Every finding on record at The Orchards at Warren

This citation pertains to Intake 2984550.Based on interview and record review, the facility failed to document and/or complete wound care for one resident (R801) out of three reviewed for wound care. Findings include: A review of the medical record revealed R801 was admitted into the facility on 7/7/2025 with the following diagnoses, Pressure Ulcer of Sacral Region, Stage 3 (full thickness skin loss and exposure of the fatty tissue beneath) and Pressure Ulcer of Left Hip, Stage 3. Further review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3/15, indicating an impaired cognition. R801 also required staff assistance with bed mobility and transfers.Further review of the Treatment Administration Record (TAR) revealed the following, Cleanse coccyx (buttocks) with NS (Normal Saline), apply medihoney gel (draws moisture from wound to promote healing), and a dry dressing. Every day shift (7AM -3:30PM). Start date:7/9/2025.Additional review of the July 2025 TAR noted on July 10th,11th,12th, and 13th, the dates were left blank, indicating the treatment was not completed. No further documentation was noted in the medical record related to the treatments not being completed on those days.On 4/16/2026 at 12:42 pm, an interview was conducted with the Director of Nursing (DON). The DON reported they were unsure why the treatment was not charted on because they had a wound care nurse who completed the treatments. The DON reported they expect all treatments to be documented as it is completed.A review of a facility policy titled, Skin Management Guidelines noted the following, The facility is committed to providing care and services to residents to prevent the development of skin breakdown.

This citation pertains to Intake 2729557.Based on interview and record review, the facility failed to provide adequate supervision to prevent an elopement for one resident (R901) from a total of three residents reviewed for supervision. Findings Include: Review of a complaint called into the State Agency revealed, Complainant states a male resident (R901) escaped from the facility two weeks ago and was found at the bus stop. Review of the clinical record revealed R901 was admitted into the facility on 4/4/2025 with the following diagnoses: Vascular Dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The Minimum Data Set Assessment (MDS) dated [DATE], indicated resident was independent with ambulation and activities of daily living, requiring assistance of one for showering and had a Brief Interview for Mental Status (BIMS) revealed a score of 15/15, indicating intact cognition. A review of the clinical record revealed R901 verbalized on 9/19/25 to staff they were discharging the next day. R901 called (name of a moving company) and their church for assistance repeatedly. R901 also told staff they were going to call the police and was re-directed and re-informed that a discharge was not ordered and could not occur until all the proper people and paperwork was done. Review of a progress note dated 9/26/25, revealed the resident was discussing their discharge set for the next day and was informed that a discharge had not been arranged. R901 then hurriedly moved toward the exit, was redirected and a wander alert device was applied to the resident's ankle. The 9/26/25 care plan reflected the resident was now an elopement risk, but not that a wander alert device was applied to their ankle.An Elopement Risk assessment dated [DATE] indicated R901 was to be at Low Risk for elopement with a score of 8/15, despite multiple conversations of wanting to be discharged .Review of an investigation file provided by the facility revealed on 12/6/25 at 2:00 PM, R901 observed outside of the building walking on the drive around the building, coming from the direction of their room by the Housekeeping Supervisor (HS) E. Unable to coax R901 back into the building the HS E called to the facility for assistance and two employees came to help. R901 returned to the building about 15 minutes after reinforcements arrived.According to the investigation file, R901 removed screws from the inside-window casing that were placed to prevent the window from opening more than 2-3 inches. Once the screws were removed, the resident was able to open the window enough to climb out and was observed unattended. The care plan was updated on 12/18/25 indicating a wander alert device was placed on R901's ankle. On 2/26/26 at 10:15 AM, an interview with Maintenance Director (MD) C revealed they were part of the investigation to determine how R901 was able to exit the building unnoticed. MD C revealed R901 had removed the stop screws that were installed in the inside track of the window to prevent it opening more than 2-3 inches. On 2/26/26 at 10:30 AM, an interview with HS E revealed as they drove on the driveway around the building they noted R901 coming out between the building and asked them where they were going. R901 said they were leaving while HS E attempting to coax them back into the building. During this time R901 was adamant they were not returning, telling HS E over and over, I am leaving, I am not going back in. When they reached the main road, the HS E, contacted the facility and requested help. Two employees then attempted to coax R901 back into the building and after about 15 minutes R901 returned to the building. HS E confirmed, staff did not know the resident was not in the building.On 2/26/26 at 11:00 AM, an interview with the Nursing Home Administrator (NHA) confirmed the events and added R901 preferred to have their door closed at all times and it was difficult to provide privacy along with increased supervision for an elopement risk resident.On 2/26/26 at 12:41 PM, a request for the documentation policy was requested for nurses and Certified Nursing Assistants. The Director of Nursing indicated there was not a policy for documentation.

This citation pertains to Intake 2717353.Based on observation, interview, and record review, the facility failed to timely provide incontinence care or repositioning for three residents (R902, R905, and R906) of three residents reviewed for activities of daily living care (ADL). Findings include:R902On 01/21/26 at 7:17 AM and 8:02 AM, R902 was observed to be supine in bed, dressed in a hospital style gown, the head of bed up slightly, a mat was on the floor at the right side of the bed, a low air loss mattress unit was at the foot of the bed, the bed was in a lowered position, R902 had a pillow on the right side under the arm, heel boots on, the call light was clipped to the side of the mattress at the head of the bed, the tray table was at the foot of the bed. Certified Nursing Assistant (CNA) A reported there were two or three aides on the unit.At 8:19 AM, R902 was supine in bed with the head of the bed up around 45-60 degrees. The breakfast tray was on the tray table over the lap of R902 and the mat was folded up on the floor at the right side of the bed. The bed was up slightly higher. R902 was dressed in a hospital style gown, their hair was sticking out stiffly toward the right side.At 10:13 R902 continued in bed as before with their head over toward the right shoulder with their eyes closed. The breakfast tray had been removed, and an empty juice cup and white foam water cup had been left. The bed had been lowered. The variable length of the fingernails was observed, and the nails were observed with soil underneath.At 10:50 AM, CNA A was walking toward the room of R902 and reported they were going to check and change (provide incontinence care) R902. CNA A then went and brought the unit manager who was working the medication cart to assist. R902 was soiled with loose stool in a sufficient amount to cover the private area around the pubic bone. CNA A reported they had been to other residents that were more significantly wet. R902 was not observed to have been check for incontinence prior to 10:50 AM.A review of the record for R902 revealed R902 was admitted into the facility 12/19/25. Diagnoses included High Blood Pressure and Pain. The Minimum Data Set (MDS) assessment dated [DATE] indicated moderately impaired cognition and the need for substantial/maximal assistance from staff for toileting hygiene, personal hygiene, and bathing and also required meal set up. The active care plan documented, .am incontinent of bowel and bladder . check me at least every two hours during the day .R905On 01/21/26 at 10:30 AM, R905 was observed to be supine in bed, with the head of the bed up around 45 -60 degrees. The breakfast tray was on the tray table across the bed of R905. The tray table deck was at the level of R905's mouth and nose. R905 had a utensil in their right hand. R905 did not answer queries about the food or positioning and made nonsensical verbalizations. A urine odor was noted.At 10:38 AM, Licensed Practical Nurse (LPN) C was asked about the position of R905 for their meal and reported R905 could use the call light and may move the bed up and down. LPN C made no attempt to adjust the resident and commented R905 was a slow eater. The bed controller was observed toward the foot of the bed beyond the reach of R905. At 11:07 AM, R905 had been raised up to a height above the tray table, with scant amount of food eaten when CNA A came and took the tray away.At 11:12 AM, an observation of care, with CNA A and LPN C revealed the odor of urine and a visibly urine soiled brief. Upon completion of the care with R905, CNA A was asked about the care of R902 and R905 and reported it had been the first time they had provided incontinence care to the residents since the start of their shift (7AM). A review of the record for R905 revealed R905 was admitted into the facility on [DATE]. Diagnoses included Adult Failure to Thrive, Heart Disease and Alzheimer's. The MDS assessment dated [DATE] indicated severely impaired cognition and the need for substantial/maximal staff assistance for toileting hygiene and dependent on staff for bathing, dressing and personal hygiene, and partial assistance to roll in bed and meal set up assistance. The active care plan documented, .am incontinent of bowel and bladder . am at nutritional risk . I can feed myself with set up and supervision .R906On 01/21/26 at 11:44 AM, 12:30 PM, 1:20 PM and 2:18 PM, R906 was observed to be supine in bed, eyes closed, with the head of the bed up around 30-45 degrees. R906 was dressed in a hospital gown, had a blanket covering the feet to the abdomen, their legs elevated on a device with heel boots on and their head on a pillow. R906 did not open their eyes to a knock on the door.At 2:18 PM, R906's head was off the right side of the pillow, the eyes remained closed.At 2:48 the position of R906 had not changed. A review of the record for R906 revealed R906 was admitted into the facility on [DATE]. Diagnoses included Paralysis of the left side, Stroke and Malnutrition. The active care plan documented, .incontinent of bowel and bladder . needs assistance with ADLs . totally dependent on staff for repositioning me in bed at least every two hours and as necessary .On 01/21/26 at 3:00 PM, the Director of Nursing (DON) was asked about the observations and noted the aides may prioritize the timing of the care for the residents based on needs.At 3:55 PM, the DON followed up and indicated the aide had completed rounds initially and between 9AM and 9:30 AM. It was noted that the position of the residents was not observed to have been changed.A review of the facility nursing standard operating procedure titled Toileting revealed, .When a resident indicates verbally or non-verbally a need to use the bathroom staff should promptly assist the resident .

This citation pertains to intake 2718756.Based on observation, interview, and record review, the facility failed to ensure essential equipment was readily for use, for one sampled resident (R904) of three reviewed for patient care equipment. Findings include:A review of an Intake revealed, AED (Automated external defibrillator) pads not on crash cart. The Complainant reported on 1/15/26 on [NAME] unit R904 had a code blue and when the staff went to use the unit's AED, staff had to go and get another AED from another unit due to the closest AED not having pads. A review of R904's medical record noted R904 was admitted to the facility on [DATE] and readmitted on [DATE]. R904's medical record documented on 1/15/26 after a code and 911 were called, the resident was transferred to the local hospital. A review of R904's Minimum Data Set (MDS) assessment noted R904 with intact cognition and required assistance from staff to complete activities of daily living. A review of R904's advanced directive was noted as full code. During the survey a phone call was made to the nurse K involved in the code and a voice message was left but the call was not returned.On 01/21/26 at 7:42 AM, a red cased AED on top of the crash cart outside reception was observed to be cracked open and a status light could not be seen in the status window.At 9:15 AM, on the [NAME] unit, the crash cart and log were observed with all items checked for the day. Just above the crash cart and attached to the wall, a white box labeled AED was observed to be empty (without the AED inside the box). At 9:19 AM and 2:33 PM, the crash cart in the large dining room was observed with soiled towels on the top of the cart. The cart was without a form to indicate/monitor the inventory inside the cart. The towels remained on top of the cart during the length of the survey.On 1/21/26 at 9:25 AM, the crash cart on the [NAME] unit was observed with a completed inventory sheet. The AED machine was observed on the top of the cart inside a red case labeled AED, once opened the machine was observed with the battery on the outside of the machine.On 1/21/26 at 12:40 PM, Central supply Staff J was asked about replacement pads for the AED machines. Staff J was then observed with three replacement pads one for the AED machines. Staff J was asked the process of notification when the pads need to be replaced and reported the nurses, or the Unit Manager would let them know.On 1/21/26 at 12:57 PM, Rose/Lavender Unit Manager (Nurse I) was asked about the AED machine for the Lavender unit. Nurse I was observed to locate the crash cart for the unit and opened the AED wall container. Inside the container was a Red case which contained the AED, the battery was observed on the outside of the machine. Nurse I was asked why the battery was not left inside of the machine and explained the machine would continuously beep and may drain the battery.On 1/21/26 at 1:50 PM, the Director of Nursing (DON) was asked about R904's code blue and if the AED machine closest to R904 was used. The DON explained that the Nurse called and gave report but did not report which AED machine was used. The DON was asked about the two AED machines that had the battery observed on the outside of the machine and confirmed they are kept that way in order to maintain the battery. A review of the manufacture's manual was reviewed with the DON and made aware of the manual's documentation, Note: Always store the (name of AED machine) with a set of SMART Pads and a battery installed, so it will be ready to use and can perform daily self-tests. Further review of the manual noted the AED Machine completed automatic self-tests. On 1/21/26 at approximately 2:40 PM, the [NAME] unit manager Nurse B was asked to demonstrate the self-test on the red case AED. Nurse B was observed to open the red case, place the battery inside the machine, and turned it on. The machines automated voice said to connect the pads, which Nurse B reported it would be a waste of pads to continue. Nurse B was shown the manual that noted the self-test instructions. Nurse B report they were unable to complete it without connecting the pads.A review of the owner's manual for the (Name of) Defibrillator Edition 13, revealed, . 4. After Using the (name of defibrillator) . 6. The (name of defibrillator) will automatically run a self-test when the battery is inserted. Press the Shock button and On/Off button when instructed. Be sure to let the self-test run all the way to completion. When the self-test is over, the (name of defibrillator) will report the result, and tell you to push the green On/Off button in case of an emergency. Then the (name of defibrillator) will turn off and go to standby mode. The green Ready light will be blinking to show the (name of defibrillator) is ready for use. ( Note: Always store the (name of defibrillator) with a set of SMART Pads and a battery installed, so it will be ready to use and can perform daily self-tests.). 7. Return the (name of defibrillator) to its storage location so it will be ready for use when needed. Place the updated inspection log/maintenance booklet on the defibrillator wall mount or cabinet. A facility's policy was requested to address the AED machines and crash cart. The Nursing Home Administrator reported the facility did not have polices for those items requested.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by eliminating harborage conditions. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:On 12/1/25 at 9:10 AM during an observation of the kitchen, the stainless-steel table holding the coffee maker was observed with a built-in drainage well. The drainage pipe under the table was observed to be propped up by a cardboard box. The box was water damaged, and there were numerous gnats observed on the box and drainage pipe. When queried, Dietary Manager K stated the box was being used to support the pipe. No explanation was provided for why the water damaged cardboard had not been discarded or the observed gnats.According to the 2022 FDA Food Code section 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A)Routinely inspecting incoming shipments of FOOD and supplies;(B)Routinely inspecting the PREMISES for evidence of pests;(C)Using methods, if pests are found, such as trapping devices or other means of pest control as specified under SS 7-202.12,7-206.12, and 7-206.13; and (D)Eliminating harborage conditions.

Based on observation, interview, and record review, the facility failed to maintain a home-like environment for two of two residents (R108 and R11), and two (rooms [ROOM NUMBERS]) of 24 resident rooms reviewed for home-like environment. Findings include: R108 On 12/1/25 at 9:23 AM, R108's bathroom door in their room was observed to have a square broken area in the wood of the door approximately a third of the way from the top of the door. R108 was asked about the damage to the door and indicated that they did not like it and that it bothered them. On 12/2/25 and 12/3/25 the bathroom door in R108's room was observed to remain damaged. On 12/3/25 at 3:49 PM, Director of Maintenance (DM) E was interviewed and asked about the damaged bathroom door in R108's room. DM E stated, We don't inspect the rooms. DM E indicated that something should be put into TELs (Electronic maintenance request system) so we can address it. A review of R108's electronic medical record (EMR) revealed that R108 was most recently admitted to the facility on [DATE] with diagnoses that included Collapsed vertebra and Chronic obstructive pulmonary disease (COPD). R108's most recent minimum data set assessment (MDS) dated [DATE] revealed that R108 had an intact cognition and required maximum assistance with all activities of daily living (ADLs) other than eating and oral care. On 12/01/2025 at 9:47 AM, the bathroom in room [ROOM NUMBER] was observed. The toilet was observed with an unknown brown substance inside the toilet bowl and seat. The floor was observed with visible debris around the perimeter of the bathroom which was odorous of urine and feces. On 12/01/2025 at 12:45 PM, the bathroom of room [ROOM NUMBER] was observed. The smell of the bathroom was odorous of feces; the toilet seat had a copious amount of smeared feces which was also observed on the floor and inside the garbage can. Gnats were observed flying around the bathroom near the feces. On 12/1/2025 at 1:20 PM, the resident in room [ROOM NUMBER] was observed asking their assigned certified nursing assistant if they had spoken to housekeeping about the bathroom due to the poor condition. She advised she would notify housekeeping again. R11 On 12/01/2025 at 11:30 AM, R11 was observed in bed asleep. The resident's tube feeding pole and base in addition to the floor, was observed with spilled brown tube feeding liquid. On 12/01/2025 at 4:03 PM, R11 remained in bed asleep. The same tube feeding liquid remained on the pole, base and floor. On 12/02/2025 at 8:54 AM, R11 was observed lying in bed asleep. The resident's tube feeding pole, base and floor remained soiled with the same tube feeding liquid observed from the day prior. On 12/02/2025 at 1:05 PM, R11's room was observed with the same tube feeding liquid on the floor as observed earlier the same morning. On 12/01/2025 at 11:48 AM, the bifold closet door for the first closet was missing. The mounting hardware at the floor was observed to be rusted. Clothing items were in a pile on the floor and filled the space wall to wall. In room [ROOM NUMBER] the shared bathroom had an approximately four-foot-long piece of cove based peeled away from the wall to the left of the hand sink. Also, in the room [ROOM NUMBER] bathroom a graduated basin for urine (a hat) had a residual amount of yellow liquid in the bottom and had been left on the back of the toilet.

Based on interview and record review, the facility failed to conduct quarterly care conferences for five residents (R1, R8, R9, R79, R109) of five reviewed for care conference participation. Findings include: R1 A review of the record for R1 revealed R1 was admitted into the facility on [DATE]. Diagnoses included Bipolar Disorder, Epilepsy and Stroke. A review of the active care plan documented multiple Focus entries which included, incontinent of bowel and bladder related to immobility, I am on a restorative nursing program, I am dependent on staff for meeting emotional, intellectual, physical, and social needs, and I have an ADL (activities of daily living) deficit requiring assistance. A review of the documented care conferences in the electronic medical record revealed dates for 10/21/25 and 05/29/25. Additional documentation of quarterly care conferences held was requested but not received prior to survey exit. R8 A review of the record for R8 revealed R8 was admitted into the facility on [DATE]. Diagnoses included Failure to Thrive, Physical Debility, and Stroke. A review of the active care plan documented multiple Focus entries which included, incontinent of bowel and bladder related to inability to get to the toilet, I am on a restorative nursing program, I am dependent on staff for meeting emotional, intellectual, physical, and social needs, and I have an ADL (activities of daily living) deficit requiring assistance. A review of the documented care conferences in the electronic medical record revealed dates for 09/30/25 and 07/31/25. Additional documentation of quarterly care conferences held was requested but not received prior to survey exit. R9 A review of the record for R9 revealed R9 was admitted into the facility on [DATE]. Diagnoses included Heart Disease, Quadriplegia and Stroke. A review of the active care plan documented multiple Focus entries which included, incontinent of bowel and bladder related to impaired cognition, I am on a restorative nursing program, I am dependent on staff for meeting emotional, intellectual, physical, and social needs, and I need assistance with my ADL's related to Weakness. A review of the documented care conferences in the electronic medical record revealed dates for 10/10/24 and 05/28/25 and 09/16/25. Additional documentation of quarterly care conferences held was requested but not received prior to survey exit. R79 A review of the record for R79 revealed R79 was admitted into the facility on [DATE]. Diagnoses included Dementia, Epilepsy and Heart Failure. A review of the active care plan documented multiple Focus entries which included, I am incontinent of bowel and bladder related to immobility, have a history of traumatic events that continue to affect me negatively, I am dependent on staff for meeting emotional, intellectual, physical, and social needs, and I require supervision and 07/31/25. An October 2025 nor October 2024 care conference was documented. Additional documentation of quarterly care conferences held was requested but not received prior to survey exit. R109 On 12/1/25 at 9:59 AM, R109 was interviewed regarding their satisfaction with the care and services that they were receiving at the facility. R109 indicated that they had been at the facility for approximately a year and that they had no idea when they were going to be discharged . R109 was asked if they had ever attended any care conference meetings during their stay at the facility. R109 stated, No and indicated that they would like to be included in their care conference meetings. A record review of R109's electronic medical record (EMR) revealed that R109 was most recently admitted to the facility on [DATE] with diagnoses that included Hypertensive urgency and Type 2 diabetes. The most recent minimum data set assessment dated [DATE] revealed that R109 had an intact cognition and required maximum to moderate assistance for all activities of daily living (ADLs) other than eating. A review of R109's quarterly care conference documentation revealed that care conferences were conducted and R109 was documented as having attended the care conferences on 2/28/25 and 9/16/25. There was no documentation of a quarterly care conference meeting being held during May of 2025. On 12/3/25 at 12:56 PM, Social Services Director (SSD) C was interviewed and asked about their expectations for care conferences being conducted with residents. SSD C indicated that care conferences are completed quarterly and should be documented in the resident's record. R109's care conferences were reviewed with SSD C and it was determined that R109's care conference that should have been conducted in May or June of 2025 was not documented in their EMR. SSD C did not provide an explanation on why it was not documented in the resident's record. On 12/3/25 at 1:02 PM, the Administer (NHA) was interviewed about resident care conferences at the facility and indicated that the facility was without a social worker for a period of time over the past year and that they were trying to play catch up with care conferences.

Based on observation, interview, and record review, the facility failed to document the physician's order, consent for use, risk versus benefits, attempted alternatives, and consistently monitor for the use of side rails for two residents (R50 and R89) of two residents reviewed for side rails. Findings include: R50 On 12/1/25 at 12:00 PM, R50 was observed sitting in their wheelchair. An observation of the resident's bed revealed two black side rails approximately 32 inches in length. R50 was asked about the rails and explained they like them there because they make them feel safe. A review of R50's medical record revealed they were admitted into the facility on [DATE] with diagnoses which include Cerebral Infarction, Acute Respiratory Failure with Hypoxia, and Heart Failure. Further review revealed the resident was cognitively intact and required 2-person assist for bed mobility, per their care plan. Further review of the care plan did not address the resident's side rails, and there were no physician orders in place for the side rails. A review of the Nursing Side Rail assessment dated [DATE] noted the side rails were being ordered for positioning, and a trapeze (intended to provide a resident change position in bed) had been tried as an alternative. In addition, the assessment had seven questions related to the measurements of the side rail in relation to the mattress, headboard, and footboard, and the spots for the completion of those questions were blank. On 12/2/25 at 3:08 PM, a request for documented informed consent for the use of the side rails was requested in addition to a maintenance assessment to the facility, however, it was not received by the end of the survey. 12/3/25 at 9:56 AM, R50 was observed in bed and asked about the side rails again. They explained the rails were taken off last night and placed back on. The resident was asked if they had ever trialed an alternative for the side rails for repositioning, such as a trapeze, and the resident indicated they had not. On 12/3/25 at 1:47 PM, the Director of Rehabilitation (DOR D) was asked about R50's side rail and indicated they are being used for mobility, and the side rails are actually assist bars for the older model bariatric bed the resident is using. DOR D was asked for the process of installing side rails and explained an assessment is completed, the side bars are installed, and there are ongoing assessments for safety. DOR D was asked for documentation of risk versus benefits of the side rail, and explained there is nothing written, but was discussed with the resident. Regarding the side rail assessment indicating a trapeze had been attempted as an alternative, DOR D admitted it had not been trialed due to R50 not having the strength to utilize it. On 12/3/25 at 3:45 PM, Director of Maintenance (DOM E) was asked about maintenance checks of assist bars and side rails on residents' beds, and explained that safety checks are completed monthly however, there isn't any documentation of the checks. On 12/3/25 at 2:56 PM, the Director of Nursing (DON) was asked about the side bars and explained they were advised by the provider they obtained the bed from, that the side bars were assist bars which is what she thought they were. The DON further explained that maintenance completes the measurements of the bars, and therapy completes the risks versus benefits. On 12/3/25 at 10:16 AM, a request for a Bed Rails policy was requested, and not received by the end of the survey. R89 On 12/3/2025 at 2:14 PM, R89 was observed sitting in bed in an upright position. R89 was noted to have two side rails installed on the resident's bed. The side rails were approximately 32 inches in length. R89 reported the side rails help them push up in bed and move side to side. A review of the medical record revealed R89 admitted into the facility on 1/4/2025 with the following diagnoses, Muscle Weakness and Age-Related Physical Debility. A review of the most recent Minimum Data Assessment (MDS) set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R89 also required staff assistance with bed mobility and transfers. Further review of the MDS, physician orders, or care plan, did not note R89 having side rails in place. A consent was not observed in the medical record for the side rails as well. Further review of the medical record revealed Nursing Side Rail Assessments with the effective dates of 3/5/2025, 7/4/2025, and 10/3/2025. The section with the header of Measurements are in inches is blank on all three assessments. A request for a facility policy related to side rails was requested but not obtained by the end of survey.

Based on observation, interview and record review, the facility failed to provide an appropriate size bed for one (R108) resident of one reviewed for accommodation of needs. Findings include:On 12/1/25 at 10:19 AM, R108 was observed lying perpendicular across their bed with their legs slightly bent and their feet positioned firmly against the footboard. The right side of R108's body was positioned close to the side of the bed nearest to the door of their room. R108 stated, This bed is uncomfortable, I feel like I'm going to fall off the bed. Upon further questioning R108 indicated that they had mentioned to different staff on multiple occasions that they would like a larger bed. R108 was asked if they had completed a facility grievance form regarding their bed. R108 stated, No one ever told me that I needed to do that. R108 stated, I'm tall and need a larger bed. While in the resident's room it was observed that their call light was on the floor underneath the left side of their bed. On 12/1/25 at 2:09 PM, R108 was observed lying perpendicular across their bed with their legs slightly bent and their feet positioned firmly against the footboard. The right side of R108's body was positioned close to the side of the bed nearest to the door of their room. R108's call light remained on the floor underneath the left side of their bed. On 12/2/25 at 10:30 AM, R108 was observed lying perpendicular across their bed with their legs slightly bent and their feet positioned firmly against the footboard. The right side of R108's body was positioned close to the side of the bed nearest to the door of their room. R108 expressed feeling uncomfortable and again indicated they needed a larger bed. R108 further indicated the current bed had been in the room upon their admission and placement in the room. R108 reiterated they had asked multiple times to get a new bed and nothing had been done. On 12/3/25 at 9:35 AM, Director of Maintenance (DM) E was shown R108's bed and interviewed regarding the process for ensuring that residents had a comfortable appropriately sized bed. DM E indicated if a resident needed a different mattress and/or bed, staff was supposed to put a maintenance request into TELS (Electronic maintenance notification system). MD E was interviewed and asked if a TELs request had been put in for R108. MD E stated, No.On 12/3/25 at 9:45 AM, R108's assigned Certified Nurse Assistant (CNA) G was shown R108's bed and asked if R108 had ever discussed being uncomfortable in their current bed and wanting a new bed. CNA G indicated R108 had commented to them recently about wanting a new bed that fit them better. CNA G was asked if they had put a request in TELS regarding this issue. CNA G stated, No. A review of R108's electronic medical record (EMR) revealed that R108 was most recently admitted to the facility on [DATE] with diagnoses that included Collapsed vertebra and Chronic obstructive pulmonary disease (COPD). R108's most recent minimum data set assessment (MDS) dated [DATE] revealed that R108 had an intact cognition and required maximum assistance with all activities of daily living (ADLs) other than eating and oral care. R108's most recent weight as of 11/23/25 was documented to be 223 pounds. A review of R108's care plan revealed an intervention which stated, Be sure my call light is within reach .On 12/3/25 at 1:02 PM, the Administrator (NHA) was interviewed and asked about their expectations regarding accommodating residents' requests for replacing their bed. The NHA indicated the expectation is that staff let the appropriate manager know so that a bed can be provided.A review of a facility policy titled, Resident Rights with no date, stated the following, Respect and Dignity. The resident has the right to be treated with respect and dignity, including C. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences .

Based on observation, interview and record review, the facility failed to don appropriate personal protection equipment (PPE) when providing care for two residents (R1 and R8) of three observed for Enhanced Barrier Precautions (EBP - use of gloves and gowns for high-contact care activities). Findings include: On 12/02/2025 at 9:27 AM, a medication administration was observed with Licensed Practical Nurse (LPN) I for R1. The room of R1 had a sign on the door which indicated R1 was on Enhanced Barrier Precautions (EBP). LPN I entered the room and donned a pair of gloves. A gown was not worn. LPN I administered the medications separately, via a PEG (percutaneous endoscopic gastrostomy tube - tube inserted externally into the stomach for liquid nutrition). On 12/03/2025 at 8:10 AM, Certified Nursing Assistant (CNA) J was observed to enter the room of R8 with a clear plastic bag of wash towels. CNA J then exited the room. CNA J re-entered the room of R8 and closed the door. The sign on the door indicated both residents residing in the room were on EBP. R8 was observed to have tube feeding via a PEG tube and a pump. The EBP sign documented that gloves and a gown were required for dressing, bathing showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. CNA J was staff not observed to put on PPE for resident care. A plastic cart with PPE was observed to the right side of the door to R8's room. On 12/03/2025 at 8:14 AM, CNA J reported they had repositioned R8 when in room providing care. CNA J confirmed R8 was on enhanced barrier precautions and acknowledged they should have donned PPE before going in to provide care. On 12/03/2025 at 11:38 AM, the Director of Nursing (DON) reported staff should have donned the PPE of a gown and gloves for the care provided to R1 and R8. A review of the undated policy titled, Enhanced Barrier Precautions (EBP) revealed, It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms . Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms . Initiation of Enhanced Barrier Precautions - Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. Examples include but are not limited to: Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Infection or colonization with a novel or targeted MDRO when contact precautions do not apply .

Based in interview and record review, the facility failed to notify the physician regarding abnormal laboratory (lab) results (blood glucose level of 34 - normal range for a blood glucose level per the lab report was 82-115 mg/dl-milligrams per deciliter) for one resident (R1) of three whose labs were reviewed. Findings include: A review of the lab results dated 07/28/25 and reported 07/28/25 at 9:06 PM revealed R1 had a critical blood glucose level of 34. A review of the record for R1 revealed R1 was admitted into the facility on [DATE]. Diagnoses included Bipolar Disorder, Epilepsy and Stroke. A review of the active care plan documented I am dependent upon tube feeding, I am NPO (noting by mouth), I have the potential for fluid imbalance, I have an ADL (activities of daily living) deficit requiring assistance, and I have altered cardiovascular status related to Hypertension (high blood pressure), Hyperlipidemia (high cholesterol). A review of the progress notes revealed no documentation the physician was notified or what action was taken.On 12/03/2025 at 12:48 PM, the Director of Nursing (DON) reported the nurse should notify the physician of abnormal lab values and document the notification in the progress notes or put it in the doctors' logbook. On 12/03/2025 at 12:59 PM, a review of the assigned physician's logbook revealed no entries for R1 on 7/28 or later related to the abnormal lab value. A review of the undated Acute Change in Condition policy revealed, An Acute Change of Condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains . Changes (symptoms) are communicated to the physician via: Phone call (urgent), Physician Log (non-urgent), Physician rounds .

Based on observation, interview and record review, the facility failed to provide podiatry services for one resident (R84) out of two reviewed for foot care. Findings include:On 12/01/2025 at 9:30 AM, an interview was conducted with R84. R84 stated they had been asking to see the podiatrist for months now and had yet to see them. R84 reported they have long toenails and that they hurt.A review of the medical record revealed R84 admitted into the facility on 5/9/2025 with the following medical diagnoses, Parkinson's Disease and Muscle Weakness. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. R84 also required staff assistance with bed mobility and transfers.A request for R84's most recent podiatry note was requested and not received by the end of survey.On 12/2/2025 at 11:15 AM, an observation of R84's toenails were completed with Certified Nursing Assistant (CNA) A. CNA A reported they had given R84 a shower the day prior and marked on the shower sheet that R84 needed their toenails cut. R84's toenails were observed to be thick, and curled due to their long length, they were also noted to be yellowish in color with black on some of the toenails.A review of R84's shower documentation for the months of November and December had the question, Does the resident need he/her toenails cut? marked as yes on the following days, 11/24/2025,11/27/2025, and 12/1/2025.On 12/3/2025 at 9:11 AM, an interview was conducted with Social Service Director (SSD) C. SSD C reported if a resident wants to see podiatry, then the floor staff will usually inform them, and they will get added to the book to be seen. SSD C reported the podiatry group also sends over their own list and then they will update need be. SSD C reported they were asked to send a referral over for R84 the day prior and had already sent an email over to add R84 to the podiatry list to be seen at their next visit.On 12/03/2025 at 2:52 PM an interview was conducted with the Director of Nursing (DON) The DON reported their expectation is that once they get the shower sheets back from the CNA's and there is an issue documented such as long toenails, they should let Social Work know that and then the resident should be put on the podiatry list as soon as possible.A facility policy related to podiatry services was requested but not received by the end of the survey.

Based on interview and record review, the facility failed to ensure a prescribed medication (lacosamide-anticonvulsant medication) was available for administration for one resident (R1) of 24 whose medications were reviewed. Findings Include:A review of the record for R1 revealed R1 had an original admission date of 06/06/19 with a readmission on [DATE]. Diagnoses included Seizures, Epilepsy, and Stroke. A review of the active care plan documented, I have a seizure disorder related to Disease process Seizure, Date Initiated: 09/19/2022. Give me my medications as ordered. Observe me for effectiveness and side effects. Date Initiated: 09/19/2022.A review of the medication orders revealed, Lacosamide oral solution 100 mg (milligrams)/ 10 ml (milliliters) Give 20 ml two times a day related to Generalized Idiopathic Epilepsy and Epileptic Syndrome . A review of the December 2025 Medication Administration Record (MAR) revealed the Lacosamide was not documented as given twice daily on 12/01, 12/02, with the morning dose missed on 12/3. A review of the nursing progress notes for the December dates documented the medication was unavailable and on order.On 12/03/2025 at 2:48 PM, the missed Lacosamide doses were reviewed with the Director of Nursing (DON) who reported medications should be reordered by the nurse and administered as ordered. On 12/03/2025 at 2:19 PM, R1 reported I need that for my Epilepsy when asked about the missed doses of the Lacosamide.A review of the facility policy titled, Medication Orders did not address timely administration of ordered medications.

Based on observation, interview, and record review, the facility failed to ensure an oral surgeon consultation was completed timely for one resident (R8) of three whose ancillary services were reviewed. Findings include: On 12/01/2025 at 10:18 AM, R8 was observed to be in their room lying in bed dressed in a hospital style gown. R8 was asked about mouth care and when asked if it was completed daily R8 showed their teeth and shook their head No. The middle upper teeth were missing or appeared broken. The front teeth on the lower jaw were more aligned but with a build of white debris in the spaces between the teeth. R8 shook their head yes when asked if they would like their teeth brushed more often. R8 was observed to have a hand contracture on the left and when asked if they could move their arms lifted them a few inches off the bed and was not able to move beyond that position. R8 reported they would allow staff to brush their teeth. R8 was receiving tube feeding and reported they also received a tray of food with meals. On 12/01/2025 at 1:10 PM, R8 was observed assisted to eat by staff. A review of the record for R8 revealed R8 was admitted into the facility on [DATE]. Diagnoses included Failure to Thrive, Physical Debility, and Stroke. A review of the active care plan documented Focus entries which included, I am dependent on staff for meeting emotional, intellectual, physical, and social needs, and I have an ADL (activities of daily living) deficit requiring assistance. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated moderately impaired cognition. The section for Oral/Dental status indicated as no the answer to Obvious or likely cavity or broken natural teeth. A review of the visiting dental group exam note dated 06/16/25 documented, .Patient reports that (they are) having oral discomfort. Recommend extraction of non-restorable teeth (#4,5, 6, 7, 9, 15, 18, 31) with oral surgeon (OS) . It was also indicated to follow up for dentures and patient would benefit from assistance with toothbrushing and flossing. A 07/29/25 dental group note documented, .not due for treatment. Patient has not yet seen oral surgeon. A 08/13/25 dental group noted documented, .Pt was examined bedside; Intraoral exam shows non-restorable teeth still present; patient has not yet seen oral surgeon. Social Services reports that facility is working on getting patient scheduled with OS .On 12/03/2025 at 12:41 PM, Social Worker C was asked about the referral documentation for an oral surgery appointment requested for R8 by the visiting dentist. At 2:28 PM, SW C provided an appointment that been scheduled for the 07/10/25 timeframe. It was noted the appointment had been cancelled due to the need for R8 to go on a stretcher. SW C was asked why there was an additional four-month delay and SW C reported they had not been aware the cancelled visit had not been followed up. SW C provided a dispatch form dated 07/10/25 which indicated R8 as unable to sit up safely in wheelchair, the visiting dental group exam noted dated 06/16/25 and the 06/16/25 physician order for the referral to oral surgery confirmed by the unit manager.On 12/03/2025 at 2:38 PM, Staff F reported they had made the appointment with the oral surgeon, but it had been cancelled due to the need for a stretcher. Staff F reported they did not know why the appointment had not yet been completed and was not sure would have followed up to ensure it was done.On 12/03/2025 at 2:51 PM, the Director of Nursing (DON), reported staff should have followed up the cancelled appointment and notified the social worker or the unit manager. The DON reported SW does the ancillary physician appointments. A policy related to outside appointments was requested on 12/03/25 but not received prior to survey exit.

This citation pertains to Intake: MI00149450. Based on interview and record review, the facility failed to notify the resident's representative of a change in condition for one resident (R901) of one resident reviewed for a change in condition. Findings include: On 1/21/25 at 9:32 AM, Confidential Family Member A was interviewed regarding R901, and explained they were unaware that R901 was showing any signs of a change in condition until another family member went to visit the resident on 1/9/25, and noticed a change in their abilities. Family Member A explained they requested the resident be transferred to the hospital on that day, and was later informed R901's physician had ordered tests to be completed days before the transfer, but wasn't informed of this, as they would have liked to be a part of the decision-making regarding the care of their loved one. A review of R901's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia, Diabetes, Dementia, and Heart Failure. Further review revealed the resident was severely cognitively impaired, and required limited assistance of one person for transfers and bed mobility per their care interventions initiated on 4/12/24 and 5/7/24. Further review of R901's medical record revealed the following progress notes: 1/6/2025 06:42 (6:42am) Nurses Note Note Text: CNA (certified nursing assistant) reported changes in PT's (patient's) condition. PT no longer assist with bed mobility, noticed not transferring with wheelchair to toilet or bed . 1/6/2025 14:58 (2:58pm) Nurses Note Note Text: Writer informed that resident has a change in condition. Resident has not been transferring or toileting as [R901] normally does. Resident needs 2 people and maximum assist with transfers and toileting. Resident is now needed to be changed instead of toileting and transferring [themselves] . 1/6/2025 15:06 (3:06pm) Nurses Note Note Text: Resident has complained of leg and ankle pain. Denies having any falls. 1/7/2025 19:20 (7:20pm) Nurses Note Note Text: Resident observed in room with mid (mild) distress noted. Resident complains of back and left knee pain. Writer informed that resident has a change in condition. Resident has not been transferring or toileting as [R901] normally does. Resident needs 2 people and maximum assist with transfers and toileting. Resident is now needed to be changed instead of toileting and transferring herself . 1/9/2025 02:41(2:41am) Nurses Note Note Text: Patient has had an acute change in condition, observed within past 2 weeks no longer transferring with w/c (wheelchair), toileting self or getting out of bed . Further review of R901's progress notes revealed R901's guardian had not been contacted when the resident began showing a change in condition. On 1/21/25 at 1:32 PM, an interview was completed with Licensed Practical Nurse (LPN) B regarding R901's change in condition, and explained they were not that familiar with R901 but was initially informed of their change in condition, and asked to complete the documentation. LPN B explained Unit Manager C indicated they would contact the family. On 1/21/25 at 2:17 PM, Unit Manager C was interviewed via phone about R901's change in condition, specifically the family being contacted regarding the change. Unit Manager C explained they contacted the family however, they did not document the attempt. On 1/21/25 at 2:05 PM, the Director of Nursing (DON) was asked about R901's change in condition, and the family not being contacted. The DON explained the family should be notified of a change in condition. A review of the facility's Acute Change in Condition policy did not address the resident's representative being notified of a change in condition.

This citation pertains to Intake M100147854. Based on interview and record review, the facility failed to complete a comprehensive nutritional assessment in a timely manner for one (R801) of three residents reviewed who were admitted with nutrional at-risk indicators. Findings include: Review of the facility record for R801 revealed an admitted [DATE] with diagnoses including Dysphagia (difficulty swallowing), Diabetes Mellitus, and Dementia. A transfer order from the hospital indicated the resident required a pureed diet. The resident's weights were documented on 10/15/24 (140 pounds) and 11/02/24 (131.7 pounds). R801's Care Plan indicated they required Extensive Assistance for eating. The Nurse Practitioner (NP) progress note dated 10/21/24 stated decreased oral intake, monitor for now. The Change of Condition note dated 11/08/24 indicated decreased appetite. Further review revealed no comprehensive nutritional assessment was completed by the Registered Dietician (RD). On 11/08/24 at 12:06 PM, RD A was interviewed by phone. RD A reviewed R801's record and confirmed they had not completed a nutritional assessment and stated It looks like it got missed. RD A reported their resident assessment would normally be completed within the first week of the resident's stay. On 11/08/24 at 12:57 PM, the facility Director of Nursing (DON) indicated the RD had located additional information so RD A was interviewed further via phone. RD A reported they had completed the Minimum Data Set (MDS) nutrition (Section K) assessment on 10/18/24 but confirmed the MDS section was not a comprehensive dietary evaluation and the full assessment did get missed. Considering the multiple dietary-related indicators (dysphagia/pureed diet, requiring eating assistance, decreased oral intake, decreased appetite and weight loss) RD A was asked if it was likely completion of a full RD assessment would have led to additional care interventions and they were not able to provide a definitive answer. On 11/08/24 at 1:02 PM, the DON was asked what their expectation was for completion of the Registered Dietician's full initial assessment and they stated they would have to review the policy before providing that information. By completion of the survey a response regarding the expectation was not provided. A facility policy addressing the indications for and the timeliness of a dietary evaluation was requested however the provided policy addressed only the MDS assessments.

Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for one resident (R47) and ten confidential group residents of thirteen reviewed for food palatability, resulting in dissatisfaction during meals. Findings include: On 9/17/24 at 9:25 AM, R47 was met in their room for observation and interview. R47's breakfast was observed to consist of two biscuits, two pancakes, cereal, a small carton of milk, syrup and butter. The only protean observed with R47's breakfast was the carton of milk. R47 was interviewed about the food served to them at the facility and stated, The food is [swear word]. On 9/18/24 at 8:38 AM, a followup visit was conducted with R47 and they were asked how their breakfast was. R47 stated, It tasted like garbage, I had two hard boiled eggs, toast, and cereal. A review of R47's electronic medical record (EMR) revealed that R47 was most recently admitted to the facility on [DATE] with diagnoses that included Congestive heart failure and Type 2 diabetes. R47's most recent quarterly minimum data set assessment (MDS) revealed that R47 had a moderately impaired cognition. A review of Food Council Meeting notes dated 8/12/24 revealed the following, The food is horrible, the green beans are nasty and not seasoned at all. The chicken tenders are horrible and the breading is soggy. The food is terrible, I can't eat the food, it has no taste and it's cold. Need more soups, can't mess that up. I wish the food could be better at times. The meat doesn't taste like meat. The pork chop can't even be cut with a knife and the meatloaf is nasty. On 9/18/24 at 10:05 AM, a confidential group meeting was conducted with a group of of ten residents and they were asked about the taste and temperature of the food served to them at the facility. The whole group indicated that the food was cold and didn't taste good. One group member indicated that the dinner portions were small and they frequently were still hungry after finishing their dinner. On 9/18/24 at 12:30 PM, a food cart on one of the units was observed with two food trays on top of the cart, no plate warmers underneath the plates, and the doors to the food cart open while staff was serving meals to the residents. On 9/18/24 at 12:33 PM, Dietary Manager (DM) A temperature tested a random tray and the results were the following, Crusted Parmesan Chicken: 113 degrees Fahrenheit. There was no sauce observed on the chicken. Garlic Buttered Fettuccini: 115.6 degrees Fahrenheit. The noodles appeared to be plain with no butter on them. There was no cooked carrots or apple crumble observed on the plate, these items were indicated to be part of the meal per the menu. DM A was asked about no carrots being served with the meal and stated, Do you want some. DM A was asked about the preferred temperature for the food and stated 100 degrees Fahrenheit or above and per resident preference. 22960 On 9/17/24 at 12:45 PM, a test tray was done. The internal temperature of the pork chop was measured to be 107 degrees Fahrenheit. The pork chop was tasted and was lukewarm. The pork chop was extremely fatty, with very little actual meat available to eat. A review of a policy titled, Food Palatability-Hot Food Temperatures Date: 3.13.2018 revealed the following, Policy: The healthcare community prepares and serves food .that [is] palatable, attractive and .[at] appetizing temperature[s].

This citation pertains to Intake: MI00146189 Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by eliminating harborage conditions in the kitchen. This deficient practice has the potential to affect all residents in the facility. Findings include: 09/17/24 at 9:15 AM, there was standing, stagnant, slimy water observed on the floor, in the corner underneath the garbage grinder at the 3 compartment sink. In addition, there were cobwebs and numerous gnats observed in the same area. When queried, Dietary Manager (DM) A stated that the pipe for the garbage grinder was small and sometimes over-flows. DM A did not provide an explanation for why the standing water in the kitchen was not cleaned up, in order to prevent a breeding ground for gnats. On 9/17/24 at 9:20 AM, there was standing water on the floor between the coffee maker and the juice dispenser. There were gnats observed flying about in the same area. When queried, DM A was unsure where the water was coming from. Review of the pest control service reports for 9/12/24 and 9/5/24 noted that the target pests were gnats, and the service report for 8/22/24 noted lots of gnats. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions.

Based on observation, interview, and record review, the facility failed to ensure resident medications were not left at the bedside for four residents (R22, R44, R63 and R71) of four residents reviewed for medication storage. Findings include: R71 On 9/16/24 at 8:40 AM, R71 was observed lying in bed. An inhaler was observed lying on their bedside table. A review of R71's medical record revealed the resident was admitted into the facility on [DATE] with diagnoses included Chronic Obstructive Pulmonary Disease, Alcohol Abuse, and Adjustment Disorder. Further review revealed the resident was moderately cognitively impaired, and required limited assistance with Activities of Daily Living. On 9/17/24 at 12:55 PM, R71 was observed lying in bed awake, inhaler located on their bedside table. On 9/19/24 at 9:19 AM, R71 was observed lying in bed, inhaler lying on their bedside table. R71 was asked about the inhaler, and explained it's their Albuterol recuse inhaler. R71 was asked when was the last time they used it and stated, Today. Just now. A review of R71's physician orders revealed an order for ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally four times a day for sob (Shortness of Breath). Further review of the medical record did not reveal an assessment for the self-administration of medications. On 9/19/24 at 9:24 AM, Unit Manager H was asked about the inhaler at R71's bedside and whether there was an assessment completed for the resident to self-administer their own medications. Unit Manager H explained they were unable to locate one for the resident. R63 9/17/24 at 11:06 AM, R63 was observed in bed, and easily aroused. Observed on the resident's bedside table were a stack of medication cups, and located next to the stack was a medication cup with pills inside. R63 was asked about them, and immediately ingested the medications and explained they were from last night. A review of R63's medical record revealed they were admitted into the facility on [DATE] with diagnoses included Heart Failure, Diabetes, and Chronic Kidney Disease. Further review revealed the resident was cognitively intact and required limited to supervision for Activities of Daily Living. On 9/18/24 at 8:46 AM, R63 was observed in bed asleep, a medication cup with two pills were observed sitting on the resident's bedside table. Licensed Practical Nurse (LPN) I was approached outside of R63's room, and asked if they had passed R63's medications yet. LPN I explained they had not, as they were just coming on for their shift. LPN I was asked to view the medications at R63's bedside, and explained they did not provide the resident with those medications. LPN I removed the medication cup from the room, and made observations of the medications statin, It looks like a Gabapentin and a Buspar (Pain medication and an anti-anxiety medication). 50223 R22 On 9/17/24 at 12:51 PM, R22 was observed awake lying in bed with family at bedside. An albuterol inhaler was observed on top of the dresser. R22 was asked if they use the inhaler. R22 stated sometimes. On at 9/18/24 at 8:41 AM, R22 was observed awake in bed. The albuterol inhaler was observed still on the dresser. On 9/18/24 at 8:45 AM, Licensed Practical Nurse (LPN) J was shown the inhaler in the room and was asked if the inhaler should be at R22's bedside. LPN J stated, no I don't think so. LPN J was asked if residents can keep medications at the bedside. LPN J explained sometimes residents keep medications at the bedside but there should be a physician order if they do. A review of R22's medical record revealed they were admitted to the facility on [DATE] with the following diagnosis: Nontraumatic Subdural Hemorrhage, Unspecified. Chronic Obstructive Pulmonary Disease Unspecified. A review of R22's Brief Interview for Mental Status revealed a score of 14 indicating mild cognitive impairment. A review f R22's physician orders revealed the following: Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 base) MCG/ACT (albuterol Sulfate) 1 puff inhale orally every 4 hours as needed for SOB (shortness of breath). R44 On 9/17/24 at 9:56 AM, R44 was observed asleep in bed. Fluticasone nasal spray and saline nasal spray were observed on top of the dresser in the room. On 9/18/24 at 8:51 AM, R44 was observed awake in bed. The two nasal sprays were observed to still be on the dresser in the room. R44 was asked if they use the nasal spray. R44 explained that they hadn't used them in a while but could if they needed to. A review of R44's medical record revealed they were admitted to the facility on [DATE] with the following diagnosis: Chronic Obstructive Pulmonary Disease Unspecified; Obstructive Sleep Apnea. A review of R44's Brief Interview for Mental Status revealed a score of 15 indicating intact cognition. A review of R44's physician orders revealed the following active order: Saline Nasal Spray Solution (saline) 1 spray in each nostril every 2 hours as needed for congestion Further review revealed the following discontinued order: Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril one time a day for dryness. Discontinued 7/9/24. On 9/18/24 at 9:09 AM, LPN L was shown the two nasal sprays in R44's room and was asked if they should be in the room. LPN L stated No, they should not. (R44) does not have an order to have them at the bedside. LPN L was asked if there should be a physician order for a resident to have meds at the bedside. LPN L stated Yes. There should be an order in pcc (the electronic medical record) that says they can self-administer and keep medications at bedside. On 9/19/24 at 10:00 AM, during an interview, the Nursing Home Administrator (NHA) was asked to describe their expectation regarding medications at a resident's bed side. The NHA explained that medications should not be left at a resident's bedside unless there is a physician order and the nurse should watch the residents take their medications before leaving the room. On 9/19/24 at 11:48 AM, the Director of Nursing (DON) was informed of the observations of medications at the bedside of R22 and R44 and was asked to explain their expectation regarding medications at a resident's bedside. The DON explained medications should not be left at a resident's bedside unless the resident has had an assessment done and documented that they are able to self-administer medications and have a physician's order to self-administer the medication. A review of the facility's policy titled Self-Administration of medications by residents revealed the following: Each resident who desires to self-administer medication is permitted to do so if the facility's interdisciplinary team/or facility policy allows or has determined that the practice would be safe for the resident and other residents of the facility. Procedure. 1. Each resident is offered the opportunity to self-administer his or her medications during the routine assessment by the facilities interdisciplinary team. 3. the interdisciplinary team determines the resident's ability to self-administer medications by means of skill assessment .4. the results of the interdisciplinary team assessment are recorded on the medication self-administration form, which is placed in the resident's medical record .7. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and then give unauthorized medications to the charge nurse for return to the family or responsible party.

Based on observation, interview, and record review, the facility failed to honor a resident's request to be sent out for a higher level of care for one resident (R33) of one reviewed for self-determination. Findings include: On 9/18/24 at 8:47 AM, R33 was observed lying in bed, and asked to speak to the surveyor. R33 explained that their pain management has not been managed well, specifically with them not receiving their prescribed as needed medications timely. R33 further explained that they have a history of kidney stones, and felt as though they had one last week Wednesday, which was causing excruciating pain. R33 explained that as a result, they asked to speak to the Director of Nursing and their physician as they wanted to be transferred to the hospital. R33 further explained that they never spoke to the DON or the physician, but was told that the nurse spoke to the physician who did not order a transfer to the hospital, and that if they chose to transfer on their own they would have to sign themselves out Against Medical Advice (AMA), and be responsible for the transportation bill. R33 further explained that they didn't want a bill, and remained in excruciating pain for the duration of the day and night. A review of R33's medical record revealed that she was admitted into the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Acute Pyelonephritis (Kidney Infection), and Anemia. Further review revealed that the resident was moderately cognitively impaired, and required one-person for assistance for bed mobility, toileting and dressing. Further review of R33's medical record revealed the following progress notes: 9/11/2024 15:41 (3:41pm) Nurses Note Text: Resident states at 10:30am [they want] to speak with [physician] and DON regarding pain/kidney stones. Both notified. Pain meds given as ordered. Resident states ineffective. 9/12/2024 16:30 (4:30pm) Physician Progress Notes Late Entry: Note Text: Called to bedside secondary to medical evaluation and maintenance of care Increased pains in b/l (bilateral) mid-back. Hx (history) of kidney stones and stated similar pains to that. Pain improved today, but quite bad yesterday. Pt (patient) stated [they] requested to go to hospital, but staff stated physician denied. No conversation did occur to indicate [they] needed transfer the night prior when discussing with nursing. Apologized for not completing [their] needs - indicate will work better in future to do so. Pt appears to be ok with today's results. Indicated will start IV (intravenous) to flush any remaining stone that may be present and reminded of muscle relaxers ordered . On 9/19/24 at 10:07 AM, a phone call was made to Licensed Practical Nurse (LPN G), the nurse assigned to R33 during midnight shift on 9/11/24. LPN G explained that they had received report from the previous nurse informing them that R33 was in pain, and that the doctor had been contacted. LPN G explained that they provided R33 their pain medications per the active orders, and attempted to contact the physician again to no avail. On 9/19/24 at 11:35 AM, an interview was completed with LPN C, assigned nurse during the day shift for R33. LPN C was asked about R33's complaints of pain, and request to go to the hospital. LPN C explained that R33 did request to go to the hospital, but when they spoke to the physician regarding the resident's concerns, they did not provide any new orders for the resident. LPN C reports that she continued to provide R33 their pain medications per their current orders. LPN C was asked if they were aware of anyone telling the resident that they would have to sign themselves out AMA, and they stated that they are not sure. On 9/19/24 11:47 AM, an interview was completed with the DON regarding R33 and their request to go to the hospital. The DON explained that the resident has a right to go out to the hospital when they chose, and would follow-up with the resident regarding their concerns. On 9/19/24 at 1:29 PM, the Nursing Home Administrator (NHA), was asked about a resident being told that they couldn't be transferred to the hospital if initiated by the resident themselves, and it being considered an AMA. The NHA explained that it is the resident's right to be transferred and it would not be considered an AMA. A review of the facility's Resident Rights policy revealed the following, .Resident rights. The resident has the right to a dignified existence, self -determination, and communication with and access to persons and services inside and outside the facility 6. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to .b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .

Based on observation, interview, and record review, the facility failed to appropriately monitor and timely address a significant weight loss for one sampled resident (R74) of one resident reviewed for nutrition resulting in, undetected significant weight loss, and the potential for further weight loss and decline in nutritional status. Findings include: On 7/31/23 at 2:20 PM, R74 was observed in bed asleep, appearing small in stature. Attempts to arouse R74 were made to no avail. A review of R74's medical record revealed that the resident was initially admitted into the facility on [DATE], hospitalized from 5/29/23, and readmitted on [DATE]. R74's diagnoses include Cerebral Infarction, Dysphagia, Cognitive Communication Disorder, and Legal Blindness. Further review of the medical record revealed a Minimum Data Set (MDS) assessment dated for 6/7/23 revealing a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. Further review revealed that R74 required for extensive assistance for eating, bed mobility, and transfers. The care plan titled: Goal: I am at nutritional risk r/t protein calorie malnutrition, tube feeder .Interventions: Provide, serve me my diet as ordered - in addition to observing my intake and record per policy. Date Initiated: 05/21/2023. Further review of R74's medical record revealed the following weights indicating that the resident had a significant weight loss of 18.47% between 6/17/23 and 7/8/23: 7/8/2023 94.9 Lbs (pounds) 6/24/2023 97.3 Lbs 6/17/2023 116.4 Lbs 6/10/2023 115.6 Lbs 5/21/2023 116.0 Lbs 5/20/2023 116.0 Lbs Further review of R74's medical record revealed that interventions for R74's weight loss were not implemented until 7/28/23 as revealed by a review of R74's physician orders, care plan, and the following progress note: 7/28/202316:17 (4:17pm). Weight Change Note Text: Resident was reviewed r/t (related to) significant weight loss x 30/90/180 days. Wt (weight): 94.9# (pounds) BMI (body mass index): 15.3 - underweight. Resident recently approved for PO diet (by mouth) and regular tube feeding d/c ' d (discontinued) unless resident consumes less than 50% of [their] meal. Recommend [nutritional supplement] BID (2 times a day). Current diet and tube feeding regimen with recommended nutritional supplements will likely meet estimated nutritional needs. Recommendations above, otherwise, continue with current plan of care and will adjust as needed. Will continue to monitor for any changes, weights, PO intake acceptance/tolerances, skin, nutrition-related labs and will f/u (follow-up) as needed. On 8/2/23 at 2:50 PM, an interview was completed with Registered Dietician B regarding the weight loss of R74. She explained that upon R74's initial admission, they were receiving nothing by mouth, and relied upon their tube feeding for nutritional needs. She explained that R74 was transferred to the hospital on 5/29/23 and returned to the facility on [DATE] for a clogged tube and returned with an upgraded pureed diet, along with their tube feeding. Registered Dietician B explained that currently, R74 receives 1:1 assistance for feeding, and bolus of [nutritional formula] if they consume less than 50% of their meal. She explained that the resident was also started on a supplement two times a day. Registered Dietician B was asked for the reasoning that intervention for R74's weight loss was just implemented on 7/28/23, and explained that she would have liked to have seen the weight loss documentation sooner, and did not provide any other explanation. On 8/2/23 at 4:05 PM, the Director of Nursing (DON) was asked about their expectation for ensuring residents don't experience significant weight loss, and she explained that weekly weights should be completed and monitored to ensure that the dietician assesses the resident and add interventions as needed. A review of the facility's Unintended Weight Change policy was reviewed and revealed the following, Residents with unintended weight loss/gain will be assessed by the interdisciplinary team and interventions will be implemented to prevent further weight loss/gain .unintended weight loss/gain is unavoidable if the facility properly assessed, care planned, implemented the care pan, evaluated the resident outcome, and revised the care plan through the duration of a resident's weight loss/gain. If not, the weight loss/gain is avoidable .The weights documented in [electronic medical record] will be reviewed by the Dietary Manager/RD, recommendations made as indicated. Implementation of recommended interventions will be documented in the medical record .

This citation pertains to Intake MI00138416. Based on observation, interview and record review, the facility failed to ensure interventions were implemented to prevent development of a pressure sore for one resident (R68) of three reviewed for pressure sore, resulting in the development and or worsening of an unstageable pressure sore to the right medial heel. Findings include: On 07/31/23 at 11:33 AM, a wound was observed with the family of R68. The wound was located on the medial aspect of the right heel. The tissue over the wound appeared moist, mostly gray with areas of black. This was non viable tissue slough and eschar. The dressing appeared with a brown and black drainage. The wound was more oval than circular and around a half dollar in size. The family members reported they had brought the wound to the attention of the facility and the facility had wrapped it in dry gauze. The family and R68 were concerned for infection. The family provided a picture of the wound when first discovered. The wound appeared dry with darker areas and intact skin. The wound appeared to have worsened from the time of the photo. The family also reported the leg and foot had been swollen for the last three weeks. Swelling was visible and greater from the ankle up the leg. R68 reported chronic pain from the back down the leg and a history of cancer and a wound on the tailbone. It was further reported that R68 had been seen by the wound doctor. R68 had a personal pillow in the bed that was tan and had shag carpet type fabric over it. The family and R68 reported the heels had not been floated consistently especially when the feet and legs were more swollen. The family and R68 also noted R68 was unable to walk and spent most days in the bed. R68 appeared to favor laying slightly onto their left side. R68 and the family reported they had not seen the use of any type of boot over the heel. A review of the clinical record for R68 revealed R68 was admitted into the facility on [DATE]. Diagnoses included Heart Failure, Difficulty Walking, and Bipolar Disorder. The I have an Activities of Daily Living (ADL) deficit . care plan with revision date of 07/07/22 indicated, Bed Mobility: I require supervision for safety with bed mobility. The I display cognitive impairment .I experience impaired judgement and insight .: care plan dated 04/10/23 indicated, Cue orient and supervise me as needed . The I am at increased (risk) for developing impairment to skin integrity . care plan revised 07/07/22 indicated, .If my skin is impaired, observe and document the location . The care plan did not reference the heel wound but did note a history of a pressure wound to the coccyx. A review of the wound progress note dated 07/18/23 indicated a wound size of 2.5 centimeters (cm) by 2.0 cm and 100% eschar (falling away of dead skin) covered. Diagnosis: Eschar, right medial heel . Apply Dry dressing every three days .Additional orders: Turn/reposition every two hours. Avoid direct pressure to wound site. Facility pressure injury intervention/relief protocol. Low air loss mattress or low air loss bed, offload bilateral heels. Soft heel boots . A 07/25/23 noted documented the wound to be 100% eschar and 2.5 cm by 1.8 cm with no drainage noted. Diagnosis: Eschar, right medial heel . Apply Dry dressing every three days .Additional orders: Turn/reposition every two hours. Avoid direct pressure to wound site. Facility pressure injury intervention/relief protocol. Low air loss mattress or low air loss bed, offload bilateral heels. Soft heel boots . On 07/31/23 at 4:35 PM R68 was observed to be in bed with their heels on the bed, not elevated on a pillow and without any heel boots. The pillow was on top of the heater. R68 leaned slightly toward the left with the knees flexed slightly. On 08/01/23 at 7:34 AM, 9:37 AM, 11:16 AM, 1:06 PM, 1:40 PM and 2:02 PM, R68 was observed to be in bed with their heels on the bed, not elevated on a pillow and without any heel boots. The pillow was on top of the heater. R68 leaned slightly toward the left with the knees flexed slightly with the head of the bed up around 30-45 degrees. A low air loss mattress was not in place. At 4:59 PM, R68 continued in bed, turned to slightly left, feet and heels on the bed with no pillow and no boots. A dressing was visible and covered the right ankle and heel area. The heel was medially on bed. On 08/02/23 at 6:50 AM and 8:17 AM, R68 was observed to be in bed with their heels on the bed, not elevated on a pillow and without any heel boots. The pillow was away from the bed on top of the heater between the window and a wheelchair. R68 leaned slightly toward the left with the knees flexed slightly with the head of the bed up around 30-45 degrees. At 8:26 AM, the concern for the lack of interventions for R68 was reviewed with the Wound Care Nurse. The Nurse reported they had been in their role about three weeks and took care of most of wound treatments during the day. The Wound Care Nurse reported they had been looking for a boot for R68. The Wound Care Coordinator reported the wound was first documented on 07/18/23. At 11:45 AM R68 reported it was often their choice not to get not get of bed as they can't walk and was uncomfortable sitting in the wheelchair. A cloth heel cup boot was observed in place. R68 remained facing slightly toward the left with the medial side of the right heel on the bed. At 1:14 PM, the Director of Nursing (DON) was made of aware of the lack of implementation of orders and for R68 asked about the expectation to follow the care plan and implement physician orders for care and reported it was the expectation that staff implement the plan of care as ordered. The DON further reported the heel wound for R68 was acquired at the facility and did have a discussion with staff. A review of the Pressure Ulcer and Skin Care Management policy documented, Policy: A person who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing .

This citation pertains to intake MI 096 Based on observation, interview, and record review, the facility failed to 1) Implement interventions in a timely manner after a change in condition for one sampled resident (R281) out of one reviewed for a change in condition and 2) Provide [CONDITION(S)] medication as ordered for one sampled resident (R330) resulting in hospitalization and death and the potential for increased [CONDITION(S)] activity. Findings include: Resident 281 (R281) A review of intake MI 096 noted the following, Complainant states on 2/16/22 [Family Member] received a call and was told the resident was not eating and they suspected that [R281] may have a [CONDITION(S)] (Urinary Tract Infection). Complainant states [Family Member] was told they would schedule [R281] to see the doctor. Complainant states on 2/22/22 while the resident was hospitalized [Family Member] contacted the facility to see how the resident condition changed so abruptly after being seen by the doctor and was told no orders were ever put in for the resident to see the doctor. Complainant states the doctor visits on Tuesdays and Thursdays and the resident could have and should have been seen by the doctor on 2/17/22. On 5/18/2022 at 1:50 PM, a phone interview was conducted with Family Member J. Family Member J stated, When she went to the hospital, they stated that [R281] was really dehydrated and [R281] sodium was extremely high to the point that it was fatal. [R281] death certificate listed cause of death as acute kidney injury. [R281] also had a severe [CONDITION(S)]. The Wednesday prior to [R281] going to the hospital I was told that [R281] had stopped eating and they expected a [CONDITION(S)], and they would have a physician look at it. No one ever did anything about it. A review of the medical record revealed that R281 was admitted into the facility on [DATE] with the following diagnoses, Dementia, Muscle Weakness, and Dysphagia. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 99 indicating that R281 was unable to complete the assessment. R281 also required one-to-two-person total dependence with bed mobility and transfers. R281 was transferred to the hospital on 2/21/2022, R281 was a full code at the time of transfer. A review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . [R281] was on hospice care before .The patient may benefit from hospice care again due to [their] medical decline. A review of physician orders did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Further record review revealed a change in condition form dated 2/16/2022 that noted the following, A. Situation 1. The change in condition, symptoms or signs I calling about is/are 13. Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) 2. This started on 2/14/2922. Physician Recommendation: UA (Urinalysis) C&S (Culture and Sensitivity) A request for all R281's lab results from January 2022 and February 2022 were requested, but were not provided prior to survey exit. An email form the Nursing Home Administrator noted, [R281] did not have any labs completed during that time. On 5/19/2022 at 8:04 AM an interview was conducted with Social Work Director (SSD) C regarding the physician notes stating R281 was hospice appropriate. SSD C stated, I was never made aware of that. The physician notes get uploaded into the system and that one was never uploaded. There was never a hospice order put in either. On 5/19/2022 at 11:06 AM, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) related to R281 care while in the facility. The DON was queried about the follow up with R281 noted medical decline. The DON stated, My understanding is that the nurse spoke to the family and then R281 began to eat again. The decline was quick in the dining room and the nurse acted on it quickly. The DON was queried about the physician documenting that R281 had a medical decline in their January and February notes, but no interventions were implemented and/or completed. The DON stated, I will have to look further into that. However, no further information was provided prior to survey exit. A review of an undated policy titled, Acute Change in Condition revealed the following, An Acute Change of Condition (ACOC) is sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. Resident #330 (R330) On 05/17/2022 at 11:18 AM, Resident #330 was observed sitting up in their wheelchair dressed and groomed. The Resident had clear speech and answered questions appropriately. When asked about the care received at the facility, Resident #330 stated, I didn't get my [CONDITION(S)] medication for three days when I first got here. Resident #330 was asked if they had a [CONDITION(S)] during that time and explained that they did not. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #330 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders for Resident #330 revealed the following: Lacosemide (a [CONDITION(S)] medication) 10 mg (milligrams) two (pills) twice per day. A review of the April 2022 Medication Administration Record (MAR) revealed that the Lacosemide medication was not given on 04/28/2022 or 04/30/2022. On 04/29/2022, the medication was signed out as given during the day, but not signed out given during the afternoon shift. A review of the May 2022 MAR revealed that Resident #330 had not received their Lacosemide on 05/01/2022 for either shift. On 05/19/2022 at 11:10 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed in regard to the process of ordering medications upon admission for new residents. The DON explained that the nurse reviews the hospital orders and calls the physician. Once the physician approves the medication, the nurse orders the medications from the pharmacy. The DON was asked about what happened with Resident #330's [CONDITION(S)] medication upon admission. The DON stated, We just started using a new pharmacy. (Resident #330) got their [CONDITION(S)] meds, we went through this with (Resident #330). The DON was asked to clarify the MAR indicating that the medication was not given, and stated, I would have to look at that one. The DON never provided and explanation for the medication not being signed out as given from 04/28/2022-05/01/2022 prior to survey exit. A review of the facility policy titled Medication Administration and General Guidelines dated 2022 revealed the following: .Medications are administered in accordance with written orders of the attending physician .10. Medications are administered within one hour of the scheduled time .

This citation pertains to intake MI 329. Based on observation, interview, and record review, the facility failed to administer ordered medication for constipation when indicated and failed to conduct follow-up assessments after a known alteration in bowel pattern for one sampled resident (R902) of three reviewed for assessment/monitoring, resulting in a bowel obstruction and hospitalization . Findings include: A review of intake MI 329 revealed: Complainant states [R902] went 1 week without being able to use the restroom and the staff did not document it. Complainant states the resident ended up having a severely impacted bowel which caused [them] to start vomiting feces. Complainant states the resident had to be hospitalized as a result. On 4/20/21 at 10:31 AM, R902 was observed lying in bed in their room. R902 was interviewed and queried regarding their most recent hospitalization and replied, I was in the hospital for .days, I almost choked on my own [expletive]. It was terrible, I was puking up my own poop .They (staff) had to dial 911 for me to go to the hospital, it was an emergency, they almost had to do emergency surgery on me . When queried further about what lead up to the hospitalization , R902 stated, I was constipated for 4-5 days .I puked Thursday (4/8/21) .Friday (4/9/21) .I looked like I was 9 months pregnant, my stomach was hard as a brick. R902 was unable to provide a reason as to why they had become so constipated and also indicated that they were unable to walk. When queried about interventions for bowel maintenance at the facility, R902 indicated they had a scheduled stool softener but prior to the hospitalization that it was 4-5 days they had gone without a bowel movement. R902 denied having a history of constipation or bowel obstruction. R902 stated, [Certified Nursing Assistant (CNA) B] was the one who was trying to tell the nurses that I was puking up my own feces, she said she kept telling them something was wrong and they wouldn't listen to her. A review of R902's progress notes and medical record revealed the following: 3/31/2021 12:57 (PM) NURSE PRACTIONER NOTES Note Text: Encounter for Palliative Care: Patient with constipation no bm (bowel movement) in 3 days. BS (bowel sounds) diminished (abnormal finding) x 4 quads (quadrants) abd (abdomen) distended. New orders for milk of mag (milk of magnesia - a laxative) 30 ml po q day prn (milliliters by mouth every day as needed) for constipation. Pt c/o (complains of) pain in left arm bedside nurse notified of both to administer milk of mag and Tylenol full note to follow. Written by Nurse Practitioner (NP) C. A review of NP Cs full note from 3/31/21 revealed, .[R902] Reports [they] has not had a BM in 'days' .PE (Physical Exam) systems .Gastrointestinal (GI): Abnormal .Organ system comments, GI: abdominal distention, BS diminished x 4 quads Output/Input: Constipation, Problems: Constipation, Plan: Pt (patient) abdomen firm distended with diminished bs throughout. No documented bm in the last 3 days. New orders for milk of magnesia 30 ml po q day prn. Instructed bedside nurse to administer milk of mag. Current bowel regimen -[MEDICATION(S)] (stool softener) 100 mg PO BID (by mouth twice a day), add Senna (laxative) 8.6 2 tabs at HS (bedtime) Monitor response. The order, Milk of Magnesia Suspension 400 MG/5 ML (Magnesium Hydroxide) Give 30 ml by mouth every 24 hours as needed for constipation if no bm in 3 days, was entered in on 3/31/2021 at 1:00 PM by NP C. Upon review of R902's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No corresponding progress notes regarding administration of the Milk of Magnesia to R902 were found. No order for the Senna at HS after 3/31/21 until 4/6/21 was found upon review of the record, and only one administration of the Senna was noted on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] No progress notes were present in R902's record after NP C progress note until 4/4/21. 4/4/2021 00:02 (12:02 AM) Behavior Note Note Text: Upon rounds patient was observed yelling and screaming in room during the night while roommate is sleeping. Writer educated patient on use of call light and respect of other sleep results was ineffective .unable to be redirected. Dr. called new order for one time dose of [MEDICATION(S)] 0.5 mg po (benzodiazepine - a central nervous system depressant). The note did not include a physical assessment nor mention of follow-up to the resident's constipation and abdominal distention. No additional progress notes on 4/4/21 or 4/5/21 were found in R902's medical record. The next note present in R902's record was dated 4/6/21 at 1:20 PM by NP D and included: Progress Note 4/6/21 .[R902] reports constipation for 4 days. Abdomen: soft, hypoactive positive bowel sounds, mild distention, non tender .1. Constipation- on [MEDICATION(S)] 100 mg PO BID, add Senna 8.6 2 tabs at HS, Palliative ordered MOM 30 ml as needed Monitor response . No further progress notes on 4/6/21 were present upon review. R902's record included one note on 4/7/21 from psychiatric services and no medical/nursing notes. The next note present in R902's record was dated 4/8/2021 06:35 (AM) and included: Note Text: Patient emesis x 3 brown in color thin no food was noted. Patient had serval (sic) cokes soda patient has Dx (diagnosis) GERD (gastroesophageal reflux disease). Dr (doctor) and NP called unable to reach will endorse to oncoming. No physical assessment of the resident to accompany this progress note was present in R902's medical record. The subsequent progress notes for R902 were reviewed and revealed: 4/8/2021 13:34 (1:34 PM) Nurses Note Note Text: Resident has had emesis x3. Medical Director contacted and ordered STAT ABD (abdominal) xray to r/o (rule out) bowel blockage. 4/8/2021 13:49 (1:49 PM) Nurses Note Note Text: NPO (nothing by mouth) except for medication pending outcome of x ray. 4/8/2021 16:46 (4:46 PM) Transfer to Hospital Summary Note Text: It was reported to writer that on the night shift [R902] vomited 3 times, emesis being brown in color. It was reported by CNA that resident had not had a BM since Thursday of last week. Dr was called and ordered a STAT ABD xray and for resident to be NPO pending results. X-ray was taken and preliminary impression was given that there may be a blockage of the bowels. Residents stomach was severely distended and resident continues to have multiple emesis brown in color and c/o (complains of) sever (sic) abd pain. Dr contacted regarding the the increase in abd size, pain, emesis and xray and orders were given to send resident to the hospital. Attempt made to call [ambulance company] for transport but wait exceeded 3hrs (hours) and they stated they did not pick up pt with emesis. DR ordered writer to call 911. Resident transferred to hospital at approximately 1630 (4:30 PM). All parties notified. -Written by Licensed Practical Nurse (LPN) A. R902's transfer form dated 4/8/21 revealed the following vital signs and information: Blood Pressure: 181/101 (elevated) (mmHg - millimeters of mercury) Date: 4/8/2021 16:25 (4:25 PM) Pulse: 112 (elevated) (bpm - beats per minute) Date: 4/8/2021 16:25 Pain Level: 10 (out of 10) Date: 4/8/2021 16:25 Pain Scale: Numerical Pain Location: stomach Usual Functional Status: Not ambulatory. A review of R902's hospital documentation dated 4/13/21 indicated that R902 was sent to the hospital on 4/9/21 and was discharged on [DATE] and returned back to the nursing facility. Further review of the documentation revealed: Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Chief Complaint: Feculent Vomiting .This patient .coming to the emergency department for nausea vomiting and constipation, patient states .last bowel movement was approximately 3 days ago .[they are] not sure if [they are] passing gas but patient is actively vomiting feces in the emergency department .patient seems pretty certain that .last bowel movement was 3 days ago and patient was persistently nauseous in the emergency department despite doses of [MEDICATION(S)] [MEDICATION(S)] .General impression: Alert and attentive, patient is in moderate distress .While in the emergency department patient had laboratory evaluation .white blood cell count was slightly elevated at 11,000 .electrolytes showed decreased potassium at 3.4 and decreased sodium at 131 as well as low chloride at 93 .CT abdomen and pelvis showed obstruction with rectum dilated to 9.2 cm (centimeters) and internal fecal impaction, patient is going to be admitted to medicine team with surgery on consult .Surgical consult: Assessment/plan .abd pain 2/2 (secondary to) small/large bowel obstruction 2/2 large fecal impaction. Will disimpact at bedside. Maintain NGT-[NAME] (nasogastric tube at low intermittent suction) until pt has bowel function . A review of R902's Point of Care (POC - charting typically entered by CNAs) for Consistency of BM: revealed the following: 3/27/21 - none 3/28/21 - one formed/normal charted at 11:06 AM 3/29/21 - none 3/30/21 - none 3/31/21 - none 4/1/21 - none 4/2/21 - none 4/3/21 - none 4/4/21 - none 4/5/21 - one formed/normal charted at 2:52 AM 4/6/21 - one loose/diarrhea charted at 1:43 PM 4/7/21 - one putty like charted at 5:25 PM 4/8/21 - one formed/normal charted at 3:47 AM. On 4/20/21 at 11:53 AM, CNA B was interviewed via phone call and queried regarding taking care of R902 when they were vomiting, CNA B indicated that Wednesday 4/7 and/or Thursday 4/8/21, sounded about right. CNA B explained, I was cleaning [R902] up, [the resident] was complaining that their stomach was hurting. I reported it to the nurse. The nurse came to get me to ask to clean the resident up and said the bed was wet. I said sure, because the aide who usually takes care of [R902] was on break. I went right in there .[the vomit] was a brownish reddish color. When asked if the resident was sent to the hospital right after she had witnessed the resident feeling sick/vomiting, CNA B stated, No, not that I recall. The next day I was off. CNA B did not remember who the assigned nurse was that she spoke with regarding R902. On 4/20/21 at 12:07 PM, Licensed Practical Nurse (LPN) A was interviewed via phone. When queried regarding the events leading up to R902's transfer to the hospital on 4/8/21, LPN A stated, I was asked to come in Thursday morning shift. [R902] had been vomiting the night before, brown emesis. To make a long story short - I found that [R902] hadn't had a bowel movement since Friday, and was sent out on Thursday 4/8 for an impaction. [R902] had to have a tube down [their] throat and was there for 4 days. LPN A indicated that when she had attempted to talk to staff and administration about R902 not having a bowel movement, they Told me to check the task bar (POC documentation). And I said (to them), I respect that the CNAs documented that [R902] was having BMs, but that wasn't what the nursing assessment was showing. [R902] was in pain and stomach was distended. An aide had told me [R902] had felt sick for days. Multiple nurses told me things were given (to R902 for constipation) but there were no nurses' notes put in regarding any of that. When queried regarding what the off-going nurse had told her in report on the morning of 4/8/21, LPN A stated, They were an agency nurse. She told me that [R902] had vomited three times through the night, that was it. Her note said it was brown, that's all she said. Then I reported to the oncoming nurse, [LPN E], what happened. [LPN E] told me that [R902] told her that [they] hadn't pooped for 3 days and [LPN E indicated] that she gave [R902] prune juice. But that wasn't documented. So, I was the one that sent [R902] out. We got the x-ray that showed an impaction. On 4/20/21 at 1:47 PM, NP C was interviewed via phone and queried regarding assessing R902 on 3/31/21. When queried regarding her assessment of R902 at the time and new orders for constipation-relieving medication, NP C stated, Even though I'm palliative, if I see someone who hasn't had a BM, and see distention, I'm not going to just let it go. I'm going to order something and say give this milk of mag. I was just in to do a routine assessment and I saw that [R902] was distended. I was palpating (R902's abdomen) and listening to bowel sounds. NP C was asked if she had expected the nurse to have given R902 the Milk of Magnesia that was ordered on 3/31 to which she responded, Yes. NP C was asked if it was her intention with the order for the nurse to have given the Milk of Magnesia right away and stated, Yes. I collaborated with the nurse. [R902] said [they] hadn't had a BM in a few days. I wanted to make sure it (Milk of Mag) was given to [R902]. I think [R902] ended up going out to the hospital. On 4/20/21 at 2:00 PM, R902 was observed lying in bed with the head of the bed elevated. On 4/20/21 at 1:56 PM, the Nursing Home Administrator (NHA) was asked who R902's assigned nurses were on 3/31/21. The NHA responded that Registered Nurse (RN) F was the day shift nurse and LPN E had been the night shift nurse assigned to R902. On 4/20/21 at 2:47 PM, attempts were made via phone to interview RN F, however, a message was unable to be left for callback, and no call back was received prior to survey exit. On 4/20/21 at 3:14 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed and asked if they could provide an explanation as to why R902 did not receive the milk of magnesia on 3/31/21 ordered by NP C to help relieve their constipation. The NHA stated, It's not on the MARs that [R902] got it? We believe that [LPN E] gave it. The NHA and DON were then asked if LPN E gave the medication, if it would be documented to which the DON stated, Normally, and the NHA responded, It should be documented if she gave the milk of mag. We need to look at nursing notes. And if you're saying it's not on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . But I know they documented that [R902] had a few BMs before [they] went out .There was a note from a nurse before [R902] went out with the concern that the resident didn't have a bowel movement so we went back and we saw that there were BMs documented .I didn't realize the resident was sick, I know [R902] hadn't been feeling good .I saw a basin in the room with some tissues but did not see [R902] vomiting. The DON was then asked 1) where the nursing assessments of a problem such as constipation are documented in the record and 2) where assessment of the effectiveness of a medication/intervention to help relieve constipation is documented. The DON stated, It would be in a progress note. Or you could do a bowel and bladder assessment or progress note. The DON and NHA were then asked if they would have expected R902's nurse(s) to have made notes/assessments when R902's distention was noted. The NHA stated, The nurse made the note the day [R902] was sent out. No further explanation was provided at this time regarding lack of nursing progress notes/assessments. The DON and NHA were asked about no BM recorded from 3/29/21 to 4/4/21 in R902's record. The DON and NHA stated that staff should have given R902 the ordered milk of magnesia or called the physician. The DON and NHA were then asked if they would have expected follow-up nursing documentation after the resident's new onset constipation noted on 3/31/21 to which the NHA responded, Yes .and the milk of magnesia order does read, after 3 days [the resident] is to get it. When queried if R902 could walk, the DON responded, No. The NHA stated, The resident likes to stay in bed. The DON and NHA were then asked per their facility policy, if interventions are needed to help relieve constipation, should the type of intervention and response to the intervention be documented, to which the DON stated, Yes. When asked if nursing should have documented assessments or progress notes for R902 and their bowel issues, the NHA stated, Yes. It doesn't make sense that there's no assessment from the nurse or doctor .But we only looked back [in R902's] record three days before they went out. During the interview, the DON exited to get her laptop and came back at 3:40 PM. The NHA directed the DON to review R902's chart and stated, There should have been some kind of assessment documented by the nurse. The DON stated, It should've triggered for the nurse if the resident had no BM for three days. And whenever there is an order, the reason the order was written was because [R902] had no BM, I would expect to see an assessment. The DON confirmed the lack of nursing progress notes and assessments from the time of NP C's note on 3/31/21 until 4/8/21. The DON stated, There's nothing in the assessments .It should have been in there .I would've expected nursing assessments or notes after 3/31. The resident went out on 4/8. We should've gone back further in the documentation. The NHA indicated that it looked as though nursing did not assess R902 for bowel concerns after NP C's note due to the lack of documentation in the record. On 4/21/21 at 8:11 AM, LPN E was interviewed and queried regarding interventions or assessments carried out related to R902's constipation leading up to their hospitalization . LPN E was unable to provide any information regarding 3/31/21. LPN E explained that on the day the Senna was ordered for R902, she was told by the resident that they had not had bowel movements. LPN E stated, I didn't feel [R902] as distended that day. I gave [R902] milk of magnesia but [they] wouldn't take it, [and] gave [R902] prune juice. And gave the Senna per the order. LPN E was asked if she documented the refusal of the milk of magnesia, administration of prune juice, or any other assessment or intervention related to relieving R902's constipation to which she responded, No, I didn't. When asked about the milk of magnesia, LPN E stated, [R902] threw up. When asked if any of that was documented in R902's medical record, LPN E stated, No, and indicated that normally she would document nursing assessments and interventions. When queried, LPN E indicated she did not recall ever collaborating with NP C about R902's constipation. On 4/21/21 at 8:21 AM, the DON and NHA were asked if they had any further documentation they wanted to provide for review prior to survey exit. The NHA stated, No, I don't have anything else to give. Just prior to exiting the facility on 4/21/21 at 8:45 AM, the NHA handed this surveyor a handwritten note dated 4/21/21 at 8:37 AM on a piece of lined paper, filled out by the social services coordinator. The NHA indicated that the resident signed the paper to say that they had received something for their constipation. This documentation was not a part of R902's official medical record and was not present in the resident's record during the survey period or before the handwritten note was presented. A review of R902's medical record and Minimum Data Set (MDS) assessment dated that the resident was originally admitted into the facility on [DATE] and most recently readmitted on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that the resident was cognitively intact, incontinent of bowel and bladder, required extensive assistance from staff for bed mobility, dressing, and hygiene bathing, had upper and lower extremity impairments on one side. Ambulation and locomotion were both marked as Did not occur, on the MDS. A review of the facility's policy/procedure titled, Bowel Management Interventions, undated, revealed: 1. Monitor the resident daily for bowel movements. 2. If the resident has a history of constipation, follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse should monitor the bowel records and address residents whose pattern has changed from baseline or who have not had a bowel movement for three days .If interventions needed, document type and response. Notify MD of any discomfort or if no bowel movements after protocol completed.

This citation pertains to intakes 0, 0, and 1. Based on observation, interview, and record review, the facility failed to protect and prevent physical and mental abuse of a vulnerable, cognitively impaired resident (R901 and R902) of seven residents reviewed for abuse, resulting in an immediate jeopardy (IJ) when facility staff grabbed R902 by the arms, dropped them to the floor, aggressively lifted them up and flung the resident back into the wheelchair and continued to abuse R902 by grabbing them on the back of the neck and repetitively pushed the resident's head into the nursing station counter and R901 being grabbed under the arms and forcefully pushed back into their chair, resulting in mental anguish and pain from physical abuse, using the reasonable person concept. This puts the residents at risk for serious injury, harm or death. The Immediate Jeopardy started on 2/2/2020 and was identified on 2/19/2020. The Administrator was notified of the Immediate Jeopardy on 2/19/2020 at 2:01 PM and was asked to submit a plan to remove the immediacy. The IJ was removed on 2/21/20, based on the facility's implementation of the removal plan as verified onsite on 2/21/20. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings Include: R902 On 2/19/2020 at 9:49 AM, the Nursing Home Administrator (NHA) was interviewed about the facilities recorded camera footage of R#902, Licensed Practical Nurse (LPN) A, Certified Nursing Assistant (CNA) B, and CNA C. The camera footage was without sound. An observation of the camera footage recorded on 2/2/2020 at approximately 2:00 AM, revealed the following: R902 sitting in their wheelchair in front of the nurse's station. R902 was seen pointing their finger down the hallway and attempting to get out of their wheelchair. CNA B was observed making gestures with their hand directly in front of the face of R902 and appeared to be speaking to the resident. CNA B pulled R902 back into their wheelchair. The NHA said that by looking at the video you can see that (CNA B) was telling (R902) to shut-up. During the video observation, R902 stood-up and walked away from the wheelchair. LPN A walked over toward R902, grabbed R902 by the arms, turned R902 around, dropped R902 to the floor, then lifted the resident up off the ground and vigorously flung R902 into their wheelchair. At this point, CNA B was observed to walk into the camera screen. CNA B took R902 out of the camera's view. At this time, the NHA switched camera views toward the nurse's station camera. The following was observed: CNA B propelled (via wheelchair) R902 from the hallway to the nurse's station. LPN A was observed sitting at the nurse's station looking at a computer screen. R902 was observed seated at the nurse's station counter and trying to get up from their wheelchair. LPN A stood up and forcefully grabbed R902 by the back of the neck and repetitively pushed R902's head down towards the nurse's station counter. LPN A was observed leaning closely towards R902 and spoke directly into R902's ear as if to scold the resident and then forcefully pushed R902's wheelchair toward the counter. R902 was observed rubbing their head, and covered their mouth while they spoke to LPN A. LPN A walked towards R902, handed them a paper towel, and R902 wiped their forehead (the camera footage was not clear enough to identify what the resident was wiping). R902 continued to attempt to get-up from the wheelchair. LPN A again, forcefully pushed R902 back against the nurse station counter. LPN A then placed tape on R902's forehead. On 2/20/2020 at 9:45 AM, Laundry Room Aide G was interviewed via phone and queried regarding the incident with R902. Laundry Room Aide G said, I work in the laundry room. I was delivering laundry (on the memory unit) and saw (R902) around 11 PM on February first. There was nothing wrong with (R902) at that time . Around 3 AM, I heard (R902) saying, 'Why did you do me like that, why you throw me against the wall, you didn't have to do that to me'. (R902) had tape on (their) forehead. (LPN A) was staring at the computer like a zombie. I asked (CNAs B and C) what happened to (R902). The laundry room aid stated CNAs B and C texted supervisor LPN D, but made no further comment. On 2/21/2020 at 9:38 AM, the Director of Nursing (DON) was interviewed regarding LPN A, CNA B, CNA C and queried if they considered their actions against R901 and R902 as abuse. The DON stated, Yes. On 2/21/2020 at 10:54 AM, the NHA was interviewed and queried if they considered the action of LPN A abusive. NHA stated, 100%. That's why I called the police, reported them (CNA B, CNA C and LPN A) to the board (of nursing and CNA registry), and fired (Laundry room aide G, LPN D). A review of R902's electronic medical record noted the resident was admitted to the facility for respite care (temporary facility placement for caregiver relief outside the home) on 1/31/2020 with the [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDS) noted a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (severe cognitive impairment). The care plan initiated on 1/31/2020 noted R902 required assistance with all activities of daily living and required supportive care and assistance with mobility. A review of the facility's Abuse and Neglect Prohibition Policy dated 11/2019 noted the following: Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion .mental abuse facilitated .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment .Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Person Centered Care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. R901 On 2/19/20 at 7:52 AM, an attempt to interview R901 was made. R901 appeared frail and was sitting calmly in their wheelchair. R901 responded to their name, and when asked if anyone was too rough with them recently at the facility, stated, Yeah. When asked when this was, R901 stated, I'm not sure. When asked if anyone was too rough with them while moving them, R901 stated, Yeah. R901 was unable to explain further details. When asked if they felt scared when it happened, the resident nodded their head and said, Uh huh. When asked if they still felt scared about someone being too rough with them, R901 stated, Yeah, while wringing their hands together. On 2/19/20 at 9:49 AM, the NHA and DON were queried regarding CNA's B and C who were working on the unit with LPN A on 2/2/20. The NHA indicated he had camera footage that happened approximately 5 to 10 minutes prior to LPN A dropping R902 in the hallway. The NHA indicated this occurred at approximately 1:40 AM - 1:50 AM on 2/2/20. The following was observed on the hallway camera footage: CNA C entered the screen along with CNA B. R901 was observed in the hallway in their geri chair (padded reclining chair used for comfort and positioning). R901 was then observed attempting to get up out of their chair. CNA C was observed to grab R901 underneath the arms and quickly and forcibly yanked the resident back into the chair. Shortly after that, LPN E entered the unit and was seen talking with the CNAs. Again, R901 was observed trying to get out of their geri chair and was forcibly yanked back by their underarms into their chair by CNA C. LPN E was observed to be present when R901 was yanked into their chair a second time, but was facing away from R901 and talking with R902. The NHA stated, (LPN E) stated she didn't see anything because she was talking with (R902). On 2/20/20 at 8:47 AM, an attempt to contact CNA B was made via phone. A voicemail message was left for call back, however no call back was received prior to survey exit. On 2/20/20 at 12:16 PM, the DON was interviewed and asked if he considered what CNA B and CNA C did to be abuse towards R901 as well as R902. The DON stated, Yes, pieces of what they did. With (CNA C), it appeared she needed more training on repositioning because she asked if she did something wrong. What prompted us to report them was during the video surveillance, during the part where (LPN A) was picking up (R902) off the floor, you can see (CNA B) observe (LPN A) directly. (CNA C) did acknowledge observing (LPN A) being abusive at some point as well. When queried regarding LPN E being present when CNA C grabbed R901, the DON stated, What I recall is she denied seeing anything unusual or mishandling of residents while on the unit. On 2/20/20 at 1:13 PM, LPN E was interviewed and queried if she witnessed CNA C mishandle R901 on 2/2/20. LPN E stated, No, I did not see anything. I was talking to the residents while they were in a circle. When asked if she witnessed any mishandling of any residents by any staff while she was on the unit on 2/2/20, LPN E stated, No. On 2/20/20 at 1:38 PM, CNA C was interviewed via phone and queried regarding their handling of R901 on 2/2/20. CNA C stated, They (administration) asked me about transferring a resident (R901). (The resident) was on the edge of their geri chair and I was told if we are short staffed we need to do everything we can to stop them from hitting the floor. I was told to reach under their arms and grab under their pants and pull them back. I asked, 'Did I do it wrong? Did I not do what I was supposed to do?' And the only reason I didn't have my gait belt on was because it was soiled. He (the DON) told me I was fine on that, it was a 'gray area.' CNA C was then asked if the way she handled R901 was how she was trained to reposition residents to which she responded, That's how I was taught to do it, there was no one there to help me and I didn't have the gait belt. When asked if she felt like she could have repositioned R901 in a more gentle manner, CNA C stated, I didn't feel like I was rough. (R901) was holding onto the chair and I didn't know it. Didn't seem like I hurt (the resident). They told me with the video with no sound it appeared a little rough. I didn't want (R901) to fall, it was not my intention to hurt them. On 2/21/20 at 9:38 AM, the DON was queried further regarding the way CNA C handled R901 on 2/2/20. The DON was asked if he recalled mentioning to CNA C that the way she repositioned R901 was a gray area, or that she did the right thing to keep the resident from falling. The DON replied, I recall educating her on that. Maybe there are situations where you might grab someone to protect them quickly, but it was not the case in that situation. I meant more so like supporting them from falling or protecting them as they fall. Not yanking them back into the chair. On 2/21/20 at 10:54 AM, the NHA was interviewed and asked if what CNA B and CNA C did on 2/2/20 was abusive behavior. The NHA stated, 100%, yes. That is why they were reported and terminated. A review of R901's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was severely cognitively impaired and required extensive assistance from staff for bed mobility, transfers and activities of daily living, and total assistance from staff for locomotion (via wheelchair). A review of the facility's Abuse and Neglect Prohibition Policy dated 11/2019 noted the following: Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion .mental abuse facilitated .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment .Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Person Centered Care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. Removal plan Element 1: Resident #902 admitted on Friday January 31, 2020 at 3:38 PM and left on Monday, February 3rd, 2020 11.25 am. R902 is diagnosed with [REDACTED]. Resident does not reside at the facility. Resident # 901 remains at the facility and was admitted to facility on January 7th, 2020. Resident skin assessment was completed on February 3rd with no noted injury. Resident was assessed by psych on February 4th, 2020 and no ill effect was noted denies any issues and feels safe also resident #901 was followed by social services on February 4th and no ill effect noted. Family of residents #901 and #902 were informed of the incident and police was called State and Medical Director were informed. By the time the facility discovered what did happened, Resident #902 was already discharged . A call was initiated to PACE at that time and call was made to the family to get to hospital for an exam if they felt they need to. All perpetrators were suspended and ended to be terminated from the facility. LPN nurse was suspended on 02.02.2020, terminated on 02.07.2020 and apprehended by the police on 02.07.2020. His license was reported on 02.05.2020 to the Board of Nursing. The two CNAS involved, were suspended on 02.03.2020, terminated on 02.07.2020 and reported to Prometric on 02.06.2020. Element 2: Residents that reside at the facility have the potential to be affected. Residents skin was assessed started on 02.03.2020, BIMS taken were started on 02.03.2020, interviewed with BIMS of 8 and above and seen by psych started on 02.03.2020. The outcome of the audits shows no issues of abuse. This was an isolated incident. Ad-hoc was conduct on February 5th with the medical director. All residents in the facility were physically assessed started on 02.03.2020. 68 residents were with intact cognitions (BIMS 8 or more) in the facility and were interviewed for concerns started on 02.03.2020. Mentation of residents that had possible interaction with the Nurse in question were evaluated and BIMS scores were obtained and updated. Interview of all residents at the facility was initiated started on 02.03.2020. For the incident, the footage taken were from two different cameras, yet the facility will be committed and will conduct searches started on 02.03.2020. Weekly random search on camera footage of the last 7 days to ensure that no abuse was happening started on 02.20.2020 Element 3: The Abuse policy was reviewed by the IDT (interdisciplinary team) and deemed appropriate on 02.03.2020 Transferring protocol was reviewed and deemed appropriate 02.03.2020. Facility staff were re-educated on Abuse policy and procedure, including reporting of Abuse allegations, or suspected abuse, initiated 02.03.2020. Same for the transferring protocols. Training on Dementia / Cognitive impaired residents is done upon hire and yearly. Training on dementia/cognitive is initiated again on 02.20.2020.

This citation pertains to intakes 0, 0, and 1. Based on observation, interview, and record review, the facility failed to ensure an environment free from physical restraints for one sampled resident (R902) of seven reviewed, resulting in a cognitively impaired resident being repeatedly and intentionally positioned at the nurse's station so their movement was impeded for staff convenience, for approximately four hours. This resulted in resident feelings of increased agitation, anxiety, panic, and imprisonment utilizing the reasonable person concept. Findings include: On 2/19/20 at 10:03 AM, the Nursing Home Administrator (NHA) was asked to play camera footage of R902 at the nurse's station with Licensed Practical Nurse (LPN) A recorded on 2/2/20. The NHA indicated it was just after 2:00 AM on 2/2/20 and the following was observed on the recorded video: Certified Nursing Assistant (CNA) B pushed R902 up to the nurse's station counter and locked the wheelchair in place. LPN A then pushed R902 up further underneath the nurse's station counter. LPN A was then seen sitting towards the back wall of the nurse's station on the right side of the screen. R902 was observed facing toward the nurse's station desk (in the middle/left side of the screen), pointed away from the back wall and counter. R902 was positioned so their wheelchair was underneath the counter at the nurse's station. R902 was seen attempting to get up, however there was a rolling chair positioned behind their wheelchair. The chair behind R902, along with the counter in front of the resident impeded the movement of R902 so they were not able to stand and/or easily move their wheelchair. R902 was then observed looking over their left shoulder, trying to talk to LPN A behind them. R902 was observed to continue to try to get up. LPN A then stood up, quickly moved behind R902 and grabbed the resident by the back of the neck. LPN A then repeatedly pushed R902's head down towards the counter. The resident was observed to be flailing and attempting to move in their wheelchair. LPN A continued to lean down and speak closely into R902's ear, then re-positioned the rolling chair behind R902's wheelchair and ensured the resident's wheelchair was locked in place under the nurse's station counter so R902 could not move their wheelchair or get up. Shortly thereafter, R902 again attempted to move in their wheelchair. LPN A forcibly pushed the resident in their wheelchair underneath the nurse's station counter. R902 again was seen looking over their left shoulder, attempting to talk to LPN A. R902 again attempted to move away from the counter but was unable to move in their wheelchair. The NHA was queried at this time and confirmed that the resident was attempting to move and could not. The NHA stated, This happens over the course of about an hour. (R902) gets up, then again, then again . Approximately 20-30 minutes later on the video, LPN A was again observed pushing R902's wheelchair up against the nurse's station counter. R902 was attempting to move backward in their wheelchair and was trying to stand. LPN A grabbed R902's arm, pushed them down into the wheelchair, and moved the wheelchair up to the counter of the nurse's station and locked it in place. Approximately five minutes after that, LPN A was observed to wave his finger at R902 while they attempted to get up from their wheelchair. LPN A again pushed the resident down into their wheelchair and locked it in place at the nurse's station. LPN A was observed doing this action to R902 again a few minutes later. R902 was then observed again trying to stand. LPN A again pushed the wheelchair up against the nurse's station counter. LPN A leaned down and was observed talking closely into the resident's ear. LPN A adjusted R902's wheelchair twice, ensured it was sitting as far underneath the nurse's station counter as it would go, and ensured it was locked in place. Approximately six minutes later, LPN A was observed doing the same action again to R902, and this continued until approximately 3:00 AM. At approximately 3:00 AM and shortly thereafter, both CNA B and CNA C were observed up at the nurse's station where R902's wheelchair was still locked in place. R902 appeared to sit and not attempt to get up from their wheelchair as long as staff was sitting and speaking calmly with them. Just before 4:00 AM, LPN D was observed to be sitting with the resident and talking with them, and just before 4:30 AM, LPN D was observed to be changing a bandage on the resident's forehead before leaving the unit. At approximately 5:00 AM, LPN A was observed putting their medication cart behind R902, while the resident was still in their locked wheelchair that was positioned up against the nurse's station counter. The medication cart remained behind the resident, impeding their movement for 20 to 30 minutes. The NHA stated, You are going to see here they take the cart away, then staff puts a chair behind (R902's) wheelchair and someone will sit in the chair behind (R902). The video then showed CNA C sitting in a rolling chair back-to-back with R902's wheelchair while the resident was still positioned at the counter. CNA C sat and scrolled on a cell phone while R902 attempted to move in their wheelchair. R902 was finally able to move freely in their wheelchair away from the nurse's station at approximately 6:45 AM. On 2/20/20 at 8:47 AM, an attempt to interview CNA B was made via phone call. CNA B was left a voicemail for call back, but no call back was received prior to survey exit. On 2/20/20 at 9:25 AM, LPN D was interviewed via phone regarding the morning of 2/2/20 and R902. When queried regarding seeing R902 at the nurse's station on 2/2/20, LPN D stated, The only time I saw (R902) was when I went to change the bandage. They were sitting at the desk with the two aides (CNA B and CNA C). Nothing was said to me. I saw the tape and the aides told me the resident fell , and (LPN A) also told me (R902) fell . When queried regarding the positioning of the resident up at the nurse's station, LPN D stated, I want to say (R902) was positioned between the two aides, one was on the side and I think one was at the (resident's) back. When queried regarding the restraint policy and procedure at the facility, LPN D stated, To my knowledge, they don't have any restraints. They are not to restrain anyone. On 2/20/20 at 10:23 AM, an attempt to contact LPN A via phone was made, however the number dialed indicated the person could not take calls at this time. On 2/20/2020 at 12:16 PM, the Director of Nursing (DON) was interviewed regarding the night of 2/1/20 into the morning of 2/2/20, and the incident involving LPN A and R902. When queried regarding restraints at the facility, the DON stated, We only have one resident assessed for restraints in the facility, and they have side rails. The DON was then asked if the following actions observed on the video footage, would be considered a restraint: When R902 was attempting to get up and was pushed back down by LPN A, when R902 was locked in their wheelchair at the nurse's station counter, when a medication cart was placed behind R902's wheelchair, and when a chair was placed behind R902's wheelchair with or without staff sitting in it. The DON stated, Yes, and indicated he considered all those actions to be restraints. When asked if R902 was assessed for use of restraints, the DON stated, I would have to verify in the chart, but I do not believe so. The DON was then queried when abuse training occurs and stated, Upon hire, annually, and as needed. When queried regarding when training on restraints and what constitutes a restraint occurs, the DON stated, I believe upon hire and I believe that we cover that in our annual abuse training, and involuntary seclusion. Review of R902's medical record at this time did not reveal progress notes, care plan, consents, physician orders, assessments, or medical indication warranting use of any restraints. On 2/20/20 at 1:38 PM, CNA C was interviewed via phone regarding working the night of 2/1/20 into 2/2/20. When queried regarding working that night with R902 and LPN A, CNA C stated, I worked a double that Saturday, we had 41 residents and it was just the two of us. We also had two residents that were supposed to be 1:1 so we had six residents up at the nurse's station. Between 1 AM and 3 AM me and (CNA B) decided we needed to lay some people down, do rounds, change some people. (R902) was one of the ones left up. I left the nurse's station and (R902) was still up there. CNA C was then asked to explain why they were sitting in a chair behind R902's wheelchair as observed on the camera footage. CNA C stated, (R902) kept getting up. (The resident) can walk, but they're a fall risk. But (R902) would not stop getting up. So (LPN A) told us we needed to keep (R902) there because the resident would keep getting up. That's something we've always done when we don't have the help we need. We sit behind them, so they don't get up and fall. When asked if they have sat back to back in a chair with other residents as they did with R902, CNA C stated, I haven't done that with other residents, but other staff do that. Or nurses tell the aides to push them under the desk and move them so they can't get up and hurt themselves. When asked if they received training on use of restraints, CNA C stated, No. Our in-services are they give us a piece of paper and say, Here, sign this.' When queried if a medication cart was placed behind R902, CNA C stated, Yes, (LPN A) did that. He told us no one can watch (R902) so he had to put it there. (R902) kept saying to (LPN A), 'Why would you do me like this? Why would you do this?' On 2/21/20 at 9:38 AM, the DON was interviewed and queried regarding the training and expectation of staff to keep residents from falling or to try to keep them safe. The DON responded, If they're in a wheelchair trying to get up, recognize the pattern. Offer re-direction by toileting, something to eat, or 1:1 conversation. For those who can ambulate, walk them down the hall, walk them back to the chair. When asked if R902 could ambulate, the DON indicated they could and stated, (Staff) could have maybe walked with (R902), offered toileting. The DON was then asked if staff was ever told to hold a resident at the nurse's station, and/or keep something behind the resident to keep them from falling or keep them in one place? The DON indicated this was not the expected practice, and stated, I would see that as a moment to provide education on the other ways to keep residents safe. When queried if the facility provides annual education on that, and if CNA B and CNA C received that education, the DON stated, Yes (we provide education). (CNA B) was right around the year mark when the incident happened but upon hire she did receive that training. When queried regarding staff stating they were told to modify their care when they are short staffed, i.e. to put something behind a chair to keep residents in place in an attempt to keep them safe, the DON stated, That would be news to me. That would certainly warrant 1:1 education, extensively. They were not short staffed in that particular situation. The situation did not demonstrate any interventions that were attempted to try and calm the situation down. On 2/21/20 at 10:54 AM, an interview was conducted with the NHA. The NHA queried regarding the camera footage involving R902 on 2/2/20, and was asked if per facility policy, the actions of LPN A and CNAs B and C would be considered a restraint. The NHA replied, Yes, 100%. Even just locking (R902's) wheelchair under the nurse's station would be considered a restraint. A review of R902's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] and discharged on [DATE], and was in the facility for respite care (temporary facility placement for caregiver relief outside the home). R902 had medical [DIAGNOSES REDACTED]. Further review revealed the resident required limited assistance from staff for transfers, mobility, and locomotion, and was moderately cognitively impaired. Section P - Restraints and Alarms indicated no use of any restraints or alarms for R902. A review of the facility's policy titled, Corporal Punishment, Bed Rails, and Restraints, dated April 2019, revealed, Each resident has the personal right to be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature .Restraints are typically defined as anything that may prevent a resident from free movement .Procedure: 1. Corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature are never used in caring for a resident. 2. A physical restraint may only be used if authorized in writing by the attending physician for a specified and limited time as necessitated by an emergency to protect the resident from injury to self or others. A qualified individual will document the circumstances requiring this action and communicate the same to the attending physician and responsible party of the resident immediately. 3. Restraints will only be used as a last resort and with the consent of the physician, resident or responsible party .

This citation pertains to intake MI 443. Based on observation, interview, and record review, the facility failed to prevent R700 from putting a pillow over the face of R704 on 12/6/19 at 10:45 PM. R700 has a Brief Interview for Mental Status (BIMS) of 9 and a known history of aggressive behaviors including attempting to suffocate another resident, resulting in an Immediate Jeopardy, and the likelihood of serious injury, harm, or death. In addition, the facility failed to prevent unwanted physical contact and conduct a thorough investigation regarding an allegation of abuse for one additional sampled resident (R#705) reviewed for abuse, resulting in R#700 punching R#705's legs, and verbalization of the resident feeling frightened. The Immediate Jeopardy (IJ) started on 12/6/19 and was identified on 12/16/19. The Administrator was notified of the Immediate Jeopardy on 12/16/19 at 3:35 PM and was asked to submit a plan to remove the immediacy. The IJ was removed on 12/17/19, based on the facility's implementation of the removal plan as verified onsite. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings Include: On 12/16/19 at 8:10 AM, a review of the complaint indicated the following: (R700) is a resident of (Facility). (R700) has been diagnosed with [REDACTED]. The Director of Nursing at (the Facility) has refused to accept patient back to the facility, even after they have not arranged an alternative discharge plan. On 12/16/19 at 8:24 AM, Social Worker C was contacted regarding the complaint about(R700). Social Worker C stated, (R700) was actually my case. (R700) was sent to the hospital for behavioral issues. The Director of Nursing (DON) at the facility initially refused to accept (R700) back into the facility. (R700) was admitted to the hospital for a urinary tract infection. (R700) was on a medical unit and was seen by psychiatry. (R700) was discharged on [DATE] and then accepted back to the nursing home. On 12/16/19 at 8:45 AM, R700 was observed in their room by themselves, making their bed and was pleasantly confused. R700's electronic medical record was reviewed and noted the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDS) noted a Brief Interview for Mental Status (BIMS) score of 9 out of 15. The care plan initiated on 7/17/19 noted the following: Focus: I have the potential to be physically aggressive. Goal: I will not harm myself or others .I require approaches that maximize involvement in daily decision making and activity . I have a behavior problem at times, I may become combative with staff after [MEDICAL CONDITION] activity. I may not recognize personal boundaries of my peers. I may touch my peers belongings without their permission. I like to make my own bed and decline offers of assistance. Additional record review revealed that R700 was transferred from the facility to the hospital on [DATE] with the primary [DIAGNOSES REDACTED]. A review of the hospital's history and physical note by Doctor D noted the following: (R700) presents to the ER (Emergency Department) from (their) nursing home facility where (R700) resides. (R700) is here for evaluation of aggressive behavior .UA (Urinary Analysis) was positive .(R700) was started on IV (Intravenous) antibiotics. Psych was consulted. A review of the hospital's consult by Nurse Practitioner [NAME] Behavioral Health-Psychiatry on 12/9/19 noted the following: (R700) was admitted to the observation unit d/t (due to) agitated behavior at the nursing home. (They) were found to have a UTI which according to the medical record (R700) had before and exhibited similar features .Normal Strength .Coherent .No Hallucinations, No Delusions, No Preoccupation with violence .Impaired Recent Memory, Normal Remote Memory . On 12/16/19 at 11:45 AM, the Director of Nursing (DON) was asked why R700 was transferred to the hospital on [DATE]. The DON said, Well, to be transparent, I'm sure you know that we received an IJ back in (MONTH) regarding (R700). I did not feel that it was deserving. The IJ said the resident put a pillow over another resident's face .But, (R700) was only making the bed with the resident in the bed . (R700) have a problem with [MEDICAL CONDITION]. (R700's) [MEDICAL CONDITION] are different. (R700) walks around and have behavioral issues with [MEDICAL CONDITION] activities. The DON was asked why they refused to accept the resident back while in the ER but accepted (R700) back on 12/10. The DON said, I did not refuse (R700). I don't know who did. But we did accepted (R700) on the 10th (12/10/19). Actually, the DON has the right to refuse or accept any resident. The DON was asked why there was not a note in the electronic medical record regarding R700's [MEDICAL CONDITION] activity when they were sent to the hospital on [DATE]. The DON said, There is a progress note in there. While reviewing R700's progress notes with the DON, two progressed notes Strike Out out and noted as an Unusual Occurrence Note. Incorrect Documentation (the two notes had a line drawn through, meaning incorrect documentation). The progress note was dated 12/6/19 at 10:37 PM and written by Nurse A and noted the following: Resident (R700) was observed in (R704 room) standing over (R704) and covering (R704) from head to toe in sheets and bedding. Resident (R700) was immediately removed from the room to protect resident (R704). Upon the removal of the resident from the situation, the Certified Nurse Assistance (CNA F) reported to writer (Nurse A) that resident from (R700) had placed a pillow over residents face ((R704) that the CNA (CNA F) had to remove. Resident (R700) would not answer writers (Nurse A) inquiries of events and reasoning for the events. Instead the resident (R700) became restless and difficult to redirect. Resident (R700) was placed on one to one care with staff CNA (CNA F) until resident petitioned out. Resident (R700) was petitioned out to (hospital). Private transport ambulance en route. All parties aware. A review of the second progress note with a Strike Out out and noted as an (Change of Condition Note. Incorrect Documentation (the two notes had a line drawn through, meaning incorrect documentation). The progress note was dated 12/6/19 at 10:52 PM and written by Nurse A and noted the following: Resident was observed in room standing over (R704) and covering (R704) from head to toe in sheets and bedding. Resident (R700) was immediately removed from the room to protect resident in (room of R704). Upon the removal of the resident (R700) from the situation, the CNA (CNA F) reported to writer (Nurse A) that resident from (R700) had placed a pillow over residents face (R704), that the CNA (CNA F) had to remove. Resident (R700) would not answer writers inquiries of events and reasoning for the events. Instead the resident (R700) became restless and difficult to redirect. Resident was placed on one to one care with staff CNA (CNA F) until resident (R700) petitioned out. Resident (R700) was petitioned out to (hospital). Private transport ambulance en route. All parties aware. Both progress notes were noted as Strike Out on 12/13/19 at 4:40 PM. A review of R700's progress note, effective date 12/13/19 at 4:40 PM, entered as a Late Entry for date 12/6/19 noted the following: Resident (R700) was observed holding a pillow over (R704) face .Resident (R700) was immediately removed from the room to protect resident (R704). Upon the removal of the resident from the situation, resident (R700) became difficult to redirect. Resident (R700) would not answer writers (Nurse A) inquiries of events and reasoning for the events. Instead the resident (R700) became restless and difficult to redirect. Resident (R700) was placed on 1 to 1 care with staff CNA (CNA F) until resident (R700) petitioned out. Resident (R700) was petitioned out to (hospital). Private transport ambulance en route. All parties aware. Note, the incident regarding R700 placing the pillow on the face of R704 was omitted from this progress note. On 12/16/19 at 11:45 AM, the DON was queried about the two Strike Out progress notes. The DON said, We are working on training some nurses how to properly document. Sometimes they document too much information. I had to learn that because I come from a psych background. The DON was asked if R700 had placed a pillow over another resident's face. The DON said No. That's why we called (Nurse A) to change the note. Sometimes the nurses get too excited and document the wrong information. That's why (Nurse A) was called in to change the progress note. The DON was asked if they had concern about the content of the two progress notes. The DON said, This is not a concern. The nurse documented too much information. That did not happen. On 12/16/19 at 12:29 PM, the DON called Nurse A on their cell phone and placed the call on speaker. Nurse A was asked if they felt comfortable with the DON being on the call and Nurse A answered, Yes. Nurse A was queried about R700 going into R704's room on 12/6/19, covering R704 with the sheets and placing a pillow on their face. Nurse A said, The resident was making the bed while the resident was in bed. (R700) covered the resident (R704) with the sheets. After we removed (R700) from the room, the CNA (CNA F) told me that (R700) also placed a pillow over the resident's (R704's) face. I was told to strike my note out by the Assistant DON. The Assistant DON said that (they) investigated the situation and found out that (R700's) past job was making beds and that (they) likes making beds. I was only doing my job, I did what my boss told me to do. The DON left the conference room and Nurse A was queried again and said, The note that was Strike Out is what actually happened. (R700) pulled the sheets over the resident's (R704's) head and the CNA (CNA F) told me that (R700) also placed a pillow over the resident's (R704's) face. I did what I was told to do by the Assistant DON. They made me change the note. On 12/16/19 at 12:40 PM, the Assistant DON was interviewed with the DON present. The Assistant DON was queried about the investigation of R700 and the progress notes that Nurse A had Strike Out. The Assistant DON said, I performed an investigation and the Nurse (Nurse A) and the CNA (CNA F) said (R700) did not place a pillow over the resident face. (R700) was making the bed with (R704) in the bed. Sometimes staff gets worked up and document certain things, later they realize it did not happen. They said the incident did not happen. I had the Nurse (Nurse A) come in and change the notes. The DON and Assistant DON were informed that Nurse A said that the first notes were correct and that the Assistant DON told Nurse A to change it. The Assistant DON said, No it was not correct. She made a mistake. The DON said, (Assistant DON) performed a thorough investigation that weekend and it concluded that the resident (R700) did not put the pillow over the Resident's (R704's) face. (R700) were only making the bed. That's why we did not report it to the State. The DON was asked if they normally reported resident on resident incidents. The DON did not provide an answer. On 12/16/19 at 1:32 PM, CNA F was called using the facility's phone at the nurse station. CNA F was interviewed and queried about the incident on 12/6/19 with R700. CNA F said, The room mate (R705) put on the call light. I went to the room and found (R700) pulling the sheet over the Resident's (R704's) head and then put the pillow over (R704's) face. I told (R700) to stop and took (R700) out of the room and closed the residents' door. (R700) had a strange look on (their) face. (R700) is normally nice. (R700) did this before to another resident back during the summer. (R700) put a pillow over (another resident's) face. That's why (700's) in a room alone. R704's electronic medical record was reviewed and noted the resident originally admitted to the facility on [DATE] and recently readmitted on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] with a Brief Interview for Mental Status (BIMS) score of 00, severely impaired cognition. R704 is totally dependent and requires extensive one person assist with all Activities of Daily Living. R704 is dependent upon staff for management of peg tube and feedings. The care plan noted the following: I have a communication problem r/t (related to) dx (diagnosis) cognitive communication deficit and decreased hearing-dated 3/8/19 .I have impaired cognitive function/dementia or impaired thought processes r/t impaired decision making. I have a dx of late onset Alzheimer's dementia .I have long and short-term memory deficits. I have difficulty making my needs known-revision date 7/23/19. Protect me from injury and avoid sudden movements, jarring, or bumps as much as possible-dated 9/26/17 .Anticipate and meet my needs since I do not use a call light-dated 4/5/19. A review of the progress note for R704's, entered as a late entry generated on 12/7/19 at 5:37 AM for effective date of 12/6/19 at 10:52 PM and written by Nurse A noted the following: Late Entry: Note Text: at approx 2245 (approximately 10:45 PM), staff (CNA F) responded to the call light in (R704 room). Staff (CNA F) called for the writer (Nurse A). Writer responded. Writer observed resident (R700) standing over resident (R704), covering (R704) up with the sheet, including over (R704) face. Resident (R704) was immediately protected from resident from (R700) as (R700) was hastily redirected and guided out of the room by writer (Nurse A) and CNA (CNA F). Resident (R704) assessed, no apparent injury. CNA (CNA F) then reported that resident from (R700) had placed a pillow over residents face (R704) in , and that (CNA F) had removed it (pillow). Resident (R704) in unable to relay event to writer d/t DX of cognitive communication deficit, unspecified dementia with behavioral disturbances and other speech disturbances. resident remains in bed resting. This not was not a Strike Out as noted in R700's progress note. A review of the progress noted dated 12/9/19 at 2:36 PM, by Social Worker G noted the following: Writer attempted to visit (R704), whom was sleeping comfortably .displayed no s/s (signs and symptoms) of distress. (R704) (family member) was present and she also indicated that (R704) appeared comfortable while sleeping. No change in psychosocial disposition. A review of R700's Incident Report dated 12/6/19 with time of incident 10:45 PM noted the following: Resident (R700) observed standing over resident (704) bed. Covering (R704) up with sheets, trying to make the bed with resident (R704) in it. Resident (R700) was immediately removed from. No apparent injury noted .Vital signs not documented on Incident Report, pain scale not documented on Incident Report, Neuro-check not documented on Incident Report. Report prepared by Nurse A, Director of Nursing signed report on 12/11/19, Administrator signed report on 12/16/19. A review of R704's Incident Report dated 12/6/19 with time of incident 10:45 PM noted the following: Resident observed lying in bed while resident from room (R700), covered (R704) up with sheets, trying to make the bed with (R704) in it. Resident (R700) immediately removed from room to protect resident (R704) No apparent injury noted .Vital signs not documented on Incident Report, pain scale not documented on Incident Report, Neuro-check not documented on Incident Report. Report prepared by Nurse A, Director of Nursing signed report on 12/11/19, Administrator signed report on 12/16/19. Resident #705 On 12/17/19 at 8:58 AM, R#705 was interviewed in their room while they were sitting up in bed. When queried regarding another resident being in their room recently, R#705 stated, There was a (resident) trying to mess with my bed and that bed (pointed to roommate, R#704). The (resident) hit me on my legs. (They) punched my legs. R#705 described the resident in question as R#700 and continued, (They) were throwing (R#704's) clothes on the floor. I don't know what (they) were doing, it was bad, whatever it was. I was scared! (R#700) came through that door right there. I looked up, (they) woke me up. I thought they took (R#700) to jail because the police came here. A review of R#705's progress notes revealed the following: Created By: (Nurse A), Created Date: 12/7/2019 05:00 (5:00 AM), at approx 0200 (approximately 2:00 AM), resident voiced a c/o (complaint of) resident (#700), going into room around 22:40 (10:40 PM) on 12/6/19 and punching (them) on (their) legs. resident states that (R#700) actions happened prior to (R#705) putting the call light on to alert staff of resident being in room. writer assessed resident. no apparent injury. all parties notified. Created By: (Assistant Director of Nursing (ADON)), Created Date: 12/7/2019 14:19 (2:19 PM), spoke with resident about the occurrence last night that (they) reported (another resident) in (their) room. (R#705) stated (R#700) was pulling the blankets off room mates bed and remaking the bed which (they) found odd .stated (R#700) pulled off all the blankets and put them on the floor and then proceeded to remake the bed .when asked if (their) room was dark (R#705) stated no that is how (they) could see what (R#700) was doing. when asked if (they) thought that (R#700) could have been trying to pull (their) blankets off as well, (R#705) stated maybe that's why I felt (R#700) sort of grabbing by my leg. resident states that (they) feel safe . On 12/17/19 at 11:39 AM, Nurse A was interviewed via phone regarding her progress note and the interaction between R#700 and R#705. Nurse A explained, After (R#700) was out of the room, (R#705) had put on their call light maybe a few hours later and reported that (R#700) was in their (R#705's) room hitting their legs before (R#700) went over to the other bed to R#704). I didn't see anything when I did a skin assessment. I filled out an unusual occurrence report. Nothing was reported back to me after I did it. No one had asked me about the report or asked me about what happened, or followed up about it even though I had reported it. If someone followed up on it they didn't say anything to me. The way the event went was (R#700) was lead to their room for the evening and I went to finish my medication pass. Then the call light goes on for (R#705's) room. An aide went in and yelled down the hallway for help saying that (R#700) was in the room. When I got down there (R#700) was already at (R#704's) bed. So that situation was taken care of. A couple hours later (R#705) put on their call light voicing concern that (R#700) had been in there punching on their legs and no one came to tell them where (R#700) went. Those were (R#705's) words, not mine. So I didn't want to dismiss what they said, I had to do something. I was wondering why (R#705) didn't say something when we were in there the first time. (R#705) stated they were more worried about their roommate (R#704) first, but told me after they thought about what happened they became scared. I had to ensure (R#705) that (R#700) was no longer in the building at the time. I came to work the next night and (R#705) was still stating that they were concerned. A review of R#705's incident report filled out by Nurse A and dated 12/7/19 at 2:00 AM revealed the following: Resident states that the (resident) that was in (their) room earlier that night, (R#700), had punched (them) in the legs when (they) were in (R#705's) room. Writer assessed resident. No apparent injury. Resident does not know why (they) waited to tell staff. An addendum was added on 12/7/19 with unidentifiable initials that stated, Upon interview, resident clarified (R#700) was grabbing at blankets not punching. On 12/17/19 at 11:56 AM, the ADON was interviewed regarding R#705's allegation of R#700 punching their legs. The ADON stated, This happened on Friday, I came in on Saturday, everything was kind of all together with the incidents with (R#700). I went in and talked to (R#705) about (R#700) coming in the room. I asked what happened. (R#705) told me (R#700) walked by their bed and bumped their feet, and then was messing with the roommate's bed. (R#705) asked me if (R#700) was still here, but they were more focused on (R#700) grabbing the blankets and the roommate. When queried if she spoke with Nurse A, who filled out the incident report regarding R#700 and R#705, the ADON stated, I didn't talk to the nurse, she had gone home from working midnights. The ADON indicated there was no further investigation completed involving R#700 and R#705, and the investigation consisted mostly of the incident between R#700 and the roommate, R#704. The ADON stated, I had the social worker check on (R#705). They had no further complaints. I don't know why people document what they do, it's like a knee-jerk response. On 12/17/19 at 2:10 PM, the Director of Nursing (DON) was queried regarding R#705's allegation of R#700 punching their legs. The DON stated, I was not aware of this until the review of the incident report on around 12/11/19. I was aware that the resident was interviewed and gave some statements but I did not know of the incident until I read the report. I do recall when (ADON) came to work on the investigation from the occurrence on 12/6/19 involving (R#700 and R#704), (R#705) made some statement about covers being pulled or their legs being pulled. When queried about follow-up on R#705's statements, and when made aware of R#705's statements during interview at 8:58 AM, the DON stated, After reading the incident report I would've expected some follow-up investigation. I would expect someone to have followed up with (Nurse A) about the statements. A review of R#705's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed a Brief Interview for Mental Status (BIMS) score of 4/15 indicating an impaired cognition, and need for extensive assistance from staff for transfers, bed mobility, hygiene, and dressing. A review of the facility's policy titled, Abuse and Neglect Prohibition, reviewed and/or revised 11/2019 revealed, Physical abuse includes hitting, slapping, pinching, and kicking. 1. The facility Administrator, or designee, will oversee the investigation of an alleged abuse/neglect or misappropriation of resident property in accordance with state law .5. The facility will investigate all patterns, trends or incidents that suggest the possible presence of abuse .6. The facility Administrator, or designee will conduct interviews with like residents to assess for patterns of abuse or to collect witness statements .Each resident has the right to be free from abuse, mistreatment, neglect . C. Prevention . 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring . 4. Staff is to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect, or misappropriation of resident property, and intervene as appropriate. 5. Residents identified by staff as being self-injurious or exhibiting abusive behavior, which require professional services not provided in the facility will be reviewed by the physician as soon as possible and treatment plans modified as appropriate . D. Identification 1. The facility will monitor residents for changes in behavior, bruises/injuries of unknown origin . 4. When known, the facility will accommodate the needs of residents . who have been involved in incidents (recent or past) of abuse to minimize risk . E. Investigation . The facility Administrator, or designee, will oversee the investigation of an alleged abuse/neglect . in accordance with state law . 5. The facility will investigate all patters, trends or incidents that suggest the possible presence of abuse . 6. the facility Administrator, or designee will assess the resident's mood state to determine is new or additional interventions are needed to ensure the residents' psychosocial well-being. 8. The Social Worker or designee will follow up with the resident to ensure that the resident is satisfied with the investigation outcome . F. Protection: 1. The facility will protect residents from hard during the investigation . 3. The Social Worker or designee will assess the resident to ensure they feel safe in the facility . [NAME] Reporting and Response: 1. The staff will report all allegations of abuse, neglect . to the Administrator immediately . 3. The Administrator or designee is responsible for reporting to the State Agency all alleged violations involving abuse, neglect . Immediately but no later than 2 hours after the allegation is made if the allegation involves abuse . The facility's removal plan: Element 1: Resident #700 is alleged to have attempted suffocation of Resident #704. Resident #700 was noted with an acute change of condition on 12/6/19 and was observed by roommate of Resident #704 and by CNA and LPN, removing linens from bed and remaking the bed while occupied with Resident #704. Resident #700 was immediately redirected and placed under 1:1 supervision due to change of condition, and LPN immediately assessed resident #704, who was observed with no distress, abnormalities, or adverse outcomes. Resident #700 was petitioned to the hospital with use of State of MI form PCM 201, for psychiatric and medical evaluation. Resident # 704 and their roommate were visited by Social Services Coordinator for Psychosocial eval with no adverse effect noted with relation to the bed being made by Res. #700 while occupied by Res. #704. Further investigation led to updating of Care planning upon return of Res. #700 from the hospital, due to long history of tending to tidying, bedmaking, sweeping, as res. Worked midnight shift in janitorial field many years, and often would perform repetitive housekeeping/bedmaking tasks prior to admission to SNF. Resident #700 was evaluated by Attending MD within 24 hours of readmission. Resident #700 & 704 were also assessed by Psychiatry NP and no abnormalities were noted in relation to Res. #704's bed being made while occupied. Element 2: Residents that reside at the facility have the potential to be affected. Residents that reside at the facility were reviewed by IDT on 12/16/19, and no significant behavioral abnormalities/changes were noted. Social Services reviewed psychosocial assessments protocol with Psychiatry NP on 12/16/19. Care plans of Resident's #700 and 704 were reviewed by Social Services and Nursing on 12/16/19 and deemed individualized and appropriate. Phone Call placed to Ombudsman on 12/16, for assistance in potential alternative placement of resident #700. Element 3: The Abuse policy was reviewed by the IDT and deemed appropriate. Facility staff were re-educated on Abuse policy and procedure, including reporting of Abuse allegations, or suspected abuse, by 12/17/19. Resident #700 has been placed on 1:1 Precautions as of 12/17/19. Element 4: Audits will be conducted on a weekly basis by social worker/ designee to ensure residents that have behaviors continue to be discussed in behavior management meeting weekly, and that interventions, including alternative placement, are considered as indicated. Results of the audits will be reviewed by the IDT and brought to QAPI Meeting monthly. Audits will continue until substantial compliance is achieved as determined by QAPI committee. Element 5: Administrator/Designee will be responsible for sustaining compliance. Date of Compliance: 12/17/19 Surveyor: Mauer, [NAME REDACTED]

Based on observation, interview and record review, the facility failed to ensure interventions were implemented to prevent development and/or worsening of a pressure sore, and/or wound treatments were done per order for three (R25, R69, and R81) sampled residents of five reviewed for the care of wounds and pressure ulcer management, resulting in inconsistent provision of wound care treatments, and a blister (stage two pressure ulcer) becoming a stage three (full thickness skin loss) pressure ulcer and development of an additional wound. Findings include: R25 Record review revealed that R25 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and required extensive assistance of two persons for bed mobility and transfers. A review of the care plans for R25 revealed the following: I have the potential for developing impaired skin integrity r/t (related to) debility, fragile skin, incontinence, and use of incontinence products (initiated 08/15/19). Goal- I will maintain or develop clean and intact skin by the review date. Target date 10/30/19. I have an ADL (activities of daily living) deficit and require assistance r/t debility, muscle weakness, myalgia, abnormalities of gait and mobility, and mild cognitive impairment, Date Initiated: 08/15/2019 Intervention-Bed Mobility: I require extensive x 1 person assistance with turning and positioning while in bed. Date Initiated: 08/15/2019. Interventions did not include frequent repositioning nor a pressure reducing mattress or low air loss mattress. No care plan for an actual wound or pressure injury was found in the active or resolved care plans. Review of a facility Admission Nursing Assessment for R25 dated 07/24/19 indicated, No skin issues. Review of a facility Head to Toe Skin assessment dated : 07/26/19 indicated a fluid filled blister and on 07/31/19 a blister left buttock. A wound consult provider note dated 08/05/19 revealed: Wound #1 left buttock is a stage two pressure injury pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 1.2 cm (centimeters) length x 1.5 cm width .Pressure relief/offloading: pressure reduction mattress, frequently reposition. A progress note dated 08/12/2019 16:17 (4:17 PM), Alert Note Text: New skin issue observed by CNA (certified nursing assistant) assessed by wound care. A progress note by Nurse D dated 08/12/2019 16:11 (4:11 PM) Alert Note Text: pt (patient) has a sore on butt, on left cheek, Resident assessed by wound care. A wound consult provider note dated 08/12/19 revealed: Wound #1 left buttock is a stage three pressure injury pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 0.7 cm (centimeters) length x 0.8 cm width x .01 cm depth .Pressure relief/offloading: low air loss mattress or low air loss bed, frequently reposition. A wound consult provider note dated 08/19/19 revealed: Wound #1 left buttock is a stage three pressure injury pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 0.6 cm (centimeters) length x 0.9 cm width x .01 cm depth .Pressure relief/offloading: low air loss mattress or low air loss bed, frequently reposition. A wound consult provider note dated 08/26/19 revealed: Wound #1 left buttock is a stage three pressure injury pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 0.8 cm (centimeters) length x 0.9 cm width x .01 cm depth .Pressure relief/offloading: low air loss mattress or low air loss bed, frequently reposition. A wound consult provider note dated 09/03/19 revealed: Wound #1 left buttock is a stage three pressure injury pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 0.9 cm (centimeters) length x 0.9 cm width x .01 cm depth .Pressure relief/offloading: low air loss mattress or low air loss bed, frequent repositioning. A wound consult provider note dated 09/09/19 revealed: Wound #1 left buttock is a stage three pressure injury pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.4 cm (centimeters) length x 1.0 cm width x 1.4 cm depth .Pressure relief/offloading: low air loss mattress or low air loss bed, frequently reposition. A wound consult provider note dated 09/16/19 revealed: Wound #1 left buttock is a stage three pressure injury pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.1 cm (centimeters) length x 0.9 cm width .Pressure relief/offloading: low air loss mattress or low air loss bed, frequently reposition. A dietary progress note dated 09/16/2019 17:55 (5:55 PM) dietary notes Note Text: Resident has stage III pressure ulcer to L(left) buttock. A wound consult provider note dated 09/23/19 revealed: Wound #1 left buttock is a stage three pressure injury pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 0.8 cm (centimeters) length x 0.9 cm width .Pressure relief/offloading: low air loss mattress or low air loss bed, frequently reposition. On 10/07/19 at 9:11 AM, at 11:01 AM, at 1:22 PM, 1:47 PM, at 2:37 PM, and at 5:04 PM, R25 was observed to be laying in bed on their back and buttocks. The left leg was flexed and the right leg straight. R25 appeared angled across the bed right to left from the top of the bed. R25 was eating breakfast. A pressure reduction mattress was in place, but a low air loss mattress was not in place for the dates of the survey. On 10/08/19 at 8:00 AM, R25 was observed to be in bed. On 10/08/19 from 10:14 AM until 5:28 PM, R25 was observed seated in a wheel chair. R 25 was observed seated next to their bed at 10:14 AM, in the dining room during the lunch meal, in an activity at 4:28 PM and at 5:28 PM prepared for dinner. R25 was not observed to be returned to bed on 10/08/19. On 10/08/19 at 5:17 PM, the wound care nurse F was asked about R 25 wounds and stated, (R25) had a blister type wound when they got here and is gradually getting smaller. The medical record for R25 was reviewed with Nurse F. Nurse F was shown the 07/24/19 nursing admission assessment which indicated no skin issues on admission and that the care plan did not have reference to or interventions for the actual wound. Documentation for the wound present on admission and a comprehensive care plan were requested at this time. It was also noted that the recent MDS assessment did not indicate a turn and repositioning program intervention. On 10/09/19 at 8:13 AM and 9:01 AM, R25 was observed to be laying in bed on their back and buttocks with the head of the bed up slightly. On 10/09/19 at 9:45 AM, Wound Nurse F was asked if a care plan for the actual wounds was done or an additional admission note to document the presence of the wound and reported there was no additional care plan for the wound and had not found additional admission notation for the presence of the wound before 9/26/19. On 10/09/19 at 10:14 AM, R25 continues in bed on back, with the head of the bed up around 45 degrees. On 10/09/19 at 10:50 AM, R25 was observed to be laying in bed, slumped down, with shoulders below the midline of the upper portion of bed. On 10/09/19 at 10:56 AM, CNA G was asked about the mobility of R25 and reported R25 as total care (dependent for all care needs) and in need of assistance for bed mobility and dressing. CNA G also reported that R25 moves less when the head of the bed is up higher, but rolls more when the head of the bed is down. On 10/09/19 at 12:06 PM, the Director of Nursing (DON) was asked about the care of the wounds for R25 and the DON stated, Wounds are considered acquired wounds if not noted within 48 hours. My understanding is (R25) was admitted with a wound. The nurse who completed the admission assessment may have felt it was cicatrix (healed pink tissue). (Wound Nurse F) had assessed it as a stage two to three. (R25) can be difficult to motivate and initially did not want to get out of bed, family was involved and has improved as this point, but still needs to be encouraged. There should be a care plan for what the resident is at risk for and what is occurring now. We have had that in QAPI (quality assurance performance improvement)for a few months, but it is a work in progress. It was noted the Braden (an assessment tool to determine a resident's risk of developing a pressure ulcer) score was 17 on 07/24/19 showing risk for skin breakdown. The DON was asked about the resident observed in bed all day Monday and in the wheelchair most of Tuesday and stated, The check and change every two hour offloads direct pressure on sacrum if only for the short time it takes. The incontinence and fall care plan were identified by the DON as related to repositioning, but the care plans did not address the need for frequent repositioning nor the wound. On 10/09/19 at 12:30 PM, a wound observation was conducted with Wound Care Nurse F for R25. It was noted hands were washed but no barrier was observed under the extra gloves nor the measuring strip. The extra gloves rested on a pair of the resident's eye glasses. The gauze dressing rested on a styrofoam tray. Two wounds to the left buttock were observed. The superior wound measured 0.9 (centimeters) cm x 0.4 cm with a ruby, pink base. The distal (more lower buttock) wound measured 1.0 cm x 0.5 cm, cicatrix appeared above and below the wound. This cicatrix was comparable to the size of the wound noted as wound #1 in the wound consult notes. Both wounds appeared without measurable depth. Wound Nurse F was asked if there were two wounds when observed on Monday and stated, On Monday it looked like a shearing when I saw it. It was noted that a wound consult note was completed on Monday with the treatment changed to every three days. Wound Nurse F then reported upon query, that they had seen only one wound on Monday 10/07/19. The wound consult sheet was requested and upon review indicated, one wound, stage three, which measured 0.4 cm x 0.4 cm x 0.2 cm. Resident #69 On 10/8/19 at 8:26 AM, a wound care observation for R#69 was conducted with Wound Care Nurse (WCN) F. WCN F indicated R#69 has a Stage 3 (full thickness tissue loss) pressure ulcer on the coccyx (tailbone). Upon observation of the wound care and removal of the resident's brief, R#69 was noted to have no current dressing in place over their wound. WCN F was asked if they had already removed the old dressing. WCN F replied, No. There's not one there. R#69 was asked when the dressing had been removed and stated, Probably last night. An unused dressing was observed on the resident's bedside table with a date of 10/7/19. WCN F indicated there should have been another dressing put in place when the old one was removed. A review of R#69's order revealed the following: Cleanse coccyx with wound cleanser apply therahoney gel cover with dry dressing daily and PRN (as needed), one time a day for wound care and as needed, Active 7/2/2019. A review of R#69's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive to total assistance from staff for bed mobility, dressing, toilet use, and hygiene. Resident #81 On 10/8/19 at 8:46 AM, a wound care observation for R#81 was observed with WCN F. Upon entering R#81's room, the low air loss mattress setting was noted to be set at Soft, <80 pounds (lbs). Two labels on the unit were noted to state, Do not change setting from 150 lbs. When queried regarding the finding, WCN F stated, I could scream. I labeled that. It should be at this 150 lb mark, I even marked it with a black pen. The following observations were made during R#81's wound care: R#81 had a very large right hip wound, covering the entire hip, covered with black necrotic (dead tissue) tissue. Yellow slough (soft, dead tissue) was around the edges of the wound. R#81 had a large coccyx wound with visible tunneling and necrotic slough on the right edges with a red base. There was an overwhelmingly foul odor when the wound was uncovered. R#81's left hip had a very large wound similar in appearance to the right hip wound. R#81's left pelvis wound appeared smaller, with visible tunneling, a yellow slough base, and rolled edges. R#81 also had pressure wounds to the inner right and left heels. A review of R#81's wound care Treatment Administration Record (TAR) for the months of (MONTH) through (MONTH) 2019 revealed the following: Cleanse left heel with wound cleanser apply sureprep apply abd and kerlix q2d (every 2 days) one time a day every 2 day(s) for wound care -D/C (discontinued) Date-06/11/2019 - No documentation indicating treatment was given on 5/1, 5/9, 5/15, 5/21, 5/27, and 5/29. Apply dry dressing right heel every 3 days and PRN one time a day every 3 day(s) for wound care -D/C Date-06/25/2019 - No documentation indicating treatment was given on 5/9, 5/15, 5/21, 5/27 and 6/20. Apply sure prep dry dressing and kerlix to right heel every two days and PRN one time a day every 2 day(s) for wound care-D/C Date-06/25/2019 - No documentation indicating treatment was given on 6/12 and 6/20. TheraHoney Gel (Wound Dressings) Apply to left buttock topically one time a day for wound care -D/C Date-06/25/2019 - No documentation indicating treatment was given on 5/1, 5/2, 5/9, 5/15, 5/21, 5/27, 5/29, 6/9, 6/12, and 6/20. Cleanse right heel with wound cleanser apply sure prep, abd and kerlix secure with tape Q2D and PRN one time a day every 2 day(s) for wound care - No documentation indicating treatment was given on 7/4, 7/18, 7/24, 8/3, 8/11, 8/17, 8/19, 8/23, 8/20, 8/25, 9/16, and 9/26. Cleanse right hip with wound cleanser apply dry dressing abd pad and secure with tape every two days and PRN one time a day every 2 day(s) for Skin care -D/C Date-10/04/2019 - No documentation indicating treatment was given on 7/18, 7/24, 8/3, 8/17, 8/19, 8/25, 9/16, and 9/26. Cleanse left hip with wound cleanser apply therahoney cover with dd (dry dressing) daily and prn one time a day for wound care -D/C Date-10/04/2019 - No documentation indicating treatment was given on 5/27, 5/29, 6/9, 6/12, 6/20, 7/4, 7/18, 7/24, 8/3, 8/17, 8/19, 8/20, 8/25, 8/26, 9/16, 9/26, and 9/27. TheraHoney Gel (Wound Dressings) Apply to LT (left) posterior pelvic topically one time a day for wound care -D/C Date-10/08/2019 - No documentation indicating treatment was given on 5/1, 5/2, 5/9, 5/15, 5/21, 5/27, 5/29, 6/9, 6/12, 6/20, 7/4, 7/18, 7/24, 8/3, 8/11, 8/17, 8/19, 8/20, 8/25, 8/26, 9/16, 9/26, 9/27, and 10/6. TheraHoney Gel (Wound Dressings) Apply to left heel topically one time a day for wound care -D/C Date-10/04/2019 - No documentation indicating treatment was given on 6/12, 6/20, 7/4, 7/18, 7/24, 8/3, 8/11, 8/17, 8/19, 8/20, 8/23, 8/25, 8/26, 9/16, 9/26, and 9/27. Cleanse left buttock with wound cleanser apply hydrogel impregnated gauze and cover with dry dressing daily and PRN one time a day for wound care-D/C Date-10/04/2019 - No documentation indicating treatment was given on 8/3, 8/17, 8/19, 8/20, 8/25, 8/26, 9/16, 9/26, and 9/27. On 10/09/19 at 1:23 PM, the Director of Nursing (DON) was queried regarding wound care documentation. The DON indicated the wound care treatments are documented as given on the TAR. When asked what it means if there is a blank space in the TAR, the DON stated, If it's not documented, it's not done. When asked about the expectation for completing treatments as ordered, the DON stated, I haven't heard any problems of people having issues with getting things documented. I would expect what is ordered to be done and documented as such. A review of the facility policy/procedure Pressure Ulcer and Skin Management revealed: Policy: A resident who enters the facility without pressure ulcers does not develop pressures ulcers unless the resident's clinical condition demonstrates that they are unavoidable; and a resident having pressures ulcers receives treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers from developing. 7. The interdisciplinary team will develop a care plan addressing risk factors and periodically review and update the care plan to minimize risk and promote healing. 8. The nursing staff reviews the pressure ulcer prevention and treatment procedures with the resident's physician. They select the treatment procedures appropriate for the resident and the type of pressure ulcer or wound. The licensed nurse implements the wound care treatment procedures in accordance with current standards of practice.

This Citation Pertains to Intake Number MI 671. Based on observation, interview and record review, the facility failed to monitor and assess new onset of aggressive behaviors for one (#701) sampled resident who was observed actively attempting to smother a nonverbal resident (#702) with a bed sheet, resulting in an Immediate Jeopardy, and the likelihood of serious injury, harm, or death. The Immediate Jeopardy (IJ) started on 7/10/19 and was identified on 7/17/19. The Administrator was notified of the Immediate Jeopardy on 7/17//19 and was asked for a plan to remove the immediacy. The IJ was removed on 7/17/19, based on the facility's implementation of the removal plan as verified onsite on 7/17/19 Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings include: Record review on 7/16/19 of facility submitted incident report dated 7/11/19 at 11:16 AM revealed, (Resident #701) was found in their room leaning over their roommate (Resident #702) with a sheet attempting to cover (Resident #702's) face. (Resident #701) was assisted into their chair. (Resident #701 displayed) increased agitation and unable to redirect . When did the incident occur . 7/10/19 11:30 AM . An interview was conducted with the facility Administrator on 7/16/19 at 9:10 AM. When queried regarding the incident, the Administrator stated, (Resident #701) was sent out (to the hospital) and came back three days later. The Administrator revealed Resident #701 was placed in a different room, in the same area of the facility as Resident #702, upon their return. When queried regarding Resident #702, the Administrator stated, (Resident #702) does not speak English. Their BIMS is 0 and they are on Hospice. With further inquiry regarding Resident #702 following the incident, the Administrator did not provide further explanation. Record review on 7/16/19 of Resident #701's medical record revealed the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, required supervision to limited assistance to perform Activities of Daily Living (ADLs), and did not display any behaviors. Additional record review at this time of Resident #701's medical record revealed the Resident was transferred from the facility due to assaulting Resident #702 on 7/10/19. Review of Resident #701's care plans on 7/16/19 revealed the Resident did not have a current, active care plan pertaining to behaviors and/or mental health. Review of the Resident's care plans, prior to transfer on 7/10/19, revealed the Resident had a care plan entitled, I have a dx (diagnosis) of conversion d/o (disorder) with [MEDICAL CONDITION]/convulsions, psychotic d/o with delusions and adjustment d/o with anxiety and depressed mood. I have no current moods of concern. I receive an antipsychotic and antidepressant med (Initiated: 5/6/19; Revised: 5/21/19; Closed due to discharge: 7/11/19). Record review on 7/16/19 of Resident #702's medical record revealed the Resident was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident required extensive assistance to perform Activities of Daily Living (ADLs) and did not include a Brief Interview for Mental Status (BIMS-evaluation to evaluate level of cognition) score. The MDS indicated the Resident sometimes understands (others) and is rarely/never understood. The MDS did not include any information pertaining to the Resident's preferred language and/or wanting/requiring a language interpreter. An interview was conducted with Unit Manager Nurse A on 7/16/19 at 9:56 AM. When queried regarding unusual occurrences between Resident #701 and Resident #702, Nurse A stated, (Resident #701) had a [MEDICAL CONDITION] the day before it happened. (Resident #701) was kind of out of it and was acting odd. With further inquiry, Nurse A stated, (Resident #701 was taking their clothes off. During the night, they found (Resident #701) in bed with (Resident #702). When asked how long Resident #701 had been in Resident #702's bed, Nurse A revealed they spoke to night shift staff and stated, It could have been two hours from when they (staff) had checked on the Residents last. Nurse A then stated, The next day, Resident #701 was even more agitated. The Nursing Assistant tried to get them dressed, but (the Resident) just got even more agitated then they pulled the sheet up over (Resident #702's) head. When queried, Nurse A stated, (Resident #701) did not want to let go of the sheet. I had to pick up their hands and guide them away. (Resident #701) was combative but I was able to get them to sit in a wheelchair and I removed them from the room. When asked about Resident #702, Nurse A stated, (Resident #702) speaks [MEDICATION NAME] and has not been in the United States that long from my understanding. The family used to visit quite a bit when they were trying to get (Resident #702) citizenship but we don't see them very much anymore. When asked how Resident #702 reacted to Resident #701 holding the sheet over their head, Nurse A stated, (Resident #702 was petrified. Their eyes were huge. (Resident #702) has contractures and is not really able to do anything on their own. On 7/16/19 at 10:40 AM, Resident #701 was observed sitting in a wheelchair in their room. An interview was conducted with the Resident at this time. The Resident was alert and orientated to person, place, and time with occasional confusion and was a poor historian. The Resident had a flat affect and hand tremors were observed. When asked if they had always been in their current room, Resident #701 stated, No. When asked if they had a roommate, Resident #701 replied, Before. When asked if they had liked their roommate, Resident #701 stated, I don't know. When queried if they moved rooms after returning from the hospital, Resident #701 did not respond. When asked if they had been in hospital, Resident #701 indicated they were. When asked why they were in the hospital, Resident #701 replied, I had a [MEDICAL CONDITION], at least that is what they said. When asked if they left their room often and had friends at the facility, Resident #701 stated, No friends but I talk to people. On 7/16/19 at 10:50 AM, Resident #702 was observed in their room. The Resident was laying in bed, positioned on their back, and wearing a hospital gown. An interview was attempted to be completed with the Resident at this time. When spoke to, the Resident made eye contact but did not respond verbally to questions. A language interpretation and/or communication board was not observed in the room. On 7/16/19 at 11:00 AM, an interview was conducted with Nursing Assistant B. When queried regarding Resident #702, Nursing Assistant B indicated the Resident does not speak English and was completely dependent upon staff for care and stated, (Resident #702) is a feeder. With further inquiry regarding how staff communicate with the Resident, Nursing Assistant B stated, You can talk to (the Resident) and point at things. When asked if the Resident had a communication board and/or language interpretation device, Nursing Assistant B indicated no devices are used by staff. When queried if they provided care to Resident #701 and Resident # 702, Nursing Assistant B indicated they had been working the day of the incident. Nursing Assistant B then stated, (Resident #701) had a [MEDICAL CONDITION] the day before. They (Resident #701) were on the floor with their dresser on top of them. The next day the Wound Care Nurse found (Resident #701) holding a sheet over (Resident #702's) head. When asked if they were assigned to care for Resident #701 and Resident #702 on that day, Nursing Assistant B indicated they were. When asked when the incident occurred, Nursing Assistant B replied, Right before lunch. With further inquiry regarding Resident #701, Nursing Assistant B indicated aggressive behaviors were new for the Resident and had started after the Resident had a [MEDICAL CONDITION]. An interview was conducted with Staff C on 7/16/19 at 11:49 AM. When queried if they had observed any unusual occurrences between Resident #701 and Resident #702, Staff C stated, Yes, I was cleaning in the next room. I heard something and went in the bathroom (rooms share a bathroom). (Resident #701) was standing at the side of (Resident #701's bed). (Resident #701) took the covers and covered (Resident #702's) face. (Resident #702) was struggling, they were moving their arms. (Resident #702) got their left arm out of the side of the blanket and was trying to hit up at (Resident #701). With further inquiry regarding how Resident #701 was holding the covers, Staff C revealed Resident #701 had both of their hands on either side of Resident #702's face. When asked how the blanket was over the Resident's face and how tight the blanket was, Staff C indicated Resident #701 had pulled it up and was holding it with both of their hands. A demonstration of the how Resident #701 was holding the blanket over Resident #702's face was completed at this time utilizing a pillowcase. Demonstration revealed the blanket had been held tightly over Resident #702's face. Record review of facility staffing sheets on 7/16/19 revealed Nursing Assistant D worked during the day shift in the area of the facility where Resident #701 and Resident #702 reside on 7/9/19 and 7/10/19. On 7/16/19 at 11:56 AM, an interview was conducted with Nursing Assistant D. When queried regarding Resident #701 and Resident #702, Nursing Assistant D stated, I knew (Resident #701) had a [MEDICAL CONDITION] the day before. Somebody said (Resident #701) was on the floor and they put them back in bed. I had them the next day. I went in (to the Resident's room) and got stuff ready for a shower. (Resident #701) got up and then when I went to help them put a gown on, they went ballistic. I tried to get (Resident #701) to sit in the wheelchair and (Resident #701) just started swinging. I couldn't get past (Resident #701) so I yelled for help. When asked if they witnessed any occurrences between Resident #701 and Resident #702, Nursing Assistant D indicated they did not and stated, I went back to check on (Resident #702) later and asked them if they were okay. I told (Resident #702) to blink if they was okay and they didn't blink. I told (Resident #702) to not be scared. An interview was conducted with Nursing Assistant [NAME] on 7/16/19 at 12:09 PM. When queried regarding Resident #701, Nursing Assistant [NAME] stated, I went in to help one of the other Aides (Nursing Assistants). (Resident #701) was swinging and throwing things and kept trying to get into bed with (Resident #701). When asked if that was normal behavior for Resident #701, Nursing Assistant [NAME] indicated it was not and stated, They (night shift staff) reported (Resident #701) had been trying to do it all night. When asked what Resident #701 had been trying to do all night, Nursing Assistant [NAME] replied, Being combative, throwing stuff, trying to get in bed with Resident #702. When asked about Resident #702, Nursing Assistant [NAME] stated, (Resident #702) seems different. You can tell (Resident #702) seems a little scared and nervous. Like when I try to do something, (Resident #702) grabs my hand and just tries to hold on to it. (Resident #702) normally don't do that. When asked how they communicate with Resident #702, Nursing Assistant [NAME] revealed the Resident doesn't speak English and stated, I still talk to them and I point at stuff, so they know (what I'm doing). An interview was completed with Nursing Assistant F on 7/16/19 at 12:39 PM. When queried regarding if Resident #701 and Resident #702, Nursing Assistant F indicated they were not assigned to care for the Residents on 7/9/19 or 7/10/19 but have cared for both Residents on other days. With further inquiry regarding the Residents, Nursing Assistant F stated, (Resident #702) don't talk. (The Resident) don't speak English. When asked how they communicated with the Resident and if the Resident understood them, Nursing Assistant F replied, I don't think so. (Resident #702) never talked English. Record review of Resident #701's medical record on 7/16/19 revealed the following documentation: -7/9/19 at 11:28 AM: Clinical NP (Nurse Practitioner) Progress Note . Chief Complaint: having a [MEDICAL CONDITION] . I was called urgently to the room to evaluate the patient per staff that (Resident #701) was found lying in bed with legs twitching and non-verbally responding to the staff . history of [MEDICAL CONDITION] disorder and is on both [MEDICATION NAME] ([MEDICAL CONDITION] medication) and [MEDICATION NAME] ([MEDICAL CONDITION] medication) daily. No recent documented [MEDICAL CONDITION] activity. (Resident #701) is alert and lying in bed, unable to follow commands at this time, no apparent distress . + anxious, non-verbal, difficult to redirect . Assessment/Plan: Break through [MEDICAL CONDITION] . Altered mental status; secondary to above; Stat (laboratory testing) . Debility; high fall risk; maintain safety precautions . -7/9/19 at 11:45 AM: Health Status Note: Observed lying on floor on back with dresser lying on legs with full body tremors, resident not responding verbally to questions asked. ROM within normal limits . Assisted into bed. Continues with full body tremors NP gave order for 1 mg (milligram) [MEDICATION NAME] [MEDICATION]) be given. Continued to tremor until 11:45 am. (Physician H) aware. (Family) aware . Resident is very restless in bed. BP (Blood Pressure) 154/83 T (Temperature) 97.6 P (Pulse) 66 R (Respiratory Rate) 18, O2 sat (Oxygen Saturation) 98%, BS (Blood Sugar) 125. -7/9/19 at 6:29 PM: Health Status Note: observed sitting on floor at side of bed on floor mat, assisted back into bed, not (no) injury noted. Continues to be very restless. Was again observed sitting on floor at end of bed, again assisted back into bed. (Physician H) and Family aware of above. Still waiting for STAT lab draw. -7/9/19 at 6:42 PM: Health Status Note: unable to get VS (Vital Signs) resident pushed me out of the way and made attempt to walk over their bed and continued to dresser and then attempted to put their foot on top of dresser to walk over it. is at this time sitting in chair in front of TV. -7/10/19 at 2:50 AM: Behavior Note: upon staff rounds, resident was observed lying in bed with roommate. when staff attempted to redirect resident into his own bed, resident became combative towards staff and flung his arms around with clenched fists. resident was successfully redirected without injury to self or staff. meds as ordered . -7/10/19 at 11:46 AM: Clinical NP (Nurse Practitioner) Progress Note . Chief Complaint: Agitation and assault .I was called urgently to evaluate patient as (Resident #701) was found in his room leaning over roommate with a sheet attempting to cover (Resident #702's) face. (Resident #701) was assisted into chair. Increased agitation and unable to redirect. Decision was made to transfer patient to acute care facility for psychiatric evaluation . Assessment/Plan: Altered mental status; with aggressive behaviors and assault to another resident; due to safety for patient and residents, patient to be transferred to acute care facility for further evaluation .[MEDICAL CONDITION] disorder . noted with break-through [MEDICAL CONDITION] 7/9 . Patient petitioned and cert to be completed at (Emergency Department); safety maintained prior to transfer . -7/10/19 at 1:49 PM: Nurse-to-Nurse Hospital Communication: Resident became agitated @ 11:30 am CNA was trying to do care and (Resident #701) became violent unable to redirect. Writer, 2 CNA's and Unit Manger came to assist. Resident tried to harm his roommate and staff Dr. and family was called and Writer petition out to the Hospital for mental status change. Transportation came at 12:25 PM . Record review of Resident #702's medical record on 7/16/19 revealed Resident #702 was seen by Nurse Practitioner O on 7/10/19 at 12:55 PM. The note revealed, I was asked to see patient today per staff concern it was witnessed with roommate standing over bed pulling the sheet to cover face . The medical record also revealed Significant Change Social Services notes pertaining to the Resident's admission to Hospice services dated 7/10/19 at 6:54 PM and 7:03 PM. The notes did not address completion of any psychological and/or psychosocial assessment of Resident #702 related to the incidents that transpired with Resident #701. On 7/16/19 at 1:20 PM, an interview was conducted with Nurse [MI] When queried regarding Resident #701, Nurse L stated, I worked on 7/9/19 (midnight shift). In report, when I got there, they (prior staff) said (Resident #701) had a [MEDICAL CONDITION] and was kinda irate and trying to mess with (Resident #702) after that. When asked, Nurse L indicated Resident #701 was not their assigned Resident. An interview was conducted with Nurse M on 7/16/19 at 1:30 PM. When queried regarding Resident #701 and Resident #702, Nurse M replied, We found (Resident #701) in (Resident #702's) bed. (Resident #701) was combative when we tried to get them out of the bed. They kind of like tried to push us away. With further inquiry, Nurse M stated, (Resident #702) was positioned on their right side in the bed and (Resident #702) was right next to them. (Resident #702) was on the window (left) side) of the bed and had their arm around (Resident #702). When asked, Nurse M revealed they could not recall if Resident #702 was under the covers. When asked, Nurse M stated, (Resident #702) did not have a shirt on, I think they had on pajama pants. With further inquiry regarding Resident #702's clothing and behaviors, Nurse M replied, (Resident #702) kept taking off all their clothes (during the shift). When asked if that was normal behavior for Resident #701, Nurse M indicated no and stated, It was reported to me that (Doctor H) did not want (Resident #701) shipped out (to the hospital) after the [MEDICAL CONDITION]. When queried regarding Resident #702's response to the incident, Nurse M stated, (Resident #702) just kind of stared, (the Resident) just stated with their eyes wide open. I asked (Resident #702) if they were okay and they just stared. (Resident #702) doesn't really ever talk. When asked if Resident #702 understands them, Nurse M stated, Probably not because there is a language barrier. I have never heard (Resident #702) say anything in English other than no and that was only when they were first admitted . On 7/16/19 at 1:45 PM, an interview was conducted with Social Services Coordinator N. When queried regarding Resident #701, Coordinator N indicated the Resident was transferred for evaluation following the occurrence with Resident #702 and has returned to a different room in the facility. When queried regarding the plan of care and care plan for Resident #701, Coordinator N stated, Psych will see them on Thursday and I am making daily visits. When queried regarding the psychiatric [DIAGNOSES REDACTED]. sheet or medical [DIAGNOSES REDACTED]. Resident #701's medical record was reviewed with Coordinator N at this time. When asked regarding the origin of the [DIAGNOSES REDACTED]. I am not sure. When asked why the Resident was being treated with [MEDICAL CONDITION] medications if they do not have an indication and/or diagnosis, Coordinator N was unable to provide and explanation and stated, I will look and let you know if I find something. When queried regarding assessment of Resident #702 following the incidents which occurred when Resident #701 was found in their bed and then found covering their face and smothering them with a sheet, Coordinator N indicated they did not assess the Resident following the incidents to determine psychosocial distress or harm. Coordinator N then stated, (Resident #702) has dementia and doesn't talk. Coordinator H further revealed the Resident did not speak English. When queried if a Resident who has dementia, does not speak, and who's primary language is not English is able to suffer negative effects of psychosocial distress, Coordinator N did not provide a response. When asked how a reasonable individual would feel if someone climbed into their bed in the middle of the night and then covered and tightly held a sheet over their face the next morning when they are physically incapable of defending themselves, Coordinator N replied, I see what you are saying. I really let the ball drop on that one. When queried regarding staff statements of Resident #702 grabbing their hands and appearing fearful, Coordinator N indicated they were unaware Resident #702 had a change in their behavior and responses to facility staff. When asked how they communicate with Resident #702, Coordinator N indicated Resident #702 has severe dementia and is severely cognitively impaired and communication occurs through the Resident's family. When asked how they knew the Resident was comfortable communicating through their family, how they were able to accurately access the Resident's cognitive function and ensure they were receiving unbiased information, Coordinator N stated, I just look at the Resident's face. When queried asked how psychiatric services communicate with the Resident, Coordinator N replied, The family. The son-in-law does the talking. Record review on 7/16/19 of facility provided investigation documentation of incident on 7/10/19 included the following documentation: -Printed Electronic Medical Record (EMR) documentation, care plan, and facesheet for Resident #701 -Incident and Accident Report (I and A) for Resident #701. Review of the report revealed, Date of the Incident: 7/11/19 . Time of the Incident . 12:00 PM . Brief Description: (Resident #701) was observed pulling sheet over roommates head . Treatment: Sent to Hospital . Vital Signs . Refused . -Care plan and facesheet for Resident #702 -Incident and Accident Report (I and A) for Resident #702. Review of the report revealed, Date of the Incident: 7/11/19 . Time of the Incident . 12:00 PM . Brief Description: Roommate had placed sheet over head . -Statement authored by Wound Care Nurse G. The statement revealed, 7/10/19 Approx. 11:20-11:25 AM. Upon entering room for wound care . Observed (Resident #701) standing at (Resident #701) bedside with (Resident #702) sheets in hands .Instructed to let go of the sheets and return to their side of the bed. (Resident #701) continue with bed making motions pulling up the sheets over (Resident #702) head . -Statement authored by Unit Manager A. The statement revealed, On 7/8/19, I was on the unit. I was notified of the issue between (Resident #701) and roommate (Resident #702). I entered the room and assisted removing (Resident #701) from the room. (Resident #701) was swinging with a closed fist, elbowing staff, and trying to get back to (Resident #702) . Once in the hall, (Resident #701) was agitated but there was no harm to anyone. Record review on 7/16/19 of additional facility provided Incident and Accident Reports for Resident #701 revealed the following: -7/9/19 at 11:15 AM: Was Incident Witnessed: No . Brief Description: Observed lying on floor on back with dresser lying on lower legs with full body tremors, Resident not responding verbally to questions asked. ROM (Range of Motion) within normal limits. Assisted into bed. Continues with full body tremors. NP (Nurse Practitioner) came and assessed . Temperature 97.6 . Pulse 66 . Respirations 18 . Lying BP (Blood Pressure) 154/83 . New Action taken to prevent reoccurrence . low bed . floor mat . fall precautions . low bed . -7/9/19 at 5:45 PM: Was Incident Witnessed: No . Brief Description: Observed sitting on floor next to bed. ROM within normal limits, assisted back to bed, changed brief and was resting . Vital Signs . Unable to get, Resident refused . -7/9/19 at 6:00 PM: Was Incident Witnessed: No . Brief Description: Observed sitting at the foot of bed. ROM within normal limits. Assisted back into bed. No injury noted . Vital Signs . Unable to get, Resident refused . -7/10/19 at 2:45 AM: Brief Description: Resident observed laying in Roommates (Resident #702's) bed along side roommate. When staff attempted to redirect Resident into own bed, the Resident became combative toward staff . Vital Signs . Unable to get . -7/11/19 (7/10/19) at 12:00 PM: Brief Description: (Resident #701) was observed pulling sheet over roommates head . Vital Signs . Refused . On 7/16/19 at 2:23 PM, an interview was conducted with Wound Care Nurse G. When queried regarding Resident #701 and #702, Nurse G stated, First, I was in the hallway when I heard the CNA (Nursing Assistant) yelling for help. They needed help trying to get (Resident #701) dressed. When asked why the Nursing Assistant needed help, Nurse G revealed (Resident #701) was being combative. Nurse G then stated, I went out (of the room) to get stuff for a dressing change and started talking to someone in the hall. Nurse G then stated, When I went back in to (Resident #701 and Resident #702's) room (after the incident of Resident #701 being combative) to do (Resident #702's) dressing change, (Resident #701) was standing on the side of (Resident #702's) bed and was pulling the sheet up over (Resident #702's) head. Nurse G then stated, I called for help and got it (sheet) off. When queried, Nurse G revealed Resident #702 did not want to let go of the sheet and became combative. When asked how Resident #702 reacted, Nurse G stated, Honestly, (Resident #702) seemed scared. When queried regarding communication with Resident #702, Nurse G replied, (Resident #702) does not speak English and has dementia. With further inquiry regarding how they were able to discern the Resident was scared when there is a language barrier, Nurse G replied, You could see it in (the Resident's) eyes. You could just tell. When asked if they interacted with either Resident on 7/9/19, Nurse G stated, No, I didn't do wound care on Tuesday. An interview was conducted with Nurse I on 7/16/19 at 2:52 PM. When queried, Nurse I indicated they provided care to Resident #701 and Resident #702 on 7/9/19. When asked about Resident #701, Nurse I stated, The Housekeeper came to me and said (Resident #701) was on the floor and shaking. I spoke to the Doctor and the House Nurse Practitioner ordered STAT (urgent) labs and [MEDICATION NAME] (medication used in for anxiety and short-term treatment of [REDACTED]. When queried regarding facility incident reports indicating Resident #701 had three unwitnessed falls in the facility on 7/9/19 with two of the falls occurring within 15 minutes of each other, Nurse I indicated they had completed the Incident and Accident Reports. When queried regarding monitoring of the Resident after an unwitnessed fall, Nurse I indicated neuro checks are supposed to be completed for unwitnessed falls per facility policy/procedure. When asked if neuro checks were completed, Nurse I stated, No, (Resident #701) wouldn't let me. (The Resident) wouldn't even let me get their blood pressure. They kept throwing off the cuff. With further inquiry, Nurse I revealed Resident #701 was being combative and would not keep their clothes on. When queried if that was normal behavior for the Resident, Nurse I replied, No. When asked if the Resident's physician was made aware of the behaviors and the STAT laboratory testing not being obtained, Nurse I stated, Yes, (Physician H) was notified every time. When queried how long it is supposed to take to get STAT laboratory testing results, Nurse I stated, It is supposed to take two to three hours but this is not the first time that hasn't happened (STAT lab orders taking longer). An interview was conducted with the facility Administrator and Director of Nursing on 7/16/19 at 3:30 PM. When queried regarding lack of documentation of assessment of Resident #702's psychosocial status and well-being following the Resident #701 getting in their bed for an undetermined amount of time and observation of Resident #701 actively smothering them by tightly covering and holding a bedsheet over their face, the Administrator indicated Resident #702 was assessed and that there were no indications of a negative outcome. When asked about staff statements of the Resident appearing fearful and displaying a new behavior of grabbing and holding their hands, the Administrator and DON indicated they were unaware of any changes. With further inquiry regarding Social Services Coordinator [NAME] revealing they did not assess the Resident and statement of let the ball drop on that one, the Administrator replied, They (Coordinator E) said that? No further explanation was provided. On 7/16/19 at 4:15 PM, an interview was conducted with Nursing Assistant J. When queried regarding Resident #701, Nursing Assistant J stated, I'm a float on afternoons. I worked the day (Resident #701) had the [MEDICAL CONDITION]. I had to go in (to the Resident's room) and help because (Resident #701) kept sitting on the floor butt naked. (Resident #701) kept taking their clothes off and were combative. We kept trying to put a gown on them and (Resident #701) kept taking it off. I'm not a doctor or anything but (Resident #701) was not acting like themselves. The next day when I got in (to work), they told me they sent (Resident #701) to the hospital because they got into bed with (Resident #702). On 7/16/19 at 4:45 PM, an interview was conducted with Laboratory Staff K. When queried regarding the time frame for STAT laboratory tests ordered at the facility, Staff K stated, STAT Labs are a five hour around time. An interview was completed with Physician H on 7/16/19 at 4:52 PM. When queried regarding staff notification of Resident #701 having three falls within the facility on 7/9/19, Physician H revealed they were aware. When queried regarding their orders/instructions to facility nursing staff following the first incident of [MEDICAL CONDITION] activity with a fall, Physician H replied, I expect staff to keep an eye on (Resident #701) and to have fall precautions in place. When queried how long STAT laboratory testing results typically take, Physician H replied, Same day usually. With further inquiry regarding the medical plan of care for Resident #701, related to the change in their condition and behaviors and why the Resident was not sent to the hospital for evaluation, Physician H stated, The staff did not report a change in condition to me. Nursing note documentation pertaining to notification and change in Resident #701's condition was reviewed with Physician H at this time. When queried regarding documentation of staff notifying them of the Resident's condition three times, Physician H stated, I was not aware of a change. It was a normal postictal phase (period directly following a [MEDICAL CONDITION]). When queried regarding their assessment and documentation of the Resident following the [MEDICAL CONDITION] activity and falls, Physician H stated, I did not see (Resident #701). No further explanation was provided. On 7/16/19 at 5:12 PM, an interview was conducted with Unit Manager Nurse A. When queried regarding staff notification of Physician H, Nurse A indicated they were aware staff had notified the Physician. When queried if

This citation pertains to MI 198. Based on interview and record review the facility failed to assess and monitor a foot injury for 1 (#105) of 25 sampled resident with a history of Diabetes (DM) and [MEDICAL CONDITIONS], resulting in a transfer to the emergency room , worsening of a toe injury that appeared gangrenous and black in color, an extremely large closed bullae (bubble-like cavity filled with air or fluid) that covered the entire heel, and discomfort. Findings include: On 7/18/18 at 1:00 PM, a review of R105's clinical record revealed an admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/13/17, indicated a severely impaired cognition and extensive assistance of two persons for all activities of daily living. Section M. Skin: At risk for developing pressure ulcer. No Pressure Ulcer. Foot problems. No. On 7/18/18 at 1:55 PM, a review of an Incident and Accident Report dated 1/13/18 at 7:30 AM revealed, cna (Certified Nursing Assistant) was getting resident ready for her shower. We noticed her right foot was red and her great toe was bruised with a blister on it . On 7/18/18 at 1:56 PM a review of a progress note, dated 1/13/18 revealed, At 7:30 am cna was getting resident ready for her shower. We noticed her right foot was red and her great toe was bruised with a blister on it. She could not tell me what happened. (Doctor) called and ordered a right foot and toes x-ray. Progress note dated 1/13/18 at 19:46 (7:46 PM), X-Ray performed (R) foot and (R) great toe at this time results pending. On 7/18/18 at 2:00 PM a review of R105's X-ray results, dated 1/13/18 revealed , No acute fx (fracture) or dislocation. The osseous structures appear intact. Joint spaces are narrowed. Soft tissues are unremarkable. No acute osseous abnormality. [MEDICAL CONDITION] changes. On 7/18/18 at 2:01 PM a review of lab notes, dated, 1/15/2018 revealed,Lab results forwarded to physician for further evaluation, awaiting further orders. There was no other documentation provided for R105's right foot blister and bruise for between the dates of 1/14/18 - 1/24/18. Review of the resident's Treatment Administration Record (TAR) and Medication Administration Record [REDACTED]. Care plan reviewed and revealed no plan on the care for R150's right foot and toe. On 7/18/18 at 2:06 PM a review of the Transfer to Hospital Summary Note, dated 1/25/18 at 19:01 revealed, 16:30 (4:30 PM) resident was transferred to (local) hospital for evaluation and treatment of [REDACTED]. On 7/18/18 at 2:10 PM a review of the Infectious Disease Consult Note, dated 1/25/18, For antibiotic management; HPI (history of present illness): consult was requested after wound care noticed that her right foot wounds had worsened. Medical history is significant for DM and [MEDICAL CONDITION] as well as left-sided [MEDICAL CONDITION] from [MEDICAL CONDITION] dementia . The right foot is examined; the great toe appears gangrenous and is black in color and non-blanchable, with a small open area and minimal drainage. There is also noted significant surrounding [DIAGNOSES REDACTED] extending from the toe across the top of the foot toward the ankle. The right heel is also noted to have an extremely large closed bullae that covers the entire heel and is very deep purple in color. The patient does express discomfort when dressing and manipulating the foot. Case discussed with (Doctor) and the patient is being transferred to (local hospital) ER (emergency room ) for surgical evaluation/possible amputation of the great toe . Assessment: 1. Gangrenous R (right) great toe. 2. R heel pressure wound, unstageable . On 7/18/18 at 2:14 PM a review of the Podiatry Visit Summary Foot Examination/Procedures Performed, dated 11/13/17, revealed, debridement of nails, foot exam, visual inspection. Skin Right: Abnormal - no hair growth the toes, thin, shiny, strophic, decreased turgor, toes cool to touch. Skin Left: Same as Right . Pedal Pulse Right: Abnormal - 0/4 Dorsalis Pedis (blood vessel of the lower limb that carries [MEDICATION NAME] blood to the dorsal surface of the foot), 0/4 Posterior Tibial (tendon dysfunction). Vascular Assessment Right: Abnormal - cool temp with pallor (an unhealthy pale appearance) . On 7/19/18 at 8:23 AM, during an interview, the Director of Nursing (DON) was asked what did the facility do after the initial bruise was discovered on R105's foot. The DON stated X-Ray was done on the 1/13/18 and got the results on the 1/13/18. The DON was asked how did the facility take care of R105's toe blister and bruise. The DON stated, I think after we talked to the Doctor (Dr.) (they) decided to send her out. The DON was asked what happened between the 1/13/18 through 1/25/18 before R105 was sent out to the hospital. The DON stated, When they seen the blister it was just to keep it dry. The DON was asked for any documentation regarding the care for R105's toe between 1/13/18 and 1/25/18. The DON stated, I don't see any treatment for [REDACTED]. The DON stated, When the change occurred that's when I saw it and got involved. We called the (Dr.) and sent (R105) out. The DON was asked when was it determined she had gangrene. The DON stated, On 1/25/18. On 7/19/18 at 11:41 AM, the DON provided documentation from the hospital, dated 1/28/18, History of presenting illness: . admitted to hospital with severe pain and discomfort involving right lower extremity . found to have ischemic toe secondary to severe peripheral artery disease . On 7/19/18 at 11:50 AM, a review of the facility's policy titled Acute Change in Condition, undated, noted Acute Change of Condition is sudden, clinically important deviation from a resident's baseline in physical cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. Guidelines: . Changes (symptoms) in a resident's condition are communicated by any staff member to nurse .

This Citation Pertains to Intake MI 798. Based on observation, interview and record review, the facility failed to provide assessment and care of an indwelling urinary catheter per professional standards of practice for one (702) of two Residents reviewed for catheter care, from a total sample of three, resulting in catheter malfunction, infection, and hospitalization . Findings include: On 3/6/18 at 7:39 AM, an interview was completed with Confidential Witness B. When queried regarding Resident #702, Witness B stated, It was in July. They (Facility) were not changing (Resident #702's) catheter. They (facility staff) couldn't even tell us when it had been changed last. Whenever we went to visit (the Resident), you could smell urine but it was strong like an infection. We asked the staff about it because (Resident #702) was having pain but they just blew us off. Witness B then stated, When they finally did try to change it (catheter) they couldn't get it out. They couldn't even flush it so they finally sent (the Resident) to the emergency room . The Emergency Doctor had trouble getting the catheter out and told us it was because it was in so long. (Resident #702) had a really bad infection. Record review on 3/6/18 at 9:30 AM revealed Resident #702 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, required extensive to total assistance to perform Activities of Daily Living (ADL's), and had a suprapubic catheter (surgically created method to drain urine from the body). Further review of Resident #702's medical record at this time revealed the Resident was transferred from the facility to the hospital on [DATE] due to abdominal pain and readmitted on [DATE] with a [DIAGNOSES REDACTED]. On 3/6/18 at 10:40 AM, Resident #702 was observed laying in their bed in the facility. The Resident was very hard of hearing, pleasantly confused, and did not provide meaningful answers to questions. The Resident's catheter tubing was draining dark colored urine with large amounts of visible sediment in the tubing. When queried regarding their catheter, the Resident did not respond. An interview was completed with Nurse A on 3/6/18 at 11:00 AM. When queried regarding Resident #702, Nurse A stated, (Resident #702) gets [MEDICAL TREATMENT] three times a week. They are non-compliant with their medications. With further inquiry, Nurse A stated, (The Resident) on an antibiotic now. When asked what the antibiotic was for, Nurse A replied, (The Resident) has an abscess on their abdomen but I don't know what it is from. When queried regarding the Resident's suprapubic catheter, Nurse A stated, It gets changed once a month now. Review of Resident #702's medical record on 3/6/18 at 11:40 AM revealed a care plan entitled, have a catheter Indwelling Suprapubic [MEDICAL CONDITION] bladder (Initiated and Revised: 6/30/17). The care plan included the following interventions: -I have a catheter, please position my catheter bag and tubing below the level of my bladder and away from entrance room door. Provide me with a leg strap and use a dignity bag to cover my catheter bag -Observe me for any s/sx (signs/symptoms) of UTI such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, and report -Observe me for pain/discomfort due to my catheter -Please check to make sure my tubing has no kinks in it Additional record review at this time of Resident #702's Medication Administration Record [REDACTED]. Review of progress note documentation did not reveal documentation indicating the catheter had been changed. Review of Physician orders [REDACTED]. On 3/6/18 at 2:20 PM, record review of documentation within Resident #702's medical record revealed a form entitled, Nursing Home to Hospital Transfer Form dated 7/13/17 at 12:24 PM. Documentation on the form indicated, Res (Resident) was complaining of pain in abdomen. Abdominal and pelvic ultrasound still waiting for result. Suprapubic catheter irrigated, staff tried to change S/P (suprapubic) catheter can't removed it. S/P catheter have not been change for awhile res refused. MD ordered to transfer res to hospital and also per res request. Additional review at this time did not reveal documentation of Resident #702 refusing suprapubic catheter change and/or care. The Resident did not have a care plan in place related to refusal of care. Review of Resident #702's hospital discharge documentation entitled Hospital Transfer Form, dated 7/17/17 revealed, Reason for Visit: Acute Suprapubic catheter malfunction with susp. (suspected) Uros (Urosepsis) . Diagnosis: [REDACTED]. The form further revealed Resident #702 received Intravenous (IV) antibiotics while in the hospital and returned to the facility with an order for [REDACTED]. An interview was completed with the Assistant Director of Nursing (ADON) Nurse C on 3/6/18 at 2:45 PM. When queried regarding Resident #702's catheter including documentation of catheter change and care before the Resident was sent to the hospital in (MONTH) (YEAR), Nurse C reviewed the medical record and stated, There isn't any documentation that the catheter was changed. When queried regarding documentation of refusal of care, Nurse C indicated there was no documentation of the Resident's refusal of catheter care prior to transfer to hospital. With further inquiry regarding completion of a urinalysis for the Resident prior to or after hospitalization , Nurse C reviewed the medical record and stated, There wasn't a UA (urinalysis) done. When asked about documentation of the Resident's urine output and characteristics, Nurse C indicated they would need to review the medical record further. On 3/6/18 at 4:00 PM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #702's suprapubic catheter, the DON stated, It wasn't changed. With further inquiry regarding documentation of catheter care being completed or Resident refusal of care, the DON was unable to provide documentation. Record review of facility policy entitled, Suprapubic Catheter Care (No Date) on 3/6/18 at 6:00 PM revealed, Purpose: Proper care of the catheter site reduces skin irritation and/or infection . Documentation of Resident #702's urine output and urine characteristics were requested but not received by the conclusion of the survey.

This citation pertains to intake number MI 547. Based on observation, interview, and record review the facility failed to provide an adequate fluid intake and monitor fluid intake for one (#503) of four sampled residents reviewed for hydration from a total sample of four, resulting in dehydration requiring the infusion of intravenous (IV) fluids to resolve dehydration. Findings include: On 3/27/15 at 10 a.m., resident #503 was observed reclining in bed. His lips and mouth appeared dry and he stated, "(I) would like a drink." On 3/27/15 at 11:30 a.m., a review of the electronic health record revealed that resident #503 was originally admitted into the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set of 2/21/15 indicated his cognition was moderately impaired. The facility's integrated care plan effective 1/7/15 identified resident was at risk for dehydration related to [DIAGNOSES REDACTED].#503 experienced a hospital stay between 3/5/15 and 3/14/15. His comprehensive nutrition assessment of 3/17/15 indicated his daily fluid requirement was 1950 cc (cubic centimeters). On 3/27/15 at 12:00 p.m., further review of the electronic clinical record revealed a dietary notes dated 2/20/15 which documented resident #503's weight was 174.4 pounds. A dietary note dated 3/26/15 documented resident's weight as 151.4 pounds. Depressed appetite since re-admission and emesis. No emesis noted since 3/17/15. On 3/27/15 at 4:15 p.m. resident #503 was lying awake in bed. Observations were made of his physical appearance. His lips and mouth appeared chapped and dry. On 3/30/15 at 1:20 p.m., Registered Dietitian (RD) "D" was asked about resident #503's fluid intake. RD "D" revealed that resident #503 has to be assisted to drink and that he is on nectar thick liquids. She further added, "He is on a diuretic and this increases his fluid requirement. She said an elevated (blood) sodium and urea nitrogen shows a need for additional fluids." RD "D" indicated that from dietary's point of view, he was being provided two beverages with each meal. RD "D" stated resident #503 should have fluids offered to him every shift. She was not sure if there were procedures in place that required a Certified Nurse Assistant (CNA) to offer resident fluids apart from his meals. She indicated there was no documentation available to verify that resident #503 was receiving his daily fluid requirement. On 3/30/15 at 1:50 p.m., CNA "E" was interviewed. She indicated she fed resident #503 breakfast this morning but did not document his intake. CNA "E" stated, "before today (3/30/15) we (CNAs) were not giving resident #503 water (or other fluids) apart from his meal." On 3/30/15 at 3:05 p.m., RD "D" provided documentation of Resident #503's food intake since his return from the hospital (3/14/15). A document titled, "Meal Intake Chart Detail Report" showed all observations between 3/15/15 12:00 a.m. and 3/30/15 1:29 p.m. There were four entries that documented his intake: 3/17/15-breakfast, 3/17/15-lunch, 3/26/15-dinner, and 3/27/15-breakfast. This document did not specify resident's fluid intake. On 3/30/15 at 3:15 p.m., the Assistant Director of Nursing provided a document titled, "Fluid Intake Chart Detail Report". This document contained two entries that documented resident's fluid intake since 3/14/15: 3/17/15-breakfast 240 (cc) and 3/27/15-breakfast 240 (cc). Record review on 3/30/15 at 3:30 p.m. revealed the following: **Resident #503's labratory blood value results revealed the following: 3/25/15- Sodium (normal 135-145), result 151. Chloride (normal (98-109), result 110. Urea Nitrogen (normal 8-20), result 22. 3/30/15- Sodium (normal 135-145), result 136. Chloride (normal (98-109), result 101. Urea Nitrogen (normal 8-20), result 11. **Nursing clinical note dated 3/27/14 indicated, "new order of IV D5 (5% [MEDICATION NAME] in water) water infused at 80 cc/hour for 48 hours. Hold [MEDICATION NAME] until further notice." **Physician note of 3/27/15 indicated the following: "[MEDICAL CONDITION] (elevated blood sodium), increased chloride secondary to dehydration will start hydration with D5 W. Hold [MEDICATION NAME]. Continue Novalog coverage for glycemia. Dysphagia .... pureed diet and thickened fluids discussed with dietitian. Will have speech reassess if (Resident) can tolerate thin fluids. Resident doesn't like to drink thickened (fluids.)" **Physician note of 3/30/15 indicated the following: "[MEDICAL CONDITION], increased chloride was identified. .... D5W, [MEDICATION NAME] held. Encourage increase oral fluids. Labs pending. BS (blood sugars) better controlled. Weight loss was discussed with dietitian post IV hydration. Continue to monitor." A telephone interview was conducted with Physician "F" on 3/30/15 at 3:50 p.m. Physician "F" stated, "(Resident #503) was started on IV (intravenous) fluids due to elevated sodium and chloride levels. These levels are elevated most commonly due to [MEDICATION NAME] use and diminished fluid intake. His blood sugars were elevated. Patient has dysphagia (difficulty swallowing) and takes thickened liquids. His fluid intake should be monitored to ensure he is adequately hydrated." Review of the facility document titled, "Dysphagia Diets", undated, documented the following: "It is recommended that solid foods and fluids be ordered separately so ability to consume a complete meal is maximized for the individual. The registered dietitian work(s) with the (Speech Language Pathologist) to ensure the meals/beverages served meet the nutritional requirements and are accepted by the individual. Individuals who receive thickened liquids are at risk for dehydration when they refuse the beverages based on taste and palate feel." Facility document titled, "Calculating Adult Nutrition Needs", undated, documented the following: "Fluid Needs: The goals of calculating fluid needs include ensure water and electrolyte balance, and tissue perfusion. Tools for evaluating the outcomes of fluid management include: --weight records --intake and output records --serum electrolyte levels" ( )

Based on observation, interview and record review the facility failed to provide adequate supervision and assistance to prevent accidents for one of three (resident #201) sampled residents of a total of three reviewed for falls, resulting in resident #201 falling when left in room sitting up in a shower chair without two person assistance with care (based on current plan of care) sustaining a laceration to the back (left side) of head requiring emergency hospital care with five staples. Findings include: On 12/3/2014 at 10:00 A.M. the facility's Unplanned Occurrence Report dated 11/04/14 at 4:10 P.M., was reviewed. It stated, "The resident (Resident #201) was found lying on the floor in room, having fallen from the shower chair. The resident had just been showered and returned to the room. On assessment the resident was observed lying partially on the left side at the foot of the bed. A moderate to large amount of bleeding from the head was noted. Pressure applied to scalp, wound. Attempted to calm and reassure the resident. Unable to assess due to resistance/combativeness. Placed in bed by the (mechanical lift). Unable to determine the exact location and severity of the injury. The resident was transferred to ER (emergency room ) per the physician's orders [REDACTED]. A review of the facility investigation report dated 11/04/14, described that the resident was being cared for by the hospice aide (employee "F"), and fell forward from the shower chair. Preventive measures and/or corrective action taken: Educate staff on safe practices/procedures for showers and transfers. A review of the emergency room records dated 11/04/14 (time not identified). Findings: Laceration to scalp (a laceration is a cut through the skin) with five staples. On 12/3/14 at 10:30 A.M. Resident # 201's clinical record was reviewed. The resident's current admission was 05/07/10. [DIAGNOSES REDACTED]. The Nursing Home Resident Assessment and Care Screening dated 10/22/14, described cognitive skills that were "severely" impaired. The resident required moderate to extensive assistance with bed mobility, transfers and ambulation. A plan of care was in place, dated 10/23/14. The resident had a decline in activity of daily living (ADL) and overall condition. Interventions included to two person assist with ADLs, to keep environment hazard free, to monitor resident condition, changes in cognition, etc...She was at risk for falls and was unaware of safety concerns. On 12/3/14 at 12 noon, the Clinical Care Coordinator, employee "C" was interviewed. Employee "C" stated, "I was in the facility at the time of the fall. I had instructed the aide of a two person assist during showers and care with the resident (resident #201). The resident had a history of [REDACTED]. The aide was familiar with the resident's care requirements. I responded and observed the resident lying on the floor near the heat register...I recall seeing aide in hallway moments before looking for the lift not realizing that the resident had been left in room alone in shower chair. Upon arriving into the facility the aide should review the kiosk for care requirements." The Director of Nursing (DON) identified, on 12/3/14 at 2:30 P.M., that employee "F", worked for an hospice agency. The hospice aide had returned the resident to her room following a shower and while receiving care by the hospice aide the resident fell with injury. The DON identified that following the incident the aide was reassigned and no longer comes to the facility. The employee failed to follow the resident's plan of care. Employee "F" was not available for interview. On 12/3/14 at 5:00 P.M., the assigned CNA, employee "D" was interviewed. Employee "D" stated, "I went to get the resident clean linen after the shower (given by hospice aide, employee "F"). I noticed that the sling was not in place for the mechanical lift. I went down the hall to another resident room and waited while staff completed their lift transfer (approximately three minutes) when employee "F" opened the door. I said I will be right there, wondering to myself if the aide had left the resident unassisted. Moments later I exited the room with the lift and the hospice aide was in the doorway (resident #201's room) yelling that the resident was on the floor." The facility's ADL policy, dated May 2008 was reviewed. Purpose: To document and provide individualized ADL care to the resident...2. The guide sheet will indicate the care that will be required for each resident on a daily basis. The falls policy was requested but not provided by the end of the survey. ( )

This citation has two deficient practices. Deficient practice #1: This citation pertains to intake #MI 986 Based on observation, interview and record review, the facility failed to prevent a Resident from falling out of the bed while providing direct care for one Resident (#901), out of three Residents reviewed for falls from a total sample of three, resulting in the Resident requiring emergency medical care, sustaining a broken scapula (shoulder) and a head laceration requiring five staples. Findings include: On 7/16/14 at 9:20 A.M., Resident #901 was observed lying in bed. The Resident had her eyes closed, but was alert and groaned as a CNA placed protective boots on her feet. An approximate 1 inch long scar, with approximately 5 staples applied to it, was observed on the Resident's left forehead. On 7/16/14 at 9:50 A.M., Resident #901's clinical record and "Unusual Occurrence Report" was reviewed. Review of Resident #901's face sheet revealed the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #901's "Rehabilitation Screen", dated 4/16/13, revealed, "Rehab (rehabilitation) Screen is complete. There is no change - decline in functional status - limited ROM (range of motion) in L (left) elbow, shoulder, R (right) wrist, elbow, shoulder, B (bilateral) knees. Resident is not a candidate for rehab at this time." Review of Resident #901's "Rehabilitation Screen", dated 2/3/14, revealed, "Resident screen completed. Resident continues to show limited R (right) UE (upper extremity) and LE (lower extremity) ROM (range of motion) without any change in ROM from prior. Resident continued to remain at prior functional level. Resident is not a candidate for skilled therapy." Review of Resident #901's most recent quarterly Minimum Data Set (MDS) Assessment, dated 4/11/14, revealed the Resident's cognition was severely impaired, the Resident required extensive assistance of one person for bed mobility, hygiene and dressing. The MDS revealed the Resident was incontinent of bowel and bladder, had unclear speech, low to no comprehension and poor vision. The MDS also revealed that the Resident had been administered Antianxiety medications 7 out of 7 days during the MDS's look back period. Review of Resident #901's ADL (Activities of Daily Living) Care Plan, effective 7/19/13, prior to being updated on 7/14/14, revealed, "ADL Impairment AEB (as evidenced by) Resident requires extensive to total assist with her ADL's r/t (related to) impaired mobility and cognition secondary to DX (diagnoses) of CHF (Congestive Heart Failure), HTN (Hypertension), CAD (Coronary Artery Disease), and Dementia. Resident will be clean, comfortable, and well groomed." Review of Resident #901's Falls Care Plan, effective 10/21/13, prior to being updated on 7/1/14, revealed, "Resident is at risk for fall r/t (related to) [DIAGNOSES REDACTED]. Goals: Will minimize Resident risk for injury r/t falls. Interventions: bed in lowest position available." The Falls Care Plan did not note how to prevent the Resident from falling during care, until the Care Plan was updated on 7/1/14 to read: "Position Resident in center of bed during care if Resident becomes combative." Review of Resident #901's Dementia with Behavioral Disturbance Care Plan, effective 9/24/13, prior to being updated on 7/9/14, revealed, "Resident has dx Dementia with behavioral disturbance, depression and anxiety. Resident can resist care at times. She can become agitated and grab staffs' hands and/or feeding tube. Goals: Episodes of resisting care will decrease to 2x (two times) or less monthly. Interventions: Approach Resident from the front. Gain Resident's attention prior to beginning care. Approach Resident in a calm manner. Provide gentle touch and reassure Resident as needed. If Resident becomes agitated reapproach Resident." Review of An "Unplanned Occurrence Report", revealed that on 7/1/14 at 6:15 A.M., "CNA was taking care of Resident (#901). Resident combative with CNA. CNA stopped momentarily. Resident fell out of bed. 1 inch cut on L (left) side of forehead. Assisted back to bed with Easy Lift (full hydraulic lift device). Neuro-checks started. Preventative measures and/or corrective actions taken: 1 -2 CNA's needed at all times with care of Resident." The "Unplanned Occurrence Report" listed CNA "A" as being a witness to the incident. On 7/16/14 at 10:10 A.M., Nurse Unit Manager "D" was queried as to how a Resident's level of assistance for ADL (Activities of Daily Living) care is determined. Unit Manager "D" indicated Therapy conducts an assessment to determine the level of assistance a Resident needs. Nursing makes recommendations to Therapy. Unit Manager "D" stated, "We (management) tell CNA's if you feel you need more help in taking care of the patient always do that, then we make a recommendation to Therapy to reassess (the Residents level of assistance needed to provide safe care)." On 7/16/14 at 10:30 A.M., the facility's written investigation related to the fall Resident #901's sustained on 7/1/14 was reviewed. A faxed handwritten statement from Resident #901's daughter, Daughter "C", dated 7/1/14, addressed to the facility's Administrator, read, "Mom was hospitalized today as a result of falling out of bed and hitting her head. The information we received from (facility) staff is sketchy. Please investigate this incident to determine how and why mom fell and whether or not mom fell as a result of abuse or neglect." A written statement signed by CNA "A", dated 7/1/14, written by Nurse "E" as she interviewed CNA "A", read, "You were providing A.M. care to (Resident #901)? Yes. She (Resident #901) was on her side. I was about to change her (provide incontinence care). She was swinging (arms) at me. I stepped back to get out of her way. I guess I had her too far over because she rolled off the bed. It (the bed) wasn't (in) the highest position, just high enough for me to change her. The floor mat was on the opposite side. I don't know what she hit her head on to sustain the cut." A written, signed, statement, dated 7/1/14, provided by Nurse Unit Manager "E" read, "I asked (CNA "A") what bed the height was in. She stated 'just high enough to change her'. She stated she (Resident #901) had a floor mat, but it was on the opposite side of the bed. She stated 'when (Resident #901) started swinging', she backed off and she must of had (Resident #901) too close to the edge, because she rolled off the bed and fell on the floor." A written, signed, statement, dated 7/1/14, provided by Nurse "F" read, "Saw (Resident #901) after EMS (Emergency Medical Service) arrived. Looked large (wound to left side of head) with active bleeding." A written, signed, statement, dated 7/1/14, provided by Assistant Director of Nursing (ADON) read, "Did you go into (Resident #901)'s room? Yes, around 8:30 A.M. because CCC (Nurse Unit Manager) reported she (Resident #901) had a fall. (The Resident was) lying flat in bed with 2 steristrips on around L (left) side of forehead. Blood noted on steristrips and hematoma. 0 guaze noted over steristrips. I immediately went to place pressure dressing and ice to affected area, and called (doctor). Then (doctor) stated to send out (to hospital)." On 7/16/14 at 10:45 A.M., the facility's Assistant Administrator was interviewed in regards to the fall Resident #901 sustained on 7/1/14. The Assistant Administrator indicated that the Resident was not combative, but was more "reaching out", and stated, "The CNA had her on her side. The Resident was going at (grabbing at) the CNA's abdomen area. The CNA stepped back (and Resident #901 fell to the floor)." The Assistant Administrator when queried if Resident #901 had a history of [REDACTED]. We'll have to check." At 11:35 A.M., the Assistant Administrator stated, "We checked the behavior log. There was nothing noted from the last year (any behaviors for Resident #901)." On 7/16/14 at 11:05 A.M., an interview was conducted with Resident #901's daughter, Daughter "C". Daughter "C" stated, "I don't think it was very good (the fall and fracture Resident #901 sustained on 7/1/14). They (facility's Administration) said the aide (CNA) stepped away because my mom was grasping at her." On 7/16/14 at 12:25 P.M., Resident #901's most recent Therapy Screens were reviewed with Therapy Director "G". Therapy Director "G", when queried in regards to Resident #901's bed mobility, stated, "She's dependent for ADL's (Activities of Daily Living), bathing, dressing, grooming. Therapy's recommendation was for the least amount of assistance (1 person assist), but if direct care staff need more help they are to request it." On 7/16/14 at 2:00 P.M., Resident #901's hospital records were reviewed. The "Triage Note", dated 7/1/14, revealed, "Visit reason: Fall, Lac (laceration) to head." The "CT (Cat Scan, diagnostic X-ray scan) Head or Brain w/o (without) Contrast" report, dated 7/1/14, revealed, "Comparisons: CT head dated 1/16/11. Noncontrast axial CT imaging of the brain was performed. Impression: Left lateral scalp soft tissue swelling." The "XR Humerus Left" report, dated 7/1/14, revealed, "[AGE] year-old female with left upper extremity pain after fall, head injury. Findings: There is a mildly displaced proximal left clavicle fracture better visualized on cervical spine CT exam." The "History and Physical" report, dated 7/2/14, revealed, "(Resident #901) resides at a nursing facility. She had a fall out of bed. She had a laceration on her scalp. She was sent to the emergency room . She had sutures. She was also found to have a left clavicle fracture. She has Dementia. She is pretty much nonverbal. She has been seen by orthopedics, who will treat the fractures supportively. Left lateral scalp soft tissue swelling. Left-sided scalp laceration, status [REDACTED]. On 7/16/14 at 3:30 P.M., the facility's Director of Nursing (DON) was interviewed regarding the fall Resident #901 sustained on 7/1/14. The DON stated, "We tried to look at the root cause (of Resident #901's fall on 7/1/14). That CNA had provided care for years for that Resident. What was different that day? The CNA said 'nothing'. When she (the CNA) stepped forward (after stepping back while the Resident was up on her side) she couldn't catch the Resident time enough. The DON was queried as to what her expectation was for staff when Residents grab at staff during care. The DON stated, "I'd like to see the Resident properly positioned before she stepped away. Lower bed. Call out. Scream out. Safety first. I understand Resident has a grip, but safety first. We did not deviate from our plan of care, but did she (CNA "A") make a bad decision? Absolutely." On 7/16/14 at 5:00 P.M., reeducation documentation provided for CNA "A" was reviewed. The document entitled, "Education/Inservice Record", signed as being completed by CNA"A" on 7/14/14, read, "2. If Resident is demonstrating behaviors, associate (CNA) is to stop what they are doing and make sure the Resident is safe, and then notify the nurse. If Resident is not safe, i.e. not in a safe position, ex. (example) near edge of bed and not in center of bed, the Associate is to maintain Resident's safety and call for nurse." On 7/16/14 at 7:30 P.M., a telephone interview was conducted with CNA "A". CNA "A" indicated that she had provided care for Resident for #901 for several years. CNA "A" stated, "I went to change her (provide incontinence care). (Resident #901) became combative and I didn't ask for help. Instead of me leaving her alone, I was still trying to change her, and she was still being combative. I sat her up on her side, I stepped away and she fell . She (Resident #901) was swinging her arms and hit me on my arms and was kicking her feet." When CNA "A" was queried as to if the Resident had ever reacted physically during care in the past, CNA "A" responded, "Yes, but before I'll (I would) ask for help and two of us would go in and change her. This night I didn't ask for help. I should have." To determine the height of the bed at the time Resident #901 fell , CNA "A" was queried as to what position the bed was in while she was providing pericare for the Resident. CNA "A" indicated that the bed, while providing pericare to Resident #901, was higher than waist height. CNA "A" responded, "It was probably a little higher than that for me to change her (bed was higher than the waist of the CNA)." On 7/16/14 at 7:40 P.M., the facility's fall policy, dated 9/2009, entitled, "Fall Prevention Red Star Program: High Risk for Falls", was reviewed. The policy addressed interventions put in place to prevent Residents from falling due to risky Resident behaviors (ie. attempting to ambulate with an unsteady gait); however, the policy as provided did not address how to keep a Resident who had no bed mobility (unable to move in bed without staff assist) from falling out of the bed while care is being provided by staff. The facility's policy on preventing Resident falls during care was requested, but was not received by survey exit. Deficient practice #2: This citation pertains to intake #MI 079 Based on observation, interview and record review, the facility failed to provide supervision or feeding assistance for one (#902) of three Residents reviewed for accidents, out of a total sample of three, resulting in a second degree burn to the Resident's right thigh. Findings include: On 7/15/14 at 9:40 A.M., Resident #902's daughter, Daughter "H", was contacted and interviewed via telephone. According to Daughter "H", Resident #902 was admitted into the facility in March, 2014 due to a fall and fracture the resident sustained [REDACTED].#902) definitely needed help eating. Two Care Conferences ago (several months ago)." Daughter "H" continued, "I did not arrive (at the facility on 6/9/14) until the end of dinner. I got to the lunch room at 6:15 P.M. At 6:30 P.M., Dad (Resident #902) told me 'I spilled soup on myself. I saw the video. No one stopped to check on him (staff did not provide feeding assistance or supervision while the Resident was dining in the Dining Room that evening). He sat at the table alone and no one paid any attention and they kept walking by him. We (Resident #902's family) told them three times he needs help to eat. Sometimes the food is very hot when it gets to my Dad and I'll say 'Dad you'll have to wait. It's too hot.' When I came at dinner his pants were wet on the upper right side and he had food all over his lap." On 7/16/14 at 9:15 A.M., an unannounced site visit was made to the facility. On 7/16/14 at 1:30 P.M., Physician "I", Resident #902's attending physician, was interviewed in regards to the burn Resident #902 sustained on 6/9/14. Physician "I" stated, "They (staff) informed me on the day it occurred (on 6/9/14 when Resident #902 was burned on his right thigh). We initiated first aid. I saw him on 6/11/14. There was red skin with two areas of blisters (on the right thigh)." When Physician "I" was queried as to if the Resident suffered from tremors due to the Residents [DIAGNOSES REDACTED]. He does not have tremors, but (he is) slow to respond. At the time he was supervised feeding. He can have soup. It's not a problem, but its up to the nurse how much supervision is provided." When Physician "I" was queried as to if Resident #902 would have needed staff assistance to eat a bowl of hot soup on 6/9/14, Physician "I" stated, "Yes. That is why he (Resident #902) is Long Term (in the nursing facility). " Physician "I" went on to explain that the burn Resident #902 experienced was a "simple burn" near a "simple bone", but due to the Resident's frail state, Resident #902's burn wound had been slow to heal. On 7/16/14 at 2:10 P.M., Resident #902's Care Conference Summaries were reviewed and revealed the following: 1) The typed summary revealed: "Care Conference held 3/20 (2014) with IDT (Interdisciplinary Team), wife (of Resident #902), daughter and son-in-law. Dietary discussed eating habits, assist with eating, recommendation for 24/7 care r/t (related to) Parkinson's." The handwritten summary for the same date revealed: "Care Plan Conference Summary. Plan of Care: Fed by staff. ADL's (Activities of Daily Living including eating) Max Physical Assist (by staff). Wife aware of Resident needing assist with eating. Recommendation is for 24/7 supervision." 2) The handwritten summary revealed: "Care Plan Conference Summary. Date: 5/16/14. Wife, three daughters (of Resident #902) present. Plan of Care: Dependent for ADL's (including eating); unable to make needs known. Special Care Conference held at (attending physician's) request to address issues with family. IDT, spouse and (three daughters) in attendance." On 7/16/14 at 2:10 P.M., Resident #902's clinical record, "Unusual Occurrence Report", "Clinical Notes Report", "Care Plan" and "Rehabilitation Screens" were reviewed. Resident #902's face sheet revealed the Resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]., and Dysphagia (difficulty swallowing). Resident #902's most recent quarterly Minimum Data Set (MDS) Assessment, dated 6/12/14, revealed the Resident's cognition was severely impaired, and the Resident required extensive assistance of one person physical assist for most Activities of Daily living, including bathing, dressing and eating. Per the MDS, the Resident had clear speech, but only sometimes understands others. The MDS also noted that the Resident showed periods of fluctuating "inattention" during the Assessment, and had difficulty focusing attention or was easily distracted. An "Unplanned Occurrence Report", revealed that on 6/9/14 (no time of day was indicated on report), "Resident reported to CNA (Certified Nursing Assistant) "I spilled soup on myself." Per CNA, upon assessment, noted a reddened, blistered area on right upper thigh measuring 16.9 cm (centimeters) x 5.5 cm. Full investigation to be completed. Applied ice pack to reddened area. Therapy to evaluate for safety. Resident to have assistance with all meals." A review of the "Clinical Notes Report" for Resident #902 revealed the following: 5/16/14, at 11:49 A.M., "Special Care Conference held at (attending physician's) request to address issues with family. Family is aware Resident is assisted with eating." 5/16/14, at 1:06 P.M., "Staff is encouraging and assisting food and fluids at all meals." A review of the Hot Liquid Safety Care Plan for Resident #902 revealed, "Effective: 3/7/14 - Present. Problem: Hot Liquid Risk. Resident is at high risk with management of hot liquids r/t: Intermittent confusion. Interventions: Resident will be safe with hot liquids when OOB (out of bed)/up in wc (wheelchair)." On 7/16/14 at 2:20 P.M., Resident #902's "Rehabilitation Screening" forms were reviewed with Therapy Director "G". The "Rehabilitation Screening" forms, completed by licensed therapists, contained a section labeled "Hot Liquid Safety". Resident #902's "Rehabilitation Screening", dated 3/11/14, revealed, "Hot Liquid Safety: Staff administering liquid/controlling safe oral intake." Resident #902's "Rehabilitation Screening", dated 5/13/14, revealed, "Hot Liquid Safety: Staff administering liquid/controlling safe oral intake. Applies to: All hot liquids. Recommend speech services to assess for appropriate diet and safe feeding strategies." Therapy Director "G" stated, after reviewing the "Rehabilitation Screening" form dated 5/13/14, "He (Resident #902) was having trouble feeding himself and required assist." When Therapy Director "G" was further queried if the Resident should have had assistance to eat Jumbolaya or soup on 6/9/14, Therapy Director "G" stated, "Yes." On 7/16/14 at 3:45 P.M., skin assessments for Resident #902 were reviewed and revealed the Resident had no new skin problems up until 6/7/14. On 7/16/14 at 3:55 P.M., temperature logs for the soup Resident #902 was served during the dinner meal on 6/9/14 were requested. The facility's Registered Dietitian confirmed that it was not hot soup that was served the evening of 6/9/14, it was "Jumbolaya". The temperature log revealed that on 6/9/14 the "soup" was measured at 190 degrees Fahrenheit at the "mid" (middle) of service and 178 degrees Fahrenheit at the "End" of service. The RD confirmed that even though the temp log read "soup" the temperature entries for that evening was for the Jumbolaya, and further indicated that the "end" temperatures are taken at approximately 7:00 P.M. On 7/16/14 at 4:00 P.M., Wound Care Physician Notes for Resident #902 were reviewed and revealed the following: 6/18/14 - "New Patient Consultation for Wound Care"; He (Resident #902) had burn when he spilled warm soup on himself. He did not tell the nurse until she changed him and they started the (burn Medication) right away. He is alert and oriented x 1 (cognitively impaired). The right anterior thigh had a clear blister that open and now measures 3.5 x 9.0 x 0.1 (l x w x h, in centimeters), 100% granular tissue of the base. Second degree burn. We will continue with precautions with the hot fluids." 6/25/14 - "Established Patient (Resident #902). Progress Note for Wound Care. I am here to see the patient again for his right anterior thigh burn. At the right anterior thigh wound, measures 3.5 x 9.0 (centimeters), unable to determine the depthness. I crosshatched with a #10 blade of scalp debridement to the subcutaneous tissue." 7/2/14 - "Established Patient. Progress Note for Wound Care. I met with the family and the (attending physician) in the case (for Resident #902). In this meeting, I explained the situation of the wound being necrotic tissue and slough about 20% necrotic tissue and 80% of slough that surgical debridement will potentially help to speed up the healing. The patient is very confused, forgetful, and that has not been changed for him. His right anterior thigh burn measures 3.0 x 10.0 x unable to determine depthness. I used #10 blade scalpel and did a sharp excisional debridement, removed all slough. There was a dry slough and necrotic tissue, coming to a healthy bleeding base." 7/9/14 - "Established Patient. Progress Note for Wound Care. He (Resident #902) is able to answer yes or no to questions, very simple questions, follow simple commands. The right anterior thigh burn now measures 3.0 x 10.0 x unable to determine depthness, has 30% of slough, 70% of granular tissue of the base, mild serous drainage." On 7/16/14 at 5:05 P.M., the facility's Director of Nursing (DON) was interviewed in regards to the burn Resident #902 experienced on 6/9/14. The DON stated, "We didn't notice until night time (that the Resident had been burned by Jumbolaya during the dinner meal) and he was being changed for bed." The DON indicated that the video of the incident did not directly show the soup spilling on the Resident, but according to the DON the video revealed the following: "She (Resident #902's daughter) dabbed him (tried to wipe the spill from Resident #902's clothes) on camera and brings the Resident out (of the Dining Room) back to his room and goes to laundry and gets a shirt. The daughter asked the nurse to put him (Resident #902) in bed and CNAs noticed the burn." The DON was queried as to why Resident #902 was not assisted by staff to eat hot Jumbolaya on 6/9/14 at the dinner meal to "administer liquid and control safe intake" as the Rehab Screen noted on 5/13/14. The DON indicated that there had been recent discussions among management regarding the clarity of the form, and stated, "We (facility staff) were not intentionally bypassing therapy's recommendations, but the recommendations could have been more clear." The review of the written statement, signed by RN "J", dated 6/11/14, read, "I fed (Resident #902) on 6/9/14 at lunch. No soup was served during lunch." The facility's DON provided a "Timeline of Events" for Resident #902 for 6/9/14. A review of the "Timeline of Events" provided indicated (on 6/9/14), at 6:15 P.M., Resident #902 was "seen lifting bowl to mouth"; at 6:21 P.M., Resident #902's daughter wheels Resident out of the dining room and takes Resident to his room; at 7:15 P.M. Nurse aide approaches nurse at the nurses' station to report the observation of the reddened area (on Resident #902's right upper thigh). On 7/16/14 at 6:00 P.M., Resident #902 was observed sitting in his bed watching television. The Resident was alert and was slow to provide answers to simple, yes, and no questions. On 7/16/14 at 6:30 P.M., the facility's policy entitled, "Promoting Safety with Hot Liquids", Revised 6/2011, was reviewed and revealed, "There is an inherent risk for potential injury to all Residents electing to handle and/or consume a hot liquid. All risk cannot be eliminated. Many Residents have conditions that may put them at increased risk for burns caused by scalding, including decreased agility, decreased cognition or dementia, decreased mobility and decreased ability to communicate." The policy continued, "The degree of injury from burns or scalding caused by hot water or other liquids depends on the temperature of the liquid, the amount of skin exposed and the duration of exposure. Promoting safety with hot liquids among our Residents, will be an interdisciplinary commitment between Therapy, Nursing, and Dining Services. Hot liquids are defined as liquids at temperatures of 140 - 185 degrees (Fahrenheit). Upon admission and quarterly, the Residents are screened by Therapy to determine their ability to safety manage hot liquids." The policy further documented "Track A High Risk" and "Track B Not High Risk", but did not discuss the other option on the "Rehabilitation Screening" form: "Staff administering liquid/controlling safe oral intake." ( )

Based on observation, interview, and record review, the facility failed to properly monitor the use of anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) for one (#203) of 24 sampled residents reviewed for medications from a total sample of 24, resulting in [MEDICATION NAME] toxicity (abnormally high blood level) requiring hospitalization and subtherapeutic (ineffectively low) [MEDICATION NAME] levels that could lead to [MEDICAL CONDITION] activity. Findings include: On 5/20/14 at 9:30 AM, resident #203 was observed lying in bed receiving incontinence care by staff. The resident was alert, non-verbal, but able to reliably respond to questions by nodding and pointing, and was able to indicate her needs to staff. On 5/23/14 at 10:45 AM, the clinical record for resident #203 was reviewed with the Director of Nursing (DON). The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident required extensive assistance for activities of daily living per minimum data sets dated 9/26/13 and 3/25/14. Resident #203's monthly medication renewal orders dated June 2013 noted that the resident was prescribed [MEDICATION NAME] 100 milligrams (mg) three times a day. A physician order [REDACTED]. The normal therapeutic blood level range for [MEDICATION NAME] was 10-20. From 6/2013 thru 10/13/13, the resident continued to receive [MEDICATION NAME] 100 mg three times a day. There was no documented order to monitor the [MEDICATION NAME] level. Per review of a hospital history and physical report contained in the clinical record for resident #203, the resident was hospitalized from [DATE] thru 10/19/13 for the following: "She came into the emergency room with altered mental status. She has been more confused and lethargic at the nursing facility for the last few days....Her [MEDICATION NAME] level was....found to be high....Her [MEDICATION NAME] was held. She was admitted for acute [MEDICAL CONDITION] (abnormal brain function)....She was more confused and combative earlier....Currently she is more lethargic than her baseline, but she is answering some questions. She states that she does not feel good....[MEDICATION NAME] level on admission was 40.8...." (twice the normal range). "Impression....Acute [MEDICAL CONDITION]. [MEDICATION NAME] toxicity." Resident #203 was readmitted to the facility on [DATE] with an order for [REDACTED]. From 6/2013 thru 4/2014, there was no documented recommendation by the facility's pharmacy to obtain levels during monthly reviews of the resident's medications. There was a verbal order reviewed in the chart by the resident's Primary Care Physician (PCP 'E') dated 5/22/14: [MEDICATION NAME] level stat (immediate) and [MEDICATION NAME] level every six months. When asked about the results, the DON presented a lab report dated 5/22/14: The [MEDICATION NAME] level was again 8.9 (subtherapeutic). When queried about periodic monitoring of resident #203's [MEDICATION NAME] level prior to 5/22/14, in lieu of the history of toxicity and the subtherapeutic levels, the DON said, "The physician didn't order it. It's up to him to order them." When asked about a standing order (medications that require associated lab tests) for monitoring [MEDICATION NAME] levels, the DON said, "We don't have standing orders." There was no documented indication of discussions with the physician by nursing staff regarding monitoring the level. On 5/23/14 at 12 noon, Pharmacist 'I' was queried by phone regarding recommendations or standards of practice for monitoring [MEDICATION NAME]. Pharmacist 'I' said, "There is no standard of practice. There is no recommendation. It is up to the physician to order it." At 12:10 PM, when queried about obtaining [MEDICATION NAME] levels prior to 5/22/14 for resident #203, PCP 'E' said, "I usually go by pharmacy recommendations" then said, "I usually see what the level is then order the levels repeated." The PCP said, "I spoke to the pharmacy (on 5/22/14) and they recommended every six months." On 5/23/14 at 10:45 AM, a review of resident #203's "[MEDICAL CONDITION]" care plans dated 7/1/13 and 3/20/14 revealed: Goals: "Resident will remain free from injury and will be free from signs/symptoms of adverse reaction...." Interventions included: "Monitor labs for serum drug levels as ordered...." and "Maintain safety issues in event of [MEDICAL CONDITION]." On 5/23/14 at 2 PM, a review of the facility's "Laboratory Services" policy dated 5/2008 revealed: "The facility and Medical Director will determine if lab tests need to be standardized with medications that require lab testing. These guidelines are also referenced under F-329 related to recommended tests for medications and the pharmacy guidelines for review. The facility will develop a Quality Assurance (QA) program to check that labs that are ordered and medications that require labs have been completed....The pharmacy provider would also participate in this QA process....It is important....to have a process to monitor those residents who are on high-risk medications such as:[MEDICATION NAME]." ( )

This citation has two deficient practices: Deficient Practice #1 Based on observation, interview, and record review, the facility failed to consistently implement and/or document interventions and provide close supervision for the prevention of multiple falls for two (#'s 209 and 219) of nine sampled residents reviewed for falls/accidents, out of a total of 24, resulting in a hematoma, fracture and pain. Findings include: On 5/20/14 at 9:45 a.m., during the initial tour of the facility with the Assistant Director of Nurses (ADON) Resident #209 was observed sleeping in a low bed with a bed alarm in place. The ADON stated, "(Resident #209) has a history of falls and fracture of the nose. She has a rocker chair in her room in which she utilizes when she is tired or fatigued." On 5/20/14 at 2:10 p.m. Resident #209 was observed wheeling her wheelchair up to the nurses station and stated "I want to take a nap." The resident continued to ask staff if she could have a nap. The resident was taken down to the dining area for an activity. On 5/20/14 at 2:10 p.m. Resident #209's medical record was reviewed and revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's minimum data set assessment (MDS), dated [DATE], revealed that the resident's cognition was severely impaired and required extensive assistance for most activities of daily living (ADL's). The MDS noted that the resident had a history of [REDACTED]. On 5/22/14 at 10:20 a.m., Resident #209's Unplanned Occurrence Reports and medical record were reviewed with the ADON. The ADON stated, "She had alarms in place because she always tries to get up on her own. She has rest periods throughout the day." Review of resident #209's Physician order [REDACTED]. Wheelchair with gel cushion and non skid pad. Mat alarm to bed and wheelchair." Review of Unplanned Occurrence Report, dated 7/21/13 at 10:05 p.m., revealed "Resident calling for help. Observed resident lying on the floor near the foot of her bed between her wheelchair and the wall with her head resting on the foot brake of a parked carefoam chair. States she wanted to go to bed." The Interdisciplinary Post fall Summary, dated 7/24/13, was reviewed and revealed "Alert, confused and forgetful resident, cognitively impaired. Needs assist with ADL's. Does not use call light, does not always ask for assist or wait for assistance. Staff heard alarm sounding and resident calling for help. Intervention: Recommend asking resident after dinner when she would like to go to bed to meet her bedtime preference and continue with alarms." Post fall risk score 14, 15 or more high risk (for falls). Review of Unplanned Occurrence Report, dated 9/25/13 at 2:15 p.m., revealed "Heard resident yelling help, alarm sounding, observed resident on the floor, sitting with her back leaning on the bed. Preventative measures and/or corrective action: Resident to be put in a carefoam chair for a nap after lunch, resident to stay in the hallway." Review of clinical notes, dated 9/27/13, revealed "Continues to require monitoring for unsafe transfers." Review of the Post Fall Summary, dated 9/26/13, revealed "Per staff resident had been laid down for a nap. She had been toileted prior to being put to bed. IDT (interdisciplinary team) met and concurred that after lunch and toileting if resident needs to nap, she should be placed in a carefoam chair (specialty chair) in hallway where she can be monitored for restlessness." The ADON was queried regarding resident #209's fall risk score after the fall and stated, "I'm sorry. I don't have one (Fall Risk Assessment) for that fall." Review of resident #209's physician order, dated 9/25/13, revealed "Resident to be put to carefoam chair after lunch for a nap." Review of Unplanned Occurrence Report, dated 10/7/13 at 5:05 p.m., revealed "Resident fell forward out of wheelchair as a staff member began to move her chair through the dining room doorway. Resident was wearing her glasses at the time resulting in a superficial abrasions/contusions to left periorbital area. Hematoma to left forehead. Preventative measures and/or corrective actions taken: Assist to and from dining room. Assure resident sitting safely in wheelchair when assisting from the dining room." Fall risk assessment, dated 10/8/13, revealed a score of 15, indicating high risk for falls. Review of "Interdisciplinary Post-Fall Summary," dated 10/8/13, revealed "IDT met and concurred that not only does resident need assist in and out of dining room but assure she is sitting safely in wheelchair when assisting her." The ADON was queried as to what took place and stated, "They (staff) were assisting her out of the dining room. She went forward in her chair. Sometimes she scoots up and tries to stand." When queried as to if staff was educated on ensuring the resident is sitting properly in chair before attempting to assist resident from the dining room, the ADON stated, "No. We didn't feel that the staff did anything wrong. They were there to assist her." Review of Unplanned Occurrence Report, dated 1/14/14 at 2:20 p.m., and Clinical Notes, dated 1/14/14 at 3:50 p.m., and the Post Fall Summary were reviewed and revealed that Resident #209 was observed sitting on the floor mat on the side of her bed. The post fall intervention was for the resident to be "Up in carefoam chair. Naps to be in carefoam chair in hallway for monitoring." The ADON was queried as to why Resident #209 was not in a carefoam chair for her after lunch nap at the time of the fall and stated, "That's a problem. That was a previous intervention. I am not sure why it was not implemented." When queried as to if there was any staff education regarding Resident #209's plan of care, the ADON stated, "I will see if there was any education." Review of Unplanned Occurrence Report, dated 2/17/14 at 7:00 a.m., revealed "Resident found sitting on floor beside bed. Preventative measures and/or corrective actions taken: When alarm sounds and resident at side of bed, get resident up in chair." Post fall summary dated 2/18/14, revealed "If alarm is sounding and/or resident is attempting to sit on side of bed, she should be gotten up into wheelchair." The ADON was queried regarding the incident and stated, "If it is early they must go to her immediately and get her. She needs to be monitored in a common area." When queried as to if the floor mat was in place and the bed in low position, the ADON stated, "It does not say." Review of Unplanned Occurrence Report, dated 4/8/14 at 6:10 a.m., revealed "Bed alarm was sounding. Entered room, observed resident sitting on the floor with her back against the bed. Stated, 'I don't know what happened. I was turning, turning, turning and then I was here.' Preventative measures and/or corrective actions taken: Ordered a winged mattress." Review of Unplanned Occurrence Report, dated 4/21/14 at 5:05 p.m., revealed "Called to dining room by activities aide. Resident observed on floor face down with chair alarm sounding. Injury sustained to nose." Review of Clinical progress notes, dated 4/21/14 at 6:50 p.m., revealed "During activities, writer called down to Rose dining room by activities staff. Observed resident lying on right side face down on floor with blood coming out and from her nose with alarm sounding. Range of motion performed on all extremities and pain verbalized from resident on right lower extremity. First aid administered to stop bleeding from nose/ineffective ..." Clinical progress notes, dated 4/22/14 at 1:30 a.m., revealed "Bruising to bilateral eyes, swelling and cut to bridge of nose noted." Clinical notes, dated 4/22/14 at 9:52 a.m., revealed "periorbital bruising on bilateral eyes, abrasions and slight swelling on the bridge of her nose." Clinical progress notes, dated 4/22/14 at 8:11 p.m., revealed "Resident has fractured nose from the fall." Review of resident #209's "Radiology Report," dated 4/21/14, revealed "Conclusion: nasal bone fracture." Review of resident #209's "Proof of Internal Investigation Report," for the fall on 4/21/14, revealed "Brief description of the alleged incident in the words of the person who reported/informed: Resident attempt to stand fell in dining room alarm sounding activities aide present at time of fall unable to prevent fall. What long term policies were implemented or re-implemented to prevent a similar future occurrence? Anti roll back applied to wheelchair. Continue with wheelchair alarms and monitor resident in common area. Conclusion from investigation: After thorough investigation no abuse no deviation from plan of care. Resident is currently on Red Star (fall program). Fall happen after group activities was over. Activity assistant in dining room-not close enough to prevent fall." Staff Interview, Activities (Employee "H" ), dated 4/22/14, was reviewed and revealed "Were you in the dining room when (resident #209) had a fall? Yes, I didn't see the fall. I heard the fall. I was talking to (another resident and resident husband) and I hear the thump. Did you hear the alarm sounding? After I heard the thump. Activities was over at the time of fall I was on my way out of the dining room it happen around 5:05 p.m." The video of the incident was reviewed with the ADON. The ADON was queried regarding the incident and stated, "Activities just ended. It looked like she (resident #209) was leaving the dining room. The activities person is (inside the dining room) talking to a resident and resident husband, but around the corner from the door (The resident is not in site line of the activity aide)." When queried about supervision and who was to assist the residents out of the dining room, the ADON stated, "Our staff (nursing) and activities. One staff stays in the dining room the others help get them out." The ADON was queried as to what staff were assisting the residents out of the dining room but provided no comment. When queried regarding Employee "H's" comment that she was talking with a family and on her way out of the dining room, as to who was supervising the dining room, the ADON provided no comment. Further review of the facility investigation into resident #209's fall revealed a "Activity Colleague Meeting," dated 2/12/14 and revealed "When doing groups, ensure that all residents, are near you, bring them closer in a circular groups if possible, never turn your back to resident be where you are able to monitor the entire dining room, for safety." Review of resident #209's care plan titled, "Resident is at risk for fall related to: fall risk assessment 14, resident frequently gets out of bed without utilizing call light and is unsafe with ambulating or transferring, frequently attempts to toilet self ...," no initiation date, revealed "Interventions: assist to and from dining room as needed 10/7/13. Place resident in carefoam chair after lunch for a nap. Assist resident with locomotion on the unit." The care plan was not updated with the fall risk score of 15 noted on the fall risk assessment dated [DATE]. On 5/22/14 at 2:10 p.m., the ADON stated "There was no CNA education for the fall on 10/7/13 (when staff assisted the resident out of the dining room). We felt there was no need for education. She (the staff) was trying to unclutter the area. There is no documentation as to whether the bed was in low position or the mat in place ( for the incident on 2/17/14) and no documentation as to why the resident had not been in the carefoam chair as ordered (incident on 1/14/14)." On 5/22/14 at 2:50 p.m., the facility Director of Nursing was queried regarding resident #209's falls, interventions not put in place and supervision but provided no comment. Review of the facility's policy titled, "Fall Prevention Red Star Program: High Risk for Falls," dated 9/2009, revealed "Any resident who has at least two of the following criteria will also be considered at high risk for falls and placed on the Red Star Program: Resident has at least a score of fifteen or greater on the... fall risk assessment and any one or more of the following: resident had one fall within the past three months in the building. Resident attempts unsafe self transfers. Resident frequently gets out of bed without utilizing call light and is unsafe with ambulating and/or transferring. Resident has unsteady gait and has high tendency to fall. The following interventions will be applied while a resident is on the Red Star Program...these residents will be a priority for all Nurse Assistants to ensure the resident's needs are met timely. The activity department will develop specific programming which can assist the resident to be involved in meaningfully engaged activities while out of the room. All residents that fall have a post fall assessment and a fall risk assessment completed after each fall." ( ) On 5/23/14 at 11:10 a.m., review of Resident #219's face sheet revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #219's annual Minimum Data Set (MDS) assessment, dated 5/20/14, indicated an intact cognition, required extensive assistance with activities of daily living (ADL's), and extensive assistance with walking. The MDS also indicated that Resident #219 was not steady, was only able to stabilize with staff assistance for the following: 1. Moving from seated to standing position, 2. Moving on and off toilet, and 3. Surface-to-surface transfer (transfer between bed and chair or wheelchair). On 5/23/14 at 11:50 a.m., review of Resident #219's clinical record and Incident and Accident (I/A) reports were reviewed with the Unit Nurse Manager (Nurse "C"). The following incidents were reviewed with concerns: Incident #1: Occurred on 7/23/13 at 4:00 a.m. The I/A report revealed the following documentation: "Observed resident (#219) lying on floor on left side near roommate's bed." The incident report did not indicate that the sensor pad alarm sounded when Resident #219 was observed on the floor. Resident #219's care plan for falls indicated that an alarm (sensor pad alarm) should have been in place at the time. Nurse "C" was queried regarding the alarm. Nurse "C" stated, "He (#219) was known to turn off his alarm. We started hourly rounds. He wanted to use the the bathroom. We started toileting him at intervals and had him wear non-skid sock while in bed. He was placed on our Red Star Program (Program for residents at high risk for falls) on admission." The interventions that were documented on the I/A report included: "Toilet every 2 hours, anti-skid socks, check placement every shift, and medication review." Incident #2: Occurred on 7/25/13 at 1:15 p.m. The I/A report revealed the following documentation: "Attempted to toilet self, transfer from w/c (wheelchair) to toilet without assistance." Post fall interventions included: "Resident's slippers given to family, lime green tape applied to call light and bed control." Again, there was no mention of the sensor pad alarm sounding. There was no explanation provided as to why Resident #219 was in the area alone and not supervised. Incident #3: Occurred on 7/29/13 at 8:25 a.m. The I/A report revealed the following documentation: "Attempted to get OOB (out of bed). Appears to have slid off mattress to floor mat..." The I/A report included the interventions: "Midnight shift to assist resident out of bed before 7 - 3 shift and dressed." There was no documentation of the sensor pad alarm sounding. Nurse "C" stated, "He (#219) was found sitting on the fall mat. He (#219) complained of left hip pain. An x-ray was ordered and it was negative for fracture." Incident #4: Occurred on 8/19/13 at 4:45 p.m. The I/A report revealed the following documentation: "Resident noted in sitting position on floor with pants and shoes off. Resident states, 'I was changing my diaper.' There was no documentation of when the last time Resident #219 was seen by staff. Preventative measures documented on the I/A report read: Collaborate with activities to ensure resident (#219) does not ambulate without being assisted to unit by Activities." Review of the addendum Nurse's note, dated 8/20/13, revealed the following documentation: "Resident observed sitting on floor...Noted small hematoma on right side near temple. Ice applied...Stop sign on door post applied for cueing. Complained of discomfort on right side near ribs. Stat (immediate) x-rays were ordered of the skull, ribs, arm and knee..." All of the x-rays were negative. There was no documentation of the sensor pad alarm sounding. Nurse "C" reported that resident #219 was in an activity and that he left the activity without the staff noticing. Incident #5: Occurred on 8/28/13 at 10:30 a.m. The I/A report revealed the following documentation: "Resident was sitting by the edge of the bed while waiting to be changed, ADL by the therapy, resident slide down on his buttock, sitting on the floor with back against the bed..." Nurse "C" reported that resident #219 had this fall while therapy was helping him with his ADLs. Nurse "C" was then queried if the therapy staff person was available for an interview regarding the incident. The Certified Occupational Therapist Assistant (COTA "Z") identified herself as the person who observed Resident #219 on the floor when she entered his room. COTA "Z" stated, "I observed the resident on the floor. He was already on the floor when I entered the room. I then reported it to the nurse. I can't remember if the alarm was sounding." Nurse "C" stated, "We then started doing hourly checks and a winged mattress was added to his bed." Nurse "C" had no explanation for the inconsistent details of the incident. The nurse's note (dated 8/28/13 at 9:46 a.m.) for the incident read: "Slid off the bed during ADLs by the PT (physical therapist). Noted at bedside before sliding off the bed." Incidents #6, #7, and #8; each occurred on 8/30/13 at 1:55 p.m., 10/21/13 at 1:45 p.m., and on 11/7/13 at 11:45 a.m.: The incident and accident reports indicated Resident #219 was found in the bathroom on the floor each time. Per all three I/A reports, staff did not know how Resident #219 had gotten into the bathroom and indicated that they did not know he was there until the sensor alarm sounded. Nurse "C" was queried regarding the toileting schedule and reported that Resident was toileted every 2 hours or as needed. Resident #219's evaluation for bowel and bladder training was never presented after requested. Incident #9 occurred on 4/30/14 at 6:00 a.m. The I/A report revealed the following documentation: "Resident was observed lying on the floor next to his bed. Incident was unwitnessed..." The post fall interventions listed on the I/A report included: "Remind resident to call for assistance using call light. Hourly check for toilet assist." On 5/23/14 at 12:30 p.m., Resident #219 was observed sitting in a wheelchair in the dining room awaiting lunch. A sensor pad alarm device was noted in place (a device that alarms when pressure relief is detected). Resident #219 answered select questions with short one to three word answers. On 5/23/14 at 2:20 p.m., review of the facility's policy entitled "Fall Prevention Red Star Program : High Risk for Falls," dated September 2009, (for residents who are on the Red Star Program) included the following interventions: "Bed and wheelchair alarm will be used for all residents, Non-skid pad (dicem) to wheelchair for all residents to prevent slipping out of wheelchair, and Schedule toileting program as necessary for each resident as determined by their Evaluation for Bowel and Bladder Training." The policy also indicated that residents placed on the Red Star Program would not be left in their room or bathroom alone unless they are lying down. The Activity department will develop specific programming which can assist the resident to be involved in meaningful engaged activities while out of the room. On 5/23/14 at 3:10 p.m., The Director of Nurses (DON) was informed of Resident #219's falls. The DON stated, "We did everything for him. There was nothing left for us to do." ( ) Deficient Practice #2 Based on observation, interview, and record review, the facility failed to implement interventions to prevent the ingestion of a prescription external use only medication for one (#216) of nine sampled residents reviewed for accidents, out of a total of 24, resulting in the ingestion of a steroid cream. Findings include: On 5/22/14 at approximately 9:30 a.m., Resident #216 was observed sitting in her wheelchair. The resident had a wheel chair alarm attached to her chair and was able to answer yes and no questions. On 5/22/14 at 9:45 a.m., Resident #216's medical record was reviewed and revealed an admission into the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's minimum data set assessment ((MDS) dated [DATE], revealed that the resident's cognition was severely impaired and required extensive assistance for most activities of daily living. Review of resident #216's Clinical Notes, dated 5/9/14 at 11:02 a.m., revealed "At around 8:40 a.m. CNA (certified nursing assistant) reported that resident had eaten Fluocinolone Cream (topical corticosteroid) that was in BR (bathroom); checked mouth and hands no residue of cream noted... poison control called." Review of resident #216's physician orders [REDACTED]." On 5/22/14 at 1:40 p.m., Resident #216's "Unplanned Occurrence Report," dated 5/9/14, was reviewed and revealed "Reported by CNA that resident had eaten Fluocinolone cream that was in BR...Preventative measures and/or corrective actions taken: No cream to be left where resident can get to it (nurse educated)." On 5/22/14 at 2:25 p.m., the Assistant Director of Nursing (ADON) was queried regarding the incident with resident #216 and stated, "The cream was in the bathroom. The nurse was going to apply but she (resident #216) had another bowel movement so the CNA had to clean her up. She (the nurse) mistakenly left it (the medication/cream) there. The CNA turned her back and the resident put it in her mouth. We called poison control. The nurse was educated. It should not have been left there. It is a medication." On 5/22/14 at 2:50 p.m., the Director of Nurses (DON) was queried regarding the incident with resident #216 but made no comment. On 5/22/14 at 3:00 p.m., the facility's policy titled "Storage of Medication," dated 8/2008, was reviewed and revealed "Medications are stored in each elders room much like they are stored at home. Locked and secured medication cabinets are contained in each resident room." The policy did not discuss that a medication should not be left in the resident's room accessible to the resident. Review of the package insert for "Fluocinolone Acetonide Ointment USP, 0.025%," was reviewed and revealed "Fluocinolone Acetonide Ointment USP, 0.025% is intended for topical administration. Topical corticosteroids share anti-inflammatory activity, anti-pruritic and vasoconstrictive actions. This medication is to be used as directed by the physician. It is for external use only." ( )

THIS CITATION HAS MULTIPLE DEFICIENT PRACTICE STATEMENTS AND PERTAINS TO INTAKE #MI 444. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF ONE RESIDENT (RESIDENT #101) OF 8 SAMPLED RESIDENTS, REVIEWED FOR SAFETY FROM A TOTAL SAMPLE OF 8, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHO ELOPED FROM THE FACILITY UNBEKNOWNST TO FACILITY STAFF ON 8/21/2012 AT 6:35 P.M. THE STAFF HAD FAILED TO SUPERVISE AND CORRECTLY ASSESS RESIDENT #101 AND FAILED TO PUT NEEDED INTERVENTIONS INTO PLACE. THIS DEFICIENT PRACTICE PLACED RESIDENT #101 AS WELL AS 21 OTHER RESIDENTS WHO HAD BEEN IDENTIFIED AS BEING AT RISK FOR ELOPEMENT, AT HIGH RISK FOR PHYSICAL HARM OR DEATH. FINDINGS INCLUDE: RESIDENT #101: ACCORDING TO THE FACILITY RECORDS RESIDENT #101 WAS A COGNITIVELY IMPAIRED [AGE] year OLD FEMALE WHO HAD [DIAGNOSES REDACTED]. RESIDENT #101'S ADMISSION assessment dated [DATE] INCLUDED A RISK FOR ELOPEMENT SECTION (SECTION "O") WHICH DETERMINED THAT RESIDENT #101 had a history of [REDACTED]. ACCORDING TO THE ADMISSION ASSESSMENT, STAFF MEMBERS WERE REQUIRED TO IMPLEMENT A CARE PLAN FOR POTENTIAL ELOPEMENT. ACCORDING TO THE CARE PLAN DATED 7/9/2012, RESIDENT #101 WANDERED THROUGHOUT THE FACILITY AND WAS ASSESSED AT RISK FOR ELOPEMENT. INTERVENTIONS IMPLEMENTED INCLUDED REQUIRING RESIDENT #101 TO WEAR A CODE ALERT ANKLET, AN ALARMED WANDERER MANAGEMENT SYSTEMS DESIGNED TO KEEP RESIDENTS FROM ENDANGERING THEMSELVES BY "WANDERING" OUT OF EXIT DOORS WITHOUT SUPERVISION. ACCORDING TO THE WANDER DATA COLLECTION TOOL DATED 7/9/2012, RESIDENT #101 HAD WANDERED IN HER PREVIOUS LIVING SETTING AND RESIDENT #101'S WANDERING PLACED HER AT RISK OF GETTING TO A POTENTIALLY DANGEROUS PLACE (OUTSIDE THE FACILITY). ACCORDING TO THE WANDER DATA COLLECTION TOOL, RESIDENT #101 WAS COGNITIVELY IMPAIRED WITH POOR DECISION MAKING SKILLS, AND WAS A NEW RESIDENT THAT HAD NOT ACCEPTED THE SITUATION OF BEING PLACED IN A NURSING HOME. INTERVENTIONS IMPLEMENTED TO ENSURE RESIDENT #101'S SAFETY INCLUDED PERSONAL SAFETY ALARMS, EXIT AND STAIRWELL ALARMS, IDENTIFICATION BRACELET AND BED ALARMS. ACCORDING TO THE PHYSICIAN ORDER [REDACTED].#101'S ANKLE EVERY SHIFT AND CHECK FOR PROPER ANKLET FUNCTIONING EVERY WEEK. ACCORDING TO THE NURSE'S NOTE DATED 7/14/2012, RESIDENT #101 EXPERIENCED A FALL WHILE SHE WAS "...TRYING TO GET UP SO I COULD GET OUT OF HERE..." ACCORDING TO THE NURSE'S NOTE DATED 7/24/2012, RESIDENT #101 "...WAS AGITATED THE WHOLE EVENING AND WANTS TO GO HOME..." ACCORDING TO THE NURSE'S NOTE DATED 8/1/2012, RESIDENT #101 WAS CONFUSED AND "...WANDERING IN W/C (WHEELCHAIR) IN (THE) FACILITY, ATTEMPTING TO FIND (HER) APARTMENT..." ACCORDING TO THE PSYCHIATRIC EVALUATION DATED 7/25/2012 RESIDENT #101 WAS "...SEVERELY CONFUSED..." AND HAD 2 RECENT FALLS SECONDARY TO "...RESIDENT WANTING TO LEAVE THE FACILITY..." ACCORDING TO THE SOCIAL WORKER NOTES DATED 8/1/2012, RESIDENT #101 WAS "...LOOKING FOR ELEVATOR TO GET DOWNSTAIRS..." AND WAS WANDERING IN THE HALLWAYS THROUGHOUT THE DAY. ACCORDING TO THE SOCIAL WORKER NOTES DATED 8/6/2012, RESIDENT #101 "...WILL WANDER IN (THE) FACILITY... "BUT WEARS A CODE ALERT TO ENSURE HER SAFETY. ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #101 WANDERED 4 TO 6 DAYS A WEEK DURING THE EVALUATION PERIOD, BUT LESS THAN DAILY. REVIEW OF RESIDENT #101'S CLINICAL RECORD REVEALED THAT ON 8/8/2012, RESIDENT #101 WAS SENT TO A LOCAL AREA HOSPITAL FOR treatment of [REDACTED]. RESIDENT #101'S ADMISSION assessment dated [DATE] INCLUDED THE SAME RISK FOR ELOPEMENT SECTION (SECTION "O"). ACCORDING TO THE ASSESSMENT COMPLETED, RESIDENT #101 HAD NO HISTORY OF ELOPEMENT OR WANDERING AND NO CARE PLAN FOR POTENTIAL ELOPEMENT WAS IMPLEMENTED. ACCORDING TO THE INTERDISCIPLINARY REVIEW UPON READMISSION OR CHANGE OF CONDITION FORM, DATED 8/14/2012, RESIDENT #101 SHOWED NO EVIDENCE OF CHANGES IN COGNITION, MOOD AND BEHAVIOR SINCE HER PREVIOUS ADMISSION. ON READMISSION TO THE FACILITY, NO WANDER DATA COLLECTION TOOL WAS COMPLETED AS IT WAS ON 7/9/2012. DURING AN INTERVIEW ON 8/28/2012 THE REGISTERED NURSE (RN #1) SAID SHE WAS RESIDENT #101'S NURSE ON THE DAY OF READMISSION TO THE FACILITY. RN #1 SAID THAT SHE HAD NO INFORMATION ABOUT PRIOR ATTEMPTS TO ELOPE OR WANDER SO SHE CONSIDERED HER A LOW RISK FOR ELOPEMENT. RN #1 SAID SHE DID NOT KNOW RESIDENT #101 WAS A READMISSION TO THE FACILITY, "...SO I ONLY CONSIDERED HER CURRENT STATUS..." AT THE TIME OF RE-ADMISSION. RN #1 AGAIN SAID SHE DID NOT KNOW RESIDENT #101 had a history of [REDACTED].#101 WAS A READMISSION TO THE FACILITY. RN #1 SAID SHE BELIEVED RESIDENT #101 WAS NON AMBULATORY DUE TO HER HIP SURGERY, AND DID NOT KNOW RESIDENT #101 had a history of [REDACTED]. RN #1 SAID THAT IF SHE HAD BEEN ABLE TO REVIEW RESIDENT #101'S HISTORY SHE (RN #1) "...WOULD HAVE SAID SHE (RESIDENT #101) WAS AT RISK..." RN #1 SAID SHE HAD NO OTHER INFORMATION AVAILABLE SINCE SHE DID NOT KNOW RESIDENT #101 WAS A READMISSION TO THE FACILITY. RN #1 WAS THEN ASKED TO READ HER (RN #101) ADMISSION NOTE DATED 8/13/2012. RN #1 SAID, "...THE NOTE SAYS readmitted RESIDENT. OK, I DID NOT HAVE TIME TO GO OVER HER OLD RECORDS..." RN #1 SAID SHE DID NOT CALL FOR NOR ASK FOR RESIDENT #101'S PRIOR CLINICAL RECORDS WHEN ADMITTING RESIDENT #101. RN #1 SAID, "...I WAS NOT THINKING...IT WAS A MISTAKE...I ONLY CONSIDERED HER STATUS AT THE TIME..." RN #1 SAID SHE "...SHOULD HAVE ASKED FOR THE OLD CHART..." SO SHE COULD REVIEW RESIDENT #101'S PRIOR ASSESSMENTS AND WANDERING HISTORY. RN #1 SAID SHE ALSO COULD HAVE ASKED THE SUPERVISOR ABOUT RESIDENT #101'S HISTORY, BUT DID NOT. RN #1 SAID THAT RESIDENT #101 "...SHOULD HAVE BEEN ASSESSED CORRECTLY, INTERVENTIONS SHOULD HAVE BEEN PUT IN PLACE..." IN AN INTERVIEW ON 8/28/2012, THE CERTIFIED NURSE ASSISTANT (CNA #1) SAID THAT ON 8/21/2012, RESIDENT #101 WAS MOVING ABOUT THE FACILITY AND WAS WANDERING TOWARD ANOTHER UNIT. CNA #1 SAID THAT RESIDENT #101 SAID SHE (#101) WANTED TO GO OUTSIDE, AND THAT SHE NEEDED TO GO. CNA #1 SAID RESIDENT #101 WAS WAITING FOR HER DAUGHTER TO COME GET HER. CNA #1 SAID SHE TOLD RESIDENT #101 SHE COULDN'T GO OUTSIDE BECAUSE SHE NEEDED SOMEONE WITH HER. CNA #1 SAID SHE DID NOT INFORM ANYONE OF RESIDENT #101'S WANDERING AND DID NOT IMPLEMENT ANY INTERVENTIONS TO REDUCE THE RISK OF ACCIDENT OR ELOPEMENT. IN AN INTERVIEW THE CERTIFIED NURSE ASSISTANT (CNA #2) SAID THAT ON 8/21/2012 RESIDENT #101 WAS SEEN WANDERING EARLIER THAT DAY. CNA #2 SAID SHE DID NOT INFORM ANYONE OF RESIDENT #101'S WANDERING AND DID NOT IMPLEMENT ANY INTERVENTIONS TO REDUCE THE RISK OF ACCIDENT OR ELOPEMENT. CNA #2 EXPLAINED, "...IT WAS LESS THAN SHE WANDERED BEFORE THE ADMISSION TO THE HOSPITAL..." ACCORDING TO THE FACILITY INCIDENT REPORT DATED 8/22/2012, FACILITY STAFF FOUND RESIDENT #101 ON THE PATIO OUTSIDE THE FACILITY AT AN UNDOCUMENTED TIME ON 8/21/2012. ON 8/28/2012 AT 11:45 A.M. THE SURVEYOR REVIEWED THE TIME CODED VIDEO SURVEILLANCE OF RESIDENT #101'S ELOPEMENT OUT THE FRONT DOOR OF THE FACILITY ON 8/21/2012. AT 6:33:47 P.M. RESIDENT #101 WAS OBSERVED IN A WHEELCHAIR ENTERING INTO THE LOBBY OF THE FACILITY. AT 6:34:55 P.M. RESIDENT #101 PRESSED THE AUTOMATIC DOOR AND WHEELCHAIR ASSISTANCE BUTTON AT THE FRONT DOOR AND THE AUTOMATIC DOOR OPENED. AT 6:35 P.M. RESIDENT #101 EXITED THE FRONT DOOR OF THE FACILITY. AT 6:42:35 P.M. THE LICENSED PRACTICAL NURSE (LPN #1) EXITED THE FRONT DOOR OF THE FACILITY. AT 6:43:33 P.M. LPN #1 RETURNED INSIDE THE FACILITY PUSHING RESIDENT #101 IN HER WHEELCHAIR. IN AN INTERVIEW ON 8/28/2012, LPN #1 SAID THAT ON 8/21/2012 SHE WAS WORKING ON A DIFFERENT UNIT IN THE FACILITY. LPN #1 SAID THAT AT APPROXIMATELY 6:40 PM SHE PICKED UP HER LUNCH FROM THE KITCHEN AND WALKED AROUND THE FACILITY LOOKING FOR A SUPERVISOR. LPN #1 SAID SHE "...JUST HAPPENED TO BE IN THE RIGHT PLACE..." LPN #1 SAID SHE HAPPENED TO WALK NEAR THE FRONT DOOR AND SAW A WHEELCHAIR OUTSIDE. LPN #1 SAID THE WHEELCHAIR WAS OUTSIDE IN THE PARKING LOT DROP OFF AREA TO THE RIGHT OF THE PATIO, SO SHE WENT OUTSIDE TO SEE WHO IT WAS SEATED IN THE CHAIR. LPN #1 SAID AS SHE WENT OUTSIDE, RESIDENT #101 STARTED YELLING AND SAYING SHE WAS WAITING FOR HER DAUGHTER TO COME GET HER. LPN #1 SAID SHE THEN BROUGHT RESIDENT #101 BACK INTO THE FACILITY AND TO THE NURSING STATION. DURING AN INTERVIEW ON 8/28/2012, THE ENVIRONMENTAL SERVICES DIRECTOR (EVS) #1 SAID THE CODE ALERT ANKLETS HAD A RANGE OF 6 TO 8 FEET. EVS #1 SAID THAT IF RESIDENT #101 HAD THE ANKLET ON AS SHE DID PREVIOUSLY, THE DOOR TO THE FACILITY WOULD HAVE LOCKED AS SHE APPROACHED AND RESIDENT #101 WOULD NOT HAVE BEEN ABLE TO EXIT THE FACILITY. IN AN INTERVIEW ON 8/28/2012, THE FACILITY ADMINISTRATOR (ADM #1) SAID RESIDENT #101 WAS A CONFUSED RESIDENT WHO ON 8/21/2012 LEFT THE FACILITY WITHOUT STAFF KNOWLEDGE OR SUPERVISION. ADM #1 SAID RESIDENT #101 WAS AN ELOPEMENT RISK, WHO WANDERED AND STATED DESIRES TO LEAVE THE FACILITY. ADM #1 SAID WHEN RESIDENT #101 WAS readmitted TO THE FACILITY THERE WAS AN ERROR IN HER ASSESSMENT AND HER HISTORY OF WANDERING AND PREVIOUS ATTEMPTS TO LEAVE THE FACILITY WAS NOT CONSIDERED IN ASSESSING HER RISK FOR ELOPEMENT. ADM #1 SAID THE FACILITY STAFF FAILED TO CORRECTLY ASSESS RESIDENT #101'S INDIVIDUAL RISK OF AVOIDABLE ELOPEMENT. ON 8/29/2012 11:36 A.M. AN IMMEDIATE JEOPARDY SITUATION WAS IDENTIFIED AT F-323. ON 8/30/2012, AT 2:59 P.M., THE ADMINISTRATOR WAS INFORMED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 8/21/2012 AT 6:35 P.M., WHEN THE FACILITY FAILED TO PREVENT THE ELOPEMENT OF AND ENSURE THE SAFETY OF RESIDENT #101 AND PLACED AN ADDITIONAL 21 AT RISK FOR ELOPEMENT AT RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. ON 8/31/2012, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 8/31/2012, THE SURVEYOR VERIFIED THAT ON 8/21/2012 RESIDENT #101 WAS BROUGHT BACK INTO THE FACILITY, WAS ASSESSED AND WAS FOUND TO BE WITHOUT INJURY. 2. ON 8/31/2012, THE SURVEYOR VERIFIED THAT ON 8/21/2012 RESIDENT #101'S PHYSICIAN AND FAMILY WERE NOTIFIED OF RESIDENT #101 ' S ELOPEMENT FROM THE FACILITY. 3. ON 8/31/2012, THE SURVEYOR VERIFIED THAT ON 8/21/2012 RESIDENT #101 WAS REASSESSED FOR HER ELOPEMENT RISK AND A CODE ALERT TRANSMITTER BRACELET WAS PLACED ON RESIDENT #101'S ANKLE. 4. ON 8/31/2012, THE SURVEYOR VERIFIED THAT ON 8/22/2012 ALL RESIDENTS IN THE FACILITY WERE ASSESSED FOR ELOPEMENT RISK AND 21 OTHER RESIDENTS WERE IDENTIFIED AS ELOPEMENT RISKS. 5. ON 8/31/2012, THE SURVEYOR VERIFIED THAT ON 8/22/2012 ALL 22 RESIDENTS IN THE FACILITY IDENTIFIED AS ELOPEMENT RISKS WERE CHECKED AND PROPER CODE ALERT TRANSMITTER PLACEMENT AND CODE ALERT TRANSMITTER FUNCTIONING FOR THESE RESIDENTS WAS ENSURED. 6. ON 8/31/2012, THE SURVEYOR VERIFIED THAT ON 8/22/2012 ALL ALARMED AND LOCKING DOORS IN THE FACILITY WERE CHECKED AND PROPER FUNCTIONING WAS ENSURED. 7. ON 8/31/2012, THE SURVEYOR VERIFIED THAT ON 8/22/2012 STAFF EDUCATION BEGAN RELATED TO THE PREVENTION OF ELOPEMENT. 8. ON 8/31/2012, THE SURVEYOR VERIFIED THAT EMPLOYEES WERE NOTIFIED ON 8/22/2012, NO EMPLOYEE WOULD BE ALLOWED TO WORK WITHOUT FIRST BEING IN-SERVICED ON THE PREVENTION OF ELOPEMENT. 9. ON 8/31/2012, THE SURVEYOR VERIFIED THAT AS OF 8/31/2012, 205 OF 223 EMPLOYEES HAD COMPLETED THE REQUIRED IN-SERVICE. 10. ON 8/31/2012, THE SURVEYOR VERIFIED THAT AS OF 8/17/2012 ALL RESIDENTS IN THE FACILITY IDENTIFIED AS ELOPEMENT RISKS WERE CHECKED FOR PROPER CODE ALERT TRANSMITTER PLACEMENT. 11. ON 8/31/2012, THE SURVEYOR VERIFIED THAT AS OF 8/17/2012, ALL RESIDENTS IN THE FACILITY IDENTIFIED AS ELOPEMENT RISKS WERE CHECKED FOR CODE ALERT TRANSMITTER FUNCTIONING. 12. ON 8/31/2012, THE SURVEYOR VERIFIED THAT AS OF 8/22/2012 ALL RESIDENTS readmitted TO THE FACILITY WERE TO BE AUDITED FOR ACCURATE RISK FOR ELOPEMENT ASSESSMENT. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 8/22/2012, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY BECAUSE NOT ALL STAFF HAS BEEN EDUCATED IN THE PERTINENT POLICIES AND BECAUSE THE FACILITY'S SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( ) BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT ADEQUATE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS AND TO MODIFY THE INTERVENTIONS IN THE PLANS OF CARE AS NECESSARY FOR 2 RESIDENTS (RESIDENT #101 AND RESIDENT #104) OF 4 SAMPLED RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 8, RESULTING IN THE POTENTIAL FOR FUTURE FALLS WITH INJURY. FINDINGS INCLUDE: RESIDENT #101: THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #101 WAS A [AGE] year OLD FEMALE WITH IMPAIRED COGNITIVE ABILITIES. RESIDENT # 101 REQUIRED EXTENSIVE ASSISTANCE FROM FACILITY STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING TRANSFERS, HYGIENE AND BED MOBILITY. ACCORDING TO THE FACILITY RECORDS, RESIDENT #101 HAD [DIAGNOSES REDACTED]. ACCORDING TO THE CARE PLAN DATED 7/9/2012, RESIDENT #101 WAS DETERMINED TO BE AT HIGH RISK FOR FALLS. THE FACILITY IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING ASSISTANCE WITH TRANSFERS AND AMBULATION, TOILETING, AND BED AND CHAIR ALARMS. ACCORDING TO THE PHYSICIAN ORDERS [REDACTED]. ACCORDING TO THE THERAPY DEPARTMENT'S REHABILITATION SCREEN DATED 7/9/2012, RESIDENT #101 REQUIRED THE EXTENSIVE PHYSICAL ASSISTANCE OF 1 STAFF MEMBER FOR ALL TRANSFERS AND AMBULATION, AND SHOULD BE ON FALLS PRECAUTIONS. ACCORDING TO THE NURSE'S NOTE DATED 7/14/2012, RESIDENT #101 EXPERIENCED A FALL WHILE SHE WAS "...TRYING TO GET UP SO I COULD GET OUT OF HERE..." RESIDENT #101 WAS ASSESSED AND NO OBVIOUS INJURIES WERE FOUND. ACCORDING TO THE UNPLANNED OCCURRENCE REPORT DATED 7/14/2012, FACILITY STAFF FAILED TO PROVIDE ASSISTANCE WITH AMBULATION WHEN RESIDENT #101 WAS FOUND ON THE FLOOR AT 4:15 P.M., IN THE HALLWAY OUTSIDE HER ROOM. THERE WAS NO DOCUMENTED EVIDENCE THAT EITHER A BED OR A CHAIR ALARM, AS REQUIRED IN RESIDENT #101'S CARE PLAN WERE IN PLACE AT THE TIME OF THE INCIDENT. ACCORDING TO THE UNPLANNED OCCURRENCE REPORT DATED 7/14/2012, PREVENTATIVE MEASURES TAKEN TO PREVENT REOCCURRENCE INCLUDED ASSIST RESIDENT TO AMBULATE A FEW FEET ROUTINELY. ACCORDING TO THE CARE PLAN DATED 7/16/2012, RESIDENT #101'S CARE PLAN WAS UPDATED TO INCLUDE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING, AMBULATION, TOILETING, LOCOMOTION IN WHEELCHAIR ON AND OFF UNIT, ALL TRANSFERS AND BED MOBILITY; INTERVENTIONS WHICH HAD ALL BEEN PREVIOUSLY IMPLEMENTED. NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR THAT THERE WERE ANY NEW INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #101. ACCORDING TO THE NURSE'S NOTES DATED 7/24/2012 FACILITY STAFF FAILED TO PROVIDE ASSISTANCE WITH AMBULATION TOILETING AND TRANSFERS WHEN RESIDENT #101 WAS "FOUND ON THE FLOOR IN THE BATHROOM." RESIDENT #101 WAS ASSESSED AND NO OBVIOUS INJURIES WERE FOUND. ACCORDING TO THE UNPLANNED OCCURRENCE REPORT DATED 7/24/2012 FACILITY STAFF FAILED TO PROVIDE ASSISTANCE WITH AMBULATION, TRANSFERS AND TOILETING WHEN RESIDENT #101 WAS FOUND ON THE FLOOR AT10:30 P.M., IN THE BATHROOM. THERE WAS NO RECORD THAT THE BED AND CHAIR ALARMS THAT WERE REQUIRED BY THE CARE PLAN WERE IN PLACE AT THE TIME OF THE INCIDENT. ACCORDING TO THE UNPLANNED OCCURRENCE REPORT DATED 7/24/2012 PREVENTATIVE MEASURES TAKEN TO PREVENT REOCCURRENCE INCLUDED, "IF RESIDENT BECOMES AGITATED OR CONFUSED, PLACE THE RESIDENT AT THE NURSE'S STATION." NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CLINICAL RECORD TO INDICATE ANY CHANGES IN SUPERVISION OR THAT THERE WERE ANY NEW INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #101. ACCORDING TO THE CLINICAL RECORD THERE WERE NO OTHER FALLS WHILE IN THE FACILITY. ACCORDING TO THE FACILITY INCIDENT REPORT SUMMARY ON 8/7/2012, RESIDENT #101 VOICED A COMPLAINT OF PAIN IN THE LEFT HIP AND X-RAYS WERE ORDERED. ACCORDING TO THE RADIOLOGY REPORT DATED 8/7/2012, RESIDENT #101 SUFFERED FROM A FRACTURE AT THE BASE OF THE NECK OF THE LEFT FEMUR (BROKEN LEFT HIP). ACCORDING TO THE FACILITY INCIDENT REPORT PROOF OF INVESTIGATION, A PHYSICIAN REVIEW OF THE X-RAYS WAS COMPLETED. ACCORDING TO THE FACILITY INCIDENT REPORT PROOF OF INVESTIGATION, THERE WAS A LINE GOING UP THE FEMUR THAT WAS APPARENT ON THE X-RAY. THIS APPEARED TO BE A HAIRLINE FRACTURE FROM A PREVIOUS FALL. ACCORDING TO THE FACILITY INCIDENT REPORT PROOF OF INVESTIGATION, WALKING AND THERAPY MAY HAVE CAUSED THE FRACTURE TO WORSEN AND COMPLETELY BREAK. IN AN INTERVIEW ON 8/31/2012 AT 1:00 P.M., THE DIRECTOR OF NURSING (DON #1) REVIEWED RESIDENT #101'S CLINICAL DOCUMENTATION AND SAID THERE WAS NO RECORD OF RESIDENT #101'S ALARMS BEING IN PLACE AT EITHER FALL. DON #1 SAID THE PREVENTATIVE MEASURES TAKEN TO PREVENT REOCCURRENCE WERE "...LACKING SUBSTANCE. IF YOU REALIZE SOMEONE IS RESTLESS, GIVE THEM SOMETHING TO DO..." DON #1 SAID, "...WE HAVE A PROBLEM WITH OUR FALLS PROGRAM. IT'S GETTING BETTER BUT WE HAVE ISSUES WITH IMPLEMENTING INTERVENTIONS AND CHANGING THE PLAN OF CARE IMMEDIATELY TO ENSURE RESIDENT SAFETY. THERE SHOULD HAVE BEEN A ROOT-CAUSE ANALYSIS OF THE FALLS COMPLETED WITH IMMEDIATE IMPLEMENTATION OF INTERVENTIONS, BUT I CAN'T SEE THAT WAS DONE ... " ( ) RESIDENT #104: ACCORDING TO THE FACE SHEET RESIDENT #104 WAS [AGE] year OLD FEMALE WHO HAD [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #104 HAD IMPAIRED COGNITIVE ABILITIES AND REQUIRED ASSISTANCE FROM FACILITY STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING TRANSFERS, HYGIENE AND BED MOBILITY. ACCORDING TO THE CARE PLAN DATED 7/25/2012, RESIDENT #104 WAS DETERMINED TO BE AT HIGH RISK FOR FALLS. THE FACILITY IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING ASSISTANCE WITH TOILETING, TRANSFERS AND AMBULATION, BED AND CHAIR ALARMS, NONSKID PADS IN RESIDENT #104'S WHEELCHAIR AND NONSKID FOOTWEAR. ACCORDING TO THE CARE PLAN, RESIDENT #104 REQUIRED ASSISTANCE WITH TOILETING AND SAID "...DO NOT LEAVE ALONE WHILE IN THE BATHROOM..." ACCORDING TO THE NURSE'S NOTES DATED 8/9/2012 RESIDENT #104 WAS ASSISTED TO THE TOILET BY FACILITY STAFF AND RESIDENT #104 fell TO HER KNEES "...WHILE I'M (FACILITY STAFF WAS) GETTING A PULL UP IN THE CLOSET..." ACCORDING TO THE NURSE'S NOTE AN ASSESSMENT WAS COMPLETED AND NO INJURY WAS APPARENT. ACCORDING TO THE UNPLANNED OCCURRENCE REPORT FORM DATED 8/9/2012, RESIDENT #104 SUSTAINED A BRUISE BELOW THE LEFT KNEE MEASURING 4 X 4 CM. RESIDENT #104 COMPLAINED OF PAIN TO BOTH KNEES. ACCORDING TO THE UNPLANNED OCCURRENCE REPORT DATED 8/9/2012, PREVENTATIVE MEASURES TAKEN TO PREVENT REOCCURRENCE INCLUDED FOR STAFF TO ADVISE RESIDENT #104 TO ASK FOR ASSISTANCE AND TO ENROLL THE RESIDENT IN THE RED STAR (FALL PREVENTION) PROGRAM. RESIDENT #104'S CARE PLAN WAS UPDATED TO INCLUDE EDUCATION TO STAFF TO TAKE BRIEFS AND PULL UPS INTO THE ROOM WITH THEM. DURING AN INTERVIEW ON 8/31/2012 AT 10:50 A.M., THE REGISTERED NURSE (RN #1) SAID THAT ON 8/9/2012 SHE TOOK RESIDENT #104 TO THE BATHROOM AND THEN WALKED OUT OF BATHROOM. RN #1 SAID SHE LEFT RESIDENT #104'S BATHROOM DOOR SLIGHTLY OPEN, "...SO I COULD SEE HER..." RN #1 THEN SAID SHE TURNED AWAY FROM RESIDENT #104 AND LOOKED INTO THE CLOSET LOCATED TO THE LEFT OF THE BATHROOM. RN #1 SAID SHE LOCATED RESIDENT #104'S BRIEFS AND REACHED FOR HER THEM. RN #1 SAID WHEN SHE TURNED HER ATTENTION BACK TO RESIDENT #104; SHE (#104) HAD STOOD AND PULLED AT HER GOWN. "...I (RN #1) TURNED BACK TO SEE HER (#104) STANDING AND FALLING TO HER KNEES..." RN #1 SAID RESIDENT #104 fell TO HER KNEES "...AND I COULD NOT GET TO HER IN TIME..." RN #1 REVIEWED RESIDENT #104'S CARE PLAN AND SAID RESIDENT #104 WAS NOT TO BE LEFT ALONE IN THE BATHROOM. RN#1 COULD NOT EXPLAIN WHY SHE LEFT RESIDENT #104 ALONE AND UNSUPERVISED AND SAID THAT IF SHE WAS INSIDE THE BATHROOM AS REQUIRED, SHE (RN #1) "...MAY HAVE BEEN ABLE TO REACH HER BEFORE SHE fell ..." RN #1 SAID THAT AFTER THE INCIDENT, RESIDENT #104 'S CARE PLAN WAS UPDATED WITH ENROLLMENT IN THE RED STAR PROGRAM. RN #1 SAID THE RED STAR REQUIRES RESIDENTS TO NOT BE LEFT ALONE IN THE BATHROOM. RN #1 WAS UNABLE TO EXPLAIN HOW THE RED STAR ENROLLMENT WAS DIFFERENT THAN THE CARE PLAN THAT WAS IN PLACE PRIOR TO THE FALL. RN #1 SAID, "...WE DON'T LOOK AT THE WHOLE CARE PLAN, JUST THE FALLS SECTION. WE WOULD LET HER GO TO THE BATHROOM ALL THE TIME ALONE..." IN AN INTERVIEW ON 8/31/2012 AT 1:00 P.M., THE DIRECTOR OF NURSING (DON #1) REVIEWED RESIDENT #104'S CLINICAL DOCUMENTATION AND SAID RESIDENT #104 WAS NOT PROVIDED WITH THE SUPERVISION SHE REQUIRED TO BE SAFE. DON #1 SAID, "...WE HAVE A PROBLEM WITH OUR FALLS PROGRAM. IT'S GETTING BETTER BUT WE HAVE ISSUES WITH IMPLEMENTING INTERVENTIONS AND CHANGING THE PLAN OF CARE IMMEDIATELY TO ENSURE RESIDENT SAFETY. THERE SHOULD HAVE BEEN A ROOT CAUSE ANALYSIS OF THE FALLS COMPLETED WITH IMMEDIATE IMPLEMENTATION OF INTERVENTIONS BUT I CAN'T SEE THAT WAS DONE..." DON #1 SAID, "...THE FALLS PROGRAM HAS COME A LONG WAY AND IS MUCH BETTER THAN IT WAS, BUT THESE 2 (FOR #101 AND #104) CHARTS DON'T REFLECT THAT..." ( )

THIS CITATION PERTAINS TO INTAKES #MI 109 AND MI 421. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF 2 OF 10 SAMPLED RESIDENTS (RESIDENT #105 AND RESIDENT #102), FROM A TOTAL OF 10 SAMPLED RESIDENTS REVIEWED FOR SAFETY AND SUPERVISION, RESULTING IN: 1). AN IMMEDIATE JEOPARDY FOR RESIDENT #105, WHO WAS IDENTIFIED AS AN ELOPEMENT RISK, WHO EXITED THE FACILITY ON 5/21/12 UNBEKNOWNST TO FACILITY STAFF AND WAS GONE FOR APPROXIMATELY 19 MINUTES BEFORE A FACILITY EMPLOYEE FOUND RESIDENT #105 PACING ON THE SIDEWALK LOCATED IN FRONT OF THE FACILITY, AND 2). AN IMMEDIATE JEOPARDY FOR RESIDENT #102, WHO WAS NOT IDENTIFIED AS AN ELOPEMENT RISK, EXITED THE FACILITY ON 5/6/12, UNBEKNOWNST TO FACILITY STAFF, AND WAS BROUGHT BACK INTO THE FACILITY 12 MINUTES LATER FROM THE FACILITY PARKING LOT. THESE DEFICIENT PRACTICE PLACED AN ADDITIONAL 21 RESIDENTS, IDENTIFIED AS AT RISK FOR ELOPEMENT, AT HIGH RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #105 ACCORDING TO THE FACE SHEET, DATED 5/16/2012, RESIDENT #105 WAS AN [AGE] year OLD MALE WHO LIVED IN THE FACILITY SINCE 4/26/2012. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 5/09/2012, RESIDENT #105 WAS ASSESSED AS HAVING NO COGNITIVE IMPAIRMENTS AND REQUIRED A WHEELCHAIR AND/OR WALKER FOR LOCOMOTION. NURSING NOTES, DATED 5/17/2012 AT 8:00 A.M., DOCUMENTED THAT RESIDENT #105 WAS CONFUSED TO PLACE, TIME AND EVENTS WHEN HIS UNIT MANAGER, REGISTERED NURSE (RN) #1 ASSESSED HIM THAT MORNING. RN #1 DOCUMENTED IN THE NURSING NOTES THAT RESIDENT #105 WAS "LOOKING FOR (AN) EXIT BECAUSE HE NEEDED TO MEET HIS HOME THERAPIST." ADDITIONAL NURSING NOTES, DATED 5/17/2012 AT 3:00 P.M., DOCUMENTED RESIDENT #105 WAS "OBSERVED TRYING TO LOOK FOR THE EXIT DOOR AT 7:20 A.M." FURTHER REVIEW OF RESIDENT #105'S CLINICAL RECORD REVEALED THAT AN ELOPEMENT RISK ASSESSMENT WAS COMPLETED ON 5/17/12, AFTER RESIDENT #105 DEMONSTRATED EXIT-SEEKING BEHAVIORS. DURING AN INTERVIEW ON 5/06/2012 AT 2:00 P.M., RN #1 SAID WHEN SHE ASSESSED RESIDENT #105 ON 5/17/2012, HIS CONFUSION WAS SIGNIFICANT ENOUGH TO PLACE HIM AT RISK FOR ELOPEMENT. RN #1 SAID A CODE ALERT BRACELET WAS IMMEDIATELY PLACED ON RESIDENT 105'S LEFT ANKLE TO ENSURE HIS SAFETY. NURSING NOTES, DATED 5/21/2012 AT 4:00 A.M., NOTED THAT STAFF FOUND RESIDENT #105 RESTLESS THROUGHOUT THE NIGHT. LICENSED PRACTICAL NURSE (LPN) #1 WROTE IN THE NURSING NOTES THAT RESIDENT #105 HAD INCREASED CONFUSION WHILE SELF-AMBULATING IN THE HALLWAYS. DESPITE THIS PROFESSIONAL ASSESSMENT, STAFF FAILED TO IMPLEMENT ANY ADDITIONAL SUPERVISION OR ASSISTIVE SAFETY DEVICES IN THE CARE PLAN OF RESIDENT #105 TO ENSURE HIS FUTURE SAFETY. IN A WRITTEN STATEMENT, DATED 5/23/2012, LPN #1 DOCUMENTED RESIDENT #105 "WAS VERY RESTLESS THAT NIGHT...AND WAS SEEN TRYING TO EXIT OUT OF THE SIDE DOOR ON LOW END." IN A WRITTEN STATEMENT, DATED 5/23/2012, CERTIFIED NURSING ASSISTANT (CNA) #1 DOCUMENTED RESIDENT #105 WAS RESTLESS "THAT NIGHT (5/21/2012)." A PROOF OF INTERNAL INVESTIGATION REPORT, DATED 5/21/2012 AT 6:20 A.M., NOTED THAT RESIDENT #105 WAS FOUND UNSUPERVISED, OUTSIDE OF THE FACILITY BY STAFF WHO ARRIVED FOR WORK THAT MORNING. DURING AN INTERVIEW ON 6/01/2012 AT 1:55 P.M., HOUSEKEEPER (HK) #1 SAID SHE WAS CONCERNED WHEN SHE ARRIVED FOR WORK ON 5/21/2012 AT 6:20 A.M. AND NOTICED A CONFUSED, UNSUPERVISED MAN IN FRONT OF THE FACILITY, PACING UP AND DOWN THE SIDEWALK, BESIDE A BUSY FOUR-LANE ROAD. HK #1 SAID THE MAN DID NOT APPEAR SAFE, SO SHE LOCATED TRANSPORTER (TR) #1, WHO APPROACHED RESIDENT #105 TO FURTHER EVALUATE THE SITUATION. HK #1 SAID TR #1 WAS ABLE TO IDENTIFY THE MAN PACING THE SIDEWALK AS RESIDENT #105 FROM HIS IDENTIFICATION BRACELET. THE UNPLANNED OCCURRENCE REPORT, DATED 5/21/2012 AT 6:30 A.M., REVEALED RESIDENT #105 HAD LEFT THE FACILITY UNSUPERVISED WITH A CODE ALERT MONITOR ON HIS ANKLE THAT DID NOT FUNCTION. DURING A TELEPHONE INTERVIEW ON 6/04/2012 AT 2:30 P.M., THE FACILITY ADMINISTRATOR SAID HE REVIEWED THE VIDEO FOOTAGE AND DETERMINED RESIDENT #105 WAS LAST SEEN IN THE FACILITY ON 5/21/2012 AT 5:57 A.M. BY LPN #1. THE ADMINISTRATOR SAID RESIDENT #105 INDEPENDENTLY LEFT THE FACILITY THROUGH THE FRONT DOOR AT 6:01 A.M. AND WAS FOUND, 19 MINUTES LATER OUTSIDE THE FACILITY, UNSUPERVISED. ON 6/01/2012 AT 12:40 P.M. THE ADMINISTRATOR SAID, "YOU HAVE TO REMEMBER NOT ONLY DID THE ALARM NOT SOUND (WHEN RESIDENT #105 EXITED THE FRONT DOOR OF THE FACILITY ON 5/21/2012 AT 6:01 A.M. WITH THE CODE ALERT ON HIS BODY) BUT THE DOOR DID NOT LOCK" TO PREVENT HIS EXIT. THE ADMINISTRATOR SAID THE FACILITY'S INVESTIGATION, COMPLETED AFTER THE INCIDENT, CONCLUDED THAT THE CODE ALERT ALARM MAY HAVE FAILED ON 5/21/2012 AT 6:01 A.M. (WHEN RESIDENT #105 EXITED) AND AT 6:20 A.M. (WHEN HE RETURNED) DUE TO INTERFERENCE CREATED BY THE LOBBY'S DIMMER SWITCH. RESIDENT #102 ACCORDING TO THE FACE SHEET, DATED 5/22/2012, RESIDENT #102 WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 2/26/2008. HER [DIAGNOSES REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated [DATE], RESIDENT #102 HAD SEVERELY IMPAIRED DECISION MAKING WITH BOTH LONG AND SHORT TERM MEMORY LOSS. SHE DID NOT WALK, USED A WHEELCHAIR AND REQUIRED HUMAN ASSISTANCE TO BALANCE, TRANSFER AND ALL LOCOMOTION. RESIDENT #102 REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE EXTENSIVE ASSISTANCE WITH BED MOBILITY, DRESSING, EATING, TOILETING, HYGIENE AND BATHING. A WANDER DATA COLLECTION TOOL, DATED 12/07/201,1 IDENTIFIED RESIDENT #102 AS BEING AT RISK FOR ELOPEMENT. AN ELOPEMENT CARE PLAN, DATED 12/07/2011, REQUIRED STAFF TO APPLY A CODE ALERT ALARM TO RESIDENT #102 TO ENSURE HER SAFETY. REPEATED QUARTERLY ASSESSMENTS RESULTED IN A WANDER DATA COLLECTION TOOL UPDATED ON 3/26/2012. THIS ASSESSMENT DETERMINED RESIDENT #102 HAD NO ELOPEMENT ATTEMPTS SINCE BEFORE 12/07/2011 AND SUBSEQUENTLY WAS NO LONGER AT RISK FOR ELOPEMENT. HER CODE ALERT ALARM WAS DISCONTINUED THE SAME DAY. AN UNPLANNED OCCURRENCE REPORT, DATED 5/06/2012 AT 11:50 A.M., REVEALED RESIDENT #102 WAS FOUND UNSUPERVISED OUTSIDE IN THE PARKING LOT. A WRITTEN STATEMENT, DATED 5/06/2012, DOCUMENTED THAT RN #1 FOUND RESIDENT #102 UNSUPERVISED, OUTSIDE, SITTING IN HER WHEELCHAIR ON THE WEST SIDE OF THE BUILDING ON A BLACKTOP DRIVEWAY AT APPROXIMATELY 11:50 A.M.. ON 6/01/2012 AT 12:30 P.M. THE FACILITY ADMINISTRATOR SAID VIDEO FOOTAGE SHOWED A VISITOR HELD THE DOOR OPEN AND PERMITTED WHEELCHAIR-BOUND RESIDENT #102, UNSUPERVISED ACCESS OUTSIDE, THROUGH THE WEST LOBBY DOOR ONTO THE DRIVEWAY, UNBEKNOWNST TO STAFF, ON 5/06/2012 AT 11:40 A.M. THE ADMINISTRATOR SAID INTERVIEWS REVEALED THE VISITOR'S INTENT WAS TO BE HELPFUL, NOT HARMFUL. THE ADMINISTRATOR SAID RESIDENT #102 SPENT 12 MINUTES UNSUPERVISED, OUTSIDE THE FACILITY, BEFORE STAFF FOUND HER AND ESCORTED HER BACK INSIDE THE BUILDING. AN ELOPEMENT CARE PLAN, DATED 5/06/2012, REQUIRED STAFF TO APPLY A CODE ALERT ALARM TO RESIDENT #102'S WHEELCHAIR. IN AN OBSERVATION ON 6/05/2012 AT 10:45 A.M. REVEALED THE CODE ALERT ALARM WAS FUNCTIONAL AND PRESENT ON THE LEFT SIDE OF RESIDENT #102'S WHEELCHAIR. IN AN INTERVIEW ON 6/1/12 AT 1:30 P.M., ADMINISTRATOR #1 REPORTED THERE WERE NO DOOR SIGNS PRESENT ON THE DOORS PRIOR TO RESIDENT #102'S ELOPEMENT, BUT THAT SIGNS ASKING VISITORS TO NOT ALLOW RESIDENTS OUTSIDE WITHOUT FACILITY STAFF WERE PLACED ON THE FACILITY EXIT DOORS ON 5/7/12. IN AN OBSERVATION ON 6/1/12 AT 10:45 A.M., THIS SURVEYOR NOTED THE ABOVE SIGNS WERE ON THE EXIT DOORS OF THE FACILITY. OBSERVATIONS MADE OF THE FACILITY DOORS ON 6/1/12 AT 3:00 P.M. AND AGAIN ON 6/5/12 REVEALED ALL EXIT DOORS THAT WERE ALARMED HAD FUNCTIONAL DOOR ALARMS. IN AN OBSERVATION ON 6/5/12 BETWEEN THE HOURS OF 8:00 A.M. AND 5:00 P.M., ALL 23 RESIDENTS, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK AND HAD WANDERGUARD BRACELETS WERE OBSERVED. ALL WANDERGUARD'S WERE FOUND TO BE IN PLACE PER THE CARE PLAN AND IN FUNCTIONAL ORDER. THE ADMINISTRATOR WAS NOTIFIED ON 06/20/12 P.M. OF THE IMMEDIATE JEOPARDY WHICH BEGAN ON 05/06/12 DUE TO RESIDENT #102, WHO WAS NOT IDENTIFIED AS AN ELOPEMENT RISK, EXITED THE FACILITY ON 5/6/12 UNBEKNOWNST TO FACILITY STAFF, AND RESIDENT #105, WHO WAS IDENTIFIED AS AN ELOPEMENT RISK, EXITED THE FACILITY ON 5/21/12 UNBEKNOWNST TO FACILITY STAFF. 1. ON 6/05/2012 THE SURVEYOR VERIFIED THE FACILITY IMPLEMENTED THE FOLLOWING BY 5/21/2012 TO REMOVE THE IMMEDIATE JEOPARDY: 2. ON 5/21/12, RESIDENT #105 WAS EXAMINED AND FOUND FREE OF INJURY. 3. ON 5/21/12, RESIDENT #105 HAD A NEW CODE ALERT TRANSMITTER APPLIED. 4. ON 5/21/12, THE TRANSMITTER BRACELET WORN AT THE TIME OF EXIT WAS CHECKED FOR PROPER FUNCTION AND FOUND TO BE WORKING. 5. ON 5/21/12, THE LOBBY DOOR EXITED WAS tested WITH A TEST TRANSMITTER AND FOUND TO BE WORKING. 6. ON 5/21/12, ALL 164 RESIDENTS RESIDING IN THE FACILITY WERE REASSESSED FOR THE NEED FOR CODE ALERT BRACELETS AND CARE PLANS UPDATED IF NEEDED. NO ADDITIONAL RESIDENTS WERE IDENTIFIED AS BEING AT RISK FOR ELOPEMENT. 7. ON 5/21/12, ALL RESIDENTS ASSESSED AS NEEDING CODE ALERT BRACELETS HAD THE BRACELETS CHECKED FOR PLACEMENT AND FUNCTION. 8. ON 5/21/12, THE CONTROL LIST AND PHOTO BOOKS WERE UPDATED TO INCLUDE ALL RESIDENTS CURRENTLY ASSESSED AS HAVING TRANSMITTER BRACELETS. 9. ON 5/21/12, THE MIDNIGHT SHIFT STAFF WERE INTERVIEWED AND ALL REPORTED THAT NO DOOR ALARM OR OVERHEAD PAGE SOUNDED. 10. ON 5/21/12, STAFFING FOR THE UNIT WAS EVALUATED AND FOUND TO MEET REGULATORY REQUIREMENTS. 11. ON 5/21/12, PLAN OPERATIONS STAFF tested ALL DOORS ALARMED WITH CODE ALERT SYSTEM AND ALL DOORS WERE FOUND TO BE FUNCTIONING. ROUTINE DAILY DOOR CHECKS HAVE BEEN COMPLETED SINCE MEETING MANUFACTURER'S WEEKLY RECOMMENDATION. 12. ON 5/21/12, RF TECHNOLOGY (THE FACILITY'S OUTSIDE VENDER) WAS CALLED IN TO ASSESS THE PROPER FUNCTION OF THE SYSTEM AND IT WAS FOUND TO BE WORKING PROPERLY. 13. ON 5/21/12, RF TECHNOLOGY PERFORMED AN INDEPENDENT VERIFICATION TEST ON THE DOOR ALARMS SYSTEM AND FOUND ALL DOORS WORKING PROPERLY. 14. ON 5/21/12, THE TRANSMITTER FIELD FOR THE DOOR, FROM WHICH RESIDENT # 105 EXITED, WAS EXTENDED FROM TWO FEET TO FOUR FEET. 15. ON 5/21/12, INTERFERENCE FROM THE DIMMER SWITCH WAS IDENTIFIED DURING THE EVALUATION OF THE DOOR'S FUNCTIONALITY AND IT WAS DETERMINED TO BE THE LIKELY CAUSE OF SYSTEM FAILURE. THE FACILITY REMOVED THE DIMMER SWITCH AND REPLACED IT WITH AN "ON/OFF" SWITCH THAT DID NOT APPEAR TO CREATE THE INTERFERENCE.. 16. ON 5/21/12, STAFF EDUCATION BEGAN AND NO STAFF WERE PERMITTED TO WORK AFTER 3:30 P.M. WITHOUT THE MANDATED EDUCATION BEING COMPLETED. 17. ON 5/21/12, THE ADMINISTRATOR AND DIRECTOR OF PLANT OPERATIONS REVIEWED THE POLICY AND PROCEDURES FOR CODE ALERT AND FOUND IT WAS APPROPRIATE. 18. ON 5/21/12, QUALITY ASSURANCE TRACKING METHODS WERE DEVELOPED AND INITIATED. 19. ON 5/7/12, THE FACILITY PLACED A NOTICED ON EACH EXIT DOOR ADVISING FAMILIES TO NOT ASSIST UNATTENDED RESIDENTS OUTSIDE OF THE BUILDING DUE TO POSSIBLE SAFETY ISSUES. 20. ON 5/6/12, RESIDENT #102 WAS PLACED ON 15 MINUTE CHECKS AND HAD A WANDERGUARD CODE ALERT BRACELET PLACED ON THE WHEELCHAIR. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 5/21/2012, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROPERLY POSITION THE RESIDENT'S FOOT TO PREVENT PRESSURE ON THE TOES AND HEAL OF ONE (#416) OF 10 SAMPLED RESIDENTS REVIEWED FOR WOUNDS FROM A TOTAL OF 26 , RESULTING IN THE DEVELOPMENT OF FACILITY ACQUIRED PRESSURE SORES. FINDINGS INCLUDE: ON 5/16/12 AT 9:40 AM, RESIDENT #416'S SKIN WAS OBSERVED WITH NURSE 'A.' THE RESIDENT WAS ON HIS BACK IN BED, ALERT, AND HAD HIS RIGHT FOOT RESTING AGAINST THE FOOTBOARD WITH BED COVERS RESTING UNDER PRESSURE ON THE TIPS OF HIS TOES. THE RESIDENT'S RIGHT HEEL WAS ELEVATED FROM THE BED BY A ROHO (FLOTATION) CUSHION. RESIDENT #416'S RIGHT GREAT TOE WAS SOLID BLACK WITH NECROTIC (DEAD) TISSUE. A DRESSING WAS REMOVED FROM THE RIGHT FOOT AND REVEALED THE ENTIRE HEEL WAS ALSO SOLID BLACK. WHEN QUERIED ABOUT THE PRESSURE SORES TO THE RESIDENT'S RIGHT HEEL AND GREAT TOE, NO VERBAL EXPLANATION WAS OFFERED. NURSE 'A' WAS UNABLE TO EXPLAIN HOW AND WHY THEY DEVELOPED. RECORD REVIEW REVEALED THAT RESIDENT #416 WAS ORIGINALLY admitted INto the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. MINIMUM DATA SETS DATED 1/4/12 AND 2/8/12 NOTED THE RESIDENT HAD AN INTACT COGNITION, REQUIRED EXTENSIVE ASSISTANCE FOR BED MOBILITY, AND HAD NO PRESSURE SORES. REVIEW OF A NURSE'S NOTE DATED 2/27/12 INDICATED: "UPON MAKING ROUNDS, OBSERVED RESIDENT'S RIGHT GREAT TOE BRUISED, PURPLISH-BLACK....FOOT PROPPED UP AGAINST FOOTBOARD; 2/28/12: BLANKET CRADLE (TO KEEP COVERS LIFTED FROM THE TOES), LONGER BED ORDERED." REVIEW OF A physician's orders [REDACTED]. REVIEW OF A BRADEN SCALE DATED 2/8/12 DOCUMENTED A SCORE OF 13 (MODERATE RISK). REVIEW OF NURSES NOTE DATED 3/15/12: "SLIGHT AMOUNT REDNESS NOTED RIGHT HEEL; RIGHT HEEL ON PILLOW; NOT TOUCHING MATTRESS; INSTRUCTED RESIDENT TO MOVE FOOT AROUND WHILE LAYING IN BED." ON 3/16/12: "UPON MAKING ROUNDS, OBSERVED RESIDENT (RIGHT) HEEL PURPLISH IN COLOR, SOFT....WRITER ELEVATED FOOT OFF BED...." A REVIEW OF "PRESSURE ULCER/NON-PRESSURE ULCER HEALING RECORD" DATED 3/15/12 IDENTIFIED THE WOUND AS A PRESSURE ULCER ON 3/15/12 MEASURING 3 CENTIMETERS (CM) BY 4 CM, NO STAGE, AND "SLIGHTLY RED." ON 3/19/12: "RIGHT HEEL HAS 3 X 3 CM ESCHAR (DEAD TISSUE) NOTED" AND THE ROHO CUSHION WAS PROVIDED. ON 3/23/12, THE WOUND CARE CONSULTANT NOTED THAT THE RIGHT HEEL HAD A "LARGE PRESSURE ULCER (4.5 X 5 CM)....RECOMMEND OFF-LOAD (PRESSURE FROM) RIGHT HEEL." ON 5/11/12, THE WOUND SPECIALIST NOTED THAT THE WOUND MEASURED 5.5 X 4.5 CM AND WAS BLACK WITH NECROTIC TISSUE. RESIDENT #416'S "RISK FOR SKIN BREAKDOWN" CARE PLAN DATED 11/9/11 THRU 5/8/12 NOTED AN INTERVENTION: "FLOAT HEELS WHILE IN BED." THERE WAS NO MENTION OF THE LONGER BED OR THE BLANKET CRADLE. A PRESSURE ULCER CARE PLAN DATED 3/19/12 NOTED THE ROHO CUSHION AND FLOATING THE HEEL, BUT DID NOT MENTION THE LONGER BED AND BLANKET CRADLE. THROUGHOUT EACH DAY OF THE SURVEY, RESIDENT #416 WAS OBSERVED IN BED WITHOUT A BLANKET CRADLE WITH THE BED COVERS RESTING ON THE TIP OF THE RIGHT GREAT TOE. ON 5/17/12 AT 11:35 A.M., NURSE SUPERVISOR 'A' WAS QUERIED REGARDING THE MISSING BLANKET CRADLE. SHE LOOKED THROUGH THE RESIDENT'S CHART AND STATED, "I CAN'T SEE WHERE THE BLANKET CRADLE WAS DISCONTINUED." SUPERVISOR 'A' WAS UNABLE TO EXPLAIN WHY THE BLANKET CRADLE WAS NOT IN USE, OR IF IT WAS EVER IN USE. SUPERVISOR 'A' DID NOT PROVIDE AN EXPLANATION AS TO WHY THE LONGER BED HAD NOT BEEN OBTAINED TO ASSIST IN THE PREVENTION FOR PRESSURE ULCERS ON THE FOOT/HEEL. A "PREVENTING PRESSURE ULCERS" GUIDELINE PRESENTED BY THE FACILITY DATED 2008 WAS NOT SPECIFIC REGARDING INTERVENTIONS TO PREVENT PRESSURE SORES ON HEELS AND TOES. ( ) ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROPERLY ASSESS, CARE PLAN, AND PROVIDE APPROPRIATE PRE/POST-FALL/ACCIDENT INTERVENTIONS FOR THREE (#'S 308, 312, AND 315) OF 18 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 25, RESULTING IN FALLS, ACCIDENTS, FRACTURES, AND THE POTENTIAL FOR FURTHER ACCIDENTS. FINDINGS INCLUDE: ON 7/19/11 AT 12:20 PM, RESIDENT #308 WAS OBSERVED IN THE DINING ROOM IN A WHEELCHAIR LEANING TO THE RIGHT SIDE BEING FED BY STAFF. AT 2 PM, THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL AND admitted for POSSIBLE PNEUMONIA AND MENTAL STATUS CHANGES. THE CLINICAL RECORD AND AN INCIDENT/ACCIDENT (I/A) REPORT KNOWN AS AN "UNPLANNED OCCURRENCE REPORT" WERE REVIEWED. RESIDENT #308 WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. AN MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT RESIDENT # 308 COGNITION AS SEVERELY IMPAIRED, IMPAIRED RANGE OF MOTION TO ALL EXTREMITIES, REQUIRED EXTENSIVE "TWO-PERSON" ASSISTANCE FOR TRANSFERS, AND EXTENSIVE ASSISTANCE FOR ALL ACTIVITIES OF DAILY LIVING (ADLS). ON 6/7/11 AT 5:30 PM, NURSE 'T' (WHO WAS UNAVAILABLE FOR COMMENT) NOTED FOR RESIDENT #308: NURSE AIDE 'C' REPORTED THAT WHILE TRANSFERRING THE RESIDENT FROM WHEELCHAIR TO BED, THE RESIDENT BUMPED HER LEFT LEG AGAINST THE BED ASSIST RAIL. THE RESIDENT COMPLAINED OF PAIN. AN X-RAY WAS ORDERED. THE X-RAY WAS PERFORMED IN THE EARLY MORNING OF 6/8/11. THE RESULTS: "SUSPICIOUS IMPACTED FRACTURE OF THE PROXIMAL SHAFT OF THE TIBIA...." RESIDENT #308 WAS TRANSFERRED TO THE hospital on [DATE] AT 5:50 AM AND diagnosed with [REDACTED]. REVIEW OF THE I/A REPORT WRITTEN BY NURSE 'T,' NURSE AIDE 'C' "REPORTED TO THIS WRITER THAT RESIDENT BUMPED LEFT LEG AGAINST ASSIST RAIL...." THE CORRECTIVE ACTIONS TAKEN TO PREVENT REOCCURRENCE: "(NURSE AIDE 'C') IN-SERVICED." ON 7/20/11 AT 11 AM, THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING HER WRITTEN INVESTIGATION REGARDING RESIDENT #308'S FRACTURE WHILE BEING ASSISTED BY AIDE 'C.' THE DON NOTED THAT THE FOLLOWING OCCURRED DURING THE TRANSFER: "RESIDENT BECAME WEAK DURING TRANSFER AND FEET DID NOT PIVOT DURING TRANSFER. WHILE HOLDING THE ASSIST BARS DURING THE TRANSFER, RESIDENT LET GO, LEG TWISTED WHILE TRANSFERRING ON TO BED....RESIDENT'S LEG TWISTED DURING TRANSFER WHICH RESULTED IN A FRACTURE OF THE TIBIA AFTER TRANSFER. RESIDENT AND NURSE ASSISTANT ('C') CONFIRMED LEG DID NOT HIT ASSIST BAR...." HOWEVER, THE DON NOTED WHEN SHE INTERVIEWED THE RESIDENT REGARDING THE INCIDENT: "RESIDENT STATED SHE HURT HER LEG "MOVING TO THE BED WITH THE GIRL." UNABLE TO ANSWER FURTHER QUESTIONS RELATED TO INCREASED CONFUSION...." THERE WAS NO QUOTE FROM THE RESIDENT STATING THAT THE LEG WAS NOT BUMPED. WHEN ASKED, THE DON WAS UNABLE TO STATE WHY THE RESIDENT WAS NOT TRANSFERRED WITH ASSISTANCE OF TWO-PERSONS OR VIA A MECHANICAL LIFT. SHE WAS UNABLE TO PROVIDE DOCUMENTED EVIDENCE THAT A GAIT BELT WAS USED BY AIDE 'C' TO HELP TRANSFER THE RESIDENT. THE DON STATED THAT THE TRANSFER WAS PERFORMED PROPERLY BY THE AIDE. THE DON WAS ASKED WHY AIDE 'C' REQUIRED IN-SERVICE TRAINING FOLLOWING THE INCIDENT AS A CORRECTIVE MEASURE AND WHAT WAS THE TOPIC OF THE IN-SERVICE TRAINING . THE DON SAID, "I DON'T KNOW. I DON'T HAVE THE (TRAINING) RECORD." SHE DIRECTED THE ASSISTANT DIRECTOR OF NURSING (ADON) TO LOOK FOR THE RECORD. THE ADON LOOKED AND REPORTED THAT THERE WAS NO RECORD OF IN-SERVICE TRAINING FOR AIDE 'C' AFTER THE INCIDENT. ON 7/21/11 AT 10 AM, RESIDENT #308'S DAUGHTER WAS INTERVIEWED BY PHONE REGARDING THE FRACTURE. THE DAUGHTER SAID, "THEY CALLED AND TOLD ME THAT SHE HIT HER LEG ON A BAR ON THE BED. THEY USUALLY PUT HANDS UNDER HER ARMS AND LIFT HER FROM THE CHAIR TO THE BED." THE DAUGHTER STATED THAT THE RESIDENT WAS TRANSFERRED IN THIS MANNER BY ONE-PERSON. THE DAUGHTER SAID, "SHE WAS DEAD WEIGHT. SHE'S BEEN THIS WAY FOR A LONG TIME" AND STATED "THERE WAS NO WAY" THAT THE RESIDENT WAS ABLE TO STAND, PIVOT, OR MOVE HER FEET IN ORDER TO TRANSFER. ON 7/21/11 AT 7:40 PM, NURSE AIDE 'C' WAS INTERVIEW BY PHONE REGARDING THE INCIDENT. AIDE 'C' SAID, "I WAS PIVOTING HER FROM THE WHEELCHAIR TO BED WITH A GAIT BELT. SHE STOOD AND WAS HOLDING THE BAR AND STARTED SLIDING. I PIVOTED HER TO THE BED TO PREVENT HER FROM FALLING BUT HER LEG WAS CAUGHT BEHIND THE BAR. WHEN I PUT HER ON THE BED, SHE COMPLAINED THAT SHE HURT HER LEG. SHE SAID THAT HER LEG GOT CAUGHT ON SOMETHING." AIDE 'C' STATED THAT SHE DID NOT SEE THE POSITION OF THE RESIDENT'S FEET BEFORE THE TRANSFER. WHEN ASKED, THE AIDE STATED THAT SHE RECEIVED IN-SERVICE TRAINING THE DAY AFTER THE INCIDENT BY THE DON AND NURSE MANAGER 'G' ON SAFE TRANSFERS OF RESIDENTS. ON 7/22/11 AT 9:30 AM, WHEN QUERIED, NURSE 'G' SAID THAT AIDE 'C' "WAS IN-SERVICED BY ME AND (THE DON) REGARDING SAFE TRANSFERS AND USING PROPER TECHNIQUE." NURSE 'G' ENTERED RESIDENT #308'S ROOM AND STATED THAT THE AIDE DID NOT ENSURE THAT THE RESIDENT'S FEET WERE IN THE RIGHT POSITION AND HER LEG TWISTED. THERE WERE ASSIST BARS OBSERVED MOUNTED TO THE SIDE OF THE BED THAT EXTENDED SEVERAL INCHES BELOW THE BED FRAME. ON 7/22/11 AT 10:10 AM, THE CERTIFIED OCCUPATIONAL THERAPY ASSISTANT (COTA) 'B') WAS QUERIED REGARDING A REHABILITATION THERAPY SCREEN WRITTEN BY HER FOR RESIDENT #308 DATED 4/11/11. REGARDING THE RESIDENT'S ABILITY TO TRANSFER (STAND AND PIVOT), SHE NOTED: "EXTENSIVE 1 PERSON" PRIOR TO THE MDS dated [DATE] INDICATING 2-PERSON. WHEN ASKED TO EXPLAIN, THE COTA SAID, "I DON'T KNOW ABOUT TRANSFERS. I COULD NOT TOUCH HER. I AM ONLY A COTA." COTA 'B' INDICATED THAT SHE DID NOT OBSERVE THE RESIDENT'S ABILITY TO TRANSFER. THE RESIDENT'S LAST DOCUMENTED OCCUPATIONAL THERAPY EVALUATION (DATED 5/17/10) WAS DISCUSSED WITH THE THERAPY MANAGER ON 7/22/11 AT 10:30 AM: "N/A" WAS NOTED FOR TRANSFERS. WHEN ASKED TO CLARIFY, THE MANAGER STATED THAT "N/A" MEANT THAT THE RESIDENT WAS UNABLE TO TRANSFER FROM CHAIR TO BED. RESTORATIVE THERAPY NOTES DATED 11/3/10 THRU 6/27/11 DID NOT NOTE THAT THE RESIDENT WAS ABLE TO STAND AND PIVOT DURING TRANSFERS. AN "ADL" CARE PLAN FOR RESIDENT #308, LAST UPDATED ON 4/20/11, NOTED THAT THE RESIDENT REQUIRED "ONE-PERSON" TRANSFER ASSISTANCE, CONTRARY TO THE MDS. INTERVENTIONS INCLUDED: "ASSIST WITH TRANSFER BY GUIDING, MONITOR FOR UNSTEADINESS, ENSURE SAFETY AT ALL TIMES." A "FALLS" CARE PLAN DATED 6/2/11 NOTED THAT RESIDENT #308 WAS "LOW" RISK FOR FALLS DUE TO POOR BALANCE WHEN SEATED. THE CARE PLAN DID NOT ADDRESS 2-PERSON ASSISTANCE FOR TRANSFERS OR USE OF A MECHANICAL LIFT FOR SAFE TRANSFER OF THE RESIDENT. PER THE FACILITY'S "TRANSFER WITH A GAIT BELT" POLICY DATED 1/2010: GAIT BELTS MUST BE USED FOR ALL RESIDENTS NEEDING ASSISTANCE FOR TRANSFERS BUT MUST NOT BE USED TO "LIFT" RESIDENTS. BELTS MUST BE USED FOR RESIDENTS WHO ARE PARTIALLY DEPENDENT DURING TRANSFERS. IF THE RESIDENT MUST BE LIFTED, MORE THAN ONE CAREGIVER MAY BE NEEDED. ( ) ON 7/19/11 AT 3:45 PM, RESIDENT #315 WAS OBSERVED IN BED. THE RESIDENT WAS ALERT BUT LEGALLY BLIND. SHE WAS UNABLE TO LOCATE HER CALL LIGHT TO SUMMON STAFF. THE RESIDENT STATED THAT SHE WANTED TO GET OUT OF BED. THE CALL LIGHT WAS FOUND ROLLED UP INTO THE BED COVERS. A REVIEW OF THE CLINICAL RECORD FOR RESIDENT #315 NOTED: THE RESIDENT WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS dated [DATE] NOTED THAT THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE FOR TRANSFERS, BED MOBILITY, TOILETING, AND AMBULATION. ON 4/6/11, THE FALL RISK ASSESSMENT NOTED THAT RESIDENT #315 WAS AT "HIGH RISK" FOR FALLS WITH A SCORE OF 15. A FALL CARE PLAN DATED 4/14/11 NOTED THAT THE RESIDENT WAS AT "LOW" RISK FOR FALLS, THOUGH THERE WAS LEGAL BLINDNESS AND A HISTORY OF FALLS. ON 7/19/11 AT 6:30 PM, THE RESIDENT'S DAUGHTER WAS INTERVIEWED BY PHONE. THE DAUGHTER SAID, "MY MOM CAME IN FOR A FRACTURED (LEFT) ARM AND THEN fell AND BROKE HER HIP. SHE SAID SHE HAD THE CALL LIGHT ON AND NO ONE CAME TO TAKE HER TO THE BATHROOM SO SHE GOT UP ON HER OWN AND GOT DISORIENTED I GUESS. THEY FOUND HER IN THE HALLWAY. SHE WAS LOOKING FOR THE BATHROOM. SHE IS LEGALLY BLIND....THEY SEEM SHORT OF STAFF. WHEN SHE PUTS ON HER LIGHT, SHE HAS TO WAIT AND WAIT...." ON 7/20/11 AT 8:50 AM, THE RESIDENT WAS OBSERVED IN BED EATING BREAKFAST. THE CALL LIGHT WAS CLIPPED TO THE UNDERSIDE OF A PILLOW BEHIND HER HEAD, ON THE LEFT SIDE. WHEN ASKED TO LOCATE THE CALL LIGHT, THE RESIDENT STARTING FEELING AROUND FOR IT AND SAID, "THEY ALWAYS MOVE IT. I DON'T KNOW WHERE IT IS. I WISH THEY WOULD PUT IT ON THE RIGHT SIDE TO MAKE IT MORE CONVENIENT." THE RESIDENT STATED THAT SHE WAS RIGHT HANDED. WHEN TOLD WHERE THE LIGHT WAS LOCATED, THE RESIDENT WAS UNABLE TO REACH IT WITH HER LEFT HAND BECAUSE SHE COULD NOT LIFT HER ARM HIGH ENOUGH, OR HER RIGHT HAND. ON 7/20/11 AT 2:15 PM, RESIDENT #315 WAS OBSERVED SITTING IN THE WHEELCHAIR ALONE IN HER ROOM, AT THE FOOT OF THE BED. THE CALL LIGHT WAS STRETCHED ACROSS THE MIDDLE OF THE BED OUT OF REACH. AT 3:45 PM, THE RESIDENT WAS IN BED WITH THE CALL LIGHT ACROSS THE LAP AREA. THE LIGHT WAS NOT ANCHORED TO THE BED TO PREVENT SHIFTING OR FALLING OUT OF PLACE. ON 7/21/11 AT 8:50 AM, RESIDENT #315 WAS IN BED EATING BREAKFAST WITH THE CALL LIGHT PINNED TO THE UNDERSIDE OF THE PILLOW BEHIND HER HEAD, ON THE LEFT SIDE. WHEN ASKED, SHE WAS UNABLE TO LOCATE THE CALL LIGHT. ON 7/22/11 AT 8:45 AM, THE RESIDENT WAS IN BED WITH THE CALL LIGHT WRAPPED AROUND THE BED ASSIST BAR, ON THE LEFT SIDE. THE RESIDENT WAS UNABLE TO LOCATE THE CALL LIGHT WHEN ASKED TO DO SO. THE RESIDENT REPEATED AGAIN, "I WISH THEY WOULD PUT IT ON THE RIGHT SIDE WHERE I CAN FIND IT." NURSE MANAGER 'G' ENTERED THE ROOM AND WAS QUERIED ABOUT THE CALL LIGHT. THE RESIDENT WAS ASKED TO REACH FOR HER LIGHT. WHEN SHE WAS UNABLE TO DO SO, NURSE 'G' MOVED IT TO THE RIGHT SIDE OF THE BED AND PINNED IT TO A SITE DESIGNATED BY THE RESIDENT. WHEN ASKED WHY THE CALL LIGHT WAS LOCATED ON THE SIDE OF THE FRACTURED ARM/SHOULDER, THE NURSE STATED THAT THE RESIDENT USED TO BE ABLE TO REACH OVER WITH HER RIGHT HAND AND USE THE CALL LIGHT ON THE LEFT SIDE. THE RESIDENT DID NOT RESPOND TO THE COMMENT. THE CLINICAL RECORD FOR RESIDENT #315 AND AN I/A REPORT, ALSO CALLED AN "UNPLANNED OCCURRENCE REPORT" DATED 4/25/11 AT 6:30 AM, WERE REVIEWED WITH NURSE 'G.' PER NURSES NOTES DATED 4/25/11, THE RESIDENT WAS FOUND ON THE FLOOR IN THE HALLWAY. SHE COMPLAINED OF PAIN TO THE ARM AND BILATERAL LOWER EXTREMITIES AND "STATED SHE WAS TRYING TO GO TO THE BATHROOM." X-RAYS WERE ORDERED. THE X-RAYS TAKEN ON 4/25/11 REPORTED: FRACTURE OF THE RIGHT HIP AND AN UNHEALED FRACTURED OF THE UPPER LEFT ARM NEAR THE SHOULDER. THE RESIDENT WAS TRANSFERRED TO THE hospital on [DATE], HAD SURGICAL REPAIR OF THE HIP ON 4/27/11, AND WAS TRANSFERRED BACK to the facility on [DATE]. ACCORDING TO THE FALL INVESTIGATION DOCUMENTED BY NURSE 'G,' THE CALL LIGHT WAS LOCATED ON THE BED ASSIST BAR, ON THE LEFT SIDE, AT THE TIME OF THE FALL. NURSE 'G' NOTED: "QUESTIONED RESIDENT ON HOW SHE GOT OUT OF BED WHEN UNABLE TO USE LEFT ARM. SHE DEMONSTRATED HOW SHE GRABBED RIGHT ASSIST BAR WITH RIGHT HAND AND SLOWLY SAT UP AND GOT OUT OF BED. (PER RESIDENT) "WHEN YOU HAVE TO USE THE BATHROOM, YOU HAVE TO GO." ALSO STATED WHEN SHE WAS WALKING TO THE BATHROOM, HER LEGS GAVE OUT AND SHE WENT DOWN ON THE FLOOR." THE CORRECTIVE MEASURES TO PREVENT REOCCURRENCE INCLUDED: "FLORESCENT ROPE AROUND CALL LIGHT FOR EASY VISIBILITY." THIS INTERVENTION WAS NOT UPDATED TO THE NEW FALL CARE PLAN DATED 4/30/11 THAT IDENTIFIED THE RESIDENT AS "HIGH" RISK FOR FALLS. "VISION" CARE PLANS DATED 4/19/11 AND 5/11/11, AND "ADL" CARE PLANS DATED 4/19/11 AND 5/10/11 DID NOT INCLUDE THIS INTERVENTION. NURSE 'G' WAS UNABLE TO VERIFY THAT A FLUORESCENT LIGHT WAS ATTEMPTED AND WHY THE CARE PLANS WERE NOT UPDATED. THE HIGH RISK FOR FALLS CARE PLAN WAS DISCONTINUED ON 5/24/11. THERE WERE NO FURTHER DOCUMENTED CARE PLANS FOR FALLS. NURSE 'G' WAS UNABLE TO STATE WHY. THE ADL AND VISION CARE PLANS NOTED INTERVENTIONS: -ANTICIPATE RESIDENTS NEEDS. -CALL LIGHT WITHIN REACH. -KEEP CALL LIGHT WITHIN REACH OR ALLOW RESIDENT TO PLACE IT IN A LOCATION OF THEIR OWN CHOOSING. THE FACILITY DID NOT PROVIDE A POLICY FOR RESIDENTS DEEMED "LOW" RISK FOR FALLS BY THE END OF THE SURVEY. ( ) ON 7/19/11 AT 9:30 A.M., DURING THE INITIAL ROUNDS WITH THE UNIT MANAGER (NURSE "I"), IT WAS REPORTED THAT RESIDENT #312 had a history of [REDACTED]. FALL MATS ON EACH SIDE OF THE RESIDENT'S BED WERE NOTED ON THE FLOOR. ON 7/19/11 AT 1:45 P.M., RECORD REVIEW OF RESIDENT #312'S CLINICAL RECORD REVEALED THE FOLLOWING: THE FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM DATA SET (MDS), dated [DATE], INDICATED THE RESIDENT HAD A SEVERE IMPAIRED COGNITION AND REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF THE NURSE'S NOTES AND INCIDENT/ACCIDENT REPORTS REVEALED THE RESIDENT HAD FOUR FALLS SINCE BEING admitted INTO THE FACILITY. ALL OF THE FALLS OCCURRED ON THE AFTERNOON SHIFT. THE NURSE'S NOTES AND THE INCIDENT/ACCIDENT REPORTS WERE REVIEWED WITH THE UNIT MANAGER (NURSE "I") ON 7/21/11 AT 11:50 A.M., THE FOLLOWING FALLS WERE REVIEWED AND REVEALED: FALL #1 OCCURRED ON 5/29/11 AT 10:30 P.M. (5 DAYS AFTER ADMISSION). REVIEW OF THE NURSE'S NOTE, DATED 5/29/11 REVEALED DOCUMENTATION THAT READ: "CENA (CERTIFIED NURSING ASSISTANT) OBSERVED RESIDENT SITTING ON THE FLOOR ON BUTTOCKS IN HALLWAY OUTSIDE HER ROOM. RESIDENT STATES SHE GOT OUT OF HER BED AND CRAWLED TO THE HALLWAY." NURSE "I" WAS QUERIED WHAT INTERVENTIONS WERE IN PLACE. NURSE "I" REPORTED THE FOLLOWING INTERVENTIONS WERE IN PLACE; A LOW BED, FALL MATS, SENSOR ALARM TO BED AND SHE WAS IN THE "FALLING STAR PROGRAM FOR HIGH RISK FOR FALLS. WHEN A RESIDENT IS ON THE FALL STAR PROGRAM, THEY SHOULD NOT BE IN A ROOM ALONE EXCEPT WHEN THEY ARE IN BED." THE INCIDENT/ACCIDENT REPORT NOR THE NURSE'S NOTE INDICATED THE BED SENSOR ALARM SOUNDING. NURSE "I" DID NOT KNOW WHETHER OR NOT THE ALARM SOUNDED DURING THE INCIDENT. REVIEW OF THE "FALL PREVENTION" CARE PLAN INDICATED THAT THE CARE PLAN WAS REVIEWED ON 5/29/11, BUT THERE WERE NO NEW INTERVENTIONS ADDED. THE ADDED CONCERNS NOTED ON THE CARE PLAN ON 5/29/11 INCLUDED: "RESIDENT HAD ONE FALL WITHIN THE PAST THREE MONTHS IN THE BUILDING, RESIDENT ATTEMPTS UNSAFE SELF-TRANSFERRING, AND RESIDENT FREQUENTLY GETS OUT OF BED WITHOUT UTILIZING CALL LIGHT AND IS UNSAFE WITH AMBULATING AND/OR TRANSFERRING." NURSE "I" DID NOT REPORT ANY NEW INTERVENTIONS AFTER THE FALL. FALL #2 OCCURRED ON 6/17/11 AT 5:15 P.M., THE INCIDENT/ACCIDENT REPORT INDICATED THE RESIDENT WAS IN THE DINING ROOM. THE INCIDENT/ACCIDENT REPORT REVEALED THE FOLLOWING DOCUMENTATION: "REPORTED BY CENA THAT RESIDENT WAS OPENING DRAWER STANDING IN FRONT OF HER WHEELCHAIR WHEN SHE SLOWLY SLID ON THE FLOOR." UNDER THE SUBTITLE OF "PREVENTATIVE MEASURES/CORRECTIVE ACTIONS TAKEN," ON THE INCIDENT/ACCIDENT REPORT, REVEALED DOCUMENTATION THAT READ: 'SOCKS AND SHOES REMOVED AFTER DINNER TO PREVENT RESIDENT FROM SLIDING OUT OF WHEELCHAIR. PT (PHYSICAL THERAPY) AND OT (OCCUPATIONAL THERAPY) FOR SAFETY FOR STRENGTHENING.' THE FALL CARE PLAN WAS REVIEWED WITH NURSE "I." THE FALL CARE PLAN REVEALED NO INTERVENTION TO REMOVE SHOES AND SOCKS AFTER DINNER NOR ANY OTHER UPDATED INTERVENTIONS. NURSE "I" WAS QUERIED REGARDING HOW RECOMMENDATIONS WRITTEN ON THE INCIDENT/ACCIDENT REPORTS WERE COMMUNICATED TO THE CENA'S AND OTHER STAFF, SUCH AS REMOVING THE SHOES AND SOCKS FOR RESIDENT #312 AFTER DINNER. NURSE "I" REPORTED THAT SHE ADDED THE INTERVENTION TO THE "CARE TRACKER (AN ELECTRONIC RECORD USED TO COMMUNICATE AMONG THE STAFF RELATED TO CARE CONCERNS)." WHEN REQUESTED TO SHOW THE INTERVENTION ADDED TO CARE TRACKER, NURSE "I" WAS UNABLE TO DO SO. NURSE "I" REPORTED BEING NEW TO CARETAKER AND THOUGHT SHE ADDED THE INTERVENTION, BUT ACTUALLY DID NOT. FALL #3 OCCURRED ON 6/22/11 AT 6:15 P.M. REVIEW OF THE NURSE'S NOTE FOR THIS INCIDENT REVEALED DOCUMENTATION THAT READ, "PATIENT OBSERVED SITTING ON FLOOR IN FRONT OF WHEELCHAIR...PATIENT STATED SHE WAS FIXING HER SHOES AND SOCKS AND SLIPPED OUT OF WHEELCHAIR ONTO FLOOR." REVIEW OF THE FALL CAREPLAN REVEALED NO UPDATES AND INDICATIONS OF REVIEW. ON 6/23/11 A STAT (IMMEDIATE)X-RAY OF THE RIGHT HIP, RIGHT FEMUR, AND RIGHT KNEE WAS COMPLETED. THE X-RAYS WERE NEGATIVE FOR FRACTURES. FALL #4 OCCURRED ON 6/27/11 AT 9 P.M. REVIEW OF THE NURSE'S NOTE FOR THE INCIDENT REVEALED DOCUMENTATION THAT READ, "PATIENT WAS FOUND ON THE FLOOR. THE CENA FOUND HER FIRST WHEN SHE HEARD HER WHEELCHAIR ALARM. SHE CALLED MY ATTENTION AND I FOUND HER ON THE FLOOR. THE PATIENT SAID THAT SHE DID NOT FALL. SHE TRIED TO REMOVE HER SHOES AND SOCKS." REVIEW OF THE FALL CARE PLAN DID NOT REVEAL ANY UPDATES, REVISIONS, OR REVIEWS. THE UNIT MANAGER REPORTED THE RESIDENT WAS THEN PUT ON EVERY 15 MINUTE CHECKS AND THE "RED STAR" PROGRAM WAS DISCONTINUED. ( )

THIS CITATION PERTAINS TO INTAKES MI 163 AND MI 290 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO ENSURE THE RESIDENTIAL ENVIRONMENT WAS SAFE AND FAILED TO PROVIDE ADEQUATE SUPERVISION FOR 2 OF 8 SAMPLED RESIDENTS (#501 AND #508) WHICH RESULTED IN IMMEDIATE JEOPARDY FOR RESIDENT #501. THIS PLACED 14 OTHER RESIDENTS WITH DYSPHAGIA (SWALLOWING IMPAIRMENT) AND IMPAIRED COGNITION AT HIGH RISK FOR SERIOUS HARM DUE TO THE FACILITY'S FAILURE TO ENSURE THAT THESE RESIDENTS DID NOT HAVE ACCESS TO FOOD THAT COULD BE HARMFUL. RESIDENT #501, WHO HAD A [DIAGNOSES REDACTED]. RESIDENT #508 WHO HAD A [DIAGNOSES REDACTED]. FINDINGS INCLUDE: RESIDENT #501 REVIEW OF THE CLOSED CLINICAL RECORD FOR RESIDENT #501 REVEALED [DIAGNOSES REDACTED]. THE PHYSICIAN ORDERS [REDACTED]." ON [DATE], AT 2:00 P.M., AN INTERVIEW WITH THE PHYSICIAN REVEALED THAT RESIDENT #501, WHO HAD A LONG HISTORY OF DYSPHAGIA, HAD RECENTLY PRESENTED WITH A WEIGHT LOSS AND THE MBS EVALUATION WAS TO EVALUATE CHANGES IN RESIDENT #501'S SWALLOWING AND EXPLORE ALTERNATE FEEDING OPTIONS. THE PHYSICIAN FURTHER REPORTED THAT SHE WAS PRESENT DURING THE MBS EVALUATION THAT WAS COMPLETED AT AN AREA HOSPITAL ON [DATE]. THE PHYSICIAN STATED THAT AS A RESULT OF THE MBS EVALUATION IT WAS RECOMMENDED THAT RESIDENT #501 REMAIN ON A DYSPHAGIA PUREED DIET WITH ONE-TO-ONE SWALLOW SUPERVISION. REVIEW OF THE HOSPITAL OUT-PATIENT MBS EVALUATION DATED [DATE], REVEALED THAT THE RECOMMENDATION WAS FOR RESIDENT #501 TO RECEIVE A PUREED DIET AND ONE-TO-ONE SWALLOW SUPERVISION. THIS WAS ALSO VERIFIED BY AN INTERVIEW WITH THE HOSPITAL OUT-PATIENT SLP (SPEECH/LANGUAGE PATHOLOGIST) AT 11:30 A.M., ON [DATE]. THE SLP STATED THAT RESIDENT #501 REQUIRED ONE TO ONE SUPERVISION WHENEVER TAKING FOOD BY MOUTH AT THE FACILITY. FURTHER REVIEW OF THE CLINICAL RECORD FOR RESIDENT #501 REVEALED ON THE COMPREHENSIVE ASSESSMENT, DATED [DATE], THAT RESIDENT #501 HAD BOTH SHORT AND LONG TERM MEMORY IMPAIRMENT WITH SEVERELY IMPAIRED COGNITION. RESIDENT #501 WAS NON AMBULATORY AND UTILIZED A "ROCK-AND-GO" WHEELCHAIR FOR MOBILITY. REVIEW OF RESIDENT #501'S CLINICAL RECORD INDICATED ON THE COMPREHENSIVE CARE PLAN, DATED [DATE], A BEHAVIORAL PROBLEM THAT ADDRESSED THE BEHAVIOR, "GRABS FOOD". AN INTERVENTION LISTED ON THE CARE PLAN TO ADDRESS RESIDENT #501'S BEHAVIORAL PROBLEM INCLUDED, "PLACE BY NURSING STATION FOR INCREASED SUPERVISION." A NUTRITIONAL CARE PLAN DATED [DATE] AND REVISED ON [DATE], INDICATED THAT THE RESIDENT RECEIVED A PUREE DIET WITH THICKENED LIQUIDS, AND THAT THE RESIDENT "TRY'S TO GRAB FOOD/FLUIDS OFF TRAYS." REVIEW OF "NURSE'S NOTES" DOCUMENTED TWO INCIDENTS WHERE RESIDENT #501 HAD GRABBED FOOD OFF TRAYS AND PUT IT IN HIS MOUTH INCREASING HIS RISK FOR ASPIRATION. A "NURSE'S NOTE" DATED [DATE], AT 8:15 P.M., INDICATED, "RESIDENT OBSERVED, GRABBED PEANUT BUTTER SANDWICH FROM SNACK CART, WRITER TRIED TO TAKE BACK SANDWICH EXPLAINING TO RESIDENT HE WON'T BE ABLE TO EAT IT BUT RESIDENT FOUGHT WITH WRITER AND ATE ,[DATE] OF THE SANDWICH, RESIDENT ABLE TO SWALLOW WITHOUT DIFFICULTY, NO CHOKING NOTED NOR ANY DISCOMFORT NOTED." THE NURSE'S ENTRY WAS DOCUMENTED BY EMPLOYEE "A". ON [DATE], AT 3:30 P.M., AN INTERVIEW WITH EMPLOYEE "A" VERIFIED THE INCIDENT AS SHE HAD DOCUMENTED IN RESIDENT #501'S CLINICAL RECORD ON [DATE]. WHEN QUERIED WHY EMPLOYEE "A" CONFISCATED THE PEANUT BUTTER SANDWICH FROM RESIDENT #501 SHE REPLIED, "HE (#501) HAD DYSPHAGIA AND WAS ONLY ALLOWED PUREED FOOD AND COULD CHOKE ON THE SANDWICH." EMPLOYEE "A" STATED THAT RESIDENT #501 REQUIRED CLOSE SUPERVISION DURING MEALS BECAUSE OF THE HIGH RISK THAT HE COULD ASPIRATE AND HAD A TENDENCY TO GRAB FOOD OFF OF TRAYS. A "NURSE'S NOTE" DATED [DATE], INDICATED THAT RESIDENT #501 HAD GRABBED FOOD OFF OF ANOTHER RESIDENT'S TRAY. THE STAFF MEMBER DOCUMENTED, "DURING LUNCH TIME RESIDENT TOOK BREAD AND RICE FROM A TRAY IN FRONT OF HIM AND I NOTICED THAT HE WAS CHOKING. HEIMLICH MANEUVER WAS DONE ONE TIME AND RESIDENT WAS ABLE TO COUGH UP FOOD AND BREATH SPONTANEOUSLY." THIS ENTRY WAS DOCUMENTED BY EMPLOYEE "F". ON [DATE], AT 3:45 P.M., INTERVIEW WITH EMPLOYEE "F" VERIFIED THE INCIDENT THAT SHE HAD DOCUMENTED IN RESIDENT #501'S CLINICAL RECORD ON [DATE]. EMPLOYEE "F" STATED THAT AT THE TIME OF THE INCIDENT RESIDENT #501 HAD A [DIAGNOSES REDACTED]. EMPLOYEE "F" STATED THAT RESIDENT #501 REQUIRED FEEDING ASSISTANCE AND CLOSE SUPERVISION DURING MEALS SINCE HE WAS AT RISK FOR ASPIRATION AND ALSO HAD A TENDENCY TO GRAB FOOD OFF OF OTHER TRAYS. ON [DATE], AT 9:30 A.M., INTERVIEW WITH THE ADMINISTRATOR AND DIRECTOR OF NURSING REVEALED THAT AT APPROXIMATELY 9:04 P.M., ON [DATE], RESIDENT #501 HAD TAKEN PEANUT BUTTER SANDWICHES OFF A SNACK TRAY THAT WAS LEFT UNATTENDED AT THE NURSING STATION AND WAS LATER FOUND UNRESPONSIVE. RESIDENT #501 WAS TAKEN TO HIS ROOM WHERE A MOUTH SWEEP AND SUCTIONING REVEALED THE PRESENCE OF A LARGE AMOUNT OF PARTIALLY MASTICATED (CHEWED) PEANUT BUTTER SANDWICHES. NURSING STAFF INITIATED A FULL CODE THAT INCLUDED CPR (CARDIOPULMONARY RESUSCITATION). EMERGENCY MEDICAL SERVICES (EMS) RESPONDED AT APPROXIMATELY 9:30 P.M. AND INTUBATED (PUT A TUBE DOWN THE THROAT TO FACILITATE BREATHING) RESIDENT #501 AND TRANSPORTED HIM TO AN AREA HOSPITAL WHERE RESIDENT #501 REPORTEDLY expired on [DATE]. ON [DATE], AT 10:00 A.M., INTERVIEW WITH THE DIRECTOR OF FOOD SERVICES REVEALED THAT DIETARY PERSONNEL DELIVER THE EVENING SNACK TRAYS BETWEEN 6:30 P.M., TO 6:45 P.M., ON A DAILY BASIS. THE DIRECTOR OF FOOD SERVICES STATED THAT THE SNACK TRAYS WERE LEFT ON THE COUNTER AT EACH NURSING STATION AND THAT THE SNACKS ARE DISTRIBUTED BY NURSING PERSONAL TO THE RESIDENTS. THE DIRECTOR OF FOOD SERVICES STATED THAT THE SNACK TRAY INCLUDED BOTH PREPARED SNACKS THAT ARE LABELED FOR SPECIFIC RESIDENTS AND OTHER SNACKS THAT ARE PROVIDED UPON RESIDENT REQUEST. THE FOOD SERVICE DIRECTOR STATED THAT SNACKS INCLUDE WRAPPED SANDWICHES, CRACKERS, AND COOKIES. ON [DATE], AT 10:45 A.M., REVIEW OF A SURVEILLANCE VIDEO SHOWED THAT AT APPROXIMATELY 9:00 A.M., RESIDENT #501 WAS SEATED IN A "ROCK-AND-GO" WHEELCHAIR ACROSS FROM THE NURSING STATION COUNTER. A LICENSED PRACTICAL NURSE (EMPLOYEE #B) WAS OBSERVED SEATED INSIDE THE COUNTER AREA. AT APPROXIMATELY 9:04 P.M., RESIDENT #501 IS OBSERVED MOVING HIS "ROCK-AND-GO" WHEELCHAIR CLOSER TO THE NURSING COUNTER AND PULLING THE ENTIRE TRAY ON HIS LAP AND REMOVING SNACK ITEMS THAT INCLUDED HALF PEANUT BUTTER SANDWICHES. RESIDENT #501 IS THEN OBSERVED LIFTING THE TRAY OFF HIS LAP AND PLACING IT BACK ON THE COUNTER. IN FACT, EMPLOYEE "B" IS OBSERVED REACHING WITH HER HAND AND POSITIONING THE SNACK TRAY ON THE COUNTER. AT APPROXIMATELY 9:06 P.M., RESIDENT #501 IS OBSERVED UNWRAPPING THE SANDWICH AND PUTTING IT IN HIS MOUTH. AT APPROXIMATELY 9:10 P.M., A PORTER IS OBSERVED WITH A LARGE TRASH BARREL AND MOVES RESIDENT #501 IN HIS WHEELCHAIR SEVERAL FEET AWAY FROM THE NURSING STATION. THE PORTER IS OBSERVED MOVING THE LARGE BARREL DOWN THE HALLWAY. AT 9:19 P.M., A CERTIFIED NURSING ASSISTANT (EMPLOYEE "C") WAS OBSERVED APPROACHING RESIDENT #501 AND INFORMED BOTH EMPLOYEE "B" AND A LICENSED PRACTICAL NURSE (EMPLOYEE "D") THAT RESIDENT #501 "LOOKS LIKE HE'S DEAD." AT 9:20 P.M., EMPLOYEES "B" AND "D" INITIATE A FULL CODE AND MOVE RESIDENT #501 INTO HIS ROOM AND BEGIN CARDIOPULMONARY RESUSCITATION. AT 9:29 P.M., EMS PERSONNEL ARRIVE AND INTUBATE RESIDENT #501 AND TRANSPORT HIM AT 9:44 P.M., TO THE HOSPITAL. ON [DATE], AT 10:00 A.M., AN INTERVIEW WITH EMPLOYEE "B" REVEALED THAT DIETARY STAFF BROUGHT THE SNACK TRAY AT APPROXIMATELY 6:00 P.M., TO THE NURSING STATION ON [DATE]. EMPLOYEE "B" STATED THAT THE SNACK TRAY REMAINED UNATTENDED ON THE COUNTER AND SNACKS HAD NOT BEEN DISTRIBUTED SINCE THERE WERE ONLY 3 CNA'S (CERTIFIED NURSING ASSISTANTS) ON THE AFTERNOON SHIFT SCHEDULED ON [DATE]. EMPLOYEE "B" STATED THAT THE UNIT IS ROUTINELY STAFFED WITH 4 CNA'S. EMPLOYEE "B" STATED THAT AT 9:00 P.M., SHE RECALLED SITTING AT THE NURSING STATION TO CHART IN RESIDENT RECORDS. EMPLOYEE "B" STATED THAT WHILE SEATED AT THE NURSING STATION SHE "THOUGHT SOMEONE HAD BRUSHED AGAINST THE SNACK TRAY ON THE COUNTER". EMPLOYEE "B" STATED THAT SHE REACHED WITH HER HAND AND RE-POSITIONED IT ON THE COUNTER. EMPLOYEE "B" STATED THAT, "I DID NOT GET UP FROM MY CHAIR TO LOOK OR CHECK WHO BRUSHED AGAINST IT." EMPLOYEE "B" STATED THAT SHE WAS NOT FAMILIAR WITH RESIDENT #501, OR THAT HE HAD A [DIAGNOSES REDACTED].#501 SITTING ACROSS FROM THE NURSING STATION. EMPLOYEE "B" STATED THAT ANOTHER LICENSED PRACTICAL NURSE (EMPLOYEE "D") RETURNED TO THE NURSING STATION AT APPROXIMATELY 9:15 P.M., AFTER BEING ON A BREAK. EMPLOYEE "B" STATED THAT WITHIN MINUTES SHE AND EMPLOYEE "D" WERE APPROACHED BY EMPLOYEE "C" WHO STATED THAT RESIDENT #501 "LOOKED DEAD." EMPLOYEE "B" STATED THAT SHE STOOD UP AND OBSERVED RESIDENT #501 SITTING IN HIS WHEELCHAIR IN THE HALLWAY OUTSIDE OF HIS ROOM WITH HIS HEAD DOWN. EMPLOYEE "B" STATED THAT EMPLOYEE "D" IMMEDIATELY CHECKED RESIDENT #501'S PULSE AND SAID IT WAS FAINT. EMPLOYEE "B" STATED THAT SHE IMMEDIATELY CHECKED RESIDENT #501'S CHART AND SAW THAT HE WAS A FULL CODE AND SHE AND EMPLOYEE "D" IMMEDIATELY CALLED A CODE BLUE AND STARED CPR. EMPLOYEE "B" STATED THAT WHEN SHE DID AN ORAL SWEEP OF RESIDENT #501'S MOUTH, SHE FOUND A LARGE AMOUNT OF PARTIALLY MASTICATED PEANUT BUTTER SANDWICH. EMPLOYEE "B" FURTHER STATED THAT WHEN SHE SUCTIONED RESIDENT #501 THERE WAS A LARGE AMOUNT OF "CREAMY UNDIGESTED FOOD." EMPLOYEE "B" STATED THAT SHE ALSO OBSERVED PIECES OF PEANUT BUTTER SANDWICH ON RESIDENT #501'S CLOTHING WHILE PERFORMING CPR. EMPLOYEE "B" STATED EMS STAFF ARRIVED AT APPROXIMATELY 9:30 P.M., AND TRANSPORTED RESIDENT #501 TO THE HOSPITAL. ON [DATE], AT 1:15 P.M., INTERVIEW WITH A CNA (EMPLOYEE "C") REVEALED SHE FOUND RESIDENT #501 SITTING IN THE HALLWAY OUTSIDE OF HIS ROOM IN HIS "ROCK-AND-GO" WHEELCHAIR AND DESCRIBED HIM AS "BLUISH IN COLOR AND NOT BREATHING." EMPLOYEE "C" STATED SHE IMMEDIATELY TOLD THE LICENSED NURSES WHO WERE BOTH AT THE NURSING STATION THAT "HE LOOKS DEAD." EMPLOYEE "C" STATED THEY IMMEDIATELY CHECKED AND TOOK HIM (RESIDENT #501) INTO HIS ROOM AND STARTED CPR. EMPLOYEE "C" STATED SHE OBSERVED "PIECES OF PEANUT BUTTER SANDWICH" ON HIS CLOTHING. EMPLOYEE "C" STATED THAT AFTER RESIDENT #501 WAS TAKEN BY EMS TO THE HOSPITAL SHE CLEANED HIS ROOM AND FOUND PIECES OF PEANUT BUTTER SANDWICH ON THE FLOOR INCLUDING A PLASTIC WRAPPER. EMPLOYEE "C" STATED THAT THE PLASTIC WRAPPER WAS LABELED WITH THE NAME OF RESIDENT #506. REVIEW OF THE CLINICAL RECORD FOR RESIDENT #506 REVEALED THAT SHE WAS SCHEDULED TO RECEIVE ,[DATE] OF A PEANUT BUTTER SANDWICH EACH EVENING ON THE SNACK TRAY. FURTHER INTERVIEW WITH EMPLOYEE "C" REVEALED THAT ON [DATE], THERE WERE ONLY 3 CNA'S SCHEDULED FOR THE AFTERNOON SHIFT ON [DATE], INSTEAD OF 4 CNA'S. EMPLOYEE "C" FURTHER STATED THAT SHE WAS VERY FAMILIAR WITH RESIDENT #501, AND HE had a history of [REDACTED]. ON [DATE], AT 2:20 P.M., INTERVIEW WITH AN LPN (EMPLOYEE "D") REVEALED THAT ON [DATE], SHE RETURNED FROM A BREAK AT APPROXIMATELY 9:15 P.M., AND WAS APPROACHED BY EMPLOYEE "C" WHO STATED RESIDENT #501 "LOOKED DEAD." EMPLOYEE "D" STATED SHE IMMEDIATELY CHECKED HIS PULSE AND FOUND IT TO BE FAINT. EMPLOYEE "D" STATED SHE AND EMPLOYEE "B" IMMEDIATELY TOOK RESIDENT #501 INTO HIS ROOM AND STARTED CPR. EMPLOYEE "B" STATED THAT SHE DID AN ORAL SWEEP OF RESIDENT #501'S MOUTH AND REMOVED SOME PIECES OF UNDIGESTED PEANUT BUTTER SANDWICH. EMPLOYEE "D" STATED SHE ALSO SUCTIONED RESIDENT #501 AND OBSERVED A CREAMY WHITE SUBSTANCE. EMPLOYEE "D" STATED THAT SHE WAS FAMILIAR WITH RESIDENT #501 AND KNEW HE HAD A [DIAGNOSES REDACTED]. EMPLOYEE "D" FURTHER STATED THAT THERE WERE ONLY 3 CNA'S SCHEDULED ON THE AFTERNOON SHIFT WHICH IS GENERALLY STAFFED WITH 4 CNA'S. ON [DATE], AT 10:30 A.M., AN INTERVIEW WITH A CNA (EMPLOYEE "E") REVEALED THAT SHE WAS ASSIGNED AS THE AFTERNOON SHIFT CNA FOR RESIDENT #501. EMPLOYEE "E" STATED THAT RESIDENT #501 had a history of [REDACTED]. WHEN EMPLOYEE "E" WAS ASKED WHY NO ONE NOTICED RESIDENT #501 WITH THE SANDWICH SHE REPLIED, "WE WERE WORKING SHORT, WITH ONLY 3 CNA'S THAT NIGHT WHEN WE USUALLY ALWAYS' WORK WITH 4 CNAS." EMPLOYEE "E" STATED THAT SHE WAS ASSISTING ANOTHER RESIDENT AT THE TIME THAT THE CODE BLUE WAS CALLED ON RESIDENT #501. ON [DATE], AT 11:00 A.M., INTERVIEW WITH THE DIRECTOR OF NURSING REVEALED THAT THE AFTERNOON SHIFT ON [DATE], THE UNIT WHERE RESIDENT #501 RESIDED, WAS STAFFED WITH 3 CNA'S AND WAS "ROUTINELY STAFFED WITH 4 CNA'S." ON [DATE], AT 9:00 A.M., REVIEW OF THE HOSPITAL RECORD REVEALED THAT RESIDENT #501 WAS TRANSPORTED BY EMS TO THE emergency room AT 2151 (MILITARY TIME) OR 9:51 P.M., ON [DATE]. REVIEW OF THE EMS RUN SHEET INDICATED, "UNRESPONSIVE. STAFF PERFORMING CPR. FOOD FOUND IN PATIENT'S MOUTH." REVIEW OF THE HOSPITAL RECORD, DATED [DATE], "status [REDACTED]. REVIEW OF A HOSPITAL PROGRESS NOTE INDICATED RESIDENT #501 WAS PRONOUNCED DEAD AT 3:30 P.M. ON [DATE]. DURING THE SURVEY THE ADMINISTRATOR AND DIRECTOR OF NURSING REPORTED THAT ON [DATE], A TOTAL OF 14 RESIDENTS HAD A [DIAGNOSES REDACTED]. THE ADMINISTRATOR WAS NOTIFIED VERBALLY AT 3:00 P.M. ON [DATE] AND IN WRITING ON [DATE], AT 11:25 A.M., OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE], AT 9:19 P.M., WHEN RESIDENT #501 WAS DISCOVERED UNRESPONSIVE DUE TO ASPIRATION ASSOCIATED WITH CONSUMPTION OF PEANUT BUTTER SANDWICHES WHEN HE HAD A [DIAGNOSES REDACTED]. ON [DATE], AT 3:00 P.M., THE SURVEYOR VERIFIED THAT THE FACILITY IMPLEMENTED THE FOLLOWING MEASURES TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], ALL 14 RESIDENTS IDENTIFIED WHO HAD A [DIAGNOSES REDACTED]. TWO OTHERS WERE STRICTLY NPO (NO FOOD BY MOUTH) AND IMMOBILE UNLESS TRANSPORTED BY STAFF. 3 OF THE 14 ARE ABLE TO MOVE FREELY THROUGHOUT THE FACILITY AND HAD NO BEHAVIORAL PROBLEM OF TAKING FOOD ITEMS OFF SNACK TRAYS OR MEAL TRAYS. 2. ON [DATE], ALL 14 RESIDENTS HAD BEEN REVIEWED AND NO RESIDENT WAS IDENTIFIED WITH A BEHAVIOR OF TAKING FOOD ITEMS FROM SNACK TRAYS OR FROM OTHER RESIDENT FOOD TRAYS. ON [DATE], NINE (9) ADDITIONAL RESIDENTS WERE IDENTIFIED WITH SWALLOWING PROBLEMS AND REVIEWED BY NURSING AND SPEECH THERAPY. NO RESIDENTS WERE IDENTIFIED WITH A BEHAVIOR OF TAKING FOOD ITEMS FROM SNACK TRAYS OR OTHER RESIDENT'S FOOD TRAYS. 3. ON [DATE], THE FACILITY IMPLEMENTED THE FOLLOWING SYSTEMIC CHANGES THAT INCLUDED SNACKS ARE TO BE DELIVERED ON A TRAY WITH A COVER OR IN A COVERED CONTAINER. SNACKS MUST BE KEPT BEHIND THE NURSE STATION OR IN A PLACE THAT IS OUT OF REACH OF RESIDENTS. STAFF ARE TO ENSURE THAT RESIDENTS ONLY RECEIVE SNACKS THAT ARE CONSISTENT WITH THEIR DIET ORDER. STAFF ARE TO ENSURE THAT RESIDENTS RECEIVE ASSISTANCE WITH CONSUMING THE SNACK AS NOTED IN THEIR CARE PLAN. ON [DATE], THE FACILITY INITIATED A PLAN TO INSERVICE ALL STAFF ON THE SYSTEMIC CHANGES AND NOT ALLOW ANY MEMBER OF THE NURSING DEPARTMENT TO WORK WITHOUT RECEIVING INSERVICING. 4. AS OF [DATE], 202 OF 165 STAFF MEMBERS WERE INSERVICED. AN ADDITIONAL 8 STAFF MEMBERS WERE PROVIDED THIS INSERVICE VIA TELEPHONE. AN ADDITIONAL 29 STAFF MEMBERS WHO ARE ON LEAVE, VACATION OR HAVE NOT WORKED WERE MAILED INSERVICE INFORMATION. AS OF [DATE], 172 STAFF MEMBERS HAD BEEN INSERVICED ON THE SYSTEMIC CHANGES. 5. ON [DATE], THE FACILITY IMPLEMENTED THE FOLLOWING SYSTEMIC CHANGES WHICH INCLUDED THAT EVENING SNACKS ARE NOT TO BE DELIVERED BEFORE 7:45 P.M. AND PERISHABLE ITEMS SHOULD BE OFFERED TO RESIDENTS AS SOON AS POSSIBLE FOLLOWING DELIVERY AND REFRIGERATED IF NOT ACCEPTED. ON [DATE], THE FACILITY INITIATED A PLAN TO INSERVICE ALL LICENSED NURSES ON THE SYSTEMIC CHANGES AND NOT ALLOW A LICENSED NURSE TO WORK WITHOUT RECEIVING THE INSERVICE REGARDING THE EVENING SNACK DELIVERY CHANGES. 6. ON [DATE], 18 LICENSED NURSES WERE INSERVICED IN PERSON OUT OF A TOTAL OF FORTY- EIGHT (48). NINETEEN (19) LICENSED NURSES WHO ARE ON LEAVE, VACATION, OR HAVE NOT WORKED WERE MAILED INSERVICE INFORMATION. AS OF [DATE], THIRTY TWO (32) LICENSED NURSES OF FORTY EIGHT (48) WERE INSERVICED IN PERSON. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATION AND SEVERITY OF NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO NOT ALL STAFF HAVE BEEN INSERVICED AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. RESIDENT #508 REVIEW OF THE CLINICAL RECORD FOR RESIDENT #508 REVEALED THAT HE WAS INITIALLY admitted on [DATE]. THE MONTHLY PHYSICIAN ORDER [REDACTED]. THE PREADMISSION SCREENING (PAS) FORM DATED [DATE], INDICATED A [DIAGNOSES REDACTED]. ON [DATE], AT 8:45 A.M., THE ADMINISTRATOR AND DIRECTOR OF NURSING INFORMED THE SURVEYOR THAT, AT APPROXIMATELY 1:00 P.M., ON [DATE], RESIDENT #508 WHO HAD A [DIAGNOSES REDACTED]. RESIDENT #508 REPORTEDLY HAD TAKEN SOME CHICKEN OFF THE LUNCH PLATE OF ANOTHER RESIDENT WHO WAS SEATED AT SAME TABLE DURING THE LUNCH MEAL. THE ADMINISTRATOR REPORTED THAT A LICENSED PRACTICAL NURSE (EMPLOYEE "G") HAD ENTERED THE MAIN DINING ROOM AT APPROXIMATELY 1:00 P.M., AND OBSERVED RESIDENT #508 CHEWING FOOD AND ASKED HIM TO SPIT OUT THE FOOD INTO A NAPKIN. THE DIRECTOR OF NURSING STATED THAT THERE WAS NO NEGATIVE OUTCOME ASSOCIATED WITH THE INCIDENT. THE DIRECTOR OF NURSING ALSO STATED THAT EMPLOYEE "G" NOTIFIED HER ABOUT THE INCIDENT AT APPROXIMATELY 4:00 P.M., ON [DATE]. ON [DATE], AT 9:30 A.M., INTERVIEW WITH EMPLOYEE "G" REVEALED THAT ON [DATE], AT APPROXIMATELY 1:00 P.M., SHE ENTERED THE MAIN DINING ROOM WHERE SHE OBSERVED RESIDENT #508. EMPLOYEE "G" STATED THAT SHE OBSERVED, "A LOT OF SOMETHING IN HIS MOUTH", AND THAT HE WAS "CHEWING A LARGE AMOUNT OF SOMETHING." EMPLOYEE "G" STATED THAT SHE KNEW THAT RESIDENT #508 HAD A [DIAGNOSES REDACTED]. EMPLOYEE "G" STATED THAT THE RESIDENT COMPLIED WITH HER REQUEST AND SHE OBSERVED "LARGE CHUNKS OF CHICKEN IN THE NAPKIN." EMPLOYEE "G" DENIED THAT THERE WAS ANY OTHER FOOD IN THE RESIDENT'S MOUTH. EMPLOYEE "G" STATED THAT RESIDENT #508 DID NOT ASPIRATE ON THE PARTIALLY MASTICATED FOOD NOR DID HE EXHIBIT ANY SIGNS OF DISCOMFORT AFTER THE INCIDENT. EMPLOYEE "G" REPORTED THAT AT THE TIME OF THE INCIDENT SHE OBSERVED ONE OTHER NURSE IN THE DINING ROOM, WHO WAS IDENTIFIED AS A REGISTERED NURSE (EMPLOYEE "H"). EMPLOYEE "G" STATED THAT SHE OBSERVED EMPLOYEE "H" FEEDING ANOTHER RESIDENT ON THE OPPOSITE END OF THE MAIN DINING ROOM. THERE WERE NO OTHER NURSING PERSONNEL PRESENT IN THE DINING ROOM. EMPLOYEE "G" STATED THAT SHE IMMEDIATELY REPORTED HER OBSERVATION TO EMPLOYEE "H" AND ALERTED THE DIRECTOR OF NURSING ABOUT THE INCIDENT "AROUND 4:00 P.M., ON [DATE]. ON [DATE], AT 11:00 A.M., AN INTERVIEW WITH EMPLOYEE "H" REVEALED THAT ON [DATE], SHE WAS ASSIGNED AS THE DAY SHIFT CHARGE NURSE ON THE UNIT WHERE RESIDENT #508 RESIDED. EMPLOYEE "H" STATED THAT SHE KNEW THAT RESIDENT #508 HAD A [DIAGNOSES REDACTED]. EMPLOYEE "H" VERIFIED THAT SHE WAS IN THE MAIN DINING ROOM ON [DATE], AND AT APPROXIMATELY 1:00 P.M., SHE WAS INFORMED BY EMPLOYEE "G" THAT SHE HAD FOUND RESIDENT #508 WITH PARTIALLY MASTICATED FOOD IN HIS MOUTH. EMPLOYEE"H" STATED THAT SHE WAS FEEDING ANOTHER RESIDENT AND SITTING AT THE OPPOSITE END OF THE MAIN DINING ROOM WITH HER BACK TO RESIDENT #508. EMPLOYEE "H" ALSO STATED THAT SHE DID NOT OBSERVE ANY OTHER NURSING PERSONNEL IN THE DINING ROOM AT THE TIME WHEN EMPLOYEE "G" INFORMED HER ABOUT THE INCIDENT. REVIEW OF THE CLINICAL RECORD FOR RESIDENT #508 INDICATED A physician's orders [REDACTED]." A CARE PLAN DATED [DATE], ADDRESSED, "IMPAIRED SWALLOWING" AND THAT THE RESIDENT NEEDED TO TAKE SMALL BITES AND SLOW FOOD INTAKE. A NUTRITIONAL CARE PLAN DATED [DATE], ALSO ADDRESSED THE RESIDENT'S DIFFICULTY WITH SWALLOWING AND RECOMMENDATION FOR A PUREE DIET. A NUTRITIONAL PROGRESS NOTE DATED [DATE], INDICATED "RESIDENT EATS VERY FAST. STAFF ENCOURAGE RESIDENT TO SLOW DOWN TO PREVENT ASPIRATION." THE PHYSICIAN ORDERS, DATED [DATE], INDICATED A DIET CHANGE AND FOR RESIDENT #508 TO RECEIVE A PUREED DIET WITH THIN LIQUIDS. ON [DATE], AT 1:15 P.M., AN INTERVIEW WITH THE FACILITY'S SLP (SPEECH AND LANGUAGE PATHOLOGIST) REVEALED THAT RESIDENT #508 HAD SHOWN PROGRESS WITH BOTH FOOD AND FLUID CONSUMPTION AND THAT HE HAD SLOWED DOWN WITH HIS ORAL INTAKE AND NO LONGER REQUIRED SUPERVISED EATING. THE THERAPIST STATED THAT SPEECH THERAPY SERVICES WERE DISCONTINUED ON [DATE], AND THAT RESIDENT #508 REMAINS ON A PUREED DIET WITH THIN LIQUIDS. THE SLP FURTHER STATED THAT NURSING STAFF HAD INFORMED HER ABOUT THE INCIDENT THAT OCCURRED ON [DATE]. THE SLP STATED THAT SHE RECOMMENDED SUPERVISED DINING FOR RESIDENT #508 IN RECOGNITION OF THE INCIDENT. ON [DATE], AT 12:15 P.M., AN OBSERVATION REVEALED THAT RESIDENT #508 WAS SITTING IN THE MAIN DINING ROOM. RESIDENT #508 WAS PROVIDED A PUREE LUNCH WITH TWO 8 OUNCE GLASSES OF ORANGE DRINKS THAT WERE THIN IN CONSISTENCY. RESIDENT #508 WAS SITTING ALONE AT THE DINING ROOM TABLE AT THE TIME OF THIS OBSERVATION. THE POTENTIAL FOR SERIOUS HARM INCLUDING ASPIRATION AND POSSIBLY DEATH INCREASED WHEN STAFF FAILED TO PROVIDE ADEQUATE AND APPROPRIATE SUPERVISION DURING MEALS FOR RESIDENT #508, AND RESIDENTS WHO HAD A [DIAGNOSES REDACTED].