always been a Sara 3000. On 1/17/19 at 5:15 p.m., during an interview, when queried about R#701's transfer status and fractured femur, the Director of Nursing (DON) stated, 'The fracture did not come from using the wrong lift. The fracture happened when the CA was trying to reposition her (R#701's) brief. When she (CNA) went to fix the brief, (Name) R#701 stated her legs were giving . That's when the CNAs lowered her to the floor. A review of the facility's policy dated 5/31/15 revealed the following: Policy Resident handling devices include lifting and repositioning devices. Lifting devices are utilized whenever a resident is not independently mobile or when a resident is on the floor and cannot get up independently. Repositioning devices are used whenever a resident cannot reposition themselves independently. All centers are designated as minimal lift centers, which require staff to use the resident handling devices as assessed for each resident during every lift or transfer to eliminate manual lifting as much as possible. As a result, one person or multiple persons lifting or assisting beyond only contact guard or standby assists are not acceptable practices. This policy has been developed for the safety and security of our residents and staff. Procedure 3. h. If the need for a resident handling device has been identified upon Assessment, the nurse will transfer that information (including sling or repositioning size) to the Care Plan and Resident Summary, and any other appropriate communication tools used in the care of the resident. The information must be in at least two separate areas for resident care staff to confirm the information .

This citation pertains to complaint Intake # MI 138 and MI 157 Based on observation, interview and record review the facility failed to prevent accidents for 2 residents (#103 and #104) of 3 of 6 residents reviewed for falls by not answer a call light promptly for Resident #103 resulting in a fall with injury and leaving Resident #104 unsupervised in the dining room resulting in a fall with injuries. Findings include: According to the facility policy Fall Prevention, dated 4/6/17, . Care plans for those residents at risk for falls will be initiated upon admission and updated as needed. With the completion of the MDS assessment, the care plan will be reviewed and updated quarterly. Resident #103: Review of Resident #103's Electronic Medical Records (EMR) face sheet, physician orders, Minimum Data Assessment, and Care plans revealed Resident was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #103's Incident Report dated 6/1/18 at 6:30 PM, stated, Said he slipped to floor by bed. No injury. There was no documentation of any assessment. Call light in reach Yes. Call light on No. :Physical exam documented, Yes. Review of Resident #103's call light alarm history report dated 6/1/18 at 6:25:12 PM, revealed the alarm was not cleared until 6:55 PM (30 minutes). According to the Incident Report dated 6/1/18 Resident was reported to have a fall on 6/1/18 at 6:30 PM, and had not activated his call light. Review of Resident #103's Nurse Progress note dated 6/1/18 at 19:01 PM, Patient was found by aide on side of bed halfway on bed and right knee on the floor left was stretched out per cena. Patient stated he just slipped down to floor and lowered his self. Patient sustained no injuries. Vitals are t-97.9 bp 170.72, p82 r 20 O2 95% room air. Patient encouraged to use call light for assistance. Bed was in lower position. No pain noted. Safety precautions in place will monitor. Dr. notified at 6:41 PM, voice mail and daughter notified 6:51 PM (name). There was no documentation of an assessment of Resident #103's legs in nurse progress note or that the nurse completed an assessment other than a check on the incident report. Review of Resident #103's Nurse Progress note dated 6/3/18 at 4:40 AM, revealed Resident complain of pain x-ray order at 4:34 AM bilateral extremities 2 views. Review of Resident #103's Nurse Progress note dated 6/3/18 at 13:28 (1:28 PM), revealed At 7:45 AM x-ray results received . left/right tib/fib normal . Entered resident's room a 8:10 am. Resident voicing 9/10 discomfort despite PRN [MEDICATION NAME] administered at 7:30 AM. Observed extensive swelling to bil knees, warm and tender to touch, new onset. LLE (Left lower extremity) with 3+ [MEDICAL CONDITION] thigh to ankle, new onset. BLE (Bilateral Lower Extremity) braces adjusted for comfort and function. S/P (Status/Post) day #2 Call placed to Dr (name) with return call at 8:20 am, update provided and verbal order obtained to transfer to (hospital) for eval and tx . Review of Resident #103's care plan dated 6/1/18 at 1:29 PM,Resident #103 is at risk for falls R/T decreased mobility (HTN) hypertension, 6/1/18 fall in room no injury. Review of Resident #103's facility transfer form dated 6/2/18 for bilat knee increased swelling , warmth, pain, post fall. On 9/19/18 at 6:37 PM, during a phone interview, Resident #103 stated, When I fell (6/1/18) I was on the floor and staff did not answer the call light very quick it was over 20 minutes. Resident stated, I used the call light if I needed help. I transferred myself but, I slipped and fell and needed help to get up and they did not answer the light. On 6/24/18 at 6:22 PM, during a phone interview, Resident #104 stated The nurse never looked at my legs following the fall or that night, I complained of pain all night, and requested to go to the hospital during the night. Resident #104 stated, The little girl nurse you know, came in the next day, looked at my legs and said you can't be here like that. Resident #104: According to Resident #104's Face Sheet Resident was an [AGE] year old female admitted on [DATE] [DIAGNOSES REDACTED]. Resident #104's Care Plan is at risk for falls was dated 8/13/18, fell in bathroom of room [ROOM NUMBER] laceration to left side of face-sent to ER. Review of Resident #104's Nurse progress note dated 3/7/18 revealed Resident had a fall at home with large bruise start starts on left side of forehead and continues behind her ear. Bruise also travels downward onto her chest area and down to the top of her left thigh area. She also has a bruise on her bilateral upper knees. Abrasion on the top of her left knee. Bruise on her right shoulder blade. She also has numerous bruises on her UE (Upper Extremity) from IV's that were in place in the hospital. Resident has scars on both knees from old knee surgeries. Review of Resident #104's Nurse progress note dated 3/13/18 at 3:01 AM, Pt is alert to self with confusion noted. 1 person extensive assist with ADLs and transfers. Mobilizes via W/C, able to self-propel through out unit PTT has a dx of s/( fall, nasal fx, and dementia. Can be incontinent of bladder, kept clean and dry. Continent of bowels . Pt requires close monitoring as pt is quick to get up and walk through out unit. Gait unsteady. yellow-green bruising noted to l (left) face that is healing Review of Resident #104's Nurse Progress note dated 3/13/18 Resident was found by visitors next door to room [ROOM NUMBER] in bathroom. Resident stated she was going to the bathroom and fell and hit her head resident vitals was bp 157/77, p-71, O2 97, T-97.7. Resident expressed her head hurt and she feels dizzy. Resident head has a hematoma with a gash to left side and visible blood. EMS was called and resident was sent out via ambulance. Resident on blood thinners and has had episodes of continuous falls, resident is non compliant with assistance. Resident's family was called and notified of what hospital mother was being taken to. (Nursing Supervisor E) notified at 7:22 PM of resident condition, MD notified also. Resident was last seen by cna in dining room eating dinner. Apparently resident got up unassisted and ambulated by self to the bathroom. Review of Resident #104's Incident Report dated 3/13/18 at 7:10 PM, revealed, Resident stated she fell hit her head. Notified by visitors help needed in room [ROOM NUMBER]. Bathroom floor dry, left side of head injury gash to left side of head . Resident impulsive and insists on ambulating by herself. On 9/19/18 at 4:00 PM, during an interview, Certified Nurse Aide (CNA) P (who was responsible for resident at the time of the fall) stated, I set resident up for dinner, when I left the dining room resident (#104) was eating, I took a tray to another resident down the hall, went to the bathroom and when I came back (to the dining room) she was not there, CNA P stated, There were no other staff in the dining room at the time just the kitchen staff. CNA P agreed I left resident unsupervised. On 9/19/18 at 4:45 PM, during an interview, Unit Clerk G stated, A visitor came and got me at the desk, reported a noise/yelling in the next room, Resident #104 was on the floor of the bathroom on her right side. On 9/19/18 at 4:47 PM, during an interview and observation of the dinner, Licensed Practical Nurse (LPN) U was observed in the dining room area during the meal with residents present, and reported had responded to Resident #104's yelling for help and stated, Resident #104 was on the floor of the bathroom in room [ROOM NUMBER], on her back with her head in the door of the bathroom facing out of the bathroom door. On 9/19/18 at 3:10 PM, during an interview, Unit Manager C reported had investigated Resident #104's fall on 3/13/18, and it was discovered while CNA staff were delivering trays to rooms, visiting family member in room [ROOM NUMBER] heard a loud crashing noise in the next room which was vacant. LPN I observed Resident sitting on the floor bleeding on the left side of her upper face from a laceration on her head. Resident had reported she had to use the bathroom. Resident was found to have her pants down to her thighs and a small amount of formed BM was observed on the floor of the bathroom. UN C reported resident was assessed, administered first aid to the laceration, vitals were obtained and due to previous injuries on Resident #104's head and face and complaining of dizziness and pain, 911 was called for further evaluation. UM C reported staff Resident #104's wheel chair was found in the dining room next to the table resident when they prepared to transfer her from the floor to her wheel chair. It was assumed that she had walked from the dining room in the vacant room without the use of any device. UM C reported CNA P was provided education on 3/19/19 to communication with co-workers when handling a high fall risk resident needing supervision. UM C reported at the conclusion of the investigation Resident #104 was not supervised in the dining room at the time of the fall. On 9/20/18 at 2:15 PM, during an interview, Director of Nursing and Administrator both reported in addition to dietary staff being in the dining room there is normally a nurse present in the dining room. On 9/20/18 at 9:20 AM, during an interview, Registered Dietician (RD) V stated, The dietary staff are responsible only to set up meals and dining, they are not responsible for resident care and as soon as the meal is served they pack the food and head back to the kitchen area.

Based on observation, interview and record review the facility failed to provide appropriate supervision to a resident consuming hot liquids based on the Resident's assessment of needs and history of non-compliance with handling hot liquids for one Resident (#702) of nine residents reviewed for accidents and hazards from a total of twenty-three, resulting in second and third degree burns to Resident #702's right thigh and subsequent pain. Findings include: On 12/5/16 at 11:30 a.m., Resident #702 was observed lying in her bed. Resident #702 was alert and showed signs of confusion. When queried as to life in the Facility, Resident #702 stated, I'm not staying here long. I am waiting for my parents to come and get me so I can go home (it should be noted that that Resident #702 is [AGE] years old). When asked how she was feeling, Resident #702 pointed to her Right thigh and stated it was hurting her. Resident #702 was not able to detail the cause of the pain. On 12/5/16 at 3:00pm, the clinical record for Resident #702 was reviewed and revealed the resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the Resident's clinical record progress notes was conducted and revealed the following documentation: Social Worker Progress Note (10/12/16): .Alert and oriented to person and situation scored a Brief Interview for Mental Status (BIMS) of 5 reflecting cognitive impairment, unable to recall correct year, month or day of the week. Exhibits impairments to both STM (short term memory) and LTM (long term memory) cognitive functioning . Skin Risk Evaluation (11/14/16)(authored by treating physician): Second or third degree burns lower extremity (R) reddened small drainage. Wound Care Services (11/22/16)(authored by wound physician) Notes: We are asked to see patient for a right thigh wound that was substantiated after a burn injury resulting in blister formation that began at the Facility 11/13/16. Medihoney was initiated but staff report that there is little improvement noted and they are concerned about the imbalance in moisture/drainage .This task is too complex for nursing . Wound #1: Right, Lateral Thigh is a Burn and have received status of Not healed. Initial wound measurement are 6 cm (centimeters) x 4 cm width, with an area of 18.65 sq (square) cm.the tissue is 25% epithelial (tissue that is healing) and 75% necrotic (dead tissue which results from inadequate blood supply). A review of the the Facility's Incident and Accident Reports pertaining to a Resident #702's documented the following: 7/28/16 (11:30 a.m.) Describe: Resident in dining room. Sitting in W/C (wheelchair) spilled coffee on her pants. Results: No injury What action initiated immediately: Put lid on coffee cup and instructed to use lids for coffee 9/11/16 (5:45 p.m.) Describe: CNA (certified nursing assistant) stated she bumped into resident resident spilled coffee on legs. Describe injury: no redness noted. Investigation Summary: A staff member (CNA) bumped into resident in the dining room causing coffee to be spilled on resident's legs.no injuries obtained. Resident did accept lid to be placed on coffee cup at time of incident. At times resident is non-complaint with lids on her coffee cup will continue to encourage and assist resident to place lids on her coffee cup. 11/13/16 (5:50 p.m.) Describe: Resident in wheelchair at coffee machine in dining room Describe injury: Ruptured blister at intact skin to R (right) outer aspect of thigh. Length 7.5 x 5.5 cm (centimeters); pink in color. Resident grimacing. Investigation Summary:Resident in dining room obtained her own coffee. The resident reported to nurse that she spilled coffee on her right thigh. Resident is non-compliant with asking for assistance, is not compliant with having lids on her coffee mug .Resident is able to and wants to continue to get her own coffee, resident continues to maintain her independence. Staff will continue to offer and assist as she accepts and obtain coffee and other lids. Progress Note (11/20/16) : .Resident is non-compliant with using lids for coffee. Resident spilled coffee at 3:30 p.m. on L (left) hand and L upper anterior thigh. No injuries noted, no redness, nurse contacted Director of Nursing (DON). It's care planned that Resident is non-compliant with lids. As long as no injuries do not need to do incident report because no injuries. Nurse will continue to monitor, continuing education and reminding resident to have lid on coffee. On 12/5/16 at 3:30 p.m., a review of Resident #702's Care Plan pertaining to hot liquids dated current revealed the following: Problems: Resident #702 is non-compliant with recommendations to put a lid on hot liquids while traveling in hallways. 9/11/16 resident did not use top of coffee cup, resident spilled coffee on legs. no injuries noted 11/20/16, resident did not use top of coffee cup, resident spilled coffee on left hand and left anterior upper thigh, no redness, no injuries noted. Interventions: · Offer & Encourage resident to use lid when leaving dining room with hot liquids · Assist resident with carrying coffee · Encourage & Assist Resident with wearing a thermal back clothing protector. · Encourage Resident to use travel mug with lid grand-daughter brought in On 12/5/16 at 4:20 p.m., Resident #702 was observed as she was wheeled into the dining room by CNA E. CNA E left the Resident in front of the commercial hot coffee dispenser located adjacent to the dining room. The Resident was holding a metal travel coffee mug. The lid of the cup was off and the Resident's cup was filled with coffee. No attempt to place the lid on the cup was observed. No attempt to place a clothing protector on the Resident was observed. CNA E left the dining room area. Resident #702 wheeled herself over the sugar and cream area, approximately 25 feet away. Resident opened a pack of sugar and poured it into the coffee mug and wheeled herself to a dining room table without the lid. There was no staff present that attempted to assist the Resident with carrying the coffee and/or offering a clothing protector. After consuming the coffee, Resident #702 wheeled herself over to the commercial hot coffee dispenser, pulled down the nozzle and put more coffee in the coffee cup. The Resident did not put the lid back on the cup. Again, Resident #702 wheeled herself over to the sugar and cream area and placed sugar in the cup and continued to wheel herself to the dining table. No Staff was observed monitoring the Resident to ensure an attempt to place a lid on the cup was made or assist the Resident in carrying the mug. No Staff was observed attempting to offer a clothing protector. At 4:50 p.m., Nurse B was queried as to why Resident #702 was not wearing a clothing protector and why Staff were not monitoring the Resident to assure a lid was placed on the cup. Nurse B stated, She is non-compliant and wants to do things on her own. On 12/6/16 at 4:20 p.m., Resident #702 was observed in the dining room commercial hot coffee dispenser area holding a plastic cup of coffee without a lid. Resident #702 was wheeling herself to the sugar/cream area. CNA D was asked why she was not using a travel mug with a lid. CNA D stated, I know she had one that her daughter gave her. I don't know what happened to it. At the time the Resident was wearing a clothing protector that covered her chest, abdomin and top part of her legs. CNA D left the dining room area. No other Staff was present in the room for several minutes. Resident #702 was observed wheeling herself with a coffee cup with no lid to a dining room table and then again to the hot coffee dispenser. At 4:30 p.m., the metal travel mug with lid was observed in the Resident's room on the bedside table. CNA D was asked why she did not offer the travel mug with lid to the Resident. CNA D stated, I guess I did not see it. CNA D was further queried as to whether Resident #702 needed to be watched while holding hot liquid. CNA D stated, She does this all the time. She loves coffee. On 12/6/16 at 5:00 p.m. an interview was conducted with the DON and Nurse Unit Manager C. The DON was queried as to Resident's assessment for hot liquids. A review of the last Hot Liquid Assessment document dated 7/2/16 was conducted. The Assessment was checked yes for the following: Self Decision Making Ability, Resident can hold cup/bowl safely while sitting in a chair, Resident can hold cup/bowl safely while in bed. When queried as to whether Resident #702 was reassessed for hot liquid following any of the incidents pertaining to hot coffee spills on 7/28/16, 9/11/16, 11/13/16, and 11/20/16, the DON stated, No, but we updated the care plan. Resident #702 is non-compliant with her coffee lids. The DON was informed that on two occasions (12/5/16 & 12/6/16) it was observed that no staff was supervising or offering assistance with hot coffee and/or providing clothing protectors. The DON stated, Staff should have at least been offering assistance with the coffee. I agree that she can't be non-compliant if she is not offered assistance. On 12/7/16 at 10:05 a.m., treatment of [REDACTED]. During treatment as a dressing was removed and new one was being applied Resident #702 grimaced and yelled, ouch. Nurse C described the wound as, granulated with epithelization and yellow slough and open blister. A darker brown area was also noted. On 12/7/16 at 3:30 p.m., a review of the Facility's Hot Liquid Assessment Policy revised 1/15 was conducted and documented the following: Purpose: To prevent Burns Policy: Each resident will be assessed upon admission, or significant change for ability to handle hot liquids. Any resident that needs assistance will only be allowed coffee or other hot beverages while supervised. A thermal backed clothing protector and/or cup with a lid for hot liquid will be provided for residents who are assessed at risk ( )

Based on observation, interview, and record review, the facility failed to implement safety precautions for a resident that had received multiple medications known to cause sedation and dizziness, for one (#708) of six residents reviewed for antianxiety/hypnotic/anti-depressants ([MEDICAL CONDITION]) medications from a total sample of 21 sampled residents, resulting in the resident falling and sustaining nasal bone fractures and traumatic (permanent) nerve paralysis of the right eye. Findings include: On 12/9/15 at 4:00 pm, Resident #708 was observed sitting up in a chair in the dining room. There was a white bandage/eye patch taped over her left eye. Review of the admission face sheet revealed that Resident #708 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to a quarterly minimum data set, with an assessment reference date of 7/23/15, Resident #708 had severe cognitive impairment. A Care Area Assessment (CAA) for falls for Resident #708, completed 2/4/15, noted that the resident was not steady when moving from a seated to standing position, and when walking. In addition, the CAA noted that Resident #708 was receiving antianxiety and antidepressant medications, which were noted as high risk factors for potential falls. A Care Area Assessment (CAA) for [MEDICAL CONDITION] medication use for Resident #708, completed 2/4/15, noted the following: Classes of medication this resident is taking: Antianxiety, Antidepressant Adverse consequences of Anxiolytics exhibited by this resident: Sedation manifested by short-term memory loss, decline in cognitive abilities, slurred speech, drowsiness, disturbances of balance, gait, positioning ability. Analysis of Findings: (Resident #708) is taking antianxiety and antidepressant medications routinely. She has impaired balance at times and has dementia. Will proceed to care plan. Review of a Physical Therapy evaluation for Resident #708, dated 5/28/15, noted: Resident (#708) demonstrates significant decline in functional mobility secondary to new onset of BLE (bilateral lower extremity) weakness leading to increased difficulty with functional transfers, and has impaired standing balance .Due to worsening of symptoms of dementia, resident also demonstrates altered gait pattern leading to increased risks of falls. Review of a nursing note for Resident #708 noted: Late entry 9/24/15: At 11:00 pm, writer walked off elevator and observed resident laying face up on floor, with blood coming from her nose. Aide stated she woke her up (was in recliner) and resident took a few steps and fell face forward, the aide turned her over as she was facing down when she fell . Administered first aide to nose and assessed for injury. Stated left upper leg was hurting. Nose and face began to swell. Glasses were broken . Review of an Event Report for Resident #708 noted the following: Date: 9/23/15 Time: 11:30 pm Description: On floor in hallway. Aide woke her from chair and she walked a few steps and fell . Nose bleeding from both nostrils, nose swollen, c/o pain to left upper leg. Medication factors: Taking [MEDICATION NAME]. Root cause determination by Charge Nurse: Was sleepy/drowsy when stood up. Summary: Resident had received an antianxiety medication and another medication to aide with sleep. Resident will be closer monitored when readying for bed if sleeping/dozing in a recliner. Review of a physician's orders [REDACTED]. Review of a radiology report for Resident #708, dated 9/24/15, noted: Exam: CT Maxillofacial Reason for Exam: Trauma Interpretation: There are comminuted nasal bone fractures. Review of the September 2015 Medication Administration Record [REDACTED] [MEDICATION NAME] (an antianxiety medication) .5 milligrams (mg), [MEDICATION NAME] (a medication used to treat dementia) 10 mg, [MEDICATION NAME] (an antidepressant) 10 mg, and [MEDICATION NAME] (a medication used to aide in falling asleep) 3 mg. All four medications were listed on the MAR indicated [REDACTED]. May cause dizziness. Further review of the clinical record for Resident #708 revealed no care plan or interventions at the time of the fall, which addressed the Resident receiving multiple medications which could cause drowsiness, dizziness, and an increased risk for falls. Review of a fall investigation summary, undated, for Resident #708, completed by Nurse J, noted: A note was added to the care plans for CNA's (certified nurse aide) informing them that (Resident #708) takes medications near bedtime that may cause her to be drowsy and increase her fall risk. Review of the current CNA care plan for Resident #708 revealed no such documentation to inform the CNA's that Resident #708 receives medications which may cause drowsiness and dizziness, and may increase her risk for falls. On 12/9/15 at 10:40 am, CNA I (the assigned CNA for Resident #708) was queried about the care needs of Resident #708. CNA I referred to the CNA care guide for Resident #708, and stated that the resident was to have stand by assist with transfers and walking. When queried as to what this meant, CNA I stated, just be close by in case she needs help. When queried as to being informed of any medications that the resident may have taken, which could impair functioning, CNA I stated, I guess I would just rely on a verbal report from the nurse to know if they had taken a medication that would make them drowsy. On 12/9/15 at 12:00 pm, Family Member L was queried regarding the 9/23/15 fall for Resident #708. Family Member L stated, They gave her a sleeping pill, and they didn't assist her to bed. I was told that the Aide that woke her up did not normally work that floor, and she wasn't aware that they had given her a sleeping pill. She should have been assisted with a wheelchair. Since the fall, her dementia has worsened, and she is cognitively not as good as she was before the fall. After the fall, her eyes were crossing, and she couldn't even see my fingers in front of her eye, so I made an appointment for her to have her eyes evaluated. That's when it was discovered that her right eye is paralyzed now from the fall, and her lens in the left eye has dropped due to the fall. The pressure in her left eye was extremely high. They added 2 different types of drops for her eyes to try and bring the pressure down. She had surgery scheduled on the left eye for today, but the pressure was still too high, so they were unable to do the surgery. The nerve paralysis in he right eye is likely permanent. Review of a consulting Physician's Note, dated 10/01/15, noted the following: (Resident #708) with a past ocular history of high myopia (near sightedness/short sightedness) .On September 24, 2015, she suffered a fall when ambulating in her nursing home. She fell forward injuring her face .Since then she has noted poor vision in her left eye and she has been noted to have intermittently inturned eyes .Visual Acuity: Left eye- Hand Motions (a means of measuring eyesight in patients with very low vision, patient is able to see hand motions waved in front of the eye), Right Eye- 20/80 .Intraocular Pressure: Left Eye- 43 (normal 12-22) .Ocular Motility: Right eye- No abduction (no movement of the eye towards the nose) .Diagnoses: [REDACTED].In summary, (Resident #807) has a complicated clinical picture at this time with evidence of recent facial and periocular trauma from her recent fall. She has what appears to be a new right abducens nerve palsy, likely secondary to her trauma .Referral to a local anterior segment ophthalmologist is advised for further evaluation and care to prevent further permanent vision loss. On 12/9/15 at 2:15 pm, the Director of Nursing (DON) was queried regarding Resident #807's fall, which resulted in traumatic nerve paralysis to the right eye and nasal bone fractures. The DON stated that the fall investigation summary had been completed by Nurse J. The DON stated that the Resident's fall care plan had been updated after the fall to include an intervention to assist the patient with ambulation when she was noticeably sleepy. When queried about what interventions were in place before the fall to address the use of [MEDICAL CONDITION] medications for Resident #708, and the increased potential for falls due to their use, the DON stated, A contracted mental health provider would address the medications. On 12/10/15 at 9:30 am, the Consultant Pharmacist (CP) BB was queried regarding the medication regimen for Resident #708. CP BB stated that after the 9/23/15 fall sustained by Resident #708, he made a recommendation to the physician on 10/6/15 to re-evaluate the medication usage of [MEDICATION NAME], and [MEDICATION NAME] for Resident #708, but that there had been no changes made regarding the dosages or frequency of these medications. Review of the Facility's Fall Prevention policy, dated 11/16/15, noted: Policy: The goal of this policy/procedure is to promote a safe environment and reduce the number of falls and severity of injuries related to fall and other incidents. Policy Interpretation: .All necessary fall precautions will be implemented .d. Staff to assist with toileting and transfers when appropriate. e. Staff to assess gait and balance. ( )

Based on observation, interview, and record review, the Facility failed to thoroughly document, care plan, and ensure appropriate and timely implementation of preventive interventions for three (#'s 701, 709, and 711) of five sampled residents reviewed for pressure ulcers, from a total of 21, resulting in the development of pressure sores. Findings include: Resident #709 On 12/7/15 at 9:00 a.m., during an initial tour of Facility, Resident #709 was observed lying flat in his bed on his back. On 12/7/15 at 12:00 p.m., Resident #709 was observed lying flat in his bed on his back. On 12/7/15 at 3:30 p.m., Resident #709 was observed lying flat in his bed on his back. On 12/7/15 at 3:30 p.m., Resident #709 was queried as to life in the Facility and the how he was feeling. Resident #709 stated, I came here after I broke my right ankle. I was supposed to have rehabilitation, but it just didn't work so well. I am not able to walk. I really don't feel that great. My bottom really hurts me. The Resident asked to be repositioned in bed. When further queried as to whether the Resident was repositioned by staff on a regular basis, Resident #709 stated, Well now they seem to turn me more because they have to treat my bottom. They didn't turn me much before. I guess that is the reason I have the sore. On 12/7/15 at 4:00 p.m., the clinical record for resident #709 was reviewed and revealed the following: The Resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Resident was placed under hospice services on 10/23/15. The Resident's Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #709 was cognitively intact and required extensive assistance with bed mobility, transfers and activities of daily living (ADLs). The MDS noted that the Resident had no pressure ulcers upon entry, but was at risk for development. A progress note dated 11/20/15 at 12:33 p.m., revealed the following: Resident alert and oriented, no apparent distress noted, denies pain at this time. Extensive assist with ADLs and transfers, ambulate via wheelchair, Foley cath in place and patient incontinent of bowel deep purple non-blanchable open area noted on coccyx and no improvement noted A progress note dated 11/27/15 at 4:28 a.m., revealed the following: Resident alert and oriented x 3 able to make needs known, denies having pain this shift dressing changes to right ankle open area and left heel protective dressing, coccyx open area done and resident tolerated well . A progress note dated 11/29/15 at 3:31 a.m. revealed the following: Resident alert and oriented x 2 with periods of forgetfulness. Able to make needs known. Resident skin checked and pressure ulcer to coccyx 10 x 5.5 cm (centimeters) yellow slough (necrotic, dead, liquid tissue in the process of separating from the visible portions of the body) over wound bed and edges pink with musky odor On 12/8/15 at 8:30 a.m., Nurse Supervisor W was asked to arrange an observation of the wound with the wound care physician at 10:30 a.m. At 10:20 a.m., the wound care physician was approached regarding the wound observation scheduled for 10:30 a.m. The wound physician stated, I already treated the wound. The wound was very large, approximately 10 x 5 cm and probably at least 2 cm deep. I was going to cut off the slough, but he has a DPOA (Durable Power of Attorney) and I might have to consult with that person. Do you know what should be done? When queried about the treatment of [REDACTED]. I work only on Tuesdays. My understanding was that he had some redness in that area for a while and it opened up. Last Friday (12/4/15) I became aware of the wound. On 12/9/15 at 11:00 a.m., a second wound observation was scheduled with nurse W for 1:30 p.m At 1:30 p.m. an observation of treatment to the coccyx was conducted with Nurse X and revealed thick yellow/green slough with edges of the wound dark pink/red in color and appeared deep. The wound was odorous (smelled infected). Additional skin irritation was observed near the bottom of the dressing. The wound appeared approximately 10 cm x 5 cm and was unstageable (full thickness skin loss with depth unknown as it is completely obscured by slough in the wound bed). On 12/9/15 at 2:15 p.m., an interview and record review was conducted with nurse W concerning Resident #709's acquired pressure ulcer to the coccyx. Nurse W stated, I can't really say for sure what happened. I know that he has always had a red area to the coccyx, but nothing was open. I was off for the Thanksgiving Holiday from 11/23-12/1/15. When I came back I was told he had the very large unstageable wound. An order was initiated on 12/1/15 for him to see the wound doctor, but the doctor only works on Tuesdays, so yesterday is the first time he was seen by her. She changed his order and hopefully that will help. When further queried if there was a non-compliance care plan or documentation that the Resident refused to be turned, nurse W stated, I don't believe we have a care plan for that. We don't keep a log book or anything that documents Resident's refusal. The only place you will probably see that is in the Resident's progress notes or in the shower day documents done by the CNAs that highlight skin concerns. There may also be some notes in the Hospice section. However, there was no documentation of non-compliance reviewed or provided by the end of the survey. Nurse W was asked to provide documentation of the Resident's Skin Assessments, Care Plan, Skin Inspections and Physician orders [REDACTED].>11/20/15: Skin Risk Evaluation General Skin Appearance: Type: Pressure Ulcer Body Part: Buttock Location: Left Right Appearance: Non-blanchable (un-opened Stage I pressure ulcer), no odor, drainage, length, width or depth was indicated on the form. 11/27/15: Skin Risk Evaluation General Skin Appearance: Type: Ulcer-pressure Body Part: Coccyx Location: Medial Appearance: Yellow Odor: Musky Drainage: small/purulent (pus)/yellow Length: 10.00 (cm)/ Width (cm) 5.50. Resident #709's Care Plan for Skin Integrity dated 9/30/15 and updated 12/4/15 was reviewed and revealed, in part, the following: Problems: Resident is at risk for skin integrity related to impaired mobility. Interventions: · Use pillows, pads or wedges to reduce pressure on heals and pressure points. Turn/reposition (9/30/25) · Do not message skin over pressure areas (9/30/15) · Check skin daily (9/30/15) · Pressure relieving device on chair (9/30/15) · Barrier cream to peri area as needed. (9/30/15) Additional interventions added 12/4/15: · Has air mattress on bed (12/4/15) · consult wound care services as needed (12/4/15) · turn and reposition 4-5 times per shift (12/4/15) Continued review of the Resident's clinical record was conducted with Nurse W. Nurse W was questioned as to why interventions (air mattress, wound care and repositioning 4/5 times per shift) were not initiated earlier as the 11/20/15 as progress notes indicated an open wound. Nurse W stated, Again, I'm not sure. I was not aware of the open wound until I returned from the Thanksgiving holiday. I believe he had an air loss mattress before 12/4/15. I can have maintenance check on the date issued. No documentation was provided by the end of the survey to indicate the date a low risk air mattress was provided. As for skin inspection documentation only three sheets dated 11/10/15, 12/1/15 and 12/4/15 were provided by the end of the survey. On 12/9/15 at 4:35 p.m., an interview was conducted with the Director of Nursing (DON) regarding Resident #709's pressure ulcer to the coccyx. The DON was asked to provide an explanation as to why the Resident's pressure ulcer had become so large and odorous and what interventions were in place to prevent the significant increase. The DON stated, I'm not really sure what happened. I am not sure when it was first noticed. We were all surprised as to the size. I know that the Resident is Hospice. You could talk with the Hospice nurse. ( ) Resident #711: On 12/8/15 at 10:45 a.m., a skin assessment was conducted on Resident #711. During that assessment an open area, approximately the size of a dime was noted to her coccyx area. The open area was pink in color without any drainage noted. Resident #711 stated, I have been hurting back there (coccyx area) for a while. I asked for some foam for my wheelchair because my butt hurts bad when sitting in that chair. On 12/8/15 at 2:20 p.m., record review of Resident #711's face sheet revealed an initial admission into the facility on [DATE] and a re-admission on 11/30/15 with [DIAGNOSES REDACTED]. Review of Resident #711's most current quarterly Minimum Data Set (MDS), dated [DATE], indicated an intact cognition, she required one person to physically assist for bed mobility, and for activities for daily living (ADLs). Also, per this MDS Resident #711 was assessed to be at risk for developing pressure ulcers. This MDS indicated that she did not have any pressure ulcers at the time of assessment. On 12/9/15 at 11:40 a.m., an interview and record review of Resident #711's clinical record with the Unit Manager (UM W, first floor) revealed the following: Nurse W was queried regarding interventions for Resident #711's pressure ulcer. Nurse W stated, I didn't know she even had a pressure ulcer. I don't think she has one at this moment. Review of Resident #711's current clinical record revealed no comprehensive care plans developed for the prevention and treatment of [REDACTED]. Resident #711's face sheet revealed a re-admission into the facility on [DATE]. The admission skin assessment, dated 11/30/15, indicated there were no pressure ulcers or wounds. The Norton Risk Assessment (assessment used for determining the risk of developing PU) indicated that Resident #711 was at high risk for developing PU. The current doctor's orders revealed no treatment nor any orders in place for the prevention and/or treatment of [REDACTED]. Nurse W stated, She does not have had a care plan for the treatment of [REDACTED]. Nurse W was unable to provide an explanation as to why there was no care plan in place for the prevention of pressure ulcers. Nurse W was informed of the observation of the open area on Resident #711's coccyx on 12/8/15. On 12/9/15 at 2:45 p.m., a skin assessment was performed on Resident #711 with Unit Manager E (second floor Nurse Manager). Nurse E measured the open area on the coccyx area at 1.0 centimeter (cm) X 0.1 cm. The wound bed was 100% redden. On 12/9/15 at 2:55 p.m., record review of Resident #711's current clinical record, with Nurse E, revealed the following: Resident #711's current Treatment Administration Record (TAR) revealed no documentation of any treatments for the prevention of pressure ulcers, nor did the doctor's orders. Again, review of the care plans revealed no care plans or interventions for the prevention of pressure ulcers. Nurse E stated, She has a history of skin breakdown. She had a skin care plan that ended/resolved on 9/8/15 .not sure why it resolved .maybe it healed at that time. ( ) Resident #701: On 12/8/15 at 10:20 AM, resident #701's clinical record was reviewed with nurse Unit Manager 'E'. The resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had severe cognitive impairment, required extensive assistance for transfers and bed mobility and had no pressure sores. On 11/14/15, the resident had a fall and a [MEDICAL CONDITION] was discovered per X-ray reports dated 11/15/15 and 11/16/15. Skin Risk Evaluations for resident #701 dated 10/3/15, 11/14/15, and 11/16/15, noted the resident was at high risk for pressure sores. The resident's clinical record and incident reports noted the following: On 11/4/15, a pressure sore, identified as a small pink open area was observed on the sacral area per nursing progress notes. A moisture barrier protective cream was applied twice a day per the resident's medication record until 11/23/15. There was no mention of a protective dressing. An incident report dated 11/23/15 noted small open area to coccyx measuring 1 centimeters (cm) by 0.4 cm. An absorbant, protective dressing was then applied to this stage II (partial thickness skin loss) pressure sore every three days. When asked if a protective dressing should have been implemented when an open area was discovered on 11/4/15, nurse 'E' indicated that she was unaware of it until the incident report was written on 11/23/15. On 11/25/15, a stage II pressure sore, identified as a skin tear on an incident report measuring 3 cm by 2.3 cm, was discovered on the right shoulder area. The resident's skin was noted to be thin and fragile. A dressing was applied daily. On 11/30/15, a stage II pressure sore, identified as skin shearing on an incident report, was discovered on the left inner knee measuring 3 cm by 4 cm. A dressing was applied daily. Resident #701's At Risk for Impaired Skin Integrity care plan, effective 10/15/15 noted: Problems-Stage II pressure ulcers to sacrum, right shoulder, and left inner knee. Interventions included: Use pillows, pads, or wedges to reduce pressure on pressure points, Has knee separator between knees when up in chair Use pillow between knees when in bed (added to the care plan on 12/1/15), Use body pillow for positioning when in bed (added on 12/3/15). When asked why resident #701 developed three pressure sores at the facility and why all of the interventions were not immediately care planned and implemented following the fracture, nurse 'E' did not respond. When asked if the resident had been evaluated by the wound specialist (physician), who came to the facility every Tuesday, nurse 'E' said that the resident was going to be evaluated today (a Tuesday). A wound care referral dated 12/1/15 written by nurse 'E', was for evaluation of the sacral wound with no mention of the shoulder or the knee. When asked why the resident was not seen on 12/1/15 (a Tuesday) when the referral was written, nurse 'E' said, (The specialist) left before the referral was written. On 12/8/15 at 11 AM, resident #701's skin was observed with nurse Unit Manager 'E' and the wound care specialist. The resident was alert, confused, positioned on the right side, and had to be repositioned by nurse aides that were present. The resident kept her lower extremities in a flexed position with knees held together with a pillow in between and resisted having them extended or separated by staff. She kept her upper extremities flexed and held tightly against her body. There were no elbow pads present or pillows/wedges on the right side near the shoulder between the resident and the mattress. A dressing, saturated all the way through dated 12/8/15, was removed from resident #701's coccyx area revealing the pressure sore underneath. The dressing was ordered to be changed once a day. Nurse 'E' said that the dressing had been changed during the previous midnight shift. The wound specialist described the wound as measuring 4 centimeters (cm) by 2 cm, was 40% necrotic (black dead tissue), had serous drainage, and was unstageable. When the specialist was asked if she was going to evaluate the resident's other wounds, she stated that she was not aware of them as they were not mentioned in the referral. The specialist then began to evaluate them. When dressings to these areas were removed, the specialist said the left inner knee wound measured 1.1 cm by 1 cm at stage II and the right shoulder was 1 cm by 1 cm at stage II on a bony prominence. On 12/8/15 at 4 PM, when resident #701's facility acquired pressure sores were discussed with the Administrator and the Director of Nursing, they had no response. On 12/9/15 at 3:50 PM, nurse aides 'P' and 'Q' were observed entering resident #701's room after the resident had been placed in bed by the day shift, to check her incontinence brief and reposition her. The resident was positioned on the right side. There was no pillow between her knees to prevent pressure. Her flexed right elbow was pressing on the mattress with no padding. A cube-shaped knee separator that was to be used when up in the chair, was lying on the bed. The aides said that a pillow should have been placed between the knees and pointed out how they usually kept bilateral pillows between the flank and elbow to prevent pressure because she holds her arms so tight to the body. On 12/9/15 at 4:05 p.m., review of the facility's policy titled, Preventing Pressure Ulcers, dated 10/25/15, revealed the following documentation: The purpose of this procedure is provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. 1. Identify risk factors for pressure ulcer development, 3. Change position at least 4 to 5 times per shift or more frequently if needed, 4. Determine if resident needs a special mattress (low air loss), 12. Assess and document the condition of the resident's skin per facility wound and skin care program and for any signs and symptoms of irritation or breakdown, 13. Immediately report any signs of a developing pressure ulcer to the nurse. For residents with risk factors, implement preventive measures as indicated: use moisturizers on dry skin, consult the dietician for correct nutritional deficiencies by increasing protein and calorie intake .Notify the supervisor if the resident refuses the procedure or change in condition. The policy also noted: Use pillows and position devices (wedges, rolls) to keep bony prominences from direct contact with each other. Review of the facility's policy titled Skin Assessments, dated 11/16/15, revealed the following documentation: To assess and appropriately respond to a resident's skin concern. The procedure included: The caregiver shall look at the resident's skin for any and all concerns on an ongoing basis during resident's routine schedule shower, person care needs, while dressing, and undressing. Any concerns ae to be reported to the charge nurse immediately. When a skin concern is found, findings shall be reported to the resident's physician and the resident's responsible party. ( / / )

On 1/27/15 at 9:50 AM, resident #501 was observed in bed, and alert, but confused. The resident had a dressing wrapped around the right arm and 10 steri-strips on the left forearm underneath geri-sleeves. On 1/27/15 at 3:15 PM, resident #501 was alert and sitting in his room in a wheelchair talking to his son. The resident was confused and wearing geri-sleeves. The son said, "He didn't have those on a few months ago." A fall safety alarm box was attached to the back of the wheelchair. The resident's assigned nurse aide ('B') entered the room and was asked to observe the alarm controls. The control box was set in the "off" position. Aide 'B' said, "Oh my God" and did not respond why the alarm was turned off, when asked. On 1/28/15 at 9:25 AM, resident #501 was in the wheelchair, alone in his room. His assigned nurse aide ('D') entered the room and was asked to observe the the alarm controls. The control box was set in the "off" position. Aide 'D' did not respond why the alarm was turned off, when asked. On 1/30/15 at 10 AM, resident #501's clinical record and "Event Reports" were reviewed with nurse Unit Manager 'A'. The resident was originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets ((MDS) dated [DATE] and 12/26/14 noted that the resident was non-ambulatory, extensively dependent on staff for transfers and mobility, and on the 12/26/14 MDS, had moderate cognitive impairment. A fall risk evaluation dated 8/31/14 for resident #501 noted that the resident was at high risk for falls. A score of 10 or more=high risk. The event reports noted the following falls and injuries for resident #501: 1. On 8/31/14, the resident was on the floor with no injury. 2. On 9/18/14, the resident was on the floor in his room with no injury. A fall safety alarm was noted to be sounding to alert staff . 3. On 10/9/14, the resident was on the floor in his room with no injury a few hours after returning from a three day hospital stay. The report noted that the resident was refusing care, agitated, combative, and anxious upon his return, and had an alarm. There was no indication that the alarm sounded to alert staff of attempts to self transfer. Nurse 'A' did not respond why the resident was left alone in his room in an agitated state, when asked. His fall risk score was 21. 4. On 10/12/14, resident #501 was on the floor in his room. He sustained the following skin tears: a 9 centimeter (cm) by 4 cm skin tear to the top of the head, a 4 cm by 1.2 cm tear to the back of the head, three tears to the left wrist, and three to the right knee. A clip-type alarm was noted to be unclipped from the resident, indicating that it did not sound. The alarm type was changed to a sensor alarm (a type that you sit on to detect motion). Nurse 'A' did not respond why the alarm was unclipped. A "fall" care plan dated 10/13/14 noted an intervention: "Sensor alarm to wheelchair and bed at all times." 5. On 10/15/14, the resident was lying across the wheelchair with feet touching the floor, alone in his room, and sustained a 5 cm by 2 cm skin tear to the left forearm. The resident stated that he "wanted to get up." The alarm was noted to be "in place and functioning," however, staff was noted to become aware of the situation by overhearing the resident "yelling for help." Per nurses notes, prior to the fall on this date, the resident was confused, non-compliant, yelling, and anxious throughout the day. There was no indication that the alarm sounded. Nurse 'A' did not respond why the resident was left alone in the room unsupervised in his state. The fall risk score was 20. A fall care plan intervention dated 10/15/14 noted: "Check on resident at least every (left blank) hours....Keep in view as much as possible." 6. On 11/1/14, resident #501 was observe with a skin tear to the right forearm sustained during care by a nurse aide. Geri-sleeves were noted to be "initiated," but no indication that the sleeves were placed on the resident. 7. On 11/3/14, the resident fell , sustained two skin tears to the back of the head and a left elbow skin tear re-opened. There was no indication that geri-sleeves were on at the time. There was a written order for geri-sleeves dated 11/3/14. Nurse 'A' stated that she ordered them after this incident and did not respond why they were not already on. The fall score was 20. 8. On 11/12/14, resident #501 was on the floor and sustained a skin tear to the left elbow. The resident was noted to be attempting to get out of bed. There was no indication that geri-sleeves were on or that the alarm sounded. The fall risk score was 22. 9. On 11/13/14, per nurses notes, the resident was on the floor. There was no indication that the alarm sounded. There was no documented event report. 10. On 11/14/14, the resident was on the floor and sustained skin tears to the forehead, right knee, and right wrist. The alarm was noted to be "in place and functioning," however, "alarm was not sounding." The corrective action to prevent reoccurrence: "Ensure bed alarm (is) in place." There was no indication geri-sleeves were on. The fall risk score was 21. Fall care plan interventions dated 11/20/14 noted: "Offer and encourage rest periods in bed after lunch daily" and "Allow resident to remain up in wheelchair in evening until he feels sleepy and is ready to go to bed." 11. On 1/2/15, per nurses notes by nurse 'C', resident #501 sustained an unexplained "15 cm" skin tear to the left lower arm. There was no documented event report. There was no indication that geri-sleeves were in place or that an alarm sounded in case there was a fall. Twenty seven days later (on 1/29/15, during the survey), nurse 'C' noted that this skin tear on 1/2/15 was 1.5 cm in length. (On 1/27/15, the resident was observed to have 10 steri-strips in place to close this wound.) 12. On 1/23/15, resident #501 sustained a skin tear from contact with a jagged window sill. Geri-sleeves were noted to be "initiated." Nurse 'A' said that there were no geri-sleeves in place because she "had to re-order them." On 1/30/15 at 2 PM, the facility's policy on "Fall Prevention" was reviewed and revealed the following: "The goal of this policy/procedure is to promote a safe environment and reduce the number of falls and severity of injuries related to fall and other incidents....With the occurrence of a fall....an Incident/Accident report will be completed by the nurse on duty....amend the resident's care plan....Any injury of unknown cause will also be documented on an Incident/Accident report." ( ) This citation has two Deficient Practice Statements. Deficient Practice Statement #1: Based on observation, interview, and record review, the facility failed to provide adequate devices and supervision to prevent falls based on the residents' assessed needs, and failed to ensure staff assisted resident transfers were performed safely and with the appropriate assistive equipment based on the resident's assessed needs, for three (#501, #502, #508) of 22 residents reviewed for falls and accidents, out of a total sample of 24, resulting in multiple falls with injuries, including a broken nose, head injuries which required emergency care at a hospital, and skin tears. Findings include: Resident #508: On 1/28/15 at 3:30 P.M., Resident #508 was observed in a wheelchair with a sensor pad alarm (personal safety device). The resident was alert with confusion, and was unable to state her name when asked. The resident did not speak when addressed, but made eye contact and smiled. On 1/29/15 at 3:00 P.M., Resident #508's clinical record and facility Incident and Accident Reports (I&A) were reviewed with the Director of Nursing (DON) who was also the acting Unit Manager for the nursing unit where Resident #508 lived. The following information was revealed: Resident #508 had fallen four times in the facility since 4/1/14, per facility I&A, resulting in two transfers to the hospital emergency department (ER), and a head hematoma, a head injury requiring staples, and a broken nose. A face sheet documented that Resident #508 was admitted into the facility on [DATE], with a readmission after hospitalization on [DATE]. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #508 had severe cognitive impairment,was rarely or never able to understand or make herself understood, had impaired balance, impaired vision, needed extensive physical assistance for ambulation on the unit, for transfers to the wheelchair, and for mobility once in the wheelchair. The MDS documented that Resident #508 was often, but not consistently incontinent of bowel and bladder. Review of physician's orders [REDACTED].#508 was prescribed an anticoagulant (bloodthinner), "Warfarin three milligrams (mg) daily (qd)", and a diuretic (water pill), "furosemide 40 mg qd". At this time, the Director was requested to provide Fall Risk Assessments and Nursing Care Plans for Resident #508 in place at the time of Resident #508's first reviewed fall, on 4/20/14 to the present, and the following undated care plans were provided and reviewed. The DON stated that new interventions were added to existing care plans as needed, and stated that she did not know how to make the dates of newly added interventions appear on the electronic record or when printed. Provided care plans were reviewed at this time, and revealed: An undated, "Active" Care Plan for Resident #508 entitled "Walk in Room", with a goal date of 9/11/14, noted, "Remind (Resident #508) not to stand/walk alone". When asked how this would work for Resident #508, a resident with severe dementia, who was unable to understand or be understood, the DON stated, "We try to keep her in areas where staff can see her. If they see her trying to stand up, they help her to sit back down." An undated "Active" Care Plan for Resident #508, titled, "At risk for bleeding related to (r/t) (brand name for Warfarin)", noted the intervention, "Implement safety precautions such as fall management protocols." An undated "Active" Care Plan for Resident #508, with a goal date of 9/11/14, titled, "Impaired short term and long term memory", contained the interventions, "supervise activities as needed to ensure safety", and "maintain a consistent routine environment." An undated "Active" Care Plan for Resident #508, with a goal date of 9/11/14, titled, "Is receiving diuretics on a regular basis", had the intervention, "Respond promptly to calls for assist to the toilet." When asked how a resident who was unable to communicate meaningfully could call for assistance for toileting, the DON stated, "the staff check her regularly, and after meals." An undated "Active" Care Plan for Resident #508, with a goal date of 9/11/14, titled, " Has a history of falling", had the following intervention, "Monitor and keep in view of staff at all times." The DON was unable to provide documentation that a yearly or quarterly Fall Risk Assesssment had been done for Resident #508, prior to the resident's fall on 4/20/14. When asked about this, the DON had no comment, but noted that the Nursing Care Plan did document that Resident #508 had a history previous falls in the facility. Review of a facility I&A and "Post Fall Investigation" report for Resident #508's fall on 4/20/14 at 2:15 P.M., revealed the following, "Staff suddenly heard body alarm going, and ran to the direction where it was coming from. Observed resident standing up and took a step, but tripped on her wheelchair (w/c) foot pedal. fell on face. Resident fell forward and hit face on floor. Bleeding noted from nose." The event was documented as, "alleged fall, unattended." The post fall investigation noted, "Bloody nose, x-ray taken, no injury noted." "Summary" noted, "Only to have foot rest on when being transported." A subsequent I&A for Resident #508, dated 4/23/14 at 10:00 A.M., documented "right hand discoloration with purple and redness. Discoloration on both sides of hand." The conclusion ("Root Cause") of the bruising was determined to be, "related to incident on 4/20/14." On 1/29/15 at 3:15 P.M., the DON was questioned about Resident #508's fall on 4/20/14, and stated, "She was being supervised. The staff got to the area in time to see her fall, but just couldn't get there in time. They left the footrest on her wheelchair, because she can be resistant when they push her in the wheelchair. She'll put her foot down while they're pushing her, and that's a safety risk for falling." When asked if the facility had provided sufficient supervision to prevent falls, if staff were too far away to reach the resident in time to prevent a fall, the DON stated, "Sometimes the staff have to help other residents." A Falls Risk Evaluation for Resident #508, dated 4/20/14, documented the following, "balance problem while standing", "Fall Risk Score: 12. Total scores of 10 or more represent high risk for fall". On 1/29/15 at 3:20 P.M., review of an I&A for Resident #508 for a fall dated 6/27/14 at 7:30 A.M, with the DON revealed the following, "Resident was sitting in her w/c in front of the television (TV). Alarm was heard sounding. Resident was leaning forward and fell on floor face down. resident sustained [REDACTED]. Bleeding noted from nose." The action to prevent reoccurrence was documented as, "Observation and kept in view of staff". The event was described as, "alleged fall, unattended." Results were documented as, "Transfer to emergency room (ER)", "Bruise on forehead", and "Fracture (broken bone)". The Post Fall Investigation report documented that Resident #508's eyeglasses were being repaired at the time of the fall, and "Resident leaned forward while sitting in her w/c as she tried to propel self out, her w/c got stuck on another resident's w/c." On 1/29/15 at 3:25, the DON was queried about Resident #508's fall on 6/27/14, and stated, "She has very poor vision. She didn't have her glasses at the time." When asked why Resident #508 was not supervised at the time of the fall, the DON stated, "The fall was witnessed, because they could document how it happened." Review of Nursing Notes for Resident #508 with the DON at this time, revealed no additional information. When asked if the facility had provided sufficient supervision to prevent falls if staff were too far away to reach the resident in time to prevent a fall, and whether the situation was similar to Resident #508's fall on 4/20/14, the DON did not respond. When asked if new interventions were added to Resident #508's Care Plan to prevent similar falls, the DON reported, "No." On 1/29/15 at 3:30 P.M., Resident #508's I&A for a fall dated 1/1/16 at 10:00 A.M., was reviewed with the DON. A Fall Risk Evaluation for Resident #508, dated 6/27/14, noted that the resident was at high risk for falls, with a score of 19. When queried about the year noted on the I&A, the DON reported, "It's a mistake, it's 2015." The I&A documented, "Observed resident standing up from w/c and fell to her bottom on floor. No injury. Alarm on and working." the event was described as, "alleged fall, unattended." The "Investigation Summary" was documented as, "Resident needed to have BM and attempted to get out of chair." The DON was queried about this, and could not explain why closer supervision was not provided for Resident #508, due to two prior falls under similar circumstances. When queried, the DON stated that no new interventions were added to prevent additional falls of the same type. When queried, The DON was unable to state how Resident #508's toileting needs were assessed or anticipated, as the resident was unable to make her needs known due to dementia. On 1/29/15 at 3:35 P.M., Resident #508's I&A for a fall dated 1/10/15 at 1:30 P.M., was reviewed with the DON. A Fall Risk Evaluation for Resident #508, dated 1/1/16 was reviewed with the DON at this time and revealed that the resident's risk of falling had decreased after the fall, with a score of 10. The DON reported that the evaluation was done after the resident's fall on 1/1/15, and was unable to explain why the resident's risk had decreased to a score of 10 post fall, from a risk score of 19 on 6/27/14. Review of Resident #508's I&A dated 1/10/15 at 1:50 P.M. documented, "Patient sitting in front of TV in w/c. Alarm in place and working. Patient yelling on floor, posterior head bleeding. Posterior head shows an abrasion with some bleeding three centimeters in diameter." The report noted, "alleged fall unattended", "Transfer to ER." What action nurse initialted immediately to prevent reoccurrence was documented as, "Adequate staffing." The "Investigation Summary" documented, "Resident stood up, and w/c rolled away from resident. Hit head - to ER for evaluation. Returned with staples in back of head." Time last toileted was documented as, "10:30 A.M. One aide assigned to floor." The DON was unable to provide additional information when queried, and delined additional comment. On 1/30/14 at 10:45 A.M, during a review of Resident #508's paper clinical record (hard chart) with Charge Nurse, Licensed Practical Nurse (LPN) "N", who was interviewed regarding Resident #508's falls at this time, a Hospital Radiology "Final Report", dated 6/28/14, revealed that Resident #508 had a broken nose following the fall on 6/27/14, documented as, "a minimally displaced fracture of the right and left nasal bone." LPN "N" stated, "Yes, I remember that. That's when she had the raccoon eyes and all." LPN "N" stated that Resident #508 ambulated (walked) on the unit sometimes, using a rolling walker with staff holding on to her. When asked why the resident had been left without adequate supervision, when the resident had a history of [REDACTED]. The last fall that she had (1/10/15), we only had one Certified Nursing Assistant (CNA) on the floor, they pulled our other CNA to another floor because there was a call in. I wasn't here the day she broke her nose, so I can't tell you about that." On 1/30/15 at 10:50 A.M., CNA "M" was interviewed regarding Resident #508, and stated, "I was here when she (Resident #508) broke her nose. They (midnight staff) probably had the foot pedals on her wheelchair because she was asleep in her wheelchair (w/c), and they were going to take her to the dining room for breakfast once they'd gotten everybody up, and were busy getting other residents up, and to the dining room. She was asleep in her wheelchair. They set her up in the hallway to wait until someone could take her to the dining room. I don't know how long she'd been there. The midnight staff get her up anywhere from 5:00 A.M., to 7:00 A.M., before we get here (at 7:00 A.M.)." When asked who was supervising the resident while she was sleeping in her w/c in the hallway, CNA "N" stated, "It was shift change. I'd just walked off the elevator. Everyone was busy either getting residents up or giving report." On 1/30/15 at 11:00 A.M., CNA "M" was interviewed regarding Resident #508's fall on 1/10/15, and stated, "I was here then, too. She (Resident #508) was sleeping at the dining room table during lunch. One of the volunteers moved her to the TV area and didn't lock the w/c, so she stood up and the w/c rolled away. She wasn't taken to the bathroom after the meal.We usually take her to the bathroom after meals. I was her assigned CNA, but I ended up being the only CNA on the floor with my nurse. There were 17 residents on the floor. (CNA "O") was assigned to work with me but she got pulled to the second floor. I didn't have time to toilet her, and I don't know if the volunteer was in the TV area (at the time of the fall), or whether she was helping to get everyone out of the dining room." On 1/31/15 at 11:40 A.M., the facility staffing coordinator, "P" was interviewed regarding staffing on the Dementia Unit where Resident #508 resided, and stated, "There should be two CNAs and one Nurse on that unit." When asked if the third floor was adequately staffed on 1/10/15, the staffing coordinator stated, "I'll have to look. That date sounds familiar." Staffing and staff assignments were requested at this time, and review of the "Daily Staffing Sheet", dated 1/10/15 for the 7-3:30 P.M. shift, revealed the total staffing exceeded the state minimum levels, but CNA "O" was noted to have signed in twice, on both the second floor census and on the third floor census, as assigned to work on both of these floors on the same date, during the same shift. The DON was unavailable for comment, and the Administrator was unavailable for interview regarding staffing at the time of Resident #508's fall with head laceration requiring staples, on 1/10/15. Resident #502 On 1/28/15 at 11:20 A.M., Resident #502 was observed in bed in the room. The resident was alert and oriented and able to answer simple questions. An adaptic (gel bandage) was noted on the resident's left outer leg, just below the knee. When queried, the resident stated that she had had a skin tear there that kept reopening, but that it was now healed and the bandage was there, "for protection." When asked how the skin tears had happened, Resident #502 stated, "I bumped my leg three or four times when they were getting me up." On 1/29/15 at 2:30 P.M., Resident#502's responsible party (RP) "Q" was interviewed and reported, "She (Resident #502 has had three or four skin tears due to staff not giving her time to find her feet when they get her up." On 1/29/15 at 2:45 P.M., Resident #502's clinical record and facility Incident and Accident Reports (I&A) were reviewed with the Director of Nursing (DON), who was also interviewed at this time, and revealed the following: A face sheet documented that Resident #502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] documented that Resident #502 had moderately impaired cognition, and needed limited physical assistance for transfers to the wheelchair, did not walk, needed extensive assistance for dressing and hygiene, and had impaired balance. A Mobility Assessment for Resident #502, dated 8/5/14 documented that Resident #502 was unable to pull herself into a standing position, required assistance with lateral transfers, and was assessed as a candidate for a (brand name of mechanical sit to stand lift). The assessment also documented that this was "Care Planned" and "Added to Resident Summary". An I&A, dated 8/27/14 at 4:20 P.M., noted, "I hit my leg when she was getting me up out of bed." The injury was noted as, "Skin tear left lower leg. 2.5 centimeters (cm) long by 2 cm wide." The I&A documented that steri-strips (paper tape to hold skin together instead of stitches) were applied to the wound. The Action to prevent reoccurrence was documented as, "Inform Certified Nursing Assistant (CNA) to be careful when getting resident out of bed and make sure (brand name of mechanical sit to stand patient lift device) with small sling is being used." The I&A "Event Report", documented, "skin: fragile", "Was the Care Plan followed: No". The "Investigation summary" , dated 8/28/14, documented, "CNA given verbal education for not using lift as care- planned." When queried about this, the DON reported that Resident #502 had fragaile skin, and did not move well, so transfers out of bed were care planned to be performed using the (brand name of sit to stand mechanical lift). An I&A dated 1/21/15 at 3:00 P.M., documented that Resident #502, "Hospice Aide soaking foot and legs in room and re-opened old wound. Tear is on lower left leg approximately one cm long by one cm wide. Bleeding slightly from transfer with Hospice Aide." The action to prevent reoccurrence was documented as, "Re-educate aide on safety with transfers." The "Investigation Summary", dated 1/26/15 noted, "Hospice CNA providing care for resident bumped resident's leg during transfer, reopening a previously healing area. Resident transfers with (brand name of sit to stand mechanical lift) and one (staff) assist. Treatment was initiated and the Hospice CNA was given a verbal education/reminder to use caution with fragile skin." The investigation CNA interview form was not completely filled out (questions left blank), and was signed by the Hospice CNA on 1/21/15 (time left blank), and described, "Bumped (Resident#502)'s leg on wheelchair while transferring, gave her a skin tear on left leg. Was hit previously." When queried, the DON was unable to provide documentation the Hospice CNA involved in this incident was Re-educated or counseled regarding safe transfers, or that this CNA was re-assessed (re-evaluated during a demonstration) for the ability to safely transfer residents.The DON was unable to explain why the resident and the responsible party were of the impression that the transfer was done without using the lift, while the I&A investigation documented that the Care Plan was followed. The DON was also unable to explain why Resident #502, and the resident's RP both stated that there were three or four transfer incidents, and specifically named a CNA who transferred Resident #502 using a pivot transfer(standing on feet and pivoting with staff support), resulting in a skin tear below the knee on the left shin, snd there was no facility documentation of this. The DON was unable to explain how Resident #502 got the "previously healing area", which was "hit previously", documented as reopened on 1/21/15 during the CNA assisted transfer. On 1/29/15 at 3:05 P.M., CNA "R" was interviewed regarding Resident #502's transfer injury on 8/27/14, and stated, "It was my first time taking care of her (Resident #502). The CNA who gave me report (at shift change) told me she was a one person transfer and she didn't need a lift. It turns out she does need a lift. I transferred her with a pivot transfer and she got a skin tear, I didn't have time to go to check her care guide." Deficient Practice Statement #2: Based On Observation, interview and record review, the facility failed to ensure that oxygen was stored safely in upright secured holders, and failed to ensure that oxygen in use by a resident was not exposed to direct heat in the hairdressing salon, for one sampled resident (#502), out of one resident reviewed for oxygen use out of a total sample of 24, and one supplemental sampled resident (#70), resulting in the potential for oxygen combustion, tank explosions and resident burns and injury. Findings include: On 1/27/15 at 3:10 P.M., Resident #502 was observed in a wheelchair in the facility beauty parlor. The resident was sitting under an operating stationary hair dryer, with her hair in curlers. The resident had oxygen administered at three liters per minute (3 L per min) through a nasal cannula, from a portable oxygen tank attached to the back of her wheelchair. When tested by placing a hand over the top of the oxygen tank, the hair dryer was blowing hot air directly on to the outlet valve at the top of the oxygen tank from the space between the back of the resident's head and the dryer hood. Palpation of the oxygen tubing carrying oxygen into the resident's nasal cannula revealed the plastic tubing to be warm to touch.The oxygen gauge on Resident #502's oxygen tank was checked with the Hairdresser "T", and the tank was observed to be three quarters full (3/4) and running through the tubing at 3 L per min. At 3:15 P.M., Resident #502 stated, "I can't hear anything. I had to take my hearing aides out so they wouldn't get ruined by the heat fron the hairdryer." At 3:16 P.M., the facility hairdresser, "T", stated, "I've been doing this here for [AGE] years and nobody ever said anything about not using oxygen in the beauty shop. I didn't know it (oxygen) was flammable." The hairdresser left the resident under the dryer with the heat on and the oxygen running, and returned to tasks at the other end of the salon. From 3:10 P.M., until 3:25 P.M., Resident #502 was observed sitting under the operating stationary hairdryer, while receiving oxygen at 3 L per min through a nasal cannula, attached to an oxygen tank on the back of the resident's wheelchair, with the oxygen tank on the back of the resident's wheelchair (w/c) located directly under the gap between the resident's head and the dryer hood. When advised again that direct heat applied to an oxygen tank, or flowing oxygen to the resident was a fire hazard, as well as a potential explosive hazard, Hairdresser "T", repeated, "I've been in this beauty shop for [AGE] years, no one's ever said anything." At this time, the facility Director of Nursing (DON) was paged to the area per request. At 3:27 P.M., the DON entered the facility beauty parlor, and observed Resident #502 under the hairdryer with the oxygen running, and said, "Oh, No.", and immediately went to the hair dryer, turned off the oxygen tank (shut the valve) and took Resident #502 out from under the dryer hood and propelled Resident #502 in the w/c towards the door of the hairdressing salon. Hairdresser "T" stated, "She's not dry yet." The DON answered, "No oxygen in the beauty shop." Hairdresser "T" then said to the DON, "I've been here [AGE] years, and nobody's ever said that. Is there any reason she can't be in here if the hair dryers are all off?" On 1/27/15 at 3:33, Resident #502's Clinical Record, and physician's orders [REDACTED]. A face sheet documented that Resident #502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] documented that Resident #502 had moderately impaired cognition, and needed limited physical assistance for transfers to the wheelchair, did not walk, needed extensive assistance for dressing and hygiene, and received oxygen therapy. A physician's orders [REDACTED].#502, dated 1/1/15 through 1/31/15, revealed the following order, "Maintain oxygen saturation at 92 percent (%) or greater at 3 L per min via nasal cannula." The DON stated, "Her oxygen saturation was 97% this morning according to the TAR." On 1/27/13 at 3:37 P.M., Licensed Practical Nurse (LPN) "S", Resident #502's assigned nurse, was asked, in the presence of the DON, what the facility policy was for sending residents on oxygen therapy to the beauty parlor, and stated, "Give them a portable tank. It attaches to the back of the w/c." When told that oxygen was extremely flammable and that oxygen compressed under pressure in a portable tank could explode when exposed to heat, LPN "S" stated, "Not unless there's a spark." The DON stated, "I'm shaking." On 1/27/15 at 4:00 P.M., the DON and the facility administrator were interviewed and the facility policy on oxygen administration was requested. The Administrator stated, "We've been looking for one, but we don't have a policy that covers oxygen use in the hairdresser. We're writing one right now." The DON stated, "We called the doctor and got an order to take the oxygen off for hairdresser appointments with monitoring of oxygen saturation while the oxygen is off. When asked, the Administrator stated, "I don't know how old those hairdryers are. I've asked the Plant Supervisor and he said they've been the same ones for at least the past [AGE] years." Preventative maintenance logs for the hairdryers, and/or documentation of hairdryer inspections for frayed cords or worn parts was requested but not provided by survey exit. On 1/30/15 at 12:00 P.M., review of the manufacturer's "Dryer Instructions" for the "professional salon dryers", revised 8/02 revealed no instructions regarding oxygen use around the dryers, but contained the following warnings regarding flammable materials, "Do not operate the hair dryer at the sa

Based on observation, interview, and record review, the facility failed to apply a brace in a manner to prevent pressure points, and failed to implement pressure reduction padding and float heels as ordered by the physician, resulting in the development of multiple pressure sores for one (#514) of 10 sampled residents reviewed for pressure sores from a total sample of 24. Findings include: On 4/10/14 at 11 AM, resident #514's clinical record and an incident/accident (I/A) report, were reviewed with the Director of Nursing (DON) and the resident's primary care physician (PCP), who was also the medical director. The resident was originally admitted on [DATE] with [DIAGNOSES REDACTED]. The resident also had surgery on 1/22/14 for a fractured right femur with surgical reconstruction and application of a leg brace. The resident was enrolled into a hospice program on 3/21/14. Review of the minimum data sets ((MDS) dated [DATE] and 4/6/14 for resident #514 noted that the resident required extensive assistance for bed mobility and transfers. The resident's cognition was intact with no pressure sores on the 2/6/14 MDS, but the 4/2/14 MDS noted that cognition was moderately impaired and the resident had one stage II (partial skin thickness) pressure sore to the sacral area. A nurse assessment dated [DATE] for resident #514 indicated that the resident had no pressure sores and had a pressure risk score of 13. A score of 10 or less indicated high risk. The I/A report dated 4/1/14 noted: a dark blue bruise was discovered to resident #514's right outer calf measuring 7.5 centimeters (CM) by 1.5 CM in diameter. The report noted: "Increase risk for skin breakdown due to....pressure applied to right leg due to resident being turned and repositioned every two hours with right leg immobilizer on....new order written for (thick) pads on....right lower extremity." Resident #514's PCP presented a written timeline of events involving the resident. Per the timeline, on 3/16/14 "brace causing skin irritation...." Per progress notes dated 3/16/14: "....the right knee brace....has too many pressure points....I ordered a softer knee immobilizer." On 3/28/14 the PCP noted: "Leg OK. Patient is wearing a much softer right leg brace." The PCP stated that the brace/immobilizer was changed several times because of "parts inside that caused pressure." He stated on 4/1/14, the brace was removed and a posterior splint was applied due to pressure. On 4/1/14, the PCP ordered: (thick) padding to inside of immobilizer. Per a progress note by the PCP dated 4/3/14: "Patient complaining brace rubbing....has had 2 braces....she still has pressure points....I removed the old knee immobilizer...." and "....placed (the mold)....then it was secured with three rolls of 4 inch ace wraps." Per an order dated 4/4/14: unwrap and check skin under splint every shift. On 4/10/14 at 11:40 AM, resident #514's skin was observed with hospice nurse 'M', the Director of Nursing (DON), and the PCP. The resident was lying in bed with an ace wrap on the right lower extremity from the foot to the thigh. A posterior splint, from the foot to the thigh, was underneath the ace wrap. A thin, non-stick petroleum dressing was observed on the right lateral calf. There was a black, linear shaped pressure sore with areas of necrosis beneath the dressing approximately 7.5 centimeters (cm) by 1.5 cm in diameter. Dark drainage was observed on the inside of the mold and on the non-stick dressing. There was no padding over the non-stick dressing to prevent pressure. The PCP said, "She (the resident) could use more padding inside." The resident was also observed to have a dark, intact pressure sore on the right heel approximately 2 cm in diameter. There was no padding to protect this area. When queried about the right heel, the PCP and the hospice nurse stated they were unaware it was present. A "weekly skin assessment" form dated 4/6/14 noted: site location-"right foot" and frequent pain over last five days to right foot with the skin noted to be "intact" and no pressure sore. Resident #514's treatment records for 3/2014 noted interventions: "Float both heels while in bed, check heels every shift" and "apply (thick padding) to areas where straps come in contact with skin to prevent pressure." This record and the 4/2014 record did not indicate that thick padding was applied. In addition, on 4/9/14 at 12 noon during a skin observation with nurse 'L', resident #514's heels were resting on the bed. A sign was posted over the bed that read: "Float heels at all times." The nurse did not respond why the heels were not floated. During the skin observation with the PCP and DON on 4/10/14, the heels were not floated. On 4/11/14 at 9:20 AM, the left heel was not floated. On 4/11/14 at 3 PM, review of the facility's "Pressure Ulcer and Prevention policies dated 11/30/11 and 3/5/12 noted: -Routinely assess and document the condition of the skin for any signs of developing pressure sores. -Maximize the potential for healing. -Protect the wound, prevent friction, and implement pressure relieving devices according to assessed needs. ( )

Based on observation, interview and record review the facility failed to provide clinical diagnoses/justification for indwelling urinary catheters, failed to obtain Physician orders for indwelling urinary catheters, and failed to document indwelling urinary catheter care was provided for three (#'s 502, 517 and 521) of eight sampled Residents reviewed for indwelling catheters from a total sample of 24, resulting in Urinary Tract infections [MEDICAL CONDITION], and Acute [MEDICAL CONDITION]. Findings include: On 4/8/14 at 2:35 P.M. Resident # 502 was observed sitting in a wheelchair in the room. Resident #502 was lethargic, and was slumped forward with eyes closed, but made eye contact and responded appropriately to questioning. Resident #502 stated, "I feel sick. I'm dizzy. I wish someone could tell me what's wrong with me." Resident #502 stated, "I had a catheter (tube from the urethra into the bladder, to drain urine) for a long time, it seems. They took it out recently, I can't remember exactly when. I got it in the hospital before I came here, and I think I had it for a long time." A sign indicating visitors should see the nurse prior to entering the room was posted outside Resident #502's room. There was a cart containing personal protective equipment located by the doorway to the room. On 4/8/14 at 2:45 P.M., Certified Nursing Assistant (CNA) "G" was asked if Resident #502 was on isolation precautions for an infection, and replied, "She's on contact precautions. She has VRE ([MEDICATION NAME] Resistant [MEDICATION NAME] - a drug resistant microorganism) in the urine." On 4/10/14 at 10:10 A.M., Resident #502's clinical records were reviewed and revealed the following: A face sheet documented that Resident #502 was originally admitted into the facility on [DATE] with a readmission on 12/6/13, with [DIAGNOSES REDACTED]. A Minimum Data Set assessment ((MDS) dated [DATE] revealed Resident #502 had intact cognition, had an indwelling urinary catheter for urination, and had had a Urinary Tract Infection [MEDICAL CONDITION] during the lookback period. An MDS dated [DATE] also documented that Resident #502 had an indwelling urinary catheter, and had had a UTI during the lookback period. An active nursing care plan for Resident #502, dated 12/24/13 with the following title, "has indwelling (urinary) catheter, admitted to (facility) with orders for (urinary) catheter." Admission Physician's orders for Resident #502, dated 10/26/13, revealed an order for [REDACTED]. An admission Physician's History and Physical (H&P) for Resident #502, dated 10/27/13 documented, "complication: [MEDICAL CONDITION]. Plan: remove (D/C) (indwelling catheter) once patient is up (not bedbound)." A Physician's History and Physical (H&P) for Resident #502, dated 10/29/13 documented, "(Resident #502) had post operative (after surgery) [MEDICAL CONDITION] that was treated with a catheter." A hospital lab report dated 2/24/14 ( for hospital admitted [DATE]) documented that Resident #502 had an indwelling urinary catheter and a urine sample collected on 2/21/14 was positive for VRE. A Hospital Course Summary dated 3/14/14 at 4:41 P.M., documented Resident #502 was transferred to the hospital on [DATE] for "Candidal (yeast) UTI, Acute Kidney Failure, Acute UTI." The Physician's Summary for the 3/14/14 report documented , "history of recurrent UTI's ...was brought in from (long term care center) due to a change in mental status. We did a urinalysis (UA) that came back positive for urinary tract infection. She was started on IV (intervenous) antibiotics. We did send a urine culture that came back positive for Pseudomonas (disease causing bacteria) and [MEDICAL CONDITION](yeast). She had a (indwelling urinary) catheter on admission. Acute Kidney Injury." A Physician's Progress Note dated 3/20/14, documented the following, "Seen and examined with (indwelling urinary catheter) for UTI. Plan: D/C (indwelling urinary catheter) On 4/10/14 at 3:25 P.M., review of additional Physician's H&P in Resident #502's current and closed (previous admissions) clinical records with the Director of Nursing (DON) revealed no additional documentation indicating the Physician had reviewed the need for Resident #502's indwelling urinary catheter after 10/29/13, until 3/10/14. The DON was requested at this time to provide any additional documentation that this was done. On 4/10/14 at 3:30 P.M., review of the Physician's orders for Resident #502 with the DON revealed an order dated 3/25/14 to d/c (remove) Resident #502's urinary catheter. The DON was asked if Resident #502 had had the urinary catheter since initially admitted on [DATE] ( a total of five months). The DON stated that review of closed and current clinical records, medication administration records (MAR) and Treatment records (TAR) indicated that Resident #502 had an indwelling urinary catheter since originally admitted on [DATE]. At this time, The DON was requested to provide any additional documentation to indicate that an attempt was made to d/c Resident #502's urinary catheter prior to the 3/25/14 Physician order. On 4/11/14 at 9:50 A.M., Resident #502's physician was contacted by telephone and stated that he was unable to remember whether an attempt was made to d/c Resident #502's urinary catheter prior to 3/25/14, or whether diagnostic tests to confirm a medical need for the indwelling urinary catheter were done. On 4/11/14 at 10:45 A.M. The Registered Dietitian (RD) "I" reported that Resident #502 had lost 24 pounds in the past three months, a "severe" weight loss of 12% of body weight, and stated, "It was probably related to her multiple hospitalization s and being sick." On 4/11/14 at 11:50 A.M., the DON stated, "I've had the IDT (Interdisciplinary Care Team) team looking, but we can't find any documentation of a urology consult, or anything more that says we did tests to see if she needed that catheter. We couldn't find any doctor's orders or nursing notes to say we attempted to d/c it since her first admission. It looks like she had it the whole time. She probably had that catheter since admission, and somehow, probably because of all of her readmissions, it got overlooked. The paperwork is shoddy. The order for the catheter isn't consistently on the monthly order summaries, but it doesn't need to be, because an order stays valid until the physician writes an order to d/c it. There was a [DIAGNOSES REDACTED]. The physician initially diagnosed (Resident #502) with post operative [MEDICAL CONDITION]. That's an acute condition, not a chronic one. Temporary [MEDICAL CONDITION] after surgery is quite common, especially in the elderly. Someone should have addressed that catheter, but I don't see any evidence of it. I know that's a problem. I know that we're looking at harm, because of the hospital transfers and UTI's she's had." The DON was unable to provide documentation that Resident #502 had the urinary catheter d/ced prior to 3/25/14. The DON was unable to provide documentation that the physician had written orders to d/c Resident #502's urinary catheter prior to 3/20/14. The DON was unable to provide documentation that diagnostic tests were done, or a urologist consulted to determine if Resident #502's catheter was medically necessary. The DON was also unable to explain the five day delay between the Physician's note dated 3/20/14, indicating the physician's plan to D/C the catheter, and the order to D/C it on 3/25/14. The DON was requested to provide a facility policy regarding indwelling urinary catheter management. On 4/11/14 at 2:00 p.m., review of the facility's policy titled, "(Brand name) Catheter , dated 5/2013, did not address having medical justification for the use of an indwelling catheter. ( ) During the initial tour of the facility on 4/8/14 begining at 9:15 a.m., Resident # 517 was observed in bed with a indwelling urinary Catheter in place to dependent drainage. A review of Resident #517's clinical record on 4/10/14 at 10:00 a.m. revealed an admission to the facility on [DATE] from an acute care hospital with an indwelling catheter. Resident #517's admission [DIAGNOSES REDACTED]. There was no order or justification for the indwelling catheter documented. The admission order sheet documented "(brand name) Cath (catheter): yes, Cath care every shift." The 1/10/14 Admission Minimum Data Set (MDS) assessment documented Resident # 517's cognition was intact and the resident was sometimes incontinent of bowel and not rated for urinary continence (indicating the resident had some type of urinary catheter)--The MDS did not document a [DIAGNOSES REDACTED]. Further review of Resident #517's clinical record revealed Physician Order sheets for 1/2014, 2/2014 and 4/2014 (no monthly Physician order sheet was found in the record for 3/2014), the order sheets did not have any documentation related to Resident #517 having an indwelling urinary catheter or for catheter care. Review of all interim Physician orders contained in the clinical record did not reveal any orders related to Resident # 517's indwelling catheter. A review of a Physician consult sheet dated 12/30/14, noted "(Resident #517) has a (indwelling urinary catheter)." A review of Physician "Progress/monthly note" sheets documented, "+ (positive) (indwelling urinary catheter)" on 1/14/14 and 3/6/14. physician progress notes [REDACTED].#517 had an indwelling urinary catheter. The Physician notes did not document a [DIAGNOSES REDACTED]. The clinical record revealed an active Nursing care plan for Resident #517, dated 1/9/14, titled, "Recent hospitalization , weakness and deconditioning", with interventions that included "Provide (indwelling urinary) catheter care daily. Monitor color and odor of urine" and "keep catheter below the level of the bladder and tubing free from kinks." A review of Resident # 517's Treatment Administration Records (TAR)s revealed the following: The 1/2014 TAR noted "Change (brand name of indwelling catheter) q (every) month." There was no documentation that the indwelling catheter had been changed for the month of 1/2014. The 2/2014 and 3/2014 TARs documented the indwelling catheter was changed on 2/6/14 and 3/2/14. The TARs documented "(brand name) cath (catheter) care every shift." Review of the area for Nurse's to initial care was provided revealed blank spaces (no initials) on 2/5/14 and 2/6/14 on the 7:00 p.m. to 7:00 a.m. shift, on 2/11/14, 2/27/14 and 2/28/14 on the 7:00 a.m. to 7:00 p.m. shift and on 3/23/14 on the 7:00 a.m. to 7:00 p.m. shift. Indicating no catheter care had been provided on those dates and times. There was no entry on 4/2014 TAR to direct staff to provide changing of the indwelling catheter or to provide catheter care for Resident #517's indwelling catheter. Resulting in no documentation that it had been changed or that catheter care was provided for 4/2014. Review of Nurse's notes for 4/1/14 to 4/11/14 did not document any catheter care had been provided by the Nurses. During an observation and interview on 4/10/14 at 10:45 a.m. Resident #517 was observed in bed with the indwelling catheter in place secured to her left thigh and to dependent drainage. When queried Resident #517 indicated she came from the hospital with the indwelling catheter in place, and stated it had been in place for a "long time." On 4/10/14 at 12:50 p.m. the facility Director of Nursing (DON) was queried regarding Resident #517's indwelling catheter. The DON reviewed the clinical record and said she did not find a diagnosis, or a Physician order for [REDACTED]. No further documentation was provided by the end of the survey. On 4/11/14 at 11:45 a.m. the second floor Licensed Practical Nurse (Staff "F") reviewed the 4/2014 TAR's for Resident #517 and said she did not see any reference to the indwelling catheter or any Physician order for [REDACTED]. On 4/11/14 at 2:05 p.m. the DON was queried regarding the lack of documentation related to the indwelling catheter for 4/2014 and stated she was not able to find any documentation that any indwelling catheter care had been documented as provided by Certified Nursing Assistants for 4/2014. ( ) On 4/8/14 at 9:30 a.m., during the initial tour of the first floor nursing station, resident #521 was observed to have an indwelling catheter in place. The resident was asked and stated, "I don't know why I have this thing in. I have asked the staff why I have it in, and they say maybe it's because I had surgery." On 4/9/14 at 10:00 a.m., record review revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #521's Admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident's cognition was intact and required limited assistance with all activities of daily living. Review of the monthly physician orders dated 4/1/14-4/30/14 documented no medical justification/[DIAGNOSES REDACTED]. The "At risk for infection related to indwelling catheter" care plan dated 4/4/14, did not indicate the rational for the use of the indwelling catheter. The admission "Nursing Evaluation " dated 4/11/14 documented a "Bowel and Bladder Risk Score of 19 (18-24 = potential bowel and bladder retraining). " On 4/9/14 at 1:55 p.m., Unit Manager, Nurse "A" was interviewed regarding the indwelling catheter for resident #521. Nurse "A" said that when a resident is admitted into the facility with an indwelling catheter, that information is placed on the doctors log for the physician to evaluate for it's use. Nurse "A" stated, "The attending physician was on vacation when that resident was admitted and the physician that was covering, did not address the catheter. It should have been removed." On 4/11/14 at 10:00 a.m., the Director of Nursing (DON) was queried regarding the facility's policy on the use of indwelling catheters, and stated, "We discuss admissions every day. When a resident comes in (to the facility) with a catheter, the unit manager addresses it with the attending physician to make sure there is justification for it's use. In this case, the catheter did not get addressed and did not get removed, there was no reason for it." On 4/11/14 at 2:00 p.m., review of the facility's policy titled, "(Brand name) Catheter Insertion, Male/Female Resident", dated 5/2013, documented "Verify that there is a physician's order for this procedure." The policy did not address having medical justification for the use of an indwelling catheter. ( )

Based on observation, interview, and record review, the facility failed to implement appropriate safety interventions and transfer assistance based on the resident's assessed needs, for one (#514) of 11 sampled residents reviewed for accident hazards from a total sample of 24, resulting in falls, skin tears, a hematoma, extreme pain, fractures and hospitalization for surgical repair, and post-surgical wound infection. Findings include: On 4/8/14 at 9:30 AM, resident #514 was observed lying in bed with an ace wrap on the right lower extremity from the foot to the thigh. The resident constantly grimaced and moaned in pain when the ace wrap was removed by nurse 'L'. A posterior splint, from the foot to the thigh, was underneath the ace wrap. The resident's knee was swollen with pale purple bruising. The resident was alert, said that she was in pain, and was able to reliably respond to some questions. The resident yelled out when the nurse applied strips of tape to re-secure the ace wrap across the top of the knee. On 4/10/14 at 10:30 AM, resident #514's clinical record and incident/accident (I/A) reports, were reviewed with the Director of Nursing (DON). The resident was originally admitted on [DATE] with [DIAGNOSES REDACTED]. The resident also had a past history of fractured vertebrae and fractured right femur with joint reconstruction. Review of the minimum data set ((MDS) dated [DATE] for resident #514 noted that the resident required supervision only for bed mobility, limited assistance for transfers, and was non-ambulatory. The 6/5/13 MDS noted limited assistance for bed mobility. The 9/5/13, 2/6/14, and 4/2/14 MDS' noted extensive assistance for bed mobility and transfers. The resident had intact cognition on the MDS' dated 3/5/13 thru 2/6/14. The MDS dated [DATE] noted cognition was moderately impaired. Resident #514's "fall" care plan dated 6/12/12 thru 1/9/14 noted that the resident had a history of [REDACTED]. The goal: The resident would be "free from major injury caused from falling...." A fall risk assessment dated [DATE] noted that the resident scored 10. A score of 10 or greater indicated high risk for falls. The I/A reports noted the following: 1. On 4/11/13 at 6:30 AM, resident #514 fell off of the toilet, complained of severe back pain, and was transferred to the hospital emergency room . A hospital x-ray report was negative for acute fracture to the spine upon review. The I/A report indicated that the resident self-transferred to the bathroom. There were no documented corrective actions to prevent reoccurrence. 2. On 6/2/13 at 10 PM, resident #514 fell next to the toilet while being assisted during a transfer by a nurse aide. The corrective action: gripper socks. When queried, the DON did not respond why the aide did not ensure that the resident had appropriate footwear during the transfer. Per nurses notes, on 6/3/13, the resident complained of left rib pain. A stat (immediate) x-ray was taken of the rib area that was negative upon review. 3. On 6/8/13 at 4:20 PM, resident #514 attempted a self transfer from bed to wheelchair and fell . The corrective action: a fall safety alarm was added to the wheelchair and bed. Per nurses notes, a sensor-type alarm was placed on the bed. Per review of an order dated 6/10/13 by the resident's primary care physician (PCP), who was also the medical director, and the fall care plan, the alarm for the "wheelchair" was discontinued because the resident was removing it. When queried, the DON did not respond why there was no indication that the bed alarm sounded to alert staff, why the wheelchair alarm was not positioned where the resident could not reach it, or why the alarm was not replaced with a different type. 4. On 7/25/13 at 12:40 AM, resident#514 attempted a self transfer from bed to wheelchair and fell . There was no mention that the bed alarm sounded. The DON did not respond why. The resident complained of right hip pain. An x-ray of the hip was negative for acute fracture upon review. The corrective action: add a body alarm. Per nurses notes dated 7/26/13: "Resident had fall yesterday, complained of pain x 3 today. Resident complained of pain and remained in bed for most of the day." 5. On 8/20/13 at 6:55 AM, resident #514 was found on the floor in the bathroom following an attempted self-transfer and complained of hip pain (no indication which hip). The corrective action: "alarm ordered." When queried, the DON did not know why there was no indication that the bed or body alarm sounded and why an alarm had to be "ordered." 6. On 9/28/13 at 4:30 AM, resident #514 was on the floor in the bathroom with skin tears to the right hand and wrist following an attempted self-transfer. The corrective action: the resident was told to ask for assistance. When queried about the alarm, the DON said, "There's no indication there was an alarm" at the time of the fall. On 9/30/13, the PCP ordered the alarm discontinued. The DON did not know why when asked. 7. On 12/10/13 at 8:40 PM, resident #514 attempted a self transfer to bed, "slipped on carpet," and fell . The resident sustained [REDACTED]." When queried regarding the circumstances of this fall, the DON stated that the resident was "preparing herself for bed." The DON did not respond why the resident was not wearing proper footwear at the time of the incident and no indication that she could remove any footwear on her own. 8. On 1/9/14 at 2:10 PM, resident #514 was on the bathroom floor. Review of an x-ray to the right knee dated 1/9/14 revealed: "acute non-displaced fracture....of the femur" near the joint reconstruction site that the resident had prior to admission. The corrective action: A body alarm was placed on the resident and place on a toileting program. When asked why the resident did not already have an alarm, the DON did not respond. When asked if the resident should have been on a toileting program already in lieu of the numerous falls in the bathroom, the The DON said, "I agree." 9. A review of hospital records revealed that resident #514 was hospitalized from [DATE] thru 1/26/14 for right knee pain and found to have worsening of the 1/9/14 fracture. An x-ray report dated 1/20/14 noted a "comminuted displaced (bones separated and broken into pieces)" fracture of the right femur which was 4.5 centimeters from the joint reconstruction site that the resident had prior to admission. On 1/22/14, the resident required a repeat of reconstruction surgery of the right femur. On 4/10/14 at 11:15 AM, resident #514's PCP was queried regarding the fractures on 1/9/14 and 1/20/14. When asked why the resident did not go to the hospital until 1/20/14, the PCP said, "We weren't going to do surgery and just wanted it immobilized (a leg immobilizer), but it got worse, so we sent her to the hospital." When asked how the fracture became displaced and comminuted, the PCP said, "I don't know. I think she must have put some weight on it and tried to walk." There was no documented I/A report regarding this event. The resident's fall care plan noted on 1/16/14 that the resident's status was "WBAT" (weight bearing as tolerated). The PCP did not respond when asked if the resident was supposed to bear weight after the initial fracture. 10. On 2/5/14 at 11:15 AM, resident #514 was being assisted during a transfer off of the toilet by an aide and the resident's legs "gave out on her....(and) she just sat down hard on the toilet...." The resident complained of "increase pain to right hip and leg." The DON stated that the resident was non-weight bearing on the right side. Corrective action: "Taught aide resident's legs give out on her sometimes...." The DON said, "She should have been a two person assist." Review of hospital records noted that the resident was hospitalized from [DATE] thru 2/23/14 due to "surgical wound infection involving the right knee area with evidence of underlying abscess. High likelihood of involvement of underlying hardware and osteo[DIAGNOSES REDACTED] (bone infection) of the femur." On 2/18/14, the surgeon noted: the resident "developed significant swelling and [DIAGNOSES REDACTED] (redness) and pain in the right knee area....purulent (pus) drainage coming out of the incision....wound culture....is positive for MRSA (methicillin resistant staph aureus)." The resident was placed on two intravenous (IV) antibiotics and the abscess was drained. The resident was re-admitted to the facility on [DATE] with IV antibiotics and a leg brace. On 2/26/14, the resident was sent back to the hospital for one day for wound exploration and cleaning. A review of progress notes written by resident #514's PCP dated 2/23/14 thru 3/16/14 also revealed: complaints of right leg pain and "increase in blood sugars likely due to right leg fracture and infection...." On 4/11/14 at 3 PM, a review of the facility's "Fall Prevention" policy dated 9/10/12 revealed: "Appropriate in-services and interventions will be implemented according to....findings of any trends, patterns, or safety issues...." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO APPLY, POSITION AND MONITOR A KNEE IMMOBILIZER SO AS TO PREVENT SKIN BREAKDOWN FOR ONE (#404) OF TWO RESIDENTS REVIEWED FOR PRESSURE ULCERS OUT OF A TOTAL SAMPLE OF 20, RESULTING IN THE DEVELOPMENT OF AN UNSTAGEABLE (DEPTH CANNOT BE DETERMINED DUE TO COVERING OF DEAD TISSUE) INFECTED PRESSURE ULCER. FINDINGS INCLUDE: ON 2/26/13 AT 2:00 P.M., RESIDENT #404 STATED, "I GOT A SORE ON MY LEG FROM THE BRACE I WAS WEARING AFTER MY HIP SURGERY. I KEPT TELLING THE NURSES AND MY AIDES THAT THERE WAS A LOOSE STAVE (REMOVABLE METAL SUPPORTS) THAT WAS DIGGING INTO ME, BUT IT TOOK DAYS OF COMPLAINING BEFORE ANYBODY TOOK A LOOK TO SEE WHAT I WAS COMPLAINING ABOUT. BY THE TIME I FINALLY GOT MY NURSE TO OPEN UP THAT BRACE AND CHECK IT, I HAD A BIG HOLE IN MY LEG. IT'S QUITE DEEP AND IT HURTS A LOT. RESIDENT #404 STATED THAT THE ONLY TIME THE BRACE WAS TAKEN OFF WAS ONCE A WEEK, AFTER THE SHOWER. THE RESIDENT STATED THAT SOME SHOWERS WERE DONE WITH A PLASTIC BAG OVER THE BRACE SO THAT IT DID NOT HAVE TO BE REMOVED." WHEN ASKED HOW NURSES ASSESSED THE SKIN UNDER THE BRACE FOR WOUNDS OR RASHES, RESIDENT #404 STATED, "THEY DIDN'T, MAYBE THEY TOOK IT OFF FOR MY SHOWER ONCE A WEEK, BUT THAT'S ALL. THEY TOLD ME THAT I HAD TO KEEP THE BRACE ON ALL THE TIME, 24- 7 (24 HOURS PER DAY, SEVEN DAYS A WEEK.) WHEN DR (THE WOUND CARE PHYSICIAN) SAW THE HOLE IN MY LEG, HE GOT REAL MAD AND PULLED THE STAVES OUT OF THAT BRACE AND THREW THEM ACROSS THE ROOM. IT WAS INFECTED TOO. I JUST FINISHED MY SECOND ANTIBIOTIC TREATMENT." ON 2/26/13 AT 2:30 P.M., RESIDENT #404'S RIGHT LEG KNEE IMMOBILIZER (BRACE) WAS INSPECTED WITH CERTIFIED NURSING ASSISTANT (CNA) "H". THERE WERE TWO NICKLE SIZED DRIED REDDISH BROWN STAINS ON THE BOTTOM EDGE OF THE BACK OF THE BRACE. WHEN QUERIED, CNA "H" STATED, "THOSE ARE BLOOD SPOTS ON HER BRACE WHERE HER SORE WAS. SHE KEPT COMPLAINING THAT THE BRACE WAS TOO TIGHT. SHE WAS SUPPOSED TO KEEP IT ON ALL THE TIME, WE WEREN'T SUPPOSED TO TAKE IT OFF. SHE EVEN HAD TO SLEEP WITH IT ON." WHEN QUERIED ABOUT SKIN ASSESSMENTS, CNA "H" STATED, "WE (CNAS) COULDN'T TAKE THE BRACE OFF, SO I GUESS LOOKING AT THE SKIN UNDERNEATH WOULD BE THE NURSE'S JOB." ON 2/26/13 AT 2:40 P.M., NURSE "G" WAS INTERVIEWED REGARDING RESIDENT #404 BRACE, SHE STATED, "HER BRACE GOT HER. SHE (RESIDENT #404) COMPLAINED ABOUT THE BRACE. IT KEPT RIDING UP HER LEG, SO I KEPT HAVING TO PULL IT DOWN SO IT WOULDN'T DIG INTO HER GROIN. SHE COMPLAINED A LOT ABOUT HER FOOT HURTING. I DIDN'T THINK IT HAD ANYTHING TO DO WITH THE BRACE. I ONLY LOOKED AT HER LOWER LEG ONCE A WEEK, BECAUSE I COULD DO HER HIP INCISION (SURGICAL WOUND) TREATMENT WITHOUT REMOVING THE BRACE." ON 2/26/13 AT 3:00 P.M., CNA "I" WAS INTERVIEWED AND STATED, "SHE (RESIDENT #404) ALWAYS COMPLAINED THE BRACE HURT, SO I SOMETIMES LOOSENED IT FOR HER. I NEVER CHECKED HER SKIN UNDERNEATH. THAT'S THE NURSE'S JOB." ON 2/26/13 AT 3:05 P.M., WOUND CARE FOR RESIDENT #404 BY TREATMENT NURSE "J" WAS OBSERVED AND REVEALED ON THE POSTERIOR (BACK) LOWER LEG REVEALED A PEAR SHAPED OPEN WOUND WITH PALE MOIST TISSUE WITH AREAS OF TAN SLOUGH (DEAD TISSUE) AND DARK BROWN ESCHAR (DRY, HARD DEAD TISSUE), SURROUNDED BY RED PUFFY INFLAMED TISSUE EXTENDING APPROXIMATELY FIVE CENTIMETERS (CM) AROUND THE WOUND. THE WOUND MEASURED THREE (3) CENTIMETERS (CM) LONG BY 1.5 CM WIDE. TREATMENT NURSE "J" STATED, "SHE'S JUST FINISHED A COURSE OF ANTIBIOTICS FOR THAT WOUND. IT WAS INFECTED. NOW THE SKIN AROUND IT LOOKS INFECTED AGAIN." RESIDENT #404 STATED, "IT THROBS." ON 2/26/13 AT 3:15 P.M., TREATMENT NURSE "J" WAS INTERVIEWED ABOUT RESIDENT #404'S WOUND AND STATED, "NURSE "K" CALLED ME ON 1/9/13 TO LOOK AT IT. IT WAS RED AND SWOLLEN WITH A BIG BLOOD FILLED BLISTER." REVIEW OF RESIDENT #404'S CLINICAL RECORD WITH NURSE "J" REVEALED DOCUMENTATION THAT RESIDENT #404'S KNEE IMMOBILIZER WAS REMOVED AND THE SKIN UNDERNEATH EXAMINED ONCE A WEEK, DURING THE RESIDENT'S SHOWER. THERE WAS NO DOCUMENTATION THAT THIS WAS DONE MORE FREQUENTLY, OR IN RESPONSE TO RESIDENT COMPLAINTS OF DISCOMFORT. ON 2/27/13 AT 10:25 A.M., NURSE "K" WAS INTERVIEWED ABOUT RESIDENT #404'S PRESSURE ULCER. NURSE "K" STATED, " THE CNA TOLD ME THAT HER RESIDENT WAS COMPLAINING THAT HER BRACE HURT. I TOOK IT OFF AND FOUND A BLOOD FILLED BLISTER ON THE BACK OF HER SHIN." WHEN REQUESTED, NURSE "K" WAS UNABLE TO PROVIDE DOCUMENTATION , THAT RESIDENT #404'S KNEE IMMOBILIZER WAS REMOVED AND THE SKIN UNDERNEATH INSPECTED DAILY PRIOR TO DISCOVERY OF THE WOUND ON 1/9/13. WHEN REQUESTED, NURSE "K" WAS UNABLE TO PROVIDE DOCUMENTATION THAT RESIDENT#404 WAS ASSESSED FOR THE SOURCE OF THE DISCOMFORT FROM THE IMMOBILIZER. ON 2/27/13 AT 2:15 P.M., RESIDENT #404'S CLINICAL RECORDS AND TREATMENT RECORDS (TAR) WERE REVIEWED WITH THE ASSISTANT DIRECTOR OF NURSING (ADON)/ UNIT MANAGER, NURSE "F", AND REVEALED THE FOLLOWING: RESIDENT #404 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF AN ADMISSION MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE], REVEALED RESIDENT #404 WAS COGNITIVELY INTACT, NEEDED EXTENSIVE ASSISTANCE OF TWO STAFF FOR MOVEMENT IN BED, TRANSFER TO THE WHEELCHAIR, TOILETING AND DRESSING, AND DID NOT HAVE A PRESSURE ULCER AT THAT TIME. REVIEW OF A WEEKLY SKIN assessment dated [DATE] REVEALED RESIDENT #404 HAD NO PRESSURE ULCER, AND WAS AT LOW RISK FOR DEVELOPING PRESSURE ULCERS WITH A BRADEN SCALE (PRESSURE ULCER RISK SCORE) OF 17 (LOW RISK =15-18). REVIEW OF A PHYSICIan order for [REDACTED]. TO BE OFF FOR HYGIENE AND SKIN INSPECTION WHEN PATIENT IN BED SUPINE (LYING ON HER BACK)." REVIEW OF A NURSING NOTE DATED 1/11/13 AT 6:18 P.M., REVEALED, "RECEIVED REPORT OF FLUID FILLED BLISTER ON POSTERIOR RIGHT LOWER EXTREMITY (LOWER LEG). NEW ORDER OBTAINED. THE RIGHT KNEE IMMOBILIZER BRACE CAUSING FRICTION AT THIS SITE." REVIEW OF A WOUND CARE PHYSICIAN'S NOTE FOR RESIDENT #404, DATED 1/15/13 REVEALED THE FOLLOWING, "THE WOUND IS MODERATE SEVERITY. BEGAN AS A BLISTER THEN CONVERTED INTO A NECROTIC WOUND. ORTHO SAID TO LEAVE THE IMMOBILIZER ON AND AS A RESULT, THE WOUND OCCURRED. MEASUREMENTS ARE 3.7 CM LENGTH AND 1.7 CM WIDTH. SIGNS/ SYMPTOMS OF INFECTION ARE PRESENT. PRESSURE ULCER, UNSTAGEABLE. [MEDICAL CONDITION] AND ABSCESS (INFECTION)." KEFLEX ORAL (AN ANTIBIOTIC) 500 MG THREE TIMES DAILY WAS PRESCRIBED. REVIEW OF physician's orders [REDACTED].[MEDICATION NAME] TIMES DAILY AND BACTRIM TWICE DAILY (ANTIBIOTICS) WERE ordered on [DATE] FOR A [DIAGNOSES REDACTED]." REVIEW OF A NURSING CARE PLAN FOR IMPAIRED SKIN INTEGRITY FOR RESIDENT #404, CREATED ON 1/9/13 (DATE OF DISCOVERY OF THE PRESSURE ULCER) REVEALED THERE WERE NO INSTRUCTIONS (PRIOR TO 1/11/13) TO REMOVE THE RIGHT KNEE IMMOBILIZER "OFF FOR HYGIENE AND SKIN INSPECTION WHEN THE RESIDENT WAS IN BED SUPINE", AS REQUIRED BY THE physician's orders [REDACTED]. ON 1/11/13 THE FOLLOWING INTERVENTION WAS ADDED, "MONITOR THE SKIN UNDER THE KNEE BRACE DAILY FOR SIGNS AND SYMPTOMS OF FRICTION/BREAKDOWN." ON 2/28/13 AT 9:45 A.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING RESIDENT #404'S FACILITY ACQUIRED RIGHT LEG PRESSURE ULCER. WHEN QUERIED, THE DON STATED THAT RESIDENT #404'S KNEE IMMOBILIZER SHOULD HAVE BEEN REMOVED DAILY FOR HYGIENE AND SKIN ASSESSMENT. WHEN QUERIED, THE DON STATED, "THERE MUST BE SOME MORE DOCUMENTATION SOMEWHERE. I KNOW WE HAD TO HAVE DONE THIS." THE DON WAS UNABLE TO PROVIDE DOCUMENTATION OF THIS BEFORE SURVEY EXIT. THE DON STATED, "(RESIDENT #404) HAD AN APPOINTMENT WITH DR (ORTHOPEDIC SURGEON)'S OFFICE ON 1/8/13. THEY DIDN'T DOCUMENT THAT SHE HAD A PRESSURE ULCER, SO WE KNOW THAT SHE DEVELOPED IT IN ONE DAY, BETWEEN THE DOCTOR APPOINTMENT ON 1/8/13 AND FINDING IT ON 1/9/13. IT WOULDN'T HAVE MADE ANY DIFFERENCE EVEN IF WE HAD BEEN REMOVING THE IMMOBILIZER AND DOING SKIN CHECKS DAILY (AS ORDERED)." ON 2/28/13 AT 1:30 P.M., THE ORTHOPEDIC SURGEON'S OFFICE WAS CONTACTED BY TELEPHONE, AND THE SURGICAL COORDINATOR "M" WAS INTERVIEWED ABOUT RESIDENT #404'S OFFICE VISIT ON 1/8/13. SURGICAL COORDINATOR "M" STATED THAT THE PHYSICIAN ONLY ASSESSED THE SKIN AROUND RESIDENT #404'S SURGICAL SITE (RIGHT THIGH), AND NOT THE LOWER LEG (LOCATION OF THE PRESSURE ULCER). THE SURGICAL COORDINATOR REPORTED THAT RESIDENT #404 HAD RECEIVED AN X-RAY OF THE RIGHT THIGH DURING THE 1/8/13 OFFICE VISIT, BUT THE RESIDENT'S LOWER POSTERIOR LEG WAS NOT EXPOSED OR OBSERVED DURING THE X-RAY PROCESS, SO STAFF WOULD HAVE NO WAY OF KNOWING WHETHER OR NOT THE RESIDENT HAD DEVELOPED A PRESSURE ULCER. ON 2/28/13 AT 1:50 P.M., THE THERAPY MANAGER "O" WAS INTERVIEWED ABOUT RESIDENT #404'S RIGHT KNEE IMMOBILIZER AND STATED, "I MADE SURE SHE (RESIDENT #404) HAD AN ORDER TO REMOVE THE KNEE IMMOBILIZER ONCE A DAY FOR SKIN INSPECTION AND HYGIENE. THIS IS IMPORTANT FOR ANYONE WITH ANY TYPE OF BRACE OR SPLINT. THE SKIN MUST BE KEPT CLEAN AND CHECKED FOR SKIN BREAKDOWN. MANY TIMES RESIDENTS GET SKIN CONDITIONS SUCH AS INFECTIONS OR PRESSURE ULCERS FROM THESE DEVICES." ON 3/4/13 AT 9:00 A.M., RESIDENT #404'S ORTHOPEDIC SURGEON WAS INTERVIEWED BY TELEPHONE AND REPORTED THAT HE WOULD NOT HAVE KNOWN IF RESIDENT #404 HAD A RIGHT LOWER LEG PRESSURE ULCER ON 1/8/13 (DURING THE OFFICE VISIT), BECAUSE NEITHER HE NOR HIS STAFF INSPECTED RESIDENT #404'S LOWER LEG. REVIEW OF A FACILITY POLICY ENTITLED, " SPLINT AND BRACES" DATED 2/8/13 REVEALED THE FOLLOWING NOTATIONS: "APPLY DEVICE ACCORDING TO PHYSICIAN ORDER" "OBSERVE AND MONITOR FOR CORRECT PLACEMENT OF DEVICE AND RESIDENT'S COMFORT." "OBSERVE SKIN WHILE APPLYING AND REMOVING DEVICE. NOTE ANY REDNESS OR OTHER SKIN ABNORMALITIES. DOCUMENT AS APPROPRIATE." ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PRESSURE RELIEVING INTERVENTIONS TO MAINTAIN SKIN INTEGRITY FOR TWO (#501 AND #502) OF FOUR SAMPLED RESIDENTS REVIEWED FOR PRESSURE ULCERS FROM A TOTAL OF 24, RESULTING IN THE DEVELOPMENT OF PRESSURE ULCERS. FINDINGS INCLUDE: ON 3/22/12 AT 12 NOON, RESIDENT #501'S CLINICAL RECORD WAS REVIEWED WITH UNIT NURSE MANAGER "A". THE RESIDENT WAS ORIGINALLY admitted on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT AND WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY (ADLS), INCLUDING TRANSFERS AND BED MOBILITY. RESIDENT #501'S "ALTERATION IN SKIN INTEGRITY" CARE PLAN DATED 6/15/11, INCLUDED THE FOLLOWING INTERVENTIONS TO PREVENT DEVELOPMENT OF PRESSURE SORES: "ASSIST IN TURNING AND REPOSITIONING." "MONITOR SKIN FOR REDNESS...." "ELEVATE HEELS OFF OF BED WITH PILLOWS AS NEEDED." AN "ADMISSION NURSING ASSESSMENT" DATED 6/13/11 FOR RESIDENT #501 HAD AN ILLUSTRATION NOTING THAT THE RESIDENT WAS readmitted on THAT DATE WITH AN "ABRASION" ON THE RIGHT LATERAL FOOT. THERE WERE NO OTHER SKIN ISSUES NOTED OTHER THAN BRUISING TO THE RIGHT ARM. HIS BRADEN (PRESSURE ULCER RISK) SCALE SCORE WAS 12 (10-12=HIGH RISK). RESIDENT #501'S "WEEKLY SKIN ASSESSMENT" DATED 6/18/11 HAD AN ILLUSTRATION NOTING THAT THE RESIDENT'S SACRO/BUTTOCK AREA WAS "RED." THERE WERE NO OTHER ABNORMAL SKIN AREAS NOTED. ON 7/2/11, THE ASSESSMENT NOTED, "RED" RIGHT HEEL AND THE RIGHT OUTER FOOT WAS "RED, PURPLE, CLOSED." ON 7/9/11, THE RIGHT HEEL WAS NOTED AS, "SUPERFICIAL, OPEN, (MEASURING) 4.5 X 5.2 CENTIMETERS (CM) ALONG WITH THE "RIGHT OUTER FOOT, 8.0 X 3.0, ALONG OUTER FOOT." ON 8/20/11, RESIDENT #501'S WEEKLY SKIN ASSESSMENT" NOTED: "RIGHT HEEL WOUND MEASURED "3.3 CM X 3 CM" AND THE RESIDENT HAD DEVELOPED A "STAGE II" (AN OPENING OF THE OUTER LAYER OF SKIN) PRESSURE SORE ON THE RIGHT HIP MEASURING "2.3 CM X 3.1 CM." ON 10/8/11, THE RIGHT HIP WAS DESCRIBED AS: "UNSTAGEABLE WOUND DUE TO SLOUGH (LIQUEFIED DEAD TISSUE) AND THE RIGHT HEEL WOUND WAS AT "STAGE III" (A WOUND GOING THROUGH ALL LAYERS OF THE SKIN). THERE WERE NO DOCUMENTED WOUND MEASUREMENTS. ON 10/15/11, THE RIGHT HIP WAS DESCRIBED AS: "STAGE III, 7 CM X 6 CM, SLOUGH" AND THE RIGHT HEEL: "STAGE II, 8 CM X 6 CM, SLOUGH" (HEEL AND LATERAL FOOT COMBINED). AFTER 10/15/11, RESIDENT #501'S WOUNDS WERE AS FOLLOWS: 11/15/11- RIGHT HIP: 9 CM X 7 CM; RIGHT HEEL/LATERAL FOOT: 10 CM X 6 CM. 12/13/11-RIGHT HIP: 5 CM X 4 CM; RIGHT HEEL/FOOT: 7 CM X 4 CM. 1/17/12-RIGHT HIP: 5 CM X 3 CM; RIGHT HEEL/FOOT: 7.5 CM X 3.75 CM. 1/24/12-RIGHT HIP: 2 CM X 2 CM X 1 CM DEEP; RIGHT HEEL/FOOT: 9 CM X 4 CM. RESIDENT #501 WAS hospitalized from [DATE] THRU 2/20/12 PER HOSPITAL RECORDS. THE HOSPITAL PHYSICIAN DOCUMENTED IN THE RESIDENT'S HISTORY AND PHYSICAL DATED 2/8/12 THAT THE RESIDENT HAD A TEMPERATURE OF 102.1 IN THE emergency room , WAS [MEDICAL CONDITION] (BLOOD PRESSURE 88/60), AND WAS PLACED IN THE INTENSIVE CARE UNIT (ICU). HE ALSO HAD: "DECUBITUS ULCER UNDER RIGHT HEEL WITH A NECROTIC (DEAD TISSUE) CENTER AND [DIAGNOSES REDACTED] (REDNESS) ALSO PRESENT. ALSO ONE DECUBITUS ULCER OF THE RIGHT BUTTOCK (HIP) WITH POSITIVE [DIAGNOSES REDACTED] AND LOOKS DEEP WITH A CLEAN BASE." PER A LAB REPORT, WOUND CULTURES WERE COLLECTED ON 2/8/12. ON 2/12/12 THE CULTURE AND THE HOSPITAL PHYSICIAN'S PROGRESS NOTE DATED 2/16/12 DOCUMENTED: "RIGHT HEEL AND TROCHANTERIC (HIP) DECUBITUS WOUND, CULTURES POSITIVE FOR [MEDICAL CONDITION] RESISTANT [DIAGNOSES REDACTED] AUREUS (MRSA)." PER RESIDENT #501'S TREATMENT RECORDS FOR 3/2012, THE RESIDENT CONTINUED TO HAVE PRESSURE SORES TO THE RIGHT HIP AND RIGHT HEEL. WHEN QUERIED ABOUT THE INITIAL DEVELOPMENT OF THE PRESSURE SORES, MANAGER 'A' SAID, "WE WERE TURNING HIM BUT HE WOULD NOT REMAIN IN POSITION EVEN WITH PILLOWS (USED FOR POSITIONING)" WHICH SHE SAID, WAS DOCUMENTED IN THE CLINICAL RECORD. HOWEVER, MANAGER 'A' WAS UNABLE TO LOCATE THIS DOCUMENTATION WHEN SHE LOOKED THROUGH THE RESIDENT'S RECORD. THERE WAS NO DOCUMENTED EVIDENCE OF A TURNING SCHEDULE FOR THE RESIDENT. ON 3/23/12 AT 9:20 AM, RESIDENT #501'S SKIN WAS OBSERVED WITH WOUND CARE NURSE 'D' AND NURSE 'E.' THE RESIDENT WAS NON-VERBAL, WAS RECEIVING FEEDINGS BY [MEDICAL CONDITION] TUBE, AND WAS UNABLE TO TURN AND REPOSITION HIMSELF WITHOUT ASSISTANCE BY BOTH NURSES. THE RESIDENT HAD A PRESSURE SORE ON THE RIGHT HIP THAT MEASURED 1.7 X 1.0 X 0.9 CM AT STAGE III WITH A SCANT AMOUNT OF YELLOW DRAINAGE THAT WAS POSITIVE [MEDICAL CONDITION] PER THE "WEEKLY PRESSURE ULCER HEALING ASSESSMENT" DATED 3/15/12. A PRESSURE SORE WAS OBSERVED TO THE RIGHT HEEL THAT MEASURED 3.1 X 3.0 CM WITH A SMALL AMOUNT OF YELLOW DRAINAGE THAT WAS POSITIVE [MEDICAL CONDITION] PER THE ASSESSMENT ON 3/15/12. THE WOUND HAD A NECROTIC AREA AND WAS SLIGHTLY MALODOROUS. THE WOUND HEALING ASSESSMENTS NOTED THAT [MEDICAL CONDITION] WAS "COLONIZED" (BACTERIA PRESENT WITHOUT SIGNS OF INFECTION), HOWEVER, THE CULTURE REPORTS DID NOT INDICATE COLONIZATION. WHEN QUERIED ABOUT INTERVENTIONS TO PREVENT DEVELOPMENT OF THE PRESSURE SORE ON THE RIGHT HEEL FOR RESIDENT #501, NURSE 'D' STATED THAT HEEL PROTECTORS WERE PROVIDED. A REVIEW OF THE RESIDENT'S TREATMENT RECORDS FOR 7/2011, NOTED THAT treatment for [REDACTED]. NURSE 'D' LOOKED AT THE RESIDENT'S SKIN ALTERATION CARE PLANS DATED 6/15/11, 1/24/12, AND 2/20/12, BUT HEEL PROTECTORS WERE NOT LISTED. SHE WAS UNABLE TO STATE WHY THE HEEL PROTECTORS WERE NOT INITIATED BEFORE THE PRESSURE SORE DEVELOPED FOR THIS RESIDENT WHO WAS UNABLE TO REPOSITION HIMSELF. IN ADDITION, A "RESIDENT INCIDENT/UNUSUAL OCCURRENCE" REPORT DATED 8/28/11 FOR RESIDENT #501, WAS REVIEWED WITH MANAGER "A". THE REPORT NOTED: RIGHT THIGH HAS KNUCKLE PRINTS OF RIGHT HAND. RIGHT ARM AND HAND SWELLING. RIGHT ARM, HAND, FINGERS HAVE FLUID FILLED BLISTERS, MULTI RED AND PURPLE BRUISING TO RIGHT ARM." THE CORRECTIVE ACTION TO PREVENT REOCCURRENCE: "ONE TO ONE (TRAINING) WITH (NURSE AIDES) ON TWO HOUR REPOSITIONING PROTOCOL AND CORRECT POSITIONING OF WEAKER SIDE....ALWAYS TURN RESIDENTS ON THEIR SCHEDULED REPOSITIONING TIMES. ALWAYS MAKE SURE RESIDENT'S LIMBS ARE NOT TUCKED UNDER THEIR BODY." MANAGER "A" WAS UNABLE TO EXPLAIN WHY THE RESIDENT WAS NOT TURNED AT LEAST EVERY TWO HOURS TO OFF-LOAD PRESSURE. ON 3/21/12 AT 11 AM, RESIDENT #502'S SKIN WAS OBSERVED WITH NURSE 'E' AND NURSE 'K.' THE RESIDENT WAS NON-VERBAL AND HAD TIGHTLY CONTRACTED HANDS (IN FISTS). THE RIGHT HAND HAD GAUZE DRESSINGS PLACED BETWEEN THE FINGERS AND A CARROT (SOFT HAND ROLL) WEDGED INTO THE PALM. THE FINGERS OF THE LEFT HAND HAD FOAM PADDING IN BETWEEN. WHEN THE PADDING WAS REMOVED FROM THE LEFT HAND, THE RESIDENT'S THUMB PRESSED ON TO THE INDEX FINGER NEXT TO IT. A DRYING PRESSURE SORE WAS OBSERVED ON THE THUMB AND ON THE INDEX FINGER DIRECTLY WHERE THE THUMB WAS RESTING. RESIDENT #502'S FINGERNAILS WERE LONG AND PRESSING INTO THE PALM OF THE LEFT HAND INCREASING THE RISK OF FURTHER PRESSURE SORES. WHEN QUERIED ABOUT THE LONG NAILS, NURSE 'K' SAID, "I WAS AFRAID TO CUT THEM BECAUSE THE SKIN UNDERNEATH EXTENDS HIGH UP UNDER THE NAIL. HOSPICE (STAFF) WAS SUPPOSED TO DO IT. THE PODIATRIST WOULD NOT DO IT." NURSE 'E' THEN SAID, "MAYBE WE CAN FILE THEM DOWN." THEY WERE UNABLE TO EXPLAIN WHY THE RESIDENT DEVELOPED THE PRESSURE SORES. A REVIEW OF RESIDENT #502'S CLINICAL RECORD REVEALED: THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS dated [DATE] AND 12/20/11 NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT AND WAS TOTALLY DEPENDENT FOR ALL ADLS, INCLUDING MOBILITY. A NURSES NOTE DATED 1/10/12 NOTED: "PRESSURE ULCER DISCOVERED BY MASSAGE THERAPIST WITH TWO CM DIAMETER BLOOD FILLED HEMATOMA ON LEFT FIRST FINGER. RESIDENT HOLDS THUMB AGAINST FIRST FINGER CREATING PRESSURE." THE RESIDENT'S TREATMENT RECORD FOR 1/10/12 NOTED THAT THE INDEX FINGER PRESSURE SORE WAS AT STAGE III (NO MEASUREMENTS) AND WOUND CARE WAS ALREADY IN PROGRESS FOR "OPEN AREA ON LEFT THUMB PAD" SINCE 1/1/12. THE RESIDENT'S "SKIN INTEGRITY" CARE PLAN DATED 9/26/11 NOTED THAT THE resident had a history of [REDACTED]. THERE WAS NO MENTION OF INTERVENTIONS TO PREVENT PRESSURE SORES FOR THE LEFT HAND. THE CARE PLAN NOTED, ON 12/19/11, AN INTERVENTION WAS ADDED: "USE OF ROLLED WASH CLOTH IN RIGHT HAND RELATED TO UNABLE TO PLACE HAND SPLINT/CONE RELATED TO CONTRACTURE. ON 1/16/12: "LEFT INNER THUMB STAGE II (PRESSURE SORE)" WAS DISCOVERED AND WOUND CARE WAS INITIATED TO THE THUMB. RESIDENT #502'S "WEEKLY SKIN ASSESSMENT" DATED 1/31/12 NOTED: THE RESIDENT'S BRADEN SCORE WAS 9 (VERY HIGH RISK) AND THAT THE THUMB ULCER WAS RED WITH "PURULENT" DRAINAGE. THE SKIN INTEGRITY CARE PLAN NOTED: -ON 2/6/12: "LEFT INNER THUMB STAGE III." AN UPDATE WAS ADDED: "CARROT PROVIDED FOR RIGHT HAND, NURSE TO INSERT IN RIGHT HAND STARTING FROM SMALL FINGER AND INSERTING AS FAR AS POSSIBLE INTO PALM." ON 1/31/12: "USE OF HAND CONE AS TOLERATED." -ON 2/20/12: "LEFT INNER THUMB STAGE III TO IV (A WOUND THROUGH ALL LAYERS OF SKIN DOWN TO BONE UNDERNEATH)." -ON 3/18/12: "UNABLE TO MEASURE (LEFT INNER THUMB WOUND) RELATED TO CONTRACTURES, STAGE IV." ON 8/31/11, THE OCCUPATIONAL THERAPIST (OT) NOTED: "BILATERAL HAND CONTRACTURES. USING BILATERAL HAND ROLLS." ON 12/20/11, THE OT WROTE: "ASSESSMENT FOR CONTRACTURE IN BILATERAL HANDS....HAS ORDERS FOR HAND ROLLS OF RIGHT HAND." ON 1/12/12, TWO DAYS AFTER THE PRESSURE SORE WAS DISCOVERED ON THE LEFT INDEX FINGER: "CARROT SPLINT FOR HAND CONTRACTURE FOR RIGHT HAND. PATIENT TOLERATED WELL. INSERTED SMALL STICK AND PULLED ORTHOTIC THROUGH...." THERE WAS NO MENTION OF INTERVENTIONS FOR THE LEFT HAND. ON 3/23/12 AT 10 AM, WHEN QUERIED ABOUT INTERVENTIONS TO PREVENT PRESSURE SORES FOR RESIDENT #502, WOUND CARE NURSE 'D' WAS UNABLE TO EXPLAIN WHY THERE WERE NO DOCUMENTED INTERVENTIONS FOR THE CONTRACTED LEFT HAND BEFORE THE PRESSURE SORES DEVELOPED. PER THE FACILITY'S POLICIES ON "PRESSURE ULCER TREATMENT" REVISED 10/2010 AND "DECUBITUS ULCER PREVENTION" REVISED 1/24/12: -THE FACILITY SHOULD "ENSURE THAT RESIDENTS THAT ARE AT RISK FOR DEVELOPING DECUBITUS ULCERS ARE TURNED AND REPOSITIONED." -IMMOBILE RESIDENTS SHOULD BE ON A TURNING SCHEDULE. -"CHARGE NURSE TO MONITOR RESIDENT'S POSITION." -"DETERMINE CAUSE OF PRESSURE AND RELIEVE; REDISTRIBUTE PRESSURE; IMPLEMENT PRESSURE-RELIEVING DEVICES IN ACCORDANCE WITH RESIDENT'S ASSESSED NEEDS." ( )

THIS CITATION CONTAINS MULTIPLE DEFICIENT PRACTICES. DEFICIENT PRACTICE STATEMENT #1 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION AND INTERVENTIONS TO PREVENT ACCIDENTS FOR THREE SAMPLED (#514, #518, AND #522) OF 13 RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 24, RESULTING IN FALLS AND ACCIDENTS WITH FRACTURES AND A DISLOCATION OF A JOINT PROSTHESIS (ARTIFICIAL JOINT). FINDINGS INCLUDE: ON 3/21/12, AT 9:50 A.M., RESIDENT #514 WAS OBSERVED IN A WHEELCHAIR IN HER ROOM. THERE WERE NO PERSONAL SAFETY DEVICES NOTED. RESIDENT #514 REPORTED THAT SHE HAD FALLEN "QUITE A FEW TIMES" DURING THE PAST YEAR. RESIDENT #514 STATED THAT SHE HAD COME TO THE FACILITY, "TO RECOUPERATE AND GET BACK ON (HER) FEET AFTER (RIGHT HIP REPLACEMENT) SURGERY." WHEN ASKED IF SHE HAD EXPERIENCED ANY FALLS IN THE FACILITY, THE RESIDENT STATED, "I HAD SOME PROBLEMS AFTER I WAS admitted . I HAD TO GO BACK TO THE HOSPITAL A COUPLE OF TIMES." ON 3/22/12 AT 12:10 P.M., RESIDENT #514'S CURRENT AND CLOSED (PREVIOUS ADMISSION) CLINICAL RECORDS AND FACILITY "UNUSUAL EVENT REPORTS (I&A) WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON) AND THE MEDICAL RECORDS COORDINATOR, "M". THE RECORD REVIEW REVEALED THE FOLLOWING: AN I&A FOR RESIDENT #514, DATED 12/11/11 REVEALED THE FOLLOWING STATEMENT, "ALLEGED FALL, UNATTENDED". THE I& A DOCUMENTED, "WAS ON RIGHT SIDE WITH WHEELCHAIR (W/C) OVER HER IN ROOM. COMPLAINED (C/O) PAIN TO RIGHT HIP, STATED SHE HIT HER HEAD." THE "RESIDENT STATMENT" WAS DOCUMENTED AS, "I WAS TRYING TO GET THAT THING OUT OF MY SHOE." THE "ROOT CAUSE DETERMINATION", WAS DOCUMENTED AS, "RESIDENT IS IMPULSIVE- REACHED DOWN TO SHOES TO TRY TO REMOVE SOMETHING WITHOUT ASKING FOR ASSISTANCE." A RADIOLOGY (X-RAY) REPORT FOR RESIDENT #514 TAKEN ON 12/11/11 (THE DATE OF THE FALL) DOCUMENTED THE FOLLOWING NEW FINDINGS, "ACUTE POSTERIOR DISLOCATION OF FEMORAL HEAD PROSTHESIS (ARTIFICIAL HIP) WITH INWARD ROTATION OF FEMUR (THIGH BONE). OSSEOUS (BONY) FRAGMENT SUGGESTS LATERAL (SIDE) ACETABULAR (HIP SOCKET) FRACTURE." AN OUTPATIENT MEDICAL CENTER FACE SHEET DOCUMENTED RESIDENT #514 WAS admitted on [DATE] FOR "DISLOCATED RIGHT HIP PROSTHESIS", AND UNDERWENT, "CLOSED REDUCTION OF RIGHT HIP PROSTHETIC DISLOCATION UNDER GENERAL ANESTHESIA WITH MANIPULATION." A CLOSED RECORD FACE SHEET DOCUMENTED THAT RESIDENT #514 WAS admitted to the facility on [DATE]. AN UNDATED "MEDICAL PROBLEM LIST" FOUND IN THE CLOSED RECORD REVEALED [DIAGNOSES REDACTED]. AN ADMISSION MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE], DOCUMENTED THAT RESIDENT #514 HAD MODERATELY IMPAIRED COGNITION, NEEDED EXTENSVE STAFF ASSISTANCE FOR AMBULATION, TRANSFERS TO THE WHEELCHAIR, DRESSING, TOILETING AND HYGIENE. THE MDS ALSO DOCUMENTED THAT RESIDENT #514 HAD UNSTEADY BALANCE AND REQUIRED STAFF ASSISTANCE FOR STABILITY DURING AMBULATION AND MOVEMENT BETWEEN SURFACES. THE MDS ALSO DOCUMENTED THAT RESIDENT #514 had a history of [REDACTED]. A NURSING ADMISSION assessment dated [DATE] DOCUMENTED THAT RESIDENT #514 WAS ALERT WITH CONFUSION AND WAS AT RISK FOR FALLS WITH A "FALL PRONE EVALUATION" SCORE OF 20 ("IF POINTS TOTAL 10 OR MORE, RESIDENT SHOULD BE IDENTIFIED AT RISK FOR FALLS".) A "RISK FOR FALLS" assessment dated [DATE] DOCUMENTED THAT RESIDENT #514 WAS AT RISK FOR FALLS WITH A SCORE OF 19 (>10 INDICATED RISK), DUE TO : "LOSS OF BALANCE WHILE STANDING, DECREASE IN MUSCULAR COORDINATION, INTERMITTENTLY CONFUSED", AND A HISTORY OF, "MORE THAN 2 FALLS IN THE PAST 6 MONTHS." A PHYSICAL THERAPY (PT) assessment dated ("START OF CARE DATE DATE") 11-22-11, REVEALED THAT RESIDENT #514 REQUIRED "HIP PRECAUTIONS", AND WAS A "SAFETY, INCREASED FALL RISK", WITH IMPAIRED COGNITION. REVIEW OF A CARE PLAN FOR RESIDENT #514 TITLED, "RESIDENT IS AT RISK FOR FALLS DUE TO IMPAIRED BALANCE", DATED 11/8/11 AND REVISED 11/21/11 REVEALED THE INTERVENTION, "ASSIST WITH TRANSFERS, AMBULATION AS NEEDED", BUT CONTAINED NO SAFETY INTERVENTIONS TO ALERT STAFF OF UNASSISTED TRANSFERS OR MOVEMENT OUT OF THE WHEELCHAIR, AND NO INTERVENTIONS TO ASSURE SAFETY DUE TO POOR SIT POSTURE AND IMPAIRED SEATED BALANCE. THERE WAS NO DOCUMENTATION THAT RESIDENT #514 WAS ON THE FACILITY "FALL RISK PROGRAM." AN I&A FOR RESIDENT #514, DATED 12/10/11 REVEALED THE FOLLOWING "INVESTIGATIVE SUMMARY", "RESIDENT OFTEN TRANSFERS SELF. CARE PLAN (CP) NON COMPLIANCE OF CALL LIGHT USE. " ON 3/22/12 AT 12:10 P.M. THE DON WAS QUERIED WHY NO SAFETY INTERVENTIONS TO ALERT STAFF OF ATTEMPTS TO SELF TRANSFER, AND IMPULSIVE BEHAVIOR WERE IMPLEMENTED FOR A CONFUSED RESIDENT WITH A FALLS RISK SCORE OF 19 AND DOCUMENTATION OF PREVIOUS SELF TRANSFER ATTEMPTS, THE DON STATED, "WE DON'T PUT PERSONAL TAB ALARMS (SAFETY DEVICE ATTACHED TO RESIDENT CLOTHING) ON RESIDENTS WITH GOOD MANUAL DEXTERITY." WHEN QUERIED, THE DON COULD NOT EXPLAIN WHY OTHER SAFETY INTERVENTIONS WERE NOT IMPLEMENTED. THE FACILITY POLICY TITLED "FALL PREVENTION/INCIDENT", REVISED 11/29/11 WAS REVIEWED AND REVEALED THE FOLLOWING STATEMENTS: 1. "ALL NECESSARY FALL PRECAUTIONS WEIL BE IMPLEMENTED." 2. "UPON ASSESSMENT, IF A FALL RISK SCORE IS 10 OR GREATER, THE FOLLOWING WILL BE IMPLEMENTED: A STAR WILL BE PLACED ON THE RESIDENT CARE CARD (ADL PLAN OF CARE), SSTAFF WILL BE INFORMED THAT THE RESIDENT IS AT RISK FOR FALLS." 3. "AN INCIDENT/ACCIDENT MONTHLY SUMMARY REPORT WILL BE COMPLETED BY THE NURSE MANAGER. APPROPRIATE INTERVENTIONS WILL BE IMPLEMENTED ACCORDING TO THE SUMMARY'S FINDINGS OF ANY TRENDS, PATTERNS OR SAFETY CONCERNS." ( ) RESIDENT #508 ON 3/20/12 AT 6:55 P.M., DURING THE INITIAL ROUNDS ACCOMPANIED BY STAFF NURSE (NURSE "O") IT WAS REPORTED THAT RESIDENT #508 had a history of [REDACTED]. RESIDENT #508 WAS OBSERVED IN THE DINING ROOM DURING DINNER IN A CHAIR WITH A TAB ALARM ATTACHED. THE RESIDENT WAS NOT ABLE TO ANSWER QUESTIONS APPROPRIATELY. ON 3/21/12 AT 3 P.M., RESIDENT #508 WAS OBSERVED SITTING IN HER WHEELCHAIR WITH A TAB ALARM ATTACHED WATCHING TV. ON 3/22/12 AT 9:20 A.M., RESIDENT #508 WAS OBSERVED SITTING IN HER WHEELCHAIR IN FRONT OF A WINDOW NEAR THE NURSES' STATION WITH A TAB ALARM ATTACHED. ON 3/23/12 AT 12:10 P.M., RESIDENT #508 WAS OBSERVED IN THE DINING ROOM EATING LUNCH WHILE SITTING IN HER WHEELCHAIR WITH THE TAB ALARM ATTACHED. REVIEW OF AN INCIDENT AND ACCIDENT (I/A) REPORT FOR RESIDENT #508 DATED 1/1/12 AT 8 P.M. DOCUMENTED: "BRUISE PURPLE IN COLOR 4 CENTIMETERS (CM) X 3.5 CM ON INNER LEFT KNEE. NOT PAINFUL TO TOUCH. BRUISE TOP OF RIGHT FOOT BETWEEN TOES. A NURSE'S NOTE DATED 1/1/12 AT 8 P.M. REVEALED THE FOLLOWING DOCUMENTATION: "BRUISE NOTED TO LEFT INNER KNEE. PURPLE IN COLOR. MEASURES 4.0 CM X 3.5 CM. NOT PAINFUL TO TOUCH. RESIDENT HAS HISTORY OF FALLS AND UNSTEADY GAIT. NO COMBATIVE BEHAVIOR NOTED AT THIS TIME. RESIDENT AMBULATES INDEPENDENTLY. NOT ABLE TO GIVE ACCURATE STATEMENT RELATED TO DEMENTIA, POOR THOUGHT PROCESS. LOGGED FOR PHYSICIAN SERVICE. FAMILY TO BE NOTIFIED OF INCIDENT IN A.M." A NURSE'S NOTE ON 1/2/12 AT 2 A.M. REVEALED DOCUMENTATION THAT READ: "BRUISING ON TOP OF RIGHT FOOT AND BETWEEN TOES NOTED. SLIGHT INFLAMMATION NOTED. STAT (IMMEDIATE) X-RAY ORDERED PER physician's orders [REDACTED]. A RADIOLOGY REPORT (RIGHT FOOT X-RAY), DATED 1/2/12 AT 10:37 A.M., FOR RESIDENT #508 REVEALED THE FOLLOWING DOCUMENTATION: "THERE IS AN ACUTE FRACTURE OF DISTAL DIAPHYSIS OF FIFTH METATARSAL (TOE) BONE WITH MILD DISPLACEMENT AND ANGULATION. CONCLUSION: 1. ACUTE FRACTURE DISTAL DIAPHYSIS FIFTH METATARSAL, WITH MILD DISPLACEMENT AND ANGULATION. 2. MILD OSTEO POROSIS DEMONSTRATED. 3. MILD OSTEOARTHRITIS." ON 3/22/12 AT 9:30 A.M., AN INVESTIGATION OF THE INCIDENT THAT INVOLVED THE DISCOVERY OF THE BROKEN/FRACTURED RIGHT TOE WAS REQUESTED FROM THE ADMINISTRATOR. THE ADMINISTRATOR STATED, "WE DON'T HAVE ONE. THE INCIDENT WAS WITNESSED." ON 3/23/12 AT 10:30 A.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING AN INVESTIGATION FOR THE INJURY OF UNKNOWN ORIGIN. SHE HAD NO EXPLANATION FOR RESIDENT #508'S DISCOVERED RIGHT TOE FRACTURE. THE DON REPORTED THAT SHE WOULD HAVE TO OBTAIN THE INVESTIGATION LATER. SHE ADDED THAT SHE WAS ON VACATION DURING THE TIME OF THE INCIDENT. ON 3/23/12 AT 1 P.M., THE DON REPORTED NOT BEING ABLE TO FIND THE INVESTIGATION. THE DON STATED, "WE ARE STILL LOOKING FOR IT." REVIEW OF RESIDENT #508'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #508'S MOST RECENT QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], INDICATED A SEVERELY IMPAIRED COGNITION, REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S), AND INDICATED A HISTORY OF WANDERING BEHAVIOR THAT SIGNIFICANTLY INTRUDED THE PRIVACY OR ACTIVITIES OF OTHERS. REVIEW OF THE FACILITY'S POLICY ENTITLED, "PREVENTING RESIDENT ABUSE," REVISED 11/2011, REVEALED DOCUMENTATION THAT READ, 'IT IS THE POLICY OF THE FACILITY THAT WE ENSURE ALL ALLEGED VIOLATIONS INVOLVING MISTREATMENT, NEGLECT, OR ABUSE, INCLUDING INJURIES OF UNKNOWN SOURCE WILL BE REPORTED IMMEDIATELY TO THE DIRECTOR OF NURSING/ADMINISTRATOR AFTER DISCOVERY OF THE INCIDENT. THE COMMUNITY INTERNAL INVESTIGATION SHALL INCLUDE; NAMING OF ANY POSSIBLE WITNESS OR INDIVIDUALS, UPDATES TO THE ADMINISTRATOR REGARDING PROGRESS AND FINDINGS OF THE INVESTIGATION, UTILIZATION OF THE INVESTIGATION CHECKLIST FORM TO DOCUMENT THE INVESTIGATION PROCEEDINGS, AND NOTIFICATION TO RELEVANT REPORTING AGENCIES. THE FACILITY DID NOT PROVIDE THE INVESTIGATION OF UNKNOWN ORIGIN FOR RESIDENT #508 BY THE TIME OF THE SURVEY EXIT, NOR WERE THERE ANY POSSIBLE OR ACTUAL EXPLANATIONS PROVIDED FOR THE FRACTURE. ON 3/22/12 AT 10:55 A.M., RESIDENT #522'S CLOSED RECORD WAS REVIEWED. THE FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #522'S "AT RISK FOR FALLS" CARE PLAN, INITIATED 2/15/10 AND LAST REVISED 12/2011, REVEALED ADDITIONAL [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #522'S MOST RECENT QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], INDICATED A SEVERELY IMPAIRED COGNITION AND WAS TOTALLY DEPENDENT UPON THE STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADL'S), INCLUDING ALL MOBILITY. RESIDENT #522 WAS IMMOBILE IN BOTH THE BED AND CHAIR PER THE MDS. REVIEW OF AN INCIDENT (I/A) REPORT FOR RESIDENT #522, DATED 2/20/12 AT 6:15 P.M., REVEALED THE FOLLOWING DOCUMENTATION: "IN DINING ROOM, RESIDENT LYING ON FLOOR BESIDE THE TABLE, CARPET FLOOR, CHAIR BEHIND RESIDENT." THE I/A REPORT INDICATED THAT THERE WERE NO INJURIES VISIBLE AT THE TIME OF THE INCIDENT. REVIEW OF THE NURSE'S NOTE FOR THE TIME OF THE INCIDENT (2/20/12 AT 7 P.M.) REVEALED DOCUMENTATION THAT READ: "RESIDENT FOUND ON FLOOR IN FRONT OF CHAIR IN DR (DINING ROOM). RESIDENT STATED, 'I SLIPPED OUT OF MY CHAIR. I DON'T KNOW HOW IT HAPPENED.' COMPLAINED OF LEG PAIN. PRN (AS NECESSARY) ROXANOL (NARCOTIC PAIN MEDICATION) GIVEN AT 6 P.M...." A NURSE'S NOTE ON THE FOLLOWING DAY (2/21/12 AT 7 A.M.) REVEALED THE FOLLOWING DOCUMENTATION: "RESIDENT NOTED MOANING AND SCHEDULED ROXANOL GIVEN AND LEFT ANKLE NOTED WITH SWELLING AND PAINFUL TO TOUCH. S/P (status [REDACTED]. OXYGEN INITIATED AT TWO LITERS PER MINUTE BY WAY OF A NASAL CANNULA, THEN SPO2 WENT UP TO 93%. X-RAY OF LEFT ANKLE ORDERED. ONCOMING NURSE ENDORSED TO MONITOR RESIDENT..." PER THE NURSE'S NOTE LATER ON THAT SAME DAY ON 2/21/12 AT 7 P.M. (12 HOURS LATER) REVEALED THE FOLLOWING DOCUMENTATION: "RESIDENT APPEARED PALE WITH COLD SWEAT DURING DINNER HOUR. SPO2 (OXYGEN LEVEL) NOTED AT 84%. OXYGEN APPLIED AT 2 LITERS/MINUTE VIA NASAL CANNULA. SPO2 INCREASED TO 97%. RESIDENT COMPLAINED OF PAIN. ROXANOL 0.25 ML (MILLILITERS) GIVEN. LEFT ANKLE X-RAY RESULTS SHOW OBLIQUE SLIGHTLY COMMINUTED FRACTURE OF DISTAL TIBIAL AND DISTAL FIBULA. EDEMA NOTED WITH BLUISH COLOR TO SKIN AROUND LEFT ANKLE..." REVIEW OF RESIDENT #522'S X-RAY REPORT, DATED 2/21/12 AT 6:32 P.M., CONFIRMED THE FRACTURES. THE X-RAY REPORT REVEALED THE FOLLOWING DOCUMENTATION: LEFT ANKLE, THREE VIEWS: THERE IS AN OBLIQUE SLIGHTLY COMMINUTED FRACTURE OF THE DISTAL TIBIA SEVERAL CENTIMETERS ABOVE THE ANKLE JOINT. THERE IS ALSO AN ASSOCIATED FRACTURE OF THE DISTAL FIBULA. THAT FRACTURE IS ALSO COMMINUTED. IMPRESSION: COMMINUTED FRACTURES OF THE DISTAL TIBIA AND FIBULA." ON 3/22/12 AT 11:25 A.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING RESIDENT #522'S FALL FROM HER WHEELCHAIR IN WHICH SHE SUSTAINED TWO FRACTURES IN HER LEFT LEG. THE DON STATED, "WE REALLY DON'T KNOW HOW IT HAPPENED. THERE WERE AT LEAST SEVEN STAFF MEMBERS AND SEVERAL RESIDENTS IN THE DINING ROOM AT THE TIME OF THE FALL. NO ONE SAW HER FALL. SHE WAS DISCOVERED ON THE FLOOR, BUT NOT ONE PERSON SAW HER ACTUALLY FALL. SHE (RESIDENT #522 WAS IN A BRODA CHAIR (SPECIALTY/THERAPEUTIC TAILORED CHAIR). SHE ALWAYS SAT SIDE WAYS IN THE CHAIR. A WEDGE CUSHION WAS USED FOR THAT REASON. IT HELPED POSITION HER. SHE HAD NO MOBILITY. WE COULD ONLY TURN HER SIDE TO SIDE. HER LEGS WERE ALWAYS BENT. SHE WAS NEVER ABLE TO LEAN FORWARD ON HER OWN. AFTER THE INCIDENT SHE WAS NOT TRANSFERRED OUT TO THE HOSPITAL DUE TO HER HOSPICE STATUS AND PER FAMILY'S REQUEST. AN AIR CAST WAS APPLIED (TO RESIDENT #522) AND SHE WAS TREATED WITH PAIN MEDICATION. SHE LATER PASSED AWAY ON 3/4/12." FURTHER INFORMATION/LITERATURE WAS REQUESTED REGARDING THE BRODA CHAIR. THE DON REPORTED THAT SHE WOULD OBTAIN INFORMATION ON THE CHAIR LATER. THE DON WAS QUERIED WHETHER THERE WERE OTHER RESIDENTS USING A BRODA CHAIR. THE DON REPORTED THAT THERE WERE NO OTHER RESIDENTS USING THE BRODA CHAIR. REVIEW OF THE physician's orders [REDACTED]. THE physician's orders [REDACTED]. KNEE SPREADER TO BE ON WHILE IN WHEELCHAIR TO KEEP IN ABDUCTION FOR POSITIONING." REVIEW OF RESIDENT #522'S "RISK FOR FALLS" CARE PLAN DID NOT INDICATE THE TYPE OF CHAIR TO USE. THE USE OF THE BRODA CHAIR WAS NOT A DOCUMENTED INTERVENTION ON THE CARE PLAN. REVIEW OF THE CERTIFIED NURSING ASSISTANT (CNA) CARE GUIDE INDICATED THE INTERVENTION FOR THE USE OF THE BRODA CHAIR FOR RESIDENT #522 ON 12/13/11. ON 3/23/12 AT 9:45 A.M., THE DON HAD A STAFF MEMBER PRESENT AN ACTUAL BRODA CHAIR. IN ADDITION, THE DON PROVIDED THE MANUFACTURER'S INFORMATION ON THE BRODA CHAIR. THE DON REPORTED THAT AT THE TIME OF THE INCIDENT FOR RESIDENT #522, THE BRODA CHAIR WAS RECLINED AT A 45 DEGREE ANGLE AND THE FOOT REST OF THE CHAIR WAS ELEVATED PRIOR TO LATER FINDING HER (RESIDENT #522) LYING ON THE FLOOR POSITIONED ON HER LEFT SIDE. THE DON STATED, "SHE (#522) COULD NOT SIT AT A 90 DEGREE ANGLE. SHE COULD ONLY BE POSITIONED FROM SIDE TO SIDE. SHE WAS IMMOBILE (UNABLE TO MOVE ON HER OWN). SHE HAD NO HISTORY OF BODY SPASMS, SEIZURES, OR ANYTHING THAT WOULD CAUSE HER TO SUDDENLY FALL FROM THE CHAIR. SHE HAD SEVERE OSTEOPOROSIS THAT WAS diagnosed PRIOR TO THE INCIDENT. HOSPICE RECOMMENDED THE CHAIR FOR HER (#522). SHE WAS A HOSPICE RESIDENT. NOBODY SAW HER FALL FROM THE CHAIR. THE STAFF AND RESIDENTS ONLY SAW HER ON THE FLOOR. AGAIN, SHE COULD NOT MOVE. I DON'T KNOW WHAT WE COULD HAVE DONE DIFFERENTLY TO PREVENT THE FALL. AT THE TIME OF THE FALL, THE CHAIR WAS STILL RECLINED AND THE LEG REST WAS STILL ELEVATED. WE NEVER HAD THIS HAPPEN BEFORE." THE DON WAS UNABLE TO PROVIDE AN EXPLANATION FOR RESIDENT #522'S FALL WITH FRACTURES. ( ) DEFICIENT PRACTICE #2: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE PROPER TECHNIQUE DURING TRANSFERS FOR FOUR (#501, 502, 506, AND 514) OF 13 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 24, RESULTING IN NUMEROUS SKIN TEARS. FINDINGS INCLUDE: ON 3/22/12 AT 12 NOON, RESIDENT #501'S CLINICAL RECORD AND "RESIDENT INCIDENT/UNUSUAL OCCURRENCE" FORMS(INCIDENT/ACCIDENT (I/A) REPORTS), WERE REVIEWED WITH UNIT NURSE MANAGER 'A.' THE RESIDENT WAS ORIGINALLY admitted on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT AND WAS TOTALLY DEPENDENT FOR ALL ACTIVITIES OF DAILY (ADLS), INCLUDING TRANSFERS AND BED MOBILITY. THE CARE AREA ASSESSMENT (CAA) FOR ADLS IN THE 5/19/11 MDS NOTED: "USE MECHANICAL LIFT FOR TRANSFERS." RESIDENT #501'S I/A REPORTS REVEALED THE FOLLOWING: 1. ON 6/29/11: "SKIN TEAR TO RIGHT ELBOW" WHEN TAKEN INTO THE SHOWER ROOM....ALL (NURSE AIDES) ARE TO USE THE LIFT WHEN TRANSFERRING RESIDENT TO PREVENT INJURY...." ON 6/29/11, THERE WAS A DOCUMENTED NURSE AIDES IN-SERVICE ON "PLACEMENT OF RESIDENT'S LIMBS DURING TRANSFERS" AND "PROPER HANDLING OF RESIDENTS WITH FRAGILE SKIN." MANAGER 'A' STATED THAT TWO NURSE AIDES TRANSFERRED THE RESIDENT WITHOUT USING A MECHANICAL LIFT. 2. ON 7/19/11: "STAFF STATES CAUGHT (RESIDENT #501'S) ARM WHILE USING LIFT....SPOKE WITH (NURSE AIDE) AT TIME OF OCCURRENCE, REVIEWED RESIDENT LIMB PLACEMENT WHILE USING LIFT WITH RESIDENT AND FRAGILE SKIN." 3. ON 8/17/11: "(NURSE AIDE) NOTIFIED NURSE THAT AFTER TRANSFERRING RESIDENT WITH LIFT TO CHAIR, A RIGHT ARM SKIN TEAR (OCCURRED). ALSO STATED TWO OPEN AREAS BY MOUTH....ALWAYS PUT ARM/FOOT PROTECTORS ON PRIOR TO TRANSFER TO CREATE AN EXTRA CUSHION FOR FRAGILE SKIN....ALWAYS HAVE TWO PEOPLE FOR LIFT USAGE." MANAGER 'A' STATED THAT TWO AIDES SHOULD HAVE BEEN PRESENT DURING THE LIFT TRANSFER. 4. ON 12/27/11: "TWO (NURSE AIDES) WERE AT BEDSIDE ASSISTING RESIDENT (#501) WITH DRESSING IN CLOTHING. WHEN TURNED TO ONE SIDE, LEFT ARM BUMPED ENABLERS (GRAB BARS) CAUSING LEFT ELBOW 4 CM (CENTIMETER) X 2 CM (SKIN TEAR)." THERE WAS NO EXPLANATION WHY ENABLERS WERE ON THE BED FOR A RESIDENT WHO WAS UNABLE TO USE THEM FOR BED MOBILITY. THE CORRECTIVE ACTION: "APPLY PADDING TO ENABLERS." 5. ON 2/25/12: "SKIN TEAR ON RIGHT ELBOW ABOUT TWO CM LONG" WAS OBSERVED BY THE RESIDENT'S SON WHEN HE PULLED UP THE RESIDENT'S SLEEVE FOLLOWING A TRANSFER TO THE WHEELCHAIR. "RESIDENT HAS VERY FRAGILE SKIN AND MANY OLD BRUISES; PRONE TO SKIN TEARS. LOOSE CLOTHING NEEDED." 6. ON 3/1/12: "14 CM SKIN TEAR TO RIGHT UPPER ARM." PER NURSES NOTES ON 3/1/12: "(NURSE AIDE) CALLED NURSE INTO RESIDENT (#501'S) ROOM....SKIN TEAR NOTED TO RIGHT UPPER ARM MEASURING 14 CM IN LENGTH. (NURSE AIDE) STATED SHE WAS DRESSING RESIDENT WHEN SHE FELT SOMETHING COLD ON HER HANDS, LOOKED, AND IT WAS BLOOD....RESTORATIVE (THERAPY) DEPARTMENT NOTIFIED IN AN ATTEMPT TO ORDER RESIDENT EXTRA LARGE GERI-SLEEVES TO PROTECT ENTIRE ARM. AN "ADL" CARE PLAN DATED 6/14/11 FOR RESIDENT #501 NOTED AN INTERVENTION: "SELECT CLOTHING THAT IS EASILY REMOVED." A "SKIN INTEGRITY" CARE PLAN DATED 6/15/11 NOTED: "AVOID FRICTION WHEN LIFTING, TRANSFERRING, OR POSITIONING." THE CARE PLANS DID NOT NOTE THAT THE RESIDENT'S SKIN WAS FRAGILE. THE CARE PLAN WAS UPDATED ON 6/29/11: "ELBOW PADS WHILE USING LIFT." AN UPDATE ON 8/17/11: "PADDED POTENTIAL PROBLEM AREAS; CHECK CLOTHING FOR PROPER FIT. GERI-SLEEVES OR ELBOW PROTECTORS." ON 1/3/12; "ENABLERS TO BE REMOVED FROM BED." WHEN QUERIED WHY SKIN TEARS REPEATEDLY OCCURRED FOR RESIDENT #501, MANAGER 'A' SAID, "THE (RESIDENT'S) SON DOESN'T WANT LONG SLEEVES OR GERI-SLEEVES ON HIM BECAUSE HE SAID THEY WERE TOO HOT AND THERE WAS DOCUMENTATION OF SAME IN THE CLINICAL RECORD. HOWEVER, WHEN THE MANAGER LOOKED THROUGH THE RESIDENT'S RECORD, THE DOCUMENTATION WAS NOT THERE. WHEN ASKED ABOUT THE SKIN TEARS OCCURRING DURING TRANSFERS, THE MANAGER SAID, "WE REALIZE THAT RESIDENTS HAVE FRAGILE SKIN AND HAVE DISCUSSED IT." ON 3/23/12 AT 9:20 AM, RESIDENT #501'S SKIN WAS OBSERVED WITH WOUND CARE NURSE 'D' AND NURSE 'E.' HE WAS WEARING A SHORT SLEEVED HOSPITAL GOWN. HIS RIGHT ARM HAD NUMEROUS DARK PURPLE BRUISES FROM THE UPPER ARM DOWN TO THE WRIST. A LARGE CLEAR DRESSING WAS OBSERVED ABOVE THE ELBOW AREA WITH A DEEP PURPLE BRUISE UNDERNEATH. ( ) THROUGHOUT EACH DAY OF THE SURVEY, RESIDENT #502 WAS OBSERVED RECLINED IN A GERI-CHAIR. THE RESIDENT WAS NON-VERBAL, HER HANDS WERE TIGHTLY CONTRACTED (IN FISTS), AND HER LIMBS WERE VERY RIGID. ON 3/22/12 AT 9:30 AM, RESIDENT #502'S CLINICAL RECORD AND I/A REPORTS WERE REVIEWED WITH NURSE MANAGER 'A.' THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS dated [DATE] AND 12/20/11 NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT AND WAS TOTALLY DEPENDENT FOR ALL ADLS, INCLUDING TRANSFERS AND MOBILITY. RESIDENT #502'S I/A REPORTS REVEALED THE FOLLOWING: 1. ON 6/26/11: "(NURSE AIDE) REPORTED TO NURSE NOTED SKIN TEAR TO RIGHT TOP OF HAND, STATED IT HAPPENED DURING TRANSFER." STERI-STRIPS WERE APPLIED AND "IN-SERVICE STAFF IMMEDIATELY....TRANSFER PROPERLY KEEPING ARMS/LEGS IN LINE TO AVOID SKIN TEARS OR INJURIES." 2. ON 7/23/11: "PATIENT WAS BEING TRANSFERRED BY (NURSE AIDE) AND RECEIVED SKIN TEAR TO THE BACK OF RIGHT HAND AND BRUISING TO RIGHT LATERAL FOREARM. STERI-STRIPS TO SKIN TEAR. GAVE (NURSE AIDE) REMINDER ON TRANSFERRING OF PATIENTS AND PATIENT SAFETY." THE RESIDENT WAS NOTED TO HAVE A ONE INCH SKIN TEAR ON THE HAND AND A 1.5 INCH BRUISE NEAR THE ELBOW. 3. ON 12/9/11: "(NURSE AIDE) STATED RESIDENT'S ARM OUT WHEN TRANSFER WAS INITIATED....SKIN TEAR X 2 TO RIGHT TOP HAND....REMINDED STAFF TO OBSERVE RESIDENT'S EXTREMITIES WHEN TRANSFERRING." 4. ON 1/27/12: "(NURSE AIDE) REPORTED RESIDENT HAD A SKIN TEAR DURING TRANSFER. (NURSE AIDE) NOTICED SKIN TEAR TO RIGHT FOREHEAD AFTER PUTTING RESIDENT TO BED. SKIN TEAR, 2 CM LONG, BLEEDING." A REVIEW OF RESIDENT #502'S "SKIN INTEGRITY" CARE PLANS DATED 9/26/11, REVEALED NO INTERVENTIONS RELATED TO FRAGILE SKIN ON EXTREMITIES OR PROTECTION OF LIMBS DURING TRANSFERS AND CARE. MANAGER 'A' WAS UNABLE TO EXPLAIN WHY, STATE WHAT INTERVENTIONS WERE IN PLACE TO HELP PREVENT SKIN TEARS, OR WHY THE TEARS REPEATEDLY OCCURRED DURING TRANSFERS INVOLVING STAFF. ( ) ON 3/21/12, AT 9:50 A.M., RESIDENT #514 WAS OBSERVED IN A WHEELCHAIR IN THE ROOM. A SMALL RED CRESCENT SHAPED OPEN AREA WAS NOTED ON THE MIDDLE OF THE RESIDENT'S LEFT SHIN. WHEN ASKED HOW AND WHEN THE WOUND OCCURRED, THE RESIDENT STATED, "I DON'T KNOW." ON 3/22/12 AT 12:10 P.M., RESIDENT #514'S CURRENT AND CLOSED (PREVIOUS ADMISSION) CLINICAL RECORDS AND FACILITY "UNUSUAL EVENT REPORTS (I&A) WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON) WITH ASSISTANCE FROM THE MEDICAL RECORDS COORDINATOR, "M", AND REVEALED THE FOLLOWING: A CLOSED RECORD FACE SHEET DOCUMENTED THAT RESIDENT #514 WAS admitted to the facility on [DATE]. THE CURRENT CLINICAL RECORD FACE SHEET DOCUMENTED RESIDENT #514 WAS REadmitted on [DATE] AFTER A hospitalization WITH [DIAGNOSES REDACTED]. A SIGNIFICANT CHANGE MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE], DOCUMENTED THAT RESIDENT #514 HAD SEVERELY IMPAIRED COGNITION, DID NOT AMBULATE, AND WAS DEPENDENT ON STAFF ASSISTANCE FOR TRANSFERS TO THE WHEELCHAIR, DRESSING, AND TOILETING. REVIEW OF NURSING CARE PLANS FOR RESIDENT #514 REVEALED A CARE PLAN TITLED, "RESIDENT IS AT RISK FOR FALLS", DATED 11/8/11 AND REVISED 11/21/11 WITH THE INTERVENTION, "ASSIST WITH TRANSFERS AS NEEDED." REVIEW OF A FACILITY UNUSUAL EVENTS REPORT (I&A) FOR RESIDENT #514, DATED 1/18/12 AT 8:30 A.M., REVEALED THE FOLLOWING, "IN HER WHEELCHAIR AND HER SKIN WAS TORN. DOES NOT REMEMBER." THE REPORT DOCUMENTED THE RESIDENT HAD A ONE CENTIMETER (CM) BY ONE CM ROUND SKIN TEAR. "THE ROOT CAUSE DETERMINATION" WAS DOCUMENTED AS, "SCRAPPED HER SHIN ON HER WHEELCHAIR (W/C) WHILE TRANSFERRING." WHEN QUERIED ABOUT THIS, THE DON STATED THAT INSPECTION OF THE W/C REVEALED NO SHARP EDGES OR DEFECTS. THE DON WAS UNABLE TO STATE IF STAFF WERE INTERVIEWED OR REASSESSED TO DETERMINE COMPETENCY WITH RESIDENT TRANSFERS. REVIEW OF A FACILITY I&A FOR RESIDENT #514, DATED 2/25/12 AT 12:20 A.M., DOCUMENTED, "BEING TRANSFERRED FROM BED TO WHEELCHAIR, HIT LEG ON THE WHEELCHAIR PEDAL, CAUSING A SMALL SKIN TEAR. PER AIDE (CNA) ASSIGNED W/C WAS NEXT TO BED AND PT WAS TRANSFERRED WITH ASSISTANCE, HIT THE PEDAL OF HER W/C CAUSING SKIN TEAR." THE SKIN TEAR WAS DOCUMENTED AS MEASURING 0.5 CM BY 0.5 CM. THE "ROOT CAUSE DETERMINATION" WAS DOCUMENTED AS, "ATTENTION TO BE PAID MORE WHEN TRANSFERRING PT AT ALL TIMES." THE DON WAS ASKED HOW RESIDENT #514 SCRAPED HER LEG ON THE W/C PEDAL DURING TRANSFER IF THE LEG RESTS WERE EITHER REMOVED OR SWIVELED BACK AGAINST THE FRAME PER STANDARD OF CARE. THE DON REPORTED THAT THE TRANSFER WAS DONE IMPROPERLY, AND PROVIDED DOCUMENTATION THAT THE CNA INVOLVED WAS REINSERVICED (RE EDUCATED) ON TRANSFERRING RESIDENTS. ( ) A REVIEW OF AN INCIDENT/ACCIDENT (I/A) REPORT DATED 1'30'12 NOTED: "(NURSE AIDE) STATED SHE WAS TRANSFERRING RESIDENT TO WHEELCHAIR AND RESIDENT HIT LEFT SHIN ON BED....SMALL SKIN TEAR TO LEFT SHIN" MEASURING 0.5 CM LONG. THE POST INCIDENT REVIEW NOTED: "ONE TO ONE (TRAINING) WITH (NURSE AIDE) REGARDING SAFE TRANSFERS." PER CLINICAL RECORD, RESIDENT#506 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT'S MINIMUM DATA SET NOTED THAT THE RESIDENT HAD NO COGNITIVE DEFICITS, WAS NON-AMBULATORY, AND REQUIRED EXTENSIVE ASSISTANCE FOR TRANSFERS. ON 3/21/12 AT 11 AM, DURING AN INTERVIEW WITH UNIT NURSE MANAGER 'A,' SHE SAID, "WE GO THROUGH ALL INCIDENT AND ACCIDENT REPORTS IN OUR MORNING MEETINGS AND IF NEEDED WE IN-SERVICE HOW TO TRANSFER RESIDENTS." PER THE FACILITY'S POLICIES ON "SAFE LIFTING AND MOVEMENT OF RESIDENTS" REVISED 10/2009 AND "LIFTING MACHINE, USING A PORTABLE" REVISED 1/19/12: -"IN ORDER TO PROTECT THE SAFETY AND WELL-BEING OF....RESIDENTS, AND TO PROMOTE QUALITY CARE, THIS FACILITY USES APPROPRIATE TECHNIQUES AND DEVICES TO LIFT AND MOVE RESIDENT." -THE RESIDENT SHOULD HAVE BOTH ARMS FOLDED ACROSS THE CHEST AREA DURING TRANSFERS WITH LIFTS. ( ) ( )

THIS CITATION PERTAINS TO MI 460. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT ACCIDENTS AND PROVIDE APPROPRIATE SUPERVISION IN 1 OF 4 SAMPLED RESIDENTS (#502) WHO WERE AT RISKS FOR FALLS, IN A TOTAL SAMPLE OF 4 RESIDENTS, RESULTING IN hospitalization AND RIGHT KNEE SURGERY WHEN RESIDENT #502 WAS FOUND ON THE BATHROOM FLOOR AND HAD SUSTAINED A RIGHT FEMUR FRACTURE AND THREE RIB FRACTURES. FINDINGS INCLUDE: RESIDENT #502 NO LONGER LIVED AT THE FACILITY AT THE TIME OF THE COMPLAINT INVESTIGATION CONDUCTED ON 11/7/11 THROUGH 11/9/11. REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD DATED 10/6/11 REVEALED RESIDENT #502 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED RESIDENT #502'S [DIAGNOSES REDACTED]. THE MDS REVEALED RESIDENT #502 HAD SEVERE COGNITIVE IMPAIRMENTS, REQUIRED LIMITED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S), AND AMBULATED WITH A WALKER. REVIEW OF THE ADMISSION NURSING assessment dated [DATE], REVEALED RESIDENT #502 HAD A FALL RISK SCORE OF 20 AND WAS CONSIDERED AT RISK FOR FALLS. THE ASSESSMENT REVEALED RESIDENT #502 DID NOT USE THE CALL LIGHT EFFECTIVELY AND HAD DECREASED SAFETY AWARENESS. REVIEW OF A FALLS CARE PLAN DATED 10/4/11, REVEALED RESIDENT #502 WAS AT RISK FOR FALLS DUE TO IMPAIRED BALANCE, GENERALIZED WEAKNESS, AND DEMENTIA. THE CARE PLAN REVEALED A BED SENSOR WAS APPLIED FOR RESIDENT #502 ON 10/6/11 AND WAS THEN DISCONTINUED ON 10/6/11. INTERVENTIONS INCLUDED ASSISTING WITH TRANSFERS AND AMBULATION AS NEEDED AND MONITORING RESIDENT #502'S GAIT FOR UNSTEADINESS. REVIEW OF A NURSE'S NOTE DATED 10/7/11 AT 2:10 AM, REVEALED THE BODY (BED) ALARM WAS DISCONTINUED BECAUSE IT KEPT RESIDENT #502'S ROOMMATE AWAKE AT NIGHT. THE NOTE REVEALED RESIDENT #502 WAS INCONTINENT OF BLADDER, NEEDED MODERATE ASSISTANCE WITH ADL'S DUE TO INCREASE CONFUSION, HAD AN UNSTEADY GAIT, AND CONTINUED TO WANDER. THE NOTE REVEALED RESIDENT #502'S CALL LIGHT WAS WITHIN REACH AND MONITORING CONTINUED. REVIEW OF AN INCONTINENCE CARE PLAN DATED 10/5/11 REVEALED RESIDENT #502 WAS OCCASIONALLY INCONTINENT DUE TO HAVING DEMENTIA AND TAKING DIURETICS (WATER PILLS). REVIEW OF THE CERTIFIED NURSING ASSISTANT'S (CNA) ADL PLAN OF CARE REVEALED RESIDENT #502 NEEDED REMINDERS TO USE WALKER AND REQUIRED STAND BY ASSIST WITH AMBULATION. THE PLAN OF CARE DID NOT IDENTIFY RESIDENT #502 AS A FALL RISK OR THAT SHE WAS INDEPENDENT WITH A WALKER. IN AN INTERVIEW ON 12/9/11 AT 4:07 PM, CNA #10 REPORTED SHE WAS NOT AWARE THAT RESIDENT #502 WAS A FALL RISK. CNA #10 REPORTED THE CNA ADL PLAN OF CARE WOULD INDICATE IF A RESIDENT WAS A FALL RISK. REVIEW OF LABORATORY REPORT DATED 10/16/11 REVEALED RESIDENT #502 HAD A URINARY TRACT INFECTION (UTI). REVIEW OF A NURSE'S NOTE DATED 10/17/11 AT 3:30 PM, REVEALED RESIDENT #502 WAS STARTED ON AN ANTIBIOTIC FOR A UTI. REVIEW OF A "RESIDENT INCIDENT/UNUSUAL OCCURRENCE" DOCUMENT DATED 10/17/11, REVEALED ON 10/17/11 AT 6:30 AM, RESIDENT #502 WAS OBSERVED ON THE FLOOR BY HER BED. THE DOCUMENT REVEALED NO INJURIES WERE NOTED FOR RESIDENT #502. THE DOCUMENT REVEALED RESIDENT #502'S CLOTHING WAS CHECKED FOR PROPER FIT, ROOM WAS MONITORED, AND A THREE DAY INCIDENT CHARTING WAS INITIATED. IN AN INTERVIEW ON 12/7/11 AT 10:05 AM, CNA #7 REPORTED SHE CHECKED ON RESIDENT #502 ON 10/18/11 AT APPROXIMATELY 2:45 PM. CNA #7 REPORTED RESIDENT #502 WAS SITTING IN HER RECLINER CHAIR AND DID NOT REQUEST FOR ANY ASSISTANCE AT THAT TIME. REVIEW OF THE "RESIDENT INCIDENT/UNUSUAL OCCURRENCE" DATED 10/19/11 REVEALED ON 10/19/11 AT 3:00 PM, RESIDENT #502 WAS FOUND ON THE BATHROOM FLOOR NEXT TO THE TOILET. IN AN INTERVIEW ON 12/7/11 AT 10:15 AM AND REVIEW OF A WITNESS STATEMENT DATED 10/19/11, REGISTERED NURSE (RN) #5 REPORTED RESIDENT #502 WAS CONFUSED AND UNABLE TO REPORT WHAT HAPPENED. RN #5 REPORTED RESIDENT #502 WAS COMPLAINING OF RIGHT LEG PAIN WITH RANGE OF MOTION AND WAS TRANSFERRED TO THE hospital on [DATE] AT 3:35 PM. REVIEW OF THE HOSPITAL'S X-RAY REPORT DATED 10/19/11 REVEALED RESIDENT #502 SUSTAINED A RIGHT FEMUR (LEG) FRACTURE AND THREE RIB FRACTURES. REVIEW OF THE HOSPITAL OPERATIVE REPORT DATED 10/20/11 REVEALED RESIDENT #502 HAD RIGHT KNEE SURGERY. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND FAILED TO ENSURE THAT PERSONAL ALARMS WERE FUNCTIONING FOR ONE (#610) OF 11 SAMPLED RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 20, RESULTING IN A FALL WITH HEAD TRAUMA AND LACERATIONS TO THE SCALP. IN ADDITION, THE FACILITY FAILED TO SECURE UNLOCKED AND UNATTENDED MEDICATION AND TREATMENT CARTS, DOUBLE LOCK CONTROLLED SUBSTANCES AND FAILED TO MAINTAIN SAFE WATER TEMPERATURES FOR 5 ( #'S 6, 83, 84, 85 AND 86) OFF SAMPLED RESIDENTS, RESULTING IN THE POTENTIAL FOR THE ACCIDENTAL INGESTION, ABUSE AND DIVERSION OF MEDICATIONS AND THE RISK OF SKIN BURNS. FINDINGS INCLUDE: ON 5/3//11 AT 10:45 A.M., RESIDENT #610 WAS OBSERVED SITTING IN A HIGH BACK WHEELCHAIR, WITH A TAB ALARM (A DEVICE THAT PRODUCES A SOUND ALERT IN THE EVENT OF AN ATTEMPTED UNSUPERVISED TRANSFER), ATTACHED TO HER UPPER CLOTHING AND THE WHEELCHAIR. THE RESIDENT HAD A LAB BUDDY RESTRAINT (USED TO PREVENT UNASSISTED TRANSFERS) ATTACHED TO HER WHEELCHAIR. ON 5/3/11 AT 11:30 A.M., RECORD REVIEW REVEALED THAT RESIDENT # 610 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #610 WAS REadmitted on [DATE] WITH ADDITIONAL [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS), dated [DATE] INDICATED THAT RESIDENT #610'S COGNITION WAS SEVERELY IMPAIRED AND WAS DEPENDENT ON STAFF FOR TRANSFERS, AMBULATION, TOILETING AND ACTIVITIES OF DAILY LIVING. THE ADMISSIONS "FALL PRONE EVALUATION" DATED 8/4/10 SCORED THE RESIDENT AT 45 POINTS (IF POINTS TOTAL 10 OR MORE, RESIDENT SHOULD BE IDENTIFIED AS AT HIGH RISK FOR FALLS). REVIEW OF RESIDENT #610'S FALLS CARE PLAN DATED 8/4/10 INCLUDED THE FOLLOWING INTERVENTIONS: 1. PLACE CALL LIGHT IN REACH. 2. ENCOURAGE RESIDENT TO OBTAIN ASSISTANCE FOR TRANSFERS AND AMBULATION. 3. BED ALARM. 4. BODY ALARM. 5. ENABLER BARS ON BED. 6. WANDERGUARD. ON 5/5/11 AT 8:40 A.M., REVIEW OF RESIDENT #610'S NURSES NOTES WAS CONDUCTED WITH THE RESTORATIVE NURSE (RN), THE INFECTION PREVENTION NURSE (IPN) AND THE DIRECTOR OF NURSING (DON) REVEALED THE FOLLOWING: 1. ON 8/13/10, "OBSERVED IN OTHER RESIDENTS ROOMS ...STANDING AT OTHER RESIDENT'S BED SIDE ... UNDRESSED THREE TIMES AND LEFT HER CLOTHS IN DIFFERENT ROOMS ...WANDERS AT A SLOW PACE." THE RN AND IPN WERE QUERIED REGARDING WHO WAS SUPERVISING THE RESIDENT AND WHY HER BODY ALARMS WERE NOT SOUNDING. NO EXPLANATION WAS OFFERED. 2. ON 8/14/10, "OBSERVED SITTING BESIDE THE BED ON THE FLOOR ...HAS A 0.5 CENTIMETER (CM) LACERATION TO THE LEFT THIGH." THERE WAS NO DOCUMENTATION THAT THE RESIDENT'S ALARMS WERE IN PLACE OR SOUNDING. 3. ON 8/15/10, "CONTINUES TO WANDER, GETS INTO OTHER RESIDENTS ROOMS, TAKES STUFF AND LEAVES THEM BEHIND." THE RN AND IPN WERE QUERIED REGARDING WHY HER BODY ALARMS WERE NOT SOUNDING. NO EXPLANATION WAS OFFERED. 4. ON 8/17/10, "NURSE OBSERVED RESIDENT AMBULATING IN THE FRONT SITTING AREA; BENT OVER TO PICK UP SOMETHING ...fell TO THE FLOOR." ON 8/17/10, RESIDENT 610'S CARE PLAN WAS UPDATED TO INCLUDE THE FOLLING INTERVENTIONS: "STAFF TO RESPOND PROMPTLY TO SOUNDING ALARMS, MONITOR RESIDENT'S GAIT FOR UNSTEADINESS, MONITOR RESIDENT'S LOCATION." 5. ON 9/30/10, "UNDRESSING IN HALLWAY, PULLED HER PANTS DOWN AND DEFECATED ON CHAIR ...TAKES CLIPBOARD, TEARS PAPERS AT NURSES DESK." 6. ON 10/3/10, "RESIDENT CONTINUES WANDERING BEHAVIOR ...ENTER ALL ROOMS, REMOVING ITEMS, TEARS PAPERS AND TAKES OTHER RESIDENTS ITEMS." THE RN AND IPN WERE QUERIED REGARDING SUPERVISION AND REDIRECTING AND WHY HER ALARMS WERE NOT SOUNDING. NO EXPLANATION WAS OFFERED. 7. ON 10/12/10, "NURSE HEARD A YELL FROM CERTIFIED NURSING ASSISTANT (CNA) TO COME TO THE RESIDENT'S (#610) ROOM ...RESIDENT WAS FOUND ON THE FLOOR IN A SUPINE POSITION IN THE DOORWAY...THE RESIDENT HAD BLEEDING TOWARD THE BACK OF THE CRANIAL (HEAD). PRESSURE WAS APPLIED TO THE BACK OF THE HEAD. EMERGENCY MEDICAL SERVICES (EMS) CALLED. RESIDENT WAS TRANSFERRED TO THE HOSPITAL FOR EMERGENCY TREATMENT." THERE WAS NO DOCUMENTED EVIDENCE THAT RESIDENT 610'S PERSONAL ALARMS WERE SOUNDING PRIOR TO BEING FOUND ON THE FLOOR. THE RN AND IPN WERE QUERIED REGARDING WHO WAS SUPERVISING THE RESIDENT AND WHY HER ALARMS WERE NOT SOUNDING. THE RN STATED SHE (RESIDENT #610) MUST BE TAKING HER ALARMS OFF. REVIEW OF THE HOSPITAL RECORDS DATED 10/12/10 REVEALED THAT RESIDENT #610 HAD "INITIAL [DIAGNOSES REDACTED]. THE RESIDENT'S LACERATIONS WERE CLOSED WITH SKIN STAPLES AND SHE WOULD BE admitted TO THE HOSPITAL FOR FURTHER OBSERVATIONS AND TESTING." ON 10/14/10 AT 4:30 P.M., THE NURSES NOTE DOCUMENTED "RESIDENT (#610) WAS readmitted INTO THE FACILITY WITH 9 STAPLES ON A LACERATION ON THE SCALP." REVIEW OF THE ADMISSIONS "FALL PRONE EVALUATION" SCORED RESIDENT #610 AT 45 POINTS (POINTS 10 OR MORE, RESIDENT SHOULD BE IDENTIFIED AT HIGH RISK FOR FALLS). REVIEW OF THE physician's orders [REDACTED]." 8. ON 10/14/10 AT 4:48 P.M., "WRITER HEARD A THUMP AND UPON CHECKING...RESIDENT (#610) NOTED TO HAVE WALKED FROM HER ROOM AND fell IN THE HALLWAY IN FRONT OF THE CNA STATION ...HER HEAD WAS AGAINST THE WALL AND SHE WAS PARTIALLY SITTING ON THE FLOOR. NEUROLOGICAL CHECKS STARTED." THE RN AND IPN WERE QUERIED REGARDING WHY THE RESIDENTS ALARMS WERE NOT SOUNDING WHEN SHE ATTEMPTED TO SELF TRANSFER. NO EXPLANATION WAS OFFERED. 9. ON 10/15/10, "RESIDENT OBSERVED GETTING OFF FLOOR...SMALL ABRASION TO RIGHT KNEE." 10. ON 10/19/10, "RESIDENT (#610) WAS OBSERVED SITTING ON THE FLOOR IN HER BATHROOM ...EMERGENCY CALL LIGHT FLASHING." THE RESIDENT'S INCIDENT/UNUSUAL OCCURRENCE DATED 10/19/10 DOCUMENTED, "SENSOR ALARM, BED ALARM AND FALL MATS IN PLACE PRIOR TO THE INCIDENT ...NO ALARMS WERE SOUNDING WHEN WRITER WENT TO CHECK ON RESIDENT, CNA HAD CLOSED THE RESIDENT ' S DOOR SO SHE (RESIDENT #610) COULD TAKE A NAP. THE CNA WAS INSTRUCTED NOT TO CLOSE THIS RESIDENT'S DOOR." REVIEW OF THE ONE-ON-ONE COACHING / INSERVICE DATED 10/25/10 DOCUMENTED, "CNA STATEMENT, I WAS NEVER INFORMED NOT TO SHUT A RESIDENT'S DOOR; I THOUGHT IT WAS ALSO A PRIVACY ISSUE. I AM NOW AWARE OF THIS OPEN DOOR POLICY AND WILL DEFINITELY ADHERE TO IT IN THE FUTURE." THE RN, DON AND IPN WERE QUERIED REGARDING WHY WASN'T' THE SENSOR PAD ALARM SOUNDING. THE RN STATES, "WE HAVE A LOT OF WORK TO DO INCLUDING TRAINING AND BETTER DOCUMENTATION RELATED TO SAFETY PRECAUTIONS". ON 5/5/11 AT 11:30 A.M., THE FACILITY'S POLICY ENTITLED, "FALL PREVENTION/INCIDENT POLICY " , REVISED 11/2008, DOCUMENTED "APPROPRIATE IN-SERVICES WILL BE IMPLEMENTED ACCORDING TO THE SUMMARY'S FINDINGS OF ANY TRENDS, PATTERNS OR SAFETY ISSUES. THESE RESULTS AND INTERVENTIONS WILL ALSO BE INCLUDED IN THE FACILITY'S QA PROCESS." ( ) ON 5/3/11 AT 1:56 P.M., DURING GENERAL OBSERVATIONS ON THE FACILITY'S FIRST FLOOR IT WAS NOTED THAT AN UNATTENDED AND UNLOCKED MEDICATION CART WAS LOCATED IN THE HALL ACROSS FROM THE NURSES STATION. THE HALL WAS ACCESSIBLE TO NON-CLINICAL STAFF, RESIDENTS AND VISITORS. THE CART WAS OUT OF VIEW OF THE UNIT NURSE. THE CART CONTAINED A SINGLE-LOCKED CONTROLLED SUBSTANCE DRAWER. AT 2:00 P.M., NURSE "I" WAS QUERIED AND STATED, "I JUST WALKED AWAY FOR A MINUTE, IT SHOULD BE LOCKED." ON 5/3/11 AT 2:30 P.M., DURING GENERAL OBSERVATION ON THE FACILITY'S THIRD FLOOR (DEMENTIA UNIT), IT WAS NOTED THAT AN UNLOCKED AND UNATTENDED TREATMENT CART WAS LOCATED IN THE HALL ADJACENT TO THE NURSES STATION. THE TOP DRAW OF THE CART CONTAINED SHARP SCISSORS. THE CART ALSO CONTAINED WOUND CARE SUPPLIES INCLUDING OINTMENTS AND DISINFECTANTS. THE HALL WAS ACCESSIBLE TO NON-CLINICAL STAFF, SEVERELY COGNITIVELY IMPAIRED RESIDENTS AND VISITORS. THE CART WAS OUT OF VIEW OF THE UNIT NURSE. AT 2:35 P.M., NURSE "E" RETURNED TO THE CART AND ATTEMPTED TO CLOSE THE DRAWS. SHE STATED, "THE DRAWS AREN'T CATCHING LIKE THEY SHOULD." NURSE "E" WAS ABLE TO LOCK ALL DRAWS IN THE CART. ON 5/5/11 AT 2:00 P.M., THE FACILITY'S POLICY ENTITLED "ADMINISTERING MEDICATION" UNDATED, DOCUMENTED "THE MEDICATION CART IS KEPT CLOSED AND LOCKED WHEN OUT OF SIGHT OF THEIR MEDICATION NURSE OR AID." ( ) ON 5/3/11 AT 1:00 P.M., THE DOMESTIC HOT WATER TEMPERATURES WERE CHECKED ON EACH FLOOR. THE HOT WATER TEMPERATURE THE ROOMS OF RESIDENT #'S 6, 83, 84, 85 AND 86 WERE OBSERVED TO EXCEED THE MAXIMUM ALLOWABLE TEMPERATURE OF 120 DEGREES FAHRENHEIT(D.F.): ROOM TEMPERATURE RESIDENTS 104 120.9 #6 303 122.0 #83 , #84 304 121.8 #85, #86 REVIEW OF THE WEEKLY DOMESTIC HOT WATER TEMPERATURE LOG ON 5/2/11 INDICATED A MIXING VALVE TEMPERATURE OF 122 D.F.. THE FACILITIES SUPERVISOR WAS INTERVIEWED AND ACKNOWLEDGED THE EXCESSIVE TEMPERATURE AND INDICATED THAT THE TEMPERATURE OF THE WATER WOULD BE ADJUSTED IMMEDIATELY. ( )