Every finding on record at The Orchards at Niles

This citation pertains to intake: 2709637, 2718464Based on interview and record review, the facility licensed staff failed to follow professional standards of practice, communicate effectively with a provider for an acute change in condition for 1 (Resident #100) of 3 residents reviewed for change in condition, resulting in delay in care for blood in the stool, increased confusion, and leading to the potential of a decline in overall physical, mental, and psychosocial well-being.Findings include: Review of an admission Record revealed Resident #100 was a female with pertinent diagnoses which included dementia, sleep disorders, mild cognitive impairment, muscle weakness, lack of coordination, dysphagia (damage to the brain responsible for production and comprehension of speech), cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language), and need for assistance with personal care. Review of Nurses Note dated [DATE] at 02:15 AM, revealed, .Patient looked confused and restless, Checked temp and was 97.8 , checked Oxygen it was 88% . I gave patient Oxygen at 2L (liters), and the Oxygen went up to 93%. There was blood in her stool. Put a note in the Physician book. Review of Resident #100's medical record revealed no documentation in progress notes or vitals section of blood pressure results, temperature results, or pulse results for the concern documented dated [DATE]. Review of Physician's Binder dated [DATE] revealed, .She was confused and when time to change her there was blood in the stool. Need to be checked . In an interview on [DATE] at 11:47 AM, Licensed Practical Nurse (LPN) F confirmed when the provider placed the initial swirl it was noting the resident was seen. In an interview on [DATE] at 3:37 PM, Director of Nursing (DON) B reported she was off the week of [DATE]th, 2025. DON B reported the previous provider group's contract expired on [DATE]. This writer requested the provider notes for Resident #100 to determine if she had been seen by a provider for those concerns. Review of the facility provided Provider Notes for Resident #100 revealed no follow up note by a provider which indicated Resident #100 had not been seen for the concern with low oxygen saturation, confusion, and blood in her stool. In an interview on [DATE] at 12:11 PM, LPN C reported the facility had standing orders for oxygen for any levels below 90%. LPN C reported she would contact the provider to obtain an order for the placement of oxygen and obtain further directives on how the provider wanted to proceed. LPN C reported if the resident's mental status was altered, she would obtain a full set of vitals as the resident may have an infection or something else had happened to the resident. LPN C reported with the altered mental status, oxygen level low and blood in the stool could indicate a GI (gastrointestinal) bleed. LPN C reported she would contact the provider whenever there was a new issue, and/or a change with the resident beyond their norm/baseline. In an interview on [DATE] at 1:46 PM, Unit Manager (UM) D reported she would contact the provider to obtain orders for oxygen and any other directive the provider wanted for Resident #100. In an interview on [DATE] at 11:48 AM, DON B reported the nurse who noted the blood in the stool and low oxygen level should have called the doctor right then due to a change in condition and not place a notation in the doctor's book especially as it was a holiday week and the weekend was near. DON B reported the physician should have been called. Review of policy, Acute Change in Condition (ACOC) provided on [DATE], revealed, .Changes (symptoms) in a resident's condition are communicated by any staff member to nurses via (see warning signs): Stop and Watch/Interact; lntershift rounds findings; 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. 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 delirium, fluid and electrolyte imbalance, infection, and medication related effects is the cause for the ACOC .7. A change in a resident's status that affect the problem(s)/goal(s) or approach (es) on his/her care plan are documented as revisions and communicated to the interdisciplinary caregivers .8. Communicate changes of condition at the stand-up meeting to the interdisciplinary team .9. Review resident with an acute change of condition daily in Stand Up .Cognitive Symptoms: a Abrupt onset of, or increase in, confusion Onset of hallucinations, delusions or paranoia .Significant fluctuations in level of confusion during the day or over several days .Sensory: a New onset of impaired balance, *Dizziness, * Worsening vision impairment .Bleeding from any orifice: *Appearance of frank blood in stool, urine or vomit . According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 20717-20719). Elsevier Health Sciences. Kindle Edition.The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient .

Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings Include:On 8/25/25 at 9:36 AM, An interview with Dietary Manager D found that items in the kitchen are held for three days before being discarded. Observation of the three door True Cooler found a bag of shredded lettuce dated 8/18 to 8/20 with a best by date of 8/23. Further review of the unit found a box of Nutritional Mighty Shakes with no date to indicate discard, item states they are good 14 days from thaw. An interview with DM D found that when the Shakes get delivered, they place them directly into the refrigeration unit and go by the date the item was delivered. A review of the box of Shakes found that it was delivered on 7/31/25. About 24 shakes were left in the box. Next to the shakes were 8 small containers of Magic Cups with no date to indicate discard. The item states consume within 5 days under refrigeration. A further review of the cooler found a case of whipped cream bags. The box of whipped cream bags states to Keep Frozen and that the item is perishable after 2 weeks under refrigeration. A review of the delivery date of the box found it came in on 8/11/25.On 8/25/25 at 10:47 AM an interview with Dietary Manager (DM) D found that kitchen staff do not check resident refrigeration units at the nurses' stations. When asked where snacks are delivered, DM D stated that dietary staff bring carts down for snacks and do not stock refrigeration units at the nurses stations. On 8/25/25 at 11:23 AM, Observation of the [NAME] nurses station found the following items: an open container of Half and Half labeled and dated 8/9/25 with manufactures directions that state the item is only good for 7 days after opening, a ziplock bag with pizza labeled with no date to indicate discard, a ziplock bag with cut up vegetables labeled and dated for 8-14-25, and a cup of soup labeled with no date to indicate discard. On 8/26/25 at 9:20 AM, A review of the three door True Cooler found an open bag of shredded lettuce dated 8/25 to 8/28 with a best by date of 8/23/25. The box of whipped cream bags was still located in the same location inside of the unit. On 8/26/25 at 9:25 AM, A review of the two door True Cooler found a bag of sliced bologna with no date. A record review of the facility policy entitled Use and Storage of Food Brought in by Family/Visitors, Last revised 1/1/25, found that, The prepared food must be consumed by the resident within 3 days. And that If not consumed within 3 days, food will be thrown away by facility staff.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . On 8/25/25 at 10:03 AM, An interview with DM D found that their sanitizer is typically 200 parts per million (ppm). Upon checking a sanitizer bucket near the dish machine, with facility test strips, it was found to be between 0-50 ppm. A further review of the three-compartment, which contains a sanitizer pre-dispense unit, found that it was also dispensing between 0-50 ppm. An interview with DM D found that she was going to call the vendor and have it checked out. On 8/26/25 at 11:13 AM, A follow up interview with DM D found that the sanitizer has been fixed and that the vendor stated the eyelet that determines the concentration of sanitizer was broken and needed to be changed. According to the 2022 FDA Food Code section 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), P (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling, P and (3) Be used only in water with 500 MG/L hardness or less or in water having a hardness no greater than specified by the EPA-registered label use instructions.According to the 2022 FDA Food Code section 7-204.11 Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P, or (B) Meet the requirements as specified in 40 CFR 180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations. On 8/25/25 at 10:08 AM, Observation of the Juice dispenser found an accumulation of sticky debris on the underside of the unit near the base of the spouts. When asked if she could see the accumulation, DM D stated yes. On 8/25/25 at 10:12 AM, An interview with DM D found that maintenance takes care of the ice machine cleaning. Observation of the ice machine found a white slimy layer of accumulation near the bottom lip of the machine that was able to be wiped away with a clean paper towel. Further review of the ice machine area found the scoop and holder on the wall near a window air conditioning unit. The holder was found with some debris accumulation on the inside bottom as well as a beetle looking insect found dead in the bottom of the holder. On 8/26/25 at 9:50 AM, A review of the clean mechanical scoop drawer found three mechanical scoops with dried stuck on food debris stored with clean utensils. On 8/26/25 at 12:01 PM, a review of the clean pots and pans storage rack found a saucepan, stacked with clean pans, that had greasy sticky residue on the cooking surface of the pan. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 8/25/25 at 2:08 PM, Observation of the Woods Spa room found chipping and bubbling of the wall surfaces behind the commode and along the wall leading to the sink. Further observations found portions of the wall had deteriorated and shown exposed drywall behind the commode with the vinyl coving coming off the wall. An interview with Maintenance Director (MD) I found that when the wall gets this way, she typically would scrape away the loose debris, skim coat the wall with plaster and repaint, but stated it comes right back overtime. When asked if they have ever used a non-porous wall covering in these problem areas, MD I stated she would look into using it. On 8/25/25 at 2:44 PM, Observation of the central supply room found two boxes of TwoCal nutritional supplements stored on the floor. When asked if this is where these are normally stored, MD I stated no. On 8/26/25 at 10:03 AM, Observation of the River Spa room found vinyl coving to the left of the shower coming off of the wall with excess bubbling and chipping of the wall surface. A review of the shower equipment found a padded seat cushion with brown and orange greasy debris on its side and a shower bed with leftover bits of hair shavings and an accumulation of white crusted debris on the underside mesh of the bed. A review of the cabinet found Comet Bleach cleaner comingled with body wash and other personal hygiene products. Further review of the room found that the call light located in the shower did not turn on the call light in the hallway when tested. On 8/26/25 at 11:20 AM, Observation of the Memory Unit found a foul odor upon walking into the unit and through the hall. A review of the exhaust ventilation in the soiled utility room found the exhaust vent above the cabinet was closed, not allowing odors to be efficiently removed from the room. Further review of the hall found a strong odor in the shared bathroom between resident rooms [ROOM NUMBERS]. Observation of the shared bathroom found it clean with no noticeable reason for the odor. At this time, the exhaust ventilation was not able to be audibly heard running or shown to attract suction when a piece of toilet paper was held near the duct. Observation of the bathroom of resident room [ROOM NUMBER] found no audible noise from the exhaust ventilation or the ability to show suction. On 8/26/25 at 1:33 PM, Observation of both outside trash dumpsters found them with the back sliding doors open leaving the ability for pests and precipitation to get inside.On 8/26/25 at 1:37 PM, Observation of the Oxygen tank storage found two storage containers with no conspicuous designation between full and empty tanks. Further observation found that the oxygen storage container on the left was found with 21 empty to near empty oxygen tanks standing upright that were not secure.

Based on interview and record review, the facility failed to track and offer the pneumococcal vaccine for 1 Resident (#4) of 5 residents reviewed for immunizations. Findings include: Resident #4: Review of an admission Record revealed Resident #4 was a male with pertinent diagnoses which included diabetes, dialysis, high blood pressure, acute respiratory failure with hypoxia (impaired ability to transfer oxygen into the blood and eliminate carbon dioxide). Review of Centers for Disease Control (CDC) Vaccine Schedules says, .For Adults 50 years or older: Previously received both PCV13 and PPSV23 but NO PPSV23 was received at age [AGE] years or older: 1 dose PCV20 or 1 dose PCV21 at least 5 years after the last pneumococcal vaccine dose . Review of Resident #4's immunization status revealed, .PCV (Prevnar) 13 was administered on 12/22/2015 .Pneumococcal PPSV23 was administered on 08/06/2014 . In an interview on 08/27/2025 at 10:24 AM, Unit Manager (UM) S reported there was no refusal noted in the medical record and he should have had the booster for the pneumococcal or been offered. UM S reviewed the medical record to determine if there was a declination and there was not a declination in the record. UM S reviewed the immunization binder in case it was not scanned in and was unable to locate it.

Based on observation, interview, and record review, the facility failed to monitor dietary recommendations and swallowing precautions for one Resident (#59) of 18 residents reviewed for dietary orders/needs. Findings include:Resident #59 (R59)Review of R59's medical chart revealed diagnoses including spastic quadriplegic cerebral palsy (severe form of cerebral palsy that affects all four limbs caused by damage to the brain during or shortly after birth with symptoms that include difficulty with feeding and swallowing), epilepsy (neurological disorder causing abnormal electrical activity in the brain), intellectual disabilities and Rett's syndrome (rare genetic mutation affecting brain development). Review of R59's medical chart revealed the following:-Order Summary dated 5/1/2024, revealed, Regular diet pureed texture, thin liquids consistency, fortified foods at each meal. -Care Plan Swallowing date initiated 10/15/24, indicated the resident was at risk for swallowing issues/aspiration related to family non-compliance with prescribed diet. Family has brought in outside foods not noted on resident diet. The goal was for the resident to be compliant with diet using interventions that included educate the family on diet Give diet as ordered -Care Plan Nutritional Potential Nutritional Problem revision date 2/6/25, indicated a pureed diet to ease chewing/swallowing while dependent on staff for feeding. The goal was for R59 to maintain adequate nutritional status by tolerance of diet consistency using interventions that included providing and serving diet as ordered general puree diet with thin liquids -Nutritional assessment dated [DATE] indicated a pureed diet was needed with total feeding assistance. According to Centers for Disease Control and Prevention, cdc.gov/nutrition, A pureed diet consists of smooth, pudding-like foods that require no chewing and are easy to swallow, typically used for individual with difficulty chewing or swallowing. For general pureed diets, foods should be blended until no lumps remain, ensuring moisture and cohesive consistency. On 8/25/25 at 1:20 PM, Family Member (FM) AAA was observed with R59 in the courtyard with no staff visible. Observed FM AAA using a clear plastic spoon to feed R59. Mechanically altered pieces/lumps of pasta in an orange sauce were observed on the spoon. FM AAA also was observed giving R59 a straw to drink from a cup. A visitation restriction for R59 was implemented by the Guardian for FM AAA to have supervised visits. During an interview on 8/25/2025 at 1:47 PM, FM U stated, When family first started visiting (R59), guardianship started the agreement (referring to the Visitation Requirement). There was a list of things family was supposed to follow. The facility did not like that (FM AAA) was not following policy and was being disruptive. They did not want her to visit unless there were supervised visits. I was the 3rd party to supervise visits between (R59 and FM AAA). I needed a break and have not been in a while, probably the last I was there was in May 2025. I did not talk to the Social Worker and told her I was no longer coming. (FM AAA) would sometimes bring food from home. There were food texture issues because (R59) had a hard time swallowing. Every time I went (FM AAA) would feed her lunch. During an observation on 8/25/25 at 2:00 PM, the Nursing Home Administrator (NHA) A observed with surveyor R59 with FM AAA in the dining room by front desk. No staff were visible in the dining room. During an interview on 8/25/25 at 2:18 PM, R59's Guardian VV stated, (R59) still has a visitation agreement in effect. I lifted the supervision visits with her mother and stepfather a while ago. I sent the facility a letter. I allow the mother to come Monday through Friday but not on the weekends. One time the mother undid the safety harness from the wheelchair. (R59) wiggles around and she could have fallen out of her wheelchair. The mother can come around for lunch because she likes to feed (R59). She can go into the public dining room and outside. (R59) is on certain dietary restrictions. I heard today that the mother was feeding (R59) a thick pasta-like food. That is not on the approved food list. (R59) produces thick secretions and the thick pasta-like food could cause her to choke. The RD (Registered Dietician) should know what foods (R59) can eat. The mother should be checking in the food with the facility when she brings it in for intake purposes and dietary restrictions. The mother knows what food is on (R59's) list of foods. She knows what food (R59) can have and why she cannot have other foods. (FM AAA) should be feeding (R59) in the dining room for staff observation. I'm going to have to guess the mother snuck the pasta-like food in today. I've allowed the mother access of the foods (R59) can have and knows (R59's) dietary restrictions.During an interview and record review on 8/25/2025 at 2:42 PM Director of Nursing (DON) B stated while reviewing a letter from R59's Guardian VV dated 5/2/25 who made the decision for unsupervised visits Monday-Friday, 11 am-2pm in the dining room or outside in the visiting area, I've talked to the facility's (Social Worker T) who said she did not place the updated visitation agreement into R59's medical records. The facility has had the letter since the beginning of May (2025). The only way staff would know about the changes would be communication. I do not know what staff are communicating with each other. My expectation is that staff observe what (FM AAA) is feeding (R59). If (FM AAA) is not following dietary restrictions for (R59) then she should not bring in any food at all. I looked at the food and it did look like it was pureed. (R59) has thick secretions and she could choke on anything but pureed. During an interview and record review on 8/26/25 at 2:05 PM, Social Worker T stated regarding R59, (R59) had a visitation restriction put in place by her guardian as long as a 3rd party was in attendance. A new restriction was added the first part of May. It was not put into place but is uploaded now in (R59's) medical chart. (FM AAA) is difficult at times. She argues with staff over (R59's) care. Guardianship lifted supervised visits. The mother sometimes feeds her. Staff do not watch the mother feed (R59). I assume the mother knows what pureed food looks like. (R59's) diet restrictions include pureed food and thin liquids. It's hard to know what (R59) wants. I often see the mother bring in pudding but no other foods. Maybe the facility should check on what foods the mother brings in or not feed (R59) at all. The facility had not thought about inspecting food brought in. (R59) is a choking hazard. During an interview on 8/27/25 at 12:58 PM, Speech Therapist (SLP) BB stated, (R59) was on mechanical soft (food that is soft, moist, and tender but still requires chewing) when she was first admitted . But she was not chewing well so she was placed on pureed foods. She has some things going on now with her swallowing and is scheduled to be seen by therapy. Her mother feeds her sometimes. Review of R59's Progress Note dated 8/20/25 at 2:07 PM, revealed a CNA (certified nursing assistant) notified licensed staff R59 was having a hard time swallowing and hardly ate anything. The resident was also noted to be coughing when she was eating and holding food in her mouth. Speech therapy was notified to screen.

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer in 1 Resident (#10) of 5 residents reviewed for pressure ulcers resulting in Resident #10 developing a stage 2 (a partial-thickness loss of skin; open wound; bedsore) pressure ulcer on her right shoulder.Findings include:Resident #10Review of an admission Record revealed Resident #10 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: displaced fracture of the greater trochanter of the right femur (fractured hip), muscle weakness, and unspecified fall.Review of a Minimum Data Set (MDS) assessment for Resident #10, with a reference date of 8/20/2025 revealed a Section GG - Functional Ability- Mobility- score of 02- (Substantial/maximal assistance- Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) A. Roll left and right: the ability to roll from lying on back to left and right side and return to laying on back.In a telephone interview on 8/25/2025 at 2:01 pm, Family Member (FM) Y reported that Resident #10 had taken a turn for the worse and was now on hospice services. FM Y reported Resident #10 now had a bedsore but the details of where it came from or how it happened were vague, and he was unsure of the details. Review of Social Service Progress Note for Resident #10 dated 8/13/2025 at 15:14 pm, (3:14 pm) revealed .Res (Resident) admitted to Name Omitted hospice today.Review of Nursing Progress Note for Resident #10 dated 8/15/2025 at 11:08 am, revealed .Resident has had a significant decline.Review of Nursing Note for Resident #10 dated 8/19/2025 at 12:18 pm, revealed Late Entry: Resident #10 acquired in-house pressure wound stage 2 to right posterior shoulder: measurements 1.5 cm x 1.0 cm x 0.1 cm.Review of Weekly Wound/Ulcer Observation for Resident #10 dated 8/22/2025 at 11:18 am, revealed .weekly observation of pressure ulcer/injury. Location: Right shoulder (rear) - Pressure: Length = 1.5, width = 1.5, depth = 0.1 - Stage II (2) Light amount of serous (thin, clear, and watery type of liquid that leaks from a wound) drainage noted. care plan has been reviewed/revised as indicated based on assessment finings.Review of Care Plan for Resident #10 revealed .Focus Resident #10 has limited physical mobility r/t (related to) impaired physical mobility, generalized weakness.Intervention: .observe for any s/sx (signs and symptoms).skin-breakdown.Date initiated 3/03/2025. provide supportive care, assistance with mobility as needed.Date initiated 3/03/2025.has potential impairment to skin integrity r/t general weakness, impaired physical mobility. Date initiated 2/12/2025.will remain clean and intact skin.Date initiated on 2/12/2025.Keep skin clean and dry.use draw sheet or lifting device to move resident. Date initiated 2/12/2025. No care plan was noted related to Resident #10's wounds.During an observation on 8/26/2025 at 9:50 am, Registered Nurse (RN) R with the assistance of RN Q were noted to turn Resident #10 in bed, assisting Resident #10 to hold the position, up on her left side, to expose her right shoulder for a dressing change. Resident #10 did not assist with turning in bed. No draw sheet was present under Resident #10 for staff to use during repositioning and/or lifting. Following the completion of the dressing change, Resident #10 was positioned onto her left side with the assistance of both RN R and RN Q and the use of pillows for Resident #10 to maintain the position in bed. Resident #10 did not actively assist to reposition self or resist care during the observation. In an interview on 8/26/2025 at 10:00 am, RN R reported Resident #10's was not able to reposition herself in bed at this time and RN R reported the wound on Resident #10's right shoulder was pressure related.Review of UDA Note for Resident #10 dated 5/12/2025 at 10:08 am, revealed .BRADEN Scale (a standardized, evidence-based assessment tool used in healthcare to assess a patient's risk for developing pressure injuries) completed today with a score of 15.0 (15-17 moderate risk) indicating that Resident #10 is at AT RISK for pressure injury/wound development. In an interview on 8/27/2025 at 9:53 am, Certified Nurse Assistant (CNA) II reported Resident #10 had a decline about a month ago, and she now needed more help from staff. CNA II reported Resident #10 needed staff to provide all her care including repositioning in bed. CNA II reported Resident #10 was no longer getting out of bed.In an interview on 8/27/2025 at 10:10 am, RN Q reported Resident #10 was weak and now bed bound. RN Q reported Resident #10 was dependent on staff for all cares.In an interview on 8/27/2025 at 11:03 am, RN R reported care plans are completed by floor nurses and the management nurses. RN R reported wound specific care plans should be created, and that she may be responsible for creating them. RN R reported turning and repositioning a resident was a standard of care and was not always listed as an intervention on a care plan. RN R reviewed Resident #10's care plan and reported Resident #10 did not have pressure ulcer prevention interventions in her care plan. RN R confirmed that Resident #10's pressure wound on her right shoulder was facility acquired and was pressure related.In an interview on 8/27/2025 at 11:26 am, MDS Nurse (MDSN) XX reported the wound nurse should create care plans related to wounds and skin. MDSN XX reported the nurse managers collaborated on care plans during IDT (interdisciplinary Team) meeting and made changes as needed. MDSN XX reported that Resident #10 had recently had a significant change and her care plan was reviewed and updated last week. MDSN XX reported Resident #10's care plan was updated after her pressure wound was found.In an interview on 8/27/2025 at 11:38 am, Director of Nursing (DON) B reported the IDT team does a clinical review of care plans, and that MDSN XX manages care plans. DON B reported the IDT team was reviewing a few care plans at each meeting.In an interview on 8/27/2025 at 11:44 am, Unit Manager (UM) S reviewed Resident #10's care plan and stated .skin on page 4 and she has gone hospice since that. use a draw sheet. I need to update this one too. In an interview on 8/27/2025 at 11:48 am, DON B reported her expectations were that a resident's care plan was a direct reflection of the resident's current condition.

This citation pertains to MI 1241872.Based on interview and record review, the facility failed to report a resident-to-resident physical incident to the State Agency for 2 (Resident #3, Resident #5) of 5 residents reviewed for abuse, resulting in the potential for continued resident to resident incidents, an incomplete investigation and residents not being protected from abusive individuals. Findings include:Resident #3 (R3)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3 admitted to the facility on [DATE] with pertinent diagnoses including schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly and is characterized by thoughts or experiences that seem out of touch of reality, disorganized speech or behavior and decreased participation in daily activities), anxiety, and adult failure to thrive. Brief Interview for Mental Status (BIMS) was not able to be completed due to R3 being cognitively impaired. R3 was discharged to a psychiatric hospital on 6/19/2025 and did not return to the facility prior to exit. Resident #5 (R5)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R5 admitted to the facility on [DATE] with pertinent diagnoses including Alzheimer's disease, depression, anxiety and dementia (memory loss and impaired judgement that interferes with daily functioning). Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which indicated R5 was severely cognitively impaired (00 to 07 is severe cognitive impairment).Review of R3's progress note dated 5/12/2025 revealed Nursing Note: Pt {Patient (R3)} went up to pt. {resident name omitted (R5)} yelled at her and hit her in the right upper arm. No bruising, swelling, redness, or pain noted.Another progress note dated 5/12/2025 revealed Nursing Note: The incident was unprovoked. The incident was observed by (Certified Occupational Therapist Assistant (COTA) F).Review of R3's Progress note dated 5/13/2025 revealed an IDT NOTE (interdisciplinary note) completed by Director of Nursing (DON) R Intended to document: Resident struck out at another resident.Review of the incident report dated 5/12/2025 at 7 AM revealed (R5) encountered (R3) yelling at her and got hit in the right upper arm while wheeling around the dining room, no bruising, swelling, redness, or pain noted. Incident was unprovoked. (COTA F) witnessed the incident. Under Agencies/People Notified, the State Agency was not notified. Review of the MI (Michigan) FRI (Facility Reported Incident) website revealed that the facility did not submit an initial report of the resident-to-resident incident and a final investigation to the State Agency.During an interview on 7/15/2025 at 11:44 AM, COTA F stated on 5/12/2025 she came through the front door at the facility and glanced into the dining room and saw R5 entering the dining room. R3 was sitting in the dining room and all of a sudden R3 got upset and hit R5 on her arm. COTA F' said she told the nurse about the incident but didn't let Nursing Home Administrator (NHA) Q know about it since it was early and he wasn't in the building yet.During an interview on 7/15/2025 at 11:51 AM, Registered Nurse (RN) P stated that she prepared the incident report and that COTA F witnessed the incident. RN P said that she reported the incident to NHA Q and DON R. RN P stated that DON R said she would handle the paperwork and contact the appropriate parties related to the incident. During an interview on 7/15/2025 at 11:57 AM, Social Services Director (SSD) E stated that the IDT (interdisciplinary team) discussed the incident between R3 and R5 on the morning of 5/12/2025 and they decided to send R3 to the psychiatric hospital that day. SSD E said that DON R was in the meeting and put a note in, but she wasn't sure if DON R or NHA Q reported the incident to the State Agency. SSD E stated that any resident-to-resident incident must be reported to the NHA. During an interview on 7/15/2025 at 1:17 PM, Unit Manager (UM) D stated that she didn't witness the incident on 5/12/2025 but it was discussed in IDT and both NHA Q and DON R were aware of the incident. UM D stated that any resident-to-resident incident must be reported to the NHA. During an interview on 7/15/2025 at 1:30 PM, NHA A stated that she couldn't find a file on the resident-to-resident incident with supporting documentation and whether it was reported to the State Agency since she wasn't the NHA at that time. Review of the Abuse, Neglect and Exploitation Policy with a review date of 10/20/2022 revealed .VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Abuse Coordinator/Administrator, State Agency, Adult Protective Services and to all other required agencies.B. The Administrator will follow up with government agencies during business hours to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident as required by state agencies.

This citation pertains to intake #MI00147923. Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 4 residents (Resident #202) reviewed for medical records, resulting in the lack of documentation pertaining to catheter care, test results, vital signs, and resident status, as it related to an impending UTI (urinary tract infection). Findings include: Review of an Admission Record revealed Resident #202 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary retention. In an interview on 11/13/24 at 1:51 PM, Licensed Practical Nurse (LPN) K reported that she had noticed on 11/10/24 that Resident #202 was not himself, was pale in color, not eating and drinking, had a large amount of sediment and blood in his urine, and was not using his typical sign language to communicate. LPN K reported that she had come across UA (Urinalysis:urine test) results that clearly indicated an infection, but were incomplete, so she called for the final results. LPN K reported that the results were from several days prior, but did not appear to have been addressed. In an interview on 11/14/24 at 2:56 PM, LPN M reported that she was concerned about Resident #202's UA results on 11/8/24 and had sent MD (Medical Director) C an email, but did not hear anything back prior to finishing her shift on 11/9/24. LPN M reported that Resident #202's urine was cloudy and bloody, and based on the UA result, he had a UTI. LPN M reported that typically UA results were available in 48 hours or less, and C&S takes at least 48 hours. LPN M reported that Resident #202's urine color and clarity should have been documented in progress notes, the CNA's (Certified Nursing Assistants) are expected to document color and amount of output, and the nurses should have orders in place to ensure catheter care was being provided. Review of Resident #202's Progress Note dated 11/3/24 at 7:20 PM revealed, at 7:30 PM urine specimen collected and sent to (lab name). There were no nurse's notes, and/or physician visits recorded between the above note on 11/3/24 and 11/8/24. Review of Resident #202's Progress Note dated 11/8/24 at 10:02 PM revealed, sent a message to Dr. to review resident's UA (urinalysis: urine test) results. There were no nurse's notes, and/or physician visits recorded between the above note on 11/8/24 and 11/10/24. Review of Resident #202's Progress Note dated 11/10/24 at 2:16 PM revealed, observed UA results at nurse's station today with no susceptibility results. Called for results to be faxed. Called (Medical Director (MD) C) who says to send to ER (emergency room ). Resident's V/S (vital signs): 92/70 (blood pressure) 113 (heart rate) 97.3 (temperature) 93% (blood oxygen level) .Resident is not eating and drinking as per his normal and appears weak. Called DON (Director of Nursing) with update . Review of Resident #202's UA Results were collected on 11/3/24 at 8:08 PM, and resulted on 11/3/24 at 8:49 PM. The results indicated the urine was turbid (cloudy), contained a moderate amount of blood, a large amount of Leukocyte esterase (indicates a UTI or inflammation), greater than 100 WBC (white blood cells: indicates infection), 48 RBC (red blood cell count: indicates issues such as infection), and a moderate amount of bacteria (indicates an infection). The report had a print stamp by facility staff on 11/4/24 at 10:52 AM. Based on the abnormal results, a Urine C&S was automatically added to the UA test. The C&S results were final on 11/8/24 at 9:10 AM. The results indicated greater than 100,000 CFU/ml Pseudomonas Aeruginosa (indicating a serious bacterial infection), and the recommended antibiotics to treat the infection. The C&S report was received via fax by facility staff on 11/10/24 at 1:54 PM. Review of Resident #202's documentation of Vital Signs indicated that the resident had normal vital signs, including temperatures on 11/3/24 and 11/7/24, but there were no vital signs recorded after that until 11/10/24 when the resident was sent to the hospital. Review of Resident #202's Treatment Administration Record (TAR) revealed no orders for catheter care and/or monitoring. Review of Resident #202's documentation of CNA (Certified Nursing Assistant) Tasks from the past 30 days revealed, Catheter Care was recorded as performed 0/30 days, and Catheter Output (urine) Amount was recorded as performed 0/30 days. In an interview on 11/14/24 at 1:38 PM, DON/Infection Preventionist B reported that Resident #202 did not have any documentation of his signs or symptoms related to a UTI, and was not being regularly monitored for a UTI. DON/IP B reported that with Resident #202 being lethargic, and considering his history of repeated UTI's, he should have had regular monitoring of vital signs, and prompt follow up of his urine test results. In an interview on 11/14/24 at 2:47 PM, CNA I reported that Resident #202 had decrease appetite, and his urine was cloudy a couple days prior to his hospitalization . CNA I reported that the CNA's are expected to report catheter output to the nurse and then the nurse documents it in the record. In an interview on 11/14/24 at 2:25 PM, CNA J reported that catheter output amounts are reported to the nurse. In an interview on 11/14/24 at 2:30 PM, LPN K reported that the CNA's should be documenting catheter output amounts.

Based on observation, interview, and record review, the facility failed to ensure adaptive dining equipment was provided per physician's order for 1 (Resident #201) of 3 residents reviewed for food, resulting in the potential for difficulty with self-feeding and weight loss. Findings include: Resident #201 Review of an Admission Record revealed Resident #201 was a female, with pertinent diagnoses which included: vascular dementia, unspecified severity; unspecified lack of coordination; and stiffness of unspecified hand. Review of a current Physician's Order for Resident #201 revealed, Regular diet Mechanical Soft texture, Thin Liquids consistency, Divided plates for all meals .Order Status Active Order Date 5/12/2023 Start Date 5/12/2023 . Review of a current Care Plan for Resident #201 revealed a focus of (Resident #201) is at risk for nutritional problem or potential nutritional problem r/t (related to) Dementia secondary HTN (high blood pressure), hyperlipidemia (elevated levels of fat in the blood), vascular dementia with behavioral disturbance, mild cognitive impairment, obesity, wt (weight) fluctuations with diuretics in place, dysphagia (swallowing difficulty) with mech (mechanical) soft diet in place last revised 7/18/24 with pertinent interventions which included Provide divided plate for all meals with a date initiated of 8/9/24. During an observation on 11/13/24 at 12:53 PM in the dining room, noted Resident #201 was seated at a table with her lunch meal in front of her. The entree, which appeared to be chicken casserole, was served on a regular flat plate, and not in a divided dish as specified on Resident #201's Tray Ticket. Review of a Tray Ticket for Resident #201 revealed .INSTRUCTIONS: Real Silverware, NO Styrofoam, Divided Plate In an interview on 11/14/24 at 11:31 AM, Registered Dietitian (RD) Q reported sometimes Resident #201 needed help to eat and sometimes she was able to eat on her own. RD Q reported Resident #201 used a divided dish to help with self-feeding ability because it made it a little easier for her to see what food she had and helped her to get food onto her utensils because of the edges in each of the wells of the plate. RD Q reported Resident #201 should have a divided plate for all meals.

Based on observations, interviews, and record review, the facility failed to ensure a positioning device (a left resting hand splint) was applied per therapy recommendations for 1 (Resident #201) of 3 residents reviewed for therapy services, resulting in the potential for contracture progression (hardening of the muscles, tendons, and other tissues), pain, and decline in range of motion. Findings include: Resident #201 Review of an Admission Record revealed Resident #201 was a female, with pertinent diagnoses which included: vascular dementia, unspecified severity; and stiffness of unspecified hand. Review of a current Care Plan for Resident #201 revealed a focus of (Resident #201) has an ADL (activities of daily living) self-care performance deficit r/t (related to) dementia, HTN (high blood pressure), lack of coordination, balance issues . last revised on 10/18/24 with care planned interventions which included (Resident #201) is to wear left resting hand splint (a positioning device) when out of bed with a date initiated of 10/22/24. A review of Resident #201's current Order Summary Report on 11/14/24 at 10:50 AM, revealed no physician order for Resident #201 for a left resting hand splint. During an observation on 11/13/24 at 12:28 PM, Resident #201 was seated at a table in the dining room waiting for her lunch meal. Resident #201 was not wearing a left resting hand splint. During an observation on 11/13/24 at 1:49 PM, Resident #201 was seated in her wheelchair across from the nurses' station on the unit where she resided. Resident #201 was not wearing a left resting hand splint. During an observation on 11/14/24 at 10:26 AM, Resident #201 was seated at a table in the dining room observing other residents who were engaged in a kickball activity. Resident #201 was not wearing a left resting hand splint. During an observation on 11/14/24 at 12:41 PM, Resident #201 was seated at a table in the dining room waiting for her lunch meal to be served to her. Resident #201 was not wearing a left resting hand splint. In an interview on 11/13/24 at 3:14 PM, Certified Nurse Aide (CNA) G was queried by this surveyor about Resident #201's left resting hand splint. CNA G reported thought Resident #201 had something for her wrist at some point, but haven't seen that in a while and that therapy usually handled that. In an interview on 11/14/24 at 10:34 AM, Physical Therapist (PT) P reported therapy had recommended the left resting hand splint for Resident #201 because of hand pain. PT P reported Resident #201 had previously had a different hand splint but that she would remove it, so therapy recommended the current left resting hand splint in hopes that Resident #201wear it without trying to remove it. PT P reported the purpose of the splint was to prevent/manage contracture progression and pain of Resident #201's left hand. PT P reported therapy had given nursing staff training on applying the splint and instructed on the splint wearing schedule. Review of Resident #201's Occupational Therapy Treatment Encounter Note dated 10/23/24 revealed, .Manual tx (treatment): provided joint mobilization techniques and stretching of shortened connective tissue left hand .pt (patient) indicated no pain with movement this date; resting hand splint applied following manual tx .Skilled interventions focused on caregiver education for resting hand splint application and wearing schedule, instruction provided to unit nurse and CNAs (certified nurse aides) . In an interview on 11/14/24 at 1:32 PM, Licensed Practical Nurse (LPN) K reported she regularly worked with Resident #201. LPN K reported hadn't seen a splint for Resident #201 for quite some time. LPN K reported knew Resident #201 had a splint at one point and thought maybe it had been discontinued. LPN K reported if a CNA attempted to apply the splint to Resident #201's hand and she refused to wear it, the refusal should be documented in the medical record. LPN K reported there should be a physician order if a resident was to wear a splint or other positioning device. In an interview on 11/14/24 at 12:50 PM, Director of Nursing (DON) B reported there was no physician order entered for Resident #201's left resting hand splint but there should have been. DON B reported if staff attempted to apply the splint and Resident #201 refused, there would be documentation in Resident #201's medical record. DON B reported there was no documentation in Resident #201's medical record to show that she was offered or refused to wear the left resting hand splint that was recommended by therapy.

This citation pertains to intake #MI00147923. Based on interview and record review, the facility failed to ensure adequate monitoring, assessment and care for 1 resident (Resident #202) of 3 residents, with an indwelling catheter, reviewed for urinary catheter/UTI (urinary tract infection) care, resulting in hospitalization due to severe UTI and Sepsis. Findings include: Review of an Admission Record revealed Resident #202 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary retention. In an interview on 11/13/24 at 1:51 PM, Licensed Practical Nurse (LPN) K reported that she had noticed on 11/10/24 that Resident #202 was not himself, was pale in color, not eating and drinking, had a large amount of sediment and blood in his urine, and was not using his typical sign language to communicate. LPN K reported that she had come across UA results that clearly indicated an infection, but were incomplete, so she called for the final results. LPN K reported that the results were from several days prior, but did not appear to have been addressed. LPN K reported that she called DON B and MD C to get permission to send Resident #202 to the hospital. In an interview on 11/14/24 at 2:56 PM, LPN M reported that she was concerned about Resident #202's UA results on 11/8/24 and had sent MD C an email, but did not hear anything back prior to finishing her shift on 11/9/24. LPN M reported that Resident #202's urine was cloudy and bloody, and based on the UA result, he had a UTI. LPN M reported that UA results are available in 48 hours or less and C&S takes at least 48 hours. LPN M reported that Resident #202's urine color and clarity should have been documented in his progress notes, the CNA's are expected to document color and amount of output, and the nurses should have orders to ensure catheter care is being provided. Review of Resident #202's Urology Visit Notes dated 10/31/24 revealed, .Hospital follow up .Exam: .foley draining cloudy urine .Assessment/Plan: 1. Urolithiasis (stone in urinary system) .Discussed with caregiver that we need permission from (guardian) to proceed with cystoscopy (procedure to see the inside of the bladder and urethra), litholapaxy (procedure to break up bladder stones), bilateral ureteroscopy (procedure to examine and treat the upper urinary tract), laser lithotripsy (procedure to break up kidney stones) and bilateral stent exchange once his infection is cleared .plan for this 11/6. In the meantime, we will have (facility) change foley and submit urine for C&S in the next 24 hours .4. UTI and suspect upper tract involvement - last urine culture with morganella (bacteria), pseudomonas (bacteria) and proteus (bacteria), he completed tx (treatment) with Cefepime (antibiotic) on 10/18 .(facility) change foley and submit urine for C&S (culture and sensitivity test to determine which antibiotic will be needed to treat the bacteria) in the next 24 hours . The visit note was printed by facility staff on 11/5/24. There were no nurse's notes, and/or physician visits recorded between 10/23/24 and 11/3/24. Review of Resident #202's Progress Note dated 11/3/24 at 7:20 PM revealed, at 7:30 PM urine specimen collected and sent to (lab name). The urine test was obtained 36 hours after Resident #202's urology appointment, and not 24 hours as ordered. There were no nurse's notes, and/or physician visits recorded between the above note on 11/3/24 and 11/8/24. Review of Resident #202's Progress Note dated 11/8/24 at 10:02 PM revealed, sent a message to Dr. to review resident's UA (urinalysis: urine test) results. There were no nurse's notes, and/or physician visits recorded between the above note on 11/8/24 and 11/10/24. Review of Resident #202's Progress Note dated 11/10/24 at 2:16 PM revealed, observed UA results at nurse's station today with no susceptibility results. Called for results to be faxed. Called (Medical Director (MD) C) who says to send to ER (emergency room ). Resident's V/S (vital signs): 92/70 (blood pressure) 113 (heart rate) 97.3 (temperature) 93% (blood oxygen level) .Resident is not eating and drinking as per his normal and appears weak. Called DON (Director of Nursing) with update . Review of Resident #202's UA Results were collected on 11/3/24 at 8:08 PM, and resulted on 11/3/24 at 8:49 PM. The results indicated the urine was turbid (cloudy), contained a moderate amount of blood, a large amount of Leukocyte esterase (indicates a UTI or inflammation), greater than 100 WBC (white blood cells: indicates infection), 48 RBC (red blood cell count: indicates issues such as infection), and a moderate amount of bacteria (indicates an infection). The report had a print stamp by facility staff on 11/4/24 at 10:52 AM. Based on the abnormal results, a Urine C&S was automatically added to the UA test. The C&S results were final on 11/8/24 at 9:10 AM. The results indicated greater than 100,000 CFU/ml Pseudomonas Aeruginosa (indicating a serious bacterial infection), and the recommended antibiotics to treat the infection. The C&S report was received via fax by facility staff on 11/10/24 at 1:54 PM. Review of Resident #202's Ambulance Report dated 11/10/24 revealed, .On scene 2:28 PM .Patient was found laying in bed .Patient skin was pale, extremely warm and dry. Patient had a urinary catheter and it was cloudy and thick sediment in the tubing and blood was noted as well. Staff on scene advised that the patient got a UA done on November 3rd and got the results on November 4th that he had a UTI and was septic. Nurse advised that since she last worked there has been no new notes in the system and no vital signs charted on the patient. Nurse also advised that the facility doctor was made aware of the UA results on November 8th .Nurse stated that when she called the facility doctor today to get permission to send the patient out and the doctor stated on the phone that she had zero idea of the results . Review of Resident #202's Hospital Records course of stay 11/10/24 to present (11/14/24) revealed, .significant medical history of recurrent urinary tract infections with a chronic indwelling Foley catheter .presented to the emergency department for altered mental status .Review of previous microbiology (urine test) showed susceptibility to Zosyn (antibiotic) and this was started in the ED (emergency department). Vancomycin (antibiotic) also started. Labs were remarkable for elevated WBC and creatinine. Due to most recent history, obtained a CT (detailed x-ray image) of the abdomen and pelvis without contrast. Imaging was remarkable for misplaced Foley catheter and severely distended urinary bladder. Likely contributing to AKI (acute kidney injury). Replaced catheter in the ED with good output .Attempted to call (facility) however unable to reach RN (registered nurse). Patient is also unable to give history. He has a significant medical history of a chronic indwelling Foley catheter, bilateral deafness, learning delay. Of note, patient was recently in the hospital on October 2, 2024 for septic shock secondary to urosepsis .Clinical impression/plan: .Septic shock due to Pseudomonas .secondary to urologic infection as noted by CT scan with hydronephrosis (back up of urine into the kidney), Foley catheter balloon inflation in urethra, both urine and blood cultures showing both Pseudomonas and Proteus . Review of Resident #202's documentation of Vital Signs indicated that the resident had normal vital signs, including temperatures on 11/3/24 and 11/7/24, but there were no vital signs recorded after that until 11/10/24 when the resident was sent to the hospital. Review of Resident #202's Treatment Administration Record (TAR) revealed no orders for catheter care and/or monitoring. Review of Resident #202's documentation of CNA (Certified Nursing Assistant) Tasks from the past 30 days revealed, Catheter Care was recorded as performed 0/30 days, and Catheter Output (urine) Amount was recorded as performed 0/30 days. In an interview on 11/14/24 at 1:38 PM, DON/Infection Preventionist B reported that she was not made aware that Resident #202's urologist had wanted Resident #202's catheter changed and a urine C&S obtained immediately after his appointment on 10/31/24. DON/IP B reported that the facility did not send a communication sheet along with residents and/or have a process in place to receive information such as visit notes and test results, timely and efficiently. DON/IP B reported that due to Resident #202's upcoming surgery, they changed his catheter and obtained a urine specimen for testing. DON/IP B reported that Resident #202 was lethargic (drowsy) and suspected to have a UTI on 11/3/24, but that was not the reason that the UA was obtained. DON/IP B reported that Resident #202 did not have any documentation of his signs or symptoms related to a UTI, and was not being regularly monitored for a UTI. DON/IP B reported that with Resident #202 being lethargic, and considering his history of repeated UTI's, he should have had regular monitoring of vital signs, and prompt follow up of his urine test results. In an interview on 11/14/24 at 2:47 PM, CNA I reported that Resident #202 had decrease appetite, and his urine was cloudy a couple days prior to his hospitalization . CNA I reported that the CNA's are expected to report catheter output to the nurse and then the nurse documents it in the record. In an interview on 11/14/24 at 2:25 PM, CNA J reported that catheter output amounts are reported to the nurse. In an interview on 11/14/24 at 2:30 PM, LPN K reported that the CNA's should be documenting catheter output amounts.

Based on interview and record review, the facility failed to provide annual required abuse prevention education for all employees. This has the potential to affect all 79 residents residing in the facility at the time of the survey. Findings include: Review of Preventing The Abuse of Residents with Dementia or Alzheimer's Disease In The Long-Term Care Setting: A Systematic Review, Published by The National library of Medicine, 2019, revealed . there is an increasing rate of abuse in the long-term care setting, specifically for those individuals with either dementia or Alzheimer's. Common causes and risk factors leading to this abuse include poor training . In an interview on 09/11/24 at 11:06 AM, Certified Nursing Assistant (CNA) V reported (Vendor) training application was on a schedule to be completed. CNA V reported there was not much time at work to complete the trainings as would get pulled to the floor to work and/or they have their charting to do for the residents and it doesn't leave much time to complete the assigned trainings. CNA V reported they were able to access the application at home and could complete the training at home and would submit a slip to the timekeeper to get paid for completion of the training. In an interview on 09/11/24 at 12:34 PM, Receptionist EEE reported she would run reports, employees needed certain classes to start work on the floor for any department. Receptionist EEE reported she would during orientation, checked completed the classes to ensure they were finished prior to the staff working on the floor. Receptionist EEE reported the staff have different due dates for the training to be finished based on their hire dates. Receptionist EEE reported she would send reminders to each employee to complete the trainings, a report would be generated by department each month and sent to the supervisor to remind the employees. In an interview on 09/11/24 at 12:29 PM, Administrator A reported nursing would complete any trainings when needed as well as the training required for completion in the (Vendor) program. The electronic training in (Vendor) program was tracked by Receptionist EEE. Review of the facility's Employee training records, revealed the facility was unable to provide evidence 33 out of 104 staff members received annual abuse prevention training prior to the beginning of the survey on 9/10/24. Review of (Vendor) Training Plans received on 9/11/24, revealed, .New Hire Orientation: All courses marked with an asterick (*) must be completed prior to working independently .All Staff: Preventing, Recognizing, and Reporting Abuse . Review of policy Abuse, Neglect, and Exploitation revised on 10/20/22, revealed, .11. Employee Training .A. New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation .B. Existing staff will receive annual education through planned in-services and as needed .C. Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; 3. Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources; 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out; and e. Difficulty in adjusting to new routines or staff .

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards. Findings include: In an interview on 09/12/24 at 10:09 AM, Director of Nursing (DON) B reported that she was the facilities IP, and ran the infection control program for the facility, with the assistance of Unit Manager (UM) LL. DON B reported that she had completed all of the modules from the CDC (Center for Disease Control and Prevention) IP certification training program, but did not complete the post test. DON B reported that she did not have an IP certificate. DON B reported that the facility does not have anyone from corporate overseeing their infection control program, and that it had been DON B's sole responsibility. In an interview on 09/12/24 at 10:10 AM, UM LL reported that she had not completed the IP certification training, therefore was not a certified IP. In an interview on 09/12/24 at 02:13 PM , Nursing Home Administrator (NHA) A reported that she was not aware that DON B had not completed the IP certification training.

Based on interview and record review, the facility failed to ensure that Quality Assessment and Assurance (QAA) meetings were held at least quarterly and the required individuals attended the meetings resulting in the potential for quality deficiencies not being identified or corrected. Findings include: Review of the Quality Assurance and Performance Improvement (QAPI) meeting sign in sheets revealed that the facility had QAPI meetings on 10/20/2023, 12/21/2023, 1/25/2024 and 8/29/2024. The Medical Director did not attend the QAPI meeting on 1/25/2024 and on 8/29/2024. There were no QAPI meetings from 1/25/2024 to 8/29/2024. During an interview on 9/12/2024 at 11:08 PM, Nursing Home Administrator (NHA) A stated that there wasn't a QAPI meeting since 1/25/2024 until 8/29/2024 but she had been meeting with each department head individually and goes over information for the month. Review of the Quality Assurance and Performance Improvement (QAPI) Policy with an implementation date of 3/2023 and a review date of 2/2024 revealed Policy Explanation and Compliance Guidelines: 1. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. 2. The QAA Committee shall be interdisciplinary and shall: a. Consist at a minimum of: i. The Director of Nursing Services; ii. The Medical Director or his/her designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other Individual in a leadership role; and iv. The Infection Preventionist. b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary.

Based on interview and record review, the facility failed to employ a dietary manager with appropriate training and certifications to provide oversight of the kitchen increasing the potential for food service sanitation failures and food borne illness for all residents that consume food from the kitchen. Findings include: During the initial tour of the kitchen on 9/10/2024 at 9:30 AM, Dietary [NAME] (DC) H stated that they haven't had a dietary manager in the kitchen for over a month since the last dietary manager left. DC H said she wasn't sure when the Registered Dietitian (RD) comes in and if she monitors the kitchen when she is there. During an interview on 9/10/2024 at 4:58 PM, Nursing Home Administrator (NHA) A stated that she was aware that there isn't a manager in the kitchen and she tries to go back there to help but she is busy with her own job. During another interview on 9/11/2024 at 9:26 AM, NHA A stated that the RD comes in about 8 hours a month and doesn't monitor the kitchen when she is there.

Based on observation, interview and record review, the facility failed to provide consistent, meaningful and person-centered activities for 4 of 7 residents (Resident #16, #56, #60, #178) reviewed for activities provided by the facility, resulting in the potential for loss of interaction, joy, self-esteem, growth, sense of wellbeing, autonomy, connectedness, identity, creativity, independence, pleasure, and comfort. This has the potential to affect all 15 residents residing on the dementia care unit. Findings include: Review of Facility assessment dated [DATE], revealed, .Activities: Assistant 4 FT .Activity Assistant- High School Diploma or GED, prior experience in a resident activities program in a health setting preferred, prior completion of a state-approved training course or willingness to complete such a course within 6 months of employment .Previous experience within a healthcare setting .Activities Management Administration 1 Experience with persons with dementia Previous experience within a healthcare setting . Review of the September 2024 activity calendar revealed, Tuesday, September 10, 24: 9:30 Roll N Stroll .10:30 Board Games .12:00 Day in History .2:45 Pool Noodle Hockey .4:00 Ants on a log .7:15 Lucky Bingo; Wednesday, September 11, 24: 9:30 Bible Stories, 10:30 Dominoes, 12:00 BlackJack .2:30 [NAME] (music entertainer) .4:15 Men's Club; Thursday, September 12, 24: 9:30 Short Stories .10:30 Coffee Club .11:30 Book Club .12:15 YouTube Trivia .2:30 PM Movie & Popcorn . Review of the September 2024 activity calendar on the Memory Care Unit (MU), revealed, .Tuesday, September 10, 24: Room visits, Pictionary, Coffee Time, Manicures, Cooking Ants on Log, Outside/Exercise .Wednesday, September 11, 24: Room visits, Chair Exercise, Coffee Time, 2:30 [NAME], Ball toss, Word Games, Outside/Reminiscence .Thursday, September 12, 24: Room visits, Fish Bowl Game, Coffee Time, Devotional, Card game, Movie + Popcorn, Ball Toss . During an observation on 9/10/24 on the memory care unit, no activities that were posted on the scheduled activities on the board in the TV room area were observed from 10:00 am through 3:30 pm. Also noted, no individualized activities throughout initial tour, unit observations, sampled resident observations, as well as individual non-sampled residents in their rooms/hallways were observed throughout the day. During an observation on 09/10/24 at 10:34 AM, located in the TV room under the TV was the activity cart which had a radio, bible stories book, dominoes, magnet tiles and items in the cart. Next to the cart on the floor were a smaller ball and an inflatable medium beach ball. There was a basket with items to fold in it on the cart, a container with blocks under it and a bag with Lilo and stitch on it on top of it which had stuffies and babies. There were a couple books of word searches and a few magazines as well. Resident #16: Review of an Admission Record revealed Resident #16 was a female with pertinent diagnoses which included dementia, anxiety, stroke, and dysphagia (damage to the brain responsible for production and comprehension of speech). Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 9/11/23 revealed, .Section F: Somewhat important: Books, newspapers, and magazines to read; listen to music you like; around animals, keep up with the news, get fresh air when weather is good, participate in religious services or practices, do things with groups of people, and do your favorite activities . Review of current Care Plan for Resident #16, revised on 9/13/23, revealed the focus, .Care Plan: (Resident #16) is new to healthcare facility environment little to no involvement r/t (related to) participation in therapy and or family visits .She enjoys music and singing, crafts, socializing. She used to work at the school . with the intervention .Encourage invite and assist as needed to activities of choice/interest as tolerated by (Resident #16) .Offer 1 step instruction or demonstration as needed for task related activities .(Resident #16) interests include crafts, music, socializing, church .ACTIVITIES: Invite to activity programs that encourage physical activity, physical mobility, such as exercise group, walking activities to promote mobility . Review of Activities Interview -Daily and Activity Preferences was last completed on 9/11/23. Review of Resident #16's Activity Task in the electronic medical record was conducted for a 30-day look back period. Documentation revealed R#16 had only two documented one-on-one activities. Review of Resident #16's Activity Task in the electronic medical record was conducted for a 30 day look back period. Documentation revealed R#16 did not have any group activities documented for 8/15/24, 8/21/24, 8/23/24, 8/24/24, 9/1/24, 9/4/23, 9/7/24, and 9/10/24. During an observation on 09/10/24 at 10:05 AM, Resident #16 was observed seated next to Resident #39 in the TV room in the recliners. She had her eyes closed. During an observation on 09/10/24 at 10:22 AM and 09/10/24 at 11:05 AM, Resident #16 was seated in a recliner in the tv room. During an observation on 09/10/24 at 12:27 PM, Resident #16 was observed ambulating in the hallway and went into the TV room area and was asking if she should stay right here. She took a seat in the TV room. During an observation on 09/10/24 at 12:40 PM, Resident #16 was observed exiting her room and went down the hallway towards another resident's room and closed the door and then came back down the hallway. During an observation on 09/10/24 at 01:15 PM, Resident #16 was observed seated at a table in the dining room and she had a cup of coffee. During an observation on 09/10/24 at 01:10 PM, Resident #16 was attempting to gather meal trays from the cart in the tv room. During an observation on 09/11/24 at 11:16 AM, Resident #16 was observed seated in a recliner in the tv room area. During an observation on 09/12/24 at 10:59 AM, Resident #16 was ambulating in the tv and dining room area and appeared confused. She left the room and headed to her room. Resident #16 was not observed to be involved in church activities, crafts, singing and walking activities for the duration of the survey. Resident #56: Review of an Admission Record revealed Resident #56 was a female with pertinent diagnoses which included dementia, anxiety, major depressive disorder, lack of coordination, muscle weakness, cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language) and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #56, with a reference date of 7/11/24, revealed Section F: Very important to the resident to: do things with groups of people; do your favorite activities, and to go outside to get fresh air when the weather is good . Review of current Care Plan for Resident #56, revised on 6/26/23, revealed the focus, .(Resident #56) is dependent on staff for activities, cognitive stimulation, social interaction r/t cognitive deficits. She had stated her interests as being reading, music, going outside, church, games, puzzles, crafts . with the intervention .All staff to converse with (Resident #56) while providing care .Assure the activities (Resident #56) is attending are: compatible with physical and mental capabilities; compatible with known interests and preferences; Adapted as needed (such as large print, holders if (Resident #56) lacks hand strength, task segmentation, Compatible with individual needs and abilities, and age appropriate .Invite and escort as needed to activities of choice. Target music, religious groups, outdoor groups crafts, games and social groups .Offer (Resident #56) materials for independent use. (Resident #56) likes mysteries, word search and stated she knits and crochets . Review of Resident #56's Activity Task in the electronic medical record was conducted for a 30 day look back period. Documentation revealed Resident #56 did not have any group activities documented for 8/15/24, 8/21/24, 8/23/24, 8/24/24, 9/1/24, 9/4/23, and 9/7/24. Review of Resident #56's Activity Task in the electronic medical record was conducted for a 30-day look back period. Documentation revealed Resident #56 only had 6 days of documented one-on-one activities. Note Resident #56 had only one Activities Interview - Daily and Activity Preferences completed on 6/28/23. Resident #56 was not observed to be reading, completed word searches, knitting, or crocheting during the duration of the survey. Resident #60: Review of an Admission Record revealed Resident #60 was a male with pertinent diagnoses which included dementia, borderline personality disorder, anxiety, PTSD, and glaucoma. Review of a Minimum Data Set (MDS) assessment for Resident #60, with a reference date of 11/16/23 revealed, .Section F: Preferences for Routine & Activities revealed, Somewhat important - to have books, newspapers, and magazines to read, to do things with groups of people, to do your favorite activities, to go outside to get fresh air when the weather is good, participate in religious services and practices .Very important - have music you like . Review of current Care Plan for Resident #60, revised on 7/10/2018, revealed the focus, .(Resident #60) is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits . with the intervention .(Resident #60) needs assistance/escort to activity functions .Prefers to socialize with staff and other residents .Invite to scheduled activities .Provide a program of activities that is of interest and empowers (Resident #60) by encouraging/allowing choice, self-expression, and responsibility .Ensure that the activities (Resident #60) is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Compatible with individual needs and abilities . Review of Activities Initial assessment dated [DATE], revealed, .(Resident #60) likes to talk about life experiences. His conversation is disorganized. During this interview he did not answer any questions .Try to phrase questions so they can be answered with yes or no . Note: this was the only assessment completed for Activities. During an observation on 09/10/24 at 11:05 AM, Resident #60 was seated in his wheelchair next to a recliner in the doorway to the dining room area. He was not participating in an activity. During an observation on 09/11/24 at 11:16 AM, Resident #60 was observed seated in his wheelchair next to the sink in the tv room area, he appeared between sleepiness and awake. During an observation on 09/12/24 at 10:59 AM, Resident #60 was observed in the tv room area and he was asleep in his wheelchair. During an observation on 09/12/24 at 01:28 PM, Resident #60 was observed asleep in his wheelchair, had his chin resting on his chest area while seated in the dining room. Review of Resident #60's Activity Task in the electronic medical record was conducted for a 30 day look back period. Documentation revealed Resident #60 did not have any group activities documented for 8/15/24, 8/21/24, 8/23/24, 8/24/24, 9/1/24, and 9/7/24 and only had 3 days of documented one-on-one activities other than watching television Resident #60 was not observed to have books, newspapers, and magazines to read, to do things with groups of people, to do his favorite activities, participate in religious services and practices and listened to music he liked. Resident #178: Review of an Admission Record revealed Resident #178 was a male with pertinent diagnoses which included fracture of right humerus, restlessness and agitation, anxiety, dementia, and fall on same level from slipping, tripping, and stumbling. Review of a Minimum Data Set (MDS) assessment for Resident #178, with a reference date of 9/3/24 revealed, .Section F: Staff Assessment: snacks between meals, listening to music, doing things with groups of people, participating in favorite activities, and spending time outdoors . Review of current Care Plan for Resident #178, revised on 9/2/24, revealed the focus, .(Resident #178) is dependent on staff for activities, cognitive stimulation, social interaction r/t dementia. (Resident #178) was a computer technician, he loves trains, and train models. (Resident #178) likes camping and going for walks. He likes pets, kids and is friendly. (Resident #178) does not watch TV with the intervention .All staff to converse with resident while providing care .(Resident #178) needs assistance/escort activity functions .Encourage ongoing family involvement. Invite (Resident #178's) family to attend special events, activities, meals .Introduce (Resident #178) to residents with similar background, interests and encourage/facilitate interaction .Invite (Resident #178) to scheduled activities .Thank resident for attendance at activity function .When (Resident #178) chooses not to participate in organized activities, respect his decision and allow him to just observe, to provide sensory stimulation . Review of Resident #178's Activity Task in the electronic medical record was conducted for a 30 day look back period. Documentation revealed R#178 did not have any group activities documented for 8/27/24, 8/29/24, 8/30/24, 9/1/24, 9/2/24, 9/4/24, 9/6/24, 9/7/24, 9/8/24, 9/9/24, 9/10/24, and 9/11/24. Resident #178 was not observed to have any activities which dealt with computers, trains or model trains. (Resident #178) liked camping and going for walks. There were no pet visits for the duration of the survey. During an observation on 09/10/24 at 10:14 AM, Resident #178 got up from the recliner and headed to the sink area and looked at items around the sink. He headed out of the tv room area and went to the hallway to self ambulate. During an observation on 09/10/24 at 10:22 AM, Resident #178 was observed pushing on the back door and set off the alarm. During an observation 09/10/24 at 11:05 AM, Resident #178 was observed seated in a recliner in the corner in the tv room area. During an observation 09/10/24 at 12:23 PM, Resident #178 was observed ambulating by the door on the hallway where you enter the unit. During an observation on 09/10/24 at 12:27 PM, Resident #178 continued to self ambulate up and down the hallway. During an observation on 09/11/24 at 11:16 AM, Resident #178 was self ambulating in the dining room area, walked around, left and walked back out to the tv room area. During an observation on 09/12/24 at 10:59 AM, Activities Director (AD) D came to the memory care unit and gathered residents to go to the coffee time in the main dining room. Only 3 residents were brought out of the unit to the main dining room. In an interview on 09/10/24 10:55 AM, Activities Director (AD) D reported she was going around and checking to ensure the activity calendars were still up as they tend to get taken down. She reported Activity Aide (AA) E was the only AA today as the other person called in sick, and the other AA was out on personal time off. In an interview on 09/12/24 10:26 AM, Activity Aide (AA) E reported she would go around and ask everybody, document the refusals, and for those residents who were bed bound we would do a sensory group every morning for those who were impaired. AA E reported she had time between each activity and she would take that time to document in the records of those residents who participated in the activity. In an interview on 09/12/24 01:20 PM, AD D reported she was an assistant last fall and when the previous director left she was placed in that position. AD D reported then she was out the end of April 24 for a few months and she was new to the position really, still trying to catch up on the assessments, training of the activity aides as there were two new ones. AD D reported the residents should have had an activities assessment completed yearly and quarterly. AD D reported she would look at the likes and dislikes of each resident, talk to family about the resident's interests, and confer with staff as they would pick up on things the residents like or dislike. AD D reported she had been training the AAs to complete the documentation in the electronic medical record for each resident as prior it had been done on paper. AD D reported there were processes which needed tweaked and there needs to be some improvement. Review of policy, Dementia revised on 7/2024, revealed, .Our focus in the care of the resident with Dementia is on functioning, not etiology or pathology. Activities: Activities should be available around the clock. There are meaningful activities that can be done if the resident cannot sleep, that would not disturb other residents. Group activities should not have more than 10-15 in a group. Mentally stimulating activities should occur early in the day when cognitive function is at its highest . Review of Activity Involvement and Quality of Life of People at Different Stages of Dementia in Long Term Care Facilities, [NAME] & Twist (2015), published in Aging Mental Health, revealed Despite a Resident's cognitive status, their activity involvement was significantly related to better scores on care relationships, positive affect, restless tense behavior, social relations and having something to do. Review of The Needs of Older People with Dementia in Residential Care, Woods & [NAME] (2006), published in the International Journal of Geriatric Psychiatry revealed Determining which activities have high degree of meaningfulness can aide recreation staff in creating programs more likely to promote health and wellness for persons with dementia.

Based on observation, interview and record review, the facility failed to ensure proper label and dating of foods in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: During the initial tour of the main kitchen on 9/10/2024 at 9:30 AM, the cook's reach in refrigerator was observed to have the following: bag of open cheese slices in a ziploc bag with no label and date shredded pork thawing on the middle rack on a cookie sheet with ready to eat food below it The dietary aide's reach in refrigerator was observed to have the following: 1 gallon open Vit D milk jug with no label and date 1 gallon open 2% milk jug with no label and date 1 8-ounce milk in cup, covered with plastic wrap on tray with no label or date During another tour of the kitchen on 9/11/2024 at 9:26 AM, the dietary aide's reach in refrigerator was observed to have the following: cranberry concentrate in a plastic container which was open and had a use by date of 8/14/2024 The main kitchen was observed to have the following: bread crumbs stored in big plastic container which had a preparation date of 6/20/2024 with no use by date thickener stored in big plastic container which had a preparation date of 7/25/2024 with no use by date sugar stored in big plastic container with no label or date The reach in freezer was observed to have the following: open bacon bits in a package with no label and date According to the 2017 FDA Food Code revealed: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Review of the Date Marking for Food Safety Policy with an implementation date of 12/2023 and a review date of 5/2024 revealed Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of the day/date of opening, and the day/date the item must be consumed or discarded. 5. The discard day or date may not exceed the manufacturer's use-by date, or three days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday). 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed.

Based on interview and record review, the facility failed to ensure the provision of training for behavioral health care and services for 104 staff reviewed for behavioral health care training. This deficient practice had the potential to result in unmet behavioral health care needs and services for residents. Findings include: In an interview on 09/11/24 at 11:06 AM, Certified Nursing Assistant (CNA) V reported (Vendor) training application was on a schedule to be completed. CNA V reported there was not much time at work to complete the trainings as would get pulled to the floor to work and/or they have their charting to do for the residents and it doesn't leave much time to complete the assigned trainings. CNA V reported they were able to access the application at home and could complete the training at home and would submit a slip to the timekeeper to get paid for completion of the training. In an interview on 09/11/24 at 12:34 PM, Receptionist EEE reported she would run reports, employees needed certain classes to start work on the floor for any department. Receptionist EEE reported she would during orientation, checked completed the classes to ensure they were finished prior to the staff working on the floor. Receptionist EEE reported the staff have different due dates for the training to be finished based on their hire dates. Receptionist EEE reported she would send reminders to each employee to complete the trainings, a report would be generated by department each month and sent to the supervisor to remind the employees. In an interview on 09/11/24 at 12:29 PM, Administrator A reported nursing would complete any trainings when needed as well as the training required for completion in the (Vendor) program. The electronic training in (Vendor) program was tracked by Receptionist EEE. Review of the facility's Employee training records, revealed the facility was unable to provide evidence 78 out of 104 staff members received annual abuse prevention training prior to the beginning of the survey on 9/10/24.

Based on observation and interview the facility failed to provide proper notification of a room change to 1 (Resident #20) of 1 resident reviewed for room change resulting in feelings of anger and frustration. Findings include: Resident #20 Review of an Admission Record revealed Resident #20 had pertinent diagnoses which included: osteomyelitis (an infection in a bone) and end stage renal disease with dialysis (a condition when the kidneys no longer function, and dialysis- a procedure to filter the blood of the body when the kidneys no longer function). Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 8/6/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #20 was cognitively intact. In an interview on 9/11/24 at 4:18 PM., Resident #20 reported he had been moved rooms after he complained to administration about a confrontation he had with his former roommate. Resident #20 reported he refused to move rooms when administration asked him to move rooms, but he still was the one that was moved. Resident #20 reported he was not provided any paperwork regarding a room change. Review of Census for Resident #20 revealed a documented room change on 5/7/24. Review of Social Service Note for Resident #20 dated 4/24/24 at 16:23 PM., revealed .received a phone call .demanding that I moved his roommate .offered a room change . Res (resident) refused room change stating that he was there first . In an interview on 9/12/24 at 11:42 AM., Nursing Home Administrator (NHA) A reported there was no reported or documented confrontation between Resident #20 and his former roommate. In an interview on 9/12/24 at 11:57 AM., Social Services Director (SSD) NN reported there was no reported or documented confrontation between Resident #20 and his former roommate. SSD NN reported Resident #20 had asked for his roommate to be moved, and the roommate refused to move. SSD NN reported that she offered a room changed to Resident #20 and he refused a room change because he was there first. When asked why Resident #20 was moved rooms, SSD NN reported that Resident #20 agreed to move rooms. This surveyor asked SSD NN for documentation that supported Resident #20's agreeance to move or written notice of a room change, and SSD NN was unable to provide any documentation. SSD NN stated she documented in Resident #20's record that that he refused a room change, but she did not document when Resident #20 agreed to move rooms. In an interview on 9/12/24 at 12:10 PM., NHA A reported she was aware of Resident #20's room change. NHA A reported Resident #20 told her him and his former roommate did not get along. NHA A reported Resident #20 was presented with the opportunity to change rooms several times, and he refused. NHA A reported she was informed Resident #20 did finally agree to move rooms. NHA A reported SSD NN was the staff member residents discuss a room change with, and SSD NN was responsible for documentation and notification of room change. When asked for the documentation regarding Resident #20 agreeance or written notification for Resident #20's room change, NHA A stated I don't have any. Review of facility policy Change of Room or Roommate with a reviewed date of 7/2024 revealed .the notice of a change in room or roommate will be provided in writing .will include the reason (s) why the move or changed is required .

Based on interview and record review the facility failed to maintain the dignity of 1 (Resident #20) of 1 reviewed for dignity resulting in feelings of anger and frustration. Findings include: Resident #20 Review of an Admission Record revealed Resident #20 had pertinent diagnoses which included: osteomyelitis (an infection in a bone) and end stage renal disease with dialysis (a condition when the kidneys no longer function, and dialysis- a procedure to filter the blood of the body when the kidneys no longer function). Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 8/6/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #20 was cognitively intact. In an interview on 9/11/24 at 4:14 PM., Resident #20 reported he recently had asked to go to the hospital, and when Medical Director (MD) WW spoke with him (Resident #20) on the phone, MD 'WW's tone was short and curt when MD WW told Resident #20 he did not think he needed to go to the hospital and would not approve a transfer to the emergency room . Resident #20 reported he was angry and frustrated when MD WW told him he did not need to go to the hospital. Review of Progress Notes for Resident #20 dated 8/29/24, 11:23 PM., authored by Licensed Practical Nurse (LPN) EE revealed . I (LPN EE) spoke with him (Resident #20) about having the physician here look at it and prescribe an antibiotic if need and he (Resident #20) said no I am in so much pain and you don't have the proper pain meds (medications) to treat me here . called MD WW and he spoke with the resident as well stating this is not a life-threatening emergency and that a trip to the ER (emergency room ) is not necessary .MD WW did tell resident he was not approving this transport to the emergency room as he did not feel it was an emergency . resident (#20) refused to stay here (in the facility) and insisted on being treated at the hospital .MD WW was informed of the resident (#20) insistence of going to the emergency room and stated that was fine, but that he is not in approval of him going to the emergency room . In an interview on 9/12/24 at 7:09 AM., LPN EE reported Resident #20 asked to go to the hospital and she called MD WW. LPN EE reported that she informed MD WW that Resident #20 wanted to go to the ER, and that MD WW told LPN EE Resident #20 could be treated at the facility, and they have to watch their numbers. LPN EE explained that numbers refer to residents who are sent to the hospital. LPN EE reported MD WW did speak to Resident #20 via a cell phone speaker phone, and LPN EE did hear MD WW tell Resident #20 that he did not approve or support his (Resident #20) transfer to the hospital. LPN EE reported she sent Resident #20 to the emergency room that night. In a telephone interview on 9/12/24 at 11:32 AM., MD WW recalled the telephone conversation with Resident #20 regarding his wish to be transferred to the ER. MD WW reported that he had to watch his numbers with transfers to the hospital. When asked what watching his numbers means, MD WW reported too many transfers to the hospital is not good. MD WW reported he did tell Resident #20 that he did not think he needed to go to the hospital and that he did not support his (Resident #20) choice to go to the emergency room . During the telephone conversation, MD WW referred to Resident #20 as a frequent flyer. When asked what a frequent flyer was, MD WW stated someone who go to the emergency room often.

This citation pertains to intake MI 388. Based on observation, interview and record review the facility failed to maintain sufficient hydration/nutrition in 4 of 4 residents (Resident #5, #22, #26, and #38) reviewed for hydration/nutrition resulting in weight loss and the potential for dehydration, unmet resident needs, unnecessary negative physical, mental and psychosocial outcomes. Findings include: Resident #26 Review of a Face Sheet revealed Resident #26 was a male, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for Resident #26, with a reference date of 2/3/22, revealed a Brief Interview for Mental Status (BIMS) score of 99 which prompted a staff assessment for Resident #26's cognitive status and revealed a score of 3 indicating severe cognitive impairment. Further review of Resident #26's MDS revealed: Section GG-Self Care- (Resident #26) was coded as 01-for EATING .Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity EATING: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident . In an observation on 4/5/22 at 11:03 AM., Resident #26's water was on his bedside table out of Resident #26's reach. The water had no date, no straw and was full to the top. In an observation on 4/5/22 at 11:40 AM., Resident #26's water was on his bedside table out of Resident #26's reach. The water had no date, no straw and was full to the top. In an observation on 4/5/22 at 12:15 PM., Resident #26's water was on his bedside table out of Resident #26's reach. The water had no date, no straw and was full to the top. In an observation on 4/5/22 at 1:01 PM., Resident #26 was propped up in his waiting for lunch. Resident #26's water was on his bedside table out of Resident #26's reach. The water had no date, no straw and was full to the top. In an observation on 4/05/22 at 1:29 PM., during peri care Resident #26's water was on the bedside table the water had no straw, and was out of Resident #26's reach. While 2 Certified Nurse Aides (CNA's) CNA's M & O , did not offer drinks of water at any point during Resident #26's care. In an observation on 4/05/22 at 1:41 PM., Resident #26's water was on his bedside table out of Resident #26's reach. The water had no date, no straw and was full to the top. In an observation on 4/06/22 at 8:08 AM., Resident #26's water was on his nightstand and out of Resident #26's reach. The water had no date and was full to the top. In an observation on 4/06/22 at 9:12 AM., Resident #26's water was on his nightstand and out Resident #26's of reach. The water had no date and was full to the top. In an observation on 4/06/22 at 9:29 AM., observed wound care for Resident #26. Licensed Practical Nurse (LPN) J and CNA M provided Resident #26 with morning cares (bed bath, peri are cleaned and wound dressing change) which lasted from 9:29 AM-10:00 AM. Noted neither LPN J & CNA M offered or provided any water during this time. During an interview on 4/6/22 at 10:40 AM., LPN J reported Resident #26 is dependant on staff for nutrition and hydration needs. LPN J reported water should be offered to dependant residents (including Resident #26) every time direct care staff enter the residents room. In an observation on 4/06/22 at 11:25 AM., Resident # 26's water was on his nightstand and out of Resident #26's reach. The water had no date and was full to the top. In an observation on 4/06/22 at 1:10 PM., Resident #26's water was on his nightstand and out of Resident #26's reach. The water had no date and was full to the top. In an interview on 4/06/22 at 4/06/22 01:40 PM., Resident #26's water was on his nightstand and out of Resident #26's reach. The water had no date and was full to the top. In an observation on 4/07/22 at 8:01 AM., Resident #26 was observed with no water at bedside. Resident #38 Review of a Face Sheet revealed Resident #38 was a female, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for Resident #38, with a reference date of 2/11/22, revealed a Brief Interview for Mental Status (BIMS) score of 00 which prompted a staff assessment for Resident #38's cognitive status and revealed a score of 3 indicating severe cognitive impairment. Further review of Resident #38's MDS revealed: Section GG-Self Care- (Resident #38) was coded as 01-for EATING .Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity EATING: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident . In an observation on 4/5/22 at 11:06 AM., noted Resident #38's water was on her bedside table out of Resident #38's reach, with no straw and was completely full. In an observation on 4/05/22 at 11:44 AM., noted on Resident #38's bedside table a cup of water. The cup was noted to be full, with no straw in it, and no date of the cup. Noted next to the water was a full cup of orange juice, with a straw. Both liquids were out of Resident #38's reach. In an observation on 4/5/22 at 12:29 PM., noted Resident #38's water was on her bedside table out of Resident #38's reach, with no straw and was completely full. In an observation on 4/5/22 at 1:14 PM., noted Resident #38's water was on her bedside table out of Resident #38's reach, with no straw and was completely full. In an observation on 4/5/22 at 1:29 PM., noted Resident #38's water was on her bedside table out of Resident #38's reach, with no straw and was completely full. In an observation on 4/5/22 at 1:48 PM., noted Resident #38's water was on her bedside table out of Resident #38's reach, with no straw and was completely full. In an observation on 4/5/22 at 3:40 PM., noted Resident #38's water was on her bedside table out of Resident #38's reach, with no straw and was completely full. In an observation on 4/6/22 at 8:00 AM., noted Resident #38's water was on her bedside table out of Resident #38's reach, with a straw and was completely full. In an observation on 4/6/22 at 8:45 AM., noted Resident #38's water was on her bedside table out of Resident #38's reach, with no straw and was completely full. In an observation on 4/6/22 at 9:15 AM., noted Resident #38's water was on her bedside table out of Resident #38's reach, with no straw and was completely full. In an observation on 4/06/22 at 1:15 PM., noted Resident #38's water was on her bedside table out of Resident #38's reach, with no straw and was completely full. In an observation on 4/07/22 at 8:02 AM., Resident #38 was observed with no water at bedside. Review of Resident #38's Care Plan revealed: Focus I (Resident #38) at risk for Nutritional Problem or Potential Nutritional Problem r/t (related to) dx of Alzheimer's. Date Initiated: 11/23/2021 Revision on: 11/23/2021 .Goal I (Resident #38) will maintain adequate nutritional status as evidenced by maintaining weight within 5# +/- (pounds) of usual body weight range, have no s/sx of malnutrition, and consuming at least 75% of all meals daily through review date. Date Initiated: 11/23/2021 Revision on: 02/22/2022 Target Date: 06/01/2022 Interventions: Provide and serve diet as ordered. Date Initiated: 11/23/2021 Provide: serve diet as ordered. Monitor intake and record (every) meal. Date Initiated: 11/23/2021 .RD (Registered Dietician) to evaluate and make diet change recommendations PRN. Date Initiated: 11/23/2021 Diet Weigh per doctor orders. Date Initiated: 11/23/2021 Revision on: 11/23/2021 . further review of Resident #38's Care Plans revealed no specific indication of a hydration care plan noted to be resident focused, nor did Resident #38's Care Plan reflect her hydration needs. During an interview on 4/06/22 at 3:27 PM., Certified Nurse Aide (CNA) M reported all dependant resident should be offered water to drink every time staff who are certified (nurses & CNA's) enter resident rooms. CNA M reported all resident should be reminded to drink water regardless of their functional status. CNA M reported both Resident #26 and Resident #38 are dependant on staff to assist them with eating and drinking. CNA M reported Resident #26 and Resident #38 are able to hold water cups without assistance from staff. Resident #22: During an interview on 04/05/22 at 10:39 AM, Resident #22 reported he used to weigh approximately 230 pounds and couldn't remember if he spoke with the registered dietitian or not and couldn't remember if anyone had educated/discussed his weight loss with him. During an interview on 04/06/22 at 11:02 AM, Dietary Manager Z reported she didn't know why Resident #22 didn't have a January 2022 weight. During an interview on 04/06/22 at 01:30 PM, Registered Dietitian (RD) GG reported she didn't remember getting a nutrition referral to assess Resident #22 on or around 1/18/2022 or 10/25/2021 (The dates of Dietary Manager Z 's nutrition assessments that indicated a referral was made; admission and quarterly). RD GG reported if she would have received a referral she would have a note in the resident record and confirmed she had no documentation of any notes/assessments for Resident #22. RD GG confirmed there was no January 2022 weight for Resident #22 and there was no notes that assessed/addressed the resident's weight loss. During an interview on 04/06/22 at 04:50 PM, Dietary Manager Z reported she only had proof that one referral was sent to the Registered Dietitian. During an interview on 04/07/22 at 09:34 AM, Registered Dietitian GG reported she couldn't find any documentation that showed a referral was received to see/assess Resident #22. Review of Resident #22's weight summary, dated 10/22/2021-4/5/2022, revealed Resident #22 had a 7.21 percent weight loss since admission over approximately 6 months. This was a 16.5 pound weight loss since admission. On 10/22/21 Resident #22 weighed 229 pounds and on 4/5/2022 he was 212.5 pounds. The facility failed to obtain a January 2022 weight so it was unknown the extent of weight loss during the time period from 12/5/2021 to 2/3/2022. On 12/5/2021 Resident #22 weighed 223 pounds and on 2/3/2022 Resident #22 was down to 216 pounds. Review of Resident #22's Nutritional Status Review, dated 10/25/2021, the summary stated, New Admit: .Current weight 229# (pounds), .Will monitor and refer to RD., and Refer to RD (Registered Dietitian) .Yes. Review of Resident #22's Nutritional Status Review, dated 1/18/2022, the summary stated, Quarterly Review: .(Resident #22) has had a 5% weight loss over one month. Current weight 223# (pound) .Will monitor and refer to RD (Registered Dietitian)., and Refer to RD (Registered Dietian) .Yes. Review of Resident #22's most recent Minimum Data Set, dated dated [DATE], had a brief interview for mental status score of 3 which reflected he had severe cognitive impairment. Review of Resident #22's Resident's ability to participate in own healthcare decisions, dated 3/5/2022, indicated Resident #22 was not able to make healthcare decisions due to TBI ([CONDITION(S)]) .very poor s/t (short term) and l/t (long term) memory. Review of Resident #22's physician diagnoses, print date 4/7/2022, included, Benign Neoplasm (abnormal mass) of Brain, convulsions, anxiety, and depression. Review of Resident #22's nutrition care plan, dated 10/25/2021, stated, I am at risk for nutritional problem or potential nutritional problem r/t (related to) long term care placement .I will maintain adequate nutritional status . with an intervention of RD (Registered Dietitian) to evaluate and make diet change recommendations PRN (as needed). Resident #5 Review of a Face Sheet revealed Resident #5 was a female, originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 3/30/22 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated Resident #5 was cognitively impaired. Review of Resident #5's current nutrition/hydration Care Plan revealed a focus of I am at nutrition and/or hydration risk and dx (diagnosis) [CONDITION(S)], [CONDITION(S)], IBS; poor/varying PO (by mouth) intake; muscle mass depletion noted; [CONDITION(S)] medication with a date initiated of 9/24/21 and revision on 2/4/22 with a complete list of interventions, all of which were initiated on 9/24/21 which included Monitor & record weights per facility policy .Provide and serve diet as ordered .Provide and serve supplements as ordered .Provide, serve diet as ordered .Monitor intake and record q (every) meal .RD (Registered Dietitian) to evaluate and make diet change recommends PRN (as needed). Review of a Weight Summary report for Resident #5 on 4/6/22 at 1:43 PM revealed the following weight measurement entries since readmission: 9/23/21 - 157.0 Lbs; 10/10/21 - 145.5 Lbs (a 7.3% decrease in less than 30 days from 9/23/21); 11/4/21 - 139.5 Lbs (an 11.1% decrease in less than 90 days from 9/23/21); 11/16/21 - 139.5 Lbs (an 11.1% decrease in less than 90 days from 9/23/21); 12/13/21 - 138.5 Lbs (an 11.8% decrease in less than 90 days from 9/23/21); 1/11/22 - 137.0 Lbs (a 12.7% decrease in less than 180 days from 9/23/21); 1/19/22 - 127.0 Lbs (a 19% decrease in less than 180 days from 9/23/21); 2/3/22 - 105 Lbs (indicating a 33% decrease in less than 180 days from 9/23/21); 2/16/22 - 115.6 Lbs; 2/24/22 - 115.0 Lbs; 3/9/22 - 117.5 Lbs; 4/5/22 - 110.0 Lbs (indicating Resident #5 had lost a total of 47 pounds, or 29.9% of body weight from 9/23/21). A review of Resident #5's Nutritional Status Review dated 9/23/21 and completed by Certified Dietary Manager (DM) Z revealed, SUMMARY / PLAN / PROGRESS NOTE .CBW (current body weight) 157# (pounds), BMI (body mass index) 27.8, Wt hx (weight history) stable Skin: intact. Avg (average) meal acceptance of ~38% .Monitor and refer to RD (Registered Dietitian) as needed A review of Resident #5's Nutritional Status Review dated 12/24/21 and completed by DM Z revealed Resident #5's weight was 138.5#'s. DM Z documented in the assessment that Resident #5 had no change in her weight status. A review of Resident #5's medical record revealed no subsequent completed Nutritional Status Review documents. A review of Resident #5's Progress Notes was conducted for the period 9/23/21 to 4/5/22 for evidence of nutrition progress notes related to ongoing monitoring of Resident #5's nutritional status and weight loss by a qualified nutrition professional. A total of two (2) Dietary (nutrition) progress notes, dated 9/24/21 at 12:19 PM (the day after resident was readmitted and before a weight loss had occurred) and 12/24/21 at 11:25 AM, were found. The nutrition progress note dated 12/24/21 did not address Resident #5's significant weight loss. Review of a SNF (skilled nursing facility) Routine Visit nurse practitioner note dated 10/21/21 revealed, no assessment of Resident #5's weight loss of 11.5 lbs between 9/23/21 and 10/10/21. Review of a Skilled Nursing Facility 60d (60 day) post admit physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a SNF Acute Visit nurse practitioner note dated 1/26/22 revealed, .Patient is seen at the request of staff to evaluate for decline, loss of appetite and nausea .Per staff she is eating minimally and report nausea most of the time. She has a loss of 10lbs in last month noted .Assessment .2. Weight Loss .6. Severe protein-calorie malnutrition .follow up next week for evaluation of decline. It is noted that as of 1/26/22, Resident #5's weight had declined from 157.0 lbs on 9/23/21 to 127 lbs on 1/19/22 without added interventions. Review of a Skilled Nursing Facility 60d (60 day) post admit physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Wt (weight change): net loss 42 lb .HPI (history of present illness) .Of late she has been losing wt (weight) rapidly; is confused; complains of dysuria (pain when urinating), and health is generally in decline, such that hospice is being consulted .Assessment .steady wt loss; not eating well; FTT (failure to thrive) .With her age and decline, son here; lengthy discussion; he is in favor of hospice; I would anticipate demise in the coming days or weeks . In an interview on 4/6/22 beginning at 12:57 PM, DM Z reported they completed a nutrition progress note when a resident was admitted and completed the regularly scheduled nutrition assessments. DM Z reported when a resident had a weight change, the contracted Registered Dietitian was alerted to further evaluate the resident's nutrition status and suggest/implement nutritional interventions. DM Z reported all nutritional charting for residents was located in the electronic medical record under dietary/nutrition Progress Notes and Nutritional Status Review and would not be located anywhere else in the chart. DM Z reviewed Resident #5's electronic medical record for dietary/nutrition Progress Notes and reported there were notes on 9/24/21 at 12:19 PM and 12/24/21 at 11:25 AM. DM Z stated, I don't see any other charting from us. DM Z reported the facility had a Weight Monitoring policy and that when a resident was weighed and there was a 3-5# difference from the previously recorded weight, the resident should be re-weighed. DM Z reported if the reweight confirmed a weight loss of 3-5# or more, the resident would be referred to the Registered Dietitian for Nutrition at Risk review and would be weighed weekly for closer monitoring until their weight stabilized. DM Z reported Resident #5 should have been weighed weekly but was not. In an interview on 4/6/22 at 1:15 PM, contracted Registered Dietitian (RD) GG reported had worked with the facility since September, 2021. RD GG reported it was the facility's responsibility to inform them (RD GG) of resident weights or nutritional concerns that needed further evaluation by the Registered Dietitian. RD GG reported had written a nutrition progress note for Resident #5 yesterday. RD GG reported the facility had not previously alerted them (RD GG) that Resident #5 had experienced a significant weight loss and would need ongoing monitoring and evaluation for nutritional intervention. RD GG stated, she should have been seen by me more frequently .that may have been missed. Review of the facility policy Nutritional Management with a date implemented of 8/1/21 revealed, Policy: 2. Identification/assessment .A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed .5. Monitoring/revision: Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis .d. The physician will be notified of: Significant changes in weight, intake, or nutritional status . Lack of improvement toward goals . Any complications associated with interventions . Review of the facility policy, Weight Monitoring with a date implemented of 8/1/21 revealed, Policy: .5. A weight monitoring schedule will be developed upon admission for all residents .b. Newly admitted residents - monitor weight weekly for 4 weeks, c. Residents with weight loss - monitor weight weekly, d. If clinically indicated - monitor weight daily, e. All others - monitor weight monthly 6. Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (180 days) .7. Documentation: Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions .e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. f. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate .

This citation has 2 Deficiency Practice Statements (DPS), 1 and 2. DPS #1: Based on observation, interview, and record review the facility failed to provide adequate supervision for 1 of 3 residents (Resident #68) reviewed for accidents/hazards/supervision, resulting in Resident #68 sustaining a fall with fracture to left femur, left hip and right femur which negatively affected the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #68: Review of Admission Record revealed for Resident #68 was a female, with pertinent diagnoses which included Alzheimer's disease, [CONDITION(S)], anxiety, dementia with behavioral disturbances, [CONDITION(S)] with delusions, restlessness and agitation, sleep disorders, lack of coordination, abnormalities of gait and mobility, [CONDITION(S)], high blood pressure, displaced fracture of left femur, and fracture of neck of right femur. Review of a current comprehensive Care Plan for Resident #61 revised on 4/28/21 revealed the focus, .I am at risk for falls r/t Confusion, Gait/balance problems, Incontinence, Poor communication/comprehension, Psychoactive drug use, Unaware of safety needs, Wandering . with the intervention .Assist resident to common room to attempt activities with staff as she allows when increased restlessness is noted .Monitor for increased S&S of pain/restlessness and give PRN pain medication as indicated .Resident working with (Behavior Services Group) to lessen behaviors .Staff to anticipate resident's needs .Follow facility fall protocol .Resident is at HIGH Risk for falls .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Ensure that the resident is wearing appropriate footwear (SPECIFY and describe correct client footwear i.e. brown leather shoes, tartan bedroom slippers, black non- skid socks) when ambulating or mobilizing in w/c (wheelchair) . Fall #1: Review on Incident Note dated 7/5/2021 at 18:31 PM, .Note Text: Resident attempting to pull DVD player off cabinet. Nurse was redirecting her to her supper tray and resident swung fist at nurse and lost balance. Nurse could not stop her from sitting on floor she fell on buttocks. She c/o (complains of) some pain but did move all extremities and stated to nurse and CNA help me up. She sat in chair in tv room and ate most of supper. Call to on call MD service and left message to call us. Call to guardianship and left message to call us about fall. She did not hit head, nurse did witness fall. Informed manager (LPN E) of incident. In an interview on 4/7/21 at 10:35 AM, Unit Manager (UM) T reported (Resident #68) was trying to take the DVD player off the shelf, with one hand, she had other hand occupied with her baby doll, and when I was trying to get her to leave the DVD player alone she turned around and swung at me, lost her balance and she went down and sat on the floor. UM T reported resident yelled at her to get her up off the floor, assisted off the floor after assessing her, and placed her in a chair in the day room where she took a nap. Review of Progress Notes dated 7/5/2021 at 19:21 PM, revealed, .Note Text: Call back from (On call NP) on call person and informed of witnessed fall. Resident sleeping in recliner at this time. She states monitor resident and if she has increased c/o pain send to ED for assess and treat . Review of Progress Note dated 7/5/2021 at 21:16 PM, revealed, .Note Text: Per day nurse report, resident had a ground level fall at approx. 1810 which resulted in resident having an increased amount of pain in her bottom area. Day nurse called this nurse on other unit to inform me that resident was currently sleeping at change of shift. Also the day nurse informed me that she had spoken with the on call physician and day nurse stated that she was worried about this resident. And that it would be fine to send resident to the ER if she was having increased pain. Review of Progress Note dated 7/5/21 at 21:16 PM, revealed, .At approx. 2040 this nurse was called to (Memory care unit) to assist in helping get this resident sent to the ER ASAP due to resident's pain of 10/10 and inability to bare weight. Placed call to 911 at approx. 2048 for transfer to ER. At approx. 2055, EMS arrived and then left with resident to (Local Hospital) at approx. 2100. Review of Patient Transfer Nurse Assessment - Extended Care dated 7/12/21, revealed, .Nurse Discharge Summary/Current Problem: L femur fx (fracture) . Review of Progress Note dated 7/12/2021 at 09:14 PM, revealed, .Nursing Admission Late Entry: Note Text: Resident arrived via stretcher accompanied by EMT/Paramedics. admitted from (Local Hospital) .MORSE Fall Risk Score of 65.0 indicates that (Resident #68) is at High Risk. Wander/Elopement Risk Score of 15.0 indicates that (Resident #68) is at High Risk for elopement/wandering. Physical and Supplemental Assessments completed. Baseline Care Plan implemented accordingly . Review of the Fall care plan dated 4/28/21 revealed there were no modifications to comprehensive care plan to prevent falls. No individualized care plan interventions to meet/anticipate resident's needs and protect resident from additional falls. Fall #2: Review of Progress Note dated 7/16/2021 at 01:07 AM, revealed, .Note Text: 7/15/21 7:20pm The resident in (Resident #68's room) came to the TV room and said she needed help getting her roommate up that she was sitting on the floor. CNA and this nurse went to see and observed this resident sitting on the floor close to the bathroom door. no cuts bumps or bruises noted at this time. Resident could move all extremities but did say her left hip hurt some. Resident alert but confused as usual tried to get vitals but not holding still enough for accurate B/P . B/P 195/106 T 97 P98 R 18. Resident was assisted to w/c and taken to TV room to sit by CNA as she kept trying to get up and walk. No bumps noted on her head. Neuro checks were initiated resident not very cooperative would not hold still kept trying to get up and walk. DON notified 7:35pm On Call (Nurse Practitioner) NP notified 7:37pm N/O May get Mobile Xray of right and left hips due to recent Fx of Left femur. Message left for (Resident #68's Guardianship) 7:45pm Mobile Xray ordered # 217 . Review of Progress Note dated 7/18/21 at 11:35 AM, .She (Resident #68) is nwb (non weight bearing) and on bed rest d/t nondisplaced hip fx . Review of the Fall care plan dated 4/28/21 revealed there were no modifications to comprehensive care plan to prevent falls. No individualized care plan interventions to meet/anticipate resident's needs and protect resident from additional falls. Fall #3: Review of Incident Report dated 8/24/21 at 3:09 PM, revealed, .Incident Description: Was observed in a sitting position in her room by roommate bed .No injuries observed post incident .Predisposing Physiological Factors: Confused, Gait imbalance, Impaired memory .Predisposing Situation Factors: Ambulating without assist, Wanderer . Review of Post Fall Review dated 8/24/21 at 15:09 PM, revealed, .Where was the resident prior to the fall .Bed .Predisposing Diseases .f. Dementia/Alzheimer's .Conditions that may contribute .a. Unsteady gait .b. History of fall(s) .f. Cognitive Deficits .Call Light Use: 7. Can resident demonstrate use of call light in room? .b. No .8. Can resident demonstrate use of call light in bathroom? .b. No .MORSE Fall Risk Scale: Score 75 .High Risk for Falling . Review of Progress Notes dated 8/25/21 at 1:23 PM, revealed, .CNA doing care found resident on the toilet in her room, she has ambulated herself without assistance . Fall #4: Review of Incident Report dated 9/2/21 at 1:25 PM, revealed, .Resident slipped from w/c while sitting at the table eating lunch . Review of Progress Note dated 9/2/21 at 1:30 PM, revealed, .Resident was observed on sitting floor in front of w/c. Resident was assessed by nurse, (Nurse), no injuries noted. Moves all extremities without difficulty .Transferred to bed x2 assist .Complaints et denies pain at this time .Will cont to monitor . Review of IDT Review: Root Cause Analysis dated 9/2/21 at 1:25 PM, .Resident was observed on floor at table .She was unable to tell staff what happened .Non skid pad to w/c (wheelchair) to be placed in w/c . During an observation and interview on 4/6/22 at 12:51 PM, RN W asked a CNA to come sit in the day room to sit with residents in the day room. RN W reported staff need to be present in the day room at all times to supervise the residents. Review of the Fall care plan dated 4/28/21 revealed the fall intervention for non-skid pad was not placed in the comprehensive care plan. Comprehensive care plan shows no care plan interventions included following 9/2/21 fall. Fall #5: Review of Incident Report on 11/9/21 at 5:11 AM, revealed, Resident found in room on floor by roommate. Injury noted to right thigh. Pain level was scored at 8 due to calling out, moaning, groaning, crying, facial grimacing, unable to console/reassure, rigid/fists clenched/knees pulled up/pulling or pushing away/striking out. Resident was diagnosed with dementia, restlessness, agitation, anxiety, and history of falls. Resident was unable to use call light per evaluation completed by nurse. Resident was transferred to the local hospital for evaluation and treatment. Review of IDT (Interdisciplinary Team) Review on 11/16/21 at 12:25 PM, revealed, Resident was noted to be in a sitting position on the floor by her bed. Call light was in reach and non-skid footwear on. Review of Progress Note dated 11/9/21 at 5:21 AM, revealed, .Note Text: Staff alerted this writer that Resident found on floor after her roommate came and informed them that she was in need of help, Upon assessing resident unable to complete ROM on Right lower extremity Resident crying and guarding limb saying it hurt, Resident unable to describe what happened Nuero (sic) assessment initiated, Telephone order obtained to Transfer for evaluation and treatment to nearest ER. Report called in to charge (LPN E), Message left for (Guardian for Resident #68) to inform of resident Transfer, DON (Director of Nursing) notified, and chart noted Resident transferred via stretcher at 0452 . Review of IDT Note dated 11/11/2021 at 11:06 AM, revealed, .Note from hospital from eval shows xray R femoral fracture, surgery 11/10 for repair. UA was negative, Covid tests negative . In an interview on 4/6/22 at 2:27 PM, Certified Nursing Assistant (CNA) CC reported resident was found on the floor in her room. CNA CC reported she and anther CNA went to assist the nurse. CNA CC stated, .When the nurse completed her assessment the resident was saying Ouch, ouch, ouch. The nurse told us to get her up but she couldn't put any weight on her legs .We had to pick her up and place her in her chair to get her off the floor like the nurse told us to do .She wanted us to then move her to the bed but (Resident #68) was very painful .We picked her up by arm and leg (placing there arms under her arm pit and using their other arm/hand to pick her up under her legs) to get her off the floor . CNA CC reported the resident's recliner had been moved around in the room as it was over by the roommate's side of the room. The other CNA who assisted CNA CC on 11/9/21 no longer works at the facility and her phone number was out of service. In an interview on 4/6/22 at 2:42 PM, spoke with LPN D and she reported she was not working when the incident occurred and the resident had already been sent to the hospital. Her name was on documents as she as completing the necessary documentation for the previous nurse. LPN D reported she believed it was Unit Manager T who was working. In an interview on 4/7/21 at 10:35 AM, Unit Manager (UM) T reported she could not remember if she worked that night but she stated, Her nature she was always busy, has a baby doll she carries around and involved in different activities . Note: Comprehensive care plan interventions shows no individualized care plan interventions to meet/anticipate resident's needs and protect resident from additional falls. Care plan intervention mentions to ensure call light was within reach. Resident has been assessed as unable to use call light due to her diagnoses. In an interview on 4/7/22 at 2:15 PM, Director of Nursing (DON) B reported the facility was unable to find any incident reports completed for Resident #68's falls on 7/5/21 and 7/15/21. DON B reported the nurses would follow the policy when a resident has a fall like completing an incident report in (electronic medical record program). DON B reported when a resident was on the floor and assessed for an injury following the fall, the resident would remain on the floor until EMS arrived to assist the resident for transport. Review of policy Fall Management Program revised 10/10/21, revealed, .Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .5. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program . i. Indicate fall risk on care plan .b. Implement interventions from Low/Moderate Risk Protocols .c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status .d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices .ii. Increased frequency of rounds .iii. Medication regimen review .iv. Low bed .v. Alternate call system access .vi. Scheduled ambulation or toileting assistance .vii. Family/caregiver or resident education .viii. Therapy services referral .6. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .a. Interventions will be monitored for effectiveness .b. The plan of care will be revised as needed .7. When any resident experiences a fall, the facility will: a. Assess the resident .b. Complete a post-fall assessment .c. Complete an incident report .d. Notify physician and responsible party, if applicable .e. Review the resident's care plan and update as indicated .f. Document all assessments and actions .g. Obtain witness statements in the case of injury . According to The Fundamentals of Nursing (Potter and Perry, 6th Edition, 2005), Nursing interventions are prioritized to provide safe and efficient care .The client's mobility problem is an obvious priority because of its influence on skin integrity and risks for falls. The nurse plans individualized interventions based on the severity of risk factors and the client's developmental stage, level of health, lifestyle, and culture .nursing interventions are directed toward maintaining the client's safety in all types of settings. Nursing measures for providing a safe environment include health promotion, developmental interventions, and environmental interventions .To promote an individual's health, it is necessary for the individual to be in a safe environment to practice a lifestyle that minimizes risk of injury. DPS #2 Based on observation, interview, and record review the facility failed to minimize the risk of scalding and [CONDITION(S)] by allowing domestic hot water to exceed 120°F. This resulted in an increased risk of injury and burn among residents who reside in the [NAME] Section. Findings include: During an initial tour of the facility, at 1:09 PM on 4/5/22, it was found that all rooms in the memory care and woods section of the facility shown temperatures below 120°F. During an initial tour of the facility, at 1:33 PM on 4/5/22, a rapid read thermoworks thermometer (RRTT) found the hot water in the family room bathroom to reach a temperature of 136.4°F. During an initial tour of the facility, at 1:38 PM on 4/5/22, a RRTT found the hot water in the bathroom of resident room 10 at 134°F. During an initial tour of the facility, at 1:40 PM on 4/5/22, a RRTT found the hot water in the bathroom of resident room 12 at 133.2°F. During an initial tour of the facility, at 1:43 PM on 4/5/22, a RRTT found the hot water in the bathroom of resident room 20 at 133.7°F. During an initial tour of the facility, at 1:45 PM on 4/5/22, a RRTT found the hot water in the bathroom of resident room 32 at 134.1°F. During an initial tour of the facility, at 1:49 PM on 4/5/22, a RRTT found the hot water in the bathroom of resident room 22 at 132°F. In an interview with DON B, at 1:53 PM on 4/5/22, the surveyor informed the facility of concerns regarding excessive hot water in the central hall and the [NAME] section of the building. During a tour to the facility's main boiler room, at 2:05 PM on 4/5/22, it was observed that the thermometer stating Hot Water To Rooms of the main hall and the [NAME] section of the facility, read 133°F. An interview with Housekeeping LL, at 2:10 PM on 4/5/22, found that the Woods and Memory Care unit was on a different hot water supply, as this section of the building was added on in 1987. In an interview on 4/05/22 at 2:01 PM., Housekeeper (Hsk) Q reported the water does get pretty hot here, sometimes we have to wait for it to get hot but it does get very hot. In an interview with NHA A, at 2:19 PM on 4/5/22, the surveyor informed NHA A of concerns regarding excessive hot water in rooms on the main hall and the [NAME] section of the facility. NHA A stated the issue would be addressed immediately and Maintenance Director KK would be in the next day. During a tour of the facility, at 9:07 AM on 4/6/22, a review of the thermometer stating Hot Water To Rooms of the main hall and the [NAME] section, was shown to be 115°F. An interview with Maintenance KK, at 9:56 AM on 4/6/22, found that he does keep track of domestic temperatures throughout the facility and was unsure why the hot water reached as high as it did yesterday. MD KK stated he takes three hot water temperatures everyday, with no issues noted, however he had been away from the facility since the start of April, and hadn't yet taken any April water temperatures. When asked about his process for taking temperatures, MD KK stated that he would let the water run for five seconds and place the thermometer under for another five seconds and that usually the water temperature was steady by then. A review of the Water Temps Log, dated March 2022, provided by MD KK, found the last time the hot water had been tested was 3/21/22.

This citation has 2 Deficiency Practice Statements, A & B Deficiency Practice Statement A This citation pertains to Intake # MI 008. Based on observation, interview, and record review, the facility failed to provide adequate supervision, maintain functional facility door locks, and respond appropriately to an exit alarm for a cognitively impaired resident, in 1 of 4 residents (Resident #63) reviewed for safety/supervision resulting in an Immediate Jeopardy when on 1/4/20 at approximately 1:30 P.M. to 1:40 P.M., Resident #63 exited the facility unbeknownst to facility staff. This deficient practice placed 16 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of the facility policy Accident-Incident-Elopement-Wandering Resident last revised 6/1/16 revealed, Purpose-To identify resident at risk for wandering and/or elopement and to provide a mechanism to ensure the safety of all residents. General Guidelines 1. All residents who are at risk for harm because of wandering/elopement will be assessed as follows: The mini-mental Evaluation and Wandering Behavioral Assessment will be completed with three (3) days of admission. The interdisciplinary team will meet and discuss the findings of the assessment and will institute placement on the Program, if resident is at risk. The physician will be notified of findings. The resident will be evaluated monthly for three (3) consecutive months, quarterly, with significant changes of condition and upon discharge. 2. The resident's current MDS 3.0 will be reviewed to determine what changes have occurred that would trigger wandering/elopement episodes. 3. A picture of the resident will be placed with the receptionist to alert him/her of the potential and to monitor resident location when in the lobby area. This program is chosen to alert staff of the potential for wandering and possible wandering/elopements. 4. Appropriate assessment will be completed on residents who have been deemed wandering/elopement risks as noted above. The At Risk Committee will meet weekly to review each resident on the program for changes. The At Risk log notes that new at risk residents will be monitored weekly times 4 weeks. Continue monitor with changes or increased wandering. 5. The resident's care plan will be modified to indicate the resident is at risk for wandering/elopement episodes. Staff will be informed at shift change of the modifications to the resident's care plan and place any behavior changes on nursing 24 hour report to notify DON and interdisciplinary team. 6. Interventions into wandering/elopement episodes will be entered onto the resident's care plan and medical record. 7. Should a wandering/elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the resident's medical record and review by the interdisciplinary team. 8. If a resident repeatedly wanders off the unit, an increased supervision monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as to the implementation of the monitoring schedule. 9. If a resident is discovered to be missing, a search shall behind immediately. 10. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 11. Should an employee observe a resident leaving the premises, he/she should: a. Attempt to prevent the departure: b. Obtain assistance from other staff members in the immediate vicinity, if necessary; c. Instruct another staff member to inform the charge nurse of director of nursing services that a resident has left the premises; and d. Be courteous in preventing the departure and in returning the resident to the facility. 12. Upon return of the resident to the facility, the director of nursing services or charge nurse should: a. Examine the resident for injuries; b. Contact the attending physician and report what happened; c. Contact the resident's responsible party/POA and inform him/her of the incident; d. Complete and file an incident report; and e. Make appropriate notations in the resident's medical record. f. Interdisciplinary team make revisions and update care plan as appropriate. 13. Should an employee discover that a resident is missing from the facility, he/she should: a. Determine if the resident is out on an authorized leave or pass. If not; b. Make a thorough search of the building(s) and premises. If not located; c. Notify the administrator and the director of nursing services; d. Notify the resident's responsible party/POA; e. Notify the attending physician; g. Notify law enforcement officials (if indicated); h. If necessary, notify volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); i. Provide search teams with resident identification information; and j. Make an extensive search of the surrounding area. 14. Upon return of the resident to the facility, the director of nursing services or charge nurse should: a. Examine the resident for injuries; b. Contact the attending physician and report findings and conditions of the resident. Follow orders; c. Notify the resident's responsible party/POA; d. Notify search teams that the resident has been located (if applicable); e. Complete and file an incident report; and report to state system as applicable f. Make appropriate entries into the resident's medical record. g. Interdisciplinary team make revisions and update care plan as appropriate. (sic) Resident #63 Review of a Face Sheet revealed Resident #63 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #63, with a reference date of 12/22/19, revealed a .Staff Assessment for Mental Status .Moderately impaired-decisions poor, cues/supervision required .Signs and Symptoms of [MEDICAL CONDITION] .C. Disorganized thinking-Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? 1=Behavior continuously present, does not fluctuate . Review of Resident #63's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #63 had a score of 0 out of 15 which indicated Resident #63 was severely cognitively impaired. Review of Resident #63's Staff Assessment for Mental Status dated 1/4/19 revealed Resident #63 scored a 3 which indicated he was severely cognitively impaired. Review of Resident #63's hospital Discharge Summary dated 12/14/19 revealed, The facility is aware that the patient has been requiring a sitter (1:1 staff member) as well as restraints . Review of Resident #63's Baseline Care Plan dated 12/19/19 revealed, .I am at risk for elopement as evidence by .dementia .[MEDICAL CONDITION] .interventions .Elopement Risk Assessment .Secure Unit . During an interview on 01/08/2020 at 12:45 P.M., Licensed Practical Nurse/MDS Nurse N reported that Resident #63 was admitted to the facility on [DATE] following a hospitalization . Prior to the hospitalization , Resident #63 resided in an Assisted Living Memory Care Unit. Resident #63 was placed on the facility's secured memory unit due to his history of residing in a memory care unit and his risk of elopement. Review of Resident #63's Elopement Risk assessment dated [DATE] revealed, Resident is at risk for elopement at this time-Yes. The Elopement Risk Assessment was not completed prior to the elopement. Review of the Incident report revealed, Date/Time Incident Discovered: 1/4/2020 01:40 PM-Date/Time Incident Occurred: 1/4/2020 01:30 PM. Incident Summary: Resident (#63) was in memory care unit at 1:30, seen by activity staff as she was finishing up her activity and two certified nursing assistants sitting at the table. At 1:40PM staff member accompanied resident to memory unit after hearing someone knock on the door from outside. head to toe assessment completed with no injuries noted. Review of Resident #63's Incident Report dated 1/4/19 revealed, Patient was found wondering (sic) outside of the door by staff, after he walked out of the memory unit and was found outside the Rivers room [ROOM NUMBER] exit door time line of the incident placed him in the memory unit at 130pm and he was returned to the unit at 140pm .Meds taken during last 8 hours .[MEDICAL CONDITION]/Antipsychotics .Mobility: Ambulates-independ .Mental: Alert, orient to person only .Medical risk factors possibly related to incident: Fall History .Confusion/Disorientation. Review of a facility form revealed, .On (MONTH) 4th 2020 at approx. 2:17pm a resident was noted at the door of the Rivers unit. The resident was noted to be within the fenced court yard of the facility. Upon further investigation, the finding below were noted .BIMS (Brief Interview for Mental Status): 0 (indicating severe cognitive impairment) .Staff Present: (Activity Staff AS P)/ (CNA X), (CNA W) and (CNA MM)/ (Licensed Practical Nurse LPN CC). Resident was noted in the dining room on the memory care unit during lunch from 12-1pm. Last tray taken up at 2 minutes to 1pm, noted due to nurses coordinating lunch breaks. Housekeeping on unit to clean following lunch, while (AS P) was still on unit, resident was moved away from the tables to allow housekeeping to come in. Resident (#63) moved to tv area and noted to be watching a western show with Einstein book in his hands at 1:20pm. Nurse inquired what the name of the book was, which prompted notification of time. Nurse walked out of tv area leaving (AS P) with activities and (CNA MM) and (CNA X) both CNA's on the unit, in the area at 1:20pm. Noted because the nurses were still coordinating lunch breaks. (CNA MM) was in room [ROOM NUMBER] and (CNA X) was in the tv area with (AS P) from Activities shortly after 1:20pm, during this time, (LPN CC) the nurse was assisting another nurse, with sending another resident out to the hospital. At 1:30pm, following residents on unit incontinent care, (AS P) saw resident sitting in front of tv on memory care unit, At 1:30pm (AS P) exited unit. Nurse was walking to service door when (CNA W) from Rivers unit, was noted walking up the hall to the memory care unit at 1:40pm with resident (#63). Resident never left facility grounds and was within resident's gated courtyard at door. Resident uses a wheelchair for mobility but does ambulate. Resident is alert and oriented to self. Resident ambulated independently, no assistive devices. Resident wears incontinent garment and states I have to go, I have go, I have to go when he has to go to the bathroom. Resident will also stand and begin to walk around when he needs to use the restroom. Resident was not noted with incontinence prior to exit or upon return. Resident also did not verbalize need to use restroom. Resident care plan updated to reflect resident characteristics and to show resident being placed on bowel and bladder program. Resident activities also adjust to show that he enjoys being outside, per responsible representative. Resident Responsible Representative, (name omitted) was notified and stated that resident does have a tendency to go outside. Dr. (name omitted) was already in facility and was notified while on site, no new orders. Skin assessment was completed on resident with no injuries. Skin temp. WNL (within normal limits), turgor appropriate and no complaints voiced from resident. No signs or symptoms of trauma, pain or discomfort noted. Resident placed on 15 minute checks and staff re- in serviced on properly closing doors behind them. Doors adjusted by maintenance director to close quicker behind those entering and exiting. Reminders placed to alert staff to double check doors prior to walking away. Staff re- in-serviced on procedure when doors alarm . (sic) During an interview on 1/8/19 at 10:40 [NAME]M., Administrator (NHA) A reported that it was determined that Resident #63 exited the memory care unit dining room door and then exited the courtyard door which was kitty corner from the memory care unit dining room door (the door was located across the hall from the Physical Therapy room). NHA A reported that she was unable to determine which staff member shut off the door alarm for the door that Resident #63 exited on 1/4/19. NHA A reported that the alarm for the doors to the courtyard could be shut off at the nurses station. NHA A reported that she did not believe staff walked out into the courtyard to determine if a resident had exited the door and instead shut the alarm off. During an observation on 1/8/20 at 2:00 P.M., the doors which lead to the courtyard were assessed with [REDACTED]. The door could not be opened from the courtyard to regain entry into the facility. The door across from the Physical Therapy room did not have a 15 second delay and was easily opened. The door could be opened from the courtyard to regain entry into the facility. The door next to room [ROOM NUMBER] could not be opened from the courtyard to regain entry into the facility. The door next to room [ROOM NUMBER] could not be opened from the courtyard to regain entry into the facility. LPN [NAME] reported that the only door that is unlocked to regain entry into the facility is the door across from the Physical Therapy room. Review of a Witness Statement dated 1/4/20 revealed, .(Resident #63) ate lunch in the dining area .after lunch complete resident was moved to T.V Room (around 1pm) he was sitting with a book and looking around at the T.V. I (LPN CC) left unit at 120p to help (name omitted) nurse on woods to get a hospital patient out. When I left unit he was sitting in w/c (wheelchair) in front of T.V. (Activities Staff P) from activities was on unit. I observed (CNA W) walking back to unit prior to 141 (1:41 P.M.) as I clocked for lunch. Time Line 12:00p-1p MU (memory unit) Dining Rm (room) 1pm-1:20pm Last seen in TV room [ROOM NUMBER]pm Returned to unit by Rivers CN[NAME] Vital Signs: (Temperature) 98.3, (pulse) 72, (respirations) 19, (blood pressure) 121/62. I asked MU (memory unit) staff how resident was able to leave. All doors to unit were double checked 2 front doors noted being locked. All staff in building decline that they reset the alarm. Report from (CNA W) He found resident outside Rm 19 stating that resident was walking outside no wheelchair with him (CNA W) used a rivers extra w/c to return resident . (sic) Review of Resident #63's Departmental Notes written by LPN CC and dated 1/4/19 at 11:12 P.M. revealed, .Resident was up during the morning shift attended therapy, and then was in the dining room for lunch after eating lunch dining room (12p-1P) was cleared and the resident was moved to the TV room to watch TV he was also thumbing through a book. The activity aid was inside for a group activity, this nurse left the unit around 120p to assist the [NAME] nurse, noting that 1 CNA was assisting a resident in (a room) and the other was going between the TV and listening in the hall. Around 140p an aid from Rivers unit was assisting him back to the MU (memory unit) after he was outside. Patient is noted to have a pair of trousers and long sleeved sweatshirt on with shoes and socks. After returning to the unit he was assessed vitals taken skin check completed with no new areas found, He was placed on q (every) 15 minute checks. (Physician) was notified while in the building doing rounds and the family POA (Power of Attorney) (name omitted) was notified. The remainder of the shift he remained uneventful, after supper he was assisted back to his bed and laid down for the night . (sic) Review of a Witness Statement dated 1/4/20 revealed, I (CNA W) was in room [ROOM NUMBER] on rivers giving resident's care. I heard the knock and yelling out. When I came out the resident room, I saw (Resident #63) knocking the glass exit door from outside. I took the wheelchair and helped the resident getting inside. I took him back to Memory Unit and reported to the nurse and manager on Duty. This happened around 1:40 pm. During an interview on 1/8/20 at 9:40 [NAME]M., CNA W reported that on 1/4/19 he was assisting a resident in room [ROOM NUMBER]. When CNA W exited the room he saw Resident #63 on the outside of the door knocking on the door in an attempt to reenter the facility. CNAW reported that Resident #63 appeared agitated and scared. CNA W reported that there was no overhead page to indicate a resident was missing. CNA W stated, .at that point I was the only one who knew he was missing . Review of a Witness Statement dated 1/4/20 revealed, I (Activity Staff AS P) seen (sic) (Resident #63) in memory unit at around 1:30pm when I finished my activit (sic) in the memory unit . During an interview on 1/7/20 at 4:27 P.M., AS P reported that she left the memory care unit at approximately 1:30 P.M. and Resident #63 was in the TV room. AS P reported that when she left the memory care unit she believed the doors were locked. AS P reported that the memory care dining room door does not always lock. During an observation on 1/7/20 at 4:45 P.M., the memory care unit dining room door was not latched and opened easily. During an interview on 1/7/20 at 4:45 P.M., Human Resources Director (HRD) O reported that the memory care unit dining room door should be completely closed and locked at all times. On 1/8/20, Administrator A was notified of an Immediate Jeopardy that began on 1/4/20 when Resident #63, who was identified as an elopement risk, eloped from the memory care unit and facility, unbeknownst to facility staff. On 1/10/20, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Resident #63 was immediately placed on increased supervision of 15-minute checks which initiated at 2:00 p.m. and continued until 1/9/20. 2. On 1/4/20 at 1:50 p.m., CNA on unit was assigned the responsibility for visually monitoring Resident #63 within line of sight until 3:00 p.m. Starting at 3:00 p.m. there were two new staff members, a CNA and nurse, who were alternatively, assigned the responsibility of monitoring resident #63 within line of sight. This lasted until 7:00 p.m. 3. Resident #63 was assessed immediately on 1/4/20 at 1:41 p.m. by the licensed nurse for signs and symptoms of injury with no negative outcome. 4. Resident #63's care plan was updated by the Director of Nursing on 1/4/20. 5. On 1/4/20, the Maintenance Director tightened the door arm to the memory care dining room, to increase the speed in which the door closed. 6. On 1/4/20 at 3:00 p.m., the manager on duty posted bright colored signs to remind staff to ensure the door to the memory unit and memory dining room closed securely following entrance or exit. 7. Door alarm checks/drills were started on 1/4/20 at 4:30 p.m., performing 1 drill during 7:00 a.m.-7:00 p.m. shift and 1 drill on 7:00 p.m.-7:00 a.m. shift with the last drill being on 1/8/20. Elopement drill performed on 1/5/20 during 7:00 p.m.-7:00 a.m. shift and on 1/6/20 during 7:00 a.m.-7:00 p.m. shift. 8. The Director of Nursing/MDS Coordinator updated 14 Elopement Risk Assessments on Memory Care residents, including Resident #63, on 1/6/20. 9. The Director of Nursing reviewed Care Plans for 14 residents found to be at risk for elopement and ensured interventions were effective on 1/6/20. 10. On 1/7/20, at 4:50 p.m., the Maintenance Director placed latch alarm on the door entering and exiting the memory care dining room door. 11. Elopement Risk books were reviewed and updated by the Director of Nursing on 1/4/20. 12. Staff education was immediately started on 1/4/20 on ensuring doors close properly, utilizing current policy Accident/ Incident/ Elopement/ Wandering Resident. 13. As of 1/8/20, 100% of all staff have been in-serviced on the policy Accident/Incident/Elopement/Wandering Resident. 14. Door security has been maintained 100% as of 1/7/20. 100% of current residents are present from 1/4/20- present (1/9/20), with no other elopements or unsupervised exits from the facility. 15. Starting 1/4/20 all current employees will be in-serviced on Accident/Incident/Elopement/Wandering Residents during their annual evaluations and starting 1/4/20 all new hires will be in-serviced upon hire on Accident/Incident/Elopement/Wandering Residents. Although the immediate jeopardy was removed on 1/7/20, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. Deficiency Practice Statement B Based on observation, interview, and record review, the facility failed to implement interventions for fall prevention in 1 of 6 residents (Resident #22) reviewed for falls, resulting in a fall with an ankle fracture and the potential for additional falls with injury. Findings include: Review of The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities, revealed .Falls are common in nursing facilities. Of the 1.6 million residents in U.S. nursing facilities, approximately half fall annually. About 1 in 3 of those who fall will fall two or more times in a year .Falls often have serious consequences, especially in frail older residents. Fall-related injuries decrease the resident's quality of life and ability to function .Many nursing facilities have fall programs in place, but recognize that there is always room for improvement. While not all falls and injuries can be prevented, it is critical to have a systematic process of assessment, intervention and monitoring that results in minimizing fall risk .When a fall occurs, careful evaluation and investigation, along with immediate intervention during the first 24 hours, can help identify risk and prevent future incidents .Staff should monitor and manage the resident's response, making care plan revisions as needed . Content last reviewed (MONTH) (YEAR). Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man1.html Resident #22 Review of a Face Sheet revealed Resident #22 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #22, with a reference date of 10/29/19, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated moderate cognitive impairment. Further review of this MDS assessment, with a reference date of 10/29/19, revealed Resident #22 required extensive staff assist with transfers and toileting, and was not steady for balance. Review of the Care Plan for Resident #22, printed 1/10/20, revealed .At risk for falls with injury R/T (related to) DMII (diabetes), meds (medications), depression, decreased mobility, h/o (history of) falls. Res (resident) noted to have a fall on 12/28/19 resulting in ST (skin tear) to right toe . with interventions which included .Non-slip, well fitting footwear, as resident will allow . with a start date of 8/12/19. In an observation on 1/8/20 at 8:24 a.m., observed Resident #22 laying in bed in her room, with a dressing noted to her right ankle. Noted that her left foot was bare. In an observation on 1/8/20 at 10:46 a.m., observed Resident #22 laying in bed in her room, with a dressing noted to her right ankle. Noted that her left foot was bare. In an interview on 1/8/20 at 10:46 a.m., Resident #22 reported she injured her right ankle after a fall in her bathroom. Resident #22 reported a CNA was helping her wash up after using the restroom when the fall occurred. Resident #22 stated .I told her I've got to sit down .my legs are going to give out .I'm going to faint .I went down .I fainted . In an observation on 1/10/20 at 10:13 a.m., observed Resident #22 laying in bed in her room with her eyes closed, with a dressing noted to her right ankle. Noted that her left foot was bare. Review of an Incident Report dated 12/28/19, revealed Resident #22 had a fall in her bathroom at 3:45 a.m. Per the report, .CNA (Certified Nursing Assistant) alerted nurse to go to residents room where other CNA was present with resident .Skin came off right great toe. Approx (approximately) 3 cm circular .First aid to right great toe, gripper socks applied . Review of a Fall Scene Investigation for Resident #22, dated 12/28/19 at 3:45 a.m., revealed .What was resident doing during or just prior to fall .At sink getting washed up by CNA .Footwear at time of fall .Bare feet .ROOT CAUSES OF THIS FALL .Footwear .Knees gave out, lost balance .Initial intervention to prevent future falls .Gripper socks/shoes during transfers . Review of the Care Plan for Resident #22, printed 1/10/20, revealed a new intervention for .Res (resident) sent to ER (emergency room ) for c/o (complaints of) pain following fall. Results show ankle fx (fracture). CAM boot in place and follow up with ORTHO as indicated . with a start date of 12/30/19. No other interventions or updates were noted to Resident #22's care plan after her fall on 12/28/19. In an interview on 1/10/20 at 12:11 p.m., Licensed Practical Nurse (LPN) FF reported she was notified of Resident #22's fall on 12/28/19 at 3:45 a.m. LPN FF reported she assessed Resident #22 after the fall and found a skin tear on her right great toe. LPN FF reported that due to increased swelling later in the shift, an X-ray was ordered of Resident #22's right ankle. LPN FF reported the Certified Nursing Assistants (CNA's) were helping Resident #22 get washed up after using the restroom when her .legs gave way . LPN FF stated .the only thing she did not have on was slipper socks (grip socks) or shoes .She was barefoot .As a standard, she should of had grip socks or shoes on (for the transfer) . Review of an Emergency Department Provider Note for Resident #22, dated 12/28/19, revealed .Elderly female, Mostly nonambulatory at SNF (Skilled Nursing Facility). Does stand to transfer at times. fell out of W/C (wheelchair) while attempting to transfer. [MEDICAL CONDITION], bruising, and deformity to R (right) ankle. XR (X-ray) showing bimalleolar ankle fracture. CAM walker boot so that wound management can be more easily done at SNF (wound to bottom of great toe from fall) .[DIAGNOSES REDACTED].Laceration of right great toe . Review of an Incident Report dated 1/4/20, revealed Resident #22 had an unwitnessed fall out of bed in her room at 3:20 p.m. Per the report, .this nurse was called into the resident's room at around 3:20 p.m .observed resident sitting on the floorbacking (sic) her bed .Immediate Post-Incident Action .Resident assessed with [REDACTED]. Resident to use call light when she needs assistance .because she can not get up by herself d/t (due to) her fracture to the right ankle . Review of the Care Plan for Resident #22, printed 1/10/20, revealed no new interventions were added after Resident #22's fall on 1/4/20. In an interview on 1/10/20 at 1:25 p.m. with Director of Nursing (DON) B and Unit Manager E, DON B reported she was notified of Resident #22's fall on 12/28/19. DON B reported that an X-ray of Resident #22's right ankle was ordered due to increased swelling after the fall, however, due to complaints of increased pain, the resident was sent to the emergency room for further evaluation and treatment. DON B reported the care plan should have been updated with a new intervention to prevent future falls by LPN FF after Resident #22's fall on 12/28/19.

Based on observation, interview and record review the facility failed to follow physician's orders to prevent, adequately assess and treat a pressure ulcer of the coccyx in 1 of 3 sampled residents (#5) evaluated for pressure ulcers, from a total sample of 15 residents, resulting in a facility acquired non-healing stage 4 pressure ulcer with pelvic osteo[DIAGNOSES REDACTED]. Findings include: According to the Face Sheet and Minimum Data Set (MDS-resident assessment), dated 1/22/14, Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #5 had a Brief Interview of Mental Status of zero, (unable to assess), had both short and long term memory problems, required assistance of 1 staff member with bed mobility, wheelchair propulsion, dressing, eating, hygiene, bathing and toileting. The MDS indicated Resident #5 needed the assistance of 2 staff with transfers, was always incontinent of bowel and bladder, was at risk for skin breakdown and had an un-stageable pressure wound on her left heel and redness on her right ankle. Review of the "At Risk for Skin Breakdown" care plan dated 1/29/13 revealed Resident #5 was at risk for skin breakdown due to impaired physical mobility secondary to generalized weakness. Approaches included "reposition as tolerated, place pressure-reduction mattress to bed and cushion to chair, assess nutritional status, provide incontinence care as needed to prevent excess moisture and excoriation, skin assessment weekly and prn, moisture barrier as needed. " According to the facility's "Nursing Admission Assessment", dated 12/31/13, Resident #5 had no documentation regarding any skin problems or breakdown of the coccyx. According to facility's "Pressure Sore Risk Assessment", dated 1/10/14, Resident #5 was at high risk for pressure ulcer development, and the facility was to complete a, "Pressure Ulcer Development Check List" and proceed to care planning. During an interview on 9/18/14 at 4:11 p.m., Director of Nursing (DON) "B" reported that the "Pressure Ulcer Development Check List" had not been completed for Resident #5. Although requested from the DON "B" and Nurse Consultant "S", no blank copy of the check list was provided prior to exit conference on 9/19/14 at 2:30 p.m. According to the facility's "Weekly Skin Integrity Assessment", dated 1/23/14, Resident #5 had a "redness" to her buttocks and was to be "turned q (every) 2 hours". According to the physician's progress note, dated 1/29/14, Resident #5 had a "small open area on her coccyx...". The note indicated that Resident #5, "is declining and this is an unavoidable situation. She does not stay off it." Since Resident #5 required assistance of staff to reposition, the latter statement was unclear. According to the facility's, "Individual Resident Pressure Ulcer Tracking Tool", dated 1/30/14, Resident #5 developed an un-stageable pressure wound on her coccyx that measured 7 centimeters (cm) long x 2 cm wide x no depth (1 inch = 2.5 cm). Resident #5's tracking tool was checked "none" for drainage, and "eschar (dark colored, dead material on top of live tissue)". The treatment was to cleanse with normal saline, apply xeroform (Vaseline) gauze and cover with a padded dressing. According to the pressure ulcer care plan, dated 1/30/14, Resident #5 had an "un-stageable open area to the left buttocks r/t (related to) poor nutritional intake, impaired physical mobility, incontinence of bowel and bladder secondary to [DIAGNOSES REDACTED]. Approaches included: reposition as tolerated, wound care as ordered, pain medication, 2 person assist with repositioning to avoid skin friction/sheering, encourage nutritional intake and supplemental nutritional support, weekly evaluation of wound healing, daily observation of skin with routine care, adjust my treatment plan if no healing within 2-4 weeks. Under approaches, undated and hand-written, was, " I have a LAL (low air loss) mattress to my bed". According to the pressure ulcer tracking tool, dated 2/6/14, Resident #5 had small amount of serous (thin, yellowish) drainage and eschar checked. Resident #5's wound measurements and depth were unchanged. According to the pressure ulcer tracking tool, dated 2/13/14, Resident #5 had small amount of drainage and eschar checked, as well as slough. Resident #5's wound measurements were decreased to 6 cm x 2 cm, still without depth. The treatment was changed to calcium alginate (absorbs excess fluid, keeps wound moist) with a dressing that promotes healing, covered by a padded dressing. According to the pressure ulcer tracking tool, dated 2/20/14 and 2/27/14, Resident #5 had a small amount of drainage and eschar checked, as well as slough. Resident #5's wound measurements were unchanged, as was the treatment. The hand-written comment was, "area showing some improvement...", but the statement was confusing since the wound assessment did not reflect improvement. Nothing was documented about the amounts of eschar and slough. According to the pressure ulcer tracking tool, dated 3/3/14, Resident #5's pressure wound measured an abrupt decrease to 3 cm x 3 cm x 1 cm in depth. The drainage had changed to serosanguinous (lightly blood-tinged), and eschar and slough were checked. Again, "area showing improvement and LAL (low-air-loss mattress)", was hand written. According to the assessment information, Resident #5's pressure wound now had depth which was not improvement, but nothing was documented about the actual amounts of eschar and slough. Treatment was unchanged. According to the pressure ulcer tracking tool, dated 3/27/14, Resident #5's pressure wound measurements and treatment were unchanged, although the drainage had increased to moderate amount. According to the recently instituted electronic medical records, "Pressure Ulcer Tracking Tool", dated 4/1/14, Resident #5's pressure wound measurements increased to 3.5 cm x 2.5 cm x 1.5 cm. Documentation for wounds now provided an area to enter percentages of tissues in the wound bed (bottom of wound) as follows: 10% granulation (healthy, new tissue), 50% slough and 40% eschar. The wound status was documented as, "unchanged" despite increasing measurements. According to the documentation, it had been 5 weeks since the treatment for [REDACTED]. The physician was documented as being notified on 3/26/14, prior to the above noted measurements and wound condition were assessed. According to the pressure wound tracking tool, dated 4/8/14, Resident #5's measurements were increased to 3 cm x 2 cm x 4.5 cm, and the wound bed was described as being 10% granulation and 90 % eschar. Treatment orders were documented as, "pending". According to the pressure wound tracking tool, dated 4/16/14, Resident #5's were 3 cm x 2.5 cm x 3.5 cm, and assessed as infected. the wound bed was documented as being 25% granulation and 75 % eschar. The new treatment (after 7 weeks) was cleanse with normal saline, pack, lightly, with a saline gauze and cover with a padded dressing. Resident #5 was to see the wound specialist on 4/24/14. On 9/18/14 at 12:00 p.m., DON "B" was interviewed. When asked what Resident #5's wound looked like when it first appeared, DON "B" said, "I saw the wound, and recall purplish, intact skin on her (Resident #5's) coccyx. It resembled a deep tissue injury. It was not hard to the touch. I did not see eschar". When asked what training LPN "U" received as a wound nurse, DON "B" shook his head back and forth and said, "No special training". In an interview on 9/18/14 at 12:30 p.m., when asked to describe eschar, Licensed Practical Nurse (LPN) "U" said, "It is blackened, purplish dead skin, usually hard to the touch". When asked if eschar could vary in size, LPN "U" answered, "Yes, as it heals it can get smaller". When asked to describe slough, LPN "U" said, "It is yellowish-white, mushy, stringy, dead skin, usually at the bottom of a pressure ulcer". When asked what she could recall if Resident #5's pressure wound was open when she initially evaluated it, LPN "U" said that she couldn't remember anything about the pressure wound. On 9/17/14 at 10:35 a.m., Wound Nurse LPN "N" was observed as she changed Resident #5's pressure wound dressing on the coccyx. LPN "N" assembled her supplies, washed her hands and donned gloves. Then, LPN "N" removed the old padded dressing and used a Q-tip to gently roll the old packing from the open wound, into her left hand. The packing was saturated with dark brown drainage without noticeable odor. Without washing hands and donning new gloves, LPN "N" placed a clean 4 x 4 (inch), fluffed gauze in her left hand and soaked the gauze with normal saline. LPN "N" gently inserted the soaked gauze into the wound, rotated the gauze 360 degrees, with her right hand and removed and discarded the gauze. There was no tissue or discoloration on the gauze. The wound was not measured but appeared to be approximately 3 cm x 3 cm x 4 cm. LPN "N" washed her hands and donned new gloves, and using a Q-tip, inserted a 2 inch x 2 in calcium alginate dressing (to loosen dead tissue) to the base of the wound followed by a dry, fluffed gauze placed into the wound and paper-taped a padded dressing over all. On 9/18/14 at 11:45 a.m., Certified Wound Nurse "Y", from the wound center, was interviewed via telephone. When asked about the process of cleansing Resident #5's stage 4 pressure wound, Nurse "Y" said that a wound without obvious slough, should be irrigated with 120 to 150 cc of saline, using a pre-packaged bottle of the correct amount of saline or a large syringe with an 18 gauge needed attached. When asked about the observed practice of LPN "N" inserting the fluffed and saturated 4 x 4 into Resident #5's wound and rotating it, Nurse "Y" paused, then said doing that could disrupt the growth of live tissue, and should only be done if there was a large amount of loosened slough in the wound. According to documentation from the wound center, dated 5/6/14, Resident #5's pressure wound was surgically debrided, resulting in a [DIAGNOSES REDACTED]. The wound physician's measurements were 3 cm x 2 cm x 3.8 cm which amounted to 4 square cm of tissue area area. On 9/19/14 at 10:15 a.m., DON "B" was interviewed. When asked how the decision was made to send Resident #5 to the wound center after 7 weeks of unchanged or worsening assessments, DON "B" said that he had not observed the wound since 1/30/14, and when he saw the wound, on 4/16/14, he knew, "It was time for the wound clinic, if the family agreed". Review of the Wound Care note dated 5/5/14 revealed Resident #5's coccyx was debrided (surgical removal) of, "subcutaneous tissue, fascia, and bone. Cultures were sent of the soft tissue and bone and separate bone pathology specimen was sent." The wound measurement prior to debridement was 5.5 cm x 3 cm x 4 cm with necrotic tissue, fascia(tendons and ligaments) and bone. Resident #5's wound had 100% pink tissue after debridement. The final procedure [DIAGNOSES REDACTED]. According to the Wound Care note dated 5/23/14 revealed Resident #5 had debridement of her sacral ulcer 3 weeks ago, and was to allowed to be up for 2 hour at a time with each meal. During an observation on 9/16/14: at 9:20 a.m. Resident #5 was lying in her room in bed on her left side with the head of the bed at approximately 40 degrees and was being fed breakfast. Resident #5 was observed to have a significant kyphosis (curve of the upper spine - dowager's hump). At 10:50 a.m. Resident #5 was observed to remain on her left side with the head of the bed flat. At 11:40 a.m., Resident #5 was observed to remain on her left side. In an observation on 9/16/14 at 12:00 p.m., Resident #5 was transferred to a wheelchair by 2 CNA's and taken to the dining room at 12:00 p.m. At 2:20 p.m., (2 hours and 20 minutes later) Resident #5 remained in her wheelchair, in her room, in front of the television which was on. At 3:30 p.m., Resident #5 was observed in the same position in her wheelchair in her room with the TV on. At 4:00 p.m., Resident #5 was placed back in bed on her right side by Charge Nurse/LPN "O" and an evening CNA. Resident #5 was in her wheelchair for a total of 4 hours. On 9/18/14 at approximately 11:00 am, CNA "T" was interviewed. When asked, CNA "T" said that she was familiar with Resident #5. When asked how long Resident #5 was to be up in her wheelchair, CNA "T" said, "One hour"? When asked to comment on this surveyor's observations of Resident #5 in her wheelchair for a total of 4 hours, 12:00 p.m. until 4:00 p.m. on 9/16/14, CNA "T" did not answer. Review of the Wound Care note dated 8/28/14 revealed an order for [REDACTED]. There was no documented evidence in the medical record that this wound care order was transposed into Resident #5's care plan or CNA Resident Care Guide. According to the undated CNA "Resident Status Sheet" there were no instructions about when CNA's were to reposition Resident #5 , nor the length of time or when she was to be in the wheelchair. The special mattress was not mentioned, nor was the pressure wound or it's location. According to the electronic "Scheduled Task List", dated 1-1-00, for Resident #5, the first thing to"pop up" read, "FYI , - Reposition every 2hrs (2 hours) side to side. Do not position on back...". Nothing was added to direct time limits for Resident #5 to be in her wheelchair. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT FALLS FOR 1 OF 6 (#1) SAMPLED RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 15 RESIDENTS RESULTING IN A HIP FRACTURE WITH SURGICAL REPAIR, PAIN, AND DECREASED MOBILITY. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION FACE SHEET (NO DATE), RESIDENT #1 WAS AN [AGE] year OLD FEMALE ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] FROM AN ACUTE CARE HOSPITAL FOLLOWING SURGICAL REPAIR OF A FRACTURED HIP. ACCORDING TO THE ADMISSION FACE SHEET (NO DATE), RESIDENT #1 HAD THE FOLLOWING DIAGNOSES; RIGHT HIP FRACTURE, URINARY TRACT INFECTION, KIDNEY FAILURE, [DIAGNOSES REDACTED], CHRONIC OBSTRUCTIVE PULMONARY DISEASE, DEMENTIA AND DEPRESSION. ACCORDING TO THE "NURSING ADMISSION ASSESSMENT 3.0" DATED 7/18/2011, RESIDENT #1 DID NOT REPORT ANY PAIN. RESIDENT #1 SCORED A 16 ON THE FALLS ASSESSMENT WITH A SCORE "GREATER OR EQUAL TO 10 INDICATES A HIGH RISK OF FALLS." THE ADMISSION ASSESSMENT ALSO IDENTIFIED RESIDENT #1 AS UTILIZING A WALKER FOR MOBILITY. ACCORDING TO THE MOST RECENT MINIMUM DATA SET (MDS), A RESIDENT ASSESSMENT TOOL), DATED 4/21/2012, RESIDENT #1 SCORED A 2 ON THE STAFF ASSESSMENT FOR COGNITION INDICATING MODERATELY IMPAIRED COGNITION (REASONING SKILLS). ON THE SAME MDS, RESIDENT #1 WAS IDENTIFIED AS REQUIRING EXTENSIVE ASSISTANCE OF TWO STAFF PERSONS FOR BED MOBILITY, TOILETING AND TRANSFERS. THE MDS ALSO INDICATED THAT RESIDENT #1 DID NOT AMBULATE IN HER ROOM OR IN THE CORRIDOR. IN THE SECTION FOR BALANCE DURING TRANSITIONS AND WALKING, THE MDS IDENTIFIED RESIDENT #1 AS NOT STEADY WITH SURFACE TO SURFACE TRANSFERS, MOVING ON AND OFF THE TOILET AND MOVING FROM SEATED TO STANDING POSITION AND WAS ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE. DURING THE INITIAL TOUR OF THE FACILITY ON 9/11/2012, RESIDENT #1 WAS IDENTIFIED AS HAVING A FALL WITH FRACTURE IN 3/2012. A REVIEW OF THE INCIDENT REPORTS FOR FALLS FOR RESIDENT #1 BETWEEN 1/2012 AND 3/2012 REVEALED THE FOLLOWING: ACCORDING TO A "RESIDENT INCIDENT REPORT" DATED 1/23/2012, RESIDENT #1 SUSTAINED A FALL ON 1/23/2012 IN HER ROOM AT 11:20 PM. THE NARRATIVE INDICATED RESIDENT #1 WAS "OBSERVED SITTING ON FLOOR WITH LEGS STRETCHED OUT AND BACK LEANING AGAINST END OF BED AND BY WHEELCHAIR." ACCORDING TO THE INCIDENT REPORT, RESIDENT #1 DID NOT SUSTAIN ANY INJURIES AND UNDER THE SECTION "IMMEDIATE ACTION TAKEN", RESIDENT #1 WAS OFFERED TO GO TO RESTROOM AND ASSISTED BACK TO BED. ACCORDING TO A NEW FALLS RISK ASSESSMENT COMPLETED ON 1/24/2012, RESIDENT #1 SCORED A 21 WITH 10 OR MORE INDICATING A HIGH RISK OF FALLS. ALSO, ON THE FALLS RISK assessment dated [DATE], RESIDENT #1 WAS IDENTIFIED AS "CONFUSED". UNDER THE "FALL RISK SUMMARY" ON THE SAME FORM, THE STAFF WROTE, "RESIDENT INDEPENDENT WITH TRANSFERS." A REVIEW OF THE NURSING CARE PLAN FOR RISK FOR FALLS PRINTED ON 8/2/2011 AND REVIEWED ON 1/2012 AND 2/2012 REVEALED NO UPDATES OR NEW INTERVENTIONS TO PREVENT FURTHER FALLS WERE MADE TO THE CARE PLAN FOLLOWING THIS FALL. A REVIEW OF THE REHABILITATION (REHAB) SCREEN DATED 1/24/2012 REVEALED NO NEW RECOMMENDATIONS WERE MADE FROM PHYSICAL THERAPY. DURING REHAB, RESIDENT #1 WAS IDENTIFIED AS HAVING IMPAIRED SAFETY AWARENESS. ACCORDING TO THE SAME INCIDENT REPORT, RESIDENT #1'S MENTAL STATUS PRIOR TO THE FALL WAS DESCRIBED AS "ALERT BUT ORIENTED TO PERSON ONLY ". RESIDENT #1 WAS IDENTIFIED AS USING A WHEELCHAIR AND HAD A POSITIVE HISTORY FOR FALLS. ACCORDING TO A "RESIDENT INCIDENT REPORT" DATED 1/26/2012, RESIDENT #1 SUSTAINED A FALL ON 1/26//2012 IN HER ROOM AT 9:35 PM. THE NARRATIVE INDICATED RESIDENT #1 WAS "OBSERVED SITTING BETWEEN BED AND WHEELCHAIR WITH HER LEGS STRETCHED OUT, BACK LEANING AGAINST THE WALL". ACCORDING TO THE INCIDENT REPORT, RESIDENT #1 DID NOT SUSTAIN ANY INJURIES AND UNDER THE SECTION "IMMEDIATE ACTION TAKEN", RESIDENT #1 WAS ASSISTED BACK TO BED. ACCORDING TO A NEW FALLS RISK ASSESSMENT COMPLETED ON 1/27/2012, RESIDENT #1 SCORED A 21 WITH 10 OR MORE INDICATING A HIGH RISK OF FALLS. UNDER THE "FALL RISK SUMMARY" ON THE SAME FORM, THE STAFF WROTE, "RESIDENT INDEPENDENT WITH TRANSFERS." A REVIEW OF THE NURSING CARE PLAN FOR RISK FOR FALLS PRINTED ON 8/2/2011 AND REVIEWED ON 1/2012 AND 2/2012 REVEALED NO UPDATES OR NEW INTERVENTIONS TO PREVENT FURTHER FALLS WERE MADE TO THE CARE PLAN FOLLOWING THIS FALL. A REVIEW OF PHYSICAL THERAPY (PT) REHAB SCREEN DATED 1/30/2012 REVEALED NO NEW RECOMMENDATIONS AND RESIDENT #1 WAS IDENTIFIED AS HAVING IMPAIRED SAFETY AWARENESS. THE PT DEPARTMENT DOCUMENTED THAT RESIDENT #1 IS CURRENTLY RECEIVING OT SERVICES. ACCORDING TO THE SAME INCIDENT REPORT DATED 1/26/2012, RESIDENT #1'S MENTAL STATUS PRIOR TO THE FALL WAS DESCRIBED AS "ALERT BUT ORIENTED TO PERSON ONLY ". RESIDENT #1 WAS IDENTIFIED AS USING A WHEELCHAIR WITH A POSITIVE HISTORY FOR FALLS. ACCORDING TO A "RESIDENT INCIDENT REPORT" DATED 2/5/2012, RESIDENT #1 SUSTAINED A FALL ON 2/5/2012 IN THE DINING ROOM AT 7:30 AM. THE NARRATIVE INDICATED RESIDENT #1 WAS "REACHING OUT TO PICK SOMETHING UP OFF THE FLOOR". ACCORDING TO THE INCIDENT REPORT, RESIDENT #1 DID NOT SUSTAIN ANY INJURIES AND UNDER THE SECTION "IMMEDIATE ACTION TAKEN", RESIDENT #1 WAS ASSISTED BACK TO HER WHEELCHAIR. ACCORDING TO A NEW FALLS RISK ASSESSMENT COMPLETED ON 2/6/2012, RESIDENT #1 SCORED A 24 WITH 10 OR MORE INDICATING A HIGH RISK OF FALLS. ALSO, ON THE FALLS RISK ASSESSMENT, RESIDENT #1 WAS IDENTIFIED AS "CONFUSED." UNDER THE "FALL RISK SUMMARY" ON THE SAME FORM, THE STAFF WROTE, "RESIDENT INDEPENDENT WITH TRANSFERS." A REVIEW OF THE NURSING CARE PLAN FOR RISK FOR FALLS PRINTED ON 8/2/2011 AND REVIEWED ON 1/2012 AND 2/2012 REVEALED NO UPDATES OR NEW INTERVENTIONS TO PREVENT FURTHER FALLS WERE MADE TO THE CARE PLAN FOLLOWING THIS FALL AND NO NEW RECOMMENDATIONS WERE MADE FROM PHYSICAL THERAPY ACCORDING TO THE REHAB SCREENING NOTE OF 2/6/2012. THE REHAB SCREENING NOTES IDENTIFIED RESIDENT #1 AS HAVING IMPAIRED SAFETY AWARENESS. ACCORDING TO THE SAME INCIDENT REPORT DATED 2/5/2012, RESIDENT #1'S MENTAL STATUS PRIOR TO THE FALL WAS DESCRIBED AS "ALERT BUT ORIENTED TO PERSON ONLY". RESIDENT #1 WAS IDENTIFIED AS USING A WHEELCHAIR WITH A POSITIVE HISTORY FOR FALLS. ACCORDING TO A "RESIDENT INCIDENT REPORT" DATED 2/13/2012, RESIDENT #1 SUSTAINED A FALL ON 2/13/2012 IN HER ROOM AT 10:45 PM. THE NARRATIVE INDICATED RESIDENT #1 WAS "MAKING NOISES IN HER ROOM AND UPON ENTERING ROOM OBSERVED RESIDENT SITTING ON FLOOR WITH BACK AGAINST BED". ACCORDING TO THE INCIDENT REPORT, RESIDENT #1 DID NOT SUSTAIN ANY INJURIES AND UNDER THE SECTION "IMMEDIATE ACTION TAKEN", RESIDENT #1 WAS ASSISTED BACK TO BED. ACCORDING TO A NEW FALLS RISK ASSESSMENT COMPLETED ON 2/14/2012, RESIDENT #1 SCORED A 22 WITH 10 OR MORE INDICATING A HIGH RISK OF FALLS. UNDER THE "FALL RISK SUMMARY" ON THE SAME FORM, THE STAFF WROTE, "RESIDENT INDEPENDENT WITH SURFACE TO SURFACE TRANSFERS." A REVIEW OF THE NURSING CARE PLAN FOR RISK FOR FALLS PRINTED ON 8/2/2011 AND REVIEWED ON 1/2012 AND 2/2012 REVEALED AN UPDATE WAS MADE TO THE CARE PLAN IN FEBRUARY 2012 (NO SPECIFIC DATE) TO "LEAVE WHEELCHAIR WITHIN CLOSE REACH NEXT TO BED WHILE RESIDENT IN BED". ACCORDING TO THE REHAB SCREENING NOTES DATED 2/14/2012, RESIDENT #1 WAS IDENTIFIED AS HAVING IMPAIRED SAFETY AWARENESS YET NO NEW RECOMMENDATIONS WERE MADE TO PREVENT FALLS FOR RESIDENT #1. ACCORDING TO A "RESIDENT INCIDENT REPORT" DATED 3/6/2012, RESIDENT #1 SUSTAINED A FALL ON 3/6/2012 IN HER ROOM AT 2:00 PM. THE NARRATIVE INDICATED RESIDENT #1 WAS "OBSERVED SITTING ON THE FLOOR IN FRONT OF HER WHEELCHAIR FACING THE BED". ACCORDING TO THE INCIDENT REPORT, RESIDENT #1 DID NOT SUSTAIN ANY INJURIES AND UNDER THE SECTION "IMMEDIATE ACTION TAKEN", RESIDENT #1 WAS ASSISTED TO HER WHEELCHAIR." ACCORDING TO A NEW FALLS RISK ASSESSMENT COMPLETED ON 3/7/2012, RESIDENT #1 SCORED A 22 WITH 10 OR MORE INDICATING A HIGH RISK OF FALLS. ON THIS SAME INCIDENT REPORT, DATED 3/6/2012, RESIDENT #1 WAS IDENTIFIED AS "CONFUSED". UNDER THE "FALL RISK SUMMARY" ON THE SAME FORM, THE STAFF WROTE, "RESIDENT INDEPENDENT WITH SURFACE TO SURFACE TRANSFERS." A REVIEW OF THE NURSING CARE PLAN FOR RISK FOR FALLS PRINTED ON 8/2/2011 AND REVIEWED ON 1/2012 AND 2/2012 REVEALED NO UPDATES OR NEW INTERVENTIONS TO PREVENT FURTHER FALLS WERE MADE TO THE CARE PLAN FOLLOWING THIS FALL. ACCORDING TO THE REHAB SCREENING NOTES DATED 3/9/2012, RESIDENT WAS DISCONTINUED FROM THERAPY SERVICES IN FEBRUARY 2012. NO NEW RECOMMENDATIONS WERE MADE FROM PHYSICAL THERAPY EVEN THOUGH RESIDENT #1 CONTINUED TO HAVE FALLS AND WAS IDENTIFIED AS HAVING POOR SAFETY AWARENESS. ACCORDING TO THE SAME INCIDENT REPORT DATED 3/6/2012, RESIDENT #1'S MENTAL STATUS PRIOR TO THE FALL WAS DESCRIBED AS "ALERT BUT ORIENTED TO PERSON ONLY". RESIDENT #1 WAS IDENTIFIED AS USING A WHEELCHAIR WITH A POSITIVE HISTORY FOR FALLS. ACCORDING TO A "RESIDENT INCIDENT REPORT" DATED 3/17/2012, RESIDENT #1 SUSTAINED A FALL ON 3/17/2012 IN HER ROOM AT 7:50 AM. THE NARRATIVE INDICATED RESIDENT #1 WAS "OBSERVED SITTING ON THE FLOOR LOWER EXTREMITIES EXTENDED, BACK LEANING AGAINST THE HEAT REGISTER, UPON ASSESSMENT, RESIDENT COMPLAINED OF RIGHT HIP PAIN. RIGHT LOWER EXTREMITIES EXTERNAL ROTATION, UPON TOUCHING LEG RESIDENT COMPLAINS OF PAIN, ROM (RANGE OF MOTION) OF LEFT LEG WNL (WITHIN NORMAL LIMITS) SKIN INTACT NO NOTED BRUISING". UNDER THE SECTION "IMMEDIATE ACTION TAKEN", RESIDENT #1 WAS SENT TO (ACUTE CARE HOSPITAL) FOR FURTHER EVALUATION. ACCORDING TO THE FACILITY FORM "RESIDENT INCIDENT FOLLOW UP" DATED 3/17/2012, RESIDENT #1'S 24 HOUR CONDITION WAS REPORTED AS "FRACTURE TO RIGHT HIP." ALSO, IN THE AREA TITLED, "INCIDENT/EVENTS COMMITTEE INTERVENTION RECOMMENDATIONS/CORRECTIVE ACTIONS" DATED 3/17/2012, THE FACILITY DOCUMENTED, "WILL REVIEW UPON RETURN FROM HOSPITAL USE OF BED ALARM, WILL BE CONSIDERATION. RESIDENT RESENTS THE USE OF A CHAIR ALARM." ON THE BOTTOM OF THE SAME FORM, IN THE SECTION, "5-7 DAY POST-EVENT FOLLOW UP", THE FACILITY DOCUMENTED, "RESIDENT IS COMPLIANT WITH BED AND CHAIR ALARMS, INTERVENTION IS EFFECTIVE." A REVIEW OF OCCUPATIONAL THERAPY PROGRESS NOTES FROM 12/30/2011 UNTIL 1/19/2012 REVEALED RESIDENT #1 WAS CONSISTENTLY IDENTIFIED AS HAVE DECREASED BILATERAL UPPER EXTREMITY STRENGTH, DECREASED ACTIVITY TOLERANCE, DECREASED SAFETY SKILLS AND DECREASED DRESSING AND BATHING SKILLS. NO NEW INTERVENTIONS RELATED TO POOR SAFETY AWARENESS AND INCREASED RISK OF FALLS WERE MADE TO THE CARE PLAN DURING THAT TIME. A REVIEW OF THE FACILITY DOCUMENT, "FALLS MANAGEMENT", (NO DATE), REVEALED UNDER #9, "REVIEW AND REVISE INTERDISCIPLINARY PLAN OF CARE" AND UNDER #10, "UPDATE AND COMMUNICATE INTERVENTIONS ON THE PLAN OF CARE." RESIDENT #1 WAS OBSERVED IN AN EXERCISE ACTIVITY IN THE DINING ROOM ON 9/12/2012 AT APPROXIMATELY 10:40 AM. RESIDENT #1 WAS SEATED IN A WHEELCHAIR AND HAD A TAB ALARM ATTACHED TO THE BACK OF HER CHAIR. RESIDENT #1 APPEARED CONTENT, WAS PARTICIPATING IN THE ACTIVITY AND OFFERED NO COMPLAINT CONCERNING THE ALARM. AN INTERVIEW WITH THE DIRECTOR OF NURSING TOOK PLACE ON 9/12/2012 AT 9:30 AM IN THE CONFERENCE ROOM. EACH OF THE ABOVE FALLS FOR RESIDENT #1 WERE REVIEWED WITH THE DON. THE DON VERIFIED THAT NO NEW INTERVENTIONS WERE PUT INTO PLACE AFTER EACH FALL TO PREVENT FURTHER FALLS. THE DON CONFIRMED NEW INTERVENTIONS WERE INITIATED, FALL CARE PLAN DATED BY THE COMPUTER ON 3/22/12 AT 8:37 AM, THE DAY FOLLOWING THE RESIDENTS READMISSION TO THE FACILITY (3/21/12). THE DON STATED THAT A HAND WRITTEN DATE OF 3/6/12 PLACED ON THE POST FRACTURE CARE PLAN WAS INCORRECT, AS THE NEW CARE PLAN INTERVENTIONS WERE PUT INTO PLACE UPON THE RESIDENTS RETURN TO THE FACILITY FOLLOWING THE FALL WITH FRACTURE. ( )

This citation pertains to intake number #MI 101 Based on observation, interview, and record review the facility failed to ensure the safety of 1 of 3 sampled residents (Resident #500) resulting in an Immediate Jeopardy when: 1) Resident #500, who was being transferred with a Vander-Lift (mechanical lift) fell out of the sling while she was approximately 3 ,[DATE] feet in the the air, hit her head, and landed face down causing Resident #500 to be transferred to the hospital where she subsequently died of a ruptured spleen, and 2) the facility failed to follow manufacturer's instructions in regard to use of the correct sling for a mechanical lift causing Resident #500 to fall out of a mechanical lift sling while being transferred placing 4 additional residents identified to require the use of a mechanical lift for transfers to be at high risk for serious harm, injury, or death. Findings include: Per the facility face sheet Resident #500 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the "Minimum Data Set" ((MDS) dated [DATE] revealed that Resident #500 was totally dependent on staff for transfers in an out of bed, did not ambulate, and was totally dependent on staff for hygiene, dressing, eating, and toileting. The MDS also revealed that Resident #500 had limited range of motion to both sides of her body. Review of a "Resident Assessment Protocol" (RAP) dated [DATE] revealed that Resident #500's decisions were impaired and she had periods of forgetfulness with confusion. Another RAP dated [DATE] revealed that Resident #500 had difficulty making herself understood due to a speech disturbance. Record review of a "Care Plan" dated [DATE] titled "Physical Mobility Impaired" revealed an intervention that Resident #500 was to be transferred via a mechanical lift with two (2) staff assistance for all transfers. Record review of a facility investigation dated [DATE] through [DATE] revealed that at 10:00 AM on [DATE] Staff Member #1; Resident #500's primary Certified Nurse Aid (CNA), and Staff Member #2 a CNA, transferred Resident #500 using a mechanical lift from her bed to a chair. The report revealed that Resident #500's weight shifted to one side, resulting in Resident #500 sliding out of the sling and onto the floor. The report revealed that the mechanical lift did not malfunction and was in proper working order. No parts or pieces were missing from the mechanical lift. The report revealed that the sling that was used was still attached to the arms of the mechanical lift after Resident #500 fell on to the floor. No deficits to the sling were noted. The report also revealed that Staff Member #1 and Staff Member #2 had been trained on the use of a mechanical lift on [DATE] and [DATE]. The report also revealed that both CNA's, Staff Member #1 and Staff Member #2, checked to assure that Resident #500 was secure in the sling prior to moving her out from over the bed. The report revealed that the physician assessed Resident #500 immediately after her fall from the mechanical lift, and indicated Resident #500 had no apparent injuries. The report revealed that Resident #500 was transferred to the hospital for further evaluation, but did not specify for what reason based on the physician findings. The report revealed that Resident #500 expired at the hospital and on [DATE] the facility received notice from Resident #500's family physician that Resident #500 had a ruptured spleen, causing her death. During the initial tour of the facility with Staff Member #3, the Director of Nursing (DON) on [DATE] at 10:30 AM it was identified that there were two (2) mechanical lifts in the facility. One lift was a "Vander-lift" and the other was a "Drive". Staff Member #3 stated that the "Vander-lift" was the lift that was used on Resident #500 the day of the incident. Observation of Staff Member #1 and Staff Member #2 performing a mechanical lift (using a "Drive" lift) on a sampled resident (Resident #502) was conducted on [DATE] at 10:50 AM. The technique was observed for transferring, such as, applying the sling under Resident #502, attaching the sling to the arms of the mechanical lift, assessing that Resident #502 was secure, lifting Resident #500 into the air, proper guidance from Staff Member #1 and #2 during the transfer process, and lowering of Resident #502 into a chair. The technique was performed according to facility policy and procedure. Observation of the sling that was used for the "Drive" mechanical lift revealed that the sling was an "Invacare" sling and not of the same manufacturer. Staff Member #3, the DON, was interviewed on [DATE] at 12:44 PM. He was asked by the surveyor for the instruction manuals for the "Vander-lift" and "Drive" lift. The DON said that the facility did not have manuals because the lifts were old. The DON said that he phoned the "Vander-Lift" company and received a fax from them of pages ,[DATE] of the instruction manual last week. Review of the "Vander-lift" manufacturer's manual dated [DATE] revealed that the sling for the "Vander-lift" was called a "Vander-Fit" sling. According to a picture of the sling, it had two (2) plastic head support bars along to the top of the sling that were imbedded into the material. The sling had four (4) straps that were used to attach the sling to the "Hanger rods" on a mechanical lift, two (2) on the top of the sling and two (2) on the bottom of the sling. Page five (5) of the manual had the warning, "Vander-lift sling may be used with the Vander-Lift only. Using other manufacturer's patient lift with Vander-Lift slings is also prohibited." The manual also revealed another warning, "Before using the Vander-Lift ...patients must be assessed by the facility's professional nursing or professional rehabilitation staff to determine which patients are suitable for transfer with the Vander-Lift ...which Vander-Lift transfer technique to use, which size sling is appropriate, and the number of staff members necessary to transfer each patient." The manual also revealed that with the sling there were two methods of transfer for a resident. One method was a "Crossed Loop Connection" method (the bottoms straps are brought up between the legs to create a chair effect while in the sling). The manual revealed that with this method the resident must have predictable, cooperative behavior and have normal to rigid muscle tone. The other method was a "Crossed Leg Support Method" (the straps cross under the legs and brought up around the outside if the legs). With this method the manual revealed that a resident must have normal to rigid muscle tone. The manual also revealed with the "Crossed Leg Support Method", "A patient with loose muscle tone who is at risk of sliding through the small space at the horseshoe area of the sling should be transferred in a lying position with a one piece double safety belt amputee sling." Staff Member #3, the DON, was interviewed on [DATE] at 8:55 AM. He stated the facility did not have an "Amputee" sling for the "Vander-lift." Staff Member #4, a Certified Occupational Therapy Assistant (COTA), was interviewed on [DATE] at 10:15 AM. She said that therapy did not make the decision on what size sling to use on a resident. She said that therapy only informs the nursing and CNA staff that a mechanical lift was required for transferring of a resident. Staff Member #5, a Licensed Practical Nurse (LPN), was interviewed on [DATE] at 10:35 AM. She said that nursing and management made the decision on what size sling to use. She said that it was not ever documented anywhere and it is just verbally told to the CNA's. She said the size and type of the sling was based on the resident's weight. She said that if a resident was an amputee or paralytic their weight still determined what type and size of sling to use. Staff Member #5 said that a regular sling would still be used for a resident that was paralyzed or had an amputation of a lower extremity; stating that such a resident would still fit in the regular sling. Staff Member #1, Resident #500's primary CNA, was interviewed on [DATE] at 1:27 PM. She was asked how she knew what size sling to use on a resident. Staff Member #1 said that she just visualized the resident and judged what sling to use. She said that she made sure the resident's body fit into the sling. She said there was no chart on the slings that told what size to use. Staff Member #1, Resident #500's primary CNA, was interviewed on [DATE] at 11:30 AM. She said that she was getting Resident #500 up from her bed to her chair. Staff Member #1 said that she transferred Resident #500 everyday to her chair. Staff Member #1 said that she took care of Resident #500 every time that she worked. She said that on [DATE] she was a bit slower with her resident care. She said that she asked Staff Member #2, another CNA, to assist her with the transfer of Resident #500. She said Staff Member #2 assisted her with the transfer at 10:00 AM. She said that she used the lift that did not have the scale on it (the "Vander-Lift"). She said that she rolled Resident #500 in her bed to place the sling under her. She said that Resident #500 could grab the bed rail with her right arm but was flaccid (no control) in her left arm and both legs. Staff Member #1 said that Resident #500 appeared to be afraid of the mechanical lift. She said that some of the slings in the facility had plastic bars in them to support a resident while up in the air in a mechanical lift. Staff Member #1 said that Resident #500's husband did not want the sling with the plastic support bars used on Resident #500, because he did not want Resident #500 sitting on the plastic for long periods of time while she was in her chair. She said that Resident #500 was not able to adjust her position on her own, while sitting in her chair. Staff Member #1 said that she did not know what sling went to which mechanical lift and she just grabbed any sling that was available for use. She said that the slings were normally stored in the utility room and that was where staff would obtain one for use. Staff Member #1 said that Resident #500 had two (2) slings in her room at all times (Invacare slings) and the two slings were used on Resident #500 only. She said that the color around the border of the sling indicated the size of the sling. Staff Member #1 said on [DATE] at 10;00 AM Resident #500 fell out of the side of the sling in-between the top strap and the bottom strap on the left side of the sling and hit her head on the floor. She said that Resident #500 fell Staff Member #1 said that the normal practice for transferring of Resident #500 was to have Resident #500 hold her left arm with her right arm while up in the sling. She said that Resident #500 would place her right arm over her chest and hold her bad arm (left). She said that she was at Resident #500's feet and Staff Member #2 was behind Resident #500 with the control panel for raising and lifting the mechanical lift. No one was on the side of Resident #500. Staff Member #1 said that as Resident #500 was up in the air, she turned the mechanical lift and Resident #500 let go of her left arm, which "flopped" over the side of the sling, between the straps, and then Resident #500's body followed her arm over and out the side of the sling and onto the floor. Staff Member #1 said the bottom straps were crossed over Resident #500's legs but her legs also fell out of the sling and onto the floor. She said Resident #500 hit the left side of her forehead on the floor, which made a solid noise when her head hit the floor. She said that she went to get help and had Staff Member #2 stay with Resident #500. She said that when she got back into Resident #500's room, Resident #500 said, "I hurt". She said that Resident #500 had become a bit disoriented and the physician assessed her after the fall. She said that no bleeding was noticed, only a red area on Resident #500's forehead. Staff Member #1 said the physician assessed Resident #500 and found no injuries. She said the physician ordered neurological assessments to be done on Resident #500 every hour. She said that after the physician left Resident #500's room, Resident #500 began to vomit and the physician ordered Resident #500's transfer to the hospital. Staff Member #1 said that she left Resident #500's room at that time and did not see her again. She said that she had not worked at the facility for a year yet. She said that she had not had any formal training on the mechanical lifts, but was observed using one by another staff member and was deemed safe. Staff Member #1 was again interviewed on [DATE] at 11:09 AM. She said that it was always hard to get Resident #500 in the correct position in the sling because Resident #500 leaned over to the left side all the time. She said that she would get the sling under Resident #500 correctly while Resident #500 was in bed, but upon lifting Resident #500 up in the air, Resident #500 would lean to the left causing the sling to be in an incorrect position. She said that she would put more of the sling on Resident #500's right side in order to balance the sling, but that would only work some of the time. Staff Member #1 said that she never reported this problem with the sling to any other staff member. Staff Member #1 said that she usually stood on Resident #500's left side while Resident #500 was up in the air, but on [DATE] she stood at Resident #500's feet instead. She said that Resident #500's fall out of the sling happened so quickly that she did not have time to react or stop the fall. Staff Member #1 said that she would measure the size and type of sling herself; by placing a sling next to a resident to see if the sling was appropriate. Staff Member #1 said that she never had nursing or anyone else tell her what type or size of sling to use on a resident. She said that she never had used an amputee sling with a safety belt before. Staff Member #1 said that Resident #500 suspended in the air approximately ,[DATE] ,[DATE] feet above the floor when she fell out of the sling. An observation of the slings available at the facility was conducted on [DATE] during the interview with Staff Member #1. Staff Member #1 identified the blue sling with the green border (Invacare sling) as the sling that was used on Resident #500 on [DATE] at the time of the incident. The sling, which was used on Resident #500, did not have the plastic support bars in it. An observation of the slings available at the facility was again conducted on [DATE] at 2:00 PM. The observation revealed that there were two (2) slings with the plastic support bars. One of the slings was tagged to be a Vander-Lift sling and the other had no identification as to what type of lift it was to be used with. The Vander-Lift sling had a tag on it that revealed, "Warning, for resident safety, Vander-Lift slings may be used with the Vander-Lift only." There were four (4) additional slings available for use at the facility and none of the four (4) had any identification for what type of sling it was to be used with. The sling identified to have been used for Resident #500's transfer on [DATE] revealed a tag with a warning, "Warning, use on Invacare lift only." The facility did not have an Invacare lift in the building, as observed during the initial tour. Another sling that was in use at the facility was identified, per the tag, to be a "Hoyer" sling. The "Hoyer" tag revealed, "Hoyer slings and lifts are not interchangeable with other manual products, may cause serious injury." Two (2) other slings that were light blue, one (1) with a darker blue border and the other with a green border did not have any identification as to what type of sling they belonged to. One (1) additional sling had no tags and no writing anywhere to identify the type of mechanical lift it should be used on. Staff Member #2, the CNA who assisted with Resident #500's transfer on [DATE] at 10:00 AM, was interviewed on [DATE] at 12:09 PM. She said that she was observed performing a mechanical lift transfer about one (1) year after employment at the facility. Staff Member #2 said that she did not know what slings went to which mechanical lifts. She said that she usually just grabbed any sling to use on the mechanical lift for transferring residents. Staff Member #2 said that she went into Resident #500's room to assist with the transfer of Resident #500 on [DATE]. She said that Resident #500 always had a large sling that was used for her. She said she hooked the straps up to the lift and made sure Resident #500 was sitting correctly in the sling. Staff Member #2 said that she stood behind Resident #500 while Staff Member #1 guided Resident #500's legs. Staff Member #2 said that she had Resident #500 use her right arm to hold onto her left arm. She said that was how Resident #500 was always transferred holding onto her own arm. Staff Member #2 said that Resident #500 let go of her left arm and her left arm swung down over the side of the sling causing Resident #500 to topple out of the sling, onto the floor. Staff Member #2 said that Resident #500 hit her head on the floor, stating that she heard it when Resident #500's head hit the floor. She said that she stayed with Resident #500 while Staff Member #1 got assistance. Staff Member #2 said Resident #500 told her, "I hurt" after her fall from the sling. Staff Member #2 said the physician had come into the room to assess Resident #500 and she was pulled out of Resident #500's room. Staff Member #6, an LPN, was interviewed on [DATE] at 10:47 AM. She said that when she entered Resident #500's room, after the fall, she saw that Resident #500 was face down on the floor. She said that Resident #500's legs were lying over one of the legs of the mechanical lift. She said Resident #500 was alert but had redness over her left eyebrow area. She said that it was apparent that Resident #500 was cleared from the bed when she fell out of the sling. Staff Member #6 said that Resident #500 was paralyzed on her left side. Staff Member #7, Resident #500's primary LPN, was interviewed on [DATE] at 11:37 AM. She said that when she entered Resident #500's room, after the fall, Resident #500 was already in bed. She said that she did not know why the physician ordered Resident #500 to be transferred to the hospital. She said that she went out of the room and prepared the essential paper work for the transfer. She said the physician said to cancel the transfer initially but re-ordered the transfer after Resident #500 began vomiting. Staff Member #7 said that when she first saw Resident #500 after the fall, Resident #500 had a discoloration on her left eye (forehead area) to the side of her mouth. She said that she did not note any bleeding or swelling. Staff Member #7 was asked who made the decision (assessment) of what type and size of sling to use for a resident. Staff Member #7 said, "I have no idea". Staff Member #7 said that she had never seen an amputee sling in the facility and that she did not even know what an amputee sling was. Staff Member #8, an LPN, was interviewed on [DATE] at 10:10 AM. Staff Member #8 asked sampled Resident #501 if the surveyor could observe his transfer from his bed to his chair. Resident #501 refused to transfer at the time. Staff Member #8 said that the facility did not have a special sling for amputees or paralyzed residents. She said that she had never seen an amputee sling in the facility and was not aware of one. Staff Member #8 said that usually restorative staff or nursing made the decision of what size of sling to use on a resident. Resident #500's primary physician was interviewed on [DATE] at 11:36 AM. He said that he was in the facility at the time of the Resident #500's fall. He said that as staff swung Resident #500 while up in the mechanical lift she slipped out of the sling, hitting her head on the floor. He said that was reported to him because Resident #500 was back in her bed when he entered her room. The physician said that Resident #500 did not have a change in her level of consciousness, but was not focused. He said that Resident #500 was usually able to point to her pain area with her right arm but did not do this when he asked her to. He said that her stomach was soft when he left her room. He said that Resident #500 had begun to vomit so he ordered her transfer to the hospital. He said that he was told that upon arrival to the hospital Resident #500 was fine, but had begun to decline about five (5) to ten (10) minutes after her arrival to the hospital. The physician said that he questioned whether Resident #500 had a head injury. He said that the Medical Examiner (M.E.) reported to him that Resident #500 had a ruptured spleen and she had bled out into her abdomen as a result. The physician stated Resident #500's ruptured spleen was from the fall out of the mechanical lift, per the M.E. The physician also stated that Resident #500 had a small bleed in her head, but it was not determined if the bleed was old or new. He said that Resident #500's ruptured spleen was the result of a trauma, because the spleen would not rupture without a traumatic event, stating that spleens do not just spontaneously just rupture. He said the M.E. reported that Resident #500's abdomen was full of blood. Attempts were made on [DATE] to contact the Medical Examiner but were unsuccessful. Record review the ambulance run sheet dated [DATE] at 10:17 AM revealed that upon arrival Resident #500 was in bed and staff reported to the emergency crew that Resident #500 had fallen out of a mechanical lift and was unresponsive for a brief amount of time. Record review of hospital records dated [DATE] revealed that upon arrival to the hospital at 10:56 AM Resident #500 was awake but her skin was cold, clammy, and mottled (turning purple in color). The record revealed that at 11:30 AM resident #500 had become less responsive and would not respond to her name. At 11:35 AM the record revealed that Resident #500's respirations had become agonal (struggling to breathe) and her skin was cool to the touch. At 11:40 AM Resident #500's heart rate dropped and her respirations were 6 per minute. The record revealed that at 11:50 AM Resident #500 had no spontaneous breathing, heart rate of 38, and no blood pressure. At 11:56 AM the record revealed that Resident #500 had no heart rate and she was pronounced dead at 11:56 AM. Record review of Resident #500's autopsy report dated [DATE] revealed that Resident #500 had a ruptured spleen with intra-abdominal hemorrhage of 1.5 liters of blood which was indicated to be the cause of death. The report also revealed that Resident #500 had a subdural hematoma (a collection of blood on the surface of the brain) of ,[DATE] milliliters of blood. The report revealed that the cause of death for Resident #500 was, "Hemorrhagic shock, intra-abdominal hemorrhage." The manner of death was documented as, "Accident". Record review of the facility policy and procedure (no original dated but revised [DATE]) for the use of a mechanical lift revealed no indication of what types of lifts were utilized at the facility or where the manufacturer's manual was located in order for staff to review the safe and appropriate use of the mechanical lifts. The Administrator was notified on [DATE] of the Immediate Jeopardy that began on [DATE] as a result of the facility's failure to prevent the fall from a mechanical lift for Resident #500, when Resident #500 fell out of the mechanical lift sling and onto the floor, hitting her head on the floor, which required her transfer to the hospital where she was diagnosed with [REDACTED]. On [DATE] the surveyor confirmed the facility had implemented to following to remove the Immediate Jeopardy: 1) On [DATE] the mechanical lifts were inspected by the Maintenance Supervisor with no deficits noted. 2) On [DATE] the slings for the mechanical lifts were inspected by the Maintenance Supervisor and Laundry Supervisor and no deficits were identified. 3) On [DATE] all licensed personnel and CNA's were educated on the safe use of a mechanical lift, along with observation of staff performing a lift. 4) On [DATE] all slings that were not manufactured by the "Vander-Lift" company were removed from use at the facility. 5) On [DATE] the DON placed the correct slings in resident rooms that utilized a mechanical lift. 6) On [DATE] all licensed and non-licensed (CNA's) were re-educated on proper sling to use on a mechanical lift per the manufacturers instructions. Staff that had not received the in-service will not be permitted to work until they attend the in-service. 7) On [DATE] the facility ordered additional slings, including two (2) amputee slings for the appropriate mechanical lift. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a score and severity of pattern with no actual harm but potential for more than minimal harm, due to all staff had not been in-serviced, staff were aware of who was responsible for assessing the residents and recommend the proper type and size of sling to use, and sustained compliance had not been verified by the State agency. ( )