Every finding on record at The Orchards at Southgate

This citation pertains to intake 2732359. Based on observation, interview and record review, the facility failed to verify tube placement and assess gastric residual prior to administering medication one resident (R402) of one resident observed receiving medications via peg tube resulting in the potential for aspiration respiratory compromise.Findings include:On 2/18/26 at 3:55 PM, the surveyor observed Licensed Practical Nurse (LPN) B crush and administer oxycodone 5mg one tab via peg tube to R402.Prior to administering the medication, LPN B did not check for tube placement and did not assess gastric residual.On 2/18/26 at 4:05 PM, LPN B was interviewed about PEG tube protocol. LPN B said they did not check placement or residual at that time because they had checked it earlier in the day and did not believe it needed to be rechecked.On 2/18/26 at 4:20 PM, the Director of Nursing (DON) was interviewed and said that tube placement and residual should be checked every time prior to using the PEG tube for medication or feeding administration. Record review of electronic medical record (EMR) indicated R402 was initially admitted on [DATE] with diagnosis including cerebral infarction (stroke), type II diabetes mellitus, pneumonia, tracheostomy, gastrostomy and adjustment disorder with depression.Review of the 1/2/2026 Minimum Data Set (MDS) assessment indicated R402 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment.Review of facility document titled, Medication VIA Gastrostomy Tube (undated) indicated that tube placement should be checked via auscultation or aspiration.

This citation pertains to intake 2732359.Based on observation, interview and record review, the facility failed to ensure staff performed hand hygiene after removal of soiled gloves and prior to donning clean gloves during wound related care for one resident (R402) of three residents observed receiving wound care. This deficient practice had the potential to increase the risk of cross-contamination and infection transmission.Findings include:On 2/18/2026 at 11:20AM, during an observation, Wound Care Nurse (WCN) A cleansed the wound in R402 perineal area. WCN A removed the soiled gloves, applied a clean pair of gloves, and then applied cream to R402's perineal area.No handwashing or use of alcohol-based hand rub (hand hygiene) was observed between glove removal and the application of new gloves.On 2/18/2026 at 12:05 PM, WCN A was interviewed and acknowledged they did not perform hand hygiene after removing the soiled gloves and prior to donning clean gloves to continue wound care.On 2/18/2026 at 12:30 PM, the Director of Nursing (DON) was interviewed and said staff are expected to follow facility policy and perform hand hygiene when providing care. The DON further said the facility policy may need to be more detailed regarding performing hand hygiene more frequently during wound care.Record review of electronic medical record (EMR) indicated R402 was initially admitted on [DATE] with diagnosis including cerebral infarction (stroke), type II diabetes mellitus, pneumonia, tracheostomy, gastrostomy and adjustment disorder with depression.Review of the 1/2/2026 Minimum Data Set (MDS) assessment indicated R402 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment.Policy review of facility policy titled, Hand Hygiene (undated) indicated hand hygiene is the single most important means of preventing the spread of infections. The policy further noted that the use of gloves does not replace handwashing.

Based on observation, interview and record review, the facility failed to implement interventions to prevent and promote healing of a facility acquired unstageable pressure ulcer (a severe skin injury that occurs at the heel and cannot be accurately staged because the wound base is covered by dead tissue) for one resident (R4) of three residents reviewed for pressure ulcers, resulting in the development of an unstageable heel pressure ulcer.Findings include:On 9/9/2025 at 12:13 PM, R4 was observed in bed, wearing a hospital gown, and watching TV. R4's head of bed was slightly raised, and their right heel was positioned off of the bottom of the mattress without support of heel protectors or a pillow for support. R4's right foot revealed a heel dressing with the date of 9/8/2025. R4 was asked what happened to their foot. R4 said the wound occurred on their foot from laying their foot on the footboard and bed frame. R4 stated their mattress was not long enough. R4 said, I'm kind of tall and my feet hangs over.On 09/09/2025 at 2:27 PM, R4 was observed in bed with their right leg uncovered. R4 was not wearing a heel protector. There were no interventions in place to promote wound healing.On 09/10/2025 at 08:55 AM, R4 was observed in bed and was not wearing heel protectors. There were no interventions in place to promote wound healing.09/10/2025 at 10:00 AM, Wound Care Nurse A was observed preparing to perform wound treatment for R4. The wound was located on the right heel. At that time was observed a wound that extended through all skin layers. There was a scant amount of wound drainage present and pink tissue. Wound Care Nurse A was asked how R4 developed the foot wound. Wound Care Nurse A said that R4 developed an unstageable right heel wound from resting their right foot against the bed frame and footboard. Wound Care Nurse A was asked if the wound was facility acquired and said, Yes it was. Wound Care Nurse A added that the facility extended the bed and applied a mattress spacer (foam cushion used to fill in the space between the mattress and the footboard). After Wound Care Nurse A performed wound care, she was queried if R4 required heel protectors. Wound Care Nurse A stated, Yes, but I couldn't find them in the room.On 09/10/2025 at 1:17PM, R4 was observed without heel protectors or any interventions to promote wound healing.A review of R4's Treatment Administration Record (TAR) was conducted. The facility documented that R4 refused to wear the heel protectors on day shift 9/9/25, and night shift documented that the heel protectors were applied on 9/10 and 9/11. The heel protectors were not available in the room on 9/9, 9/10, and 9/11.A review of R4's electronic medical record (EMR) revealed an admission to the facility on [DATE] with a diagnosis of Cerebral Infarction (stroke) left side dominant (left hemisphere controls the body's right side-damage there can lead to weakness or paralysis on the right side of the face, arm, and leg), Type II Diabetes Mellitus, Foot drop (the inability to lift the front part of the foot), and Chronic Kidney Disease. R404's Brief Interview for Mental Status (BIMS) score dated 08/06/2025, was 15/15, which indicated no cognitive impairment. A review of R4's Minimum Data Set (MDS) (assesses residents' ability to perform daily activities such as walking, eating, and personal hygiene) dated 8/07/2025 revealed resident's Lower extremity (hip, knee, ankle, foot) was impaired on both sides and was dependent with lower body activities.A review of R4's care plan revealed the following: I have an unstageable pressure injury to my right heel.Revision on 07/16/2025.follow your Skin Management Program.I require total assistance with transfers, toileting, personal hygiene, lower body dressing.Revision on 05/13/2025.A review of the care plan did not reveal that R4 was noncompliant with wearing heel protector or wound care interventions. In addition, the care plan did not describe the Skin Management Program details or resident specific interventions.A review of R4's Braden Scale (an assessment tool used to predict a patient's risk for developing pressure ulcers or skin breakdown) dated 3/20/2025 (admission date) revealed a score of 14/23 (moderate risk for developing pressure sore). In addition, R4 was admitted to the facility with a coccyx pressure ulcer (damage to the skin and underlying tissues that occur over the bony prominence of the coccyx-tailbone).A review of R4's EMR revealed the following: Weekly Head-To-Toe Assessment-Licensed NursesDate: 3/20/2025.Coccyx pressure wound. Moles Keloid on upper left side of back. Raised skin mid back. Bilateral fungal nail infection. Bilateral foot drop.A review of R4's Weekly Head-To-Toe Assessment-Licensed Nurses dated 3/28/2025 revealed the following: Note: no new areas (wounds, skin concerns) of concern.A review of R4's Weekly Head-To-Toe Assessment-Licensed Nurses dated 4/4/2025 revealed the following: Note: no new areas (wounds, skin concerns) of concern.A review of R4's Weekly Head-To-Toe Assessment-Licensed Nurses dated 4/4/2025 revealed the following: PEG (Percutaneous Endoscopic Gastrostomy). It is a medical procedure that involves inserting a feeding tube directly into the stomach) tube removed from abdomen, dressing intact with dried serosanguinous drainage no new skin integrity issues observed at this time.A review of R4's Weekly Head-To-Toe Assessment-Licensed Nurses dated 4/25/2025 revealed the following: Resident has open area on right heel, treatment is in place. Writer observed no other skin issues at this time.A review of R4's progress notes created by Licensed Practical Nurse C revealed the following: 4/13/2025 11:38 Nurse into (sic) see resident for wound treatment. Redden area noted to right heel MD (physician) notified new to clean right heel with wound cleanser pat dry apply 4x4 ABD pad gauze (a highly absorbent, sterile pad designed to protect and manage heavily draining wounds) to heel wrap with kerlix roll secure with tape. Wound consult order.A review of R4's progress notes created by Wound Care Nurse A revealed the following: 4/14/2025 13:53 Note Text: writer observed resident skin this am noted dry skin and soft unopened nontender area to r (right) heel.A review of R4's progress notes created by Wound Care Nurse A revealed the following: Wound Care Nurse A 4/23/2025 08:05 Skin/Wound Note Text: resident (R4) received longer bed r/t (related to) resident resting BL (bilateral) heels on foot board causing unstageable to heel. resident was educated to not rest feet upon footboard, resident (R4) stated understanding, the rested his feet upon footboard.A review of R4's progress notes created by Wound Care Nurse A revealed the following: Wound Care Nurse A 4/23/2025 07:58 Skin/Wound Note Text: resident right heel is an acute unstageable pressure injury obscured full thickness skin and tissue loss pressure ulcer, initial wound encounter measurements 4cm x 6cm without depth.A review of R4's progress notes created by Wound Care Nurse A revealed the following: 4/25/2025 08:37Skin/Wound Note Text: for wound visit 4-24-2025 resident right heel is an acute unstageable pressure injury obscured full thickness skin and tissue loss pressure ulcer, initial wound encounter measurements 4cm x 6cm without depth.A review of R4's progress notes created by MDS Coordinator D revealed the following: 4/30/2025 12:24 Note MDS (Minimum Data Set) Coordinator D Note Text: Significant change for (R4) due to new unstageable wound to right heel.A review of R4's physician order dated 5/5/2025 revealed the following: Order Summary: apply heel protectors while in bed as resident will allow every shift for protection.A review of R4's progress notes created by Wound Care Nurse A revealed the following: 7/26/2025 09:18 Skin/Wound Note A skin/subcutaneous level excisional/surgical debridement (a procedure where a surgeon uses a scalpel (sharp surgical knife) or other metal instruments to remove dead, infected, or nonviable tissue from a foot ulcer to promote healing) was performed of the right heel.subcutaneous was removed along with devitalized tissue (dead or non-viable tissue that has lost its blood supply and ability to function normally): necrotic/eschar and slough, using a blade. There was a minimal amount of bleeding which was controlled using pressure.Post debridement stage noted as unstageable pressure injury obscured (covered by) full thickness skin and tissue loss.A review of R4's progress notes created by Wound Care Nurse A revealed the following: 8/24/2025 09:27 Skin/Wound Note Text: for wound visit 8-14-2025 Resident right heel is an acute unstageable pressure injury obscured full thickness skin and tissue loss pressure ulcer, subsequent wound measurements 3.1cm x 4.8cm.There is a small amount of serosanguineous drainage without odor. On 09/11/2025 at 8:31 AM, Wound Physician E was interviewed and queried about R4's unstageable heel wound. The Wound Physician E said they were consulted to provide care to the wound. Wound Physician E said the wound was doing better especially after the debridement. Wound Physician E stated padding might have helped to relieve pressure. On 09/11/2025 at 10:22 AM, R4 was observed in bed, a dressing was observed on R4's right foot and was not wearing heel protectors. R4 was interviewed and asked if they remembered when the last time was wearing foot protectors and R4 said about a week ago.On 09/11/2025 at 10:25 AM, Nurse B was interviewed and queried about R4's wound and heel protectors. Nurse B said the wound was healing and the wound care nurse was going to retrieve R4 another pair.On 09/11/2025 at 11:51 AM, The Director of Nursing (DON) was interviewed and queried about R4's unstageable heel wound and interventions not being followed. The DON said nursing staff should follow the physician orders and policy to prevent wounds.A review of the facility's policy Skin Management Facility Guidelines (undated) revealed the following: Conduct a baseline head-to-toe skin check on each resident upon admission, readmission, and quarterly and with significant change.A care plan is developed upon admission and may address Preventative devices, education when appropriate.

Based on observation, interview, and record review, the facility failed to develop an individualized anticoagulant (a blood thinner that prevents blood clots from forming but increase the risk of bleeding) comprehensive care plan for one resident (R103) out of five residents reviewed for injuries of unknown origin. Findings include:On 8/20/25 at 10:13 AM, R103 was observed awake and sitting in a wheelchair in her room. When asked how she was doing, R103 stated that this morning a CNA (Certified Nurse Aide) asked her about bruises on her upper right arm and lower left leg. R103 said she had no idea how the bruises got there. During an observation and interview on 8/20/25 at 10:17 AM of R103's right arm and left leg, Licensed Practical Nurse (LPN) B said R103 has a circular bruise on the upper outside of her right arm and a bruise just below the left knee. LPN B said the bruise on the arm was purple and yellow. The knee bruise was purplish. R103 again reiterated that the CNA that assisted her getting dress this morning mentioned the bruises to her. LPN B reviewed R103's electronic health record (EHR) and confirmed there were no progress notes regarding R103's bruises. During an observation and interview on 8/20/25 at 10:23 AM of R103's right arm and left leg, Unit Manager/Registered Nurse (UM/RN) C said the bruise on the right arm was approximately three fingers below the shoulder and was approximately the size of a silver dollar and irregularly shaped. The center part of the bruise on the arm was pale yellow, and the circumference was a light purplish color. UM/RN C said it felt like a healing bruise and felt no lumps when palpated. R103 reported no pain when touched. UM/RN C said the bruise on the left shin was in a reddened state and about four fingers below the knee. UM/RN C identified another bruise on R103's shin and said it was located about four fingers below the upper bruise. It was also in a reddened state. UM/RN C stated, The bruises on the left leg most likely happened within a day, but if it is not witnessed, we don't know. UM/RN C said the bruise on the arm appeared to be about a week old because of the way that it was healing. UM/RN C said any bruise on a resident should be reported. UM/RN C was unaware of the bruises on R103 prior to this interview. UM/RN C stated, (R103) runs into things. During an interview on 8/20/25 at 10:44 AM, CNA E said she helped R103 get out of bed before 8:00 AM this morning. CNA E stated, I called the nurse in there (R103's room) and showed her the bruises. CNA E said she only works on Wednesdays and had no knowledge of the bruises before today. During an interview on 8/20/25 at 10:46 AM, LPN F said she observed the bruises on R103 this morning and was going to document her observations but had not done it yet nor had she reported it to the unit manager. LPN F said she was unaware of R103's bruises before this morning. LPN F said R103 denied that she was hurt. LPN F acknowledged that a bruise can be a sign of abuse and that was why she asked R103, How it happened? LPN F agreed that she was responsible for reporting signs of abuse. During interviews and record review beginning on 8/20/25 at 3:21 PM, the Director of Nursing (DON) stated they just found out R103 had bruises and I have to do an investigation. I look at meds to see what could cause bruising and (R103) is on aspirin. A chart review revealed R103 had been on aspirin 81 mg intermittently since 1/17/24. R103's most recent orders for aspirin 81 mg were from 1/18/25 to 6/2/25 and then 6/3/25 to the present. A review of facility documents titled, Weekly Head to Toe Assessment, dated 8/18/25, 8/8/25, 8/1/25, 7/25/25, and 7/14/25 all indicated no new skin issues. Further review of R103's EHR revealed the following care plan focus: I have potential impairment to skin integrity r/t (related to) decrease mobility, frequently incontinent of bowel and bladder. I have a history of CVA (cerebrovascular accident) and my left side is weak. I have a tendency to bruise easily r/t use of the aspirin. My skin is fragile.Date Initiated: 1/31/2025. Created by: MDS Coordinator.Revision on: 8/20/25. Revision by: Director of Nursing. A review of physician's orders for R103 documented: Monitor for bruising r/t aspirin use every shift. Date/time stamp of 8/20/25 at 10:34 AM. When queried about the physician order to monitor for bruising and care plan revision entered today, 8/20/25, specifically what evidence did the DON have that R103 has a tendency to bruise easily, the DON stated (R103) has a tendency to bruise easily because of the aspirin. It is an anticoagulant. With aspirin (the residents) can easily bruise. The DON then added that she will change the care plan to reflect that R103 may easily bruise related to the use of aspirin. The DON acknowledged that she had not completed the care plan interventions for this concern. The DON said all residents are on a skin management program. However, a person on aspirin required additional interventions. The DON indicated that prior to today, R103's care plans had not been individualized to reflect she was on aspirin, and that this should have been part of R103's care plans before today. R103's care plans did not indicate a tendency to run into things as reported by UM/RN C. A review of the clinical record for R103 documented an initial admission date of 1/16/24 and readmission date of 6/2/25. R103's diagnoses included cerebrovascular disease, paraplegia, and atherosclerotic heart disease. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of the facility policy titled, Comprehensive Plan of Care, undated but received during the survey documented in part the following:- The comprehensive care plan must be consistent with resident's right and reflect intervention to meet both short- and long-term resident goals; include intervention to attempt to manage risk factors; and be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur.- Procedures included: re-evaluate and modify care plan as necessary to reflect changes in care, service and treatment. On 8/20/25 at 4:40 PM during the exit conference the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and there was nothing else provided related to the identified concern.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 80 residents who receive meal services (3 nothing by mouth residents, or NPO) out of the facility's total census of 77 residents. Findings include: 1. On 8/7/24 at 10:44 AM, during a dietary tour of the kitchen, when asked the how the facility cleans and sanitizes work surfaces in this area, Dietary Manager, staff A, stated, we have our sanitizer buckets. At this time, staff A was asked to test a sanitizing bucket to verify its concentration. The testing of the sanitizer concentration by staff A via a test strip, and comparing its color to the test strip packaging revealed a concentration of zero. Upon observation staff A stated, This might be from this morning, it's a little cloudy. to which Cook, staff C, stated, it is, I was going to remake it now. On 8/7/24 at 10:48 AM, record review of the chemical sanitizing poster located above the 3-compartment sink revealed the expectation to maintain the sanitizer at a concentration of 200 parts per million (ppm) -400 ppm and at a temperature of 70 degrees F. When asked how the facility plans to achieve this result, Staff A stated, we change them out every two hours or as needed. Review of 2017 U.S. Public Health Service Food Code, Chapter 7-204.11 Sanitizers, Criteria, directs that: Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P 2. On 8/7/24 at 11:06 AM, observed acoustic ceiling tiles installed above the steam table serving line, food prep areas, the clean equipment and utensil storage racks, and on the clean and sanitized sides of the dish machine and 3-compartment sink. A smooth and hard faced ceiling tile was observed above the coffee urn. On 8/7/24 at 11:08 AM, upon interview with Dietary Manager, staff A, on why the ceiling had different types of tiles in different locations they stated, I'm not exactly sure, if it was from the steam or from a leak, but they changed out the tile above the coffee pot with a different type and it has been fine ever since. Review of 2017 U.S. Public Health Service Food Code, Chapter 6-201.11 Floors, Walls, and Ceilings directs that: Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. 3. On 8/7/24 at 11:16 AM, at 11:32 AM and at 12:05 PM, Dietary aide, staff D, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 8/7/24 at 11:44 AM, when asked if they had conducted any training with staff on the proper procedure to wash their hands, Staff A stated, yes, upon hire and with the normal reminders every so often. On 8/7/24 at 11:28 AM, at 11:52 AM and at 12:01 PM, Cook, staff C, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 8/7/24 at 11:23 AM, at 11:48 AM and at 12:09 PM Dietary aide, staff E, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 8/7/24 at 3:05 PM, record review of a policy titled, QRT Hand Washing revealed that the facility has a hand washing procedure in place identifying when it is required to wash hands and how it should be conducted. Review of the U.S. Public Health Service 2017 Food Code, Chapter 2-301.12 Cleaning Procedure, directs that: (C) TO avoid recontaminating their hands or surrogate prosthetic Devices, FOOD EMPLOYEES may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a HANDWASHING SINK or the handle of a restroom door. 4. On 8/7/24 at 12:15 PM, a meal test tray of the last tray from the serving cart was requested. On 8/7/24 at 12:34 PM, upon taking food temperatures of the day's meal, the roast beef was measured to be holding at a temperature between 108 degrees F and 112 degrees F. At this time staff A was asked about the current state of the meal to which they stated, we need to start to use our plate warmer again. I'll talk to them about this. Review of 2017 U.S. Public Health Service Food Code, Chapter 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding directs that: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above.

Based on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 80 residents and its staff resulting in an increased potential for harm. Findings include: On 8/7/24 between 1:32 PM, and 2:18 PM, during an environmental tour of the facility the following observations were made: Cracked and damaged floor tiles with missing pieces were observed in the elevator, in the first floor soiled utility room, and in the laundry room near the washing machines. Three shaving razors with their protective caps removed, a squeeze bottle of soap, and two used shaving cream containers were observed on the outer rim of the second floor's shower rooms designated handwashing sink. One chemical spray bottle containing a yellow liquid, and one chemical spray bottle containing a purple liquid were observed unlabeled and available for use in the soiled holding portion of the laundry room. On 8/7/24 at 1:39 PM, upon interview with Maintenance Director, staff B, regarding the current state of the elevator flooring they stated, I'm not sure if I can do those repairs because they are in the elevator, or if I need to get an elevator contractor out here. I'll look into it. On 8/7/24 at 1:47 PM, upon interview with staff B regarding the current state of the second floor's shower room they stated, I'm not sure why it was left like this. I know some residents will come in here without supervision. I'll clean this up now. On 8/7/24 at 1:59 PM, upon interview with staff B regarding the unlabeled chemical spray bottles they stated, they all know they should be labeled.

Based on observation, interview, and record review, the facility failed to ensure feeding assistance were provided timely for two Residents (R23 and R69) of three residents reviewed for activities of daily living (ADLs), resulting in the residents not eating meal timely and the potential for the residents food to be served at an inappropriate temperature. Findings include: R23 On 8/6/2024 at 12:27 p.m., R23 was observed lying in bed asleep with food tray covered undisturbed on the bedside table. Observed Multiple staff assisting with tray pass. On 8/6/2024 at 12:36 p.m., Certified Nursing Assistance (CNA) H was interviewed regarding R23's food tray. CNA H said the R23 can eat on her own, but you must wake the resident up and set the food tray up. CNA H said whoever passed R23' s food tray must not have known to wake the resident up and to set up the food tray. CNA H assisted the resident with the food tray set up. CNA H confirmed the food trays was on the unit about 12:00 noon. According to the electronic medical record, R23 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses Alzheimer's disease, anxiety disorder, dementia, dysphagia, and protein-calorie malnutrition. R23's annual Minimum Data Set (MDS) with a reference date of 6/23/2024 indicated R23 had intact cognition with a BIMS (brief interview for mental status) score of 15/15. Review of the ADL, (Activities of Daily Living) care plan-review date of 6/20/2024 documented, R23 need assistance with ADLs related to generalized weakness. Interventions as following: - Encourage resident to eat in the dining room as I enjoy socialization. - Eating: I can feed myself with set up assist and supervision. R69 On 8/6/2024 at 12:44 p.m., R69 was observed lying in bed alert with a covered undisturbed food tray on the bedside table. R69 nodded yes, indicating yes to ready to eat and needing assisting to set up the food tray when interviewed. On 8/6/2024 at 12:52 p.m., during an interview, Licensed Practical Nurse (LPN) G observed the food tray on the bedside side table. LPN 'G asked, was R69 hungry and was ready to eat. R69 nodded indicating yes. LPN G raised the head of R69's bed and assisted the resident with the food tray set up and assisted the resident with eating. R69 was observed eating with LPN G assistance. According to the electronic medical record, R69 was admitted to the facility on [DATE] with diagnoses diabetes mellitus type two, major depressive disorder, cerebral infarction (Stroke), other paralytic syndrome (a medical condition that can cause neuromuscular weakness or paralysis) following cerebral infarction, primary osteoarthritis, and vascular dementia. R69's quarterly Minimum Data Set (MDS) with a reference date of 5/15/2024 indicated R69 cognition was moderately impaired with a BIMS (brief interview for mental status) score of 07/15. Review of the ADL, (Activities of Daily Living) care plan-review date of 5/15/2024 documented, R69 need assistance with ADLs due to vascular dementia, paralytic syndrome following a cerebral infarction and metabolic encephalopathy. Interventions as following: - Eating: I am able to feed myself with tray set up. During an interview on 8/8/2024 at 3:00 p.m., the Director of Nursing (DON) was informed of R23 and R69's lunch trays on the bed table without any assistance from staff for set up. The DON said that the staff should assist the residents with their meals at the time the food trays were brought into the resident's room. According to the facility's 9/01/2021 Food and Nutrition Services policy: Meal service schedules establish mealtimes that are appropriate for residents and optimize staff's ability to assist residents during meals. Residents are served in an efficient manner that emphasizes customer service. Nursing staff, unit food carts: 1. The tray will then be served to the resident, providing set up and dining services as needed.

Based on observation, interview, and record review, the facility failed to follow-up with a dental recommendation for one resident with Medicaid benefits (R74) out of two residents reviewed for dental services resulting in R74 not having several broken/decayed teeth extracted and with complaints of tooth pain and tooth abscess and difficulty eating. Findings include: On 8/6/24 at 10:15 AM R74 was observed with several visible broken and decayed teeth. During an interview R74 pointed to his top teeth and said his teeth hurt, it is hard to eat. R74 said he saw a dentist and was supposed to get some teeth pulled, but nothing has happened since. According to the Electronic Health Record (EHR) R74 was admitted to the facility on [DATE] with diagnosis of convulsions, seizures and altered mental status. The Minimum Data Set (MDS) dated [DATE] indicated R74 had moderately impaired cognition with a BIMS (brief interview for mental status) score of 12/15. R74 was identified to require supervision and set up assistance for personal hygiene. According to the EHR R74's Medicaid insurance began retroactive on 6/1/24 with Medicaid status accepted on 7/10/24. According to a Dental Summary Report on 5/22/24: Resident (R74) Caries removed, He complains of pain in his upper and is eager to have them removed. Reviewed visit summary with social worker who reports that as soon they sort out his insurance, he will be scheduled with the oral surgeon. Review of the progress note dated 6/8/24 revealed Resident noted with c/o tooth pain unrelieved by prn pain management. Medical doctor order given for Augmentin for tooth infection and dentist referral. There was no further documentation to indicate that R74 had a follow up dental visit or tooth extractions. On 8/07/24 at 11:51 AM the Nursing Home Administrator was interviewed and said we don't have an appointment made for the resident. It should have been made once he got Medicaid on 7/10/24. The social worker just left employment and most likely did not make the appointment for the resident. The social worker is responsible for setting up dental appointments. I will follow up set up an appointment for him. According to the facility policy titled Dental Services undated revealed in part .It is the policy of this facility to assist residents in obtaining routine and 24-hour emergency dental care to meet the needs of each resident. Procedure 1. When the resident requires routine or emergency dental care, the Social Service Staff will assist the resident to secure an appointment.

This citation pertains to intake MI00142163. Based on observation, interview and record review the facility failed to provide adequate supervision. On January 15, 2024, at approximately 10:30 AM, R301 a cognitively impaired resident (BIMS of 4) eloped from the facility The recorded temperature that day was 9 degrees Fahrenheit. R301 walked down beside [NAME] Rd (A four lane highway) crossed Fort St (A six lane highway) and proceeded to (Name Redacted) Co-op Apartments (approximately 1.5 miles from facility). Director of Nursing called [NAME] Police at 11:22 AM, and it was reported resident was transported to the hospital at approximately 10:38 AM. This deficient practice resulted in the likelihood of serious injury, serious harm, serious impairment, or death related to being struck by a vehicle and/or exposure to extreme weather temperatures. Findings include: On 1/31/24 at 12:20 PM, R301 was observed. R301 was not not interviewable related to impaired cognition. Record review of R301's electronic medical record (EMR) revealed admission into the facility on [DATE] and was readmitted on [DATE] with diagnoses of unspecified dementia and paranoid schizophrenia. According to the Minimum Data Set (MDS) dated [DATE], R301 had severe impaired cognition with a BIMS (brief interview for mental status) of 0/15. Review of Elopement assessment dated [DATE], R301 scored an 11 on elopement risk scale and categorized as a High Risk to Wander. Review of Elopement Care Plan documented on 1/16/23- Please redirect and /or ask me what I am attempting to head to the first floor. Further observation revealed resident lived on second floor and had exited on the first floor of the facility. Review of document Timeline for R301 dated 1/15/24 noted the following: 10:20am - CENA observed a resident in her room at approximately 10:00am -10:20am. She was wearing a black hat, a short tan coat, with shoes. 10:30am Called code green for the unauthorized leave of (R301). All staff were searching for the grounds and surrounding areas. Review of Police Report dated 1/15/24 at 10:40 AM documented the following: . On Monday, 01/15/24, at approximately 1040hrs, Officers were dispatched to (address redacted) in the City of Riverview, in the County of [NAME], on a call of an unwanted female refusing to leave. Officers made contact with (R301). When making contact, Officers observed (R301) had soiled herself and she did not make sense when speaking with Officers . Review of hospital records revealed R301 was in emergency department on 1/15/24 at 11:37 AM. During an interview on 1/31/24 at 2:10 PM with Nursing Home Administrator (NHA), it was reported that R301 left the building approximately between 10:20 AM and 10:30 AM. NHA further stated, A group of people from bible study was coming in and the resident must have left as they came in the door. When asked if the facility failed to supervise the resident, NHA stated, We could have done better to redirect (R301) and kept her safe. Record review of policy Elopement, Potential Resident (no date) documented the following: . It is the policy of this facility to provide residents with a safe and secure environment and identify residents who may be at risk for unobserved exit from the facility. The Immediate Jeopardy began on 1/15/24 when the facility failed to provide adequate supervision. Nursing Home Administrator was notified of the Immediate Jeopardy on 1/31/24 at 12:09 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 1/16/24 prior to the start of the survey and was therefore past noncompliance. Past noncompliance: The Immediate Jeopardy that began on 1/15/24 was removed on 1/16/24 when the facility: 1. All Receptionist was in-service on notification of residents attempting to go on an unauthorized leave to the resident's nurse and or Certified Nursing Assistant. Receptionists completed in-service 1-16-24. 2. Doors and alarms were checked immediately by staff, to ensure the safety of other residents. 3. Resident that has the potential for Elopement/ and the Elopement Books located at each nurse's station were reviewed/revised as needed by the Director of Nursing/Social Service. 4. Letter placed by sign in visitor/staff sheet, letter was published on 1/15/24. 5. The Maintenance Director did a check on the door alarms with no concerns noted. The Maintenance Director implemented daily door checks on all the door alarms. Door Alarms code was changed for the safety of the residents. The deficient practice was corrected on 1/16/24 after the facility: 1. Residents were re-evaluated for the potential for elopement and documented accordingly. 2. The Elopement Policy was reviewed and deemed appropriate. Staff were re-educated on the elopement policy. 3. The Door Alarm Policy was reviewed and deemed appropriate. Staff were re-educated on the policy of Door Alarm. 4. The Maintenance Director implemented a daily check on all the door alarms for one week then three times a week for 1 month, then monthly thereafter. The Maintenance Director will report any findings to the quality assurance committee monthly for 3 months and then as directed by the committee. 5. Facility will conduct elopement drills 1x monthly to ensure facility compliance. All results of audits will be brought to QAPI. 6. New residents entering the facility will be discussed in the morning clinical meeting for potential elopement.

This citation pertains to Intakes: MI00139241 and MI00139218. Based on interview and record review the facility failed to report an incident of elopement to the State Agency for one resident (R404) out of four residents reviewed for elopement risk, resulting in the potential for further incidents of unreported elopements. Findings include: On 9/12/2023 at 8:00 A.M. an investigation was conducted concerning R404 eloping from the facility. It was reported by (Local police department and community acute care facility) on 8/19/2023 R404 walked away from the facility around 9:00 A.M. and showed up at a local hospital that was approximately four miles from the facility where the resident lived. At 9:30 A.M. during an interview the Director of Nursing of Nursing (DON) stated R404 left the facility (time unknown) but estimated after the A.M. medication pass (Approximately 12:00 P.M.). The DON reported that around 1:45 P.M. she made round at the facility to check on the staff. Upon arrival, the DON was informed R404 left the faciity on an unauthorized leave and refused to sign the Against Medical Advice (AMA) Form. According to the DON, the Administrator was informed of the missing resident after she arrived at the facility. The DON reported local hospitals in the area and the police were alerted and were provided pictures and pertinent information to locate R404. The DON stated R404 was found between 2:00 P.M. and 3:00 P.M. around the corner at a local hospital where the resident reportedly walked and sought medical supplies for colostomy care. R404 was escorted into the hospital and assessed by the medical staff and discovered to have no injuries. R404 was asked to return to the facility with the DON and Administrator, but refused voicing concerns that the facility was trying to hold her as a prisoner. At 1:30 P.M., the DON was queried regarding who was supervising R404 and how the resident was able to leave the facility without staff knowledge. The DON stated she nor the Administrator was at the facility at the time and the staff just informed her R404 had left the facility. In a subsequent interview the Administrator and the DON was queried if R404 elopement had been reported to the State Agency. The Administrator responded, no because we did not think it was an elopement. The Administrator and DON stated the resident did not want to have a guardian and they had scheduled a guardianship hearing and R404 decided to leave. A review of the facility's undated investigation was reviewed and did not indicate the elopement incident was reported to the State Agency. Review of the Admission Record for R404 revealed the resident was admitted to the facility 1/18/2023 with diagnoses which included: dementia, ulcerative intestinal obstruction, irritable bowel syndrome, colostomy, and anxiety disorder. According to the [NAME] Data Set (MDS), dated [DATE], R404 had modified independence in cognition with long- and short-term memory deficits, required supervision and ambulated independently. Upon exiting the facility on 9/12/23 at 4:30 P.M. no other information was provided.

This citation pertains to intake MI00139241 and MI00139218. Based on interview and record review the facility failed to prevent an elopement for one resident (404) of four residents reviewed for elopement, resulting in R (404) exiting the facility without staff knowledge and the potential for injury and for other elopement risk residents. Findings include: On 9/12/2023 at 8:00 A.M. an investigation was conducted concerning R404 eloping from the facility. It was reported on 8/19/2023 R404 walked away from the facility around 9:00 A.M. and showed up at a local hospital that was approximately four miles from the facility where the resident lived. At 9:30 A.M. during an interview the Director of Nursing of Nursing (DON) stated R404 left the facility (time unknown) but estimated after the A.M. medication pass (Approximately 12:00 P.M.). The DON reported around 1:45 P.M. she made round at the facility to check on the staff, upon arrival the DON was informed R404 left the faciity on an unauthorized leave and refused to sign the Against Medical Advice (AMA) Form. According to the DON, the Administrator was informed of the missing resident after she arrived at the facility. The DON reported local hospitals in the area and the police were alerted and were provided pictures and pertinent information to locate R404. The DON stated R404 was found between 2:00 P.M. and 3:00 P.M. around the corner from a local hospital where the resident reportedly walked and sought medical supplies for colostomy care. R404 was escorted into the hospital and assessed by the medical staff and discovered to have no injuries. R404 was asked to return to the facility with the DON and Administrator, but refused voicing concerns that the facility was trying to hold her as a prisoner. At 1:30 P.M. the DON was interviewed concerning who was supervising R404 and how was the resident able to leave the facility without staff knowledge. The DON stated she nor the Administrator was at the facility at the time R404 left the facility unsupervised and the staff just informed her R404 had left the facility without staff knowledge upon the DON's arrival to the facility. Review of the Admission Record for R404 revealed the resident was admitted to the facility 1/18/2023 with diagnoses which included: dementia, ulcerative intestinal obstruction, irritable bowel syndrome, colostomy, and anxiety disorder. According to the [NAME] Data Set (MDS), dated [DATE], R404 had modified independence in cognition with long- and short-term memory deficits, required supervision and ambulated independently. Review of the Elopement assessment dated [DATE], indicated R404 was at risk for wandering but had no reported episodes of exiting seeking behavior in the last three months. The facility's undated investigation was reviewed. The Administrator and the DON was queried why a code green (elopement protocol) was implemented after finding R404. Both began to explain the resident was her own guardian and R404 was scheduled for a guardianship hearing on 8/24/23 at 9:30 A.M., which the resident was aware of and R404 had indicated the facility was trying to hold her a prisoner. A review of the facility's undated policy titled; Transfers and Discharges revealed under #8 Discharge Against Medical Advice (AMA) . If the resident refuses to sign, two people from the facility should complete the form to signify the residents discharge Documentation of notification should be entered in the Nursing Progress Notes . There was no documentation in the Nursing progress notes or AMA documents pertaining R404 leaving the facility. Upon Exiting the facility at 4:30 P.M. no other additional information was provided.

Based on observation, interview, and record review the facility failed to implement nutritional interventions for weight loss for one resident (R72) of four residents reviewed for nutritional parameters, resulting in a significant weight loss. Findings include: On 7/17/23 at approximately 10:28 A.M. R72 was observed in her room in bed. The resident appeared confused, thin in statue with temporal wasting (suggestive of weight loss). On 7/17/23 at 12:30 P.M. R72 was observed sleeping throughout the lunch meal without any staff assistance with eating. At 2:30 P.M.in the evening R72 was observed wandering in her wheelchair aimlessly throughout the facility. On 7/18/23 at 8:30 A.M., review of resident's Weight and Vital Summary revealed R72 had a significant weight loss in June. The record showed a progressive decline in the resident's weight. Weights were documented as indicated: 3/30- 108.5# (Admission Weight) 3/31-108.5# 4/3- 108# 4/17-104# 5/2- 101.5# 6/6- 101# 6/28 -100# 6/28- 92.5# 7/6- 93# R72 loss a total of 15.5#'s in 3 months (significant weight loss). Review of R72 medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including altered mental status, Alzheimer's disease, dementia with agitation, falls, major depression and macular degeneration (diminish disease of the macular area of the retina of the eye). According to the Minimum Data Set (MDS) assessment dated [DATE], R72 was severely impaired in cognitive (ability to think) skills for decision making and required supervision and set up help for eating. On 7/19/23 at 10:00 A.M. review of the nutritional assessment dated [DATE] indicated R72 was ordered a regular diet with a Mighty Shake TID (three times daily) with trays. (Dietary Supplement). In a subsequent Dietary Progress Note dated 3/30/23, R72's weight was obtained from (H&P) from the hospital and documented as 113#'s, 5#'s difference than the actual recorded weight of the facility on 3/30/23, (108.5#). The Registered Dietitian (RD) recommended the following nutritional interventions: Ensure Plus one can 237 milliliters, BID (twice daily) with med pass for additional nutritional support related to (r/t) diagnoses and fluctuation in poor intake. This recommendation provides 700 calories and 26 grams of protein. R72 requires assistance with meals and the addition of the ensure plus would meet the resident's nutritional needs. Review of the Nutrition Care Plan dated 3/29/2023 and revised on 3/30/2023 stated, . I require assistance with meals. At times I want (sic) eat the meals from the facility. My family brings in meals for me. I am on Nutritional supplements for additional nutritional support and weight maintenance. Discuss my weight changes and nutrition care plan with myself and or my family. Honor my food preferences as feasible: Dislikes are anything vanilla, beverage, desserts, P.O (taken by mouth) supplements. (Provide and serve my supplements as ordered: Liquid protein-3/29/23. At 10:40 A.M. review of R72's Food Acceptance record from 6/20/23-7/17/23 indicated the resident's food intake fluctuated between 51-75%. In the absence of the RD at 12:50 P.M. the surveyor was joined by the Director of Nursing for a review of the MAR (Medication Administration Record), March 30 thru April, 24. The review revealed R72 consumed varying amounts of ensure plus BID, instead of the 237 Milligrams (mg) ordered twice a day. On 4/25 R72's Ensure Plus was discontinued, and the resident was provided Nepro (Vanilla, flavored calorically dense supplement). The percentage consumed was 25%. No other comparable nutritional supplement was provided to substitute for the recommended 2 cans of ensure plus that was ordered 3/30/23 by the RD. Further review per the MAR documented from April 1 to April 26, R72 was not given the 30 ml of protein oral liquid as ordered twice a day. From June 1, thru July 18, per MAR, R72 refused the protein supplement and received no nutritional support from any nutritional supplement. On 7/19/23 at 1:15 p.m. the DON was queried if the registered dietitian was informed of the resident's significant weight loss and why had R72 had not been given or provided another alternate for the vanilla ensure plus. The DON explained the facility only ordered vanilla flavored supplements and she wasn't aware of the different flavors or additives that were available or could have been utilized to change the flavor of the vanilla supplement. When queried why the resident continued to receive a vanilla supplement when the RD had identified vanilla as a dislike for food, dessert, beverage, and P.O. supplement the DON responded, We stopped the Ensure plus because she was also lactose free, and the family was bringing in food. The DON was informed the Ensure Plus was lactose free and when the Nepro and ensure plus supplements were discontinued R72 was receiving approximately 60 additional calories a day instead of the additional 700 calories the RD recommended for nutritional support. During the interview the DON was informed R72 was not observed being assisted with meals on 7/17/23 at lunch, on 7/18 for breakfast or lunch and breakfast on 7/19/23. At this time a weight of the resident was requested. R72 weight was 91.5#'s the resident had loss and additional 1.5 pounds more than the weight taken on 7/6/23. The DON was asked what system was in place to alert or advise the RD of residents with weight loss? The DON indicated we discussed it in morning meetings, but provided no explanation of how the weight loss was communicated to the RD. Upon exiting the facility on 7/19/23 at 4:15 P.M., no other information was provided for R72 significant weight loss. Review of the facility's undated policy titled, Unintended Weight Change documented in part, Resident with unintended weight loss/gain will be assessed by the interdisciplinary team and interventions will be implemented to prevent further weight loss/gain . #3) The Don and dietitian monitors the prevalence of unintended weight loss/ gain on a monthly basis through analysis.

Based on observation, interview, and record review, the facility failed to ensure consistent proper working order of the facility walk-in freezer and reach-in cooler which had the potential to affect all residents that eat from the kitchen and kitchen operations. Findings include: During the initial tour of the kitchen on 7/17/2023 beginning at 8:54 AM with Dietary Manager (DM) D the following was observed: - The internal temperature of the walk-in freezer was 18 F (Fahrenheit). A four- ounce cup of ice cream stored in the freezer was observed soft, not frozen solid. - The front grill located on the outside of the reach-in cooler had an accumulation of soil and dust. DM D stated that she sees dust and that it should be cleaned. During a return visit to the kitchen on 7/17/2023 beginning at 11:34 AM with DM D and Regional Food Service Manager (FSM) G, individual serving bowls of potato salad were observed on ice on the tray line. Temperatures of three bowls of potato salad were obtained and were 47 F, 48 F, and 48.9 F. Prior to being placed on the tray line, the potato salad had been held in the reach-in cooler. The internal temperature of the reach-in cooler was observed to be 50 F. The temperature of a container of tuna salad inside of the reach-in cooler was observed to be 47.9 F. DM D said the tuna salad was placed in the reach-in cooler 7/16/2023. FSM G stated the temperature of the tuna salad should be 41 degrees (or less). On 7/17/2023 at 11:43 AM, the internal temperature of the walk-in freezer was observed to be 22 F. A four-ounce cup of ice cream stored in the freezer was observed soft, not frozen solid. This finding was confirmed by DM D at the time of discovery through interview. On 7/18/2023 at 7:57 AM, the internal temperature of the walk-in freezer was observed to be 11 F. A four-ounce cup of ice cream stored in the freezer was observed soft, not frozen solid. This finding was confirmed by FSM G at the time of discovery through interview. During an interview on 7/17/2023 at 1:21 PM, Maintenance Supervisor (MS) F said he was working on the reach-in cooler coils and cleaning them up the best he can. MS F stated, The coils on the bottom were dirty. MS F suggested that dirty coils can impede the operation of the reach-in cooler. During an interview on 7/19/2023 at 1:00 PM, DM D said the temperature of the walk-in freezer should be zero degrees or less and the temperature of the reach-in cooler should be 41 degrees or less. A review of a facility document titled, Safe Storage of Food, dated 9/1/2021, revealed in part the following: - All perishable foods will be maintained at a temperature of 41F or below, except during necessary periods of preparation and service. - Freezer temperatures will be maintained at a temperature of 0F or below. A review of the 2013 FDA Food Code revealed the following: - Section 3-501.11. Stored frozen foods shall be maintained frozen. - Section 3-501.16 Potentially Hazardous Food, Hot and Cold Holding. Except during preparation, cooking, or cooling, potentially hazardous food shall be maintained at 135 degrees F or above or at 41 degrees F or less. - Section 4-501.11. Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. On 7/19/2023 at 3:45 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to (1) effectively clean multiple surfaces in the kitchen, (2) properly date-label food in the cooler and freezer, and (3) test the dish machine operating temperature prior to use. These deficient practices have the potential to affect all residents who eat food out of the kitchen resulting in the increased potential for cross-contamination, bacterial harborage, and increase potential for resident foodborne illness. Findings include: During the initial tour of the kitchen on 7/17/2023 beginning at 8:54 AM with Dietary Manager (DM) D the following was observed: - The wall behind the dish tank was soiled with an accumulation of dirt and grime. The wall paneling behind the dish tank was not sealed where it contacts the wall, leaving a gap for water and food splash to enter. - Dietary Aide (DA) E was operating the high temperature dish machine. When queried if the dish machine sanitizing temperature was obtained prior to use, DA E said it was not. - Eight ladles of varying sizes were hanging from a rack bowl side up. One ladle was observed with food debris in the bowl. - Food debris was observed in two lidless utensil storage bins containing cleaned cooking and service utensils. - Three 1/3-size pans and two 1/2-size pans were stored wet and soiled with food debris in the cleaned pot and pan area. - The following items, stored in the freezer, were opened, and did not contain a date mark to indicate when the products should be discarded: a bag of biscuits, a bag of pepperoni, and a bag of French fries. - The following items, stored in the walk-in cooler, were opened, and did not contain a date mark to indicate when the products should be discarded: a bag containing ham and a bag of shredded cheese. - A plastic container of pork cooked on 7/16/2023 was in the reach-in cooler. The cooling log for the cooked pork was requested. DM E stated, There should have been a cooling log, but there isn't one. On 7/17/2023 at 12:02 PM, observation of the doorway jamb between the kitchen and 1st floor dining room revealed an accumulation of dust and dirt. This finding was confirmed by DM D at the time of discovery through interview. During an interview on 7/19/2023 at 1:00 PM, DM D said she expects everything in the kitchen to be cleaned properly. DM D stated, I expect everyone to go by the cleaning schedule as posted. DM D said she had not been holding staff accountable for cleaning the kitchen. DM D expects staff to date label each food item with the date delivered, date opened, and date to be discarded. DM D said staff should take the temperature of the dish machine prior to washing the dishes to ensure the dish machine is sanitizing correctly. A review of the following facility documents revealed in part the following: Cleaning and Sanitizing and Proper Hair Restraints, dated 9/1/2021: - Food contact surfaces are properly cleaned and sanitized before and after use. Non-food contact surfaces are cleaned per individual facility cleaning schedule to maintain optimal cleanliness of kitchen equipment. - Non-food contact surfaces are washed with soapy water per frequency identified on the facility cleaning schedule - or as visually necessary. Safe Storage of Food, dated 9/1/2021: - All foods will be stored wrapped or in covered containers, labeled and dated. - Storage areas will be neat, arranged for easy identification, and date marked as appropriate. A review of the 2013 FDA Food Code revealed the following: - Section 3-101.11 Safe, Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented. - Section 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. - 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. - Section 4-602.13, Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. - Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under S 6-201.14 and except for anti-slip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. On 7/19/2023 at 3:45 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.

This citation pertains to Intakes MI00133548, MI00134508, MI00137641, MI00136260, MI00134591, MI00131114 Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for residents served from the 1st Floor-Short meal cart, resulting in potential dissatisfaction with the meal experience and unmet nutritional needs. Findings include: The complainants reported to the State Agency that the facility failed to serve palatable food. During an observation and interview on 7/18/2023 at 8:03 AM, a resident breakfast tray was obtained from the 1st Floor-Short meal cart to be used as a test tray. The Director of Nursing (DON) was present during the testing of food temperatures on the breakfast tray. The following temperatures were obtained using a metal stem thermometer: Pancake: 99 F (Fahrenheit) Link sausage: 89 F Milk: 49 F Orange juice: 53.9 F The softened butter did not melt when spread on the pancake. This observation was confirmed by the DON through interview. During an interview beginning on 7/19/2023 at 1:11 PM, food temperatures obtained on 7/18/2023 at 8:03 AM were reviewed with Dietary Manager (DM) D. DM D stated, When the food leaves the kitchen it should be at least 135 degrees. If the pancake was up to temperature, I would expect the butter to melt. The milk and orange juice should be less than 41 (degrees). DM D said hot food temperature at point of service should be at least 100 degrees for food palatability but there was no policy that stated that. DM D reported that there were approximately 20 trays on the 1st Floor-Short Cart. The facility document titled, Meal Distribution, dated 9/1/2021, revealed in part, Meals are transported to the dining locations in a manner that ensures proper temperature maintenance . On 7/19/2023 at 3:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on interview and record review, the facility failed to provide timely financial statements to one (R329) of one resident reviewed for resident trust fund, resulting in the resident being uninformed about personal funds. Findings include: During an interview on 7/17/2023 at 12:41 PM, Resident #329 (R329) said he withdraws money from a commercial bank and gives it to the facility to hold on to. R329 said he has not received a statement from the facility regarding the money he has in his account. During an interview on 7/18/2023 at 8:42 AM, Business Office Manager (BOM) A was queried about how residents receive statements regarding the status of their funds in the resident trust fund account. BOM A said two copies of the resident's statement are made. The resident will get a copy and a signed copy was retained for the facility's records. BOM A said she was responsible for this task. When BOM A was asked to provide R329's signed statement for the quarter ending on 3/31/2023, she was unable to locate it. When queried about the preceding quarter, ending 12/31/2022, BOM A said she did not believe there would be a signed financial statement for R329 for this quarter either. A review of the Admission Record for R329 documented an initial admitted [DATE] and re-admitted [DATE]. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of R329's clinical record documented he was his own responsible party related to finance. During an interview on 7/19/2023 at 9:29 AM, the Nursing Home Administrator (NHA) said the BOM should have ensured R329 received his statement. The NHA stated, residents should receive a quarterly statement to ensure their money is being kept, and that we are safeguarding their funds. A review of the policy titled, Resident Trust Fund: Quarterly Statement, received during the survey, documented in part, It is the policy of each facility to send a quarterly statement to the resident or their rep payee regarding trust fund balances including allocation of interest payments. On 7/19/2023 at 3:45 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

This citation pertains to intake MI00137519. Based on interview, and record review, the facility failed to ensure one resident (R2) was free from misappropriation of her Debit Card, resulting in one unsuccessful unauthorized withdrawal attempt of $200.00 and one successful $7.97 unauthorized purchase and the potential for further misappropriation to occur. Findings include: A review of an incident reported to the State Agency dated 6/4/2023 documented that R2 notified staff on 6/4/2023 that her debit card was missing. R2's debit company was notified and reported lost. The debit company did show that there were two activities that occurred on 6/4/2023 at approximately 1:05 am at the local store. Further investigation revealed that someone attempted to use the ATM to withdraw $200.00. That person was unsuccessful. There was also a transaction of $7.97 at the store checkout that was successful. The local police department was notified on 6/4/2023 and a report was made. On 6/5/2023, the Administrator went to the store to speak with the manager and to review the camera tape. When reviewing the tape, the suspended staff (Aide P) was shown in the business and walked to the ATM and then to the counter and purchased an item. The facility substantiated that the debit card was missing. The facility substantiated that there was a transaction that took place around 1:05 am at the store. A review of the clinical record for R2 revealed an initial admitted [DATE] and readmitted [DATE]. R2 's diagnoses included paraplegia, congestive heart failure, major depressive disorder, and anxiety disorder. A quarterly Minimum Data Set, dated dated dated [DATE] documented intact cognition with a BIMS (brief interview for mental status) score of 15/15. On 7/19/2023 at 2:46 PM, during an interview R2 stated, My debit card was missing. I knew it was in my phone case. I canceled the card. When I came back in my room, I went through all my things, it wasn't there. I got my money back from (The Administrator) eight dollars is what she owed me. The person who took it, she (Aide, P) was my Aide sometimes but not often. They (The credit card company) replaced my debit card since then and no one else stole anything from me. Attempt made to contact Aide P was unsuccessful. On 7/19/2023 at 3:20 PM, when the facility Administrator was queried if there was sufficient evidence that the R2's property was misappropriated, she stated, Yes. The Administrator confirmed R2's credit card was stolen by a staff member which she identified after reviewing the store's camera and the staff member, Aide, P was terminated. The administrator also said all staff was in serviced on misappropriation of resident's property. A review of the facility's policy titled, Abuse and Neglect Prohibition revised 2/17/ 2020 documented: - Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, misappropriation of property . - Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on interview and record review, the facility failed to immediately report an allegation of verbal abuse for one (R53) of 7 residents reviewed for abuse, resulting in an allegation of verbal abuse not being reported to the Nursing Home Administrator (NHA) or the State Agency timely and the potential for further allegations of abuse to occur, go unreported, and not thoroughly investigated. Findings include: On 7/18/23 at 8:40 AM R53 was seated on his bed in his room. During interview R53 said that he had reported an incident of verbal abuse to his family member and the Nursing Home Administrator (NHA) about a week ago (unsure of date). R53 said an Activity Aide (AA M) called him a 'boy' a 'fat ass' and closed the door in his face when R53 was reentering the facility after the 1:00 PM smoke break. R53 said he was so upset that he immediately told the receptionist (Staff I) of the incident and requested a concern form to fill out. R53 produced a copy of the handwritten incident dated 7/9/23. The handwritten note documented that AA M had said, Hurry up I don't have time to wait on your fat ass. I have things to do. What the fuck, you walk too slow. The note also indicated he reported the incident to Licensed Practical Nurse (LPN) J and Staff I. R53 said AA M had been terminated from the facility and he did not have any problems with any other staff member. According to R53's Electronic Health Record (EHR) he admitted to the facility with diagnoses that included Wernicke's encephalopathy (neurological condition that causes loss of muscle coordination, abnormal eye movements, and confusion). The Minimum Data Set (MDS) dated [DATE] indicated R53 was cognitively intact, free from behaviors, and was independent with activities of daily living. A smoking assessment dated [DATE] indicated R53 smoked three times a day and was able to smoke with supervision. On 7/18/23 at 09:05 AM during interview with the NHA who is the facility's 'Abuse Coordinator' was asked if there were any reported incidents of abuse from residents in the facility. She replied 'No'. The NHA was asked about R53 and AA M. NHA said she received an email from R53's family member saying an activity aide called the resident (R53) a 'fat ass' and told him to 'hurry up because I have things to do'. The NHA said she along with the Director of Nursing (DON) interviewed R53 about the incident. R53 said he was fine but did not want to be around AA M anymore. The NHA said The gentleman (AA M) had previously been suspended but now terminated from employment based on customer service issues. NHA said that she did not report the incident to the State Agency because she did not think this incident was abuse. NHA was asked if LPN J and Staff I had reported the incident to her. NHA stated, No, I got the email from R53's family member on 7/10/23 at 9:59 AM and then on 7/11/23 (2 days after the incident) called R53's family member and interviewed R53. NHA said she also got an email from LPN J on 7/10/23 at 1:32 PM that reported R53 had 'exchanged words' with AA M and R53 had requested to 'write it down'. The NHA had no additional staff interviews or documentation regarding the incident at this time. LPN J was left a voice message. No interview was conducted prior to the exit of the survey. On 7/18/23 at 9:54 AM during an interview with Staff I she was asked about the incident between R53 and AA M. Staff I said R53 came in after a smoke break and asked for a concern form because the Activity Aide called him a fat ass. Staff I said she did not report this to the NHA because she did not witness the incident. It was only what R53 had said. Staff I was unaware of any regulation to report allegations of abuse even if they are not witnessed. On 7/19/23 at 1:16 PM during interview with the NHA she said several facility staff should have reported the incident between R53 and AA M to her immediately and the incident should have been reported to the State Agency as soon as she became aware of it. According to the facility's 'Abuse and Neglect Prohibition' Policy last revised on 2/17/2020; 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 Definitions Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation G. Reporting and Response 1. The staff will report all allegations of abuse, neglect and misappropriation of property to the Administrator immediately 3. 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: a. Immediately but no later than 2 hours after the allegation is made if the allegation involves abuse or result in serious bodily injury. b. Or not later than 24 hours if the events that cause the allegation do not involve abuse or serious injury 5. The results of the investigation must be reported to State Survey Agency ([NAME]) within 5 working days of the incident.

Based on interview and record review the facility failed to accurately document the amount of administered enteral feedings (nutrition administered through tube into stomach) for one resident (R 37) out of three residents reviewed for nutrition, resulting in the potential for inaccurate nutritional intake and assessment. Findings Include: Record review of R37's face sheet revealed the admission into the facility on [DATE] with a pertinent diagnosis of gastrostomy status (tube surgically inserted into stomach). According to the Minimum Data Set (MDS) dated [DATE], R37 had impaired cognition and required total dependence for eating (nutrition intake). Record review of Medical Administration Record (MAR) dated for 7/1/23-7/31/23 documented the following order: Enteral Feed Order - 3 times a day- Jevity 1.5 (nutritional formula) three times a day, two cans at each feeding, with 100 mL water flush before and after each feed . Order was created on 7/7/23. According to the can of Jevity 1.5 each held 237 ml (milliliters) of formula, resulting in 474 ml of formula at each feeding. Further review of MAR dated 7/1/23- 7/31/23 indicated the amount of nutritional formula that was administered at each feeding: First Feed - 7/7- 100 ml, 7/8-100 ml, 7/9-250 ml, 7/10-250 ml, 7/11- 237 ml, 7/12- 237 ml, 7/14-600 ml, 7/15- 600 ml, 7/16-400 ml, 7/17-237 ml, 7/18- 237 ml.7/19/23-237 ml. Second Feed-7/7- 100 ml, 7/8-100 ml, 7/9-250 ml, 7/10-250 ml, 7/11- 237 ml, 7/12- 237 ml, 7/14-600 ml, 7/15- 600 ml, 7/16-400 ml, 7/17-237 ml, 7/18- 237 ml. Third Feed-7/7- 100 ml, 7/8-100 ml, 7/9-250 ml, 7/10-250 ml, 7/11- 237 ml, 7/12- 237 ml, 7/14-600 ml, 7/15- 600 ml, 7/16-400 ml, 7/17-237 ml, 7/18- 237 ml. During an interview on 7/19/23 at 10:20 AM with Licensed Practical Nurse (LPN) B, when questioned about the amount of nutritional formula given to R37 on the first feed and second feed on 7/18/23, LPN B then read the physician's order then replied, I gave two cans, but I accidentally put the wrong amount on the MAR. During an interview on 7/19/23 at 11:15 AM with LPN C, when questioned about the amount of nutritional formula given on the first feed of 7/19/23, LPN C said I gave one can of formula. LPN C then read physician's order and said, No, I gave two cans of formula, I just put the wrong amount of formula in the MAR. During an interview on 7/19/23 at 12:30 PM with Director of Nursing (DON) when asked about the order regarding R37 enteral feedings, it was reported that nursing should document the total amount of nutritional formula given at each feeding. The DON was then asked to provide a policy regarding this procedure. It was later reported by the DON that there was no policy available.

Based on observation, interview, and record review the facility failed to ensure the physician was notified and involved in implementing nutritional interventions for significant weight loss for one resident (R72) out of four residents reviewed for weight loss. This deficient practice resulted in the potential for the lack of physician coordination with weight loss interventions and further nutritional decline. Findings include: On 7/17/23 at approximately 10:28 A.M. R72 was observed in her room in bed. The resident appeared confused, thin in statue with temporal wasting (suggestive of weight loss). The resident was observed sleeping throughout the lunch meal without any staff assistance with eating. Later in the evening R72 was observed wandering in her wheelchair aimlessly throughout the facility. On 7/18/23 at 8:30 A.M., review of resident's weight and vital summary revealed R72 had a significant weight loss in June. The record showed a progressive decline in the resident's weight. Weights were documented as indicated: 3/30- 108.5# (Admission Weight) 3/31-108.5#degeneration. 4/3- 108 4/17-104# 5/2- 101.5# 6/6- 101# 6/28 -101# 6/28- 92.5# 7/6- 93# R72 loss a total of 15.5#'s in 3 months (significant weight loss). Review of R72 medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including altered mental status, Alzheimer's disease, dementia with agitation, falls, major depression and macular degeneration. (dimished disease of macular in the eye). According to the Minimum Data Set MDS) assessment dated [DATE], R72 was severely impaired in cognitive (ability to think) skills for decision making and required supervision and set up help for eating. On 7/19/23 at 2:46 P.M. in the absence of the registered Dietitian, the Director of Nursing (DON) and Corporate Consultant O was queired if the physician was informed of R72's weight loss. The DON responded she was not sure who was responsible for informing the physician, but she had not advised the physician of the resident's weight loss. When asked, what should have occurred when the significant weight loss occurred, no response was given. Again, the DON responded she was not sure who was responsible for informing the physician, but she had not communicated the weight loss to the physician. The DON indicated she would review the Physician Notes since the resident's weight loss had been discuss in a Quality Assurance meeting. At approximately 3:30 P.M. the DON returned and reported she could not find any Physician Notes addressing any nutritional interventions for R72. Further review of the Physician's Notes from 3/30/23 to 6/26/23 provided no documentation or notes related to nutritional interventions for R72, even though a written attendance form submitted from Quality assurance meeting dated 6/15/23 identified the medical director in attendance. On 7/19/23 at 3:50 P.M., review of the undated facility's policy titled: Unintended Weight Change documented in part: .the Dietary manager/Registered Dietitian and DON are responsible for coordination of an interdisciplinary approach to manage the process as far as prediction, prevention, treatment, monitoring and calculation of unintended weight loss/gain . #2 The attending physician reviews all cases of unintended weight loss/gain, modifies treatment as indicated and documents accordingly .#5 The nutrition professional is to communicate weight changes to the attending physician and resident's family. On 7/19/23 at 4:15 P.M. upon exiting the facility no additional information was provided regarding the physician being notified of R72's significant weight loss.

This citation pertains to intake MI 581 Based on interview and record review the facility failed to assess, monitor, and implement interventions to prevent weight loss, affecting one resident (R27) out three residents reviewed for nutrition, resulting in the significant weight loss of a resident. Findings include: Record review of R27's medical chart revealed admission into the facility on [DATE] with Pneumonia. Record review of MDS dated [DATE], R27 had intact cognition and needed extensive assistance with most Activities of Daily Living (ADLS). Record review of nutritional care plan revealed no revisions made since 11/26/21. Record review of medical chart revealed no nutritional assessment completed by a registered dietician during resident's stay. Record review of weights revealed the following information: 11/18/2021 18:29 130 Lbs. 12/09/2021 15:42 116.4 Lbs. -10.0% change [ Comparison Weight 11/10/2021,130.0 lbs.). 12/13/2021 16:10 114.4 Lbs. 01/05/2022 12:25 118 Lbs. During interview on 4/7/22 at 12:18 PM with Regional Clinical Nurse (RNC) T and Director of Nursing (DON) BB it was confirmed that R27 had a documented significant weight loss on 12/9/22. DON BB confirmed that R27's nutritional care plan was not revised, and no interventions implemented to decrease the potential of further weight loss. RNC T confirmed that no nutritional supplements were ordered to increase resident's weight. DON BB was asked if the Registered Dietician had performed a nutritional assessment and made physician aware of weight loss, DON B stated, No. When asked if it was the usual protocol of the facility was to weigh a new admission every week for a month and when a weight loss is noted should the resident be weight consistently every week, DON BB stated, Yes. DON BB confirmed that weights were not consistently documented for this resident. When asked if R27's weight loss was monitored and assessed per facility protocols, DON BB stated, No. Record review of policy Unintended Weight Change (no date) documented the following: 1. Resident with unintended weight loss/gain will be assessed by the interdisciplinary team and interventions will be implemented to prevent further weight loss/gain. 2. Weigh all new residents upon admission, and weekly X 4. 3. Residents determined to be at risk will be made known to nutrition professional for review of need of increased weight monitoring.

This citation pertains to intakes: MI 092 and MI 025. Based on observation, interview, and record review the facility failed to: 1) administer pressure ulcer treatments as prescribed for an existing pressure ulcer and 2) prevent new pressure ulcers from developing for one of five residents (R306) reviewed for pressure ulcers, resulting in R306's existing pressure ulcer to deteriorate and a new left heel pressure ulcer to develop. Findings include: According to the face sheet R306 admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] indicated that R306 had severe cognition impairment, was unable to make her needs known, and was totally dependent on two staff members for bed mobility and transferring. Section M indicated that R306 had one unstageable pressure ulcer upon admission and was not on a 'turning and repositioning, program. (Unstageable pressure ulcer is full loss of skin and tissue, but the base of the ulcer is covered with slough/dead tissue and can't be assessed) The initial skin assessment dated [DATE] identified R306 to have an unstageable pressure ulcer on the 'sacrum area' that measured 5.5 centimeter (cm) x 5.0 cm x 2.0 cm. There is no documentation regarding the heels. A care plan for 'Pressure ulcers' was initiated on 11/11/20 and included the following interventions; Encourage good nutrition and hydration in order to promote healthier all skin, follow Skin Management Program, and if skin is impaired - observe and document the location - report it to nurse as soon as possible. There were no interventions that include a specialty mattress or heel protectors. According to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 'Wound Care' consult was ordered. A review of the Treatment Administration Record (TAR) for November 2020 revealed that 6 of the 14 prescribed sacral wound skin treatments were not administered, (11/11/20 - 11/15/20, and 11/22/20). There were no corresponding nurse's note to indicate why the prescribed skin treatments were not administered. According to a 'Wound Care' consultation note dated 11/12/20; Sacrocóccyx/Bilateral Buttocks is a Stage 4 Pressure Ulcer. (Stage 4 is total loss of tissue with bone, tendon, or muscle exposed) Initial wound encounter measurements are 5.5 cm length x 6 cm width x 2.2 cm depth, with an area of 33 sq cm and a volume of 72.6 cubic cm. Bone is exposed. Undermining has been noted at 3:00 and ends at 6:00 with a maximum distance of 2.3 cm. There is a large amount of sero-sanguineous drainage noted which has a mild odor. Wound bed has Necrotic Base (dead tissue that is dark in color). The wound care practitioner ordered the following on 11/12/20: Dakins' solution 1/4 strength BID (TWICE A DAY) and PRN as needed for 14 days. Additional Orders for Pressure Relief/Offloading; Low Air Loss Mattress or Low Air Loss Bed and Frequently Reposition. A review of R306's TAR for November 2020 revealed the following order: Cleanse sacral wound with wound cleanser, apply Dakins' solution to Kerlix, lightly pack, cover with 4 x 4 gauze, apply border gauze DAILY and prn. The treatments were not ordered as BID per the wound care practitioner's orders. R306's TAR revealed that 4 of the 12 days, or 33% of prescribed treatments were not administered. ( 11/13/20 - 11/15/20, and 11/22/20). The nurse's initials were missing or documented that the treatment was not administered. There were no corresponding nurse's note to indicate why the prescribed skin treatments were not administered. According to a 'Wound Care' consultation note dated 11/19/20; Sacrocoçcyx/Bilateral Buttocks is a Stage 4 Pressure Injury. The wound is deteriorating. Subsequent wound encounter measurements are 6 cm length x 6.5 cm width x 2.6 cm depth, with an area of 39 sq cm and a volume of 101.4 cubic cm. Bone is exposed. Undermining has been noted at 3:00 and ends at 6:00 with a maximum distance of 8.7 cm. There is a large amount of sero-sanguineous drainage noted which has a strong odor. Wound bed has Necrotic Base. There is a 'Left Heel' Deep Tissue Injury and the measurements are 3 cm length x 2.5 cm width, with an area of 7.5 sq cm. The wound is dark with maroon base. Treatment Recommendations are as follows: 1) For the sacral wound: Dakins' Solution 1/4 strength BID (TWICE A DAY) and PRN for 14 days, and 2) For the Left Heel - Dry dressing Q 2 D (every two days) and PRN. Additional Orders for Pressure Relief/Offloading; Low Air Loss Mattress, Frequently reposition, Elevate Bilateral Lower Extremities, soft Heel Lift Boots, and Float Heels. A review of R306's TAR for November 2020 revealed the sacrococcyx/bilateral buttocks' continued as a Daily treatments. On 11/20/20 the TAR added the following skin treatment; Cleanse the left heel with normal saline and apply dry dressing and Kerlix every two days. The TAR revealed that 1 of 3 prescribed treatments (11/22/20) were not administered. The nurse's initials were missing on 11/22/20. There were no corresponding nurse's note to indicate why the prescribed skin treatments were not administered. A review of the R306's nursing notes, care plans, and other progress notes from 11/10/20 - 11/25/20 revealed there was no documentation or interventions to include pressure relief/offloading recommendations. There is no documentation to support that any pressure relief/offloading recommendations were provided to R306. During an interview with the Director of Nursing (DON) A on 8/5/21 at 3:40 PM she reviewed R306's medical record and confirmed that the Wound Care note's recommendations did not match the TAR. DON A said, The physician may have given a verbal order to the nurse as 'Daily' and then wrote something different on the notes. The DON did not offer an explanation as to why this occurred on both the 11/12/20 and 11/19/20 wound care note. DON A confirmed that documentation or lack of documentation on R306's November 2020 TAR indicated that several of the prescribed skin treatments had not been administered and there were no corresponding nurse's notes. According to the facility's 'Skin Management Facility Guidelines procedure (undated) the facility is committed to providing care and services to residents to prevent the development of skin breakdown. The following guidelines are in place to reach this goal: 3) Resident admitted with skin impairments will have: .appropriate interventions implemented to promote healing . 5) A Care Plan is developed upon admission and may address: .preventative devices . 10) During daily clinical meeting the Interdisciplinary Team will review and update the plan of care for residents with: Newly developed vascular/ pressure ulcers.

This citation pertains to intake #s MI 287, MI 171, MI 285, MI 183. Based on interview and record review, the facility failed to provide adequate, timely supervision and behavior management interventions as prescribed for one (#700) of five sampled residents reviewed for accident hazards, resulting in continued, unsafe, adverse behaviors leading to falls causing bruising, swelling, pain and emergency hospital treatment for [REDACTED]. The complainant reported to the state agency that resident #700 had multiple falls, one of which was unwitnessed due to lack of supervision resulting in fracture. On 7/2/19 at 1 PM, the clinical record and Incident/Accident (I/A) reports for resident #700 (R700) were reviewed and revealed the following: R700 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The 5-day minimum data set, which was completed 6/28/19, noted R700 had severe cognitive impairment, had difficulty understanding communication from staff, was incontinent of bowel/bladder, required extensive to total assistance for all care, had difficulty ambulating and had falls before admission. On 6/11/19- -A Fall Risk Assessment noted R700 was at high risk. -Per an Admission Note, R700 made attempts to get up (unassisted) multiple times and was combative with staff. -PRN (as needed) [MEDICATION NAME] twice a day for anxiety and nightly scheduled doses of the antipsychotic [MEDICATION NAME] were prescribed. -At 8 PM, R700 was observed on the floor in the dining room following an unwitnessed fall, was confused and disoriented, no noted injury per the I/A report. On 6/12/19- -A Nurse Admission Assessment noted: R700 did not understand staff, was alert but not oriented at all, had impaired cognition, no bruising, was physically aggressive and combative during care and required total assistance for all care. The assessment noted fall interventions: provide cues, reorient and supervise as needed. -Nightly scheduled doses of the antipsychotic [MEDICATION NAME] was prescribed. -Nurses noted that R700 was combative with care. -A Nurse Practitioner (NP) noted that on 6/12/19 (entered late on 6/20/19), R700 had left forehead swelling and bruising. -On 6/13/19, a mental health evaluation was ordered for review of R700's [MEDICAL CONDITION] medications. On 6/14/19- -Per an I/A report, at 6:15 PM R700 was observed sitting on the floor in the hallway following an unwitnessed fall after being seen ambulating without assistance out of the room per the roommate, was confused and disoriented, with an open area/skin alteration on the right side of the face (as illustrated on a body diagram). -Per a nursing note, bruising to right side of face. -R700 was seen by a mental health specialist who noted: Dementia with behavioral disturbances. Patient seen today awake in room, standing naked, she has advanced dementia Per staff and (medical record) patient has been very aggressive and combative with care, needing reassurance and redirection. Spoke to daughter per daughter she is not supposed to be on [MEDICATION NAME] or [MEDICATION NAME] due to it causing her to be aggressive and have increased confusion Discontinue [MEDICATION NAME] and [MEDICATION NAME] start low dose [MEDICATION NAME] (antipsychotic) to help manage behavioral disturbances. Medication records noted: [MEDICATION NAME] was given one time on 6/13/19 then discontinued; PRN [MEDICATION NAME] doses were given on 6/12, 6/13, 6/14, 6/16 and 6/19/19; [MEDICATION NAME], prescribed twice a day on 6/14/19 to help manage behaviors, was not administered until 6/19/19. The reason why was undocumented. It was unknown whether [MEDICATION NAME] was ever given as the complete medication record was not provided by the Director of Nursing (DON) when requested and was not present in the clinical record. The DON did not explain why. -On 6/15/19, R700 was observed lying on a fall safety floor mattress next to the bed per nurses notes. On 6/16/19- -Nurses noted: R700 was attempting to rise unassisted from a reclining geri-chair. -Per a nursing note, R700 was observed on the floor in the hallway. There was no further documented information. -During a phone conversation on 7/2/19 at 2:40 PM, R700's daughter reported that on Father's day (6/16/19) upon entering the room for a visit, R700 was naked and on the concrete floor next to a mattress, alone in the room with the door half closed, with stool all over that she was trying to clean up herself. I went and got some help. On 6/17/19- -An I/A report noted, at 1:25 AM R700 was witnessed standing and sliding onto the floor from the geri-chair, was confused and disoriented, no noted injury. -Per a nursing note, large purple area of latent bruising under right eye. (A photo of R700 in the clinical record revealed several bruises to the forehead and deep bruising underneath the right eye. During the phone conversation, R700's daughter said that the facial bruising developed at the facility and was not present on admission.) On 6/18/19- -Per a nursing note, R700 was alert and oriented x 0, increased confusion. -An I/A report noted, at 12:30 PM R700 was observed on the floor in the dining room following an unwitnessed fall, was confused and disoriented, no injuries noted. Monitoring checks began every 15-minutes at 2:15 PM, per Behavior Management logs. -An Elopement Assessment noted R700 was a high risk wanderer. On 6/19/19- -An I/A report noted, at 8:50 AM: Observed on floor in the dining room following an unwitnessed fall, confused and disoriented, guarding right upper extremity (due to pain). A Stat (immediate) x-ray was ordered for the right arm and hip. 1 to 1 monitoring began at 9 AM, per the Behavior Management log and a proposed trial for a self release seat belt attached to a wheelchair. -The NP noted that on 6/19/19 (entered late on 6/20/19): Saw patient in dining room on floor post fall with forehead bruising, pain to right arm, wound to left forehead, bruising under right eye, continue to monitor patient, at all times keep her visual. -A portable x-ray taken at approximately 2 PM and revealed acute displaced right humeral neck fracture (fractured shoulder). -A Change in Condition Evaluation noted: R700's blood pressure was 75/56, was complaining of pain to right upper extremity, restless, unsafe self transfers, discoloration to right upper extremity shoulder area and pain, x-ray showed fracture. -Per a hospital transfer form: Bruising noted to face, bilateral lower extremities and bilateral upper extremities post fall. At 3:10 PM, nurse aide B, who was assigned to the resident on 6/18/19, was asked about monitoring of the dining room. She said, During meals, someone was supposed to be in the dining room. When asked if R700 was able to feed herself, aide B said the resident was total care and had to be fed. When asked how the resident fell if staff was present feeding her and monitoring the dining room, aide B said, Lunch was over. She probably fell when they were taking residents out of the dining room and going back and forth. She constantly said she wanted to go home. At 5:15 PM, the Director of Nursing (DON) was queried about dining room monitoring, R700's repeated, unwitnessed falls occurring in the dining room since the first day of admission and adverse behaviors. When asked why R700 was by herself in the dining room if she could not feed herself, the DON said, We failed this resident. It was the end of lunch and people were going in and out. I was in the next room and heard a loud noise. I looked through the window and saw her on the floor. She would say she wanted to go home. Someone should have taken her out of the dining room first and let someone know, then transport the other residents out. The DON was asked why R700 was left alone in the dining room at 8 PM on 6/11/19 or at any time since she had behaviors known by staff since day one. The DON said, Staffing was a challenge. She did not explain why medication records were missing nor why 1 to 1 monitoring was not initiated sooner, versus monitoring every 15-minutes, which allowed opportunities for unassisted transfers and falls by R700, such as the fall occurring on 6/19/19 leading to fracture. R700's Fall Risk care plan initiated 6/12/19, listed an intervention: do not leave the resident alone in the bathroom. There was no mention of the dining room. On 7/3/19 at 8 AM, per review of the facility's undated policies on Fall Management Guidelines and Dining Observations: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision to minimize the risks for falls will review/modify the plan of care to minimize the risks of repeated falls. The Dining Observation policy did not address dining room monitoring before, during or after meals.

This citation pertains to Intake #MI 429. Based on interview and record review the facility failed to provide adequate supervision to prevent falls for one sampled resident (#174) out of three residents reviewed for falls from a total sample of 30 resulting in a fall with right intertrochanteric fracture ([MEDICAL CONDITION]). Findings include: Resident #174 Accidents On 1/24/18 at 9:35 a.m., record review revealed that R#174 was readmitted into the facility on [DATE] at 7:00 p.m., documented cognition of alert and oriented x's 3 (person, place and time) and [DIAGNOSES REDACTED]. The re-admission Nursing assessment dated [DATE] indicated R#174 had a history of [REDACTED]. Normally uses walker and wheelchair. Review of the re-admission Fall risk assessment dated [DATE] indicated R#174 was High risk for falling due to a fall risk score of= 95 (A High fall risk score = 45 or greater), had a weak gait (person's manner of walking), and used furniture for support, and overestimates or forgets limits. There was no Fall care plan in the re-admission clinical record. On 1/24/18 at 10:00 a.m., review of a facility provided incident and accident (I/A) report dated 12/29/17 @ 20:10 p.m. (3 hours after re-admission) documented, Resident was observed lying next to her bed, on the floor with her head up. Bed is in lowest setting, call light not on. No apparent injury noted. Patient denies any pain or hitting head. No change in mentation status or range of motion (ROM). Patient is alert and oriented x 3. Speech is clear and appropriate. Patient states, I was walking back from the bathroom and trying to get back into bed, but I slid down. Patient is encouraged to utilize her call light. Patient education, placed up in wheelchair. Review of the POS [REDACTED]. 12/30/17 2:00 a.m. (4 hours after first fall), Patient observed walking toward the nurses station, got weak and fell on her buttocks. No apparent injury noted, but patient complained of pain at the right hip. Pain rating is at a 5 out of 10 (pain scale with 10 being hurts worst). Patient was assisted into a wheel chair and kept by writers side at the nurses station. No change in range of motion (ROM). Doctor notified stat (immediate) 2 views x-ray ordered for the right hip. Results; Acute right femoral intertrochanteric fracture. On 1/24/18 at 10:30 a.m., review of the facility provided investigation for the falls that occurred on 12/29/17 and 12/30/17 revealed the following; On 12/29/17 at approximately 20:10 (Nurse I)noted (R#174) laying next to her bed. (Nurse I) assessed her (R#174), noting no injuries and placed her in a wheelchair where he (Nurse I) kept her next to him throughout his shift. (Nurse I) had left her side to use the bathroom and when her returned (R#174) was noted walking to the nursing station, lost her balance and fell on her buttocks. (R#174) denied pain upon initial assessment. (R#174) was placed back into the wheelchair where she voiced a complaint about her right hip. X-rays taken and a right femoral intertrochanteric fracture noted. (R#174) was transferred to the hospital for further intervention. 1/24/18 3:20 p.m., during an interview with the Director of Nursing (DON) she was asked about the incident with R#174. The DON was asked why a resident (R#174) who was assess to be at high risk for falls, had a weak gait, had been noted walking (unsupervised) back from the bathroom, and determined to require need 1:1 supervision after was left unattended. The DON stated that she spoke with the nurse on duty that night (Nurse I) and she said The nurse felt that the resident had deescalated enough to leave the resident unattended while he when to the bathroom. On 1/25/18 11:56 a.m., During an interview with Nurse I he said, (R#174) was agitated after the first fall. I felt she was safer with me. I know she walks independently , but her gait was weak. She needed closer supervision. I brought her with me while I did my work. Eventually, she calmed down. She had not tried to get up for the two or three hours, I asked her if she would be ok for a second if I ran to the bathroom, she said Ah huh. She didn't indicate to me that she would not try to get up. I kept her by the nursing station. I didn't think she would get up, but sadly, I was wrong she was in the middle of falling when I came out of the bathroom. I could not catch her on time. Nurse I was asked why he did not get another staff member to supervise R#174 while he stepped momentarily away from R#174 whom was at high risk for falls to which he responded, The other staff were busy providing care to the residents. I felt like she was calm relaxed, I felt she was safe to sit there. There was no documented evidence in the clinical record that R#174 had been assessed as being deescalated or displaying behaviors of being calm at the time she was left unsupervised. On 1/25/18 at 1:30 p.m., review of the facility's undated Fall Management Guidelines documented, 2. Residents identified at risk for falls will have a care plan developed and implement fall prevention interventions as needed based on their assessment.

This citation pertains to intake # MI 992. Based on observation, interview and record review the facility failed to ensure a wheelchair was safe for use for one sampled sampled resident (#502) out of three residents reviewed for accidents from a total sample of six residents, resulting in a fall and subsequently hitting the wheelchair sustaining a eight centimeter (cm) right leg laceration. Findings include: On 11/14/17 at 11:30 a.m., during an interview with R#502 he said that on 9/30/17 he fell from his wheelchair, scraping his right lower leg on an unprotected metal bolt on the front part of the wheelchair, that part (Caster Head Tube-where the bolt is enclosed in a metal tube attaching the front wheel to the frame of the wheelchair) was suppose to have a safety cap (dust cap) covering it, but it was missing. I had to go out to the hospital and get stitches. The next day the maintenance guy put the safety caps on both sides (right and left Caster Head Tubes that secure both front wheels). Record review revealed that R#502 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident cognition was intact and was independent with most activities of daily living (ADL's) Review of an Incident and Accident report dated 9/30/17 documented, Writer informed by first floor nursing staff that resident fell out of wheelchair and cut his leg. Resident with deep laceration to right lower extremity .Pressure dressing applied and resident transferred to (name of local hospital) emergency room (ER). Review of the hospital ER record dated 9/30/17 documented, Patient presents for laceration to posterior right lower leg just after he fell out of his wheelchair, cutting it on a metal bolt on his chair .8 cm (3.15 inches) laceration to right posterior lower leg . laceration is curvilinear (curved line), skin flap through the adipose (fatty layer) tissue .wound was thoroughly irrigated prior to closure (with 11 stitches) .(Name of antibiotic) was given prior to discharge for cellulitis (infection of the skin tissue). Review of an At risk for Falls care plan dated 3/3/16 documented an intervention dated 12/7/16, Maintenance to monitor for any repairs of my wheelchair. On 11/15/17 at 10:52 a.m., during a facility tour with the Maintenance Director (Staff H) he was asked about the safety caps for R#502's wheelchair. Staff H stated, I'm the only maintenance staff member at this time, I may have replaced those caps, I just can't remember. If the resident said that I did, then I did. A random audit of six wheelchair sitting in the hallway on the second floor was performed with Staff H. Three of the wheelchair were missing the safety caps (dust covers) that coved the bolt that attached the front wheels to the main frame of the wheelchair. Staff H was asked about the monitoring of the wheelchairs or any other defective equipment and how those items are identified and repaired, to which he responded, Nursing staff should be monitoring the wheelchairs and if they are defective, then place a work order for the repair needed in the maintenance log book. On 11/15/17 at 1:00 p.m., along with the facility's Director of Nursing (DON) the same six wheelchairs were observed. Three of the six wheelchairs still did not have safety caps (dust covers) replaced to cover the exposed bolts. The DON stated, I will get with maintenance and see how many we have and get them replaced. Review of the facility provided document titled, Conduct wheelchair inspections dated 11/30/17 documented, Inspect wheelchairs for damaged and missing parts. Repair or replace as necessary. Recurrence: Monthly. Review of the facility provided undated document titled, Checklist for Assessing Fall Risk or Performing a Post Fall Evaluation documented, Environmental factors: Assess presence of environmental factors that could cause contribute to falls. Assess whether patient's footwear may be contributing to fall risk .Review and modify environmental factors that could have caused or contributed to fall.

This citation pertains to intake MI 949. Based on interview and record review the facility failed to provide transfer support in accordance with the assessed resident need for one sampled resident (#501) out of three residents reviewed for care and treatment needs from a total sample of three, resulting in a transfer injury (fractured distal tibia-lower leg ankle bone). Findings include: On 8/15/17 at 9:23 a.m., review of a facility reported incident investigation documented that on 5/24/17 R#501 was being transferred back into her bed by Certified Nurse Assistant (CNA) A. The investigation revealed that CNA A placed her (R#501) back to bed by pivoting her from her wheelchair to her bed On 5/25/17 (R#501) complained of left leg pain .the resident reported that while she was being transferred yesterday (5/24/17) back into bed (by CNA A), the CNA struck her (left) ankle on the bed frame during the transfer. X-rays were obtained and revealed a mildly comminuted [MEDICAL CONDITION] tibia with no significant displacement seen. On 8/15/17 at 10:09 a.m., record review revealed that R#501 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set Assessment ((MDS) dated [DATE] (23 days prior to the incident) indicated R#501's cognition was moderately impaired and was total dependence with two person physical assist for transfers. Review of the Activities of Daily Living (ADL) care plan dated 1/26/17 had an intervention of Transfers: Max Assist x 1 with a gait belt. Review of the CNA care guide (a guide to assist the CNA in providing individualized resident care) documented R#501's Transfer: Max assist x 1 with gait belt. Review of the nurses note dated 5/24/17 at 6:09 p.m. documented Resident observed by aide intentionally sliding herself out of wheelchair onto floor. Resident had no complaints of discomfort noted. Writer assessed resident, no apparent injury noted. Writer delegated for aide (CNA A) to put resident back to bed, bed lowered, call light within reach for safety. A 5/25/17 at 6:14 a.m., a nurses note documented Resident complained of left leg pain the AM. Entered in physician log book. A Nurses note entered by the Director of Nursing (DON) on 5/25/17 at 7:07 p.m. documented, Received a call at home from the nurse(Nurse B) noting this writer that a CNA (CNA A) had transferred this resident (R#501) from the wheelchair to the bed and struck the residents ankle on the bed frame during the transfer. The resident was placed in bed and did not complain about pain immediately but after approximately 10-15 minutes, the resident became upset and started to cry. The staff members were unable to understand her concern until she settled down and then she reported that the CNA struck her ankle against the bed during transfer .The resident was transported to the hospital for further intervention. On 8/15/17 at 12:20 p.m., the DON and the MDS Coordinator were asked about the transfer status of R#501. The DON stated, The resident fluctuates, sometimes she can be a one person transfer and sometimes she requires two persons. On 5/24/17 CNA A used only one person. She was disciplined and reeducated because she didn't use a gait belt. The MDS Coordinator confirmed that based on the 5/1/17 MDS assessment, R#501 required total assistance from two staff persons for transfers. She went on to say that when the 5/1/17 MDS was completed the CNA care guide should have been updated indicating R#501 was a two person physical assist with transfers, That was a oversight on our part. Patient safety comes first. The CNA should have had two persons transfer her (R#501) back into bed that night. The DON was asked if she had a policy or procedure regarding resident transfer status to which she responded, We really don't have a procedure for that. Therapy staff do the initial transfer assessment and we continually audit to ensure accurate transfer status's are updated on the care plans and CNA care guides.

Based on observation, interview and record review, the facility failed to provide timely dental services to address Resident's mouth pain and poor dentition for one (#510) of one sampled Resident reviewed for dental needs in a total sample of 19, resulting in continued discomfort related to mouth pain, significant weight loss (7.7%) in one month and the increased potential for continued clinical compromise due to the lack of timely dental services. Findings include: On 2/7/17 at 8:55 a.m., Resident #510 was observed lying in bed with the curtains pulled shut, and lights off. At that time, the Resident gave permission to enter from behind the curtain and reported, I'm [AGE] years old. The Resident's bedside was observed with 30 salt and pepper packets, three unopened 4 oz juice containers which were dated with a sticker that read, HS (evening drink/snack) 1/05, HS 1/25, and HS 1/27; and five unopened 4 oz containers of applesauce which were dated with a sticker that read, HS 1/13, HS 1/21, HS 1/25, HS 2/04, and HS 2/03. When asked about the food items, Resident #510 stated, I use the salt for my mouth pain. On 2/7/17 at 12:43 p.m., Resident #510 was observed lying in bed with the curtains pulled shut, and the lights off. At that time, observation of the lunch food tray revealed the meal was untouched. When asked about the meal, Resident #510 stated, I can't eat. I got a hole in the roof of my mouth and it goes to my nose. At that time the Resident retrieved a partial denture from a clear container and stated, This is it. I can't eat, it hurts. Review of the clinical record revealed Resident #510 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessments, both the quarterly MDS dated [DATE] and the annual MDS dated [DATE], documented Resident #510 exhibited short and long term memory deficits with moderately impaired decision making skills, exhibited no mood or behavior concerns, required set up with meals, had no weight change, and had no pain medication or complaints of pain. At each of these assessments, the Resident's weight was noted as 174 pounds (lbs). The quarterly MDS assessment on 12/27/16 noted, Yes to Broken or loosely fitting full or partial denture. Review of the care plans revealed there were no revisions to the nutrition care plan or pain care plan in place which addressed the Resident's current status of significant weight loss, poor dentitian, actual pain, and use of prn pain medication. Review of the Pain Tool dated 1/26/17 documented, .What makes the pain worse? .eating, dental appliance moving about in mouth .Describe all methods of alleviating pain and their effectiveness: positioning dental appliance in mouth, Tylenol ES 2 tabs given . Review of the medications included, 1/26/17 Tylenol Extra Strength Tablet 500 mg give 2 tablet by mouth every 6 hours as needed for gum pain. Review of the interdisciplinary progress notes included: On 1/4/17 at 11:07, SW met with resident discussed items being taken out of his room. Resident admitted that he collects stuff. SW explained to Resident that he cannot collect paper items that come with his meals, these items must be thrown away, Resident indicated that he uses the salt packs for the pain he has in his gums, SW indicated to Resident that she would talk with the Nurse regarding his mouth pain . On 1/6/17 at 10:26, Res seen by PA (Physician Assistant) regarding dental plate, reported that resident uses salt in upper palet for gum pain .Res was educated by PA to not use salt in upper palet . On 1/6/17 at 10:57, Resident has scheduled dental exam for Friday January 13, 2017. Review of the available physician progress notes [REDACTED]. The evaluation noted the Resident had Mild Pain with no recent change in pain medications. There was no further evaluation which addressed the Resident's ongoing pain and/or weight loss. Further review of the clinical record revealed there was no current dental evaluation available for review. The last documented dental evaluation was in 2015. Review of the Resident's documented weights from 7/11/16 - 2/2/17 identified the following weight on 2/2/17 = 161.0 (lbs), and on 1/6/17 = 174.5 (lbs.). This is an approximate 7.7 % weight loss in one month. The previous weights from 7/2016 - 12/2016 were stable between 173 - 175 lbs. The most recent documented nutrition assessment available for review was on 12/30/16 which noted, res on mech soft diet with ground meats due to poor dentition . On 2/9/17 at 9:05 a.m., an interview and record review was conducted with Social Worker (SW V) who indicated she had only been at the facility since November 2016. When asked about Resident #510's dental consultation, SW V stated, He was scheduled for 1/13/17 but refused. At that time, SW V was asked to provide evidence of the Resident's refusal. On 2/9/17 at 11:55 a.m., SW V reported, He didn't refuse. The (name of contracted dental group) canceled. When asked what follow up was done to address the Resident's continued mouth pain, SW V reported she would look further. On 2/9/17 at 12:30 p.m., SW V reported, (Name of contracted dental group) subcontracted out a new dental group effective 1/23/17. When asked what the expected response time was for dental services, SW V reported They come once a month. I just obtained a dentist that accepts Medicaid. SW V was unable to provide any further information regarding the delay in dental services to address the Resident's continued mouth pain and subsequent weight loss. Review of the facility's Dental Services policy dated 1/2014 included, .When a resident requires routine or emergency dental care, the Social Service staff will assist the resident to secure an appointment .If emergency service is needed, the Social Service staff will contact the dentist for an appointment .Documentation related to dental appointments should be placed in the resident record . Review of the facility's dental contract dated 5/30/2014 included, .(name of contracted group) shall coordinate the following checked and initialed ancillary services at the Facility .Dentistry .Make Providers available to all residents of the Facility without regard to .third party payor source .Comply with all applicable statutes, regulations, policies and properly promulgated rules and regulations of Facility .

Based on observations, interviews, and record reviews, the facility failed to provide a low-air loss mattress, apply pressure relieving devices to heels, or lift heels off the mattress for one of three (#308) residents reviewed for pressure ulcers, from a total sample of 19, resulting in R#308 developing two facility acquired pressure ulcers; 1) left lateral ankle, and 2) right medial heel, along with the potential for existing pressure ulcers to worsen and new pressure ulcers to develop. Findings include: During interview and observation on 2/29/16 at 12:20 p.m., resident #308 was observed laying in his bed, partially on his left side with both heels and resting on a regular mattress. There were two white plastic inflatable heel pressure-relieving boots (air boots) laying on the resident's bedside table next to his bed. Resident #308 had dry dressings wrapped around both heels. Upon interview resident #308 said that he got the sores on his heels because he did not have a foot cradle on his wheelchair, or the blue soft foam boots (pressure relieving device) he used to wear on his feet everyday. Resident #308 said that staff does not put the white air boots on his feet, or elevate his feet with pillows. He went on to say he can't put the boots on himself because he is paralyzed from the waist down, and forgets to ask staff to apply them. Resident #308 said he prefers the soft blue foam boots, and has been waiting for staff to re-order them. An observation of the resident's wheelchair revealed a foot cradle with a foam cushion on it. Resident #308 said the wheelchair with the foot cradle was just recently acquired and he had been using a regular wheelchair earlier. During an observation on 3/1/16 at 7:00 a.m., and again at 11:00 a.m., resident #308 was laying in his bed, partially on his left sided with both of his heels flat on the mattress. The two white air boots were on his bedside table. A medical record review was conducted on 3/1/16 at 11:30 a.m. According to the Minimum Data Set ((MDS) dated [DATE], resident #306 was admitted to the facility with three pressure ulcers and a care assessment area for pressure ulcer concern was triggered. The physician prescribed a low-air-loss mattress for the resident, and heels to have 'pressure relieving devices applied'. A care plan dated 7/14/15 and revised on 2/7/16 identified the following interventions for preventing pressure sores; low-air-loss mattress and heels to be lifted while in bed. A review of the wound care physician's notes from 1/28/16 through 2/18/16 revealed that the resident's two additional bilateral heel ulcers were acquired while at the facility, and his initial sacral pressure ulcer, and right lateral ankle pressure ulcer had resolved. On 2/18/16, the wound care physician documented the following; left lateral ankle pressure ulcer, 'small scab' measured; 0.4 cm (centimeters) x 0.4 cm x 0.1 cm. Right heel; dry resolving blister, measured; 4.2 cm x 4.0 cm. There are no additional wound care physician's assessments or measurements. A 'skin/wound' note dated 2/14/16, reads as follows; resident (#308) returned to the facility from the hospital without the blue foam heel protector boots, and instead had white plastic 'air-boots'. Heels to be floated on pillows until replacement boots can be provided. There is no documentation to support the low-air-loss mattress was ordered by staff. During an observation of resident #308's pressure ulcer care with staff 'J' on 3/1/16 at 11:40 a.m., the left lateral heel had dark yellow brown drainage on the dressing and skin surrounding the ulcer. The pressure ulcer was much larger than the last documented measurement (0.4 cm x 0.4 cm). The left lateral heel pressure ulcer was dark brown in appearance and was not measured by staff 'J'. Staff 'J' said that the wound care physician's team will complete the measurements on Thursday. Staff 'J' said the resident's pressure ulcer had 're-opened', and required more than just a 'dry dressing'. Resident #308's right heel had two areas of concern, the right lateral heel was a small dry scabbed area. The right medial heel had a large darkened area of eschar (thick, leathery, blackened, dead tissue) that also was not measured. Staff 'J' said the wounds appeared to have worsened, but since she was new to the facility, was not certain of the treatment orders or plan. Staff 'J' said she would contact the physician for new pressure ulcer treatment orders, and talk with the Director of nursing about ordering a low-air-loss mattress and blue foam heel protectors for the resident. A further medical record review of the wound care physician's notes for resident #308 was conducted on 3/2/16 at 8:00 a.m., with the Director of Nursing ( staff 'B'). Staff 'B' confirmed that the last pressure ulcer assessment/measurement and documentation by the wound care physician, for resident #308 was on Thursday, 2/18/16. Staff 'B' confirmed that both the left lateral heel and right heel pressure ulcers were acquired while resident #308 was at the facility. Staff 'B' said the blue foam heel protectors and low-air loss mattress will be provided to the resident. A physician's orders [REDACTED]. '[MEDICATION NAME] alginate' every other day. ([MEDICATION NAME] alginate is dressing used for pressure ulcers with moderate to severe drainage, and aids with bacterial burden). An observation of resident #308 on 3/2/16 at 8:10 a.m., revealed that he had the white air boots on both feet, and his heels were elevated off the mattress with pillows. The resident still had a regular mattress on his bed. According to the facility's 'Pressure Ulcer and Skin Care Management' policy dated 7/2011 indicated that resident's having pressure ulcers will receive the necessary treatment and services to promote healing, prevent infection, and reduce the risk of new pressure ulcers from developing. 2. The nurse will document a body check was completed on the resident's weekly head-to-toe skin record. 8. The nursing staff reviews the pressure ulcer prevention and treatment procedures with the physician, and selects treatments appropriate for the type of pressure ulcer. 9. A licensed nurse assess and documents the status of existing wound weekly. ( )

THIS CITATION PERTAINS TO INTAKE #MI 280. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 3 (#101, #104 AND #105) OF 3 SAMPLED RESIDENTS REVIEWED FOR WOUND CARE, FROM A TOTAL SAMPLE OF 6 RECEIVED ADEQUATE CARE AND SERVICES NECESSARY TO ENSURE PROMOTE WOUND HEALING, INCLUDING NOT FOLLOWING THE WOUND CARE SPECIALIST'S RECOMMENDATIONS; NOT ACCURATELY TRANSCRIBING WOUND CARE ORDERS; NOT COMPLETING TREATMENT ADMINISTRATION RECORDS; NOT COMPLETING TREATMENTS; AND, NOT DATING TREATMENTS, RESULTING IN COMPROMISED WOUND CARE PRACTICES FOR RESIDENT #101 THAT LEAD TO hospitalization FOR WOUND DEBRIDEMENT, RESIDENT #105, AND RESIDENT #106, WITH THE POTENTIAL FOR FUTURE ASSOCIATED HEALTH COMPLICATION. FINDINGS INCLUDE: RESIDENT #101 REVIEW OF THE UNDATED FACE SHEET REVEALED THAT RESIDENT #101 WAS A [AGE] year OLD MALE admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED RESIDENT #101 WAS admitted TO THE FACILITY WITH SEVERELY IMPAIRED COGNITION, WITHOUT PRESSURE ULCERS, UNABLE TO WALK, REQUIRING MINIMALLY ONE STAFF MEMBER TO ASSIST WITH TRANSFERS, INCONTINENCE CARE, AND HYGIENE. REVIEW OF A CARE PLAN DATED 3/16/2012 REVEALED RESIDENT #101 REQUIRED THE IMPLEMENTATION OF PREVENTATIVE MEASURES, TO PREVENT SKIN BREAKDOWN, DUE TO GENERAL WEAKNESS, DECREASED MOBILITY, FRAGILE SKIN, KIDNEY DISEASE WITH [MEDICAL TREATMENT], BOWEL AND BLADDER INCONTINENCE, AND HISTORY OF PRESSURE ULCERS. REVIEW OF PRESSURE ULCERS RISK ASSESSMENTS DATED 3/22/2012, 4/29/2012, 5/03/2012, 6/29/2012, 7/15/2012 AND 8/07/2012, REVEALED RESIDENT #101 WAS AT "HIGH RISK" FOR PRESSURE ULCERS. REVIEW OF PHYSICIAN ORDERS [REDACTED]. REVIEW OF WOUND CARE PROGRESS NOTES DATED 6/18/2012, REVEALED THAT THREE DAYS EARLIER (6/15/2012), RESIDENT #101 DEVELOPED TWO PRESSURE ULCERS. ON 6/18/2012, THE WOUND SPECIALIST DOCUMENTED THAT THE ISCHIAL ULCER REQUIRED [MEDICATION NAME], APPLIED TWICE A DAY AND AS NEEDED, WHILE THE SACRAL ULCER REQUIRED ALLEVYN, APPLIED EVERY THREE DAYS AND AS NEEDED. REVIEW OF PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE TREATMENT ADMINISTRATION RECORD (TAR) REVEALED THAT RESIDENT #101 DID NOT RECEIVE HIS ISCHIAL WOUND CARE AS ORDERED, ON 6/20/2012 WHEN NURSING FAILED TO INITIAL THE TAR TO SIGNIFY COMPLETION, ON 6/22/2012 WHEN NURSING CIRCLED THEIR INITIALS INDICATING THE TREATMENT WAS NOT ADMINISTERED BUT DID NOT GIVE A MEANINGFUL CLINICAL REASON, OR ON 6/23/2012 WHEN SOMEONE WROTE "LOA (LEAVE OF ABSENCE)." REVIEW OF THE MEDICAL RECORD FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE TO SUGGEST WHY NURSING WITHHOLDING THE ORDERED TREATMENT ON 6/20/2012, 6/22/2012, AND 6/23/2012, OR HOW WITHHOLDING THE TREATMENT WAS IN THE BEST INTEREST OF RESIDENT #101. REVIEW OF WOUND CARE PROGRESS NOTES DATED 6/25/2012 REVEALED RESIDENT #101'S SKIN HAD THINNED, TURGOR WAS REDUCED, AND TWO ADDITIONAL PRESSURE ULCERS DEVELOPED. THE WOUND SPECIALIST DOCUMENTED THE TREATMENT PLAN FOR ALL FOUR WOUNDS WAS THE APPLICATION OF ANTIFUNGAL CREAM, TWICE DAILY. REVIEW OF ORDERS WRITTEN 6/25/2012 REVEALED "ALL PELVIC ULCERS AND SKIN RASH" WERE TO BE TREATED WITH "ANTIFUNGAL BARRIER CREAM TWICE DAILY AND PRN (AS NEEDED)." REVIEW OF THE TAR DATED 6/25/2012, THROUGH 9/06/2012, REVEALED THE ANTIFUNGAL CREAM ORDER WAS TRANSCRIBED FOR APPLICATION "Q (EVERY) SHIFT AND PRN," INSTEAD OF TWICE DAILY AND PRN. REVIEW OF THE TAR REVEALED THE ANTIFUNGAL CREAM HAD BEEN SCHEDULED FOR APPLICATION THREE TIMES DAILY STARTING 6/26/2012, THROUGH 9/06/2012. REVIEW OF THE WOUND CARE PROGRESS NOTES DATED 7/16/2012 REVEALED A NEW PARTIAL THICKNESS SKIN TEAR ON RESIDENT #101'S LEFT LOWER LEG. THE WOUND CARE SPECIALIST DOCUMENTED THE LEFT LOWER LEG WOULD HAVE TRIPLE ANTIBIOTIC OINTMENT AND AN [MEDICATION NAME] DRESSING FREQUENCY NOT DOCUMENTED , AND THE SACRAL ULCERS BOTH REQUIRED IODOSORB DRESSINGS APPLIED THOUGH THE FREQUENCY OF DAILY, OR TWICE DAILY, WAS UNCLEAR FROM THE WOUND CARE SPECIALIST'S DOCUMENTATION. REVIEW OF THE PHYSICIAN ORDER [REDACTED]. REVIEW OF THE TAR 7/16/2012, THROUGH 7/27/2012, REVEALED THAT THE treatment for [REDACTED]. THE ANTIFUNGAL CREAM treatment for [REDACTED]. REVIEW OF THE WOUND CARE PROGRESS NOTES DATED 7/23/2012, REVEALED THE LEFT AND RIGHT ISCHIUM STILL REQUIRED ANTIFUNGAL CREAM TWICE DAILY, THOUGH NOW STAFF HAD TO APPLY A DRY DRESSING AS WELL. REVIEW OF THE TAR DATED 7/23/2012, THROUGH 7/31/2012, REVEALED THE WOUND SPECIALIST'S RECOMMENDATIONS WERE NOT IMPLEMENTED, AND STAFF CONTINUED APPLYING THE ANTIFUNGAL CREAM, WITHOUT THE NEWLY ORDERED DRY DRESSINGS. REVIEW OF WOUND CARE PROGRESS NOTES DATED 7/30/2012 REVEALED RESIDENT #101 STILL REQUIRED ANTIFUNGAL CREAM TWICE DAILY, APPLIED TO BOTH LEFT AND RIGHT ISCHIUM, WITH A DRY DRESSING COVERING. RESIDENT #101'S TWO SACRAL ULCERS WERE TO RECEIVE IODOSORB TREATMENT ONCE DAILY AND AS NEEDED. REVIEW OF MONTHLY PHYSICIAN ORDERS [REDACTED]. ORDERS PREVIOUSLY DISCONTINUED REMAINED IN EFFECT WHEN THE PHYSICIAN SIGNED THE ORDER FORM ON 8/03/2012. THESE ORDERS INCLUDED: 1) SCROTUM/LEFT ISCHIAL: CLEANSE WITH SOAP AND WATER, APPLY [MEDICATION NAME] WITH NO DRESSING TWICE DAILY AND PRN; 2) ALL PELVIC ULCERS AND SKIN RASH: APPLY ANTIFUNGAL BARRIER CREAM TWICE DAILY AND PRN; AND 3) SCROTUM/SACRUM/ISCHIUM: APPLY ANTIFUNGAL TO OPEN AREAS EVERY SHIFT AND AS NEEDED. REVIEW OF THE TARS DATED "JULY 2012" (ACTUALLY FOR 8/2012) AND "AUGUST 2012" (ACTUALLY FOR 9/2012) REVEALED WRITTEN WOUND CARE ORDERS WERE NOT CONSISTENTLY TRANSCRIBED, IMPLEMENTED, OR CORRECTED, TO MEET THE RESIDENTS TREATMENT NEEDS. REVIEW OF PHYSICIAN ORDERS [REDACTED].#101 WAS CHANGED, AND NOW REQUIRED A DRY ABDOMINAL PAD, DAILY AND PRN. ADDITIONALLY, THE SACRAL AND LEFT ANKLE DRESSINGS WERE CHANGED, REQUIRING SANTYL, 250 MG (MILLIGRAMS) FINELY CRUSHED [MEDICATION NAME], AND DRY DRESSING, APPLIED DAILY AND AS NEEDED. REVIEW OF THE TAR DATED "JULY 2012" (ACTUALLY FOR 8/2012) AND "AUGUST 2012" (ACTUALLY FOR 9/2012), REVEALED STAFF FAILED TO IMPLEMENT THE NEWLY ORDERED LEFT HIP, SACRAL, AND ANKLE TREATMENT ON 8/27/2012, 8/28/2012, 8/30/2012, 9/01/2012, 9/06/2012, AND 9/07/2012. REVIEW OF TARS 5/2012 THROUGH 9/2012 REVEALED THAT STAFF FAILED TO CONDUCT SKIN ASSESSMENTS, FAILED TO REVIEW SKIN INTEGRITY, AND/OR FAILED TO APPLY DRESSINGS AS ORDERED ON VARIOUS WOUNDS ON DATES 5/09, 5/10, 5/17, 5/24, 5/26, 6/07, 6/20, 6/22, 6/23, 6/26, 6/27, 6/28, 6/29, 6/30, 7/1, 7/2, 7/3, 7/4, 7/5, 7/6, 7/7, 7/8, 7/9, 7/10, 7/11, 7/12, 7/13, 7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21, 7/22, 7/23, 7/24, 7/25, 7/26, 7/27, 7/28, 7/29, 7/30, 7/31, 8/1, 8/2, 8/3, 8/4, 8/5, 8/6, 8/7, 8/8, 8/9, 8/10, 8/11, 8/12, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24, 8/25, 8/26, 8/27, 8/28, 8/29, 8/30, 8/31, 9/01, 9/5, 9/6, AND 9/07. DURING AN INTERVIEW 2/06/2013 AT 1:00 P.M., DIRECTOR OF NURSING (DON) #1 REVIEWED AND ACKNOWLEDGED THE FOLLOWING WOUND CARE CONCERNS: 1) THE WOUND CARE SPECIALIST'S RECOMMENDATIONS WERE NOT CONSISTENTLY FOLLOWED; 2) WOUND CARE ORDERS WERE INACCURATELY TRANSCRIBED ON THE TREATMENT RECORD; 3) WOUND CARE ORDERS WERE INACCURATELY TRANSCRIBED ON MONTHLY ORDER FORMS, YET STILL SIGNED BY THE PHYSICIAN; 4) TREATMENT ADMINISTRATION RECORDS WERE NOT COMPLETE; 5) STAFF CONVENIENCE DETERMINED TREATMENTS; 6) RESIDENT SCHEDULES WERE NOT ACCOMMODATED; 7) NURSING WITHHELD TREATMENTS WITHOUT ADEQUATE DOCUMENTATION; AND 8) NURSING WITHHELD TREATMENTS WITHOUT ADEQUATE MEDICAL PURPOSE. DON #1 SAID THAT RESIDENT #101 WAS AT INCREASED RISK FOR DELAYED HEALING/SKIN BREAKDOWN, BECAUSE OF HIS KIDNEY DISEASE, AND YET STAFF FAILED TO ADMINISTER HIS TREATMENTS AS ORDERED. OBSERVATIONS OF RESIDENT #101 WERE NOT POSSIBLE DURING THE SURVEY PROCESS AS HE NO LONGER LIVED AT THE FACILITY. physician progress notes [REDACTED]. RESIDENT #104 ACCORDING TO THE UNDATED FACE SHEET, RESIDENT #104 WAS A [AGE] year OLD MALE LAST admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED RESIDENT #104 HAD NO COGNITIVE IMPAIRMENTS, HAD UNHEALED PRESSURE ULCERS, WAS AT RISK FOR CONTINUED SKIN BREAKDOWN, DID NOT WALK, WAS BED BOUND, INCONTINENT OF STOOL, REQUIRING MINIMALLY ONE STAFF MEMBER TO GET DRESSED, EAT, USE THE TOILET AND FOR BATHING. REVIEW OF A CARE PLAN DATED 11/14/2012 REVEALED RESIDENT #104 HAD MULTIPLE PRESSURE RELATED AREAS UPON ADMISSION, COMPLICATED BY RESISTANCE TO CARE, CONTRACTED LEGS AND END STAGE LIVER DISEASE. REVIEW OF PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE TAR DATED 1/2013, REVEALED STAFF FAILED TO ADMINISTER THE ORDERED WOUND CARE FOR RESIDENT #104 ON DATES 1/04, 1/05, 1/06, 1/07, 1/08, 1/09 AND 1/10. REVIEW OF THE MEDICAL RECORD FOR RESIDENT #104 FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE OF ROUTINE, THOROUGH WOUND CARE EVALUATIONS BETWEEN 11/23/2012 AND 1/02/2013. DURING AN INTERVIEW 2/06/2013 AT 2:00 P.M., LICENSED PRACTICAL NURSE/WOUND CARE NURSE (WC-LPN) #2 SAID THAT THE EVENING DRESSINGS ORDERED FOR RESIDENT #104 WERE NEVER COMPLETED ON DATES 1/02, 1/05, 1/06, 1/07, 1/08, 1/09 OR 1/10 BECAUSE STAFF DID NOT HAVE THE TIME. SHE FAILED TO EXPLAIN WHY THE DRESSINGS WERE NOT COMPLETED DURING THE DAY SHIFT ON 1/05, 1/06, AND 1/10. RESIDENT #105 ACCORDING TO THE UNDATED FACE SHEET, RESIDENT #105 WAS A [AGE] year OLD MALE admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED THAT RESIDENT #105 HAD IMPAIRED COGNITION, POTENTIAL FOR SKIN BREAKDOWN, INTERMITTENT BOWEL AND BLADDER INCONTINENCE, REQUIRING ASSISTANCE FROM MINIMALLY ONE STAFF MEMBER FOR BED MOBILITY, AMBULATION, DRESSING, TOILET USE, HYGIENE AND BATHING. REVIEW OF A CARE PLAN DATED 2/21/2012 REVEALED RESIDENT #105 HAD ALTERED SKIN INTEGRITY RELATED TO HIS [MEDICAL CONDITION], NON-COMPLIANCE WITH OFF-LOADING HEELS, TAKING REST PERIODS OR ELEVATING HIS LEGS. REVIEW OF PHYSICIAN ORDERS [REDACTED]. OBSERVATIONS OF THE DRESSING CHANGE 2/05/2013 AT 2:00 P.M., REVEALED THE TWO OLD DRESSING BEING REMOVED FROM RESIDENT #105'S BUTTOCK HAD NOT BEEN TIMED, DATED OR INITIALED WHEN IT WAS APPLIED. DURING AN INTERVIEW 2/05/2013 AT 2:05 P.M., WC-LPN #2 SAID SHE COULD NOT TELL WHEN THE RESIDENT'S BUTTOCK DRESSINGS WERE APPLIED BECAUSE THEY WERE NOT DATED OR INITIALED.

REFER TO INTAKE NUMBER MI 843 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 (RESIDENT #502) OF 4 RESIDENTS REVIEWED FOR SAFE TRANSFER TECHNIQUE FROM A TOTAL SAMPLE OF 4 WAS TRANSFERRED SAFELY AND IN A MANNER CONSISTENT WITH HIS COMPREHENSIVE ASSESSMENT, RESULTING IN hospitalization DUE TO FRACTURE OF THE LEFT HIP REQUIRING SURGERY. FINDINGS INCLUDE: RESIDENT # 502 WAS admitted to the facility on [DATE]. ACCORDING TO PT (PHYSICAL THERAPY) TRANSFER AUDIT SHEET DATED 6/6/2011, RESIDENT #502 REQUIRED "MIN A X 2" (MINIMUM ASSISTANCE OF 2 PERSONS) FOR TRANSFERS SECONDARY TO COGNITION AND RESISTIVE BEHAVIOR DURING CARE. RESIDENT #502'S CAREPLAN, UPDATED ON 7/15/11, NOTED TRANSFER STATUS WAS MINIMUM ASSIST OF 2 PERSONS, ASSIST RELATED TO COGNITION. THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 8/15/11, NOTED THAT THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE TO TOTAL DEPENDENCE IN PERFORMING ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING TRANSFERS, TOILET USE, AND HYGIENE AND SHOWERS. PHYSICAL THERAPIST (PT) #8 WAS INTERVIEWED ON 9/7/11. PT #8 CONFIRMED THAT ACCORDING TO RESIDENT #502'S PHYSICAL THERAPY assessment dated [DATE], RESIDENT #502'S TRANSFER STATUS WAS MAXIMUM ASSISTANCE X 2 PERSON AND ON 6/24/11, RESIDENT #502 WAS A MINIMUM ASSISTANCE X 2 PERSON. ACCORDING TO PT #8, THIS MEANT THAT 2 NURSE AIDES NEEDED TO BE ON EACH SIDE OF THE RESIDENT HOLDING ONTO THE GAIT BELT (TRANSFER BELT) DURING TRANSFER. ACCORDING TO AN INCIDENT REPORT DATED 8/24/11, AT 3:45 PM, RESIDENT #502 COMPLAINED OF PAIN IN THE LEFT HIP AREA. THE RESIDENT REPORTED TO NURSE #4 THAT HE fell IN THE SHOWER. NURSE #4 FOUND A SKIN TEAR ON THE RESIDENT'S LEFT ELBOW. NURSE #4 OBTAINED ORDERS FROM THE PHYSICIAN FOR A "STAT" (IMMEDIATE) XRAY TO THE LEFT HIP AND FOR PAIN MEDICATIONS. XRAY RESULTS DATED 8/24/11, REVEALED A FEMORAL NECK FRACTURE (LEFT). RESIDENT #502 WAS TRANSFERRED TO A NEARBY HOSPITAL FOR TREATMENT. HOSPITAL RECORDS DATED 8/25/11, DOCUMENTED "PATIENT fell YESTERDAY AT 2:30 P.M. INTO A CHAIR WHILE IN THE SHOWER WITH A NURSE. PER PATIENT, HE STATES HE fell TO THE FLOOR. X-RAY SHOWS LEFT FEMORAL NECK FRACTURE." THE HOSPITAL DISCHARGE /TRANSFER FORM DATED 9/7/11, DOCUMENTED THAT RESIDENT #502 UNDERWENT LEFT HIP ORIF (OPEN REDUCTION AND INTERNAL FIXATION) ON 8/27/11. NURSE #4 WAS INTERVIEWED ON 9/8/11 AT 11:27 AM. SHE STATED THAT SHE CAME TO WORK AT 3:00 PM ON 8/24/11. NURSE #4 ADMINISTERED A 4:00 PM SCHEDULED MEDICATION TO RESIDENT #502. RESIDENT #502 WAS LYING IN BED AND COMPLAINED OF PAIN TO THE LEFT HIP. HE TOLD NURSE #4: "I fell IN THE SHOWER ONE HOUR AGO." NURSE #4 WITH THE WOUND NURSE #5 ASSESSED THE AREA AND FOUND BRUISING , TENDERNESS AND DISCOLORATION ON THE LEFT HIP AND A SKIN TEAR ON HIS LEFT ELBOW. RESIDENT #501 HAD A SHOWER THAT DAY AT 1:00 PM. CNA #6 WAS ASSIGNED BUT CNA #6 HAD LEFT FOR THE DAY. an order for [REDACTED].#502. NURSE #3 WAS INTERVIEWED ON 9/8/11 AT 11:30 AM. SHE STATED THAT NURSE #4 REPORTED TO NURSE #3 THAT RESIDENT #502 DID NOT LOOK COMFORTABLE AND THAT NURSE #4 FOUND A BRUISE AREA ON HIS LEFT HIP AND SKIN TEAR ON THE LEFT ELBOW. NURSE #3 ASKED RESIDENT #502 WHAT HAPPENED. RESIDENT #502 STATED: "I fell IN THE SHOWER." DURING INVESTIGATION, THE CNA (CERTIFIED NURSE AIDE) INVOLVED WAS INTERVIEWED AND WROTE A STATEMENT OF WHAT HAPPENED DURING SHOWER. CNA #6 DOCUMENTED THAT AFTER SHE (CNA #6) HAD RESIDENT #502 STAND AT THE RAILING IN THE SHOWER ROOM, SO THAT SHE COULD PULL HIS PANTS UP, RESIDENT #502 fell BACK INTO THE SHOWER CHAIR. CNA #6 DID NOT ASK FOR ANOTHER CNA TO HELP DURING THE TRANSFER. CNA (NURSE AIDE) # 6 WAS INTERVIEWED BY TELEPHONE ON 9/9/11 AT 11:22 AM. SHE admitted TO THE SURVEYOR THAT SHE HAD RESIDENT #502 HOLD ON THE THE GRAB BAR IN THE SHOWER ROOM WHILE SHE WAS DRESSING HIM. WHEN SHE PULLED HIS PANTS UP, RESIDENT #502 SUDDENLY fell BACK AND LANDED ON THE SHOWER CHAIR. AFTER RESIDENT #502 HAD FALLEN BACK, RESIDENT #502 WAS TRANSFERRED BACK INTO THE WHEELCHAIR AND TO HIS BED WITH NO COMPLAINTS OF PAIN. CNA #5 DENIED HAVING ANOTHER CNA DURING TRANSFERS TO PHYSICALLY AND MANUALLY ASSIST WITH THE TRANSFERS. CNA #5 TRANSFERRED RESIDENT #502 FROM THE SHOWER CHAIR TO THE WHEELCHAIR, AND FROM WHEELCHAIR TO BED. CNA (NURSE AIDE) #7 WAS INTERVIEWED ON 9/8/11 AT 3:00 PM. CNA #7 STATED THAT SHE WAS IN THE SHOWER ROOM WITH ANOTHER RESIDENT WHEN THE INCIDENT HAPPENED. CNA #7 DID NOT SEE WHAT HAPPENED BUT COULD ONLY HEAR WHAT WAS GOING ON. SHE HEARD THAT RESIDENT #502 LOST BALANCE AND fell , BUT DID NOT SEE HOW OR WHERE. WHEN CNA #7 CAME TO ASSIST CNA #6, RESIDENT #502 WAS ALREADY IN THE SHOWER CHAIR WITH A GAIT BELT ON. RESIDENT #502 DID NOT APPEAR TO BE IN ANY PAIN OR DISCOMFORT. CNA #7 STATED THAT SHE LEFT THE SHOWER ROOM AND PROCEED WITH HER OTHER DUTIES. CNA #7 DID NOT KNOW THAT RESIDENT #502 REQUIRED A 2 PERSON ASSISTANCE DURING TRANSFER. CNA #7 STATED SHE HAD ANOTHER RESIDENT WITH HER IN THE SHOWER ROOM THAT TIME WHO REQUIRED A "SIT-TO-STAND" LIFT. SHE (CNA # 7) HAD ASKED CNA #6 TO HELP HER WITH THE LIFT TRANSFER . CNA #7 STATED THAT SHE DID NOT HELP CNA #6 WITH THE TRANSFER OF RESIDENT #502 FROM THE WHEELCHAIR TO THE BED AFTER THE INCIDENT OCCURRED. (INTERIM) DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON 9/7/11 AT 10:25 AM. THE DON STATED THAT RESIDENT #502 WAS ALERT AND WAS ABLE TO VERBALIZE HIS NEEDS. RESIDENT #502 STATED HE fell IN THE SHOWER. THE FACILITY'S INVESTIGATION REVEALED THAT RESIDENT #502 RECEIVED HIS SHOWER AT 1:00 PM THAT AFTERNOON. BOTH CNA #6 AND CNA #7 WERE IN THE SHOWER ROOM AND EACH CNA WAS PROVIDING CARE TO THEIR OWN ASSIGNED RESIDENT. NEITHER NURSE AIDE REPORTED THE INCIDENT TO THE CHARGE NURSE. THEY BOTH FAILED TO FOLLOW THE FACILITY'S TRANSFER PROTOCOL, RESIDENT #502'S CARE GUIDE AND CARE PLAN. RESIDENT #502 WAS A 2 PERSON ASSISTANCE DURING TRANSFER STATUS BUT CNA #6 TRANSFERRED RESIDENT #502 WITHOUT A SECOND PERSON TO ASSIST. THE ADMINISTRATOR WAS INTERVIEWED ON 9/8/11 AT 12:30 PM. ACCORDING TO THE ADMINISTRATOR, BOTH NURSE AIDES WERE TERMINATED FOR NOT REPORTING THE INCIDENT TO THE CHARGE NURSE AND FOR NOT FOLLOWING THE APPROPRIATE TRANSFER PROTOCOL. ACCORDING TO THE RESIDENT'S CARE GUIDE AND CARE PLAN. ( )

BASED ON OBSERVATION, RECORD REVIEW, AND INTERVIEW, THE FACILITY FAILED TO: 1. FAILED TO IMPLEMENT INTERVENTIONS TO PREVENT FALLS FOR ONE OF EIGHT SAMPLED RESIDENTS REVIEWED FOR FALLS (#709) FROM A TOTAL OF 19 SAMPLED RESIDENTS RESULTING IN INJURY; 2. FAILED TO SUPERVISE TWO OF EIGHT SAMPLED RESIDENTS REVIEWED FOR FALLS (#703 AND 708) RESULTING IN THE POTENTIAL FOR INJURY; AND 3. FAILED TO TRANSPORT OXYGEN IN A SAFE MANNER FOR ONE OF ONE SAMPLED RESIDENT (#712) WHO RECEIVED OXYGEN RESULTING IN THE POTENTIAL FOR AN EXPLOSION. FINDINGS INCLUDE: ON 1/19/11 AT 1:45 P.M., RESIDENT #709 WAS OBSERVED SITTING UP IN A WHEELCHAIR AS SHE WAITED FOR STAFF TO ASSIST HER TO HER BED. THE RESIDENT WAS OBSERVED TO GUARD (PROTECT) HER RIGHT ARM AS THE STAFF MEMBER TRANSFERRED HER TO THE BED. HER RIGHT ARM WAS OBSERVED TO BE DEFORMED. RESIDENT #709 STATED THAT SHE HAD FALLEN SOME MONTHS AGO AND BROKE HER ARM. THE HOSPITAL TRIED TO REPAIR IT WITH A SPLINT BUT THAT DIDN'T WORK. RESIDENT #709 FURTHER EXPLAINED THAT NOW THEY WANT TO OPERATE. SHE STATED "I DON'T WANT AN OPERATION NOW, THEY CAN JUST LEAVE IT ALONE." THE RESIDENT THEN SAID THAT SHE COULD USE HER ARM A LITTLE EVEN THOUGH IT IS DEFORMED. ON 1/20/11 AT 1:45 P.M., REVIEW OF THE INCIDENT AND ACCIDENT REPORTS (UNUSUAL OCCURRENCE REPORTS) REVEALED THE FOLLOWING: A. ON 7/5/10 RESIDENT #709 SLID OUT OF BED. INTERVENTIONS DOCUMENTED, "REORIENTATED RESIDENT TO CALL LIGHT, CONTINUE PHYSICAL THERAPY AND OCCUPATIONAL THERAPY (PT/OT), ASSIST WITH TOILETING." RECOMMENDATIONS FROM THE REVIEW TEAM DOCUMENTED, "CONTINUE WITH PT/OT, ASSIST WITH TOILETING, ASSIST BACK TO BED." THE POST-FALL ASSESSMENT NOTED THAT THE CARE PLAN WAS REVISED. B. ON 7/17/10 "CERTIFIED NURSE ASSISTANT (CNA) SAID SHE WAS IN CLOSET AND SAT BACK ON THE FLOOR." DOCUMENTED INTERVENTIONS INCLUDED, "REORIENTED RESIDENT TO CALL BELL ASSIST WITH ACTIVITIES OF DAILY LIVING (ADL'S) AS ALLOWED." RECOMMENDATIONS FROM THE REVIEW TEAM INCLUDED, "ANTICIPATE NEEDS, ASSIST WITH ADL'S AS ALLOWED, CONTINUE PLAN OF CARE, PT/OT." C. ON 7/29/10, "RESIDENT STATED THAT SHE WALKED FROM HER BED AND REACHED FOR THE BOTTOM DRAWER OF HER DRESSER AND LOWERED HERSELF TO FLOOR." DOCUMENTED INTERVENTIONS INCLUDED, "ENCOURAGED TO ASK STAFF FOR ASSISTANCE, ENCOURAGED TO USE CALL LIGHT REACHER DEVICE." RECOMMENDATIONS FROM THE REVIEW TEAM DOCUMENTED, "ENCOURAGE TO ASK FOR ASSISTANCE WITH ADL'S AS NEEDED, ENCOURAGED TO USE CALL LIGHT, REACHER ASSIGNED FOR ASSISTANCE." PER THE POST-FALL ASSESSMENT THE CARE PLAN WAS REVISED ON 7/29/10 AND IT NOTED THAT THE RESIDENT WAS ALREADY RECEIVING THERAPY. D. ON 7/31/10, "RESIDENT WAS FOUND ON FLOOR BY A NURSE. SHE SAID 'THE FLOOR IS SO SLIPPERY.' DOCUMENTED INTERVENTIONS INCLUDED TO APPLY NON SKID STRIPS ON FLOOR. RECOMMENDATIONS FROM THE REVIEW TEAM INCLUDED, "GRIPPER SOCKS, CONTINUE PT/OT, ASSIST BAR TO BED, SKID STRIPS TO FLOOR." E. ON 8/4/10, "RESIDENT STATED I WAS TRYING TO GO TO THE RESTROOM, SLIPPED AND fell ." DOCUMENTED INTERVENTIONS INCLUDED, "MAKE SURE CALL LIGHT IS WITHIN REACH, CONTINUE SAFETY CHECKS." RECOMMENDATIONS FROM THE REVIEW TEAM, "ATTEMPT TO ASSIST WITH TOILETING AS ALLOWED. ENCOURAGE USE OF CALL LIGHT AND ASSISTANCE, FURTHER PHYSICAL THERAPY REGARDING SAFETY." REVIEW OF THE CLINICAL CHART REVEALED THE FOLLOWING: PHYSICIAN ORDER DATED 8/4/10, "STAT X-RAY TO RIGHT SHOULDER AND HUMERUS."RADIOLOGY REPORT ordered on [DATE] NOTED, "TWO VIEWS OF THE RIGHT SHOULDER REVEAL A RECENT IMPACTED AND SLIGHTLY DISPLACED FRACTURE OF THE PROXIMAL SHAFT OF THE HUMERUS. MILD DEGENERATIVE CHANGES ARE NOTED AS WELL AS DEMINERALIZATION. PER THE FACE SHEET, RESIDENT WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION CARE PLAN, DATED 6/16/10, DOCUMENTED THE ADMISSION [DIAGNOSES REDACTED]." THE FALLS CARE PLAN DOCUMENTED:1. KEEP CALL BELL IN REACH2. ENCOURAGE USE OF CALL LIGHT3. INSTRUCT RESIDENT ON SAFETY MEASURES4. PT REFERRAL5. ASSESS RESIDENT'S FOOTWEAR FOR PROPER FIT AND NON-SKID SOLES THE FALLS CARE PLAN DATED 6/30/10 NOTED THE GOAL, "RESIDENT WILL REMAIN FREE FROM INJURY." INTERVENTIONS INCLUDED THE FOLLOWING:1. PLACE IN A FALL PREVENTION PROGRAM.2. KEEP CALL LIGHT IN REACH AT ALL TIMES3. PROVIDE PROPER, WELL-MAINTAINED FOOTWEARTHE CARE PLAN WAS REVIEWED BUT NO UPDATES OR CHANGES WERE NOTED ON THE CARE PLAN FOR THE FALLS ON 7/5/10 AND 7/17/10. THE ADMISSION CARE PLAN (UNDATED), DOCUMENTED THE FOLLOWING:1. KEEP CALL BELL IN REACH2. ENCOURAGE USE OF CALL LIGHT3. INSTRUCT RESIDENT ON SAFETY MEASURESTHE CARE PLAN WAS REVISED ON 7/29/10 AND ADDED A REACHER DEVICE AS AN INTERVENTION. 0N 8/4/10 THE CARE PLAN INCLUDED, "ASSIST WITH TOILETING AS ALLOWED." THE CARE PLAN WAS NOT UPDATED/REVIEWED FOR THE FALL THAT OCCURRED ON 7/31/10. THE CARE PLAN CONFERENCE SUMMARY DATED 6/30/10 NOTED UNDER DIAGNOSIS, "GAIT INSTABILITY SECONDARY TO PERIPHERAL NEUROPATHY." THE PHYSICIAN HISTORY AND PHYSICAL (H&P) ADMISSION NOTE, DATED 6/18/10 REVEALED THE FOLLOWING IMPRESSION:1. GAIT INSTABILITY SECONDARY TO PERIPHERAL NEUROPATHY.2. LEFT FOOT DROP THE physician progress notes [REDACTED]. OSTEOARTHRITIS2. HISTORY OF FALLS THE FALL RISK ASSESSMENT COMPLETED ON 7/22/10, 7/31/10 AND 8/4/10 NOTED THE TOTAL SCORES RESPECTIVELY 8, 10 AND 10. "TOTAL SCORE OF 10 OR ABOVE REPRESENTS HIGH RISK." ON 1/21/11 AT 3 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING RESIDENT #709'S MULTIPLE FALLS,THE FALL CARE PLANS AND THE PREVENTION OF A FALL WITH INJURY FOR RESIDENT #709. THE DON SAID THAT THE SAME INTERVENTIONS WERE EMPLOYED FOR EACH FALL. THE DON REVIEWED THE CARE PLANS AND NOTED THAT THEY WERE NOT REVIEWED AND OR UPDATED FOR EACH OF RESIDENT #709'S FALLS. THE DON FURTHER STATED THAT THE CARE PLANS WERE NOT REVIEWED OR MODIFIED PER THE FALLS MANAGEMENT GUIDELINES TO EVALUATE AND INVESTIGATE THE CIRCUMSTANCES AND THE CAUSE FOR THE FALLS. REVIEW OF THE FACILITY POLICY ENTITLED, "FALL MANAGEMENT GUIDELINES", REVISED ON JANUARY 2011, DOCUMENTED THE FOLLOWING: 1. THE IDT WILL REVIEW ALL RESIDENT FALLS AT THE NEXT MORNING MEETING TO EVALUATE/INVESTIGATE THE CIRCUMSTANCES AND ROOT CAUSE FOR THE FALL.2. THE IDT WILL REVIEW/MODIFY THE PLAN OF CARE TO MINIMIZE THE RISK OF REPEAT FALLS.3. THE IDT WILL COMPLETE THE INTERDISCIPLINARY POST-FALL ASSESSMENT.4. A QUALITY OF LIFE MEETING WILL BE CONDUCTED WEEKLY BY THE INTERDISCIPLINARY TEAM. RESIDENTS REVIEWED DURING THE MEETING ARE AS FOLLOWS: RESIDENTS THAT HAD A FALL SINCE THE PREVIOUS MEETING TO ASSURE MEASURES HAVE BEEN PUT INTO PLACE AND ANY NEW RISK FACTORS ADDRESSED. ( ) ACCORDING TO THE CLINICAL RECORD FACE SHEET, RESIDENT #703 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE QUARTERLY RESIDENT ASSESSMENT, DATED 12/29/10 FOR RESIDENT #703 REFLECTED THAT HE HAD IMPAIRED DECISION-MAKING SKILLS, WAS NON-AMBULATORY REQUIRED ASSISTANCE FOR TRANSFERS AND HIGH RISK FOR FALLS. THE CARE PLAN, DATED 9/22/10, FOR RESIDENT #703 REFLECTED: "...RESIDENT AT RISK FOR FALLING... KEEP CALL LIGHT IN REACH AT ALL TIMES..., FREQUENT VISUAL OBSERVATION CHECKS..." ON 1/20/11 AT 10:00 AM, REVIEW OF AN INCIDENT REPORTS FOR RESIDENT #703, REVEALED THE FOLLOWING: 10/15/10, RESIDENT #703 WAS FOUND IN HIS ROOM ON THE FLOOR NEXT TO HIS BED, RESIDENT #703 COMPLAINED OF BUMPING HIS HEAD. 11/08/10, RESIDENT #703 WAS FOUND IN HIS ROOM ON THE FLOOR NEXT TO HIS BED. RESIDENT #703 REPORTED THAT HE ATTEMPTED TO SIT ON HIS WHEEL CHAIR NEXT TO THE BED AND SLID ONTO THE FLOOR. 11/09/10, RESIDENT #703 WAS FOUND ON THE FLOOR IN HIS ROOM. RESIDENT #703 REPORTED THAT HE ATTEMPTED TO TRANSFER FROM BED TO HIS WHEEL CHAIR. 12/01/10, RESIDENT #703 WAS FOUND ON THE FLOOR IN HIS ROOM. RESIDENT #703 fell AND BUMPED HIS HEAD ON THE BED, WHILE TRANSFERRING FROM THE BED TO HIS WHEEL CHAIR. 1/18/11 RESIDENT #703 WAS FOUND ON THE FLOOR MAT. RESIDENT #703 REPORTED THAT HE WAS ATTEMPTING TO TRANSFER FROM HIS WHEEL CHAIR TO THE BED. ON 1/20/11 AT 11:00 AM, RESIDENT #703 WAS OBSERVED IN HIS ROOM, SEATED IN HIS WHEEL CHAIR. RESIDENT #703 WAS MOVING HIS TORSO BACK AND FORTH. AT THAT TIME, RESIDENT #703 STATED, "I'M TRYING TO LAY DOWN." THE CALL LIGHT CORD WAS TIED IN A KNOT, HANGING AT THE BEDSIDE ON THE OPPOSITE WALL, OUT OF RESIDENT #703'S REACH. ON 1/20/11 AT 11:00 AM, REVIEW OF THE CLINICAL RECORD REVEALED NO EVIDENCE THAT RESIDENT #703'S PATTERN OF FALLS HAD BEEN REVIEWED. FURTHER, THERE WAS NO EVIDENCE THAT INTERVENTIONS HAD BEEN IMPLEMENTED, EVALUATED AND REVISED TO LIMIT THE POTENTIAL FOR FALLS AND INJURIES. ON 1/21/11 AT 10:00 AM, THE DIRECTOR OF NURSING CONFIRMED THAT THE FACILITY HAD NO EVIDENCE THAT INTERVENTIONS HAD BEEN IMPLEMENTED FOR RESIDENT #703, TO LIMIT THE POTENTIAL FOR FALLS AND INJURIES. ( ) ON 1/19/11 AT 2:25 P.M. RESIDENT #708 WAS OBSERVED ON THE FLOOR IN HER ROOM. ON 1/20/11 AT 10:30 A.M., RESIDENT #708 WAS OBSERVED SITTING IN A WHEELCHAIR IN HER ROOM. THERE WERE NO ALARMS ON THE WHEELCHAIR OR BED. AT 2:15 P.M. THE RESIDENT WAS OBSERVED LYING IN BED NEAR THE FOOT OF HER BED. THE FOOTBOARD WAS CLOSE TO HER HEAD. THE RESIDENT'S ROOMMATES DRESSER WAS APPROXIMATELY ONE FOOT FROM THE FOOTBOARD. A BLUE MAT WAS POSITIONED AGAINST THE WALL FROM THE MIDDLE OF THE BED TO BEYOND THE FOOTBOARD. AN OVERBED TABLE WAS NEXT TO THE HEAD OF THE RESIDENT'S BED. A DRESSER WAS A FEW FEET AWAY. A LARGE TELEVISION WAS ON THE DRESSER. ON 1/21/11 FROM 11:00 A.M. TO 11:15 A.M., RESIDENT #708 WAS OBSERVED SEATED IN A WHEELCHAIR IN HER ROOM. HER UPPER LEFT ARM WAS POSITIONED BEHIND THE WHEELCHAIR AND "STUCK" BEHIND THE WHEELCHAIR HANDLE BAR. RESIDENT #708'S CLINICAL RECORD WAS REVIEWED ON 1/20/11 AT 10:00 A.M. ACCORDING TO THE JANUARY 2011 PHYSICIAN'S MONTHLY ORDER SUMMARY SHEET, RESIDENT #708 WAS diagnosed with [REDACTED]. THE MOST RECENT MINIMUM DATA SET (MDS) 3.0, DATED 12/21/10, DESCRIBED THE RESIDENT AS REQUIRING EXTENSIVE PHYSICAL ASSISTANCE FROM STAFF MEMBERS FOR ALL ACTIVITIES OF DAILY LIVING (EATING, WALKING, DRESSING, AND BATHING). RESIDENT #708 WAS AWARE OF HER SURROUNDINGS AND HAD DIFFICULTY BEING UNDERSTOOD BY OTHERS. NURSING PROGRESS NOTES AND UNUSUAL OCCURRENCE REPORTS FROM 2/11/10 TO 1/19/11, REVEALED RESIDENT #708 HAD 16 RECORDED INCIDENTS IN WHICH SHE WAS FOUND OR OBSERVED ON THE FLOOR. HALF OF THE INCIDENTS (EIGHT) OCCURRED ON THE AFTERNOON SHIFT AND 10 INCIDENTS OCCURRED IN AN AREA OTHER THAN HER ROOM. THE INCIDENTS WERE AS FOLLOWS: 1. ON 2/11/10 AT 6:00 P.M. THE RESIDENT WAS "FOUND" SITTING ON THE FLOOR IN HER ROOM. THERE WERE NO INJURIES. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED "TEACH THE RESIDENT SAFETY AND DO SAFETY CHECKS". 2. ON 5/04/10 AT 1:00 A.M. THE RESIDENT'S UPPER BODY WAS OBSERVED LAYING ON THE FLOOR AND HER LOWER BODY WAS LAYING ON FLOOR MAT. "ACCORDING TO RESIDENT, SHE HIT HER HEAD ON THE FLOOR." THERE WERE NO INJURIES. NEUROLOGICAL CHECKS WERE INITIATED. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED "PLACE CALL LIGHT WITHIN REACH AND CONTINUE 15 MINUTE CHECKS." 3. ON 5/13/10 AT 8:45 P.M. THE RESIDENT WAS "OBSERVED ON THE FLOOR" IN HER ROOM. THERE WERE NO INJURIES. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED "CONTINUE 15 MINUTE CHECK". 4. ON 7/02/10 AT 2:45 P.M. THE RESIDENT WAS "FOUND" SITTING ON THE FLOOR IN THE HALLWAY. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED "USE CALM APPROACH TO EXPLAIN PROCEDURE AND OTHERS PRIVACY". 5. ON 7/02/10 AT 5:00 P.M. THE RESIDENT WAS OBSERVED SITTING ON THE FLOOR NEXT TO HER BED BETWEEN BED AND WALL. THERE WERE NO INJURIES. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED MAINTENANCE DEPARTMENT FIXING THE BRAKES ON HER BED TO KEEP THE BED IMMOBILE. 6. ON 7/31/10 AT 2:00 A.M. THE RESIDENT WAS OBSERVED SITTING ON THE FLOOR IN HER ROOM. THERE WERE NO INJURIES. INTERVENTIONS INCLUDED TO PREVENT RECURRENCE INCLUDED "CONTINUE 15 MINUTE CHECKS". 7. ON 8/01/10 AT 5:30 P.M. THE RESIDENT WAS "OBSERVED" ON FLOOR IN FIRST FLOOR DINING ROOM. THERE WERE NO INJURIES. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED "CONTINUE 15 MINUTE SAFETY/VISUAL CHECKS, RESIDENT TO BE TRANSFERRED INTO DINING ROOM CHAIR. ANTICIPATE NEEDS." 8. ON 9/04/10 AT 12:30 P.M. THE RESIDENT WAS WITNESSED STANDING UP AND THEN SITTING ON THE FLOOR IN THE DINING ROOM. THERE WERE NO INJURIES. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED "WHEN FINISHED EATING, TRANSFER INTO WHEELCHAIR AND TAKE OUT OF DINING ROOM. AMBULATE WHEN RESTLESS." 9. ON 9/10/10 AT 2:50 P.M. NURSING STAFF HEARD A "BUMP" AND OBSERVED THE RESIDENT ON THE FLOOR IN THE HALLWAY. INTERVENTIONS TO PREVENT RECURRENCE INCLUDED: "CONTINUE VISUAL CHECKS, WHEN UP, KEEP IN COMMON AREA WITH STAFF SUPERVISION". 10. ON 9/14/10 AT 4:20 P.M. THE RESIDENT WAS "OBSERVED" ON THE FLOOR IN ANOTHER RESIDENT'S ROOM. THERE WERE NO INJURIES. INTERVENTIONS TO PREVENT RECURRENCE INCLUDED TO KEEP "CLOSER WATCH OF THE RESIDENT PRIOR TO DINNER AND CONTINUE WITH SAFETY CHECKS." 11. ON 9/23/10 AT 1:00 P.M. THE RESIDENT WAS "NOTED" ON THE FLOOR IN THE DINING ROOM UNDER TABLES LOOKING FOR FOOD. THERE WERE NO INJURIES. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED STAFF TO FEED THE RESIDENT AT MEAL TIMES AND OFFER SNACKS AS NEEDED. 12. ON 10/21/10 AT 3:30 P.M. THE RESIDENT WAS NOTED MOVING AROUND IN BED AND BUMPED HER HEAD AGAINST THE BEDSIDE TABLE. NEUROLOGICAL CHECKS WERE INITIATED AND INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED THE REMOVAL OF THE BEDSIDE TABLE FROM THE RESIDENT'S ROOM. 13. ON 11/19/10 AT 10:50 A.M., THE RESIDENT WAS "OBSERVED" SITTING ON THE FLOOR IN THE DINING ROOM. THERE WERE NO INJURIES. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED AN ALARM TO WHEELCHAIR AND TO KEEP THE RESIDENT IN COMMON AREAS WITH STAFF SUPERVISION. 14. ON 11/20/10 AT 5:00 P.M. THE RESIDENT WAS "OBSERVED" SITTING ON THE FLOOR IN THE HALLWAY. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED TO KEEP THE RESIDENT IN A COMMON AREA AND DO FREQUENT VISUAL CHECKS. 15. ON 12/09/10 AT 12:15 A.M. THE RESIDENT WAS FOUND CRAWLING AROUND ON THE FLOOR IN HER ROOM. SHE HAD SCRATCHES ON THE LEFT SIDE OF HER NECK AND THE RIGHT BREAST. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED "MONITOR FREQUENTLY" AND PERSONAL ALARM IN BED. 16. ON 12/14/10 AT 8:45 P.M. THE RESIDENT WAS "NOTED" TO BE LYING ON THE FLOOR IN THE HALLWAY. INTERVENTIONS IDENTIFIED TO PREVENT RECURRENCE INCLUDED FEEDING THE RESIDENT A SNACK AND "MONITOR FREQUENTLY". THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON 1/21/11 AT 10:30 A.M. AND REPORTED THE INDICTMENTS IDENTIFIED ABOVE WERE "INTENTIONAL". THE DON WAS UNABLE TO PROVIDE AND EXPLANATION OF THE INCIDENTS WHEN IT WAS BROUGHT TO HER ATTENTION THAT ACCORDING TO THE INCIDENT REPORTS, ONLY ONE OF THE 16 EVENTS WAS WITNESSED BY FACILITY STAFF. THE DON WAS UNABLE TO EXPLAIN INCIDENTS WHERE THE RESIDENT WAS "FOUND ON THE FLOOR" IN COMMON AREAS. THE 15 MINUTE MONITORING CHECKS WERE NOT PRODUCED AND THERE WAS NO RESPONSE FOR LACK OF A PERSONAL ALARM ON THE BED OR CHAIR. ( , ) ON 1/20/11 AT 11:20 A.M., RESIDENT #712 WAS OBSERVED IN HIS WHEELCHAIR BEING PUSHED FROM HIS ROOM (LOCATED UPSTAIRS) TO THE ELEVATOR BY THE PHYSICAL THERAPIST. SITTING ON HIS LAP WAS A CYLINDER OF OXYGEN (E-TANK) WHICH HE HELD IN HIS ARMS "LIKE A BABY" (THE NECK OF THE TANK WAS IN THE CROOK OF HIS RIGHT ARM AND THE LEFT HAND HELD THE BOTTOM OF THE TANK. THE OXYGEN WAS IN THE "ON" POSITION AND BEING ADMINISTERED TO THE RESIDENT VIA NASAL CANNULA (NOSE). THE PHYSICAL THERAPIST WAS OBSERVED BEING INTERVIEWED BY FACILITY NURSE "A" IN THE ELEVATOR AND IT WAS STATED BY NURSE "A" THAT THE OXYGEN CYLINDER SHOULD NOT BE TRANSPORTED IN THE MANNER OBSERVED. ONCE THE ELEVATOR ARRIVED AT THE FIRST FLOOR, THE THERAPIST CONTINUED WITH RESIDENT #712 DOWN THE HALL, PAST THE KITCHEN AND THROUGH THE DOUBLE DOORS TO THE THERAPY GYM. THE E-TANK REMAINED ON THE RESIDENT'S LAP THE ENTIRE JOURNEY. RESIDENT #712'S CLINICAL RECORD WAS REVIEWED ON 1/20/11 AT 11:50 A.M. ACCORDING TO THE INITIAL NURSING ASSESSMENT AND THE BRIEF MENTAL STATUS EXAMINATION, DATED 1/12/11, RESIDENT #712 HAD NO INTELLECTUAL DEFICITS AND HAD "WEAKNESS IN HIS LEFT UPPER EXTREMITY". ACCORDING TO THE PHYSICIAN'S ASSESSMENT, DATED 1/13/11, RESIDENT #712 WAS diagnosed with [REDACTED]. THE RESIDENT WAS PRESCRIBED MULTIPLE TABLETS AND INHALERS TO ADDRESS BREATHING DIFFICULTIES AS WELL AS THE USE OF OXYGEN AT THE RATE OF 3 LITERS PER MINUTE "ATC" (AROUND THE CLOCK). RESIDENT #712 WAS INTERVIEWED ON 1/20/11 AT 12:20 P.M. AND REPORTED HE HELD THE OXYGEN TANK ON HIS LAP AS HE WAS TRANSPORTED TO PHYSICAL THERAPY IN THE PAST "YESTERDAY (1/19/11)." THE RESIDENT STATED, "I DON'T WANT TO GET THE THERAPIST IN TROUBLE...IT WAS THE FIRST TIME ANYONE TOLD HIM IT WAS DANGEROUS..." (TO TRANSPORT OXYGEN ON HIS LAP). ON 1/20/11 AT 12:45 P.M. THE OXYGEN STORAGE AREA WAS OBSERVED. APPROXIMATELY 8 TANKS OF OXYGEN WERE OBSERVED PLACED SECURELY IN STANDS. THERE WERE TWO OXYGEN HAND CARTS NEXT TO THE OXYGEN CYLINDERS. THE MAINTENANCE DIRECTOR WAS INTERVIEWED AT THIS TIME AND REPORTED THERE WERE NO DEVICES IN THE FACILITY THAT COULD BE PLACED ON WHEELCHAIRS TO SECURE OXYGEN CYLINDERS DURING TRANSPORT. THE FACILITY PROVIDED A POLICY AND PROCEDURE ENTITLED, "USE, HANDLING AND STORAGE OF COMPRESSED GASSES (OXYGEN) AND CRYOGENIC LIQUIDS", DATED MAY 2000. INSTRUCTED STAFF TO "TRANSPORT THE CYLINDER USING AN APPROVED GAS OR CRYOGEN CYLINDER HAND CART AS APPLICABLE. ENSURE THE CYLINDER IS PROPERLY SECURED DURING TRANSPORT." ( , )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY MONITOR, CONSISTENTLY IMPLEMENT INTERVENTIONS FOR THE PREVENTION OF PRESSURE SORES FOR ONE (#851) OF FOUR RESIDENTS REVIEWED FOR PRESSURE SORES OUT OF 11 SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF AVOIDABLE PRESSURE SORE. FINDINGS INCLUDE: ON 3/11/11 AT 12:10 P.M., RESIDENT #851 WAS OBSERVED IN THE DINING ROOM SEATED IN A WHEELCHAIR. RESIDENT #851 WAS ALERT AND VERBAL. A HEEL PROTECTOR WAS OBSERVED ON THE RESIDENT'S LEFT HEEL..THE RESIDENT'S SPOUSE WAS SEATED NEAR THE RESIDENT. AT 12:25 P.M., RESIDENT #851 WAS OBSERVED IN THE DINING ROOM BEING ASSISTED FOR LUNCH BY THE SPOUSE. RECORD REVIEW ON 3/11/11 AT 1:20 P.M. REVEALED THAT RESIDENT #851 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED AN ADMISSION assessment dated [DATE] DESCRIBING THE RESIDENT'S LEFT HEEL WITH "RED RASH", REDDENED LEFT GLUTEAL AREA AND RIGHT ARM "SCAR". ACCORDING TO THE ADMISSION ASSESSMENT RECORD, THE RESIDENT'S BRADEN SCORE WAS 15 (A TOOL TO PREDICT PRESSURE SORES, MILD RISK). THE RESIDENT'S LEFT HEEL CONDITION WAS NOT ADDRESSED UNTIL 2/11/11 WHEN "A BLOOD BLISTER" WAS NOTED. THE PHYSICIAN DIRECTED THE FACILITY TO APPLY NORMAL SALINE CLEANSE AND THE APPLICATION OF DRESSING DAILY AND AS NEEDED. ACCORDING TO THE 30 DAY MDS (MINIMUM DATA SET) DATED 2/24/11, RESIDENT #851 WAS TOTALLY DEPENDENT ON FACILITY STAFF FOR BED MOBILITY, TOILET USE AND HYGIENE MAINTENANCE REQUIRING ONE PERSON ASSIST. ADDITIONALLY, RESIDENT #851 REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFER WITH TWO PERSONS ASSIST, REQUIRED EXTENSIVE ASSISTANCE WITH LOCOMOTION ON AND OFF RESIDENT'S UNIT, DRESSING AND GROOMING WITH ONE PERSON ASSIST. ON 2/23/11 THE PHYSICIAN ORDERED TO CLEANSE THE "BLISTER" WITH NORMAL SALINE AND APPLY DRY DRESSING. THE RESIDENT'S BUTTOCKS CONDITION WAS NOT ADDRESSED IN THE NURSES NOTES OR IN THE TREATMENT SHEETS. ON 2/25/11, THE PHYSICIAN ORDERED FOR WOUND CARE CONSULT. ON 2/28/11, THE NURSES NOTES DOCUMENTED "WOUND" ON THE RIGHT AND LEFT BUTTOCKS. ON 3/7/11, THE WOUND CARE DOCTOR DOCUMENTED ABOUT THE SKIN FOLLOW-UP. THE WOUND CARE DOCTOR DOCUMENTED THAT THE LEFT BUTTOCK AND RIGHT BUTTOCK WOUNDS WERE WITH "ONSET" IN THE NURSING HOME. ADDITIONALLY, THE LEFT HEEL WOUND WAS NH ( NURSING HOME ) ONSET. THE WOUND CARE PHYSICIAN DESCRIBED THE LEFT HEEL WOUND AS FULL THICKNESS, MEASURING 4.5 CM BY 3.5 CM SLIGHTLY RAISED. THE LEFT BUTTOCK WOUND WAS CLOSED. THE RIGHT BUTTOCK AREA WOUND WAS DESCRIBED AS FULL THICKNESS, MEASURING 2.0 CM BY 1.0 CM. ANOTHER RIGHT BUTTOCK WOUND WAS DESCRIBED AS PARTIAL THICKNESS MEASURING 0.7 CM BY 0.3 CM WITH SEROUS DRAINAGE. ON 3/11/11 AT 3:40 P.M., DURING THE WOUND CARE OBSERVATION, THE FOLLOWING WERE OBSERVED: 1) RIGHT BUTTOCK, THERE WERE 2 ULCERS, ONE MEASURING 2.1 CM BY 0.8 CM WITH SCANT SEROUS DRAINAGE. THERE WAS NO ODOR., A MEDIAL RIGHT BUTTOCK WOUND WHICH MEASURED 0.5 CM BY 0.5 CM, NO DRAINAGE. 2) THE LEFT HEEL WOUND MEASURED 4.5 CM BY 2.7 CM. THERE WAS NO DRAINAGE AND THE EDGES WERE INTACT. 3) THE RIGHT HEEL WAS INTACT. DURING AN INTERVIEW WITH THE INSERVICE NURSE (WHO DID THE WOUND CARE AND TREATMENT ON 3/11/11), SHE STATED THAT THE TREATMENT NURSE HAD BEEN ON LEAVE BUT WAS NOT CERTAIN WHEN. DURING AN INTERVIEW ON 3/11/11 AT 4:00 P.M., THE DIRECTOR OF NURSING WAS NOT ABLE TO EXPLAIN WHY RESIDENT #851 DEVELOPED THE RIGHT BUTTOCK PRESSURE SORES. ( )

REFER TO INTAKE # MI 411 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND APPROPRIATE SAFETY TRANSFER AND EQUIPMENT TO PREVENT FALL FOR 2 RESIDENTS (#502 AND #504) OF 4 SAMPLED RESIDENTS RESULTING IN hospitalization DUE TO FRACTURE OF THE RIGHT DISTAL FEMUR REQUIRING SURGERY (OPEN REDUCTION AND INTERNAL FIXATION) FOR RESIDENT #502 AND MINOR SCALP ABRASION WITH ACUTE SUBDURAL BLEED LEFT TENTORIUM FOR RESIDENT #504. FINDINGS INCLUDE: RESIDENT #502 WAS [AGE] years OLD AND admitted to the facility on [DATE]. ACCORDING TO PHYSICAL MEDICINE AND REHABILITATION PHYSICAL EXAMINATION DATED [DATE], RESIDENT #502 had a history of [REDACTED]. PHYSICIAN'S PROGRESS NOTES DATED [DATE] REVEALED RESIDENT #502 HAS COGNITION IMPAIREMENT WITH CONFUSION. MDS (MINIMUM DATA SET) DATED [DATE], REVEALED THAT RESIDENT #502 REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS AND BED MOBILITY AND WAS NON AMBULATORY. ACCORDING TO RESIDENT #502'S CARE GUIDE DATED [DATE], SHE WAS A FALL RISK . PHYSICAL THERAPY PROGRESS NOTES DATED [DATE], RESIDENT #502 WAS discharged FROM THERAPY ON [DATE] WITH THE FOLLOWING RECOMMENDATION: TRANSFER FROM BED TO WHEELCHAIR REQUIRED MAXIMUM ASSISTANCE OF 2 PERSON FOR SAFETY PURPOSES. PT DAILY TREATMENT RECORD FROM [DATE] THROUGH [DATE], NOTED THAT ACTIVITIES SUCH AS SIT AND STAND AND BED TO WHEELCHAIR TRANSFERS WERE PERFORMED WITH MAXIMUM ASSISTANCE WITH 2 PERSON. ACCORDING TO THE PHYSICAL THERAPIST #3 ON [DATE] AT 12:30 PM. SHE RECALLED THAT RESIDENT #502 DURING THERAPY SESSIONS HELD FROM [DATE] TO [DATE], HAD POOR SAFETY AWARENESS DUE TO CONFUSION AND WAS AT TIMES UNCOOPERATIVE. PT #3 DOCUMENTED HER RECOMMENDATION IN HER DISCHARGE REPORT DATED [DATE], THAT RESIDENT # 502 NEEDED 2 PERSON MAXIMUM ASSISTANCE DURING TRANSFERS AT THE TIME OF DISCHARGE ([DATE]) TO NURSING FLOOR. INCIDENT REPORT DATED [DATE], DESCRIBED THE INCIDENT: CNA (NURSE AIDE) #4 TRANSFERRING RESIDENT #502 FROM BED TO WHEELCHAIR WHEN RESIDENT'S KNEES BUCKLED AND fell . XRAY REVEALED A FRACTURE OF THE RIGHT DISTAL FEMUR. RESIDENT #502 WAS TRANSFERRED TO A NEARBY HOSPITAL. NURSE AIDE #4 WAS INTERVIEWED ON [DATE] AT 11:20 AM, SHE STATED THAT RESIDENT #502 fell DURING TRANSFER FROM BED TO WHEELCHAIR. RESIDENT #502 SUDDENLY SLUMPED DOWN ON THE FLOOR. SHE WENT BACKWARD AND fell on THE FLOOR IN AN ANGLE LANDING ON HER RIGHT SIDE. THERE WAS NO ONE ELSE IN THE ROOM ASSISTING. NO OTHER WITNESS WAS PRESENT DURING THE INCIDENT. HOSPITAL XRAY RESULT DATED [DATE] SHOWED: COMMINUTED FRACTURE OF THE DISTAL FEMORAL SHAFT (RIGHT). HOSPITAL RECORD ACQUIRED ON [DATE], REVEALED THAT RESIDENT #502 WAS EXAMINED BY THE emergency room PHYSICIAN ON [DATE]. RESIDENT #502 COMPLAINED OF RIGHT THIGH PAIN AFTER SHE WAS DROPPED BY AN AIDE DURING TRANSFER. RESIDENT #502 UNDERWENT SURGERY (ORIF) ON ,[DATE]/ 2010. SHE WAS admitted TO HOSPICE AFTER SURGERY AND expired on [DATE]. RESIDENT #504: RESIDENT #504 WAS admitted to the facility on [DATE], WITH DEMENTIA. MDS dated [DATE], REVEALED THAT RESIDENT #504 REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS AND BED MOBILITY. PASSR (PREADMISSION SCREENING/ANNUAL RESIDENT REVIEW DCH FROM 3877) DATED [DATE] INDICATED THAT RESIDENT #504 HAS DEMENTIA WITH DISTURBANCES IN THOUGHTS OR JUDGEMENT AND ROUTINELY RECEIVED PRESCRIBED MEDICATION FOR THIS SPECIFIC CONDITION. OCCUPATIONAL THERAPY RECERTIFICATION /EVALUATION FORM DATED [DATE], REVEALED THAT RESIDENT #504 PRESENTED THE FOLLOWING DEFICITS: MOBILITY IMPAIREMENT, ADL IMPAIREMENT, TRANSFER DIFFICULTIES AND SAFETY IMPAIRMENT. INCIDENT REPORT DATED [DATE], RESIDENT WAS FOUND ON THE FLOOR, IN BATHROOM WITH 1 INCH LACERATION ON THE FOREHEAD. RESIDENT #504 WAS TRANSFERRED TO THE HOSPITAL FOR FURTHER EVALUATION. CNA #4 WAS INTERVIEWED BY PHONE ON [DATE] AT 11:20 AM, SHE admitted THAT SHE WAS ASSIGNED TO RESIDENT #504. AT AROUND 3:00 PM ON [DATE], CNA #4 OBSERVED RESIDENT #504 IN HER BED. CNA #4 HOWEVER, RECALLED BEING SENT TO THE OFFICE TO WRITE A STATEMENT ON A SEPARATE FALL INCIDENT THAT OCCURRED ON [DATE]. SHE WAS OFF THE FLOOR AND WAS NOT ATTENDING TO HER ASSIGNED SET OF RESIDENTS. SHE DID NOT KNOW IF SOMEONE TOOK OVER HER ASSIGNMENT WHILE SHE WAS GONE . WHEN SHE RETURNED AT AROUND 3:30 PM, RESIDENT #504 WAS ALREADY ON THE FLOOR. RESIDENT #504 WENT TO THE BATHROOM UNATTENDED AND fell . AT AROUND 3:30 PM, RESIDENT WAS ALREADY ON THE FLOOR. CNA #4 RECALLED RESIDENT HAD UNSTEADY FEET AND BILATERAL LEG WEAKNESS PRIOR TO FALL. SHE NEEDED EXTENSIVE ASSISTANCE WITH TRANSFERS AND ADLS (ACTIVITIES OF DAILY LIVING). HER NEEDS WERE ANTICIPATED AND STAFF RELIES ON HER USE OF CALL LIGHT. ADON (ASSISTANT DIRECTOR OF NURSING) DURING AN INTERVIEW CONDUCTED ON [DATE] AT 2:20 PM, STATED THAT AN INCIDENT REPORT WAS DONE BUT WAS NOT REPORTED TO THE STATE. THE RESIDENT (#504) WAS SENT TO THE HOSPITAL IMMEDIATELY AND WAS treated for [REDACTED]. SHE WAS SENT BACK TO THE FACILITY IMMEDIATELY. THE ADON admitted THAT SHE DID NOT GET INTERVIEWS OR STATEMENTS FROM STAFF AFTER THE INCIDENT. THERE WAS NO INVESTIGATION FOLDER FOR THIS PARTICULAR FALL. THE ADON RELIED ON THE UNUSUAL OCCURRENCE REPORT AND NURSE'S NOTES DATED [DATE]. HOSPITAL RECORDS ACQUIRED ON [DATE], REVEALED CT SCAN OF THE HEAD SHOWED: ACUTE BLOOD ALONG THE LEFT TENTORIUM AND LEFT SIDE OF THE POSTERIOR FALX. THIS IS FELT TO BE ACUTE SUBDURAL BLOOD. RESIDENT #504 WAS discharged on [DATE] WITH [DIAGNOSES REDACTED]. ( )