Every finding on record at Villa at Pine Place

This citation pertains to intake 3094740.Based on record review and interview, the facility failed to ensure care was provided in accordance with professional standards of practice for one resident (R700) of three reviewed for Quality of Care resulting in elevated blood pressure and blood sugar levels. Findings include:Clinical record review revealed R700 was admitted to facility on 7/10/26, had a medical history of stroke, aphasia (disorder that affects how to communicate), required nutrition via enteral feeding, diabetes, high blood pressure, and cardiac arrest in April 2026.The State Agency received a complaint alleging the facility failed to provide medication necessary for care. On 8/4/26 at 2:02 PM, a telephone interview with R700's son confirmed on 7/10/26, R700 was admitted to the facility around 3:30 PM. The son remained with R700 until 7/11/26 at 1:15 AM and R700 still had not received their insulin or blood pressure medications. When the son arrived back at the facility on 7/11/26 around 9:00 AM, they were informed that R700 had not received any insulin or blood pressure medications. The son alleged R700's blood sugar was 577, and their blood pressure was all over the place The son independently called 911 and R700 was taken to the hospital.Record review revealed admission medication orders included: Metoprolol (blood pressure medication) 50 milligram (mg) give two times a day for hypertension, Insulin Glargine, inject 10 units subcutaneously at bedtime for DM2 (diabetes mellitus type two) New admit, awaiting med [sic] from pharmacy. Record review of a nursing progress note dated 7/11/26 at 11:20 AM, authored by Licensed Practical Nurse (LPN) E documented R700 had an elevated blood pressure (BP) of 180/110 and elevated blood sugar of 577 .Reason for Transfer: Resident's son called 911 and wanted resident transferred.On 8/4/26 at 2:50 PM, LPN E was interviewed and recalled when they went to care for R700 on the morning of 7/11/26 the son was at bedside and was furious. Per the son, R700 never received their blood pressure or insulin medications. LPN E recalled the blood pressure and blood sugar were taken, resulted elevated, and when they reviewed the Medication Administration Record (MAR), they realized the assigned midnight shift Registered Nurse (RN) D did not administer the ordered medications. LPN E was asked if there was any communication in the morning nursing report of why the medication was not given, and LPN E said there was none and was unclear why RN D did not give the medication. LPN E further remarked that the nurse-to-nurse report is not good here.On 8/4/26 at 2:31 PM, RN D was contacted for an interview. No return call was made by the end of the investigation.The Nursing Home Administrator (NHA) provided the corrective action and investigation documents dated 7/13/26 and documented RN D acknowledged they did not pull the medications, did not report they could not pull the medications, and did not contact a Provider for R700.On 8/4/26 at 4:02 PM, the Director of Nursing (DON) and NHA were interviewed, and identified RN D did not have access to the back up medication administration machine. Both the NHA and DON said RN D should have asked one of the other nurses to access the medications and did not. When asked why RN D did not have access to the back up medications, it was explained RN D was never fingerprinted to open the machine and remarked they fell through the cracks stated they were not making excuses but acknowledged there was just a breakdown.Review of the Policy titled Notification of Change Guidelines dated 5/20018 documented .It is the practice of this facility that changes in a resident's condition or treatment are immediately shared.and reported to the attending physician.

This citation pertains to intake 3006555 and 3009286. Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one resident (R802) of two residents reviewed for abuse/neglect/mistreatment.Findings include:On 5/13/26 a facility reported incident (FRI) that was submitted to the State Agency was reviewed which alleged R802 was victim of verbal abuse by a facility staff member on 4/27/26.On 5/13/26 the medical record for R802 was reviewed and revealed the following: R802 was initially admitted to the facility on [DATE] and had diagnoses including Dementia, Morbid obesity and Chronic obstructive pulmonary disease. A review of R802's MDS (minimum data set) with an ARD (assessment reference date) of 3/11/26 revealed R802 needed assistance from facility staff with most of their activities of daily living. R802's BIMS score (brief interview for mental status) was 11 indicating moderately impaired cognition.On 5/13/26 at approximately 9:57 a.m., R802 was observed in their room, laying in their bed. R802 was queried regarding the facility reported incident on 4/27/26 and they indicated they could not recall the event.On 5/13/26 a review of the FRI investigation involving R802 and bus driver A (BD A) was conducted and revealed the following: NHA (Nursing Home Administrator) was informed of an alleged verbal abuse from employee to resident by Office Manager D (OM D) from [local Dermatology office] reports she and her staff witnessed our bus driver, BD A, being verbally abusive towards R802 during his appointment. Investigation initiated, employee suspended pending investigation .Investigation-Witness Statements:OM D- As [R802] was waiting to be called back for his appointment, several of my staff members witnessed the caretaker being very verbally abusive to him. She was speaking to him in a very loud and condescending tone, in addition to telling him to stop talking when he was engaged in a conversation with another individual. At one point, there seemed to be a verbal altercation between them, the caretaker got loud and asked [R802], Are you able to walk on your 2 feet? and carried on about his inability to walk. She finally said that they were leaving without being seen. [R802] attempted to object, but the caretaker would not listen. She rescheduled the appointment and left at around 3:05pm. When leaving she wheeled him to the parking lot and left him there for a few minutes [NAME] he got the van. She eventually got out and loaded him into the van and they left. Several of my staff members witnessed the behavior/interaction were visibly shaken because of it. I can only imagine how other patients in the waiting room. This kind of behavior is unacceptable and not allowed in our medical practice. [R802] has an appointment on Monday. We will gladly see him and treat his concerns, but unfortunately the caretaker that accompanied him today is not welcome to our facility anymore.Scheduler B- On April 27th I was walking in the reception area to get paper and I saw that [BD A] was visibly upset and I asked her if she was ok. [BD A] began telling me Mother******* don't have paperwork, face isn't washed, and they are not paying me no CNA (Certified Nursing Assistant) money. I'm trying to fill out paperwork for him and the mother**** can't hear s***. I'm sick of this s**** .Receptionist E- On 4/27 I received a call from the doctor's office, in which the incident took place regarding the bus driver, [BD A]. The nature of the incident wasn't clear to me at that time but based on the manager's reaction I gathered she may have been involved in some kind of altercation involving the resident. When [BD A] returned, she was in a bad mood and was loudly complaining and cursing about the appointment. Between what the managers said, and what [BD A] said, she seemed to be upset about the state of the resident (unclean) and having to fill out unexpected paperwork at the doctor's office.Conclusion: Upon review of resident, staff interviews and review of the details involving the incident, the facility does substantiate verbal abuse. [BD A] left the facility following the incident stating that she resigned effective immediately. The NHA [Nursing Home Administrator] made several attempts to contact [BD A] and obtain a statement from her about the reported incident and [BD A] has not responded .On 5/13/26 at approximately 11:04 a.m., the facility investigation was reviewed with the administrator (abuse coordinator) the NHA indicated that the incident was substantiated and that OM B had to reason to call and lie that BD A was being verbally abusive to R802. The NHA reported that due to the multiple witnesses, disciplinary actions were taken and BD A was not willing to provide a statement. TDB A was reported to the registration agency for the abuse and is no longer employed by the facility. All facility staff had been re-educated on Abuse and Abuse reporting, and a compliance date was provided for 4/29/26. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included having the perpetrator not employed by the facility and re-educating all employees on abuse. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation relates to Intake #2571092. Based on observation, interview, and record review, the facility failed to prevent an avoidable fall out of bed for one Resident (R8) of five resident reviewed for falls, resulting in actual harm for R8, who sustained a femur fracture. Findings include: Review of a complaint received by the State Agency on 7/24/25 revealed an allegation that R8 fell out of bed while they were cleaned by nursing staff and rolled over onto the floor. The complaint alleged R8 had one person assisting them and said they were supposed to have two-person assistance. The concern further revealed that R8 was hospitalized and subsequently treated for a fractured right hip. Review of R8's investigation file, related to R8's fall with major injury on 7/23/25, revealed Certified Nurse Aide (CNA) AA was providing a bed bath (care) to R8 and rolled them on their side, and R8 continued to roll out of bed directly onto the floor. R8 was found to have two skin tears on their right knee, and complained of pain in both knees, both elbows, their right shoulder and right hip. The physician and R8's guardian were notified, and R8 was sent out to the hospital emergently. On 7/24/25 R8's guardian informed the facility R8 had sustained a fracture to their right hip. The file showed R8 was care planned to need 1-2-person assistance for bed mobility. The facility found the root cause of R8's fall was R8 needed two-person assistance with bed mobility, and was care planned for 1-2-person assistance (not always having two-person assistance). R8's care plan was updated by the facility after their fall to reflect two-person transfers after the incident. Review of CNA AA 's witness statement, dated 7/23/25, revealed (CNA AA ) washed the front of (R8) and then rolled him on his side to wash the back of him. As (CNA AA) was washing (R8's) back he began to roll forward. (CNA AA) quickly attempted to grab him to pull him backwards and yelled for help, but (their) gloves were wet and (CNA AA) did not have a good grip on him. (R8) continued to roll forward out of the bed onto the floor. (Registered Nurse - RN D) heard (CNA AA) scream and quickly ran into to the room to help but (R8) was already on the floor. The statement confirmed CNA AA was providing one-person assistance to R8 with bed mobility and was behind him when he rolled off the bed (verses in front of him, per standards of practice). Review of RN D 's witness statement, dated 7/23/25, revealed RN D heard CNA AA telling R8 not to move forward, and then yelled R8 was on the floor. The report further described RN D went to R8's room and assessed R8, and found they had two skin tears on their right knee, and had pain in both knees, both elbows, their right shoulder, and right hip. RN D reportedly administered Tylenol, provided wound care, ordered x-rays, and then received orders to transfer R8 emergently to the hospital. On 8/19/25 at approximately 10:30 a.m., the Director of Nursing (DON) acknowledged with the Nursing Home Administrator (NHA) present CNA AA should have been in front of R8 while they were cleaning R8, not behind them, per standards of care. The DON confirmed if R8 had been positioned properly, R8 would have rolled towards CNA AA, and not onto the floor. The DON clarified R8's Care Plan should have designated R8 required either one-person or two-person assistance with bed mobility, as a CNA did not have the clinical expertise to make this decision. The DON reported the therapy staff made those decisions, and any facility residents who were care planned for 1-2-person assistance were changed to two-person assistance after R8's fall. The DON and NHA confirmed no abuse, or intent was suspected or found after their investigation. On 8/19/25 at 1:16 p.m., R8 was observed seated in their reclined manual wheelchair, sliding forward towards the edge of the wheelchair, with much of their weight on their back. Their bottom was sliding towards the edge of their wheelchair seat, with a full body Hoyer lift sling underneath them. R8 was pointing to their right hip, grimacing in pain, and said, Ouch, my hip, my hip, repetitively. R8 told Surveyor they needed to lay down. R8's call light was out of their reach, anchored to the wall. R8 explained they wanted to get into bed and said their right knee hurt also. On 8/19/25 at 1:17 p.m., it was observed there was no nurse on the unit hallway. On 8/19/25 at 1:18 p.m., CNA V arrived, and R8 said they wanted to go to bed. CNA V reported R8 just returned from in-house dialysis. CNA V was shown R8 had no call light, and their position. CNA V reported CNA W brought them back from dialysis, not them CNA V acknowledged R8 should have had their call light in reach. CNA V was shown R8 sliding out of their wheelchair, who stated there was a pommel cushion under their full body sling. which was supposed to prevent them from falling out of the chair, but it was under the padded sling. CNA V stated R8 had a new sling, but they were not certain how to transfer R8 and left the room. CNA W arrived shortly after, observed R8 grimacing in pain, and left the room to find CNA V. Both left the room while R8 was sliding out of their wheelchair and grimacing in pain, pointing to their right hip. On 8/19/25 at 1:34 p.m , the Rehabilitation Director, Physical Therapy Assistant, (PTA) Y , arrived, and educated the floor staff including CNA V and CNA W how to the use the full Hoyer Sling safely to transfer R8 back to bed, including which sling loop colors to use to attach to the lift anchor. Registered Nurse (RN) X, R8's nurse, was also present. On 8/19/25 at approximately 2:00 p.m., the Unit Manager, RN A , with RN X present, was asked how long R8 was using the full body lift for Hoyer transfers, since the floor staff reported did not know how to use the full body sling to transfer R8. RN A reported this was not in the medical record. RN A stated R8's guardian, Guardian Z, had declined surgery for R8's femur fracture, making Hoyer transfers difficult for them but necessary for dialysis. RN A was asked about R8's seating, sliding down the lift sling over the pommel cushion and had no explanation. Both RN A and RN X were asked about R8's call light being out of reach, given their pain and wanting to go back to bed. Both agreed R8 should have had their call light in their reach, as R8 had the potential to use their call light. On 8/19/25 at 4:30 p.m., Surveyor called R8's guardian, Guardian Z , who reported they were working the next two days, and could not be reached until 8/21/25. Review of R8's Care Plan, accessed 8/20/25, showed R8 needed two-person assistance for bed mobility as of 7/24/25 (after their fall with injury) and required 1-2-person assistance for bed mobility as of 5/28/25 (before their fall with injury). A separate care plan revision showed R8 required 2-person assistance also as of 5/28/25, revised on 7/24/25, appearing to be a discrepancy. The Care Plan showed R8 was care planned for the use of a mechanical list for two-person transfers on 8/08/25. The use of a full body sling was care planned on 8/19/25. It was noted R8's Care Plan showed the type of lift sling was not designated until after the staff education observed on 8/19/25. Review of R8's Minimum Data Set (MDS) assessment, dated 7/07/25, revealed R8 was admitted to the facility on [DATE], with diagnoses including stroke, anxiety, and depression. The assessment revealed R8 was dependent for all activities of daily living (care needs) including transfers and bed mobility. The sensory assessment revealed R8 was sometimes understood and was sometimes able to understand others and had adequate vision. The assessment further revealed that R8 had no pain and was on scheduled opioid (controlled substance) pain medication, and had no falls marked. On 8/20/25 at approximately 9:00 a.m., R8 was observed being transferred to their shower bed (a flat durable medical equipment bed for resident showers) by CNA F and another CNA. R8 grimaced in pain while being rolled to place the shower mesh sling underneath them. During the observation, CNA F was observed transferring R8 from their hospital bed to the shower bed, with two of the shower bed brakes unlocked. CNA F acknowledged afterwards they should have been locked the brakes while transferring R8 from their bed to the shower bed. On 8/20/25 at approximately 9:40 a.m., R8 was observed with the Director of Nursing (DON). R8 was in their hospital bed and had no call light near them. The DON placed the call light in R8's hand, to see if they could operate their call light to call for assistance. R8 was able to operate their call light. The DON acknowledged afterwards they understood the concerns with R8 not having the call light near them. On 8/20/25 at 10:50 a.m., the DON was asked about the concerns observed during R8's transfers and positioning on 8/19/25 and 8/20/25. The DON reported CNA V should have known how to transfer R8 with a Hoyer lift and understood the seating and positioning concerns, causing R8 pain and discomfort. The DON confirmed R8's shower bed wheels should have been locked during the Hoyer transfer on 8/20/25. The DON acknowledged R8's call light should have been in their reach on 8/19/25 and 8/20/25. On 8/20/25 at 1:06 p.m., RN D confirmed R8's fall out of bed on 7/23/25 occurred as described. RN D reported R8's fall out of bed while receiving care from CNA AA was an accident, and no abuse or intent was suspected. RN D understood CNA AA should have been in front of R8 while cleaning them, which may have prevented the fall. RN D said R8 required 1-2-person assistance with bed mobility at the time of their fall and used a Hoyer lift for transfers. RN D confirmed R8 required a Hoyer lift and was dependent for all care prior to their fall on 7/23/25. On 8/20/25 at 1:37 p.m., CNA AA confirmed R8's fall out of bed while they were rolling him while cleaning him up occurred as described. CNA AA denied any intent, and confirmed the incident was an accident, when they were providing care and one-person assistance for bed mobility, as the Kardex (CNA care guide) showed R8 required 1-2-person assistance for bed mobility. CNA AA understood they should have been in front of R8 and rolled them towards them, instead of being behind them, cleaning them up. CNA AA reported R8 was in their bariatric bed, and they had not expected them to roll off the bed, as they had positioned R8 in the center of the bed. CNA AA reported they had tried to stop R8 from rolling out of their bed, but said their hands slipped. Review of R8's hospital internal medicine report, dated 8/04/25, revealed R8 sustained a right femur fracture with conservative management (no surgery) while being changed at the facility, and had sepsis (a severe infection), a urinary tract infection, end stage renal disease (kidney disease) and atrial fibrillation (a heart rhythm disorder). The report confirmed R8 was receiving Eliquis, a blood thinner, at the time of their fall at the facility, placing them at risk of bleeding. It was also noted that R8's right knee hardware appeared loosened on a hospital imaging report. Review of R8's hospital palliative care note, dated 8/04/25, revealed R8 was diagnosed with an acute right femur fracture in the ER (emergency room). It was noted R8 also presented to ER with a dislodged suprapubic catheter, which was replaced with a Foley catheter. The assessment showed uncontrolled pain during their hospitalization with repositioning and bowel movements, which was unresponsive to Norco, an opioid pain medication, and showed R8 reported ongoing pain during their hospital stay. The assessment showed non operative management of the hip fracture with a focus on pain control and rest. Review of R8's orthopedic provider progress note, dated 8/06/25, revealed, (R8) does not have absolute contraindication to Hoyer lift. (R8) is at high risk for displacement, skin compromise from intertrochanteric (region of bony protrusions) femur fracture, so recommend safe practices, frequent skin checks, and limited transfers to those absolutely necessary. Review of R8's hospice provider note, dated 8/09/25, showed R8 was placed on hospice care after their hospitalization (discharge) back to the facility on 8/08/25, as R8's guardian did not want to put R8 through any more treatments. The report confirmed R8's Guardian declined for R8 to have surgery. R8 was shown as alert and oriented x 3 spheres during this visit and reported they did not have pain at rest but had moderate to severe pain with movement. R8 was on Norco and Tramadol (a second narcotic pain medication) at that time. Review of R8's hospice provider note, dated 8/20/25, revealed R8 had been having high pain with transfers into the dialysis chair and was started on Morphine (an opioid controlled pain medicine for pain, often prescribed when other medications have not been successful) every four hours for pain and Ativan every six hours (to relieve anxiety).Review of R8's Physical Therapy (PT) Evaluation and Treatment, dated 8/07/25, showed a full body shower sling was recommended for bathing. The assessment revealed R8 did not need PT services, as they were at baseline (no change in their prior level of function while at the facility). The assessment revealed the hospice recommendations for safe transfers and high risk for displacement. There was no documentation or plan to educate staff on transfers noted in their documentation provided by the facility. On 8/21/25 at 10:38 a.m., R8's guardian, Guardian Z, reported in a phone interview they had been made aware of R8's fall out of bed on 7/23/25, and the cause related to R8 needing 2-person assistance with bed mobility. Guardian Z clarified they did not suspect any abuse and understood R8 fell out of bed by accident when CNA AA rolled R8 out of bed during care. Guardian Z confirmed R8 was dependent on staff for all personal care and used a Hoyer lift for transfers prior to their fall. Guardian Z said they had observed staff transferring R8 in an unsafe manner with the Hoyer lift, with R8 nearly sliding out of the lift sling. Guardian Z reported they were concerned about R8's increased pain since their fall and had placed R8 on hospice care after their fall on 7/23/25, upon return to the facility on 8/07/25. Review of the fall reduction policy, dated 2/2025, revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize likelihood of falls.4. Standard Fall Risk Protocols: a. Implement universal environmental recommendations that decrease the risk of resident falling, including, but not limited to: .ii. Bed is locked.iii. Call light and frequently used items are within reach. Review of the policy, Safe Resident Handling/Transfers, dated 8/09/24, revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable environment for the resident while keeping the employees safe in accordance with current standards and guidelines .

Based on observation, interview and record review the facility failed to ensure appropriate infection control practices related to Enhanced Barrier Precautions (EBP) and hand hygiene for two residents (R#'s 58 and 65) of seven residents reviewed for infection control as well as ensure appropriate infection control practices in the facility laundry and with regards to staff fingernails. This deficient practice had the ability to affect all residents at the facility. Findings include: R58 Review of the clinical record revealed R58 was admitted into the facility on 7/8/25, discharged [DATE] and readmitted on [DATE] with diagnoses that included: acute gastric ulcer with perforation, pleural effusion, generalized acute peritonitis, atelectasis, extended spectrum beta lactamase (ESBL) resistance, fistula of intestine, candidal stomatitis, urinary tract infection, herpesviral cingivostomatitis (viral infection) and pharyngotonsillitis (an acute infection of the pharynx), acute peptic ulcer site unspecified with perforation, and peritoneal abscess. Review of the current physician orders included: “Maintain Enhanced barrier precautions for high contact resident care r/t (related to) PICC (Peripherally inserted central catheter) line/hx (history of) of MDRO (Multi-Drug Resistant Organism) every shift for PICC line/hx of MDRO”. On 8/20/25 at 9:00 AM Phlebotomist ‘U’ was observed at their cart with lab supplies in the hallway just outside R58’s room. The door to R58’s room was observed to have signage that identified anyone to lift the top sheet to review specific details about the resident. R58 was on enhanced barrier precautions (EBP). A Personal Protective Equipment (PPE) caddy was hung from the door and contained disposable gloves, masks, and gowns. At this time, Phlebotomist ‘U’ donned disposable gloves, retrieved lab supplies, then looked at the sign on the door to lift for review, but did not lift to read and proceeded to enter R58’s room and close the door. Less than a minute later, Phlebotomist ‘U’ exited the room using the same disposable gloves, touching the door handle, retrieved a bright orange band (tourniquet), then re-entered the room without changing gloves, using hand sanitizer, or donning a gown. At 9:03 AM, Phlebotomist ‘U’ was observed to not change gloves and was proceeding to push the cart to continue on. When asked to talk before they continued on, Phlebotomist ‘U’ was asked why they didn’t review the signage posted on the door to determine what type of precautions R58 was on and they stated, “They (facility) said I just left this up and nobody took this down (pointing to the bright orange sign on the door). I didn’t read cause I’ve read it before. I go by what the nurses show me, not what’s posted.” When asked if they routinely came to the facility, they reported “I’m not normally the one that comes here.” Phlebotomist ‘U’ proceeded to take their cart with lab supplies and go towards another hallway. At 9:09 AM, an interview was conducted with the Director of Nursing (DON). When asked about whether staff/visitors should be reviewing signage on doors to verify what they might need for precautions such as what PPE to don/doff, the DON reported everyone should be reviewing that. The DON further reported if signage was up, they were on precautions and they used a cover to maintain HIPAA (Health Insurance Portability and Accountability Act). The DON was informed of the observations of Phlebotomist ‘U’ and at the same time, Phlebotomist ‘U’ was observed in the hallway about to enter another resident’s room. The DON reported that should not have occurred and they would address it immediately. R65 On 8/19/25 at 10:00 AM, R65's room door was observed to have a sign to indicate they were on enhanced barrier precautions requiring the use of a gown and gloves for resident care activities. On 8/19/25 at 10:12 AM, Nurse 'S' was observed to enter R65's room with three wrapped packages of 4x4 gauze. Nurse 'S' was not observed to don an isolation gown prior to entering the room. On 8/19/25 at 10:15 AM, Nurse 'S' was observed to exit the room with an examination glove on their left hand carrying two wrapped packages of 4x4 gauze and the glove they removed from their right hand. Once in the hallway, Nurse 'S' removed the left glove and threw them in a housekeeping trash cart in the hallway. They were not observed to perform hand hygiene after removing the gloves in the hallway. After disposing the gloves, Nurse 'S' went to the treatment cart and placed the two wrapped packages of 4x4 gauze that had entered R65's room back into the treatment cart. After storing the gauze they proceeded to their medication cart where they were still not observed to perform hand hygiene and began preparing medications for administration to their next resident. On 8/19/25 at 10:17 AM, Nurse 'S' was asked what services they provided to R65 when they entered the room and reported they had changed the dressing to R65's tracheostomy opening. On 8/20/2025 at 3:43 PM, a review of R65's chart revealed an order dated 10/18/24 for them to be on enhanced barrier precautions related to presence of a feeding tube. Further review of the chart revealed an order to cover R65's trach opening with a dressing. On 8/21/25 at approximately 1:30 PM, an interview was conducted with the facility's Infection Control Preventionist and they acknowledged the concern with EBP and hand hygiene and indicated ongoing infection control education was being done. Laundry Service On 8/21/25 from 1:30 to 2:00 PM, an observation of the facility laundry room and service was conducted with Laundry Supervisor 'T'. They were asked if anyone routinely checked the concentration of their laundry soap/chemicals/bleach and said they recently switched laundry products and the company providing the new product did not routinely test but would come out if called. At that time, Supervisor 'T' said about a week ago they noticed the level of bleach in the bottle running to the washing machines hadn't moved in a few days. They said they called the company, and a representative came to the facility and fixed the problem but admitted several days of laundry were done without the use of bleach. Continued review of the laundry room revealed four clean laundry basket trunks equipped with spring lifts (a device to keep the laundry from sitting in the bottom of the cart) attached. Observation under the spring lifts in three of four of the clean basket trucks revealed copious amounts of lint, garbage debris, food debris, peanut shells, examination gloves, and lancets for checking blood sugars. Supervisor 'T' said the clean laundry basket trunks should not have any debris underneath the spring lifts. A review of a facility provided policy titled, Enhanced Barrier Precautions was reviewed and read, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds .feeding tubes .b. PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities .3. High-contact resident care activities include: .h. Wound care: any skin opening requiring a dressing . A review of Center for Disease Control Guidance titled, Clinical Safety: Hand Hygiene for Healthcare Workers | Clean Hands | CDC was reviewed and read, .Recommendations Know when to clean your hands .After touching a patient or patient's surroundings .Immediately after glove removal . A review of a facility provided policy titled, Handling Clean Linen was reviewed and read, It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection .3 Carts will be cleaned when visibly soiled, and routinely according to facility schedule. On 8/21/25 at 1:35 PM, CNA “L” was observed to have artificial fingernails approximately 1 inch in length that were [NAME]-encrusted with small to large jewels. CNA “L” was asked if she was currently providing patient care at the facility. CNA “L” explained she was working a double (two shifts, back to back) and had 12 residents on her set. On 8/21/25 at 2:36 PM, Registered Nurse (RN) “A”, who served as the Infection Preventionist, was interviewed and asked about staff having long, [NAME]-encrusted fingernails. RN “A” explained it was an infection control issue due to the inability to completely clean around the jewels, or under the artificial nails and the risk of the nails ripping the gloves. On 8/21/25 at 2:58 PM, the DON was asked if staff were allowed to have long [NAME]-encrusted nails. The DON explained staff were “forbidden” to have long nails. When informed of the observation of 1 inch [NAME]-encrusted fingernails, the DON acknowledged the concern. Review of a facility policy titled, “Dress & Personal Appearance” revised 7/11/23 read in part, “…Fingernails: …Fingernails should be at a moderate length when working in patient care areas. Artificial nails are not permitted on staff working in patient care areas (including Nursing, Recreation, and Food and Nutrition)…”

Based on observation, interview and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen and during food service for one resident (R70) and all residents that consume food from the kitchen. Findings include:On 8/20/2025 at approximately 8:37 a.m., a tour of the main kitchen was conducted with the Dietary Manager J and the following was observed: 1. A box of Taquitos was not secured/unsealed and when moved on the shelf, the individual taquitos fell out of the box. 2. The storage rack that keeps the metal pans was observed to contain stacks of pans that were not air dried and contained water droplets up and down the stack of pans. When the pans were raised, water poured out on the floor. 3. The kitchen light covers had dust and staining on them. 4. The ventilation covers had dust/debris spreading out from them onto the ceiling tiles. On 8/20/25 at approximately 9:01 a.m., Dietary Manager J was queried regarding the nesting process for the stacking of their metal pans, and they indicated that the pans should have been air dried before being stacked on top of each other. DM J was queried regarding the box of frozen taquitos that were unsealed, and they indicated that the flap on the box was weak so they would get something else to ensure it was sealed. DM J was queried regarding the cleanliness of the vents and light covers and they indicated that they would have to notify maintenance to clean them. A review of the United States Food and Drug Administration (FDA)-Food Code revealed the following: 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in ¶ (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean equipment and utensils shall be stored as specified under ¶ (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. On 8/19/25 at 12:37 PM, Certified Nurse Aide (CNA) 'M' was observed assisting R70 with setting up their lunch meal. CNA 'M' was observed to remove R70's dinner roll from their plate with their bare hand and spread butter on it. They then placed it back on R70's lunch plate. On 8/21/25 at approximately 1:30 PM, an interview was conducted with Nurse 'R', the facility's Infection Control Preventionist and they said staff should not be touching resident's food with their bare hands. A review of a facility provided policy titled, Dining Service revised 1/2025 was conducted and read, ' .10. Staff will be educated on hygienic practices such as: a. No bar hand to food contact .

This citation pertains to intake #1233191.Based on observation, interview, and record review the facility failed to ensure treatment in a dignified manner for five residents, (R20, R24, R43, R70, and R76) of six residents reviewed for dignity. Findings include:R#'s 24, 43, 70, and 20. On 8/19/25 at 9:39 AM, Certified Nurse Aide (CNA) 'M' was observed in R24's room providing one-to one feeding assistance. CNA 'M' was not observed to be seated while feeding R24, rather they were observed standing at the bedside over the resident while providing assistance. On 8/19/25 at 12:27 PM, R20 R43, and R70 were observed seated in the dining room at a table. CNA 'M' was observed to be standing at the table providing one-to-one feeding assistance alternating bites of food between R20 and R70. On 8/19/25 at 12:35 PM CNA 'M' was observed providing one-to-one feeding assistance to R20. Several times throughout the meal, CNA 'M' left the table in the middle of the meal to assist the other residents and returned to provide one-to-one feeding assistance to R20. On 8/19/25 at 12:40 PM, CNA 'M' is again observed standing at the table providing feeding assistance with alternate bites to R20 and R70. On 8/19/25 at 1:00 PM, CNA 'M' is observed in R24's room standing at the bedside attempting to provide one-to-one feeding assistance. R76 On 8/21/25 at 8:40 AM, R76 was observed near the nursing station overheard saying Isn't anyone going to help me?. At that time, R76 was asked what was going on and said they had requested pain medication, but their nurse told them they had to wait. They went on to say the nurse was sitting at the nursing station and didn't understand why they couldn't go get their pain medication for administration. On 8/21/25 at 8:43 AM, R76 was observed in the hallway near the nursing cart. Nurse 'E' was observed at the cart preparing medications for another resident on the hallway. R76 was pointing at Nurse 'E' and verbalizing complaints with the use of expletives of not receiving their pain medication and being told they, Had to wait, to Therapy Staff Member 'Q'. Staff member 'Q' was overheard to tell R76 they would be, taken care of and to stop swearing at people. Staff member 'Q' was then observed to leave the unit. Nurse 'E' did not acknowledge R76's complaints and Staff 'Q' did not inquire with Nurse 'E' why R76 had not received their pain medication. On 8/21/25 at 8:54 AM, an interview was conducted with Nurse 'E'. They were asked why R76 had not received their pain medication and said they had tried to give it earlier but R76 had gone outside. They were asked about the observed verbal exchange in the hallway with R76 complaining to Staff member 'Q' about not getting their pain medication. Nurse 'E' said, That's just how he gets. They were asked if at that time they could have acknowledged R76's complaints, as opposed to ignoring him and said they could have. On 8/21/25 10:30 AM, an interview was conducted with Therapy Staff 'Q' regarding R76's complaints to them. Staff 'Q' said, He's bipolar and unpredictable. They were asked if they could have inquired with the nurse in the hallway about his medications and said they could have acknowledged. On 8/21/25 at 2:11 PM, an interview was conducted with the facility's Director of Nursing (DON). The witnessed incident between R76, Nurse 'E', and Staff 'Q' was discussed and the DON indicated staff could have addressed R76's needs in a more appropriate way. A review of a facility provided policy titled, Resident Rights was conducted and read, .The resident has a right to be treated with respect and dignity . On 8/19/2025 at 12:15 PM, an observation of main dining room revealed concerns with dignity during dining. At one table there were three residents seated and two of the residents already had their lunch meal served and were being assisted by staff. R70 was observed seated at the table and did not have a meal tray. At 12:30 PM, R70 still did not have their lunch served. At this time, staff were observed asking out loud to one another “So we need a tray for [name of R70]?” and several other staff asking about getting the resident a meal tray. Certified Nursing Assistant (CNA ‘M‘) (who was not wearing a name badge) was observed seated next to R70 assisting another resident at the table with their meal. CNA ‘M’ was then observed telling R70 “[name of R70] they’re getting your tray right now sweet pea.” At 12:32 PM, the Director of Nursing (DON) was observed telling R70, “At least you got your coffee right there.” R70 was observed to continue watching the other residents eat their lunch meal. At that time, CNA ‘M’ stated out loud, “She looking like where's my food at. Everyone else got theirs. At that time, Nurse ‘N’ stated out loud to R70, “I know it’s coming, you're looking at me like that. At 12:35 PM, Nurse ‘N’ delivered the meal tray to R70. Upon delivering the meal tray, CNA ‘M’ repeatedly referred to R70 as “Sweet Pea”. When R70 asked CNA ‘M’ what the ground up meat was, CNA ‘M’ stated to the resident, “I believe it's ribs but I don't want to lie to you, it's some beef. On 8/19/25 at 12:40 PM, an interview was conducted with the DON. When asked why R70 was not served at the same time as other residents at their table, the DON reported R70 ate later and the meal tray usually went to their room. When asked why the staff didn’t identify it upon serving the other residents at that time, the DON reported they were not sure. When asked about whether staff should be wearing name badges, the DON reported they should and was part of their uniform. At that time, CNA ‘M’ stated out loud from R70’s table, “I have one too (name badge), but it fell off.

Based on observation and interview, the facility failed to maintain a clean, comfortable, homelike environment for multiple residents, including R60. Findings include:Observations made during the recertification survey from 8/19/25 - 8/21/25 revealed concerns with flies observed in several resident rooms and throughout the hallways.Observations of the residents that attended smoking activities revealed the doors to the courtyard were kept open to allow the residents to exit the facility.On 8/19/25 at 9:58 AM, R60 was observed lying in bed with oxygen in place via nasal cannula. There was a small black portable fan on their table next to the bed that had a large build-up of dust that hung down off the front and back of the protective outer covering and fan blades. When asked about their room environment and if they had any concerns, R60 reported, I have such allergies and they don't clean that (black fan). R60 reported housekeeping swept and mopped the floors, but didn't dust.Additional observations on 8/19/25 and 8/20/25 revealed the fan remained with a heavy accumulation of dust.On 8/20/25 at 12:12 PM - An interview was conducted with the Administrator. When asked about who was responsible for cleaning the portable fans in resident rooms, the Administrator called the Maintenance Director (Staff ‘O‘) and asked over them if there was a formal log of cleaning personal fans and it was reported there was not and if staff sees a dirty one, they should clean it.On 8/20/25 at 1:12 PM, an interview was conducted with Staff ‘O'. When asked about the facility's pest control, they provided the log which showed monthly visits and none identified concerns with flies. When asked about if flies were observed by staff, what should be done, Staff ‘O' reported staff should log in binder or put into their electronic reporting system. Staff ‘O' reported they thought flies might be getting in when residents went outside to smoke and the doors were left open to allow the residents to exit.On 8/20/25 at 1:20 PM, an observation of R60's room was conducted with Staff ‘O‘. They confirmed the same and reported they were not aware of the resident having a portable fan but if staff observed the fan with build-up, they should report that in their electronic reporting system so they knew it needed to be addressed.According to the facility's policy titled, Safe and Homelike Environment dated 4/2024: .Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on observation, interview and record review, the facility failed to prevent staff from handling resident's money (cash and cards) to purchase smoking materials for 18 (6, 11, 14, 16, 26, 29, 30, 31, 37, 40, 42, 45, 47, 50, 55, 63, 64, and 67) of 18 residents reviewed for abuse, resulting in the potential for exploitation and misappropriation of the resident's property. Findings include:On 8/19/25 at 12:20 PM, a staff member (Driver/Certified Nursing Assistant - Staff ‘P') was observed entering the main dining room with a gray plastic bag. Staff ‘P' was then observed going up to a resident and placed a debit/credit card down on the table next to R37, then proceeded to go around to several other residents while they were eating their lunch. Staff ‘P' was then observed to pull out a large wad of folded cash and then showed another resident a carton of cigarettes.On 8/19/25 at 12:26 PM, an interview was conducted with Staff ‘P' upon exiting the main dining room. Staff ‘P' reported they worked as the facility's driver and had been employed since February 28, 2025. When asked about the observation of them going to several residents, placing debit/credit cards, cash and showing cigarettes, Staff ‘P' explained they went to the smoke store for them (residents). When asked how many residents they did that for, Staff ‘P' stated Today was like five or six. When residents go out to smoke, whoever says something, I tap into each resident, take cash or card. I have clipboard all sign off on I keep in the van. Anyone knows if I mess up, it's all over. When asked if the Administration was aware this was occurring, Staff ‘P' reported they did.On 8/19/25 at 4:04 PM, an interview was conducted with the Administrator who reported they began working at the facility since August 2024. When asked about whether staff should be handling any money i.e cash/cards from residents, the Administrator reported absolutely not and further reported that had been going on when they first came and they put a stop to that because there were so many concerns with misappropriation. The Administrator was informed of the observation and interview with Staff ‘P' and they reported they were employed as a driver.The Administrator further reported they made it very clear when they started that no staff should be handling resident money. The Administrator was informed Staff ‘P' reported there was a clipboard they maintained and was requested to provide any additional documentation for review.On 8/19/25 at 4:28 PM, the Administrator provided the log maintained by Staff ‘P' and reported, Apparently, they took it upon themselves to come up with this. Review of the documentation included the logs which were from 7/15/25 - 8/19/25 of multiple residents. There was no documentation provided prior to 7/15/25. It should be noted that several residents identified by the facility following notification of this concern were not included in the log documentation, including R37 who Staff ‘P' was observed placing the debit/credit card down in the dining room. The Administrator reported they would review the logs and follow up with the residents to make sure no one has any misappropriation concerns.On 8/20/25 at 10:00 AM, review of the additional documentation provided by the facility included:A facility audit which included 18 residents (R6, R11, R14, R16, R26, R29, R30, R31, R37, R40, R42, R45, R47, R50, R55, R63, R64, R67).Resident Council minutes from 1/27/25 that documented, in part: .Administrator talked to the Council about a New Policy in effect March 1st, 2025, = The Facility will no longer be able to go out and purchase their personal smoking items. Each resident would be responsible for supplying their own, they must contact their family and or Guardians to help them.A disciplinary action for Staff ‘P' dated 8/19/25 which was a written counseling notice that read, .During annual on 8.19.25 a surveyor observed employee collecting money, debit cards to purchase tobacco items .Corrective Action Employee's <sic> cannot take resident's money/debit cards to purchase cigarettes. Money's <sic> must be handled by resident directly, families, guardians, etc .These guidelines were reviewed in resident council in February of 2025 .According to the facility's policy titled, Abuse, Neglect and Exploitation dated 6/2024: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

Based on observation, interview and record review, the facility failed to ensure food preferences were honored for four residents (R1, R24, R43, and R70) of 10 residents reviewed for dining/nutrition. Finding include R1 On 08/20/2025 at approximately 1:20 p.m., a meal tray was observed for meal service for R1 which included R1's meal preference ticket that revealed the following standing orders for their lunch meal: Standing Orders: 1. 1/2 cup of applesauce (as available). 2. 1/2 cup mashed potatoes & gravy. 3. Yogurt, Yogurt At that time, R1's lunch meal tray was observed to not contain any of the standing order items that were supposed to be provided on the meal ticket. On 8/8/25 at approximately 1:25 p.m., The Dietary Manger J (DM J) was queried regarding the dietary process for ensuring the standing orders indicated on the meal tickets are provided to the residents when the meal is served. DM J reported that the process occurs in the kitchen during the tray pass in which one of the dietary aides is responsible for reading the ticket and placing the standard order items on the meal tray for service to their room. DM J was queried why none of the items were provided on R1's meal tray at time of service and they indicated that the dietary aide missed them. On 8/8/25 the medical record for R1 was reviewed and revealed the following: R1 was initially admitted to the facility on [DATE] and had diagnoses including Iron deficiently and Dysphagia. A review of R1's MDS (minimum data set) with an ARD (assessment reference date) of 6/20/25 revealed R1 needed assistance from facility staff with most of their activities of daily living. A dietary evaluation dated 7/17/25 revealed the following: RD following resident for wt (weight) status & new order of labs. CBW (current body weight) ~110# as of 7/16 w/ BMI (body mass index) 21.4--WNL. Wt (weight) hx shows a ~11.4# wt loss since 6/12 admission. Noted res states her UBW prior to admission ~115-120#. Wt loss likely d/t (due to) to PT/OT (physical therapy/occupational therapy) services w/fatigue, fluid shifts, hx of substance disorder, and/or acute disease processes. Previous 1200mL (militers) FR d/c (discontinued) 7/7. Current diet order in place: Gen/Reg (general/regular) x 3 w/ extra protein. Po (by mouth) intakes are 100% x 5d per FAR (food acceptance record). Noted resident on Megestrol Acetate for appetite stimulation. Food preferences discussed w/ resident & remain up to date. Resident noted to have protein drinks/nutritional supplements provided from family/friends at bedside. Supplements in place: Prostat QD ~30mL (~100kcal, 15g prot/serv) & Medpass 2.0 QD (every day) ~120mL (~240kcal, 11g prot/serv) for added nutritional support & promotion of wt stability. Tolerating per resident .Rec to cont (continue) w/ POC (plan of care). Will monitor wts as available, diet tolerance/appetite . R24 On 8/19/25 at 9:21 AM, R24's breakfast meal was compared to the items listed on their meal ticket. The meal tray contained a glass of water, two sausage links, two pancakes, syrup, and jelly. R24's meal ticket indicated standing orders for 8 ounces of coffee, a half a cup oatmeal with brown sugar and a half cup of fruited yogurt that were not observed on their breakfast tray. On 8/19/25 at 12:51 PM, R24's lunch meal was compared to the items listed on their meal ticket. It was noted R24 had standing orders for pink lemonade and a chef salad (if available) that were not served with the meal. It was observed on the facility's posted menu; a chef salad was an always available menu item. On 8/20/25 at 12:39 PM, R24's lunch meal was compared to the items on their meal ticket. It was noted R24 had a standing order for a chef salad (if available) that was not served with the meal. At that time, a resident at another table in the dining room was observed to be served a chef salad. On 8/21/25 at 8:42 AM, R24's breakfast meal was compared to the items listed on their meal ticket. It was noted they had an order for 8 ounces of coffee under their standing orders that was not provided with the meal. R#'s 20, 43, and 70 On 8/19/25 at 12:27 PM, a review of R#'s 20, 43, and 70's lunch meals were compared to the items listed on their meal tickets. It was noted R20 had a standing order for a health shake and a glass of milk that were not present on the tray, R43 had a standing order for a health shake that was not provided with the meal, and R70 had standing orders for applesauce, cottage cheese, and a health shake that were not provided with the meal.

Based on observation, interview, and record review, the facility failed to ensure a pull cord for the overbed light was accessible to the resident for one (R60) of one resident reviewed for accommodation of needs. Findings include:On 8/19/25 at 9:58 AM, R60 was observed lying in bed with oxygen in place via nasal cannula. The overbed light on the wall above their bed was observed to have a pull string that was tied up and hung down approximately one foot and was not able to be reached when in bed. They reported they rarely left their room and preferred to stay in bed. When asked about their room environment and if they had any concerns, R60 discussed several concerns including the light above their bed. When asked to explain further, R60 stated, I can't reach my light to turn on cause they never brought me a longer cord.Additional observations on 8/20/25 and 8/21/25 revealed the cord remained tied up and not within reach.On 8/20/25 at 1:20 PM, an interview was conducted with the Maintenance Director (Staff ‘O‘) who reported they had worked at the facility for about 30 years. Staff ‘O' was asked to observe R60's room and confirmed the short length of the overbed light and reported those had likely been like that since the rooms were renovated a while ago.According to the facility's policy titled, Safe and Homelike Environment dated 4/2024: .The facility will provide and maintain adequate and comfortable lighting levels in all areas.The Maintenance Director will perform periodic rounds to ensure functioning lights.

This citation pertains to intake #1233191.Based on interview and record review, the facility failed to promote the resident's right to be treated with dignity and respect for one (R49) of six residents reviewed for dignity, resulting in facility staff searching a resident's personal possessions without giving the resident the opportunity to decline, in absence of concern with illegal substances, and implementing smoking suspension for three days. Findings include:On 8/19/25 at 9:35 AM, an interview was conducted with R49. When asked about the facility's smoking practices, R49 reported they smoked cigarettes and had to maintain their smoking materials with staff but further reported they were one of the residents that could smoke independently.Review of the clinical record revealed R49 was admitted into the facility on 7/1/22 and readmitted on [DATE] with diagnoses that included: alcoholic hepatic failure without coma, alcoholic cirrhosis of liver with ascites, gout, unspecified protein-calorie malnutrition, anxiety disorder, major depressive disorder, recurrent mild, and traumatic subdural hemorrhage without loss of consciousness.According to the annual Minimum Data Set (MDS) assessment dated [DATE], R49 had intact cognition and had no behavior concerns.Further review of the clinical record included an entry on 4/22/25 at 4:10 PM by Social Worker (SW ‘H‘) that read, Writer observed resident smoking outside even though the cigarette was not given to her by activity staff. Writer requested for a room search and a couple of cigarettes were found in resident's room. Writer had a conversation with resident and reminded her the smoking policy. Resident voiced being aware and understands the consequences for violating the smoking policy. This is a second violation, and the consequences is a 3-day suspension. Resident shared that she understands the consequence and will be resuming smoking on Friday 04/25/2025 at 4:00 PM. Activity staff and management team was notified.Review of the facility's policy titled, Resident Smoking dated 2/2025 documented, in part: .Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan.If a resident or family does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures.Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff.If at any time the facility changes its policy to prohibit smoking.it will allow current residents who smoke to continue smoking in an area that maintains the quality of life for these residents. There was no documentation that allowed the facility to conduct a room search, or that the resident would be penalized (such as revoking their smoking rights) included in this policy.On 8/20/25 at 11:00 AM, an interview and record review was conducted with SW ‘H' who reported they had been in their role as the sole Social Worker for the facility for about a year. When asked about R49's smoking evaluation, SW ‘H' reported R49 had been assessed to be independent with smoking for a while now and further reported they had been re-evaluated for competency in April 2025.When asked about their documentation and to recall the events that occurred on 4/22/25, SW ‘H' reported the resident was seen smoking and their room was searched and additional cigarettes were found. When asked who did the room search, SW ‘H' reported they did. When asked if the resident was given the choice to conduct a room search, or were they told their room was going to be searched, SW ‘H' reported R49 was told their room was going to be searched and further stated, We have to see if they have more cigarettes on themselves.When asked about the implementation of a 3-day smoking suspension, SW ‘H' reported that was the facility's process and they have the residents sign as well. When asked regardless if the resident is signing a document, why were they implementing punitive measures, SW ‘H' reported they felt that was a concern but was something Administration said they had to do.On 8/20/25 at 12:00 PM, an interview was conducted with the Administrator. When asked about the facility's process for smoking, the Administrator reported when they first started at the facility about a year ago, there were many issues with residents smoking or sharing cigarettes and they had implemented smoking agreements that were signed on admission and discussed disciplinary processes if the residents were found in violation.The Administrator was requested to review their smoking policy and acknowledged the one they referenced was an outdated policy and the current policy (referenced above) was the current policy and did not include punitive measures. When asked about the facility conducting room searches when there is no concerns with illegal substances, the Administrator acknowledged the recent regulatory language and recent State Agency/Provider training and stated they might not have been using the most updated policy and R49 was disciplined based on the former smoking policy (prior to 2/2025).

Based on observation, interview and record review the facility failed to protect resident privacy for one (R25) of two resident reviewed for privacy. Findings include:On 8/19/25 at 9:27 AM, R25 was observed lying in her bed which had a concave mattress (mattress with raised edges). R25 did not answer any questions asked. R25's bed was positioned to the left side directly against the wall to the hallway. The bed extended approximately 6 inches past the doorframe to the room. Upon attempting to close the door to R25's room, the door would hit the footboard of R25's bed and was not able to close. Review of the clinical record revealed R25 was admitted into the facility on 6/27/25 with diagnoses that included: dementia, diabetes and fracture of the left wrist and hand. According to a Brief Interview for Mental Status (BIMS) exam dated 8/6/25, R25 had severely impaired cognition.On 8/20/25 at 9:20 AM, Certified Nursing Assistant (CNA) F was interviewed and asked how staff closed R25's door as the bed extended past the doorframe. CNA F explained that was a bed Hospice had brought, it was longer than the facility's beds. if she needed to close the door, she would move the bed. On 8/20/25 at 11:46 AM, CNA G was interviewed and asked how staff closed R25's door. CNA G explained she guessed she would move the bed.On 8/20/25 at 1:32 PM, the Unit Manager (UM) for R25's Unit, UM A was interviewed and asked about R25's bed positioned against the wall so the end of the bed extended into the doorway. UM A explained R25's bed did not need to be against the wall due to there being a concave mattress. she had moved the bed several times, but the staff kept moving it against the wall, but the bed was too long to be against that wall.On 8/20/25 at 2:20 PM, the Director of Nursing (DON) was interviewed and asked about R25's bed blocking the door from being closed. The DON explained the bed did not need to be against the wall, and it should not block the door from being closed. When informed of the concern of R25's privacy, since her door could not be closed, the DON acknowledged the concern.Review of a facility policy titled, Resident Rights revised 2/2025 read in part, .Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups .

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from neglect, for one Resident (R10) of two residents reviewed for abuse, resulting in R10 being transferred from their wheelchair with a damaged Hoyer lift sling, hitting their head and causing pain, with the potential to affect 15 additional facility residents who used Hoyer lifts for transfers. Findings include: On 8/19/25 at 11:32 a.m., R10 was observed seated in their manual wheelchair, dressed and well-groomed, propelling their wheelchair around their room. Review of R10's nursing progress note, dated 8/19/25 at 3:29 p.m., revealed R10 had a fall out of the Hoyer lift. The note described, (R10) was in the room with two aides with Hoyer. (R10) was getting put to bed and was hooked up to the Hoyer and upon lifting (R10) was not positioned correctly and sling come loose (sic). (R10) hit head on (the) baseboard of bed when being lowered back to a sitting position in wheelchair. Review of R10's Care Plan, accessed 8/21/25, showed R10 required 2-person assistance with a Hoyer lift for transfers. The Care Plan showed no designation for the type of sling used or sling size. The Care Plan showed R10 had an increased risk for fractures related to a diagnosis of osteoporosis (weakened bones due to decreased bone density), and showed R10 was at increased risk for falls. Review of the Electronic Medical Record (EMR) showed R10 was their own responsible party. Review of R10's progress notes revealed R10 declined to be sent out emergently for a CT scan (diagnostic test) after the fall from the Hoyer lift on 8/19/25 and agreed to an x-ray. Review of R10's skull x-ray report, dated 8/20/25, showed no acute abnormalities or fractures. Review of R10's nursing assessment, dated 8/19/25 at 3:29 p.m., revealed R10 hit the back of their head on their bed involving a Hoyer lift and sling. Review of R10's pain assessment, dated 8/19/25 at 3:38 p.m., revealed R10 experienced, Moderate pain, 3 of 10 (with 10 the highest pain), after the transfer from bed. Review of R10's Minimum Data Set (MDS) assessment, dated 7/24/25, revealed R10 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (brain metabolic disorder), anxiety, and depression. The assessment revealed R10 was dependent for transfers and was cognitively intact. On 8/21/25 at 9:23 a.m., the Unit Manager, Licensed Practical Nurse (LPN) EE, was asked what occurred when R10 fell out of the Hoyer lift on 8/19/25. LPN EE described two aides started to transfer R10, when the Hoyer lift sling ripped on one side, and the aides transferred R10 into the wheelchair. LPN EE was asked to provide the damaged sling for observation and reported it was thrown away. LPN EE stated R10 bumped their head and said there was no palpable or visible lump or bruise, and confirmed they ordered an x-ray. LPN EE clarified Certified Nurse Aide (CNA) F was transferring R10 when the incident occurred, and said CNA F had received an education to inspect the lift slings prior to transferring residents. On 8/21/25 at 9:35 a.m., CNA F was asked about R10's fall from the Hoyer lift on 8/19/25, and who was working with them. CNA F reported CNA CC was the other aide present when the fall occurred. CNA F reported R10 had the sling under them in their bed, which was placed and left there by the midnight shift nursing aide staff. CNA F reported CNA CC put the green loop on their side of the lift sling onto the lift anchor, and the sling broke on the top right corner, which caused R10 to hit their head on the top metal piece of the lift. CNA F said R10 stated, Do not move me; go get the nurse, and said they positioned the wheelchair under them. CNA F reported they had not seen any concerns with the sling. CNA F acknowledged given the sling was under R10 when they arrived to transfer them, they had not fully visualized the sling.On 8/21/25 at 9:50 a.m., CNA CC was asked during a phone interview what occurred when R10 fell out of the Hoyer lift sling. CNA CC stated R10 fell during the transfer to their wheelchair, when the top of what was connected to the sling broke off (the sling loop).The sling (loop) was tattered on the end.I saw the side (a loop of the sling) on my side was faulty, so I went to a different color (loop). There are three loops (which fasten the lift sling to the lift arm anchor). I want to say the green (loop) on my side was slit and broken open, so I went to another color. And it broke on the other side (CNA F's side). I didn't put her on that sling. It was already under (R10) . CNA CC was asked why they did not get a new sling, when they saw a broken sling loop. CNA CC responded, It was the first time I ever seen it (happen).I saw one of the rings was faulty, so I went to another color. When I saw it was messed up on my side, I said, ‘This sling is faulty.'.Maybe (CNA F) overlooked it. And when I looked and (R10) had fallen, (I said), Oh, this is tattered already. I just looked at it and the way it was frayed and stuff. I knew it had to be frayed.before (CNA F) put her on there. It had to be in bad condition. CNA CC said they worked at the facility a month and a half (when the incident occurred). CNA CC was asked if they were trained to inspect the lift slings prior to transferring a resident, and responded, I can't recall. CNA CC said R10 reported they hit their head but clarified they did not see this occur. CNA CC explained when they saw the lift sling after it broke, they would have expected CNA F to have noticed the lift sling loop appeared to be damaged on their side of the sling. CNA CC did not verbalize any understanding when they moved to another sling anchoring loop (of three available) to secure the sling to the lift, that their side of the lift sling was damaged, rendering the lift sling unsafe for use prior to R10's transfer. It was clear CNA F and CNA CC had not fully inspected the lift sling prior to transferring R10, as both reported the sling was under R10 in bed. On 8/21/25 at 9:32 a.m., Surveyor asked to speak with R10 about the incident. R10 declined to speak with the Surveyor, and stated, I'm fine. Leave me alone. On 8/21/25 at 10:05 a.m., the Laundry Supervisor, Staff T, was asked about inspections of the facility lift slings. Staff T reported the slings were sent to laundry by nursing staff in the mornings when they needed to be laundered. Staff T clarified at the time of the interview there was no process in place to ensure each sling were regularly inspected, as only the slings which were dirty were inspected at the time the incident occurred. Record review of the sling inspection laundry logs for the past six months with Staff T confirmed the facility laundered one to three slings most days randomly, only those sent to be laundered when dirty. Staff T reported they removed any slings with faded words on the tags in circulation (current use) when the soiled slings were laundered. Staff T said they did an audit after the sling incident occurred on 8/19/25 and removed any slings from circulation which were damaged. On 8/21/25 at 10:20 a.m., the slings in circulation were observed with Staff T in a centrally located room adjacent to the nurse's station. Staff T reported this was the location of the facility slings in current circulation for the nursing staff to use. It was observed the padded blue full body Hoyer slings showed three loops on each side at the top of the sling, to anchor the sling to the Hoyer lift. The loops were three different colors, including green, orange, and red on one of the slings. Staff T removed four of the current full body slings in the supply room from circulation, three with faded worn tags, showing signs of wear, including one with faded colored loops, and one sling which appeared worn and faded. It was confirmed there were no other incidents with the slings by Staff T and nursing management. Staff T had no explanation why current slings with faded tags and signs of wear were found in current circulation. On 8/21/25 at 12:03 p.m., Registered Nurse (RN) DD confirmed they were R10's nurse when R10 fell from the sling on 8/19/25. RN DD reported they observed the Hoyer sling after the incident, when one of the sling loops ripped apart. RN DD described the material was frayed, and described R10 did not fall to the floor, but fell back into the wheelchair which supported them. RN DD stated R10 said they hit their head, however they could not be certain, as they did not palpate a bump, and said they provided ice for pain. Review of R10's physician visit note, dated 8/21/25 at 12:36 p.m., revealed R10 reported hitting their head on the footboard of their head when one side of the lift's screen (fabric) loosened. The note showed some tenderness reported by R10 upon palpation, with no neurological changes or change in status evident, and there was no lump or laceration. R10's physician recommended continued monitoring and educated staff on signs of head injury. Review of CNA F's employee file showed a date of hire of 10/11/23, no disciplinary action, current nurse aide registration, abuse and neglect training, and current competencies in the use of mechanical lifts. Review of CNA CC's employee file showed a date of hire as 6/09/25, no disciplinary action, current nurse aide registration, abuse and neglect training, and mechanical lift training in their orientation on 6/14/25. Review of the manufacturer's instructions for sling use, provided by the NHA, including in their staff education, showed, .Staff should always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs (included) fading, bleached areas, or permanent wrinkles on the strap from improper laundering which is unsafe and could result in injury. Any slings with signs or wear or improper laundering should be immediately removed from use.Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use. On 8/21/25 at approximately 1:16 p.m., the NHA and DON reported CNA CC declined to participate in R10's incident investigation (from 8/19/25), and they had been unable to reeducate CNA CC. Both reported they were pursuing disciplinary action, up to termination. On 8/21/25 at approximately 1:28 p.m., the NHA and DON acknowledged the concerns related to R10's sling being damaged when CNA F and CNA CC transferred R10 in the Hoyer lift on 8/19/25. The DON acknowledged the sling should not have been left under R10 by the midnight staff and understood the concern. The NHA reported they had ordered new slings and had provided each resident with their own Hoyer lift sling on 8/21/25, which would be their process going forward. Their immediate intervention was that staff could only transfer residents who used Hoyer lifts with therapy staff or a nurse present. The NHA and DON reported there were no other residents who had incidents with Hoyer lifts or slings. Both confirmed they had begun to provide staff education on safe Hoyer lift transfers and had removed any slings which were damaged after R10's fall on 8/19/25. The NHA and DON were made aware there were additional slings were found on 8/21/25 with signs of wear by Staff T, with Surveyor present, and observed the worn slings. Both reported they understood the concerns related to no routine inspection or process for each sling to be regularly inspected in the building and had been working through this concern. Both acknowledged the sling which broke apart during R10's Hoyer lift transfer on 8/21/25 had been discarded to ensure the sling was no longer available for use. Both confirmed the concern related to CNA CC transferring R10 with a damaged, frayed sling was incorrect and placed R10 at risk for injury. The NHA reported they had informed their Medical Director of the concerns who they included in an ad hoc QAPI meeting on 8/21/25. The NHA described they had added routine Hoyer sling inspections in their maintenance system and were including their therapy and nursing staff in floor staff education including observations of Hoyer lift transfers. Review of CNA F's, Total Mechanical Lift Competency Checklist re-education, dated 8/21/25, provided by the NHA, included the following directives for safe mechanical lift operation: Ensuring two caregivers were present, visually inspecting slings for signs of wear and tear, not using any sling which was visually damaged, positioning a resident on the appropriate sling and size, and removing the sling from under a resident, unless care planned otherwise. An additional Handwritten directive included: Notifying the NHA or DON immediately, if there was an incident or injury with the equipment, and defective equipment must be removed and turned into the NHA or Maintenance Director immediately, and noted, Do Not Discard. Review of laundry staff education, Hoyer Sling Education, dated 8/21/25, revealed, i. Always inspect slings prior to each wash. Signs of rips, tears, and frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. ANY slings with signs of wear or improper laundering should be immediately removed from use. ii. Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use. iii. Slings are to be washed on a cycle with NO BLEACH. Review of the policy, Safe Resident Handling Transfers, dated 8/09/24, revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy explanation: Residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts is a safer alternative and should be used in non-emergent situations. Compliance guidelines:.6. The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly. 7. Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility procedures. 8. The facility will ensure that there are appropriate amounts of varying sized slings to accommodate residents per the manufacturer's instructions on proper sling sizing. 9. Ensure that the sling designed for the lift is utilized with that specific lift. 10. Two staff members must be utilized when transferring residents with a full body mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices, to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. 12. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. 13. Resident lifting and transferring will be performed according to the resident's individual plan of care. 14. Staff will perform mechanical lifts/transfers according to manufacturers' instructions for use of the device. 15. Slings will be laundered according to the manufacturer's instructions and any damaged, broken, or unsafe slings will be removed from service and replaced. 16. Environmental services will maintain a Lift Inspection Log. a. Slings will be inspected during routine laundering. b. Slings will be assigned a number for tracking purposes. Slings will be physically labeled with their number. Review of the policy, Abuse, Neglect, and Exploitation, revised 6/24, revealed, It is the policy of this facility to provide protections to the health, welfare and rights of each resident by developing and implements written policies and procedures that prohibit and prevent abuse, neglect.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.IV. Identification.Possible indicators of abuse include but are not limited to: .8. Failure to provide care needs such as comfort, safety.turning, and positioning.6. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. analyzing the occurrence(s) to determine why abuse, neglect.occurred and what changes are needed to prevent further occurrence, b. Defining how care provision will be changed and/or improved to protect residents receiving services. c. Training of staff on changes made and demonstration of staff competency after training is implemented. d. Identification of staff responsible for implementation of correction action. E. The expected date of implementation. f Identification of staff responsible for monitoring the implementation of plan.VIII. Coordination with QAPI. A. The facility will communicate and coordinate situations of abuse, neglect.with the facility QAPI committee.

Based on interview and record review, the facility failed to provide timely incontinence care for one (R60) of one resident reviewed for bladder and bowel incontinence. Findings include:On 8/19/25 at 9:58 AM, R60 was observed lying in bed with oxygen running via nasal cannula. When asked about how they felt the care was and whether there was enough staff to meet their care needs, R60 reported concerns with not having enough staff to change their briefs regularly. The resident further reported they wore disposable briefs and they also had a UTI (Urinary Tract Infection) and still has burning (common pain from a UTI) because they felt like the UTI was because they weren't getting changed frequently. When asked what they considered as frequent, R60 reported they were trying to get a change every three to four hours, but they often had to wait a long time. When asked when the last time they were changed, R60 reported the last time was at 5:00 AM. The resident also reported it (the delay in being changed) was worse on the weekends and evenings.Review of the clinical record revealed R60 was admitted into the facility on [DATE] with diagnoses that included: chronic obstructive pulmonary disease with acute exacerbation, mild intermittent asthma, fibromyalgia, and major depressive disorder recurrent.According to the Minimum Data Set (MDS) assessment dated [DATE], R60 had intact cognition, and requires substantial/maximal assistance with lower body dressing, toileting hygiene, and is always incontinent of bladder and bowel.Review of the care plans included:I have an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) increased weakness due to hospitalization. Able to make needs known. Hearing is adequate, vision is highly impaired. Inc (Incontinent) of B (Bladder) & B (Bowel). This care plan was initiated on 10/7/21 and last reviewed on 7/22/25.Interventions included:TOILET USE: I am not toileted. Provide briefs for dignity and pericare after each incontinent episode. This intervention was initiated on 11/4/24.Review of the nursing documentation for when R60 had incontinence episodes in the task section of the clinical record for the past 30 days (maximum look back period available) revealed some days there was only documentation that incontinence care was done twice, sometimes three times, and one day four times in a 24-hour period. This documentation included the following times it was documented as being done:8/21/25 at 2:36 AM8/20/25 at 10:25 AM and 8:23 PM8/19/25 at 6:24 AM, 1:39 PM, 9:24 PM, 11:57 PM8/18/25 at 6:42 AM, 11:11 AM, 10:35 PM8/17/25 at 6:59 AM, 8:00 AM, 10:07 PM8/16/25 at 5:15 AM, 1:37 PM, 7:57 PM8/15/25 at 12:43 AM, 2:14 PM, 9:12 PM8/14/25 at 12:06 AM, 1:19 PM, 6:31 PM8/13/25 at 6:39 AM, 10:06 AM, 7:52 PM8/12/25 at 6:38 AM, 10:30 AM, 9:00 PM8/11/25 at 12:26 AM, 9:53 AM, 8:48 PM8/10/25 at 6:32 AM, 10:22 AM, 10:59 PM8/9/25 at 6:25 AM, 7:47 AM, 6:44 PM8/8/25 at 6:41 AM, 11:10 AM, 7:33 PM8/7/25 at 6:15 AM, 8 56 AM, 4:22 PM8/6/25 at 6:57 AM, 10:03 AM, 5:10 PM8/5/25 at 9:26 AM, 8:56 PM8/4/25 at 6:50 AM, 8:51 AM, 5:35 PM, 11:37 PM8/3/25 at 4:50 AM, 2:59 PM, 8:27 PM8/2/25 at 10:28 AM, 9:41 PM8/1/25 at 6:33 AM, 2:22 PM, 10:23 PM, 11:42 PM7/31/25 at 6:59 AM, 2:53 PM, 8:47 PM7/30/25 at 6:52 AM, 8:53 AM, 10:49 PM7/29/25 at 6:53 AM, 12:05 PM, 9:40 PM7/28/25 at 2:59 PM, 10:33 PM7/27/25 at 12:34 AM, 11:23 AM, 8:38 PM, 11:55 PM7/26/25 at 6:34 AM, 9:53 AM, 6:03 PM7/25/25 at 12:52 AM, 10:39 AM, 5:35 PM7/24/25 at 6:49 AM, 12:58 PM, 10:59 PM7/23/25 at 12:30 AM, 11:12 AM, 10:59 PMOn 8/21/25 at 12:25 PM, an interview was conducted with the Director of Nursing (DON). When asked what the facility's process was for incontinence care, the DON reported the CNAs (Certified Nursing Assistants) should be checking for incontinence throughout the shift. When asked how they should be documenting if incontinence care was provided, the DON reported typically they document in (name of electronic record) but a lot don't do it in real time, some document towards the end of the shift, and they liked them to chart as they go. The DON further reported the facility was aware of issues with call light response and more of issue with off-shifts like nights and weekends and were trying to hold staff accountable, but call-ins were the issue. The DON further acknowledged at times there might only be one CNA but even if they had two CNAs per hallway, the acuity was hard.

Based on observation, interview and record review the facility failed to provide snacks for a resident with low body weight for one (R54) of three residents reviewed for nutrition. Findings include: On 8/19/25 at 9:06 AM, R54 was observed lying in her bed. R54 appeared to be small and very thin and bilateral arm and hand contractures were observed. R54 was asked about care at the facility. R54 explained she did not get snacks in the evenings, she did not always like the food being served and she was hungry in the evenings and would like to get snacks. sometimes someone would give her something, but she needed assistance to eat and it was hard to get someone to assist her at snack time.Review of the clinical record revealed R54 was admitted into the facility on [DATE] with diagnoses that included: spastic quadriplegic cerebral palsy, moderate protein-calorie malnutrition and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R54 was cognitively intact. The MDS assessment also indicated R54 was dependent on staff for eating.Review of R54's weights revealed the most recent weight dated 8/7/25 was 77.4 pounds.Review of R54's nutritional care plan revised 2/17/25 revealed no intervention for providing evening snacks.Review of a 30 Day Look Back of Certified Nursing Assistant (CNA) documentation for Snacks revealed no snacks documented as given or eaten.On 8/20/25 at 8:43 AM, observation of CNA F assisting R54 with breakfast revealed R54 was not able to open items on the tray and required the assistance of staff to eat.On 8/21/25 at 9:01 AM, the Dietary Manager (DM) was interviewed and asked how evening snacks were distributed. The DM explained there was a list of residents that they would prepare a snack for and their name would be put on the snack and it was distributed to the resident in the evening. The DM was asked if R54 was on the list for evening snacks. The DM explained he would check to see.On 8/21/25 at 9:15 AM, the DM provided a list of 45 residents who were provided evening snacks. R54 was not on the list. On 8/21/25 at 10:05 AM, Registered Dietician (RD) K was interviewed and asked why R54 was not provided evening snacks. RD K explained R54 had never asked for evening snacks. RD K was asked why evening snacks were not included in R54's nutritional interventions due to her only weighing 77.4 pounds. RD K acknowledged the concern and explained he would add R54 to the list for evening snacks.On 8/21/25 at 2:10 PM, the Director of Nursing (DON) was interviewed and asked about R54 not receiving evening snacks. The DON explained R54 had never asked for evening snacks, but thought it would be a good idea since R54 only weighed 77.4 pounds.Review of a facility policy titled, Weight Monitoring revised 1/2024 read in part, .Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.

This citation pertains to intake: MI00152863. Based on interview and record review the facility failed to accurately assess a sacral/coccyx wound, implement adequate and appropriate interventions to prevent wound development, failed to timely identify the decline of a sacral/coccyx wound and notify the Physician for one (R202) of two residents reviewed for pressure wounds, which resulted in hospitalization for an infected wound, sepsis and a Stage 4 Pressure wound (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) to the sacral/coccyx. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns regarding R202's pressure wounds. A review of the medical record revealed R202 was admitted to the facility on [DATE], with diagnoses that included: dementia, gastrostomy (opening in the stomach for the insertion of a feeding tube), dysphagia (difficulty swallowing) and was dependent on staff for all Activities of Daily Living (ADLs). Review of a . Change in Condition Evaluation dated 12/18/24 at 6:53 AM, documented in part . Skin wound or ulcer . This started on 12/18/2024 . Triad (wound ointment) to open area . Coccyx - Open area to coccyx/TX (treatment) started . Review of a Wound consultation dated 12/18/24, documented in part . Established pt (patient) New wound . Bilateral Buttock Gluteal fold is a Full Thickness MASD (moisture associated skin damage) . The wound margin is undefined Wound bed has 26-50%, granulation, 26-50% slough (non-viable yellow, tan, gray, green or brown tissue . The description of the wound by the wound clinician is not the description of a MASD impairment. It is the description of a Stage 3 pressure wound (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough maybe visible). Review of the medical record and a weekly skin assessment dated [DATE], revealed no documentation of the facility to have identified the wound. A review of the care plans revealed no documentation of adequate and appropriate interventions to prevent the development of the wound. Review of progress note dated 12/26/24 at 2:00 AM, documented in part . Change in Condition . Abnormal vital signs . altered mental status, Fever, Tired, Weak, Confused or Drowsy . sending to hospital due to fever and increasing respirations . The medical record revealed R202 was readmitted to the facility on [DATE]. A medical provider note dated 1/8/25 at 9:04 PM, documented in part . Visit Type: F/U (follow up) ER (emergency room )/Hospital . Patient seen and examined for hospital follow-up . was admitted to (hospital name) for sacral decubitus ulcer 12/26/2024 to 1/7/2025. Wound was debrided while in the hospital. Foley catheter was placed for severe sacral wound. She was started on IV (intravenous) antibiotics for sepsis related to this . Review of a wound consult dated 1/8/25, documented in part . Sacral is a Stage 4 Pressure Injury Pressure Ulcer . This indicated the resident was hospitalized for an infected sacral wound and became septic. The wound required debridement which revealed a stage 4 sacral wound. Review of the medical record revealed no identification by the facility staff to have identified the sacral wound to have worsened from the 12/18/24 to 12/26/24, when the resident was transferred to the hospital. On 5/22/25 at 1:41 PM, an interview was conducted with the Administrator and Director of Nursing (DON) regarding the identified wound concerns for R202- inaccurate clinician/staff assessments, lack of appropriate interventions/treatments, the failure of the facility staff to identify the deteriorating wound and notify the physician. The Administrator stated they had identified the same concerns regarding R202's wound. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included facility wide education with the nursing staff, the termination of the wound practitioner and the hiring of the new wound clinician. Audits were provided and the documentation of Quality improvement measures implemented. The audits were still ongoing at the time of the survey. 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 maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 9/9/24 at 8:50 AM, there were 2 10-pound packages of raw ground beef thawing under running water in the 2 compartment sink. The ground beef logs were in a metal pan, with approximately 1/3 of the meat submerged in water, and the rest of the meat was sticking out of the pan. The temperature of the running water was measured to be 92 degrees Fahrenheit. On 9/9/24 at 9:15 AM, Dietary Manager B was queried about the temperature of the running water when thawing meat, and stated that the water should have been cold. According to the 2017 FDA Food Code section 3-501.13 Thawing, Except as specified in (D) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be thawed: 1. (A) Under refrigeration that maintains the FOOD temperature at 5 C (41 F) or less; or 2. (B) Completely submerged under running water: 1. (1) At a water temperature of 21 C (70 F) or below . On 9/9/24 at 8:55 AM, in the walk-in cooler, there was an undated container of chicken tenders. In addition, in the Traulsen reach-in cooler, there was an undated 3.5 quart container of sliced peaches. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. On 9/9/24 at 9:00 AM, in the dry storage room, the flooring underneath the racks was observed with a buildup of debris (flour, chocolate chips, cups, packages of snacks). On 9/9/24 at 9:10 AM, the ice machine located in the nourishment room, was observed with stagnant, standing water in the drainage bin. In addition, the flooring underneath the ice machine was wet and there was a black mold-like substance on the flooring. There was an accumulation of trash on the floor underneath the ice machine. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.

This citation pertains to intake #'s MI00146644 and MI00146449. Based on observation, interview and record review, the facility failed to ensure liquids were provided according to their prescribed therapeutic diet texture for one resident (R57) of four residents reviewed for nutrition. Findings include: On 9/9/24 at approximately 9:03 a.m., R57 was observed in their room, up in their wheelchair attempting to eat their breakfast. R57 was observed to be coughing while eating cereal and drinking their juice. Both the milk and juice appeared to be thin. A review of R57's meal ticket revealed they were supposed to have been provided nectar thick liquids for their meals. On 9/9/24 at approximately 9:07 a.m., Nurse C was informed that R57 was coughing while drinking their juice and eating their cereal. Nurse C was observed going into R57's room and assessing them and indicated that their liquids including the milk and the juice were not thickened and they indicated that R57 should have thickened liquids and was then observed pouring in thickener into the liquids. On 9/9/24 the medical record for R57 was reviewed and revealed the following: R57 was initially admitted to the facility on [DATE] and had diagnoses including Dysphagia, Mild-Protein-Calorie Nutrition and Parkinson's disease. A Physician's order dated 12/29/23 revealed the following: General diet 6-Soft and bite sized texture, Mildly thick/Nectar consistency, Plate guard for all meals A review of R57's care plan revealed the following: I have the potential for a nutritional/hydration problem r/t (related to) PMH (past medical history) of UTI (urinary tract infection), Parkinson's, hernia, restless leg syndrome, prostatic hyperplasia. For my advanced age and or cognition. For my mechanically altered diet & hx (history) of diff chewing/swallowing. Wt (weight) & appetite fluctuations may be anticipated r/t medical dx (diagnosis) and/or age maturation. I receive supplements for added nutritional support Interventions-My diet order is: Reg (regular), Soft/Bite size, Mild/Nectar Thick liquids (Bread products okay) . A nutritional assessment dated [DATE] revealed the following: Diet and Notifications-2. Type of Diet: Reg, Soft/Bite Sized, Mild/Nectar Thick .At Nutritional Risk due to: PMH: UTI, Parkinson's, hernia, restless leg syndrome, prostatic hyperplasia. Res (resident) receives a mechanically altered diet & thickened liquids .

Based on observation, interview and record review the facility failed to provide the total amount of physician ordered enteral (tube) feeding, document consistently and accurately the amount of enteral feeding infused, and ensure timely follow up with the physician for one (R63) of one resident reviewed for enteral feeding. Findings include: R63 was a long-term resident of the facility. R63 was originally admitted to the facility on [DATE]. R63 was recently hospitalized and readmitted back to the facility on [DATE]. R63's diagnoses included stroke with hemiplegia (paralysis of one side), malnutrition, and dysphagia (difficulty swallowing). R63 received part of their nutrition via Percutaneous Endoscopic Gastrostomy (PEG Tube - A tube surgically placed directly on the stomach to receive nutrition and hydration). Based on the Minimum Data Set (MDS) assessment dated [DATE], R63 had a Brief Interview for Mental Status (BIMS) score of 00, indicative of severe cognitive impairment. R63 had a family member appointed as their legal representative. An initial observation was completed on 9/9/24 at approximately 10:50 AM. R63 was observed in their bed. R63 did not answer any questions. R63's tube feeding was not connected. The tube feeding stand had a full bottle of enteral feeding (that was not opened) hanging. The bottle had a date 9/6/24 (3 days prior to the observation) with R63's name and order details. During that observation, Registered Nurse (RN) E, who was the charge nurse for the shift reported that R63 refused tube feeding for the last few days. They added that R63 was able to eat, was on a soft diet, and that it was not very appetizing. RN E added that R63 required tube feeding because their food intake was not meeting their nutritional needs and it needed to be addressed. RN 'E' reported that behavior (refusing tube feeding) was new and R63 was waiting to be seen by the physician. They also added that R63 recently returned from the hospital and they were diagnosed with a pelvic mass. The surveyor asked R63 if they had pain in abdomen and R63 nodded their head. A follow up observation was completed on 9/9/24 at approximately 2:40 PM. R63 was observed in their bed. A lunch tray was on their bedside table. They ate part of their lunch (macaroni and cheese). When asked if they had enough to eat, R63 nodded their head and did not answer further questions. Review of R63's Electronic Medical Record (EMR) revealed that R63 was recently admitted to hospital on 8/24/24 due to difficulty swallowing and to rule out stroke or respiratory infection and readmitted back on 8/31/24. Review of R63's physicians orders included: Enteral feeding order - one time a day for nutrition. Jevity 1.5 @ 55ml (milliliter)/hr. (hour) x 18 hrs. =990 ml =1485 kcal (kilocalories); up at 5 PM until dose complete - order dated 9/3/24 (3 days after admission), an order for mechanical soft (bite sized) texture and thin liquids ordered on 9/2/24, and an order for NPO (nothing by mouth) upon readmission into the facility on [DATE]. Review of R63's Enteral feeding administration record revealed that R63 received their enteral feeding as ordered on 9/6/24, 9/7/24 and refused on 9/8/24, as indicated by RN 'D's electronic signature on all the above dates. Review of R63's progress revealed the NPO diet was discontinued on 9/2/24. Further review revealed a nursing summary dated 9/3/24 at 5:40 AM, that R63 had emesis (vomiting) on 9/3/24 and enteral feeding was stopped. However, a Registered Dietician (RD) note dated 9/3/24 at 11:21 (approximately 5 hours after the vomiting episode) read in part, Resident seen bedside and appears doing well. No signs/symptoms of distress. Noted adjustments from NPO to mech soft textures and thin liquids .monitor weight trend, appetite, tube feed and diet tolerance. RD to follow. The note did not address why enteral feeding was ordered 3 days after R63's admission or the concerns with vomiting on 9/3/24. Further review of progress notes revealed no documentation that indicated R63 did not receive their enteral feeding on 9/6/24, 9/7/24 and 9/8/24. R63's clinical record revealed no evidence that a medical provider was notified of R63's tube feeding refusals, that they did not receive their tube feeding on multiple days, or that they had an episode of vomiting. After the concern was brought to the facility's attention a late entry progress for 9/8/24 was completed on 9/9/24 at 11:05 AM that read, Resident refusing enteral feedings. She is refusing, yelling, crying, shaking her 'no', patting her belly indicating discomfort .on list to see physician at next clinic day. Report passed on to next shift. An interview was completed with R63's legal representative on 9/9/24 at approximately 10:55 AM. They were queried if they were notified of R63 refusing their enteral feeding for the last few days. The legal representative stated, Nobody called me and I come there every day. They added that R63 had been different since they returned from hospital and not sure what was happening. An interview was completed with Unit Manager (UM) F on 9/10/24 at approximately 9:50 AM. They were queried about their expectation/process on R63's refusal of tube feeding for the last few days as reported by RN 'E' and the enteral feeding bottle dated 9/6/24 that was found hanging on 9/9/24. UM F reported that staff should have taken down the tube feeding from 9/6/24. If R63 refused their tube feeding the nurse should have called and notified the physician and RD. When queried why R63's representative who visited the facility every day was not notified they reported that they should have been notified. When questioned further why the enteral administration for 9/6/24 and 9/7/24 were completed as administered when R63 refused their tube feeding, they reported that they were unaware of the erroneous documentation and they would follow up with their staff. UM F reported that they understood the concern. An interview was completed with RD G on 9/10/24 at approximately 1:00 PM and they were queried about the facility process and team communication expectation if a resident refused their tube feedings. RD G reported that they expect the staff to notify them if a resident refused enteral feeding so they could follow up and address the issue in a timely manner. They added that they were notified on Monday morning (after the concern was brought to the facility's attention on 9/9/24). An interview was completed with the Director of Nursing (DON) on 9/10/24 at approximately 2:10 PM. The DON was notified on the observations of enteral feeding that was dated 9/6/24 hanging on the tube feeding pole, R63's refusals, inaccurate documentation, failure to notify the legal representative, physician, and RD. The DON reported that they were notified of the concern by the unit manager on 9/9/24 and that should not have happened. A facility provided document titled Care and Treatment of Feeding Tubes with the most recent revision date of 6/2023 read in part, Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: 1. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. 2. Only tubes designed or intended for enteral feeding will be utilized, except under extenuating circumstances and for the shortest time possible. 3. The facility will utilize the Registered Dietitian in estimating and calculating a resident's daily nutritional and hydration needs . 8. The residents plan of care will direct staff regarding proper positioning of the resident consistent with the resident's individual needs and preferences. 9. The facility will notify and involve the physician or designated practitioner of any complications, and in evaluating and managing care to address the complications and risk factors .

Based on observation, interview, and record review, the facility failed to provide consistent, meaningful and person-centered activities for one (R32) of one resident reviewed for activities, and five of seven residents who attended the confidential Resident Council interview, resulting in potential for loss of interaction, joy, self-esteem, sense of well-being, creativity, and independence. Findings include: R32 A review of R32's clinical record revealed R32 was a long-term resident of the facility and was admitted to the facility on [DATE]. R32's admitting diagnoses included anxiety disorder, bipolar-disorder, insomnia, osteoarthritis, social phobia and depression. Based on a Minimum Data Set (MDS) assessment dated [DATE], R32 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. On 9/9/24 at approximately 12:15 PM, R32 was observed in their bed. R32 was queried about their daily routine, if they attended any activities and their quality of life at the facility. R32 reported they used to go for activities but the facility did not have enough activity staff after a change in management several months ago. They added they used to have more staff and more programs and right now they had only an activities director. They added the facility had bingo two times per week and no other activities that interested them. R32 reported that one of the Bingo prizes was Bingo Bucks and they could use them to buy things from the store. The store was open for an hour and if they could not make it in the hour they had to wait until the next time. When queried if they received 1:1 activity visits from the staff, R32 reported no. They added that they did not get along with the activities director before and the department did not have any other staff. They added you can check with the other residents. Review of R32's Electronic Medical Record (EMR) revealed a Recreation assessment dated [DATE] (completed approximately over 2.5 years ago). The assessment revealed that R32 liked to play cards, arts and crafts, music and spiritual activities. Review of an activities task list for the last 30 days did not reveal any entries. Review of R32's progress notes did not reveal any activity progress notes. Review of an Activities Calendar for September 2024 from 9/1/24 through 9/7/24 included Card Club, Bingo, and Morning games two times per week between 9/3/24 and 9/6/24. On 9/1/24 (Sunday) and every Sunday in September the scheduled activity was River of Life Church for the whole day and every Saturday in September the scheduled activity was Resident Lead Activities. On 9/2/24 (Monday, which was Holiday), the scheduled activity was Resident Lead Activities. A confidential Resident Council interview was held on 9/10/24 at 10:30 AM. Seven Residents attended the meeting. During the meeting, five residents reported that the facility eliminated all the activities staff when there was a change in management. They reported they had more programs prior to that. They reported it happened several months ago. They added the facility currently had one staff member, the activities director, who tried to handle everything. Four residents confirmed the facility did not have activities staff on weekends. They added they had Church on one day. One resident added they set up some stuff and residents who were able to do things on their own could use the items. It was further reported the Activities Director tried to improvise with the staff they had. A staff member (Certified Nursing Assistant - CNA) assisted residents with smoking and assisted with some activities when they worked on weekends. Another resident stated, It is too much for one person to do. An interview was conducted with Director of Activities (DA) D on 9/9/24 at approximately 3:00 PM. DA D was queried about their activities programming, staffing and how they met the interests/needs of their residents. They reported they were the only staff member in the department at this time and had been since April 2024. They added they used to have three staff members in the department and they had a variety of programs every day of the week. They reported they were recently approved a part-time staff who assisted between nursing and activities. They had some volunteers from church helping on weekends and they were trying to do their best to meet the needs of their residents. They added they tried to spend around three hours for a resident group activity and tried to manage the 1:1 visits and their other responsibilities. An interview was conducted with the Administrator on 9/10/24 at approximately 12:45 PM. When queried about the activities program and the lack of activities and staff, the Administrator acknowledged the concerns and added they just received an approval for a part-time staff member from the management. They added they were trying to change that to a full-time staff member and were trying to have other managers assist with programming. Review of facility provided document titled Activities with a revision date of 1/1/24, read in part, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Definitions: Activities refer to any endeavor, other than routine ADLs (activities of daily living), in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. Policy Explanation and Compliance Guidelines: 1. Each resident's interest and needs will be assessed on a routine basis. The assessment shall include, but is not limited to: a. RAI (resident assessment instrument) Process: MDS/CAA(care area assessment)/Care Plan. b. Activity assessment to include resident's interest, preferences and needed adaptations. c. Social History. d. Discharge Information, when applicable. 2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Create opportunities for each resident to have a meaningful life. c. Promote or enhance physical activity. d. Promote or enhance cognition. e. Promote or enhance emotional health. f. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. g. Reflect resident's interests and age. h. Reflect cultural and religious interests of the residents. i. Reflect choices of the residents. 3. ADL-related activities, such as manicures/pedicures, hair styling, and makeovers, may be considered part of the activities program. 4. Activities may be conducted in different ways: a. One-to-One Programs. b. Person Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. c. Program of Activities - to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend .

This citation pertains to Intake #MI00143695. Based on record review and interviews facility failed to timely identify and address the nutritional needs; and monitor weights for one (R907) of two residents reviewed for nutrition and weight loss. This deficient practice for a resident admitted with higher risk resulted in decreased intake, significant undetected weight loss, and overall decline in the status. Findings include: R907 A record review revealed R907 was admitted to the facility for a short-term stay, after hospitalization on [DATE]. R907's admitting diagnoses included respiratory failure, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease (COPD). Based on the Minimum Data Set (MDS) assessment dated [DATE], R907 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. R907 was living independently in the community prior to admission to hospital on 2/10/24 with acute respiratory failure and congestive heart failure. R907 was discharged from the facility to home on 3/28/24. A complaint received from another State Agency revealed that R907 did not receive appropriate assistance and services that they needed during their stay at the facility. The complaint revealed that R907 was not positioned appropriately and did not receive the staff assistance they needed for feeding. R907 had lost between 15 lbs. - 20 lbs. during their stay at the facility. Review of R907's Electronic Medical Record (EMR) revealed an admission Minimum Data Set (MDS) assessment dated [DATE]. Review of an occupational therapy evaluation dated 2/24/24 revealed that R907 had limited Range of Motion (ROM) on both shoulders. R907 had also impaired strength in both upper extremities and significant impairment with sitting balance. R907 was able to feed independently. A review of admission physician orders revealed an order dated 2/23/24 that R907 was admitted to the facility with a regular diet. An admission nutrition assessment dated [DATE] revealed that R907 had an admission wright of 132.8 lbs. The Mini Nutritional Assessment (MNA) score on admission for R907 was 6, indicative of malnourishment. The assessment also revealed that R907 was at further risk for nutrition and hydration problems related to the current diagnoses and their co-morbidities. R907 had a recent decrease in appetite and did not have difficulty with chewing or swallowing. R907 was recommended to receive Med Pass (a nutritional supplement with added calories) 120ml.(milliliters) QD (every day) , ~240 Kilocalories, 11 gram of protein/serving for nutritional support. Further review of the physician orders and medication administration record did not reveal that R907 received their supplement as recommended by the Registered Dietician (RD). Review of R907's nutritional goals included to have a fair-good appetite and to consume at least 50% of their meals. The RD's plan for R907 revealed that they would continue to monitor and follow up as needed due to their nutritional risk. Review of R907's weight record revealed the following entries: 3/21/24 - 114.6 lbs. (18.2 lbs. weight loss in 25 days) 2/25/24 - 132.8 lbs. 2/23/24 at 22:59 - 132.8 lbs. 2/23/24 at 14:15 - 132.8 lbs. After the weight entry on 2/25/24 (two days after the admission weight) the follow-up weight was completed on 3/21/24, approximately after three weeks. There was no monitoring of R907 weights in between despite all the identified risks. Review of R907's food acceptance record for 30 days from 3/5/24 through 3/28/24 revealed the following entries. Refused - 3 meals. Ate 0% - 6 meals. Ate less than 25% - 8 meals. Ate less than 50% - 9 meals. Review of R907's nursing progress notes revealed R907 was discharged home on 3/28/24 per R907 and family member's request. Further review of R907's progress note did not reveal any follow up by RD throughout the stay at the facility. An initial History and Physical was completed by the attending physician on 2/26/24. A progress note by the practitioner for attending physician dated 2/27/24 revealed they had followed up with the pain clinic regarding R907's pain management. There was no evidence of any further follow-up by the attending physician or their practitioner during R907's stay at the facility. A review of the therapy notes revealed R907 received skilled physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services during their stay at the facility. Review of the OT discharge summary dated 3/23/24 revealed that R907 was dependent on staff assistance with their feeding with a decline in functional status. Review of R907's ST evaluation dated 3/1/24, revealed that R907 reported difficulty with chewing food, and they referred for ST evaluation. ST evaluation revealed R907 had swallowing deficits. R907's diet was downgraded from regular texture to pureed diet due to difficulty with chewing and swallowing of regular and mechanical soft (chopped up) food. Further review of R907's physician orders revealed R907 had orders for multiple diagnostic laboratory services (for blood work) dated 2/24/24, 3/5/24, and 3/12/24. R907's Electronic Medical Record (EMR) did not have any evidence of blood work results that were ordered by the physician/practitioner. There was no evidence of any follow up by the attending physician/practitioner. There was no follow up nursing documentation on the EMR. An interview with the complainant (another state agency staff) was completed on 4/3/24 at approximately at 10:05AM. The Complainant reported that they were following up on the R907 while they were living in the community. The Complainant had reported that R907 had lost over fifteen pounds of weight during their stay at the facility and was receiving purred food, and the staff did not provide the assistance they needed with eating. During an interview with Registered Dietician RD A on 4/3/24, at approximately 1:35 PM, they were queried on the facility's weight monitoring process. RD A reported that the admission weight was getting completed within seven days of admission and they were completing monthly weights unless there were other clinical risk factors identified based on the RD and interdisciplinary team assessment. RD A was queried about the admission weight time frame and if they had completed weekly weights. RD A reported that it was not a standard process rather dependent on individual assessment parameters. RD A was queried about R907 and their significant weight loss and why they were not identified and addressed timely. RD A reported that when R907 triggered for weight loss they were discharged from the facility. RD A was queried further about their initial Mini Nutritional Assessment (MNA) dated 2/27/24 with a score of 6 (score of 1ess than 17 indicates malnourishment) and identified as at risk for nutrition and hydration why there was not timely monitoring and follow up. RD A agreed on the concern and reported they had challenges obtaining weekly weights and they would follow up with the team. An interview with the Nurse practitioner C was completed on 4/4/24, at approximately 9:05 AM. Nurse practitioner C was queried about R907's significant weight loss and if they were notified. Nurse practitioner C reported that they were notified of R907's weight loss prior to going home and they did not have time to follow up and address. The Nurse practitioner was queried on how they would have addressed it and reported that they would have ordered laboratory tests, more frequent weight monitoring (weekly or even daily) and would have recommended the RD to follow-up. The Nurse practitioner was queried of they were aware of the labs that were ordered for R907 that were not completed and if they had followed up. Nurse practioner C reported that the facility had a change in lab providers, and they were not aware that labs were not completed, and they did not have access to check on their computer during the interview. An interview with the Director of Nursing (DON) was completed on 4/3/24 at 12:05 PM. The DON was queried about the facility's weight process and reported that staff were getting admission weights as soon as a resident was admitted to the facility (within the first few hours). The DON reported that they were doing weekly weights and then they were changed to monthly weights after four weeks unless the recommendations/order from the RD or physician/practitioner stated otherwise. A follow up interview was completed with the DON later that day at approximately 3 PM. The DON was queried about weight monitoring that was not followed and the significant weight loss for R907 with no follow-up from the RD and practitioner. The DON reviewed the EMR for R907 and reported that they understood the concerns. The DON also reviewed the EMR and confirmed later that R907 did not have any evidence that laboratory (blood) tests were completed as ordered for 2/24/24, 3/5/24, and 3/12/24. A facility document titled Weight Monitoring with the most recent revision date of 1/24, read in part Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systematic approach to optimize the resident's nutritional status. This process includes: a. identifying and assessing each residence nutritional status and risk factors b. Evaluating\ analyzing the assessment information c. developing and consistently implementing pertinent approaches d. monitoring the effectiveness of interventions and revising the mass necessary 2. A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Assessment should include the following information: a. General appearance b. Height c. Weight d. Food and fluid intake e. Fluid loss/gain f. Laboratory/diagnostic evaluation . 5. Weights will be obtained upon admission, readmission and weekly for first four weeks after admission and at least monthly unless ordered by the physician. If a resident declines to be weighed this should be noted in resident's record . 7. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5 change in weight in 3 months (90 days) c. 10% change in weight 6 months (180 days) .

This citation pertains to intake: MI00140321. This citation contains two Deficient Practice Statements (DPS). DPS #1 Based on interview and record reviews the facility failed to ensure a resident was properly transferred via wheelchair (R84) and ensure the required assistance level for bed mobility was provided to prevent a fall (R17), two of three residents reviewed for accidents, resulting in the resident to have verbalized pain, and ultimately resulting in an identified acute nondisplaced fracture at the proximal tibial meta diaphysis (R84). Findings include: R84 Review of Physical Therapist (PT) statement documented in part . 9-11-23 . Approx. 2:00 PM came upon (R84's name) in hallway in her w/c (wheelchair). She was leaning significantly to her left with her trunk off side of w/c. As I adjusted her upright she winced and had tears in her eyes. She c/o (complained of) pain in her R (right) knee. Attempted gentle ROM (Range of Motion) R knee (with) noted (increased) pain. Asked her what happened, and she states, the lady hurt my knee when I was in my w/c. Asked her if this occurred during hoyer lift and she stated no it happened after she was in w/c. Immediately spoke to nurse (nurse name) who ordered x-ray . Review of the medical record documented R84 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, systemic lupus, dysphagia, and dementia. Review of an Employee Counseling Notice dated 9/18/23 to Certified Nursing Assistant (CNA) T that documented in part . (CNA T name) was assigned to care for the resident on the 100 hall on 9/11/23 and per (CNA T name) transfer of the resident, she was pushing the resident in her wheelchair without a wheelchair pedal and when she approached the hallway and <sic> residents right ankle got caught under the wheelchair. Xray were ordered and results revealed possible fx (fracture) of right tibia, resident went out for further testing CAT Scan and confirmed fracture on 9/12/23 . This is a Violation of work rule #37 employees Mat <sic> not physically, verbally, emotionally, or psychologically abuse a resident, visitor, or another employee; neglect resident care duties related to the safety, health, and/or physical comfort of the residents; or engage in a serious violation of a resident's rights . The counseling notice was signed off by the Director of Nursing (DON) and CNA T. On 10/31/23 at 10:25 AM, the Director of Nursing (DON) was interviewed and asked about the incident of R84 to have obtained a fracture. The DON explained they conducted the investigation and was informed by the resident nurse that the resident was complaining of pain to the right leg. The DON stated an x-ray was ordered and they began their investigation. When they interviewed CNA T they stated R84's right leg had gotten caught in the wheelchair and their leg got bent. The DON stated CNA T asked the resident if they were okay and at the time the resident did not express any pain. The DON stated the facility does not have a policy on the use of wheelchair foot pedals and at that point they did not have it care planned for the resident, however the expectation was that was for the foot rest to be put on R84's wheelchair while pushing the resident. On 10/31/23 at 11:49 AM, CNA T was interviewed and asked about the incident that occurred with R84 on 9/11/23 and CNA T stated in part . I was getting her (R84) up . when she (R84) is successfully transferred and the hoyer was removed, I'm looking for a leg rest and couldn't find it so as I'm pushing her in the hallway the bad leg (confirmed right leg) got caught under the wheelchair . Her bad leg was the right and the good was the left . because her right side was paralyzed due to a stroke, I believe . CNA T went on to say they knew that R84 required a leg rest for their right leg so that R84's paralyzed leg would not drag on the floor. No further explanation or documentation was provided by the end of the survey. 34275 R17 On 10/30/23 at approximately 11:13 AM, R17 was observed lying in bed. The resident was alert and able to answer questions asked. When asked about care in the facility the resident reported that they came to the facility in May 2023 to obtain physical therapy and no longer were receiving care and felt they were just lying in bed. R17 reported that a few weeks ago they were being turned in their bed and a CNA rolled them out of bed. They fell to the floor and sustained injury to their legs, knees, feet and toes. R17 reported that they are still in pain from the fall. A review of R17's clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included: congestive heart failure, type II diabetes neoplasm of right breast. Review of R17's Minimum Data Set (MDS) with a date of 10/9/23 indicated the resident had Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition). Continued review of the MDS noted the resident required was totally dependent from rolling left to right and required a two person assist for bed mobility. The resident's Care Plan noted: Focus: ADL (activities of daily living) self-care performance. Deficit .increased w/(with) left side weakness .Interventions: Bed Mobility .I need 2 person assist (Date initiated 6/12/23) . Continued review of R17's clinical record revealed, in part, the following: 10/2/23(9:31 PM): Nursing Progress Note .Event occurred on 10/2/23 at 9:30 PM. Resident observed sitting on the floor in between her bed and bedside table .Abrasion noted to both knees and lower right leg. Skin tear noted to right outer foot and left second toe . 10/2/23 (9:38 PM): SBAR (situation, background ,assessment & recommendation): .The change in conditions reported .are/were falls .Nursing observations, evaluations and recommendations are .CNA was turning her to place a bedpan and resident fell off the bed .recommendations: Dressings to right food and left toe and monitor for excessive bleeding . 10/3/23 (1:18 AM): Medication Administration: Oxycodone-Acetaminophen .Give 1 tablet by mouth every 8 hours as needed for pain - BLE (bilateral lower extremities) . 10/3/23 (9:21 AM): Medication Administration: Oxycodone-Acetaminophen .Give 1 tablet by mouth every 8 hours as needed for pain .s/p (status post) fall . 10/3/23: (10:03 AM): Antigravity Team Note: .Root Cause(s) of Fall: Improper positioning . 10/3/23 (8:14 PM): Nursing Note: .S/P Fall: .Resident is alert and able to make needs known she C/O (complains of) pain and was given PRN (as needed .There after resident began to express how upset she was about her recent fall. She expressed that she no longer wanted to live .She stated this is no way to live . An e-mail request was made to the Administrator on 10/31/23 at approximately 6:43 AM asking for any Incident/Accident (IA) reports pertaining to R17 and all accompanying documents needed for the investigation such as interviews. A review of an Incident/Accident (IA) report dated 10/2/23 provided noted, in part: .date: 10/2/23 (10:30 PM) .Resident: R17 .Location: Resident's room .Incident description: Resident observed sitting on the floor in between bed and bedside table .Resident Description: CNA was turning me on the side to put a bedpan underneath me and I rolled out of bed .Witness name (CNA W) . *It should be noted that there were no further documents attached to the IA, including interviews with CNA 'W or R17. On 11/1/23 at approximately 8:24 AM, an interview was conducted with the DON. When asked as to the incident involving R17, the DON reported that CNA W was attempting to put the resident on a bedpan and rolled R17 out of bed. When asked if another person should have been present, the DON indicated the resident was a two person assist for both bed mobility and bed transfers. The facility policy titled, Fall Reduction Policy (revised 4/23) was reviewed and documented, in part, Policy: Our residents have the right to be free from falls, or to sustain no or minimal injury from falls .Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level . DPS #2 Based on observation, interview and record review the facility failed to ensure oxygen gaskets were working properly in resident rooms [ROOM NUMBERS]. This deficient practice had the potential to affect all residents residing on the 200 Hall. Findings include: On 10/30/23 at approximately 6:25 AM, and 6:40 AM, an observation was made in both room [ROOM NUMBER] and room [ROOM NUMBER]. An unidentifiable noise was heard coming out of the walls. Further investigation determined that the noise was coming from the O2 valves mounted on the wall located behind the resident's headboards. The two residents residing in room [ROOM NUMBER] and the one resident in room [ROOM NUMBER] were noted to NOT have oxygen infusing for respiratory purposes. R68 reported that the oxygen had been running for months and expressed concern that the oxygen could lead to a fire. On 10/30/23 at approximately 6:45 a.m., during a conversation with Nurse X, Nurse X was shown the oxygen coming from the wall and reported that it had been that way for weeks. Nurse X was queried if anyone was aware of the problem, and they indicated they thought maintenance had been made aware. Nurse X also reported that the same problem was happening in room [ROOM NUMBER]. On 10/30/23 at approximately 6:50 AM, Certified Nursing Assistant (CNA) Y was asked about the oxygen coming from the wall in room [ROOM NUMBER] and 214. CNA Y reported that they had been hearing the noise for a few weeks. On 10/30/23 at approximately 7:30 AM, the Maintenance Director was interviewed as to the 02 running in the rooms. The Maintenance Director also noted that the 02 had been running for a few weeks and noted that there was a leaking gasket problem that needed to be addressed. Review of the facility policy titled, Resident Environmental Quality (1/11/21) documented, in part: Policy: The facility should be designated, constructed, equipped and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public .the facility shall .Maintain all essential mechanical, electrical and patient care equipment in safe operating condition .

This citation pertains to intake: MI00140321. Based on interviews and record reviews the facility failed to timely provide medical care and ensure a timely transfer to the hospital for a resident identified with a change of condition (R84) and failed to ensure monitoring of oxygen saturation levels for (R81), two residents of two residents reviewed for a change of condition, resulting in the delayed treatment of a resident (R84) with identified acute changes who was later transferred to the hospital, intubated, and admitted into the Intensive Care Unit (ICU). Findings include: R84 Review of the medical record documented R84 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, systemic lupus, dysphagia, and dementia. Review of a Nurse Practitioner (NP) consultation dated [DATE], documented in part . Patient was seen today per facility request. Nursing staff reports patient has had changes in mental status, speaking less in the last 24 hours . Upon my examination and interview, patient states that she is having increased back pain. She seems to have difficulty expressing/answering questions . difficulty with verbal communication . Plan: Ordered: Stat (immediate) chest x-ray 2 views for abnormal lung sounds/crackles, stat (immediate) urinalysis with culture and sensitivity for mental status changes, CMP (comprehensive metabolic profile)/CBC (complete blood count) with differential. Increase patient tramadol from 50 mg (milligram) every 6 hours as needed to 100 mg every 6 hours as needed for pain, due to complaints of increased back pain . BP (blood pressure)/pulse: From [DATE], 02 sats: From [DATE], Temperature: From [DATE], Respirations: From [DATE] . Reinforced education to nursing that vital signs should be collected per protocol, meaning vital signs should be collected whenever someone has an acute change in status . Discussed with director of nursing . Advised nursing staff to please complete orders as soon as possible to increase expedient diagnosis for acute [NAME] status changes. Continue to monitor patient for signs/symptoms of respiratory distress. Continue to monitor patient for signs/symptoms of worsening mental status changes. Report any adverse events to provider as soon as possible. Discussed patient's status with multiple members of facility nursing staff . Review of the medical record revealed no results of a stat chest x-ray to have been completed and contained no documentation of frequent monitoring, vitals, or assessments for a resident with an identified acute change. Review of a Late Entry Nursing note dated [DATE] and back dated to [DATE] at 7:31 PM, documented in part . Resident's lungs sound wet but responding and talking to writer. HOB (head of bed) up at 90 degrees. Call placed to DON (Director of Nursing) and chest x-ray changed to stat. NP (Nurse Practitioner) saw her in the afternoon and ordered labs and a UA (urinalysis). Order for x-ray faxed to x-ray department. Will continue to monitor. Awaiting NP call back . This note was documented by Registered Nurse (RN) V. Further review of the medical record revealed no documentation of vitals obtained for this resident, considering staff documented the identification of the resident lung sounds as wet. Review of a change of condition assessment dated [DATE] at 8:30 PM, documented in part . Abnormal vital signs, heart rate, respiratory rate, weight change, Functional decline . BP ,d+[DATE], P 105, Pulse Oximetry 52% . Swallowing difficulty, abnormal lung sounds, Resident appears to have had a stroke with left mouth drooping and not swallowing well, lungs are wet . This EMR (electronic medical record) system documented this assessment was completed by Unit Manager (UM) P and RN V. This indicated that staff waited an hour later to obtain vitals that were identified to be abnormal, with the identification of a possible stroke and decline of the resident, with no further action or follow up documented at that time. Review of a Nursing note dated [DATE] at 9:51 PM, documented in part . NP (Nurse Practitioner name) returned call and notified of change in condition that resident had drooping left side of mouth and was having difficulty swallowing meds and water with some running out of mouth .To hold food and liquids and await chest x-ray. Order to send to hospital if condition worsens. Resident able to get medication down. O2 sat 92% on RA (room air) and B/P ,d+[DATE] . This note was documented by RN V. Review of a Nursing note dated [DATE] at 11:48 PM, documented in part . Resident O2 saturation dropped down to 52%, non-rebreather applied on 15 liters of oxygen via tank. VS (vital signs) were ,d+[DATE]-[DATE].4 and blood sugar 139. Breathing non labored. 911 called . This note was documented by RN V. This indicated the resident was identified to have declined further almost two hours later with no documentation of monitoring of vitals of the resident in between the last documented note at 9:51 PM until the next documented note at 11:48 PM. Review of a Nursing note dated [DATE] at 12:13 AM, documented in part . 911 left with resident, 02% on re-breather. Transfer forms given to paramedics . This note was documented by RN V. This note indicated the resident was eventually transferred to the hospital after multiple identified signs and symptoms of decline, which started when the nursing staff first notified the NP earlier on [DATE] and when the nursing staff identified additional signs and symptoms at 7:31 PM. This resulted in the delayed need for a higher level of care for over four hours. Review of an Emergency Medicine consultation dated [DATE] at 12:37 AM, documented in part . presents secondary to altered mental status and hypoxemia. EMS (emergency medical services) received a call from her extended care facility for altered mental status and hypoxemia. Apparently she was saturating in the 50s. Apparently she has a history of multiple strokes. Staff there stated that she has some facial drooping but they are unsure of the exact time of onset . For prior strokes she is essentially paralyzed on both sides of her body . She is somewhat somnolent in appearance . The patient is seen and evaluated. Patient presents today scented to hypoxemia. Apparently she was saturating in the 50s when EMS (emergency medical services) arrived. They placed her on nonrebreather mask which only brought her up to the mid 80's. Per nursing staff she seemed to have some facial dropping and more altered than normal. She has an unknown time of onset . She does have coarse breath sounds. She does some vomitus . Septic work-up was initiated. She started IV (intravenous) cefepime and vancomycin. She is given IV fluid bolus given she was mildly hypotensive upon arrival . After my initial assessment given the patient's lowered GCS (Glasgow coma scale) depressed level of consciousness and high NIH stroke scale and her hypoxemia despite nonrebreather mask I feel she requires intubation. Utilizing a glide scope breath. Sequence intubation was performed . Patient admitted for further work-up. Spoke with ICU (intensive care unit) team . On [DATE] at 10:57 AM, a telephone interview was attempted with RN V, a message was left on RN V voicemail with a number to return the call. On [DATE] at 11:16 AM, UM P was interviewed and asked when they were first notified of the change of condition with R84 and asked about the timeframes documented in the medical record which indicated a delay in care and the delay in transferring the resident to the hospital, UM P initially stated they believed they read a note on the resident to have had difficulty swallowing and asked the speech therapist to go and assess the resident with them. UM P was asked to provide the date, time, and documentation of the assessment. UM P stated they would review the record and follow up with the answers to the questions asked. UM P was also made aware of the attempt to interview RN V and was asked to reach out to their staff to facilitate an interview. At 12:09 PM, UM P returned and stated they attempted to reach out to RN V and was unsuccessful. UM P then apologized and stated they provided the wrong information when initially asked about when they were first informed of the change of condition for the resident. UM P stated their name was on the change of condition assessment dated [DATE] at 8:30 PM, because RN V opened the assessment at that time and didn't close the assessment. UM P stated they went in the medical record after RN V and locked the assessment and explained that was why their name was documented on the assessment for the resident. The questions were asked again why there was a delay in care and a delay in transferring the resident to the hospital when the staff identified and documented further decline of the resident that day and UM P stated they would look into it and follow back up. UM P was asked to provide the EMS or Emergency Department report to confirm that actual time that R84 was transferred to the hospital. No further information or documentation was provided by UM P by the end of the survey. On [DATE] at 2:03 PM, a telephone interview was attempted with the Nurse Practitioner that consulted and assessed the resident on [DATE], however a return phone call was not received by the end of the survey. On [DATE] at 8:09 AM, the DON was interviewed and asked why the stat x-ray was not completed timely for the resident when ordered by the NP on [DATE], and the DON stated they didn't have a chance to get the x-ray because the resident declined further and was sent out (to the hospital). The DON was asked about the delay in medical care and the delay in transferring the resident to the hospital when the staff identified further decline of the resident, the DON stated they would look into it. The DON was then asked to provide the EMS, ED (emergency department) report or any documentation that can confirm the time the resident was transferred to the hospital and the DON replied they could provide the Emergency Department (ED) consultation. The DON was informed of the attempt to interview RN V and was asked to contact RN V and facilitate a telephone interview with the surveyor. The DON returned shortly after and stated they were able to contact RN V and stated RN V is awaiting the surveyor's call. On [DATE] at 11:30 AM, a second telephone interview was attempted with RN V. A second voicemail was left with the number to return the call. A return phone call was not received by the end of the survey. No further explanation or documentation was provided by the end of the survey. 48680 R81 Record review revealed that R81 was admitted to the facility on [DATE] with a readmitted [DATE] with the medical diagnoses of acute respiratory failure with hypoxia, heart failure and weakness. Further review of the record revealed that R81's Minimum Data Set (MDS) assessment for oxygen (O2) therapy was selected with the start date of [DATE]. Record review of a nursing progress note dated [DATE] at 7:07 PM, documented in part Resident returned to facility around 1806 VIA ambulance stretcher. Resident shows no s/s (signs and symptoms) of pain, discomfort or respiratory distress noted. Resident is currently in room with call light within reach and is positioned comfortably in bed. Resident was oriented to call light system and room. Vital signs blood pressure ,d+[DATE], heart rate 110, temperature 97.1, oxygen saturation 97 percent VIA nasal cannula. The remainder of admission will be endorsed to oncoming shift. No further concerns noted. Review of the physician orders documented the following order-May use O2 as needed to maintain oxygen saturation greater than or equal to 89 percent every 12 hours as needed for Emergency use per standing orders. Review of the medical record revealed no documentation of staff to have obtained oxygen saturation levels from R81 from [DATE] until the time of death on [DATE]. The medical record contained no documentation that the facility staff monitored and ensured the resident's oxygen saturation levels were equal too and/or greater than 89 percent every 12 hours as indicated in the physician orders. On [DATE] at 12:02 PM, an interview with the DON was conducted and the DON was asked how often are vitals taken and what does vitals consist of, the DON Replied once a month for long term residents, we like to give our residents a homelike environment. The DON was asked does the Facility have a policy for obtaining vital signs, the DON replied, No. The DON was asked how often is the oxygen saturation levels checked for a resident who is administered oxygen or has an as needed order for oxygen, the DON explained that they should be checked per shift even for as needed oxygen administration. The DON was then asked if the oxygen saturation levels of R81 should have been monitored from [DATE] to [DATE] and the DON Replied yes. There was no additional information provided by the end of the survey.

This citation pertains to Intake Number(s): MI00136993. Based on interview and record review, the facility failed to accurately assess, monitor, and treat a wound for one (R803) of four residents reviewed for skin management and changes in condition. This resulted in an Immediate Jeopardy (IJ) to the health and safety of residents when a wound to R803's left great toe that was present for an undetermined amount of time was not identified or treated by the facility and resulted in a hospital transfer, diagnoses of sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) due to an infected wound with gas gangrene (a serious soft tissue infection caused by bacteria that produces gas and toxins) which required amputation and ultimately resulted in the resident's death. Findings include: The IJ began on [DATE]. The IJ was identified on [DATE]. The Administrator was notified of the IJ on [DATE] at 4:32 PM and a plan to remove the immediacy was requested. The immediacy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal verified on-site by the surveyor. Although the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a complaint submitted to the State Agency alleged the facility did not appropriately assess, monitor, and treat R803's change in condition. On [DATE] at 4:25 PM, a phone interview was conducted with the complainant. The complainant reported that R803 developed gas gangrene in their foot, the facility was not assessing their skin, and the facility did not identify the wound to R803's foot. The complainant further reported the wound and a change in condition were identified by R803's dialysis center and the facility did not address their concerns in a timely manner. The complainant explained R803 was eventually transferred to the hospital where it was discovered (the wound on their foot was infected), required amputation, and they ended up dying a few days later. An unannounced, onsite investigation was conducted from [DATE] to [DATE]. Review of R803's clinical record revealed the following: R803 was admitted into the facility on [DATE], readmitted on [DATE], and discharged to the hospital on [DATE] with diagnoses that included: end stage renal disease (ESRD), adult failure to thrive, type 2 diabetes mellitus (DM), hypertension, and heart failure. R803 was dependent on renal dialysis. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R803 had moderately impaired cognition, no behaviors including rejection of care, required extensive physical assist for bed mobility and transfers, and did not have any wounds. Review of R803's progress notes from [DATE] through [DATE] revealed no documentation of wounds. Review of R803's weekly skin assessments revealed no skin impairments to R803's left great toe. Review of R803's Physicians Orders revealed an order for dialysis every Monday, Tuesday, Thursday, and Friday at the facility's in-house dialysis unit with a chair time of 8:00 AM. Review of a Dialysis Transition of Care Form dated [DATE], revealed the following comments written by Dialysis Nurse 'C': Please check pt's (patient's) buttocks. He is having a foul odor but did not have a bowel movement and complaining his butt hurts. Review of R803's progress notes and skin assessments did not reveal that R803's skin was checked as requested by Dialysis Nurse 'C'. Review of a Dialysis Transition of Care Form dated [DATE] revealed the following comments written by Dialysis Nurse 'D': Pt off 18 minutes early. C/o (complained of) pain to bottom .Wound to L (left) great toe smells. Appears larger. Is he still seeing podiatrist weekly at nursing home? Plan? .Pt says bottom hurts also. Does he have sore? Smell from toe or bottom .temp (temperature) 100.4 (degrees Fahrenheit - F) .(down arrow indicated temperature went down) 99.3 (degrees F) .Very out of it . R803's pre-dialysis blood pressure was low at ,d+[DATE] and post-dialysis blood pressure was high at ,d+[DATE]. Review of a SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form for R803 revealed R803 was transferred to the hospital on [DATE] at 5:00 PM for Altered Mental Status. In the section for Skin/Wound Care it was documented R803 did not have any pressure ulcers, other wounds, or bruises. The transfer form was completed by Nurse 'B'. On [DATE] at 11:22 AM, a telephone interview was attempted with Dialysis Nurse 'D'. Dialysis Nurse 'D' was not available for an interview prior to the end of the survey. On [DATE] at 11:30 AM, a telephone interview was conducted with Dialysis Nurse Manager 'C'. When queried about what occurred with R803 on [DATE] when he was at dialysis, Dialysis Nurse 'C' reported they felt R803 needed to go to the hospital, but the facility did not want to send them. Dialysis Nurse 'C' reported they would provide progress notes written by Nurse 'D' from that day as well as the monthly Foot Check Assessments completed by the dialysis center. When queried about R803's skin, Nurse 'C' reported on [DATE] R803 was observed to have a foul odor and the facility was asked to check their skin and on [DATE], the foul odor remained and R803 did not seem to be feeling well. Review of R803's dialysis progress notes revealed the following: A note written by Nurse 'D' on [DATE] at 11:02 AM revealed the following documentation: Patient presented to dialysis this am (A.M.) by w/c (wheelchair). Pt seemed kind of out of it. Staff lifted patient from w/c (wheelchair) to dialysis chair by grabbing pt by armpits and lifting patient over dialysis chair and then placing him in it. Patient screaming out in pain. Writer attempted to speak with patient. Patient stated he fell and was gazing into space. Temp upon arrival 100.4 (degrees F). Later removed hat and reassessed temperature and it was 99.3 (degrees F). Pt requiring coaxing to speak. Other patient at dialysis reported that he had fallen at least 4 times from bed .Patient told writer that he hurt. Reports his shoulders, neck and right hip and butt hurt .Writer phones receptionist and requested that patient nurse phone unit (dialysis is completed on site in facility) as his mentation was not as it always had been. (Nurse) came down to unit. (Nurse) stated that he was fine and denied him having any infection .stated that patient did not like dialysis staff and did not like dialysis and that is why he was acting this way. Writer questioned (Nurse) if patient had been evaluated after fall. (Nurse) said he did not fall as DON (Director of Nursing) who came into cover did not report it to her. She said patient was just saying this as he did not want to come to dialysis. (Nurse) asked patient if he would prefer to skip dialysis. Patient said nothing .(Nurse) further proceeded to yell at RN (Registered Nurse) and state that she should not have to assess pt as writer was a nurse. Writer corrected (Nurse) and stated that his mentation was a huge change since she had seen him on Friday. (Nurse) stated that there is no need to seek medical care for pt and it was up to RN weather he dialyzed or not. It did not matter to her. Writer contacted (physician) .stated that as long as patient was not using heparin to go ahead and dialyze. If drastic change in status, orders received to send patient to EC (emergency center) for evaluation. Patient slept most of treatment . A note written by Dialysis Nurse 'D' on [DATE] at 12:59 PM revealed the following documentation: Pt completed dialysis .off early d/t (due to) complaints of pain to his bottom. Pt more alert, but still not himself . Review of R803's Foot Check Assessments completed by the dialysis center revealed the following: On [DATE] it was documented that Pt has new sores on left foot .Bandaged by another health care provider; unable to examine .foot check completed by Podiatrist/Wound Care Specialist .Pt foot dry and new sores on left foot . On [DATE] it was documented that R803's had a crusty, horny looking sore on left great toe and second toe .foot checks done by staff at ECF (extended care facility) while dressing and bathing patient . On [DATE] at 12:52 PM, an interview was conducted with Nurse 'B' who was assigned to R803 when they were transferred to the hospital on [DATE]. When queried about how the facility and dialysis center communicated resident concerns to each other, Nurse 'B' reported that if it were something significant the dialysis center would call the nurse and if it was not significant it would be documented on the communication form which was reviewed by the nurse when the resident returned from dialysis. When queried about what happened with R803 prior to being sent to the hospital on [DATE], Nurse 'B' explained the resident went to dialysis that morning and that he was already at dialysis when they arrived for their shift. Nurse 'B' received a call from the dialysis center because the dialysis nurse was concerned about R803's condition. Nurse 'B' reported they went down to the dialysis center that was located in-house and took R803's vitals which were stable and R803 did not have any concerns. The dialysis nurse expressed that they wanted to send R803 to the hospital and Nurse 'B' told them that they could make that decision. R803 finished dialysis and was brought back to the unit around 12:00 PM or 1:00 PM. Nurse 'B' reported R803 did not seem like themselves, was oriented and not lethargic, but something was weird about how he was communicating so I was wondering if maybe he had a stroke. Nurse 'B' reported they found out from R803's roommate that R803 had multiple falls in the days prior, but nobody reported the falls to Nurse 'B'. Nurse 'B' reported they contacted the physician at that time and the physician said to monitor R803. Nurse 'B' explained around 4:00 PM or 4:30 PM, they transferred R803 to the hospital due to altered mental status. When queried about any verbalized or documented concerns expressed by the dialysis center that day, Nurse 'B' reported they could not remember what the concerns were. When queried about the documentation about a foul odor and worsening wound to R803's left great toe, Nurse 'B' reported they were not aware that R803 had a wound prior to that note. When queried if they assessed R803's skin after they received the communication from the dialysis center, Nurse 'B' reported they did not remember and they may not have because they were handling the change in condition (it should be noted that there was approximately four hours between the time R803 returned from dialysis and when they were transferred to the hospital). Review of R803's clinical record revealed no evidence that R803 was assessed by Nurse 'B', no evidence that the medical provider was contacted earlier, and no evidence of a skin assessment by the facility after it was communicated by the dialysis center that R803 had a foul smelling wound. On [DATE] at 1:12 PM, an interview was conducted with the Director of Nursing (DON). The DON was not in their position at the time of R803's transfer to the hospital. When queried about the facility's protocol for managing residents' skin, the DON reported residents were assessed by a nurse upon admission, readmission, and on a weekly basis. If any skin impairments were identified, a treatment was put in place and a wound care consultation was requested. The wound team saw residents weekly and made sure treatments were appropriate. When queried about how concerns were communicated between the in-house dialysis center and the facility, the DON reported they either contacted the DON via email, called the nurse assigned to the resident, and communicated via the Dialysis Transition of Care Form. The DON explained the Dialysis transition of Care Forms were given to the nurse upon completion of dialysis and the nurse was required to review it right away. The DON reported if there was a significant concern, the dialysis center would contact the nurse. When queried about what should have been done when the dialysis center documented concerns about R803's skin, a foul odor, and worsening of a wound to their left great toe, the DON reported the nurse should have assessed R803's skin, contacted the physician, and put a treatment in place. When queried about what should have been documented by the facility nurse if dialysis expressed concerns about a change in condition and what was done to address it, the DON reported the concerns should have been documented by the nurse, as well as any communication with the medical provider. On [DATE] at 4:09 PM, a telephone interview was attempted with Nurse Practitioner (NP) 'F'. NP 'F' was not available for interview prior to the end of the survey. Review of a Certificate of Death for R803 revealed the date of R803's death was [DATE] at 9:31 AM. The Cause of Death section noted instructions to Enter the chain of events - diseases, injuries, or complications - that directly caused the death .IMMEDIATE CAUSE (Final disease or condition resulting in death) .Sequentially list conditions, IF ANY, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST . The following was documented for R803's cause of death: a. MRSA Bacteremia due to (or as a consequence of) b. Cerebral Vascular Accident due to (or as a consequence of) c. Gas gangrene of the Foot due to (or as a consequence of) d. End Stage Renal Disease. Review of R803's hospital records revealed the following: R803 arrived to the Emergency Department on [DATE] at 6:15 PM via ambulance and was admitted to inpatient care on [DATE] at 9:44 PM with a diagnosis of sepsis. R803 expired on [DATE] at 9:31 AM. An Emergency Medicine History and Physical Examination dated [DATE] at 6:15 PM revealed the following documentation: .Chief Complaint: Altered Mental Status .presents to the emergency department with concerns for altered mental status. Per EMS (emergency medical services) who provides history, the patient was at dialysis this morning and was becoming increasingly altered throughout the day. He was sent back to (facility name) and they were concerned about his mental status so they transferred him to the emergency department for evaluation. We did not have a clear last known well, but per EMS they said he was at dialysis this morning, so I do believe we are outside of 4 hours. They did note that he is usually alert and oriented x (times) 4, but has been just groaning to painful stimuli since they arrived .Vitals [DATE] 8:46 PM BP (blood pressure) ,d+[DATE] (high) .alert, but not oriented. Does not answer questions appropriately .Skin: Necrotic (dead tissue) left first great toe. Dry with no purulent drainage . A CT (computed tomography) scan conducted on [DATE] at 9:07 PM revealed, Findings compatible with acute/subacute right PCA (Posterior Cerebral Artery) distribution infarct (Stroke). An X-ray of R803's left foot on [DATE] at 9:23 PM revealed, Diffuse subcutaneous emphysema (trapped air) involving the great toe from the proximal third of the 1st metatarsal to the distal phalanx (the bone closest to the foot to the end of the toe). Findings concerning for gas-forming infection . Review of an ED Provider Note dated [DATE] revealed, .he was febrile (fever) and hypertensive (high blood pressure) upon arrival. I was also worried about an infection and particularly sepsis given his altered mentation .On exam, he did have a concerning necrotic (black dead tissue) left great toe which could be a source of his infection .He had a significant leukocytosis with a white count (white blood cell) of 26.9. 4 weeks ago it was 9.9. his lactic acid was elevated at 3.0. I was concerned for sepsis and we initiated him on broad-spectrum antibiotics .I also looked at the CT head and there was a concerning finding in his right PCA distribution. Radiology called me shortly thereafter and found that he had an acute/subacute right PCA distribution infarct .It could be safely assumed that it was over 4 hours because it happened during his dialysis session this morning and it was currently after 6 PM .Otherwise, his left foot x-ray results and revealed very concerning findings. He had diffuse subcutaneous emphysema involving the left great toe from the proximal third of the first metatarsal to the distal phalanx .I contacted podiatry who said that we would need to stabilize his blood pressures and stroke at this time before he would be an operative candidate, but likely he will go to the OR (operating room) tomorrow .I did escalate care to the ICU (intensive care unit) .admitted to ICU in critical condition . Review of a Brief Op (operation) Note dated [DATE] revealed R803 had an Amputation Left Hallux with incision and Drainage for Sepsis, Gangrene Left Foot. Review of a Neurology Consult from the hospital revealed, .Yesterday morning patient had dialysis and while at his skilled nursing facility was noted to be progressively more altered therefore patient was brought to the emergency department. In the emergency department patient was described as obtunded, not following commands, groaning to painful stimuli .It was unclear when patient was last known well . Review of a Podiatry Consultation dated [DATE] revealed, .Reason for Consult: Gangrene left great tow with infection left foot sepsis .presenting with dark black left great toe of an unknown period of time with left foot infection .He was brought to the ER noncommunicative .Physical Exam: Dark black, cold left hallux and forefoot with edema left foot, skin warm to the touch left foot proximally. Very weak, barely palpable pedal pulses left foot .Blood Culture pathogens molecular study .Specimen: Blood, Venous .Staphylococcus aureus Detected .MRSA Detected .Assessment/Plan: Gangrene left hallux with cellulitis left foot with gas in the tissues . Review of an Amputation Left Hallux with Incision and Drainage (L) Operative Note dated [DATE] revealed, .having surgery for Sepsis, Gangrene of Left foot .Findings: Purulence and necrotic tissue left foot. Gangrene left hallux . Review of an Infectious Disease Consultation dated [DATE] revealed, .IMPRESSION: Severe sepsis Staph aureus/MRSA Bacteremia likely secondary to foot infection .Acute infected left foot ulcer with cellulitis .Status post incision and drainage of left foot abscess .Likely underlying osteomyelitis of left great toe .Status post amputation of left hallux and incision of drainage of abscess .Acute metabolic encephalopathy .Acute/subacute right PCA infarct . Review of a Discharge Summary from the hospital dated [DATE] revealed the following documentation: .Discharge Diagnoses: MRSA Bacteremia .Sepsis .Acute infected left foot ulcer .admitted for management of sepsis due to infected left foot ulcer with gas, underwent amputation with podiatry. Was found to have MRSA Bacteremia .Was found to have acute/subacute R (right) PCA infarct .he had a cardiac arrest .Patient deceased . Review of a facility policy titled, Skin and Pressure Injury Risk Assessment and Prevention, revised ,d+[DATE], revealed, in part, the following: .A skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure ulcers .Documentation of skin assessment: .Document observations .Document type of wound .Describe wound .Document other information as indicated or appropriate .After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management . Review of a facility policy titled, Change in Condition revised ,d+[DATE], revealed, in part, the following: .The organization utilizes an interactive platform in the electronic health record to recognize and manage a potential change in condition .The facility will inform the resident, consult with the resident's provider, and notify, consistent with his or her authority, the resident representative(s) when there is .A significant change in the resident's physical, mental, or psychosocial status . The facility submitted the following accepted removal plan: 1. Identification of Residents Affected or Likely to be Affected: Include actions that were performed to address the citation for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed. Completion Date: [DATE] See attached roster Facility will immediately conduct skin assessments on all current residents to ensure all skin assessments are accurate and all skin integrity issues are being addressed and treated. 2. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, by whom and when those actions were completed. Completion Date: [DATE] Licensed nurses will be educated on facilities Skin and Pressure Injury Risk Assessment and Prevention Policy and Change of Condition Policy. Education will continue with all licensed nurses until it is 100% complete. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE]

Based on interview and record review the facility failed to consistently manage the pain for one (R802) of one resident reviewed for pressure wounds, resulting in multiple incomplete sessions of dialysis due to the resident's pain, verbalized frustration from the resident, and for the resident to have requested to be transferred to the hospital for better pain management. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . (R802) said (they) wanted to go to the hospital to be evaluated and treated. The rehab facility staff again refused to take (R802) to the hospital to be evaluated and or treated . Review of the medical record revealed R802 was admitted to the facility on [DATE], with diagnoses that included: end stage renal disease, type 2 diabetes mellitus, hemiplegia and hemiparesis of left non-dominant side, and the absence of the right leg below the knee. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 which indicated severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of a practitioner progress note dated 1/30/23, documented in part . Patient is seen and examine today for refill of Percocet 10-325 mg (milligram) q (every) 6 prn (as needed) for pain . He states that his bottom hurts and says he needs a pain pill. He is somewhat reluctant to engage in conversation today. I will refill his Percocet . Review of the January 2023 MAR revealed the following orders: Oxycodone w (with)/ Acetaminophen 5-325 MG, Give 2 tablets by mouth every 6 hours as needed for pain. This order had a start date of 1/25/23 and was administered almost every shift with pain ranging from a two to ten out of ten (one being the least pain and ten being the highest amount of pain). Oxycodone w/ Acetaminophen 5-325 MG, Give 2 tablets by mouth one time a day every Mon (Monday), Tue (Tuesday), Thu (Thursday), Fri (Friday) for pain meds related to LOW BACK PAIN. Give two tabs prior to dialysis at 7 AM, Mon, Tues, Thur & Friday & every 4 hours for chronic pain. This order had a start date of 1/31/23 (a day after the practitioner consultation). Review of the Clinical Notes obtained from R802's dialysis center documented the following: A Registered Nurse (RN) dated 1/30/23 at 11:14 AM, documented in part . Pt (Patient) was in pain and calling out upon arrival . He had received Midodrine per SNF (Skilled Nursing Facility) staff . staff repositioned patient frequently without decreasing pt's discomfort. With the exception of pain, he was otherwise asymptomatic. Patient requested termination of treatment d/t (due to) pain from bedsores after 1.5 hrs.(hours) of treatment . A RN dated 1/30/23 at 11:42 AM, documented in part . Staff was asked about pain meds (medications) . request made to the administrator for cushions for this patient . Note was written on . form. A RN dated 2/2/23 at 3:21 PM, documented in part . During treatment, patient required constant assistance with repositioning and providing reassurance. Due to frequent movement d/t (due to) discomfort/pain, blood flow pump stopped multiple times therefore treatment was discontinued after 2hr (hours) 19 min (minutes) d/t concern that dialysis was not being provided as well as desired and also of blood clotting in the system which would not have allowed for return of patient's . Dialysis was continues as long as able until terminated by writer . A RN dated 2/3/23 at 11:28 AM, documented in part . CNA (Certified Nursing Assistant) phoned writer this am, requesting that staff come and speak with patient regarding the importance of coming to dialysis. Patient reporting that he was in too much pain. Pt gets Percocet 10mg q 4 hours around the clock. He also gets lidocaine patch q am to his sacrum for pain. Despite writer and technician speaking with patient, he insisted he is in too much pain. He reports pain as a 10. Notified LPN (Licensed Practical Nurse) she stated that he had his med (medication). Writer got NP (Nurse Practitioner) phone number from LPN. Reached out and explained to her patient situation and she agreed that patient should be sent to the hospital for pain management. (Doctor name) notified and he agrees with plan. Later DON refused to send patient to hospital stated they would give him more pain meds here as he did not have a diagnosis of cancer, stating that it was only suspected . Patient stated only that he had a sore on his butt . Patient is alert and frustrated d/t (due to) his pain. Shared above with (dialysis staff worker) to see what appropriate actions can be taken to advocate for patient . A RN note dated 2/6/23 at 2:01 PM, documented in part . Patient (R802) told writer that he was in too much pain to come to the unit for dialysis. Writer explained that he was on dialysis as his kidneys were not working. Explained that his blood needed to be cleaned. If his blood was not cleaned, he would have a build up of toxins that would eventually cause him to expire. Writer asked him if he wanted to stop treatment as it would eventually lead to death. Patient stated that he wanted to live and agreed to come to dialysis . patient had received Percocet . 20 minutes prior . Dialysis staff noted foul stench . Shirt was damp as well. Patient had not had BM (bowel movement) . noted a stage for <sic> wound to coccyx/sacrum approximately 4 inches x 2 1/2 inches. Approximately 2 inches in depth. It appeared that old stool was in wound. Brief appeared to be saturated with drainage from the wound . Dialysis staff repositioned patient on average every 15 minutes per patients request d/t (due to) c/o (complaints of) pain. Patient managed to make it 2 1/2 hours on dialysis. Patient was c/o pain and requesting to go to the hospital . Patients treatment d/c (discontinued) early d/t complaints of pain. Staff attempted positioning of patient again. Patient stated that he wanted to go to the hospital. (Aide name) was present and she stated that she would make sure that his nurse (nurse name) was made aware. Writer f/u (followed up) with (nurse name), who stated that she told the DON (Director of Nursing) and (Wound Nurse name) that patient wanted to go to the hospital and made them aware of his sore. Nurse states that there are no orders for wound care in the record. Just to apply ointment to an old wound . Review of a RN note dated 2/6/23 at 6:15 PM, documented in part . (R802) was crying out in pain and requesting to go <sic> the EC (emergency care) . patient is not sent to hospital per his request then RN at unit is to arrange for patient to be sent. Writer went down to speak with patient's nurse . She stated that she had made the DON and (wound nurse- WN W) at the facility aware that the patient was requesting to go to the hospital and was crying out in pain. Furthermore, she described the massive wound on his sacrum/coccyx. Per ECF (Extended Care Facility) nurse, DON stated that she could see no reason for patient to be sent to the hospital as he was getting wound care . She (R802 nurse) pointed out that there were no orders for wound care except for application of a cream to a resolving wound. She stated that she was not hopeful that patient would be transferred despite patient requesting to be sent. Additional pain medications were suppose to have arrived Friday night for better coverage per NP (Nurse Practitioner) . They still have not arrived . there is no legal guardian for patient . Administrator (Administrator name) had come into dialysis unit asking how patient was doing today as he had c/o (complaints of) <sic> on Friday, that staff made him aware of. Showed administrator wound on patient's sacrum and reported no wonder he was having so much pain. Volunteered that patient had stated that he wanted to go to the hospital. Also pointed out that pain meds that were to arrive on Friday, never did. Administrator asked if writer had discussed matter with nursing staff. Stated that writer did speak with (R802's nurse) and she had f/u (followed up) with DON and WN W . Writer stated she was not receptive to patient wanting to go to the hospital on Friday. Further explained that it is difficult to reposition patient every 10-15 minutes d/t (due to) complaints of pain and how it is difficult to get them to complete their treatments when they are in so much pain . Review of the medical record revealed no documentation by the facility staff to have acknowledged the resident to have uncontrolled pain, the request of the resident to be transferred to the hospital or the concerns reported to the facility staff by the dialysis center. Further review of the medical record revealed R802 was their own responsible party and should have been transferred to the hospital for their uncontrolled pain when R802 made the request. On 3/1/23 at 8:53 AM, the DON was interviewed and asked why the resident was not transferred to the hospital when they requested to go for their uncontrolled pain. The DON stated they would look into it. At 10:24 AM, the DON returned and stated R802's brother signed the resident into hospice care with no hospitalization s. Review of a Medical Treatment Decision Form dated 2/10/23, documented the facility allowed R802's family member to sign a DNR form and allowed the family member to decline hospitalization , artificial feeding, Intravenous fluids, pain management, antibiotic treatment, blood transfusion and oxygen therapy. The family member signed as the legal representative of R802. The family member did not have the legal authority to sign the Medical Treatment Decision Form. R802 was never assessed for capacity, nor was a competency evaluation ever completed. This indicated R802's family member did not have the legal authority to consent or decline any decision regarding R802's care. No further explanation or documentation was provided before the end of the survey.

This citation pertains to intake: MI00134716. Based on interview and record review the facility failed to comply with the requirements to legally initiate an Designation of Patient advocate For Personal Care, Custody, And Medical Treatment document for one (R802) of two residents reviewed for medical appointments, resulting in the facility to allow a family member of R802 to sign the resident into hospice care, stop dialysis services and allow the family member to sign a Do Not Resuscitate form for R802 without the legal authority to do so which resulted in no attempt for Cardiopulmonary Resuscitation (CPR) for R802. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of R802 to have missed medical appointments. Review of the medical record revealed R802 was admitted to the facility on [DATE], with diagnoses that included: end stage renal disease, type 2 diabetes mellitus, hemiplegia and hemiparesis of left non-dominant side, and the absence of the right leg below the knee. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 which indicated severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of the medical record revealed R802 dialysis appointments stopped on [DATE] when the resident was admitted into hospice services. Review of a hospice contract dated [DATE], documented the signature of R802's family member as the Legal Representative that signed R802 onto hospice. Review of the medical record contained a patient advocate document which was not effective. Further review of the medical record revealed the facility failed to have a competency evaluation/capacity assessment completed for R802 which indicated the patient advocacy document was ineffective due to the resident to have never been deemed incompetent. The facility allowed the family member to sign R802 on to hospice care on [DATE] and withdrawal dialysis services which is lifesaving treatment without the legal authority to do so. Review of a Nursing note dated [DATE] at 6:22 PM, documented in part . A&Ox4 (Alert and Oriented time four- to person, place, time and even), very good historian of self. Here for PT (Physical Therapy)/OT (Occupational Therapy) and dialysis services . Review of Clinical Notes obtained from R802's dialysis center documented the following: A RN (Registered Nurse) note dated [DATE] at 2:01 PM, documented in part . Patient told writer that he was in too much pain to come to the unit for dialysis. Writer explained that he was on dialysis as his kidneys were not working. Explained that his blood needed to be cleaned. If his blood was not cleaned, he would have a build up of toxins that would eventually cause him to expire. Writer asked him if he wanted to stop treatment as it would eventually lead to death. Patient stated that he wanted to live and agreed to come to dialysis . A RN note dated [DATE] at 1:12 PM, which documented in part . pt. (patient) entered into the hospice program today. Pt. will no longer be our patient . Further review of the record revealed no dialysis communication documentation after the date of [DATE]. Review of a Medical Treatment Decision Form dated [DATE], documented the facility allowed R802's family member to sign a DNR form and allowed the family member to decline hospitalization , artificial feeding, Intravenous fluids, pain management, antibiotic treatment, blood transfusion and oxygen therapy. The family member signed as the legal representative of R802. The family member did not have the legal authority to sign the Medical Treatment Decision Form. R802 was never assessed for capacity, nor was a competency evaluation ever completed. This indicated R802's family member did not have the legal authority to consent or decline any decision regarding R802's care. Review of the medical record revealed no documentation of the resident to have been offered to complete an advance directive upon admission into the facility. On [DATE] at 3:13 PM, the Social Services Manager (SSM) I was interviewed and asked how the family member of R802 was able to sign the resident onto hospice services on [DATE] and was able to sign a DNR for the resident without the legal authority to do so and SSM I replied the hospice group allowed the resident's brother to sign R802 onto hospice and SSM I stated the facility did not have the family member sign the DNR. At this time SSM I looked through their computer and reviewed the DNR document and stated in part . we should have had the capacity done. Normally that's not how we do things. When (R802) came here (R802) was their own person. We (facility staff) dropped the ball with that. Review of a facility policy titled Residents' Rights Regarding Treatment and Advance Directives last revised ,d+[DATE], documented in part . It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive . On admission, the facility will determine if the resident has executed an advance directive, which can designate a DPOAH and/or future healthcare treatment preferences, and if not, determine whether the resident would like to formulate an advance directive . The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities . Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . No further explanation or documentation was received by the end of survey.

This citation pertains to intake: MI00134716. Based on interview and record review the facility failed to initially identify the characteristics of a coccyx (Stage III- full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present) and left buttock wound (Unstageable- Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar), failed to consistently implement effective and accurate treatment that was prescribed by the wound physician, and timely identify & acknowledged the worsening of the left buttock wound for one (R802) of one residents reviewed for pressure ulcers, resulting in the delay in identifying the worsening of the left buttock wound, a delay in implementing accurate and effective treatment for wounds. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part, . (R802) was found with a wound on his sacrum area. The wound was giving a very foul odor. It appears that the wound was being neglected. The wound was not charted at the facility, and he was not being treated for it by the staff . Review of the medical record revealed R802 was admitted to the facility on [DATE], with diagnoses that included: end stage renal disease, type 2 diabetes mellitus, hemiplegia and hemiparesis of left non-dominant side, and the absence of the right leg below the knee. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 which indicated severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of an Admission/Readmission assessment dated [DATE] at 12:28 PM, documented impaired skin . bilateral buttock . open area . the assessment did not document the Length, Width, Depth or Stage all of these sections on the form was left blank. Review of a facility policy titled Skin and Pressure Injury Risk Assessment and Prevention last revised on 7/21 documented in part, . A skin assessment will be conducted . upon admission . and weekly thereafter. The assessment may also be performed after a change of condition . Document observations . type of wound . wound (measurements, color, type of tissue in wound bed, drainage, odor, pain . The accuracy of the Admission Skin Assessment is in question as it is dated 1/26/23 at 12:28 PM, which is the day after R802's admission into the facility on [DATE] at approximately 6 PM. Review of the January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed two days after admission into the facility on [DATE] and order was implemented for BUTTOCKS: Cleanse with soap and water, dab dry, apply Triad past every shift every shift for wound care . The facility failed to implement this order timely. Review of wound care note dated 2/1/23, documented in part . recently admitted . January 25, 2023 . primary diagnosis of end-stage renal disease . During initial skin assessment patient noted multiple areas of concern . left buttocks and coccyx region. Wound care was asked to evaluate and treat . Left buttocks . Pressure unstageable . Wound base is loosely attached necrotic tissue . Area is minimally tender . Dimensions: 2.5 cm (centimeters) x 2.5 cm by UTD (unable to determine) . Coccyx . Pressure stage III . Wound base is red granulation tissue and some scare tissue formation with attached edges. There is scant serosanguineous exudate appreciated . Plan: WOUND TREATMENTS: All areas will be cleansed with wound cleansing solution and dried . LEFT BUTTOCKS PLEASE TREAT WITH SILVAKOLLAGEN Ag. COVER WITH BORDERED FOAM DRESSING APPLY DAILY AND AS NEEDED . COCCYX--- PLEASE TREAT WITH DERMASYN Ag. PLEAE (sic) APPLY DAILY AND COVER WITH BORDERED FOAM DRESSING . The Coccyx wound measurements were cut off on the wound consultation document. Treatments to both areas the left buttock and coccyx was changed that day by the wound physician. Review of the medical record revealed no documentation of the staff to have identified any decline with the left buttock and coccyx wounds prior to the wound physician visit on 2/1/23. The implementation of Triad paste on 1/27/23 is not effective treatment for an unstageable to the left buttock or for the stage III coccyx wounds. Review of the February 2023 MAR and TAR revealed the facility staff failed to implement the change of treatment as ordered by the wound physician on 2/1/23. The facility staff continued the Triad paste until 2/8/23 (the day of the follow-up wound consultation). The Triad paste was not an effective and adequate treatment for the left buttock unstageable and stage III coccyx wounds this is the reason the wound physician changed the orders. Further review of the facility policy titled Skin and Pressure Injury Risk Assessment and Prevention last revised on 7/21 documented in part, . Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present . Treatment decisions will be based on the characteristics of the wound, including the stage, size, amount of exudate, and presence of pain, infection, or non-viable tissue . Review of Clinical Notes obtained from R802's dialysis center documented the following: A RN (Registered Nurse) note dated 2/6/23 at 2:01 PM, documented in part . Patient told writer that he was in too much pain to come to the unit for dialysis. Writer explained that he was on dialysis as his kidneys were not working. Explained that his blood needed to be cleaned. If his blood was not cleaned, he would have a build up of toxins that would eventually cause him to expire. Writer asked him if he wanted to stop treatment as it would eventually lead to death. Patient stated that he wanted to live and agreed to come to dialysis . Dialysis staff noted foul stench. Requested SNF (Skilled Nursing Facility) staff to come to unit and change him. Shirt was damp as well. Patient had not had BM (bowel movement). Was noted a Stage for wound to coccyx/sacrum approximately 4 inches x 2 1/2 inches. Approximately 2 inches in depth. It appeared that old stool was in wound. Brief appeared to be saturated with drainage from the wound . The note documents the nurse assigned to the resident, the Director of Nursing (DON) and Wound Nurse (WN) N was notified of the wound and the primary nurse stated there were no orders for wound care . just to apply ointment to an old wound . This continued to document how the facility's Administrator was also made aware of the dialysis staff concerns. A RN note dated 2/6/23 at 6:15 PM, documented in part . (R802) was crying out in pain and requesting to go <sic> the EC (emergency care) . patient is not sent to hospital per his request then RN at unit is to arrange for patient to be sent. Writer went down to speak with patient's nurse . She stated that she had made the DON and (wound nurse- WN W) at the facility aware that the patient was requesting to go to the hospital and was crying out in pain. Furthermore, she described the massive wound on his sacrum/coccyx. Per ECF (Extended Care Facility) nurse, DON stated that she could see no reason for patient to be sent to the hospital as he was getting wound care . She (R802 nurse) pointed out that there were no orders for wound care except for application of a cream to a resolving wound . Explained that this odor is new and that upon investigation found out it was in fact a wound that appeared to be draining. A wound with no dressing on it. A wound about 1 1/2 deep 4 inches long and 2 1/2 inches wide . This indicated the facility staff were aware of the worsening of R802's wound and failed to notify the physician timely to implement appropriate treatment and failed to acknowledge and document the worsening of the wound in the medical record. Review of the wound consultation dated 2/8/23, documented in part . follow-up visit . Left buttocks . Pressure unstageable . Examination of this area shows a flocculent necrotic wound with an odor. Manipulation of the wound brought forth thick purulent exudate. The wound was further probed revealing a deep abscess. Approximately 50 cc (cubic centimeters) of thick purulent material was expressed. The procedure was somewhat uncomfortable with the patient. Once the purulent material was removed the area was flushed with approximately 20 cc of normal saline solution . Dimensions: 2.2 cm x 2.0 cm x0.5 cm. Wound status declined . Coccyx . Pressure stage III . Dimensions . 7.5 cm x 5.8 cm x 0.5 cm . Plan: WOUND TREATMENTS . PLEASE CLEANSE OPEN AREA(S) WITH NORMAL SALINE OR WOUND CLEANSING SOLUTION AND DRY . LEFT BUTTOCKS-PLEASE TREAT WITH SILVAKOLLAGEN Ag. COVER WITH BORDERED FOAM DRESSING APPLY DAILY AND AS NEEDED. A CBC (complete blood count) WITH DIFFERENTIAL WAS ORDERED. KEFLEX 500 mg (milligram) 3 TIMES DAILY WAS INITIATED. DISCUSSED WITH NURSING . COCCYX---PLEASE TREAT WITH- DERMASYN Ag. PLEASE APPLY DAILY AND COVER WITH BORDERED FOAM DRESSING . Review of the medical record and progress notes revealed the facility staff failed to identify the worsening of the left buttock wound and failed to acknowledge the concerns of the dialysis staff regarding the wounds, which delayed notification to the physician to timely implement appropriate treatment. Review of the February 2023 TAR documented the following orders in part, COCCYX: Cleanse with soap and water, dab dry, apply silvakollagen to wound bed, cover with border gauze daily and as needed, every night shift for wound care . BUTTOCKS: Cleanse with soap and water, dab dry, pack with lodoform and cover with border gauze daily every night shift for wound care . The facility staff did not implement the correct orders as prescribed by the wound physician for the coccyx and buttock areas. Review of the medical record revealed no documentation on why the facility staff implemented a different treatment to the coccyx and buttock areas, other than what was ordered by the wound physician. Review of the February 2023 MAR documented an order for Keflex 500 MG by mouth three time a day for abscess. This order had a start date of 2/8/23 and stopped the next day on 2/9/23 due to R802's family member to have signed a consent that stopped antibiotic treatment. Review of a Medical Treatment Decision Form dated 2/10/23, documented the facility allowed R802's family member to sign a DNR form and allowed the family member to decline hospitalization , artificial feeding, Intravenous fluids, pain management, antibiotic treatment, blood transfusion and oxygen therapy. The family member signed as the legal representative of R802. The family member did not have the legal authority to sign the Medical Treatment Decision Form. R802 was never assessed for capacity, nor was a competency evaluation ever completed. This indicated R802's family member did not have the legal authority to consent or decline any decision regarding R802's care. Review of a CBC lab dated 2/9/23, documented a White Blood Cell Count of 20.9 (normal reference range 3.5 - 10.6). On 2/28/23 at 2:04 PM, the DON was interviewed and when asked stated the facility's WN W was not in the facility on 2/28/23 and would not return until 3/1/23. The DON was then asked to provide R802's wound consultation from 2/1/23, due to the measurements to have been cut off for the coccyx wound on the wound consultation. The DON was then asked about the protocol required from staff upon identification of any skin impairment identified on a resident and the DON stated the staff will document the assessment which includes the measurements and characteristics of the wound in the medical record, notify the physician for treatment and let the wound nurse know. The DON was then asked why the staff failed to identify and document the characteristics and measurements of R802's buttock and coccyx wounds initially upon admission, the DON was asked about the inaccurate and ineffective wound treatments that were implemented by staff and the delay in identifying the worsening of the left buttock wound for R802 and the DON stated they would look into it and follow back up. The DON did not provide any further explanation or documentation regarding the above interview. On 3/1/23 at 11:47 AM, WN W was interviewed and asked to provide the original wound consultation from 2/1/23 which contained the measurements for the coccyx wound. WN W was then asked why the initial assessment of R802's coccyx and left buttock wounds documentation did not contain the measurements, stage or wound characteristics on the initial assessment in the facility, why the orders were not accurately implemented as prescribed by the physician and why staff failed to identify the decline of the left buttock wound prior to the wound physician identification of the decline on 2/8/23, WN W stated they were out of the facility at that time due to a medical issue, however would look into it and follow back up. Shortly after WN W returned with a log that they kept for all of the facility wounds, which documented on 2/1/23 R802's Coccyx wound measured at . 7 x 6 x 0.5 . No further explanation or documentation was provided by the end of survey.

This citation pertains to Intake Number(s): MI 004. Based on observation, interview, and record review, the facility failed to implement interventions to prevent falls or injury from falls, perform root cause analysis into falls, and implement new and appropriate interventions after falls for two residents (R64 and R2) of two residents reviewed for falls resulting in multiple falls with injury and requiring treatment at the hospital. Findings include: A review of a facility provided policy titled, Fall Reduction Policy revised 8/2021 was conducted and read, .Policy: Our residents have the right to be free from falls, or to sustain no or minimal injury from falls .5. When any resident experiences a fall, the facility will: .e. IDT (interdisciplinary team) review of the resident's care plan and update as indicated. f. Document assessments and actions. g. Obtain witness statements as needed . On 10/3/22 at 9:38 AM, R64 was observed lying in their bed. R64's call light was observed to be on the floor near the wall and nightstand about five feet out of reach from R64. It was also observed wheelchair pedals and a portable oxygen tank were also askew near the nightstand partially hiding the call light cord. R64 was not responsive to attempts at verbal communication at that time. An observation of the wheelchair did not reveal any dycem non-slip padding and no fall mats were observed in the room. On 10/4/22 at 8:52 AM R64's was up to their wheelchair eating breakfast. R64's call light remained on the floor near the nightstand out of R64's reach. On 10/4/22 at approximately 12:45 PM, R64 was up to their wheelchair eating their lunch. The call light remained on the floor near the nightstand out of R64's reach. On 10/5/22 at approximately 8:35 AM, R64 was observed in their bed. R64's call light remained on the floor out of reach, the wheelchair did not reveal any dycem non-slip padding, and no fall mats were observed in the room. On 10/5/22 at 1:12 PM, R64 was observed up to their wheelchair in their room. R64's call light remained on the floor in near the wall still partially obscured by the oxygen tank. On 10/4/22 at 4:24 PM and 10/5/22 at 12:47 PM, a review of R64's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: falls, dementia, heart failure, major depressive disorder, and adjustment disorder with anxiety. A review of R64's Minimum Data Set assessment dated [DATE] indicated R64 had severe cognitive impairment, was non-ambulatory and required extensive assist from staff for most activities of daily living. A review of facility provided fall reports, progress notes, and care plans were reviewed and revealed the following: A fall report dated 7/9/22 prepared by Nurse 'U', read .Nursing Description: Resident jump into bed then rolled over out of bed to the floor hit the side of her eye right. Resident Description: Resident unable to give Description . An Antigravity Team Note entered into the record by Former DON 'T' on 7/11/22 that read, .Date of Fall: 7/9 Root Cause(s) of Fall: Resident was being changed when she jumped in the bed rolling out on other side hitting right above eyes causing laceration .Prior Interventions: Call light within reach, non-slip foot wear, concave mattress, resident to be up w/c when awake in commons area. New Interventions: Therapy to evaluate . R64's care plan for falls was reviewed and revealed the only intervention implemented after the fall was, .PT (physical therapy) to eval (evaluate) r/t (related to) safety . A fall report dated 7/13/22 prepared by Former Director of Nursing (DON) 'T' read, .Nursing Description: Resident was in w/c (wheelchair) in hall, lean <sic> and slipped out of w/c sliding down right side of hall, Abrasion noted to roght <sic> forehead, skin tear to right arm. Resident Description: Resident unable to give Description . The fall report dated 7/13/22 did not include any evidence of a root cause analysis and no interdisciplinary team notes or Antigravity Team Note were documented in R64's record regarding the fall on 7/13/22. A fall report dated 8/10/22 the prepared by Nurse 'S' read, .Nursing Description: resident attempting to transfer from wheelchair to bed without assistance, resident sitting on the floor next to bed with laceration on the back of head, large amount of blood on floor and flowing from wound. Resident Description: Resident unable to give Description .Resident Taken to Hospital? Y (yes) . The fall report dated 8/10/22 did not include any evidence of a root cause analysis and no interdisciplinary team notes or Antigravity Team Note were documented in R64's record. It was further noted the only new care plan intervention added after the fall read, .Request medical evaluation . A fall report dated 9/9/22 prepared by Nurse 'V' read, .Nursing Description: Resident observed in bed sleeping at 5:27am. Noise overheard coming from resident's room by this writer .Resident observed on floor on her left side clutching pillow with her head next to roommate's bedside table frame. Blood noted on floor .Laceration and hematoma noted to back of head towards left side .7 abd (abdominal pads) soaked in blood and bleeding unable to be stopped. 911 called. Resident Description: Resident unable to give Description The fall report dated 9/9/22 did not include any evidence of a root cause analysis, nor were any interventions added to the care plan after the fall on 9/9/22. It was further noted there was an Interdisciplinary Team Note dated 9/26/22, (more than two weeks after the fall) that read, . entered into the record by Nurse Manager 'N' that read, Resident being discussed with IDT regarding a recent fall, resident was found on the floor and had a laceration and hematoma to the back of her head, she was sent to the ER for further evaluation . On 10/5/22 at 2:00 PM, an interview was conducted with the facility's Director of Nursing regarding the facility's fall protocol. The DON explained when a fall occurs the resident is assessed, checked for injury sent to the emergency room if indicated, responsible parties and physician are notified, the interdisciplinary team (IDT) would meet after the fall, a root cause analysis would be performed and the care plan is revised with new and appropriate interventions. The DON was asked specifically about the R64's multiple falls with injury and said they remembered meeting with the IDT team about the fall on 9/9/22. The DON recalled the details of the fall saying R64 got out of bed to get their water, leaned on the oxygen concentrator, the oxygen concentrator rolled and R64 fell to the floor injuring her head. The DON said former Administrator 'W' interviewed R64's roommate who corroborated the story. The DON was asked why the root cause analysis information was not documented, and said they did not know what Former Administrator 'W' did with it, but someone should have put a note in R64's record. It was brought to their attention at that time, the IDT team did put a note in the record, but the note was dated 9/26/22 and did not indicate any root cause analysis, and no new interventions were included in R64's care plan after the fall. The DON said there were other interventions and more appropriate interventions that could have been implemented after the falls such as dycem in the wheelchair seat after a fall from the wheelchair on, frequent rounding, keeping needed items in reach, and the use of fall mats to prevent injury. Resident #2 On 10/4/22 at approximately 8:47 a.m. R2 was observed in their room, laying in their bed. R2 was observed to have a low bed. No fall mat was observed next to their bed. On 10/03/22 the medical record for R2 was reviewed and revealed the following: R2 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. R2 had diagnoses including [CONDITION(S)] of B-cell type in relapse and Dementia. A review of R2's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/8/22 revealed R2 needed supervision from facility staff with their activities of daily living. R2 was documented as having severely impaired cognition. A progress note dated 6/3/22 revealed the following, Event occurred on 6/03/2022 11:55 PM. Patient was observed on the bathroom floor bleeding form left eyebrow. first aide given steri-strip and bandage to left eye brow applied. Physician and responsible party notified. An incident report dated 6/3/22 revealed the following: Incident Description: Nursing Description: Observed on the bathroom floor bleeding from left eye brow. Resident Description: Resident Unable to give Description. A progress note dated 9/1/22 revealed the following, Event occurred on 9/01/2022 7:45 AM. res (resident) found lying face down in the middle of her room. Physician and responsible party notified. A progress note dated 9/1/22 at 8:00 a.m., revealed the following: Spoke with resident regarding her fall this morning. When I asked her if she remembered falling, she stated yes. I asked her if she was standing, sitting, or rolled out of bed and she stated, I don't remember. Resident being sent out for further evaluation. An incident report dated 9/1/22 revealed the following: Incident Description: Nursing Description: This nurse along with Nurse [Name of another Nurse] was alerted by the aide that this resident was on the floor again Resident Description: Resident unable 10 <sic> provide description of incident; Immediate Action Taken: Description: Resident was assisted off the floor back into bed; VS (vital signs) were taken and were stable; Neuro assessment completed with abnormal findings: Left pupil sluggish/nonreactive, Right pupil RRL at 2mm. B/L (bilateral) hand grips equal and strong; Resident denies pain; Resident appears drowsy and is only oriented to person; [Name of provider} contacted and full report given; Orders received to send resident to ER (emergency room ) via EMS (emergency medical system) for evaluation and CT (computed tomography) Scan; .Injuries observed at time of incident: Injury type-Hematoma. Injury location-Face . A review of R2's plan of care was revealed the following: Focus-I am at an increased risk for falls r/t lack of safety awareness & poor impulse control R/T (related to) cognitive loss consistent with dementia progression. Leaning forward while ambulating and sitting. Date Initiated: 06/1/2022 .Interventions-Review information on past falls and attempt to determine cause of falls. Record possible root cause(s) and remove any potential causes as applicable. Date Initiated: 06/01/2022 .Be sure my call light is within reach and encourage me to use it for assistance as needed .Date Initiated: 06/01/2022 . Further review of R2's plan of care for fall risk revealed no interventions added to the plan of care after R2's fall on 6/3/22 or their fall on 9/1/22 until 10/5/22 which indicated the intervention of Keep bed in low position with personal items within reach. Date Initiated: 10/05/2022. On 10/05/22 at approximately 1:55 p.m., The Director of Nursing (DON) was queried regarding the falls that R2 had on 6/3/22 and on 9/1/22. The DON was queried regarding the interventions put into place to prevent future falls after the fall in the bathroom on 6/3/22 and they indicated that increased monitoring, a toileting program and low bed interventions could have been utilized to address concerns of R2 attempting to self-ambulate to the bathroom and falling. The DON was queried if they could identify any interventions added to the plan of care after their fall on 6/3/22 and they indicated they could not. The DON was queried regarding R2's fall on 9/1/22. The DON indicated that the resident should have had fall matt added as an intervention since the resident has lost the ability to safely self-ambulate. The DON was queried if the fall mat had been added to the plan of care after the second fall and they indicated it was not. The DON was queried regarding the intervention on the plan of care that stated, be sure my call light is within reach and encourage me to use it for assistance as needed. and if that intervention was appropriate for a resident with severely impaired cognition and they indicated it was not. On 10/5/22 a facility document titled Fall Reduction Policy was reviewed and revealed the following: Policy: Our residents have the right to be free from falls, or to sustain no or minimal injury from falls .4. Each resident ' s risk factors, and environmental hazards will be evaluated when developing the resident ' s comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 5. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. IDT (interdisciplinary) review of the resident ' s care plan and update as indicated. f. Document assessments and actions .

Based on interview and record review, the facility failed to increase monitoring and assessment of COVID-19 positive ill residents to identify changes in condition per Centers for Disease Control (CDC) protocol including continued assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory examination, at least three (3) times daily to identify and quickly manage serious infection concerns for four residents #703, #704, #705 and #706, resulting in Immediate Jeopardy (IJ). This deficient practice placed ill COVID-19 positive residents at risk for serious harm, injury and/or death related to COVID-19. The IJ began on [DATE], it was identified by the survey team on [DATE] and the facility was notified on [DATE] at 11:35 AM. On [DATE], the facility Plan of Removal was accepted by the State Agency. A completed onsite verification to ensure the Immediate Jeopardy was removed was conducted on [DATE], however the facility remained out of compliance at a scope of pattern and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. CDC Guidelines titled Preparing for COVID-19 in Nursing Homes (updated [DATE]) documents in part, .Residents with known or suspected COVID-19 should be cared for using all recommended PPE (personal protective equipment) .Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection . On [DATE] at approximately 9:30 AM, a facility entry interview was conducted with the Administrator and Director of Nursing (DON). The Administrator reported that the facility's current number of COVID-19 positive residents was 46. The Administrator further reported that one COVID-19 positive resident had expired, and three others were sent to the Hospital with respiratory conditions. In addition, the Administrator indicated that the facility did not currently have an employed Infection Preventionist (a person who is able to meet criteria to engage in infection control training, obtain certification and act as the person responsible for infection prevention and control programs in nursing homes. This is a mandatory requirement per Centers for Medicare and Medicaid Services CMS). It was reported that staff employees were receiving COVID-19 testing one time per week starting in [DATE] and that testing had recently increased to two times per week. In addition, testing of residents would be done if a staff member had a positive test. The Administrator and DON were queried as to outbreak of COVID-19 and when all residents in the facility were tested for COVID-19. The Administrator reported that Certified Nursing Assistant (CNA) O received a positive COVID-19 result on [DATE]. The Administrator reported that any residents that were assigned to CNA O were tested by the facility's Point of Care (POC)/rapid testing device on or about [DATE]. The Administrator indicated that they were not able to locate the results of any resident POC/rapid tests taken [DATE]-[DATE]. The Administrator was asked to provide evidence that the Infection Preventionist had created documentation that would demonstrate COVID-19 tracing and test results for both residents and staff, including, but not limited to any POC testing results for its residents The Administrator again, indicated that the facility did not currently have an Infection Preventionist and was utilizing Nurse B (an uncertified infection preventionist) and two Corporate staff persons to assist with the Infection Control program. The Administrator could not provide any paper documentation that would provide evidence of COVID-19 tracing. On [DATE] at approximately 12:00 PM, the Administrator was able to provide online viewing of one page an electronic record titled Outbreak Testing. The Administrator was not able to print the viewed document(s) and the document Outbreak Testing was not provided by the end of the Survey. R#706 Review of the clinical record revealed R#706 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS) assessment dated [DATE], R#706 scored ,[DATE] on the Brief Interview for Mental Status (BIMS) exam, indicating intact cognition. The MDS assessment also indicated R#706 required the extensive assistance of staff for Activities of Daily Living (ADL's). Continued review of R#706's clinical record documented, in part, the following: A COVID-19 Test Result Summary, date collected [DATE], date reported [DATE], Positive. Physician orders [REDACTED]. Or at least 2 of: fever, chills, rigors, muscle pain, headache, sore throat, new loss of taste/smell, N/V/D (Nausea/Vomiting/Diarrhea). Notify MD of symptoms. This order was documented on the [DATE] Medication Administration Record (MAR) for R#706 two times a day, at 7:00 AM and 7:00 PM. It should be noted that per CDC recommendations the order documented above refers to screening for COVID-19 and is not what is required for monitoring for COVID-19 positive residents. COVID-19 care plan initiated [DATE] read in part, Every shift monitoring of temperature, oxygen saturation rate, and for NSG (nursing) s/s or respiratory illness/distress or other COVID-19 symptoms. Notify medical provider of significant changes in condition . Nursing progress note dated [DATE] at 2:37 PM read in part, SBAR (Situation, Background, Assessment, Request) Summary . Patient diagnosed with [REDACTED]. Patient is more lethargic . Nursing progress note dated [DATE] at 10:32 AM read in part, SBAR Summary . COVID + (positive) with possible pneumonia/respirations between 20 to 28 . Normal respiratory rate is ,[DATE] breaths per minute. [DATE] MAR on [DATE] at 7:00 PM documented R#706 ' s vital signs the exact same as those documented as taken on [DATE] at 1:29 AM and read respirations as 24 (breaths per minute). It should be noted these vitals were 15 hours after the noted increase respiratory rate on [DATE]. Census revealed R#706 was discharged to the Hospital on [DATE]. R#703 A review of the clinical record revealed the following: R#703 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE], with a BIMS score of 5 (indicating severely impaired cognition) and was dependent on staff for all ADL ' s. A COVID-19 Test Result Summary with a report date of [DATE] documented a Positive result. A review of the MAR and Treatment Administration Record (TAR) for [DATE] documented in part, . Respiratory Illness every shift Document s/s: cough, SOB/difficulty breathing. Or at least 2 of: fever, chills, rigors, muscle pain, headache, sore throat, new loss of taste/smell, N/V/D, Notify MD (Medical Doctor) of symptoms. The vitals were scheduled to be completed at 0700 (7 AM) and 1900 (7 PM). This order had a start date of [DATE]. Per CDC ' s guidance, . Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections . The facility failed to increase the monitoring for this COVID positive resident and failed to promptly identify the resident ' s decline. A physician consultation Progress Note dated [DATE] documented in part, . Patient seen in room. He is sleepy and weak-appearing. States he is not hungry . remains on 3L (liters) of nasal cannula . Thin, frail . appears weak . Scattered rhonchi throughout, bilaterally . Plan . Check CXR (chest x-ray) . Monitor SpO2 (oxygen saturation) and report any desaturations below 90%. Continue isolation precautions . On [DATE] the 7:00 AM vitals were not completed. The 7 PM scheduled vitals were not completed until 22:00 (10 PM), which then identified the resident already in distress. Further review of the clinical record revealed no documented respiratory examination for [DATE]. A care plan titled I have confirmed COVID-19 virus r/t confirmed test Active COVID-19 with an Initiated date of [DATE] documented the following interventions, . Every shift monitoring me of temperature, oxygen saturation rate, and for s/s of respiratory illness/distress or other COVID-19 symptoms. Notify medical provider of significant changes in condition. The facility failed to increase monitoring of the resident and failed to monitor the resident at least three times a day. The facility nursing shifts are from 7am- 7pm and 7pm to 7am (two shifts). A SBAR Summary dated [DATE] at 10:25 pm, documented in part .BP (blood pressure)- ,[DATE] . P (pulse)- 94 . R (respiration)- 18 . 02 (oxygen saturation)- 82% . Respiratory distress r/t (related to) COVID . Upon assessment, writer noted that patient was in distress, unable to maintained <sic> PO2 (oxygen saturation) > (more than) 90 via non-rebreather mask . The resident was transferred to the hospital. The Facility Administrator confirmed that the resident expired at the hospital. On [DATE] at 12:49 pm, the DON was asked how often vitals are taken on COVID + residents, for staff to quickly identify if the resident requires a higher level of care. The DON replied, Three times a day. The DON was then queried on the lack of increased monitoring of the resident and did not provide any further explanation and/or documentation by the end of survey. R#704 A review of the clinical record revealed the following: R#704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS dated [DATE] documented a BIMS of 15 (indicating intact cognition) and required staff assistance for all ADL's. A review of the resident vital signs revealed the following: A review of the 02 Sats Summary documented on [DATE] the resident went from breathing on room air to needing Oxygen delivery via Nasal Cannula. A review of the nurse's documentation failed to document why. A physician consultation dated [DATE] documented in part, . Patient seen per nursing request, for the above (runny nose, congestion). Last night patient reported feeling chills, runny nose, congestion, and itchy throat. Today, he is also experiencing headaches and intermittent cough . He is currently on room air but satting at 89%. Placed on 2 L (liters) nasal cannula with Sp02 going up to 98% . Temperatures (documented in part): [DATE] at 11:09 am- 99.3, ,[DATE] at 8:44 am- 99.3, at 7:04 pm- 100.1, at 8:45 pm- 100.2 (temperature not taken again until the next morning), ,[DATE] at 8:22 am- 99.6 and ,[DATE] at 9:29 am- 101.9. A review of the clinical record revealed no increased monitoring as recommended by the CDC. A Social Services Note dated [DATE] documented in part, . Administrator phoned Resident sister to inform her that Resident tested positive for Covid . A review of the MAR and TAR for [DATE] revealed the following order, Respiratory Illness every shift Document s/s (signs/symptoms); cough, SOB/difficulty breathing. Or at least 2 of: fever, chills, rigors, muscle pain, headache, sore throat, new loss of taste/smell, N/V/D. Notify MD of symptoms . The order start date was [DATE]. The vitals were to be obtained at 0700 (7am) and 1900 (7pm). The 7 am vitals for [DATE] was not obtained until 9:29 am, which at that time the staff identified the resident already in distress. A review of the clinical record revealed no documented respiratory examination completed for the resident on [DATE]. A care plan titled I have confirmed COVID-19 virus r/t confirmed test Active COVID-19 initiated [DATE] documented the following intervention, . Every shift monitoring of temperature, oxygen saturation rate, and for s/s of respiratory illness/distress or other COVID-19 symptoms. Notify medical provider or significant changes in condition . A SBAR Summary dated [DATE] at 9:00 am documented in part, . R- 23 . T- 101.9 . Respiratory, COVID 19 . Resident sent to hospital . On [DATE] at 9:23 am, the Administrator documented in part that the resident was hospitalized on a ventilator. On [DATE] at 12:35 pm, when queried on the resident status, the Director of Nursing (DON) replied that the resident expired at the hospital. R#705 A review of R#705 ' s clinical record documented that the resident was admitted to the Facility's on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's MDS documented that the resident had a BIMS score of ,[DATE] (cognitively intact) and required supervision and set-up only for most ADL's. Continued review of R#705's clinical record, documented, in part, the following: [DATE] (1:43 PM) Activities Note: Resident was informed in person and guardian was informed via voicemail regarding positive Covid test. *There was no COVID-19 Test Results in the residents' electronic record. [DATE] (7:08 PM) (authored by the DON)- SBAR summary: .situation: Resident tested positive for Covid 19 things that make the condition or symptom better .oxygen .changes in the last week .oxygen .temperature: 98.2 (date [DATE] 12:45) .3i Most Recent 02 sats .95% Date ([DATE] 8:43 PM) .3. Respiratory .3g. Oxygen . [DATE] (7:12 AM)- Authored by Nurse M Resident spo2 85% room air and temp 99.7 .at 8 a. administered Tylenol xtra strength and oxygen via nasal canal 2L (liters) resident spo2 92% vial nasal canal 2L and tempt 98.6 . [DATE] (5:57 PM) SBAR Summary: .Description: Change in Status .Situation .lethargic, low pulse oxygen .Temp .97.4 .O2 stats .97.4 . [DATE] (6:34 PM) .lethargic . [DATE]: Physician Discharge Summary: Provisional Diagnosis: [REDACTED]. Brief history: Patient sent to hospital as she was hypoxic requiring 8L (liters) 02 high flow. The resident's Care Plan dated ([DATE]) documented, in part, the following: I have confirmed COVID-19 virus r/t (confirmed) test Active COVID-19 .Every shift monitoring of temperature, oxygen saturation rate and for s/s of respiratory illness/distress or other COVID-19 symptoms. Monitor decline of function and adjust care . A review of the resident Medication Administration Record (MAR) documented, in part, the following: Respiratory illness every shift. Document s/s (signs/symptoms) cough, SOB (shortness of breath)/difficulty breathing. Or at least 2 of fever, chills, rigors, muscle pain, headache, sore throat, new loss of taste/smell .Notify MD of symptoms . This order was completed as follows: [DATE] (7:00 AM): BP (blood pressure) ,[DATE], Temp. 98.2, Pulse 77, O2 Sats 95 [DATE] (7:00 PM): BP ,[DATE], Temp 97.8, Pulse 80, Resp 18, O2 Sats 96 [DATE](7:00 AM): BP ,[DATE], Temp 99.0, Pulse 80, Resp 18, O2 Sats 96 [DATE] (7:00 PM): BP ,[DATE], Temp 97.8, Pulse 80, Resp 18, O2 Sats 95 [DATE] (7:00 AM): BP ,[DATE], Temp 97.4, Pulse 58, Resp. 17, O2 Sats 97 The vital sign log for R#705 was reviewed and documented the following: O2 Sats Summary from [DATE]-[DATE] [DATE]: No O2 Stats documented [DATE] (1:33 AM)- 96.0% - room air [DATE] (6:29 AM) 95%, [DATE] (4:45 PM) 68%,[DATE] (5:45 PM) 68% and [DATE] (6:01 PM) 97% High Flow Oxygen. On [DATE] at approximately 9:20 AM an interview was conducted with Nurse M. Nurse M reported that she had worked at the Facility for approximately two years. When queried as to any training that she had received following the facility outbreak of the COVID-19 virus, Nurse M reported that they had returned back to the facility in the beginning of November and received in-service training that they recalled focused on hand hygiene and personal protective equipment. Nurse M could not recall if they had received training on assessing and monitoring residents with COVID-19 and indicated that they could not recall who was responsible for their training. They further indicated that there was a number of changes in staffing at the facility that included a change in the DON and no assigned infection control specialist. When queried as to the nursing note dated [DATE] (7:12 AM) that indicated that R#705 had O2 stat was 85% and they had a temp of 99.7, Nurse M reported that they had worked the evening shift (7:00 PM - 7:00 AM beginning on [DATE]). When queried as to whether increased monitoring was done at a minimum of three times daily as R#705 was a COVID-19 positive resident that was showing signs of respiratory distress, Nurse M reported that the system on the MARS only allowed response for each 12 hours shift, however they would often take vitals prior to leaving their shift to assess for changes in condition so that they could pass information on to the next nurse. * It should be noted that following Nurse M's note regarding a decrease in O2 Stats the next assessment in R#705's record does not show an increase in respiratory monitoring and assessment until [DATE] at approximately 4:45 PM. R#705 was then discharged to the Hospital for [MEDICAL CONDITION]. R#705 had not returned to the facility as of [DATE]. An interview with the Medical Director was conducted on [DATE] at 12:24 PM. The Medical Director was queried as to assessment for COVID-19 positive residents. He reported that every four hours was standard protocol and was not able to provide details on what nursing staff were actually doing. On [DATE] at 12:49 PM an interview was conducted with the DON. The DON reported that they had just started at the Facility one week prior to the survey and indicated that they had served as a DON at another facility. When queried as to the monitoring and assessment protocol for residents that are COVID-19 positive the DON reported that at their prior Nursing Home, assessments/monitoring was done at least three times per day. The DON was then queried on the lack of increased monitoring of the COVID-19 positive residents at the facility and did not provide any further explanation and/or documentation by the end of survey. On [DATE] at 8:58 AM, Licensed Practical Nurse (LPN) I was interviewed by phone and asked about recent training at the facility. LPN I explained they had received in-service training on PPE (Personal Protection Equipment) by the Unit Manager. LPN I was asked how frequently were COVID-19 residents monitored at the facility. LPN I explained on the MAR there were set times for the vitals but could be done anytime during the shift. LPN I further explained if more frequent vitals were taken, they would have to be put in a progress note as there was no place on the MAR for additional vitals. On [DATE] at 11:11 AM, RN H was interviewed by phone and asked about monitoring COVID-19 positive residents at the facility. RN H explained the orders were for one time a shift, and the MAR would only allow one entry a shift, but COVID-19 positive residents needed more frequent monitoring as their condition could change rapidly. RN H was asked what recent training had been provided by the facility. RN H explained they couldn't recall any recent training received at the facility. On [DATE] at approximately 10:40 AM, an onsite visit was initiated to ensure the facility was following their Plan of Removal. An interview with the DON and the Administrator was conducted. The DON reported that all residents were currently receiving enhanced monitoring every eight hours. When asked how Nursing Staff were ensuring increased monitoring, the DON/Administrator reported that staff were in-serviced on the increase and where documenting evidence in the resident ' s electronic record. If there were any change in the resident(s) condition the DON, physician and family should be notified. In response to the facility's Plan of Removal, a review of the MAR(s) for residents still residing in the facility revealed an order dated [DATE] that read, Respiratory Assessment-Document Y/N if resident exhibits s/s: cough, SOB/difficulty breathing. Or at least 2 of: fever, chills, rigors, muscle pain, headache sore throat, new loss of taste/sell, N/V/D. Notify MD of symptoms. Document Any s/s in Nurse Note & Notify MD of symptoms every 8 hours related to COVID-19. It should be noted that in review of the MAR's there were two separate lines, one marked N and one marked Y timed at 12:00 AM, 8:00 AM and 4:00 PM. The documentation by the nurses on the MAR's revealed inconsistent responses. For example, (name redacted) resident's MAR on [DATE] (8:00 AM) was marked N for both choices N and Y. On [DATE] (8:00 AM) the resident's MAR was marked Y for both N and Y. The DON was not able to explain the discrepancy from day [DATE] and [DATE]. On [DATE] at 11:50 AM, a phone interview was conducted with Nurse I. When queried as to when their last infection control in-service training was, Nurse I reported receiving training on PPE equipment one week ago. When asked to explain how they were addressing new orders that indicated monitoring and assessment of COVID-19 positive residents was entered into resident's records (I.e. how to address the Y / N answer in the MAR), Nurse I responded that the system was very confusing and they were not certain as how to answer and indicated that they (the facility) needed to redo the method on how to answer the assessment. On [DATE] at 2:27 PM, LPN J, an agency nurse working with the COVID-19 positive residents, was interviewed by phone, and asked how often the residents were being monitored for COVID-19. LPN J first stated, Every four hours. Then LPN J explained she looked at the orders and explained the order said every eight hours. LPN J was asked if she had worked at the facility before. LPN J explained it had been several months since she had worked at the facility but had worked at several other facilities with COVID-19 positive residents. LPN J was asked if she had received any training at the facility on how to document the respiratory assessment on the MAR. LPN J explained no one had taught her how to document the assessment, she just put in what she thought the assessment was referring to. LPN J was asked if a nurse answered Y to both Y and N, what would that mean. LPN J was not able to provide an answer. On [DATE] at approximately 3:40 PM, an additional interview was conducted with the Administrator and the DON. The DON and Administrator again acknowledged that the wording on the MAR was confusing. The Administrator further indicated that while the MAR wording might be confusing, Nursing staff were implementing Nursing Daily Skilled Charting documents into the residents' records that would include monitoring and assessment of COVID-19 positive residents. The Administrator indicated that it would be done one time per day, however there were residents that nursing staff may have failed to complete the Daily Skill Charting documents. The Administrator was not able to provide information as to how the Nursing Daily Skilled Charting documentation pertained to the Plan of Removal that indicated residents would be assessed and monitored at least every eight hours. On [DATE], the Administrator provided a revised copy of the MAR resident orders, that indicated that COVID-19 positive residents would have a Respiratory Assessment order set that would include a yes or no response versus a Y/N to eliminate confusion with interpretation of the order. Review of a facility policy titled, Tool Kit B - Section I Managing COVID-19 in your Center dated [DATE], read in part, . Caring for A Resident with Suspected / Confirmed COVID-19 . A-Team members should have increased monitoring during their shift for fever and respiratory symptoms . Initiate enhanced screening for a resident with possible COVID-19 exposure, an active case of COVID-19 in you center . template specifies taking and recording the resident's temperature, O2 sats and symptoms . On the e-MAR you will be prompted to take and record the resident's temperature and O2 Sats. This order template will prompt for additional documentation. This documentation should also indicate the presence of any other symptoms you are observing . The Plan for Removal read in part: .Facility to continue current practice of enhanced monitoring which includes Respiratory Assessment, Vital signs, and SPO2 for all residents within the facility for early identification of symptoms . Facility to increase monitoring immediately of all COVID-19 residents both Asymptomatic and Symptomatic to at least 3 times daily versus Q (every) Shift to include assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, as well as, identify and quickly manage serious infections beginning [DATE] via implementation of new order set . Licensed nurses to be reeducated on the Change of Condition Policy .

This citation pertains to intake #MI 085. Based on observation, interview, and record review, the facility failed to ensure assistive devices were available for use to promote independence for one resident, (R601) of three residents reviewed for accommodation of needs, resulting in a fall with a fracture and subsequent orthopedic surgery. Findings include: A complaint was received by the State Agency that alleged the facility took away a resident's bedside commode. While the resident was ambulating to the bathroom, they suffered an incontinent episode, urinating on the floor. Due to the floor being wet with urine, the resident slipped, fell , and fractured their wrist. On 10/19/20 at approximately 10:00 AM, R601 was observed in bed, asleep. A bedside commode was present approximately three feet adjacent to the left side of the bed. R601's right wrist was observed to have an orthopedic splint in place. A review of R601's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. It was further noted R601 had an added [DIAGNOSES REDACTED]. R601's most recent Minimum Data Set assessment dated [DATE] indicated intact cognition (a score of 15 out of 15 on a Brief Interview for Mental Status exam), required extensive assistance of one staff for transferring, had ambulated once or twice, was not coded for wheelchair mobility, and had one sided upper and lower extremity range of motion deficits. A review of R601's nursing progress notes was conducted and revealed the following: An SBAR (Situation, Background, Assessment, Recommendation) note by Licensed Practical Nurse (LPN) 'C' dated 8/26/20 that read, .Resident r (right) wrist swollen changing color .Resident didn't ask for assistance self transfer and fell in urine on floor on right wrist . A nursing note by the facility's Assistant Director of Nursing (ADON) dated 8/26/20 that read, Bedside commode to be utilized. A second nursing note by the ADON dated 8/26/20 that read, IDT (Interdisciplinary Team) met to discuss resident with recent fall. Resdient <sic> was self transfer/ambulating and did not call for assistance to toilet .Resdient <sic> urinated on floor on her way to the bathroom and slipped and fell .Provider notified and requested to send to hospital for further evaluation of wrist .Resident recently discharged from therapy after working with resdient <sic> for toileting . A review of R601's X-ray results from Hospital 'F' on 8/26/20 was conducted and read, .IMPRESSION: 1. [MEDICATION NAME] fracture distal radial metadiaphysis with apex dorsal angulation (wrist fracture). 2. Diffuse soft tissue swelling . Continued review of R601's progress notes revealed they returned to the facility from Hospital 'F with their fractured wrist on 8/26/20. On 8/28/20 an SBAR note by LPN 'C' read, .Resident has increased swollen <sic> and pain turning color and tingling with numbness . The note did not indicate R601 was sent out to another hospital, however; it was discovered R601 was sent to Hospital 'G' on 8/28/20, and was inpatient until 9/4/20. A review of a facility provided incident report for R601's fall on 8/26/20 was reviewed and read, .Resident Description: Resident states she was walking to the rest room and urinated on the floor and fell on right wrist. Resident was frustrated with removal of bedside commode to promote independence. Resident feels like removal of bedside commode she would fall . A review of R601's Occupational Therapy (OT) Discharge Summary with a discharge date of [DATE] was reviewed and revealed that R601 had met their therapy goals. The summary signed by OT 'D' read, .Discharge Recommendations: Resident is discharged from skilled OT services due to meeting all goals. Resident is SBA (stand-by assist)/ .for overall toileting task using BSC (bedside commode) next to her bed and requires assist from staff for ambulation to bathroom at cane level (SBA) .Resident is recommended the BSC next to her bed due to (urinary) urgency .Staff educated on recommendation for toileting assist . A review of R601's care plans did not include any interventions for the use of the bedside commode around the time therapy made the recommendation. On 10/19/20 at 12:25 PM, a telephone interview with OT 'H', (R601's assigned therapist) was conducted regarding R601's fall. OT 'H' explained that a nurse aide had removed the commode from the bedside, and they shouldn't have. OT 'H' said OT 'D' had recommended the commode the last time R601 had been on therapy caseload and had worked with R601 on self-transferring to the commode during times of urinary urgency when they would not be able to get to the bathroom. OT 'H' indicated the commode promoted independence and urinary continence during times of urinary urgency for R601, as they were able to safely self-transfer to the commode. On 10/19/20 at 12:50 PM, an interview with the facility's Rehab Director was conducted regarding R601's bedside commode. The Director explained the OT's ('D' and 'H') had worked in the past and were currently working with R601 on ambulation to the bathroom. The Director indicated the commode should not have been removed by nursing staff, as it would have been the Therapy Department's role to make the recommendation and they did not make the recommendation to remove it from the room. On 10/19/20 at 1:55 PM, R601 was observed sitting on the side of their bed. It was observed R601 had a right wrist splint in place. At that time, R601 was asked about the fall they sustained on 8/26/20. R601 said a few days before her fall, a Certified Nurse Aide (CNA) took the commode from her bedside. R601 said, An aide told me I couldn't have a commode anymore, but therapy said I needed one. R601 continued to explain that the CNA (who R601 did not name) told her therapy was babying her. R601 indicated they had urinary urgency and the commode was used for those times as she was able to transfer herself to the commode. R601 said she had let a nurse know she was upset the commode had been taken away, but it had not been brought back until after her fall on 8/26/20. R601 was then asked about the fall and indicated they had to urinate and since their commode was not at the bedside they attempted to ambulate to the bathroom, experienced an incontinent episode, slipped, and fell . R601 said, I knew my wrist was broken, because I have broken it before. During the interview, R601 was asked about what happened after the fall and they indicated they had been transferred to Hospital 'F', even though they wanted to be transferred to Hospital 'G'. R601 said they asked to go to Hospital 'G', but the ambulance staff told them the nurse said to take them to Hospital 'F'. R601 said Hospital 'F' took x-rays, re-set the fractured wrist, and sent her back to the facility. R601 continued to explain they experienced severe pain in their wrist and on 8/28/20, R601 requested to be sent to Hospital 'G'. R601 was queried what happened at Hospital 'G' and said, they did more x-rays and told them they needed orthopedic surgery on their wrist. R601 said they had the surgery, remained in Hospital 'G' for a few days and then discharged back to the facility. A review of R601's AFTER VISIT SUMMARY from Hospital 'G' for their stay from 8/28/20-9/4/20 was conducted and indicated they were to follow up with their orthopedic surgeon and wear their right arm brace as instructed by surgery. On 10/19/20 at 3:20 PM, an interview with the facility's Administrator and Director of Nursing (DON) was conducted regarding R601's fall resulting in a wrist fracture requiring orthopedic surgery. It was explained that CNA 'J' had removed R601's bedside commode from their room prior to the fall. It was further explained that there was a miscommunication between the Therapy Department and the Nursing Department regarding the removal of R601's bedside commode. Therapy had not made a recommendation to remove the commode, as it did promote continence and independence for R601. It was further explained the Nursing Staff received an in-service from the Therapy Staff regarding their role with activities of daily living and their recommendations for the use of, or discontinuation of assistive devices. A review of a facility provided policy titled, Resident Rights revised February 2017, was conducted and read, The facility protects and promotes the rights of each resident. The resident has a right to dignified existence, self determination .Facility staff will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes the maintenance and enhancement of his or her quality of life .The facility provides a clean, safe, comfortable home-like environment . A review of a second facility policy titled, Routine Resident Care with a revision date of September 2011 was conducted and read, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Steps are taken to ensure that resident's capacity for self-performance for these activities does not diminish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to ensure resident safety at all times . A review of a final facility provided policy titled, Fall Management revised July 2017 was conducted and read, The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls .

This citation pertains to Intake Number(s): MI 956, MI 848, MI 655, and MI 319. This citation has two deficient practices. Deficient Practice #1 Based on interview and record review, the facility failed to perform skin assessments and identify skin impairments for one (R#802) of five residents reviewed for skin management, resulting in the development of a wound with maggots. Findings include: Two complaints were received by the State Agency that alleged the following: .(R#802) weights <sic> about 400 pounds. She is bedridden and needs total care .On [DATE] (R#802) was sent to the emergency room by the nursing home for vaginal bleeding. When she arrived, it was found that she had not been 'changed' in at least a week. She had ,[DATE] sheets and pads under her, and they were stuck to her skin. She was covered in feces. As the layers were peeled off (R#802), her skin bled. Maggots were found in her wounds. Her Foley catheter had not been properly cared for, and it is believed that the blood found by the nursing home was from the catheter not her vagina. (R#802)'s blood work was not normal. She was admitted and will remain at the hospital for further treatment of [REDACTED]. Last August, resident had a UTI (urinary tract infection), cleared up and sent back to the facility. Resident fell ill with a UTI again, she was found unresponsive and sent to the hospital (hospital name redacted) last Sunday, Sept. 27th. Hospital found that she had stool all over her back side dried and matted to her skin. Maggots were also found on her back side and skin folds where her wounds were. A review of hospital records for R#802 was conducted and revealed the following: An Emergency Nursing Record dated [DATE] documented, RN (registered nurse) x 2 techs to bedside to clean pt (patient). It was found that pt was covered in stool. Pt also had multiple sheets 'stuck' to her skin from stool, sweat, urine, and other drainage. + (positive) maggots noted to right flank skin fold . On [DATE], R#802's clinical record was reviewed and revealed the following: R#802 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated [DATE] documented R#802 had intact cognition and no behaviors including no rejection of care. The MDS further documented R#802 required extensive physical assist from at least two staff members for bed mobility and did not transfer during the assessment period, was always incontinent of bowel and bladder, had no pressure ulcers, and had three venous/arterial ulcers. A 5-Day MDS assessment dated [DATE] documented R#802 was totally dependent on at least two staff members for transfers and had no venous/arterial ulcers and had one skin tear. An Admission Data Collection assessment (completed by the nurse on admission) was started on [DATE]. The section for Skin Integrity was dated [DATE] and documented R#802 had abrasions and [DIAGNOSES REDACTED] to their lower back, a skin tear to their left hand, a rash to their groin, abrasions to their sacrum, and skin tears to their bilateral lower extremities (BLEs). It was documented R#802 could not move their BLEs and was non-ambulatory. Skin-Head to Toe Skin Checks assessments for R#802 were reviewed from their readmission date of [DATE] through [DATE] and revealed no head to toe skin assessments were completed for R#802 during that time frame. The last skin assessment documented was dated [DATE] and it documented, Treatment plan currently in place for skin issues on BLE. No additional information was included on the assessment. Skin-Weekly Non-Pressure Condition Records assessments were reviewed from [DATE] through [DATE] and revealed one assessment dated [DATE] that was incomplete and not signed or locked. The assessment documented R#802 had an existing non-pressure skin condition that they were admitted with. The date of onset was documented as [DATE]. The rest of the assessment was left blank with no information about the skin impairment. Physicians Orders for R#802 revealed the following orders: Calazyme to buttocks every shift and after each incontinent episode every shift ordered on [DATE]. [MEDICATION NAME]: [MEDICATION NAME] 50:50 compound to bilateral posterior thighs Q (every)-shift/PRN (as needed) .skin care AND every day shift for skin care ordered on [DATE]. Interdry (moisture wicking fabric with antimicrobial properties) to bilateral axilla (arm pit), change Q7D (every 7 days)/PRN. Remove for daily hygiene. as needed for skin care AND every day shift every 7 day(s) for skin care ordered [DATE]. Interdry underneath bilateral breasts, change Q7D/PRN. Remove daily for hygiene. as needed for skin integrity AND every day shift every 7 day(s) for skin integrity ordered [DATE]. Rinse Left posterior lower leg with wound cleanser pat dry apply [MEDICATION NAME] AG (an absorbent antimicrobial wound dressing) and cover with boarder gauze daily and PRN every day shift for Wound care management as tolerated/allowed by resident every day shift ordered [DATE]. Rinse right plantar foot with wound cleanser pat dry apply [MEDICATION NAME] AG and cover with boarder gauze daily and PRN every day shift for Wound care management, as tolerated/allowed per resident every day shift ordered [DATE]. Rinse right posterior thigh with wound cleanser pat dry apply [MEDICATION NAME] AG and cover with boarder gauze daily and PRN every day shift for Wound care management, as tolerated/allowed per patient every day shift ordered [DATE]. Weekly head to toe skin assessment by licensed nurse, complete assessment under assessment tab every day shift every Thu (Thursday) ordered [DATE] and started [DATE]. Wound team to evaluate and treat as indicated ordered [DATE]. A progress note written by Nurse Practitioner (NP) on [DATE] documented, .Skin: .Multiple wounds to buttock due to moisture breakdown .Plan: .Skin checks .Wound care .Nutritional support .Wound care to legs/buttock . R#802's Treatment Administration Record (TAR) for [DATE] was reviewed and revealed on [DATE], the day before R#802 was transferred to the hospital, Nurse B administered treatment to R#802's thighs, left lower leg, right plantar foot, posterior thigh, and buttocks, as well as applied [MEDICATION NAME] powder to affected areas (which were unidentified areas). On [DATE] at 3:00 PM, Nurse B was interviewed. Nurse B reported they began working in the facility about one week ago. Nurse B recalled R#802 had fungus in her skin folds and dry feet but did not recall anything unusual on [DATE]. Nurse B reported R#802 willingly accepted treatment to her skin on that day and did not refuse care. Further review of the [DATE] TAR for R#802 revealed the weekly head to toe skin assessment was checked as completed on [DATE]. However, there was no documentation of the assessment. On [DATE] at 2:07 PM, an interview was conducted with CNA C via the telephone. CNA C reported they gave R#802 a bed bath but was not sure of the date, that there were multiple staff members present, and that they had to roll the resident over. When queried about whether R#802 ever refused care, CNA C reported the resident did refuse a lot, but preferred certain staff members to provide care. CNA C denied knowing of any wounds but said R#802 had skin tears. On [DATE] at approximately 2:30 PM, the facility's former Director of Nursing (DON), current DON (who began working in the facility on [DATE]), and the Administrator were interviewed. When queried about the protocol for the facility's skin management program, the former DON reported the following: On admission, a skin assessment was done as part of the Admission Data Collection and within 24 to 48 hours a second, more thorough skin assessment was done by the former DON, the assistant director of nursing (ADON), or a unit manager. During that assessment, if needed, a referral to the wound care team from an outside agency would be made, and the wound would be staged (if a pressure ulcer), measured, and a description would be documented on the respective weekly assessment forms (pressure ulcer or non-pressure ulcer). The former DON reported starting in [DATE], the facility used a telehealth physician for wound consults, that in [DATE] the contracted wound care team that came to the facility had their contract terminated, and between [DATE] and [DATE] if a resident had a bad wound, NP F would evaluate the wound and if needed Physician H would look at it. The former DON further explained that the facility had an Infectious Disease physician that would evaluate wounds that were infected. The former DON reported it was identified that weekly skin assessments were not being triggered in the electronic medical record for residents who were discharged to the hospital and then readmitted into the facility and therefore were not being completed upon admission. It was also explained that the skin assessment forms included a box to check if a resident refused an assessment. At that time, the former DON was interviewed about R#802 and if they had any wounds upon admission on [DATE]. The former DON reported R#802 had fungal areas and weeping lower extremities but was unsure about any other areas of concern. When queried about the lack of skin assessments for R#802, the former DON reported it must have been due to the glitch in the electronic medical record as mentioned above and confirmed there was no skin assessment completed until [DATE] (five days after admission) and a second skin assessment by management was not completed. The DON reported R#802 often refused care and only allowed CNAs to get her into the shower two times. When queried about the documentation of abrasions to R#802's lower back and sacrum and what was put into place to assess and treat those areas, the former DON reported they would have to look into it. The Administrator reported R#802 had the right to refuse care and explained that it was care planned that R#802 refused showers and weights. When queried about what was done to address the reason R#802 refused care and at what point was the refusal of care considered detrimental to the resident's wellbeing, the Administrator did not offer a response. At that time, the following was requested: any assessment or description off R#802's skin, what interventions and treatments were in place, and any consultation by the telehealth wound practitioner. On [DATE] at 8:15 AM, the Administrator provided the following documentation to follow up on the interview conducted on [DATE]: Behavior Notes from 2018 and 2019 (one and two years prior) that documented refusals of care. A Documentation Survey Report (a report that documents when certified nurse aides - CNAs sign off on completed tasks) for Bowel Elimination with multiple highlighted areas that indicated Not Applicable as evidenced by documentation of the number 97. There were multiple spots left blank and on [DATE], [DATE], and [DATE] 98 was documented which indicated Resident Refused in response to the question, Did resident have a Bowel Movement? It was documented R#802 had a large putty-like bowel movement on the day shift on [DATE] at 2:59 PM and the last bowel movement prior to that was documented on [DATE] during the day shift. A Documentation Survey Report for ADL (activities of daily living) - Bathing with multiple highlighted sections with 97 documented which indicated Not applicable. It was documented R#802 refused a bath/shower on [DATE] and [DATE] during the day shift and received a shower on [DATE] during the day shift with total assistance from at least two staff members and it was documented R#802 had a shower/bath on the afternoon shift of the same day with extensive assistance from one staff member. It was documented R#802 had a bath/shower on the day shift of [DATE] and [DATE]. A Nutrition care plan was provided that documented, I often refuse care, skin checks, and weights that was initiated on [DATE] and revised on [DATE]. There were no interventions that addressed refusal of skin checks and care and no new interventions since 2018. An ADL (activities of daily living) care plan initiated on [DATE] and revised on [DATE] documented, .choose not to bathe at times, choose not to have my weekly skin checks at time and prefer to stay in my bed most of the time . Interventions included the following: BATHING/SHOWERING: I am completely dependent x 2 for a bed bath. M-W-F. I prefer to stay in bed and choose not to get up for showers. My bed linens are changes every shift initiated [DATE] and revised on [DATE]. There were no interventions regarding refusal of skin checks. The report revealed inconsistent documentation in several care areas. The Bathing task documented R#802 received a bath/shower twice on [DATE], once on [DATE], and once on [DATE]. It was documented R#802 refused a bath/shower on the day shift of [DATE] and on [DATE] indicated by a 98 which according to the legend meant resident refused. Other dates were left blank or marked with a 97 which indicated not applicable. It was documented in the section for Shower Mon/Wed/Fri day shift as requested that R#802 received a shower on [DATE] at 1:36 PM and [DATE] at 11:46 AM. Further review of R#802's clinical record revealed the following: Multiple Order - Administration Notes that documented refusals by R#802. A Nursing Note dated [DATE] documented, Resident has refused all care and treatments today. She states she 'does not need the cream or powder, I am fine'. Resident educated on the treatments but continues to refuse. A Social Services Note dated [DATE] documented, Social services met with pt. today for 72-hour meeting. Pt. was pleasant and appropriate. Pt. reported that she wanted her code status to remain Full Code. Pt. reported that she will be glad when the pandemic is over. She made a request to get hot dogs. Pt. will return back to LTC after her 14-day quarantine is over. Social services will continue to follow up as needed. There was no mention of addressing care or treatment refusals. A Care Conference Note dated [DATE] documented, Care conference held for resident. IDT in attendance. Resident and family declines attendance .Chooses to stay in bed per her preference . Orders for wound to evaluate .She refuses to be weighed . There was no documentation of any discussion about wound treatment refusals. The TAR for September documented R#802 only received wound treatment and application of topical medications a few times from [DATE] through her discharge to the hospital on [DATE]. There were no progress notes that documented the physician was made aware or any conversation was had with R#802 about why they were refusing or what could be done to help meet the resident's needs. TARs for [DATE] and [DATE] documented R#802 did not refuse any wound or skin treatments during those time. There was no documentation that showed the facility attempted to find out why the resident began consistently refusing wound and skin treatments upon readmission into the facility on [DATE]. On [DATE] at 9:24 AM, the Social Services Director was interviewed. When queried about R#802 and any behaviors they exhibited and if they were followed by behavioral services, the Social Services Director stated, Not that I know of. I don't think she is seen by psych. I have only had brief interactions with her. When queried about any history of refusing care, the Social Services Director stated, No issues have been reported to me. I know she does not like showers and prefers a bed bath because she does not like to move around and go to the shower room. The Social Services Director reported they were unaware of any other refusals of care. On [DATE], further review of R#802's clinical record was conducted. A Documentation Survey Report for [DATE] for the Monitor - Behavior Symptoms section revealed R#802 rejected care on [DATE] day shift, [DATE] midnight shift, [DATE] day shift, [DATE] midnight shift, and [DATE] afternoon shift. There were no other days and shifts that documented R#802 had refused care. A review of Nursing Daily Skilled Charting assessments completed by various nurses revealed inconsistent documentation regarding R#802's skin integrity, as follows: On [DATE], it was documented R#802 had a skin tear and an abrasion. It was documented that R#802 had abrasions to lower extremities. This assessment was completed and signed by the Assistant Director of Nursing (ADON). On [DATE], it was documented R#802's skin was intact. On [DATE], it was documented R#802 had a pressure ulcer and to see the weekly pressure ulcer record. There were no weekly pressure ulcer records for R#802 after their readmission into the facility on [DATE]. On [DATE], it was documented R#802 had a pressure ulcer. On [DATE], it was documented R#802's skin was intact. On [DATE], it was documented R#802 had a skin tear. It was noted that Resident is obese and has skin tear on her thighs, legs and back. On [DATE], it was documented R#802's skin was intact. On [DATE], it was documented R#802 had a skin tear and a rash and noted, Fragile skin to lower extremities, rash under bilateral breast, groin, abdomen. On [DATE], it was documented R#802 had a bruise, skin tear, pressure ulcer, non-pressure ulcer, and other skin integrity issues. It was noted, Resident has bruises skin tear pressure ulcer and nonpressure ulcer on her upper back all the way down her feet r/t overweight and constant laying on her back. (Note: there was no other documentation of pressure ulcers or any treatment to R#802's back). On [DATE], it was documented R#802 had rashes to body folds. This assessment was completed by the ADON. On [DATE], it was documented R#802 had rashes to body folds, fragile skin lower extremities. This was completed by Nurse E. On [DATE], it was documented R#802 had a skin tear and a rash. There were no additional Daily Skilled Charting assessments provided by the facility. On [DATE], the current DON and ADON were interviewed regarding the CNA documentation and care plans provided by the Administrator. The DON reported it was not clear by the CNA documentation what care was or was not provided to R#802. When queried about whether it was possible for a resident to have maggots in a wound if they received a thorough shower or bath and proper incontinence care that morning, the DON and ADON did not offer a response. When queried about how multiple bed sheets could be stuck to R#802's skin in the emergency department of the hospital covered with stool if linens were changed according to the resident's care plan and care including a shower and incontinence care after a bowel movement was provided that same morning, the DON and ADON did not offer a response. On [DATE] at 2:00 PM, the Administrator was interviewed. When queried about whether issues with the facility's skin program was brought up as a Quality Assurance (QA) concern, the Administrator reported they always talk about skin issues in QA meetings. When queried about who conducted audits of clinical assessments, the Administrator reported the DON, ADON, and unit managers, as well as the Administrator conducted audits. The Administrator did not offer a response as to why the lack of skin assessments and inconsistency and inaccurate documentation by the CNAs was not identified. No physician notes or wound consults that addressed R#802's skin after readmission on [DATE] were received prior to the end of the survey. A facility policy titled, Skin Management (revision date: [DATE]) was reviewed and documented, .Upon admission or readmission, residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition .Residents admitted with skin impairments will have: Interventions to promote healing .A physician's orders [REDACTED].Notification of the presence of skin impairment to the resident's representative and attending physician and documentation in the .(UDA) or Progress Note .Completion of the Weekly Non-Pressure Condition Record for non-pressure areas .At-Risk Review Meetings will be conducted to review/discuss: .Residents identified at risk or with skin integrity compromise .Recommendations based on interdisciplinary evaluation .ONGOING SKIN ASSESSMENTS .A Weekly Skin Check will be completed in the resident's record using the Head to Toe Skin Check (UDA) .The nurse will initiate treatments, interventions, care plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines .NON-PRESSURE WOUNDS .The attending physician determines the etiology of the wound, as well as the treatment plan .Wounds will be assessed weekly and status/progress documented on the Weekly Non-Pressure Skin Condition Record (UDA) .Consultation with a certified wound care nurse, wound consultant, or surgeon may be appropriate . Deficient Practice #2 Based on interview and record review, the facility failed to respond to changes in condition in a timely and appropriate manner for two (R#804 and R#807) of three residents reviewed for change in condition, resulting in a delayed response to cardiovascular, respiratory, and mental status changes that required hospitalization . Findings include: R#804 A complaint was received by the State Agency that alleged the following: (R#804) .passed away on Wednesday [DATE] .(R#804) had been in and out of the hospital several times this year due to all of his health issues. Several weeks ago, (R#804) asked to go to a hospital as he was very ill and having a very hard time breathing. Staff indicated they had to do tests prior to sending him to the hospital and then refused to send him. When (R#804) arrived at the hospital, he was diagnosed with [REDACTED]. There are concerns that the nursing facility not taking (R#804) to the hospital contributed to his death. A review of R#804's clinical record was conducted and revealed the following: R#804 was admitted into the facility on [DATE], most recently readmitted on [DATE], and discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#804 had intact cognition, no behaviors, and required limited assistance from staff for bed mobility and transfers. A Nursing Note dated [DATE] at 12:00 PM written by Unit Manager, Nurse K documented, .Resident voices concerns about swelling and leg discomfort. Resident reports intermittent shortness of breath. Resident currently presents in no acute distress with regular, non-labored respiration's . A Nursing Note dated [DATE] at 4:00 PM written by Nurse K documented, .Telehealth call with NP F .Resident voiced concerns regarding shortness of breath, leg swelling and abdominal distention. Stat chest and abdominal X-rays ordered, as well as BLE (bilateral lower extremities) Doppler study . A Nursing Note dated [DATE] at 6:45 AM written by Nurse I documented, .Resident woke up at approx. 4 am and was very agitated, stating that he could not breathe. BP (blood pressure) of ,[DATE], HR (heart rate) of 100, R (respiratory rate) 21 .O2 (oxygen) sats (saturation) of 84% (normal is greater than 92%) on room air. Resident placed on O2 via NC @ 4L/min and O2 sats improved to ,[DATE]%. Scheduled [MEDICATION NAME] 0.3 mg, [MEDICATION NAME] 100 and [MEDICATION NAME] 200 mg administered for BP. Tylenol #3 and PRN [MEDICATION NAME] 0.25 mg administered for agitation. STAT CBC, BMP already ordered earlier by NP. (Physician H notified and O2 order received for 4L/min PRN. DON notified. An Orders - Administration Note dated [DATE] at 5:09 AM documented resident was given [MEDICATION NAME] and it was ineffective. The note documented, resident continues to have elevated HR of 130 and Elevated Bp of ,[DATE] . A Nursing Note dated [DATE] at 7:46 AM documented, Resident put on call light at approx. 4 am requesting help from this writer as he was experiencing SOB (shortness of breath) and was hyperventilating. BP of ,[DATE], HR of 133, R23 w/accessory muscle use, T99F and BS of 210. O2 sats @ 79% on 6L/min via NC. Resident placed on non-rebreather @ 25L/min, sit (sic) agitated but O2 sats improved to 93%. HR still elevated in 130 bpm range. PRN [MEDICATION NAME] 0.25mg, Tylenol #3, [MEDICATION NAME] 0.3mg, [MEDICATION NAME] 200 mg and [MEDICATION NAME] 40mg given. (Physician I) called, STAT CXR ordered. DON notified. Resident checked on continuously by this writer. BP of ,[DATE] and HR of 79 by 5:20 am. Resident removed from non-rebreather and placed on nasal cannula @ 6L/min with O2 sats of 94% holding steady. Resident observed to be calmly sleeping. A Nursing Note dated [DATE] at 10:30 AM documented, Resident request to go to the hospital V.S. temp. 99.4, b/p ,[DATE], hr 96 pulse ox 97% and blood sugar = 245. On call physician notified and administrator notified, order to send resident to the hospital. Next of kin notified. On [DATE] at 8:48 AM, Unit Manager, Nurse K was interviewed regarding R#804. Nurse K reported R#804 was particular and regimented about his care and would often bring concerns about his medical status and then staff would follow up. Nurse K stated, He is very conscientious about his medical care. Nurse K reported for a few weeks prior to R#804's discharge to the hospital, the resident experienced a decline in his cardiac status and was in and out of the hospital for hypertensive crises. When queried about R#804's condition on [DATE], Nurse K reported R#804 was concerned that he had more swelling in his legs and shortness of breath but was not in any distress so a telehealth call was made with NP F. Nurse K reported NP F ordered labs, a chest X-ray, and a doppler at that time to rule out any underlying causes. Nurse K reported R#804 did become anxious at times, but on this particular day he expressed more uncomfortableness and tightness in his legs due to swelling and appeared more bloated. Further interview of Unit Manager, Nurse K revealed they were not working the day R#804 went out to the hospital. Nurse K reported R#804 had asked to go to the hospital in the past and was sent out. At that time, Nurse K reviewed the progress notes written by Nurse I on [DATE] and was queried about what should have been done. Nurse K reported they would have sent the resident out 911 as they have presented that way in the past and required hospitalization . On [DATE] at 9:40 AM, a telephone interview was attempted with Nurse J. Nurse J was unavailable for interview prior to the end of the survey. On [DATE] at 9:02 AM, Nurse I was interviewed via the telephone. Nurse I confirmed they worked the midnight shift on [DATE] going into [DATE]. When queried about the condition of R#804 on [DATE] at 4:00 AM as documented in the progress note, Nurse I stated, He woke up and had a panic attack. When queried about R#804's vital signs, Nurse I stated, His blood pressure tends to run high, so I gave him his scheduled medications and then he fell asleep. When queried about how Nurse I determined R#804's abnormal vital signs were due to a panic attack versus a hypertensive crisis as per history, Nurse I reported R#804's blood pressure was always high and that he was frequently anxious. Nurse I reported R#804 was hyperventilating at the time and did request to go to the hospital. Nurse I reported they contacted the physician and by the time they called back about an hour later, R#804 was sleeping so the physician ordered a chest X-ray. When queried about R#804 requesting to go to the hospital, Nurse I stated, (R#804) had been wanting to go to the hospital but I told him I was waiting on the doctor and we were waiting on lab tests. When the doctor called back, his vitals were normal, and he was not on the non-rebreather anymore. The doctor ordered a chest X-ray. Nurse I stated, He was good when I left, but I guess he was still saying he wanted to go to the hospital and was sent later. When queried about the reason why R#804 would not be sent to the hospital per their request when they had abnormal vital signs, was hyperventilating, and required a non-rebreather for oxygen, Nurse I stated, We have residents who call 911 because they want [MEDICATION NAME] (an antacid). On [DATE] at 3:35 PM, the former Director of Nursing (DON) was interviewed in the presence of the current DON (who began working at the facility on [DATE]) and the Administrator. The former DON was queried about what should be done if someone presents like R#804 did on [DATE] (BP of ,[DATE], HR of 133, R23 w/accessory muscle use,T99F, and O2 sats @ 79% on 6L/min via NC requiring 25L/min of oxygen via a non-rebreather, remained agitated and with an elevated heart rate in the 130 bpm range). The former DON reported Nurse I reviewed text messages on their phone at that time and reported Nurse I contacted her about R#804 on [DATE] and stated, I specifically told (Nurse I) to send (R#804) to the hospital right away. On [DATE], hospital records for R#804 were reviewed and revealed the following: R#804 was admitted into the emergency department (ED) on [DATE] at 12:24 PM with a chief complaint of shortness of breath. It was documented R#804 expired in the hospital on [DATE]. A History and Physical (H&P) documented R#804 reported he is always short of breath, but it seemed to be getting more progressive. The H&P documented, At nursing facility noted to by hypoxic in the mid 80's .cough with green/clear sputum . ED triage notes documented R#804's blood pressure at 12:56 PM was ,[DATE] and it increased to ,[DATE] at 2:39 PM. An ED provider note written by the hospital Physician Assistant (PA) documented R#804 was started on intravenous (IV) antibiotics, [MEDICATION NAME], and [MEDICATION NAME] for blood pressure. An ED physician note documented, c/o (complains of) SOB, pulse ox 81% in NH (nursing home) .coughing .rattling in chest .course breath sounds .slightly tachypneic (rapid respiration rate) .pneumonia versus [MEDICAL CONDITION] .covered with antibiotics and given [MEDICATION NAME] . R#804 was admitted into the hospital from the ED. A H&P documented, Vitally RR 19, [MEDICAL CONDITION] with HR 92, hypertensive with ,[DATE], SPO2 90% on 2 L nasal cannula, afebrile .Chest x-ray showed cardiomegaly with slight interval worsening mild interstitial [MEDICAL CONDITION] and/or atypical pneumonia .RRT (Rapid Response Team) was called since the patient was shifted to floors for blood pressure of ,[DATE] .Patient has been placed on high flow nasal cannula for better saturation . A hospital Discharge Summary dated [DATE] documented R#804 was deceased with [DIAGNOSES REDACTED]. R#807 A complaint was received by the State Agency that alleged the following: (R#807) fell down the stairs on [DATE]. He broke his right wrist and a rib on the right side. Due to an [MEDICAL CONDITION], he had to undergo an emergency craniotomy. He was waking up for short periods of time off and on while in the hospital. He would nod his head at times to different questions. He also was moving all of his extremities while in the hospital .(family) called frequently to check on (R#807) .was always told sometimes he would wake up and at other times he would not. I spoke with the unit nurse manager on M(TRUNCATED)

This citation pertains to intake #'s MI 319, MI 755, and MI 158 Based on interview and record review, the facility failed to implement interventions to prevent the development or worsening of pressure ulcers, perform skin assessments accurately and consistently, obtain and record pressure ulcer measurements in a timely manner, and ensure pressure ulcer treatments were ordered and performed per physician orders for three residents (R#'s 801, 807, and 808) of five residents reviewed for pressure ulcers resulting in the development of facility acquired pressure ulcers and the worsening of existing pressure ulcers. Findings include: R801 On 9/30/20 a review of R801's closed clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R801's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated R801 had intact cognition (13/15 on a Brief Interview for Mental Status exam), did not exhibit any hallucinations, delusions, behaviors, rejection of care, or wandering, was non-ambulatory, required extensive assistance of two staff members for transferring and bed mobility, required extensive assistance of one staff member for wheelchair mobility, dressing and personal hygiene, required total assistance of one staff member for bathing, and was always incontinent of urine and stool. Further review of the MDS assessment, Section M. Skin Conditions indicated the resident did not have a pressure ulcers. On 10/1/20 at 12:30 PM, an interview with Certified Nursing Assistant (CNA) 'N' was conducted regarding the facility's turning and repositioning program. CNA 'N' indicated they reviewed the Kardex to determine who was on a turning/repositioning program and they documented it in their CNA task list. On 10/1/20 an interview with Unit Manager 'K' was conducted regarding the facility's turning and repositioning program. Unit Manager 'K' explained that any nursing staff member can turn and reposition residents, but most often it was the CNA's. When asked about which residents need to be turned or repositioned, Unit Manager 'K' indicated that residents who were total assistance and or were incontinent should be on a turning program. When asked how the CNA's would know which residents required to be turned or assisted with turning and whether it should be documented, Unit Manager 'K' explained that they could refer to the resident's Kardex and they should be documenting in their CNA task list. A review of R801's CNA Kardex (care guide) was reviewed and read, .Bed Mobility .Turn and reposition frequently to decrease pressure . R801's care plans were reviewed and included an intervention for the potential for skin breakdown initiated 9/30/19 that read, Turn and reposition frequently to decrease pressure . The care plan also included interventions for an existing pressure ulcer initiated 9/4/20 that read, Assist .to reposition and/or turn at frequent intervals to provide pressure relief . A review of R801's CNA tasks for turning and repositioning was conducted for August 2020 and of the 93 shifts (31 days x 3 shifts per day), it was documented R801 was not on a Turning and Positioning Program for 40 of those shifts, therefore; it was not documented R801 had been assisted to turn and reposition. It was further noted that 27 of the 40 No responses in August were documented between 8/7/20 and 8/21/20, just prior to the discovery of a pressure ulcer on R801's coccyx on 8/23/20. A review of the CNA task from 9/1/20-9/16/20 also revealed that of the 48 shifts, it was documented that R801 was not on a Turning and Positioning Program for 18 of those shifts. A review of R801's clinical documentation related to pressure ulcers was conducted and revealed the following: A weekly skin assessment titled Skin-Head to Toe Skin Checks dated 8/15/20 that documented R801 had no skin impairments. A weekly skin assessment dated [DATE] that documented R801 had no skin impairments. A weekly skin assessment dated [DATE] conducted by Licensed Practical Nurse (LPN) 'L' that read, .1p. Describe new or existing other issues: small round pressure ulcer on coccyx. cleansed, applied [MEDICATION NAME] and covered with Opti foam dressing (occlusive dressing) . The skin assessment did not include any measurements of the wound or pressure ulcer staging. A review of R801's orders was conducted and did not reveal a physician's order for the [MEDICATION NAME], and Opti foam treatment applied by LPN 'L'. A review of the Medication Administration Record [REDACTED]. The records indicated the first treatment order and treatment applied to the wound occurred on 8/27/20, four days after the wound was identified. A document titled, Skin-Weekly Pressure Ulcer Record dated 8/27/20 that indicated R801 had an unstageable (full-thickness skin and tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) pressure ulcer on their coccyx with an onset date of 8/27/20 that measured 3.1 cm (centimeters) in length, by 1.1 cm in width by 0.0 cm in depth. The assessment read, .Small superficial pressure area to coccyx peri area is pale and moist, Likely moisture associated. There is yellow slough over the wound bed . A telehealth wound care consult dated 8/27/20 from Physician 'M', that read .Assessed incontinence-related coccyx wound. Measurement provided by the treatment nurse .Wound Assessment(s): Wound #1 is a chronic Partial Thickness Incontinence-related wound .Wound bed has 50% slough . The consultant recommended the wound be cleansed with Dakin's Solution (a topical antiseptic) have a petroleum dressing applied and covered with a [MEDICATION NAME] (occlusive foam dressing). It was noted the wound care consultant's note did not indicate whether the wound was avoidable, or unavoidable in nature. A weekly skin assessment dated [DATE] that documented R801 had Intact Skin. It was noted the assessment form had several check boxes to indicate whether the resident had any existing or new skin impairments such as bruises, abrasions, skin tears, or pressure ulcers. A Skin-Weekly Pressure Ulcer Record assessment dated [DATE] that indicated R801 had a pressure ulcer on their coccyx that measured 2.6cm x 1.3 x 0.0 cm. It was noted the assessment form now documented the ulcer as a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough), however the description of the wound read, .Wound bed has 50% slough . A telehealth wound care consult dated 9/3/20 from Physician 'M' that read, .Conducted follow-up telehealth consultation .Wound Assessment(s) Wound #1 Coccyx is chronic Partial Thickness Incontinence-related wound .Wound bed has 75% slough .There is no change in the wound progression .Healing is delayed due to the following: .Incontinence . The consultant's treatment recommendation was to cleanse the wound with Dakin's solution, apply Santyl (wound care ointment) and a petroleum dressing, and cover with a [MEDICATION NAME]. A review of R801's physician's orders was conducted and revealed R801 never had the order placed for the use of the Santyl ointment recommended on 9/3/20. The treatment provided for R801's wound remained to be the wound care physician's first recommendation on 8/27/20 (The Dakin's solution, petroleum dressing and [MEDICATION NAME]) up until their discharge date on 9/16/20. A Skin-Weekly Pressure Ulcer Record assessment dated [DATE] that indicated R801 had a pressure ulcer on their coccyx that measured 1.9 cm x 0.7 x 0.0 cm. The assessment form documented the wound as a stage II pressure ulcer, however the description of the wound read, .Wound bed has 50% slough . A telehealth wound care consult dated 9/10/20 from Physician 'M' that read, .Conducted follow-up telehealth consultation .Assessed incontinence related coccyx wound .Wound Assessment(s) Wound #1 Coccyx is chronic Partial Thickness Incontinence-related wound .Wound bed has 75% slough .There is no change in the wound progression .Healing is delayed due to the following: .Incontinence . It was noted this consultation also recommended the use of the Santyl ointment. A review of R801's attending physician/physician extender notes was conducted and revealed a note on 9/3/20 by Nurse Practitioner 'F' that read, .Physical Exam .Skin: Inspection: No rashes or ulcers . R801's progress notes were reviewed and revealed a note on 9/16/20 that indicated R801 had been transferred to the hospital. Hospital records for R801 were obtained and the History and Physical notes revealed the following, .Patient has been deteriorating .she may have pneumonia/UTI (urinary tract infection), but definitely has some infection of the sacral wound. This is the etiology now of her septic shock . Continued review of the records read, Assessment & Plan:[MEDICAL CONDITION], Hypotensive, Possibly due to third-degree decubitus ulcer in the sacrum . A review of R801's discharge summary note from the hospital read, .Hospital Course .On examination the patient was actively dying, [MEDICAL CONDITION] pneumonia, UTI, sacral wound infection. She appeared uncomfortable with her breathing and pain from the sacrum . R808 On 9/30/20, a phone call with the complainant was conducted regarding the investigation. During the call, the complainant indicated R808 had admitted to the facility with a pressure ulcer, but during their stay at the facility the wound had gotten worse. The complainant explained that when R808 entered the facility the wound was, about the size of a quarter, and indicated that when R808 left the facility the wound was approximately 3 inches x 1.5 inches. On 9/30/20 a review of R808's closed clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R808's MDS assessment dated [DATE] indicated R808 had intact cognition (15/15 Brief Interview for Mental Status Score), was non-ambulatory, required extensive assistance of two staff members for bed mobility, required extensive to total assistance of one to two staff members for other activities of daily living, had one side upper extremity range of motion deficits, had a urinary catheter, and was always incontinent of stool. A review of a facility provided copy of R808's CNA Task List Report was conducted and read, .MONITOR-Turn and Reposition .Task Schedule: Everyday. Q (every) Shift . R801's care plans were reviewed and included an intervention that read, .BED MOBILITY: I require extensive (2) staff for repositioning and turning in bed . as well as an intervention for pressure ulcers that read, .Assist me to reposition and/or turn at frequent intervals . A review of R808's CNA task list for February 2020 was conducted and revealed that of the 32 shifts, it had been documented 11 times that R808 was not on a Turning and Positioning Program, therefore; it was not documented that R808 had been turned or assisted to turn during those shifts. A review of R808's hospital record prior to their discharge to the facility was conducted and revealed a document from the hospital internal medicine physician dated 2/14/20, that read, .Physical Exam: .Skin: .patient has a 2 mm (millimeter) to 1 cm unstageable pressure injury involving the coccyx . A review of R808's clinical documentation related to pressure ulcers was conducted and revealed the following: An admission skin assessment dated [DATE] that indicated R808 admitted to the facility with a pressure ulcer on their coccyx, however the assessment did not indicate any measurements or pressure ulcer staging. A document titled, Skin-Head to Toe Skin Checks weekly skin assessment dated [DATE] was reviewed and was noted to be blank, with a Section Status: In Progress. A weekly skin assessment dated [DATE] with a lock date of 3/7/20 that read, .Describe new or existing other issues: wound on coccyx, treatment in place . It was noted the assessment did not indicate any wound measurements or pressure ulcer staging. A weekly skin assessment dated [DATE] that read, .Describe new or existing other issues: coccyx wound, treatment as ordered . It was noted the assessment did not indicate any wound measurements or pressure ulcer staging. A wound care consult note dated 3/6/20 that read, .Wound #1 Sacrococcyx/bilat (bilateral) buttock is a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present, often include undermining and tunneling) Pressure Injury Pressure Ulcer .measurements are 8cm length x 5.5cm width x 1cm depth .Tendon and bone are exposed. Tunneling has been noted .with a maximum distance of 5cm . Wound bed has Necrotic Base [MEDICATION NAME] . It was noted this document was the first to assess R808's pressure ulcer stage and document the measurements of the wound, 16 days after their admission to the facility. A document titled, Skin-Weekly Pressure Ulcer Record dated 3/9/20 that indicated R808 had a pressure ulcer in their Sacral/coccyx area. The date of onset on the assessment was documented as 2/28/20, eight days after R808's admission to the facility. There were no Skin-Weekly Pressure Ulcer Record assessments prior to this one. A review of R808's Nursing Daily Skilled Charting assessments was conducted and revealed that on 2/21/20, 2/22/20, 2/25/20, 2/26/20, 2/27/20, 2/29/20, 3/1/20, 3/2/20, and 3/5/20 the nurses documented R808's skin was intact. On 10/1/20 at 2:15 PM, an interview was conducted with the facility's Administrator, Director of Nursing (DON), and former Director of Nursing regarding the facility's pressure ulcer program. The former DON explained that when a resident admitted to the facility, a skin assessment was done, but pressure ulcers were not measured or staged at that time. It was explained that the wound care team were the only staff that measured and staged pressure ulcers and that was done on a second skin check within a couple days of admission and documented in the clinical record. When queried about the Wound Care Physician's recommendations and whether they should be implemented (as in the case of R801 with the Santyl), the Former DON indicated it should have been ordered and implemented. Next, the Former and Current DON were asked about the accuracy of the skin assessments and indicated a head-to-toe skin assessment should be done and the assessment should accurately reflect the resident's current status. They were also asked if anyone audited the nurses' assessments for accuracy and indicated no audits were being done. R#807 A complaint was received by the State Agency that alleged the following: (R#807) fell down the stairs on March 19. He broke his right wrist and a rib on the right side. Due to an [MEDICAL CONDITION], he had to undergo an emergency craniotomy .I spoke with the unit nurse manager on May 1 and she updated me on his condition. She told me he had a decubitus (pressure ulcer) on his coccyx (tailbone) that was there when he was transferred from (name of specialty hospital redacted). It already had black tissue but wasn't too large. The plan was to get him on a special bed to keep it from getting worse. She also said it was being treated with [MEDICATION NAME] .the nurse manager (Nurse E). She said she was going to call me to talk to me about code status. When I asked her why, she said his decubitus now looked like a death decubitus .She also said that he now had a bruise on the top of his head that he came back with after returning from the CT scan. (R#807 was wearing a skull protection helmet since leaving the hospital on March 31). She asked me if the nurse called me Friday to notify me of this. I told her no .We feel he should have been admitted to the hospital at least a week earlier due to the mental status changes, the pneumonia and debridement of his decubitus. There were never any updates as to any concerns about any of these changes. As healthcare professionals, (R#807's family members) cried when turned him to look at his decubitus . On 10/1/20, a review of R#807's clinical record was conducted and revealed the following: R#807 was admitted into the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. R#807 was admitted with a tracheotomy and a PEG tube. A Minimum Data Set (MDS) assessment dated [DATE] documented R#807's cognition was not assessed, they had no speech and was rarely/never understood or understood others, and was totally dependent on staff for bed mobility, transfers, and ADLs (activities of daily living). The MDS assessment documented R#807 had one stage III pressure ulcer (full thickness skin loss) on admission. An Admission Data Collection assessment dated [DATE] (signed and locked on 4/24/20) documented R#807 had a pressure ulcer to their sacrum. No measurement or description was documented. A Skin-Head to Toe Skin Check assessment dated [DATE] documented R#807 had a pressure ulcer to their sacrum and a treatment was in place. A Skin-Head to Toe Skin Check assessment dated [DATE] (signed and locked on 5/3/20) documented R#807 had an existing necrotic pressure ulcer to their coccyx and a reddened area on their right outer ankle. A Skin-Head to Toe Skin Check assessment dated [DATE] documented R#807 had an existing necrotic pressure ulcer to their sacrum, redness to their right outer ankle, and a new redness to the top of their scalp. Notes documented, Made (Nurse Practitioner F aware of red area on crown of head, after looking at the area she ordered to cleanse area with normal saline, pat dry, apply [MEDICATION NAME] Q (every) day and PRN (as needed) to crown of head. A Skin-Weekly Pressure Ulcer Record assessment dated [DATE] (signed and locked on 4/29/20) documented R#807 had a stage III pressure ulcer on their sacrococcygeal area that measured 6.1 centimeters (cm) in length by 6.1 cm in width by 0.03 cm in depth. The assessment documented, Area 85% necrotic (dead) tissue with 15% beefy red granulation tissue to base. Scant amount of drainage. Surrounding tissue observed with deep reddish/purple [DIAGNOSES REDACTED] fragile skin 2 cm around wound. Irregular would edges . It was documented the treatment was changed to [MEDICATION NAME] cream to wound, skin prep to peri wound. Notes documented, Family aware of residents wound present on admission. Wound team to follow weekly. RD (registered dietician) to monitor for nutritional support to promote healing . A Skin-Weekly Pressure Ulcer Record assessment dated [DATE] (still in progress and not signed or locked as of 10/1/20) documented R#807 had an unstageable pressure ulcer (Obscured Full-thickness skin and tissue loss) that measured 12.4 cm x 9 cm x 0.01 cm. It was documented the wound was 60% necrotic with 40% pink epethelialized tissue. The wound bed was described as black with dark purple irregular edges. It was documented that the resident's response to current treatment was deteriorated and the treatment would be changed to skin prep the edges dressing to protect wound. Notes documented, Wound care rounds will continue with management team on Wednesday, weekly. A Skin-Weekly Pressure Ulcer Record assessment dated [DATE] (signed and locked 5/13/20, two days after R#807 was discharged from the facility) documented R#807 had a pressure ulcer (no stage was documented) that measured 10 cm x 8 cm x 0.1 cm. It was describes as necrotic area is 80% with 20 slough yellow. Wound appears shallow with irregular borders. Minimal drainage. It was documented as deteriorated with more necrotic space and no treatment change was documented. Notes documented, Continue to follow up with wound care rounds weekly. Review of the clinical record did not reveal any documented consultation by the wound team. A progress note by NP F dated 4/27/20 documented, .Patient is seen today for .sacral pressure injury. patient has an unstageable pressure injury to his sacrum that wound care has been dressing with [MEDICATION NAME] (an absorbent foam dressing). Wound has foul odor with significant amount of drainage on dressing. Concerning for possible infection and likely need for debridement .Unstageable sacral wound with surrounding [DIAGNOSES REDACTED], some areas are blanchable, but boggy. There are several smaller open areas noted on coccyx. Foam dressing saturated with foul smelling purulent drainage .Plan: .Concern for infection and likely need for debridement .Consult Infectious Disease .Continue wound care . A progress note by NP F dated 5/1/20 documented, .Unstageable sacral wound .D/W (discussed with) nursing, no debridement .Continue wound care with medahoney <sic> (medicated honey) .Monitor for s/s (signs and symptoms) of infection . A progress note by NP F dated 5/8/20 documented, .Underneath his helmet on the top of his <sic>appears to be a deep tissue pressure injury (DTPI - Persistent non-blanchable deep red, maroon or purple discoloration due to damage of underlying soft tissue) .new deep tissue pressure injury to top of the head .Unstageable sacral wound-worsened per nursing .Continue wound care with [MEDICATION NAME] . Physicians orders were reviewed and revealed the following treatment orders for R#807: Protein Liquid three times a day 30 ml (milliliters) each time ordered on [DATE]. Cleanse sacral wound gently wipe skin around wound with sure prep, apply [MEDICATION NAME] (a barrier ointment to protect skin from moisture) to sacral wound every shift and with each incontinent episode . ordered on [DATE] and discontinued on 5/5/20. Cleans <sic> sacral wound with normal saline pat dry. Apply med honey to peri wound cover with 4X4 affix with tape. every day shift for Wound care management ordered on [DATE]. Cleanse crown of head with normal saline, pat dry, apply foam dressing for protection. Assess area each time dressing is changed and report any changes to PCP (primary care physician) every 12 hours as needed .and every day shift . ordered 5/8/20. Consult infectious disease .for Sacral Wound, unstageable ordered 4/28/20. Helmet on at all times every shift ordered on [DATE]. There were no physician orders for [MEDICATION NAME] as noted in the NP progress note from 4/27/20 or orders for [MEDICATION NAME] prior to 5/5/20 (NP progress notes documented treatment with [MEDICATION NAME] on 5/1/20 and 5/8/20). Prior to 5/5/20, the only treatment provided to R#807's stage III/unstageable pressure ulcer was a barrier cream. On 10/1/20 at 3:44 PM, the former DON, the current DON, and the Administrator were interviewed and R#807's clinical record was reviewed at that time. When queried about whether R#807 was evaluated by the wound care team, the former DON reported they would have to look into it. When queried about whether R#807 was seen by the Infectious Disease doctor according to physicians orders, the former DON reported they would have to look into it. When queried about whether [MEDICATION NAME] was an appropriate treatment for [REDACTED]. The former DON, current DON, and Administrator did not offer an explanation of why the treatments documented in NP F's progress notes were not the treatments administered. The former DON was queried about any interventions to monitor R#807's skin integrity underneath the helmet that was worn at all times and reported it would be checked during skin assessments but there was no specific order regarding that area. On 10/1/20 at 4:18 PM, the former DON reported R#807 was never seen by the Infectious Disease physician according to the physicians order. No wound care consults were received prior to the end of the survey despite NP F's documentation. No explanation was given regarding who was evaluating and determining treatment for [REDACTED]. Further review of R#807's clinical record revealed an SBAR Communication Form and Progress Note assessment dated [DATE] that documented R#807 had a butterfly shape wound on coccyx. The assessment was completed by Nurse E. On 10/6/20 at 11:15 AM, Nurse E was interviewed. When queried about R#807's helmet and what was in place to monitor the skin underneath, Nurse E reported there was a physicians order to keep the helmet on at all times, but it was removed to wash the resident's hair and shave him. Nurse E stated, The girls (CNAs) were scared of it though so I often took it off for them. Nurse E reported the helmet should have been removed as part of the head to toe skin assessment and reported it was first observed the day R#807 went out for the CT scan. When queried about the pressure ulcer to R#807's sacral area and what was meant by a butterfly shaped wound, Nurse E reported they spoke with R#807's family about it and thought it might resemble a Kennedy Ulcer (a rapidly developing sore that occurs during the final stages of a person's life) . Nurse E reported the pressure ulcer was present on admission as a stage III pressure ulcer and was not diagnosed by a physician as a Kennedy ulcer. A facility policy titled, Skin Management (revision date: July 2017) was reviewed and documented the following: .Upon admission or readmission, residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition .Residents admitted with skin impairments will have: .A physician's order for treatment .Wound location and characteristics documented in the Nursing Admission Data Collection Set (UDA) .Completion of the Weekly Pressure Ulcer Record for pressure ulcers .The licensed nurse will document daily monitoring of pressure ulcers on the Treatment Administration Record (TAR) .A Physician's Order will be written to monitor each pressure ulcer and documentation on the TAR will reflect the status of the dressing, surrounding skin color and skin and pain associated with the wound .If any abnormalities are observed, a descriptive note of findings and the licensed nurse's response are documented in the Progress Notes .A Weekly Skin Check will be completed in the resident's record using the Head to Toe Skin Check (UDA) .The nurse will initiate treatments, interventions, Care Plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines .Pressure ulcers are measured and staged in accordance with the Practice Guidelines .

This citation pertains to intake #'s MI 848, MI 956 and MI 158. Based on interview and record review, the facility failed to perform accurate assessments for indwelling urinary catheters, obtain physician orders for a catheter, and ensure routine catheter care was provided for two residents (R#'s 802 and 808) of three residents reviewed for urinary catheters, resulting in catheter care not being done for 20 days, continued hematuria, [MEDICAL CONDITION] requiring a hospital admission and the potential for poor personal hygiene, embarrassment, and the continued development of urinary tract infections. Findings include: R#802 Two complaints were received by the State Agency that alleged the following: .On 9/27/2020 (R#802) was sent to the emergency room by the nursing home for vaginal bleeding .Her Foley catheter had not been properly cared for, and it is believed that the blood found by the nursing home was from the catheter not her vagina. (R#802's) blood work was not normal. She was admitted and will remain at the hospital for further treatment . Last August, resident had a UTI, cleared up and sent back to the facility. Resident fell ill with a UTI again, she was found unresponsive and sent to the hospital .last Sunday, Sept. 27th . On 9/30/20, R#802's clinical record was reviewed and revealed the following: R#802 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated [DATE] documented R#802 had intact cognition and no behaviors including no rejection of care. The MDS further documented R#802 required extensive physical assist from at least two staff members for bed mobility and did not transfer during the assessment period, was always incontinent of bowel and bladder. It was documented R#802 did not have an indwelling catheter at that time. Progress Notes were reviewed and revealed the following: On 8/28/20 at 10:12 PM, a Transfer to Hospital Note documented, Patient was transferred to . Hospital per NP (Nurse Practitioner) order for further evaluation related to abnormal lab low hbg (hemoglobin, normal is 12.1-15.1): 6.3 and hematuria . On 9/4/20 at 9:45 PM, an Admission Note documented, Resident was readmitted to the facility at 9pm .Resident has an indwelling Foley catheter that is clean and intact .IV abt (antibiotic) r/t (related to) UTI via midline . On 9/7/20 at 6:01 PM, a Nursing Note documented, Urine in foley is dark red. On call notified. Awaiting call back . On 9/25/20 at 12:06 PM, a Nursing Note documented, (NP F) in facility, notified <sic> of residents continued hematuria. Stat CBC, BMP ordered. Lab in facility, drawn at this time . On 9/27/20 at 7:56 PM, Nursing Note documented, (Physician) notified of residents change in condition and current status. Orders received to send out to ER to be further evaluated .Refer to SBAR for more detailed information. There were no progress notes that addressed any monitoring or care of R#802's indwelling urinary catheter. An SBAR Communication Form and Progress Note assessment dated [DATE] (not signed or locked and with 'errors') documented, Resident with mental status changes and increase in confusion. O2 sat on RA 78% (normal is greater than 92) with 5 L O2 85%. Resident is awake but states she is very sleepy. BP ranging from 82/34 to 104/45, afebrile at 97.6, HR is irregular and in the 80's Unmeasurable <sic> amount of urine in Foley catheter. Physicians Orders for R#802 were reviewed from their readmitted into the facility on [DATE] until their emergency discharge to the hospital on [DATE]. The following orders were written on 9/25/20 (20 days after R#802 was readmitted into the facility with a newly inserted indwelling catheter) Empty foley cath every shift and record amount. Document in progress presence of hematuria every shift. Foley catheter #16-10cc balloon to gravity drainage. Change/irrigate as needed blockage or leaking. For monitoring of continued hematuria as needed. An order dated 9/26/20 documented, Monitor for intake and output - drink at least 4 water bottles daily - every shift. There was no physician order for [REDACTED]. On 9/30/20 at 3:00 PM, Nurse B was interviewed. Nurse B was assigned to R#802 on 9/27/20 when they were transferred to the hospital. When queried about why R#802 was transferred to the hospital, Nurse B reported R#802 was confused. Nurse B reported they were new to the facility and they asked another staff member if that was baseline for the resident and they were told she was not usually confused. Nurse B further explained another nurse took R#802's blood pressure and it was low, so a complete assessment was done. Nurse B stated, Her oxygen saturation was low, and it took 5 liters of oxygen to get it up to 88-89% and she was having difficulty breathing and had no urine in the foley catheter. Nurse B reported they called the physician who wanted a bladder scan, but there was no machine in the building, so they sent the resident to the hospital. Nurse B further reported R#802 had a vaginal bleed of unknown etiology. On 10/1/20 at 3:22 PM, the former DON, current DON, and Administrator were interviewed. When queried about what was required for a resident who was admitted with an indwelling urinary catheter, the former DON reported there would be a physicians order that included the size of the catheter, when to empty the bag, and when to change the catheter. At that time, the former DON reviewed the Nursing Daily Skilled Charting assessments and the following was revealed: On 9/8/20, 9/15/20, 9/20/20, 9/21/20 it was documented R#802 was incontinent of bladder, did not assess the resident as having an indwelling urinary catheter, and documented the resident wore pads/briefs. On 9/9/20 it was documented R#802 was continent of bladder, did not assess R#802 as having an indwelling urinary catheter, was independent with toileting (R#802 was totally dependent on 2 or more staff according to the MDS assessment). On 9/10/20, 9/12/20, 9/18/20 it was documented R#802 was continent of bladder, totally dependent on staff for toileting, and wore pads/briefs, R#802's indwelling catheter was not addressed. On 9/11/20, 9/14/20 it was documented R#802 was continent with a catheter ., had a foley catheter, and did not document the urine characteristics as required on the assessment. On 9/13/20 it was documented R#802 had a foley catheter and Resident urine is red mix in blood and she's been treated for [REDACTED].#802 was independent with toileting. On 9/22/20 it was documented R#802 had intermittent catheterization with no additional information. The Former DON reported the above assessments were not consistent or accurate related to R#802. Hospital records for R#802 were reviewed and revealed the following: An Emergency Services/Physician Documentation dated 9/27/20 at 8:32 PM it was documented R#802 had a complaint of a vaginal bleed .Impression: UTI, AKI (acute kidney injury), generalized weakness . An Emergency Physician Record dated 9/27/20 documented, .Blood in urine .4-5 days ago .still present .Pt states urine was dark red 4-5 days ago then it got lighter red then today is dark red again .decreased appetite .h/o (history of) abnormal vaginal bleeding .calculus of kidney .Called NH (nursing home) .Today BP 104/41, no U.O. (urine output) 7A-4P, O2 76% RA (room air), 86% on 5L (liters) .was unresponsive .for short period of time . A Discharge Summary dated 10/5/20 documented, .Discharge Diagnosis: [REDACTED].Hospital Course: .9/29 - remains in ICU (intensive care unit), HGB (hemoglobin) low this AM. Will need transfusion .pseudomonas aeruginosa and [MEDICATION NAME] from blood .changed to meropenem and vanco (antibiotics) .10/2 no safe way to remove stones, abx tx (treatment) only. Will need suppressive abx long term. Does need to maintain foley .10/3 Per ID (infectious disease) will need 10-day course of IV abx .10/4 would like new SNF (skilled nursing facility) . R808 On 9/30/20 a review of R808's closed clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R808's MDS assessment dated [DATE] indicated R808 had intact cognition (15/15 Brief Interview for Mental Status Score), was non-ambulatory, required extensive assistance of one to two staff members for activities of daily living, and had a urinary catheter. On 10/1/20 at approximately 2:50 PM, an interview with the facility's Administrator, Former Director of Nursing (DON) and current DON was conducted. They were queried who was responsible for performing catheter care and indicated the Certified Nursing Aides (CNA) performed the care, reported to the nurse, and documented it in their CNA task list under peri-care. The DON further indicated there should be a section on the Medication Administration Record [REDACTED]. Continued review of R808's clinical record was conducted and revealed an admission assessment that indicated R808 admitted to the facility with an indwelling urinary catheter. A review of R808's physician's orders was conducted and revealed the following: An order dated 2/20/20 that read, Empty foley (catheter) every shift and record amount every shift. An order dated 2/20/20 that read, Foley cath to GD (gravity drainage) .May change/irrigate PRN (as needed) blockage/leaking .as need for foley cath. A review of R808's CNA Kardex was conducted and did not indicate any care tasks for performing peri-care or catheter care for R808. A review of R808's CNA task list was also conducted and did not include any tasks for Peri-care or catheter care. A review of R808's Nursing Daily Skilled Charting assessments was conducted and revealed a section on the assessment for [MEDICAL CONDITION] and bladder status. It was noted response c. read, Continent with a Catheter/Ostomy appliance. A review of the assessments revealed that on 2/21/20, 2/22/20, 2/25/20, 2/26/20, 2/27/20, 3/1/20, 3/2/20, and 3/5/20 the assessment documented the resident was incontinent and used pads/briefs. There were two assessments documented on 2/29/20, the first indicated the resident was continent of urine and used a commode, and the second documented the resident was continent and was on an individualized toileting program. The assessment on 3/4/20 documented R808 was incontinent and was on an individualized toileting program. Review of a nursing progress note dated 3/6/20 at 2:09 PM was conducted and read, .UA (urinalysis) C & S (culture and sensitivity lab) ordered. Foley cath changed earlier, urine obtained . A review of R808's UA and C&S obtained by the nurse on 3/6/20 prior to their discharge to the hospital was conducted and the bloodwork collected on revealed a white blood cell count of 32.9 (normal value is between 4.00-11.00) which can be indicative of infection. A review of R808's urinalysis and culture and sensitivity was reviewed and indicated R808's urine was red in color, turbid (cloudy), and contained >100,000 cfu/ml (colony forming bacterial units per milliliter) of the bacteria Escherichia coli (e. coli). On 10/5/20, a follow-up interview was conducted with the facility's Director of Nursing regarding accuracy of the Nursing Daily Skilled Charting assessments and they indicated that a head-to-to assessment was to be done daily and should accurately reflect the resident's status. A review of a facility provided document titled, Indwelling urinary catheter (Foley) care and management revised 11/15/19 was conducted read, .Provide routine hygiene for meatal care; .use a washcloth and soap and water .or a plain disposable wipe to clean the periurethral area. Clean after each bowel movement . A review of a second facility provided policy titled, Documentation revised February 2017 was conducted and read, Healthcare personnel will complete documentation as outlined below and will record in the medical record using accepted principles of documentation .Be accurate. Verify right resident, right event, right date/time, right location etc .

This citation pertains to Intake Number: MI 319. Based on interview and record review, the facility failed to ensure enteral nutrition (tube feeding - nutrition delivered via a tube inserted into the stomach) was provided according to physicians orders, weights were monitored consistently and accurately, and protein supplements were implemented in a timely manner for one (R#807) of three residents reviewed for nutrition, resulting in a significant weight loss of 7 percent (10 pounds) in 11 days and a delay in wound healing. Findings include: A complaint was submitted to the State Agency that alleged the following, .I spoke with the unit nurse manager on May 1 and she updated me on his (R#807's) condition .I asked how much he weighed, and she stated 132 lbs. My best estimate of (R#807's) weight would have been about 160-162 lbs. (pounds) upon admission to hospital. I told her .I was concerned that (R#807) was not getting adequate nutrition and that maybe his tube feeding needed to be adjusted. She never offered to get a dietician involved . On 10/1/20, a review of R#807's clinical record was conducted and revealed the following: R#807 was admitted into the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. R#807 was admitted with a tracheotomy (a surgical procedure that inserts a tube into the airway to assist with breathing) and a feeding tube. A MDS assessment dated [DATE] documented R#807's cognition was not assessed, they had no speech and was rarely/never understood or understood others, and was totally dependent on staff for bed mobility, transfers, and ADLs (activities of daily living). It was documented R#807 had a feeding tube and weighed 141 pounds with no weight loss. An Admission Data Collection assessment dated [DATE] (locked and signed on 4/24/20) documented R#807 weighed 140.7 pounds on 4/24/20. A Nutritional RD (Registered Dietician) assessment dated [DATE] documented, .Nutrition Estimated Needs: Calories 1900-2250 kcal (kilocalories .64 kg (kilograms = 141 pounds) CBW (current body weight) .Protein 77-96 (grams) .Fluid 1900 minimum .Increased nutrient needs r/t (related to) increased need for calories and protein to aid in healing AEB (as evidenced by) wounds .Diet: NPO (nothing by mouth) .[MEDICATION NAME] 1.2 bolus 3 (milliliters) x 5 daily + 50mL FWF (free water) b/a (before/after) each bolus. Provides 1800 kcal, 83g pro (protein), 2210mL FW daily .Supplement: 30mL Protein liquid TID (three times a day) (300kcal, 45g pro) .Monitor labs weight, TF (tube feeding)/flush tolerance .Follow up PRN (as needed) . A Nutrition Data Collection assessment dated [DATE] documented R#807 weighed 140.7 pounds on 4/24/20. It was documented R#807 had a pressure ulcer, was totally dependent on staff for eating, and did received all nutrition enterally and nothing by mouth. It was documented there were no labs available for the past 90 days. Weights for R#807 were reviewed and revealed the following: On 4/24/20 at 11:21 AM, 3:03 PM, and 4:55 PM, R#807's weight was recorded as 140.7 pounds by three different staff members. On 4/24/20, R#807's weight was recorded as 132.6 pounds and on 5/5/20, it was recorded as 130.8 pounds. On 4/29/20 at 9:37 AM, RD T struck out two of the weights recorded on 4/24/20 and documented, Duplicate Documentation. On 5/5/20, Nurse E struck out the third documentation of 140.7 pounds on 4/24/20 and documented, Incorrect Documentation. There were no corresponding progress notes to explain why 140.7 pounds was considered to be an incorrect weight 11 days later. Physicians orders and the Enteral Orders - Medication Administration Record/Treatment Administration Record (MAR/TAR) for R#807 were reviewed for April 2020 and May 2020 and the following was revealed: R#807 had orders for Enteral Feed Order five times a day for nutritional support [MEDICATION NAME] 1.2 Bolus 300 ml and Enteral Feed Order five times a day for hydration 50 ml H2O (water) flush before and after bolus feed with start dates of 4/23/20. Enteral Orders MAR/TAR for April 2020 revealed R#807 did not receive the ordered enteral feeding or water flushes on 4/25/20 at 1:00 AM and 5:00 AM, 4/27/20 at 8:00 PM, 4/28/20 at 1:00 AM, 5:00 AM, 3:00 PM, and 8:00 PM, 4/29/20 at 1:00 AM and 5:00 AM, and 4/30/20 at 1:00 AM and 5:00 AM, which totaled 12 missed enteral bolus feedings. Enteral Orders MAR/TAR for May 2020 revealed R#807 did not receive the ordered enteral feeding or water flushes on 5/1/20 at 1:00 AM and 5:00 AM, 5/2/20 at 8:00 PM, 5/3/20 at 1:00 AM, 5:00 AM, and 8:00 PM, 5/4/20 at 1:00 AM and 5:00 AM, 5/10/20 at 8:00 PM and 5/11/20 at 1:00 AM and 5:00 AM, which totaled 11 missed enteral bolus feedings. According to the Enteral Orders MAR/TARs for April and May 2020, R#807 did not receive a total of 23 bolus tube feedings over a period of 18 days and did not receive any nutrition by mouth. Further review of R#807's clinical record revealed they had a Stage III pressure ulcer (full thickness tissue loss) on admission on 4/22/20. A Skin-Weekly Pressure Ulcer Record assessment dated [DATE] (signed and locked on 4/29/20) documented R#807 had a stage III pressure ulcer on their sacrococcygeal area that measured 6.1 centimeters (cm) in length by 6.1 cm in width by 0.03 cm in depth. The assessment documented, Area 85% necrotic (dead) tissue with 15% beefy red granulation tissue to base. Scant amount of drainage. Surrounding tissue observed with deep reddish/purple [DIAGNOSES REDACTED] fragile skin 2 cm around wound. Irregular would edges .RD to monitor for nutritional support to promote healing . A progress note by Nurse Practitioner (NP) F dated 5/8/20 documented, .Underneath his helmet on the top of his <sic>appears to be a deep tissue pressure injury (DTPI - Persistent non-blanchable deep red, maroon or purple discoloration due to damage of underlying soft tissue) .new deep tissue pressure injury to top of the head .Unstageable sacral wound-worsened per nursing . A Physicians Order for Protein Liquid three times a day 30 ml each time was written on 5/8/20, 14 days after the RD made their recommendation on 4/24/20. There were no additional notes written by the RD for the duration of R#807's admission after the discovery of a significant weight loss and the lack of administration of tube feeding formula and recommended protein supplement. On 10/1/20 at 3:44 PM, the former Director of Nursing (DON), current DON, and Administrator were interviewed. When queried about how residents with tube feedings are monitored in the facility, the former DON reported they come with tube feeding orders from the hospital and because the facility did not have an in-house RD, the hospital will send tube feeding formula with the resident. The RD would evaluate the resident and complete a dietary assessment, calculate nutrition, then intake would be monitored as well as weights, and the tube feeding orders would be adjusted if needed. When queried about when the RD would be contacted about a resident, the former DON reported, quarterly, if there was weight loss, or if a resident developed wounds. When queried about why R#807 did not receive a total of 23 bolus tube feedings during the duration of their stay, the former DON did not offer an explanation. The Administrator reported they were unaware. When queried about why R#807's admission weight was struck out as incorrect documentation upon the discovery of an 11-pound weight loss, the former DON did not know. On 10/1/20 at 4:20 PM, Nurse E (who was the unit manager at the time R#807 was a resident at the facility) was interviewed regarding the struck-out weight for R#807 on 5/5/20. Nurse E reported they did not know why it was struck out and labeled incorrect, but stated, It is possible the 140.7 was what the hospital documented as the weight. The Enteral Feeding MAR/TARs were reviewed with Nurse E. When queried about whether any further investigation was done after R#807 triggered for an 11-pound weight loss within less than a two-week timeframe, Nurse E stated, I see your concern.

This citation pertains to intake #MI 719. Based on observation, interview and record review, the facility failed to ensure proper training and demonstrations of competency by nursing staff involving four (R#s 801, 805, 806, and 808) of six sampled residents reviewed for nursing services, resulting in staff not performing consistent assessment, evaluation, and prompt response to resident needs per plan of care leading to hospitalization for further treatment and the increased likelihood of further clinical compromise. Findings include: On 10/16/19, review of a complaint reported to the State Agency on 9/30/19, included allegations that alleged the facility nursing staff were improperly managing a resident's peripherally inserted central catheter - PICC (a form of intravenous access that is a long, thin, flexible tube called a catheter inserted into one of the large veins of the arm, and extends into up in a large vein in your chest above the heart). An onsite investigation was conducted from 10/16/19 to 10/17/19 to investigate the complainant's allegations. Resident #808 On 10/17/19, review of the resident's closed clinical record revealed R#808 was admitted into the facility on [DATE] and had been discharged to the hospital on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R#808 had intact cognition, required extensive assistance of one person for transfers, ambulation, and bathing, and received [MEDICAL TREATMENT] services. Review of R#808's hospital documentation included: .admitted : 10/05/2019 00:39 (12:39 AM) .Diagnoses: [REDACTED].presented to the ER (emergency room ) from (facility name) for rehab with chief complaints of epistaxis (nosebleed) and a bloody bowel movement .On presentation patient had blood pressure of 90/61 .His labs are significant for hemoglobin of 6.3 .At presentation patient was give 2 units of PRBC (packed red blood cells) . Review of the interdisciplinary progress notes revealed there were no documented entries from any staff between 10/1/19 at 6:13 AM until 10/4/19 at 3:29 PM. From 10/4/19 at 3:29 AM, until an SBAR (Situation, Assessment, Background, Recommendation) Summary on 10/4/19 at 10:30 PM, there was no documentation in the resident's clinical record. Review of this SBAR Summary by Registered Nurse (RN D) on 10/4/19 at 10:30 PM documented, in part, .RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: I believe the patient may be bleeding on the inside, patients vitals is fine, blood pressure a little low, patient not on any blood thinners and patient stated hasn't been on blood thinners in past. Additional Nursing Notes as applicable: At beginning of shift the nurse (RN E) I was relieving told me patient nose had been bleeding during her shift because he keeps stuffing tissue into nose. From beginning of my shift until 10 pm patients <sic> nose has continued to bleed, gave patient ice pack for nose and cold towel. At around 10 pm patient sitting on bathroom toilet and patient is now bleeding from rectum .Primary Care Clinician Notified: DON (Name of Director of Nursing) 10/4/2019 at 10:00 pm . Further review of the available documentation revealed there was not documentation that the resident's attending physician had been notified of the change in status, or recommendations for treatment. (The DON was unavailable for interview during this survey.) Further review of the resident's progress notes included: An SBAR summary on 10/11/19 at 4:41 AM documented, .What I think is going on with the reisdent is: bleeding copious amounts of blood from nose right side only .Resident was seen in the hospital about 3-5 days ago at (name of local hospital) for a nose bleed has copious amounts of blood and small blood clots .Resident has been bleeding for 2hrs (hours) with compression of a cold towel and holding head back and pinching the nose aide in stopping bleeding Resident refused to attended <sic> [MEDICAL TREATMENT] due to the nose bleed cancelled [MEDICAL TREATMENT] and transported to hospital . A nursing progress note on 10/13/19 at 12:15 PM documented, .Patient started to vomit up blood and the son notified the nursing assistant . On 10/17/19 at 1:45 PM, a phone interview was conducted with RN E. When asked to recall R#808's events from 10/4/19, RN [NAME] reported, I think when I brought in his lunch, he had a towel up his nose. I got him an ice pack and cold compress and that did stop it (nose bleed). Told him not to put paper towels up his nose. When asked if the attending physician had been informed of the change in condition, RN [NAME] reported, No. When asked if there was any documentation such as progress note or change in status report completed for that time, RN [NAME] reported, I didn't do one. It probably should've been done. When asked if she could recall whether any concerns about the continued nose bleed was reported to the oncoming nurse at shift change, RN [NAME] reported, No. I don't recall. I hope I told the next shift. On 10/17/19 at 3:20 PM, an interview was conducted with the Assistant Director of Nursing (ADON, currently the acting DON) who reported she began working at the facility on 7/22/19. When asked to explain what a nurse's role was for monitoring for resident's change in status, such as an uncontrolled nose bleed, the ADON reported, Assess, notify physician, ask if they are their own responsible party to notify anyone, if can't speak, notify emergency contact. When asked if RN [NAME] should've initially notified the attending physician at lunch time of the resident's nose bleed, the ADON reported, That would be expected, especially if history of alcoholism, which thins the blood. Ultimately the physician is the one to give further instruction. When asked where this would be documented, the ADON reported, In the progress notes and or the SBAR. When asked if residents had a change in condition, and/or required hospitalization , was that reviewed by administration, the ADON reported, Yes, discussed in morning meeting of what they (residents) went out for and follow up in the hospital. The ADON was unable to recall if R#808 had been discussed or reviewed following the hospitalization for nose and rectal bleeding. When asked about the education/orientation provided to nurses in regards to the facility's processes for monitoring residents, the ADON reported, Go through orientation. They have a check list that's supposed to be validated before they hit the floor on their own. Just recently set up our classroom to do that. We'll get them educated. At that time, the ADON was informed that R#808 had no documentation of any nose bleed, or change in condition on 10/4/19, until the SBAR from RN D at 10:30 PM, or that the attending physician had been notified. The ADON confirmed the concerns regarding lack of adequate assessment, evaluation, and prompt response for the resident's change in condition. Resident #801: Review of the clinical record for R#801 was reviewed and revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] it was documented the resident scored 15 out of 15 on a brief interview for mental status exam, which indicated the resident was cognitively intact. Review of a nursing note for R#801 dated 10/8/19 at 12:42PM documented, Resident c/o (complains of) urine retention and states I have a UTI (urinary tract infection) and request to go to hospital. Stat U/A (urinalysis) ordered, awaiting collection and result. Review of a progress note dated 10/12/19 at 9:40AM documented, (R#801), left facility with his sister without nurse's permission or DON (Director of Nursing), DON (Name Redacted) notified. Patient called police before nurse's shift starting at 7 pm, police showed up about 8 pm and investigated situation, patient stated he called police because he hadn't urinated in 5 days and nursing facility is mistreating him because they wont send him out to the hospital. Police officer discussed with patient that he could not call public police for this type of matter, that it has to be an emergency and that they would not transport him to hospital and they left facility. 20 minutes later patient wheelchair himself into hallway and down hallway and says he's about to show his (expletive). Nurse did not see patient for the next 10 minutes, patients sister all of a sudden shows up and approaches me and stated patient wants to go to hospital because has not urinated in 5 days and is suffering from end stage [MEDICAL CONDITION] and <sic> an UTI. I told patients sister resident could not leave until I discussed with the DON and its approved because it has to be an emergency to send patient out, give me 15 minutes and I will call DON and we can discuss the situation. After about 15 minutes Im looking for the patient and his sister, the front door security guard told me they left a little while ago. I notified the DON of what happened and she told me to make a note of it. I called the patients sister and no answer, (Facility Name) knows no where abouts of (R#801), we just know he said he was going to the hospital . On 10/17/19 at 10:31AM, Registered Nurse (RN) 'D', who had authored the note documented above, was queried in regard to the situation. RN 'D' explained that the resident had called the police, and she asked the resident what was wrong. RN 'D' explained the resident had told them the problem and had called the police because the facility wouldn't let (R#801) go to the hospital. RN 'D' explained the police said that they couldn't be called for a non-urgent situation. Per RN 'D', the police had communicated the resident would have to set up a ride. RN 'D' explained that she had been in the hall passing medications, and the resident rolled to the hall and said he was going to show his (expletive). RN 'D' explained that fifteen minutes later the resident's sister approached her, and communicated that the resident had not used the bathroom in five days. RN 'D' then explained per the interview that R#801 had been on antibiotics, and had a UTI and end stage [MEDICAL CONDITION]. RN 'D' explained that she was not able to call and send a resident out, and explained that she could call a supervisor. RN 'D' explained that ten to fifteen minutes had gone by and they were gone. The nurse explained she had went to the front of the building and the security guard said that they had left. Per RN 'D', the security guard had not notified the facility that the resident had left. RN 'D' was queried as to the process that was followed if a resident wanted to go to the hospital, and explained that she had to call the DON and could not make any moves or call an ambulance without approval from the DON. Per RN 'D' it was a non-urgent matter. RN 'D then explained that she had called the DON and said the resident had left, and also explained that the aide had said that they had just emptied (R#801) urinal. On 10/17/19 at 3:28PM the facility's Assistant Director of Nursing (ADON) was queried in regard to hospital transfers. Per the ADON, the resident would be assessed, the doctor would be notified, if the resident was their own responsible party then staff would ask if they wanted anyone else notified, and if not then the emergency contact would be notified. Per the ADON, approval was not needed before getting an ambulance, and the DON further explained that if the family/resident wanted to go, then the resident would go. The ADON explained that the facility did try to do a full work-up (Labs, urinalysis) if the resident was stable, and if emergent if the resident is insistent on going then they would go out. The Director of Nursing (DON) would be notified that the resident was going out. The ADON was queried in regard to determination of emergent versus non-emergent transfers, and explained that it would be determined by assessment, and if the vital signs were stable a work-up would be attempted. Resident #805 On 10/16/19 at 9:50 AM, R#805 was observed seated in a wheelchair at bedside. At that time, a PICC line dressing dated 10/2 was observed secured over the PICC line area of the resident's right upper arm. When asked about the date on the dressing, R#805 reported, I was told should've been changed every 2 days, or at least every week. The last time I was here, they didn't change it. I don't want it to become dislodged or infected! R#805 further reported concern that she had not received her medication (via PICC line) yet. On 10/16/19 at 10:12 AM, Unit Manager G and Nurse Orientee F were asked to observe R# 805's PICC line dressing. At that time, both nurses confirmed the dressing was dated 10/2. Unit Manager G reported, Ok, let me get on this now. On 10/16/19 at 1:56 PM, Unit Manager G was asked about what type of clinical assessment and/or evaluation was done to the PICC line if the dressing remained unchanged since 10/2, and Unit Manager G reported, Even if there's not an order to change the dressing, it should be done as part of the assessment of the site. Unit Manager G was asked to provide documentation of the resident's actual time the medication was documented as given. Review of the clinical record revealed R#805 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. There was no completed MDS assessment available for review. There was no care plan initiated for the use of a PICC line. Review of the physician orders [REDACTED].>An order dated 10/8/19 which read, PICC line dressing and cap change every 7 day(s) for IV ABT (intravenous antibiotic). An order dated 10/7/19 which read, [MEDICATION NAME] HCl Solution use 2 gram intravenously (IV) in the morning for infection for 21 days at 9:00 AM. Review of the resident's Medication Administration Record [REDACTED]. There were no prn treatment administrations documented. On 10/16/19 at 12:34 PM, a phone interview was conducted with RN C. At that time, RN C confirmed she had worked on 10/9/19. When asked about R#805's PICC line treatment as documented as completed on 10/9/19, RN C reported, If something was wrong or needed to be changed, (it) would be documented. When informed of the observation earlier of the date of 10/2 and the conflicting documentation that the TAR documented the dressing had been changed on 10/9 with RN Cs initials, RN C reported, I don't have a clue. I don't remember that person (R#805). When asked if she had received any education or training regarding PICC line care and management, RN C reported, Not really. Our new educator is setting up new stuff. On 10/16/19 at 1:33 PM, review of the documentation provided by Unit Manager G revealed the resident was ordered to have the intravenous antibiotic medication ([MEDICATION NAME] HCl Solution) administered at 9:00 AM. Review of the actual dose administration time read, 10:16. At that time, Unit Manager G was asked about the late administration documentation and was unable to offer any further explanation. On 10/16/19 at 1:49 PM, Licensed Practical Nurse (LPN H) was asked about the late administration of the medication and reported, I know, when you have 30 residents, I want to make sure the IV's are started right away and so that's not when I gave it, but when I got time to check it off. I know I'm supposed to do (document) right after it's done. Again, it's very hard when you have 30 residents and are the only nurse. When asked if that was typical for the day shift, LPN H reported, Yes. It's difficult. I have 30 residents, and two CNA's (certified nursing assistants) so it's busy! Resident #806 On 10/16/19 at 9:45 AM, R#806 was observed lying in bed with a PICC line dressing dated 9/27/19 to the right upper arm. On 10/16/19 at 10:10 AM, Unit Manager G and Nurse Orientee F were asked to observe R#806's PICC line dressing. At that time, both nurses confirmed the dressing was dated 9/27/19. When asked how frequent R#806's dressing should be done, Unit Manager G reported, Supposed to be done weekly and as needed. The changes should be on the MAR (Medication Administration Record). Review of the clinical record revealed R#806 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], R#806 had moderately impaired cognition. There was no care plan initiated for the use of a PICC line. Review of the physician orders [REDACTED]. every day shift every Thu (Thursday) for drsg (dressing) change. Review of the resident's MAR's and TAR's since 9/27/19 revealed RN Is initials were documented as having provided treatment to R#805's PICC line on the TAR on 10/3/19 and 10/10/19. On 10/16/19 at 3:36 PM, a phone interview was conducted with RN I. At that time, RN I confirmed she recalled working with R#806. When asked about R#806's PICC line treatment that was documented as completed on 10/3/19 and 10/10/19, RN I reported, I would make sure the number one thing is risk for infection. When informed of the observation earlier of the dressing dated on 9/27/19 and the conflicting documentation that the TAR documented the dressing had been changed on 10/3 and 10/10 with RN Is initials, RN I reported, I do recall caring for him. When asked if she had received any education or training regarding PICC line care and management, RN I reported, I don't recall off top of my head. On 10/17/19 at 9:27 AM, an interview was conducted with the ADON. When asked about the documentation of any nurse training for PICC line care and management, the ADON provided documentation of a skills checklist for total [MEDICATION NAME] nutrition (TPN) for RN I and reported, I don't have any other staffing education for PICC. That's part of the upcoming plan. There was no further training documentation provided by the end of the survey. On 10/17/19 at 3:30 PM, an interview was conducted with the ADON. When asked if there was any monitoring or oversight of the nurses for residents with PICC lines, the ADON reported, Unit Managers round Monday through Friday. I'm going to start looking into this as I'm also infection control (nurse). They (Unit Managers) meet with staff and put clinical eyes on them (residents). When asked how the dressings had not be identified as having not been completed if the Unit Managers were monitoring the resident's with PICC lines, the ADON was unable to offer any further explanation. When asked about the documentation of any nurse training for PICC line care and management, the ADON was only able to provide education/competency training for RN I. There was no further education/training documentation provided by the end of the survey. Review of a Job Description document provided by the facility for the position of LVN/LPN (Licensed Vocational Nurse/ Licensed Practical Nurse) a revision date of 10/01/03 revealed, in part, the following: SUMMARY A licensed practical nurse .provides care and treatment in accordance with physician orders. Works in a team enviornment and within scope of practice as defined by State. The LPN / LVN works under the direction of physicians and registered nurses (RNs). ESSENTIAL DUTIES AND RESPONSIBILITIES include the following .Assesses patients by physical examination, including pertinent diagnostic testing to determine health status. Administers medications and treatments. Participates in the care planning process. Supervises LPNs and certified nursing assistants. Communicates with physicians regarding changes in resident's conditions, diagnostic test results, etc. Documents assessments and care in compliance with standards of care and company practice. Educates patients and their familites on health-related issues. Completes required forms and documents in accordance with compny policy and state and/or federal regulations. Review of a Job Description document provided by the facility for the position of Registered Nurse with a revision date of 10/01/03 revealed, in part, the following: SUMMARY Assesses and evaluates the health status of resident / patient and provides care and treatment in accordance with physician orders [REDACTED]. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following .Assesses patients by physical examination including pertinent diagnostic testing to determine health status. Administers medications and treatments. Participates in the care planning process and oversees implementation of the plan. Supervises LPNs and nursing assistants. Communicates with physicians regarding changes in conditions, diagnostic test results, etc. Documents assessments and care in compliance with standars of care and company policy. Educates patients and their families on health-related issues .

This citation pertains to Intake Number(s): MI 307. Based on observation, interview, and record review, the facility failed to prevent the development and worsening of pressure ulcers, conduct thorough wound assessments, ensure timely assessment by a wound practitioner, and consistently implement physician ordered interventions and treatment after the development of a deep tissue injury (DTI - a DTI is defined as intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) for one (R#901) of four residents reviewed for pressure ulcers, resulting in the development of a DTI and subsequent worsening to a dry eschar (eschar is defined as dead, devitalized tissue) covered unstageable pressure ulcer (An unstageable pressure ulcer is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) and further worsening to a painful, draining unstageable pressure ulcer that resulted in pain for the resident. Findings include: On 9/23/19 at 9:10 [NAME]M., R#901 was observed lying in bed on her right side. R#901 appeared thin, was non-verbal, and did not have any heel protectors or pillows floating the heels. On 9/23/19 at approximately 11:30 [NAME]M., Wound Care Nurse (Nurse C) was observed providing wound care to R#901. R#901 was observed yelling out, grimacing, and squeezing her eyes shut, as Nurse C attempted to remove a soiled, undated dressing that was stuck to R#901's heel. Nurse C sprayed the dressing with wound cleanser and it took multiple attempts to remove the dressing from R#901's left heel. The surrounding skin was peeling off and the dressing was soiled with dark, dried drainage. Nurse C stated, The last time I saw it (R#901's heel) it was dry eschar (dead tissue separating from the skin). Clearly it's wet and draining now. When asked to describe the drainage present on the dressing, Nurse F stated, It's blood and I can't say what kind of drainage. Nurse C reported that the floor nurses provided wound care during the weekends. Nurse C confirmed there was no date on the old dressing that indicated when the dressing was last changed. At that time, Nurse C reported she had to change the treatment since the wound was draining. When queried about who was notified of any changes in existing wounds, Nurse C stated, The doctor would be notified on the weekends. Nurse C reported that the physician should have been notified of the change in the pressure ulcer and the floor nurse should have changed the dressing per the as needed (PRN) order if it was soiled with drainage. Nurse C returned to R#901's room to complete the wound treatment. R#901 was observed to have a black area to her left heel with peeling skin surrounding the wound. R#901 appeared to be in pain when the wound was cleaned with normal saline and was flinching and yelling out. R#901 continued to yell out when Nurse C applied the foam heel protector and was grimacing and squeezing her eyes shut when Nurse C wrapped it with kerlix. On 9/23/19 at 1:00 P.M., R#901 was observed lying in bed without her heels floated or protected. A review of R#901's clinical record revealed the following: R#901 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#901 had severely impaired cognition, required extensive assistance to total dependency on staff for transfers, bed mobility, and all activities of daily living, and had one unstageable DTI that was not present on admission into the facility. R#901 received hospice services. physician's orders [REDACTED].#901's feet every night and report any changes to the Unit Manager. The Medication/Treatment Administration Records (MAR/TAR) for (MONTH) 2019 revealed this was last completed on 9/22/19, as evidenced by the nurse's signature. A physician's orders [REDACTED]. A review of the Certified Nursing Assistant (CNA) documentation revealed R#901 was given a shower on 9/22/19. Progress notes were reviewed and revealed a Risk Meeting Note dated 7/26/19 that documented, DON (Director of Nursing), ADON (Assistant Director of Nursing) .Wound Nurse all present for at risk meeting .She has SDTI (Suspected Deep Tissue Injury) to L heel, protective dressings to bilateral heels .Continue with current P[NAME] (Plan of Care) . There were no other progress notes documented regarding R#901's pressure ulcer to the left heel. On 9/23/19 at approximately 12:30 P.M., Nurse C was interviewed and queried about when R#901's DTI was first identified and what interventions were in place prior to the development of the DTI and what was implemented afterwards. Nurse C was also queried about where any description of pressure sores was documented in the clinical record. Nurse C stated, I'm behind in documenting. Nurse C provided documentation that included physician's orders [REDACTED].#901 as follows: physician's orders [REDACTED].>7/16/19 L heel: apply skin prep; cover with bordered foam Q2D/PRN 8/8/19 L heel: apply skin prep 8/21/19 Clean left heel with normal saline, apply [MEDICATION NAME], cover with 4X4 gauze and wrap with kerlix 9/23/19 Clean left heel with normal saline, apply calcium alginate (a topical wound dressing used for draining wounds), cover with 4X4 gauze and apply heel protector, wrap with kerlix A Skin-Head to Toe Skin Checks assessment dated [DATE] and completed with Nurse C documented, New pressure ulcer .left heel .suspected deep tissue injury .Tx (treatment) initiated and applied. Wound care will follow . There was no description or measurement of the wound documented. There were no other skin assessments that documented measurements or description of the DTI to R#901's left heel in the clinical record. Nurse C also provided a Visit Report from the facility's contracted wound care team dated 8/30/19 (a month and a half after the pressure ulcer to R#901's left heel was first mentioned in the clinical record) documented, .Wound #1 Left, Medial Heel is an Eschar covered Eschar .Initial wound encounter measurements are 1.5cm length x 1.8cm width .no drainage noted. Wound bed has Dry base eschar .periwound skin texture is normal . Wound Orders were documented as follows: .Pressure reduction mattress, frequently reposition, float heels, soft heel protector boots . A care plan for R#901 initiated on 1/9/19 and revised on 4/23/19 documented, I potential impairment to skin integrity r/t (related to) incontinence, [DIAGNOSES REDACTED]. There were no interventions that addressed the DTI to R#901's left heel or evidence that the care plan was updated after the development of the DTI. Nurse C and the DON were interviewed and the above documentation on 9/23/19. When queried about who assessed, monitored, measured, and described R#901's pressure ulcer (DTI), the DON reported R#901 received hospice services and they would assess the wound, as well as Nurse C would round with the wound care team. Nurse C reported R#901 was first seen by the contracted wound team on 8/30/19. When asked about the appearance of the DTI when it was first identified, Nurse C stated, How would you even measure a DTI? All available hospice documentation was reviewed and mentioned that R#901 had a pressure ulcer, but did not include any assessment of the wound or instructions to forgo assessment of the pressure ulcer. On 9/23/19 at 4:50 P.M., the DON was interviewed. When queried about the protocol when a change in a pressure ulcer is identified, the DON stated, If you don't see improvement for two weeks you notify the physician to change the treatment. The DON reported all dressings were dated when the treatment was completed. The DON reported a dressing should be changed PRN if it was visibly soiled. On 9/24/19 at 8:05 [NAME]M., R#901 was observed again without her heels floated. A facility policy titled, Skin Management (Revision Date: (MONTH) (YEAR)) documented, .If a new pressure ulcer is identified .the wound is assessed and documented on the Weekly Pressure Ulcer Record (UDA) .A physician's orders [REDACTED].The licensed nurse will record observations and initial .A 'Weekly Skin Check' will be completed in the resident's record using the Head to Toe Skin Check (UDA) .The nurse will initiate treatments, interventions, Care Plan, and the appropriate skin documentation record in a timely manner according to Practice Guidelines .

This citation pertains to Intake Number MI 163. Based on observation, interview, and record review, the facility failed to thoroughly assess one (R#801) of two residents reviewed for quality of care for a change in condition, resulting in the resident calling 911 after having difficulty breathing and requiring a 10 day hospital admission [MEDICAL CONDITION] and acute [MEDICAL CONDITION] requiring intubation. Findings include: A complaint was submitted to the State Agency the alleged R#801 .couldn't breath and asked the staff to call 911 for him. They told him no that they would take care of his issue; but he called for an ambulance himself. When he woke up he was in the hospital on a vent . On 9/9/19 at 10:32 [NAME]M., R#801 was observed lying in bed. R#801's lower legs and feet were very swollen and wrapped and R#801 reported he had [MEDICAL CONDITION]. R#801 reported that on 6/9/19 or 6/10/19, he was having trouble breathing and asked the staff to call 911. R#801 stated, They said not to call an ambulance and they would take care of it, but I called on my own. Apparently, when I was at the hospital I went unresponsive and I woke up on a ventilator. I had an infection. R#801's clinical record was reviewed and revealed the following: R#801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#801 was discharged to the hospital on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] and 8/8/19 documented R#801 had intact cognition. Progress notes were reviewed since R#801's admission date of [DATE]. A SBAR (Situation Background Assessment Recommendation - a tool used to communicate medical information to the health care team) dated 6/9/19 documented vital signs from 6/7/19 and .What I think is going on: Psychiatric Issues . There were no progress notes prior to 6/9/19 that documented any psychiatric issues or what was going on with R#801. A readmission progress note written on 6/19/19 did not have any explanation of R#801's hospital stay. Daily Nursing Skilled Charting notes for 6/8/19 and 6/9/19 (10:42 [NAME]M. locked at 4:53 P.M.) included vital signs from 6/7/19, documented clear lungs, normal chest, and no mood or behavioral concerns or changes. An SBAR Communication Form and Progress Note assessment dated [DATE] at 11:22 P.M. and locked on 6/10/19 at 12:03 [NAME]M. documented, .Instructions .Evaluate the resident .Check vital signs BP (blood pressure), pulse, and/or apical heart rate, temperature, respiratory rate, oximetry; Review Record . Those sections were checked off as completed. The section to have relevant information available when reporting (i.e. medical record, vital signs .) was not checked off as completed. The Situation section to document The change in condition, symptoms, or signs I am calling about is/are: documented, The resident complained of SOB (shortness of breath) and have exhibited signs of anxiety. Blood pressure taken, SPO2 taken, WNL (within normal limits). Recommend and taught that I could call the on call doctor. Resident refused and called 911 immediately after exiting the room .Other relevant information: .The resident was complaining of short of breath however the resident was speaking in full sentences, respiration rate was in normal range. SPO2 was in normal limits . In the Vital Signs section, the form instructed Be sure this is the most current set of VS (vital signs) that does with your evaluation of the resident. The vital signs documented in that section were from 6/7/19 (two days prior). In the section For [MEDICAL CONDITIONS], or weight loss, the last and current weight was left blank and the most recent O2 sat was from 6/7/19. The Background section documented R#801 did not have any mental status changes, and documented shortness of breath in the Respiratory section. The symptoms or signs were documented as complaint. It was documented by Nurse (Licensed Practical Nurse - LPN) K who completed the SBAR communication form that the resident appears to have Psychiatric Issues. I suggest of request transfer to hospital (previous documentation noted Nurse K offered to call the doctor and R#801 called 911). The SBAR form documented the physician was contacted on 6/9/19 at 10:58 P.M. (the SBAR form was completed at 11:22 P.M.). Hospital records for R#801 were reviewed and revealed the following: An ED (Emergency Department) Physician Note documented R#801 was seen on 6/9/19 at 11:57 P.M. The note documented, .history of hypertension, type 2 diabetes mellitus, stage 3 [MEDICAL CONDITION], obstructive sleep apnea, [MEDICAL CONDITION], and chronic diastolic (congestive) heart failure presents to the ED via ambulance secondary to difficulty in breathing .Patient states that he has been experiencing difficulty in breathing since yesterday. The patient has also had a dry cough. He reports that this evening, his symptoms became worse. Patient notes that he also developed chills and nausea this evening this <sic> well .En route, the patient was noted to be saturating at 86% on room air so the patient was placed on 4L (liters) of oxygen .Physical Examination: .Respiratory: .Expiratory wheezing with rhonchi (low-pitched rattling sound) heard in the right mid and lower lung fields .Reexamination/Reevaluation .Based on the patient's history and physical examination [REDACTED]. His temperature is 100.4 (degrees Fahrenheit), and pulse is 118. He is not typically on oxygen but his pulse ox had dropped down into the mid 80s. he was started on oxygen at 4 L, and he is saturating at 92%. Patient's coughing with some yellow sputum .He was started on (antibiotics) .Patient white blood count is elevated at 13.9 .When sleeping, the patient's pulse ox was dropping into the 84% range .Impression and Plan Diagnosis: [REDACTED]. The ED note documented R#801 was admitted to the Intensive Care Unit on 6/10/19 at 4:37 [NAME]M. A H&P (History and Physical) General Admission note dated 6/10/19 documented, .presented .secondary to difficulty in breathing. Oxygen saturation 86% on arrival. He was placed on [MEDICAL CONDITION] but failed and ultimately intubated for [MEDICAL CONDITION]. In ER patient was [MEDICAL CONDITION] (elevated heart rate) and hypoxic (low oxygen saturation) saturating at 86% on room air. He had a temperature of 102 (degrees) F .Labs were significant for WBC (white blood count) of 14 .CXR (Chest Xray) shows [MEDICAL CONDITION] congestion and bilateral effusions .Impression and Plan .Diagnosis .Acute ventilatory dependent [MEDICAL CONDITION] (AVDRF) secondary to [MEDICAL CONDITION] .Septic Shock .secondary to HCAP (Health Care Acquired Pneumonia), bacteremia, LE (lower extremity) wounds . On 9/10/19 at 3:25 P.M., the Assistant Director of Nursing (ADON) was interviewed. The ADON reported when a resident had a change in condition, the nurse was to complete an SBAR communication form, notify the physician, and get an order to send to the hospital. When queried about how the nurse would be expected to assess the resident, the ADON stated, Complete the SBAR, take vitals, document what the change is. R#801's clinical record was reviewed with the ADON and the ADON was queried about whether or not R#801 had been thoroughly assessed and why only the previous vital signs were documented. The ADON stated, You would get current vitals unless it was an absolute emergency then you could use the previous ones. On 9/10/19 at 4:07 P.M., Nurse K (the nurse who assessed R#801 on 6/9/19) was contacted via the telephone for an interview. Nurse K was unavailable for interview prior to the end of the survey. On 9/10/19 at approximately 5:00 P.M., the Director of Nursing (DON) was queried about whether or not Nurse K did a thorough assessment on 6/9/19 when R#801 complained of shortness of breath. The DON reported that the emergency department notes from the hospital documented R#801 did not desaturate until the evening (R#801 was transferred to the hospital at night). The DON further reported that Nurse K reported R#801's vital signs were within normal limits. However, there was nothing documented about what the vital signs actually were. The DON reported that the resident didn't want to wait for facility interventions and decided to call 911 himself. A facility policy titled, Changes in Resident Condition (revised (MONTH) (YEAR)) documented, .The SBAR Communication Form and the Progress Note are used to .Assess and document changes in condition in an efficient and effective manner .Provide assessment information to the physician .Provide clear comprehensive documentation .

This citation refers to Intake # 6 Based on observation, interview and record review, the facility failed to ensure a resident's care plan was followed for one (R#702) of three residents reviewed for falls, resulting in R#702 falling out of bed and sustaining a closed head injury, toe fracture, an emergency room visit and pain. Findings include: On 7/8/19 at 4:46 PM, during a phone conversation with the complainant, it was revealed that R#702 had fallen off the bed when one staff member was providing care. The complainant indicated R#702 was supposed to have two people when care was provided. On 7/9/19 at 9:15 AM, R#702 was observed lying in bed. A computer tablet was strapped to an over the bed television with an arm able to tilt and swivel. R#702 was able to comunicate by moving his right arm enough to tap, with one finger, a keyboard on the tablet to answer questions asked. R#702 was asked about his fall. R#702 indicated it was during the night and a Certified Nursing Assistant (CNA) was changing him. There were supposed to be two CNA's, but usually it was one CNA that would provide care. The CNA was behind him and was pushing him onto his side and he fell off the bed. R#702 indicated he had banged his head on his left side, causing pain. A record review was conducted and revealed R#702 was admitted into the facility on [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. According to the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], R#702 scored 15/15 on the Brief Interview of Mental Status exam indicated intact cognition. The MDS also indicated R#702 required the extensive assistance of two staff members for all Activities of Daily Living (ADL's) including bed mobility. Review of R#702's care plan revision dated 4/9/19, revealed, in part, I have an ADL self-care performance deficit r/t (related to) immobility/[MEDICAL CONDITION] secondary to hx (history) [MEDICAL CONDITION](Stroke) . with interventions that included, BED MOBILITY I am totally dependent on 2 staff for repositioning and turning in bed revised 3/4/18. A further review of R#702's record revealed a progress note dated 6/5/19 at 2:44 AM that read in part, .RN (Registered Nurse) Assessment/LPN (Licensed Practical Nurse) Appearance of resident - What I think is going on with the resident is: fall Additional Nursing Notes as applicable: resident needs to be a two person assist with all ADL's . Review of a facility provided Incident and Accident report dated 6/5/19 at 4:06 AM read, in part, Per (CNA) Resident was getting changed and was laying on his side when he fell out of bed hitting the right side of his head resulting in an abrasion. Review of R#702's clinical record revealed hospital discharge instructions paperwork dated 6/5/19 that included Patient Education Materials: HEAD INJURY (ADULT) with a [DIAGNOSES REDACTED]. The hospital paperwork also included a CT (computed tomography) Brain without Contrast that revealed, No acute [MEDICAL CONDITION] or mass effect. No other hospital paperwork was noted in R#702's chart. On 7/9/19 at 12:35 PM, a phone interview was conducted with CNA 'G'. CNA 'G' was asked about R#702's fall. CNA 'G' stated, I still don't know how he fell . I was changing him and was holding him to put cream on his bottom. He just fell off the bed. CNA 'G' was asked how many people should have been providing care to R#702. CNA 'G' stated, There should have been two people. CNA 'G' was asked why she was the only CNA providing care. CNA 'G' stated, When I first started, I always got someone to help me. Then I noticed the other CNA's were doing it by themselves. Ever since last summer I felt confident I could change him by myself, so I would just do it by myself. It is hard to get help, it's much easier to just do it. On 7/9/19 at 1:05 PM, R#702 was observed lying in bed. R#702 was asked about his pain from the fall on 6/5/19. R#702 indicated that his left foot still hurt, and was swollen. On 7/9/19 at 1:30 PM, the Director of Nursing (DON) was asked for any addition X-rays or tests performed at the hospital on [DATE] for R#702. On 7/9/19 at approximately 2:00 PM, the DON provided additional tests performed at the hospital that included a CT of the cervical spine, chest X-ray and six X-rays of R#702's left foot. The X-rays of R#702's left foot revealed, Findings concerning for a nondisplaced fracture of distal 1st metatarsal (end of the big toe). On 7/9/19 at 2:45 PM, the DON was interviewed and queried about R#702's fall on 6/5/19. The DON stated, CNA 'G' was written up and in-serviced on following the resident's care plan. She doesn't work here anymore.' The DON was asked how many staff should have been providing care to R#702. The DON stated, Two. Review of a facility policy titled, Routing Resident Care revised (MONTH) 2011 read in part, .All direct care personnel use gait belts during ambulation and transfers for residents requiring contact guard, contact assist, or greater care in accordance with the resident's Plan of Care . The facility was asked to provide any additional information, none was provided by the end of the survey.

This citation pertains to Intake #s MI 948, MI 966, and MI 084. Based on interview and record review, the facility failed to identify a resident elopement following an exit door alarming from contact with a wander guard device for one (#701) of six residents reviewed for accidents, resulting in an Immediate Jeopardy (IJ) on Thursday 3/18/19 at 10:15 PM when R#701 exited the facility through an alarmed door in his wheelchair, wheeled himself to the street, was hit and injured during events put in motion from a passing vehicle. This deficient practice caused serious harm, and injury as the resident is currently hospitalized for [REDACTED]. on a ventilator (a machine to deliver breaths to a person who is physically unable to breathe, or breathing insufficiently). Due to this deficient practice, 23 other identified elopement risk residents are at risk for serious harm, injury, and/or death. Findings include: The IJ was started on 3/14/19 and identified on 3/18/19. The Administrator was notified of the Immediate Jeopardy on 3/18/19 at 2:06 PM. The Administrator was asked for a plan to remove the immediacy. The IJ was removed on 3/18/19 based on the provider's implementation of an acceptable plan of removal as verified onsite by the surveyor on 3/18/19. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with the likelihood for harm that is not immediate jeopardy. Review of multiple complaint allegations reported to the State Agency identified the following concerns: On 3/14/18 at 10:30 pm .male residents alarm had been going off for about 30 minutes and the resident was seen outside by the side of the road and another resident who was smoking a cigarette told the staff the guy is by the road in his wheelchair .Staff ran out to get the resident and CNA (Certified Nursing Assistant) and the resident were hit by a car .Hit and run. (R#701) is wheelchair bound .On 3/14/19, (R#701) was able to get outside (name of facility) in his wheelchair. Around 10:15 PM, (R#701) was able to get down by the road and was struck by a vehicle. It should be noted that it was raining and dark outside. (R#701) is in critical condition at (name of local hospital). There are concerns regarding improper supervision of (R#701). There are concerns regarding how (R#701) was able to get outside the facility without staff being notified. There are also concerns because there are clear instructions about how to disarm the alarm on the facility door and there are no cameras at the facility or on the property. The (name of local Sheriff department) is investigating the hit and run . Review of R#701's clinical record revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R#701 had severely impaired cognition and required limited assistance of one person for ambulation in corridor and locomotion on/off the unit. Review of R#701's elopement risk assessments documented he was At Risk since admission. Physician orders [REDACTED].<sic>. Nurse to check and function every shift. Review of R#701's elopement risk care plan initiated 1/28/19 documented: I am at risk for elopement and wandering r/t (related to) my impaired cognition r/t my dx (diagnosis) of dementia. I present as alert but with noted forgetfulness and confusion at times. I am able to propel myself in the wheelchair around the facility. I was recently admitted and have verbalized wanting to go home .I remain at risk for elopement based on my cognitive impairments and poor safety awareness .continue to monitor me. My wander guard has been placed on my wheelchair because I became combative and swing at the unit coordinator attempted to place it on my wrist. Goal - I will not leave the facility unattended and I will remain safe through the review date. Interventions/Tasks - Check placement and function of safety monitoring device every shift .Observe my location at regular and frequent intervals . Review of the hospital documentation dated 3/15/19 documented, in part: emergency room Addendum Note .presented to (name of local hospital) following a pedestrian versus auto accident .The patient was a nursing home resident who was found to be outside in the street. Staff members went to get the patient out of the street at that time as they were bringing him back in and out of the street the patient fell out of the wheelchair. Car went by at that time and hit the wheelchair and the wheelchair was pushed into the patient. The car estimated going on approximately 45 miles an hour. Upon arrival to the ER, the patient complaining of right-sided chest pain with some mild shortness of breath .Initial chest x-ray showed a right [MEDICAL CONDITION] contusion as well as a right clavicle fracture .CT chest, abdomen, and pelvis showed extensive [MEDICAL CONDITION] contusion on the right side with multiple rib fractures as well on the right side .decision was made to intubate the patient based on [MEDICAL CONDITION] contusion and increasing [MEDICAL CONDITION], increasing work with breathing. Decision was also made to place a chest tube on the right side secondary to rib fractures and small hemopneumothorax .To admitted to ICU under the care of trauma service and (name of physician) . On 3/18/19 at 12:01 PM, a phone interview was completed with a complainant who reported, I was there visiting a friend. I believe I got to the facility at 8:15 PM .I was getting ready to leave around 10 (PM) so I went in search of someone around 9:45 and another resident rolled in the door and said 'I'm trying to find someone there's someone on the side of the road.' He's yelling up and down the hall .I used the bathroom in the front and left my phone in the room and went back to get it, there's another (nurse) aide screaming that they got hit and she's seen they got hit by a car .Alarms sounding. I don't know what the hell they were. Sounded for about 10 to 15 minutes and then stopped .When I left the police were there .I know his son was there earlier in the day pushing and laughing in his wheelchair .His son told my friend he's likely not going to make it. On 3/18/19 at 12:10 PM, the Administrator and Director of Nursing (DON) were asked about R#701's elopement on 3/14/19. The DON reported, The wander guard bracelet was on his wheelchair. The Administrator reported, The alarm sounded but was immediately silenced. When asked what alarm sounded, such as the wander guard alarm, or door alarm, the Administrator reported, We don't know which one. When asked if the alarm system was able to provide a report to show times that alarms were activated and silenced, as well as any cameras to verify who had activated and/or silenced the alarm, the Administrator reported, No. It's an internal alarm system. There is no video surveillance in the facility. The Administrator and DON further reported, This past Thursday (3/14/19) evening staff were working, heard an alarm but silenced quickly. Staff continued working approximately 10 minutes later (name of another resident) comes down hall and alerts two nurses there's a gentleman outside. They immediately sent RCS's (Resident Care Specialists - Certified Nurse Aides) to respond. They retrieved him on the grass. Visualized him toward the road. All three (CNAs) tried to move him and he started tucking legs under the chair, so attempted to lift him to get further into grass, saw car slow down and speed up. They said they had lights on their phone (dark outside). Car clipped corner of wheelchair and CNA B who protected the resident and they both ended up on ground with resident on top of her .Registered Nurse (RN D) assessed (R#701) as well as CNA B and directed staff not to move either. 911 was called . On 3/18/19 at 3:34 PM, a phone interview was conducted with R#701's legal representative (LR). At that time, the LR reported, He's in critical condition .He had a tether (wander guard bracelet) on. They don't have security guards. No one at the front .They (hospital) don't think he's gonna make it. There was no one there to police (supervise) them. He's in ICU (intensive care unit), it was a hit and run .I talked to Certified Nursing Assistant (CNA B) at the hospital and she said they (other residents) were out there smoking cigarettes and the alarm goes off and no attempts to check. I left there several nights ago and no answer (response from staff to enter door alarm to exit through the main entrance). You can just push (the door) after 15 seconds can go out. If you go out door and press white button it dis-alarms .He (R#701) supposedly has a tether on that wheelchair and supposed to be above (seat) to alarm. (CNA B) told me the smokers come and said '(R#701) went out the front door you may want to grab him.' There was traffic on the other side. He has nine broken ribs, collapsed lung, major contusion on his lung, he lost a lot of blood, and on vent. On 3/19/19 at 12:02 PM, a phone interview was conducted with CNA B. When asked to recall the events from 3/14/19, CNA B reported, He (R#701) was on gravel on same side as facility. Alarms did not sound. He (another resident assessed to be independent with going on leave of absence) said he turned the alarm off. Said, 'There's a guy in a jean jacket going down the street.' .There's no button to turn off the alarm. There's a button you have to push when in the middle of the front doors .When he came in and told me, me and two other aides went running out. It's pitch black out there. When we came (upon R#701) there was already people stopping. (R#701) became combative and when pushing feet down, he's stopping (from moving the wheelchair) .He's on side of street, he's refusing to come back. My colleagues they try to encourage and this lady (passerby from a vehicle that had pulled over) pushed him into the street (in attempt to get the resident's feet out from under the wheelchair). Told her we're gonna get hit. He puts his feet down and becomes combative so she left. I told aide hold chair and try to push backwards, he slides to ground. He's in the street. We're not supposed to move residents when fall, he slid not fall, so we picked him up by his waist pant and underarms and moved him to the gravel (side of the road). We saw the car. I got hit by the car, I wasn't gonna let him get hit. He was in front of the wheelchair, I was behind the wheelchair. He's on safe ground and the car hits me. I landed into the wheelchair .the wheelchair must've impacted him when it flew. He didn't get hit by the car, the car hit me and the chair. I was on the ground with my legs open, my hip is messed up. He was on top of me. He was having trouble breathing . On 3/19/19 at 1:27 PM, a phone interview was conducted with Licensed Practical Nurse (LPN A) who reported she was the nurse assigned to R#701 on 3/14/19 at the time of the incident. When asked to recall the events from that evening, LPN A reported, .(R#701) always sat up there in the front .I came into work and checked out everybody and he was up front. I was in a room with two aides with a patient cleaning his peg site and while in the room I walked to the treatment cart and heard an alarm go off. After two to three seconds it was off. I went into the room and finished up and the aides came out. By the time I was done, (name of another resident) said 'Do you know you have a resident in a jean jacket outside?' .The girls ran outside and he was almost to the street. He was kicking them, I called 911 and when back to door both were on the ground. Three aides total outside said he was trying to cross (the street) .How he (driver of car) hit the wheelchair and they flew too .Not sure where car came from, cars were stopped on both sides. A car came around three cars, it slowed down, then pressed gas and it made car turn a little so was in middle of road . When asked why the alarm had not been responded to upon hearing the activated alarm, LPN A stated, When it went off, I thought someone turned it off. Now they (Administration) say even if off, we have to go check. When asked if she could identify whether it was the door alarm, or the wander guard alarm, LPN A reported she was unable to recall. Review of the facility's investigation included, .Staff responded immediately to the report that a resident was outside of the facility and immediately secured the resident and attempted to bring him back into the facility. Resident was assessed by a licensed nurse, Police, EMS, family and physician were notified and resident was taken to the hospital for further evaluation .(R#701) was noted to be outside of the facility on 3/14/19, another resident alerted staff of this situation. Another resident was noted to have stopped the door alarm from sounding to allow himself to go outside of the main entrance door of the building . Review of the facility's Elopement Management policy dated (MONTH) (YEAR) documented: .While alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision .The facility must intiate a response to the event . The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 3/18/19: The facility implemented the following Plan immediately on 3/14/19 in response to the report that a resident was outside the facility on 3/14/19: -Staff Immediately responded to the report that a resident was outside the facility -Staff secured and attempted to return resident to facility -Resident was assessed by Nurse & EMS - Police, Family, and Physician notified -Resident Transported to Hospital for further evaluation -Facility completed full house head count - All accounted for -Door and wanderguard alarms were tested for proper functioning - No issues identified -24/7 Supervision was immediately placed on the facility main entrance door -Immediate elopement education for all staff was initiated -Door alarm codes were changed full facility -All residents in facility were reassessed for elopement risk and Care Plans were reviewed and updated as appropriate -Completed elopement tests on each exit door for staff response on 3/14/19-3/15/19 -Further Evaluation of all exit doors on 3/15/19, added additional monitor of care hallways for security monitoring

This citation refers to Intake Number(s): MI 698 and MI 847. This citation has two deficient practices. Deficient Practice #1 Based on interview and record review, the facility failed to report multiple instances and allegations of neglect to the administrator (who functions as the facility's abuse coordinator) and/or the State Agency within the required time frames for five (#293, #64, #17, #443, and #57) of twelve residents reviewed for abuse and neglect, from a total sample of 30, resulting in an immediate jeopardy (IJ) when the abuse coordinator and state agency were not notified of Resident #443 being found by a staff member naked on the floor, shivering and covered in dried feces; the State Agency not being notified of Residents #64, #17, and #57 not receiving a brief change for seven hours; and the abuse coordinator and State Agency not being notified of an allegation of Resident #293 being left in a wheelchair for several hours yelling to go to bed. This resulted in the potential for unidentified and continued neglect. This deficient practice places all residents who reside in the facility at risk for serious harm, injury and/or death due to the potential for continued allegations of abuse and neglect to go unreported and uninvestigated. Findings include: The IJ started on 1/6/18. The IJ was identified on 3/21/18 at 4:46 P.M. The Administrator was notified of the Immediate Jeopardy on 3/21/18 at 6:40 P.M. A plan to remove the immediacy was requested. The immediacy was removed on 3/22/18 at approximately 5:00 P.M. based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the Facility's deficient practice was not corrected and remained at a pattern that is not immediate jeopardy. Resident #293 On 3/19/18 at 4:00 P.M., a complaint reported to the State Agency regarding Resident #293 was reviewed and documented, .(On) 01/03/18 - Wednesday .Mom had lunch in the dining room. She was wheeled back to her room and left facing the wall in her wheelchair with the wheels locked .She said she hit her call button and waited over 2 hours for someone to come into her room and nobody came. Mom started yelling for help because she had to use the bathroom. She hit her call button again and nobody came to help her. The supper trays were delivered and mom asked the lady delivering food to help her. The lady said she was too busy to help her and then left the room .A nurse came into mom's room and mom asked again to use the bathroom. The nurse said she couldn't move mom by herself and she would be right back with another nurse and the two could take her to the bathroom. The nurse didn't come back. 8:00 p.m. - Mom started yelling that she was going to call 9-1-1 to get some help and the nurses finally came to help her. Mom said that her right foot had gone numb from having it down for 8 hours . The complaint further documented that on 1/8/18, Resident #293 reported that Certified Nursing Assistant (CNA) N took her to the bathroom and left her naked from the waist down. When asked if she was going to put her pants back on, it was reported CNA N stated, 'I choose not to' and left Resident #293 naked from the waist down for 2 hours. The complaint documented CNA N continued to attempt to provide care to Resident #293 the following day after Resident #293 allegedly filed a written complaint. Incident and Accident (I&As) reports, grievance and/or concern forms, and investigations for Resident #293 were requested from the Administrator on 3/20/18 at 11:30 A.M. On 3/20/18 at 12:41 P.M., the Administrator reported there were no I&As or investigations for Resident #293. A grievance log was provided, but did not include any of the above concerns for Resident #293. On 3/20/18 at 4:39 P.M., an interview was conducted with the Director of Nursing (DON) regarding the facility's grievance process. The DON stated, When a concern is brought up, the grievance process is automatically started so we have a tracking. We use an ambassador process where someone is assigned daily to meet with residents. An orange concern form is automatically written up when there is a concern and we follow through within 72 hours if we do not fix it right away. When asked what would be done if someone reported they were left in a wheelchair for hours, the DON stated, I would find out who was assigned and bring it to (the Administrator's) attention immediately. The DON was further interviewed and asked if she ever received any reported complaints regarding Resident #293. The DON reported that Resident #293's family member called and expressed concerns to her. When queried about the specific concerns expressed, the DON stated, There were two that I can remember. One was the day after she was admitted she had questions about pain medication .I have a soft file on her .The second one was she called to tell me she talked to her mother on the phone and (Resident #293) reported that she had to scream out in the hallway and was not put into bed until 8:00 P.M. I was here. I stayed late. I remember walking by her room several times and I saw her in bed at 7 PM. Nurses work 12 hours and I was helping the nurse with an admission and I happened to see her around 7 P.M. She wasn't in her chair at 7 P.M. When queried about any further investigation into the above allegation regarding having to scream into the hallway and not being put into bed until 8:00 P.M., the DON indicated that she had a soft file. On 3/20/18 at 5:00 P.M., the DON provided the soft file regarding Resident #293 and it revealed the following: A typed and signed document by the DON dated 1/4/18 documented, The Director of Nursing was called by (family member of Resident #293) to inform me that her mother called her to inform her that she had to scream to get any help last night to get into bed .stated that her mother informed her that she had to wait until after 8 P.M. to get put to bed last night and was up in her w/c (wheelchair) all that time . The soft file documented that the DON saw Resident #293 in bed at 7 P.M. and had to walk by Resident #293's room several times during the time frame that she said she was calling for help. The DON was asked if the allegation made by Resident #293's family member was reported to the Administrator. The DON reported that the Administrator knew about it. When queried about any further investigation that was done to look into the alleged concern, the DON reported just what is written. On 3/21/18 at 11:30 AM, the Administrator, who functioned as the abuse coordinator for the facility, was interviewed regarding the facility's grievance process. The Administrator stated, Concern forms are completed. Residents and staff are educated to report concerns. If it can be resolved immediately, we do. Abuse issues do not go on concern forms. When queried about the facility's process when abuse or neglect allegations were made, the Administrator stated, I get notified immediately. I have to immediately figure out what is going on. I only have 2 hours to report so I will come into the building if I need to or have a manager or charge nurse start investigation and start documenting information. The Administrator was asked what the process would be if a family member or resident alleged being left in a wheelchair for several hours and had to scream into the hallway for help. The Administrator stated, That would be considered potential neglect. When queried about any allegations made regarding Resident #293, the Administrator stated, The only thing I knew was an issue with pain medication. I was never informed of anything regarding care. I know the (family member) would call the facility with issues. The soft file provided by the DON was reviewed with the Administrator at that time. The Administrator was asked if she was informed of the allegation documented regarding Resident #293 being left in a wheelchair and screaming to go to bed. The Administrator stated, I wouldn't expect her to report it, if she was next door doing a new admission. She is the Director of Nursing, so if she said she was next door, then what else would we look into. When queried about whether or not being the DON made her exempt from investigation, the Administrator stated, No. I guess she should have told me. The Administrator did not provide any additional information regarding the above allegation. On 3/21/18 at 9:08 A.M., Resident #293's clinical record was reviewed and documented the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented Resident #293 had intact cognition and required extensive assistance from two staff members for bed mobility, transfers, and toilet use. Resident #s 17, 57, 64, and #443 On 3/21/18 at 12:00 P.M. a personnel file for CNA N (the CNA who was alleged to leave Resident #293 on the toilet naked for two hours) was reviewed and revealed the following: A Disciplinary Action Record for CNA N documented an Initial Written Warning that noted the date of work rule violation as 1/6/18. The written warning documented, On Saturday 1/6/18, I (Nurse G) checked on my patients on 200 Hall at 12:00 (P.M.) Patients in (three different room numbers) all had briefs on timed and dated 1/6 05:00 (A.M.) and had not been changed at 12:00 (P.M.). Additionally, patient in (room number) was lying in bed undressed and he is normally up for breakfast. CNA N refused to sign the document. The document was signed by Nurse G (undated) and another staff member. The DON signed the document on 1/10/18 (four days after the documented incident). A second Disciplinary Action Record for CNA N that documented an Initial Written Warning on 1/10/18 and a Final Written Warning that noted, Resident in (room number) was observed by incoming RCS (Resident Care Specialist - CNA W) at 11 P.M. on the floor of his room, completely naked with dried up feces on his legs, buttocks, and torso. Resident was shivering. Door to the room was completely closed. RCS that was on duty from 3P-11PM had left assignment early and punched out at 10:53 PM not waiting for relief to come in leaving hall and her assigned patients unattended for. Assigned RCS .was CNA N. CNA N refused to sign the document and it was signed by a witness on 1/11/18, a supervisor on 1/11/18, and the DON on 1/11/18. On 3/21/18 at 12:23 P M., an attempt to contact CNA W via the telephone was made. The number was a non working number. On 3/21/18 at 12:36 P.M. the above mentioned disciplinary action records were reviewed with the DON. The DON was asked if there were investigations into either of the events documented on the forms. The DON reported she would have to look to see if she had a soft file. On 3/21/18 at 1:00 P.M. the above mentioned disciplinary action records were reviewed with the Administrator. The Administrator was asked if there were investigations into either of the documented events. The Administrator stated, That doesn't sound familiar. I will check with (the DON). On 3/21/18 at 1:21 P.M., a second attempt was made to contact CNA W via the telephone using an alternate number provided by the facility. The number provided was a wrong number. On 3/21/18 at 3:20 P.M., the Administrator provided a file and stated it contained investigations into the incidents documented on the disciplinary forms found in CNA N's file. The file contained a typed summary regarding CNA N dated 1/9/18 that documented, The Director of Nursing received a written discipline written by Nurse G regarding care issues for residents on 200 Hall on (MONTH) 9, (YEAR) for the day of (MONTH) 6, (YEAR). I reviewed these with Nurse G and reported to the Administrator, then reviewed with HR (Human Resources) to get direction . The file also contained shower sheets which the DON reported were for the residents documented on the disciplinary form. The shower sheets were dated 1/9/18 (three days after the documented incident) and were for Resident #17, Resident #57, and Resident #64. On 3/21/18 at 3:39 PM an interview was conducted with the Administrator and the DON. The statement documented on the disciplinary action form dated 1/6/18 was reviewed. When asked who completed the disciplinary form and if the incident documented on the form (multiple residents observed with briefs unchanged for seven hours and a resident in bed and not dressed) was reported to anyone (DON or Administrator), the DON stated, That's (Nurse G). He's a charge nurse. The DON further stated, (Nurse G) filled out the form and slid it under my door. When queried about whether or not Nurse G provided the disciplinary form to the DON on 1/6/18, the DON stated, I didn't get it on 1/6/18 (a Saturday). The DON and the Administrator reported that they did not receive a phone call from Nurse G regarding the documented incident. The DON was asked when she became aware of the incident and stated, Maybe the morning of the 9th (January). When queried about the process for completing disciplinary action records, the DON stated, The nurses write information on there and then I have to get clearance from HR. When queried about the three day delay between the time Nurse G discovered and documented multiple residents being left in unchanged briefs and the time the DON became aware of the incident, the DON stated, I did speak with (Nurse G) about that and he understands he didn't do the appropriate reporting. The Administrator was asked if the above incident was brought to her attention and stated, The nurse (Nurse G) never indicated that the residents' briefs were actually soiled. The Administrator reported it was not reported to the State Agency and acknowledged that three days lapsed between the time the DON received the report and the time of the actual documented incident. The Administrator reported that all allegations of abuse and neglect were to be reported to her immediately. The second Disciplinary Action Record that documented a resident was found naked with dried feces, on the floor behind a closed door shivering was discussed at that time with the Administrator and DON. The DON reported that Nurse X brought the disciplinary form to her. The DON stated, When I got the report I talked to CNA N (the day after the documented incident) and she said she left seven minutes early. When asked who the resident identified on the form was, the DON did not know. The Administrator was asked if the above incident was reported to her. The Administrator stated, I don't remember this particular situation. When queried about whether or not it was reported to the State Agency, the Administrator stated, No. The DON stated, They went down and gave him a shower. If that was indeed how he looked at the time, I would've called. They cleaned him up and got him in bed. The Administrator was asked about what the facility was required to report to the State Agency. The Administrator stated, Any allegation of abuse or neglect. When asked if the two incidents documented on disciplinary action reports would be classified as allegations of abuse or neglect, the Administrator stated, Yes. The Administrator was asked who the resident was in the room number documented on the second disciplinary action record and reported she would have to find out. The Administrator stated, This wasn't handled appropriately. It is what it is. There is a policy and process that must be followed. The resident in the second disciplinary action record was later identified by the Administrator as Resident #443. On 3/21/18 at 4:00 P.M., Resident #17's clinical record was reviewed and revealed Resident #17 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented Resident #17 had severely impaired cognition and required extensive assistance from one to two staff members for all activities of daily living (ADLs), including toilet use. The MDS documented that Resident #17 did not have any behaviors that included rejection of care. On 3/21/18 at 4:05 P.M., Resident #57's clinical record was reviewed and revealed Resident #57 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented Resident #57 had severely impaired cognition and required extensive assistance from two staff members for all ADLs except eating. The MDS documented that Resident #57 did not have any behaviors that included rejection of care. On 3/21/18 at 4:10 P.M., Resident #64's clinical record was reviewed and revealed Resident #64 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented Resident #64 had severely impaired cognition, required extensive to total assistance from two staff members for all ADLs, and had a [MEDICAL CONDITION] (a tube inserted into a surgical opening in the neck to provide an airway and to remove secretions from the lungs) and a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube surgically inserted into the stomach to provide nutrition). The MDS documented that Resident #64 did not have any behaviors that included rejection of care. On 3/21/18 at 4:30 P.M., Resident #443's clinical record was reviewed and revealed Resident #443 was admitted into the facility on [DATE] and was discharged on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented Resident #443 had severely impaired cognition, required extensive assistance from one to two staff members for all activities of daily living except eating, and did not have any behaviors that included rejection of care. It was documented in the MDS that Resident #443 did have some wandering behaviors, but they did not put the resident or other residents at risk. On 3/22/18 at 11:20 A.M., an interview with Nurse G was attempted via telephone. The call would not go through. Nurse G was unable to be interviewed prior to the end of the survey. The facility's policy titled, Abuse & Neglect Prohibition dated (MONTH) (YEAR) was reviewed on 3/21/18 at 8:30 A.M. and it documented the following: .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator . .The facility will make referrals to the appropriate state agencies as necessary, to ensure the protection of the resident or resident's property . .STATE REPORTING OBLIGATIONS: The facility will report all allegations and substantiated occurrences of .neglect .to the administrator, State Survey Agency, and law enforcement officials .in accordance with Federal and State law through established procedures. Timeline for reporting is as follows: If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after being notified of the allegation; or If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after being notified of the allegation . The Facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 3/22/18: Element #1 Resident #293 and #443 no longer reside in the facility. Resident #64, 17, and 57 were assessed and are receiving care as needed. Resident #64, 17, and 57 care plans were reviewed, revised, and deemed appropriate. An allegation of neglect was written on a Disciplinary Action Record and not immediately reported to the Administrator per policy. The Administrator was unable to complete a thorough investigation of the alleged instances of neglect since they were not reported. Element #2 All interviewable residents were asked by a member of the Interdisciplinary Team if their care needs are being met. Any concerns noted were addressed by the appropriate department and no new allegations were reported. Any resident who could not be interviewed was visually assessed by the Director of Nursing and/or the District Director of Clinical Services for evidence that care needs are being met and care plan being followed. Any resident who could not be interviewed was visually assessed by the Director of Nursing and/or the District Director of Clinical Services for evidence that care needs are being met and care plan being followed. The assessment was completed by the nurse entering the resident's room and visually assessing such things as signs of pain, that ADL care has been provided, that resident was positioned correctly, that resident centered interventions for safety were in place and other similar observations. All Disciplinary Action Records completed in the last 60 days will be reviewed by the Administrator for allegations of neglect. All allegations discovered were reported to the State agency and are being thoroughly investigated. All facility staff present have been interviewed by the Administrator and/or the Director of Nursing regarding any allegations of neglect that have not been reported to the Administrator. All remaining facility staff will be interviewed prior to their next scheduled shift. Any allegations discovered will be reported to the Administrator and thoroughly investigated. Element #3 The facility policy for Abuse and Neglect Prohibition has been reviewed and deemed appropriate. On 3/21/18 all facility staff were re-educated on the facility policy for Abuse and Neglect Prohibition and investigation requirements. Re-education included specific focus that all allegations are reported to the Administrator immediately. The Administrator's phone number is posted throughout the facility. All allegations must be reported verbally and cannot be written on a discipline form or a concern form. All remaining facility staff will be re-educated prior to their next scheduled shift. Element #4 The Administrator held an AD H[NAME] Quality Assurance Committee meeting with the interdisciplinary team and medical director. The Administrator/Designee will conduct resident and staff inquiries 5 times per week to monitor care concerns and reporting. The Administrator will report findings to the QA committee for review and recommendation. The Administrator is responsible for compliance. The Administrator requests the removal of the immediacy on 3/22/18. Deficient Practice #2 Based on interview and record review, the facility failed to report alleged misappropriation of residents' medications to the State Agency within the required time frame for four (#294, #34, #444, and #61) of six residents reviewed for misappropriation of medications, from a total sample of 30, resulting in the potential for unidentified, uninvestigated, and continued diversion of controlled substances to occur. Findings include: On 3/21/18 at 1:42 P.M., a facility reported incident submitted to the State Agency on 9/1/17 (two days after the reported incident occurred) was reviewed. It documented the following: Possible alleged misappropriation of property. Not certain this is a reportable incident facility is reporting to (err) on the side of caution. On the evening of 8-30-17 (the DON) was notified by nursing manager (Nurse T) that a medication card appeared to be tampered with. Report given to the Director of Nursing indicated that the medication card for Modafinil 200 mg (a controlled substance used to promote wakefulness) had tape over the back and was discovered to have a different type of medication inserted similar in color and shape. Facility is conducting a full investigation and will report completed findings in our 5 day report . On 3/21/18 at 1:45 P.M., a file containing an investigation conducted by the facility was reviewed. It revealed the following: A summary of the facility's investigation (which was also the 5-day investigation submitted to the State Agency) that documented, .Administrator Notified/Date: (Administrator's name) 8/30/17 .Staff Member completing this 5-Day report: (the DON) .The facility is not certain this is a reportable incident but feels this could be possible alleged misappropriation of property and is reporting to (err) on the side of caution. On the evening of 8/30/17 (the DON) was notified by Nursing Manager (Nurse T) that a medication card of Modafinil 200 mg appeared to be tampered with. The report given to the Director of Nursing indicated that the medication card had tape over the back and was discovered to have a different type of medication inserted similar in color and shape . It was documented that interviews were conducted with staff members (Nurse V, Nurse S, Nurse H, and Nurse U) on 8/31/17 and that the DON and the Administrator were notified immediately. An interview was conducted with the DON on 3/22/18 at 12:15 P.M. The facility's investigation file was reviewed with the DON at that time. The Modafinil blister pack was prescribed to Resident #294. When queried about the investigation and when she was notified of the potential tampered with blister pack of medication (Modafinil) that was prescribed to Resident #294, the DON stated, You are looking at this incident? I thought if the AG (Attorney General) was investigating, the state often stands back. They (the AG department) came, I think on 9/1/17 and basically took over. When queried about how and when the DON became aware of the issue, the DON stated, On 8/30/17 a nurse (Nurse U) discovered a Modafinil blister pack was not Modafinil. They (Nurse U) discovered the back of the blister pack had tape over them. She said it looked like [MEDICATION NAME] (a medication used to improve blood circulation). (Nurse T), the manager, working on the floor that night called me. I told her to remove the blister pack, lock it up in the med room and I would take care of it in the morning. The DON reported she received the call from Nurse T around 7:00 or 8:00 P.M. (on 8/30/17) as it was noticed during the controlled substance count at shift change from the A.M. to P.M. shift. When asked what was observed by the DON, the DON stated, I observed the (blister pack) the next day and inspected the back of the pack. There were five remaining pills and they were all taped on the back (of the blister pack). Obviously it had been tampered with. Nurse U thought the tablets in the blister pack looked like [MEDICATION NAME] and not Modafinil. The tablets in the Modafinil package looked identical to [MEDICATION NAME]. The DON was asked if the medication was verified to be [MEDICATION NAME] and reported it was not verified. The DON further stated, I didn't get a good investigation going until the AG came and took everything. They took the blister packs. The DON reported that the AG came to the facility on [DATE]. When queried about any additional blister packs found to be tampered with, the DON stated, We looked at every blister pack that was in a narcotic box and we found taped ones. I took the cards because obviously they were tampered with and disposed of the medication and reordered the medication. The facility's investigation contained photo copies of the taped blister packs for the following residents: Resident #294 - a blister pack for Modafinil 200 mg give 1 tablet per PEG tube once daily prescribed on 8/20/17. The photo of the back side of the blister pack was labeled tape in two areas where medication is typically sealed until administered. (The DON confirmed that the areas labeled tape were taped and tampered with). Resident #61 - a blister pack for [MEDICATION NAME] (a controlled substance used to treat anxiety) 0.25 mg give 1 tablet by mouth every 12 hours prescribed on 8/11/2016. The photo of front and back side of the blister pack had one area that was circled, appeared empty, and was labeled tape. Resident #34 - a blister pack for [MEDICATION NAME] (a controlled substance used to treat anxiety) 1 mg give 1 tablet by mouth every 12 hours prescribed on 8/5/17. The photo of the back side of the blister pack had one area that was circled and labeled tape. Resident #444 - a blister pack for [MEDICATION NAME] 0.25 mg tablet give 1 tablet by mouth every 12 hours as needed for anxiety. The photo on the back side of the blister pack had one area that was circled and labeled tape. The DON was asked when the additional blister packs were discovered to be tampered with. The DON stated, When the AG was here and we went through all the narcotics. When asked if the additional residents (#61, #34, and #444) were also reported to the State Agency for potential misappropriation of medication, the DON reported they were not. When asked if there was additional investigation into the additional tampered with blister packs, the DON stated, I don't know why the nurses think they can tape them. I educated them on that. On 3/22/18 at 5:00 P.M., the Administrator was interviewed regarding the facility reported incident. The Administrator was asked if and when she was notified of potential misappropriation of residents' medications (tampered with blister packs of controlled substances prescribed to residents). The Administrator stated, I was aware there was a possible issue. There wasn't even a time frame to figure out if there was an issue when the AG came into the building. When queried about the date the AG came into the building, the Administrator did not offer a response. When queried about when the DON reported the allegation to her, the Administrator stated, (The DON) notified me on Thursday morning (8/31/17). She said she didn't have her eyes on it at the time of the report (from Nurse T) and she would investigate it. The Administrator was asked why the incident was not reported to the State Agency until 9/1/17 (two days after Nurse T reported the allegation) and the Administrator did not offer a response. When queried about the additional blister packs that were found to be tampered with that belonged to Residents #61, #34, and #444 and if they were also reported to the State Agency, the Administrator stated, The AG took the blister packs, even the other ones for [MEDICATION NAME] ([MEDICATION NAME]) and Klonopin ([MEDICATION NAME]). I can't really answer these questions because I can't do medication investigations. On 3/22/18 at 4:00 P.M., Resident #294's clinical record was reviewed and revealed Resident #294 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. On 3/22/18 at 5:46 P.M., Resident # 444's clinical record was reviewed and revealed the following: Resident #444 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. On 3/22/18 at 5:50 P.M., Resident # 61's clinical record was reviewed and revealed the following: Resident #61 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED].

This citation refers to Intake Number(s): MI 698 and MI 847. This citation has two deficient practices. Deficient Practice #1 Based on interview and record review, the facility failed investigate multiple instances of neglect by the same staff member on multiple dates and failed to protect residents who resided in the facility for four (#64, #17, #443, and #57) of twelve residents reviewed for abuse and neglect, from total sample of 30, resulting in an immediate jeopardy (IJ) when documented instances of Resident #443 being left naked on the floor, shivering and covered in dried feces; and of Residents #64, #17, and #57 not receiving a brief change for seven hours were not investigated. This deficient practice put these residents at risk for unidentified and continued neglect and all other residents who reside in the facility at risk for serious harm, injury and/or death when the staff member continued to provide direct care to residents within the facility despite ongoing allegations of neglect. The IJ started on 1/6/18. The IJ was identified on 3/21/18 at 4:46 P.M. The Administrator was notified of the Immediate Jeopardy on 3/21/18 at 6:44 P.M. A plan to remove the immediacy was requested. The immediacy was removed on 3/22/18 at approximately 5:00 P.M. based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the Facility's deficient practice was not corrected and remained at a pattern that is not immediate jeopardy. On 3/19/18 at 4:00 P.M., a complaint reported to the State Agency was reviewed and documented on 1/8/18, a resident reported that Certified Nursing Assistant (CNA) N took her to the bathroom and left her naked from the waist down. When asked if she was going to put her pants back on, it was reported CNA N stated, 'I choose not to' and left the resident naked from the waist down for two hours. The complaint documented CNA N continued to attempt to provide care to the resident on the following day after the resident allegedly filed a written complaint. On 3/21/18 at 11:30 AM, the Administrator, who functioned as the abuse coordinator for the facility, was interviewed regarding the facility's grievance process. The Administrator stated, Concern forms are completed. Residents and staff are educated to report concerns. If it can be resolved immediately, we do. Abuse issues do not go on concern forms. When queried about the facility's process when abuse or neglect allegations were made, the Administrator stated, I get notified immediately. I have to immediately figure out what is going on. I only have 2 hours to report so I will come into the building if I need to or have a manager or charge nurse start investigation and start documenting information. On 3/21/18 at 12:00 P.M. a personnel file for CNA N (the CNA who was alleged to leave the subject of the complaint naked on the toilet for two hours) was reviewed and revealed the following: A Disciplinary Action Record for CNA N documented an Initial Written Warning that noted the date of work rule violation as 1/6/18. The written warning documented, On Saturday 1/6/18, I (Nurse G) checked on my patients on 200 Hall at 12:00 (P.M.) Patients in (three different room numbers) all had briefs on timed and dated 1/6 05:00 (A.M.) and had not been changed at 12:00 (P.M.). Additionally, patient in (room number) was lying in bed undressed and he is normally up for breakfast. CNA N refused to sign the document. The document was signed by Nurse G (undated) and another staff member. The DON signed the document on 1/10/18 (four days after the documented incident). A second Disciplinary Action Record for CNA N that documented an Initial Written Warning on 1/10/18 and a Final Written Warning that noted, Resident in (room number) was observed by incoming RCS (Resident Care Specialist - CNA W) at 11 P.M. on the floor of his room, completely naked with dried up feces on his legs, buttocks, and torso. Resident was shivering. Door to the room was completely closed. RCS that was on duty from 3P-11PM had left assignment early and punched out at 10:53 PM not waiting for relief to come in leaving hall and her assigned patients unattended for. Assigned RCS .was CNA N. CNA N refused to sign the document and it was signed by a witness on 1/11/18, a supervisor on 1/11/18, and the DON on 1/11/18. On 3/21/18 at 12:23 P M., an attempt to contact CNA W via the telephone was made. The number was a non working number. On 3/21/18 at 12:36 P.M. the above mentioned disciplinary action records were reviewed with the DON. The DON was asked if there were investigations into either of the events documented on the forms. The DON reported she would have to look to see if she had a soft file. On 3/21/18 at 1:00 P.M. the above mentioned disciplinary action records were reviewed with the Administrator. The Administrator was asked if there were investigations into either of the documented events. The Administrator stated, That doesn't sound familiar. I will check with (the DON). On 3/21/18 at 1:21 P.M., a second attempt was made to contact CNA W via the telephone using an alternate number provided by the facility. The number provided was a wrong number. On 3/21/18 at 3:20 P.M., the Administrator provided a file and stated it contained investigations into the incidents documented on the disciplinary forms found in CNA N's file. The file contained a typed summary regarding CNA N dated 1/9/18 that documented, The Director of Nursing received a written discipline written by Nurse G regarding care issues for residents on 200 Hall on (MONTH) 9, (YEAR) for the day of (MONTH) 6, (YEAR). I reviewed these with Nurse G and reported to the Administrator, then reviewed with HR (Human Resources) to get direction. On (MONTH) 10, (YEAR) I met with (CNA N) (four days after the incident) and RN Unit Coordinator (Nurse A). I reviewed the concern with CNA N and she stated that this was not true and that she did check on the stated residents .She stated her assignment was being changed around noon on the day of 1/6/18 so she remembered the she did her last checks and all residents were dry. She reported to me that she had no witnesses to verify .Furthermore (CNA N) stated that the resident in (room number) requested to stay in bed the morning of (MONTH) 6, (YEAR). Skin assessments were done per (Nurse A) on the mentioned residents and no issues were identified. The facility was unable to substantiate that there was any delay in caring for the residents based on intent, assessment, interview, and lack of witnesses . The file also contained shower sheets which the DON reported were for the residents documented on the disciplinary form. The shower sheets were dated 1/9/18 (three days after the documented incident) and were for Resident #17, Resident #57, and Resident #64. There was no additional information provided in the file. On 3/21/18 at 3:39 P.M., an interview was conducted with the Administrator and DON and the two Disciplinary Action Reports pertaining to CNA N and the file mentioned above were reviewed. When asked who completed the disciplinary form dated 1/6/18 that documented Resident #17, #57, and #64 with unchanged briefs for seven hours and Resident #57 being left in bed and not dressed, the DON stated, That's (Nurse G). He's a charge nurse. The DON further stated, (Nurse G) filled out the form and slid it under my door. When queried about whether or not Nurse G provided the disciplinary form to the DON on 1/6/18, the DON stated, I didn't get it on 1/6/18 (a Saturday). The DON and the Administrator reported that they did not receive a phone call from Nurse G regarding the documented incident. The DON was asked when she became aware of the incident and stated, Maybe the morning of the 9th (January). When queried about what was done to investigate the incidents, the DON stated, Obviously I would have had a conversation regarding the degree it is. The day I got it (the disciplinary action record), we went back and did skin assessments to ensure they (Residents #17, #57, and #64) weren't harmed at any level. Then I went back to (Nurse G) to ask about him doing his rounds and he said he noticed they were timed and at noon they still had the same briefs on (seven hours later). When I talked to (CNA N) she said that wasn't entirely true. I didn't have a witness to entirely validate because it was so many days later. The DON reported that she did not interview any other staff members who worked on that day and there was no evidence that other residents were interviewed or assessed. The Disciplinary Action Record dated 1/10/18 was reviewed with the DON at that time. When asked to identify the resident found on the floor, naked with dried feces, shivering behind a closed door, the DON stated, I really don't know. The DON was asked how she became aware of the incident documented on 1/10/18. The DON stated, (Nurse X) brought the form to me in the morning when I came in the next day. (CNA N) was here so we talked to her and she said that she did her last rounds and left seven minutes early. When queried about any investigation into the incident reported by Nurse X, the DON reported there was nothing additional. The Administrator was asked if there was any investigation into either of the incidents documented on disciplinary action records by two different staff members during the same week concerning the same CNA, CNA N. The Administrator stated, I don't remember this particular situation. Right now I have no documentation that this was investigated at all. The Administrator was asked what the facility's policy was when allegations of abuse or neglect were made against an employee of the facility. The Administrator stated, Employees are suspended pending the investigation. I will usually just interview over the phone and will get their statement .I have to ensure the safety of the residents and ensure they are out of harms way. Until I can substantiate or unsubstantiate the allegation, I need to get those employees out of the building. When asked if CNA N was suspended after either of these reported incidents, the DON did not offer a response. The Administrator stated, I'd have to look at her HR file. The Administrator later reported that CNA N had not been suspended. The Administrator stated, This wasn't handled appropriately. It is what it is. There is a policy and process that must be followed. The Administrator later reported that the resident mentioned in the disciplinary action record dated 1/10/18 was Resident #443. All time punches for CNA N from 1/6/18 through 2/7/18 (the date CNA N terminated employment at the facility) were reviewed on 3/21/18 at 4:30 P.M. and they revealed CNA N worked on the following days after incidents of neglect were reported: 1/6/18 from 6:58 A.M. until 10:53 P.M. 1/7/18 from 6:57 A.M. until 10:21 P.M. 1/9/18 from 2:53 P.M. until 11:01 P.M. 1/10/18 from 2:52 P.M. until 10:53 P.M. 1/11/18 from 6:53 A.M. until 11:07 P.M. 1/13/18 from 2:53 P.M. until 11:05 P.M. 1/14/18 from 8:25 A.M. until 1/15/18 at 12:09 A.M. 1/16/18 from 2:55 P.M. until 11:05 P.M. 1/17/18 from 2:53 P.M. until 11:13 P.M. 1/18/18 from 2:57 P.M. until 11:01 P.M. 1/23/18 from 2:54 P.M. until 10:54 P.M. 1/24/18 from 6:57 A.M. until 10:53 P.M. 1/25/18 from 6:56 A.M. until 10:53 P.M. 1/27/18 from 6:59 A.M. until 11:02 P.M. 1/28/18 from 11:26 A.M. until 10:53 P.M. 1/30/18 from 2:53 P.M. until 10:56 P.M. 1/31/18 from 6:56 A.M. until 3:12 P.M. Daily Assignment Sheets from 1/6/18 through 1/10/18 were reviewed and revealed CNA N was assigned to the 100, 200, and 300 halls during that time frame. On 3/22/18 at 11:10 A.M., an interview with Nurse X (the nurse who wrote the disciplinary action record on 1/10/18) was attempted via the telephone. There was no answer and a message was left. No return call was received prior to the end of the survey. On 3/21/18 at 4:00 P.M., Resident #17's clinical record was reviewed and revealed Resident #17 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented Resident #17 had severely impaired cognition and required extensive assistance from one to two staff members for all activities of daily living (ADLs), including toilet use. The MDS documented that Resident #17 did not have any behaviors that included rejection of care. On 3/21/18 at 4:05 P.M., Resident #57's clinical record was reviewed and revealed Resident #57 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented Resident #57 had severely impaired cognition and required extensive assistance from two staff members for all ADLs except eating. The MDS documented that Resident #57 did not have any behaviors that included rejection of care. On 3/21/18 at 4:10 P.M., Resident #64's clinical record was reviewed and revealed Resident #64 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented Resident #64 had severely impaired cognition, required extensive to total assistance from two staff members for all ADLs, and had a [MEDICAL CONDITION] (a tube inserted into a surgical opening in the neck to provide an airway and to remove secretions from the lungs) and a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube surgically inserted into the stomach to provide nutrition). The MDS documented that Resident #64 did not have any behaviors that included rejection of care. On 3/21/18 at 4:30 P.M., Resident #443's clinical record was reviewed and revealed Resident #443 was admitted into the facility on [DATE] and was discharged on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented Resident #443 had severely impaired cognition, required extensive assistance from one to two staff members for all activities of daily living except eating, and did not have any behaviors that included rejection of care. It was documented in the MDS that Resident #443 did have some wandering behaviors, but they did not put the resident or other residents at risk. On 3/22/18 at 11:20 A.M., an interview with Nurse G was attempted via telephone. The call would not go through. Nurse G was unable to be interviewed prior to the end of the survey. The facility's policy titled, Abuse & Neglect Prohibition dated (MONTH) (YEAR) was reviewed on 3/21/18 at 8:30 A.M. and it documented the following: .The facility will protect residents from harm during investigation . .The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment .in accordance with state law . .Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be interviewed and suspended immediately, and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated . The Facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 3/22/18: Element #1 Resident #293 and #443 no longer reside in the facility. Resident #64, 17, and 57 were assessed and are receiving care as needed. Resident #64, 17, and 57 care plans were reviewed, revised, and deemed appropriate. A neglect allegation was written on a Disciplinary Action Record and not immediately reported to the Administrator. Although neglect was not substantiated the allegation was not reported to the Administrator resulting in the allegation not being report to the State agency. Element #2 All interviewable residents were asked by a member Interdisciplinary Team if their care needs are being met. Any concerns noted were address by the appropriate department and any new allegations have been reported and are being investigated. Any resident who could not be interviewed was visually assessed by the Director of Nursing and/or the District Director of Clinical Services for evidence that care needs are being met and care plan being followed. The assessment was completed by the nurse entering the resident's room and visually assessing such things as signs of pain, that ADL care has been provided, that resident was positioned correctly, that resident centered interventions for safety were in place and other similar observations. All Disciplinary Action Records completed in the last 60 days will be reviewed by the Administrator for allegations of neglect. All employee disciplinary records were reviewed. Any allegations discovered were reported to the State agency. All staff present in the facility have been interviewed by the Administrator and/or the Director of Nursing regarding any allegations of neglect that have not been reported to the Administrator. All remaining facility staff will be interviewed prior to their next scheduled shift. Any allegations discovered will be reported to the Administrator and reported to the State agency. Element #3 The Facility Policy for Abuse and Neglect Prohibition has been reviewed and deemed appropriate. On 3/21/18 all facility staff were re-educated on the facility policy for Abuse and Neglect Prohibition and reporting requirements. Re-education included specific focus that all allegations are reported to the Administrator immediately. The Administrator's phone number is posted throughout the facility. All allegations must be reported verbally and cannot be written on a discipline form or a concern form. All remaining facility staff will be re-educated prior to their next scheduled shift. Element #4 The Administrator held an AD H[NAME] Quality Assurance Committee meeting with the interdisciplinary team and medical director. The Administrator/Designee will conduct resident and staff inquiries 5 times per week to monitor care concerns and reporting. The Administrator will report findings to the QA committee for review and recommendation. The Administrator is responsible for compliance. The Administrator requests the removal of the immediacy on 3/22/18. Deficient Practice #2 Based on interview and record review, the facility failed to thoroughly investigate alleged misappropriation of residents' medications for four (#294, #34, #444, and #61) of six residents reviewed for misappropriation of medications, from a total sample of 30, resulting in the potential for unidentified and continued diversion of controlled substances to occur. Findings include: On 3/21/18 at 1:42 P.M., a facility reported incident submitted to the State Agency on 9/1/17 (two days after the reported incident) was reviewed. It documented the following: Possible alleged misappropriation of property. Not certain this is a reportable incident facility is reporting to (err) on the side of caution. On the evening of 8-30-17 (the DON) was notified by nursing manager (Nurse T) that a medication card appeared to be tampered with. Report given to the Director of Nursing indicated that the medication card for Modafinil 200 mg (a controlled substance used to promote wakefulness) had tape over the back and was discovered to have a different type of medication inserted similar in color and shape. Facility is conducting a full investigation and will report completed findings in our 5 day report . On 3/21/18 at 1:45 P.M., a file containing an investigation conducted by the facility was reviewed. It revealed the following: A summary of the facility's investigation (which was also the 5-day investigation submitted to the State Agency) that documented, .Administrator Notified/Date: (Administrator's name) 8/30/17 .Staff Member completing this 5-Day report: (the DON) .The facility is not certain this is a reportable incident but feels this could be possible alleged misappropriation of property and is reporting to (err) on the side of caution. On the evening of 8/30/17 (the DON) was notified by Nursing Manager (Nurse T) that a medication card of Modafinil 200 mg appeared to be tampered with. The report given to the Director of Nursing indicated that the medication card had tape over the back and was discovered to have a different type of medication inserted similar in color and shape . The summary included Health Status of Residents for the following residents: Resident #294 - It was documented when resident was admitted with diagnoses, code status, and the name of the resident's responsible party. Resident #61 - The resident's admitted , diagnoses, and cognition were documented. There was information documented regarding two additional residents in the summary with code status, diagnoses, the name of the responsible party, and admitted s. It was further documented that the DON conducted interviews with staff members (Nurse V, Nurse S, Nurse H, and Nurse U) on 8/31/17 with the following responses: Nurse V - .questioned about the condition/appearance of the Modafinil blister pack that belonged to (Resident #294) and she stated she did not notice any changes in the pills or the packaging that would have alerted her that the blister pack had been tampered with . Nurse S - .stated that he did not notice anything different in the appearance or the packaging of the Modafinil blister pack . Nurse H - .stated that she did not notice anything that would have alerted her that the Modafinil was tampered with but she did state that the medication was difficult to punch out when she was administering it on 8/30/17 . Nurse U - stated that she worked (MONTH) 28, 29, and 30th and counted the cart for (Resident #294) each day she worked. She stated that she did not notice any difference in the appearance or the packaging of the Modafinil blister pack until the night of (MONTH) 30, (YEAR) and reported it to RN Unit Manager (Nurse T). The summary documented, .The Director of Nursing instructed Nurse T to remove the blister pack from the cart along with the proof of use sign out sheet and to lock it up .During the investigation it was assumed by Nurse U the medication that was replaced in the Modafinil blister pack was [MEDICATION NAME] (a medication used to improve blood circulation). There were three residents who reside in the facility taking [MEDICATION NAME] .Their medication was reviewed and was determined that they had not missed any doses .All medication carts are audited daily to ensure there are no blister packs tampered with .Conclusion: After the investigation the following conclusion was drawn. The facility is not able to substantiate if there was a misappropriation of property as the pills that were found in the blister pack of Modafinil appeared to be the same as the [MEDICATION NAME] three other residents are taking. No resident has missed any doses and there was no witness to this incident to validate it was taken from any resident in the facility . Additional information included in the investigation file was, as follows: A Incident/Accident (I&A) Report for Resident #294, dated 8/30/17 and signed by the DON on 8/31/17 that documented, .Alleged misappropriation of property .During the narcotic count tonight it was discovered (Resident #294's) Modafinil 200 mg appeared to be odd in appearance . A second typed summary dated 8/31/17 and signed by the DON which documented, .On Thursday (MONTH) 31, (YEAR), I reviewed the blister pack but was unable to identify the medication that was in the blister pack. It was obvious that the blister pack had been tampered with .I talked to (Nurse H) who was the last person to administer the medication prior to staff observing the tampered blister pack. I asked (Nurse H) if she had any trouble punching out the medication from the blister pack and she stated she did. She stated, 'In fact I thought I was going to break my nail so I went down to the next spot and was able to punch it out even though it was out of sequence .' The facility's investigation contained photo copies of the front and back of blister packs for Resident #294 (included in the report submitted to the State Agency), and Resident #61, Resident #34, and Resident #444 (not included in the report submitted to the State Agency). The photo copies revealed the following: Resident #294 - a blister pack for Modafinil 200 mg give 1 tablet per PEG tube once daily prescribed on 8/20/17. The photo of the back side of the blister pack was labeled tape in two areas where medication is typically sealed until administered. Resident #61 - a blister pack for [MEDICATION NAME] (a controlled substance used to treat anxiety) 0.25 mg give 1 tablet by mouth every 12 hours prescribed on 8/11/2016. The photo of the back and front side of the blister pack had one area that was circled, appeared empty, and was labeled tape. Resident #34 - a blister pack for [MEDICATION NAME] (a controlled substance used to treat anxiety) 1 mg give 1 tablet by mouth every 12 hours prescribed on 8/5/17. The photo of the back side of the blister pack had one area that was circled and labeled tape. Resident #444 - a blister pack for [MEDICATION NAME] 0.25 mg tablet give 1 tablet by mouth every 12 hours as needed for anxiety. The photo on the back side of the blister pack had one area that was circled and labeled tape. On 3/21/18 at 2:00 P.M., personnel files for the above mentioned nurses were reviewed and revealed the following: A Disciplinary Action Record for Nurse V signed by Nurse V and the DON on 9/13/17. The form documented Nurse V was terminated from employment at the facility due to a work rule violation on 9/1/17. The violation documented, (Nurse V) was in violation of the code of conduct .which states 'While on the job or on company property, employees may not be under the influence of alcohol or any controlled substance nor may they manufacture, distribute, possess, sell, use, offer to sell/purchase alcohol or any controlled substance while on the job or on company property. An interview was conducted with the DON on 3/22/18 at 12:15 P.M. and the investigation file provided was reviewed at that time. The DON stated, You are looking at this incident? I thought if the AG (Attorney General) was investigating, the state often stands back. They (the AG department) came, I think on 9/1/17 and basically took over. The DON was asked why Nurse V was terminated on 9/13/17. The DON stated, The AG came in and insisted she have a drug test. Based on her drug test, HR said she had to be terminated because she was positive for marijuana. The drug screen was reviewed and did not include any screening for benzodiazapines ([MEDICATION NAME] or [MEDICATION NAME]) or the stimulant Modafinil. When queried about why Nurse V was the only staff member drug screened or being investigated by the AG, the DON stated, I believe a staff member called the AG. Staff were always complaining of (Nurse V) falling asleep on the job. I think other staff members didn't like her because she was cute and petite. The DON reported that she thought the AG came out on 9/1/17 but she wasn't sure of the exact date. The DON was asked how the investigation was conducted. The DON stated, On 8/30/17 nurse (Nurse U) discovered Resident #294's Modafinil blister pack was not Modafinil. (Nurse U) discovered the back of the blister pack had tape over some of the medication slots. She said it looked like [MEDICATION NAME]. (Nurse T) was the nurse manager working on the floor that called me. I told her to remove the blister pack, lock it up in med room and I would take care of it in the morning. The DON reported Nurse U and Nurse H were the nurses conducting the controlled substance count at shift change around 7:00 or 8:00 P.M. The DON further stated, I observed the blister pack the next day and when I inspected the back of pack, there were five remaining pills and they were taped up on the back. Obviously it had been tampered with. When queried about the report from Nurse T that the pills in the Modafinil blister packs appeared to be another mediation, the DON stated, The tablets in the Modafinil package looked identical to [MEDICATION NAME]. The DON was asked if anything was done to verify what the medication was in the Modafinil blister pack. The DON reported the medication was not verified. The DON was asked how she chose residents to include in the investigation. The DON stated, I chose the residents who were on [MEDICATION NAME]. When asked why those residents were chosen when the medication placed and taped into the Modafinil pack was not officially verified as [MEDICATION NAME], the DON did not offer a response. The DON stated, I interviewed everyone who was on the count sheet (controlled substances proof of use sheet) for Resident #294's Modafinil and nobody noticed anything different about the blister pack. The only thing Nurse H noticed was that she had a hard time punching out the medication that morning but didn't look at the back of the blister pack. The DON was asked if any of the nurses were suspended after the allegation was reported. The DON reported nobody was suspended. The DON stated, Looking back we would have had to suspend all nurses who were on that cart because we would have to look at anyone who would have had access to the medications on that cart. The DON was interviewed further regarding the investigation. When asked about the photo copies of the additional blister packs labeled with tape on the back of them for Resident #61, Resident #34, and Resident #444, the DON stated, Initially when I went through we found a few with tape on them. We found three blister packs with taped areas. We looked at every blister pack that was in a narcotic box and we found taped ones. I took the cards because obviously they were tampered with, disposed of the medication and reordered the medication. When queried about what was done to investigate the additional blister packs identified as tampered with, the DON stated, At that time, there was an education with the nurses not to tape up the blister packs. I don't know why they do that. When queried about any involvement with the consulting pharmacy, the DON stated, I talked to our pharmacy to let them know it was discovered, but they didn't get involved. I don't know who I talked to. When asked what their response was when multiple controlled substances were reordered on the same day before they needed to be, the DON stated, I had to reorder them so I had to tell them why. The DON reported that there would be delivery receipts to acknowledge receipt of any medications delivered to the facility. The phone number for the pharmacy consultant and delivery receipts for all of the medications reordered as a result of the investigation were requested at that time. No delivery receipts were provided prior to the end of the survey. The Controlled Substances Proof of Use (C2) sheets for Resident #61, #34, and #444 were reviewed with the DON at that time. The DON was asked to identify signatures of nurses who were signing and cosigning for the medications on the C2 sheets. The DON was unable to identify some of the signatures and called Nurse A for assistance. Nurse A was unable to identify some of the signatures. When asked if the signatures on the C2 sheets were verified as a result of the investigation, the DON said they were not. On 3/22/18 at 4:47 P.M., Consultant Pharmacist AA was interviewed via the telephone. When asked if he was aware of any issues with controlled substances at the facility in the past year, Consultant Pharmacist AA stated, There was an issue in (MONTH) that they told me about and my understanding was that it was resolved. They didn't share much with me. When queried about any report the pharmacist would have regarding any reo (TRUNCATED)

Deficient Practice #1 This Citation Refers to Intake Number MI 403 Based on observation, interview and record review, the facility failed to provide adequate supervision, which allowed two residents (#506 and #507) of two residents reviewed as having wandering and/or exit seeking behavior to exit the facility unbeknownst to facility staff from a total of 10 sampled residents. That resulted in an Immediate Jeopardy when Resident #506's daughter returned the resident to the facility after being contacted by the local County Sheriff's Department, and Resident #507 went missing for approximately three hours, and was found at an apartment complex next to the facility by a facility staff member. This deficient practice had the potential to result in serious harm and or injury and required immediate corrective action. The Administrator was notified of the Immediate Jeopardy on 3/8/17. A plan to remove the immediacy was requested. The immediacy was removed on 3/9/17 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated / pattern /widespread with actual harm that is not immediate jeopardy. Findings Include: Resident #506 On 3/8/17 at 11:25 a.m., during an interview and record review of the facility reported incident along with the Administrator, it was revealed that Resident #506 eloped from the facility on 2/19/17, and was not discovered missing until he was returned to the facility by his daughter. The Administrator further stated,Resident #506 usually wanders around the facility visiting other residents. We wouldn't know he was missing until meal time. His daughter brought him back just before it was time to eat. A review of the facility's undated Incident Summary revealed impart the following: On 2/19/17 . Around 11:00 a.m., (Resident's Name) was seen walking east bound on (Street Name) in front of (Church Name). He was approached by (Name), an (Church Name) parishioner, who after speaking with him took him into the church. Another parishioner called the local County Sheriff Department. The resident stated he was on his way to his daughter house. (Resident's Name) provided the local County Sheriff Department with his daughter's telephone number. The sheriff deputy contacted (Resident's Name) daughter, who picked him up at the church. The daughter returned the resident to the facility at approximately 12:00 p.m . Elopement risk assessment completed and wanderguard applied On 3/8/17 at 12:30 p.m., during a telephone interview regarding the elopement of Resident #506, Licensed Practical Nurse (LPN) 'B' stated, I was at my med cart on the 300 Hall. It was between 10:15 a.m. and 10:30 a.m., when I was finishing up. Resident #506 came walking down the hall . I asked if he was lost and he said 'No, I'm just walking.' He left off the 300 Hall, and that's the last time I saw him. On 3/8/17 at 12:50 p.m., Director of Maintenance 'C' was interviewed and after checking his mobile phone, stated, On Sunday, 2/19/17, I received a call from the Administrator at 2:07 p.m. I came into the facility and checked the residents with wander guard bracelets, wander guard doors, and all the code alarm doors. Everything worked fine. When asked if he was aware of which door Resident #506 exited from, Director of Maintenance 'C' stated, I'm not aware of what door the resident left. I don't know if he (Resident #506) remembered the door code or something . On 3/8/17 at 3:45 p.m., during a telephone interview, Registered Nurse (RN) 'D' stated, I was Resident #506's nurse on the 100 Unit the day of the elopement. I saw him around 10:00 a.m., in the hall. He always walked around with a coat and hat on. RN 'D' further stated that she was not aware of the door the resident exited from. On 3/9/17 at 4:35 p.m., an interview was conducted with Medical Director 'G' concerning the elopement of Resident #506. Medical Director 'G' stated, The next day (after the elopement), I saw the resident by the door trying to leave the facility. I asked why he wanted to leave. He (Resident #506) said he was having a problem with his roommate . A review of the clinical record revealed Resident #506 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #506 was severely cognitively impaired for decision-making, and was coded (1/2) which indicated Resident #506 required supervision with one person physical assistance with locomotion on/off the unit. The admission elopement assessment, dated 2/11/17, documented that Resident #506 was not at risk for elopement. On 3/8/17 at 4:15 p.m., a physician's order for Resident #506's wander guard (a tracking device designed to prevent persons at risk from leaving the facility) was requested. The Administrator stated, There was only a verbal order from a nurse, and there was no physician order in the medical record. We just slapped it (wander guard) on him. Further review of the clinical did not reveal that Resident #506's responsible party was notified of the need for its (wander guard) use. The at risk for elopement care plan was initiated on 2/19/17 and documented the following: I am an elopement risk/wanderer. I have impaired safety awareness. I am often confused. I sometimes becomes agitated when you try to redirect me. Calling my daughter and letting me talk to her sometimes helps to calm me down . Interventions: Attempt to identify any patterns of my wandering . Call me daughter . Center elopement/wandering/exit seeking protocol initiated. Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, etc . Report any incidences of exit seeking behaviors to my nurse/sw and document as appropriate. Resident #507 On 3/8/17 at 12:20 PM an observation and interview was conducted with Resident #507. Resident #507 was observed to have a wanderguard (a tracking device designed to prevent persons at risk from leaving the facility) attached to the left wrist. Resident #507 was walking on the 100 unit of the facility with certified nursing assistant (CENA) 'N'. Resident #507 was returned to his room where he was queried regarding his leaving the facility on the morning of 3/7/17. Resident #507 appeared confused and indicated that he did not remember leaving the facility or being found by the Director of Maintenance 'C'. CENA 'N' was interviewed immediately after and indicated that Resident #507 was 1:1 today and that the resident wanders in other peoples in room. A review of clinical record on 3/8/17 at 12:45 PM, was conducted and revealed that Resident #507 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #507 was alert and oriented x 1 with confusion and required 2 person assist with activities of daily living. Resident #507 was ambulatory and required staff supervision. An interview was conducted with the Director of Maintenance 'C' on 3/8/17 at 1:00 PM. When queried regarding Resident #507 having left the faciity on the morning of 3/7/17, the Director of Maintenance 'C' stated: When I got a call from the Administrator (after checking phone) at 2:00 AM, I found him some time after 3:00AM. The Director of Maintenance 'C' indicated that the local Oakland County Sheriff department arrived at the facility with the K-9 Unit and told staff not to go outside of facility because they would contaminate the scent, however they were not able to find Resident #507. The Director of Maintenance indicated that he had found Resident #507 in the outside cubby of the hallway of the apartment complex located next to the facility and stated: He was just staring at the wall. We don't know which door he went out of. I checked the wanderguard alarm and coded doors and everything was functioning. A review of the nurse's behavior note documented by Nurse 'J' for Resident #507 dated 3/7/17 approximately a half hour prior to exiting the facility was reviewed on 3/8/17 at 1:30 PM. The behavior note documented: Resident agitated and moving furniture around in waiting area of 100 hall and placing it on top of the sofas. Resident difficult to re-orient and resistive towards staff. Resident attempted to throw end table over 100 hall nurse's desk towards this writer stating that it was left out of place. Resident keeps mentioning Richard told him to change the furniture and keeps on activating door alarms throughout facility while stating that he is trying to leave and wants to get his truck. A phone interview was conducted with Nurse 'J' on 3/8/17 at 2:35 PM. When queried regarding Resident #507, Nurse 'J' stated: At about 12:55 or 1:00 AM, I was putting in a progress note on another resident. The resident had been agitated all night and had tried to go out 100 unit. He was arranging furniture at nurse's station. I went looking for him at approximately 1:15 AM and myself and nurse's aides searched for him. I called code white (a term used to alert staff to a resident's elopement) about 3 minutes later. We looked outside the facility as well. I called 911 at 1:21 AM. The Administrator was notified. I did not here an alarm go off. From 8:00 PM on 3/6/17 until the last time I saw him (at approximately 12:55 AM on 3/7/17) the alarm went off each time and I checked the doors to make sure. Nurse 'J' indicated that the Sheriff's department arrived at approximately 1:25 AM with K-9 Unit and stated: We went room to room, inspected courtyard, the forest and trailer park across the street and apartment. I was in the facility and was notified that he was found at 3:56 AM. I noticed a discoloration under his right eye. He told us he went out the side door -North by physical/occupational therapy. A review of the physician's order for Resident #507 dated 2/28/17 was reviewed on 3/8/17 at 4:00 PM and documented: wanderguard on at all times. Nurse to check and verify placement every shift. A review of Resident #507's care plan dated 3/1/17 was conducted on 3/9/17 at 9:00 AM. Resident #507's care plan documented:Goals- I will remain safe at all times and will not wander out of the facility. A review of the facility's policy titled Elopement Management revised February 2010 documented the following: PRACTICE GUIDELINES .7. Care Plan interventions are individualized to the resident, are based on the assessed risk of elopement, and may include the placement of a signaling device. If a signaling device is determined to be an appropriate safety device and is placed on the resident, the facility is to: a. Notify the resident/responsible party of the need for its use. b. Obtain a physician's order to: i. Check placement of the signaling device every shift . ii. Check the function of the signaling device daily using test box . 8. Notices should be provided to residents and family members . Residents and visitors should not be given the code to disarm the door monitor for any reason. If this occurs, the code should be reset or changed. 9. Episodes of elopement or a resident's attempt to elope from the facility are to be documented on the 24 Hour Report and an Incident/Accident Report completed. a. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse or available nursing manager. b. If a resident is determined to be missing and cannot be located in the facility, staff is to immediately notify the Administrator and Director of Nursing and initiate the Missing Resident Guideline . 10. Facility staff reports all episodes of elopement/elopement attempts to: a. The resident's attending physician and family/responsible party. The Licensed Nurse documents notification of the physician and family/responsible party on a Change of Condition form. The completed form is placed in the Nurses Notes section of the medical record. b. The facility Administrator and Director of Nursing/designee . 17. Director of Maintenance of designee will complete preventative maintenance . On 3/8/17 at 11:30 a.m., an Immediate Jeopardy (IJ) was identified. On 3/8/17 at 2:01 p.m., the Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy that began on 2/19/17 and 3/7/17, as a result of the facility's failure to prevent the elopement and ensure safety for Residents #506 and #507, who displayed internal wandering behavior and/or exit seeking behavior. The facility failed to properly respond with protocols. A plan to remove the immediacy was requested. The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 3/9/17: Resident #506 Element 1: On February 19, 2017 the following was completed: Total head count of all residents in facility completed by line staff and 100% of all residents were accounted for. Total head to toe assessment completed, pain evaluation completed on Resident #506 with no negative findings upon return to facility. Vital signs were within normal limits. Administrator was notified and came into facility and identified and completed total head count of all residents in facility. All residents were accounted for. Resident #506's Elopement Risk assessment was updated and a wanderguard applied. Wander guards were checked on other residents and proper function was verified. Maintenance Director verified that exit doors were in proper working order. All doors were identified as functioning properly on sensor panel at the nursing station. Element #2: On February 19, 2017 the following was completed: Verification completed on elopement book for elopement risk residents. All wander guards were checked for placement and function with no negative findings. Element #3: On February 19, 2017 the facility began inservicing Floor staff on policy and procedure of elopement management. Elopement drills were conducted on all shifts for 3 consecutive days and continue on a weekly basis beginning February 19, 2017. On February (no date entered) Elopement risk assessments were reviewed and changes were made as deemed necessary. Care plans were reviewed between February 19 - 22, 2017 and revised if needed. Element #4: Beginning February 19, 2017 the Facility will conduct elopement drill weekly for 6 months. Results will be brought by the maintenance department/designee to the Quality Performance Improvement Committee monthly for review. Any abnormal findings will immediately be corrected. Resident #507 Element 1: On March 7, 2017 the following was done: Total head count of all residents in facility completed by line staff and 100% of all residents were accounted for. EMS was contacted to assess and transport to ER for evaluation. Administrator was notified and came into facility and identified and completed total head count of all residents in facility. All residents were accounted for. Resident #507 Elopement Risk assessment was updated. Wander guards were checked on other residents and proper function was verified. Maintenance Director verified that exit doors were in proper working order. All doors were identified as functioning properly on sensor panel at the nursing station. Element #2: On March 7, 2017 Verification completed on elopement book for elopement risk residents and all wander guards were checked for placement and function with no negative findings. Element #3: On March 7, 2017 the facility began in-servicing Floor staff on policy and procedure of elopement management. Elopement drills will be conducted on all shifts for 3 consecutive days and continue on a weekly basis beginning March 7, 2017. On March 7 and 8, 2017 Elopement risk assessments and Care plans were reviewed and deemed appropriate. Element #4: Beginning March 7, 2017 the Facility will conduct elopement drill weekly for 6 months. Results will be brought by the maintenance department/designee to the Quality Performance Improvement Committee monthly for review. Any abnormal findings will immediately be corrected. Administrator will attain and sustain compliance. Deficient Practice #2 This citation deficient practice refers to intake MI 402 Based on interview and record review the facility failed to prevent a resident (#505) from sustaining an injury from a fall for one sampled resident of three residents reviewed for accidents of total sample of 10 residents. This deficient practice resulted in the resident sustaining a right forehead hematoma and right ankle fracture. Findings include: A review of the clinical record on 3/8/17 at 11:00 AM, was conducted and revealed that Resident #505 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #505 was severely cognitively impaired for decision-making, and was coded (1/1) which indicated Resident #505 required supervision with locomotion on/off the unit. A review of the facility's Incident/Accident Report (I/A) dated 2/19/17 and completed by Nurse 'E' was performed on 3/8/17 at 2:00 PM and revealed impart the following: On 2/19/17 . At 9:10 AM, Roommate called staff for help. Resident (#505) observed on floor on her left side. Large purple hematoma on the right side of forehead. Right ankle edema with limited range of motion (ROM). Exact location of incident/accident- Resident's room. Physician and granddaughter notified. Ice packs applied and Resident sent to hospital. Summary of Investigation- Roommate stated that she was going into the bathroom. She fell and hit her head on the door handle. No moisture or obstructions on floor. Pt had hard-soled shoes on. Was not using walker. Further review of the I/A reports for Resident #505 revealed that the resident had a previous fall on 4/11/16 in which she had fallen in her room and was found sitting by trash can with indentation on right temporal area. An interview with Nurse 'E' was conducted on 3/9/2017 at 1:10 PM. When queried regarding Resident 505's history of falls and injury sustained from fall, Nurse 'E' stated: CENA 'O' was motioning me to come to room and roommate had been calling for help because the resident had fallen. A couple of CENAs had gotten her up and she was sitting on side of bed. She had a large hematoma on right forehead. I talked to her. She has severe dementia and speaks minimally. I helped her lie down on bed. I looked at her pupils, range of motion, took her vitals and skin/full body assessment. At that time, I hadn't noticed any issues with her ankle. I called her grand daughter and doctor. Nurse 'E' indicated that the doctor gave an order to send Resident #505 to the emergency room for a cat scan of the head. Nurse 'E' stated: The ambulance came and we were going to have her stand and pivot but when I pulled the cover back, I noticed that the ankle was swollen. Nurse 'E' indicated that Resident #505's roommate told her that the resident was just going to the bathroom and hit her head on door knob of bathroom. Nurse 'E' further stated: She is supposed to ambulate with walker but keeping her and the walker together was an undertaking. For the most part her gait had been steady. She had fallen in the past. She would ambulate with walker to other parts of the building and return without it and we would have to go find the walker. An interview was conducted with CENA 'O' on 3/9/17 at 1:30 PM, regarding Resident #505's history of falls and injury sustained from fall. CENA 'O' indicated that she was coming from the 300 unit when Resident #505's roommate was screaming. I came and looked and Resident #505 was on the floor. She was found lying straight in front of bathroom door but I noticed that the right side of her head was swelling. I told the Nurse (referring to Nurse 'E') to come here. When Nurse 'E' called her name she moved her head but did not verbalize anything. We asked her roommate what happened and roommate said she was trying to go to the bathroom. An interview was conducted with Resident #505's roommate on 3/9/17 at 2:30 PM. When queried regarding Resident #505's fall, roommate responded: I don't remember. I wish I did. An interview was conducted with the Occupational Therapist (OT) 'L' on 3/9/17 at 3:30 PM. When queried regarding Resident #505's ambulatory status and fall history, OT 'L' indicated that the resident's physical therapy evaluation dated 10/14/15 documented: Supervision with transfer and ambulation with rolling walker up to 500 feet. Resident #505 had been re-evaluated in April 2016 after the fall of 4/11/16 and had received physical therapy for 5 days which consisted of therapeutic exercises, neuromuscular re-education, gait training therapy and therapeutic activities. The Occupational Therapist indicated that Resident #505 had received safety education and gait safety instruction but demonstrated poor carryover/retention. OT 'L' further explained that Resident #505's 4 wheeled walker had been replaced with a 2 wheeled walker to decrease her speed and assist with stability, but she required reinforcement all the time to use the 2 wheel walker because she would go into other resident's room and take their walker. OT 'L' stated: She was pretty steady walking around everywhere. An interview was conducted with the Administrator on 3/9/17 at 4:00 PM. When queried regarding Resident #505's ambulatory status and fall history, the Administrator responded: We completed the 5 day (referring to the investigation protocol). The Administrator indicated that the resident used a walker to ambulate throughout the facility and that the fall which occurred on 2/19/17 was witnessed by the resident's roommate. No other explanation was given. A review of the facility's policy and procedure titled: Fall Management revision date: August 2012, was conducted on 3/9/17 at 4:30 PM. The Fall Management policy and procedure documented: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. If a fall occurs, the IDT conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls.

This citation pertains to Intake #MI 941 Based on observation, interview, and record review, the facility failed to provide sufficient nursing services and care to residents in accordance with physician's orders and care plans for seven Residents (#'s 601, 608, 609, 610, 614, 615, and 618) out of 22 residents reviewed for quality of care out of a total sample of 25 residents, resulting in an immediate jeopardy when medications (pain medications, [MEDICAL CONDITION] medications, and blood pressure medications) were not administered to four (#'s 601, 614, 615, and 618) of 22 residents, from a total sample of 25 residents, treatments were not administered for two (#609 and 610) of nine residents reviewed for treatment administration of a total sample of 25 residents, and assessments were not completed for two (#608, and 610) of 25 residents reviewed for assessments, out of a total sample of 25 residents. This deficient practice placed all 110 facility residents who receive care and services per physician's orders and plans of care at risk for serious harm, and or death. Findings include: The immediacy was removed on 2/14/17 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained at a pattern with actual harm that is not immediate jeopardy. Resident #610 On 2/12/17 at 8:30 am, an initial tour of the facility was conducted. During the tour Resident #610 was observed in her bed on a specialty low air loss mattress (a mattress used for residents with, or at risk of developing pressure ulcers. Resident #610 was on her back and her heels were not floated off the bed to prevent pressure to the bony prominence. On 2/12/17 at 10:00 am, a list of residents with pressure ulcers was provided by the facility. Resident #610 had been identified as acquiring a stage III pressure ulcer (full thickness tissue loss where subcutaneous fat may be visible and wound may have slough, ulcer could also have undermining or tunneling) on her right buttocks while residing in the facility. On 2/12/17 at 1:10 pm, Resident #610 was observed in bed, on her back and her heels were not floated off the bed; as well as pillows were not observed at the foot of the bed to be used to float heels. Observations of the resident being on her back and her heels not floated or pillows not present at the foot of the bed were also made on: 2/13/17 at 7:30 am, and 2/14/17 at 7:25 am, and 4:45 pm. On 2/12/17 at 2:05 pm, a review of Resident #610's clinical record was conducted. The record revealed an admission date of [DATE] with diagnoses that included: [MEDICAL CONDITION] disease, [MEDICAL CONDITION], heart failure, [MEDICAL CONDITION], and chronic pain. A review of Resident #610's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #610 required extensive 2 person assist with transferring and bed mobility. It was discovered that on 1/21/17, a new [DIAGNOSES REDACTED].#610's diagnosis list. The last Braden score (a score used to measure risk for the development of pressure ulcers) for Resident #610 had been conducted on 11/12/16 indicating a high risk. A review of Resident #610's assessments was conducted and revealed that the last time any type of skin assessment had been performed for Resident #610 had taken place on 12/29/16 in the form of a daily nursing assessment form. The assessment did not indicate that Resident #610 had any skin conditions or abnormalities. A wound care consult dated 1/21/17 was discovered in Resident #610's paper chart and was determined to be the first written indication of Resident #610 having developed a pressure ulcer. The wound care consult read, R. (right) buttock 1.8. x 1.5 x < 0.01 cm (centimeter), pink base, minimal serous drainage, irregular edges .Diagnosis: [REDACTED]. Buttock .Recommendations: . 2. Frequently reposition, 3. Pressure reduction mattress . A review of the treatment administration record for the month of January was conducted and revealed an order to apply a wound care treatment on the Resident's left buttock, and had been documented as being done, but the orders did not indicate an order for [REDACTED]. At that time, a second wound care consultant dated 1/26/17 read, .Diagnosis: [REDACTED]. buttocks .Recommendations: 1. [MEDICATION NAME] gel (wound care treatment), 2. frequently re-position, 3. low air loss mattress, 4. elevate BLE (bilateral lower extremities) . Orders for Resident #610 were reviewed and it was discovered that the recommendations made on 1/21/17 and 1/26/17 (for frequent re-positioning, low air loss mattress, Medi-honey gel, and elevating bilateral lower extremities, to prevent the development of ulcers on the heels) were not written and implemented until 2/4/17 up to as many as 14 days after they were recommended by the wound care consultant. It was also noted that on 2/4/17 orders were placed for Weekly Skin Checks and Head to toe Skin checks, but no evidence of skin monitoring had been in place prior to the development and worsening of the pressure ulcer on Resident #610's right buttock. A review of Resident #610's care plans for Potential for Skin Breakdown initiated on 10/16/16 was reviewed on 2/12/17 at 3:00 pm. The following interventions and initiation dates were noted: Elevate BLE's (bilateral lower extremities) 2/10/17, Nurse to check skin weekly 1/9/17, Pressure reducing mattress to bed 1/9/17, Reposition frequently when in bed and in w/c (wheelchair) 2/10/17, Weekly treatment documentation to include measurement of each area of skin breakdown width length, depth, type of tissue and exudate and any other notable changes or observations 2/10/17. On 2/12/17 at 4:10 pm, a wound care observation with Licensed Practical Nurse (LPN) 'C' was conducted. During the observation, Resident #610's heels were not observed to be floated off the mattress. LPN 'C' was asked if they were supposed to be floated and she stated, I don't remember. LPN 'C' removed Resident #610's brief and it was discovered there was not a dressing on Resident #610's right buttocks wound. The wound was observed as approximately 2 x 2 cm wound with a reddened base and irregular edges. At the time of the observation of the wound, it was noted that Resident #610 had stool in her gluteal fold. LPN 'C' was asked about the missing dressing on the wound and explained that the CNA's (certified nursing assistants) probably just changed her brief and that's why she didn't have a dressing on the wound. When asked if the CNA's should have informed her that the dressing was not in place she stated, Yes, some days it works better than others. LPN 'C' applied the [MEDICATION NAME] treatment, covered the wound with a dressing and re-closed the brief. LPN 'C' was not observed to provide incontinence care prior to cleansing the wound, applying the treatment, or after the treatment was completed. On 2/12/17 at 4:30 pm, an interview with the facility's Director of Nursing (DON) was conducted. The DON indicated she knew about the wound on the buttocks, but was unaware of when it developed. The DON had no other explanations regarding concerns brought to her attention regarding Resident #610's wound. Resident #609 On 2/12/17 at 8:15 A.M., during a tour of the facility, Resident #609 was observed seated in a wheelchair wearing a hospital gown. Resident #609's bilateral lower legs were observed to be wrapped with elastic bandages. Resident #609's skin above the elastic bandages was observed to be bright red in color with some swelling. Resident #609's right leg had a dressing underneath the elastic bandage that was soiled with yellow drainage. The tape on the outside of the elastic bandages was not dated. Resident #609 stated, I have an infection in my leg. I have [MEDICAL CONDITION]. I saw the wound doctor on Friday (2/10/17) and he told me that my right leg got worse and was infected and needed antibiotics and treatment twice a day, and a steroid. He said it bursted out worse than it was and opened up and was leaking drainage .I haven't had any treatment to my legs since Friday when I saw the wound doctor, it's Sunday today. I never got antibiotics. They said it's the pharmacy and that they never called them back when they called yesterday. On 2/12/17 at 4:00 P.M., Resident #609 was observed seated in the wheelchair with elastic bandages on his bilateral lower legs. Resident #609 stated, They finally changed by bandages, but I still haven't gotten my antibiotics. On 2/14/17 at 11:00 A.M., Resident #609 reported that the elastic bandages on his bilateral legs were supposed to be removed at night, but more times than not, that doesn't happen. I need them to do it right because I get swelling in my legs. On 2/12/17 at 4:33 P.M., Resident #609's clinical record was reviewed and revealed the following: Resident #609 was admitted into the facility on [DATE] with diagnoses that included: acute and chronic [MEDICAL CONDITIONS], type two diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION] of right and left limb. An MDS assessment dated [DATE] documented Resident #609 had intact cognition, required extensive physical assistance from one staff member for bed mobility, transfers, and activities of daily living, and had one venous ulcer (a skin ulcer that develops due to poor circulation). Physician's Order were reviewed for February 2017 and revealed an order dated 2/3/17 that documented, .Cleanse rt (right) anterior (front) leg with NS (normal saline), apply Xeroform (a medicated gauze), ABD pad (absorbent dressing) and wrap with Kerlix (gauze used to wrap a wound). There were no orders for treatment or topical antibiotic from 2/10/17 (as stated by Resident #609). On 2/13/17 at 2:35 P.M., Nurse A was interviewed regarding Resident #609 and the treatment to his right anterior leg. Nurse A stated, He (Resident #609) is saying he saw the wound doctor on Friday and he told him that he needs a cream and a topical antibiotic. I don't think he would order a topical antibiotic, but I don't know. Nurse A was asked how orders from the wound care doctor were communicated to the facility. Nurse A stated, They (wound care doctors) come in on Fridays, have a sheet that they fill out, then they give it to the nurse, discuss anything that needs to be discussed, write it up, and then the nurses put the orders in. They (wound care doctor) used to tell (the former assistant director of nursing) but he quit so I don't know what happens anymore. I don't know where their documentation is. Nurse A was queried about whether or not she followed up with anyone after Resident #609 reported that he did not receive the treatment explained to him by the wound care doctor. Nurse A stated, I asked (the DON) and she said she would get back to me. When queried about whether or not the wound doctor was contacted to clarify any changes in orders, Nurse A stated, I don't know how to contact them. I don't know who is doing what. I can log (Resident #609) to be seen this Friday (in four days). On 2/13/17 at 4:30 P.M., the DON was interviewed regarding the process of communication between the wound doctor and the facility. The DON reported that the wound doctor came on Fridays, they fill out a form, and give it to the nurses. When asked who was responsible to enter any new treatment orders, the DON reported that it was the nurses' responsibility. The DON was asked where the wound care consultation for Resident #609 from Friday 2/10/17 would be located. The DON reviewed a pile of wound care consultations and presented one for Resident #609 that was reviewed at that time. A Vascular & Wound Consultation dated 2/10/17 documented the following treatment order recommendations, [MEDICATION NAME] Cream 50 g (gram) + [MEDICATION NAME] (a cream used to reduce redness, itching, and swelling) 45 g + [MEDICATION NAME] ointment (a topical antibiotic to treat skin infections) 45 g BID (two times a day) and PRN (as needed) to right anterior leg and right popliteal/calf x 14 days as needed AND every day and evening shift for 14 days. The DON reported that Resident #609 should have received the new treatment immediately. The DON reviewed Resident #609's clinical record and reported that the above order had not been processed. All wound consults were requested at that time. On 2/14/17 at 8:00 A.M., Resident #609's clinical record and previous wound consults were reviewed and revealed the following: A Nursing Admission Assessment dated 12/28/16 documented Resident #609 had .Redness/[MEDICAL CONDITION] to LLE (left lower extremity), no drainage .Redness/[MEDICAL CONDITION] and 2 open, dry spots to RLE (right lower extremity) . A Skin-Head to Toe Skin Check assessment from 1/5/17 was left blank. A Skin assessment dated [DATE] documented, R (right) leg open with weeping areas .L (left) leg with new weeping areas . It was documented that the areas noted were vascular in nature. There were no other skin assessments completed for Resident #609. The Treatment Administration Records (TAR) from January and February 2017 documented that skin assessments were completed (indicated by the nurse's signature) on 1/12/17, 1/19/17, 1/26/17 with no corresponding skin assessment document. A TAR from January 2017 documented a physician's order from 1/1/17 and discontinued on 1/6/17 to Cleanse open areas right lower leg with cleanser, pat dry, apply Xeroform dressing, cover with 4 x 4, wrap with Kerlix to secure, every 2 days and as needed, every night shift every 2 days. The TAR documented (indicated by the absence of a nurse's electronic signature) that the treatment was not administered on 1/1/17, 1/5/17, and 1/7/17. A wound consult dated 1/6/17 documented .Assessment: R lateral leg 0.4 (cm -centimeters) x 0.3 (cm) x <0.01 (cm), pink base, minimal serous drainage, irregular edges, BLE 4+ [MEDICAL CONDITION] (swollen due to fluid accumulation with very deep pitting and grossly distorted in appearance) .Diagnosis: [REDACTED].Recommendation: Xeroform QD (daily)/PRN to R lateral leg, 2. (Elastic) wraps to BLE (bilateral lower extremities) on in AM, off in PM . The January 2017 TAR documented the order above (xeroform daily and prn) beginning 1/9/17. The TAR documented that the treatment was not administered on 1/11/17 and 1/21/17. A wound consult dated 1/21/17 documented, .R anterior leg, 10.5 (cm) x 9.0 (cm), pink base, moderate serous drainage, irregular edges, BLE 4+ [MEDICAL CONDITION] .Recommendations: [MEDICATION NAME] (a wound treatment used to prevent infections) on ABD direct QD/PRN R leg .ACE wrap on in AM, off in PM . A wound consult dated 1/27/17 documented, .R anterior leg 9.8 x 8.0 cm .moderate yellow slough (dead tissue usually white or yellow in color), heavy serous drainage .+4 [MEDICAL CONDITION] BLE .Recommendations: [MEDICATION NAME] on ABD direct QD/PRN R leg .ACE wraps on in AM, off PM . The February 2017 TAR documented the [MEDICATION NAME] order beginning on 1/21/17 and discontinued on 2/3/17. The TAR documented that the treatment was not administered on 2/1/17 and 2/3/17. A wound consult on 2/3/17 documented, .R anterior leg 7.5 x 7.0 cm multiple wounds, pink bases, moderate serous drainage .4+ [MEDICAL CONDITION] to BLE . The February 2017 TAR documented the following regarding the application and removal of the elastic bandages: The elastic bandages were not applied on 2/2/17, 2/3/17, 2/4/17, 2/5/17, 2/8/17, 2/11/17 and were not removed at night on 2/1/17 and 2/7/17. There were no care plans developed for venous ulcers, skin management, or [MEDICAL CONDITION]. Resident #608 On 2/12/17 at 12:30 P.M., family members of Resident #608 reported noticing a dark area on Resident #608's right heel over the weekend. The family member reported they were not sure what it was or how it happened. On 2/12/17 at 3:20 P.M., Resident #608's clinical record was reviewed and revealed the following: Resident #608 was admitted into the facility on [DATE] with diagnoses that included: femur fracture, traumatic subdural hemorrhage (bleeding between the skull and the brain due to trauma to the head), [MEDICAL CONDITION], patella fracture (knee cap), dysphagia, and history of falling. An MDS assessment dated [DATE] documented Resident #608 had severely impaired cognition, required extensive physical assistance from two or more staff members for transfers and bed mobility, was at risk for pressure ulcers, and had two or more falls since admission. On 2/13/17 at 8:50 A.M., an observation of Resident #608's feet was conducted with the DON. A dark colored area was observed on the back of Resident #608's right heel. When queried about what the dark area was, the DON stated, It looks like a scab. On 2/13/17 at 2:25 A.M., Resident #608 was observed seated in a wheelchair in the hallway of the 1st Street Unit. Resident #608's heels were pressed directly against the foot rest of the wheelchair. CNA Y was interviewed regarding the process for skin assessments. CNA Y stated, The nurses do the initial ones. We check their skin during showers and let the nurse know if anything is wrong. When queried about any observations of any skin changes on Resident #608, CNA Y stated, I noticed that his tailbone is red but I haven't had a chance to tell the nurse yet. CNA Y was asked if she had noticed anything on Resident #608's heels. CNA Y stated, I've never noticed anything. I don't know. I'm afraid of doing anything with his leg because he has that brace and I don't know where it hurts him so I haven't really checked his feet. On 2/13/17 at 2:35 P.M., Nurse A was interviewed about when nurses completed skin assessments. Nurse A reported skin assessments are supposed to be completed weekly. When queried about what the dark area on Resident #608's right heel was, Nurse A stated, I don't know what that is. (Resident #608's) daughter said there were undocumented falls. When asked where changes in skin would be documented and what would be done to follow up, Nurse A stated, It would be documented in the skin assessment and progress note or daily nurses note and we would contact wound care, but the guy doing wound care quit. Nurse A was asked if the dark area on Resident #608's right heel was documented anywhere and if wound care was notified. Nurse A stated, Probably not. Nurse A reviewed Resident #608s clinical record and reported that the last skin assessment was on 2/3/17 and there were no changes in skin documented. Nurse A reviewed the Daily Nurses Notes and reported there were no changes to Resident #608's skin noted. On 2/13/17 at 4:30 P.M., the DON was interviewed regarding the facility's process for identifying and addressing skin alterations. The DON stated, Nurses do weekly skin assessments. Any new skin issues get logged for the wound care doctor, the staff would let me know, an I&A (incident and accident) report would be filled out if necessary. When asked if she was aware of the skin alteration on Resident #608's right heel, the DON indicated she was not. Skin Assessments were reviewed with the DON at that time and revealed that Resident #608's last skin assessment was completed on 2/3/17 (10 days prior) and it was documented that his skin was intact. When queried about when the dark area on Resident #608's heel first developed, the DON reported that she did not know. On 2/13/17 at 5:15 P.M., Resident #608's clinical record was further reviewed and revealed the following: A care plan initiated and last revised on 1/18/17 that documented, Resident has potential skin issues related to: Potential Breakdown. Interventions were documented as, Notify MD of changes in wound or emerging wounds .Observe wound healing .Provide wound care/preventative skin care per order .Skin checks weekly per facility protocol, document findings .Turn and reposition frequently to decrease pressure . Progress Notes were reviewed since Resident #608's admitted on 1/16/17 through 2/13/17. There was no documentation regarding Resident #608's right heel. Skin-Head to Toe Skin Checks assessments were reviewed since admission. On 1/18/17, 1/27/17, and 2/3/17 there was no documentation of any changes in skin to Resident #608's right heel. On 2/14/17 at 3:00 pm, a review of the facility's policy titled, Skin Management with a revision date of August 2012 read, .2. The Braden Scale will be completed .quarterly, annually, and with a significant change of status for their risk of development of pressure ulcers .16. Skin assessments a. Weekly Skin Check will be transcribed onto the Treatment Record .b. Completion of the weekly skin assessment will be noted on the treatment Administration Record (TAR) .c. Skin assessment findings will be documented weekly on the Head to to Skin Check form .D. A Change in condition form .is to be completed and new physician's order obtained for new incidence of compromised skin integrity .17. Pressure ulcers are measured and staged weekly in accordance with the practice guidelines . A second review of the facility's policy titled, Skin Management was reviewed on 2/14/17 at 3:15 P.M. and it documented the following: .The nurse will assure treatments, interventions, Care Plan, and the appropriate skin documentation records are initiated in a timely manner . .A care plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown . .A physician's order will be written to monitor each ulcer and documentation on the TAR will reflect the status of the dressing, surrounding skin color and skin and pain associated with the wound . .Licensed nurse will record .If any abnormalities are observed, document a descriptive note of findings AND the Licensed Nurses response in the Nurses Notes section of the resident's medical record . The facility's policy titled, Physician Orders was reviewed on 2/14/17 at 3:20 P.M. and it documented, Physician's orders are obtained to provide clear direction regarding the care of the resident . Resident #614 On 2/12/17 at 8:50 A.M., Resident #614 was observed lying in bed. Resident #614 stated, Can you please help me. Nobody cares here. I can't get any help. I've only been here for a week or a few days. I'm in so much pain and nobody will give me my pain medications. I'm supposed to get them every 4 hours and they keep telling me they will give it to me. I've been waiting since 6 or 7 A.M. and now it's almost 9. They ask me how much pain I'm in between 1 and 10 and it's a 20! and they tell me I have to wait. I have lower lumbar stenosis and neck problems with nerves. I had surgery. They need to call my doctor because he knows about my pain. Resident #614 became tearful and stated, If they don't bring me my pain pill soon, I'm going to call 911 and go back to the hospital. Resident #614 pressed the call light at that time. CNA Y entered the room. Resident #614 asked CNA Y if he could have his pain medication. CNA Y stated, You already asked. The nurse is doing her rounds and when she gets to you, you will get it. On 2/12/17 at 1:00 P.M., Resident #614's clinical record was reviewed and revealed that Resident #614 was admitted into the facility on [DATE]. There were no diagnoses documented in the electronic clinical record. Physician's orders documented (brand name of narcotic pain medication) tablet 7.5-325 MG (milligram) give tablet by mouth every 4 hours as needed for pain. The MAR for February 2017 documented that Resident #614 received the narcotic pain medication at 12:07 A.M. on 2/12/17. No other doses of the as needed narcotic pain medication were documented as administered. On 2/12/17 at 1:35 P.M., Resident #614 was observed lying in bed. Resident #614 was asked if he received the pain medication he requested this morning. Resident #614 stated, No! This is horrible. I know I'm supposed to get it every four hours. I keep telling them to contact my surgeon because he knows about my pain. On 2/12/17 at approximately 2:00 P.M., Nurse A was asked when Resident #614 last received pain medication. Nurse A stated, I think he's confused. He keeps saying he gets something every four hours but I don't have an order for [REDACTED].#614's medication orders were reviewed with Nurse A at that time. There was a physician's order for a narcotic pain medication to be given every four hours as needed. Nurse A stated, I gave it to him at 9:00 Nurse A was asked to provide the documentation that the narcotic pain medication was administered. Nurse A stated, I didn't document it. When queried about why Nurse A did not document after administering a narcotic medication, Nurse A stated, I gave him Tylenol, not (the narcotic pain medication). Nurse A was asked to pull up the order for Tylenol for Resident #614. Nurse A stated, It's not entered. It's a standing order. When asked why a medication was given that there was no physician's order for, Nurse A stated, It's a standing order. I am going to enter it and then document that it was given. I wouldn't document it if it didn't actually happen. When queried about why Resident #614 was not given the narcotic pain medication that was ordered to be given as needed when he requested pain medication, Nurse A stated, He said he wasn't in that much pain. At that time, Nurse A brought the narcotic pain medication into Resident #614's room and offered it to him. Nurse A stated to Resident #614, I told you 2:00 P.M. was when you could get your medication again. Resident #614 stated, I can't have the time keep changing like that. I get it every 4 hours. I want to speak with my surgeon. I want you to speak with my surgeon. Nurse A stated, You have to ask us if you want pain meds because your order is not scheduled. Resident #614 stated, I did ask. I've been waiting. A lunch tray was observed at Resident #614's bedside untouched. Nurse A picked up the tray and began to remove it from the room. When queried about whether or not Resident #614 was done eating, Nurse A asked Resident #614 if he wanted to eat. Resident #614 stated, What is it? I didn't even try it because I was waiting for my pain medication. I can't eat when I'm in pain. On 2/12/17 at 2:37 P.M., Nurse A was asked to provide the narcotic reconciliation form. It was reviewed with Nurse A and it documented that Resident #614 received the narcotic pain medication on 2/12/17 at 12:07 A.M., 4:00 A.M. (not documented on the MAR), and 2:00 P.M. On 2/12/17 at 3:00 P.M., the MAR for Resident #614 was reviewed and documented that Resident #614's pain level at 2:40 P.M. was a 7 (on a scale of 1-10 with 10 being the worst pain possible). The DON was interviewed on 2/12/17 at 5:00 P.M. regarding the facility's process for standing orders for medications. The DON stated, I can't really answer that because I don't even know if we do them here. The DON was asked if there was a standing order for a medication would it be in the electronic medical record in the physician's orders and on the MAR. The DON stated, Yes. It would be on there. The DON reported that all physician's orders would be in the electronic medical record. When asked if nurses should administer a medication without a physician's order, the DON reported that they should not. Resident #614's physician's orders and MAR was reviewed with the DON at that time. When queried about when Resident #614 could have received the narcotic pain medication if it was documented on the narcotic reconciliation form that he last received it at 4:00 A.M., the DON stated, At 8:00 A.M. (Six hours before Resident #614 received the next dose of narcotic pain medication). On 2/13/17 at 2:10 P.M., Resident #614's clinical record was further reviewed and revealed a care plan dated 2/10/17 that documented, (Resident #614) has actual pain related to: surgical site .Observe for signs/symptoms of verbal and non-verbal indicators of pain at each medication pass, and periodically .Notify MD of unrelieved pain .Provide medication as ordered and document effectiveness results of medication administration . A Pain Assessment completed on admission on 2/10/17 documented that Resident #614 had frequent pain related to cervical (neck) spine surgery. Resident #618 On 2/13/17 at 2:55 p.m., Resident #618 was observed in her room sitting in a wheelchair wearing non-skid socks. Her left foot was observed swollen. When asked about the swelling, Resident #618 stated, I have it (pain) frequently in my left foot. It's always swollen, and the bottom is tender to the touch. My foot wakes me up at night. Resident #618 further stated, About one to two weeks ago, I asked the nurse for something extra for pain. She said she would check on it, but she never came back. When asked what time did that happen, Resident #618 stated, It was between the hours of midnight and 6:00 a.m. in the morning. A review of the clinical record revealed Resident #618 was admitted into the facility on [DATE] with diagnoses that included muscle weakness, [MEDICAL CONDITIONS], hypertension, and [MEDICAL CONDITION]. Further review of a quarterly MDS assessment dated [DATE] revealed Resident #618's BIMS (Brief Interview for Mental Status) score was 15 which indicated Resident #618 was cognitively intact for decision-making. A physician's order dated 7/29/16 documented Tylenol Tablet 325 mg (milligrams) ([MEDICATION NAME]), give 2 tablets orally every 4 hours as needed for pain . A review of the facility's January 2017 and February 2017 MARs revealed Resident #618 last received Tylenol on 1/25/17 at 2054 (8:54 p.m.) There was no documentation that Resident #618 had received any medication for pain from 2/1/17 through 2/13/17, even after Resident #618 stated she had complaints of pain. A physician's order dated 7/29/16 documented Weekly skin check by licensed nurse every night shift every wed, complete head to toe skin assessment under assessment tab. A review of the facility's January 2017 and February 2017 MARs (Medication Administration Records) revealed Resident #618's skin checks were not documented as completed on 1/11/17, 1/17/17, 2/1/17, and 2/8/17. A physician's order dated 9/20/16 documented Antifungal cream under toes, left foot every shift. A review of the MARs revealed Resident #618's medication was not documented as completed on the following dates: 1/5/17, 1/11/17, 1/13/17, 1/14/17, 1/20/17, 1/21/17, 1/26/17, 1/27/17 (0700), 1/27/17 (1900), 2/1-4/17, 2/9-10/17 (1900), and 2/13/17 (0700). A review of the nurses' Progress Notes dated 1/5/17 through 2/13/17 did not reveal Resident #618 had refused any of her medications. Further review of the facility's care plan for pain initiated 09/01/2016 and revised 02/11/2017 revealed the following: (Resident's name) has pain potential. Date Initiated: 09/01/2016 - Revision on: 02/26/2016: Administer pain medication prior to treatments and therapy, if indicated Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care . On 2/14/17 at 2:30 p.m., during an interview, when queried about Resident #618's missed medications and request for pain medication, the DON stated, Nurses should provide the medication, especially if it is requested, and assess the resident for pain. Resident #615 An interview was conducted with Resident #615's family member on 2/12/17 at 5:40 PM. Resident #615's family member indicated that the member had a spinal cord injury and has lost more function since her admission into the facility.

This citation pertains to Intake #MI 491 Based on observation, interview, and record review, the facility failed to ensure two (#612 and #616) of 22 residents reviewed for abuse, from a total sample of 25, one (#105) supplemental sampled resident, and 10 residents who attended a confidential group interview, were free from verbal abuse by staff and a resident, resulting in Resident #612 overhearing verbal abuse by staff toward Resident #105, Resident #616 being verbally abused by staff, and residents who attended group feeling intimidated and experienced mental anguish after Resident #616 verbally abused them. Findings include: Resident #612 and #105 On 2/12/17 at 8:30 A.M., during a tour of the facility, Resident #612 reported hearing aides humiliating another resident across the hall and reported it . Concern Forms and any investigations conducted by the facility were requested for Resident #612. On 2/14/17 at 11:35 A.M. a Concern Form - Action dated 1/1/17 completed by Staff CC documented, .(Resident #612) (reported) Certified Nursing Assistant - CNA X or W stated they don't get paid enough to clean up s**t. (Resident #612) overheard CNA W say to another resident that they s**t themselves on purpose and it really smelled. CNA W then stated she doesn't get paid enough to do this job . An investigation conducted by the facility for the above incident was reviewed at this time and it revealed the following: A signed Interview with CNA W on 1/4/17 regarding incident on 12/31/16 documented, At approximately 4 or 4:30 A.M. CNA X and CNA W went down 400 hall to do bed checks. Resident (#105) was found lying in bed with (another resident). Resident #105 had a brief (for incontinence) on with loose stools .CNA X asked CNA W is she wanted to take care of (Resident #105) or answer (Resident #612's) call light. CNA W stated with her hand over her mouth and nose that 'the smell was too bad and I can't stomach that .CNA W chose to answer (Resident #612's) call light . Resident #612 stated, 'Don't hurt her. Please don't hurt me bad . A documented interview with Resident #612 on 1/2/17 documented, .While in the room, (Resident #612) over heard two resident care specialists (CNAs) in the hall stating: I am not cleaning up that s**t. I am about to throw up. One (CNA) came into Resident #612's room and Resident #612 stated: If the look on your face and hearing what you are saying about the other residents, you don't have to change me. I see you all don't want to do your job .(CNA) replied: I am not going to mistreat you. Resident #612 replied: I (am) talking about how you treat the other residents .(CNA) left her (Resident #612) room and was overheard talking and laughing with another (CNA) about two other residents . A written statement by Nurse O dated 1/1/7 documented, This A.M., (Resident #612) was sitting at the top of 4th street in front of the nursing station .She began saying that the aides on mn's (midnight shift) are mean and (rude) to the people .They went into the room across from (Resident #612) and was (yelling) .saying you s(m)ell we are (tired) of cleaning your up, that's why noon want to come in here . A written statement by CNA DD dated 1/1/17 documented, I .was call in to room .by Resident #612 .Resident #612 told me the (CNA) was very rude talking about residents. The residents ask for help they was very rude to the residents, verbal abuse to the residents. She did not feel safe at all. She was afraid to ask them for assistance or help with care. Resident #612 said the (CNA) said they do not get (paid) enough for smell s**t. She know when she s**t and gave her a dirty look . The Administrator was interviewed on 2/14/17 at 12:00 P.M. regarding the concern form and investigation mentioned above involving Resident #612 and #105. The Administrator stated, We discussed this and because it was in the hallway and not in the resident's room, it isn't considered abuse. It was just a conversation amongst themselves, not directly to the residents. A review of Resident #612 clinical record was conducted on 2/12/17 at 3:00 PM and revealed, Resident #612 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #612 was alert and oriented x3 with some noted confusion and forgetfulness. Resident #612 required one person assistance from staff for all activities of daily living. The clinical record for Resident #105 was reviewed on 2/14/17 at 1:15 P.M. and revealed the following: Resident #105 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #105 had severely impaired cognition and required extensive physical assistance from one staff member for toilet use. Resident #616 and Group Residents On 2/13/17 at 8:25 am, Resident #616 was observed seated in her wheelchair at the nurses station shared by the 300 and 400 unit. Resident #616 was agitated, and was referring to staff and other residents with vulgar and profane language. Resident #616 was overheard to be calling multiple people in the area by inappropriate racial slurs. Attempts by staff to calm the resident were not successful, and Resident #616 continued her behavior of verbally harassing passers-by. On 2/13/17 at 8:30 am, Dietary Staff member 'M' was observed delivering a meal cart to the 400 unit. After leaving the meal cart on the unit he proceeded back up the hallway towards the nursing station where Resident #616 was seated in her wheelchair. Resident #616 referred to Dietary Staff member 'M' with a racial slur, and as he was walking away from Resident #616 back towards the kitchen he was observed to point back towards Resident #616 and say, I don't give a f**k what she says. On 2/13/17 at approximately 8:40 am, Dietary Staff member 'M' was observed near the 300/400 nurses station. Dietary Staff member 'M' approached the State Surveyor, pointed towards Resident #616 and stated, Can you do something about her before I knock her out. On 2/13/17 at 8:45 am, the incident was reported to the facility's Abuse Coordinator. The Abuse Coordinator had no comment on the incident. On 2/13/17 at 2:30 pm, a review of Resident #616's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] indicated moderately impaired cognition. On 2/13/17 at 10:00 A.M., a confidential group interview was conducted. During the interview, 10 residents expressed negative feelings related to another resident (Resident #616) who had been seated in the hallway between units three and four since last night screaming at everyone. The following statements were made during the group interview: I was just going to get some coffee, crossing through the area and (Resident #616) started saying, 'There's that (expletive) . It is so disturbing. The things (Resident #616) is saying to everyone, residents and staff. Other residents are suffering because of her because all the staff is tied up tending to her. I can't even come out of my hallway. She's just so horrible. She calls me (vulgar and profane language). It makes me feel so awful. (Resident #616) told me, 'I hope you die.' Nobody should have to hear those kind of things. It's hurting everyone. I don't know why (Resident #616) is still here. She needs help or something, but we shouldn't suffer because of it. When I asked the workers what could be done about it, they just told me to go another way. When asked by a show of hands, how many residents were affected by Resident #616's behavior, 10 out of 16 residents in attendance raised their hands. On 2/14/17 at 3:30 pm, a review of the facility's policy titled, Abuse & Neglect Prohibition with a revision date of January 2017 read, Each resident has the right to be free from mistreatment, neglect, abuse, exploitation, involuntary seclusion, corporal punishment, physical or chemical restraint not required to treat the resident's medical symptoms, injuries of unknown origin, and misappropriation of resident property .Verbal abuse is defined as the use of oral , written, or gestured language that willfully includes disparaging and derogatory terms to residents or to others regarding the resident, or within the resident's hearing distance regardless of their age, ability to comprehend, or disability . The facility was asked if they had any additional information to provide regarding the concern, none was received by the end of the survey.

Based on observation, interview, and record review, the facility failed to perform assessessments, implement physician ordered interventions, ensure treatments were in place, and perform wound care using aseptic technique, for one two residents reviewed for pressure ulcers (Resident #610 and #611) out of four residents reviewed for pressure ulcers, out of a total sample of 25 residents, resulting in the development of a stage III (full thickness tissue loss where subcutaneous fat may be visible and wound may have slough, ulcer could also have undermining or tunneling) pressure ulcer, the potential for the worsening of existing pressure ulcers, and the development of new pressure ulcers. Findings include: Resident #610 On 2/12/17 at 8:30 am, an initial tour of the facility was conducted. During the tour Resident #610 was observed in her bed on a specialty low air loss mattress (a mattress used for resident's with, or at risk of developing pressure ulcers.) Resident #610 was on her back and her heels were not floated off the bed to prevent pressure to the bony prominence. On 2/12/17 at 10:00 am, a list of residents with pressure ulcers was provided by the facility. Resident #610 had been identified as acquiring a stage III pressure ulcer on her right buttocks while residing in the facility. On 2/12/17 at 1:10 pm, Resident #610 was observed in bed, on her back and her heels were not floated off the bed; as well as pillows were not observed at the foot of the bed to be used to float heels. Resident #610 was asked if staff elevate her feet or assist to turn. She indicated they do not elevate her feet, and stated, Sometimes they help me turn. I know they are busy. Observations of the resident being on her back and her heels not floated or pillows not present at the foot of the bed were also made on: 2/13/17 at 7:30 am, and 2/14/17 at 7:25 am, and 4:45 pm. On 2/12/17 at 2:05 pm, a review of Resident #610's clinical record was conducted. The record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of Resident #610's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #610 required extensive 2 person assist with transferring and bed mobility. It was discovered that on 1/21/17, a new [DIAGNOSES REDACTED].#610's [DIAGNOSES REDACTED].#610 had been conducted on 11/12/16 indicating a high risk. A review of Resident #610's assessments was conducted and revealed that the last time any type of skin assessment had been performed for Resident #610 had taken place on 12/29/16 in the form of a daily nursing assessment form. The assessment did not indicate that Resident #610 had any skin conditions or abnormalities. A wound care consult dated 1/21/16 was discovered in Resident #610's paper chart and was determined to be the first written indication of Resident #610 having developed a pressure ulcer. The wound care consult read, R. (right) buttock 1.8. x 1.5 x < 0.01 cm (centimeter), pink base, minimal serous drainage, irregular edges .Diagnosis: [REDACTED]. Buttock .Recommendations: . 2. Frequently reposition, 3. Pressure reduction mattress . A review of the treatment administration record for the month of January was conducted and revealed an order to apply a wound care treatment on the Resident's left buttock, and had been documented as being done, but the orders did not indicate an order for [REDACTED]. At that time, a second wound care consult dated 1/26/17 read, .Diagnosis: [REDACTED]. buttocks .Recommendations: 1. [MEDICATION NAME] gel (wound care treatment), 2. frequently re-position, 3. low air loss mattress, 4. elevate BLE (bilateral lower extremities) . Orders for Resident #610 were reviewed and it was discovered that all the recommendations made on 1/21/17 and 1/26/17 (for frequent re-positioning, low air loss mattress, Medi-honey gel, and elevating bilateral lower extremities, to prevent the development of ulcers on the heels) were not written and implemented until 2/4/17 up to as many as 14 days after they were recommended by the wound care consultant. It was also noted that on 2/4/17 orders were placed for Weekly Skin Checks and Head to toe Skin checks, but no evidence of skin monitoring had been in place prior to the development and worsening of the pressure ulcer on Resident #610's right buttock. A review of Resident #610's care plans for Potential for Skin Breakdown initiated on 10/16/16 was reviewed on 2/12/17 at 3:00 pm. The following interventions and initiation dates were noted: Elevate BLE's (bilateral lower extremities) 2/10/17, Nurse to check skin weekly 1/9/15, Pressure reducing mattress to bed 1/9/15, Reposition frequently when in bed and in w/c (wheelchair) 2/10/17, Weekly treatment documentation to include measurement of each area of skin breakdown width length, depth, type of tissue and exudate and any other notable changes or observations 7/10/15. On 2/12/17 at 4:10 pm, a wound care observation with Licensed Practical Nurse (LPN) 'C' was conducted. During the observation, Resident #610's heels were not observed to be floated off the mattress. LPN 'C' was asked if they were supposed to be floated and she stated, I don't remember. LPN 'C' removed Resident #610's brief and it was discovered there was not a dressing on Resident #610's right buttocks wound. The wound was observed as approximately 2 x 2 cm wound with a reddened base and irregular edges. At the time of the observation of the wound, it was noted that Resident #610 had stool in her gluteal cleft. LPN 'C' was asked about the missing dressing on the wound and explained that the CNA's (certified nursing assistants) probably just changed her brief and that's why she didn't have a dressing on the wound. When asked if the CNA's should have informed her that the dressing was not in place she stated, Yes, some days it works better than others. LPN 'C' applied the [MEDICATION NAME] treatment, covered the wound with a dressing and re-closed the brief. LPN 'C' was not observed to change her gloves or perform hand hygiene during the cleansing and treatment application to the wound, or to provide incontinence care prior to cleansing the wound, applying the treatment, or after the treatment was completed. On 2/12/17 at 4:30 pm, an interview with the facility's Director of Nursing (DON) was conducted. The DON indicated she knew about the wound on the buttocks, but was unaware of when it developed. The DON had no other explanations regarding concerns brought to her attention regarding Resident #610's wound. On 2/14/17 at 3:00 pm a review of the facility's policy titled, Skin Management with a revision date of August 2012 read, .2. The Braden Scale will be completed .quarterly, annually, and with a significant change of status for their risk of development of pressure ulcers .16. Skin assessments a. Weekly Skin Check will be transcribed onto the Treatment Record .b. Completion of the weekly skin assessment will be noted on the treatment Administration Record (TAR) .c. Skin assessment findings will be documented weekly on the Head to to Skin Check form .D. A Change in condition form .is to be completed and new pysician's order obtained for new incidence of compromised skin integrity .17. Pressure ulcers are measured and staged weekly in accordance with the practice guidelines .

This citation pertains to Intake #MI 491 Based on interview and record review, the facility failed to investigate and report to the administrator and state agency actual and alleged neglect, alleged misappropriation of resident property (narcotic pain medication), and alleged physical abuse for three (#608, 612, and 615) of 22 residents reviewed for abuse from a total sample of 25, and one (#105) supplemental sampled resident; and protect residents after allegations of staff to resident abuse. This resulted in actual neglect and verbal abuse of Resident #608, #612, and #105 and the potential for undetected and continued abuse, neglect, and misappropriation of resident property that potentially could affect all 110 residents who resided in the facility, when allegations were not investigated and reported and alleged perpetrators continued to work in the facility. Findings include: #608 On 2/12/17 at 12:30 P.M., Resident #608's family member stated the following during an interview: The aides never come in to change him. They say, I have two halls, I can't do everything . I have found him (Resident #608) in a feces diaper and when I ask the aides to change him, they get in my face. He has waited two hours to get out of a feces diaper while I've been here. They say they aren't going to do it because he's combative and they can't do it alone. On 2/14/17 at 11:30 A.M., Concern Forms for Resident #608 were reviewed and revealed the following: A concern form dated 1/20/17 completed by Occupational Therapist (OT) BB documented, Upon arrival to patient's room for therapy, patient had double brief on and was filled with BM (bowel movement) and was dried on skin. Resident's buttocks (were) red. Therapist cleaned up patient, applied cream, and notified nurse. The concern form was addressed to the Director of Nursing (DON). A second concern form dated 1/23/17 completed by OT BB documented, Patient had 2 briefs on and was wet with urine. Notified nursing and RCS (resident care specialist - certified nursing assistant). The concern form was addressed to the DON. On 2/14/17 at 11:45 A.M., OT BB was interviewed regarding the above concern forms for Resident #608. OT BB stated, I went to the room to get (Resident #608) for therapy and he had two briefs on that were just filled with bowel movement. The feces was dried on his skin. I couldn't find any aides. So me and another therapist changed him and washed him, then told the nurse. OT BB was asked about the policy for reporting concerns of neglect. OT BB stated, I fill out a concern form and give it to my boss (Rehab Program Manager EE). She makes a copy and gives it to the DON. An interview was conducted with the Abuse Coordinator (Administrator) and the Director of Nursing (DON) on 2/14/17 at 12:00 P.M. The Administrator was asked what the facility's process was for addressing concern forms and allegations of abuse or neglect. The Administrator stated, Staff can contact me if I am in or out of the building. They should assess the situation and make sure the resident is safe. They can call (the DON) and she can get staff on the phone to start interviewing and start an investigation, then proceed if it needs to be reported. When queried about when an allegation of abuse would need to be reported, the Administrator stated, We go through the policy. When asked what the facility's policy was, the Administrator stated, We follow the state guidelines. When asked what the guidelines were, the Administrator stated, Abuse has to be reported .If it can be substantiated or alleged within 24 hours unless it's under the two hour rule. The Administrator was asked what was done when allegations of abuse or neglect were made against a facility staff member. The Administrator stated, We would immediately suspend the person and report immediately. The Administrator was further interviewed at this time and queried about the two concern forms mentioned above. When asked what the process was for addressing concern forms, the Administrator stated, They go to our customer service director who brings them to morning meeting. The two concern forms for Resident #608 completed by OT BB from 1/20/17 and 1/23/17 that documented Resident #608 being left soiled wearing two briefs on two occasions were reviewed with the Administrator. The Administrator reported that the two incidences were not reported to her. When queried about whether or not the incidences of neglect should be reported to the state agency, the Administrator stated, Under the new guideline, yes. The DON and Administrator were asked if the incidences were investigated and did not offer a response. On 2/12/17 at 3:20 P.M., Resident #608's clinical record was reviewed and revealed the following: Resident #608 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] documented Resident #608 had severely impaired cognition, required extensive physical assistance from two or more staff members for transfers, bed mobility, and toilet use, and was always incontinent of stool and urine. Resident #612 An interview was conducted with Resident #612 on 2/12/17 at 2:00 PM. Resident #612 indicated that a nurse who worked the afternoon/midnight shift (identified by Resident #612 as Nurse AA) had not administered medication ([MEDICATION NAME] - a narcotic pain medication) on several occasions. Resident #612 stated: She gave me something that looks like an aspirin and I say excuse me (Nurse AA) this ain't no oxy and she said yes it is- look at it. So I told her again and she persisted that it was. So, I put it in my drawer after she left. When queried regarding if the medication was still in her drawer, Resident # 612 stated: I cleaned out my drawer and threw it away. Resident #612 indicated that she had been taking [MEDICATION NAME] for years and had informed the Director of Nursing (DON) and the Assistant Director of Nursing as well as other nurses in the facility. Resident #612 further indicated that the nurse had bumped her real hard on the shoulder (could not specify date of occurrence). Resident #612 stated: I waited for her and asked if she had an issue with me. She (Nurse AA) told me that I heard you was spreading rumors about me. Resident #612 indicated that the nurse had continued to provided care to her and had provided care on the afternoon/midnight shift of 2/11/2017. A review of Resident #612's clinical record was conducted on 2/12/17 at 3:00 PM and revealed, Resident #612 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #612 was alert and oriented times 3 with some noted confusion and forgetfulness. Resident #612 required one person assistance from staff for all activities of daily living. A second interview with Resident #612 was conducted on 2/14/17 at 9:00 AM. Resident #612 indicated that Nurse 'T' had provided care on the midnight shift on 2/13/17 and was aware of her concern with Nurse AA who had not administered [MEDICATION NAME] but administered another medication. Resident #612 indicated that nurse 'T' showed her a red pill and asked if this was the medication that the nurse had administered to her in place of the [MEDICATION NAME]. Resident #612 stated: I told her yes this had been given to me but other times the pill had a crease in it like a tylenol or something. She (referring to Nurse 'T') indicted that the red pill was her room mate's blood pressure medication. Resident #612 stated: She (referring to nurse 'T') agreed to speak to you. An interview was conducted with Nurse 'T' on 2/14/17 at 10:00 AM. When queried regarding what she knew regarding Resident #612 being administered another medication instead of the [MEDICATION NAME], Nurse 'T' indicated that Resident #612 had expressed this concern and it had been reported to the DON. Nurse 'T' indicated that she believed that a nurse that worked the midnight shift was not giving her a medication. An interview was conducted with the DON on 2/14/17 at 10:50 AM. When queried regarding Resident #612's concerns with [MEDICATION NAME] not being administered as prescribed by Nurse AA, the DON stated: Yes, I was aware. The DON indicated that Resident #612 referred to the Nurse AA and stated: Resident said the pill wasn't the right thickness and said the pill was too wide. I spoke to the resident and to the nurse. The Nurse said no, I gave her exactly what was on the card. When queried further regarding if Resident # 612 had been given a concern form. The DON stated: Not aware of resident completing a concern form and can't remember if offered. I just sat the nurse down and discussed it with her. DON was further queried regarding if an investigation had been conducted and stated: No, I did not investigate. On 2/14/17 at 1:00 P.M., the Administrator was interviewed and asked if anyone had reported any incidences with Nurse AA and Resident #612. The Administrator reported that she had not heard anything. When asked if anything was reported regarding Nurse AA giving an unknown medication in place of Resident #612's narcotic pain medication, the Administrator indicated she did not know about it. Resident #612 and #105 On 2/12/17 at 8:30 A.M., during a tour of the facility, Resident #612 reported hearing aides humiliating another resident across the hall and reported it . Concern Forms and any investigations conducted by the facility were requested for Resident #612. On 2/14/17 at 11:35 A.M. a Concern Form - Action dated 1/1/17 completed by Staff CC documented, .(Resident #612) (reported) (Certified Nursing Assistant - CNA) X or W stated they don't get paid enough to clean up s**t. (Resident #612) overheard CNA W say to another resident that they s**t themselves on purpose and it really smelled. CNA W then stated she doesn't get paid enough to do this job. Resident #612 also told that a resident was locked in the bathroom for about 2 hours and CNA W refused to unlock the door and let her out . A written statement initialed by Staff CC documented, Called (the Administrator) at 1:07 P.M. and told her that Resident #612 stated that the aides that worked her hall on the night shift of 12/31/16 neglected to answer her call light for roughly 6 hours. After Resident #612's call light not being answered she got up and told the aide on the hall that she was wet. The aide threw their hands up and blew off the situation. I then told (the Administrator) that CNA W and CNA X were on the hall and they were saying extremely indignant things about residents regarding having to change them. I was told to try and find coverage for those 2 aides. I .found coverage along with (another staff member). The reason I contacted (the Administrator) was because she is our Abuse Coordinator. Furthermore, while CNA W and CNA X were changing residents they were saying out loud where other residents could (hear) that 'they s**t themselves on purpose', 'they don't get enough money and they are sick of dealing with this! .Upon telling (the Administrator) I removed the 2 suspected of these allegations CNA W and CNA X off the schedule. I was told by (the Administrator) to not take them off the schedule to instead take them off the hall and place those 2 on the other side of the building . An investigation conducted by the facility for the above incident was reviewed at this time and it revealed the following: A signed Interview with CNA W (one of the CNAs named in the concern form) on 1/4/17 (three days after the incident) regarding incident on 12/31/16 documented, At approximately 4 or 4:30 A.M. CNA X and CNA W went down 400 hall to do bed checks. Resident #105 was found lying in bed with (another resident). Resident #105 had a brief (for incontinence) on with loose stools .CNA X asked CNA W if she wanted to take care of (Resident #105) or answer (Resident #612's) call light. CNA W stated with her hand over her mouth and nose that 'the smell was too bad and I can't stomach that .CNA W chose to answer Resident #612's call light . Resident #612 stated, 'Don't hurt her. Please don't hurt me bad . A signed documented interview with CNA X (the other CNA named in the concern form) dated 1/6/17 (five days after the alleged incident) that documented, .Resident #612 came to the desk in a wheelchair and stated her call light has been on for 5 to 6 hours . A documented interview with Resident #612 on 1/2/17 documented, Resident #612 stated on the midnight shift of 12/31/16 her call light was on for six hours and no one answered her call light. She wanted some water and needed help with her brief .While Resident #612 was helped back to her room other residents at the end of the hall were calling out for help. Everything went crazy after that. While in the room, Resident #612 over heard two resident care specialists (CNAs) in the hall stating: I am not cleaning up that s**t. I am about to throw up. One (CNA) came into Resident #612's room and Resident #612 stated: If the look on your face and hearing what you are saying about the other residents, you don't have to change me. I see you all don't want to do your job .(CNA) replied: I am not going to mistreat you. Resident #612 replied: I (am) talking about how you treat the other residents .(CNA) left her (Resident #612) room and was overheard talking and laughing with another (CNA) about two other residents . A signed statement by CNA LL dated 1/4/17 (three days after the alleged incident) documented, About 4 A.M. Resident #612 came up to desk complaining about her call light being on for 5 to 6 hours .CNA X was tending to the needs of Resident #105. CNA LL went into the bathroom and started laughing at CNA X .Resident #612 stated she was concerned if this facility employees were abusive to the residents . A written statement by Nurse O dated 1/1/7 documented, This A.M., (Resident #612) was sitting at the top of 4th street in front of the nursing station .She began saying that the aides on mn's (midnight shift) are mean and (rude) to the people .They went into the room across from (Resident #612) and was (yelling) .saying you s(m)ell we are (tired) of cleaning you up, that's why noone want(s) to come in here .Spoke with the (administrator) at 8 A.M., told her about the resident and she told her that she would take care of it later. A Nurse's Note dated 1/2/17 written by Nurse O documented, Correction: On 1/1/17 spoke with administrator at 9:31 A.M. and not 8 A.M. Did tell her that resident was very upset with MN's shift, that they didn't not answer the call lights and didn't change her (Resident #612) for 6 hours. But didn't go into detail about all that resident was saying. The administrator did say that she would take care of it later . A written statement by CNA DD dated 1/1/17 documented, I .was call in to room .by Resident #612 to be told that midnight aides (were) terrible. They did not do any care last night. All the call lights (were) on and they (were) at the nurse's station .Resident #612 told me the (CNA on duty) was very rude talking about residents. The residents ask for help they was very rude to the residents, verbal abuse to the residents. She did not feel safe at all. She was afraid to ask them for assistance or help with care. Resident #612 said the (CNA) said they do not get (paid) enough for smell s**t. She know when she s**t and gave her a dirty look . A list of residents interviewed was included in the investigation. However, it did not include Resident #105. A Disciplinary Action Record for CNA X was signed by the Administrator on 1/6/17 and documented, .Employee was overheard having inappropriate conversation . The Employee Statement documented that CNA X denied the allegation. Corrective Action was documented as Being mindful of conversation within earshot of residents. CNA X refused to sign the document. A Disciplinary Action Record for CNA W was signed by the Administrator on 1/6/17 and documented, .Employee was overheard having inappropriate conversation . CNA W refused to sign the document. An interview was conducted and the concern form and investigation for Resident #612 and #105 were reviewed with the Administrator on 2/14/17 at 12:00 P.M. The Administrator was asked to explain how the above incident of verbal abuse and neglect reported by Resident #612 was investigated. The Administrator stated, It was reported by Staff CC on 1/1/17, and I was told about it at 1:07 P.M. on 1/1/17. He told me what Resident #612 said and what her concerns were. I suspended CNA W and CNA X that evening. The (former DON) came in and started the initial investigation and I came in within the 24 hours and talked with Resident #612. Based on what she said it happened out in the hallway, not in the resident's room. The Administrator was asked if the reported incident was reported to the state agency. The Administrator stated, We discussed this and because it was in the hall and not in the room, it wasn't reportable. It was just a conversation amongst themselves, not to the resident. It wasn't reportable. When queried about the interviews with CNA W and CNAX not being completed until 1/4/17 and 1/6/17, respectively (3 and 5 days after the incident was reported), the Administrator stated, They were suspended until the 4th so I took their statement then. The Administrator was asked to provide time punch documentation for CNA W and CNA X to show they did not work. When queried about whether or not the nurse who worked the midnight shift on 12/31/16 was interviewed as part of the investigation, the Administrator stated, She quit. I couldn't get a hold of her so I didn't interview her. The Administrator was asked if Resident #612's allegations of her call light not being answered for 5 to 6 hours and CNA W locking a resident in the bathroom were investigated. The Administrator stated, We did a call light audit. The call light audit was requested at this time and the Administrator stated, I didn't document it. The Administrator reported she did not investigate the alleged incident of CNA W locking a resident in the bathroom. The Administrator did not provide the time punch information for CNA W and CNA X prior to the end of the survey. A second review of the investigation (copied by the facility) on 2/14/16 at 1:10 P.M. was conducted and revealed a second Disciplinary Action Record for CNA X and CNA W that was signed by the administrator and undated and not signed by the employees, documented, You are hereby suspended pending further investigation regarding incident from 12/31/16 via telephone 1/1/16 . On 2/14/17 at 1:15 P.M., Staff CC was interviewed regarding the concern form for Resident #612 completed on 1/1/7. Staff CC stated, I was working as the weekend manager that day to help out. CNA DD came to me and was really shaken up. She said she talked to Resident #612 who said two aides, CNA W and CNA X said something that shouldn't have been said. When queried about what Resident #612 said, Staff CC stated, One aide was with another resident who went to the bathroom on herself, BM .The aide said 'That stinks, you did that on purpose. I don't get paid enough to do this. Staff CC was asked what was done after the resident reported the above information. Staff CC stated, I reached out to the administrator immediately and discussed what Resident #612 stated what happened. She told me to make sure to take them both (CNA W and CNA X) off the hall and assign them to another side of the hall. When asked if they were sent home or suspended, Staff CC stated, The Administrator did not want me to take them off of the schedule, but just move them to another assignment. I went ahead and took them off of the schedule because I felt it was verbal abuse. She (the administrator) said, 'I can't just take people off the schedule.' I called the (former) DON because I didn't think it was handled right. When asked if CNA W and CNA X were still employed by the facility, Staff CC stated, Yes. They still work here. The clinical record for Resident #105 was reviewed on 2/14/17 at 1:15 P.M. and revealed the following: Resident #105 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #105 had severely impaired cognition and required extensive physical assistance from one staff member for toilet use. Resident #615 On 2/12/17 at 5:40 PM, an interview was conducted with Resident #615's family member. Resident #615's family member indicated that that the resident had been left sitting up in urine all night in a motorized wheel chair one night in January. On January 21st 2017, the DON and Administrator had been informed by the family member of the resident left sitting up in urine all night in motorized chair as well as water being sprinkled by Nurse Z on Resident #615 as she slept. Resident #615's family member also indicated that a staff member had cursed the resident while in her room. A review of Resident #615's clinical record was conducted on 2/13/17 at 1:00 PM and revealed, Resident #615 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #615 was alert and oriented times 3 with some noted confusion and forgetfulness. Resident #615 required extensive to total assistance from staff for all activities of daily living. An interview was conducted with Resident #615 on 2/13/17 at 3:00 PM. Resident #615 indicated that Nurse Z took her cup, put her hand over it and let the water drip on her. Resident #615 further explained that she had [MEDICAL CONDITION] real bad and had spasms. Resident #615 stated: Never had spasms that bad until they left me in the wheelchair for extended time. Requested incident and accident reports for Resident #615, however did not receive I&As relevant to the above concerns. On 2/13/17 at 4:00 P.M., concern forms and any investigations regarding Resident #615 were requested. On 2/14/17 at 11:40 A.M., a folder (described as an investigation by the facility) was provided and contained the following information: A handwritten statement by Nurse Z dated 1/26/17 that documented, Resident #615 at approx. 1 A.M. and CNA MM were at the desk. Resident #615 stated she would like to go to bed. CNA MM said you need to give me a minute. I need to take care of someone. Writer was very busy with other res(idents) and tasks. Approx. 5 A.M. Resident #615 and another nurse came up to the 200 Hall nurse's station. Writer did not realize Resident #615 was still up . A typed Statement of Nurse Z [DATE] documented, I was attempting to give Resident #615 her morning meds. She was very groggy and hard to arouse as usual in the morning. I had the meds and a water cup in my hands. I did NOT pull the straw out and drip water on her! I would never do that to a resident. I treat the residents like my family. Some may have dripped from the cup when I was trying to give her meds but by no means was it intentional and I apologized and tried to explain that it was not intentional but Resident #615 began cussing and swearing at me . The statement documented the DON's name and was dated 2/3/17. A typed Statement of Nurse Z [DATE] documented, Writer called facility after report from resident aunt that Nurse Z went off on Resident #615 . Nurse Z: I didn't go off on her I asked her why she was claiming I'm doing all these things to her when I'm not. I've always been the one to help Resident #615 with anything she asked for a few days prior to when she alleges I poured water on her she was giving me huge hugs and telling me how much she loved me .I just don't understand this behavior, she targets someone new just about every week . The statement documented the DON's name and was dated 2/7/17. The Administrator and DON were interviewed at 12:00 P.M on 2/14/17 regarding the above statements. The DON and Administrator were asked what the three statements were regarding and why they were taken. Regarding the 1/26/17 statement, the DON stated, We received a report from Resident #615 that the aide didn't put her to bed. When queried about what was done after that complaint was received, the DON stated, We talked to CNA MM and she said Resident #615 said nobody got her off the commode. Regarding the 2/3/17 statement, the DON stated, Resident #615 said Nurse Z dripped water on her on purpose, but Nurse Z said that didn't happen. The Administrator and DON were queried about what was done after Resident #615 alleged Nurse Z dripped water on her on purpose. The DON stated, After the first allegation we moved Nurse Z off of the 200 Hall. Apparently she got scheduled with Resident #615 again one day so we moved her again. The DON was asked what was done to investigate the allegation made by Resident #615. The DON stated, There's no formal investigation. The Administrator and DON were queried about the statement from 2/7/17, three days after the initial allegation against Nurse Z by Resident #615, that documented Nurse Z went off on Resident #615 and Nurse Z confronted Resident #615. The Adminsitrator and DON were asked if it was investigated, the Administrator and DON did not offer a response. When asked if the allegations of physical abuse (dripping water on Resident #615), neglect (not putting Resident #615 to bed for four hours), and verbal abuse were reported to the State Agency, the Administrator did not offer a response. The DON stated, I guess we should have. When queried about how other residents were protected if a formal investigation was not completed, the state agency was not contacted, and Nurse Z was moved to another hallway, the Administrator did not offer a response. The facility's policy titled, Abuse & Neglect Prohibition (revision date: January 2017) was reviewed on 2/13/17 at 2:00 P.M. The policy documented the following: .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing . .The facility will protect residents from harm during the investigation . .The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment .or misappropriation of residents property in accordance with state law . .Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated . .The facility will report all investigative findings to the state within 5 working days of the incident . .The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials .in accordance with State law .Timeline for reporting is as follows: a. If the events that cause the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the management staff becomes aware of the allegation .b. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after the management staff becomes aware of the allegation .

Based on observation, interview and record review, the facility failed to off load pressure on bony prominences, implement air mattresses, provide timely dressing changes, perform wound treatments as ordered by the physician, failed to properly apply an immobilizer, elevate heels as required, perform risk assessments for the development of pressure ulcers, and, failed to implement dietary interventions, and perform skin checks as ordered for pressure ulcers for nine (#s 901, 902, 903, 904, 905, 910, 912, 919, 920) of 12 sampled residents reviewed for pressure ulcers, out of a total of 20, resulting in facility acquired pressure ulcers, the worsening of existing pressure ulcers, and the potential for the development of new pressure ulcers. Findings include: Resident #901: On 1/20/16 at 11:35 AM, resident #901's skin was observed with wound care nurse 'D'. The resident had contracted lower extremities, was non-verbal and totally immobile. The resident's left foot was wrapped in gauze dated 1/19/16 and resting inside of a pressure relief boot. A large amount of yellow drainage had seeped through the gauze over the entire heel area and into the inside of the boot. When asked how often the dressing was changed, in lieu of the large amount of drainage, nurse 'D' said once a day. The gauze wrap was removed to reveal a pressure sore covering the entire heel. The sore was unstageable due to necrotic (black, dead) tissue and eschar (leathery, dead tissue). When asked, nurse 'D' indicated that the sore developed in-house. A 4 x 4 gauze dressing covered the right lateral foot, labeled with the initials 'RB' and dated 1/19/16. Nurse 'D' identified the initials as belonging to nurse 'G'. When the 4 x 4 was removed, bright red blood began to ooze from a pressure sore underneath and began to drip down the foot. When asked, nurse 'D' said that this sore developed in-house. The sore was approximately 1 centimeter (cm) in diameter at stage III (full thickness skin loss). When asked if the sore was to be covered with just a dry 4 x 4, nurse 'D' said that alginate (an antimicrobial wound treatment cut to appropriate size) should have been placed directly on top of the sore before placement of the 4 x 4. On 1/21/16 at 12:45 PM, a review of the clinical record for resident #901 with nurse 'D', revealed the following: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident had severe cognitive impairment, limited range of motion to both legs and required extensive assistance for bed mobility. Pressure ulcer risk scales (Braden Scale) dated 6/13/15 and 9/3/15 noted that the resident was at high risk for development. A Nursing Admission Data Collection report (assessment) dated 6/12/15 was left blank for locations/descriptions of the pressure sores. Per a nurses note dated 6/15/15, the resident had a stage I (non-blanchable, unbroken skin with limited blood flow) area to the right lateral foot. There was no documented evidence of a sore to the left heel. Per a nurses note dated 7/7/15, the resident returned to the facility after a hospital stay. There was no documented evidence of a sore on the left heel. A Head to Toe Skin Check report dated 7/9/15 noted the presence of a 1 cm x 1 cm stage II (partial thickness skin loss) pressure sore on the right lateral foot. There was no documented evidence of a wound on the left heel. There was no prior documented Head to Toe Skin Check report. The resident was seen by a wound specialist on 8/6/15 and 8/20/15 who noted that the sore on the right lateral foot was healed. There was no documented evidence of a pressure sore on the left heel. On 9/30/15, per nurses notes: Left heel unstageable, red, purple, mushy and blanchable (positive blood flow) and three ulcers on the right foot (locations not identified). There was no documentation of an open area or wound treatment record regarding the left heel. The 10/2015 wound treatment record noted an order dated 10/19/15: Apply a wound debridement treatment to open areas on feet and cover with gauze. It was not documented whether the open areas included any on the left heel or right lateral foot. On 10/29/15, the wound specialist noted: Pressure sores to the left heel and right lateral foot, date first noticed 10/29/15. The left heel sore measured 3.6 cm x 4.4 cm and unstageable due to eschar with small amount of serous drainage. The right lateral foot sore measured 2.3 cm x 1.4 cm x 0.3 cm at stage III. On 11/13/15 nurses noted that the resident was seen that day by the wound specialist and the left heel pressure sore then measured 8 cm x 9 cm x 0.8 cm. There was no mention of the right lateral foot wound. On 12/3/15, the wound specialist noted: The left heel sore measured 4 cm x 4.8 cm x 1 cm with moderate serous drainage, slough (detaching dead tissue) and necrosis at stage IV (skin loss down to the bone/muscle). The right lateral foot wound was 1.7 cm x 1.1 cm. On 12/17/15 the wound specialist noted: The left heel sore was 5 cm x 4.5 cm x 0.7 cm with copious yellow drainage, strong odor, slough and necrosis. The right lateral foot sore was 1.5 x cm x 1 cm x 0.3 cm. The left heel wound is worse recommend cleaning with (an antiseptic solution). Apply dry gauze to the wound base. Change every shift and as needed. Per nurses notes dated 12/25/15: Wound care nurse please re-address wound on left heel and possible modify orders. There was no documented indication that this was done or the reason for the request. When asked, nurse 'D' said that she was new to her position and did not see the resident for the first time until 12/30/15. Per 12/30/15 nurses notes: Seen today by the wound specialist. The left heel sore was 4.4 cm x 4.9 cm x 0.5 cm and the right lateral foot wound was 2.2 cm x 1.4 cm x 0.1 cm. Both wounds were to be treated with alginate. Per 1/11/16 Weekly Pressure Ulcer Records by nurse 'D': The left heel sore was 4.8 cm x 4.2. cm x 0.4 cm with moderate drainage and yellow/black slough. The right lateral foot sore was 2 cm x 1.2 cm x 0.1 cm and continue the treatment with alginate. Per 1/18/16 nurses notes: Seen by the wound specialist on 1/14/16. The left heel sore was 5.8 cm x 6.6 cm x 0.1 cm with necrotic tissue and slough. The right lateral foot sore was 1 cm x 1 cm. Alginate was continued for both wounds. When asked what measures were implemented to prevent the development of the two facility acquired pressure sores on the left heel and right lateral foot, nurse 'D' provided the following: 6/16/15 order-Ensure bilateral pressure relief boots applied at all times every shift. (No mention of a pressure relief air mattress.) 7/6/15 order-Place heel protection on feet at all times every shift for wound prevention; The boots were applied per the treatment record then discontinued on 7/29/15. 7/6/15 order-Patient to have air mattress every shift for wound healing; The mattress was implemented per the treatment record then discontinued on 7/16/15. There was no documented verification that the air mattress or boots were in use from 8/2015 until 11/26/15 even though the resident was also being treated for [REDACTED]. Per an order dated 11/26/15: Air mattress to be checked by nurse every shift for ulcers, which was implemented on that date per treatment records and continued thru 1/21/16. There was no documented verification of boots being re-ordered or in use from 7/30/15 thru 1/21/16 on treatments or in nurses notes. When asked, nurse 'D' said that the boots and mattress would have been documented on treatment records, if implemented. There was no mention of boots or an air mattress as interventions on the resident's Nursing Initial Plan of Care dated 6/13/15. The goals on the resident's Pressure Ulcer care plan initiated 6/24/15 included: Prevention of developing pressure ulcers. The air mattress and boots were not added as care plan interventions until 12/4/15. Resident #903: On 1/20/16 at 12:30 PM, when asked about pressure sores for resident #903, nurse 'D' said that he was admitted with pressure sores. The resident's skin was then observed with nurse 'D'. The resident was alert and had gauze wraps on both feet. The right foot dressing was removed revealing a pressure sore on the right heel, approximately 3 cm in diameter that was unstageable due to necrosis. A thin, linear-shaped pressure sore approximately 3 cm wide, ran along the width of the posterior left ankle at the top edge. A pressure sore was also present on top of the left ankle bone approximately 2 cm in diameter. When asked about the three sores, the resident said that the sore on the ankle bone developed in-house and was caused by the leg brace. When asked if she was aware that the brace caused the sore, nurse 'D' did not respond. A full length (thigh to ankle) leg immobilizer was observed at the bedside. The resident said, I broke my leg and was wearing the brace (immobilizer), but they (nurse aides) weren't putting it on right. So, the therapist (Physical Therapy Assistant-PTA 'I') told them to stop putting it on if they couldn't put it on right. On 1/21/15 at 10:30 AM, PTA 'I' was queried regarding the brace causing the resident's pressure sore. She stated, I had to readjust it sometimes because it would slide down. He (the resident) told me that he had a sore on his ankle (bone). I saw it and told the nurse. I didn't know about the one in the back (posterior ankle). When asked, she said that there was no dressing on the sore and that He had to have the brace on (wear it) during therapy. When asked which nurse was informed of the sore, staff, 'I' said she did not remember, but I put it in my notes. Staff 'I' then proceeded to look at her notes dated 12/3/15 thru 12/23/15, in the presence of Therapy Director 'H' and Physical Therapist 'J' who also reviewed the notes. There was no mention however, of the sore being present and that a nurse was told. When asked, staff 'I' could not state when she observed the wound, but I continued to apply the brace after that. When asked if he was informed of the pressure sore, staff 'J', who was the resident's therapist, said no. Staff 'I' and 'H' both said that staff 'J' and nursing staff should have been informed and it should have been documented in therapy notes. Therapy notes documented that the resident last received therapy from staff 'I' on 12/23/15. At 11 AM, when queried further about the brace, the resident said, The (nurse) aides were always in a rush and putting it on wrong. It was digging into my leg (pointing to the posterior ankle). I couldn't tell (due to [MEDICAL CONDITION]) and then I got a mirror and I saw the sores. I told (staff 'I') and we both agreed not to wear it (brace) until they healed because it was getting worse when I wore it. When asked if the nurses knew he had wounds, the resident said not until he told them and that staff never opened the brace during the time he was wearing it. On 1/21/15 at 12:30 PM, the clinical record for resident #903 was reviewed with nurse 'D'. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted that the resident had no cognitive impairment, was non-ambulatory, required extensive assistance for bed mobility and transfers and had two stage I (non-blanchable, unbroken skin) pressure areas. The Nursing Admission Data Collection dated 12/2/15 noted that the resident had an open surgical wound to the left knee, had a left leg brace in place and that bilateral heels were boggy (mushy). There were no documented interventions for protection or pressure relief for the boggy heels in the 12/2/15 Nursing Initial Plan of Care. A 12/2/15 pressure ulcer risk scale noted the resident was at risk, but not at high risk for development. Per a physician order [REDACTED]. Remove only for skin checks. An order dated 12/4/15 noted: Weekly skin check by licensed nurse every evening shift. Every Wednesday complete head to toe skin assessment. A documented Head to Toe Skin Check report dated 12/23/15 was left blank and was noted to still be in progress when reviewed on 1/21/16. There were no prior documented Head to Toe reports. Nurses initialed on the 12/2015 treatment record that skin checks were performed on 12/9/15, 12/16/15 and 12/23/15 with no documented results. The resident's Potential/Actual Skin Issues care plan initiated 12/11/15 noted an intervention: Skin checks weekly per facility protocol and document findings. Per a nursing note by nurse 'D' dated 12/31/15, the following pressure sores were observed on 12/30/15: 1. Right heel measuring 3.4 cm x 2.6 cm and necrotic. 2. Posterior left ankle that was 3.5 cm x 2.5 cm with slough. 3. Left outer ankle (ankle bone) that was 1.7 cm x 2.7 cm with slough. Nurse 'D' noted: All wounds present upon admission. When asked why, nurse 'D ' said, I documented my impression. When asked if that was appropriate, nurse 'D' said no and was unable to verify the date that the wounds were actually discovered. There was no documented wound care on treatment records prior to 12/30/15. Weekly Pressure Ulcer Records by nurse 'D' noted the following: 1/5/16-Date of onset for the left posterior ankle pressure sore was 12/2/15 (date of admission). 1/12/16-Date of onset for the left posterior ankle sore was 12/30/15 and was at a stage III; The onset date for the right heel and left ankle (bone) pressure sores was 1/12/16; The ankle bone wound was at stage III. Nurse 'D' said that a wound specialist had not been consulted, when asked. Per a nursing note dated 1/13/2016: therapy to re-evaluate left LE splint placement Resident has decline in skin condition Discussed with IDT (interdisciplinary team) On 1/21/16 at 4 PM, when the facility acquired pressure sores for residents #901 and #903 were discussed with the Director of Nursing, she said that she had been informed and did not comment. Resident #905 On 1/19/2016 at 10:00 a.m., during the initial tour, Nurse N reported that Resident #905 had pressure sores to both the Right and Left heel and also to his hip. At 10:10 a.m., Resident #905 was observed lying in bed on his back. Resident #905 reported having severe pain to both his legs and over his entire body. Everything is hurting me. You should look at my legs. When further queried if the Resident had wound/sores on his legs or anywhere else, Resident #905 stated, I have something wrong on my heels. I also had stiches on my leg. I think there is something on my hip too. A review of Resident #905's clinical record on 1/19/2016 at 2:30 p.m., revealed that the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] documented Resident #905 had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact) and required extensive one person assistance for bed mobility, transfers and toileting Further review of the Resident #905's clinical record progress notes revealed the following: Skin Wound Note (dated 1/18/2016 - late entry) authored by Assistant Director of Nursing (ADON) Nurse D : Note Text: Late Entry. Pt seen today by wound care RN (Registered Nurse). Pt in bed sleeping. Wounds assessed. Rt (right) heel PU (pressure ulcer is resolved). 2 new DTI (deep tissue injury) to heels and one new PU to rt ischium identified. Assessments completed A review of the Resident's Pressure Ulcer Care Plan (Initiated 10/30/14)Last updated 7/14/15 revealed, in part, the following: Interventions: · Notify MD of changes in wound or emerging wounds (initiated 10/30/14) · Observe wound healing (initiated 10/30/14) · Off load heels while in bed (initiated 10/30/14) · Pressure reduction mattress and WC (wheel chair) cushion to bed and chair (initiated 10/30/14) · Provide wound care/prevention skin care per order (initiated 10/30/14) · Skin checks weekly per facility protocol, document findings (initiated 10/30/14) · Turn and reposition frequently to decrease pressure (initiated 10/30/14) · Wound care services as needed (date initiated 10/30/14) Continued review of Resident #905's on 1/19/16 Treatment Administration Record (TAR) revealed no evidence that the Resident's right and left heels were off loaded as indicated in the care interventions as dated 10/30/14. There was no evidence of any treatment being done to the Resident's Rt. Ischium. There was no evidence of treatment to the aquired pressure sore of the Left heel or indication of treatment to the second pressure sore on the Right heel. On 1/21/16 at 11:30 a.m., continued review of Resident #905's TAR indicated that purple foam boots to offload the Resident's heels were not initiated until 1/20/16 at 1900. Further, wound care to right ischium (cleanse area with normal saline, apply santyl to slough area, cover with border gauze) was not initiated until 1/21/2016. There was no documented evidence of treatment to the Left heel. On 1/20/16 at 2:50 p.m., Resident #905 was observed lying in bed. Purple foam boots were observed on both the right and left feet. A wound observation was performed with ADON D. As Resident #905 was turned to review his right hip he shouted, Ouch, this is hurting me. It is very painful. Resident #905 was observed to have a non-blanchable pressure sore on the right ischium. ADON D stated this wound was a Stage II pressure ulcer. Measurements of the wound were not performed, but the sore appeared to be the size of a dime. Further observation of right and left side of the right heel was conducted. Resident #905 continued to express pain as the heel were being observed. The Resident's right heel had two sores. ADON D pointed to one sore located on the center portion of the heel and stated, This is his old wound. It was a Stage IV pressure sore and it is almost healed. We have been treating it for several months. The wound appeared be approximately the size of a dime and black in color. ADON D then pointed to a second wound located on the right side of the left heel and stated, This is the new wound. Measurements of the wound were not performed. The new wound appeared to be the size of a dime and was black in color. The third wound was observed on the Right outer side of the heel. The wound appeared to be the size of a quarter and was deep pink and red in color with slight drainage. At 3:00 p.m., ADON D was queried regarding the development of the three (3) pressure sores for Resident #905. ADON D stated, I think it might have been on Monday (1/18/16) or maybe sometime last week, I am not sure. When queried as to interventions that were in place prior to the development of the pressure sores, ADON D stated, I'm not sure, I'd have to look at the care plan. I know that he is now wearing the boots to float the heels. On 1/21/16 at 3:00 p.m., a record review and continued interview was conducted with ADON D regarding Resident #905's pressure ulcer. Three Skin-Weekly Pressure Ulcer Record dated 1/20/16 and authored by ADON D were reviewed with ADON D. Again ADON D was queried regarding the onset of the three pressure ulcer as being 1/18/2016. ADON D responded, I guess I can't say really say that the onset date for all three was on 1/18/16. Looking at the record you can see I have the late entry note for yesterday. I wrote the onset date as 1/18/2016, but that is because that is the date I first became aware. I am fairly sure the sore on the hip occurred within the last few days. However, due to the size of the wound on the left heel, that was probably sometime within the past few weeks. It is up to the other staff (Nurses and CNAs (certified nursing assistants) to do skin checks and let me know. My guess is that they did not do a full head to toe check that would have identified the sore to the Left/Right heel or hip sooner. A review of the Resident's head-to-skin assessments performed by the nursing staff revealed that the last assessment was done on 1/7/16. ADON D was asked what interventions were in place given the Resident's history of Right and Left heel pressure ulcers, the ADON reviewed the Resident's current care plan. When queried as to why there have been no updates to the Resident's care plan interventions since 10/30/14 and/or whether the Resident's care plan was being followed as documented, ADON D stated, I'm not sure. I do not update the care plans. On 1/21/16 at 4:30 p.m., the Director of Nursing (DON) was queried as to the development and interventions used to prevent three new pressure sores, the DON stated, I'm not certain about the interventions. I know the Resident has been showing signs of decline. Any new interventions should be placed in the Resident's record. We have been having some issues with our skin program. We are trying to improve it. Resident #920 On 1/26/16 at 10:30 a.m., Resident #920 was observed sitting in his wheelchair in his room. Resident #920 was queried about life in the Facility and any wound treatments he was receiving. Resident #920 stated, I have a new one on my hip. This is the first time I ever had one. It hurts. On 1/26/15 at 11:00 a.m., a review of the Resident's clinical record revealed that the Resident's most recent admission was on 12/18/15 with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] documented Resident #920 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and required extensive two person assistance for bed mobility, transfers and toileting. Further review of the Resident's clinical record revealed a Facility Head to Toe Skin Check document dated 1/14/16 that revealed, in part, the following: A. Skin Integrity: New Pressure Ulcer Describe new or existing other issues: Left hip round with yellow/white middle, surrounding redness Site: Left trochanter (hip) Type: Pressure: Length: 1 Width: 1 On 1/26/16 at 11:30 a.m. an interview and record review was conducted with the Wound Care Nurse/ Assistant Director of Nursing (ADON) - Nurse D. Nurse D was asked if the Resident had a Braden Score (tool used to predict pressure sore risk). Nurse D stated, I do not believe a Braden Score was done upon admission. It should have been completed, that is the Facility's Policy. Nurse D was queried as to when she became aware of the Resident's Facility acquired pressure sore and when treatment was started. Nurse D reviewed the electronic medical record and stated, I believe I was told about the wound on 1/14/16. I looked at it on 1/15/16. I did not enter any notes pertaining to Resident #920's wound into the electronic record. I believe I have a paper record indicating when I observed the wound. An untitled document dated 1/15 was provided by Nurse D and revealed the following: Wound Location: Rt (right) Ishium Length: 1.2 Width: 1.6 Depth: .1 Wound Notes: yellow slough (an indication of full thickness Stage III or IV pressure ulcers.) No staging was idicated on the form. When queried as to what stage Nurse D stated, I would call it unstageable due to all the slough. A review of the Resident's Treatment Administration Record (TAR) and Physician order [REDACTED]. Order dated 1/19/16 Cleanse left hip wound with wound cleanser then apply Z-guard (a skin protectant paste), cover with border gauze every day and prn (as needed). Treatment Provided: 1/19/16, 1/20/16, 1/21/16, 1/22/16, 1/23/16 (left blank*), 1/24/16 & 1/25/16. * There were no clinical notes to explain why treatment was not performed on 1/23/16. Nurse D was asked to explain why the treatment to Resident #920's pressure ulcer was not ordered until 1/19/16 (five days after the wound was discovered) and why treatment to the wound was not given on 1/23/16. Nurse D stated, I am not sure why there was a delay in the order. It should not have taken five (5) days to start the treatment. As for the missing treatment on 1/23/16, I don't know what happened. Nurse D was asked to further review the Resident's clinical record and was queried as to the whether she had completed any Weekly Pressure Ulcer Records Assessments since the onset of the Pressure Ulcer. Nurse D stated, There is nothing in the record. I don't have anything indicating I saw the Resident after 1/15/16. Last week was very busy. I plan on doing something today. As far as the 1/15/16 Assessment, I will have to input that into the record today. When queried at to the stageing of the Resident's pressure sore, Nurse D On 1/26/16 at 2:00 p.m., Resident #920 was observed sitting in his room in his wheel chair. The Resident was asked if the Surveyor(s) could observe the wound on his hip. Resident #920 declined to have the wound observed and stated, Nurse D did a treatment about an hour ago. I really don't think I want to go through it again. It hurts me when I have to slide my pants down and it rubs against the sore. Resident #920 was queried as to the onset of the sore and stated, It started a few weeks ago. This is my first sore. When I first came here, I did not have a cushion in my wheelchair. I told them, I think the physical therapy people. I needed one and now I have the cushion. I also have a cover over the cushion. On 1/26/16 at 3:30 p.m., an interview and review of the clinical record was conducted with Registered Dietian (RD) ZZ. Resident #920's most recent care plan (dated 12/22/15) for Nutrition was reviewed and revealed, in part the following: Focus: I receive an oral diet. My BMI (body mass index) is classified as normal. Interventions: Diet (Regular)/ Obtain weight per facility policy RD C was queried as to the Facility's policy regarding what, if any, nutritional interventions were implemented to Residents with pressure ulcers. RD C stated, When we have our daily stand-up meetings those Residents with pressure ulcers are discussed. I work on Monday, Wednesday and Fridays. If I am not here the dietary manager attends and can inform me of new information. I also receive a document (Weekly Pressure Ulcer QA & A log) from Nurse C pertaining to the Residents with pressure ulcers. When I get the information, I can make updates to the Resident's care plan like increasing their protein. A review of the Weekly Pressure Ulcer QA & A logs were conducted and revealed, in part, the following: Date: 1/15/16: Resident #920's name was not on the report Date: 1/22/16: Resident #920 (site: left Ishium/size:[MEDICAL CONDITION]- unstageable) When asked why there were no nutritional interventions provided to Resident #920, RD C stated, I never even knew about the pressure ulcer until 1/25/16 (yesterday). I have not done anything yet. On 1/26/16 at 4:00 p.m., an interview was conducted with the Director of Nursing (DON) regarding Resident #920's Facility aquired pressure sore. The DON was queried as to the lack of documentation and treatment and stated, There is no reason a Braden score was not completed. There is no reason it took five days to begin treatments. I am not sure what happened. As I said before, we have been having a problem with pressure ulcers and are trying to address it. Resident #910 On 1/19/16 at 10:20 a.m., during initial rounds accompanied by the Unit Manager (Nurse A), Resident #910 was observed lying in bed resting on an alternating air mattress. She was ventilator dependent. The head of the bed was elevated at 30 degrees as she received tube feeding via a feeding tube. Bilateral soft heel boots were noted to both feet. Nurse A reported that Resident #910 had a facility acquired pressure ulcer to her upper back due to a spinal deformity (Scoliosis) and some additional facility acquired pressure ulcers. On 1/19/16 at 2:20 p.m., record review of Resident #910's clinical record revealed the following: Resident #910's face sheet indicated an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #910's admission Minimum Data Set (MDS) assessment, dated 10/15/15, indicated that her cognition was severely impaired, she was dependent upon the staff for all activities of daily living (ADLs), including bed mobility, and that she had no pressure ulcers upon entering the facility. Resident #910's admission assessment (10/2/15) indicated no areas of pressure ulcers. Her admission Braden Scale (risk assessment for pressure ulcer development), dated 10/2/15, indicated a score of 13; moderate risk for developing pressure ulcers. Resident #910's wound consults, wound notes, and weekly pressure ulcer records indicated that she had a total of four facility acquired pressure ulcers; 1. Pressure Ulcer #1 was on her upper back (PU midline [MEDICATION NAME] back), onset date of 10/26/15 (per Weekly Pressure Ulcer Record); 24 days after admission into the facility. At the time of onset, the wound was described as Area to spine is pink. Spine has a raised area. Will continue to monitor. Per the treatment administration record (TAR), treatment to the PU started on 10/25/15, despite there was documentation of the onset date of 10/26/15. 2. Pressure Ulcer #2 is on her Sacrum (onset date of 10/26/15), per Weekly Pressure Ulcer Record). At the time of onset, the wound was described as Resident has an open area to sacrum that measures 2.0 cm X 1.0 cm and is stage II and pink with scant drainage. Per the TAR, treatment to the sacrum PU started on 10/27/15. 3. Pressure Ulcer #3 is on her left heel (onset date of 10/26/15, per Weekly Pressure Ulcer Record) Per the treatment assessment record (TAR), there was no documentation of treatment until 11/26/15). Per the TAR, treatment to the PU started on 11/26/15; a month after the onset. The order to float heels off of bed or prof boots at all times was not written until 11/25/15. An entry, dated 11/3/15 (in facility's skin/wound notes) revealed documentation that read, Left heel has DTI (deep tissue injury) that measures 3.0 cm X 3.0 cm and is brown and black in color with no drainage present. On 12/28/15 an order was written for the left PU wound; dry dressing, wrap in kerlix every day shift for wound care. 4. Pressure Ulcer #4 is on her right heel (onset date of 1/18/16, per Weekly Pressure Ulcer Record) The most recent wound consultation, dated 1/7/16, revealed the following regarding the three of the four pressure ulcers: Wound #1 (midline [MEDICATION NAME] back); Measured 4.4 X 4.0 X 1.4 centimeters (cm) and has a total area of 17.6 cm. There is moderate amount of exudate in the wound. It is serosanguineous. The wound margins are irregular, thickened with undermining from 1 o'clock to 1 o'clock of depth 2.9 cm. The wound base has slough. The wound base exposed structure is bone. Stage 4 pressure ulcer. Wound #2 (Sacrum); Measured 2.5 cm X 1.7 cm X 1.1 cm, and has a total area of 4.25 cm. There is moderate amount of exudate in the wound. The color is green; It is serosanguineous. The wound margins are thickened. The wound base has slough (50%). The granulation tissue is 50%. The surrounding skin demonstrates pink, blanching skin color. The pressure ulcer is unstageable. Wound #3 (PU heel, left); Measured 2.5 X 2.7 and has a total area of 6.75 cm.

This citation pertains to M# 5576 and M# 5637 Based on observation, interview and record review the facility failed to ensure one Resident (#701), of three residents reviewed for accidents and injuries of unknown origin, out of a total sample of three, the Resident's safety during a Doppler exam, resulting in Resident # 701 sustaining a fracture of the left distal humeral shaft. Findings include: On 10/14/15 at 1:45 p.m., Resident #701 was observed lying in bed. The resident had a blank stare with no expression and was non-verbal. Resident's left arm was severely contracted. The upper part of the arm was wrapped with a soft cast and placed on a pillow. The Resident was unable to speak or answer any questions. Certified Nursing Assistant (CNA) B who was outside the Resident s room was queried about the Resident's left arm. CNA B stated, I know she has a fracture, I'm not sure what happened. You can talk to the Unit Manager or Director of Nursing (DON). On 10/14/15 at 2:00 p.m., Resident #701's clinical record and an accident/incident (A/I) report were reviewed. The Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident had severe cognition impairment, was non-ambulatory and required total assistance for all activities of daily living including bed mobility transfers. The Facility Incident/Accident (I/A) Report investigation date 9/30/15 revealed the following: Date of Incident/Accident 9/29/15. Description of Incident: LUE (left upper extremity) noted edema, discomfort. Hx (history) of DVT (deep vein thrombosis -a blood clot that occurs in the deep vein causing swelling -developed from medical conditions or failure to move for long periods of time.) Doppler (a form of ultrasound scan that measures the blood flow in the body) and XR (x-ray) noted. Doppler showed DVT. XR showed Distal humeral shaft fx (fracture). Per nurse she also stated she heard Resident yell out during Doppler. Doppler 18:30, XR 22:30. Summary of Investigation: Doppler completed first, arm is very contracted. Arm had to be pulled and moved to a somewhat straightened, rotated position for Doppler. Record review of Resident #701's radiology report dated 9/29/15 results revealed: Butterfly fracture of the distal humeral shaft with medial apex angulation. Mild swelling. 10-1-15: Licensed Practical Nurse (LPN) E : had resident over the weekend 9/26 and 9/27. LPN E stated that she moved and examined the resident several times during those 2 days. Resident ' s arms very contracted. LPN E stated that a no time did she see any edema to either arm, nor did she see any increase in pain. Resident had been weaned off Risperdal (an antipsychotic medication) and is more resistive to care, tightens up more. No signature noted. 10-2-15: Certified Nursing Assistant (CNA) C stated: cared for resident on 9-28-15 midnight shift 11p.m. to 7 a.m. States that Resident had no swelling or increased pain during care, turning arms contracted up and hands up under chin per normal for resident. No signature noted. No dated documented: CNA B : some swelling of arm on Friday 9-25 has been more resistant to care. More contracted. Tuesday more painful. Increased edema. Doppler and XR ordered. No signature noted. No date documented: LPN A : slight edema noted over the weekend. Decreased with elevation on pillows. Tuesday morning same. Doppler and XR 's ordered. No signature noted. A review of the Resident' s care plan regarding ROM (Range of Motion) and updated 10/14/15 revealed, in part, the following: · Do not force limb/joints. Monitor of increased weakness, stiffness and pain and inform nurse. On 10/14/15 at 2:30 p.m., an interview was conducted with CNA C regarding Resident #701 ' s fracture. CNA C stated, they ( the Facility) should really look to the person who did the Doppler. Her arm should not have been pulled like that. We all know how to take care of her. I heard that the Administrator wanted to blame the fracture of the Resident and wanted people to write statements to confirm. I did not write or sign any statement. That Resident can't move her arm on her own. There is no way she could have done this to herself. At 3:00 p.m., an interview was conducted with LPN A regarding Resident #701 ' s fracture. LPN A stated, all I recall was that her arm was swollen on 9/29/15. I told Nurse D about it during the shift change. To my understanding a Doppler and X-ray were ordered. I know the Resident has had swelling in the past due to DVTs. I am not sure about the fracture. The Resident is not able to move her arm. It has always been very contracted. On 10/14/15 at 4:30 p.m., an interview with the Administrator, Director of Nursing and Assistant Director of Nursing was conducted regarding the fracture sustained by Resident #701. The Administrator was further queried as to the findings of the investigation and the investigation process and stated, I did not do this investigation. The Assistant Director of Nursing (ADON) did the investigation. You can talk with her. As for a Facility Policy on investigation injuries of unknown origin, I don't think we have one. When I do this, I just interview people to try and determine the cause. In this situation, if I had to guess what happened, my guess is that the person doing the Doppler was the one that caused the fracture. When asked who performed the Doppler, the Administrator stated it was a person from our diagnostic contracted company. When asked whether the person/company performing the service would be informed of the Resident' s care plan that states do not force limbs/joints, the Admistrator, DON and ADON all stated, probably not. The DON stated, I was on vacation when this incident occurred, however, usually when these people come to the Facility to perform services they just go do what they need to do. I do know that in order to get a good view, they probably had to try and straighten out her arm. Maybe that is what caused the fracture. The ADON agreed with the DON. Following the interview, the DON suggested talking with the nurse who was working the evening the Resident received the Doppler and X-ray. On 10/14/15 at 4:40 p.m., an interview was conducted with the Afternoon Nurse Unit Manager D who was working the evening the Resident ' s Doppler and X-ray were performed. The Unit Manager stated, Yes, I remember that evening. The ultrasound/Doppler tech went into her room. I was not asked to come in or asked for any information. I did hear the Resident hollering in pain. I did not go into the room. After the tech left, I did check on the Resident. I gave her a pain pill. The X-ray person came in about two hours later. I did not hear any hollering or wincing from the Resident. When further asked about the Resident, Nurse Manager D stated, She is not able to talk. When she is in pain she will holler and you can see it in her face. A review of the Facility's policy titled General Investigation Guidelines (revised June 2012) was reviewed on 10/14/15 at 5:15 p.m., revealed in part, the following: Policy: Investigations should be conducted immediatley after an incident, event, or allegation of improper conduct or non-complaince is reported. Investigations should be thorough, accurate, and fact based. Investigation findings should be well documented, concise, and understandable. Investigation findings should be communicated as needed to approriate parties and corrective action implemented as necessary. ( )

This pertains to intake MI 671. Based on interview and record review, the facility failed to conduct a safe transfer, provide adequate supervision and consistently implement safety devices for two (#501 and #502) of three sampled residents reviewed for accidents from a total of five, resulting in falls, bruises, a skin tear, swelling, a toe nail avulsion, severe, prolonged pain, delayed assessment and treatment, and hospitalization for fractures. Findings include: On 5/14/15 from 2:45 PM to 4 PM, the clinical record and Incident/Accident Reports (I/A) for resident #501 were reviewed. During this time, the following interviews were conducted with the Director of Nursing (DON), nurse aides 'B' and 'E', and nurses 'D' and 'H'. Resident #501 was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident had severe cognitive impairment, was non-ambulatory, had difficulty communicating and understanding others, and required extensive two-person assistance for transfers. A Transfer Evaluation dated 4/30/15 noted a score of 24 for resident #501. A score of 15 or greater placed the resident at category four, meaning that staff had to perform 100% of the task of transferring the resident. The equipment to be used: Mechanical Lift (a total body lift via sling underneath the body). However, the resident's Activities of Daily Living (ADL) care plan, revised 2/12/15 and in effect though 5/10/15, noted that the resident required extensive assistance by 1-2 staff to move between surfaces. There was no mention of using a mechanical lift. Review of an I/A report and nurses notes dated 4/10/15 revealed that resident #501 had sustained a skin tear to the right shin area while attempting to reposition (#501) in wheelchair. Bright red blood continuously bleeding from area.pressure dressing applied. Per nurses notes on 5/10/15 at 8:01 AM by day shift nurse 'D': Aide 'F' was transporting resident #501 in wheelchair to breakfast. The left index toenail was hanging off and it was bleeding. The wound was cleaned and nurse 'D' applied a dressing. There was no documented I/A report that addressed this injury until midnight shift nurse ('C') initiated one that night at 11:30 PM following discovery of a leg injury. The I/A report by nurse 'C' noted: Unexplained injury. Patient observed with skin tear and large bruise to right lower leg. Patient guarding area during patient care. The notation-Left index toe nail taken off left foot-appear to have been torn off, was added to this I/A report, in a different handwriting. Per nurses notes written by nurse 'C' dated 5/11/15 at 1:08 AM: The nurse was called to the resident's room by staff and observed the skin tear, large bruise and patient('s) right knee looked out of alignment.Patient has a lot of pain when area was assessed. Right lower leg is swollen painful to touch. Patient guarding her right hip during care. X-ray ordered of knee and hip area. Skin tear was cleaned.bandage applied. Unable to use steri- strip due to no skin flap (the skin was missing). Per review of a note by nurse 'C' dated 5/11/15 at 8:02 AM: Patient('s) right knee more swollen and painful, warm to touch. Doppler (study) ordered at this time to rule out deep vein thrombosis (DVT-a blood clot). Per review of a nursing note dated 5/11/15: The doppler was done at 10:45 AM, which was negative for DVT. The X-ray was done at 11:45 AM, after the doppler was done and 12-hours after the injury was discovered, indicating that the X-ray was not taken STAT (immediately). Patient cries out in pain when extremity moved slightly.during X-ray.Tylenol 650 milligrams given.skin tear cleansed.edges approximated (brought together) as much as possible. Steri-strips applied. Dressing on left foot second toe was.removed revealing toenail partially coming off.X-ray results returned at 12:30 PM showing.tibia fracture and.fibula neck fracture.Order to transfer patient to hospital.Patient transferred.at 2:50 PM. Per review of the X-ray report for resident #501, the X-ray showed: a healed right hip fracture bridged by surgically implanted components which remained in proper alignment; a new tibia fracture and a new femoral head fracture. When asked how resident #501's injuries occurred, the DON said, I have everything (investigation documents). I figured it out. The DON's investigation summary dated 5/11/15 noted the following: On 5/11/15 at 7:20 AM, nurse 'C' came to the DON's office and reported that the skin flap was intact to right shin, deep purple bruising to the right outer leg, swollen knee, toe nail half way off on the left foot, guarding of the right leg, and redness to the lower leg. The X-rays showed fractures. The resident was totally dependent on staff to perform transfers. The resident can be combative with care by swinging arms at staff. Resident is a 1-2 person transfer. Per the investigation, the DON spoke with midnight shift aide 'A' (unavailable for comment), who was assigned to resident #501 until 7 AM the morning of 5/10/15. Aide 'A' stated that the resident was very combative while getting her dressed and ready for the day and transferring her to the wheelchair. Aide 'A' stated that she lifted the resident from underneath the armpits and pivoted her into the wheelchair. There was no mention of a gait belt being used or assistance by other staff during this improper, unsafe manual lift and transfer. In a written statement in the investigation by aide 'A' dated 5/12/15-I changed (resident #501). She fussed and cussed and was trying to hit me.I got her dressed and in her chair. No injuries noticed. The DON noted that nurse 'D', who was the resident's on-coming day shift nurse on 5/10/15 did not notice any complaints of pain except in the foot and aide 'F' stated that the resident went to the dining room for breakfast with no complaints. On-coming day shift aide 'B' was assigned to the resident that day and part of the afternoon shift until 7 PM. She and aide 'G' placed the resident back in bed via sit-to-stand (a mechanical lift with bars that a resident must be able to grip to assist in the transfer) (rather than a total body lift.) She noticed three skin tears that had (a) dressing on them, and a bruise to the knee and the resident was guarding the right leg. Aide 'B' did not say anything because (she) thought (it) was already reported because of the dressings on the areas. Aide 'B' stated that she fed the resident in bed and changed her prior to leaving at 7 PM. The investigation conclusion by the DON: Resident received fracture to right leg because of an improper transfer (by aide 'A') related to resident not having the ability to use lower extremities to assist with pivot transfer. Action: One on one in-service (training) to be given to (aide 'A') to use the sit to stand. When asked about a documented I/A report regarding the toe nail injury that had occurred in the early AM, the DON stated that the toe nail and the leg injury occurred at the same time. However, nurse 'C' documented in the I/A Investigation Follow-Up dated 5/11/15: Patient observed with bruise to right lower leg, skin tear noted same area. Unexplained. (Possible) occurred during transfer at HS (nighttime) care, care that was performed by aide 'B' on the afternoon shift. The DON did not respond why aide 'B' used a sit-to-stand lift and not the total body lift. She did not offer a response regarding why the X-ray was not done STAT and why the resident did not go to the hospital for 15-hours after the injury was discovered by nurse 'C'. On 5/14/15 at 3 PM, aide 'B' was queried about her knowledge of resident #501's injury. Aide 'B' said that when she arrived on 5/10/15 at 8:30 AM, day shift aide ('E') told her that the resident's foot was bleeding. There was blood on the floor and she had a dressing on the foot and a packing around the ankle, white bandages. Aide 'B' stated that the resident was at breakfast when she arrived and was placed in the lounge and in the hallway from there where she remained all day, indicating that the resident was not transferred, checked for incontinence, or changed during that time. Aide 'B' stated that she and aide 'G' manually lifted Resident #501 with a gait belt and placed her in bed around 9:30 (PM) and left at 10 (PM). The aide said, When I pulled her pants off, I saw the bruise and three skin tears on the right leg (pointing to the shin area). The leg was still bleeding. The aide stated that as she turned the resident from side to side changing her incontinence brief, the resident was grabbing her leg and acting like she was in pain. I didn't report it because I thought everybody knew about it. Aide 'B' said that she did not report resident #501's injuries to the on-coming midnight shift aide. When asked why she did not tell the on-coming aide to prevent possible further aggravation of the injuries, aide 'B' shrugged her shoulders and did not respond. She stated that she did not remember who the aide was. At 3:10 PM, nurse 'D' was queried about her knowledge of resident #501's injuries. She stated that aide 'F' brought the resident to the nurses station on the way to breakfast and she saw blood on the resident's sock and on the floor in her room. She cleaned the toe and put a dressing on it. When asked about a documented I/A report regarding the toe nail, nurse 'D' said, I reported it to (nurse manager 'H') because she knew the process better than I do about writing everything up. When asked, nurse 'D' stated that she was not aware of a leg injury and that she did not place a dressing on the leg. She said, I guess I should have assessed her all over, but she didn't seem to have a problem with her leg. At 3:50 PM, nurse manager 'H' was interviewed and asked why an I/A report was not written after being told by nurse 'D' about the toe nail injury. She said, I was just told about it (right before the interview). I wasn't aware she (resident #501) was injured. I wasn't told anything (by nurse 'D'). At 4 PM, the DON was queried regarding the conclusion in her investigation as to when the leg injury may have actually occurred and about aide 'B', who also failed to use proper transfer equipment and was with the resident prior to discovery of the leg injuries. The DON said, She told me that she put the resident to bed with the sit-to-stand and that she left at 7 (PM), not 10 (PM). A review of aide 'B's time punch sheet revealed however, that she punched out for the day at 10:09 PM. When asked who the midnight shift staff was who first reported the leg injury to nurse 'C', the DON stated that she did not know and that the staff assignment sheet was missing. On 5/15/15 at 10 AM, nurse aide 'I' was interviewed by phone and stated that she was the resident's assigned midnight shift aide on 5/10/15 after aide 'B' left at 10 PM. She stated that aide 'B' told her that the resident had been placed in bed and changed, and that aide 'B' did not report that the resident had injuries. Aide 'I' stated that she checked on resident #501 at 11 PM and found her brief completely soaked like she hadn't been changed, just put in the bed. When attempting to change the resident, the resident cried out Please, please, please and clutched her right leg. She stated when the covers were pulled all the way back, The knee was hot and swollen. It looked like it was shifted out of place and had a large skin tear below the knee. Aide 'I' stated, I immediately told (nurse 'C'). She looked at it and said it looked broken. Aide 'I' stated that the resident was unable to bend the right leg before the incident. It was always held straight out and she was a two-person transfer. There was no documented statement from aide 'I' or any of the staff involved in the DON's investigation, except aide 'A' and nurse 'C'. Nurse 'C' wrote the following (undated) note addressed to the DON: I tried to call you last night about (resident #501).She has a lot of pain and discomfort guarding her right hip area. (The resident's physician) was called. No return call. I also called you, (the Assistant DON), and (a registered nurse). No one returned my call. I ordered (an) X-ray.I hope the result is negative.Incident report done. During a phone interview on 5/18/15 at 1 PM with the nurse 'C', the following was revealed: Nurse 'C' stated that she called the previously mention staff, but there was no return call, so she requested the X-ray without an order, because I couldn't reach the doctor. She stated, I thought I ordered it STAT. I don't know. I ordered three different procedures that night (for resident #501) and another resident. The DON sent me a text saying that she was having surgery. When asked if the toe nail injury and the fractures happened at the same time, nurse 'C' said, When I saw her, she already had a dressing on the foot. I was told about the injury. I wrote up an I/A report about the leg. I didn't talk about the toe. I should have sent her out (to the hospital) right away. Per review (on 5/15/15 at 9 AM) of the facility's undated training Module 1: Lift and Transfer: Category 4: Caregiver performs 100% of the task. Residents classified as category 4 are lifted and transferred with the assistance of a mechanical lifting device, such as a full body lift.The resident's plans of care provide information regarding the type of lift to use depending on the.resident's clinical status. On 5/14/15 at 12 Noon, resident #502 was alert and lying in a bed placed in its lowest position with bilateral fall safety floor mats. The resident had a poor memory during conversation. The resident's nurse aide stated that there was a bed sensor pad on the bed under the resident, underneath the fitted sheet. At 3:30 PM, resident #502's clinical record was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted that the resident had moderately impaired cognition, was non-ambulatory, required assistance with transfers, and had two or more falls. Resident #502's Fall care plan, due to unsteady gait and poor safety awareness initiated 1/8/15, noted interventions that included: Sensor alarm on at all times. On 5/14/15 at 4:30 PM, the following I/A reports for resident #502 were reviewed with the DON: 1. On 2/14/15-The resident was trying to use the restroom without assistance and fell . The I/A report did not note where in the room the resident was found on the floor. There was no mention that an alarm sounded to alert staff of an attempt to self transfer. There was no noted injury. The new recommended intervention: Assist the resident and encourage the resident to use the call light. When asked, the DON did not respond why the alarm did not sound. 2. On 3/4/15-The resident was observed on the bathroom floor. Patient had been in bed, alarm was not sounding, but was on and in place. The new intervention: Toilet the resident after meals. There was no noted injury. When asked, the DON did not respond why the alarm had malfunctioned. 3. On 3/21/15 at 3:15 PM (during change of shifts)-The alarm sounded. The resident was on the floor in front of the wheelchair next to the bed and stated that she was trying to get into bed. A skin diagram noted that the resident had a bruised right head and right elbow with a tiny amount of bleeding. The new intervention: Instructed staff to assist resident into bed. 4. On 4/5/15-The resident was on the floor in the bathroom by the toilet. The resident stated that she forgot to pull the (bathroom emergency) cord for assistance. The skin diagram indicated that there was a bruise/hematoma to the left arm. When asked why there was no indication that the sensor alarm sounded, the DON said, It sounds like they (staff) put her on the toilet and left. When asked why staff left the resident on the toilet unattended in lieu of other falls, the DON said, She's impulsive. Sometimes she will use the cord, sometimes she won't. On 5/15/15 at 9 AM per review of the facility's 'fall Management policy dated 2012: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices.to minimize the risks for falls. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE RESTORATIVE SERVICES TO MAINTAIN RANGE OF MOTION (ROM), FOR TWO (#'S 704 AND 717) OF SEVEN RESIDENTS REVIEWED FOR ROM, OUT OF A TOTAL SAMPLE OF 20 RESIDENTS, RESULTING IN DECREASED FUNCTIONAL STATUS AND THE DEVELOPMENT OF CONTRACTURES. FINDINGS INCLUDE: ON 2/26/13 AT 9:00 A.M., 2/27/13 AT 9:30 A.M., 12:30 P.M. AND 3:00 P.M., AND 2/28/13 AT 9:15 A.M., RESIDENT #704 WAS OBSERVED IN HER ROOM SEATED IN A WHEELCHAIR, WITH A LAP BUDDY CUSHION ATTACHED TO THE WHEELCHAIR. THE RESIDENT DID NOT HAVE ANY SPLINTS IN PLACE ON HER LOWER EXTREMITIES. CLINICAL RECORD REVIEW ON 2/26/13 AT 2:00 P.M., REVEALED THAT RESIDENT #704 WAS ORIGINALLY admitted INto the facility on [DATE], AND WAS RE-admitted on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MOST RECENT QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], RESIDENT #704 HAD SEVERELY IMPAIRED COGNITION, AND REQUIRED EXTENSIVE ASSISTANCE FOR AMBULATION, TRANSFERS AND BED MOBILITY. THE QUARTERLY MDS ALSO NOTED THAT THE RESIDENT HAD NO IMPAIRMENT IN ROM TO THE LOWER EXTREMITIES. A CARE AREA ASSESSMENT SUMMARY (CAA) FOR RESIDENT #704, DATED 6/14/12, NOTED UNDER THE SECTION ADLS (ACTIVITIES OF DAILY LIVING) FUNCTIONAL STATUS/REHABILITATION POTENTIAL: "RISK FOR DECLINE IN ADL NEEDS, RISK FOR DECREASED MOBILITY, CONTRACTURES". REVIEW OF A PHYSICAL THERAPY DISCHARGE SUMMARY FOR RESIDENT #704, DATED 9/18/12, NOTED: "D/C (DISCHARGE) REASON: HIGHEST PRACTICAL LEVEL ACHIEVED. PROGNOSIS: PROGNOSIS TO MAINTAIN CLOF (CURRENT LEVEL OF FUNCTION) EXCELLENT WITH PARTICIPATION IN RNP (RESTORATIVE NURSING PROGRAM). RNP/FMP (FLOOR MAINTENANCE PROGRAM) TO FACILITATE PATIENT MAINTAINING CURRENT LEVEL OF PERFORMANCE AND IN ORDER TO PREVENT DECLINE...". A QUARTERLY "THERAPY SCREENING FORM" FOR RESIDENT #704, DATED 11/14/12, NOTED: "NO RECENT CHANGES VOICED BY CNA/NURSING STAFF, NONE NOTED PER MEDICAL CHARTING. THERAPY NOT INDICATED". THE SECTION FOR RESTORATIVE NURSING RECOMMENDATIONS WAS LEFT "BLANK". A "NURSING SCREEN REQUEST" FOR RESIDENT # 704, DATED 1/24/13 AND SIGNED BY NURSE "N", NOTED: "RESIDENT IS SHOWING A CHANGE IN THE FOLLOWING AREA(S): LEFT LEG CONTRACTING. LEFT LEG INCREASED STIFFNESS". A physician's orders [REDACTED]." A PHYSICAL THERAPY EVALUATION AND PLAN OF treatment for [REDACTED]. REASON FOR REFERRAL: PATIENT HAS BEEN REFERRED FOR LE (LOWER EXTREMITY) CONTRACTURE DUE TO LE STIFFNESS. RANGE OF MOTION MEASUREMENTS: RIGHT KNEE- EXTENSION = 140-30 DEGREES (-110 DEGREE RANGE). LEFT KNEE- EXTENSION = 140-50 DEGREES (-90 DEGREE RANGE). ORTHOTIC MANAGEMENT: ...KNEE HAS GONE INTO FLEXION CONTRACTURE...SPLINT COMPANY HAS BEEN CONTACTED TO EVALUATE THE PATIENT KNEE FLEXION CONTRACTURE...THE SPLINTS SHOULD BE HERE IN 2 WEEKS...LOCATION OF CONTRACTURE: LEFT KNEE AND RIGHT KNEE. RECOMMENDATIONS: IT IS RECOMMENDED THE PATIENT WEARS THE SPLINTS THAT WILL BE ARRIVING SOON ON RIGHT KNEE AND ON LEFT KNEE FOR 1 HOUR ON/1 HOUR OFF IN ORDER TO ...MAINTAIN JOINT INTEGRITY, MAINTAIN JOINT MOBILITY. ONCE THE SPLINTS ARE AVAILABLE THE FLOOR STAFF AND THE RNP WILL BE TRAINED IN CORRECT DONNING AND DOFFING OF THE SPLINT. FURTHER CLINICAL RECORD REVIEW FOR RESIDENT #704, AND INTERVIEW WITH RESTORATIVE NURSE "L" ON 3/1/13 AT 9:45 A.M., REVEALED THAT THERE WAS NO CARE PLAN FOR LOWER EXTREMITY SPLINTS, AND NO DOCUMENTED SPLINT WEARING SCHEDULE. IN ADDITION, NURSE "L" COULD NOT PROVIDE ANY RESTORATIVE NURSING DOCUMENTATION FOR RESIDENT #704, AFTER BEING discharged FROM PHYSICAL THERAPY ON 9/18/12. DURING AN INTERVIEW ON 3/1/13 AT 10:00 A.M., THE THERAPY DIRECTOR CONFIRMED THAT THE KNEE CONTRACTURES FOR RESIDENT #704, IDENTIFIED DURING THE THERAPY SCREEN ON 1/25/13, WERE A NEW DEVELOPMENT. THE THERAPY DIRECTOR STATED THAT THE KNEE CONTRACTURES HAD NOT BEEN PRESENT WHEN RESIDENT #704 HAD LAST RECEIVED THERAPY SERVICES IN AUGUST 2012. THE THERAPY DIRECTOR FURTHER STATED THAT RESIDENT #704'S KNEE SPLINTS HAD ARRIVED AT THE FACILITY ON 2/15/13. THE THERAPY DIRECTOR STATED THAT AFTER THE SPLINTS CAME IN, THE PHYSICAL THERAPIST SHOULD HAVE DOCUMENTED A SPLINT WEARING SCHEDULE ON A "THERAPY TO RESTORATIVE NURSING COMMUNICATION" FORM. NO EXPLANATION WAS GIVEN AS TO WHY THIS HAD NOT BEEN DONE. THE THERAPY DIRECTOR WAS QUERIED ABOUT DOCUMENTED EVIDENCE THAT STAFF HAD BEEN TRAINED ON HOW TO APPLY THE SPLINTS FOR RESIDENT #704. THE THERAPY DIRECTOR STATED THAT THE SPLINT REPRESENTATIVE HAD TRAINED STAFF ON HOW TO APPLY THE SPLINTS, BUT HAD NOT DOCUMENTED EVIDENCE OF THE TRAINING. ON 3/1/13 AT 10:30 A.M., RESIDENT #704 WAS OBSERVED UP IN A WHEELCHAIR IN HER ROOM, WEARING A RIGHT KNEE SPLINT. THE LEFT KNEE SPLINT WAS OBSERVED ON THE BEDSIDE TABLE. ON 3/1/13 AT 10:45 A.M., CERTIFIED NURSE AIDE (CNA) "M" STATED THAT SHE HAD ATTEMPTED TO PUT THE KNEE SPLINTS ON RESIDENT #704 WHILE SHE WAS UP IN THE WHEELCHAIR. CNA "M" STATED THAT SHE WAS ABLE TO GET THE RIGHT KNEE SPLINT ON WITH THE HELP OF RESTORATIVE CNA "K", BUT THAT SHE WAS UNABLE TO GET THE LEFT KNEE SPLINT ON, BECAUSE THE RESIDENT APPEARED TO BE IN TOO MUCH PAIN. ON 3/1/13 AT 11:00 A.M., RESTORATIVE CNA "K" STATED THAT HE OBSERVED CNA "M" ATTEMPTING TO PLACE THE KNEE SPLINTS ON RESIDENT #704 WHILE SHE WAS UP IN HER WHEELCHAIR. CNA "K" STATED THAT HE WENT INTO THE ROOM TO HELP CNA "M", AND THAT HE TOLD HER THE SPLINTS WERE SUPPOSED TO BE APPLIED WHILE THE RESIDENT WAS LYING FLAT IN BED. THE FACILITY'S POLICY, "RESTORATIVE NURSING POLICIES AND PROCEDURES", DATED 2/2012, NOTED: "...A RESTORATIVE PROGRAM WILL BE IMPLEMENTED THROUGH THE CARE PLAN TO INCREASE, MAINTAIN, OR PREVENT DETERIORATION OF JOINT MOBILITY AND TO MAXIMIZE PHYSICAL FUNCTION...UPON DISCHARGE FROM SKILLED THERAPY. ORTHOTIC...DEVICES WILL BE PROVIDED IF INDICATED. RANGE OF MOTION EXERCISES: AFTER THE EXERCISE SESSION, DOCUMENT COMPLETION OF THE PROGRAM AND TIME." ( ) ON 3/1/13 AT 9:00 A.M., RESIDENT #717 WAS OBSERVED UP IN A WHEELCHAIR IN HER ROOM. THE RESIDENT STATED SHE WAS VERY UPSET, BECAUSE NO ONE HAD GOTTEN HER UP TO PRACTICE WALKING IN ABOUT 2 MONTHS. CLINICAL RECORD REVIEW ON 2/28/13 AT 2:00 P.M., REVEALED THAT RESIDENT #717 HAD BEEN admitted INto the facility on [DATE], AND RE-admitted on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO THE ANNUAL MDS, dated [DATE], RESIDENT #717 HAD SEVERELY IMPAIRED COGNITION, AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS. THE CARE AREA ASSESSMENT SUMMARY FOR ADL FUNCTIONAL STATUS/REHABILITATION POTENTIAL, DATED 10/28/12, NOTED: "RESIDENT HAS HISTORY [MEDICAL CONDITION](STROKE) RELATED TO [MEDICAL CONDITION], AND IS UNABLE TO MAKE DECISIONS FOR HERSELF OR AMBULATE WITHOUT WALKER AND 1-2 (PERSON) ASSIST." REVIEW OF A PHYSICAL THERAPY DISCHARGE SUMMARY FOR RESIDENT #717, DATED 12/3/12, NOTED: "DISCHARGE REASON: HIGHEST PRACTICAL LEVEL ACHIEVED. PROGNOSIS: PROGNOSIS TO MAINTAIN CURRENT LEVEL OF FUNCTION (CLOF), EXCELLENT WITH PARTICIPATION IN RESTORATIVE NURSING PROGRAM (RNP). DISCHARGE RECOMMENDATIONS: ...FLOOR MAINTENANCE PROGRAM (FMP)/RESTORATIVE NURSING PROGRAM (RNP). RNP: ...ROM AND AMBULATION WITH RW (ROLLING WALKER)...". A "THERAPY TO RESTORATIVE NURSING COMMUNICATION" FORM FOR RESIDENT #717, DATED 12/3/12, NOTED: AROM (ACTIVE RANGE OF MOTION) EXERCISE TO BOTH LE (LOWER EXTREMITY) JOINTS, AMBULATE WITH ROLLING WALKER UP TO 50-70 FEET, BUE (BILATERAL UPPER EXTREMITY EXERCISES IN ALL PLANES. A THERAPY SCREENING FORM FOR RESIDENT #717, DATED 2/8/13 NOTED: "PT (PATIENT) IS...TO CONTINUE RNP/FMP TO MAINTAIN CLOF". A THERAPY SCREENING FORM FOR RESIDENT #717, DATED 2/11/13 NOTED: "PT IS TO CONTINUE RNP/FMP TO MAINTAIN CLOF". REVIEW OF THE NURSING REHAB/RESTORATIVE CARE PLAN FOR RESIDENT #717, FOR THE MONTH OF FEBRUARY 2013, REVEALED THAT RESIDENT #717 HAD BEEN discharged TO THE hospital on [DATE], AND RETURNED to the facility on [DATE]. IT WAS NOTED THAT THE RESIDENT HAD NOT RECEIVED ANY RESTORATIVE NURSING SERVICES AFTER RETURNING FROM THE hospital on [DATE] THROUGH 3/1/13. DURING AN INTERVIEW ON 3/1/13 AT 12:15 P.M., RESTORATIVE NURSE "L" STATED THAT RESIDENT #717 HAD GONE OUT TO THE hospital on [DATE], AND HAD NOT BEEN PUT BACK ON THE RESTORATIVE NURSING PROGRAM AFTER RETURNING to the facility on [DATE]. NO EXPLANATION WAS GIVEN AS TO WHY RESTORATIVE SERVICES WERE NOT CONTINUED FOR RESIDENT #717 AFTER HER RETURN FROM THE HOSPITAL. ( )

THIS CITATION CONTAINS MULTIPLE DEFICIENT PRACTICE STATEMENTS AND REFERS TO INTAKES #MI 639, #MI 223, AND #MI 728. REFERS TO MI 728 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE ASSISTANCE TO SAFELY PERFORM ACTIVITIES OF DAILY LIVING AS ORDERED FOR ONE (#103) OF 9 SAMPLED RESIDENTS, ALL REVIEWED FOR SAFE ENVIRONMENT, FROM A TOTAL SAMPLE OF 9, RESULTING IN INJURY. FINDINGS INCLUDE: RESIDENT #109 WAS admitted to the facility on [DATE]. A HOSPITAL history and physical examination [REDACTED]. RESTORATIVE ORDERS DATED 7/1/12 THROUGH 7/31/12, SPECIFIED THAT RESIDENT #109 WAS TO BE A MINIMUM ASSIST OF 1 PERSON FOR STAND AND PIVOT TRANSFERS AT VARIOUS LEVELS, WITH THE USE OF A GAIT BELT. FOR AMBULATION, RESIDENT #109 WAS TO USE A ROLLING WALKER WITH STAND BY ASSISTANCE TO WALK 75 TO 100 FEET, 5 TIMES PER WEEK. RESIDENT #109 WAS admitted TO HOSPICE CARE ON 6/19/12, FOR DEMENTIA. A physician's orders [REDACTED]. RESIDENT #109 REQUIRED LIMITED ASSISTANCE WITH BED MOBILITY BUT EXTENSIVE ASSISTANCE WITH TOILETING AND TRANSFERS. RESIDENT #109 WAS AT THE HOSPITAL AT THE TIME OF THE SURVEY 7/20/12 THROUGH 7/25/12. OBSERVATIONS WERE LIMITED TO OTHER SAMPLED RESIDENTS. ACCORDING TO AN INCIDENT REPORT DATED 7/18/12 AT 1:00 PM, "RESIDENT #109 WAS SITTING ON TOILET AND USED HER ARMS TO RAISE FROM TOILET ON ARM REST. WHEN SHE USED HER ARMS TO BEAR WEIGHT, SHE FELT A POP AND SAID HER ARM JUST BROKE. DOCTOR WAS NOTIFIED. PAIN MEDICATION GIVEN. TRANSFERRED TO HOSPITAL." ACCORDING TO X-RAY FINDINGS FROM THE HOSPITAL DATED 7/18/12, RESIDENT #109 HAD A DISPLACED FRACTURE OF THE DISTAL LEFT HUMERUS AS A RESULT OF HER ATTEMPT TO SELF-TRANSFER FROM THE TOILET. NURSE AIDE #10 WAS INTERVIEWED ON 7/25/12 AT 3:43 PM. NURSE AIDE #10 STATED THAT SHE WAS ASSIGNED TO RESIDENT #109 THAT DAY. SHE admitted THAT SHE DID NOT PUT RESIDENT #109 TO THE TOILET WHEN THE INCIDENT OCCURRED. NURSE AIDE #10 DID NOT RECALL PROVIDING CARE FOR HER AT ALL THAT MORNING. IT WAS REPORTED TO HER BY OTHER STAFF THAT RESIDENT #109 WAS INDEPENDENT WITH ALL ADLS INCLUDING TRANSFERS AND TOILETING. NURSE AIDE #10 STATED THAT SHE DID NOT PUT HER IN THE TOILET. "I FOUND HER IN THE TOILET." NURSE AIDE #10 SAID SHE (#10) WAS IN THE ADJACENT ROOM ASSISTING ANOTHER RESIDENT WHO WAS WAITING FOR HER TURN TO USE THE TOILET. RESIDENT #109 WAS ON THE TOILET SO LONG, SO NURSE AIDE #10 FINALLY WENT INSIDE AND ASKED RESIDENT #109 IF SHE NEEDED ANY ASSISTANCE. RESIDENT #109 TOLD NURSE AIDE #10, "I TRIED GETTING UP AND I BROKE MY ARM IN HALF. I COULD NOT MOVE IT TO CALL FOR HELP." RESIDENT #109 FURTHER DESCRIBED TO NURSE AIDE #10 THAT SHE WENT TO STAND UP PUSHING DOWN ON THE COMMODE ARM REST AND HER ARM SNAPPED. NURSE AIDE #10 IMMEDIATELY GOT THE NURSE TO ASSESS THE RESIDENT. LICENSE PRACTICAL NURSE #11 ON 7/25/12 AT 3:18 PM, SHE WAS ON A LUNCH BREAK WHEN THE INCIDENT OCCURRED. LPN #11 SAID SHE WAS CALLED INTO THE ROOM AND THE UNIT MANAGER WAS ALREADY THERE. ACCORDING TO LPN #11, "THE RESIDENT SAID TO ME LATER THAT SHE WAS PUSHING HERSELF UP WHEN SHE BROKE HER ARM." LPN # 11 STATED THAT RESIDENT #109 WAS ALERT AND ABLE TO MAKE HER NEEDS KNOWN. RESIDENT #109 WAS NOT INDEPENDENT WITH PERFORMING ADLS. SHE NEEDED 1-PERSON ASSISTANCE TO PERFORM ADLS AND TO TOILET. LPN #11 SAID THAT SHE (#11) WAS AT BREAK WHEN THE INCIDENT HAPPENED. SHE (#11) DID NOT KNOW IF RESIDENT #109'S CALL LIGHT WAS ON AND IF SHE (#109) USED A ROLLING WALKER OR OTHER ASSISTIVE DEVICES. LPN #11 DID NOT EXPLAIN WHY RESIDENT #109 DID NOT HAVE ASSISTANCE FOR TOILETING ON THE DAY THAT SHE BROKE HER ARM. ( ) REFERS TO MI 639 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE ASSISTANCE TO MAINTAIN SAFETY AND TO PREVENT FALLS FOR ONE (#101) OF 9 SAMPLED RESIDENTS, ALL REVIEWED FOR SAFE ENVIRONMENT, FROM A TOTAL SAMPLE OF 9, RESULTING IN FALL WITH INJURY, A FRACTURED NOSE WITH LACERATION. FINDINGS INCLUDE: RESIDENT #101 WAS admitted to the facility on [DATE] WITH A [DIAGNOSES REDACTED]. THE PHYSICIAN'S HISTORY AND PHYSICAL DATED 6/12/12, NOTED A LONG HISTORY OF MULTIPLE SCLEROSIS, PROGRESSIVE [DIAGNOSES REDACTED], STAGE 4 SACRAL ULCER, TYPE 2 DIABETES MELLITUS ON INSULIN IN ADDITION TO OTHER DIAGNOSES. THE FALL RISK EVALUATION FOR RESIDENT #101, DATED 7/6/12, WAS 15 (10 OR HIGHER IS AT RISK). THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 7/13/12 DOCUMENTED, UNDER SECTION G (FUNCTIONAL STATUS), THAT RESIDENT #101 REQUIRED EXTENSIVE PHYSICAL ASSISTANCE OF 2 PERSONS FOR BED MOBILITY, TRANSFERS AND OTHER ACTIVITIES OF DAILY LIVING (ADLS). NURSES' NOTES DATED 7/11/12, BETWEEN 3:00 AND 11:00 PM DOCUMENTED, "RESIDENT VISITING WITH FAMILY AT 4:00 PM THEY LEFT. RESIDENT SERVED DINNER TRAY AT 5:45 PM AND WAS ATTEMPTING TO SIT ON THE SIDE OF THE BED TO EAT UNASSISTED. RESIDENT fell FACE FIRST ONTO FLOOR. LACERATION TO BRIDGE OF NOSE AND LOWER LIP." THE INCIDENT AND ACCIDENT REPORT DATED 7/11/12, DESCRIBED THAT ON 7/11/12 AT 5:45 PM, "RESIDENT #101 WAS SERVED HIS DINNER TRAY IN HIS ROOM. STAFF HEARD A LOUD CRASH AND RESIDENT WAS FOUND ON THE FLOOR FACE DOWN." FINDINGS AND ANALYSIS: "RESIDENT IS CONFUSED AT TIMES, HAS AIR MATTRESS FOR STAGE 4 SACRAL WOUND. diagnosed with [REDACTED]. SAT SELF UP AND SLID OFF THE AIR MATTRESS." RESIDENT #101 WAS TRANSFERRED TO THE emergency room FOR EVALUATION AND TREATMENT AND RETURNED TO THE FACILITY WITH A FRACTURE AND LACERATION TO THE NOSE. DURING AN INTERVIEW WITH RESIDENT #101 WAS ON 7/24/12 AT 12:15 PM, HE STATED THAT HE WAS AT A PARTY AND fell OVER AND BROKE HIS NOSE. FAMILY MEMBER #5 CORRECTED RESIDENT #101 AND STATED THAT "(RESIDENT #101) MOVED THE TRAY AWAY FROM THE BED, SO HE COULD SIT UP AT THE EDGE OF THE BED WHEN HE fell . HE GETS CONFUSED AT TIMES. HE DOES NOT REMEMBER HE HAD A NEWLY AMPUTATED LEG." NURSE AIDE #6 WAS INTERVIEWED ON 7/24/12 AT 3:28 PM. NURSE AIDE #6 STATED THAT HE WAS PASSING OUT TRAYS FOR RESIDENTS ON 7/11/12, WHEN HE HEARD A LOUD CRASH. NURSE AIDE #6 WAS ASSIGNED TO RESIDENT #101 THAT DAY. HE STATED, "IT WAS ANOTHER NURSE AIDE THAT GAVE HIM HIS DINNER TRAY. WE ALL HELP IN PASSING DINNER TRAYS TO EACH RESIDENT. (RESIDENT #101) WAS SOMETIMES CONFUSED." NURSE AIDE #6 FURTHER STATED THAT HE (#6) USUALLY SAT HIM (#101) UP, REPOSITIONING THE HEAD OF THE BED UP AND WOULD SLIDE THE TRAY TABLE OVER TO GET HIM (#101) READY TO EAT. NURSE AIDE #6 DENIED GIVING RESIDENT #101 HIS DINNER TRAY. RESIDENT #101 DID NOT PRESS THE CALL LIGHT ON FOR HELP. RESIDENT #101'S BED WAS NOT IN A LOW POSITION WHEN NURSE AIDE #6 RESPONDED TO THE CRASHING NOISE AND HE (#101) HAD THE AIR MATTRESS SO IT WAS HARD FOR HIM (#101) TO MAINTAIN HIS BALANCE WHILE IN BED. PHYSICAL THERAPIST (PT) #7 WAS INTERVIEWED ON 7/24/12 AT 12:40 PM. PT #7 STATED THAT RESIDENT #101'S COGNITION AND SAFETY AWARENESS WAS IMPAIRED ACCORDING TO THE INITIAL EVALUATION, DATED 7/6/12. CONSIDERING RESIDENT #101'S MEDICAL CONDITION, RECENT AMPUTATION (LEFT BKA), MULTIPLE SCLEROSIS, RESIDENT #101 NEEDED EXTRA TIME TO PERFORM HIS DAILY TASKS. PT #7 STATED, "HE (#101) MOVES SLOWER THAN HOW HE THINKS." AT THE TIME OF THE INITIAL EVALUATION, ON 7/6/12, PT #7 SAID THAT RESIDENT #101 REQUIRED MAXIMUM ASSISTANCE WITH BED MOBILITY AND HAD POOR SITTING BALANCE. HE (#101) REQUIRED MAXIMUM ASSISTANCE TO HOLD HIMSELF UP. PT #7 AGREED THAT RESIDENT #101 WAS AT HIGH RISK FOR FALLS. OCCUPATIONAL THERAPIST (OT) #8 WAS INTERVIEWED ON 7/24/12 AT 1:00 PM. OT #8 STATED THAT RESIDENT #101HAD AN INITIAL EVALUATION ON 7/8/12. RESIDENT #101 REQUIRED SUPERVISION DUE TO POOR SAFETY AWARENESS AND POOR BALANCE. BECAUSE HIS BALANCE WAS IMPAIRED, HE WAS UNSAFE TO PERFORM ACTIVITIES OF DAILY LIVING INDEPENDENTLY. HE WAS NOT STABLE WITH BED MOBILITY. OT #8 RECOMMENDED A HOYER (MECHANICAL) LIFT FOR TRANSFERS. THE FALL RISK ASSESSMENT FOR RESIDENT #101, DATED 7/6/12, INDICATED A SCORE OF 15 (10 OR HIGHER IS AT RISK). THE NURSING CENTRAL INFORMATION TOOL INDICATED THAT RESIDENT #101'S BED MOBILITY STATUS WAS (2) LIMITED, NON-WEIGHT BEARING WITH ONE PERSON ASSISTANCE AND HOYER LIFT FOR TRANSFERS. A CARE PLAN ADDRESSING FALL RISK WAS INITIATED ON 7/12/12, AFTER RESIDENT #101 fell on [DATE]. ( ) REFERS TO MI 223 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE ASSESSMENT AND INTERVENTIONS TO PREVENT HOT LIQUIDS SPILLS TO ONE (#103) OF 9 SAMPLED RESIDENTS, ALL REVIEWED FOR SAFE ENVIRONMENT, FROM A TOTAL SAMPLE OF 9, RESULTING IN MINOR INJURY. FINDINGS INCLUDE: RESIDENT #103 WAS admitted to the facility on [DATE], ACCORDING TO THE UNDATED FACE SHEET AND HAD [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE], ASSESSMENT INDICATED THAT DUE TO HER [DIAGNOSES REDACTED]. RESIDENT #103 REQUIRED EXTENSIVE ASSISTANCE FOR ACTIVITIES OF DAILY LIVING (ADLS). RESIDENT #103 HAD WEAKNESS, BALANCE AND MOBILITY ISSUES AS WELL AS A [DIAGNOSES REDACTED]. RESIDENT #103 NEEDED CUEING TO COMPLETE TASKS. OBSERVATION IN THE DINING ROOM ON 7/20/12 AT 12:00 PM. REVEALED THAT RESIDENT #103 REQUIRED SET-UP OF HER FOOD TRAY, INCLUDING CUTTING THE FOOD UP INTO SMALL PIECES. SHE REQUIRED SUPERVISION AND VERBAL CUEING WHEN EATING. RESIDENT #103 DID NOT HAVE A HOT LIQUID SERVED TO HER DURING THE TIME OF OBSERVATION. ACCORDING TO THE FACILITY INCIDENT AND INVESTIGATION REPORT DATED 6/29/12, ON 6/25/12, AT APPROXIMATELY 10:25 AM, RESIDENT #103 WAS ATTENDING AN ACTIVITY THAT INVOLVED SERVING COFFEE. ACTIVITY ASSISTANT #9 GAVE RESIDENT #103 A CUP THAT HAD BEEN FILLED 1/4 WITH HOT COFFEE. RESIDENT #103 SPILLED THE COFFEE IN HER LAP. RESIDENT #103 WAS IMMEDIATELY ASSESSED AND treated for [REDACTED]. AT NOON, RESIDENT #103 WAS RE-ASSESSED AND FOUND TO HAVE 3 REDDENED AREAS ON HER LEFT THIGH AND 1 SMALL RED AREA ON THE RIGHT THIGH WITH NO BLISTERING. THE ACTIVITY ASSISTANT #9 WAS INTERVIEWED ON 7/20/12 AT 2:58 PM. ACTIVITY ASSISTANT #9 STATED THAT RESIDENT #103 WAS SLEEPING AND DID NOT PARTICIPATE IN THE ACTIVITY. THE ACTIVITY ASSISTANT PREPARED A FRESH POT OF COFFEE AS PART OF THE ACTIVITY OF THE DAY. ACTIVITY ASSISTANT #9 SERVED THE RESIDENTS COFFEE USING STYROFOAM CUPS WITH NO LIDS. HE (#9) RECALLED THAT HE PLACED THE STYROFOAM CUP WITHOUT A LID, BUT FILLED ONLY 1/4 WITH HOT COFFEE, ON THE TABLE. AS HE (#9) TURNED AWAY, RESIDENT #103 REACHED FOR THE CUP AND SPILLED THE COFFEE IN HER LAP. THE ACTIVITY ASSISTANT admitted THAT HE WAS THE ONLY STAFF IN THE ROOM. NO OTHER STAFF WITNESSED THE INCIDENT. RESIDENT #103 DID NOT HAVE A HOT LIQUID ASSESSMENT AND SAFETY EVALUATION UNTIL AFTER THE INCIDENT. ACCORDING TO THE DON (DIRECTOR OF NURSING) ON 7/20/12 AT 1:30 PM, RESIDENT #103 DID NOT HAVE AN ASSESSMENT FOR HANDLING HOT LIQUIDS WHEN THE INCIDENT OCCURRED. ACCORDING TO THE DON, THE PREVIOUS ADMINISTRATION DID NOT ASSESS RESIDENTS FOR HOT LIQUID SAFE HANDLING. AFTER THE INCIDENT, ALL RESIDENTS INCLUDING NEW ADMISSIONS ARE NOW ASSESSED FOR HANDLING OF HOT LIQUIDS. THE TREATMENT ADMINISTRATION RECORD (TAR) DATED 6/1/12 THROUGH 6/30/12 NOTED an order for [REDACTED]. TREATMENT STARTED ON 6/25/12 AND CONTINUED THROUGH 7/17/12. ACCORDING TO THE NURSE'S NOTES ON 7/17/12 , SILVADENE CREAM TO INNER THIGHS WAS DISCONTINUED BECAUSE "AREA IS HEALED." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 794 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO ADMINISTER MEDICATIONS AS ORDERED BY PRIMARY CARE PROVIDERS (PCP'S) FOR 1 OF 5 SAMPLED RESIDENTS (RESIDENT #103), FROM A TOTAL OF 10 SAMPLED RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY WHEN RESIDENT #103 DID NOT RECEIVE ANTIBIOTICS ([MEDICATION NAME] AND [MEDICATION NAME]) AS ORDERED, RESULTING IN THE RESIDENT EXPERIENCING A URINARY TRACT INFECTION [MEDICAL CONDITION], GRAM NEGATIVE [MEDICAL CONDITION], SEPTIC SHOCK, WITH SUBSEQUENT ADMISSION TO THE INTENSIVE CARE UNIT, AND DEATH. THIS DEFICIENT PRACTICE PLACES 13 ADDITIONAL RESIDENTS, RECEIVING ANTIBIOTIC THERAPY FOR UTI'S AND RESIDENTS IDENTIFIED WITH RECURRENT UTI'S, AT RISK FOR SERIOUS HARM AND/OR DEATH. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #103 WAS AN [AGE] year OLD WOMAN, WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS (MDS), dated [DATE], ASSESSED RESIDENT #103 AS COGNITIVELY INTACT, FREE OF HEARING IMPAIRMENT, ABLE TO UNDERSTAND OTHERS AND ABLE TO MAKE HER NEEDS KNOWN, DESPITE THE PRESENCE OF A [MEDICAL CONDITION] (SURGICAL OPENING IN THE NECK USED FOR BREATHING/VENTILATION) ATTACHED TO A VENTILATOR. ACCORDING TO THE NURSE'S NOTES, DATED [DATE] AT 3:00 P.M., RESIDENT #103 BECAME CONFUSED AND COMPLAINED OF BURNING WITH URINATION. A URINE SAMPLE WAS DOCUMENTED AS OBTAINED TO RULE OUT A UTI. THE REPORT OF A URINALYSIS, OBTAINED [DATE] AND REPORTED ON [DATE], IDENTIFIED RESIDENT #103 WITH A UTI WITH [MEDICATION NAME] FAECIUM AND PSEUDOMONAS AERUGINOSA (GRAM NEGATIVE BACTERIA). THE SENSITIVITY REPORT INCLUDED SUSCEPTIBILITY OF THE IDENTIFIED ORGANISMS TO THE ADMINISTRATION OF [MEDICATION NAME] AND [MEDICATION NAME]. THE physician progress notes [REDACTED].#103 WAS IDENTIFIED WITH A UTI WITH [MEDICATION NAME] FAECIUM AND PSEUDOMONAS AERUGINOSA (GRAM NEGATIVE BACTERIA). THE SENSITIVITY REPORT INCLUDED SUSCEPTIBILITY OF THE IDENTIFIED ORGANISMS TO THE ADMINISTRATION OF [MEDICATION NAME] AND [MEDICATION NAME]. THE PCP ORDER, DATED [DATE] AT 3:22 P.M., SPECIFIED RESIDENT #103 WAS TO RECEIVE [MEDICATION NAME] AND [MEDICATION NAME] EVERY 12 HOURS, FOR 10 DAYS, TO TREAT HER UTI. ACCORDING TO THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. AND [DATE] AT 9:00 A.M.), FROM THE DATE OF ORDER [DATE], UNTIL HER EMERGENT TRANSFER TO A LOCAL HOSPITAL ON [DATE]. THE SBAR (SITUATION, BACKGROUND, ASSESSMENT, RECOMMENDATION) DOCUMENTATION, DATED [DATE] AT 12:30 P.M., DOCUMENTED RESIDENT #103 WAS FOUND UNRESPONSIVE AND FACILITY STAFF WERE UNABLE TO OBTAIN HER PULSE, BLOOD PRESSURE, AND PULSE OXIMETRY (HAND HELD DEVICE USED TO DETERMINE BLOOD OXYGEN LEVEL) AT 12:00 P.M. THE RESIDENT'S PCP WAS DOCUMENTED AS NOTIFIED AND ORDERS WERE GIVEN TO TRANSFER THE RESIDENT TO A LOCAL HOSPITAL. THE HISTORY AND PHYSICAL, DATED [DATE] AT 6:26 AM., REVEALED RESIDENT #103 WAS treated for [REDACTED]. THE REPORT INCLUDED "SHE HAD PUS DRAINED FROM HER BLADDER WHEN A FOLEY CATHETER WAS PLACED." THE ASSESSMENT INCLUDED THAT RESIDENT #103 EXPERIENCED "SEPSIS SYNDROME WITH GRAM-NEGATIVE BACTEREMIA" AND "URINARY TRACT INFECTION." THE RESIDENT WAS REPORTED TO HAVE died [DATE]. THE MICROBIOLOGY REPORT OF THE URINE SPECIMEN OBTAINED ON THE RESIDENT UPON ADMISSION TO THE HOSPITAL ON [DATE] IDENTIFIED [MEDICATION NAME] FAECIUM. ACCORDING TO THE CERTIFICATE OF DEATH, RESIDENT #103 died on [DATE] OF "GRAM NEGATIVE [MEDICAL CONDITION]" AND "UTI." DURING AN INTERVIEW ON [DATE] AT 10:40 AM, LICENSED PRACTICAL NURSE (LPN) #4 SAID, "I DIDN'T GIVE THE 9:00 AM DOSE OF [MEDICATION NAME]. ACCORDING TO THE MAR, THE [MEDICATION NAME] WASN'T GIVEN AT ALL. I'M SUPPOSED TO CONTACT THE PHARMACY OR THE ATTENDING PHYSICIAN IF A MED'S NOT AVAILABLE TO BE GIVEN TO THE RESIDENT TO GET AN ALTERNATE. THE UTI WOULD'VE CONTINUED WITHOUT APPROPRIATE MEDICATION." DURING AN INTERVIEW ON [DATE] AT 1:50 P.M., REGISTERED NURSE (RN) #5 SAID, "SHE (RESIDENT #103) HAD [MEDICATION NAME] AND [MEDICATION NAME] ORDERED; I NOTED THE ORDER ON [DATE] AT 4:00 P.M. THE ORDER WAS FAXED TO THE PHARMACY BY ME, THEN PLACED ON THE MAR. THE PHARMACY DIDN'T' NOTIFY ME THAT THERE WAS A PROBLEM PROVIDING EITHER OF THESE MEDICATIONS. I DIDN'T CALL THE PHARMACY ABOUT A DELAY. I DID A DOUBLE SHIFT ON [DATE] (IDENTIFIED AS 7:00 A.M. TO 11:30 P.M.). I DIDN'T GIVE [MEDICATION NAME] AT ALL ON [DATE], AND I DIDN'T GIVE THE [MEDICATION NAME]; THEY PROBABLY WEREN'T HERE FROM THE PHARMACY. I DON'T RECALL NOTIFYING THE PHARMACY. I DIDN'T NOTIFY THE DOCTOR THAT THE MEDS HADN'T BEEN GIVEN. THERE WERE NO ORDERS TO HOLD EITHER THE [MEDICATION NAME] OR THE [MEDICATION NAME]. I DIDN'T DOCUMENT ON THE MAR indicated [REDACTED]. IF MEDS AREN'T AVAILABLE TO BE GIVEN, I'M TO NOTIFY THE PHARMACY THAT THE MEDS STILL AREN'T AVAILABLE, THEN DOCUMENT THE REASON MEDS AREN'T GIVEN, AND NOTIFY THE PHYSICIAN. THIS RESIDENT'S TREATMENT WAS DELAYED; INFECTION COULD GET WORSE." DURING A PHONE INTERVIEW ON [DATE] AT 12:55 PM, RESIDENT #103'S ATTENDING PHYSICIAN SAID, "WE AWAITED THE RESIDENT'S URINE CULTURE AND SENSITIVITY BECAUSE SHE'D HAD MANY UTI'S, WITH MULTIPLE RESISTANT ORGANISMS. BASED ON THE SENSITIVITY, USE OF [MEDICATION NAME] AND [MEDICATION NAME] PROVIDED THE APPROPRIATE COVERAGE FOR THE IDENTIFIED BACTERIA. I RECEIVED NO NOTIFICATION FROM FACILITY STAFF THAT THERE WERE ISSUES IN PROVIDING THE ANTIBIOTICS ORDERED. I EXPECTED THE MEDICATIONS TO BE GIVEN AS ORDERED. NOT TO RECEIVE THE ANTIBIOTICS AS ORDERED WORSENED HER MEDICAL CONDITION. RECEIVING THE MEDICATIONS AS ORDERED WOULD'VE IMPROVED HER CHANCES OF SURVIVAL." DURING AN INTERVIEW ON [DATE] AT 2:40 P.M., DIRECTOR OF NURSING #2 SAID, "IF A NURSE DOESN'T HAVE THE MED THAT'S ORDERED, THEY'RE SUPPOSED TO CALL THE PHYSICIAN. THERE WERE MISSED DOSES OF [MEDICATION NAME] FOR RESIDENT #103, AND SHE DIDN'T RECEIVE [MEDICATION NAME]." DURING AN INTERVIEW ON [DATE] AT 3:05 P.M., NURSING HOME ADMINISTRATOR #1 SAID SHE EXPECTED FACILITY STAFF TO FOLLOW PCP ORDERS COMPLETELY. ON [DATE] AT 9:55 A.M., NURSING HOME ADMINISTRATOR #1 WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON [DATE], AND BEGAN ON [DATE], WHEN THE FACILITY FAILED TO ADMINISTER ANTIBIOTICS, AS ORDERED BY RESIDENT #103'S PCP, FOR treatment of [REDACTED]. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1) BEGINNING ON [DATE], ALL MAR'S WERE REVIEWED TO DETERMINE ANTIBIOTIC USE IN THE FACILITY FOR treatment of [REDACTED]. 2) BEGINNING ON [DATE], THE POLICIES ON "RECEIPT OF INTERIM/STAT/EMERGENCY DELIVERIES OF MEDICATIONS (REVIEWED FEBRUARY 2012)" AND "DELIVERY AND RECEIPT OF ROUTINE DELIVERIES OF MEDICATIONS (REVIEWED FEBRUARY 2012) WERE REVIEWED BY THE DIRECTOR OF NURSING AND DETERMINED APPROPRIATE; NO CHANGES WERE MADE. 3) BEGINNING ON [DATE], LICENSED NURSING STAFF WERE REEDUCATED ON THE PROPER PROCEDURE OF FAXING THE ORDER TO THE PHARMACY AND DOCUMENTING THE MEDICATION IN THE MAR indicated [REDACTED]. NURSING STAFF WERE REEDUCATED ON THE PROCESS IF AN ANTIBIOTIC IS NOT AVAILABLE BY THE NEXT SCHEDULED DOSE, AFTER THE ORDER HAD BEEN WRITTEN, (CALL THE PHARMACY, DOCUMENT THE RESULTS OF THE CONVERSATION WITH THE PHARMACY ON THE BACK OF THE MAR, CIRCLE THE TIME THE MEDICATION WAS TO BE ADMINISTERED ON THE MAR, AND NOTIFY THE PCP IF PHARMACY IS UNABLE TO SEND A MEDICATION). 4) BEGINNING [DATE], AUDITS WILL BE DONE DAILY BY NURSING LEADERSHIP FOR ANTIBIOTIC AVAILABILITY FOR THE NEXT 2 WEEKS, THEN WEEKLY TIMES 4, THEN RANDOMLY. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND SEVERITY OF NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY, DUE TO SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 794 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO TRANSFER A RESIDENT WITH 2 STAFF MEMBERS AND PREVENT ACCIDENTS IN 1 OF 5 SAMPLED RESIDENTS (#103), IN A TOTAL OF 5 SAMPLED RESIDENTS, RESULTING IN RESIDENT #103 EXPERIENCING A SKIN LACERATION DURING A TRANSFER FROM HER BED TO A WHEELCHAIR, WITH SUBSEQUENT EVALUATION AT A LOCAL HOSPITAL, AND CLOSURE OF THE WOUND WITH SUTURES AND STERI-STRIPS. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #103 WAS AN [AGE] year OLD WOMAN, WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS ((MDS) dated [DATE] ASSESSED RESIDENT #103 AS COGNITIVELY INTACT, FREE OF HEARING IMPAIRMENT, ABLE TO UNDERSTAND OTHERS, AND ABLE TO MAKE HER NEEDS KNOWN, DESPITE PRESENCE OF A TRACHEOSTOMY TUBE (SURGICAL OPENING IN THE NECK USED FOR BREATHING/VENTILATION) ATTACHED TO A VENTILATOR. THOUGH TRANSFER STATUS (MOVEMENT FROM ONE SURFACE TO ANOTHER) WAS ASSESSED AS "NOT PERFORMED BY RESIDENT OR STAFF AT ALL OVER THE ENTIRE 7-DAY PERIOD," THE RESIDENT'S MDS EVALUATION INCLUDED "SURFACE-TO-SURFACE TRANSFERS WERE NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE." ACCORDING TO THE physician progress notes [REDACTED]. . . THE EXTREMITIES SHOWED SEVERE MUSCLE MASS LOSS." THE CENTRAL INFORMATION TOOL DATED 1/6/2012 SPECIFIED RESIDENT #103 WAS A MAXIMUM ASSIST OF 2 PERSONS WITH TRANSFERS. ACCORDING TO THE INCIDENT/ACCIDENT FORM DATED 1/18/2012 (UNTIMED), RESIDENT #103 EXPERIENCED A LACERATION TO HER LEFT LOWER EXTREMITY ON 1/16/2012 AT 11:00 A.M. WHEN SHE WAS TRANSFERRED BY A THERAPY ASSISTANT FROM HER BED TO A CHAIR. THE RESIDENT WAS REPORTED TO POINT OUT TO FACILITY STAFF THAT HER LEG WAS BLEEDING. THE RESIDENT WAS REPORTED TO BE SENT TO A LOCAL HOSPITAL FOR EVALUATION. ACCORDING TO THE EMERGENCY DEPARTMENT PHYSICIAN NOTES DATED 1/23/2012 AT 5:57 A.M., RESIDENT #103 WAS admitted TO THE emergency roiagnom on [DATE] WITH A "LACERATION ON THE LEFT LOWER LEG, APPROXIMATELY 45 CENTIMETERS IN LENGTH, THROUGH THE EPIDERMAL AND PARTIAL DERMAL LAYER, AND IS GAPING OPEN. A DISSOLVABLE SUTURE UNDERNEATH WAS PLACED IN ONLY ONE AREA; IT WOULD NOT TAKE IN OTHER AREAS BECAUSE OF HER VERY THIN AND FRAGILE SKIN. STERI-STRIPS WERE USED TO APPROXIMATE HER WOUND." DURING AN INTERVIEW ON 3/26/2012 AT 12:20 P.M., REHABILITATION TECHNICIAN #16 SAID, "I WAS TRANSFERRING FROM HER (RESIDENT #103) BED TO A WHEELCHAIR. SHE WAS ON A VENTILATOR. I GOT HER TRANSFERRED TO THE WHEELCHAIR. I STEPPED OUT TO GET THE RESPIRATORY THERAPIST TO DISCONNECT AND RE-ATTACH HER TO HER VENTILATOR WHEN I RETURNED TO THE ROOM WITH THE RESPIRATORY THERAPIST, THE RESIDENT POINTED TO HER LEG; IT WAS BLEEDING THROUGH A BANDAGE ALREADY THERE. THERE WAS A WOUND ON THE FRONT OF THE LEG THAT WAS NOW BLEEDING. IT WAS BLEEDING PRETTY BADLY. SHE DIDN'T BUMP ANYTHING THAT I'M AWARE OF." DURING AN INTERVIEW ON 3/26/2012 AT 12:40 P.M., LICENSED PRACTICAL NURSE (LPN) #17 SAID, "I SAW HER FOR MEDS ABOUT 9:00 A.M., SHE HAD A WOUND ON HER BACK LEFT LOWER EXTREMITY; IT HAD A BANDAGE ALREADY ON IT. I TOOK THE DRESSING OFF HER LEG; IT WAS BLEEDING PRETTY BAD. SHE NOW HAD A LACERATION ON THE FRONT OF THE LEG. I ASKED THE RESIDENT WHAT HAPPENED; SHE SAID IT GOT BUMPED, SHE MOUTHED IT TO US 'CAUSE SHE WAS ON A VENTILATOR. SHE WAS A 2 PERSON ASSIST WITH A GAIT BELT SHE WAS TOTALLY DEPENDENT WITH AN ASSIST OF 2 PERSONS FOR TRANSFERS." DURING AN INTERVIEW ON 3/26/2012 AT 1:05 P.M., PHYSICAL THERAPIST #18 SAID, "THE RESIDENT (#103) WAS A MAXIMUM ASSIST OF 2 PERSONS TO STAND AND PIVOT WITH TRANSFERS, USING A GAIT BELT. HER STANDING BALANCE WAS POOR TO POOR PLUS, WHICH IS MAXIMUM ASSIST." DURING AN INTERVIEW ON 3/26/2012 AT 3:05 P.M., NURSING HOME ADMINISTRATOR #1 SAID SHE EXPECTED FACILITY STAFF "TO WORK AS A TEAM TO PROVIDE CARE TO PROVIDE OPTIMAL SAFETY."

THIS CITATION PERTAINS TO INTAKE MI 519, MI 747, & MI 345 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO: 1.) PREVENT THE ELOPEMENT AND ENSURE THE SAFETY IN 1 OF 3 SAMPLED RESIDENTS (RESIDENT #501) FROM A TOTAL SAMPLE OF 8 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) WHEN RESIDENT #501, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, ELOPED FROM THE FACILITY ON 12/15/11 AT APPROXIMATELY 7:00 PM, UNBEKNOWNST TO FACILITY STAFF. RESIDENT #501 WAS FOUND AT APPROXIMATELY 7:15 PM WALKING IN THE EMPLOYEE PARKING LOT. THIS DEFICIENT PRACTICE PLACED 12 ADDITIONAL RESIDENTS, IDENTIFIED AS ELOPEMENT RISKS, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH, AND 2.) PREVENT FALLS IN 2 OF 7 SAMPLED RESIDENTS (RESIDENTS #503 & #505) AT RISK FOR FALLS IN A TOTAL SAMPLE OF 8 RESIDENTS, RESULTING IN A.) A LACERATION TO THE BACK OF RESIDENT #503'S HEAD REQUIRING TWO STAPLES AND B.) A LACERATION ABOVE THE RIGHT EYE LID, WHICH REQUIRED STERI STRIPS (THIN ADHESIVE STRIPS), AND A SKIN TEAR TO THE RIGHT KNEE OF RESIDENT #505. FINDINGS INCLUDE: RESIDENT #501: REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD (UNDATED) REVEALED RESIDENT #501 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE]. REVIEW OF PHYSICIAN'S PROGRESS NOTE, DATED 8/10/11, REVEALED RESIDENT #501'S [DIAGNOSES REDACTED]. RESIDENT #501 REQUIRED A HELMET TO PROTECT HER HEAD DUE TO THE ABSENCE OF A PIECE OF HER SKULL AFTER THE GUN SHOT WOUND. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED RESIDENT #501 HAD MODERATE COGNITIVE IMPAIRMENTS AND HAD A TRACHEOSTOMY (BREATHING TUBE). REVIEW OF THE ELOPEMENT CARE PLAN, DATED 10/29/11, REVEALED RESIDENT #501 WAS AT RISK FOR ELOPEMENTS AND HAD A WANDERGUARD BRACELET ATTACHED TO HER RIGHT WRIST. REVIEW OF A FALLS CARE PLAN, DATED 8/9/11 AND UPDATED ON 11/11/11, REVEALED RESIDENT #501 HAD A BED SENSOR PAD ALARM AND A WHEELCHAIR ALARM. REVIEW OF AN INCIDENT/ACCIDENT REPORT, DATED 12/15/11 AT 7:30 PM, WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #12, REVEALED RESIDENT #501 EXITED THE FACILITY ON 12/15/11 AND WAS FOUND IN THE PARKING LOT BEHIND THE FACILITY. THE INCIDENT REPORT INDICATED RESIDENT #501 WAS DRY, DESPITE BEING RAINY OUTSIDE. RESIDENT #501'S HELMET WAS IN PLACE. THE INCIDENT REPORT INDICATED RESIDENT #501 SUSTAINED NO INJURIES. THE "FINDINGS AND ANALYSIS" SECTION OF THE REPORT INDICATED RESIDENT #501 EXITED THROUGH THE DOOR NEAR THE ACTIVITIES OFFICE THAT DID NOT HAVE A WANDERGUARD ALARM INSTALLED. IN AN INTERVIEW ON 12/19/11 AT 2:15 PM, CERTIFIED NURSING ASSISTANT (CNA) #5 REPORTED SHE OBSERVED RESIDENT #501 PROPELLING IN HER WHEELCHAIR ON THE 200 UNIT ON 12/15/11 AT APPROXIMATELY 7:00 PM. IN AN INTERVIEW ON 12/19/11 AT 3:45 PM, CNA #10 REPORTED THAT ON 12/15/11 AT APPROXIMATELY 7:10 PM, SHE WENT TO CHECK ON RESIDENT #501 AND WAS UNABLE TO LOCATE HER, CNA #10 STATED THAT SHE NOTIFIED LPN #12 AND "CODE WHITE" WAS CALLED. CNA #10 REPORTED THE ACTIVITIES GYM DOOR ALARM WAS SOUNDING BECAUSE THERE WAS A "LEADER FOR THE BLIND DOGS" CLASS AND THE DOGS AND VISITORS WERE GOING IN AND OUT OF THE FACILITY. IN AN INTERVIEW ON 12/19/11 AT 2:40 PM, DIETARY COOK #6 REPORTED ON 12/15/11 (UNABLE TO STATE TIME), SHE HEARD A "CODE WHITE" OVER THE INTERCOM WHILE SHE WAS OUTSIDE IN THE EMPLOYEE PARKING LOT AND SAW RESIDENT #501 WALKING IN THE EMPLOYEE PARKING LOT. IN AN INTERVIEW ON 12/19/11 AT 2:00 PM, CNA #4 REPORTED ON 12/15/11 AT APPROXIMATELY 7:15 PM, SHE WENT TO GET A WHEELCHAIR FOR RESIDENT #501 AND LPN #6 AND CNA #7 ESCORTED RESIDENT #501 BACK TO THE FACILITY AT APPROXIMATELY 7:30 PM. CNA #4 REPORTED SHE DID NOT HEAR ANY WHEELCHAIR SENSOR ALARMS OR DOOR ALARMS SOUNDING. IN INTERVIEWS ON 12/19/11 AT 3:00 PM WITH LPN #8 AND ON 12/20/11 AT 2:00 PM WITH LPN #12, IT WAS REPORTED THEY DID NOT HEAR ANY WHEELCHAIR SENSOR ALARMS OR DOOR ALARMS SOUNDING AT THE TIME OF RESIDENT #501'S INCIDENT ON 12/15/11. IN AN INTERVIEW ON 12/22/11 AT 1:26 PM AND IN A REVIEW OF A WRITTEN STATEMENT (UNDATED), CLERICAL COORDINATOR #13 REPORTED "SOMEONE HEARD THE ALARM TO THE DOOR BUT THERE WAS CONFUSION TO WHICH DOOR IT WAS IN THE BACK AREA THAT ALARMED." CLERICAL COORDINATOR #13 REPORTED SHE FOUND RESIDENT #501'S WHEELCHAIR WITH THE BRAKES ON IN FRONT OF THE DOOR BY THE ACTIVITIES OFFICE. IN AN INTERVIEW ON 12/19/11 AT 1:05 PM, RESIDENT #501 REPORTED SHE WAS TRYING TO GO HOME AND PROPELLED HERSELF IN THE WHEELCHAIR AROUND THE FACILITY UNTIL SHE FOUND A DOOR. RESIDENT #501 REPORTED SHE LEFT HER WHEELCHAIR "DOWN THE HALL" AND EXITED THE FACILITY TO FIND HER CAR IN THE PARKING LOT. RESIDENT #501 REPORTED SHE DID NOT HEAR ANY ALARMS SOUNDING. RESIDENT #501 REPORTED SHE WAS WEARING A SHIRT, PANTS, AND A PAIR OF TENNIS SHOES AND STATED IT WAS WINDY AND COLD OUTSIDE. ACCORDING TO WEATHER UNDERGROUND, THE WEATHER ON 12/15/11 AT 7:08 PM WAS: TEMPERATURE - 41.0 ?F, WIND - WEST AT 19.6 MPH, AND LIGHT RAIN (HTTP://WWW.WUNDERGROUND.COM/HISTORY/AIRPORT/KPTK/2011/12/15/DAILYHISTORY.HTML). REVIEW OF THE NURSE'S NOTE, DATED 12/15/11 AT 7:30 PM, REVEALED LPN #12 PERFORMED A HEAD-TO-TOE ASSESSMENT WITH NO INJURIES OR DISTRESS NOTED. ON 12/19/11 AT 1:05 PM, THIS SURVEYOR OBSERVED RESIDENT #501 SITTING AT THE EDGE OF HER BED. RESIDENT #501 APPEARED WELL-GROOMED AND FREE FROM ANY UNEXPLAINED PHYSICAL INJURIES. RESIDENT #501 HAD A WANDERGUARD BRACELET, WHICH WAS FUNCTIONAL, ATTACHED TO HER RIGHT WRIST. REVIEW OF THE TREATMENT ADMINISTRATION RECORD (TAR), DATED 12/ 2011, REVEALED RESIDENTS #501'S WANDERGUARD BRACELET WAS CHECKED FOR PLACEMENT ON EVERY SHIFT. REVIEW OF THE "WANDERGUARD FUNCTION CHECKS" DOCUMENT, DATED 12/12/11 THROUGH 12/16/11, REVEALED RESIDENT #501'S WANDERGUARD BRACELET WAS CHECKED FOR FUNCTION ON MONDAYS, WEDNESDAYS, AND FRIDAYS. REVIEW OF DAILY MAINTENANCE LOGS FOR THE MONTHS OF 10/11-12/11 REVEALED ALL EXIT DOOR ALARMS (6 OUT OF 21 EXIT DOORS WERE WANDERGUARD ALARMED) WERE CHECKED AND HAD FUNCTIONED PROPERLY. AN OBSERVATION ON 12/19/11 AT 10:35 AM, REVEALED 15 OF THE 21 EXIT DOOR ALARMS FUNCTIONED PROPERLY AND THE 6 OF 21 EXIT DOORS, THAT HAD WANDERGUARD ALARMS, ALSO FUNCTIONED PROPERLY. AN OBSERVATION ON 12/19/11 AT 11:00 AM, REVEALED 11 OUT OF 12 WANDERGUARD BRACELETS FUNCTIONED PROPERLY. ON 12/21/11 AT 10:30 AM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 12/15/11, WHEN THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF RESIDENT #501, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, ELOPED FROM THE FACILITY ON 12/15/11 AT APPROXIMATELY 7:00 PM, UNBEKNOWNST TO FACILITY STAFF. RESIDENT #501 WAS FOUND AT APPROXIMATELY 7:15 PM WALKING IN THE EMPLOYEE PARKING LOT. THIS DEFICIENT PRACTICE PLACED 12 ADDITIONAL RESIDENTS, IDENTIFIED AS AN ELOPEMENT RISK, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 12/19/11. ON 12/22/11 AT 3:15 PM, THIS SURVEYOR CONFIRMED THAT THE FACILITY STAFF IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #501 WAS RE-ASSESSED ON DECEMBER 15, 2011 AND ON DECEMBER 21, 2011 FOR ELOPEMENT RISK AND PLAN OF CARE WAS REVIEWED WITH NO CHANGES MADE. RESIDENT #501 WAS ASSESSED BY NURSING ON DECEMBER 15, 2011, POST EXIT FROM BUILDING AND IT WAS NOTED THAT THE RESIDENT DID NOT HAVE ANY PHYSICAL OR COGNITIVE CHANGES. 2. ON DECEMBER 21, 2011, THE FACILITY LEADERSHIP REVIEWED ELOPEMENT POLICIES AND DETERMINED THEY WERE APPROPRIATE AND NO CHANGES WERE MADE. 3. ON DECEMBER 21, 2011, RESIDENTS, WHO WERE AN ELOPEMENT RISK, WERE RE-ASSESSED UTILIZING AN ELOPEMENT RISK ASSESSMENT FORM BY NURSING MANAGEMENT BEGINNING AT 11:00 AM AND ENDING AT 1:00 PM. NO CHANGES WERE MADE TO THE PLANS OF CARE OF THE 12 RESIDENTS, WHO WERE IDENTIFIED AS ELOPEMENT RISKS. 4. ON DECEMBER 22, 2011, THE REMAINING RESIDENTS (94 OF 106) WERE RE-ASSESSED USING THE ELOPEMENT RISK ASSESSMENT FORM BY NURSING MANAGEMENT BEGINNING AT 9:30 AM AND ENDING AT 12:10 PM. NO CHANGES WERE MADE TO THE PLANS OF CARE OF THE 94 RESIDENTS ASSESSED. 5. ON DECEMBER 21, 2011, ALL WANDERGUARDS (12 OF 12) WERE RE-ASSESSED FOR FUNCTIONALITY, BEGINNING AT 11:00 AM AND ENDING AT 11:30 PM, BY RESTORATIVE NURSING. ALL ALARMED DOORS (21 OF 21) WERE RE-ASSESSED FOR FUNCTIONALITY, BEGINNING AT 12:00 PM AND ENDING AT 12:40 PM. ALL WANDERGUARD WIRED DOORS (6 OF 21 FACILITY DOORS) WERE RE-ASSESSED FOR FUNCTIONALITY, BEGINNING AT 12:00 PM AND ENDING AT 12:40 PM, BY THE MAINTENANCE DEPARTMENT. ALL ALARMS IN THE FACILITY AND WANDERGUARDS WERE FOUND TO BE FUNCTIONAL AT THE TIME OF THE AUDIT. 6. ON DECEMBER 21,2011 CARE PLANS WILL CONTINUE TO REFLECT RESIDENT DETERRENTS FOR FUTURE ATTEMPTS TO ELOPE FROM THE BUILDING. RESIDENT-SPECIFIC INTERVENTIONS WILL BE INITIATED AS APPROPRIATE. CARE PLANS FOR CURRENT RESIDENTS WERE REVIEWED AND UPDATED TO REFLECT CURRENT SAFETY MANAGEMENT ON 12/21/11 BY THE NURSING MANAGEMENT TEAM. TWELVE OUT OF 106 RESIDENTS CONTINUE TO USE A WANDERGUARD DUE TO EXIT SEEKING BEHAVIOR. 7. ON DECEMBER 21, 2011, 58 OF 170 FACILITY STAFF WERE RE-EDUCATED BY FACILITY LEADERSHIP ON ELOPEMENT POLICY, ELOPEMENT RISK AND THE FACILITY SIGNAL CODE, E.G. "CODE WHITE," TO DESIGNATE A MISSING RESIDENT. NO STAFF WILL BE PERMITTED TO WORK UNTIL RE-EDUCATION HAS BEEN COMPLETED BY FACILITY LEADERSHIP 8. ALL RESIDENTS admitted TO THE FACILITY AFTER 1:00 PM ON DECEMBER 21,2011 WILL CONTINUE TO HAVE AN ELOPEMENT ASSESSMENT COMPLETED AS PART OF THEIR ADMISSION PAPERWORK. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 12/22/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO THE FACT THAT ALL IN-SERVICING HAD NOT BEEN COMPLETED, SUSTAINED COMPLIANCE HAD NOT YET BEEN VERIFIED BY THE STATE AGENCY, AND THE INCIDENT OF RESIDENT #503'S FALL WITH HEAD INJURY REQUIRING STAPLES. ( & ) RESIDENT #503 REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD (UNDATED) REVEALED RESIDENT #503 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED RESIDENT #503 WAS NOT COGNITIVELY IMPAIRED AND REQUIRED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF THE FALL CARE PLAN, DATED 11/8/11, REVEALED RESIDENT #503'S FALL RISK ASSESSMENT SCORE WAS 22, WHICH INDICATED RESIDENT #503 WAS AT HIGH RISK FOR FALLS. THE CARE PLAN REVEALED RESIDENT #503 WAS TO HAVE BED AND WHEELCHAIR PERSONAL TAB ALARMS AND A LOW BED. THE CARE PLAN REVEALED ON 12/5/11 (2 DAYS AFTER A FALL), RESIDENT #503'S BED AND WHEELCHAIR ALARMS WERE CHANGED TO SENSOR PAD ALARMS. REVIEW OF THE CENTRAL INFORMATION TOOL (UNDATED) (USED BY NURSE AIDES TO INDICATE CARE REQUIRED) REVEALED RESIDENT #503'S SENSOR PAD ALARM MUST BE ON AT ALL TIMES. REVIEW OF THE TREATMENT ADMINISTRATION RECORD (TAR), DATED 12/1/11-12/31/11, REVEALED RESIDENT #503'S SENSOR PAD ALARM MUST BE ON AT ALL TIMES AND THE NURSE WAS TO CHECK PLACEMENT AND FUNCTION EVERY SHIFT. REVIEW OF A NURSE'S NOTE DATED, 12/3/11 AT 7:00 PM, REVEALED RESIDENT #503 WAS OBSERVED WALKING ON THE UNIT WITH ALARMS SOUNDING. THE NURSE'S NOTE REFLECTED STAFF "EXPLAINED TO RESIDENT THAT THIS WASN'T SAFE SHE COULD FALL." THE NURSE'S NOTE INDICATED RESIDENT #503'S PERSONAL TAB ALARM WAS ATTACHED AND FUNCTIONING PROPERLY. REVIEW OF AN INCIDENT/ACCIDENT REPORT, DATED 12/3/11, REVEALED ON 12/3/11 AT 10:45 PM, RESIDENT #503 STATED SHE SELF-TRANSFERRED HERSELF FROM THE BATHROOM TO THE ROOM AND fell on THE BATHROOM FLOOR. THE REPORT REVEALED "(PERSONAL TAB) ALARMS WERE ATTACHED BUT NOT SOUNDING." REVIEW OF A NURSE'S NOTE, DATED 12/3/11 AT 10:45 PM, REVEALED RESIDENT #503 SUSTAINED A LACERATION TO THE BACK OF HER HEAD AND WAS TRANSFERRED TO THE HOSPITAL. REVIEW OF A NURSE'S NOTE, DATED 12/4/11 AT 3:50 AM, REVEALED RESIDENT #503 RETURNED FROM THE HOSPITAL WITH TWO STAPLES TO THE BACK OF HER HEAD. IN AN INTERVIEW ON 12/22/11 AT 11:25 AM, RESIDENT #503 REPORTED SHE GOT OUT OF BED AND INTO HER WHEELCHAIR TO GO TO THE BATHROOM AND fell . RESIDENT #503 REPORTED THAT HER ROOMMATE PUSHED THE CALL LIGHT BUTTON FOR HELP AND IT TOOK STAFF ABOUT 20 MINUTES TO ANSWER THE CALL LIGHT. RESIDENT #503 REPORTED THAT THE "THE BED ALARM DID NOT SOUND. I WAS TOLD TO PUSH THE WHITE BUTTON WHEN MY ALARM DOES NOT GO OFF, BUT I FORGOT." IN A TELEPHONE INTERVIEW ON 12/27/11 AT 10:30 AM, CERTIFIED NURSE AIDE (CNA) #14 REPORTED AT 9:45 PM ON 12/3/11, SHE OBSERVED RESIDENT #503 IN BED WITH A BED SENSOR ALARM ON. CNA #14 REPORTED SHE DID NOT HEAR AN ALARM SOUNDING BUT HEARD RESIDENT #503'S BATHROOM CALL LIGHT AROUND 10:30 PM ON 12/3/11. CNA #14 REPORTED SHE OBSERVED RESIDENT #503 LYING ON THE BATHROOM FLOOR WITH BLOOD COMING FROM THE BACK OF HER HEAD. CNA #14 REPORTED "SHE MUST HAVE WALKED TO THE BATHROOM AND fell TRYING TO GET BACK TO HER BED BECAUSE HER WHEELCHAIR WAS NOT IN THE BATHROOM." DURING THE INITIAL TOUR, CONDUCTED ON 12/19/11 FROM 10:35 AM TO 11:55 AM, THIS SURVEYOR AND LICENSED PRACTICAL NURSE (LPN) #11 FOUND BOTH RESIDENT #503 AND UNSAMPLED RESIDENT "A" WITH THEIR BED SENSOR PAD ALARMS OFF; BOTH RESIDENTS WERE LYING IN BED. LPN #11 REPORTED "I DON'T KNOW" WHEN ASKED WHY THE ALARMS WERE OFF. ( & ) RESIDENT #505 REVIEW OF THE FACE SHEET (UNDATED) IN THE CLOSED MEDICAL RECORD REVEALED RESIDENT #505 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED RESIDENT #505 WAS IDENTIFIED AS A FALL RISK AND REQUIRED EXTENSIVE PHYSICAL ASSISTANCE WITH BED MOBILITY, TRANSFERS, AND ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF THE FALL CARE PLAN, DATED 8/11/11 AND UPDATED ON 9/7/11, REVEALED RESIDENT #505'S FALL RISK ASSESSMENT SCORE RANGED BETWEEN 21-25 WHICH INDICATED RESIDENT #505 WAS AT HIGH RISK FOR FALLS. THE CARE PLAN REVEALED RESIDENT #505 WAS TO HAVE A BED AND WHEELCHAIR ALARM, FALL MAT AT BEDSIDE, AND A LOW BED. REVIEW OF RESIDENT #505'S INCIDENT/ACCIDENT REPORTS DATED 9/3/11, 9/7/11, 9/10/11, 9/21/11, AND 9/29/11 REVEALED RESIDENT #505 HAD DOCUMENTED FALLS WITHOUT INJURY ON: 1. 9/3/11 ALARM NOT SOUNDING "PATIENT REMOVED TAB ALARM;" 2. 9/7/11 ALARM SOUNDING; 3. 9/10/11 ALARM NOT SOUNDING "RESPIRATORY THERAPIST DID NOT TURN ALARM BACK ON;" 4. 9/21/11 UNKNOWN IF ALARM SOUNDED AND; 5. 9/29/11 "SENSOR PAD IN CHAIR BUT DID NOT ALARM." REVIEW OF TREATMENT ADMINISTRATION RECORDS (TARS), DATED 9/1/11 THRU 10/31/11, REVEALED RESIDENT #505'S SENSOR PAD ALARM MUST BE ON AT ALL TIMES, SAFETY MAT ON FLOOR BETWEEN BED AND DOORWAY, AND NURSE TO VERIFY PLACEMENT EVERY SHIFT. REVIEW OF A NURSE'S NOTE, DATED 10/24/11 AT 2:00 PM, REVEALED RESIDENT #505 WAS FOUND ON THE FLOOR BY A FAMILY MEMBER WALKING BY. RESIDENT #505 WAS FOUND WITH BROKEN EYEGLASSES, A SMALL LACERATION OVER RIGHT EYE, AND A SKIN TEAR TO THE RIGHT KNEE. REGISTERED NURSE (RN) #2 WAS NOTIFIED AND EXAMINED RESIDENT #505'S EYE. REVIEW OF AN INCIDENT/ACCIDENT REPORT, DATED 10/24/11, REVEALED ON 10/24/11 AT 11:45 AM, RESIDENT #505 WAS FOUND ON FLOOR IN FRONT OF WHEELCHAIR AND THE ALARM WAS NOT ATTACHED. REVIEW OF INCIDENT/ACCIDENT INVESTIGATION FINDINGS, DATED 10/24/11, REVEALED RESIDENT #505'S "ALARM WAS NOT ATTACHED, WOUND TO PATIENT EYELID, STERI STRIPS APPLIED, SENSOR PAD ON BED (NOT ON CHAIR) CERTIFIED NURSING ASSISTANT (CNA) #17 DISCIPLINED." REVIEW OF SKULL AND FACIAL BONES X-RAYS, COMPLETED ON 10/24/11, REVEALED NO DEFINITE EVIDENCE OF FRACTURE. ( & )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 602. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ALL VENTILATOR ALARMS REMAINED FUNCTIONAL PER MANUFACTURER'S RECOMMENDATIONS FOR 1 (RESIDENT #500) OF 3 SAMPLED VENTILATOR-DEPENDENT RESIDENTS FROM A TOTAL SAMPLE OF 3 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #500, WHO had a history of [REDACTED]. STAFF DID NOT RESPOND TO THE INTERNAL ALARM AND THE EXTERNAL ALARM DID NOT SOUND. THIS DEFICIENT PRACTICE PLACED ALL 13 RESIDENTS WHO REQUIRED VENTILATOR USE AT RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET, MINIMUM DATA SET (MDS), dated [DATE], PHYSICIAN ORDERS [REDACTED].#500 WAS admitted to the facility on [DATE], WAS VENTILATOR DEPENDENT, REQUIRED ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADL'S), WAS HARD OF HEARING WITH IMPAIRED COMMUNICATION, IMMOBILE, TUBE FED, COGNITIVELY IMPAIRED AND HAD PERIODS OF RESTLESSNESS AND WOULD AT TIMES GRAB AT ITEMS IN AN NON-PURPOSEFUL MANOR. RESIDENT 500'S [DIAGNOSES REDACTED]. RESIDENT #500 WAS NOT AT THE FACILITY AT THE TIME OF THE INVESTIGATION [DATE] THROUGH [DATE]. REVIEW OF RESIDENT #500'S [MEDICAL CONDITION] CARE PLAN, DATED [DATE], REFLECTED "MAINTAIN VENTILATOR, CHECK SETTING AND ALARM PER PROTOCOL". IN AN INTERVIEW ON [DATE] AT 7:50 A.M., THE DIRECTOR OF NURSING (DON) #1 REPORTED SHE WAS UNAWARE OF A FACILITY POLICY/PROTOCOL FOR CHECKING THE INTERNAL AND EXTERNAL VENTILATOR ALARMS TO ENSURE THEY ARE IN PROPER WORKING CONDITION. IN A TELEPHONE INTERVIEW ON [DATE] AT 9:48 A.M., RESPIRATORY THERAPIST (RT) #6, REPORTED HE/SHE HAD NEVER SEEN OR BEEN INFORMED OF A FACILITY POLICY/PROTOCOL FOR CHECKING AND ENSURING VENT ALARMS WERE IN PROPER WORKING CONDITION. REVIEW OF THE FACILITY INVESTIGATION REPORT, DATED [DATE], REVEALED ON [DATE] AT APPROXIMATELY 2:50 A.M. (THIRD SHIFT FOR [DATE]), RESPIRATORY THERAPIST (RT) #2 HEARD RESIDENT #500'S INTERNAL VENTILATOR ALARM SOUNDING. THE REPORT INDICATED WHEN RT #2 WENT INTO RESIDENT #500'S ROOM, SHE FOUND RESIDENT #500 DISCONNECTED FROM HER VENT AND CYANOTIC. RT #2 STARTED RESCUE BREATHING IMMEDIATELY WITH AN AMBU BAG (A DEVICE USED TO DELIVER BREATHS) FOR RESIDENT #500. THE REPORT INDICATED THAT STAFF DID NOT HEAR RESIDENT #500'S EXTERNAL VENT ALARM (HALL ALARM) SOUND, WHEN RESIDENT #500 DISCONNECTED HERSELF FROM THE VENT. THE FACILITY INVESTIGATION REFLECTED THE EXTERNAL VENT ALARM WAS FOUND BY RT #2 TO BE TURNED OFF. REVIEW OF THE RESPIRATORY NOTES, DATED [DATE] AT 2:50 A.M., REVEALED "RESPONDING TO VENT INTERNAL ALARM BEEPING, FOUND PT (PATIENT) UNRESPONSIVE AND BLUE IN COLOR, SPO2 (OXYGEN SATURATION LEVEL) LESS THEN 81%, BAGGED PT". REVIEW OF NURSING NOTES, DATED [DATE] AND [DATE], REVEALED NO DOCUMENTATION OF THE INCIDENT ON [DATE] AT 2:50 A.M., WHEN RESIDENT #500 WAS FOUND IN RESPIRATORY DISTRESS AND REQUIRED RESCUE BREATHING. REVIEW OF THE NURSES NOTES, DATED [DATE] AT 7:10 P.M., REVEALED "PT (RESIDENT #500) PULLED OUT HER PICC LINE (AN INTRAVENOUS CATHETER) BLEEDING CONTROLLED WITH PRESSURE". REVIEW OF NURSES NOTES, DATED [DATE] ON THIRD SHIFT, REFLECTED "TORE OFF DRSG (DRESSING) OFF R (RIGHT) FOREARM HAD BLOOD ALL OVER BED AND LINEN". REVIEW OF THE physician's orders [REDACTED].#500) ON IV ABT (INTRAVENOUS ANTIBIOTIC)". REVIEW OF THE NURSE'S NOTES, DATED [DATE] AT 11:00 P.M., REVEALED AFTER RESIDENT #500 DISCONNECTED HERSELF ON [DATE], SHE TORE OFF HER DRESSING FOR A SECOND TIME. IN AN INTERVIEW ON [DATE] AT 5:08 P.M., AND ON [DATE] AT 2:00 P.M., RT #2, STATED "I WAS IN A RESIDENTS ROOM AT THE OTHER END OF THE HALL; I COULD NOT HEAR THE ALARM (RESIDENT #500'S INTERNAL VENT ALARM). RESIDENT #500 WAS BLUE, UNRESPONSIVE WITH A COUPLE OF SHALLOW BREATHS; I BAGGED HER (RESCUE BREATHING). RT #1 WAS WALKING UP TO THE DESK. I DID NOT EVEN LOOK AT THE ALARM. I DIDN'T HEAR RT #1 SAY ANYTHING. THE NURSES AND CERTIFIED NURSING ASSISTANTS (CNA'S) WERE SITTING AT THE DESK. THE REPORT (THE FACILITY INVESTIGATION DATED [DATE]) IS NOT ACCURATE. I NEVER EVEN LOOKED AT THE EXTERNAL ALARM; I HAD MORE IMPORTANT THINGS TO DO. I CAME OUT OF THE ROOM AND WENT TO THE DESK TO TELL THE OTHER RT (RT #1). ALL THE REST OF THEM (2 NURSES AND 2 CNA'S) WERE SITTING AT THE DESK TALKING. THE EXTERNAL ALARM WAS NOT SOUNDING, BUT THE INTERNAL ALARM WAS". REVIEW OF RT #2'S WRITTEN STATEMENT, DATED [DATE], REFLECTED "ON [DATE] (ON THIRD SHIFT, [DATE]) AT APPROXIMATELY 2:50 A.M., I (RT #2) WAS COMING OUT OF A RESIDENTS ROOM AT THE OTHER END OF THE HALL WHEN I HEARD A CONSTANT INTERNAL VENT ALARM SOUNDING. I IMMEDIATELY WENT DOWN THE HALL AND FOUND THE SOURCE OF NOISE; RESIDENT #500 WAS DISCONNECTED OFF VENT, TUBING ON FLOOR. PATIENT WAS BLUE, DIAPHORETIC AND UNRESPONSIVE. I IMMEDIATELY RECONNECTED PT TO VENT, IMMEDIATELY GRABBED AMBU BAG, BAGGED PT. I NEVER LOOKED AT THAT OUTSIDE VENT ALARM. I DID NOTICE ALL, TWO NURSES AND BOTH 2 CNA'S SITTING AT DESK WHEN I RESPONDED INITIALLY TO THE ALARM AND WHEN I LEFT THE ROOM AFTER STABILIZING PATIENT, ALL FOUR PEOPLE STILL REMAINED SITTING AT NURSES STATION". ON [DATE] AT 2:30 P.M., THE SURVEYOR AND DIRECTOR OF MAINTENANCE #1 MEASURED THAT THE DISTANCE FROM THE NURSES' STATION TO RESIDENT #500'S ROOM WAS "30 FEET". IN AN INTERVIEW ON [DATE] AT 5:12 P.M. AND ON [DATE] AT 9:00 A.M., RT #1 REPORTED SHE WAS AT LUNCH AND WHEN SHE RETURNED, RT #2 INFORMED HER THAT RESIDENT #500 DISCONNECTED HERSELF FROM HER VENT. RT #1 STATED "NO I DID NOT TURN OFF THE ALARM (RESIDENT #500'S EXTERNAL VENT ALARM). RT #1 REPORTED 4 STAFF MEMBERS WERE SITTING AT THE NURSES' STATION (2 NURSES AND 2 CNA'S) AND SAID THEY DID NOT RESPOND TO RESIDENT #500'S INTERNAL VENT ALARM AND THAT THE EXTERNAL ALARM DID NOT SOUND. RT #1 SAID ONLY A RESPIRATORY THERAPIST COULD TURN OFF AN EXTERNAL VENT ALARM WHEN THE RESIDENT LEFT THEIR ROOM OR deceased . RT #1 SAID A CNA (CNA #2) SAID SHE HAD TURNED OFF THE RESIDENTS ALARM, BUT SHE DENIED TURNING IT OFF. IN A TELEPHONE INTERVIEW ON [DATE] AT 4:55 P.M., CNA #1 STATED "I AM NOT 100% SURE THAT HER (RESIDENT #500'S) ALARM WAS TURNED OFF, NO I DIDN'T SEE IT TURNED OFF. I DIDN'T HEAR HER ALARM, SHE HAD BEEN DISCONNECTING HERSELF ALL NIGHT, THE ALARM WAS GOING OFF (THE INTERNAL ALARM). SHE (RT #1) MAY NOT HAVE TURNED THE ALARM (EXTERNAL ALARM) BACK ON; I HEARD ONLY PART OF THE CONVERSATION (BETWEEN RT #1 AND RT #2). CNA #1 WAS NOT ABLE TO CONFIRM THAT RESIDENT 500'S EXTERNAL ALARM WAS TURNED OFF AND DENIED SEEING THE ALARM TURNED OFF. IN A TELEPHONE INTERVIEW ON [DATE] AT 4:35 P.M., CNA #2 SAID, "I DON'T KNOW IF HER ALARM WAS OFF". CNA #2 WAS NOT ABLE TO CONFIRM THE RESIDENT 500'S EXTERNAL ALARM WAS TURNED OFF AND DENIED SEEING THE ALARM TURNED OFF. IN AN INTERVIEWON [DATE] AT 1:06 P.M., REGISTERED NURSE (RN) #1 STATED "HER (RESIDENT #500'S) ALARMS WERE GOING OFF (ON [DATE]); SHE DID HAVE A HISTORY OF DISCONNECTING HER TUBE. RESPIRATORY THERAPY TOLD ME THAT SHE WAS GOING TO DISCONNECT HERSELF AND WE NEEDED TO MONITOR HER. SHE WAS ON 3 ANTIBIOTICS AND SHE WAS CONFUSED (ON [DATE]-[DATE]), SHE USUALLY WAS NOT. RT #2 CAME OUT OF RESIDENT #500'S ROOM AND TOLD ME SHE JUST HAD TO BAG (RESCUE BREATH) RESIDENT #500, AT THAT TIME I DID NOT HEAR ANY ALARMS. AFTER THE INCIDENT I WENT DOWN TO THE RESIDENT'S ROOM, SHE WAS OK. I DIDN'T DO AN ASSESSMENT, THE RT (RT #2) DID ONE WHEN SHE WAS IN THE ROOM. IN A TELEPHONE INTERVIEW ON [DATE] AT 4:45 P.M., LICENSED PRACTICAL NURSE (LPN) #2 STATED "I DID NOT HEAR THE EXTERNAL ALARM GO OFF. I DON'T RECALL HEARING RT #2 SAY SHE FOUND THE ALARM OFF. I DO REMEMBER SOMEONE SAID (RT #1) TURNED OFF THE EXTERNAL ALARM. I DID NOT HEAR (RT #1) SAY SHE TURNED THE ALARM OFF. THIS RESIDENT (RESIDENT #500) HAD DISCONNECTED HERSELF SEVERAL TIMES THAT NIGHT. IN AN INTERVIEW ON [DATE] AT 8:45 A.M., THE DIRECTOR OF RESPIRATORY THERAPY #1 CONFIRMED RESIDENT #500 had a history of [REDACTED]. THE DIRECTOR OF RESPIRATORY THERAPY #1 STATED RESIDENT #500 "WAS VERY SQUIRMY". REVIEW OF THE FACILITY PRESSURE ALARM CLINICAL MANUAL (EXTERNAL VENT ALARM MANUAL), DATED [DATE], REVEALED BATTERIES IN THE EXTERNAL VENT ALARMS WERE RECOMMENDED TO BE CHANGED EVERY 2 WEEKS, THE ALARMS MUST BE CALIBRATED EVERY 12 MONTHS AND ON PAGE #5, "CHECK AND MAINTAIN THE PRESSURE ALARM (EXTERNAL VENT ALARM) TO INSURE PROPER OPERATION". OBSERVATION ON [DATE] AT 12:35 P.M., OF THE VENT UNIT REVEALED THE FACILITY DID NOT USE THE AC ADAPTER FOR THEIR EXTERNAL VENT ALARMS. ALL EXTERNAL ALARMS WERE USING 9 VOLT BATTERIES. IN AN INTERVIEW ON [DATE] AT 1:50 P.M., THE DIRECTOR OF MAINTENANCE #1 SAID HE STARTED CHECKING AND CHANGING THE BATTERIES AND DOCUMENTING THE VENT UNITS EXTERNAL VENT ALARMS ON [DATE] (THE FIRST DAY OF THE SURVEY). THE DIRECTOR OF MAINTENANCE #1 STATED "I AM CHANGING THE BATTERIES NOW AND I AM CHANGING THE BATTERIES BI-WEEKLY, THAT'S WHAT THE MANUFACTURER'S BOOK SAYS, I TOLD THEM (MANAGEMENT) THEY SHOULD A LONG TIME AGO. I JUST MADE UP A PM (PREVENTIVE MAINTENANCE) LOG TO TRACK IT, THEY DIDN'T HAVE ANYTHING. I AM ALSO GOING TO HAVE SOMEONE COME IN AND CALIBRATE THEM, IT SHOULD BE DONE YEARLY". IN AN INTERVIEW ON [DATE] AT 9:25 A.M. AND 11:25 P.M., THE RESPIRATORY EQUIPMENT TECHNICIAN #1 STATED "THEY (ALL FACILITY EXTERNAL VENT ALARMS) NEED TO BE CALIBRATED EVERY 12 MONTHS AND THE BATTERIES NEED TO BE CHANGED EVERY 2 WEEKS PER GUIDELINES. WE NEED TO DO A PERFORMANCE AND SAFETY CHECK OF EACH IN-USE EXTERIOR VENT ALARM. APPROXIMATELY A WEEK AGO THE FACILITY NOTIFIED (THE RESPIRATORY EQUIPMENT COMPANY) OF THE NEED TO COME IN AND EVALUATE THE EXTERIOR ALARMS". REVIEW OF THE FACILITY'S RESPIRATORY POLICY FOR PREVENTIVE MAINTENANCE, DATED ,[DATE], REFLECTED "POLICY: TO PROVIDE A MECHANISM FOR PERFORMANCE OF PREVENTIVE MAINTENANCE ACCORDING TO A SET SCHEDULE AND MANUFACTURER'S GUIDELINES FOR FREQUENCY, CONTENT, AND TECHNICIAN REQUIREMENTS". ON [DATE] AT 2:00 P.M., THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON [DATE] AND BEGAN ON [DATE], DUE TO THE FACILITY'S FAILURE TO ENSURE ALL VENTILATOR ALARMS REMAINED FUNCTIONAL PER MANUFACTURER'S RECOMMENDATIONS, RESULTING IN AN EXTERNAL VENTILATOR (VENT) ALARM NOT SOUNDING WHEN RESIDENT #500, WHO WAS VENTILATOR DEPENDENT, DISCONNECTED HERSELF FROM HER VENTILATOR ON [DATE] AT APPROXIMMATELY 2:50 AM. RESIDENT #500, WHO had a history of [REDACTED]. THIS DEFICIENT PRACTICE PLACES ALL 13 RESIDENTS, WHO REQUIRED VENTILATOR, USE AT RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. RESIDENT #500 WAS discharged TO ACUTE CARE ON [DATE]. 2. ON [DATE], A LOG WAS IMPLEMENTED BY MAINTENANCE TO TRACK THE ANNUAL SERVICE AND CALIBRATION OF THE VENTILATOR ALARMS PER THE MANUFACTURER'S GUIDELINES. THIS WILL BE REVIEWED BY THE ADMINISTRATOR ON AN ONGOING BASIS. 3. ON [DATE] AT 4:00 P.M., THE DIRECTOR OF RESPIRATORY THERAPY AND A REGISTERED NURSE VALIDATED THAT ALL VENTILATOR ALARMS WERE FUNCTIONING APPROPRIATELY. 4. BEGINNING ON [DATE], AT THE START OF EACH SHIFT, THE RESPIRATORY THERAPIST AND CHARGE NURSE WILL CHECK AND VALIDATE THAT ALL VENTILATOR ALARMS ARE FUNCTIONING APPROPRIATELY AND DOCUMENT IN THE TREATMENT ADMINISTRATION RECORD. 5. ON [DATE] AT 2:30 P.M. TO 4:30 P.M., 34 STAFF WERE RE-EDUCATED ON THE PROPER FUNCTIONING AND VALIDATION OF THE VENTILATOR ALARMS. ALL 128 RESPIRATORY THERAPISTS AND LICENSED STAFF WILL BE RE-EDUCATED ON THE PROPER FUNCTIONING AND VALIDATION OF THE VENTILATOR ALARMS AND STAFF ON THE VENTILATOR UNIT WILL NOT BE PERMITTED TO WORK UNTIL THIS IS COMPLETED BY THE NURSE MANAGERS. 6. THE VENTILATOR BATTERIES WILL BE CHECKED EVERY TWO WEEKS BY THE DIRECTOR OF MAINTENANCE AND THE DIRECTOR OF RESPIRATORY THERAPY PER THE MANUFACTURER GUIDELINES AND WILL DOCUMENT THE VALIDATION OF FUNCTION. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL STAFF HAVE NOT BEEN IN-SERVICED AND THE STATE AGENCY HAS NOT VERIFIED SUSTAINED COMPLIANCE. (# )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 602. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SUPERVISE AND ENSURE THE SAFETY IN 2 OF 4 SAMPLED RESIDENTS (#500 AND #501) FROM A TOTAL SAMPLE OF 4 RESIDENTS, WHO WERE DEPENDENT ON OXYGEN, RESULTING IN AN IMMEDIATE JEOPARDY WHEN: 1) RESIDENT #501, WHO had a history of [REDACTED]. RESIDENT #501 SUBSEQUENTLY died on [DATE] AT 7:45 PM, AND 2) RESIDENT #500, WHO had a history of [REDACTED]. THESE DEFICIENT PRACTICES PLACE ALL 19 RESIDENTS, WHO RESIDE ON THE VENTILATOR UNIT, AT RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #501: REVIEW OF THE FACE SHEET, MINIMUM DATA SET ((MDS) dated [DATE], PHYSICIAN ADMITTING ORDERS DATED [DATE], physician progress notes [REDACTED].#501 WAS admitted to the facility on [DATE], WAS VENTILATOR DEPENDENT, RECEIVED TUBE FEEDING, HAD SHORT AND LONG TERM MEMORY LOSS, EXHIBITED NON-COMPLIANT BEHAVIORS INCLUDING DISCONNECTING HERSELF FROM HER OXYGEN AND REQUIRED STAFF ASSISTANCE WITH ALL ADL'S. THE RESIDENT'S [DIAGNOSES REDACTED]. REVIEW OF THE FACILITY PRE-RESTRAINING EVALUATION, DATED [DATE], AND SIGNED BY THE ASSISTANT DIRECTOR OF NURSING (ADON), REVEALED RESIDENT #501 WAS TO HAVE "B (BI-LATERAL, BOTH HANDS) HAND MITTS" TO "DETER SELF DECANNULATION (REMOVING TRACHEOSTOMY TUBE FROM NECK)". REVIEW OF THE FACILITY SELF DECANNULATION CARE PLAN FOR RESIDENT #501, DATED [DATE], STATED "APPLY MITT TO BI-LATERAL (PUT HAND MITTS ON BOTH HANDS), DECANNULATED SELF [DATE]". REVIEW OF THE REHABILITATION CARE PLAN, DATED [DATE], STATED "ENSURE THAT HAND MITTENS ARE IN PLACE AS ORDERED". REVIEW OF THE FACILITY TREATMENT SHEETS, DATED ,[DATE] AND ,[DATE], REVEALED RESIDENT #501 WAS TO HAVE "B HAND MITTS". REVIEW OF THE TREATMENT SHEET DATED ,[DATE], REVEALED RESIDENT #501'S HAND MITTS WERE "DC'D (DISCONTINUE) [DATE]". REVIEW OF THE PHYSICIAN ORDERS, DATED [DATE] THROUGH [DATE], REVEALED THERE WAS NO DOCUMENTATION OF AN ORDER TO DISCONTINUE THE HAND MITTS. IN TELEPHONE INTERVIEWS ON [DATE] AT 11:25 A.M. AND ON [DATE] AT 11:45 A.M., RESPIRATORY THERAPIST (RT) #1 REVEALED ON [DATE] AT APPROXIMATELY 6:45 P.M., RT #1 WENT INTO RESIDENT #501'S ROOM AND "HER OXYGEN TUBING WAS ON THE FLOOR (DISCONNECTED). SHE (RESIDENT #501) HAD PULLED HER OXYGEN OFF MANY TIMES, WE (RT'S) COMPLAINED ABOUT HER NEEDING MITTS. THE NIGHT SHE died ([DATE]) SHE DID NOT HAVE HAND MITTS ON, THEY HAD BEEN REMOVED. I CAME ON AND I SAW HER NOT BREATHING, WITH NO PULSE, AN ASHEN (GRAY) COLOR. THE OXYGEN TUBING WAS LYING ON THE FLOOR BESIDE THE BED. WE DID CARDIOPULMONARY RESUSCITATION (CPR) UNTIL EMERGENCY MEDICAL SERVICES (EMS) GOT THERE AND THEN THEY DID CPR". REVIEW OF RESIDENT #501'S INCIDENT/ACCIDENT REPORT GIVEN TO THE SURVEYOR BY DON #1 DATED [DATE] AT 11:50 A.M., INDICATED RESIDENT #501 WAS OBSERVED BY STAFF "SITTING ON THE FLOOR". REVIEW OF THE NURSES NOTES DATED [DATE] AT 6:45 P.M., REFLECTED "RESIDENT (#501) FOUND UNRESPONSIVE BY RT, 911 CALLED, CPR PERFORMED, TIME OF DEATH AT 7:45 P.M. BY EMS AFTER UNSUCCESSFUL ATTEMPTS TO REVIVE HER". IN AN INTERVIEW ON [DATE] AT 2:15 P.M.; LICENSED PRACTICAL NURSE (LPN) #3 STATED "SHE (RESIDENT #501) WAS FOUND ON THE FLOOR (ON [DATE] AT 11:50 A.M.); AT THAT TIME WE WERE TRYING TO GET RID OF ALL RESTRAINTS (INCLUDING HAND MITTS). WE (CHARGE NURSES) WOULD PUT OUR MED CARTS BY HER ROOM BECAUSE SHE WOULD DISCONNECT HERSELF (FROM THE OXYGEN). SHE DID NOT HAVE MITTS ON WHEN I CAME ON AT 3:00 P.M. (ON [DATE]). IN AN INTERVIEW ON [DATE] AT 2:45 P.M., CERTIFIED NURSING ASSISTANT (CNA) #4 STATED "SHE (RESIDENT #501) WAS DOING MUCH BETTER; SHE WAS CONNECTED TO THE OXYGEN NOT THE VENT AT THAT TIME (ON [DATE]). I HAD HER SITTING UP IN HER WHEELCHAIR IN HER ROOM. I THEN PUT HER TO BED AND CHANGED HER, AND THEN I WENT TO LUNCH, AT 6:15 P.M. TO 6:30 P.M. SHE DID NOT HAVE MITTS ON. THEY (THE MANAGER AND THE DON) D/C'D (DISCONTINUED) THE MITTS. SHE OFTEN WOULD DISCONNECT HERSELF FROM HER OXYGEN. NO ONE HAD TOLD ME SHE HAD FALLEN EARLIER (ON [DATE]). IN AN INTERVIEW ON [DATE] AT 9:20 A.M., CNA #2 STATED "SHE (RESIDENT #501) WAS ISSUED MITTS AND SHE TOOK THEM OFF. THE NIGHT BEFORE SHE died , SHE DECANNULATED. I HELPED (LPN #2) HOLD HER HANDS DOWN SO THE RT'S COULD PUT THE CANNULA IN. THE NURSE (LPN #2) AND I HELD HER ARMS DOWN, SHE DID NOT HAVE MITTS ON. THE MITTS WERE IN THE ROOM." IN A TELEPHONE INTERVIEW ON [DATE] AT 9:40 A.M., RT #7 STATED, "YES, SHE (RESIDENT #501) DECANNULATED HERSELF ON [DATE] AT 2:30 A.M. I CALLED (RT #6) IN TO ASSIST ME WITH RE-INSERTING HER CANNULA". IN A TELEPHONE INTERVIEW ON [DATE] AT 9:48 A.M., RT #6 STATED THAT HE REMEMBERED ASSISTING RT #7 WITH RE-INSERTING RESIDENT #501'S CANNULA ON [DATE] AND THAT HE WAS ABLE TO GET IT (THE TRACH) IN. RT #7 REPORTED THAT RESIDENT #501 HAD A LOT OF ATTEMPTS OF DECANNULATING HERSELF. IN A TELEPHONE INTERVIEW ON [DATE] AT 3:40 P.M., LPN #4 STATED "SHE (RESIDENT #501) had a history of [REDACTED]. WHEN I SAW HER UP DURING THE DAY (ON [DATE]), SHE DID NOT HAVE MITTS ON. WE WERE TRYING TO KEEP HER MITTS OFF BECAUSE SHE WAS PROPELLING HERSELF IN THE HALLWAY". IN AN INTERVIEW ON [DATE] AT 11:20 A.M., THE DIRECTOR OF NURSING (DON) #1 REVEALED THE RESIDENT ALSO HAD SPLINTS ORDERED AND STATED "SPLINTS ARE USED FOR CONTRACTURES AND MITTS ARE USED TO KEEP RESIDENTS FROM CAUSING HARM TO SELF, DECANNULATING AND PULLING OFF OXYGEN". DON #1 REVEALED A PHYSICIAN ORDER [REDACTED]. IN AN INTERVIEW ON [DATE] AT 11:45 A.M., ADON #2 STATED " IF THERE IS an order for [REDACTED]. IF YOU'RE GOING TO GET RID OF THE MITTS, YOU NEED an order for [REDACTED]. REVIEW OF THE RESPIRATORY NOTES ARE AS FOLLOWS: -[DATE] AT 4:30 P.M., "PT DECANNULATED HERSELF, TRACH RE-INSERTED". -[DATE] (NO TIME), "SELF DECANNULATED, RE-INSERTED". -[DATE] (12:10 A.M.), "PT FOUND WITH B/L (BI-LATERAL) HAND MITTS OFF AND POSEY TRACH TIES UNDONE WITH TRACH ? WAY OUT, NURSE CALLED INTO ROOM FOR ASSISTANCE". -[DATE] (7:05 A.M.), "MITTENS ARE "OFF', (CLINICAL COORDINATOR) AWARE, PT AGREES NOT TO PULL TRACH OUT". -[DATE] AT 8:50 P.M., "MITTENS ARE OFF DUE TO SKIN BREAKDOWN PER NURSE". REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. -[DATE] (NO TIME), "PT PLACED IN TRACH COLLAR PT VERY COMBATIVE AND PULLING INNER AND VENT TUBING OFF". -[DATE] AT 6:45 P.M., "PT AWAKE AND PULLING AT TRACH". -[DATE] AT 7:55 A.M., "PULLS AT TUBING". -[DATE] AT 12:45 P.M., "RESIDENT IS PULLING AT EVERYTHING". -[DATE] AT 2:00 A.M., "PT ALERT UP ON SIDE OF BED HAS DISCONNECTED SELF FROM VENT A FEW TIMES DURING SHIFT". -[DATE] AT 12:10 A.M., "SHE (THE RESIDENT) KEEPS TAKING OFF HER O2 (OXYGEN)". -[DATE] AT 6:50 A.M., "PT DOES PULL TRACH COLLAR OFF OCCASIONALLY". -[DATE] T 2:30 A.M., "THE NURSE (CHARGE NURSE LPN #7) INFORMED ME THAT THE PT'S TRACH WAS OUT ON THE FLOOR". REVIEW OF DAILY NURSES NOTES ARE AS FOLLOWS: [DATE] AT 4:30 P.M., "NEIGHBOR (RESIDENT #501) SELF DECANNULATED, ORDER FOR B HAND MITTS ATC (HAND MITTS ON BOTH HANDS, AROUND THE CLOCK)". [DATE] (NO TIME) "PT IS ALERT AWAKE, ATTEMPTING TO REMOVE BI-LAT MITTS THROUGHOUT SHIFT". [DATE] AT 1:00 A.M., "PT ATTEMPTING TO DECANNULATED SELF, PT WAS ATTEMPTING TO PUNCH STAFF, PT TOOK OFF MITTS". [DATE] AT 2:00 A.M., "PT CONT. TO TAKE HERSELF OFF VENT". [DATE] (NO TIME), "MITTS WERE OFF". [DATE] (2:00 A.M.), "RESTLESS THIS SHIFT AND KEEPS PULLING OFF VENT TUBING". [DATE] AT 2:45 P.M., "NEIGHBOR (THE RESIDENT) IS PULLING AT TRACH AND UNTIE THE TIES". [DATE] AT 2:00 A.M., "MITTS NOT ON AT THIS TIME". [DATE] AT 7:00 A.M., "MITTS OFF AT THIS TIME". [DATE] (NO TIME), "MITTS OFF". [DATE] AT N12:00 P.M., "MITTS OFF". [DATE] AT 3:00 A.M., "BI-LAT MITTS NOT ON AT THIS TIME". [DATE] AT 11:55 A.M., "RESIDENT FOUND ON FLOOR". REVIEW OF THE NURSES NOTES AND RESPIRATORY THERAPY NOTES, DATED [DATE], REVEALED AT 2:30 A.M., RESIDENT #501 HAD DECANNULATED HERSELF AND AT 11:55 A.M., AND WAS FOUND ON THE FLOOR IN HER ROOM. REVIEW OF THE SPEECH EVALUATION AND PLAN OF TREATMENT, DATED [DATE], REFLECTED RESIDENT #501 HAD "BEHAVIORS IMPACTING SAFETY: ACTIVE RESPIRATORY DISEASE AND DECREASED SAFETY AWARENESS". REVIEW OF THE FACILITY RESTRAINT POLICY AND PROCEDURE, DATED ,[DATE], REVEALED A PHYSICIAN ORDER [REDACTED]. THE RESTRAINT POLICY STATED "THE FACILITY WILL ENGAGE IN A SYSTEMIC AND GRADUAL PROCESS TOWARDS REDUCING ANY RESTRAINTS". RESIDENT #500: REVIEW OF THE FACE SHEET, MINIMUM DATA SET (MDS, RESIDENT ASSESSMENT TOOL) DATED [DATE], PHYSICIAN ORDERS [REDACTED].#500 WAS admitted to the facility on [DATE], WAS VENT DEPENDENT, REQUIRED ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADL'S), WAS HARD OF HEARING WITH IMPAIRED COMMUNICATION, IMMOBILE, TUBE FED, COGNITIVELY IMPAIRED AND HAD PERIODS OF RESTLESSNESS, AND AT TIMES WOULD GRAB AT ITEMS IN AN NON-PURPOSEFUL MANOR. RESIDENT #500'S [DIAGNOSES REDACTED]. REVIEW OF THE FACILITY INVESTIGATION REPORT, DATED [DATE], REVEALED THAT ON [DATE] AT APPROXIMATELY 2:50 A.M., RESPIRATORY THERAPIST (RT) #2 HEARD RESIDENT #500'S INTERNAL VENTILATOR ALARM SOUNDING. RT #2 WENT INTO RESIDENT #500'S ROOM AND FOUND RESIDENT #500 DISCONNECTED FROM HER VENT, CYANOTIC AND REQUIRING IMMEDIATE RESCUE BREATHING REVIEW OF THE RESPIRATORY NOTES, DATED [DATE] AT 2:50 A.M., STATED "RESPONDING TO VENT INTERNAL ALARM BEEPING, FOUND PT (PATIENT) UNRESPONSIVE AND BLUE IN COLOR, SPO2 (OXYGEN SATURATION LEVEL) LESS THEN 81% (NORMAL 90% TO 100%), BAGGED PT". REVIEW OF THE NURSES NOTES, DATED [DATE] AT 7:10 P.M., REVEALED "PT (RESIDENT #500) PULLED OUT HER PICC LINE (AN INTRAVENOUS CATHETER) BLEEDING CONTROLLED WITH PRESSURE". DATED [DATE]. REVIEW OF THE NURSES NOTES, DATED [DATE] AT 11:00 P.M., REFLECTED "PT TORE OFF DRSG ON ARM AND MADE HERSELF BLEED". REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. INTERVIEW'S WERE DONE ON [DATE] (AT 5:08 P.M.) AND ON [DATE] (AT 2:00 P.M.). WITH RT#2. RT #2 STATED "I WAS IN A (RESIDENT'S) ROOM AT THE OTHER END OF THE HALL, I COULD NOT HEAR THE ALARM (VENT ALARM). SHE (RESIDENT #500) WAS BLUE, UNRESPONSIVE WITH A COUPLE OF SHALLOW BREATHS (WHEN ENTERED ROOM); I BAGGED HER (RESCUE BREATHING). I CAME OUT OF THE ROOM (AFTER STABILIZING THE RESIDENT) AND WENT TO THE DESK TO TELL THE OTHER RT (RT) #1. IN TELEPHONE INTERVIEW'S ON [DATE] AT 5:12 P.M., AND ON [DATE] AT 9:00 A.M., RT#1 REVEALED SHE WAS AT LUNCH AND WHEN SHE RETURNED RT #2 INFORMED HER THAT RESIDENT #500 HAD DISCONNECTED HERSELF FROM HER VENT. RT #1 REPORTED 4 STAFF MEMBERS WERE SITTING AT THE NURSES STATION AND SAID THEY DID NOT HEAR THE RESIDENT'S INTERNAL VENT ALARM GOING OFF AND HER EXTERNAL ALARM DID NOT SOUND. IN A TELEPHONE INTERVIEW ON [DATE] AT 4:55 P.M., CNA #1 STATED "SHE (RESIDENT #500) HAD BEEN DISCONNECTING HERSELF ALL NIGHT (ON [DATE]-[DATE], THIRD SHIFT); THE ALARM WAS GOING OFF (THE INTERNAL ALARM ONLY)". IN AN INTERVIEW ON [DATE] AT 1:06 P.M., REGISTERED NURSE (RN) #1 STATED "SHE DID HAVE A HISTORY OF DISCONNECTING HER TUBE. RESPIRATORY THERAPY TOLD ME THAT SHE (RESIDENT #500) WAS GOING TO DISCONNECT HERSELF AND WE NEEDED TO MONITOR HER. SHE WAS ON 3 ANTIBIOTICS AND SHE WAS CONFUSED (ON [DATE]-[DATE], THIRD SHIFT). SHE USUALLY WAS NOT. RT #2 CAME OUT OF RESIDENT #500'S ROOM AND TOLD ME SHE JUST HAD TO BAG THE RESIDENT. AFTER THE INCIDENT I WENT DOWN TO RESIDENTS #500'S ROOM, SHE WAS OK. I DIDN'T DO AN ASSESSMENT. RT #2 DID ONE WHEN SHE WAS IN THE ROOM. RN #1 SAID SHE DID NOT GET an order for [REDACTED]. SHE WAS "PULLING HER PICC OUT, DISCONNECTING FROM THE VENT AND PULLING HER DRESSING OFF." REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. IN A TELEPHONE INTERVIEW ON [DATE] AT 4:45 P.M., LPN #2 STATED "THIS RESIDENT (RESIDENT #500) HAD DISCONNECTED HERSELF SEVERAL TIMES; THEY HAD TO GO IN HER ROOM SEVERAL TIMES THAT NIGHT ([DATE]-[DATE], THIRD SHIFT). WE DON'T USE RESTRAINTS (HAND MITTS). MOST PATIENTS LIKE THAT WE GIVE PRN (AS NEEDED) MEDICATIONS, SHE SHOULD OF HAVE HAD MITTS ON". LPN #2 SAID THE FACILITY WAS "RESTRAINT FREE", SO THE RESIDENT DID NOT HAVE HAND MITTS ORDERED. IN AN INTERVIEW ON [DATE] AT 8:45 A.M., THE DIRECTOR OF RESPIRATORY THERAPY #1 STATED RESIDENT #500 "WAS VERY SQUIRMY". THE DIRECTOR OF RESPIRATORY THERAPY #1 CONFIRMED RESIDENT #500 had a history of [REDACTED]. UPON REVIEW OF RESIDENT #500'S CLINICAL RECORD, THE DIRECTOR OF RESPIRATORY #1 WAS UNABLE TO FIND DOCUMENTATION OF RESIDENT #500 DISCONNECTING HERSELF FROM THE VENT. REVIEW OF RESIDENT #500'S RESPIRATORY FAILURE CARE PLAN, DATED [DATE], AND THE CENTRAL INFORMATION TOOL (THE CNA'S RESIDENT CARE GUIDE), UN-DATED, DID NOT CONTAIN DOCUMENTATION OF ANY SAFETY DEVICES IN PLACE TO PREVENT RESIDENT #500 FROM DISCONNECTING HERSELF FROM THE VENT. REVIEW OF THE HOSPITAL CONSULTATION NOTE DATED [DATE], REFLECTED "SHE (RESIDENT #500) IS NONVERBAL WITH TRACH ON VENT, BLIND AND HARD OF HEARING". REVIEW OF THE HOSPITAL physician progress notes [REDACTED]. ON [DATE] AT 2:00 P.M., THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY IDENTIFIED ON [DATE] AND WHICH BEGAN ON [DATE], WHEN: 1) RESIDENT #501, WHO had a history of [REDACTED]. RESIDENT #501 SUBSEQUENTLY died on [DATE] AT 7:45 PM, AND 2) RESIDENT #500, WHO had a history of [REDACTED]. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. RESIDENT #500 WAS ASSESSED ON [DATE] BY THE RESPIRATORY THERAPIST PRIOR TO GIVING RESCUE BREATHING AND WAS RE-CONNECTED TO THE VENTILATOR. THE RESPIRATORY THERAPIST INFORMED THE CHARGE NURSE AND STAFF MONITORED THE RESIDENT. RESIDENT #501 EXPIRED [DATE]. 2. ON [DATE], RESIDENTS WITH VENTILATORS AND WITH TRACHEOSTOMY TUBES WERE ASSESSED FOR RESTRAINTS AND APPLICATIONS BY A REGISTERED NURSE AND THE DIRECTOR OF RESPIRATORY. 3. ON [DATE], CARE PLANS FOR CURRENT RESIDENTS WERE REVIEWED AND UP-DATED TO REFLECT CURRENT SAFETY MANAGEMENT BY THE MANAGEMENT TEAM. ONE OUT OF THIRTY RESIDENTS CONTINUES TO USE A HAND MITT DUE TO ATTEMPTS TO DECANNULATE HIMSELF. 4. ON [DATE], AN AUDIT WAS COMPLETED FOR AVAILABILITY OF HAND MITTS IN THE FACILITY BY THE RESPIRATORY UNIT MANAGER. THE FACILITY WILL MAINTAIN 10 SETS OF HAND MITTS FOR USE IN EMERGENCY SITUATIONS OR IN FOLLOWING A physician's orders [REDACTED]. 5. ON [DATE] AT 2:30 P.M., 34 STAFF WERE RE-EDUCATED ON USE OF RESTRAINTS, OXYGEN THERAPY AND ALARMS RELATED TO SAFETY FOR VENTILATOR DEPENDENT AND TRACHEOSTOMY RESIDENTS. 34 STAFF WERE EDUCATED BY 4:30 P.M. AND NO NURSING OR RESPIRATORY STAFF WILL BE PERMITTED TO WORK AT THE FACILITY, UNTIL THEY HAVE COMPLETED THEIR EDUCATION ON RESTRAINTS, OXYGEN AND ALARMS RELATED TO THE VENT UNIT AND RESIDENT SAFETY. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL STAFF HAVE NOT BEEN IN-SERVICED AND THE STATE AGENCY HAS NOT VERIFIED SUSTAINED COMPLIANCE. (# )

THIS CITATION PERTAINS TO INTAKE: MI 183. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORDS REVIEW THE FACILITY FAILED TO PROVIDE INTERVENTIONS TO ADDRESS WEIGHT LOSS IN 2 OF 13 RESIDENTS (#105, AND #110) REVIEWED FOR WEIGHT LOSS IN A TOTAL SAMPLE OF 23, RESULTING IN SIGNIFICANT WEIGHT LOSS FOR RESIDENT #105 WHO LOST 10.8% OF HER WEIGHT IN 6 MONTHS, AND RESIDENT #110 WHO LOST 24.6% OF HER BODY WEIGHT IN 2 MONTHS. FINDINGS INCLUDE: ON 6/21/11 AT 1:15 P.M., THE REGISTERED DIETITIAN (RD) WAS INTERVIEWED. ACCORDING TO THE RD, ON 6/20/11, SHE WAS INFORMED THAT THERE WERE TWO RESIDENTS, #105 AND #110, WHO HAD SUSTAINED SIGNIFICANT WEIGHT LOSS. THE RD SAID SHE COMES TO THE FACILITY TWICE A MONTH AND MAINLY REVIEWS RESIDENTS ON TUBE FEEDINGS, OR SPECIFIC THERAPEUTIC DIETS. THE ONLY WAY SHE WOULD BE AWARE OF A RESIDENT WITH SIGNIFICANT WEIGHT LOSS WOULD BE IF A NURSE LEFT A NOTE ON HER DESK OR SPECIFICALLY INFORMED HER. THE RD SAID THERE IS A FULL-TIME STAFF MEMBER AT THE FACILITY WHO IS RESPONSIBLE TO ENTER THE RESIDENT'S WEIGHT IN THE COMPUTER, BUT IT IS NOT ALWAYS COMPLETED. THAT RD STATED THAT AFTER SHE WAS INFORMED OF THE SIGNIFICANT WEIGHT LOSS, SHE ADDED SUPPLEMENTS, AND AN EXTRA SNACK IN THE EVENING IN AN ATTEMPT TO INCREASE THE CALORIC INTAKE OF BOTH RESIDENT #105 AND RESIDENT #110, ACCORDING TO THE NUTRITION POLICIES AND PROCEDURES DATED 10/09, THE RD/OR DESIGNEE IS RESPONSIBLE TO INPUT MONTHLY WEIGHTS INTO THE COMPUTERS "WEIGHT TRACKER" PROGRAM. THE RD/OR DESIGNEE ADDRESSES WEIGHT LOSS IMMEDIATELY IN THE DIETARY PROGRESS NOTES AND DEVELOP OR UPDATE A CARE PLAN. RESIDENT #105: ACCORDING TO THE MEDICAL RECORDS, RESIDENT #105 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. RESIDENT #105 WAS PRESCRIBED A MECHANICAL SOFT DIET WITH 8 OUNCES OF PRUNE JUICE DAILY. ON 6/20/11 AT 11:00 A.M., RESIDENT #105 WAS OBSERVED TO BE SEATED IN HER WHEELCHAIR IN HER ROOM. SEVERAL OF HER EVENING SNACKS (PEANUT BUTTER CRACKERS AND FRUIT BAR) WERE OBSERVED ON HER BEDSIDE TABLE, UNOPENED AND NOT IN HER REACH. RESIDENT #105 WAS ALERT, BUT UNABLE TO BE SUBSTANTIALLY INTERVIEWED DUE TO COGNITION DEFICITS. ON 6/20/11 AT 11:05 A.M., CERTIFIED NURSE AIDE (CNA) #19 SAID SHE WAS UNAWARE IF RESIDENT #105 ATE HER EVENING SNACKS, BECAUSE THAT WOULD BE DONE ON THE AFTERNOON SHIFT. CNA #19 SAID SHE THOUGHT RESIDENT #105 ATE WELL AND ONLY NEEDED A SET-UP ASSISTANCE. CNA #19 DID NOT KNOW IF RESIDENT #105 WAS ON AN INCREASED CALORIE DIET, OR IF SHE NEEDED ENCOURAGEMENT TO EAT. ACCORDING TO THE VITAL SIGNS AND WEIGHT RECORD FOR 2011, ON 1/10/11 RESIDENT #105 WEIGHED 104.6 LBS (POUNDS). THERE WERE NO ADDITIONAL DOCUMENTED WEIGHTS UNTIL 5/16/11, WHEN RESIDENT #105'S WEIGHT WAS DOCUMENTED AS 96.6 LBS., A 7.6% WEIGHT LOSS IN 5 MONTHS. ON 6/2/11, RESIDENT #105'S WEIGHT WAS DOCUMENTED AS 93.2 LBS., A 10.8% WEIGHT LOSS IN 6 MONTHS. A REVIEW OF THE PHYSICIAN'S PROGRESS NOTES, THE DIETARY MANAGERS (DM) NOTES, AND THE REGISTERED DIETITIAN'S (RD) NOTES, REVEALED THERE WAS NO DOCUMENTATION TO SUPPORT MONITORING OF RESIDENT #105'S WEIGHT LOSS, OR RECOMMENDATIONS TO STABILIZE RESIDENT #105'S WEIGHT. A REVIEW OF RESIDENT #105'S ORDER'S REVEALED NO ORDERS OR RECOMMENDATIONS TO MONITOR OR INCREASE THE RESIDENT'S CALORIC INTAKE, ADD SUPPLEMENTS, OR MONITOR THE RESIDENT'S WEIGHT ON WEEKLY BASIS. A REVIEW OF RESIDENT #105'S CARE PLANS REVEALED THERE WERE NO INTERVENTIONS TO MONITOR OR INCREASE THE RESIDENTS ORAL INTAKE. THERE WERE NO INTERVENTIONS TO MONITOR THE RESIDENT'S WEIGHT ON A WEEKLY BASIS. ON 6/20/11 AT 3:00 P.M., THE DIRECTOR OF NURSING (DON) COULD NOT PROVIDE ANY ADDITIONAL DOCUMENTATION TO SUPPORT THAT RESIDENT #105'S WEIGHT WAS MONITORED BETWEEN 1/11 AND 5/11. THE DON SAID THE RESIDENT SHOULD HAVE HAD HER WEIGHT MONITORED WEEKLY AND PROVIDED ADDITIONAL CALORIES IN HER DIET. ON 6/21/11 AT 3:10 P.M., THE RESTORATIVE AIDE SAID THAT SHE COMPLETES THE MONTHLY WEIGHTS AND RECORDS THEM ON A SHEET OF PAPER FOR THE DIETARY MANAGER TO REVIEW AND RECORD. THE RESTORATIVE AIDE SAID SHE WEIGHED RESIDENT #105 ON 6/2/11 AND RECORDED 93.2 LBS ON THE SHEET OF PAPER. ON 6/21/11, RESIDENT #105'S WEIGHT WAS DOCUMENTED AS 94.6 LBS. THE RESTORATIVE AIDE SAID THERE WERE NO WEIGHTS RECORDED FOR THE MONTHS OF 2/11 THROUGH 5/11 BECAUSE DURING THAT TIME, DIRECT CARE STAFF WERE RESPONSIBLE TO COMPLETE THE MONTHLY WEIGHTS. RESIDENT #110: ACCORDING TO THE MEDICAL RECORDS, RESIDENT #110 WAS A [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. A REVIEW OF THE CARE PLAN DATED 1/19/11 AND DIETARY RECOMMENDATIONS REVEALED RESIDENT #110 LIKED TO EAT WITH HER FINGERS AND A MENU WAS PLANNED BASED ON FINGER FOODS, RESIDENT "LIKES," AND ENCOURAGEMENT TO INCREASE ORAL INTAKE. ON 6/20/11 AT 10:50 A.M., RESIDENT #110 WAS OBSERVED TO BE ASLEEP IN HER BED WITH 2 DAYS WORTH (PACKAGES WERE DATED 6/18, 6/19) OF EVENING SNACKS (PEANUT BUTTER CRACKERS, JUICE, AND COOKIES) RESTING ON HER BEDSIDE TABLE, UNOPENED AND OUT OF HER REACH. ON 6/20/11 AT 12:30 P.M., RESIDENT #110 WAS OBSERVED TO BE UP IN HER WHEELCHAIR IN THE ASSISTED DINING ROOM. RESIDENT #110 WAS EATING WITH HER FINGERS, AND APPEARED TO HAVE A GOOD APPETITE. THE RESIDENT'S DINING MENU CARD REVEALED THAT SHE LIKED FINGER FOODS. ACCORDING TO THE VITAL SIGNS AND WEIGHT RECORD FOR 2011, ON 2/16/11, RESIDENT #110 WEIGHED 149 LBS. ON 4/19/11, RESIDENT #110'S WEIGHT WAS RECORDED AS 112.2 LBS., A 34.8 LB WEIGHT LOSS, OR 24.6% LOSS OF BODY WEIGHT IN 2 MONTHS. A REVIEW OF THE PHYSICIAN'S PROGRESS NOTES, THE DIETARY MANAGERS (DM) NOTES, AND THE REGISTERED DIETITIAN'S (RD) NOTES, REVEALED THERE WAS NO DOCUMENTATION TO SUPPORT MONITORING OF RESIDENT #110'S WEIGHT LOSS, OR RECOMMENDATIONS TO STABILIZE RESIDENT #110'S WEIGHT UNTIL 5/11/11 (22 DAYS AFTER DOCUMENTED SIGNIFICANT WEIGHT LOSS). A REVIEW OF RESIDENT #110'S ORDER'S REVEALED NO ORDERS OR RECOMMENDATIONS TO MONITOR OR INCREASE THE RESIDENT'S CALORIC INTAKE, ADD SUPPLEMENTS, OR MONITOR THE RESIDENT'S WEIGHT ON WEEKLY BASIS UNTIL 5/11/11. A REVIEW OF RESIDENT #110'S CARE PLANS REVEALED THERE WERE NO INTERVENTIONS TO MONITOR OR INCREASE THE RESIDENTS ORAL INTAKE UNTIL 5/11/11. THERE WERE NO INTERVENTIONS TO MONITOR THE RESIDENT'S WEIGHT ON A WEEKLY BASIS. ON 6/2/11, RESIDENT #110 WAS RECORDED TO WEIGH 122.6 LBS, A 17.7 % WEIGHT LOSS IN A 4 MONTH TIME FRAME. THE RESIDENT CONTINUED TO ONLY BE WEIGHED ON A MONTHLY BASIS. ON 6/20/11 AT 3:00 P.M., THE DIRECTOR OF NURSING (DON) COULD NOT PROVIDE ANY ADDITIONAL DOCUMENTATION TO SUPPORT THAT RESIDENT #110'S WEIGHT WAS MONITORED FROM 2/16/11 THROUGH 4/19/11. THE DON SAID THE RESIDENT SHOULD HAVE HAD HER WEIGHT MONITORED WEEKLY AND HAD AN INCREASE IN HER CALORIC INTAKE AS OF 4/19/11. THE DON COULD NOT EXPLAIN THE DELAY IN treatment for [REDACTED].

THIS CITATION PERTAINS TO INTAKE: MI 228 BASED ON STAFF INTERVIEWS AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND THE APPLICATION OF AN APPROPRIATE TYPE OF ALARM TO PREVENT A FALL IN 1 (RESIDENT #121) OF 9 SAMPLED RESIDENTS REVIEWED FOR FALLS IN A TOTAL SAMPLE OF 23, RESULTING IN RESIDENT #121 REMOVING HER TAB ALARM, SELF-TRANSFERRING TO THE BATHROOM, FALLING, AND SUSTAINING A PELVIC FRACTURE. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INCIDENT REPORT DATED 6/2/11, ON 5/25/11 AT APPROXIMATELY 6:30 A.M. RESIDENT #121 WAS FOUND LYING ON THE BATHROOM FLOOR BY CERTIFIED NURSING ASSISTANT (CNA) #25. RESIDENT #121 WAS ASSESSED AND RETURNED TO THE WHEELCHAIR AND THEN PLACED IN BED BY LICENSED PRACTICAL NURSE (LPN) #24. INITIALLY RESIDENT #121 COMPLAINED OF RIGHT ELBOW PAIN AND WAS ABLE TO STAND AFTER THE FALL FOR TRANSFER BACK TO THE WHEELCHAIR, THE BED AND FOR A BRIEF CHANGE. APPROXIMATELY 30 MINUTES AFTER THE FALL, RESIDENT #121 REQUESTED TO BE TRANSFERRED TO THE TOILET AGAIN, BUT COMPLAINED OF RIGHT LEG PAIN AND COULD NOT TOLERATE ANY MOVEMENT. RESIDENT #121 WAS TRANSFERRED TO THE emergency room FOR EVALUATION AND TREATMENT. THE HOSPITAL'S RADIOLOGY RECORDS DATED 5/25/11 AT 10:30 A.M., REPORTED THE FOLLOWING FINDINGS FOR RESIDENT#121: SUPERIOR AND INFERIOR PUBIC FRACTURES ON THE RIGHT. DURING A TELEPHONE INTERVIEW ON 6/16/11 AT 1:00 P.M., CNA #25 SAID THAT DURING ROUNDS SHE FOUND RESIDENT #121 ON THE BATHROOM FLOOR. CNA #25 SAID SHE IMMEDIATELY NOTIFIED LPN #24 AND ASSISTED WITH TRANSFERRING THE RESIDENT BACK TO THE WHEELCHAIR. LPN #24 ASSESSED RESIDENT #121 AND TRANSFERRED HER BACK TO BED WITHOUT COMPLAINTS OF LEG PAIN. ABOUT 30 MINUTES LATER, RESIDENT #121 REQUESTED TO USE THE BATHROOM AGAIN, BUT COULD NOT BE TRANSFERRED BECAUSE SHE COMPLAINED OF SEVERE RIGHT LEG PAIN. RESIDENT #121 WAS SENT OUT TO THE HOSPITAL FOR TREATMENT. CNA #25 SAID RESIDENT #121 HAD AN ALARM THAT WAS SUPPOSE TO BE CLIPPED ONTO HER CLOTHES, BUT THE RESIDENT'S ALARM WAS NOT SOUNDING WHEN SHE FOUND HER IN THE BATHROOM . CNA #25 COULD NOT RECALL WHERE THE ALARM BOX WAS. CNA #25 SAID RESIDENT #121 OFTEN REMOVED HER ALARM AND ATTEMPTED TO SELF-TRANSFER HERSELF TO THE BATHROOM REGULARLY. CNA #25 SAID SHE ATTEMPTED TO CLIP RESIDENT #121'S ALARM WHERE SHE COULD NOT REACH IT, BUT SOMEHOW SHE (RESIDENT #121) MANAGED TO REMOVE IT WITHOUT SETTING OFF THE ALARM. CNA #25 COULD NOT EXPLAIN WHY THE RESIDENT WAS NOT CHANGED TO A PRESSURE SENSOR TYPE OF ALARM. DURING A TELEPHONE INTERVIEW ON 6/16/11 AT 1:15 P.M., LPN #24 SAID SHE WAS NOTIFIED BY CNA #25 THAT RESIDENT #121 WAS ON THE FLOOR IN THE BATHROOM. LPN #24 SAID SHE ASSESSED RESIDENT #121 AND SHE (RESIDENT #121) DENIED ANY PAIN AND WAS TRANSFERRED BACK TO THE WHEELCHAIR. LPN #24 SAID THE RESIDENT DID NOT HAVE ANY SIGNS OF INJURY AT THAT TIME AND WAS THEN ASSISTED TO STAND UP, HAVE HER BRIEF CHANGED AND THEN RETURNED TO BED. LPN # 24 SAID SHE WAS CALLED BACK TO RESIDENT #121'S ROOM ABOUT 30 MINUTES LATER BECAUSE RESIDENT #121 WAS UNABLE TO TOLERATE ANY MOVEMENT WITHOUT SEVERE PAIN. LPN # 24 SAID RESIDENT #121'S ALARM HAD BEEN DISCONTINUED A FEW WEEKS EARLIER BECAUSE THE RESIDENT KEPT REMOVING IT OR SHUTTING IT OFF. LPN #24 SAID SHE PLACED A WHEELCHAIR TAB ALARM ON RESIDENT #121 EARLIER IN THE SHIFT ON 5/25/11 BECAUSE SHE HAD FOUND RESIDENT #121 SELF-TRANSFERRING HERSELF OUT OF THE WHEELCHAIR WITHOUT PLACING THE BRAKES ON THE CHAIR. A RECORD REVIEW FOR RESIDENT #121 REVEALED THAT SHE WAS A [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] AFTER FALLING AT HOME AND SUSTAINING A RIGHT HIP FRACTURE. A REVIEW OF THE PROGRESS NOTES, NURSING NOTES, AND SOCIAL WORKERS NOTES FROM 1/22/11 THROUGH 5/25/11, REVEALED THAT RESIDENT #121 DISPLAYED INCREASING SIGNS OF MEMORY LOSS AND ATTEMPTED SELF-TRANSFERS. THE CARE CONFERENCE DATED 4/21/11 DOCUMENTED THE FOLLOWING: THE FAMILY OF RESIDENT #121 REPORTED THE FACILITY STAFF REALLY NEEDS TO WATCH THE RESIDENT BECAUSE SHE HAS LEARNED HOW TO TURN OFF HER ALARMS AND WILL ATTEMPT TO SELF-TRANSFER MORE NOW. THE FALL RISK ASSESSMENTS DATED 1/19/11 AND 4/19/11, IDENTIFIED RESIDENT #121 AS BEING AT "HIGHER RISK" FOR FALLS. HOWEVER, THE CARE PLAN FOR FALL PREVENTION INITIATED ON 1/26/11 HAD DISCONTINUED THE WHEELCHAIR AND BED ALARM ON 4/14/11. NO ADDITIONAL INTERVENTIONS FOR FALLS WERE INITIATED AFTER THE ALARMS WERE DISCONTINUED. ACCORDING TO THE COGNITION IMPAIRMENT CARE PLAN DATED 1/31/11, RESIDENT #121 SCORED A 8 OUT OF 15 ON THE BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) AND ON 4/25/11 RESIDENT #121 SCORED A 4 OUT OF 15, (SHOWING A SIGNIFICANT DECREASE IN MENTAL STATUS). ON 6/21/11 AT 3:00 P.M., THE DIRECTOR OF NURSING (DON) SAID RESIDENT #121'S ALARMS WERE DISCONTINUED ON 4/14/11 BECAUSE SHE (THE RESIDENT) WAS ABLE TO TURN THEM OFF ANYWAY, AND THE RESIDENT HAD NOT SUSTAINED A FALL WHILE AT THE FACILITY UNTIL 5/25/11. THE DON COULD NOT PROVIDE AN EXPLANATION FOR WHY THERE WERE NO ADDITIONAL INTERVENTIONS TO PREVENT FALLS FOR RESIDENT #121 AFTER 4/14/11 WHEN THE RESIDENT WAS STILL IDENTIFIED AS A BEING AT A "HIGHER RISK" FOR FALLS. THE DON COULD NOT EXPLAIN WHY THE STAFF COULD NOT "FIND" A PLACE TO CLIP THE RESIDENT'S ALARM OR PLACE THE ALARM BOX WHERE THE RESIDENT COULD NOT REACH IT WITHOUT SETTING OFF THE ALARM. A REVIEW OF THE FACILITY'S FALL MANAGEMENT PROGRAM DATED 10/10 REVEALED SEVERAL ADDITIONAL INTERVENTIONS THE FACILITY STAFF COULD UTILIZE TO MANAGE RESIDENTS WHO ARE AT RISK FOR FALLS. THE LIST OF INTERVENTIONS THE FACILITY COULD USE TO MANAGE FALLS INCLUDE THE FOLLOWING: FLOOR MATS, BOWEL AND BLADDER PROGRAM, RECOGNIZING WHEN INDEPENDENT AMBULATION IS NOT SAFE, NON-SKID PAD IN WHEELCHAIR, AND USE OF BED/CHAIR ALARMS. ( )

This citation refers to intake #MI 715, MI 766, MI 786 Based on interview and record review, facility staff failed to provide adequate supervision to prevent accidents for 1 (#101) of 5 sampled residents who were diagnosed with [REDACTED].#3) and was not provided with 1:1 feeding assistance, as ordered, which resulted in Resident #101 choking on a broccoli spear and death on [DATE]. Findings include: Resident #101 was a [AGE] year-old male who was diagnosed with [REDACTED]. He was admitted on [DATE] to the facility for rehabilitation due to his difficulty swallowing food. A record review of the director of nursing's (DON) five day report to the state indicated that on [DATE] at approximately 11:30 AM, CNA #3 brought in a lunch tray to Resident #101's room. The food on the tray consisted of ground meat over noodles (beef stroganoff), fruit cocktail and broccoli spears. CNA #3 placed the tray on Resident #101's bedside table and CNA #3 placed the table in front of Resident #101, who was sitting in his wheelchair. CNA #3 then left Resident #101's room to continue passing trays. Around 11:40 AM, a student nurse heard a loud crash from Resident #101's room and found Resident #101 lying on the floor. The student nurse summoned LPN #4, who was caring for Resident #101. LPN #4 assessed Resident #101 and, with the help of a physical therapist, transferred Resident #101 to his bed. Around 12:10 PM, when Resident #101 had no pulse or respirations, cardiopulmonary resuscitation (CPR) was started and 911 was phoned. A record review of consultation notes from a hospital dated [DATE] revealed the Resident #101 was initially diagnosed with [REDACTED]. In [DATE], Resident #101 experienced progression of symptoms, including increased difficulty in swallowing food resulting in weight loss. Due to his progressive deterioration, he was admitted to a hospital for consultation and evaluation of his condition. While in the hospital, Resident #101 had a PEG tube inserted to assist in feeding and was transferred to the facility for rehabilitation for dysphagia. The percutaneous endoscopic gastrostomy (PEG) tube provides nutrition for patients who are having difficulty swallowing. A record review of Minimum Data Set 3.0 (MDS) and associated Care Area Assessment (CAA) forms dated [DATE] indicated that Resident #101 was able to answer simple questions, could make his needs known but was unable to make any decisions on his own. A record review of physician's orders [REDACTED]. 1:1 assistance recommended." The attending physician co-signed the order on [DATE]. A record review of the nutrition policy and procedure (P/P) for pleasure feedings was reviewed. According to the policy, "pleasure feedings may be ordered for residents who receive the majority of their nutrients via tube feeding, and who occasionally take small amounts of food by mouth ". Recommended food items include applesauce, cottage cheese, gelatin, ice cream and other similar foods. A record review of the nutrition nursing care plan regarding Resident #101 contained detailed notes concerning the pleasure tray, which was to contain pureed and nectar thickened foods, and documented the need for one to one (1:1) assistance during the lunch meal. On [DATE] at 10:00 AM, a phone interview was conducted with sergeant #5 from the sheriff's office who responded to the 911 call and was present in the facility on [DATE]. Sergeant #5 witnessed the removal of the four inch piece of broccoli from Resident #101's throat. Sergeant #5 stated that the police had the four inch un-chewed piece of broccoli in their possession. Sergeant #5 stated that the police were blocked from interviewing any staff members after the incident because the corporate council for the facility spoke to the police directly and ordered them to "cease and desist asking question of the staff". On [DATE] at 2:00 PM, CNA #3 was brought to the conference room by the Administrator. After the state surveyor instructed the Administer to leave the room, the surveyor attempted to interview CNA #3. CNA #3 refused to answer any questions regarding Resident #101 and the incident. Initially, she invoked her Fifth Amendment rights and then said she would not speak about the event unless her lawyer was present. On [DATE] at 3:25 PM, Licensed Practical Nurse (LPN) #4 was interviewed. According to LPN #4, when she was called to Resident #101's room on [DATE] at 11:40 AM. LPN #4 initially thought Resident #101 was having a seizure as his jaw was clamped shut and LPN #4 was unable to do a mouth sweep for foreign materials. Resident #101 did not respond to his name. When Resident #101 was put into his bed, Resident #101's color improved slightly and LPN #4 was able to palpate a pulse. In addition, LPN #4 stated that his nail beds blanched (became pale with pressure and became pink when pressure was removed) when she put pressure on them. LPN #4 initiated nasal oxygen when she was unable to get an oxygen reading from a pulse oximeter device (a small machine that indirectly monitors oxygen saturation in the blood). Respiratory Therapy #6 entered the room and placed Resident #101 on a non-rebreather (a device that delivers high concentrations of oxygen to a patent who can breathe for himself during a medical emergency). At noon, Resident #101 had no pulse or respirations and CPR (cardiopulmonary resuscitation) was initiated. Two respiratory therapists (Respiratory Therapy #6 and the Director of Respiratory Therapy) were assisting Resident #101 to breathe by using an Ambu Bag (self-inflating bag used to help a patient to breathe during a medical emergency). LPN #4 did chest compressions. In addition, 911 was called. At 12:20 PM, EMS arrived. The EMT #18 (Emergency Medical Technician) started an intravenous line and attempted to intubate (Pass a breathing tube into the larynx to assist with breathing) Resident #101. EMT #18 was unable to do so because there was a blockage. EMT #18 used a pair of forceps to remove an un-chewed four-inch piece of broccoli from Resident #101's larynx (organ in the neck that functions as an airway to the lungs). Once the airway had no further obstructions, EMT #18 was able to intubate Resident #101 successfully. CPR continued until 1:00 PM when CPR was stopped and Resident #101 was pronounced dead. On [DATE] at 10:20 PM, in an interview with the Director of Respiratory Therapy, she stated that the Director of Respiratory Therapy arrived at Resident #101's room just before noon. She assisted Resident #101 to breathe and assisted with the Cardiopulmonary resuscitation until the EMS team arrived. The Director of Respiratory Therapy stated she (Director of Respiratory Therapy witnessed EMS #18 remove a "long piece of broccoli" from Resident #101's throat. The Director of Respiratory Therapy stated "it was not a little thing (referring to the broccoli), it was big". On [DATE], during a review of the witness statements presented to this surveyor by the DON, when the DON interviewed the Director of Respiratory Therapy, the Director of Respiratory Therapy stated she "saw forceps used and extraction of food". On [DATE] at 11:10 AM, the Director of the dietary department stated he personally entered all diet orders into a dietary data base. The meal tickets were printed out and reflected what was entered into the dietary database. When asked about ''pleasure trays'', the Director stated that the kitchen staff were not aware when a tray was classified as a ''pleasure tray''. When asked about Resident #101, the Director stated that he was not aware that Resident #101 had a swallowing problem. When asked how Resident #101 received a tray containing solid food instead of the pureed food ordered by the physician, the Director said "either the wrong food was on the tray or the wrong tray was served to Resident #101. A record review of the "Patient Care Report" generated by EMS (Emergency Medical Services) describing the events of [DATE] when EMS responded to a 911 call at the facility due to Resident #101 having no heartbeat or respirations. Under the topic of ''Assessment'' of the lungs, the following was written in the report: "Completely obstructed. When going to place the king tube (a specific name for a tube used to assist breathing), quick checked airway and saw there was a foreign object blocking the airway. Object removed with Magill (brand name) forceps. Foreign object was a large whole piece of broccoli about 4 inches long." The Administrator was notified on [DATE] at 4:06 PM of the Immediate Jeopardy that began on [DATE] when staff served Resident #101 a meal which contained solid foods and did not provide 1:1 feeding assistance which subsequently led to the death of Resident #101 and placed 16 other residents with swallowing difficulties at high risk for serious harm, injury and/or death. On [DATE], the surveyor verified that the facility implemented the following to remove the Immediate Jeopardy. 1. Beginning [DATE], the DON and Nursing Administrative staff identified residents with current diet consistency restrictions to assure that current interventions were able to prevent aspiration/choking. 2. The Dietary Service Director and Dietician re-educated 100% of the dietary staff beginning on [DATE] and completed by [DATE] at 7:00 AM regarding Tray Line policies and process. 3. The Director of Nursing and Nursing Administrative staff conducted in-service education for licensed nursing staff regarding the process to follow when completing a physician order. Education began on [DATE] and continued until [DATE] at 7:00 AM when 26 of 30 staff received education. Those staff who did not receive the inservice will be educated before beginning their shift on their next scheduled workday. Nursing audits will occur weekly to ensure compliance with ordered interventions. The interventions ordered will be written in the "Central Information Tool" form located in a red binder in the residents' room as a communication tool for all caregivers. 4. The Director of Nursing and Nursing Administrative staff conducted an in-service education regarding meal service, meal delivery and therapeutic diet policies. Training began on [DATE] and was completed by [DATE] at 7:00 AM. 85 of 96 staff were re-educated. The 11 staff members who did not receive the inservice will be educated before beginning their shift on their next scheduled workday. 5. Tray accuracy audits began on [DATE] and will continue to be conducted by the charge nurses at all meals before trays are delivered to the residents. Audits will continue until no tray issues are identified for two weeks and then will occur randomly after that to maintain compliance. 6. On [DATE], residents identified with swallowing issues had blue armbands placed on their arms by the Director of Nursing and Nursing Administrative staff and the care plans updated. The blue bands indicate that there is a diet consistency restriction for that resident. Education about the blue bands was initiated on [DATE] and was completed on [DATE]. 85 of 96 staff were re-educated. The 11 staff members who did not receive the inservice will be educated before beginning their shift on their next scheduled workday. In addition, charge nurses will observe and record on the Medication Administration Record (MAR) that the blue arm band is in place each shift. 7. All new residents will be assessed on admission for dietary consistency issues and a blue band will be given to the residents as needed. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at an isolated scope and severity of no actual harm but potential for more than minimal harm but no Immediate Jeopardy due to the in-service of all staff has not been completed and continued compliance of all elements has not been verified by the State. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 350. BASED ON INTERVIEW AND RECORDS REVIEW, THE FACILITY FAILED TO PREVENT FALLS IN 1 OF 4 SAMPLED RESIDENTS (#103) WHO WAS TRANSFERRED FROM HIS BED TO A MOTORIZED WHEELCHAIR WITHOUT USE OF A TRANSFER BELT, AND WITH ASSIST BY ONE FACILITY STAFF, RESULTING IN A FALL WITH SUBSEQUENT LEFT OBLIQUE FRACTURE OF THE PROXIMAL TIBIA, EXTENDING FROM THE LATERAL CONDYLE TO THE PROXIMAL MEDIAL DIAPHYSIS (BROKEN BONE LEFT LOWER EXTREMITY). FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #103 WAS AN [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS ((MDS) dated [DATE] REVEALED RESIDENT #103 WAS COGNITIVELY INTACT, EXPERIENCED NO LONG OR SHORT TERM MEMORY LOSS, WAS ABLE TO MAKE HIS NEEDS KNOWN, EXPERIENCED DEFICITS IN FUNCTION OF HIS ARMS AND LEGS, AND REQUIRED EXTENSIVE ASSISTANCE OF 2 FACILITY STAFF WITH ACTIVITIES OF DAILY LIVING, INCLUDING TRANSFERS (MOVEMENTS FROM SURFACE TO SURFACE). THE FALL RISK assessment dated [DATE], REVEALED RESIDENT #103 WAS IDENTIFIED AT RISK FOR FALLS. THE INTERDISCIPLINARY PLAN OF CARE, INITIATED 10/15/2009, AND REVISED 12/14/2010, IDENTIFIED RESIDENT #103 AT RISK FOR FALLS, AND INCLUDED AS APPROACHES TO CARE, TOTAL ASSIST WITH TRANSFERS. THE CENTRAL INFORMATION TOOL (INFORMATION SHEET USED BY NURSE AIDES DETAILING CARE PROVIDED TO THE RESIDENT) DATED 2/17/2010 SPECIFIED RESIDENT #103 REQUIRED TOTAL ASSISTANCE WITH TRANSFERS PERFORMED BY 2 FACILITY STAFF MEMBERS. THE FACILITY POLICY/PROCEDURE ENTITLED AMBULATION/TRANSFER, REVISED 11/2009, STATED "ALWAYS USE AMBULATION/GAIT BELTS ON ALL PATIENTS/RESIDENTS FOR SAFETY." THE FACILITY DID NOT REPORT THE FALL WITH FRACTURE EXPERIENCED BY RESIDENT #103 TO THE STATE AGENCY. THE FACILITY POST-FALL assessment dated [DATE], AND THE INCIDENT AND ACCIDENT INVESTIGATION FINDING FORM DATED 2/11/2011, REVEALED RESIDENT #103 WAS IN PROCESS OF TRANSFER FROM HIS BED TO HIS MOTORIZED WHEELCHAIR ON 2/8/2011 (UN-TIMED) WHEN HE EXPERIENCED A FALL. IDENTIFIED AS A REASON FOR THE FALL WAS "CNA SHOULD HAVE USED ANOTHER AIDE TO ASSIST IN THE TRANSFER." THE RESIDENT WAS REPORTED AS SENT TO A LOCAL HOSPITAL FOR EVALUATION. ACCORDING TO THE EMERGENCY SERVICES/PHYSICIAN DOCUMENTATION FORM DATED 2/9/2011 AT 3:12 A.M., RESIDENT #103 HAD SUSTAINED AN "OBLIQUE FRACTURE OF THE PROXIMAL TIBIA WITH MINIMAL DISPLACEMENT (FRACTURE OF HIS LEFT LEG)." THE REPORT INCLUDED THE RESIDENT WAS RETURNED to the facility on [DATE] FOR FURTHER CARE. DURING AN INTERVIEW ON 2/25/2011 AT 12:45 P.M., RESIDENT #103 SAID, "MY AIDE (CERTIFIED NURSE AIDE, CNA, STAFF MEMBER #9) TRANSFERRED ME FROM MY BED TO MY WHEELCHAIR (MOTORIZED). SHE DID IT BY HERSELF, WITHOUT ANY HELP. SHE DIDN'T USE THE BELT. SHE SHOULD'VE HAD HELP. I CAN'T STAND ON MY OWN." DURING AN INTERVIEW ON 3/1/2011 AT 10:30 A.M., A PHYSICAL THERAPIST (STAFF MEMBER #11) SAID, "THIS RESIDENT (#103) LAST HAD EVALUATIONS DONE BY THERAPY STAFF IN MARCH AND MAY OF 2008. HE WAS, AND CONTINUES TO BE, A MAXIMUM ASSIST OF 2 FACILITY STAFF MEMBERS WITH TRANSFERS. HE HAD POOR STANDING BALANCE. HE IS A TOTAL ASSIST WITH TRANSFERS. HE USES A MOTORIZED WHEELCHAIR. HE SHOULD HAVE 2 PERSONS ASSISTING HIM WITH TRANSFERS AT ALL TIMES, AND A TRANSFER BELT SHOULD BE USED. IT WOULD BE TOTALLY UNSAFE FOR THIS RESIDENT TO BE TRANSFERRED FROM SURFACE TO SURFACE BY ONE PERSON AND NO TRANSFER BELT USED." DURING AN INTERVIEW ON 3/1/2011 AT 11:30 A.M., A NURSE (STAFF MEMBER #12) SAID, "I WAS ASSIGNED TO THE RESIDENT (RESIDENT #103) ON 2/8/2011 AT THE TIME OF HIS FALL. HE USED A MOTORIZED WHEELCHAIR. HE CAN'T STAND ON HIS OWN. HE NEEDED THE USE OF A GAIT BELT FOR TRANSFERS. TWO PEOPLE DO HIS TRANSFERS. A CNA (STAFF MEMBER #9) DID HIS TRANSFER BY HERSELF. SHE SHOULD'VE HAD A SECOND PERSON HELP HER WITH THE TRANSFER, AND A GAIT BELT SHOULD HAVE BEEN USED." DURING A PHONE INTERVIEW ON 3/1/2011 AT 12:10 P.M., THE NURSE AIDE (STAFF MEMBER #9) WHO WAS ASSIGNED TO RESIDENT #103 ON 2/8/2011, DURING THE PERIOD OF HIS FALL, SAID, "I COULDN'T FIND ANYONE TO HELP ME WITH HIS TRANSFER, AND I WAITED A LONG TIME. I TOLD HIM I COULDN'T FIND ANY HELP AND THAT WE WERE GOING TO TRANSFER HIM BY OURSELVES. I DIDN'T USE A GAIT BELT WITH HIM. I GRABBED HIM BY HIS PANTS AND UNDER HIS ARM. HE WAS TOO HEAVY FOR ME TO TRANSFER; I FOUND THAT OUT ABOUT HALF WAY INTO THE TRANSFER TO HIS WHEELCHAIR. I COULDN'T LIFT HIM UP HIGH ENOUGH TO SIT ON THE WHEELCHAIR." DURING AN INTERVIEW ON 3/3/2011 AT 10:15 A.M., THE DIRECTOR OF NURSING SAID, "GAIT BELTS SHOULD BE USED WITH TRANSFERS. ALL STAFF SHOULD WEAR ONE; IT SHOULD BE PART OF THEIR UNIFORM. PHYSICAL ASSIST WITH TRANSFERS ARE SPECIFIED BY THERAPY STAFF, AND CNA'S CAN REFER TO THE RESIDENTS' CENTRAL INFORMATION TOOLS FOR THIS INFORMATION." DURING AN INTERVIEW ON 3/3/2011 AT 10:35 A.M., THE NURSING HOME ADMINISTRATOR SAID, "ALL EMPLOYEES ARE PROVIDED WITH GAIT BELTS; THEY'RE TO BE USED WITH TRANSFERS. IF A RESIDENT IS SPECIFIED TO BE A 2 PERSON ASSIST WITH TRANSFERS, THEN THERE NEEDS TO BE 2 PEOPLE DOING IT."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 335. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT ABUSE IN 1 OF 5 SAMPLED RESIDENTS (#101) WHO WAS VERBALLY ABUSED (CALLED A MOTHER [***] ) AND PHYSICALLY ABUSED (HANDLED ROUGHLY DURING ADL'S) BY A CERTIFIED NURSE AIDE (CNA) RESULTING IN THE RESIDENT EXPERIENCING FEAR, PAIN, ANGER, EMBARRASSMENT, AND FEELINGS OF VULNERABILITY. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #101 WAS A [AGE] year OLD MAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS ((MDS) dated [DATE] REVEALED RESIDENT #101 WAS MODERATELY COGNITIVELY INTACT, WAS ABLE TO MAKE HIS NEEDS KNOWN, REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S) INCLUDING TOILETING (CLEANSING SELF AFTER ELIMINATION), AND EXPERIENCED INCONTINENCE OF URINE AND STOOL. THE CENTRAL INFORMATION TOOL (INFORMATION SHEET USED BY NURSE AIDES SPECIFYING CARE TO BE PROVIDED TO THE RESIDENT) DATED 10/7/2010 IDENTIFIED RESIDENT #101'S DEPENDENCE ON FACILITY STAFF TO PROVIDE INCONTINENCE NEEDS. ACCORDING TO THE FACILITY INCIDENT REPORT, AND THE FACILITY INVESTIGATION REPORT DATED 12/18/2011, RESIDENT #101 REPORTED TO FACILITY STAFF ON 2/9/2011 (UN-TIMED) THAT A NURSE AIDE (STAFF MEMBER #19) HAD USED PROFANITY AND HANDLED THE RESIDENT ROUGHLY DURING POSITIONING IN BED ON 2/9/2011. DURING AN INTERVIEW ON 2/25/2011 AT 12:05 P.M., RESIDENT #101 SAID, "I'VE HAD A STROKE. SHE (STAFF MEMBER #19) DOESN'T LIKE ME; I'VE TOLD PEOPLE THAT. SHE WENT TO CHANGE MY DIAPER AND ACCUSED ME OF MAKING A MESS; I WENT TO THE BATHROOM IN MY DIAPER. SHE (STAFF MEMBER #19) CALLED ME A MOTHER [***] . SHE OVERLY SPREAD MY LEGS, SLAMMING THEM OPEN. THAT PHYSICALLY HURT ME. I WAS AFRAID OF HER. I HAD NO MEANS TO DEFEND MY SELF." DURING AN INTERVIEW ON 2/25/2011 AT 3:00 P.M., A NURSE (WITNESS #3) SAID, "HE (RESIDENT #101) TOLD ME HE HAD BEEN ABUSED BY A NURSE AIDE (CNA, STAFF MEMBER #19). I REPORTED THE INCIDENT; I BELIEVED HIM. I WORK WITH HIM EVERY DAY; HE DOESN'T LIE. HE'S BEEN THROUGH A LOT. HE TOLD ME ON 2/9/2011 THAT THE NURSE AIDE (STAFF MEMBER #19) HAD CALLED HIM A MOTHER [***] . HE TOLD ME SHE SCARED HIM. HE SAID HE WAS FEARFUL TO TELL ANYONE SHE'D ABUSED HIM, AFRAID SHE WOULD RETALIATE AGAINST HIM IF SHE FOUND OUT HE'D REPORTED HER. I HAD TO REASSURE HIM THAT SHE WOULDN'T BE TAKING CARE OF HIM ANY MORE." DURING A PHONE INTERVIEW ON 2/28/2011 AT 1:45 P.M., A NURSE AIDE (WITNESS #9) SAID, "I KNOW THIS RESIDENT VERY WELL. HE'S VERY FRAGILE AND CALLS OUT IN PAIN WITH ANY MOVEMENT. ANOTHER NURSE AIDE (STAFF MEMBER #19) WAS HELPING DO HIS CARE. THE OTHER NURSE AIDE WAS DISTRACTED; SHE WAS HAVING A BAD DAY. SHE WAS SAYING SOMETHING TO THE RESIDENT, UNDER HER BREATH, THAT I DIDN'T HEAR, BUT THE TONE WAS DISRESPECTFUL. I BELIEVE SHE HURT THE RESIDENT'S SHOULDER (RESIDENT #101). SHE WAS IN A HURRY AND HAD A "JUST GET THIS DONE" ATTITUDE. SHE OVER STRETCHED HIM MANY TIMES. I DID HEAR HER SWEAR AT HIM A FEW TIMES. AFTER WE WERE FINISHED, THE OTHER AIDE LEFT THE ROOM. I ASKED HIM (RESIDENT #101) IF HE WAS OK. HE TOLD ME HIS RIGHT SHOULDER HURT HIM AND HE DIDN'T WANT TO GO TO THERAPY BECAUSE OF WHAT JUST HAPPENED. I BELIEVE SHE ABUSED THE RESIDENT." DURING AN UNANNOUNCED, ON SITE INVESTIGATION, BOTH FACILITY SOCIAL WORKERS WERE INTERVIEWED ON 2/28/2011 REGARDING THEIR PARTICIPATION IN FOLLOW UP TO THE REPORTED INCIDENT OF 2/9/2011; BOTH SOCIAL WORKERS SAID THEY HAD NOT PROVIDED FOLLOW UP SOCIAL WORK SERVICES TO RESIDENT #101 THROUGH 2/28/2011 IN THE AFTERMATH OF THE INCIDENT. A REVIEW OF RESIDENT #101'S MEDICAL FILE DID NOT INCLUDE NOTES FROM THE ATTENDING PHYSICIAN(S)/PRIMARY CARE PROVIDERS, OR PSYCHIATRIC FOLLOW UP IN THE AFTERMATH OF THE REPORTED INCIDENT. DURING AN INTERVIEW ON 3/3/2011 AT 10:15 A.M, THE DIRECTOR OF NURSING SAID THE FACILITY HAD SUSPENDED, THEN TERMINATED THE NURSE AIDE (STAFF MEMBER #101) FOR THE INCIDENT WITH RESIDENT #101 ON 2/9/2011. SHE SAD THE FACILITY ON HAD ZERO TOLERANCE OF ABUSE. DURING AN INTERVIEW ON 3/3/2011 AT 10:35 A.M., THE NURSING HOME ADMINISTRATOR SAID, AS THE ABUSE COORDINATOR FOR THE FACILITY, SHE HAD THE ABILITY TO EITHER COUNSEL STAFF AFTER SUBSTANTIATION'S OF ABUSE, OR TERMINATE THEIR EMPLOYMENT. THE ADMINISTRATOR DEFINED ABUSE AS THE "WILLFUL INFLICTION OF PAIN, INCLUDING PHYSICAL, VERBAL, AND MENTAL ON A RESIDENT. SHE SAID THE FACILITY HAD ZERO TOLERANCE OF ABUSE; THE NURSE AIDE (STAFF MEMBER #19) WAS TERMINATED.