Every finding on record at The Villa at Great Lakes Crossing

Based on observation, interview and record review, the facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) by wearing the required personal protective equipment (PPE) during wound care for three residents (R401, R402 and R403) of three residents reviewed under EBP due to colonization or risk factors associated with multidrug-resistant organisms (MDROs). The failure to utilize required isolation gowns during high-contact resident care increased the risk of transmission of MDROs and other infectious pathogens among residents.Findings include:On 6/10/26 at 10:40 AM, observed the Wound Care Nurse (WCN) perform wound care to R403's sacral/coccyx wound. After gathering supplies, the WCN cleansed and changed the dressing. Throughout the wound care procedure, the WCN did not wear an isolation gown as required under EBP.On 6/10/26 at 10:50 AM, observed the WCN perform wound care to R401's sacral/coccyx wound. The WCN cleansed the wound and changed the dressing without wearing an isolation gown.On 6/10/26 at 11:20 AM, observed the WCN perform wound care to R402's right heel wound. The WCN cleansed the wound and changed the dressing without wearing an isolation gown.Record review revealed:R403 was admitted on [DATE] with diagnoses including major depressive disorder, hypertension, myocardial infarction, atrial fibrillation, pneumonia, chronic obstructive pulmonary disease and acute respiratory failure.Review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief interview for Mental Status (BIMS) score of 14/15 reflecting that the resident was cognitively intact.R401 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, atherosclerotic heart disease, congestive heart failure and osteoarthritisReview of the MDS dated [DATE] indicated resident had a BIMS of 12/15 (moderate impaired cognition).R402 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including non-pressure chronic ulcer of the right heel and midfoot, hemiplegia and hemiparesis following cerebral infarction, lumbar spinal stenosis, vascular dementia, epilepsy, mood disorder and history of falls.Review of MDS dated [DATE] noted a BIMS score of 11/15 (moderate impaired cognition).On 6/10/26 at 11:35 AM, the WCN was interviewed and said that an isolation gown was not worn during wound care because the available gowns did not fit them. The WCN further said that a request had been made for larger sized isolation gowns. The WCN acknowledged that gowns are required during wound care to reduce the risk of pathogen transmission and to protect residents from infection.On 6/10/26 at 11:45 AM, the Director of Nursing (DON) and the Nursing Home Administrator were interviewed. The DON said the purpose of EBP is to protect residents and staff from the transmission of infectious organisms. The DON said that staff are expected to wear both gowns and gloves when providing wound care and other high-contact resident care activities. The NHA said that the facility had not previously received requests from staff for larger sized isolation gowns.Review of the facility policy titled, Personal Protection Equipment Guidelines, revised 4/12/24, indicated that EBP require the use of gowns and gloves during high-contact resident care activities. The policy further identified wound care, device care, hygiene care and bathing as examples of high-contact care and noted that the use of gowns and gloves reduces the transmission of MDROs between staff and residents.

Based on observation, interview, and record review, the facility failed to ensure meals were delivered in a timely manner and in accordance with the scheduled mealtimes for the residents. Findings:On 2/18/26 at 11:30 AM, during observation of kitchen lunch service with AM Cook/Manager-in-Training (MiT) D, Dietary Manager (DM) F, and Regional Dietary Director (RDD) K, the steam table was set with pans of food ready to be served to facility residents. The following was noted while obtaining the temperatures of food on the steam table:- The mechanical soft beef stew contained large pieces of stew meat and potatoes approximately the size of golf balls.- The vegetables designated for the residents on a pureed diet contained pieces of pea-sized vegetables.- No pans of pureed meat were present.- The first meal ticket on the tray service line was for a resident on a mechanical soft diet. On 2/18/26 at 11:50 AM, DM F was queried about the consistency of the food prepared for the residents on mechanical soft and pureed diets. DM F said that AM Cook/MiT D indicated that the situation had been handled. Presently, AM Cook/MiT D had stepped out of the kitchen. On 2/18/26 at 12:02 PM, RDD K said they were going to have to hand deliver the mechanical soft diet meal trays, so the tray line was not delayed more. On 2/18/26 at 12:03 PM, upon returning to the kitchen, AM Cook/MiT D was interviewed regarding the missing pureed meat and the consistency of the stew meat, potatoes, and vegetables. AM Cook/MiT D stated, I was doing too much today. AM Cook/MiT D obtained the food processor and began to further process the mechanical soft beef stew meat and the pureed vegetables. AM Cook/MiT D obtained stew meat and processed it for the residents on pureed diets. On 2/18/26 the first lunch meal cart was completed and left the kitchen for delivery to the residents' floor at 12:13 PM. A review of a facility document provided during the survey titled, Meal Times, indicated that scheduled lunch service begins at 11:30 AM. On 2/20/26 at 10:57 AM, DM F said lunch meal service starts at 11:30 AM and the first lunch meal cart should leave the kitchen around 11:45 AM. When queried about lunch service on 2/18/26 DM F stated, The start was late. On 2/20/26 at 12:03 PM, the Nursing Home Administrator (NHA) said it was not acceptable for the meal to be served late because the food was not prepared timely. On 2/20/26 at 3:00 PM, the NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was none.

Based on observation, interview, and record review, the facility failed to ensure the reach-in cooler, located in the dietary office, was maintained in good working order. Findings include: On 2/18/26 at 9:09 AM, during a tour of the kitchen with Dietary Manager (DM) F, the following was noted: - The temperature log for the reach-in cooler located in the dietary office documented the following AM temperatures:2/15/26: 49 F (Fahrenheit).2/16/26: 48 F2/17/26: 44 F2/18/26: 45 F- The thermometer inside of the reach-in cooler registered 47 F.- The gasket for the left positioned cooler door was not installed which kept the cooler door ajar, causing the internal temperature to rise above safe levels. The door gasket was observed lying on top of a metal shelving unit.DM F said they have been having a little problem with this unit, and that maintenance had been fixing on it. DM F said this refrigerator should be maintained between 30-40 degrees. Staff were to contact maintenance if the temperature was above 40 degrees. On 2/18/26 at 9:11 AM, AM [NAME] D indicated maintenance did not come to the kitchen regarding the reach-in cooler while they worked yesterday. On 2/18/26 at approximately 9:20 AM, Maintenance Director (MD) E was in the kitchen. MD E said they were not notified yesterday regarding the elevated temperature of the reach-in cooler. MD E obtained the door gasket from the metal shelf and re-installed it on the door. MD E indicated that a properly installed gasket was necessary to get a proper seal on the reach-in cooler door. On 2/20/26 at 3:00 PM, the Nursing Home Administrator and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was none. A review of the 2013 FDA Food Code documented the following, Section 4-501.11, Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.

Based on observation, interview, and record review, the facility failed to: 1. Ensure wall surfaces were in good repair and cleanable; 2. Ensure light fixtures, vents, and a resident refrigerator were maintained in a clean and sanitary manner; 3. Ensure cleaned ladles were properly stored; and 4. Properly date-label food in the resident refrigerators. Findings include: On 2/18/26 at 8:47 AM, a tour of the kitchen was conducted with AM [NAME] and Manager in Training (MIT) D and then with Dietary Manager (DM) F. The following items were noted: The wall behind the clean pot/pan shelving unit showed surface damage and paint loss from repeated impact. Two wall panels beside the three-compartment sink drainboard were detached, exposing the raw block wall behind them. A light fixture cover positioned above the cooking range exhibited visible grease accumulation in the form of suspended droplets. DM F said the hood and light fixture covers were cleaned once a month. DM F added, If something looks like it's going to drop in the food, we move stuff (the cooking food) over and clean the light fixture. Four ladles of varying sizes were hanging from a rack, bowl side up. DM F said dust could collect inside of the bowls. The air conditioning unit vents in the room housing a reach-in cooler, reach-in freezer, and single-service items were soiled with accumulated dust. On 2/18/26 at 12:14 PM, Maintenance Director E said the wall panels/covering for the wall near the kitchen three-compartment sink were not in stock and will have to be ordered. On 2/20/26 at 9:49 AM, the contents of the 2nd floor resident refrigerator were observed with Licensed Practical Nurse (LPN) H and revealed a 3.7 oz. opened and unlabeled container of cheddar cheese sauce. LPN H said the cheddar cheese sauce was supposed to be dated and have the resident's name on it. On 2/20/26 at 10:20 AM, the contents of the 3rd floor resident refrigerator were observed with LPN I and revealed an opened and unlabeled 12 oz. can of carbonated beverage. The inside shelving of the refrigerator was stained with substances that appeared to be dried and sticky. The thermometer inside the refrigerator registered at 46 F (Fahrenheit). On 2/20/26 at 10:57 AM, DM F said that refrigerators should be maintained between 30-40 F. DM was unsure of who was responsible for cleaning the resident refrigerators. DM F confirmed that food stored in the resident refrigerators should be dated and labeled with the resident's name. DM F indicated the chipped paint behind the clean pot/pan shelving and the exposed block wall were a concern. On 2/20/26 at 11:56 AM, the Director of Nursing (DON) stated, I don't know who is responsible for cleaning the resident refrigerators. On 2/20/26 at 12:03 PM, the Nursing Home Administrator (NHA) said resident refrigerators should be clean, maintained at the correct temperature, and resident food items should be labeled and dated. On 2/20/26 at 3:00 PM, the NHA and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was none. A review of the facility document titled, Personal Food Guideline, dated 3/12/18, was reviewed and revealed in part the following:- Food brought from outside sources by residents, friends or family will be stored in a designated location and labeled as such, separately from facility food. Labeling will include received date, use by date, and resident name.- Staff members will ensure food should be labeled, dated, (and) stored in proper temperature zone. A review of the 2013 FDA Food Code documented the following: Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Section 4-602.13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Section 4-903.11. Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable.

Based on observation, interview, and record review, the facility failed to prepare meat and vegetables to the proper food consistency for the 23 residents receiving mechanical soft textured meals and 4 residents receiving pureed textured meals in the facility. Findings include: On 2/18/26 at 11:30 AM, during observations of the kitchen lunch service with AM Cook/Manager-in-Training (MiT) D, Dietary Manager (DM) F, and Regional Dietary Director (RDD) K, the steam table was set with pans of food ready to be served to facility residents. The following was noted while obtaining the temperatures of food on the steam table:- The mechanical soft beef stew contained large pieces of stew meat and potatoes approximately the size of golf balls.- The vegetables designated for the residents on a pureed diet contained pieces of pea-sized vegetables.When queried about the size of the stew meat, potatoes, and vegetables, AM Cook/MiT D stated, I was doing too much today. On 2/20/26 at 10:57 AM, DM F indicated that AM Cook/MiT D was informed that the size of the stew meat was too big for the residents on mechanical soft diets and that pureed vegetables should not be chunky with lumps in it. Pureed vegetables should be smooth like mashed potatoes. A review of a facility document titled, Mechanical Soft Diet, dated 2017, revealed in part: Unless otherwise indicated, meat and meat substitutes will be mechanically ground. A review of a facility document titled, Guidelines for Pureed Preparation., dated 2018, revealed in part: The pureed diet provides food with a semi-liquid to semi-solid consistency (i.e. pudding-like). On 2/20/26 at 3:00 PM, the Nursing Home Administrator and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was none.

Based on interview and record review the facility failed to complete and/or ensure the timely completion of comprehensive resident assessments (a complete interdisciplinary evaluation of a resident's physical , mental, psychosocial and functional status) in accordance with regulatory requirements for 13 residents (R4, R6, R33, R53, R72, R93, R94, R95, R101, R114, R124, R125, and R139) out of 13 residents reviewed for Minimum Data Set (MDS) assessment accuracy and timeliness.Findings include:During record review the following was identified: R4 Record review of R4's electronic medical record revealed admission into facility on 2/19/25 with a pertinent diagnosis of schizophrenia (mental disorder). Record review of R4's MDS Quarterly Assessment with a due date of 1/29/26 was not completed as required. R6 Record review of R6's electronic medical record revealed admission into facility on 3/4/20 with a pertinent diagnosis of hemiplegia (paralysis). Record review of R6's MDS Quarterly Assessment with a due date of 1/14/26 was completed on 2/19/26. R33 Record review of R33's electronic medical record revealed admission into facility on 12/16/20 with a pertinent diagnosis of schizophrenia (mental disorder). Record review of R33's MDS Annual Assessment with a due date of 1/13/26 was not completed as required. R53 Record review of R53's electronic medical record revealed admission into facility on 9/30/19 with a pertinent diagnosis of muscle weakness. Record review of R53's MDS Quarterly Assessment with a due date of 1/25/26 was not completed as required. R72 Record review of R72's electronic medical record revealed admission into facility on 6/23/22 with a pertinent diagnosis of cerebral vascular accident (stroke). Record review of R72's MDS Quarterly Assessment with a due date of 1/15/26 was not completed as required. R93 Record review of R93's electronic medical record revealed admission into facility on 5/26/23 with a pertinent diagnosis of sepsis due to pseudomonas (life threatening infection). Record review of R93's MDS Quarterly Assessment with a due date of 1/15/26 was not completed as required. R94 Record review of R94's electronic medical record revealed admission into facility on 12/25/20 with a pertinent diagnosis of diabetes. Record review of R94's MDS Annual Assessment with a due date of 1/25/26 was not completed as required. R95 Record review of R95's electronic medical record revealed admission into facility on 3/14/25 with a pertinent diagnosis of epilepsy (seizure disorder). Record review of R95's MDS Quarterly Assessment with a due date of 12/29/25 was completed on 2/10/26. R101 Record review of R101's electronic medical record revealed admission into facility on 10/4/23 with a pertinent diagnosis of muscle weakness. Record review of R101's MDS Quarterly Assessment with a due date of 1/25/26 was not completed as required. R114 Record review of R114's electronic medical record revealed admission into facility on 4/12/24 with a pertinent diagnosis of Alzheimer's (neurological disorder). Record review of R114's MDS Quarterly Assessment with a due date of 1/20/26 was not completed as required. R124 Record review of R124's electronic medical record revealed admission into facility on 12/30/24 with a pertinent diagnosis of an injury to head. Record review of R124's MDS Quarterly Assessment with a due date of 1/20/26 was not completed as required. R125 Record review of R125's electronic medical record revealed admission into facility on 8/4/22 with a pertinent diagnosis of dysphagia (difficulty swallowing). Record review of R125's MDS Quarterly Assessment with a due date of 1/31/26 was not completed as required. R139 Record review of R139's electronic medical record revealed admission into facility on 10/8/25 with a pertinent diagnosis of chronic kidney disease. Record review of R139's MDS Discharge Assessment with a due date of 12/20/26 was not completed as required. During an interview conducted on 2/20/26 at 11:35 AM with MDS Coordinator (MC) C, it was reported that resident assessments were not completed by the due date or finished in a timely manner. During an interview conducted on 2/20/26 at 12:40 PM with the Nursing Home Administrator (NHA), it was reported that MDS resident assessments should be completed as required by the regulations.

Based on interview and record review, the facility failed to ensure three out of five Certified Nurse Aides (CNA O, P, and Q) completed the required 12 hours of annual training to ensure adequate resident care.Findings include:On 2/20/2026 at 10:35 AM, the CNA in-service logs were reviewed with the Human Resources Manager (HRM) R. HRM R said that there were no records for trainings for CNA P and CNA Q and that CNA O did not have the required dementia training. HRM R said the trainings were important because the staff interacts with resident's who have dementia.On 2/20/2026 at 1:05 PM, the Director of Nursing (DON) was interviewed and said the expectation is for CNAs to receive 12-hour annual training including dementia and abuse since we have numerous residents with dementia.Review of the facility policy titled Training Requirements revised 2/2026 revealed in part.2. The following additional training requirements are outlined for all nurse aids: Must be no less than 12 hours per year. Address the care of the cognitively impaired.

Based on observation, interview, and record review, the facility failed to provide scheduled showers for one resident (R37) and timely nail care for one resident (R18) out of three residents reviewed for activities of daily living (ADL). Findings include: R37 – On 2/18/26 at 10:57 AM, R37 was observed awake and lying in bed. R37 stated, I'm not getting showers on a regular basis. I've gone a week and half without one. R37 reported that staff attributed the missed showers to low staffing levels. A review of the clinical record for R37 documented an admission date of 1/2/26 with diagnoses of thoracic spinal cord injury, colostomy status, and neuromuscular dysfunction of bladder. A Minimum Data Set assessment dated [DATE] documented intact cognition and dependence on staff for shower/bathing. Review of R37's care plans documented in part the following: Focus: (R37) requires assistance with daily care needs related to paraplegia. Intervention: Assist resident with ADL's. Total dependence with bathing (on) Tuesday and Friday afternoon and as needed. Date initiated 1/2/26. During an interview on 2/19/26 at 12:17 PM, Certified Nurse Aide (CNA) L said when a resident receives a shower or bed bath, a paper shower sheet is completed and point of care documentation is entered in the electronic health record (EHR). CNA L added that the completed paper shower sheets are given to the nurse. During an interview on 2/19/26 at 12:20 PM, Licensed Practical Nurse (LPN) M indicated paper shower sheets were stored in a shower book. LPN M looked for shower sheets for R37 in the shower book and there were none. LPN M said their unit manager collects them. On 2/19/26 at 12:44 PM, an interview and review of R37's clinical record was conducted with Unit Manager (UM)/LPN N. UM/LPN N confirmed CNAs document resident showers/bed baths on shower sheets and in the resident's EHR. UM/LPN N conducted a review of the shower sheets in their office and stated, I don't see any shower sheets for (R37). UM/LPN affirmed that there should be shower sheets and skin assessments completed for R37 and that refusal of care was to be documented. A review of R37's EHR, including the care plans, yielded no evidence that R37's declined showers/bed baths. UM/LPN N indicated that showers help to keep skin clean and fresh. CNA documentation of showers/bed baths in the EHR for R37 during the past 30 days revealed the following: Bed bath given on 1/22/26 Shower given on 1/30/26 Bed bath given on 2/1/26 UM/LPN N said there were multiple days R37 should have gotten a shower/bed bath and there was nothing documented. For the past 30 days those days included 1/20/26, 1/27/26, 2/3/26, 2/6/26, 2/10/26, 2/13/26, and 2/17/26. During an interview on 2/20/26 at 11:46 AM, the Director of Nursing (DON) said resident showers were needed for cleanliness, decrease infection risk, check the resident's skin, and basic hygiene. On 2/20/26 at 3:00 PM, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was none. R18 On 2/18/2026 at 9:50 AM, R18 was observed in bed with long fingernails with debris under the end of the nails. When asked if R18 wanted his nails cut R18 stated, I need help with care, I'd like my nails cut. On 2/19/2026 at 9:30 AM, R18 was interviewed and said that he received a bed bath the previous night (2/18/2026) and the aide didn't offer to cut my nails. R18 was observed with long fingernails with debris under the end of the nails. On 2/19/2026 at 10:15 AM, R18 was observed with Certified Nursing Assistant (CNA) S and Licensed Practical Nurse (LPN) T. When asked about nail care CNA S said R18's nails needed be cleaned and clipped they were dirty and long. LPN T said R18's fingernails should have been cleaned and trimmed when he was given a bed bath the night before. Record review of R18's Electronic Health Record (EHR) revealed admitted to facility on 12/24/2025 with pertinent diagnosis of Primarily Generalized Osteoarthritis, Myalgia, and Difficulty in walking. Review of the Minimum Data Set (MDS) dated [DATE] for R18 revealed a Brief interview for Mental Status (BIMS) of 15/15 intact cognition. Review of R18's care plan revealed, Focus: R18 requires assist with daily care needs r/t (related to) Generalized weakness date initiated 12/24/2025. Staff will anticipate and meet all of residents' needs on a daily basis through next review ie: clean, dry, groomed, turned and positioned. Date initiated 12/24/2025 Target Date 06/28/2026. Intervention: Hygiene Total dependence with personal hygiene Date initiated 12/24/2025. Total dependence for bathing Wednesday and Saturday morning and PRN Date initiated 12/24/2025. There were no documented refusals of ADL care. On 2/20/2026 at 1:07 PM, the Director of Nursing (DON) was interviewed and said the expectation is for all staff to identify and address ADL care with residents, CNAs and nurses. All ADLs should be addressed on showers days or as needed including nail care. Review of the facility policy titled Activities of Daily Living (ADL), Supporting revised March 2018 revealed in part.Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview and record review the facility failed to ensure medications were properly stored in accordance with accepted standards in one of three medications refrigerators reviewed. This deficient practice had the potential to affect the safety and integrity of medications stored for resident use.Findings include:An observation conducted on 2/19/2026 at 2:48 PM revealed the second- floor medication refrigerator had multiple medications stored at a temperature of 28 degrees Fahrenheit.Record review of the second-floor medication refrigerator temperature log revealed recorded temperatures ranging between 28 degrees Fahrenheit (F) and 30 degrees Fahrenheit from February 1 through February 19. 2026.Record review of Manufacturers Guidelines a list prepared for all the medications observed in second-floor medication refrigerator by the Director of nursing (DON) revealed that the medications should be stored at a temperature of 36 degrees Fahrenheit to 46 degrees Fahrenheit.During an interview, conducted on 2/20/26 at 11:17 AM with the DON, it was reported that the medication had been stored improperly in the second-floor medication refrigerator.Record review of facility's policy Medication Storage in the Facility dated May 2022, documented the following:All medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC).1. Room Temperature 59 to 77'F (15 C (Celsius) to 25 C).2. Controlled Room Temperature (the temperature maintained thermostatically) 68 to 77 F (20 to 25 C).3. Refrigerated 36F to 46 (2 to 8 C) with a thermometer to allow temperature monitoring.4. Frozen in the freezer at 14 to 20 (-10 to -7 C).

Based on interview and record review the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and/or DCH-3878 documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for mental illness needs in a timely manner for three (R13, R15, and R56) of five residents reviewed for PASAAR, resulting in the potential for residents not to receive care and services appropriate to their mental health needs. Findings include: R13: On 1/12/25 at 1:15 p.m. review of the electronic medical record documented R13 was initially admitted into the facility on [DATE] with a readmission on 12/20/24 with diagnoses that included paranoid schizophrenia. According to the quarterly Minimum Data Set assessment dated [DATE], R13 had a BIMs of 12 (moderate impaired cognition), and required total assistance with activities of daily living. Review of the Preadmission Screening (Level I Screen, 3877) dated 6/6/24, documented R13 had mental illness and receiving antidepressant/antipsychotic that was checked Yes. Explain any Yes: Schizophrenia. The prescribed antipsychotic or antidepressant was not documented on the 3877. R13 was prescribed haloperidol (antipsychotic) 5mg three times a day. Review of the electronic medical record did not include a Level II evaluation (a comprehensive evaluation by the appropriate state-designated authority - cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs .) or evidence the evaluation was requested by the facility for 2024. On 1/14/25 at 1:47 p.m. Corporate Social Worker J was interviewed and said a determination letter (a letter stating a Level II evaluation was not required) should have been sent by the state local agency due to R13 having a dementia diagnoses. Social Worker J acknowledged the 3877 did not document a dementia diagnosis but was documented on the 3878 (form for patients who meet certain criteria for exemption from Level II screening for nursing facilities). Review of the electronic medical record did not reveal a 3878 was completed for R13. Review of the facesheet, psychiatric and physician notes did not document R13 had a dementia diagnosis only the paranoid schizophrenia diagnoses. R15: On 1/12/25 at 1:45 p.m. review of the electronic medical record documented R15 was initially admitted into the facility on [DATE] with diagnoses that included unspecified dementia, psychotic disorder, and mood disorder. Review of the quarterly MDS assessment dated [DATE], R15 had a BIMs of 14 (cognitively intact), and required total assistance with activities of daily. Review of the electronic medical record revealed the most recent 3878 was dated 4/14/23 which documented dementia exemption. The medical record did not include an annual 3877 or 3878. On 1/13/25 at 3:12 p.m. a 3877 dated 7/1/24 was submitted by the facility. The 3877 was checked Yes for mental illness and receiving treatment. The annual Level II evaluation or letter of determination was submitted. On 1/14/25 at 1:35 p.m. the Corporate Social Worker J was interviewed and acknowledged the current 3877 was not in the medical record and per the facility's policy, the PASSARs do not have to put the resident's record. Social Worker J was informed PASSARs are part of the resident's medical record and should be complete. Social Worker J said they were not aware. R56: On 1/12/25 at 1:52 p.m. review of the electronic medical record documented R56 was initially admitted into the facility on [DATE] with diagnoses that included schizophrenia and vascular dementia. According to the quarterly MDS assessment dated [DATE], R56 had a BIMs of 10 (moderate cognitive impairment), and required total assistance with activities of daily living. Review of the medical record revealed on 7/12/23 OBRA Determination Letter, a Level II evaluation is needed by 7/10/24. The annual Level II evaluation was not in the medical record. The annual 3878 was not in the medical record. On 1/14/25 at 1:30 p.m. Corporate Social Worker 'J was interviewed and said the request for a Level II was submitted too early and was rejected by OBRA. However, the request should have been inquired about by the facility's social worker. The annual Level II should have been completed by 7/1/24 had it been resubmitted. Review of the facility's policy titled PASARR Guideline dated 11/28/17, documented in part the following: The purpose of this guideline is to define and set expectations regarding the appropriate preadmission assessment of all individuals with a mental disorder and individuals with intellectual disability. It is the practice of the facility to coordinate the assessment process with the preadmission screening and annual resident review (PASARR) program under Medicaid . This includes incorporating the recommendations from the PASARR level II determination and evaluation in the residents' assessment, care plan, and transition of care; and referring all level II residents and all residents with new or evident conditions related to Level II review upon significant change in status assessment . Annually and with any significant change status, the facility will complete the PASARR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly. Review of the DCH-3877, PREADMISSION SCREENING (PAS)/ ANNUAL RESIDENT (ARR) (Mental Illness/Intellectual Developmental Disability/Related Conditions Identification) Michigan Department of Health and Human Services Level I Screening form revised 3-22 documented in part: DISTRIBUTION: If any answer to items 1 - 6 in SECTION 3 is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative .

Based on observation, interview, and record review the facility failed to develop, implement, and revise care plans for one resident (R83) of two residents reviewed with an indwelling catheter, resulting in the potential for a lack of monitoring, implementation of interventions and unmet care needs. Findings include: On 1/13/25 at 5:00 P.M. License Practical Nurse G (LPN) was asked to assist in observing R83's indwelling catheter. Prior to the observation Nurse G reported the resident only had several nephrectomy tubes (a thin flexible tube that drains urine from the kidney into a bag outside the body) and not an indwelling catheter. During the observation Nurse G indicated the indwelling catheter had been discontinued a while ago. However, during the observation an indwelling catheter was present. Review of the electronic medical record (EMR) revealed R83 was admitted to the facility on [DATE] with diagnoses of: Encephalopathy, epilepsy, acute kidney failure, dissection of abdominal aorta and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated R83 had a Brief interview for Mental Status (BIMs) of 15 (cognitively intact), required assistance and supervision with Activities of Daily Living (ADL's). Review of the Care Plans revealed there were no care plan addressing the resident's indwelling catheter. During the review of the resident's care plan Nurse G acknowledged there were no care plans or interventions for the indwelling catheter only the nephrectomy tubes. On 1/14/25 at 1:45 P.M. during an interview with the Director of Nursing (DON) concerning care of R83's indwelling catheter, the DON reviewed the care plan section of the EMR and acknowledged there were no care plans for R83's indwelling catheter. The DON indicated at one time R83 had multiple catheters and was not sure exactly what happened to the care plans. On 1/15/25 at 10:00 a.m. review of the facility's policy titled: Care Plan Standard Guidelines, dated 11/28/2017 stated in part The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with resident's rights that includes measurable objectives and timeframe's to meet a resident medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review the facility failed to ensure appropriate and safe storage of an oxygen tank at the bedside of one Resident 54 (R54) of three residents reviewed for respiratory care, resulting in the potential for environmental hazard and resident injury. Findings include: On 01/12/25 at 10:44 am, an observation of R54 room revealed an oxygen cylinder without a stand, propped between the resident's bed and bedside table. Near the top of the oxygen cylinder regulator, the gauge was at Full. This indicated the cylinder was full of oxygen. If an oxygen tank falls over, it can become a dangerous projectile due to the high-pressure valve releasing oxygen rapidly, creating a risk of explosion, fire, and personal injury. R54 was observed sitting in their wheelchair wearing a nasal canula oxygen tubing. R54 said that they need their oxygen to breathe. R54 stated, Sometimes I get really short of breath and have to turn my oxygen up higher. R54 was asked if he notified staff when they are short of breath and R54 said, Sometimes I do but I know how to turn my oxygen up. On 1/12/24 at 11:55 am Nurse F was interviewed regarding the oxygen cylinder inappropriately stored at R54's bedside. Nurse F removed the cylinder while stating, This should not be in here .it is full. A review of R54's electronic medical record indicated that the resident was admitted to the facility on [DATE] with the diagnosis of Chronic Obstructive Pulmonary Disease (respiratory disorder), Anxiety, Difficulty Walking, and Muscle Weakness. On 12/10/24) Brief Interview for Mental Status (BIMS, A standardized test that assesses a person's cognitive health) scored 15/15 (cognition is intact). A review of R54's Care Plan noted the following Intervention .The resident needs a safe environment . On 1/14/24 at 11:18 am, the Nursing Home Administrator (NHA) was interviewed about how to store oxygen tanks. The NHA said staff were responsible for removing oxygen equipment out of the medication rooms and ensure they are stored and placed safely. Review of the facility's policy titled Medical Gas Cylinder and Bulk Tank Storage Revised on dated 6/2012 noted the following: General Storage Requirements for All Medical Gas Cylinders 2.1 All medical gas cylinders (including E cylinders) must be physically supported, either in a stand or rack or chained or strapped to the wall. This requirement is intended to prevent mechanical hazards caused by a sudden release of gas if a tank falls over. 2.2 Oxidizing gases such as oxygen, nitrous oxide, and nitrogen must not be stored with flammable gases. 2.3 Medical gas cylinders should not be stored near radiators, steam pipes, heat ducts, or other sources of heat.

Based on observation, interview, and record review the facility failed to ensure an indwelling foley catheter was secured for one resident R16 of four residents reviewed for catheter care with the potential to cause irritation and/or trauma. Findings include: On 1/13/2025 at 11:40 AM, R16 was observed without a leg strap to secure their indwelling foley catheter. R16 was initially admitted on [DATE], with a pertinent diagnosis of Pneumonia, Congestive Heart Failure, Dysphagia (impaired speech), Muscle Weakness, and Bipolar. Record review for R16 Electronic Medical Record (EMR) revealed R16 Annual Brief Interview for Mental Status, (BIMS) on 10/25/2024 was 15/15 for cognition (intact cognition.) On 1/13/2025 at 11:45 AM, an interview with Certified Nursing Assistant, (CNA) D, said there was no leg strap and they would go and get one. On 1/13/2025 at 11:45 AM, an interview with Wound Care Nurse, (WCN) E revealed there was no anchor device attached and they would apply one when they finished wound care. On 1/13/2025 at 11:50 AM, an interview with Licensed Practical Nurse, (LPN) C revealed R16 should have had a leg strap to prevent the pulling of catheter. LPN C said that pulling on catheter could cause it to be pulled out and can cause R16 a lot of pain. On 1/14/2025 at 1:35 PM, an interview with the Director of Nursing, (DON) revealed foley catheter straps should be checked daily with AM and PM care. Review of Urinary Catheter Policy dated (March 2014) noted a leg strap should be used and be secured to the inner thigh if possible. According to the policy the catheter strap should be checked to prevent movement of the catheter and friction at the insertion site.

Based on observation, interview, and record review the facility failed to date respiratory equipment for two residents (F9 and F16) of three residents reviewed for respiratory care. Findings include: R16 On 1/14/2025 at 10:00 AM, R16 was observed with a nebulizer mask and connecting tubing that were not dated. R16 was initially admitted on [DATE], with a pertinent diagnosis of Pneumonia, Congestive Heart Failure, Dysphagia (impaired speech), Muscle Weakness, and Bipolar. Record review of the Electronic Medical Record (EMR) noted R16 Annual Brief Interview for Mental Status, (BIMS) on 10/25/2024 was 15/15, indicating intact cognition. On 1/14/2025 at 10:05 AM Licensed Practical Nurse, (LPN) A was interviewed and said the contracted Respiratory Company comes out on Friday and changes and dates the tubing. R9 On 1/14/2025 at 9:51 AM, R9 was observed with a nebulizer mask and connecting tubing that were not dated. Record Review for R9 EMR showed R9 Annual BIMS on 11/1/2024 was 0/15 for cognition (impaired cognition.)R9 was initially admitted on [DATE] with a pertinent diagnosis of Sepsis, Respiratory Failure, Dysphagia (impaired speech), Failure to Thrive, Muscle Weakness, and Depression. On 1/14/2025 at 9:55 AM, Licensed Practical Nurse, (LPN) A was interviewed and said the nebulizer mask should have been dated. On 1/14/2025 at 1:35 PM, the Director of Nursing, (DON) was interviewed and said they have a company that comes out every Friday to change and label respiratory tubing. The DON said staff should be checking daily to ensure all tubing has accurate dates on it. Review of the facility policy titled, Respiratory Policy dated July of 2015 documented the following The center requires that respiratory supplies are routinely changed or cleaned to prevent nosocomial infections . The facility should change nebulizers weekly or as needed. All supplies should be dated upon opening including oxygen tubing.

This citation pertains to intake #MI00148730 Based on observation, interview, and record review, the facility failed to ensure the use of an appropriate wheelchair for one resident (R902) of three residents reviewed for accidents, resulting in a fractured tibia and fibula (the two long bones in the lower leg that connect the knee to the ankle). Findings include: An anonymous complaint received by the State Agency alleged R902 was not placed in an appropriate wheelchair for transport and sustained a broken tibia and fibula. On 12/11/24 at 9:34 AM, a power wheelchair was observed in the hallway outside R902's room. It was observed the power chair had very long and wide foot rests to prevent feet from slipping off the foot rests. On 12/11/24 at 9:38 AM, R902 was observed in their bed. At that time, an interview was conducted with R902 regarding an accident that occurred resulting in their broken leg bones. R902 said on the morning of 11/11/24 two Certified Nurse Aides (CNA's), CNA 'A' and CNA 'B' transferred them into a manual wheelchair so they could attend an eye appointment. R902 said they were supposed to go to their appointment in their power chair but the CNA's told them the power chair would not fit in the transport van so they were going by manual wheelchair. R902 continued to explain that while they were being pushed down the hall in the manual wheelchair by CNA 'B' their foot slipped off the foot pedal, their leg got caught under the chair as it was in forward motion and she sustained two fractures in their right leg. A review of a facility provided investigation into the accident was conducted and a statement from CNA 'B' read, .on nov (November) 11-2024 I (CNA 'B') assist the cna (CNA 'A') with a transfer of putting (R902) in the chair, for a DR (doctor) appt, (appointment) upon putting her in the chair her foot slid off the pedal, i <sic> had the cna (CNA 'A') put it back on the foot pedal, then as i <sic> went to push her down the hall, her foot fell off the foot pedal again, and (R902) said my feet is off the pedal its <sic> on the floor, and (R902) said my foot hurts, so I went and get <sic> the nurse to help us pull her up, and help put her foot back on the foot pedal. A progress note dated 11/11/24 by a physician's extender was reviewed and read, Nurse notified provider that patient has pain, warmth, swelling of section of right lower extremity. Findings are concerning .and may have had possible trauma to right lower extremity today with transfer. Patient to be sent to (Hospital Name) ER (emergency room ) for further evaluation and management. Review of a Health Status Note dated 11/14/24 was conducted and read, Patient was admitted from (Hospital Name). Patient has a right tibia and fibula fracture. Patient has a stabilizer and is warm to touch with swelling . On 12/11/24 at 11:31 AM, an interview was conducted with Nurse 'C', R902's assigned nurse on 11/11/24. They were asked about the incident and said CNA 'B' reported to them R902's foot slipped off the wheelchair pedal. They were asked if it would be normal to report a resident's foot slipping off a wheelchair pedal and they said they thought it was kind of odd. They said they went to the resident, observed both feet on the pedals and said R902 denied pain so they were sent to their appointment. They further reported when R902 arrived back to the facility after their appointment they were complaining of pain in their right leg. They said they looked at the leg noticed it was red and swollen, and they notified the nurse practitioner. On 12/11/24 at 11:39 AM, an interview was conducted with CNA 'B', who was pushing R902 in the wheelchair when the incident occurred. They said they assisted CNA 'A' transfer R902 into the manual wheelchair and put their feet on the wheelchair pedals. They said R902's right foot slipped off the pedal prior to starting the transport and they put it back on the pedal. They further said the right foot slipped off the pedal a second time while they were pushing the resident down the hall. They said their leg/foot got caught under the wheelchair during the transport and R902 complained of pain in their leg so they reported it to the nurse. They were asked why R902 was using a manual wheelchair and not their power chair and they said the power chair would not fit in the transport van. A review of a progress note in the record dated 4/24/24 was reviewed and read, .Reason for Visit: Mobility Evaluation .She is unable to ambulate or propel with manual wheelchair due to immobility .Manual wheelchair would not be appropriate for patient due to decreased active range of motion of lower extremities. Resident does not have enough strength to propel manual wheelchair .(R902) does have physical and mental ability to operate a power wheelchair safely. A power wheelchair will significantly improve patient's life by enabling her to be out of bed and participate in social activities at facility. Also, would help make transfers to outside appointments easier for patient . A review of a therapy note dated 9/5/24 after a hospital stay from 8/30/24 to 9/5/24 was conducted and read, .Physician's order received for skilled physical therapy .Also recommended gerichair <sic> (a large, padded, reclining chair with wheels that is designed to help people with limited mobility) when out of bed properly positioned with extra pillows as needed . It was noted that was the last therapy recommendation prior to the R902 fracturing their leg on 11/11/24, and nothing indicated R902 would have been appropriate for either their power chair or a manual wheelchair at the time of the incident. On 12/11/24 at 3:50 PM, an interview was conducted with the Administrator and Director of Nursing (DON) regarding R902's accident and fractured tibia and fibula. They were asked why a manual wheelchair had been used for transport and said R902 couldn't go in their power chair because it would not fit in the transport van, and they couldn't go in a geri-chair because there was no way to safely strap a geri-chair into the van, so they were sent in a manual wheelchair. Finally, they were asked that if neither the power chair or geri-chair could be used, could R902 have gone to their appointment by a stretcher and they said they would find out, however; a reply to the question was not provided by the end of the survey. A review of a facility provided policy titled WHEEL CHAIR <sic> USE AND POSITIONING dated 4/2017 was conducted and read, .All residents are assessed for mobility. To encourage a resident's independence when needed a wheel chair will be utilized as a means of mobility .Residents are assessed for the appropriate type and size of wheelchair. The assessment is updated as indicated .assist the resident to place their feet on the footrest <sic> placing legs and feet in proper alignment if possible .

This citation pertains to intake #MI00147795 Based on observation, interview, and record review, the facility failed to appropriately assess and treat pain for one resident (R903) of three residents reviewed for pain. Findings include: On 12/11/24 at 11:45 AM, R903 was observed in their wheelchair in the activity room on the second floor, it was observed their tongue was protruding from their mouth. Conversation was attempted with R903, however; they did not engage in any type of verbal communication. A review of R903's clinical record was conducted and revealed they admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included: cerebral palsy, nutritional deficiency, protein calorie malnutrition, aphasia, and heart failure. R903's most recently completed Minimum Data Set assessment dated [DATE] revealed R903 had severely impaired cognition per staff assessment. Continued review of the record revealed a note entered into the record by Nurse 'D' dated 11/22/24 at 8:22 PM that read, .Activity Aide reported resident had pain in left foot upon assessment resident would not let underwriters <sic> touch foot with facial grimaces and moaning. Underwriter called Dr. and ordered x-ray of left foot . A Health Status Note entered into there record on 11/23/24 that read, Resident had Lt (left) [NAME] <sic> (foot) x-ray results received. Resident has Acute Second metatarsal neck fracture (2nd toe fracture) . A review of R903's documented pain assessments was conducted and revealed a numerical pain score (an assessment that rates pain verbally on a scale of zero to ten with zero being no pain and 10 being the worst pain one has experienced) of 4 on 11/22/24 at 4:04 PM, and a numerical score of 5 on 11/22/24. It was noted the scores were documented on the day it was discovered R903 had a fractured toe. A review of R903's physician's orders and medication administration record was conducted and revealed the first order for pain medication was dated 11/23/24 (a day after the discovery of the fracture), and no pain medication had been administered on 11/22/24. On 12/11/24 at 2:25 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R903's ability to cognitively and accurately participate in a numerical pain scale rating, and they indicated a numerical pain scale would not be appropriate for R903. They were then asked to provide any additional information to show R903 had been given pain medication after the discovery of their toe fracture and demonstration of facial grimaces, and, moaning referenced in Nurse 'D's progress note on 11/22/24, however; no evidence of the administration of pain medication was provided by the end of the survey. A review of a facility provided policy titled, Pain Management dated 11/17 was conducted and read, It is the facility practices to observe residents for pain upon admission, quarterly, with a significant change in condition that may cause an onset or increase pain and any time it is suspected a resident is in pain .The facility clinicians use standardized scales .Residents with a cognitive impairment will be evaluated for pain based on objective observations referencing the PAINAD (a tool used to assess pain in people with dementia or other cognitive impairments) scale .The physician and interdisciplinary team will establish a medication treatment regimen .Pharmacological interventions (i.e., analgesics) may be prescribed to manage pain .

This citation pertains to intake #MI00148730. Based on observation, interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin for one resident (R903) of three residents reviewed for abuse. Findings include: An anonymous complaint received by the State Agency alleged the facility improperly transferred a resident causing a broken toe. On 12/11/24 at 11:45 AM, R903 was observed seated in their wheelchair in the dining room on the second floor. It was observed their tongue protruded from their mouth. An interview was attempted with R903, however; they did not verbally respond to attempts at conversation. A review of R903's progress notes was conducted and revealed the following: A note entered into the record by Nurse 'D' dated 11/22/24 that read, .Activity Aide reported resident had pain in left foot upon assessment resident would not let underwriters <sic> touch foot with facial grimaces and moaning. Underwriter called Dr. and ordered x-ray of left foot . A Health Status Note entered into the record on 11/23/24 that read, Resident had Lt (left) [NAME] <sic> (foot) x-ray results received. Resident has Acute Second metatarsal neck fracture (2nd toe fracture) . Continued review of R903's record revealed they admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included: cerebral palsy, nutritional deficiency, protein calorie malnutrition, aphasia, and heart failure. R903's most recently completed Minimum Data Set assessment dated [DATE] revealed R903 had severely impaired cognition per staff assessment. On 12/11/24 at 1:05 PM, a review of a facility provided incident report was reviewed but did not demonstrate a thorough investigation into the fracture. The report did not contain any interviews with any staff assigned to R903's care. The report only contained a nursing description of the incident, an assessment, a statement that read, .Resident keeps legs in scissor position when up in chair, elevating Left foot higher than Right, increasing foot exposure to environments ., and a note at the bottom of the report that read, Reviewed resident's history and had discussion this date with IDT (interdisciplinary team) regarding residents friability <sic> due to osteoporosis and DJD (degenerative joint disease and need to prevent future injury to LE (lower extremity . On 12/11/24 at 2:25 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the incident report provided. They were asked if they had any additional information such as statements or interviews with caregivers for R903 on the day they experienced pain from their toe. They said they did not, they watched the surveillance video of the resident in activities and the DON said the fracture occurred, spontaneously when the activity aide placed R903's feet on the wheelchair pedals. They were asked if it was possible the fracture occurred prior to them being taken to the activity room or prior to their demonstration of pain with movement, and they had no reply. A review of a facility provided policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident property Effective 11/28/17 was conducted and read, .It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source . are promptly and thoroughly investigated .

This citation pertains to intake MI00146222. Based on interview and record review the facility failed to inform the Physician of an abnormal x-ray result in a timely manner for one resident (R901) out three residents reviewed for notification of change, resulting in a delay in further treatment. Findings include: During an interview on 8/13/24 at 9:30 AM, R901 reported that after a fall on 7/25/24, pain was controlled with medications, but was not sent to hospital until 7/30/24. Record review of R901's electronic medical record revealed admission into the facility on [DATE] with a pertinent diagnosis of muscle wasting. According to the Minimum Data Set (MDS) dated [DATE], R901 had moderately impaired cognitive function and required substantial/maximal assistance with Activities of Daily Living (ADLS). Record review of Progress Notes dated 7/25/24, R901 had an unwitnessed fall. The Physician ordered an x ray of right foot. Record review of Radiology Results Report dated 7/26/24 documented, an x-ray was completed on 7/25/24 at 10:48 PM. Results were reported to facility on 7/26/24 at 12:16 AM. Further review of the x-ray results documented, Conclusion: No visible foot fracture. Acute distal tibial (lower leg) fracture; recommend a three view ankle series. Record review of the Progress Notes from 7/26/24 to 7/29/24 revealed no documentation that the Physician was notified of abnormal x-ray results. Further review revealed on 7/30/24 at 10:14 AM, Licensed Practical Nurse (LPN) A documented, Still awaiting call back from physician regarding x-ray results, MD called at this time, with new order to send resident to (name redacted) hospital. During an interview on 8/13/24 at 11:30 AM with LPN A, it was reported that Physician B was texted on 7/26/24 at 10:13 AM but was not called. It was further reported that there is no documentation that nursing staff followed up or attempted to call the physician to provide notification of an abnormal x-ray result when there was no response from the text. During an interview on 8/13/24 at 12:53 PM with Physician B, it was reported that the nursing staff did not call and give notification of R901's abnormal x-ray results until 7/30/24, and patient was then sent to the hospital. It was further reported that nursing staff should call the physician when there is abnormal lab or x- ray results immediately. During an interview on 8/13/24 with the Medical Director (MD) C, it was reported that the nursing staff should notify the physicians when there is an abnormal x-ray result in a timely manner. During an interview on 8/14/24 at 10:30 AM with the Director of Nursing (DON), it was reported that when the x- ray result came in on 7/26/24 at 12:16 AM, the nurse on duty should have called the physician at that time. When asked should nursing staff had made more than one attempt to contact the physician when there is no timely response, DON said, Nursing staff should have made more attempts to contact the physician, if there is no response, the DON should have been called; and then the Medical Director would then be called to provide instructions on how to proceed. It was further reported that nursing staff should document when the physician is called and any new orders that were given. Record review of policy Notification of Change Guidelines dated 7/24/19 documented, 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 .

This citation pertains to MI00144894. Based on observation, interview, and record review the facility failed to administer tube feeding per physician order for one (R604) of three resident's reviewed for tube feeding, resulting in the potential for nutrition needs not being met and un-intended weight loss. Findings include: In an observation on 6/18/24 at 9:09 a.m., R604 did not have a tube feeding running (connected and actively providing nutrition). The tube feeding pump in R604's room did not have formula or water hanging. In an observation and interview on 6/18/24 at 1:44 p.m., Licensed Practical Nurse A turned on R604's tube feeding pump. R604's pump revealed R604 received 815 ml fed and 276 ml flush when the pump was last used. LPN A reported R604's feeding comes down depending on what time it was started. Review of an Admission Record revealed, R604 admitted to the facility on [DATE] with pertinent diagnosis which included dysphagia and nutritional deficiency. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R604 had severely impaired cognition and required a feeding tube. Review of Physician orders revealed, R604 had the following orders: Enteral Feed one time a day Auto Flush = 25cc/hr (milliliters/hour) for 18 hours (450cc) with a revised date of 5/25/24. Enteral Feed one time a day Jevity 1.5(tube feeding formula) at 75cc/hr for 18 hours (up at 5p and down next day at 11a or until 1350cc reached) with a revised date of 5/25/24. Review of a Medication Administration Record (MAR) from May through June 2024 revealed, R604's enteral feeding was not documented as given on 5/25/24. In an interview on 6/18/24 at 2:20 p.m., LPN A was queried and stated, I know I didn't take him off (stopped the tube feeding). LPN A reported R604 should have received 1350 ml before the feeding was removed. In an interview on 6/18/24 at 2:25 p.m. Unit Manager B reported she did not take the R604 off the tube feeding today. In an observation and interview on 6/18/24 at 2:26 p.m., the Director of Nursing (DON) confirmed that R604's tube feeding pump read 815 ml fed and 276 ml flush. The DON then acknowledged that R604 should have received 1350 ml before the pump was shut off. On 6/18/24 at 3:04 p.m., the DON reported the midnight nurse took R604 off the tube feeding because R604 was pulling on it. The DON reported the nurse did not document the removal in a progress note.

Based on interview and record review, the facility failed to submit Minimum Data Set (MDS) assessments in a timely manner, for nine (R3, R6, R8, R18, R19, R39, R43, R47, and R73) of 11 residents reviewed for resident assessments, resulting in the delay of time-sensitive information, potentially affecting the level of care and quality of life for the identified residents. Findings include: R18 On 3/27/24 at 11:50 A.M. record review for R18 indicated the resident was admitted to the facility on [DATE]. Review of MDS record revealed R18's MDS assessment was overdue by 120 days. Further record review revealed the assessment completion date was more than 14 days after the assessment reference date (late). R43 On 3/27/24 at 2:30 PM, record review of resident's MDS data revealed R43 was admitted to the facility on [DATE]. R43's quarterly MDS was scheduled to be submitted to the Center for Medicaid Services (CMS) in October of 2023. Record review revealed that the MDS was not submitted until January 2, 2024. 39465 R8 On 3/27/2024 at 12:00 p.m., record review revealed R8 was initially admitted into the facility on [DATE] and readmitted on [DATE]. Review of the MDS assessments revealed R8 quarterly MDS assessment was 120 days overdue. Last reviewed quarterly assessment in R8's medical record revealed 11/8/2023. R47 On 3/27/2024 at 12:00 p.m., record review revealed R47 was initially admitted into the facility on [DATE] and readmitted on [DATE]. Review of the MDS assessments revealed R47 quarterly MDS assessment was 120 days overdue. Last reviewed quarterly assessment in R47's medical record revealed 10/26/2023. 46865 R3 On 3/27/23 at 12:05 PM, record review revealed R3 was admitted to the facility on [DATE]. A review of R3's MDS assessments revealed R3's quarterly MDS assessment was 120 days overdue. According to the MDS assessments, the most recent quarterly review should have been completed 1/30/24. R6 On 3/27/23 at 12:07 PM, record review revealed R6 was admitted to the facility on [DATE]. A review of the MDS assessments revealed that R6 had a MDS assessment that was overdue by 120 days. Further review revealed the assesssment completion date was more than 14 days after the assessment reference date (late). R19 On 3/27/23 at 12:10 PM, record review revealed R19 was admitted to the facility on [DATE]. A review of R19's MDS assessments revealed R19's quarterly MDS assessment was 120 days overdue. According to the MDS assessments, the most recently quarterly review should have been completed 1/30/24. R39 On 3/27/23 at 12:15 PM, record review revealed R39 was admitted to the facility on [DATE]. A review of the MDS assessments revealed that R39 had a MDS assessment that was overdue by 120 days. Further review revealed the assessment completion date was more than 14 days after the assessment reference date (late). 49103 R78 On 3/27/24 at 12:10 PM record review for R78 revealed the resident was admitted to the facility 1/25/23. Review of MDS assessments for R78 revealed no updated quarterly MDS assessment. The quarterly MDS assessment was 120 days overdue. On 3/27/24 at 12:00 P.M. and at 2:50 P.M. during interview with corporate MDS Coordinator G and MDS Nurse C, corporate MDS Coordinator G acknowledged their corporate office had switched to a new vendor for submitting MDS Assessments to CMS (Center for Medicare and Medicaid Services) and staff was not aware how to read the submission and confirmation data. Corporate MDS coordinator G further commented there was a glitch in the system on both ends and the facility was attempting to correct the problem. Corporate MDS Coordinator G explained some of the MDS's had been missed (3) an approximately (6) should have been submitted in October 2023 but were late.

This citation pertains to Intakes MI 174 and MI 867 Based on interview and record review the facility failed to provide adequate supervision during care, affecting one resident (R#146) out of 22 residents reviewed for falls, resulting in an injury sustained during a fall. Findings include: On 11/5/19, record review revealed R#146 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], R#146 had impaired cognition and was extensive assist with two persons to assist with bed mobility (the ability to perform movement while in bed). Review of an investigation implemented by facility documented that on 5/4/19 at 5:24 a.m., Certified Nurse Assistant (CNA) B reported to Nurse T that R#146 had rolled out of the bed on to floor mat .Nurse T performed a head to toe assessment and R#146 had a skin tear to right posterior thigh. On 5/6/19 R#146 was noted to have discoloration around right eye. On 11/6/19 at 9:30 a.m., during phone interview with a family member, when asked the condition of his/her parent after the fall, family member stated, My mother/father had a black eye from the fall out of the bed. How does someone who can't move fall out of bed? Further review of investigation documented on 5/13/19- Investigation revealed (R#146) sustained a fall during care giving on 5/4/19. Investigation and interview revealed the fall occurred when the CNA (CNA B) turned to her side and (R#146) fell . The bruise is believed to be the result of the fall . Review of Interview/Statement Record with CNA B documented the following: Q (question)- Was anyone with you? A (answer) - Ms. (NAME REDACTED) (another CNA) was with the other patient (R#146's roommate). Q- How was R#146 positioned? A- On her right side on the edge of the bed. I guess he/she was too close to the edge of the bed. As I turned to the side, he/she fell . On 11/7/19, during review of R#146's Activites of Daily Living (ADL) care plan dated 3/16/12-Resident is dependent on staff at all times for toileting, dressing, bathing and bed mobility. The Kardex (a reference for CNA's regarding needs of residents) documented (R#146) is total dependent for bed mobility. On 11/7/19 at 10:08 a.m., during interview with Assistant Director of Nursing (ADON), when asked should R#146 have been assisted by two staff members during care according to the MDS dated [DATE]. ADON stated Yes. When asked if CNA B turn away from resident during care, according to the interview conducted, ADON stated Yes When asked if R#146 had been centered in the bed instead of the edge, may that have prevented the fall, ADON stated, Yes. When asked according to the care plan and the Kardex, R#146 had always been totally dependent with bed mobility by staff, ADON, stated, Yes. When asked, did the resident fall and receive a black eye resulting from the fall? ADON stated Yes When asked if there were interventions in place that were ignored by the staff when performing care? ADON stated, Yes. When asked, Did this fall cause harm to the resident? ADON stated Yes. 11/7/19, review of Fall Evaluation Safety Guideline effective 11/28/17 documented 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 to: To achieve each resident's maximum potential of physical functioning. To prevent or reduce injuries related to falls. To enhance resident dignity and self-worth. To rehabilitate residents to their fullest potential of function.

This citation pertains to Intake/ FRI #MI 7 & #MI 0. Based on interview and record review, the facility failed to protect a vulnerable resident from a sexual assault by a male employee (whom had previous allegations of sexual abuse reported by female residents against him), resulting in an immediate jeopardy for one resident (#506) out of a sample of four residents reviewed for abuse resulting in actual harm, mental anguish, feelings of compromised safety, and the overall safety for all residents that reside in the facility. The immediate jeopardy was identified on 12/19/18 at 1:52 p.m. The immediate jeopardy began on 12/14/18 at 12:33 a.m. when an employee observed a sexual assault occurring by a male employee against a female resident. The Administrator was notified of the Immediate Jeopardy on 12/19/18 at 3:15 p.m and a plan for removal was requested. The immediacy was removed on 12/14/18 when the employee was removed from the resident's room, escorted off the facility's premises and apprehended by the police. Surveyors verified the removal of the immediacy on site by record review and interview on 12/19/18. Although immediacy was removed, the facility's deficit practice was not corrected and remained isolated with harm that is not immediate jeopardy. Findings include: On 12/18/18 at 12:32 p.m., review of R#506's clinical record documented the Resident was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], the Resident had severe cognitive impairment and required supervision/setup with most activities of daily living (ADLs). On 12/18/18 at 9:36 a.m., the facility submitted a facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 12/14/18. It was reported R#506 was allegedly witnessed (by CENA A) being sexually abused by a male CENA at the facility. The employee was escorted out of the facility, and suspended pending investigation. The CENA was later detained by local law enforcement. R#506 was transferred to the hospital on [DATE] and later transferred to another facility after hospitalization subsequent to the incident occurring. On 12/18/18 at 4:41 p.m., a Nurse's note dated 12/14/18 was reviewed and documented: 12/14/2018 03:38 *Health Status Note (nurses note) Note Text: On MN shift, the CNA assigned to (resident's name) informed the nurse that when she went back into resident's room, she caught the male CNA with his pants and underwear down, standing behind the resident while her pants and underwear were down-performing sexual activity on the resident in the resident's bathroom. Resident stated, I'm glad y'all caught that man he always in here touching and grabbing on me. The DON, Administrator, Police Dept., Unit Mgrs, and investigation team are aware of the situation. Voicemail was left for Guardian and MD. The investigation is ongoing at this time. Resident was transferred out to (hospital's name). On 12/19/18 at 8:49 a.m., CENA A was interviewed. CENA A confirmed being the CENA that witnessed the incident. CENA A also confirmed being R#506's consistent CENA as well as the other resident that resides in the room. CENA A was asked to recall the incident that occurred on 12/14/18 on the midnight shift. CENA A stated, I was doing my rounds changing a resident (R#506 roommate) when I noticed (male CENA name) standing behind me in the door way. He stated he was coming to visit R#506 because he heard she was not feeling well and had she found her purse. R#506 was in bed. I went across the hall to take care of another resident and asked (male CENA) to assist me. After helping that resident, I stayed in the room and he left the room. I thought he went back down to the first floor. I went to get (R#506's roommate) a blanket and noticed the Resident was not in bed. It seemed weird to me because she doesn't usually get up to go to the bathroom at night. I then noticed the bathroom light was on and the door was open, the rest of the room was dark. When I looked into the bathroom the male CENA had his pants and underwear down to his knees while standing behind the Resident. The Resident had her pants down to her knees. The Resident was bent over the sink with her head down in the sink while holding on to the sink. I saw the male CENA was humping on the Resident from behind until he saw me standing there. I said loudly, 'BRO SERIOUSLY!', that's when he hurried to pull up his pants up and the Resident's pants. He rushed out the bathroom. I was yelling, 'BRO SERIOUSLY, ARE YOU FOR REAL, JUST GET OUT, GET OUT!'. When I started yelling, he tried to calm me down and keep me quiet. He kept putting his hands around my shoulders and keep me from going out the room, the whole time I was yelling for him to leave the room. I was also yelling at him when I told him to stop touching me and get out the room, that's when I pushed him out of the room into the hall and started yelling again. That's when the nurse came to the room from the nurse's station and asked what happened. The male CENA then walked down the hall trying to explain himself as I walked to the nurse's station. CENA A was asked where and what was the Resident doing while she tried to get the male CENA out of the room. CENA A stated, She was standing by the bathroom door. She didn't say much. CENA A was asked to describe the Resident's reaction. CENA A stated, She appeared shaken but easily calmed especially after changing her clothes. She just kept saying Nurse C was asked to describe the condition the Resident was in. Nurse C stated the Resident told her, He is always in here grabbing on me, trying to have sex with me but I fought him off., Thank you baby. Thank you. CENA A was then asked, to her knowledge, if the male CENA was supposed to be on that floor (3rd floor), if not what was the reason. CENA A stated, No he wasn't supposed to be on the third floor because of some other incidents that happened when he worked on the third floor. I heard about them but didn't see them for myself. On 12/19/18 at 2:17 p.m., Nurse C was interviewed via telephone. Nurse C confirmed being the third-floor midnight shift nurse on 12/14/18. Nurse C was asked to recall the incident. Nurse C stated, I heard screaming coming from the back hall. I ran to where the screaming was coming from and heard the CENA (CENA A) yell 'I CAUGHT YOU!' I saw the male CENA try to put the CENA (CENA A) in the room. That's when she told me what happened. Nurse C was asked was the male CENA assigned to the third floor. Nurse C stated, No he was not. He was assigned to the first floor. Nurse C was asked was the male CENA supposed to be on the third floor. Nurse C stated, I know he wasn't supposed to work on the third floor but nothing about visiting. Nurse C was asked the reason the male CENA could no longer work on the third floor. Nurse C stated, Because there was an incident a while back and he was moved to another floor after that. Nurse C was asked to describe the condition the Resident was in. Nurse C stated the Resident told her, He is always in here grabbing on me, trying to have sex with me but I fought him off. She didnt appear to be in distress at that time. On 12/19/18 at 10:05 a.m., review of the staffing schedule documented the male CENA was scheduled on 12/14/18, midnight shift, first floor. On 12/19/18 at 10:20 a.m., the Staffing Coordinator was interviewed. The Staffing Coordinator confirmed the male CENA was assigned to the first floor in (MONTH) due to an allegation of sexual abuse made by a resident. The Staffing Coordinator was asked if the male CENA was to go on the third floor after the allegation was made. The Staffing Coordinator stated, I'm not sure what all happened with the allegation, but I was told to schedule him to the first floor and he was not to go to the third floor. The Staffing Coordinator was asked who gave the directive for the male CENA not to go to the third floor. The Staffing Coordinator stated, The DON gave an in-service about it. The DON confirmed this was the statement she had documented. The DON was asked if the male CENA had previous allegations made against him. The DON stated the male CENA had two allegations made against him in which he was named directly in them. The DON also stated the allegations were unsubstantiated. The DON was asked what the outcome from the previous allegations were. The DON stated, Besides being suspended pending investigation, the CENA was given a Skills Assessment and assigned to a different floor. Interventions were also done with the residents. A verbal conversation was had with the CENA, me, the Administrator, and Unit Manager to permanently stay on the first floor, however it was not a directive. The DON was asked was it was communicated to other staff that the CENA was not to go on the third floor. The DON stated, It was just discussed between the CENA, me, the Unit Manager, and scheduler to lessen the rumors and gossip amongst the other staff. He was not to work on the third floor, but he was not banned. On 12/19/18 at 3:32 p.m., review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 11/28/2017 included: 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 . 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. On 12/19/18 at 3:55 p.m., the Administrator and Directior of Clinical Services presented the facility's plan to remove immediacy. The plan included: Element #1 1. On 12.14.2018 at 1233AM an allegation of sexual assault was launched against a nurse aide at the facility. The nurse aide was immediately removed from the alleged victim's room by the facility staff. The alleged violator was escorted of the premises by the Midnight Charge Nurse. 2. At 1250 the facility staff and the administrator were called and informed of the incident. The facility nurse called local law enforcement. The violator was taken into custody by law enforcement from his home. 3. Resident #506. was a [AGE] year old female with a BIMS of 06 and was alert and oriented x1. She had a history of [REDACTED]. The alleged perpetrator was immediately removed from the Resident's room and the Resident's room and the Resident was assessed, vital signs were taken. Post incident vital signs: BP 127/81, P 87, R 20, SpO2 96, T 97.9. Head to toe assessment completed. No negative findings indicated. Resident had staff with her until she was sent to the hospital at approximately 0200 via EMS. 4. The Physician, Medical Director, and guardian were also notified. 5. Resident was fully assessed at the hospital. Pleasant and cooperative with mild abdominal pain. 6. On 12.15.2018 Resident transferred to another Villa facility upon discharge from the hospital. Reported that resident is in good spirits and medically stable. Element #2 7. The company's policy on abuse and neglect and elder justice was reviewed and deemed appropriate. On 12.14.2018 at approximately 0800 education was initiated for all staff regarding abuse and neglect and elder justice. 8. The registered nursing staff was educated on clinical documentation and reporting and findings of abnormal vaginal discharge, vaginal bleeding, and pelvic pain. 9. No employees worked or cared for any resident until they received the mandated education. Employers on vacation or FMLA are to be educated prior to working. Certified letters have been sent to those individuals. 10. A questionnaire was conducted with each resident or family member concerning the safety of their environment. 11. Residents who currently reside in the facility have had a complete head to toe skin assessment. Female residents were assessed for vaginal bleeding, vaginal discharge, and pelvic pain. No negative findings reported. Element #3 12. The facility will continue to perform background checks and reference checks upon hire and monitor background checks as needs. 13. An audit was conducted on employee background checks and reference checks to ensure the required components of personnel files are completed. 14. The facility will continue to complete head to toe skin checks weekly and report any negative findings to clinical administration. 15. The facility will continue to assess for signs and symptoms of abnormal vaginal discharge, vaginal bleeding, and pelvic pain; including but not limited to diagnostic results. All negative finding will be reported to clinical administration. Element #4 16. Random audits of employee files will continue to be audited by Human Resources. Findings will be reviewed in QAPI. 17. The facility will continue to ask resident and family members at random if they feel their environment is safe. Findings will be reviewed in QAPI. 18. Abuse and neglect and elder justice policy will continue to be educated annually and upon new hire orientation. Findings will be reviewed in QAPI. 19. The DON will randomly audit weekly skin check for accuracy and completion. Findings will be reviewed in QAPI. Element #5 20. Plan of Correction is in progress as of 12.14.2018. the facility is requesting immediacy to be removed as of this date.

This citation has two deficient practices. Deficient practice #1. This citation pertains to MI 689 Based on interview and record review, the facility failed to implement timely safety measures for one (#702) of three sampled residents reviewed for falls and accidents from a total sample of seven, resulting in the resident sustaining a trimalleolar fracture with associated pain and discomfort. Findings include: On 2/5/18 a review of the clinical record for Resident #702 (R702) was begun. R702 was admitted into the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to R702's Minimum (MDS) data set [DATE], her cognition was severely impaired and she was totally dependent upon two plus persons' physical assistance for transfer. Further review of the clinical record for R702 documented the following progress notes: --9/30/17 at 12:54 PM - health status note: Today CNA (Certified Nurse Aide) informed me that patient complained of ankle pain. Upon assessment (the ankle) felt warm to touch and swollen; notified hospice was asked to get a VO (verbal order) from attending physician; contacted (doctor); transcribed order; notified family called medical diagnostic services and faxed to medical diagnostic services; pain medicine given will continue to monitor; safety precautions in place and call light within reach. Note written by License Practical Nurse, Staff P. --9/30/17 at 5:14 PM - health status note: (R702) was observed by staff on several occasions that she has been constantly swinging and sliding her feet out of the geri-chair. The persistent action directly resulted to injury of her ankle. Note written by Regional Director of Clinical Education (DRCE). --9/30/17 at 11:56 PM - health status note: Writer received fax of right ankle x-ray results approx. (10:00 PM). Notified DON (Director of Nursing), ADON (Assistant Director of Nursing), Dr. (physician of record), hospice, and resident's family. Hospice said have MD send resident out to ER. Dr. (physician of record) ordered resident taken to (local hospital) asap to splint the ankle Note written by Registered Nurse (RN) Staff N. --10/2/17 hospital discharge form documented R702's primary [DIAGNOSES REDACTED]. --10/2/17 at 4:19 PM - nursing admission summary: Resident arrived to facility via ambulance .Resident has splint applied to L (left) ankle/foot. Resident showing signs of discomfort .PRN (as needed) 20.3 ml Tylenol administered . Note written by LPN Staff Q. --10/2/17 - hospice note: (R902) returned from (hospital) .Has a splint to right lower extremity that extends from the foot up to the upper thigh. Patient appears to be in pain and is irritable. (LPN Q) medicated patient . --10/3/17 at 8:04 PM - physician note: .(R902 transferred) to hospital after discovering ankle swelling and abnormal x ray. X-ray right foot at the hospital showed closed displaced trimalleolar fracture of right ankle. Has post cast in place-wrapped with ACE wrap. Tends to dangle her feet outside of her Geri chair and at times tries to stand up .Records from hospital reviewed. X-ray at hospital reviewed .Therapy eval in place. Tends to (fracture) easy (secondary) to [MEDICAL CONDITION] per hospital attending record. Note written by Medical Provider R (MP R). --10/6/17 at 1:47 PM - IDT (interdisciplinary team note): Events reviewed and P[NAME] (plan of care) completed. PT (Physical Therapy) eval completed. Recliner wheelchair provided by hospice, with roho (cushion) and dycem (non-slid mat). Pain management review. No other concerns at this time. Note written by DRCE. --10/6/17 at 4:55 PM - IDT note: Granddaughter .is in the facility. Asking the cause of (R702's) fracture as she was told by (hospital) ER doctor. Writer told the (granddaughter) that this is the first time we're hearing about the fracture. The initial x-ray showed dislocation and (MP R) ordered resident to be hospitalized for [REDACTED]. Note written by DRCE. --10/6/17 at 8:15 p.m. - physician's note: .(R702) still kicks her legs around and they tend to dangle off the bed or her Geri chair and sometimes get caught in metallic part of the chair/bed. Her chair was recently changed to accommodate that since that kicking likely caused her recent ankle dislocation/minor fracture/disruption of the mortice. Her old age with immobility and resulting [MEDICAL CONDITION] making bones brittle and easy to fracture . Note written by MP R. Facility document titled, Verification of Investigation Conclusion, dated 9/30/17, documented: according to (Registered Nurse, Staff N) in the afternoon on 9/28/17 (R702) has been redirected several times because she's been scooting, sliding, hitting, and swinging both her legs and feet out of the Geri-chair. This is further confirmed by (Nurse Practitioner, Staff M). According to (Staff M) she even has to pick-up the resident's leg back to the Geri-chair a couple of times. On 2/6/18 at 11:36 a.m., when Nurse Practitioner, Staff M was interviewed over the telephone, she said, At times I saw (R702) swing her legs (from the wheelchair). I noticed she does that. When queried about the time frame of her observations, Staff M said, I saw her do it within the last month. Staff M stated she felt the way she observed R702 swing her leg could result in harm. Staff M stated she helped to reposition R702's leg on occasion. When Staff M was queried about what action she took related to her observations, she said, I notified the nurse and mentioned it to the doctor. Staff M stated she was not sure what they did with that information. On 2/6/18 at 12:20 p.m., afternoon nursing supervisor, Staff N was interviewed over the telephone regarding her observations of R702. Staff N said, (R702) needed quite a bit of care as far as feeding her; transferring her; she was pretty much total care. When queried about R702's ankle fracture, she said, R702 was always in the Geri-chair. I personally had to move her legs back into the Geri chair. I saw (R702's) legs hanging and moving. She could swing her legs. She swung her leg and moved it off the chair. Staff N said he felt the dangling and swinging of the legs could cause an injury. When queried about what interventions were in place to prevent R702's legs from dangling and hitting the chair or if she notified the therapy department about her concerns, Staff N said, I would just monitor her and put her legs back. 2/6/18 at 1:10 PM., a review of R702's medical record was conducted with the DON and the Regional Director of Clinical Education (RDCE). The DON was not employed by the facility when R702 sustained the trimalleolar fracture of right ankle. The RDCE was involved in the investigation of the ankle fracture. The RDCE stated the conclusion of the investigation determined that R702 swung her leg and sustained a fracture. Per the DON and RDCE, a review of R702's progress notes did not reveal any documentation of staff observations of R702 swinging her legs while sitting in the Geri chair prior to 9/30/17. A review of R702's care plans was conducted with the DON and RDCE. A Safety care plan initiated on 9/30/17 documented the following focus: (R702) is at risk for falls related to confusion and weakness. Potential for injury due to constant swinging and sliding motion while in Geri chair. When queried if R702 had a care plan that addressed Geri chair safety concerns prior to the ankle fracture, the RDCE said, I'm not seeing that. On 2/6/18 at 1:41 PM, Social Worker, Staff K was interviewed and her progress notes reviewed. Staff K stated she did not receive reports of R702 swinging her leg from the Geri chair. The RDCE indicated R702 was receiving hospice services. The RDCE agreed there should be coordination of services between the facility and the hospice provider. The RDCE was queried if hospice was notified about R702 swinging her legs from the Geri chair. The RDCE reviewed the hospice notes and could not find documentation of this concern. When the RDCE was queried about what action staff should have taken when R702 was observed swinging her legs from the Geri chair, he said, There should have been a psych referral. A psych consult would have addressed the behavior; but on the other hand, the behavior may not be agitation. It could be an involuntary movement; therefore it would (require) clinical/medical intervention. The doctor could have seen it and addressed it by therapy or medication. A review of the clinical record with the DON and RDCE did not reveal implementation of psych or clinical/medical interventions for R702's observed behavior of swinging her legs from the Geri chair prior to sending her out to the hospital. Deficient practice #2. This citation pertains to MI 892. Based on observation and interview, the facility failed to ensure an exit corridor was adequately unobstructed when the 1st floor North exit door was observed to have several large bulky items stored on each side of the hallway, resulting in the potential for a delay in resident egress in the event of an emergency. Findings include: On 2/5/18 at 10:44 AM, when the 1st floor Unit Manager, Staff L, was asked to identify the exit door near the 1st floor nurse's station, she stated it was the north exit door. The following was observed in the proximity of the 1st floor north exit door: --placed on one side of the hallway was a crash cart and treatment cart --placed on the other side of the hallway was a nondescript cart (later identified as an IV cart). The signage on the 1st floor north exit door indicated Do not block the exit with the cart. On 2/5/18, at 11:30 AM, 3:00 PM, and 4:20 PM the placement of the three carts were observed unchanged in the proximity of the 1st floor north exit door. On 2/5/18 at 4:22 PM, when Unit Manager, Staff L was queried if she would use the 1st floor exit door in an emergency, she said, Yes. On 2/5/18 at 4:23 PM, Maintenance Director, Staff C was observed moving the IV cart away from the proximity of the 1st floor north exit door. When queried why he moved the cart, Staff C said, The cart was blocking the pass way to the stairway. The stairway is an exit. On 2/6/18 at 2:30 PM, when the Administrator was queried about her expectations for storing equipment in the hallway, she said, Space is limited, however, items should not be stored near exit doors because it's a safety hazard.

This citation pertains to intake MI 194. Based on observation, interview, and record review the facility failed to implement measures for elopement behaviors identified on the care plan for one resident (#501) of two residents sampled for elopement, from a total of five sampled residents, allowing the resident to enter a code lock elevator unobserved, descend to the second floor, and successfully exit the facility unobserved by staff. The facility remained unaware of the missing resident until local law enforcement returned the resident to the facility. The resident was missing 52 minutes without staff being aware she was missing. This deficient practice placed a total of eight other residents identified by the facility as exhibiting elopement risk behavior for the potential of bodily harm and/or death. The Immediate Jeopardy (IJ) was identified on 2/15/17 at 3:51 p.m., and the Administrator was asked for a plan of removal at 5:20 p.m., on 2/15/17. The IJ was removed on 2/16/17 at 5:25 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 2/15/17 at 9:00 a.m., the Administrator was asked for instances of elopement that occurred in the last 15 days including the Incident and Accident (I & A) reports with investigations. At 11:57 a.m., the Administrator provided one file regarding a resident elopement that involved Resident #501. On 2/15/17 at 9:15 a.m., resident # 501 was observed standing in her room and when greeted smiled and stated, I guess I'm tired, and unfolded a pair of clean socks and pointed to her name written on the socks. When asked about her feelings on living at the nursing home she replied, I like it right here, and pointed to the floor where she was standing, But when you go over there you get real old, and pointed to her roommates space. When asked if she went outside in the cold lately, I went with my mother and my father, pointing at the bathroom. On 2/15/17 at 9:30 a.m., review of Resident # 501's medical record revealed she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident # 501's annual Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) indicating severely impaired cognition. Further review of the medical record revealed the resident's care plan interventions that included: Monitor whereabouts when out of the room and monitor whereabouts throughout the day. On 2/15/17 at 11:25 a.m., documents at the third floor nurses station were reviewed. The resident census on the third floor on 2/9/17 was 42 residents. The document further indicated that there were two nurses (Nurses K and P) and four Certified Nurses Aides (CNA's). (CNA's B, C, H, and Q). CNA C was assigned to resident # 501. On 2/15/17 at 11:35 a.m., an interview with CNA B was conducted. CNA B was asked if she was familiar with resident # 501 and if she could recall resident # 501 eloping on 2/9/17. CNA B stated, Yes, I'm a float but I know her. She's always trying to get into the elevator. She was in the bathroom and when the elevator opened she darted in. I was taking down trays at he time, there were nurses at the desk, and we were taking care of the residents. I was down stairs, the camera showed that she went from the bathroom to the elevator. On 2/15/17 at 11:42 a.m., an interview with CNA C was conducted. CNA C was asked if she could recall anything regarding the elopement of resident # 501 on 2/9/17. CNA C stated, She was in the room while I changed her room mate, she left and went down the hall, the nurse saw her walk down the hall. Then I took her room mate to the dayroom around 1:30 p.m., then the nurse got the call that she (resident # 501) left the floor. On 2/15/17 at 11:45 p.m., an interview with Nurse K was conducted. Nurse K was asked if she could recall anything regarding the elopement of resident #501 on 2/9/17. Nurse K stated, They brought her back at 2:00 p.m., and the receptionist called a little earlier. No injuries upon return, I called the family to let them know. She doesn't always try to get out from the elevator, normally she walks down the hall and stands in front of the window, that end or the other. On 2/15/17 at 12:45 p.m., an interview with the Receptionist was conducted. The Receptionist was asked if could recall anything regarding the elopement of resident # 501 on 2/9/27. The Receptionist stated, That day I had received a phone call and was looking at the census list. I did not see or hear the resident leave. It's a very quiet door, and the combination lock was not on. On 2/15/17, throughout the tour of the facility it was noticed that the stairwells were alarmed upon opening, but none of the staff reacted to the alarms when the surveyor used the stairwells. On 2/15/17 at 11:57 a.m., record review of resident # 501's I & A report was conducted. Part of the I & A was staff interviews, including Nurse P, CNA's B, C, H, L, and Q, and the Receptionist. All interviewed staff denied seeing resident leaving the third floor or the building. On 2/15/17 at 3:00 p.m., the Administrator was asked about the elopement of resident # 501 and stated, She went to the apartment building behind the gas station. (about 100 yards away on the other side of a major intersection) The manager of the apartment building took her in and called the police The Administrator showed the video recorded on the day of resident's elopement. Using the time frame recorded on the video the following was observed: - at 12:58 p.m., resident # 501 was observed to leave her room and walk passed the elevator. - at 1:00 p.m., the resident was observed standing in front of the elevator momentarily. - at 1:01 p.m., Nurse K was observed exiting the elevator, looking left and right before turning left. Also observed was Nurse P walking passed the elevator following Nurse K. At that time the resident entered the elevator and the door closed. - at 1:03 p.m., the elevator opened on the second floor, the resident exited the elevator while an unidentified staff with a cart entered the elevator. Resident # 501 proceeded to walk passed CNAs' H and L and Housekeeper M walked passed the resident and the resident turned right into the lobby. The Receptionist was observed to be on the phone looking down and resident walked passed her. - at 1:04 p.m., in the ante-chamber between the lobby and the outdoors was observed Corporate employee O, resident # 501 left the building. - at 1:52 p.m., a local law enforcement officer entered the building and was seen speaking to office personnel then left the building. - at 1:54 p.m., the officer returned with the resident who was greeted by the Director of Nursing (DON), the Administrator, and several other staff members that had gathered in the lobby after the officer entered the building at 1:52 p.m. On 2/15/17 at 3:33 p.m., an interview with the Administrator and the DON was conducted. When asked if anyone knew that Resident # 501 left the building, both stated, No one knew. When asked why this incident was not reported to the State Agency, the Administrator stated, I didn't think I had to, I felt there was a two hour, here were no injuries, we put things in place to prevent it happening again, did a lock down, If she was injured I would have. I did a power point on abuse, neglect, and elopement, I thought there was a two hour. The Administrator never defined a two hour. On 2/16/17 at 1:34 p.m., the DON was again interviewed and was asked how does your staff monitor the residents with elopement risk behavior per the care plan and stated, We actually create tasks, it's on the Kiosk (computer terminals for CAN's use), they actually chart. When asked what method of monitoring the residents is used. They monitor them visually. When asked how often the residents are visually monitored the DON stated, Well it's every one hour now. When asked how often the residents were visually monitored before 2/9/17, the DON did not answer. The Administrator and DON were asked to provide a list of residents that have elopement risk behavior. The DON left the room and came back with a binder labeled Elopement Book, within the book each resident had a photograph and their face sheet in a plastic sleeve, the residents included: Sampled residents #'s 501 and 505, and supplementary residents #'s 2, 16, 24, 34, 47, 76, and 86. The DON was then asked where these binders are kept and stated, At the nurses stations and the reception desk. On 2/16/17 at 2:00 p.m., the Receptionist was asked about receiving the elopement book, I got it last week. The Receptionist was then asked if there was anything at the reception desk to help identify residents with elopement risk behavior prior to last week, the Receptionist shook her head no. On 2/16/17 at 2:30 p.m., the Director of Maintenance (DOM) was asked about the code alarm on the lobby door and stated, It was installed a few years ago, it's on 24/7 now. The DOM was further asked what times the front doors code alarm was activated prior to 2/9/17 and stated, Roughly 5:00 p.m. to 6:00 a.m. On 2/16/17 at 5:15 p.m., the facility provided the following removal plan for the immediate jeopardy regarding the failure to prevent the elopement of resident # 501 on 2/9/17. IJ Removal Plan: Element #1 1. On 2/09/2017 at 2:10 p.m., Resident #501 had eloped unbeknownst to facility staff and was returned to the facility by the local police department. An immediate investigation was initiated. 2. As of 2/16/2017 resident 501 remains at the facility with no negative effects from the incident. Resident has had no additional elopement attempts. 3. On 2/09/2017 a full body check and assessment was completed at 2:30 by LPN NS son to rule out any injury was completed with no negative findings was immediately completed. Family was notified on 2/9/17 at 3:30 p.m Physician was notified on 2/9/17 at 3:00 p.m Medical Director was notified on 2/10/17 at 1:35 p.m Resident was placed on a 1:1 at 2:10 p.m. on 2/9/17 until building was secured by activating the alarm on the front door of the facility . At 2:54 p.m. on 2/9/17 fifteen minute checks were initiated. 4. On 2/09/2017 at approximately 2:30 p.m. full house head count was completed to ensure all residents were in house and safe. All elopement binders were confirmed to be located at reception area and nurses station. 9 residents were identified at risk for elopement. 8 of the residents were located on the 3rd floor, and one resident was located on the 1'1 floor. 5. On 2/10/2017 Resident 50l's Elopement Risk Observation and BlM's score was updated to reflect resident's current cognitive status. 6. On 2/14/2017 resident 501 was evaluated by Senior Wellness Group of Michigan (Psychiatry Group). Current medications reviewed with no changes made. Element #2 7. On 2/09/2017 at approximately 3:00 p.m. the video footage of the incident was reviewed by the NHA and Maintenance Director which showed the resident exiting the front door at 1:20 p.m The front door has a mag lock system in place which is turned on at nights. As a permanent and immediate intervention the mag lock on the front door will remain on at all times (24/7) securing and locking the building at all times. The only method to enter or exit is to utilize the keypad. 8. On 2/09/2017 at approximately 4:30 p.m., elopement education was initiated for all facility staff. No staff worked or cared for residents until they received education. Employees on vacation or FMLA to be educated prior to working. Employees were educated on elopement guidelines, placement of secure alarm on the front door at all times, and the elopement binders. 9. One elopement drill was conducted on 2/10/2017 at approximately 5:50 p.m. The facility will conduct an additional elopement drill on each shift by 2/22/17. Elopement drills are scheduled and being conducted on a quarterly basis. 10. On 2/10/2017 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. Care Plans were updated to reflect current status of resident risk of elopement. Elopement books were updated to reflect current status of residents at risk for elopement confirming that the receptionist had an elopement binder readily available. 11. The nurses' aides care kardex on Point of Care will reflect which of those identified residents are at risk for elopement for those 9 residents who have been identified. Element #3 12. On 2/15/2017 an additional intervention of placing an employee in the hallway to 24 hours a day was added to monitor the 3rd floor elevator and stairwell doors until all staff have been educated on the updated intervention/care plan of Q 1 hour monitoring; 13. On 2/15/2017 additional education was initiated for all staff related to door chimes. No staff worked or cared for residents until they received education. New employees or employees on vacation or FMLA will be educated prior to working. 14. On 2/16/2017 an additional intervention was implemented by ensuring all residents that have been identified as an elopement risk are monitored via visual hourly checks to be overseen by the nursing department. An in-service for employees that will work on the 3rd floor will be educated on the new care plan/intervention. Element #4 15. On 2/9/2017 an additional audit was initiated to ensure that the front door magnetic lock is active and working. Doors will be checked daily for two weeks and weekly there-after. 16. Care plan audits of residents who are at risk will be audited weekly X 4 then monthly thereafter. 17. Hourly audit check of visualization of the residents at risk for employment will be audited 3 X weekly then weekly thereafter. 18. All audits and findings will be reported and review at facility's quality review committee meetings. Element #5 The Administrator is responsible for ensuring that the plan of correction is implemented as of 2/16/2017, and sustaining compliance.

Based on observation, interview and record review, the facility failed to ensure that an indwelling catheter (Foley) was properly secured to prevent pulling and damage to the meatus (opening of the penis) for one (#502) of two residents observed with catheters, from a total of 17 sampled residents, resulting in damage to the meatal opening of Resident #502's penis with visible bleeding. Findings include: On 10/7/14 at 8:50 a.m., during an initial tour of the facility, Resident #502 was observed in his room laying in bed in supine (back) position. Resident #502 was observed with an indwelling urinary catheter that was not anchored to his leg. A review of the clinical record revealed that Resident #502 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #502 had moderately impaired cognitive skills for decision making and required total physical assistance of staff with all activities of daily living including, bed mobility, transfers, dressing, eating, hygiene and bathing. The MDS acknowledged the presence of an indwelling catheter. On 10/7/14 at 11:15, Resident #502 was observed in his room laying in bed. Resident #502's Foley catheter tubing was not been secured in order to prevent tugging and pulling at the meatus. A review of Resident #502's "Indwelling Catheter" care plan dated 7/14/14 documented: "Indwelling urinary catheter related to [MEDICAL CONDITION] and sacral decub (pressure sore). Plan: Anchor Foley Catheter." On 10/8/14 at 10:55 a.m., during a skin assessment and wound care observation, Resident #502 was observed in his room laying in bed in supine position. Upon repositioning, Resident #502 was observed with bleeding from the meatal opening of his penis. Blood was noted to his brief and linens. LPN "I" (Licensed Practical Nurse/wound care nurse) who was present to change Resident #502's dressings, reported, "He didn't have a leg strap on. I put one on just yesterday. It was much later in the afternoon. I didn't document the time." CNA "H" (Certified Nursing Assistant) who was present to assist with repositioning during the wound care observation reported, "I came in this morning and his (Resident #502) Foley was dislodged. It was just laying across him and urine was on his pad. I told the nurse and she put it back in." LPN "I" then reported, "The opening of his penis is elongated. It's sliced from the Foley catheter because it wasn't strapped down." On 10/10/14 at 9:00 a.m., Resident #502 was observed in his room laying in bed. LPN "J" assisted with the observation which revealed a loosely, ill-fitting catheter leg strap to Resident #502's left leg and visible bleeding from the opening of Resident #502's penis (Foley insertion site). The Foley catheter tubing was noted to be underneath Resident #502's left leg and the tubing was taught and pulling at Resident #502's penis. LPN "J" reported, "It shouldn't be under his leg." RN "G" (Registered Nurse) then entered the room and requested to assess Resident #502's penis and the status of his bleeding and reported, "I see the bleeding and that the opening is elongated. I'm going to call the doctor." On 10/10/14 at 9:15 a.m., during a subsequent interview, RN "G" reported, "I didn't see a tear when he (Resident #502) was admitted . there is nothing in his wound care notes and no charting indicating he had any previous tears or damage to the meatal opening. I documented on the 24 hour report to monitor for any further bleeding but I didn't put it on the CNA care guide." When asked who was ultimately responsible for ensuring the Foley catheter tubing was secured, RN "G" reported, "The CNA's but the nurses are to monitor as well." RN "G" placed a telephone call to Resident #502's physician then reported, "The physician said the tear and bleeding is possibly due to the Foley catheter tugging and he instructed me to monitor for any further bleeding." On 10/10/14 at 10:40 a.m., during an interview, The director of Nursing (DON) was queried and reported, "You always have to anchor the catheter to the leg with a strap. It it pulls out, the resident can have an injury or a tear to the penis. I took a look at it when I heard about the bleeding and the opening is much wider than normal. Much wider than a normal penis opening should be. I attribute that to the pulling at the penis and with the leg strap not being there, it could make the opening wider." The facility administrative staff was unable to explain why Resident #502's Foley catheter tubing had not been properly secured in order to prevent pulling and tugging at the meatal opening (Foley insertion site) resulting in tearing and bleeding to the meatus. A review of the facility's "Catheter Care" policy, dated 2/13 documented: "Position the resident so that the catheter and tubing are free from kinks or pulling." "Use leg strap to anchor the catheter tubing to resident's thigh to prevent pulling of catheter when repositioning which can cause tissue injury and discomfort to resident."

THIS CITATION PERTAINS TO INTAKE #MI 229, MI 231, AND MI 418. BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO SUPERVISE AND PROVIDE THE NECESSARY SAFETY DEVICES REQUIRED TO PREVENT FALLS FOR 2 (#101 AND #104) OF 4 SAMPLED RESIDENTS REVIEWED FOR SAFETY, FROM A TOTAL SAMPLE OF 4, RESULTING IN A LEFT LEG LACERATION FOR RESIDENT #101, AND IN RECURRENT FALLS WITHOUT INJURY FOR RESIDENT #104 WITH THE POTENTIAL FOR FUTURE FALLS WITH INJURY. FINDINGS INCLUDE: RESIDENT #101 REVIEW OF THE FACE SHEET DATED 4/22/2013 REVEALED RESIDENT #101 WAS AN [AGE] year OLD FEMALE admitted TO THE FACILITY 9/11/2012 WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #101 HAD IMPAIRED COGNITION WITH BOTH LONG AND SHORT TERM MEMORY LOSS, SHE COULD NOT BALANCE, DID NOT WALK, fell TWICE SINCE HER ADMISSION, AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST HER WITH TRANSFERS. REVIEW OF THE FALL ASSESSMENT CARE PLAN DATED 9/20/2012 REVEALED RESIDENT #101 had a history of [REDACTED].#101'S ABILITY TO ASSIST AT THE TIME OF THE TRANSFER. THE CARE PLAN WAS MODIFIED 1/26/2013 TO HAVE RESIDENT #101 GET OUT OF BED BEFORE DAY SHIFT, AFTER STAFF FOUND HER ON A MAT NEXT TO HER BED. THE LAST CARE PLAN MODIFICATION OCCURRED THREE DAY LATER WHEN STAFF APPLIED BED BOLSTER, BECAUSE THEY FOUND RESIDENT #101 ON A MAT NEXT TO HER BED AGAIN. REVIEW OF THE "RESTRAINT ASSESSMENT" FORM DATED 3/22/2013 REVEALED RESIDENT #101 REMAINED AT RISK FOR FALLS, EXHIBITED COGNITIVE IMPAIRMENTS, A FALL HISTORY, WEAKNESS, AND AN INABILITY TO BALANCE WHILE SITTING, STANDING, TRANSFERRING, OR WALKING. REVIEW OF PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE MEDICAL RECORD FAILED TO PROVIDE DOCUMENTED EVIDENCE TO SUGGEST PHYSICAL AND OCCUPATIONAL THERAPY EVER COMPLETED THESE ORDERED EVALUATIONS. REVIEW OF AN INCIDENT REPORT DATED 4/14/2013 AT 6:00 A.M., REVEALED THAT STAFF FOUND RESIDENT #101 SITTING ON THE FLOOR MAT, NEXT TO HER BED WITH A LEFT GREAT TOE ABRASION. THE FORM DID NOT DOCUMENT ANY NEW SAFETY DEVICES AND/OR SUPERVISION IMPLEMENTED TO PREVENT FUTURE FALLS WITH INJURY, AND UNDER SECTION "14" OF THE INCIDENT REPORT, STAFF LEFT THE "CORRECTIVE MEASURE TAKEN" BLANK. REVIEW OF THE MEDICAL RECORD FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE TO SUGGEST STAFF HAD IMPLEMENTED ANY ADDITIONAL SUPERVISION AND/OR SAFETY DEVICES TO KEEP RESIDENT #101 SAFE AFTER SHE fell [DATE]. REVIEW OF THE "FALL SCREEN" DATED 4/14/2013 REVEALED STAFF APPLIED THE BED BOLSTERS FOR RESIDENT #101 INCORRECTLY, WHICH CAUSED HER TO FALL. REVIEW OF THE UNDATED "ADL (ACTIVITIES OF DAILY LIVING) PLAN OF CARE" FORM REVEALED RESIDENT #101 WAS A FALL RISK, WHO REQUIRED CHAIR ALARMS, A LOW BED, BED ALARMS, FLOOR MATS, BED BOLSTERS AND A WEDGE CUSHION. DESPITE THE PRIMARY FUNCTION OF THIS FORM BEING TO PROVIDE CERTIFIED NURSING ASSISTANTS WITH ACCURATE INFORMATION TO PROVIDE SAFE CARE, IT ONLY DOCUMENTED ONE STAFF MEMBER WAS NEEDED FOR TRANSFERS, WHEREAS THE CARE PLAN TO ADDRESS FALLS REQUIRED TWO STAFF MEMBERS AT TIMES. REVIEW OF AN INCIDENT REPORT DATED 4/02/2013 AT 8:30 A.M., REVEALED CERTIFIED NURSING ASSISTANT (CNA) #1 HAD INDEPENDENTLY TRANSFERRED RESIDENT #101 FROM HER BED INTO HER WHEELCHAIR BEFORE SHE WITNESSED BLEEDING COMING FROM RESIDENT #101'S LEFT LEG. REVIEW OF NURSING NOTES DATED 4/21/2013 AT 9:00 A.M., REVEALED RESIDENT #101 WAS "...TRANSFERRED TO (NAME) A LOCAL AREA HOSPITAL FOR DEEP LACERATIONS TO (THE) LOWER LEFT LEG..." AND RETURNED SIX HOURS LATER WITH 22 STITCHES HOLDING THE WOUND TOGETHER. REVIEW OF THE MEDICAL RECORD FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE TO SUGGEST STAFF HAD IMPLEMENTED ANY ADDITIONAL SUPERVISION AND/OR SAFETY DEVICES TO KEEP RESIDENT #101 SAFE AFTER HER INJURY 4/21/2013. REVIEW OF ORDERS DATED 4/22/2013 REVEALED THE PHYSICIAN AGAIN REQUESTED PHYSICAL AND OCCUPATIONAL THERAPY TO COMPLETE THE EVALUATION INITIALLY 4/05/2013 THAT HAD YET TO BE COMPLETED. REVIEW OF THE "ADL/SAFETY ASSESSMENT" FORM DATED 4/25/2013 REVEALED OCCUPATION THERAPY COMPLETED THEIR EVALUATION, AND DETERMINED RESIDENT #101 INDEED REQUIRED MINIMALLY TWO STAFF MEMBERS TO ASSIST WITH ALL TRANSFERS. REVIEW OF A WRITTEN STATEMENT DATED 4/21/2013 REVEALED LICENSED PRACTICAL NURSE (LPN) #1 ASSESSED THE PHYSICAL ENVIRONMENT AFTER THE INJURY OCCURRED. LPN #1 DOCUMENTED THE BRAKE HANDLE ON RESIDENT #101'S WHEELCHAIR NO LONGER HAD ITS PROTECTIVE RUBBER COVER, AND WAS A POTENTIAL CAUSE FOR THE INJURY SUSTAINED. REVIEW OF AN EMPLOYEE DISCIPLINE FORM DATED 4/23/2013 REVEALED " ON 4/21/2013 AT 8:23 A.M., (CNA #1) TRANSFERRED A RESIDENT FROM HER BED TO A WHEELCHAIR CAUSING INJURY TO RESIDENT'S (#101) LOWER LEFT LEG." REVIEW OF THE FIVE DAY INVESTIGATION REPORT SUBMITTED TO THE STATE OF MICHIGAN BY THE FACILITY DATED 4/29/2013 REVEALED THAT WHEN CNA #1 INDEPENDENTLY TRANSFERRED RESIDENT #101 FROM HER BED INTO HER WHEELCHAIR, CNA #1 FELT RESIDENT #101'S BODY BUMP SOMETHING. THE ADMINISTRATOR DOCUMENTED CNA #1 BELIEVED AT FIRST HER (#101) BUTT HIT THE CHAIR BUT AFTER WITNESSING THE INJURY BELIEVED "IT WAS HER (RESIDENT #101) LEFT LEG BEING SCRAPED ACROSS THE BRAKE EXTENDER." DURING AN INTERVIEW 5/07/2013 AT 12:40 P.M., DIRECTOR OF NURSING (DON) #1 WAS UNABLE TO ADEQUATELY EXPLAIN 1) HOW RESIDENT #101 fell FROM HER BED 4/14/2013 IF HER REQUIRED BED BOLSTERS WERE IMPLEMENTED APPROPRIATELY; 2) WHY STAFF HAD NOT IMPLEMENT ANY ADDITIONAL SUPERVISION AND/OR SAFETY DEVICES TO KEEP RESIDENT #101 AFTER SHE fell [DATE]; 3) WHY PHYSICIAN ORDERS [REDACTED]. AFTER REVIEWING THE INCIDENT REPORT FOR 4/21/2013 DON #1 SAID, "I DON'T THINK IT WAS A SAFE TRANSFER." RESIDENT #104 REVIEW OF THE FACE SHEET DATED 10/01/2012 REVEALED RESIDENT #104 WAS A [AGE] year OLD FEMALE admitted TO THE FACILITY 9/28/2013 WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #104 EXPERIENCED MILD CONFUSION, HAD TWO RECENT FALLS, COULD NOT BALANCE WITHOUT ASSISTANCE, DID NOT WALK AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS. REVIEW OF THE RISK FOR FALLS CARE PLAN DATED 10/22/2012 REVEALED RESIDENT #104 HAD CONFUSION, COGNITIVE IMPAIRMENTS, LEFT SIDE PARALYSIS, INCONTINENCE, AND REQUIRED MINIMALLY TWO PEOPLE FOR ALL TRANSFERS. MODIFICATIONS MADE TO THIS CARE PLAN BETWEEN 10/27/2012 AND 1/28/2013 NOTED THAT A LOW BED, WINGED MATTRESS, BED ALARMS, CHAIR ALARMS, FLOOR MATS, AND DIRECT OBSERVATION WHILE TOILETING WERE ALSO REQUIRED FOR HER SAFETY. REVIEW OF THE "RESTRAINT ASSESSMENT" FORM DATED 1/24/2013 REVEALED RESIDENT #104 WAS FOUND LYING ON HER BEDROOM FLOOR, HER MOBILITY EFFECTED BY POOR BALANCE, POOR POSTURE, WEAKNESS AND COGNITIVE IMPAIRMENTS. PHYSICAL THERAPY DOCUMENTED THE "TEAM RECOMMENDATION" WAS TO HAVE RESIDENT #104 "...SUPERVISED DURING (THE) NIGHT" WITH SKILLED THERAPY INITIATED FOR STRENGTH TRAINING. REVIEW OF NURSING NOTES DATED 1/24/2013 AT 1:00 A.M. REVEALED RESIDENT #104 MADE MULTIPLE ATTEMPTS TO GET OUT OF BED AND REQUIRED ADDITIONAL SUPERVISION. ON 1/28/2013 AT 2:00 A.M., STAFF DOCUMENTED, "RESIDENT AWAKE, ALERT, CONSTANTLY RINGING CALL LIGHT AND ATTEMPTING TO GET OUT OF BED, MONITORING." REVIEW OF AN INCIDENT REPORT DATED 2/11/2013 AT 3:45 A.M., REVEALED RESIDENT #101 ASKED TO GET HER OUT OF BED AND WAS TOLD BY STAFF , "...IT WAS STILL TOO EARLY..." THE SAME NURSING NOTE DOCUMENTED THAT " A FEW MINUTES LATER...RESIDENT (#104) HAD ROLLED HERSELF OUT OF BED ONTO THE FLOOR." REVIEW OF THE CARE PLAN DATED 2/12/2013 REVEALED RESIDENT #101 WOULD BE GOTTEN UP WHEN SHE CHOOSE NOT TO SLEEP. REVIEW OF AN INCIDENT REPORT DATED 2/23/2013 AT 3:50 A.M., REVEALED RESIDENT #104 WAS FOUND ON THE FLOOR NEXT TO HER BED. REVIEW OF RESIDENT #104'S ADL CARE PLAN DATED 10/22/2012, REVEALED THAT AS OF 2/26/2013, RESIDENT #104 WAS TO HAVE A LAP TRAY APPLIED TO HER WHEELCHAIR. REVIEW OF THE MEDICAL RECORD REVEALED STAFF FAILED TO IMPLEMENT ANY ADDITIONAL SUPERVISION, THE LAP TRAY, AND/OR OTHER SAFETY DEVICES TO ENSURE RESIDENT #104 REMAINED SAFE AFTER SHE fell [DATE]. REVIEW OF NURSING NOTES DATED 3/12/2013 AT 2:30 A.M., REVEALED STAFF FOUND RESIDENT #104 "...ON THE FLOOR MAT NEXT TO HER BED..." NURSING DOCUMENTED THAT RESIDENT #104 WAS CLOSELY MONITORED THE REST OF THE NIGHT, BUT FAILED TO DOCUMENT ANY ONGOING SUPERVISION AND/OR INTERVENTIONS IMPLEMENTED TO ENSURE RESIDENT #104 REMAINED SAFE WHEN THE NEXT SHIFT STARTED. REVIEW OF THE RISK FOR FALL CARE PLAN UPDATE 3/12/2013 REVEALED A URINE TEST WOULD BE CONDUCTED TO RULE OUT INFECTION. HOWEVER, REVIEW OF THE MEDICAL RECORD REVEALED ONGOING IMMEDIATE SUPERVISION AND/OR SAFETY DEVICES WERE NOT IMPLEMENTED TO KEEP RESIDENT #104 SAFE WHILE THE RESULTS OF THIS TEST WERE OBTAINED AND TREATMENT RENDERED IF NECESSARY. REVIEW OF THE URINE CULTURE REPORT DATED 3/15/2013 REVEALED RESIDENT #104 DID NOT HAVE A URINARY TRACT INFECTION. REVIEW OF THE MEDICAL RECORD REVEALED EVEN AFTER THE NEGATIVE URINE RESULT WAS OBTAINED, NO ADDITIONAL SAFETY MEASURES WERE IMPLEMENTED TO ENSURE RESIDENT #104 REMAINED SAFE. REVIEW OF AN INCIDENT REPORT DATED 4/21/2013 AT 1:30 A.M., REVEALED THAT STAFF FOUND RESIDENT #104 "...SCOOTING HERSELF OFF THE BED, ONTO THE FLOOR." REVIEW OF THE RISK FOR FALL CARE PLAN DATED 4/23/2013 REVEALED A SECOND URINE TEST WOULD BE CONDUCTED TO RULE OUT INFECTION. HOWEVER, REVIEW OF THE MEDICAL RECORD REVEALED ONGOING IMMEDIATE SUPERVISION AND/OR SAFETY DEVICES WERE NOT IMPLEMENTED TO KEEP RESIDENT #104 SAFE WHILE THE RESULTS OF THIS TEST WERE OBTAINED AND TREATMENT RENDERED IF NECESSARY. ON 5/07/2013 AT 10:00 A.M., OBSERVATION REVEALED THAT RESIDENT #104 WAS IN THE SECOND FLOOR DINING ROOM, ASLEEP IN HER WHEELCHAIR. RESIDENT #104 DID NOT HAVE A LAP TRAY ON HER WHEELCHAIR. DURING AN INTERVIEW 5/07/2013 AT 12:45 P.M., DON #1 WAS UNABLE TO ADEQUATELY EXPLAIN 1) WHY STAFF REFUSED TO ASSIST RESIDENT #104 OUT OF BED WHEN SHE ASKED 2/10/2013; 2) WHY FREQUENT SELF-TRANSFER ATTEMPTS FROM HER BED ON MIDNIGHTS WAS NOT RECOGNIZED AS A PATTERN; 3) WHY STAFF FAILED TO IMPLEMENT, ANY IMMEDIATE, ONGOING, SUPERVISION AND OR SAFETY DEVICES AFTER EACH FALL; OR, 4) WHY A FACILITY THAT DOES NOT USE LAP TRAYS HAD IT DOCUMENTED AS AN INTERVENTION ON THE CARE PLAN.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY ASSESS, ANTICIPATE AND RECOGNIZE SYMPTOMS OF PAIN (SUCH AS CLENCHED TEETH, FACIAL GRIMACING, AND A FURROWED FOREHEAD) AND PROVIDE PAIN CONTROL MEASURES FOR ONE (#506) OF FOUR SAMPLED RESIDENTS REVIEWED FOR PAIN (#506) FROM A TOTAL OF 17 SAMPLED RESIDENTS, RESULTING UNIDENTIFIED AND UNMANAGED PAIN, PAIN MEDICATION NOT ADMINISTERED. FINDINGS INCLUDE: THE INITIAL TOUR OF THE FIRST FLOOR NURSING UNIT WAS CONDUCTED ON 12/11/12 AT 8:30 A.M., WITH THE ASSISTANT DIRECTOR OF NURSING (ADON/FIRST FLOOR UNIT MANAGER). DURING THE TOUR RESIDENT #506 WAS OBSERVED IN BED. THE ADON REPORTED RESIDENT #506 WAS admitted INTO THE FACILITY WITH A STAGE FOUR PRESSURE SORE (SKIN BREAKDOWN EXPOSING MUSCLE AND OR BONE) ON THE SACRUM AND HAD ADDITIONAL WOUNDS TO THE HEELS. THE ADON REPORTED RESIDENT #506 WAS ON "CONTACT ISOLATION" FOR MULTIPLE DRUG RESISTANT ORGANISMS (INFECTIONS) IN THE WOUNDS. RESIDENT #506 WAS RESTLESS WITH A TENSED FACIAL EXPRESSION, CLENCHED TEETH, AND A WRINKLED BROW. RESIDENT #506 WORE BILATERAL HAND MITTENS. RESIDENT #506'S MITTEN-COVERED HANDS WERE IN CONSTANT RESTLESS MOTION AS THEY MOVED UP AND DOWN AND SIDE TO SIDE AGAINST THE RESIDENTS CHEST AND ABDOMEN. THE ADON REPORTED THE MITTENS WERE TO PREVENT RESIDENT #506 FROM PULLING OUT THE PERIPHERAL INSERTED CENTRAL CATHETER (PICC LINE-A CATHETER INSERTED IN A VEIN) USED TO ADMINISTER INTRAVENOUS ANTIBIOTIC THERAPY. AT 2:00 P.M, RESIDENT #506 WAS OBSERVED LYING IN BED. RESIDENT #506 WAS OBSERVED WITH THE SAME TENSED EXPRESSION, CLENCHED TEETH AND FACIAL GRIMACING. THE RESIDENT'S HAND WERE THRASHING AGAINST HIS CHEST AND ABDOMEN. ON 12/12/12 AT 9:00 A.M., RESIDENT #506 WAS OBSERVED LYING IN BED, WITH CLENCHED TEETH, WRINKLED BROW, AND GRIMACING. THE RESIDENT'S MITTEN-COVERED HANDS THRASHED AND RUBBED AGAINST HIS CHEST AND ABDOMEN. A REVIEW OF THE ADMISSION RECORD, DATED 12/03/12, INDICATED RESIDENT #506 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION NURSING ASSESSMENT, DATED 11/29/12, DOCUMENTED THAT RESIDENT #506 WAS ALERT, NON-VERBAL WITH ABSENT SENSORY AND COMMUNICATION. THE NURSING ADMISSION ASSESSMENT FURTHER DOCUMENTED THAT RESIDENT #506 HAD A "...LARGE OPEN STAGE IV WOUND ON THE COCCYX AND BILATERAL HEEL ULCERS. THE ADMISSION Minimum Data Set, dated dated [DATE], INDICATED THAT RESIDENT #506 WAS MODERATELY IMPAIRED IN COGNITIVE SKILLS FOR DAILY DECISION MAKING AND WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. THE ADMISSION CARE AREA ASSESSMENT (CAA) FOR PSYCHOSOCIAL WELL BEING, "ANALYSIS OF FINDING", STATED "...WHEN CARE IS GIVEN HE (RESIDENT #506) SOMETIMES MUMBLEING, DOES NOT ANSWER/FOLLOW DIRECTIONS...NONVERBAL MOST OF THE TIME..." ON 12/13/12 AT 9:30 A.M., A DRESSING CHANGE AND WOUND CARE OBSERVATION WAS CONDUCTED FOR RESIDENT #506 WITH THE FACILITY'S TREATMENT NURSE, STAFF (E). THE TREATMENT NURSE FAILED TO ASSESS RESIDENT #506 FOR PAIN BEFORE INITIATING THE WOUND CARE PROCEDURE. AT THAT TIME, IT WAS OBSERVED THAT RESIDENT #506 WAS "GRIMACING" (FACIAL EXPRESSION). THE RESIDENT'S BODY WAS TENSED AND HIS TEETH WERE CLENCHED. THE RESIDENT'S MITTEN-COVERED HANDS THRASHED AGAINST HIS CHEST AND ABDOMEN. THE WOUND NURSE, REPLIED, "...NO I DID NOT ASSESS HIM (RESIDENT #506 FOR PAIN)..." I'LL CHECK WITH THE NURSE AND SEE IF HE HAS ANY PAIN MEDICATION ORDERED..." THE WOUND CARE AND DRESSING FOR RESIDENT #506 WAS POSTPONED. AT 9:30 A.M., MEDICATION NURSE (D) WAS INTERVIEW REGARDING ASSESSING RESIDENT #506 FOR PAIN. NURSE (D) REPLIED RESIDENT #506 HAD NOT YET BEEN ASSESSED FOR PAIN ON THE A.M., SHIFT (7:00 A.M.-3:00 P.M.). NURSE (C) REPLIED RESIDENT #506 WAS EXHIBITING PAIN "...BY GRIMACED FACIAL EXPRESSIONS AND RESTLESSNESS..." ON 12/13/12 AT 10:20 A.M., THE DRESSING CHANGE AND WOUND CARE OBSERVATION WAS CONDUCTED WITH TREATMENT NURSE (E). IT WAS OBSERVED THAT RESIDENT #506 HAD A STAGE IV SACRAL WOUND THAT MEASURED 7.0 CENTIMETERS (CM) LONG X 9.0 CM WIDE X 2.0 CM DEEP. THERE WAS A STAGE II PRESSURE ULCER ON THE RESIDENT'S RIGHT HEEL THAT MEASURED 2.9 CM LONG X 1.5 CM WIDE. THE Medication Administration Record, [REDACTED]. AT 10:30 A.M., RESIDENT #506'S RESTLESSNESS HAD VISIBLY SUBSIDED. HIS TEETH WERE NOT CLENCHED, AND HIS BROWS WERE SMOOTH. ON 12/13/12 AT 10:45 A.M., THE FIRST FLOOR UNIT MANAGER/ADON WAS INTERVIEWED REGARDING PAIN MANAGEMENT FOR RESIDENT #506 AND THE FOLLOWING WAS REVEALED: THE "PAIN ASSESSMENT" FOR RESIDENT #506, DATED 11/29/12, DOCUMENTED THAT RESIDENT #506 HAD A DIAGNOSIS "...WHICH WOULD INDICATE THE PROBABILITY OF PAIN..STAGE IV DECUBITUS ULCER..." THERE WERE 26 DESCRIPTIONS OF PAIN FOR A NON-VERBAL RESIDENT AND ALL 26 DESCRIPTIONS WERE "CHECKED" AS "INDICATORS OF PAIN" FOR THIS RESIDENT. THESE INDICATORS WERE BROKEN DOWN INTO THREE MAIN CATEGORIES THAT INCLUDED "FACIAL EXPRESSION, VOCALIZATION, AND BODY ACTIONS/OBSERVED BEHAVIORS". RESIDENT #506 DEMONSTRATED "GRIMACING/DISTORTED FACE, CLENCHED JAW/TEETH, WRINKLED BROWN, AND THRASHING". AN INITIAL CARE PLAN DATED 11/29/12 ENTITLED, "PAIN" RELATED TO COCCYX WOUND STAGE IV..." HAD NO NURSING INTERVENTIONS TO ADDRESS PAIN CONTROL AND PAIN MANAGEMENT FOR RESIDENT #506. A REVIEW OF THE PHYSICIAN'S ORDER FOR RESIDENT #506, DATED 12/01/12, READ "[MEDICATION NAME] 650 MILLIGRAMS BY MOUTH... AS NEEDED FOR FEVER..." THERE WERE NO PHYSICIAN'S ORDERS TO ADDRESS PAIN FOR RESIDENT #506. THE NURSING Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ON 12/13/12 AT 10:00 A.M., AN INTERVIEW WAS CONDUCTED WITH THE ADON AND IT WAS REPORTED IT IS EXPECTED AND LIKELY RESIDENT#506 EXPERIENCED PAIN RELATED TO THE PRESSURE ULCERS/SORES. THE ADON EXPLAINED PAIN MANAGEMENT AND PAIN CONTROL HAD BEEN DISCUSSED WITH RESIDENT #506'S PRIMARY PHYSICIAN; HOWEVER, RESIDENT #506'S PRIMARY PHYSICIAN HAD "REFUSED" TO ORDER PAIN MEDICATION FOR RESIDENT #506, DESPITE, THE RESIDENT'S GRIMACING, TEETH CLENCHING, AND FURROWED BROW AS WELL AS THE FACT RESIDENT #506 WAS NON-VERBAL AND UNABLE TO MAKE HIS NEEDS. THE ADON REPORTED THE PHYSICIAN DID NOT KNOW RESIDENT #506 WELL AND DID NOT WANT TO PRESCRIBE PAIN MEDICATION. THERE WAS NO EVIDENCE TO SUPPORT THE ADON CONTACTED THE PHYSICIAN REGARDING PAIN CONTROL. ON 12/13/12, A REVIEW OF THE UNDATED FACILITY POLICY ENTITLED "POLICY AND PROCEDURE FOR PAIN MANAGEMENT" STATED, "PURPOSE: TO PROVIDE ACCURATE, ONGOING ASSESSMENT OF RESIDENT TO ACHIEVE OPTIMAL COMFORT AND CONTROL OF PAIN...IT IS THE POLICY...TO ASSESS ALL RESIDENT FOR PAIN UPON ADMISSION WHENEVER...SYMPTOMS OF DISCOMFORT IS EVIDENCED..AND PROVIDE MEDICATION TO ALLEVIATE PAIN." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 817 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY ASSISTANCE AND/OR ASSISTIVE DEVICES IN 5 OF 8 SAMPLED RESIDENTS (#101, #102, #104, #106, AND #107) REVIEWED FOR SAFETY WITH TRANSFERS AND TOILETING FROM A TOTAL SAMPLE OF 8, RESULTING IN: 1.) AN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHO SUSTAINED AN INOPERABLE, COMPLEX, COMPOUND, OPEN, TIBIA FIBULA FRACTURE OF THE RIGHT LEG. RESIDENT #101 SUBSEQUENTLY REQUIRED A BELOW THE KNEE AMPUTATION OF THE RIGHT LEG. THIS DEFICIENT PRACTICE PLACED 59 RESIDENTS IDENTIFIED AT RISK FOR INJURY DURING TRANSFERS AND TOILETING, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH, AND 2.) THE POTENTIAL FOR HARM IN RESIDENT #102, #104, #106, AND #107 DUE TO LACK OF SUPERVISION AND/OR ASSISTIVE DEVICES TO PREVENT INJURIES. FINDINGS INCLUDE: RESIDENT #101: ACCORDING TO THE FACE SHEET DATED 8/08/2011, RESIDENT #101 WAS A [AGE] year-old-FEMALE WHO LIVED AT THE FACILITY FROM 8/05/2011 UNTIL 8/12/2011. HER [DIAGNOSES REDACTED]. ACCORDING TO AN INCIDENT REPORT DATED 8/12/2011 AT 1:35 P.M., REVEALED CERTIFIED NURSING ASSISTANT (CNA) #1 INDEPENDENTLY TRANSFERRED RESIDENT #101 FROM HER WHEELCHAIR TO THE TOILET AND RESIDENT #101'S "RIGHT FOOT GOT CAUGHT". THE INCIDENT REPORT DOCUMENTED THERE WAS A "MAJOR INJURY" TO RESIDENT #101'S RIGHT ANKLE. RESIDENT #101 WAS TRANSFERRED TO THE HOSPITAL FOR EMERGENCY CARE. REVIEW OF THE "FACILITY INVESTIGATION REPORT" COMPLETED BY THE DIRECTOR OF NURSING (DON) ON 8/16/2011 REVEALED RESIDENT #101 SAID HER ANKLE "TWISTED" BEHIND HER WHEN CNA #1 LIFTED HER FROM THE WHEELCHAIR ONTO THE TOILET 8/12/2011 AT 1:35 P.M. DURING AN INTERVIEW ON 9/08/2011 AT 12:30 P.M., CNA #1 SAID SHE TRANSFERRED RESIDENT #101 FROM HER WHEELCHAIR TO THE TOILET ON 8/12/2011 AT 1:35 P.M. CNA #1 SAID SHE ASSISTED RESIDENT #101 TO A STANDING POSITION FROM THE WHEELCHAIR, PIVOTED RESIDENT #101 APPROXIMATELY 90 DEGREES, THEN LOWERED RESIDENT #101 DOWN ONTO THE TOILET. CNA #1 SAID NO OTHER STAFF WERE PRESENT TO ASSIST WITH THIS TRANSFER, PIVOT, OR TOILETING PROCEDURE. CNA #1 SAID SHE NEVER USED A SLIDE BOARD FOR THIS TRANSFER. CNA #1 SAID SHE KNEW RESIDENT #101 HAD PLACED WEIGHT ON HER RIGHT LOWER EXTREMITY/FOOT TO ASSIST IN THE TRANSFER. CNA #1 SAID SHE COULD NOT SEE THE POSITION OF RESIDENT #101'S RIGHT FOOT DURING THE TRANSFER. CNA #1 SAID, "I ... LOOKED DOWN AFTER THE TRANSFER AND SAW THERE WAS A LOT OF BLOOD ON THE FLOOR". CNA #1 SAID RESIDENT #101 WAS BLEEDING FROM HER RIGHT ANKLE, "SO I CALLED FOR THE NURSE (LICENSED PRACTICAL NURSE (LPN) #1)". ON 8/12/2011 AT 1:25 P.M., LPN #1 ASSIGNED TO RESIDENT #101 DOCUMENTED IN THE NURSES NOTES THAT STAFF INFORMED HER RESIDENT #101 WAS "BLEEDING PROFUSELY" FROM HER RIGHT FOOT. LPN #1 DOCUMENTED RESIDENT #101'S RIGHT ANKLE AND FOOT WERE NO LONGER ALIGNED AND HAD AN "OPEN AREA AT (THE) ANKLE." IN AN INTERVIEW ON 9/08/2011 AT 12:10 P.M. LPN #1 SAID SHE KNEW THE INJURY RESIDENT #101 SUSTAINED ON 8/12/2011 WAS AN OPEN FRACTURE OF THE RIGHT LEG. LPN #1 SAID THE RIGHT INNER ANKLE LOOKED AS THOUGH "SOMEONE HAD JUST PEELED THE SKIN BACK AND THERE WAS THE BONE". ACCORDING TO A PHYSICIANS PROGRESS NOTE DATED 8/12/2011, A ORTHOPEDIC (BONE) SURGEON EVALUATED RESIDENTS #101 AT THE HOSPITAL. THE ORTHOPEDIC SURGEON DETERMINED RESIDENT #101 HAD AN "OPEN BIMALLEOLAR FRACTURE OF (THE) RIGHT ANKLE" AND THAT "ANY TREATMENT OPTION INVOLVING SALVAGE OF THE RIGHT LOWER EXTREMITY WOULD BE FRUITLESS DUE TO HER INABILITY TO HEAL." ACCORDING TO A VASCULAR SURGEON'S PROGRESS NOTE DATED 8/15/2011, "ORTHOPEDIC DETERMINED...(RESIDENT #101 HAD AN OPEN BIMALLEOLAR FRACTURE), THAT WAS NON-OPERABLE AND UNABLE TO BE STABILIZED." THE VASCULAR SURGEON DOCUMENTED AN "AMPUTATION WOULD BE THE APPROPRIATE COURSE OF ACTION..." FOR RESIDENT #101. ACCORDING TO THE HOSPITAL OPERATIVE REPORT DATED 8/15/2011 RESIDENT #101 WAS TAKEN TO SURGERY AND HER RIGHT LEG WAS AMPUTATED BELOW THE KNEE. REVIEW OF THE MEDICAL RECORDS RECEIVED WITH THE PATIENT ON ADMISSION 8/05/2011, SKILLED THERAPISTS FROM A PRIOR FACILITY DETERMINED ON 7/11/2011, RESIDENT #101 WAS AT RISK FOR FALLS. THESE RECORDS INDICATED THAT RESIDENT #101 HAD WEIGHT BEARING PRECAUTIONS AND NEEDED MAXIMUM STAFF ASSISTANCE WITH ALL TRANSFERS, TOILETING, AND PIVOTING. ACCORDING TO THE 2007 VERSION OF THE "INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPY ASSISTANTS" WRITTEN BY OLGA DREEBEN (PAGE 233) MAXIMUM STAFF ASSISTANCE MEANS "STAFF MUST ASSIST THE RESIDENT WITH APPROXIMATELY 75% OR MORE OF THE PATIENTS TOTAL WORK." REVIEW OF THE PHYSICIANS HISTORY AND PHYSICAL RECORD DATED 8/06/2011, INDICATED FACILITY STAFF WERE TO ENSURE RESIDENT #101'S PARTICIPATION IN ACTIVITIES WAS "LIMITED". THE PHYSICIAN DOCUMENTED RESIDENT #101'S POTENTIAL FOR REHABILITATION WAS "FAIR". REVIEW OF THE FALL RISK assessment dated [DATE] REVEALED RESIDENT #101 WAS AT RISK FOR FALLS DUE TO RECENT FALLS, VISUAL IMPAIRMENTS, OCCASIONAL INCONTINENCE, AN INABILITY TO INDEPENDENTLY COME TO A STANDING POSITION, A LOSS OF BALANCE WHILE STANDING, THE USE OF ASSISTIVE DEVICES, AND BECAUSE RESIDENT #101 WAS "CONFINED" TO A WHEELCHAIR. REVIEW OF THE SKIN assessment dated [DATE] REVEALED RESIDENT #101 WAS "CHAIRFAST: (RESIDENT #101'S) ABILITY TO WALK (WAS) SEVERELY LIMITED OR NONEXISTENT. (SHE) COULD ...NOT BEAR (HER) OWN WEIGHT" AND/OR NEEDED ASSISTANCE INTO A CHAIR OR WHEELCHAIR. REVIEW OF THE NURSES NOTE DATED 8/05/2011 AT 8:25 P.M. REVEALED RESIDENT #101 HAD WEIGHT BEARING RESTRICTIONS DUE TO "MUSCULAR WASTING". THE NURSES NOTE DID NOT INDICATED HOW MUCH WEIGHT RESIDENT #101 WAS ALLOWED TO BEAR, WHICH EXTREMITY HAD THE WEIGHT BEARING RESTRICTIONS, NOR ANY CLARIFICATION FROM THE PHYSICIAN OF RESIDENT #101'S WEIGHT BEARING STATUS. THE NURSING ADMISSION assessment dated [DATE] INDICATED RESIDENT #101 WAS "TOTALLY DEPENDENT" ON FACILITY STAFF FOR TOILETING AND TRANSFERS. A REVIEW OF THE ACTIVITY OF DAILY LIVING CARE PLAN DATED 8/05/2011 INDICATED RESIDENT #101 REQUIRED ONE PERSON ASSISTANCE WITH TRANSFERS, PIVOTING, AND TOILETING (CONTRADICTORY TO THE NURSING ADMISSION assessment dated [DATE]). THE CARE PLAN'S INTERVENTIONS ALSO INCLUDED FACILITY STAFF WERE TO IMPLEMENT THE "FALLING OAKS PROTOCOL" AND "PROVIDE (RESIDENT #101 WITH) ASSISTIVE DEVICES AS NEEDED/ORDERED". IN AN INTERVIEW ON 9/08/2011 AT 11:40 P.M. THE DIRECTOR OF NURSING (DON) REPORTED THAT THE FACILITY HAD NO FALLS PROGRAMS CALLED "FALLING OAKS PROTOCOL". REVIEW OF THE HIGH RISK FOR FALL/INJURY CARE PLAN DATED 8/08/2011 REVEALED FACILITY STAFF WERE TO "ASSIST (RESIDENT #101) WITH ALL TRANSFERS". THE CARE PLAN DID NOT INDICATE HOW MANY STAFF WERE TO ASSIST OR LIST ANY EQUIPMENT REQUIRED TO COMPLETE THIS TASK SAFELY. ON 8/10/2011 OCCUPATIONAL THERAPIST (OTR) #1 EVALUATED RESIDENT #101 AND DEVELOPED AN INDIVIDUALIZED CARE PLAN. IN THIS EVALUATION, OTR #1 INDICATED A PHYSICIANS CLARIFICATION WAS REQUIRED TO ESTABLISH IF RESIDENT #101 COULD SAFELY PLACE WEIGHT ON HER RIGHT LOWER EXTREMITY/FOOT. REVIEW OF THE OCCUPATIONAL THERAPY EVALUATION/CARE PLAN DATED 8/10/11 REVEALED RESIDENT #101 REQUIRED "MAXIMUM TO TOTAL ASSISTANCE FOR ALL TOILETING NEEDS AND TRANSFER HER USING A SLIDING BOARD". ON 9/08/2011 AT 1:30 P.M., THE MANAGER OF THE THERAPY DEPARTMENT (OTR #2) STATED THAT MAXIMUM TOTAL ASSISTANCE FOR TOILETING MEANS "YOU BETTER HAVE TWO PEOPLE (STAFF) THERE" PROVIDING PHYSICAL ASSISTANCE FOR THE RESIDENT. REVIEW OF THE PHYSICAL THERAPY EVALUATION DATED 8/9/2011 REVEALED RESIDENT #101 WAS "UNABLE" TO WALK, HAD "P (POOR) STANDING BALANCE AND WAS AT RISK FOR FALLS". THE PHYSICAL THERAPIST (PT #1) DOCUMENTED THE WEIGHT BEARING STATUS FOR RESIDENT #101 WAS "NOT SPECIFIED CLEARLY" AND REQUIRED CLARIFICATION FROM A PHYSICIAN. REVIEW OF THE PHYSICAL THERAPY EVALUATION/CARE PLAN DATED 8/9/11 REVEALED FACILITY STAFF WERE TO PROVIDE RESIDENT #101 WITH "MAXIMUM ASSISTANCE" FOR ALL TRANSFERS USING A "SLIDING BOARD". ON 8/09/ 2011 THE PHYSICAL THERAPIST (PT #1) COMPLETED AN " INTEROFFICE COMMUNICATION " FORM AND PLACED IT IN THE PHYSICIANS REVIEW BOOK. THIS FORM REQUESTED A PHYSICIAN TO CLARIFY WHAT WEIGHT BEARING RESTRICTIONS RESIDENT #101 HAD. IN AN INTERVIEW ON 9/08/2011 AT 1:00 P.M., PT #1 SAID, THE PHYSICIAN AND/OR PRACTITIONER DID NOT CLARIFY RESIDENT #101'S WEIGHT BEARING STATUS PRIOR TO DISCHARGE (ON 8/12/2011). ON 9/08/2011 AT 2:00 P.M., THE DIRECTOR OF NURSING AND UNIT MANAGER (UNIT MANAGER REGISTERED NURSE (RN) #1) SAID THE CARE PLANS SUBMITTED BY OCCUPATIONAL THERAPY AND PHYSICAL THERAPY FOR RESIDENT #101 HAD NOT BEEN REVIEWED OR IMPLEMENTED BY NURSING STAFF. UNIT MANAGER RN #1 SAID CNA #1 FAILED TO PROVIDE THE APPROPRIATE LEVEL OF SUPERVISION AND ASSISTIVE DEVICES NECESSARY TO KEEP RESIDENT #101 SAFE WHEN CNA #1 TRANSFERRED RESIDENT #101 FROM THE WHEELCHAIR TO THE TOILET, RESULTING IN INJURY. ON 9/15/2011 AT 10:45 A.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 8/12/2011 AND WAS IDENTIFIED ON 9/14/2011 WHEN THE FACILITY FAILED TO PROVIDE THE NECESSARY ASSISTANCE AND/OR ASSISTIVE DEVICES FOR RESIDENT #101 WHO SUSTAINED AN INOPERABLE, COMPLEX, COMPOUND, OPEN, TIBIA FIBULA FRACTURE OF THE RIGHT LEG WHERE RESIDENT #101 SUBSEQUENTLY REQUIRED A BELOW THE KNEE AMPUTATION OF THE RIGHT LEG. THIS DEFICIENT PRACTICE PLACED 59 RESIDENTS IDENTIFIED AT RISK FOR INJURY DURING TRANSFERS AND TOILETING, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON 9/19/2011, THIS SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. AS OF 8/12/2011 RESIDENT #101 NO LONGER LIVED AT THE FACILITY. 2. AS OF 8/17/2011, 28 OF 66 NURSING STAFF RECEIVED EDUCATION ON PROPER TRANSFER TECHNIQUES. 3. ON 9/16/2011, THE ADMINISTRATIVE TEAM REVIEWED THE FACILITY'S "TRANSFER POLICY" AND DEEMED IT ADEQUATE. 4. ON 9/15/2011, THERAPY HAD DEVELOPED AN ACTIVITY OF DAILY LIVING/SAFETY ASSESSMENT FORM. 5. ON 9/15/2011 THE FACILITY IMPLEMENTED A NEW PROTOCOL TO ENSURE SAFE TRANSFERS AND TOILETING FOR ALL RESIDENTS. THE FOLLOWING COMPONENTS OF THE PLAN WERE IN PLACE: A) AS OF 9/15/2011, 80 OF 80 RESIDENTS WHO LIVED AT THE FACILITY HAD INITIAL CARE PLANS DEVELOPED BY NURSING STAFF. THE FACILITY HAD NO NEW ADMISSION SINCE 9/15/2011. B) AS OF 9/16/2011, 80 OF 80 RESIDENTS WHO LIVED THAT THE FACILITY WERE REVIEWED AND EVALUATED BY THE THERAPY DEPARTMENT. THESE ASSESSMENTS WERE DOCUMENTED ON INDIVIDUAL ACTIVITY OF DAILY LIVING (ADL)/SAFETY FORMS. THERAPY DOCUMENTED THE RESIDENTS FUNCTIONAL ABILITY FOR ADL'S AND HAND DELIVERED ALL 80 FORMS TO NURSING STAFF. NURSING STAFF SIGNED FOR THE RECEIPT OF ALL 80 FORMS. C) AS OF 9/16/2011, NURSING MODIFIED CARE PLANS AND ADL PLANS FOR ALL 80 RESIDENTS WHO LIVED AT THE FACILITY. THE CHANGES REFLECTED THERAPY'S EVALUATION AND RECOMMENDATIONS. 6. AS OF 9/16/2011, 65 OF 66 NURSING STAFF HAD COMPLETED MANDATORY EDUCATION THAT STARTED ON 9/15/2011 ON THE FACILITY'S NEW PROTOCOLS AND HOW TO ENSURE SAFETY DURING TRANSFERS/TOILETING. 1 STAFF MEMBER REMAINED ON MEDICAL LEAVE BUT THE FACILITY PRODUCED A COPY OF A CERTIFIED LETTER/EDUCATION MAILED TO HER ON 9/16/2011. 7. AS OF 9/15/2011 A WEEKLY AUDIT TOOL FOR MONITORING TRANSFERS WAS DEVELOPED FOR USE BY UNIT MANAGERS. AS OF 9/16/2011 AUDITS FOR TRANSFERS BY CERTIFIED NURSING ASSISTANTS MET STATED REQUIREMENTS AND REMAINED ONGOING. AS OF 9/16/2011 TRANSFER AUDITS HAD NOT IDENTIFIED ANY IMPROPER OR UNSAFE TRANSFERS. 8. AS OF 9/16/2011 THE DIRECTOR OF NURSING HAD DEVELOPED AN AUDIT TOOL TO REVIEW SYMMETRY BETWEEN RESIDENT CARE PLANS, ADL PLANS AND THE ADL/SAFETY ASSESSMENT. AS OF 9/16/2011 THE AUDITS MET STATED REQUIREMENTS AND REMAINED ONGOING. NO DEFICIENCY HAD BEEN IDENTIFIED. 9. ON 9/17/2011 AND 9/19/2011 CERTIFIED NURSING ASSISTANTS DEMONSTRATED PROPER, SAFE TRANSFERS FOR 4 OF 4 RESIDENTS REVIEWED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 9/17/2011, 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 AS SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. RESIDENT #102 ACCORDING TO THE FACE SHEET DATED 8/31/2011, RESIDENT #102 WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 4/20/2009. RESIDENT #102'S [DIAGNOSES REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated dated ,[DATE], RESIDENT #102 HAD IMPAIRED DECISION MAKING WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. RESIDENT #102 COULD NOT BALANCE WITHOUT HUMAN ASSISTANCE AND REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH ALL TRANSFERS, TOILETING AND AMBULATION. A REVIEW OF PHYSICAL THERAPY NOTES DATED 1/18/2011 REVEALED RESIDENT #102 NEEDED STAFF ASSISTANCE FOR TOILETING. REVIEW OF A FALLS CARE PLAN DATED 1/31/2011 REVEALED RESIDENT #102 WAS AT RISK FOR FALLS AND REQUIRED STAFF ASSISTANCE FOR ALL TRANSFERS, FREQUENT MONITORING TO ENSURE HER BED/CHAIR ALARM WERE TURNED ON AND THAT SHE WAS TOILETING BEFORE MEALS, AFTER MEALS, BEFORE GOING TO BED AND AS NEEDED. NURSING NOTES DATED 1/31/2011 AT 8:15 P.M., REVEALED RESIDENT #102 SELF-TRANSFERRED WITHOUT ASSISTANCE. NURSING NOTES DATED 2/01/2011 AT 6:45 A.M., REVEALED RESIDENT #102 "CONTINUED TO ATTEMPT TO GET UP WITHOUT ASSISTANCE". NURSING NOTES DATED 2/01/2011 REVEALED RESIDENT #102 PLAYED WITH HER CHAIR ALARM, "POSSIBLY TURNING IT OFF". THERE WAS NO DOCUMENTATION OF ANY NEW SAFETY MEASURES IMPLEMENTED. NURSING NOTES DATED 4/04/2011 REVEALED RESIDENT #102 "WAS OBSERVED STANDING ALONG THE RAIL IN THE BATHROOM ... (AND) SHE LOWERED HERSELF TO (THE) FLOOR". FACILITY STAFF WERE NOT PRESENT TO ASSIST RESIDENT #102 WITH THIS TRANSFER. AN INCIDENT REPORT DATED 5/12/2011 AT 6:20 P.M., REVEALED STAFF FOUND RESIDENT #102 ON THE FLOOR IN THE MAIN BATHROOM AND HER ALARM WAS NOT SOUNDING. BASED ON NURSING DOCUMENTATION (ON 5/12/11), RESIDENT #102 fell WHEN SHE ATTEMPTED TO SELF-TRANSFER BECAUSE STAFF LEFT HER "UNATTENDED ON (THE) TOILET". THERE WAS NO DOCUMENTATION OF ANY NEW SAFETY MEASURES IMPLEMENTED. ON 5/13/2011, THE FACILITY'S FALL COMMITTEE DOCUMENTED "STAFF INSTRUCTED TO TOILET HER (RESIDENT #102) BEFORE AND AFTER MEALS AND BEFORE BEDTIME. STAFF INSTRUCTED TO CHECK HER ALARM WHENEVER THEY SEE HER. RESIDENT HAS A HISTORY OF REMOVING OR SHUTTING OFF ALARM." ON 9/12/2011 AT 12:45 P.M. THE DIRECTOR OF NURSING WAS INTERVIEWED AND SAID NO NEW INTERVENTIONS WERE IMPLEMENTED AFTER THIS FALL. THE DIRECTOR OF NURSING SAID THE INTERVENTIONS RECOMMENDED BY THE FALLS COMMITTEE ON 5/13/2011 HAD BEEN IMPLEMENTED SINCE 1/18/2011 WITHOUT CHANGES. REVIEW OF A FALL CARE PLAN DATED 5/16/2011 REVEALED RESIDENT #102 REMAINED AT RISK FOR FALLS AND REQUIRED STAFF ASSISTANCE WITH ALL TRANSFERS, REQUIRED A BED ALARM, A WHEELCHAIR ALARM (BOTH ALARMS TO BE KEPT OUT OF RESIDENT #102'S REACH), AND TOILETING BEFORE MEALS, AFTER MEALS, BEFORE GOING TO BED, AND AS NEEDED. REVIEW OF THE FALL assessment dated [DATE] REVEALED RESIDENT #102 WAS AT RISK FOR FALLS BASED ON HER DIAGNOSES, HISTORY OF "MULTIPLE FALLS", CONFUSION, OCCASIONAL INCONTINENCE, INABILITY TO INDEPENDENTLY COME TO A STANDING POSITION, LOSS OF BALANCE WHILE STANDING AND AS A RESULT OF BEING "CONFINED TO CHAIR AND DISORIENTED". REVIEW OF THE OCCUPATIONAL THERAPY NOTES DATED 5/24/2011 INDICATED RESIDENT #102 WAS A FALL RISK AND REQUIRED STAFF TO PROVIDE MINIMUM TO MODERATE ASSISTANCE WHILE ALL TOILETING AND TRANSFERS. ACCORDING TO AN INCIDENT REPORT DATED 5/26/2011 AT 3:00 P.M., STAFF FOUND RESIDENT #102 ON THE FLOOR IN THE BATHROOM. STAFF DOCUMENTED THE WHEELCHAIR BREAKS HAD NOT BEEN LOCKED WHEN RESIDENT #102 "SELF-TRANSFERRED". REVIEW OF THE MEDICAL RECORD REVEALED ON 5/30/2011 THE FACILITY'S FALL COMMITTEE DOCUMENTED "STAFF WILL CONTINUE TO MONITOR (THE) RESIDENT AND TOILET HER BEFORE AND AFTER MEALS." NO NEW INTERVENTIONS WERE PUT IN PLACE FOR RESIDENT #102 TO PREVENT FALLS. NURSING NOTES DATED 5/29/2011 AT 7:00 P.M., REVEALED RESIDENT #102 "REQUIRED CUEING FROM STAFF (TO) SIT DOWN." NURSING NOTES DATED 6/03/2011 AT 3:00 P.M., REVEALED RESIDENT #102 "CONTINUED TO TAKE HERSELF TO (THE) BATHROOM." NURSING NOTES DATED 6/09/2011 AT 10:00 P.M., REVEALED "INCREASED CONFUSION, SEVERAL ATTEMPTS MADE TO GET OUT OF (HER) CHAIR." ACCORDING TO AN INCIDENT REPORT DATED 8/15/2011 AT 12:00 P.M., STAFF FOUND RESIDENT #102 SITTING ON THE FLOOR IN HER BATHROOM. STAFF DOCUMENTED RESIDENT #102 "SELF-TOILETED" AND "SLID TO THE FLOOR AFTER USING THE BATHROOM." NO NEW INTERVENTIONS WERE PUT IN PLACE TO PREVENT FALLS. ON 9/12/2011 AND 1:00 P.M. RESIDENT #102 WAS OBSERVED BY THIS SURVEYOR SITTING IN HER WHEELCHAIR, AT HER BEDSIDE. RESIDENT #102'S WHEELCHAIR SENSOR ALARM WAS IN PLACE ON THE WHEELCHAIR. IN AN INTERVIEW ON 9/12/2011 AT 12:45 P.M., THE DIRECTOR OF NURSING SAID, "I TOTALLY AGREE" RESIDENT SAFETY CAN ONLY BE ACHIEVED IF STAFF INTERVENE AND CHANGE CARE PLANS THAT DID NOT WORK. IN AN INTERVIEW ON 9/12/2011 AT 12:45 P.M., THE UNIT MANAGER SAID RESIDENT #102 HAS DEMONSTRATED THE ABILITY TO REMOVE HER OWN ALARMS AND ATTEMPT MULTIPLE UNSUCCESSFUL SELF-TRANSFERS SINCE HER ADMISSION 4/20/2009. THE UNIT MANAGER DID NOT IDENTIFY ANY INTERVENTIONS IMPLEMENTED SINCE 1/18/2011 TO IMPROVE RESIDENT #102'S SAFETY. RESIDENT #104 ACCORDING TO THE FACE SHEET DATED 7/28/2011, RESIDENT #104 WAS AN [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 5/01/2007. HER [DIAGNOSES REDACTED]. ACCORDING TO HER MINIMUM (MDS) data set [DATE], RESIDENT #104 HAD IMPAIRED DECISION MAKING SKILLS WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. RESIDENT #104 COULD NOT WALK, COULD NOT BALANCE AND WAS DEPENDENT ON MINIMALLY ONE STAFF FOR ALL TOILETING AND TRANSFERS. REVIEW OF THE MEDICAL RECORD REVEALED ON 4/06/2011, RESIDENT #104 WAS readmitted TO THE FACILITY AT 6:00 P.M. AFTER A BRIEF hospitalization . NURSES DOCUMENTED ON THE ADMISSION HISTORY AND PHYSICAL, THAT RESIDENT #104 WAS COMPLETELY DEPENDENT ON STAFF FOR BED MOBILITY, TRANSFERS AND TOILETING. REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE THE SKIN assessment dated [DATE] REVEALED RESIDENT #104 WAS "CHAIRFAST: (HER) ABILITY TO WALK (WAS) SEVERELY LIMITED OR NONEXISTENT...". RESIDENT #104 COULD "NOT BEAR (HER) OWN WEIGHT AND/OR MUST BE ASSISTED INTO (HER) CHAIR OR WHEELCHAIR". REVIEW OF THE PHYSICAL AND OCCUPATIONAL THERAPY NOTES DATED 4/07/2011 REVEALED RESIDENT #104 WAS AT RISK FOR FALLS, COULD NOT WALK AND REQUIRED STAFF TO PROVIDE MAXIMUM PHYSICAL ASSISTANCE WITH ALL BED MOBILITY AND TRANSFERS. THE INITIAL CARE PLAN FOR FALLS DATED 4/06/2011 REVEALED RESIDENT #104 WAS AT RISK FOR FALLS. THERE WERE NO INTERVENTIONS DOCUMENTED TO PREVENT RESIDENT #104 FROM FALLING. REVIEW OF NURSING NOTES DATED 4/25/2011 AT 10:00 A.M., REVEALED RESIDENT #104 ROLLED OFF HER BED ONTO A FLOOR MAT. NURSING NOTES INDICATED RESIDENT #104'S ALARM WAS CHECKED AND WAS REPLACED DUE TO A MALFUNCTION. ON 9/12/2011 AT 11:00 A.M., RESIDENT #104 WAS OBSERVED BEING TRANSFERRED FROM HER WHEELCHAIR TO THE BED BY CERTIFIED NURSING ASSISTANTS IDENTIFIED AS CNA #2 AND CNA #3. CNA #2 AND CNA #3 TRANSFERRED RESIDENT #104 IN COTTON SOCKS WITH NO TREAD. THE WHEELCHAIR SENSOR PAD/ALARM WAS IN PLACE BUT DID NOT SOUND WHEN RESIDENT #104 WAS MOVED FROM THE WHEELCHAIR TO HER BED. CNA #2 INSPECTED THE DEVICE AND SAID, FRAYED WIRES PREVENTED THE DEVICE FROM PROPERLY FUNCTIONING/ALARMING. OBSERVATIONS MADE ON 9/12/2011 AT 11:05 A.M., REVEALED FRAYED WIRES WERE PRESENT AT THE JUNCTION WERE THE SENSOR PADS WIRE AND ALARM BOX MET. PRESSURE WAS APPLIED TO THE SENSOR PAD AND THEN REMOVED THREE SEPARATE TIMES AND THE DEVICE DID NOT ALARM/SOUND. ON 9/12/2011 AT 12:45 P.M., THE DIRECTOR OF NURSING SAID THE SENSOR ALARM FOR RESIDENT #104 DID NOT WORK WHEN RESIDENT #104 fell FROM HER BED ON 4/25/2011 AT 10:00 A.M. THE DIRECTOR OF NURSING SAID STAFF FOUND THE RESIDENT LYING ON THE FLOOR SOME TIME AFTER THE FALL. THE DIRECTOR OF NURSING DID NOT IDENTIFY WHY RESIDENT #104'S SENSOR PAD/ALARM FAILED TO FUNCTION BUT STATED THE ALARMS USED AT THIS FACILITY "ARE JUST MADE CHEAP". THE DIRECTOR OF NURSING IDENTIFIED DEAD BATTERIES AND FRAYED WIRES AS TWO OF THE MOST COMMON CAUSES FOR ALARM MALFUNCTIONS AT THE FACILITY. THE DIRECTOR OF NURSING SAID THE FACILITY DOES NOT HAVE A PROGRAM TO ENSURE RESIDENTS SAFETY DEVICES ARE FUNCTIONING. THE DIRECTOR OF NURSING SAID PREVIOUSLY SHE HAD NOTIFIED THE ADMINISTRATOR OF THE NEED TO REPLACE THE CURRENT SENSOR PADS AND OBTAIN "BETTER" ONES. RESIDENT #106 ACCORDING TO THE FACE SHEET DATED 8/31/2011, RESIDENT #106 WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 7/12/2011. RESIDENT #106'S [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #106 HAD IMPAIRED DECISION MAKING SKILLS WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. RESIDENT #106 REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE PHYSICAL ASSISTANCE WITH AMBULATION, TOILETING AND TRANSFERS. REVIEW OF THE NURSING NOTES DATED 7/12/2011 AT 11:20 A.M., REVEALED RESIDENT #106 REQUIRED STAFF ASSISTANCE FOR AMBULATION AND TOILETING. THERE WAS NO DOCUMENTATION OF ANY ASSISTIVE DEVICES OR NUMBER OF STAFF MEMBERS NECESSARY TO PERFORM THESE DUTIES. REVIEW OF THE PHYSICIAN ORDERS [REDACTED].#106. REVIEW OF THE PHYSICAL AND OCCUPATIONAL THERAPY NOTES DATED 7/12/2011 REVEALED RESIDENT #106 WAS AT RISK FOR FALLS AND REQUIRED MINIMUM TO MODERATE ASSISTANCE WITH ALL TRANSFERS. REVIEW OF THE THE INITIAL CARE PLAN DATED 7/12/2011 REVEALED RESIDENT #106 WAS AT RISK FOR FALLS DUE TO AN UNSTEADY GAIT AND FREQUENT SELF-AMBULATION ATTEMPTS. REVIEW OF THE NURSING NOTES DATED 7/12/2011 AT 9:00 P.M., REVEALED RESIDENT #106 AMBULATED MULTIPLE TIMES WITHOUT ASSISTANCE. NURSING NOTES DATED 7/12/2011 AT 11:15 P.M., REVEALED "RESIDENT (#106) ATTEMPTED TO GET UP AND AMB(ULATE) SEVERAL TIMES." NURSING NURSING NOTES DATED 7/16/2011 AT 2:00 P.M., REVEALED "RESIDENT (#106) HAS BEEN REDIRECTED SEVERAL TIMES TO SIT BACK IN WHEELCHAIR...". REVIEW OF A FALL CARE PLAN DATED 8/02/2011 REVEALED RESIDENT #106 WAS AT RISK FOR FALLS AND REQUIRED STAFF TO ASSIST HER WITH ALL TRANSFERS. REVIEW OF THE NURSING NOTES DATED 9/4/2011 AT 2:30 P.M., REVEALED RESIDENT #106 WAS OBSERVED ON THE FLOOR IN THE DAY ROOM. FACILITY STAFF WERE NOT PRESENT TO ASSIST RESIDENT #106 WITH THIS TRANSFER. RESIDENT #106 SUSTAINED NO INJURIES. REVIEW OF THERAPY NOTES DATED 9/07/2011 RECOMMENDED "UP CLOSE AND FREQUENT MONITORING." AS OF 9/19/2011, THE SAFETY CARE PLANS FOR RESIDENT #106 DID NOT REFLECT THERAPY'S RECOMMENDATIONS. RESIDENT #107 ACCORDING TO THE FACE SHEET DATED 8/31/2011, RESIDENT #107 WAS AN [AGE] year OLD FEMALE RESIDENT WHO LIVED AT THE FACILITY SINCE 7/05/2011. RESIDENT #107'S [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #107 HAD IMPAIRED DECISION MAKING SKILLS WITH BOTH LONG AND SHORT TERM MEMORY LOSS. RESIDENT #107 DID NOT WALK AND REQUIRED STAFF ASSISTANCE FOR ALL TRANSFERS AND AMBULATION. REVIEW OF THE THE FALL assessment dated [DATE] REVEALED RESIDENT #107 WAS AT RISK FOR FALLS DUE TO A HISTORY OF FALLS, CONFUSION, VISUAL IMPAIRMENTS, BOWEL AND BLADDER INCONTINENCE, INABILITY TO INDEPENDENTLY COME TO A STANDING POSITION, AND FROM BEING DISORIENTED WHILE CONFINED TO A WHEELCHAIR. REVIEW OF A FALL CARE PLAN DATED 7/19/2011 IDENTIFIED RESIDENT #107 WAS AT RISK FOR FALLS AND REQUIRED STAFF ENSURE ALL ASSISTIVE DEVICES WERE SAFELY IMPLEMENTED. RESIDENT #107 WAS NOT TO BE LEFT ALONE WITHOUT HER SAFETY DEVICES. DIRECT OBSERVATIONS MADE OF RESIDENT #107 IN HER BEDROOM ON 9/16/2011 AT 11:34 A.M. REVEALED RESIDENT #107 HAD BEEN LEFT UNATTENDED BY STAFF, UNSUPERVISED, SITTING IN A BROKEN GERI-CHAIR WITH THE SEAT PARTIALLY RECLINED. THE POSITIONING LOCK FOR THE SEAT WAS DEFORMED AND COULD NOT BE LATCHED. IN AN INTERVIEW ON 9/16/2011 AT 11:40 A.M., THE ASSIGNED NURSE (LPN #2) FOR RESIDENT #107 SAID, STAFF PLACED RESIDENT #107 IN AN UNSAFE CHAIR THAT HAD THE POTENTIAL TO CAUSE INJURY.