Every finding on record at The Villa at City Center

This citation pertains to Intake 3024714. Based on interview and record review, the facility failed to ensure the resident's medications were available to administer per physician's orders for one resident (R901) of one reviewed for pharmacy services. Findings include:A review of a complaint called into the State Agency revealed the resident's (R901) seizure medication ran out and had to be reordered resulting in missed doses. A review of R901's medical record revealed they were admitted into the facility on 4/6/26 and discharged on 5/26/26 with diagnoses of Unspecified Convulsions. Further review revealed the resident was cognitively intact and required assistance with activities of daily living.Review of the medical record revealed the resident had the following physician's order dated, 4/29/26 to 5/27/26, Lacosamide (an anticonvulsive medication used to treat seizures) Oral Tablet 200 MG (milligrams) Give 1 tablet by mouth two times a day for convulsions.Review of R901's May Medication Administration Record (MAR) revealed the resident was not administered the Lacosamide on the following dates on the morning shift (7AM to 3:30 PM): 5/6, 5/8, 5/10, 5/19, 5/20, and 5/21, and on the afternoon shift (3PM to 11PM): 5/7, 5/8, 5/9, 5/10, 5/19, and 5/20.A review of progress notes revealed the following reasons why the medication had not been administered:5/6/2026 11:56 (11:56am) .Writer spoke with pharmacy and a new signed script is needed.Strength is not supplied in back up box, MD (medical doctor) aware.5/7/2026 21:45 (9:45pm) .Awaiting from Pharmacy.5/8/2026 13:59 (1:50pm) .on order.5/9/2026 01:36 (1:36am) .awaiting pharmacy delivery.5/9/2026 10:56 (10:56am) .on order.5/10/2026 05:30 (5:30am) .awaiting pharmacy delivery.5/10/2026 13:21 (1:21pm) .spoke with pharmacy medication will be delivered tonight.5/10/2026 21:21 (9:21pm) .Not available.5/19/2026 09:41 (9:41am) .on order.5/20/2026 04:02 (4:02am) .awaiting delivery.5/20/2026 10:16 (10:16am) .on order.5/21/2026 13:35 (1:35pm) .on order.5/21/2026 20:36 (8:36am) .N/A.On 6/10/26 at 4:00 PM, the Director of Nursing (DON) and Unit Manager A were interviewed regarding R901's medication not being documented as administered as well as concerns with the pharmacy. The DON explained there was a discrepancy with the pharmacy with the number of pills provided and that approval had been provided from R901's physician to utilize their home supply, acknowledging the resident should not have had to supply their own medication. The DON and Unit Manager A acknowledged the medications were not marked off as being administered on the MAR, and the resident did not have an order or assessment completed for self-administration of medications. A review of the Physician Medication Orders policy revealed the following, Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily av

Based on interview and record review, the facility failed to timely submit a MDS (Minimum Data Set) assessment for five residents (R8, R30, R39, R88, R97) of nine residents reviewed for resident assessment. Findings Include:R8A record review revealed the MDS discharge assessment was 120 days overdue. Further review of the medical record noted R8 was admitted to the facility on [DATE]. R8 was discharged on 10/26/25. A review of the Minimum Data Set (MDS) assessment did not reveal a discharge MDS having been submitted. R30A record review revealed R30 was admitted to the facility on [DATE]. R30 was discharged on 12/7/25. A discharge MDS was not submitted.R39A record review revealed R39 was admitted to the facility on [DATE]. R39 was discharged on 12/7/25. A MDS was not submitted.R88A record review revealed R88 was admitted to the facility on [DATE]. R88 was discharged on 12/13/25. A MDS was not submitted.R97On 3/11/26, a record review revealed R97 was admitted to the facility on [DATE]. R97 was discharged on 12/8/25. A discharge MDS was not submitted.On 3/11/26 at 12:13 PM, an interview with Minimum Data Set (MDS) Nurse C revealed that R8, R30, R39, R88, and R97's discharge MDS's were not submitted.On 3/11/26 at 12:30 PM, an interview with MDS Supervisor B confirmed that R8, R30, R39, R88, and R97's discharge RAI were not submitted. MDS Supervisor B revealed their vacation was around the time the discharge MDS's were due.

Based on interview and record review, the facility failed to develop a baseline care plan for one (R5) of six residents reviewed for baseline care plans. Findings include:A review of the record revealed R5 was admitted to the facility on [DATE] with relevant diagnoses of Intracerebral hemorrhage, Congestive Heart Failure, Benign Prostatic Hyperplasia and Urinary Retention. R5 was admitted with an indwelling urinary catheter and was on Enhanced Barrier Precautions (EBP). Further review of the Minimum Data Set Assessment (MDS) revealed R5 had a Brief Interview for Mental Status score of 13/15 indicating no cognitive impairment. Further review revealed R5 required partial/moderate assistance for upper body activities and substantial/maximum assistance for lower body activities including bathing and transfers. A review of the medical record revealed a baseline care plan that did not include the use of the indwelling catheter, infection control, activities of daily living, mobility or the level of assistance required. On 3/11/26 at 11:30 AM, in an interview with Licensed Practical Nurse-Unit Manager (LPN) D, she revealed the baseline care plan was not complete. A review of the policy titled Care plan Standard Guideline effective date 11/28/2017 revealed 1. The interdisciplinary team will collect and record data within 24 hours for the admission Baseline Care Plan. 2. The interdisciplinary team will continue develop a resident/client centered care plan that includes problem, need, or strength statements, measurable goal statements and resident/client specific interventions.The Baseline Careplan will 1. Be developed within 48 hours of a resident's admission .2. Include the inimum healthcare information necessary to properly care for a resident,,,

Based on interview and record review, the facility failed to follow through on physician recommendations following a change in condition for one (R5) of three residents reviewed for laboratory services. Findings include: A review of a progress note dated 3/9/26 revealed R5 experienced a change in mental status (disorganized thinking) during a Physical Therapy (PT) treatment session and was returned to his room and Medical Doctor (MD) K was called. A progress note dated 3/9/26, revealed MD K was notified of the change in mental status for R5, and recommended a Complete Blood Count (CBC) and Urinalysis (UA). Review of the physician orders did not reveal an order or results for the CBC or UA. A review of the record revealed R5 was admitted to the facility on [DATE] with relevant diagnoses of Intracerebral hemorrhage, Congestive Heart Failure, Urinary Retention. R5 was admitted with a urinary catheter. Further review of the record revealed R5 had a Brief Interview for Mental Status score of 13/15 indicating no cognitive impairment. On 3/12/26 at 11:47 AM, in an interview with the Licensed Practical Nurse, Unit Manager (LPN) D revealed there were no physician orders or results entered for the recommended lab work. LPN D determined that the order into the lab system had been entered incorrectly.

Based on observation, interview, and record review, the facility failed to ensure resident food preferences were honored for four residents (R32, R44, R65, R146), three anonymous residents, and three anonymous resident council group residents from a census of 137. Findings include: On 03/10/2026 at 9:05 AM, an anonymous resident reported the food was not grade A and was processed and overall did not care for it too much. The resident further reported dinner was the one to mostly come up cold. On 03/10/2026 at 9:23 AM, a second anonymous resident reported the food was good and bad but did not elaborate. On 03/10/2026 at 12:23 PM, the rice for R32 was served without gravy. R32 was asked if they received a regular or alternative menu and reported they did not but it would be good to have one. R32 reported the food for lunch was not hot and less than room temperature when served. LPN L was asked about the chance of getting gravy for the rice. LPN L reported that it was hit and miss on getting the kitchen on the phone. R32 reported they drink coffee because it is usually the one thing that was hot. On 03/11/2026 9:13 AM, R32 reported they were headed out for a doctor's appointment and would not likely get a warm lunch when they got back. R32 commented they had been told aides are not allowed to warm up food. At 12:25 PM R32 returned to their room and indicated they would not eat lunch. On 03/10/2026 at 12:35 PM, R146 reported concerns with day-to-day care. A sub style sandwich was observed on the bed. R146 reported they get one daily with lunch. R146 reported they used to have to order it but now it was on their meal ticket to be sent with lunch. ,R146 reported they would not eat the chicken and rice. R164 was asked about a menu and reported they did not have a menu. R146 commented they may get one sometimes but it was not a consistent practice and it would be nice to have one so they will know if going to like something or not. R146 noted that is why they have the sub ordered. On 03/10/2026 at 12:42 PM, R44 reported they had called down for a sub sandwich and had not received it. R44's roommate had sub and reported if you call early enough you can get one brought up. Neither resident had received a copy of the menu and commented it would be nice to have one. A [NAME] salad was brought up for R44. R44 commented it was OK but it was not a sub. On 03/10/2026 at 12:58 PM, R65 reported they felt they had received hot dogs too often as the alternative. R65 did not have a copy of the regular or the alternate menu. R65 noted that they would prefer a grilled cheese sandwich as an alternate choice. On 03/10/2026 at 5:12 PM, the pork chop was firm and slightly tough to cut, but easy enough to chew. On 03/11/2026 at 1:14 PM, Certified Nursing Assistant (CNA) O reported the kitchen does not always answer the phone so would then just go to the kitchen and ask for the resident request. CNA O reported it generally takes up to ten minutes to get the ordered food. CNA O also noted breakfast was the meal residents most often report as cold. On 03/11/2026 at 3:42 PM, CNA P reported some residents have requested more variety in the alternative menu. The current alternatives were reported as a hot dog, cheeseburger, salad or grilled cheese and sometimes resident can get a sub. On 03/11/2026 at 4:22 PM, a third anonymous resident reported it would be nice to have menu, but they were not really affected by not having one. On 03/12/2026 at 10:54 AM, the registered dietitian (RD) Q reported that if food preferences are communicated ahead of time and if available, residents can usually get what they want. On 03/12/2026 at 12:59 PM, Activity Staff R reported the most recent resident council had reported some cold food concerns but nothing about food preferences not honored. Staff F reported their practice had been to pass out menus to those residents who asked for one or if asked to bring one to a resident. Staff R pointed out the stack of weekly menus that had been printed out and put at the reception desk. On 03/12/2026 at 1:04 PM, the RDs reported the resident food preference information is started on admission and updated as requested and at least quarterly. A review of the Food Committee minutes dated 2/19/26 noted food is not hot but warm. A review of the facility policy titled, Resident Rights dated 11/28/17 documented the resident has The right to the reasonable accommodation of your needs so long as it doesn't endanger the health or safety of you or other residents. A review of resident council meeting notes for the months of November 2025 through February 2026, revealed resident concerns related to being uninformed of menu alternatives. On 3/11/26 at 1:30 PM, a resident council meeting was held with six group residents, and they were asked about alternative menu items being offered to them at the facility. Three group residents, who indicated that they resided on the second floor of the facility, revealed that they did not receive advance notice of alternative food items being offered during meals, on a daily basis. The three residents indicated that they were not provided with alternative food menus and expressed displeasure over not being able to plan their menu choices in advance.

Based on observation, interview and record review the facility failed to implement post fall interventions for one resident (R145) of three whose falls were reviewed. Findings include: On 03/10/2026 at 9:52 AM, R145 was observed to be off balance as they walked up the hallway from the nurse station. R145 approached the surveyor and commented they felt dizzy and reported they felt like they were drunk but had not been drinking. R145 then began to turn around and as R145 turned around to their right they fell toward the handrail. R145 caught themself on the handrail. Licensed Practical Nurse (LPN) L noticed walked up and took R145 by the hand. They walked back toward the resident's room and R145 was observed to be on their knees in the intersection of the hallways by the nurse station holding onto the nurses' hand. At that time two additional staff walked up to LPN L and R145 with a wheelchair and the staff assisted R145 up and to their room. At 1:25 PM, R145 was seen walking out of another resident's room. At 3:51 PM, R145 continued walking around, but appeared more stable. On 03/11/2026 at 8:21 AM, R145 walked in and out of their room three times in succession. R145 was dressed and had with shoes on. On 03/11/2026 at 1:56 PM, the Director of Therapy, reported R145 did not normally have issues with balance and had not heard about any change in elevation or fall for R145. On 03/12/2026 at 2:16 PM and 2:30 PM, the Unit Manager for the unit of R145 LPN M, was asked about the incident involving R145. LPN M initially reported they would look into it and reported that they had been made aware of it this day and the nurse reported R145 was losing their balance and was subsequently lowered to the floor. LPN M commented LPN L did not consider the incident a fall for R145. LPN M then reported any change in plane or condition would need to be documented and the physician and family called, and this was not done. A review of the record for R145 revealed R145 was admitted into the facility on [DATE]. Diagnoses included Difficulty Walking, Muscle Weakness, Lack of Coordination, and Dementia. The active care plan documented, has had an actual fall on10/10/25 . Anticipate and meet the resident's need . Medication review . offer rest periods during ambulation initiated 10/10/25 . Resident is a wanderer related to dementia . had an actual fall on 01/26/26 . educate resident on importance of complying with safety measures . encourage and offer rest periods during ambulation . x-ray of skull and right leg Date Initiated: 01/26/2026 . is a potential risk for falls . Date Initiated: 08/04/2025 . Anticipate and meet the resident's needs. Date Initiated: 04/22/2025 . No care plan intervention or review was documented. The most recent date from the care plan was 01/28/26 related to nutrition and the fall on 01/26/26. A review of the progress notes dated for 03/10/26 and 03/11/26 revealed no documentation for notification of the family or medical practitioner related to the incident. A review of the facility policy titled, Care Plan Guidelines dated, 11/28/17 revealed, Guideline: .The interdisciplinary team will continue (to) develop a resident/client centered care plan that includes problem, need, or strength statements, measurable goal statements and resident/client specific interventions . The care plan is to be revised to reflect the current status of the resident .

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 1/6/25 between 9:00 AM-9:30 AM, during an initial tour of the kitchen with Certified Dietary Manager (CDM) E, the following items were observed: At the hand washing sink near the dish machine room, there was no hand washing signage, no paper towels, and no liner in the trash can. CDM E confirmed the lack of signage, towels and liner. According to the 2017 FDA Food Code section 6-301.12 Hand Drying Provision, Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels;. According to the 2017 FDA Food Code section 6-301.14 Handwashing Signage, A sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees. In the walk-in cooler, there was a pan of sloppy [NAME] meat with a use-by date of 1/4. CDM E discarded the meat mixture. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. The grates of the vent hood were soiled with grease buildup. CDM E stated the grates would be cleaned right away. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The handwashing sink near the 3 compartment sink, was blocked with carts and was not accessible. According to the 2017 FDA Food Code section 5-205.11 Using a Handwashing Sink, 1. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. Pf The ice scoop holder located in the ice machine room on the 2nd floor was observed with black debris on the bottom inside surface. CDM E stated the holder would would cleaned right away. According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not potentially hazardous (time/temperature control for safety food) . There was an unlabeled, uncovered pitcher with a white powder substance, stored on a shelf near the oven. According to the 2017 FDA Food code section 3-302.12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD.

Based on observation, interview, and record review, the facility failed to ensure meals were served at a preferred and palatable temperature for one resident (R80) and four of eight confidential group residents reviewed for food palatability. Findings include On 01/06/25 at 10:02 AM, R80 was observed in room watching television. When asked about concern, R80 stated the food was often cold at meals. R80 stated the sausage for breakfast that morning was cold. On 01/07/25 at 09:30 AM, R80 was observed eating breakfast in the room. When asked about the meal, R80 stated it was cool but better than the previous day. On 1/07/25 at 2:00 PM, a confidential group meeting was conducted with a group of eight facility residents. The group members were asked about food palatability at the facility and four of the eight group residents indicated the food was frequently cold when it was served to them. On 1/08/25 at 12:50 PM, a lunch tray from second floor East food cart and tested by the Dietary Supervisor. The lunch tray foods tested as follows: Half of a baked potato-110.7 Degrees Fahrenheit, Glazed carrots -101.8 Degrees Fahrenheit, Baked ham -90.1 Degrees Fahrenheit. On 1/8/25 at 1:00 PM, during an interview with the Dietary Service Director (DSD) they confirmed the temperature of the tray was cool, and that food temperatures should be at least 110 to 120 Degrees Fahrenheit upon reaching the residents. A facility policy titled, Food Palatability - Hot Food Temperatures was reviewed and documented the following, The healthcare community prepares and serves food and beverages that are palatable, attractive and at safe and appetizing temperature. Hot foods will be held at or above 135 Degrees Faranheit.

Based on observation, interview, and record review, the facility failed to complete assessments to determine need for bed rails for one resident (R24) of one residents reviewed for bed rails. On 1/06/25 at 9:12 AM, R24 was observed lying in bed watching television with bilateral bed rails up on each side of the bed. On 1/07/25 at 11:07 AM, R24 was observed laying in bed with the bilateral bed rails up on each side of the bed. R24 was asked why there were rails on the bed and R24 shrugged shoulders and stated they keep me safe. A review of R24 medical record revealed R24 was admitted on [DATE] with multiple diagnosies including muscle weakness, type II diabetes mellitus with diabetic peripheral angiopathy with gangrene, and artherosclerosis of native arteries of extremities with gangrene right leg. A review of R24's Minimum Data Set (MDS) assessment dated on 10/2/2024 revealed a Brief Interview of Mental status (BIMS) assessment of 06 indicating moderate cognitive impairment. Further review of R24's medical records revealed no documentation of a physician's order, a bed rail assessment, a bed rail care plan, or signed consent for the use of the bilateral bed rails. Per medical record, R24 signed onto hospice services on 9/26/24 and recieved the hospital bed with bed rails on 10/25/24. On 1/08/25 at 1:25 PM, an interview was held with the Director of Nursing (DON). The DON confirmed there was no assessment for the use of the bed rails. When asked about the expectation of bed rails, DON stated,I would expect that every resident would have bed rails per policy guidelines. On 1/8/25, the Nursing Home Administrator (NHA) at 1:50 PM also confirmed there was no consent or documentation for the bed rail use. A review of the policy titled, Bed Rail Device Guide dated 11/28/17 revealed the following, the practice of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including 1) regular bed maintenance and 2) individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable, and homelike environment, the facility ' s regular maintenance program will include regular inspection of all bed systems (e.g. rails (positioning bars), frames, and mattresses, and operational components) to ensure they are clean, comfortable, and safe. The facility will also ensure individual resident bed rail evaluations are performed on a regular basis. Individual bed rail evaluations will include data collection analysis and determination of potential alternatives to bed rail use. When bed rail(s) are deemed necessary and appropriate, the facility will provide education to resident or resident ' s representative pertaining to the risk and benefits of bed rail use. The facility's priority is to ensure safe and appropriate bed rail use.

Based on observation, interview, and record review the facility failed to ensure medications and supplies were discarded when expired in two of two medication carts and one of one medication storage room. Findings include: On 1/07/25 at 8:44 AM, a review of the medication cart on the low side of two east unit with Licensed Practical Nurse (LPN) B revealed an expired bottle of cranberry supplement with an open date of 10/23. On 1/07/25 at 9:00 AM, a review of the medication cart on the high side of the two west unit with LPN C revealed a bottle of aspirin with an expiration date of 9/5/24. On 1/8/25 at 9:30 AM, a review of the medication storage room on the two west unit with LPN D revealed an expired tube of Silvadene cream dated 2022 and an IV (intravenous) start kit with an expiration date of 5/23. On 01/08/25 at 11:44 AM, the Director of Nursing (DON) explained pharmacy staff is supposed to come monthly to stock items and throw out expired meds. The DON also explained the nursing staff should check the medication carts weekly for expired medications. A review of the facility's policy titled Storage of Medications revealed the following: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

This citation pertains to Intake MI00146289. Based on observation, interview, and record review, the facility failed reposition a dependent resident while in bed for one resident (R902) of three reviewed for skin management resulting in the re-opening of a sacral wound. Findings include. On 08/14/24 at 8:45 AM, 10:50 AM, 11:10 AM, R902 was observed to be on their back in bed. The arms were to the sides and the legs were crossed at the feet. Large puffy green boots which covered the foot and ankle were in place on both feet. R902 was dressed in a hospital style gown and the head of the bed was up around 45-60 degrees. No pillow, wedge or other device was observed to off load pressure from the back and buttocks area. At 1:15 PM, a staff member was observed standing at the left side of the bed assisting R902 to eat. The head of the bed was up 45-60 degrees, with R902 on their back in bed without any offload devices at the sides. At 3:44 PM, the head of the bed was lower around 30-45 degrees and R902 was on their back in bed arms to the sides, without a device to off load pressure at the sides. On 08/14/24 at 3:48 PM, Certified Nursing Assistant (CNA) D reported R902 required total care and need help to eat, bath and to be change when incontinent. CNA D reported You have to move (R902). (R902) does not move themselves, observed resident (themselves). R902 was observed with CNA D and noted without pillows or devices to the sides to off load pressure. On 08/14/24 at 4:50 PM, a skin observation was conducted with Lincensed Practical Nurse (LPN) E. Observation of the coccyx/tailbone area revealed a nickel to quarter size area of non intact skin. The distal end was loose and the base of the wound area appeared as a dusky purple to pink color. On 08/14/24 at 5:20 PM, the Director of Nursing (DON) acknowledged the concern for the repositioning of R902. On 08/14/24 at 6:06 PM, Wound Care Nurse LPN C reported staff would be re-educated on the need to reposition resident per the plan of care. A review of the record for R902 revealed, R902 was admitted into the facility 04/01/19. Diagnoses included Dementia, Contracture and Depression. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition and the need for substantial/maximal assistance to roll left and right, and sit up in bed. R902 was documented as dependent for personal hygiene, bathing, dressing and toileting hygiene. The has potential for impairment to skin integrity care plan initiated 09/13/22 documented, .Apply barrier cream per facility protocol to help protect skin from excess moisture .use wedge to improve positioning . The has actual impairment to skin integrity care plan initiated 09/13/22 and last updated 03/12/24 documented, .assist with reposition frequently while in bed . A review of the facility policy titled, Skin Management Guidelines dated 11/28/17 revealed, Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care .Interventions for prevention, removing and reducing predicting factors and treatment for skin may include: Pressure redistribution surface for bed and seating surfaces: Specified through clinical evaluation and determination. Adaptive equipment and seating to support and encourage correct anatomical alignment. Elevating heels: For residents that cannot turn and reposition themselves. For residents that have diminished sensory perceptions of the lower extremities that may affect and independent ability to turn, reposition and off load pressure. Offloading devices may vary, may include pillows and should be selected based on resident comfort and positioning needs .

This citation pertains to Intake MI00146289. Based on interview and record review, the facility failed to ensure the resident's responsible party was informed of skin changes for one resident (R901) of three residents reviewed for skin management. Findings include: A review of the skin observation dated 06/18/24 at 1926 (7:26 PM) documented, Does the resident have any new skin issues? The yes box was checked. The form identified the right buttock as an open area and the left as excoriation (rash like area of skin disruption). Measurements for the areas were not included or documented. The observation and related progress note did not indicate the responsible party was notified. A review of the progress note for R901 dated 06/20/24 by Wound Care Nurse, Licensed Practical Nurse (LPN) A revealed, Writer alerted by (midnight) MN (certified nursing assistant) CNA regarding new skin impairment observed during (activities of daily living) ADL care. It was noted that the resident has a new skin impairment observed to sacrococcyx/bilateral buttocks. Treatment initiated and rendered to affected area. Resident has pain medication in place to aid in healing and comfort as needed. Resident repositioned for comfort with bed in lowest position and call light within reach. Wound care will continue to follow and treat as indicated. Notification to the responsible party was not documented. A review of the treatment record for June 2024 documented wound treatments to the right lateral calf 06/04 to 06/30/24 and the sacrococcyx/bilateral buttocks 06/20 to 06/30/24. The treatment record for July 2024 documented treatments to the right lateral calf, sacrococcyx/bilateral buttocks and the right foot. A skin observation note dated 07/29/24 documented wounds to the right knee, left knee, right lower leg, right heel, left ankle, and sacrum. On 08/14/24 at 11:18 AM, the Director of Nursing (DON) was asked about quality assurance meetings and reported that infections, falls, wound care and skin management are review at the daily risk meetings. On 08/14/24 at 11:34 AM, the responsible party (RP) was asked about their knowledge of the wound to the buttocks and reported R901 had seven wounds now and they had only been aware of one, a leg wound. The RP reported they were not made aware of the buttock and sacral wound until 7/14/24 when the resident was at the hospital. They also noted the leg wound had become larger. The RP also denied having received any updates on any wounds or a copy of the care plan. The RP reported someone visited R901 approximatley two or three times a week. On 08/14/24 at 5:20 PM the wounds were reviewed with the DON. The DON acknowledged the RP of R901 should have been notified of the buttocks wounds. It was noted that documentation of the RP's notification was requested and documentation of the sacral wound assessments prior to 7/10/24 was requested. On 08/16/24 at 6:18 PM, the Administrator brought in care conference notes dated 07/01/24 and confirmed the note did not specifically address the RP was notified of the wound to the sacrum and updated accordingly with wound changes until notification on 07/10/24 per a progress note. R901 was subsequently hospitalized on [DATE] for the change in condition, infection and wounds. Documentation of notification to the RP about the initial buttocks wound and subsequent wound changes was requested but not received prior to survey exit. A review of the record for R901 revealed R901 was admitted into the facility on [DATE]. Diagnoses included Dementia, Chronic Kidney Disease, and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE] documented moderate to severely impaired cognition, functional range of motion limitations to one upper and both lower extremities and substantial/maximal assitance to roll left and right, sit up in bed, bathing and personal hygiene. A review of the policy titled, Change in a Resident's Condition or Status dated 06/29/21 revealed, Our facility shall promptly notify the resident, consult with his or her Attending Physician, and notify, consistent with his or her authority, the resident representative(s) of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) .Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident ' s representative when: There is a significant change in the resident ' s physical, mental, or psychosocial status .

This citation pertains to Intake MI00141837. Based on interview and record review, the facility failed to hold a medication per physician order for one resident (R700) out of one reviewed for physician orders. Findings include: A review of the medical record revealed that R700 admitted into the facility on [DATE] with the following diagnoses, Dysphagia and Weakness. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 10/15 indicating an impaired cognition. R700 also was also dependent for transfers and bed mobility. A review of the progress notes revealed the following, Date:12/31/2023 at 15:27 PM (3:27 PM) .Upon doing wound care resident sacral wound started to bleed. Writer applied pressure and it stopped and then started again upon doing patient care but this time there was a significant amount of bright red blood noted coming from wound. Pressure has been applied and there has been no blood noted since. [Physician] has been informed and [they] ordered to hold Eliquis (anticoagulant) for 48 hours and if bleeding was to continue to send resident to hospital for evaluation. Wound consult has been put in. W/C (will continue) to monitor and with plan of care. A review of the physician orders revealed the following, Order: Eliquis .Directions: Give one tablet via peg-tube two times a day for DVT (Deep Vein Thrombosis) .Start Date: 12/11/2023 .End Date: 1/17/2024. Administrative Orders: Date:12/31/2023 15:33 (3:33PM) .Type: Hold .Notes: Bleeding from wound. A review of the Medication Administration Record (MAR) for December and January revealed that R700 received Eliquis on the following days: 12/31/2023 at 9:00 AM and 9:00PM, 1/1/2024 at 9:00 AM and 9:00 PM, 1/2/2024 at 9:00 AM. R700 was then sent to the hospital on 1/2/2024. On 1/31/2023 at 3:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when a nurse gets a verbal hold order from an physician then they should put it in (name of electronic medical record system) as an hold order and then document the conversation and order as well. The DON confirmed that the Eliquis was supposed to be held per the progress note. The DON confirmed the nurse did call them about the medication and informed them that they would be putting the Eliquis on hold but did not say for how long. The DON did not know why the Eliquis was not held nor see any notes in the record. A review of a facility policy titled, Medication Monitoring and Management did not address following a physician's hold order.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 10/23/23 between 8:50 AM-9:20 AM, during an initial tour of the kitchen with Corporate Consultant D, the following items were observed. In the reach-in cooler, there was a pan of vanilla pudding with a use by date of 10/16. Corporate Consultant D stated they would discard the outdated pudding. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. On the clean dishware rack across from the 3 compartment sink, there were 2 stacks of metal pans, with visible water/moisture on the inside surface of the pans. Corporate Consultant D confirmed the pans should be dry before stacked. According to the 2017 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, (A) Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: .(1) In a self-draining position that allows air drying; . The white wall/backsplash located directly above the soiled drainboard of the dish machine, was observed to be soiled with a black mold-like substance. In addition, the flooring underneath the soiled drainboard was heavily soiled with food debris and a black, slimy substance. There were gnats observed flying around in the area under the dish machine. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. 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. There was a 2-shelf rolling cart near the dish machine, which was heavily soiled with food spills and a milky liquid pooling on the bottom shelf of the cart. There were numerous gnats observed flying around the soiled cart. Corporate Consultant D confirmed the cart was in need of cleaning. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on interview and record review, the facility failed to respond timely to monthly medication regimen review (MRR) recommendations for noted irregularities for five residents (R28, R31, R38, R92, and R100) of five residents reviewed for MRR's, resulting in the potential for unnecessary and unmonitored medication use. Findings include: R28 A review of R28's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included End Stage Renal Disease, HIV, Anemia, Post-Traumatic Stress Disorder. Further review revealed that the resident was cognitively intact and required limited to supervision with Activities of Daily Living. Further review of R28's medical record revealed that the resident had MRRs with pharmacy recommendations on 3/9/23 and 6/5/23, and the two reports were requested from the facility on 10/24/23 at 2:03pm. A review of the pharmacist's 6/5/23 recommendation noted the following, The resident has an order for acetaminophen 650 mg (milligrams) ER (extended release) every 4 hours as needed for pain. The manufacture recommends ATC (Around-The-Clock) administration since it is extended release with a late onset of pain relief. The regular strength (325mg) or the extra strength (500mg) are more appropriate for PRN (as needed) use and are both immediate release. Please consider changing acetaminophen to 325 mg at 2 tablets every 4 hours a needed for pain. Further review of the recommendation in which the physician was to respond was blank regarding whether they agreed, disagreed, or other, and there was no signature noted. Further review of R28's physician orders noted that the recommendation was implemented on 10/19/23 (4 months later). The 3/9/23 report was not provided by the end of the survey. R38 A review of R38's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Diabetes, End Stage Renal Disease, Endocarditis. Further review revealed that they were cognitively intact and required extensive assistance for Activities of Daily Living. Further review of R38's medical record revealed that the pharmacist made recommendations on 4/5/23, 7/7/23, 8/4/23, and 10/7/23. The reports for the four dates were requested from the facility on 10/24/23 at 2:03pm. A review of the pharmacist's 7/7/23 recommendation noted the following, Resident has a PRN (as needed) medication order for guaifenesin 200 mg tablet every 4 hours as needed for congestion and has not been used in the past 30 days. Unused PRN's tend to expire on the med cart and can result in an increased risk of errors and increased cost. Please evaluate if guaifenesin 200 mg could be discontinued to help decrease the number of medication for [R38] to under 30. Further review of the recommendation in which the physician is to respond was blank regarding whether they agreed, disagreed, or other, and there was no signature noted. Written on the corner of the recommendation was D/C (discontinued) 8/8 A review of the pharmacist's 8/4/23 recommendation noted the following, This resident is receiving an antibiotic, mupirocin 2% ointment to nose twice daily since 5/9/23 and does not have a stop date. Please clarify intended duration of therapy and provide a stop date and help get [R38] under 30 meds. 2nd request: unable to determine last month's request: Estimated creatinine clearance for [R38] is less than 10ml/min. Resident is receiving loratadine 10 mg daily, which is excreted primarily via kidney and accumulated with decreased renal function. Please consider reducing dose of loratadine to 10 mg every other day. Further review of the recommendation in which the physician was to respond was blank regarding whether they agreed, disagreed, or other, and there was no signature noted. Written on the corner of the recommendation was D/C (discontinued) 8/16. The 4/5/23 report was not received by the end of the survey. R92 A review of R92's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Dementia, Muscle Weakness, and Diabetes. Further review revealed that the resident was cognitively impaired and required extensive assistance with Activities of Daily Living. A review of the pharmacist's 3/12/23 recommendation noted the following, This resident is on quetiapine 75 mg at bedtime, but was unable to locate any monitoring for EPS (extrapyramidal symptoms) side effects related to antipsychotic medication therapy. Please consider AIMS (abnormal involuntary movement scale) testing and provide the results in [electronic medical record]. Further review of the recommendation in which the physician is to respond was blank regarding whether they agreed, disagreed, or other, and there was no signature noted. Further review of R92's medical record revealed that AIMS testing was not completed until 9/9/23. A review of the pharmacist's 7/6/23 recommendation noted the following, The resident has been taking an antipsychotic, quetiapine 75 mg at bedtime, since 1/11/23 for dementia. Federal nursing facility regulations require that for ALL antipsychotics being used to manage behavior or stabilize mood .Please consider a GDR (gradual dose reduction) of quetiapine and decrease the dose to 50 mg at bedtime. If therapy is to continue at the current dose, please provide rationale describing a dose reduction as clinically contraindicated. Additionally, the facility interdisciplinary team should ensure both ongoing monitoring for potential adverse consequences and implementation and monitoring of resident-specific interventions . Further review of the recommendation in which the physician is to respond was blank regarding whether they agreed, disagreed, or other, and there was no signature noted. On 10/25/23 at 1:31 PM, the Nursing Home Administrator (NHA) was asked about the delay in response from the facility's physicians to the pharmacy recommendations. The NHA explained that during survey this concern was identified that they will be working on fixing the process in the way the MRRs are handled. A review of the facility's 'Medication Regimen Review policy revealed the following, .Timeliness of Medication Regimen Review (MRR) Reports .The attending physician is expected to review and sign the residents individual MRR and document that he/she has reviewed the pharmacist's identified irregularities within 5 days of receipt .If the attending physician does not respond to the resident ' s MRR report within 6 days the director of nursing will notify the physician of pending MRR reports .If by the 7th day, the attending physician has not yet responded to the resident ' s individual MRR report, the director of nursing will notify the medical director to review and respond to the pending MRR reports 34851 R31 A review of R31's progress notes, revealed Medication Regimen Reviews (MMR's) dated 8/17/23, 9/19/23 see report. A review of R31's medical record revealed, R31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Cerebral infraction. A review of R31's Minimum Data Set (MDS) assessment dated [DATE] noted, R31 with an impaired cognition and required extensive assistance from one staff person for activities of daily living (ADLs). A review of the two pharmacist's recommendations dated, 8/17/23 and 9/19/23 both revealed the following: [R31] has an order for lisinopril 10 mg (milligram) daily and has had either high normal or above high normal serum potassium levels in the past several months. Please consider if lisinopril can be withheld or discontinued and will continue to monitor serum potassium. Further review of the recommendation in which the physician is to respond was blank regarding whether they agreed, disagreed, or other, and there was no signature noted. 44750 R100 A review of the medical record revealed that R100 admitted into the facility with the following diagnoses, Borderline Personality Disorder and Mood Disorder. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 9/15 indicating an impaired cognition. R100 also required set up help with supervision for bed mobility and transfers. A review of R100's Medication Regimen Review (MRR) recommendation dated 9/20/2023 revealed the following, .Please consider a GDR (Gradual Dose Reduction) of quetiapine to 12.5 in the afternoon and at bedtime. If therapy is to continue at the current dose, provide rationale describing a dose reduction as clinically contraindicated. Additionally, the facility interdisciplinary team should ensure both ongoing monitoring for potential adverse consequences and implementation and monitoring of resident-specific interventions. Further review of the MRR did not contain a signature from the physician with their response to the recommendation. On 10/25/2023 at 2:20 PM, an interview was conducted with the Director of Nursing (DON) regarding the MRR not being followed up on by the physician. The DON stated that they discovered there was a gap in the facility receiving the MRR's and getting them to the physician. The DON stated that they have identified the problem and will be working on the process. On 10/25/2023 at 1:30 PM, an Quality Assurance Performance Improvement (QAPI) meeting was held with the Nursing Home Administrator (NHA) stated that they identified that there was a issue with the process of the physician receiving MRR's. The NHA stated that they are working on a new process to ensure that the physician is receiving them and responded to them. A review fo a facility policy titled, Medication Regimen Review noted the following, 4. The DON or his/her designee is responsible for ensuring that each recommendation issued by the consultant pharmacist is followed up on timely. All recommendations that are rejected/declined by the recipient must include written rationale to explain why the recommendation is not being accepted.

This citation pertains to Intakes MI00138808 and M100139419. Based on observation, interview and record review, the facility failed to ensure that one (R8) of seven residents reviewed was treated with dignity, resulting in the resident experiencing feelings of depression and hopelessness regarding their potential for improved independence and increased socialization. Findings Include: Review of the facility record for R8 revealed an admitted [DATE] with diagnoses that included Multiple Sclerosis, Paraplegia, Major Depressive Disorder and Stage IV (full thickness skin and tissue loss with exposed dermis, adipose (fat) tissue and various underlying structures) Sacral Pressure Ulcer. The Minimum Data Set (MDS) assessment dated [DATE] indicated R8 required primarily Total/Maximum level assistance for transfers, mobility and bathing/dressing. The Brief Interview for Mental Status (BIMS) assessment score of 14/15 indicated intact cognition. On 10/23/23 at 11:03 AM, during initial resident screening R8 expressed concern that they could not use their power wheelchair. R8 reported that they are occasionally assisted into a lounge style chair and that they do not use a manual wheelchair. R8 reported that they own a power wheelchair and they hoped to be able to use it in the facility in order to be more independently mobile and not so isolated in their room. When asked if they had discussed this issue with the facility R8 reported that they asked Licensed Practical Nurse (LPN) C about it and LPN C stated that they couldn't have their power wheelchair because We can't have you running people over in here. On 10/24/23 at 12:15 PM, after being provided with additional information regarding the rationale for currently avoiding electic wheelchair use was related to their wound healing, R8 was asked about LPN C stating we can't have you running people over in here. R8 stated I thought it was disrespectful you know, after I had used the chair for a long time. If I was going to run someone over I would have to do it on purpose, not because I'm not safe. It made me feel like, as far as they are concerned, I'm just going to be stuck in this bed as long as I'm here. The thing about me needing to have my wound healed before I sit up a lot makes sense. I don't know why [LPN C] couldn't have said that. It would give me some hope or a goal. On 10/25/23 at 11:25 PM, R8 reported that LPN C came to them yesterday (10/24/23) after this surveyor had left the room from speaking with them and asked them what the surveyor was asking and what R8's responses were to the surveyor. On 10/25/23 at 12:36 PM, R8 was interviewed regarding their report that LPN C was asking them what was discussed with this surveyor and R8 stated It bothered me, I didn't feel like they had any right to ask me about that and it was uncomfortable because I didn't know if I was supposed to be saying anything about that. When I told [LPN C] that we talked about my wheelchair [LPN C] said That's not up to him. On 10/25/23 at 1:00 PM, the facility Administrator (NHA) was asked about staff questioning a resident about their interactions with the surveyor and the NHA stated It is inappropriate, that shouldn't happen. On 10/25/23 at 3:10 PM, the facility Director of Nursing (DON) reported that it was not appropriate for staff to question a resident regarding their interaction with a surveyor. Regarding the incident of the staff member stating we can't have you running people over in here the DON stated that's insensitive, it shouldn't be addressed that way. The DON reported that after the issue of the discussions between R8 and LPN C were brought to the NHA's attention and investigated, LPN C acknowledged to the DON that the alleged interaction took place. Review of the facility policy titled Resident Rights dated 11/28/17 includes, under the heading Respect, Dignity and Self-Determination, the entry [resident has] The right to be treated with respect and dignity. The undated addendum facility policy titled Dignity includes the following entry: It is the policy of this facility to assure residents are treated in a manner that preserves the resident's dignity and promotes a quality life experience. PROCEDURE: 1. All residents will be treated with respect.

This citation pertains to Intake MI00138776. Based on interview and record review, the facility failed to conduct quarterly care conferences for one resident (R67) out of one reviewed for care planning, resulting in the guardian not being involved in the plan of care. Findings Include: A review of Intake MI00138776 revealed the following, As [R67] legal guardian and [family member], I am the first point of contact, and I was not notified of any health concerns [R67] was having . A review of the medical record revealed that R67 readmitted into the facility on [DATE] with the following diagnoses, Dysphagia and Alzheimer's Disease. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating that R67 was unable to complete the assessment. R67 also required extensive two person assist with transfers and limited one person assist with bed mobility. Further review of the medical record did not reveal any care conference notes and none were provided by end of survey. On 10/25/2023 at 11:07 AM, an interview was conducted with Social Service Director (SSD) A. SSD A stated that care conferences are done on admission, quarterly, and at resident/family request. The SSD A stated that care conferences were not being completed as they should prior, however they are on a schedule now and being completed. SSD A stated that they were newer to the company and did not have an explanation as to why R67 did not have a care conference. On 10/25/2023 at 2:13 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they talk about care conferences in the morning meetings, and they know they need to be completed at admission, quarterly, and at resident request. The DON stated that as they will be more involved in care conferences and ensuring that they are being completed and nursing be involved. On 10/25/2023 at 1:30 PM, a Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Nursing Home Administrator (NHA). The NHA stated that it was identified that care conferences were not being completed consistently prior to their arrival. The NHA stated that they now obtain a list and ensure that they are being followed through and scheduled. The NHA stated that they are improving on the process. A review of a facility policy titled, Care plan Standard Guideline noted the following, .8. The care plans will be reviewed and revised at the care conference in collaboration with the resident and /or resident representative.

Based on interview and record review, the facility failed to readmit or document reason for readmission to the facility following a hospitalization , for one sampled resident (R187) of three residents reviewed for hospitalization , resulting in dissatisfaction in care and a transfer to another facility. Findings include: On 10/23/23 at 9:38 AM, during initial tour R187 was interviewed and stated, I am happy to be back here. They said I couldn't come back when I was in the hospital. R187 further explained that they went out to the hospital and was not allowed to return to this facility. R187 was not sure what happened but was told by the hospital that they had a Covid outbreak. R187 explained that when it was time for discharge from the hospital the facility did not allow them to come back to their bed and was transferred to a sister facility. R187 was asked when this happened and stated, about 3 weeks ago. A review of R187's medical record revealed, R187 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Non-St Elevation Myocardial Infarction. A review of R187's five day admission Minimum Data Set (MDS) assessment dated [DATE] revealed, R187 with an intact cognition and required extensive assistance by staff to complete activities of daily living. A review of R187's progress notes revealed, 10/2/2023 19:07 (7:07 PM) Discharge/Transfer Summary Note Text: Around 6 in the evening Resident start having complaints of chest pain. Resident states having the feeling of 'tightness and aching pain in the middle of [R187's] chest radiating up to the left side of [R187] chest and left side of shoulder.' and rates pain as 8 out of 10. Writer administered 3 doses of nitro (nitroglycerine) in a total of 15 minutes with no relief of chest pain along with 1 tablet 81 mg (milligram) aspirin. Resident had persistent chest pain with no relief after attempts of PRN (as needed) medication being administered. After 15 minutes of no relief, writer contacted physician and provided physician with information regarding patient of medication administration and most recent vital signs . Physician ordered writer to send Resident out to hospital. Writer sent resident out via 911 emergency, notified responsible party . and interim Director of Nursing (DON) . Paramedics arrived approx. (approximately) 7:07 pm; Writer sent patient out with medication orders summary and face sheet. Resident was sent to [local hospital]. Continued review of R187's medical record noted an electronic form Transfer to Hospital revealed, section documents sent, checked as given to resident were a Face sheet and Current medication list or MAR. Not checked was bed hold. On 10/25/23 at 8:56 AM, during the infection control task the DON was asked about the Covid outbreak that was reported to R187. The DON explained, the facility did not have a Covid outbreak during that time but did not have a bed for the resident. The Nursing Home Administrator was present and was asked if R187 was gone more than 10 days from the facility. The NHA stated No. and explained they had moved some residents around in the facility and R187's bed was no longer available. The NHA was asked if R187's bed hold was honored and if R187 should have been allowed back to the facility, the NHA explained that R187 should have been allowed back to this facility. A review of the facility's policy titled, Bed Hold and Return Guideline dated, 4/25/2019, noted, Purpose: It is the practice of that residents who were transferred to the hospital or go on a therapeutic leave are provided with written information about the State ' s bed hold duration and payment amount before the transfer. Additionally, this facility permits residents to return to the facility after hospitalization or therapeutic leave if their needs can be met by the facility, they require the services provided by the facility and they are eligible for Medicaid or Medicare covered serves or services covered by another payer. Residents and their representative will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave. The facility will maintain in contact with the resident and representative while the resident is absent from the facility and arrange for their return if appropriate .

Based on observation, interview, and record review, the facility failed to implement care planned interventions for two residents (R11 and R9) out of four reviewed for care plans, resulting in the increased potential for accidents, hazards and unmet care needs. Findings Include: R11 On 10/24/2023 at 9:00 AM, R11 was observed eating breakfast. R11's ticket noted that they were supposed to have a disposable set-up. R11 was observed with a regular plate and silverware. On 10/24/2023 at 12:29 PM, R11 was observed eating lunch with a regular plate and silverware. A review of the medical record revealed that R11 admitted into the facility on [DATE] with the following diagnoses, Cerebral Infarction and Dysphagia. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 6/15 indicating impaired cognition. R11 also required one-to-two-person extensive assistance with bed mobility and transfers. Further review of the care plan revealed the following, Focus: I am at nutritional risk r/t (related to) CVA (Cerebrovascular Accident), dysphagia, dementia (PO (by mouth) intakes may vary with disease process), depression, T2DM (Type 2 Diabetes Mellitus) .I require 1:1 feeding assistance. Interventions .Plastic/disposable dishware, spill proof cup, scoop plate) 1:1 feed. On 10/24/2023 at 1:14 PM, an interview was conducted with Dietary Manager (DM) B. DM B stated that disposable set-up on the dietary ticket means that R11 should have paper products, such as a disposable container. DM B stated that they were going to look into why R11 did not have paper dishware. On 10/25/2023 at 2:16 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that R11 is supposed to have disposable dishware due to R11 throwing plates and all types of things. 40384 R9 On 10/23/23 at 11:54 AM, R9 was observed in bed and asked about their stay in the facility. The resident was extremely hard of hearing and as a result, the surveyor had to type out questions for the resident to read and respond. R9 explained that they were missing their hearing aids which had gone missing for several weeks, and believes that they may have gotten wrapped up in their linen or possibly thrown away. A review of R9's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Acute Respiratory Failure, Chronic Kidney Disease, and Irritable Bowel Disease. Further review of their Quarterly Minimum Data Set assessment dated [DATE] revealed that they had a Brief Interview for Mental Status score of 12/15 indicating an intact cognition, and required extensive assistance for Activities of Daily Living. Further review of the medical record revealed a care plan that did not address the resident's hearing loss or use of hearing aids. A review of R9's medical record revealed the following progress notes addressing R9's hearing and hearing aids: 6/5/2023 17:38 (5:38pm) Social Service Note Text: Resident inquired about hearing aids, writer reached out to [audiology company], submitted a physician order and uploaded into resident chart. Resident will be added to the list for June Audiology visit. Writer will continue to monitor and assist. 6/19/2023 14:53 (2:53pm) Health Status Note Text: Resident's [family member] picked up hearing aid to take it to be fixed. 6/28/2023 13:02 (1:02pm) Social Service Note Text: Writer sent an email request from [insurance] for resident to see the Audiologist. A review of R9's Quarterly Minimum Data Set assessment dated [DATE] revealed that the resident's hearing was adequate, and that during the hearing assessment, Hearing aid or other hearing appliance used was coded as No. On 10/25/23 at 11:08 AM, Social Worker A was asked about R9's missing hearing aids, and she explained that she just learned about the hearing aids last week and that the resident had been placed on the list to be seen by the audiologist. On 10/25/23 at 2:56 PM, the Director of Nursing (DON) was asked about R9's care plan not addressing their hearing loss, and she explained that the resident's hearing loss should be included in their care plan. A review of a facility policy titled, Care plan Standard Guideline noted the following, Comprehensive Careplan The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident ' s medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment 4. Interventions should be specific to reflect the specific goal. The intervention should be individualized to the resident.

This citation pertains to Intake: MI00140274. Based on interview and record review, the facility failed to operationalize policies and procedures by notifying the resident's representative and physician of a fall in a timely manner for one resident (R387) of one reviewed for notification resulting in, the resident's representative and physician being unaware, and the inability to participate and make medical decisions regarding care and treatment. Findings include: A review of R387's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Cerebral Infarction, Hypertension, Dysphagia and Dementia. Further review of R387's medical record revealed that they were severely cognitively impaired, and required extensive to total dependence on staff for Activities of Daily Living. A review of R387's medical record revealed the following late entry progress notes entered on 10/12/23 from a fall that occurred on 10/5/23: 10/5/2023 23:00 (11:00pm) SBAR (situation background, assessment, recommendation) - Fall Late Entry: Situation: [R387] had a fall. The fall was un-witnessed. resident was observed sitting on the floor next to [their] bed .Resident has NO injury. No pain is noted. Neurological changes are NOT noted. Response: [blank] Request: [blank] Recommendations: [blank] Recommendation/Response: Facility fall protocol. Further review of R387's progress notes did not reveal that the resident's responsible party had been contacted following the fall, and a review of the Incident and Accident report dated 10/5/23 indicates that the resident's physician was contacted on 10/11/23 at 2:28pm regarding the fall. Further review of R387's progress notes revealed the following: 10/13/202313:30 (1:30pm). Health Status Note Text: Patient was sent to [local hospital]at approx.(approximately) around 1:30pm accompanied by two EMT (emergency medical technician) via stretcher. Patient was sent out by MD (medical doctor) for a CAT scan post fall. Patient is very lethargic and family was concern about [them] due to this not being her normal. On 10/25/23 at 2:56 PM, the Director of Nursing (DON) was asked for her expectations for staff following a fall of a resident. She explained the fall policy, and indicated that her expectation is for staff to contact the resident's doctor, responsible party, and the DON. A review of the facility's Fall Evaluation Safety Guideline revealed the following, Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention .Facility staff across all departments together with resident representatives and residents provide resourceful information with individualizing care and approaches .

This citation pertains to Intake MI00134689. Based on observation, interview, and record review, the facility failed to protect the resident's (R702's) right to be free from sexual abuse by another resident (R701), resulting in R702 experiencing unwanted sexual touching and advances, disturbed sleep with feelings of distress and sadness, and the potential for ongoing and/or future decreased psychosocial well-being. Findings include: A facility-reported incident (FRI) submitted to the State Agency included the following allegation: It was reported a male resident was sexually aggressive toward a female resident. Resident #702 (R702) A review of R702's record revealed that the resident was admitted into the facility on [DATE] with medical diagnoses of Parkinson's Disease, Major Depressive Disorder, and Anxiety. A review of R702's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident is is cognitively intact and requires supervision of staff for activities of daily living (ADLs). On 3/2/2023 at 8:54 AM, R702 was interviewed in her room. She was observed to be petite and thin/frail, (documented weight on 3/1/23 was noted to be 85 lbs) and upon approach the resident indicated that she is deaf. This surveyor communicated with the resident by writing down interview questions that the resident could read and respond to verbally. The resident was asked about an incident that happened with a man at the facility that touched and/or tried to touch her, and if she could explain what occurred. R702 responded that there was a man who tried to touch her like this (resident re-created the incident by putting her hands up and down her chest over her breasts). The resident stated, I said, 'What's your name, what room are you in?' and he said room [ROOM NUMBER] .He pulled his pants down in the front and he wanted me to touch his penis. I pulled my hand away from him. R702 gave a physical description of the male perpetrator. Upon inquiry to confirm the details of the event, R702 confirmed and acted-out how R701 made contact with her chest/breasts and also attempted to grab her hand to get her to touch his exposed private area. R702 was asked where staff was when this was happening. R702 responded, We were waiting to play bingo, and so they were gathering the (other) people. R702 continued, And so he pulled his pants back up, I stayed real calm, didn't say nothing. I played bingo, and then I came back upstairs and I couldn't go to sleep that night. So, I went and talked to the nurse, asked her to make a report. They came and asked me questions and they took him out of here. All these women in here, he could've touched anyone. R702 was asked how her mood has been since the incident occurred. R702 stated, I am still a little shaky over it, and they've got me on Xanax for anxiety. The resident could not recall the name of the staff member she initially reported the incident to and did not know the name of the perpetrator nor the names of any potential witnesses to the event. R702 also indicated that she has still been attending group activities at the facility. A review of R702's progress notes revealed the following: -2/5/2023 20:36 (8:36 PM) *Physician/PA/NP - Progress Note (Narrative) Note Text: .(T)here was an incident between [R702] and a male resident at the same facility over this weekend. On the day of the incident, [R702] had come downstairs to the recreational area at about 1:15 PM for an event that started at 2 PM. It is seen on cameras that the male resident then approached her, then touched her chest and tried to grab her hand. He is also seen getting physically close to her and manipulating his pants. This interaction took place from 1:17 PM - 1:32 PM. This was all reported to me by [Nurse Manager B] over the phone, as I did not see this video myself and I have not been present at the facility at any time (I am a telemedicine provider) . I spoke with [R702] through a video call today in the privacy of her room. The nurse manager .was at bedside throughout and helped ensure clear communication between myself and [R702] . [The resident] states that she feels better now that she has talked about the incident with the police and with the staff at this facility. Patient clearly denies any injuries from the incident .She states that she feels a little bit anxious, and she was worried earlier that the man who assaulted her might know what room she is in and do something to her while she was in her room .She admits to a history of anxiety and depression. She states this incident has made her more anxious .She said she feels a little bit scared and thinks it will take time to not be scared of this happening again to herself or someone else. Patient states that her main concern is if the man who assaulted her may assault someone else, and this is why she feels better having talked about it. Patient says she knew what the man was trying to do was wrong. She states this has never happened to her before in her life. Exam: .she appears mildly anxious, but is very cooperative and polite to me. She answers questions thoroughly, smoothly, and in complete sentences. Good eye contact throughout. Smiles politely when we greet and say goodbye . A review of R702's medication list revealed that the resident does currently take Xanax twice a day for generalized anxiety. On 3/2/23 at 9:34 AM, via the Nursing Home Administrator's (NHA) phone, camera footage was reviewed of the incident involving R701 and R702. R702 was seen on camera seated in her wheelchair at a back table in the 1st floor dining room. R702 was at a table by herself when a male resident in a wheelchair (R701) approached R702. The male resident was observed to glance around before reaching toward R702 to try and grab her. The NHA indicated she believes R701 was trying to be sneaky. Staff were seen on camera coming in and out of the dining room briefly, but the dining room was mostly empty when the event on R702 occurred. On 3/2/23 at 10:53 AM, LPN A was interviewed via phone. LPN A was asked to describe what occurred when the incident between R701 and R702 was reported to her. LPN A stated the following: I was sitting at desk charting around 1 AM (2/5/23) or so. [R702] walked up to me crying, I was trying to console her. She is hard of hearing, she was saying how an incident had happened during the day. She said [a male perpetrator] touched her breast and he was trying to get her to put her hands on his pants. I started writing things down asking her questions. LPN A explained that in order to gather what happened, she wrote down questions on a piece of paper that R702 could respond to regarding the incident. LPN A added, [R702] was telling me she can't sleep. I was just asking her who, what, when, where, pretty much everything (about what happened). She said a .guy [physical description] in a wheelchair .room [ROOM NUMBER]. After I got my information from her, I contacted the Director of Nursing (DON), the administrator, wrote an incident report out, and asked them to run the cameras back. I know the resident is not confused and didn't think she was lying .The resident was clear and adamant it happened. And kept saying it was around 1-2 PM, around lunch time (2/4/23). LPN A added that she informed the weekend supervisor, LPN B, when she arrived for her shift at 7 AM, and let her know what was going on. LPN A stated that she communicated with the supervisor to ensure the facility continued to keep R702 safe and away from the 1st floor/where the perpetrator might be. On 3/2/23 at 10:59 AM, Licensed Practical Nurse (LPN) B, the weekend nurse supervisor, was called for an interview and left a voicemail. A call back was not received prior to survey exit. On 3/2/23 at 11:24 AM, when queried regarding interviewing the facility's social worker, the NHA indicated that Social Worker D was currently not at the facility due to being at an outside appointment. A review of the facility's investigation of the incident, submitted by the NHA, indicated that the facility-reported incident (FRI) was substantiated based on R701's confession to law enforcement that he had made physical contact with R702. 34851 Resident #701 (R701) R701 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE], with diagnosis of Cerebral Infarction, and Major Depressive disorder. A review of R701's Minimum Data Set (MDS) assessment dated [DATE] revealed, R701 with an intact cognition. R701's activities of daily living documented the following: as bed mobility 3/2 (extensive assistance/one person), transfer 3/2, walking in room, walk in corridor did not occur, locomotion on & off unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair) 3/2, Dressing 3/2, Eating 1/1 supervision setup help only. Toilet use 4/2 (total dependence one person assist, and personal hygiene 3/2. A review of R701's care plan noted, Focus: [R701] has history of being sexual inappropriate with female staff in the facility. Date Initiated: 11/10/2022. Goal: The resident will have no evidence of behavior problems. Date Initiated: 11/10/2022. Intervention: Psychiatric/Psychogeriatric consult as indicated. Date Initiated: 11/10/2022. Provide a calm and safe environment to allow resident to express feelings as needed. Date Initiated: 11/10/2022. Provide resident with area for decreased stimulation as needed for negative behaviors. Date Initiated: 11/10/2022. The Director of Nursing (DON) was asked for R701's history of sexual inappropriate behavior and provided R701's psychological evaluations; [Local psych group] dated: 11/10/22 . Complaint: Requested to see by SW (social work), DON. Reports resident making sexual comments, pushing a female staff person head down during care. Resident has hx (history of) of MDD (major depressive disorder) and PTSD (post traumatic stress disorder) . Last seen by [local psych group] psychiatrist 10/14/2022. Also is followed by [local psych group] psychiatrist . Psych meds reviewed for continued efficacy and potential side effects. SW/DON (social worker) reports resident making sexual comments, pushing a female staff person head down during care . [Local psych group]11/15/22 Complaint: Depressed mood, impulsive behavior HPI (History of Present Illness): [R701] who was reported to be expressing sexual comments and inappropriate touching of female staff. Reviewed most recent psychiatry note with GDR (gradual dose reduction) of Trazodone (antidepressant). Behaviors displayed before medication adjustment. [R701] presented today as tired but willing to talk. When asked about reports of sexual talk and touching [R701] denied any awareness of such a problem. [R701] acknowledged the need to be respectful of staff .Treatment Plan: Relationship Between Signs/Symptoms & Primary Focus of Therapeutic Encounter: +Session focused on improving mood.; Session focused on addressing inapporpriate verbalizations; Session focused on decreasing inappropriate sexual behavior; Primary Goals: Goal 1: Elevate his mood - reported feeling tired but mood has been alright Goal 2: Improve coping / reduce anxiety - increase in impulsive behavior which is not what goal was hoping for but, more activity. Motivation and Cognitive Capacity to Benefit from Therapy: Resident's cognitive functioning is intact and resident is capable of full participation in the therapeutic process . 2/7/23 Complaint: Depressed mood, impulsive behavior . Has history of depression and PTSD from military service. He has been seen before by [local psych group] psychiatry & psychology. Has Rx (prescription) of Trazodone, Cymbalta (antidepressant) and Seroquel (antipsychotic). Can display impulsive behavior, particularly toward females. [R701] was recently involved in an incident where [R701] touched a [R702] peer without her permission. [R701] was seen today for follow up of [R701's] status. [R701] has a 1 to 1 staff to provide structure and supervision. [R701] was alert and lying in bed. [R701] reported[R701] knew why [R701] was in trouble around here. [R701] acknowledged [R701's] behavior and expressed some regret for [R701's] actions. [R701] was provided with mild confrontation of this behavior as [R701] has had instances previously of questionable judgment around female staff. Discussed more appropriate ways for [R701] to address [R701's] sexuality and loneliness. [R701] reported [R701] would make the effort to be more respectful of others .Assessment and Plan: Major depressive disorder, recurrent, moderate (noted) Plan: Continue psychology interventions, currently has 1 to 1 staff monitoring to help with impulse control. On 3/2/23 at 11:37 AM, Licensed Practical Nurse (LPN F) was asked about R701's behavior and explained that R701 has grabbed her breast a couple of times or has said things to her when [R701] first got here. On 3/2/23 at 1:44 AM, Certified Nursing Assistant (CNA E) was asked if they worked with R701 on the day of the incident and stated, Yes, that day I got [R701] dressed and as soon as I was finished [R701] went down to [unknown resident's] room. [Unknown resident] has dementia and sometimes will take [their] shirt off (chest exposed) and we have to redirect [them]. So [R701] was in front of that door and I told [R701] that [they] could not go into that room and [R701] was upset and said why? CNA E explained that she redirected R701 to go to activities and that she wheeled R701 halfway down the hall in the direction of the dining room for activities. CNA E further explained, When I was done with my other residents, I saw [R701] wasn't in [their] room and so I asked them where [R701] was, they didn't know, I then saw [R701] coming back on the unit. I didn't know something happened. CNA E stated, [R701] would try to touch your butt or grab your breast. One time I was giving [R701] a shower, [R701] acted like [they] could not wash [their private area]. So [R701] said they can't, I go to wash the [private area] while I was washing [R701] pushed my head down (towards the private area). CNA E was asked if they reported the incidents to the nurse and stated, That was reported to the nurse. CNA E was asked if the other incidents of R701 touching her were reported, CNA E explained that initially she reported but after a while when nothing was being done, she just learned how to handle [R701]. On 3/2/23 at 1:02 PM, the DON and Nursing Home Administrator were asked if all incidents of inappropriate behavior should be reported and they explained, that all behavior should be reported to them each time the behavior happens. A review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11.28.2017, revealed, .ii. Sexual abuse is non-consensual sexual contact of any type with a resident .It is the policy of the Facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident ' s medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties.

Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to provide goods, services and necessary care and to prevent neglect from occurring by its failure to administer medications, perform treatments, and complete assessments on the 7:00 PM to 7:00 AM shift on 08/02/22 and 08/16/22. An Immediate Jeopardy (IJ) occurred when, on 8/2/22 on the 7:00 PM to 7:00 AM shift, a nurse for the 1-East Unit did not report for work. The on-site nursing staff did not assume the duties of the nurse. An Agency nurse replaced the nurse at approximately 11:00 PM on 8/2/22 but did not perform the scheduled medications and assessments for the evening of 8/2/22. As a result, no medications were administered nor were assessments completed for the evening of 8/2/22 for 38 of 39 residents reviewed. On 8/16/22 on the 7:00 PM to 7:00 AM shift, Nurse A for the 2-East Unit, had to leave the facility at approximately 10:20 PM due to a family emergency. The on-site nursing staff did not assume the Nurse's duties. As a result, no medications were administered nor were assessments, and/or treatments completed for the evening of 8/16/22 for 29 of 35 residents reviewed. This deficient practice resulted in a determination of Immediate Jeopardy with the likelihood of adverse consequences, serious harm and/or death due to the failure to administer physician-ordered medications, perform treatments and assessments for the management of medical conditions and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Immediate Jeopardy: The Immediate Jeopardy began on 08/02/22. The Immediate Jeopardy was identified on 08/25/22. The Administrator was notified of the Immediate Jeopardy on 8/25/22 at 9:50 AM and was asked for a plan to remove the immediacy. The Immediate Jeopardy was removed on 08/17/22 based on the approval and implementation of the facility's Removal Plan as verified on site on 08/25/22. Findings include: A review of the facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, effective date on 9/11/2020, revealed, .An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator . Definitions of Abuse and Neglect . f. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Resident #10: A review of Resident #10's medical record, revealed an admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS, dated [DATE], revealed a BIMS score of 15/15 that indicated intact cognition and needed extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. On 8/16/22 at 1:03 PM, an observation was made of Resident #10 lying in bed. The Resident was interviewed and conversed in conversation. The Resident complained of short staffing and stated, They just don't have enough on afternoons and nights. About three weeks ago, there was no nurse staffed on the hall, and indicated the hall was left in the evening with no nurse and stated, We didn't get our medication. The Resident reported being upset/scared with having no nurse and stated, I have an open wound on my leg, I can't get out of bed, and reported she could hear other residents coming out to try to find the nurse and get their medications. The Resident reported it was a Saturday night on the 7 to 7 shift, in the evening, and stated, No one scheduled. The day shift nurse left, and they had no one to cover. Review of Resident #10's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 7.5 mg (milligrams) for depression at 9:00 PM. [MEDICATION(S)] Lotion 12% to lower legs topically for dry skin at 9:00 PM. [MEDICATION(S)] 6.25 mg for hypertension at 9:00 PM without a blood pressure monitored. Sennosides-[MEDICATION(S)] for constipation at 9:00 PM. [MEDICATION(S)] 650 mg for hypertension at 9:00 PM. Covid-19 signs/symptom monitoring for PM. Prostat Sugar Free for wound healing at 9:00 PM Pain-evaluate pain every shift for PM. Resident #67: A review of Resident #67's medical record revealed an admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment, dated 6/23/22, revealed a BIMS score of 15/15 that indicated intact cognition and needed extensive assistance with ADLs that included bed mobility, transfers, dressing, toilet use and personal hygiene. On 8/17/22 at 12:06 PM, an observation was made of Resident #67 lying in bed. The Resident was interviewed and conversed in conversation. The Resident reported she took insulin for diabetes and complained of not getting her insulin until late at night, sometimes not until one or two o'clock in the morning. The Resident reported one night there was no nurse taking care of Residents and did not receive her insulin that night at all. The Resident indicated she had waited for the Nurse to come in with her medications and stated, I had fallen asleep but I had issues with my blood sugar all day (the next day after not receiving her evening dose of insulin). Review of Resident #67's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] KwikPen (Insulin) 20 Units at 9:00 PM. [MEDICATION(S)] 20 mg for cholesterol at 9:00 PM. Sennosides 8.6 mg, two tablets at 9:00 PM. [MEDICATION(S)] 50 mg for depression at 9:00 PM. [MEDICATION(S)] for Beta Blocker at 9:00 PM. [MEDICATION(S)] for diabetes at 9:00 PM. Omeprazole for ulcer management at 9:00 PM. Vital signs for the PM. Covid-19 signs/symptoms monitoring for the PM. Pain evaluation for the PM. [MEDICATION(S)] 4 mg for musculoskeletal therapy at 10:00 PM. Resident #97: A review of Resident #97's medical record, revealed an admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment, dated 7/15/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, that indicated intact cognition and the Resident needed supervision with Activities of Daily Living (ADL) that included bed mobility, transfers, walking, dressing, toilet use and personal hygiene. On 8/16/22 at 11:24 AM, an observation was made of Resident #97 dressed and lying in bed. An interview was conducted with the Resident. When asked about pain and pain management, the Resident indicated he had problems with pain in his back, shoulders, pretty much all over. The Resident reported having scheduled pain medication. The Resident complained that he did not always get his medication at night for pain and medication for sleep. When asked about why he had not received medication, the Resident stated, There was no nurse in the building to give the medication, so I didn't get it. When asked why there was no nurse, the Resident was unsure but indicated a couple weeks ago there was no nurse on the floor at night. He reported wondering why he was not getting his medication and was told by the CNA that there was no nurse. The Resident indicated that he had heard other Residents asking for medication also. Review of Resident #97's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] for depression at 9:00 PM. [MEDICATION(S)]-Salmeterol 500-50 mcg/dose (micrograms per dose) at 9:00 PM. Naproxen for pain at 9:00 PM. Covid-19 Signs/Symptoms monitoring for the PM. [MEDICATION(S)] for anxiety at 9:00 PM. Pain evaluation for PM. Vital signs for PM. Resident #103: A review of Resident #103 medical record revealed an admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment, dated 7/18/22 revealed a BIMS score of 15/15 which indicated intact cognition and the Resident needed extensive assistance with bed mobility, dressing and toilet use. On 8/17/22 at 11:07 AM, an observation was made of Resident #103 lying in bed. An interview was conducted with the Resident and the Resident conversed with conversation. When asked about staffing, the Resident reported that a nurse did not show up for work and there was no nurse to take care of the people on the unit and stated, No insulin, no meds. The Resident indicated they did not have a nurse on the unit and that him and his roommate did not receive any medications that night. The Resident reported that he took medication for diabetes and that insulin was usually given at night but he never got the medication that night. The Resident stated, It's happened more than once, and indicated he had missed his insulin and other medications. Review of Resident #103's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Insulin [MEDICATION(S)] 30 Units for diabetes at 9:00 PM. Blood Sugars monitoring for diabetes at 9:00 PM. Guaifenesin ER (extended release) 600 mg at 9:00 PM. [MEDICATION(S)] 500 mg for diabetes at 9:00 PM. [MEDICATION(S)] 0.2 mg for blood pressure management at 9:00 PM. [MEDICATION(S)] 5 mg for spasms at 9:00 PM. [MEDICATION(S)] 300 mg for nerve pain at 9:00 PM. Resident #112: A review of Resident #112's medical record, revealed an admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment dated [DATE] revealed a BIMS score of 13/15 that indicated intact cognition and the Resident needed supervision assistance with bed mobility, transfers, walking in room and corridor and needed limited assistance with dressing, toilet use and personal hygiene. Review of Resident #112's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22 at 10:51 AM, an observation was made of Resident #112, sitting on his bed, dressed. An interview was conducted with the Resident and the Resident conversed with conversation. The Resident was asked if he had any pain or discomfort. The Resident indicated he had pain and took medication. The Resident reported not getting his medication about two weeks ago. The Resident expressed concern that there was no nurse to give medication, he didn't get his medication and worried about it happening again and stated, I was in mental anguish, do I have to put up with this every time! When asked if he was scared about missing his medication the Resident stated, It was more of an anger. I had to prepare myself mentally to prepare if I have to deal with it again, and talked about concern of going into withdrawals and having pain that night and stated, There was the mental aspect (of going through withdrawal) and the pain was involved. I felt like I was a bum on the street, and talked about trying to find pain medication and going through withdrawals. Review of Resident #112's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Docusil 100 mg for constipation at 9:00 PM. [MEDICATION(S)]-Salmeterol inhalation aerosol powder breath activated 100-50 MCH/ACT, two puffs at 9:00 PM. Senna-[MEDICATION(S)] for stool softener at 9:00 PM. [MEDICATION(S)] Sublingual Film 8-2 mg([MEDICATION(S)]-[MEDICATION(S)] HCl Dihydrate for opiate dependence at 9:00 PM. Prostat sugar free for wound healing at 9:00 PM. Pain- Evaluate Pain every shift for pain Evaluation for the PM. Vital signs for the PM. [MEDICATION(S)] 750 mg for muscle relaxer at 9:00 PM. A review of the nursing staff schedule, provided by the facility, for 8/2/22 revealed Unit 1E (East) had Nurse AF scheduled and crossed off for the 2nd shift nurse (7 PM to 7 AM) with Nurse AC written below the other Nurse's name. On 8/18/22 at 4:52 PM, an interview was conducted with Certified Nursing Assistant (CNA) AG regarding the complaints of Resident's not receiving their medication and not having a nurse available. The CNA was asked what took place on that night. The CNA reported that on Tuesday, (8/16/22), there was an agency nurse that had come in and then she just left. She didn't tell anyone she was leaving, she just left, and reported there was no nurse on the 2-East unit when CNA AG came into work at 11:00 PM on 2-East that night. The CNA was unsure what time Nurse A had left the building. The CNA reported that Residents were asking for medication and stated, We told them someone was coming we just didn't know when. The CNA indicated that there was no Nurse that came to the Unit until the next agency Nurse arrived about 11:30 PM or 12:00 AM. The CNA reported no communication or seen a Nurse on the Unit until agency Nurse AA arrived. The CNA reported that Nurse A left the keys for the medication cart/narcotic keys behind the printer/fax machine at the nurses station and had seen the agency Nurse AA retrieve the keys left there. When asked about another night (8/2/22) there was no nurse on the 1-East Unit, the CNA stated, It was kind of the same situation. We didn't have a nurse. The CNA was unsure why there was not a Nurse. The CNA reported that she worked the third shift that night and when she had gotten to work, there was no nurse on the 1-East Unit until an agency Nurse came in but was unsure when the Nurse had gotten there. The CNA reported that Residents were calling and asking for there medications. On 8/22/22 at 1:32 PM, an interview was conducted with the Staff Coordinator (SC)AI. The SC indicated that the other Staff Coordinator AJ no longer worked at the facility and that she was filling in. A review of the schedule for 8/2/22 with Staff Coordinator AI revealed that Nurse AC was on for the night shift that was from 6 PM to 6 AM. The SC reported not being able to know when the Nurse had come in due to Agency Nurses not punching in, they sign a paper with the time they arrive and give it to there agency and indicated the only way to know when she came in was to check the kiosk when they screen for Covid-19 upon entering the building. SC stated, Day shift (Nurse) should not have left until someone came in. On 8/22/22 at 1:36 PM, Nurse AC was contacted on the phone by Staff Coordinator AI and an interview was conducted. When asked about working on 8/2/22, Nurse AC reported she had not been scheduled but had been informed of the opening that night. The Nurse indicated she had come in about 11:00 to 11:30 PM to work the 1 East Unit. The Nurse indicated there was no Nurse on the Unit when she arrived, did not receive report from a nurse and had gotten the keys from a staff Nurse (AK) who was on the 2-West Unit. When asked if Nurse AK had given her report, Nurse AC reported she had not gotten report. When asked if she had done a narcotic count with the Nurse from the 2-West unit, the Nurse stated, No. I did my own personal count. When asked if the evening medications were passed, the Nurse indicated she had not gotten report from another nurse but that some of the Residents said they didn't get their meds. When asked why she had not passed the evening medications, the Nurse stated, The medications were due four hours prior to me entering the building. When asked who was responsible for Resident care, the Nurse reported she did not know and that she had no other contact with other nurses. When asked if she had talked to Administrator (NHA) or the Director of Nursing (DON) regarding no Nurse on the Unit when she arrived and no nursing duties provided to the Residents, the Nurse reported she had not talked to the Administrator or DON. The Nurse stated, There was no Administration here to talk to that night. I talked to (name of Staff Coordinator AJ) the next day. I thought they were aware. I thought she (Staff Coordinator) would let them (Administration) know. On 8/22/22 at 1:51 PM, Nurse AF, who was scheduled, and name crossed out on 2nd shift (7 PM to 7 AM shift) for 1-East Unit on 8/2/22, was phoned by SC AI and an interview was conducted. Nurse AF was asked if she had been scheduled to work the 7 PM to 7 AM shift on 8/2/22. The Nurse indicated she looked at her past schedule and reported she had not been scheduled that day but had been scheduled the following day and stated, She (Staff Coordinator AJ) probably had me down in error. I wasn't supposed to be there that day. The interview continued with Staff Coordinator AI regarding the lack of Nurse coverage for the 1-East Unit on 8/2/22 7 PM to 7 AM shift. SC indicated that the two nurses on day shift needed to stay and both needed to count the narcotics and stated, They should decide who will stay until a Nurse comes in. Nurse AE who was the nurse on the day shift was called, but there was no answer after two calls made by SC. Nurse AK who was the Nurse on the 2-West Unit, was contacted by SC, but there was no answer. Nurse AD who was scheduled on the day shift on the 1-East Unit on 8/2/22 was contacted and an interview was conducted. The Nurse verified that she had worked on 8/2/22 on the 1-East Unit on the day shift when a Nurse did not show for the 7 PM to 7 AM shift. Nurse AD reported that the medication/narcotic keys were left with Nurse AK and report was given to that Nurse and stated, I counted and gave report. It was time for me to leave, and did not talk to the Administrator or Director of Nursing about the Nurse not coming in and that no-one talked to her about staying over. Staff Coordinator AI was asked who had come in on 8/16/22 but was unable to provide an answer. There was no other name on the schedule that SC reviewed except for Nurse A who had left the facility. On 8/22/22 at 2:27 PM, an interview was conducted with Human Resources staff (HR) AN regarding the Nurse that would have come in on 8/16/22 for the 7 PM to 7 AM shift for the 2-East Unit. The HR and Staff Coordinator were unsure who the Nurse was that had come in on that night. HR indicated that the Kiosk used to screen staff coming into the facility would indicated what time agency staff came into and out of the facility. After review of the Kiosk, it was determined that Nurse A had come in at 7:07 PM and screened out at 10:20 PM. HR stated, It shows only one punch out, no clocking back in. HR staff was asked to find out who the Nurse was that came in and indicated that CNA AG had reported that a male nurse had come in. After review of the kiosk data, the HR staff reported that Nurse AA had come into the facility on [DATE] at 12:01 AM and had punched out at 7:21 AM. The Nurse was identified as a male agency nurse, was called but there was no answer, and a message was left for a return phone call. On 8/22/22 at 3:15 PM, a phone call was placed to Staff Coordinator AJ that was no longer employed by the facility, but there was no answer with a message the phone number was not accessible, and a message was not able to be left. Multiple calls made on 8/23/22 were made, but there was no answer, and a message was not able to be left. There was no return call from Staff Coordinator AJ prior to the exit of the survey. On 8/22/22 at 4:11 PM, an interview was conducted with Nurse A regarding the 7 PM to 7 AM shift on 8/16/22. The Nurse expressed that shift was the first shift at the facility and that she worked as an agency Nurse. The Nurse indicated she had clocked in at 7:05 PM and left at 10:21 PM due to a family emergency and she had to get to her family. The Nurse reported she had not received any orientation to the facility or unit, did not get a log-in until 8:30 PM and was unable to start medication pass until the computer log-in was established. The Nurse had received notice of a family emergency and had to leave. The Nurse reported she had gone to the 2-West Unit that was a unit behind locked doors and tried to give report and the narcotic/medication cart/medication room keys to Nurse AK. The Nurse stated, She (Nurse AK) refused the keys and refused to count (narcotic medication) with me and stated, I tried to give her report, but she would not take it. The Nurse reported that the Nurse and a CNA had told her to call the Staff Coordinator AJ which she had done and stated, I asked again for (Nurse AK) to take report and the keys and she still refused. The Nurse was asked what she did with the keys and reported that the Staff Coordinator told her to place them where the next nurse would be able to retrieve them. The Nurse reported putting the keys behind the printer/fax machine at the nurses' station and let the Staff Coordinator know where they were. When asked about report, the Nurse indicated that the Nurse on the other side of the second floor (Nurse AK) refused to take report and she had left without giving report. The Nurse denied anyone calling for report later. When asked about the evening medication pass, the Nurse reported that due to not having the log in, she was unable to pass most of the medications and reported not hanging the tube feedings or giving evening insulin. When asked if the Administrator or the Director of Nursing were notified of the circumstance, the Nurse indicated she had only talked to the Staff Coordinator that night and was unsure if the Staff Coordinator had contacted the DON or Administrator. The Nurse stated, No one followed up on anything, and indicated no one called for report and she had not gotten a call from the DON or Administrator. The Nurse indicated that she was instructed to call Staff Coordinator AJ and that was who she had talked to and got instructions prior to leaving the facility. On 8/22/22 at 4:50 PM, an interview was conducted with the Director of Nursing (DON) and Unit Manager N regarding the lack of Nurse coverage for the 1-East Unit on 8/2/22. The DON reported that she had heard of medications not being given by a complaint from a Resident and started looking at MAR's (Medication Administration Records) and reported the evening medications had not been given to the Residents on the 1-East Unit. The DON indicated that all the Residents that had not received medication on the 1-East Unit were assessed on 8/3/22, and the doctor was notified after she had found out of the lack of nursing care and medications were not administered for the evening shift on 8/2/22. When asked what should staff do when no nurse coverage occurs, the DON stated, I should have been notified that night, 8/2/22 and indicated she would have notified the nurse managers, made sure nurse coverage was provided to the Residents until a replacement came in. When asked who should have notified her, the DON indicated that the Staff Coordinator should have notified me. When asked about the keys and the narcotic count, the DON indicated that Nurse AK should have counted with the Nurse (AC) when the Nurse arrived after 11:00 PM on 8/2/22. The DON reported that the Nurse should have called the Physician when the Residents on the 1-East Unit had not been given any medication on the evening shift, to get orders to give or not to give the late medications. A review of Nurse A leaving due to a family emergency that was scheduled for the 7 PM to 7 AM shift on 8/16/22 on the 2-East Unit. The DON reported not being made aware of the Nurse having to leave the facility and reported that Nurse AK, Staff Coordinator AJ nor Nurse A had notified the DON of the Nurse leaving for a family emergency, was not aware that the medications had not been given or that the med cart/narcotic/medication room keys had been left unsecured behind the fax machine at the nurses' station. The DON reported that her phone number was listed on the units as well as the unit managers phone numbers and her phone number was also listed in the electronic charting system. Concern of the lack of communication with administration regarding staffing concerns to deal with nursing coverage and the Residents did not receive care, assessments and/or medications administered on 8/2/22 then again on 8/16/22 that was within two week time frame was reviewed with the DON. The DON indicated they try to have consistent staffing and stated, If I am aware, I can have it covered. If I don't know, I can't put things in place. On 8/23/22 at 8:07 AM, an interview was conducted with Nurse AK who had worked the 7 PM to 7 AM shift on 8/3/22 and 8/16/22 on the 2 West Unit. When asked about the evening of 8/2/22, Nurse AK indicated that the Staff Coordinator had said someone (a nurse) was coming but did not give a time that a Nurse would be there (to work the 1-East Unit). Nurse AK reported that she had counted narcotics with the day shift nurses and that report consisted of nothing that needed to pass on. The Nurse indicated that when Nurse AC arrived, approximately 11:00 PM, she had given her the keys but did not count with the nurse and indicated she had nothing to report. When asked if she had passed the evening scheduled medications or did the scheduled assessments on the 1-East unit, the Nurse stated, No, I was passing my own medications. The Nurse indicated that the oncoming nurse was aware there had not been a nurse on the 1 East Unit and stated, She knew no nurse was there, she would see that they were not passed. The Nurse denied going back down to the 1-East Unit. When asked about the evening on 8/16/22. Nurse AK reported that Nurse A had came to the 2-West Unit, which was a locked unit with doors that secured the unit, and told her she had to leave and stated, I was passing medication. I didn't take the keys. I didn't want the two floors (units), and indicated she did not get report either. The Nurse reported that she had told her to call the scheduler (Staff Coordinator AJ) and reported that she wanted to give me the keys and get report but she did not take either. The Nurse reported the Nurse had left the unit and no one contacted her that the Nurse had left. When asked she had contacted the DON or Administrator, the Nurse stated, I didn't talk to anybody. I didn't know she was going to leave, she went back (to the 2-East Unit) and I didn't know what happened next. The Nurse was asked if the Staff Coordinator had contacted her regarding covering the 2-East Unit until another nurse arrived. The Nurse stated, I didn't talk to anyone again, and reported she was not aware Nurse A had left and stated, I did not follow up and no one called me. The Nurse reported that she saw Nurse AA come in and stated, That's when I knew she had left. When asked if she had passed any medication on the 2-East Unit, the Nurse reported that she was not aware that they weren't passed. The Nurse was asked if she had gone to the 2-East Unit and reported she had not, the Staff Coordinator had not informed her the Nurse had left the building and she had not called the Administrator or Director of Nursing and stated, I thought the Staff Coordinator would talk to them and have communication with them. On 8/23/22 at 9:30 AM, an interview was conducted with the Administrator (NHA) regarding the occurrence of Residents not receiving nurse care, assessments and medication administration on the 1-East Unit on 8/2/22 and on the 2- East Unit on 8/16/22. A Nurse not completing the scheduled assessments and prescribed medication due to a lack of Nurse coverage on the 1 East Unit on 8/2/22 and then when a Nurse had to leave the building for a family emergency on 8/16/22 with Residents on the 2-East Unit without Nurse coverage and a lack of scheduled assessments and prescribed medication not administered and lack of communication with Administration was reviewed with the NHA. The NHA reported that phone numbers for Administrative staff were located on each unit and that the staff should have contacted the DON at the time of occurrence. The NHA reported that the DON was made aware afterwards and assessments had been completed on the Residents involved. It was conveyed to the NHA that the DON reported she was unaware of the 8/16/22 occurrence. The NHA indicated she would ask the DON regarding her knowledge on 8/17/22. On 8/23/22 at 12:30 PM, the DON came to clarify that she was notified of the Residents' missed medications on 8/17/22, after the Resident's had not been administered their medication on the evening of 8/16/22 and reported that the physician had been notified and the Residents had been assessed. The DON reported she had not been aware of the keys for the medication cart and medication room had not been secured and were placed behind the printer/fax machine. When asked if she had been notified when the Nurse had left the building on 8/16/22, the DON reported she had not been informed until the next day. On 8/25/22, an interview was conducted with the Physician/Medical Director regarding the lack of staffing for 8/2/22 on the 1-East Unit and 8/16/22 on the 2-East Unit, the Residents not receiving goods and services in the evening. The Physician indicated that there was no identified harm and he had been notified after the incidents occurred. The Physician reported that he was available to be called at any time for any issues that arise regarding Resident care but was not notified until the day after. It was explained to the Medical Director that neglect occurred when goods and services were not provided to a large group of Residents with the likelihood of adverse consequences, harm and/or death to occur. There were two occurrences of the neglect in providing goods and services, the first on 8/2/22 and the second about two weeks later 8/16/22. On 8/31/22 at 10:18 AM, an interview was conducted with Nurse AA regarding working at the facility on 8/16/22. The Nurse reported that the need for a nurse come up on the agency app and he came into the facility as his first time. When asked if he had any orientation to the facility or unit, he reported he had no orientation. When asked if he had received report about the Residents he was assigned to care for, Nurse AA stated, No. I printed off a census sheet. The Nurse reported that a Nurse on the 1st floor had told him how

Based on observation, interview and record review, the facility is placed in Immediate Jeopardy due to the facility's failure to provide quality of care in accordance with professional standards of practice for 3 resident's (Resident #24, Resident #86, and Resident #138), with Intravenous catheters (IV's) and subcutaneous fluid administration (Hypodermoclysis) by ensuring that the residents had 1) Current physicians' orders for use, maintenance and monitoring of the sites, administration of fluids/medications, line flushes, dressing changes and discontinuation of the catheter and 2) Documentation of care, to aid in preventing serious complications/harm, including, inflammation, pain, blood clots, infections, Central Line Associated Blood Stream Infections (CLABSI), hospitalization s and/or death. Resident #24: The facility was administering subcutaneous fluids to Resident #24 with a discontinued order. The dressing, bag of fluids and tubing were all undated. There were no notes or assessments of the insertion or maintenance of the needle site, dressing, amount of fluids given or the resident's response to the fluid administration. The resident received subcutaneous fluids for 3 days with no provider's order or monitoring. Resident #86 received 69 doses of IV antibiotics with 138 missed doses of IV flushes. There were no orders for Central Line IV dressing changes or maintenance. There was no documentation that the care was provided. Resident #138: The facility administered 2 different IV antibiotics to Resident #138 without obtaining a provider's order for a saline flush before and after administration of the antibiotic. There were no orders for Central Line dressing changes or IV maintenance to aid in preventing the potential for a central-line-associated blood stream infection, per standards of practice, which could lead to [CONDITION(S)]. 53 doses of the antibiotics were given without providing the necessary saline flush before and after administration of the medication, meaning 106 IV flushes were not provided. The APIC Text: Long-Term Care, copyright 2022 by the Association for Professionals in Infection Control and Epidemiology (APIC), revealed, .The long-term care facility provides a home for elderly, physically disabled, and cognitively impaired residents, presenting unique challenges for the infection prevention and control program . Most commonly, residents who occupy LTCFs are over [AGE] years of age, with the mean age of 80 The aging population faces challenges to combating infection as their immunological systems become compromised as a result of changes related to aging, malnutrition, comorbidities, and medications that may alter their immune status . Prevention of HAIs (Healthcare Associated Infections) should be of high importance . Residents in LTCFs may be chronically dependent on ventilators, have indwelling urinary catheters, or have long-term indwelling central venous catheters. Longevity of stay within LTCF, for many residents, places them at greater risk for HAIs . Hypodermoclysis for Frail Patients and Patients in Long Term Care: A Review of Clinical Effectiveness, Cost Effectiveness, and Guidelines, Ottawa (ON): 2020 [DATE], revealed .Hypodermoclysis (HDC) is a method of administering fluids or medication subcutaneously (under the skin), as opposed to intravenously (IV; into a vein) or intramuscularly (into a muscle). As the number of intravascular devices in LTCFs has increased, so too has the number of complications. CDC guidelines for prevention of intravascular catheter-related infection recommend aseptic insertion, daily inspection, and quality control of intravenous fluids and administration set . Immediate Jeopardy: The Immediate Jeopardy began 8/13/2022. The Immediate Jeopardy was identified on 08/22/2022. The Administrator was notified of the Immediate Jeopardy (IJ) on 08/22/2022 at 1:20 PM. A plan to remove immediacy was requested. The Immediate Jeopardy was removed 08/23/2022 based on the facility's implementation of the removal plan as. verified on site on 08/31/2022. Findings Include: Resident #24: On 8/15/22 at 12:24 PM, Resident #24 was observed sitting in a wheelchair at bedside. She was observed to have 0.9% sodium chloride solution, 1000 cc bag hanging on IV pole with 400 cc remaining in the bag; 600 ml had been administered. The resident pulled up her shirt and showed the fluids were running via a needle into her abdominal subcutaneous tissue. She stated, I think they put it in Thursday. It runs into my stomach. I think I was dehydrated. That is what they said. Observed IV site on right abdomen, taped, no date, time or initials;IV bag not labeled, dated, timed initialed to identify when the fluid administration was initiated. The resident stated, Yesterday morning, they said I have a [CONDITION(S)]. They hung another bag yesterday and they gave me a shot. It's once a day. They straight cathed me. I can't walk. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #24 was admitted to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] revealed the resident needed assistance with all care and had full cognitive abilities with a Brief Interview for Mental Status score (BIMS) of 15/15. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Use 75 ml/hr intravenously one time only for Fluid electrolyte imbalance for 2 days, start date 8/10/2022 and end date 8/11/2022. 2. Use 100 ml/hr intravenously one time only for Fluid electrolyte imbalance for 2 days, start date 8/11/2022 and end date 8/12/2022. 3. Use 100 ml/hr intravenously one time only for Fluid electrolyte imbalance for 2 days. There was no order to provide the electrolyte fluid replacement subcutaneously via hypodermoclysis. The order indicated intravenously ( via an intravenous catheter inserted into a blood vessel). A review of the Medication Administration Records and Treatment Administration Records revealed three entries for fluid replacement therapy: 1. Order date 8/10/2022, Sodium Chloride Solution 0.9%, Use 75 ml/hr intravenously one time only for Fluid/electrolyte imbalance for 2 days, discontinue date 8/11/2022. There was one entry initialed and timed as given on 8/10/22 at 3:54 PM. The 8/11/22 entry was blank. 2. Order date 8/11/2022, Sodium Chloride Solution 0.9%, Use 100 ml/hr intravenously one time only for Fluid/electrolyte imbalance for 2 days, discontinue date 8/12/2022. There was one entry initialed on 8/11/2022 at 4:51 PM. The entry on 8/12/2022 was blank. 3. Order date 8/12/2022, Sodium Chloride Solution 0.9%, Use 100 ml/hr Intravenously one time only for Fluid/electrolyte imbalance for 1 day, Stop after 2 liters. At 100 ml/hr, it would take 20 hours to administer 2 liters of fluid (1000 ml per liter/2000 ml = 2 liters). There was one entry signed as given on the MAR on 8/12/2022 at 3:03 PM. The 8/13/2022 entry was blank and all other dates in August 2022, including 8/14/2022 and 8/15/2022 were crossed off, because the order had discontinued. On 8/15/22 at 3:15 PM, interviewed the Administrator and Nurse AY during an observation of Resident #24. The resident still had Sodium Chloride 0.9% solution being administered via hypodermoclysis ( a small needle into the subcutaneous tissue in the abdomen.) There was a small dressing over the needle site without a date. The tubing lay on the floor on a soiled piece of brief. The bag of fluids was undated. The Administrator was asked what the tubing was laying on and stated, A piece of a brief. On 8/15/22 at 3:25 PM, reviewed medical record documentation for Resident # 24 with Nurse AY and the Administrator. Nurse AY said she inserted the needle for the hypodermoclysis, unclear on the date and said she made a note. The Nurse was asked if she had assessed or documented on the fluids that were still being administered and she said she had not because there was no order for the fluids. On review of the progress notes, There were two nursing notes on 8/9/2022 the day before the IV fluids were ordered that provided the following: 8/9/2022 at 11:49 AM, written by a provider, Note Text: Staff alerted writer that resident was experiencing fever (100.6), chills, and had 2 episodes of emesis . Rapid Covid-19 test administered with negative results . Orders as follows: 1. STAT CBC, CMP 2. STAT UA with C/s 3. STAT (xray) . 8/9/2022 at 4:23 PM, a nurses note, Note Text: Resident complained of feeling very sick to her stomach and nauseated along with having chills . Resident will be seen by (doctor) this evening . From 8/10/2022 until 8/15/2022 there was no nursing note indicating electrolyte replacement fluids were being administered via hypodermoclysis. There was no mention of insertion of the needle, the site on the abdomen or the resident's response to therapy. On 8/15/2022 at 4:10 PM, a Late entry physician/provider note revealed, Scheduled follow up for resident (Resident #24) who is being seen for management of acute [CONDITION(S)] (urinary tract infection) and [CONDITION(S)] (bowel inflammation) . Orders as follows . 0.9% normal saline for gentle hydration for 3 liters total . On 8/16/2022 at 1:01 AM, a nurses note provided, Note Text: IV fluids completed, d/c (discontinue) order, pt (patient) tolerated the IV well, IV site pain free, no swelling, area is red and cool to touch . There was no another note or assessment until 8/23/2022 at 11:28 AM, provider note, Resident assessed today for follow up . after completion of IM antibiotic therapy for acute [CONDITION(S)] with gentle hydration via hypodermoclysis . Resident #24 had 3 orders for IV fluids from 8/10/2022 to 8/12/2022. The fluids were to be completed by 8/13/2022. They were still being administered subcutaneously via the same abdominal site on 8/15/2022. The needle had been in place for 6 days. The site had not been changed. There was no nursing assessment, dressing changes, monitoring, or notation of the total amount of fluids administered to Resident #24. A review of the Care Plans for Resident #24 provided the following: (Resident #24) has dehydration or potential fluid deficit related to diabetes, mobility, (pressure ulcer), date initiated 1/27/2021 with Interventions: Hydration interventions per Physician orders, date initiated 1/27/2021; Administer medications as ordered. Monitor/document for side effects and effectiveness, date initiated 1/27/2021. The Care Plan had not been updated since 1/27/2021. There was no mention of the resident's current dehydration, electrolyte fluid replacement or [CONDITION(S)]. (Resident #24) has a potential and a (history) of actual Urinary Tract Infection, date initiated 8/31/2021 with Interventions: Monitor/document/report to MD (as needed) for signs and symptoms of [CONDITION(S)] . date initiated 4/7/2022 and Obtain and monitor lab/diagnostic work as ordered . date initiated 4/7/2022. There were only 2 interventions. The Care Plan had not been updated to include electrolyte replacement therapy as ordered 8/10/2022. There was no Care Plan that mentioned administration of IV fluids, hypodermoclysis, side effects or monitoring. A review of the facility policies revealed the following: Infusion Therapy: Clinical and Pharmacy Services Policies and Procedures for Long-Term Care: 010-N: Appendix B: Hypodermoclysis Therapy Care Plan, dated April 2017 provided, Problem/Needs: Patient is mildly to moderately dehydrated, and requires short-term hydration . Potential for leaking prominent swelling, and local infection . Assess sites at least every 2 hours during infusion, and at least every shift when not in use . Infuse solutions at appropriate rates for hypodermoclysis: Up to 80 ml/hr at a single site, and 62 ml/hr at each of 2 sites . Rotate subcutaneous sites after 1.5-2 liters has infused at a single site . Rotate sites at least every 24-48 hours . Specific Medication Administration Procedures, date April 2018 M: Document in Nursing Progress Notes: . date . time . Medication, solution . infusion rate . site assessment, complications if any . Patient response to procedure . duration of medication infusion . any untoward reactions. Resident #86: On 08/16/22 at 10:30 AM Resident #86 was observed in her room sitting in a chair. Resident was pleasant and had time to talk. When asked if she had any concerns with her care she answered, not at all. Her discharge date was coming up and resident was excited to return home. She stated she had an antibiotic IV therapy (after her back surgery) while she was in a facility. PICC (peripherally inserted central catheter) line dressing was observed on resident's left upper arm. Clear film dressing was reinforced by tape around the edges. Corners of the taped dressing were loose. Resident stated nurses were trying to keep it intact and put some tape to hold it down. On 08/18/22 at 03:20 PM during the 1 West Unit tour with ADON Resident #86 was observed in her chair in her room. She was excited to share that she is leaving tomorrow. Resident stated she was done with antibiotic therapy as of today, on 8/18/22. ADON asked resident to look at Resident #86's PICC line dressing. It was covered with clear tape around the edges and small pieces of it were peeling off. Two Sodium Chloride prefilled syringes were observed on a side table next to the resident. When asked about it, ADON stated it was not an accepted practice to leave an unattended medication in a resident's room. Resident #86 said that nurses sometimes leave it on a side table for the next antibiotic administration. According to admission face sheet, Resident #86 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) dated [DATE], Resident #86 was scored BIMS of 15/15 on the Cognition Assessment, indicating no cognition impairment or memory problem. According to the MDS, Resident #86 required one staff assistance with bed mobility, transfers, care, and toileting. Record review for Resident #86 revealed following orders: 1) [MEDICATION(S)] Injection Solution Reconstituted 3 (2-1) gm ([MEDICATION(S)] & Sulbactam Sodium). Use 3 gram intravenously every 6 hours for infection for 42 days. Order date 7/7/22 at 00:06 AM. 2) Sodium Chloride Flush Intravenous solution 0.9%; use 10 ml intravenously every 6 hours for flush before and after Antibiotic therapy. Order date 07/25/22. Review of Medication and Treatment administration records (MAR and TAR) for Resident #86 for July and August 2022 indicated that resident was not given 10 of 168 prescribed IV antibiotic doses. Doses that were missing in July 2022 not given on: 07/08 at 18:00 (6PM) 07/12 at 06:00 AM 07/16 at 18:00 (6PM) 07/21 at 06:00 AM 07/26 at 18:00 (6PM) Doses that were missing in August 2022 not given on: 08/04 at 12:00 PM 08/05 at 00:00 AM 08/08 at 06:00 AM 08/14 at 00:00 AM 08/15 at 06:00 AM Resident was discharged on [DATE] and did not receive the full prescribed IV antibiotic therapy. Sodium Chloride flushes were ordered only on 7/25/22 to administer flushes before and after each antibiotic IV administration, which resulted in 158 total missed doses of Sodium Chloride flushes. Further review on 08/22/22 of Resident #86's provider's orders revealed no PICC line dressing changes ordered. Review of Medication and Treatment administration records (MAR and TAR) for Resident #86 for July and August 2022 indicated no PICC line dressing changes completed for 45 days since resident's admission to facility on 07/06/22. Resident #86's Care Plan had the following documented: Focus: Resident is on IV (intravenous) Antibiotics medications for Discitis (initiated 7/21/22- 14 days after resident's admission to facility and start of the IV antibiotic therapy) Goal: Resident will be free of any discomfort or adverse side effects of antibiotic therapy through next review (initiated 7/21/22) Interventions: - IV flushes and Dressing Changes per orders (initiated 7/21/22) - Administer antibiotic medications as ordered by physician (initiated 7/21/22) - Monitor/document side effects and effectiveness every shift (initiated 7/21/22) - Report pertinent laboratory results to MD (initiated 7/21/22) No documented interventions were noted for PICC line site assessment or monitoring for infection. Resident #138: On 08/16/22 at 10:20 AM Resident #138 was observed resting in bed with eyes closed. IV pole was noted on a side of the resident's bed with a small IV medication bag (not infusing) on the pole with tubing attached and capped to itself in a loop. Small amount of medication was noted still in a bag. On 08/17/22 at 10:00 AM Resident #138 was observed in her room in bed. Resident expressed high satisfaction with her care in a facility. IV pole was observed next to the resident's bed. There was a small IV medication bag still hanging on it with little amount of medication present in a bag, tubing not capped. Resident was asked if she receives antibiotic therapy and she responded yes. She stated her pressure injures were infected and she was receiving therapy for that. Resident #138 was asked to see her central line IV site and dressing. She showed her left arm. Clear dressing was noted covering PICC line site insertion. It was not adhering to the resident's skin in a bottom part of it. It was bunched up due to a gauze folded under it, which obstructed the view of the insertion site. Dressing was secured with multiple tapes around its perimeter and across the top portion of the dressing. Some of the tapes were not holding dressing in place anymore. The sterility of the dressing was visibly compromised. Third observation was made on 08/18/22 at 07:40 AM during Resident #138's wound care procedure. Resident's central line dressing was still bunched up at the bottom and plastic outer portion of the dressing was not adhering to the skin. Dressing was taped to secure at the top with paper tape. According to admission face sheet, Resident #138 was a [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) dated [DATE], Resident #138 was scored BIMS of 15/15 on the Cognition Assessment, indicating no cognition impairment. According to the MDS, Resident #138 required one staff assistance with bed mobility, transfers, care, and toileting. Review of Resident #138 electronic medical records revealed the following orders: 1) [MEDICATION(S)] intravenous solution, reconstituted 350 mg. Use 350 mg intravenously one time a day for [CONDITION(S)] of foot until 09/09/22 23:59. Order date 08/02/22 at 0038 AM. 2) [MEDICATION(S)] 1 gm/100 ml NS, MB+; use 1 gram intravenously every 8 hours for [CONDITION(S)] for 9 weeks. Order date 08/02/22 at 09:47 AM, discontinued date 08/15/22 at 22:09. 3) [MEDICATION(S)] 1 gm/100 ml NS, MB+; use 1 gram intravenously every 8 hours for [CONDITION(S)] until 09/09/22 23:59. Order date 08/15/22 at 22:09. 4) Sodium Chloride Solution 0.9%. Use 10 ml intravenously every 8 hours for Antibiotics flush before and after IV administration. Order date 08/16/22 at 11:27 AM. IV Sodium Chloride flush was ordered on 8/16/22, 13 days after the start of antibiotic therapy. No IV Sodium Chloride flush was ordered for flushes before and after [MEDICATION(S)] IV administration. Resident #138 missed total of 112 IV Sodium Chloride flushes with her antibiotic therapy. Record review on 08/18/22 revealed no orders for Resident #138's PICC line dressing changes. Review of Resident #138's Medication and Treatment administration records (MAR and TAR) for August 2022 indicated no PICC line dressing changes completed for 17 days since resident's admission to facility on 08/01/22. Resident #138's Care Plan had the following documented: Focus: Resident is receiving IV (intravenous) Antibiotics medications related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Goal: Resident will have no complications related to IV therapy through the review date (initiated 8/10/22) Interventions: - IV flushes and Dressing Changes per orders (initiated 8/10/22) - Administer antibiotic medications as per MD order (initiated 8/10/22) - Follow facility policy and procedures for reporting infections (initiated 8/10/22) - Maintain universal precautions when providing resident care (initiated 8/10/22) No documented resident centered interventions were noted for monitoring IV antibiotic effectiveness/side effects/tolerance. No interventions were noted for PICC line site assessment and monitoring. On 08/18/22 at 03:20 PM during the 1 West Unit tour with ADON Resident #138 was observed resting in her bed. ADON asked resident to show her PICC line site. ADON observed dressing that was not intact and a bag of medication hanging on the pole, which was not infusing at that moment. ADON was asked if the PICC line dressing site looked appropriate. She responded that it was not. Further, she was asked if that was considered a safe practice for a resident with history of [CONDITION(S)] and current infection in her bones, ADON responded that it was not. When queried if bag of antibiotic medication was appropriately left in a room with the resident, ADON said it was not. Review of the facility provided Intravenous Administration of Fluids and Electrolytes Policy (dated April 2017, no revision date) had the following: Staff will be knowledgeable regarding the safe and aseptic administration of intravenous fluids and electrolytes for hydration. General Guidelines 1. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Assess resident's lung and heart status and vital signs before and during therapy to assess for fluid overload. No guidelines specific to intermittent IV antibiotic therapy was found in a provided Policy. According to Infusion Nursing Standards of Practice published by The Infusion Nurses Society (INS) in 2021 Central Venous Access Device (CVAD) Dressing Changes: Dressing change frequency to central lines is dependent upon what type dressing that is in use. For the Transparent Semi-permeable Membrane (TSM), the dressing change frequency is every 5-7 days, and for gauze dressings the frequency is every 48 hours. There is no evidence to support one type of dressing is superior to the other, but gauze is preferable if the patient is diaphoretic. Remember, CVAD site care consists of removing the old dressing, cleansing the catheter skin junction with appropriate antiseptic(s), replacement of stabilization device, and application of a sterile dressing. Standard 59: Infusion Medication and Solution Administration. Another issue is delivering IV medications via a mini-bag and a primary administration set (i.e., gravity infusion) often used with IV antibiotics. There can be a significant potential loss of medication in the administration set, especially with small volume mini-bags (e.g., 50 mL). In the context of antimicrobial stewardship, it is important that patients receive their antibiotics with minimal loss of drug. An additional primary solution to clear the IV tubing is a consideration (p. S182). For example, 25 mL of saline solution after the antibiotic container is empty. (https://www.ins1.org/publications/infusion-therapy-standards-of-practice/) According to Oncology Nurse Advisor article published in 2019 Guidelines related to the required amount of normal saline solution (NSS) to flush a line between medications vary and appear to be institution-based. The only consistency in the literature is that all lines should utilize a 10-mL syringe to preserve the patency and functionality of the catheter in adult patients and 3 mL for pediatric patients. The California Department of Health Care Services recommends flushing the IV line between medications based on the type of line (i.e., PICC vs [NAME]). These guidelines suggest flushing the line with as little as 3-10 mL NSS after antibiotics. Review of the Institute for Safe Medication Practices provides very little standards for the amount for flushing but does endorse the use of a 10-mL syringe. (https://www.oncologynurseadvisor.com/home/cancer-types/general-oncology/guidelines-for-flushing-iv-lines-between-medications/) According to CDC website, Central line-associated bloodstream infections (CLABSIs) result in thousands of deaths each year and billions of dollars in added costs to the U.S. healthcare system, yet these infections are preventable. CDC is providing guidelines and tools to the healthcare community to help end CLABSIs. A central line-associated bloodstream infection (CLABSI) is a serious infection that occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line. Healthcare providers must follow a strict protocol when inserting the line to make sure the line remains sterile and a CLABSI does not occur. In addition to inserting the central line properly, healthcare providers must use stringent infection control practices each time they check the line or change the dressing (https://www.cdc.gov/hai/bsi/clabsi-resources.html) Abatement/Removal Plan: The facility staff did the following to remove the Immediate Jeopardy: 8/22/2022: The facility reviewed Resident's #'s 24, 86 and 138. R #86 was no longer at the facility; R #24 was no longer receiving fluids; R#138 had orders updated to include saline flushes, PICC line dressing changes and maintenance. 8/23/2022: All residents in the facility with vascular devices or subcutaneous fluids were reviewed by the facility to ensure there were physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . One additional resident was found to need orders for: Dressing changes, monitoring, and saline flushes. Residents with [CONDITION(S)] catheters were screened by the facility and received updated orders for monitoring on 8/23/22. 8/22/2022: The facility reviewed their policies: Guidelines for Preventing Intravenous Catheter-Related Infections; Intravenous adminstraton of fluids and electrolytes, hypodermoclysis therapy care plan; Infusion therapy medication administration. Nursing education began 8/18/2022 related to: orders are in place for the route of administration, IV flushes, care, maintenance and assessment of resident response to treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 8/22/2022: The facility started ongoing reviews of residents receiving IV therapy or subcutaneous fluids: 3 times per week for 4 weeks, then weekly with results to the QAPI committee.

Based on interview and record review, the facility failed to assess, monitor, and provide timely interventions for 2 residents (Resident #117 and Resident #143) of 35 residents reviewed from a census of 139 residents, resulting in Resident #117 transferring to the hospital and Resident #143 dying while both developed changes of condition without nursing assessments to aid in identifying a decrease in cognition and an overall decline in condition. Findings Include: Resident #117: A review of the Face Sheet and MDS assessment indicated Resident #117 was admitted to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] indicated the resident needed assistance with all care and had full cognitive abilities with a BIMS score of ,d+[DATE]. A record review revealed Resident #117 was discharged from the facility on [DATE] due to problems with the indwelling Foley catheter, pain and an electrolyte imbalance. Labs were drawn [DATE] with results on [DATE]: high potassium 5.4, low sodium 132 WBC 13.84. At the time of survey exit on [DATE], the resident had not returned to the facility. A record review of the assessments and progress notes indicated the nurses were not completing skilled nursing assessments or any routine assessment since the Nursing admission assessment Nursing Evaluation on [DATE]. Vital signs: blood pressure, pulse, respirations, temperature and pain were assessed daily, but there was no documentation of nursing assessments. A progress note dated [DATE] at 11:33 AM revealed, Labs reviewed, logged for doctor. No new orders. There was no further explanation. The resident had a Care Management note providing a summary of the resident's plan of care and discharge plans: [DATE]. The nurses were not providing, routine assessments and monitoring of Resident #117 to aid in detecting a change of condition and to ensure the resident received the care and services needed, prior to a change of condition on [DATE] when the resident was transferred to the hospital; an ER transfer note was then documented. A review of the physician/provider progress notes indicated 4 progress notes: [DATE], [DATE], [DATE] and [DATE]. A physician/provider progress note dated [DATE] revealed, Late entry: Labs with [NAME] imbalances, elevated BUN (kidney function test), and leukocytosis (identifies infection/inflammation), complains of intractable pain to hip impairing participation in therapies . There were no nursing assessments to indicate the providers findings were being monitored. The last progress note prior to discharge was dated Effective Date [DATE], however the note had been written by Nurse Practitioner V on [DATE]- 9 days after the resident was discharged to the hospital: Foley remains for retention post-op. Last labs with [NAME] imbalances, elevated BUN and leukocytosis. Pain better controlled . BP labile (fluctuates) . A provider note written on the day of discharge [DATE] at 9:19 PM provided, Labs with significant [CONDITION(S)] (low sodium) . [CONDITION(S)] and thrombocytosis. Removed Foley with recent retention due to catheter causing pain . Send to . ER for further tx (treatment) of lab abnormalities, Removed Foley and bladder scan . A review of the resident's Lab Results Report, collection date [DATE] and reported date [DATE] indicated Resident #117 had many abnormal labs. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Care Plans provided the following: (Resident #117) has actual ADL (activities of daily living) self-care performance deficit, date initiated [DATE] with Interventions: Monitor/document/report PRN (as needed) any changes . date initiated [DATE]. (Resident #117) has shortness of breath (SOB) when laying flat, date initiated [DATE] with Intervention: Elevate HOB (head of be) to alleviate shortness of breath. Position resident with proper body alignment for optimal breathing pattern, date initiated [DATE]. There were no other interventions. There was no mention of assessment. (Resident #117) has Foley Catheter, date initiated [DATE] with Interventions: Monitor/record/report to MD for s/sx [CONDITION(S)] . date initiated [DATE]. There was only one intervention. There was no mention of why the Foley was in use or that it was causing the resident pain. There was no mention on the care plan that the facility attempted to remove the Foley. On [DATE] at 1:43 PM, Unit Manager U was interviewed related to the absence of nursing assessments. She said the nurses should have completed nursing assessments for the resident. Also reviewed the late provider progress note dated [DATE] for [DATE] and Nurse U stated, Oh, that is late. Resident # 143: A record review of the Face Sheet and MDS assessment indicated the Resident #143 was admitted to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] indicated Resident #143 had mildly impaired cognitive abilities, with BIMS score ,d+[DATE], and needed one staff assistance with daily care, bed mobility, transfers, and toileting. Review of Resident #143 electronic medical records (EMR) revealed that resident was admitted to facility on [DATE] for skilled nursing care and rehabilitation after hospitalization . There was a Nurse Practitioner note dated [DATE] that had the following documentation: Patient is a [AGE] year-old male that is seen for medical follow up. Patient is in facility for subacute rehabilitation and attending therapies as scheduled. Patient has medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is awake and alert with periods of confusion. He states that he is feeling well. No chest pain, SOB (shortness of breath), abdominal pain, nausea, or dizziness. Patient requires assistance with ADLs (activities of daily living). No change in appetite, pureed diet is maintained. No difficulty with bowel or bladder. Resident is a well-developed [AGE] year-old male is seen sitting up in bed in no acute distress. Cardiovascular assessment: Regular rhythm, no murmur, rubs, or [NAME]. There was a Comprehensive Nursing Assessment on admission completed on [DATE]. Record review on [DATE] revealed notification in Resident#143's EMR: Daily Skilled Nursing Evaluation-V 5: 62 days overdue-[DATE]. Further review of resident's records revealed no nursing notes or skilled nursing assessments from [DATE] till [DATE]. A review of the resident's Care Plans provided the following: Focus: Resident #143 has a dual lead left sided cardiac pacemaker (initiated [DATE]) Goal: Resident will remain free from signs and symptoms of pacemaker malfunction or failure through the review date (initiated [DATE]) Interventions: -Monitor vital signs. Notify MD of significant abnormalities (initiated [DATE]) -Monitor/document/report as needed any signs and symptoms of altered cardiac output or pacemaker malfunction: dizziness, [CONDITION(S)], difficulty breathing, pulse rate lower than programmed rate, lower than baseline Blood Pressure (initiated on [DATE]) -Pacemaker checks as ordered and document in chart: heart rate, rhythm, battery check (initiated on [DATE]). Review of Resident #143's provider's orders revealed no orders for pacemaker checks and no nursing assessments documented about resident's heart rate being evaluated to his pacemaker programmed rate. On [DATE] at 03:10 PM Unit Manager N was interviewed related to the absence of nursing assessments for Resident #143. She stated the nurses in care should have completed nursing assessments for the resident. When queried if nurses are expected to document changes in condition assessments and communication to the physician in electronic medical record she said yes, they are. There was a nursing note dated [DATE] at 01:10 PM with following documentation: Writer summoned to bedside, pt (Resident #143) unresponsive to name, touch, and sternum rub. Writer called code blue, CPR (cardio-pulmonary resuscitation) started, and #911 called. Pt (resident) never regained pulse, heart rate and respirations. Paramedics arrived and took over CPR. Next nursing note was dated [DATE] at 02:05 PM: #911 team ended CPR per physician [name] from hospital [name] at 13:42 (01:42 PM). Writer called and informed family [name and phone number]. Writer informed her that resident had died . She was very upset and states she will come to agency (facility). Last Vital Signs documented for Resident #143 were from [DATE] taken before 10 AM: Blood pressure- ,d+[DATE] Temperature-97 F Pulse- 70 Respirations-20 Oxygen saturation- 96 No documented communication record with provider on call on [DATE] was available. No provider's note who received change in condition communication on [DATE] was noted in Resident #143's record. On [DATE] at 02:20 PM Registered Nurse Q who was providing care to Resident #143 on [DATE] was interviewed. She shared that she remembered the resident and she had no concerns that day with regards to his health condition. She stated he took his pills in the morning and ate his breakfast. When asked about change in condition documentation and assessments RN Q stated that she had her hands full that day and did not have a change to properly document everything. She said that staff are doing the best they can here for the residents. Some days they just can't get everything done. When queried how many times she took care of Resident #143 during his stay in a facility, she said maybe 3 or 4 times. She was asked if she documented any progress notes or her nursing assessments in resident's medical record during these shifts. RN Q said that she couldn't find documentation in resident's record. Further, RN Q was questioned if she notified on call provider or physician regarding Resident #143 change in condition. She answered I usually would. I probably paged him. The nurses were not providing routine nursing assessments and monitoring of Resident #143 to aid in detecting a change of condition and to ensure that the resident received the care and services needed, prior to his change of condition on [DATE] when the resident was found unresponsive and subsequently died on [DATE] at 01:42 PM. No notes were found in resident's record about the time, date and the name of the funeral home that picked up the body. Facility's Notification of Changes Guidelines were reviewed. There was the following: Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). Nurses and other care staff are educated to identify changes in resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. Overview of the components of the guideline: 1. Requirements for notification of resident, the resident representative, and their physician: 1) An incident involving the resident, which results in injury and has the potential for requiring physician intervention. 2) A significant change in the resident's physical, mental, or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. Facility's Policy for Nursing Assessment was requested on [DATE] and was not provided.

This citation is related to intake #MI 623 Based on observation, interview, and record review, the facility failed to prevent the development, assess and monitor a stage 4 pressure ulcer for one Resident (#1) and failed to complete wound care per standards of practice for two Residents (#7, #9) out of 6 Residents reviewed for pressure ulcers. This deficient practice resulted in the worsening of a stage four pressure ulcer and the potential for infection. Findings include: Resident #1 A review of Resident #1's record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 6/9/21 Minimum Data Set (MDS) assessment revealed she scored 4 out of 15 on the Brief Interview of Mental Status (BIMS) assessment, indicating severely impaired cognition. A review of Resident #1's progress note dated 9/3/20 revealed, .education given that sacrum excoriation would benefit from repositioning every 2-3 hours while in bed and that continuous positioning to any area of the body leads to skin breakdown . A review of a 9/4/20 Skin Observation assessment revealed, No new skin issues. A review of a 9/11/21 Skin Observation assessment revealed, (location): Sacrum . Followed by wound care. (Facility documentation shows this wound was documented as being on the sacrum and the coccyx). A review of the first Wound Assessment Details assessment was dated 10/8/20 and revealed Resident #1 had a Healed Stage 3 pressure ulcer, yet there was no indication that Resident #1 had ever had a Stage 3 pressure ulcer. This wound to the Coccyx was documented as being 3.6 centimeters in length, 3.20 centimeters in width, and 0.6 centimeters in depth. The MDS reflected a Stage 3 Pressure ulcer as: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. In review of Resident #1's physician orders, it revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was started on 8/27/2020 and was discontinued on 9/4/2020. This shows that Resident #1 had skin breakdown starting in August of 2020, yet no Wound Assessment Detail assessment was completed until 10/8/20. A review of Doctor (Dr. E's) Progress Note dated 10/20/2020 reflected a chief complaint of wound care, that she was there to see R1 regarding their sacral stage IV pressure ulcer and left foot wound. The physical skin exam reflected: Sacral stage IV pressure ulcer measures 5.5 x 3.5 x 3.5, it has undermining all around and the wound worse at 3:00 measuring 2.5 cm (centimeters). It has 100% granular tissue at the base, moderate amount of serous drainage, mild odor no [CONDITION(S)] no [CONDITION(S)] around. Treatment: Cleanse with Dakin's solution, dry, apply hydrogel, pack of the wound with gauze, cover with bordered gauze to change daily and as needed . Under diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected a Stage 4 Pressure ulcer as: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling A review of a wound progress note dated 1/4/21 revealed Resident #1's wound increased in size to: 5.0 centimeters long x 3.0 centimeters wide x 2.0 centimeters deep. A review of a wound progress note dated 3/30/21 revealed, 4.5 cm (long) x 3.5 cm (wide) x 3.0 (centimeters deep). Tunneling observed @ 3 o'clock with depth of 2.5 cm . The tunneling of the wound indicates the wound was worsening below the surface. A review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Increased in size, serosang (sic) drainage, slough with granular edges, PUSH score (score to evaluate pressure ulcers) trending up. Antibiotics adjusted . A review of the facility policy titled, Skin Management Guideline dated 11/28/17 revealed, .It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care .If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 1. Review the wound formulary for guidance 2. Consult with the Physician/NP and Resident Representative 3. Notify Supervisor/Designee as assigned .10. Initiate the Wound Initial Documentation Observation in (the electronic medical record (EMR)) which will include: type of wound, location, date, stage (pressure ulcers only) or indicate partial of full-thickness (arterial, venous, [CONDITION(S)]/diabetic ulcers), length, width and depth; wound base description, wound edge description and if present: drainage, odor, undermining, tunneling, and/or pain. The Weekly Wound Documentation Observation in (the EMR) should only have ONE WOUND per observation. See Weekly Wound Documentation Progress Sheet & Wound Documentation Guidelines for instructions. 11. When a pressure ulcer is present, daily wound monitoring should include:· An evaluation of the ulcer, if no drainage is present. An evaluation of the status of the dressing, if present. The status of the area surrounding the ulcer (that can be observed without removing the dressing). The presence of the possible complications, such as signs of infections. Whether pain, if present, is being adequately controlled . On 6/22/21 at 8:30 AM Licensed Practical Nurse (LPN) A and LPN B were observed performing wound care for Resident #7. LPN A was touching her goggles with gloved hands both during wound cleansing and wound dressing reapplication. LPN A and LPN B were both observed performing hand washing for less than 10 seconds. Upon completion of the dressing change while LPN A and LPN B were washing their hands Resident #7 complained her dressing was not changed over the weekend on Sunday 6/20/21. LPN A and LPN B acknowledged the complaint and stated they would look into it. Resident #7 also complained about not receiving the protein supplement she was ordered (Prostat AWC[Advanced Wound Care]) like she is supposed to for wound care healing for three days (Friday 6/18/21, Saturday 6/19/21, and Sunday 6/20/21). When asked, LPN A and LPN B stated Resident #7 was supposed to be getting the Prostat AWC daily. On 6/22/21 at 10:25 AM, during an interview, LPN A stated she was told on Monday 6/21/21 by Resident #7, her dressing was not changed on Sunday 6/20/21. LPN A stated she forwarded this information on to LPN B and Unit Manager LPN C who stated they would follow up with the concern. LPN A stated she believed the dressing for Resident #7 had Saturday's date 6/19/21 on the dressing, but was not sure. LPN A however stated what she was sure of, was the dressing was not dated with the Sunday 6/20/21 date when they performed the Monday 6/21/21 dressing change. LPN A stated the issue of dressings not being done on the weekends has been a problem. LPN A stated the roommate (Resident #9) who also had a wound, when she heard about Resident #7's complaint also complained about her wound not being done over the weekend. On 6/22/21 at 11:45 AM, during an interview regarding missing wound care treatments over the weekend, LPN B stated she was aware the dressings were reported as being missed over the weekend because she was changing the dressings with LPN A on Monday 6/21/21 when it was reported. LPN B stated the dressing on Resident #7 had Saturday's date 6/19/21 on the dressing and when asked about Resident #1, stated there was no date on the dressing for Resident #1. LPN B was asked why this issue identified on 6/21/21 was not addressed until 6/22/21, and stated she was not able to identify Registered Nurse (RN) D who was responsible for the missed dressing change issue until today 6/22/21. LPN B stated she figured out it was RN D when Resident #7 and Resident #9 were better able to describe her. LPN B stated Resident #7 and Resident #9 told her RN D made the excuse to the Residents (#7, #9) she was too busy and did not have time to change the dressings. LPN B stated apparently the residents saw her outside their room smoking (at front entrance area courtyard). LPN B stated Resident #7 and Resident #9 were upset because RN D could find the time to smoke, but not change their dressings. A review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 revealed a Brief Interview of Mental Status (BIMS) assessment of 13 out of 15, indicating cognition was intact. A review of an admission MDS dated [DATE] which was in progress for Resident #7, revealed a BIMS assessment which was signed completed with a score of 15 out of 15, indicating cognition was intact. On 6/23/21 at 9:30 AM, during a follow-up interview, LPN B was asked to estimate how often the treatments were being missed on the weekends and reported to the leadership over the last three months. LPN B stated At least once a month. On 6/23/21 at 10:15 AM, during an interview, the Director of Nursing (DON) was asked when she was informed of missing treatments by RN D. The DON stated she was informed on 6/22/21 by LPN B. The DON was asked if there had been issues in the past with RN D regarding dressing changes and stated, No. The DON stated she started her employment with the facility in November 2020, and she was told about the missing treatment issues early on when she first started. The DON stated she was not aware of anything recently until this instance. When asked how the issue was addressed with RN D, the DON stated she was called over the phone and interviewed. The DON stated RN D was given a disciplinary action for missing wound care dressing treatments and also for signing them out as being completed, when they were not completed for Resident #7 and Resident #9. The DON stated RN D admitted to not doing the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN D then stated to the DON she did not realize she had signed it out as being completed and said it was a mistake. On 6/23/21 at 11:15 AM, during an interview, Resident #9 stated she was upset because RN D told her she would not be able to get to her dressing when resident asked her Sunday morning 6/20/21. Resident #9 said she was especially upset because she could smell smoke on RN D when she entered the room the second time she asked for her dressing to be changed. Resident #9 stated to this Surveyor, She got time to smoke, but not time to do dressings? Resident #9 was asked if she could see RN D was outside smoking as reported by LPN B. Resident #9 stated she did not see RN D outside, RN D came in the room smelling like smoke that is why Resident #9 was so upset. Resident #9 stated when she had asked RN D again at 5 pm to do her dressing change knowing it needed to be done daily, RN D told her there was not enough staff for her to do Resident #9's dressings. On 6/23/21 at 11:45 AM, during an interview, RN D stated the dressing changes for Resident #7 and Resident #9 were not completed on 6/20/21. When asked why the dressings were not completed, RN D stated, I don't have enough Certified Nurse Aides (CNA's) on the floor, and on that night particularly I barely had enough staff to do basic care let alone treatments. RN D stated she only had two CNA's and one other nurse for the entire 1 West unit ([RN D stated it was about 35 residents on the day in question] approximately 25 residents on entrance to the facility). RN D was asked how often staffing is like this on the weekends and stated, This is every weekend. When asked why it was charted as completed RN D stated, It was a mistake on my part. RN D revealed she was questioning continuing to work at the facility and that she was fearful of issues against her license with the staffing challenges of the facility. RN D stated, I barely have enough time to keep them (residents) clean let alone wound treatments.

Based on observation, interview, and record review, the facility failed to properly maintain infection control practices per the Centers for Disease Control and Prevention (CDC) guidelines, resulting in sustained spread of COVID-19, the likelihood for continued exposure/transmission of COVID-19 for up to 141 facility residents, facility staff members, and potential decline in overall health which resulted in Immediate Jeopardy. Findings Include: Licensed Practical Nurse (LPN A) tested positive for COVID-19 in the middle of their shift on 4/12/21 at approximately 2:30 PM. LPN A was not sent home but directed by the Infection Control Nurse (LPN B) to work the remainder of their shift in the facility, on a non-positive COVID-19 unit, which included testing an entire unit of 35 residents for COVID-19 and passing medications. Whereby, 12 out of the 35 residents had not been vaccinated for COVID-19. The facility had 17 residents and 7 staff members test positive for COVID-19 since 4/12/21. On 5/17/21 at 2:30 PM and on 5/18/21 at 9:00 AM, the Director of Nursing (DON) was interviewed about the residents and staff members that tested positive in the month of April and May 2021. The DON revealed that most of the residents resided on 1 East, and a couple resided on 1 West. The DON explained that the following Residents (R) tested positive for COVID-19 on the following dates: R601 - 4/14/21, R602 - 4/14/21, R603 - 4/21/21, R604 - 4/21/21, R605 - 4/22/21, R606 - 4/22/21, R607 - 4/22/21, R608 - 4/26/21, R609 - 4/27/21, R610 - 4/27/21, R611 - 4/27/21, R612 - 4/27/21, R613 - 4/30/21, R614 - 5/5/21, R615 - 5/5/21, R616 - 5/5/21, and R617 - 5/13/21. The DON was asked if the facility determined the possible source of the outbreak and revealed, R606 and R608 were possibly exposed by LPN A. The DON explained that the following staff members tested positive for COVID-19 on the following dates: LPN A - 4/12/21, who worked on 1 east and covered 2 West on 4/12/21. Registered Nurse J (RN J) - 4/17/21, who worked on 2 East. CAN (Certified Nursing Assistant) K - 4/15/21, who worked on 2 East. CNA L - 4/15/21, who worked on 2 East. CNA M - 4/29/21, who worked on 1 East and 1 West. Dietary Aide G - 5/5/21. Dietary Aide H - 5/6/21. On 5/18/21 at 10:50 AM and 11:49 AM, LPN A was interviewed via phone and queried regarding testing positive on 4/12/21, and whether or not they had symptoms prior to working. LPN A stated, I think it was April 12th, I came in and did the screening, and did not have a temperature, just had an irritated throat and some sneezing, but I thought it was my allergies. LPN A was asked for the reason, she was tested for COVID-19 and stated, It was the regular COVID-19 testing day. LPN A was asked for the time she was tested and stated, It was right before my break around 2:00 PM or 3:00 PM, because I left out to go get a [Pop] for my throat, and they called me back to the building during my break. [LPN B] told me that I was positive and asked why I didn't tell her that I had COVID-19 symptoms. LPN A was asked if she was directed to clock out and go home, and she stated, No. I was told by [LPN B] to go up to my unit and swab (rapid COVID-19 test) all the residents. LPN A was asked how many residents they swabbed after being told they were positive for COVID-19 and stated, I run the floor alone, maybe around 38 or 40 residents. LPN A was asked if they worked their entire scheduled shift from 7:00 AM to 7:00 PM and stated, Yes. LPN A was asked the reason they continued to work with residents and staff after testing positive for COVID-19 and stated, I was told by [LPN B] to go back up and wait for clarification (another test by an outside lab). LPN A was asked if they started having more symptoms and stated, Yes. It became difficult to finish. I was passing meds and I could not get it done. I became fatigued towards the end of my shift and needed help to finish swabbing all the residents. LPN A was asked if they left to go home when they started feeling fatigued and stated, No. I finished and was relieved by the next Nurse (LPN C). LPN A was asked for the time, the second test was completed by the outside lab. LPN A explained that they did not recall the time when the second test was completed but was called near the end of their shift confirming positive COVID-19 results. LPN A was again asked why they remained at work after knowing they had a positive result for COVID-19 and stated, I asked [LPN B], if I was supposed to clock out and she told me, `No go back upstairs and wait for clarification`. On 5/18/21 at 11:26 AM, the Nursing Home Administrator (NHA) was asked for LPN A's actual time worked dated 4/12/21. The NHA stated, She worked from 7:16 AM and left at 8:56 PM. On 5/18/21 at 12:17 PM, LPN D provided test results for LPN A and was asked for the time the test was completed. LPN D stated, I don't have a time, but [LPN B] completed the first (round of) testing between 6:00 AM to 10:00 AM and then the (second round) from 2:00 PM to 6:00 PM. The documented test results noted, [LPN A] COVID-19 Ag ([MEDICATION(S)]) Card Date S&S (signs and symptoms) identified (blank). Time S&S Identified: Verified PCR (Polymerase Chain Reaction) + (Positive) 4/12. [Signed LPN B]. On 5/18/21 at 1:15 PM, the DON was asked for the number of residents LPN A was assigned to on 4/12/21 and stated, 35 residents. [LPN A] was the only Nurse on 2 West. The DON was asked if LPN A worked after being told they were positive for COVID-19 and stated, I'm not sure I was on vacation. I was told [LPN A] was sent home. The DON was asked who was told about LPN A's positive result and stated, the [NHA] was on site. The DON was asked what time the lab came in to test LPN A on 4/12/21 and explained that they would find out. On 5/18/21 at 2:18 PM, the DON explained the lab reported that they may have been here to test LPN A after 6:00 PM for the second test, and that results may have be in around 7:46 PM on 4/12/21 to LPN B. The DON was asked if a staff person should be working while waiting on their confirmed COVID-19 test results and stated, They should not continue to work. On 5/18/21 at 2:40 PM, the NHA was asked if they were notified that LPN A tested positive for COVID-19 at approximately 2:00 PM or 3:00 PM. The NHA stated, [LPN B] called me at home and told me [LPN A] had a positive result from the [Lab], and that they tested her because [LPN A] was having symptoms. I had no communication about [LPN A] having a rapid (test) that was positive earlier. That was not reported to me. On 5/17/21 at 9:05 AM, R601 was interviewed in their room. R601 explained that they had recently been at a different facility for two weeks because they were sick with COVID-19. R601 explained that they had mild symptoms and had not received the COVID vaccine prior to falling ill. The resident mentioned that staff told them there had been multiple recent cases of COVID-19 in the facility. When queried if the resident had been tested during routine facility testing or due to symptoms, R601 stated, I asked to be tested because I couldn't taste my food. I let them know what was going on when I lost my taste. When queried regarding infection control practices in the facility, R601 stated, One aide works afternoons but I don't know her name. She doesn't wear a mask. They had activities at one point, and the dining room used to be open but now we are on lockdown and it's terrible. When queried about where they thought they had caught COVID-19, Resident #601 stated, In here. I didn't go anywhere. [Registered Nurse (RN) J] tested positive and I tested positive, she had given me a shower. She didn't wear a mask and I don't wear a mask when I shower. A review of the facility's list of COVID-19 positive residents and staff revealed that RN J tested positive for COVID-19 on 4/17/21, and R601 tested positive on 4/26/21. The list indicated that RN J possibly exposed residents on the 2 East unit, which was where R601 had resided prior to testing positive for COVID-19. On 5/17/21 at 9:15 AM, during an interview with R601 in their room, Nurse Aide K entered the room and was observed not wearing eye protection. Multiple signs posted throughout the facility and entrances to the units indicated that masks and eye protection (i.e., goggles/face shield) were required for entry. On 5/17/21 at 9:25 AM, Nurse Aide L was observed sitting at the 2 East nurse station wearing a mask and regular glasses but no eye protection. Nurse Aide L indicated they had started working at the facility two weeks ago. Nurse Aide L revealed she was not familiar with the facility's sick leave policy and procedures. On 5/17/21 at 9:29 AM, LPN M was observed in the hallway on 2 East with no eye protection on. On 5/17/21 at 10:29 AM, a tour through the facility's observation unit 1 West (isolation for newly admitted residents) was conducted. Signage to the unit indicated that full Personal Protective Equipment (PPE: gown, gloves, eye protection, mask) were required in rooms on the observation unit. CNA F was observed to be in room [ROOM NUMBER] assisting a resident who was under isolation precautions. CNA F was observed to not be wearing eye protection nor a gown while in the room. When queried, CNA F stated that goggles and gowns were required in the rooms. CNA F was not observed to wash or sanitize her hands prior to donning full PPE before re-entering room [ROOM NUMBER]. The 1 West manager, LPN D was interviewed and queried regarding PPE requirements for the non-observation units in the facility. LPN D indicated that a KN95 mask and eye protection were required. When queried regarding recent COVID-19 positive cases in the facility, LPN D stated, Positives in the facility recently have not been on the [observation] unit, they have come from elsewhere. On 5/17/21 at 11:15 AM, scheduled COVID-19 testing for facility staff was observed. LPN D was conducting the testing. It was noted that LPN D did not have a roster list of staff and was queried how did she know, she had tested everyone working in the building. LPN D stated, Tally everyone up at the end of the day. At 11:19 AM, LPN D conducted a COVID-19 test via nasal swab for LPN O. LPN D set the test down on top of a sheet with LPN O's name and the date. It was noted that the time the swab was collected was not written down, nor was there a visible timer running or clock nearby. When queried regarding how she would know when 15 minutes had passed for the result of the COVID-19 test, LPN D stated, Oh, I had my phone out. I put it away .I should have a timer going. On 5/17/21 at 2:00 PM, R603 was interviewed in their room and queried regarding recently testing positive for COVID-19. R603 stated, I had a cold. I was stuffed up. My memory wasn't too good. When queried regarding where they thought they had become infected with COVID-19, R603 stated, I don't know baby, I ain't go nowhere unless I got it from PACE (Program of All-Inclusive Care for the Elderly). I go there every once in a while. R603 was queried as to the last time they had been at PACE before they got sick, however, R603 could not remember when they had gone last. On 5/18/21 at 11:50 AM, RN J was contacted via phone but did not answer. A voicemail was left for callback, however a call back was not received prior to survey exit. On 5/18/21 at 12:07 PM, 1:19 PM, and 2:15 PM, the DON was interviewed and queried regarding LPN A and where she normally worked in the facility. The DON indicated that LPN A normally worked on the 1 East unit. The DON was then asked to provide information as to when LPN A had last worked on the 1 East unit. The DON provided information showing that LPN A had worked on the 1 East unit on 4/7/21 and 4/8/21 prior to testing positive for COVID-19. The DON was queried as to what guidance the facility used related to staff COVID-19 testing as well as guidance for staff who are sick or test positive for COVID-19. The DON indicated the facility followed guidance from the Centers for Disease Control and Prevention (CDC). When queried regarding which residents on the 2 West unit LPN A passed medications to on 4/12/21, the DON stated, [LPN A] would've passed medications on all 35 residents on 2 West and were also swabbed (tested for COVID) by that nurse. The DON provided sheets with COVID-19 test results for all the residents on the 2 West unit on 4/12/21. All the sheets were signed by LPN A. The DON stated that she was, Under the impression that [LPN A] had gone home .If you find out you're positive of course you should go home. The DON was not sure when LPN A swabbed the residents on 2 West and stated, [Not sure] if it was before or after she found out she was positive. On 5/18/21 at 1:30 PM, the 2 West unit manager, LPN E, was interviewed and queried if she had been working on the unit, on 4/12/21 when LPN A was there. LPN E stated, My very first day at the facility was 4/12/21, I was downstairs with [LPN D] and I wasn't on the floor. Boxes of COVID-19 tests were observed in the 2 West charting room. LPN E was queried regarding testing on the unit. LPN E indicated that 2 West nurses are responsible for testing the residents for COVID on the unit every Wednesday. When queried regarding the unit being tested on [DATE], which was a Monday, LPN E indicated that the testing was not routine for residents that day but was a routine testing day for staff. On 5/18/21 at 1:38 PM, LPN B was contacted via phone but did not answer. A voicemail was left for callback however, a call back was not received prior to survey exit. On 5/18/21 at 2:20 PM, LPN C was interviewed via phone. LPN C was noted to be the midnight shift nurse who relieved LPN A on 4/12/21. LPN C stated that she remembered relieving LPN A on 4/12/21 on the 2 West unit, after arriving at 7 PM. LPN C stated, [LPN A] normally works on 1 East. LPN C was then asked if LPN A had mentioned anything about feeling sick, or if she had been made aware there had been a positive COVID test in the facility to which LPN C responded, I noticed [LPN A] had a cold. I noticed it because her voice was kind of .you know. I heard her coughing just slightly I asked if she was okay, she said she was fine. She had been doing some COVID testing to our residents. LPN C indicated that LPN A had on goggles and a mask when she saw her, and that LPN A was the only nurse working on the unit for the day shift. When asked if she remembered seeing the infection control nurse (LPN B) on 4/12/21, LPN C stated, No. On 5/18/21 at 2:40 PM, LPN N was observed sitting at the 1 East nurse station. LPN N's mask was observed to be completely off of his face and sitting on the desk. LPN N was observed to be wearing no eye protection. LPN N was seated at the desk in close proximity to two other unidentified female staff members. On 5/18/21 at 3:07 PM, LPN N was again noted to be sitting at the 1 East nurse station. LPN N's mask was observed to be pulled under his chin and was not covering his nose nor mouth. Two unidentified female staff remained in close proximity to LPN N at the desk. LPN N was asked if they normally took their mask off at the nurse station to which they replied, No, I do not. I normally always have it pulled up. LPN N then pulled their mask up over their nose and mouth and put on eye protection. A review of the facility's policy/procedure titled, Testing Requirements for Staff and Residents, revised 9/30/20, revealed, Decision Making Algorithm: Does the resident or healthcare personnel (HCP) have symptoms consistent with COVID-19? Symptomatic -> POC [MEDICATION(S)] Test -> Positive: No confirmatory test needed. Isolate/exclude from work . Asymptomatic -> Facility with an outbreak (Resident and HCP serial testing) -> POC [MEDICATION(S)] testing every 3-7 days -> Positive: No confirmatory test needed. Isolate/exclude from work .Facility without an outbreak (HCP serial screening testing) -> HCP POC [MEDICATION(S)] screening interval per CMS requirements -> Positive: Especially in low incidence counties, consider performing confirmatory RT-PCR test within 48 hrs. Exclude from work, pending confirmatory test . The Immediate Jeopardy (IJ) began on 4/12/21 and was identified on 5/18/21. The Nursing Home Administrator (NHA) was notified of the IJ on 5/18/21 and was asked for a plan to remove the immediacy. The IJ was removed on 5/18/21, based on the facility's implementation of the removal plan as verified onsite on 5/19/21. Removal Plan: Element 1 Staff member was off of work for the required period of time and returned to work on 4/26/21. The Infection Preventionist is no longer employed by the (name of facility). (Name of facility) Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (Covid 19) is in place and available in the Covid Resource Manual. The DON who is the acting Infection Preventionist has been educated in regards to testing requirements and isolation/quarantine requirements to include: All staff are tested weekly per county positivity rates and with any covid related symptoms. All residents are tested weekly per CDC guidelines and prn (as needed) with any covid related symptoms. Rapid tests are performed and with any positive test, a PCR (Polymerase Chain Reaction) is required for confirmation. All interventions will immediately be initiated based on the positive rapid test. Residents will be isolated (both positive and exposed) per CDC and local Health Department recommendations. Any staff member will be escorted to an isolated area and will remain at the facility only if the laboratory can arrive within 1-2 hours to obtain the required specimen for the PCR testing and will be sent home immediately after. If the laboratory is unable to arrive within 1-2 hours, the staff will be instructed to obtain a PCR from an outside source asap. Staff will not be able to return to work without appropriate negative results. If the positive test is confirmed via PCR, the staff member will not be allowed to return to work before the 10 day recommended period and must have a release to work signed be a physician if symptoms persist past the 10 days. Element 2 Residents who reside in the facility as well as staff have the potential to be affected. Staff and residents have the potential to be impacted by failure to follow current guidance on covid testing and subsequent isolation/quarantine with positive results. Residents and staff have the potential to be impacted by failure to adequately isolate/quarantine covid positive staff or residents. Any staff member will be escorted to an isolated area and will remain at the facility only if the laboratory can arrive within 1-2 hours to obtain the required specimen for the PCR testing and will be sent home immediately after. If the laboratory is unable to arrive within 1-2 hours, the staff will be instructed to obtain a PCR from an outside source asap. Staff will not be able to return to work without appropriate negative results. If the positive test is confirmed via PCR, the staff member will not be allowed to return to work before the 10 day recommended period and must have a release to work signed be a physician if symptoms persist past the 10 days. Element 3 DON/acting Infection Preventionist was educated by Administrator on proper quarantine/isolation of covid positive residents/staff. Facility COVID policy remains in place. Element 4 The Infection Control nurse or /designee will oversee all covid testing for all staff and residents to ensure compliance is maintained. Administrator or designee will audit test results weekly for a period of 4 weeks, then monthly for a period of 2 months to ensure compliance and audit results will be reported to QAPI. Element 5 Date of Abatement 5/18/21 Although the immediacy was removed, the facility's deficient practice remained as a pattern, actual harm that was not immediate jeopardy.

Based on interview and record review, the facility failed to implement effective person-centered interventions pertaining to nutritional status for two sampled residents (R500 and R502) of two residents reviewed for nutrition, resulting in both residents experiencing severe weight loss. Findings include: This citation pertains to intake numbers 3 and 3. R500 On 3/30/21 at 9:15 AM, A review of a written document received from confidential family member C indicated the following, .states staff members were not properly caring for the resident, specifically, assisting them with feeding .states they observed during several window visits food trays sitting in front of resident untouched .states because resident was not being helped they were not eating and ultimately became weaker and weaker .was told by staff the resident needed to be taken out because they were no longer eating. On 3/30/21 at 10:30 AM, confidential family member C was contacted by phone and interviewed about R500's nutrition while at the facility. Confidential family member C responded, Me and my brother would visit the resident through the window and they would have a full plate of food in front of them and no one would be helping them eat. Then they would take the tray away. They got weak when they were there. Confidential family member C was queried on, if anyone from the facility contacted them to discuss R500's food preferences with them. Confidential family member C stated, No one ever called me at all. I would try and call there and no one would answer the phone. On 3/30/21 at 10:48 AM, A review of R500's electronic health (EHR) record revealed the following, R500 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R500 was discharged from the facility on 1/1/21. R500's minimum data set assessment (MDS) dated [DATE], indicated that the resident had moderately impaired cognition and required one person physical assist with eating. On 3/30/21 at 11:15 AM, a review of R500's weights while at the facility revealed the following in pounds, 12/7: 115.4; 12/8: 115.4; 12/10: 115.7; 12/14: 116.4; 12/28: 96.4; 12/29: 100. On 3/30/21 at 11:34 AM a review of dietary progress notes in R500's EHR stated the following, 12/30/2020 08:36 *Weight Change Note Note Text: Weight loss confirmed per re-weight 12/29: 100#, BMI=17.7. Hi Cal increased to TID (three times a day). Will continue to monitor resident as needed. 12/29/2020 09:13 *Weight Change Note Note Text: WEIGHT WARNING: Value: 96.0 Vital Date: 2020-12-28 12:53:33.0 -5.0% change [ 16.8% , 19.4 ] -3.0% change over 30 day(s) [ 16.8% , 19.4 ] -7.5% change [ 16.8% , 19.4 ] -10.0% change [ 16.8% , 19.4 ] Question significance of weight loss over ~2 weeks. Re-weight has been requested. The resident is receiving a low fat/low cholesterol/NAS diet with mechanical soft texture and thin liquids. Recent reported intakes have been variable, mostly 26-100% per FAR. Hi Cal 120 cc ordered BID (twice a day) to promote weight gain. Will increased to TID at this time due to possible weight loss. Will f/u (follow up) when reweight obtained. C/P (care plan) updated. 12/9/2020 12:42 *Comprehensive Nutrition Assessment Food/Nutrition-Related History: Reason for evaluation is initial. The resident has a Diet. Diet is: No Added Salt (NAS). Diet is: Low fat/Low Cholesterol. Texture is: Mechanical Soft. Liquids are: Thin.Resident interviewed on Preferences & Dislikes. Food preferences: obtained. Food dislikes: obtained. Although R500 had been discharged from the facility on 1/1/21, on 3/30/21 at 11:45 AM a plan of care was discovered to had been created for R500 dated 3/30/21, which reflected the following: Focus, .has increased nutrient needs related to underweight status as evidenced by BMI (body mass index) < 23. Date Initiated: 3/30/21. Goal, Resident will consume an average of at least 75% of food .at meals. Date Initiated: 03/30/2021 Target Date: 01/06/2021. Resident will consume adequate energy to gain weight towards BMI > 23. Date Initiated: 03/30/2021 Target Date: 01/06/2021. Interventions, Allow resident sufficient time to eat. Date Initiated: 03/30/2021. Evaluate any weight changes, determine percentage changed, and follow facility protocol. Date Initiated: 03/30/2021. Obtain and document weights per MD orders and facility protocol. Date Initiated: 03/30/2021. Monitor/record/report to MD prn (as needed) s/sx (signs/symptoms) of malnutrition, emaciation, muscle wasting, significant weight loss: 3 lbs (pounds) in 1 week,>5% in 1 month>7.75% in 3 months>10% in 6 months. Date Initiated: 03/30/2021. Provide and serve supplement as ordered HiCal 120 cc (cubic centimeters). Date Initiated: 03/30/2021. On 3/30/21 at 12:21 PM, a review of R500's MAR (meal acceptance record) for 12/8/20-1/1/21 revealed the following: resident ate 26% - 50% of their breakfast on 12/22/20, 12/23/20, and 12/29/20. Resident ate 26% - 50% of their lunch on 12/22/20 and 12/31/20. Resident ate 26% -50% of their dinner on 12/17/20, 12/18/20, 12/21/20, 12/29/20, and 12/31/20. On 3/31/21 at 9:49 AM, Registered Dietician (RD) A was queried regarding R500's fifteen pound weight loss while at the facility. RD A indicated that they question the accuracy of R500's weights. We gave her supplements three times daily. RD A was queried on if they worked full time as the RD at this facility. RD A stated, No I float between two facilities. RD A was queried on if residents are allowed to eat and socialize together in a dinning area at the facility. RD A stated, No all residents eat in their rooms. On 3/31/21 at 10:45 AM, the Director of Nursing (DON) was queried on their expectations for ensuring that residents receive proper nutrition. The DON stated, I expect nursing and dietary to speak with the residents regarding their likes and dislikes, reach out to family to discuss the resident's food preferences. It's really important to reach out to the resident's family. One to one assistance and supplements should be provided to residents as needed. R502 On 3/30/21 at 9:30 AM, A review of a written document received from confidential family member B indicated the following, During 3 months .[resident] went from 150 pounds to 112 pounds. [Resident] was taken out of [facility] on 6/30/20 .resident was taken to [hospital] to be evaluated, doctor indicated that [resident] was suffering from malnutrition. On 3/30/21 at 11:09 AM, confidential family member B was spoken to by phone and queried about R502's nutrition while at the facility. Confidential family member B stated, They lost forty pounds while at the facility. No one told us anything. We called the facility multiple times to check on them, they told us everything was fine. We visited through the window, they looked thinner and we observed an untouched food tray. On 3/30/21 at 12:40 PM, A review of R502's electronic health (EHR) record revealed the following, R502 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R502 was discharged from the facility on 6/30/20. R502's minimum data set assessment (MDS) dated [DATE], indicated that the resident had a moderately impaired cognition and required one person physical assist with eating. On 3/30/21 at 12:45 PM, a review of R502's weights from when they were readmitted to the facility on [DATE], revealed the following, 3/13/20: 154; 4/6/20: 152; 5/6/20: 118; 6/8/20: 121.6. On 3/30/21 at 1:34 PM a review of dietary progress notes in R502's EHR stated the following, 5/18/2020 11:02 *Quarterly Nutrition Assessment Food/Nutrition-Related History: The resident has a Diet. Diet is: No Added Salt (NAS). Diet is: Low fat/Low Cholesterol. Texture is Mechanical Soft. Liquids are: Nectar Thick. Resident interviewed on Preferences & Dislikes. Food preferences: updated. Food dislikes: updated. On 3/30/21 at 1:40 PM the following order was reviewed in R502's EHR which was dated 5/18/20 and indicated the following, Magic Cup Dessert, one time a day for variable po (by mouth) intake with lunch. On 3/30/21 at 2:00 pm R502's nutrition care plan was reviewed and revealed the following, Focus, Difficulty swallowing related to Dysphagia as evidenced by mechanically altered diet. Date Initiated: 03/31/2021. Goal, Resident will consume adequate energy to maintain weight at 131 +/- 5% Date Initiated: 03/31/2021 Target Date: 03/13/2020. Resident will consume an average of at least (76-100)% of food .at meals Date Initiated: 03/31/2021 Target Date: 03/13/20. Interventions, Allow resident sufficient time to eat Date Initiated: 03/31/2021. Evaluate any weight changes. Determine percentage changed and follow facility protocol for weight change Date Initiated: 03/31/2021. Obtain and document weights per MD orders and facility protocol Date Initiated: 03/31/2021. Provide feeding/dinning assistance as needed .Date Initiated: 03/31/2021. Provide and serve supplements as ordered magic cup Date Initiated: 03/31/2021. Provide and serve diet as ordered. Monitor intake and record q (every) meal Date Initiated: 03/31/2021. On 3/30/21 at 2:23 PM, a review of R502's MAR (meal acceptance record) for 3/13/20-5/31/20 revealed the following: During the month of March R502 ate 26%-50% of their dinner on 3/24, 3/26, 3/27, and 3/28. During the month of April R502 ate 26%-50% of their breakfast on 4/18, 4/19, 4/20, and 4/27. They ate 26%-50% of their lunch on, 4/18, 4/19, 4/20, and 4/25. They ate 26%-50% of their dinner on , 4/1, 4/2, 4/7, 4/9, 4/10, 4/14, 4/15, 4/17, 4/18, 4/19, 4/20, 4/22, 4/28, and 4/29. During the month of May R502 ate 0%-25% of their breakfast on 5/20 and dinner on 5/7, and 5/26. They ate 26%-50% of their breakfast on 5/1, 5/7, 5/9, 5/10, 5/19, 5/22, 5/25, and 5/29. They ate 26%-50% of their lunch on 5/1, 5/7, 5/19, 5/20, 5/25, and 5/29. They ate 26%-50% of their dinner on 5/1, 5/3, 5/5, 5/8, 5/12, 5/13, 5/14, 5/15, and 5/27. On 3/31/21 at 9:45 AM, RD A was queried about the 32 pound weight loss of R502 while at the facility. RD A stated, The resident was started on a magic cup supplement on 5/18/20 and had a weight gain. I question the accuracy of the resident weights. On 3/31/21 at 10:05 AM a facility policy titled Nutritional Status Management Revised: 4.2.2018 stated the following, Purpose: It is the practice, in accordance with advanced directives to provide interventions to maintain, improve and respond to nutritional needs. Measures will be taken to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balances, unless the residents clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The facility will both evaluate and record meal intake and document within the medical record. The interdisciplinary team together with the resident and / or resident representative will identify, evaluate risk factors and individualize interventions to meet the nutritional needs of the residents and determine through monitoring of health status the effectiveness. 6. Development and Implementation of individualized interventions based on interdisciplinary evaluations, resident and / or resident representative goals to promote the highest level of function and dignity .7. Dietician consultation should follow: Modify, with the interdisciplinary team, including the resident and resident representative the plan of care with interventions to address risk factors and restore desired weight goals. 8. Care planning: Must address, to the extent possible, identified causes of impaired nutritional status, reflect the resident personal goals, preferences and identify specific interventions, timeframes and parameters for monitoring. The resident and / or resident representative involvement to ensure goals and preferences.

Based on observation, interview, and record review, the facility failed to properly maintain infection control practices during a COVID-19 (a contagious respiratory infection) Infection Control Survey, by not providing proper isolation (Resident #703, whom was tested positive for COVID-19, was sharing a room with Resident #704, a known negative), not donning and doffing Personal Protective Equipment (PPE) per standards of practice, not screening visitors appropriately, and not placing a resident (Resident #706) in isolation when first presented with COVID-19 signs and symptoms, and not designating a COVID-19 Unit for three of six residents reviewed for infection, resulting in the likelihood of serous illness or death from the spread of COVID-19 to staff and/or other residents. Findings include: The Immediate Jeopardy (IJ) started on 7/14/2020 and was identified on 7/14/2020. The Administrator was notified of the Immediate Jeopardy on 7/14/2020 at 2:00 PM and was asked for a plan to remove the immediacy. The IJ was removed on 7/14/2020, based on the facility's implementation of the removal plan as verified onsite on 7/15/2020. Although the immediacy was removed, the facility's deficient practice was not corrected and remained with actual harm that is not immediate jeopardy. On 7/14/2020 at 8:44 AM, upon entering the facility, Receptionist C was behind a desk and took the temperature of this Surveyor. The Receptionist then explained to put on a gown and a mask and to proceed to the resident care areas. There were no other screening questions asked. Upon entering the resident care areas, this Surveyor was greeted by the Director of Nursing (DON). The DON explained that the Administrator was out of town. The DON also explained that the Infection Control Preventionist had resigned last week without notice and that she was doing the job now and trying to figure out what they did. With further inquiry, the DON explained that there were two residents that were tested positive for COVID-19 and that they (the facility) no longer had a COVID-19 designated unit. The DON stated that one resident was admitted from the hospital with COVID-19, was in a private room, and the other resident (#703) was asymptomatic but tested positive and was in-house acquired. The DON was asked if Resident #703 was in a private room, the DON stated, No. When asked if the roommate (Resident #704) had been tested , the DON said the roommate was negative. When queried why a positive resident was in with a negative resident, the DON stated, They just kept the resident in their own room and isolated both of them. During the initial tour of the facility, there were several empty, unused, clean resident rooms available. On 7/14/2020 at 11:40 AM, Resident #703 was observed in their room with the door wide open. The window inside the room was open about six inches. Resident #703's roommate was in bed one (closest to the door) and Resident #703 was by the window. Licensed Practical Nurse (LPN) B was observed in the room talking to Resident #703 at their bedside wearing a gown, gloves, face mask and face shield. Once LPN B was done talking to Resident #703, she walked over and spoke with Resident #704 at the bedside with the same PPE on. Then, LPN B exited the room and left the door open. LPN Bproceeded to remove her gloves and performed hand hygiene at her medication cart. LPN B then proceeded to pass medications and enter in and out of other resident rooms (that were COVID-19 negative) without changing her gown or PPE. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #703 had an intact cognition and was most recently admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A record review of the COVID-19 test results for Resident #703 revealed positive results on 7/10/2020. A record review of the Care Plan for Resident #703 revealed no COVID-19 related care plan had been created. At 7/14/2020 at 1:00 PM, the DON was asked again why Resident #703 was placed in a room with a resident that had been tested negative and stated, We did not move (Resident #703) because we believe it's a false negative, they are asymptomatic, we put them both in isolation. The DON was queried if she was able to identify the root cause of the in-house acquired COVID-19 infection (Resident #703) and stated, I have no idea. At 7/14/2020 at 1:15 PM, LPN B was queried on what PPE should be worn when entering Resident #703's room. LPN B explained to wear a gown, gloves, mask and shield. LPN B was asked if gowns should be changed after they exit Resident #703's room and stated, Yes. LPN B was asked to show this Surveyor where a gown could be obtained and then walked over to the PPE caddy hanging on the outside of the door. LPN B then began rifling though the items on the door and began unraveling rolled up blue plastic gowns and stated, Oh, yes, I guess these are gowns. When queried if she was supposed to wear the disposable gown when entering Resident #703's room, like she did earlier, LPN B did not answer. At 7/14/2020 at 1:30 PM, Resident #703's room door was wide open. The Resident was awake in bed. Alert and oriented with clear speech. Resident #703 denied any signs or symptoms. When questioned about having COVID-19, Resident #703 stated, It's not my fault! If the staff would keep their hands off my damn body! Resident #704 was in their bed as well and was queried if they had the COVID-19 infection and stated, No way! A record review of the MDS dated [DATE] revealed that Resident #704 was most recently admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #704 was cognitively intact. A record review of the COVID-19 test results for Resident #704 revealed the a negative test result on 5/7/2020 and 6/29/2020. On 7/15/2020 at 8:30 AM, upon arrival into the facility, Receptionist C again, took this Surveyor's temperature and then advised to put on a gown and new mask upon entering the resident care area. Approximately 20 minutes later, Receptionist C approached this Surveyor to fill out the COVID-19 specific screening questions. Receptionist C stated, I forgot to have you fill this out. The visitor log had one other entry listed that also did not have the entire screening filled out. On 7/16/2020 at 9:38 AM, Resident #703 was observed to be moved in a newly designated COVID-19 unit with a new roommate. Unit Manager D was present in the hallway. Unit Manager D was queried on the placement of Resident #703 and stated, (Resident #703) was moved down here (Person Under Investigation/PUI Unit) yesterday. Unit Manager D was asked about the current roommate that was now sharing a room with Resident #703 and stated, The roommate is also positive, that test came back yesterday. While on the PUI Unit, there was another room that also had two residents in it. Per Unit manager D, the other room contained the resident that was admitted positive from the hospital and a newly in-house acquired positive resident (#706), bringing the total of four COVID-19 positive residents. Resident #706's door was open. Resident #706 was resting in bed with their eyes closed. Resident #706 was very thin and frail. A record review of Resident #706's MDS assessment dated [DATE] revealed that the Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].#706 had a mild cognitive impairment. A record review of the Progress Notes for Resident #706 revealed the following: 7/8/2020 19:02 (7:02 PM) .(nurses note) .Resident retested for COVID -19 today 7/10/2020 09:45 (AM) .(nurses note) .Residents temp is 101.3. Unit manager notified, fan as taken in the room CNA (Certified Nursing Assistant) applied cool towels to residents body. PRN (as needed) Tylenol was administered. will continue to monitor. 7/10/2020 10:50 (AM) .(nurses note) .Resident had nosebleed x 2. Writer applied pressure and stopped the bleeding. Vitals are stable Temp (temperature) is 101.3. A record review of the physician orders revealed that Resident #706 was not placed in isolation until 7/14/2020, after they tested positive for COVID-19. On 7/15/2020 at 10:10 AM, the DON was questioned about Resident #706 having a fever on 7/10/2020 and not being placed in isolation as a PUI and stated, Our air conditioner was broke then too, so we thought maybe it was that. The DON was queried in regard to not having a PUI or COVID Unit but having positive residents and stated, We had a unit but we got rid of it when the last resident graduated from the unit, that was in June sometime. The DON was asked about the two newly diagnosed in-house residents from yesterday, if their was a determination of how the infection may have spread, the DON did not have an answer. The DON was asked if any staff were tested positive for COVID-19 and stated, Yes, we have a list of them off, they stay off for 14 days. The DON was asked how many staff members were currently out with the infection and stated, I am not sure. The Administrator was not available for interview by the end of the survey. A review of the facility policy titled Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronaries (COVID-19) revised 4/6/2020 revealed the following: Prior to admission, identify during the preadmission process if resident is exhibiting symptoms of any respiratory infection (i.e. cough, fever, shortness of breath, etc.) to determine appropriate placement. The facility will admit residents from hospitals where a case of COVID-19 was/is present. If possible,dedicate a unit/wing for any residents admitted or readmitted from the hospital. The resident(s)will remain on the wing for 14 days with no symptoms. A resident with known or suspected COVID-19, immediate infection prevention and control measures will be put into place. Symptoms may vary in severity. If symptoms are mild and do not require transfer to the hospital. Place resident on both contact and droplet precautions. Full PPE should be worn per CDC (Centers for Disease Control) guidelines of the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE If possible, the facility will dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usual on short-term rehab unit or returning to long-stay original room). F880 Abatement Plan Element 1 Resident 703 moved to a space within the facility dedicated to care for residents with COVID 19. (a group of rooms at the end of the unit that will be used to co-hort COVID19) Resident 704 will remain in a single room. Nurse immediately educated on guidance on proper PPE use- nurse completed return demonstration and feedback regarding education provided. Villa Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus ( Covid 19) is in place and available in the Covid Resource Manual. Receptionist was educated on the need to not only assess temperature and instruct regarding hand washing, but to also complete symptom screening of all visitors. One other resident resides in the facility with a positive Covid 19 status. He was moved to a space within the facility dedicated to care for residents with Covid 19. Element 2 Residents who reside in the facility have the potential to be affected. All current residents COVID status were reviewed and are properly co-horted together. Staff and residents have the potential to be impacted by failure to follow current guidance on PPE use when caring for Covid-19 positive residents. Residents and staff have the potential to be impacted by failure to adequately screen visitors and staff. All newly admitted residents with Covid 19 positive status will be cared for in a space within the facility dedicated to care for residents with COVID 19. (a group of rooms at the end of the unit that will be used to co-hort COVID19) Element 3 Nurse managers were educated by Regional Director of Clinical operations on proper cohorting of residents with known Covid- 19 positive status. Administrator will be educated upon her return from current leave, prior to resident contact. Staff will be in-serviced and educated on the proper PPE use. Education began immediately with all staff on duty. Staff not currently working were provided verbal education via phone. Staff will receive face to face education prior to having any resident contact. Facility COVID policy remains in place. Front desk receptionists will be in-serviced on having all visitors sign in on log. Admissions coordinators and nurse managers were educated on ensure any Covid 19 positive resident that is admitted , resides in a designated space within the facility. Administrator will be educated upon her return from current leave, prior to resident contact. Element 4 The Infection Control nurse or /designee will complete random audits of staff hand washing, 3 x per week for 4 weeks, then weekly until substantial compliance is achieved, to ensure implementation of appropriate times to use hand hygiene. Results of these observations will be provided to the QAPI committee for review and further recommendations. Element 5 Date of Abatement July 14, 2020

This citation pertains to intake MI 322 & MI 430 Based on observation, interview, and record review, the facility failed to properly transfer a resident per the resident's documented assessed needs for 1 (#801) of 2 residents reviewed for accidents, from a total sample of three, resulting in a leg fracture and pain. Findings include: On 5/2/18 at 10:20 a.m., Resident #801 was observed laying in bed watching television, during that time an interview was conducted. Resident #801 was asked if she she had a fall in (MONTH) (YEAR), Resident #801 said, They put me on this thing (sit to stand lift) that made me stand and I kept telling them not to put me on it. I told them I could not stand . I didn't fall, that lift stretched me and broke my pelvis. I was hollering, because I was in pain . I kept hollering it hurt so bad . On 5/02/18 at approximately 11:45 a.m., the clinical record for Resident #801 was reviewed and revealed that the resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated cognitive impairment and required total assistance of two persons for all activities of daily living. Further review of Resident #801's clinical record revealed the following: Progress Notes: 09/22/17 Health Status Note Text: Resident continue to cooperate with therapy. Resident is a hoyer lift with transfers due to left sided weakness from history of stroke. no c/o (complaint of) pain no s/s (signs or symptoms) of distress. Care Plan: Date initiated: 3/8/2017. Focus: Resident has actual/potential for ADL self-care performance deficit r/t (related to) left upper and lower impairments from a [MEDICAL CONDITION]. Interventions/Tasks: Resident requires extensive assistance with transfers, . requires total assist of 2 staff for transfers date initiated: 3/29/17, Transfers: Resident requires Total/Hoyer mechanical lift x (times) 2 person assist, date initiated: 9/11/17 . 11/11/17. Note Text: X-ray ordered d/t (due to) increased left leg pain. Pain med given. 11/11/17. Note Text: Resident transferred out to (local hospital) via stretcher at 12:10 for an abnormal x-ray. X-ray showed an acute femur fx (fracture) DON (Director of Nursing) was called as well as the physician, and responsible party. Radiology Report dated 11/11/17. Results: There is a fracture involving proximal femur with lateral displacement . Conclusion: Acute left femur fracture is described . 11/14/17. Late Entry: For 11/11/17 CNA (Certified Nursing Assistant) came and told writer . resident c/o pain to her left leg. Writer asked what happened. Resident said she told CNA she didn't want to shower and that they used that machine (sit to stand lift). Writer gave resident pain med for her leg pain . 11/15/17 Admission: . 3 surgical incisions present with a total of 15 staples . Nursing Evaluation date 11/15/17: A. Reason for Evaluation 1. Readmission . K. ADLs Functional Status Evaluation: Range of Motion Status, 1a. Resident has had recent hip surgery . Record review of the facility's investigation interviews: Verification of Investigation: dated 11/15/17, Resident Interview/Summary of findings or Allegation: Left Femur Fracture Summary of Findings: Investigation is based on employee interviews, resident interview, and video camera Day shift nurse (Nurse E) was interviewed via phone: She (Nurse E) stated upon entering the room, the resident stated she hurt her leg on the shower day and that they used that machine to transfer her and lowered her to the floor . The resident was able to recall the CNA and Nurse (CNA D and Nurse C) who were involved with the transfer . DON interviewed the CNA (D), CNA (F), and Nurse (C) by phone . According to interview with nurse (C) she was summoned to room with CNA (F) and CNA (D) present. She stated that the patient said, she did not want shower. The nurse stated to the patient that a shower may help her have a bowel movement and the patient agreed at that time to have a shower. The nurse stated that she noticed the sit to stand lift in the patient's room and stated to the CNA (D) that is not the lift this patient uses for transfer. CNA (D) and Nurse (C) then performed a full body lift to assist patient to shower chair and Nurse C left the room at that time . According to CNA (D) she then took the patient to the shower room, performed shower care and returned the patient to her room. Prior to assisting to the bed, the patient had a significant bowel movement while in the shower chair. In an effort to move the patient to the bed quickly to clean her up, the CNA (D) used the sit to stand which was already at the bed side for transfer. The CNA (D) proceeded to perform ADL care after transfer to bed . During the investigation, the CNA (D) was queried as to how the patient transfers and she stated she uses a hoyer lift. The CNA (D) was queried as to how the resident was transferred back to bed following the shower and the CNA (D) stated that she used the sit to stand lift to put resident back to bed. When CNA (D) was asked who assisted her, she replied no one, she did it herself. The CNA (D) was queried as to how many people are needed for a lift transfer, she replied two. The CNA (D) was queried why she sit to stand lift was used to transfer the patient back to bed and why she used the lift without assistance. The CNA (D) replied she was in a hurry to place her back to bed because the patient had a BM (bowel movement) all over . The DON called the patient daughter . it seems it may have happened during shower on Thursday, (MONTH) 9, (YEAR) . The patient stated . They were just trying to transfer me, but I told them not to use that machine, it stretched my whole body. She (Resident #801) stated that the pain started bad today but she doesn't like that machine that stretches her body and told them not to use it . She was asked if she fell or had been dropped and she stated no it happened in that machine that stretches your body . DON received confirmation from the patient that the patient believed the fracture was resulting from the transfer to bed using the sit to stand . After resident returned approximately 7:30 p.m., on (MONTH) 15, (YEAR) DON interviewed resident once again. Resident restated the events that the pain started from the machine that CNA (D) used to put her back in bed . On 5/2/18 at 2:10 p.m., during an interview, Nurse C was asked regarding Resident #801's shower day on 11/11/17. Nurse C said, I was called into the room and told that Resident #801 did not want to take a shower. I convinced her to take one and that it would help with her having a bowel movement. I noticed the sit to stand lift already in the room and told CNA D that is not the lift for her. Instead of going out to find one (hoyer), I said it would be safe to do a full body lift. I grab the upper body and CNA D grabbed the lower and put her on the shower chair. Nurse C was asked why the sit to stand lift was not the correct lift for Resident #801, Nurse C said, You have to hold on to the handles and she can not because of weakness. Nurse C was asked if Resident #801 complained of pain after the full body transfer, Nurse C said, No. I left out and continued to pass medication. Nurse C was asked if she assisted CNA D with the transfer of Resident #801 back into bed, Nurse C said, No. I was not asked for assistance. Nurse C was asked if CNA D reported how the transfer went, Nurse C said, No. CNA D did not report the transfer. Nurse C was asked if she saw Resident #801 any time after the shower, Nurse C said, No. I was done with her for that day. Nurse C continued and said, I got a phone call that Saturday (November 11, (YEAR)) and was told about the x-ray results and asked what happened, I then gave a my verbal statement to the DON. On 5/2/18 at 2:24 p.m., during a interview via phone, CNA F was asked regarding Resident #801's shower day, CNA F said, I was asked to assist with a transfer by CNA D, I don't remember if the lift was in the room before or after I got in there, but the resident refused the shower. CNA D got the Nurse (C). The resident agreed to the shower. Nurse C told us that was the wrong lift. They (CNA D and Nurse C) did a body lift and I left after the transfer. I did not help with the transfer back to bed. On 5/2/18 at 2:40 p.m., during a interview via phone, CNA D was asked regarding Resident #801's transfer status on Thursday, (MONTH) 9, (YEAR), CNA D said, Hoyer lift. CNA D was asked how was Resident #801 transfer that day for a shower, CNA D said, I called in the nurse (Nurse C) because the resident refused the shower. Nurse C came in and we did a body transfer. I took her to the shower room and gave her the shower. I brought her back to the room and told Nurse C that it was time to transfer her back to the bed. Nurse C never came. The resident had a bowel movement everywhere in the room. I used the sit to stand lift by myself to transfer her to bed and cleaned her up. On 5/2/18 at 3:14 p.m., during an interview, the DON was asked about the fracture of Resident #801's We reviewed the video and saw CNA D take Resident #801 back into the room after the shower alone. CNA D came out the room for towels and returned to the room. Then out later with the sit to stand lift. The DON continued and explained, There was not report of pain until Saturday, (MONTH) 11, (YEAR), a stat x-ray was ordered. CNA D was wrong for transferring the resident in the sit to stand and alone. On 5/2/18 at 2:32 p.m., a review of the facility's undated titled policy, Safe Patient Lifting Guideline, noted, Purpose: The safe patient lifting guidelines exists to ensure a safe working environment for resident handlers . The transfers will be designated into one of the followings: . 2 = b2 person transfer (should only be used when patient is not medically appropriate Sit to Stand or Total Lift) (Extensive Assist). SSS = Sit to Stand with Standard Sling with 2 caregivers (Extensive Assist). SSC = Sit to Stand with Carrier Sling with 2 Care caregivers (Extensive Assist). H = Total Lift Transfer (Hoyer type) with 2 caregivers (Total Assist) .

This citation pertains to intakes MI 805 and MI 960 Based on observation, interview, and record review, the facility failed to provide proper supervision to prevent an elopement incident for one resident (#501) from a total of 7 sampled residents reviewed for elopement/exit seeking behavior. Resident (#501) eloped on 3/14/17 at 4:15 p.m., from a secured keycode pad door on the dementia unit, exited out of the facility and was missing until 10:10 p.m., when returned to the facility by her family. Review of an elopement care plan, dated 3/14/17, revealed that following the elopement incident an intervention was implemented to apply an alarm alert bracelet to the resident's wrist. On 3/16/17, the nurse Unit Manager reported that Resident # 501 had removed the alarm bracelet earlier that same morning and it was found on the resident's nightstand by a Certified Nursing Assistant and a new alert bracelet was applied. The Immediate Jeopardy (IJ) was identified on 3/16/17 at 2:30 p.m., and the Administrator was asked for a plan of removal of the immediacy at 3:15 p.m., on 3/16/17. The IJ was removed on 3/20/17 at 4:37 p.m., based on the facility's implementation of the plan of removal as verified by the surveyors. Although the IJ was removed the facility's deficient practice was not corrected and remained isolated with no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Findings include: On 3/16/17 at 10:05 a.m., the Administrator and Director of Nursing (DON) was queried regarding the elopement incident involving resident #501. The Director of Nursing explained, The resident #501 arrived to the facility on [DATE], from (Sinai Grace Hospital). During the afternoon of 3/14/17, the resident exited the secured dementia unit at the same time that a visitor K was exiting the Dementia unit. The resident followed visitor K, towards the exit door stairwell of the second floor leading downstairs to an outside exit. The resident and visitor K appeared in the parking lot of the facility and as visitor K entered her vehicle, resident #501 requested directions to the bus stop. Visitor Kdirected resident (#501) to the bus stop near facility on 10 mile road. The DON further explained that she reviewed facility video footage and interviewed visitor K in determining how Resident #501 eloped. On 3/16/17 at 10:16 a.m., the DON escorted the surveyor to the secured unit located on the second floor. Resident #501 was observed ambulating, without difficulty, accompanied by Certified Nursing Assistant A, designated as a 1:1 sitter following Resident #501's return from the elopement on 3/14/17. Resident #501 appeared clean, fully dressed with tennis shoes on and wearing a red hat. Resident #501 was verbalizing and requesting to be taken home stating, My doctor said I could go home today. The DON identified interventions initiated upon Resident #501's return to the facility. The DON stated, The facility implemented the following changes: 1) created a new access code upon exiting the secured dementia unit, 2) staff are required to let visitors off unit, 3) visitors will no longer have access to our exit codes, and 4) applied a wander guard alert device to the Resident's #501 right wrist. On 3/16/17 at 10:31 a.m., the facility's surveillance video of Resident #501's elopement, dated 3/14/17 at 4:02 PM, was reviewed with the Administrator and DON. The video showed the following activities on 3/14/17 at: 4:02:00 p.m., Resident #501 was observed on video with her coat on, purse/handbag in hand, pants, and shoes on, seated in a chair in front of the nursing station, with exit door insight. Two nurses, LPN B and the facility's Nurse Practitioner (NP) Z sat at the nursing station with an unobstructed view of Resident #501. 4:03:42 p.m., Resident #501 was observed watching visitor K exiting the secured dementia unit. Resident #501 gathered her purse and quickly walked through the exit door beside visitor K. 4:03:57 p.m., visitor K exited the secured unit first, then held the door open for Resident #501 to exit. Resident #501 followed visitor K out of the door. 4:04:00 p.m., Resident #501 walked with visitor K outside of the secured unit of 2 West, side by side, through the common area to the stairwell door. 4:04:31 p.m., The stairwell door was opened by the facility's dietitian and Visitor K and Resident #501 went into the stairwell together. 4:04:59 p.m. - 4:05:50 p.m., Resident #501 and visitor K exited the building together and Resident #501 was observed talking to Visitor K. (The DON and Administrator revealed when they interviewed Visitor K that the conversation that was taking place involved Resident #501 asking where the bus stop was and Visitor K directed resident #501 to the bus stop near the facility on 10 Mile Rd.) The video continues: 4:07:33 p.m., visitor K left the parking lot in her car and Resident #501 walked behind the facility to the back of the parking lot. 4:07:49 p.m., Resident #501 looked around and appeared confused. 4:09:07 p.m., Resident #501 appears on the West side of the facility, in the west driveway, ambulating independently down driveway. 4:09:51 p.m., Resident #501 appeared walking on the public sidewalk, walking toward 10 Mile Rd. 4:10:31 p.m., Resident #501 walked past the bus stop on 10 Mile Rd. and continued walking toward Hoover Rd. 4:11:06 p.m., Resident #501 walked out of the view of the surveillance camera. On 3/16/17 at 11:00 a.m., the DON and Administrator were further queried regarding the search effort for Resident #501 and reported the following: On 3/14/17 at approximately 4:15 p.m., we noticed she (Resident #501) was missing and staff members began to search for her in their own cars. In addition to staff searching for Resident #501, visitor K, whom Resident #501 had exited the facility with and the local police searched for her. Her family brought her back at 10:10 p.m. that evening, 3/14/17. On 3/16/17 at 11:30 a.m., review of Resident #501's clinical record revealed an admitted [DATE]. [DIAGNOSES REDACTED]. Review of resident #501's Minimum Data Set ((MDS) dated [DATE], did not reveal a Brief Interview for Mental Status (BIMS) score. Social Worker D provided an assessment tool, titled, BIMS (Brief Interview for Mental Status), dated 3/16/17, revealed a BIMS score of 7.0, which indicated Severe Cognitive Impairment. Further review of Resident #501's nursing care plan for elopement risk/wanderer, dated 3/13/17, documented the goal, The resident will not leave facility unattended . The care plan interventions included: - Secured Unit: dated initiated 3/13/17 - 1:1 Monitoring in place: date initiated 3/13/17 - Exit and Stairwell Alarms: date initiated 3/13/17 - Identification Bracelet: date initiated 3/13/17 - Recreational Activities: date initiated 3/13/2017 - Monitor location every 15 min in 1:1 capacity. Document wandering behavior and attempted diversional interventions: date initiated the morning of 3/14/17 On 3/16/17 at 12:48 p.m., Resident #501 was observed in her room. Resident #501 asked the surveyor, Are you here to take me home, see I'm ready. There were several stacks of folded clothing on the resident's bed. There was a wanderguard alert bracelet on the resident's right wrist. The resident was queried regarding the color of her bracelet and stated, I took this off, I put one on the nightstand this morning. I didn't want it on, so I took it off. CNA (A)stated, I gave it to the nurse. On 3/16/17 at 12:55 p.m., an interview with LPN B revealed, the events prior to resident #501's elopement on the day 3/14/17. She stated, I came in at 7:00 a.m. at the beginning of my shift. Around breakfast, resident #501 dressed her self independently, at approximately 1:00 p.m., resident #501 began walking around unit. LPN B redirected resident #501 into the activities room, where residents were watching movies and eating popcorn. LPN B observed the frequency of resident #501 requesting to leave the facility, LPN B contacted Unit Manager C and performed a wonderer assessment, then every 15 minute visual checks on resident #501 were implemented. LPN B stated, At 2:00 p.m. on 3/14/17, resident #501) remained in activities from 1:00 p.m. until approximately 2:00 p.m., resident #501 began walking up and down, pacing back and forth. LPN B stated, At 3:00 p.m., shift change, resident #501, continued walking around unit and listening to gospel music CD. At approximately 4:00 p.m., LPN B, CNA L and resident #501 walked towards the nursing station, then a CNA called LPN B into the shower room (located near the nursing station) to assist with a skin assessment. LPN B stated, I was in the shower room for no more than a minute or two, when I came out of the shower room resident #501 was no longer insight. Upon review of the surveillance video for this time frame, no staff members were observed supervising resident #501 prior to exiting unit with visitor K. On 3/16/17 at 1:25 p.m., Unit Manager C was queried regarding staffing on 3/14/17, she stated, we had two nurses, myself, LPN B, three Certified Nursing Assistants and one activity aide. Unit Manager C further queried regarding resident #501's wanderguard bracelet, she stated, During 8:00 a.m., rounds, the sitter gave me the wanderguard bracelet and said, resident #501 just took this off, then I walked into the medication room from the resident bedroom, retrieved a new wanderguard bracelet and reapplied it. Unit Manager C was further queried regarding her recollection of the recent elopement of resident #501 on 3/14/17, she stated, On 3/14/17 at 7:00 a.m., 15 minutes visual checks were initiated, because resident #501 had a restless night and wanted to go home, staff called me at home that night, stating, The new lady wants to go home, she's just walking around with her coat on. At 8:00 a.m., on 3/14/17, resident #501 still had her coat on during breakfast. At approximately 10:00 a.m., until 11:00 a.m., resident had clothing packed and coat on, we had to remove her coat at least three times, on 3/14/17, she wouldn't let anyone else remove her coat but me. Unit Manager C, stated, At approximately 4:20 p.m., I was made aware that resident #501 was missing, but staff had already begun the search. LPN B brought to my attention, before you leave, I need you to help me find resident #501. I ran looking for her, then I went to the administrators office and asked if he could play the video back, so I can see how resident #501 got off the unit. I watched the video and saw how the resident #501 exited with a family member. On 3/16/17 at 4:00 p.m. & 5:39 p.m., resident #501's Durable Power of Attorney (DPOA), daughter F was contacted via telephone, resides in Ohio, was queried regarding the elopement incident, she stated, The day after she was admitted , I called up there after lunch around 1:00 p.m. or 2:00 p.m., to see how my mother was doing and they told me that my mother wanted to leave. I talked to my mother and I told her that my brother would be up there later when he got off work around 4:30 p.m. I didn't hear anything else from them (the facility), until after my brother got there to visit my mother and the DON told my brother she couldn't be found. Daughter K further explained that the Detroit Police found her mother on 7 mile and Van Dyke. Daughter K explained that her mother told the police the address of her family home on Prevost St. in Detroit where her three brothers resided. Daughter K stated that her brother picked her mother up from the home and took her back to the nursing home. I told employee's E and G in admissions that my mother has wandered away from the group home many times. She further explained that employee G came out to do the home evaluation a week before her mother was admitted to the nursing home. I told him we needed a place that is locked for her safety, that was the purpose of being her there. The Admission Director (E), Unit Manager Cdenied any knowledge of resident #501's elopement history. On 3/20/17 at 9:44 a.m., Social Worker D was queried regarding interactions with resident #501 on 3/14/17, and she explained, I performed a BIMS (Brief Interview for Mental Status), she scored 7.0, indicating severe cognitive impairment. Resident #501 was very anxious, refused to sit, so I walked with her, she didn't want to talk to me. Social Worker D provided documents titled, BIMS, signed and dated 3/14/17 and handwritten 3/16/17 on top of page. On 3/20/17 at 10:00 a.m., the Admission Coordinator E was queried regarding knowledge of elopement history prior to admission for resident #501 into facility. Admission Coordinator E, stated, I had no prior knowledge of resident #501's elopement history, I was aware that she does have a history wandering, that's why she was a candidate for the secured unit. Family member F didn't discuss the elopement history only wandering. Admission Coordinator E stated, I provided the Unit Manager with the admission information either 3/9/17 or 3/10/17, and nursing establishes the perimeters for residents on that unit. Resident #501's original admitted was scheduled for 3/14/17 from home, however the family sent her to (proper name of hospital) with complaints of chest pain on 3/12/17, then the hospital transferred her to the facility, one day earlier than scheduled. On 3/20/17, at 10:51 a.m., Unit Manager C was queried regarding prior knowledge of resident #501's elopement history, upon admission onto the secured dementia unit on 3/13/17. She stated, No, I wasn't informed, the admission information was obtained early on 3/13/17 from E of the Admissions Department, the resident arrived later that afternoon. Admission Coordinator E said to me, take a look at this patients information packet. I looked at the medications, behaviors, no mention of elopement history or wandering activities. On 3/20/17 at 2:20 p.m., visitor K was queried regarding the elopement incident on 3/14/17, involving resident #501, she stated, As I approached the door, she (resident #501) got up and came over to the door and we left together. I didn't know she was a resident because I hadn't seen her here before and she had her purse and coat on already. When I received a call from the facility about the missing resident, I came back and searched for an hour. On 3/20/17 at 1:15 p.m., a review of the police report from the Warren Police Department, recorded date of 3/14/17 & time of 5:00 p.m., facility reported incident involving resident #501. The facility Administrator contacted Warren Police Department reporting at approximately 4:15 p.m., they noticed resident #501 was no longer on nursing unit, according to security footage resident #501 exited the secured unit at approximately 4:00 p.m., followed a guest off the unit and then exited the building via the main entrance. Upon further review of the report from Warren Police Department, On 3/14/17 at 9:30 p.m., Officer M spoke with resident 501's son N, he stated, Resident #501 was located at 7 Mile Rd. and Van Dyke Rd. in Detroit, by Detroit Police Officers. Resident's son N stated that the Detroit Police Department officers transported resident #501 to her last known address. At approximately 7:30 p.m., resident's son N found his mother (resident #501) at her previous address, where he resides, stating she seemed a little tired and out of it, but otherwise in good health. Son N brought resident #501 to Warren Police Department front desk and Officer M observed resident #501 in good health and appeared to be in the right mind. Resident #501 was returned to the facility at 10:10 p.m., per family, on 3/14/17 per facility Administrator and Director of Nursing. On 3/16/17 at 2:40 p.m., the DON reported that there were 14 residents who currently were exhibiting exit seeking/elopement behavior and stated that a wanderguard device was applied to 4 ( # 92, # 117, # 42 & # 82 ) of the 14 residents. The DON was uncertain if any of these 4 residents had exhibited behavior to remove the wanderguard device. On 3/16/17 at 4:25 p.m., a review of facility policy, titled, Wandering, Unsafe Resident, revealed Policy Statement, stated, The Facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and Implementation: (5.) Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. On 3/14/17 at approximately 10:10 p.m., upon resident #501's return to the facility, a wanderguard bracelet was applied to the residents right wrist. On the morning of 3/16/17, resident #501 removed the initial wander guard bracelet applied the previous night and a new wander guard bracelet was applied per Unit Manager, C. No documentation noted in resident #501's clinical record regarding the removal of the initial wanderguard bracelet. On 3/16/17 at 12:50 p.m., the Director of Nursing stated, I wasn't aware, she'd removed her wanderguard this morning, until earlier today. On 3/17/17 at 10:34 a.m., the facility provided the following removal plan for the immediate jeopardy regarding the failure to prevent the elopement of Resident #501 on 3/14/17. IJ removal Plan: Element #1 On 3/13/2017, Resident #501 was admitted to the facility and identified to have a history of Alzheimer's and Dementia. She was placed on the facility's secured memory care unit, which is monitored by video cameras and an Egress Locking System. On 3/14/2017 at approximately 1615 MT (military time) a visitor in the facility escorted Resident #501 out of the building unbeknownst to the staff. If was identified on 3/14/2017 at 1621, nearly 6 minutes later, that Resident #501 had left the facility accompanied by a visitor. An immediate investigation was initiated. On 3/14/2017 at 0700 it was observed by the Licensed Nurse that Resident #501 was a new resident and required frequent monitoring for a history of exit seeking behavior. She was then placed on 15 minute visual checks by the nursing staff; intervention was placed on 24 hour communication log and updated in care plan. Later that day at 1315, it was reported to the Unit Manger by the Licensed Nurse that that the Resident may benefit from a Wander Guard. The Nurse documented a note in Point Click Care to be reviewed by the Interdisciplinary Team at 1630 in daily Stand down Review Meeting. Resident #501 was escorted out of the facility 15 minutes prior to the Interdisciplinary Team meeting. The facility immediately alerted the staff of a missing resident and a pursuit party was initiated. The local Warren police department was notified, as well as the family, physician, medical director, and it was reported to the Michigan Department of Regulatory Affairs. The police successfully found Resident #501. She was taken to the Warren police department and family returned her to the facility at 2200. The Director of Nursing completed full head-to-toe comprehensive assessment to rule out harm and injury. All findings were within normal parameters. Vital Signs stable. Upon returning to the facility, Resident #501 was immediately placed on 1:1 staff observation for continuous monitoring and will remain on 1:1 observation until it is determined by the IDT that it is safe to discontinue. A Wander Guard Device was placed on the resident's right wrist; however, due to the fact that she is not compliant the Wander Guard it has been discontinued on 3/16/2017 at approximately 1630. Care plan updated to reflect modification. On 3/14/2017 at approximately 1630, the facility completed a visual check of all residents residing in the building to ensure location and safety. All residents were accounted for. Elopement binders were confirmed to be located at reception area and all four nurses' stations. Social Services is monitoring Resident #501 for any negative effects. On 3/14/2017, Resident #501 was evaluated by Senior Care Network of Michigan (Psychiatry Group). Current medications reviewed; no changes in medications were recommended at this time. As of 3/16/2017, Resident #501 remains at the facility with no negative effects from the incident. Element #2 On 3/14/2017 at approximately 1630 the video footage of the incident was reviewed by the Administrator and DON which displayed the resident exiting the front door accompanied by a visitor at 1615. The front door has a fully functioning Egress Locking System in place which is continually activated 24 hours per day 7 days per week. As a permanent and immediate intervention the passcode to the Egress Locking System was changed. The only method to exit the facility is with the assistance of a facility employees. On 3/14/2017 at approximately 1900, elopement education was initiated for all facility staff. The facility will add to the abatement plan that upon admission, staff will be educated on the plan of care particularly addressing the known indications of when staff should anticipate wandering or an elopement. For example- Resident #501 refuses to take off her coat and is asking to leave; based on known history staff should immediately place on 1:1, inform the nurse for an evaluation, and determine based on the evaluation and interdisciplinary team approach continued monitoring, intervention and appropriate supervision. All staff will be educated prior to caring for the residents until they received proper education. Employees on vacation or FMLA are to be educated prior to returning to working. Employees were educated on elopement guidelines, passcode of Egress Locking System, and updating elopement binders as soon as a resident is identified as a risk. The facility will conduct an additional elopement drill on each shift by 3/17/2017. Elopement drills are being conducted on a monthly basis. On 3/17/2017 all residents who currently reside in the facility were re-evaluated for Elopement Risk Observation using the facilities Elopement Risk Observation evaluation in Point Click Care. Residents who currently have a Wander Guard have been reviewed for episodes of removal and non-compliance. A total for four residents have been identified and do not have a history of removing their Wander Guard; the Wander Guards have been deemed an appropriate intervention and will remain in place. Care Plans were updated to reflect current status of resident who are at risk of elopement. Change of condition in MDS completed to reflect current status. Elopement books were updated to reflect current status of residents at risk for elopement confirming that the receptionist desk and four nurses' stations have up to date Elopement Binder. The nurses' aides care kardex on Point of Care reflect which of those identified residents are at risk for elopement for those 14 residents who are at risk. The 14 residents identified have been placed on 1 hour visual checks until IDT and Medical Director revise interventions. Element #3 Upon admission the Admissions Director or Designee will inform the DON or Designee that a new admission to the facility is a potential for exit seeking behaviors. Those residents identified will immediately be placed in the Elopement Binder and will be placed on a 1 hour visual check for 72 hours. New employees, employees on vacation or FMLA will be educated on the facility's elopement policy and procedures prior to working. Element #4 On 3/15/2017 an additional audit was initiated to ensure that the Wander Guard system was functioning properly and all exits had the newly changed passcode. Doors will be checked daily for two weeks and weekly there-after. Care plan audits of residents who are at risk will be audited weekly for 4 weeks, then monthly thereafter. Hourly audit check of visualization of the residents at risk for employment will be audited 3 times a week then weekly thereafter. All audits and findings will be reported and reviewed at the facility's quality review committee meetings. Element #5 The Administrator is responsible for ensuring that the POC is implemented and sustaining regulatory compliance.

This citation pertains to intakes MI 050 and MI 081 Based on interview and record review, the facility failed to provide a safe transfer with the assistance of 2 staff members, in accordance with the resident's assessment, for one (#701) of three sampled residents, all reviewed for accidents and falls, resulting in the resident sustaining a fractured ankle. Findings include: Review of the closed record for Resident #701 on 9/19/14 at 10:00 a.m., revealed that Resident #701 was readmitted into the facility on [DATE], with [DIAGNOSES REDACTED]. According to a quarterly minimum data set (MDS), dated [DATE], Resident #701 had severe cognitive impairment, and required total dependence from staff for bed mobility and transfers. Review of an Incident Report for Resident #701 dated 9/4/14, revealed the following: Description of Incident: Left ankle swollen and discolored. Description of incident by person involved: Unable to tell. X-Ray ordered: Yes Comments: "...S/P (status [REDACTED]. Resident is a 2 PA (two-person assist)...". Review of an x-ray report for Resident #701, dated 9/4/14, noted the following: Exam: Ankle AP (anteroposterior) and Lat (lateral), Left Results: There is fracture involving the distal tibia and possibly the fibula with no displacement. Review of the Nursing Daily Skilled Summary for Resident #701, dated 9/4/14 noted: "Called to room by assigned CENA. Noted L (left) ankle swollen and discolored at approximately 11 a.m. Resident c/o (complained of) pain. Pain RX (medication) given and Dr. notified. STAT x-ray ordered. Results revealed FX (fracture). Dr. notified, orders written to transfer to hospital...". Review of a falls care plan for Resident #701, initiated on 9/26/13, noted that the Resident was to have 2 PA (two-person assist) for transfers. The "Resident Status" sheet for Resident #701, also noted that the resident was to have 2 staff assist for transfers. On 9/19/14 at 9:40 a.m., Resident #701's family member ("A") was queried by telephone. Family Member "A" stated that approximately 2 weeks ago, Resident #701 was transferred to the hospital from the facility with a broken ankle. Family Member "A" stated that the administrator told the family that he thought the resident's ankle might have gotten caught during a transfer. Family Member "A" stated that Resident #701 was in a great deal of pain, and that the Resident spent over a week in the hospital. Family Member "A" stated that Resident #701 was completely bed-ridden, that she did not walk, and that she could not tell anyone what happened. Family Member "A" further stated that she had observed staff transferring Resident #701 with only one person on many occasions, even though the Resident was supposed to have 2 person assistance for all transfers. On 9/19/14 at 10:30 a.m., the Director of Nursing (DON) was queried regarding ankle fracture that Resident #701 sustained on 9/4/14. The DON stated that during the course of her investigation, it was determined that Nurse "C" had observed Resident #701 on 9/4/14 at approximately 8:15 a.m., and again at 10:30 a.m., on both occasions the Resident was in bed, and showed no evidence of distress. At approximately 11:00 a.m., CENA "D" asked Nurse "C" to look at Resident #701's ankle. At this time, Resident #701 was up in a geriatric (geri) chair, and the Left ankle was observed to be swollen and discolored. Nurse "C" immediately notified Nurse Manager "B", who then notified the DON, and an investigation was begun. The DON stated that when she queried CENA "D" about how she had transferred Resident #701 from the bed into the geri chair, CENA "D" stated that she had done the transfer by herself. When CENA "D" was asked if she had checked the transfer status of Resident #701 on the "Resident Status Sheet", she stated "No." The DON stated that because CENA "D" had not transferred Resident #701 with a 2 person assist according to her assessment, that she was terminated.

REFER TO INTAKE # MI 720 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE INTERVENTIONS TO MAINTAIN TO ONE RESIDENT (#501) OF 4 SAMPLED RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 4, RESULTING IN A FALL WITH INJURY (CLOSED HEAD INJURY AND LACERATION REQUIRING SURGICAL SUTURES TO RIGHT SCALP AND RIGHT FOREHEAD). FINDINGS INCLUDE: RESIDENT #501 WAS [AGE] years OLD, admitted to the facility on [DATE]. ACCORDING TO THE PREADMISSION SCREENING (PAS)/ANNUAL RESIDENT REVIEW (ARR) DATED 4/3/12, RESIDENT #501 HAD A [DIAGNOSES REDACTED]. RESIDENT #501'S FALL RISK ASSESSMENT, DATED 8/24/2011, INDICATED THAT RESIDENT #501 WAS AT "HIGH RISK" FOR FALLS. THE MDS (MINIMUM DATA SET) ASSESSMENT, DATED 3/27/12, DOCUMENTED THAT RESIDENT #501 REQUIRED EXTENSIVE TO TOTAL DEPENDENCE TO NURSING STAFF WITH BED MOBILITY, TRANSFERS, DRESSING, TOILET USE, BATHING AND HYGIENE. RESIDENT #501 WAS INCONTINENT OF BOTH BOWEL AND BLADDER. SECTION E (PSYCHOSIS) OF THE MDS dated [DATE] NOTED THAT RESIDENT #501 HAD DELUSIONS. SECTION C1300 OF THE MDS NOTED THAT RESIDENT #501 WAS INATTENTIVE, (EASILY DISTRACTED, OUT OF TOUCH, DIFFICULTY FOLLOWING WHAT WAS SAID) AND HAD DISORGANIZED THOUGHTS OR WAS INCOHERENT. AN INCIDENT REPORT, DATED 4/16/12 AT 7:30 AM, DESCRIBED RESIDENT #501 AS LYING ON HER LEFT SIDE CRYING OUT, "I'M HURT" WITH A LACERATION TO HER FOREHEAD AND THE TOP OF HER HEAD. THE INCIDENT REPORT FURTHER NOTED THE ASSESSMENT OF THE LACERATION AS A 2 CENTIMETERS (CM) L SHAPED LACERATION ON THE FOREHEAD AND 1.5 CM ON THE TOP OF THE HEAD. THE INCIDENT OCCURRED IN THE RESIDENT'S ROOM AND WAS NOT WITNESSED BY ANYONE. LICENSED PRACTICAL NURSE (LPN) #4 WAS INTERVIEWED ON 5/11/12 AT 10:35 AM. NURSE #4 STATED THAT ON 4/14/12, WHILE SHE (#4) WAS DOING HER MORNING ROUNDS, SHE ENTERED RESIDENT #501'S ROOM AND FOUND RESIDENT #501 YELLING, BECAUSE SHE (#501) WANTED TO GET UP, GET DRESSED AND GET UP INTO THE WHEELCHAIR. NURSE #4 LEFT THE ROOM AFTER ASSURING RESIDENT #501 THAT SHE (#4) WOULD LET HER (#501) AIDE KNOW OF HER REQUEST. RESIDENT #501 SAID "OKAY." AS NURSE #4 REACHED THE NURSE STATION, SHE HEARD A LOUD NOISE FROM RESIDENT #501'S ROOM. RESIDENT #501 WAS FOUND ON THE FLOOR WITH THE LACERATION TO HER FOREHEAD. NURSE #4 ASSESSED RESIDENT #501 IMMEDIATELY AND APPLIED FIRST AIDE TO BLEEDING FROM THE HEAD LACERATIONS. NURSE #4 STATED THAT SHE (#4) DID NOT SECURE A CALL LIGHT FOR RESIDENT #501 BECAUSE RESIDENT #501 WAS KNOWN TO NOT BE ABLE TO OPERATE THE CALL LIGHT DUE TO HER DEMENTIA. SHE (#501) DID NOT HAVE A BED ALARM AND SHE DID NOT HAVE FLOOR MAT IN USE AS FALL INTERVENTIONS. NURSE #4 AGREED THAT RESIDENT #501 WAS AT HIGH RISK FOR FALLS, CONSIDERING THAT SHE WAS [AGE] years OF AGE WITH DEMENTIA. ACCORDING TO NURSE AIDE #3, INTERVIEWED ON 5/11/12 AT 9:20 AM, SHE (#3) GOT HER ASSIGNMENT AT ABOUT 7:10 AM ON 4/16/12 AND GOT STARTED AT AROUND 7:20 AM. NURSE AIDE #3 STATED THAT SHE WAS ASSIGNED TO CARE FOR RESIDENT #501. NURSE AIDE #3 RECALLED THAT SHE IMMEDIATELY WENT DOWNSTAIRS TO THE LAUNDRY TO GET HER LINENS. NURSE AIDE #3 admitted THAT SHE STARTED HER SHIFT AT 7:00 AM, BUT DID NOT GO TO CHECK ON HER ASSIGNED RESIDENTS AFTER GETTING THE ASSIGNMENT. INSTEAD SHE (#3) WENT DOWNSTAIRS TO GET HER LINEN FOR THE DAY. ACCORDING TO NURSE AIDE #3, LINENS WERE NOT READILY AVAILABLE ON THE FLOOR WHEN SHE CAME IN. NURSE AIDE #3 STATED, "I NEVER SAW HER (#501) OR CHECKED HER BEFORE I WENT TO GET MY LINEN. WHEN I RETURNED BACK ON THE FLOOR, (RESIDENT #501) WAS ALREADY ON THE FLOOR BLEEDING FROM HER FOREHEAD." NURSE AIDE #3 ADDED THAT RESIDENT #501 WAS KNOWN TO ATTEMPT TO SELF-TRANSFER FROM BED TO THE WHEELCHAIR. SHE RECALLED, "(RESIDENT #501) SOMETIMES WILL SIT ON THE SIDE OF THE BED OR MOVE BY HERSELF IN BED." NURSE AIDE #3 DENIED HAVING ANY INTERACTION WITH RESIDENT #501 BEFORE THE RESIDENT fell . ACCORDING TO THE NURSE MANAGER ON 5/11/12 AT 10:25 AM, RESIDENT #501'S BED ALARM WAS DISCONTINUED IN DECEMBER 2011 BECAUSE THE RESIDENT HAD NOT FALLEN SINCE APRIL 2011. THE NURSE MANAGER WROTE IN THE NURSE'S NOTES (DATE WAS NOT LEGIBLE, BUT WRITTEN IN 2012) "SAFETY PREVENTION: BECAUSE THE ALARM DOES MAKE HER (RESIDENT #501) MAD IN THE BED WITH THE NOISE, WE WILL DISCONTINUE THE ALARM AT THIS TIME. THE REASON FOR ALARMS IS NO LONGER IN PLACE. THERE HAVE BEEN NO FALLS SINCE 4/2011." ACCORDING TO THE DON (DIRECTOR OF NURSING) INTERVIEWED ON 5/11/12 AT 12:30 PM, THE FACILITY'S POLICY REQUIRES A PHYSICIAN'S ORDER TO INITIATE THE BED/CHAIR ALARM AND A PHYSICIAN'S ORDER TO DISCONTINUE THE ALARM. THERE WAS NO PHYSICIAN'S ORDER FOUND IN RESIDENT #501'S CLINICAL RECORD TO DISCONTINUE THE BED OR CHAIR ALARM. THERE WERE NO PROGRESS NOTES FROM THE PHYSICIAN RECOMMENDING DISCONTINUING THE BED/CHAIR ALARM. THERE WAS NO EVIDENCE OF ANY OTHER FALL PREVENTION INTERVENTIONS (INCLUDING FALL RISK RE-ASSESSMENT) THAT HAD BEEN PUT IN PLACE TO REPLACE THE BED/CHAIR ALARM THAT WAS DISCONTINUED AT THAT TIME. ACCORDING TO RESIDENT #501'S CARE PLAN THAT ADDRESSED "HIGH RISK" FOR FALLS SELF/INJURY, REVISED 1/2/12, INTERVENTIONS TO PREVENT FALLS WERE: 1.) CLEAN CLUTTER FREE ENVIRONMENT; 2.) KEEP PERSONAL ITEMS/CALL LIGHT AND WATER WITHIN REACH; 3.) ASSESS RESIDENT FOR CHANGES IN FUNCTIONAL STATUS OR LOC (LEVEL OF CONSCIOUSNESS); AND, 4.) PROVIDE VERBAL AND MANUAL CUES FOR SAFETY, MONITOR SAFETY AWARENESS AND CALL LIGHT. THE NURSE AIDE CARE GUIDE FOR RESIDENT #501, ACCORDING TO THE ADON (ASSISTANT DIRECTOR OF NURSING) ON 5/11/12 AT 12:40 PM, DID NOT HAVE INTERVENTIONS OR PRECAUTIONS TO PREVENT FALLS FOR RESIDENT #501, WHO WAS AT HIGH RISK FOR FALLS. HOSPITAL RECORDS OBTAINED ON 5/18/12, REVEALED THAT ON 4/16/12, RESIDENT #501, WHO WAS [AGE] years OLD WITH DEMENTIA, WAS TREATED AT AN ACUTE CARE HOSPITAL emergency room FOR A CLOSED HEAD INJURY, WITH FOREHEAD AND SCALP LACERATIONS SECONDARY TO FALL. RESIDENT #501 UNDERWENT SURGICAL REPAIR (SUTURES) FOR THE LACERATIONS ON THE SCALP AND RIGHT FOREHEAD. RESIDENT #501 WAS discharged FROM THE emergency roiagnom on [DATE], TO ANOTHER NURSING HOME FACILITY PER THE FAMILY'S REQUEST. ( )

THIS CITATION PERTAINS TO INTAKE # MI 785. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 (#101) OF 5 RESIDENTS REVIEWED FOR THERAPEUTIC DIETS FROM A TOTAL SAMPLE OF 9 RECEIVED A THERAPEUTIC DIET THAT TOOK INTO ACCOUNT THE RESIDENT ' S CLINICAL CONDITION, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHO RECEIVED A FOOD TRAY WITH FOOD THAT WAS NOT APPROPRIATE FOR HER. RESIDENT #101 EXPERIENCED A CHOKING EPISODE AND SUBSEQUENTLY died . THE POTENTIAL REMAINS FOR SERIOUS INJURY, HARM, IMPAIRMENT OR DEATH TO ANY RESIDENT WHO REQUIRES A THERAPEUTIC DIET. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE FACE SHEET DATED [DATE], RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #101 REQUIRED SUPERVISION BY FACILITY STAFF WHEN EATING. SHE HAD SEVERAL [DIAGNOSES REDACTED]. THE RESIDENT HAD A physician's orders [REDACTED]. THE CARE PLAN DATED [DATE] IDENTIFIED RESIDENT #101'S RISK OF ASPIRATION AND LISTED SEVERAL INTERVENTIONS INCLUDING A MECHANICAL SOFT DIET AND "...MONITOR...FOR DIFFICULTY SWALLOWING, HOLDING FOOD IN MOUTH, PROLONGED SWALLOWING TIME, DROOLING, POCKETING FOOD IN MOUTH..." THE SPEECH THERAPY EVALUATION DATED [DATE], SAID THAT RESIDENT #101 SUFFERED FROM OROPHARYNGEAL DYSPHAGIA (DIFFICULTY EMPTYING MATERIAL FROM THE ORAL CAVITY INTO THE ESOPHAGUS), REDUCED MASTICATION (NOT CHEWING AS MUCH AS NORMAL) AND POCKETING (LEAVING FOODS IN THE MOUTH WHEN SWALLOWING). THE SPEECH THERAPY EVALUATION REQUIRED ASPIRATION PRECAUTIONS (MEASURES DESIGNED TO PREVENT THE DRAWING OF A FOREIGN SUBSTANCE, SUCH AS THE [MEDICAL CONDITION] CONTENTS OR FOOD, INTO THE RESPIRATORY TRACT) AND SUPERVISION TO BE IMPLEMENTED FOR RESIDENT #101. ACCORDING TO THE NURSE'S NOTES AND SPEECH THERAPY EVALUATION, DATED [DATE], RESIDENT #101 MOMENTARILY CHOKED ON SPINACH ON [DATE] AT 1:30 P.M., BUT HAD NO NEGATIVE EFFECTS. RESIDENT #101 WAS IMMEDIATELY REASSESSED BY THE SPEECH THERAPIST (SPT) #1. ACCORDING TO SPT #1'S NOTES DATED [DATE], RESIDENT #101 WAS NO LONGER SAFE TO EAT A MECHANICALLY SOFT DIET AND THE PHYSICIAN WAS CONTACTED FOR A CHANGE IN THE DIET ORDER. ACCORDING TO THE NURSE'S NOTES DATED [DATE], A physician's orders [REDACTED].M. THAT CHANGED RESIDENT #101'S DIET ORDER TO A PUREED DIET WITH NECTAR THICK LIQUIDS. WHEN SPT #1 WAS INTERVIEWED ON [DATE] AT 11:00 A.M., SHE SAID THAT HAD SHE ASSESSED RESIDENT #101 AFTER THE CHOKING EPISODE THAT OCCURRED ON [DATE], AND, THAT ACCORDING TO HER ASSESSMENT, RESIDENT #101 HAD AN INCREASED RISK FOR ASPIRATION AND WAS NO LONGER SAFE TO EAT MECHANICAL SOFT FOODS. SPT #1 SAID THAT RESIDENT #101 NEEDED HER DIET CHANGED IMMEDIATELY TO BE SAFE, SINCE SHE HAD ALREADY CHOKED ON THE MECHANICAL SOFT FOOD. SPT #1 SAID SHE SPOKE WITH THE PHYSICIAN TO OBTAIN THE ORDER FOR A PUREED DIET. SPT #1 SAID THAT SOMETIME BETWEEN 2:00 P.M. AND 2:30 P.M., SHE (SPT #1) SPOKE TO THE DIETETIC TECHNICIAN IN PERSON AND TOLD THE DIETETIC TECHNICIAN THAT THE RESIDENT #101 NEEDED TO HAVE A PUREED DIET. IN AN INTERVIEW ON [DATE] AT 2:55 P.M., LICENSED PRACTICAL NURSE (LPN) #2 SAID THAT ON [DATE] AT APPROXIMATELY 5:30 P.M. HE PICKED UP RESIDENT #101'S MEAL TRAY WITH THE TRAY ASSEMBLY TICKET FROM THE DIETARY DEPARTMENT. LPN #2 SAID THE MEAL TRAY ASSEMBLY TICKET SAID RESIDENT #101 WAS TO RECEIVE A MECHANICALLY SOFT DIET. LPN #2 SAID HE THEN PROVIDED THE MECHANICALLY SOFT MEAL TRAY TO RESIDENT #101. RESIDENT #101 WAS SITTING IN THE SECTION OF THE DINING ROOM WHERE THE INDEPENDENT EATERS SAT. LPN #2 SAID THAT HE WAS REQUIRED TO BE IN THE REGULAR SIDE OF THE DINING ROOM SUPERVISING RESIDENTS INCLUDING RESIDENT #101 DURING THE EVENING MEAL ON [DATE], BUT THAT HE LEFT THE DINING ROOM AND NO ONE WAS SUPERVISING RESIDENT #101 WHILE SHE ATE. ON [DATE] AT 10:00 A.M., CERTIFIED NURSE AIDE (CNA) #1 WAS INTERVIEWED. CNA #1 SAID THAT ON [DATE] AT APPROXIMATELY 5:36 P.M., A VISITOR TOLD CNA #1 THAT SHE BELIEVED RESIDENT #101 WAS CHOKING. CNA #1 SAID SHE WENT TO RESIDENT #101'S TABLE, SAW SHE (#101) WAS NOT BREATHING, AND THAT SHE WAS UNRESPONSIVE. CNA #1 SAID THAT SHE PUT RESIDENT #101 INTO A WHEEL CHAIR AND RAN TO THE 1-WEST NURSES' STATION. IN AN INTERVIEW ON [DATE] AT 2:55 P.M., LPN #2 SAID THAT ON [DATE], CNA #1 BROUGHT RESIDENT #101, WHO WAS SEATED IN A WHEEL CHAIR TO THE 1-WEST NURSES' STATION AND SAID THAT SHE (#101) HAD CHOKED WHILE IN THE DINING ROOM. LPN #2 SAID HE IMMEDIATELY ASSESSED RESIDENT #101 AND FOUND SHE WAS NOT CONSCIOUS OR BREATHING. RESIDENT #101 WAS TRANSPORTED TO A LOCAL HOSPITAL WHERE, ACCORDING TO THE MEDICAL RECORDS, IT WAS DETERMINED THAT THE RESIDENT HAD CHOKED ON HER FOOD AND STOPPED BREATHING. RESIDENT #101 HAD A VERY POOR PROGNOSIS WITH [DIAGNOSES REDACTED]. RESIDENT #102 expired on [DATE] AT 10:50 A.M. ON [DATE] AT 1:10 P.M. THE DIETETIC TECHNICIAN (TECH #1) WAS INTERVIEWED AND SAID A NURSE AIDE BROUGHT RESIDENT #101'S DIET CHANGE ORDER TO THE DIETARY STAFF ON [DATE], BEFORE THE DINNER TRAY WAS DELIVERED TO RESIDENT #101. TECH #1 SAID SPT #1 DELIVERED THE DIET ORDER TO HER (TECH #1) PERSONALLY, AND THE NURSE AIDE TOOK A COPY TO THE KITCHEN. BOTH OF THESE ACTIONS TOOK PLACE ON [DATE], BEFORE THE EVENING MEAL WAS SERVED. TECH #1 SAID RESIDENT #101 WAS SERVED THE WRONG FOOD AND CHOKED. ON [DATE] AT 12:35 P.M., THE FOOD SERVICES DIRECTOR (CDM #1) SAID THAT AFTER SPT #1 ASSESSED RESIDENT #101, SHE (SPT #1) CONTACTED THE PHYSICIAN AND RECEIVED A PHYSICIAN 'S ORDER TO CHANGE RESIDENT #101'S DIET TO "PUREED." CDM #1 SAID THAT RESIDENT #101 RECEIVED A MECHANICALLY SOFT DIET WITH CHOPPED MEAT FOR THE EVENING MEAL ON [DATE]. CDM #1 SAID RESIDENT #101 DID NOT RECEIVE A PUREED DIET AS ORDERED. CDM #1 SAID THAT RESIDENT #101'S DIET CHANGE WAS NOT MADE UNTIL [DATE]. ACCORDING TO FACILITY RECORDS, THE PHYSICIan order for [REDACTED].M." ON [DATE] AT 11:00 A.M., SLP #1 SAID SHE WAS SURPRISED RESIDENT #101 WAS SERVED THE WRONG FOOD, BUT "...WAS NOT SURPRISED SHE CHOKED..." SLP #1 SAID, "...THE DIET SHOULD HAVE BEEN CHANGED IMMEDIATELY..." ON [DATE] AT 1:14 P.M., RESIDENT #101'S ATTENDING PHYSICIAN (MD #1) SAID THE FACILITY CONTACTED HER RELATED TO RESIDENT #101'S DIET CHANGE. MD #1 REVIEWED RESIDENT #101'S MEDICAL RECORD AND SAID THAT THE DIET ORDER WAS CHANGED BEFORE 4:00 P.M. MD #1 SAID, "...I EXPECT ORDERS TO BE FOLLOWED IMMEDIATELY..." MD #1 SAID THAT RESIDENT #101 SHOULD HAVE GOTTEN A PUREED DIET AT THE EVENING MEAL ON [DATE]. IN AN INTERVIEW ON [DATE] AT 12:25 P.M., THE DIRECTOR OF NURSING (DON #1) SAID THAT RESIDENT #101 RECEIVED A MECHANICALLY SOFT DINNER TRAY, BUT SHOULD HAVE RECEIVED A PUREED DINNER TRAY, BASED ON physician's order [REDACTED].#1 SAID SHE DID NOT KNOW HOW RESIDENT #101 GOT THE WRONG TRAY. DON #1 STATED, "...DIETARY STAFF GOT IT (THE ORDER)... " DON #1 SAID THAT ACCORDING TO HER INVESTIGATION, DIETARY STAFF MADE TWO DINNER TRAYS FOR RESIDENT #101, ONE THAT CONSISTED OF PUREED FOODS AND THE OTHER WITH MECHANICAL SOFT FOODS. RESIDENT #101 RECEIVED THE WRONG TRAY. ACCORDING TO THE FACILITY POLICY, "DINING ROOM MONITORING AND NURSING RESPONSIBILITIES" DATED [DATE], NURSING STAFF WERE REQUIRED TO "...SEE THAT ALL RESIDENTS RECEIVE THE CORRECT TRAY ..." AND "...MAKE SURE THAT (THE RESIDENT'S) TRAY IS PREPARED APPROPRIATELY FOR RESIDENTS..." ON [DATE] THE FACILITY IDENTIFIED 68 OTHER RESIDENTS IN THE FACILITY WITH PHYSICIAN ORDERS [REDACTED]. ON [DATE], AT 12:38 P.M. AN IMMEDIATE JEOPARDY SITUATION WAS IDENTIFIED AT F-325. THE ADMINISTRATOR WAS INFORMED ON [DATE], AT 2:47 P.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] WHEN THE FACILITY FAILED TO ENSURE RESIDENT #101 RECEIVED A THERAPEUTIC DIET IN ACCORDANCE WITH RESIDENT NEEDS AND PHYSICIAN ORDERS. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] THE DIETARY TECH DEVELOPED A LIST OF 68 RESIDENTS IN THE FACILITY THAT RECEIVED A MODIFIED CONSISTENCY DIET. 2. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE], THE DIETARY TECH AUDITED ALL 68 CHARTS OF RESIDENTS DESIGNATED AS MODIFIED CONSISTENCY DIETS TO ENSURE THE ORDER IN THE CHART MATCHED THE DIET CARDS IN THE DIETARY DEPARTMENT. 3. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] A CHOKING EPISODE PROTOCOL WAS ESTABLISHED BY THE MEDICAL DIRECTOR OF THE FACILITY. 4. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] 26 OUT OF 40 NURSES WERE EDUCATED ON THE CHOKING EPISODE PROTOCOL. 5. ON [DATE], THE SURVEYOR CONFIRMED THAT ALL WRITTEN DIET CHANGE ORDERS MADE SINCE [DATE] WERE DELIVERED TO THE DIETARY DEPARTMENT AND TIME TAMPED FOR ACCURACY. 6. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] THE DIETARY SUPERVISOR BEGAN MONITORING ALL DIET CHANGES INITIATED. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN 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 OBSERATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO INVESTIGATE A FRACTURED FIBULA (BROKEN LEG) INJURY OF UNKNOWN ORIGIN FOR ONE (#408) OF 14 RESIDENTS REVIEWED FOR ABUSE OUT OF A TOTAL SAMPLE OF 24, RESULTING IN THE POTENTIAL FOR UNDETECTED, UNCORRECTED ABUSE OR NEGLECT. FINDINGS INCLUDE: ON 10/18/11 AT 11:30 A.M., 12:15 P.M., 12:50 P.M., 2:00 P.M. AND 3:00 P.M., RESIDENT #408 WAS OBSERVED SITTING IN A GERI CHAIR (WHEELED RECLINING CHAIR) WITH A TRAY TABLE RESTRAINT ATTACHED. THE RESIDENT WAS ALERT, WITH SOME CONFUSION BUT WAS ABLE TO ANSWER SIMPLE QUESTIONS. ON 10/19/11 AT 11:00 A.M., RESIDENT #408'S CLINICAL RECORD AND INCIDENT AND ACCIDENT REPORTS (I&A) WERE REVIEWED WITH THE UNIT MANAGER, NURSE "A", AND REVEALED THE RESIDENT HAD FALLEN TWICE IN THE FACILITY SINCE 01/2011, AND HAD SUFFERED A FRACTURED FIBULA (BROKEN ANKLE ) OF UNKNOWN ORIGIN ON 7/29/11. A PHYSICIAN'S NOTE FOR RESIDENT #408, DATED 8/1/11 REVEALED THE FOLLOWING NOTATION, "THE PATIENT IS BEING FOLLOWED UP TODAY, SHE WAS SEEN ON FRIDAY JULY 29/2011. SHE WAS NOTED TO HAVE INCREASED [MEDICAL CONDITION] AND PAIN OF THE RIGHT LOWER EXTREMITY. SHE WAS SENT OVER TO THE HOSPITAL HER X-RAYS DID REVEAL A COMPRESSION [MEDICAL CONDITION] (HEEL). SHE WAS NOTED TO HAVE A SIMPLE RIGHT FIBULAR FRACTURE UNDISPLACED (BROKEN LEG.)" A NURSING NOTE DATED 7/29/11 AT 6:30 A.M., DOCUMENTED THE FOLLOWING, "RIGHT ANKLE SWELLING." THERE WAS NO DOCUMENTATION OF ANY FALL OR INCIDENT IN JULY. A HOSPITAL PHYSICIAN'S SUMMARY, DATED 7/29/11 AT 9:44 P.M., DOCUMENTED THE FOLLOWING, "HISTORY, PATIENT HAS SWELLING TO RIGHT ANKLE FOR 13 HOURS", "PER NURSING HOME, SUSPECTED CALCANEUS FRACTURE AFTER A FALL", AND CLINICAL HISTORY, "TRAUMA". THE [DIAGNOSES REDACTED]. NO OTHER AUTE FRACTURE IDENTIFIED. PLANTAR CALCANEAL SPUR (HEEL SPUR)." A HOSPITAL X RAY REPORT DATED 7/29/11 AT 8:30 P.M., DOCUMENTED "ACUTE NONDISPLACED FRACTURE IN THE DISTAL FIBULA. NO OTHER ACUTE FRACTURE IS IDENTIFIED." A PORTABLE X- RAY REPORT TAKEN AT THE FACILILTY PRIOR TO TRANSFER TO THE HOSPITAL, DATED 7/29/11 AT 1:36 P.M., DOCUMENTED THE RESIDENT HAD ONLY A MILD DEGREE OF [MEDICAL CONDITION], "THE BONY MINERALIZATION IS MILDLY DECREASED." A SOCIAL WORK NOTE DATED 2/25/11 DOCUMENTED THE FOLLOWING FOR RESIDENT #408, "THE RESIDENT CAN BECOME EASILY ANNOYED WITH STAFF AT TIMES, AND EVEN COMBATIVE (PHYSICALLY AGRESSIVE) WITH CARE." REVIEW OF RESIDENT #408'S NURSING CARE PLANS REVEALED THE RESIDENT WAS INDEPENDENT FOR AMBULATION (WALKING) UNTIL SHE BROKE HER ANKLE ON 7/29/11. THE UNIT MANAGER "A" STATED, "THE INJURY ON 7/29/11 WAS A STRESS FRACTURE FROM CONSTANT WALKING. THE RESIDENT WALKED ALL OVER THE FACILITY ALMOST NONSTOP FROM MORNING TO NIGHT." UNIT MANAGER "A" REPORTED THAT HE WAS RESPONSIBLE FOR INVESTIGATION AND REPORTING OF ALL INJURIES OF UNKNOWN ORIGIN AND INCIDENTS SUSPICIOUS FOR NEGLECT OR ABUSE ON THE UNIT. UNIT MANAGER "A" WAS ASKED TO PROVIDE THE FULL FACILITY INVESTIGATION INTO RESIDENT #408'S FRACTURE OF UNKNOWN ORIGIN. THIS WAS REVIEWED WITH UNIT MANAGER "A" AND THE DIRECTOR OF NURSING (DON) ON 10/21/11 AT 9:10 A.M. AND REVEALED THE FOLLOWING: 1. THERE WAS NO INCIDENT/ ACCIDENT REPORT OR EVENT REPORT DOCUMENTING THE DISCOVERY OF RESIDENT #408'S INJURY. 2. THERE WAS NO DOCUMENTATION THAT ANY POTENTIAL WITNESSES TO THE CAUSE OF RESIDENT #408'S INJURY WERE INTERVIEWED. WHEN QUERIED ABOUT THIS, UNIT MANAGER "A" PRODUCED A SIGNED STATEMENT BY NURSE "E" INDICATING THAT SHE HAD NOT NOTICED ANYTHING UNUSUAL FOR RESIDENT #408 ON 7/26/ TO 7/28/11. WHEN QUERIED WHY THIS STATEMENT HAD NOT BEEN IN THE INVESTIGATION FILE ON 10/20/11, UNIT MANAGER "A" REPORTED THAT HE HAD GOTTEN THE STATEMENT FROM NURSE "E" THE PREVIOUS EVENING, ON 10/20/11, NEARLY THREE MONTHS AFTER THE INJURY WAS DISCOVERED. 3. THE PROBLEM INVESTIGATION FORM SUMMARY, DATED 8/1/11 CONCLUDED, "IT IS LIKELY THAT A STRESS FRACTURE HAS OCCURRED." WHEN QUERIED WHETHER RESIDENT #408'S INJURY OF UNKNOWN ORIGIN HAD BEEN REPORTED TO THE STATE AGENCY AS REQUIRED, UNIT MANAGER STATED IT WAS NOT, AS IT WAS NOT AN INJURY OF UNKNOWN ORIGIN, AS IT WAS SIMPLY A STRESS FRACTURE DUE TO THE RESIDENT'S CONSTANT WALKING. WHEN ASKED TO PROVIDE DOCUMENTATION INDICATING HOW THIS HAD BEEN DETERMINED, THE UNIT MANAGER PROVIDED A PAGE FROM A WEBSITE ENTITLED "SMART FEET SAVANNA (HTTP://WWW. SMARTFEETSAVANAH.COM/SMART REFERENCE-LIBRARY) INDICATING THAT "CALCANEAL FRACTURES, COMMONLY CAUSED HEEL FRACTURES, CAN OCCUR WITH OVERUSE." WHEN QUERIED ABOUT THIS, THE UNIT MANAGER AND THE DON WERE UNAWARE THAT THE HOSPITAL X-RAY AND PHYSICIAN'S NOTES INDICATED THAT RESIDENT #408 HAD SUFFERED AN ACUTE FIBULAR FRACTURE, BUT DID NOT HAVE A COMPRESSION [MEDICAL CONDITION]. REVIEW OF RESIDENT #408'S CLINICAL RECORD REVEALED A FACE SHEET DOCUMENTING THAT RESIDENT #408 WAS admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A MINIMUM DATA SET assessment dated [DATE] REVEALED THE RESIDENT HAD SEVERELY IMPAIRED COGNITION (DEMENTIA), AND NEEDED EXTENSIVE ASSISTANCE FOR MOST ACTIVITIES OF DAILY LIVING AND WAS DEPENDANT ON STAFF FOR TRANSFERS AND AMBULATION. AN MDS dated [DATE] DOCUMENTED THAT RESIDENT #408 HAD SEVERE COGNITIVE IMPAIRMENT AND WAS INDEPENDENT FOR TRANSFERS AND AMBULATION. ON 10/21/11 AT 11:30 A.M., THE DIRECTOR OF NURSING WAS INTERVIEWED AND STATED SHE REALIZED THAT THERE WERE PROBLEMS WITH THE INVESTIGATION INTO THE CAUSE OF RESIDENT #408'S BROKEN LEG OF UNKNOWN ORIGIN. ( )

THIS CITATION PERTAINS TO INTAKE # MI 785. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMMEDIATELY REPORT AN ALLEGATION OF POTENTIAL NEGLECT TO THE STATE SURVEY AND CERTIFICATION AGENCY FOR 1 RESIDENT (#101) OF 5 RESIDENTS REVIEWED FOR ABUSE AND NEGLECT FROM A TOTAL SAMPLE OF 9, RESULTING IN AN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHO CHOKED ON FOOD THAT WAS NOT APPROPRIATE FOR HER WHILE EATING UNSUPERVISED. EMERGENCY LIFE SAVING PROCEDURES AND THE [MEDICATION NAME] MANEUVER WERE NOT PERFORMED ACCORDING TO PROFESSIONAL STANDARDS OF QUALITY. RESIDENT #101 SUBSEQUENTLY died . THE POTENTIAL REMAINS FOR SERIOUS INJURY, HARM, IMPAIRMENT OR DEATH FOR ANY RESIDENT WHO COULD BE SUBJECTED TO NEGLECT. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE FACE SHEET DATED [DATE], RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #101 REQUIRED SUPERVISION BY FACILITY STAFF WHEN EATING. SHE HAD SEVERAL [DIAGNOSES REDACTED]. THE RESIDENT HAD A physician's orders [REDACTED]. THE CARE PLAN DATED [DATE] IDENTIFIED RESIDENT #101'S RISK OF ASPIRATION AND LISTED SEVERAL INTERVENTIONS INCLUDING A MECHANICAL SOFT DIET AND "...MONITOR...FOR DIFFICULTY SWALLOWING, HOLDING FOOD IN MOUTH, PROLONGED SWALLOWING TIME, DROOLING, POCKETING FOOD IN MOUTH..." THE SPEECH THERAPY EVALUATION DATED [DATE], SAID THAT RESIDENT #101 SUFFERED FROM OROPHARYNGEAL DYSPHAGIA (DIFFICULTY EMPTYING MATERIAL FROM THE ORAL CAVITY INTO THE ESOPHAGUS), REDUCED MASTICATION (NOT CHEWING AS MUCH AS NORMAL) AND POCKETING (LEAVING FOODS IN THE MOUTH WHEN SWALLOWING). THE SPEECH THERAPY EVALUATION REQUIRED ASPIRATION PRECAUTIONS (MEASURES DESIGNED TO PREVENT THE DRAWING OF A FOREIGN SUBSTANCE, SUCH AS THE [MEDICAL CONDITION] CONTENTS OR FOOD, INTO THE RESPIRATORY TRACT) AND SUPERVISION TO BE IMPLEMENTED FOR RESIDENT #101. ACCORDING TO THE NURSE'S NOTES AND SPEECH THERAPY EVALUATION, DATED [DATE], RESIDENT #101 MOMENTARILY CHOKED ON SPINACH ON [DATE] AT 1:30 P.M., BUT HAD NO NEGATIVE EFFECTS. RESIDENT #101 WAS IMMEDIATELY REASSESSED BY THE SPEECH THERAPIST (SPT) #1. ACCORDING TO SPT #1'S NOTES DATED [DATE], RESIDENT #101 WAS NO LONGER SAFE TO EAT A MECHANICALLY SOFT DIET AND THE PHYSICIAN WAS CONTACTED FOR A CHANGE IN THE DIET ORDER. ACCORDING TO THE NURSE ' S NOTES DATED [DATE], A physician's orders [REDACTED].M. THAT CHANGED RESIDENT #101'S DIET ORDER TO A PUREED DIET WITH NECTAR THICK LIQUIDS. WHEN SPT #1 WAS INTERVIEWED ON [DATE] AT 11:00 A.M., SHE SAID THAT HAD SHE ASSESSED RESIDENT #101 AFTER THE CHOKING EPISODE THAT OCCURRED ON [DATE], AND, THAT ACCORDING TO HER ASSESSMENT, RESIDENT #101 HAD AN INCREASED RISK FOR ASPIRATION AND WAS NO LONGER SAFE TO EAT MECHANICAL SOFT FOODS. SPT #1 SAID THAT RESIDENT #101 NEEDED HER DIET CHANGED IMMEDIATELY TO BE SAFE, SINCE SHE HAD ALREADY CHOKED ON THE MECHANICAL SOFT FOOD. SPT #1 SAID SHE SPOKE WITH THE PHYSICIAN TO OBTAIN THE ORDER FOR A PUREED DIET. SPT #1 SAID THAT SOMETIME BETWEEN 2:00 P.M. AND 2:30 P.M., SHE (SPT #1) SPOKE TO THE DIETETIC TECHNICIAN IN PERSON AND TOLD THE DIETETIC TECHNICIAN THAT THE RESIDENT #101 NEEDED TO HAVE A PUREED DIET. SPT #1 SAID RESIDENT #101 NEEDED ATTENTION WHILE EATING AND DIRECT SUPERVISION BY STAFF. SPT #1 SAID SHE IMPLEMENTED ASPIRATION PRECAUTIONS AND SUPERVISION FOR RESIDENT #101, WHICH REQUIRED SOMEONE TO BE PHYSICALLY PRESENT AT THE TABLE SUPERVISING RESIDENT #101 TO ENSURE SHE ATE SAFELY. IN AN INTERVIEW ON [DATE] AT 2:55 P.M., LICENSED PRACTICAL NURSE (LPN) #2 SAID THAT ON [DATE] AT APPROXIMATELY 5:30 P.M. HE PICKED UP RESIDENT #101'S MEAL TRAY WITH THE TRAY ASSEMBLY TICKET FROM THE DIETARY DEPARTMENT. LPN #2 SAID THE MEAL TRAY ASSEMBLY TICKET SAID RESIDENT #101 WAS TO RECEIVE A MECHANICALLY SOFT DIET. LPN #2 SAID HE THEN PROVIDED THE MECHANICALLY SOFT MEAL TRAY TO RESIDENT #101, WHO WAS SITTING IN THE FACILITY DINING ROOM, A LARGE ROOM THAT IS SEPARATED BY A WIDE PASSAGEWAY AND A HALF-HEIGHT WALL PASSING THROUGH THE MIDDLE OF THE ROOM. INDEPENDENT EATERS SIT ON ONE SIDE (REGULAR SIDE) OF THE HALF-HEIGHT WALL, AND DEPENDENT EATERS ("FEEDERS") SIT ON THE OPPOSITE SIDE, BEYOND THE WIDE PASSAGEWAY. THE SET-UP OF THE ROOM REQUIRES SEPARATE NURSES TO SUPERVISE THESE TWO GROUPS OF RESIDENTS DUE TO THE SEPARATE VISUAL FIELDS. RESIDENT #101 WAS SITTING IN THE SECTION OF THE ROOM WHERE THE INDEPENDENT EATERS SAT. LPN #2 SAID THAT HE WAS REQUIRED TO BE IN THE REGULAR SIDE OF THE DINING ROOM SUPERVISING RESIDENTS INCLUDING RESIDENT #101 DURING THE EVENING MEAL ON [DATE], BUT THAT HE LEFT THE DINING ROOM AND NO ONE WAS SUPERVISING RESIDENT #101 WHILE SHE ATE. IN AN INTERVIEW ON [DATE] AT 10:00 A.M., CERTIFIED NURSING ASSISTANT (CNA) #1 SAID THAT THREE OTHER CNAS AND A NURSE WERE FEEDING RESIDENTS ON THE "...FEEDER SIDE..." CNA #1 SAID THAT SHE WAS IN THE PASSAGEWAY BETWEEN THE DINING AREAS PASSING TRAYS TO THE RESIDENTS AND THAT NO STAFF MEMBERS WERE ON THE "...REGULAR SIDE..." OF THE DINING ROOM. CNA #1 SAID THAT RESIDENT #101'S BACK WAS TOWARDS HER (CNA #1). CNA #1 SAID NEITHER SHE, NOR ANY STAFF MEMBER WAS SUPERVISING RESIDENT #101 DURING THE EVENING MEAL ON [DATE]. CNA #1 WENT ON TO SAY THAT ON [DATE] AT APPROXIMATELY 5:36 P.M., A VISITOR TOLD CNA#1 THAT SHE BELIEVED RESIDENT #101 WAS CHOKING. CNA #1 SAID SHE WENT TO RESIDENT #101'S TABLE, SAW THAT SHE (#101) WAS NOT BREATHING, AND THAT SHE WAS UNRESPONSIVE. CNA #1 SAID THAT, ALTHOUGH SHE (CNA #1) WAS CERTIFIED IN CARDIOPULMONARY RESUSCITATION (CPR) AND THE [MEDICATION NAME] MANEUVER, SHE DID NOT PLACE RESIDENT #101 ON HER BACK AND PERFORM THE [MEDICATION NAME] MANEUVER. CNA #1 SAID THAT, INSTEAD, SHE GRABBED A WHEELCHAIR, PUT RESIDENT #101 INTO IT AND RAN TO THE 1-WEST NURSES' STATION. CNA #1 DID NOT SAY WHY SHE DID NOT ATTEMPT TO USE THE [MEDICATION NAME] MANEUVER ON RESIDENT #101. IN AN INTERVIEW ON [DATE] AT 2:55 P.M., LPN #2 SAID THAT ON [DATE], CNA #1 BROUGHT RESIDENT #101, WHO WAS SEATED IN A WHEEL CHAIR, TO THE 1-WEST NURSES' STATION AND SAID THAT SHE (#101) HAD CHOKED WHILE IN THE DINING ROOM. LPN #2 SAID HE IMMEDIATELY ASSESSED RESIDENT #101 AND FOUND SHE WAS NOT CONSCIOUS OR BREATHING. LPN #2 SAID THAT HE AND THE 1-EAST CHARGE NURSE (CHARGE NURSE #1) TOOK TURNS PICKING UP RESIDENT #101 FROM BEHIND WHILE THE RESIDENT REMAINED SEATED IN THE WHEEL CHAIR, WHILE ATTEMPTING ABDOMINAL THRUSTS. ACCORDING TO LPN #2, THEY (THE TWO NURSES) DID NOT PLACE RESIDENT #101 ON HER BACK, AND DID NOT PROVIDE ADDITIONAL SUPPORT OR POSITIONING. LPN #2 WAS UNABLE TO EXPLAIN HOW RESIDENT #101'S HEAD AND CHIN WERE PREVENTED FROM FALLING FORWARD TO HER CHEST WHILE HE PERFORMED THE ABDOMINAL THRUSTS, AS HAVING THE HEAD AND CHIN IN THIS POSITION WOULD MAKE THE EXPELLING OF AN AIRWAY OBSTRUCTION MORE DIFFICULT. LPN #2 SAID HE AND CHARGE NURSE #1 PROVIDED RESIDENT #101 WITH "...BACK BLOW ..." LPN #2 SAID THAT ALTHOUGH HE DID NOT SEE ANYTHING IN RESIDENT #101'S MOUTH, HE AND CHARGE NURSE #1 GAVE RESIDENT #101 BLIND "...FINGER SWEEPS..." IN AN INTERVIEW ON [DATE] AT 2:29 P.M., CHARGE NURSE #1 SAID SHE HEARD NOISE ON THE 1-WEST NURSING UNIT AND WENT TO HELP. CHARGE NURSE #1 SAID SHE SAW LPN #2 PICK UP RESIDENT #101, WHO WAS SEATED IN A WHEEL CHAIR, FROM BEHIND AND ATTEMPT ABDOMINAL THRUSTS WHICH WERE UNSUCCESSFUL IN DISLODGING WHATEVER WAS IN RESIDENT #101'S AIRWAY. CHARGE NURSE #1 SAID SHE DID NOT INITIALLY PLACE RESIDENT #101 ON HER BACK, BUT INSTEAD PICKED RESIDENT #101 UP FROM BEHIND AND ATTEMPTED TO GIVE THE RESIDENT ABDOMINAL THRUSTS, WHICH WERE ALSO UNSUCCESSFUL. CHARGE NURSE #1 WAS UNABLE TO EXPLAIN HOW RESIDENT #101'S HEAD AND CHIN WERE PREVENTED FROM FALLING FORWARD TO HER CHEST WHILE SHE WAS PERFORMING THE ABDOMINAL THRUSTS. CHARGE NURSE #1 SAID SHE AND LPN #2 PROVIDED RESIDENT #101 WITH ...BACK BLOWS..." CHARGE NURSE #1 SAID THAT ALTHOUGH SHE DID NOT SEE ANYTHING IN RESIDENT #101'S MOUTH, BOTH SHE AND LPN #2 GAVE RESIDENT #101 BLIND "...FINGER SWEEPS..." CHARGE NURSE #1 SAID SHE THEN TOOK RESIDENT #101 TO HER ROOM AND PLACED HER (#101) IN BED. CHARGE NURSE #1 WENT ON TO SAY THAT AFTER THE RESIDENT WAS LYING IN BED, SHE AND LPN #2 ALTERNATED IN GIVING THE RESIDENT ABDOMINAL THRUSTS AND BLIND FINGER SWEEPS. ACCORDING TO CHARGE NURSE #1, BOTH NURSES COMPLETED THIS PROCEDURE TWICE AND UPON THE THIRD REPETITION, SOFT UN-CHEWED BREAD WAS EXPELLED FROM RESIDENT #101'S AIRWAY. ON [DATE] AT 1:10 P.M. THE DIETETIC TECHNICIAN (TECH #1) WAS INTERVIEWED AND SAID A NURSE AIDE BROUGHT RESIDENT #101'S DIET CHANGE ORDER TO THE DIETARY STAFF ON [DATE], BEFORE THE DINNER TRAY WAS DELIVERED TO RESIDENT #101. TECH #1 SAID SPT #1 DELIVERED THE DIET ORDER TO HER (TECH #1) PERSONALLY, AND THE NURSE AIDE TOOK A COPY TO THE KITCHEN. BOTH OF THESE ACTIONS TOOK PLACE ON [DATE], BEFORE THE EVENING MEAL WAS SERVED. TECH #1 SAID RESIDENT #101 WAS SERVED THE WRONG FOOD AND CHOKED. ON [DATE] AT 11:00 A.M., SPT #1 SAID SHE WAS SURPRISED RESIDENT #101 WAS SERVED THE WRONG FOOD, BUT "...WAS NOT SURPRISED SHE CHOKED..." SPT #1 SAID, "...THE DIET SHOULD HAVE BEEN CHANGED IMMEDIATELY..." ON [DATE] AT 1:14 P.M., RESIDENT #101'S ATTENDING PHYSICIAN (MD #1) SAID THE FACILITY HAD CONTACTED HER RELATED TO RESIDENT #101'S DIET CHANGE. MD #1 REVIEWED RESIDENT #101'S MEDICAL RECORD AND SAID THAT THE DIET ORDER WAS CHANGED BEFORE 4:00 P.M. MD #1 SAID, "...I EXPECT ORDERS TO BE FOLLOWED IMMEDIATELY..." MD #1 SAID RESIDENT #101 SHOULD HAVE GOTTEN A PUREED DIET AT THE EVENING MEAL ON [DATE]. RESIDENT #101 WAS TRANSPORTED TO A LOCAL HOSPITAL WHERE, ACCORDING TO THE MEDICAL RECORDS, IT WAS DETERMINED THAT THE RESIDENT HAD CHOKED ON HER FOOD AND STOPPED BREATHING. RESIDENT #101 HAD A VERY POOR PROGNOSIS WITH [DIAGNOSES REDACTED]. RESIDENT #102 expired on [DATE] AT 10:50 A.M. IN AN INTERVIEW ON [DATE] AT 12:25 P.M., THE DIRECTOR OF NURSING (DON #1) SAID THAT RESIDENT #101 HAD A CHOKING EPISODE FROM A FOOD ITEM THAT WAS NOT APPROPRIATE FOR HER. ON [DATE] AT 12:25 P.M., DON #1 SAID THAT ON THE EVENING OF [DATE], THE NURSE WAS NOT IN THE ROOM AND NO ONE FROM THE NURSING STAFF WAS SUPERVISING RESIDENT #101 AT THE TIME SHE CHOKED ON HER FOOD. DON #1 WAS UNABLE TO EXPLAIN WHY THE STATE SURVEY AND CERTIFICATION AGENCY WAS NOT NOTIFIED OF THIS INCIDENT. DON #1 SAID, "IT SHOULD HAVE BEEN (REPORTED). DID IT FALL THROUGH THE CRACKS? I CAN TELL YOU WE WENT THROUGH A BAD SPELL RIGHT AFTER THIS. IT SHOULD HAVE BEEN..." ON [DATE] AT 1:30 P.M., THE ADMINISTRATOR SAID CNA #1 PANICKED AND DID NOT PROVIDE THE RESIDENT WITH EMERGENCY CHOKING CARE AS SHE SHOULD HAVE. ON [DATE] AT 2:45 P.M., THE ADMINISTRATOR SAID THAT ALTHOUGH HE WAS AWARE OF THE PROBLEMS THAT OCCURRED, THE EVENT WAS NOT REPORTED TO THE STATE SURVEY AND CERTIFICATION AGENCY. THE ADMINISTRATOR SAID THAT AN INVESTIGATION WAS CONDUCTED, BUT SO MUCH WAS GOING ON, THAT "...I HONESTLY LOST TRACK OF IT..." THE ADMINISTRATOR SAID THAT THE STAFF DID NOT PROVIDE THE RESIDENT WITH THE CARE SHE NEEDED AND THAT THE EVENT SHOULD HAVE BEEN REPORTED TO THE STATE. ON [DATE] THE FACILITY IDENTIFIED 68 OTHER RESIDENTS IN THE FACILITY WITH PHYSICIAN ORDERS [REDACTED]. ON [DATE], AT 12:38 P.M. AN IMMEDIATE JEOPARDY SITUATION WAS IDENTIFIED AT F-225. THE ADMINISTRATOR WAS INFORMED ON [DATE], AT 2:47 P.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] WHEN THE FACILITY FAILED TO REPORT AN INCIDENT INVOLVING POSSIBLE NEGLECT, OR ABUSE TO THE STATE SURVEY AND CERTIFICATION AGENCY. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] THE NURSING ADMINISTRATIVE STAFF REVIEWED AND REVISED THE ACCIDENT AND INCIDENT REVIEW PROCESS TO INCLUDE TWO CHECKPOINTS IN THE PROCEDURE TO ASSURE THAT THE STATE AGENCY IS NOTIFIED AT THE APPROPRIATE REPORTING INTERVALS. 2. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] 6 OF 6 ADMINISTRATIVE NURSES WERE EDUCATED ON THE ACCIDENT AND INCIDENT REVIEW PROCESS. 3. ON [DATE], THE SURVEYOR REVIEWED INCIDENTS THAT HAVE OCCURRED IN THE FACILITY IN THE LAST THREE MONTHS AND CONFIRMED THAT THERE WERE NO OTHER INCIDENTS THAT MET THE CRITERIA OF STATE REPORTABLE INCIDENTS THAT WERE NOT REPORTED TO THE STATE SURVEY AND CERTIFICATION AGENCY. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF WIDESPREAD 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. ( )

THIS CITATION PERTAINS TO INTAKE # MI 785. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 (#101) OF 5 RESIDENTS REVIEWED FOR QUALITY OF NURSING CARE FROM A TOTAL SAMPLE OF 9 RECEIVED NURSING SERVICES THAT MET PROFESSIONAL STANDARDS OF QUALITY IN RESPECT TO EMERGENCY LIFE SAVING PROCEDURES AND THE [MEDICATION NAME] MANEUVER, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHO EXPERIENCED A CHOKING EPISODE, AND HAD THE [MEDICATION NAME] MANEUVER PERFORMED INCORRECTLY. RESIDENT #101 SUBSEQUENTLY died . THE POTENTIAL REMAINS FOR SERIOUS INJURY, HARM, IMPAIRMENT, OR DEATH TO ALL RESIDENTS IN THE EVENT OF A CHOKING EPISODE. FINDINGS INCLUDE: ACCORDING TO "HOW TO DO THE [MEDICATION NAME] MANEUVER, THE [MEDICATION NAME] MANEUVER? FOR CHOKING ADULTS (2007)," A CHOKING VICTIM "NEEDS YOUR HELP IMMEDIATELY AND WHEN A VICTIM BECOMES UNCONSCIOUS THE RESCUER MUST PLACE THE VICTIM ON HIS OR HER BACK. FACING THE VICTIM, KNEEL ASTRIDE THE VICTIM'S HIPS. WITH ONE OF YOUR HANDS ON TOP OF THE OTHER, PLACE THE HEEL OF YOUR BOTTOM HAND ON THE UPPER ABDOMEN BELOW THE RIB CAGE AND ABOVE THE NAVEL. USE YOUR BODY WEIGHT TO PRESS INTO THE VICTIM'S UPPER ABDOMEN WITH A QUICK UPWARD THRUST. REPEAT UNTIL OBJECT IS EXPELLED." ACCORDING TO "THE [MEDICATION NAME] MANEUVER: BEST TECHNIQUE FOR SAVING ANY CHOKING VICTIM'S LIFE. (1990) HENRY J. [MEDICATION NAME], MD, SCD EDWARD A. PATRICK, MD, PHD, POSTGRADUATE MEDICINE, 87:6,,[DATE], [DATE]," THE RESCUER SHOULD "NEVER PROBE THE MOUTH, AND SHOULD NEVER HIT THE CHOKING VICTIM ON THE BACK." THE REPORT CONCLUDED THAT "A BACK SLAP CAN DRIVE A FOREIGN OBJECT EVEN DEEPER INTO THE THROAT," AND, THAT AN "ATTEMPT TO REMOVE THE FOREIGN BODY WITH THE FINGER" CAN FORCE A FOREIGN BODY INTO THE AIRWAY FURTHER. "...THE [MEDICATION NAME] MANEUVER SHOULD BE THE ONLY METHOD USED TO RELIEVE AN AIRWAY OBSTRUCTION BY A FOREIGN BODY...IMPROVISATION COULD BE EXTREMELY DANGEROUS OR LETHAL..." RESIDENT #101 ACCORDING TO THE FACE SHEET DATED [DATE], RESIDENT # 101 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #101 REQUIRED SUPERVISION BY FACILITY STAFF WHEN EATING. SHE HAD SEVERAL [DIAGNOSES REDACTED]. THE RESIDENT HAD A physician's orders [REDACTED]. THE CARE PLAN DATED [DATE] IDENTIFIED RESIDENT #101'S RISK OF ASPIRATION AND LISTED SEVERAL INTERVENTIONS INCLUDING A MECHANICAL SOFT DIET AND "...MONITOR...FOR DIFFICULTY SWALLOWING, HOLDING FOOD IN MOUTH, PROLONGED SWALLOWING TIME, DROOLING, POCKETING FOOD IN MOUTH..." IN AN INTERVIEW ON [DATE] AT 2:55 P.M., LICENSED PRACTICAL NURSE (LPN) #2 SAID THAT ON [DATE] AT APPROXIMATELY 5:30 P.M., HE PROVIDED A MECHANICALLY SOFT MEAL TRAY TO RESIDENT #101, WHO WAS SEATED WITH RESIDENTS WHO WERE INDEPENDENT FOR EATING IN THE DINING ROOM. ON [DATE] AT 10:00 A.M., CERTIFIED NURSE AIDE (CNA) #1 WAS INTERVIEWED. CNA #1 SAID THAT ON [DATE] AT APPROXIMATELY 5:36 P.M., A VISITOR TOLD CNA#1, SHE BELIEVED RESIDENT #101 WAS CHOKING. CNA #1 SAID SHE WENT TO RESIDENT #101'S TABLE, SAW SHE WAS NOT BREATHING, AND THAT SHE WAS UNRESPONSIVE. CNA #1 SAID THAT, ALTHOUGH SHE (CNA #1) WAS CERTIFIED IN CARDIOPULMONARY RESUSCITATION (CPR) AND THE [MEDICATION NAME] MANEUVER, SHE DID NOT PLACE RESIDENT #101 ON HER BACK AND PERFORM THE [MEDICATION NAME] MANEUVER. CNA #1 SAID THAT, INSTEAD, SHE GRABBED A WHEELCHAIR, PUT RESIDENT #101 INTO IT AND RAN TO THE 1-WEST NURSES' STATION. CNA #1 DID NOT SAY WHY SHE DID NOT ATTEMPT TO USE THE [MEDICATION NAME] MANEUVER ON RESIDENT #101. IN AN INTERVIEW ON [DATE] AT 2:55 P.M., LPN #2 SAID THAT ON [DATE], CNA #1 BROUGHT RESIDENT #101, WHO WAS SEATED IN A WHEEL CHAIR TO THE 1-WEST NURSES' STATION AND SAID THAT SHE (#101) HAD CHOKED WHILE IN THE DINING ROOM. LPN #2 SAID HE IMMEDIATELY ASSESSED RESIDENT #101 AND FOUND SHE WAS NOT CONSCIOUS OR BREATHING. LPN #2 SAID THAT HE AND THE 1-EAST CHARGE NURSE (CHARGE NURSE #1) TOOK TURNS PICKING UP RESIDENT #101 FROM BEHIND WHILE THE RESIDENT REMAINED SEATED IN THE WHEEL CHAIR, WHILE ATTEMPTING ABDOMINAL THRUSTS. ACCORDING TO LPN #2, THEY (THE TWO NURSES) DID NOT PLACE RESIDENT #101 ON HER BACK, AND DID NOT PROVIDE ADDITIONAL SUPPORT OR POSITIONING. LPN #2 WAS UNABLE TO EXPLAIN HOW RESIDENT #101'S HEAD AND CHIN WERE PREVENTED FROM FALLING FORWARD TO HER CHEST WHILE HE PERFORMED THE ABDOMINAL THRUSTS, AS HAVING THE HEAD AND CHIN IN THIS POSITION WOULD MAKE THE EXPELLING OF AN AIRWAY OBSTRUCTION MORE DIFFICULT. LPN #2 SAID THAT HE AND CHARGE NURSE #1 PROVIDED RESIDENT #101 WITH "...BACK BLOWS..." LPN #2 SAID THAT ALTHOUGH HE DID NOT SEE ANYTHING IN RESIDENT #101'S MOUTH, HE AND CHARGE NURSE #1 GAVE RESIDENT #101 BLIND "...FINGER SWEEPS..." IN AN INTERVIEW ON [DATE] AT 2:29 P.M., CHARGE NURSE #1 SAID SHE HEARD NOISE ON 1-WEST NURSING UNIT AND WENT TO HELP. CHARGE NURSE #1 SAID SHE SAW LPN #2 PICK UP RESIDENT #101, WHO WAS SEATED IN A WHEEL CHAIR, FROM BEHIND AND ATTEMPT ABDOMINAL THRUSTS WHICH WERE UNSUCCESSFUL IN DISLODGING WHATEVER WAS IN RESIDENT #101'S AIRWAY. CHARGE NURSE #1 SAID SHE DID NOT PLACE RESIDENT #101 ON HER BACK, BUT INSTEAD PICKED RESIDENT #101 UP FROM BEHIND AND ATTEMPTED TO GIVE THE RESIDENT ABDOMINAL THRUSTS, WHICH WERE ALSO UNSUCCESSFUL. CHARGE NURSE #1 WAS UNABLE TO EXPLAIN HOW RESIDENT #101'S HEAD AND CHIN WERE PREVENTED FROM FALLING FORWARD TO HER CHEST WHILE SHE WAS PERFORMING THE ABDOMINAL THRUSTS. CHARGE NURSE #1 SAID SHE AND LPN #2 PROVIDED RESIDENT #101 WITH "...BACK BLOWS..." CHARGE NURSE #1 SAID THAT ALTHOUGH SHE DID NOT SEE ANYTHING IN RESIDENT #101'S MOUTH, BOTH SHE AND LPN #2 GAVE RESIDENT #101 BLIND "...FINGER SWEEPS..." CHARGE NURSE #1 SAID SHE THEN TOOK RESIDENT #101 TO HER ROOM AND PLACED HER (#101) IN BED. CHARGE NURSE #1 WENT ON TO SAY THAT AFTER THE RESIDENT WAS LYING IN BED, SHE AND LPN #2 ALTERNATED IN GIVING THE RESIDENT ABDOMINAL THRUSTS AND BLIND FINGER SWEEPS. ACCORDING TO CHARGE NURSE #1, BOTH NURSES COMPLETED THIS PROCEDURE TWICE AND UPON THE THIRD REPETITION, SOFT UN-CHEWED BREAD WAS EXPELLED FROM RESIDENT #101'S AIRWAY. RESIDENT #101 WAS TRANSPORTED TO A LOCAL HOSPITAL WHERE, ACCORDING TO THE MEDICAL RECORDS, IT WAS DETERMINED THAT THE RESIDENT HAD CHOKED ON HER FOOD AND STOPPED BREATHING. RESIDENT #101 HAD A VERY POOR PROGNOSIS WITH [DIAGNOSES REDACTED]. RESIDENT #101 expired on [DATE] AT 10:50 A.M. IN AN INTERVIEW ON [DATE] AT 11:35 A.M., THE 1-WEST UNIT MANAGER (CHARGE NURSE #2) SAID THAT WHEN A RESIDENT IS CHOKING, STAFF SHOULD LOOK FOR FOOD IN THE MOUTH, BUT SHOULD NEVER DO BLIND FINGER SWEEPS OR BACK BLOWS. CHARGE NURSE #2 PROVIDED THE SURVEYOR WITH THE FACILITY POLICY ENTITLED "[MEDICATION NAME] MANEUVER," AND SAID THE POLICY WAS NOT CLEAR. CHARGE NURSE #2 SAID, "...YOU SHOULD NEVER DO BACK BLOWS OR BLIND FINGER SWEEPS, BUT THE STAFF DID..." IN AN INTERVIEW ON [DATE] AT 12:25 P.M., THE DIRECTOR OF NURSING (DON #1) SAID SHE WAS AWARE THAT THE [MEDICATION NAME] INSTITUTE NO LONGER RECOMMENDED FINGER SWEEPS DUE TO "...THE CHANCE OF SHOVING FOOD DOWN THE THROAT...NOBODY SHOULD BE DOING FINGER SWEEPS..." ON [DATE] AT 12:30 P.M., THE IN-SERVICE DIRECTOR (RN #1) SAID THAT ONLY IF FOOD WAS VISIBLE SHOULD FINGER SWEEPS BE PERFORMED. RN #1 SAID NO ONE SHOULD EVER DO BLIND FINGER SWEEPS. RN #1 SAID THAT WHEN A PERSON IS NOT CONSCIOUS OR RESPONSIVE AND HAS CHOKED, CARE SHOULD ONLY BE PERFORMED WITH THE PERSON LYING DOWN. RN #1 SAID THAT ABDOMINAL THRUSTS SHOULD NOT BE DONE BY PICKING UP A RESIDENT IF THE RESIDENT IS NOT CONSCIOUS. ON [DATE] AT 1:30 P.M., THE ADMINISTRATOR SAID THAT THIS SITUATION HAD BEEN DISCUSSED BY THE FACILITY ' S QUALITY ASSURANCE COMMITTEE. ACCORDING TO THE ADMINISTRATOR, IT WAS THE COMMITTEE'S CONSENSUS THAT THE [MEDICATION NAME] SHOULD HAVE BEEN PERFORMED IMMEDIATELY ON THE RESIDENT, WHILE SHE (#101) WAS STILL IN THE DINING ROOM. THE COMMITTEE WAS CONCERNED BECAUSE THE [MEDICATION NAME] WAS DELAYED. THE ADMINISTRATOR SAID CNA #1 PANICKED AND DID NOT PROVIDE THE RESIDENT WITH EMERGENCY CHOKING CARE AS SHE SHOULD HAVE. ON [DATE], AT 12:38 P.M. AN IMMEDIATE JEOPARDY SITUATION WAS IDENTIFIED AT F-281. THE ADMINISTRATOR WAS INFORMED ON [DATE], AT 2:47 P.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] WHEN THE FACILITY FAILED TO PERFORM EMERGENCY LIFE SAVING PROCEDURES AND THE [MEDICATION NAME] MANEUVER ON A CHOKING RESIDENT ACCORDING TO PROFESSIONAL STANDARDS OF QUALITY. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] THE FACILITY POLICY CONSULTED A REPRESENTATIVE OF THE LOCAL EMERGENCY MEDICAL SERVICE TO OBTAIN THE LATEST INFORMATION ON PROCEDURES FOR APPROPRIATE TECHNIQUE RELATED TO EMERGENCY LIFE SAVING PROCEDURES AND THE [MEDICATION NAME] MANEUVER. 2. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] AND [DATE] THE FACILITY POLICY ADDRESSING THE [MEDICATION NAME] MANEUVER WAS REVIEWED AND REVISED. 3. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] 26 OUT OF 40 NURSES WERE REEDUCATED ON PROPER EMERGENCY LIFE SAVING PROCEDURES AND THE [MEDICATION NAME] MANEUVER. 4. ON [DATE], THE SURVEYOR CONFIRMED THAT [DATE] AND [DATE] HAVE BEEN RESERVED ON THE EDUCATIONAL SCHEDULE FOR REEDUCATION ON PROPER EMERGENCY LIFE SAVING PROCEDURES AND THE [MEDICATION NAME] MANEUVER. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF WIDESPREAD 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. ( )

THIS CITATION CONTAINS MULTIPLE DEFICIENT PRACTICES: I. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT PERSONAL SAFETY DEVICES (ALARMS) WERE IN WORKING ORDER, AND FAILED TO UPDATE SAFETY INTERVENTIONS AFTER FALLS FOR ONE (#410) OF SIX RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 24, RESULTING IN THE POTENTIAL FOR INJURY DUE TO UNPREVENTED FALLS. FINDINGS INCLUDE: ON 10/18/11 AT 2:30 P.M., RESIDENT #410 WAS CRYING OUT FROM THE ROOM, "HELP! HELP! HELP!." THE RESIDENT 'S CRIES WERE AUDIBLE FROM THE NURSING STATION. AT 2:32 P.M., RESIDENT #410 WAS OBSERVED SITTING ON THE PROTECTIVE MAT ON THE FLOOR BY THE BED, AND WAS STILL CALLING OUT, "HELP ME PLEASE! I GOTTA GO WEE WEE." THE RESIDENT'S BED WAS IN THE LOW POSITION, AND A PERSONAL SAFETY ALARM WAS ATTACHED TO THE BED, BUT WAS NOT SOUNDING (ALARMING). AT 2:35 P.M., CHARGE NURSE "P" ENTERED THE ROOM. THE NURSE THEN CALLED CERTIFIED NURSING ASSISTANT (CNA) "Q" TO ASSIST WITH RETURNING THE RESIDENT TO BED AND ASSESSING THE RESIDENT FOR INJURY. UPON REQUEST, NURSE "P" CHECKED THE RESIDENT'S BED ALARM (PERSONAL SAFETY DEVICE). NURSE "P" NOTED THAT THE ALARM HAD FAILED TO SOUND WHEN RESIDENT #408 GOT OUT OF BED. NURSE "P" CHECKED THE ALARM AND REPORTED THAT IT WAS IN PLACE AND TURNED ON, BUT HAD MALFUNCTIONED. ON 10/20/11 AT 10:15 A.M., RESIDENT #410'S FACILITY "EVENT REPORTS" (I&A) WERE REVIEWED AND REVEALED THE RESIDENT HAD SUFFERED FOUR FALLS IN THE FACILITY, AND FOR THREE OF THE FOUR FALLS, THE RESIDENT'S PERSONAL ALARM HAD FAILED TO SOUND. ON 10/21/11 AT 9:10 A.M., RESIDENT #410'S CLINICAL RECORD AND FACILITY "EVENT REPORTS" (I&A) WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON) AND THE UNIT MANAGER, NURSE "A" AND REVEALED THE FOLLOWING: 1. A FACE SHEET DOCUMENTED THAT RESIDENT #410 WAS admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A MINIMUM DATA SET ASSESSMENTS ((MDS) dated [DATE] REVEALED THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT (DEMENTIA), NEEDED SUPERVISION FOR TRANSFER FROM BED, NEEDED ASSISTANCE FROM STAFF FOR AMBULATION (WALKING), DRESSING, TOILETING AND HYGIENE, AND WAS OCCASIONALLY INCONTINENT OF BLADDER. THE MDS ALSO DOCUMENTED THE RESIDENT HAD UNSTEADY BALANCE DURING WALKING AND TRANSITIONS. AN MDS dated [DATE] REVEALED THE RESIDENT HAD SUFFERED A DECLINE IN ABILITIES, AND NEEDED EXTENSIVE ASSISTANCE FOR TRANSFER FROM BED, AMBULATION AND TOILETING. 2. TWO NURSING CARE PLANS FOR FALLS FOR RESIDENT #410 WERE FOUND IN THE CLINICAL RECORD, ONE DATED 11/29/10, REVISED 5/17/11, AND ANOTHER DATED 8/12/10, REVISED 10/18/11. THE UNIT MANAGER WAS UNABLE TO EXPLAIN WHY THERE WERE MULTIPLE ACTIVE CARE PLANS. BOTH FALLS CARE PLANS REVEALED THAT RESIDENT #408 WAS AT MODERATE RISK FOR FALLS, DESPITE SUFFERING FOUR FALLS IN THE FACILITY SINCE JANUARY 2011. THE NURSE MANAGER WAS QUERIED ABOUT THIS, AND REPORTED THAT FALLS RISK ASSESSMENTS WERE PERFORMED YEARLY, BUT DID NOT EXPLAIN WHY THEY WERE NOT UPDATED AS RESIDENT #410'S ABILITIES AND BALANCE DECLINED. THE FALLS CARE PLAN DATED 8/12/10 HAD AN INTERVENTION INITIATED (STARTED) ON 8/12/11 "ALARMS ON BED AND WHEELCHAIR. ENSURE THE DEVICE IS WORKING AND IN PLACE AS NEEDED." WHEN QUERIED ABOUT THIS, THE UNIT MANAGER "A" REPORTED THAT RESIDENT #410'S PERSONAL ALARMS HAD BEEN IN PLACE FOR A LONG TIME, BUT WHEN REQUESTED, WAS UNABLE TO PROVIDE DOCUMENTATION OF WHEN THEY WERE FIRST IMPLEMENTED. 3. REVIEW OF A PHYSICIAN'S ORDERS SUMMARY DATED 10/1/11, REVEALED AN ORDER, "BED ALARM FOR SAFETY." 4. AN I&A DATED 3/10/11 DOCUMENTED THAT RESIDENT #410 WAS FOUND ON THE FLOOR OF THE ROOM AT 2:00 A.M. THE REPORT NOTED THAT THE BED AND CHAIR ALARMS WERE INTACT, BUT "WERE NOT WORKING." THE REPORT DOCUMENTED THAT NO CHANGES WERE MADE TO THE PLAN OF CARE. REVIEW OF THE NURSING CARE PLANS FOR FALLS REVEALED THAT NO NEW POST FALLS INTERVENTIONS WERE ADDED. 5. AN I&A DATED 3/27/11 DOCUMENTED THAT RESIDENT #410 WAS FOUND ON THE FLOOR OF THE ROOM AT 11:15 P.M. THE REPORT NOTED THAT THE RESIDENT HAD SUFFERED, "A SMALL GASH ON RIGHT UPPER LATERAL SIDE OF HEAD." WHEN REQUESTED, UNIT MANAGER "A" WAS UNABLE TO PROVIDE DOCUMENTATION THAT THE PERSONAL ALARMS WERE IN PLACE AND FUNCTIONING AT THE TIME OF THE FALL. THE COMMENTS DOCUMENTED, "ADD LOW BED AND FLOOR MAT WITH ALARM BED AND W/C (WHEELCHAIR)." WHEN REQUESTED, NEITHER THE DON NOR THE UNIT MANAGER COULD EXPLAIN WHAT THIS MEANT, AS THE RESIDENT ALREADY HAD BED AND W/C ALARMS IN PLACE. REVIEW OF THE NURSING CARE PLANS FOR FALLS REVEALED THAT NO NEW POST FALLS INTERVENTIONS WERE ADDED. 6. AN I&A DATED 5/27/11 DOCUMENTED THAT RESIDENT #410 WAS FOUND ON THE FLOOR BY THE BED AT 9:20 P.M. THE REPORT NOTED, "NO CHANGE TO PLAN OF CARE IS EFFECTIVE." A "FIRST RESPONDER ANALYSIS", DATED 5/27/11, DOCUMENTING THE FALL DOCUMENTED THAT, "BED ALARM WAS ON BUT IT'S NOT ALARMING." REVIEW OF THE NURSING CARE PLANS FOR FALLS REVEALED THAT NO NEW POST FALLS INTERVENTIONS WERE ADDED. 7. AN I&A DATED 10/18/11 DOCUMENTED THAT RESIDENT #410 WAS FOUND ON THE FLOOR AT 2:35 P.M. THE REPORT NOTED, "BED ALARM IN PLACE. HAS SHORT IN CORD." THE REPORT NOTED, "ALARM WAS MALFUNCTIONING. WILL REPLACE BED ALARM AND RUN ALARM AUDITS ON ALL ALARMS IN UNIT." WHEN QUERIED, UNIT MANAGER "A" AND THE DON WERE UNABLE TO EXPLAIN WHY RESIDENT #410'S PERSONAL ALARM MALFUNCTIONED ON THREE SEPARATE OCCASIONS, RESULTING IN FALLS. REVIEW OF THE FACILITY POLICY TITLED, "FALL PREVENTION PROGRAM", REVISED 3/21/11, REVEALED THE FOLLOWING STATEMENTS: 1. " WHEN A RESIDENT HAS A SIGNIFICANT CHANGE OR FALLS, A FALL ASSESSMENT IS TO BE DONE." 2. IF RESIDENT CANNOT TRANSFER WITHOUT ASSISTANCE, WALK WITHOUT ASSISTANCE, STAND INDEPENDENTLY, RESIDENT CANNOT USE THE CALL LIGHT INDEPENDENTLY, "THE FOLLOWING INTERVENTIONS IMPLEMENTED, SAFETY ALARMS." ( ) II. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT AN UNATTENDED MEDICATION CART WAS SECURELY LOCKED, AND NARCOTICS WERE DOUBLE LOCKED, RESULTING IN THE POTENTIAL FOR POISONING DUE TO ACCIDENTAL INGESTION BY RESIDENTS WITH DEMENTIA, AS WELL AS THE POTENTIAL FOR SUBSTANCE ABUSE FROM STOLEN PSYCHOACTIVE MEDICATIONS. FINDINGS INCLUDE: ON 10/19/11 AT 9:A.M., NURSE "S" WAS OBSERVED ADMINISTERING MORNING MEDICATIONS (MED PASS) TO RESIDENT #3. THE NURSE ENTERED THE ROOM WITHOUT LOCKING THE MEDICATION CART, AND ADMINISTERED THE MEDICATIONS TO RESIDENT #3. THE MEDICATION CART REMAINED UNLOCKED IN THE HALLWAY, OUT OF THE NURSE'S VIEW, AS SHE ADMINISTERED THE MEDICATIONS. THE NURSE WAS QUERIED ABOUT THE UNLOCKED UNATTENDED MEDICATION CART, AND REPORTED, "I USUALLY LOCK IT." ON 10/20/11 AT 3:30 P.M. THE DIRECTOR OF NURSING (DON) WAS QUERIED AND REPORTED THAT MEDICATION CARTS MUST BE LOCKED WHEN OUT OF THE NURSE'S SIGHT TO PREVENT ACCIDENTAL INGESTION OF MEDICATIONS BY CONFUSED RESIDENTS. THE FACILITY POLICY ON MEDICATION STORAGE WAS REQUESTED, AND A POLICY TITLED, " MEDICATION STORAGE" , REVISED 2009, WAS PROVIDED AND REVIEWED, AND CONTAINED THE FOLLOWING INFORMATION, "MEDICATIONS MUST BE KEPT LOCKED AT ALL TIMES WHEN NOT IN USE." ( )

THIS CITATION PERTAINS TO INTAKE # MI 785. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION TO 1 RESIDENT (#101) OF 9 RESIDENTS REVIEWED FOR SUPERVISION DURING MEALS TO ENSURE SAFE SWALLOWING, FROM A TOTAL SAMPLE OF 9 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHO WAS EATING UNSUPERVISED AND HAD A CHOKING EPISODE FROM A FOOD ITEM THAT WAS NOT APPROPRIATE FOR HER. RESIDENT #101 SUBSEQUENTLY died . THE POTENTIAL REMAINS FOR SERIOUS INJURY, HARM, IMPAIRMENT OR DEATH TO ANY RESIDENT WHO REQUIRES SUPERVISION WHILE EATING. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE FACE SHEET DATED [DATE], RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT # 101 REQUIRED SUPERVISION BY FACILITY STAFF WHEN EATING. SHE HAD SEVERAL [DIAGNOSES REDACTED]. THE RESIDENT HAD A physician's orders [REDACTED]. THE SPEECH THERAPY EVALUATION DATED [DATE], SAID THAT RESIDENT #101 SUFFERED FROM OROPHARYNGEAL DYSPHAGIA (DIFFICULTY EMPTYING MATERIAL FROM THE ORAL CAVITY INTO THE ESOPHAGUS), REDUCED MASTICATION (NOT CHEWING AS MUCH AS NORMAL) AND POCKETING (LEAVING FOODS IN THE MOUTH WHEN SWALLOWING). THE SPEECH THERAPY EVALUATION REQUIRED ASPIRATION PRECAUTIONS (MEASURES DESIGNED TO PREVENT THE DRAWING OF A FOREIGN SUBSTANCE, SUCH AS THE GASTRIC CONTENTS OR FOOD, INTO THE RESPIRATORY TRACT) AND SUPERVISION TO BE IMPLEMENTED FOR RESIDENT #101. THE CARE PLAN DATED [DATE] IDENTIFIED RESIDENT #101'S RISK OF ASPIRATION AND LISTED SEVERAL INTERVENTIONS INCLUDING A MECHANICAL SOFT DIET AND "...MONITOR...FOR DIFFICULTY SWALLOWING, HOLDING FOOD IN MOUTH, PROLONGED SWALLOWING TIME, DROOLING, POCKETING FOOD IN MOUTH..." ON [DATE] AT 11:00 A.M., THE SPEECH THERAPIST (SPT #1) WAS INTERVIEWED REGARDING RESIDENT #101. SPT #1 SAID RESIDENT #101 NEEDED ATTENTION WHILE EATING AND DIRECT SUPERVISION BY STAFF. SPT #1 SAID SHE IMPLEMENTED ASPIRATION PRECAUTIONS AND SUPERVISION FOR RESIDENT #101, WHICH REQUIRED SOMEONE TO BE PHYSICALLY PRESENT AT THE TABLE SUPERVISING RESIDENT #101 TO ENSURE SHE ATE SAFELY. ACCORDING TO THE NURSE'S NOTES AND SPEECH THERAPY EVALUATION, DATED [DATE], RESIDENT #101 MOMENTARILY CHOKED ON SPINACH ON [DATE] AT 1:30 P.M., BUT HAD NO NEGATIVE EFFECTS. RESIDENT #101 WAS IMMEDIATELY REASSESSED BY THE SPEECH THERAPIST (SPT) #1. ACCORDING TO SPT #1'S NOTES DATED [DATE], RESIDENT #101 WAS NO LONGER SAFE TO EAT A MECHANICALLY SOFT DIET AND THE PHYSICIAN WAS CONTACTED FOR A CHANGE IN THE DIET ORDER. ACCORDING TO THE NURSE ' S NOTES DATED [DATE], A physician's orders [REDACTED].M. THAT CHANGED RESIDENT #101'S DIET ORDER TO A PUREED DIET WITH NECTAR THICK LIQUIDS. IN AN INTERVIEW ON [DATE] AT 2:55 P.M., LICENSED PRACTICAL NURSE (LPN) #2 SAID THAT ON [DATE] AT APPROXIMATELY 5:30 P.M., HE PROVIDED A MECHANICALLY SOFT MEAL TRAY TO RESIDENT #101, WHO WAS SITTING IN THE FACILITY DINING ROOM, A LARGE ROOM THAT IS SEPARATED BY A WIDE PASSAGEWAY AND A HALF-HEIGHT WALL PASSING THROUGH THE MIDDLE OF THE ROOM. INDEPENDENT EATERS SIT ON ONE SIDE (REGULAR SIDE) OF THE HALF-HEIGHT WALL, AND DEPENDENT EATERS (" FEEDERS") SIT ON THE OPPOSITE SIDE, BEYOND THE WIDE PASSAGEWAY. THE SET-UP OF THE ROOM REQUIRES SEPARATE NURSES TO SUPERVISE THESE TWO GROUPS OF RESIDENTS DUE TO THE SEPARATE VISUAL FIELDS. RESIDENT #101 WAS SITTING IN THE SECTION OF THE ROOM WHERE THE INDEPENDENT EATERS SAT. LPN #2 SAID THAT HE WAS REQUIRED TO BE IN THE REGULAR SIDE OF THE DINING ROOM SUPERVISING RESIDENTS INCLUDING RESIDENT #101 DURING THE EVENING MEAL ON [DATE], BUT THAT HE LEFT THE DINING ROOM AND NO ONE WAS SUPERVISING RESIDENT #101 WHILE SHE ATE. IN AN INTERVIEW ON [DATE] AT 10:00 A.M., CERTIFIED NURSING ASSISTANT (CNA) #1 SAID THAT THREE OTHER CNAS AND A NURSE WERE FEEDING RESIDENTS ON THE "...FEEDER SIDE..." CNA #1 SAID THAT SHE WAS IN THE PASSAGEWAY BETWEEN THE DINING AREAS PASSING TRAYS TO THE RESIDENTS AND THAT NO STAFF MEMBERS WERE ON THE "...REGULAR SIDE..." OF THE DINING ROOM. CNA #1 SAID THAT RESIDENT #101'S BACK WAS TOWARDS HER (CNA #1). CNA #1 SAID NEITHER SHE, NOR ANY STAFF MEMBER WAS SUPERVISING RESIDENT #101 DURING THE EVENING MEAL ON [DATE]. ON [DATE] AT 10:00 A.M., CERTIFIED NURSING ASSISTANT (CNA) #1 SAID THAT ON [DATE] AT APPROXIMATELY 5:36 P.M., A VISITOR TOLD CNA #1 SHE BELIEVED RESIDENT #101 WAS CHOKING. CNA #1 WENT TO RESIDENT #101'S TABLE, SAW SHE WAS NOT BREATHING AND WAS UNRESPONSIVE. CNA #1 SAID THAT SHE GRABBED A WHEELCHAIR, PUT RESIDENT #101 INTO IT AND RAN TO THE 1-WEST NURSES' STATION. IN AN INTERVIEW ON [DATE] AT 2:55 P.M., LPN #2 SAID THAT, ON [DATE], CNA #1 BROUGHT RESIDENT #101 TO THE 1-WEST NURSES' STATION AND SAID THAT RESIDENT #101 CHOKED WHILE IN THE DINING ROOM. LPN #2 SAID HE IMMEDIATELY ASSESSED RESIDENT #101 AND FOUND SHE WAS NOT CONSCIOUS OR BREATHING. LPN #2 SAID HE AND LPN #1 TOOK TURNS PERFORMING THE HEIMLICH MANEUVER ON RESIDENT #101, WHO WAS UNCONSCIOUS, AND PROVIDED RESIDENT #101 WITH "...BACK BLOWS AND FINGER SWEEPS..." RESIDENT #101 WAS TRANSPORTED TO A LOCAL HOSPITAL WHERE, ACCORDING TO THE MEDICAL RECORDS, RESIDENT #101 CHOKED ON HER FOOD AND STOPPED BREATHING. RESIDENT #101 HAD A VERY POOR PROGNOSIS, WITH [DIAGNOSES REDACTED]. RESIDENT #101 expired on [DATE] AT 10:50 A.M. ON [DATE] AT 11:18 A.M., CNA #3 WAS INTERVIEWED. CNA #3 SAID THAT ASPIRATION PRECAUTIONS MEANT THERE WAS "...A GOOD CHANCE SHE (RESIDENT #101) COULD CHOKE..." AND THAT RESIDENT #101 NEEDED "...TO BE MONITORED..." CNA #3 SAID THAT THREE CNAS AND A NURSE WERE FEEDING RESIDENTS ON THE "...FEEDER SIDE..." CNA #3 SAID THAT NO STAFF MEMBERS WERE ON THE "...REGULAR SIDE..." OF THE DINING ROOM SUPERVISING RESIDENT #101. CNA #3 SAID RESIDENT #101 SHOULD HAVE BEEN ON THE FEEDER SIDE OF THE DINING ROOM SO THAT SHE COULD HAVE BEEN SUPERVISED DIRECTLY. ON [DATE] AT 10:40 A.M., THE DIRECTOR OF NURSING (DON #1) SAID THAT ACCORDING TO THE RESIDENT'S ASSESSMENT, A LICENSED NURSE SHOULD HAVE BEEN WITH HER (RESIDENT #101) SUPERVISING HER FOOD CONSUMPTION. DON #1 SAID THAT AT THE FACILITY, ASPIRATION PRECAUTIONS MEANT THAT NURSES WERE TO KEEP THE HEAD OF THE BED FOR RESIDENTS RECEIVING TUBE FEEDINGS AT OR ABOVE 30 DEGREES. DON #1 SAID, "...I BELIEVE THE STAFF KNOWS WHAT TO DO FOR RESIDENTS..." WITH ORDERS FOR ASPIRATION PRECAUTIONS ORDERED WHO ARE TAKING FOOD ORALLY. DON #1 SAID THAT THERE WAS NO POLICY OR PROCESS FOR NURSING STAFF THAT DEFINED WHAT IS MEANT BY "ASPIRATION PRECAUTIONS." DON #1 SAID AFTER THIS INCIDENT, SPT #1 "DID SOME EDUCATION FOR THE STAFF...IS IT TIGHT ENOUGH? NO, IT'S NOT..." ON [DATE] AT 12:35 P.M., THE FOOD SERVICE DIRECTOR (CDM #1) SAID THAT ASPIRATION PRECAUTIONS MEANT THAT FACILITY STAFF MUST DIRECTLY OBSERVE THE RESIDENT DURING MEALS FOR SAFETY OR FEED THEM. CDM #1 SAID SHE DIDN'T KNOW OF ANY SPECIFIC POLICY IN THE FACILITY THAT DEFINED THE MEANING OF ASPIRATION PRECAUTIONS TO THE NURSING STAFF. ON [DATE] AT 12:35 P.M., THE ASSISTANT DIRECTOR OF NURSING (DON #2) SAID ASPIRATION PRECAUTIONS MEANT THAT STAFF MUST OBSERVE RESIDENTS DURING MEALS FOR SAFETY. ACCORDING TO THE FACILITY POLICY, "DINING ROOM MONITORING AND NURSING RESPONSIBILITIES," DATED [DATE], NURSING STAFF WERE REQUIRED TO "...SEE THAT ALL RESIDENTS RECEIVE THE CORRECT TRAY, MAKE SURE THAT (THE RESIDENT'S) TRAY IS PREPARED APPROPRIATELY FOR RESIDENTS..." AND "...MONITOR RESIDENTS FOR ASSISTANCE WITH FEEDING..." ON [DATE] AT 12:25 P.M., DON #1 SAID THAT ON THE EVENING OF [DATE], THE NURSE WAS NOT IN THE DINING ROOM AND NO STAFF MEMBER WAS SUPERVISING RESIDENT #101 AT THE TIME SHE CHOKED ON HER FOOD. ON [DATE] THE FACILITY IDENTIFIED 68 OTHER RESIDENTS IN THE FACILITY WITH PHYSICIAN ORDERS [REDACTED]. ON [DATE], AT 12:38 P.M., AN IMMEDIATE JEOPARDY SITUATION WAS IDENTIFIED AT F-323. THE ADMINISTRATOR WAS INFORMED ON [DATE], AT 2:47 P.M., OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] WHEN THE FACILITY FAILED TO ADEQUATELY SUPERVISE A RESIDENT WHO REQUIRED SUPERVISION AND ASPIRATION PRECAUTIONS WHEN EATING. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] NURSING DEPARTMENT MONITORING AND SUPERVISING ASSIGNMENTS HAVE BEEN MADE TO COVER THE MEALTIME HOURS. 2. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] THE FACILITY'S UNIT COORDINATORS WERE EDUCATED ON THE NURSING DEPARTMENT MONITORING AND SUPERVISING ASSIGNMENTS. 3. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] THE FACILITY IMPLEMENTED THE NURSING DEPARTMENT MONITORING AND SUPERVISING ASSIGNMENTS PLAN. 4. ON [DATE], THE SURVEYOR CONFIRMED THAT THE "DINING ROOM MONITORING NURSING RESPONSIBILITIES" PROTOCOL WAS REVIEWED AND REVISED ON [DATE]. 5. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] 26 OUT OF 40 NURSES WERE IN-SERVICED ON THEIR RESPONSIBILITIES WHEN ASSIGNED TO THE DINING ROOM. 6. ON [DATE], THE SURVEYOR CONFIRMED FOR ALL DINING AREAS THE FACILITY'S DINING ROOM CALENDAR VERIFICATION OF NURSING PRESENCE IN THE DINING ROOM FOR RESIDENT SUPERVISION WHICH BEGAN ON [DATE]. 7. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] THE UPDATED PROTOCOL FOR DINING ROOM MONITORING WAS DEVELOPED. 8. ON [DATE], THE SURVEYOR CONFIRMED THAT ON [DATE] 37 OUT OF 40 NURSES WERE IN-SERVICED ON THE UPDATED PROTOCOL FOR DINING ROOM MONITORING. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF WIDESPREAD 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. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER (S): MI 117, MI 179 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PREVENTIVE AND ADEQUATE INTERVENTIONS TO PREVENT FALLS FOR ONE (#501) OF THREE RESIDENTS REVIEWED FOR FALLS FROM A TOTAL OF SIX SAMPLED RESIDENTS RESULTING IN RESIDENT #501 SUSTAINING A FALL WITH FRACTURE. FINDINGS INCLUDE: A COMPLAINT ON FILE ALLEGED THAT RESIDENT #501 fell AND SUSTAINED INJURY. ACCORDING TO THE ADMISSIONS FACE SHEET, RESIDENT #501 WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT RESIDENT #501 REQUIRED EXTENSIVE ASSISTANCE WITH AMBULATING IN ROOM AND IN CORRIDORS, DRESSING, PERSONAL HYGIENE AND BATHING AND REQUIRED A WHEELCHAIR AND/OR WALKER FOR MOBILITY. THE CARE AREA ASSESSMENT (CAA) REVEALED "...RESIDENT (#501) HAS BOTH SHORT TERM AND LONG TERM DEFICITS. HE HAS A [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #501'S "FALL ASSESSMENT" DATED 5/17/11, REVEALED THAT RESIDENT #501 HAD A FALL RISK SCORE OF 17. THE ASSESSMENT FURTHER INDICATED THAT "(...A SCORE OF 16 OR MORE INDICATES RISK OF FALLING), KEEPS TRANSFERRING SELF WITHOUT CALLING FOR ASSISTANCE, UNABLE TO INDEPENDENTLY COME TO A STANDING POSITION, LOSES BALANCE WHILE STANDING, USES ASSISTIVE DEVICES..." ACCORDING TO RESIDENT #501'S "RESIDENT STATUS SHEET" RESIDENT #501 WAS CONFUSED AND REQUIRED ONE PERSON ASSISTANCE FOR TRANSFERS AND MOBILITY AND WAS TO AMBULATE WITH USE OF A GAIT BELT (USED TO ASSIST IN TRANSFERS AND AMBULATION). A REVIEW OF RESIDENT #501'S "PHYSICAL THERAPY EVALUATION/CARE PLAN" DATED 6/10/11, RESIDENT #501 REQUIRED STAND BY ASSISTANCE AND CONTACT GUARD WITH TRANSFERS AND REQUIRED CONTACT GUARD ASSISTANCE WITH GAIT/AMBULATION. A REVIEW OF A PHYSICAL THERAPY NOTE DATED 7/8/11 REVEALED "...HE (#501) BENEFITS FROM CONTACT GUARD ASSISTANCE FOR TRANSFERS SECONDARY TO MENTATION/SAFETY AWARENESS..." A REVIEW OF THE FACILITY'S "EVENT REPORT" DATED 7/14/11 REVEALED THAT ON 7/14/11 AT 1:50 A.M., RESIDENT #501 WAS "...NOTED SITTING UP ON THE FLOOR BETWEEN THE BED AND DRESSER WITH HIS WHEELCHAIR CLOSE BY AND ALARM SOUNDING. 1.5 CM (CENTIMETER) BY 2 CM RED, MINOR LIMITED ROM (RANGE OF MOTION), SWELLING AND PAIN..." THE EVENT REPORT FURTHER REVEALED "...RESIDENT (#501) ATTEMPTING TO SELF TRANSFER OOB (OUT OF BED) TO WHEELCHAIR POSSIBLY TOILETING. RESIDENT DID NOT KNOW. DID FALL HITTING HIS HEAD AND RIGHT KNEE. WHEN TOLD HE WASN'T GOING TO HOSPITAL, RESIDENT STARTED SCREAMING "MY LEG, MY LEG" RESIDENT REFUSED FURTHER EXAMINATION AND INSISTED HIS LEG WAS SEVERELY HURT. BECAUSE OF HIS SCREAMING AND CARDIOPULMONARY HISTORY, SENT TO ER (emergency room ). WE WILL PUT LOW BED, BLOOR MAT AND BED ALARMS TO PLAN OF CARE..." A REVIEW OF THE FACILITY'S "FIRST RESPONDER ANALYSIS REPORT" DATED 7/14/11 REVEALED "..RESIDENT ATTEMPTED TO TRANSFER SELF OUT OF BED TO THE WHEELCHAIR. DID NOT USE CALL LIGHT. TILE FLOOR, NO NON SKID SOCKS OR SHOES, DEMENTIA, POOR SAFETY AWARENESS, WEAKNESS, LOSS OF BALANCE AND COORDINATION RELATED TO DEMENTIA. RESIDENTS FOOT SLIPPED DURING TRANSFER, LOST HIS BALANCE AND fell . RESIDENT HAS PREVIOUS HISTORY OF NON ASSISTED TRANSFERS. WILL GET LOW BED AND FLOOR MAT..." A physician's orders [REDACTED]." A REVIEW OF RESIDENT #501'S X-RAY REPORT DATED 7/14/11 REVEALED "...TWO VIEWS OF THE RIGHT LOWER LEG WERE OBTAINED. EVALUATION OF THE LOWER LEG IS SLIGHTLY LIMITED BY UNDER PENETRATION OF THE FILMS. THERE IS NO APPARENT FRACTURE. IMPRESSION: NO EVIDENCE OF FRACTURE..." A REVIEW OF RESIDENT #501'S HOSPITAL RECORDS REVEALED "...PATIENT'S NURSING HOME STATED THAT THE PATIENT fell ABOUT TWO FEET FROM THE SIDE OF THE BED EARLY THIS MORNING, LANDING ON HIS RIGHT KNEE. RIGHT KNEE IS EDEMATOUS (SWOLLEN) AND PATIENT IS CRYING OUT WHILE HOLDING HIS RIGHT KNEE..." "...FALL RISK: CONFUSION OR DISORIENTATION, UNABLE O RISE WITHOUT ASSISTANCE, FALL RISK ID (IDENTIFICATION) BAND APPLIED..." "...PATIENT APPEARS ANXIOUS, CONFUSED, IN DISTRESS DUE TO PAIN, RESTLESS, UNCOMFORTABLE..." A REVIEW OF THE HOSPITAL CT (COMPUTED TOMOGRAPHY) PELVIS WITH REFORMATTED IMAGES FROM 7/15/11 REVEALED "...IMPRESSION: IMPACTED SUBCAPITAL FRACTURE INVOLVING THE RIGHT FEMORAL NECK AS DESCRIBED..." A REVIEW OF RESIDENT #501'S HOSPITAL DISCHARGE DOCUMENT REVEALED "...THIS IS A [AGE] year OLD MALE PRESENTING TO THE EMERGENCY DEPARTMENT FROM A NURSING HOME AFTER FALLING FROM HIS BED AND FALLING ON HIS RIGHT SIDE. AN EMERGENCY CONSULTATION WAS PLACED TO THE ORTHOPEDIC SERVICES. THEY DID PERFORM SURGERY ON THE PATIENT, WHICH CONSISTED OF A CLOSED REDUCTION, INTERNAL FIXATION OF THE RIGHT FEMORAL NECK..." ON 7/28/11 AT 11:32 A.M., DURING AN INTERVIEW, RN #1 REPORTED "...HE (#501) fell on [DATE] ATTEMPTING TO SELF TRANSFER..." WHEN ASKED HOW HE WAS MADE AWARE THAT RESIDENT #501 WAS ATTEMPTING TO SELF TRANSFER AT THE TIME OF THE FALL, RN #1 SAID "...THE AIDE SAID THAT HE WAS IN BED PREVIOUSLY SO THE ASSUMPTION WAS MADE THAT HE WAS SELF TRANSFERRING..." WHEN ASKED IF RESIDENT #501 WAS IDENTIFIED AS A FALLS RISK UPON ADMISSION, RN #1 SAID "...YES. HE'S HAD PREVIOUS FALLS DUE TO ATTEMPTS TO SELF TRANSFER. HE fell BACK IN MAY ALSO..." REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #501 HAD A PREVIOUS FALL ON 5/17/11 AND WAS "...OBSERVED SITTING ON THE FLOOR ON HIS BUTTOCKS BETWEEN THE BED AND THE DRESSER AND IN FRONT OF HIS UNLOCKED WHEELCHAIR. HAS ALARM IN BED AND WHEELCHAIR. REFERRAL MADE TO PT (PHYSICAL THERAPY) FOR SAFETY AND TRANSFER STRENGTHENING..." WHEN ASKED WHAT INTERVENTIONS WERE IMPLEMENTED AFTER RESIDENT #501 fell on [DATE], RN #1 SAID "...NO ADDITIONAL INTERVENTIONS. I JUST REFERRED TO PT. HE HAD AN ALARM TO HIS BED AND WHEELCHAIR. HE DIDN'T HAVE A LOW BED OR CONCAVE MATTRESS. HE DIDN'T HAVE BARS ON HIS BED OR FLOOR MATS..." ON 7/28/11 AT 3:15 P.M., WHEN QUERIED ABOUT RESIDENT #501'S TRANSFER STATUS, THE PHYSICAL THERAPIST (PT) REPORTED "...I DID AN EVALUATION ON HIM (#501) AND WROTE A NOTE IN THE CHART." THE PT REFERRED TO A NOTATION IN THE CLINICAL RECORD DATED 6/10/11, WHICH REVEALED "...PT (PATIENT) NEEDS SAFETY REFRESHERS AS HE TENDS TO MOVE/TRANSFER WITHOUT ASKING FOR HELP. WILL FOCUS ON SAFETY AND CONTINUE STRENGTHENING PROGRAM..." WHEN ASKED IF RESIDENT #501 WAS A FALLS RISK, THE PT SAID "YES, HE REQUIRES ASSISTANCE WITH TRANSFERRING AND AMBULATING. HE NEEDS SOMETHING ELSE IN PLACE BECAUSE HE'S GOING TO KEEP TRYING TO GET UP ON HIS OWN..." ON 7/28/11 AT 3:20 P.M., DURING A SUBSEQUENT INTERVIEW, RN #1 WAS QUERIED ABOUT THE THERAPY NOTATION REGARDING RESIDENT #501'S LACK OF SAFETY AWARENESS. WHEN ASKED IF HE (RN #1) HAD REVIEWED PT'S NOTE IN THE CLINICAL RECORD, RN #1 SAID "...YES. I THINK I'M THE ONE WHO REFERRED HIM (#501) TO THERAPY IN THE FIRST PLACE AFTER HE fell IN MAY..." WHEN ASKED WHY NO ADDITIONAL INTERVENTIONS WERE IMPLEMENTED AFTER PHYSICAL THERAPY'S EVALUATION, RN #1 SAID "...I REALLY DON'T KNOW. IT JUST DIDN'T SEEM THAT MUCH OF A DIRE NEED AT THAT POINT..." RN #1 FURTHER STATED "...IF HE'D (#501) HAD A MAT ON THE FLOOR NEXT TO HIS BED OR A LOW BED, HE PROBABLY WOULD'VE ONLY GOTTEN AN ABRASION WHEN HE fell ..." RN #1 HAD NO EXPLANATION OF WHY NO ADDITIONAL INTERVENTIONS WERE IMPLEMENTED AFTER RESIDENT #501 fell IN MAY OF 2011 WHICH COULD HAVE PREVENTED SIGNIFICANT' INJURIES TO RESIDENT #501 AFTER THE FALL HE SUSTAINED ON 7/14/11. ON 7/28/11 AT 4:10 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED "...HE (#501) SHOULD HAVE A MAT (FLOOR MAT)..." ON 7/28/11 AT 5:05 P.M., DURING AN INTERVIEW, CERTIFIED NURSING ASSISTANT (CNA) #1 REPORTED "...I WAS GIVING CARE TO ANOTHER RESIDENT AND I HEARD AN ALARM SO I WENT INTO HIS (#501) ROOM AND HE WAS ON THE FLOOR BETWEEN THE DRESSER AND THE BED..." WHEN QUERIED ABOUT THE LAST TIME RESIDENT #501 HAS BEEN TOILETED, CNA #1 SAID "...WE DON'T DOCUMENT THE TIME, JUST THE NUMBER OF TIMES WE TOILET THE RESIDENTS..." CNA #1 FURTHER REPORTED "...HE ALWAYS ATTEMPTS TO GET OUT OF BED BY HIMSELF. HE'S NOT AWARE OF WHAT HE CAN AND CANNOT DO. HE DIDN'T HAVE A LOW BED OR A FALL MAT ON THE FLOOR. THE ALARMS WEREN'T GOOD ENOUGH. HE'S CONFUSED AT TIMES AND ALWAYS THINKS HE SEES SOMETHING IN HIS BED SO HE TRIES TO GET OUT..." THE FACILITY'S "FALLING STAR PROTOCOL" WAS REVIEWED AND REVEALED "...PERSONAL ALARMS, CHAIR/BED MAY BE UTILIZED TO ALERT NURSING STAFF WHEN RESIDENT ATTEMPTS TO TRANSFER UNASSISTED..." THE FACILITY'S FALL POLICY DID NOT ADDRESS UPDATING AND IMPLEMENTING ADDITIONAL INTERVENTIONS TO ENSURE THEIR EFFECTIVENESS AS THEY PERTAIN TO THE INDIVIDUAL RESIDENT'S NEEDS.

This citation pertains to MI 852 and MI 859 Based on observation, interview and records review, the facility failed to provide the appropriate assistance during transfers in 1 of 4 sampled residents (#101) that resulted in injury. Findings include: Review of MDS (Minimum Data Set) dated 2/3/11 revealed Resident #101's cognitive status "severely impaired" (never/rarely made decisions). Review of "Physician Orders" dated 5/1/11 revealed Resident #101 had [DIAGNOSES REDACTED]. Resident #101 was interviewed on 5/24/11 at 10:30 am in resident room. No useful information was obtained. On 5/25/11 at 2:00 pm, Resident 101's legs and feet were observed accompanied by the DON (Director of Nurses). Observation revealed left and right toes were in same plane as left and right ankle; DON indicated "foot drop". The left foot big toe was bruised. There was a splint on the left leg. Review of falls RAP (Resident Assessment Protocol) dated 5/10/10 revealed Resident #101, "...require full staff involvement of 2 persons for all transfers and repositioning." Review of the "Event Report" (incident report) dated 5/5/11 at 10:00 am revealed the following for Resident #101: "(Observed left medial knee and mid neck with purplish discolorations. Left knee observed with swelling.)" (sic). The Event report indicated "observed" fall "During Assisted Transfer". In a telephone interview on 5/24/11 at 12:15 pm CNA (Certified Nursing Assistant) #3 and review of the written statements dated 5/6 and 5/9/11 were confirmed by CNA #3. CNA #3 stated, "....on 5/3/11, transferred Resident #101 back to bed using stand pivot transfer (transfer method-resident must sit, stand and bear weight on a leg)...as I turned Resident #101 toward the bed, Resident's left knee buckled, I held Resident tight against myself with my chin...my chin was against residents neck...I didn't know anything happened (if a fracture occurred)...Resident didn't fall...since Resident didn't fall, I didn't report it (event) to the nurse...it happened on the 1st shift...Resident #101 is a 2 person assist, but I did it by myself..." (sic) Review of "Nursing Aide Assignment Sheet" dated 5/3 and 5/4/11 revealed CNA #4 cared for Resident #101 on the 2nd shift. In a telephone interview on 5/24/11 at 2:15 pm CNA #4 was interviewed and written statements dated 5/11/11 and a second written statement not dated were confirmed by CNA #4. CNA #4 stated, "...nothing happened on afternoon shift...I transferred Resident #101 to bed. Resident #101 was fine...I didn't see any bruising...Basically, I do Resident #101 by myself. Resident #101 is not heavy. I handle Resident #101 by myself...According to the DON, Resident #101 is a 2 person assist...". Review of the X-ray report dated 5/6/11 at 6:09 pm revealed Resident #101's left tibia (shinbone) had "fractures". The report also indicated Resident #101 had "severe osteoporosis".