Every finding on record at The Orchards at Samaritan

Based on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 04/22/2026 at 7:54 AM observed brown and black residue beneath the sink in the green unit nourishment room.On 04/22/2026 at 8:18 AM observed a brown stained white towel under the hand sink in the blue unit nourishment room. A brown streak was observed on the wall, extending from the drain line exit point in the wall to the base of the cabinet floor. Black splatter marks were observed near the bottom portion of the wall. Further observation found the adjacent cabinet with an approximate three by three inch black discoloration penetrating in the cabinet wood, and a yellow stain surrounding the area.On 04/22/2026 at 8:20 AM observed an accumulation of small dried brown debris under the sink cabinet in the blue unit kitchenette.On 04/22/2026 at 8:55 AM a tour of housekeeping and laundry was conducted with Housekeeping and Laundry Director (HLD) D.On 04/22/2026 at 8:56 AM observed several drop ceiling tiles missing, partially attached, and sagging, with evidence of water damage in the laundry washing room. An interview with HLD D was conducted at this time regarding the condition of the ceiling tiles. HLD D indicated there had been a leak the previous month and they believe a pipe had burst causing ceiling tiles to become saturated with water and fall. When asked who is responsible for repairs, HLD D indicated they were unsure if it was the building maintenance or their maintenance department is responsible for addressing the issue.On 04/22/2026 at 8:59 AM when asked to see the area behind the dryers, HLD D indicated they don't ever go back there. Observation of the room found a layer of dust coating the dryer surfaces and floor of the dryer room. An interview at this time with HLD D found they are unsure if anyone goes back and cleans.On 04/22/2026 at 9:00 AM observed the floor tile area near the washing machines and in the sorting area cracked, crumbled, and missing. A brown residue was found coating the floor surface between the washing machines. In an interview at this time regarding the condition of the floor, HLD D indicated they were unaware whether the building maintenance or their maintenance department was responsible for repairs. When asked if there is a maintenance system in which repair requests could be submitted, HLD D indicated they have TELS but do not have access to submit requests, however they could notify maintenance for help. When asked if they had discussed repairs with maintenance, HLD D indicated the maintenance director is newer and they had talked to them but had not gotten an answer.On 04/22/2026 at 9:09 AM observed the clean linen storage area in the laundry room with multiple drop ceiling tiles missing and stained brown indicating evidence of water damage.On 04/22/2026 at 9:11 AM observed multiple drop ceiling tiles missing and stained brown in the laundry bulk storage room. An interview at this time with HLD D regarding the brown staining found it was the result of a previous leak that occurred before they had moved bulk linen into the room.On 04/22/2026 at 9:15 AM observed a janitor sink with a missing atmospheric vacuum [NAME] (AVB) in the red unit janitor closet. Further observation of the floor found black residue coating the floor surface.On 04/22/2026 at 9:21 AM observed two packages of briefs on the floor next to the storage rack in the red unit clean linen room. In an interview at this time, when asked if briefs are normally stored on the floor, HLD D indicated they are unsure, and think they are normally on the top of the storage rack.On 04/22/2026 at 9:24 AM observed a box of gloves and two packages of briefs on the floor in the green unit clean linen room. A plastic bag and towel were observed on the floor next to the rack. HLD D indicated the staff clean these rooms in the afternoon.On 04/22/2026 at 9:26 AM observed equipment stored in the janitor sink and a missing AVB in the green unit janitor closet. An interview with HLD D at this time found the sink does not work and it is used as storage. When the faucet was turned on, water was observed discharging from the portion of the fixture where the AVB would be located. On 04/22/2026 at 9:28 AM observed cloudy water in the bowl of the hopper in the green unit soiled utility room. The faucet handles and spray hose were inoperable. A cut out hole was observed in the wall adjacent to the hopper. Further observation of the room found cardboard and supplies including toilet paper and gloves piled on the counter of the sink limiting access to the hand sink. Bulk trash items including a cabinet next to the countertop, a fan beneath the sink and a poster board placed on top of a small refrigeration unit were also observed in the room. An interview with HLD D at this time found a staff member removes cardboard once a day and maintenance takes care of bulk trash. HLD D indicated soiled utility serves as a temporary holding place for bulk trash, and the cabinet had come in last Thursday. When asked if staff clean the room, HLD D indicated staff clean the floor and hopper daily.On 04/22/2026 at 9:34 AM observed the hand sink inoperable in the green unit soiled utility room.On 04/22/2026 at 9:36 AM an interview with HLD D found the red, blue and green unit shower rooms were out of order, and brown unit is the only one working currently. The door was observed to be locked in the green unit shower room upon attempting to enter.On 04/22/2026 at 9:37 AM observed four packages of briefs on the floor in the brown unit clean linen room. HLD D indicated central supply restocks. On 04/22/2026 at 9:49 AM observed three packages of briefs on the floor in the blue unit clean linen room. On 04/22/2026 at 9:52 AM an interview with HLD D found the utility sink in the blue unit janitor closet is not in operation. Upon entering the room, the janitor sink was observed with a missing AVB. When the faucet was turned on, water was observed discharging from the portion of the fixture where the AVB would be located. On 04/22/2026 at 9:54 AM observed pieces of hair and debris in the sink of the blue unit soiled utility room. An interview at this time with HLD D found housekeeping cleans sinks and floors in this room. Further observation found stacks of bed mats on the floor below the sink. HLD D indicated the beds were trash.On 04/22/2026 at 9:55 AM observed a black bag in the ceiling with a hose extending from the bag and draining into the hopper in the blue unit soiled utility room. The area surrounding the bag was observed stained brown with evidence of water damage. When asked how long the hose had been there, HLD D indicated it has been about six months. Further observation found a hole cut out in the wall next to the hopper and a disposable glove in the hopper water. A plastic container was observed positioned under the foot pedals used to operate the spray hose on the hopper. When foot pedals were activated, water began spraying from the AVB onto the floor.On 04/22/2026 at 9:58 AM observed a pool of water near the hand sink in the blue unit shower room. HLD D indicated that the room is out of order because it leaks to the first floor. When asked if the sink is being used, HLD D indicated it is not being used that they know of. On 04/22/2026 at 10:01 AM an interview with HLD D found housekeeping staff clean floors, sink, and microwave in the nourishment rooms. When asked about the stained towel beneath the sink, HLD D indicated they did not know what had happened.On 04/22/2026 at 10:03 AM observed the hand sink inoperable in the blue unit nourishment room.On 04/22/2026 at 10:07 AM HLD D stated that the maintenance director was unable to come in today.On 04/22/2026 at 10:44 AM observed black sludge and a reflective grease film layer indicative of sewage backup pooled at the bottom of the utility sink in the brown unit janitor closet. A strong foul odor was present upon entering the room. Further observation revealed the AVB missing from the facet. Plastic bags, a box of tissues, a box of gloves and a plastic container were observed on the floor. An interview with HLD D at this time found they were not sure what had happened regarding the sludge or who would be responsible for cleaning it up.On 04/22/2026 at 10:49 AM observed a dirty linen cart with a torn and fraying fabric netting in the brow unit soiled utility room. An interview with HLD D at this time found this is the only cart they have in bad condition, and they had requested a new one in December around the time maintenance directors were changing. HLD D indicated they had not heard back or checked in again.On 04/22/2026 at 11:06 AM an interview with Nursing Home Administrator (NHA) regarding maintenance found the building had switched responsibilities and now it is unclear who is responsible for what. NHA indicated if there is an issue they send an email to the building maintenance department to get clarity on responsibility. NHA indicated anything on their floor would be their responsibility.04/22/2026 at 11:15 AM an interview with Maintenance Director (MD) G from another facility was conducted regarding facility maintenance. MD G was unaware of repairs in the building and indicated they would find out more information. 04/22/2026 at 11:22 AM observed the door handle missing on the inside of the blue unit clean linen room. 04/22/2026 at 11:29 AM observed water stains and evidence of water damage in several drop ceiling tiles in the red unit 201-214 hall. On 04/22/2026 at 11:32 AM observed handles missing from hand sink in the red unit dining room.On 04/22/2026 at 11:40 AM observed black buildup along the edges of the air vent outside of the green unit dining hall.On 04/22/2026 at 11:51 AM an interview with NHA found the building maintenance department placed the hose in the ceiling to drain into the hopper and was unable to fix the problem requiring them to contact an outside source. When asked if they were aware of when the building maintenance was notified of the leak, NHA stated they were not sure. On 04/22/2026 at 11:57 AM an interview with NHA and Property Management Associate (PMA) I was conducted. PMA I indicated the building is responsible for maintaining structure and roof, and the tenants are responsible for maintaining drains, and equipment. NHA indicated the facility would be responsible for maintaining ceiling tiles. On 04/22/2026 at 12:15 PM observed the hand sink laminate lifting from the surface in the brown unit dining room. On 04/22/2026 at 12:33 PM observed evidence of water damage on two tiles above the bed in resident room [ROOM NUMBER].On 04/22/2026 at 1:46 PM an interview regarding maintenance was conducted with Property Manager (PM) H. When asked about the hose draining from the ceiling, PM H indicated they did know about it and indicated they had to hire someone to look at it. PM H indicated there is an email maintenance inquiries can be sent to and the building maintenance will report back who is responsible. When asked if there has been an email sent regarding the laundry room ceiling tiles, PM H indicated they did not believe so. When asked about the shower rooms that are closed, PM H indicated the showers were leaking to the floor below, and they had been out at least two to three weeks. PM H stated that would be the facility's responsibility.A record review of the facility provided document titled Preventative Maintenance Policy states, Preventative maintenance is performed according to the schedule to ensure equipment is maintained is safe, working condition. Under procedure step four states The Maintenance Director should log into the TELs system routinely to record preventative maintenance activity and assure scheduled needs.A record review of the facility provided document titled UTILITY ROOM CLEANING states, Utility rooms are cleaned to remove dust, dirt, soil, and foreign matter from walls, floors, fixtures, equipment, and storage surfaces., step four and five under procedure states 4. Clean the utility sink according to toilet cleaning procedure. (see Bathroom Cleaning). 5. Remove trash and replace liner.

Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Based on observation, staff interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with infection control standards, including failure to post required EBP signage and failure to ensure staff utilized appropriate personal protective equipment (PPE) during resident care. This deficient practice was identified for four residents (R10, R13, R36 and R122) of eight residents reviewed for infection control and had the potential to affect all residents requiring EBP. Findings include: On 04/22/2026 at 7:09 AM observed an inoperable water fountain indicating possible stagnant water on the fourth floor near the elevator. On 04/22/2026 at 9:17 AM observed a hopper in the red unit soiled utility room. The spray hose was inoperable, indicating possible stagnant water. An interview at this time with Housekeeping and Laundry Director (HLD) D found the staff do not use the hopper. When asked if they are on the water management team HLD D stated no. On 04/22/2026 at 9:28 AM observed cloudy water in the bowl of the hopper in the green soiled utility room. The faucet handles and spray hose were inoperable, indicating possible stagnant water. A cut out hole was observed in the wall adjacent to the hopper. On 04/22/2026 at 9:34 AM observed the hand sink inoperable in the green soiled utility room indicating possible stagnant water in the water line. On 04/22/2026 at 9:36 AM an interview with HLD D found the red, blue and green unit shower rooms were out of order, and brown unit is the only one working currently. The door was observed to be locked in the green unit shower room upon attempting to enter. On 04/22/2026 at 9:39 AM observed hopper with an inoperable spray hose indicating possible stagnate water in the brown unit soiled utility room. On 04/22/2026 at 9:52 AM an interview with HLD D found the utility sink in the blue unit janitor closet is not in operation. Upon entering the room, the janitor sink was observed with a missing Atmospheric Vacuum Breaker (AVB). When the faucet was turned on, water was observed discharging from the portion of the fixture where the AVB would be located. On 04/22/2026 at 9:55 AM Observed a hole cut out in the wall next to the hopper and a disposable glove in the hopper water in the blue unit soiled utility room. A plastic container was observed under the foot pedals used to operate the spray hose on the hopper. When foot pedals were activated, water began spraying from the AVB onto the floor. On 04/22/2026 at 9:58 AM observed a pool of water near the hand sink in the blue unit shower room. In an interview at this time, when asked why the shower room is out of order HLD D indicated that it leaks to the first floor. When asked if the sink is being used, HLD D stated it is not being used that they know of. On 04/22/2026 at 10:03 AM observed the hand sink inoperable in the blue unit nourishment room. On 04/22/2026 at 10:07 AM HLD D stated that the maintenance director was unable to come in today. On 04/22/2026 at 10:09 AM requested information regarding water management from the Nursing Home Administrator (NHA). On 04/22/2026 at 11:00 AM an interview with NHA was conducted regarding water management. When asked if they were able to locate materials related to the water management plan, NHA stated someone would be coming to help and have that information hopefully. When asked if they had attended a meeting regarding water management, NHA indicated they had not in the time they had been at the facility since January. When asked if they were a member of the team, NHA stated if they are supposed to be. 04/22/2026 at 11:17 AM an interview with Maintenance Director (MD) G from another facility was conducted. When asked if they would have additional information on water management, MD G indicated they would look. On 04/22/2026 at 11:32 AM observed handles missing from hand sink in the red unit dining room indicating possible stagnant water. On 04/22/2026 at 11:53 AM an interview with NHA found they were continuing to look for the water management policy and found the building maintenance does some testing of water. On 04/22/2026 at 12:58 PM an interview with NHA regarding water management was conducted. When asked if there are any control measures the facility takes, NHA indicated the city of Detroit puts chorine in the water, and ice machines are cleaned per manufacturer's instructions. When asked if there is a policy, NHA indicated they were still looking for it. On 04/22/2026 at 1:04 PM MD G provided the water management policy. An interview with NHA at this time found they are unsure if the building as a whole has a water management program. On 04/22/2026 at 1:17 PM an interview with Director of Nursing (DON) found they are not on the water management team and indicated there have been no outbreaks of Legionella. On 04/22/2026 at 1:46 PM an interview regarding maintenance was conducted with Property Manager (PM) H. When asked about the shower rooms that are closed, PM H indicated the showers were leaking to the floor below, and they had been out at least two to three weeks. A record review of the facility provided document titled Water Management Program states, It is the policy of the facility to ensure that the facility has a plan that reduces the risk of growth and spread of Legionella and other opportunistic pathogen in the building water systems. Under procedure states, Complete the CDC Worksheet to Identify Buildings at Increased Risk for Legionella Growth and Spread to identify need for a water management program. Create the water management team Identify and document the building description, including location, age, uses, and occupants and visitors including the water system description (general summary, uses of water, aerosol-generating devices (e.g., hot tubs, decorative fountains, cooling towers), and process flow diagram). Identify vulnerable areas in the system and create a diagram to visually pinpoint areas for monitoring and control. Identify control measures, including points in the system where critical limits can be monitored and where control can be applied. Confirm procedures are in place, including verification steps to show that the program is being followed as written and validation to show that the program is effective Document collection and transport methods and which lab will perform the testing if environmental testing is conducted Water heaters should be maintained water temperature per the Federal guidelines and document. A record review of the facility provided service report including water treatment on the cooling tower and closed loop dated was 01/26/2026. The report includes conductivity, pH, P-Alkalinity, and Nitrite levels recorded. A record review of the facility provided service report including water treatment on the cooling tower and closed loop dated was 04/30/2025. The report includes conductivity, PTSA, pH, Total Chlorine, P-Alkalinity, Nitrite levels. Next to total chlorine in the cooling tower pavilion read a level of 0.2. A record review of the facility provided document titled Sample Water Flow Chart ALC includes a diagram with labels along the margins identifying areas such as the boiler room, cold water distribution, heating, boiler room and waste. The flow diagram contains several boxes that are blank with the exception of two boxes labeled Water Heater 1st and Hot Water Storage 1stFloor. The remaining components of the system are not identified or described. R122 On 4-22-26 at 1:34 PM, observed R122 had a stoma (opening in the voice box). R122 room door did not have Enhanced Barrier Precaution (EBP) signage posted. On 4-23-26 at 7:40 AM observed R122 room door did not have EBP posted on door or wall outside of the door. On 4-23-26 at 7:40 AM interviewed certified nurse aid (CNA) A who acknowledged R122 room door did not have (EBP) signage posted. On 4-23-26 at 7:43 AM, the Director of Nursing (DON) was interviewed and acknowledged R122 had an artificial airway and should have (EBP) signage posted on the door. R122 was admitted on [DATE] diagnosed with the following: MALIGNANT NEOPLASM OF GLOTTIS, MALIGNANT NEOPLASM OF RIGHT BRONCHUS OR LUNG, CARCINOMA IN SITU OF PHARYNX and PRESENCE OF ARTIFICIAL LARYNX. Review of R122 Minimum Data Set (MDS) date 4-8-26 resident Brief Interview for Mental Status (BIMS) score was a 15 out of 15 cognitively intact. Review of R122 care plan indicated Enhanced Barrier Precautions was initiated on 4-7-26. This care plan goal was to prevent transmission of Multiple Drug Resistance Organisms (MDROs) to other residents, staff, and visitors. Review of facilities policy titled, Enhanced Barrier Precautions undated indicated the purpose (EBP) prevent the transmission of (MDROs. The policy listed under explanation of compliance guidelines noted clear signage will be posted. The guideline indicated that signage would be posted on the door or wall outside room of the resident identified as needing these precautions. R36 During an observation on 4/23/26 at 3:18 P.M. Certified nurse Aide (CNA) W was observed providing catheter care to R36 without applying a gown or washing her hands after completing the care. CNA W was interviewed after the observation and reported I do not normally work on this side of the building, I did not know. The signage posted on the resident's door was pointed out to CNA W in addition to the PPE cart positioned outside of the resident's door in the hallway. During the interview and observation nurse Z joined stating 'I told you to put on gown and gloves. Resident 36 (R36) was admitted to the facility on [DATE], with diagnoses which included: surgical amputation, diabetes mellitus, acute osteomyelitis, peripheral vascular disease, cognitive communication deficit, absence of right leg above knee, dementia and history of traumatic brain injury. According to the Minimum Data Set (MDS) dated [DATE], R36 had a Brief Interview for Mental Status (BIMs) of 9 indicating moderate cognitive impairment (ability to think). Review of the Physician Orders dated 10/15/2025, stated Enhanced Barrier Precautions (EBP) r/t Foley/ wound. Review of Care plan dated 11/25/25 Clean foley catheter with warm water and soap each shift, monitor for s/s of infection, monitor for kinks. Every shift for foley care On 4/24/26 at 2:30 P.M. the Director of Nursing (DON) was interviewed concerning the observation. The DON stated: I am aware of your observation, staff were educated on EBP and wearing the appropriate PPE for providing care. Staff should adhere to policy. R36 has had multiple hospitalizations and used antibiotics . R10 On 4/23/2026 at 8:15 AM, Licensed Practical Nurse (LPN) N was observed administering medications to R10 via a PEG tube (feeding tube inserted directly into the stomach). An Enhanced Barrier Precautions sign was posted on R10's door. LPN N was observed wearing gloves. When LPN N was asked about R10's precautions LPN N replied, I should have worn a gown when I administered R10's medications through his PEG tube. I see the sign on the door. Review of R10's Electronic Health Record (EHR) revealed admission to the facility on 9/7/2023 with diagnoses that included Human Immunodeficiency Virus Disease, Dysphagia following other Cerebrovascular Disease, and Severe Protein Calorie Malnutrition. A Minimum Data Set (MDS) assessment dated [DATE] documented resident is rarely understood, dependent care for personal hygiene and had a PEG tube. Review of R10's care plan revealed, Focus I have impaired immune system related to HIV. I take antiviral medication: Biktarvy oral tablet family to supply medication. Revision on 12/6/2023. Goal I will not display any complications related to immune deficiency. Date initiated 9/8/2023. Interventions enhanced barrier precautions. Date initiated 10/4/2024 Review of R10's physician orders dated 1/24/2025 revealed, Enhance barrier precautions r/t (related to) Peg tube. R35 On 4/23/2026 at 9:44 AM, LPN O was observed administering medications to R35. LPN O was observed to place a bottle of eye drops containing Timolol Maleate ophthalmic Solution directly onto R35's soiled bedside table. LPN O uncapped the eye drop container, placed the cap directly onto R35's soiled bedside table then administered the eye drops, recapped the bottle and placed the eye drop bottle back into the medication cart. When LPN O was asked about proper infection control standards during medication administration LPN O replied, I should have used a barrier and/or sanitized the bottle prior to returning it to the medication cart. Review of R35's Electronic Health Record (EHR) revealed admission to the facility on 5/11/2022 with diagnoses that included Combined forms of age-related cataract, Bilateral, and other specified glaucoma. A Minimum Data Set (MDS) assessment dated [DATE] documented severe impaired cognition, dependent care for personal hygiene. On 4/24/2026 at 12:34 PM, the Director of Nursing (DON) was interviewed and said the expectation is for staff to follow Enhanced barrier precautions by wear gloves and gowns for direct care activities and for staff to use a barrier during medication administration and maintain hygienic conditions.

Based on interview and record review, the facility failed to ensure that five of five sampled Certified Nurse Aides (CNAs R, S, T, U, and V) completed the required 12 hours of annual training to ensure adequate resident care. Findings include:On 4/24/2026 at 10:09 AM, Staff Scheduler Q was interviewed and said the facility did not have a staff educator. The 12-hour annual CNA Inservice trainings were requested for CNAs R, S, T, U and V.On 4/24/2026 at 2:20 PM, the Director of Nursing (DON) said there were no records for the requested CNAs. The DON further said the expectation was for all CNAs to have completed annual 12-hour training including dementia and abuse training.Review of the facility policy titled 12-hour nurse aid training date revised 2/17/202 revealed in part.Purpose to assure nursing assistants receive at least 12 hours of training annually. 2. During the year, the staff development Coordinator should monitor the 12-hour training records to assure CNAS are on track with training programs. 3. CNAs who do not meet the 12-hour annual training requirements will be removed from the schedule on their hire anniversary date and will not be put back on the schedule until 12-hour training has been achieved.

Based on observation, interview, and record review, the facility failed to maintain best practices and general maintenance of foodservice equipment resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/22/2026 at 7:56 AM observed the ice machine door gasket cracked and worn in the green unit nourishment room. Further observation found spots of corrosion on the surface of the interior metal shield. An interview with Dietary Manager (DM) C at this time found the ice machines are cleaned by an outside company, and they are unsure frequency of cleaning. On 04/22/2026 at 7:59 AM observed an ice scoop holder with a pool of water and debris at the bottom of the holder in the green unit nourishment room. An interview with DM C regarding frequency of cleaning of ice scoops and the holders found dietary cleans them every day or every other day when the Certified Nursing Assistant's (CNA) send the scoops down to the kitchen. When asked about the scoop holder, DM C indicated it is detachable and is sent down as well.On 04/22/2026 at 8:09 AM observed brown residue on the interior bottom surface of the microwave in the blue unit nourishment room. An interview with DM C at this time found housekeeping is responsible for cleaning the microwave.On 04/22/2026 at 8:18 AM observed the door gasket on the ice machine cracked and split open in the blue unit nourishment room. As well as spots of corrosion on the surface of the interior metal shield and black particulate accumulated in the bottom corner of the shield. Further observation found white residue, brown debris, and a small piece of dried paper towel on the inside of ice scoop holder. DM C acknowledged the inside of the ice scoop holder.On 04/22/2026 at 8:50 AM observed the ice scoop holder with black and white residue coating the interior in the brown unit nourishment room. Further observation found a small pool of water with brown debris floating at the bottom of the ice scoop holder. On 04/22/2026 at 10:01 AM an interview with Housekeeping and Laundry Director (HLD) D found housekeeping staff clean floors, sinks, and the microwave in the nourishment rooms. On 04/22/2026 at 1:22 PM an interview was conducted with CNA E regarding cleaning of ice scoops and holders. When asked if they clean ice scoops, CNA E indicated they clean ice scoops with soap and water for ice carts on hall. When asked about ice scoops in the nourishment rooms, CNA E indicated they cleaned before use.On 04/22/2026 at 1:25 PM an interview was conducted with CNA F regarding cleaning of ice scoops and holders. When asked if they clean ice scoops, CNA F indicated the ice cart scoops are sent down in the morning to the kitchen to be cleaned. When asked about ice scoops in the nourishment rooms, CNA F indicated they do not clean those, the kitchen does.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.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.On 04/22/2026 at 8:02 AM observed an opened container of yogurt with a facility marked received date of 03/05/2026. In an interview at this time, DM C indicated it is CNAs responsibility to mark the open date.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 .On 04/22/2026 at 8:06 AM observed the drain line from the ice machine leading directly into the floor drain creating an improper air gap in the brown unit nourishment room.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.A record review of the facility provided document titled Water Appliances Inspection & Maintenance states, Ice MachinesCheck ice machines at least weekly.Assure that ice machine is producing the correct amount of ice:According to manufacturer's specification,The ice making components are working properly,The machine is clean inside and outside, andThe machine is draining properly.

Based on interview and record review, the facility failed to electronically submit complete accurate and timely direct care staffing information for the Payroll Based Journal (PBJ) entry to the Centers of Medicare and Medicaid Services (CMS) for the first financial quarter (October 1st-December 31) for 2026.Findings include:On 4/24/2026 at 10:09 AM, Human Resources Director (HRD) P was interviewed and said she submits the quarterly PBJ data to the regional human resources director. HRD P said the regional human resources director then submits the PBJ information to CMS. The PBJ staffing data report was reviewed with HRD P. When HRD P was asked the reason for the 1-star rating for quarter 1 for 2026 HRD P replied, The first quarter PBJ data was not submitted in time.On 4/24/2026 at 12:32 PM, the Nursing Home Administrator (NHA) was interviewed and said the expectation is for the PBJ information to be submitted to CMS timely and accurately as required.On 4/24/2026 at 10:54 AM, a facility PBJ policy was requested, the facility provided the CMS PBJ policy manual.

Based on interview and record review, the facility failed to develop a comprehensive care plan for two (R2 and R13) of 21 residents reviewed for care plans resulting in inadequate care.Findings include: R2 On 4/22/26 at 3:30 P.M. review of the admission Record revealed R2 was admitted to the facility on [DATE], with diagnoses of dislocation of right knee, asthma, injury nerve at the lower right leg, displaced bicondylar fracture of right tibia, cellulitis of right lower limb, severe morbid obesity and subsequent falls. According to the admission Data Set (MDS) dated [DATE], R2 was cognitively intact (ability to think) with a Brief interview for Mental status (BIMs) of 15 of 15. R2 had no behaviors, was incontinent of bowel and bladder, required four-person assistance with Activities of Daily Living (Adl's) for bed mobility, transfer, toileting, personal hygiene, dressing and bathing. On 4/23/26 at 9:00 A.M. review of the Care Plan section of the Electronic Health Record stated the following: I am incontinent of Bowel and bladder initiated 3/26/26. The documented interventions included in part these interventions: *Check me at least every two hours during the day and change my brief if needed. *Keep me as clean and dry as possible and apply protective barrier cream as needed (PRN). *Observe and report any signs and symptoms of infection such as frequency, urgency, burning during urination, mental status change fever. Further review of the care plan for R2's revealed there were no identified goals or interventions that addressed R2's bariatric status or accommodations implemented to address the resident's special needs. There was no evidence of an individualized resident centered care plan. personal preferences for incontinence briefs or accommodating equipment. Review of the facility's undated Comprehensive Plan of care policy stated in part. The comprehensive care plan must be resident centered, and developed within 7 days after the completion of a comprehensive assessment. R13 On 4/22/2026 at 8:17 AM, R13 was observed dressed sitting in a wheelchair in his room with a catheter bag lying directly on the floor. R13 was observed self-propelling in the room while dragging the catheter bag on the floor. When R13 was asked about catheter care R13 said the bag usually hangs on his wheelchair and there was no leg anchor to attach the catheter tube to his leg. On 4/23/2026 at 11:25 AM, R13 was observed dressed sitting in a wheelchair with a catheter bag lying directly on the floor. When R13 was asked about catheter care R13 stated, There is no anchor I use my waistband to hold the tube in place, so it doesn't tug on me. R13 demonstrated using the waistband of his pants to prevent the foley catheter tube from pulling on him. On 4/23/2026 at 1:28 PM, R13 was observed Licensed Practical Nurse (LPN) N. When LPN N assessed R13, LPN N said R13 did not have a foley leg anchor and should to prevent the foley tube from pulling on him. Review of R13's Electronic Health Record (EHR) revealed admission to the facility on 3/27/2026 with diagnoses that included Metabolic Encephalopathy, and chronic kidney disease. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition and moderate assistance for personal hygiene and a foley catheter. Review of R13's physician orders revealed Cath care every shift. Review of R13's care plan revealed, Focus I have a foley catheter (Specify: Condom/intermittent/indwelling Suprapubic) Date initiated 3/28/2026 Revision on 4/15/2026. Goal I will remain free from catheter related trauma through review date. Date initiated 3/28/2026, target date 7/12/2026. Interventions, please check to make sure my tubing has no kinks in its flowing down date initiated 3/28/2026. The care plan did not specify which type of catheter, how to store the collection bag and did not specify use of a foley anchor. On 4/24/2026 at 12:28 PM, the Director of Nursing (DON) was interviewed, and said the expectation is for all residents to have a comprehensive care plan. The DON further said R13's foley catheter care plan was not comprehensive and did not specify which type of catheter and did not include all the recommended interventions such as bag placement, anchor use, and frequency of monitoring. Review of the facility policy titled Comprehensive Plan of Care undated revealed in part.The comprehensive plan of care must be consistent with resident's rights and address the residents' individual needs, strengths and preferences in an I format. Reflects current standard of professional practice. Be periodically reviewed and revised by the interdisciplinary team as changes in the residents' care and treatment occur.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two residents (R97 and R117) out of two residents reviewed for accommodation of needs and preferences. Findings include:R97On 4/23/2026 at approximately 12:30 PM, R97 was observed in their room in bed preparing for lunch. R97's call light was on the floor next to their bed. On 4/24/2026 at approximately 9:00 AM, R97 was observed in their room in bed eating breakfast. R97's call light was on the floor next to their bed. When asked if they could reach their call light, R97 said no - it's on the floor. When asked how they would ask for assistance from staff if they could not reach their call light, R97 responded, I would get on the floor and pick it up. A record review revealed that R97 was admitted to the facility on [DATE] with diagnoses that included type II diabetes, chronic kidney disease, and heart disease. Section C of the Minimum Data Set with an Assessment Reference Date of 3/31/2026 revealed R97 scored a 15/15 on the Brief Interview for Mental Status assessment - indicative of no cognitive impairment. Section GG of the Minimum Data Set with an Assessment Reference Date of 3/31/2026 revealed R97 needed partial to moderate assistance with most activities of daily living. A review of R97's care plan revealed the following interventions dated 3/27/2026: Provide me a safe environment: Have my call light within reach .R117On 4/22/2026 at approximately 8:07AM, R117 was observed in their room in their bed. The resident presented alert and able to communicate appropriately. During the conversation, R117 requested their water which was on their over-bed table. The over-bed table was not within reach of R117. When asked if they were able to push their call light for assistance, R117 said that their call light was not within reach. R117's call light push pad was observed attached to the call light cord and hanging on the wall - not within reach. On 4/24/2026 at approximately 8:15AM, R117 was observed in their room in bed. Upon entering, R117 immediately said, I'm in pain - I need pain medication. When asked if they could press their call light for assistance, R117 said they were unable to get to it. The call light push pad was observed to be hanging over the headboard of their bed - not within reach. When queried to how often their call light is not within reach, R117 said, I don't know. When asked how they request assistance from staff if they are unable to reach their call light, R117 said they would yell for the nurse. A record review revealed R117 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic kidney disease, respiratory failure, and malignant neoplasm of bronchus or lung. A Social Services Comprehensive assessment dated [DATE] revealed R117 was alert and oriented. A Nursing admission assessment dated [DATE] revealed R117 needed assistance with activities of daily living. R117's care plan was reviewed and revealed the following interventions dated 4/15/2026: be sure my call light is within reach and encourage me to us for assistance as needed, and I need a safe environment.a working and reachable call light, the bed in lowest position, and personal items within reach. On 4/24/2026 at approximately 9:10 AM, Certified Nursing Assistant (CNA) B was asked to observe R117 and asked to locate their call light. CNA B confirmed the call light was attached to the wall, then placed it next to R117 in bed. When queried as to why the call light was not within reach, CNA B stated, it was my fault - I was feeding (R117) and moved the call light out of the way and forgot to put it back so (R117) could reach it. On 4/24/2026 at approximately 9:30 AM, the Director of Nursing (DON) was interviewed regarding accessibility of call lights. The DON said it was their expectation that call lights be within reach. When asked why it was important that call lights be within the residents' reach, the DON stated, for their safety, to communicate their needs, and for patient-centered care. A document titled, Call Light Policy last updated 7/2018 was provided but not did address call light accessibility or ensuring call lights were within reach of residents.

This citation pertains to intake 2959471.Based on interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property by an employee for one (R115) out of two residents reviewed for abuse resulting in an employee using R115's debit card.Findings include:On 3/16/2026 the State Agency (SA) received a complaint with an allegation of misappropriation of property.On 4/24/2026 at 9:00 AM, the facility incident report dated 2/3/2026 and the facility investigation report and addendum dated 2/13/26 were reviewed with the Nursing Home Administrator (NHA). The NHA said R115 reported on 2/3/2026 that her debit card was missing $981 dollars. Review of the facility investigation revealed that an employee, Certified Nursing Assistant (CNA) J was identified as using R115's debit card based off financial records provided by the debit card company reviewed by the NHA with family friend K.On 4/24/2026 at 9:30 AM, CNA J' was contacted via phone with no response.On 4/24/2026 at 9:35 AM, an attempt was made to contact R115 via phone. The phone number was not in service and no other working phone numbers were available in the medical record.Review of R115's Electronic Health Record (EHR) revealed admission to the facility on 1/27/2026 and a discharge date of 2/9/2026 with diagnosis that included Cerebral infarction, Malignant Neoplasm.On 4/24/2026 at 9:40 AM, the NHA was interviewed and said that CNA J was terminated on 2/24/2026 based on the facilities investigation which determined that CNA J used R115's debit card without consent. The NHA said the expectation is for residents to be protected from misappropriation of property.Review of the facilities policy titled Abuse and Neglect Prohibition Policy reviewed 2/17/2020 revealed in part.Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, and misappropriation of property.

This citation pertains to intake 2959471.Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of an injury of unknown origin to the State Agency (SA) for one (R115) of two residents reviewed for abuse.Findings include:On 3/16/2026 the State Agency (SA) received a complaint with an allegation of a resident fall with injury.Review of R115's progress note dated 2/1/2026 revealed, New order for resident per Dr. to complete neuro checks for 3 days every 6 hours for bruise on left side of forehead on eyebrow. New order for Tylenol 650mg q6h prn and apply ice to bruise.Review of R115's Unwitnessed incident report dated 2/2/2026 revealed, Resident observed laying in bed experiencing involuntary rapid movements. Resident observed hitting her right eye and attempting to hold her right arm with her left hand. These movements are uncontrollable by resident at times. Right eye discoloration observed with swelling. Resident has involuntary movement with her head. Swings head abruptly especially when speaking. Resident unable to give description. Resident unable to give consistent information when asked did she fall 3 separate occasions. Level of consciousness: Alert. Mobility: bedridden.Review of the admission skin note dated 1/27/2026 did not reveal facial bruising.On 4/23/2026 at 3:45 PM, Licensed Practical Nurse/Unit Manager (LPN) L was interviewed and said LPN M notified her on 2/1/2026 she observed bruising on R115's face that could not be explained and was not witnessed. LPN L stated, I did not report the injury to the abuse coordinator but should have.On 4/24/2026 at 8:16 AM, LPN M was contacted by phone for an interview with no return call by survey exit.Review of 115's Electronic Health Record (EHR) revealed admission to the facility on 1/27/2026 and a discharge date of 2/9/2026 with diagnosis that included Cerebral infarction, Malignant Neoplasm. An admission Minimum Data Set (MDS) assessment documented intact cognition and max assistance for personal hygiene. On 4/24/2026 at 9:02 AM, the Nursing Home Administrator (NHA) was interviewed and said neither LPN M or LPN L reported R115's facial injuries. The NHA said the expectation is for all suspicious injuries and abuse to be reported to her immediately so she can complete the proper procedures as abuse coordinator. Review of the facility policy titled Abuse and Neglect Prohibition Policy reviewed 2/17/2020 revealed in part.Identification 1. The facility will monitor residents for changes in behavior, bruises/injuries of unknown origin or of a suspicious nature, or other types of patterns, occurrences and trends that may constitute potential abuse and investigate such situations. Investigation 1. The facility Administrator or designee will oversee the investigation of an alleged abuse/neglect or misappropriation of resident property in accordance with state law. 3. The facility Administrator will report all investigation findings to the state as per federal and state regulations. The staff will report all allegations of abuse, neglect and misappropriation of property to the administrator immediately. The administrator is responsible for reporting to the State Agency alleged violations involving abuse, including injuries of unknown origin.

Based on observation, interview and record review the facility failed to ensure the correct size incontinence brief was provided for one bariatric resident (R2) out of two residents reviewed, resulting in the resident verbalizing frustration and discomfort.Findings include:Review of the admission Record for resident2 (R2) the resident was admitted to the facility on [DATE], with diagnoses of dislocation of right knee, asthma, nerve injury at the lower right leg, displaced bicondylar fracture of right tibia, cellulitis of right lower limb, severe morbid obesity and subsequent falls.According to the admission Data Set (MDS) dated [DATE], R2 was cognitively intact (ability to think) with a Brief interview for Mental status (BIMs) of 15 of 15. R2 had no behavior, was incontinent of bowel and bladder, required four-person assistance with Activities of Daily Living (Adl's) for bed mobility, transfer, toileting, personal hygiene, dressing and bathing. On 4/22/26 at 8:30 a.m. R2 was located on the Burgundy Unit and interviewed concerning her care at the facility. R2 was observed to be bedbound, morbidly obese, with a hospital gown covering the front section of her body. R2 was asked about receiving showers and equipment for home use. R2 stated the staff is out of the correct size incontinence briefs I normally use, but they should be delivered by tomorrow. It has taken the facility a while to get the right size. It should not take that long.On 4/23/26 at 8:01 A.M. R2 was observed in bed with a stained colored pad underneath her. R2 stated the facility was still providing the wrong size incontinence brief and when she asked the CNA's(names not known) to check they continue to indicate the briefs are on order. I have been here about a month and the 2XL brief size I use now is not as absorbent or comfortable as the 5XL Bariatrics, there is a big difference. The resident explained that even when the CNA's left the correct size the next day someone would borrow her briefs and not replace them for the next day. The next morning staff would place 2XL briefs on her. R2 was asked to explain how the briefs were applied. One brief would be placed in front of her and the other positioned in back on her buttocks as much as possible in addition to an extra wide pad because the 2XL brief was much smaller, neither side of the briefs were fastened or closed causing a shift in positioning of the brief and urine leakage. R2 stated I am a big girl; I am over 600 pounds the briefs they got me trying to use just are too small. When I urinate the bed, the extra wide pads are soaked, my skin becomes moist and I begin to itch I cannot get up to use the bedside commode and it's difficult moving with all this equipment on my leg.On 4/23/26 at 8:25 A.M. with permission of R2 the resident's closet was inspected for the incontinence brief left for use. There was one package of regular briefs stored on the bottom section of the resident's closet. R2 was asked if the briefs displayed were the correct size? The resident responded no that size is even smaller than the 2XL staff have been using. (normally fits a hip/waist size of 44-48 inches). This size brief was half the size brief R2 stated or required.On 4/24/26 at 12:52 P.M. R2's closet was checked with the resident's permission. Inside of the closet was one package of 4XL Bariatric incontinence brief. R2 checked the size stating that it was better than yesterday but still the wrong size.Review of the brief packages left in the storage closet on the resident's unit, measured as follows:3XL/3x Grand -65-84 inches4XL4X Bariatric-65-94 inches5XL/5X Bariatric-90-106 inches (the resident stated she needed this size to avoid soiling her bed).At 1:00 P.M. nurse Y was interviewed concerning the availability of incontinence briefs for R2. Nurse Y explained Central supply was responsible for delivering and ordering incontinence briefs for residents on the unit. The nurse was asked how staff knew what size brief a resident required specifically a bariatric resident? Nurse Y reported the resident should be assessed shortly after admission and that information communicated to staff. When asked where that information would be documented, the nurse said in the book at the desk and on the Kardex for the CNAs to use.Review of the unidentified Book at the nursing station and the CNA's Kardex revealed no evidence of documentation of the size of brief required for R2.On 4/24/26 at 2:00 P.M. Manager X reported the correct size brief for R2 has always been available. I ordered the correct size brief and deliver them to the unit every Tuesday and Friday and place the briefs on the units in the storage area. I placed 5XL bariatrics briefs in the Burgundy unit closet on Tuesday.At 2:15 P.M. observation of the Burgundy Unit supply closet revealed and assortment of sizes of bariatric incontinence briefs. Located on the second shelf of the rack were several packages of 5XL bariatric briefs. Manager X commented they did not look or ask. Those briefs were there all the time. I make sure they have enough briefs, especially R2, that size is the largest the company supplies.At 2:50 P.M. during an interview with the Director of Nursing (DON) concerning the availability of briefs and how the facility assesses the correct size of brief for bariatric residents. The DON stated R2 should have been assessed upon admission for the correct size brief, and CNAs should not be borrowing briefs from one resident to another. The DON was unable to recall where the assessment for incontinence briefs was documented but recalled recently using the assessment but was unable to locate the information. Upon exiting the facility on 4/24/26 at 4:30 P.M. the requested policy and procedure for assessment for incontinence briefs for bariatric residents was not provided as requested.

Based on observation, interview and record review, the facility failed to ensure proper anchoring/securing of an indwelling urinary catheter for two (R36 and R13) out of three residents reviewed for urinary catheters.Findings include: R36 On 4/22/2026 at 9:32 a.m. R36 was observed in bed with a foley catheter bag lying on the floor. The resident's left leg was observed entangled in the catheter tubing. On 4/23 a.m.at 9:11 a.m. The resident was lying on his back with the catheter bag positioned on the floor at the side of the bed. There was no visible leg band or tape holding the tubing to the resident's left leg. The resident was asked, why was the foley bag on the floor? The resident stared out without a response. On 4/23/26 at approximately 2:30 pm during a wound care observation the resident was observed without a foley leg strap or anchoring device. Review of the physician orders dated 11/20/25 stated: secure foley to leg, ensuring that catheter is not pulling on resident or pressed into skin each shift. Record review of the electronic health record indicated R36 was admitted to the facility on [DATE], with diagnoses which included: surgical amputation, diabetes mellitus, acute osteomyelitis, peripheral vascular disease, cognitive communication deficit, absence of right leg above knee, dementia and history of traumatic brain injury. According to the Minimum Data Set (MDS) dated [DATE], R36 had a Brief Interview for Mental Status (BIMs) of 9 indicating moderate cognitive impairment (ability to think). The resident was enrolled in hospice care and was totally dependent on staff to provide all Activities of Daily Living( ADLs). On 4/23/2026 at 3:30 pm Nurse Z was queried concerning the physician orders. Nurse Z indicated R36 was never out of bed and when he was in bed, he would manipulate the foley tubing when agitated. A review of the facilities undated indwelling foley catheter policy, under section 22 for male residents: tape to thigh or lower abdomen. Or use a leg band with Velcro closure. R13 On 4/22/2026 at 8:17 AM, R13 was observed dressed sitting in a wheelchair in his room with a catheter bag lying directly on the floor. R13 was observed self-propelling in the room while dragging the catheter bag on the floor. When R13 was asked about catheter care R13 said the bag usually hangs on his wheelchair and there was no leg anchor to attach the catheter tube to his leg. On 4/23/2026 at 11:25 AM, R13 was observed dressed sitting in a wheelchair with a catheter bag lying directly on the floor. When R13 was asked about catheter care R13 stated, There is no anchor I use my waistband to hold the tube in place, so it doesn't tug on me. R13 demonstrated using the waistband of his pants to prevent the foley catheter tube from pulling on him. On 4/23/2026 at 1:28 PM, R13 was observed Licensed Practical Nurse (LPN) N. When LPN N assessed R13, LPN N said R13 did not have a foley leg anchor and should to prevent the foley tube from pulling on him. Review of R13's Electronic Health Record (EHR) revealed admission to the facility on 3/27/2026 with diagnoses that included Metabolic Encephalopathy, and chronic kidney disease. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition and moderate assistance for personal hygiene and a foley catheter. Review of R13's physician orders revealed Cath care every shift. Review of R13's care plan revealed, Focus I have a foley catheter (Specify: Condom/intermittent/indwelling Suprapubic) Date initiated 3/28/2026 Revision on 4/15/2026. Goal I will remain free from catheter related trauma through review date. Date initiated 3/28/2026, target date 7/12/2026. Interventions, please check to make sure my tubing has no kinks in its flowing down date initiated 3/28/2026. On 4/24/2026 at 12:28 PM, the Director of Nursing (DON) was interviewed, and the expectation is for all residents who have a foley catheter to have leg strap or anchor in order to prevent the foley tube from pulling out. Review of the facility policy titled Indwelling Catheter Insertion undated revealed in part.Purpose an indwelling catheter remains in the bladder to provide continuous urine drainage. 22. Hang collection bag below bladder level. 22. Tape Catheter. For male resident, tape to thigh, or lower abdomen, or use leg band with Velcro closure.

Based on interview and record review the facility failed to administer medications according to physician orders for one (R703) of four reviewed for medications. Findings include:A review of the Electronic Medical Record (EMR) revealed R703 was originally admitted on [DATE] and readmitted [DATE] with diagnoses included Chronic systolic (Congestive) Heart Failure, Acute Kidney Failure and Traumatic Subarachnoid Hemorrhage. Further review revealed a Brief Interview for Mental Status score of 15/15 which indicated intact cognition. Further review of the medical record revealed a progress note dated 2/18/2026 at 20:03 which stated Received resident sitting in chair with pants off with some sob writer administered breathing treatment and explained to resident that dr started them on new med prednisone to help reduce sob (shortness of breath) and to help their lungs fight back writer able to calm resident tolerated meds well can make needs known, continent of bowel & bladder, call light within reach will continue to monitor 123/88 98 94 20 BS 118 A review of the physician's orders revealed an order on 2/17/26 for Albuterol Sulfate Inhalation Nebulization (2.5 MG/3ML 0.083% to be given 1 vial inhale orally via nebulizer one time only for S.O.B (shortness of breath) for 1 day. A review of the February 2026 medication administration record showed that the medication was given on 2/17/25. There was no order for another breathing treatment from physician.On 3/12/26 at 11:30 am, the Director of Nursing (DON) was queried about the medication orders. The DON reviewed the orders and stated that the order was for one time only and should not have been given without the physician's order. A review of the undated Medication Orders Policy noted the following: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: completed a thorough investigation to identify root cause; did an on the spot education for licensed nurses in the facility at time of notification of this error.; Immediately re-educate all the licensed nurses on a) administering medications without a physician orders (medication administration policy) b)Transcribing physician orders c) Notifying the PCP and family on a change in condition d)Expected documentation in PCC following an event e) PCP notified regarding a medication error.How the facility monitors the effectiveness of its quality improvement measures: the nurse managers will do grand rounds daily. All findings will be discussed in the AM clinical / stand down; Weekly the Administrator will conduct random rounds. With all findings being discussed in the AM clinical with any needed follow up being done immediately. All findings will be reported to the QA team monthly; Results of these audits will be submitted to the QA Committee monthly for review and further recommendations: The Director of Nursing is responsible for compliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. Date of compliance 2/20/26.

This citation pertains to intakes 2687870 and 2692032.Based on observation, interview, and record review, the facility failed to protect the resident's (R701) right to be free from physical abuse by Certified Nursing Assistant (CNA) B resulting in hospitalization for a dislocated shoulder.Findings include: On 12/16/25 at 10:55 a.m. R701 was observed self-propelling in a wheelchair, with a sling applied to the right arm. R701 was asked what happened to the arm. R701 began to laugh and made an unclear statement. R701 was asked if the arm was in pain. R701 looked at the arm, smiled, and rolled away. On 12/15/25 at 11:35 a.m. the Nursing Home Administrator (NHA) provided the facility reported incident regarding an allegation of staff to resident abuse that occurred on 12/1/25 between 9:30 p.m. and 10:00 p.m. (reported on 12/2/25) involving R701. R701 sustained a dislocated right shoulder and was sent to the hospital for treatment. Review of the Incident Summary documented in part: On 12/2/25 at approximate 4:30 AM, a report from CNA (Certified Nursing Assistant) A, stating that CNA B was observed twisting the arm of R701during care. R701 was assessed for injury by RN C. No injuries were noted and per report from RN C, resident was able to move both arms with no indication of pain. R701 was later reassessed and was noted to have slight bruising to wrist and grimacing was noted when right arm was raised. Facility received x-ray results for dislocation. The resident was transferred to the hospital for treatment. Law Enforcement was contacted. Review of the hospital Discharge summary dated [DATE] documented: Call to schedule follow up appointment for shoulder dislocation s/p (status post) reduction (procedure to restore the correct alignment of a dislocated joint). Review of the Skin/Wound Note dated 12/2/25 at 18:53 (6:53 pm) documented: BL (bilateral) upper arms, area of discoloration noted on assessment. Review of the Diagnostic Report (x-ray) dated 12/3/25 14:01 (2:01 pm) documented: MD/NP notified of x-ray results, resident sent to ER. There was no physician order written to send R701 to the hospital. Review of the Interdisciplinary Note dated 12/5/25 documented in part the following: IDT team met to discuss resident r/t right dislocated shoulder. Resident has a sling on right arm at all times. On 12/15/25 at 6:13 p.m. CNA A was contacted via telephone. CNA A was asked to recall the events that occurred on 12/1/25. CNA A reported on 12/1/25 on the night shift (7pm-7am), between 9:30-10:00 p.m., CNA B was observed in the hall attempting to ambulate R701 to the bedroom. R701 was becoming aggressive towards CNA B due to being grabbed on by the arm. CNA B was also observed sitting on R701's lap while in the wheelchair causing R701 to become agitated and aggressive. R701 requires two-person assistance with care. CNA A was asked to assist with putting R701 to bed. Once in the bedroom, CNA A heard CNA B say, I'm putting you to bed. You are getting on my nerves. CNA A then observed CNA B forcefully twisted R701's right arm behind the back and stated, I hope the bitch is broke. R701 was observed squirming and moving trying to get arm free. CNA A verbally stopped CNA B from further causing harm to R701 and assisted with care. CNA A said there were no other staff around and did not know where the unit charge nurse was located. CNA A did not report the incident immediately to the unit charge nurse due to fear of retaliation. CNA A was moved to another unit due to staffing issues and about two hours later (3:30 a.m.) reported the incident to the NHA who was in the facility at the time. On 12/15/25 at 6:53 p.m. CNA B was contacted via telephone and asked to recall the events that occurred on 12/1/25. CNA B reported being the assigned CNA for R701 during the shift 7 pm-7 am. Between 7:30-8:00 pm R701 was in the dining room and had a bowel movement. R701 was taken to the bedroom to get cleaned up. CNA B asked CNA A to assist with care because R701 was a two-person assist. CNA B while rushing, wet and soaped a towel that dripped on the floor, slipped and grabbed R701's right arm to keep from falling. CNA A and CNA B proceeded to clean R701 and put to bed. CNA B said nothing out of the usual happened prior or after the incident, I don't know how (R701) arm got broke. I grabbed her arm to keep from falling. On 12/16/25 at 1:14 p.m. the NHA was interviewed about the events that occurred on 12/1-12/2 (midnight shift). The NHA recalled arriving at the facility on 12/2/25 at 2:15-2:30 am. At 4:30 a.m., CNA A reported, There's abuse in here. There's a situation with a male CNA while providing care. The CNA twisted (R701's) arm. The NHA reported CNA A was visibly upset and became agitated while being interviewed. CNA A stopped engaging which ended the interview. The NHA added they attempted to interview CNA B at 6:30 a.m. A statement was not obtained from CNA B due to immediate suspension and removal from the facility pending investigation. CNA B was asked to return to the facility on [DATE] and gave a statement to law enforcement. The NHA said law enforcement reported CNA B stated R701 had a bowel movement. There was water on the floor and grabbed the resident's arm. Review of the clinical record documented R701 was initially admitted into the facility on 5/7/20 and readmitted on [DATE] from the hospital for a right dislocated shoulder. R701's other diagnoses include unspecified psychosis, polyneuropathy, adjustment disorder, and dementia. According to the quarterly Minimum Data Set assessment dated [DATE], R701 had severe impaired cognition (BIMS-3) and required total assistance with two-person assistance with activities of daily living. PNCAfter all observations, interviews, and record reviews, the facility provided evidence of a Past Non-Compliance on 12/15/25.The Past-Non-Compliance was reviewed and accepted by the reviewing surveyor. The facility was found to be in substantial compliance with F-tag 600 on 12/15/25 when the following interventions were noted to be put into place by the surveyor on 12/16/25. The facility's past non-compliance indicated the following: Measures or systemic changes made to ensure the deficient practice will not re-occur and affect others: A QAPI Meeting was held to determine the root cause analysis for complaints of abuse. The facility identified the resident affected and residents having potential to be affected by the same deficient practice. Corrective Action was taken for the resident affected (assessments, hospitalization, psych services consultations, and employee termination). The facility monitors are taking corrective actions to ensure deficient practices are corrected and will not occur by weekly random audits for four months then monthly for three months to ensure that residents are free from any forms of abuse.All facility staff have been educated on the abuse policy that included: Prevention: Residents, families and staff will be able to report concerns, incidents and grievances without fear of retribution. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk of occurring. Protection: The facility will protect residents from harm including and during investigations. Should the allegation allege a staff person, that individual will be suspended pending the outcome of the investigation. Reporting: The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source to the Administrator and DON immediately. The Administrator or designee will notify any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours).

This citation pertains to intakes 2687870 and 2692032. Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of physical abuse for one (R701) in accordance with section 1150B of the Act, resulting in acts of physical abuse going unreported in a timely manner and further placing residents in harm's way.Findings include: Review of the clinical record documented R701 was initially admitted into the facility on 5/7/20 and readmitted on [DATE] from the hospital for a right dislocated shoulder. R701's other diagnoses include unspecified psychosis, polyneuropathy, adjustment disorder, and dementia. According to the quarterly Minimum Data Set assessment dated [DATE], R701 had severe impaired cognition (BIMS-3) and required total assistance with two-person assistance with activities of daily living. On 12/15/25 at 11:35 a.m. the Nursing Home Administrator (NHA) provided the facility reported incident regarding an allegation of staff to resident abuse that occurred on 12/1/25 between 9:30 p.m. and 10:00 p.m. (reported on 12/2/25) involving R701. R701 sustained a dislocated right shoulder and was sent to the hospital for treatment. Review of the Incident Summary documented in part: On 12/2/25 at approximate 4:30AM, a report from CNA (Certified Nursing Assistant) A, stating that CNA B was observed twisting the arm of R701during care. R701 was assessed for injury by RN C. No injuries were noted and per report from RN C, resident was able to move both arms with no indication of pain. R701 was later reassessed and was noted to have slight bruising to wrist and grimacing was noted when right arm was raised. Facility received x-ray results for dislocation. The resident was transferred to the hospital for treatment. Law Enforcement was contacted. On 12/15/25 at 6:13 p.m. CNA A was contacted via telephone. CNA A was asked to recall the events that occurred on 12/1/25. CNA A reported on 12/1/25 on the night shift (7pm-7am), between 9:30-10:00 p.m., CNA B was observed in the hall attempting to ambulate R701 to the bedroom. R701 was becoming aggressive towards CNA B due to being grabbed on by the arm. CNA B was also observed sitting on R701's lap while in the wheelchair causing R701 to become agitated and aggressive. R701 requires two-person assistance with care. CNA A was asked to assist with putting R701 to bed. Once in the bedroom, CNA A heard CNA B say, I'm putting you to bed. You are getting on my nerves. CNA A then observed CNA B forcefully twisted R701's right arm behind the back and stated, I hope the bitch is broke. R701 was observed squirming and moving trying to get arm free. CNA A verbally stopped CNA B from further causing harm to R701 and assisted with care. CNA A said there were no other staff around and did not know where the unit charge nurse was located. CNA A did not report the incident immediately to the unit charge nurse due to fear of retaliation. CNA A was moved to another unit due to staffing issues and about two hours later (3:30 a.m.) reported the incident to the NHA who was in the facility at the time. CNA A stated, I don't know why I didn't report it immediately to the supervisor before I saw the Administrator. On 12/16/25 at 1:14 p.m. the NHA was interviewed about the events that occurred on 12/1-12/2 (midnight shift). The NHA recalled arriving at the facility on 12/2/25 at 2:15-2:30 am. At 4:30 a.m., CNA A reported, There's abuse in here. There's a situation with a male CNA while providing care. The CNA twisted (R701's) arm. The NHA reported CNA A was visibly upset and became agitated when asked why the incident was not reported immediately to the nurse supervisor. CNA A stopped engaging which ended the interview. The NHA was queried about reporting CNA B license to the state agency. The NHA stated, No. I had not. There was so much going on, I didn't think to report the license. Review of the facility's policy titled Abuse and Neglect Prohibition Policy revision date 2/17/20 documented in part the following: Reporting and Response:1. The staff will report allegations of abuse, neglect and misappropriation of property to the Administrator immediately.2. The Administrator or designee is responsible for reporting to the State Agency all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of property:Immediately but no later than 2 hours after the allegation is made if the allegation involves abuse or result in serious bodily injury. Or not later than 24 hours if the events that cause the allegation do not involve abuse or serious injury.3. If the alleged violation is verified, appropriate corrective action must be taken including proper reporting to the State Agency, the local Police Department, See Facility Suspected Crime Report - Elder Justice Act Policy and Procedure.4. The facility will report any occurrences of abuse by licensed, registered or certified staff to the State Board as required by state law.

This citation pertains to intakes MI00152529 and MI00153381. Based on interview and record review the facility failed to prevent verbal abuse for two residents (R901 and R909) out of five residents reviewed for abuse. Findings include: Record review of Facility Reported Incident dated 5/21/25 revealed an allegation of a staff to resident verbal altercation. Record review of R901's electronic medical record revealed admission into the facility on 7/29/24 with a malignant neoplasm (cancer) of ovary. The Electronic Medical Record (EMR) further revealed R901 had scored 15 out of 15 (intact cognition) on a Brief Interview for Mental Status (BIMS) dated 5/5/25. Record review of R908's EMR revealed admission into the facility on 6/15/23 with a pertinent diagnosis of unspecified dementia. EMR further revealed resident had scored 3 out of 15 (severe impairment) on a Brief Interview for Mental Status (BIMS) dated 6/27/25. Review of a signed written statement from R901 dated 5/21/25, it was documented by R901 that Certified Nursing Assistant (CNA) D was witnessed talking loud to R909 on 5/20/25. During their conversation CNA D said to R908, Fuck this (R909) you not going to talk to me like that. It was then documented that after CNA D removed R909 from area, CNA D returned and got in R901's face and said, Don't be checking me bitch your (sic) dying from cancer anyway. I told (CNA D) to back up off me and (CNA B) got between us. It was then documented that R901 reported the incident to Licensed Practical Nurse (LPN) C. It was further documented that CNA D came back and said, Nigga, bitch what's up, go in your mother fuckin room. R901 was not available for interview due to a recent discharge to the hospital. An interview was conducted on 7/8/25 at 11:30 AM with R909. The resident was observed to be confused and did not remember the incident that happened on 5/20/25. A phone interview was conducted on 7/9/25 at 3:01 PM with CNA B, who verified she had witnessed CNA D cursing at R901 and R909 on 5/20/25. Review of a signed written statement dated 5/21/25 by Registered Nurse (RN) E, documented the following, The Burgundy Nurse (LPNC) called me for altercation between CNA D and the resident in room [ROOM NUMBER] (R901). When I came to the unit the CNA was verbally abusive to R901 and the nurse. CNA was using B words to the resident. It was further documented that CNA continued to be more aggressive and was sent home. RN E was not available for an interview. An interview was conducted on 7/8/25 at 10:58 AM with the Director of Nursing, it was reported that the behavior by the staff member was not appropriate and does not adhere to our standards of practice. An interview was conducted on 7/8/25 at 1:00 PM with Social Worker (SW) A, it was reported that follow up interviews were conducted with R901, and a psychology interview was conducted and the resident had no concerns and felt safe in facility. It was further reported that residents in the facility should not be disrespected and spoken to in that manner. An interview was conducted on 7/8/25 at 3:10 PM with the Nursing Home Administrator, it was reported that staff members should not behave in this manner, and it was against the facility's policy and procedures. It was further reported that CNA D was terminated from her position. An interview was conducted on 7/9/25 at 4:05 PM with the Medical Director, it was reported that this should be a Never Event, meaning residents should never be spoken to in a disrespectful manner. Record review of facility's policy Abuse and Neglect Prohibition it was documented, Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, misappropriation of property and mental abuse facilitated or enabled using technology. Each resident will be free from chemical or physical restraints imposed for purposes of discipline or convenience that are not required to treat resident symptoms. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

Based on observation, interview and record review the facility failed to provide a safe and sanitary kitchen for food storage, preparation and service, resulting in the potential for food borne illnesses. This deficient practice affected 99 of the 104 residents within the facility. Findings include: On 3/24/25 at 10:00 A.M. and 3/25/25 at 11:40 A.M. the A.M. cook was observed wearing a beard restraint covering his beard but not his mustache. During a follow up observation on 3/25/25 at 11:50 A.M. in the presence of Area Manager (A.M.) F the employee was made aware of the improper use of the restraint and then adjusted it to cover the mustache and beard appropriately. On 3/25/25 at 12:15 P.M. during a lunch meal observation in the [NAME] Unit Dining room (400 hall) a tray with approximately eight containers of potato salad and assorted desserts were placed on top of the steam table cart. At 12:40 P.M., the temperature of the potato salad was recorded at 60 Degrees Fahrenheit (D.F.) There was no ice bath or cooling device in place to maintain proper holding temperature while the items awaited service. According to the 2023 Food Code, 3-501.16 2(a) cold potentially hazardous foods must be maintained at 41 D.F. or below. In the facility's main kitchen, the caulking along the scrape table of the dish machine was noted to be cracked and detached from the back splash. Accumulated within the broken caulking was standing water, food debris and a black, mold-like substance which was also observed on both the backsplash and the dish machine door. The exhaust hoods in the kitchen were heavily soiled with visible accumulation of grease, lint and food ash. A review of the maintenance cleaning records indicated the last professional cleaning of the exhaust hoods occurred on 1/7/25 and the next scheduled cleaning was not until 7/15/25. During an interview with Food Service Supervisor (FSS)'D concerning cleaning of the vents during interval scheduled cleaning FSS D indicated the kitchen staff had cleaned the hoods however, the supervisor was unsure of the last time they were cleaned. When asked to provide the cleaning schedule or tasks assignments from the previous month of sanitation, no documentation was provided. On 3/26/25 at 11:30 A.M., a walkthrough of the kitchen was conducted with Area Manager (A.M.) F, joined by the Administrator to review the ongoing sanitation concerns. During this observation, the same deficiencies were again visible. A.M. F acknowledged the concerns but did not offer an explanation as to why they had not been addressed. During this interview and observation A.M. F was asked to present and review the last month's cleaning schedule. The schedule was not provided as requested. In accordance with the 2023 Food Code: Hair Restraints 2-402.11. Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens . Due to the facility's failure to maintain basic sanitation and follow required food safety protocols, residents were placed at risk for food borne illness. The lack of timely corrective action and failure to provide requested documentation reflect a breakdown in kitchen safety practices and oversight. Upon exiting the facility on 3/26/25 at 4:30 P.M. no additional information was provided related to the sanitation in the kitchen area.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all residents in the facility. Findings include: On 3/26/25 at 8:16 AM review of the nurses' schedule for the months of October, November and December 2024 with staffing coordinator H, revealed there was no Registered Nurse (RN) coverage on the following date: October 20th, 2024. Staffing coordinator H acknowledged the facility had difficulty in the past finding RN coverage for weekends and that sometimes the Director of Nursing (DON) would cover a shift. Staffing coordinator H was not aware that the DON coverage does not count towards RN coverage when the facility census is greater than 60 residents. On 3/26/25 at 12:30 PM the DON was interviewed and said there have been times when an RN was not available, and the expectation is that there is 8-hour RN coverage 7 days per week. The DON agreed the resident population required RN supervision. On 3/26/25 at 12:14 PM a RN coverage policy was requested. On 3/26/25 at 3:43 PM the Nursing Home Administrator was interviewed and said the facility does not have a RN coverage policy and that the facility refers to the Center for Medicare and Medicaid Services guidelines.

Based on observation, interview and record review the facility failed to employee sufficient dietary staff and ensure operational consultation was provided to supervisory staff, resulting in inadequate sanitation in the kitchen. This deficient practice had the potential to affected 99 of the 104 residents that consumed meals from the kitchen. Findings include: On 3/24/25 at approximately 9:15 A.M. Food Service Supervisor (FFS) D was observed on the [NAME] unit assisting in collecting trays and transporting food carts to the elevator to go to the kitchen. while collecting trays and carts FSS D was checking unit refrigerators and taking resident's requests. At 10:00 A.M. during an observation of the kitchen FSS D was observed organizing the walk-In refrigerator and freezer to place delivered stock. During the observation FSS D was queried concerning current staffing in the department. FSS D reported one employee had called in the current morning and one dietary aide had resigned the previous month, and that position was vacant. During the observation of the sanitation in the kitchen FSS D was asked how frequently sanitation audits or monitoring was performed. The supervisor indicated all staff was encouraged to clean as they completed tasks, and the facility had a cleaning schedule which could not be located during the observation but would be provided later. On 3/25/25 at 12:00 P.M. FSS D was asked to present any cleaning schedule or consultations that had been performed FSS D indicated about a month earlier Fine Dining was restarted with the lunch meal being served to the residents. According to FSS D all residents received their breakfast and dinner meals in their rooms, but lunch was served from the four-unit kitchens. Currently, one unit was identified as not being used because of Covid precautions and equipment that had been ordered for service for that unit. On 3/24/25 at 12:30 P.M. lunch was not served in the [NAME] Dining room. FSS D was interviewed concerning what was done when dietary had staff shortages? FSS D was asked how many hours the department was budgeted? FSS D reported 51 hours a day which did not include the supervisor's position or any extra hours for call in coverage for staff. When there is a call-in staff members are asked to pick up hours, or we share tasks and sometimes I fill in. The supervisor was asked if that's what happened on Monday when there were only two dietary aides to cover the three units, no response was provided. On 3/26/25 at 2:50 P.M. joined by (Area Manager) A.M. F and FSS Dduring an interview and record review of the schedule revealed on Tuesdays, Wednesdays and Thursdays the department had one am (morning) cook and 4 aides to cover breakfast and lunch. On Mondays and Fridays there were only three dietary aides and one cook for breakfast and lunch. Reviewing the current schedule jointly (there was a shortage of staff on 3/24/25). Each Monday and Friday the department was short of one dietary aide and one supervisor for coverage. A.M. F indicated the schedule hours originally provided was incorrect and the facility had scheduled 55 hours instead of 51 hours. At this time A. M. F offered no reason why the sanitation in the kitchen had not been addressed with the four additional hours. A.M. F was asked to provide any dietary audits, reports, or evidence of consultation for the kitchen. On 3/26/25 at approximately 3:40 P.M. during Quality Assurance Interview, the Administrator indicated staffing was being reviewed but provided no explanation for the lack of monitoring and oversight in the kitchen. Upon exiting the facility on 3/26/25 at 4:30 P.M. the submitted audit Form provided for the department was blank, and no cleaning schedule was provided as requested.

Based on observation, interview and record review, the facility failed to ensure proper cleaning and disposal of loose medications were conducted for one medication cart (400 Hall Cart) of four medication carts observed for medication storage and cleanliness. Findings include: On 03/26/25 at 09:35 AM, an observation and interview were conducted with Nurse G's 400 hall medication cart. Upon inspection of medication cart 400, a total of 19 loose pills were scattered on the bottom of the first and second drawers of the medication cart. The loose pills were varied in shapes, colors and sizes. In addition, the first and second drawers of medication cart 400 had dried tan stains, lint, and dust. On 03/26/25 at 09:45 AM, an interview was conducted with Nurse G regarding the loose medications and uncleanliness of medication cart 400. Nurse G said that the cart should be clean. When asked about their policy for loose medications, Nurse G said the pills should have been thrown away. On 03/26/25 at 10:35 AM, an interview was conducted with the Director of Nursing (DON) regarding the 19 loose pills and the debris found in medication cart 400. The DON said that the nurse managers were expected to check and clean the medication carts on their units. A review of the facility's policy Medication Storage in the Facility dated 3/2025, revealed the following: Medication storage areas are kept clean .and free of clutter.

Based on observation, interview, and record review the facility failed to repair the floor of one resident (R95) of three reviewed for a homelike environment resulting in frustration and a potential hazard. Findings include: On 3/24/25 at 11:10 AM, R95 was interviewed about living conditions at the facility and stated, There is a hole in my floor. I asked them to fix it, it's been a year. There was an approximate six by -four-inch patch of missing floor covering observed near R95's foot of bed. R95 verbalized frustration that the hole had not been fixed. On 3/26/25 at 7:43 AM, R95's room was observed with Maintenance Supervisor (MS) C. MS C acknowledged the missing floor tile near the foot of R95's bed. When queried about a work order for the missing tile MS C replied, I'm aware of the tile issue but haven't had the opportunity to fix it yet. MS C said there wasn't a work order for the flooring and the facility staff were not utilizing a formal work order system. MS C acknowledged the repair was not completed timely. On 3/26/25 at 8:00 AM maintenance room audits were requested and were not provided by the end of survey. On 3/26/25 at 12:55 PM, R95's room was observed with the Nursing Home Administrator (NHA). R95 was observed sitting in a wheelchair holding a rolling walker. The NHA acknowledged the hole in R95's floor and agreed the flooring needed to be repaired and that the hole in the flooring created a tripping hazard and could not be cleaned properly. Record review of R95's Electronic Health Record (EHR) revealed admission to the facility on [DATE] with diagnoses which included chronic heart failure and age-related physical debility. Review of R95's Brief interview for Mental Status (BIMS) assessment performed on 2/5/25 revealed a BIMS of 12/15 moderately impaired cognition. Review of R95's fall risk assessment dated [DATE] revealed a weak ambulator-steps are short resident may shuffle. Review of the facility policy titled Resident Room Maintenance dated 2009, revealed in part: Resident rooms are inspected and maintained on a periodic basis to ensure proper function. To check each room at least once a week, it is necessary to schedule blocks of rooms to be checked each workday. Check for chipped paint on doors, woodwork, walls and ceilings. Check walls and ceilings for damage. Check for stained, broken, or chipped floor tile or sheet vinyl. Record preventative maintenance and equipment repairs or replacement in the TELS system.

This citation pertains to intakes MI00145596 and MI00145720. Based on interview and record review the facility failed to ensure scheduled and as needed pain medications were administered per the physician's orders for one (R103) of three residents reviewed for pain management resulting in uncontrolled pain, frustration, anger, and feelings of helplessness. Findings include: On 11/6/24 at 11:57 a.m. the complainant (R103) was contacted and spoken to about the allegations submitted to the state agency complaint hotline on 7/11/24. The complainant said the complaint was made because of multiple daily calls from R103 not getting pain medication ((R103) would literally be in tears begging me to come get him because he was in so much pain. (R103) called me the first night he was there crying because he couldn't get his pain pill. Nobody would answer the call bell.) The complainant also said R103 left the facility due to not receiving decent medical care. Nurse progress note dated 8/20/24 documented R103 left the facility against medical advice. Review of the clinical record documented R103 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included malignant neoplasm of mouth, dysarthria and anarthria, dysphonia, macular degeneration, generalized anxiety disorder, depression, chronic kidney disease, stage 3, and glaucoma. According to the admission Minimum Data Set (MDS) assessment dated [DATE] R103 was cognitively intact (BIMS=15) and required limited one person assistance with activities of daily living. The MDS also documented R103 received scheduled and PRN (as needed) pain regimen and experienced pain or hurting. Review of the hospital discharge report dated 7/3/24 documented additional diagnoses that included mandible (jaw bone) pain, chronic pain due to neoplasm, cancer related pain, and post-operative pain. The discharge report also included a prescription for Oxycodone 5 mg immediate release tablet with instructions to take 1-2 tablets (5-10 mg total) by mouth every 4 hours as needed for up to 3 days, for oral cancer. R103 was administered Oxycodone 10 mg at 3:43 p.m. on 7/3/24 (prior to transfer to facility). Review of the July Medication Administration Record (MAR) documented on July 3rd, evening medications were administered except for the Oxycodone. Record review revealed the facility administered R103 pain medication on 7/4/24 at 9:30 am. R103 did not receive Oxycodone for 17 hours (last dose on 7/3/24 at 3:43 pm). Review of the physician's orders documented the following pain medication regimen to be administered: Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 10 mg by mouth every 4 hours for pain hold if RR <14. Start date: 7/10/24. Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 10 mg by mouth every 4 hours as needed for as needed for pain Hold if respiratory rate less than 14. Start date: 7/4/24. Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 5 mg by mouth every 4 hours as needed for as needed for pain. Start date: 7/3/24. PLEASE ALL MEDICATIONS MUST BE ADMINISTERED ON TIME every 4 hours for PAIN CONTROL. Start date: 7/10/24. The following Nurse progress notes documented the following: -On 07/03/24 at 18:49 (6:49 pm) Note Text: Patient admitted from hospital at 5pm. He's being admitted due to oral cancer ( Para neo-Plastic Syndrome) . -On 07/04/2024 12:49 Note Text: Resident with C/O pain at beginning of shift. Resident medications had not been delivered pharmacy contacted once open at 9am for off (sic) to pull, C2 script was not sent to pharmacy. MD contacted and script was sent, off (sic) to pull for 5mg 1-tab Q4hrs PRN. Resident was given 1 tab at 9:30am. -On 07/09/2024 01:34 (1:34 am) Type: Behavior Note: . was waiting for a pain pill that he arrived too early for . Resident when told he had to wait 20 minutes for his pain medication, began to berate the Nurse, while threatening to report and have the Nurse fired from duty, I'll call the State on you . Nurse provided pain medication at time it was available . -On 8/11/24 00:00 (12:00 am) oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 10 mg by mouth every 4 hours for pain hold if RR <14 was on hold for behaviors. Behaviors were not documented to justify withholding pain medication. -On 08/19/2024 20:06 (8:06 pm) Note Text : Resident observed having emesis throughout the shift c/o of severe pain and cramping. Resident refused to go to radiation. Resident spoke with doctor at treatment center and stated he was having a mental break down. Dr contacted our facility to inform us of the situation. Staff nurse spoke with resident assuring him his medication will come today. Pharmacy contacted and stated medication in route. -On 8/20/2024 03:06 (3:06 am) Type: Nurses Note Text : Resident received in fair condition with current concerns of not having his scheduled Oxycodone for multiple days, resident states his mental health has been affected with the pain and overall condition related to his cancer and treatment involved . Resident states he doesn't feel well, has not slept in a few days . @ 1900 Nurse endorsed ongoing concern of missing oxycodone, script sent on previous shift, Nurse and supervisor attempted to pull medication from back up supply EXCEPT pyxis was empty - No oxycodone 5mg or 10mg was available . Resident continues to feel uneasy, afraid to go to sleep . Review of the following physician's notes documented complaints from R103 about pain: -On 8/19/2024 19:14 (7:14 pm) Physical Medicine Rehabilitation Note Text: Revision of meds. Pain is controlled most of the time. -On 8/12/2024 17:40 (5:40 pm) Physical Medicine Rehabilitation Note Text: Patient was seen today at bedside due to inability to perform ADLs Independently related to Cancer-related pain. -On 08/02/2024 11:33 (11:33 am) Physician Progress Notes Text : Medicine Progress: Previously patient had reported that his pain is well-controlled with the pain medication. However, he has been complaining of pain not being controlled to the staff (sic). - 08/01/2024 11:26 (11:26 am) Physician Progress Notes Text: Medicine Progress Note: Uncontrolled pain . Patient states pain is not well controlled. Review of the Pain care plan dated 7/5/24 documented: I have the potential for pain/discomfort r/t removal of oral cavity squamous cell carcinoma stage IV, wound to right leg. Interventions: -Administer my analgesic per orders. Give approx. 1/2 hour - 45 min before treatments or care when needed. -Anticipate my need for pain relief and respond as soon as possible to all and any complaint/signs of pain. - Attempt nonpharmacological interventions prior to giving me medication for pain. On 11/8/24 at 2:03 p.m. the Director of Nursing (DON) was interviewed regarding R103 not receiving pain medication as ordered. The DON did not recall the circumstance surrounding the resident not receiving pain medication due to behaviors. The DON said having behaviors does not justify pain medications to be withheld. Other non-pharmacological interventions could have been implemented or attempted. All medications should be administered per the physician's orders. On 11/8/24 at 3:07 LPN C was the midnight shift nurse for R103. An attempt to contact LPN C was made, however there has been no call back. On 11/8/24 at 1:01 p.m. R103 was contacted, however did not return the call until 11/13/24 at 2:24 p.m. R103 was interviewed and stated, My time at (facility) name) was horrible and I wouldn't wish what happened to me on my worst enemy. Most of my problems happened on the late shift and weekends. The one nurse (didn't remember nurse, confirmed to be LPN C) played God with my pain medications all the time. My pain medications were often not available, or the nurses just didn't want to give it to me. My pain level was always at an 8-9. I am always in constant pain, and I am trying to deal with it the best I can. It's depressing to be in pain all the time. It's more depressing when the people that are supposed to help you make you feel more helpless. Being in pain all the time will make any angry especially when denied the one thing to help make the pain better. I felt ignored when I would ask for my medication and had to wait to get it. I was forced to leave because they wouldn't help me. I had to leave for my own safety. R103 was very emotional and cried during the interview. Review of the facility's policy titled Medication Administration and General Guidelines (no date) documented the following: Medications are administered as prescribed. In accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so . Medications are administered in accordance with written orders of the attending physician . Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time then the med must be given 30 minutes prior to 30 minutes after the specified time (unless facility policy directs otherwise) . If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time . An explanatory note is entered on the reverse side of the record provided for PRN documentation. The physician must be notified when a dose of medication has not been given . Review of the facility's policy titled Pain Management (no date) documented the following: The facility will assess and identify residents experiencing pain, determine the type and severity of the pain and develop a care plan for pain management. The care plan is implemented and continually evaluated for its effectiveness. The staff monitors and documents the resident's response to pain management interventions . The pain experience is very subjective; pain is whatever the resident says it is .

This citation pertains to intake MI00135781 and MI00135936. Based on observation, interview and record review, the facility failed to implement interventions to prevent the development and worsening of a pressure ulcer for one (R707) of three residents reviewed, resulting in a facility acquired Stage 3 pressure ulcer (Full thickness tissue loss potentially extending into the subcutaneous tissue layer). Findings include: In an observation and interview on 5/24/23 at 8:57 a.m., Wound Nurse (WN) A reported R707 had a Stage 3 facility acquired pressure ulcer on the buttocks. WN A removed a heavily soiled dressing with no date from R707's buttocks. A foul smell was noted when the dressing was removed. R707 had an area the size of a grapefruit with a black center and red edges on the buttocks. WN A then provided wound care to R707's buttocks. Review of an admission record revealed, Resident #707 (R707) admitted to the facility 4/12/23 with pertinent diagnosis which included Vascular Dementia and Peripheral Vascular Disease. Review of a Minimum Data Set (MDS) assessment, with a reference date of 4/16/23 revealed R707 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15 and required extensive assistance of two staff with bed mobility. R707 was at risk for pressure ulcers. Review of a Braden scale (tool used to determine pressure ulcer risk) with a date of 4/12/23 revealed R707 was at risk for pressure ulcers with a score of 15 out of 23. Review of a progress notes revealed the following: 4/12/23 at 2:00 p.m., . Resident transferred to facility for long term care. Skin warm and dry, cicatrix (scar of a healed wound) observed to B/L (bilateral) buttocks and lower extremities . 4/27/23 at 11:54 a.m., New skin issue observed by CNA (Certified Nursing Assistant), wound care notified. 5/8/23 at 4:14 p.m, Res (resident) added to wound care case load for care of sacral/bil butt stage 3 p/u (pressure ulcer) that presents with multiple pink bases with scattered yellow necrosis. there is moderate serous drainage . Review of skin assessments revealed, R707 had cicatrix (scar indicative of a healed area) to bil buttocks on 4/12/23. On 4/27/23 R707 had no skin concerns. On 5/4/23, R707 skin was clean and intact. Review of Physician orders revealed R707 had the following orders: Cleanse sacrum/bil (bilateral) butt with wound cleanser, pat dry, apply skin prep, apply santyl ointment, cover with dry dressing. every day shift for wound healing AND every 24 hours as needed for wound healing with an order date of 5/23/23. Silver Sulfadiazine Cream 1 % Apply to coccyx/bil butt topically every day shift for wound healing AND Apply to coccyx/bil butt topically every 24 hours as needed for wound healing with a start date of 4/27/23 and discontinued on 5/15/23. R707 did not have treatment orders in place between 5/15/23 and 5/23/23. Review of the Treatment Administration Record (TAR) for April and May 2023 revealed, R707 did not receive a treatment for sacrum/bilateral buttocks from 5/15-5/23. Review of weekly wound consultation progress notes revealed: On 5/8/23 R707 had a Stage 3 pressure ulcer on the sacral/bilateral buttocks which measured 6cm x 8.5cm x 0.2cm. On 5/15/23 R707 had a Stage 3 pressure ulcer on the sacral/bilateral buttocks which measured 5.8cm x 8.5cm x 0.2cm with Wound bed has a Necrotic Base granulation. Santyl daily and as needed was ordered to treat the pressure ulcer. On 5/22/23, R707 had a Stage 3 pressure ulcer on the sacral/bilateral buttocks which measured 5cm x 9cm x 0.2cm with Wound bed has a Necrotic Base granulation. Santyl daily and as needed was ordered to treat the pressure ulcer. In an interview on 5/24/23 at 2:15 p.m., WN A reported R707's wound was discovered on 4/27/23. WN A reported R707 was assessed by the Nurse Practitioner (NP) on 5/15/23 and stated, It is possible the order was discontinued and not reordered. WN A then confirmed there was no order to treat R707's pressure ulcer from 5/15/23-5/23/23. WN A reported R707's current treatment order started on 5/23/23. WN A reported R707 did not like to be repositioned because it is uncomfortable and preferred to lay on the back. In an interview on 5/24/23 at 2:39 p.m., the Director of Nursing (DON) reported the wound nurse should put in the new orders after rounding with the wound NP. The DON reported there must be an order to treat wounds and the NP recommendations should be followed for wound care. In an interview on 5/24/23 at 3:04 p.m., the DON reported she could not find a wound order for R707 during the period of 5/15-5/23/23. The DON reported there is no excuse for the treatment not to be ordered. The DON queried if the wound nurse were completing the treatment without entering the order, would she have noticed the order was missing when she documented, the DON reported she asked the same question and did not get a response. In an interview on 5/25/23 at 9:17 a.m., the DON reported skin assessments should reflect the residents skin condition, when asked why skin assessments revealed R707's skin was intact. The DON then reported R707 was not admitted with a Stage 3 pressure ulcer and was unsure of how the facility acquired pressure ulcer developed. Review of the facility policy titled Pressure Ulcer & Skin Care Management (undated) documented, A resident who enters the facility without pressure ulcers does not develop ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing . 3. The presence of any pressure ulcer, wound, or other skin conditions is documented I the designated area . 8. The nursing staff reviews the pressure ulcer prevention and treatment procedures with the resident's physician. They select the treatment procedures appropriate for the resident and type of pressure ulcer or wound. The licensed nurse implements the wound care treatment procedures in accordance with current standards of practice. 9. A licensed nurse assesses and documents that status of existing wounds weekly .

This citation pertains to Intake MI 717 Based on observation, interview, and record review the facility failed to 1. Administer wound treatments consistently. 2. Assess, document, and revise wound care plan interventions. 3. Prevent new potential pressure ulcers 4. Notify Attending Physician and family of change in condition, Affecting One Resident (R#701) out of three residents investigated for wound care treatment, resulting in the prevention of worsening wounds and failure to notify Physician and family of changes in R#701's condition. Findings include: On 8/19/20, review of document provided by facility Facility Past Non-Compliance dated 1/9/20 documented the following: In depth analysis of how the deficiency occurred: Lack of documentation of assessments/progress notes pertaining to weekly wound healing with holes in the TAR (Treatment Administration Record), resulting in current treatment in progress for a resident being ineffective and wound worsening. On 8/19/20, record review of R#701 revealed admission into facility on 3/22/19 and readmission on 10/21/19 with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], R#701 has severe impaired cognition and was extensive assist with all Activities of Daily Living (ADLS). On 8/19/20, record review revealed last documentation of R#701's wounds in facility. Review of Visit Report for R#701 on 12/17/19 documentation was provided wound care consultant and documents the following: Wound #1 Left Great Toe Tip is a Vasculitic Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 0.4 cm length x 0.4 cm width, with an area of 0.16 sq. cm. There was no drainage noted. Wound bed has Dry Base [MEDICATION NAME]. This was last documentation of wounds in facility until admission to hospital. Wound #2 Left, Plantar Foot is a Vasculitic Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2 cm length x 3 cm width x 0.3 cm depth, with an area of 6 sq. cm and a volume of 1.8 cubic cm. There is a small amount of serous drainage noted which has no odor. Wound bed has Necrotic Base [MEDICATION NAME]. The peri wound skin texture is normal. The peri wound skin moisture is normal. The peri wound skin color Is normal. Peri wound skin does not exhibit signs or symptoms of infection. General Notes: Minimal pink tissue exposed, Irregular edges Wound #3 Left, Distal Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 0.3 cm length x 0.3 cm width x 1 cm depth, with an area of 0.09 sq. cm and a volume of 0.09 cubic cm. There is a small amount of serous drainage noted. Wound bed has Yellow Base [MEDICATION NAME]. The peri wound skin texture is normal. The peri wound skin moisture Is normal. The peri wound skin color is normal. General Notes: Irregular edges Wound #4 Left, Anterior Ankle is a Vasculitic Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 0.5 cm length x 0.5 cm width, with an area of 0.25 sq. cm. There was no drainage noted. Wound bed has Dry Base [MEDICATION NAME]. The peri wound skin texture is normal. The peri wound skin moisture is normal. The peri wound skin color Is normal. General Notes: Irregular edges On 8/19/20, review of Final Report admission wound care notes at hospital documented on 1/2/20 the following: 1. Left plantar great toe/foot with a full thickness venous wound that measures 2cmx3cmx0 3 cm, 50% of the wound base with a dry intact dark black/brown necrotic tissue and 50% with red wound base a scant amount cf a serosang drainage noted Peri wound skin intact with no [DIAGNOSES REDACTED] noted Recommend to cover with an allevyn foam to protect 2. Left great toe with a dry necrotic wound that measures 0.7cmx0.7cm, intact with black tissue, no drainage no [DIAGNOSES REDACTED]. Keep open to air and monitor. 3. Left lateral heel with a deep tissue injury that measures 3cmx3cm, skin intact with a dark purple non-blanchable coloration, no drainage. Monitor and reduce pressure. 4. Left lateral mid foot with a deep tissue injury that measures 2cmx1cm, skin intact with a dark purple coloration, no drainage, [DIAGNOSES REDACTED]. Monitor and reduce pressure 5. Left lateral distal foot with a deep tissue injury that measures 1 cm x 0.5 cm, skin intact with a dark purple coloration, no drainage, monitor and reduce pressure. 6. left ischium with a full thickness opening that measures 0.5 cm x 0.5 cm x 1.5 cm, with undermining circumferentially that measures 3 cm. Wound draining a brown stringy drainage, mild odor. Peri wound skin intact with a light purple/red coloration. Recommend surgery to evaluate. Loosely pack with [MEDICATION NAME] Ag rope and allevyn foam 7. Scrotum with moisture associated [MEDICAL CONDITION], skin with [DIAGNOSES REDACTED] and partial thickness wound that measures 1cmx1cm. Recommend applying barrier cream to protect. On 8/19/20, record review of Weekly Wound Healing Records (an assessment done weekly to document residents wounds measurements and notify Physician and family of any changes) revealed the last completed assessment was performed on 10/8/19. Review of Skin/wound note provided no documentation of Physician or family notification of change in wounds or documentation of assessment of wounds. Review of wound care plan revealed no revision to update interventions of wounds in December 2019. Review of Treatment Administration Record (TAR) revealed multiple treatments not provided in the month of December 2019. On 8/19/20 at 12:30 pm, during interview with Director of Nursing (DON), when asked if Wound Care Nurse (WCN) G failed to Assess wounds weekly, document, revise wound care plans and provide consistent wound care for R#701, DON stated, Yes. When asked if it was the responsibility of WCN G to notify the Physician and the family when there is a change in the condition of a residents wounds, DON stated, Yes, WCN G did not share this information at meetings either. When asked if this resulted in the worsening of R#701's wounds, DON stated, Yes. On 8/19/20, record review of Facility Acquired Pressure Ulcers documented the following: PROCESS 1. All residents will be screened on admission, quarterly, annually, and with a significant change of status, for their risk for development of pressure ulcers. 41 1. Residents identified as at risk for development of pressure ulcers will have a care plan developed and interventions included in the care plan to reduce the risk. 2. All residents will be assessed from head to toe weekly by a licensed nurse to identify any new pressure ulcers or other types of skin alterations. Results of weekly assessment will be documented by the licensed nurse on the weekly head to toe skin check form. 3. When a pressure ulcer is identified, the licensed nurse will document in the progress notes and on the Weekly Wound/Skin Healing Record, to include size, stage, location, drainage, and odor; obtain treatment order, initiate a care plan, and notify the interdisciplinary team, including the dietitian. 4. The licensed nurse will communicate all identified pressure ulcers to the attending physician and resident's family or responsible party. The licensed nurse will document notifications in the resident's medical record and the 24-hour report. 5. A Risk Management Meeting will be conducted weekly by the Interdisciplinary Team. Residents reviewed for skin alterations are as follows: · Newly developed vascular/pressure ulcers · Any pressure or non-pressure area that has shown no signs of healing during a two-week timeframe · New admissions & readmissions with skin conditions (pressure, non-pressure, surgical sites, rashes, etc.) 6. The physician will review all cases of pressure ulcer development, modify treatment, as indicated, and document accordingly.

This citation pertains to MI 459. Based on interview and record review, the facility failed to ensure a resident was free from physical restraint for one (#601) resident reviewed for abuse, resulting in a complete anterior dislocation of the shoulder and the potential for further mistreatment and injuries to occur. Findings include: The facility reported an injury of unknown origin. The facility further reported that on [DATE] at approximately 10:30 PM, CNA A, CNA B, and CNA C provided care in R601's room. While providing care, R601 became combative. CNA C held her legs. CNA A held her arms. CNA B cleaned her. The Director of Nursing (DON) heard the resident screaming and went into the room attempting to assist in calming the resident down related to the catastrophic reaction she was having. CNA A again entered R601's room at 2:15 AM and noticed that R601's shoulder appeared to look different than the other and immediately reported this to the nurse. According to the clinical record, Resident #601 (R601) had an original admission date of [DATE] and readmission date of [DATE]. Her [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] documented severe cognitive impairment, physical behaviors occurred ,[DATE] days, verbal behaviors occurred ,[DATE] days, and rejection of care occurred ,[DATE] days. R601 died at the facility on [DATE]. Further review of R601's clinical record documented in part the following progress notes: --[DATE] at 2:31 AM: CNA (Certified Nurse Aide) states resident complains of right shoulder pain. Writer assessed resident. Resident has limited ROM (range of motion) in right shoulder. Resident grimaces when arm is lifted. No trauma associated nor post fall. Dr. notified. Will continue to monitor --[DATE] at 4:21 AM: X-ray of right shoulder requested. --[DATE] at 8:37 AM: X-ray to right shoulder results: Complete anterior dislocation of the glenohumeral (shoulder) joint. Bony irregularity along the inferior rim of the glenoid (part of the shoulder). Acromioclavicular (top of the shoulder) joint is intact. Soft tissue swelling noted. Physician was called; received new order to send the resident to hospital. --[DATE] at 5:23 PM: Resident back from the hospital, right arm put on sling. A review of R601's care plans documented the following: Focus: I have a behavior problem, at times I may wander into peers' rooms and get into their beds or go into their night stands and bother their personal belongings. I am combative with staff when they try to help me with my daily care. Initiated: [DATE] Interventions included: Approach me and speak in a calm manner. Divert my attention and remove me from a situation as needed. Initiated: [DATE] Explain procedures to me before starting and allow me to adjust to changes. Initiated: [DATE] If reasonable, discuss my behavior with me and why it is inappropriate and/or unacceptable. Initiated: [DATE] On [DATE] beginning at 12:35 PM, when the DON was queried about what happened to R601 on the evening of [DATE], she said, The Resident was restrained. The CNAs should not have done that. They have been taught to walk away. Get someone else to come in. That's why CNA A was suspended and received a disciplinary. The DON added, If they (the residents) are combative you have to let them go. On [DATE] at 1:20 PM, when a telephone interview was conducted with CNA B regarding the [DATE] incident, she said, I am very familiar with (R601). I assisted two other CNAs to put (R601) to bed. After we put her in the bed and undressed her, I went to gather soap and towels. I performed the care. CNA B stated R601's backside was facing her. The other two CNA's were on the opposite side of the bed keeping her to one side. It takes three people to assist (in R601's care). CNA B said, (R601) would yank away. She can snatch away hard. We were trying to hold on to her, so she doesn't hurt herself. She was throwing punches. We try our best to clean her. We should have probably walked away because of what they told us happened after the fact. When CNA B was queried if she was familiar with a catastrophic reaction, she said, Somewhat. It's something big. I heard of that in school. It's been a while. On [DATE] at 1:56 PM, when a telephone interview was conducted with CNA A regarding the [DATE] incident, she said, We were getting her out of the wheelchair and into the bed. I was holding the wheelchair from behind. The wheelchair was lifting up because (R601) was grabbing the (wheelchair) armrest. She will wrestle with you. Once R601 was in the bed, CNA A added, She was fighting so bad. I was holding her wrist. The other CNA was holding her legs. The other CNA was getting towels and soap to wash her up. When queried what happened while you were holding R601's wrist and the other CNA was holding her legs, CNA A said, She was wrestling and wiggling. She was screaming really loud. When queried if R601 is very strong, CNA A said, Very, very, very. CNA A added, That last time she snatched away from me, I just let her (go) to give her some time. The DON walked in and said, You can't be holding her like that; you don't have to do it like that. When CNA A was queried if she was familiar with a catastrophic reaction, she said, I would have to look through my book. On [DATE] at 2:10 PM, when Staff Development Coordinator, Nurse D was queried about a catastrophic reaction, she said, It's an abnormal reaction to a normal stimuli. When queried if CNAs should know what a catastrophic reaction is, Nurse D said, They should because residents can have a catastrophic reaction and they need to know what it is and how to deal with it. When queried if when R601 becomes combative during care, is that a catastrophic reaction, Nurse D said, Not necessarily; for her, it's a behavior. We care plan it because she can be combative with care. R601's care plan related to combativeness during care was reviewed with Nurse D. The related intervention stated to Explain procedures to me before starting and allow me to adjust to changes. Nurse D was queried, When is holding someone down with your hands a form of restraint? Nurse D said, When they can't move, and they want to. That is restraining them. On [DATE] at 3:20 PM, when the facility Administrator was queried, What is a physical restraint?, he said, Something that restricts someone's movement. The Administrator added, I believe they (the three CNAs) were trying to take care of her. That's (R601's) normal behavior. When queried if they followed the care plan, the Administrator said, Yes. When queried about the purpose of allowing someone time to adjust, the Administrator said, So they don't have anxiety about what's going to happen. So as not to startle them. When queried if the three CNAs gave R601 time to adjust once she became combative, the Administrator said, No. There should have been non-chemical interventions for her behavior. The facility document titled, Abuse and Neglect Prohibition Policy, dated [DATE], was reviewed and documented the following: --Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, misappropriation of property and mental abuse facilitated or enabled through the use of technology. Each resident will be free from chemical or physical restraints imposed for purposes of discipline or convenience that are not required to treat resident symptoms. --Mistreatment is defined as inappropriate treatment or exploitation of a resident. The facility document titled, Physical Restraint Management, undated, was reviewed and document the following: --Physical restraints are not for purpose of discipline or convenience, but only as required to treat the resident's medical symptom. --A care plan will be developed and implemented addressing the restraint, medical symptom, least restrictive alternatives attempted, as well as intervention to promote restraint reduction or elimination. --Emergency Use: Restraints may be used with a physician order [REDACTED]. nursing notes. An intervention will need to be implemented to monitor/check at/on frequent intervals.

This citation pertains to Intake #M 5519 Based on observation interview and record review the facility failed to ensure a sit-stand mechanical Lift (a device most commonly used to move those who are unable to stand on their own; making it unsafe to move or lift manually) was used for transfer for one (R#2) of one resident reviewed for falls, resulting in the resident sustaining an acute [MEDICATION NAME] proximal tibia and fibula (leg). Findings include: On 8/20/19 at 10:10, review of the Facility's Unusual Occurrence Investigation stated: On 8/9/19 at 10:54 A.M., Resident #2 sustained a fall. The resident voiced pain to the right knee an x-ray was completed, and results of the x-ray were received 8/10/19. The x-ray indicated R#2 had an Acute [MEDICATION NAME] proximal tibia and Fibula (leg). The resident was sent to the hospital for evaluation and treatment of [REDACTED]. Based on the summary/conclusion of the Investigation, R#2 reported Certified Nurse Aide (CNA) C was assisting her with transferring from her bed to her wheelchair, the resident's legs were underneath her during the transfer when the resident heard a pop and was lowered to the floor. The resident stated: that the lift was not offered at that time. (The resident was care planned for a sit to stand lift with 1-2-person assist). CNA C was immediately suspended, and the Facility started an investigation of the incident. On 8/20/19 at 10:35 A.M. (R#2) was observed in her room with a right leg cast. The resident was asked what happened to her leg? R#2 responded, I had a fall. A Certified Nurse Aide (CNA) was trying to transfer me from the bed to my wheelchair, my legs gave away and I have a fracture. The resident explained I fell on my right leg for approximately two minutes, I heard two pops, but I had no idea it would be a fracture. During the interview R#2 stated: The CNA did not offer me the machine (lift). I did not refuse the lift; they are trying to say I refused the lift, but I did not refuse. R#2 commented, I had another fall a couple of weeks ago, I wonder if that fall had anything to do with this one? On 8/21/19 at 4:00 P.M. Review of the clinical record revealed R#2 was admitted to the facility on [DATE], with muscle weakness, anxiety disorder, diabetes mellitus with diabetic [MEDICAL CONDITION], difficulty walking, [MEDICAL CONDITIONS], spinal stenosis, hypertension, polyarthritis, and [MEDICAL CONDITION]. R#2 had a brief interview for mental status (BIMS) score of 15/15 (brief screener that aids in detecting cognitive impairment. The score indicated a high level of cognitive (thought process) functioning. According to the Minimum Data Set ((MDS) dated [DATE], R#2 was totally dependent and required two-person physical assist with transfer from the bed, chair, or wheelchair Review of the care plan for R#2 under the transfer section initiated on 5/3/19, the interventions indicated: Transfer with (1 or2) person with Sit-Stand Lift On 8/21/19 at 5:35 P.M., during an interview with Physical Therapist D he reported R#2's upper strength did vary during the day but the transfer status recommended on 5/3/19 indicated: Transfer with 1-2 person with a sit-stand lift, for safety the therapist commented I always use two person. In addition, Physical Therapist D stated a gait belt should have been used and a sit-stand lift especially if R#2 was transferring from the bed to a wheelchair. On 8/21/19 at 5:00 P.M. during interview with the Administrator concerning the documentation of refusal for R#2, she acknowledged there was no documentation of refusal in the Nurses Notes or The CNA's Kardex. On 8/22/19 at 11:00 A.M. review of CNA C statement was presented and reviewed with the Director of Nursing. According to the statement CNAC was transferring R#2 from the bed to the wheelchair with a one person assist that resulted in a fall with the fracture. The CNA should have used the sit -stand as documented in the CNA's Kardex. The Certified Nurse Aide did not use a gait belt and there was no documentation of R#2 refusing the Lift. The Director of Nursing reported gait belts were provided to the CNA's during orientation and they are taught to utilize the gait belts and bring them to their assigned unit daily. On 8/22/19 at 12:05 P.M. CNAC is no longer employed at the facility however agreed to a phone interview concerning R#2. CNAC acknowledged the Kardex documented the resident was to be transferred with 1-2 person with sit-stand but no sit-stand lift was used when transferring R#2 from the bed to the wheelchair. The CNA stated, she assisted the resident but did not use a gait belt or any other device. When asked, about the documentation of R#2 refusal to transfer with the sit-stand lift the CNA indicated she never reported the resident's refusal and never entered the refusals in the Kardex. On 8/22/19 at 1:30 P.M., review of the facility's undated Lifting Policy documented under #1 and #2 To safely move residents the employee must: 1. Know how many people are needed- The care plan will identify the number of people needed to safely reposition, transfer, or lift a resident. If two people are needed, no less than two people should be involved. 2. The type of equipment needed- Gait Belt are mandatory for all transfers and assistance with ambulation. Additional equipment needed for safe lifting or transferring will be identified on the care plan and must be used to assist the resident. All Hoyer-type lifting devices require at least two people to assist in the lifting. A sit to stand will only require one assistant unless otherwise determined by the therapist and will be reflected on the resident care plan.

This citation pertains to intake MI 170. Based on interview and record review the facility failed to provide timely care and services (Hypodermoclysis-hypoderm-subcutaneous infusion of fluid replacement) based on a physician's orders [REDACTED].#504) resulting in hospitalization and subsequent death. Record review revealed that R#504 was admitted into the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident's cognition was severely impaired and required extensive assistance for all activities of daily living. Review of the clinical record documented the following: -6/14/19 Nurse Practitioner Note: Patient seen for acute visit for diarrhea and nausea. Patient reported that episodes had been since yesterday, however, stated that she felt better today and episodes have decreased . -6/18/19 Nurse Practitioner Note @ 11:28 AM: Patient continues to have bouts of diarrhea. Patient does report that it is affecting her appetite. Stated that she had not eaten much since having diarrhea. Stated that she does have nausea. Does not have severe abdominal pain but does complain of discomfort .Decreased appetite most likely related to diarrhea, ordered hypoderm at this visit, encourage small portions of bland food, encourage fluids, ordered (name of laboratory tests). -6/18/19 physician's orders [REDACTED].@ 70 cubic centimeters (cc's)/hour (hr), 1 liter via hypoderm. Diagnoses: [REDACTED]. -Cognitive functioning impaired care plan dated 5/16/19 had an intervention of Administer my medications as ordered. Observe for side offects and effectivness. -6/19/19 Nursing Note @ 3:13 AM (12 hours after hypoderm was ordered): New order for hypodermacolysis 0.9% normal saline @ 70 cc/hr. Writer unable to administer fluids on order. Medication was unavailable in the (name of back up medication system), awaiting pharmacy delivery . -6/19/19 Nursing Note @ 23:37 PM (32 hours after hypoderm was ordered): Order as of 6/18/19 noticed: Please give 0.9% @ 70 cc/hr, 1 liter via hypoderm. [DIAGNOSES REDACTED]. Pharmacy notified to drop ship (delivery within 2-4 hours). -6/19/19 Nursing Note @ 23:38 PM: call to pharmacy regarding delivery of 0.9 normal saline, per pharmacy, order not received, instructed to refax. Order refaxed and drop ship requested. Nurse Practitioner notified of delay of treatment via text . -6/20/19 Nursing Note @5:55 AM (2 days after hypoderm was ordered): 0.9 normal saline not available in back up box at this time. awaiting drop ship of 0.9 normal saline from pharmacy to begin Hypodermoclysis. Endorsed to day shift to follow up on delivery . -Review of the (MONTH) 2019 Medication Administration Records (MAR's) revealed that R#504 never received the 0.9% normal saline 70 cc/hr x 1 liter as ordered. -6/20/19 Social Service Note @ 14:22 PM: This morning, Registered Dietician informed worker that resident 'does not look good', 'eyes sunken in and she is sweaty'. Worker asked her to inform charge nurse and worker went to get Unit Manger .Resident was sent out to the hospital per nursing staff. -6/20/19 Nursing Home to Hospital Transfer Form: Blood Pressure (B/P): 65/42 (Resident's normal range 165/76). -6/20/19 (name of hospital) emergency room report: Date time of evaluation; 6/20/19 11:42 AM. .brought in from nursing home for lethargy and [MEDICAL CONDITION] (low blood pressure). On arrival patient is hypotensive (B/P 78/49) . Temperature 100 degrees rectally. Diarrhea on rectal exam .decision was made to make patient Do Not Resuscitate (DNR) .blood pressure and pulse rate dropped time of death 13:07 (1 hour and 15 minutes after arrival to the ER). At 1:59 PM, During an interview with the facility's Director of Nursing (DON) she was asked about the events for R#504. The DON states that she was doing an investigation on the occurrence and will be inservicing the nurses. Review of the facility's undated policy titled, Acute Change in Condition documented, Changes (symptoms) are communicated to the physician via: Phone call (urgent), Physician's log (non-urgent) and physician's rounds . Review of the facility's Medication Shortages/Unavailable Medications policy dated 12/1/07 revised 1/1/13 documented, 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or direction .

Based on interview and record review, the facility failed to prevent a fall with major injury for one (R#304) of three Residents reviewed for falls and safety, by pushing two Residents while in wheel chairs at the same time, resulting in a preventable fall, subsequently causing a facial fracture. This deficient practice also required the Resident to be hospitalized for [REDACTED]. Finding include: On 4/2/19 at 2:00 p.m., review of the clinical record revealed R#304 was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#304 was severely cognitively impaired, required extensive assistance with one person for transfers, and all activity daily living (ADLs). On 4/2/19 at 2:00 p.m., review of the resident's Transfer care plan dated 12/11/18 documented, I have limited mobility related to muscle weakness; locomotion: I am totally dependent on you for locomotion via my wheel chair. Review of the resident's Fall care plan dated 12/11/19 documented, I am at risk for falls related to a history of falls at home and the hospital. On 4/2/19 at 2:31 p.m., review of the facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 3/1/19 approximately 4:20 p.m. documented, The Resident was being pushed by the certified nurse assistant (CENA) in a wheel chair when the resident placed both feet on the ground. This caused the resident to fall. The resident was sent to the hospital for treatment and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The CENA was also given a one-to-one in-service on using the proper technique with transporting residents via wheel chair. On 4/2/19 at 3:05 p.m., the witness statement from CENA B was reviewed. CENA B stated, I was pushing the resident down the hall, then the wheel chair hit the wall. I was transporting residents back to the units from daily activities. I was pushing two residents at the same time. The residents were helping by using their feet, and the wheels on the chair went sideways. Then the wheel chair hit the wall and the resident fell forward toward the floor causing injuries. I helped the resident up, then I took the resident to the nurse to assess. Her nose was bleeding, and I placed a towel on her nose. On 4/2/19 at 3:34 p.m., CENA B was contacted for an interview via telephone. CENA B was asked to recall the incident that occurred on 3/1/19 with R#304. CENA B stated, I was asked by a nurse to assist with some residents from the blue unit to the brown unit. I was pushing two residents at the same time when the wheel chair was going into the wall. I tried to catch the resident before she fell but it happened so fast. I helped the resident back into the wheel chair, as I was hollering for the nurse, I saw that the resident's nose was bleeding. I went and got a towel to put on the resident's nose, then the nurse came to examine the resident. CENA B was then asked, have you been in-serviced on the proper way to transport residents while in wheel chairs? CENA B stated, Yes, when I was hired and since this happened. CENA B was also asked, have you pushed two residents at the same before? CENA B stated, Yes, I have pushed two residents before, and nothing happened. On 3/2/19 at 5:35 p.m., the Director of Nursing (DON) was interviewed and asked, is it safe for the CENAs to push two residents at the same time? The DON stated, No and that is why she was in-serviced on pushing residents in their wheel chairs. On 4/2/19 at 4:55 p.m., the DON presented a policy titled Transfer Between Surfaces (no date). However, it did not document the procedures for transporting residents in a wheel chair. The DON also presented a document titled CENA Competency Evaluation (no date) that documented CENA B was in serviced for positioning, person centered care, transfers/lifts, and safety.

This citation pertains to intake MI 213: Based on observation, interview, and record review, the facility failed to: ensure heel protectors were applied, treatments were done according to physician orders, timely incontinence care was provided, a wound care consult was obtained, dietary was informed of skin breakdown, and/or the plan of care was updated for two (#801 & #804) of three residents reviewed for Pressure Ulcers (PU), resulting in the development of new PUs (#801) and the potential worsening of an existing PU (#804). Findings include: Resident #801 On 5/8/18 at 7:57 AM, Resident #801 was observed lying in bed on her back. Resident #801's heels rested on the the mattress. There was no device under her legs to lift her heels off the mattress. There were two yellow foam heel protectors were in the geri-chair in the corner of the room. Resident #801 was asked to see her feet and pulled the covers, that were loose at the foot of the bed, toward her head. Resident #801 had dressing on her feet that were dated 5/5/18. There were brown stains on the white sheet at the foot of the bed. Resident #801 raised her foot and brown stains could be seen on the dressings under her heels. At 9:00 AM, the Administrator was asked if the facility had a Wound Care Nurse (WCN). The Administrator revealed the WCN had been out on a medical leave of absence, but the nurses were doing the treatments. On 5/8/18 at 9:06 AM, observation of Resident #801's wounds was made with the Director of Nursing (DON) and Nurse G. Resident #801's left heel had an unstageable PU (Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) that measured 3.5 centimeters (cm) long X 4.0 cm wide. The wound bed had yellow slough (Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) with macerated edges from 9 O'clock to 4 [NAME]lock. The right heel had an unstageable PU that measured 2.5 cm long X 3.0 wide. The wound bed had slough. The wound edges had scar tissue. When Resident #801's foot was set down on the mattress, the PUs rested on the mattress. The DON was asked about the stains on the sheets, the heel protectors being in the geri-chair in the corner of the room and the dressings being dated 5/5/18. the DON revealed the heel protectors were supposed to be on her feet and the Nurses were supposed to the treatments because the WCN has been off for one and a half weeks. On 5/8/18 at 9:45 AM, a review of the doctor's orders, dated 3/26/18, documented Apply lift boots daily/ free float heels off bed for pressure reduction; Apply dry dressing to bilateral feet once a day every 2 days for fragile skin. At 9:52 AM, WCN H was asked about Resident #801's wound care. WCN H revealed Resident #801 was supposed to be seen by the Wound care physician and his team. However, when WCN H looked in the computer program for the note, she revealed the wound care consultant had not seen Resident #801's wounds. WCN H stated, she was on the list, but they haven't seen her. Her wounds were dry and dark. They were not open. It was Deep Tissue Injury. They were dark purple in color, but they were closed. (Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) WCN H reviewed the progress notes for a description of the (DTI) and further assessments of the area and revealed she didn't see any documentation. The weekly head-to-toe skin assessments, done by the nurses, failed to document the condition of the heels and when the wounds opened up. WCN H revealed she was not aware the wounds had opened until today. The WCN H was asked if dietary had been notified that Resident #801 that Resident #801 had DTI on the heels or that the areas had opened. WCN H reviewed the progress notes, dated 3/25/18 to 5/8/18 and revealed she didn't see documentation they had been informed. WCN H stated, They needed to know so they could add protein to her diet. On 5/8/18 at 10:28 AM, a review of the clinical record revealed that Resident #801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #801 had severely impaired cognition, required extensive physical assistance from staff to complete activities of daily living. The Braden Scale (An assessment tool used to assess the risk for the development of PU), dated 2/21/18, revealed that Resident #801 was at moderate risk to develop PUs. The Admission documentation revealed upon admission Resident #801 had no skin breakdown on her body. The nursing care plan I have actual impairment to skin integrity of the bilateral heels/feet was initiated 3/25/18 and documented the interventions: Clean dry dressing to bilateral heels/feet/lift boots daily/free float heels off bed. There was no plan of care presented that documented interventions that had been put in place to prevent skin breakdown between 1/31/18 and 3/25/18. Additionally, there was a Weekly Head-to-Toe Assessment, dated 2/18/18, that documented Suspected deep tissue wounds to bilateral heels, bilateral great toes, bilateral second toes. However, there was was no description of the areas, interventions to prevent worsening of the areas, or documentation it was reported to the WCN and a physician. A review of the Treatment Administration Record (TAR), dated (MONTH) (YEAR), revealed Resident #801's dressings had not been changed on 5/3/18 and 5/7/18 as stated in the physician orders. On 5/8/18 at 11:27 AM, Registered Dietitian (RD) N and Dietary Manager M was asked if they had been informed of Resident #801's wounds. RD N reviewed the progress notes and revealed they had not been made aware of the wounds. Resident #804 On 5/8/18 at 9:20 AM, Resident #804 was observed lying in his bed looking at television and singing. Resident #804 was asked if he had any wounds. Resident #804 stated, Yes and revealed it was on his butt. Resident #804 was asked if staff changed the dressings on his wound as they were supposed to. Resident #804 stated, They have, but they haven't this last week or so. At 9:25 PM, Unit Manager K was asked to see Resident #804's wound. Unit Manager K stated, Okay. He refuses care a lot of times. Resident #804's brief was saturated with urine, the dressing was saturated and did not adhere to the skin over the PU, there was no date on the dressing. There was a very unpleasant urine odor around Resident #804's bed. There was a brownish hue to the brief and linen. The PU on the right buttock had a pink base. Unit Manager K revealed it couldn't be stool because the resident had a [MEDICAL CONDITION]. Unit Manager K was asked about Resident #804's incontinence care and dressing change. Unit Manager K stated, I don't know. I just know he refuses care at times, but he hasn't this morning. On 5/8/18 at 9:31 AM, Certified Nurse Aide (CNA) L revealed she was assigned to Resident #804 that shift. CNA L was asked if incontinence care had been provided to Resident #804 that morning. CNA L stated, I did not provide care to him. I was pulled from another unit. I got to the unit at 7. The midnight aide told me she just got finish and took care of him. So I proceeded to get the people that up for breakfast, cleaned and dressed. I passed out hall trays and I picked up hall trays and went to the bathroom. He had brown rings. It takes some time for that to happen. On 5/8/18 at 11:45 AM, a review of the clinical record revealed that Resident #804 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated that Resident #804 had moderately impaired cognition and requires extensive assistance from staff to complete most activities of daily living. The MDS failed to indicate that Resident #804 rejected care. A review of the nursing care plans failed to reveal Resident #804 refused care, even though the progress notes documented some refusals. The I have actual impairment to skin integrity of the sacral area documented the intervention Keep my skin clean and dry . According to the wound care consultant notes, dated 4/24/18, documented that Resident #804 had a stage 3 PU on the right buttock that measured 6.5 cm long X 1.4 cm side, had a small amount of serosanguineous drainage and pink base. A review of the physician orders, dated 4/18/18, revealed that Resident #804 was to have the antibiotic [MEDICATION NAME] 500 milligrams crushed and applied to wound topically one time a day for 7 days (4/19/18 - 4/25/18) when the dressing changes were done. However, a review of the TAR revealed antibiotic/ treatment was not done on 4/21, 4/24, 4/25, 5/2, 5/3, 5/4, and 5/7. There was no documentation Resident #804 had refused the treatment. There was a physician's orders [REDACTED]. However, it was not reflected on the TAR. On 5/8/18 at 11:46 AM, the DON and WCN H was asked about the undocumented treatment areas on the TAR. The DON was asked what the nurses were supposed to do. The DON stated, Chart. There is a code for refusals and a box pops up (in the software) where they have to type in a note. They didn't do that. A review of the facility's undated Pressure Ulcer & Skin Care Management Policy, stated, A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce risk of new pressure ulcers developing.

This citation pertains to intake MI 192 Based on interview and record review, the facility failed to provide ongoing assessment, monitoring, and treatment for one (#901) of four residents reviewed for wound care, from a total sample of seven, resulting in resident pain and hospitalization for wound irrigation and debridement. Findings include: On 11/14/17 at 9:22 a.m., an interview was conducted with a concerned family member of Resident #901 (R901). The concerned family member stated the following: --On 10/31/17 R901 called the concerned family member crying because she was in pain. --On 10/31/17 upon arrival to the facility, the concerned family member observed R901's right leg to be swollen and had draining secretions. --On 11/1/17 R901 was admitted to the hospital where she presently remains. On 11/14/17 at 11:30 a.m., a review of the clinical record for R901 was begun and revealed the following. R901 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] documented intact cognition, R901 was in occasional moderate pain, and there was a surgical wound present. A review of R901's care plans, initiated 10/19/17, documented the following: Focus: I have [MEDICAL CONDITION] of the right (related to) infection (of the) leg. Intervention: I will have no complications. Interventions: Observe/document healing. On 11/14/17 at 2:35 p.m., a review of the R901's clinical record was conducted with the Director of Nursing (DON) and the following was noted: --10/18/17 admission note documented, [MEDICAL CONDITION] of right lower extremity (status [REDACTED]. --10/19/17 head to toe assessment: no new skin issues noted from head to toe. Sutures remain dry and intact. No skin issues noted at this time. --physician orders [REDACTED]. --R901 had a weekly skin assessment completed on 10/18/17. The DON said, The second weekly skin assessment was due on 10/26/17 and was not done. When queried about the importance of weekly skin assessments the DON said, They are important to see the resident's baseline and monitor whatever may be going on with the resident. --Review of nursing notes revealed no other skin assessments or monitoring of R901's surgical wound. The DON stated that when a resident is admitted (to the facility) with sutures, the admitting nurse and/or wound care nurse should secure an order for [REDACTED]. When asked if it was a concern that R901 had not been seen by the wound care nurse, the DON said, The wound care nurse is supposed to see everyone within 24 hours of admission. Then, if there is a resident with an open area (or need for wound care), the resident's orders for care are generated. On 11/14/17 at 3:25 p.m., when Wound Care Nurse, Staff B was queried about the care of R901's sutures, she stated she was unaware that R901 had sutures. When R901's physician's orders [REDACTED]. A review of hospital discharge instructions dated 10/18/17 documented a follow up appointment with the bone surgeon on 10/25/17. A facility document titled, Report of Consultation, dated 10/25/17 was reviewed with the DON and revealed: Findings - Proximal sutures were removed today in clinic. Incision is stable without any signs of infection; Diagnosis - Tibial plateau fracture, right.; Recommendations: Non-weight bearing to right leg. She may shower but do not soak. Follow up next week for wound check. A review of R901's nursing notes and treatment records with the DON revealed that no assessments, monitoring, or treatments of R901's surgical wound were documented between 10/25/17 and 11/1/17. A facility document titled, Report of Consultation, dated 11/1/17 was reviewed with the DON and revealed: Findings - Patient has wound infections; Diagnosis - Right tibia wound infections; Recommendations: Patient will require transfer to emergency room and planning for irrigation and debridement of right lower extremity tomorrow at (hospital). When the DON was queried if the infection developed at the facility, she said, Most definitely. On 11/14/17 at 2:48 p.m., when Ward Clerk, Staff A and the DON, were queried about the consultation report dated 11/1/17, Staff A stated this documentation was generated by a physician who saw R901 during an offsite medical appointment. The DON stated R901 did not return to the facility but went straight to the hospital following the 11/1/17 medical appointment. On 11/14/17 at 4:15 p.m., the facility document titled, Wound Care Protocol Check List, undated, revealed the following: Weekly head-to-toe skin checks: Completed every 7 days by the licensed nurses. Initiate the weekly Wound/Skin Healing Report for .Non-Pressure Skin Condition Report for other identified areas of impaired skin.

This citation pertains to intake number MI 279 Based on observation, interview and record review, the facility failed to prevent an episode of resident-to-resident physical abuse for two (#501 and 502) residents who had a known history of conflict with each other, of three residents reviewed for abuse, from a total of three sampled residents, resulting in Resident #502, who voiced intentions of harming Resident #501, striking Resident #501 in the head with a stick. Resident #501 sustained a hematoma and 2.0 centimeter (CM) laceration on his head. Findings include: On 8/7/14 at 10:00 a.m., a Facility reported incident on file reported a "resident to resident incident that did not result in injury." A typed statement from the facility's former Director of Nursing (DON) was provided for review by the Administrator. The statement was as follows: "Was made aware at approximately 10:30 a.m. that Resident #502 and Resident #501 had gotten into a physical altercation. Went to assess Resident #501 and observed a hematoma on the top left of his head. Resident #501 only complained of mild pain 5 out of 10 (pain scale), Resident #502 verbalized that he wished to harm Resident #501 and that he continues to want to harm him, he also stated that Resident #501 makes slanderous remarks to him, after interviews...After concluding the interviews, it was deemed that Resident #502 needed immediate psychotic assistance." Resident #501 On 8/7/14 at 10:25 a.m., Resident #501 was observed in his room laying in bed. A healed one inch scar was observed to the left top of his head. There was no redness or bruising noted. Review of the clinical record on 8/07/14 at 11:30 a.m. revealed that Resident #501 had been readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #501 had severely impaired cognitive skills for decision making and required limited to extensive physical assistance from staff with all activities of daily living (ADLS) including transfers, dressing, eating, hygiene and bathing. A review of Resident #501's "Behavior" care plan, which was updated on the day of the resident-to-resident altercation (7/9/14) was as follows: "I (Resident #501) am combative with care at times. I refuse medications at times. I use profanity at times and yell at times. I sometimes wander outside my room in my brief. I posture aggressively, i.e. raising my fist. I wander. 7/8/14 reportedly hit another resident's in arm." A "Progress Note/Incident Note" dated 7/8/14 was as follows: "Resident #501 on another unit in wheelchair. Resident hit another resident on the arm." The following day, a "Progress Note/Psychosocial Note" dated 7/9/14 documented the following: "this day resident was escorted to activity with staff member (Certified Nursing Assistant/CNA "A") on green unit. Resident from green unit, (Resident #502), with whom resident (#501) had conflict (with) yesterday, reportedly hit resident with a stick. Staff separated residents and removed stick from his possession." A "Psychosocial Note" dated 7/9/14 documented, "Behavior: 7/8/14 Resident (#501) wandered onto another unit, was in conflict verbally with another patient (#502) (and) reportedly hit this other patient in arm...per psychology recommendation, resident (#501) should be kept separated from other patient with whom he had this conflict." Resident #502 On 8/7/14 at 10:32 a.m., Resident #502 was observed in his room sitting in a wheelchair with his left arm resting on a wheelchair armrest tray to support his left arm. When greeted and asked if he recalled an altercation with another resident, Resident #502 stated, "Resident #501 is always picking with me. I told the social worker and she did nothing. Resident #501 called me a SOB (son of a [***] ). He attacked me again in the lobby. He punched me before and one of the aids (CNAS) made him leave me alone. The next day (7/9/14) the aid (CNA "A") wheeled him down the hall and he called me a SOB and balled up his fist at me. Someone had been working in here (Resident's room) and left a long stick in the room. I had to protect myself because Resident #501 was coming after me. They (facility) sent me to the Psych ward. They don't protect me here. It seems if I defend myself, it's wrong. They said I chased him (Resident #501) but I can't even walk. I never go on his unit--He comes around here. The last time he came after me, I came in my room and shut my door. They told me they weren't going to let him come back around here. I'm not a son of a [***] ! My mother is not a [***] . That's what SOB means. One time the nurse had to pull him (Resident #501) off me. I just want to live out my last days in peace" Review of the clinical record on 8/07/14 at 1:30 p.m. revealed that Resident #502 had been initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that Resident #502 was cognitively intact and required extensive physical assistance of staff with all activities of daily living including transfers, dressing, hygiene, bathing and toileting. the MDS further revealed that Resident #502 was non-ambulatory, had an unsteady gait, used a wheelchair for mobility and had left sided impairment (paralysis). There was no behavior care plan identified for this resident prior to the incident on 7/09/14. On 8/7/14 at 10:47 a.m., during an interview, LPN "B" reported, "Resident #502 is a sweet guy, no problems...no trouble. He likes to stay in his room. He eats in the dining room and goes right back in his room. He stays to himself. He has complained to me about Resident #501 before. He said that Resident #501 was going to do something to him and that's why he stays in his room. He told me that one time Resident #501 came at him with his fist balled up so he went into his room and closed the door. Resident #501 is a trouble maker. He's always trying to fight with other residents. The nurse endorsed to me that Resident #501 had used a lot of profanity during his shift once. This has been going on for some time. Resident #502 told me that he is afraid of Resident #501." On 8/7/14 at 11:37 a.m., the Social Services Director (SWD) was interviewed about the physical altercation that occurred between Resident #501 and Resident # 502 on 7/09/14. The Social Service Designee stated, "I have a poor memory so I'll have to look in the computer...Okay, I remember now. I was in my office and I heard commotion. The other social worker summoned me. (NAME) Residents #501 and #501 had already been separated. (Name) Resident #502 was agitated...Someone said he had hit (Name) Resident #501. I met with Resident #502 later--He was angry and felt like he was discriminated against. (Name) Resident #502 is alert and oriented times three (A/O x 3) and isolates himself in his room. (Name) Resident #501 does wander on the unit at times. I don't recall being told of any interactions between the two residents prior (to the physical altercation on 7/09/14)." The SWD then stated, "Wait. Let me think. The day before, (7/8/14), (Name) Resident #501 came on the green unit where (Name) Resident #502 resides. There was some kind of exchange. Resident #501 wanders. He postures aggressively toward staff. He could stand up and ball up and raise his fist. Staff has to redirect him. The day before there was an exchange. Resident #502 thought Resident #501 said something to him. We separated them and there was no incident." On 8/7/14 at 12:45 p.m., an interview was conducted with CNA "C" who reported, "I was Resident #502's assigned CNA on 7/8/14. I heard Resident #502 say that Resident #501 hit him. I heard Resident #502 yelling. Resident #501 and #502 were arguing back and forth. Me and LPN "F" separated them. This happened on the green unit (where Resident #502 resided). Resident #501 wanders onto other units. I had knowledge of the stick the day before (7/8/14). After the incident where Resident #501 his Resident #502, Resident #502 was called in to talk with the SWD. On 7/8/14 after Resident #502 was done talking with the SWD, he went in his room to get the stick. He (Resident #502) said it was to protect himself in case Resident #501 came back. I saw the SWD talking to him on 7/8/14. I went back to the SWD's office and told her that Resident #502 had a stick and I told her what he said he would use it for. SWD came out her office and went and took him into her office. I informed her before lunch that Resident #502 had the stick. I saw that he still had the stick afterwards. He had it tucked in the side of his wheelchair and it remained there up until I left. I leave at 3:00 p.m.. I also told the former DON and she just said "We'll handle it." I also informed LPN "F". He wouldn't give the stick to me so that's when I told SWD." On 8/7/14 at 1:30 p.m., during a telephone interview, LPN " F" reported, "CNA "C" told me Resident #502 had a stick. I didn't do anything because I was told SWD took care of it. I do know that on 7/8/14 Resident #501 hit Resident #502 and I had to fill out an incident report." On 8/7/14 at 2:15 p.m., the current Director of Nursing (DON) was queried. When asked why facility staff and SWD failed to remove the stick from Resident #502 on 7/8/14 once they were made aware and why Resident #501 was not monitored in order to keep him from repeatedly antagonizing Resident #502, the DON reported, "I have no response." The administrator, who was present during the interview, reported, "I knew there was an interaction on 7/8/14. I knew they (#501 and #502) made contact. I had no knowledge of the stick until after the incident on 7/9/14. I would have expected the SWD to take the stick away." On 8/7/14 at 3:25 p.m., the administrator presented an "Unusual Occurrence Report" dated 7/8/14 and reported, "This was in the former DON's office. I never saw it." The unusual Occurrence Investigation Report revealed, "Per Resident #502, Resident #501 was propelling in wheelchair, attempting to pass him and hit him on his right arm wanting him to move. Resident #501 became angry, stood from his chair and attempted to hit Resident #502." On 8/7/14 at 4:50 p.m., during a follow up interview, the SWD was queried. When asked why she failed to acknowledge the behavior between resident ' s #501 and #502 the day prior to Resident #502 hitting Resident #501, the SWD reported, " I observed he (#502) had a stick. He told me it was for his protection. I mean, I couldn't take it from him. He had it wedged on the side of his wheelchair. I asked him to give it to me and he wouldn't. He tucked it away in his chair. " When asked how she managed to remove the stick from Resident #502 after he had hit Resident #501 in the head, the SWD reported, " The other social worker helped me take it out of his hand. " When asked why she failed to obtain assistance removing the stick, that would later be used as a weapon against Resident #501, when she first learned that Resident #502 had the stick, the SWD reported, " No one anticipated the other resident (#501) would come near Resident #502 but unfortunately he did. I didn't get assistance getting the stick from Resident #502 the day before he hit Resident #501. " A review of the facility's "Abuse and Neglect Prohibition Policy and Teaching Toll" policy revised 12/11 documented: "Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property." "Residents identified by staff as being self-injurious or exhibiting abusive behavior, which requires professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate...To intervene with an individual who is physically or verbally aggressive and not able to be deescalated..."..To intervene with an individual who has verbalized or exhibited intent to do harm with a weapon."

There are two deficient practice statements Deficient Practice #1: Based on observation, interview, and record review, the facility failed to provide daily pressure sore treatments as prescribed by the physician and ensure respositioning devices were used to relieve pressure on areas where pressure sores were identified for three (#502, 517, and 523) of eight sampled residents reviewed with pressure sores, from a total of 24 sampled residents, resulting in an increased size and depth of Stage III and IV pressure sores and the potential for pressure sore infection, pain, and delayed healing. Findings include: On 06/17/2014 at approximately 9:45 a.m., the facility's treatment nurse (B) was queried about the wound treatments in the facility, and explained that she recently took over the responsibility of wound care two months ago, however, a wound consultant visits the facility and does weekly wound rounds on residents who require wound treatments, and a new treatment nurse was recently hired to assist with the wound care. Resident #502 On 06/17/2014 at 11:30 a.m., and 6/18/14 at 10:00 a.m., 1:00 p.m. and 3:00 p.m., Resident #502 was observed laying in bed in a supine position (on her back) most of the day. There was no positioning device utilized to offload pressure for #502. The resident was unable to be interviewed. Tube feeding formula was noted running at 70 cc per hour. The resident had an indwelling urinary catheter and the urine collection bag was observed hanging on the side of the bed. On 06/17/14 at 1:30 p.m., review of the clinical record for Resident #502 revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment ((MDS) dated [DATE] revealed that the resident was severely cognitively impaired for decision-making skills and required extensive to total physical assistance from nursing staff with bed mobility, transfers, and activities of daily living. The physician prescribed the following treatment order: "Cleanse Sacrococcygeal/bilateral buttocks with wound cleaner then apply calcium alginate with 4 x 4 gauze, ABD (abdominal) tape each day and as needed". The most recent Braden scale for predicting pressure sore risk for Resident # 502 was dated 04/01/14. Resident #502 score was 11 (A total score of 12 or less represented high risk for the development of pressure ulcers). The skin integrity care plan, initiated 5/29/14 revealed the following interventions: "...Administer my treatments as ordered and monitor for effectiveness...Assess/record/monitor my wound healing ..., I need (SPECIFY: monitoring/reminding/assistance) to turn/reposition at least every 2 hours, more often as needed or requested...,monitor my dressing to ensure it is intact and adhering ..." On 06/18/14 at 11:00 a.m. a wound care observation was made with treatment nurse (B). The old saturated wound dressing was removed from Resident #502's coccyx wound and there was a large amount of serosanguinous drainage (blood-tinged fluid) noted coming from the wound. The large coccyx wound was approximately 7.0 x 5.0 in size x 2.5 cm deep. The wound was treated with calcium alginate. Review of the treatment order revealed "calcium alginate daily and prn on Sacrococcygeal." According to the "Vascular and Wound Consultant" reports generated by the weekly wound rounds, the Sacrococcygeal wound on resident #502 progressively deteriorated over time. The reports described the deterioration as follows: On 01/07/2014 the Sacrococcygeal wound was 4.4 x 3.2 x 0.5 cm in size with a pink base and moderate serosanguinous drainage. The wound had irregular edges. On 02/04/14 the Sacrococcygeal wound was 4.7 x 0.5 x 0.7 cm with a pink base and heavy serosanguinous drainage. On 04/29/14 the wound was 5.5 x 3.2 x 0.4 cm with a pink base and scatter yellow necrosis with heavy serous drainage. On 05/13/14 the wound was 7.5 x 7.0 x 2.5 cm with a pink base and heavy drainage, irregular wound edges with bone exposure. The documentation indicated an increase in the size of the wound since January 2014 and an increased drainage and necrotic tissue. On 06/18/14 at 2:00 p.m. the treatment administration record (TAR) was reviewed for the month of April, May and June 2014 which revealed that the facility failed to provide several wound treatments as ordered by the consultant physician. For the month of April 2014 there were thirteen days of the month that wound treatment was not documented as having been provided daily as ordered by the physician (4/1/14, 4/2/14, 4/5/14, 4/6/14, 4/12/14, 4/13/14, 4/16/14, 4/19/14, 4/20/14, 4/23/14, 4/26/14, 4/27/14, and 4/30/14). For the month of May 2014, there were thirteen days that Resident #502 did not have daily wound care treatment documented (5/3/14, 5/4/14, 5/7/14, 5/11/14, 5/14/14, 5/18/14, 5/20/14, 5/25/14, 5/26/14, 5/27/14, 5/28/14, 5/29/14, and 5/30/14). As of the last day of the annual survey on June 20, 2014 there were 11 days in June that resident #502 went without receiving daily wound care (6/7/14, 6/8/14, 6/9/14, 6/11/14, 6/12/14, 6/13/14, 6/15/14, 6/15/14, 6/16/14, 6/17/14, and 6/19/14). On 06/18/14 resident #502 was observed at several different times throughout the day laying in a supine position (on her back) without a positioning device in place. On 6/19/14 and 6/20/14 resident #502 was continued to be observed laying on her back. On 06/19/14 a positioning wedge was noted next to the resident on her left side, however resident #502's position was not adjusted with the wedge, she was still flat on her back. On 6/20/14 at 9:30 a.m., the facility unit manager was asked about the positioning device and provision of wound care as ordered by the physician. The Unit manager ws unable to explain why consistent skin care was not provided for Resident #502 or why the positioning device was not utilized to relieve pressure. RESIDENT #517 According to the clinical record which was reviewed on 06/19/14 at 3:00 p.m., Resident #517 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment revealed that Resident #517 had severely impaired cognition and required total physical assistance from facility staff for bed mobility, transfers and all ADL's. The treatment nurse (B) was queried about the resident's wounds on 06/18/14 at 8:15 a.m. and reported that the resident was admitted into the facility with the Sacrococcygeal wound. Review of the weekly pressure ulcer log revealed that Resident #517's coccyx wound progressively worsened since her admission. At the time of admission, (on 5/6/14) the Sacrococcygeal wound measured 9.5 cm x 8.5 cm with no depth noted. There was denuded tissue (loss of the epidermis) with a medium amount of drainage. On 6/17/14 the wound measured 10.5 cm x 6.0 cm x 2.8 cm and was noted with heavy purulent (containing pus) drainage. According to the altered skin integrity care plan initiated on 5/7/14 the following interventions were identified: "avoid positioning me on my back and follow the skin management program". Review of the Braden Scale assessment dated [DATE] revealed that resident #517 was at "very high risk" for developing pressure ulcers. A wound observation was made on 06/20/14 at around 11:45 a.m., with treatment nurse (B). The resident was observed to be laying on her back. The wound was large with a foul odor, heavy drainage noted and tunneling was observed in the wound and described by the wound care nurse measuring 10.5 cm x 6.0 cm x 2.0 cm with heavy purulent (containing pus) drainage. Further review of Resident #517's clinical record on 6/20/14 at 12:00 p.m. and 7/01/14 at 10:00 a.m. revealed the following: On 5/07/14, the physician ordered the following treatment for [REDACTED]. Cleanse right heel with wound cleanser then apply dry dressing every two days and prn" On 5/14/14, the treatment order changed to the following: "Cleanse Sacrococcygeal with wound cleanser then apply [MEDICATION NAME] with 4 x 4 gauze, ABD pads, daily and prn. Cleanse right heel and right hallux with wound cleaner then apply 4 x 4 gauze and ABD every other day". On 5/20/14, the physician's orders [REDACTED]. Right gluteal cleanse with wound cleanser and apply allevyn every two days and prn, Right foot, dry dressing every two days and prn." According to the TAR for May 2014, Resident #517 did not receive wound treatment until 5/15/14 which was nine days after her admission into the facility. The May 2014 TAR revealed that five treatments were missed between 5/15/14 and 5/31/14 (5/22, 5/24, 5/25, 05/26, and 5/31). Treatments were ordered daily and as needed. On 06/17/14 the treatment order prescribed by the physician for the Sacrococcygeal area was changed [MEDICATION NAME] gel daily and as needed with a 4 x 4 gauze and an ABD pad. Review of the TAR for June 2014 revealed that 11 days of missed treatments occurred for Resident #517 on the following dates: 6/1/14, 6/3, 6/5, 6/6, 6/7, 6/9, 6/11, 6/12, 6/14, 6/15, 6/18, 6/21, and 6/22/14. On 6/24/14 the treatment order prescribed by the physician for the Sacrococcygeal area was changed to [MEDICATION NAME] gauze daily with a 4 x 4 gauze and an ABD pad every two days and as needed. (Note: The difference between [MEDICATION NAME] gel and [MEDICATION NAME] gauze is the amount of "active" ingredient). According to the June 2014 TAR, the treatment order was changed by the physician on 06/24/14 ([MEDICATION NAME] gauze); however, the order was not transcribed to the treatment administration record and Resident #517 continued to be treated with the [MEDICATION NAME] gel rather than the [MEDICATION NAME] gauze on 6/24, 6/25, 6/26, 6/27, 6/28, 6/29, and 6/30/14. On 7/01/14 at 10:00 a.m., the treatment nurse (B) was asked about the order and reported the resident was being treated with [MEDICATION NAME] gel, and stated, "that was my mistake, I continued to treat her with the gel instead of the gauze." When asked if the facility had the [MEDICATION NAME] gauze available in stock, treatment nurse (B) replied, 'yes.' Closer examination of the June 2014 treatment administration record revealed treatment nurse (B) documented she completed Resident #517's treatment on 6/29/14. When queried about providing Resident #517 treatment on 6/29/14 (Sunday), treatment nurse (B) reported she did not do the treatment that day and stated, "...I don't work on Sundays." Review of the assignment sheet did not reveal any nurse with the same initials as the treatment nurse who worked on 6/29/14. There was no indication on the initial or signature line that indicated which staff member documented treatments were completed on the TAR. The Director of Nursing was interviewed on 6/19/14 at 4:30 p.m. and 7/01/14 at 4:00 p.m. and was unable to explain why pressure ulcer treatments had not been provided to residents on a consistent basis. On 07/01/2014, at 2:30 p.m. a telephone interview with the wound consultant physician was conducted. The wound consultant explained that he was not aware that wound treatments were not consistently being provided to residents as ordered. The consultant explained that it was his understanding that they had a treatment nurse on staff and he did not understand why the treatment had not been provided. When queried about the frequency of treatment changes for the residents, the wound consultant explained "if the wound is not improving with the current treatment, we change the treatment based on if it is not improving. We put things in place with the expectation that the staff will physically provide the wound treatment." Resident #523 On 07/01/14 at 10:00 a.m., treatment nurse (B) was queried about Resident #523's wounds and reported Resident #523 was admitted into the facility with "skin abrasions" and they "opened-up"since admission. The treatment nurse described Resident #523 was "non-compliant" with having her wound treatments done and Resident #523 refused to get in bed so that the wound team could evaluate her wounds yesterday (6/30/14). The clinical record for Resident #523 was reviewed on 07/01/14 at 10:30 a.m. and revealed that Resident #523 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated that the resident was cognitively intact. Resident #523 was totally dependent on staff for assistance with transfers and bathing and required extensive physical assistance from staff with bed mobility and other ADL needs. Review of the Braden scale assessment revealed that Resident #523 was at "high risk" for developing pressure ulcers. Review of the care plan for impaired skin integrity revealed "I require a pressure reducing device in my chair-including a geri chair, observe my dressing to ensure it is intact and adhering report my loose dressing to my nurse, I need assistance to reposition at least every two hours. According to June 2014 pressure ulcer log, Resident #523 had pressure ulcers described as follows: Right posterior thigh/Right gluteal measuring 12.5 x 8.0 cm, pink base with serous drainage, Right posterior thigh which measured 18 x 2.1 cm, necrotic base with serous drainage, Left posterior thigh measuring 13 x 7.5 cm, pink base with serous drainage, and Left perirectal wound 4 x 4 cm, necrotic base with serous drainage. Review of the TAR's for the month of June 2014 revealed the physician treatment order: "cleanse right posterior thigh with wound cleanser then apply [MEDICATION NAME] gauze, 4 x 4 gauze and ABD pad daily and prn" was not done on 06/12/14, 06/14/14, and 06/15/14. On 6/18/14, the physician changed the treatment to the following: "Cleanse Right gluteal/posterior thigh, Left posterior thigh, Left perirectal area with wound cleanser then apply [MEDICATION NAME]/[MEDICATION NAME] 50/50 with 4 x 4 gauze, ABD pads every shift daily and prn". According to the June 2014 TAR, treatments were not done on the day shift on 6/20/14, 6/21/14, 6/22/14, 6/25/14 and 6/30/14 because the resident "refused to go back to bed" for her treatment. Treatments were not done on the afternoon shift on 6/19/14, 6/20/14, 6/21/14, 6/22/14, 6/23/14 (with a reason documented as resident sleeping at 9:30 p.m.) and 6/24/14, 25/14 and 6/26/14. Treatments were not done on the midnight shift on 6/29 and 6/30/14. On 07/01/14 at 11:20 a.m. an interview was conducted with Resident #523 in the 300 unit lounge. When queried about compliance with wound care treatments, Resident #523 stated, "that's a lie, I am not refusing wound care." The resident explained that she did not like to get right back in bed after she has gotten up in the morning and she didn't understand why wound treatment was not done before she got up. Resident #523 was asked what time she usually lays back down in the evening and she stated that she goes back to bed at 4:00 p.m. When queried about not being seen by the wound team yesterday, Resident #523 stated that they did not put her back in bed for wound treatment yesterday. Resident #523 reported, "I know that they have to aggressively treat my wounds three time a day now. When I am in the bed, they don't do the treatment, especially on the afternoon shift. I request to have my wound treatment and the nurse has told me that she didn't see anywhere in the chart for the treatment to be done". A wound care observation was made on 07/01/14 at 1:00 p.m. with treatment nurse (B). Resident #523 was observed with multiple wounds on her right and left posterior thigh and left perirectal area. Two horizontal wounds on the posterior thighs appeared to have been congruent with the hard surface of the wheelchair. When queried about the wheelchair, Resident #523 reported she was suppose to have a seat cushion and stated, "they haven't given me a wheelchair cushion since I returned from the hospital." The treatment nurse (B) stated, "I was told that her cushion was here." Observation of the bariatric wheelchair revealed a "small crumpled pillow" on the seat of the chair. Resident #523 was asked if she assisted with repositioning herself at least every two hours while in bed and Resident #523 replied, "No". The treatment nurse was queried about Resident 523's right and left posterior thigh wounds in the presence of the resident and stated, "I didn't even know that I had wounds on the left side, I thought that I only had a wound on the right." The wounds on the resident's buttock was not covered. There was a curled up piece of gauze observed near the large gluteal wound of the wounds--date not visible. The wound had bloody drainage. There was no gauze or ABD pads covering the other wounds. The wounds were odorous. Treatment nurse (B) used [MEDICATION NAME] to treat the wounds, as she reported that the facility did not have the [MEDICATION NAME] as ordered, so she had to contact the pharmacy to order more. Nurse (B) was asked if the wounds seemed to be improving with the current treatment, and she replied "No." ( ) Deficient Practice #2: Based on observation, interview, and record review, the facility failed to prevent the development of pressure sores for one (#506) of eight sampled residents reviewed for pressure sores, from a total of 24 sampled residents resulting in the development of a Stage II pressure sore. Findings include: Resident #506 Resident #506's family member "P" was interviewed on 6/17/14 at 2:10 P.M. and reported that Resident #506 had a wound on his "tailbone". When queried about how the family members found out about the wound, family member "Q" reported that she sometimes assisted with changing Resident #506's brief and noticed it then. A wound observation was made with Wound Treatment Nurse "B" on 6/18/14 at 10:30 A.M. and revealed a superficial wound on Resident #506's right buttock that measured 0.5 cm by 0.5 cm with a red base and scant drainage. Resident #506's clinical record was reviewed on 6/17/14 at 2:30 P.M. and on 6/20/14 at 11:00 A.M. Resident #506 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Nursing Progress Note dated 4/15/14 at 7:30 A.M. documented "Skin assessment completed. Skin intact, warm to touch, no open areas noted. Will continue to monitor." There was no further documentation of any skin assessment, monitoring, or changes after 4/15/14 in the Nursing Progress Notes. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #506 had severely impaired cognition; required limited physical assistance from staff for bed mobility, transfers, and ambulation and extensive physical assistance from staff for toileting. Resident #506 was assessed to be frequently incontinent of urine and stool. A BRADEN SCALE (Tool to assess risk for developing pressure ulcers) dated 4/14/14 revealed that Resident #506 scored "mild risk" for pressure sore development. There was one "Weekly Head-To-Toe Assessment" for Resident #506 dated 6/11/14 that documented a "healing open area" on the sacrum. Resident #506's Nursing Care Plans were reviewed from the time of admission. The "Admission Care Plan" for Pressure Sores/Skin Care was left "blank" and did not document any interventions to prevent the development of pressure sores. There were no other Nursing Care Plans for preventative skin care in Resident #506's clinical record. On 5/27/14, the Physician ordered the following: "Cleanse R (right) buttock with wound cleaner then apply Allevyn (a wound dressing) Q (every) 2 days and PRN (as needed). According to the form titled, "Vascular & Wound Consultation," dated 5/27/14 Resident #506 had a Stage II pressure sore (partial thickness skin loss) on the right buttock measuring 4.0 centimeters (cm) by 2.6 cm. The Director of Nursing (DON) was was interviewed on 6/20/14 at 9:35 A.M. regarding Resident #506's pressure ulcer. The DON reported that the pressure ulcer developed "the day before the wound doctor came (5/26/14)". When queried, the DON reported there was no documentation of when the pressure ulcer developed. The DON reported per facility policy, "Weekly Head-To-Toe Assessments" should have been completed by nurses on the units. The DON was unable to provide evidence of any "Weekly Head-To-Toe Assessments" other than the assessment dated [DATE]. An interview was conducted with Wound Treatment Nurse "B" on 6/20/14 at 10:47 A.M. Wound Treatment Nurse "B" reported that she received a verbal report from one of the Certified Nursing Assistants (CNA) regarding skin changes on Resident #506's buttock. Wound Treatment Nurse "B" stated, "I don't remember who the CNA was who reported it (skin changes). I don't have any documentation. I should have wrote a nurse's note." ( ) On 6/20/14 at 9:15 a.m., the Administrator was queried regarding missed treatments for wounds and pressure ulcers. The Administrator stated, "That was identified as a concern a month ago. We hired a new treatment nurse the Monday before last." There was no further explanation. On 6/20/14 at 3:45 p.m., review of the facility's policy entitled, "Pressure Ulcer and Skin Care Management," dated July 2011, revealed the following documentation: "A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcer developing. A resident having pressure ulcers received necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing..." ( / / )

This citation pertains to MI 965 The complaint alleged that resident developed a pressure sore that was not there on admission. Based on observation, interview, and record review, the facility failed to adequately assess and implement interventions to prevent the development of pressure sores for one (#509) of two residents reviewed for pressure sores out of a total of 12 sampled residents, resulting in the development of a mushy right heel and the development of an unstageable pressure sore on the resident's left heel. Findings include: On 9/25/13 at 10:45 A.M., a review of the face sheet in the clinical record revealed resident # 509 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS), dated [DATE] indicated that resident #509 had severely impaired cognition and required extensive physical assistance with activities of daily living and required the physical assistance to two staff members for bed mobility. A review of the "CNA (certified nurse aide) Resident Status Record", dated 2/15/13, failed to indicate that resident #509's heels were supposed to be "floated" (not to have direct contact with a surface to prevent pressure). The box that stated, "Elevate Heels off Mattress/Recliner" was not checked. A review of the nursing care plan, dated 2/6/13, stated "Float BLE" (bilateral lower extremities). A review of the wound care consult form, dated 9/4/13, stated, "bilateral heels are intact". On 9/25/13 at 11:05 A.M., Resident #509 was observed lying in bed. Resident #509's had on cloth heel protectors and her heels rested on the mattress. There were no positioning devices observed in the bed. A dressing change observation and skin assessment was conducted with the wound care nurse "L" and nurse "J". Wound care nurse "L" revealed the only treatment ordered for resident #509 was to treat a recurrent pressure sore on the coccyx/right buttocks areas. Resident #509's coccyx area was observed to have two wounds that measured 1.5 centimeters (cm) X 3.0 cm with a bridge. The wounds had pink bases with moderate serous sanguineous drainage. An assessment of resident #509's right heel revealed it was wrinkled and discolored. The treatment nurse describe it as "very mushy" and the area measured 2.3 cm X 2.5 cm. An assessment of the left heel revealed a large black area the wound care nurse described as "eschar (dead) tissue". The left heel wound had purple edges, was not open, and was not draining. The pressure sore on the left heel measured 4.0 cm X 5.0 cm. The wound care nurse was asked if she had seen the areas on resident #509's heels and stated, "I see it now." The wound care nurse revealed she did not know the pressure sores were there and stated, "Absolutely not. I'm the treatment nurse, but I've been taken off the floor a lot because we are short of nurses. That's why I didn't know." Following the treatment observation, resident #509's cloth heel protectors were put on, but her heels were not placed in a floated position. On 9/25/13 at 11:30 A.M., a review of the clinical record was done with the wound care nurse. The wound care nurse revealed that weekly skin assessments were supposed to be done by the floor nurses on shower days. The wound care nurse revealed that resident #509's shower days were Tuesdays and Fridays. However, a review of the "Weekly Head To Toe Skin Checks" form revealed that skin assessments scheduled to be done on 8/2/13, 8/7/13, 8/16/13, 8/23/13, 8/30/13, prior to resident #509 going to the hospital on [DATE] and skin assessments scheduled for 9/6/13, 9/13/13, and 9/20/13, after the 9/1/13 re-admission had not been done. The wound care nurse stated, "The unit manager is supposed to check them. The nurses are supposed to write an "Early Warning Report" and give it to me." The wound care nurse revealed she had not gotten an "Early Warning Report" form for resident #509's heels". A review of the nursing notes, dated 9/1/13-9/25/13, failed to document that skin assessments had been done. The nursing care plan, dated 2/6/13, stated "Float BLE" (bilateral lower extremities). Resident #509's heels were supposed to be floated (elevated so there's no pressure on the heels from the mattress). The wound care nurse stated, "We put the stuff in there, but poof, it's gone. We try to keep it in there. An extra pillow was on the chair instead of under her heels." On 9/25/13 at 3:00 P.M., certified nurse aide (CNA) "O" was asked about the pressure sore on resident #509's heel and the brown, discolored, mushy, right heel. CNA "O" revealed she had not looked at resident #509's heels that morning when she applied resident #509's anti-embolism stockings. On 9/26/13 at 10:00 A.M., the Director of Nursing (DON) and Unit Manager "I" was asked about resident #509's heels. Unit Manager "I" stated, "I don't know what happened with them reporting it to us..." The DON stated, "Her heels are supposed to be floated." Unit Manager "I" stated, "The skin assessments are supposed to be done once a week and checked between myself and the wound care nurse." The DON stated, "When the wound care nurse is pulled to the floor, the nurses do their own wound care." On 9/27/13 at 1:00 P.M., a review of the facility's policy titled "Facility-Acquired Pressure Ulcers", revised January 2013, stated, "Residents at risk for pressure ulcers will be identified and will receive interventions to reduce the risk of pressure ulcer development ... all residents will be assessed from head to toe weekly by a licensed nurse to identify any new pressure ulcers or other types of skin alterations." ( )

THIS CITATION PERTAINS TO INTAKE # MI 127. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR THE EFFECTIVENESS OF THE INTERVENTIONS AND MODIFY THE INTERVENTIONS AS NECESSARY WHEN ONE (#101) OF FOUR SAMPLED RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 4, WAS OBSERVED UNSAFELY TRANSFERRING HERSELF OUT OF BED AND TO THE BATH ROOM, RESULTING IN RESIDENT #101 FALLING AND SUSTAINING A LEFT HIP FRACTURE WHILE UNSAFELY TRANSFERRING HERSELF OUT OF BED. FINDINGS INCLUDE: ACCORDING TO THE UNDATED FACE SHEET, RESIDENT #101 WAS admitted to the facility on [DATE]. ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #101 HAD SEVERAL [DIAGNOSES REDACTED]. RESIDENT #101 WAS UNSTEADY WHEN ATTEMPTING TO BALANCE AND WAS ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE REQUIRED THE EXTENSIVE ASSISTANCE OF STAFF AND PHYSICAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY WALKING, EATING, TRANSFERS AND TOILETING. ACCORDING TO THE CARE PLAN DATED 2/6/2012 RESIDENT #101 WAS AT RISK FOR FALLS AND REQUIRED STAFF ASSISTANCE WITH MOBILITY TASKS. THE CARE PLAN REQUIRED STAFF TO IMPLEMENT ASSISTIVE DEVICES AS NEEDED, OBSERVE FOR AND REPORT ANY CHANGES IN FUNCTIONAL AND/OR MENTAL STATUS THAT MAY HAVE INCREASED SAFETY RISKS AND RESPOND QUICKLY TO REQUESTS FOR OR INDICATIONS OF RESIDENT #101'S NEED FOR BOWEL AND BLADDER ASSISTANCE. ACCORDING TO RESIDENT #101'S HISTORY AND PHYSICAL DATED 1/28/2013, RESIDENT #101 WAS admitted TO A LOCAL AREA HOSPITAL AFTER A FALL AT HOME AND WAS diagnosed with [REDACTED]. RESIDENT #101 admitted TO THE NURSING FACILITY WITH A FAIR TO GUARDED REHABILITATION POTENTIAL. THE PLAN OF CARE INCLUDED PHYSICAL AND OCCUPATIONAL THERAPY FURTHER ASSESSMENTS AND FALL PRECAUTIONS. ACCORDING TO THE PHYSICAL THERAPY CARE PLAN DATED 1/26/2013, RESIDENT #101 HAD DECREASED LOWER EXTREMITY (LEG) STRENGTH, DECREASED STABILITY, DECREASED COORDINATION, AN UNSTEADY GAIT AND WAS UNSAFE TO TRANSFER. ACCORDING TO THE PHYSICAL THERAPY EVALUATION DATED 1/29/2013, RESIDENT #101 REQUIRED MOD ASSIST (MODERATE ASSISTANCE) FOR BED MOBILITY HAD POOR STANDING BALANCE AND FAIR SITTING BALANCE, REQUIRED MAX ASSIST (MAXIMUM ASSISTANCE)FOR WALKING 5 FEET ONCE STANDING, REQUIRED MAX ASSIST FOR MAINTAINING BALANCE FOR 5 FEET, REQUIRED MAX ASSIST FOR ALL TRANSFERS. ACCORDING TO THE PHYSICAL THERAPY EVALUATION DATED 1/29/2013, RESIDENT #101 REQUIRED FALLS PRECAUTIONS TO BE TAKEN. ACCORDING TO THE OCCUPATIONAL EVALUATION DATED 1/28/2013, RESIDENT #101 REQUIRED MIN (MINIMUM ASSISTANCE) TO MAX ASSIST (MAXIMUM ASSISTANCE) FOR TOILETING. ACCORDING TO "INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPIST ASSISTANTS" BY OLGA DREEBEN, PUBLISHED BY JONES & BARTLETT PUBLISHERS, 2006, MAXIMUM ASSISTANCE REQUIRES THE STAFF TO CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 75 % OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS. MODERATE ASSISTANCE REQUIRES THE STAFF TO CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 50 % OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS. MINIMUM ASSISTANCE REQUIRES THE STAFF TO CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 25 % OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS. ACCORDING TO THE ACTIVITIES FOR DAILY LIVING (ADL) REPORT, RESIDENT #101 WAS NOT PROVIDED WITH PHYSICAL ASSISTANCE WALKING, EATING, TRANSFERS AND TOILETING CONSISTENTLY. ACCORDING TO THE ADL REPORT DATED 2/1/2013, RESIDENT #101 WAS INDEPENDENTLY TOILETING HERSELF. ACCORDING TO THE ADL REPORT DATED 2/4/2013, RESIDENT #101 WAS INDEPENDENTLY TOILETING HERSELF. ACCORDING TO THE ADL REPORT DATED 2/7/2013, RESIDENT #101 WAS INDEPENDENTLY TOILETING HERSELF. ACCORDING TO THE ADL REPORT DATED 2/8/2013, RESIDENT #101 WAS INDEPENDENTLY TOILETING HERSELF. NO EVIDENCE COULD BE FOUND TO INDICATE ANY NEW INTERVENTIONS WERE IMPLEMENTED TO ENSURE THE REQUIRED SUPERVISION WAS RECEIVED TO PREVENT AVOIDABLE ACCIDENTS FOR RESIDENT #101. IN AN INTERVIEW ON 3/1/2013 AT 2:00 P.M., THE MINIMUM DATA SET NURSE (MDS #1) A REGISTERED NURSE, SAID THAT THE FACILITY'S UNIT MANAGERS REVIEWED THE ADL REPORTS ON A DAILY BASIS. MDS #1 SAID THAT THE ADL REPORTS REFLECT THE CARE ACTUALLY PROVIDED TO THE RESIDENTS ON A DAILY BASIS. MDS #1 SAID THE CERTIFIED NURSE ASSISTANT (CNA) SHOULD DOCUMENT IN THE ADL REPORT EVERY TIME THEY ASSIST A RESIDENT. MDS #1 SAID THAT THE FACILITY HAD PROVIDED ADDITIONAL EDUCATION TO THE CNAS SINCE JANUARY 2013 TO ENSURE THE ACCURACY OF THE DOCUMENTATION. MDS #1 SAID REVIEWED THE CNAS' DOCUMENTATION AND SAID THAT NOTES ON THE DATES REFERENCED WOULD REFLECT DATES OR TIMES RESIDENT #101 WAS OBSERVED PERFORMING THE ACTIVITIES WITHOUT STAFF ASSISTANCE. MDS #1 WAS ASKED TO CLARIFY WHAT SHE MEANT AND MDS #1 SAID RESIDENT #101 WAS A RESIDENT WHO WOULD NOT ALWAYS WAIT FOR STAFF. MDS #1 SAID THAT RESIDENT #101 "...WAS ONE OF THOSE PATIENTS THAT WOULD TRY TO GET OUT OF BED OR UP TO THE BATHROOM ON HER OWN...SHE (#101) WAS A PATIENT ON MY FLOOR AND I REMEMBER A FEW TIMES WHEN THE CALL LIGHT WAS ON AND I WENT IN THE ROOM. WHEN I GOT THERE SHE WOULD ALREADY BE UP AND TRYING TO DO THINGS ON HER OWN. SO I WOULD HELP HER..." MDS #1 SAID THAT INFORMATION ABOUT RESIDENT #101 ATTEMPTING TO TRANSFER AND TOILET HERSELF WITHOUT STAFF ASSISTANCE WAS TAKEN TO THE DAILY STANDUP MEETINGS, BUT WAS UNABLE TO ADVISE WHAT INTERVENTIONS WERE PUT IN PLACE ONCE THE FACILITY BECAME AWARE OF THE PROBABILITY RESIDENT #101 WOULD ATTEMPT TO TRANSFER AND TOILET HERSELF WITHOUT STAFF ASSISTANCE. DURING AN INTERVIEW ON 3/1/2013 AT 12:21 P.M., CNA #1 SAID THAT ON 2/10/2013 AT ABOUT 10:00 A.M., SHE WENT INTO RESIDENT #101'S ROOM AND CLEANED HER (#101) UP. CNA #1 SAID SHE THEN LEFT RESIDENT #101 IN BED. CNA #1 SAID SHE VISUALIZED RESIDENT #101 AS SHE (CNA #1) DID ROUNDS AFTER LUNCH. CNA #1 SAID, "...IT WAS ABOUT 1:00 (P.M.), SHE WAS IN THE BED, AND HAD A KNOT ON THE LEFT SIDE OF THE FOREHEAD..." CNA #1 SAID THAT AS SHE LOOKED AROUND, RESIDENT #101 WAS IN A DIFFERENT POSITION IN THE BED THAN WHEN SHE (CNA #1) LEFT THE ROOM EARLIER IN THE MORNING, AND THAT THE SHEETS COVERING RESIDENT #101 WERE PULLED BACK. CNA #1 SAID SHE ASKED WHAT HAPPENED AND RESIDENT #101'S ROOMMATE SAID SHE (#101) "...fell OUT OF THE BED..." RESIDENT #101 CONFIRMED THAT SHE HAD FALLEN. CNA #1 SAID RESIDENT #101 TOLD HER THAT SHE (#101) "...WAS OK," BUT THAT HER HIP WAS HURTING. CNA #1 SAID SHE THEN WENT TO GET A NURSE AND APPLIED ICE TO RESIDENT #101'S HIP. CNA #1 SAID THERE WERE "...A COUPLE OF INCIDENTS WHERE SHE (#101) WOULD TRY TO GET OUT OF THE BED..." ACCORDING TO THE NURSE'S NOTE DATED 2/10/2013, CNA #1 SUMMONED REGISTERED NURSE (RN) #2 TO COME TO RESIDENT #101'S ROOM. RN #2 DOCUMENTED THAT BRUISING WAS NOTED ON RESIDENT #101'S FOREHEAD. ACCORDING TO THE NURSE'S NOTE, RESIDENT #101'S PHYSICIAN WAS CONTACTED AND AN X-RAY WAS ORDERED. ACCORDING TO THE RADIOLOGY REPORT DATED 2/10/2013, RESIDENT #101 SUFFERED FROM A "...LEFT INTERTROCHANTERIC FRACTURE WITH NO DISPLACEMENT..." THE RADIOLOGY REPORT CONCLUDED RESIDENT #101 HAD AN "...ACUTE LEFT HIP FRACTURE..." ACCORDING TO THE NURSE'S NOTE, RESIDENT #101 WAS SENT TO THE LOCAL AREA HOSPITAL FOR FURTHER TREATMENT. IN AN INTERVIEW ON 3/4/2013 AT 1:07 P.M., RN #2 SAID THAT ON 2/10/2013, CNA #1 NOTIFIED HER THAT RESIDENT #101 HAD A BRUISE ON HER FOREHEAD. RN #2 SAID SHE WENT INTO THE ROOM AND ASKED RESIDENT #101 WHAT HAPPENED. RN #2 SAID RESIDENT #101 SAID SHE fell , BUT WAS UNABLE TO SAY HOW OR WHEN, SO RN #2 ASKED HER ROOMMATE. RN #2 SAID THAT RESIDENT #101'S ROOMMATE SAID RESIDENT #101 fell AND GOT BACK INTO BED HERSELF. RN #2 SAID RESIDENT #101'S ROOMMATE SAID THAT RESIDENT #101 HAD REGULARLY GOTTEN UP AT NIGHT WITHOUT HELP. RN #2 SAID SHE KNEW RESIDENT #101 REQUIRED ASSISTANCE AND DID NOT PERSONALLY KNOW THAT THE CNAS WERE DOCUMENTING RESIDENT #101 WAS GETTING UP WITHOUT ASSISTANCE. RN #2 SAID NURSES DO NOT REVIEW THE COMPUTERIZED DOCUMENTS AND DO NOT REVIEW THE CNA DOCUMENTATION. ACCORDING TO RN #2, "...SOMETIMES THE CNAS DO NOT TELL THE NURSES WHAT THEY SHOULD. AND WE DO NOT HAVE ACCESS TO SEE WHAT THE CNA DOCUMENTS IN THE COMPUTER..." DURING AN INTERVIEW ON 3/1/2012 AT 12:50 P.M., THE UNIT MANAGER (UM #1) A REGISTERED NURSE, SAID THAT WHEN QUESTIONING RESIDENT #101'S ROOMMATE ABOUT THIS INCIDENT, "WE FOUND OUT THAT (RESIDENT #101) WOULD GET OUT OF BED UNASSISTED BY FACILITY STAFF ALL THE TIME..." UM #1 SAID SHE WAS AWARE OF "...ONLY A FEW INSTANCES..." WHEN RESIDENT #101 WOULD GOT OUT OF BED UNASSISTED PRIOR TO FALLING. UM #1 WAS UNSURE OF THE QUANTITY OF TIMES AND WAS UNABLE TO ADVISE OF ACTIONS TAKEN BY THE FACILITY TO ENSURE RESIDENT #101 RECEIVED THE REQUIRED SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS. IN AN INTERVIEW ON 3/1/2012 AT 11:10 A.M., THE DIRECTOR OF NURSING (DON #1) SAID THAT SHE REVIEWED THE INCIDENT INVOLVING RESIDENT #101 AND "...I (DON #1) BELIEVE THE INJURY TO HER HIP IS CONSISTENT WITH THE POSITION OF HER TOILETING ASSIST BARS ..." DON #1 SAID, "...SHE (#101) COULD HAVE REASONABLY LOST HER BALANCE WHILE TOILETING AND HIT HER HEAD ON THE WALL AS SHE fell ..." DON #1 SAID THAT RESIDENT #101 SUFFERED A LEFT HIP AND LEFT FOREHEAD INJURY. DON #1 REVIEWED THE CLINICAL DOCUMENTATION AND SAID THAT ACCORDING TO THE INFORMATION, RESIDENT #101 WOULD INDEPENDENTLY TOILETING HERSELF. DON #1 SAID THE FACILITY'S UNIT MANAGERS WERE REVIEWING THE ADL REPORTS ON A DAILY BASIS BUT WAS UNABLE TO ADVISE OF ACTIONS TAKEN BY THE FACILITY TO ENSURE RESIDENT #101 RECEIVED THE REQUIRED SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS. DON #1 SAID SHE WAS UNAWARE THAT RESIDENT #101 HAD BEEN OBSERVED BY FACILITY STAFF ATTEMPTING TO GET OUT OF BED UNSUPERVISED. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 727 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT FALLS FOR ONE RESIDENT (#501) OF THREE RESIDENTS REVIEWED FOR FALLS FROM A TOTAL OF THREE SAMPLED RESIDENTS RESULTING IN RESIDENT #501 SUSTAINING A FALL WITH A LEFT HIP FRACTURE. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S FACE SHEET, RESIDENT #501 WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] NOTED THAT RESIDENT #501 REQUIRED LIMITED ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, LOCOMOTION ON AND OFF THE UNIT, DRESSING, TOILETING, PERSONAL HYGIENE AND REQUIRED EXTENSIVE ASSISTANCE WITH BATHING. THE MDS DOCUMENTED THAT #501 WAS "...NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE WITH MOVING FROM SEATED TO STANDING POSITION, WALKING, TURNING AROUND, MOVING ON AND OFF TOILET AND SURFACE TO SURFACE TRANSFERS..." A REVIEW OF THE FALL RISK assessment dated [DATE], #501 HAD A FALL RISK SCORE OF 13. "...TOTAL SCORE ABOVE 10 REPRESENTS HIGH RISK..." A REVIEW OF THE FACILITY'S "FACILITY INCIDENT REPORT -24 HOURS" DATED 4/19/12 REVEALED, "...RESIDENT (#501) ROOMMATE REPORTED (RESIDENT #501) WAS PUSHING BEDSIDE TRAY TABLE AND fell . (RESIDENT #501) WAS TRANSPORTED TO THE HOSPITAL FOR EVALUATION AND TREATMENT. HOSPITAL REPORTED (RESIDENT #501) HAS LEFT HIP FRACTURE. (RESIDENT #501) HAD SURGERY AND REPORTED TO BE CURRENTLY STABLE..." A REVIEW OF A HOSPITAL DOCUMENT DATED 4/19/12 REVEALED, "...REASON FOR VISIT: FALL: LEFT HIP FRACTURE WITH LEFT HEMIARTHROPLASTY (SURGICAL REPAIR)...' A PHYSICIAN'S PROGRESS NOTE DATED 4/22/12 REVEALED, "...ACUTE LEFT FEMORAL NECK FRACTURE status [REDACTED]. A REVIEW OF THE "CNA (CERTIFIED NURSING ASSISTANT) STATUS RECORD UNDATED REVEALED "...MOBILITY AND TRANSFER: AMBULATE, ASSIST OF ONE, WALKER, WHEELCHAIR..." A REVIEW OF THE "PHYSICAL THERAPY DISCHARGE SUMMARY" DATED 2/2/11 REVEALED: "...AMBULATE WITH RW (ROLLING WALKER) WITH ASSISTANCE. PRECAUTIONS: FALLS. SIT TO STAND: MODIFIED ASSIST. BED TO CHAIR: STANDBY ASSIST. CURRENT STATUS FOR TRANSFER TRAINING TO INDEPENDENT: STAND BY ASSIST/MODIFIED ASSIST. CURRENT STATUS FOR AMBULATION: 35 FEET WITH ROLLING WALKER/STAND BY ASSIST..." ON 5/3/12 AT 12:30 P.M., RESIDENT #501 WAS OBSERVED SEATED IN HER ROOM IN A HIGH BACK WHEELCHAIR HOLDING AN ICE PACK TO HER LEFT HIP. WHEN GREETED, RESIDENT #501 SAID, "...MY LEFT HIP IS HURTING ME. THE NURSE GAVE ME AN ICE PACK BUT IT ISN'T HELPING..." WHEN ASKED TO RECALL THE EVENTS THAT TRANSPIRED DURING HER FALL, RESIDENT #501 REPORTED THE FOLLOWING, "...I WAS UP WALKING AROUND IN MY ROOM. I WAS FOLDING SOME THINGS ON MY TABLE AND THAT CRAZY WOMAN (ROOMMATE AT THE TIME) TOLD ME TO STOP. SHE THEN PUSHED THE TABLE AND I fell ..." A REVIEW OF A STATEMENT TAKEN FROM #501'S ROOMMATE DATED 4/19/12 REVEALED, "...(RESIDENT #501) GOT UP FROM HER BED AND PROCEEDED TO MOVE HER BEDSIDE TABLE ON WHEELS TO THE CENTER OF THEIR SHARED ROOM. AS (RESIDENT #501) WAS WALKING HOLDING ON TO THE BEDSIDE TABLE, SHE LOST HER BALANCE AND fell DOWN..." THE STATEMENT FURTHER REVEALED THAT #501'S ROOMMATE "...LOOKED OUT THE DOOR AND DIDN'T SEE NOBODY FOR 20 MINUTES. THE PILL MAN CAME AND GOT (RESIDENT #501) UP OFF THE FLOOR..." ON 5/3/12 AT 3:15 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED. WHEN ASKED IF #501 WAS A FALL RISK ON ADMISSION, THE DON REPORTED, "YES. ACCORDING TO THE STAFF, SHE (#501) TRANSFERRED HERSELF. SHE DIDN'T HAVE ANY ALARMS TO HER BED OR CHAIR AND NO PRIOR FALLS IN HER CHART..." ON 5/7/12 AT 10:15 A.M., DURING A SUBSEQUENT INTERVIEW, THE DON WAS QUERIED ABOUT #501'S AMBULATION STATUS AND REPORTED, "...ACCORDING TO HER ASSESSMENT, SHE (#501) SHOULD NOT HAVE BEEN AMBULATING WITHOUT STAFF ASSISTANCE..." ON 5/7/12 AT 10:45 A.M., DURING AN INTERVIEW, THE PHYSICAL THERAPY MANAGER (PTM) WAS QUERIED ABOUT #501'S AMBULATION STATUS. WHEN ASKED IF #501 WAS ASSESSED AS BEING ABLE TO AMBULATE INDEPENDENTLY, THE PTM REPORTED, "...NO. SHE WAS TO AMBULATE WITH A ROLLING WALKER AND STAND BY ASSIST. SHE SHOULD NOT HAVE BEEN ALLOWED TO AMBULATE WITHOUT ASSISTANCE. SHE (#501) WAS REFERRED TO RESTORATIVE NURSING IN ORDER TO MAINTAIN HER CURRENT LEVEL OF FUNCTIONING TO AVOID A DECLINE IN FUNCTIONING. SHE NEEDS ASSISTANCE. I MEAN, SHE'S OVER [AGE] years OLD..." THE FACILITY ADMINISTRATIVE STAFF WAS UNABLE TO EXPLAIN WHY RESIDENT #501 WAS NOT ADEQUATELY SUPERVISED ON 4/18/12 AT 12:00 A.M., WHEN SHE AMBULATED WITHOUT STAFF ASSISTANCE AND SUBSEQUENTLY fell AND STAINED A LEFT HIP FRACTURE REQUIRING SURGICAL REPAIR. A REVIEW OF THE FACILITY'S "FALL MANAGEMENT GUIDELINES" POLICY DATED JANUARY 2009, REVEALED: "...EACH RESIDENT IS ASSISTED IN ATTAINING/MAINTAINING HIS OR HER HIGHEST PRACTICABLE OF LEVEL OF FUNCTION BY PROVIDING THE RESIDENT ADEQUATE SUPERVISION, ASSISTIVE DEVICES, AND/OR FUNCTIONAL PROGRAMS AS APPROPRIATE TO MINIMIZE THE RISK FOR FALLS..."

THIS CITATION PERTAINS TO MI 544. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT ACCIDENTS AND PROVIDE ADEQUATE SUPERVISION IN 1 OF 4 SAMPLED RESIDENTS (#501) WHO WERE AT RISK FOR FALLS, IN A TOTAL SAMPLE OF 4 RESIDENTS, RESULTING IN hospitalization WHEN RESIDENT #501 WAS FOUND ON THE BEDROOM FLOOR AND SUSTAINED A RIGHT MAXILLARY SINUS FRACTURE AND A RIGHT SHOULDER DISLOCATION. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD (UNDATED) REVEALED RESIDENT #501 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE]. REVIEW OF THE PHYSICIAN'S PROGRESS NOTE DATED 1/25/12 REVEALED RESIDENT #501 HAD [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED RESIDENT #501 HAD MODERATE COGNITIVE IMPAIRMENTS AND REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF THE FALL RISK assessment dated [DATE] AND UPDATED ON 1/24/12 REVEALED RESIDENT #501'S FALL RISK SCORES WERE 10 ON 1/7/12, 14 ON 1/12/12, AND 13 ON 1/24/12. THE ASSESSMENT REVEALED RESIDENT #501 WAS CONSIDERED A HIGH FALL RISK. REVIEW OF THE FALL CARE PLAN DATED 1/25/12 REVEALED RESIDENT #501 WAS TO HAVE A BED SENSOR PAD ALARM AND FLOOR MATTS. IN AN INTERVIEW ON 2/6/12 AT 10:00 AM, LICENSED PRACTICAL NURSE (LPN) #4 REPORTED RESIDENT #501 WOULD REMOVE THE TAB ALARM AND "GET UP FROM THE BED AND WHEELCHAIR" UNASSISTED. IN AN INTERVIEW ON 2/6/12 AT 2:05 PM, CERTIFIED NURSING ASSISTANT (CNA) #11 REPORTED RESIDENT #501 FREQUENTLY SELF-TRANSFERRED HERSELF FROM THE WHEELCHAIR TO THE BED. REVIEW OF THE UNUSUAL OCCURRENCE REPORT DATED 1/18/12 REVEALED ON 1/18/12 AT 9:30 PM, RESIDENT #501 WAS FOUND LYING FACE DOWN ON THE BEDROOM FLOOR. THE REPORT REVEALED RESIDENT #501 WAS SITTING IN THE WHEELCHAIR AND TRIED TO SELF-TRANSFER FROM THE WHEELCHAIR TO THE BED. IN AN INTERVIEW ON 2/6/12 AT 1:55 PM, CNA #8 REPORTED SHE PROPELLED RESIDENT #501 IN THE WHEELCHAIR TO HER ROOM ON 1/18/12 AT 9:15 PM. CNA #8 REPORTED RESIDENT#501 WAS IN HER WHEELCHAIR AND HAD THE TAB ALARM CLIPPED TO HER CLOTHING WHEN SHE LEFT RESIDENT #501'S ROOM TO CHECK ON OTHER RESIDENTS. CNA #8 REPORTED AT APPROXIMATELY 9:30 PM, SHE CAME BACK TO CHECK ON RESIDENT #501 AND FOUND RESIDENT #501 LYING FACE DOWN ON THE FLOOR. CNA #8 REPORTED SHE DID NOT HEAR RESIDENT #501 TAB ALARM SOUND BETWEEN 9:15 PM AND 9:30 PM. IN AN INTERVIEW ON 2/3/12 AT 2:25 PM, LPN #6 REPORTED SHE LAST OBSERVED RESIDENT #501 ON 1/18/12 AT APPROXIMATELY 8:45 PM AND RESIDENT #501 HAD A TAB ALARM CLIPPED TO HER CLOTHING AT THAT TIME. LPN #6 REPORTED WHEN SHE CAME INTO RESIDENT #501'S ROOM AT APPROXIMATELY 9:30 PM, SHE OBSERVED RESIDENT #501'S TAB ALARM ON THE NIGHT STAND. LPN #6 REPORTED SHE DID NOT HEAR RESIDENT #501 TAB ALARM SOUND BETWEEN 8:45 PM AND 9:30 PM. LPN #6 REPORTED RESIDENT #501 FREQUENTLY REMOVED HER TAB ALARM. LPN #6 REPORTED RESIDENT #501 WOULD NOT USE THE CALL LIGHT TO ASK FOR ASSISTANCE AND WOULD SELF-TRANSFER HERSELF FROM THE BED TO THE WHEELCHAIR AND FROM THE WHEELCHAIR TO THE BED. REVIEW OF A HOSPITAL'S COMPUTED TOMOGRAPHY (CT) SCAN DATED 1/19/12 REVEALED RESIDENT #501 SUSTAINED A RIGHT MAXILLARY SINUS FRACTURE. REVIEW OF A HOSPITAL'S X-RAY REPORT DATED 1/18/12 REVEALED RESIDENT #501 SUSTAINED A RIGHT SHOULDER DISLOCATION. IN AN OBSERVATION ON 2/3/12 AT 10:45 AM, RESIDENT #501 WAS IN THE DAY ROOM IN A GERI-CHAIR WITH A SLING ON HER RIGHT ARM. ON 2/6/12 AT 1:30 PM, RESIDENT #501 HAD A CHAIR SENSOR PAD IN PLACE AND FUNCTIONING. ( )

REFER TO INTAKE #MI 860 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADMINISTER THE FACILITY IN A MANNER USING ITS STAFFING RESOURCES EFFECTIVELY AND EFFICIENTLY TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL AND PSYCHOSOCIAL WELL BEING FOR ALL OF THE 28 RESIDENTS IN THE BROWN UNIT RESULTING IN ALL 28 RESIDENTS NOT RECEIVING THEIR MORNING AND NOON SCHEDULED MEDICATIONS AS PRESCRIBED DUE TO NO LICENSED NURSE AND ONLY 2 CERTIFIED NURSE AIDE'S AVAILABLE TO PROVIDE NURSING CARE FOR ALL 28 RESIDENTS ON 1/9/11 FROM 7:00 AM - 2:00 PM RESULTING IN THE POTENTIAL FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: THE ADMINISTRATOR ON 2/24/11 AT 10:15 AM, STATED THAT SHE DID NOT RECEIVE ANY CALLS FROM THE SUPERVISOR ON CALL (RD #3), DIRECTOR OF NURSING, NOR THE ON-CALL NURSE #7 THAT SUNDAY (1/9/11). SHE WAS UNAWARE OF THE STAFFING PROBLEM AND LACK OF NURSE COVERAGE UNTIL THE NEXT DAY (1/10/11). THE REGISTERED DIETICIAN (RD) #3 IN AN INTERVIEW ON 2/24/11 AT 1:05 PM, STATED THAT SHE ARRIVED AT THE FACILITY BETWEEN 8:30-9:00 AM ON 1/9/11 AND WAS THE FACILITY SUPERVISOR FOR THE DAY. RD #3 REPORTED SHE WAS NOT AWARE UNTIL 9:30 AM THAT THERE WAS NO DAY SHIFT NURSE ON DUTY ON THE BROWN UNIT. RD #3 STATED SHE IMMEDIATELY CALLED THE ON-CALL NURSE #7 AND MADE HER AWARE THAT THE BROWN UNIT DID NOT HAVE A LICENSED NURSE ON DUTY AND THERE WERE ONLY 2 NURSE AIDES WORKING IN THE UNIT INSTEAD OF THE 4 THAT SHOULD HAVE BEEN ON DUTY. RD #3 THEN ASSUMED THE ON-CALL NURSE #7 TOOK CARE OF IT. RD #3 REPORTED THAT AT APPROXIMATELY 1:30 PM, SHE WAS PAGED TO THE BROWN UNIT BECAUSE RESIDENT #510'S FAMILY WAS VERY UPSET AND HAD THREATENED TO CALL THE STATE BECAUSE RESIDENT #510 HAD BEEN IN PAIN AND HAD NOT RECEIVED ANY OF HER SCHEDULED MEDICATIONS. RD #3 REPORTED SHE WENT TO THE OTHER 3 SCHEDULED NURSES (WHO HAD REFUSED TO ASSUME CARE EARLIER) AND BEGGED THEM TO ADMINISTER RESIDENT #510'S PAIN MEDICATION BUT THEY CONTINUED TO REFUSE TO HELP. RD #3 THEN CALLED THE DON REGARDING THE 3 NURSES REFUSING TO PROVIDE CARE AND RESIDENT #510'S REQUEST FOR PAIN MEDICATIONS AND THE FAMILY THREATENING TO CALL THE STATE. THE DON ARRIVED THE FACILITY AT 2:00 PM ON 1/9/11. THE ON-CALL NURSE #7 ARRIVED AT AROUND 2:30 PM ON 1/9/11. IN AN INTERVIEW ON 2/24/11 AT 11:05 AM THE DON (DIRECTOR OF NURSING) STATED THERE WAS NO NURSE THAT WORKED AT THE BROWN UNIT ON 1/9/11 STARTING FROM 7:00 AM UNTIL 2:00 PM AND THERE WERE 28 RESIDENTS RESIDING ON THE BROWN UNIT THAT DAY. THE DON STATED THAT DAILY SCHEDULED MEDICATION (9:00 AM AND 12:00 PM) WERE NOT ADMINISTERED TO ALL 28 RESIDENTS. THE DON REPORTED LICENSED PRACTICAL NURSE (LPN#6) LEFT THE BROWN UNIT MEDCART KEY INSIDE THE MEDICATION CART AND LEFT THE BUILDING WITHOUT TELLING ANYONE. NO ONE KNEW WHAT TIME THE MIDNIGHT NURSE LEFT. THE DON ARRIVED THE FACILITY AT 2:00 PM ON 1/9/11. THE DON admitted THAT SHE WAS NOT AWARE THAT THE ON-NURSE CALL #7 WAS IN LANSING THAT MORNING AND SHE DID NOT KNOW THAT LPN #11 WAS IN TO DO TREATMENTS THAT DAY. THE DON DENIED KNOWLEDGE ABOUT THE BROWN UNIT NURSE AIDE SHORTAGE. SHE STATED THAT SHE COULD HAVE USED THE RESTORATIVE NURSE AIDE #12 TO WORK ON THE BROWN UNIT BUT SHE WAS NOT AWARE THAT THEY WERE IN THE BUILDING. WE DID NOT REALIZED THEY WERE THERE UNTIL WE SAW THE SCHEDULE SHEET. REVIEW OF THE STAFF ASSIGNMENT FOR 1/9/11 SHOWED EVIDENCE THAT THERE WAS NO NURSE ON THE BROWN UNIT STARTING 7:00 AM ON 1/9/11. ALSO, THERE WAS ONLY 2 CNA (#4 AND #5) ON THE BROWN UNIT INSTEAD OF 4. CNA#14 WAS A NO SHOW AND CNA #13 CAME IN AT 7:00 AM BUT LEFT SICK AT 9:30 AM. NO REPLACEMENT WAS ARRANGED FOR EITHER CNA (#13 OR #14). THE FACILITY'S PUNCH DETAIL REPORT DATED 1/9/11, REVEALED LPN # 11 (WOUND TREATMENT NURSE) PUNCHED IN AT 9:42 AM AND WORKED UNTIL 5:05 PM. ANOTHER STAFF, RESTORATIVE CNA #12, ACCORDING TO THE 1/9/11 PUNCH DETAIL REPORT, WAS IN THE BUILDING FROM 5:51 AM AND LEFT AT 2:02 PM. LPN #11 AND CNA #12 WAS NOT ASSIGNED TO ANY UNITS. RESTORATIVE CNA #12 WAS ASSIGNED TO DO RESTORATIVE DUTIES AND LPN #11 WAS TO DO WOUND TREATMENTS FOR THE DAY. ACCORDING TO LPN #11 ON 3/10/11 AT 9:10 AM, SHE WORKS ALMOST EVERY WEEKEND AT THE FACILITY AS A TREATMENT NURSE AND REPORTED AT TIMES SHE WORKED ON THE FLOOR WHEN THE FACILITY IS SHORT OF STAFF. LPN #11 STATED SHE CAME IN AFTER 9:00 AM THAT SUNDAY (1/9/11) AND SAW ALL 3 NURSES (LPN# 5, LPN #8 AND LPN# 9) IN EACH OF THE ASSIGNED UNITS. SHE SAW THE ON-CALL NURSE #7 AT AROUND 2:30 PM ON THE BROWN UNIT NEXT TO THE MEDCART. SHE THOUGHT SHE WAS THE NURSE ASSIGNED THERE THAT MORNING. LPN #11 STATED SHE WORKED UNTIL 5:00 PM THAT DAY AND NO ONE ASKED HER TO WORK ON THE BROWN UNIT FROM 9:00 AM- 5:00 PM ON 1/9/11. AN ATTEMPT TO REACH CNA #12 ON 3/11/11 AT 3:10 BY TELEPHONE WAS DONE. THIS SURVEYOR WAS UNSUCCESSFUL. IN AN INTERVIEW ON 2/23/11 AT 2:45 PM THE ON-CALL NURSE # 7 STATED THAT SHE WAS ON CALL ON 1/9/11. SHE STATED SHE WAS IN LANSING WHEN THE FACILITY SUPERVISOR (RD#3) CALLED HER AT 9:30 AM ABOUT THE CNA SHORTAGE. SHE KNEW ABOUT THE BROWN UNIT WITH NO NURSE PRESENT BUT COULD NOT GET TO THE FACILITY. THE ON-CALL NURSE # 7 STATED SHE INSTRUCTED THE 3 NURSES TO SPLIT UP THE 28 RESIDENTS AMONG THEMSELVES, BUT THE 3 NURSES REFUSED. THE ON-CALL NURSE # 7 REPORTED SHE ARRIVED THE FACILITY AT 2:30 PM ON 1/9/11 AND WORKED AS THE AFTERNOON SHIFT NURSE (3-11 PM) ON THE BROWN UNIT THAT NIGHT BECAUSE THERE WAS NO NURSE ASSIGNED FOR THE SHIFT. IN A TELEPHONE INTERVIEW ON 3/9/11 AT 2:00 PM, THE MIDNIGHT SHIFT (LPN #6) REPORTED SHE FOUND OUT THERE WAS NO DAY SHIFT NURSE TO COUNT THE NARCOTICS WITH AT AROUND 7:30 AM ON 1/9/11. SHE INFORMED THE ON-CALL NURSE #7 IMMEDIATELY. THE ON-CALL NURSE #7 TOLD LPN #6 THAT SHE WAS NOT COMING AND TO TELL THE 3 NURSES ASSIGNED TO THE OTHER 3 UNITS, TO SPLIT THE BROWN UNIT ASSIGNMENT BETWEEN THEMSELVES. LPN # 6 REPORTED SHE CALLED THE DON AROUND 9:00 AM AND INFORMED HER THAT THE 3 NURSES REFUSED TO COUNT THE NARCOTICS WITH HER AND REFUSED TO PICK UP MORE RESIDENTS THAN WHAT THEY ALREADY HAD. LPN #6 DENIED ADMINISTERING ANY SCHEDULED MEDICATIONS DUE AT 9:00 AM IN BROWN UNIT. LPN #6 REPORTED SHE DECIDED TO LOCK THE MEDCART (MEDICATION CART) KEYS INSIDE THE CART AND LEAVE THE BUILDING WITHOUT LETTING ANYONE KNOW. ALL 28 RESIDENTS ON THE BROWN UNIT DID NOT RECEIVE ANY OF THE 7:00 AM, 9:00 AM, OR 12:00 PM MEDICATIONS PRESCRIBED. ORDERED MEDICAL TREATMENTS WERE NOT DONE FOR ANY OF THE RESIDENTS ON THE BROWN UNIT ON 1/9/11 FROM 7:00 AM - 2:00 PM. IN AN INTERVIEW ON 2/24/11 AT 2:30 PM, CNA #4 REPORTED THERE WAS NO NURSE ON THE BROWN UNIT ON 1/9/11 FROM 7:00 AM UNTIL THE DON CAME AT 2:00 PM. CNA #4 ALSO RECALLED THAT THE UNIT STARTED OUT WITH 3 CNA'S AT 7:00 AM BUT THE 3RD CNA LEFT SICK AROUND 9:30 AM. CNA #4 STATED CALL LIGHTS WERE BEING ACTIVATED ON THE UNIT AND RESIDENTS WERE ASKING FOR THEIR MEDICATIONS. CNA #4 SAID, "THERE WAS NO NURSE AT THE BROWN UNIT THAT TIME AND WE WERE SHORT OF 2 CNA'S". CNA #4 WAS ABLE TO SPECIFICALLY IDENTIFY RESIDENT (#510) WHO WAS BED BOUND WITH A BAD BEDSORE AND ANOTHER RESIDENT (#511), WITH BOTH LEGS AMPUTATED, WHO WERE ASKING FOR THEIR PAIN MEDICATIONS BUT DID NOT RECEIVE THEM BECAUSE THERE WAS NO NURSE ON THE UNIT. ACCORDING TO CNA #5 ON 2/24/11 AT 2:30 PM, SHE RECALLED CALL LIGHTS WERE GOING OFF THAT DAY AND THERE WERE ONLY 2 CNA'S ON THE UNIT. CNA #5 SAID, "WE DID THE BEST WE COULD TO GET EVERYBODY UP FOR MEALS BUT THE RESIDENTS KEPT ASKING FOR THEIR MEDICATIONS. THERE WAS NO NURSE THAT MORNING AND THERE WERE ONLY 2 CNA'S ON THE UNIT INSTEAD OF 4". CNA #5 REPORTED RESIDENT (RESIDENT #511), WHO WAS A BILATERAL [MEDICAL CONDITION], WAS "IN SEVERE PAIN THAT WE (CNA #4 AND CNA #5) HAD TO PUT HER BACK TO BED BECAUSE WE DID NOT KNOW WHAT ELSE TO DO FOR PAIN RELIEF. THERE WAS NO NURSE UNTIL AROUND 2:00 PM, RIGHT BEFORE OUR SHIFT ENDED." IN AN INTERVIEW ON 2/25/11 AT 10:22 AM LPN #5 STATED THAT A COMMUNICATION ERROR OCCURRED THAT DAY. LPN #5 STATED SHE WAS THE NURSE ASSIGNED TO THE GREEN UNIT AND HAD 2 EMERGENCIES THAT MORNING. LPN #5 STATED SHE SENT 2 RESIDENTS TO THE HOSPITAL DUE TO MEDICAL RELATED ISSUES. LPN #5 DENIED RECEIVING ANY DIRECTIVE FROM ANYONE TO GO TO BROWN AND SPLIT ASSIGNMENTS UNTIL AFTER SHE WAS DONE WITH THE 12:00 MEDICATIONS. LPN #5 DENIED GETTING A CALL FROM THE ON-CALL NURSE #7, NOR FROM THE RECEPTIONIST. LPN #5 STATED SHE WENT TO THE BROWN UNIT AT AROUND 2:30 PM AND AT THAT TIME, THE DON AND THE ON-CALL NURSE #7 WERE ALREADY PASSING MEDICATIONS. IN AN INTERVIEW ON 2/25/11 AT 1:45 PM LPN #8 STATED THAT SHE RECALLED THAT LPN #6 APPROACHED HER AT AROUND 9:00 AM TO COUNT AT THE BROWN UNIT BUT SHE WAS RUNNING BEHIND SCHEDULE AND DIDN'T COUNT WITH HER. NURSE #8 STATED SHE DID NOT KNOW WHAT TIME LPN #6 LEFT THE FACILITY AND THAT AROUND 1:30 PM, RD#3 APPROACHED HER IF SHE COULD GIVE RESIDENT #510 AT THE BROWN UNIT A PAIN PILL. NURSE #8 REPORTED SHE DID NOT KNOW THE RESIDENTS IN THE BROWN UNIT AND FELT UNSAFE GIVING RESIDENT #510 ANY PAIN MEDICATIONS WITHOUT VALIDATION FROM THE PHYSICIAN. NURSE #8 STATED THAT SHE HAD TO CALL THE PHYSICIAN FOR ORDER VERIFICATION OF THE PAIN MEDICATIONS BUT SHE DID NOT GIVE ANY PAIN MEDICATION TO RESIDENT #510. THIS SURVEYOR LEFT A VOICEMAIL FOR LPN #9 ON 2/28/11 AT 11:00 AM, AND TO RETURN THE SURVEYOR'S CALL. NO RESPONSE WAS RECEIVED. THE ADMINISTRATOR AND THE DON WERE INFORMED ON 2/28/11 AT 12:35 PM, OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 1/9/11 AT 7:00 AM, WHEN THERE WAS NO DAY SHIFT NURSE ASSIGNED TO THE BROWN UNIT WITH 28 RESIDENTS REQUIRING 24 HOUR NURSING CARE AND WHEN THE LPN #6 LEFT THE FACILITY WITHOUT NOTIFYING THE DON, THE ON-CALL NURSE #7, OR FACILITY SUPERVISOR (RD #3) WHICH LEFT NO NURSE ON DUTY TO CARE FOR THE 28 BROWN UNIT RESIDENTS AND ONLY 2 OF THE 4 CNA'S ON DUTY IN THE BROWN UNIT PLACING ALL 28 RESIDENTS ON THE BROWN UNIT AT HIGH RISK FOR SERIOUS HARM, INJURY AND OR DEATH. ON 3/2/2011, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON JANUARY 9, 2011, AT 3:00 PM, ALL 28 BROWN UNIT RESIDENTS HAD BEEN PROVIDED WITH MEDICATIONS, WERE ASSESSED FOR COMPLICATIONS, AND STAFFING WAS STABLE. THE 3 STAFF NURSES AND THE ON-CALL NURSE WERE IMMEDIATELY IN-SERVICED BY THE DON, REGARDING THE REFUSAL OF A WORK ASSIGNMENT AND THE PROFESSIONAL STANDARDS OF PRACTICE. 2. ON 1/14/2011, THE 3 NURSES WHO REFUSED TO WORK ON THE UNIT AND THE MIDNIGHT NURSE WERE TERMINATED UPON CLEARANCE FROM HUMAN RESOURCE DIRECTOR. 3. BEGINNING JANUARY 10, 2011, THE DON EDUCATED THE 3 OUT OF 3 NURSE MANAGERS ON HOW TO HANDLE NURSES WHO REFUSE ASSIGNMENT, THE PROTOCOL FOR MANAGEMENT NOTIFICATION, AND THE CONSEQUENCE OF IMPROPER REPORTING RESIDENT SAFETY AND STAFFING CONCERNS. 4. STARTING JANUARY 10, 2011, THE ADMINISTRATOR DISCUSSED STAFFING WITH THE STAFF COORDINATOR AND THE ADMINISTRATOR REVIEWED THE DAILY PER PATIENT DAY STAFFING HOURS MONDAY THROUGH FRIDAY, THE STAFFING COORDINATOR MONITORS STAFFING AND ASSURES THE UNITS ARE COVERED PER THE STAFFING GRID. ISSUES ARE ADDRESSED WITH THE UNIT MANAGERS WHO REWORK ASSIGNMENTS IF NEEDED. 5. ON JANUARY 11 AND JANUARY 12, 2011, THE ADMINISTRATOR COMMUNICATED TO THE MANAGEMENT TEAM THE CRITICAL IMPORTANCE OF CONTACTING HER IN THE EVENT OF ANY UNSAFE SITUATION, WHICH INCLUDES STAFFING. THE CORPORATE CLINICAL NURSE DISCUSSED WITH THE DON THE IMPORTANCE OF STAFFING PROPERLY. THE ADMINISTRATOR EDUCATED 14 OF 14 MANAGEMENT TEAM DURING THE MORNING MEETINGS ON JANUARY 11 AND 12 TO REINFORCE THE CRITICAL IMPORTANCE OF NOTIFYING THE ADMINISTRATOR OF STAFFING SHORTAGES AND ANY UNSAFE SITUATION. THE ADMINISTRATOR CALLS ON WEEKENDS, MONITORS E-MAILS AND VOICEMAIL TO ASSURE THAT SHE IS UPDATED ON INFORMATION. THE ADMINISTRATOR COMES IN PERIODICALLY ON THE WEEKEND TO ASSURE PROPER STAFFING AND RESIDENT CARE IS PROVIDED. 6. ON JANUARY 11, 2011, THE ADMINISTRATOR CHECKS STAFFING DAILY TO ASSURE THE UPCOMING SHIFTS ARE COVERED AND THERE ARE PLANS IN PLACE TO ADDRESS ANY CALL INS. IF THERE IS A NEED TO SPLIT THE UNIT, THE DON OR NURSING MANAGER NOTIFIES THE ADMINISTRATOR AND THE ADMINISTRATOR CONFIRMS THAT THERE IS A CLEAR UNDERSTANDING OF ASSIGNMENTS. 7. BEGINNING JANUARY 11, 2011, THE ADMINISTRATOR CHECKS STAFFING DAILY TO ENSURE COVERAGE OF UPCOMING SHIFTS. PPD'S ARE MONITORED DAILY THROUGH THE KEY FACTOR REPORT AND TIME CARD PUNCH DETAILS ARE REVIEWED BY THE DIRECTOR OF NURSING AND THE ADMINISTRATOR DAILY. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 1/12/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT AN IMMEDIATE JEOPARDY DUE TO SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

THIS CITATIONS PERTAINS TO INTAKE NUMBER'S: MI 860 & MI 426. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO: 1) MAINTAIN PROFESSIONAL STANDARDS OF QUALITY REQUIRED TO PROVIDE CARE INCLUDING MEDICATION ADMINISTRATION, THE ASSESSMENT AND MONITORING OF PAIN, PROVIDE WOUND CARE AND ORDERED TREATMENTS FOR ALL 28 RESIDENTS (#502, #504, #505, #506, #507, #510, #511, #512, #513, #515 AND FACILITY IDENTIFIED RESIDENTS #401, #402, #403, #404, #405, #406, #407, #408, #409, #410, #411, #412, #413, $414, #415, #416, #417, AND UNSAMPLED RESIDENT #30) ON THE BROWN UNIT, AND 2) ENSURE A LICENSED NURSE AND AN ADEQUATE NUMBER OF CERTIFIED NURSE AIDES (CNA'S) WERE ON DUTY TO PROVIDE CARE RESULTING IN AN IMMEDIATE JEOPARDY WHEN ALL 28 RESIDENTS ON THE BROWN UNIT DID NOT RECEIVE SCHEDULED AND AS NEEDED MEDICATIONS, AND NURSING CARE AND SERVICES FROM A LICENSED NURSE BETWEEN 7:00 AM - 2:00 PM ON [DATE], PLACING ALL 28 RESIDENTS ON THE BROWN UNIT AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: According to the Code of Ethic for Nurses (American Nurses Association, 2001, pg. 14), the nurse's primary commitment is to the health, well-being, and safety of the patient. The nurse must take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team. The Code of Ethics for Nurses (pg. 17) goes on to state the nurse is accountable to the quality of nursing care give to patients and the delegation of nursing care activities of other health care workers. The nurse is responsible for monitoring the activities of these individuals and evaluating the quality of the care provided. ACCORDING TO CREIGHTON IN "LAW EVERY NURSE SHOULD KNOW" (5TH ED. P. 13), AN ANA STANDARD OF PRACTICE INCLUDES: "THE COLLECTION OF DATA ABOUT A HEALTH STATUS OF THE PATIENT IS SYSTEMATIC AND CONTINUOUS. THESE DATA ARE COMMUNICATED TO APPROPRIATE PERSONS, RECORDED AND STORED IN A RETRIEVABLE AND ACCESSIBLE SYSTEM." (P. 98) "LEGALLY, NURSES MUST OBEY THE ORDERS OF THE PHYSICIAN IN CHARGE OF THE PATIENT, UNLESS THE ACT WOULD RESULT IN INJURY TO THE PATIENT IF IT WERE CARRIED OUT." ON [DATE] AT 11:05 AM, THE DIRECTOR OF NURSING (DON) admitted THERE WAS NO NURSE WHO WORKED AT THE BROWN UNIT ON [DATE] FROM 7:00 AM UNTIL 2:00 PM. THERE WERE 28 RESIDENTS RESIDING IN THE BROWN UNIT THAT DAY. RESIDENTS' DAILY SCHEDULED MEDICATIONS (9:00 AM AND 12:00 PM) WERE NOT ADMINISTERED TO ALL 28 RESIDENTS. THE MIDNIGHT NURSE (LPN#6) LEFT THE BROWN UNIT MEDICATION CART KEY INSIDE THE CART AND LEFT THE BUILDING WITHOUT TELLING ANYONE. NO ONE KNEW WHAT TIME THE MIDNIGHT NURSE LEFT. THE DON DID NOT ARRIVE AT THE FACILITY UNTIL 2:00 PM ON [DATE]. IN A TELEPHONE INTERVIEW ON [DATE] AT 2:00 PM, THE MIDNIGHT SHIFT (LPN #6) REPORTED SHE FOUND OUT THERE WAS NO DAY SHIFT NURSE TO COUNT THE NARCOTICS AT AROUND 7:30 AM ON [DATE]. SHE INFORMED THE ON-CALL NURSE #7 IMMEDIATELY. THE ON-CALL NURSE #7 TOLD LPN #6 THAT SHE WAS NOT COMING AND TO TELL THE 3 NURSES ASSIGNED TO THE OTHER 3 UNITS, TO SPLIT THE BROWN UNIT ASSIGNMENT AMONG THEMSELVES. LPN # 6 REPORTED SHE CALLED THE DON AROUND 9:00 AM AND INFORMED HER THAT THE 3 NURSES REFUSED TO COUNT THE NARCOTICS WITH HER AND REFUSED TO PICK UP MORE RESIDENTS OTHER THAN WHAT THEY ALREADY HAD. LPN #6 REPORTED SHE DECIDED TO LOCK THE MEDCART (MEDICATION CART) KEYS INSIDE THE CART AND LEAVE THE BUILDING WITHOUT LETTING ANYONE KNOW. THE REGISTERED DIETICIAN (RD) #3 IN AN INTERVIEW ON [DATE] AT 1:05 PM, STATED THAT SHE ARRIVED AT THE FACILITY BETWEEN 8:,[DATE]:00 AM ON [DATE] AND WAS THE FACILITY SUPERVISOR FOR THE DAY. RD #3 REPORTED SHE WAS NOT AWARE UNTIL 9:30 AM THAT THERE WAS NO DAY SHIFT NURSE ON DUTY ON THE BROWN UNIT. RD #3 STATED SHE IMMEDIATELY CALLED THE ON-CALL NURSE #7 AND MADE HER AWARE THAT THE BROWN UNIT DID NOT HAVE A LICENSED NURSE ON DUTY AND THERE WERE ONLY 2 NURSE AIDES WORKING IN THE UNIT INSTEAD OF THE 4 THAT SHOULD HAVE BEEN ON DUTY. RD #3 THEN ASSUMED THE ON-CALL NURSE #7 TOOK CARE OF IT. RD #3 REPORTED THAT AT APPROXIMATELY 1:30 PM, SHE WAS PAGED TO THE BROWN UNIT BECAUSE RESIDENT #510'S FAMILY WAS VERY UPSET AND HAD THREATENED TO CALL THE STATE BECAUSE RESIDENT #510 HAD BEEN IN PAIN AND HAD NOT RECEIVED ANY OF HER SCHEDULED MEDICATIONS. RD #3 REPORTED SHE WENT TO THE OTHER 3 SCHEDULED NURSES (WHO HAD REFUSED TO ASSUME CARE EARLIER) AND BEGGED THEM TO ADMINISTER RESIDENT #510'S PAIN MEDICATION BUT THEY CONTINUED TO REFUSE TO HELP. RD #3 THEN CALLED THE DON REGARDING THE 3 NURSES REFUSING TO PROVIDE CARE AND RESIDENT #510'S REQUEST FOR PAIN MEDICATIONS AND THE FAMILY THREATENING TO CALL THE STATE. THE DON ARRIVED THE FACILITY AT 2:00 PM ON [DATE]. THE ON-CALL NURSE #7 ARRIVED AT AROUND 2:30 PM ON [DATE]. RESIDENT #510 RESIDENT #510 WAS [AGE] years OLD WHO WAS admitted to the facility on [DATE]. REVIEW OF THE HISTORY AND PHYSICAL DATED [DATE] REVEALED RESIDENT #510 HAD [DIAGNOSES REDACTED]. REVIEW OF THE THE WOUND EVALUATION DATED [DATE] REVEALED RESIDENT #510 HAD AN EVALUATION AND treatment for [REDACTED]. THE WOUND EVALUATION DID NOT INDICATE ANY SIGNS AND SYMPTOMS OF INFECTION. REVIEW OF THE MAR (MEDICATION ADMINISTRATION RECORD) REVEALED THAT ON [DATE], RESIDENT #510'S 9:00 AM SCHEDULED MEDICATIONS WERE NOT ADMINISTERED. RESIDENT #510'S MAR indicated [REDACTED]' S REQUEST FOR PAIN RELIEF THAT DAY. PER A PHYSICIAN'S ORDER DATED [DATE], RESIDENT #510 WAS TO RECEIVE A [MEDICATION NAME] PATCH (PAIN PATCH) 25 MCG Q 72 HOURS FOR PAIN AND [MEDICATION NAME] (PAIN MEDICATION) ,[DATE], 2 TABLETS BY MOUTH EVERY 4 HOURS AS NEEDED. THERE WAS NO RECORD OF ANY [MEDICATION NAME] GIVEN FOR THE MONTH OF JANUARY AND THE LAST [MEDICATION NAME] PATCH WAS APPLIED ON [DATE] AT 6:00 AM. REVIEW OF THE CLINICAL RECORD REVEALED RESIDENT #510'S PHYSICIAN'S ORDERS DATED [DATE], WERE NOT ACCURATELY TRANSCRIBED INTO THE [DATE] MAR. RESIDENT #510'S [MEDICATION NAME] ORDERS WERE NOT FOUND IN THE JANUARY MAR. THERE WAS NO EVIDENCE THAT RESIDENT #510 RECEIVED ANY [MEDICATION NAME] AS NEEDED FOR PAIN FROM [DATE]-[DATE] AS ORDERED. ADDITIONAL MEDICATIONS, INCLUDING [MEDICATION NAME] (BLOOD PRESSURE MEDICATION) 10 MG I TABLET DAILY, ARTIFICIAL TEARS 1 DROP IN BOTH EYES DAILY, CALCITROL (VITAMIN D) 0.25 MCG 1 CAPSULE DAILY, WERE ORDERED BUT WERE ALSO NOT LISTED IN THE [DATE] MAR. THERE WAS NO EVIDENCE THAT THESE MEDICATIONS WERE ADMINISTERED AS ORDERED. [MEDICATION NAME] SULFATE (IRON) 325 MG, 1 TABLET BY MOUTH TWICE DAILY WAS ADMINISTERED ONLY ONCE A DAY. TWO PRN (AS NEEDED) ORDERS: [MEDICATION NAME] (STOOL SOFTENER) 100 MG AND MILK OF MAGNESIA WAS ORDERED, BUT WAS GIVEN DAILY AT 9:00 AM. NO ASSESSMENT AND REASON FOR GIVING BOTH PRN ORDERED [MEDICATION NAME] AND MILK OF MAGNESIA WAS FOUND IN THE MAR indicated [REDACTED] IN AN TELEPHONE INTERVIEW ON [DATE] AT 9:10 AM THE TREATMENT NURSE (LPN #11) STATED THAT SHE ARRIVED AT THE FACILITY AT APPROXIMATELY 9:00 AM ON [DATE]. LICENSED PRACTICAL NURSE (LPN) #11 REPORTED GOING TO RESIDENT #510'S ROOM BETWEEN 1:00 -2:00 PM, BUT RESIDENT #510 COMPLAINED OF PAIN WHEN LPN #11 MOVED HER LEG. LPN #11 admitted SHE DID NOT DO THE TREATMENT TO HER COCCYX DUE TO RESIDENT #510'S PAIN ON [DATE]. SHE DOCUMENTED ON THE BACK OF THE TREATMENT SHEET DATED [DATE], "RESIDENT (#510) UNABLE TO TURN FOR SACRO/COCCYX WOUND HAVING PAIN (REFUSED)". LPN #11 ADDED THAT SHE FAILED TO ASK FOR HELP FROM NURSING ASSISTANTS TO POSITION THE RESIDENT DURING THE ATTEMPTED WOUND treatment for [REDACTED]. LPN #11 STATED SHE FAILED TO INFORM THE NURSE (THERE WAS NONE ON THE BROWN UNIT) THAT RESIDENT #510'S COCCYX WOUND TREATMENT WAS NOT DONE DUE TO HER COMPLAINTS OF PAIN. LPN#11 ALSO STATED SHE DID NOT CALL THE PHYSICIAN TO DISCUSS ANY OTHER PAIN CONTROL OPTIONS. LPN #11 LEFT RESIDENT #510 WITHOUT PROVIDING PAIN RELIEF AND WITHOUT PERFORMING WOUND CARE AS ORDERED. LPN #11 SAID, "I WAS MORE CONCERNED WITH PROVIDING RESIDENT #501 COMFORT MEASURES SO I DECIDED NOT PERFORM THE WOUND TREATMENT TO HER BOTTOM". IN AN INTERVIEW ON [DATE] AT 2:30 PM, CNA #4 REPORTED THERE WAS NO NURSE ON THE BROWN UNIT ON [DATE] FROM 7:00 AM UNTIL THE DON CAME AT 2:00 PM. CNA #4 ALSO RECALLED THAT THE UNIT STARTED OUT WITH 3 CNA'S AT 7:00 AM BUT THE 3RD CNA LEFT SICK AROUND 9:30 AM. CNA #4 STATED CALL LIGHTS WERE BEING ACTIVATED ON THE UNIT AND RESIDENTS WERE ASKING FOR THEIR MEDICATIONS. CNA #4 SAID, "THERE WAS NO NURSE AT THE BROWN UNIT THAT TIME AND WE WERE SHORT OF 2 CNA'S". CNA #4 WAS ABLE TO SPECIFICALLY IDENTIFY RESIDENT (#510) WHO WAS BED BOUND WITH A BAD BEDSORE AND ANOTHER RESIDENT (#511), WITH BOTH LEGS AMPUTATED, WHO WERE ASKING FOR THEIR PAIN MEDICATIONS BUT DID NOT RECEIVE THEM BECAUSE THERE WAS NO NURSE ON THE UNIT. ACCORDING TO CNA #5 ON [DATE] AT 2:30 PM, SHE RECALLED CALL LIGHTS WERE GOING OFF THAT DAY AND THERE WERE ONLY 2 CNA'S ON THE UNIT. CNA #5 SAID, "WE DID THE BEST WE COULD TO GET EVERYBODY UP FOR MEALS BUT THE RESIDENTS KEPT ASKING FOR THEIR MEDICATIONS. THERE WAS NO NURSE THAT MORNING AND THERE WERE ONLY 2 CNA'S ON THE UNIT INSTEAD OF 4". CNA #5 REPORTED RESIDENT (RESIDENT #511), WHO WAS A BILATERAL [MEDICAL CONDITION], WAS "IN SEVERE PAIN THAT WE (CNA #4 AND CNA #5) HAD TO PUT HER BACK TO BED BECAUSE WE DID NOT KNOW WHAT ELSE TO DO FOR PAIN RELIEF. THERE WAS NO NURSE UNTIL AROUND 2:00 PM, RIGHT BEFORE OUR SHIFT ENDED." ACCORDING TO THE AMBULANCE RUN SHEET DATED [DATE], RESIDENT #510 WAS TRANSPORTED TO THE HOSPITAL ON [DATE] AT 3:30 PM. REVIEW OF THE HOSPITAL RECORDS REVEALED RESIDENT #510 ARRIVED AT THE emergency roiagnom on [DATE] AT 3:36 PM WITH A PRESENTING [DIAGNOSES REDACTED]. THE SKIN ASSESSMENT AT THE emergency room DATED [DATE] AT 6:11 PM, DESCRIBED A SACRAL/COCCYX WOUND (STAGE 4 ULCER) THAT MEASURED 14.0 CM X 10.0 CM AND A LEFT LEG WOUND MEASURING 7.0 CM X 2.0 CM. RESIDENT #510 IMMEDIATELY RECEIVED ANTIBIOTIC INTRAVENOUSLY (THROUGH THE VEIN) AND HAD SURGICAL DEBRIDEMENT (REMOVAL OF DEAD TISSUE) OF HER DECUBITUS ULCER. RESIDENT #510 expired on [DATE] AT THE HOSPITAL DUE TO MEDICAL COMPLICATIONS. RESIDENT #511 REVIEW OF THE FACE SHEET REVEALED RESIDENT # 511 WAS [AGE] years OLD admitted to the facility on [DATE]. REVIEW OF THE HISTORY AND PHYSICAL DATED [DATE], REVEALED RESIDENT #511 HAD BILATERAL (BOTH) ABOVE THE KNEE AMPUTATION (AKA), INSULIN DEPENDENT DIABETES, CEREBRO VASCULAR ACCIDENT (STROKE) WITH [MEDICAL CONDITION] (DIFFICULTY WITH SPEECH), AND RIGHT SIDE [MEDICAL CONDITION] (WEAKNESS). REVIEW OF THE PHYSICIAN'S ORDER DATED [DATE], REVEALED RESIDENT #511 WAS TO HAVE PAIN MONITORING AND MEDICATIONS FOR BILATERAL AMPUTATION AND SCHEDULED INSULIN INJECTIONS AT 8:00 AM, 11:30 AM, AND 6:00 PM WITH ACCUCHECK (BLOOD SUGAR) MONITORING AT 6:30 AM, 11:30 AM, 4:30 PM, AND 9:00 PM. RESIDENT #511'S MEDICAL RECORD ON [DATE] DID NOT SHOW EVIDENCE THAT SHE RECEIVE ANY MEDICATIONS FOR PAIN, NO ACCUCHECK WAS COMPLETED NOR INSULIN ADMINISTERED BETWEEN 7:00 AM - 2:00 PM ON [DATE]. THE CLINICAL RECORD REVEALED NO NURSES NOTES OR DOCUMENTED ASSESSMENTS WERE ENTERED FROM [DATE]-[DATE]. RESIDENT #511 WAS TRANSFERRED TO A NEARBY HOSPITAL ON [DATE], DUE TO CHEST PAIN AND [MEDICAL CONDITION] CLINICAL RECORD FOR OTHER RESIDENTS (#512, #513, #507,#505, AND #515) REVEALED: REVIEW OF THE CLINICAL RECORDS REVEALED ALL THE ABOVE RESIDENTS DID NOT RECEIVE ANY OF THEIR SCHEDULED MEDICATIONS FROM 7:00 AM-2:00 PM. THERE WERE NO PHYSICIAN'S ORDERS IN THE CHARTS TO ALLOW A DELAY OR SKIP IN MEDICATIONS THAT WERE DUE ON [DATE] (7:,[DATE]:00 SHIFT). THERE WERE NO physician progress notes [REDACTED]. RESIDENT #512, ACCORDING TO THE CNA #4 AND CNA #5 ON [DATE] AT 2:30 PM, WAS COMPLAINING OF PAIN ALL MORNING. THE MAR indicated [REDACTED]. REVIEW OF THE DOCTOR'S ORDER DATED [DATE], REVEALED RESIDENT #512 WAS TO RECEIVE THE PAIN MEDICATION [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME] ,[DATE]) 1 TABLET PO (BY MOUTH) EVERY 4 HOURS AROUND THE CLOCK. THE CLINICAL RECORD REVEALED RESIDENT #513 REQUIRED AN ACCUCHECK WITH SLIDING SCALE INSULIN COVERAGE AT 6:00 AM, 11:00 AM, 4:00 PM, AND 9:00 PM. REVIEW OF THE MAR indicated [REDACTED]. NO DOCUMENTATION WAS FOUND IN THE NURSE'S NOTES INDICATING THAT THE BLOOD SUGAR LEVELS WERE WITHIN THE NORMAL LIMITS ON [DATE], [DATE] AND [DATE] AT 11:00 AM. ACCORDING TO CNA #5 ON [DATE] AT 2:30 PM, RESIDENT #507 COMPLAINED OF PAIN ON THE MORNING OF [DATE]. CNA #5 REPORTED RESIDENT #507 REQUESTED A PAIN PILL SEVERAL TIMES THAT DAY. A REVIEW OF RESIDENT #507'S [DATE] MAR indicated [REDACTED]. THERE WAS NO PAIN MEDICATION ADMINISTERED ON [DATE]. THE PAIN ASSESSMENT WAS LEFT BLANK DURING 7AM -3 PM SHIFT ON [DATE]. REVIEW OF THE CLINICAL RECORD REVEALED RESIDENT # 505 HAD SEVERE DIARRHEA IN THE EARLY MORNING HOURS AND WAS GIVEN A STANDING ORDER OF [MEDICATION NAME] AT 5:00 AM ON [DATE]. RESIDENT #505 CONTINUED TO HAVE DIARRHEA THROUGHOUT THE DAY. AS THERE WAS NO NURSE ON THE UNIT ALL MORNING, RESIDENT #505 WAS NOT ASSESSED AND MONITORED FOR COMPLICATIONS OF DIARRHEA (ESSENTIAL FLUID LOSS, ELEVATED POTASSIUM, DEHYDRATION). ACCORDING TO CNA #5 ON [DATE] AT 2:30 PM, SHE REMEMBERED RESIDENT #505 WAS HAVING SEVERAL EPISODES OF LOOSE STOOL ALL MORNING, BUT THERE WAS NO NURSE AVAILABLE TO ASSIST. RESIDENT # 505'S PHYSICIAN'S ORDER DATED [DATE], REVEALED: [MEDICATION NAME] .083% INHALER ([MEDICATION NAME][MEDICATION NAME] USED TO OPEN THE AIRWAY) SOLUTION INHALE 1 UNIT DOSE VIA AEROSOL EVERY 6 HOURS (6 AM, 12 NOON, 6 PM AND 12 MN), [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME] USED TO OPEN THE AIRWAY) .02% SOLN. INHALE 1 UNIT DOSE VIA AEROSOL EVERY 6 HOURS FOR WHEEZING, [MEDICATION NAME] (USED TO PREVENT AIRWAY SPASMS) 18 MCG CP-HANDIHALER INHALE 1 CAPSULE USING 2 INHALATIONS, VIA HANDIHALER ONCE DAILY (9:00 AM). ALL RESIDENT #505'S RESPIRATORY MEDICATIONS AND TREATMENTS WERE NOT ADMINISTERED AS ORDERED ON [DATE] AT 6:00 AM, 9:00 AM, AND AT 12:00 PM. THERE WAS NO EVIDENCE THAT THE OXYGEN (AT ,[DATE] LITERS PER NASAL CANNULA) WAS MONITORED FOR FUNCTION, PATENCY, OR EFFECTIVENESS. THE ADMINISTRATOR ON [DATE] AT 10:15 AM, STATED THAT SHE DID NOT RECEIVE ANY CALLS FROM THE SUPERVISOR ON CALL (RD #3), DIRECTOR OF NURSING, NOR THE ON-CALL NURSE #7 THAT SUNDAY ([DATE]). SHE WAS UNAWARE OF THE STAFFING PROBLEM AND LACK OF NURSE COVERAGE UNTIL THE NEXT DAY ([DATE]). THE ADMINISTRATOR AND THE DON WERE INFORMED ON [DATE] AT 12:35 PM, OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AT 7:00 AM, DUE TO THE FAILURE TO: 1) MAINTAIN PROFESSIONAL STANDARDS OF QUALITY REQUIRED TO PROVIDE CARE INCLUDING MEDICATION ADMINISTRATION, THE ASSESSMENT AND MONITORING OF PAIN, PROVIDE WOUND CARE AND ORDERED TREATMENTS FOR ALL 28 RESIDENTS ON THE BROWN UNIT, AND 2) ENSURE A LICENSED NURSE AND AN ADEQUATE NUMBER OF CERTIFIED NURSE AIDES (CNA'S) WERE ON DUTY TO PROVIDE CARE RESULTING IN AN IMMEDIATE JEOPARDY WHEN ALL 28 RESIDENTS ON THE BROWN UNIT DID NOT RECEIVE SCHEDULED AND AS NEEDED MEDICATIONS, AND NURSING CARE AND SERVICES FROM A LICENSED NURSE BETWEEN 7:00 AM - 2:00 PM ON [DATE], PLACING ALL 28 RESIDENTS ON THE BROWN UNIT AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON [DATE] AT 4:00 PM, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE] AT 2:15, THE DON INSTRUCTED THE BURGUNDY UNIT NURSE TO CONTACT THE MEDICAL DIRECTOR FOR PERMISSION TO GIVE DAILY MEDICATIONS LATE. PERMISSION WAS GRANTED. BY 3:00 PM ON [DATE], RESIDENTS HAD BEEN PROVIDED WITH MEDICATIONS, HAD BEEN ASSESSED, AND THE STAFFING WAS STABLE. 2. ON [DATE], THE 3 STAFF NURSES (WHO HAD REFUSED TO ASSUME CARE OF THE BROWN UNIT RESIDENTS) AND THE ON-CALL NURSE (#7) WERE IMMEDIATELY INSERVICED BY THE DIRECTOR OF NURSING, REGARDING THE REFUSAL OF A WORK ASSIGNMENT AND THEIR PROFESSIONAL STANDARDS OF PRACTICE. 3. BEGINNING [DATE] AND COMPLETED ON [DATE], THE DON EDUCATED 3 OF 3 NURSE MANAGERS ON HOW TO HANDLE NURSES WHO REFUSE ASSIGNMENT, THE PROTOCOL FOR NOTIFYING MANAGEMENT OF STAFFING ISSUES, AND THE CONSEQUENCE OF IMPROPER REPORTING RESIDENT SAFETY AND STAFFING CONCERNS. 4. STARTING [DATE], THE ADMINISTRATOR DISCUSSED STAFFING WITH THE STAFF COORDINATOR AND THE ADMINISTRATOR REVIEWED THE DAILY PER PATIENT DAY STAFFING HOURS MONDAY THROUGH FRIDAY, THE STAFFING COORDINATOR MONITORS STAFFING AND ASSURES THE UNITS ARE COVERED PER THE STAFFING GRID. ISSUES ARE ADDRESSED WITH THE UNIT MANAGERS WHO REWORK ASSIGNMENTS IF NEEDED. THERE HAVE BEEN NO EPISODES OF NON COVERAGE OF A UNIT SINCE [DATE] BECAUSE MONITORING OF ASSIGNMENTS. FURTHER EDUCATION WAS GIVEN TO 3 OUT OF 3 UNIT MANAGERS ON REVIEW OF STAFFING/ON CALL RESPONSIBILITIES DOCUMENT. 5. ON [DATE] AND [DATE], THE ADMINISTRATOR COMMUNICATED TO THE MANAGEMENT TEAM THE CRITICAL IMPORTANCE OF CONTACTING HER IN THE EVENT OF ANY UNSAFE SITUATION, WHICH INCLUDES STAFFING. THE CORPORATE CLINICAL NURSE DISCUSSED WITH THE DON THE IMPORTANCE OF STAFFING PROPERLY. THE ADMINISTRATOR EDUCATED 14 OF 14 MANAGEMENT TEAM DURING THE MORNING MEETINGS ON [DATE] AND 12 TO REINFORCE THE CRITICAL IMPORTANCE OF NOTIFYING THE ADMINISTRATOR OF STAFFING SHORTAGES AND ANY UNSAFE SITUATION, INCLUDING STAFFING. AS OF [DATE], THE ADMINISTRATOR CALLS ON WEEKENDS, MONITORS E-MAILS AND VOICEMAIL TO ASSURE THAT SHE IS UPDATED ON INFORMATION. THE ADMINISTRATOR COMES IN PERIODICALLY ON THE WEEKEND TO ASSURE PROPER STAFFING AND RESIDENT CARE IS PROVIDED. 6. BEGINNING [DATE], THE ADMINISTRATOR CHECKS STAFFING DAILY TO ENSURE COVERAGE OF UPCOMING SHIFTS. PPD'S ARE MONITORED DAILY THROUGH THE KEY FACTOR REPORT AND TIME CARD PUNCH DETAILS ARE REVIEWED BY THE DIRECTOR OF NURSING AND THE ADMINISTRATOR DAILY. 7. ON [DATE], THE DIRECTOR OF NURSING INSERVICED MIDNIGHT NURSE #6 ON THE INAPPROPRIATENESS OF HER LEAVING KEYS IN THE CART AS WELL AS PROFESSIONAL STANDARDS OF PRACTICE. 8. THE 3 NURSES WHO REFUSED TO WORK ON THE UNIT AND LPN #6 WERE TERMINATED ON [DATE] UPON CLEARANCE OF HUMAN RESOURCE DIRECTOR. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT AN IMMEDIATE JEOPARDY DUE TO SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

REFER TO INTAKE #'S: MI 860, MI BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE, ASSESSMENT AND MONITORING FOR ALL 28 RESIDENTS IN THE BROWN UNIT AND FAILED TO ASSESS AND PROVIDE PAIN RELIEF TO 2 OF 15 SAMPLED RESIDENTS (#510 AND #511) RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #510 AND #511 SUFFERED PERSISTENT, UNRELIEVED PAIN ON [DATE] FROM 7:00 AM - 2:00 PM DUE TO A LACK OF A LICENSED NURSE AVAILABLE TO ADMINISTER PRESCRIBED MEDICATIONS AND TREATMENTS FOR RESIDENT #510 AND #511 (WHO RESIDED ON THE BROWN UNIT) AND THE ADDITIONAL 26 RESIDENTS WHO ALSO RESIDED ON THE BROWN UNIT, PLACING ALL RESIDENTS ON THE BROWN UNIT AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: ACCORDING TO THE STAFFING REPORT AND CLINICAL RECORDS,THERE WAS NO NURSE COVERAGE ON THE BROWN UNIT (WITH A CENSUS OF 28 RESIDENTS) ON [DATE] FROM 7:00 AM-2:00 PM. ALL 28 RESIDENTS IN THE BROWN UNIT DID NOT RECEIVED ANY OF THEIR SCHEDULED MORNING AND NOON MEDICATIONS OR TREATMENTS ON [DATE] FROM 7:00 AM-2:00 PM. ON [DATE] AT 11:05 AM, THE DIRECTOR OF NURSING (DON) admitted THERE WAS NO NURSE WHO WORKED AT THE BROWN UNIT ON [DATE] FROM 7:00 AM UNTIL 2:00 PM. THERE WERE 28 RESIDENTS RESIDING IN THE BROWN UNIT THAT DAY. RESIDENTS' DAILY SCHEDULED MEDICATIONS (9:00 AM AND 12:00 PM) WERE NOT ADMINISTERED TO ALL 28 RESIDENTS. THE MIDNIGHT NURSE (LPN#6) LEFT THE BROWN UNIT MEDICATION CART KEY INSIDE THE CART AND LEFT THE BUILDING WITHOUT TELLING ANYONE. NO ONE KNEW WHAT TIME THE MIDNIGHT NURSE LEFT. THE DON DID NOT ARRIVE AT THE FACILITY UNTIL 2:00 PM ON [DATE]. IN A TELEPHONE INTERVIEW ON [DATE] AT 2:00 PM, THE MIDNIGHT SHIFT (LPN #6) REPORTED SHE FOUND OUT THERE WAS NO DAY SHIFT NURSE TO COUNT THE NARCOTICS AT AROUND 7:30 AM ON [DATE]. SHE INFORMED THE ON-CALL NURSE #7 IMMEDIATELY. THE ON-CALL NURSE #7 TOLD LPN #6 THAT SHE WAS NOT COMING AND TO TELL THE 3 NURSES ASSIGNED TO THE OTHER 3 UNITS, TO SPLIT THE BROWN UNIT ASSIGNMENT AMONG THEMSELVES. LPN # 6 REPORTED SHE CALLED THE DON AROUND 9:00 AM AND INFORMED HER THAT THE 3 NURSES REFUSED TO COUNT THE NARCOTICS WITH HER AND REFUSED TO PICK UP MORE RESIDENTS OTHER THAN WHAT THEY ALREADY HAD. LPN #6 REPORTED SHE DECIDED TO LOCK THE MEDCART (MEDICATION CART) KEYS INSIDE THE CART AND LEAVE THE BUILDING WITHOUT LETTING ANYONE KNOW. THE REGISTERED DIETICIAN (RD) #3 IN AN INTERVIEW ON [DATE] AT 1:05 PM, STATED THAT SHE ARRIVED AT THE FACILITY BETWEEN 8:,[DATE]:00 AM ON [DATE] AND WAS THE FACILITY SUPERVISOR FOR THE DAY. RD #3 REPORTED SHE WAS NOT AWARE UNTIL 9:30 AM THAT THERE WAS NO DAY SHIFT NURSE ON DUTY ON THE BROWN UNIT. RD #3 STATED SHE IMMEDIATELY CALLED THE ON-CALL NURSE #7 AND MADE HER AWARE THAT THE BROWN UNIT DID NOT HAVE A LICENSED NURSE ON DUTY, THAT LPN #6 HAD LEFT THE FACILITY WITHOUT COUNTING NARCOTICS AND WITHOUT DISCLOSING THE LOCATION OF THE KEY TO THE MEDICATION CART, AND THERE WERE ONLY 2 NURSE AIDES WORKING IN THE UNIT INSTEAD OF THE 4 THAT SHOULD HAVE BEEN ON DUTY. THE ON-CALL NURSE #7 TOLD RD #3 BY TELEPHONE AT AROUND 9:30 AM, THAT SHE HAD ASSIGNED THE 3 DAY SHIFT NURSES FROM THE OTHER 3 UNITS TO SPLIT THE 28 RESIDENTS AMONG THEMSELVES. RD #3 THEN ASSUMED THE ON-CALL NURSE #7 TOOK CARE OF IT. RD #3 REPORTED THAT AT APPROXIMATELY 1:30 PM, SHE WAS PAGED TO THE BROWN UNIT BECAUSE RESIDENT #510'S FAMILY WAS VERY UPSET AND HAD THREATENED TO CALL THE STATE BECAUSE RESIDENT #510 HAD BEEN IN PAIN AND HAD NOT RECEIVED ANY OF HER SCHEDULED MEDICATIONS. RD #3 REPORTED SHE WENT TO THE OTHER 3 SCHEDULED NURSES (WHO HAD REFUSED TO ASSUME CARE EARLIER) AND BEGGED THEM TO ADMINISTER RESIDENT #510'S PAIN MEDICATION BUT THEY CONTINUED TO REFUSE TO HELP. RD #3 THEN CALLED THE DON REGARDING THE 3 NURSES REFUSING TO PROVIDE CARE AND RESIDENT #510'S REQUEST FOR PAIN MEDICATIONS AND THE FAMILY THREATENING TO CALL THE STATE. THE DON ARRIVED THE FACILITY AT 2:00 PM ON [DATE]. THE ON-CALL NURSE #7 ARRIVED AT AROUND 2:30 PM ON [DATE]. IN AN INTERVIEW ON [DATE] AT 2:45 PM THE ON-CALL NURSE # 7 STATED THAT SHE WAS ON CALL THAT DAY BUT WAS IN LANSING WHEN SHE RECEIVED A CALL FROM THE FACILITY SUPERVISOR (RD #3) AT 9:30 AM AND COULD NOT GET TO THE FACILITY. SHE ARRIVED AT THE FACILITY AT 2:30 PM ON [DATE]. SHE WORKED AS THE AFTERNOON SHIFT NURSE OF THE BROWN UNIT THAT NIGHT BECAUSE THERE WAS NO NURSE ASSIGNED TO THE BROWN UNIT FOR THE AFTERNOON SHIFT. RESIDENT #510 RESIDENT #510 WAS [AGE] years OLD WHO WAS admitted to the facility on [DATE]. REVIEW OF THE HISTORY AND PHYSICAL DATED [DATE] REVEALED RESIDENT #510 HAD [DIAGNOSES REDACTED]. REVIEW OF THE THE WOUND EVALUATION DATED [DATE] REVEALED RESIDENT #510 HAD AN EVALUATION AND treatment for [REDACTED]. THE WOUND EVALUATION DID NOT INDICATE ANY SIGNS AND SYMPTOMS OF INFECTION. REVIEW OF THE MAR (MEDICATION ADMINISTRATION RECORD) REVEALED THAT ON [DATE], RESIDENT #510'S 9:00 AM SCHEDULED MEDICATIONS WERE NOT ADMINISTERED. RESIDENT #510'S MAR indicated [REDACTED]' S REQUEST FOR PAIN RELIEF THAT DAY. PER A physician's orders [REDACTED]. THERE WAS NO RECORD OF ANY [MEDICATION NAME] GIVEN FOR THE MONTH OF JANUARY AND THE LAST [MEDICATION NAME] PATCH WAS APPLIED ON [DATE] AT 6:00 AM. THE NEXT [MEDICATION NAME] PATCH WAS APPLIED TO RESIDENT #510 ON [DATE] AT 9:00 PM. HOWEVER, ACCORDING TO THE AMBULANCE RUN SHEET DATED [DATE], RESIDENT #510 WAS TRANSPORTED TO THE HOSPITAL ON [DATE] AT 3:30 PM. IN AN TELEPHONE INTERVIEW ON [DATE] AT 9:10 AM THE TREATMENT NURSE (LPN #11) STATED THAT SHE ARRIVED AT THE FACILITY AT APPROXIMATELY 9:00 AM ON [DATE]. LPN #11 STATED SHE WAS UNAWARE ABOUT THE STAFFING PROBLEM AND NO ONE APPROACHED HER THERE WAS NO NURSE ON DUTY ON THE BROWN UNIT. LPN #11 REPORTED GOING TO RESIDENT #510'S ROOM BETWEEN 1:00 - 2:00 PM, BUT RESIDENT #510 COMPLAINED OF PAIN WHEN LPN #11 MOVED HER LEG. LPN #11 admitted SHE DID NOT DO THE TREATMENT TO HER COCCYX DUE TO RESIDENT #510'S PAIN ON [DATE]. SHE DOCUMENTED ON THE BACK OF THE TREATMENT SHEET DATED [DATE], "RESIDENT (#510) UNABLE TO TURN FOR SACRO/COCCYX WOUND HAVING PAIN (REFUSED)". LPN #11 ADDED THAT SHE FAILED TO ASK FOR HELP FROM NURSING ASSISTANTS TO POSITION THE RESIDENT DURING THE ATTEMPTED WOUND treatment for [REDACTED]. LPN #11 STATED SHE FAILED TO INFORM THE NURSE (THERE WAS NONE ON THE BROWN UNIT) THAT RESIDENT #510'S COCCYX WOUND TREATMENT WAS NOT DONE DUE TO HER COMPLAINTS OF PAIN. LPN#11 ALSO STATED SHE DID NOT CALL THE PHYSICIAN TO DISCUSS ANY OTHER PAIN CONTROL OPTIONS. LPN #11 LEFT RESIDENT #510 WITHOUT PROVIDING PAIN RELIEF AND WITHOUT PERFORMING WOUND CARE AS ORDERED. LPN #11 SAID, "I WAS MORE CONCERNED WITH PROVIDING RESIDENT #501 COMFORT MEASURES SO I DECIDED NOT PERFORM THE WOUND TREATMENT TO HER BOTTOM". IN AN INTERVIEW ON [DATE] AT 2:30 PM, CNA #4 REPORTED THERE WAS NO NURSE ON THE BROWN UNIT ON [DATE] FROM 7:00 AM UNTIL THE DON CAME AT 2:00 PM. CNA #4 ALSO RECALLED THAT THE UNIT STARTED OUT WITH 3 CNA'S AT 7:00 AM BUT THE 3RD CNA LEFT SICK AROUND 9:30 AM. CNA #4 STATED CALL LIGHTS WERE BEING ACTIVATED ON THE UNIT AND RESIDENTS WERE ASKING FOR THEIR MEDICATIONS. CNA #4 SAID, "THERE WAS NO NURSE AT THE BROWN UNIT THAT TIME AND WE WERE SHORT OF 2 CNA'S". CNA #4 WAS ABLE TO SPECIFICALLY IDENTIFY RESIDENT (#510) WHO WAS BED BOUND WITH A BAD BEDSORE AND ANOTHER RESIDENT (#511), WITH BOTH LEGS AMPUTATED, WHO WERE ASKING FOR THEIR PAIN MEDICATIONS BUT DID NOT RECEIVE THEM BECAUSE THERE WAS NO NURSE ON THE UNIT. ACCORDING TO CNA #5 ON [DATE] AT 2:30 PM, SHE RECALLED CALL LIGHTS WERE GOING OFF THAT DAY AND THERE WERE ONLY 2 CNA'S ON THE UNIT. CNA #5 SAID, "WE DID THE BEST WE COULD TO GET EVERYBODY UP FOR MEALS BUT THE RESIDENTS KEPT ASKING FOR THEIR MEDICATIONS. THERE WAS NO NURSE THAT MORNING AND THERE WERE ONLY 2 CNA'S ON THE UNIT INSTEAD OF 4". CNA #5 REPORTED RESIDENT (RESIDENT #511), WHO WAS A BILATERAL [MEDICAL CONDITION], WAS "IN SEVERE PAIN THAT WE (CNA #4 AND CNA #5) HAD TO PUT HER BACK TO BED BECAUSE WE DID NOT KNOW WHAT ELSE TO DO FOR PAIN RELIEF. THERE WAS NO NURSE UNTIL AROUND 2:00 PM, RIGHT BEFORE OUR SHIFT ENDED." REVIEW OF THE HOSPITAL RECORDS REVEALED RESIDENT #510 ARRIVED AT THE emergency roiagnom on [DATE] AT 3:36 PM WITH A PRESENTING [DIAGNOSES REDACTED]. THE SKIN ASSESSMENT AT THE emergency room DATED [DATE] AT 6:11 PM, DESCRIBED A SACRAL/COCCYX WOUND (STAGE 4 ULCER) THAT MEASURED 14.0 CM X 10.0 CM AND A LEFT LEG WOUND MEASURING 7.0 CM X 2.0 CM. RESIDENT #510 IMMEDIATELY RECEIVED ANTIBIOTIC INTRAVENOUSLY (THROUGH THE VEIN) AND HAD SURGICAL DEBRIDEMENT (REMOVAL OF DEAD TISSUE) OF HER DECUBITUS ULCER. RESIDENT #510 expired on [DATE] AT THE HOSPITAL DUE TO MEDICAL COMPLICATIONS. RESIDENT #511 REVIEW OF THE FACE SHEET REVEALED RESIDENT # 511 WAS [AGE] years OLD admitted to the facility on [DATE]. REVIEW OF THE HISTORY AND PHYSICAL DATED [DATE], REVEALED RESIDENT #511 HAD BILATERAL (BOTH) ABOVE THE KNEE AMPUTATION (AKA), INSULIN DEPENDENT DIABETES, CEREBRO VASCULAR ACCIDENT (STROKE) WITH [MEDICAL CONDITION] (DIFFICULTY WITH SPEECH), AND RIGHT SIDE [MEDICAL CONDITION] (WEAKNESS). REVIEW OF THE physician's orders [REDACTED]. RESIDENT #511'S MEDICAL RECORD ON [DATE] DID NOT SHOW EVIDENCE THAT SHE RECEIVE ANY MEDICATIONS FOR PAIN, NO ACCUCHECK WAS COMPLETED NOR INSULIN ADMINISTERED BETWEEN 7:00 AM - 2:00 PM ON [DATE]. THE CLINICAL RECORD REVEALED NO NURSES NOTES OR DOCUMENTED ASSESSMENTS WERE ENTERED FROM [DATE]-[DATE]. RESIDENT #511 WAS TRANSFERRED TO A NEARBY HOSPITAL ON [DATE], DUE TO CHEST PAIN AND [MEDICAL CONDITION] THE ADMINISTRATOR ON [DATE] AT 10:15 AM, STATED THAT SHE DID NOT RECEIVE ANY CALLS FROM THE SUPERVISOR ON CALL (RD #3), DIRECTOR OF NURSING, NOR THE ON-CALL NURSE #7 THAT SUNDAY ([DATE]). THE ADMINISTRATOR STATED SHE WAS UNAWARE OF THE STAFFING PROBLEM AND LACK OF NURSE COVERAGE UNTIL THE NEXT DAY ([DATE]). THE ADMINISTRATOR AND THE DON WERE INFORMED ON [DATE] AT 12:35 PM, OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AT 7:00 AM, DUE TO THE FAILURE TO: 1) MAINTAIN PROFESSIONAL STANDARDS OF QUALITY REQUIRED TO PROVIDE CARE INCLUDING MEDICATION ADMINISTRATION, THE ASSESSMENT AND MONITORING OF PAIN, PROVIDE WOUND CARE AND ORDERED TREATMENTS FOR ALL 28 RESIDENTS ON THE BROWN UNIT, AND 2) ENSURE A LICENSED NURSE AND AN ADEQUATE NUMBER OF CERTIFIED NURSE AIDES (CNA'S) WERE ON DUTY TO PROVIDE CARE RESULTING IN AN IMMEDIATE JEOPARDY WHEN ALL 28 RESIDENTS ON THE BROWN UNIT DID NOT RECEIVE SCHEDULED AND AS NEEDED MEDICATIONS, AND NURSING CARE AND SERVICES FROM A LICENSED NURSE BETWEEN 7:00 AM - 2:00 PM ON [DATE], PLACING ALL 28 RESIDENTS ON THE BROWN UNIT AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE] AT 2:15, THE DON INSTRUCTED THE BURGUNDY UNIT NURSE TO CONTACT THE MEDICAL DIRECTOR FOR PERMISSION TO GIVE DAILY MEDICATIONS LATE. PERMISSION WAS GRANTED. BY 3:00 PM ON [DATE], RESIDENTS HAD BEEN PROVIDED WITH MEDICATIONS, HAD BEEN ASSESSED, AND THE STAFFING WAS STABLE. 2. ON [DATE], THE 3 STAFF NURSES (WHO HAD REFUSED TO ASSUME CARE OF THE BROWN UNIT RESIDENTS) AND THE ON-CALL NURSE (#7) WERE IMMEDIATELY INSERVICED BY THE DIRECTOR OF NURSING, REGARDING THE REFUSAL OF A WORK ASSIGNMENT AND THEIR PROFESSIONAL STANDARDS OF PRACTICE. 3. BEGINNING [DATE] AND COMPLETED ON [DATE], THE DON EDUCATED 3 OF 3 NURSE MANAGERS ON HOW TO HANDLE NURSES WHO REFUSE ASSIGNMENT, THE PROTOCOL FOR NOTIFYING MANAGEMENT OF STAFFING ISSUES, AND THE CONSEQUENCE OF IMPROPER REPORTING RESIDENT SAFETY AND STAFFING CONCERNS. 4. STARTING [DATE], THE ADMINISTRATOR DISCUSSED STAFFING WITH THE STAFF COORDINATOR AND THE ADMINISTRATOR REVIEWED THE DAILY PER PATIENT DAY STAFFING HOURS MONDAY THROUGH FRIDAY, THE STAFFING COORDINATOR MONITORS STAFFING AND ASSURES THE UNITS ARE COVERED PER THE STAFFING GRID. ISSUES ARE ADDRESSED WITH THE UNIT MANAGERS WHO REWORK ASSIGNMENTS IF NEEDED. THERE HAVE BEEN NO EPISODES OF NON COVERAGE OF A UNIT SINCE [DATE] BECAUSE MONITORING OF ASSIGNMENTS. FURTHER EDUCATION WAS GIVEN TO 3 OUT OF 3 UNIT MANAGERS ON REVIEW OF STAFFING/ON CALL RESPONSIBILITIES DOCUMENT. 5. ON [DATE] AND [DATE], THE ADMINISTRATOR COMMUNICATED TO THE MANAGEMENT TEAM THE CRITICAL IMPORTANCE OF CONTACTING HER IN THE EVENT OF ANY UNSAFE SITUATION, WHICH INCLUDES STAFFING. THE CORPORATE CLINICAL NURSE DISCUSSED WITH THE DON THE IMPORTANCE OF STAFFING PROPERLY. THE ADMINISTRATOR EDUCATED 14 OF 14 MANAGEMENT TEAM DURING THE MORNING MEETINGS ON [DATE] AND 12 TO REINFORCE THE CRITICAL IMPORTANCE OF NOTIFYING THE ADMINISTRATOR OF STAFFING SHORTAGES AND ANY UNSAFE SITUATION, INCLUDING STAFFING. AS OF [DATE], THE ADMINISTRATOR CALLS ON WEEKENDS, MONITORS E-MAILS AND VOICEMAIL TO ASSURE THAT SHE IS UPDATED ON INFORMATION. THE ADMINISTRATOR COMES IN PERIODICALLY ON THE WEEKEND TO ASSURE PROPER STAFFING AND RESIDENT CARE IS PROVIDED. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT AN IMMEDIATE JEOPARDY DUE TO SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

REFER TO INTAKE # MI 860 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE PRESSURE SORE CARE FOR 1 OF 15 SAMPLED RESIDENTS (RESIDENT #510) RESULTING RESIDENT #510 BEING TRANSFERRED TO THE HOSPITAL FOR INFECTED DECUBITUS ULCERS [MEDICAL CONDITION]. FINDINGS INCLUDE: RESIDENT #510 RESIDENT #510 WAS [AGE] years OLD WHO WAS admitted to the facility on [DATE]. REVIEW OF THE HISTORY AND PHYSICAL DATED [DATE] REVEALED RESIDENT #510 HAD [DIAGNOSES REDACTED]. REVIEW OF THE THE WOUND EVALUATION DATED [DATE] REVEALED RESIDENT #510 HAD AN EVALUATION AND treatment for [REDACTED]. THE WOUND EVALUATION DID NOT INDICATE ANY SIGNS AND SYMPTOMS OF INFECTION. ON [DATE], WOUND RE-EVALUATION CONSULT REVEALED, PRESSURE ULCER: (1) STAGE 3 SACCROCOCCYX BILATERAL BUTTOCKS WITH [MEDICAL CONDITION], (2)PRESSURE AREA STAGE 4 LEFT LATERAL LEG/POSTERIOR LEG, (3) DEEP TISSUE INJURY LEFT GLUTEAL, (4) POSTERIOR BLISTER BILATERAL ANKLE, LEFT LATERAL HEEL, RIGHT HEEL. THE CLINICAL RECORD REVEALED NO FURTHER ASSESSMENT AND MONITORING WAS NOTED BETWEEN [DATE] TO [DATE]. ON [DATE], LPN #11 WROTE ON THE BACK OF THE TREATMENT SHEET DATED [DATE], "RESIDENT (#510) UNABLE TO TURN FOR SACRO/COCCYX WOUND HAVING PAIN (REFUSED)". RESIDENT #510'S WOUND ASSESSMENT AND TREATMENT WAS NOT PERFORMED. REVIEW OF THE NURSES NOTES, TREATMENT ADMINISTRATION SHEET, AND NO-PRESSURE SKIN CONDITION REPORT DATED BETWEEN [DATE] THROUGH [DATE] DID NOT SHOW ANY EVIDENCE THAT WOUND ASSESSMENT AND MONITORING OF THE SACCROCOCCYX AND BILATERAL LEG WOUND WAS DONE ON RESIDENT #510. REVIEW OF THE MAR (MEDICATION ADMINISTRATION RECORD) REVEALED THAT ON [DATE], ALL OF RESIDENT #510'S 9:00 AM SCHEDULED MEDICATION WERE NOT ADMINISTERED. RESIDENT #510'S MAR indicated [REDACTED]' S REQUEST FOR PAIN RELIEF THAT DAY. IN AN TELEPHONE INTERVIEW ON [DATE] AT 9:10 AM THE TREATMENT NURSE (LICENSED PRACTICAL NURSE - LPN) #11 STATED THAT SHE ARRIVED AT THE FACILITY AT APPROXIMATELY 9:00 AM ON [DATE]. LICENSED PRACTICAL NURSE (LPN) #11 REPORTED GOING TO RESIDENT #510'S ROOM BETWEEN 1:00 -2:00 PM, BUT RESIDENT #510 COMPLAINED OF PAIN WHEN LPN #11 MOVED HER LEG. LPN #11 admitted SHE DID NOT DO THE TREATMENT TO HER WOUNDS OR ASSESS RESIDENT #510'S SACROCOCCYX ULCER DUE TO RESIDENT #510'S PAIN ON [DATE]. LPN #11 ADDED THAT SHE FAILED TO ASK FOR HELP FROM NURSING ASSISTANTS TO POSITION THE RESIDENT DURING THE ATTEMPTED WOUND treatment for [REDACTED]. LPN #11 STATED SHE FAILED TO INFORM THE NURSE (THERE WAS NONE ON THE BROWN UNIT) THAT RESIDENT #510'S COCCYX WOUND TREATMENT WAS NOT DONE DUE TO HER COMPLAINTS OF PAIN. LPN#11 ALSO STATED SHE DID NOT CALL THE PHYSICIAN TO DISCUSS ANY OTHER PAIN CONTROL OPTIONS. LPN #11 LEFT RESIDENT #510 WITHOUT PROVIDING PAIN RELIEF AND WITHOUT PERFORMING WOUND CARE AS ORDERED. LPN #11 SAID, "I WAS MORE CONCERNED WITH PROVIDING RESIDENT #501 COMFORT MEASURES SO I DECIDED NOT PERFORM THE WOUND TREATMENT TO HER BOTTOM". CERTIFIED NURSE AIDE (CNA) #4 ON [DATE] AT 2:30 PM, SHE STATED THAT THERE WAS NO NURSE IN THE BROWN UNIT FROM 7:00 AM UNTIL 2:00 PM ON [DATE]. CNA #4 REPORTED RESIDENT #510, WHO WAS BED BOUND WITH A BAD BEDSORE, ASKED FOR HER PAIN MEDICATIONS BUT DID NOT RECEIVE THEM BECAUSE THERE WAS NO NURSE IN THE UNIT. CNA #4 DENIED SEEING A LPN #11 ON THE UNIT ON [DATE]. IN AN INTERVIEW ON [DATE] AT 10:22 AM LPN #16, STATED THAT RESIDENT #510 WAS SENT TO THE HOSPITAL ON [DATE], BECAUSE HER WOUND HAD A LOT OF DRAINAGE AND IT SMELLED. LPN #16 STATED "(RESIDENT #510) WAS OBSERVED WITH INTERMITTENT CONFUSION AND MENTAL STATUS CHANGES. SHE WAS NOT ANSWERING QUESTIONS APPROPRIATELY THAT DAY. SHE HAD WOUNDS ON HER BACK AND SEVERAL OTHER AREAS ON BOTH HER LOWER EXTREMITIES. SHE HAD A SLIGHT FEVER (99.4 F) WHEN WE SENT HER OUT". REVIEW OF THE NURSE'S NOTES DATED [DATE] AT 2:22 PM REVEALED RESIDENT #510'S WOUND "IS NOW COVERING THE ENTIRE BUTTOCKS WITH YELLOW FOUL SMELLING DRAINAGE. RESIDENT (#510) ALSO HAS SEVERAL OPEN NON-HEALING DECUBS (DECUBITUS ULCERS). DOCTOR WAS NOTIFIED AND ORDERED THE TRANSFER TO HOSPITAL". THERE WAS NO EVIDENCE THAT RESIDENT #510'S IMPAIRED SKIN INTEGRITY CARE PLAN WAS REVISED SINCE [DATE]. REVIEW OF THE HOSPITAL RECORDS REVEALED RESIDENT #510 ARRIVED AT THE emergency roiagnom on [DATE] AT 3:36 PM WITH A PRESENTING [DIAGNOSES REDACTED]. THE SKIN ASSESSMENT AT THE emergency room DATED [DATE] AT 6:11 PM, DESCRIBED A SACRAL/COCCYX WOUND (STAGE 4 ULCER) THAT MEASURED 14.0 CM X 10.0 CM AND A LEFT LEG WOUND MEASURING 7.0 CM X 2.0 CM. RESIDENT #510 IMMEDIATELY RECEIVED ANTIBIOTIC INTRAVENOUSLY (THROUGH THE VEIN) AND HAD SURGICAL DEBRIDEMENT (REMOVAL OF DEAD TISSUE) OF HER DECUBITUS ULCER. RESIDENT #510 expired on [DATE] AT THE HOSPITAL DUE TO MEDICAL COMPLICATIONS. IN AN INTERVIEW ON [DATE] AT 2:30 PM CNA #5, SAID SHE RECALLED RESIDENT #510 BEING IN A LOT OF PAIN BUT DID NOT GET HER PAIN MEDICATIONS. CNA #5 STATED, "RESIDENT #510 HAD A BAD SORE ON HER BACK. THERE WAS NO NURSE UNTIL AROUND 2:00 PM, RIGHT BEFORE OUR SHIFT ENDED". CNA #5 DENIED SEEING LPN #11 ON THE BROWN UNIT ON [DATE]. ( )

THIS CITATION PERTAINS TO INTAKE #'S MI 136 AND MI 212. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE APPROPRIATE EQUIPMENT AND ADEQUATE ASSISTANCE TO PREVENT A FALL FOR ONE (RESIDENT #108) OF 8 SAMPLED RESIDENTS RESULTING IN hospitalization DUE TO A FRACTURE OF THE DISTAL RIGHT FEMUR. FINDINGS INCLUDE: RESIDENT #108 WAS [AGE] years OLD, admitted to the facility on [DATE]. A history and physical examination [REDACTED]. MDS (MINIMUM DATA SET) DATED 8/16/10, INDICATED THAT SHE WAS INDEPENDENT COGNITIVELY AND, ALTHOUGH SHE WAS CONTINENT WITH BLADDER AND BOWEL ELIMINATION PATTERN, RESIDENT #108 REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH PERFORMING ADLS (ACTIVITIES OF DAILY LIVING) SUCH AS TRANSFERS, BED MOBILITY, DRESSING, TOILET USE AND HYGIENE. RESIDENT STATUS SHEET (UNDATED) SPECIFIED RIGHT SIDED WEAKNESS REQUIRING 1 PERSON ASSIST WITH TRANSFERRING AND REPOSITIONING. RESIDENT #108 WAS INTERVIEWED AT THE hospital on [DATE] AT 11:10 AM. SHE REMEMBERED THE INCIDENT WHEN SHE fell AT THE FACILITY. SHE RECALLED, "THE CNA (CERTIFIED NURSE AIDE) TOLD ME TO GRAB THE BATHROOM RAIL AND HELD ME THE WRONG WAY WHEN SHE TOOK ME TO THE BATHROOM. MY RIGHT SIDE WAS WEAK AND MY LEGS WENT OUT ON ME. MY WEAK SIDE WAS NOT SUPPORTED. I WOULD NOT HAVE FALLEN IF I WAS HANDLED THE RIGHT WAY. THE CNA DID NOT USE A GAIT BELT AND PANICKED WHEN SHE SAW ME FALLING." RESIDENT #108 APPEARED VERY TIRED AND COMPLAINED OF SEVERE PAIN AND DISCOMFORT ON THE RIGHT KNEE. HOSPITAL RECORDS REVEALED RESIDENT WAS EXAMINED AT THE emergency roiagnom on [DATE]. IT REVEALED, "EXTERNAL ROTATION WITH SHORTENING OF RIGHT LEG AND KNEE. PAIN WITH PALPATION OF DISTAL FEMUR". THE RESULTS OF HOSPITAL XRAY DATED 10/5/10, REVEALED, "COMMINUTED FRACTURE INVOLVING THE MID-DISTAL DIAMETHAPHYSEAL FEMUR". RESIDENT #108 WAS diagnosed with [REDACTED]. THE FACILITY INCIDENT REPORT DATED 10/4/10,WAS REVIEWED. IT WAS DESCRIBED THAT THE CNA WAS PUTTING RESIDENT #108 ON THE TOILET AND RESIDENT #108 LOST HER BALANCE AND LANDED ON FLOOR. INJURY WAS, SKIN TEAR LEFT KNEE/LEG ABRASION. PHYSICIAN WAS NOTIFIED ON 10/4/10 AT 11:00 PM, AND ORDERED FOR XRAY RIGHT KNEE A/LEG. FAMILY WAS NOTIFIED OF THE INCIDENT AT 11:00 PM ON 10/4/10. CNA #7 ON 10/12/10 AT 1:15 PM, admitted THAT SHE NEGLECTED TO PUT THE GAIT BELT ON RESIDENT #108 DURING TRANSFER. CNA #7 EXPLAINED THAT ON 9/4/10 AT 10:45 PM, SHE WAS TAKING RESIDENT #108 TO THE BATHROOM. CNA#7 INSTRUCTED RESIDENT #108 TO USE THE POLE (GRAB BAR) TO PULL HERSELF UP FROM HER WHEELCHAIR. SHE FURTHER EXPLAINED THAT RESIDENT #108 DOES IT HERSELF BUT AT THAT TIME RESIDENT # 108 ' S LEG SUDDENLY WENT OUT. CNA # 7 TRIED TO BREAK THE FALL BUT IT HAPPENED SO QUICKLY AND DECIDED TO EASED HER DOWN ON THE FLOOR. SHE CALLED FOR ASSISTANCE AND THE CHARGE NURSE CAME IMMEDIATELY TO ASSESS HER.. CNA #7 REPEATEDLY STATED THAT RESIDENT #108 DID NOT FALL BUT WAS EASED DOWN THE GROUND. SHE COULD NOT EXPLAIN WHAT CAUSED HER TO HAVE A FRACTURE, THE DON (DIRECTOR OF NURSING) ON 10/11/10 AT 12:00 PM STATED THAT RESIDENT # 108 WAS ALERT, ORIENTED AND WAS HER OWN RESPONSIBLE PARTY. ON 10/4/10 AT 10:45 PM , RESIDENT #108'S LEG DURING TRANSFER GOT WEAK, fell AND SUSTAINED A FRACTURE OF THE RIGHT KNEE AND SKIN TEAR/ABRASION ON LEFT KNEE AND SHIN. AFTER A THOROUGH INVESTIGATION, WE CONCLUDED THAT RESIDENT #108 ' S RIGHT KNEE MUST HAVE HIT THE WALL WHICH CAUSED THE FRACTURE AND THE LEFT LEG ABRASION/SKIN TEAR WAS FROM THE LEG-REST OF THE WHEELCHAIR DURING THE FALL. THE FOLLOWING MORNING, DAY SHIFT NURSE FOUND THE RIGHT KNEE SWOLLEN WITH COMPLAINING OF PAIN. AN XRAY WAS ORDERED AND FOUND A FRACTURE OF THE RIGHT FEMUR. RESIDENT #108 WAS IMMEDIATELY TRANSFERRED TO THE HOSPITAL. ACCORDING TO THE CHARGE NURSE #8 ON 10/11/10 AT 1:20 PM, CNA #7 WAS TRYING TO GET RESIDENT #108 TO THE TOILET WHEN RESIDENT #108 LOST HER BALANCE AND WENT DOWN ON THE FLOOR. CHARGE NURSE #8 RESPONDED IMMEDIATELY AFTER SHE HEARD CNA #7 CALLING FOR ASSISTANCE. CHARGE NURSE #8 FOUND THE RESIDENT #108 ON THE FLOOR AND INDICATED SKIN TEAR/ ABRASION ON HER RIGHT LEG. SHE DENIED OBSERVING IF THERE WAS A GAIT BELT ON RESIDENT #108'S WAIST. SHE WAS AWARE THAT IT IS THE FACILITY'S POLICY TO USE GAIT BELT DURING TRANSFERS ESPECIALLY WHEN RESIDENT'S HAD RIGHT SIDED WEAKNESS LIKE RESIDENT #108 AND WAS A HEAVY LADY. RESIDENT #108 DENIED PAIN AFTER FALL ASSESSMENT . CHARGE NURSE #8 CALLED TO NOTIFY THE PHYSICIAN AND CONTACTED THE FAMILY. SHE ALSO REPORTED THE INCIDENT TO THE MIDNIGHT SHIFT NURSE FOR POST FALL INCIDENT OBSERVATIONS AND FOLLOW-UP. THE FACILITY'S "ASSIST THE RESIDENT TO STAND" POLICY DATED December 2008, SPECIFIED: ? PUT GAIT BELT ON RESIDENT ? IF RESIDENT IS ALERT AND HAS FAIR GOOD STRENGTH, PLACE FEET FLAT ON FLOOR WITH THE HAND UNDER THE GAIT BELT TO PREVENT FALLING. ? IF RESIDENT NEEDS HELP STANDING UP, POSITION YOUR KNEES AT EITHER SIDE OF THE RESIDENT ' S KNEES. BEND YOUR KNEES, PUT YOUR ARMS AROUND THEIR WAIST, HANDS AND INSTRUCT RESIDENT TO PUSH UP FROM THE BED WITH RESIDENT ' S ARMS. ? ONCE RESIDENT STANDS, YOU CAN PIVOT AND LOWER THEM INTO AN ARM CHAIR OR WHEELCHAIR, OR YOU CAN BEGIN TO WALK WITH RESIDENT. ( )

THIS CITATION PERTAINS TO INTAKE #MI 018. BASED ON OBSERVATION, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE SUPRAPUBIC CATHETER CARE FOR 1 (RESIDENT #103) OF 8 SAMPLED RESIDENTS RESULTING IN RESIDENT #103 GETTING A URINARY TRACT INFECTION. FINDINGS INCLUDE: RESIDENT #103 WAS [AGE] years OLD; REadmitted to the facility on [DATE]. ACCORDING TO HISTORY AND PHYSICAL DATED 9/20/10, RESIDENT #103 HAD [MEDICAL CONDITION] (PARALYZED) SECONDARY TO A GUN SHOT WOUND, [MEDICAL CONDITION] (A DECREASE IN SENSATION) WITH LEFT FOREARM AND HAND ATROPHY. ACCORDING TO THE NURSING COMPREHENSIVE assessment dated [DATE], RESIDENT #103 HAD A SUPRAPUBIC CATHETER (A CATHETER PLACED IN THE LOWER PART OF THE ABDOMEN FOR URINE DRAINAGE), DRAINING AN AMBER COLORED URINE. NO FOUL ODOR WAS NOTED. THE MINIMUM DATA SET ((MDS) dated [DATE], REVEALED THAT RESIDENT #103 WAS COGNITIVELY INDEPENDENT AND REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING. RESIDENT #103 HAD AN INDWELLING CATHETER. ACCORDING TO THE URINE CULTURE DATED 10/1/10, URINE SPECIMEN WAS COLLECTED ON 9/29/10. THE RESULTS WERE: MULTIPLE ORGANISMS PRESENT; PROBABLE CONTAMINATION; PLEASE REPEAT CULTURE IF INDICATED. ORGANISMS FOUND WERE: 10-100,000 CFU/ML GRAM NEG. BACILLI NON LACTOSE FERMENTER 10-100,000 CFU ML GRAM NEG. BACILLI NON LACTOSE FERMENTER NO. 2 10-100,000 CFU ML STAPHYLOCOCCUS SPECIES 10-100,000 CFU ML STREPTOCOCCUS SPECIES 10-100,000 CFU ML STREPTOCOCCUS SPECIES NO. 2 URINALYSIS RESULTS DATED 9/29/10, NOTED: URINE APPEARANCE WAS TURBID, BLOOD 3+, PROTEIN =TRACE,BACTERIA 3+, WBC (WHITE BLOOD COUNT) = >100. NO RECORD OF REPEAT URINE SPECIMEN WAS SUBMITTED TO THE LABORATORY PER RECOMMENDATION. ACCORDING TO THE PHYSICIAN'S PROGRESS NOTES DATED 10/6/10, "NO CULTURE ON CHART". PHYSICIAN ORDER [REDACTED]. ON 10/6/10, THE PHYSICIAN IMMEDIATELY ORDERED FOR [MEDICATION NAME] MG. 1 TABLET BY MOUTH BID TWICE A DAY X 10 DAYS FOR UTI (URINARY TRACT INFECTION). THE RESULTS OF THE LABORATORY TEST (URINALYSIS AND URINE CULTURE) SUBMITTED ON 9/29/10 WAS NOT REPORTED TO THE PHYSICIAN UNTIL 10/6/10. NO FOLLOW-UP WAS NOTED IN THE NURSE'S NOTES REGARDING THE LABORATORY RESULTS. PHYSICIANS ORDER DATED 9/30/10, REVEALED AN ORDER TO CHANGE RESIDENT #103'S SP (SUPRAPUBIC) CATHETER MONTHLY. MAR (MEDICATION ADMINISTRATION RECORD) AND TAR (TREATMENT ADMINISTRATION RECORD) DATED September 2010 AND October 2010 SHOWED NO EVIDENCE OF SUPRAPUBIC CATHETER SITE ASSESSMENT, MONITORING OR TREATMENT. THERE WAS NO EVIDENCE THAT RESIDENT #103 ' S SUPRAPUBIC CATHETER SITE WAS CLEANSED, ASSESSED, OR MONITORED. THERE WAS NO RECORD ON WHEN IT WAS LAST CHANGED. NO CARE PLAN WAS FOUND IN RESIDENT #103 ' S CLINICAL RECORD FOR SUPRAPUBIC CATHETER CARE FROM admitted D 9/17/10. ON 10/12/10, INFECTION CONTROL NURSE SUBMITTED A CARE PLAN FOR UTI WITH A START DATED OF 10/7/10, AFTER TREATMENT ORAL ANTIBIOTIC FOR UTI STARTED. THE CAREPLAN FOR INFECTION [MEDICAL CONDITION] REVEALED THAT IT WAS A COMPUTER GENERATED CAREPLAN AND DID NOT SPECIFY THAT RESIDENT #103 HAS A SUPRAPUBIC CATHETER OR ANY URINARY INDWELLING CATHETER. THE CARE PLAN DID NOT SPECIFY INTERVENTIONS IN ACCORDANCE TO THE FACILITY SUPRAPUBIC CATHETER CARE POLICY. ACCORDING TO THE NURSE ON DUTY ON 9/13/10 AT 12:25 PM SHE STATED THAT THE TREATMENT NURSE DID THE SUPRAPUBIC CATH CARE. SHE DID NOT ASSESS, MONITOR OR DO SUPRAPUBIC CARE treatment for [REDACTED]. DIRECT OBSERVATION OF RESIDENT # 103'S SUPRAPUBIC CATHETER SITE ON 10/13/10 AT 12:30 PM, SHOWED DRY, CRUSTY MATERIAL SURROUNDING THE SUPRAPUBIC CATHETER SITE LOCATED ON THE RIGHT LOWER QUADRANT OF THE ABDOMEN. NO DRESSING WAS FOUND. AN INTERVIEW WITH RESIDENT # 103 ON 10/12/10 AT 12:30 PM, WAS CONDUCTED. HE DENIED RECEIVING ANY SUPRAPUBIC (SP) CATHETER TREATMENT SINCE ADMISSION. RESIDENT #103 DENIED RECEIVING HEALTH EDUCATION FROM THE FACILITY FOR PROPER SUPRAPUBIC CATHETER CARE. HE DID NOT HAVE ANY HEALTH TEACHING SINCE ADMISSION NOR WAS CLEARED TO DO HIS OWN SP TREATMENT. HE CLAIMED THAT HE CLEANS HIS SP SITE WHEN HE CAN BUT COULD NOT SEE IT WELL BECAUSE HIS ABDOMEN WAS COVERING IT. HE ALSO COMPLAINED THAT HIS SP CATHTER HAD NOT BEEN CHANGED SINCE AUGUST. HE RECALLED THE DOCTOR ORDERED TO CHANGE THE SP CATHETER EVERY ONCE MONTH TO PREVENT INFECTION BUT IT HAD NOT BEEN CHANGED. ( )

BASED ON INTERVIEWS AND CLOSED RECORD REVIEW, FACILITY STAFF FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING RELATED TO ASSESSING AND MONITORING THE DECLINING MEDICAL CONDITION FOR 1 (#500) OF 4 SAMPLED RESIDENTS IN A TOTAL SAMPLE OF 5 RESIDENTS WITH EVENTUAL CARDIOPULMONARY ARREST. FINDINGS INCLUDE: RESIDENT #500, [AGE] years OLD, WAS admitted to the facility on [DATE] PER THE ADMISSIONS RECORD. TRANSFER RECORDS FROM THE HOSPITAL, DATED [DATE], INDICATED THAT THE RESIDENT WAS treated for [REDACTED]. HOSPITAL RECORDS ALSO DOCUMENTED [DIAGNOSES REDACTED]. ACCORDING TO A [DATE] MENTAL STATUS EXAM, RESIDENT #500 HAD INTACT MENTAL FUNCTION. NURSE #23, INTERVIEWED [DATE] AT 3 P.M. BY TELEPHONE, SAID THE RESIDENT WAS ALWAYS LAUGHING AND JOKING WITH STAFF. AN [DATE] MDS (MINIMUM DATA SET) INDICATED THAT THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE WITH SEVERAL ACTIVITIES OF DAILY LIVING. A NURSE'S NOTE ON [DATE] INDICATED THAT RESIDENT #500 RECEIVED ANTIBIOTIC THERAPY FOR "? [MEDICAL CONDITION]". THE NURSE WROTE, "(R) (RIGHT) LEG CONT (CONTINUES) TO BE SWOLLEN, WARM ON PALPATION, WITH REDNESS & WEEPING". ACCORDING TO A PHYSICIAN'S [DATE] HISTORY & PHYSICAL REPORT, THE RESIDENT DID HAVE RIGHT LOWER EXTREMITY [MEDICAL CONDITION] (SKIN INFECTION) AND STAPLES OF THE RIGHT LOWER EXTREMITY. ON [DATE] A WOUND CARE SPECIALIST DOCUMENTED "MULTIPLE INCISIONS OF RIGHT KNEE HEALING SATISFACTORILY . . . LESS [DIAGNOSES REDACTED] (REDNESS), IMPROVING." A NURSE'S NOTE ON [DATE] INDICATED THAT RIGHT LOWER EXTREMITY STAPLES WERE REMOVED. THE OCCUPATIONAL THERAPIST AND PHYSICAL THERAPIST, INTERVIEWED ON [DATE] AT 1:45 P.M., SAID RESIDENT #500 HAD MADE PROGRESS DURING SKILLED REHABILITATION SESSIONS. THEY SAID SHE WAS A WILLING PARTICIPANT, DECREASED ENDURANCE WAS AN ISSUE, AND PAIN DID NOT SEEM TO BE A LIMITING FACTOR. ACCORDING TO SKILLED THERAPY PROGRESS NOTES, RESIDENT #500'S LAST THERAPY SESSION OCCURRED ON [DATE]. HOSPITAL TRANSFER DOCUMENTS, DATED [DATE], INDICATED THAT RESIDENT #500'S HOME MEDICATIONS, PRIOR TO hospitalization , HAD INCLUDED [MEDICATION NAME] (NARCOTIC [MEDICATION NAME]), [MEDICATION NAME] (NARCOTIC [MEDICATION NAME]), TYLENOL ([MEDICATION NAME]), [MEDICATION NAME] (NARCOTIC [MEDICATION NAME]), [MEDICATION NAME] (SLEEPING PILL),[MEDICATION NAME](SLEEPING PILL), AND [MEDICATION NAME] (ANTI-ANXIETY). ON ADMISSION ([DATE]), RESIDENT #500 HAD A PAIN ASSESSMENT COMPLETED. THE RESIDENT COMPLAINED OF CHRONIC, DAILY, RIGHT KNEE PAIN, DESCRIBED AS SHARP AND THROBBING. RESIDENT #500 RATED THE PAIN AS A "4" (HURTS WHOLE LOT), ON A PAIN SCALE OF "0" (NO HURT) TO "5" (HURTS WORST). ON [DATE] RESIDENT #500 HAD A physician's orders [REDACTED]. ON [DATE] THE physician's orders [REDACTED]. ON [DATE] [MEDICATION NAME] (NARCOTIC [MEDICATION NAME]) 2 MG EVERY 4 HOURS AS NEEDED FOR PAIN WAS ADDED. ON [DATE] THE RESIDENT WAS ALSO PRESCRIBED [MEDICATION NAME] (USED FOR NEURALGIA OR NERVE PAIN), [MEDICATION NAME] (ANTIANXIETY), AND [MEDICATION NAME] (SLEEPING PILL). A PHYSICIAN'S PROGRESS NOTE ON [DATE] NOTED THAT RESIDENT #500 WAS SEEN BECAUSE OF "SEVERE PAIN AND TREMORS". ACCORDING THE THE PROGRESS NOTE, THE RESIDENT SAID CURRENT MEDICATIONS WERE NOT EFFECTIVE IN RELIEVING HER PAIN. THE PHYSICIAN'S PHYSICAL EXAMINATION, ACCORDING TO THE PROGRESS NOTE, WAS UNREMARKABLE. THE PROGRESS NOTE DID NOT IDENTIFY THE LOCATION OR CHARACTERISTICS OF THE PAIN. THE PHYSICIAN, ON [DATE], DISCONTINUED THE [MEDICATION NAME] AND ORDERED [MEDICATION NAME] SR (NARCOTIC [MEDICATION NAME]) 40 MG TWICE DAILY. ON [DATE] AND [DATE] THERE WAS AN INTERIM ORDER FOR A ONE TIME DOSE OF [MEDICATION NAME] WHEN THE RESIDENT COMPLAINED OF PAIN BEFORE THE NEXT DOSE OF [MEDICATION NAME] WAS DUE. THE DOSE OF [MEDICATION NAME] WAS INCREASED TO 4 MG EVERY FOUR HOURS AS NEEDED FOR PAIN ON [DATE]. ACCORDING TO NURSES' NOTES RESIDENT #500 COMPLAINED OF PAIN IN THE RIGHT LOWER EXTREMITY ([DATE], [DATE], [DATE], [DATE], AND [DATE]), "GENERALIZED PAIN" ([DATE]), "LOWER PELVIC PAIN" ([DATE]), RIGHT LEG PAIN ([DATE]), AND BILATERAL LEG PAIN ([DATE]). CNA (CERTIFIED NURSING ASSISTANT) #14 WAS INTERVIEWED ON [DATE] AT 2 P.M. CNA #14 SAID SHE WORKED THE DAY SHIFT ON [DATE], [DATE], AND [DATE]. SHE STATED THAT THE RESIDENT WAS "MORE SLEEPY ON [DATE]. ACCORDING TO THE CNA, THE RESIDENT WAS USUALLY "JOLLY, TALKING, HAPPY", BUT NOT ON [DATE] OR [DATE]. THE CNA SAID "Thursday WAS THE LAST TIME I HAD A GOOD CONVERSATION WITH HER." PER THE CNA, ON [DATE] THE RESIDENT DID NOT EAT ANYTHING AT BREAKFAST OR LUNCH AND WENT BACK TO SLEEP EVERY TIME I WOKE HER UP. CNA #11 WAS INTERVIEWED ON [DATE] AT 3:45 P.M. SHE SAID SHE WORKED THE AFTERNOON SHIFT ON [DATE], AND THE RESIDENT HAD BEEN "SLEEPING A LOT" THE THREE DAYS PRIOR TO [DATE]. SHE SAID THE RESIDENT WOULD BECOME CONFUSED AND SAY THINGS WHICH DID NOT MAKE SENSE. CNA #11 SAID SHE TOLD THE NURSE ABOUT THE UNUSUAL STATEMENTS AND WAS TOLD IT WAS BECAUSE MEDICATIONS WERE BEING CHANGED. THE CNA SAID RESIDENT #500 "WAS USUALLY ON HER CALL LIGHT BUT NOT THE LAST WEEK". CNA #10 WAS INTERVIEWED ON [DATE] AT 3:15 P.M. SHE SAID SHE WAS ASSIGNED TO RESIDENT #500 ON [DATE] DURING THE AFTERNOON SHIFT. SHE SAID AT 3 P.M., WHEN SHE MADE ROUNDS, THE RESIDENT WAS "SNORING". "SHE NEVER WOKE UP BETWEEN 3 P.M. AND 6 P.M." THE CNA SAID SHE WOKE THE RESIDENT UP AT 6 P.M. FOR DINNER, AND THE RESIDENT SPOKE TO HER. AT 7:30 P.M. CNA #10 SAID SHE WENT BACK INTO THE RESIDENT'S ROOM TO PICK UP HER TRAY, BUT THE RESIDENT HAD NOT EATEN ANYTHING. CNA #10 SAID SHE WOKE HER UP AGAIN. THE CNA LEFT ONE-HALF OF THE SANDWICH AND THE JUICE WITH THE RESIDENT WHO INDICATED SHE WOULD EAT IT. THE CNA SAID, "SHE USUALLY HITS THE CALL LIGHT A LOT, BUT FOR THREE DAYS SHE HAD NOT DONE THAT." THE CNA SAID THE RESIDENT WAS MAKING UNUSUAL STATEMENTS, FOR EXAMPLE, SHE WAS GOING TO GET HER LEG CUT OFF. CNA #10 SAID SHE WAS OFF THE UNIT WHEN THE A CODE WAS CALLED, BUT WHEN SHE WENT BACK IN THE ROOM AFTER THE RESIDENT LEFT THE FACILITY, THE SANDWICH AND JUICE HAD NOT BEEN TOUCHED. THE CNA SAID THE NURSES WERE AWARE THAT THE RESIDENT HAD BEEN SLEEPING A LOT. THERE WERE NO NURSE'S NOTES WRITTEN FOR RESIDENT #500 ON [DATE]. ACCORDING TO THE MAR (MEDICATION ADMINISTRATION RECORD), THE RESIDENT RECEIVED [MEDICATION NAME] SR, [MEDICATION NAME], AND [MEDICATION NAME] AS SCHEDULED. THE [MEDICATION NAME] SR (SUSTAINED RELEASE) WAS ADMINISTERED AT 9 A.M. AND 5 P.M., RATHER THAN AT THE RECOMMENDED SCHEDULE OF EVERY 12 HOURS (WWW.RXLIST.COM/[MEDICATION NAME]-DRUG.HTM). ACCORDING TO CONTROLLED SUBSTANCES PROOF OF USE SHEETS, THE RESIDENT RECEIVED FOUR DOSES OF [MEDICATION NAME] ON [DATE]. RESIDENT #500 RECEIVED 2 MG OF [MEDICATION NAME] AT 5 A.M., 1 P.M., AND 2:40 P.M. AT 10 P.M. THE RESIDENT RECEIVED 4 MG OF [MEDICATION NAME]. TWO DOSES OF [MEDICATION NAME] WERE ADMINISTERED ON [DATE]. THE 5 A.M. DOSE WAS 2 MG, AND THE 1 P.M. DOSE WAS 4 MG. THERE WAS NO DOCUMENTATION REGARDING THE LOCATION OR CHARACTERISTICS OF PAIN. NURSE #13 WAS INTERVIEWED ON [DATE] AT 1:20 P.M. SHE SAID SHE CARED FOR RESIDENT #500 ON [DATE] DURING THE DAY SHIFT. SHE SAID SHE GAVE THE SCHEDULED [MEDICATION NAME] SR AT 9 A.M. THE NURSE SAID THE RESIDENT WAS MORE SLEEPY THAN NORMAL. LATER IN HER SHIFT NURSE #13 SAID THE RESIDENT "WAS HARDER TO AROUSE THAN EARLIER THAT DAY." NURSE #13 DOCUMENTED THAT THE RESIDENT TOOK SIPS OF WATER AND CONSUMED <25% OF BREAKFAST AND LUNCH. (THIS WAS INCONSISTENT WITH CNA #14 STATEMENTS.) AT 2:30 P.M. ON [DATE] NURSE #13 DOCUMENTED VITAL SIGNS; BLOOD SUGAR OF 120 MG/DL, BLOOD PRESSURE OF ,[DATE], RESPIRATORY RATE OF 18, PULSE OF 97 BEATS PER MINUTE. NURSE #13 SAID SHE WAS CONCERNED THAT THE BLOOD PRESSURE WAS HIGH AND THE RESIDENT WAS LETHARGIC. SHE NOTIFIED THE PHYSICIAN AND ADMINISTERED, PER ORDERS, TWO DOSES OF [MEDICATION NAME] (NARCOTIC ANTAGONIST). AFTER THE FIRST AND SECOND DOSE OF [MEDICATION NAME] AT 2:55 P.M. AND 3:00 P.M., THE RESIDENT WAS ABLE TO STATE HER NAME, BIRTHDAY, AND A CURRENT DATE. AFTER THE SECOND DOSE OF [MEDICATION NAME], THE RESIDENT COULD ALSO STATE HER DAUGHTER'S NAME, ACCORDING TO NURSE #13. THERE WAS NO DOCUMENTATION THAT ANY NEUROLOGICAL ASSESSMENTS HAD BEEN DONE PRIOR TO THE [MEDICATION NAME] EXCEPT THAT THE RESIDENT WAS "LETHARGIC EASILY AROUSED BY VERBAL & TACTILE STIMULI". NO OTHER BODY ASSESSMENTS WERE DOCUMENTED ON [DATE] DURING THE DAY SHIFT. WHEN THE [MEDICATION NAME] WAS ORDERED, THERE WAS ALSO A physician's orders [REDACTED]. IN AN INTERVIEW ON [DATE] AT 2 P.M., THE PHYSICIAN STATED THAT HE RECEIVED A TELEPHONE CALL FROM NURSING AFTER THE [MEDICATION NAME] AND WAS TOLD THAT RESIDENT #500 WAS MORE ALERT. THE PHYSICIAN SAID HE ASKED THAT THE RESIDENT BE ASSESSED EVERY ,[DATE] MINUTES AND BE NOTIFIED OF CHANGES IN CASE THE RESIDENT REQUIRED MORE [MEDICATION NAME] OR IF SHE NEEDED TO BE TRANSFERRED TO THE HOSPITAL FOR EVALUATION. HE SAID HE RECEIVED NO ADDITIONAL TELEPHONE CALLS UNTIL THE RESIDENT EXPIRED. ON [DATE] AT 8:20 P.M. NURSE #12 DOCUMENTED THAT A CODE WAS CALLED BECAUSE RESIDENT #500 WAS FOUND UNRESPONSIVE AND WITHOUT PULSES. CPR WAS INITIATED, AND AT 8:26 P.M. THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL. IN A LATE ENTRY ON [DATE] AT 3 P.M. NURSE #12 DOCUMENTED THAT THE RESIDENT WAS OBSERVED "SLEEPING" AT 5:10 P.M., PT (PATIENT) WAS AWAKE, RESPONSIVE BUT INCOHERENT IN HER SPEECH. VS (VITAL SIGNS) ,[DATE] (BLOOD PRESSURE) 71 (PULSE RATE) 18 (RESPIRATORY RATE) WITH FS (BLOOD SUGAR) 112 MG/DL. PT EXHIBITED NO SIGNS OF DISTRESS AND WAS BEING MONITORED CLOSELY. AT 8:20 PM WRITER CALLED IN ROOM BY CENA, PT FOUND UNRESPONSIVE, CODE BLUE ANNOUNCED. CPR PERFORMED UNTIL PARAMEDICS ARRIVED. PT LEFT FACILITY ABOUT 8:30 P.M. FOR (NAME OF HOSPITAL)." THERE WAS NO SYSTEMS ASSESSMENT DOCUMENTED DURING THE AFTERNOON SHIFT ON [DATE] NURSE #12 WAS INTERVIEWED ON [DATE] AT 4:15 P.M. HE SAID HE CARED FOR RESIDENT #500 ON [DATE] AND [DATE]. HE SAID THE RESIDENT WAS NOT LETHARGIC ON [DATE], BUT WAS "ON AND OFF SLEEPING AND VERBAL." HE SAID HE THOUGHT SHE HAD PAIN ON [DATE] AND ADMINISTERED THE SCHEDULED PAIN MEDICATIONS. NURSE #12 SAID HE WAS AWARE AT THE START OF HIS SHIFT ON [DATE] THAT THE RESIDENT HAD RECEIVED [MEDICATION NAME]. HE SAID HE TRIED TO CHECK ON HER ONCE IN A WHILE DURING HIS SHIFT. NURSE #12 SAID HE TOOK VITAL SIGNS AT 5:30 P.M. AT THAT TIME, PER NURSE #12, THE RESIDENT WAS "ALERT BUT NOT ORIENTED, STILL LETHARGIC. SHE WAS NOT ABLE TO HOLD A CONVERSATION." HE SAID HE PASSED BY THE DOOR AT 6:30 P.M., AND SHE WAS SLEEPING. THE NURSE SAID THE RESIDENT CONTINUED BREATHING OR THE CNA WOULD HAVE CALLED ME. HE SAID HE DOUBTED WHETHER THE RESIDENT ATE ANY DINNER. HE SAID HE DIDN'T KNOW WHETHER THE RESIDENT HAD ANY URINE OUTPUT. HE SAID A CNA REPORTED THAT THE RESIDENT WAS NOT BREATHING AT 8:20 P.M. GEORGE-GAY & CHERNECKY, IN "CLINICAL MEDICAL-SURGICAL NURSING" (2002) STATE THE FOLLOWING. "DOCUMENTATION SHOULD ENHANCE CONTINUITY OF CARE BY PROVIDING THE OPPORTUNITY FOR OTHER MEMBERS OF THE HEALTH CARE TEAM TO EVALUATE THE PATIENT'S PROGRESSION." (P. 18) THERE WAS AN OBVIOUS CHANGE IN RESIDENT #500'S CONDITION ON [DATE] AND [DATE]. THERE WAS NO DOCUMENTATION REGARDING PAIN AND EFFECTIVENESS OF PAIN MEDICATION WITH THE CHANGE IN THE PAIN REGIMEN. THERE WERE NO SYSTEMS ASSESSMENTS WHICH WOULD MONITOR THE RESIDENT'S PROGRESSION OF MEDICAL DECLINE. REGULAR ASSESSMENTS FOLLOWING THE ADMINISTRATION OF [MEDICATION NAME] WERE NOT DONE. HOSPITAL RECORDS WERE REVIEWED ON [DATE] AT 9:15 A.M. EMERGENCY DEPARTMENT RECORDS STATED THAT RESIDENT #500 WAS admitted on [DATE] AT 8:52 P.M. THE RECORDS INDICATED THAT CPR WAS IN PROGRESS ON ADMISSION. THERE WAS NO CARDIAC RESPONSE TO CPR. PER THE RECORD, THE TIME OF THE CARDIOPULMONARY ARREST WAS NOT KNOWN. DEATH WAS PRONOUNCED AT 9:01 P.M. ( )