Every finding on record at Wellspring Lutheran Nursing and Rehab Services

Based on observation, interview and record review, the facility failed to ensure the highest level of incontinence functioning was maintained for four (R4, R62, R64 and R81) of eight residents reviewed for quality of life, resulting in feelings of embarrassment, humiliation, and degradation.Findings include: As a result of an administrative decision to discontinue brief liners for cost cutting measures, residents (R4, R62 and R64) stated that they are embarrassed to socialize and engage in activities and are experiencing high anxiety due to the lack of incontinence protection the brief inserts provided. Residents R4, R62 and R64 shared concerns with the facility regarding suffering stress, anxiety, humiliation and dehumanization with this change during a Resident Council meeting on 3/13/2026. The facility failed to provide an environment to support good quality of life for R4, R62 and R64. This created an environment reflecting a disregard for residents' well-being and quality of life, which has caused a negative psychosocial outcome related to residents' self-worth, self-esteem and well-being. R4 On 03/19/2026 at 12:59 PM, R4 reported being upset with the facility for no longer providing brief inserts. R4 reports being informed of the discontinuation of the brief inserts 2-3 weeks ago. R4 described an incident on St. Patrick's Day where her dress was soiled due to the lack of brief inserts. R4 expressed having great anticipation of a St. Patrick's Day celebration within the facility on 03/17/26, with an exciting expectancy of wearing a green dress in honor of this occasion. R4 stated, I was very upset after soiling my dress early in the activity due to no longer having the brief inserts which I'm accustomed to wearing. R4 described the experience as disappointing, saddening, stressful, humiliating and embarrassing. Record Review revealed, according to the last quarterly Minimum Data Set (MDS) dated [DATE], R4 has a Brief Interview of Mental Status (BIMS) of 15 out of 15 (Cognitively Intact) with a diagnosis of Retention of urine, Congenital malformation of kidney, Myeloproliferative Disease and Lymphoma. Record review of Care Plan dated: 2/9/26 revealed the following focus: I have urge/OAB bladder incontinence and bowel incontinence r/t impaired mobility, need for assistance and weakness with the following intervention: TOILET USE: . I wear pull up briefs at all times.I make my bowel and bladder needs known, please provide incontinence care PRN. R62 On 03/17/2026 at 10:29 AM, R62 was interviewed and reported being upset about the discontinuation of brief inserts. R62 said the facility informed residents that they were no longer providing brief inserts due to the expense. R62 said the NHA informed residents that the brief inserts would not be provided unless they obtain a doctor's order or self-purchase. R62 stated I can't afford this! R62 stated, I obtained a doctor's order for the brief inserts, but they still are not being provided. Record review revealed R62 has an order for brief inserts dated 03/14/2026- Brief liner to be utilized in brief as needed three times a day. Record review further revealed R62 was admitted to the facility on [DATE], has a BIMS score of 15 out of 15 indicating being cognitively intact, with a diagnosis of Overactive Bladder, Diabetes, Kidney Disease and Parkinsons Disease. Resident reports feeling embarrassed by the lack of bladder control that is evidence when she soils her clothes while attending activities. R62 stated, I have had a lot of stress over this change, and it has caused a great deal of frustration. R62 stated, I don't understand why I had to get my own doctor's order and why they are not providing the brief inserts. This is so stressful and very embarrassing! R64 On 03/19/2026 at 1:12 PM, R64 was interviewed and discussed concerns over the facility failing to meet his needs regarding incontinent care which has caused psychosocial distress. R64 expressed displeasure with the discontinuation of brief liners. R64 reports being made aware 2-3 weeks ago that the facility would no longer provide brief inserts. R64 stated that the discontinuation of the brief inserts took away his level of independence. R64 reports without the brief liners, he now requires staff assistance for frequent brief changes which he previously completed independently. R64 said he was first informed that he could get a doctor to write an order for the liners but was later told by CENA C that with or without an order, the facility will no longer provide the brief liners. R64 said the NHA attended the resident council meeting in March, 2026 and answered questions by several residents regarding their frustration over losing access to the brief inserts. R64 stated, I don't know why I am responsible for getting a doctor's order, isn't that their job! R64 reports seeking assistance from family members to help obtain a doctor's order and/or resolve this issue. R64 reports suffering from higher levels of anxiety because of this change. R64 reports feeling humiliated when others witness his lack of bladder control. R64 described a recent incident where he sat in the dining room with a female resident and became embarrassed and humiliated after leaving a puddle under his wheelchair. R64 stated When I had the brief liners, this never happened! Record review of Care Plan dated 2/9/26 revealed R64 has a diagnosis of Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms and a BIMS of 15 out of 15 (Cognitively Intact). Care Plan Focus: I have renal insufficiency r/t chronic kidney disease and MDRO'S in my urine. I have urge/OAB bladder incontinence and bowel incontinence r/t impaired mobility, need for assist and weakness. Intervention: TOILET USE: I require partial to extensive assistance with toileting. At times I will self-transfer and attempt hygiene on my own when feeling strong enough. I wear pull up briefs at all times. please provide incontinence care PRN.I'm a heavy wetter. On 03/19/2026 at 9:05 AM, Nursing Health Administrator (NHA) was interviewed and said an administrative decision was made to discontinue brief inserts in February 2026 due to the cost. Queried as to the plan for residents with a corresponding medical diagnosis and a doctor's order for the brief inserts. The NHA stated, Those residents with a doctor's order and medical diagnosis should continue to receive the inserts. On 03/19/2026 at 10:50 AM, Central Supply Personnel A was interviewed and stated Three to four weeks ago, the NHA and corporate decided the peri pads are too expensive and would no longer provide these items to residents. Central Supply Personnel A stated, The residents were very upset about this! Queried about the process for orders. Central Supply Personnel A said once a resident receives a doctor's order, the order is placed and delivery is provided overnight. On 03/19/2026 at 2:12 PM, the NHA was interviewed to determine awareness of the level of stress, disappointment and frustration expressed by residents who no longer receive brief inserts. The NHA reports receiving resident feedback at a Resident Council meeting on 3/13/2026 where this issue was discussed and concerns were expressed. According to the NHA, residents must have a doctor's order for the brief inserts to resume. Queried as to who is responsible for obtaining doctor's orders for supplies which is causing high anxiety for the residents. The NHA stated that it is the responsibility of staff to obtain doctor's orders for supplies needed for residents. No current plan in place to obtain orders for the residents affected by this change or to order this supply for residents who have successfully obtained a doctor's order with a corresponding medical diagnosis. According to the facilities policy entitled, Federal Resident Rights and Facility Responsibilities -page 16 reads in part: A resident has a right to receive the services and/or items included in the plan of care. R81- On 3/19/2026 at 11:27 a.m. R81 was observed in the bedroom, sitting in a wheelchair. R81 was alert, oriented to person, place, and situation. R81 voiced a concern with the facility no longer providing incontinence liners (also known as incontinence pads or panty liners for incontinence designed to manage urinary leakage). R81 said the liners were used twice a day to prevent accidents (urinary leakage) when not able to get to the toilet timely and had used them for quite some time. R81 stated, I don't want anyone to know when I have had an accident. It's very embarrassing to be at an activity and everyone knows I had an accident. The liners help because they absorb a lot of urine and is easy for me to remove and replace myself in case staff are too busy to help me. At this time R81 had five liners remaining which are being used sparingly (only at night). R81 said a week ago, Central Supply Aide A said the facility was not ordering the liners anymore unless paid for out of pocket. R81 was not informed of the reason. R81 stated, I think the liners should be apart of my care especially since the doctor wrote an order for me to have them. I can't afford to buy them on my own. I'm on a fixed income and all my money goes to the facility. The liners help because they absorb a lot of urine and is easy for me to remove and replace myself in case staff are too busy to help me. On 3/19/26 at 11:45 a.m., there were no liners in the linen/supply closet located on the 200 Unit. Incontinence briefs were only observed. Review of the clinical record documented R81 was initially admitted into the facility on [DATE] with diagnoses that included chronic pain, peripheral vascular disease, and polyneuropathy. According to the quarterly MDS assessment dated [DATE], R81 was cognitively intact with a BIMS of 15, and required two-person assistance with toileting and transfers. The assessment also documented that R81 had frequent urinary incontinence. Review of the Bowel and Bladder care plan dated 2/10/26 documented in part the following: I have stressed bladder incontinence and frequent bowel incontinence related to history of urinary tract infection, impaired mobility, and loss of peritoneal tone. Interventions dated 2/10/26, 5/8/2025, 5/8/2023, and 8/23/2022 documented, I request to wear nighttime briefs with a liner at all times d/t increased urinary leakage. Review of the physician's order dated 3/13/26 documented the following: Brief liner to be utilized in brief as needed. Three times a day. Review of the progress note (Health Status Note) dated 3/13/2026 documented Physician in for visit. Received order for liners to be used in brief as needed, resident aware and agrees with plan of care at this time. On 3/19/26 at 10:00 a.m. the Nursing Home Administrator was queried was the concern with inadequate incontinence supplies, as voiced by multiple residents, addressed in QA/QAPI. The Nursing Home Administrator said it was not.

Based on interview and record review the facility failed to educate and offer Covid-19 vaccination to four residents (R2, R16, R22, and R72) out of five residents reviewed for infection control. This deficient practice resulted in residents being at increased risk for exposure to Covid-19, which may lead to serious illness, complications and potential adverse outcomes.Findings include:R2Record review of electronic medical records (EMR) revealed R2 was admitted to the facility on [DATE] with a pertinent diagnosis of chronic kidney disease. Further review revealed the facility failed to provide education regarding Covid-19 and failed to offer the Covid-19 vaccine to the resident in 2025.R16Record review of electronic medical records (EMR) revealed R16 was admitted to the facility on [DATE] with a pertinent diagnosis of hemiplegia (paralysis). Further review revealed the facility failed to provide education regarding Covid-19 and failed to offer the Covid-19 vaccine to the resident in 2025.R22Record review of electronic medical records (EMR) revealed R22 was admitted to the facility on [DATE] with a pertinent diagnosis of chronic obstructive pulmonary disease (COPD). Further review revealed the facility failed to provide education regarding Covid-19 and failed to offer the Covid-19 vaccine to the resident in 2025.R72Record review of electronic medical records (EMR) revealed R72 was admitted to the facility on [DATE] with a pertinent diagnosis of heart failure. Further review revealed the facility failed to provide education regarding Covid-19 and failed to offer the Covid-19 vaccine to the resident in 2025.An interview was conducted on 3/19/26 at 10:30 AM with Infection Control Preventionist (ICP) D. During the interview, ICP 'D confirmed the facility did not ensure residents were consistently educated regarding Covid-19 vaccination and boosters and did not ensure the vaccine was offered in accordance with the facility's policy.An interview was conducted on 3/19/26 at 11:30 AM with the Director of Nursing (DON). The DON reported that the facility should have ensured residents were educated and offered the Covid-19 vaccine.Record review of facility's policy Infection Control Policy dated 8/25 the following was documented, 12. Offer each resident any recommended COVID-19 vaccines or boosters they are eligible for at the time of admission and ongoing as indicated per CDC (Centers for Disease Control and Prevention) guidelines.

Based on interview and record review the facility failed to ensure nursing services were provided in accordance with professional standards for one resident (R401) of three residents reviewed for medication administration. This failure had the potential to place R401 at risk for adverse medication effects.Findings include:Findings include:On 10/6/25 at 11:35 AM R401 was interviewed regarding the care the facility provided. R401 said the nurse (later identified as LPN A) had given her a double dose of a medication called Budesonide. R401 said she usually takes two pills but there were four pills in the cup. R401 said when she questioned the nurse, the nurse admitted there should only be two pills. R401 said the medication mix up concerned her because it will come a day when she does not remember what medications and how many she is supposed to be taking.On 10/6/2025 at 2:35 PM Licensed Practical Nurse (LPN) A was interviewed and queried about R401 Budesonide medication. LPN A said she had received report and the off going nurse had informed her there was a change in R401's medication. LPN A said she thought it was a new medication being added. LPN A said she did give four pills in the medication cup given to R401. LPN A said because she is a new nurse she was not familiar with the computer system and did not know the first order was discontinued. LPN A admitted she did not do a progress note about the incident.On 10/6/2025 at 3:40 PM, Nurse B was interviewed and said they were the Director of Nursing (DON) at the time of the incident. Nurse B said they were contacted by R401 resident representative and informed of the incident. Nurse B said they informed LPN A they needed to follow the five rights when passing medications. Nurse B said she also informed LPN A in the future they need to document such incidents as a near miss medication incident.On 10/6/2025 at 3:50 PM, the Nursing Home Administrator (NHA) and the DON were interviewed. The DON said LPN A had only been a nurse since May of 2025. The DON said they expect all nurses to verify orders and follow correct procedures when passing medication. The NHA had no additional information to add.Record review of document titled, Grievance and Complaint Report noted the facility was informed on 8/27/2025 by R401's resident representative that LPN A attempted to administer four capsules instead of the prescribed two capsules of Budesonide ER 3mg to R401.Record review of document titled, Medication Pass Guidelines with a date of September 2023. The section labeled Physician's Orders, documented medications should be given in accordance with the attending physician orders. In addition, it noted if the order seems excessive the physician should be contacted.Record review revealed R401 was admitted on [DATE] with the following diagnosis: Gastroenteritis and colitis, Major Depressive Disorder, Atrial Fibrillation and DementiaReview of R401 Electronic Medical Orders (EMR) revealed the provider ordered Budesonide ER 3 mg 2 capsules by mouth one time a day for COPD. The order had a start date of 8/2/2025 for COPD and the order was discontinued on 8/26/2025 at 2:11 PM. The EMR documented there was an order Budesonide ER 3mg 2 capsules to start on 8/27/25 at 9:00 AM by mouth one time a day for bowels. Review of Minimum Data Set (MDS) with an effective date of 10/1/2025 for Brief Interview for Mental Status (BIMS) R401 was a 15 out of 15 which indicated intact cognition.The NHA had no additional information to provide at the end of the survey.

This citation pertains to intake MI00149175. Based on interview and record review the facility failed to ensure residents privacy was maintained for two residents (R16 and R22) out of 20 residents reviewed for residents' rights. Findings include: Review of a facility reported incident sent to the state agency dated 12/20/24, reported a staff member sent videos to a coworker using Instagram (social media) using private messaging. R16 Review of electronic medical records (EMR) documented R16 was initially admitted into the facility on [DATE] with a pertinent diagnosis of Alzheimer's disease (common cause of Dementia and memory loss). Review of Brief interview for Mental Status (BIMS) dated 10/7/24, R16 scored 3 out of 15 (severe cognitive impairment). Review of Minimum Data Set (MDS) dated [DATE], documented R16 required substantial/maximal assist with most Activities of Daily Living (ADLS). An interview was conducted on 1/12/25 at 11:25 AM with R16, resident had no recollection of the event. Review of Video 2.mov (no date) revealed Resident Assistant (RA) A standing in front of R16 eating a cookie. A caption at the bottom of the screen noted, Eating a cookie and dripping all the crumbs on the devil's floor because she beats me on a regular. R22 Review of EMR documented R22 was initially admitted into the facility on [DATE] with a pertinent diagnosis of dementia (a group of symptoms affecting memor). Review of Brief interview for Mental Status (BIMS) dated 11/14/24, R22 scored 1out of 15 (severe cognitive impairment). Review of Minimum Data Set (MDS) dated [DATE], documented R22 required substantial/maximal assist with most Activities of Daily Living (ADLS). An interview was conducted on 1/12/25 at 12:15 PM, R22 was not able to respond appropriately related to impaired cognition. Review of Video 2.mov (no date) RA A's video revealed an empty plastic drinking cup on the floor, RA A then holding a cat, followed by another empty plastic drinking cup on the floor. Finally, R22 sitting in a wheelchair. A caption at the bottom of the screen noted, Came back and (R22) took my Dr. Pepper (soda) drank all of it and then put it on the floor. An interview was conducted with Social Worker (SW) B on 1/14/25 at 10:03 AM, it was reported the video recordings of the residents were inappropriate and was an invasion of the resident's privacy. An interview with Nursing Home Administrator (NHA) on 1/14/25 at 11:30 AM, reported that RA A had made videos using Snapchat (social media) with private messaging and had sent the videos of the two residents (R16 and R22) without any consent. It was further reported that the videos of the residents were an invasion of their privacy. Finally, it was reported by the NHA that RA A was terminated related to the videos of the residents. Review of the facility's policy Personal Communication Devices (Cell Phones) (no date), documented .6.Photographing residents with any and all devices is prohibited.7.Employees who use an electronic device as mentioned above which constitutes an interference with resident care or uses a device in a manner that is profane, indecent, or obscene or constitutes an invasion of privacy will be subject to disciplinary action including termination. Review of Admission Booklet (no date), documented Privacy-A resident is entitled to privacy, to the extent feasible, in treatment and in caring for personal needs with consideration, respect, and full recognition of his or her dignity and individuality.

Based on interview and record review the facility failed to ensure an annual PASARR (Preadmission Screening (PAS) Annual Resident Review (AAS) screening, for one resident (R52) of one reviewed for PASARR, resulting in the potential for the lack of adequate mental health care and services. Findings include: Record review of R52's electronic medical record revealed admission into the facility on [DATE] with diagnoses that included hemiplegia (weakness). According to the Minimum Data Set R52 had a BIMS of 15/15, indicating intact cognition. Further review revealed R52 had a new onset of Bipolar Disorder dated 4/5/23. Record review revealed there was no annual PASARR for R52 for 2022 and 2023. On 12/20/23 at 9:10am Social Worker (SW) C was interviewed and reported that the annual PASARR should be completed every year. It was further reported by SW C: that a significant change PASARR should have been completed with new diagnosis of bipolar disorder in May 2023. Record review revealed the Significant Change PASARR was not completed until 12/19/23. The completed Significant Change occurred after survey inquiry. On 12/20/23 at approximately 10:00 AM, the Nursing Home Administrator (NHA) was interviewed and reported that a significant change PASARR should have been completed at the time of the new onset of bipolar disorder which occurred May 2023. The NHA also confirmed that annual PASSAR should be completed in a timely manner. Review of the facility's policy titled Resident Assessment - Coordination with PASARR Program dated August 23, 2023 documented the following: . 6. The social services director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. 8. Any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review.

Based on interview and record review the facility failed to ensure Dementia Management training was performed for one Certified Nurse Assistant (CNA) B out of five CNAs reviewed for in-service training resulting in the potential for unmet resident care needs. Findings include: On 12/19/23 at 2:24 PM, review of five CNAs in-service training education content revealed the following: CNA B Date of hire (DOH)- 8/31/22. Review of a facility provided transcript dated 11/1/22 through 12/19/23 for CNA B, failed to identify dementia management training. On 12/20/23 at 8:42 AM in an interview with Assistant Director of Nursing (ADON)/Staff Development A revealed there was no record of dementia training for CNA B and said the training was due on 9/30/23. When queried about the significance of CNA trainings, ADON A stated, It is important to have trainings for the CNAs to meet their requirements and to provide education for what they do daily to meet resident needs. On 12/20/23 at 9:30 AM in an interview with the Director of Nursing (DON) agreed that CNAs are expected to have yearly training that includes dementia management.

Based on interview and record review the facility failed to ensure adequate assistance during a mechanical lift transfer for one resident (Resident #26) out of three residents reviewed for falls, resulting in a laceration to the back of the head and hospitalization . Findings include: Review of a Mechanical Lift Transfer policy with a revised date of July 2018 revealed, The purpose of this procedure is to assist with lifting or transferring residents using a manual lifting device . Procedure 1. Review the Resident Plan of Care to assess for any special needs of the resident. 2. Gather equipment . 3. Two nursing assistants are required for a safe transfer . Resident #26 Review of an Admission Record revealed, Resident #26 admitted to the facility with pertinent diagnosis which included Dementia, Alzheimer's Disease with Early Onset and Muscle Weakness. Review of a Minimum Data Set (MDS) assessment, with a reference date of 1/26/22 revealed Resident #57 had severely impaired cognition and required total dependence of two staff with transfers. Review of a Activities of Daily Living (ADL) Care Plan with a revised date of 5/13/21 for Resident #26 included interventions, TRANSFER: maxi lift x2 assist .BED MOBILITY: I require x2 staff participation to reposition and turn in bed . Review of a Kardex for Resident #26 revealed, Transferring, TRANSFER: maxi lift x2 assist. Review of a Progress Note with a date of 1/16/22 at 5:29 p.m. for Resident #26 revealed, Around 3:30 pm writer was asked to come to the residents room writer walked into the room and resident was lying on her back with her head on the leg of the lift her legs were on the other leg of the lift and there was blood coming from her head family and physician notified resident sent to (Hospital name) for treatment and evaluation around 4 pm. Review of a Progress Note with a date of 1/16/22 at 6:39 p.m. for Resident #26 revealed, Spoke with ED (Emergency Department) nurse resident has two lacerations to the back of her head that was stapled she is coming back with instructions on staple removal and a kit to remove them in about 8-10 days Review of a Incident/Accident Report with a date of 1/16/22 at 3:30 p.m. revealed, Resident #26 had a fall. Resident was being transferred to Broda chair by lift and slipped out of the sling falling on the floor and hitting her head on the floor. The incident was witnessed by Certified Nursing Assistant (CNA) N. Interventions implemented included Use two people when using a lift with a resident. Review of statement by CNA N with a date of 1/16/22 revealed, I (CNA N) was transferring (Resident #26) from her chair to bed using Maxi lift (mechanical lift) . As I was transferring (Resident #26) she fell through sling and fell , hitting her head . Review of Community Referral Form with a admitted [DATE] revealed, Resident #26's discharge instructions The encounter diagnosis was fall, initial encounter . (Resident #26) will need her staples removed in approximately 7-14 days. She did receive 2 staples today . Review of Physician Orders revealed, Resident #26 had orders send to (hospital name) for treatment with an order date of 1/16/22. Cleanse back of head laceration . pat dry may leave open to air. Monitor for s/s infection. every night shift for laceration with 2 staples. (sic) with an order date of 1/20/22. In an interview on 2/3/22 at 10:44 a.m., LPN O reported CNA N transferred Resident #26 with no assistance. CNA M notified LPN O after Resident #26 fell . When LPN O entered the room Resident #26's head was near the mechanical lift legs and was bleeding. LPN O educated CNA N that Resident #26 required two person assist with transfers. In an interview on 2/3/22 at 10:49 a.m., CNA N reported Resident #26 required mechanical lift with two staff assistance for transfers CNA N reported she did not have help to transfer Resident #26 and did it alone. In an interview on 2/3/22 at 12:39 p.m., Director of Nursing (DON) B reported two CNAs are required to perform a mechanical lift transfer. DON B reported staff are not trained to have one person transfer with a mechanical lift.

Based on observation, interview, and record review the facility failed to administer medications per Physicians orders for one resident (Resident #57) of four residents during medication pass, resulting in a medication error rate of 17.86%. Review of a Medication Pass Guidelines policy with a revised date of April 2021 revealed, Purpose To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing the administration of drugs in an accurate, safe, timely, and sanitary manner and to systematically distribute medications to residents in accordance with state and federal guidelines .physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Verify the medication label against the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Follow safe preparation practices . Never administer medications supplied for one resident to another resident . Resident #57 Review of an Admission Record revealed, Resident #57 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 1/15/22 revealed Resident #57 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. In an observation on 2/2/22 at 8:46 a.m., Licensed Practice Nurse (LPN) M prepared medication for Resident #57 which included, 2 tablets of Acetaminophen (Tylenol) 500mg, [MEDICATION(S)] (treats irregular heart rate) 200mg, [MEDICATION(S)] (treats depression) 20mg, Fish Oil 1,000mg, and [MEDICATION(S)] 250mg. In an observation on 2/2/22 at 8:55 a.m., LPN M entered Resident #57's room and administered medication to Resident #57. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 2/2/22 at 10:33 a.m., LPN M reported the medication (med) package with some of the meds given to Resident #57 belonged to another resident. LPN M reported Resident # 57 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN M reported the nurse should use a triple check system when administering meds. LPN M then stated, I double and triple check meds . I don't know how this happened. In an interview on 2/2/22 at 1:22 p.m., Director of Nursing (DON) B reported to ensure medications are given accurately the nurse should use the 5 rights (right patient, drug, dose, route, and time). DON B then reported the nurse should check the medication packet against MAR (Medication Administration Record). Review of a Progress Note with a date of 2/2/22 at 2:24 p.m. for Resident #57 revealed, Physician notified of med irregularity .

Based on observation, interview, and record review the facility failed to follow infection control standards of practice for one (R71) of three residents reviewed for urinary catheters resulting in the potential for urinary tract infections (UTIs) when R71's indwelling urinary catheter (foley) collection bag was observed in the resident's trash can with used tissues and napkins on top of the catheter tubing and collection bag. Findings include: On 2/01/22 at 11:34 AM, R71 was observed seated in a recliner chair with his foley catheter collection bag inside the trash can next to the recliner and had used tissues and a napkin with chewed up food in it resting on top of the collection bag. R71 was queried and said he did not know his urinary catheter collection bag was in the trash can. R71 confirmed that he had put his used tissues and napkin in the trash can because, I didn't know it was in. R71's family members confirmed that the catheter collection bag was inside the trash can when they arrived. On 2/01/22 at 11:41 AM, Registered Nurse (RN) K was asked about the foley catheter and observed R71's collection bag inside the trash can. RN K said, No, that is not suppose to be in there. RN K removed R71's foley collection bag from the trash and said she would change it immediately. According to R71's Electronic Medical Record (EMR) he had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/26/22 the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1) Catheter: 12 french (fr) Foley with 10 cc (cubic centimeter) balloon placed on 1/23/22 for Urinary Retention. Maintain Foley. Due not discontinue. F/U (follow-up ) with Dr. [NAME] (urologist). 2) Catheter Care Q shift. Monitoring that tubing is not kinked and foley is patent. Leg strap is in place and if missing replaced. Dignity bag is in place. The Minimum Data Set, dated dated dated [DATE] indicated R71 had 'intact cognition' with a BIMS (brief interview for mental status) score of 13/15 and required extensive assistance from one staff member for transfers from surface to surface. A care plan initiated on 1/26/22 for urinary catheter included the following intervention; Urinary catheter care QS (every shift). A progress note dated 2/1/2022 at 8:33 PM documented the following; Placed Foley catheter leg band to stabilize catheter and replaced catheter bag as clip was broken and did not hang properly. According to the facility's Indwelling Catheter Care' policy revised on 10/2017: Policy Routine catheter care helps prevent infections and other complications, and is usually performed daily. This can be performed by a CNA. Fundamental Information Maintenance Inspect the catheter and tubing periodically to detect compression or kinking that could obstruct urine flow. Ensure tubing is secured using a leg strap (securement device). Keep the drainage tube and collection bag lower than bladder at all times. Ensure bag and tubing is not lying on the floor. Empty the collection bag at least every 8 hours. Drainage collection bag should be placed in a privacy bag.

Based on observation, interview and record review the facility failed to properly assure all staff were screened upon entering facility, Two staff members (A and B) out of a total of 58 staff members did not record their temperatures and answer questions related to Covid -19 protocols, resulting in the potential for spread of Covid-19 infection through out facility. Findings include: On 12/1/20 at 9:00 a.m., it was observed by Surveyor that staff were entering building taken temperatures and answered questionnaire independently. On 12/1/20, record review of Employee Log Screen and all scheduled staff for 12/1/20 revealed staff members (A and B) had not independently recorded temperature or documented answers to questionnaire. On 12/1/20 @ 11:30 a.m., during interview with Director of Nursing (DON) when asked if all employees were to independently record temperatures and document answers to questionnaire upon entering the facility, DON stated, Yes. After reviewing Employee Log Screen for 12/1/20 with DON it was confirmed that two staff members had not recorded and documented their temperatures or answered questionnaire on screening logs. On 12/1/20, record review of facilities Coronavirus Covid-19 Surveillance policy documented the following: 3. Screening for visitors and staff : a. Staff/ volunteers will complete a screening tool including signs or symptoms of a respiratory infection, such as a fever, cough and sore throat and have their temperature taken as well as any other recommended screening questions whenever entering a facility. If any signs and symptoms are noted, a fever over 100.1 F* is taken, or any screening questions are answered that do not result in a negative screening, then this will be reported immediately to the Infection Control & Preventionist/ Designee for follow-up. Staff failing the screening will not proceed into the building or any care areas.

Based on observations, interviews, and record review the facility failed to properly store insulin by not discarding expired insulin, and failing to date 'opened insulin' in two of four medication carts inspected, resulting in the potential for expired medications and/or ineffective medications to be administered. Findings include: On 10/14/20 at 8:16 AM during an observation of the B north medication cart, an insulin 'kwik pen' for R#15 was observed to have an 'opened date' of 9/10/20. There was no other 'kwik pen' in the medication cart available to use for R#15. Nurse B was asked about the expiration date for the insulin 'kwik pen'. Nurse B said, This should've been discarded after 28 days, so probably on 10/8/20. Nurse B confirmed that R#15 was receiving insulin from the insulin 'kwik pen', and her last dose had been this morning. Nurse B discarded the 'kwik pen' for R#15 and obtained a new one that was available in the B-wing's medication room. On 10/14/20 at 9:24 AM during an observation of the E wing medication cart, and insulin 'kwik pen' for R#135 was observed to be opened and not dated. Nurse D was asked about the facility's policy. Nurse D said, all insulins must be dated upon opening because they are only good for 28 days. Nurse D discarded R#135's insulin 'kwik pen' and obtained a new one from the E-wing's medication room. According to the insulin's 'kwik pen' manufacturer's 'how-to-use' and 'care for' instructions'; Once the pen is 'opened, and injections have begun, store it at room temperature and throw it away after 28 days, even if there is insulin left in the pen.

Based on observations, interviews, and record review the facility failed to properly clean, disinfect, and store respiratory equipment, a [MEDICAL CONDITION]/[MEDICAL CONDITION] machine and tubing for one of one resident (#32) reviewed for respiratory care, resulting in the potential for the equipment to grow colonies of bacteria and mold that cause respiratory infections. [MEDICAL CONDITION] ( bilevel positive airway pressure) and [MEDICAL CONDITION] (continuous positive airway pressure) machines blow air at a pressure that keeps airways open during sleep. Findings include: At 10/13/20 at 11:37 AM during an observation and interview with R#32, she said that her [MEDICAL CONDITION] machine had not been cleaned since she arrived at the facility and the clip that holds the straps to the face mask needs to be replaced. R#32 said she had called the '1-800 number' on the machine to request assistance on two separate times and had not had success with that. R#32 was using oxygen at this time through nasal cannula tubing connected to an oxygen concentrator. There was also a nebulizer machine ( machine that delivers respiratory treatments by aerolizing the medication) sitting on her end table near her recliner chair. All three machines, the oxygen concentrator including the tubing, the nebulizer, and the [MEDICAL CONDITION] machine were serviced by the same company, and had the same '1-800- number' sticker attached to call for assistance. The resident said that her oxygen tubing and nebulizer had been cleaned and updated, but nothing with the [MEDICAL CONDITION] machine. At this time the [MEDICAL CONDITION] machine was on the bedside table with visible water and moisture inside the machines compartment and throughout the inside of the corrugated tubing that was still attached to the machine and a face mask. There was an opened gallon of distilled water that was approximately 2/3 full and dated 6/18/20. The face mask was laying open to air and not covered. On 10/13/20 at 11:53 AM staff nurse A came into the room and was asked about the [MEDICAL CONDITION] machine. Nurse A said that a company comes in provides respiratory equipment and is suppose to clean the machines. Nurse A said that she had not cleaned the machine or the tubing for R#32, and did not even know how to do that because there were no instructions or cleaning supplies at the facility. On 10/14/20 at 2:14 PM, R#32 was observed seated in her recliner. The [MEDICAL CONDITION] machine and tubing was laying horizontal on the resident's bedside table, with visible water and moisture in the machine's compartment and corrugated tubing that goes to the face mask. R#32 said that she does use the [MEDICAL CONDITION] mask every night and it helps until the mask becomes loose, but that she is worried about it not being cleaned properly. The resident confirmed that no one had come to clean it yet. The opened gallon of distilled water dated 6/18/20 was still next to the machine. At 2:24 PM CeNA (certified nursing assistant) E entered R#32's room, and was asked about care of the [MEDICAL CONDITION] machine. CeNA E said that she had never cleaned the [MEDICAL CONDITION] machine and was never instructed on how to do it, nor where any cleaning supplies for the machine were kept. On 10/15/20 at 09:14 AM, R#32 reported that both her and nurse A attempted to call the '1-800- number yesterday and the company said that no service provider would come out because of the Covid-19 virus. The [MEDICAL CONDITION] machine is in the same position as it was on 10/13/20 and 10/14/20 with the visible water in the compartment and moisture/condensation in the corrugated tubing. At this time CeNA C entered the resident's room and was asked about the care and cleaning of the [MEDICAL CONDITION] machine. CeNA C said that she had never cleaned the [MEDICAL CONDITION] machine, tubing, or the mask and was not given any instruction to do so. On 10/15/20 at 09:20 AM, nurse B was interviewed regarding the [MEDICAL CONDITION] machine. Nurse B said she had never cleaned the [MEDICAL CONDITION] machine, nor had she seen anyone else do it. Nurse B was asked about the opened gallon of distilled water dated 6/18/20. Nurse B replies, We should probably get rid of that, and at least get a new one. Nurse B said that she would attempt to call the company's 1-800 number to acquire service for the machine. On 10/15/20 at 09:24 AM, the Administrator was asked about R#32's [MEDICAL CONDITION] machine. The Administrator said that since the Covid-19 pandemic the company that services the oxygen equipment has just been dropping the equipment off and not coming into the building. The Administrator said that he would call the company immediately and see what can be done regarding this issue. According to R#32's medical record, she admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident is dependent on oxygen and was prescribed to wear a [MEDICAL CONDITION]/[MEDICAL CONDITION] mask every night. According to the MDS (minimum data set) dated 8/11/20, the resident had a BIMS (brief interview for mental status) score of 14/15. R#32 had a care plan for '[MEDICAL CONDITION]/respiratory problem' initiated on 7/31/20 that indicated she was to wear a [MEDICAL CONDITION]/[MEDICAL CONDITION] mask every night, but there is no intervention for cleaning/storing the mask. According to the facility's [MEDICAL CONDITION]/[MEDICAL CONDITION] Therapy procedures, release date December 2008, the policy is as follows: To assure consistent monitoring and delivery of [MEDICAL CONDITION]/[MEDICAL CONDITION] therapy for residents requiring specialized oxygen therapy. This is performed by a licensed nurse or a respiratory therapist. Monitoring of residents with [MEDICAL CONDITION]/[MEDICAL CONDITION] therapy will be done according to the following guidelines: b. Tubing and masks should be washed in warm soapy water after each use and hung to dry.

Based on observation, interview and record review the facility failed to administer a medication in accordance with the physician's order for one sampled resident (R#91) resulting in the likelihood of missed medication administration. Findings include: FACILITY Medication Administration On 6/12/19 at 8:42 AM, Nurse A was observed preparing the 9:00 AM medications for R#91. The nurse prepared 10 medications which included a patch and oral pills. Upon medication reconciliation, a physician's order documented; [MEDICATION NAME] Solution 0.5% Instill 1 drop in both eyes one time a day related to low-tension [MEDICAL CONDITION], bilateral, severe stage. Review of the (MONTH) 1st through 31st, 2019 and (MONTH) 1st through 11th, 2019 Medication Administration Records (MAR's) revealed that R#91 had received the eye drop at 9:00 AM daily. (MONTH) 12th, 2019 (the day of the medication pass observation) through (MONTH) 30th, 2019 the [MEDICATION NAME] eye drop solution time was changed to 2000 (8:00 PM). Review of the electronic clinical record revealed no documentation or physician's order to explain the changed administration time (from 9:00 AM to 8:00 PM) for the entire month of (MONTH) for the [MEDICATION NAME] eye drop solution. At 11:01 AM, Nurse A was interviewed and asked why she did not administer the [MEDICATION NAME] eye drop at 9:00 AM as indicated on the MAR. The nurses stated, The eye drops were not in the cart, so I re-ordered them from pharmacy and changed the time to 8:00 PM so that they would be given later today. Nurse A was asked what the facility's procedure was when a medication is not available at the scheduled time, to which she responded, I should have called the physician and asked him what he would like me to do. At 12:08 PM, during an interview with the facility's Director of Nursing (DON) she said that she was aware of the eye drops not availed for the 9:00 AM medication pass for R#91. The DON said that the nurse should have re-ordered the eye drops from pharmacy, then contacted the physician to get an order to administer the eye drops when they come in from pharmacy for today's dose only. Record review revealed that R#91 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented the resident's cognition was severely impaired and required extensive assistance from staff for all activities of daily living. Review of a 8/28/17 care plan, I have potential decrease in visual function .Goal of maintain current visual function through review date. The care plan, I have [MEDICAL CONDITION] and have a history of blood transfusion .Intervention of give medications as ordered. The care plan, I have impaired cognitive function .Intervention keep my routine consistent .as much as possible in order to decrease confusion. Review of the facility's policy titled, Medication Storage/Unavailable Medications dated 12/1/07 revised 1/1/13 documented, .4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. 5. If the medication is unavailable from pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. 6. If the medication is unavailable from pharmacy due to formulary coverage, contraindication, drug-drug interaction, drug-disease interaction, allergy or other clinical reason, facility should collaborate with pharmacy and physician/prescriber to determine a suitable therapeutic alternative. If facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, facility nurse should notify the nursing supervisor and contact facility ' s Medical Director for orders/direction, making sure to explain the circumstances of the medication shortage.

Based on observation, interview, and record review, the facility failed to ensure safety interventions were applied according to the plan of care for one Resident (R#56) out of eight residents reviewed for falls, resulting in the likelihood for injuries. Finding included: On 6/11/19 at 10:44 a.m., during the initial pool process, R#56 was observed sitting in her room. The Resident presented as alert, oriented to person only. R#56 was observed with a diminished discoloration to the right forehead. R#56 was unable to recall any incident that caused the discoloration to the forehead. On 6/12/19 at 4:02 p.m., R#56 was observed lying in bed with the bed in a high position and a folded floor mat under the bed. On 6/12/19 at 4:05 p.m., Nurse B was asked during an interview, did R#56 had any prior incidents to cause the discoloration to the forehead. Nurse B stated, No, this is my first time noticing that mark on her forehead. Nurse B was asked, should the floor mat be at the resident's bedside. Nurse B' stated, oh yes, it should be on the side of the bed on the floor. Nurse B took the floor mat from underneath the bed and place the mat on the floor at the resident's bedside. Nurse B then took R#56's bed remote control and lowered the Resident's bed from a high position to the lowest the bed remote control allowed. ON 6/12/19 at 4:30 p.m., review of R#56's clinical record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the annual MDS assessment dated [DATE], R#56 was severely cognitively impaired, required extensive assistance of two person for transfers, and all Activity Daily Living (ADLs). On 6/12/19 at 4:35 p.m., review of the resident's Fall care plan dated 3/21/17 documented, I am a high risk for falls related to not always aware of safety needs, Hard of hearing, drop foot to right foot, Gait/balance problems, medications used, decrease range of motion of right hip and knee due to pain. Interventions: Bed in low position with mat next to bed when occupied.

Based on observation, interview, and record review, the facility failed to maintain a sanitary condition in the kitchen and failed to properly store food, resulting in the increased potential for foodborne illnesses. These deficient practices have the potential to affect all 115 residents that receive food from the kitchen. Findings Include: On 7/16/18 at 9:13 AM., during an initial brief tour of the kitchen, the following observations took place: 1). A build-up of black debris observed on the interior surface of the oven. Registered Dietitian A was queried about the cleaning frequency and stated that the oven was scheduled to be cleaned soon. Record review of the document titled: WEEKLY SANITATION AUDIT dated 7/9/18, noted NI (Need Improvement), suggestion deep clean the oven. Record review of the document titled: Cleaning List Week of 7/9/18 noted, Ovens-Deep clean. 2). The mixer exterior surface had a build-up of debris and white food particles encrusted underneath the mixer and the cover was soiled with brown debris. The Registered Dietitian A was queried about the cleaning frequency and stated the mixer should be cleaned after each use. 3). The microwave had debris on the interior and exterior surfaces. Registered Dietitian A was queried about best practice and stated the microwave should be cleaned after each use. 4). Toast(NAME)equipment had a visible accumulation of debris and bread crumbs encrusted on the interior surface. The Registered Dietitian A stated the toast king should be cleaned weekly. On 7/16/18 at 9:37 AM., observed four brown soiled ceiling tiles located directly above the dirty side of dish machine. Registered Dietitian A stated he was not aware the ceiling tiles were soiled. On 07/16/18 at 12:06 PM., during dining room observations inside the Main dining room an uncovered tray of cookies was observed on the counter in the sublet kitchenette area. The Registered Dietitian A was queried about best practice and stated that the cookies should have been covered with clear saran wrap, until the dietary aide was ready to serve the cookies with the resident's food trays. According to the 2013 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. According to the 2013 FDA Food Code Section 6-501.12 Cleaning, Frequency, and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean .

Based on observation, and interview the facility failed to properly maintain ventilation and plumbing systems and store single use items in a sanitary manner, resulting in the potential for an uncomfortable and unsanitary environment. These deficient practices have the potential to affect all 115 residents within the facility. Findings Include: On 07/16/18 at 11:03 AM., observed clear condensate dripping from the ceiling ventilation cover onto the floor inside the kitchen near the food tray line. Registered Dietitian A was queried and stated the maintenance personnel will be notified. On 07/17/18 at 9:09 AM., observed inside the laundry room on the dirty side the hand sink cold water faucet was leaking. Maintenance Worker E stated the valve stem will have to be replaced to prevent the access water from dripping. On 07/17/18 at 9:24 AM., observed two bulk size cardboard boxes was being stored on the floor inside the Beauty shop room. One cardboard box contained beverage lids and the other cardboard box contained Styrofoam cups. Maintenance Worker E was queried about best practice and stated that the boxes belong to the Nursing department and he was not aware that the beverage lids and Styrofoam cups needed to be stored off the floor. On 07/17/18 at approximately 10:50 AM., observed clear condensate dripping from the ceiling air ventilation cover located in the Church Street Hallway area. Maintenance Worker E was queried and stated, due to the hot weather, condensate had been accumulating on the exterior surface of the ventilation covers and maintenance staff are monitoring the situation by periodically cleaning and/or wiping away the excess condensate from the exterior surface of the ventilation covers throughout the facility.

Based on interview and record review, the facility failed to demonstrate professional standards of practice by not ensuring blood glucose levels were monitored according to physician's orders [REDACTED].#27) residents reviewed for physician's orders [REDACTED]. Findings include: On 7/17/18 at 10:35 AM, a review of the clinical record for Resident #27 (#27) was begun. R27 was admitted into the facility on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] documented moderate cognitive impairment. The physician's orders [REDACTED].Inject as per sliding scale: if (blood sugar is) 151-200 (give) 2 units; 201-250 (give) 4 units; 251-300 (give) 6 units; 301-350 (give) 8 units; 351-400 (give) 10 units; 401-450 (give) 12 units; 451 or greater give 12 units and recheck (blood sugar) in 1 hour, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with Diabetic [MEDICAL CONDITION] .ordered 1/24/18 On 7/17/18 at 2:13 PM, when Licensed Practical Nurse, Staff J, was queried about what method was used to monitor blood sugar levels for residents diagnosed with [REDACTED]. When queried about the method used to communicate high or low blood sugar levels to other staff members, LPN J said, We document the elevated blood sugars in the computer. On 7/18/18 at 11:05 AM, a review of nursing documentation of R27's blood sugar values from (MONTH) 1, (YEAR) to (MONTH) 16, (YEAR) was conducted with the Director of Nursing (DON). This review revealed R27's blood sugar values were over 450 at the following dates and times: 462 on 6/5/18 at 9:00 PM 592 on 6/8/18 at 5:00 PM 488 6/12/18 at 7:00 AM 494 on 6/16/18 at 9:00 PM 517 on 6/26/18 at 9:00 PM 462 on 7/5/18 at 9:00 PM 483 on 7/14/18 at 5:00 PM As previously indicated, R27's current physician order [REDACTED]. sugar was not rechecked in one hour as ordered for the following dates: 6/5/18, 6/8/18, 6/12/18, 6/16/18, 6/26/18, 7/5/18, and 7/14/18. The DON said, We should have rechecked the blood sugar. When the DON was queried about the importance of rechecking R27's blood sugar in one hour as ordered, she said, It's important to make sure the blood sugar is not too low or to make sure the insulin has worked. A facility policy regarding following physician orders [REDACTED]. On 7/18/18 at 1:13 PM, the Facility Administrator indicated the facility does not have a written policy regarding following physician orders [REDACTED].

Based on observation, interview and record review, the facility failed to obtain, formulate and/or provide thorough and accurate Advance Directives for two (#s 117 and 472) of four sampled residents reviewed for health care advocacy, resulting in the potential for care and treatment wishes not being honored as intended by the residents. Findings include: On [DATE] at 10 AM, 10:30 AM, 11:15 AM and 12:15 PM and on [DATE] at 9:46 AM and 12:15 PM, resident #472 was observed asleep and difficult to arouse, even as staff attempted to feed her lunch on those days. On [DATE] at 11:35 AM, the resident's clinical record was reviewed. The resident was admitted into the facility on [DATE] from a hospital following surgical repair of a [MEDICAL CONDITION] on [DATE], with [DIAGNOSES REDACTED]. The hospital records noted that the resident was ambulatory at home until she tripped, fell and sustained the fracture. The resident was taking [MEDICATION NAME] and [MEDICATION NAME] antipsychotics at home and in the hospital, which continued at the facility. A Health Status Note dated [DATE], noted: Lethargic. Hospital reports that she has been this way since post-surgery yesterday. Resident #472's clinical record noted that she was her own responsible party. However, a mental status assessment dated [DATE] noted that the resident was extremely cognitively impaired. The resident's son signed a Psychoactive Medication Consent Form on [DATE] authorizing continued use of the antipsychotics. The record contained a draft of a Durable Power Of Attorney For Health Care (DPOA) document dated 1994 signed by the resident noting two daughters were to be designated as healthcare advocate in the event I become unable to participate in medical treatment decisions. The son was not designated. The draft revealed that there were no documented witnesses to the resident's signature and no signatures of the daughters to indicate that they accepted the designation of health care advocate for the resident. The draft further noted: The determination of when I am unable to participate in medical treatment decisions shall be made by my attending physician and another physician or licensed psychologist. There was no documented determination made by a physician or psychologist. On [DATE] at 2:58 PM, Admissions nurse 'H', who was responsible for obtaining signed consents for care and health care advocacy records, was asked about #472's DPOA paperwork. She looked at the DPOA draft and said, It's not even signed. It's not in effect. When asked why the resident's son was allowed to sign the consent for [MEDICATION NAME] and [MEDICATION NAME] in the resident's behalf, nurse 'H' said, I don't know. On [DATE] at 8:51 AM, when asked about health care decisions for resident #472, the Director of Nursing (DON) said, She's her own responsible party. When asked if the resident was competent enough to make her own medical decisions, the DON did not respond. Upon further questioning, the DON said the resident had not been evaluated for competency or deemed incompetent by medical staff and said, He (the resident's son) should not have signed (for the psychoactive medications). On [DATE] at 8 AM, per review of the facility's Policy and Procedure for Advance Directives dated ,[DATE]: On admission, the facility will determine whether the resident has executed advance directives, if not, whether the resident would like to execute advance directives The Admission Coordinator/Designee obtains copies of advance directives and places a copy of the same in the resident's chart As long as the resident is capable of making his/her own medical decisions, the resident will be consulted personally about his/her care and treatment. A Patient Advocate may only make health care decisions on behalf of the resident in the event that the resident becomes unable to make informed health care decisions as determined by the resident's attending physician and a second physician or licensed psychologist. Resident #117 On [DATE] at 11:45 AM, a review of the clinical record documented Resident #117 did not want to have Cardiopulmonary Resuscitation (CPR) performed if her heart stopped beating and she stopped breathing. (CPR is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after [MEDICAL CONDITION]. Source: cpr.heart.org) The Electronic Medical Record (EMR) documented the code status, DNR (Do Not Resuscitate) updated [DATE]. However, the Code Status form in Electronic Medical Record (EMR), dated [DATE], signed by Resident #117, documented that CPR was to be done. On [DATE] at 2:00 PM, a review of the clinical record revealed that Resident #117 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #117 was cognitively intact, but required extensive assistance from staff to complete activities of daily living. On [DATE] at 04:15 PM, Social Worker F was asked about the different code statuses listed in the clinical record. Social Worker F stated, She is cognitively intact. She is her own person (able to made medical decisions and has not been deemed incapacitated). Social Worker F checked the EMR and revealed she did not see documentation, dated [DATE], that Resident #117 requested a DNR status. Social Worker F did reveal the Code Status form in, dated [DATE], signed by Resident #117, that CPR was to be done. Social Worker F checked the paper chart and revealed a code status form, dated [DATE], signed by a family member, that documented No CPR. Social Worker F revealed Resident #117 has always been able to make her own decisions and has never needed a guardian since being in the facility. Social Worker F was unable to find documentation the resident agreed to be DNR. On [DATE] at 04:29 PM, Resident #117 was observed sitting in a recliner in her room and was asked if her heart should stop and she stopped breathing, would she want staff to do CPR on her to revive her. Resident #117 stated, Why yes of course . Why wouldn't I want them to revive me? I want them to do everything to stay alive. At 04:36 PM, Social Worker F was asked who had the responsibility to makes sure a resident's code status was updated and correct. Social Worker F stated, The social worker. Social Worker F revealed the code status of the a resident was reviewed every three months and if it (code status) changed the resident/guardian making the changed did not have to sign a new form. The change would be documented in the progress notes. On [DATE] at 1:20 PM, the Administrator was asked about the differences in the code statuses in Resident #117's medical records. The Administrator stated, A resident's code status is updated annually and then quarterly. We do have them sign another form with their wishes. On [DATE] at 1:42 PM, a review of the facility's Advance Directives Policy & Procedure, revised ,[DATE], stated, 6. Determine Resident's Capacity. All individuals are presumed to have the capacity to make informed health care decisions unless the individual has been adjudicated as incompetent in a court of law or unless a determination is made by two physicians, the residents attending physician and another physician or a licensed psychologist, that the individual does not have the capacity to make health care decisions. As long as the resident is capable of making his/her own medical decisions, the resident will be consulted personally about his/her care and treatment .When the annual MDS, quarterly MDS or a significant change MDS is completed, the Interdisciplinary Team reviews the resident's treatment choices and options and the relevance of those options to the resident's goals, wishes, medical condition and prognosis with the resident and/or representative and notes the review in the medical record

Based on observation, interview and record review, the facility failed to properly monitor the use of antipsychotic medications for one (#472) of eight sampled residents reviewed for unnecessary medications, resulting in signs of lethargy with difficulty in arousing the resident. Findings include: On 7/16/18 at 10 AM, 10:30 AM, 11:15 AM and 12:15 PM, resident #472 was observed asleep and difficult to arouse, even during lunch as staff attempted to feed her at 12:15 PM. On 7/17/18 at 9:46 AM, resident #472 was observed sitting in a wheelchair leaning forward with her forehead resting on her knees asleep during a religious activity and difficult to arouse by staff. The resident was removed and taken to her room. On 7/17/18 at 11:35 AM, resident #472's clinical record was reviewed. The resident was admitted into the facility on [DATE] from a hospital following surgical repair of a [MEDICAL CONDITION] on 7/5/18, with [DIAGNOSES REDACTED]. Per the hospital History and Physical dated 7/2/18, the resident was ambulatory prior to a trip and fall at home resulting in the fracture and was taking [MEDICATION NAME] and [MEDICATION NAME] antipsychotics at home with no recent changes. The decision was made to continue home medications at the hospital. The antipsychotics were continued upon admission into the facility by the attending physician, [MEDICATION NAME] 300 milligrams (mg) and [MEDICATION NAME] 2 mg daily. A mental status assessment dated [DATE] noted that the resident was extremely cognitively impaired. Per a Health Status Note dated 7/6/18: (Resident #472) is alert to self only. Lethargic. Hospital reports that she has been this way since post-surgery yesterday. They feel it is from anesthesia and pain meds. She is having difficulty swallowing. She pockets (food) and can take up to 10 minutes to swallow one bite. Oral meds held at hospital today due to this reason. (Attending physician) feels that these symptoms will diminish Patient does respond when spoken to however drifts back to sleep easily Patient goals are to walk and return back home with son. Per a Health Status Note dated 7/11/18: Patient's daughter approached writer and stated that her mother was experiencing hallucinations Staff will continue to monitor for worsening hallucinations. A urine culture was ordered at that time to rule out whether the hallucinations were associated with a urinary tract infection [MEDICAL CONDITION]. The culture was negative per a Health Status Note on 7/14/18. There was no documented order for evaluation of the antipsychotics by the facility's contracted mental health professionals after the urine culture was found to be negative. Per a Health Status Note dated 7/15/2018 at 12:37 PM: Patient had an episode where she was not responding to staff On 7/17/18 at 12:25 PM, the resident was observed being fed by staff opening her eyes when spoken to, but drifting off between bites of food. At 2:00 PM, social worker (SW) 'F' was queried as to the schedule for visits by mental health staff. She said that the staff came to the facility every Wednesday and was due the next day. When asked if resident #472 was going to be seen, SW 'F' said that there were no plans at all for the resident to receive mental health services. When asked why, she said, Because the family didn't request it then said, Nursing (staff) didn't request it then said, Social services didn't request it. When asked about the reported hallucinations on 7/11/18, the episode of unresponsiveness on 7/15/18 and the observations of continued lethargy during the survey, SW 'F' said, I will have the resident seen tomorrow and could not answer why there was no prior plan for a mental health referral for a psychoactive medication review. At 2:30 PM, the Director of Nursing (DON) was asked if resident #472's lethargy was still related to the anesthesia received during surgery on 7/5/18 and she said, no. A [MEDICATION NAME] level was requested to determine whether the resident's blood level of the drug was within normal range. The DON said, She had blood work on 7/15(2018), but a [MEDICATION NAME] level was not included. She looked in the resident's record, said that there was no level and that one would be ordered. When asked why there was no plan to evaluate the antipsychotics by mental health staff following the unresponsive episode and a UTI being ruled out as causing hallucinations, the DON said, Usually residents on the rehab unit (like resident #472) are not seen (by mental health staff) but that's no reason why she can't be. On 7/18/18 at 8:51 AM, the DON provided a [MEDICATION NAME] level from when the resident was in the hospital. There was no explanation why the facility did not seek the results before the survey and ensure they were on file for monitoring purposes. At 9:10 AM, the resident was observed asleep in a wheelchair in hallway. Two staff members were trying to wake the resident and were overheard saying that the resident was placed in the hall while waiting to be taken to therapy. The resident did not wake up when spoken to. At 9:20 AM, the sleeping resident was reapproached by staff who said, Let's take her to her room and put her in the recliner (chair). The resident was removed from the hallway and observed asleep reclined in a chair with her feet up, five minutes later. On 7/19/18 at 8 AM, per review of the facility's [MEDICAL CONDITION] Medication Assessment and Monitoring policy dated 11/2017: Purpose to monitor the effects of [MEDICAL CONDITION] medications Each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing The Interdisciplinary Team assesses and monitors the appropriateness, effectiveness and the side effects associated with [MEDICAL CONDITION] medications for each resident

Based on interview and record review, the facility failed to ensure an effective system to notify a physician of high blood sugar levels was established for one resident (#27) reviewed for blood sugar management, resulting in episodes of [MEDICAL CONDITION] going untreated. Findings include: On 7/17/18 at 10:35 AM, a review of the clinical record for Resident #27 (#27) was begun. R27 was admitted into the facility on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] documented moderate cognitive impairment. The physician's orders [REDACTED].Inject as per sliding scale: if (blood sugar is) 151-200 (give) 2 units; 201-250 (give) 4 units; 251-300 (give) 6 units; 301-350 (give) 8 units; 351-400 (give) 10 units; 401-450 (give) 12 units; 451 or greater give 12 units and recheck (blood sugar) in 1 hour, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with Diabetic [MEDICAL CONDITION] .ordered 1/24/18. Further review of R27's clinical record document a blood sugar management care plan revised on 5/9/18, included the following intervention: My physician is involved for ongoing medical management of my blood sugars. On 7/17/18 at 2:13 PM, when Licensed Practical Nurse, Staff J, was queried about what method was used to monitor blood sugar levels for residents diagnosed with [REDACTED]. When queried about the method used to communicate high or low blood sugar levels to other staff members, LPN J said, We document the elevated blood sugars in the computer. LPN J added, If the blood sugar (level) was over the parameters of the sliding scale, I would call or page the doctor to get a onetime order (for additional insulin administration). On 7/18/18 at 11:05 AM, a review of nursing documentation of R27's blood sugar values from (MONTH) 1, (YEAR) to (MONTH) 16, (YEAR) was conducted with the Director of Nursing (DON). This review revealed no evidence of physician notification when R27's blood sugar values were over 450 as indicated below: 462 on 6/5/18 at 9:00 PM 592 on 6/8/18 at 5:00 PM 488 6/12/18 at 7:00 AM 494 on 6/16/18 at 9:00 PM 517 on 6/26/18 at 9:00 PM 462 on 7/5/18 at 9:00 PM 483 on 7/14/18 at 5:00 PM Further clinical record review documented R27's Hgb A1c (a lab test which reflects blood sugar levels over the past six to eight weeks) level on 5/24/18 was 10.7. A 5/25/18 nursing note documented: Recent HgbA1C results and glucometer readings reviewed with PA (Physician Assistant), new order to increase [MEDICATION NAME] 5 mg po (by mouth) to 3 x daily. Will update resident. When the DON was queried if she felt a Hgb A1c of 10.7 reflected that R27 was in good blood sugar control, she said, No. When the DON was queried about her expectations regarding physician notification when a resident demonstrated a high blood sugar level, she said, It is different for each resident. When the DON was queried about physician notification when R27 demonstrated high blood sugar levels, the DON said, The (insulin sliding scale) order doesn't say when to call the physician. So, the nurse technically did not have to call. But then the DON added, The physician should have been notified. I would call if the blood sugar was over 450 just to make sure the physician didn't want to order anything else, because 450 is a pretty high blood sugar. (R27's) blood sugar order is unusual because it did not specify when to call the physician. R27's physician's progress note dated 6/9/18 was reviewed with the DON. When the DON was queried if this doctor's note addressed R27's elevated blood sugar levels, she said, No. The note should have addressed the elevated blood sugars. When the DON was asked to identify R27's physician she indicated Medical Doctor I (MD I). On 7/18/18 at 12:28 PM, a telephone conversation was conducted with MD I. When MD I was queried about when he should be notified about R27's high blood sugars, he said, Usually when the blood sugar is over 450 they should notify me, so the medication can be adjusted. That's why the phone call is necessary, so we can make changes in the blood sugar management. When MD I was queried about why his progress note of 6/9/18 did not address R27's blood sugar management, he said, When I'm in the building, I round with the nurses and ask the nurses if there are concerns. I look (rely) on the nurses to alert me to make changes. When queried about his thoughts on R27's Hgb A1c of 10.7 obtained on 5/24/18 in terms of it not being addressed in his 6/9/18 progress note, MD I said, That was an oversight. We have to do something about that.

Based on interview and record review the facility failed to implement preventative safety interventions (gait belt) for one sampled resident (#614) of 16 resident's reviewed for accident hazards from a total of 23 resulting in a fall with femoral (leg) neck fracture. Findings include: On 5/24/17 at 10:40 a.m., during a interview with R#614 she said that about a year ago she had a fall fracturing her right leg. R#614 went on to explain that she was walking with her walker from her room out into the hallway heading toward the dining room for lunch. (Nurse J) was following behind me with my wheelchair. She went on to say that when she got to the nurses station (approximately 10-12 feet from her room) her nose started running so she stopped to reach for a tissue (on the nurses station) with her right hand. R#614 stated, As I was reaching for a tissue, I lost my balance and fell on to my right side. The resident stated, She (Nurse J) didn't have a gait belt on me. They are suppose to have a gait belt on me. On 5/24/17 at 11:00 a.m., review of the facility provided document titled, Incident/Accident-Unusual Occurrence Investigation Form dated 9/9/16 documented, Resident ambulating with walker complained of nose running. Nurse followed with wheelchair and observed resident leaning to right and falling onto right leg. Interventions: X-ray ordered to rule out fracture. Pain medication given. Ice pack to right leg. fall checks initiated. Pain medication ineffective, notified physician, resident sent out to hospital. Review of hospital radiology report of right hip and pelvis dated 9/10/17 documented, Impacted subcapital right femoral neck fracture. On 5/24/17 at 11:30 a.m., record review revealed that R#614 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented the resident's cognition was intact and required extensive, one person physical assist with walking in room and corridor. Review of the Activities of Daily Living (ADL) self care performance care plan dated 6/3/15 documented approaches which included, AMBULATION: x1 moderate assist (level of assistance where staff perform about 50% of work necessary and resident performs about 50% of work necessary). ASSISTIVE DEVICES: 2 wheeled walker and handled gait belt. Review of the High risk for falls care plan dated 6/3/15 documented, Risk for falls related to: Gait/balance problems, severe symptomatic anemia, history of falls at home with fractures, medication side effects, vision and hearing deficit, abnormal posture, dementia, dizziness, incontinence, impulsiveness, unaware of safety needs, falling intentionally to get attention, noncompliance with using call light and self transfers. On 5/24/17 at 2:15 p.m., along with the Director of Nursing (DON) the facility's incident investigation was reviewed. The DON said that (Nurse J) entered R#614's room and noted that resident was independently walking with her rolling walker into the corridor. (Nurse J) proceeded to follow behind pushing (R#614's) wheelchair. The DON said that (Nurse J) was interviewed and stated R#614 was not wearing a gaitbelt because the resident had already risen and had begun ambulating with her walker out of her room. The DON stated, Nurses are not required to wear gait belts. Only the Certified Nurse Assistants (CNA's). The CNA's were all busy at this time getting other resident's to the lunch room. The DON was asked why, if the resident is at such a high risk for falls, they did not have a gait belt (a safety device per the plan of care) readily available for all staff's use in the residents room or in storage bag attached to the resident wheelchair to which she responded, I can't answer that. We have a gait belt there now. Record review revealed a nurses note dated 9/14/17 documenting the resident's post hospitalization return to the facility with having had a right hip arthroplasty (surgical repair to the right hip) with 43 staples. On 5/24/17 at 4:00 p.m., review of the facility's policy titled Fall Management Guidelines dated 12/2011 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.

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 765 AND MI 209. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND SERVICES TO PREVENT FALLS FOR TWO RESIDENTS (#501, #503) OF FIVE RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF FIVE, RESULTING IN FALLS WITH FRACTURE. FINDINGS INCLUDE: #501 ON 10/8/12 RESIDENT #501 WAS OBSERVED AT 2:40 P.M. AND AGAIN AT 4:00 P.M. SITTING IN HER ROOM IN A LOUNGE CHAIR. DURING AN INTERVIEW, RESIDENT #501 REPORTED, "...I HAD A BRUISE ON MY BACK. I WAS WALKING AND MY FOOT GOT CAUGHT AND I fell . I WAS WALKING WITH MY FRIEND..." THE FACILITY'S "ADMISSION SHEET" DOCUMENTED THAT RESIDENT #501 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATE SET (MDS) ASSESSMENT, DATED 5/2/12, DOCUMENTED THAT RESIDENT #501 REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING HYGIENE, BATHING AND TOILETING AND REQUIRED THE USE OF A WALKER TO ASSIST WITH AMBULATION DUE TO AN UNSTEADY GAIT. THE MDS FURTHER DOCUMENTED THAT #501 REQUIRED LIMITED ASSISTANCE OF ONE PERSON PHYSICAL ASSIST WHEN WALKING IN CORRIDOR AND REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON PHYSICAL ASSIST FOR LOCOMOTION OFF UNIT. A REVIEW OF THE FACILITY'S "INCIDENT/ACCIDENT REPORT-UNUSUAL OCCURRENCE FORM" DATED 7/3/12 REVEALED THAT ON 7/3/12 AT 11:00 A.M., "...LEAVING BUILDING WITH FRIEND. (RESIDENT #501) STATED "I WAS GOING AROUND THE CORNER AND I JUST fell ."...RESIDENT OBSERVED SITTING ON FLOOR NEAR ENTRANCE OF FACILITY. SITTING ON BUTTOCK. UPON SITTING IN WHEELCHAIR, RESIDENT COMPLAINED OF BACK PAIN 5-6 ON A 0-10 PAIN SCALE. LUMBAR AND SACRUM X-RAYS ORDERED. DOES THE RESIDENT/CLIENT HAVE AN ACUTE PROCESS (INFECTION) OCCURRING? IF SO, LIST: YES, UTI (URINARY TRACT INFECTION, CAUSES MENTAL STATUS CHANGES)...RECOMMENDATIONS: ENCOURAGE RESIDENT, FAMILY AND FRIENDS TO TAKE (RESIDENT #501) ON OUTINGS IN HER WHEELCHAIR FOR INCREASED SAFETY AND TO PREVENT FATIGUE. ON 7/4, X-RAY SHOWED FRACTURE RIGHT 7TH AND 8TH RIBS. MONITOR HEMATOMA RIGHT UPPER BACK. MONITOR PAIN. treatment for [REDACTED]. A REVIEW OF THE FACILITY'S "5-DAY INVESTIGATION" (UNDATED), REVEALED, "...ON 7/3/12 AT 11:00 A.M., (RESIDENT #501) WAS AMBULATING WITH HER FRIEND, USING HER PERSONAL WALKER, TOWARD THE FRONT ENTRANCE OF THE FACILITY. AS THEY APPROACHED THE ENTRANCE, (RESIDENT #501'S) FRIEND WAS GOING TO GET HER CAR, AND (RESIDENT #501) WAS GOING TO SIT ON THE BENCH TO WAIT FOR HER FRIEND. AS (RESIDENT #501) TURNED TOWARD THE BENCH, THE LEG OF HER WALKER BUMPED THE LEG OF THE BENCH AND SHE LOST HER BALANCE AND fell TO THE FLOOR...ON 7/4/12 (RESIDENT #501) COMPLAINED OF PAIN TO HER RIGHT SHOULDER AND RIB AREA. A LARGE HEMATOMA WAS NOTED AT THE APPROXIMATE LEVEL OF RIGHT LATERAL BREAST AT 10 CM (CENTIMETERS) BY 9 CM, AND A BRUISE BELOW THE HEMATOMA AT 11 CM X 3 CM. THE PHYSICIAN WAS NOTIFIED AND ORDERED STAT (IMMEDIATE) X-RAYS OF RIGHT RIBS, SHOULDER AND CLAVICLE...PRIOR TO THE FALL (RESIDENT #501) WAS ABLE TO AMBULATE IN ROOM AND CORRIDOR WITH SUPERVISION OR STAND-BY-ASSISTANCE OF ONE." A REVIEW OF #501'S X-RAY REPORT DATED 7/4/12 REVEALED, "...FINDINGS: NONDISPLACED LATERAL 7TH RIGHT RIB FRACTURE IS NOTED. MINIMALLY DISPLACED LATERAL RIGHT 8TH RIB FRACTURE IS ALSO SEEN. IMPRESSION: LATERAL FRACTURES OF THE RIGHT 7TH AND 8TH RIBS..." RESIDENT #501'S ADMISSION FALL RISK ASSESSMENT, DATED 4/26/12 IDENTIFIED RESIDENT #501 AT HIGH RISK FOR FALLS. ON 10/8/12 AT 4:09 P.M., DURING AN INTERVIEW, THE PHYSICAL THERAPIST (PT #1) REPORTED, "...I DID HER INITIAL EVALUATION AND SAW HER FROM 4/27/12 TO 6/13/12. SHE (#501) WAS TO AMBULATE WITH A FOUR-WHEEL WALKER (4 WW). SHE COULD AMBULATE 150 TO 200 FEET AS TOLERATED UNDER SUPERVISION. I WAS MADE AWARE OF THE FALL. SHE (#501) WAS TO BE UNDER STAFF SUPERVISION NOT THE SUPERVISION OF THE VISITOR..." ON 10/8/12 AT 4:30 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) WAS QUERIED. WHEN ASKED IF STAFF ACCOMPANIED #501 TO THE FRONT ENTRANCE TO ENSURE HER SAFETY, THE DON REPORTED, "...NO ONE ELSE WAS THERE BECAUSE SHE (#501) WAS SIGNED OUT OF THE BUILDING WITH HER FRIEND ON A VISIT. I AGREE THAT SHE SHOULD HAVE HAD SUPERVISION BUT I THOUGHT HER CARE PLAN SAID MODIFIED INDEPENDENCE..." A REVIEW OF RESIDENT #501'S "RISK FOR FALLS" CARE PLAN REVEALED THAT SOME INTERVENTIONS DATED 4/30/12 WERE LISTED, HOWEVER, THERE WERE NO INTERVENTIONS SPECIFYING THAT RESIDENT #501 WAS TO HAVE ASSISTANCE WITH AMBULATION. A "THERAPY WEEKLY PROGRESS REPORT" DATED 6/7/12 NOTED, "...AMBULATE/4WW/CGA (CONTACT GUARD ASSIST)/150-200 FEET. PATIENT NOT TOO CONFIDENT WITH HER NEW 4WW..." A "THERAPY DISCHARGE NOTE" DATED 6/13/12 DOCUMENTED, "...PT (PATIENT) AMBULATE/4WW/SUPERVISION/150-200 FEET. TRANSFERS AND BED MOBILITY MODIFIED INDEPENDENCE..." A REVIEW OF RESIDENT #501'S "KARDEX" (CNA CARE GUIDE) REVEALED, "...MOBILITY: AMBULATION: I REQUIRE SBA (STAND BY ASSISTANCE) X 1 WITH RW (ROLLING WALKER)... " ON 10/9/12 AT 10:30 A.M., DURING AN INTERVIEW, THE FACILITY'S ADMINISTRATOR REPORTED, "...JUST LIKE IN THE HOSPITALS, WE SHOULD HAVE WALKED HER (#501) ALL THE WAY OUT TO MAKE SURE SHE WAS SAFE. THAT WAY, WE RELEASE THE LIABILITY. SHE HAD GONE OUT OTHER TIMES AND I GUESS STAFF GOT COMFORTABLE DOING IT THE SAME WAY. THERE IS NO EXCUSE... " #503 ON 10/8/12 AT 2:55 P.M., RESIDENT #503 WAS OBSERVED SITTING IN THE DINING ROOM DURING ACTIVITIES IN HER WHEELCHAIR. ACCORDING TO THE FACILITY'S "ADMISSION RECORD," RESIDENT #503 WAS ORIGINALLY admitted to the facility on [DATE], AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT RESIDENT #503 REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING, TOILETING, PERSONAL HYGIENE AND BATHING. RESIDENT #503 REQUIRED LIMITED ASSISTANCE OF ONE PERSON PHYSICAL ASSIST WITH WALKING IN ROOM, THE CORRIDOR AND LOCOMOTION OFF THE UNIT AND REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON PHYSICAL ASSIST WITH LOCOMOTION ON THE UNIT. THE MDS FURTHER DOCUMENTED THAT RESIDENT #503 USED A WALKER AND WHEELCHAIR FOR MOBILITY AND WAS "NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE" FOR MOVING FROM SEATED TO STANDING POSITION AND SURFACE TO SURFACE TRANSFERS. RESIDENT #503'S FALL RISK ASSESSMENT IDENTIFIED HER AS "MODERATE RISK" FOR FALLS. A REVIEW OF THE FACILITY'S "INCIDENT/ACCIDENT REPORT - UNUSUAL OCCURRENCE FORM" DATED 8/22/12 REVEALED THAT ON 8/22/12 AT 3:30 P.M., RESIDENT #503 HAD A FALL. THE INCIDENT/ACCIDENT REPORT DOCUMENTED THAT RESIDENT #503 STATED, "I WAS TRYING TO GET A CARD ACROSS THE ROOM...ALARM SOUNDING, CNA (CERTIFIED NURSING ASSISTANT) RESPONDED, RESIDENT OBSERVED LYING ON LEFT SIDE ON FLOOR WITH HEAD UNDER BED...ASSESSED RESIDENT FOR INJURY TO LEFT HIP/LEG, RESIDENT ASSISTED TO WHEELCHAIR (W/C) WITH ASSIST X 3. DECLINE IN ROM (RANGE OF MOTION) LEFT LEG NOTED AT THIS TIME. UNABLE TO BEAR WEIGHT AND COMPLAINED OF PAIN, DOCTOR NOTIFIED. ORDER RECEIVED TO SEND TO ER (emergency room ) FOR EVALUATION AND TREATMENT..." A REVIEW OF #503'S X-RAY REPORT DATED 8/22/12 REVEALED, "...THE STUDY OF LEFT FEMUR DEMONSTRATES OF OBLIQUE OR SPINAL FRACTURE AT DISTAL LEFT FEMUR WITH SLIGHT DISPLACEMENT. IMPRESSION: OBLIQUE OR SPINAL FRACTURE AT DISTAL LEFT FEMUR..." ON 10/9/12 AT 1:13 P.M., DURING AN INTERVIEW, CNA #1 REPORTED, "...I WAS #503'S ASSIGNED CNA THE DAY SHE fell . IT'S USUALLY HECTIC AFTER THE ACTIVITIES. WHEN IT HAPPENED (THE FALL), I WAS IN WITH ANOTHER RESIDENT TRANSFERRING HIM TO THE BATHROOM. I HEARD AN ALARM GOING OFF BUT HAD TO MAKE SURE MY RESIDENT WAS OKAY FIRST, THEN ME AND THE OTHER CNA WENT TO HER (#503) ROOM. (RESIDENT #503) WAS ON THE FLOOR WITH HER HEAD UNDER THE HEAD BOARD. WHEN I LAST SAW HER, SHE WAS SITTING IN HER LAZY BOY (CHAIR) AND THE ALARM WAS UNDERNEATH HER BUTT ...IT WAS ABOUT 2:25 P.M. AND SHE WAS LAST TOILETED ABOUT 2:00 P.M...." CNA #1 FURTHER REPORTED, "...(RESIDENT #503) HAD HER MOMENTS WHERE SHE WOULD BE CONFUSED. WE ONLY HAD TWO CNAS THAT DAY. WE WERE SUPPOSED TO HAVE THREE DUE TO THE ACUITY LEVEL OF THE RESIDENTS. IT'S HARD TO KEEP UP WITH ALL THE ALARMS AND THE RESIDENTS TOO WITH JUST TWO CNAS...THERE WERE TWO "LIGHT DUTY" CNAS JUST SITTING AT THE NURSE'S STATION WHEN (RESIDENT #503'S) ALARM SOUNDED. ME AND ANOTHER CNA CAME OUT OF THE RESIDENT'S (ROOM) THAT WE WERE TOILETING IN ORDER TO RESPOND TO (RESIDENT #503'S) ALARM. THE TWO LIGHT DUTY CNAS WERE STILL SITTING AT THE NURSING STATION. THEY COULD HAVE RESPONDED TO THE ALARM. WHEN ME AND THE OTHER CNA HEADED TOWARD (RESIDENT #503'S) ROOM, THE TWO LIGHT DUTY CNAS SAID, "OH, AN ALARM" THEN THEY FOLLOWED US DOWN THE HALL AND INTO (RESIDENT #503'S) ROOM. IT WAS ABOUT THREE MINUTES BEFORE WE COULD RESPOND TO THE ALARM BECAUSE THE RESIDENT THAT WE WERE TOILETING WAS IN THE LIFT (TRANSFER DEVICE) AT THE TIME SO WE HAD TO COMPLETE THE TRANSFER AND MAKE SURE HE WAS SAFE..." ADDITIONALLY, CNA #1 REPORTED, "...THE LIGHT DUTY CNAS WERE RESPONSIBLE FOR PASSING ICE AND CHECKING VITAL SIGNS. THEY HAVE 10 POUND RESTRICTIONS BUT THEY COULD HELP WITH ALARMS. WHEN THEY ARE ON LIGHT DUTY, THEY CANNOT BE PLACED ON AN ASSIGNED HALL. THEY WERE JUST SITTING THERE AT THE NURSE'S STATION. I FEEL THAT IF THEY (LIGHT DUTY CNAS) HAD ASSIGNMENTS, THEY COULD HAVE CAUGHT (RESIDENT #503) BEFORE SHE fell BECAUSE WHERE SHE WAS SEATED, SHE HAD TO SCOOT FORWARD AND GRAB ONTO SOMETHING IN ORDER TO STAND. THE ALARM IS DESIGNED TO GO OFF WITH THE SHIFT OF MOVEMENT. EVEN IF SHE (#503) LEANED TO ONE SIDE, THE ALARM WOULD STILL GO OFF..." ON 10/9/12 AT 2:00 P.M., THE ASSISTANT DIRECTOR OF NURSING (ADON) WAS INTERVIEWED AND REPORTED THE FOLLOWING, "...LIGHT DUTY CNAS PASS WATER, FEED RESIDENTS, MAKE BEDS AND SIT WITH RESIDENTS. I WASN'T AWARE THAT THEY WERE JUST SITTING AT THE NURSE'S STATION. THAT'S NOT ACCEPTABLE..." WHEN ASKED IF THE LIGHT DUTY CNAS WERE RESPONSIBLE FOR RESPONDING TO ALARMS, THE ADON SAID, "...IT DOESN'T SAY THAT IN THEIR JOB DESCRIPTION..." ON 10/10/12 AT 11:15 A.M., THE ADON PRESENTED WITH THE FACILITY'S "LIGHT DUTY JOB DESCRIPTION," WHICH REVEALED THE FOLLOWING TASKS: "...TAKE VITAL SIGNS, PASS TRAYS AND FEED RESIDENTS, SHOWER RESIDENTS, PASS WATER, PASS SNACKS, PASS CLEAN LINEN, AM & HS (NIGHT) CARE, STOCK SHOWER, NAILS, ASSIST BY TOILETING AMBULATORY RESIDENTS, CLEAN RESIDENT'S BATHROOMS AND BEDSIDE TABLES, STOCK TREATMENT ROOMS AND CARTS, CLEAN OUTSIDE OF RESIDENT'S CHARTS..." THE "LIGHT DUTY JOB DESCRIPTION" DID NOT ADDRESS RESPONDING TO CALL LIGHTS OR ALARMS IN ORDER TO ENSURE RESIDENT SAFETY. A REVIEW OF THE FACILITY'S "ALARM/RESTRAINT FREE DEVICES" POLICY DATED MAY 2012 REVEALED: "...RESTRAINT-FREE DEVICES ARE MONITORING SYSTEMS DESIGNED FOR USE TO HELP PREVENT FALLS BY ALERTING STAFF THAT THE RESIDENT IS ABOUT TO, OR HAS EXITED THE CHAIR OR BED AND MAY NEED ASSISTANCE WITH TRANSFERS AND AMBULATION..." "...ALARMS ARE INTERVENTIONS WHICH ALERT STAFF OF RESIDENTS' ATTEMPTS TO RISE OF CHANGE POSITION WHICH COULD LEAD TO A RESIDENT FALL..." THE ADON WAS UNABLE TO EXPLAIN WHY THE FACILITY'S LIGHT DUTY CNAS FAILED TO RESPOND TO RESIDENT #503'S AUDIBLE ALARM IN ORDER TO ENSURE HER SAFETY.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 052 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE TOILETING ASSISTANCE FOR 1 (#502) OF 5 SAMPLED RESIDENTS, ALL REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 5, WHEN RESIDENT #502 ATTEMPTED TO SELF-TOILET AND fell , RESULTING IN INJURY (FRACTURE). FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S "ADMISSION RECORD," RESIDENT #502 WAS admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT RESIDENT #502 WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, DRESSING, EATING, PERSONAL HYGIENE AND BATHING. THE MDS FURTHER DOCUMENTED THAT #502 WAS "NOT STEADY, ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE" AND HAD "IMPAIRMENT ON ONE SIDE." THE MDS ALSO DOCUMENTED THAT #502 had a history of [REDACTED]. A REVIEW OF THE FACILITY'S "INCIDENT/ACCIDENT REPORT" DATED 6/30/12 REVEALED THAT ON 6/30/12 AT 6:55 A.M., RESIDENT #502 WAS OBSERVED "...ON RIGHT SIDE/HIP LYING WITH HEAD NEAR BATHROOM DOOR. (RESIDENT #502) WITHOUT ROLLING WALKER. ALARM SOUNDING. (RESIDENT #502) STATED "I HIT MY HEAD BUT I'M NOT HURT." TYPE OF INJURY RIGHT HIP, RIGHT ARM AND LEFT FOREHEAD PAIN..." THE FACILITY'S "INCIDENT/ACCIDENT - UNUSUAL OCCURRENCE INVESTIGATION FORM" DATED 6/30/12 DOCUMENTED, "...TOILETED ON PREVIOUS SHIFT, NOT YET ON DAYS, RESIDENT TAKES MULTIPLE MEDS (MEDICATIONS)..." A REVIEW OF THE FACILITY'S "5 DAY REPORT" REVEALED, "...(LICENSED PRACTICAL NURSE/LPN #2) RESPONDED IMMEDIATELY TO ALARM. WHEN (LPN #2) ARRIVED AT THE ROOM, SHE OBSERVED (RESIDENT #502) ON HER RIGHT SIDE LYING NEAR THE BATHROOM DOOR. (LPN #2) CALLED (LPN #1) TO ASSIST HER AT THAT TIME. AS (LPN #1) ENTERED THE ROOM, (RESIDENT #502) STATED, "I HAVE TO GO TO THE BATHROOM." WHEN ASKED WHAT HAPPENED, (RESIDENT #502) STATED, "I JUST GOT UP TO GO TO THE BATHROOM, I KNOW I SHOULD HAVE PUT ON MY CALL LIGHT. PLEASE JUST HELP ME UP AND TAKE ME TO THE BATHROOM." UPON PHYSICAL ASSESSMENT, (RESIDENT #502) COMPLAINED OF RIGHT HIP AND RIGHT ARM PAIN. (RESIDENT #502) ALSO STATED UPON ASSESSMENT, "I HIT MY HEAD TOO, DOESN'T HURT..." THE REPORT FURTHER NOTED, "...(RESIDENT #502) WAS ATTEMPTING TO TRANSFER HERSELF FROM HER BED TO THE BATHROOM WITHOUT ASSISTANCE WHICH LED TO HER FALL..." A REVIEW OF RESIDENT #502'S X-RAY REPORT DATED 6/30/12 REVEALED, "...MULTIPLE VIEWS OF THE RIGHT HIP OBTAINED REVEAL SLIGHTLY IMPACTED AND ANGULATED FRACTURE INVOLVING THE PROXIMAL TO MID ASPECT OF THE RIGHT FEMORAL NECK. IMPRESSION: FRACTURE RIGHT FEMORAL NECK..." A NURSE'S NOTE DATED 6/28/12 AT 9:23 P.M. DOCUMENTED, "...(RESIDENT #502) SHOWING INCREASE CONFUSION THIS SHIFT, SAYING SHE DOES NOT LIVE HERE AND IS LEAVING, YELLING AT STAFF AT TIMES..." A NURSE'S NOTE DATED 6/29/12 AT 8:48 P.M. DOCUMENTED, "...(RESIDENT #502) ONLY ACCEPTED KLONOPIN ([MEDICATION NAME] - USED TO TREAT [MEDICAL CONDITION], CAUSES DIZZINESS, UNSTEADINESS, DIFFICULTY THINKING, PROBLEMS WITH COORDINATION) AND [MEDICATION NAME] ([MEDICATION NAME] - USED TO TREAT DEPRESSION. CAUSES DROWSINESS, DIZZINESS, CONFUSION) THIS SHIFT..." A REVIEW OF THE "MEDICATION ADMINISTRATION RECORD" (MAR) FOR JUNE 2012 REVEALED THAT RESIDENT #502 RECEIVED KLONOPIN AND [MEDICATION NAME] ON 6/29/12 AT 9:00 P.M. A REVIEW OF RESIDENT #502'S CARE PLAN KARDEX REPORT (NURSING ASSIST GUIDE) REVEALED, "TOILET USE: I AM NOT TOILETED. I HAVE AN INDWELLING CATHETER RELATED TO TERMINAL DIAGNOSIS. CHECK AND CHANGE EVERY 2 HOURS FOR BOWEL INCONTINENCE. TRANSFER: MAXI LIFT X 2 (2-PERSON)." ON 10/9/12 AT 2:28 P.M., DURING AN INTERVIEW, THE NURSING ASSISTANT RESPONSIBLE FOR RESIDENT #502'S CARE FOR THE MIDNIGHT SHIFT, CERTIFIED NURSING ASSISTANT (CNA) #2 WAS ASKED WHEN SHE (#2) LAST TOILETED OR PROVIDED INCONTINENCE CARE FOR RESIDENT #502 PRIOR TO THE FALL. CNA #2 REPORTED, "...I CAN'T REMEMBER. I WORKED ALL OVER. I JUST CAN'T REMEMBER..." ON 10/10/12 AT 11:55 A.M., DURING AN INTERVIEW, LPN #1 REPORTED, "...SHE (#502) HAD AN UNSTEADY GAIT. SHE WAS ON THE FLOOR IN HER ROOM NEAR THE BATHROOM. SHE WAS FACING THE DOOR. HER LEG WAS EXTERNALLY ROTATED. SHE (#502) TOLD ME SHE WAS GOING TO THE TOILET. SHE WAS OCCASIONALLY LETHARGIC AND SICK LOOKING AT TIMES. I KNOW SHE WAS ON CONTROLLED SUBSTANCES BUT CAN'T REMEMBER WHICH ONES. I KNOW THAT SHE (#502) DID HAVE ACCIDENTS AT TIMES AND SHE WORE ADULT INCONTINENCE PRODUCTS..." WHEN ASKED OF THE LAST TIME #502'S BRIEF HAD BEEN CHECKED, LPN #1 WAS UNABLE TO RESPOND. A REVIEW OF THE FACILITY'S WITNESS STATEMENTS TAKEN REVEALED NO DOCUMENTED EVIDENCE THAT #502 HAD BEEN TOILETED. WHEN THE FACILITY'S ADL SHEETS WERE REQUESTED, THE ADON REPORTED THAT THE FACILITY DOESN'T HAVE ADL SHEETS. THE FACILITY'S TOILETING POLICY WAS REQUESTED BUT NOT SUBMITTED AT THE TIME OF THE INVESTIGATION.

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ONE RESIDENT'S (#715) DIGNITY WAS MAINTAINED OF 20 RESIDENTS SAMPLED FOR DIGNITY OUT OF A TOTAL OF 22 SAMPLED, RESULTING IN SEVERE HUMILIATION FROM THE RESIDENT BEING DEMEANED BY STAFF, URINATING ON HIMSELF AND HAVING TO LAY IN SOILED BRIEFS FOR EXTENDED PERIODS OF TIME, AND DEMONSTRATING MOOD CHANGES RESULTING IN FEELING BAD ABOUT HIMSELF. FINDINGS INCLUDE: ON 7/18/12 AT 1:00 P.M., DURING THE GROUP MEETING, RESIDENT #715 VERBALIZED COMPLAINTS AND CONCERNS ABOUT INTERACTIONS WITH CERTIFIED NURSING ASSISTANTS FROM THE AFTERNOON AND MIDNIGHT SHIFT (CNA'S). WHEN FURTHER QUERIED, RESIDENT #715 STATED THAT "I WAS ON DIURETICS THAT SOMETIMES I GET URINE ON THE FLOOR. ONE NIGHT, THEY GIVE ME A URINAL AND THEY STOOD WAITING FOR ME TO URINATE AND THAT IT IS HARD FOR ME TO URINATE ON DEMAND WITH SOMEONE JUST STANDING THERE, IT TAKES ME TIME TO GO." AGAIN, DURING THE SAME CONVERSATION, RESIDENT #715 STATED, "ONE NIGHT, I TURNED THE CALL LIGHT ON AND THE CNA CAME INTO MY ROOM AND SAID, "WHAT, AGAIN," THEN "I FELT EMBARRASSED AND I COULD HEAR THEM OUTSIDE OF THE BATHROOM TALKING, THEY SAID, NEXT TIME HE WILL GET IT ALL OVER THE FLOOR, I FELT SO BAD THAT I JUST DIDN'T BOTHER TO CALL THEM AGAIN, SO I JUST WENT IN MY BRIEFS. " RESIDENT #715 STATED THAT HE REPORTED HIS CONCERNS TO STAFF "J" AT THE FACILITY AND TO THE NURSING SUPERVISORS. ON 7/20/12 AT 8:30 A.M., REVIEW OF #715'S CLINICAL RECORD DOCUMENTED THAT RESIDENT #715 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] ASSESSED RESIDENT #715 TOILETING NEEDS BEING EXTENSIVE ASSIST WITH TWO PERSONS AND ADDITIONALLY NOTED UNDER RESIDENT'S MOOD SECTION AS HAVING FEELING DOWN, DEPRESSED, HOPELESS WITH A FREQUENCY NEARLY EVERYDAY, HAVING A POOR APPETITE OR OVEREATING 12-14 DAYS AND FEELING BAD ABOUT SELF 2-6 DAYS OVER A TWO WEEK PERIOD AFTER THE INCIDENT. THE PREVIOUS ANNUAL MDS FOR 4/7/12 MOOD ASSESSMENT DID NOT HAVE MOOD SCORES AT ALL IN THESE SAME AREAS. REVIEW OF THE NURSES NOTES DURING THIS SAME TIME, DOCUMENTED ENTRIES CONCERNING RESIDENTS CONCERNS WITH STAFF AS FOLLOWS: "ON 6/11/12 15:12 COMPLAINS OF BEING UPSET WITH CARE ON NIGHT SHIFT RESIDENT GIVEN OPPORTUNITY TO VERBALIZE CONCERNS WRITER APOLOGIZED AND WILL F/U WITH STAFF. CONTINUE TO MONITOR..." "6/30/12 14:16 RESIDENT VERBALIZED FRUSTRATIONS WITH STAFF , STAY HERE AND AGGRAVATION WITH NEEDS...OPPORTUNITY TO VERBALIZE FRUSTRATION." ON 7/19/12 AT 3:15 P.M., THE ADMINISTRATOR AND THE DIRECTOR OF NURSING (DON) WAS QUERIED IF THEY WERE AWARE OF CARE COMPLAINTS RESIDENT #715 HAD REGARDING STAFF TREATMENT OR HOW CNA'S ON THE AFTERNOON OR MIDNIGHT SHIFT ADDRESSED THE TOILETING NEEDS OF RESIDENT #715. THE DON RESPONDED WITH "WE KNEW THAT THERE WERE CONCERNS EXPRESSED ABOUT THE MIDNIGHT SHIFT," WHEN ASKED IF THEY INVESTIGATED ALLEGATIONS WITH THESE TYPES OF CONCERNS THE DON STATED, "WE INVESTIGATED IT". ON 7/20/12 AT 1:30 P.M., TWO SHEETS WERE PROVIDED, ONE WAS TITLED, "INVESTIGATIVE REPORT", DATED 7/2012, SUMMARY STATED THAT RESIDENT #715 EXPRESSED CONCERNS ABOUT THE 2ND SHIFT STAFF TAKING HIM TO THE BATHROOM MULTIPLE TIMES, THAT THERE WAS A FEMALE CNA ON THE 2ND SHIFT WHO HE WOULD NOT ASK TO TAKE HIM TO THE BATHROOM AS HE STATED , SHE IS NOT NICE..." THE SECOND SHEET HAD NO TITLE HOWEVER HAD ONLY THE RESIDENT'S NAME AND IDENTIFIED THE CARE CONFERENCE HELD ON 7/10/12 AT 1:15 P.M.. RESIDENT #715 EXPRESSED IN THE SECOND SHEET THAT HE HAD TO URINATE OFTEN AND THAT THE STAFF COMPLAINED ABOUT TAKING HIM TO THE BATHROOM FAIRLY OFTEN. ONE AID ON THE AFTERNOON SHIFT STATED, INSTEAD OF ASKING HER TO HELP HIM, HE WET HIMSELF. ( )

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 858 AND MI 832 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR TWO RESIDENTS (#503 AND # 504) OF THREE SAMPLED RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF FIVE SAMPLED RESIDENTS, RESULTING FALLS WITH INJURIES (#503 SUSTAINING A FRACTURED NOSE AND #504 SUSTAINING A HEAD LACERATION). FINDINGS INCLUDE: RESIDENT #503 ON 6/26/12 AT 4:45 P.M., #503 WAS OBSERVED IN HER ROOM LYING IN HER BED. RESIDENT #503 HAD VISIBLE BRUISING TO BOTH SIDES OF HER FACE AND UNDERNEATH HER EYES. FURTHER OBSERVATIONS REVEALED THAT AN ALARM WAS ATTACHED TO #503'S PERSON AND A SENSOR TRIP ALARM WAS ATTACHED TO THE FOOT OF RESIDENT #103'S BED FRAME. A REVIEW OF THE FACILITY'S "ADMISSION RECORD" AND "[DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) ASSESSMENT REVEALED THAT RESIDENT #503 HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DECISION MAKING, LONG AND SHORT TERM MEMORY LOSS AND REQUIRED SUPERVISION TO EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, AMBULATION, DRESSING, EATING, HYGIENE, BATHING AND TOILETING. AN ADDENDUM ON THE CARE AREA ASSESSMENT (CAAS) DATED 1/27/12 DOCUMENTED, "..SBA X 1 (STAND BY ASSIST OF ONE PERSON) WITH AMBULATION, AND TRANSFERS, MAY AMBULATE INDEPENDENTLY IN HALLWAY WITH ROLLING WALKER, ALARMS CONTINUE..." A REVIEW OF #503'S FALLS RISK assessment dated [DATE] REVEALED THAT #503 WAS DEEMED TO BE AT MODERATE RISK FOR FALLS AND "...STRAYS OFF THE STRAIGHT PATH OF WALKING..." A REVIEW OF THE FACILITY'S "INCIDENT/ACCIDENT REPORT-UNUSUAL OCCURRENCE FORM" DATED 6/10/12, REVEALED THAT ON 6/10/12 AT 5:40 A.M., #503 HAD A FALL. "...CNA (CERTIFIED NURSING ASSISTANT) FOUND THIS RESIDENT KNEELING ON FLOOR IN ANOTHER RESIDENT'S ROOM BY THE BED WITH HER HANDS ON THE BED. (RESIDENT #503) APPEARED TO BE TRYING TO STAND UP, THEN SAT ON HER BUTTOCKS AND STRAIGHTENED BOTH HER LEGS OUT IN FRONT OF HER. (RESIDENT #503) STATED, "I'M SCARED AND I WANT MY DAD." (RESIDENT #503) ATTEMPTING TO GET UP BY HERSELF. CNA SAT ON FLOOR WITH RESIDENT WHILE RESIDENT WAS BEING ASSESSED. 3 CM (CENTIMETER) SKIN TEAR TO POSTERIOR LOWER ARM. NOSE BLEEDING. LEFT KNEE SWOLLEN. ROM (RANGE OF MOTION) WNL (WITHIN NORMAL LIMITS). C/O (COMPLAINED OF) PAIN ON FACE AND RIGHT ARM..." A REVIEW OF THE FACILITY'S INVESTIGATIVE REPORT DATED 6/10/12 REVEALED, "...CHARGE NURSE HAD BEEN GIVING MEDICATION TO OTHER RESIDENTS. UPON ASSESSMENT A 3 INCH SKIN TEAR WAS NOTED TO (RESIDENT #503'S) RIGHT LOWER POSTERIOR ARM, (RESIDENT #503'S) NOSE WAS BLEEDING AND HER LEFT KNEE WAS SWOLLEN, (RESIDENT #503) COMPLAINED OF PAIN ON THE FACE AND TO HER RIGHT ARM, ADDITIONALLY NOTED, A 2 CM (CENTIMETER) BRUISE TO LEFT CHEEK AND A 4 CM BRUISE TO RIGHT POSTERIOR HAND. SHE WAS TRANSFERRED TO THE HOSPITAL FOR FURTHER EVALUATION AND TREATMENT..." THE INVESTIGATIVE REPORT FURTHER DOCUMENTED, "...UPON RETURN TO THE FACILITY, THE DON (DIRECTOR OF NURSING) PLACED (RESIDENT #503) ON 1:1 (ONE-TO-ONE) CARE GIVING RATIO FOR INCREASED SAFETY INTERVENTION DUE TO RESIDENT'S INCREASED WEAKNESS AND RESTLESSNESS. RESIDENT (#503) REMAINS ON 1:1 CARE GIVING RATIO AT THIS TIME WHILE WAITING FOR FURTHER MEDICAL INTERVENTIONS..." DURING TOUR OF THE FACILITY, NO STAFF WERE OBSERVED THAT PROVIDED 1:1 CARE GIVING. RESIDENT #503 WAS OBSERVED ALONE IN HER ROOM DURING SURVEYOR OBSERVATIONS. A REVIEW OF THE HOSPITAL CT (COMPUTED TOMOGRAPHY) SCAN DATED 6/10/12 REVEALED, "...CT-FACIAL/SINUS WITHOUT CONTRAST. CLINICAL DATA: fell . IMPRESSION: SLIGHTLY DEPRESSED FRACTURE TIP OF NASAL BONE..." ON 6/26/12 AT 4:50 P.M., DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) AND THE ADMINISTRATOR, THE DON WAS ASKED TO EXPLAIN WHERE THE ASSIGNED NURSING AND DIRECT CARE STAFF WERE DURING THE TIME OF THE FALL. THE DON REPORTED, "...THERE WERE TWO CNAS (CERTIFIED NURSING ASSISTANT) IN RESIDENTS' ROOMS PROVIDING CARE. WHEN RENDERING CARE, THE ROOM DOORS ARE CLOSED SO IT WOULD BE HARD TO HEAR ANY AUDIBLE ALARMS FROM OTHER RESIDENT'S ROOMS..." WHEN QUERIED ABOUT APPROPRIATE STAFFING, THE DON REPORTED, "...WE USUALLY HAVE FOUR NURSES BUT AT THAT TIME, WE ONLY HAD THREE. WE HAD A CALL OUT FOR ANOTHER NURSE BUT SHE HADN'T MADE IT IN YET. WE'RE WORKING ON STAFFING..." THE DON WAS QUERIED ABOUT THE ACUITY LEVEL ON THE UNIT WHERE #503 RESIDED. THE DON REPORTED THAT ON THE UNIT WHERE RESIDENT #503 RESIDED, THEY HAD RESIDENTS THAT HAD [DIAGNOSES REDACTED]. THE DON FURTHER REPORTED THAT SOME OF THE RESIDENTS WERE CLASSIFIED AS ELOPEMENT RISKS AND REQUIRED GREATER SUPERVISION. DURING THE INTERVIEW, THE DON AND THE FACILITY ADMINISTRATOR ACKNOWLEDGED THAT INCREASED SUPERVISION WAS IN FACT NECESSARY. ON 6/27/12 AT 11:45 A.M., DURING AN INTERVIEW, CNA #2 REPORTED THE FOLLOWING, "...I WAS NOT #503'S ASSIGNED CNA. I WAS IN A ROOM PROVIDING CARE TO A RESIDENT AND THE DOOR TO THE ROOM WAS CLOSED. THERE WAS ALSO A FAN RUNNING IN THE ROOM. I GOT BEHIND IN MY WORK BECAUSE THE RESIDENTS REQUIRE A LOT. I TOOK SOME LINEN OUT OF THE ROOM AND WENT BACK IN TO GIVE THE RESIDENT SOME WATER. I HAD HEARD AN ALARM WHEN I TOOK THE LINEN OUT BUT I DIDN'T RESPOND TO IT BECAUSE I THOUGHT THE OTHER CNA WAS DOWN THE HALL BUT I DIDN'T SEE HER OR ANY OTHER STAFF IN THE HALLWAY AT THAT TIME..." CNA #2 FURTHER REPORTED, "...AFTER I FINISHED CARING FOR MY RESIDENT, I NOTICED THAT (RESIDENT #503'S) ALARM WAS STILL SOUNDING SO I WENT TO CHECK IT OUT AND I NOTICED THAT (RESIDENT #503) WAS NOT IN HER ROOM. I FOUND HER (#503) DOWN THE HALL IN ANOTHER RESIDENT'S ROOM TRYING TO GET OFF THE FLOOR. SHE (#503) WAS ON HER LEFT SIDE WITH HER HEAD NEAR THE FOOT OF THE BED. SHE WAS TRYING TO GET UP SO I YELLED FOR ANOTHER CNA, WHO WAS FIVE ROOMS AWAY, TO GET THE NURSE. IT TOOK A WHILE FOR THE NURSE TO ARRIVE TO THE ROOM..." ADDITIONALLY, CNA #2 REPORTED, "...HER (#503) FACE WAS COVERED IN BLOOD AND SHE WAS RUBBING HER KNEE. THERE WAS A BIG OPEN AREA TO HER RIGHT ARM..." WHEN ASKED ABOUT THE NUMBER OF STAFF ASSIGNED ON THAT PARTICULAR UNIT, CNA #2 REPORTED, "...THERE WAS JUST TWO OF US AND JUST TWO NURSES ALL TOGETHER BUT OUT NURSE WAS SPLIT BETWEEN TWO UNITS. THAT'S PROBABLY WHY IT TOOK HER A WHILE TO ARRIVE TO THE ROOM WHEN (RESIDENT #503) fell . (#503) WAS ON THE SPECIALIZED UNIT. THERE ARE SEVERAL WANDERERS ON THAT UNIT AND WE CAN'T WATCH THEM ALL. THEY'VE ADDED ADDITIONAL STAFF SINCE HER FALL. SHE (#503) MAKES ME REALLY NERVOUS BECAUSE SHE CAN GET WOBBLY WHEN SHE WALKS AT TIMES..." FURTHER REVIEW OF #503'S CLINICAL RECORD REVEALED THE FOLLOWING PREVIOUS UNSUPERVISED INCIDENT WHICH RESULTED IN INJURY: 5/2/12 AT 3:50 P.M. "...CNA REPORTED THAT SHE OBSERVED RESIDENT ON HALLWAY FLOOR FACE DOWN, BRIGHT PINK AREAS TO BILATERAL KNEES, LEFT KNEE SLIGHTLY EDEMATOUS, LEFT ELBOW RED AREA, COMPLAINED OF BILATERAL KNEE PAIN. RESIDENT NOW IS ON STAND BY ASSIST X 1 WITH ROLLING WALKER, IMMEDIATE INTERVENTIONS: X-RAY BILATERAL KNEES, 1-2 ASSIST AT ALL TIMES WITH ROLLING WALKER DURING AMBULATION..." RESIDENT #504 ON 6/26/12 AT 3:15 P.M., #504 WAS OBSERVED IN HIS ROOM ASLEEP IN HIS RECLINER. DURING AN INTERVIEW, WHEN ASKED TO RECALL THE EVENTS OF HIS FALL ON 6/7/12, RESIDENT #504 REPORTED, "...I WAS SITTING IN A CHAIR WHILE I WAS SHAVING. I GRABBED ONTO THE CHAIR TO STAND AND I LOST MY BALANCE BECAUSE I WAS SITTING IN ONE OF THOSE FOLDING CHAIRS AND IT JUST TIPPED BACK. I TRIED TO REACH FOR THE DOOR KNOB BUT I COULDN'T REACH IT..." RESIDENT #504 FURTHER REPORTED, "...I HAD TO GET STAPLES IN MY HEAD..." A REVIEW OF THE FACILITY'S ADMISSION RECORD REVEALED THAT #504 WAS A [AGE] year OLD MALE WHO WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. A PHYSICIAN'S PROGRESS NOTE DATED 5/18/12 REVEALED, "...HE HAD A SYNCOPE (DIZZINESS) EPISODE. THE PATIENT fell AND INJURED THE LEFT HAND AND THUMB. HE HAD OPEN REDUCTION AND INTERNAL FIXATION AND NOW IN A CAST..." THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT #504 REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, AMBULATION IN THE ROOM AND ON THE UNIT, DRESSING, HYGIENE, BATHING AND TOILETING. A REVIEW OF #504'S FALL RISK assessment dated [DATE] REVEALED THAT #504 WAS AT MODERATE RISK FOR FALLS. A REVIEW OF THE FACILITY'S "INCIDENT/ACCIDENT REPORT" DATED 6/7/12 REVELED THAT ON 6/7/12 AT 8:30 A.M., "...PATIENT (#504) NOTED LAYING ON LEFT SIDE IN HIS ROOM BY DOORWAY (DOOR OPEN). LACERATION NOTED TO POSTERIOR HEAD BEHIND LEFT EAR APPROXIMATELY 3 CM IN LENGTH. (RESIDENT #504) STRAIGHT CANE LAYING BESIDE HIM. BLOOD NOTED ON POSTERIOR HEAD..." A REVIEW OF THE FACILITY'S SUMMARY OF INVESTIGATION REPORT DATED 6/14/12 REVEALED, "...#504 HAS ALSO BEEN ENCOURAGED TO USE HIS CALL LIGHT IF HE FEELS DIZZY, AND TO TAKE CARE WHEN REACHING FOR MOVEABLE ITEMS TO HOLD ONTO FOR STABILITY..." A physician's orders [REDACTED]. A physician's orders [REDACTED]. A REVIEW OF THE FACILITY'S "PHYSICAL THERAPY EVALUATION" DATED 5/18/12 REVEALED, "...MEDICAL HISTORY: SYNCOPE, WEAKNESS, OPEN WOUND, ANXIETY, MALAISE AND FATIGUE. PRECAUTIONS/COMPLICATIONS: FALL RISK. GATE DEVIATIONS: UNSTEADY. FALL RISK: MODERATE RISK FOR FALL DUE TO DECREASED BALANCE. DECREASED SAFETY. FALL RECOVERY POOR. GAIT ASSISTANCE: MODERATE X 1..." A REVIEW OF #504'S "FALLS" CARE PLAN DATED 5/25/12, REVISED ON 6/1/12, REVEALED, "...I AM A HIGH RISK FOR FALLS RELATED TO USE OF ANTIANXIETY, ANTIDEPRESSANT AND USE OF HYPNOTIC..." A REVIEW OF #504'S "ADL" CARE PLAN DATED 5/25/12, REVISED ON 6/1/12, REVEALED, "...I HAVE AN ADL SELF CARE PERFORMANCE DEFICIT RELATED TO WEAKNESS FROM HOSPITAL STAY FOR FALL WITH FRACTURED THUMB. MODERATE INDEPENDENT WITH 4 WHEEL ROLLING WALKER ON E WING. STAND BY ASSIST WITH BATHROOM ASSIST X 1. I AM NON WEIGHT BEARING TO LEFT ARM... ON 6/26/12 AT 3:00 P.M., DURING AN INTERVIEW, CNA #1 REPORTED, "...I WAS HIS ASSIGNED CNA. HE (#504) CAN'T WALK WITHOUT A WALKER. PHYSICAL THERAPY (PT) IS TRYING TO WORK WITH HIM WITH A CANE BUT HE'S INDEPENDENT IN HIS ROOM WITH SUPERVISION..." "...HE WANTED TO SHAVE SO I SET HIM UP IN FRONT OF THE SINK AND I STEPPED OUT OF THE ROOM TO ASSIST ANOTHER RESIDENT. HE WAS IN A FOLDING CHAIR WITH NO ARMS TO SUPPORT HIMSELF. BEING A FOLDING CHAIR, THE CHAIR IS UNSTABLE. THAT WAS MY MISTAKE. HAD HE BEEN IN A CHAIR WITH ARMS, I DON'T THINK HE WOULD HAVE LOST HIS BALANCE. HE DIDN'T HAVE HIS BALANCE DUE TO THE INSTABILITY OF THE CHAIR..." ON 6/26/12 AT 3:25 P.M., LICENSED PRACTICAL NURSE (LPN) #1 REPORTED, "...HE (#504) WAS NEVER INDEPENDENT WITH AMBULATION. HE ALWAYS NEEDED ASSISTANCE..." ON 6/26/12 AT 4:20 P.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED ON RESIDENT USE OF FOLDING CHAIRS. THE DON REPORTED, "...IT'S NOT A COMMON PRACTICE TO USE FOLDING CHAIRS FOR OUR RESIDENTS. WE USUALLY DON'T EVEN KEEP FOLDING CHAIRS IN RESIDENT'S ROOMS. WE ONLY USE THEM FOR VISITORS..." ON 6/26/12 AT 4:25 P.M., AN INTERVIEW WAS CONDUCTED WITH THE THERAPY DEPARTMENT MANAGER (OT #1) WHO REPORTED, "...WE EDUCATE RESIDENTS NOT TO USE FOLDING CHAIRS. WE WANT THEM TO USE CHAIRS WITH ARM RESTS SO THEY CAN PUSH DOWN ON THE ARM RESTS AND USE THEM FOR SUPPORT. I'M SURPRISED TO LEARN THAT (RESIDENT #504) WAS PLACED IN A FOLDING CHAIR AT THE TIME OF HIS FALL." THE FACILITY'S ADMINISTRATIVE STAFF COULD NOT EXPLAIN WHY #504 WAS NOT PROVIDED WITH A STABLE CHAIR IN ORDER TO PERFORM HIS ADL TASKS, WHY HE WAS LEFT UNSUPERVISED OR WHY HE WAS ALLOWED TO PERFORM TASKS WITHOUT ASSISTANCE IN LIGHT OF THE physician's orders [REDACTED]. A REVIEW OF THE FACILITY'S "FALL MANAGEMENT GUIDELINES" POLICY REVISED 12/2011 REVEALED, "...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."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 067 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT A FALL (RESIDENT WAS LEFT IN BATHROOM UNSUPERVISED), FOR 1 (#101) OF 5 RESIDENTS REVIEWED FOR SAFETY, FROM A TOTAL SAMPLE OF 5 RESIDENTS, RESULTING IN A FRACTURED FEMUR (THIGH BONE) AND MALALIGNMENT OF THE HIP. FINDINGS INCLUDE: RESIDENT #101 WAS AN [AGE] year OLD FEMALE WHO WS admitted to the facility on [DATE]. RESIDENT #101'S [DIAGNOSES REDACTED]. PER THE MDS (MINIMUM DATA SET) assessment dated [DATE], RESIDENT #101 WAS MODERATELY COGNITIVELY IMPAIRED, SHE WAS ABLE TO MAKE HERSELF UNDERSTOOD AND TO UNDERSTAND OTHERS. SHE REQUIRED 1 PERSON ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, WHICH INCLUDED TOILETING AND TRANSFERS. FURTHER REVIEW OF RESIDENT #101'S CLINICAL RECORD REVEALED A FALL assessment dated [DATE], THAT DOCUMENTED RESIDENT #101 WAS AT HIGH RISK FOR FALLS RELATED TO A HISTORY OF MULTIPLE FALLS, MEDICATIONS, INCONTINENCE, INABILITY TO STAND WITHOUT ASSISTANCE, LOSS OF BALANCE AND DECREASED MUSCLE COORDINATION. THE CLINICAL RECORD INCLUDED A CNA (CERTIFIED NURSING ASSISTANT) FLOW SHEET DATED 1/17/12, A FALL CARE PLAN AND ACTIVITIES OF DAILY LIVING CARE PLAN EACH DATED 5/11/11, WITH INTERVENTIONS TO PREVENT FALLS THAT INCLUDED THE FOLLOWING: 1-2 PERSON ASSISTANCE WITH ALL TRANSFERS, AMBULATION AND TOILETING AND RESIDENT "NOT TO BE LEFT ALONE IN THE BATHROOM." ON 4/12/12 AT 2:40 P.M., DURING THE INITIAL TOUR OF THE FACILITY, OBSERVATIONS OF RESIDENT #101'S DOOR REVEALED A "DOT SYSTEM" CARE GUIDE. PER THE DOT SYSTEM CARE GUIDE KEY, RESIDENT #101'S CARE INCLUDED HIGH RISK FOR FALLS, BED AND CHAIR ALARMS, 2-3 PERSON ASSISTANCE AND STAND BY ASSISTANCE/SUPERVISION WITH TOILET USE. RESIDENT #101 WAS OBSERVED IN HER ROOM, IN A RECLINER CHAIR WITH A SENSOR ALARM IN PLACE. SHE WAS CLEAN, AND DRESSED APPROPRIATELY. RESIDENT #101 WAS QUERIED BY THE SURVEYOR. HER ANSWERS TO QUESTIONS WERE NOT CONSISTENTLY ACCURATE. SHE DID RECALL FALLING IN THE BATHROOM AND STATED, "I THINK I DROPPED A PIECE OF PAPER AND WENT TO FAR TO GET IT." PER THE FACILITY INCIDENT/ACCIDENT REPORT-UNUSUAL OCCURRENCE FORM DATED 3/23/12, RESIDENT #101 WAS DISCOVERED AT 1:30 P.M. LYING ON THE FLOOR NEXT TO THE TOILET IN HER BATHROOM. IT DOCUMENTED THAT RESIDENT #101 SUSTAINED A BRUISE/HEMATOMA TO THE LEFT KNEE AND LEFT BUTTOCK, AND INJURY TO LEFT LEG AND HIP. RESIDENT #101'S PAIN ASSESSMENT WAS DOCUMENTED AS 8-10, SEVERE PAIN. THE FACILITY INCIDENT/ACCIDENT STATEMENT FORM DOCUMENTED CNA #11'S STATEMENT WHICH READ, "I PUT HER ON THE TOILET....AND LEFT THE ROOM AND TOLD HER TO PULL THE CORD WHEN SHES READY. I WENT AND HELPED (CNA # 1)...AND WHEN I WENT BACK TO CHECK ON HER (#101) AND FOUND HER ON THE FLOOR." AN UNSUCCESSFUL ATTEMPT WAS MADE TO CONTACT CNA #11 PER PHONE. A MESSAGE WAS LEFT WITH NO RETURN PHONE CALL. ON 4/12/12 AT 2:10 P.M., CNA #1 WAS QUERIED BY THE SURVEYOR REGARDING RESIDENT #101'S FALL. SHE STATED THAT CNA #11 HAD TAKEN THE RESIDENT TO THE BATHROOM AND TOLD HER (#101) TO CALL FOR ASSISTANCE WHEN FINISHED. CNA #1 WAS QUESTIONED BY THE SURVEYOR ABOUT RESIDENT #101'S REQUIREMENT FOR SUPERVISION IN THE BATHROOM. SHE (#1) SAID SHE THOUGHT RESIDENT #101 COULD BE LEFT IN THE BATHROOM. SHE SAID SHE WAS TOLD BY THE ASSISTANT DIRECTOR OF NURSING AFTER THE INCIDENT THAT SHE COULD NOT. WHEN CNA #1 WAS ASKED BY THE SURVEYOR HOW NURSING ASSISTANTS KNOW RESIDENTS' CARE NEEDS ARE, CNA #1 SAID, "CHECK THE DOT SYSTEM ON THE DOOR. I DIDN'T LOOK AT IT THAT DAY." ON 4/13/12 AT 1:35 P.M., LPN (LICENSED PRACTICAL NURSE) #7 SAID SHE WAS CALLED TO THE ROOM BY CNA #1. LPN # 7 SAID WHEN SHE ENTERED RESIDENT #101'S BATHROOM SHE (#7) OBSERVED HER (#101) ON THE FLOOR NEXT TO THE TOILET, COMPLAINING OF PAIN TO HER LEFT KNEE AND HIP. LPN #7 NOTED THAT RESIDENT #101'S LEFT FOOT WAS TURNED OUT. LPN # 7 STATED SHE CONTACTED THE PHYSICIAN AND THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL. LPN #7 SAID SHE ASKED CNA #11 ABOUT RESIDENT #101'S SUPERVISION IN THE RESTROOM AND CNA #11 SAID SHE THOUGHT THE RESIDENT COULD BE LEFT ALONE. LPN #7 SAID SHE REVIEWED RESIDENT #101'S DOT SYSTEM CARE GUIDE AT THAT TIME AND THE CARE GUIDE DOCUMENTED SHE (#101) COULD NOT BE LEFT ALONE. ON 4/13/12 AT 11:05 A.M. THE DRC (DIRECTOR OF RESIDENT CARE) STATED RESIDENT #101 REQUIRED STAND BY ASSISTANCE AND SUPERVISION IN THE RESTROOM AND SHOULD NOT HAVE BEEN LEFT ALONE IN THE BATHROOM. THE DRC STATED CNA #11 LEFT ON A MEDICAL LEAVE OF ABSENCE BEFORE SHE (#11) COULD BE DISCIPLINED. A REVIEW OF THE FACILITY IN-SERVICE INSTRUCTION FOR SAFETY, FALLS AND THE DOT SYSTEM DOCUMENTED CNA #11 RECEIVED IN-SERVICES ON 9/26/11, 9/27/11,10/5/11 AND 10/7/11. A REVIEW OF THE HOSPITAL EMERGENCY RECORD X-RAY REPORT DATED 3/23/12 REVEALED RESIDENT # 101 HAD A DISPLACED IMPACTED SUBCAPITAL FRACTURE OF THE LEFT FEMUR. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT FALLS WHILE BEING TOILETED FOR ONE (#606) OF 11 SAMPLED RESIDENTS AT RISK FOR FALLS, OUT OF A TOTAL SAMPLE OF 23 RESIDENTS, RESULTING IN A FALL WITH A HEAD INJURY. FINDINGS INCLUDE: REVIEW OF THE ADMISSION FACE SHEET ON 9/7/11 AT 2:30 PM REVEALED THAT RESIDENT #606 WAS ORIGINALLY admitted to the facility on [DATE], AND WAS REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE "ADMITTING CHECKLIST FOR EVALUATION FALL/FALLS RISK" FOR RESIDENT #606, DATED 7/21/11, NOTED THE FOLLOWING: MEDICATION CATEGORIES ASSOCIATED WITH FALLING: MULTIPLE MEDICATIONS, ANTIEPILEPTICS, ANTIHYPERTENSIVES, PSYCHOTROPICS. FACTORS ASSOCIATED WITH FALLING: HISTORY OF FALLS, PROBLEMS WITH GAIT/MOBILITY, VISUAL AND AUDITORY IMPAIRMENTS. AN "OCCUPATIONAL THERAPY EVALUATION" FOR RESIDENT #606, DATED 7/22/11 NOTED THAT THE RESIDENT WAS TO HAVE "SBA (STAND BY ASSIST) WITH TOILETING". ON 7/28/11, RESIDENT #606 WAS LEFT UNATTENDED BY STAFF WHILE BEING TOILETTED, fell AND SUSTAINED A HEAD INJURY REQUIRING TRANFERRING TO A HOSPITAL FOR TREATMENT. ACCORDING TO AN "ACTIVITIES OF DAILY LIVING ASSISTANCE" EVALUATION FOR RESIDENT #606, DATED 7/28/11, THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE WITH 2 PLUS PERSON PHYSICAL ASSIST FOR TOILETING. REVIEW OF THE NURSE'S NOTES FOR RESIDENT #606 REVEALED THAT THE RESIDENT HAD A SIGNIFICANT CHANGE IN CONDITION AND WAS AT INCREASED RISK FOR FOR FALLS AS FOLLOWS: 7/26/11 9:30 AM PATIENT COMPLAINED OF RIGHT SIDE NOT MOVING, NOTED MOVING RIGHT ARMS AND LEGS. 7/26/11 1900 PERSONAL ALARM ADDED TO BED DUE TO INCREASED LETHARGIC/CONFUSION, DECREASED COORDINATION FOR SAFETY. 7/26/11 2200 PATIENT IS DIFFICULT TO AROUSE...INCREASED LETHARGY. 7/27/11 11-7 PATIENT UP TO RESTROOM TIMES 3, GAIT UNSTEADY. 7/27/11 1300 PATIENT FAMILY WITH CONCERN DUE TO LETHARGY, FATIGUE AND CONFUSION. 7/28/11 10:00 AM PATIENT URINE OBTAINED, NOTED POSITIVE FOR BACTERIA. 7/28/11 11:20 AM ...PATIENT LETHARGY, DIFFICULTY AMBULATING. 7/28/11 1505 CERTIFIED NURSE AIDE (CNA) CALLED OUT TO NURSE PATIENT ON FLOOR IN BATHROOM. WRITER AND TWO OTHER FLOOR NURSES ENTERED PATIENT BATHROOM. PATIENT ON FLOOR FACING DOWN. PATIENT COMPLAINED OF "MY JAW, MY ELBOW, AND MY EYE HURTS". RIGHT SIDE OF FACE ABOVE EYE SKIN TEAR, 2 CENTIMETERS IN SIZE WITH RED DRAINAGE NOTED...CNA REPORTED PATIENT WAS ASSISTED TO TOILET TIMES 2...PATIENT SEEMED STABLE...PATIENT REQUESTED PRIVACY ON TOILET. CALL LIGHT WAS GIVEN TO RESIDENT... 7/28/11 1530 AMBULANCE ARRIVED...ASSISTED PATIENT TO STRETCHER. 7/28/11 1700 (HOSPITAL) CALLED. PATIENT admitted WITH [DIAGNOSES REDACTED]. AN "INCIDENT/ACCIDENT REPORT" FOR RESIDENT #606 NOTED THE FOLLOWING: 7/28/11 "PATIENT ASSISTED TO BATHROOM BY CNA'S, LEFT ON TOILET PER PATIENT REQUEST FOR PRIVACY. STAFF OPENED DOOR AND NOTED PATIENT ON FLOOR IN FRONT OF TOILET...RED DRAINAGE FROM RIGHT CHEEK PROXIMAL TO EYE 2 CENTIMETER CUT...SENT TO emergency room ..." THE FOLLOWING STATEMENTS WERE OBTAINED ON 7/28/11 FROM THE TWO CNA'S WHO LEFT RESIDENT #606 ON THE TOILET PRIOR TO THE FALL: CNA "A": "...WE HELPED HER TO STAND AND PIVOT ONTO THE TOILET. ONCE ON THE TOILET...I ASKED IF SHE WAS GOING TO HAVE A BOWEL MOVEMENT AND IF SHE FELT MORE COMFORTABLE WITH US OUT OF THE ROOM. SHE SAID YES SHE WOULD PREFER PRIVACY...CNA "B" AND I LEFT THE ROOM. CNA "B" WAS IN THE HALLWAY AND I USED THE RESTROOM AT THE NURSE'S STATION...". CNA "B": "...WE HELPED (RESIDENT #606)...ONTO THE TOILET. WE THEN ASKED HER IF SHE NEEDED TO HAVE A BOWEL MOVEMENT, SHE SAID YES, THEN WE ASKED HER IF SHE WOULD PULL HER CALL LIGHT WHEN SHE WAS FINISHED, SHE ALSO SAID YES...CNA "A" WENT TO THE BATHROOM WHILE I STAYED IN THE HALL...". DURING AN INTERVIEW ON 9/9/11 AT 1:45 PM, THE DIRECTOR OF NURSING (DON) STATED THAT THE CNA'S WERE QUESTIONED ABOUT LEAVING THE RESIDENT ON THE TOILET, AND THAT THEY STATED SHE WAS LEFT ON THE TOILET FOR PRIVACY REASONS. SHE HAD NO EXPLANATION FOR WHY A RESIDENT WHO HAD BEEN EXPERIENCING INCREASED LETHARGY, CONFUSION AND WAS AT RISK FOR FALLS WAS LEFT ON THE TOILET UNSUPERVISED. WHEN ASKED IF THE CNA'S HAD BEEN INSERVICED REGARDING LEAVING RESIDENT #606 ON THE TOILET, SHE STATED "NO". WHEN ASKED WHAT THE FACILITY EXPECTS FROM STAFF WHEN A RESIDENT HAS BEEN ASSESSED AS A "STAND BY ASSIST" FOR TOILETING, THE DON STATED THAT STAFF WOULD BE EXPECTED TO STAY RIGHT THERE CLOSE TO THE RESIDENT. ( )