Every finding on record at Villa at Borgess Place

This citation pertains to intake 2988571Based on observation, interview, and record review the facility failed to promote the healing of an existing pressure ulcer and to prevent pressure ulcer development for one resident (#3) out of three residents reviewed resulting in a stage 2 pressure ulcer (partial-thickness skin injury) developing to an unstageable pressure ulcer(a full-thickness tissue loss where the depth is covered by eschar or slough tissue), the development of a new unstageable pressure ulcer, and the resident experience a pain level of 9 out of 10 (pain scale 1 - least pain and 10 being the most pain).Findings Included:Resident #3 (R3)Review of the medical record demonstrated that R3 was admitted to the facility on [DATE] with diagnoses that included encounter for surgical aftercare following surgery on the circulatory system, muscle disorder, difficulty in walking, lack of coordination, abnormal posture, cognition communication deficit, dysphagia (difficulty swallowing), atherosclerotic heart disease (plaque buildup in coronary arteries), hypertension, gastro-esophageal reflux, irritable bowel syndrome, overactive bladder, constipation, peripheral vascular disease (PVD), pneumonia, urinary retention, osteoarthritis (degenerative wear of bone joints), mild cognitive impairment, hyperlipidemia (high fat content in blood), and osteoporosis (bone weaking). Review of R3's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/26/2026, revealed R3 had a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment) out of 15. Review of section M-Skin Conditions, of the MDS with the same MDS, revealed R3 had one unstageable pressure ulcers upon admission. R3 was discharged to the hospital 04/14/2026 and readmitted [DATE].On 04/21/2026 at 01:41 p.m. during observation and interview R3 was observed lying down in bed. R3 explained that she had a wound on her coccyx and had developed another wound on the left side of her buttock. R3 explained that her bottom felt as if it was on fire. R3 rated the pain, on her bottom, to be a 9 on a scale of 1 to 10, with one being the least and 10 being the worst. An air mattress pump was observed at the foot of the bed and appeared to be operational.Review of R3's medical record revealed Wound Assessment Details document for a wound on R3's sacrum, which was present on admission. The Wound Assessment Details, dated 03/22/2026 revealed a stage 2 pressure ulcer on R3's sacrum measuring 0.7cm(centimeters) length, 0.5cm width, 0.2cm depth, and 0.35cm2 surface area. The same document revealed the wound as having 100% epithelial tissue.The Wound Assessment Details, dated 03/23/2026, revealed an unstageable pressure ulcer on R3's sacrum measuring 2.0cm length, 1.3cm width, and 0.2cm depth. And 2.60cm2 surface area. The same document revealed the wound as having 20% intact skin, 20% epithelial tissue, and 60% slough (dead tissue).The Wound Assessment Details, dated 03/30/2026, revealed an unstageable pressure ulcer on R3's sacrum measuring 6.8cm length, 5.0cm width, 0.2cm depth, and 34.00 cm2 surface area. The same document revealed the wound as having 20% intact skin, 20% epithelial tissue, and 60% slough tissue. No Wound Assessment Details was provided for the date of 0407/2026.Review of the Wound Assessment Details, dated 04/13/2026, revealed an unstageable pressure ulcer on R3's sacrum measuring 8.50cm length, 8.50cm width, 0.10cm width, and surface area of 72.25cm2. The same documentation did not reveal any evaluation of the intact skin or slough.Review of R3's medical record revealed Wound Assessment Details document for a wound on R3's dorsal sacral area, which was documented as facility acquired. The Wound Assessment Details document, dated 04/07/2026 revealed an unstageable pressure ulcer on R3's dorsal sacral area measuring 2.8cm (centimeters) length, 2.20cm width, 0.10cm in depth, and 6.16cm2 in surface area. The same documentation revealed the wound had 90% non-granulation tissue and 10% slough (dead tissue).Review of the Wound Assessment Details document, dated 04/13/2026, revealed an unstageable pressure ulcer on R3's dorsal sacral area measuring 4.20cm length, 2.70cm width, 0.10cm depth, and 11.24cm2 surface area. The same documentation did not reveal any evaluation of the intact skin or slough. Review of Wound Physician Assistant PA documentation, dated 04/13/2026, revealed .Wound bed has 100% slough, no eschar and no epithelization (healing tissue) present.Review of the R3's facility incident report, dated 04/06/2026, revealed During wound rounds, noted to have open are to dorsal sacrum, assessed with Wound PA. No route cause analysis was provided at the time of survey.Review of R3's plan of care revealed a problem statement, initiated 04/20/2026 Skin: Resident has actual skin breakdown r/t(related to) coccyx. The care plan did not include any interventions to treat or prevent further decline of the wound or interventions to prevent further skin breakdown. R3's plan of care, initiated 03/20/2026 entitled, Skin: Resident has potential for skin breakdown r/t mobility deficits. Interventions with this plan of care revealed When care is done being provided, please ensure that air mattress function is back to alternating setting and the state feature is off (initiated 03/20/2026), alternating air mattress (initiated 03/20/2026), assist and encourage resident to turn and reposition frequently and prn (initiated 03/20/2026). Plan of care revealed problem statement, initiated 04/07/2026, Skin: Resident has pressure ulcer to sacrum. No new interventions were added to the plan of care after development of new wound.Review of provided document entitled Wound Care: Pressure Injury Unavoidable Evaluation, dated 04/07/2026, listed pressure injury being acquired to coccyx on 04/06/2026. Same document list Risk Factors: immobility, chronic bowl incontinence, chronic heart disease, weight loss/poor nutrition. The section of the documents for wt. loss was not completed. Same document revealed Summary section that that had a physician signature that was blank. Review of R3's physician orders revealed an order, dated as discontinued on 03/20/2026, Pressure reducing mattress. Review of R3's physician orders also revealed an order, dated active on 04/20/2026, Pressure reducing mattress. Further review of physician orders revealed an order dating 03/21/2026 to 04/02/2026 cleanse wound on coccyx with normal saline, pat dry, apply calcium alginate and 4x4 bordered gauze and an order dating 04/02/2026 to 04/07/2026 cleanse wound on coccyx with normal saline, cleanse with 1/2 strength dakins pat dry, apply calcium alginate and 4x4 bordered gauze. The next physician order for 04/08/2026 to 04/15/2026 cleanse wound on coccyx with normal saline, cleanse with 1/2 strength Dakin's pat dry, apply medihoney, calcium alginate and 4x4 bordered gauze. No order for the lateral sacrum was found.Review of R3s' medical record for wound care orders on 04/21/2026 at 11:45 a.m. did not reveal that any treatment orders for R3's wounds. Review of R3's April Treatment Record (TAR) did not demonstrate that any treatment had been completed on R3's sacral dorsal wound.On 04/21/2026 at 11:57 a.m. Director of Nursing (DON) B was asked to review R3's medical record and provide documentation that interventions were in place prior to the development of the dorsal sacral wound. DON B explained that she could not demonstrate that any interventions had been in place prior to the development of the unstageable dorsal sacral wound on 04/07/2026. DON B explained that an order was not written until 04/07/2026 for the alternating pressure mattress even though it had been listed on the plan of care on 03/20/2026. DON B was asked to provide documentation that R3's dorsal sacral wound had an order for treatment when the wound was identified on 04/06/2026. DON B could not provide an order for treatment of R3's dorsal sacral wound. DON B could not explain why preventative measure had not been put in place to prevent the further development of a pressure wound for R3. DON 'B could explain why a treatment order had not been written for R3's dorsal sacral wound that developed on 04/07/2026. DON B confirmed that no wound treatment orders had been written upon R3's return to the facility on [DATE] and could not offer an explanation.On 04/21/2026 at 02:03 p.m. Wound Nurse (WN) G was explained that she would be completing the wound dressings for R3. WN G was followed into the room of R3. All wound care supplies were observed on top of a barrier on the over bed table. R3 was observed lying in bed. WN G explained to R3 that she would be completing her dressing to her bottom. Registered Nurse (RN) I (in room to assist) removed the dressing that was on R3 buttock. The dressing was dated 04/20/2026. R3 was observed to have what appeared to be an unstageable wound to her coccyx and to her left sacral area, with both having eschar (dead tissue) present in the wound beds. The removed dressing was observed to contain red drainage. The removed foam dressing was covering both the wound to the coccyx and to the left dorsal sacral wound. WN G measured the left dorsal sacral wound which was 5.0 cm (centimeter) length, 4.0cm width, and 0.3cm depth. The WN G then took picture of the left dorsal sacral wound. Wound bed was observed to be red around the edges and black eschar tissue was observed. WN G explained that the wound was unstageable and the wound had 65% eschar. WN G was then observed complete the treatment according to the current order. WN G was observed to measure the coccyx wound which measured 10.0cm length, 9.0cm width, and 1cm depth. The coccyx wound was observed to have eschar present. WN G explained that the wound had approximately 85% eschar present. WN G then preformed the treatment to the coccyx per the physician orders.

This citation pertains to intake 2972335Based on interview and record review the facility failed to provide Activities of Daily Living (ADL) care for one (#1) of three residents reviewed for ADL care.Findings Included:Resident #1 (R1)Review of the medical record demonstrated that R1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type 2 diabetes, staphylococcal arthritis (serious, rapid-onset infection of a joint cause by staphylococcus aureus bacteria) left shoulder, metabolic encephalopathy (a broad term for brain dysfunction), staphylococcal arthritis right knee, pancytopenia (simultaneous reduction of red blood cells, white blood cells, and platelets), abnormalities of gait and mobility, lack of coordination, dysphagia (difficulty swallowing), insomnia, vascular dementia with agitation, methicillin susceptible staphylococcus aureus (a type of bacterium resistant to many antibiotics), peripheral vascular disease (PVD), congestive heart disease(CHF), restless leg syndrome, hyperlipidemia (high fat content in blood), atrial flutter, hypertension, obesity, malignant neoplasm of upper lobed, left bronchus or lung (lung cancer), gastroesophageal reflux disease, and chronic kidney disease. Review of R1's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/14/2026, revealed R1 had a Brief Interview for Mental Status (BIMS) of 6 (severe impairment in cognitive function) out of 15. Review of Section GG- Functional Abilities of the MDS, with the same ARD, revealed R1 required partial/moderate assistance with eating, dependent for oral hygiene, dependent for toileting hygiene, dependent for shower/bathing, dependent for upper body dressing, dependent for lower body dressing, dependent for putting on/taking off footwear, and dependent for all transfers. R1 was discharged from the facility on 02/02/2026.On 04/17/2026 at 09:33 a.m. during a telephone interview, R1's family member K explained that R1 had not received assistance with his activities of daily living (ADL's) on a regular basis. R1's family member K also explained that R1 had informed him that he was not getting meals on a regular basis.Review of R1's medical record revealed plan of care documentation for ADL/GG (activities of daily living/functional abilities of the Minimum Data Set) hygiene (oral, toileting, personal) was blank on the following dates and times: 01/11/2026-6A-6P(6am to 6pm), 01/12/2026-6A-6P, 01/15/2026 - 6A-6P and 6p-6a, 01/16/2026- 6A-6P, 01/17/2026- 6A-6P, 01/24/2026-6A-6P, and 01/31/2026 -6p-6a.Review of R1's medical record revealed plan of care documentation for ADL/GG (activities of daily living/functional abilities of the Minimum Data Set) Eating (ability, percentage eaten) was blank on the following dates and times 01/11/2026 - 0900/1300(1pm), 01/12/2026- 0900/1300, 01/15/2026-0900/1300, 01/16/2026- 0900/1300, 01/17/2026- 0900/1300, 01/24/2026- 0900/1300, and 01/25/2026- 0900/1300. Review of the same document listed above, revealed NA (nonapplicable) was documented for the 6pm meal on the following dates: 01/11/2026 to 01/13/2026, 01/15/2026, 01/17/2026 - 01/25/2026, and 01/28/2026 -01/31/2026.On 04/21/2026 at 08:45 a.m. Director of Nursing (DON) B explained that certified nursing aides (CNA's) worked 6am to 6pm and 6pm to 6am (12 hours shifts). DON B explained that it was the facility expectation that Activity of Daily Living (ADL) task were to be completed each shift. DON B also explained that ADL care included hygiene (oral, toileting, and personal). DON B explained that it was the facility expectation that each CNA documented in the resident's plan of care after ADL's were performed. DON B also explained that NA' s (nonapplicable) should not be documented in the resident's plan of care for any task. DON B explained that plan of care documentation for eating was to have been documented after all meals. DON B confirmed R1's medical record demonstrated blank documentation for ADL care (as listed above) and confirmed NA was documented for meals (as listed above) . DON B explained that blank documentation and documentation of NA did not demonstrate that the R1's had been provided ADL services on those dates and times. DON B explained that NA documentation had not demonstrated that R1 was provided meals.

Based on observation, interview, and record review the facility failed to follow acceptable infection control procedures for one resident (#3) of three residents observed during clean dressing changes.Findings Included::Resident #3 (R3)Review of the medical record demonstrated that R3 was admitted to the facility on [DATE] with diagnoses that included encounter for surgical aftercare following surgery on the circulatory system, muscle disorder, difficulty in walking, lack of coordination, abnormal posture, cognition communication deficit, dysphagia (difficulty swallowing), atherosclerotic heart disease (plaque buildup in coronary arteries), hypertension, gastro-esophageal reflux, irritable bowel syndrome, overactive bladder, constipation, peripheral vascular disease (PVD), pneumonia, urinary retention, osteoarthritis (degenerative wear of bone joints), mild cognitive impairment, hyperlipidemia (high fat content in blood), and osteoporosis (bone weaking). Review of R3's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/26/2026, revealed R3 had a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment) out of 15. Review of section M-Skin Conditions, of the MDS with the same MDS, revealed R3 had one unstageable pressure ulcers upon admission. R3 was discharged to the hospital 04/14/2026 and readmitted [DATE].On 04/21/2026 at 01:41 p.m. during observation and interview R3 was observed lying down in bed. R3 explained that she had a wound on her coccyx and had developed another wound on the left side of her buttock. On 04/21/2026 at 02:03 p.m. Wound Nurse (WN) G was explained that she would be completing the wound dressings for R3. WN G was followed into the room of R3. All wound care supplies were observed on top of a barrier on the over bed table. R3 was observed lying in bed. WN G explained to R3 that she would be completing her dressing to her bottom. Registered Nurse (RN) I was observed sanitizing hands and then placed on a gown and gloves. Certified Nursing Aide (CNA) J was observed sanitizing hands and then placed on a gown and gloves. RN I and CNA J rolled R3 to her right side. RN I performed peri care and incontinent bowel movement care. RN I removed her soiled gloves, sanitized her hands, and then removed the dressing that was on R3 buttock. The dressing was dated 04/20/2026. R3 was observed to have what appeared to be an unstageable wound to her coccyx and to her left sacral area, with both having eschar (dead tissue) present in the wound beds. WN G was observed sanitizing hands, then placed gloves and gown on. WN G then took picture of the left dorsal sacral wound. WN G removed her gloves and sanitized her hands and replaced gloves. WN G was then observed to rinse wound with wound wash and wipe with 4x4 gauze, then patted it dry with 4x4 gauze and applied the ordered dressing. WN G was then observed to pick up the phone to take a picture of the wound on the coccyx. WN G removed gloves and proceed to cleanse the coccyx wound with wound cleanser and wiped with a 4 x 4 gauze. WN G was observed to apply ordered dressing. WN G then was observed placing the phone (used to acquire wound pictures) into her pocket without cleaning. WN G then removed her gloves and gown and sanitized her hands.On 04/21/2026 at 02:50 p.m. Director of Nursing (DON) B was asked to explain her expectation and professional practice of a clean dressing change. DON B explained that all supplies would be gathered prior to performing the treatment, according to physician orders. DON B explained that the supplies would be placed on a clean barrier. DON B explained that the nurse would wash her hands, place on gloves, and a gown. DON B explained that the old dressing would be removed, then the nurse would remove the soiled gloves, sanitize her hands, and place on new gloves. DON B explained that then the wound area would be cleansed, in accordance with physician orders, and the nurse would remove the soiled gloves, sanitize her hands, and place on new gloves. DON B explained that the wound pictures would be obtained now and measurements would be taken, then the nurse would remove the soiled gloves, sanitize her hands, and place on new gloves. DON B explained that the dressing would be applied according to physician orders at this point. DON B explained once the treatment had been completed the nurse would sanitize the phone and place on barrier. DON B explained then the nurse would remove her gloves, remove her gown, and wash/sanitize her hands. DON B explained that it was professional standards to perform each step for each individual wound site.

This citation pertains to Intake #2799926.Based on interview, and record review, the facility failed to ensure that interventions for increased supervision and assistance were implemented for residents at high risk for falls for 1 resident (Resident #101) of 3 residents reviewed for fall prevention, resulting in an unwitnessed fall with laceration to the head and subsequent hospitalization for SAH (subarachnoid hemorrhage) and SDH (subdural hematoma). Findings include:Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: sepsis (life threatening condition cause by an infection), weakness, cognitive deficit (impaired mental processes), insomnia (unable to sleep) and repeated falls. Review of Resident #101's Social Services Note dated 1/16/26 indicated, a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated Resident #101 had severe cognitive impairment. Review of Resident #101's Fall Assessment dated 1/15/26 at 2:02 PM revealed, High Fall Risk. Score: 24.3 or more falls in past 3 months, intermittent confusion, Ambulation/elimination status: ambulatory/continent.hospitalization history in the last 30 days, Mobility: Is resident able to walk with or without assistance and/or device? NO. If the resident is unable to walk, describe the resident's mobility in wheelchair: Confined in a wheelchair and disoriented. A score of 10 or higher indicates the resident is at high risk of fall. It was noted that the mobility status assessment was not an accurate reflection of Resident #101's status.Review of Resident #101's Fall Prevention Care Plan revealed no care plan developed related to fall prevention and/or the resident being at high risk for falls until 1/20/26, after resident #101 fell and discharged to the hospital. Review of Resident #101's ADL (activities of daily living) Care Plan revealed, Resident requires assist with daily care needs r/t (related to) general weakness/debility. Date initiated: 1/16/26. Interventions: Dining: Resident with direct feeding assistance for po (by mouth) intake.Date initiated: 1/16/26. The remainder of the interventions were created 1/19/26 after Resident #101 fell and discharged to the hospital. The record did not indicate if the resident was continent or incontinent and/or if there was a toileting program.Review of Resident #101's Incident Report-Fall Unwitnessed dated 1/19/26 at 6:00 AM revealed, .Resident had an unwitnessed fall. Aide walked into resident's room and observed resident sitting on the floor in front of the toilet, resident was sitting on her bottom with legs crisscross, blood trail from room to bathroom, resident had an episode of emesis (vomiting) . Resident bleeding from right side of head, resident unable to describe what she was doing at the time of fall, nurse asked resident if she was in pain, resident stated yes but could not describe pain or describe location. Nurse manager agreed with nurse to send resident out after observing resident's head. Resident was assisted off floor by aid and nurse manager into shower chair and transferred from shower chair to stretcher by EMS (emergency medical services) .Review of Resident #101's Hospital Records dated 1/19/26 revealed, .presenting after being found down at her nursing home. Patient not able to answer questions for me or follow commands. laceration to R (right scalp).Impression and Plan: .presenting with SAH (subarachnoid hemorrhage) and SDH (subdural hematoma) (these are both serious forms of brain bleeding) after being found down at her nursing home.Neurosurgery recommending MMA (middle meningeal artery) embolization (a procedure to block the flow of blood that is causing the brain bleed).In an interview on 3/25/26 at 9:07 AM, Family Member (FM) T reported that Resident #101 had fallen in the facility on 1/19/26 and was hospitalized due to head injury and brain bleed; Resident #101 transitioned to hospice and recently passed away. FM T reported that Resident #101 had fallen multiple times at home prior to admitting to the facility and did not understand that she was not safe to walk on her own.In an interview on 3/25/26 at 9:26 AM, Licensed Practical Nurse (LPN) E reported that she was notified shortly after 6:00 AM on 1/19/26 that Resident #101 had been found on the floor in her bathroom and there was a large amount of blood on the floor around her and a trail of blood from her bed to the bathroom. LPN E reported that the blood was coming from Resident #101's head but her hair was saturated and matted, so the actual laceration was not observed. LPN E reported that she called 911 right away and then notified the provider and the nurse manager. LPN E reported that Registered Nurse Manager (RNM) F assessed Resident #101 and agreed that the resident needed to be sent to the hospital.In an interview on 3/25/26 at 2:29 PM, RNM F reported that he had assessed Resident #101's head to determine where the blood was coming from and found a laceration on the back of her head. RNM F reported that Resident #101 could not verbalize what had happened. RNM F reported that Resident #101 was not safe to ambulate on her own, she was very weak, a new admit, and required at least 1 person to assist with transfers and ambulation. RNM F reported that Resident #101 had a baseline care plan developed within 24 hours of admission, but it did not include being at high risk for falls, fall prevention interventions or the level of assistance that she needed for transfers and ambulation. RNM F reported that after Resident #101's fall on 1/19/26 the care plans for high risk for falls, actual fall, skin, and pain were created and the ADL care plan was updated to reflect that she needed 1 person assistance. RNM F reported that having at least the transfer needs on the baseline care plan is important so that direct care staff know how to care for the resident.In an interview on 3/25/26 at 4:55 PM, Certified Nursing Assistant (CNA) M reported that during her initial rounds on 1/19/26 approximately 6:00 AM, Resident #101's door was closed and when she opened the door she noticed a lot of blood on the floor of the bedroom, leading into the bathroom. CNA M reported that she immediately alerted LPN E and then opened the bathroom door, finding Resident #101 sitting in a puddle of blood and vomit, with a large amount of blood in her hair. CNA M reported that she had worked with Resident #101 once before that day and the resident was able to get out of bed and walk on her own, but she was unsteady. CNA M reported that she did not think Resident #101 was a major risk for falling because normally when a resident is at high risk for falling there are signs up in the room, a cushion on the floor by the bed, and we know to check on them frequently, but Resident #101 did not have those things.In an interview on 3/26/26 at 8:47 AM, CNA J reported that she was working with Resident #101 on 1/19/26 but had left the facility at 6:00 AM. CNA J reported that she heard that Resident #101 had fallen and was sent to the hospital. CNA J reported that she had only worked with Resident #101 one other time and other staff had told her that the resident liked to walk around her room and do her own thing. CNA J reported that she did not know if Resident #101 was continent or incontinent, and the resident could not communicate toileting needs. CNA J reported that Resident #101's door was closed all night. CNA J reported that the last time she checked on Resident #101 was before 4:00 AM because after that time she was in a different resident's room until 6:00 AM because he had fallen, stating, that night was crazy. CNA J reported that she would refer to the Kardex (care guide for CNA's) if she needed to find transfer and ambulation status.In an interview on 3/26/26 at 9:19 AM, Director of Nursing (DON) B reported that Resident #101 was assessed by nursing to be at high risk for falls upon admission and was evaluated by therapy and determined to require at least 1 assist for transfers and ambulation. DON B reported that the nurse managers should enter that information into the care plan. DON B reported that Resident #101 did not have a fall care plan and/or her transfer status documented in her care plan or Kardex until after she had fallen which was 4 days after admission. DON B reported the care plan carries over direct care needs to the Kardex. DON B reported that the CNA's are expected to refer to the information in the Kardex to determine the resident's needs; Resident #101 was at high risk for falls and she should have had frequent checks and should not have been ambulating on her own. DON B reported that she was not aware that Resident #101's care plan/kardex was missing the information until talking to this surveyor.In an interview on 3/26/26 at 11:25 AM, Occupational Therapist (OT) R reported that Resident #101 could not follow commands, did not use her call light, got up and walked on her own, but required assistance of at least one person to be safe. OT R reported that Resident #101 was evaluated and then discharged before treatment started.Review of Resident #101's Occupational Therapy Evaluation dated 1/16/26 revealed, .Functional Skills Assessment-Functional Mobility: .Transfers: toilet transfer: partial/moderate assistance.Cognition/Communication Assessment: . Safety awareness: Impaired.Assessment Summary: .requires min a (minimal assistance) for ADLs.Review of Resident #101's Physical Therapy Evaluation dated 1/16/26 revealed, .Functional Mobility Assessment: .Transfers: .Partial/moderate assistance. Ambulation: Partial/moderate assistance. Assessment Summary: .Cognition: decision making ability for routine activities: severely impaired.Review of the facility policy Fall Evaluation Safety Guideline dated 11/28/17 revealed, 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: .prevent or reduce injuries related to falls. Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible.Procedure: 1. Fall Risk Evaluation will be completed. 2. If evaluation finds the resident at risk, implement resident specific interventions/precautions. 3. Initiate, review and revise the fall care plan as appropriate, with new or discontinued interventions. Falls Prevention: environmental evaluation, individual risk factors, rounding, applied appropriate supervision, footwear, medication regimen review, management of incontinence/toileting program, evaluation for pain, evaluation of mental status, strength and balance, exercise programs, education.

This citation pertains to Intake #2795029.Based on interview and record review the facility failed to implement an effective discharge planning process to ensure a safe and orderly discharge for 1 resident (Resident #103) of 3 residents reviewed for discharge process, resulting in lack of a capable caregiver in place and the necessary durable medical equipment available prior to discharge to the community.Findings include: Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: aftercare following joint replacement surgery, artificial left knee joint, and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (inability to move one side of the body due to brain damage from a blood clot).Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 2/11/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #103 was cognitively intact. Review of Resident #103's Discharge Care Plan revealed, .has care needs that presently requires the support and services of the skilled rehabilitation care setting. Discharge potential and discharge planning needs have been assessed by the interdisciplinary team (IDT). Discharge potential is good, and the stay is presently identified as short-term. I intend to work with my social worker on discharge planning to the community and d/c (discharge) to the community when I am clinically cleared to be able to do so. Date initiated: 1/12/26. Goal: Resident will work to regain strength and abilities and discharge to the community when clinically cleared to be able to do so, by next review. Target date: 4/12/26. Interventions: .Arrange for a physician's order for discharge. be sure to include any necessary recommendations as made by the IDT .Coordinate, communicate, and confirm all discharge arrangements such as home health, outpatient, physician appointments, and equipment needs. D/C Planning: Evaluate discharge potential including medication compliance, independence, self-care/hygiene, ADL (activities of daily living) deficits and self-management skills as indicated, initiate assistance with discharge planning as necessary. It is important that any discharge be to a safe environment where the resident will receive on-going medical and mental health services. Discuss resident strengths and abilities with the therapy team. Recognize that multiple co-morbidities will impact discharge planning. Document, explain/teach follow up care techniques as required and provide written instructions to both resident and healthcare representative. Help the resident and support system identify a post-discharge care plan that will provide necessary services and minimize future hospitalizations which may include in-home caregivers. If DME (durable medical equipment) is needed, Please assist resident with gathering the necessary paperwork from their physician .Meet with resident and their family/representative to discuss plans for discharge. Discuss expectations and resources necessary for their return home .In an interview on 3/24/26 at 1:36 PM, Licensed Practical Nurse (LPN) C reported that she had taken over care for Resident #103 about 2 hours before her shift was over (4:00 PM) on 2/23/26 and was told that the resident was all packed and ready to discharge and his paperwork was on the counter. LPN C reported that Social Services (SS) S told her that Resident #103's family member (FM U) had been in the facility earlier that day and then left upset about the resident having to discharge but was going home to prepare the house and arrange for transportation. LPN C reported that she did not have any discharge conversations with Resident #103 or FM U and was not aware that Resident #103 had been picked up by the ambulance until a Certified Nursing Assistant (CNA) notified her that the resident had left.Review of Resident #103's Nurse's Note by LPN C created on 2/27/26 at 1:24 PM, effective date 2/23/26 at 5:15 PM revealed, Received report that resident was awaiting a ride for discharge, assisted resident with packing his room, assisted aide with toileting resident. Went to check on resident during report resident was out of room, ride for pick up did not get D/C (discharge) paperwork that had been printed and was ready for resident upon pick up.In an interview on 3/24/26 at 11:32 AM, Business Office Manager (BOM) V reported that Resident #103 was served a notification on 2/20/26 stating that his last covered service day was 2/22/26. BOM V reported that on 2/23/26, FM U told her that she had appealed the insurance denial of coverage but BOM V had not receive a notification that an appeal was started therefore informed FM U of the cash cost per day. BOM V reported that normally while an appeal was pending the resident would be allowed to continue services in the facility but since there was no pending appeal on record, the resident would have to discharged or pay cash. BOM V reported that she was not involved in the actual discharge planning or insurance appeals process but did discuss costs with residents if they wanted to stay and pay cash. BOM V reported that she had told FM U what the cost would be to pay cash and FM U decided to bring Resident #103 home. BOM V reported that she found out later that FM U had called the wrong phone number to request an appeal for Resident #103 to remain in the facility.In an interview on 3/24/26 at 12:14 PM, FM U reported that Resident #103 had called her from the facility on 2/20/26 after 5:00 PM and told her that the social worker had given him a notice that he would have to discharge on [DATE] but that he had signed a paper to appeal the decision. FM U reported that she had not heard anything more about a discharge until 2/23/26 at 10:10 AM when she received a call from the facility informing her that Resident #103 would be discharging at 11:00 AM that day. FM U reported that she realized that when Resident #103 had signed the form, it was not considered appealing the decision; FM U called the insurance company right away and left a message. FM U drove to the facility and spoke with SS S to tell her that they were appealing the notification to discharge and was waiting to hear back from the insurance. SS S told FM U that Resident #103 would have to discharge that day or pay cash but did not offer assistance with understanding the appeal process. FM U expressed her anxiety about not being able to take care of Resident #103 at home and asked to borrow a wheelchair, but when she was denied any assistance from the facility, she packed Resident #103's belongings, called an ambulance to pick up the resident, and went home to prepare the house; FM U contacted neighbors to be present to help her with Resident #103 when the ambulance arrived. FM U reported that she did not have any discharge planning discussions with the facility, she did not get any caregiver instructions or education, the facility did not assist with a referral for outpatient therapy services, home health services or durable medical equipment. FM U reported that it took about a week to get a wheelchair and hospital bed donated and delivered to their house, but until then Resident #103 laid in bed. FM U reported that after Resident #103 discharged , FM U had called the facility multiple times trying to get discharge paperwork and finally had to ask the ombudsman for assistance to get the paperwork. Review of Resident #103's Notice of Medicare Non-Coverage revealed, .The effective date coverage of your current services will end: 2/22/26. The notice was signed by Resident #103 on 2/20/26.Review of Resident #103's Social Services Note written by SS S dated 2/23/26 at 10:24 AM revealed, Spoke with resident's wife regarding discharge today. Resident has filed an appeal with the insurance company and awaiting answer. Wife expressed anxiety with today's discharge and states that she does not have transportation scheduled at this time, but she will coordinate after speaking with insurance. There were no other notes related to discharge communication with resident and family.In an interview on 3/26/26 at 10:48 AM, SS S reported that she was very new to the facility and the social services role on 2/20/26 and had only a few days of training. SS S reported that she had a conversation with Resident #103 on 2/20/26 about his discharge and he signed the notification of benefits ending; SS S reported that by him signing, that was his confirmation that he understood his right to the appeal the discharge. SS S did not remember having a conversation about the resident's discharge plans, in-home services or outpatient therapy with FM U and/or Resident #103 but normally that conversation would happen when the resident declined appealing the insurance and planned to discharge. SS S reported that she was not aware that FM U had any concerns about Resident #103's discharge and did not recall assisting Resident #103 or FM U with the appeals process.In an interview on 3/24/26 at 2:33 PM, MDS Coordinator (MDS-C) K reported that they submitted paperwork to Resident #103's insurance company on 2/20/26 and predicted that he would require about 40 days longer before his goals would be met, but they ultimately denied further services. He was progressing in therapy but was still dependent with transfers and not safe to discharge without an able caregiver.In an interview on 3/26/26 at 10:00 AM, Director of Nursing (DON) B reported that the social services staff were responsible for the discharge process and they should document their conversations in a progress note to reflect that a safe discharge was in place. Resident #103's progress notes were reviewed and there were no progress notes related to discharge discussions except for the one on 2/23/26 where the family was anxious about discharge.In an interview on 3/26/26 at 12:41 PM, Nurse Practitioner (NP) H reported that he did not recall any concerns with Resident #103's discharge and that the resident was here for IV (intravenous) antibiotics and those were completed on 2/20/26. After review of the discharge order in the record, NP H reported that the provider visit notes do not indicate that he was discharging or that a discharge was discussed but usually the social worker makes a discharge packet and the provider reviews the orders, signs it and gives it back to the social worker. Review of Resident #103's last NP Visit dated 2/20/26 revealed, .seen in follow-up at rehab.today is his last day of antibiotics, participating in PT (physical therapy)/OT (occupational therapy).Assessment/Plan: .he is being moved using a hoyer (mechanical lift). There was no documentation related to discharge.Review of Resident #103's Recapitulation of Stay dated 2/23/26 at 9:44 AM revealed, Discharge information: Reason for transfer/discharge: end of skilled stay. Disposition home. Summary of stay: (list of diagnoses only) Further description of diagnosis/conditions: (blank) Pertinent current lab values: (blank) Pertinent on-going labs needed: (blank) Other/future diagnostic tests and results: (blank) Documented Consultations: The physician orders have been received and verified for discharge and/or transfer. The resident will be returning to the community. The resident did not trigger the CAA (care area assessment) for return to community referral. Other pertinent information for continuing care and/or special instructions or precautions for continuing care: (blank) Additional information: (blank) Practitioner Contact information: (blank) Resident Representative Contact information: (blank) Advanced directives: (blank) Comprehensive Care Plan Goals: (blank) All other necessary information: (blank).In an interview on 3/26/26 at 11:25 AM, Physical Therapy Assistant (PTA) Q reported that the last time Resident #103 had therapy was on (Friday) 2/20/26 and at that time they were not aware that he was being discharged on Monday 2/23/26. PTA Q reported that the resident was dependent with transfers on 2/20/26 and not safe to stand at all, and there were never discussions related to his family being able to care for him at home, due to his level of care it would not have been possible. PTA Q reported that they were not involved in the discharge process for the resident but would have recommended at least an in-home health aide and therapy services.In an interview on 3/26/26 at 11:50 AM, Rehab Director (RD) O reported that she received an email on 2/20/26 at 1:26 PM that Resident #103's services were being cut but usually we wait to hear from the social worker to know if the resident is appealing the end date of services being 2/22/26. RD O reported that they received notice on 2/23/26 that Resident #103 did not appeal and was discharging, so they did not have time to plan for discharge or complete a discharge assessment. RD O reported that Resident #103 should have been referred for home services because the family was not physically able to care for him.In an interview on 3/26/26 at 2:45 PM, MDS-C K reported that Resident #103 should have had a discharge packet scanned into his record after it was reviewed and signed by the resident, but there was no packet scanned into his record. MDS-C K reported that she was on the email thread on Friday 2/20/26 that indicated Resident #103's last covered day was 2/22/26 and needed to be served a notification of his insurance benefits ending. MDS-C K reported she realized at 4:10 PM on 2/20/26 that the new social services staff SS S was not included on the email thread, so she forwarded it to her so that Resident #103 could be notified and file for an appeal if desired.Review of Resident #103's Discharge Packet that was discovered in a shred box by MDS-C K on 3/26/26 at approximately 3:30 PM, included Resident #103's medication orders, care plan, and a discharge document. The discharge document My Transition Home-Discharge was dated 2/23/26 at 9:44 AM revealed, .Post-discharge resources: Home health care, physical therapy, occupational therapy. Home health Agency (name omitted) (no addresses or phone numbers entered in document blanks), Post-Discharge Equipment/Supplies Needed: Wheelchair, Ambulation: Needs physical assistance: extensive assist with transfer. discharge date : [DATE]. Method of transportation for discharge: (question not completed). Discharge Instructions reviewed with: (question not completed). Signatures: signature confirming you have reviewed this document and acknowledge a copy is being given to resident and/or resident representative. Resident or Resident Representative: (No signatures entered) Date: (no date entered). Printed name of staff member: (no name entered).Review of the facility policy Transfer and Discharge Guidelines dated 5/5/2025 revealed, .The facility will work with the physician to obtain adequate documentation about the reason to discharge the resident. The facility will provide preparation and orientation to the resident, family and receiving facility prior to discharge . The facility may not transfer or discharge a resident while the appeal process is pending . Notifications: The interdisciplinary team designee will meet with the resident and resident representative as applicable to review the discharge/transfer notice and its contents . Appealing the notice: The interdisciplinary team designee will meet with the resident to review and explain the notice to the resident and their representative and discuss the resident's right to appeal the discharge. a. If the resident wishes to appeal the social worker will provide information and assistance to obtain, complete, and submit the appeal request. b. During the appeal process, the resident will not be discharged . D. Documentation of notification: a. The resident's physician and facility staff will document in the resident's record: The resident's health status at the time of notice. Reason the services provided by the facility are no longer needed, document discharge needs and discharge plan . Date when staff reviewed the notice and its contents with the resident and resident representative. Date of formal discharge planning meeting and appeal rights. b. Documentation will include the basis for the transfer and the services to be provided by the receiving health care provider that will meet the resident's needs . F. Orientation for transfer/discharge: a. The facility will provide the resident with sufficient preparation and orientation to the upcoming discharge to ensure that the discharge is safe and orderly. The orientation will be provided to the resident and resident representative in a form and manner that can be understood .f. The facility will provide the appropriate education related to medication, treatments, medical care and services, psychosocial needs, care interventions and approaches and other applicable approaches for a safe care transition . Documentation: a. The resident needs and discharge plan must be documented in the medical record. If a discharge to the community is determined to not be feasible, document who made the determination and reason. b. The resident and resident representative will be informed of the final discharge plan . c. An evaluation of the resident's discharge needs will be documented in the resident record on a timely basis. The results of this evaluation will be discussed with the resident or resident representative .

This citation pertains to Intake #2799926.Based on interview and record review, the facility failed to develop a baseline care plan related to high risk for falls in 1 resident (Resident #101) of 3 residents reviewed for falls, resulting in an unwitnessed fall with major injury.Findings include: Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: sepsis (life threatening condition cause by an infection), weakness, cognitive deficit (impaired mental processes), insomnia (unable to sleep) and repeated falls. Review of Resident #101's Social Services Note dated 1/16/26 indicated, a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated Resident #101 had severe cognitive impairment.Review of Resident #101's Fall Assessment dated 1/15/26 at 2:02 PM revealed, High Fall Risk. Score: 24.3 or more falls in past 3 months, intermittent confusion, Ambulation/elimination status: ambulatory/continent.hospitalization history in the last 30 days, Mobility: Is resident able to walk with or without assistance and/or device? NO. If the resident is unable to walk, describe the resident's mobility in wheelchair: Confined in a wheelchair and disoriented. A score of 10 or higher indicates the resident is at high risk of fall. It was noted that the mobility status assessment was not an accurate reflection of Resident #101's status.Review of Resident #101's Fall Prevention Care Plan revealed no care plan developed related to fall prevention and/or the resident being at high risk for falls until 1/20/26, after resident #101 fell and discharged to the hospital. Review of Resident #101's ADL (activities of daily living) Care Plan revealed, Resident requires assist with daily care needs r/t (related to) general weakness/debility. Date initiated: 1/16/26. Interventions: Dining: Resident with direct feeding assistance for po (by mouth) intake.Date initiated: 1/16/26. The remainder of the interventions were created 1/19/26 after Resident #101 fell and discharged to the hospital. The record did not indicate if the resident was continent or incontinent and/or if there was a toileting program.Review of Resident #101's Incident Report-Fall Unwitnessed dated 1/19/26 at 6:00 AM revealed, .Resident had an unwitnessed fall. Aide walked into resident's room and observed resident sitting on the floor in front of the toilet, resident was sitting on her bottom with legs crisscross, blood trail from room to bathroom, resident had an episode of emesis (vomiting). Resident bleeding from right side of head, resident unable to describe what she was doing at the time of fall, nurse asked resident if she was in pain, resident stated yes but could not describe pain or describe location. Nurse manager agreed with nurse to send resident out after observing resident's head.In an interview on 3/25/26 at 2:29 PM, Registered Nurse Manager (RNM) F reported that Resident #101 was not safe to ambulate on her own, she was very weak, a new admit, and required at least 1 person to assist with transfers and ambulation. RNM F reported that Resident #101 had a baseline care plan developed within 24 hours of admission, but it did not include being at high risk for falls, fall prevention interventions or the level of assistance that she needed for transfers and ambulation. RNM F reported that after Resident #101's fall on 1/19/26 the care plans for high risk for falls, actual fall, skin, and pain were created and the ADL care plan was updated to reflect that she needed 1 person assistance. RNM F reported that having at least the transfer needs on the baseline care plan is important so that direct care staff know how to care for the resident.In an interview on 3/25/26 at 4:55 PM, Certified Nursing Assistant (CNA) M reported that she had worked with Resident #101 once before the day of the fall, and the resident was able to get out of bed and walk on her own, but she was unsteady. CNA M reported that she did not think Resident #101 was a major risk for falling because normally when a resident is at high risk for falling there are signs up in the room, a cushion on the floor by the bed, and we know to check on them frequently, but Resident #101 did not have those things.In an interview on 3/26/26 at 8:47 AM, CNA J reported that she was working with Resident #101 on 1/19/26 but had left the facility at 6:00 AM. CNA J reported that she heard that Resident #101 had fallen and was sent to the hospital. CNA J reported that she had only worked with Resident #101 one other time and other staff had told her that the resident liked to walk around her room and do her own thing. CNA J reported that she did not know if Resident #101 was continent or incontinent, and the resident could not communicate toileting needs. CNA J reported that Resident #101's door was closed all night. CNA J reported that the last time she checked on Resident #101 was before 4:00 AM. CNA J reported that she would refer to the Kardex (care guide for CNA's) if she needed to find transfer and ambulation status.In an interview on 3/26/26 at 9:19 AM, Director of Nursing (DON) B reported that Resident #101 was assessed by nursing to be at high risk for falls upon admission and was evaluated by therapy and determined to require at least 1 assist for transfers and ambulation. DON B reported that the nurse managers should enter that information into the care plan. DON B reported that Resident #101 did not have a fall care plan and/or her transfer status documented in her care plan or Kardex until after she had fallen which was 4 days after admission. DON B reported the care plan carries over direct care needs to the Kardex. DON B reported that the CNA's are expected to refer to the information in the Kardex to determine the resident's needs; Resident #101 was at high risk for falls and she should have had frequent checks and should not have been ambulating on her own. DON B reported that she was not aware that Resident #101's care plan/kardex was missing the information until talking to this surveyor.In an interview on 3/26/26 at 11:25 AM, Occupational Therapist (OT) R reported that Resident #101 could not follow commands, did not use her call light, got up and walked on her own, but required assistance of at least one person to be safe. OT R reported that Resident #101 was evaluated and then discharged before treatment started.

This citation pertains to Intake #2791318.Based on interview and record review the facility failed to ensure residents received care in accordance with professional standards and per physician orders for 1 resident (Resident #104) of 3 residents reviewed for quality of care, when nursing staff failed to administer medications per physician order and resident request.Findings include: Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic bronchitis (a long-term type of COPD (chronic obstructive pulmonary disease that makes breathing difficult) characterized by a persistent, mucus-producing cough). Review of Resident #104's Brief Interview for Mental Status (BIMS) dated 2/23/26 revealed, a score of 15, out of a total possible score of 15, which indicated Resident #104 was cognitively intact.Review of Resident #104's Care Plan revealed no documentation of chronic bronchitis, COPD, and/or cough. No documentation related to physician ordered medications.In a phone interview on 3/24/26 at 9:45 AM, Resident #104 reported that he was in the facility recovering from influenza and when he tried to rest or lay down, he would cough a lot. Resident #104 reported that he was prescribed Tessalon [NAME] (medication for cough) at the hospital because nothing else seemed to be effective. Resident #104 reported that there were multiple days between 2/15/26 and 2/19/26 that he asked repeatedly for the Tessalon [NAME] and was told that he could not have them. Resident #104 reported that he became angry with Registered Nurse (RN) D because he was coughing and could not sleep; Resident #104 reported that RN D got very defensive and refused to give him the medication. Resident #104 reported that RN D started offering cough syrup but refused to give him the Tessalon [NAME].Review of Resident #104's Physician Orders revealed, Benzonatate (cough suppressant) oral capsule (common name Tessalon [NAME]) give 1 capsule by mouth every 8 hours as needed for cough. Start date 2/9/26. DC (discontinue) date 2/13/26. The medication was administered 5 times over 4 days but not at all on 2/11/26.Review of Resident #104's Physician Orders revealed, Benzonatate oral capsule give 1 capsule by mouth every 8 hours as needed for cough for 10 days. Start date 2/13/26. DC date 2/23/26. The medication was administered 13 times over 11 days but not at all on 2/15/26, 2/17/26, 2/18/26 or 2/19/26. RN D's initials were NOT listed on any of the doses that were administered.Review of Resident #104's Physician Orders revealed, Guaifenesin (cough suppressant) oral syrup.give 10 ml by mouth every 4 hours as needed for cough. Start date: 2/17/26. There were 3 doses administered on 3 separate days, 2/17/26, 2/18/26 and 2/19/26. All doses were initialed by RN D.In an interview on 3/25/26 at 10:43 AM, Licensed Practical Nurse (LPN) X reported that Resident #104 had a persistent cough and regularly requested the Tessalon [NAME]. LPN X reported that the medication was stored in the medication cart and she did not remember a time that it was unavailable.In an interview on 3/25/26 at 10:56 AM, Certified Nurses Assistant (CNA) Y reported that Resident #104 would frequently get upset about not receiving his medications on time.In a phone interview on 3/26/26 at 8:05 AM, RN D reported that Resident #104 was insistent on getting the Tessalon [NAME] for his cough and he frequently asked for the medication. RN D reported that Resident #104 did not have an order for that medication, so she was not able to administer it. RN D reported that she did not notify the physician and she did not remember ever administering a cough syrup.In an interview on 3/26/26 at 3:25 PM, Nurse Manager (NM) F reported that there was an issue involving Registered Nurse (RN) D not honoring Resident #104's request for his cough medication. NM F reported that Resident #104 had brought it to the attention of NM F and RN D had no good explanation for why the resident did not receive his medication. NM F reported that Resident #104 had the physician's order for Tessalon [NAME] and the medication was available and should have been administered.Review of Resident #104's Provider Visit Note dated 2/20/26 revealed, .He has a multitude of complaints about some medications, timing of the medications. Recently had influenza A and was treated with Tessalon [NAME] and Tamiflu and apparently significant improvement. He also has a history of COPD, was an ex-smoker.He still has some intermittent cough which is mostly dry.He has a multitude of mostly administrative complaints regarding his medication timing.

This citation pertains to intake #2668784Based on observation, interview, and record review the facility failed to maintain resident dignity in 2 (Resident #1 and Resident #3) of 5 sampled residents, resulting in feelings of humiliation, embarrassment, and shame. Findings include:Resident #1Review of an admission Record revealed Resident #1 was a female who admitted to the facility on [DATE] and had pertinent diagnoses which included: displaced intertrochanteric fracture of the left femur (fractured left hip) malnutrition, and chronic obstructive pulmonary disease (COPD- a chronic lung disease that restricts breathing).Review of a Social Service Evaluation with a date of 10/24/25 completed at admission for Resident #1 indicated Resident #1's Brief Interview for Mental Status (BIMS) score of 15/15 indicated Resident #1 was cognitively intact.In a telephone interview on 12/04/25 at 3:40 PM Family Member (FM) U reported during a visit with Resident #1, she had an episode of incontinence (a lack of control over voluntary urination) when she had to wait over an hour for her call light to be answered. FM U reported Resident #1 was embarrassed, humiliated, and frustrated that she had peed the bed. FM U reported Resident #1 apologized to staff for being a bother, and not being able to hold her urine when they arrived to answered her call light. In an interview on 12/08/25 at 10:51 AM Certified Nurse Assistant (CNA) L reported call lights should be answered when they are observed to be on. CNA L reported that call lights should be answered by everyone.In an interview on 12/09/25 at 3:08 PM Nurse Manager/Registered Nurse (NM/RN) S reported he had received a complaint from Resident #1's family related to long call light wait times. NM/RN S reported Resident #1's family was concerned with Resident #1's dignity if she urinated on herself. NM/RN S reported he reviewed the call light log and confirmed that Resident #1's call light had been on for 45 minutes one time and 1.5 hours another time during the time when the concern was voiced by family members.Review of Concern/Grievance Form for Resident #1 dated 10/27/25 revealed . date of occurrence 10/26 and 10/27.stated resident's call light was on for extended periods of time through the weekend (10/26 and 10/27) and this morning.call light log was pulled. Resident did have call light on for extended time.In an interview on 12/09/25 at 3:15 PM Nursing Home Administrator (NHA) A provided her computer with the call light log for Resident #1's call light during the dates of 10/26 and 10/27, NHA reported she was unable to print the information and provide it to surveyor.On 12/09/25 at 3:20 PM visual review of the call light log for Resident #1 during the dates of 10/26 and 10/27 revealed . on 10/26/25 at 5:11 AM the call light was on for 1 hour and 28 minutes and on 10/27/25 at 8:23 AM Resident #1's call light was on for 29 minutes.In an interview on 12/09/25 at 3:21 PM, NHA A reported call lights should be answered timely and 29 minutes and 1.5 hours was not considered timely.Resident #3Review of an admission Record revealed Resident #3 was a female who admitted to the facility on [DATE] and had pertinent diagnosis which included: minimally displaced zone 1 fracture of the sacrum (a break in the wedge-shaped bone (sacrum) at the base of the spine where the bone fragments have not significantly shifted or separated).Review of a Social Service Evaluation with a date of 12/5/25 completed at admission for Resident #3 indicated Resident #3's Brief Interview for Mental Status (BIMS) score of 15/15 indicated Resident #3 was cognitively intact.Review of Care Plan for Resident #3 revealed .Foley: Resident requires use of an indwelling catheter r/t (related to) .Keep drainage bag covered to promote privacy. with an initiation date of 12/04/25.On 12/08/25 at 11:05 AM, Resident #3 was observed as she exited her room while sitting in her wheelchair, her urine collection bag connected to a foley catheter was noted to be attached to the wheelchair and the urine was visible. There was no privacy bag or covering present on the urine collection bag. Resident #3 was addressed by Licensed Practical Nurse (LPN) P and LPN P instructed Resident #3 to return to her room as she needed a privacy bag applied to her wheelchair to cover her urine collection bag. Resident #3 stated I wish I had that yesterday. I went to therapy yesterday and I ran into a friend from church and my pee bag was out for everyone to see, I was so embarrassed. Resident #3 was observed to be flushed in the face, emotional, and crying when communicating this information to LPN P.In an interview on 12/08/25 at 11:06 AM LPN P reported that all urine bags should have a privacy covering.In an observation and interview on 12/08/25 at 1:23 PM, Resident #3's urine collection bag was in a privacy bag. Resident #3 reported it was very embarrassing and humiliating when you run into someone you know, and they see your urine in a bag. Resident #3 was observed to be flushed in the face, emotional and crying when discussing this experience.In an interview on 12/09/25 at 2:28 PM NM/RN S reported he recalled seeing Resident #3's catheter on the far side of the bed, but he was unsure if there was a privacy bag on her wheelchair. NM/RN S reported all urine collection bags should have privacy bags.Review of facility policy Urinary Indwelling Catheter Management Guideline with an effective date of 11/28/17 revealed .Drainage collection devices will have a dignified intervention ensuring elimination is covered and mobility is encouraged with placement of a device on the leg or chair.

Based on observation, interview, and record review the facility failed to ensure a baseline care plan was developed for 1 (Resident #3) of 5 sampled residents resulting in the potential for unmet care needs.Findings include:Resident #3Review of an admission Record revealed Resident #3 was a female who admitted to the facility on [DATE] and had pertinent diagnosis which included: minimally displaced zone 1 fracture of the sacrum (a break in the wedge-shaped bone (sacrum) at the base of the spine where the bone fragments have not significantly shifted or separated).Review of a Social Service Evaluation with a date of 12/5/25 completed at admission for Resident #3 indicated Resident #3's Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact.On 12/8/25 at 11:05 AM Resident #3's door frame to her room was observed to have signage present indicating that Resident #3 was in Enhanced Barrier Precautions (EBP). In an interview on 12/8/25 at 1:23 PM Resident #3 reported some of the staff wear gown when helping her and sometimes they don't. Resident #3 reported she did not know why the staff wore the gown when caring for her.Review of Care Plan for Resident #3 revealed .Foley: Resident requires use of an indwelling catheter r/t (related to) . with an initiation date of 12/4/25, there was no noted documentation for Resident #3 to be in Enhanced Barrier Precautions.In an interview on 12/9/25 at 9:13 AM Registered Nurse (RN) DD reported residents who had indwelling catheters required EBP and it should be on the care plan.In an interview on 12/9/25 at 9:30 AM Certified Nurse Assistant (CNA) E reported Resident #3 was in EBP because she had an indwelling catheter. CNA E reported the nurses put EBP on the resident's care plans and Kardex (medical-patient information allowing nurses to easily reference key patient information from the care plan). When asked, CNA E reported she knew Resident #3 was in EBP when she saw the resident's catheter tubing, she was unsure if EBP was on Resident #3's care plan.Review of Kardex on 12/8/25 for Resident #3 revealed no noted documentation of EBP.In an interview on 12/9/25 at 10:30 AM Assistant Director of Nursing/Infection Preventionist (ADON/IP) D reported it was a team effort to create care plans, but nursing managers should be the ones to create the care plans.In an interview on 12/9/25 at 11:42 AM Director of Nursing (DON) B reported her expectations were that EBP were part of a resident's baseline care plan if it was indicated. DON B reported Resident #3 should have had EBP in her baseline care plan and confirmed that she had created Resident #3's EBP care plan that day, 5 days after Resident #3 admitted to the facility.Review of facility policy Careplan Standard Guideline with an effective date of 11/28/17 revealed .The interdisciplinary team will collect and record data within 24 hours for the admission baseline Care Plan.it is the practice of this facility to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care. The baseline careplan will . be developed within 48 hours of the resident's admission.

This citation pertains to intake #2668784Based on observation, interview, and record review the facility failed to ensure that professional standards of nursing practice were maintained by following physician orders in 1 (Resident #1) of 4 residents reviewed for professional nursing standards and physician orders resulting in laboratory diagnostic testing not being completed as ordered. Findings include:Resident #1Review of an admission Record revealed Resident #1 was a female who admitted to the facility on [DATE] and had pertinent diagnoses which included: displaced intertrochanteric fracture of the left femur (fractured left hip) malnutrition, and chronic obstructive pulmonary disease (COPD- a chronic lung disease that restricts breathing).Review of a Social Service Evaluation with a date of 10/24/25 completed at admission for Resident #1 indicated Resident #1's Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #1 was cognitively intact.In a telephone interview on 12/4/25 at 3:40 PM Family Member (FM) U reported Resident #1 did not have the recommended laboratory testing done to monitor a new condition of anemia (blood disorder characterized by low red blood cells or hemoglobin leading to reduced oxygen delivery to the body's tissues) that resulted from the surgery Resident #1 underwent to repair her broken hip. Review of Order Summary for Resident #1 revealed Laboratory- cmp cbc 10/29/2025. (complete metabolic panel a blood test that measures protein and electrolyte levels in the blood) and (a complete blood count a blood test that measures red blood cells, white blood cells, hemoglobin and platelets ) which was entered on 10/27/25 by Nurse Practitioner (NP) BB.Review of Order Summary for Resident #1 revealed CBC, CMP, TSH FT4 today; call report to me, one time only for anemia; weakness; post op; wt (weight) loss for one day. which was entered by Medical Doctor (MD) CC on 10/31/25. Review of Order Summary for Resident #1 revealed cmp, cbc TSH (a blood test that measures thyroid -stimulating hormone levels to assess thyroid function) FT4 (a blood test to measure the level of T4 in the blood used for thyroid function assessment) one time only on 11/5/25 for med monitoring, verbal order created on 11/1/25.Review of Medication Administration Record (MAR) for Resident #1 for October 2025, revealed CBC, CMP, TSH FT4 today; call report to me, one time only for anemia; weakness; post op; wt loss for one day.ordered to be completed on 10/31/25, was blank, there was no documentation indicating the lab draw was completed.In an interview on 12/8/25 at 11:00 PM, Licensed Practical Nurse (LPN) P reported the providers order admission baseline labs when residents are admitted .In an interview on 12/8/25 at 1:54 PM, LPN Q reported the provider usually orders a CBC and CMP to be drawn for baseline labs on the next lab day after admission. LPN Q reported the lab day was on Wednesdays. LPN Q reported the provider may order labs on a day when the lab did not provide services to the building, and the labs would need to be drawn by a qualified nurse working in the building. In an interview on 12/9/25 at 9:13 AM, Registered Nurse (RN) DD reported most labs were drawn by the lab nurse, weekly on Wednesday, but if the order for a lab was on a different day, the responsibility was then the nurses in the building. Review of Medication Administration Record (MAR) for Resident #1 for November 2025, revealed CBC, CMP, TSH FT4 today; call report to me, one time only for anemia; weakness; post op; wt loss for one day.ordered to be completed on 11/1/25, was documented as 9- see progress note.Review of EMAR (electronic medication administration record) administration note for Resident #1 dated 11/1/25 revealed CBC, CMP, TSH FT4 today; call report to me, one time only for anemia; weakness; post op; wt (weight) loss for one day. incorrect date rescheduled for routine med management lab date Wednesday.In an interview on 12/8/25 at 10:08 AM Nurse Manager/Registered Nurse (NM/RN) R confirmed Resident #1 had laboratory orders and she was unable to locate any results. NM/RN R reported it did not appear Resident #1's ordered labs had been completed.In an interview on 12/9/25 at 1:00 PM, Director of Nursing (DON) B reported it appeared Resident #1's ordered labs had not been completed. DON B reported she was unable to locate any results.In an interview on 12/9/25 at 1:03 PM, Regional Nurse Consultant (RNC) Y confirmed Resident #1 had labs ordered on both 10/29/25 and 10/31/25 and neither time was the order completed.

Based on observation, interview, and record review the facility failed to ensure proper management of an indwelling urinary catheter in 1 (Resident #3) of 1 resident reviewed for an indwelling urinary catheter resulting in the potential for unmet care needs.Findings include:Resident #3Review of an admission Record revealed Resident #3 was a female who admitted to the facility on [DATE] and had pertinent diagnosis which included: minimally displaced zone 1 fracture of the sacrum (a break in the wedge-shaped bone (sacrum) at the base of the spine where the bone fragments have not significantly shifted or separated).Review of a Social Service Evaluation with a date of 12/5/25 completed at admission for Resident #3 indicated Resident #3's Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact.On 12/8/25 at 11:05 AM, Resident #3 was observed to have a urine collection bag on the side of her wheelchair.Review of Physician Orders for Resident #3 on 12/8/25 revealed no orders noted related to an indwelling/foley catheter.Review of Care Plan for Resident #3 revealed .Foley: Resident requires use of an indwelling catheter (a tube placed directly into the bladder to drain urine) r/t (related to).keep drainage bag lower then level of bladder. keep drainage bag covered to promote privacy.monitor for s/s (signs and symptoms UTI (urinary tract infection) . provide catheter care and empty bag every shift and as needed. with an initiation date of 12/4/25.Review of Health Status Note for Resident #3 dated 12/4/25 at 20:19 (8:19 pm) revealed .patient has a foley catheter in place .Review of Nursing Bladder and /or Bowel Evaluation for Resident #3 dated 12/5/25 at 01:36 AM revealed .reason for evaluation was admission, bladder continence status was urinary catheter.supporting diagnosis for the catheter is other-sacral fx (fracture).In an interview on 12/8/25 at 1:23 PM, Resident #3's reported she had no idea why she had the catheter, and she did not have one before going to the hospital. Resident #3 reported the first few days she was at the facility; no one emptied her urine bag. Resident #3 stated it seemed like they didn't even know I had a catheter. In an interview on 12/9/25 at 9:38 AM Licensed Practical Nurse (LPN) O reported the admitting nurse was who should verify a residents admission orders. LPN O reported the admitting nurse should give a resident's admission orders to the facility providers, the providers should confirm and/or change any orders and then sign for the orders they want in place, and after that the nurse mangers were to review the resident's orders to make sure they were accurate. LPN O reported resident admission orders were essentially triple checked for accuracy. In an interview on 12/9/25 at 9:45 AM Nurse Manager/Registered Nurse (NM/RN) R reported physician orders were required for a resident who had an indwelling urinary catheter/foley catheter.Review of Order Summary for Resident #3 on 12/9/25 revealed .Foley catheter care every shift.Foley catheter - change PRN (as needed).Foley Catheter Sioze- 16 Fr (French); Balloon 10 mL (milliliters) for a diagnosis of retention. all orders were noted to be entered on 12/9/25.In an interview on 12/9/25 at 11:42 AM Director of Nursing (DON) B reported nurse managers were responsible to verify that all resident orders were correct and in place. DON B reported nurse managers were responsible for their assigned units, and they need to verify that the orders are in and correct, as well as care plans and care plan interventions. When queried, DON B reported she added physician orders related to Resident #3 indwelling catheter care today. DON B reported that orders for Resident #3's catheter should have been in place when she admitted on [DATE].In an interview on 12/9/25 at 2:28 PM NM/RN S stated I remember her (Resident #3) having a catheter, it was on the other side of the bed, but I never followed up on the orders for it. When queried, NM/RN S reported he did not know why Resident #3 had an indwelling urinary catheter.Review of facility policy Urinary Indwelling Catheter Management Guidelines with an effective date of 11/28/17 revealed .Indwelling catheters may be associated with significant complications.Indwelling catheter evaluations and a Medical Necessity for Indwelling catheter evaluation will be completed .upon admission with observation of an indwelling urinary catheter.Physician orders should reflect these recommendations.

Based on observation, interview, and record review the facility failed to ensure proper management of a PICC (Peripherally Inserted Central Catheter - intravenous tube used for prolonged vascular access) in 1 (Resident #5) of 1 resident reviewed for a PICC resulting in the potential for unmet care needs.Findings include:Resident #5Review of an admission Record revealed Resident #3 was a female who admitted to the facility on [DATE] and had pertinent diagnosis which included: intraspinal abscess and granuloma (a localized collection of pus around the spinal canal, typically resulting from infections, and a mass of tissue that forms as a response from inflammation). On 12/10/25 at 1:00 PM, Licensed Practical Nurse (LPN) M was observed in Resident #5's room disconnecting IV (intravenous) tubing from a PICC line in Resident #5's left arm.Review of Order Summary for Resident #5 printed on 12/10/25 at 13:48 (1:48 PM) revealed no noted documented order for a PICC line or a noted order for monitoring the site of the PICC line.During an interview on 12/10/25 at 2:15 PM Resident #5 reported she came to the facility on [DATE] and already had to go back to the hospital to have her IV line replaced. Resident #5 reported she needed to have antibiotics through her IV for a week or two for her blood infection. Resident #5's dressing covering her PICC line was observed to be dated 12/7/25, Resident #5 reported they applied that dressing at the hospital when they put the new one in.Review of Nursing Admission for Resident #5 dated 12/5/25 at 17:58 (5:58 PM) revealed .IV present, in right upper arm, size-NA, Length- NA, Arm Circumference-NA, observation of IV site- clean and dry.Review of Transfer to Hospital or other Facility note for Resident #5 dated 12/6/25 at 8:34 AM revealed .redness, swelling on left upper arm around PICC, reason for transfer, redness, swelling on left upper arm around PICC.In an interview on 12/10/25 at 1:22 PM, Nurse Manager/Registered Nurse (NM/RN) S reported Resident #5 had a PICC line for 8 weeks of antibiotic therapy. NM/RN S reported he was not sure if a physician order was needed for a PICC line. NM/RN S reported he had no idea when the dressing should be changed on a PICC line.In an interview on 12/10/25 at 2:23 PM Director of Nursing (DON) B reported PICC line dressing should be changed every 7 days and there should be orders in place for that dressing change. DON B reported a PICC must have an order from a physician and there should also be orders in place to monitor the PICC line. Review of facility policy Guidelines for Preventing Intravenous Catheter Related Infection with a date of May 2022, revealed .surveillance.observe insertion site.on every shift, on admission, and with dressing changes. change.dressing on CVAD (central venous access device (included a PICC line)). every 5 to 7 days or PRN (as needed) if damp, loosened, or visibly soiled.monitor the catheter site visually during dressing changes. Palpate catheter-skin junction site for tenderness at least daily through the intact dressing.Documentation.the following should be recorded in the resident's medical record: objective information regarding appearance of insertion site, catheter, and dressing.2. Any interventions that were done.

Based on observation, interview, and record review the facility failed to ensure proper use of personal protective equipment (PPE) during cares while in enhanced barrier precautions for 1 (Resident #5) of 3 residents reviewed for PPE use during cares while in enhanced barrier precautions (EBP), resulting in the potential for the introduction of and/or the spread of infection.Findings include:Resident #5Review of an admission Record revealed Resident #3 was a female who admitted to the facility on [DATE] and had pertinent diagnosis which included: intraspinal abscess and granuloma (a localized collection of pus around the spinal canal, typically resulting from infections, and a mass of tissue that forms as a response from inflammation). On 12/10/25 at 12:59 PM, observed signage outside of Resident #5's room indicated enhanced barrier precautions were in place during cares for Resident #5. The sign indicated that staff were to wear a gown and gloves when providing high contact care for Resident #5.On 12/10/25 at 1:00 PM, Licensed Practical Nurse (LPN) M was observed in Resident #5's room disconnecting IV (intravenous) tubing from a PICC (peripherally inserted central catheter, an intravenous access in the upper arm used for long term antibiotic administration) line in Resident #5's left arm. LPN M was not wearing a gown. Review of Orders for Resident #5 revealed .Enhanced barrier precautions (EBP) wound and PICC line.for infection control. with a start date of 12/05/25.Review of care plan for Resident #5 revealed .Resident requires Enhanced Barrier Precautions r/t (related to) PICC line. initiated on 12/07/25In an interview on 12/10/25 at 1:01 PM, LPN M reported Resident #5 was in EBP due to a PICC line in her left arm. LPN M reported she should wear a gown when working with Resident #5's PICC line. LPN M confirmed she did not wear a gown when she disconnected Resident #5's IV line and she should have.In an interview on 12/10/25 at 1:50 PM, Nursing Home Administrator (NHA) A reported LPN M should have worn a gown when caring for Resident #5's PICC line.In an interview on 12/10/25 at 2:23 PM Director of Nursing (DON) B reported Resident #5 was in EBP due to her PICC line, and her expectations were that staff wore PPE when in contact with Resident #5's PICC line.Review of facility policy Personal Protective Equipment Preventative Approach Guideline with an effective date of 7/13/2022 revealed .Enhanced Barrier Precautions .refer to the use of gown and gloves during high-contact resident care activities that provide the opportunity for transfer of MDROs (Multi-Drug Resistant Organisms).examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: .device care or use: central line.

Based on observation, interview and record review, the facility failed to develop a person-centered care plan for the prevention of pressure ulcers for 1 (Resident #47) of 18 residents reviewed for person centered care plans resulting in Resident #47 developing an open wound on his coccyx (tail bone area) and a pressure ulcer on his left heel.Findings include:Review of an admission Record revealed Resident #47 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: CVA (cerebral vascular accident/ stroke), hemiplegia of the left side (inability to move the left side of the body), peg-tube (percutaneous endoscopic gastrostomy tube- a tube inserted into the stomach to provide artificial nutrition) and aphasia (a disorder that affect show a person communicates).Review of a Minimum Data Set (MDS) assessment for Resident #47, with a reference date of 8/1/2025 revealed Section GG - Functional Abilities - Admission coding included self-care.code the resident's usual performance at the start of the stay for each activity . Mobility.Roll left and right, sit to lying, lying to sitting on the side of the bed, chair/bed-to-chair transfer, all areas Resident #47 was as 01-dependent.Section M - Skin Conditions - Determination of Pressure Ulcer/Injury Risk.Risk of Pressure Ulcer/Injuries. is this resident at risk of developing pressure ulcer/injuries? coded 1- Yes.Unhealed pressure ulcers/injuries.Does this resident have one or more unhealed pressure ulcers/injuries? Coded 0 - No.In an interview on 8/11/25 at 11:23 am, Family Member (FM) UU reported Resident #47 had been in the facility for almost 3 weeks and he now has multiple wounds. FM UU reported Resident #47 did not have any wounds when he admitted to the facility.Review of Braden Score (a standardized, evident-based assessment tool used in healthcare to assess a patient's risk for developing pressure injuries) for Resident #47 dated 7/26/25 at 3:04 pm revealed 12 High Risk.Review of Nursing Evaluation- Section Skin for Resident #47 dated 7/26/2025 at 17:06 (5:06 pm) revealed Resident #47 had no skin impairments on admission. Review of Care Plan for Resident #47 revealed Focus. the resident has limited physical mobility r/t weakness and CVA with left sided weakness. resident will remain free of complications related to immobility.skin-breakdown.interventions. provide supportive care, assistance with mobility as needed. Document assistance as needed.initiated on 7/26/2025.Focus. The resident has potential for impairment to skin integrity r/t recent CVA with left sided weakness, decreased mobility, and strength, MASD (moisture associated skin damage).Goal. The resident will remain free of new skin impairment.Monitor skin when providing care, notify nurse of any changes in skin appearance. initiated on 7/26/2025. There was no care planned preventative measures noted for Resident #47 with a Braden score of 12, high risk to prevent skin breakdown.In an interview on 8/11/25 at 11:53 am, FM UU reported the facility staff started repositioning Resident #47 off his bottom after the wound on his coccyx developed.Review of Care Management note for Resident #47 dated 7/30/2025 at 13:30 (1:30pm) revealed .Interdisciplinary Care Management Summary: .The IDT (interdisciplinary team) agrees with plan of care.In an interview on 8/13/2025 at 9:50 am, Wound Care Nurse/Registered Nurse (WCN/RN) S reported she was new to the wound nurse roll and her responsibilities were still being defined. WCN/RN S reported Resident #47 had care plan interventions in place such as floating heels on a pillow, turn every 2-3 hours, monitor wound weekly and take measurements and that she had initiated those interventions on 8/5/2025 when the wound was noted on his coccyx.In an interview on 8/13/2025 at 1:14 pm, LPN D reported she has never been shown anything related to care plans and she has never put one in place.Review of Care Plan for Resident #47 revealed .focus.The resident has an actual ADL self-care performance deficit r/t his impaired strength, mobility , left sided weakness.interventions: PRAFO boots when in bed date initiated 8/11/2025.PT/OT (physical therapy/occupational therapy) evaluate and treat.initiated 8/11/2025.Focus.The resident has potential for impairment to skin integrity r/t CVA with left sided weakness, decreased mobility and strength, impaired safety.MASD.Interventions: apply barrier cream per facility protocol to help protect skin from excess moisture.initiated 8/11/2025.change bedding/clothing if moist.initiated 8/11/2025.Air mattress as ordered.initiated 8/11/2025.elevate heels while resting is lying in bed with heel protectors as he allows. initiated 8/11/2025.Turn and reposition resident every 2-3 hours, use wedge cushion.initiated 8/11/2025.Focus The resident has actual impairment to skin integrity MASD to coccyx and right buttock.initiated 8/5/2025.Goal. Resident's skin integrity will improve.initiated on 8/5/2025. Interventions. Educate resident/family caregiver of causative factors and measures to prevent skin injury. initiated 8/5/2025.ensure resident has bilateral (both feet) heel protecting boots on at all times as resident allows. initiated 8/5/2025. Keep skin clean and dry. Try to reduce as much moisture as possible 8/5/2025.turn and reposition eve3ry 2-3 hours and PRN (as needed). initiated 8/5/2025.Use a draw sheet or lifting device to move resident. initiated on 8/5/2025. Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudated (drainage) and any other notable changes or observations initiated on 8/5/2025.Focus. Resident has condom catheter size large. the resident will show no s/sx (signs and symptoms) of urinary infection. initiated on 8/6/2025.In an interview on 8/13/2025 at 1:16 pm, Nurse Manager/Licensed Practical Nurse (NM/LPN) M reported care plans should be developed within 24-48 hours of admission. NM/LPN M reported that floor nurses are responsible for care plan development when a resident admits on a weekend.In an observation and interview on 8/13/2025 at 1:44 pm, Nurse Manager/Registered Nurse (NM/RN) N was observed creating a custom wound care plan for Resident #47 and reported she had been instructed by Director of Nursing (DON) B to create the wound care plans. NM/RN N reported the former wound nurse would create care plans related to wounds, and the position was vacated on 7/12/2025. NM/RN N reported she was not sure who was doing wound care plans after the position was vacated. NM/RN N reported that floor nurses could create care plans, with interventions that directly reflect the resident's assessment and/or Braden scale, but they were still working on the floor nurses doing it as they were not fluent in care plan language. NM/RN N reviewed Resident #47's skin care plan and stated, it's not good: I don't know what to say. NM/RN N reviewed Resident #47's medical record and noted that Resident #47 admitted to the facility on [DATE], when NM/RN N noted Resident #47's admission dates she exclaimed out loud OH MY GOSH! Did he go that long with no interventions? NM/RN N continued to review Resident #47's care plan and stated, What is documented in Resident #47's care plan is that there were no interventions in place until 8/5/25 after the wound on his coccyx was found, and then again on 8/11/25 when the wound on his left heel was found.In an interview on 8/13/2025 at 2:34 pm, Director of Nursing (DON) B reported Resident #47's had 3 wounds now and no wounds were not present on admission. DON B reviewed Resident #47's care plan and reported barrier cream was put in today, float heels was put in yesterday, draw sheet on 8/5/2025, turn and reposition on 8/5/2025, pressure relieving mattress put in on 8/12/2025. DON B stated Resident #47 had an air mattress on his bed since he admitted , but there was no care plan intervention in place. DON B stated if it wasn't documented it wasn't done. DON B reported that Resident #47 should have had pressure ulcer prevention interventions in place at admission, he was clearly at risk for pressure ulcers related to his Braden score, and her expectations were that interventions were put in place at admission when a resident was at risk for developing pressure ulcers.Review of facility policy Careplan Standard Guideline with an effective date of 11/28/2017 revealed .All resident/client will be evaluated for individual risk factors.The interdisciplinary team will collect and record data within 24 hours for the admission baseline care plan.Interventions should be specific to reflect the specific goal. The intervention should be individualized to the resident.

Based on observation, interview, and record review the facility failed to provide adequate care to prevent the development of pressure ulcers in 1 (Resident #47) of 5 residents reviewed for pressure ulcers resulting in Resident #47 developing pressure ulcers in the coccyx (the tailbone area of the body) and the left heel.Findings include:Resident #47Review of an admission Record revealed Resident #47 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: CVA (cerebral vascular accident/ stroke), hemiplegia of the left side (inability to move the left side of the body), peg-tube (percutaneous endoscopic gastrostomy tube- a tube inserted into the stomach to provide artificial nutrition) and aphasia (a disorder that affect show a person communicates).Review of a Minimum Data Set (MDS) assessment for Resident #47, with a reference date of 8/1/2025 revealed Section GG - Functional Abilities - Admission coding indicated Resident #47 was dependent on staff for activities of daily living (ADL) care and transfers. The MDS indicated he was at risk for pressure ulcers but did not have any unhealed pressure ulcers at the time of assessment. During an observation on 8/11/2025 at 8:47 am, Resident #47 was lying supine (on his back) in bed with a pillow under the left arm and was noted to have a PRAFO boot (pressure relieving ankle foot orthosis, a specialized device designed to support the foot and ankle, a plastic boot shaped shell with a soft liner that fastens to the leg with straps helping to maintain or increase the range of movements at the ankle) on the right foot. The left foot was noted to have a bandage wrapped around it and his left heel was resting directly on the mattress.Review of Kardex (a collection of instructions generated from a care plan for the certified nurse's assistants to reference that indicate the needs of the residents they are caring for) for Resident #47 revealed PRAFO boots on when in bed. bed mobility: Physical Assist.In an interview on 8/11/25 at 11:23 am, Family Member (FM) UU reported Resident #47 had been in the facility for almost 3 weeks and he now has multiple pressure wounds. FM UU reported Resident #47 did not have any wounds when he admitted to the facility. FM UU reported she felt that Resident #47 never should have gotten a pressure wound, and now she had to be present in the facility every day to make sure he gets the care she felt he should have.During an observation and interview on 8/11/2025 at 11:26 am, Resident #47 was observed in bed and was noted to be positioned supine with pillows under his right arm and his left elbow (the same position he was observed in approximately 3 hours earlier). No other pillows noted for positioning. Resident #47 was also noted to be wearing PRAFO boots on both his right and left foot. Noted on the dry erase board in the room was boots on 2 hours and off for 4 hours. Licensed Practical Nurse (LPN) T was present in the room administering a bolus (large dose of formula given all at once) to Resident #47. LPN T reported Resident #47 was dependent (required staff to perform all care and positioning) for all care and bed mobility, and that Resident #47 was to have his boots on when he was in bed.In an interview on 8/11/25 at 11:53 am, FM UU reported the wound physician explained to her that Resident #47's wound on his coccyx was due to him being wet with urine related to his incontinence. FM UU reported after the wound physician started caring for Resident #47, the facility staff started positioning him off his bottom. FM UU reported Resident #47 had been up in his wheelchair only one time since he was admitted to the facility. FM UU reported that Resident #47 had a wound on his left heel and the dressing should be changed every day and it was not being changed every day.Review of Nursing Evaluation- Section Skin for Resident #47 dated 7/26/2025 at 17:06 (5:06 pm) revealed does the resident have any skin integrity concerns? Answer -No.Review of Skin Observation for Resident #47 dated 7/26/25 at 17:48 (5:48 pm) revealed Does the resident have any NEW skin issues observed? Answer No. other observations.skin is intact. Review of Braden Score (a standardized, evident-based assessment tool used in healthcare to assess a patient's risk for developing pressure injuries) for Resident #47 dated 7/26/25 at 3:04 pm revealed 12 High Risk. Review of Care Plan for Resident #47 revealed Focus.The resident has an actual ADL (activities of daily living) self-care performance deficit r/t (related to) his impaired strength, mobility, left sided weakness, communication and cognitive skills due to recent CVA. initiated on 7/26/2025.Goals.The Resident's ADLs needs will be anticipated and met by staff . initiated on 7/26/2025.Interventions.bed mobility physical assist.dressing physical assist.transfers: resident requires total/hoyer mechanical lift x 2 staff.bath shower max physical assist. all initiated on 7/26/2025.Focus. the resident has limited physical mobility r/t weakness and CVA with left sided weakness. initiated on 7/26/2025 resident will remain free of complications related to immobility, including contractures, thrombus formation (blood clots), skin-breakdown, fall related injuries. initiated on 7/26/2025.interventions. provide supportive care, assistance with mobility as needed. Document assistance as needed.initiated on 7/26/2025.Focus. the resident has bowel incontinence r/t functional, communication and cognitive limitations d/t (due to) recent CVA . initiated on 7/26/2025.Goal. The resident will remain free from skin breakdown due to incontinence and brief use.initiated on 7/26/2025.Interventions. provide pericare after each incontinence episode. initiated on 7/26/2025.Focus. The resident has potential for impairment to skin integrity r/t recent CVA with left sided weakness, decreased mobility, and strength, impaired safety awareness, cognition and communication skill deficits, bowel incontinent, gastrostomy tube, oxygen use, MASD (moisture associated skin damage).initiated on 7/26/2025. Goal. The resident will remain free of new skin impairment. initiated on 7/26/2025.Monitor skin when providing care, notify nurse of any changes in skin appearance. initiated on 7/26/2025.Review of Nutrition/Dietary Note for Resident #47 dated 7/31/2025 at 12:02, revealed .Resident with pressure area on heel, recommend 30 mL proheal critical care BID (twice a day) to further increase protein.Review of Skin Observation for Resident #47 dated 8/4/2025 at 15:12 (3:12 pm) revealed .Does the resident have a NEW skin issued observed? Answer Yes.Coccyx small open to gluteal cleft, measuring approx. 2 cm x 1 cm, coccyx also in gluteal cleft to the right of center, approx., 1.5 cm in diameter.Review of Health Status Note for Resident #47 dated 8/4/2025 at 17:18 pm (5:18 pm) revealed .small open area to inner gluteal cleft, see skin assessment for details. UM (unit manager) and NP (nurse practitioner) notified. orders for barrier cream.Review of Daily Skilled Nursing Note for Resident #47 dated 8/10/2025 at 15:09 (3:09 pm) revealed .Resident with pressure wound. Left heel and buttock.During an observation and interview on 8/12/2025 at 8:20 am, Resident #47 was lying supine in bed with a wedge noted on the left side of his body, and his left heel had a dressing present that was saturated and colored red, with his heel pressing directly on the mattress. FM UU present in the room reported that wound providers were present yesterday, and the coccyx wound was much worse and Resident #47 was not to wear the PRAFO boots any more. FM UU reported the dressings on Resident #47's wounds were not being changed like they should be. FM UU reported she was upset, frustrated, and concerned that Resident #47 was not getting out of bed, his dressings were not being changed, and he was not being moved around like he should be. FM UU reported the staff continues to tell her they were sorry Resident #47 has wounds now. FM UU stated Telling me sorry doesn't work for me, you need to do something.During an observation and interview on 8/12/2025 at 10:10 am, Resident #47 was noted to be sitting in his wheelchair outside on the patio with FM UU. FM UU reported that this was the second time Resident #47 was out of bed since he arrived at the facility.In an interview on 8/12/2025 at 2:10 pm, Certified Nurse Assistant (CNA) CC reported Resident #47 was dependent for cares, he needed to be rotated every two hours because he had a significant wound on his bottom, and he had to wear a boot on his one foot. CNA R reported Resident #47 should be turned from side to side every two hours when in bed, and to use pillows and wedges to keep him off his weak side. CNA CC reported Resident #47 should be changed every two hours. CNA CC and CNA R reported there was no place to document when a resident was repositioned. When queried regarding any wounds, CNA R stated he has gauze on the one foot, but I don't know if he has a wound under there.During an observation on 8/12/2025 at 2:13 pm, Resident #47 was sitting in his wheelchair in his room next to his bed. His left arm was hanging over the arm rest, extended straight towards the floor, and his entire upper body was leaning to the left side with his ribs pressed against the wheelchair arm rest. There was a pillow noted between the wheelchair outer arm rest and the bed not in contact with the resident at all. A wedge (triangle shaped pillow) was present between the inside of the arm rest and Resident #47's left hip not under the resident. Resident #47's left foot was noted to be wrapped with gauze, soiled and saturated at the heel and resting in direct contact with the footrest of the wheelchair. Resident #47 was observed making facial grimacing and appeared to be uncomfortable. It was noted that Resident #47 had been sitting in his wheelchair (though not in this position) since the last observation at 10:10 am.On 8/13/2025 at 9:37 am, Resident #47 was observed positioned supine in bed, with his left heel wrapped with gauze, saturated and soiled at the heel and with the left heel laying in direct contact with the mattress of his bed.On 8/13/2025 at 9:45 am, Resident #47 was observed positioned supine in bed with both heels laying directly in contact with the mattress.During an observation and interview on 8/13/2025 at 9:50 am, the gauze dressing to Resident #47's left heel was noted to be saturated and soiled. The sheet beneath Resident #47's heel area was noted to be soiled in a circular pattern directly under where Resident #47's heel had been observed resting directly on the mattress. Wound Care Nurse/Registered Nurse (WCN/RN) S reported Resident #47's was followed by wound providers, and that they changed orders for his dressing changes yesterday. WCN/RN S reported Resident #47 he did not move himself in bed, needed total assistance for cares, and was no longer to wear the PRAFO boots. When queried, WCN/RN S reported that the provider changed the orders for his PRAFO boots on Monday due to his legs looking like bowling pins with edema. Resident #47's heel wound was noted to be malodorous when WCN/RN S removed the dressing. Resident #47's left heel wound was observed to be a slit shaped opening in the back of the heel with a darker circular shaped area that surrounded the slit in the back of the left heel. WCN/RN S reported Resident #47's left heel wound was not present on admission, that the wound was pressure related, and facility acquired. WCN/RN S reported that Resident #47's coccyx wound was caused by moisture from incontinence. During wound care and pericare WCN/RN S verbalized that she now noted a new pink area on the left side of Resident #47's scrotum that was not there yesterday. WCN/RN S was observed applying barrier cream to the left side of Resident #47's scrotum. WCN/RN S reported Resident #47 had care plan interventions in place such as floating heels on a pillow, turn every 2-3 hours, monitor wound weekly and take measurements and that she had put in those interventions when she started which was last week. WCN/RN S reported she was not sure if care plans were her responsibility or not, she was new and was still learning her role. In an interview on 8/13/2025 at 9:54 am, CNA EE reported that Resident #47 was a check and change every 2 hours. CNA EE reported that Resident #47 needed two people to assist to reposition him as he was very heavy.Review of Care Plan for Resident #47 revealed .focus.The resident has an actual ADL self-care performance deficit r/t his impaired strength, mobility , left sided weakness.interventions: PRAFO boots when in bed date initiated 8/11/2025.PT/OT (physical therapy/occupational therapy) evaluate and treat.initiated 8/11/2025.Focus.The resident has potential for impairment to skin integrity r/t CVA with left sided weakness, decreased mobility and strength, impaired safety.MASD.Interventions: apply barrier cream per facility protocol to help protect skin from excess moisture.initiated 8/11/2025.change bedding/clothing if moist.initiated 8/11/2025.Air mattress as ordered.initiated 8/11/2025.elevate heels while resting is lying in bed with heel protectors as he allows. initiated 8/11/2025.Turn and reposition resident every 2-3 hours, use wedge cushion.initiated 8/11/2025.Focus The resident has actual impairment to skin integrity MASD to coccyx and right buttock.initiated 8/5/2025.Goal. Resident's skin integrity will improve.initiated on 8/5/2025. Interventions. Educate resident/family caregiver of causative factors and measures to prevent skin injury. initiated 8/5/2025.ensure resident has bilateral (both feet) heel protecting boots on at all times as resident allows. initiated 8/5/2025. Keep skin clean and dry. Try to reduce as much moisture as possible 8/5/2025.turn and reposition eve3ry 2-3 hours and PRN (as needed). initiated 8/5/2025.Use a draw sheet or lifting device to move resident. initiated on 8/5/2025. Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudated (drainage) and any other notable changes or observations initiated on 8/5/2025.Focus. Resident has condom catheter size large. the resident will show no s/sx (signs and symptoms) of urinary infection. initiated on 8/6/2025.In an interview on 8/13/2025 at 1:16 pm, Nurse Manager/Licensed Practical Nurse (NM/LPN) M reported care plans should be developed within 24-48 hours of admission and should include transfer status, bed mobility, dining needs, ADLs (activities of daily living) needs, and things like any assistive device needs. NM/LPN M reported that floor nurses are responsible for care plan development if a resident admits on a weekend.In an observation and interview on 8/13/2025 at 1:44 pm, Nurse Manager/Registered Nurse (NM/RN) N was observed creating a custom care plan for Resident #47 and reported she was responsible for creating care plan. NM/RN N reported she did not normally do wound care plans and had never created one before. NM/RN N reported she had been instructed by Director of Nursing (DON) B to separate out each of Resident #47's wounds and created a separate care plan for each of the 3 wounds that Resident #47 was documented to have now. NM/RN N reported care plans should be created 24-48 hours after admission, or ASAP (as soon as possible) and they included ADLs, transfer status, dining, showers, turn and reposition every 2 hours if needed. NM/RN N reviewed Resident #47's medical record and stated, What is documented in Resident #47's care plan is that there were no interventions in place until 8/5/25 after the wound on his coccyx was found, and then again on 8/11/25 when the wound on his left heel was found. NM/RN N continued to review Resident #47's record and stated, I just can't even, I know we did stuff, but nothing is documented here. NM/RN N reported Resident #47's pressure ulcers were not present on admission, and now the staff was using wedges for positioning since pillows did not work. Resident #47's boots (PRAFO boots) were just DC'd (discontinued), and Resident #47 just started to get out of bed in the last two days. NM/RN N reported that turning and repositioning were standards of care and reviewed Resident #47's medical record and reported there was no documentation by the CNAs when Resident #47 was being repositioned.Review of Care Management note for Resident #47 dated 7/30/2025 at 13:30 (1:30pm) revealed .Interdisciplinary Care Management Summary: The anticipated discharge date is 08//29/2025.The IDT (interdisciplinary team) agrees with plan of care.Review of Treatment Administration Record (TAR) for Resident #47 revealed .Condom cath.start date 8/6/2025.Weekly skin check every day shift every Wed (Wednesday) for skin integrity. start date 8/13/2025.Wound treatment - left heel, apply betadine to heel, cover with abd (abdominal) pad, secure and wrap with kerlix (rolled gauze) every day shift for wound management.start date 8/13/2025. wound treatment - left heel, apply betadine, cover with abd and kerlix every day shift for wound management. start date 8/7/2025.D/C date 8/12/2025. No documentation was noted indicating completion on 8/7/25, 8/8/2025 and 8/11/2025.Wound treatment: cleanse buttock with dakins and pat dry, apply santyl to wound bed, apply dakins soaked gauze dover santyl then cover with a bordered gauze once per day and as needed fi dressing becomes soiled every day shift for MASD. start date 8/13/2025. Wound Treatment: cleanse buttock with normal saline and pat dry, apply maxsorb to wound and cover with bordered gauze once per day and as needed if dressing comes soiled every day shift for MASD. start date 8/6/2025.D/C date 8/12/2025.with no documentation indicating completion on 8/11/2025 .Heel protector to Right heel for prevention every day and night shift. start date 8/13/2025.Heel protectors to prevent decubitus ulcers on the heels two times a day with a start date of 7/30/2025. D/C date 8/13/2025. no documentation was noted indicated completion on 8/9/2025 at 2000 (8pm). Reposition resident every 2-3 hours and PRN; use wedge cushion at resident's bedside to assist with reposition every 3 hours for MASD, pressure ulcer prevention with at start date of 8/5/2025.No noted documentation indicated completion was noted on 8/9/2025 at 2100 (9pm), 8/10/2025 at 0000 (midnight) and 0300 (3 am) and 8/13/2025 at 0300.In an interview on 8/13/2025 at 2:34 pm, Director of Nursing (DON) B reported Resident #47's had 3 wounds now and no wounds were not present on admission. DON B reviewed Resident #47's care plan and reported barrier cream was put in today, float heels was put in yesterday, draw sheet on 8/5/2025, turn and reposition on 8/5/2025, pressure relieving mattress put in on 8/12/2025. DON B stated Resident #47 had an air mattress on his bed since he admitted , but there was no care plan intervention in place. DON B stated if it wasn't documented it wasn't done. DON B reported that Resident #47 should have had pressure ulcer prevention interventions in place at admission, he was clearly at risk for pressure ulcers related to his Braden score, and her expectations were that interventions were put in place at admission when a resident was at risk for developing pressure ulcers.Review of facility policy Skin Management Guidelines with an effective date of 11/28/2017 revealed .Purpose: to ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measure and individualized interventions to prevent, reduce and treat skin breakdown.Prevention of Pressure Ulcers.All residents admitted to the facility will be evaluated for actual and potential skin integrity issues.the pressure injury notice will be completed and provided for the resident and/or resident representative providing notice of predicting factors and baseline care plan interventions to support prevention, treatment and healing.A. turning and repositioning observation (tissue tolerance) pressure is the primary cause of pressure ulcers. An effective turning and repositions schedule can help reduce the risk of developing a pressure ulcer.it is important to individualize each resident's turning and repositioning scheduled. Monitoring of skin integrity. The care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident.

Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: On 8/11/25 at 7:40 AM, an interview with Manager in Training (MIT) HHH found that the kitchen date marks items made in house for 7 Days and would datemark sliced meats for 10 days. On 8/11/25 at 7:46 AM, observation of the walk-in cooler found a large chunk ham open with some pieces sliced from it. The ham was dated 8/6 to 9/15. On 8/11/25 at 8:02 AM, observation of the four door Traulsen cooler found the following items: a container of hardboiled eggs with no date, a container with sliced chunk ham dated 8/5 to 9/5, and a container of hot dogs dated 8/8 to 8/20. On 8/11/25 at 3:24 PM, observation of the Spiritual Garden kitchen found the following items: Sliced ham with no date, hot dogs in a plastic bag sitting in a container dated 7/15 to 8/15, a vanilla Med Pass 2.0 dated 8/6 to 8/10 with the product stating, consume within 4 days, and an open bag of lettuce with no discard date. On 8/12/25 at 8:00 AM, observation of the walk-in cooler found two bags of cilantro, one open, with best by dates of 7/20/2025. The product had portions that were brown in color and looked slimy to the touch. On 8/12/25 at 8:05 AM, observation of the four door Traulson cooler found hot dogs dated 8/8 to 8/20 and a container of ham dated 8/6 to 8/16. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . On 8/11/25 at 8:11 AM, an interview with MIT HHH found that clean scoops are stored in a bin near the cook line. Observation of the mechanical scoop bin found two scoops with dried stuck on food debris on the inside of the scoop mechanism. Further observation found that an accumulation of crumb debris was evident in the bottom of the clean utensil bin. When asked about cleaning the clean utensil bins, MIT HHH stated that staff try to get to them twice a week. On 8/11/25 at 8:14 AM, observation of the clean pot and pans storage rack found two 1/8th pans and three 1/4 pans stacked and stored with water droplets and moisture accumulation between the pans. Further observation found a 1/4 pan with a golf ball size spot of oatmeal stuck on the inside of the pan. On 8/11/25 at 8:35 AM, observation of the main ice machine found some black accumulation on the inside plastic lip of the ice machine. Particularly near the top hinge portion of the door of the unit. On 8/11/25 at 9:18 AM, a tour of the four bistros found heavy accumulation of dried stuck on food debris on the insides of all four bistro microwaves. Food District Manager (FDM) JJJ stated she would get staff to clean them. On 8/12/25 at 8:14 AM, observation of the clean pots and pans storage rack found six 1/4 pans stacked and stored with water accumulation between each pan. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD. On 8/11/25 at 8:46 AM, A review of the facility document entitled Dish Machine Log, dated [DATE], located next to the dish machine, stated it required a Final Rinse: Minimum of 180F. Further observation of the log found temperatures were recorded for dishes done during Breakfast, Lunch, and Dinner each day. The log listed 30 final rinse temperatures from the 1st through the 10th of the month, with every final rinse temperature recorded below the required 180F. According to the 2022 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than:.(2) For all other machines, 82C (180F). On 8/12/25 at 7:55 AM, a revisit to the walk-in cooler found a large container of raw pork chops marinating on the storage shelf. Under the pork chops were a package of ready-to-eat hot dogs. On 8/12/25 at 8:11 AM, a revisit to the four door Traulson cooler found that shell eggs were stored on the second to the bottom shelf in the unit, and ready to eat peanut butter and jelly sandwiches were stored underneath the shell eggs. According to the 2022 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables,(b) Cooked READY-TO-EAT FOOD. On 8/11/25 at 8:40 AM, observation of the dry storage room found a brown aqueous substance lining the back left floor juncture of the room. When asked if she was knew what had happened, FDM JJJ stated it looked like something had spilled down the back wall and onto the floor. On 8/11/25 at 8:48 AM, Observation of the dish machine area found an accumulation of debris on the top of the dish machine as well as a dark brown splatter on the wall between the dish machine and the hand sink. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.

Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect for 8 of 8 residents who attended a confidential group meeting, resulting in feelings of frustration, decreased self-worth and embarrassment.Findings include: During an observation on 8/12/25 at 10:00am, an unknown Certified Nursing Assistant (CNA) on the heirloom unit, sat outside a resident's room and conducted a personal conversation using the speakerphone feature on her personal cellphone. The conversation could be heard from inside the occupied resident room.In a confidential group meeting on 8/12/25 at 1:00pm, 8 of 8 residents in attendance reported staff members used their personal cellphones, sometimes with earbuds, while providing care to them. One resident reported a staff member joined him in the bathroom, to assist with personal hygiene and completed the task while talking to someone via the use of earbuds. When queried, the resident reported he felt unimportant and embarrassed by the situation. A female resident reported she was left sitting naked on a shower chair while a CNA made a phone call on her cellphone outside the shower area. Another resident reported he was frustrated when he overheard a staff member arguing with her children on the cellphone while she waited for him in the bathroom.In an interview on 8/13/25 at 12:43pm, Nursing Home Administrator (NHA) A confirmed it was the expectation that staff would not use their personal cellphones during cares or in public areas while working.Review of a Dignity policy with a reference date of 12/21 revealed Each resident shall be cared for in a manner that promotes and enhances.dignity.Policy Interpretation.A. Residents shall be treated with dignity and respect at all times.H. Associates shall promote.resident privacy.during assistance with personal care.I. Demeaning practices .that compromise dignity are prohibited.

This citation pertains to intake #2586142Based on observation, interview, and record review the facility failed to: 1. provide an environment that was free from accident hazards for 2 residents (Resident #73 and Resident #40) of 5 residents reviewed for accidents. This deficient practice resulted in an elopement for Resident #73 and Resident #40 repeatedly walking unassisted thereby creating the potential for more than minimal harm. 2. To ensure wander alert equipment was working properly and effectively to ensure the safety of residents at risk for elopement. This deficient practice has the potential to impact 10 residents who currently require the use of personal wander alert devices and are at risk for elopement. Findings include: Resident #73 Review of an admission Record revealed Resident #73 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: parkinson’s disease (a disorder of the central nervous system that affects movement that may also cause hallucinations (sensory experiences that seem real but are created by the mind), metabolic encephalopathy (disorder that affects the brain’s function), weakness and anxiety (persistent state of worry). Review of a Minimum Data Set (MDS) assessment for Resident #73 with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #73 was cognitively intact. Section “E” of the MDS revealed Resident #73 wandered 1 to 3 days during the assessment. Section “GG” revealed Resident #73 required the use of a wheeled walker to safely ambulate. Review of a “Care Plan” for Resident #73 with a reference date of [DATE], revealed a focus/goal/interventions of: “Focus: (Resident #73) is an elopement risk/wanderer sundowner (phenomenon where those with cognitive impairments experience worsening of symptoms in the late afternoon or evening). Goal: The resident’s safety will be maintained…Interventions: exit and stairwell alarms…photo on wander list, staff aware of residents wander risk…wander ALERT personal safety device: Right ankle). Review of a “Wander/Elopement Risk Evaluation” with a reference date of [DATE] (Resident #73’s date of admission) revealed a score of “7”, low risk. Review of a “Wander/Elopement Risk Evaluation” with a reference date of [DATE] revealed a score of “14”, at risk. Review of “Physician’s Orders” for Resident #73 with a reference date of [DATE] revealed “Wander Device, Check Placement on right ankle every shift for elopement risk”. Review of a “Wander/Elopement Risk Evaluation” with a reference date of [DATE] revealed Resident #73 scored a “21”, high risk for elopement. In an interview on [DATE] at 2:51pm Certified Nursing Assistant (CNA) “C” reported Resident #73 frequently wandered around the building and could walk very fast. In an interview on [DATE] at 4:45pm, Director of Nursing (DON) “B” reported Resident #73 wandered frequently and got lost within the building. In an interview on [DATE] at 2:19pm, Licensed Practical Nurse (LPN) “Q” reported Resident #73 frequently wandered throughout the building, entered unauthorized areas such as the employee bathrooms and was exit seeking. In an interview on [DATE], at 2:26pm, Confidential Informant (CI) “DDD” reported they were caring for another resident in their room one afternoon, when they (CI “DDD”) looked outside and saw Resident #73 walking in the service driveway alone, without her walker. CI “DDD” reported this incident occurred “within the last few months”. CI “DDD” reported they ran outside and found Resident #73 alone, walking down the service drive of the facility, toward the front of the building, approximately 100’ from the emergency exit on her unit. CI “DDD” reported Resident #73 was not safe to leave the building alone because she got confused at times and lacked safety awareness. CI “DDD” reported LPN “MM” also responded to the situation and together they assisted Resident #73 back inside. CI “DDD” reported upon returning Resident #73 to the unit, she was approached by Nursing Home Administrator (NHA) “A” and DON “B” who instructed CI “DDD” not to document in the electronic medical record (EMR) regarding the incident. CI “DDD” reported following the incident, Resident #73’s room was moved because it was believed she exited the building through a door that was next to her room. In an interview on [DATE] at 11:07am, LPN “MM” reported Resident #73 eloped from the building and was found alone, walking briskly down the service drive, approximately 100’ from the nearest exit. LPN “M” reported she was unsure of the date of the incident, but an incident report had been written. When further queried about Resident #73’s elopement, LPN “MM” reported she was caring for a resident in room [ROOM NUMBER] when she heard a beeping alarm that sounded like a call light going off. LPN “MM” completed the cares and upon exiting room [ROOM NUMBER] noticed the beeping was much louder than a call light, at which time she recognized it as a door alarm. LPN “MM” reported she ran to the alarming door, went outside to the service driveway and saw CI “DDD” running toward Resident #73. LPN “MM” reported Resident #73 was approximately 100’ away from the door, walking briskly and that she had to run to catch up to the resident. Together, LPN “MM and CI “DDD” escorted Resident #73 back inside. LPN “MM” reported she told NHA “A” Resident #73 had eloped and that the door alarm had been sounding for a few minutes, but she didn’t recognize the sound of the alarm from behind a closed resident door. LPN “MM” reported she completed an incident report and assessed that Resident #73 was not injured. In an emailed response on [DATE] at 2:51pm, NHA “A” reported the facility had no incident reports related to Resident #73’s elopements. In an interview on [DATE] at 11:50am, Family Member (FM) “CCC” reported the facility called her twice since Resident #73’s admission to report the resident had eloped from the building. FM “CCC” reported the first elopement occurred shortly after the resident was admitted to the facility on [DATE] and again, “sometime in the last few months”. FM “CCC” reported she was the activated durable power of attorney (DPOA) for Resident #73 and did not want her to exit the building alone because she was not safe to do so. FM “CCC” stated “She (Resident #73) wanted to come to a facility rather go to her own home after a hospitalization in 1/25 because she recognized she needed to have someone care for her”. FM “CCC” reported during the most recent elopement, Resident #73 was hallucinating and thought she saw her deceased daughter outside so Resident #73 exited the building to try to catch her. FM “CC” reported after Resident #73’s first elopement, the facility had implemented the use of a personal safety wander alert anklet to maintain her safety. FM “CC” reported after the second elopement, the facility moved Resident #73 to a room that was not as close to an exit door. In an interview on [DATE] at 3:11pm, Resident #73 reported sometimes she “gets a little out of sorts” and becomes confused. Resident #73 recalled becoming confused in the last few months and confirmed that she exited the building alone after she believed she saw deceased relatives outside. Resident #73 lifted her pant leg and gestured toward her personal safety device on her left ankle, then stated “it’s to keep me safe”. During an observation on [DATE] at 12:17pm, a delayed egress door was located next to the room that Resident #73 occupied from [DATE]-[DATE]. The egress alarm activated when the release bar was pushed, the door unlocked and opened after 15 seconds. There was no wander alert detector on the door. Beyond the door, a short sidewalk led to an 8” curb between the service driveway and employee parking area. The sidewalk ended on a curve between the service driveway and the employee parking lot. The service driveway was also accessible by walking across an area landscaped with river rocks and thick grass. The service driveway was paved with 2” deep cracks that stretched across the width of the drive. A retaining pond, enclosed by a 4’ fence, was on the opposite side of the drive. During an observation and interview on [DATE] at 8:47am, DON “B” toured the “Spiritual Garden”, a separate free-standing building, with this writer. DON “B” confirmed Resident #73 resided in this building now and her safety was maintained in part by use of a personal safety wander device. During the tour an exit door was noted in the service corridor. The service corridor was accessible through 2 unlocked, unalarmed double doors, the exit door (which led outdoors) was approximately 30’ beyond the double doors. The exit door had a wander guard detector and a delayed egress release bar. During an observation and interview on [DATE] at 8:55am, DON “B” activated the wander alert alarm at the exit door in the service corridor. The double doors leading to the service corridor were closed. The alarm was heard faintly by the surveyor while standing in the common area, in front of the nurse’s station. When queried, LPN “I” reported she could not hear the alarm as she stood next to the survey in front of the nurse’s station. LPN “I” was asked which residents in this building were at risk for elopement and how she would know. LPN “I” she would look in each resident’s electronic medical record to determine if they were at risk for elopement. LPN “I” listed residents she believed were at risk but did not include Resident #73. In an interview on [DATE] at 10:16am, DON “B” reported nurses were expected to use an electronic reader device each shift to ensure resident wander devices were working properly. DON “B” reported she thought the electronic reader devices were kept in the medication carts, but she was not sure. DON “B” reported she found a device reader at the front desk, but it was not charged. In an interview on [DATE] at 11:19am, Unit Manager/Registered Nurse (UM/RN) “N” reported nurses should check each resident’s wander alert device every shift using the reader device. In an interview on [DATE] at 10:10am, LPN “I”, who was assigned to care for Resident #73 on this date, reported she checked the placement of the resident’s personal wander device daily but did not know how to check the functionality of the device. LPN “I” searched her medication cart and reported there was no reader device. LPN “I” reported she called DON “B” and was told the device was in the main building but was not currently useable because the batteries were not charged. In an interview on [DATE] at 10:23am RN “NN” reported she thought it was the expectation that nurses use the electronic reader device once a week to ensure resident wander devices were working properly. RN “NN” reported the facility only had 1 reader and it was kept at the front desk. In an interview on [DATE] at 10:25am, LPN “MM” reported she never checked resident wander devices to ensure they were working. LPN “MM” stated “someone else does that and they’ll let me know if it’s not working”. LPN “MM” checked each compartment of her medication cart and stated, “there’s no device in here for that”. In an observation and interview on [DATE] at 2:20pm LPN “Q” reported she was not responsible for checking resident wander devices to ensure they were working properly. LPN “Q” stated “someone from management checks them daily”. LPN “Q” reported she did not know where to find a wander device reader. In an interview on [DATE] at 10:17am, Central Supply Clerk (CSC) “Y” reported when she previously worked as the scheduler, it was her responsibility to check resident wander devices daily to ensure they were working properly. CSC “Y” reported there had been a lot of staff turnover for the scheduler position, and although she was covering scheduling at this time, the position was no longer had the responsibility of checking resident wander devices. In an interview on [DATE] at 3:41pm Maintenance Director (MD) “GG” report the facility placed wander detector devices on 2 of the 5 exit doors of the main building of the facility to reduce the likelihood of resident elopements. MD “GG” reported residents at risk for elopement wore a bracelet that triggered the wander detector when the resident was within 15’ of the door, which cause an alarm to sound. MD “GG” reported the wander detector devices at the doors were supposed to be checked weekly and the checks were documented in a “door log”. MD “GG” reported the remaining doors of the facility were all equipped with delayed egress locks that when activated, would only open after the release bar was pressed for 15 seconds. MD “GG” reported maintenance staff ensured the delayed egress locks were activated once a day, 5 days a week. MD “GG” reported there was no logbook for checking the delayed egress doors and there was no plan in place for checking the doors when maintenance staff was not in the building. MD “GG” reported nurses and other staff members had keys to activate and deactivate the delayed egress alarms. Review of a “Door Logbook” revealed 5 occurrences in which the wander alert alarms were not checked every 7 days during the date range of [DATE]-[DATE]. During an observation on [DATE] at 3:41pm a red light shone on the delayed release bar of the exit door near the kitchen of the main building. When queried, MD “GG” reported the delayed egress alarm was not activated but should have been. In an interview on [DATE] at 12:07pm, NHA “A” reported she thought she may have a “soft file” regarding an “incident of wandering” for Resident #73. NHA “A” then provided a manilla folder with a single document titled “Verification of Investigation”. Review of a “Verification of Investigation” report with a reference date of [DATE] revealed “(Resident #73) was noted with wandering behaviors and wandered through egress door to outside…staff immediately responded to alarm and went to resident…modified interventions to the plan of care… Resident’s room will be moved…further away from outside access…”. In an interview on [DATE] at 12:48pm, NHA “A” reported Resident #73 exited the building on [DATE]. NHA “A” reported the incident was not submitted to the state agency as required because she believed the incident was witnessed by staff. When further queried, NHA “A” reported she did not have any signed, documented staff interviews related to the incident and was not aware of any documentation of the event in the resident’s medical records. NHA “A” confirmed documentation of the event should be in the resident’s medical record so staff could be aware of potential hazards for the resident. NHA “A” reported she had no awareness of an elopement that occurred shortly after Resident #73’s admission because it had not been documented. Review of Resident #73’s progress notes for [DATE]-[DATE] revealed no documentation of elopement(s). Review of an “Accidents” facility policy with a reference date of [DATE] revealed “Purpose: To ensure the environment is free from accident hazards over which the facility has control and provide supervision…to each resident to prevent avoidable accidents through a systematic approach. “Avoidable Accident” means that an accident occurred because the facility failed to: …evaluate/analyze hazards and eliminate them…implement measures to reduce risks…implement interventions/including adequate supervision and assistive devices to…reduce risk of an accident…assistive device refers to any item…that is used by, or in care of a resident to promote…the resident’s safety….a systematic approach identifies equipment and devices that are defective…are disabled/removed…and enables leadership and direct care staff to work together to communicate the observation of hazards, record resident specific information,…monitor data related to care processes that potentially lead to accidents…” Review of a “Wandering and Elopement Guideline” with a reference date [DATE] revealed “This facility will provide the least restrictive and safe environment for wandering residents at risk for elopement. Process: Upon admission…and upon change of condition our residents will be evaluated for potential elopement risk…Residents identified at risk will have an elopement risk bracelet application placed…Bracelets will be checked for placement and function every shift…” Resident #40 Review of an admission Record revealed Resident #40 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: weakness, reduced mobility, other muscle spasms, and cutaneous abscess of right foot (a localized collection of pus within the skin and underlying tissues). Review of a Minimum Data Set (MDS) assessment for Resident #40, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #40 was cognitively intact (BIMS score 13-15 indicates no cognitive impairment); “Section GG- Functional Abilities- I. Walk 10 feet: Once standing the ability to walk at least 10 feet in a room, corridor, or similar space… Coded “04- defined as “Supervision or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity. Assistance may be provided throughout the activity or intermittently.” On [DATE] at 8:03 am, Resident #40 was observed walking in the hallway towards her room. Resident #40 was walking unassisted with a two wheeled walker approximately 3 feet behind “Certified Nursing Assistant” (CNA) “L” as they returned to Resident #40’s room from the spa room. CNA “L” was walking in front of Resident #40 and did not have her in any direct visualization. Resident #40 was not wearing a gait belt. (a safety device used to assist individuals with mobility issues, worn by patients, and allows caregivers to safely move or support the patient while walking or transferring.) On [DATE] at 9:15 am, Resident #40 was observed walking alone with a two wheeled walker in the hallway outside of her room. No noted staff present in the hallway. On [DATE] at 10:29 am, Resident #40 was observed walking alone with a two wheeled walker in the hallway outside of her room. No noted staff present in the hallway. In an interview on [DATE] at 8:26 am, “Registered Nurse” (RN) “PPP” reported Resident #40 was “able to get up and walk around alone”. On [DATE] at 9:45 am, Resident #40 was observed walking out of her room into the hallway with her two wheeled walker alone. Resident #40 was overheard speaking to two transport individuals requesting the use of a wheelchair since going to the doctor was “too long of a walk for her to make without falling.” RN “PPP” was observed entering Resident #40’s room, retrieving a wheelchair, and placing the wheelchair in the hallway for Resident #40 to sit in. Resident #40 was overheard stating “the last thing I want to do is fall and break something.” RN “PPP” looked at this surveyor and stated, “she can be up by herself.” Review of “Kardex” (a easily referenced key patient information system that originates from the patient’s nursing care plan) for Resident #40 with a review date of [DATE] revealed “…Mobility…Uses walker, uses wheelchair (foot pedals as needed), I use a wheelchair in hallways, walker in room with assist, (Name Omitted) Resident #40 can walk with stand by assist with two wheel walker and gait belt in room…” In an interview on [DATE] at 11:56 am, “Director of Rehab” (DOR) “FFF” reported that she was new to the director position and stated, “we are not great at getting evaluation information like transfer status to the floor and the nursing staff.” On [DATE] at 3:35 pm, Resident #40 was observed walking alone with a two wheeled walker in the hallway outside of her room. CNA “G and CNA “R” present in the hallway. No direct observation of Resident #40 by staff was noted. On [DATE] at 3:45 pm, Resident #40 was observed walking alone with a two wheeled walker in the hallway outside of her room. CNA “G” and CNA “R” were standing in the hallway observing Resident #40 from a distance while talking with this surveyor. In an interview on [DATE] at 3:45 pm, CNA “G” reported the management changes the resident’s care plan and doesn’t make sure we know it has been changed. CNA “G” reported the information for a resident’s transfer status was in the care plan and the Kardex but stated “who has time to check that every day?” In an interview on [DATE] at 3:45 pm, CNA “R” reported that Resident #40 walks in the hallway independently “all the time” and she does fine with it. In an interview on [DATE] at 3:45 pm, this surveyor walked next to Resident #40 in the hallway outside of her room and when queried, Resident #40 stated “I think I can be up walking in the hallway. The girls aren’t saying “(Name Omitted) get back to your room”. Resident #40 stated “I just look both ways and go for it. I’ll wait to hear if I’m not supposed to walk alone in the hallway.” In an interview on [DATE] at 8:59 am, DOR “FFF” reported Resident #40 was evaluated by therapy on [DATE] and her current status was “supervision” for assistance. DOR “FFF” reported that Resident #40 required the wearing of a gait belt and staff presence when walking in the hallway; DOR “FFF” reported staff did not have to touch her when she was walking, but they did need to observe/supervise her when she walked in the hallway. DOR “FFF” reported Resident #40 was not independent in walking in the hallway. Review of “Physical Therapy PT evaluation and Plan of Treatment” for Resident #40 dated [DATE] revealed “…new goal Resident will be able to function and ambulate (walk) independently on the hallway with her 2WW (two wheeled walker) safely > (greater than) 150 feet and back (target date [DATE]) …baseline… currently ambulating with 2WW at supervision…” In an interview on [DATE] at 1:16 pm, “Nurse Manager/Licensed Practical Nurse” (NM/LPN) “M” reported that therapy department did not have access to update care plan interventions, and any changes should be made by nursing staff and/or nurse managers. NM/LPN “M” reported she received an email if therapy made changes to a resident’s transfer status and the floor nurse received a communication form from the therapy department if changes were made. In an interview on [DATE] at1:30 pm, CNA “F” reported Resident #40 was independent now. When queried about how CNA “F” knew that Resident #40 was independent, CNA “F” stated “she shows me she is independent when she does things for herself.” In an interview on [DATE] at 1:35 pm, CNA “EE” reported Resident #40 staff needs to be in the room when Resident #40 was doing ADLs (activities of daily living), but she would walk the unit by herself. CNA “EE” reported Resident #40 has a “walking routine” that she completed with therapy during her sessions and she would practice it when she wasn’t working with therapy by walking around the unit by herself. In an interview on [DATE] at 2:27 pm, “Director of Nursing” (DON) “B” reported her expectations were that care plans were updated when needed and consistently done quarterly with the quarterly assessments. DON “B” reviewed Resident #40’s care plan and confirmed Resident #40 should have a gait belt on and staff standing by; Resident #40 should not be walking independently in the hallway.

This citation pertains to intake # 2586142Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in 5 of 18 residents (Resident #10, #99, #100, #73 & #47) reviewed for accuracy of medical records, resulting in inaccurate treatment records and the potential for providers to not have an accurate picture of resident status and condition.Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations 24106-24108). Elsevier Health Sciences. Kindle Edition. Resident #10: Review of an admission Record revealed Resident #10 was a female with pertinent diagnoses which included paralysis on her right dominant side, stroke, long term use of insulin, pain in right shoulder, tube feeding, NPO (nothing by mouth), and nerve pain. In an interview on [DATE] at 2:11 PM, Licensed Practical Nurse (LPN) D reported in the medication administration and treatment administration records (MAR TAR) if a resident refused, the nurse would document the refusal in there. For some refusals, it would bring up a note for the nurse to document or the nurse could create their own note for the progress notes. In an interview on [DATE] at 2:15 PM, LPN PP reported in the MAR/TAR, if a resident refused they would select refused and put in a progress note for the resident's refusal. Review of Treatment Administration Record (TAR) for [DATE], revealed, .Acetaminophen Tab 325 mg .Give 2 tablet via peg tube every 6 hours for pain . On [DATE]: missing notation of administration of medication and pain level assessed. Review of Treatment Administration Record (TAR) for [DATE], revealed, .one time a day for Pleasure .Resident to have ice cream once daily. Sitting up at a 90 degree angle, and can be fed by nurse, SLP (speech language pathologist) or trained activity staff only .Trained activity staff are: (First name), (First name), and (First name) .For pleasure feeding On [DATE]: missing notation of administration for administration of pleasure feeding for Resident #10. Review of Treatment Administration Record (TAR) for [DATE], revealed, .Enteral Feed Order at bedtime Change drain sponge around G tube q (every) HS (hour of sleep) . On [DATE]: missing notation of administration for Bedtime drain sponge change around G tube for Resident #10. Review of Treatment Administration Record (TAR) for [DATE], revealed, .Acetaminophen Tab 325 mg .Give 2 tablet via peg tube every 6 hours for pain . On [DATE]: missing notation of administration of medication and pain level assessed. Review of Treatment Administration Record (TAR) for [DATE], revealed, .Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector .Inject 30 unit subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITH OTHER DIABETIC KIDNEY COMPLICATION (E11.29) . On [DATE]: missing notation of administration of medication at bedtime and results of blood sugar check. In an interview on [DATE] at 2:19 PM, Unit Manager (UM) “N” reviewed Resident #10's MAR/TAR and reported if an entry was not there, it was assumed it was not done as the staff could not be sure the resident had received the medication or treatment. UM N reported the Director of Nursing (DON) created a report in the electronic medical record to audit if a medication or treatment was missing. UM N reported that the nurse who was assigned to the resident during the missing documentation would be contacted to determine if this was just an omission or the medication/treatment was not completed. UM N reviewed Resident #10's MAR/TAR for June, July and August. UM N reported if the sponge was not changed on the G-tube this could cause infection. UM N reported if scheduled pain medication was missed the resident's pain could get out of control and the facility could have trouble getting it back under control. UM N reported that if the blood sugar and insulin were not completed it could have significant consequences for the resident. In an interview on [DATE] at 2:43 PM, Director of Nursing (DON) “B” reported every morning the clinical staff reviewed the progress notes from the day prior. DON “B” reported when she was a floor nurse she would put in a progress note and noted on the MAR/TAR the resident had refused the medication or treatment as she was unsure of the policy. Resident #99 (R99) / Resident #100 (R100) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R99 admitted to the facility on [DATE] with pertinent diagnoses including spinal fracture and alcohol abuse. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R99 was cognitively intact (13 to 15 cognitively intact). R99 had a previous admission at the facility from [DATE] to [DATE]. During an observation on [DATE] at 8:18 AM, Certified Nursing Assistant (CNA) “KK” was sitting outside R99’s bedroom door. CNA “KK” stated that R99 was on a 1:1 observation at all times for several days but she didn’t know why. During an interview on [DATE] at 8:38 AM, R99 stated that he was on 1:1 observation since he went into a resident’s room (R100) the other day. During an interview on [DATE] at 8:31 AM CNA “RR” said that she thought R99 was on 1:1 observation since he was inappropriate with a female resident. During an interview on [DATE] at 8:37 AM, Licensed Practical Nurse (LPN) “T” stated that R99 was on 1:1 observation but she didn’t know why. Review of R99’s chart revealed a behavior note documented by Licensed Practical Nurse (LPN) “LLL” from a previous admission dated [DATE] “Location/Cause: Resident room, passing AM medication Behavior: Resident grabbing at nurses breast and groin, started fondling self. Description of behavior: sexually inappropriate. Behavior/Intensity: Non Pharmacological Interventions: spoke with resident stated I am your nurse and this is not appropriate to grab me.” During a telephone interview on [DATE] at 12:28 PM, LPN “LLL” stated that the incident occurred when she was taking R99’s vitals. LPN ‘LLL” said she told her supervisor about the incident and documented the behavior in a progress note. LPN “LLL” said that R99 was sexually inappropriate and was often seen touching his private area in his bed. During an interview on [DATE] at 12:49 PM, Nurse Manager (NM) “N” stated that R99 was on 1:1 since [DATE] since he was found in R100’s room. NM “N” said R100 was next to his room and she was moved immediately afterwards. During a telephone interview on [DATE] at 11:57AM, LPN “OO” stated that she was working the day of the incident with R99 and R100. LPN “OO” said that FM “VV” told her what happened and that R99 was not observed touching R100. Then, she notified Director of Nursing (DON) “B” and DON “B” contacted NHA “A”. LPN “OO” said she didn’t complete an incident report or complete any charting related to incident since NHA “A” came in and she thought she would take care of it. During an interview on [DATE] at 8:24 AM, RN “NN” stated that when she walked into R99’s room several times he appeared to be masturbating. She also said he likes to brush up against staff but she hadn’t observed any behaviors with residents. RN “NN” stated that management knew about R99’s sexual behaviors since Wound Care Nurse (WCN) “S” told some staff to keep an eye on R99 since he was on the Michigan Sex Offender Registry List. During an interview on [DATE] at 9:02 AM, WCN “S” reported that she knew R99 was on the Michigan Sex Offender Registry List since he came from another facility where she worked at. WCN “S” stated that some staff were aware of R99 being on the list and his behaviors since she told some CNAs and the nurse when she had to do a skin assessment on R99 upon his admission. Review of both R99’s and R100’s charts revealed that there was no documentation of the incident on [DATE]. Review of R99’s chart revealed no behaviors documented since admission. Review of Social Services Evaluation completed on [DATE] by Social Service Assistant (SSA) “HH” revealed “…. Screening for Abuse/Neglect…8. History of or presence of behaviors, such as provoking, aggressive manner, manipulative, derogatory, disrespectful, obnoxious, abhorrent, insensitive, attention seeking, and/or otherwise abrasive/inappropriate behavior: Yes…9. History of mistreating others (i.e. verbal/physical/sexual/ financial exploitation) and/or information presented by a reliable source that indicates there is a history of mistreating others: Yes” During an interview on [DATE] at 10:37 AM, Social Worker Director (SWD) “FF” and Social Worker Aide (SSA) “HH” stated that they were not aware of the incident between R99 and R100 on [DATE] since they weren’t part of the investigation, they only knew R99 had a 1:1 staff observation. Social Worker Director (SWD) “FF” and Social Worker Aide (SSA) “HH” also noted that the behavior log didn’t document any of the behaviors R99 was exhibiting with staff. SSA “HH” acknowledged this. During an interview on [DATE] at 10:44 AM, NHA “A” stated that she did not have an incident report for the (R99) and (R100) incident on [DATE] or an incident report from the previous admission from [DATE] with LPN “LLL”. NHA “A” acknowledged that there was no documentation in R99’s or R100’s chart regarding the incident on [DATE]. Resident #73 Review of an admission Record revealed Resident #73 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: parkinson’s disease (a disorder of the central nervous system that affects movement and may also cause hallucinations (sensory experiences that seem real but are created by the mind), metabolic encephalopathy (disorder that affects the brain’s function), weakness and anxiety (persistent state of worry). Review of a Minimum Data Set (MDS) assessment for Resident #73 with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #73 was cognitively intact. Section “E” of the MDS revealed Resident #73 wandered 1 to 3 days during the assessment period. Section “GG” revealed Resident #73 required the use of a wheeled walker to safely ambulate. Review of a “Care Plan” for Resident #73 with a reference date of [DATE], revealed a focus/goal/interventions of: “Focus: (Resident #73) is an elopement risk/wanderer sundowner (phenomenon where those with cognitive impairments experience worsening of symptoms in the late afternoon or evening). Goal: The resident’s safety will be maintained…Interventions: exit and stairwell alarms…photo on wander list, staff aware of residents wander risk…wander ALERT personal safety device: Right ankle). In an interview on [DATE], at 2:26pm, Confidential Informant (CI) “DDD” reported they were caring for another resident in their room one afternoon, when they (CI “DDD”) looked outside and saw Resident #73 walking in the service driveway alone, without her walker. CI “DDD” reported this incident occurred “within the last few months”. CI “DDD” reported they ran outside and found Resident #73 alone, walking down the service drive of the facility, toward the front of the building, approximately 100’ from the emergency exit on her unit. CI “DDD” reported Resident #73 was not safe to leave the building alone because she got confused at times and lacked safety awareness. CI “DDD” reported LPN “MM” also responded to the situation and together they assisted Resident #73 back inside. CI “DDD” reported upon returning Resident #73 to the unit, she was approached by Nursing Home Administrator (NHA) “A” and DON “B” who instructed CI “DDD” not to document in the electronic medical record (EMR) regarding the incident. CI “DDD” reported following the incident, Resident #73’s room was moved because it was believed she exited the building through a door that was next to her room. In an interview on [DATE] at 11:07am, LPN “MM” reported Resident #73 eloped from the building and was found alone, walking briskly down the service drive, approximately 100’ from the nearest exit. LPN “M” reported she was unsure of the date of the incident, but an incident report had been written in the resident’s electronic medical record. LPN “MM” reported she told NHA “A” Resident #73 had eloped. In an interview on [DATE] at 11:50am, Family Member (FM) “CCC” reported the facility called her on two separate occasions to report Resident #73 had eloped from the building. FM “CCC” reported the first elopement occurred shortly after the resident was admitted to the facility on [DATE] and again, “sometime in the last few months”. In an interview on [DATE] at 3:11pm, Resident #73 reported sometimes she “gets a little out of sorts” and becomes confused. Resident #73 recalled becoming confused in the last few months and confirmed that she exited the building alone after she believed she saw deceased relatives outside. Resident #73 lifted her pant leg and gestured toward her personal safety device on her left ankle, then stated “it’s to keep me safe”. Review of Resident #73’s progress notes for [DATE]-[DATE] revealed no documentation of elopement(s). In an emailed response on [DATE] at 2:51pm, NHA “A” reported the facility had no incident reports related to Resident #73’s elopements. In an interview on [DATE] at 12:07pm, NHA “A” reported she thought she may have a “soft file” regarding an “incident of wandering” for Resident #73. NHA “A” then provided a manilla folder with a single document titled “Verification of Investigation”. Review of a “Verification of Investigation” report with a reference date of [DATE] revealed “(Resident #73) was noted with wandering behaviors and wandered through egress door to outside…staff immediately responded to alarm and went to resident…modified interventions to the plan of care… Resident’s room will be moved…further away from outside access…”. In an interview on [DATE] at 12:48pm, NHA “A” reported Resident #73 exited the building on [DATE]. NHA “A” reported the incident was not submitted to the state agency as required because she believed the incident was witnessed by staff. When further queried, NHA “A” reported she did not have any signed, documented staff interviews related to the incident and was not aware of any documentation of the event in the resident’s medical records. NHA “A” reported she had no awareness of an elopement that occurred shortly after Resident #73’s admission because it also was not documented in the medical record. NHA “A” confirmed that each resident’s medical record should contain all the information necessary for staff to maintain the resident’s safety, including past elopements. Resident #47 Review of an admission Record revealed Resident #47 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: CVA (cerebral vascular accident/ stroke), hemiplegia of the left side (inability to move the left side of the body), peg-tube (percutaneous endoscopic gastrostomy tube- a tube inserted into the stomach to provide artificial nutrition) and aphasia (a disorder that affect show a person communicates). Review of “Treatment Administration Record” (TAR) for Resident #47 for the month of [DATE] revealed: “…Wound Treatment- Left heel: apply betadine, cover with abd (abdominal) pad and kerlix (a long continuous wrap of gauze) every day shift for wound management with a start date of [DATE] and a D/C (discontinuation) date of [DATE]… there was no noted, documentation for completion on [DATE], [DATE] nor [DATE]… Wound treatment: cleanse buttocks with normal saline and pat dry, apply maxsorb (an alginate material that absorbs drainage and turns into a gel that creates a moist wound environment for healing) to wound and cover with boarder gauze once per day and as needed if dressing becomes soiled every day shift for MASD (moisture associated skin damage) with a start date of [DATE] and a D/C date of [DATE], there was no noted documentation for completion on [DATE], the date was blank . Ammonium Lactate External Lotion 5% .Apply to arms and legs topically every morning and at bedtime for dry skin with a start dates of [DATE]… there was no noted documentation for completion on [DATE] at bedtime… Heel protectors to prevent decubitus ulcers on the heels two times a day with a start date of [DATE] and a D/C date of [DATE] with no noted documentation of completion on [DATE] at 2000 (8 pm)… Reposition resident every 2-3 hours and PRN (as needed); use wedge cushion at resident’s bedside to assist with repositioning every 3 hours for MASD, pressure ulcer prevention with a start date of [DATE] with no noted documentation of completion on [DATE] 21:00 (9:00 pm), [DATE] at 0000 (12:00 am) and 0300 (3:00 am)…” During an observation on [DATE] at 11:49 am, “Licensed Practical Nurse” (LPN) “T” was observed performing oral suctioning on Resident #47. Review of the “TAR” for Resident #47 revealed “…May suction as needed as needed for secretions with a start date of [DATE] and the only noted documented date of suctioning was [DATE]…” During an interview on [DATE] “Nurse Manager/Registered Nurse” (NM/RN) “N” reported that dressing changes and treatments should be documented in the record. NM/RN “N” reported that documentation was required when performing oral suctioning for Resident #47. NM/RN “N” stated “If it wasn’t documented, it wasn’t done”.

Based on interview and record review the facility failed to ensure the explanation of their binding arbitration agreement was explained in a clear and concise manner to residents to ensure understanding at admission for 3 (Resident #71, Resident #37, and Resident #27) and 8 more residents during a confidential group meeting, resulting in residents expressing confusion and concerns regarding entering into and agreeing to a binding arbitration agreement.Findings include:In an interview on 8/11/2025 at 9:15 am, Nursing Home Administrator (NHA) A reported the facility did not maintain a list of residents who signed a binding arbitration agreement. NHA A informed this surveyor arbitration agreements were in the resident's records and cold be viewed there. This surveyor requested a list of current residents who had signed a binding arbitration agreement.Review of a word document provided by NHA A including a list of residents who signed a binding arbitration agreement, included Resident #27, Resident #37, and Resident #71. Resident #71Review of an admission Record revealed Resident #71 was a female who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: schizophrenia.Review of Resident #71's admission agreement revealed Resident #71 signed accepting agreement to arbitrate health care negligence claims on 3/19/2025.In an interview on 8/12/2025 at 10:20 am, Resident #71 reported she had no recollection of signing a binding arbitration agreement and had no idea what it was. After explaining to Resident #71 the basics of a binding arbitration agreement Resident #71 reported she would not agree to it. Resident #71 stated I would never sign anything like that. Resident #37Review of an admission Record revealed Resident #37 was a male who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: sepsis (infection of the blood).Review of Resident #37's admission agreement revealed Resident #37 signed declining agreement to arbitrate health care negligence claims on 7/11/2025.In an interview on 8/12/2025 at 10:32 am, Resident #37 stated . I was pretty drugged when I got here, I signed whatever they put in front of me. Resident #37 reported he had no idea what a binding arbitration agreement was, had no recollection of it being explained to him, and he would need to consult with a lawyer to determine if he should sign an arbitration agreement or not. Resident #27Review of an admission Record revealed Resident #27 was a female who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: hemiplegia and hemiparesis following cerebral infarction affecting the right dominate side (inability to move the right side of the body, following a stroke).Review of Resident #27's admission agreement revealed Resident #27 signed accepting agreement to arbitrate health care negligence claims on 11/12/2024.In an interview on 8/12/25 at 11:39 am, Resident #27 reported she had no idea what a binding arbitration agreement was, she did not sign it, and if she did sign it, she had no idea what she was signing at the time.In an interview on 8/12/2025 at 11:21 am, Director of Admissions (DOA) X reported she did not know if the arbitration agreement could be rescinded. DOA X reported if a resident wanted to rescind an arbitration agreement, she would have to complete the admission agreement in its entirety again. When queried, how she explained to admitting residents what a binding arbitration agreement was, DOA X stated I explain it to the residents as do you want a mediator if you sue us or not.In an interview on 8/12/2025 at 11:49 am, DOA X reported she was responsible for completing the arbitration agreement with residents at admission. DOA X reported some residents read it and others do not. The ones that don't read it ask me to explain it. DOA X reported she explains it as Yes for a mediator, no for no mediator. DOA X reported she also signed binding arbitration agreements for resident to agree to enter into a binding arbitration agreement. DOA X reported when she signed the agreement it indicated she had explained the arbitration agreement to the resident.During a confidential resident meeting with 8 residents in attendance, it was communicated to the surveyors that none of the residents in attendance knew what a binding arbitration agreement was, how it worked, nor if they had agreed to it. Review of a word document provided by NHA A including a list of residents who signed a binding arbitration agreement, included 5 or 8 residents had signed binding arbitration agreements at admission. In an interview on 8/13/2025 at 2:17 pm, NHA A reported binding arbitration agreements were completed at admission, and if the resident entered into an agreement, they have the right to change their mind and there was no time limit for the change. When queried, NHA A stated do they (the resident) want a mediator, or do they want a lawyer, that's how I understand it, but I'm not the person who does the agreements or the education.

This citation pertains to intake MI00153113.Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls for 1 (Resident #105) of 3 residents reviewed for falls, resulting in a fall with major injury requiring hospitalization and surgical intervention for Resident #105 and potential for additional falls with injury. Findings include: Resident #105 Review of an admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified abnormalities of gait and mobility and muscle weakness.Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 2/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #105 was cognitively intact. Review of Resident #105's Fall Risk Evaluation dated 9/9/24 revealed that Resident #105 had recent falls, generalized weakness and mobility, was taking an anti-epileptic (medication used to treat epilepsy or other seizure disorders) medication and was taking 9 or more medications which scored Resident #105 at a 13 (any score over 5 indicates high fall risk). Review of Resident #105's Care Plan revealed, (Resident #105) needs assistance with ADL (activities of daily living) self-care performance r/t (related to) fatigue, limited mobility . Intervention: Do not leave (Resident #105) unattended in the bathroom. Date initiated: 9/11/24 .Review of Resident #105 Incident Report dated 5/9/25 revealed, Nursing Description: CNA (Certified Nursing Assistant) came to this nurse to notify that resident had a fall. This nurse entered room and noted resident sitting upright, leaned to the right. CNA stated she had witnessed the fall . Resident had a small, slightly raised reddened area to top/back of the head. Resident c/o (complained of) lower back pain. Rated pain 8/10. Resident Description: . Resident stated I was brushing my teeth. I fell. My back and head hurts. I fell back. Immediate Action Taken: Received prn Norco (pain medication) at 2300 (11:00 PM), Bio freeze gel applied to lower back .At 7:15 (Family Member) notified. Wanted resident sent to the hospital. (Facility provider) gave the okay to send resident out for further evaluation Resident picked up and transported via (local EMS provider) at 08:15 AM .Review of Resident #105's Hospital Records dated 5/9/25 revealed, . Chief complaint: (Resident #105) presenting via EMS from facility for a fall that occurred yesterday . Given this morning he was still endorsing severe low back pain they are seeking medical attention currently. Patient is currently admitting to mild to moderate neck pain, headache, and severe low back pain. Low back pain exacerbated by any movement .ED Course: MRI (Magnetic Reasoning Imaging) lumbar spine with acute compression fracture at L3 and L4 (areas of the spine). CT (Computed tomography) lumbar spine with acute L3 and L4 compression fracture .Found to have an acute L3 and L4 superior endplate compression fracture. IR (interventional radiology) consulted, amenable to intervention. Noted to have fevers as well as hypoxic failure, undergoing infectious workup and found to have pneumonia. Completed antibiotics and improved. He also needed 5 days off Plavix (antiplatelet medication) in order to have IR address his vertebral fracture but he finally underwent intervention for that on 5/19/25 Procedure: L3/L4 verterbroplasty (Vertebroplasty is a procedure to treat compression fractures in the spine) .In an interview on 6/3/25 at 11:13 AM, Resident #105 reported that he was in his bathroom standing at the sink when he suddenly lost his balance and fell back. Resident #105 reported that Certified Nursing Assistant (CNA) Y was in his room with him, but she had left him in the bathroom by himself. Resident #105 confirmed that he was in a lot of pain after the fall so he he went to the hospital where is was discovered that he had fractures in spine and required surgery .In an interview on 6/3/25 at 11:48 AM, Licensed Practical Nurse (LPN) P reported that she was the nurse caring for Resident #105 the night that she fell. LPN P reported that CNA Y had told her to come assess Resident #105 because she had just witnessed him fall in his bathroom. LPN P reported that she was told by CNA Y that Resident #105 had slipped in his bathroom, and that she was not in the bathroom with Resident #105 when he fell. LPN P reported that Resident #105 was reporting pain in his back and head, so she gave him pain medication. LPN P confirmed that Resident #105 was in so much pain the following morning that the facility sent him to the hospital. LPN P confirmed that Resident #105 was not supposed to be left in the bathroom alone, because he was at high risk for falls. This writer attempted to contact CNA Y on 6/3/25 at 3:11 PM, 6/4/25 at 8:12 AM, and 6/9/25 at 9:38 AM. This writer was unable to speak to CNA Y prior to survey exit. In an interview on 6/5/25 2:26 PM, Nursing Home Administrator (NHA) A and Director of Nursing (DON) B reported that they had learned about Resident #105's fall on 5/9/25 and began an investigation into the fall. NHA A and DON B reported that they were able to identify that CNA Y had not followed Resident #105's care plan. NHA A and DON B confirmed that Resident #105 was diagnosed with a compression fracture which required hospitalization and surgical intervention. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education with all staff on following resident care plans, reviewing all resident care plans for accuracy, and continued audits to ensure resident care plans were being followed by staff. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to assess, manage, and prevent complication from the use of Foley catheter in 1 of 4 sampled residents (Resident #7), reviewed for Foley's, from a total sample of 19 residents, resulting in pain, delay in treatment and urinary tract infections. Findings include: Review of the Catheter Insertion Policy dated 11/11/13, reflected .The Center for Disease Control and Prevention and the Agency for Health Care Research and Quality has identified four situations for the use of long-term use of indwelling catheters as appropriate: [MEDICAL CONDITION] that cannot be otherwise managed, management of the terminally ill or severely ill resident, management of residents with Stage 3 or 4 pressure ulcers on trunk until ulcers are healed, and management of urinary incontinence in residents who are incapable of self-toileting and facility staff are unable to manage the incontinence effectively any other way .Equipment .2. Leg strap . Procedure: 21. Secure catheter to thigh with catheter strap/leg band. Review of the Profile Face Sheet revealed Resident #7 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 12/8/16, revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated that the resident was moderately cognitively intact. Review of the Hospital Records dated 7/11/16 at 12:43 a.m., reflected Resident #7's chief complaint was hypertension (high blood pressure), abnormal vaginal bleeding, Follow -up instructions: Urology (name and address given) within 5 to 7 days. Review of the Interdisciplinary Notes dated 7/11/16 at 3:27 p.m., reflected Resident #7 will be coming back to facility. To follow up with urologist and primary doctor. Order script [MEDICATION NAME] mg twice a day x 7 days - urinary tract infection. Has a three-way urinary catheter inserted and color of urine is pinkish; to stay in place till seen by primary physician. Review of the Lab Microbiology Report dated 9/3/16, reflected that Resident #7 had a Urinary Tract Infection that required treating with an antibiotic. Review of the Hospital Progress Note dated 9/18/16, reflected that Resident #7 was diagnosed with [REDACTED].With that she recently had a UTI culture on 31 August indicated [DIAGNOSES REDACTED] (a bacteria in urine) and Pseudomonas (bacteria in urine), I believe was treated Impression and Plan 1. Recurrent UTI Review of the Urinary Incontinent/Indwelling Catheter Care Plan dated 9/20/16, reflected Resident #7 has a Foley catheter place 7/11/2016 for hemorrhagic [MEDICATION NAME] (lower urinary tract symptoms that include hematuria and irritative voiding symptom), Avoid pulling on catheter tubing with transfers and repositioning (9/20/16), Follow up with urologist if needed (9/20/16), Use catheter strap (9/20/16). Review of the Physician Monthly Order dated 2/1/17 through 2/28/17, reflected the [DIAGNOSES REDACTED].#7's foley catheter since July 2016. In an interview on 2/8/17 at 2:30 p.m., Director of Nursing (DON) B reported that when there was a new order the nurse who received the order, puts the order in the system, but in July 2016 there were different staff and a problem was found in orders getting transcribed in the cottages that were not in the main building. DON B reported that she was not sure what the policy was for using a leg strap to secure the catheter, but confirmed the leg strap was necessary for comfort when a resident had a Foley catheter inserted. DON B reported that she could find no record of bladder training or post void residual checks. DON B reported that there was now an order to send Resident #7 to see a Urologist (which was ordered as of 9/2016). In an interview and observation on 2/6/17 at 3:30 p.m., Resident #7 was laying in bed, Foley catheter (tubing inserted into the bladder to drain urine) draining to gravity. Resident #7 stated the Foley had been in her for the last 5 months and she wanted it to go away, Resident #7 reported that it hurt when she went to the bathroom. In an observation and interview dated 2/8/17 at 8:35 a.m., CNA WW assisted Resident #7 to reposition in bed, CNA WW reported that Resident #7 could let her know when she needed a brief change, that Resident #7 had been checked at shift change, and should be fine until at least lunch, but that she would take the brief down for a skin check to be observed. CNA WW set up for the brief change, left the room to get wash cloths, re-gloved, took the brief down, and noted Resident #7 had a bowel movement. Resident #7 appeared to be pushing more stool and wanted to try and finish, CNA WW ask if Resident #7 wanted to get up to the toilet, she declined, so CNA WW gave her the call light. At 9:02 a.m. CNA WW left the building and did not return until 9:17 a.m. At 9:30 a.m. CNA WW reported that Resident #7 should be ready. Resident #7 stated is my light working she reported that she had pushed it more than 5 minutes ago. CNA WW entered the room and CNA XX came in also, she stated she worked as the scheduler but was going to help with the care. Resident #7 stated, It hurts when I start to go to the bathroom. Peritoneal care was completed . Resident #7 Foley tubing was under her legs and Resident #7 bent her knees and pushed herself up in bed several times missing stepping on her Foley tubing by less than an inch. Resident #7 reported that she was able to reposition herself. Resident #7's catheter tubing was not secured by a leg anchor or catheter strap.

This citation pertains to intake number MI 098. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent the elopement and ensure the safety of 1 of 6 sampled residents (Resident #500) reviewed for a safe environment, from a total sample of 6 residents, resulting in an Immediate Jeopardy when, on 9/9/16 Resident #500, who was identified as at risk for elopement, had a history of [REDACTED].#1 did not reset the door alarm correctly. This deficient practice placed 14 other residents identified to be at risk for elopement at high risk for serious injury, harm, and/or death. Findings include: Per the Face Sheet Resident #500 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] revealed Resident #500 had a Brief Interview for Mental Status (BIMS) dated 9/2/2016 score of 5 out of 15, indicating Resident #500 had a cognitive impairment. Review of the MDS also revealed Resident #500 displayed a behavior of wandering, and his wandering placed him at a significant risk of getting to a potentially dangerous place. The MDS revealed Resident #500's behavior (rejection of care and/or wandering) had become worse from his previous assessment. Review of the Elopement Risk Screening and Evaluation dated 9/2/2016 revealed Resident #500 scored a 30 (score greater than 10 revealed an elopement risk) on his assessment for being an elopement risk. The assessment revealed Resident #500 could propel himself in his wheelchair, had 1 or more elopement attempts, and had attempts within the last 30 days. Review of a care plan titled, Cognitive Loss/Dementia revealed as of 8/30/2016 Resident #500 had a wanderguard bracelet (bracelet that alarms when resident approaches an alarmed door) on his person. The care plan did not reveal an intervention to increase supervision for Resident #500 until 9/9/2016 the day he eloped from the facility. Review of the facility's investigation dated 9/13/2016 revealed that on 9/9/2016 Resident #500 was found to be sitting approximately 3 feet outside the main entrance doors by RN (Registered Nurse) #2. The report revealed Resident #500 was approximately 80-90 feet from the Heirloom door that he exited from. The report revealed that the Heirloom fire door was found to be slightly ajar and the alarm was deactivated. The report revealed Resident #500 had exit seeking behaviors, and had attempts at opening the fire exit doors. The investigation revealed that on 9/8/2016 at 6:18 PM Resident #500 had triggered the Heirloom fire door alarm. LPN #1 re-directed Resident #500 and re-set the fire door alarm. LPN #1 believed the door alarm was activated when she re-set the alarm because a red light was on. The investigation revealed that LPN #1 required education on re-setting the door alarms, because the red light indicated the alarm was deactivated, and the green light on indicated the alarm was active. The Heirloom fire exit door alarm was not activated from the hours of 6:18 PM on 9/8/16 through 4:45 AM on 9/9/2016. The report revealed that Resident #500 was suspected to have been outside for approximately 5 minutes. In an interview on 9/28/2016 at 8:35 AM, LPN #1 said she thought the red light meant the alarm was active on the fire exit door. LPN #1 said she thought she had received education on the exit door alarms approximately 3 years or more ago, but had not received any additional education since then. LPN #1 said she thought maybe if she pushed on the door handle, after re-setting the alarm it would have sounded, and given her an indication the alarm was on. LPN #1 said she did not push on the handle to assure the alarm was on. Observation on the Heirloom fire exit door and the route Resident #500 took was conducted on 9/27/2016 at 9:00 AM. It was observed that Resident #500 walked either on the sidewalk or in the driveway. Multiple cars were observed to be parked in the parking lot, along with driving around the circled driveway. Observation on 9/29/2016 at 10:30 AM, revealed another sampled Resident #503 (identified to be an elopement risk) resided on the Heirloom hall, the same hall Resident #500 resided on. It was observed Resident #503's room was 3 doors away from the Heirloom fire exit door that Resident #500 exited out of on 9/9/2016. In an interview on 9/27/2016 at 9:00 AM Director of Nursing (DON) #4 stated the nurse (LPN #1) thought she had set the alarm on the Heirloom fire exit door. DON #4 said LPN #1 though the red light being on meant that the door was alarmed, but actually the green light meant that the door was alarmed. DON #4 said staff at the facility did not know Resident #500 had eloped out of the building and was outside. DON #4 said RN #2 (The Nursing Supervisor) had walked by the front door of the facility and noticed Resident #500 sitting outside, in his wheelchair, by the facility front door. DON #4 said Resident #500 would wander the halls, and try to open the fire exit doors. DON #4 said Resident #500 would push on the fire exit door handles and set off the door alarms. DON #4 said Resident #500 had been wandering the halls, and trying to open door on 9/8/2016, the day he eloped out of the facility. DON #4 said an increase in supervision for Resident #500 was not done before he eloped, and while he was wandering the halls and trying to open the fire exit doors. DON #4 said the 3 Certified Nurse Aids (CNAs) would tag team Resident #500, but stated that no staff member was assigned to Resident #500 in regards to increased supervision before Resident #500 eloped from the building. In an interview on 9/27/2016 at 2:34 PM, RN #2 said she was the supervisor on the evening on 9/8 through 9/9/2016. RN #2 said Resident #500 had been going in different directions, and a CNA brought Resident #500 to the nurses' station. RN #2 said at some point Resident #500 left the nurses' station. RN #2 said she had left the Heirloom hall and walked past the front door of the facility when she observed Resident #500 sitting outside in his wheelchair at the front door. RN #2 stated that Resident #500 was confused and not able to state where he was going. In an interview on 9/27/2016 at 3:10 PM, CNA #5 stated that she did not hear any alarms sounds during the time between 4:00 and 4:45 AM. CNA #5 said she did not know when the last time was that she saw Resident #500, and stated that she had no idea Resident #500 had gotten out a door. In an interview on 9/27/2016 at 3:35 PM, CNA #6 said Resident #500 had pushed on the fire alarm door that was in the Flower hall and the alarm went off. CNA #6 said Resident #500 was re-directed back to the Heirloom hall. CNA #6 stated that to her knowledge Resident #500 was not on 15 minute checks, nor any type of increased supervision before his elopement, and stated that the CNAs were just told to, keep an extra eye on him (Resident #500). Additionally CNA #6 stated that she did not know what the red or green light on the fire exit door meant, and said she normally would just push on the door handle to make certain the alarm was activated. In an interview on 9/29/2016 at 10:10 AM, DON #4 stated that there was no documented education for the nursing staff on how to properly alarm the fire exit doors, and which light, green or red, should be on when the door was alarmed. On 9/28/2016 at 4:45 PM, Administrator was notified of the Immediate Jeopardy that was identified on 9/27/2016, and began on 9/9/2016, when LPN #1 failed to assure the Heirloom fire exit door was properly alarmed and Resident #500 eloped out of the Heirloom fire exit door sometime between the hour of 4:30 AM and 4:45 AM, unbeknownst to facility staff. On 9/29/2016 the surveyor verified that the facility implemented the following in request for Past Non-compliance and removal of the Immediate Jeopardy: 1). On 9/9/2016 at approximately 4:50 PM the door system was checked on 100% of the facility doors which exited to the outside. The Heirloom Garden fire exit door was found ajar and deactivated; the door was closed and reactivated. All other doors were functioning properly. 2). On 9/9/2016 at 5:00 AM, the Director of Nursing was notified of the occurrence (Resident #500's elopement). 3). On 9/9/2016 at 5:00 AM, the Director of Nursing began interviewing facility employees, and began an investigation. 4). On 9/9/2016 as of 7:30 PM, 100% of nurses were re-educated with return demonstration that the door light will turn green when it is activated and alarmed. One Hundred percent of nursing staff received education of the fire exit door and what he green light versus the red light meant. 5). On 9/9/2016 at 11 AM, all of the fire exit doors were labeled appropriately to verify what color the light on the door should be to ensure it is alarmed and activated. 6). On 9/9/2016 signs were ordered that will replace the labels once arrived. 7). On 9/9/2016 an audit was conducted of the 98 residents in house, which resulted in no new findings for elopement risk. Fourteen Residents continued with wanderguard (a bracelet that is worn around the ankle and alarms when the person gets to close to a wanderguard alarmed exit door) placement. 8). Beginning 9/9/2016 the night shift supervisor is performing an audit of the fire exit doors twice daily for functionality for the next 12 weeks. 9) Beginning on 9/9/2016 Environmental Services will perform daily alarm testing on all of the doors Monday thru Friday. 10). Beginning 9/9/2016, new nurse employees will be oriented on fire exit door activation with return demonstration in orientation. 11). Beginning 9/9/2016, all nurses will have yearly competency to include fire exit door activation with return demonstration in orientation. 12). Beginning 9/9/2016, the Director of Nursing will conduct an audit of nurse orientations for 2 months to ensure that all nurses are being educated on the fire exit door procedure. 13). Beginning 9/9/2016, all fire exit doors will continue to be locked 24 hours a day. The Immediate Jeopardy was removed on 9/9/2016 and Past Non-compliance was requested and accepted. ( )

This citation pertains to intake number MI 314. Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent a fall in 1 of 3 residents reviewed with falls (Resident #53), in a total sample of 4 residents and 1 supplemental resident, resulting in a fracture and a decline in function. Findings include: On 8/11/16 at 12:40 PM, Resident #53 was observed sitting the the Oaks dining room in a wheelchair with a sling on her right arm. Resident #53's Profile Face Sheet record printed on 8/12/16 revealed she was [AGE] years old with the [DIAGNOSES REDACTED]. Resident #53's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview For Mental Status (BIMS, Cognition Assessment) score of 7, indicating a severe impairment in cognition ability. The same MDS assessment indicated during a 7 day look back period, Resident #53 required supervision (oversight, encouragement or cueing) and one person physical assistance for walking in the corridor on the unit. The Interdisciplinary Notes dated 7/20/16 revealed Resident #53 ambulated with the use of a walker, had a slow gait (manner of walking) and walked with a limp due to a history of Polio. The same note indicated Resident #53 was incontinent of B & B (bowel and bladder) and needs to be checked on frequently as she will toilet herself but will not clean herself appropriately and will also deny that she is the one that caused the mess/BM (bowel movement) on her own skin. The Accident/Incident Report dated 7/23/16 at 1:15 PM revealed a nurse heard Resident #53 yelling from her room and was found on the floor in her bathroom between the sink and the toilet. The same report indicated Resident #53 had left her walker outside the bathroom door entrance. Per the same report, Resident #53 complained of shoulder pain but was not able to articulate a pain rating via a pain rating scale and simply pointed to the nurse the location of her pain. The Accident/Incident Report dated 7/23/16 at 1:15 PM revealed Resident #53 sustained a fractured right clavicle (collarbone). Director of Nursing (DON) B was interviewed on 8/11/16 at 4:25 PM and stated that it was not communicated to her that Resident #53 needed to be checked on more frequently, as noted in the Interdisciplinary Notes dated 7/20/16. According to the Centers for Medicare & Medicaid Services, Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, September, 2010; A previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls. Indisciplinary Notes dated 7/26/16 indicated Resident #53 required stand by assist for transfers and toileting, was impulsive and non-compliant in asking for assistance. The Accident/Incident Report dated 8/9/16 at 7:45 AM, revealed Resident #53 was observed lying on her stomach on the floor of the Enchanted Bistro dining room. The same report indicated no staff witnessed Resident #53's fall. The same incident report indicated Resident #53 left her walker at the entrance to the dining room and continued to ambulate to her dining room chair without her assistive device. The same Accident/Incident Report revealed Resident #53 was sent to the emergency room and a x-ray confirmed a right humerus (long bone in the upper arm) fracture. The same report indicated Resident #53 was to wear a sling on her right arm. According to Resident #53's Care Plan changes titled P2 Care Plan/PN ADL (activities of daily living) Daily Care List Change History for 8/9/16 thru 8/9/16, received from facility on 8/12/16 via electronic mail; Resident #53's care plan prior to 8/9/16 read I use a walker for ambulation, I need reminders to use the walker and I require redirection and reminders at times. On 8/12/16 at approximately 8:20 AM, Registered Nurse (RN) F stated she was the first person on the scene following Resident #53's fall on 8/9/16. During the same interview, RN F indicated breakfast was running late that day and they are at the .mercy of the kitchen. RN F stated in the same interview that there were not any staff in the dining room, that staff were brining residents to the Bistro dining room for breakfast at the time of Resident #53's fall. RN F indicated during the same interview that Resident #53 had left her walker at the entrance to the dining room, next to the radio and across from where a medication cart was parked in the doorway. Administrator A was interviewed on 8/11/16 at 3:45 PM, and stated the Dietary aide was running back and forth the morning of 8/9/16 and did not witness the fall. Administrator A stated during the same interview that she would not expect the Dietary Aide to remind a resident to use their walker. On 8/12/16 at approximately 7:35 AM, a sign was observed posted in the Bistro Dining Room indicating breakfast was at 7:30 AM. Resident #53's Plan of treatment for [REDACTED].#53 had decreased mobility skills and decreased ability to ambulate in that she required increased assistance from staff. On 8/12/16 at 7:35 AM, Resident #53 was observed in the Bistro dining room seated in a wheelchair with a sling on her right arm. Certified Nurse Assistant (CNA) G set an 8 ounce glass of nutrition supplement with a plastic lid cover on the table in front of Resident #53. During the same observation, CNA G did not remove the cover nor offer the supplement to Resident #53; and then CNA G left the dining room. On 8/12/16 at 8:10 AM, RN F asked Resident #53 if she was done eating her breakfast. During the same observation, RN F gave instructions to CNA E to take Resident #53 to the restroom. Resident #53's nutrition supplement remained on the table; untouched, uncovered, and not offered to Resident #53. RN F followed CNA E and Resident #53 out of the dining room. There were no staff supervising residents' in the Enchanted Bistro Dining Room on 8/12/16 at approximately 8:15 AM. During the same observation, another resident, (Resident #54) that was previously sitting across from Resident #53 during the breakfast meal, picked up Resident #53's nutritional supplement and proceeded to drink it. CNA G was interviewed on 8/12/16 at approximately 8:20 AM and verified the the liquid that she placed in front of Resident #53 at the start of breakfast was a nutritional supplement ordered for Resident #53. CNA G then asked this writer where the glass went, and was informed by this writer that Resident #54 had actually drunk Resident #53's supplement. On 8/12/16 at 8:40 AM, CNA G stated she had worked at the facility for 6 years and was familiar with Resident #53. CNA G stated during the same interview that it was a common occurrence for Resident #53 to leave her walker at the entrance of the Enchanted Bistro dining room prior to her falling on 8/9/16. According to Resident Council Meeting minutes dated 6/27/16, several residents wondered why the shower aide position had moved from that assignment to another assignment because they had previously received their showers on time and the staff now appeared to be rushed. The same document indicated under Follow-Up that the shower aide was moved due to necessary staffing changes. On 8/12/16 at 10:40 AM, DON B indicated the shower aide reference in the 6/27/16 Resident Council Meeting minutes was related to a staffing change; the shower aide had worked on the Enchanted Garden and Tea Garden units and was switched to the rehabilitation side of the building. DON B stated during the same interview that the shower aide was not replaced, that the CNA's now do their own showers for their scheduled residents 7 days a week. DON B stated in the same interview that during meal times the shower aide was assigned to assist in the Enchanted Garden and Tea Garden Bistro dining rooms. One less staff person was supervising the dining rooms following the elimination of the shower aide position. ( )

This citation pertains to intake #MI 319 Based on observation, interview, and record review, the Facility failed to provide the necessary care and services (two person transfer) in 1 of 4 sampled Residents (#201) with a fractured right leg, from a total sample of 4 residents, resulting in Resident #201 bearing weight on her fractured right leg requiring hospitalization for surgical repair of the significantly displaced fractured Fibular bone. Findings include: Review of the clinical record face sheet revealed Resident #201 was a [AGE] year old woman admitted to the facility on Friday 9/30/11 at 5:30 PM, directly from a Hospital where she was diagnosed with [REDACTED]. Resident #201 had no cognitive deficits according to her Minimum (MDS) data set [DATE] and had [DIAGNOSES REDACTED]. Review of the Admission Nursing assessment dated [DATE] at 6:00 PM revealed Resident #201 had instructions for nursing that Resident #201 was "non-weight bearing to lower right extremity." Review of the physician progress notes [REDACTED]. Review of the Physician transfer record dated 9/30/11 revealed instructions for Resident #201 to be "up with assist and walker, Occupational and Physical Therapy to evaluate". The report indicated that Resident #201 was a fall risk. In an interview on 11/3/11 at 1:15 PM, Occupational Therapist (OT) #1 said she assessed Resident #201 on Saturday morning (10/1/11) and instructed nursing staff to transfer Resident #201 via a Hoyer mechanical lift because she was non-weight bearing and unable to be transferred via a pivot transfer until assessed by Physical Therapy. Review of the "Fall" care plan dated 9/30/11 revealed instructions for nursing to transfer Resident #201 with moderate assist of two persons. On 10/11/11 another intervention was written, "transfer with 2 persons". Both of the care plan interventions were discontinued on 10/17/11 and instructions to transfer with Hoyer mechanical lift was written. In an interview on 11/3/11 at 2:55 PM, Licensed Practical Nurse (LPN) #1 said she worked on 10/1/11, 10/2/11, 10/5/11, 10/6/11, 10/7/11 and 10/10/11 and was the nurse in charge of Resident #201. LPN #1 said she assisted a Certified Nurse Aide (CNA - unable to recall the name) during a 2 person pivot transfer for Resident #201 at some time in Resident #201's first week of stay at the Facility, but was not sure of the exact day but said it was on either 10/5/11, 10/6/11 or 10/7/11. LPN #1 said she told Resident #201 not to bear weight on her right leg and Resident #201 informed her, during the transfer, she could not help putting weight on her right fractured leg. When asked if she changed Resident #201 from a 2 person pivot transfer to a mechanical lift transfer after Resident #201 stated she could not help to put weight on her right leg, LPN #1 said, "I don't believe so." LPN #1 said on 10/10/11, Resident #201 was seen by her Orthopedic Surgeon who took x-rays of her right leg and found that the fractured bone had become worse and required surgical intervention. LPN #1 said Resident #201 surgery was postponed, however, because she developed an Upper Respiratory Infection. In an observation on 11/3/11 at 10:30 AM, Resident #201 was in her room, being transferred by CNA #3 and CNA #4 using a Hoyer mechanical transfer machine. Resident #201's right leg had a cast which started under her right knee and continued to cover her toes. During an interview after the transfer Resident #201 said, "I was a two person transfer when I first came but they didn't have enough staff and transferred me with only one person. I'm a big person. I weigh 190 pounds." Resident #201 said she wasn't suppose to bear weight on her right leg when she first arrived at the Facility but had to because they didn't always use two people to transfer her. Resident #201 said, "Orthopedic said he took an x-ray to show how it damaged the leg and pushed down the bone which slid inside each other because I bear weight". Resident #201 said one of the CNA's "told me I looked like a big strong woman and when I stood up he relaxed his grip and I had to bear weight." In an interview on 11/3/11 at 11:40 AM, CNA #2 said on Monday 10/3/11 Resident #201's call light was on and she transferred Resident #201 by herself from her bed to a wheelchair. CNA #2 said she was not aware Resident #201 was non-weight bearing status. Review of the nurse's notes dated 10/1/11 at 2:02 PM, 10/5/11 at 11:00 AM, 10/5/11 at 10:30 PM, 10/6/11 at 10:55 AM, 10/6/11 at 10:45 PM, 10/7/11 at 1:48 PM, 10/12/11 at 2:50 AM revealed Resident #201 was transferred with assist of one and complained of right lowered extremity pain daily. Review of the nurse's notes dated 10/2/11 at 11:45 PM, revealed Resident #201 did not have an appropriate wheelchair and remained in bed. Review of the nurse's notes dated 10/10/11 at 11:16 AM and 10/14/11 at 10:00 AM revealed Resident #201 requested assistance of two for transfers and was seen by the Orthopedic Surgeon. Nurse's note dated 10/14/11 at 1:30 PM revealed Resident #201 was transferred to the hospital for surgical repair of her displaced, fractured right ankle. According to the nurse's notes Resident #201's surgery was postponed until 10/14/11 due to her developing an Upper Respiratory Infection. Review of the Nurse's Notes dated 10/17/11 at 7:55 PM Resident #201 was readmitted to the Facility following a surgical Open Reduction, Internal Fixation (ORIF) of Right ankle with strict orders to transfer per Hoyer and 2 persons. Review of the Facility's investigation dated 10/21/11 revealed Resident #201 complained that she was not transferred with 2 staff consistently which caused her to put weight on her right lower extremity during the transfers. The report documented;"The results of the investigation substantiated that, while a deficient practice did not cause the actual fracture, it impeded the healing process and surgery was indicated." #

THIS CITATION PERTAINS TO INTAKE MI 923. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO NOTIFY THE PHYSICIAN OF A SIGNIFICANT CHANGE IN PHYSICAL CONDITION IN 1 (#105) OF 8 SAMPLED RESIDENTS OUT OF A TOTAL SAMPLE OF 8, RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #105'S PHYSICIAN WAS NOT NOTIFIED IN A TIMELY MANNER THAT RESIDENT #105 WAS EXPERIENCING SEVERE DIFFICULTY IN BREATHING WHICH RESULTED IN RESIDENT #105'S TRANSFER TO THE HOSPITAL AND SUBSEQUENT VENTILATOR SUPPORT. THESE DEFICIENT PRACTICES PLACE ALL RESIDENTS WITH AN ACUTE CHANGE OF CONDITION AT HIGH RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: ACCORDING TO THE FACILITY ROSTER MATRIX, RESIDENT #105 WAS NOT LIVING AT THE FACILITY AT THE TIME OF THE INVESTIGATION (5/31/11 THROUGH 6/10/11). REVIEW OF RESIDENT #105's MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE admitted to the facility on [DATE], discharged TO THE hospital on [DATE] AND RE-admitted to the facility on [DATE], THEN discharged TO THE hospital on [DATE]. HER [DIAGNOSES REDACTED]. FACILITY DISCHARGE SUMMARY FOR RESIDENT #105 (UNDATED) DOCUMENTED THAT THE PLAN WAS SHORT TERM REHABILITATION AT THE FACILITY THEN RETURN HOME WITH HER HUSBAND. FACILITY NURSE'S NOTES DATED 5/24/11 DOCUMENTED RESIDENT #105 HAD AUDIBLE WHEEZING, THE NURSE PRACTITIONER (NP) WAS NOTIFIED, AND AN ORDER WAS GIVEN FOR A RESPIRATORY INHALER OF [MEDICATION NAME] TO BE GIVEN FOUR TIMES A DAY. FACILITY NURSE'S NOTES, DATED 5/25/11 AT 10:15 PM AND SIGNED BY REGISTERED NURSE (RN) #3, DOCUMENTED THAT RESIDENT #105 WAS WHEEZING, BUT CLEARED WITH POSITION CHANGE AND DEEP BREATHING/COUGHING. PHYSICIAN #13 CALLED AND REQUESTED RESIDENT #101 TO START [MEDICATION NAME] (REMOVES FLUID FROM BODY TO TREAT [MEDICAL CONDITION], AND IMPROVE RESPIRATORY WHEEZING) 20 MG DAILY, AND [MEDICATION NAME] 25 MG DAILY. NURSE'S NOTES DATED, 5/25/11 AT 11:30 PM AND SIGNED BY RN #3, DOCUMENTED THAT RESIDENT #105 COMPLAINED OF WHEEZING AND SHORTNESS OF BREATH. THE NEXT ENTRY ON NURSE'S NOTES FOR RESIDENT #105 WAS DATED 5/26/11 AT 7:05 AM, SIGNED BY RN #15, AND DOCUMENTED THAT RESIDENT #105 WAS SEVERELY SHORT OF BREATH WITH A BLOOD OXYGEN LEVEL OF 69 PERCENT (NORMAL IS 95 TO 100%). RN #15 DOCUMENTED THAT THE NP WAS CALLED AND THAT RESIDENT #105 WAS SENT TO THE HOSPITAL BY AMBULANCE. HOSPITAL EMERGENCY PHYSICIAN REPORT FOR RESIDENT #105, DATED 5/26/11, DOCUMENTED RESIDENT #105 CAME IN FROM NURSING HOME WITH ACUTE ONSET OF DIFFICULTY IN BREATHING, COUGHING, FEVER AND CHILLS WITH A HYPOXIC (NO OXYGEN SUPPLY) EPISODE IN THE FACILITY. THE HOSPITAL emergency room PHYSICIAN DOCUMENTED THAT RESIDENT #105 WAS admitted to the hospital with [REDACTED]. HOSPITAL HISTORY AND PHYSICAL FOR RESIDENT #105, DATED 5/26/11 DOCUMENTED THAT RESIDENT #105 WAS INTUBATED (BREATHING TUBE PLACED THROUGH THE MOUTH AND INTO THE LUNGS, WHICH IS ATTACHED TO AN OXYGEN SUPPLY, TO PROVIDE OXYGEN) IN THE emergency room . THE HISTORY AND PHYSICAL DOCUMENTED ASSESSMENT AS [MEDICAL CONDITION] WHICH WAS LIKELY SECONDARY TO HEALTHCARE-ACQUIRED PNEUMONIA [MEDICAL CONDITION], AND THAT RESIDENT #105 WAS INTUBATED. IN AN INTERVIEW ON 6/7/11 AT 2:30 PM, PHYSICIAN #13 STATED HE HAD CALLED RN #3 AT APPROXIMATELY 7:00 PM ON 5/25/11 AND TOLD HER TO START RESIDENT #105 ON [MEDICATION NAME] AND [MEDICATION NAME]. PHYSICIAN #13 TOLD RN #3 TO START THE MEDICATION THAT NIGHT AND WAS UPSET WHEN HE FOUND OUT THE NEXT DAY THAT THE RESIDENT HAD BEEN SENT TO THE HOSPITAL, WAS ON VENTILATOR SUPPORT AND THE MEDICATION THAT HE ORDERED, HAD NOT BEEN GIVEN TO RESIDENT #105. PHYSICIAN #13 STATED IT HAD NOT BEEN REPORTED TO HIM THAT RESIDENT #105 HAD AN ELEVATED TEMPERATURE, NOR THAT SHE HAD AN EXTREMELY LOW OXYGEN LEVEL. PHYSICIAN #13 STATED THAT RESIDENT #105 WAS STILL IN THE HOSPITAL ON A VENTILATOR SUPPORT AND WAS NOT DOING WELL. IN AN INTERVIEW ON 6/7/11 AT 2:40 PM, THE DIRECTOR OF NURSING (DON) STATED THAT STAFF RN #3 WAS OBSERVED ON THE FACILITY VIDEO MONITORING SYSTEM ON 5/25/11 ENTERING RESIDENT #105'S ROOM BETWEEN 6:00 AND 7:00 PM, AND THAT STAFF RN #3 WAS NOT OBSERVED ENTERING RESIDENT #105'S ROOM AGAIN UNTIL 6:40 AM ON 5/26/11. THE DON admitted THAT RESIDENT #105 HAD BEEN VERY ILL FOR SEVERAL DAYS, HAD COMPLAINED OF DIFFICULTY BREATHING TO STAFF RN #3 BETWEEN 6:00 AND 7:00 PM ON 5/25/11, AND THAT STAFF RN #3 DID NOT ASSESS THE RESIDENT AGAIN UNTIL 12 HOURS LATER AT 6:40 AM ON 5/26/11. THE DON STATED THAT RESIDENT #105 WAS TRANSFERRED TO THE HOSPITAL THE MORNING OF 5/26/11 AND WAS PLACED ON VENTILATOR SUPPORT. THE DIRECTOR OF NURSING GAVE A CORRECTIVE ACTION FORM TO THE SURVEYOR WHICH STATED RN #3 HAD BEEN TERMINATED EFFECTIVE 5/31/11. THE FORM WAS NOT SIGNED BY RN #3 OR THE ADMINISTRATOR OR DIRECTOR OF NURSING. THE SURVEYOR INFORMED THE DIRECTOR OF NURSING THAT A COPY OF RN #3'S SIGNED RESIGNATION LETTER HAD BEEN PROVIDED TO THE SURVEYOR. WHEN ASKED IF RN #3 HAD BEEN TERMINATED OR IF SHE HAD RESIGNED, THE DON STATED RN #3 RESIGNED BEFORE THEY COULD TERMINATE HER. IN AN INTERVIEW ON 6/7/11 AT 3:30 PM, THE DON STATED THAT SHE WAS MISTAKEN AND STAFF RN #3 HAD ALSO GONE INTO THE ROOM OF RESIDENT #105 AT 11:00 PM. IN AN INTERVIEW ON 6/7/11 AT 9:00 AM, RN #3 STATED THAT PRIOR TO RESIDENT #105 BEING TRANSFERRED TO THE hospital on [DATE], SHE HAD BEEN SICK FOR SEVERAL DAYS, AND THE NURSE PRACTITIONER HAD ORDERED AN INHALER FOR HER WHEEZING. RN #3 STATED THE INHALER WOULD HELP FOR A SHORT TIME, BUT RESIDENT 105'S WHEEZING WOULD BE QUITE BAD BY THE TIME SHE WAS DUE FOR THE NEXT DOSE. RN #3 STATED SHE GOT A CALL FROM PHYSICIAN #13 ON THE NIGHT OF 5/25/11 BECAUSE RESIDENT #105'S FAMILY HAD CALLED PHYSICIAN #13 ABOUT THEIR CONCERN'S WITH RESIDENT #105'S DIFFICULTY IN BREATHING. RN #3 STATED PHYSICIAN #13 TOLD HER TO START RESIDENT #105 ON [MEDICATION NAME] AND [MEDICATION NAME] THAT NIGHT. RN #3 STATED SHE DID NOT GIVE THE [MEDICATION NAME] OR [MEDICATION NAME] TO RESIDENT #105 DURING HER SHIFT, BUT DID ADMINISTER THE [MEDICATION NAME] TO RESIDENT #105 JUST BEFORE THE AMBULANCE PERSONNEL TOOK THE RESIDENT OUT TO THE HOSPITAL. RN #3 STATED THAT SHE WENT INTO RESIDENT #105'S ROOM BETWEEN 6:00 PM AND 7:00 PM AND THAT RESIDENT #105 COMPLAINED OF BEING SHORT OF BREATH. RN #3 STATED RESIDENT #105 WAS WHEEZING AT THAT TIME, AND SHE ADMINISTERED THE ORDERED INHALER MEDICATION TO RESIDENT #105. RN #3 STATED BY THE TIME MORNING CAME, SHE WAS READY FOR HER INHALER AGAIN, SO SHE WENT INTO THE RESIDENT'S ROOM TO GIVE IT TO HER. RN #3 STATED RESIDENT #105 STATED SHE DID NOT FEEL WELL AND REQUESTED TO GO TO THE HOSPITAL, SO SHE STARTED THE PAPER WORK TO TRANSFER THE RESIDENT TO THE HOSPITAL. RN #3 STATED SHE DID NOT CHECK ANY VITAL SIGNS ON RESIDENT #105 AT THAT TIME, AND DID NOT KNOW WHAT HER OXYGEN LEVEL WAS. RN #3 STATED RESIDENT #105 WAS WHEEZING, AND WAS EXPERIENCING SHORTNESS OF BREATH. RN #3 STATED SHE THOUGHT RESIDENT #105 WAS JUST ANXIOUS AND WAS NOT CRITICALLY ILL ON HER SHIFT. RN #3 STATED RN # 15 CAME IN FOR THE FIRST SHIFT AT THAT TIME AND TOOK CARE OF TRANSFERRING RESIDENT #105 TO THE HOSPITAL. RN #3 STATED SHE DID NOT CALL THE DOCTOR DURING THE NIGHT TO REPORT A CHANGE IN RESIDENT #105'S CONDITION. RN #3 STATED WHEN SHE CAME INTO WORK THE NEXT DAY, THE DON SUSPENDED HER. WHEN ASKED BY THE SURVEYOR IF THE DON TOLD HER WHY SHE WAS BEING SUSPENDED, RN #3 STATED, "THEY KEPT FOCUSING ON THE FACT THAT I HADN'T GONE IN THE RESIDENTS ROOM ALL NIGHT", AND "THEY SAID I GOT ORDERS AND DIDN'T GIVE THE MEDICATION". RN #3 STATED SHE WAS NOT TERMINATED, THAT SHE HAD RESIGNED BECAUSE SHE WAS NOT A GOOD FIT WITH THE FACILITY. IN AN INTERVIEW ON 6/9/11 AT 11:35 AM, RN #15 STATED SHE WAS THE NURSE WHO TRANSFERRED RESIDENT #105 TO THE HOSPITAL. RN #15 STATED SHE CAME ON FOR HER FIRST SHIFT AND RN #3 TOLD HER IN REPORT THAT RESIDENT #105 NEEDED TO BE SENT TO THE HOSPITAL, THAT SHE (RN#3) HAD GIVEN RESIDENT #105 HER INHALER, BUT SHE WAS STILL WHEEZING. RN #15 STATED SHE ASKED RN #3 IF RESIDENT #105 HAD A [DIAGNOSES REDACTED]. RN #15 STATED SHE ASKED RN #3 WHAT RESIDENT #105'S OXYGEN LEVEL WAS AND RN #3 STATED SHE DIDN'T KNOW. RN #15 STATED SHE ASKED IF RESIDENT #105 HAD ANY [MEDICATION NAME] ORDERED AND RN #3 TOLD HER THAT THE DOCTOR HAD CALLED THE NIGHT BEFORE AND ORDERED [MEDICATION NAME] AND [MEDICATION NAME], BUT SHE HADN'T GIVEN IT. RN #15 STATED SHE AND RN #3 WENT INTO RESIDENT #105'S ROOM AND FOUND HER TO BE ON THE PHONE WITH HER HUSBAND AND SHE (RESIDENT #105) "COULD BARELY BREATHE" AND WAS USING HER ACCESSORY MUSCLES TO BREATHE. RN #15 STATED SHE CHECKED RESIDENT #105'S OXYGEN LEVEL AND IT WAS 69 PERCENT, SO SHE TOLD RN #3 TO GET THE OXYGEN, AND THEN SHE (RN #15) CALLED THE DOCTOR. RN #15 STATED RESIDENT #105'S HUSBAND THEN CALLED HER (RN #15) AND STATED THAT HIS WIFE COULDN'T BREATHE. RN #15 STATED SHE REASSURED THE HUSBAND AND TOLD HIM THAT SHE WAS BEING SENT TO THE HOSPITAL RIGHT AWAY. RN #15 STATED SHE THEN TOLD RN #3 TO GIVE [MEDICATION NAME] TO RESIDENT #105. RN #15 STATED SHE SAT IN THE ROOM NEXT TO RESIDENT #105 UNTIL THE AMBULANCE ARRIVED. RN #15 STATED RN #3 KEPT COMING IN THE ROOM TO TALK ABOUT OTHER RESIDENTS AND ASKED WHAT TIME SHE SHOULD PUT ON THE MEDICATION SHEET FOR SOME MEDICATION. RN #15 STATED, "IT WAS RIDICULOUS" RN #15 STATED SHE TOLD RN #3 THAT IT WASN'T THE APPROPRIATE TIME FOR THAT, AND HER FOCUS SHOULD BE ON RESIDENT #105 RIGHT NOW. RN #15 STATED THAT RN #3 HAD NOT CALLED THE PHYSICIAN OR NURSE PRACTITIONER TO REPORT A CHANGE IN RESIDENT #105'S STATUS. REVIEW OF RN #3's PERSONNEL RECORD ON 5/31/11 REVEALED A CORRECTIVE ACTION FORM DATED 4/29/11 WHICH DOCUMENTED THAT IS WAS REPORTED TO MANAGEMENT THAT RN #3 DID NOT RESPOND OR FOLLOW UP APPROPRIATELY TO A FAMILY MEMBER REQUEST REGARDING A RESIDENT SAFETY CONCERN. IN ADDITION, IT WAS REPORTED TO MANAGEMENT THAT RN #3's WORK BEHAVIOR TOWARD CO-WORKERS WAS PERCEIVED AS RUDE AND DISRESPECTFUL. A CORRECTIVE ACTION FORM DATED 5/31/11, WAS GIVEN TO THE SURVEYOR ON 6/7/11 BY THE DIRECTOR OF NURSING, DOCUMENTED ON 5/26/11 RN #3 FAILED TO COMPLETE A NURSING ASSESSMENT/COMMUNICATE THE CHANGE IN CONDITION TO THE ON-CALL NURSE PRACTITIONER FOR A RESIDENT THAT WAS EXPERIENCING RESPIRATORY DIFFICULTY. THE RESIDENT SUBSEQUENTLY WAS TRANSPORTED TO THE emergency room AND admitted to the hospital with [REDACTED].#3'S PERSONNEL FILE DATED BY RN #3 ON 6/1/11 AND SIGNED BY FACILITY HUMAN RESOURCE MANAGER AS RECEIVED ON 6/1/11. ON 6/9/11 AT 1:25 PM, THE ADMINISTRATOR AND THE DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 5/25/11 WHEN RESIDENT #105'S PHYSICIAN WAS NOT NOTIFIED IN A TIMELY MANNER THAT RESIDENT #105 WAS EXPERIENCING SEVER DIFFICULTY IN BREATHING WHICH RESULTED IN RESIDENT #105'S TRANSFER TO THE HOSPITAL AND SUBSEQUENT VENTILATOR SUPPORT. THESE DEFICIENT PRACTICES PLACE ALL RESIDENTS WITH AN ACUTE CHANGE OF CONDITION AT HIGH RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON 6/10/11 AT 1:30 PM, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. RESIDENT #105 REMAINED hospitalized . 2. NURSE #3 IS NO LONGER EMPLOYED AT THE FACILITY EFFECTIVE 6/1/11. 3. ON 6/9/11, THE ADMINISTRATOR MET WITH THE DON AND HUMAN RESOURCES DIRECTOR TO DISCUSS THE IMPORTANCE OF FOLLOWING THE CORRECTIVE DISCIPLINARY PROCESS IN A TIMELY MANNER FOR DEFICIENT PRACTICES OBSERVED WITH STAFF. 4. ON 6/9/11, THE "CHANGE IN RESIDENT CONDITION" POLICY WAS REVIEWED AND REVISED BY THE ADMINISTRATOR AND DON TO INCLUDE: OBTAINING A PULSE OXIMETRY READING AS INDICATED FOR RESIDENTS EXPERIENCING ACUTE RESPIRATORY DISTRESS/SHORTNESS OF BREATH AND CHANGE IN LEVEL OF CONSCIOUSNESS. 5. ON 6/9/11, AN AUDIT WAS INITIATED BY DON AND ADMINISTRATOR OF THE 24-HOUR NURSING REPORTS TO IDENTIFY RESIDENTS EXPERIENCING ACUTE CHANGE IN CONDITION, AND WILL INCLUDE ENSURING THE IS PHYSICIAN CONTACTED, AND ANY ORDERS RECEIVED HAD BEEN CARRIED OUT. 6. BEGINNING 6/9/11 ALL STAFF WILL RECEIVE TRAINING SPECIFIC TO RESIDENT ABUSE, PHYSICAL, VERBAL, SEXUAL, AND NEGLECT, AND REPORTING REQUIREMENTS. THIS TRAINING WILL STRESS THE DEFINITION OF NEGLECT IN THE FORM OF FAILURE TO PROPERLY ASSESS AND MONITOR A RESIDENT EXPERIENCING AN ACUTE CHANGE OF CONDITION. AS OF 6/9/11 39 OF 136 EMPLOYEES WERE IN-SERVICED. NO FACILITY STAFF WILL BE ALLOWED TO WORK PRIOR TO RECEIVING THE EDUCATION. 7. BEGINNING 6/9/11, ALL LICENSED NURSING STAFF WORKING WILL RECEIVE TRAINING SPECIFIC TO RESIDENT ASSESSMENTS AND CONTACTING THE PHYSICIAN FOR ACUTE CHANGES IN CONDITION. AS OF 6/9/11, 13 OF 32 LICENSED NURSES HAVE RECEIVED THE EDUCATION. NO LICENSED NURSES WILL BE ALLOWED TO WORK PRIOR TO RECEIVING THE EDUCATION. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 6/9/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND SEVERITY OF NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO NOT ALL FACILITY STAFF HAVE RECEIVED THE IN-SERVICE EDUCATION AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY.

THIS CITATION PERTAINS TO MI 923. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE 1 (#101) OF 8 SAMPLED RESIDENTS OF A TOTAL SAMPLE OF 8 WERE FREE FROM ABUSE, RESULTING IN AN IMMEDIATE JEOPARDY WHEN FACILITY STAFF USED PHYSICAL FORCE TO PRY APART THE SEVERELY CONTRACTED LEGS OF RESIDENT #101 DURING A CATHETERIZATION (TUBE PLACED IN THE BLADDER, THROUGH THE URINARY OPENING, TO DRAIN THE BLADDER) PROCEDURE, CAUSING MUSCLE AND LIGAMENT INJURY, BRUISING, AND PAIN TO RESIDENT #101'S LEFT LEG, LEFT GROIN, AND LABIA. THIS DEFICIENT PRACTICE PLACED ALL 94 RESIDENTS IN THE FACILITY AT HIGH RISK FOR SERIOUS HARM AND/OR INJURY. FINDINGS INCLUDE: REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. physician progress notes [REDACTED]. physician progress notes [REDACTED]. physician progress notes [REDACTED].#101 HAS CONTRACTURE OF BILATERAL KNEES AND HIPS. physician progress notes [REDACTED]. physician progress notes [REDACTED]. LEFT QUADRICEPS STRAIN WITHOUT COMPLETE LIGAMENT TEAR THIRD DEGREE. FACILITY NURSE'S NOTES FOR RESIDENT #101 DATED 12/8/10 AT 11:00 PM, AND SIGNED BY RN #3 DOCUMENTED FOLEY CATHETER INSERTED. FACILITY NURSE'S NOTES FOR RESIDENT #101 DATED 12/9/10 AT 3:00 AM DOCUMENTED THAT RESIDENT #101 WAS OBSERVED TO HAVE LEFT LEG PARTIALLY OFF BED, BILATERAL LEGS VERY RELAXED, WHICH WERE USUALLY CONTRACTED TIGHTLY TOGETHER AND VERY HARD TO SEPARATE. NURSE'S NOTES DATED 12/9/10 AT 7:20 AM DOCUMENTED RESIDENT #101 OBSERVED IN FROG-LEGGED POSITION AND FLINCHED WITH PAIN WHEN LEFT LEG AND HIP WERE TOUCHED AND THAT THE NURSE PRACTITIONER AND DIRECTOR OF NURSING WERE NOTIFIED. DURING OBSERVATIONS ON 6/3/11, RESIDENT #101 WAS OBSERVED SITTING IN A WHEELCHAIR IN THE DINING ROOM, WITH A CUSHION PLACED BETWEEN HER LEGS AND CONE SHAPED SPLINTS IN THE PALM OF BOTH HANDS. CNA #19 WAS ASSISTING RESIDENT #101 WITH HER MEAL. CNA #19 TOLD THE SURVEYOR THAT THE PURPOSE OF THE CUSHION BETWEEN RESIDENT #101'S LEGS WAS TO KEEP HER LEGS POSITIONED BECAUSE SHE HAD BAD CONTRACTURES WHICH MADE HER LEGS STAY TOGETHER. CNA #19 ALSO STATED THAT RESIDENT #101 HAD CONTRACTURES IN HER HANDS. IN AN INTERVIEW ON 6/7/11 AT 8:45 AM, LPN #5 STATED THAT SHE AND CNA (CERTIFIED NURSE AIDE) #9 HAD FOUND RESIDENT #101 IN HER BED, DURING THE NIGHT SHIFT ON 12/9/10, WITH HER LEGS APART AND HER LEFT LEG PARTIALLY OFF THE EDGE OF THE BED. LPN #5 STATED THIS WAS VERY UNUSUAL FOR RESIDENT #101, BECAUSE HER LEGS HAD ALWAYS BEEN CONTRACTED TOGETHER AT THE KNEES. LPN #5 STATED SHE HELPED CNA #9 CHANGE RESIDENT #101'S INCONTINENT BRIEF, AND THE RESIDENT FLINCHED WHEN HER LEFT LEG WAS MOVED. LPN #5 STATED RESIDENT #101 WAS LAYING IN A SORT OF FROG LEG POSITION (LEGS APART AT THE KNEES WITH LEGS SLIGHTLY BENT). LPN #5 STATED SHE HAD THE NURSE WHO WAS COMING ON FOR THE NEXT SHIFT ASSESS RESIDENT #101, WHO ALSO THOUGHT IT WAS UNUSUAL FOR RESIDENT #101'S LEGS TO BE APART. LPN #5 STATED SHE CALLED THE NURSE PRACTITIONER, WHO ORDERED SOME PAIN MEDICATIONS AND AN XRAY OF RESIDENT #101's LEFT HIP. LPN #5 STATED SHE THOUGHT THERE HAD BEEN AN INJURY TO RESIDENT #101's LEFT HIP, SO SHE FILLED OUT AN INCIDENT REPORT AND BEGAN TO ASK STAFF MEMBERS IF THEY KNEW ANYTHING ABOUT AN INJURY TO RESIDENT #101's LEFT LEG. LPN #5 STATED CNA #8 TOLD HER IT MUST HAVE HAPPENED WHEN RN #3 PUT A CATHETER IN RESIDENT #101. LPN #5 STATED SHE ASKED CNA #8 WHY SHE THOUGHT THAT AND CNA #8 STATED THAT A CNA HAD TOLD HER THAT RN#3 HAD HER AND ANOTHER CNA PRY RESIDENT #101'S LEGS APART FOR A CATHETER PROCEDURE AND THAT HER LEGS WERE RELAXED AFTER THE PROCEDURE. LPN #5 STATED SHE REPORTED THE INCIDENT TO THE DIRECTOR OF NURSING AND THE ADMINISTRATOR. LPN #5 STATED THAT 2 DAYS LATER, RESIDENT #101'S LEFT THIGH HAD BRUISES ALL OVER IT AND WOULD FLINCH WITH PAIN EVERY TIME HER LEFT LEG WAS MOVED OR TOUCHED. IN AN INTERVIEW ON 6/7/11 AT 1:00 PM, LPN #4 STATED SHE WAS CALLED INTO RESIDENT #101'S ROOM BY LPN #5 TO ASSESS THE RESIDENT'S LEGS. LPN #4 STATED RESIDENT #101'S LEGS WERE USUALLY STRAIGHT AND TOGETHER OR CROSSED, BUT ON THE MORNING OF 12/9/10, SHE (LPN) OBSERVED RESIDENT #101 IN HER BED WITH HER LEGS APART. LPN #4 STATED CNA #8 STATED SHE HAD HEARD RN #3 HAD PLACED A CATHETER IN RESIDENT #101 THE NIGHT BEFORE AND HAD DIFFICULTY DOING IT. LPN #4 STATED SHE HAD PLACED CATHETERS IN RESIDENT #101 SEVERAL TIMES IN THE PAST AND HAD ALWAYS PLACED HER ON HER SIDE FOR THE PROCEDURE DUE TO HER CONTRACTED LEGS. LPN #4 STATED THAT SEVERAL DAYS LATER, BRUISING APPEARED ON RESIDENT #101'S LEGS. IN AN INTERVIEW ON 6/8/11 AT 9:15 AM, CNA #8 STATED THAT CNA #6 CAME UP TO HER IN THE HALL AND ASKED HER IF SHE HAD SEEN RESIDENT #101. CNA #8 STATED SHE ASKED WHY AND CNA #6 TOLD HER THAT SHE AND CNA #7 HAD HELD RESIDENT #101'S LEGS APART WHILE RN #3 PLACED A CATHETER IN HER, AND THAT RESIDENT #101'S LEGS WERE NO LONGER CONTRACTED. CNA #8 STATED CNA #6 WAS VERY EXCITED AND CALLED IT A "MIRACLE OF GOD". IN AN INTERVIEW ON 6/3/11 AT 11:50 AM, RN #3 STATED SHE REMEMBERED THE INJURY TO RESIDENT #101'S LEG, AND THAT SHE HAD PLACED A FOLEY CATHETER IN RESIDENT #101 THE DAY BEFORE THE INJURY WAS DISCOVERED. RN #3 STATED "ALL I KNOW IS THAT THEY TRIED TO ACCUSE ME OF CAUSING HER (RESIDENT #101) TO HAVE FLACCID LEGS AND HER LEGS NOT LAYING RIGHT". RN #3 STATED THERE WAS AN XRAY DONE OF RESIDENT #101'S LEG AND IT WAS NEGATIVE FOR FRACTURE. RN #3 STATED, "IF THERE WAS ANYTHING WRONG WITH HER (RESIDENT #101), AND I DON'T THINK THERE WAS, IT WASN'T RELATED TO THE FOLEY (CATHETER) PLACEMENT I DID. RN #3 STATED NO DOCTOR HAD DOCUMENTED THAT RESIDENT #101 HAD AN INJURY. RN #3 STATED CNA #6 AND CNA #7 HELPED HOLD RESIDENT #101 IN PLACE SO THE CATHETER COULD BE INSERTED, AND THAT RESIDENT #101 WAS IN THE LITHOTOMY POSITION (POSITION IN WHICH THE PATIENT IS ON THEIR BACK WITH THE HIPS AND KNEES FLEXED AND THIGHS APART) WHEN THE CATHETER WAS PLACED. IN AN INTERVIEW ON 6/3/11 AT 11:30 AM, CNA #6 STATED THAT ON 12/8/10, SHE AND CNA #7 ASSISTED RN #3 WITH A CATHETER PLACEMENT FOR RESIDENT #101. CNA #6 STATED THAT SHE AND CNA #7 WERE HOLDING RESIDENT #101'S LEGS DURING THE PROCEDURE AND THAT RESIDENT #101'S LEGS WERE EXTREMELY STIFF AND HAD BEEN THAT WAY FOR THE THREE YEARS THAT SHE HAD WORKED AT THE FACILITY. CNA #6 STATED THAT DURING THE PROCEDURE, RN #3 WAS GETTING FRUSTRATED AND YELLING AT HER AND CNA#7 TO OPEN RESIDENT #101'S LEGS HARDER. CNA #6 STATED THAT SHE WAS TOLD LATER BY A NURSE THAT AN INJURY TO RESIDENT #101'S LEFT LEG WAS FROM THE CATHETER PROCEDURE. ON 6/7/11 AT 2:00 PM, NURSE PRACTITIONER #12 STATED THAT RESIDENT #101 had a history of [REDACTED]. NURSE PRACTITIONER #12 STATED THAT SHE ASSESSED RESIDENT #101 SHORTLY AFTER THE CATHETER PLACEMENT ON 12/8/10 AND FOUND HER LEFT LEG WAS NOT CONTRACTED ANYMORE. NURSE PRACTITIONER #12 STATED THAT RESIDENT #101 HAD SUFFERED A LIGAMENT INJURY TO HER LEFT LEG, A MUSCLE STRAIN IN HER LEFT LEG AND HAD DEVELOPED BRUISING AND SWELLING ON HER LEFT INNER LEG, GROIN AND LABIA AFTER THE CATHETER PROCEDURE. NURSE PRACTITIONER #12 STATED THAT THE, "COLOR OF THE BRUISING DATED THE INJURY BACK TO THE CATHETER PLACEMENT TIME." IN AN INTERVIEW ON 6/1/11 AT 12:10 PM, THE DIRECTOR OF NURSING STATED THAT THIRD SHIFT CNA #9 AND THIRD SHIFT LPN #5 HAD DISCOVERED BRUISING ON RESIDENT #101'S LEGS ON THE THIRD SHIFT AND REPORTED IT TO HER (DIRECTOR OF NURSING). THE DIRECTOR OF NURSING STATED CNA #6 AND CNA #7 DESCRIBED TO HER THAT THEY HELD RESIDENT #101'S LEGS BACK WHILE RN #3 WAS "CATHING" RESIDENT #101. THE DIRECTOR OF NURSING STATED SHE HAD THE FACILITY STAFF EDUCATOR DO A ONE TO ONE INSERVICE WITH RN #3 ON HOW TO PLACE A CATHETER ON A FEMALE RESIDENT WITH CONTRACTURES IN A MORE COMFORTABLE MANNER. WHEN THE SURVEYOR ASKED THE DIRECTOR OF NURSING WHY SHE WANTED RN #3 EDUCATED, THE DIRECTOR OF NURSING STATED THAT THERE WERE OTHER WAYS TO CATHETERIZE A RESIDENT WITH CONTRACTURES SO IT IS MORE COMFORTABLE. IN AN INTERVIEW ON 6/3/11 AT 10:50 AM, THE DIRECTOR OF NURSING STATED WHEN SHE CAME INTO WORK IN THE MORNING ON 12/9/10, LPN #5 REPORTED TO HER THAT SOMETHING WAS WRONG WITH RESIDENT #101 AND THAT THE RESIDENT MAY HAVE A [MEDICAL CONDITION]. THE DIRECTOR OF NURSING STATED THAT CNA #9 AND LPN #5 WERE CONCERNED BECAUSE RESIDENT #101'S LEGS WERE NORMALLY CONTRACTED TIGHT TOGETHER, AND NOW HER LEGS WERE VERY RELAXED AND THEY HAD FOUND HER IN A FROG LEG POSITION. THE DIRECTOR OF NURSING STATE SHE WAS UPSET WITH LPN #5 BECAUSE SHE HAD INITIATED AN INVESTIGATION DURING THE NIGHT, AND HAD NOT CALLED HER (DIRECTOR OF NURSING) IMMEDIATELY REGARDING THE INJURY TO RESIDENT #101. WHEN THE SURVEYOR ASKED THE DIRECTOR OF NURSING WHAT THE RESULTS OF HER (DIRECTOR OF NURSING) INVESTIGATION IN THE INJURIES OF RESIDENT #101 WERE, THE DIRECTOR OF NURSING STATED THAT RN #3 HAD CNA #6 AND CNA #7 HOLD AND SPREAD THE LEGS OF RESIDENT #101 DURING A CATHETERIZATION PROCEDURE. THE DIRECTOR OF NURSING STATED SHE REMEMBERED HAVING A CONVERSATION WITH THE NURSE PRACTITIONER, BECAUSE THE X-RAY OF RESIDENT #101'S LEFT HIP SUGGESTED AN MRI (MAGNETIC IMAGING) BE DONE, WHICH WOULD HAVE REQUIRED SEDATION OF RESIDENT #101. THE DIRECTOR OF NURSING STATED IT WAS DETERMINED THAT RN #3 HAD AN ORDER FROM THE PHYSICIAN TO PLACE A CATHETER IN RESIDENT #101 AND THAT IS WHAT SHE WAS DOING. THE DIRECTOR OF NURSING STATED SHE DID ASSESS RESIDENT #101 SEVERAL DAYS AFTER THE CATHETER PROCEDURE AND OBSERVED YELLOW BRUISING ON HER LEGS AND THAT HER LEGS WERE RELAXED. THE DIRECTOR OF NURSING WAS UNABLE TO PRODUCE DOCUMENTATION OF ANY INSERVICE DONE WITH RN #3 REGARDING THE CATHETERIZATION OF FEMALE RESIDENTS WITH CONTRACTURES. THE DIRECTOR OF NURSING STATED THAT RN #3 WAS NOT DISCIPLINED FOR THE INJURIES SUSTAINED BY RESIDENT #101. REVIEW OF RN #3's PERSONNEL RECORD ON 5/31/11 REVEALED A CORRECTIVE ACTION FORM DATED 4/29/11 WHICH DOCUMENTED THAT IS WAS REPORTED TO MANAGEMENT THAT RN #3 DID NOT RESPOND OR FOLLOW UP APPROPRIATELY TO A FAMILY MEMBER REQUEST REGARDING A RESIDENT SAFETY CONCERN. IN ADDITION, IT WAS REPORTED TO MANAGEMENT THAT RN #3's WORK BEHAVIOR TOWARD CO-WORKERS WAS PERCEIVED AS RUDE AND DISRESPECTFUL. A TYPED LETTER OF RESIGNATION WAS LOCATED IN RN#3'S PERSONNEL FILE DATED BY RN #3 ON 6/1/11 AND SIGNED BY FACILITY HUMAN RESOURCE MANAGER AS RECEIVED ON 6/1/11. IN AN INTERVIEW WITH THE ADMINISTRATOR ON 6/3/11 AT 10:20AM, SHE STATED THAT THE FACILITY STAFF WAS UNABLE TO LOCATE AN INCIDENT REPORT FOR THE INJURY OF RESIDENT #101 ON 12/8/10. ON 6/9/11 AT 1:25 PM, THE ADMINISTRATOR AND THE DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 12/8/11 WHEN RESIDENT #101 HAD HER SEVERELY CONTRACTED LEGS FORCED APART BY STAFF DURING A CATHETERIZATION PROCEDURE, RESULTING IN MUSCLE AND LIGAMENT INJURY, BRUISING, AND PAIN TO RESIDENT #101'S LEFT LEG, LEFT GROIN AND LABIA. ON 6/10/11 AT 1:30 PM, THE SURVEYOR VERIFIED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #101 WAS ASSESSED BY THE NURSE PRACTITIONER ON 6/9/11. 2. NURSE #3 IS NO LONGER EMPLOYED AT THE FACILITY. 3. CNA #6 WAS TERMINATED ON 6/9/11. 4. CNA #7 WAS TERMINATED ON 6/9/11. 5. ON 6/9/11, THE ADMINISTRATOR MET WITH THE DON AND HR DIRECTOR TO DISCUSS THE IMPORTANCE OF FOLLOWING THE CORRECTIVE DISCIPLINARY PROCESS IN A TIMELY MANNER FOR DEFICIENT PRACTICES OBSERVED WITH STAFF. 6. ON 6/9/11, THE ABUSE, NEGLECT, MISAPPROPRIATION MISTREATMENT AND INJURIES OF UNKNOWN SOURCE : PROHIBITION, INVESTIGATION AND REPORTING ABUSE POLICY WAS REVIEWED. NO REVISIONS WERE DEEMED NECESSARY. 7. ON 6/9/11, THE ADMINISTRATOR AND DON REVIEWED FEMALE RESIDENT TO IDENTIFY ANY OTHER FEMALE RESIDENTS WITH CONTRACTURES WHO MAY REQUIRE CATHETERIZATION. NONE WERE IDENTIFIED. 8. ON 6/9/11, THE ADMINISTRATOR AND DON REVIEWED AND REVISED "FEMALE CATHETERIZATION" POLICY TO INCLUDE, "POSITION FEMALE RESIDENT IN SIDE-LYING (SIMS) POSITIONS WITH UPPER LEG FLEXED AT HIP IF UNABLE TO ASSUME DORSAL RECUMBENT POSITION. NEVER ATTEMPT TO SEPARATE KNEES PAST THE POINT OF RESISTANCE IN CARRYING OUT THE PROCEDURE". 9. BEGINNING 6/9/11, ALL STAFF WILL RECEIVE TRAINING SPECIFIC TO RESIDENT ABUSE INCLUDING A DETAILED DESCRIPTION OF WHAT CONSTITUTES PHYSICAL, VERBAL, SEXUAL ABUSES, NEGLECT, AND REPORTING REQUIREMENTS. THIS TRAINING ALSO INCLUDED ROUGHNESS AS A FROM OF PHYSICAL ABUSE. AS OF 6/9/11 39 OF 136 EMPLOYEES WERE INSERVICED. NO FACILITY STAFF WILL BE ALLOWED TO WORK PRIOR TO RECEIVING THE EDUCATION. 10. BEGINNING 6/9/11, ALL NURSING STAFF WILL RECEIVE TRAINING SPECIFIC TO THE URINARY CATHETER PROCEDURE FOCUSING ON FEMALE RESIDENTS WITH LOWER EXTREMITY CONTRACTURES. ON 6/9/11, 13 OUR OF 32 NURSES WERE INSERVICED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 6/9/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND SEVERITY OF ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO NOT ALL FACILITY STAFF HAVE RECEIVED THE IN-SERVICE EDUCATION AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. #

THIS CITATION PERTAINS TO MI 923. BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE SERVICES THAT MEET PROFESSIONAL STANDARDS OF QUALITY FOR 1 (#105) OF 8 SAMPLED RESIDENTS OF A TOTAL SAMPLE OF 8, RESULTING IN AN IMMEDIATE JEOPARDY WHEN: 1) RN #3 FAILED TO ASSESS AND MONITOR RESIDENT #105 FOR AT LEAST 7 HOURS WHILE SHE WAS EXPERIENCING RESPIRATORY DIFFICULTY, AND 2) FAILED TO ADMINISTER MEDICATIONS ORDERED BY THE PHYSICIAN, RESULTING IN RESIDENT #105 HAVING EXTREME DIFFICULTY IN BREATHING, BEING TRANSFERRED TO THE THE HOSPITAL REQUIRING CONTINUOUS VENTILATORY SUPPORT. FINDINGS INCLUDE: THE NURSE IS OBLIGATED TO FOLLOW THE physician's order [REDACTED]. (FUNDAMENTALS OF NURSING, CONCEPTS, PROCESS, AND PRACTICE, MOSBY, PATRICIA A. POTTER, ANNE G. PERRY, 1985) ACCORDING TO THE LEGAL AND ETHICAL ISSUES IN NURSING, FOURTH EDITION, BY GUIDO (2006), "STANDARDS OF CARE MUST HAVE AND USE THE KNOWLEDGE AND SKILL ORDINARILY POSSESSED AND USED BY NURSES ACTIVELY [MEDICATION NAME] IN THE NURSE'S SPECIALTY AREA." THE PROFESSIONAL STANDARDS OF QUALITY FOR STAFF ROLES AND RESPONSIBILITIES IN MONITORING PATIENTS WITH ACUTE CHANGES OF CONDITION FOR THE NURSE INCLUDES RECOGNIZING CONDITION CHANGE EARLY AND ASSESSING THE PATIENT'S SYMPTOMS AND PHYSICAL FUNCTION AND DOCUMENT DETAILED DESCRIPTION OF OBSERVATIONS AND SYMPTOMS (PROCESS GUIDELINES FOR ACUTE CHANGE OF CONDITION, AMDA, CLINICAL PROCESS GUIDELINES, 2003). THE PROFESSIONAL STANDARD OF QUALITY FOR PERFORMING COMPLETE RESPIRATORY ASSESSMENTS IS TO ASSESS RESPIRATION RATE, RHYTHM AND DEPTH, INCREASED, DECREASED OR IRREGULAR RESPIRATIONS, LUNG SOUNDS, OXYGEN SATURATION LEVEL, HYPOXEMIA (LOW OXYGEN SATURATION LEVEL), LABORED OR PAINFUL BREATHING, USING CHEST MUSCLES TO BREATH, A BLUISH COLOR OF SKIN, NAIL BEDS, LIPS OR MOUTH, RESTLESSNESS, IRRITABILITY, CONFUSION, REDUCED LEVEL OF CONSCIOUSNESS, THICK OR BLOOD-TINGED SPUTUM, AND THE ASSESSMENT OF LABS. (MOSBY SIXTH EDITION MEDICAL-SURGICAL NURSING CONCEPTS AND CLINICAL PRACTICE, PHIPPS, SANDS, MAREK) ACCORDING TO THE FACILITY ROSTER MATRIX, RESIDENT #105 WAS NOT LIVING AT THE FACILITY AT THE TIME OF THE INVESTIGATION (5/31/11 THROUGH 6/10/11). REVIEW OF RESIDENT #105's MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE admitted to the facility on [DATE], discharged TO THE hospital on [DATE] AND RE-admitted to the facility on [DATE], THEN discharged TO THE hospital on [DATE]. HER [DIAGNOSES REDACTED]. FACILITY DISCHARGE SUMMARY FOR RESIDENT #105, WHICH WAS UNDATED, DOCUMENTED THAT THE PLAN WAS SHORT TERM REHABILITATION AT THE FACILITY AND THEN RETURN HOME WITH HER HUSBAND. FACILITY NURSE'S NOTES DATED 5/24/11 DOCUMENTED RESIDENT #105 HAD AUDIBLE WHEEZING, THE NURSE PRACTITIONER (NP) WAS NOTIFIED, AND AN ORDER WAS GIVEN FOR A RESPIRATORY INHALER OF [MEDICATION NAME] TO BE GIVEN FOUR TIMES A DAY. FACILITY NURSE'S NOTES DATED 5/25/11 AT 10:15 PM AND SIGNED BY RN #3, DOCUMENTED THAT RESIDENT #105 WAS WHEEZING, PHYSICIAN #13 CALLED AND REQUESTED RESIDENT #101 TO START [MEDICATION NAME] (REMOVES FLUID FROM BODY TO TREAT [MEDICAL CONDITION], AND IMPROVE RESPIRATORY WHEEZING) 20 MG DAILY, AND [MEDICATION NAME] 25 MG DAILY. NURSE'S NOTES DATED 5/25/11 AT 11:30 PM AND SIGNED BY RN #3, DOCUMENTED THAT RESIDENT #105 COMPLAINED OF WHEEZING AND SHORTNESS OF BREATH. THE NEXT ENTRY ON NURSE'S NOTES FOR RESIDENT #105 WAS DATED 5/26/11 AT 0705 WAS SIGNED BY RN #15, AND DOCUMENTED THAT RESIDENT #105 WAS SEVERELY SHORT OF BREATH WITH AN OXYGEN LEVEL IN HER BLOOD OF 69 PERCENT (NORMAL IS 95 TO 100%). RN #15 DOCUMENTED THAT THE NP WAS CALLED AND THAT RESIDENT #105 WAS SENT TO THE HOSPITAL BY AMBULANCE. HOSPITAL EMERGENCY PHYSICIAN REPORT FOR RESIDENT #105, DATED 5/26/11, DOCUMENTED RESIDENT #105 CAME IN FROM NURSING HOME WITH ACUTE ONSET OF DIFFICULTY IN BREATHING, COUGHING, FEVER AND CHILLS WITH A HYPOXIC (NO OXYGEN SUPPLY) EPISODE IN THE FACILITY. THE HOSPITAL emergency room PHYSICIAN DOCUMENTED THAT RESIDENT #105 WAS admitted to the hospital with [REDACTED]. HOSPITAL HISTORY AND PHYSICAL FOR RESIDENT #105, DATED 5/26/11 DOCUMENTED THAT RESIDENT #105 WAS INTUBATED (BREATHING TUBE PLACED THROUGH THE MOUTH AND INTO THE LUNGS, WHICH IS ATTACHED TO AN OXYGEN SUPPLY, TO PROVIDE OXYGEN) IN THE emergency room . THE HISTORY AND PHYSICAL DOCUMENTED ASSESSMENT AS [MEDICAL CONDITION] WHICH WAS LIKELY SECONDARY TO HEALTHCARE-ACQUIRED PNEUMONIA [MEDICAL CONDITION], AND THAT RESIDENT #105 WAS INTUBATED. IN AN INTERVIEW ON 6/7/11 AT 2:30 PM, PHYSICIAN #13 STATED HE HAD CALLED RN #3 AT APPROXIMATELY 7:00 PM ON 5/25/11 AND TOLD HER TO START RESIDENT #105 ON [MEDICATION NAME] AND [MEDICATION NAME]. PHYSICIAN #13 TOLD RN #3 TO START THE MEDICATION THAT NIGHT AND WAS UPSET WHEN HE FOUND OUT THE NEXT DAY THAT THE RESIDENT HAD BEEN SENT TO THE HOSPITAL, WAS ON VENTILATOR SUPPORT AND THE MEDICATION THAT HE ORDERED, HAD NOT BEEN GIVEN TO RESIDENT #105. PHYSICIAN #13 STATED THAT RESIDENT #105 WAS STILL IN THE HOSPITAL ON VENTILATOR SUPPORT AND WAS NOT DOING WELL. IN AN INTERVIEW ON 6/7/11 AT 2:40 PM, THE DIRECTOR OF NURSING (DON) STATED THAT STAFF RN #3 WAS OBSERVED ON THE FACILITY VIDEO MONITORING SYSTEM ON 5/25/11 ENTERING RESIDENT #105'S ROOM BETWEEN 6:00 AND 7:00 PM, AND THAT STAFF RN #3 WAS NOT OBSERVED ENTERING RESIDENT #105'S ROOM AGAIN UNTIL 6:40 AM ON 5/26/11. THE DON admitted THAT RESIDENT #105 HAD BEEN VERY ILL FOR SEVERAL DAYS, HAD COMPLAINED OF DIFFICULTY BREATHING TO STAFF RN #3 BETWEEN 6:00 AND 7:00 PM ON 5/25/11, AND THAT STAFF RN #3 DID NOT ASSESS THE RESIDENT AGAIN UNTIL 12 HOURS LATER AT 6:40 AM ON 5/26/11. THE DON STATED THAT RESIDENT #105 WAS TRANSFERRED TO THE HOSPITAL THE MORNING OF 5/26/11 AND WAS PLACED ON VENTILATOR SUPPORT. THE DON GAVE A CORRECTIVE ACTION FORM TO THE SURVEYOR WHICH STATED RN #3 HAD BEEN TERMINATED EFFECTIVE 5/31/11. THE FORM WAS NOT SIGNED BY RN #3 OR THE ADMINISTRATOR OR DON. THE SURVEYOR INFORMED THE DON THAT A COPY OF RN #3'S SIGNED RESIGNATION LETTER HAD BEEN PROVIDED TO THE SURVEYOR. WHEN ASKED IF RN #3 HAD BEEN TERMINATED OR IF SHE HAD RESIGNED, THE DON STATED RN #3 RESIGNED BEFORE THEY COULD TERMINATE HER. IN AN INTERVIEW ON 6/7/11 AT 3:30 PM, THE DON STATED THAT SHE WAS MISTAKEN AND STAFF RN #3 HAD ALSO GONE INTO THE ROOM OF RESIDENT #105 AT 11:00 PM. IN AN INTERVIEW ON 6/7/11 AT 9:00 AM, RN #3 STATED THAT PRIOR TO RESIDENT #105 BEING TRANSFERRED TO THE hospital on [DATE], SHE HAD BEEN SICK FOR SEVERAL DAYS, AND THE NURSE PRACTITIONER HAD ORDERED AN INHALER FOR HER WHEEZING. RN #3 STATED THE INHALER WOULD HELP FOR A SHORT TIME, BUT RESIDENT 105'S WHEEZING WOULD BE QUITE BAD BY THE TIME SHE WAS DUE FOR THE NEXT DOSE. RN #3 STATED SHE GOT A CALL FROM PHYSICIAN #13 ON THE NIGHT OF 5/25/11 BECAUSE RESIDENT #105'S FAMILY HAD CALLED PHYSICIAN #13 ABOUT THEIR CONCERN'S WITH RESIDENT #105'S DIFFICULTY IN BREATHING. RN #3 STATED PHYSICIAN #13 TOLD HER TO START RESIDENT #105 ON [MEDICATION NAME] AND [MEDICATION NAME] THAT NIGHT. RN #3 STATED SHE DID NOT GIVE THE [MEDICATION NAME] OR [MEDICATION NAME] TO RESIDENT #105 DURING HER SHIFT, BUT DID ADMINISTER THE [MEDICATION NAME] TO RESIDENT #105 JUST BEFORE THE AMBULANCE PERSONNEL TOOK THE RESIDENT OUT TO THE HOSPITAL. RN #3 STATED THAT SHE WENT INTO RESIDENT #105'S ROOM BETWEEN 6:00 PM AND 7:00 PM AND THAT RESIDENT #105 COMPLAINED OF BEING SHORT OF BREATH. RN #3 STATED RESIDENT #105 WAS WHEEZING AT THAT TIME, AND SHE ADMINISTERED THE ORDERED INHALER MEDICATION TO RESIDENT #105. RN #3 STATED BY THE TIME MORNING CAME, SHE WAS READY FOR HER INHALER AGAIN, SO SHE WENT INTO THE RESIDENT'S ROOM TO GIVE IT TO HER. RN #3 STATED RESIDENT #105 STATED SHE DID NOT FEEL WELL AND REQUESTED TO GO TO THE HOSPITAL, SO SHE STARTED THE PAPER WORK TO TRANSFER THE RESIDENT TO THE HOSPITAL. RN #3 STATED SHE DID NOT CHECK ANY VITAL SIGNS ON RESIDENT #105 AT THAT TIME, AND DID NOT KNOW WHAT HER OXYGEN LEVEL WAS. RN #3 STATED RESIDENT #105 WAS WHEEZING, AND WAS EXPERIENCING SHORTNESS OF BREATH. RN #3 STATED SHE THOUGHT RESIDENT #105 WAS JUST ANXIOUS AND WAS NOT CRITICALLY ILL ON HER SHIFT. RN #3 STATED RN # 15 CAME IN FOR THE FIRST SHIFT AT THAT TIME AND TOOK CARE OF TRANSFERRING RESIDENT #105 TO THE HOSPITAL. RN #3 STATED WHEN SHE CAME INTO WORK THE NEXT DAY, THE DON SUSPENDED HER. WHEN ASKED BY THE SURVEYOR IF THE DON TOLD HER WHY SHE WAS BEING SUSPENDED, RN #3 STATED, "THEY KEPT FOCUSING ON THE FACT THAT I HADN'T GONE IN THE RESIDENTS ROOM ALL NIGHT", AND "THEY SAID I GOT ORDERS AND DIDN'T GIVE THE MEDICATION". RN #3 STATED SHE WAS NOT TERMINATED, THAT SHE HAD RESIGNED BECAUSE SHE WAS NOT A GOOD FIT WITH THE FACILITY. IN AN INTERVIEW ON 6/9/11 AT 11:35 AM, RN #15 STATED SHE WAS THE NURSE WHO TRANSFERRED RESIDENT #105 TO THE HOSPITAL. RN #15 STATED SHE CAME ON FOR HER FIRST SHIFT AND RN #3 TOLD HER IN REPORT THAT RESIDENT #105 NEEDED TO BE SENT TO THE HOSPITAL, THAT SHE (RN#3) HAD GIVEN RESIDENT #105 HER INHALER, BUT SHE WAS STILL WHEEZING. RN #15 STATED SHE ASKED RN #3 IF RESIDENT #105 HAD A [DIAGNOSES REDACTED]. RN #15 STATED SHE ASKED RN #3 WHAT RESIDENT #105'S OXYGEN LEVEL WAS AND RN #3 STATED SHE DIDN'T KNOW. RN #15 STATED SHE ASKED IF RESIDENT #105 HAD ANY [MEDICATION NAME] ORDERED AND RN #3 TOLD HER THAT THE DOCTOR HAD CALLED THE NIGHT BEFORE AND ORDERED [MEDICATION NAME] AND [MEDICATION NAME], BUT SHE HADN'T GIVEN IT. RN #15 STATED SHE AND RN #3 WENT INTO RESIDENT #105'S ROOM AND FOUND HER TO BE ON THE PHONE WITH HER HUSBAND AND SHE (RESIDENT #105) "COULD BARELY BREATHE" AND WAS USING HER ACCESSORY MUSCLES TO BREATHE. RN #15 STATED SHE CHECKED RESIDENT #105'S OXYGEN LEVEL AND IT WAS 69 PERCENT, SO SHE TOLD RN #3 TO GET THE OXYGEN, AND THEN SHE (RN #15) CALLED THE DOCTOR. RN #15 STATED RESIDENT #105'S HUSBAND THEN CALLED HER (RN #15) AND STATED THAT HIS WIFE COULDN'T BREATHE. RN #15 STATED SHE REASSURED THE HUSBAND AND TOLD HIM THAT SHE WAS BEING SENT TO THE HOSPITAL RIGHT AWAY. RN #15 STATED SHE THEN TOLD RN #3 TO GIVE [MEDICATION NAME] TO RESIDENT #105. RN #15 STATED SHE SAT IN THE ROOM NEXT TO RESIDENT #105 UNTIL THE AMBULANCE ARRIVED. RN #15 STATED RN #3 KEPT COMING IN THE ROOM TO TALK ABOUT OTHER RESIDENTS AND ASKED WHAT TIME SHE SHOULD PUT ON THE MEDICATION SHEET FOR SOME MEDICATION. RN #15 STATED, "IT WAS RIDICULOUS" RN #15 STATED SHE TOLD RN #3 THAT IT WASN'T THE APPROPRIATE TIME FOR THAT, AND HER FOCUS SHOULD BE ON RESIDENT #105 RIGHT NOW. A CORRECTIVE ACTION FORM DATED 5/31/11, WAS GIVEN TO THE SURVEYOR ON 6/7/11 BY THE DON, DOCUMENTED ON 5/26/11 RN #3 FAILED TO COMPLETE A NURSING ASSESSMENT/COMMUNICATE THE CHANGE IN CONDITION TO THE ON-CALL NURSE PRACTITIONER FOR A RESIDENT THAT WAS EXPERIENCING RESPIRATORY DIFFICULTY. THE RESIDENT SUBSEQUENTLY WAS TRANSPORTED TO THE emergency room AND admitted to the hospital with [REDACTED].#3'S PERSONNEL FILE DATED BY RN #3 ON 6/1/11 AND SIGNED BY FACILITY HUMAN RESOURCE MANAGER AS RECEIVED ON 6/1/11. ON 6/9/11 AT 1:25 PM, THE ADMINISTRATOR AND THE DON WERE NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 5/25/11 FOR RESIDENT #105 WHO EXPERIENCED SEVERE DIFFICULTY IN BREATHING, WAS TRANSFERRED TO THE HOSPITAL, AND REQUIRED SUBSEQUENT VENTILATOR SUPPORT. THESE DEFICIENT PRACTICES PLACE ALL RESIDENTS WITH AN ACUTE CHANGE OF CONDITION AT HIGH RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON 6/10/11 AT 1:30 PM, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. AS OF 6/10/11, RESIDENT #105 REMAINED hospitalized . 2. NURSE #3 IS NO LONGER EMPLOYED AT THE FACILITY EFFECTIVE 6/1/11. 3. ON 6/9/11, THE ADMINISTRATOR MET WITH THE DON AND HUMAN RESOURCES DIRECTOR TO DISCUSS THE IMPORTANCE OF FOLLOWING THE CORRECTIVE DISCIPLINARY PROCESS IN A TIMELY MANNER FOR DEFICIENT PRACTICES OBSERVED WITH STAFF. 4. ON 6/9/11, THE "CHANGE IN RESIDENT CONDITION" POLICY WAS REVIEWED AND REVISED BY THE ADMINISTRATOR AND DON TO INCLUDE: OBTAINING A PULSE OXIMETRY READING AS INDICATED FOR RESIDENTS EXPERIENCING ACUTE RESPIRATORY DISTRESS/SHORTNESS OF BREATH AND CHANGE IN LEVEL OF CONSCIOUSNESS. 5. ON 6/9/11, AN AUDIT WAS INITIATED BY DON AND ADMINISTRATOR OF THE 24-HOUR NURSING REPORTS TO IDENTIFY RESIDENTS EXPERIENCING ACUTE CHANGE IN CONDITION, AND WILL INCLUDE ENSURING THE IS PHYSICIAN CONTACTED, AND ANY ORDERS RECEIVED HAD BEEN CARRIED OUT. 6. BEGINNING 6/9/11 ALL STAFF WILL RECEIVE TRAINING SPECIFIC TO RESIDENT ABUSE, PHYSICAL, VERBAL, SEXUAL, AND NEGLECT, AND REPORTING REQUIREMENTS. THIS TRAINING WILL STRESS THE DEFINITION OF NEGLECT IN THE FORM OF FAILURE TO PROPERLY ASSESS AND MONITOR A RESIDENT EXPERIENCING AN ACUTE CHANGE OF CONDITION. AS OF 6/9/11 39 OF 136 EMPLOYEES WERE IN-SERVICED. NO FACILITY STAFF WILL BE ALLOWED TO WORK PRIOR TO RECEIVING THE EDUCATION. 7. BEGINNING 6/9/11, ALL LICENSED NURSING STAFF WORKING WILL RECEIVE TRAINING SPECIFIC TO RESIDENT ASSESSMENTS AND CONTACTING THE PHYSICIAN FOR ACUTE CHANGES IN CONDITION. AS OF 6/9/11, 13 OF 32 LICENSED NURSES HAVE RECEIVED THE EDUCATION. NO LICENSED NURSES WILL BE ALLOWED TO WORK PRIOR TO RECEIVING THE EDUCATION. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 6/9/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND SEVERITY OF ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO NOT ALL FACILITY STAFFS HAVE RECEIVED THE IN-SERVICE EDUCATION AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. #

THIS CITATION PERTAINS TO INTAKES MI 923 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING (DID NOT ASSESS AND MONITOR A RESIDENTS ACUTE CHANGE OF CONDITION) FOR 1 OF 8 SAMPLED RESIDENTS (#105) FROM A TOTAL SAMPLE OF 8 RESIDENTS WHO HAD THE POTENTIAL FOR AN ACUTE CHANGE OF CONDITION, RESULTING IN AN IMMEDIATE JEOPARDY FOR RESIDENT #105 WHO EXPERIENCED SEVERE DIFFICULTY IN BREATHING, WAS TRANSFERRED TO THE HOSPITAL, AND REQUIRED SUBSEQUENT VENTILATOR SUPPORT. THESE DEFICIENT PRACTICES PLACE ALL RESIDENTS WITH AN ACUTE CHANGE OF CONDITION AT HIGH RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #105: ACCORDING TO THE FACILITY ROSTER MATRIX, RESIDENT #105 WAS NOT LIVING A THE FACILITY AT THE TIME OF THE INVESTIGATION (5/31/11 THROUGH 6/10/11). REVIEW OF RESIDENT #105's MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE admitted to the facility on [DATE], discharged TO THE hospital on [DATE] AND RE-admitted to the facility on [DATE], THEN discharged TO THE hospital on [DATE]. HER [DIAGNOSES REDACTED]. FACILITY DISCHARGE SUMMARY FOR RESIDENT #105, WHICH WAS UNDATED, DOCUMENTED THAT THE PLAN WAS SHORT TERM REHABILITATION AT THE FACILITY AND THEN RETURN HOME WITH HER HUSBAND. FACILITY NURSE'S NOTES DATED 5/24/11 DOCUMENTED RESIDENT #105 HAD AUDIBLE WHEEZING, THE NURSE PRACTITIONER (NP) WAS NOTIFIED, AND AN ORDER WAS GIVEN FOR A RESPIRATORY INHALER OF [MEDICATION NAME] TO BE GIVEN FOUR TIMES A DAY. FACILITY NURSE'S NOTES DATED 5/25/11 AT 10:15 PM AND SIGNED BY RN #3, DOCUMENTED THAT RESIDENT #105 WAS WHEEZING, PHYSICIAN #13 HAD CALLED AND REQUESTED RESIDENT #101 TO START [MEDICATION NAME] (REMOVES FLUID FROM BODY TO TREAT [MEDICAL CONDITION], AND IMPROVE RESPIRATORY WHEEZING) 20 MG DAILY, AND [MEDICATION NAME] 25 MG DAILY. NURSE'S NOTES DATED 5/25/11 AT 11:30 PM AND SIGNED BY RN #3, DOCUMENTED THAT RESIDENT #105 COMPLAINED OF WHEEZING AND SHORTNESS OF BREATH. THE NEXT ENTRY ON NURSE'S NOTES FOR RESIDENT #105 WAS DATED 5/26/11 AT 0705, AND WAS SIGNED BY RN #15, WHICH DOCUMENTED THAT RESIDENT #105 WAS SEVERELY SHORT OF BREATH WITH AN OXYGEN LEVEL IN HER BLOOD OF 69 PERCENT (NORMAL IS 95 TO 100%). RN #15 DOCUMENTED THAT THE NP WAS CALLED AND THAT RESIDENT #105 WAS SENT TO THE HOSPITAL BY AMBULANCE. HOSPITAL EMERGENCY PHYSICIAN REPORT FOR RESIDENT #105, DATED 5/26/11, DOCUMENTED RESIDENT #105 CAME IN FROM NURSING HOME WITH ACUTE ONSET OF DIFFICULTY IN BREATHING, COUGHING, FEVER AND CHILLS WITH A HYPOXIC (NO OXYGEN SUPPLY) EPISODE IN THE FACILITY. THE HOSPITAL emergency room PHYSICIAN DOCUMENTED THAT RESIDENT #105 WAS admitted to the hospital with [REDACTED]. HOSPITAL HISTORY AND PHYSICAL FOR RESIDENT #105, DATED 5/26/11 DOCUMENTED THAT RESIDENT #105 WAS INTUBATED (BREATHING TUBE PLACED THROUGH THE MOUTH AND INTO THE LUNGS, WHICH IS ATTACHED TO AN OXYGEN SUPPLY, TO PROVIDE OXYGEN) IN THE emergency room . THE HISTORY AND PHYSICAL DOCUMENTED ASSESSMENT AS [MEDICAL CONDITION] WHICH WAS LIKELY SECONDARY TO HEALTHCARE-ACQUIRED PNEUMONIA [MEDICAL CONDITION], AND THAT RESIDENT #105 WAS INTUBATED. IN AN INTERVIEW ON 6/7/11 AT 2:30 PM, PHYSICIAN #13 STATED HE HAD CALLED RN #3 AT APPROXIMATELY 7:00 PM ON 5/25/11 AND TOLD HER TO START RESIDENT #105 ON [MEDICATION NAME] AND [MEDICATION NAME]. PHYSICIAN #13 TOLD RN #3 TO START THE MEDICATION THAT NIGHT AND WAS UPSET WHEN HE FOUND OUT THE NEXT DAY THAT THE RESIDENT HAD BEEN SENT TO THE HOSPITAL, WAS ON VENTILATOR SUPPORT AND THE MEDICATION THAT HE ORDERED, HAD NOT BEEN GIVEN TO RESIDENT #105. PHYSICIAN #13 STATED THAT RESIDENT #105 WAS STILL IN THE HOSPITAL ON VENTILATOR SUPPORT AND WAS NOT DOING WELL. IN AN INTERVIEW ON 6/7/11 AT 2:40 PM, THE DIRECTOR OF NURSING (DON) STATED THAT STAFF RN #3 WAS OBSERVED ON THE FACILITY VIDEO MONITORING SYSTEM ON 5/25/11 ENTERING RESIDENT #105'S ROOM BETWEEN 6:00 AND 7:00 PM, AND THAT STAFF RN #3 WAS NOT OBSERVED ENTERING RESIDENT #105'S ROOM AGAIN UNTIL 6:40 AM ON 5/26/11. THE DON admitted THAT RESIDENT #105 HAD BEEN VERY ILL FOR SEVERAL DAYS, HAD COMPLAINED OF DIFFICULTY BREATHING TO STAFF RN #3 BETWEEN 6:00 AND 7:00 PM ON 5/25/11, AND THAT STAFF RN #3 DID NOT ASSESS THE RESIDENT AGAIN UNTIL 12 HOURS LATER AT 6:40 AM ON 5/26/11. THE DON STATED THAT RESIDENT #105 WAS TRANSFERRED TO THE HOSPITAL THE MORNING OF 5/26/11 AND WAS PLACED ON VENTILATOR SUPPORT. THE DON GAVE A CORRECTIVE ACTION FORM TO THE SURVEYOR WHICH STATED RN #3 HAD BEEN TERMINATED EFFECTIVE 5/31/11. THE FORM WAS NOT SIGNED BY RN #3 OR THE ADMINISTRATOR OR THE DON. THE SURVEYOR INFORMED THE DON THAT A COPY OF RN #3'S SIGNED RESIGNATION LETTER HAD BEEN PROVIDED TO THE SURVEYOR. WHEN ASKED IF RN #3 HAD BEEN TERMINATED OR IF SHE HAD RESIGNED, THE DON STATED RN #3 RESIGNED BEFORE THEY COULD TERMINATE HER. IN AN INTERVIEW ON 6/7/11 AT 3:30 PM, THE DON STATED THAT SHE WAS MISTAKEN AND STAFF RN #3 HAD ALSO GONE INTO THE ROOM OF RESIDENT #105 AT 11:00 PM. IN AN INTERVIEW ON 6/7/11 AT 9:00 AM, RN #3 STATED THAT PRIOR TO RESIDENT #105 BEING TRANSFERRED TO THE hospital on [DATE], SHE HAD BEEN SICK FOR SEVERAL DAYS, AND THE NURSE PRACTITIONER HAD ORDERED AN INHALER FOR HER WHEEZING. RN #3 STATED THE INHALER WOULD HELP FOR A SHORT TIME, BUT RESIDENT 105'S WHEEZING WOULD BE QUITE BAD BY THE TIME SHE WAS DUE FOR THE NEXT DOSE. RN #3 STATED SHE GOT A CALL FROM PHYSICIAN #13 ON THE NIGHT OF 5/25/11 BECAUSE RESIDENT #105'S FAMILY HAD CALLED PHYSICIAN #13 ABOUT THEIR CONCERN'S WITH RESIDENT #105'S DIFFICULTY IN BREATHING. RN #3 STATED PHYSICIAN #13 TOLD HER TO START RESIDENT #105 ON [MEDICATION NAME] AND [MEDICATION NAME] THAT NIGHT. RN #3 STATED SHE DID NOT GIVE THE [MEDICATION NAME] OR [MEDICATION NAME] TO RESIDENT #105 DURING HER SHIFT, BUT DID ADMINISTER THE [MEDICATION NAME] TO RESIDENT #105 JUST BEFORE THE AMBULANCE PERSONNEL TOOK THE RESIDENT OUT TO THE HOSPITAL. RN #3 STATED THAT SHE WENT INTO RESIDENT #105'S ROOM BETWEEN 6:00 PM AND 7:00 PM AND THAT RESIDENT #105 COMPLAINED OF BEING SHORT OF BREATH. RN #3 STATED RESIDENT #105 WAS WHEEZING AT THAT TIME, AND SHE ADMINISTERED THE ORDERED INHALER MEDICATION TO RESIDENT #105. RN #3 STATED BY THE TIME MORNING CAME, SHE WAS READY FOR HER INHALER AGAIN, SO SHE WENT INTO THE RESIDENT'S ROOM TO GIVE IT TO HER. RN #3 STATED RESIDENT #105 STATED SHE DID NOT FEEL WELL AND REQUESTED TO GO TO THE HOSPITAL, SO SHE STARTED THE PAPER WORK TO TRANSFER THE RESIDENT TO THE HOSPITAL. RN #3 STATED SHE DID NOT CHECK ANY VITAL SIGNS ON RESIDENT #105 AT THAT TIME, AND DID NOT KNOW WHAT HER OXYGEN LEVEL WAS. RN #3 STATED RESIDENT #105 WAS WHEEZING, AND WAS EXPERIENCING SHORTNESS OF BREATH. RN #3 STATED SHE THOUGHT RESIDENT #105 WAS JUST ANXIOUS AND WAS NOT CRITICALLY ILL ON HER SHIFT. RN #3 STATED RN # 15 CAME IN FOR THE FIRST SHIFT AT THAT TIME AND TOOK CARE OF TRANSFERRING RESIDENT #105 TO THE HOSPITAL. RN #3 STATED WHEN SHE CAME INTO WORK THE NEXT DAY, THE DON SUSPENDED HER. WHEN ASKED BY THE SURVEYOR IF THE DON TOLD HER WHY SHE WAS BEING SUSPENDED, RN #3 STATED, "THEY KEPT FOCUSING ON THE FACT THAT I HADN'T GONE IN THE RESIDENTS ROOM ALL NIGHT", AND "THEY SAID I GOT ORDERS AND DIDN'T GIVE THE MEDICATION". RN #3 STATED SHE WAS NOT TERMINATED, THAT SHE HAD RESIGNED BECAUSE SHE WAS NOT A GOOD FIT WITH THE FACILITY. IN AN INTERVIEW ON 6/9/11 AT 11:35 AM, RN #15 STATED SHE WAS THE NURSE WHO TRANSFERRED RESIDENT #105 TO THE HOSPITAL. RN #15 STATED SHE CAME ON FOR HER FIRST SHIFT AND RN #3 TOLD HER IN REPORT THAT RESIDENT #105 NEEDED TO BE SENT TO THE HOSPITAL, THAT SHE (RN#3) HAD GIVEN RESIDENT #105 HER INHALER, BUT SHE WAS STILL WHEEZING. RN #15 STATED SHE ASKED RN #3 IF RESIDENT #105 HAD A [DIAGNOSES REDACTED]. RN #15 STATED SHE ASKED RN #3 WHAT RESIDENT #105'S OXYGEN LEVEL WAS AND RN #3 STATED SHE DIDN'T KNOW. RN #15 STATED SHE ASKED IF RESIDENT #105 HAD ANY [MEDICATION NAME] ORDERED AND RN #3 TOLD HER THAT THE DOCTOR HAD CALLED THE NIGHT BEFORE AND ORDERED [MEDICATION NAME] AND [MEDICATION NAME], BUT SHE HADN'T GIVEN IT. RN #15 STATED SHE AND RN #3 WENT INTO RESIDENT #105'S ROOM AND FOUND HER TO BE ON THE PHONE WITH HER HUSBAND AND SHE (RESIDENT #105) "COULD BARELY BREATHE" AND WAS USING HER ACCESSORY MUSCLES TO BREATHE. RN #15 STATED SHE CHECKED RESIDENT #105'S OXYGEN LEVEL AND IT WAS 69 PERCENT, SO SHE TOLD RN #3 TO GET THE OXYGEN, AND THEN SHE (RN #15) CALLED THE DOCTOR. RN #15 STATED RESIDENT #105'S HUSBAND THEN CALLED HER (RN #15) AND STATED THAT HIS WIFE COULDN'T BREATHE. RN #15 STATED SHE REASSURED THE HUSBAND AND TOLD HIM THAT SHE WAS BEING SENT TO THE HOSPITAL RIGHT AWAY. RN #15 STATED SHE THEN TOLD RN #3 TO GIVE [MEDICATION NAME] TO RESIDENT #105. RN #15 STATED SHE SAT IN THE ROOM NEXT TO RESIDENT #105 UNTIL THE AMBULANCE ARRIVED. RN #15 STATED RN #3 KEPT COMING IN THE ROOM TO TALK ABOUT OTHER RESIDENTS AND ASKED WHAT TIME SHE SHOULD PUT ON THE MEDICATION SHEET FOR SOME MEDICATION. RN #15 STATED, "IT WAS RIDICULOUS" RN #15 STATED SHE TOLD RN #3 THAT IT WASN'T THE APPROPRIATE TIME FOR THAT, AND HER FOCUS SHOULD BE ON RESIDENT #105 RIGHT NOW. A CORRECTIVE ACTION FORM DATED 5/31/11, WAS GIVEN TO THE SURVEYOR ON 6/7/11 BY THE DON, DOCUMENTED ON 5/26/11 RN #3 FAILED TO COMPLETE A NURSING ASSESSMENT/COMMUNICATE THE CHANGE IN CONDITION TO THE ON-CALL NURSE PRACTITIONER FOR A RESIDENT THAT WAS EXPERIENCING RESPIRATORY DIFFICULTY. THE RESIDENT SUBSEQUENTLY WAS TRANSPORTED TO THE emergency room AND admitted to the hospital with [REDACTED]. ON 6/9/11 AT 1:25 PM, THE ADMINISTRATOR AND THE DON WERE NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 5/25/11 FOR RESIDENT #105 WHO EXPERIENCED SEVERE DIFFICULTY IN BREATHING, WAS TRANSFERRED TO THE HOSPITAL, AND REQUIRED SUBSEQUENT VENTILATOR SUPPORT. THESE DEFICIENT PRACTICES PLACE ALL RESIDENTS WITH AN ACUTE CHANGE OF CONDITION AT HIGH RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON 6/10/11 AT 1:30 PM, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. AS OF 6/10/11, RESIDENT #105 REMAINED hospitalized . 2. NURSE #3 IS NO LONGER EMPLOYED AT THE FACILITY EFFECTIVE 6/1/11. 3. ON 6/9/11, THE ADMINISTRATOR MET WITH THE DON AND HUMAN RESOURCES DIRECTOR TO DISCUSS THE IMPORTANCE OF FOLLOWING THE CORRECTIVE DISCIPLINARY PROCESS IN A TIMELY MANNER FOR DEFICIENT PRACTICES OBSERVED WITH STAFF. 4. ON 6/9/11, THE "CHANGE IN RESIDENT CONDITION" POLICY WAS REVIEWED AND REVISED BY THE ADMINISTRATOR AND DON TO INCLUDE: OBTAINING A PULSE OXIMETRY READING AS INDICATED FOR RESIDENTS EXPERIENCING ACUTE RESPIRATORY DISTRESS/SHORTNESS OF BREATH AND CHANGE IN LEVEL OF CONSCIOUSNESS. 5. ON 6/9/11, AN AUDIT WAS INITIATED BY DON AND ADMINISTRATOR OF THE 24-HOUR NURSING REPORTS TO IDENTIFY RESIDENTS EXPERIENCING ACUTE CHANGE IN CONDITION, AND WILL INCLUDE ENSURING THE IS PHYSICIAN CONTACTED, AND ANY ORDERS RECEIVED HAD BEEN CARRIED OUT. 6. BEGINNING 6/9/11 ALL STAFF WILL RECEIVE TRAINING SPECIFIC TO RESIDENT ABUSE, PHYSICAL, VERBAL, SEXUAL, AND NEGLECT, AND REPORTING REQUIREMENTS. THIS TRAINING WILL STRESS THE DEFINITION OF NEGLECT IN THE FORM OF FAILURE TO PROPERLY ASSESS AND MONITOR A RESIDENT EXPERIENCING AN ACUTE CHANGE OF CONDITION. AS OF 6/9/11 39 OF 136 EMPLOYEES WERE IN-SERVICED. NO FACILITY STAFF WILL BE ALLOWED TO WORK PRIOR TO RECEIVING THE EDUCATION. 7. BEGINNING 6/9/11, ALL LICENSED NURSING STAFF WORKING WILL RECEIVE TRAINING SPECIFIC TO RESIDENT ASSESSMENTS AND CONTACTING THE PHYSICIAN FOR ACUTE CHANGES IN CONDITION. AS OF 6/9/11, 13 OF 32 LICENSED NURSES HAVE RECEIVED THE EDUCATION. NO LICENSED NURSES WILL BE ALLOWED TO WORK PRIOR TO RECEIVING THE EDUCATION. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 6/9/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND SEVERITY OF ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO NOT ALL FACILITY STAFFS HAVE RECEIVED THE IN-SERVICE EDUCATION AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. #

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE CARE AND SERVICES TO ADDRESS AND MANAGE PAIN IN 3 (#1, #8, #10) OF 17 RESIDENTS REVIEWED IN A TOTAL SAMPLE OF 20 RESIDENTS, RESULTING IN INEFFECTIVE PAIN RECOGNITION AND MANAGEMENT THAT PLACES RESIDENTS AT RISK OF A DIMINISHED QUALITY OF LIFE. FINDINGS INCLUDE: RESIDENT #1 IS A [AGE] year OLD FEMALE THAT WAS ORIGINALLY admitted TO BORGESS GARDENS ON 7/11/05 WITH A [DIAGNOSES REDACTED]. RESIDENT IS NOT ABLE TO ANSWER SIMPLE QUESTIONS OR COMMUNICATE VERBALLY. RESIDENT #1 IS DEPENDENT IN ADL (ACTIVITIES OF DAILY LIVING) CARE. ACCORDING TO MOST RECENT MDS (MINIMUM DATA SET), ASSESSMENT REFERENCE DATE OF 4/18/11, RESIDENT ' S COGNITION IS MODERATELY IMPAIRED AND DID NOT IDENTIFY INDICATORS OF PAIN. IN A RECORD REVIEW, ON 5/25/11 RESIDENT #1 RECEIVED an order for [REDACTED]. DURING AN OBSERVATION OF A DRESSING CHANGE ON 6/8/11 AT 2:05 P.M., IN RESIDENT #1'S ROOM, THE RESIDENT WAS OBSERVED WITH FACIAL GRIMACING WHEN NURSE "M" AND CNA "N" LIFTED THE RESIDENTS LEFT LEG TO PERFORM TREATMENT TO THE LEFT FOOT WOUND. NURSE " M " STATED THAT SHE GAVE THE RESIDENT SCHEDULED [MEDICATION NAME] AT 1:30 P.M. NURSE " M " ALSO STATED THAT THE DOCTOR HAD REMOVED ESCHAR FROM THIS WOUND THIS MORNING. NURSE " M " DID NOT ACKNOWLEDGE THE FACIAL GRIMACING. NURSE " M " DID NOT DOCUMENT PAIN OBSERVED OR THE EFFECTIVENESS OF THE [MEDICATION NAME] IN THE " CLINICAL RECORD " OBSERVED DURING THE DRESSING CHANGE ON 6/8/11. AS OF 6/9/11 AT 9:00 A.M., THE LAST NURSES ' NOTE IN THE DOCUMENT TITLED " CLINICAL RECORD " WAS DATED 06/02/11 AT 1925 (7:25 P.M.). THERE WAS ON ANY DOCUMENTATION IN THE " CLINICAL RECORD " REGARDING THE PRESENCE OR ABSENCE OF PAIN BETWEEN 6/2/11 AT 7:25 P.M. AND 6/9/11 AT 9:00 A.M. THE POLICY AND PROCEDURE TITLED " PAIN MANAGEMENT POLICY " , EFFECTIVE DATE OF 1/10/03, STATES THAT THE NURSE IS TO ASSESS THE EFFECTIVENESS OF TREATMENT ON A REGULAR BASIS. ON 6/8/11 AT 12:05 P.M., IN THE OAKS DINING ROOM, STAFF " T " RUBBED RESIDENT #1 ' S RIGHT ARM AFTER TRYING TO GIVE BITE OF FOOD, RESIDENT GRIMACED IN RESPONSE. ON 6/9/11 AT 12:35 P.M. IN THE OAKS DINING ROOM, RESIDENT #1 WAS SITTING AT THE TABLE FOLLOWING HER LUNCH MEAL AND WAS OBSERVED WITH FACIAL GRIMACING AND CLENCHED TEETH, THE RESIDENT WAS RUBBING SELF WITH RIGHT HAND BETWEEN THE LEGS. THIS BEHAVIOR WAS OBSERVED 7 TIMES WHILE SITTING IN THE OAKS DINING ROOM WITHOUT ACKNOWLEDGEMENT BY STAFF. IN AN INTERVIEW ON 6/10/11 AT 10:35 A.M. WITH DPOA (DURABLE POWER OF ATTORNEY) OF RESIDENT #1, SHE STATED THAT SHE HAS NOTED FACIAL GRIMACING WHEN VISITING RESIDENT AND FEELS IT MAY BE RELATED TO BEING FRIGHTENED OR ANXIOUS. THE " CLINICAL RECORD " WAS REVIEWED FROM 4/21/11 TO 6/2/11 AND DID NOT INDICATE OBSERVATIONS OF FACIAL GRIMACING DESPITE OBSERVATIONS NOTED ON 6/8/11 AND 6/9/11 AND OBSERVATIONS PREVIOUSLY NOTED BY DPOA. THE DON WAS INTERVIEWED ON 6/10/11 AT 11:45 A.M., AND STATED WAS NOT ABLE TO FIND ANY RECENT PAIN ASSESSMENTS FOR RESIDENTS #1. THE DON STATED THAT SHE DID NOT FIND IN THE RECORD THAT PAIN WAS ASSESSED AT TIME OF STARTING [MEDICATION NAME] ON 5/25/11, AND WAS NOT SURE WHY TYLENOL WAS DISCONTINUED AND [MEDICATION NAME] STARTED. THERE WAS NOT AN ASSESSMENT OR NURSES NOTE PROVIDING JUSTIFICATION IN THE CHANGE OF PAIN MEDICATION, FROM TYLENOL TO [MEDICATION NAME] OR THE EFFECTIVENESS OF THAT MEDICATION CHANGE. THE MOST RECENT " PAIN ASSESSMENT " IN THE CLINICAL RECORD WAS DATED 5/3/11 AND DID NOT INDICATE SIGNS OR SYMPTOMS OF PAIN AND DID NOT INCLUDE THE " DISCOMFORT SCALE FOR DEMENTIA OF ALZHEIMER ' S TYPE OR NON VERBAL RESIDENTS " ASSESSMENT. IN REVIEWING THE PREVIOUS " PAIN ASSESSMENT " DATED 1/22/11 WITH PAGE 2 TITLED " DISCOMFORT SCALE FOR DEMENTIA OF ALZHEIMER ' S TYPE OR NON VERBAL RESIDENTS " , A CALM RELAXED FACIAL EXPRESSION AND RELAXED BODY LANGUAGE WAS NOTED. RESIDENT #8 IS A [AGE] year OLD FEMALE admitted TO BORGESS GARDENS ON 10/11/07 WITH A [DIAGNOSES REDACTED]. RESIDENT #8 IS DEPENDENT IN ADL (ACTIVITIES OF DAILY LIVING) CARE. RESIDENT WAS SIGNED ONTO HOSPICE ON 6/9/10 AND RECENTLY RE-CERTIFIED WITH THE 6 TH BENEFIT PERIOD FROM 6/4/11 TO 8/2/11, WITH THE PRIMARY [DIAGNOSES REDACTED]. ACCORDING TO MOST RECENT MDS (MINIMUM DATA SET), ASSESSMENT REFERENCE DATE 4/11/11, RESIDENT ' S COGNITION IS MODERATELY IMPAIRED AND DID NOT IDENTIFY INDICATORS OF PAIN. RESIDENT #8 IS NON VERBAL. In a record review titled " NP FACE TO FACE " , HOSPICE RECERTIFICATION, DATED 05/13/2011, IT STATES RESIDENT #8 HAS HAD INCREASED PAIN IN THE RIGHT HAND IN WHICH INDOCAM MEDICATION AND A RIGHT HAND SPLINT WAS OBTAINED. IN A RECORD REVIEW, A DOCUMENT TITLED " BORGESS GARDENS PAIN ASSESSMENT " WAS LAST COMPLETED ON 4/19/2011 AND THE NURSE DOCUMENTED THAT THE RESIDENT DID NOT HAVE SIGNS OR SYMPTOMS OF PAIN. THE CARE PLAN FOR " RISK FOR PAIN " WAS IMPLEMENTED ON 9/18/09 AND WAS LAST REVIEWED ON 4/19/11. THE FACILITY FAILED TO ASSESS PAIN AND CARE PLAN PAIN INTERVENTIONS IDENTIFIED AND IMPLEMENTED BY HOSPICE. THE POLICY AND PROCEDURE TITLED " PAIN MANAGEMENT POLICY " , EFFECTIVE DATE OF 1/10/03, STATES THAT THE NURSE IS TO ASSESS THE EFFECTIVENESS OF TREATMENT ON A REGULAR BASIS. THE CARE PLAN AT WHICH " RISK FOR PAIN " WAS STARTED ON 09/18/09 AND LAST REVIEWED ON 4/19/11 AND WAS NOT REVIEWED OR UPDATED WITH INCREASED PAIN NOTED. THE CARE PLAN TITLED " HOSPICE " , DATED AS ONSET OF 08/18/10, WAS LAST REVIEWED ON 4/19/11. RESIDENT # 8 WAS RE-CERTIFIED FOR HOSPICE ON 5/13/11, FOR CERTIFICATION PERIOD FROM 6/4/11 TO 8/2/11, IN WHICH INCREASED PAIN CARE PLAN IS NOTED IN THE RIGHT HAND, NEITHER THE FACILITY PAIN NOR HOSPICE CARE PLAN (LAST REVIEWED 4/19/11), ACKNOWLEDGES THE RESIDENTS RIGHT HAND PAIN. ( ) ( ) ACCORDING TO THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RESIDENT #10 WAS RECEIVING [MEDICAL TREATMENT] AT A NEARBY DIALYSES CENTER EVERY MONDAY, WEDNESDAY AND FRIDAY. COMMUNICATION SHEETS WERE TO BE USED BETWEEN THE FACILITY AND THE [MEDICAL TREATMENT] CENTER THAT INCLUDE WHAT MEDICATIONS WERE GIVEN, THE RESIDENTS PRE AND POST WEIGHT, FOOD AND FLUID INTAKE, AND HOW THE PROCEDURE WAS TOLERATED. ALONG WITH A SECTION FOR A NARRATIVE TO BE WRITTEN BY OTHER DISCIPLINES AS TO WHAT THE RESIDENTS NEEDS WERE. THE COMMUNICATION SHEETS FOR 5/18, 5/20, 6/6, 6/8 WERE UNABLE TO BE LOCATED IN THE "DIALYSES COMMUNICATION" BOOK LOCATED AT THE NURSES STATION. ON 6/9/11 AT 2:10 P.M. IN THE NURSES OFFICE AT THE SUPERIOR COTTAGE, DURING AN INTERVIEW WITH THE CLINICAL COORDINATOR (STAFF "B") REPORTED THAT THE INFORMATION SHOULD BE IN THE COMMUNICATION BINDER SO THAT THE NURSE THAT CARED FOR THE RESIDENT WOULD BE ABREAST OF THE INFORMATION AND NEEDS THE RESIDENT HAD. STAFF "B" WAS NOT CERTAIN WHERE THE INFORMATION WAS OR IF THERE WERE ANY ISSUES FROM THE [MEDICAL TREATMENT] CENTER. ( )

THIS CITATION PERTAINS TO MI 923. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ADMINISTER THE FACILITY IN A MANNER WHICH ALLOWED 2 (#101, #105) OF 8 SAMPLED RESIDENTS OF A TOTAL SAMPLE OF 8, TO MAINTAIN OR ATTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL BEING, RESULTING IN AN IMMEDIATE JEOPARDY WHEN THE FACILITY ADMINISTRATIVE STAFF FAILED TO PREVENT THE ABUSE OF RESIDENT #101; FAILED TO PREVENT THE NEGLECT OF RESIDENT #105; REPORT THE ABUSE OF RESIDENT #101, WHICH OCCURRED ON 12/8/10, AND THE NEGLECT OF RESIDENT #105, WHICH OCCURRED ON 5/25/11, AND THE FAILURE OF THE FACILITY ADMINISTRATIVE STAFF TO DISCIPLINE OR IN-SERVICE STAFF RN #3 FOR THE ABUSE OF RESIDENT #101. FINDINGS INCLUDE: RESIDENT #101: REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. physician progress notes [REDACTED]. physician progress notes [REDACTED]. physician progress notes [REDACTED].#101 HAS CONTRACTURE OF BILATERAL KNEES AND HIPS. physician progress notes [REDACTED]. physician progress notes [REDACTED]. LEFT QUADRICEPS STRAIN WITHOUT COMPLETE LIGAMENT TEAR THIRD DEGREE. FACILITY NURSE'S NOTES FOR RESIDENT #101 DATED 12/8/10 AT 11:00 PM, AND SIGNED BY RN #3 DOCUMENTED FOLEY CATHETER INSERTED. FACILITY NURSE'S NOTES FOR RESIDENT #101 DATED 12/9/10 AT 3:00 AM DOCUMENTED THAT RESIDENT #101 WAS OBSERVED TO HAVE LEFT LEG PARTIALLY OFF BED, BILATERAL LEGS VERY RELAXED, WHICH WERE USUALLY CONTRACTED TIGHTLY TOGETHER AND VERY HARD TO SEPARATE. NURSE'S NOTES DATED 12/9/10 AT 7:20 AM DOCUMENTED RESIDENT #101 OBSERVED IN FROG LEGGED POSITION AND FLINCHED WITH PAIN WHEN LEFT LEG AND HIP TOUCHED AND THAT THE NURSE PRACTITIONER AND DIRECTOR OF NURSING WERE NOTIFIED. DURING OBSERVATIONS ON 6/3/11, RESIDENT #101 WAS OBSERVED SITTING IN A WHEELCHAIR IN THE DINING ROOM, WITH A CUSHION PLACED BETWEEN HER LEGS AND CONE SHAPED SPLINTS IN THE PALM OF BOTH HANDS. CNA #19 WAS ASSISTING RESIDENT #101 WITH HER MEAL. CNA #19 TOLD THE SURVEYOR THAT THE PURPOSE OF THE CUSHION BETWEEN RESIDENT #101'S LEGS WAS TO KEEP HER LEGS POSITIONED BECAUSE SHE HAD BAD CONTRACTURES WHICH MADE HER LEGS STAY TOGETHER. CNA #19 ALSO STATED THAT RESIDENT #101 HAD CONTRACTURES IN HER HANDS. IN AN INTERVIEW ON 6/7/11 AT 8:45 AM, LPN #5 STATED THAT SHE AND CNA (CERTIFIED NURSE AIDE) #9 HAD FOUND RESIDENT #101 IN HER BED, DURING THE NIGHT SHIFT, WITH HER LEGS APART AND HER LEFT LEG PARTIALLY OFF THE EDGE OF THE BED. LPN #5 STATED THIS WAS VERY UNUSUAL FOR RESIDENT #101, BECAUSE HER LEGS HAD ALWAYS BEEN CONTRACTED TOGETHER AT THE KNEES. LPN #5 STATED SHE HELPED CNA#9 CHANGE RESIDENT #101'S INCONTINENT BRIEF, AND THE RESIDENT FLINCHED WHEN HER LEFT LEG WAS MOVED. LPN #5 STATED RESIDENT #101 WAS LAYING IN A SORT OF FROG LEG POSITION (LEGS APART AT THE KNEES WITH LEGS SLIGHTLY BENT). LPN #5 STATED SHE HAD THE NURSE WHO WAS COMING ON FOR THE NEXT SHIFT ASSESS RESIDENT #101, WHO ALSO THOUGHT IT WAS UNUSUAL FOR RESIDENT #101'S LEGS TO BE APART. LPN #5 STATED SHE CALLED THE NURSE PRACTITIONER, WHO ORDERED SOME PAIN MEDICATIONS AND AN XRAY OF RESIDENT #101'S LEFT HIP. LPN #5 STATED SHE THOUGHT THERE HAD BEEN AN INJURY TO RESIDENT #101'S LEFT HIP, SO SHE FILLED OUT AN INCIDENT REPORT AND BEGAN TO ASK STAFF MEMBERS IF THEY KNEW ANYTHING ABOUT AN INJURY TO RESIDENT #101'S LEFT LEG. LPN #5 STATED CNA #8 TOLD HER IT MUST HAVE HAPPENED WHEN RN #3 PUT A CATHETER IN RESIDENT #101. LPN #5 STATED SHE ASKED CNA #8 WHY SHE THOUGHT THAT AND CNA #8 STATED THAT A CNA HAD TOLD HER THAT RN#3 HAD HER AND ANOTHER CNA PRY RESIDENT #101'S LEGS APART FOR A CATHETER PROCEDURE AND THAT HER LEGS WERE RELAXED AFTER THE PROCEDURE. LPN #5 STATED SHE REPORTED THE INCIDENT TO THE DIRECTOR OF NURSING AND THE ADMINISTRATOR. LPN #5 STATED THAT 2 DAYS LATER, RESIDENT #101'S LEFT THIGH HAD BRUISES ALL OVER IT AND WOULD FLINCH WITH PAIN EVERY TIME HER LEFT LEG WAS MOVED OR TOUCHED. IN AN INTERVIEW ON 6/7/11 AT 1:00 PM, LPN #4 STATED SHE WAS CALLED INTO RESIDENT #101'S ROOM BY LPN #5 TO ASSESS THE RESIDENT'S LEGS. LPN #4 STATED RESIDENT #101'S LEGS WERE USUALLY STRAIGHT AND TOGETHER OR CROSSED, BUT ON THE MORNING OF 12/9/10, SHE (LPN) OBSERVED RESIDENT #101 IN HER BED WITH HER LEGS APART. LPN #4 STATED CNA #8 STATED SHE HAD HEARD RN #3 HAD PLACED A CATHETER IN RESIDENT #101 THE NIGHT BEFORE AND HAD DIFFICULTY DOING IT. LPN #4 STATED SHE HAD PLACED CATHETERS IN RESIDENT #101 SEVERAL TIMES IN THE PAST AND HAD ALWAYS PLACED HER ON HER SIDE FOR THE PROCEDURE DUE TO HER CONTRACTED LEGS. LPN #4 STATED THAT SEVERAL DAYS LATER, BRUISING APPEARED ON RESIDENT #101'S LEGS. IN AN INTERVIEW ON 6/8/11 AT 9:15 AM, CNA #8 STATED THAT CNA #6 CAME UP TO HER IN THE HALL AND ASKED HER IF SHE HAD SEEN RESIDENT #101. CNA #8 STATED SHE ASKED WHY AND CNA #6 TOLD HER THAT SHE AND CNA #7 HAD HELD RESIDENT #101'S LEGS APART WHILE RN #3 PLACE A CATHETER IN HER, AND THAT RESIDENT #101'S LEGS WERE NO LONGER CONTRACTED. CNA #8 STATED CNA #6 WAS VERY EXCITED AND CALLED IT A "MIRACLE OF GOD". IN AN INTERVIEW ON 6/3/11 AT 11:30 AM, CNA #6 STATED THAT ON 12/8/10, SHE AND CNA #7 ASSISTED RN #3 WITH A CATHETER PLACEMENT FOR RESIDENT #101. CNA #6 STATED THAT SHE AND CNA #7 WERE HOLDING RESIDENT #101'S LEGS DURING THE PROCEDURE AND THAT RESIDENT #101'S LEGS WERE EXTREMELY STIFF AND HAD BEEN THAT WAY FOR THE THREE YEARS THAT SHE HAD WORKED AT THE FACILITY. CNA #6 STATED THAT DURING THE PROCEDURE, RN #3 WAS GETTING FRUSTRATED AND YELLING AT HER AND CNA#7 TO OPEN RESIDENT #101'S LEGS HARDER. CNA #6 STATED THAT SHE WAS TOLD LATER BY A NURSE THAT AN INJURY TO RESIDENT #101'S LEFT LEG WAS FROM THE CATHETER PROCEDURE. IN AN INTERVIEW ON 6/3/11 AT 11:50 AM, RN #3 STATED SHE REMEMBERED THE INJURY TO RESIDENT #101'S LEG, AND THAT SHE HAD PLACED A FOLEY CATHETER IN RESIDENT #101 THE DAY BEFORE THE INJURY WAS DISCOVERED. RN #3 STATED "ALL I KNOW IS THAT THEY TRIED TO ACCUSE ME OF CAUSING HER (RESIDENT #101) TO HAVE FLACCID LEGS AND HER LEGS NOT LAYING RIGHT". RN #3 STATED THERE WAS AN XRAY DONE OF RESIDENT #101'S LEG AND IT WAS NEGATIVE FOR FRACTURE. RN #3 STATED, "IF THERE WAS ANYTHING WRONG WITH HER (RESIDENT #101), AND I DON'T THINK THERE WAS, IT WASN'T RELATED TO THE FOLEY (CATHETER) PLACEMENT I DID. RN #3 STATED NO DOCTOR HAD DOCUMENTED THAT RESIDENT #101 HAD AN INJURY. RN #3 STATED CNA #6 AND CNA #7 HELPED HOLD RESIDENT #101 IN PLACE SO THE CATHETER COULD BE INSERTED, AND THAT RESIDENT #101 WAS IN THE LITHOTOMY POSITION (POSITION IN WHICH THE PATIENT IS ON THEIR BACK WITH THE HIPS AND KNEES FLEXED AND THIGHS APART) WHEN THE CATHETER WAS PLACED. RN #3 STATED SHE WAS NOT DISCIPLINED FOR ANYTHING INVOLVING THE CATHETER PROCEDURE AND DENIED RECEIVING ANY SPECIAL TRAINING OR INSERVICING ON CATHETER INSERTION FOR RESIDENTS WITH CONTRACTURES. ON 6/7/11 AT 2:00 PM, NURSE PRACTITIONER #12 STATED THAT RESIDENT #101 had a history of [REDACTED]. NURSE PRACTITIONER #12 STATED THAT SHE ASSESSED RESIDENT #101 SHORTLY AFTER THE CATHETER PLACEMENT ON 12/8/10 AND FOUND HER LEFT LEG WAS NOT CONTRACTED ANYMORE. NURSE PRACTITIONER #12 STATED THAT RESIDENT #101 HAD SUFFERED A LIGAMENT INJURY TO HER LEFT LEG, A MUSCLE STRAIN IN HER LEFT LEG AND HAD DEVELOPED BRUISING AND SWELLING ON HER LEFT INNER LEG, GROIN AND LABIA AFTER THE CATHETER PROCEDURE. NURSE PRACTITIONER #12 STATED THAT THE, "COLOR OF THE BRUISING DATED THE INJURY BACK TO THE CATHETER PLACEMENT TIME." IN AN INTERVIEW ON 6/1/11 AT 12:10 PM, THE DIRECTOR OF NURSING STATED THAT THIRD SHIFT CNA #9 AND THIRD SHIFT LPN #5 HAD DISCOVERED BRUISING ON RESIDENT #101'S LEGS ON THE THIRD SHIFT AND REPORTED IT TO HER (DIRECTOR OF NURSING). THE DIRECTOR OF NURSING STATED CNA #6 AND CNA #7 DESCRIBED TO HER THAT THEY HELD RESIDENT #101'S LEGS BACK WHILE RN #3 WAS "CATHING" RESIDENT #101. IN AN INTERVIEW ON 6/3/11 AT 10:50 AM, THE DIRECTOR OF NURSING STATED WHEN SHE CAME INTO WORK IN THE MORNING ON 12/9/10, LPN #5 REPORTED TO HER THAT SOMETHING WAS WRONG WITH RESIDENT #101 AND THAT THE RESIDENT MAY HAVE A [MEDICAL CONDITION]. THE DIRECTOR OF NURSING STATED THAT CNA #9 AND LPN #5 WERE CONCERNED BECAUSE RESIDENT #101'S LEGS WERE NORMALLY CONTRACTED TIGHT TOGETHER, AND NOW HER LEGS WERE VERY RELAXED AND THEY HAD FOUND HER IN A FROG LEG POSITION. THE DIRECTOR OF NURSING STATE SHE WAS UPSET WITH LPN #5 BECAUSE SHE HAD INITIATED AN INVESTIGATION DURING THE NIGHT, AND HAD NOT CALLED HER (DIRECTOR OF NURSING) IMMEDIATELY REGARDING THE INJURY TO RESIDENT #101. WHEN THE SURVEYOR ASKED THE DIRECTOR OF NURSING WHAT THE RESULTS OF HER (DIRECTOR OF NURSING) INVESTIGATION IN THE INJURIES OF RESIDENT #101 WERE, THE DIRECTOR OF NURSING STATED THAT RN #3 HAD CNA #6 AND CNA #7 HOLD AND SPREAD THE LEGS OF RESIDENT #101 DURING A CATHETERIZATION PROCEDURE. THE DIRECTOR OF NURSING STATED SHE REMEMBERED HAVING A CONVERSATION WITH THE NURSE PRACTITIONER, BECAUSE THE XRAY OF RESIDENT #101'S LEFT HIP SUGGESTED AN MRI (MAGNETIC IMAGING) BE DONE, WHICH WOULD HAVE REQUIRED SEDATION OF RESIDENT #101. THE DIRECTOR OF NURSING STATED IT WAS DETERMINED THAT RN #3 HAD AN ORDER FROM THE PHYSICIAN TO PLACE A CATHETER IN RESIDENT #101 AND THAT IS WHAT SHE WAS DOING. THE DIRECTOR OF NURSING STATED SHE DID ASSESS RESIDENT #101 SEVERAL DAYS AFTER THE CATHETER PROCEDURE AND OBSERVED YELLOW BRUISING ON HER LEGS AND THAT HER LEGS WERE RELAXED. THE DIRECTOR OF NURSING STATED SHE HAD THE FACILITY STAFF EDUCATOR DO A ONE TO ONE INSERVICE WITH RN #3 ON HOW TO PLACE A CATHETER ON A FEMALE RESIDENT WITH CONTRACTURES IN A MORE COMFORTABLE MANNER. WHEN THE SURVEYOR ASKED THE DIRECTOR OF NURSING WHY SHE WANTED RN #3 EDUCATED, THE DIRECTOR OF NURSING STATED THAT THERE WERE OTHER WAYS TO CATHETERIZE A RESIDENT WITH CONTRACTURES SO IT IS MORE COMFORTABLE. THE DIRECTOR OF NURSING WAS UNABLE TO PRODUCE DOCUMENTATION OF ANY INSERVICE DONE WITH RN #3 REGARDING CATHETERIZATION OF FEMALE RESIDENTS WITH CONTRACTURES. THE DIRECTOR OF NURSING STATED THAT RN #3 WAS NOT DISCIPLINED FOR THE INJURIES SUSTAINED BY RESIDENT #101. REVIEW OF RN #3'S PERSONNEL RECORD ON 5/31/11 REVEALED A CORRECTIVE ACTION FORM DATED 4/29/11 WHICH DOCUMENTED THAT IS WAS REPORTED TO MANAGEMENT THAT RN #3 DID NOT RESPOND OR FOLLOW UP APPROPRIATELY TO A FAMILY MEMBER REQUEST REGARDING A RESIDENT SAFETY CONCERN. IN ADDITION, IT WAS REPORTED TO MANAGEMENT THAT RN #3'S WORK BEHAVIOR TOWARD CO-WORKERS WAS PERCEIVED AS RUDE AND DISRESPECTFUL. A TYPED LETTER OF RESIGNATION WAS LOCATED IN RN#3'S PERSONNEL FILE DATED BY RN #3 ON 6/1/11 AND SIGNED BY FACILITY HUMAN RESOURCE MANAGER AS RECEIVED ON 6/1/11. IN AN INTERVIEW ON 6/1/11 AT 12:15 PM, THE DIRECTOR OF NURSING AND ADMINISTRATOR STATED THAT THE INJURIES SUSTAINED BY RESIDENT #101 ON 12/8/10 WERE NEVER REPORTED TO THE STATE AGENCY. ON 6/1/11 AT 10:30 AM, THE SURVEYOR REQUESTED A COPY OF THE INCIDENT REPORT WHICH WAS FILLED OUT BY LPN#5 ABOUT THE INJURY OF RESIDENT #101 ON 12/8/10. IN AN INTERVIEW WITH THE ADMINISTRATOR ON 6/3/11, SHE STATED THAT THE FACILITY STAFF WAS UNABLE TO LOCATE AN INCIDENT REPORT FOR THE INJURY OF RESIDENT #101 ON 12/8/10. RESIDENT #105: REVIEW OF RESIDENT #105'S MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE admitted to the facility on [DATE], discharged TO THE hospital on [DATE] AND RE-admitted to the facility on [DATE], THEN discharged TO THE hospital on [DATE]. HER [DIAGNOSES REDACTED]. FACILITY DISCHARGE SUMMARY FOR RESIDENT #105, WHICH WAS UNDATED, DOCUMENTED THAT THE PLAN WAS SHORT TERM REHABILITATION AT BORGESS GARDENS THEN RETURN HOME WITH HER HUSBAND. FACILITY NURSE'S NOTES DATED 5/24/11 DOCUMENTED RESIDENT #105 HAD AUDIBLE WHEEZING, THE NP (NURSE PRACTITIONER) WAS NOTIFIED, AND AN ORDER WAS GIVEN FOR A RESPIRATORY INHALER OF [MEDICATION NAME] TO BE GIVEN FOUR TIMES A DAY. FACILITY NURSE'S NOTES DATED 5/25/11 AT 10:15 PM AND SIGNED BY RN #3, DOCUMENTED THAT RESIDENT #105 WAS WHEEZING, PHYSICIAN #13 HAD CALLED AND REQUESTED RESIDENT #101 TO START [MEDICATION NAME] (REMOVES FLUID FROM BODY TO TREAT [MEDICAL CONDITION], AND IMPROVE RESPIRATORY WHEEZING) 20MG DAILY, AND [MEDICATION NAME] 25 MG DAILY. NURSE'S NOTES DATED 5/25/11 AT 11:30 PM AND SIGNED BY RN #3, DOCUMENTED THAT RESIDENT #105 COMPLAINED OF WHEEZING AND SHORTNESS OF BREATH. THE NEXT ENTRY ON NURSE'S NOTES FOR RESIDENT #105 WAS DATED 5/26/11 AT 0705, AND WAS SIGNED BY RN #15, WHICH DOCUMENTED THAT RESIDENT #105 WAS SEVERELY SHORT OF BREATH WITH AN OXYGEN LEVEL IN HER BLOOD OF 69 PERCENT (NORMAL IS 95 TO 100%). RN #15 DOCUMENTED THAT THE NP WAS CALLED AND THAT RESIDENT #105 WAS SENT TO THE HOSPITAL BY AMBULANCE. HOSPITAL EMERGENCY PHYSICIAN REPORT FOR RESIDENT #105, DATED 5/26/11, DOCUMENTED RESIDENT #105 CAME IN FROM NURSING HOME WITH ACUTE ONSET OF DIFFICULTY IN BREATHING, COUGHING, FEVER AND CHILLS WITH A HYPOXIC (NO OXYGEN SUPPLY) EPISODE IN THE FACILITY. THE HOSPITAL emergency room PHYSICIAN DOCUMENTED THAT RESIDENT #105 WAS admitted to the hospital with [REDACTED]. HOSPITAL HISTORY AND PHYSICAL FOR RESIDENT #105, DATED 5/26/11 DOCUMENTED THAT RESIDENT #105 WAS INTUBATED (BREATHING TUBE PLACED THROUGH THE MOUTH AND INTO THE LUNGS, WHICH IS ATTACHED TO AN OXYGEN SUPPLY, TO PROVIDE OXYGEN) IN THE emergency room . THE HISTORY AND PHYSICAL DOCUMENTED ASSESSMENT AS [MEDICAL CONDITION] WHICH WAS LIKELY SECONDARY TO HEALTHCARE-ACQUIRED PNEUMONIA [MEDICAL CONDITION], AND THAT RESIDENT #105 WAS INTUBATED. IN AN INTERVIEW ON 6/7/11 AT 2:30 PM, PHYSICIAN #13 STATED HE HAD CALLED RN #3 AT APPROXIMATELY 7:00 PM ON 5/25/11 AND TOLD HER TO START RESIDENT #105 ON [MEDICATION NAME] AND [MEDICATION NAME]. PHYSICIAN #13 TOLD RN #3 TO START THE MEDICATION THAT NIGHT AND WAS UPSET WHEN HE FOUND OUT THE NEXT DAY THAT THE RESIDENT HAD BEEN SENT TO THE HOSPITAL, WAS ON VENTILATOR SUPPORT AND THE MEDICATION THAT HE ORDERED, HAD NOT BEEN GIVEN TO RESIDENT #105. PHYSICIAN #13 STATED THAT RESIDENT #105 WAS STILL IN THE HOSPITAL ON VENTILATOR SUPPORT AND WAS NOT DOING WELL. IN AN INTERVIEW ON 6/7/11 AT 2:40 PM, THE DIRECTOR OF NURSING (DON) STATED THAT STAFF RN #3 WAS OBSERVED ON THE FACILITY VIDEO MONITORING SYSTEM ON 5/25/11 ENTERING RESIDENT #105'S ROOM BETWEEN 6:00 AND 7:00 PM, AND THAT STAFF RN #3 WAS NOT OBSERVED ENTERING RESIDENT #105'S ROOM AGAIN UNTIL 6:40 AM ON 5/26/11. THE DON admitted THAT RESIDENT #105 HAD BEEN VERY ILL FOR SEVERAL DAYS, HAD COMPLAINED OF DIFFICULTY BREATHING TO STAFF RN #3 BETWEEN 6:00 AND 7:00 PM ON 5/25/11, AND THAT STAFF RN #3 DID NOT ASSESS THE RESIDENT AGAIN UNTIL 12 HOURS LATER AT 6:40 AM ON 5/26/11. THE DON STATED THAT RESIDENT #105 WAS TRANSFERRED TO THE HOSPITAL THE MORNING OF 5/26/11 AND WAS PLACED ON VENTILATOR SUPPORT. DURING THE INTERVIEW ON 6/7/11 AT 2:40 PM, THE DIRECTOR OF NURSING GAVE A CORRECTIVE ACTION FORM TO THE SURVEYOR WHICH STATED RN #3 HAD BEEN TERMINATED EFFECTIVE 5/31/11. THE FORM WAS NOT SIGNED BY RN #3 OR THE ADMINISTRATOR OR DIRECTOR OF NURSING. THE SURVEYOR INFORMED THE DIRECTOR OF NURSING THAT A COPY OF RN #3'S SIGNED RESIGNATION LETTER HAD BEEN PROVIDED TO THE SURVEYOR. WHEN ASKED IF RN #3 HAD BEEN TERMINATED OR IF SHE HAD RESIGNED, THE DON STATED RN #3 RESIGNED BEFORE THEY COULD TERMINATE HER. IN AN INTERVIEW ON 6/7/11 AT 3:30 PM, THE DON STATED THAT SHE WAS MISTAKEN AND STAFF RN #3 HAD ALSO GONE INTO THE ROOM OF RESIDENT #105 AT 11:00 PM. IN AN INTERVIEW ON 6/7/11 AT 9:00 AM, RN #3 STATED THAT PRIOR TO RESIDENT #105 BEING TRANSFERRED TO THE hospital on [DATE], SHE HAD BEEN SICK FOR SEVERAL DAYS, AND THE NURSE PRACTITIONER HAD ORDERED AN INHALER FOR HER WHEEZING. RN #3 STATED THE INHALER WOULD HELP FOR A SHORT TIME, BUT RESIDENT 105'S WHEEZING WOULD BE QUITE BAD BY THE TIME SHE WAS DUE FOR THE NEXT DOSE. RN #3 STATED SHE GOT A CALL FROM PHYSICIAN #13 ON THE NIGHT OF 5/25/11 BECAUSE RESIDENT #105'S FAMILY HAD CALLED PHYSICIAN #13 ABOUT THEIR CONCERN'S WITH RESIDENT #105'S DIFFICULTY IN BREATHING. RN #3 STATED PHYSICIAN #13 TOLD HER TO START RESIDENT #105 ON [MEDICATION NAME] AND [MEDICATION NAME] THAT NIGHT. RN #3 STATED SHE DID NOT GIVE THE [MEDICATION NAME] OR [MEDICATION NAME] TO RESIDENT #105 DURING HER SHIFT, BUT DID ADMINISTER THE [MEDICATION NAME] TO RESIDENT #105 JUST BEFORE THE AMBULANCE PERSONNEL TOOK THE RESIDENT OUT TO THE HOSPITAL. RN #3 STATED THAT SHE WENT INTO RESIDENT #105'S ROOM BETWEEN 6:00 PM AND 7:00 PM AND THAT RESIDENT #105 COMPLAINED OF BEING SHORT OF BREATH. RN #3 STATED RESIDENT #105 WAS WHEEZING AT THAT TIME, AND SHE ADMINISTERED THE ORDERED INHALER MEDICATION TO RESIDENT #105. RN #3 STATED BY THE TIME MORNING CAME, SHE WAS READY FOR HER INHALER AGAIN, SO SHE WENT INTO THE RESIDENT'S ROOM TO GIVE IT TO HER. RN #3 STATED RESIDENT #105 STATED SHE DID NOT FEEL WELL AND REQUESTED TO GO TO THE HOSPITAL, SO SHE STARTED THE PAPER WORK TO TRANSFER THE RESIDENT TO THE HOSPITAL. RN #3 STATED SHE DID NOT CHECK ANY VITAL SIGNS ON RESIDENT #105 AT THAT TIME, AND DID NOT KNOW WHAT HER OXYGEN LEVEL WAS. RN #3 STATED RESIDENT #105 WAS WHEEZING, AND WAS EXPERIENCING SHORTNESS OF BREATH. RN #3 STATED SHE THOUGHT RESIDENT #105 WAS JUST ANXIOUS AND WAS NOT CRITICALLY ILL ON HER SHIFT. RN #3 STATED RN # 15 CAME IN FOR THE FIRST SHIFT AT THAT TIME AND TOOK CARE OF TRANSFERRING RESIDENT #105 TO THE HOSPITAL. RN #3 STATED WHEN SHE CAME INTO WORK THE NEXT DAY, THE DON SUSPENDED HER. WHEN ASKED BY THE SURVEYOR IF THE DON TOLD HER WHY SHE WAS BEING SUSPENDED, RN #3 STATED, "THEY KEPT FOCUSING ON THE FACT THAT I HADN'T GONE IN THE RESIDENTS ROOM ALL NIGHT", AND "THEY SAID I GOT ORDERS AND DIDN'T GIVE THE MEDICATION". RN #3 STATED SHE WAS NOT TERMINATED, THAT SHE HAD RESIGNED BECAUSE SHE WAS NOT A GOOD FIT WITH THE FACILITY. IN AN INTERVIEW ON 6/9/11 AT 11:35 AM, RN #15 STATED SHE WAS THE NURSE WHO TRANSFERRED RESIDENT #105 TO THE HOSPITAL. RN #15 STATED SHE CAME ON FOR HER FIRST SHIFT AND RN #3 TOLD HER IN REPORT THAT RESIDENT #105 NEEDED TO BE SENT TO THE HOSPITAL, THAT SHE (RN#3) HAD GIVEN RESIDENT #105 HER INHALER, BUT SHE WAS STILL WHEEZING. RN #15 STATED SHE ASKED RN #3 IF RESIDENT #105 HAD A [DIAGNOSES REDACTED]. RN #15 STATED SHE ASKED RN #3 WHAT RESIDENT #105'S OXYGEN LEVEL WAS AND RN #3 STATED SHE DIDN'T KNOW. RN #15 STATED SHE ASKED IF RESIDENT #105 HAD ANY [MEDICATION NAME] ORDERED AND RN #3 TOLD HER THAT THE DOCTOR HAD CALLED THE NIGHT BEFORE AND ORDERED [MEDICATION NAME] AND [MEDICATION NAME], BUT SHE HADN'T GIVEN IT. RN #15 STATED SHE AND RN #3 WENT INTO RESIDENT #105'S ROOM AND FOUND HER TO BE ON THE PHONE WITH HER HUSBAND AND SHE (RESIDENT #105) "COULD BARELY BREATHE" AND WAS USING HER ACCESSORY MUSCLES TO BREATHE. RN #15 STATED SHE CHECKED RESIDENT #105'S OXYGEN LEVEL AND IT WAS 69 PERCENT, SO SHE TOLD RN #3 TO GET THE OXYGEN, AND THEN SHE (RN #15) CALLED THE DOCTOR. RN #15 STATED RESIDENT #105'S HUSBAND THEN CALLED HER (RN #15) AND STATED THAT HIS WIFE COULDN'T BREATHE. RN #15 STATED SHE REASSURED THE HUSBAND AND TOLD HIM THAT SHE WAS BEING SENT TO THE HOSPITAL RIGHT AWAY. RN #15 STATED SHE THEN TOLD RN #3 TO GIVE [MEDICATION NAME] TO RESIDENT #105. RN #15 STATED SHE SAT IN THE ROOM NEXT TO RESIDENT #105 UNTIL THE AMBULANCE ARRIVED. RN #15 STATED RN #3 KEPT COMING IN THE ROOM TO TALK ABOUT OTHER RESIDENTS AND ASK WHAT TIME SHE SHOULD PUT ON THE MEDICATION SHEET FOR SOME MEDICATION. RN #15 STATED, "IT WAS RIDICULOUS" RN #15 STATED SHE TOLD RN #3 THAT IT WASN'T THE APPROPRIATE TIME FOR THAT, AND HER FOCUS SHOULD BE ON RESIDENT #105 RIGHT NOW. REVIEW OF RN #3'S PERSONNEL RECORD ON 5/31/11 REVEALED A CORRECTIVE ACTION FORM DATED 4/29/11 WHICH DOCUMENTED THAT IS WAS REPORTED TO MANAGEMENT THAT RN #3 DID NOT RESPOND OR FOLLOW UP APPROPRIATELY TO A FAMILY MEMBER REQUEST REGARDING A RESIDENT SAFETY CONCERN. IN ADDITION, IT WAS REPORTED TO MANAGEMENT THAT RN #3'S WORK BEHAVIOR TOWARD CO-WORKERS WAS PERCEIVED AS RUDE AND DISRESPECTFUL. A CORRECTIVE ACTION FORM DATED 5/31/11, WAS GIVEN TO THE SURVEYOR ON 6/7/11 BY THE DIRECTOR OF NURSING, DOCUMENTED ON 5/26/11 RN #3 FAILED TO COMPLETE A NURSING ASSESSMENT/COMMUNICATE THE CHANGE IN CONDITION TO THE ON-CALL NURSE PRACTITIONER FOR A RESIDENT THAT WAS EXPERIENCING RESPIRATORY DIFFICULTY. THE RESIDENT SUBSEQUENTLY WAS TRANSPORTED TO THE emergency room AND admitted to the hospital with [REDACTED].#3'S PERSONNEL FILE DATED BY RN #3 ON 6/1/11 AND SIGNED BY FACILITY HUMAN RESOURCE MANAGER AS RECEIVED ON 6/1/11. ON 6/9/11 IT WAS VERIFIED WITH THE STATE AGENCY THAT NO INCIDENT OF NEGLECT FOR RESIDENT #105 HAD BEEN REPORTED. THE DIRECTOR OF NURSING IS RESPONSIBLE FOR THE QUALITY OF CARE DELIVERED TO RESIDENTS IN THE FACILITY. ACCORDING TO THE CODE OF ETHIC FOR NURSES (AMERICAN NURSES ASSOCIATION, 2001, pg. 14), THE NURSE'S PRIMARY COMMITMENT IS TO THE HEALTH, WELL-BEING, AND SAFETY OF THE PATIENT. THE NURSE MUST TAKE APPROPRIATE ACTION REGARDING ANY INSTANCES OF INCOMPETENT, UNETHICAL, ILLEGAL, OR IMPAIRED PRACTICE BY ANY MEMBER OF THE HEALTH CARE TEAM. THE CODE OF ETHICS FOR NURSES (pg. 17) GOES ON TO STATED THE NURSE IS ACCOUNTABLE TO THE QUALITY OF NURSING CARE GIVEN TO PATIENTS AND THE DELEGATION OF NURSING CARE ACTIVITIES OF THESE INDIVIDUALS AND EVALUATING THE QUALITY OF CARE PROVIDED. ON 6/9/11 AT 1:25 PM, THE ADMINISTRATOR AND THE DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 12/8/11: 1) WHEN RESIDENT #101 HAD HER SEVERELY CONTRACTED LEGS FORCED APART BY STAFF DURING A CATHETERIZATION PROCEDURE, RESULTING IN MUSCLE AND LIGAMENT INJURY AND BRUISING AND PAIN TO RESIDENT #101'S LEFT LEG, LEFT GROIN AND LABIA AND, 2) WHEN STAFF RN #3 FAILED TO ASSESS AND MONITOR RESIDENT #105, ON 5/25/11, WHEN SHE WAS EXPERIENCING RESPIRATORY DIFFICULTY RESULTING IN RESIDENT #105 BEING TRANSFERRED TO THE HOSPITAL AND REQUIRING CONTINUOUS VENTILATORY SUPPORT. ON 6/10/11 AT 1:30 PM, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. NURSE #3 IS NO LONGER EMPLOYED AT THE FACILITY EFFECTIVE 6/1/11. 2. NURSE #3 WAS REPORTED TO THE BUREAU OF HEALTH PROFESSIONS. 3. THE ADMINISTRATOR MET WITH THE DON AND HR DIRECTOR ON 6/9/11 TO DISCUSS THE IMPORTANCE OF FOLLOWING THE CORRECTIVE DISCIPLINARY PROCESS IN A TIMELY MANNER FOR DEFICIENT PRACTICES OBSERVED WITH STAFF. 4. THE ADMINISTRATOR FOR THE FACILITY DURING THE INCIDENT INVOLVING RESIDENT #101 IS NO LONGER EMPLOYED AT THE FACILITY EFFECTIVE 1/3/11. 5. ABUSE, NEGLECT, MISAPPROPRIATION MISTREATMENT AND INJURIES OF UNKNOWN SOURCE : PROHIBITION, INVESTIGATION AND REPORTING ABUSE POLICY WAS REVIEWED. NO REVISIONS MADE. 6. ON 6/9/11 THE QA/ IN-SERVICE COORDINATOR WAS ISSUED A CORRECTIVE DISCIPLINE FOR FAILURE TO PROVIDE 1:1 EDUCATION TO STAFF RN #3 AS DIRECTED. 7. ADMINISTRATOR AND DON REVIEWED MICHIGAN DEPTARTMENT OF COMMUNITY HEALTH REQUIREMENTS FOR REPORTING INCIDENTS OF ABUSE AND NEGLECT ON 6/9/11 AT 2:30 PM. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 6/9/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND SEVERITY OF ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. #