Every finding on record at The Orchards at Harper Woods

Based on observation, interview, and record review, the facility failed to maintain the exterior trash refuse area in a clean manner, resulting in the potential for odors and the attraction of pests and rodents. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:On 5/5/26 at approximately 9:00 AM, the exterior dumpster area was observed with a pile of various trash items on the ground behind the dumpster, and the trash was sitting in a pool of stagnant, standing water. When queried on 5/5/26 at 2:30 PM, the Maintenance Director confirmed the trash buildup and stated one of his guys had already gone out and cleaned it up. Review of the facility's undated policy Physical Plant Exterior Maintenance On 5/7/26 at 11:00 AM noted: Building Grounds 1. Clean the building's exterior and grounds of all trash, rubbish, debris, unused equipment/furniture, in addition to periodic cleaning of problem areas.

This citation pertains to intake 3004617Based on observation, interview, and record review, the facility failed to provide showers as scheduled and per resident preferred frequency for three (R1, R11, R118) of five residents reviewed for showers and failed to provide set up and feeding assistance for one (R104) of one resident reviewed for feeding assistance. Findings include: R1 On 05/05/2026 at 11:27 AM, R1 was interviewed at bedside and reported they were not getting their showers. R1 was asked if they preferred a bed bath or a shower and reported they preferred a shower and denied refusing showers. Review of the facility record revealed R1 was initially admitted into the facility on [DATE] with diagnoses including Cerebral Infarction with Left Hemiplegia. The Minimum Data Set (MDS) assessment dated [DATE] indicated R1's cognition was intact and they were dependent on staff for bathing. On 05/07/2026 at 11:01 AM, Certified Nursing Assistant (CNA) D was interviewed and asked how they know their schedule of resident's to be bathed and how they document bathing. They showed the location of a binder which contained the daily shower schedule as well as the shower sheets (paper documents used to document bathing) to be completed when bathing and skin inspection is completed. They reported bathing is also documented in the electronic medical record (EMR) under the task tab. Review of R1's shower schedule, shower sheets, and EMR bathing task record revealed they were scheduled for a shower every Tuesday and Friday during the day shift. Of ten scheduled showers between 03/06/26 and 04/07/26, two showers were documented as completed and one documented as refused. For the remaining seven scheduled showers there were no shower sheets completed, and five of the seven dates were documented in the EMR as Not Applicable rather than as completed or refused. There were no progress notes documenting an explanation for the Not Applicable status. On 05/07/2026 at 11:39 AM, R1 was interviewed at bedside and asked about the missing showers they reported. R1 reported they had not been given any explanation for missed showers. When asked how they feel when they don't have a shower they stated, No good. R11 On 05/05/2026 at 11:01 AM, R11 was interviewed at bedside and reported they were not getting a shower regularly. Review of R11's facility record revealed the most recent admission date of 01/17/25 with diagnoses including Spina Bifida (neurological condition causing incontinence, loss of sensation, and leg paralysis) and Local Infection of the Skin and Subcutaneous (just below the skin) Tissue. The MDS assessment dated [DATE] indicated R11's cognition was intact and they required Maximal Assistance for bathing completion. On 05/06/2026 at 9:13 AM, R11 reported they were scheduled for a shower on Tuesday and Saturday's during the afternoon shift and they did not receive a shower the previous day Tuesday. On 05/07/2026 at 11:20 AM, R11 was interviewed at bedside. They were asked if they preferred to have a shower once or twice weekly and they reported they preferred twice saying when they don't have a shower regularly, they worry if they smell poorly and about their skin. Review of R11's shower schedule, shower sheets, and EMR bathing task revealed they were scheduled for showers on Tuesday and Saturday afternoons. The shower sheets and bathing task record revealed during the period between 03/24/26 and 04/28/26 that five of eleven scheduled showers were not documented as completed. There were no progress notes addressing any missed or refused showers. R118 On 05/05/2026 at 11:00 AM, R118 was interviewed at bedside and reported they were not getting their shower on a regular basis. Review of the facility record for R118 revealed they were admitted into the facility on [DATE] with diagnoses including Heart Failure and Recent Fall from/on Steps/Stairs. The MDS assessment dated [DATE] indicated R118's cognition was intact and they required Moderate Assistance for bathing completion. On 05/07/2026 at 11:29 AM, R118 was interviewed in their room and asked if they could recall ever being given a reason for not getting their shower and they reported they could not. They were asked if they ever refuse their shower and they stated I only refused it one time and that was because the person walked in and I didn't even know who they were and they said, You're getting a shower today in a rude way so I didn't take it. When asked how they feel when they don't have a shower R118 stated Grungy .smelly. Review of R118's shower schedule, shower sheets, and EMR bathing task record revealed they were scheduled for showers on Monday and Thursday afternoon shift, and five of eleven scheduled showers were not documented as being completed between admission and 05/05/26. There were no progress notes in R11's record addressing missed showers. The EMR bathing task was recorded as Not Applicable on 04/16/26 and 04/27/26. On 05/07/2026 at 12:02 PM, Unit Manager (UM) B was interviewed and asked their expectation for resident's who are scheduled for twice weekly bathing. UM B reported they should be offered a shower on their scheduled day and if they refuse they should be offered a bed bath as an alternative. UM B reported if the resident refuses three times on the scheduled shift they should be asked the following day. UM B reported any bathing completion or bathing refusals should be documented on shower sheets as well as in the EMR bathing task record. On 05/07/2026 at 12:15 PM, Assistant Director of Nursing (ADON) A was interviewed in the conference room and asked their expectation for bathing for residents who are scheduled for twice weekly showers. ADON A reported the shower should be offered on the scheduled days and any refusals should be documented on the shower sheet and on the bathing task item in the electronic medical record. A facility policy addressing general expectations for Activities of Daily Living (ADL) care was requested. The provided policy addressed only the procedural checklist for bathing a resident and did not address frequency or resident preference for frequency of bathing. The facility Administrator reported no additional ADL policy was available. R104 On 5/5/2026 at 2:20 PM, R104 was observed lying in bed with their lunch tray in front of them. R104 was observed eating a magic cup (nutritional supplement) independently. R104's hands were noted to be shaking, and some of the magic cup was observed spilled on R104's sheets. A review of the medical record revealed R104 was admitted into the facility on [DATE] with the following medical diagnoses, Parkinsons Disease and Seizures. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7/15 indicating impaired cognition. R104 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed the following order, Order: 1:1 assist with meals.Ordered:1/9/2025.Status: Active. On 5/6/2026 at 12:39 PM, R104 was observed lying in bed, sleeping. R104's bed was in the lowest position with their head of bed slightly elevated. R104's lunch tray was noted to be in front of them on their bedside table. R104's lunch tray was noted to have the lid still on it, covers on the magic shakes, and the milk and juice cartons were unopened. At 12:47 PM, R104's tray remained untouched and no one was in the room assisting with feeding. R104 tray was picked up by the Certified Nursing Assistant (CNA) untouched. On 5/7/2026 at 8:55 AM, R104 was observed lying in bed, sleeping. R104's bed was in the lowest position with their head of bed slightly elevated. R104's lunch tray was noted to be on their bedside table, on the side of them. R104's lunch tray was noted to have the lid still on it, covers on the magic shakes, and the milk and juice cartons were unopened. On 5/7/2026 at 9:01 AM, an interview was conducted with CNA M. CNA M reported when someone requires feeding assistance, it is usually on the tray ticket and R104 did not have it listed on their tray ticket. CNA M reported they were still going to assist in feeding R104 because they noticed they had not touched their food. On 5/7/2026 at 10:24 AM, an interview was conducted with Registered Dietitian (RD) L. RD L reported R104 had some weight loss in the past but has since gained it back and is stable. RD L reported R104 prefers supplements, rather than eating food and they are hit or miss. RD L reported because of this they are a 1:1 feeding assistance, for encouragement and help if needed. RD L reported their expectation is that the staff provide set up tray assistance (taking off coves, lids, and opening cartons) for R104 and provide additional help if needed.

Based on observation, interview, and record review, the facility failed to develop a comprehensive pressure ulcer care plan with goals, interventions, and desired outcomes for one resident (R35) out of seven residents reviewed for care planning. Findings include:On 05/06/2026 at 2:27 PM, R35 was observed lying in bed on an air mattress with the air mattress pump device resting face down on the floor near the foot of the bed. Registered Nurse (RN) F, who was nearby in the hallway, was asked if the air mattress pump was on. Along with the nurse, the device was observed to be off.A review of R35's Electronic Medical Record (EMR) revealed they were admitted into the facility 10/01/2024 with diagnoses of cerebral infarction (stroke), weakness, and vascular dementia. R35's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that they were not able to complete their mental status interview. Review of section M of this MDS revealed R35 had one stage two pressure ulcer (partial-thickness loss of skin presenting as a shallow open ulcer) that was not present upon admission.Further review of R35's EMR did not reveal a care plan for management of pressure ulcers.On 05/07/2026 at 9:36 AM, an interview was conducted with Wound Care Licensed Practical Nurse (LPN) E who said, it is standard procedure for every resident with a skin issue to get a care plan for it.On 05/07/2026 at 10:32 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When asked about care planning for residents with pressure ulcers, they stated that a pressure ulcer care plan specific to each resident's wound care needs should be in place, especially when it is actively being treated.Review of a facility policy titled MDS Standard Operating Procedures: Comprehensive Plan of Care revealed that The comprehensive care plan must be patient centered.and describe that each resident is provided the necessary care and services including resident's choices to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment or quarterly review.

Based on interview and record review, the facility failed to revise and implement specific interventions on the fall care plan following a fall for one resident (R41) of seven reviewed for accidents. Findings include:On 5/5/26 at 10:00 AM, R41 was interviewed and asked if they had ever fallen at the facility. R41 indicated they had bumped their leg on their wheelchair a few days ago. A review of an incident/accident report involving R41 revealed the following, 3/1/2026 .Description: At approximately 4:00 PM, resident was observed .sitting in wheelchair and slid down from chair on to [their] buttocks .Resident found sitting on floor. Resident assisted back to wheelchair .Action Taken: Resident assessed head-to-toe. Vital signs obtained. No injuries noted . A review of R41's fall care plan and interventions revealed no additional fall interventions had been added to their care plan following their fall on 3/1/26. A further review of R41's electronic medical record (EMR) revealed R41 was originally admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-lung disease) and Dementia. R41's most recent minimum data set assessment (MDS) dated [DATE] revealed R41 had a moderately impaired cognition and required assistance for all activities of daily living (ADLs) other than eating. On 5/7/26 at 11:33 AM, an interview was conducted with the Assistant Director of Nursing (ADON) and they were asked about the process for adding interventions to a residents' care plan following a fall. The ADON indicated nursing should complete an assessment following the fall and an additional intervention should be added to the care plan to avoid another fall. A facility policy titled, Fall Management Guidelines revealed the following, .Guidelines .12. The IDT [Interdisciplinary Team] will review/modify the plan of care to minimize the risk of repeat falls.

This citation pertains to intake 3004617.Based on observation, interview, and record review, the facility failed to follow physician ordered heel boots and palm protectors for two residents (R14 and R45) and implement orders following a change in skin for one resident (R113) out of four reviewed for quality of care. Findings include:R14A review of the medical record revealed that R14 admitted into the facility on 5/10/2021 with the following medical diagnoses, Hypertension and Peripheral Vascular Disease. A review of the MDS dated [DATE] revealed a BIMS score of 9/15, indicating an impaired cognition. R14 also required staff assistance with bed mobility and transfers. Further review of the physician's orders noted the following, Order: Heel Protectors while in bed as tolerated.Status: Active.On 5/5/2026 at 1:45 PM, R14 was observed in bed. No heel boots were observed in place.On 5/6/2026 at 8:56 AM and 11:09 AM, R14 was observed in bed. No heel boots were in place.On 5/7/2026 at 9:05 AM, an interview was conducted with R14. R14 reported they used to wear heel boots, but someone took them away and gave them to their roommate. R14 reported they used to have something on their heel, but they don't anymore.A review of the Treatment Administration Record (TAR) had check marks in the following days in the month of May, indicating that the heel protectors were applied, 5/1,5/2,5/5, and 5/6.On 5/7/2026 at 9:05 AM, an interview was conducted with Certified Nursing Assistant (CNA) K. CNA K reported they thought R14 had some heel boots in the room but were unable to find them. CNA K reported they were going to get some replacements from therapy. On 5/7/2026 at 11:51 AM, an interview was conducted with the Assistant Director of Nursing (ADON). ADON reported they expect the nurses to complete proper documentation and ensure they are following the physician's orders. The ADON reported the heel protectors' boot should be applied for preventative measures. R45A review of the medical record revealed R45 admitted into the facility on 1/26/2022 with the following medical diagnoses, Dementia, and Anxiety Disorder. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating R45 was unable to complete the assessment. R45 also required staff assistance with bed mobility and transfers.Further review of the physician orders revealed the following, Nursing Maintenance Program .Resident wears B/L (bilateral) palm protectors at all times except for hygiene care QD (everyday) by CNA's (Certified Nursing Assistant).On 5/5/2026 at 9:20 AM, R45 was observed laying in bed. R45 was noted to have contractures to both hands. No palm protectors were in place. On 5/6/2026 at 9:01 AM,11:07 AM, and 12:14 PM, R45 was observed laying in bed. No palm protectors were in place. On 5/7/2026 at 9:14 AM, R45 was observed laying in bed. No palm protectors were in place. On 5/7/2026 at 9:14 AM, an interview was conducted with CNA J. CNA J reported they do not apply palm protectors, and restorative staff are the ones that apply them and remove them. On 5/7/2026 at 9:15 AM, an interview was conducted with Restorative I. Restorative I reported R45 is no longer on the restorative program, and it is probably an old order. On 5/7/2026 at 11:55 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON reported they expect the order to be discontinued if it is no longer needed. R113A review of intake 3004617 noted the following, Complainant states that [NAME] did not have wounds when she entered the facility.A review of the medical record revealed that R113 was admitted into the facility on 3/31/2026 with the following medical diagnoses, Severe Protein Calorie Malnutrition and Anemia. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9/15, indicating an impaired cognition. R113 also required staff assistance with bed mobility and transfers. Further review of the medical record revealed a progress note dated 4/5/2026 that noted the following, The resident has a open area on back left side thigh. Writer asked resident does she know how it got there. Resident doesn't know how it got there. Triple Antibiotic ointment applied to area.A review of a skin note dated 4/15/2026 noted the following, Coccyx MASD(Moisture Associated Skin Damage) 5.5 x 1.3 x 0.2 cm with red excoriated weeping tissue. Periwound with surrounding area pink wound edges attached to wound base.Recommended treatment: Cleanse apply Triad leave open to air apply dailyFurther review of the physician orders did not reveal a treatment order related to the open area. On 5/7/2026 at 1:09 PM, an interview was conducted with Wound Care Nurse (WCN) E. WCN E reported when they were alerted about the open area, they put a wound care consult in and they discharged from the facility an hour after seeing wound care. WCN E was asked about the progress note dated 4/5/2026 that mentioned an open area to the thigh. WCN E reported they were unaware of R113 having an open area at that time. A request for a policy related to following physician's orders was requested, but not received by end of survey.

Based on observation, interview, and record review, the facility failed to check and replace a wander guard (bracelet style device used to help prevent elopement) for one resident (R43) out of two reviewed for supervision. Findings include:On [DATE] at 12:49 PM, R45 was observed self-propelling in their wheelchair aimlessly throughout the hallway. R45 was observed wearing a wander guard on their right ankle.A review of the medical record revealed R43 was admitted into the facility on [DATE] with the following medical diagnoses, Major Depressive Disorder and Psychotic Disorder with Delusions. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating R43 was unable to complete the assessment and required staff assistance with bed mobility and transfers. Further review of the physician orders revealed the following, Wander Guard EXP May2025 FCC ID: KNKTX0003 A20080903 430KHZ, check for placement/ working properly, test and expiration date.On [DATE] at 10:31 AM, a request was made for documented checks or testing of the wander guard.On [DATE] at 11:31 AM, an interview was conducted with the Director of Nursing (DON) and they confirmed were unable to find any documentation the wander guard was being checked or tested (for functionality). The DON reported the order was not entered correctly, and it was not coming up on the treatment administration record (TAR) to check for placement, testing and expiration date.On [DATE] at 10:57 AM, an interview was conducted with Licensed Practical Nurse (LPN) H. LPN H reported they check the wanderguard devices on the TAR. LPN H reported it will pop up with the expiration date and placement. LPN H stated it does not pop up to check on the TAR for R45.On [DATE] at 11:57 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated if the order was entered properly it would have popped up on the TAR and they would have known it expired in [DATE] (over 1 year ago). The ADON reported if the wander guard device is expired and not working, it becomes a safety issue because it would not activate the alarm at the door if R45 were to attempt to elope from the facility.A review of a facility policy titled, Elopement did not address wander guard devices.

Based on observation, interview, and record review, the facility failed to properly store medications for one resident (R123) of one reviewed for medication storage. Findings include:On 05/05/2026 at 10:54 AM, the surveyor entered into the room of R123 who was not visibly seen at that time. An observation of their bedside table revealed a medication cup containing approximately 10 pills. R123 at this time exited the bathroom and was asked about the medications. R123 explained they were going to take them but had to use the bathroom first. On 05/05/2026 at 11:03 AM, the Director of Nursing (DON) was observed in the hallway and was requested to make the observation of R123's medications. The DON observed the medications, and requested the resident consume the medications in their presence. The DON asked the resident why they hadn't taken their medication and they explained they had to use the bathroom first. A review of R123's medical record revealed they were admitted into the facility on 4/4/23 with diagnoses which included Heart Disease, Anxiety and Hyperlipidemia. Further review revealed the resident was cognitively intact and required supervision for activities of daily living. Further review of R123's medical record did not reveal documentation that they were able to administer their own medications. On 05/06/2026 at 12:00 PM, the DON approached the surveyor and indicated that R123's assigned nurse is a newer nurse. A review of the facility's Medication Administration and General Guidelines policy revealed the following, .1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws .4. Residents are allowed to self-administer medications when specifically authorized by the attending physician and accordance with policy and procedure for self-administration of medications .

Based on observation, interview, and record review, the facility failed to follow dentist recommendations for follow-up appointments for two residents (R56 and R86) out of two residents reviewed for dental services. Findings include:R56 On 5/5/2026 at 2:07 PM, R56 was observed laying in bed eating lunch. R56 was noted to have teeth missing. R56 was unable to recall if they had never seen a dentist in the facility. A review of the medical record revealed that R56 admitted into the facility on 6/30/2023 with the following medical diagnoses, End Stage Heart Failure and Anemia. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6/15, indicating an impaired cognition. R56 also required staff assistance with bed mobility and transfers. Further review of a dental consult dated 11/20/2026 noted the following, Action Required by Nursing Home Staff: Recommend patient be seen by an outside dentist, likely in a hospital setting, comprehensive care, including any extractions, fillings, cleanings, radiographs due to inability to perform thorough exam and patients' inability to articulate any dental concerns. On 5/6/2026 at 11:41 AM, an interview was conducted with the Director of Nursing (DON). The DON reported when there is a dental consult, they get an email and put the order in for any recommendations. The DON reported they never received an email regarding the recommendation. On 5/7/2026 at 9:54 AM, an interview was conducted with Social Worker (SW) G. SW G reported typically they receive an email summary form the dental service and they coordinate with the team. On 05/05/2026 at 9:06 AM, an interview and observation of R86's mouth revealed many worn down and missing teeth. They stated they need some teeth implants, and that they've asked staff to see a dentist but have not seen one yet. On 05/06/2026 at 9:48 AM, an additional interview was conducted with R86. They said they did not recall seeing a dentist this year, and that during their last appointment they remember being told someone would come in to clean their teeth, but they said that did not happen. A review of R86's Electronic Medical Record (EMR) revealed they were admitted into the facility on 4/14/2021 with diagnoses of hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (stroke), type two diabetes, and major depressive disorder. R86's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. A review of notes from R86's most recent annual dental exam dated 6/17/2025 revealed the following recommendations: Recommend an exam and cleaning every 6 months due to plaque and calculus buildup Recommend visit with the hygienist ASAP (as soon as possible) due to plaque and calculus buildup Periodic oral exam 12/17/2025 and Adult prophy (prophylaxis) 6/18/2025. Review of R86's EMR did not reveal that these recommended follow-up dental appointments were conducted. On 05/07/2026 at 1:00 PM, an interview was conducted with Scheduler C. They stated they did not get an order for scheduling any follow-up dental appointments for R86 after their annual dental exam on 6/17/25. Review of a facility policy titled Social Service SOP (standard operating procedure): Dental Services, revealed that When a resident requires routine or emergency dental care, the Social Service staff will assist the resident to secure an appointment.

This citation pertains to intakes 2696242, 2694434, and 2696027. Based on observation, interview, and record review, the facility failed to prevent verbal abuse for one resident (R604) and resident to resident physical abuse for two residents (R603 and R605), out of three reviewed for abuse. Findings include:R604 On 12/18/25 at 10:33AM, R604 was asked about the incident that occurred with Nurse A. R604 reported, at around 7:30pm they had pressed their call light to get pain medication and some cough syrup. R604 explained it was an hour later at 9:00 PM, when Nurse A told R604 that she was unable to give them their medications at that time because she had just received the keys. R604 reported they followed Nurse A to the medication cart and they started having an argument with each other. R604 explained they called Nurse A names and that she called R604 names. A review of R604's medical record revealed, R604 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disorder. A review of R604's social service assessment dated [DATE] noted, R604 with an intact cognition. On 12/18/25 at 12:28 PM, Nurse A was called, a voice message was left. Nurse A did not return a call before the end of this survey. A review of Nurse A's facility statement noted, The CENA (Competency Evaluated Nursing Assistant) reported to me (Nurse A) that R604 requested (R604's) pain pill, and I explained to [R604] that I had just received my keys, and [R604] immediately started cursing at me and calling me names. I left [R604's] room and continued to pass meds and then [R601] came out of [their] room and [R601] wheeled up to me and was calling me name and was raising [R601's] hands and acting as if [R601] was going to hit me. At that point I tried to explain to [R601] that I had just received my keys but [R601] was not listening and [R601] continued to argue with me. Eventually [R601] wheeled away. Did you use any curse words? Yes. What was your intent when you used the curse words? I felt threatened and felt that [R601] was going to hit me and I was trying to get [R601] to back off. My intent was not to curse [R601] but rather to protect myself. On 12/18/25 at 12:42 PM, the Director of Nursing (DON) was asked the facility's expectation regarding staff's behavior. The DON explained for staff to maintain professionalism. On 12/28/25 at 1:15 PM, the Nursing Home Administrator (NHA) was asked the facility's expectation, the NHA explained for staff to deescalate and to get help if needed. R603 and R605 A review of Facility Reported Incident (FRI) 2696242 noted the following, Incident Summary: At approximately 10:43pm the administrator received a call from the DON [Director of Nursing] and the DON reported that approximately around 10:30pm CNA [Certified Nursing Assistant] entered resident [R603] room and noticed [R603's] lip was bleeding and some redness under [their] eye. CNA asked [R603] what happened and [R603] was unable to say however [they] pointed towards [their] roommate [R605]. Staff immediately conducted a pain assessment and no pain noted. Staff then conducted a room change and moved resident [R603] to another room. Resident is calm and remains safe in new room. On 12/18/2025 at 10:40 AM, R603 was observed lying in bed, sleeping. No bruises were noted on their face. On 12/18/2025 at 11:16 AM, an interview was conducted with CNA A. CNA A reported they were about to get R603 dressed and up in their wheelchair. CNA A reported they heard about the incident from R603's current roommate but did not notice any changes in R603's behavior. A review of the medical record revealed R603 admitted into the facility on 4/5/2013 with the following medical diagnoses, Major Depressive Disorder and Dysphagia. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief interview for Mental Status (BIMS) score of 0/15, indicating an impaired cognition. R603 also required staff assistance with bed mobility and transfers. On 12/18/2025 at 10:52 AM, R605 was observed sitting in their bed. R605 was unable to answer any questions related to the incident with R603. A review of the medical record revealed that R605 was admitted into the facility on 1/6/2022 with the following medical diagnoses, Unspecified Dementia without behavioral disturbance and Adult Failure to Thrive. A review of the most recent MDS assessment revealed a BIMS score of 0/15 indicating impaired cognition. R605 also required staff assistance with bed mobility and transfers. On 12/18/2025 at 11:57 AM, a phone interview was conducted with CNA B. CNA B reported they worked the night of the incident between R603 and R605. CNA B reported they heard R605 screaming loudly, and it was not their usual scream, so they went in the room to check on them. CNA B reported they observed R605 trying to pull R603 out of the bed. CNA B stated they observed R603 shaking their head and saying no, with water all over them and a busted lip. CNA B reported they removed R605 out of the room and got the nurse for the room. CNA B reported the nurse then called the DON. On 12/18/2025 at 12:08 PM, an attempted phone call was made to Licensed Practical Nurse (LPN) C with no answer. On 12/18/2025 at 12:29 PM, an interview was conducted with Social Worker (SW) D. SW D reported that R605 is not known to have aggressive behaviors and that R603 and R605 are no longer roommates. SW D reported R605 is currently in a room alone and they are both provided supportive visits. SW D reported that neither R603 or R605 can articulate what happened. On 12/18/2025 at 12:43 PM, an interview was conducted with the DON. The DON reported they are unsure what happened because the whole incident was not witnessed. The DON reported R605 is not aggressive and that the only thing they do is refuse care sometimes. The DON reported R603's bedding was wet, but the canister and plunger for the tube feeding was observed to be on the bed. The DON reported they still separated the residents and will be keeping R605 by themselves for a while to make sure they are not missing anything. The DON reported R603 and R605 have never had issues before and that R605 has never had any incidents before this one and none after. A review of a facility policy titled, Abuse and Neglect Prohibition noted the following, Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, misappropriation of property and mental abuse or enabled through the use of technology.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week potentially affecting all 132 residents residing in the facility. Findings include: A review of the Centers for Medicare & Medicaid Services (CMS) PBJ (Payroll Based Journal) Staffing Data Report for the 1st quarter of 2025 (October 1 to December 31) revealed the facility triggered for excessively low weekend staffing. A review of requested Daily Staffing Sheets from the 1st quarter of 2025 revealed the following dates without RN coverage: 10/15/25, 10/16/25, 10/25/25, 11/6/24, 11/13/24, 11/14/24, 11/18/24, 11/19/24, 11/20/24, 12/7/24 and 12/24/24. On 3/25/25 at 9:43 AM, Staff Scheduler D was interviewed regarding RN coverage and explained that it is difficult to hire and retain registered nurses, and explained that call in's occur often. On 3/25/25 at 3:57 PM, the Director of Nursing (DON) was asked for her expectations in ensuring RN coverage was adequate, and she explained that the expectation is that there be coverage. A review of the Staffing and Scheduling policy revealed, Staffing for acuity involve understanding the needs of residents and staffing according to assure care can be provided to address resident needs .

Based on interview and record review, the facility failed to ensure certified nurse aides (CNAs) completed the required 12 hours of in-service education annually for three (E, F, and G) of five CNAs reviewed for inservice education. Findings include: A review of the following three certified nurse aide annual 12-hour nurse aide training/ in-services were reviewed: CNA E was hired on 3/1/22. There were no 12-hour training/ in-services provided by the facility. CNA F was hired on 3/16/22. There were no 12-hour training/ in-services provided by the facility. CNA G was hired on 3/14/17. There were no 12-hour training/ in-services provided by the facility. On 3/25/25 at 3:37 PM, Staff Developer B was asked about the missing 12 hours of training, and explained that she is new in the position, and acknowledged that she has been trained differently on when and how CNA's 12 hours of training annually were met. On 3/25/25 02:00 PM, the Director of Nursing (DON) was asked about the 12 hours of CNA training not being completed, and she explained her expectation is that CNAs meet their required training. A review of the facility's, Facility Assessment revealed the following, Required in-service training for nurse aides. In-Service training must be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year .

Based on observation, interview and record review, the facility failed to timely revise care plans to accurately reflect identified problems and interventions for one resident (R55) of one residents. Findings include: On 3/23/23 at 9:00 AM, R55 was noted in their room noted laying halfway off the bed and on the floor. R55 was noted to be in a wet brief which was hanging off. When asked about about the care, R55 appeared confused and stated they were unsure about what to do. On 3/24/25 at 8:45 AM, R55 was observed in their room with a shirt on, no brief, no non-slip socks, looking for something to eat. On 03/25/25 at 9:00 AM, R55 observed in their room walking barefoot. A review of R55's electronic medical record revealed R55 was admitted on [DATE] with multiple diagnoses including Acute Respiratory Failure, Dementia, Anxiety and Macular Degeneration. A review of R55's Minimum Data Set (MDS) assessment dated on 12/26/2024 revealed a Brief Interview of Mental status (BIMS) assessment of 13 indicating resident is cognitively intact. Further review of R55's revealed a recent fall on 3/21/25 the history of falls care plan last revised on 9/11/24, revealed several previous interventions but no subtantional most recent intervention. On 03/25/25 at 1:45 PM, The Director of Nursing (DON) was interviewed regarding updated care plans. She indicated the expectation is care plans for falls are updated after the team reviews the fall. A review of the facility policy titled, Comprehensive Care Plans revealed the following: The comprehensive care plan must be patient centered, be in the I care plan format and consistent with resident rights and describe that each resident is provided the necessary care and services including resident's choices to attain or maintain the highest practible physical, mental, and psychosocial well-being consistent with the residen'ts comprehensive or quarterly ; assessment. The comprehensive care plan must be consistent with resident's rights and : reflects current standards of practice

Based on observation, interview, and record review, the facility failed to provide adaptive equipment for one resident (R40) out of three reviewed for Activities of Daily Living (ADLs). Findings include: On 3/24/2025 at 2:18 PM, R40 was observed in their room eating lunch. R40 was observed trying to pick their water cup up and dropped the cup on themselves. R40's water cup was noted to be in a foam cup. R40 reported they usually have a smaller sippy cup that makes it easier for them to drink their water. R40 reported the cup broke about two months ago and someone stated they were ordering a new one. R40 indicated they had not heard anything else about the new cup. A review of the medical record revealed that R40 admitted into the facility on [DATE] with the following medical diagnoses, Epilepsy and Dysphagia. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status assessment score of 10/15 indicating an impaired cognition. R40 also required staff assistance with bed mobility and transfers. Further review of the medical record revealed the following physician orders, Modified light weight water cup for daily use .Active. Please ensure that resident has smaller drinking cup at bedside .Active. On 3/25/2025 at 10:47 AM, R40 was observed in bed with no modified light weight water cup at the bedside. On 3/25/2025 at 10:59 AM, an interview was conducted with the Registered Dietitian (RD) A. RD A stated they had spoken to the Occupational Therapist (OT) that was caring for R40, and they indicated R40 could use a regular foam cup, and the other order needed to be discontinued. On 3/25/2025 at 11:58 AM, an interview was conducted with the Director of Nursing (DON). The DON stated there used to be a sippy cup that was easier for R40 to use, and they would have to look into reordering one. A review of a facility policy titled, Adaptive Eating Equipment noted the following, Policy: It is the policy of this facility to assure adaptive equipment is available for those residents who would benefit from their use, based on comprehensive assessment, to assist the resident to achieve his/her highest functioning potential.

Based on observation, interview, and record review, the facility failed to complete and document skin treatments for one resident (R93) of one reviewed for skin treatments/documentation. Findings include: On 3/23/25 at 9:24 AM, R93 was observed sitting on the side of their bed, right leg observed wrapped in a bandage and undated. R93 explained that they had gotten into an accident which caused the wound on their leg, but was unsure of the last date their bandage had been changed. A review of R93's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Cellulitis of the Right Lower Limb and Peripheral Vascular Disease. Further review revealed that the resident was cognitively intact and required limited assistance with toilet use, bathing, and dressing. Further review of the medical record revealed the following physician order dated 1/8/25, Right Lower Leg: Cleanse with Wound Cleaner, pat dry apply medihoney cover with Abd (abdominal pads) and kerlex. every day shift for WD (wound dressing) and every 24 hours as needed. A review of the January 2025 Treatment Administration Record (TAR) revealed the following dates with missing treatments, 1/16, 1/18, 1/19, 1/21, 1/23, 1/24, 1/26, 1/29, and 1/30. A review of the February 2025 TAR revealed the following missing treatment dates: 2/6, 2/9, 2/12, 2/16, 2/20, 2/21, 2/22, 2/23, and 2/25. A review of March 2025 TAR revealed the following missing treatment dates: 3/2, 3/5, 3/6, 3/7, 3/12, 3/14, 3/17, 3/18, 3/19, 3/22, and 3/23. On 3/25/25 at 1:54 PM, the Director of Nursing (DON) was interviewed regarding the missing TAR treatments, and she explained the expectation is that the treatments are completed as ordered. A review of the facility's policy revealed the following, .3. Residents admitted with skin impairments will have appropriate interventions implemented to promote healing, a physician's order for treatment, treatment record initiated .

Based on observation, interview and record review, the facility failed to turn, reposition, and implement offloading interventions to prevent further skin breakdown for one resident (R85) of three residents reviewed for pressure ulcers. Findings include: On 3/24/25 at 2:29 PM, R85 was observed laying on their backside without pillows under either side of R85's body. On 3/25/25 at 9:12 AM and 11:15 AM, R85 was observed laying on their backside without pillows under either side of R85's body. A pillow was observed under R85's feet. On 3/25/25 at 12:19 PM, an observation of R85's wound was made, the wound was clean, with some slough present, and scar tissue was observed surrounding wound. On 3/25/25 at 2:05 PM, R85 was observed laying on their backside without pillows under either side of R85's body. Three pillows were observed laying in a chair. A review of R85 medical record revealed, R85 was admitted to the facility on [DATE] with diagnosis of Encephalopathy. A review of R85's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted R85 with a severely impaired cognition and with total dependence of staff to complete activities of daily living. A review of R85's medical record noted, 3/7/2025 10:51 Nurses Note: CNA (Certified Nursing Assistant) notified that patient had open wound on buttock. Cleansed area with soap and water, applied barrier cream. Further review noted, 3/11/2025 at 16:28, Skin/Wound Note Text: Resident noted with re-current open area to Sacrococcyx @ (at) 5.0x3.0x0.2 centimeters (cm) pale yellow base, scant serous drainage, irregular edges. No objective s/s (signs and symptoms) of pain noted. Attending NP (Nurse Practitioner) notified new order noted. A note dated 3/12/2025 at 11:46, Skin/Wound Note Late Entry: Encounter Date: 03-12-2025. Chief Complaint: Follow up consult regarding sacrococcygeal . Patient examined and noted to have stage III pressure ulcer (full-thickness skin loss) sacrococcygeal treatment and offloading interventions implemented. Skin: No rash, warm and dry; Right buttocks which previously extended into sacrococcygeal resulting in stage III pressure ulcer resolved and reopened as unstageable pressure ulcer 3.0 x 4.0 x utd (Unstageable Full Thickness Depth) unable to determine 9 cm, red pink tissue and 20% eschar (dead tissue) with scant serous drainage . Assessments/Plans: Sacrococcygeal unstageable pressure ulcer . Recommended treatment Cleanse pat dry apply Medihoney cover with dry dressing change every other day and as needed Reposition Low-air-loss mattress ensure settings are appropriate and functioning for patient every shift . A review of R85's care plan revealed, Focus: I need assistance with my ADL's. Date Initiated: 08/20/24. Goal: I will maintain my current level of functioning through the review date. Date Initiated: 08/20/24. Interventions: I require total assistance with bed mobility, transfers, toileting, personal hygiene, dressing, bathing and eating. Date initiated: 8/20/24. Focus: I have potential/actual impairment to skin integrity of the (Sacrococcyx/bilateral buttocks) r/t (related to) Stage III Pressure Injury, Per wound NP res (resident) has multiple underlying medical conditions, wound may not heal & formation of more wounds may be unavoidable: Impaired mobility, incontinent. Date initiated:11/06/2024. Goal: By allowing staff allocated interventions my risk for healing complications and further skin breakdown will be reduced. Date imitated: 11/06/24 . Order: Coccyx/Bilat Buttocks: Cleanse w (with)/soap and water apply house barrier every shift and as needed every shift for skin and every 12 hours as needed. Start: 12/05/24. Order: Sacrococcygeal: Cleanse w/Dakins (a cleansing solution), pat dry, apply Medihoney cover w/dry dressing every day shift for skin and every 48 hours as needed for skin. Start: 3/14/25. A review of the March 2025, Treatment Administration Record (TAR) revealed, treatments not documented as completed on 15th,16th, 19th, 20th, and 22nd. On 3/25/25 at 1:43 PM, the Director of Nursing (DON) was asked about R85's care planned interventions. The DON reported R85 is high risk (for skin breakdown) and should be repositioned every 2 hours with pillows. A review of the facility's policy Facility-Acquired Pressure Ulcers undated, revealed, Anticipated Outcome: Residents will be identified for their risk of skin breakdown. Residnets admitted without pressure ulcers will have measures implemented to reduce the prevalence of acquired pressure uclers .

Based on observation, interview, and record review, the facility failed to apply a splint/brace for one resident (R34) out of two reviewed for limited mobility. Findings include: On 3/24/2025 at 8:30 AM, R34 was observed laying in the bed, a towel was observed rolled up in their left hand. No brace/splint was observed to be in place. A review of the medical record revealed that R34 admitted into the facility with the following medical diagnoses, Dysphagia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating they were unable to complete the assessment. R34 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed the following orders, B/L (Bilateral) elbow splint/hand splint .Active. On 3/25/2025 at 8:58 AM, R34 was observed laying in the bed, a towel was observed rolled up in their left hand. No brace/splint was observed to be in place. On 3/25/2025 at 11:57 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the schedule and application of R34's B/L elbow/hand splint. The DON indicated they would have to look more into the application for the elbow/splint. On 3/25/2025 at 12:01 PM, an interview was conducted with Restorative Nurse B. Restorative Nurse B' stated R34 is on the nurse maintenance program and is reflected on the care plan. Restorative Nurse B indicated they do not apply the splint through the restorative program and said nursing staff apply resident's splints. An application schedule for the splint/brace was requested, but not received by end of survey. A review of a facility policy titled, Braces and Splints noted the following, 8. Restorative staff or the licensed nurse will be responsible for application and removal of splints.

Based on observation, interview, and record review, the facility failed to ensure meals were served at a preferred and palatable temperature for three sampled residents (R20, R31, and R94) from a total of three sampled residents reviewed for food palatability. Findings include: R20 On 3/23/25 at 9:30 a.m., R20 was observed laying in the bed. R20 expressed several concerns pertaining to the meals. R20 saying, it is a shame that my daughter has to spend money to buy food so I can have something decent to eat. The vegetables served last week were cold and hard. A review of R20's electronic medical record revealed R55 was admitted on [DATE] with multiple diagnoses including Chronic Obstructive Pulmonary Disease, Bilateral Osteoarthritis of the knee, Major Depressive Disorder and Alcohol Abuse. A review of R20's Minimum Data Set (MDS) assessment dated on 2/08/2025 revealed a Brief Interview of Mental status (BIMS) assessment of 15 indicating resident is cognitively intact. 34851 R31 On 3/23/25 at 9:26 AM, R31 reported the food at the facility is bad. R31 was asked which meals. R31 reported all meals at the facility are not good. R94 On 3/23/25 at 9:57 AM, R94 reported the food doesn't look good and that when it is good, they are not given enough food. A review of the resident council meeting minutes for February 2025, revealed multiple complaints regarding the food. The meeting minutes reflected concerns about food being cold when they receive their food trays and food carts being left on the units for long periods of time. A review of the facility policy titled, Food Palatability-Hot Food Temperatures dated 2018, Policy: The healthcare community prepares and serves food and beverages that are palatable, attractive and at safe and appetizing temperature. Procedure: Hot foods will be held at or above135 F. Once the food is plated for serving the food temperature will begin to drop. By the time the hot food reaches the client it is expected to be less than 135 F. Variance in hot food temperatures occurs due to the ability of different foods to hold heat. For example mashed potatoes stay hot longer than rice . (3). The healthcare community makes every effort to take all factors into consideration to ensure that hot food and beverages are served at a safe and appetizing temperature.

Based on interview and record review, the facility failed to obtain consent and/or declination for influenza and pneumococcal immunizations for two residents (R34 and R92) out of five reviewed for immunizations. Findings include: On 03/25/2025 at 11:30 AM, the infection control task was completed with the Director of Nursing (DON) and acting Infection Control Preventionist (ICP) C. R34 A request was made to review the influenza and pneumonia consents and/or declinations for R34. ICP C stated they knew the responsible party for R34 refused all vaccinations, however they did not know where the papers were with the refusals. A review of the medical record revealed that R34 admitted into the facility with the following medical diagnoses, Dysphagia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating they were unable to complete the assessment. R34 also required staff assistance with bed mobility and transfers. No consent or declination was received by the end of survey. R92 A request was made to review the influenza and pneumonia consents and/or declinations for R92. The sheet provided did not have any signatures on it. The sheet documented the words disconnected 11/11/24, 15:15 written at the bottom. A review of the medical record revealed that R92 admitted into the facility with the following medical diagnoses, Cerebral Infarction and Sepsis. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 11/15 indicating an impaired cognition. R92 also required staff assistance with bed mobility and transfers. ICP C stated they knew the phone line was disconnected when the previous ICP tried to get consent from the responsible party, but they were unsure what happened after that. A review of a facility policy titled, Pneumonia noted the following, Procedure .1. Offer pneumococcal vaccine to residents on admission .2. Offer annual influenza vaccine.

Based on interview and record review, the facility failed to obtain consent or declination for the COVID-19 immunization for two residents (R34 and R92) out of five reviewed for immunizations. Findings include: On 03/25/2025 at 11:30 AM, the infection control task was completed with the Director of Nursing (DON) and acting Infection Control Preventionist (ICP) C. R34 A request was made to review the Covid-19 consent or declination for R34. ICP C stated they knew that the responsible party for R34 refused all vaccinations, however they did not know where the papers were with the refusal. A review of the medical record revealed that R34 admitted into the facility with the following medical diagnoses, Dysphagia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating they were unable to complete the assessment. R34 also required staff assistance with bed mobility and transfers. No consent or declination was received by the end of survey. R92 A request was made to review the Covid-19 consent or declination for R92. The sheet provided did not have any signatures. The sheet documented the words disconnected 11/11/24, 15:15 written at the bottom. A review of the medical record revealed that R92 admitted into the facility with the following medical diagnoses, Cerebral Infarction and Sepsis. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 11/15 indicating an impaired cognition. R92 also required staff assistance with bed mobility and transfers. ICP C stated they knew the phone line was disconnected when the previous ICP tried to get consent from the responsible party, but they were unsure what happened after that. A review of a facility policy titled, Covid noted the following, .Documenting COVID-19 .The facility will maintain documentation for all residents and staff on COVID-19 vaccination.

Based on observation, interview, and record review, the facility failed to maintain a tube feeding pole and floor in a sanitary manner for three sampled residents (R3, R19, and R85) out of five reviewed for tube feeding. Findings include: R3 On 3/23/25 at 10:01 AM, R3 was observed in bed with a tube feeding pole next to the bed. The pole and floor were observed with large amounts of dried formula on them. On 3/24/25 at 9:04 AM and at 2:27 PM, the tube feeding pole and floor was observed in the same condition. A review of R3's medical record noted, R3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Debility, Cardiorespiratory Conditions. A review of R3's annual Minimum Data Set (MDS) assessment, dated 2/2/25 noted, R3 with a severely impaired cognition and dependent of staff for activities of daily living (ADLs). A review of R3's order noted, in the evening Jevity 1.5 @60cc/hr x 16 hrs (hours) Up at 6pm for 16 hours or until dose complete to provide 960cc (cubic centimeter) formula, 1440 kcal (Kilocalorie), 61.2g (grams) protein. Provide 35cc/hr x 16hrs water to provide 560cc. 4/5/24. R19 On 3/23/25 at 11:21 AM, R19 was observed in bed with a tube feeding pole next to the bed. The pole and floor were observed with large amounts of dried formula on them. On 3/24/25 at 2:24 PM, the tube feeding pole and floor was observed in the same condition. A review of R19's medical record noted, R19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis with Hemiplegia and Hemiparesis, aphasia follow CVA (Cerebrovascular Accident). A review of R19's MDS assessment dated [DATE] noted R19 with a severely impaired cognition and dependent of staff for ADLs. A review of R19's order revealed, one time a day Jevity 1.5 via PEG continuously via pump @ 70cc/hr x 12 hrs. Up @ 730pm until 730am dose complete to provide 840cc, 1260kcal, 53.6g pro. Provide 480cc water via auto flush over 12 hrs (40cc/hr x 12hrs). R85 On 3/23/25 at 10:06 AM, R85 was observed in bed with a tube feeding pole next to the bed. The pole and floor were observed with large amounts of dried formula on them. On 3/24/25 at 9:45 AM, the tube feeding pole and floor was observed in the same condition. On 3/25/25 at 1:46 PM, the Director of Nursing (DON) was asked the facility's expectation regarding cleaning spilled formula. The DON reported the Nurses are wiped if down if they spill and housekeeping when there is a needed. A review of the facility's policy titled, Daily Cleaning Procedures undated revealed, . 5) Disinfect. Work your way clockwise around the room (starting at the door and finishing at the door) and disinfect flat surfaces and high-touch items. This includes, but is not limited to: doorknobs, light switches, call lights, TV remotes, bed side [NAME], bed frames, footboards and headboards, bedside tables, closet handles, window sills, chairs . 9. Damp Mop. Damp mop perimeter of the room. Then stat at back of room and use a figure 8 motion to damp mop the entire floor while working your way back to the door .

This citation pertains to intake #'s MI 865 and MI 858 Based on interview and record review, the facility failed to complete preventative routine skin assessments and complete and/or document wound care treatments for one resident (Resident #709) of two residents reviewed for pressure ulcer (a wound caused by prolonged pressure on the skin over a bony prominence) care, resulting in the development and worsening of a stage 3 pressure ulcer and hospitalization . Findings include: A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #709 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #709 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition and needed extensive assistance from staff for bed mobility and transfers. Section M (skin section) on the MDS reflected no skin issues or wounds. Section M also described a Stage 3 pressure ulcer as: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling On 10/04/2021 at 12:42 PM, Confidential Witness B was interviewed via telephone. According to Confidential Witness B, Resident #709 was hospitalized due to [CONDITION(S)] (a severe infection) and eventually passed away at the hospital. Confidential Witness B explained that the facility had not explained to him the severity of Resident #709's wounds. A record review of the Weekly Head to Toe Assessments for Resident #709 revealed the following: 04/25/2021-no new skin issues . 07/11/2021-PU (pressure ulcer) coccyx (area just above the buttocks below lower back) L (length/centimeters) 0.5 x 0.2 (width/centimeters) . There were no weekly head to toe skin assessments in the medical record between 04/25/2021-07/11/2021. A record review of the progress notes for Resident #709 revealed the following: 07/29/2021 12:50 (PM) .Resident seen weekly by wound care team. Coccyx / bilateral buttocks is a stage 3 pressure injury (the wound extends through the first two layers of skin and into the muscle), no progression in wound this week. Treatment: [MEDICATION(S)] daily and prn (as needed) for 7 days. Preventative measures: low air loss mattress, frequently reposition, float heels. Resident receiving liquid protein BID (twice per day), protein enhanced fruit juice with meals to aid in promotion of wound healing. Will continue to monitor. 08/08/2021 12:18 (PM) Nurses Note .Wound care NP (Nurse Practitioner) and MD (Medical Director) notified via phone for wound care orders, per wound care NP resident was to start on [MEDICATION(S)] (antibiotic) 100 mg (milligrams) po (by mouth) TID (three times per day) for 7 days, wound orders clarified and carried out. Assigned nurse made aware of new orders . 8/10/2021 16:01 (04:01 PM) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .has stage 3 wound on lower back .being followed by wound care team. There is some drainage noted and started on [MEDICATION(S)]. Clinically stable . A record review of the physician orders revealed the following wound care orders for Resident #709: 07/12/2021-07/26/2021-Cleanse coccyx with wound cleanser, pat dry then apply [MEDICATION(S)] gel then cover with dry dressing daily and prn 07/13/2021-09/13/2021-low air loss mattress, frequently reposition, float heels. Staff to monitor every shift. 08/09/2021-08/16/2021-Irrigate sacrococcyx / bilateral buttocks with dakins solution then apply dakins soaked gauze to wound then cover with dry dressing daily and prn for 7 days A record review of the Treatment Administration Record (TAR) for Resident #709 reflected the following: July 2021 (Initiated 07/13/2021)-low air loss mattress, frequently reposition, float heels. Staff to monitor every shift every shift for monitor. The order was not signed out as being completed on 07/15/2021 for both shifts and on 07/16/2021, 07/19/2021, 07/24/2021, 07/25/2021, 07/29/2021 and 07/30/2021 on day shift. On 07/21/2021 and 07/22/2021 it was not signed out as being completed on the night shift. Cleanse coccyx with wound cleanser, pat dry then apply [MEDICATION(S)] gel then cover with dry dressing daily and prn every day shift for pressure injury stage 3. The treatment was not signed off as being completed on 07/24/2021, 07/25/2021 or 07/26/2021. August 2021 (Initiated 08/09/2021-08/15/2021)-Irrigate sacrococcyx/bilateral buttocks with dakins solution then apply dakins soaked gauze to wound then cover with dry dressing daily and prn for 7 days every day shift for wound infections for 7 days. The treatment was not signed out as being completed on 08/09/2021-08/10/2021, 08/12/2021-08/14/2021. low air loss mattress, frequently reposition, float heels. Staff to monitor every shift every shift for monitor. The order was not signed out as being completed on 08/09/2021-08/10/2021, 08/12/2021-08/14/2021. A record review of the Wound Clinic Notes for Resident #709 revealed the following: 07/19/2021- .Coccyx stage 2 pressure Injury PU 4.4 x 6.5 x 0.2 cm (centimeters) Wound base pink base epithelialization 40% necrosis (black/dead tissue) . 07/26/2021- .7.5 x 8 x 0.2 cm .[MEDICATION(S)] x 7 d (days) . 08/02/2021- .9 cm x 10 cm x 0.2 cm .underlying [CONDITION(S)] (skin infection) . A record review of the Care Plan for Resident #709 revealed the following: Focus-I have potential impairment to skin integrity r/t (related to) my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Date initiated 09/14/2018. Goal-I will be free from injury through the review date. Interventions-Encourage good nutrition and hydration in order to promote healthier skin. If my skin is impaired - observe and document the location - report it to my nurse as soon as possible. Keep my skin clean and dry. Use lotion on dry skin. Focus-I have a rash of the Coccyx/Bilateral Buttock r/t Contact [CONDITION(S)]. Initiated 11/22/2019. Goal-I will have no s/sx (signs and symptoms) of infection of the rash . Interventions-Encourage me to get out of bed as tolerated. For dry and flaky skin use high quality moisturizers to rehydrate my skin. heel lift boots. Observe my skin rashes for increased spread or signs of infection. Pressure relieving Mattress/Low Air Loss. Provide me with the treatment as ordered by my doctor. Focus-I have actual impairment to skin integrity of the coccyx r/t pressure injury stage 3. Initiated 07/12/2021. Goal-I will have no complications r/t pressure injury of the coccyx. Interventions-Encourage good nutrition and hydration in order to promote healthier skin. Follow your Skin Management Program. If my skin is impaired - observe and document the location - report it to my nurse as soon as possible. Weekly treatment documentation to include measurement of each area of my skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. On 10/06/2021 at 09:33 AM, Wound Care Nurse A was interviewed in regards to the skin prevention program. Wound Care Nurse A explained that she was new to the position. She was asked who completes the wound care and stated, I do wounds, when short staffed, I have to work on the floor, then the nurses on the floor have to do them. I monitor them. The Wound Nurse Practitioner comes in every Monday to round. We assess everyone who has wounds in the facility, and update orders if needed. I do huddles with my CNA's (Certified Nurse Assistant) and tell them if there are new issues, to tell me. I have a wound nurse that works weekends and I check on new admissions on Mondays. Wound Care Nurse A was asked about how often skin assessments were done on all the residents in the facility and stated, The nurse is supposed to do skin assessments on shower days (weekly). Wound Care Nurse A revealed there was a chart that was out on the floor for nurses and CNA's to follow. The chart listed the residents to be showered and the skin assessments that were due. Wound Care Nurse A further stated, CNA's verbally tell me or write me a note or chart it when they see new skin issues. Wound Care Nurse A was asked what happens if a resident does not get their shower or bed bath and explained that the nurses on the floor are still required to complete skin checks. Wound Care Nurse A was asked to review the missing treatments and skin assessments for Resident #709 and stated, I started right when (Resident #709) had went to the hospital. I am not sure what happened (why the treatments or assessments were not completed). On 10/06/2021 at 01:42 PM, the Director of Nursing (DON) was interviewed in regards to skin assessments of residents and stated, Skin assessments are done weekly by the nurses (on the floor) and wound care (nurses). If they need a treatment in place, those are put in place at that time, preventative measures (are put in place), and a wound consult. The DON was asked who was responsible for completing the wound care and explained that if the wound nurse is not available, then everyone (floor nurses) would do them. The DON stated, The Wound Nurse does wounds, except on Tuesdays, that is her paperwork day. The DON was asked to review Resident #709's July and August 2021 TARs and the lacking in documentation of the treatments/interventions to the wound not being completed and stated, It should be done with the Wound Nurse or the nurses on the floor. The DON was asked to review the Weekly Head to Toe Skin Assessments for Resident #709. The DON was asked about the missing assessments and stated, I can't speak for them (the floor nurses). I had just started, I am not sure why they (skin assessments) were not done. A review of the facility policy titled Skin Management Facility Guidelines (no date) revealed the following: The facility is committed to providing care and services to residents to prevent the development of skin breakdown. The following guidelines are in place to reach this goal .7. Place each resident on a weekly head-to-toe skin assessment on [Electronic Medical Record] and indicate day and shift on which the check will be conducted .

This citation pertains to intakes MI 691, MI 993, MI 037, MI 637. Deficient Practice Statement 1 of 2: Based on observation, interview, and record review, the facility failed to prevent neglect for two sampled residents (R909 and R910) of three reviewed for care concerns, resulting in the potential for as well as actual unmet care needs, worsening of a pressure ulcer, skin breakdown, burning pain, resident frustration, feelings of despair, humiliation and loss of dignity. Findings include: A review of intake MI 637 revealed the following: .This facility is more concerned about getting paid .instead of .quality of care various statements that have been verbalized .[to my family member from staff, such as] Sometimes we are short staffed so we are unable to change [R909] right away, . [R909] has layers of dirt under [their] nails hands and feet .This facility is beyond unprofessional and provides poor patient care . A review of intake MI 037 revealed, It was alleged the resident was left soiled for an extended period of time. A review of intake MI 993 revealed, It was alleged call lights are not being answered in a timely manner. R909 A review of R909's Minimum Data Set (MDS) assessment dated [DATE] reflected that the resident was initially admitted into the facility on [DATE] and readmitted on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that the resident was moderately cognitively impaired and required extensive assistance from staff for bed mobility, dressing, and hygiene/bathing. On 5/10/21 at 10:13 AM, R909 was observed lying on their side in bed. R909 stated, My bed is wet, and a wet spot was observed in the middle of R909's fitted sheet. When queried if staff at the facility change their brief often, R909 stated, No. They change me when necessary. R909 was observed to hit their call light button multiple times. The call light was observed to activate both inside the room and outside in the hallway. On 5/10/21 at 10:33 AM, R909's call light was observed to still be on. On 5/10/21 at 10:39 AM, R909 was asked if staff had come to change them yet and responded, Nope. R909 was asked if they had a wound on their bottom to which they responded, Yep. R909's call light remained on at that time. R909's record reflected they were admitted to the facility with a Stage IV (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone) pressure ulcer to the coccyx. The (name of company) wound care note dated 4/27/21 reflected: R909 had a Stage 4 sacrococcyx/bilateral buttocks pressure ulcer, that had a status of not healed. The wound measured at 9.5 cm (centimeters) in length, 4 cm width, 5 cm depth and had exposed bone. When queried further about call light response times, R909 stated, It sometimes takes them 20 minutes to come in here. R909 indicated that they were unable to walk. At 10:43 AM, a visitor came to R909's window and they began speaking with the visitor on the phone. An unidentified staff member knocked on R909's door and entered the room wearing full personal protective equipment (PPE) due to the resident being on the observation unit. The staff member did not ask R909 if they needed anything, turned R909's call light off, removed their PPE, and exited the room. R909's visitor and phone call ended just after the staff member exited the room. R909 stated, I still need to be changed .I used the bathroom on myself about 30 minutes ago. R909 indicated they were going to wait and see if staff were going to come back and then stated, They probably won't come back. When asked if that was usually the case, R909 stated, It depends .Sometimes I just call, call, call, call and they don't come. Sometimes they do, it depends on who is working .I usually have to scream or raise my voice to be heard, that's how much they don't come. R909 then pressed their call button which was confirmed to turn on at 10:51 AM. On 5/10/21 at 11:03 AM, R909 was observed to press their call button five more times despite it still being on. On 5/10/21 at 11:07 AM, Nurse Manager G entered R909's room and asked the resident what they needed. Nurse G stated she would go get some help and shut R909's call light off. Staff entered back into R909's room at 11:14 AM (1 hour and 1 minute after call light request for incontinent assistance). R909's top dressing for their wound was observed to be soiled and sitting atop their bedside table. R909's brief was observed to be wet. The resident's wound packing was observed to be soiled with purulent drainage and had come out of R909's wound. While providing care to R909, Certified Nursing Assistant (CNA) H was queried as to when the last time R909 was changed. CNA H stated, Before breakfast. CNA H indicated that R909 was supposed to be checked and changed every two hours and stated, But sometimes though [R909] will call. On 5/10/21 at 12:54 PM, CNA I was observed going in and out of resident rooms on the Oak unit, attempting to assist residents with lunch. CNA I was the only staff member observed on the unit at the time. CNA I was interviewed regarding their assignment for the shift and indicated that she alone was responsible for about 14 or 15 residents. On 5/10/21 at 2:50 PM, R909's room was entered, where the call light was observed to already have been activated. R909 was asked how long their call light had been on for to which the resident responded, About 15 minutes. See how long they make me wait? R909 was observed to hit their call button multiple times despite the call light already being active. R909's wound dressings were visibly soiled and on the resident's bed, and the resident's brief was observed to be halfway pulled off. R909 stated, I went to the bathroom on myself. R909 indicated they had urinated and needed to be changed. When asked how it made them feel to have to wait so long for staff to help them, R909 stated, It makes me feel lost. On 5/10/21 at 3:20 PM, R909's call light remained on. Activity Aide E came into R909's room and gave the resident some snacks. Activity Aide E left the room, then came back at 3:25 PM and asked R909 what they needed since their call light was on. R909 stated, I need to be changed. Aide E left, then came back and told R909 that she informed the resident's nurse and aide. On 5/10/21 at 3:30 PM, this surveyor exited R909's room to the hallway just outside of the room. R909's call light was still activated in the hall. Hallway call light indicators were also on for neighboring rooms [ROOM NUMBER]. An IV pump was heard beeping in room [ROOM NUMBER]. No staff were visible in the vicinity or at the nurses' station. The resident in room [ROOM NUMBER] was heard yelling, It's going to keep going off! Come here, come here! On 5/10/21 at 3:40 PM, R909's call light remained on. Licensed Practical Nurse (LPN) J was observed going into room [ROOM NUMBER] where the IV pump was still beeping. LPN J was heard telling the resident in room [ROOM NUMBER], I was with another patient, that's why I didn't come. Upon exiting the room, LPN J was queried regarding the location of her fell ow staff members. LPN J stated, We just got three admissions. Two of the afternoon CNAs that came in are on 1:1 sitter assignments .I haven't seen any additional CNAs here for afternoon shift other than the ones assigned to sit. On 5/10/21 at 3:45 PM, the call lights for R909, room [ROOM NUMBER], and room [ROOM NUMBER] remained on. The phone was heard at the nurses' station to repeatedly ring with no one present at the desk. LPN J opened R909's door and the resident told her they needed to be changed. LPN J indicated she would be back as she went to the nurses' station to answer the phone. An unidentified resident in a hospital-type gown was now observed standing at the nurses' station looking around. No other staff were visible in the vicinity other than LPN J. At 3:48 PM, LPN J went and opened the door to room [ROOM NUMBER] where the resident was heard asking to be changed. LPN J responded, I need to change somebody else, then I'll be back, and turned the call light off to room [ROOM NUMBER]. At 3:50 PM, LPN J gathered items to go into R909's room to change them (1 hour after call light request for incontinent assistance). Before entering R909's room, LPN J stated, This is the first I've seen it be almost 4 PM with no aide. We normally have two and that's not usually enough. LPN J was still in R909's room at 3:57 PM, and room [ROOM NUMBER]'s call light remained activated. On 5/11/21 at 12:30 PM, the Assistant Director of Nursing (ADON) was interviewed. The ADON indicated that the Director of Nursing (DON) was currently off and not present for the survey. The ADON was queried regarding the expectation for answering resident call lights. The ADON stated, Me personally I would expect within 3 minutes. Everyone is accountable for answering call lights. When queried regarding staffing challenges at the facility, the ADON did not wish to comment other than stating that the facility does have call-offs and that can present a challenge. When queried regarding how long residents should be expected to wait to receive incontinence care, the ADON responded, They should be checked and changed every 2 hours, but staff should try not to wait that long. Try to get to them as soon as possible because we don't want any breakdown .It's important for a resident with an existing wound, too. We don't want it to get worse or infected. When queried regarding the expectation for turning off a resident's call light and when that is to be done, the ADON stated, [Staff] needs to make sure whatever the resident needs is done before turning the call light off. A review of R909's care plan reflected: I need assistance with my ADL's (activities of daily living) R/t (related to) Osteomyelytis (sic) to Sacral Coccyx .and [CONDITION(S)] Date Initiated: 04/08/2021. TOILET USE: I need (Extensive assistance x 2) by you for toileting. Date Initiated: 04/08/2021. Check me at least every two hours during the day and change my brief if needed. Date Initiated: 04/08/2021. Keep me as clean and dry as possible .Date Initiated: 04/08/2021. Be sure my call light is within reach and encourage me to use it for assistance as needed. Date Initiated: 04/08/2021. I prefer to have my sleep interrupted as little as possible at night, so please use the extended wear briefs on me. Date Initiated: 04/08/2021. R910 A review of R910's MDS assessment dated [DATE] reflected that the resident was initially admitted into the facility on [DATE] and most recently readmitted on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that the resident was cognitively intact, was always incontinent of bowel, frequently incontinent of bladder, and required extensive assistance from staff for bed mobility, dressing, and hygiene/bathing. On 5/10/21 at 9:43 AM, R910 was observed lying in bed. Upon inquiry, R910 indicated they were mostly incontinent and required brief changes. R910 stated, Sometimes I have to wait hours to be changed. R910 was then asked when was the last time, they had to wait an extended period to be changed to which they replied, Just yesterday (Sunday 5/9/21). It was in the early afternoon. R910 was observed to have a clock on their wall that reflected the correct time and was asked what time they called the previous day to be changed. R910 stated, I think it was around 1 o'clock PM, and I finally got changed around 8 o'clock (PM). You talk to and aide and say, 'I need to be changed' and they either forget or just don't come back. The shift varies, it depends on who's working. Some workers would give you the shirt off their back and some don't follow up .The worst I ever had here was 18 hours I had to wait, that was last year sometime. People just tell me they'll come back and then they don't follow through, that's very common here. They say things like they're the only person here right now or they need to finish their rounds, etc. so you might ask 3 or 4 people in a row. I've brought it up to the 'higher-ups' but haven't seen a big difference. On 5/11/21 at 1:23 PM, R910 was observed lying in bed in their room. R910 stated, This morning, I called at 5:30 AM to be changed and didn't get changed until after 10:30 AM. When asked how many times they hit their call light to be changed, R910 stated, Probably about twice. When asked if they had a skin issue on their bottom, R910 stated, Yes. CNA L entered the room to collect the resident's lunch tray and was queried as to when R910 was last changed. CNA L stated, About 12:30 PM. When asked when the resident was changed before then, CNA L stated, I don't know if [R910] was changed when I got here. I got here at 8 AM today. R910 indicated they had urinated in their brief during lunch and CNA L stated she would be back. R910 stated, They usually change me within an hour (of calling) about 20% of the time. It's rare .Asking for things here doesn't really mean much. R910 was asked if they ever refuse to be changed to which they responded, Only if I haven't soiled myself, then there's no reason to be changed. When asked if staff put cream on their bottom when they were changed, R910 responded, Yes, they have the last couple of times here. On 5/11/21 at 1:47 PM, CNAs K and L entered the room to provide incontinence care to R910. CNA L stated, [R910] is good about calling when they need to be changed. R910 was rolled to their side where a brief, wet with urine was observed. Redness was present over R910's buttocks with excoriation present and multiple bloody weeping areas were noted. Bloody drainage was noted on the resident's sheets, brief and under their buttocks. R910's skin appeared fragile and moisture-laden. Redness extended up from R910's buttocks to their upper back. A spot of bloody drainage was also noted on R910's sheets closer to their pillow and appeared to have come from their upper back area. CNA K indicated that she and CNA L had told the resident's nurse earlier about the status of R910's skin and stated, [The nurse] said it was probably because the resident isn't turning in bed. On 5/11/21 at 1:54 PM, Registered Nurse (RN) M was asked to enter R910's room. While attempting to interview RN M about R910's skin, RN M indicated they did not work with the resident often and provided no further information. RN M stated they would go get the wound care nurse (WCN) and quickly exited the room. CNA L stated, This is not new, this did not just happen. At 1:57 PM, the WCN entered the room. An attempt to interview the WCN about R910's skin was made. The WCN stated the floor nurses do weekly skin assessments and alert her for new issues. Questions regarding the details of R910's skin were asked of the WCN who repeatedly said, That's on the floor nurses. When asked if she was notified regarding the status of R910's buttocks/back, the WCN responded, No. The WCN indicated she had a family member on the phone on hold and left the room. R910 was queried as to how long their buttocks had been in its current state to which the resident replied, Oh, probably weeks. And the nurses never come in and look at my bottom specifically. Just the CNAs. CNAs K and L indicated they report skin issues to nursing. R910 was noted to have been receiving wound care treatment from the wound care team on their legs and was asked when the wound care team performed full skin assessments on them. R910 stated, Wound care never assessed my bottom. A nurse does not come in to look at my bottom specifically. They come into give me meds and things but don't come in to look at my bottom. On 5/11/21 at 2:10 PM, the WCN was queried regarding any treatments that the wound care team had been providing to R910 and any existing skin issues. The WCN indicated that within the last couple of weeks the team had resolved the resident's leg wounds and had not seen the resident since then. When queried regarding R910's skin issues she observed today during incontinence care, the WCN again stated that the floor nurses were supposed to do a weekly skin assessment for residents and that CNAs could flag a skin alert in the computer for the nurses. The WCN stated, I don't go behind floor nurses to check the skin assessments, they're supposed to alert [me] with a new condition, and there is supposed to be an incident report for a change in skin. R910's record was reviewed. The most recent, Weekly Head-To-Toe Assessment-Licensed Nurses, for R910 was noted as completed on 1/23/21. Multiple wound care assessments titled, Weekly Wound Healing Record-Wound Care Nurse, were present but only addressed R910's lower extremity wounds. No change in skin report was noted in the resident's record. When queried regarding R910's not having a more recent weekly skin assessment in the record, the WCN stated, That's not on me, that's on the unit manager and floor nurses. The WCN reviewed R910's care plan and indicated that the resident had a Stage II pressure ulcer that had resolved in January 2021. On 5/11/21 at 2:19 PM, RN M was interviewed regarding receiving a skin alert for R910's bottom. RN M did not provide any information and indicated that LPN N was normally the nurse assigned to R910. LPN N was interviewed about the last time they had observed R910's skin, specifically their buttocks/back. LPN N stated they had not recently seen it, because the wound care nurse had been taking care of the resident. LPN N was queried regarding weekly skin assessments and indicated that floor nurses do skin assessments on resident shower days. LPN N confirmed that the floor nurses' skin assessments were titled, Weekly Head-To-Toe Assessment-Licensed Nurses, under the assessment tab in the medical record. LPN N added, We get a lot of agency nurses coming in . they pass meds and they're on their way. On 5/11/21 at 2:30 PM, the WCN was asked if she felt R910's observed buttock excoriation was moisture-related. The WCN stated, It could be. Nurses are responsible for signing off putting barrier cream on. [RN M] signed off on it today. So, if he signed the cream off today, he could've told me what he saw then. On 5/11/21 at 3:45 PM, R910 was observed lying in bed in their room. R910's turning wedge was observed lying atop their roommate's empty bed. When queried regarding the wedge not being in place for them, R910 stated, They didn't put it back. R910 was asked if their bottom caused them pain to which they responded, Yes it does. When asked to rate and describe their pain, R910 stated, Right now I'd say about a 7 (out of 10) .feels like a burn .I've had it for weeks. The Verywell Health 2020 online medical reference numerical rating pain scale, reflected 7 through 10 as severe pain. R910 was asked when was the last time, a nurse had them roll on their side to assess their skin. R910 responded, I can't remember, that's how long it's been. Virtually never, they never come in there to look at it. When asked how it made them feel having to sit with a soiled brief waiting to be changed, R910 stated, Quite miserable. It [CONDITION(S)], it does not feel good whether it's urine or feces .It doesn't help to sit here for hours on end with the pain after going to the bathroom. R910 denied that they were checked at 8:00 AM this morning and confirmed that they had not been changed all morning until about 12:30 PM. When queried if they had issues with the skin on their bottom in the past, R910 stated, Yes, I've had it at times in the past. When queried regarding being turned in bed, R910 stated that staff sometimes turn them in bed with the wedge but added, The issue is them not changing me enough. On 5/11/21 at 3:56 PM, Nurse Manager F was queried regarding R910's skin and indicated that as far as she knew, any skin issues that R910 had on their bottom were resolved. When queried regarding skin assessments, Nurse F stated, Floor nurses should be putting in an assessment for any new skin issues noted. There's definitely an area to document that. When queried regarding the latest skin assessment for R910 having been completed on 1/23/21. Nurse F stated she needed to go talk to the MDS nurse, so R910 would be flagged as needing a skin assessment done and was not sure why they were not flagging. Nurse F stated, There are supposed to be weekly skin assessments done by floor nurses. I am going to make sure a skin assessment is put in by [RN M] because he saw [R910's] skin. On 5/12/21 at 10:55 AM, the ADON was interviewed and asked if wound care does a full skin assessment, and if they were seeing R910. The ADON indicated that the wound care team and wound care nurse address existing wounds and that the floor nurses were responsible for doing weekly skin assessments. When queried regarding R910's most recent weekly skin assessment dated [DATE] the ADON stated, Of course [R910] should have had more since then. A review of R910's care plan revealed: Check me at least every two hours during the day and change my brief if needed. Date Initiated: 03/06/2020. Keep me as clean and dry as possible. Apply protective barrier cream prn (as needed). Date Initiated: 03/06/2020. Check my whole body for breaks in skin and treat me promptly as ordered by my doctor. Date Initiated: 02/22/2020. Follow your Skin Management Program Date Initiated: 02/24/2020. If my skin is impaired - observe and document the location - report it to my nurse as soon as possible. Date Initiated: 02/22/2020. On 5/12/21 at 2:25 PM, the Nursing Home Administrator (NHA) was interviewed and queried regarding his expectations related to answering call lights and providing incontinence care. The NHA stated that his expectation was that call lights are answered, As timely as possible, and [for residents] to be changed as needed. When queried regarding, what was the expectation of staff if they answer a call light, and are unable to assist the resident at that very moment? The NHA responded, If they let a resident know they will be back, they should be coming back. The NHA deferred clinical questions regarding skin assessments to the WCN and the ADON. A review of the facility's policy/procedure titled, Call Light Policy, updated 07- 2018, revealed, Policy: It is the policy of this facility to answer call lights as promptly as possible. Procedure: 1. Call lights should be answered by available staff as promptly as possible. 2. When answering the call light, the staff member should inquire as to the need, and if possible, meet that need as soon as practicable. 3. If the staff member cannot meet the need due to certification or licensure issues, the staff member should seek assistance from a qualified staff member. 4. The staff member who answers the call light should follow through with the resident to assure the resident's need was met. 5. Call light monitoring records are not retained more than 24 hours. A review of the facility's policy/procedures titled, Personal Care Needs: Briefs and Underpads, and Personal Care Needs: Perineal Care, both undated, revealed, 1. The licensed nurse should assess the resident to determine if he/she is a candidate for the extended use brief. Residents with open areas on the sacral area of buttocks should not use the extended use brief . Documentation: Report and document any change in skin condition. A review of the facility's policy/procedures titled, Skin: Pressure Ulcer & Skin Care Management, and Skin: Pressure Ulcer Preventative Measures 1. A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions: .Weekly on residents .2. The licensed nurse documents that the body check was completed on the resident's weekly head to toe skin record. 3. The presence of any pressure ulcer, wound, or other skin condition is documented in the designated area. 2. Residents should be monitored during care and consistently by licensed nurses to identify potential areas for skin breakdown and integrity of overall skin. 3. The nurse aide inspects the resident's skin during bathing, dressing and undressing, assisting with toileting or incontinent care. 4. The nurse aide reports to the nurse any reddened areas and/or breaks in the resident's skin. 5. The nurse inspects any reddened areas and/or breaks in the resident's skin and documents the inspection. 6. Clean skin at routine intervals and after each incontinence. 7. Individualize the frequency of skin cleansing according to the need and/or resident preference. This citation pertains to Intake: MI 781. Deficient Pratice Statement 2 of 2: Based on observation, interview and record review, the facility failed to prevent physical abuse for one sampled resident (R901) of two residents reviewed for abuse and neglect resulting in R901 sustaining a hematoma to their left eye, and psychosocial distress using the reasonable person concept. Findings include: A review of MI 781 dated 12/30/20 revealed the following, .[R901] was observed with the left side of [their] face including [their] eye blackened. According to the nursing home, a tenant that was rooming with [them] assaulted [R901]. The attachments to this intake were reviewed and included a photo taken on 12/21/20 of R901's left eye, which was observed as a large contusion, discolored and dark in color underneath the eye. On 5/10/21 at 9:29 AM, R901 was observed lying in bed. Upon approach, R901 was asked if anyone hurt them, they stated No. When asked if anyone hit them in their eye and caused an injury, they stated, No. A review of R901's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/21 at 2:30 PM, Confidential Witness A was interviewed about the alleged incident and reported that during a window visit on [R901's] birthday, they observed a black eye on R901's left eye. Confidential Witness A explained that the facility stated that R901's roommate tripped over an oxygen tank and fell on R901 causing a black eye. Confidential Witness A explained that they felt as though the incident was taken too lightly. On 5/11/21 at 10:03 AM, an interview was completed with Nurse B, assigned nurse to R901 the date of the incident. Nurse B explained that it was a little after 3:00 PM when she heard R901 hollering from their room. She explained that when she arrived to the room, she observed R901's roommate, R911 standing at the bathroom door with R901's oxygen tubing around their ankle, non-sensical in speech, and grabbing at the bathroom door. Nurse B explained that she called the assigned CNA (Certified Nursing Assistant) to the room to assist with R901 and R911, and when the CNA arrived and lifted a pillow off of R901's face, it revealed a hematoma on their eye. Nurse B was asked if the hematoma was there at the beginning of her shift at 7:00 AM, and stated, No. Nurse B was asked how the pillow appeared on top of R901's face and explained that she didn't know. Nurse B was asked about R911's behaviors at that time and explained that they were non-sensical in speech and attempting to fight staff. Nurse B also explained that R911 can be vicious, fighting and everything toward staff. Nurse B explained that R911 was moved to another room on that date, was ultimately removed from that room because they assaulted their new roommate, went out to the hospital, and was then placed in a private room where they currently remained. Nurse B was asked if they asked R901 what happened, and she explained that R901 initially stated, [R911] beat me up. Nurse B stated that as they continued assessing R901, they began accusing staff of beating them up. Nurse B was asked what the injury looked like on R901's face and stated, It looked like a lump. Blood filled. It looked like a hematoma. A review of R911's medical record was reviewed and revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R911's MDS dated [DATE] revealed that they had a BIMS of 3/15, indicating severely impaired cognition, and required extensive assistance with ADLs. R911 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . UR#1 explained that R911 was sitting in their wheelchair, but touching items on UR#1's personal table, so they asked R911 what they were doing. UR#1 explained that R911 shocked them because they stood up out of their wheelchair and grabbed them by the front of their gown and wouldn't let go. UR#1 explained that they yelled for help, and the CNA came in and removed R911 from the room. UR#1 was asked how long after R911 moved into their room did this incident occur, and stated, About a week. UR#1 was asked if they had any marks or bruises from the incident and stated, No. UR#1 was asked how that incident made them feel and stated, It's part of being here. On 5/12/21 at 9:10 AM, an interview was conducted with CNA C, assigned CNA for R901 and R911 the morning of the incident. CNA C stated that prior to the end of her shift at 3:00 PM, she did not observe any injuries on R901. On 5/12/21 at 9:23 AM, an interview was completed with CNA D who was assigned to the same unit the morning of the alleged incident. She denied that she was assigned to R901 or R911 the date of the incident. CNA D was asked if she saw R901's face the following day, and what it looked like, and stated, [R901] had purple bruising around [their] eye. A review of R901's Weekly Head-To-Toe Assessment-Licensed Nurses was reviewed and revealed that the assessment was completed on 12/20/20 and indicated the following: Site: Left Eye. Type: Hematoma. Notes: Resident noted to have a Dark Colored Hematoma Approx. (Approximately) 2.5 cm (centimeters) x 1.5 cm with a small scratch under the hematoma. No other skin defects noted. Resident deny pain at this time. On 5/12/21 at 12:10 PM, the Assistant Director of Nursing (ADON) was interviewed regarding the incident as she was responsible for completing the investigation. She stated, From what I can remember, [R911] was trying to go to the bathroom and the oxygen tubing was too long. [They] got caught in the O2 tubing and slipped. The ADON further explained that when the police arrived, they determined that R911 fell on top of R901 causing the bruising to the eye, and that they couldn't get an answer out of R901 because [they] were confused. The ADON was asked if they had determined that the incident was an accident, why they removed R911 and placed them in a different room. The ADON stated, Just in case it was something different we moved [them] .[R911] did have some behavior issues. The ADON further stated that the conclusion of their investigation determined it was an accident based on discussion with the police, the Nursing Home Administrator (NHA), CNA and Nurse. The ADON was asked if R911 had displayed any behaviors towards staff and residents and explained that R911's behaviors were related to hollering, screaming and refusing care, and didn't remember R911 doing anything to any other residents. The ADON was asked what R901's injury loo[TRUNCATED]

This citation pertains to intake MI 993. Deficient Practice Statement 1 of 1: Based on interview and record review, the facility failed to adequately monitor fluid/nutritional status, document information related to [CONDITION(S)], and document follow-up after notification of a physician related to noted changes in condition for one sampled resident (R907) of three reviewed for change in condition, resulting in incomplete monitoring and documentation of resident health status, potentially delayed treatment and hospitalization . Findings include: A review of intake MI 993 included the following allegation: It was alleged staff failed to assess and monitor the resident's respiratory difficulties resulting in hospitalization . On 5/10/21 at 9:11 AM, Confidential Witness R was interviewed regarding R907's stay at the facility. Witness R explained that in the days leading up to R907's discharge to the hospital from the facility, was due to the resident having Too much fluid. Witness R explained that they could hear that R907 had crackles in their lungs while speaking to the resident on the phone. Witness R explained that on the day the resident was transferred to the hospital, R907's [CONDITION(S)] center had Pulled off 3 liters [of fluid]. Witness R explained that R907 ended up in the hospital for three weeks due to fluid overload. A review of R907's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed, that the resident was admitted into the facility on (Friday) 3/19/21 and discharged to the hospital on 3/30/21. R907's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident was cognitively intact and Section I of the resident's MDS assessment read, Indicate the resident's primary medical condition category that best describes the primary reason for admission: 13. Medically Complex Conditions. A review of R907's weights and vital signs revealed that no weights were documented in the resident's record as taken by the facility for the duration of the resident's stay. The resident's admission notice was reviewed and included: Hospital Documented: Height: 69 in (ches), Weight: 140 lbs (pounds) .HD TTS (Hemodialysis Tuesday, Thursday, Saturday) .10:30 chair time. R907's transfer form from the hospital dated 3/19/21 listed the resident's weight at 63.6 kg (kilograms)/(139.92 pounds/lbs) and included the following, Problems: Acute CHF . The Mayo Clinic 2021 online Medical Education and Research reference reflected the following related to CHF: Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions, such as narrowed arteries in your heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or stiff to fill and pump efficiently. Heart failure can be ongoing (chronic), or your condition may start suddenly (acute). Heart failure signs and symptoms may include: · Shortness of breath (dyspnea) when you exert yourself or when you lie down · Fatigue and weakness · Swelling ([CONDITION(S)]) in your legs, ankles and feet · Rapid or irregular heartbeat · Reduced ability to exercise · Persistent cough or wheezing with white or pink blood-tinged phlegm · Increased need to urinate at night · Swelling of your abdomen (ascites) · Very rapid weight gain from fluid retention · Lack of appetite and nausea · Difficulty concentrating or decreased alertness · Sudden, severe shortness of breath and coughing up pink, foamy [MEDICATION(S)] · Chest pain if your heart failure is caused by a heart attack Further review of R907's record also revealed that a nutritional and/or hydration assessment had not been completed during the resident's stay at the facility. The Registered Dietitian (RD) entered a Dietary Assessment - Admission/Quarterly, into R907's record on 3/31/21 (the day after the resident was discharged to the hospital) that included only the following comment: Resident not in facility at this time. Will assess upon readmit. [CONDITION(S)] communication forms for R907's [CONDITION(S)] appointments that occurred on 3/20/21 and 3/30/21 were not found in the medical record, nor provided by the facility upon request. All [CONDITION(S)] communication forms for R907 were requested from the facility on 5/11/21 at 11:33 AM and the only forms provided prior to survey exit were dated 3/23/21, 3/25/21, and 3/27/21. No documentation indicating that R907 went to their [CONDITION(S)] appointment on 3/20/21 and no blood pressure readings for that date were found in the record. The following weights were obtained from R907's [CONDITION(S)] communication forms: 3/23/21: Pre-Weight - 69.7 kg (153.34 lbs), Post-Weight - 68.3 kg (150.26 lbs) 3/25/21: Pre-Weight - 68.9 kg (151.58 lbs), Post-Weight - 67.8 kg (149.16 lbs) 3/27/21: Pre-Weight - 68.8 kg (151.36 lbs), Post-Weight - 66.8 kg (146.96 lbs). R907's MDS assessment dated [DATE] under Section K listed the resident's height as 69 inches and weight as 173 lbs. A review of R907's progress notes revealed the following: A physician note dated 3/22/21 at 7:11 AM that indicated, Has been on PEG (feeding tube) for one month per pt (patient) .was losing weight and hence [their] nephrologist advised [them] to eat regular food and not renal diet. patient ate 3 good meals yesterday. regular texture. has diarrhea when [they] gets PEG feeds .will continue nutrition and PT (physical therapy) weight loss hold PEG feeds. Encourage oral feeds. regular diet. will check with nephrology . A review of R907's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician note dated 3/25/21 at 10:20 PM that indicated, .no other complaints .no distress .lungs CTAB (Clear To Auscultation Bilaterally) .LE (lower extremities) no [CONDITION(S)] .will check with dietary to change to regular diet . R907's diet remained as a renal diet for the duration of their stay with no corresponding dietary progress notes present in the record. No skilled charting (full nursing assessment) was present in R907's record on 3/25/21. R907's COVID-19 Monitoring assessment dated [DATE] at 13:41 (1:41 PM) indicated that the resident had a cough and included, Resident is alert and able to make needs known to staff. Denies pain nor discomfort. Peg tube intact/patent. Left chest perm cath CDI (clean dry intact), no s/s (signs symptoms) of infection noted. Non productive cough noted; no congestion noted. Afebrile. Resident LOA (leave of absence) to [CONDITION(S)] with no s/s of acute distress. R907's Medicare-Skilled Charting assessment dated [DATE] 11:14 (AM) marked the resident's respiratory status as WNL (within normal limits), but noted that the resident had pitting [CONDITION(S)] present and marked as, 1+. Mild pitting, slight indentation, no perceptible swelling of the leg, with no further information provided. No follow-up documentation to the noted [CONDITION(S)] was found. 3/26/2021 23:28 (11:28 PM) Nurses Note Note Text: resident alert, c/o (complaints of) sob (shortness of breath). spo2 (oxygen saturation) 99% with o2 (oxygen) via n/c (nasal cannula). hob (head of bed) elevated. r20 (respirations 20). non productive cough noted with congestion. prn (as needed) breathing tx (treatment) with + results. declined starting of t/f (tube feeding). MD (physician) message. (Written by agency nurse). A change in condition assessment corresponding with this note was not found. No subsequent progress note or nursing assessment to the above nurses note from 3/26/21 was found in R907's record. A documented response to the physician notification was not found. No medicare skilled charting assessments were present in the record for night shift on 3/26/21, 3/27/21, or 3/28/21. The day shift medicare skilled charting assessments on 3/27/21 and 3/28/21 included no assessed abnormalities. No corresponding progress notes were found in R907's medical record for 3/27/21 or 3/28/21. The final progress notes written after 3/26/21 in R907's record included: 3/29/2021 22:50 (10:50 PM) Nurses Note Note Text: Resident continues to have on-going cough without temperature. Has some SOB (shortness of breath) when lying flat or exertion. Follow request made to Physician concerns. Order obtained for STAT [labs and diagnostic testing] orders noted and transmitted. Family member .notified regarding concerns. [Family] stated [CONDITION(S)] removed 2 liters this past Saturday. Resident confirmed exact amount of fluid taken off. Also resident knew exact amount of fluid removed Thursday. [Resident] stated last time [they] had these same symptoms when [they] had pneumonia. On-coming nurse made aware of new orders and resident status. R907's change in condition assessment dated [DATE] 22:29 (10:29 PM) listed a, Congested cough, that started on: 3/29/21. CHF was marked as a medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment also included the following: This condition, symptom or sign has occurred before: [left blank/not answered]. 3/30/2021 02:20 (AM) Nurses Note Note Text: Rapid COVID-19 test performed as ordered by writer. Result negative. No further progress notes were present in the record on 3/30/21 until the following: 3/30/2021 18:18 (6:18 PM) Nurses Note Note Text: Sent out to ER per resident request. Will notified MD. 3/30/2021 18:19 (6:19 PM) Nurses Note Note Text: Writer called to speak with [family] of resident .Writer spoke in regards to resident had been to [CONDITION(S)] [and] had a great amount of fluid taken off, she states she is aware she went to [CONDITION(S)] to be with [R907] and [the resident] was like this at [CONDITION(S)] but wants resident .to go to hospital and she has already called 911. Writer made [family] aware of resident Covid and chest x ray results .Writer went to room resident room where [resident] was being transferred to stretcher .Writer spoke to physician herself she is aware of all results and is aware transfer . [Written by Nurse Manager F]. A review of R907's chest x-ray obtained by the facility on 3/29/21 and resulted in the early morning on 3/30/21 revealed, There is mild pulmonary vascular congestion. On 5/11/21 at 12:21 PM and on 5/12/21 at 10:55 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON indicated that the Director of Nursing (DON) was currently off and not present for the survey. The ADON was queried regarding [CONDITION(S)] communication forms. The ADON stated, There is a communication form filled out [here] that goes with the resident and then comes back and the nurse fills out vital signs after. The ADON was queried if a communication form should be present in the resident's record for every [CONDITION(S)] visit to which she replied, Yes. When asked if a communication form should be present in R907's record if they went to their [CONDITION(S)] appointments on 3/20/21 and 3/30/21, the ADON responded, There should be a form in there. When queried regarding obtaining a resident's weight upon admission, the ADON indicated there should be an admission weight in the record. When queried regarding any documentation required of nursing related to [CONDITION(S)], the ADON stated, Nurses might document that that person is out to [CONDITION(S)] but they normally do the communication form and it gets uploaded (into the record) .[Vitals are put] on the form and there should be vitals in PCC (medical record) as well. When queried regarding a Congestive Heart Failure (CHF) protocol at the facility, the ADON stated, We don't have one per se, there's things we look for if a resident has CHF, monitor for shortness of breath, things like that .Nurses are expected to report any changes. When queried what is expected after a physician notification, the ADON stated, There should be a follow-up note if the doctor was notified .absolutely. When queried regarding the timing of nutritional assessments, the ADON stated, They should be right away if we see that there's an issue. I believe [the RD] assesses all new residents .it should be in [the record]. [The RD] also puts some assessments under progress notes. When queried regarding a nutritional and/or fluid assessment being completed for a resident with multiple medical conditions such as hemodialysis, CHF, and a PEG tube, the ADON stated, We should have a nutritional assessment right away. Admissions gives us notes about special accommodations. When queried regarding documentation of coordination between the RD, physician, and staff related to a resident's nutritional/fluid status, the ADON stated, If nurses notice somebody that might need supplements or something like that, they will call the doctor and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON indicated that the RD is at the facility Maybe three times a week. On 5/11/21 at 2:42 PM, MDS Nurse T was queried as to where the weight of 173 lbs (on the MDS dated [DATE]) for R907 was obtained from. MDS Nurse T reviewed multiple areas in the resident's record including the admission notice sheet and the [CONDITION(S)] communication forms. MDS Nurse T indicated the weights did not match. MDS Nurse T then opened R907's care plan and stated, No weight in there, the dietitian didn't do the care plan .The [RD] is supposed to put Section K in [the MDS assessment] .not sure where that's from. MDS Nurse T continued and stated, I would normally get that weight from the weight obtained here [at the facility], but there are none in the chart. MDS Nurse U, who was also present during the interview, stated that she remembered R907. MDS Nurse U stated, They wouldn't give [R907] a regular diet and [the resident] didn't want the tube feeds. MDS Nurse T agreed. When queried regarding a nutritional assessment for R907, both MDS Nurses indicated that those are completed by the dietitian. On 5/12/21 at 9:00 AM, Nurse Manager F was queried regarding the note dated 3/26/21 in R907's chart and asked what is expected of the nurse after writing such a note. Nurse F stated, Well if the physician doesn't answer the medical director can be messaged, that way you have your follow-up and orders if needed. You have to do something, the patient is complaining .it should be reported from one nurse to the next and follow-up with the doctor. That's how that should've went, so they don't drop the ball. Nurse F indicated that she would expect something to be written as a follow-up note after physician notification of a change in condition. Nurse F stated, There should've been another piece there. When queried regarding the agency nurse who wrote the note, Nurse F stated, We don't have agency right now and I'm not familiar with the nurse that wrote that note. When queried regarding who is responsible for coordinating [CONDITION(S)] appointments and transportation, Nurse F indicated that Receptionist S is responsible. On 5/12/21 at 9:04 AM, Receptionist S was interviewed and asked if they had information related to when R907 was transported to their [CONDITION(S)] appointment on 3/20/21. Receptionist S stated, The resident had [CONDITION(S)] Tuesday, Thursday, and Saturday. When asked how one would know that the resident went to their appointment, Receptionist S stated, We send the communication form and that goes between the nurses here and there. I am not here on Saturdays and that (3/20/21) was a Saturday .The way you confirm a resident went to [CONDITION(S)] is by the communication form. On 5/12/21 at 9:15 AM, the RD was interviewed. When queried regarding the expectation for completing a nutritional assessment after admission to the facility, specifically for a resident with multiple complex medical conditions, the RD stated, Our policy is to have it done within 14 days .I don't believe it specifies to have it done sooner than 14 days. When queried regarding the diet, tube feeding, and flush orders for R907 while at the facility the RD explained that since she did not have a weight for the resident taken when they entered the facility, she Went based on the weight they sent over with the admission paperwork. When queried as to why R907's weight was not obtained upon admission into the facility, the RD stated, A weight is typically taken within 48 hours of the admission, I just used the weight I had available at the time to make sure orders could be placed .I believe the resident should have gotten weighed. The RD indicated that weights could also be obtained from [CONDITION(S)] communication forms. The RD continued and stated, In regards to the flushes, between the tube feeding, autoflush, and bolus flush, I believe I set it up to be about 1500 mL of water a day. I set that up as the fluid restriction. When queried regarding an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When queried who determines if a fluid restriction would be appropriate, the RD stated, Technically I could have determined that, but a doctor or a nurse, or [CONDITION(S)] .Typically I communicate with [CONDITION(S)]. When queried if she had collaborated with R907's [CONDITION(S)] provider, the RD stated, I'm not sure. I don't have a progress note in for it, so I would say no. The RD was then asked why R907 was receiving a renal diet and not receiving a regular diet per the hospital transfer form dated 3/19/21 to which the RD responded, This diet order was put in by a nurse and signed by the doctor. The docs typically sign off on it if a nurse puts it in. When queried where the diet order came from if there was no dietary or nutritional assessment done for the resident upon admission, the RD stated, Well, I look at the admission notice .so they [must've] went off the admission notice. When asked to review the admission notice for R907, the RD indicated she did not see anything indicating a renal diet order. When queried regarding documentation indicating that R907's [CONDITION(S)] center removed 2.4 liters of fluid on 3/27/21, the RD stated, That's going to vary. With [R907's] dry weight of 66.8 kg (146.96 lbs) I feel that I still had the appropriate orders for tube feeding, etc. in place. That weight is not significantly different from the weight they gave me initially, which I got from the admission notice. When queried regarding obtaining further information about the resident's nutritional preferences, as noted in the physician documentation, the RD stated, I wasn't able to but the dietary manager could have. When queried regarding the resident's weight as 69.7 kg (153.34 lbs) compared to the admission notice weight of 140 lbs, the RD responded, I would expect [R907] to be slightly higher going into [CONDITION(S)]. When asked if she ever spoke with a physician about R907, the RD stated, I don't believe so. When queried regarding the physician note on 3/22/21 that mentioned, .hold PEG feeds, encourage oral feeds . the RD responded, That would've been communicated to the nurses, they would be the ones to put the feeding on hold .the weight loss, hold PEG is interesting. This would've had to be communicated to the nurses and followed up with them and they make the changes in the chart if that were the case. On 5/12/21 at 2:25 PM, the Nursing Home Administrator (NHA) was interviewed. When queried regarding expectation for documentation related to a resident's change in condition the NHA deferred questions related to a change in condition to the ADON. When queried regarding [CONDITION(S)] communication forms, then NHA indicated there should be a form present in the record for each [CONDITION(S)] session a resident attends. A review of the facility's policy/procedure titled, Acute Change in Condition, undated, revealed, An Acute Change of Condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death . 3. Changes (symptoms) in a resident's condition are communicated by any staff member to nurses via (see warning signs): Stop and Watch/Interact, Clinical Rounds findings, Verbal reports, Huddle reports 4. Utilize care paths, Document findings, assessments and interventions on the CHANGE OF CONDITION. Tip: If CHANGE OF CONDITION is complete with all components than it can be used as your progress note. 5. Changes (symptoms) are communicated to the physician via: Phone call (urgent), Physician Log (non-urgent), Physician rounds 6. If a plausible cause was not found readily in someone with an ACOC, assess whether [CONDITION(S)], fluid and electrolyte imbalance, infection, and medication related effects is the cause for the ACOC .The following symptoms may suggest ACOC or require additional assessment: Respiration (12-20 breaths/minute is considered the normal range) Respiratory rates >28 breaths/minute, Marked change from the usual respiration pattern or rhythm, Irregular breathing, long pauses between breaths, audible noises related to breathing, Struggling to breathe, i.e. gasping for breath, using accessory muscles of the neck .Evaluate signs and symptoms that may suggest fluid imbalance (e.g., [CONDITION(S)] or change in [CONDITION(S)]). Acute, rapid weight gain may indicate an ACOC that is accompanied by fluid accumulations (e.g., acute CHF). Acute, rapid weight loss over several days should trigger concern about a hydration emergency . A review of the facility's policy/procedure titled, [CONDITION(S)] Communication Form Procedure, dated 1/19, revealed, Purpose: It is the policy of this facility to assure that resident's receiving [CONDITION(S)] have communication between the facility and the [CONDITION(S)] facility. Staff is to evaluate the resident's response to [CONDITION(S)] and develop/revise the plan of care in collaboration with the [CONDITION(S)] facility. Procedure & Documentation: Pre-[CONDITION(S)], The Nurse is to complete [CONDITION(S)] Communication Form (DCF) prior to the resident leaving for [CONDITION(S)]. Document the vital signs on the [CONDITION(S)] Communication Form and in PCC. If there are any abnormal vital signs notify the physician and the [CONDITION(S)] center .Post-[CONDITION(S)], Document in PCC the time that the resident left the facility .Obtain vital signs and document on the form and in PCC . A review of the facility's policy/procedure titled, Nutrition Assessment, undated, revealed, Policy: The nutritional assessment is a collaborative process that includes an interdisciplinary approach. Procedure: 1. The Clinical Dietitian or Culinary Manager in conjunction with the nursing staff, Attending Physician or Nurse practitioner, and pharmacist will assess nutritional issues for each resident admitted to the facility. 2. Nutritional assessment will be completed within 14 days of admission or readmission as per state and federal guidelines .3. Nutrition assessments will review: The need of a therapeutic or liberalized diet based on health status., Review of food preferences., Supplements in place., Ability to chew and swallow safely., Ability to feed self or the level of assistance needed (including adaptive equipment)., Current weight, weight changes back to 180 days and weight compared to usual body weight., Medications that may be effecting appetite., Lab review as available., Estimated nutritional needs and review of plan to meet needs. 4. Nutritional assessment will be initiated prior to developing the resident's MDS assessment and completed prior to care planning . A review of the facility's policy/procedure titled, Nutritional Care, undated, revealed, Policy: Nutritional care is an individualized approach, which includes identifying and assessing each resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistently implementing pertinent approaches, and monitoring the effectiveness of interventions and revising them as necessary. Procedure: 1. On Admission: a. A food preference and diet history is obtained according to facility policy (see COP 304). b. A nutrition assessment, Minimum Data Set (MDS) Section K and L, and Care Area Assessment (CAA) are completed as per facility policy . This citation pertains to intake: MI 077. Deficient Practice Statement 2 of 2: Based on interview and record review, the facility failed to consistently assess a resident following a fall, and document and monitor for a change in condition for one sampled resident (R902) reviewed for a change in condition, resulting in the potential for unmet care needs. Findings include: A review of Intake MI 077 revealed the following, [R902] was admitted to [Nursing Facility] for respite care on 12-14-2020 .When admitted to the facility [R902] was walking with assistance, transferring with assistance, eating, drinking, and conversing. Due to COVID-19 restrictions, no visitors were allowed in the facility unless the resident was deemed 'actively dying' or end of life. [R903] was admitted to the same room with [R902] for respite care and was able to communicate [R902's] condition to me, on 12/28/2020 [R903] stated [R902] could no longer communicate . I called the facility daily from that point on and received no information that [R902's] health was deteriorating and was not informed that I would be able to visit. I was told [R902's] vital signs are stable, and [they] are more sleepy, but that [R902] wakes when spoken to .My [family member] fell out of [their] wheelchair, face first onto the floor within 10 minutes of being wheeled into their isolation room. I specifically asked the administrator if the post-fall protocol was followed properly and he deferred me to the DON (Director of Nursing) A review of R902's medical record revealed that the resident was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R902's Minimum Data Set Assessment revealed that the resident had a Brief Interview for Mental Status score of 3/15 indicating severely impaired cognition, and required extensive assistance with activities of daily living including eating, toileting, mobility and transfers. Further review of R902's medical record revealed the following hospice progress note: 12/14/2021, RN On-call visit. 22:05-00:30 (10:05 PM-12:30 am). Post-fall. Patient had an unwitnessed fall in room from wheelchair to floor. No bruising, contusions or lacerations noted. Complaint of headache on L (left) side of face of head. Was given Tylenol. Neuro checks (neurological checks, an exam to assess sensory and motor responses) performed, equally bilaterally hand grips. Pupils equal and reactive to light . 12/15/2021, 03:53 (3:43 am). Resident observed on floor in room. [R903] called for assistance when their [spouse] was on the floor. They stated [R902] slid out of the wheelchair. Resident unable to tell writer what [they] were doing. Writer assessed resident. Full range of motion were normal. Writer and other nurse assisted resident in bed. Writer asked [spouse] if [R902] hit [their] head. [Spouse] stated [R902] did. Writer initiated neuro checks. Resident is a hospice patient. Hospice was called. Hospice arrived at 2200. (name of Hospice Nurse) the hospice nurse assessed the resident as well . Resident c/o (complain of headache) . R902's neuro checks were reviewed and revealed that they were completed on 12/14/2021 at the following times: 8:00 PM, 8:15 PM, 8:39 PM, 9:12 PM and 10:08 PM. Neuro checks were completed on 12/15/2021 at the following times: 12:05 am, 1:18 am, 2:40 am and 3:45 am. There were no other neuro checks documented in R902's medical record. In addition, there was an incomplete post-fall assessment. On 5/10/21 at 12:00 PM, all Incident and Accident reports for R902 were requested. One report was provided however, it was related to a fall R902 sustained on 12/15/21. Further review of R902's progress notes revealed the following: 12/14/2020 18:37 (6:37 PM) Type: Admission Note Text. admitted [Identifying Information] approximately 4:30 PM .transported from home via private vehicle by daughter. DX (diagnosis) chronic UTI (urinary tract infection), dementia with behaviors, [CONDITION(S)]. [Medical doctor] notified. Medications verified. Hospice nurse onsite to reconcile medications. Remainder of admission endorsed to oncoming nurse. Resident alert and oriented x 2 (oriented to person and place) with no acute distress noted. VS (vital signs) stable . 12/15/2020, 15:13 (3:13 PM) Type: Social Services Note Text: Writer met with resident on 12/14/20 in [their] room for respite admission. Resident presents A&Ox 1 (oriented to person) pleasant. Resident has dx of dementia . 12/17/2020 16:55 (4:55 PM) Type: Quality of Life Note Text: [R902] with a hx (history) of unspecified dementia with behavioral disturbance, chronic obstructive pulmonary disease with (acute) exacerbation, acute systolic (Congestive) heart failure. The resident is new admit to the facility as a hospice respite with [their spouse], the resident is noted to be alert to self most of the time with periods of alertness . 12/18/2020 22:05 (10:05 am) Type: Physicians H & P (history and physical). LATE ENTRY Note Text: [R902's Identifying Information] with a history of dementia, [CONDITION(S)], chronic diastolic heart failure, anxiety, [CONDITION(S)] with pacemaker, constipation, depression, diabetes, history of falls urinary incontinence, [CONDITION(S)] disease. Apparently, the patient has been admitted to the hospice. Patient is here for respite stay .Patient is alert and oriented to self but is not responding verbally. 12/21/2020 14:56 (2:56 PM) Type: Life Enrichment Notes. Note Text: Resident is alert and oriented and is able to voice likes and dislikes, [R902] enjoys music, watching television, reading and spending time with [spouse]. Record review reflected no progress notes documenting R902's status between 12/21/20 and 12/27/20. 12/27/2020 22:19 Type: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is to be at [their] baseline .General Impression: Alert and oriented x 1, person. Not in acute distress. Plan: Continue all medications at this time. Pain medicines have been completed. Continue to monitor for falls. Patient is a DNR (Do not resuscitate). Apparently, the patient does eat by mouth, we will continue to encourage oral feeding Patient is hospice care. Will need to contact hospice for any acute changes . There were no progress notes or Skilled Medicare Charting from 12/25/20 to 1/4/21 which assessed or documented a change in condition except for progress notes entered regarding the resident's medications being held. There were also no progress notes indicating that hospice had been contacted regarding a change in condition as they were last seen by hospice on 12/23/20. 01/03/2021 05:42 (5:42 am) Type: Nurses Note LATE ENTRY Note Text: Resident still responsive to tactile and painful stimuli [they] still can swallow drop by drop liquid by mouth at this time . 01/03/2021 07:47 Type: Nurses Note Note Text: Resident was able to take all meds by mouth slowly with little amounts of water. 01/04/2021 01:51 Type: Orders - Administration Note Note Text: [MEDICATION(S)] Tablet 5 MG (milligrams). Give 2 tablet by mouth at bedtime for [CONDITION(S)] Med (medication) held pt.(patient) was lethargic. 01/04/2021 01:52 Type

This citation pertains to intake: MI 077. Based on interview and record review, the facility failed to appropriately monitor and address a significant weight loss for one sampled resident (R902) of two residents reviewed for nutrition resulting in, a significant weight loss not being identified or addressed. Findings include: A review of Intake MI 077 revealed the following, [R902] was admitted to [Nursing Facility] for respite care [DATE] .When admitted to the facility [R902] was walking with assistance, transferring with assistance, eating, drinking, and conversing. [R903] was admitted to the same room with [R902] for respite care and was able to communicate [R902's] condition to me .[R903] told me that most times no staff helped [R902] eat or drink, that it was left up to [them] .[R903] has very bad [CONDITION(S)], so this was difficult - but [they] did it. While [R903] was still feeding [R902] the staff would come in and clear the tray . A review of R902's medical record revealed that the resident was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R902's Minimum Data Set Assessment revealed that the resident had a Brief Interview for Mental Status score of ,d+[DATE] indicating a severely impaired cognition and required extensive assistance with activities of daily living (ADLs) including eating, toileting, mobility and transfers. There was one nutrition assessment located in the resident's medical record, which was completed on the date that the resident expired on [DATE] and noted, Resident expired. Further review of R902's medical record revealed the following weights for R902 noting an 8.4% weight loss in 14 days: -[DATE] 16:21 (4:21 PM) 140.4 Lbs. (pounds) -[DATE] 13:39 (1:39 PM) 137.3 Lbs. -[DATE] 13:39 (1:39 PM 128.6 Lbs. A review of R902's care plan revealed the following: Focus: I need require extensive assistance with my adls. Date Initiated: [DATE]. Revision on: [DATE]. Observe me for pain/discomfort during care and report. Date Initiated: [DATE]. Observe me and report any changes, any potential for improvement, reasons for self-care deficit, expected course and a decline in my function. Date Initiated: [DATE]. Further review of R902's medical record revealed that there was no food amount documented or assistance provided for dinner on [DATE], all three meals on [DATE], dinner on [DATE] and breakfast and lunch on [DATE]. In addition, there were multiple days documented that R902 had eaten the following meals independently on the following dates: -[DATE], dinner -[DATE], breakfast and lunch -[DATE], lunch -[DATE], lunch -[DATE], dinner -[DATE], breakfast and lunch -[DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], dinner. On [DATE] at 12:25 PM, an interview was completed with the facility's Registered Dietitian (RD) and was asked to please point out progress notes or nutritional assessments for R902. The RD acknowledged that she did not see any and acknowledged that there would normally be one in this case. The RD stated, So [R902] was hospice .um I believe that [R902's] appetite was very poor and being on hospice, weight loss was to be expected. I am trying to recall back to that time. I believe [R902] passed shortly after I received that weight. I did not get the full assessment in before [R902] passed away. I think we expected weight loss for [R902] and natural decline. The RD was asked if that was documented somewhere and stated, I'm trying to see . let me look. I don't see anything where I indicated it in [their] progress notes. The RD was asked if there was anything from the physician or hospice, and she stated, On ,d+[DATE] there's a note regarding 50% or less showing signs symptoms of adult failure to thrive on hospice. The RD was asked if the Failure to Thrive was a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I think they were just saying [R901] was showing signs of it. On [DATE] at 1:00 PM, the Assistant Director of Nursing (ADON) was asked about the facility's expectation for handling the weight loss of a resident who is on hospice. The ADON explained that the dietitian would notify hospice, and they would have to be involved and make the decision on how to address it. The ADON was asked if significant weight loss in a hospice resident should be addressed and stated, Yes I would think it would need to be addressed, I can't think of any different circumstance with hospice. The doctor should be notified of what's going on and at the very least hospice notified. The ADON was asked, if the care plan notes that a resident needs extensive assistance with ADLs, would she expect the charting to be indicating that the resident is eating independently, and she stated, No, if the care plan says the resident needs extensive assistance it should go straight to the Kardex (an overview of resident care needs) for the CNAs (Certified Nursing Assistants). CNAs are supposed to go to each resident's Kardex before doing care, so they know what needs to be done. It should not be different from what the resident actual need is. On [DATE] at 2:20 PM, the Nursing Home Administrator was asked about weight loss of residents in the facility, and deferred the question to the ADON. A review of the facility's Nutritional Care policy noted the following, 3. Significant change related to Nutrition or Annual Assessment. a. A Nutrition Assessment form will be completed according to facility policy and includes: i. A review of current interventions and evaluation if they have been properly implemented ii. Are interventions working iii. A discussion statement if the significant change is related to nutrition or can have an impact on nutrition 5. Residents at risk that require additional intervention a. Will be reviewed during an IDT meeting. b. Nutrition professional will be notified of significant resident changes in order to intervene timely. 6. Care Plan Goals and Interventions a. Goals and interventions will be mutually developed by: i. The resident and or responsible party ii. Interdisciplinary team iii. Usual body weight is the most relevant basis for weight related interventions. b. Interventions should be individualized and monitored for effectiveness. 7. Follow up and monitoring a. Residents that have a new significant confirmed weight change will be reviewed in a IDT meeting where risk and interventions can be reviewed.

This citation pertains to intakes 6 and 2. Based on interview and record review, the facility failed to provide wound care treatments per order and document implementation of pressure ulcer interventions for prevention/treatment of [REDACTED]. Findings include: A review of R901's Minimum Data Set (MDS) assessments dated 10/23/2020 and 11/5/2020 revealed that the resident was originally admitted into the facility on [DATE] and most recently re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was severely cognitively impaired and required extensive to total assistance from staff for bed mobility, transfers, dressing, eating, and hygiene/bathing. The MDS dated [DATE] indicated the resident had three Stage III (full thickness skin loss that may extend into the subcutaneous tissue layer) pressure ulcers. The MDS dated [DATE] indicated the resident had two Stage III pressure ulcers and one Stage IV (full thickness skin loss extending to muscle, tendon, or bone) pressure ulcer. A review of R901's medical record including wound care notes, administration records, and progress notes revealed the following: 4/19/2020 19:53 (7:53 PM) Admission Note .Open area to coccyx, top right foot black area, black area to right heel, dry left heel . Wound care team notes were not present or provided by the facility upon request for R901 for April 2020 - May 2020. Wound care order, [MEDICATION NAME] Wound/Burn Dressing Paste (Wound Dressings) Apply to Coccyx topically one time a day for Wound care Cleanse area with NS (normal saline), Pat dry, apply [MEDICATION NAME], cover with border gauze, not checked off as completed in the Treatment Administration Record (TAR) on 4/22/20. Wound care order, TheraHoney Gel (Wound Dressings) Apply to Sacrococcyx topically every day shift for Pressure Injury After cleaning with wound cleaner, cover with dry dressing, not checked off as completed in the TAR on 5/2/20, 5/4, 5/8, 5/12, 5/18, 5/19, 5/22, 5/23, 5/27, 5/28, 5/29, 6/3, 6/6, 6/7, 6/10, 6/12, and 6/15/20. Wound care order, cleanse coccyx/bilateral buttocks with wound wash then pat dry then apply Plurogel + [MEDICATION NAME] AG and cover with dry dressing qd (every day) and PRN (as needed) every day shift for skin, not checked off as completed in the TAR on 6/19, 6/22, 6/24, 7/5, 7/15, 8/15. Wound care order, Cleanse right heel with wound cleanser, pat dry, apply dry dressing, cover with dry dressing and wrap with kerlix every 2 days and prn every day shift every 2 day(s) for wound healing, not checked off as completed in the TAR on 7/15/20. Wound care order, Cleanse left medial leg with wound cleanser, pat dry, apply [MEDICATION NAME] gel and cover with dry dressing daily and prn every day shift for wound care, not checked off as completed in the TAR on 8/15/20 and 9/1/20. Wound care order, Cleanse right heel with wound cleanser pat dry apply [MEDICATION NAME] gel and cover with dry dressing daily and prn every day shift for wound care, not checked off as completed in the TAR on 8/15/20 and 9/1/20. Wound care order, Cleanse right medial leg with wound cleanser pat dry apply [MEDICATION NAME] gel and cover with dry dressing daily and prn every day shift for wound care, not checked off as completed in the TAR on 8/15/20 and 9/1/20. Physician order, Nurse to ensure pillow is between knees each shift every shift for protection, not checked off as completed in the TAR on day shift 8/15 and evening shift 8/21. (Order discontinued on 9/3/20). Wound care order, Cleanse bilateral hips with soap and water pat dry and apply [MEDICATION NAME] dressing every 2 days and prn for protection every day shift every 2 day(s) for protection, not checked off as completed in the TAR on 9/1/20. Wound care order, Cleanse coccyx/ bilateral buttocks with wound cleanser pat dry then apply plurogel + [MEDICATION NAME] AG cover with dry dressing daily and prn every day shift for wound care, not checked off as completed in the TAR on 9/1/20. Wound care order, Cleanse left foot bunion with wound cleanser and pat dry apply dry dressing every 2 days and prn every day shift every 2 day(s) for wound care, not checked off as completed in the TAR on 9/1/20. Wound care order, Cleanse coccyx/right buttocks with wound cleanser, pat dry, apply [MEDICATION NAME] AG daily and prn every day shift for promote wound healing, not checked off as completed in the TAR on 9/20, 9/22, 9/28, and 10/7/20. Wound care order, Cleanse right heel. Pat dry. apply therahoney gel with 4x4 gauze and ABD wrap with kelix every day shift for wound healing, not checked off as completed in the TAR on 9/15, 9/20, 9/22, 9/28. Wound care order, Cleanse left hip with wound cleanser, pat dry, apply therahoney, cover with dry dressing daily and prn every day shift for promote wound healing, not checked off as completed in the TAR on 11/18, 12/25, and 12/26/20. Wound care order, Cleanse right heel with wound cleanser, pat dry, apply therahoney, cover with dry dressing, wrap with kerlix daily and prn every day shift for promote wound healing, not checked off as completed in the TAR on 11/18, 12/25, and 12/26/20. Wound care order, Cleanse sacrococcyx/right buttock with wound cleanser, pat dry, apply [MEDICATION NAME] AG, cover with dry dressing daily and prn every day shift for promote wound healing, not checked off as completed in the TAR on 11/18, 12/25, and 12/26/20. Wound care order, Cleanse right hip with wound cleanser, pat dry apply [MEDICATION NAME] gel then cover with dry dressing daily and prn every day shift for wound care, not checked off as completed in the TAR on 12/25, and 12/26/20. Visit Report (Wound Care) .Date: 6/16/2020 .Coccyx/Bilateral Buttocks is a Stage 3 Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 3.2cm (centimeters) length x 2 cm width x 1 cm depth, with an area of 6.4 sq cm and a volume of 6.4 cubic cm. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has Pink Base [MEDICATION NAME] .Scattered yellow Necrosis, Wound is positional, irregular edges .Diagnosis: [REDACTED].frequently reposition . Visit Report (Wound Care) .Date: 6/23/2020 .Coccyx/Bilateral Buttocks is a Stage 3 Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3.5 cm length x 2 cm width x 1 cm depth, with an area of 7 sq cm and a volume of 7 cubic cm. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has Pink Base [MEDICATION NAME] . irregular edges .Diagnosis: [REDACTED].frequently reposition . Visit Report (Wound Care) .Date: 6/30/2020 .Coccyx/Bilateral Buttocks is a Stage 3 Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3 cm length x 2 cm width x 0.6 cm depth, with an area of 6 sq cm and a volume of 3.6 cubic cm. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has Pink Base [MEDICATION NAME] . irregular edges .Diagnosis: [REDACTED].frequently reposition . Visit Report (Wound Care) .Date: 7/7/2020 .Coccyx/Bilateral Buttocks is a Stage 3 Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3.5 cm length x 2 cm width x 1 cm depth, with an area of 7 sq cm and a volume of 7 cubic cm. There is a small amount of sero-sanguineous drainage noted. Wound bed has Pink Base [MEDICATION NAME], Minimal Yellow Slough slough .irregular edges .Diagnosis: [REDACTED].frequently reposition . Visit Report (Wound Care) .Date: 7/21/2020 .Coccyx/Bilateral Buttocks is a Stage 3 Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3.1 cm length x 2 cm width x 1 cm depth, with an area of 6.2 sq cm and a volume of 6.2 cubic cm. There is a moderate amount of sero-sanguineous drainage noted .Wound bed has Pink Base [MEDICATION NAME] .irregular edges . Right Heel is an Eschar and has received a status of Not Healed. Initial wound encounter measurements are 5 cm length x 8 cm width, with an area of 40 sq cm .Diagnosis: [REDACTED].Low Air Loss Mattress or Low Air Loss bed, frequently reposition . Weekly Wound Healing Record, Date: 8/4/2020: Location: Right Heel Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired Date acquired: 7/8/2020 Type: Pressure Pressure Ulcer Stage: III (Stage 3) Overall Impression: First Observation, no reference [MEDICATION NAME] tissue present (pink) Drainage: Serosanguinous, Moderate Wound Measurements: Length (cm - centimeters): 1.5, Width: 4, Depth: 0.2, with an area of 6 sq cm and a volume of 1.2 cubic cm .The periwound skin texture is normal, moisture is normal, skin color is normal. Irregular edges Current treatment plan: [REDACTED].Continue with treatment as ordered and report any changes to MD and wound care team. Date: 8/4/2020: Location: coccyx/ bilateral buttocks Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired Date acquired: 4/1/2020 Type: Pressure Pressure Ulcer Stage: III (Stage 3) Overall Impression: First Observation, no reference [MEDICATION NAME] tissue present (pink), Slough tissue present (yellow, tan, white, stringy) .Wound bed has a pink base [MEDICATION NAME], minimal yellow slough Wound Measurements: Length (cm - centimeters): 4.5, Width: 2.5, Depth: 0.5 .with an area of 11.25 sq cm and a volume of 5.625 cubic cm Current treatment plan: [REDACTED].Continue with treatment as ordered and report any changes to MD and wound care team. Weekly Wound Healing Record, Date: 8/25/2020: Location: coccyx/ right buttock Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired Date acquired: 4/1/2020 Type: Pressure Ulcer Stage: III (Stage 3) Overall Impression: Worsening, [MEDICATION NAME] tissue present (pink), Necrotic tissue present (brown, black, leather, scab-like) .30% necrosis right buttock Length 5, Width: 6.5, Depth 1.5 .with an area of 32.5 sq cm and a volume of 48.75 cubic cm. Date: 8/25/2020: Location: Right Heel Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired Date acquired: 7/8/2020 Type: Pressure Pressure Ulcer Stage: III (Stage 3) Overall Impression: Unchanged . Necrotic tissue present (brown, black, leather, scab-like) Wound Measurements: Length (cm - centimeters): 1, Width: 2.4, Depth: 0.2, with an area of 2.4 sq cm and a volume of 0.48 cubic cm Date: 8/25/2020: Location: left medial leg Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired. Date acquired: 8/11/2020 Type: Pressure Pressure Ulcer Stage: III (Stage 3) Date: 8/25/2020: Location: right medial leg Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired. Date acquired: 8/11/2020 Type: Pressure Pressure Ulcer Stage: III (Stage 3) Date: 8/25/2020: Location: left bunion Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired. Date acquired: 8/25/2020 .Intact blister .Length 0.5 Width 2.5 Depth 0. Upon continued review of the resident's Weekly Wound Healing Records, the resident's right heel and coccyx wounds were assessed as Unchanged, per the records dated 9/16/2020 and 9/23/2020. The right medial leg wound was noted to be healed on 9/16/2020 and the left medial leg wound was noted to be healed on 9/2/2020. On 10/7/2020, the Weekly Wound Healing Record noted an initial assessment of an acquired left medial lower leg and a right distal knee deep tissue wound with acquired dates of 10/6/2020. The left wound was assessed to have a dark maroon base with a length of 3 cm by 1.5 cm width and the right wound was assessed to have a dark maroon base with a length of 1 cm by 1.5 width. The resident was also noted to have an initial assessment of an acquired left hip Stage II pressure ulcer with an acquired date of 10/6/2020, with [MEDICATION NAME] tissue present (pink), length of 1 cm by 1 cm width. Also on 10/7/20, the Weekly Wound Healing Record noted the Stage III coccyx/right buttock pressure ulcer as Unchanged .minimal necrosis, with a measurement of 5 cm by 5.4 cm by 2 cm and the right heel Stage III pressure ulcer as Unchanged, with Yellow necrotic tissue and a measurement of 0.7 cm by 1.3 by 0.2. Continued review of R901's wound care visit noted revealed the following: Visit Report (Wound Care) .Date: 10/13/2020 .Coccyx/Bilateral Buttocks is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 6 cm length x 6 cm width x 2 cm depth, with an area of 36 sq cm and a volume of 72 cubic cm. There is a moderate amount of sero-sanguineous drainage noted .Wound bed has Pink Base [MEDICATION NAME] .There is no change noted in the wound progression .scattered yellow necrosis. Right Heel is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 1.5 cm length x 1.5 cm width x 0.2 cm depth, with an area of 2.25 sq cm .Scant amount of serous drainage noted .wound bed has Yellow Necrotic Base [MEDICATION NAME] .There is no change noted in the wound progression . Left, Medial Lower Leg is an Abrasion and has received a status of Not Healed. Subsequent wound encounter measurements are 2.5 cm length x 1.5 cm width x 0.1 cm depth . Right, Distal Knee is an Abrasion and has received a status of Not Healed. Subsequent wound encounter measurements are 0.6 cm length x 1.3 cm width x 0.1 cm depth . Left Hip is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3 cm length x 4 cm width x 0.1 cm depth, with an area of 12 sq cm and a volume of 1.2 cubic cm .scant amount of sero-sanguineous drainage .Irregular with maroon discolored edges. Diagnosis: [REDACTED]. Visit Report (Wound Care) .Date: 10/20/2020 .Coccyx/Bilateral Buttocks is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 6 cm length x 6 cm width x 2 cm depth, with an area of 36 sq cm and a volume of 72 cubic cm. There is a moderate amount of sero-sanguineous drainage noted .Wound bed has Pink Base [MEDICATION NAME] .Irregular edges with scattered yellow necrosis. Wound measurement is positional. Please note change in wound diagnosis. Right Heel is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 0.5 cm length x 0.5 cm width x 0.2 cm depth, with an area of 0.25 sq cm .Scant amount of serous drainage noted .wound bed has Yellow Necrotic Base [MEDICATION NAME] . Left, Medial Lower Leg is an Abrasion and has received a status of Not Healed. Subsequent wound encounter measurements are 1 cm length x 1 cm width x 0.1 cm depth . Right, Distal Knee is an Abrasion and has received an outcome of Resolved. General Notes: Cicatrix noted (scarring). Left Hip is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2.5 cm length x 2.5 cm width x 0.1 cm depth .There is no change noted in the wound progression . Diagnosis: [REDACTED]. No wound care team notes were found for R901 for November 2020, and Weekly Wound Healing Records were not found in the assessments for the week of 11/22/20 through 11/28/20. The Weekly Wound Healing Records dated 12/30/20 indicated R901's Left Hip, Coccyx, and Right Heel pressure ulcers were relatively unchanged. The records also indicated a newly acquired Stage III pressure ulcer to the right hip, with an acquired date of 12/21/20 with wound measurements of 3 cm length by 2 cm width. The resident was transferred out of the facility on 1/8/21. On 1/27/21 at 1:25 PM, the current wound care nurse, Licensed Practical Nurse (LPN) A was interviewed. LPN A indicated she helped with wound care in December 2020 and just recently took on the wound care nurse role. LPN A indicated that wound care assessments are due every week, and treatments are to be done every day per order. LPN A also stated that the visiting wound care team was following R901, Once a month (after October 2020) because the resident was hospice. LPN A indicated that she was unable to provide background information about R901's wound development in the facility, as she had not been working at the facility at that time. LPN A stated, We had (R901) on a low air loss mattress, frequent repositioning, positioning wedges, soft heel lift boots. (R901's) wounds were unavoidable. LPN A was unable to indicate where the pressure ulcer interventions were documented as carried out in the resident's record and stated, We don't document anything we just educate staff, nurses, and aides and make sure the interventions are in place. When queried if she would expect wound care treatments to be given and charted off per order, LPN A stated, Yes, that's what we do, we do it daily and as needed. We follow the wound care physician's orders [REDACTED]. hip, LPN A stated, I'm not sure why. Skin assessments are done by the nurses on the floor. I can't answer. A review of R901's progress notes revealed no notes indicating turning/repositioning of R901 was carried out after June 2020. On 1/27/21 at 2:48 PM, the interim Director of Nursing (DON) was interviewed. The DON provided requested POC (Point of Care) documentation for R901, however the documentation did not include skin management/pressure ulcer interventions. When queried regarding documentation of carrying out pressure ulcer treatment/prevention interventions, the DON indicated she didn't believe there was a place where the interventions for R901 could be checked off or documented. The DON continued and stated, The information should be on the Kardex. I don't believe it always goes from the Kardex to the POC documentation, though. Turning/repositioning and interventions may be in the progress notes. The DON was queried regarding ordered wound care treatments and indicated she expected wound care treatments to be given per order and documented on the TAR. On 1/27/21 at 3:37 PM, the Nursing Home Administrator (NHA) was interviewed and queried regarding expectation for wound care treatment orders. The NHA indicated he expects wound care treatments to be given per order. When queried regarding documentation preventative measures and implementation of interventions for pressure ulcer treatment/prevention, the NHA indicated it should be on the care plan. When queried if the interventions on the care plan are documented as being carried out anywhere in the medical record, the NHA stated, If it's a treatment intervention it's going to be on the TAR. I would expect the interventions on the care plan to be carried out. There are some interventions per physician order. The NHA indicated interventions per physician order [REDACTED]. The NHA provided no further information regarding R901's wounds. A review of the facility's policy/procedures titled, Pressure Ulcer & Skin Care Management, and Pressure Ulcer Preventative Measures, undated, revealed, A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing .A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions: Weekly on residents .The presence of any pressure ulcer, wound, or other skin condition is documented in the designated area .The nursing staff reviews the pressure ulcer prevention and treatment procedures with the resident's physician. They select the treatment procedures appropriate for the resident and the type of pressure ulcer or wound. The licensed nurse implements the wound care treatment procedures in accordance with current standards of practice .A licensed nurse assesses and documents that status of existing wounds weekly .Residents at risk for the development of pressure ulcers receive interventions to reduce the risk of pressure ulcers .Residents should be monitored during care and consistently by licensed nurses to identify potential areas for skin breakdown and integrity of overall skin .Establish a repositioning schedule. Encourage residents, who are able, to shift their weight periodically. Periodically reposition residents who are unable to shift their weight. Reposition bed- and chair-bound residents at least every two hours .Document approaches and interventions on the care plan.

This citation pertains to Intake number MI 936. Based on interview and record review the facility failed to provide two person assistance during incontinence care for one sampled resident (R501) of three residents reviewed for falls, resulting in the resident falling out of bed and the potential for injuries. Findings include: Review of R501's Electronic Health Record (EHR) revealed R501 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed R501 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating a moderately impaired cognition, and needed extensive assistance of one person for bed mobility and extensive assistance of two people for transfers. Review of R501's Incident and Accident (I&A) report dated, 12/24/20 19:30 (7:30 PM) Pt (patient) found on floor facing Bedroom door laying on left side Certified Nurses Aide (CNA) standing by. Assisted pt two person assist into bed w/o (without) injury VS (vital signs) taken and recorded WNL (within normal limits) Neuros (Neurological checks) started .Skin intact, no injuries present. Pt head did come into contact w/ (with) floor. Neuros stable as night progresses. Re-educated staff on pt safety during care. PROMS (passive range of motion) with all extremities. pt tol (tolerated) well. The facility's investigation of the I&A revealed, Immediate Corrective Action Taken: Staff re-educated w/ (CNA B) about Pt safety during pt care. Bed mat on right side of bed, bed lowest to the floor. Review of R501's care plan revealed, Focus I am at risk for falls r/t (related to) (SPECIFY) OR I have a history of falls r/t Dementia, Gait/balance problems, incontinence reviewed 12/22/2020 Date initiated: 12/22/2020. Goal I hope to be free from falls without serious injury by next review. Date Initiated: 12/22/2020 Target Date: 04/17/2021. Interventions Anticipate and meet my needs, I require bilateral floor mats. The care plan did not address the number of persons required when providing care for R501. The care plan for ADL care with a focus of I need extensive to total assistance 2/2 (secondary to) DX (diagnoses) . Date initiated: 01/16/2017 and a Revision on 10/29/2020. The care plan did not specify the number of persons R 501 required for extensive to total assistance. On 12/30/2020 at 17:35 (5:35 PM) the previous Director of Nursing (DON) documented in the progress notes, Quality of Life Note Text: The resident is noted to have had a fall on 12/24/2020 that was witnessed, the fall occurred while the resident was being provided with incontinence care by the nursing assistant. The resident is noted to have fallen from the bed during care and the nursing assistance (Certified Nurses Aide, CNA B) was not able to break the resident fall from the bed. Per statements the resident suffered or exhibited any s/s (signs/symptoms) of injury related to the fall. The immediate nursing intervention put in place was staff re-education on proper brief care for patients who require assistance with incontinence care. The IDT (Interdisciplinary Team) has met and reviewed the intervention and has deemed appropriate to maintain safety. On 01/12/2021 at 2:08 PM, an interview was conducted with Unit Manager, Nurse A regarding the R501's fall on 12/24/2020 and stated, I don't know what happened, I wasn't here when (R501) fell . On 01/12/2021 at 2:24 PM, an interview was conducted with Nurse G regarding R501's fall on 12/24/2020 and stated, I got there around 18:20 (6:20 PM) because I like to be early. I saw that (R501) was soiled and I helped CNA B to clean (R501) up. CNA B was putting a clean gown on so I left the room and went to the next room. When I got back to the desk I heard a thump and CNA B calling for help. I saw (R501) on the floor by the door and CNA B by the sink. Nurse G was asked what could have been the cause of the fall and stated, I think (CNA B) pushed (R501) too hard and out of the bed. On 01/12/2021 at 2:44 PM, a telephone interview was conducted with CNA B regarding R 501's fall on 12/24/2020 and stated, Nurse G and I went in to change (R501) because (R501) was incontinent and I needed help because (R501) is a two person assist. I was the only aide on in that hall. I was on the side of the bed facing the window and Nurse G was on the other side. Nurse G said they had to leave and I said 'No' because (R501) was so close to the edge of the bed. As soon as Nurse G left, (R501's) legs went over the side of the bed and (R501) hit the floor. The bed was in the high position. I called for help and Nurse G and a nurse from another hall came and helped get (R501) back into the bed. On 01/12/2021 at 2:54 PM, the DON was interviewed regarding the policy and procedure regarding falls and 501's fall on 12/24/2020 and stated, Nurse G called me and told me that the resident fell and the in-service was done because the expectation is that we don't roll the resident away from us we roll them towards us. Nurse G did a complete assessment per policy and found no injuries. Review of the facility's undated policy and procedure titled, Fall Management Guidelines revealed, falls during ADL care was not addressed.

This citation pertains to intake # 8. Based on interview and record review, the facility failed to adequately assess a pressure ulcer (a wound caused by pressure being applied to the skin over a bony prominence for an extended period of time), failed to update the care plan, and failed to document the completion of treatments for one resident (Resident #702) of two residents reviewed for pressure ulcer care, resulting in the likelihood of the worsening of the pressure ulcer, unnecessary pain, and infection. Findings include: A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #702 was most recently admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #702 needed extensive assistance with toileting needs, bed mobility, and transfers. Resident #702 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating a severely impaired cognition. The MDS also indicated that Resident #702 had a stage three pressure (wounds staged according to depth of skin damage, with stage three and unstaged wounds being the most severe) wound. The previous MDS on [DATE] did not indicate that Resident #701 had a wound. A record review of the discharges (discharged for more than 24 hours and admitted to the hospital) and admissions (back to the facility) revealed the following: Admit [DATE]-[DATE] (discharged for scheduled surgery). Admit [DATE]-[DATE] (discharged for dislodgement of [MEDICAL TREATMENT] port per Confidential Witness H). Admit [DATE]-[DATE] (discharged directly from [MEDICAL TREATMENT] for wound noted on buttocks causing pain-per Confidential Witness H). There were no notes confirming the reason for the [DATE] and [DATE] discharges. A record review of the Head to Toe Skin Assessment completed for the [DATE] admission revealed the following for Resident #702: rt (right) butt healing wound, left buttock .has healing wound on .buttock with black center and red rigged boarder . A record review of the Weekly Skin Assessments dated [DATE] revealed the following: Sacrum (near buttocks region) pressure .Deep tissue wound present on coccyx/upper buttock region .Dressing changes q (every) shift. A record review of the Progress Notes for Resident #701 revealed the following: [DATE] 15:09 (3:09 PM) NURSE PRACTIONER NOTES .Sacrococcyx/Bilateral Buttock (Coccyx yellow tissue) 18.0 x 6.0 x 0.2 cm (centimeters) approximately Necrotic (black, dead tissue, indicating at least a stage four pressure ulcer) Base Eschar entire Base Dry Base yellow tissue via edges scant serosanguinous (clear, blood tinged) drainage irregular edges, Right Heel Deep Tissue Injury 4.5 x 3.0 x <0.01 cm approximately discolored base, Left Heel Deep Tissue Injury (Unable to determine extent of tissue damage) 7.5 x 5.5 x <0.01cm approximately dry discolored base . There were no other Progress Notes or Weekly Skin Notes describing the sacrococcyx/bilateral buttock wound or heel injuries of Resident #702 in the medical record. A record review of Resident #702's Physician Orders revealed the following wound care orders for [DATE]: Dakins .Solution .Apply to Sacrococcyx/Bil. (bilateral) Buttocks topically every day shift for Pressure Injury After cleaning with wound cleaner,cover with dry dressing. Dry Dressing to Right/Left Heel every day shift every other day for Pressure Injuries (SDTI/suspicious deep tissue injury) After cleaning with wound cleaner. Both wound orders were initiated on [DATE]. A record review of the Treatment Administration Assessment (TAR) for the most recent admission from [DATE]-[DATE] revealed the following for Resident #702: There was no documentation of the completion of the wounds for the sacrococcyx/buttocks wounds for [DATE]-[DATE], [DATE] and [DATE], [DATE], and [DATE]-[DATE]. There was not any documentation of the completion of treatments ordered for the heel wounds present on the TAR. A record review of the Skin Care Plan revised [DATE] for Resident #702 revealed the following: Focus-I have the potential/actual for skin breakdown r/t (related to) fragile skin Goal-I will be free from injury through the review Intervention- Encourage good nutrition Follow your Skin Management Program Observe me for side effects of the antibiotics and over-the-counter pain medications: [REDACTED]. There were no further updates/interventions added to the skin care plan. On [DATE] at 12:10 PM, an interview was completed with the Director of Nursing (DON). The DON reviewed the TAR and was asked if there were other records indicating the treatments had been done as ordered for Resident #701 and stated, I will get back to you on that. At this time, more weekly measurements and assessments of the wounds for Resident #702 were requested, but not provided by the end of the survey. On [DATE] at 12:33 PM, the DON revealed that there were no other measurements and that the wound nurse currently in the building was new and was not familiar with the resident. The DON further explained that wounds are part her QAPI (quality assurance process improvement) right now since she was new to the facility. On [DATE] at 3:05 PM, the Nursing Home Administrator (NHA) was interviewed regarding the lack of assessment of the wounds for Resident #702 and stated, It was during COVID (pandemic), the doctors weren't able to come in. We lost our wound nurse. It probably got on the way side. On [DATE] at 4:40 PM, an interview was completed via phone with Confidential Witness H. According to Confidential Witness H, Resident #702 was now deceased and had expired in the hospital. Confidential Witness H explained that on [DATE], Resident #702 had been receiving [MEDICAL TREATMENT] treatment and had complained about pain in their buttocks region. The [MEDICAL TREATMENT] staff looked at the area and notified the daughter that they were going to transfer the resident out to the hospital to have the wound evaluated. Confidential Witness H further explained that the hospital had called her to notify her that there were wounds to each heel and buttocks that were extensive. A review of the facility policy titled, Pressure Ulcer and Skin Care Management (no date) revealed the following: Policy A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing. Procedure 1. A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions: At admission or readmission to the facility, Whenever the resident arrives by medical transport, Weekly on residents, and Prior to discharge. 2. The licensed nurse documents that the body check was completed on the resident's weekly head to toe skin record. 3. The presence of any pressure ulcer, wound, or other skin condition is documented in the designated area. 5. The interdisciplinary team reviews skin risk and initiates or updates care plans accordingly. 9. A licensed nurse assesses and documents that status of existing wounds weekly. 11. The interdisciplinary team will review residents with skin conditions regularly to monitor treatment and support effectiveness and recommend changes as needed. 12. Document skin status in the resident record. A review of the facility policy titled, Wound Measurement (undated) revealed the following:Pressure Ulcer Stages Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (sic) and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (sic) and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed.

This citation pertains to intake 6. Based on interview and record review, the facility failed to initiate and implement individualized fall prevention interventions, and provide adequate supervision for one sampled resident (R703), resulting in multiple falls, falls with injury, and transfer to the hospital for treatment. Findings include: On 9/10/20 at 8:46 AM, Confidential Witness A was interviewed regarding R703's care in the facility. Witness A stated that R703 fell in the facility multiple times, and the last fall sustained in the facility resulted in an injury. Witness A stated, (The facility) knew (R703) was high risk for falls. But (some staff members) didn't seem familiar that (R703) was at risk for falls. They brought (R703) in the hall to keep an eye on (them) and (R703) still fell and had to get 8 stitches. They were not watching (R703). When asked about how many times R703 fell in the facility in 2020, Witness A stated, Over eight times. They called me every time (R703) fell . I called the Ombudsman, was told to give the facility a chance. Then the facility called me and told me what they were doing to help keep (R703) from falling. A week later (R703) fell and was bleeding and had to go to the hospital. A review of R703's Minimum Data Set assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] and discharged on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was mildly cognitively impaired and required extensive assistance from staff for bed mobility, transfers, locomotion, dressing, eating, and hygiene/bathing. The MDS noted that the resident had upper extremity Range of Motion (ROM) impairment on one side of the body. A review of the facility's Incident/Accident (I/A) reports for R703's falls were reviewed and revealed the following: Date of Incident: 7/24/20 Time of Incident: 10:45 AM Was Incident Witnessed? No Brief Description: Resident observed on floor in hallway w w/c (with wheelchair) foot rest under resident leg. Large laceration noted to forehead w profuse bleeding, Resident alert (and) responsive to verbal stimuli, c/o (complaints of) head pain. Passive ROM (Range of Motion) to all extremities, all limbs moving without difficulty. Injury Type: Abrasion, Laceration, Hit Head - w/ apparent injury Treatment: Sent to hospital, Call 911 New action taken to prevent reoccurrence: Other: Re-assess resident upon return. (Written by Licensed Practical Nurse (LPN) C). Date of Incident: 6/25/20 Time of Incident: 6:55 PM Was Incident Witnessed? No Brief Description: Resident was observed lying face down on mat with blood coming from upper lip area, area was cleansed. Ice applied. Injury Type: Bleeding, upper lip, laceration, Hit Head - no apparent injury Treatment: First Aid New action taken to prevent reoccurrence: Monitor closely Anticipate Needs. Date of Incident: 6/16/20 Time of Incident: 12:40 PM Was Incident Witnessed? No Brief Description: I had just stepped out of the room from feeding resident CNA was walking past room observed resident on floor lying on .right side holding .TV .ROM was done to all ext (extremities) Neurochecks initiated, resident stated I was trying to get in the bed. Injury Type: Abrasion, Bruise/Hematoma, Hit Head - No apparent injury Treatment: (blank) New action taken to prevent reoccurrence: (Care Plan) Reviewed, Low Bed, Floor Mat. Date of Incident: 6/4/20 Time of Incident: 3:55 PM Was Incident Witnessed? No Brief Description: Resident was found on the floor in .room .said .was trying to get back in bed. Back was to w/c, legs straight out front. Injury Type: Other - Complaint of rt (right) shoulder pain Treatment: X-ray ordered New action taken to prevent reoccurrence: (Care Plan) Reviewed. Date of Incident: 5/28/20 Time of Incident: 5:00 PM Brief Description: Resident and resident's roommate stated resident (R703) fell a few nights ago, it was unwitnessed by any staff member. Injury Type: (blank) Treatment: X-ray ordered New action taken to prevent reoccurrence: Reviewed Care Plan. Date of Incident: 3/4/20 Time of Incident: 4:30 AM Was Incident Witnessed? No Brief Description: Resident observed on floor. No injuries. ROM performed. (No) c/o pain (No) difficulty with ROM. Writer asked resident what (they were) attempting to do. Resident was unable to tell writer. (Doctor) notified . Injury Type: No apparent injury New action taken to prevent reoccurrence: (Care Plan) Reviewed. A review of R703's progress notes revealed the following: 5/13/2020 08:01 (8:01 AM): Resident observed sitting on the floor on the side of the bed. Resident unable to communicate what (they were) trying to do. Head to toe assessment complete. ROM complete. Neurochecks intiated (sic). Doctor notified .Care plan updated. No corresponding I/A form was provided for this documented fall during the survey. 5/28/2020 09:21 (9:21 AM) NURSE PRACTIONER (sic) NOTES .Chief Complaint: Fall, facial pain and dysphagia .I was called to see patient today per staff and family due to concern patient had a fall on 5/13 and noted with right sided facial pain, swelling and bruising under (their) right eye .under right eye bruising noted .Assessment/Plan: - Fall from bed; noted without acute injury, no indication for further radiology studies; neurochecks completed and wnl (within normal limits) to date; concave mattress to be placed and bedside mats . 5/28/2020 20:06 (8:06 PM): Resident c/o left shoulder pain Tylenol .given .(Doctor) made aware of residents c/o pain .order a stat xray of residents left shoulder, xray ordered . 6/4/2020 17:00 (5:00 PM) Resident was found on the floor .back was against the wheelchair and .legs were straight out in front .Writer was alerted and immediately assessed resident for pain and injuries. Vitals were taken and neuro checks were started. Resident stated .was trying to get back in bed. Resident didn't ring .light or ask for assistance .Resident did complaint of right shoulder pain .Doctor was notified .ordered an x-ray of the right shoulder due to complaints of shoulder pain . 6/16/2020 20:32 (8:32 PM): Resident has a fall today at approx 12:40 PM I had just exited the room .went across the hall to answer a call light CNA was walking down the hall a yelled (R703's) on the floor .went to the room and observed resident lying on the floor holding onto .TV stating did I break my TV resident stated I hit my head an abrasion red in color was noted right side of residents forehead . 6/21/2020 17:56 (5:56 PM): Resident noted with large bruise on right arm above the elbow some parts of bruising is starting to yellow other parts are red and some parts are blue resident c/o pain upon palpation also states it is sore .(Doctor) made aware .(ordered) a stat xray of residents right shoulder, elbow and wrist. Resident had a fall on 6/16/20, resident had no c/o pain or discomfort to the right arm at that time . 6/24/2020 11:53 (11:53 AM) NURSE PRACTIONER NOTES .Patient was seen today after urinalysis was resulted and + (positive) for urinary tract infection .noted with recent recurrent falls from bed, no injuries noted post falls .Assessment/Plan: (did not mention fall assessment/plan) . 6/25/2020 20:58 (8:58 PM): Resident observed lying face down on the floor a top of the mat beside .bed at 6:55 PM blood noted to be all over the floor in front of resident upon assessment of residents face resident noted to be bleeding from (their) upper lip area cleansed ice applied ROM to all ext done no c/o pain voiced tylenol .given at 7 pm for c/o mouth pain .(Doctor) was called no answer left a message r/t (related to) the fall. 6/29/2020 17:11 (5:11 PM) COMMUNICATION - with Family/NOK/POA: Writer spoke to resident (family) in detail in regards to safety measures in place for resident safety. (Family) had no medications concerns. (Family) is aware pt (patient) is in high traffic areas during the day for safety. (Written by Licensed Practical Nurse (LPN) B). 7/24/2020 11:00 (11:00 AM): writer summoned to 3rd bay hallway by housekeeper resident and w/c lying on the floor, resident noted lying on .left side w/ large laceration to forehead with profuse bleeding. resident responding to name, c/o pain to head PROM to all extremities moves freely with no c/o pain .ambulance summoned 911 . 7/24/2020 11:03 (11:03 AM) NURSE PRACTIONER NOTES .Chief Complaint: Fall with head trauma .I was called urgently to see patient today after (they were) found lying on the floor in the hallway with .w/c near .was noted with Bright red blood from facial/forehead. Patient is on asa (aspirin) daily .has a history of falls, last one without injury on 6/25 . 7/24/2020 17:33 (5:33 PM): Received resident from .hospital via stretcher .admitting [DIAGNOSES REDACTED]. A review of R703's care plan revealed the following: Focus: I am at risk for falls and I have a history of falls r/t (related to) my dx (diagnosis) [MEDICAL CONDITION](stroke) with right sided weakness, R (right) eye [MEDICAL CONDITION]; Reviewed 6-18-19, 7-9-2019, Resident had a fall on 8/9/19 no injuries noted. Resident should be out of .room unless staff or family is present or in bed. Care plan reviewed 9/3/19. 06/16/20 REVIEWED 05/29/2020, //11/12/19 reviewed 12/17/2019, 01/21/2020,01/26/2020,03/04/2020 Date Initiated: 02/19/2019 Revision on: 08/10/2020 (cancellation date, post-discharge) Revision by: (MDS Coordinator) Cancelled Date: 08/10/2020. Goals: I hope to be free from falls without a serious injury by next review. Care plan reviewed 1/21/20 Care plan reviewed 3/11/2020. Date Initiated: 02/19/2019 Target Date: 08/27/2020 Cancelled Date: 08/10/2020. Interventions: -Anticipate and meet my needs. Date Initiated: 04/09/2019 Revision on: 08/10/2020, Revision by: (MDS Coordinator). -Be sure my call light is within reach and encourage me to use it for assistance as needed. Date Initiated: 02/19/2019, Revision on: 08/10/2020. -Bil (bilateral) floor matt to each side of bed while in bed. Date Initiated: 02/25/2019, Revision on: 08/10/2020. -BILATERAL FLOOR MATS AT BEDISDE (sic). Date Initiated: 11/12/2019, Revision on: 08/10/2020. -Do not leave me alone in the bathroom: Reviewed 6-18-2019, 7-9-19. Date Initiated: 04/09/2019, Revision on: 08/10/2020. -Ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). Date Initiated: 02/19/2019, Revision on: 08/10/2020. -I am to have non skid footwear on when up. Date Initiated: 04/09/2019, Revision on: 08/10/2020. -I have a perimeter mattress on my bed. Date Initiated: 05/29/2019, Revision on: 08/10/2020. -I need a safe environment with floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in lowest position and personal items within reach. Date Initiated: 02/19/2019, Revision on: 08/10/2020. -I need to be laid down in bed right after meal time is complete. Date Initiated: 01/21/2020, Revision on: 08/10/2020. -I require a dycem in the seat of my w/c. Date Initiated: 12/11/2019, Revision on: 08/10/2020 -I use a wheelchair and need assistance with locomotion. Place dycem on top of the w/c cushion. Date Initiated: 07/06/2019, Revision on: 08/10/2020. -Keep my bed in it's lowest position after giving care. Date Initiated: 02/21/2019, Revision on: 08/10/2020. -PT / OT (physical therapy / occupational therapy) to evaluate and treat as needed. Date Initiated: 02/19/2019, Revision on: 08/10/2020. -Pt to screen and evaluate as needed. Date Initiated: 02/21/2019, Revision on: 08/10/2020. -Toilet resident before and after meals and prior to bed. Date Initiated: 04/09/2019, Revision on: 08/10/2020. The intervention -concave mattress, Date Initiated: 05/13/2020. Revision on 08/10/2020, was found under the focus area: I need ext. (extensive) assistance with my ADL's (activities of daily living) r/t my dx [MEDICAL CONDITION] right sided weakness, right eye [MEDICAL CONDITION], hx of falls, and not located in the fall risk focus area of the care plan. On 9/10/20 at 9:58 AM, Licensed Practical Nurse (LPN) D was interviewed and indicated they and one aide (Certified Nursing Assistant F) were the only staff assigned to the north side of the hall, with CNA F also being assigned to the south side of the hall. LPN D indicated that CNA F was currently assigned to care for 29 patients total. LPN D stated, That has become pretty typical of this hallway. We had a lot of fall risks over here. When queried regarding how they handled residents who were fall risks, LPN D stated, I park by their room if there is a risk of someone falling out of bed. Try to have good rapport. Have to bring residents out and sit next to them. When queried regarding R703, LPN D stated, I would park outside of (R703's) room. They were a high fall risk. I didn't have any issues (with R703), I kept (them) up in the chair and kept them by me but I had good rapport. (R703) was extremely active. It was hard (but was okay) as long as someone was there with (R703) to redirect and stay active with (the resident). When queried how they were able to supervise fall risk residents with two staff members, LPN D stated, Keep (residents) out in the hall where I can see them .I feel like (R703) would've been better someplace with better ratios not 1 nurse to 30 residents. Felt like something else could've been done to calm (them) down maybe medication, (R703) was all over the place. I only had one fall with (R703). I had no CNAs on that day (last year, 2019) and I was the only staff member. A CNA came in at 5 (PM) and found (R703) on the floor. LPN D continued and stated they felt like Something more could've been done, not acceptable even for someone active to be falling. LPN D was queried if any other staff were working today who had worked with R703 and indicated CNA E was working and knew the resident. On 9/10/20 at 10:16 AM, CNA F was interviewed and confirmed that they were assigned to care for 29 residents today on 3rd bay. CNA F was asked how they are able to complete rounds on 29 residents and stated, I try to do the best I can. Yesterday I wasn't able to, it got to be too much. A girl from restorative was able to help a few people for me. When queried regarding ability to complete safety checks on residents who require more supervision, CNA F stated, I try to do my best. The nurse helps but their work gets hectic, too. When queried regarding R703 and interventions done for fall prevention, CNA F indicated R703 required more frequent visual checks, Every hour, hour and a half would need to lay eyes on (R703). (the resident) could self propel. Would be in the hall then make it back to (their) room. One time, (R703) did make it back to the room and fell . On 9/10/20 at 12:05 PM, CNA E was asked if they were available for interview. CNA E stated, I am so busy right now. I am so busy. CNA E stated they were pulled from 3rd bay to work on 1st bay, Because there was no one down there to work. CNA E stated they were assigned to care for more than 20 residents today. On 9/10/20 at 12:36 PM, CNA E was available for interview and was queried what fall interventions were in place for R703. CNA E indicated R703 had previously gone to group activities and was able to stay busy that way but, They stopped having activities in the dining room because of COVID. CNA E stated, (R703) sat in the hall with a nurse, sometimes CNAs would sit with (the resident). But if there were no nurse or CNA and there were no activity people around and they'd walk away, (R703) would roll themselves in the room and try to get into bed. CNA E continued and stated, We have been having staffing challenges long before COVID, and indicated they felt (R703) falling was a consequence of not enough people being around to supervise the resident. When queried regarding the resident falling multiple times despite staff knowing the resident was a fall risk, CNA E stated, (R703) actually needed 1:1 care but they never placed on a 1:1. We had the bed low and mats on the floor and that was it. Basically the resident moved a lot, never stayed still. Staff was well aware of this. I feel like (R703) needed to be on 1:1, all I could do was suggest that but I'm not management. When queried regarding the effectiveness of the interventions in place in R703's care plan for fall prevention, CNA E stated, It definitely wasn't working. One of the interventions should've been 1:1 care. CNA E explained they had been off sick but was told R703 was sent to the hospital because they, fell and busted (their) head open. I believe (they) had to get stitches. I don't think those things would've happened if we had enough people, but we don't have enough staff. On 9/10/20 at 1:40 PM, LPN C was interviewed and queried regarding the circumstances surrounding R703's fall on 7/24/20 and subsequent transfer to the hospital for treatment. LPN C stated, It was my first time ever taking care of (R703). At the time, I didn't know that (R703) was an impulsive person to fall or prone to falling. I passed my meds in the vicinity with (R703) that morning. I had two CNAs on my side that day (on 3rd bay). (At) 10:20-10:30 AM I finished meds, (R703) was still sitting up. Two CNAs were in (a room at end of the hall) doing care. I said I'm going take my cart back and park it. I turned the corner, 3-5 minutes gone and one of the housekeepers called and said come quickly. (R703) had fallen from (their) chair. When asked if they knew of any fall interventions in place for (R703) at that point, LPN C stated, No. I didn't know that there was a need for it. Nothing in report that (R703) was someone that needed interventions that (they were) a fall risk. So the CNAs told me and (the resident) stayed with me. When (R703) was with me, I never had to tell (them) to sit down, didn't have to redirect or nothing. (R703) was fine. One of the CNAs who never had (R703) before as well, asked if (R703) was someone that could lay back down after breakfast. I was thinking skin issues. (So they) didn't lay (R703) down after breakfast, (R703) was still up. We were pretty well staffed that day if I can remember and it still happened. Report was never given to me that (R703) was someone I needed to monitor for falls. On 9/10/20 at 2:00 PM, Unit Manager LPN B and the Director of Nursing (DON) were interviewed. When queried regarding the effectiveness of the interventions in place in R703's care plan for fall prevention and R703's multiple falls, LPN B stated We had behavior services (see the resident) because it seemed more like more of a behavior than anything. We put everything in place that we could to prevent (R703) from falling. When asked if the nurse assigned to care for the resident should know if the resident is a fall risk, LPN B stated, Yes, well the nurse was with (R703). The aides were in a room the nurses were at a code. When asked which care plan interventions related to behaviors and behavioral falling were in place for R703, LPN B stated, I would have to see. I can't remember everything off the top of my head. When queried regarding care plan interventions for fall prevention put into place for R703 after multiple falls with injury, LPN B indicated they were aware of the fall that required the resident to get stitches but would have to review the previous I/As before that fall. LPN B stated, After the falls with injury, (R703) was referred to psych services. When queried regarding when psych services saw the resident and if the behavioral visit addressed the falling, the DON indicated that consulting psych services was the intervention that was done. A review of the Behavioral Care Behavioral (psych) visit for R703 dated 7/14/20 did not reveal any mention of falls, and the psych visit was not noted on R703's care plan as an intervention for fall prevention. On 9/10/20 at 2:21 PM, the Nursing Home Administrator (NHA) was interviewed regarding R703 and their multiple falls in the facility. When queried how the facility handles residents who have multiple falls, the NHA stated, We (interdisciplinary team) review in morning meeting and do a risk management meeting. And review anything that has to do with quality of life. When queried regarding changes made to R703's care plan after multiple falls and multiple falls with injury, the NHA stated, They should be making changes, adding, changing interventions, all of the above. And then discussing them in morning meeting. When informed that LPN B stated psych services was consulted as an intervention for R703's falls, the NHA was then asked if that intervention should have been put into R703's care plan. The NHA reviewed the care plan and did not provide an answer. When queried if new or revised interventions were put into place in R703's care plan after the falls on 6/16 and 6/25 where the resident sustained [REDACTED]. I don't see any in there either. The NHA was then asked if any interventions were part of the post-fall assessments for R703. The NHA reviewed R703's post-fall assessments and indicated that is not the place new interventions get added and stated, Not seeing any interventions on there. The NHA was then asked should the behavioral visit for R703 have addressed the falling if that was why staff stated the resident was seen and done as an intervention, the NHA stated, They should (have), they should address if it's a behavior. The NHA then reviewed the psych note from 7/14/20 and was asked if they saw any mention of falls in the note. The NHA stated, Not seeing anything. When queried regarding the expectation for supervision of R703, the NHA stated, High traffic area, where (they) can be around staff. In activities programs and that kind of thing. A lot of folks went to activities (pre-COVID). Could've gotten activities more involved with (R703). When asked if the nurse who is taking care of a resident should be aware of the resident's risk of falling and fall interventions, the NHA stated, Yes, they should be aware, yes. When asked if the nurse should be aware of a resident's risk of falling even if it is their first time caring for the resident, the NHA stated, Yes, they should have it (the information) in the handoff (from previous shift). When queried if they felt R703's care plan interventions related to falls had been effective, the NHA stated, Hard to say. They (interventions) seemed to be effective when we were doing those with other folks (residents). A review of the facility's policy/procedure titled, Fall Management Guidelines, undated, revealed: Overview Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. Fundamental Information, Definition Fall refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost balance and would have fallen were it not for staff intervention, in other words, an interrupted fall is still a fall .The presence or absence of a resultant injury is not a factor in the definition of a fall. A fall without injury is still a fall. When a resident is observed on the floor, the facility is obligated to investigate to determine how he or she got there and put into place an intervention to minimize it from recurring. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred. Practice Guidelines: 1. Residents will be assessed for fall risk at least upon admission, quarterly, and annually with a significant change. 2. Residents identified at risk for falls will have a care plan developed and implement fall prevention interventions as needed based on their assessment. 3. When a fall occurs, the nurse should assess the resident for injury and provide the appropriate first aid based on standard of practice. If there is a suspected head injury, neuro checks should be completed per physician order [REDACTED]. After each fall, the nurse will assess for pain and document findings. If the resident complains of pain or has a new onset of pain, the Pain Evaluation form should be completed with a new fall evaluation. 5. The licensed nurse will document the incident on: Unusual Occurrence Report, 24 Hour Report, Nurse's notes, Post-Fall Assessment (if the incident is a fall), Charting in the nurses notes over the next 72 hours, Update the care plan, Pain Evaluation . 12. The IDT will review/modify the plan of care to minimize the risk of repeat falls .1. A Risk Management Meeting is conducted as needed according to the resident. Residents reviewed during the meeting are as follows: Residents that had a fall since the previous meeting to assure measures have been put into place and any new risk factors addressed.

Deficient Practice Statement #1 Based on interview and record review, the facility failed to identify a deteriorating medical condition and transport a resident who requested to go to an acute care setting, for one resident (#703) of three reviewed for a change in condition, resulting in Resident #703 becoming increasingly ill, uncomfortable, and expiring within the facility. Findings include: The Immediate Jeopardy (IJ) started on [DATE] and was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:18 PM and was asked for a plan to remove the immediacy. The IJ was removed on [DATE], based on the facility's implementation of the removal plan as verified onsite on [DATE]. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. On [DATE] at 11:22AM, a Confidential Resident (D) was interviewed regarding the facility and their method of communication to update current residents in the facility about the [MEDICAL CONDITION]. Confidential Resident D explained that they felt the facility was not notifying the residents of how many positive cases are within the facility. Confidential Resident D also stated that they were upset because they had lost a friend (Resident #703), whom was another resident in the facility, from the Coronavirus. A record review was completed for Resident #703. The electronic medical record (EMR) revealed the resident was admitted to the facility originally on [DATE], was sent out to the hospital on [DATE] for a fever and a decrease in oxygen saturation requiring a new order for oxygen. Resident #703 was readmitted to the facility on [DATE]. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #703 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The MDS also revealed that the resident needed extensive assistance from staff for activities of daily living (ADL) and had the [DIAGNOSES REDACTED]. A record review of the Advanced Directives revealed that Resident #703 was a full code and wished to be transferred to the hospital for changes in medical status as of [DATE]. A record review of the facesheet indicated Resident #703 had one emergency contact (daughter) and was listed as self, meaning own responsible party. An attempt to interview the emergency contact via phone was made on [DATE] at 9:00am and 1:00pm with no call back by the end of the survey. A record review of the care plan for Resident #703 revealed the following: Focus-I have altered respiratory status/difficulty breathing OR potential for an alteration in respiratory status r/t (related to) my history of COVID-19, pneumonia, acute respiratory status with [MEDICAL CONDITION] Revised [DATE]. Goal-I will maintain normal breathing pattern as evidenced by normal respirations .and regular respiratory rate/pattern . Interventions-Monitor for s/sx (signs and symptoms) of respiratory distress .increased respirations; Decreased pulse oximetry, increased heart rate ([MEDICAL CONDITION] .Lethargy; Confusion . A record review of the progress notes for Resident #703 revealed the following: [DATE] 23:36 (11:36PM) Admission Note .Resident (#703) readmitted . with Dx (diagnosis) of Covid-19 (+), Pneumonia,[MEDICAL CONDITION](high blood pressure) . O2 (oxygen) on via nasal cannula at 4L (liters)/min (minute), HOB ^(head of bed up). Resident alert and responsive, able to make needs known . [DATE] 13:30 (1:30PM) Respiratory Therapy Note .Resident seen by Skilled RT (respiratory therapy). Resident has been transferred to isolation and is receiving Covid 19 screening daily. Resident has a history of [MEDICAL CONDITION]. RT found resident on room air. Sp02 (pulse ox) 60% (normal is ,[DATE]%). RT placed resident on 4 liters via nasal cannula. Sp02 increased to 96%. HR (heart rate) 112 (normal is ,[DATE]) RR (respiratory rate) 20. Breath sounds are bilateral with coarse rhonchi (rattling respiratory sounds usually caused by secretions in the airways). Respiration are uneven (lungs not expanding at the same time) and slightly labored (normal is even, unlabored). Continued oxygen support is indicated. RT communicated with nurse and notified of resident's Sp02, HR, and RR. Oxygen order 4 liters and pulse ox q (every) 6 (hours) placed in (EMR) by RT. Skilled RT spent approximately 30 minutes with resident. [DATE] 14:40 (2:40PM) Respiratory Therapy Note . Resident seen by Skilled RT. Resident has been transferred to isolation and is receiving Covid 19 screening daily. Resident has a history of [MEDICAL CONDITION]. Sp02 94% on 4 liters via nasal cannula. HR 85 RR 20. Breath sounds are bilateral with scattered rhonchi. Respiration are uneven and slightly labored. Continued oxygen support is indicated. RT communicated with nurse and notified of resident's Sp02, HR, and RR. Oxygen order 4 liters . Skilled RT spent approximately 20 minutes with resident. [DATE] 19:59 (7:59PM) Nurses Note Late Entry .Resident Alert, very lethargic (drowsy) sleeping on and off. BP (blood pressure) ,[DATE] (normal is ,[DATE]) MD (Medical Doctor/Dr. B) notified, resident 0.9 sodium chloride ordered to hang at 70cc's (cubic centimeters) x3 1000 bags hypodermoclysis (a method of fluid infusion underneath the skin tissue) location site left side. Site dry intact. BP medications on hold x3 days . An attempt was made to call ([DATE] 10:00AM) the nurse who authored this note, however, the nurse did not return telephone calls by the end of the survey. [DATE] 12:00 (PM) Respiratory Therapy Note .Resident seen by Skilled RT. Resident is receiving Covid 19 screening daily. Sp02 91% on 4 liters via nasal cannula. HR 101 RR 22. Breath sounds are bilateral and diminished (air or fluid build up in or around the lungs). Respiration uneven and labored with dyspnea (difficulty breathing). Continued oxygen support is indicated. RT communicated with nurse and notified of resident's Sp02, HR, and RR. Oxygen order 4 liters .Skilled RT spent approximately 15 minutes with resident. [DATE] 11:23 (AM) Nurses Note .Writer noted that res (resident) had a very small amount of emesis (vomit) W/a (with a) very small amount of blood, VS (vital signs) assessed & recorded BP: ,[DATE], P: 76, T: 97.7, RR: 18, 02SAT 95% via N/C (nasal cannula) infusing @ 5LPM (liters per minute), W/O (without) resp.(respiratory) distress noted, res stated that they wanted to be transferred from facility (to hospital), writer informed assigned MD regarding all stated above, MD prescribed no new orders & denied transfer (to hospital) D/T (due to) res not having an acute reason for hosp.(hospital) transfer, res also C/O (complained of) hypodermaclysis site .writer removed hypodermaclysis .writer will cont (continued) to monitor res. Authored by Licensed Practical Nurse (LPN) A. [DATE] 09:35 (AM) Respiratory Therapy Note .Resident seen by Skilled RT. Resident is receiving Covid 19 screening daily. Sp02 91% on 4 liters via nasal cannula. HR 105 RR 22. Breath sounds are bilateral and diminished. Respiration uneven and labored with dyspnea increased O2 to 5 liters [DATE] 10:00 (AM) Respiratory Therapy Note .Resident seen by Skilled RT. Resident is receiving Covid 19 screening daily. Sp02 94% on 5 liters via nasal cannula. HR 115 RR 22. Breath sounds are bilateral and diminished. Respiration uneven and labored with dyspnea. Continued oxygen support is indicated. RT communicated with nurse and notified of resident' s Sp02, HR, and RR. RT notified nurse of resident lethargic state and 'twitching' with upper body. Nurse assessed and called NPA (Nurse Practitioner), who arrived to room. Oxygen order 5 liters .Skilled RT spent approximately 25 minutes with resident. An attempt was made to call the above mentioned RT on [DATE] at 11:00am, the RT was on bereavement leave and unavailable per the Nursing Home Administrator (NHA). A record review of the COVID-19 Monitoring Assessment for Resident #703 revealed the following: [DATE]-Res (resident) A&O (alert and oriented) C/O pain whenever repositioned .res produces a very small amount of emesis W/a (with a) very small amount of blood noted this A.M. res. request to be transferred to (local hospital) assigned MD notified regarding findings with no new orders prescribed & denied res request .meals intake adequate, need to assist at times. [DATE]-Pulse 106, loss of appetite checked. Narrative note stated, Resident A&Ox,[DATE] with come (sic) confusion, able to make needs known .Patient c/o n/v (nausea and vomiting). [MEDICATION NAME] (an anti-nausea medication) given. [DATE] 09:00 (AM) NURSE PRACTIONER (NP C) .Progress Note .altered mental status .This is a [AGE] year old .with a past medical history including and not limited to heart failure, diabetes, hypertension, [MEDICAL CONDITION]([MEDICAL CONDITION]/stroke) .required transfer to acute care facility on ,[DATE] when .found in .room with lethargy, elevated temperature of 103 and hypoxemia (low oxygen saturation) at 79% on 15 liters mask .treated for [REDACTED]. Patient was seen today per staff concern .was noted with restlessness and c/o worsening muscle weakness .alert and responds to verbal stimuli .no apparent distress, seen sitting up in bed in .room .does require assistance with meals due to weakness since returning from the hospital .denies pain overall .Appears somewhat more confused than baseline. ASSESSMENT/PLAN: - Altered mental status; accucheck 107 (blood glucose levels), VSS (vital signs stable); no noted hypoxemia. Will obtain STAT (Urgent) CBC (complete blood count) and BMP (basic metabolic panel), UA (urinalysis) to r/o (rule out) underlying metabolic cause. - COVID 19; s/p (status [REDACTED].Debility .Patient is stable to remain in the facility at this time, will require close monitoring over the next 24 hours to ensure ongoing improvement, any further changes in condition .may require transfer to acute care facility for further evaluation. Attending was updated and agreeable to plan of care. [DATE] 20:04 (8:04PM) Nurse Note .At 9:50 a.m. noted to be twitching from left side of .body down to .foot. NP notified STAT labs and STAT urine ordered. Refused to let nurse straight catheter .unit manager and DON (Director of Nursing) notified, awaiting labs to be drawn. VS ,[DATE] 115 (pulse) 98.2 ax (temperature-normal is between ,[DATE]) .O2 sat 93% O2 @ 5L/min. Authored by Licensed Practical Nurse A. [DATE] 20:26 (8:26PM) Nurses Note . Lab arrived around 2:20 p.m. drew blood, around ten minutes later therapy went in to do therapy and (Resident #703) was unresponsive. Code called, unable to obtain VS, staff performed CPR (cardiopulmonary resuscitation) until 911 services arrived .Emergency responders performed two epi ([MEDICATION NAME]) series and @ 15:11 (3:11) p.m .pronounced (Resident #703) decease .At 5:40 p.m .Funeral Home signed for the remains. On [DATE] at 11:12AM, the NHA was asked the expectations of staff for a resident (#703)that is not improving medically, a full code, with an intact BIMS, and had asked to go to the hospital and stated, We would pull the IDT (interdisciplinary team) together and call the Doctor and discuss. He (Doctor) was not seeing a change in condition and with the COVID pandemic we were trying to follow CDC (Centers for Disease Control) guidelines and not send (Resident #703) to the hospital if we didn't have to. The NHA was asked if knowing the outcome (Resident #703 expiring in the facility on [DATE]) if he would have sent Resident #703 to the hospital and stated, Well yeah, hindsight is always different. Usually it is the opposite, the Doctor wants them (residents) to go to the hospital and they don't want to go, we have to respect their wishes. The NHA was asked if a resident's wishes are to go to the hospital, is that their right, and stated, (Resident #703) was delusional. When asked if Resident #703 was normally delusional, the NHA stated, Usually, no, they came back to us that way from the hospital. The NHA was asked if Resident #703 was at baseline ever when returned to the facility and stated, No, (Resident #703) wasn't. On [DATE] at 11:32AM, NP C was interviewed in regard to the choice to not send Resident #703 to the hospital with a deteriorating condition and a direct request to be sent out and stated, Initially when (Resident #703) returned they did not want to have to go back to the hospital. When asked if that was in writing, the NP stated, I did not say that, I said initially they did not want to go back. At the time, the vital signs were stable and the [MEDICAL CONDITION] had resolved. On [DATE] at 11:47AM, LPN A was interviewed regarding the condition of Resident #703 on [DATE] and stated, They were twitching. LPN A was asked if it was [MEDICAL CONDITION] activity and stated, No. When asked what NP C did about the situation, LPN A stated, Labs and a UA were ordered. On [DATE] at 12:05PM, LPN A was interviewed per telephone and stated, I asked for (Resident #703) to go to the hospital and I grabbed (NP C), and had her look at them. She ordered labs and called the Doctor (Dr. B) to discuss with him what was going on and he said to not send (Resident #703) to the hospital. LPN A was asked what they did next and stated that she attempted to get the UA but the resident refused. LPN A was asked if they felt that Resident #703 needed to go to the hospital and explained that she felt that the resident should have been sent to the hospital. On [DATE] at 12:40PM Dr. B was interviewed via phone and was asked for the reason why Resident #703 was not transported to the hospital upon their request and with a change in condition and stated, I can't recall if I seen them but the vital signs were stable and did not show decomposation. We need to see them and then decide if it is and emergency of if we can treat them in the facility. She was medically stable. The Dr. was asked if he was aware of the RT charting of several days of unlabored breathing and stated, Their lung sounds were clear to auscultation when I seen them. On [DATE] at 1:14PM, the DON was interviewed in regard to Resident #703 requesting to be hospitalized and declining in their overall health condition and stated, We wouldn't deny anybody to go to the hospital. They were seen by our NP and the Doctor. They probably felt like (Resident #703) could be treated here. The DON was asked if she was aware of the resident's condition and stated, Yes, I knew them well, they were one of my favorites. (Resident #703) called my personal cell phone and asked me to bring them hot tea and honey. I brought some tea up there at 10 at night and sat with them and we prayed (for their health) together .(Resident #703) had aches and pain and was on [MEDICATION NAME] (a pain reliever) and would refuse anything stronger. (NP C) did order some'labs. The DON was asked if the nurses are allowed to make a judgement call and send a full code resident that is medically declining to the hospital if they request and stated, We have an NP in the building, they can always ask her or the Doctor. I am not sure why the Doctor did not send (Resident #703), that is a NP or Doctor question. A review of the facility policy titled, Acute Change in Condition (undated) revealed the following: An acute change in condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that without intervention, may result in complications or death. Guidelines-#2. Residents are assessed upon admission to establish 'Baseline Data'. Interact ACOC Warning Signs-Blood Pressure .any significant decrease may trigger an ACOC (e.g.,systolic (top number of BP) BP < (less than) 100 .decline in BP accompanied by other symptoms such as dizziness, decline in systolic BP<15mm (millimeter) in systolic BP, combination of pulse >100 beats . Pulse-Sustained change from normal range .Pulse> (greater than)100 bpm (beats per minute) accompanied with other symptoms (e.g., .dyspnea). Weight/Eating Patterns .A change in eating/drinking patterns. Level of Consciousness-Level of consciousness is the degree of awakeness, i.e. alert, drowsy/lethargic . Weakness-New onset of weakness .Significant variation from baseline .Significant change in ADL ability. Cognitive Symptoms-abrupt onset of, or increase in, confusion. Onset of hallucinations, delusions, or paranoia. Bleeding-Appearance of frank blood in stool, urine, or vomit. A review of the facility policy titled, Advanced Directives Policy(not dated) revealed the following: Policy-The Facility will honor valid advanced directives or treatment preferences made by the resident or healthcare legal decision maker for the resident. Decision-Making Authority-No one can make medical decisions for a resident with capacity, except the resident. A review of the facility policy titled, Resident Rights (undated) revealed the following: 3. Planning and Implementing Care .e. The right to request, refuse, and/or discontinue treatment . IJ Abatement Plan - F684 1. Resident #703 is no longer in the facility. 2. All 102 residents have the potential to be affected. - Residents with Change of condition will be identified immediately, changes will be communicated to the physician/IDT. Physician recommendations will be followed in agreement with the residents or responsible party wishes. Family will be notified of changes. Care plan will be implemented and updated as required. - Adhoc QAPI (Quality Assurance Process Improvement) completed with Medical Director, Administrator, DON, Unit Manager to discuss change in condition; identification and plan of care. 3. 45 Licensed Nursing staff will be re-educated on Policy and Procedure on Acute Change in Condition, including immediate physician notification and updating plan of care as needed. Licensed nursed (sic) will be required to be educated prior to the start of the next shift. All Licensed nursing out on leave will have education sent via certified mail. 4. Changes (symptoms) in a resident's condition are communicated by any staff member to nurses via (see warning signs): a. Stop and Watch/Interact b. Clinical Rounds findings c. Verbal reports d. Huddle reports Nursing rounds will be completed daily and any change in conditions identified will be communicated to the IDT and physicians to implement/update plan of care. DON and/or Designee will ensure immediate compliance by auditing 102 residents residing in the facility. Daily audits will be completed x1 week, weekly x4 and monthly x 4. Report findings to QAPI Committee for further instruction. 5. Compliance date: [DATE] This citation pertains to intake MI 863. Deficient Practice Statement Two: Based on interview and record review, the facility failed to enact policies and procedures to ensure timely and comprehensive assessment and monitoring and failed to notify family representative of a change in condition related to Covid-19 infection for one (#707) of three Residents reviewed for Covid-19 and change in condition, resulting in inconsistent and no assessment documentation in the days preceding the Residents decline in condition, transfer to the hospital, and ultimate death. Findings include: Record review revealed Resident #707 was originally admitted to the facility on [DATE] and readmitted on [DATE] for short term rehabilitation with [DIAGNOSES REDACTED]. Review of the Resident's admission assessment, dated [DATE], revealed the Resident was alert and orientated to person, place and time. The admission assessment further revealed the Resident required set up to one-person assistance to perform Activities of Daily Living. Resident #707 was transferred from the facility, to the Emergency Department, on [DATE]. A detailed review of Resident #707's medical record revealed no nursing and/or health care provider note documentation from [DATE] until [DATE] and on [DATE]. The following clinical progress note documentation was contained in the Resident's medical record: -[DATE] at 8:15 PM: physician progress notes [REDACTED]. had fever and mild dyspnea (difficulty breathing) . Blood Pressure: ,[DATE] (at) [DATE] 6:23 (AM) Temperature: 98.5 (on) [DATE] (at) 3:42 PM . O2 sats: 97.0 % (on) [DATE] (at) 3:42 PM . [MEDICAL CONDITION] with dyspnea. CXR (chest X-Ray) with [MEDICAL CONDITION] congestion. empirically treat after testing for Covid 19 monitor closely for symptoms . -[DATE] at 8:02 PM: Nurses Note . Resident noted to be disoriented, without co-ordination; unable to feed self . C/O (complain of) pain in chest on inspiration; gurgling noted on inspiration. C/o difficulty breathing, using accessory muscles to breathe, skin color pale; Oxygen saturation 79% on 2L (liters) via n/c (nasal cannula); began to mouth breath. Mask applied and oxygen increased but O2 sat only increased to ,[DATE]%. Skin clammy to touch; Attempted to face time with physician, but physician's phone unable to connect to face time. 911 initiated and resident was transferred . Resident's family . informed. V/s (Vital Signs) (Blood Pressure) ,[DATE]- (Temperature) 100.2 (elevated) -(Pulse) 77 - (Respiratory Rate) 28 (normal rate ,[DATE]) . Resident #707's medical record further revealed an order to start [MEDICATION NAME] ([MEDICATION NAME]- used as an off label treatment for [REDACTED]. Review of Resident #707's vital sign documentation in the medical record revealed the Resident's temperature had been obtained on [DATE] at 8:16 PM, [DATE] at 2:36 PM, [DATE] at 3:42 PM, [DATE] at 8:28 PM, and [DATE] at 2:14 PM. On [DATE] at 2:14 PM, Resident #707's temperature was 100.2 degrees Fahrenheit. An interview was conducted with Resident #707's family member, Confidential Witness S on [DATE] at 5:10 PM. When queried regarding Resident #707, Witness S stated, (Resident #707) passed away on [DATE]. Witness S revealed the Resident died from Covid-19 infection and stated, (Resident #707) didn't have it (Covid-19) when they went to the facility. When queried regarding Resident #707's care within the facility including communication regarding the Resident's medical status, Confidential Witness S stated, They didn't get in touch with us other than when (Resident #707) fell and then when they (facility) transferred (Resident #707) to (the Emergency Department) because they were having trouble breathing. Confidential Witness S was then asked when Resident #707's condition declined and replied, They never told us (Resident #707) had Covid. Witness S further revealed they were not made aware by the facility that Resident #707 was started on medications to treat Covid-19. Review of Resident #707's medical record revealed no documentation of facility notification related to Covid-19 [DIAGNOSES REDACTED]. An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:20 AM. When queried regarding the frequency of vital signs, including temperature, monitoring and documentation for Residents per policy/procedure, the DON replied, Twice a day. When queried regarding Resident #707's transfer to the hospital and lack of consistent and twice daily nursing documentation prior to transfer due to a decline in condition, the DON reviewed the Resident's medical record and stated, I'm not sure when cooperate changed the policy. I'll have to find out. When queried regarding the Physician note dated [DATE] which indicated the Resident had a temperature and dyspnea but no nurses documentation, the DON reviewed the Resident's medical record and stated, I don't see any nurses notes either. When queried if there should have been nursing documentation, the DON stated, They could have documented inside the Covid assessment. When asked if there was Covid Assessment documentation, the DON reviewed the Resident's medical record and stated, No, they don't (have documentation). The DON further stated, They should have made a note. When queried how staff were assessing and responding to a change in condition without vital sign and assessment documentation, the DON replied, Should have been documented. When queried regarding facility policy/procedure pertaining to notification of family, the DON revealed family should be notified of all changes. When queried regarding Resident #707 being started on medications for treatment of [REDACTED].#707's medical record and stated, Nope, I don't see it. Lord have mercy. No further explanation was provided. A review of the facility policy entitled, Acute Change in Condition (undated) revealed, An Acute Change in Condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. 'Clinically important' means a deviation that without intervention, may result in complications or death .Level of Consciousness-Level of consciousness is the degree of awakeness, i.e. alert, drowsy/lethargic . Weakness-New onset of weakness .Significant variation from baseline .Significant change in ADL ability .Cognitive Symptoms-abrupt onset of, or increase in, confusion. Onset of hallucinations, delusions, or paranoia . Review of facility policy/procedure entitled, COVID-19 INTERIM PANDEMIC GUIDELINES (Updated [DATE]) revealed, All residents should have a daily narrative nursing note. The note includes: Vital signs, assessment of reason for Medicare coverage, skilled nursing intervention provided, and response to treatment . If the resident is being admitted under COVID positive or surveillance, the following should be documented in the narrative area of the COVID assessment . Narrative note to include: Review of vital signs - if temp, response to Tylenol, if Pulse is abnormal, interventions taken. If respirations abnormal - fast or slow, are accessory muscles being used (if yes, take action because the breathing is labored unless this is baseline such as someone with chronic [MEDICAL CONDITION]). Description and nature of symptoms (ie cough - dry or productive, headache - dull or pounding etc.). Lung sounds - clear, wheezing, congested, absent (perhaps in a lower lobe). Description of breathing and SPo2 level - if low, intervention provided and effect. Use of oxygen - how many liters, is the resident keeping it on? Skin color particularly around the mouth and nail beds. Pink, pale, bluish in color (take action if blue in color). Skin turgor . Appetite and fluid intake. Interventions currently provided (example IV fluids, Tylenol, respiratory treatment, medications). Response to treatments provided - follow up from previous shift . The policy further revealed, Steps to Having Care Planning Discussions . 4. Document discussion and treatment choice: a. Document in medical record . c. Communicate with family, resident wishes, if family not present .

Based on observation, interview, and record review, the facility failed to provide feeding assistance as ordered, initiate interventions for weight loss prevention, conduct a follow up assessment after noted significant weight loss, and/or update the care plan and/or medical record after weight loss for two sampled residents (R#30 and R#[AGE]) of two reviewed for nutrition, resulting in the potential for further weight loss. Findings include: Resident #30 On 2/11/20 at 9:41 AM, R#30 was interviewed and asked if they had lost any weight. R#30 stated, Yes. I don't know why. I'm not eating like I should. The food is alright I just don't want to eat a lot. When asked when that started, R#30 stated, About a month ago. They said I lost about 10 pounds (lbs). R#30 indicated they received Ensure (supplemental nutritional drink) and drinks it. When asked if they had eaten breakfast this morning, R#30 said, Yes, they're keeping track of what I'm eating, They come tell me 'You didn't eat this, you didn't eat this.' R#30 did not indicate that they received help eating from staff. Upon review of R#30's medical record, it was noted the resident weighed 145 lbs on [DATE], and weighed 123.3 lbs on 2/3/20, which is a -14.[AGE]% loss On 2/12/20 at 12:55 PM, R#30 was observed alone in their room, with a lunch tray sitting in front of them. R#30 had their face resting in their hand and was not eating their food. The resident was then noted to take a drink of their Ensure. R#30 then set the drink down and continued resting their face in their hand. On 2/12/20 at 1:05 PM, R#30 remained with their face resting in their hand and was observed to not have touched any of the lunch on their tray. On 2/12/20 at 1:11 PM, multiple staff were observed collecting lunch trays from resident rooms. Certified Nursing Assistant (CNA) O entered R#30's room to collect their lunch tray. CNA O asked if R#30 was going to eat any more, but was not observed to provide feeding assistance to the resident. The other assigned CNA, CNA G entered the hallway and was queried regarding residents on their assigned unit who required feeding assistance. CNA G stated, Lately we've only had two aides for the whole bay (unit), which is hard. I try my best to do what needs to be done. I've been doing this for a long time but we have (resident name - withheld) who needs to be fed, and (R#[AGE]), and now we have (R#30) who needs coaxing to eat, and we also have (another resident name - withheld). It gets to be a lot when we only have two aides for the hallway. It's better when we have three but we have been working with two. A review of R#30's medical record did not reveal any dietary progress notes and contained one nutrition assessment from the resident's original admission in December 2019. Further review revealed the following order: 1:1 Feed With All Meals, entered by Unit Manager (UM) H on 2/2/20. On [DATE] at 9:28 AM, the Nursing Home Administrator (NHA) was asked if the facility's Registered Dietician (RD) was in the building. The NHA indicated the facility shared a RD with a sister facility and stated he would see which building she was currently at. On [DATE] at 9:31 AM, the RD was interviewed and indicated they had just started providing RD service at the facility in December 2019. When queried regarding R#30, the RD stated, (R#30 is one of my newest ones. I have notes from a Quality of Life meeting from this past Friday. Their current weight is 123.3 and may be attributed to going out to the hospital twice. They have a fair appetite. I took measures to order Med Pass (fortified nutritional shake) twice a day for weight stabilization. This resident is on hospice. Upon reviewing R#30's medical record with the RD, no order was seen for Med Pass for the resident. The RD confirmed there was no order and stated she was sure that she entered it and was not certain what happened. The RD verified that there were no dietary progress notes and no current nutritional assessment in R#30's medical record since their hospitalization s, weight change, and/or entering hospice services. When queried if she had put in the order for 1:1 assist during meals for R#30, the RD stated, No, I did not put in that order but I believe (R#30) would benefit from it. On [DATE] at 9:55 AM, Unit Manager H was queried regarding the feeding assist order for R#30. UM H stated, (R#30) should be getting fed. UM H was then shown the Kardex (care guide for nursing and nursing assistants) for R#30 which read, EATING: I am able to feed myself with set-up assistance. UM H indicated that was incorrect and stated, I should've updated that. (R#30) came back (from the hospital) as a 1:1 assist for meals. (R#30) should be getting help with every meal and I should have updated that. A review of R#30's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] and re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Resident #[AGE] On 2/11/20 at 12:14 PM, R#[AGE] was observed in their bed. R#[AGE] appeared thin, with no visible teeth present and sunken cheeks. The resident was unable to appropriately answer interview questions. A review of R#[AGE]'s record revealed: On 8/7/19, the resident weighed 148.2 lbs and on 2/4/20, the resident weighed 136 pounds which is a -8.23% loss. R#[AGE]'s weights were reviewed and were as follows: 2/4/2020: 136.0 Lbs 1/26/2020: 137.4 Lbs 1/11/2020: 137.0 Lbs 1/8/2020: 139.3 Lbs 1[DATE]19: 147.0 Lbs 11/9/2019: 151.6 Lbs 10/5/2019: 151.8 Lbs 9/2/2019: 151.3 Lbs 8/7/2019: 148.2 Lbs Further review revealed the following note in R#[AGE]'s medical record: 6/18/2019 12:31 Weight Change Note Note Text: Resident had -6.8% sig (significant) wt (weight) loss x 30 days. Resident has poor PO (oral) intake. Receiving (sic) frozen nutritional treat BID (twice a day), medpass BID added. Will continue to monitor PO intake + wt. The following searches were done in R#[AGE]'s medical record, to locate a follow up dietary note after [DATE]: Nutrition/Dietary Note, Dietary Progress Notes, Dietary Notes, Dietary (retired). All remaining progress notes for R#[AGE] were then reviewed. No follow up notes to the one written on [DATE] were found, and no dietary notes were seen in R#[AGE]'s record from [DATE] until 1/24/20. Further review revealed a dietary assessment completed on 5/6/19 with no follow up assessment completed for R#[AGE] until 1/22/20. A review of R#[AGE]'s care plan revealed no mention of the resident's significant weight loss noted in June 2019. R#[AGE]'s care plan goals were dated as last revised on 8/2/2019, and the care plan had no new or revised nutritional interventions entered in 2019 or thus far in 2020. R#[AGE]'s care plan focus area read as follows: I am at nutritional risk r/t (related to) I have a chronic disease .I am edentulous and receive a mechanically altered diet. I have a hx (history) of slow weight loss, my weight has triggered in the past within a [AGE]d ([AGE] day) period. CBW (current body weight): 137# (lbs), IBW (ideal body weight): 166#, BMI (body mass index): 19.7. Date Initiated: 07/25/2018 .Revision on: 01/28/2020. On [DATE] at 9:37 AM, the RD was interviewed regarding R#[AGE] and their weight loss. When queried if they are responsible for updating a resident's care plan relating to weight loss and nutrition, the RD stated, It depends. If someone else doesn't do it, I will. I added new orders for R#[AGE] in January. When asked about care plan interventions, the RD indicated they would've expected interventions to be added or revised for R#[AGE] when the weight loss was noted in 2019, and would've expected a follow up note after the noted significant weight loss in June 2019. The RD stated, I would like to have seen something there but can't speak for that time frame. The original weight loss I looked at was from December (2019) to January (2020). The RD was asked if that meant they did not look at any weight loss prior to December 2019 and the RD indicated that was correct. On [DATE] at 2:34 PM, the Director of Nursing (DON) was interviewed and queried regarding R#30 and R#[AGE]. The DON stated, We haven't had a full time RD in the building for a very long time. Months, if not a year. When asked about significant weight loss notes with no follow up, the DON stated, Sometimes corporate was coming in to help, sometimes we just didn't have anyone at all. In terms of following up, it was left up to maybe, the Nurse Practitioner or the dietary manager at the time but she's gone now. When asked about addressing the noted weight loss, the DON stated, It should be discussed and something new should be added. Try to get labs, things like that. When queried regarding R#[AGE]'s care plan interventions not being added or revised since 2018, with the noted weight loss in 2019 and into this year, the DON stated, I would've expected some things to get updated since then with everything going on with (R#[AGE]). When queried regarding orders for 1:1 feeding assistance and updating the Kardex, the DON stated, I expect someone to sit down and feed someone if there is an order for [REDACTED]. A review of R#[AGE]'s MDS assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE], had medical [DIAGNOSES REDACTED]. A review of the facility's policies titled, Nutritional Supplementation, and Nutritional Care, (provided in one document), undated, were reviewed and revealed the following: When a resident is identified as having a sudden or progressive decline in nutritional status or weight, the clinical nutrition staff will assess the resident and provide alternative food substitutes to stop or slow the decline .these interventions will be monitored at least quarterly and documented in the Nutrition Progress notes .3. Significant change related to Nutrition or Annual Assessment a. A Nutrition Assessment form will be completed according to facility policy and includes: i. a review of current interventions and evaluation if they have been properly implemented ii. are interventions working iii. a discussion statement if the significant change is related to nutrition or can have an impact on nutrition .nutrition professional will be notified of significant resident changes in order to intervene timely .6. Care plan goals and interventions a. goals and interventions will be mutually developed by: i. the resident and or responsible party ii. interdisciplinary team (IDT) iii. unusual body weight is the most relevant basis for weight related interventions. b. Interventions should be individualized and monitored for effectiveness. 7. Follow up and monitoring a. Resident that have a new significant confirmed weight change will be reviewed in a IDT meeting where risk and interventions can be reviewed. b. Residents with continued gradual weight loss or gain will be documented on a minimum of monthly unless it is documented that the resident chooses no further interventions.

This citation pertains to intake # 0 and 7. Based on observation, interview and record review, the facility failed to place timely, effective interventions to prevent repeated physical abuse from one (#701) resident with a known history of physical abuse, resulting in the hitting of two unsampled residents with closed fists, causing lacerations, the need for medical care and the likelihood of repeated physical abuse on to other residents. Findings include: On 11/25/19 at 10:25 AM, Resident #701 was observed in their room sitting on a chair with no shoes on and their bare feet resting on a folded white towel on the floor in front of them. Certified Nursing Assistant (CNA)C was observed sitting in a chair outside of the room. Resident #701 was attempted to be interviewed but was very difficult to understand. Per CNA C, Resident #701 can make needs known and does get combative and will tell people to stay out of their room. A record review of Resident #701's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #701 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition and had hallucinations, physical and verbal behaviors directed towards others and put others in significant risk of injury. A review of the care plan for Resident #701 revealed the following: Focus: I have a behavior problem .when I become agitated I will throw things around .use profanity towards others. I require a private room as I have a history of being aggressive with roommates. Initiated 1/12/17 and revised on 10/15/19. Interventions: Anticipate and meet my needs divert my attention and remove me from a situation as needed .Assist me to develop more effective ways of coping and interacting .Minimize the potential for my disruptive behavior, offer tasks which divert my attention . A review of progress notes revealed the following: 8/12/19 10:57 AM (Nurses note)- .Writer informed of resident hitting another resident writer escorted female resident down to her nursing station and reported incident to her nurse. 8/12/19 11:51 AM (Nurses note)- .Writer attempted to meet with resident in their room. Resident presents with high agitation hit multiple staff in the face. PA (Physician Assistant) from behavioral care solutions attempted to meet with resident in their room ,and resident hit her in the face. Due to high agitation and safety of others, writer called doctor and informed of situation. Writer petitioned resident . 8/30/19 3:30 PM (Nurses note)-IDT (interdisciplinary team) met to discuss residents behavior in behavior management. Resident reporting hallucinations at night time, presenting with agitation and physically aggressive with staff. 9/4/19 9:25 PM (Psych note)- .Resident is still having nighttime hallucinations and agitation. Resident sitting in chair upon approach. Anxious and irritable about their tremors. Some drooling noted. 10/12/19 4:35 PM (Nurses note)-Resident .observed to have walked out of their room, walked up to resident . and hit him in the face, making contact with his nose and mouth. Witness states she began calling for a nurse and at that time resident turned around, looked at her, went back to their room and closed the door. CNA came and informed writer of what occurred. Writer attempted to attain resident's vitals and resident refused; resident was sitting in a chair their room as writer entered. Writer asked resident if they were able to recall and explain what happened. Resident began to attempt to explain but writer was unable to understand resident due to speech impairment . 10/12/19 10:35 PM (Nurses note)- .Resident in bed continues to show agitation after oral [MEDICATION NAME] (antianxiety medication) administered. Resident is reaching in upward from the bed, pointing their finger and fussing. Writer attempted to redirect resident and assure them their was no one there to harm them. Resident begin to swing their closed hand. 10/13/19 4:51 PM (Nurses note)- .reported to writer that resident tore their shirt off and threw it in the corner. Writer went to talk to resident and observed resident to have increased agitation and raising voice to writer . 10/14/19 (authored by Social Worker/SW A)- . Writer met with resident in their room regarding incident. Resident found reading book in their room. Resident presents A&ox3 (alert and oriented to person, place and time). Writer asked resident about incident and resident expressed, Yeah, I hit that man because my heart was pumping and pounding .Resident reporting hallucinations as people in their shower. 10/14/19 6:30 PM (Psych note)-Complaint: asked to see as a priority re aggressive behavior .with a PMH (past medical history) of .depression, aggressive behavior and paranoid [MEDICAL CONDITION] . On 10/12 (Resident #701) walked up to another resident and punched him in the face unprovoked without remorse .Resident continues to show agitation and aggression and use abusive language to staff .Becomes easily agitated and frustrated, which worsen their speech and tremors . 10/16/19 5:30 PM (Nurses note)-Residents behavior consist of physically aggressive with staff, use profanity, agitation and will throw things in their room and come to nurses station and throw items. Resident will become upset if others sitting next to them and are loud. Resident at times report hallucinations in shower room. 10/22/19 3:50 PM (Nurses note)- .Resident agitated about the television not displaying a clear picture; Resident observed to have walked out of the room and threw a cup filled with water toward the desk and walked back into their room. 11/4/19 1:52 PM (Psych note)- .being seen today for follow up by facility request due to aggressive behavior and mood disturbance. (Resident #701) has been documented at being difficult to redirect, throwing objects, talking to themselves, punching in the air. Resident has a long history of aggressive behavior and treatment of [REDACTED]. There has been 1 incident of threatening behavior in last 15 days. They are alert but irritable upon approach. 'Just leave me alone!' (Resident #701) was guarded and angry upon approach. Spoke with staff who states resident can be unpredictable and difficult to redirect. 11/6/19 6:06 PM (Nurses note)- .Writer met with resident in the room with charge nurse. Resident said that they were frustrated at their teeth and threw them in the hall. 11/6/19 6:15 PM (Nurses note)- .Resident came out of their room and assaulted another resident who was sitting in front of dining room. (Resident #701) hit resident in her face and returned to their room, and sat down . 11/8/19 8:16 PM (Nurses note)- .Writer met with resident in the room immediately following incident where they left the room entered the hallway and assaulted a wheelchair bound resident by punching her in the mouth and drawing blood. Resident denied being in pain and could not articulate what had triggered his behavior . 11/13/19 2:22 PM (Psych note)-(Resident #701) was petitioned out for assaulting another resident. This was one of many episodes of aggressive and inappropriate behavior. On 10/28/19, I discussed with Dr. (Doctor) regarding resident's tremors and aggression. Dr. does not feel the tremors are a result of the PD ([MEDICAL CONDITION]). I called resident's brother .to get some additional background information. Brother states (Resident #701) has always been aggressive, even as a teen and young adult, loosing their temper . A review of the incident and accident report dated 10/12/19 for Resident #701 revealed the following: Description-Resident was observed to have walked out of their room, walked up to resident, hit him in the nose and mouth and when they heard the housekeeper call for the nurse, the resident turned, looked a them then went to their room and shut the door. A review of the incident and accident report for the resident that was hit by Resident #701 on 10/12/19 that is no longer in the facility revealed the following: Resident (#701) was observed by staff hitting resident in the face three times. writer observed a skin (tear) 0.5 cm (centimeters) on resident's nose and bleeding on the left side of his lip. A record review of the incident and accident report dated 11/8/19 from the Unsampled Resident that was hit by Resident #701 revealed the following: .bleeding skin tear bottom lip. Police called . X-ray negative. On 11/25/19 at 9:40 AM, an interview was completed with the Unsampled Resident that was hit by Resident #701. The Unsampled Resident was dressed and slightly confused, sitting up at the nurses station in their wheelchair. The Unsampled Resident was asked about the incident on 11/8/19 and explained that Resident #701 was standing about 10 feet away and walked over to them and hit them in the face with a closed fist. On 11/25/19 at 12:05 PM, SW A was interviewed in regards to the physical behaviors imposed on other residents by Resident #701 and stated, (Resident #701) just started this (aggressive behaviors) a few months ago. If there is a lot going on outside their room it seems to trigger them. I am working with mental health for proper placement. On 11/25/19 at 12:15 PM, Housekeeper B was interviewed in regards to the incident of Resident #701 hitting another resident on 10/12/19 and stated, I was turning around to put a caution sign out because the floor was wet and they came out of the room. (Unknown Resident) was sitting out side the dining room and (Resident #701) went up to them and punched them twice in the nose and lip. It was bleeding. On 11/25/19 at 1:30 PM, the Administrator was interviewed regarding Resident #701 hitting two residents (10/12/19 and 11/8/19) and stated, I was here for the second incident. I plan to keep (Resident #701) on 1:1 (supervision) until we can get them to a different place. (SW A) is working with (Resident #701) for placement. (Resident #701) wouldn't even talk to me when I interviewed them, they have a good relationship with (SW A). On 11/25/19 at 1:45 PM, the Director of Nursing (DON) was interviewed in regards to the physical behaviors of Resident #701 towards other residents on 10/12/19 and what the intervention was for that particular incident and stated, I did get called, one resident was in the hallway and (Housekeeper B) walked out of a room and seen (Resident #701) hit them. (Resident #701) was petitioned out and they (the hospital) sent them right back (to the facility). Psych was seeing them and (Resident #701) was 1:1 and it stopped for a minute. We put them on 1:1 each time and then had psych see them and they put (Resident #701) on that [MEDICATION NAME] (an antipyschotic medication) and did that geno testing (a test to determine the most effective medication to utilize on a person). At this time (Resident #701) is on 1:1 until we find different placement. A review of the facility policy titled Abuse and Neglect Prohibition Policy (undated) revealed the following: Each resident has the right to be free from abuse . Identification-1. The facility will monitor residents for changes in behavior .

This citation pertains in part to intakes 2 and 9. Based on interview and record review, the facility failed to accurately and thoroughly assess skin integrity upon admission, and initiate pressure ulcer interventions and/or treatment when determined to be at risk and per recommendation for one sampled resident (R#902) of four reviewed for pressure ulcers, resulting in a significant decline in skin integrity (two Stage 3 pressure ulcers), hospitalization , pain, surgical debridement, and the potential for bone and/or systemic infection. Findings include: On 10/15/19 at 9:10 AM, an interview with Confidential Witness A was conducted regarding R#902's stay at the facility. Confidential Witness A stated, (R#902) now has bad pressure ulcers. They were sent to the hospital from the facility because of them. They have a long healing process ahead of them. They had two huge pressure ulcers but they cut out the whole section so it looks like one big one now. It's bigger than an avocado and now down to the bone. (R#902) has been on antibiotics, tons of pain medication, and had to have surgery to clean them (the wounds) up. I was not aware of the severity of the wounds while (R#902) was at the facility. We never saw them. They (staff) always asked us to leave out the room when they changed (R#902) and also told us that (R#902) was getting better. Then I was called one night and told that (R#902) had a bad fever and had a really bad infection. They had to put (R#902) on oxygen and transfer them to the hospital. I am their responsible party. (R#902) had blood drawn and their white blood cell count was really high and so they sent (R#902) to the emergency room (ER). The doctor saw (R#902) in the ER and they had to call me before I could even get there to get consent for surgery to clean the bed sores. They told me if they didn't get to it right away (R#902) wouldn't survive this. The nurse at the ER told me it was terrible and that it was neglectful. They did surgery later in the afternoon. (R#902) had been getting up and getting some therapy but whenever I came in (R#902) was in bed and always in the same position. I don't think they got up every day. But if they did, then they would sit in the same spot for a long time in the wheelchair. Before going to the facility, on (MONTH) 9th, they did not have any wounds when they were in the hospital. Then they went to a different nursing facility. Two days before (R#902) was being transferred from that place, they told me (R#902) had a small abrasion on the bottom. My daughter saw the abrasion before she got to this facility and she said it wasn't deep at all and was maybe the size of a quarter. So it all got worse after they were at this facility. They told me the wound care nurse would see (R#902) and keep tabs on it but I never saw that. They were supposed to be turning (R#902). They need to have a wound vac now (suctioning wound device to aid in healing). A review of R#902's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was cognitively intact, and required extensive assistance from staff for transfers, dressing, bed mobility, toileting, and hygiene. R#902's admission MDS indicated that the resident had no existing skin issues, wounds, or pressure ulcers, and was at risk for pressure ulcer development. A review of R#902's Braden Scale Score (assesses a patient's risk of developing a pressure ulcer) dated 9/9/19 revealed a score of 17, indicating the resident was at risk of pressure ulcer development. R#902's admission skin assessment dated [DATE] revealed, Skin intact no skin breakdown noted. A review of R#902's skin assessment dated [DATE], completed by Nurse D indicated no wounds and revealed, No open areas reported at this time. A review of R#902's Wound Care Visit Reports revealed the following: Dated 9/17/19 at 3:13 PM: Wound #1 Right Buttock is a Stage 2 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.5 cm (centimeters) length x 0.5 cm width, with an area of 0.75 sq cm (square centimeters). There is a small amount of serous drainage noted. Wound bed has Pink Base [MEDICATION NAME], Two wounds with a bridge granulation. The periwound (around the wound) skin exhibited: Rash, Moist, [DIAGNOSES REDACTED] (red, swollen) .Plan: [MEDICATION NAME] + [MEDICATION NAME] 50/50 (skin protectant and antibiotic cream mixture) Qshift (every shift) and PRN (as needed) - R (Right) buttock, Low air loss mattress or low air loss bed, frequently reposition. Dated 9/24/19 at 10:40 AM: Wound #1 Right Buttock is a Stage 3 (full thickness skin loss) Pressure .Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2.1 cm length x 1.3 cm width x 0.01 cm depth, with an area of 2.73 sq cm .There is a small amount of serous drainage noted. Wound bed has Yellow Necrotic (dead tissue) Base [MEDICATION NAME] .The periwound skin exhibited: Rash, Moist, [DIAGNOSES REDACTED]. Wound #2 Left Buttock is a Stage 3 Pressure .Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.2 cm length x 1.3 cm width x 0.2 cm depth, with an area of 2.86 sq cm. There is a small amount of serous drainage noted. Wound bed has Pink Base [MEDICATION NAME]. The periwound skin .is normal .Plan: Therahoney gel daily and PRN, L (Left) buttock R (Right) buttock. Dated 10/1/19 at 10:17 AM: Wound #1 Right Buttock is a Stage 3 Pressure .Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 1.9 cm length x 0.5 cm width x 0.5 cm depth, with an area of 0.95 sq cm .There is a small amount of serous drainage noted. Wound bed has Yellow Necrotic Base [MEDICATION NAME] .The periwound skin exhibited: Rash, Moist, [DIAGNOSES REDACTED]. Wound #2 Left Buttock is a Stage 3 Pressure .Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 5.1 cm length x 2.1 cm width x 0.01 cm depth, with an area of 10.71 sq cm. There is a small amount of serous drainage noted. Wound bed has Yellow Necrotic Base [MEDICATION NAME]. The periwound skin .is normal. A review of R#902's orders revealed the [MEDICATION NAME] + [MEDICATION NAME] 50/50 treatment and low air loss mattress were not initiated until 9/20/19. A review of R#902's Nurse Practitioner Progress note dated 10/2/19 revealed: Chief Complaint: Leukocytosis (high white blood cell count, indicating presence of infection) .I was asked to see patient today per routine lab report noting elevated wbc count of 18.5 (normal range is 4 to 11) .has been treated by wound care for stage III decubitus ulcerations topically. Patient currently is seen in bed, c/o (complains of) back and pain to coccyx .(resident) states overall 'I do not feel well.' SKIN: Dry and intact, warm. + stage III - IV (3 to 4) bilateral buttock ulceration with copious serosanguineous (thin, yellowish bloody) drainage + [DIAGNOSES REDACTED]. A progress note dated 10/2/19 (by Nurse F) revealed: Acute Transfer Form: Sent To: (Acute Care Hospital), Date: 10/02/2019 11:00 .Reason(s) for Transfer: R/O (rule out) osteo[DIAGNOSES REDACTED] (bone infection). During the survey, a request was made from the acute care hospital for R#902's current records since their transfer on 10/2/19. Documentation was received on 10/15/19 at 10:40 AM and revealed the following: 10/2/19 12:41 (PM): Pt (patient) presents to EC (emergency center) .to rule out osteo[DIAGNOSES REDACTED] .has sores on bottom and is not able to ambulate independently. 10/2/19 16:54 (4:54 PM): 1. Leukocytosis, could be secondary to UTI (urinary tract infection) vs sacral decubitus ulcer infection, monitor WBC count .consult surgery for [REDACTED]. Documentation included a photo of R#902's wounds, which appeared to extend over the left and right buttocks. 10/2/19 17:26 (5:26 PM): Final impression: .Decubitus Stage 3 Ulcers. 10/3/19 10:57 (AM): .Presented to the ED on 10/2/19 .to rule out sacral osteo[DIAGNOSES REDACTED] .started on IV antibiotics and admitted .currently c/o pain on buttocks where the wounds are present .would benefit from surgical debridement .physician exam findings consistent with unstageable sacral decubitus ulcers with underlying necrotic tissue .discussed surgical intervention with (family member) via telephone. After thorough discussion, informed consent was obtained. 10/3/19 12:16 (PM): .Sacral decubitus ulcer with infection, surgery is following, plan for debridement today. 10/3/19 19:05 (7:05 PM): Operation: Excisional debridement of necrotic skin, soft tissue, and muscle .After all the identified necrotic tissue was excised .the wound was measured and was found to be 10 cm wide by 7 cm vertically for a total square surface of 70 sq cm. A review of R#902's care plan revealed: I have impaired skin integrity r/t (related to) I am frail and have bony prominences. I have Right/Left Buttock Pressure Injury. Date Initiated: 09/20/2019. All interventions under this care plan area were initiated on 9/20/19. On 10/15/19 at 10:18 AM, the Wound Care Nurse Practitioner (WCNP) was at the facility and asked if they recalled seeing R#902. The WCNP stated they did not recall the resident, but pulled up the resident's wound care records and stated that 9/17/19 was the first assessment. The WCNP indicated when they first saw the resident in (MONTH) they ordered a [MEDICATION NAME] 50/50 treatment first, to be started on the day of assessment. The WCNP stated, (R#902) had a small stage 2 pressure ulcer (partial-thickness skin loss, usually a blister or abrasion). They declined week by week. I don't believe they were hospice. While reviewing R#902's treatment orders with WCNP, it was revealed on the Treatment Administration Record (TAR) that a treatment for [REDACTED]. The WCNP indicated the treatment should have started on 9/17/19. The Wound Care Nurse (WCN) approached and stated, I remember (R#902) they were always saying 'Ow, ow, my butt.' I rewrote that treatment order. When queried as to why the treatment was not initiated until 9/20/19, the WCN provided no further explanation. The WCN was further queried regarding R#902 having any wounds. The WCN stated, (R#902) came in with a wound. The WCN was then asked to review R#902's admission skin assessment that indicated no skin issues. The WCN stated, (R#902) did have one on admission, they came on (MONTH) 9th, I saw them the next week. They were going to therapy a little bit but not much. I should have some documentation in there from my admission assessment. The resident's progress notes were then reviewed with the WCN, however a skin/wound progress note written by her was not found. The WCN stated, (R#902) came in with a reddened area that progressed to two wounds. I thought I wrote that progress note. When queried regarding R#902's wound progression, the WCN stated, I believe there was a system breakdown in the beginning where I wasn't told to see the patient. Upon further review of the resident's record, the WCN acknowledged that the resident was not seen by wound care until 9/17/19 and that wound interventions were not put into place until 9/20/19. The WCN stated, The admitting nurses are being trained now to do the skin assessment on admission and go ahead and put in interventions, treatments (if required), and a care plan. Ideally (R#902) would have had skin/wound interventions on admission. On 10/15/19 at 10:53 AM, Nurse D was contacted and queried regarding the skin assessment for R#902 they documented on 9/16/19. Nurse D stated, I don't remember anything about that. I can't even put a face to the name. On 10/15/19 at 10:57 AM, R#902's admitting nurse, Nurse [NAME] was contacted but unable to be reached for interview. On 10/15/19 at 11:50 AM, Nurse F was contacted and queried regarding R#902's transfer to the hospital. Nurse F stated, I don't really remember any details just that I was instructed to send the resident out by (Nurse Manager G). I didn't get much of a chance to do anything for the resident that day because they were sent out. I had taken care of them previously only two or three times. I'm not familiar with the wound but I did know they had one. On 10/15/19 at 12:00 PM, Nurse Manager G was interviewed regarding R#902's wound and subsequent hospitalization . Nurse Manager G stated, I kind of remember (R#902). I believe they were sent out because of their wounds. The Nurse Practitioner had seen the WBC come back elevated and was worried [MEDICAL CONDITION] (blood infection affecting the whole body). She looked at the wound and called the doctor. The doctor said to send the resident to the hospital. I held the resident while she looked at the wound, it had a strong infected odor to it. I'm not sure what the treatment was for the wound. I had seen it prior to that, not sure when, but when I had seen it before it did not have that odor. I know that the (family member) had discussed a wound in the care conference meeting. When (R#902) first came in I think the wound on the bottom was a stage 2, I don't believe it was a 3. I was never made aware that the wound was getting worse so I never went in to check on it. (Certified Nursing Assistant (CNA) H) may have worked with that resident because that's her regular unit. Nurse Manager G was asked if the resident was up out of bed, and if they had any positioning devices and replied, I don't know about a wedge, I think they were using pillows. (R#902) would get up in their wheelchair but would also want to stay in bed sometimes. The times they were up in the wheelchair or laying down would vary. On 10/15/19 at 12:49 PM, CNA H was interviewed regarding the care of R#902. CNA H indicated they took care of R#902 almost every day. When queried regarding R#902's skin status on admission, CNA H stated, There was a red area on the buttocks but it didn't look open. I'm not sure when but they gave us a cream to put on after incontinence care. I did see it progressively getting worse. I recall the area being open not too long after admission. (R#902) was having a lot of diarrhea at first. When asked if R#902 was on a turning/repositioning program, CNA H stated, No. They were up almost every day because they had therapy. But (R#902) spent most of their time in their wheelchair. I'm wondering if it was sitting in the chair for long periods and the diarrhea that made the wound get worse. (R#902) had mentioned to (Nurse E) that their bottom was irritated and hurt when they first got here. I remember that because (Nurse E) had helped me take (R#902) to the bathroom when they were having diarrhea. On 10/15/19 at 2:25 PM, the Director of Nursing (DON) was interviewed regarding R#902. When queried regarding what her expectation would be for an admission Braden Scale Score of 17, the DON replied, I would expect interventions to be put in place. Pressure relieving devices, dietary consult, have therapy do an evaluation, have in the care plan to turn and reposition. To have pressure relieving devices on the wheelchair and bed. To have things put in place right away to prevent an ulcer from developing. Our admission assessment has care plan options built right into it. So if there is a risk for skin breakdown that is one of the care plans that should be going into place. We want to prevent breakdown for everybody. When asked about documentation of no skin issues on R#902 on 9/9 and 9/16 but multiple staff stating the resident did have a reddened area, the DON stated, I expect to see an accurate reflection of what is actually present. I was told after the fact that the wound care nurse was talking to (Nurse E) and the family had been concerned with the resident coming with a reddened area on the bottom. They wanted to let us know it was there. When queried regarding a recommendation for treatment from the WCNP on 9/17/19 that was not initiated for R#902 until 9/20/19, the DON responded, The expectation would be that the orders and recommendation from (WCNP) should've been put in place immediately, on that same day. When asked if she was present when R#902 was sent out to the hospital, the DON stated, The NP came and got me. I saw the wound the day the resident was sent out. It had a necrotic base, with a red, angry perimeter and it looked infected. (R#902) wasn't a big person so it was like skin touching bones, it was hard to tell a depth because it looked like there wasn't a lot of fat layer, it looked like it was probably going down to the bone. When queried regarding the decline of the wound, the DON stated, (R#902) did like laying on their back. I had seen the wound a week before that and it didn't look that bad so I couldn't believe it when I saw it. We don't document turning and repositioning but it's a standard of care. (R#902) was mostly bed bound, rarely got up. But when they were up they would complain of pain because it was so bony back there and their bottom was hurting. I know they were incontinent. I'm concerned my nurse missed all of this on admission because the family had been concerned about the resident's bottom on admission. I'm planning to inservice the nurses on how to do a thorough skin assessment and look at our entire wound care and skin management program. What I want to see and what will happen is preventative measures put into place immediately when someone comes in at risk for skin issues or with existing skin issues. On 10/15/19 at 2:52 PM, the Nursing Home Administrator (NHA) was interviewed and queried regarding expectation for care with an admission Braden Scale Score of 17. The NHA stated, On admission I would expect an accurate skin assessment, have a skin integrity care plan in place, and implement interventions to prevent skin breakdown. With a score of 17, I would want to see something in place right away for sure. The skin assessment should be completed and documented and reflective of the current health status. Ideally we would not want a delay in interventions, prevention, and treatment. A review of the facility's policy titled, Pressure Ulcer & Skin Care Management, undated, revealed: Policy: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing .A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions .at admission .weekly .The presence of any pressure ulcer, wound, or other skin condition is documented in the designated area. A licensed nurse completes a pressure ulcer risk assessment: at admission. The interdisciplinary team reviews skin risk and initiates or updates care plans accordingly .the licensed nurse implements the wound care treatment procedures in accordance with current standards of practice . A review of the facility's policy titled, Pressure Ulcer Preventative Measures, undated, revealed: Policy: Residents at risk for the development of pressure ulcers receive interventions to reduce the risk of pressure ulcers .resident should be monitored during care and consistently by licensed nurses to identify potential areas for skin breakdown and integrity of overall skin .the nurse inspects any reddened areas and/or breaks in the resident's skin and documents the inspection .establish a repositioning schedule .use positioning devices .avoid uninterrupted sitting in a chair or wheelchair .document approached and interventions on the care plan. A review of the facility's policy titled, Baseline Interim Plan of Care, undated, revealed: Each resident will have a baseline care plan developed and implemented within 48 hours of admission to the facility which includes the instructions needed to provide effective and patient centered care that meets the professional standards of quality care .The admitting nurse will perform an initial physical and mental assessment of the resident and .initial resident physical assessment documentation (including skin integrity and other risk areas) .within 48 hours of admission to the facility the nurse will use the initial physical .information to initiate an individualized, Baseline Interim Plan of Care for the resident .will consider the following areas when developing the individualized care plan: .Risk factors: .Pressure Injuries .

Based on observation, interview, and record review, the facility failed to ensure the delivery of planned therapeutic diets and failed to identify, assess, and monitor decreased oral intake and implement interventions pertaining to nutritional status in a timely manner for 2 (#'s 125 and 128) of 6 Residents reviewed for nutrition and hydration, from a total sample of 27, resulting in Resident #125 not receiving ordered thickened liquids, Resident # 128 experiencing a 15.09 % (24.5 pound) weight loss in 30 days and a 21.2 % (37.1 pound) weight loss in 90 days, and the potential for aspiration, respiratory infections, malnutrition, and a decline in overall health status. Findings include: Resident #125 On 3/27/18 at 10:25 AM, Resident #125 was observed in their room lying in the bed and positioned on their back. A 1.1-quart bottle of Glucerna 1.5 cal (calorie) was noted siting on the bedside table on the left side of the Resident's bed. The Glucerna bottle was opened and dated 3/23/18 at 3:30 PM. A 20-ounce Styrofoam cup was also observed on the bedside table. The cup was dated 3/27/18 and contained regular consistency water without ice. The cup was not within reach of the Resident and an overbed table was not observed in their room. An interview was attempted to be completed with Resident #125 at this time. When spoke to, Resident #125 would make eye contact but did not respond verbally to questions. An interview was completed with Confidential Witness K on 3/27/18 at 11:37 AM. When queried regarding Resident #125's nutrition, Witness K stated, When (Resident #125) first came in, they had an NG (Nasogastric) tube (tube inserted through the nose and into the stomach which may be used to provide nutrition). Confidential Witness K then stated, They (facility staff) sent (Resident #125) out to the hospital because they pulled out their NG tube. (Resident #125) hasn't had anything to eat since then. Doesn't eat at all. With further inquiry, Witness K indicated the Resident was receiving Hospice services. When queried regarding when the Resident was admitted to Hospice services, Witness K indicated they were not aware of the date. On 3/27/18 at 11:48 AM, Witness K was observed asking Unit Manager M about Resident #125's nutrition and eating. Unit Manager told Witness K that Resident #125 no longer receives tube feeding but does get a pleasure tray. Unit Manager M further told Witness K that Resident #125 received a pureed diet with honey thick liquids. On 3/28/18 at 4:15 PM, Resident #125 was observed in their room, lying in bed with their eyes closed. A 20-ounce Styrofoam cup was observed on Resident #125's bedside table. The cup was dated 3/28/18 and contained water (regular consistency) without ice. Record review on 3/28/18 at 8:30 AM revealed that the Resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive assistance to perform Activities of Daily (ADL's). Additional review of the resident's medical record revealed [REDACTED]. On 3/29/18 at 8:50 AM, observation of daily care for Resident #125 occurred with Nursing Assistant N and Nursing Assistant O. The Resident was in their room, lying in bed during care. A 20-ounce Styrofoam cup was observed on Resident #125's bedside table. The cup was dated 3/29/18 and contained water (regular consistency) without ice. The water was approximately one inch below the fill line on the cup. An interview was completed with Nursing Assistant N at this time. When queried how often the Resident is provided with oral hydration, Nursing Assistant N stated, Every time we (staff) come in the room, give a sip. (Resident #125) doesn't drink much. When queried regarding the Resident's diet, Nursing Assistant N stated, (The Resident) has a pureed diet. With further inquiry regarding liquid consistency, Nursing Assistant N stated, Thickened. When queried if the current cup of water on the Resident's bedside table was for the Resident, Nursing Assistant N indicated it was. When queried if the water in the cup was thickened, Nursing Assistant N opened the cup and stated, No. It should be. I'm will get rid of it. Nursing Assistant N then stated, Midnights passed that one. When queried regarding observations of the Resident's water not being thickened previously, Nursing Assistant N stated, I don't know. It should be thickened. Record review of Resident #125's care plans on 3/29/18 at 9:00 AM revealed a care plan entitled, I am at nutritional risk r/t (related to) I have a chronic disease (Anxiety, Depression, Diabetes, Dementia), I receive a mechanically altered diet and thickened liquids, I have wounds, and I require assistance with eating. I previously had an NG tube but removed it. I have had weight loss since initial admission likely due to fluid as I have [MEDICAL CONDITION] present which is likely to cause weight fluctuations. I am also under hospice services and weight loss may be unavoidable due to poor po (oral) intake (Initiated 3/16/18; Revised: 3/27/18). Care plan interventions included: -Provide, serve me my diet as ordered - in addition to observing my intake and record per policy. I receive a pureed diet and honey thick liquids (Initiated 3/16/18; Revised: 3/21/18) -Weigh me weekly x 4 upon admission, then monthly and prn. Weigh me at same time of day as much as possible, and weigh me using the same scale (Initiated and Revised: 3/21/18) On 3/29/18 at 9:31 AM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #125's water not being thickened, the DON indicated they were just informed by facility staff. With further inquiry regarding the water not being thickened and facility policy/procedure, the DON was unable to provide an explanation. An interview was completed with Unit Manager M on 3/29/18 at 9:38 AM. When queried regarding Resident #125's diet order, Unit Manager M indicated the Resident received a pureed diet with thickened liquids. When queried further regarding observations of non-thickened water in Resident #125's room, Unit Manager M stated, That is not okay. No further explanation was provided. Resident #128 Record review on 3/27/18 at 2:00 PM revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, had minimal depression, required supervision (oversight, encouragement, and cueing) to eat and extensive assistance to perform other Activities of Daily Living (ADL's). Record review of Resident #128's medical record on 3/27/18 at 2:11 PM revealed the following weight documentation: -3/23/18 at 6:43 PM: 132.2 pounds (Lbs) -3/16/18 at 5:47 PM: 135.9 Lbs -3/10/18 at 2:53 PM: 137.9 Lbs -2/10/18 at 11:30 AM: 162.4 Lbs -1/10/2018 at 5:15 PM: 161.8 Lbs -12/10/17 at 5:06 PM: 175.0 Lbs Review of Dietary Assessment documentation, dated 3/7/18, at this time indicated the Resident had decreased intake. On 3/29/18 at 8:57 AM, Resident #128 was observed in their room in the bed with head of the bed elevated at approximately 45 to 55 degrees. The Resident was positioned on their back with an over bed table in front of them containing an uneaten breakfast tray. When queried regarding their breakfast, Resident #128 began to talk about their name. The Resident was pleasantly confused and did not provide meaningful answers to questions. An interview was completed with Registered Dietician L on 3/29/18 at 3:33 PM. When queried regarding Resident #128's weight loss, Dietician L replied, (The Resident's) intake has went down. They used to eat much better, but they have been eating less than 50%. Dietician L then stated, (Resident #128) pretty much stopped eating for the most part. When queried how and when they became aware of the Resident's intake, Dietician L stated, I found out (The Resident) wasn't eating about one week before I got the weight. With further inquiry, Dietician L stated, I looked back at the FARS (Food Acceptance Records) and for the past two weeks (the Resident) really wasn't eating. When I saw (Resident #128) at one point I thought maybe their dentures were the problem because there was food in them (dentures). Dietician L then indicated they contacted an outside agency to coordinate dental care for the Resident. When queried if the Resident had been seen by a dentist, Dietician L indicated they did not think so. With inquiry related to when they based the Resident, Dietician L reviewed Resident #128's medical record and stated, I did an assessment on 3/7/18. (Resident #128) told me they didn't have much of an appetite recently but that they were feeling a little bit better. Dietician L stated, I added foods to meals that they like. When queried why the Resident was not weighed until 3/10/18 when a concern had been identified and they had completed their assessment on 3/7/18, Dietician L replied, So kinda how that works is that the Restorative CNA's (Nursing Assistants) take all the weights within the first ten days of the month and give it to me. With further inquiry Dietician L indicated the Resident's weight had fluctuated in the past related to [MEDICAL CONDITION]. When asked why the Resident was not weighed more frequently than once a month if [MEDICAL CONDITION] and weight was an identified concern, Dietician L did not provide an explanation. Dietician L stated, Then I added med pass supplement on the 13th twice a day. When asked why med pass was added on 3/13/18 when the Resident had been weighed on 3/10/18, Dietician L did not provide an explanation. With further inquiry, Dietician L stated, I got another weight on the 16th and it went down. This last week their weight down more so I increased the med pass to three times a day. When queried regarding facility policy/procedure related to communication when there is a change in Resident's eating and/or intake, Dietician L stated, They (staff) usually let me know. When queried if they were made aware of Resident #128's decreased intake, Dietician L replied, No. Review of Weight Change progress notes in the medical record on 3/29/18 at 4:00 PM revealed the following: -3/27/18 at 9:22 AM: Weight Warning: Value: 132.2. Vital Date: (YEAR)-03-23 . MDS: -10.0% change over 180 day (s) . Resident has had significant weight loss for the month of March. 120 mL (milliliter) med pas supplement BID (twice a day) was started previously for extra calories/protein as the Resident's intake was decreased. Current weight (132.2#) is somewhat more decreased. Noted Resident triggers intake alert. (Resident) received a regular diet. Per FAR (Food Acceptance Record), Resident's intake remains decreased with 25 meals recorded as <50%% intake and 10 recorded as 51-75% intake over the last 14 days. Per (MONTH) MAR, Resident has mostly accepted 100 mL supplement. Spoke with Resident in room at dinner 3/26/18. Observed only a few bites of meal consumed at time of visit . Resident reported not feeling hungry . Resident reported they are receiving too much food. Reports feeling overwhelmed and not feeling hungry. Discussed providing small portions and meals to prevent Resident from feeling overwhelmed ant to promote intake . Discussed weight with Resident . Does not desire with loss. Recommend increasing med pass supplement to TID (three times a day) at this time for additional calories/protein to promote weight gain/maintenance as Resident's intake remains decreased. Also encouraged Resident intake to prevent weight loss and Resident voiced understanding. No dietary concerns voiced . Phoned Resident's guardian today 3/27/18 . -3/13/18 at 5:49 PM: Weight Warning: Value: 137.9. Vital Date: (YEAR)-03-10 . MDS: -5.0% change over 30 day (s), MDS: -10.0% change over 180 day (s) . Resident has had significant weight loss over the last 30, 90, and 180 days. Current weight is 137.9 and weight was 162.4# last month in February. Noted Resident recently triggered intake alert. Spoke with Resident recently. Updated food preferences and encouraged intake . Observed dentures moving around in couth at time of visit . Discussed med pass supplement with Resident and Resident agreeable as they would like to gain weight if able . Will continue to monitor weight weekly until stable/increasing . -1/15/17 at 1:07 PM: Weight Warning: Value: 161.8. Vital Date: (YEAR)-01-10 . MDS: -5.0% change over 30 day (s) . Resident has had significant weight loss over the last 30 days (-7.54%). Current weight is 161.8# and 175# was (MONTH) weight which was high for Resident. After (MONTH) weight was obtained, Resident was assessed for [MEDICAL CONDITION] and noted to have BLE (Bilateral Lower Extremity) [MEDICAL CONDITION] and was started on [MEDICATION NAME] (diuretic medication) for 5 days . Resident does have a history of [MEDICAL CONDITION] which may cause weight to fluctuate. (Resident) does not receive any nutrition supplements Per health status note 1/15/18, Resident does not have any [MEDICAL CONDITION] to BLE at this time. Suggest weight decrease over the last month related to resolving [MEDICAL CONDITION] .Will continue to monitor weight monthly . An interview was completed with the facility Administrator on 3/29/18 at 4:56 PM. When queried regarding Resident #128's weight loss and monitoring, the Administrator stated, That's a problem. Record review on 3/29/18 at 6:30 PM of facility policy/procedure entitled, Weight Management (p. 79-80, No Date) revealed, Resident's will be monitored for significant weight change on a regular basis. Resident are expected to maintain acceptable parameters of nutritional status such as usual body width and protein levels . 6. Ensure that each Resident identified with significant weight change is on a weekly schedule . Review of facility policy entitled, Unintended Weight Change (p. 81-82, No Date) revealed, Resident's with unintended weight loss/gain will be assessed by the interdisciplinary team and interventions will be implemented to prevent further weight loss/gain . Process . 3. Re-weights are initiated for a five pound variance if the Resident is > than 100 pounds . Re-weights will be done within 24 . 4. Residents determined to be at risk will be make known to nutrition professional for review of need of increased weight monitoring. At risk Residents may be identified as: Refusing to eat, diabetes, depression, [MEDICAL CONDITIONS], malnutrition . Alzheimer's/dementia .pressure ulcers, medication usage suck as diuretics . A facility policy/procedure related to therapeutic diets was requested but not received by the conclusion of the survey.

This citation pertains to intakes and Based on interviews and record review, the facility failed to prevent an ongoing staff to resident abuse when a staff member first deliberately pulled a [AGE] year old resident's hair and then use his fist to strike the resident in the face, nose, lip , and chest for one (#901) of three sampled residents reviewed for abuse, from of a total sample of four, resulting in facial, nose, and chest contusions, lower lip swelling, bleeding from the left nostril, facial lacerations, scratches, bruises and subsequent pain, a transfer to the emergency department (acute care), and an Immediate Jeopardy (IJ) to the residents health and safety. The IJ was identified on 3/7/18 at 1:00 p.m. The Administrator was notified of the Immediate Jeopardy on 3/13/18 at 4:25 p.m. The Administrator was instructed to submit a plan of correction to remove the immediacy. The immediacy was removed on 3/14/18, based on the facility's implementation of the removal plan as verified onsite. Although the IJ was removed, the facility deficient practice remained at isolated. Actual harm that is not immediate jeopardy. Findings include: On 3/13/18 at 9:19 a.m., an interview was conducted with an anonymous complainant (Complainant E) by telephone regarding an incident that occured on 3/7/18. Complainant E stated, I didn't actually see the incident, but I was told about it by several employees that work there. They say it happened on Wednesday (3/7/18). The boy (Employee C) punched the resident (#901) in the face. The next day the resident went to the hospital at the daughter's request. On 3/13/18 at 9:20 a.m., review of Resident #901's face sheet revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 1/29/18, indicated a severely impaired cognition, and required extensive assistance with activities of daily living (ADLs). On 3/13/18 at 9:24 a.m., the Administrator was interviewed regarding the alleged incident that involved Employee C and Resident #901. The Administrator stated, This incident happened, but it has not been substantiated. The investigation is not complete. The Resident said he was hit by the Certified Nurse Assistant (CNA) (C). The resident had a scratch on his face, above left eye brow, had swelling to the left side of his lip, dry blood in nostrils, and small scratches to the left side of his nose. On 3/13/18 at 9:35 a.m., review of the facility's incident report, dated 3/7/18 (no time documented), authored by Nurse D, regarding Resident #901 revealed the following documentation: Resident stated to writer that the 'sissy boy' came in his room and put a blanket over his head and punched him. Writer observed resident laying in bed with blood on his left sleeve, the bottom sheet of the bed and a small amount of blood on the floor. The incident report included documentation of two scratches, small scratch above left eye brow, left lower lip swelling, blood from left nostril in mustache. The report also indicated that the Director of Nursing (DON) and the Unit Manager (Nurse A) were made aware of the incident. On 3/13/18 at 9:38 a.m., the Activities Aide (Employee G) was interviewed regarding the incident. Employee G stated, It happened around 1:00 p.m. I just came back from lunch. He was sitting on the side of the bed. He wanted to urinate and go back to bed. CNA C (assigned CNA) walked in the room. I told him that he (#901) wanted assistance to use the restroom. I then left the room. I did not notice any injuries or scratches to the resident's face at that time. This was a little before 1:00 p.m. Ten minutes after I left the room, they (staff) said he was beat up and blood was in his room, on the floor. They told me he had blood in his nose. I did see the blood on the floor. It happened in less than ten minutes. When I left the room only CNA C and the resident (#901) were in the room. They were the only two in the room. On 3/13/18 at 9:47 a.m., Housekeeper F was interviewed regarding the incident. Housekeeper F stated, Around 1:00 p.m., after my lunch, I was asked if I had anything to clean the blood that was on the floor in his (#901) room. I don't know where it came from. I cleaned up the blood. The resident was back in bed. He was up in the chair earlier. On 3/13/18 at 10:17 a.m., the Director of Nurses (DON) was interviewed regarding the incident. The DON stated, There should be an incident report. When asked if the alleged perpetrator (CNA C) was still working, the DON stated, The employee is still on staff. He was sent home before his shift ended. I saw a little blood on the floor. I didn't see any injuries to his face. I didn't see swelling or scratches. This was before I sent CNA C home. I didn't see blood to his nose. He had some fresh blood on his sheets. He stated CNA C hit him. I then went to get CNA C. CNA C denied hitting him. We have no explanation for the resident's facial injuries, other than the resident stating he was hit by the CNA. We have a past non-compliance. On 3/13/18 at 10:37 a.m., the Social Worker (SW H) was interviewed regarding the incident. SW H stated, Before lunch he was his usual self. He was sitting in his wheelchair at the nurses' station. He was calm. I went back to my office. After lunch, around 1:30 p.m., the Administrator told me to talk to him. The Social Work Director and I went to interview him together. He was in bed It was a cut on his left cheek under his glasses. Blood was on the floor, linen sheet, and left side of his shirt. He said someone hit him in the face, a Black male. He describe the person as wearing burgundy. That's the color the CNAs wear. The police came out the next morning (3/8/18) and the resident was sent to the hospital the next morning (3/8/18). CNA C was the only male on duty that fit the description and he was the CNA that was assigned to Resident #901. On 3/13/18 at 11:35 a.m., Resident #901's hospital emergency department (ED) Triage Notes were reviewed. The ED Triage Notes had a Creation Time of 3/8/18 at 11:14 a.m. The note revealed the following documentation: Arrived via EMS (Emergency Medical Services) from the nursing with c/o (complaints of) having been assaulted by a staff member yesterday. Patient's two nieces are with patient and state that yesterday they were called by facility and told he was allegedly assaulted. This morning when they arrived at nursing home they found patient with dried blood on face and neck and he told them the staff member 'beat me all over.' Nieces state they called police and made a report and insisted that patient be sent here for evaluation. Patient is alert, oriented to person and place only, states, 'I was sitting in the hallway and the guy took me in a room and just started to beat on me,' indicating left side of head, face, and torso. When asked if he lost consciousness, states, 'yes' and states, 'there was blood all over.' C/O pain left side of face and head, left ear and left rib area; dried blood visible on mustache and chin. The doctor's dictation, dated same day, revealed the following documentation under Final Impressions: 1. S/P (status [REDACTED].>2. Facial and nose contusions 3. No sign of closed head injury 4. Chest contusion On 3/13/18 at 12:35 p.m., an attempt was made to talk with the Officer that handled the incident, but he was not available. On 3/13/18 at 12:49 p.m., the Administrator and DON were interviewed and the Administrator stated, The police was called the next day. I did not see the resident the day it happened. I heard the employee hit the resident. I delegated the allegation to the Unit Manager and the DON. The DON stated, I didn't inform the police. I saw the blood on the floor when they first called me in the room. The Resident (#901) alleged the CNA (C) hit him. I didn't see any abnormal findings to his face. The nurse said it came from his nose. He was just making an allegation. I did not see any serious bodily injury. When I saw him he was normal. The Administrator stated, I was informed of the allegation. I did not call the police because it was an allegation. It should have been called in according to the Elder Justice Act. I didn't call the police within two hours. The next day the family called. The facility never called the police. We have not identified any other incidents where the injuries could have resulted from. I still need to interview the Activities Aide (Employee G) because she transfered the resident (#901) that day. On 3/13/18 at 1:10 p.m., The facility's investigation was reviewed and a Time Line of the incident was reviewed. The Time Line was for (MONTH) 7, (YEAR) 11:50 a.m. - 1:00 p.m. The Time Line included the following documentation: 11:50 am - CENA C returns to the resident room from the hall, exits the room less than thirty seconds. 11:51 am - Resident exits the room one minute after being returned to the room. 12:15 pm - CENA L returns the resident to his room, from the hall, exits the room less than thirty seconds 12:33 pm - Activity Aide (Employee G) enters the room, exits the room in less than two minutes 12:34 pm - CENA C enters the room, exits and enters the room from 12:34 pm to 12:40 pm going from the residents room to the Soiled Utility Room. 12:46 pm Nurse K enters the room, exits at 12:55 pm. Review of Nurse K's written statement, dated 3/7/18 (no documented time) revealed the following documentation: That fag boy that just left out of here beat me up. Review of CENA L's written statement, dated 3/7/18 (no documented time), revealed the following documentation: I gave him his lunch tray. The resident stated, 'The fag boy beat me up. On 3/13/18 at 1:16 p.m., the Activities Aide (Employee G) was interviewed again regarding the incident. Employee G stated, The day of the incident he was sitting on the edge of his bed. I helped put his legs in the bed I just transfered his legs onto the bed. This was around 1:00 p.m. I just got back from lunch. I only noticed a pimple to his cheek, nothing else. CNA C then entered the room. I left the room leaving CNA C to assist him with the rest room. Approximately 10 minutes later they said the incident occured. On 3/13/18 at 1:25 p.m., an interview was conducted with the nurse (Nurse D) who authored the incident and accident report regarding the alleged incident. Nurse D identified herself as one of the charge nurses in the facility. Nurse D reported that she was at lunch when the incident occured. Nurse D went on to state, I was on lunch when I got '911' text messages regarding the resident (#901). The texts were '911, emergency,' telling me to come back from lunch early. CNA C said the resident was bleeding. I noticed the blood on his sleeve, chin area, floor, and sheet. The resident reported that CNA C jumped on him, put a blanket over his head and started punching him. His left nostril had blood in it. There was bleeding into his mustache. The DON and Unit Manager (Nurse A) then entered the room. There was a scratch above his left eye brow and left cheek area. This was pointed out to the DON and Nurse A. The DON told me to do a skin assessment and pain assessment. The resident complained of tightness on the left side of his face, which was swollen. I don't know why the police was not called. The DON saw the resident's injuries. Nurse A was also present during the initial assessment. On 3/13/18 at 2:04 p.m., CNA C was interviewed by telephone and was queried regarding the alleged incident. CNA C stated, I was his (Resident #901) CNA. I would never do that to a resident. I saw some bleeding. It was after lunch. I saw him after lunch with the Activity Aide (Employee G). I didn't notice anything unusual while I was in the room with the resident and the Activities Aide. She left the room. I gave him a urinal, then I left out of the room. They sent me home. He (Resident #901) said I jumped on him with a blanket. I was sent home around 1:30 p.m. On 3/13/18 at 3:55 p.m., the Unit Manager (Nurse A) was interviewed regarding the incident. Nurse A stated, I didn't see anything out of the ordinary except a scratch on his left cheek with dry blood. It was blood on his left sleeve. I didn't see any bruising and swelling. Resident #901 stated, 'The fag boy hit me, beat me up.' I was there with the DON during the initial assessment. On 3/14/18 at 8:45 a.m., further review of the facility's written employee statements regarding the incident were reviewed. Upon review, another incident was noted earlier in the day on 3/7/18 when CNA C was witnessed assaulting Resident #901. The noted written statements revealed the following: Laundry Aide (Employee B) written statement, dated 3/7/18 (no documented time), obtained by the Unit Manager (Nurse A) revealed the following documentation: I witnessed the CENA (Certified Nursing Assistant C) grab the resident (#901) by the back of the head and pull his hair at approximately 9:00 a.m. I reported the incident to the Nurse (Staff Nurse D). Unit Manager (Nurse A) written statement for Nurse D, dated 3/7/18 (no documented time), revealed the following documentation: I attempted to administer the resident's (#901) medication during the morning. I assessed the resident after the incident was reported at approximately 1:00 p.m. At approximately 11: a.m. a hair pulling incident was reported to me by the House Keeper, I instructed her to report the incident to management. The written statement further quoted Resident #901 as stating, I want to speak with Social Work. On 3/14/18 at 9:15 a.m., the Administrator stated, The hair pulling allegation was not investigated. I didn't ask CNA C because he was already gone. I had suspended him for the other allegation. The Administrator reported knowing about the allegation on 3/7/18. On 3/14/18 at 9:23 a.m., Charge Nurse D was interviewed regarding the alleged hair pulling incident for Resident #901 on 3/7/18. Nurse D stated, The hair pulling incident was reported to me around 10:30 a.m. I told them to talk to the DON and Unit Manager. Charge Nurse D reviewed her written statement and stated, The written statement is accurate. On 3/14/18 at 9:38 a.m., review of the Laundry Aide's (Employee B) written statement, dated 3/7/18 (no documented time), revealed the following documentation: I witnessed CNA C grab the resident (#901) by the back of the head and pull his hair at approximately 9:00 a.m. I reported the incident to the nurse (Nurse D). For clarification, Employee B reported that she was a housekeeper on the floor, but now her new job title is Laundry Aide (Employee B). On 3/14/18 at 9:41 a.m., Employee B was interviewed regarding the alleged hair pulling incident that involved Resident #901. Employee B reported that her written statement was correct and stated, I witnessed this around 9:00 a.m. Resident #901 was swinging his arms at CNA C as I approached the utility room. CNA C pulled Resident 901's hair, wrapped and yanked on his hair. Resident #901 was yelling 'Oh, oh, oh. I'm bleeding. That He could have done anything to this man. I can't believe it is cruel people out here like that. I never witnessed anything like it before. On 3/14/18 at 9:52 a.m., the Unit Manager (Nurse A) was interviewed regarding the incident. Nurse A stated, I was made aware of the hair pulling incident. I was made aware of this incident during the initial investigation. On 3/14/18 at 9:57 a.m., the DON was interviewed. The DON stated, I was made aware of the incident after 1:00 p.m. We did not interview staff regarding the allegation. I just interviewed Employee B regarding the incident. On 3/4/18 at 10:15 a.m., CNA J was interviewed regarding both incidents. CNA J stated, I did not witness anything. He (#901) told me, 'The sissy boy beat me up.' I saw the blood in his right nostril, sheet, and on the floor. It looked like it was splattered. The facility's IJ Removal Plan received on 3/13/18: Element 1 On 3/7/18 at approximately 1:00pm the nurse aide reported it to Unit Manager. At approximately 1:15pm the alleged perpetrator was interviewed by the DON and Unit Manager. Administrator was notified by DON of the allegation and an investigation was immediately initiated and the alleged perpetrator was immediately placed on suspension based on facility policy at approximately 1:33pm on 3/7/18 and has been terminated. The allegation was immediately reported to MDCH on 3/7/2018. Resident #901 immediately assessed by the nurse, the resident was assessed for pain and had a complaint having tightness to the left side of the face and refused pain medications at time of assessment. The resident also was assessed for any skin alteration and was noted to have scratches above the left eyebrow and swelling to the lip. The family and physician was notified concerning the allegation immediately. Resident #901 was seen by the social worker and denies any psychosocial distress and denies feeling afraid or feeling unsafe at the facility. The resident continued to be monitored throughout the shift and no signs and symptoms of distress and mood changes were noted. Resident #901 was sent out to the hospital for further observation and no longer resides in the facility. Element 2 Current residents residing the facility have the potential to be at risk for abuse. A facility wide audit was conducted on 3/13/18 of the all interviewable residents to determine if they had any concerns with how care was being provided and if they felt safe in the facility. Any resident identified to have a concern had it placed on a resident concern form for immediate follow up. The social worker will do ongoing random audits to ensure that all residents feel safe and any concern is placed on a concern form for immediate follow up). Current residents have been assigned a guardian angel who will follow up with the resident weekly and any concerns noted will be placed on a concern form for immediate follow up. Element 3 All staff currently working have been educated on the Abuse and Neglect prohibition policy and the Elder Justice Act beginning 3/8/18 and is ongoing. Staff will not be allowed to work until educated on the policy for Abuse and Neglect. The DON and Administrator also received a one to one education on the Abuse and Neglect prohibition policy and the Elder Justice Act. The SDC/Designee will do random audit to ensure staff understand the Abuse and Neglect prohibition policy and the Elder Justice Act and the importance of reporting Abuse. The Abuse and Neglect Policy and the Elder Justice Act was reviewed and deemed appropriate. Element 4 The Administrator/designee will audit daily M-F for 4 weeks, and then 2 times a week for 2 weeks and then monthly until compliance is achieved for indications of abuse. The Administrator/designee will audit 5 staff member daily for 4 weeks and the 2 times weekly for 2 weeks and monthly until compliance is achieved on the their responsibility for reporting abuse immediately. All findings will be submitted to the QAPI committee for review and discussion monthly. The Administrator is responsible for sustained compliance. D[NAME]: 3/14/2018

This citation pertains to intakes and Based on interview and record review, the facility failed to report to local law enforcement when there were allegations of a staff member striking and pulling the hair and injuries of unknown origin for of one (#901) of three sampled residents reviewed for abuse, out of a total of four resulting in Resident #901 being denied the right to press legal charges, feelings of anger, and hopelessness. Findings include: On 3/13/18 at 9:19 a.m., an interview was conducted with an anonymous complainant (Complainant E) by way of phone regarding an incident that occured on 3/7/18. Complainant E stated, I didn't actually see the incident, but I told about it by several employees that work there. They say it happened Wednesday (3/7/18). The boy (Employee C) punched the resident (#901) in the face. The next day the resident went to the hospital at the daughter's request. On 3/13/18 at 9:20 a.m., review of Resident #901's face sheet revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #901's most recent Minimum Data Set (MDS) assessment, dated 1/29/18, indicated a severely impaired cognition. Extensive assistance was required for activities of daily living (ADLs). On 3/13/18 at 9:24 a.m., the Administrator was interviewed regarding the alleged incident that involved Employee C and Resident #901. The Administrator stated, This incident happened, but it has not been substantiated. The investigation is not complete. The Resident said he was hit by the CNA (C). The resident had a scratch on his face, above left eye brow, had swelling to the left side of his lip, dry blood in nostrils, and small scratches to the left side of his nose. On 3/13/18 at 9:35 a.m., review of the facility's incident report, dated 3/7/18 (no time documented), authored by Nurse D, regarding Resident #901 revealed the following documentation: Resident stated to writer that the 'sissy boy' came in his room and put a blanket over his head and punched him. Writer observed resident laying in bed with blood on his left sleeve, the bottom sheet of the bed and a small amount of blood on the floor. The incident report included documentation of two scratches, small scratch above left eye brow, left lower lip swelling, blood from left nostril in mustache. The report also indicated that the Director of Nursing (DON) and the Unit Manager (Nurse A) were made aware of the incident. On 3/13/18 at 9:38 a.m., the Activities Aide (Employee G) was interviewed regarding the incident. Employee G stated, It happened around 1:00 p.m. I just came back from lunch. He was sitting on the side of the bed. He wanted to urinate and go back to bed. CNA C (assigned CNA) walked in the room. I told him that he (#901) wanted assistance to use the restroom. I then left the room. I did not notice any injuries or scratches to the resident's face at that time. This was a little before 1:00 p.m. Ten minutes after I left the room, they (staff) said he was beat up and blood was in his room, on the floor. They told me he had blood in his nose. I did see the blood on the floor. It happened in less than ten minutes. When I left the room only CNA C and the resident (#901) were in the room. They were the only two in the room. On 3/13/18 at 9:47 a.m., Housekeeper F was interviewed regarding the incident. Housekeeper F stated, Around 1:00 p.m., after my lunch, I was asked if I had anything to clean the blood that was on the floor in his (#901) room. I don't know where it came from. I cleaned up the blood. The resident was back in bed. He was up in the chair earlier. On 3/13/18 at 10:17 a.m., the Director of Nurses (DON) was interviewed regarding the incident. The DON stated, There should be an incident report. When asked if the alleged perpetrator (CNA C) was still working, the DON stated, The employee is still on staff. He was sent home before his shift ended. I saw a little blood on the floor. I didn't see any injuries to his face. I didn't see swelling or scratches. This was before I sent CNA C home. I didn't see blood to his nose. He had some fresh blood on his sheets. He stated CNA C hit him. I then went to get CNA C. CNA C denied hitting him. We have no explanation for the resident's facial injuries, other than the resident stating he was hit by the CNA. We have a past non-compliance. On 3/13/18 at 10:37 a.m., the Social Worker (SW H) was interviewed regarding the incident. SW H stated, Before lunch he was his usual self. He was sitting in his wheelchair at the nurses' station. He was calm. I went back to my office. After lunch, around 1:30 p.m., the Administrator told me to talk to him. The Social Work Director and I went to interview him together. He was in bed It was a cut on his left cheek under his glasses. Blood was on the floor, linen sheet, and left side of his shirt. He said someone hit him in the face, a Black male. He describe the person as wearing burgundy. That's the color the CNAs wear. The police came out the next morning (3/8/18) and the resident was sent to the hospital the next morning (3/8/18). CNA C was the only male on duty that fit the description and he was the CNA that was assigned to Resident #901. On 3/13/18 at 11:35 a.m., Resident #901's hospital emergency department (ED) Triage Notes were reviewed. The ED Triage Notes had a Creation Time of 3/8/18 at 11:14 a.m. The note revealed the following documentation: Arrived via EMS (Emergency Medical Services) from the nursing with c/o (complaints of) having been assaulted by a staff member yesterday. Patient's two nieces are with patient and state that yesterday they were called by facility and told he was allegedly assaulted. This morning when they arrived at nursing home they found patient with dried blood on face and neck and he told them the staff member 'beat me all over.' Nieces state they called police and made a report and insisted that patient be sent here for evaluation. Patient is alert, oriented to person and place only, states, 'I was sitting in the hallway and the guy took me in a room and just started to beat on me,' indicating left side of head, face, and torso. When asked if he lost consciousness, states, 'yes' and states, 'there was blood all over.' C/O pain left side of face and head, left ear and left rib area; dried blood visible on mustache and chin. The doctor's dictation, dated same day, revealed the following documentation under Final Impressions: 1. S/P (status [REDACTED].>2. Facial and nose contusions 3. No sign of closed head injury 4. Chest contusion On 3/13/18 at 12:35 p.m., an attempt was made to talk with the Officer that handled the incident, but he was not available. On 3/13/18 at 12:49 p.m., the Administrator and DON were interviewed and the following was reported: The Administrator stated, The police was called the next day. I did not see the resident the day it happened. I had a Surveyor in the building. I heard the employee hit the resident. I delegated the allegation to the Unit Manager and the DON. The DON stated, I didn't inform the police. I saw the blood on the floor when they first called me in the room. The Resident (#901) alleged the CNA (C) hit him. I didn't see any abnormal findings to his face. The nurse said it came from his nose. He was just making an allegation. I did not see any serious bodily injury. When I saw him he was normal. The Administrator stated, I was informed of the allegation. I did not call the police because it was an allegation. It should have been called in according to the Elder Justice Act. I didn't call the police within two hours. The next day the family called. The facility never called the police. We have not identified any other incidents where the injuries could have resulted from. I still need to interview the Activities Aide (Employee G) because she transfered the resident (#901) that day. On 3/13/18 at 1:25 p.m., an interview was conducted with Nurse D who authored the incident and accident report regarding the alleged incident. Nurse D identified herself as one of the charge nurses in the facility. Nurse D reported that she was at lunch when the incident occured. Nurse D went on to state, I was on lunch when I got '911' text messages regarding the resident (#901). The texts were '911, emergency,' telling me to come back from lunch early. CNA C said the resident was bleeding. I noticed the blood on his sleeve, chin area, floor, and sheet. The resident reported that CNA C jumped on him, put a blanket over his head and started punching him. His left nostril had blood in it. There was bleeding into his mustache. The DON and Unit Manager (Nurse A) then entered the room. There was a scratch above his left eye brow and left cheek area. This was pointed out to the DON and Nurse A. The DON told me to do a skin assessment and pain assessment. The resident complained of tightness on the left side of his face, which was swollen. I don't know why the police was not called. The DON saw the resident's injuries. Nurse A was also present during the initial assessment. On 3/13/18 at 2:04 p.m., CNA C was contacted by way of phone and was queried regarding the alleged incident. CNA C stated, I was his (Resident #901) CNA. I would never do that to a resident. I saw some bleeding. It was after lunch. I saw him after lunch with the Activity Aide (Employee G). I didn't notice anything unusual while I was in the room with the resident and the Activities Aide. She left the room. I gave him a urinal, then I left out of the room. They sent me home. He (Resident #901) said I jumped on him with a blanket. I was sent home around 1:30 p.m. On 3/13/18 at 3:55 p.m., the Unit Manager (Nurse A) was interviewed regarding the incident. Nurse A stated, I didn't see anything out of the ordinary except a scratch on his left cheek with dry blood. It was blood on his left sleeve. I didn't see any bruising and swelling. Resident #901 stated, 'The fag boy hit me, beat me up.' I was there with the DON during the initial assessment. On 3/14/18 at 8:45 a.m., further review of the facility's written employee statements regarding the incident were reviewed. Upon review, another incident was noted earlier in the day on 3/7/18 when CNA C was witnessed assaulting Resident #901. The noted written statements revealed the following: Laundry Aide (Employee B) written statement, dated 3/7/18 (no documented time), obtained by the Unit Manager (Nurse A) revealed the following documentation: I witnessed the CENA (Certified Nursing Assistant C) grab the resident (#901) by the back of the head and pull his hair at approximately 9:00 a.m. I reported the incident to the Nurse (Staff Nurse D). Unit Manager (Nurse A) written statement for Nurse (D), dated 3/7/18 (no documented time), revealed the following documentation: I attempted to administer the resident's (#901) medication during the morning. I assessed the resident after the incident was reported at approximately 1:00 p.m. At approximately 11: a.m. a hair pulling incident was reported to me by the House Keeper, I instructed her to report the incident to management. The written statement further quoted Resident #901 as stating, I want to speak with Social Work. On 3/14/18 at 9:15 a.m., the Administrator stated, The hair pulling allegation was not investigated. I didn't ask CNA C because he was already gone. I had suspended him for the other allegation. The Administrator reported knowing about the allegation on 3/7/18. On 3/14/18 at 9:23 a.m., Charge Nurse D was interviewed regarding the alleged hair pulling incident for Resident #901 on 3/7/18. Nurse D stated, The hair pulling incident was reported to me around 10:30 a.m. I told them to talk to the DON and Unit Manager. Charge Nurse D reviewed her written statement and stated, The written statement is accurate. On 3/14/18 at 9:38 a.m., review of the Laundry Aide's (Employee B) written statement, dated 3/7/18 (no documented time), revealed the following documentation: I witnessed CNA C grab the resident (#901) by the back of the head and pull his hair at approximately 9:00 a.m. I reported the incident to the nurse (Nurse D). For clarification, Employee B reported that she was a housekeeper on the floor, but now her new job title is Laundry Aide (Employee B). On 3/14/18 at 9:41 a.m., Employee B was interviewed regarding the alleged hair pulling incident that involved Resident #901. Employee B reported that her written statement was correct and stated, I witnessed this around 9:00 a.m. Resident #901 was swinging his arms at CNA C as I approached the utility room. CNA C pulled Resident 901's hair, wrapped and yanked on his hair. Resident #901 was yelling 'Oh, oh, oh. I'm bleeding. That He could have done anything to this man. I can't believe it is cruel people out here like that. I never witnessed anything like it before. On 3/14/18 at 9:52 a.m., the Unit Manager (Nurse A) was interviewed regarding the incident. Nurse A stated, I was made aware of the hair pulling incident. I was made aware of this incident during the initial investigation. On 3/14/18 at 9:57 a.m., the DON was interviewed. The DON stated, I was made aware of the incident after 1:00 p.m. We did not interview staff regarding the allegation. I just interviewed Employee B regarding the incident. On 3/4/18 at 10:15 a.m., CNA J was interviewed regarding both incidents. CNA J stated, I did not witness anything. He (#901) told me, 'The sissy boy beat me up.' I saw the blood in his right nostril, sheet, and on the floor. It looked like it was splattered. On 3/14/18 at 4:30 p.m., review of the facility's policy titled Reporting Suspected Crimes Under the Federal Elder Justice Act, revision date of (MONTH) 2012, revealed the following documentation: The Elder Justice Act (EJA) requires: Each covered individual shall report to the Michigan Department of Licensing and Regulatory Affairs (LARA)/Bureau of Health Systems and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. Timing: If the events that cause suspicion; (A) result in serious bodily injury, the individual shall report the suspicion immediately, but no later than two hours after forming the suspicion; and (B) do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion.

This citation pertains to intake MI 510 Based on observation, interview and record review the facility failed to ensure that Resident (#501) who was assessed as an elopement risk, of three residents sampled for elopement risk of a total sample of five residents, was provided adequate supervision when he exited an emergency exit door at 8:48 p.m., on [DATE]. The emergency exit door alarm was disengaged at 5:28 p.m., to accommodate entrance for funeral home personnel and remained disarmed until 11:07 p.m., on [DATE]. Failure to properly re-engage the door alarm on the 4 North unit also placed at total of 21 other residents at potential risk for elopement. The Immediate Jeopardy (IJ) was identified on [DATE] at 9:00 a.m., and the Administrator was asked for a plan of removal of the immediacy at 11:00 a.m., on [DATE]. The IJ was removed at 5:06 p.m., on [DATE], based on the facility's implementation of the plan of removal of the immediacy as verified by the surveyor. Although the IJ was removed, the facility's deficient practice was not fully corrected and remained isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: On [DATE] at 10:21 a.m., the Administrator and the DON (Director of Nursing) were asked about the facility reported incident involving the elopement of Resident #501, and reported the following: Resident #501 exited the facility though the 4 north emergency exit at 8:48 p.m. on [DATE] and re-entered the building though the 3 north emergency exit at 8:56 p.m., on [DATE]. The DON stated that he wandered around the side of the building for a couple of minutes, knocked on the next door down (3 North Emergency Door) to get back in. The door that Resident #501 had exited did not have a wander alert but it did have another alarm that can be disengaged by a nurse with a key. The 4 north door alarm had been previously disengaged due to funeral home personnel making an entry at the 4 north door picking up a deceased resident at approximately 5:28 p.m., on [DATE]. The Administrator was queried if the door alarm was re-engaged after the funeral home left the facility and she stated that it wasn't. She was queried as to when was the alarm on the 4 north door was re-engaged and she indicated that the midnight supervisor re-engaged it when he stated his shift at approximately 10:45 p.m., on [DATE]. The Administrator was queried if the emergency doors should be opened at any time and she stated I would say no. The NHA (Administrator) and the DON (Director Of Nursing) further reported that in addition to resident #501 there were 21 other residents who had been assessed at risk for elopement from a total census of 137 residents. On [DATE] at 1:55 p.m., the facility security tape was reviewed with the Administrator and revealed the following: At 5:17 p.m., nurse B was observed walking down toward the 4th north emergency door. The door could not be seen on the camera but the Administrator explained what was happening. She stated that nurse B disengaged the alarm so that the funeral home personnel could enter the building. Staff member C was observed standing by the emergency door when the funeral home personnel entered to pick up a deceased resident. The funeral home personnel was observed leaving the facility though the 4 north emergency exit at 5:28 p.m., on [DATE]. The funeral home personnel were observed to not have any facility staff escorting them out of the facility to rearm the door alarm. At 8:48 p.m., on [DATE], Resident #501 was observed on camera standing out of his wheelchair and heading towards the 4 north emergency exit door. He was observed again at 8:52 p.m., walking outside on the facility back driveway. He was observed at 8:56 p.m., to be led back down the 3 unit hallway. At 11:07 p.m., nurse A as observed on camera heading down the 4 north hallway in which the Administrator stated That is nurse A turning the alarm back on. On [DATE] at 2:48 p.m., Nurse A was queried regarding the elopement of #501 on [DATE] and reported, I (Nurse A) entered the building at approximately 10:45 p.m., (to begin my shift). He stated he was told there was an elopement but doesn't remember who told him. He went to check all the emergency doors in the facility and when he came to the 4 north door, the door alarm was in the off position. When he saw that the alarm was disengaged he used his key to rearm it. He was queried if the emergency alarm should have been disarmed at that time and he stated it shouldn't have been. On [DATE] at 3:00 p.m., Staff member D who was a nurse on unit 4 was queried if she knew that the alarm on the unit was disengaged and she stated that she didn't. She states that she forgot to check the alarm for the 4 north emergency door before the shift change and that she didn't report it to the oncoming nurse because she didn't know it was disarmed. She stated that she should have checked the emergency exit before she left the building. On [DATE] at 3:03 p.m., A review of the medical record of #501 was completed and revealed the following: Resident #501 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His comprehensive MDS assessment (minimum data set) with a reference date of [DATE] revealed a brief assessment of mental status score (BIMS) of four indicating severely impaired cognition. He also needed limited assistance with bed mobility, transfers and extensive assistance with dressing, personal hygiene and bathing. A nurses noted on [DATE] at 23:11 titled Incident Note was reviewed and revealed the following: Patient eloped from facility and was found at 3rd bay door on the right. Patient was found by nurse aide and was re directed back to room and a full head to toe assessment was completed to check for injuries. No injuries to report at this time. Per elopement precaution a code green was called a complete head count of everyone in the building for safety precaution was resident accounted for. Administrator and Director of nursing notified. Dr. Notified of elopement as well as family. All door alarms checked and functioning. Patient was talk to again by supervisor to check and see if patient has any intentions of eloping. Pt stated no. Patient will be on a 1 on 1 for today and tomorrow. 24 hours one on one. One on one initiated immediately. Patient is currently sitting in chair. A document titled Elopement Assessment-V2 dated [DATE] revealed the following: J. (Scoring) ,[DATE] Low Risk, ,[DATE] At risk to wander 11-above High risk to wander Score: 21. I. (Comments) Resident has a wander guard in place and does seek to exit at times, confused and transfer self and also ambulate without assist. A facility incident and accident report for #501 dated [DATE] at 9:30 p.m., revealed the following: Pt was observed outside of facility by 3rd bay door. Pt. redirected back to facility in room. Pt stated I got out the back door when asked how did he get out. Pt. assessed. A review of the current care plan was completed and revealed the following: Problem: I am an elopement risk as I wander aimlessly due to high confusion R/T Dx of dementia Goal: I will not leave the facility unattended through the review date. Intervention: At times you may have to monitor my location. If this occurs, document my wandering behavior and attempted diversional interventions in behavior log. On [DATE] at 4:00 p.m., a document titled Elopement, Potential Resident last revised in [DATE] was reviewed and revealed the following: Policy-It is the policy of the facility to provide residents with a safe and secure environment and identify residents ho may be a risk for unobserved exit from the facility. Fundamental Information: Resident who enter the facility may display behaviors that are unsafe particularly since they are entering an environment that is unfamiliar. Resident with cognitive loss or impaired judgement may attempt to leave the premises, known as exit seeking behavior. Residents are most vulnerable in the early admission period, however residents with progressive cognitive disorders can begin displaying exit seeking behavior at any time. Resident with cognitive loss who leave the facility without authorization and without an escort will be considered an elopement and will be assessed to minimize the risk of repeat unauthorized exits. On [DATE] at 5:12 p.m., the facility provided the following removal plan for the immediate jeopardy regarding the failure to prevent the elopement of Resident #501 and all other residents assessed as being at risk for elopement: Element 1: Resident was assessed for injury at 9 p.m. No injuries noted. Resident did have Wanderguard in place on right ankle . Administrator and DON notified on [DATE] at 10:34 p.m. Resident placed on 1:1 supervision at approximately 11 p.m., for duration of stay at facility (discharged on [DATE]). Element 2: . Head Count was completed of facility at 9:15 p.m., to ensure no other residents had exited the building. All residents accounted for. Nurse checked the alarms on the doors at 10:35 p.m., and Nurse Supervisor checked the facility alarmed doors at 11:00 p.m., and discovered that the 4 North door was unalarmed. Nurse alarmed the door at 11:00 p.m Element 3: Inservice specifically on red alarm boxes to remain alarmed at all times and on elopement policy started immediately on [DATE] at midnight and continued daily through [DATE] until all staff completed. Funeral homes are no longer to be entering facility via emergency exits, memo distributed [DATE] and inservicing started on this specifically on funeral home and vendors not using emergency exits [DATE]. Nurse inserviced [DATE] at 10:35 p.m., on timely reporting of incidents. Staff were inserviced on [DATE] individually on responsibility of ensuring red alarm boxes are alarmed at all times. 5 employees have not been inserviced due to being on leave, these employees have been removed from the schedule and will not be allowed to work until inservice is received. Element 4: Alarm audits implemented on each nursing cart on [DATE]. Each nurse assigned to a cart is to verify emergency door alarms are on every 3 hours around the clock. Only licensed nurses have keys to these alarms. Daily Audits to continue x 90 days with findings submitted to QAPI committee x 3 months or until further directed. Administrator is responsible for plan of correction implementation and compliance maintained.

This citation pertains to Intake Numbers MI 421 and MI 516 Based on observation, interview and record review, the facility failed to ensure that one (#405) of seven residents reviewed for abuse from a total sample of seven residents was free from physical and verbal abuse and neglect. Resident #405 was handled roughly by certified nursing assistant (CNA) F and Licensed Practical Nurse (LPN) G; verbally abused by CNA F; and neglected by LPN G who failed to assess the resident's injuries attributed to rough handling. This deficient practice resulted in evidence of physical trauma that included bruising on the resident's arms; not immediately assessing the resident's injuries; and misidentifying a catastrophic reaction with the potential for feelings of fear. Findings include: On 5/16/17 at 8:35 a.m., during an interview with witness H, it was reported that on 5/9/17 at around 8:00 p.m., in the evening, that she observed a small Caucasian woman who had multiple bruises on her arm and stated that she observed a CNA (Certified Nursing Assistant/known as CNA F) push her (Resident #405) and roughly picked her up off the floor and put her in her wheelchair (w/c). Witness H further explained, I video taped the incident and and showed it to them (the facility staff), they said they were going to look at the details from my camera then they are going to look at their video. This all happened on Tuesday May 9, 2017, during the night shift at 8:15 p.m Witness H further stated that she had reported to the facility that staff was rough and she suspected abuse. Witness H reiterated that What was observed was resident on the floor and staff inappropriately telling her that she is always falling in a demeaning tone. Witness H stated that she heard the resident say to the CNA (CNA F), No, you pushed me down. During the initial tour of the facility on 5/11/17 at 8:45 a.m., Resident #405 was observed in the facility's dining room and was sleeping, staff attempted to arouse, however, would not wake and was unable to be queried regarding event that happened to her on 5/9/17. On 5/16/17 at 10:48 a.m., during review of Resident #405's clinical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED].#405's face sheet included; Muscle Weakness, generalized, Urinary Tract Infection and [MEDICAL CONDITION]. A recent Minimal Data Set (MDS) dated , 5/4/17, scored resident's cognition as severely impaired. The MDS' assessment revealed that resident #405 was dependent on staff for her transferring needs and revealed that resident #405 did not have a fall since last assessment. The clinical records further revealed documentation that revealed the following: On 5/9/2017 00:03 (three minutes after midnight) Behavior Note Note Text: Resident was severely agitated, hitting, kicking staff, yelling out on the top of her lungs disturbing co-residents, Doctor E (resident #405's primary care physician (PCP))was called and ordered [MEDICATION NAME] (used to treat anxiety disorders)1 mg (milligram) intramuscularly and was administered intramuscularly on the Left deltoid muscle as ordered. The documentation did not reveal staff attempting to use a less restrictive means first to calm resident or see why resident was agitated. On 5/16/17 at 10:48 a.m., review of resident #405's clinical record revealed a Nurse Practitioner's assessment that documented the following: 5/9/2017 at 18:30 NURSE PRACTITIONER NOTES Late Entry: Note Text: Re (regarding): Resident #405 CC: Agitation SUBJECTIVE: Patient sitting up in hallway. Mood is labile, yells out that people are picking on her and when distracted with other questions demeanor changes. She had received a couple doses of IM (intramuscularly) [MEDICATION NAME] for increased agitation and PO (by mouth) [MEDICATION NAME] recently changed to Q6 (every six hours). She denies chest pain, shortness of breath, fever, chills, constipation or diarrhea. OBJECTIVE: Most current vital signs: 135/60, HR 84, R 18, T 97.4, 99% on RA General: Alert and oriented x 1 (to only one sphere), no acute distress. HEENT (Head Ears Eyes and Throat): monometallic, a traumatic Respiratory: Lungs clear to auscultation bilaterally, no wheezes, no bronchi, no rales. Cardiovascular: RRR, S1 and S2 normal, no murmur, no gallop, no rub. On 5/16/17 at 8:30 a.m., the Administrator was requested to provide the facility's Incident and Accident reports (I&A's). Upon review of the I&A concerning the allegation for resident #405 revealed that the aforementioned allegation did happen on 5/9/17 at 8:15 p.m. and that the facility management and administration was made aware of the situation on 5/11/17 at around 2:00 p.m Furthermore, the management at the facility (Administrator, Director of Nursing, and Maintenance Director) watched the video surveillance and the area that the incident took place was in a Blind spot per the administrator. The I&A documented that The resident #405 suffered Batesmans Purpura (A condition that is common among senior citizens and is connected to an underlying condition) on both forearms and a scratch on her left forearm, which could be caused by grabbing. The Administrator further added, A 5 day report was sent to the State and completed today 5/17/17. On 5/17/17 at 1:00 p.m., during an interview with the Administrator and the Director of Social Services, staff B, revealed when queried about what happened to the two staff CNA F and LPN G involved with the incident responded, The staff CNA F and LPN G were terminated (On 5/11/17). Staff B stated she did witness the video and you could identify the staff and what and who said it and what was said. They (CNA F and LPN G) were rough and spoke in a demeaning way to the resident. On 5/17/17 at 2:00 p.m., the facility's Surveillance Video was viewed with the Maintenance Director and the Administrator, the following was observed: Video tape revealed that there were staff members around the nurse's station and that they were in close and viewable proximity of where the allegation took place. The Administrator was queried on who those staff members were and if she had interviewed them concerning the allegation of abuse? The Administrator responded that she did not interview those staff members, I don't know who they are. The Administrator stated that it was Pharmacy who was at the corner of the nursing station near the second bay unit. Two staff observed the incident but Administrator when queried, stated, I did not interview them, I don't know who they are. Additionally, the observed staff did not report to the facility either. Continued observation revealed that the pharmacist was looking down the hallway towards incident at time incident was happening and another Certified Nursing Assistant (CNA) was passing water to other residents. They both could see the incident. An unidentified resident was in the hallway dressed in white and was in view of the incident during suspected time frame. The two staff member's, involved and named in the allegations, were: staff F, a CNA, and staff G, a nurse. the CNA was the one who spoke to the resident in a demeaning tone you always falling per the Administrator. Continued viewing of the surveillance did not show resident falling the next observation revealed that staff F and G both walked away and left Resident #405 in her wheelchair in the hallway (no immediate intervention to prevent another fall no assessment for injury). At that time, it could be viewed on the video tape that the visitor walked over to the resident and bent over appearing to be talking to the resident (Per complainant, she had asked her if she was ok and the resident stated, no. ) Per Social Worker B written statement on the Investigation Summary: Resident #405, See statement from the SW (social worker) director. Video showed both staff F, CNA, and staff G, nurse - pick resident #405 up off the floor after falling out of her wheelchair. They each grabbed her forearm and lifted her off the floor. (staff F grabbed left forearm and staff G grabbed right forearm). Resident was somewhat Plopped back into the chair (not gently placed into chair). Staff F then said to her in a demeaning tone you always falling. And then they both walked away and left her in the chair in the hallway. (no immediate intervention to prevent another fall). At that time a visitor (complainant) walked over to resident #405 and asked her if she was OK, and she stated, NO. On 5/17/17 at 12:54 p.m., further review Resident #405's clinical record and of the I&A report documented the following: Social Workers (SW) written report: On 5/11/17 a family member H of a resident who was at the facility for short term rehab, provided writer with information and a video that she recorded on her phone on 5/9/17 that occurred between two staff (F and G)and resident #405. Family member who recorded video was educated on HIPPA (sic HIPAA -Health Insurance Portability Act to safeguard medical information) and privacy policy of residents who reside in nursing home. Upon writer viewing the previously recorded video, writer observed on the video from 5/9/17 around 8:10 p.m , or a little after resident #405 was lying on the floor and wheelchair behind her, while she was on the floor CNA F and Nurse G who's name tag was not visible grabbed the resident by her forearms and placed her back in her wheelchair, at no time did they ask if she was okay. CNA F grabbed her left forearm and the nurse G grabbed her right forearm. CNA F stated, you always falling during her placing the resident back in her wheelchair. Person recording video H, walked over to resident #405 who was placed back to the nursing station by staff G and asked if resident was okay, resident stated, No. signed by Social Worker Director B LLMSW. (Noted the I&A did a fall report which was dated 5/9/17 and at documented that at 6:40 a.m the MD (medical doctor E ) was notified and the family, although the fall was on 5/9/17 at 8:10 p.m. The I&A did not indicate resident was assessed). Nursing notes from 5/9 to 5/15 no mention of assessment until physician's progress note. Nurse Practitioner Notes revealed the following: 5/15/2017 at 17:08 physician progress notes [REDACTED].#405 is seen today as per request of staff as she was noticed to have bruises on both arms. Per staff these are old bruises and no recent h/o (history of) any falls or agitation. Patient herself is unaware about it but she has advanced dementia. Examination: Multiple healing bruises noted on bilateral forearms close to wrist. Non tender and not swollen. Good brachial pulses and normal muscle grip of both hands. Assessment and Plan: Benign healing bruises of forearms. Expected to resolve. Supportive and symptomatic care. Discussed with staff. Physician E's Progress Notes revealed the following: On 5/16/2017 17:15 physician progress notes [REDACTED]. SUBJECTIVE: Staff noted bruising to patient's arms bilaterally but are unsure when this occurred. Patient states she does not remember injuring herself and does not remember anyone grabbing her arms. She is unsure how the bruising occurred. otherwise, she states she is doing well. Denies any SOB (shortness of breath), cough, N/V(nausea and vomiting), constipation. OBJECTIVE: VS (vital signs): 163/58 (blood pressure), HR (heart rate) 88, T 97.4 (temperature), Spo2: 99% (percent of oxygen in blood) on room air. Exam NAD, A&O x 1-2 (awake and oriented to two spheres), sitting upright in chair. Heart: RRR S1S2 no m, g, r. (assessed the quality of the hearts rhythm) Lungs: CTAB (clear to auscultation bilaterally) no rales, bronchi, or wheezing. Abd (abdomen): +BS (positive bowel sounds), soft, ND (non-distended), NT (nontender). MSK(muscle skeletal): +3-4/5 UE grip strength bilaterally (assessing strength on both arms). trace [MEDICAL CONDITION] of the LE (fluid retained to both lower extremities) bilaterally. Skin: +old bruising at least one week old as the area is resolving and very faint on the bilateral forearms it is also scattered with no discernible pattern. There are small petechiae (red dots caused by internal bleeding) scattered on the arms as well. There is a small about 1cm (centimeter) laceration (cut) to the left forearm which is scabbed over and appears to be healing well. Neuro: Pleasantly confused, no appreciable focal deficits. 5/16/2017 17:15 physician progress notes [REDACTED]. ASSESSMENT AND PLAN: 1. Senile Purpura, continue with fall precautions, last CBC was checked in 02/2017: Hb 9.2, platelet count: 128. Will recheck platelet count as this makes her more prone to bruising and will monitor. Currently on ASA daily. 2. [MEDICAL CONDITION], again as per #1, will check CBC and monitor. 3. [MEDICAL CONDITION] of chronic disease, likely related to her [MEDICAL CONDITION], Hb 9.2, monitor CBC. 4. CKD3. CRE: 1.57 from 02/2017, continue to monitor. 5. Dm (diabetes) type 2, continue to monitor CBG. 6. Dementia with behavioral disturbance. Continue re-direction of behavior. Continue [MEDICATION NAME], patient is also on [MEDICATION NAME]. 7. Essential HTN, Bp moderately elevated last time but was checked very early in am prior to am med's. Continue to monitor. signed, physician E On 5/17/17 at 2:45 p.m., physician E was interviewed via phone and was queried if he was made aware of the aforementioned incident and fall of resident #405 on 5/9/17? Physician E responded, He was told by the Nurse Practitioner. When further queried why then did he indicate on his documentation, dated 5/16/17, that he did not know how the bruises to resident #405's arms got there and after reading to him his documentation and those of his Nurse Practitioner's notes dated, 5/15/17, that those notes revealed a lack of knowledge indicating on how the bruises were acquired on resident # 405's arms. Additionally, the nurse practitioner's notes indicated staff's lack of knowledge of how the bruises were acquired. When the physician was queried if he was treating the resident for a 'Dyscaria' or condition of the blood? He stated, Yes. When physician E was further queried whether he had thought the bruises were related to the condition of the blood, responded, Yes and when queried, were you informed of two staff grabbing the resident and that the resident fell ? The physician stated, NO. On 5/17/17 at 3:03 p.m., daughter I of resident #405 and also the Medical Durable Power of Attorney was queried regarding if she was informed about the incident that happened on 5/9/17? Daughter I stated, she was aware of a fall that was unrelated to the incident (happened prior to the more current fall). When asked if she was aware of an incident where her mother acquired bruises to her arms, stated, she was never notified on that date however, the staff called on the 11th and told her that they had to let two staff (F and G) go because they verbally abused her. When further queried, was she made aware of the bruises and how they got there? Stated, the facility never told her about the bruises and that she did not know about them until she went to visit her mother and that she was the Medical Durable Power of Attorney. On 5/17/17 at 3:15 p.m., Resident #405 was interviewed and at this time both of her of her arms were observed; both arms appeared to have multiple bruises that were faded. The appearance of the bruises were equally light to dark purple on both the right forearm and the left forearm. The bruising went from the wrist to mid-forearm and the right forearm had multiple skin tears; one was scabbed and the three further up the arm look as though a nail could have caused the injury and appeared almost healed. Resident was pleasantly confused and could not answer as to how those bruises were obtained. On 5/17/17 at 2:16 p.m., the facility's policy and procedure titled, Abuse and Neglect Prohibition Policy, dated, November 2016, revealed that, Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, misappropriation of property and mental abuse facilitated or enabled through the use of technology. Each resident will be free from chemical or physical restraints imposed for purposes of discipline or convenience that are not required to treat resident symptoms. DEFINITIONS: Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Physical Abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Mental Abuse includes but is not limited to. derogatory statements directed to the resident. Mistreatment is defined as inappropriate treatment or exploitation of a resident. Neglect means a failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, pain mental anguish, or emotional distress. PREVENTION 4. Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect, or misappropriation of resident property, and intervene as appropriate. IDENTIFICATION 1. The facility will monitor residents for changes in behavior, bruises/injuries of unknown origin or of a suspicious nature, or other types of patterns, occurrences and trends that may constitute potential abuse and investigate such situations. REPORTING AND RESPONSE 1. The staff will report all allegations of abuse, neglect. to the Administrator immediately.

Based on observation, interview, and record review, the facility failed to consistently implement interventions to prevent the development and/or promote the healing of pressure ulcers (PU) for 5 (#s 804, 806, 814, 818, and 821) of 10 residents reviewed for pressure ulcers out of a total of 24 sampled residents, resulting in the development of new facility acquired pressures sores and the potential for worsening of pressure sores. Findings include: Resident #814 On 1/9/17 at 1:38 p.m., a review of the clinical record revealed that Resident #814 was initially admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #814 had severely impaired cognition, and required extensive to total physical assistance from staff to complete activities of daily living (ADL), including turning from side to side and body positioning while in bed. The nursing care plan, initiated 8/25/16 and revised on 1/10/17, documented, I have a pressure ulcer stage 4 to my sacrum . and listed the interventions of Assist in repositioning me frequently in my bed or chair, avoid positioning me on my sacrum for extended periods of time, follow the skin management program, low air loss mattress and heel lift boots . A review of the Braden Scale, dated 8/22/16, documented that Resident #814 was at Very High Risk for the development of pressure ulcers. The admission nursing assessment documented Resident #814 had no skin breakdown. However, the skin assessment completed by the wound care nurse documented Resident #814 had a pressure ulcer on the right inner buttock and bilateral boggy heels. However, the progress note from the wound care consultant, dated 8/23/16, failed to document there was compromised skin on the buttocks or heels. On 1/9/17 at 4:00 p.m., during an interview, Family Member H was asked about Resident #814's PUs. Family Member H revealed that Resident #814 developed most of the PUs while in the facility. Family Member H was asked if Resident #814's dressings were being changed and if staff turned and repositioned the resident frequently. Family Member H stated, Well, no. They don't turn her every two hours. I do wish they'd turn her every 2 hours. Sometimes I have to go and get someone to turn her because she lays in the same position so long. I've also asked them to get her up for a couple of hours. I talked to the treatment nurse and we agreed that she would get up for a couple of hours on Monday, Wednesday, and Friday. But they aren't doing that either. I come when I get off work and she's not being gotten up. I know she can't stay up for long, but we agreed on a couple of hours three days a week. On 1/10/17 at 9:10 a.m., the wound care observation was done. Resident #814 had a dressing on the right foot. There was an area of eschar on the heel that measured 3.0 centimeters (cm) X 4.0 cm. (Eschar is dead tissue that sheds or falls off from healthy skin .and also occurs in pressure wounds (bedsores). Eschar is typically tan, brown, or black, and may be crusty. Source: Healthline.com). Wound Care Nurse A was asked how the resident got the wound. Wound Care Nurse A stated, It is a deep tissue injury that she acquired here (in the facility) in December last year. Either her heel boots were not on properly or not on period . There was a treatment on Resident #814's left foot near the metatarsophalangeal (near the big toe) on the left foot (Bunion) that had a red base and measured 1.0 cm X 1.5 cm with no drainage. Wound Care Nurse A revealed that Resident #814 developed the pressure ulcer in the facility and stated, This one opened last week. Again, she had a different type of boot, a longer boot. I feel her boot was pushed forward. Wound Care Nurse A revealed the boot was too long and did not stay in position to protect the heels. There was a dressing on Resident #814's sacrum area. Wound Care Nurse A stated, She got this one here too. It is a stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) She acquired it in September. I think we were not repositioning her like we should. She came in with two gluteal and then she acquired the sacrum one. She did go out to the hospital and they debrided it, put in a feeding tube, and she came back with a stage IV. She wasn't eating . But it started here as Deep Tissue Injury (a pressure related injury to subcutaneous tissues under intact skin .(Source: WoundEducators.com) On 1/11/17, Resident #814 was observed lying in the bed on her right side from 1:32 p.m. to 5:29 p.m. (4 hours). On 1/11/17, Resident #814 was observed lying in bed on her right side from 11:01 a.m. to 2:30 p.m. (3-1/2 hours). On 1/11/17 at 1:15 p.m., an interview and a review of the clinical record for Resident #814 was done with Wound Care Nurse A and the Director of Nursing (DON). Wound Care Nurse A revealed the pressure ulcer on Resident #814's sacrum was discovered on 9/27/16 and that the staging of the PU could not be determined. Wound Care Nurse A was asked how the wound was discovered. Wound Care Nurse A looked in the progress notes and revealed there was no note about the wound. The review revealed on 9/15/16 a Nickel size open area was found on the left buttock. However, there was no description, measurements, or documentation of a treatment that was done. Wound Care Nurse A revealed the nurses were supposed to do weekly skin assessments. However, the clinical record revealed that weekly skin assessments had not been consistently completed. The clinical record revealed weekly skin assessments had been done on (8/23/16, 9/2/16, 9/21/16, 9/28/16, 10/14/16, 10/19/16, 12/15/16, 12/22/16, 12/29/16, and 1/5/17). Wound Care Nurse A revealed the weekly skin assessments were supposed to be done every Thursday. There was no explanation why the licensed nurses did not do the weekly skin assessments on 8/29/16, 9/13/16, November 2016, and 12/8/16. The DON and Wound Care Nurse A were asked what interventions were put in place in August 2016 upon admissin, since it was documented that Resident #814 was at Very High Risk for the development of PUs, had poor nutrition, and could not reposition herself. Wound Care Nurse A stated, She should have had frequent repositioning and her heels floated. We don't put someone on a low air loss mattress unless they have multiple stage 2 PUs or stage 3 or 4 pressure ulcers. When she developed the PU on the sacrum, we put her on a loss air loss mattress. Wound Care Nurse A was asked if Resident #814 got up out of bed. Wound Care Nurse A stated, She is supposed to be gotten up on Monday, Wednesday, and Friday by 2:30 PM. because the daughter gets off work at 3:30 PM and comes to see her. Me and the daughter talked about that. Resident #814 was observed not up on Monday, 1/9/17. The DON stated, We knew we had a problem with facility acquired pressure ulcers and we inserviced staff on repositioning and applying boots properly. Each unit has a list of those that are high risk (to develop PU). The Nurses should be making sure the residents are turned every 2 hours. Then it is the unit managers responsibility to make sure it is done, but mainly the CNAs and nurses. Resident #821 On 1/10/17 at 5:11 p.m., a review of the clinical record revealed that Resident #821 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated that Resident #821 had severely impaired cognition and required extensive physical assistance from staff to complete activities of daily living (ADL), including turning from side to side and body positioning while in bed. The nursing care plan, initiated 11/25/16 and revised 1/10/17, documented, I have a pressure ulcer (unstageable) to my sacral . and listed the interventions: heel lift boots bilateral for protection, low air loss mattress, Follow your skin management program. The Care plan further documented that Resident #821 was at moderate risk for the development of pressure ulcers. However, the care plan did not list the intervention of frequent repositioning. On 1/11/17, Resident #821 was observed lying in bed on her back from 8:45 a.m. to 11:02 a.m At 11:16 a.m., Resident #821 was observed seated in the geri-chair on a ROHO cushion. At 1:14 p.m., Resident #821 was observed back in bed lying on her back. Resident #821 was no repostioned off of the sacrum for 8:45 a.m. to 1:14 p.m At 1:46 p.m., Wound Care Nurse A and the DON was asked about Resident #821's pressure ulcer. Wound Care Nurse A stated, She had 2 PU when she got here, she went out to the hospital and came back with a stage 3 pressure ulcer. Yesterday, it looked infected and she was started on Bactrim DS twice a day for 14 days. It had heavy purulent drainage and he (Wound Care Doctor) did a sharp debridement. (Stage 3 PU is Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) The DON, Wound Care Nurse A, and Unit Manager C were informed of the above repositioning observations. Wound Care Nurse A sighed and stated, Her wound has gotten worse too. She should have been laid down on her side. The DON stated, There is a list out to see (make sure) that they were turned every 2 hours .I have no excuses. Unit manager C revealed a list had been put out. At 2:00 p.m., a review of the Wound Care progress notes of the wound consultant documented: 12/13/16 - Sacral Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.), that measured 1.5 cm X 0.6 cm with no signs of infection, a red base, no dead tissue and no purlent drainage. There were no preventative care recomendations listed; 12/27/16 - Sacral (unstageable) that measured 2.5 cm X 5.5 cm. There were no preventative care recommendations ordered; and 1/3/17 sacral unstageable 5.0 cm X 6.0 cm. Resident #821's PU was getting larger. The DON and Wound Care Nurse A revealed that even though the resident was on hospice their inteventions should be followed. On 1/11/17 at 3:30 p.m., a review of the facility's policy titled Pressure Ulcer & Skin Management, dated 7/2011, stated, Residents at risk for the development of pressure ulcers receive interventions to reduce the risk of pressure ulcers .Establish a repositioning schedule: Encourage residents, who are able, to shift their weight periodically; Periodically reposition residents who are unable to shift their weight; Reposition bed-and chair-bound residents at least every 2 hours . ( ) Resident #804 On 01/9/17 at 2:30 p.m., 3:35 p.m., and at 5:30 p.m., Resident #804 was observed laying in an low air loss mattress. Resident #804's low air loss mattress (LALM) was to be used as an intervention to promote healing of a pressure ulcer by redistributing pressure. During these times of observation, only three LED indicators were observed to be lit on the low air loss mattress pump. A large red arrow was taped to the operation pad and pointing at the fourth red LED indicator which was not lit. On 01/10/17 at 8:00 a.m., 9:00 am, 11:20 a.m., 4:20 p.m., and at 5:15 p.m., Resident #804 was observed in bed. Only three LED lights on Resident #804's control pad were observed to be lit. On 01/11/17 at 9:25 a.m., Resident #804 was observed in bed. The LED indicator pad was observed to have only three LED indicators lit. At this time Resident #804's wound care was observed. Treatment Nurse 'A' removed a dressing from Resident #804's left foot which revealed a pressure ulcer with slough, a red base, and with moderate serosanguinous drainage. Treatment Nurse 'A' reported that the left heel pressure ulcer was facility acquired and that it opened up on 1/5/17. Resident #804 was then repositioned and a bandage to the sacrum was removed and revealed a Stage IV pressure ulcer. Treatment Nurse explained that the Resident #804 was admitted with the wound, and that It has never closed. It shows improvement, then it gets worse. At this time, the LED indicator lights for Resident #804's LALM was brought to the attention of Treatment Nurse 'A' and Treatment Nurse 'S'. Treatment Nurse 'A' acknowledged that only three LED lights were lit at the time of wound care and that she placed an arrow pointing to the fourth LED light which indicated that Resident #804's LALM was to be on the fourth LED light. Both Treatment Nurses explained that staff may have bumped the control pad and inadvertently changed the amount of pressure redistribution then Treatment Nurse 'A' added, The mattress should be set to four. Treatment Nurse 'A' then explained that the number of LED indicators that are lit are determined according to the patient's weight. At that time the observation of Resident #804's LED indicators was shared with Treatment Nurse. When asked who was responsible for ensuring that Resident #804's Low Air Loss Mattress (LALM) was on the correct setting in order to provide the optimal environment to promote the healing of Resident #804's community acquired and facility acquired pressure ulcers, Treatment Nurse explained that all nursing staff is responsible, if the Certified Nurse Assistants bump the control pad they should report it to the nurse. When asked if the nurses are required to document that Resident #804's LALM was on the correct setting, Treatment Nurse stated, It is an FYI (for your information) on the MAR (medication administration record). It should be checked daily by nursing. On 01/11/17 at 10:25 a.m., Restorative Certified Nurse Assistant 'T' was observed to weigh Resident #804. Resident #804's weight was recorded as 163.2 pounds. On 01/10/17 at 4:20 p.m., clinical record review revealed that Resident #804 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set ((MDS) dated [DATE], Resident #804 had severely impaired cognition and required total assistance from one to two staff for all activities of daily living. Further review of the MDS revealed that Resident #804 was at risk for the development of pressure ulcers and was admitted with one unhealed pressure ulcer. The pressure ulcer (sacrum) was a Stage IV and measured 2.0 cm (centimeters) width, 1.5 cm in length, and 1.0 centimeters in depth. A wound care note dated 12/06/16 indicated Low air loss mattress (LALM) to promote wound healing. Review of a Weekly Head to Toe Assessment dated 01/05/17, revealed the discovery of a Stage II pressure ulcer that measured 3.5 cm in width and 3.0 cm in length, there was no depth indicated. Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister (NPUAP, 2007). A wound care note dated 01/05/17 documented a pressure ulcer wound to the left heel that measured 2.0 cm x 1.0 cm x 0.3 cm. A wound care note dated 01/11/17 documented 2.5 cm x 1.5 cm x 1.0 cm measurements (an increase in size and a Stage III) for the same left heel wound. A Stage III pressure ulcer is, Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (NPUAP, 2007). On 01/11/17 at 2:50 p.m., the Director of Nursing (DON) was made aware of the findings regarding Resident #804 and explained that she was informed of the incident, however the DON was unable to provide a verbal explanation as to why the LED lights were not on the number of lights indicated by the Treatment Nurse. At that time, the LALM user manual was requested. On 01/11/17 at 4:00 p.m., review of the LALM user manual was reviewed and revealed that residents with a weight between 150 - 170 pounds should have 5 LED Indicators. At this time it was brought to the DON's attention. The DON acknowledged that Resident #804 should have been set to 5 LED indicators, instead of 4 as indicated by the Treatment nurses, to promote pressure ulcer healing and prevent the development of pressure ulcers. The DON was unable to provide an explanation as to why Resident #804 was laying on a LALM that did not provide the optimal environment to promote healing and prevent the development of pressure ulcers for Resident #804. Resident #818 On 01/10/17 at 4:45 p.m. and at 5:15 p.m. and on 1/11/17 at 9:10 a.m. and at 9:45 a.m., Resident #818 was observed sitting in her wheelchair at bedside. On 01/10/17 at 2:40 p.m., clinical record review revealed Resident #818 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE], revealed that Resident #818 had intact cognition, and required extensive assistance with transfers, ambulation, dressing, and hygiene. Resident #818 was coded to be continent with bowel. Resident #818's bladder continence was coded as not rated. The admission MDS documented that Resident #818 was at risk for the development of pressure ulcers, however Resident #818 had no pressure ulcers on admission. The quarterly MDS dated [DATE], assessed that Resident #818 had become frequently incontinent of bowel and bladder. A care plan related to pressure ulcer prevention revised on 12/9/16 revealed no interventions related to turning and repositioning or checking Resident #818 for episodes of incontinence. A care plan titled, Potential to Skin Integrity dated 8/10/16 noted, place a pressure reducing cushion in my chair. However, there was no review of the care plan that indicated that the intervention was effective. In addition, there was no Activities of Daily Living care plan developed after there was a change in Resident #818's bowel habits that was documented on the quarterly MDS assessment, which could contribute to the development of pressure ulcers. A nurses note dated 12/8/16 noted, Pressure Ulcer is now a Stage III. An IDT note dated 12/12/16 documented, Resident (#818) sacrum wound has gotten worse. A nurses note indicated that Resident #818 had a Stage II wound that resolved on 10/5/16 and reopened on 11/29/16. A wound care note dated 1/3/17 documented that Resident #818's Stage II pressure ulcer to her sacrum had progressed (gotten worse) to a Stage III. On 01/11/17 at 10:00 a.m., Treatment Nurse 'A' was queried regarding the Resident #818's seat cushion device. It was observed that Resident #818 was seated on a cushion to help promote weight distribution to prevent the development of pressure ulcers. When asked if the [MEDICAL TREATMENT] center that Resident #818 visited three days a week (Monday, Wednesday, and Friday) for 4-6 hours each visit, was aware of Resident #818's pressure ulcer. Treatment Nurse stated, She sits in the wheelchair with the cushion while she is here, but I am not aware of what she sits on while at [MEDICAL TREATMENT]. When asked if she communicated the reopening of the sacral (sit bones) pressure ulcer to the [MEDICAL TREATMENT] center, Treatment Nurse stated, I have not communicated to [MEDICAL TREATMENT] that she has a Stage III pressure ulcer. She does sit there for a while. When asked if the the Interdisciplinary Team (IDT)presented Resident #818's wound to determine why the pressure ulcer developed and reopened, Treatment Nurse 'A' was unable to explain. On 01/11/17 at 11:40 a.m., Unit Manager 'U' was interviewed regarding Resident #818's facility acquired pressure ulcer that developed and reopened. When asked if the information was shared with [MEDICAL TREATMENT] since Resident #818 spends 4 to 6 hours, three days a week in a [MEDICAL TREATMENT] chair, Unit Manager 'U' stated, I have not communicated that to the [MEDICAL TREATMENT] center. I will make sure that they are aware of the pressure ulcer. Maybe they could use the cushion that she has. On 01/11/17 at 2:50 p.m., Resident #818's facility acquired pressure ulcer development and reopening was discussed with the DON. The DON explained that she had concerns with pressure ulcers and had done some in-services during the month of December 2016. However, when queried the DON was unable to explain why the [MEDICAL TREATMENT] center was not made aware of Resident's pressure ulcer in order to ensure consistent care to promote healing and prevent the development of future pressure ulcers. The DON was unable to explain why Resident #818's care plans (toileting and the appropriate seating device) were not specific to Resident #818's care needs. When queried further, the DON was unable to explain if the seat cushion was effective in prevention of the sacral pressure ulcer since Resident #818 developed the pressure ulcer after the cushion was implemented on 08/10/16. On 01/11/17 at 3:00 p.m., review of the facility policy titled, Pressure Ulcer Preventative Measures released in 2014, noted, Residents at risk for the development of pressure ulcers receive interventions to reduce the risk of pressure ulcers and listed the following interventions, Individualize the frequency of skin cleansing according to the need and/or resident preference, establish a repositioning schedule (encourage residents, who are able, to shift their weight periodically), for residents in bed, who are completely immobile, use devices that relieve pressure on the heels .when using a specialty support surface, follow manufacturer's instructions, use pressure redistribution, avoid uninterrupted sitting in a chair or wheelchair, and document approaches and interventions on the care plan. ( ) Resident #806 On 01/09/17 at 9:40 a.m., an observation of resident #806's sacral pressure ulcer was conducted with the wound care nurse and revealed a stage three (full thickness tissue loss, may show fat) which measured a 1 cm (centimeters) by 1 cm irregular area with a red/pink base with surrounding exposed fatty tissue with a total area of 3.5 cm by 3.0 cm. The wound nurse had indicated prior to the observation the wound was a reopening of an old stage three. On 01/09/17 at 2:14 p.m., 3:12 p.m., 4:00 p.m., 4:39 p.m. and 5:09 p.m., and on 01/10/17 at 7:16 a.m. and 8:19 a.m. resident #806 was observed in bed positioned onto the left side. On 01/10/17 at 12:06 p.m., 12:47 p.m., 1:18 p.m. 3:11 p.m. 3:24 p.m., and 3:40 p.m., resident #806 was observed to be seated in a wheelchair. On 01/11/17 at 9:15 a.m., the wound care physician notes for resident #806 were reviewed and revealed: A note dated 11/08/16 which indicated, Sacral Incontinence [MEDICAL CONDITION] (spotty redness, fragile tissue) resolved. No open areas were noted on this date. A note dated 12/27/16 which indicated, Sacral stage three, measures 1.2 cm by 2.0 cm, granular, red tissue. A note dated 01/03/17 which indicated, Sacral stage 3, measures 2.0 cm by 2.5 cm, red tissue. Further review of the medical record for resident #806 revealed: Resident #806 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] indicated severely impaired cognition with a three out of 15 BIMS (brief interview of mental status) score, the need for total assistance of one person for bed mobility, transfer, dressing, bowel and bladder care, hygiene and bathing. The MDS indicated resident #806 was at risk but did not have a pressure sore. A in progress significant change MDS dated [DATE] indicated a stage three pressure sore which measured 1.2 cm by 2.0 cm by 0.0 cm. A nursing care plan dated 12/21/16 indicated I have a pressure ulcer stage three to my sacrum, a Braden of 15 puts me at risk for developing pressure ulcers. Follow the skin management program. A care plan had [MEDICAL CONDITION] left side assist with range of motion exercises as needed, turn and reposition at least every two hours and as needed. ( )

THIS CITATION PERTAINS TO INTAKE #MI 117, MI 535 & MI 554 BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF 1 (#104) OF 6 RESIDENTS REVIEWED FOR SAFETY AND SUPERVISION, FROM A TOTAL SAMPLE OF 6, RESULTING IN IMMEDIATE JEOPARDY WHEN, UNBEKNOWNST TO FACILITY STAFF, RESIDENT #104 ELOPED FROM THE FACILITY ON 2/26/2012. ADDITIONALLY, THE FACILITY FAILED TO PROVIDE A SAFE ENVIRONMENT AND APPROPRIATE ASSISTIVE DEVICES AND INTERVENTIONS FOR 2 (#101 AND #105) OF 6 RESIDENTS REVIEWED FOR SAFETY AND SUPERVISION, FROM A TOTAL SAMPLE OF 6 RESULTING IN FALLS WITH INJURY. FINDINGS INCLUDE: RESIDENT #104 ACCORDING TO THE FACE SHEET, DATED 3/05/2012, RESIDENT #104 WAS AN [AGE] year OLD FEMALE, WHO WAS admitted INto the facility on [DATE]. HER [DIAGNOSES REDACTED]. A REVIEW OF THE FACILITY'S DOCUMENTED "ACCIDENT/INCIDENT REPORT," DATED 2/26/2012 AT 7:15 P.M., REVEALED THAT RESIDENT #104 HAD INTERMITTENT CONFUSION AND DESPITE THE IMPLEMENTATION OF A WHEELCHAIR ALARM, BED ALARM AND ALARMING DOORS TO THE EXTERIOR OF THE BUILDING, RESIDENT #104 WAS "FOUND WALKING IN (THE) PARKING LOT..." BASED ON THE RESIDENT'S LIMITED LENGTH OF STAY, A MINIMUM DATA SET WAS NOT AVAILABLE FOR REVIEW AS OF 3/14/2012. ACCORDING TO THE HOSPITAL "DISCHARGE INSTRUCTIONS," DATED 2/24/2012 AND RECEIVED BY THE FACILITY WHEN RESIDENT #104 WAS admitted , SHE HAD BEEN diagnosed with [REDACTED]." admission orders [REDACTED]. RN (REGISTERED NURSE) #1 SIGNED THIS HAND WRITTEN DOCUMENT AFTER A REVIEW TO ENSURE THAT THE INFORMATION WAS CORRECT. THE PHYSICIAN'S ADMISSION HISTORY AND PHYSICAL, DATED 2/27/2012, DOCUMENTED THAT RESIDENT #104 WAS NOT MENTALLY COMPETENT. THE PHYSICIAN DOCUMENTED THAT RESIDENT #104 WAS ORIENTED TO PERSON BUT NOT TO PLACE, TIME OR EVENT. THE PHYSICIAN FELT THE PATIENT WAS NOT AWARE OF HER [DIAGNOSES REDACTED]. DURING AN INTERVIEW ON 3/08/2012 AT 1:20 P.M., RN #1 SAID THAT ON THE DAY OF ADMISSION, 2/24/12, RESIDENT #104 WAS ORIENTED TO PERSON, HER DAUGHTER (WHO ARRIVED LATER THAT DAY) AND HERSELF. RN #1 SAID RESIDENT #104 NEEDED TO BE TOLD REPEATEDLY WHERE SHE WAS AND EVEN WITH CONSTANT REPETITION RESIDENT #104 COULD NOT RETAIN THIS INFORMATION. RESIDENT #104 REQUIRED REPEATED ORIENTATION TO HER NEW ROOM. RN #1 SAID THAT SHE DETERMINED RESIDENT #104 WAS GENERALLY ORIENTED TO TIME WHEN AT 2:50 P.M., THE RESIDENT REPEATEDLY SAID SHE HAD TO LEAVE, TO GO HAVE DINNER WITH HER DAUGHTER. OTHERWISE, ACCORDING TO RN #1, RESIDENT #104 WAS CONFUSED. REVIEW OF THE "INITIAL CARE PLAN", DATED 2/24/2012 AND SIGNED BY RN #1, REVEALED RN #1 ASSESSED RESIDENT #104 AND DETERMINED SHE HAD COGNITIVE LOSS/DEMENTIA AND REQUIRED "ASSISTANCE PRN (AS NEEDED) AND CUES/SUPERVISION." REVIEW OF RESIDENT #104'S ELOPEMENT RISK ASSESSMENT, DATED 2/24/2012, REVEALED RN #1 HAD NOT IDENTIFIED RESIDENT #104 AS BEING AT RISK FOR ELOPEMENT, WITH A SCORE OF ONLY "5". DURING AN INTERVIEW ON 3/14/2012 AT 1:30 P.M., NM (NURSE MANAGER) #1 SAID RN #1 INACCURATELY DOCUMENTED RESIDENT 104'S ELOPEMENT RISK ON 2/24/2012. NM #1 STATED THAT RN #1DID NOT PROPERLY ACKNOWLEDGE RESIDENT #101'S 1) DESIRE TO LEAVE THE FACILITY; 2) HER NEW ADMISSION STATUS AND, 3) HER NEW ROOM (AS A NEW ADMISSION). ACCORDING TO NM #1, THE FACILITY IMMEDIATELY APPLIES WANDERGUARDS (A DEVICE THAT TRANSMITS A SIGNAL WHICH ACTIVATES AN ALARM WHEN THE SIGNAL IS RECEIVED, USUALLY AT A DOORWAY) TO ALL RESIDENTS ASSESSED AT "8" OR ABOVE ON THE ELOPEMENT RISK ASSESSMENT TO KEEP THEM SAFE. NM #1 SAID AN ACCURATE ASSESSMENT OF RESIDENT #104'S ELOPEMENT RISK WOULD HAVE RATED RESIDENT #104, SEVEN POINTS HIGHER, AT A RISK OF "12". NM #1 SAID THAT THE ACCURATE AND CUMULATIVE SCORE OF TWELVE WOULD HAVE REQUIRED STAFF TO PLACE A WANDERGUARD ON RESIDENT #104 TO MINIMIZE HER RISK FOR ELOPEMENT. NM #1 AGREED THE ONLY REASON A WANDERGUARD WAS NOT APPLIED TO RESIDENT #104 WAS BECAUSE STAFF FAILED TO COMPLETELY AND ACCURATELY ASSESS AND DOCUMENT RESIDENT #104'S ASSESSMENT ON THE ELOPEMENT RISK ASSESSMENT FORM. A REVIEW OF THE FACILITY'S DOCUMENTED "ACCIDENT/INCIDENT REPORT", DATED 2/26/2012 AT 7:15 P.M., REVEALED RESIDENT #104 WAS "FOUND WALKING IN (THE) PARKING LOT..." SILENT VIDEO FOOTAGE PROVIDED BY THE FACILITY WAS REVIEWED WITH THE ADMINISTRATOR, THE DIRECTOR OF NURSING (DON), THE MAINTENANCE SUPERVISOR AND THE DIRECTOR OF SUPPORT SERVICES ON 3/08/2012 AT 11:00 A.M. THE VIDEO FOOTAGE SHOWED LICENSED PRACTICAL NURSE (LPN) #1 RESPONDING TO THE MAIN CONTROL PANEL OF THE FACILITY'S SECURITY ALARMS ON 2/26/2012 AT 7:03:06 P.M. VIDEO FOOTAGE FROM BAY #4, DATED 2/26/2012 AT 7:02:16 P.M., REVEALED RESIDENT #104 USED A WALKER AND INDEPENDENTLY AMBULATED FROM HER BEDROOM IN THE DIRECTION OF AN EXTERIOR DOOR ON THE NORTHEAST SIDE OF THE BUILDING. EXTERIOR CAMERA FOOTAGE, WHICH COVERED THE BUILDING'S EXITS ON THE NORTHEAST SIDE, PERMITTED VISUALIZATION OF EXITS FROM BAY #2, BAY #3, THE DELIVERY BAY AND BAY #4. AT 7:03:24 P.M., THIS CAMERA SHOWED FOOTAGE OF RESIDENT #104 AS SHE EMERGED OUTSIDE, UNSUPERVISED, VIA THE BAY 4 EXIT DOOR ONTO THE FACILITY'S DRIVEWAY AND BEYOND INTO A GRASSY REGION BY A FENCE. DURING AN INTERVIEW ON 3/08/2012 AT 12:00 P.M., LPN #1 SAID THAT, WHILE ASSIGNED TO BAY #3 ON 2/26/2012, SHE RESPONDED TO A LOUD BELL SOUNDING AT THE MAIN CONTROL PANEL OF THE FACILITY'S SECURITY ALARM. LPN #1 SAID SECTION #21 ON THE PANEL WAS LIT, WHICH INDICATED AN EXTERIOR DOOR ON BAY #4 HAD BEEN OPENED UNEXPECTEDLY. LPN #1 SAID THE ALARM MAY HAVE INDICATED THAT A RESIDENT ELOPED. LPN #1 SAID SHE IMMEDIATELY TURNED OFF THE AUDIBLE FACILITY ALARM AND USED A TELEPHONE AT BAY #3 TO PAGE BAY #4. LPN #1 SAID HER PAGE REQUESTED BAY #4 STAFF TO EVALUATE ALL OF THEIR EXIT DOORS. LPN #1 SAID SHE THEN RETURNED TO HER DUTIES ON BAY #3. VIDEO FOOTAGE OF THE FACILITY'S EXTERIOR NORTHEAST AND INTERIOR BAY #4 NORTHEAST HALL SHOWED THAT NO STAFF RESPONDED TO CHECK THE SECURITY OF RESIDENTS AT THE BAY #4 NORTHEAST EXIT DOOR. THE VIDEO FOOTAGE CONFIRMED LPN #1'S ACTIONS WERE CONSISTENT WITH HER INTERVIEW RESPONSES. THE VIDEO FOOTAGE AT 7:04:52 P.M. SHOWED OFF-DUTY DIETARY AIDE (DA) #2 STANDING OUTSIDE OF THE BUILDING, IN THE DELIVERY AREA LOOKING TOWARD THE PARKING LOT. DURING THE REVIEW OF THE VIDEO FOOTAGE, THE ADMINISTRATOR POINTED TO THE VIDEO SCREEN, TIME STAMPED 7:04:54 P.M., AND SAID THE PERSON SEEN IN THE VIDEO WAS ONE OF TWO DIETARY AIDES WHO RESPONDED OUT THE BAY #4 NORTHEAST DOORS IN RESPONSE TO THE FACILITY'S SECURITY ALARMS. DURING AN INTERVIEW ON 3/08/2012 AT 11:45 A.M., DA (DIETARY AIDE) #1 SAID SHE AND DA #2 HAD WORKED ON 2/26/2012 UNTIL APPROXIMATELY 7:00 P.M. DA #1 SAID NO ALARMS WERE SOUNDING WHEN SHE LEFT THE FACILITY AND STAFF DID NOT APPEAR TO BE LOOKING FOR A LOST RESIDENT. DA #1 DEMONSTRATED THE ROUTE SHE AND DA #2 TOOK FROM THE BASEMENT, INTO THE ELEVATOR, ONTO BAY #3 AND OUT THE CODED, KEY PADDED "DELIVERY DOOR" EXIT. DA #1 SAID AS THEY APPROACHED THE CAR OWNED BY DA #2, WHICH WAS PARKED ON THE NORTHEAST SIDE OF THE BUILDING, SHE WITNESSED RESIDENT #104 ALONE. RESIDENT #104 WAS WEARING A "LIGHT" HOSPITAL GOWN, HOLDING A WALKER, STANDING IN THE GRASS AND ATTEMPTING TO GET INTO DA #2'S CAR. DA #1 SAID THAT ALTHOUGH SHE DID NOT KNOW OR RECOGNIZE RESIDENT #104, SHE (DA #1) REALIZED THE PERSON TRYING TO GET INTO THE CAR WAS A RESIDENT FROM HER CLOTHING AND THE WALKER. DA #1 SAID RESIDENT #104 WAS NOT DRESSED FOR THE "COLD" WEATHER CONDITIONS. DA #1 SAID SHE (DA #1) THEN WALKED BACK TO THE FACILITY INTO BAY 3 FROM THE DELIVERY DOOR AND ALERTED LPN #1 THAT "A RESIDENT" WAS OUTSIDE, UNSUPERVISED. DA #1 SAID THAT WHEN SHE (DA #1) LOCATED THE NURSE, LPN #1 WAS PREPARING HER MEDICATIONS. CONTINUED REVIEW OF VIDEO FOOTAGE FROM BAY #3, THE EXTERIOR DELIVERY AREA AND THE NORTHEAST SIDE OF THE BUILDING, CONFIRMED THAT DA #1'S ACTIONS WERE CONSISTENT WITH HER INTERVIEW RESPONSES. IT WAS UNCLEAR WHY THE ADMINISTRATOR ASSERTED THAT DIETARY AIDES #1 AND #2 WERE RESPONDING TO AN ALARM. AT 7:05:55 P.M., JUST SHY OF THREE MINUTES AFTER THE ALARM HAD SOUNDED, LPN #1 RESPONDED FROM BAY #3 TO THE PARKING AREA ON THE NORTHEAST SIDE OF THE BUILDING AND BROUGHT RESIDENT #104 BACK INSIDE. DURING A REVIEW OF INSIDE VIDEO FOOTAGE FROM BAY 4, DATED 2/26/2012, ON 3/08/2012 AT 1:00 P.M., THE DIRECTOR OF NURSING SAID, THOUGH REQUIRED, FACILITY STAFF FAILED TO RESPOND TO THE ALARMING OF THE EXIT DOOR THROUGH WHICH RESIDENT #104 DEPARTED THE BUILDING, AND FAILED TO MONITOR THE DOOR FOR POTENTIAL ELOPEMENT. THE DON DID NOT EXPLAIN WHY FACILITY STAFF DID NOT RESPOND TO LPN #1'S PAGE ALERTING THEM TO CHECK THE BAY #4 DOOR. THE DIRECTOR OF NURSING SAID HE INTERVIEWED STAFF AFTER THE ELOPEMENT, AND DETERMINED THAT RESIDENT #104 INDEPENDENTLY DISABLED THE WHEELCHAIR ALARM. HE SAID THAT, DESPITE THE APPLICATION OF A WHEELCHAIR ALARM BY THE ASSIGNED CERTIFIED NURSING ASSISTANT (CNA) JUST BEFORE 7:00 P.M., THE WHEELCHAIR ALARM DID NOT SOUND WHEN RESIDENT #104 STOOD FROM HER WHEELCHAIR, GOT HER WALKER AND AMBULATED OUT OF THE FACILITY. DURING A TELEPHONE INTERVIEW ON 3/08/2012 AT 3:00 P.M., THE ADMINISTRATOR SAID SHE INTERVIEWED ALL STAFF WHO WORKED ASSIGNED TO BAY #4 ON 2/26/2012 AT APPROXIMATELY 7:00 P.M. THE ADMINISTRATOR SAID EACH STAFF MEMBER INTERVIEWED SAID THE SECONDARY ALARM (SECONDARY TO THE PANEL ALARM) ON THE NORTHEAST DOOR OF BAY #4 DID NOT FUNCTION, WHEN RESIDENT #104 EXITED THE BUILDING UNSUPERVISED SHORTLY BEFORE 7:03:06 P.M. THE ADMINISTRATOR WAS NOTIFIED ON 3/08/2012 THAT IMMEDIATE JEOPARDY HAD BEEN IDENTIFIED ON 3/07/2012 AND BEGAN ON 2/26/2012 WHEN FACILITY STAFF FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF A COGNITIVELY IMPAIRED RESIDENT (RESIDENT #104) WHO ELOPED FROM THE FACILITY ON 2/26/2012 AT 7:03 P.M., UNBEKNOWNST TO FACILITY STAFF. ON 3/13/2012 THE SURVEYOR VERIFIED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: RESIDENT #104 NO LONGER LIVED AT THE FACILITY, AS DOCUMENTED IN THE MEDICAL RECORD AND ON THE ROSTER. ON 3/09/2012, THE FACILITY DOCUMENTED ELOPEMENT RISK/ASSESSMENTS ON 135 OF 136 RESIDENTS ON THE FACILITY ROSTER. ONE RESIDENT HAD NOT BEEN ASSESSED DUE TO A CURRENT hospitalization . ACCORDING TO THE ADMINISTRATOR THIS RESIDENT WILL BE REVIEWED UPON HER RETURN TO THE FACILITY. NO ADDITIONAL RESIDENTS NEEDING WANDERGUARDS WERE IDENTIFIED. ON 3/09/2012, THE 9 SECONDARY ALARMS USED PRIOR TO 3/07/2012 HAD BEEN REMOVED FROM EXTERIOR DOORS ON 3/09/2012, 11 NEW SECONDARY ALARMS WERE INSTALLED ON ALL EXIT DOORS WITH TWO ADDITIONAL ALARMS PLACED ON THE EXTERIOR DOORS IN THE THERAPY AREA. THESE ALARMS ARE TAMPER PROOF AND REQUIRE NURSING STAFF TO CARRY A KEY NECESSARY TO DISABLE ALL ACTIVE ALARMS. ON 3/13/2012 THESE ALARMS WERE PRESENT, FUNCTIONAL AND MONITORED BY STAFF IN ACCORDANCE WITH THE NEW FACILITY POLICY. ON 3/09/12, A NEW ALARM SYSTEM POLICY WAS IMPLEMENTED AND A COPY OF THE POLICY PROVIDED TO THE STATE REGULATORY AGENCY. ON 3/13/2012, STAFF DEMONSTRATED COMPETENCY IMPLEMENTING 100% OF THE REQUIREMENTS WITHIN THE NEW ALARM SYSTEM POLICY. ON 3/09/2012, ONGOING STAFF EDUCATION STARTED ON THE NEW ALARM POLICY. ALL 162 STAFF MEMBERS WILL RECEIVE THE NECESSARY IN-SERVICE TRAINING PRIOR TO RETURNING TO THEIR DUTIES. AS OF 3/13/2012 #152 EMPLOYEES HAD RECEIVED THE NECESSARY INSTRUCTION. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 3/09/2012, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO THE LACK OF INTERVENTIONS TO PREVENT FALLS RESULTING IN INJURY RELATED TO RESIDENTS #101 AND #105. RESIDENT #101 ACCORDING TO THE FACE SHEET, DATED 2/28/2012, RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 2/27/2008. HER [DIAGNOSES REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated [DATE], RESIDENT #101 HAD SEVERELY IMPAIRED COGNITIVE FUNCTIONALITY WITH BOTH LONG AND SHORT TERM MEMORY LOSS. SHE COULD NOT BALANCE INDEPENDENTLY AND REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE EXTENSIVE ASSISTANCE WHILE WALKING. RESIDENT #101 REQUIRED ONE STAFF MEMBER TO PROVIDE LIMITED ASSISTANCE WITH ALL TRANSFERS. REVIEW OF A QUARTERLY FALL RISK ASSESSMENT, DATED 2/07/2012, REVEALED THAT RESIDENT #101 WAS AT "HIGH RISK" FOR FALLS DUE TO HER INTERMITTENT CONFUSION, INCONTINENT YET AMBULATORY STATUS, BALANCE PROBLEM AS SHE STOOD, BALANCE PROBLEM AS SHE WALKED, DECREASED MUSCULAR COORDINATION, GAIT PATTERN CHANGE WHEN SHE WALKED THROUGH DOORS, JERKING OR UNSTABLE MOTIONS WHEN SHE MADE TURNS, HER NEED OF ASSISTIVE DEVICES (WHEELCHAIR) AND MULTIPLE MEDICAL CONDITIONS THAT PREDISPOSED HER TO FALLS. REVIEW OF THE LAST DOCUMENTED "POSITIONING AND RESTRAINT ASSESSMENT," COMPLETED BY OCCUPATIONAL THERAPY ON 3/13/2009, REVEALED THAT RESIDENT #101 REQUIRED AT LEAST ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS TO KEEP HER SAFE. YEARLY REHABILITATION SCREENS DONE IN 3/2010 AND 2/2011 REVEALED "NO SIGNIFICANT CHANGES WITH (RESIDENT #101'S) FUNCTIONAL NEEDS." DURING AN INTERVIEW ON 3/14/2012 AT 2:00 P.M. THE DIRECTOR OF NURSING SAID THERAPY REPORTED RESIDENT #101'S ONLY SAFETY DEVICES, IN PLACE BEFORE SHE fell on [DATE], WAS A GEL WHEELCHAIR CUSHION AND A WHEELCHAIR PRESSURE ALARM. DURING AN INTERVIEW ON 3/14/2012 AND 2:15 P.M., CNA #3 SAID THAT SHE WORKED AS THE FULL TIME DAY SHIFT AIDE WITH RESIDENT #101 FOR "A LONG TIME." CNA #3 SAID SHE KNEW RESIDENT #101 HAD THE ABILITY TO INDEPENDENTLY TRANSFER HERSELF FROM THE WHEELCHAIR AND WAS KNOWN TO STAND AND WALK IN HER ROOM AT LEAST ONCE A WEEK. CNA #1 SAID THE CHAIR ALARM ALWAYS SOUNDED WHEN RESIDENT #101 ENGAGED IN THIS UNSAFE BEHAVIOR. CNA #3 SAID STAFF WOULD FIND RESIDENT #101 "NOT TOO FAR" FROM HER WHEELCHAIR AND WOULD RETURN HER TO THE WHEELCHAIR WITH ASSISTANCE BECAUSE SHE (#101) WAS VERY UNSTEADY. CNA #3 SAID RESIDENT #101 STOOD UP TO "FUSS" WITH HER BED COVERS, STOOD TO LOOK IN HER BEDSIDE DRAWERS AND STOOD TO WALK AT TIMES. CNA #3 SAID EVEN THOUGH STAFF KNEW FOR MONTHS RESIDENT #101 ROUTINELY SELF-TRANSFERRED AND INDEPENDENTLY AMBULATED IN HER BEDROOM, NO ADDITIONAL SAFETY MEASURE WERE PLACED TO KEEP HER SAFE BECAUSE SHE NEVER fell . CNA #3 SAID JUST BEFORE THE FALL ON 2/12/2012 AT 9:50 A.M., SHE (#3) SAT RESIDENT #101 UP IN HER WHEELCHAIR, ENSURED THE WHEELCHAIR'S ALARM WAS ON, NOTED THAT RESIDENT #101 WAS AGITATED AND LEFT HER IN HER BEDROOM ALONE. CNA #3 SAID STAFF CALLED HER BACK TO THE RESIDENT'S ROOM SHORTLY THEREAFTER AND SAID RESIDENT #101 WAS FOUND ON THE FLOOR BETWEEN THE WHEELCHAIR AND HER BED. CNA #3 SAID SHE ASSISTED RESIDENT #101 BACK INTO THE BED BUT RESIDENT #101 "SHOOK AND YELLED OUT IN PAIN." CNA #3 SAID RN #2 WAS PRESENT IN THE ROOM BUT DID NOT OFFER TO ASSIST WITH THE TRANSFER. CNA #3 SAID NO ADDITIONAL SAFETY MEASURES WERE IMPLEMENTED TO KEEP RESIDENT #101 SAFE AFTER SHE fell . CNA #3 SAID, "YOU COULD TELL ALL DAY, SHE WAS IN A LOT OF PAIN," BUT, ACCORDING TO CNA #3, THE RESIDENT'S CLOTHES WERE NOT REMOVED TO EXAMINE FOR CAUSE. DURING THE SAME INTERVIEW ON 3/14/2012 AT 2:00 P.M., THE DIRECTOR OF NURSING SAID HE DID NOT KNOW RESIDENT #101 FREQUENTLY AND ROUTINELY SELF-TRANSFERRED IN HER BEDROOM. THE DIRECTOR OF NURSING SAID HIS STAFF WAS NOT PRESENT TO PROVIDE RESIDENT #101 WITH THE ASSESSED ONE PERSON ASSIST REQUIRED FOR A SAFE TRANSFER ON 2/12/2012 AT 9:50 A.M. THE DIRECTOR OF NURSING SAID FOR ELEVEN HOURS AFTER THE FALL, STAFF FAILED TO PROVIDE ADEQUATE, ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION, TO ENSURE RESIDENT #101 WAS SAFE, BEFORE THEY TRANSFERRED HER TO THE LOCAL AREA HOSPITAL AT 8:30 P.M. LOCAL HOSPITAL REPORTS, DATED 2/13/2012 AT 3:00 A.M., REVEALED RESIDENT #101 SUSTAINED A LEFT "SUPRACONDYLAR FEMORAL FRACTURE" AFTER FALLING AT HER NURSING HOME. RESIDENT #105 ACCORDING TO THE FACE SHEET, DATED 2/07/2012, RESIDENT #105 WAS A [AGE] year OLD MALE RESIDENT WHO LIVED AT THE FACILITY SINCE 6/01/2011. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated [DATE], RESIDENT #105 HAD MILDLY IMPAIRED COGNITIVE FUNCTION WITH SHORT TERM MEMORY LOSS. HE COULD NOT WALK, COULD NOT BALANCE INDEPENDENTLY, HAD FUNCTIONAL LIMITATIONS OF BOTH LOWER EXTREMITIES, HAD FUNCTIONAL LIMITATIONS OF ONE UPPER EXTREMITY, HAD PRESSURE ULCERS AND WAS DEPENDENT ON TWO STAFF MEMBERS TO ASSIST WITH ALL TRANSFERS. THE SUBJECT OF THE REPORT WEIGHED 155 POUNDS. PHYSICIAN ORDERS, DATED 3/01/2012 THROUGH 3/31/2012, NOTED THAT RESIDENT #105 TOOK SUPPLEMENTAL MEDICATIONS FOR OSTEOPOROSIS- OYSTER SHELL CALCIUM, TWICE A DAY. REVIEW OF THE FALL RISK ASSESSMENT, DATED 1/30/2012, REVEALED THE SUBJECT OF THE REPORT WAS AT "HIGH RISK" FOR FALLS BASED ON HIS INTERMITTENT CONFUSION AND CHAIR-BOUND STATUS, COMBINED WITH THE MULTIPLE MEDICAL [DIAGNOSES REDACTED]. STAFF DOCUMENTED HIS "BALANCE" WAS "NOT APPLICABLE" WHEN THEY COMPLETED HIS FALL ASSESSMENT. REVIEW OF CARE PLANS, DATED 2/11/2012, REVEALED THE SUBJECT OF THE REPORT had a history of [REDACTED]. TO AVOID SUDDEN MOVEMENTS AND/OR BUMPS DURING HIS CARE, RESIDENT #101 WAS TO AVOID ALL TWISTING MOVEMENTS ACCORDING TO THIS CARE PLAN. A FALL CARE PLAN, DATED 8/08/2011, IDENTIFIED RESIDENT #105 AS BEING AT RISK FOR INJURY AND REQUIRED STAFF TO POSITION THE RESIDENT SAFELY WHILE RENDERING CARE, USING AN "ADEQUATE AMOUNT OF STAFF FOR ALL TRANSFERS OR (THE) USE OF A MECHANICAL LIFTING DEVICE." PHYSICAL THERAPY NOTES, DATED 2/17/2012, CHANGED THE TRANSFER METHOD FROM A HOYER (MECHANICAL) LIFT TO MAXIMUM ASSISTANCE FROM 1 OR 2 STAFF MEMBERS USING "A MODIFIED PIVOT TRANSFER." DURING AN INTERVIEW ON 3/14/2012 AT 2:30 P.M. PT (PHYSICAL THERAPIST) #1 SAID SHE WAS ASKED DURING A MORNING MEETING (ON OR AROUND 2/17/2012, THE EXACT DATE IS UNKNOWN) TO RE-EVALUATE RESIDENT #105'S TRANSFER REQUIREMENTS. PT #1 SAID STAFF WAS USING THE HOYER LIFT FOR TRANSFERS, BECAUSE THE RESIDENT'S SKIN CONDITION WARRANTED NO FRICTION OR SHEARING, BUT THAT ISSUE HAD BEEN SIGNIFICANTLY RESOLVED. DESPITE THE ORDERED SUPPLEMENTS FOR BONE DEMINERALIZATION, THE [DIAGNOSES REDACTED].#1 SAID SHE TRANSFERRED RESIDENT #105 ON 2/17/2012 FROM HIS WHEELCHAIR. PT #1 SAID SHE PLACED HIS FEET ON THE FLOOR (WITH APPROPRIATE TRACTION SOLED SHOES) AND TWISTED HIS BODY FROM THE WHEELCHAIR BESIDE THE BED, APPROXIMATELY 90 DEGREES AND PLACED HIM IN THE BED. PT #1 SAID RESIDENT #101 REQUIRED HER (PT #1) TO PERFORM 75% OF THE TASK AND COULD NOT MOVE HIS OWN FEET. PT #1 SAID RESIDENT #101 WAS SIMPLY REQUIRED TO PLACE 155 POUNDS OF WEIGHT ON HIS FEET AND LEGS WHILE SHE TWISTED HIM TO THE BED. PT #1 SAID THE TRANSFER SHE DID WAS SUCCESSFUL IN PREVENTING FRICTION AND SHEARING AND SINCE RESIDENT #101 ONLY REQUIRED THE HOYER LIFT TO PREVENT SKIN SHEARING, SHE (PT 31) DISCONTINUED THE USE OF THE MECHANICAL LIFT. PT #1 THEN DOCUMENTED IN THE MEDICAL RECORD THAT RESIDENT #105 COULD USE A MODIFIED PIVOT TRANSFER WITH THE ASSISTANCE OF 1 TO 2 PEOPLE, TWISTING HIM FROM THE WHEELCHAIR TO HIS BED. physician progress notes [REDACTED]. RESIDENT #105 REPORTED HE HAD SUDDEN AND SEVERE PAIN DURING THE TRANSFER, FEELING HIS LEG MAY HAVE HIT HIS BED IN THE COURSE OF THE TRANSFER. THE PHYSICIAN REPORTED THE LEFT KNEE WAS PAINFUL, SWOLLEN AND REQUIRED AN X-RAY TO RULE OUT FRACTURE. THE X-RAY, DATED 3/2/2012, SHOWED AN "UNDISPLACED FRACTURE" OF THE LEFT FEMUR (LEG) WITH OSSEOUS DEGENERATION AND DEMINERALIZATION OF THE BONE. DURING AN INTERVIEW ON 3/14/2012 AT 3:00 P.M., THE DIRECTOR OF PHYSICAL THERAPY AND THE DIRECTOR OF NURSING SAID THEY HAD CNA #4 DEMONSTRATE A MODIFIED STAND PIVOT TRANSFER ON 3/02/2012 AND SHE PERFORMED IT CORRECTLY. HOWEVER, NEITHER EXPLAINED HOW REMOVING THE HOYER LIFT AND USING A MODIFIED STAND PIVOT TRANSFER TECHNIQUE, THAT CAUSED TWISTING OF RESIDENT #105'S LOWER EXTREMITIES WHILE HIS FEET STAYED STATIONARY WITH TRACTION SOLED SHOES, WAS IN THE BEST INTEREST OF RESIDENT #105, WHO HAD BEEN diagnosed with [REDACTED]. BOTH STAFF MEMBERS JUST KEPT SAYING HE COULD BEAR SOME WEIGHT, SO IT WAS OKAY. OBSERVATIONS COULD NOT BE MADE OF RESIDENT #105 AS HE REMAINED AT A LOCAL AREA HOSPITAL FOLLOWING SURGICAL REPAIR OF THE LEFT LEG FRACTURE. CNA #4 COULD NOT BE CONTACTED FOR AN INTERVIEW ON 3/13/2012 OR 3/14/2012.

THIS CITATION PERTAINS TO INTAKE #MI 554BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO HONOR THE RIGHT OF 1 (#104) OF 4 SAMPLED RESIDENTS (#104) REVIEWED FOR MEDICAL DECISION-MAKING, FROM A TOTAL SAMPLE OF 6, TO MAKE DECISIONS ABOUT MEDICAL CARE AND TO REFUSE TREATMENT WHEN RESIDENT #104 UNDERWENT PODIATRIC TREATMENT WITHOUT INFORMED CONSENT, RESULTING IN THE POTENTIAL FOR CONTINUED VIOLATION OF RESIDENT RIGHTS. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET DATED 3/05/2012, RESIDENT #104 WAS AN [AGE] year OLD FEMALE WHO WAS admitted INto the facility on [DATE]. HER [DIAGNOSES REDACTED]. RESIDENT #104'S DAUGHTER WAS DOCUMENTED AS THE ONLY EMERGENCY CONTACT ON THIS FORM.A MINIMUM DATA (MDS) ASSESSMENT SET WAS NOT AVAILABLE FOR RESIDENT #104 DUE TO HER LIMITED LENGTH OF STAY AT THE FACILITY. SIGNATURES OBTAINED ON THE FACILITY ADMISSION FORMS AND CONSENTS TO TREAT, IDENTIFIED RESIDENT #104'S DAUGHTER AS THE INTERESTED FAMILY MEMBER WHO MADE HER MOTHER'S HEALTH CARE DECISIONS. THE PHYSICIAN'S ADMISSION HISTORY AND PHYSICAL DATED 2/27/2012 DOCUMENTED THAT RESIDENT #104 had a history of [REDACTED]." THE PHYSICIAN DOCUMENTED RESIDENT #104 WAS ONLY ORIENTED TO PERSON, NOT TIME AND NOT PLACE. THE PHYSICIAN DOCUMENTED RESIDENT #104 WAS NOT AWARE OF HER DIAGNOSES, DUE TO HER DEMENTIA. HER PHYSICIAN DOCUMENTED RESIDENT #104 WAS NOT MENTALLY COMPETENT. NURSING NOTES DATED 2/25/2012, 2/26/2012, 2/27/2012, 2/28/2012, 2/29/2012, 2/30/2012, 3/01/2012, 3/02/2012 AND 3/03/2012 DOCUMENTED RESIDENT #104 WAS CONFUSED. DURING AN INTERVIEW ON 3/08/2012 AE (ADMISSION EMPLOYEE) #1 SAID SHE COMPLETED RESIDENT #104'S ADMISSION PROCESS ON 2/24/2012, WITH THE PRIMARY CARE PROVIDER ASSIGNED THE LAST SIX YEARS, HER DAUGHTER. AE #1 SAID RESIDENT #104'S DAUGHTER COMPLETED THE NECESSARY LEGAL DOCUMENTS REQUIRED BY THE FACILITY TO ESTABLISH ADMISSION AND CARE CHOICES. AE#1 SAID RESIDENT #104'S DAUGHTER DOCUMENTED THAT THE FACILITY DID NOT HAVE PERMISSION TO PROVIDE PODIATRY SERVICES TO RESIDENT #104. RESIDENT #104'S PERMISSION FOR SERVICES RECORD DATED 2/24/2012 WAS REVIEWED AND RESIDENT #104'S DAUGHTER HAD SPECIFICALLY LISTED PODIATRY SERVICES AS "NOT AUTHORIZED." DESPITE THIS DOCUMENTATION, "PODIATRY CARE AS NEEDED" WAS DOCUMENTED ON THE ADMISSION ORDER FORM, WHICH WAS LATER SIGNED BY HER PHYSICIAN. DURING AN INTERVIEW ON 3/08/2012 UM (UNIT MANAGER) #1 SAID RESIDENT #104 WAS SEEN BY HER PRIMARY PHYSICIAN ON 03/01/2012 AND HE ORDERED A PODIATRY CONSULT. UM #1 SAID THE PHYSICIAN WOULD NOT HAVE SEEN THE FAMILY'S DOCUMENTED REQUEST TO DENY PODIATRY SERVICES BECAUSE THIS FORM IS NEVER PLACED IN THE MEDICAL RECORD FOR REVIEW. ON 03/01/2012, RESIDENT #14'S PHYSICIAN IDENTIFIED AN INFECTIOUS PROCESS OF THE LEFT GREAT TOENAIL AND ORDERED A PODIATRY CONSULT. DURING THE SAME INTERVIEW ON 03/08/2012, UM #1 SAID SHE CONTACTED THE PODIATRIST OFFICE DIRECTLY. UM #1 SAID THAT SHE DID NOT OBTAIN VERBAL OR WRITTEN CONSENT FROM RESIDENT #104'S DAUGHTER FOR THIS CONSULT. DURING AN INTERVIEW ON 3/08/2012 THE DIRECTOR OF NURSING SAID HE REVIEWED RESIDENT #104'S MEDICAL RECORD AND FOUND NO EVIDENCE RESIDENT#104'S DAUGHTER HAD EVER BEEN INFORMED OR CONSENTED TO THE PODIATRY CONSULT AS ORDERED. THE PODIATRIST'S HISTORY AND PHYSICAL DATED 3/03/2012 DOCUMENTED HE EXAMINED RESIDENT #104 AND DETERMINED THAT SHE HAD AN INGROWN LEFT GREAT TOENAIL. THE PODIATRIST FAILED TO DOCUMENT THE RESIDENT'S LEVEL OF ORIENTATION AND WROTE, "VERBAL CONSENT GIVEN TO UNIT MANAGER (UM #1) BY FAMILY FOR TREATMENT." DURING AN INTERVIEW DATED 3/08/2012 UM (UNIT MANAGER) #1 SAID RESIDENT #104 WAS NOT MENTALLY COMPETENT TO MAKE HER OWN MEDICAL DECISIONS. UM #1 SAID RESIDENT #104'S DAUGHTER TOOK A VERY ACTIVE ROLE IN HER HEALTH DECISIONS. UM #1 SAID THOUGH SHE INFORMED RESIDENT #104'S DAUGHTER THAT A PODIATRIST HAD BEEN CONSULTED BY THE PRIMARY PHYSICIAN, SHE "NEVER" OBTAINED VERBAL OR WRITTEN CONSENT FOR THESE SERVICES. THE PODIATRIST'S HISTORY AND PHYSICAL DATED 3/03/2012 DOCUMENTED THAT "INFORMED VERBAL CONSENT (GIVEN) BY PATIENT PRIOR TO PROCEDURE." DURING THE SAME INTERVIEW ON 03/08/2012 THE DIRECTOR OF NURSING SAID RESIDENT #104 WAS NOT CAPABLE OF MAKING INFORMED MEDICAL DECISIONS. THE DIRECTOR OF NURSING SAID THE PODIATRIST SAW RESIDENT #104 ON 03/03/2012. THE DIRECTOR OF NURSING SAID STAFF FAILED TO CONTACT AND PROVIDE RESIDENT #104'S DAUGHTER WITH THE NECESSARY INFORMATION REQUIRED TO MAKE INTELLIGENT, INFORMED MEDICAL DECISIONS FOR RESIDENT #104 REGARDING HER LEFT GREAT TOENAIL BEFORE IT WAS REMOVED BY THE PODIATRIST.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION, AND CONSISTENTLY IMPLEMENT APPROPRIATE SAFETY DEVICES AND INTERVENTIONS FOR EIGHT (#'S 603, 604, 606, 609, 611, 614, 619 AND 622) OF 11 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 26, RESULTING IN FALLS, INJURIES, AND THE POTENTIAL FOR FURTHER ACCIDENTS. FINDINGS INCLUDE: ON [DATE] AT 1:15 PM, INCIDENT/ACCIDENT (I/A) REPORTS FOR RESIDENT #622 WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON) AND THE RESIDENT'S CLINICAL RECORD WAS REVIEWED. PER THE ADMISSION FACE SHEET, THE RESIDENT WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. PER MINIMUM DATA SET ((MDS) dated [DATE] AND [DATE], THE RESIDENT REQUIRED EXTENSIVE TWO-PERSON ASSISTANCE FOR TRANSFERS AND WAS NON-AMBULATORY. NURSES NOTES FROM ,[DATE] THRU ,[DATE] REVEALED THAT THE RESIDENT WAS FREQUENTLY CONFUSED, AGITATED, AND COMBATIVE WITH STAFF. THE FALL RISK ASSESSMENTS FOR RESIDENT #622 DATED [DATE] AND [DATE] NOTED THAT THE RESIDENT WAS AT HIGH RISK FOR FALLS. PER physician's orders [REDACTED]. THE PHYSICIAN ORDER [REDACTED]. A "FALL" CARE PLAN DATED [DATE], DID NOT INCLUDE THE ALARMS AS SAFETY INTERVENTIONS. RESIDENT #622 HAD THREE FALLS RESULTING IN INJURIES. THE DETAILS WERE AS FOLLOWS: 1. ON [DATE] AT 12 AM, RESIDENT #622 WAS "OBSERVED SITTING ON THE FLOOR MAT. THE ALARM DID NOT WORK THUS IT DID NOT SOUND BUT THE I/A REPORT ALSO NOTED EVIDENCE ALARM IS WORKING PROPERLY...." A NEW ALARM WAS THEN PROVIDED. WHEN QUERIED, THE DON WAS UNABLE TO STATE WHY THE ALARM DID NOT SOUND AND WHETHER OR NOT THE ALARM CONTROL BOX WAS TURNED TO THE OFF POSITION WHEN THE FALL OCCURRED. THERE WAS NO NOTED INJURY. THE FALL RISK ASSESSMENTS DATED [DATE] AND [DATE] NOTED THAT RESIDENT #622 WAS AT HIGH RISK FOR FALLS. 2. ON [DATE] AT 8:45 AM, RESIDENT #622 WAS OBSERVED ON THE FLOOR IN FRONT OF THE WHEELCHAIR. ACCORDING TO WITNESS STATEMENTS, AT 7:45 AM THE RESIDENT WAS IN THE HALLWAY IN THE WHEELCHAIR. A STAFF MEMBER PUSHED THE RESIDENT TO HIS ROOM AND INFORMED HIS ASSIGNED NURSE AIDE OF HIS WHEREABOUTS. AT 8:45 AM, HIS ASSIGNED AIDE HEARD THE RESIDENT YELLING AND OBSERVED THE RESIDENT ON THE FLOOR. THERE WAS NO DOCUMENTATION THAT THE AIDE CHECKED ON THE RESIDENT AFTER HE WAS TAKEN TO HIS ROOM. THE ALARM WAS IN PLACE BUT DID NOT SOUND. CORRECTIVE MEASURES INCLUDED: "REPLACE SENSOR PAD (ALARM) ON WHEELCHAIR," AND "CHECK ALARM EVERY SHIFT." THE DON WAS UNABLE TO STATE WHY THE ALARM'S FUNCTION WAS NOT CHECKED BEFORE THE FALL. PER NURSES NOTES ON [DATE] FOLLOWING RESIDENT #622'S FALL, THE RESIDENT HAD BRUISING TO THE RIGHT HIP, PAIN ON MOVEMENT, GUARDING OF THE RIGHT LEG, WAS UNABLE TO PLACE HIS RIGHT FOOT ON THE FLOOR, AND BEGAN YELLING "IT'S BROKEN." THE RESIDENT WAS TRANSPORTED TO THE HOSPITAL WHERE HOSPITAL X-RAYS REVEALED A RIGHT FEMORAL NECK FRACTURE. ON [DATE], THE RESIDENT HAD SURGICAL REPAIR OF THE FRACTURE. HE WAS TRANSPORTED BACK to the facility on [DATE]. ON [DATE], THE INITIAL CARE PLAN FOR RESIDENT #622 NOTED BED AND CHAIR ALARMS AS FALL INTERVENTIONS. ON [DATE], THE PHYSICIAN ADDED THE [DIAGNOSES REDACTED]. 3. ON [DATE] AT 2:15 PM, RESIDENT #622 fell FROM THE TOILET WHILE BEING ASSISTED BY A NURSE AIDE. THE AIDE WROTE IN A STATEMENT: "WHILE TOILETING RESIDENT (#622), THE RESIDENT KEPT LEANING FORWARD ON COMMODE. I DID INFORM RESIDENT THAT LEANING WAS DANGEROUS. I PROCEEDED WITH CLOTHING RESIDENT. I TURNED TOWARD THE SINK TO GRAB PANTS AND WHEN TURNING BACK, THE RESIDENT WAS FALLING OFF THE COMMODE." THE CORRECTIVE MEASURES INCLUDED: "CAREGIVERS SHOULD USE TWO PERSONS TO TRANSFER AND TOILET RESIDENT" AND THE AIDE THAT WAS ASSISTING THE RESIDENT WAS GIVEN ONE-TO-ONE INSERVICE TRAINING. PER NURSES NOTES, RESIDENT #622 SUSTAINED A HEMATOMA WITH BLEEDING TO THE FRONT OF THE SKULL AND A LACERATION MEASURING 0.5 X 1.5 CM (CENTIMETERS). THE RESIDENT ALSO HAD A RIGHT ELBOW SKIN TEAR MEASURING 1.2 X 1.5 CM AND COMPLAINED OF RIGHT HIP PAIN. A STAT (IMMEDIATE) HIP X-RAY WAS PERFORMED WHICH WAS NEGATIVE FOR FRACTURE. WHEN QUERIED, THE DON STATED THAT THE AIDE SHOULD HAVE ASKED FOR HELP AND SHOULD HAVE HAD ALL SUPPLIES WITHIN REACH PRIOR TO ASSISTING THE RESIDENT. RESIDENT #609 WAS OBSERVED ON [DATE] AT 8:55 AM. THE RESIDENT WAS SMALL, FRAIL, AND HAD SEVERE KYPHOSIS (CURVATURE) OF THE SPINE. SHE COULD NOT LIFT HER HEAD UP ABOVE SHOULDER LEVEL DUE TO THE CURVATURE. THERE WAS A DARK PURPLE BRUISE COVERING THE ENTIRE RIGHT SHOULDER THAT EXTENDED TO THE SIDE OF THE RIGHT BREAST AND UNDER THE ARM. HER RIGHT 5 TH FINGER WAS PURPLE AND HER 3RD AND 4 TH FINGERS WERE BRUISED FROM TOP TO BOTTOM. SHE COMPLAINED OF PAIN TO THE SHOULDER AND FINGERS. ON [DATE] AT 1:30 PM, INCIDENT/ACCIDENT (I/A) REPORTS FOR RESIDENT #609 WERE REVIEWED WITH THE DON AND THE RESIDENT'S CLINICAL RECORD WAS REVIEWED. PER THE ADMISSION FACE SHEET, THE RESIDENT WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. MDS' DATED [DATE] AND [DATE] NOTED THAT THE RESIDENT WAS NON-AMBULATORY AND REQUIRED MODERATE TO EXTENSIVE ASSISTANCE FOR TRANSFERS. FALL RISK ASSESSMENTS DATED [DATE], [DATE], [DATE], [DATE], [DATE], AND [DATE] NOTED THAT RESIDENT #609 WAS AT HIGH RISK FOR FALLS. PHYSICIAN ORDER [REDACTED]. THE ORDER SHEET FOR ,[DATE] NOTED THAT THE ALARMS WERE TO BE CHECKED EVERY SHIFT FOR PROPER FUNCTION AND POSITION. A "FALL" CARE PLAN DATED [DATE] THRU [DATE], TWO "OSTEOPOROSIS" CARE PLANS DATED [DATE] AND [DATE], AND AN "INJURY" CARE PLAN DATED [DATE] DID NOT INCLUDE THE ALARMS AS SAFETY INTERVENTIONS. DETAILS OF 10 DOCUMENTED I/A REPORTS FOR RESIDENT #609 WERE AS FOLLOWS: 1. ON [DATE] AT 1:20 PM, THE RESIDENT WAS ON THE FLOOR IN THE BATHROOM. THE I/A REPORT NOTED THAT THE ALARM WAS NOT IN PLACE AND DID NOT SOUND. THE RESIDENT COMPLAINED OF PAIN TO THE RIGHT HIP. AN X-RAY WAS DONE WHICH WAS NEGATIVE FOR FRACTURE. THE CORRECTIVE MEASURE: PHYSICAL THERAPY WAS TO EVALUATE FOR AN "ALTERNATE ALARM TO ALERT STAFF WHEN RESIDENT IS TRANSFERRING INDEPENDENTLY...." THE DON STATED THAT THE RESIDENT HAD REMOVED THE ALARM. 2. ON [DATE] AT 11:20 PM, RESIDENT #609 WAS ON THE FLOOR IN THE BATHROOM. THE I/A REPORT NOTED THAT THE ALARM WAS IN PLACE AND SOUNDED BUT THE CORRECTIVE MEASURES INCLUDED: "CONTINUE TO MONITOR USE OF ALARM IN WHEELCHAIR" AND "ENCOURAGE RESIDENT NOT TO REMOVE PRESSURE (PAD) ALARM." THERE WERE NO NOTED INJURIES. 3. ON [DATE] AT 10 PM, RESIDENT #609 WAS ON THE FLOOR IN THE BATHROOM. THE ALARM WAS NOT NOTED TO BE IN PLACE AND DID NOT SOUND. THE DON WAS UNABLE TO VERIFY WHY. THE CORRECTIVE MEASURES INCLUDED: PHYSICAL THERAPY WAS TO RE-EVALUATE THE TYPE OF ALARM. PER NURSES NOTES DATED [DATE], THE resident sustained [REDACTED]. 4. ON [DATE] AT 12:45 PM, RESIDENT #609 WAS ON THE FLOOR IN THE BATHROOM. THE ALARM WAS NOTED TO SOUND. PER NURSES NOTES DATED [DATE], THE resident sustained [REDACTED]." X-RAYS WERE DONE WHICH WERE NEGATIVE FOR FRACTURE. CORRECTIVE MEASURES INCLUDED REINFORCING WITH THE RESIDENT THE NEED TO ASK FOR ASSISTANCE DURING TRANSFERS. 5. ON [DATE] AT 1:45 PM, RESIDENT #609 WAS ON THE FLOOR IN HER ROOM. THE ALARM WAS NOTED TO SOUND. THE I/A REPORT NOTED THAT THE RESIDENT "SLID FROM WHEELCHAIR" AND SUSTAINED A "RIGHT SKULL HEMATOMA" AND COMPLAINED OF PAIN TO THE RIGHT HAND. THE CORRECTIVE MEASURES INCLUDED AN EVALUATION BY PHYSICAL THERAPY FOR USE OF THE ALARMS AND A SKID GUARD FOR THE WHEELCHAIR SEAT. THE SKID GUARD WAS NOTED TO BE INEFFECTIVE. 6. ON [DATE] AT 3 PM, RESIDENT #609 WAS ON THE FLOOR IN HER ROOM. THE ALARM WAS NOTED TO BE IN PLACE BUT DID NOT SOUND. CORRECTIVE MEASURES INCLUDED: INSTRUCTED THE RESIDENT NOT TO TURN OFF THE ALARMS. THE DON WAS UNABLE TO VERIFY THAT THE RESIDENT HAD TAMPERED WITH THE ALARM AND COULD NOT EXPLAIN WHY THE ALARM CONTROL BOX WAS NOT POSITIONED OUT OF THE RESIDENT'S REACH, IF TAMPERED WITH. THERE WAS NO NOTED INJURY. 7. ON [DATE] AT 10:35 PM, RESIDENT #609 WAS ON THE FLOOR IN THE BATHROOM AND WAS NOTED TO HAVE HIT THE BACK OF HER HEAD. A STAT SKULL X-RAY WAS DONE WHICH WAS NEGATIVE FOR FRACTURE. CORRECTIVE MEASURES: MONITOR THE RESIDENT FREQUENTLY AND OFFER FREQUENT TOILETING. 8. ON [DATE] AT 5:30 AM, RESIDENT #609 WAS ON THE FLOOR IN THE BATHROOM. THE ALARM WAS NOTED TO HAVE SOUNDED. THERE WAS NO NOTED INJURY. THE CORRECTIVE MEASURE: CONTINUE WITH CURRENT OF CARE. AN X-RAY DATED [DATE] NOTED: FRACTURE OF THE 7 TH RIB AND POSSIBLY 6 TH RIB SINCE A PRIOR X-RAY ON [DATE]. ADDITIONALLY, THERE WERE OLD BILATERAL RIB FRACTURES THAT WERE PRESENT BUT STABLE. THERE WAS NO MENTION OF A FALL AND NO DOCUMENTED I/A REPORT. PER A PHYSICIAN'S PROGRESS NOTE DATED [DATE], THE RESIDENT HAD A FALL ON [DATE], AFTER THE RIB FRACTURE WAS DETERMINED ON THE [DATE] X-RAY. THERE WAS NO DOCUMENTED I/A REPORT AND NO FURTHER MENTION OF THE FALL. ACCORDING TO AN EMERGENCY RESPONSE TEAM'S RUN SHEET DATED [DATE] AT 2:04 AM, RESIDENT #609 WAS TRANSPORTED TO THE HOSPITAL DUE TO "RIB PAIN." PER NURSES NOTES, THE RESIDENT RETURNED TO THE FACILITY THE SAME MORNING. 9. ON [DATE] AT 1:15 PM, FOLLOWING HER RETURN FROM THE HOSPITAL, THE RESIDENT HAD ANOTHER FALL IN THE BATHROOM. THE RESIDENT STATED THAT SHE HAD BUMPED HER HEAD. THE I/A REPORT NOTED THAT THE RESIDENT COMPLAINED OF PAIN TO THE RIGHT SIDE OF THE HEAD AND THE RIGHT TRUNK AREA OF THE BODY. THE ALARM WAS NOTED TO HAVE SOUNDED. THE CORRECTIVE MEASURES INCLUDED: RESIDENT ENCOURAGED TO PUT ON CALL LIGHT AND WAIT FOR ASSISTANCE. WHEN QUERIED, THE DON WAS UNABLE TO RESPOND REGARDING THE FRACTURED RIBS FOUND ON [DATE], THE FALL MENTIONED IN THE physician progress notes [REDACTED]. 10. ON [DATE] AT 10:20 PM, RESIDENT #609 WAS ON THE FLOOR IN HER ROOM LYING ON HER RIGHT SIDE WITH HER HAND UNDERNEATH HER. SHE HAD FALLEN ASLEEP IN THE WHEELCHAIR, LEANED FORWARD, AND fell OUT OF THE WHEELCHAIR. THE I/A REPORT AND NURSES NOTES DID NOT INDICATE THAT THE ALARM WAS IN PLACE OR THAT IT SOUNDED. THE CORRECTIVE MEASURES INCLUDED: CLOSE MONITORING AND BED/CHAIR ALARMS. THE I/A REPORT FURTHER NOTED THAT THE RESIDENT WAS NON-COMPLIANT AND REMOVED THE ALARM, HOWEVER, PER A WITNESS STATEMENT BY THE RESIDENT'S NURSE DURING THE INCIDENT, "ALARM WAS SOUNDING." THE DON WAS UNABLE TO EXPLAIN THE DISCREPANCY. AN X-RAY OF THE RIGHT HAND WAS ORDERED ON [DATE]. THERE WAS NO DOCUMENTATION REGARDING THE APPEARANCE OF THE HAND. THE X-RAY WAS NOT ORDERED TO BE DONE STAT. ON [DATE] AT 1 PM, NURSES NOTED THAT RESIDENT #609 COMPLAINED OF SHOULDER PAIN. DURING THE ,[DATE] PM SHIFT (TIME NOT NOTED), A BRUISE WAS OBSERVED TO THE RIGHT SHOULDER AND THE RESIDENT COMPLAINED OF PAIN. PER CONTROLLED SUBSTANCE RECORDS, THE RESIDENT RECEIVED ONE DOSE OF HYDROCODONE (FOR PAIN) ON [DATE] BUT RECEIVED THREE DOSES OF HYDROCODONE ON [DATE]. THERE WAS NO SHOULDER X-RAY ORDERED. A HAND X-RAY WAS NOT DONE. ON [DATE] AT 8 AM, NURSES NOTED THAT BRUISING WAS PRESENT TO THE RIGHT SHOULDER. A STAT SHOULDER X-RAY WAS ORDERED. ON [DATE] BETWEEN 12 NOON AND 1 PM, X-RAYS WERE TAKEN OF BOTH THE RIGHT SHOULDER AND THE RIGHT HAND WHICH REVEALED: "ANTERIOR DISLOCATION OF THE HUMERAL HEAD (RIGHT SHOULDER)" AND "SLIGHTLY DISPLACED FRACTURE AT TH BASE OF THE PROXIMAL PHALANX OF THE FIFTH FINGER." THE RESIDENT WAS TRANSPORTED TO THE HOSPITAL ON [DATE] AND RETURNED BACK TO THE FACILITY THE SAME DAY. A REPEAT SHOULDER X-RAY AT THE HOSPITAL REVEALED NO EVIDENCE OF FRACTURE OR DISLOCATION TO THE RIGHT SHOULDER AND diagnosed THE RESIDENT AS HAVING A SHOULDER CONTUSION. THERE WAS NO DOCUMENTED DESCRIPTION OF THE FINGERS. WHEN QUERIED, THE DON WAS UNABLE TO EXPLAIN WHY RESIDENT #609 WAS NOT ADEQUATELY SUPERVISED TO PREVENT NUMEROUS FALLS OCCURRING MAINLY IN THE BATHROOM. DURING THE SURVEY, ON [DATE] AT 2:55 PM, RESIDENT #609 WAS OBSERVED ASLEEP IN BED. THE SAFETY ALARM WAS NOT ATTACHED TO THE ALARM CONTROL BOX. THE LOOSE CORD WAS DANGLING OVER AND BEHIND THE HEADBOARD. NURSE 'J' AND NURSE MANAGER 'C' ENTERED THE ROOM AND SAW THE DETACHED ALARM. THEY WERE UNABLE TO EXPLAIN WHY THE ALARM WAS DISCONNECTED. WHEN QUERIED, THE DON WAS UNABLE TO RESPOND WHY THE ALARM WAS DISCONNECTED. THERE WAS NO INDICATION THAT THE RESIDENT'S FALL CARE PLAN INTERVENTIONS WERE EVER REVISED WITH NEW SAFETY INTERVENTIONS. THE DON DEFERRED TO PHYSICAL THERAPIST (P.T.) 'L' REGARDING OTHER DEVICES AND INTERVENTIONS, BESIDES ALARMS, TO KEEP THE RESIDENT SAFE. ON [DATE] AT 2 PM, P.T. 'L' WAS QUERIED ABOUT SAFETY INTERVENTIONS/DEVICES FOR RESIDENT #609 AND THE RESIDENT'S THERAPY RECORDS WERE REVIEWED. THERE WAS NO DOCUMENTATION THAT THE RESIDENT WAS SEEN BY THE THERAPY DEPARTMENT FOR REVISION OF SAFETY MEASURES. P.T. 'L' STATED THAT DEVICES, SUCH AS AN ALARMING SELF-RELEASE SEATBELT TO HELP REMIND THE RESIDENT TO WAIT FOR ASSISTANCE, WAS NOT ATTEMPTED. DEVICES, SUCH AS A SPECIALTY CHAIR OR POSITIONING WEDGE CUSHION TO PREVENT UNASSISTED TRANSFERS OR FALLS, WAS NOT ATTEMPTED. A HALF TRAY WAS NEVER ATTEMPTED FOR THE WHEELCHAIR FOR ARM SUPPORT TO PREVENT THE RESIDENT FROM FALLING FORWARD. P.T. 'L' WAS UNABLE TO EXPLAIN WHY. SHE SAID, "I GUESS WE COULD TRY A TILT-BACK CHAIR" (TO MAKE IT DIFFICULT FOR THE RESIDENT TO RISE BY HERSELF). SHE SAID, "I WILL TRY A TRAY ON THE WHEELCHAIR." ON [DATE] AT 10 AM, THE CLINICAL RECORD FOR RESIDENT #606 WAS REVIEWED. THE RESIDENT WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. PER THE MDS' DATED [DATE] AND [DATE], THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT AND WAS TOTALLY DEPENDENT ON STAFF FOR ALL MOBILITY. A "FALL" CARE PLAN DATED [DATE] FOR RESIDENT #606 NOTED THAT THE RESIDENT WAS AT HIGH RISK DUE TO WEAKNESS AND LACK OF SAFETY AWARENESS. ACCORDING TO AN I/A REPORT DATED [DATE], THE RESIDENT WAS FOUND ON THE FLOOR IN HER ROOM ON TOP OF THE SAFETY MAT. THE I/A REPORT NOTED THAT SHE HAD A SAFETY ALARM IN PLACE BUT IT DID NOT SOUND. THERE WAS NO DOCUMENTED REASON WHY. THERE WERE NO NOTED INJURIES. ON [DATE] THE PHYSICIAN ORDERED AN ALARMING SEATBELT FOR THE WHEELCHAIR. ON [DATE] AT 3 PM, RESIDENT #606, WHO WAS CONFUSED AND UNABLE TO RESPOND TO QUESTIONS, WAS OBSERVED SITTING IN A WHEELCHAIR ALONE IN HER ROOM. NURSE 'Q' ENTERED THE ROOM AND WAS ASKED IF THE RESIDENT'S SAFETY ALARM WAS FUNCTIONING. WHEN THE NURSE UNFASTENED THE RESIDENT'S ALARMING SEATBELT, THE ALARM DID NOT SOUND AS IT SHOULD HAVE. SHE WAS UNABLE TO EXPLAIN WHY. A CLIP-TYPE ALARM WAS ATTACHED TO THE BACK OF THE RESIDENT'S RIGHT SHOULDER. THE RESIDENT'S ASSIGNED NURSE AIDE ('R') ENTERED THE ROOM. THE NURSE ASKED AIDE 'R' ABOUT THE CLIP ALARM. THE AIDE SAID, "I ATTACHED THAT ALARM TO HER SHOULDER." THE NURSE SAID, "SHE (THE RESIDENT) TOOK IT OFF EARLIER SO I HAD TO MOVE IT TO THE BACK SO SHE COULDN'T REACH IT." ANOTHER AIDE ENTERED THE ROOM AND THE THREE EMPLOYEES LOOKED AT THE SEATBELT ALARM. THE THIRD EMPLOYEE STATED THAT THE CLIP ALARM WAS ATTACHED BECAUSE THE SEATBELT ALARM DID NOT WORK. SHE STATED THAT THE ALARM HAD THE WRONG TYPE OF CONTROL BOX. THEY COULD NOT STATE WHY. ON [DATE] AT 12 NOON, RESIDENT #606 WAS SITTING IN A SMALL TELEVISION ROOM WITH FIVE OTHER COGNITIVELY IMPAIRED AND IMMOBILE RESIDENTS. THE SEATBELT WAS DETACHED AND THE ENDS WERE AT THE SIDE OF THE RESIDENT'S LAP AREA. P.T. 'L' WAS QUERIED ABOUT THE DISCONNECTED ALARMING SEATBELT. SHE SAID, "SHE PROBABLY REMOVED IT HERSELF." SHE WAS UNABLE TO EXPLAIN WHY THE BELT DID NOT ALARM WHEN IT WAS DETACHED. WHEN P.T. 'L' ATTEMPTED TO RECONNECT THE BELT, THE BUCKLE HAD BEEN TIGHTENED TO PREVENT THE BELT FROM EXTENDING ACROSS THE LAP. SHE LOOSENED THE BUCKLE AND RECONNECTED THE BELT. THE RESIDENT WAS ASKED TO DEMONSTRATE THE ABILITY TO UNFASTEN THE BELT. HOWEVER, SHE WAS TOO CONFUSED AND WEAK TO FOLLOW THE COMMAND, INDICATING THAT SHE COULD NOT HAVE UNFASTENED THE BELT INDEPENDENTLY. P.T. 'L' WAS UNABLE TO EXPLAIN WHY THE ALARM WAS NOT IN USE AS PRESCRIBED. PER THE FACILITY'S UNDATED 'FALL PROTOCOL:" FALL PREVENTION AND INTERVENTIONS INCLUDE, USE OF SITTERS FOR COGNITIVELY IMPAIRED RESIDENTS, P.T. CONSULTS, BED/WHEELCHAIR ALARMS, AND COMFORT/TOILETING ROUNDS EVERY HOUR. PER THE FACILITY'S "INCIDENT AND ACCIDENT" POLICY DATED [DATE]: -THE NURSING CARE PLAN SHOULD BE UPDATED AND CAN BE FURTHER UPDATED BY THE FALL COMMITTEE WHEN THEY MEET AND REVIEW A FALL. CARE PLANS MUST DOCUMENT THAT PREVIOUSLY SELECTED INTERVENTIONS WERE RE-EVALUATED IF FALLING CONTINUED. -WHENEVER A FALL OCCURS, THE REHAB DEPARTMENT MUST BE NOTIFIED FOR POST FALL SUGGESTIONS. -DAILY ROUNDS FOR SAFETY SHOULD BE PERFORMED TO ENSURE ORDERED RECOMMENDED DEVICES ARE IN PLACE AND IN WORKING ORDER. ( ) ON [DATE] AT 10:00 A.M., DURING THE INITIAL TOUR RESIDENT #604 WAS OBSERVED IN BED VOICING CONCERNS OF SOME DISCOMFORT IN HIS LEFT KNEE. THE RESIDENT STATED THAT HE WAS STIFF AFTER A RECENT FALL IN THE BATHROOM THAT RESULTED IN A FRACTURE OF THE LEFT KNEE. REVIEW OF THE CLINICAL RECORD AND AN I/A REPORT REVEALED RESIDENT #604 WAS REadmitted to the facility on [DATE], AFTER HE WAS TRANSFERRED TO A LOCAL HOSPITAL ON [DATE] FOLLOWING A FALL. THE ADMISSION FACE SHEET DOCUMENTED [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) DATED [DATE], DOCUMENTED RESIDENT #604 HAD MODIFIED INDEPENDENCE IN COGNITIVE SKILLS FOR DAILY DECISION MAKING AND REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING, INCLUDING TRANSFERS AND MOBILITY. FALL RISK ASSESSMENTS DATED [DATE], [DATE], AND [DATE] NOTED THAT THE RESIDENT WAS AT HIGH RISK FOR FALLS. REVIEW OF THE CARE PLANS FOR RESIDENT #604 DATED [DATE], [DATE], AND [DATE] NOTED INTERVENTIONS: " KEEP URINAL AND OTHER FREQUENTLY USED ITEMS WITHIN HIS EASY REACH. BE AVAILABLE FREQUENTLY TO LISTEN EXPLAIN CALL BELL/LIGHT. ASSESS RESIDENT'S ABILITY TO USE AND ANSWER PROMPTLY. INSTRUCT RESIDENT TO SEEK ASSISTANCE WITH ANY ATTEMPTS TO TRANSFER OR TO AMBULATE." SUBSEQUENT ENTRIES ON THE CARE PLAN DOCUMENTED REVIEW DATES OF [DATE] AND [DATE] WHICH REPEATEDLY DOCUMENTED "CONTINUE WITH PLAN" ACCORDING TO THE NURSES NOTES, THE RESIDENT WAS FOUND ON THE FLOOR (LOCATION NOT NOTED) ON [DATE] AT 10:20 AM WITH A LEFT FOREHEAD HEMATOMA AND A SKIN TEAR TO THE LEFT 5TH FINGER. HIS TEMPERATURE AT THE TIME OF THE INCIDENT WAS 101 DEGREES. THE HEMATOMA WAS NOTED TO HAVE INCREASED IN SIZE BY THE TIME OF THE TRANSFER AT 11:30 AM. PER A HOSPITAL PHYSICIAN'S CONSULTATION REPORT DATED [DATE]: THE RESIDENT STILL HAD A TEMPERATURE OF 101 DEGREES UPON ARRIVAL AND HE TOLD THE PHYSICIAN THAT HE HAD AN ILLUSION OF SEEING HIS deceased WIFE AT THE TIME OF THE FALL. THE RESIDENT COMPLAINED OF A HEADACHE AND LEFT KNEE PAIN. HE HAD A "CONTUSION" ON THE LEFT TEMPORAL AREA AND A BRUISE AROUND THE LEFT EYE. THE KNEE WAS "VERY TENDER" WITH "WARMTH PRESENT." THE RESIDENT HAD AN "INTRACTABLE, DRY COUGH" AND "INTRACTABLE NAUSEA AND VOMITING." A CHEST X-RAY SHOWED: "RIGHT LOWER INFILTRATE (PNEUMONIA)." THE RESIDENT WAS ALSO diagnosed with [REDACTED]." A HEAD CAT SCAN ON [DATE] NOTED: "A FAIRLY LARGE SUBCUTANEOUS HEMATOMA OF THE LEFT FRONTAL SCALP." A KNEE X-RAY ON [DATE] WAS NEGATIVE FOR FRACTURE. THE RESIDENT WAS RETURNED to the facility on [DATE]. THE REPORT OF A REPEAT KNEE X-RAY ON [DATE] REVEALED: FINDINGS SUGGESTIVE OF NON-DISPLACED FRACTURE OF THE PATELLA, SOFT TISSUE SWELLING, AND JOINT EFFUSION. INCIDENT AND ACCIDENT (I/A) REPORTS FOR RESIDENT #604 WERE REQUESTED ON [DATE] AT 11:00 A.M., 2:50 P.M., AND AT 3:40 P.M. ON [DATE] AT 3:10 P.M. THE FACILITY PRESENTED ONE INCOMPLETE I/A REPORT DATED [DATE], WITH NO DESCRIPTION OF THE INCIDENT, RESIDENT STATEMENT OF THE EVENT, OR AN INVESTIGATION. THE I/A REPORT NOTED THAT THE RESIDENT WAS FOUND ON THE FLOOR IN THE SHOWER ROOM, THAT (UNIDENTIFIED) SAFETY DEVICES WERE IN PLACE, ALARMS DID NOT SOUND, AND THAT THE RESIDENT WAS BEING SUPERVISED AT THE TIME OF THE FALL. THE I/A REPORT NOTED A STATEMENT BY NURSE AIDE 'HH' THAT NOTED: "OBSERVED RESIDENT ON FLOOR IN BATHROOM...." AIDE 'HH' WAS UNAVAILABLE FOR COMMENT. THE CORRECTIVE MEASURE TO PREVENT REPEAT OCCURRENCES: THE RESIDENT WAS INSTRUCTED TO ASK FOR ASSISTANCE. ON [DATE] AT 10:20 A.M., DURING AN INTERVIEW WITH RESIDENT #604 CONCERNING THE FALL, THE RESIDENT GAVE THIS ACCOUNT OF THE INCIDENT: "I NEEDED TO BE ASSISTED TO THE BATHROOM. I PUT ON MY CALL LIGHT AND AFTER WAITING AND WAITING, I GOT IN MY WHEEL CHAIR AND WENT TO THE BATHROOM (HE DID NOT STATE WHERE). WHEN I GOT READY TO STAND UP I fell AND MY FACE HIT THE TOILET. I CALLED AND CALLED UNTIL (AIDE 'HH') HEARD ME AND CAME TO ASSIST ME. I WAITED ABOUT ,[DATE] MINUTES FOR SOME ONE TO COME AND HELP ME." WHEN ASKED WHERE HIS URINAL WAS, THE RESIDENT STATED, "I DIDN'T HAVE ONE. THE AIDE TOOK MY URINAL TO EMPTY IT AND NEVER RETURNED IT." DURING AN INTERVIEW ON [DATE] AT 1 PM, THE DON WAS UNABLE TO CONFIRM WHERE THE RESIDENT WAS LOCATED DURING THE FALL. SHE COULD NOT EXPLAIN WHY THE I/A REPORT WAS INCOMPLETE, WHY THE RESIDENT WAS NOT INTERVIEWED, WHY THE RESIDENT DID NOT HAVE HIS URINAL, AND WHY THE STAFF DID NOT RESPOND TIMELY TO THE RESIDENT'S CALL FOR ASSISTANCE. PER THE FACILITY'S UNDATED "FALL PROTOCOL:" PERSONAL CARE ITEMS (SUCH AS URINALS) SHOULD BE WITHIN ARM LENGTH. ( ) RESIDENT #604'S FALL CARE PLANS HAD NOT BEEN REVISED WITH NEW SAFETY INTERVENTIONS SINCE THE FALL INCIDENT ON [DATE]. PER NURSES NOTES DATED [DATE] AT 10:50 PM, RESIDENT #604 HAD A FALL "OUT OF BED" AND SUSTAINED A HEMATOMA TO THE LEFT SIDE OF THE HEAD. FOLLOWING THE INCIDENT, AT 11:30 PM, THERE WAS an order for [REDACTED]. ON [DATE], THE RESIDENT COMPLAINED OF THE AREA BEING "TENDER TO THE TOUCH." ON [DATE], NURSES NOTED THAT THE RESIDENT WAS "COMPLAINING OF A HEADACHE" AND VICODIN WAS GIVEN. ON [DATE] AN ORDER WAS WRITTEN: "BED IN LOWEST POSITION." PER PROGRESS NOTES, RESIDENT #604 WAS NOT SEEN BY THE PHYSICIAN UNTIL [DATE]. ON [DATE], THE PHYSICIAN ORDERED TRANSPORT TO THE HOSPITAL AND A CAT SCAN STAT OF THE HEAD DUE TO "MENTAL STATUS CHANGES." PER NURSES NOTES DATED [DATE], THE RESIDENT REFUSED TO GO TO THE HOSPITAL. ANOTHER PHYSICIAN WAS NOTIFIED WHO ORDERED TO CANCEL THE CAT SCAN AND STATED THAT HE/SHE WOULD SEE THE RESIDENT THE FOLLOWING DAY. ON [DATE], THE PHYSICIAN SAW THE RESIDENT AND RE-ORDERED THE HOSPITAL TRANSPORT AND CAT SCAN. PER NURSES NOTES, THE RESIDENT WAS TRANSPORTED TO THE HOSPITAL ON [DATE] AND KEPT OVERNIGHT FOR OBSERVATION DUE TO THE HEMATOMA. HE RETURNED ON [DATE]. ON [DATE], THE PHYSICIAN ORDERED: BED IN LOWEST POSITION AND A SAFETY ALARM FOR THE BED. WHEN QUERIED ON [DATE] AT 1 PM, THE DIRECTOR OF NURSING WAS UNABLE TO EXPLAIN WHY THE RESIDENT DID NOT HAVE FLOOR MATS AND WHY THE BED WAS NOT IN ITS' LOWEST POSITION AT THE TIME OF THE FALL AND WHY THE RESIDENT, WITH A HEMATOMA WAS NOT SEEN BY THE PHYSICIAN FROM [DATE] UNTIL [DATE]. ( ) ON [DATE] AT 10:45 A.M., RESIDENT #603 WAS OBSERVED RESTING IN BED WITH A SCABBED OVER SORE ON HER RIGHT ELBOW. RESIDENT #603 WAS REadmitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. ON [DATE] AT 1:05 P.M., A REVIEW OF RESIDENT #603'S READMISSION MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED RESIDENT #603 NEEDED EXTENSIVE ASSISTANCE WITH TRANSFERS AND BED MOBILITY WITH TWO PERSON PHYSICAL ASSISTANCE. ADDITIONALLY, RESIDENT #603 NEEDED EXTENSIVE ASSISTANCE WITH DRESSING, HYGIENE, BATHING AND TOILET USE WITH ONE PERSON PHYSICAL ASSISTANCE. ON [DATE] AT 3:30 P.M., A RECORD REVIEW OF RESIDENT #603'S ACCIDENT/INCIDENT REPORT DATED [DATE] AT 11:15 P.M., DOCUMENTED THE FOLLOWING: "RESIDENT #603 WAS OBSERVED "SITTING ON THE FLOOR, AT THE SIDE OF HER BED, HOLDING ONTO BED RAIL. OBSERVED TO HAVE A SKIN TEAR ON HER RIGHT ELBOW. ALARM NOT SOUNDING, BUT WAS IN PLACE." RECOMMENDATIONS: "INSTRUCT CARE GIVER ON PROPER TRANSFER AND SAFETY WHILE CARING FOR RESIDENT." CERTIFIED NURSE ASSISTANT (CNA) WITNESS STATEMENT: "UPON DOING PT. CARE, PT. ROLLED OVER, AND ROLLED OUT OF BED... PT. WAS CLEANED, CENTERED IN MIDDLE OF BED, BED WAS IN LOWEST POSITION. AS WRITER (CNA) STEPPED OUTSIDE THE DOOR TO GET COVER OFF CART, WRITER (CNA) HEARD PT. YELLING FOR HELP. WRITER (CNA) CALLED FOR HELP..." ON [DATE] AT 3:30 P.M., A REVIEW OF RESIDENT #603'S FALL CARE PLAN DATED [DATE], DOCUMENTED... "POTENTIAL FOR FALLING..., BOUTS OF CONFUSION...DX OF MUSCLE WEAKNESS...NONAMBULATORY WHICH ALSO PLACES HER AT RISK." FURTHER REVIEW OF THE FALL CARE PLAN REVEALED, "MONITOR POSITIONING IN BED AND IN CHAIR..." A REVIEW OF RESIDENT #603'S ACTIVITIES OF DAILY LIVING (ADL) CARE PLAN REVEALED "...UTILIZE A 2-PERSON ASSIST WITH TRANSFERS AND MECHANICAL-LIFTS, IF NEEDED." ON [DATE] AT 9:30 A.M., DURING THE INITIAL TOUR, RESIDENT #611 WAS OBSERVED ASLEEP IN BED WITH A LACERATION ACROSS THE BRIDGE OF HER NOSE AND BRUISES UNDERNEATH HER EYES. ON [DATE] AT 1:15 P.M., A REVIEW OF AN ACCIDENT/INCIDENT REPORT DOCUMENTED RESIDENT #611 WAS LAST REadmitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. ON [DATE] AT 1:30 P.M., REVIEW OF RESIDENT #611'S ANNUAL MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED RESIDENT #611 FOR "WANDERING BEHAVIOR THAT OCCURRED DAILY." A REVIEW OF RESIDENT #611'S FACILITY ACCIDENT/INCIDENT REPORTS FOR THE LAST SIX MONTHS REVEALED THE FOLLOWING: 1. ON [DATE] AT 7:45 A.M., RESIDENT #611 "WALKED INTO ANOTHER RESIDENT'S ROOM AND TRIPPED OVER MATS ON THE FLOOR." INJURY: HEAD/LACERATION ACROSS BRIDGE OF NOSE WITH BLEEDING. SAFETY DEVICES: MAT ON FLOOR. ALARMS SOUNDING: NO. RECOMMENDATIONS: CONTINUE TO MONITOR RESIDENT CLOSELY AND REDIRECT WHENEVER NEEDED TO MAINTAIN SAFETY. 2. ON [DATE] AT 2:30 A.M., RESIDENT #611 WAS "OBSERVED LYING ON THE FLOOR POSITIONED ON HER LEFT SIDE OF BODY. INJURY: NONE NOTED. SAFETY DEVICES: LOW BED. ALARMS SOUNDING: N/A. RECOMMENDATIONS: STAFF CONTINUE TO MAKE ROUNDS. CONTINUE TO MAKE SURE THAT BED IS IN LOW POSITION AND SAFE." 3. ON [DATE] AT 1:00 P.M., BEHAVIOR INCIDENT: RESIDENT #611 WALKED INTO ANOTHER RESIDENT (#613'S) ROOM AND "PUNCHED ANOTHER RESIDENT IN THE FACE. OTHER RESIDENT RESPONDED BY PUNCHING RESIDENT #611 BACK IN THE FACE." PART OF BODY INVOLVED/INJURY: FACE. SAFETY DEVICES: N/A. RECOMMENDATIONS: PSYCH REFERRAL/SOCIAL WORK FOLLOWUP." 4. ON [DATE] AT 8:30 A.M., "OBSERVED OLD BRUISE ON RIGHT FEMUR AND LEFT UPPER ARM." SAFETY DEVICES: N/A. RECOMMENDATIONS: MONITOR RESIDENT WITH INDEPENDENCE WITH AMBULATION... 5. ON [DATE] AT 12:10 P.M., RESIDENT OBSERVED "SITTING ON FLOOR WITH HER BACK AGAINST THE BED." INJURY: NONE NOTED. SAFETY DEVICES: N/A. RECOMMENDATIONS: MAKE SURE BED WHEELS ARE LOCKED. 6. ON [DATE] AT 12:45 A.M., RESIDENT #611 WAS OBSERVED "SITTING IN ANOTHER RESIDENT (#50'S) ROOM IN A BEDSIDE CHAIR (CRYING). INJURY: "A REDDENED BRUISE AREA. SAFETY DEVICES: N/A. RECOMMENDATIONS: MONITOR CONTINUE TO MONITOR FOR SAFETY, AND WHERE ABOUT,...KEEP RESIDENT FROM OTHER RESIDENTS' ROOMS, REDIRECTIONS BY STAFF MEMBER." 7. ON [DATE] AT 6:30 A.M., RESIDENT #611 WAS "IN HALL IN FRONT OF ROOM, LOST BALANCE" AND fell . INJURY: NONE NOTED. SAFETY DEVICES: N/A. RECOMMENDATIONS: POSSIBLE MEDICATION CHANGE. MONITOR RESIDENT FOR SAFETY. 8. ON [DATE] AT 5:00 P.M., "RED TENDER AREA ON KNUCKLE." INJURY: RIGHT HAND RING FINGER. SAFETY DEVICES: N/A. RECOMMENDATIONS: MONITOR WHEREABOUTS. 9. ON [DATE] AT 11:40 P.M., RESIDENT #611 "SITTING ON THE FLOOR WITH (BOTH FEET ON THE FLOOR, AND ONE HAND) ON THE (4 TH BAY) HALLWAY." INJURY: BUTTOCKS EXAMINED. SAFETY DEVICES: N/A. RECOMMENDATIONS: MONITOR RESIDENT AT BEDTIME/MAKING SURE SHE IS IN HER BEDROOM... WHEN NEEDED, MONITOR RESIDENT ONE ON ONE... ON [DATE] AND THROUGHOUT THE DURATION OF THE SURVEY, RESIDENT #611 WAS OBSERVED WANDERING ON DIFFERENT BAYS AROUND THE FACILITY, AT TIMES WITHOUT SUPERVISION. ON [DATE] AT 2:30 P.M., A REVIEW OF RESIDENT #611'S WANDERING CARE PLAN DATED [DATE], REVEALED ASSESS FUNCTIONING OF ALARM SYSTEM ROUTINELY AND PRN (AS NEEDED). COLLABORATE WITH RESIDENT, FAMILY, AND PHYSICAN FOR POSSIBLE NEED FOR ALARM SYSTEM (WANDERGUARD). REDIRECT TO ROOM, UNIT, ACTIVITIES ECT. BEHAVIOR WHEN OBSERVED. HOWEVER, THERE WERE NO ALARMS OBSERVED FOR RESIDENT #611 DURING THE ENTIRE SURVEY. A REVIEW OF RESIDENT #611'S BEHAVIOR CARE PLAN DATED [DATE], REVEALED RESIDENT WANDERS FACILITY, CAN BE AGGRESSIVE. MONITOR LOCATION AND MAINTAIN SAFETY. PROVIDE FREQUENT AND CONSISTENT SUPERVISION." HOWEVER, RESIDENT #611 STILL WANDERED INTO OTHER RESIDENTS' ROOMS. A REVIEW OF AN ACTIVITIES OF DAILY LIVING CARE PLAN DATED [DATE], DOCUMENTED "FREQUENTLY CHECK ON RESIDENT FOR NEEDS, MONITOR WHEREABOUTS... " HOWEVER, RESIDENT #611 WAS STILL ABLE TO GO INTO OTHER AREAS UNSUPERVISED. A REVIEW OF AN ANTI-PSYCH CARE PLAN DATED [DATE], DOCUMENTED "PROVIDE 1 ON 1 (SUPERVISION) FOR RESIDENT WHEN BEHAVIORS ARE INAPPROPRIATE." A REVIEW OF NURSES NOTES DATED [DATE] (3 PM-11 PM), DOCUMENTED RESIDENT UP WALKING AROUND FACILITY IN AND OUT OF OTHER RESIDENTS' ROOMS... AN ADDITIONAL NURSES NOTES DATED [DATE] AT 7:00 A.M., DOCUMENTED "RESIDENT UP AMBULATING FACILITY THROUGHOUT THE NIGHT... REDIRECTED BY NURSES AND CERTIFIED NURSE ASSISTANTS MULTIPLE TIMES BACK TO ROOM. ATTEMPTS WERE UNSUCCESSFUL..." ON [DATE] AT 12:15 P.M., DURING AN INTERVIEW WITH THE ADMINISTRATOR AND DIRECTOR OF NURSING, THEY STATED, "WE BELIEVE SHE (RESIDENT #611) WOULD BE MORE APPROPRIATE FOR A DEMENTIA FACILITY, BUT RESIDENT #611'S SON WON'T HEAR OF IT, AND WOULD RATHER HAVE MOTHER MEDICATED OR SEDATED THAN TO BE REMOVED FROM THE FACILITY." THEY WERE UNABLE TO EXPLAIN WHY RESIDENT #611 WAS NOT MONITORED ONE TO ONE WHILE UNDER THE FACILITY'S CARE. ( ) REVIEW OF THE CLINICAL RECORD AND FACE SHEET ON [DATE], AT 3:00 PM, REVEALED, RESIDENT #614 WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. PER MINIMUM DATA SET (MDS), DATED [DATE], RESIDENT #614 WAS SEVERELY COGNITIVELY IMPAIRED, AND REQUIRED EXTENSIVE ONE PERSON PHYSICAL ASSISTANCE FOR TRANSFERS. REVIEW OF FALL RISK ASSESSMENTS FOR RESIDENT #614 DATED [DATE] AND [DATE] NOTED THAT THE RESIDENT WAS AT HIGH RISK FOR FALLS. REVIEW OF THE FALLS RISK CARE PLAN, DATED [DATE], NOTED TRANSFER WITH 2-PERSON TECHNIQUE OR LIFT IF NEEDED AND PLACE RESIDENT IN HALLWAY FOR MONITORING AS FALL INTERVENTIONS. ON [DATE] AT 1:00 PM, REVIEW OF THE INCIDENT/ACCIDENT (I/A) REPORTS FOR RESIDENT #614 REVEALED THE FOLLOWING: 1. ON [DATE] AT 6:26 PM, RESIDENT #614 fell FROM THE WHEELCHAIR WHILE BEING ASSISTED BY A CERTIFIED NURSE ASSISTANT (CNA). PER CNA WRITTEN STATEMENT: "WHILE TRANSFERRING RESIDENT (#614), FROM THE WHEELCHAIR TO THE SHOWER CHAIR, I WAS TOLD SHE COULD STAND. WHEN I MOVED THE WHEELCHAIR TO MAKE THE TRANSFER, SHE LOST HER BALANCE AND SLID TO THE FLOOR."THE CORRECTIVE MEASURES INCLUDED: 2 PERSON ASSISTANCE, INSERVICE TO BE REVIEWED WITH CNA's, PRESSURE ALARMS TO BED AND WHEELCHAIR, WHEN IN WHEELCHAIR, HAVE RESIDENT IN HALLWAY. THERE WERE NO INJURIES NOTED. 2. ON [DATE] AT 4:00 AM, RESIDENT #614 fell TO FLOOR WHILE BEING ASSISTED BY TH

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE PAIN MANAGEMENT, APPLY ANTI-[MEDICAL CONDITION] COMPRESSION HOSE AND FOLLOW physician's orders [REDACTED].#31) OFF-SAMPLE RESIDENT , RESULTING IN PROLONGED, UNCONTROLLED PAIN, THE POTENTIAL FOR BLOOD CLOT FORMATION, AND COMPROMISE/DECLINE IN CARDIAC STATUS. FINDINGS INCLUDE: ON 6/17/11 AT 8:15 AM, RESIDENT #617 WAS OBSERVED LYING ACROSS THE BED IN A FETAL POSITION, MOANING AND ROCKING BACK AND FORTH IN PAIN. SHE HAD HER HANDS BETWEEN HER THIGHS. HER BREAKFAST WAS AT THE BEDSIDE AND BARELY EATEN. WHEN QUERIED, THE RESIDENT SAID, "IT HURTS" WHILE POINTING AT HER PELVIC AREA. SHE SAID, "I HAVE FEMALE PROBLEMS." THE DIRECTOR OF NURSING (DON) AND NURSE MANAGER 'C' WERE IMMEDIATELY QUERIED AND THE RESIDENT'S CHART WAS REVIEWED. PER THE ADMISSION FACE SHEET, RESIDENT #617 WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. AN MINIMUM DATA SET ((MDS) dated [DATE] NOTED THAT THE RESIDENT EXPERIENCED FREQUENT PAIN. A "PAIN" CARE PLAN DATED 10/10/10 FOR RESIDENT #617 NOTED THAT THE RESIDENT HAD THE "POTENTIAL" FOR PAIN RELATED TO ARTHRITIS, AAA, RECTAL PROLAPSE, AND HEMORRHOIDS. INTERVENTIONS INCLUDED: ASSESS PAIN CHARACTERISTICS: DURATION, LOCATION, AND QUALITY, ASSESS EFFECTIVENESS OF PAIN MEDICATION, ADDRESS COMPLAINTS OF PAIN PROMPTLY WITH MEDICATION, ASSESS EFFECTIVENESS OF PAIN MEDICATION, AND PROVIDE ONGOING ASSESSMENT OF PAIN STATUS. WHEN QUERIED ABOUT THE RESIDENT BEING IN PAIN AND POINTING TO HER PELVIS, THE DON AND NURSE 'C' STATED THAT THE RESIDENT HAD PAIN DUE TO RECTAL PROLAPSE (WHEN THE RECTUM SLIPS OUTSIDE OF THE BODY). THE NURSES STATED THAT SURGICAL REPAIR OF THE PROLAPSE WAS CONTRAINDICATED BECAUSE OF THE AORTIC ANEURYSM. ACCORDING TO RESIDENT #617'S PROOF OF USE (NARCOTIC) RECORD, THE RESIDENT LAST RECEIVED [MEDICATION NAME] FOR PAIN THE PREVIOUS DAY (6/16/11) AT 9 AM. THE DON DIRECTED NURSE 'N' TO GIVE THE RESIDENT PAIN MEDICATION. WHEN NURSE 'N' ASKED THE RESIDENT TO RATE HER PAIN ON A SCALE FROM 1-10, THE RESIDENT SAID, "IT'S 10, THE WORSE." PER RESIDENT #617'S NURSES NOTES ON THE FOLLOWING DATES: 9/26/10, 9/27/10, 10/6/10, 10/10/10, 11/7/10, 11/10/10, 11/13/10, 11/18/10, 11/23/10, 11/24/10, 11/15/10, 11/17/10, 11/18/10, 12/2/10, 12/6/10, 12/20/10, 12/25/10, 1/24/11, 1/30/11, 2/3/11, 2/8/11 (ALL DAY), 2/11/11, 2/16/11, 2/17/11, 2/20/11, 2/21/11, 2/27/11, 3/8/11, 3/25/11, 4/1/11, 4/2/11, 4/3/11, AND 5/6/11, RESIDENT #617 COMPLAINED OF PAIN WITH THE FOLLOWING SIGNS/SYMPTOMS OF PAIN: THRASHING, POINTING TO THE PELVIC AREA, CONFUSION, CONSTANTLY PUTTING ON CALL LIGHT, URINATING IN THE CORNER OF HER ROOM, AGITATION WITH INABILITY TO BE RE-DIRECTED, EXTREME AGITATION, REFUSING TO EAT, ASKING STAFF NOT TO LEAVE HER, PULLING AT OR STRIPPING OFF HER INCONTINENT BRIEF, TEARING OFF HER NIGHTGOWN, RESTLESSNESS, NOT SLEEPING ALL NIGHT, SCRATCHING AT HER PERINEAL AREA, LYING ON THE FLOOR UNDERNEATH THE BED (ON 11/24/10), ROLLING AROUND IN BED, SMEARING FECES ON THE BED, HOLDING THE VAGINAL AREA, REFUSING TO SIT OR LAY DOWN, BLEEDING AT THE RECTAL AREA, AND ASKING TO GO TO THE HOSPITAL (3/8/11). FROM 7/26/10 THRU 3/24/11, THE RESIDENT WAS PRESCRIBED: 1. TYLENOL (PAIN) 650 MG (MILLIGRAMS) EVERY SIX HOURS "AS NEEDED" THRU 3/24/11. 2. [MEDICATION NAME] (ANTI-ANXIETY) 0.25 MG TWICE A DAY "AS NEEDED" FROM 10/11/10 THRU 11/23/10. 3. [MEDICATION NAME] (ANTI-ANXIETY) 0.25 MG BY INJECTION "AS NEEDED" DAILY FROM 9/16/10 THRU 2/3/11. 4. [MEDICATION NAME] 0.5 MG TWICE A DAY BY MOUTH "AS NEEDED" FROM 2/3/11 THRU 3/24/11. 5. [MEDICATION NAME] 5/500 MG ONE TABLET EVERY SIX HOURS "AS NEEDED." ACCORDING TO THE RESIDENT'S MARS (MEDICATION ADMINISTRATION RECORDS), THESE MEDICATIONS WERE GIVEN REPEATEDLY, ALMOST DAILY, INCLUDING THE [MEDICATION NAME] INJECTIONS DURING THE DATES OF THE PRESCRIPTIONS. NURSING STAFF FREQUENTLY PUSHED THE RECTUM BACK INTO PLACE OR ATTEMPTED TO DO SO WITHOUT SUCCESS. PER AN INCIDENT/ACCIDENT REPORT, ON 3/24/11 RESIDENT #617 WAS TRANSFERRED TO THE HOSPITAL FOR A FRACTURED JAW FROM A FALL. ACCORDING TO A HOSPITAL X-RAY. THE RESIDENT WAS ALSO NOTED TO HAVE A HEMATOMA OF THE RIGHT EYE AND A LACERATED CHIN. SHE WAS TRANSFERRED BACK to the facility on [DATE]. RESIDENT #617 WAS PRESCRIBED [MEDICATION NAME] 5/500 MG, 1-2 TABLETS EVERY FOUR HOURS "AS NEEDED," AND [MEDICATION NAME] 0.5 MG TWICE A DAY UPON HER RETURN TO THE FACILITY. THERE WAS NO ORDER FOR ROUTINE/SCHEDULED PAIN MEDICATION. PER physician progress notes [REDACTED]., WHO WAS ALSO THE MEDICAL DIRECTOR, OR HIS ASSOCIATE, UNTIL 4/4/11. THERE WAS NO MENTION OF PAIN IN THE NOTES. PER THE MARS, THE RESIDENT CONTINUED TO REQUIRED REPEATED DOSES OF [MEDICATION NAME] AND [MEDICATION NAME] ALMOST EVERY DAY DURING APRIL 2011. THERE WERE NO NURSES NOTES AFTER 5/6/11 REGARDING RESIDENT #617'S PAIN AND SYMPTOMS. HOWEVER, THE MARS FOR MAY AND JUNE 2011 NOTED THAT THE RESIDENT REQUIRED DOSES OF [MEDICATION NAME] SEVERAL TIMES ALMOST EVERY DAY ALONG WITH THE SCHEDULED [MEDICATION NAME]. WHEN ASKED WHY THE RESIDENT WAS NOT ON ROUTINE, SCHEDULED DOSES OF [MEDICATION NAME] OR SOME OTHER PAIN MEDICATION, NURSE 'C' SAID, "SHE IS GETTING TYLENOL." HOWEVER, WHEN THE CHART WAS REVIEWED, THE RESIDENT WAS NOT ON ANY SCHEDULED PAIN MEDICATION. THE DON AND NURSE 'C' THEN STATED THAT THE RESIDENT WAS GETTING SCHEDULED [MEDICATION NAME] INSTEAD "BECAUSE SHE GETS ANXIOUS FROM THE PAIN." THEY WERE UNABLE TO EXPLAIN WHY THE ROOT CAUSE OF THE ANXIETY (THE PAIN) WAS NOT BEING ADEQUATELY ADDRESSED AND WHY THE [MEDICATION NAME] WAS PRESCRIBED FOR PAIN MANAGEMENT. RESIDENT #617'S CHART REVEALED A NOTE TO PHYSICIAN 'V' FROM THE PHARMACY CONSULTANT DATED 5/25/11: "RESIDENT IS EXHIBITING SIGNS AND SYMPTOMS OF PAIN IN THE MEDICAL RECORD, AS EVIDENCED BY FREQUENT REQUESTS FOR (AS NEEDED [MEDICATION NAME]), BUT DOES NOT TAKE ROUTINE [MEDICATION NAME] THERAPY. RECOMMENDATION: PLEASE CONSIDER A THOROUGH INITIAL PAIN ASSESSMENT AND, IF WARRANTED, INITIATING ROUTINE PAIN MEDICATION, MONITORING FOR EFFECTIVENESS...." THE PHYSICIAN'S RESPONSE: "CONTINUE CURRENT PAIN MED, NO CHANGE, (THE RESIDENT WAS) STABLE WITH IT." ON 6/17/11 AT APPROXIMATELY 9:30 AM, NURSE 'C' REPORTED THAT AN ORDER WAS RECEIVED TO PLACE THE RESIDENT ON SCHEDULED PAIN MEDICATION AND TO GIVE THE [MEDICATION NAME] ON AN "AS NEEDED" BASIS. SHE WAS UNABLE TO EXPLAIN WHY THIS WAS NOT DONE MONTHS PRIOR. WHEN INTERVIEWED ON 6/23/11 AT 1 PM, PHYSICIAN 'V' STATED THE THE RESIDENT WAS PREVIOUSLY ON SCHEDULED PAIN MEDICATION. HOWEVER, THERE WAS NO DOCUMENTED EVIDENCE OF SCHEDULED PAIN MEDICATION BEFORE THE RESIDENT WENT TO THE HOSPITAL OR AFTER SHE RETURNED WITH A FRACTURED JAW, IN ADDITION TO THE RECTAL PROLAPSE. THE PHYSICIAN WAS UNABLE TO EXPLAIN WHY. HE SAID, "SHE IS ON SCHEDULED PAIN MEDS NOW (AS OF 6/17/11)." ( ) RESIDENT #609 WAS OBSERVED ON 6/14/11 AT 9 AM AND 6/15/11 AT 8:55 AM. THE RESIDENT WAS OBSERVED TO BE SMALL, FRAIL, AND HAD SEVERE KYPHOSIS (CURVATURE) OF THE SPINE. SHE COULD NOT LIFT HER HEAD UP ABOVE SHOULDER LEVEL DUE TO THE CURVATURE. SHE WAS ALERT, TALKATIVE, ABLE TO CONVERSE, AND RESPONDED APPROPRIATELY TO QUESTIONS. THERE WAS A DARK PURPLE BRUISE COVERING THE ENTIRE RIGHT SHOULDER THAT EXTENDED TO THE SIDE OF THE RIGHT BREAST AND UNDER THE ARM. HER RIGHT 5 TH FINGER WAS PURPLE AND HER 3RD AND 4 TH FINGERS WERE BRUISED FROM TOP TO BOTTOM. SHE COMPLAINED OF PAIN TO THE SHOULDER AND FINGERS. ON 6/15/11 AT 12 NOON THE RESIDENT'S CLINICAL RECORD WAS REVIEWED WITH THE DON. PER THE ADMISSION FACE SHEET, THE RESIDENT WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS dated [DATE] NOTED THAT THE RESIDENT HAD FREQUENT PAIN. "PAIN" CARE PLANS DATED 3/23/10 AND 5/11/11/ FOR RESIDENT #609 NOTED THAT THE RESIDENT HAD AN ALTERATION IN COMFORT RELATED TO [MEDICAL CONDITION] AND JOINT PAIN. INTERVENTIONS INCLUDED: ADMINISTER PAIN MEDICATION AS ORDERED, ASSESS EFFECTIVENESS OF PAIN MEDICATION, ADDRESS COMPLAINTS OF PAIN PROMPTLY WITH MEDICATION, AND ASSESS EFFECTIVENESS OF PAIN MEDICATION. THE RESIDENT WAS PRESCRIBED: [MEDICATION NAME] (NERVE PAIN AND [MEDICAL CONDITION]) 50 MG TWICE A DAY, [MEDICATION NAME] 5/500 MG (MILLIGRAMS) EVERY FOUR HOURS AS NEEDED, AND [MEDICATION NAME] (PAIN) 50 MG EVERY EIGHT HOURS AS NEEDED. NURSES NOTES DATED 6/11/11 REVEALED THAT RESIDENT #609 HAD FALLEN ASLEEP, LEANED FORWARD, AND fell OUT OF THE WHEELCHAIR LANDING ON HER RIGHT SIDE AND HAND. THERE WAS NO DOCUMENTATION REGARDING THE APPEARANCE OF THE HAND BUT AN X-RAY OF THE RIGHT HAND WAS ordered on [DATE]. THE X-RAY WAS NOT ORDERED TO BE DONE STAT (IMMEDIATELY). ON 6/12/11 AT 1 PM, NURSES NOTED THAT RESIDENT #609 COMPLAINED OF SHOULDER PAIN. DURING THE 3-11 PM SHIFT (TIME NOT NOTED), A BRUISE WAS OBSERVED TO THE RIGHT SHOULDER AND THE RESIDENT COMPLAINED OF PAIN. PER CONTROLLED SUBSTANCE RECORDS, THE RESIDENT ONLY RECEIVED ONE DOSE OF [MEDICATION NAME] PRIOR TO THE FALL ON 6/11/11 BUT REQUIRED THREE DOSES OF [MEDICATION NAME] ON 6/12/11. THERE WAS NO SHOULDER X-RAY ORDERED AND NO INDICATION THAT THE DON WAS INFORMED. THE HAND X-RAY WAS NOT DONE. ON 6/13/11 AT 8 AM, NURSES NOTED BRUISING TO RESIDENT #609'S RIGHT SHOULDER. A STAT SHOULDER X-RAY WAS ORDERED. ON 6/13/11 BETWEEN 12 NOON AND 1 PM, X-RAYS WERE TAKEN OF BOTH THE RIGHT SHOULDER AND THE RIGHT HAND WHICH REVEALED: "ANTERIOR DISLOCATION OF THE HUMERAL HEAD (RIGHT SHOULDER)" AND "SLIGHTLY DISPLACED FRACTURE AT THE BASE OF THE PROXIMAL PHALANX OF THE FIFTH FINGER." THERE WAS NO DOCUMENTED DESCRIPTION OF THE RESIDENT'S FINGERS IN THE CHART. THE DON WAS UNABLE TO EXPLAIN WHY. SHE WAS UNABLE TO STATE WHY THE SHOULDER X-RAY WAS NOT ORDERED STAT WHEN BRUISING AND PAIN WAS INITIALLY NOTED ON 6/12/11. THE RESIDENT WAS TRANSPORTED TO THE hospital on [DATE]. A REPEAT SHOULDER X-RAY AT THE HOSPITAL REVEALED NO EVIDENCE OF FRACTURE OR DISLOCATION BUT A [DIAGNOSES REDACTED]. PER NURSES NOTES, RESIDENT #609 REQUESTED PAIN MEDICATION UPON HER RETURN. THE PROOF OF USE RECORD INDICATED THAT A [MEDICATION NAME] TABLET WAS NOT GIVEN, UNTIL 11:30 PM, BY NURSE 'U' ON 6/14/11 AT 7:15 AM, THE PHYSICIAN PRESCRIBED [MEDICATION NAME] 5/500, TWO TABLETS, EVERY FOUR HOURS FOR SEVEN DAYS THEN RESUME THE PREVIOUS "AS NEEDED" [MEDICATION NAME] ORDER. PER THE PROOF OF USE (CONTROLLED SUBSTANCE) RECORD, AT 7:30 AM NURSE 'U' GAVE THE RESIDENT ONLY ONE TABLET. ON 6/14/11 AT 9 AM, RESIDENT #609 COMPLAINED OF PAIN TO THE FINGERS AND ASKED FOR A PAIN PILL. A NURSE, WHO WAS PASSING BY IN THE HALLWAY, WAS NOTIFIED AND STATED THAT SHE WOULD FOLLOW-UP. AT 1 PM, THE RESIDENT WAS OBSERVED IN HER ROOM WITH HER LUNCH UNTOUCHED. WHEN QUERIED, THE RESIDENT SAID, "I'M TOO SORE TO EAT. MY SHOULDER IS HURTING." SHE WAS MOANING IN PAIN. SHE WAS GUARDING AND HOLDING HER ARM. THERE WAS NO SUPPORT FOR THE INJURED ARM, SUCH AS A SLING OR A PILLOW. THE PROOF OF USE RECORD WAS REVIEWED. THE RESIDENT HAD NOT RECEIVED [MEDICATION NAME] SINCE THE 7:30 AM DOSE. NURSE 'M' WAS ASKED ABOUT RESIDENT #609'S PAIN MEDICATION. SHE SAID, I GAVE HER (AS NEEDED) [MEDICATION NAME] AT 10 (AM)." HOWEVER, THE NURSE DID NOT DOCUMENT ON THE MEDICATION RECORD THAT SHE HAD GIVEN IT. THE NURSE WAS UNABLE TO STATE WHY THE RESIDENT WAS NOT GIVEN TWO [MEDICATION NAME] TABLETS DUE AT 11:30 AM AND WHY THERE WAS NO INDICATION THAT THE RESIDENT RECEIVED THE [MEDICATION NAME]. AT 1:20 PM, NURSE 'M' ADMINISTERED TWO [MEDICATION NAME] TABLETS, ALMOST TWO HOURS LATE. THE PROOF OF USE RECORD NOTED THAT RESIDENT #609 DID NOT RECEIVE ANY MORE [MEDICATION NAME] AFTER 1:20 PM ON 6/14/11 UNTIL 7 AM ON 6/15/11. THE NEXT DOSE WAS GIVEN AT 11:30 AM ON 6/15/11. THE MEDICATION RECORD REVEALED THAT STAFF HAD INCORRECTLY TRANSCRIBED THE NEW [MEDICATION NAME] ORDER. THE MEDICATION RECORD READ [MEDICATION NAME] 5/500 TWO TABLETS BY MOUTH EVERY FOUR HOURS "AS NEEDED" FOR SEVEN DAYS, RATHER THAN EVERY FOUR HOURS AS PRESCRIBED. THE DON WAS UNABLE TO EXPLAIN WHY THE RESIDENT DID NOT RECEIVE TWO [MEDICATION NAME] TABLETS EVERY FOUR HOURS AS PRESCRIBED AND WHY THE ORDER WAS NOT PROPERLY TRANSCRIBED. PER THE PROOF OF USE FORM, RESIDENT #609 DID NOT RECEIVE [MEDICATION NAME] AFTER THE 11:30 AM DOSE ON 6/15/11, UNTIL 6/16/11 AT 6:45 AM. THE NEXT DOSE WAS GIVEN AT 11 AM BUT THE FOLLOWING DOSE WAS GIVEN TWO HOURS LATE, AT 5 PM. THE [MEDICATION NAME] ORDER WAS NOT CLARIFIED TO READ "EVERY FOUR HOURS" ON THE MEDICATION RECORD UNTIL 6/16/11. ON 6/15/11, PHYSICIAN 'V' WROTE an order for [REDACTED].' WAS UNABLE TO RESPOND. A NURSE WHO OVERHEARD THE CONVERSATION SAID, "SHE WASN'T SENT BACK (FROM THE HOSPITAL) WITH A SLING." THEY WERE UNABLE TO EXPLAIN WHY THE FACILITY DID NOT ORDER ONE IMMEDIATELY. WHEN QUERIED AGAIN, PHYSICIAN 'V' STATED THAT THE SLING WAS NOT PRESCRIBED UNTIL 6/15/11 "BECAUSE I HAD NOT SEEN HER" UNTIL 6/15/11, WHICH WAS CONFIRMED BY PROGRESS NOTES. THE PHYSICIAN NOTED ON 6/15/11 THAT THE SHOULDER WAS "PAINFUL" UPON RANGE OF MOTION AND BRUISED. ON 6/16/11 AT 8:50 AM, RESIDENT #609 WAS NOT WEARING A SLING. AT 10:50 AM, A SLING WAS IN PLACE. NURSE 'C' STATED THAT THE SLING WAS SUPPLIED BY THE THERAPY DEPARTMENT. THE RESIDENT HAD A SPLINT ON THE 5 TH RIGHT FINGER WITH AN ACE WRAP COVERING THE SPLINT AND FINGER. ON 6/17/11 AT 8:45 AM, RESIDENT #609 WAS SEATED IN HER WHEELCHAIR WEARING A CARDIGAN SWEATER THAT WAS BUTTONED UP. THE RESIDENT SAID THAT SHE HAD SHOULDER PAIN. THE SLING WAS LYING ON THE BED. THERE WAS NO PILLOW UNDER THE ARM FOR SUPPORT. THE SPLINT WAS ON THE OVERBED TABLE WITH THE ACE DRESSING NEATLY WRAPPED AND PLACED ON THE TABLE. NURSE 'G' WAS QUERIED ABOUT THE SPLINT AND SLING NOT BEING IN PLACE. THE NURSE WAS UNABLE TO RESPOND. NURSE 'J' ENTERED THE ROOM AND STATED THAT THE RESIDENT TOOK OFF THE SLING AND SPLINT. SHE WAS UNABLE TO EXPLAIN HOW THE RESIDENT REMOVED THE SLING FROM UNDERNEATH THE BUTTONED UP SWEATER AND HOW SHE WAS ABLE TO REMOVE THE SPLINT AND NEATLY WRAP THE ACE DRESSING WHILE HAVING PAIN AND THE USE OF ONLY ONE ARM AND HAND. THEY ATTEMPTED TO PUT THE SLING ON UNDERNEATH THE SWEATER WITHOUT REMOVING THE SWEATER. THE RESIDENT SAID, "YOU HAVE TO TAKE THE SWEATER OFF TO PUT ON THE SLING." THEY FINALLY HAD TO MANEUVER HER ARM OUT OF THE SLEEVE BECAUSE SHE COULD NOT LIFT HER ARM. WHEN QUERIED, THE RESIDENT STATED THAT SHE HAD NOT REMOVED THE SLING. PER THE FACILITY'S UNDATED "PAIN MANAGEMENT" POLICY: IF PAIN MEDICATION IS GIVEN, THE NURSE MUST INITIAL THE MEDICATION RECORD TO INDICATE THAT IT WAS GIVEN. THE PROOF OF USE SHEET MUST BE SIGNED TO INDICATE THE USE OF THE DRUG. THE RESIDENT MUST BE RE-ASSESSED IN 30-45 MINUTES FOR EFFECTIVENESS OF THE MEDICATION. IF THE MEDICATION IS INEFFECTIVE, CALL THE PHYSICIAN TO OBTAIN AN INCREASE IN THE DOSE, THE FREQUENCY, OR A CHANGE IN THE MEDICATION. PER THE FACILITY'S "MEDICATION ORDERS" POLICY DATED 8/2007: TRANSCRIBE NEWLY PRESCRIBED MEDICATIONS ON TO THE MAR. WHEN A NEW ORDER CHANGES THE PREVIOUSLY PRESCRIBED MEDICATION, DISCONTINUE THE PREVIOUS ENTRY BY WRITING "DISCONTINUED" AND THE DATE HIGHLIGHTED IN YELLOW. ALSO, ON 6/15/11 AT 10:15 AM, RESIDENT #609 WAS OBSERVED DRESSED AND SITTING IN HER WHEELCHAIR. ANTI-[MEDICAL CONDITION] COMPRESSION HOSE WERE OBSERVED ON THE NIGHTSTAND. THE RESIDENT'S TREATMENT RECORD WAS REVIEWED. THE RECORD NOTED THAT THE RESIDENT WAS PRESCRIBED THE COMPRESSION HOSE. NURSE 'C' ENTERED THE RESIDENT'S ROOM AND SAW THE HOSE ON THE NIGHTSTAND. SHE WAS UNABLE TO EXPLAIN WHY THE RESIDENT WAS NOT WEARING THE HOSE AS PRESCRIBED. WHEN ASKED ABOUT THE HOSE, THE RESIDENT SAID, "OH, MY LONG SOCKS. I WANT THEM ON." PER A physician progress notes [REDACTED]." AND "[MEDICAL CONDITION]" TO BILATERAL LOWER EXTREMITIES. THE RECOMMENDATION: COMPRESSION HOSE AND [MEDICATION NAME] (DIURETIC) DAILY. ON 5/23/11, ORDERS WERE WRITTEN FOR THE [MEDICATION NAME], AND FOR KNEE HIGH BILATERAL COMPRESSION HOSE TO BE PUT ON IN THE MORNING AND REMOVED AT BEDTIME. THE DON WAS UNABLE TO EXPLAIN WHY THE RESIDENT WAS NOT WEARING THE HOSE. PER THE FACILITY'S "IMPAIRED MOBILITY" POLICY DATED 12/2010: ASSESS FOR SIGNS/SYMPTOMS OF DEEP VEIN [MEDICAL CONDITION] MEANING [MEDICAL CONDITION], REDNESS, PAIN, WARMTH OF THE EXTREMITY, AND APPLY AND MAINTAIN COMPRESSION HOSE AS PRESCRIBED. ( ) ON 6/16/11 AT 10:45 A.M., DURING OBSERVATION OF MEDICATION ADMINISTRATION FOR RESIDENT #31 WITH NURSE "'T", REVEALED, THAT THE RESIDENT WAS ADMINISTERED THE following medications: [REDACTED] ASPIRIN 325 MG (THE HEART) , [MEDICATION NAME] (BLOOD PRESSURE), [MEDICATION NAME] (POTASSIUM SPARING DIURETIC), [MEDICATION NAME] (STEROID), [MEDICATION NAME] ( LOOP DIURETIC), [MEDICATION NAME] (BLOOD PRESSURE), AND POTASSIUM (MINERAL REPLACEMENT). ON 6/16/11 AT 2:30 PM., RECORD REVIEW REVEALED THAT RESIDENT #31 WAS readmitted INto the facility on 4/28/11, WITH [DIAGNOSES REDACTED]. ATRIA FIBRILLATION, HYPERPOTASSEMIA, DYSPHAGIA, AND PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBE. REVIEW OF A PHYSICIANS ORDER DATED 6/01/11, DOCUMENTED, "[MEDICATION NAME] 5 MILLIGRAMS (MG) DAILY ONE HALF HOUR BEFORE [MEDICATION NAME] ([MEDICATION NAME]). ON 6/16/11 AT 3:00 PM, NURSE "T" WAS QUERIED REGARDING THE ADMINISTRATION OF [MEDICATION NAME] 5 MG (MILLIGRAMS) THAT WAS GIVEN AT THE SAME TIME AS THE [MEDICATION NAME] ([MEDICATION NAME]), INSTEAD OF ONE HALF HOUR BEFORE AS PER PHYSICIAN ORDERS. NURSE "T" REPLIED "SOMETIMES ITS HARD TO GIVE HIM THE MEDICATION ONE HALF HOUR BEFORE BECAUSE HE GOES TO THERAPY SO I HAVE TO GIVE IT WHEN I CAN." ON 6/17/11 AT 11:30 AM, PER THE WEBSITE: "FIND ARTICLES. COM," IN AN ARTICLE PRESENTED BY THE PHARMACY CONSULTANT IN "THE NEPHROLOGY NURSING JOURNAL" TITLED, "PRE-DOSING [MEDICATION NAME] WITH LOOP DIURETIC COMBINATION REGIMENS:" "FOR THE RESOLUTION OF [MEDICAL CONDITION], WHEN THE SECOND DIURETIC ([MEDICATION NAME]), IS COMBINED WITH A LOOP DIURETIC ([MEDICATION NAME]), THE SECOND DRUG (([MEDICATION NAME]), IS BEST GIVEN BEFORE THE LOOP DIURETIC ([MEDICATION NAME])". THE ARTICLE ALSO DOCUMENTED THAT HYPOKALEMIA IS A SIDE EFFECT AND RESIDENTS RECEIVING THIS REGIME SHOULD BE CAREFULLY MONITORED TO AVOID EXCESSIVE DIURESIS AND HYPOKALEMIA. ( )