Every finding on record at Wellspring Lutheran Services

Based on observation, interview and record review, the facility failed to ensure a timely response to a change in condition for Resident #65; assess/respond to abnormal vital signs for Resident #52 and Resident #65; and ensure antibiotics were ordered and administered timely for Resident #63, for three residents (#52, #63 and #65) of four residents reviewed for a change in condition and antibiotic administration, resulting in a delay in treatment, increased abdominal pain and hospitalization for Resident #65, and a delay of antibiotics for Resident #63 with the potential for continued infection and delay in assessment/treatment of abnormal vital signs for Resident #52.Resident #52: A review of Resident #52’s medical record revealed an admission into the facility on [DATE] and date of discharge [DATE] with diagnoses that included fracture of right humerus and greater trochanter of right femur, chronic kidney disease, heart failure, atrial fibrillation, and hyperkalemia (a medical condition where the body has high levels of potassium in the blood). Further review of the medical record revealed the Resident had gone unresponsive, cardiopulmonary resuscitation was initiated and the Resident died at the facility. A review of Resident #52’s medical record of documented Pulses revealed the following abnormal vital signs of heart rate (Pulse): [DATE] at 11:57 PM, Pulse of 58 bpm (beats per minute). [DATE] at 11:57 PM, Pulse of 59 bpm. [DATE] at 6:46 PM, Pulse of 45 bpm. [DATE] at 10:03 PM, Pulse of 50 bpm. [DATE] at 12:54 AM, Pulse of 46 bpm. [DATE] at 7:48 PM, Pulse of 42 bpm. [DATE] at 10:15 PM, Pulse of 37 bpm. [DATE] at 1:22 PM, Pulse of 42 bpm. [DATE] at 2:10 AM, Pulse of 56 bpm. [DATE] at 12:38 AM, Pulse of 54 bpm. [DATE] at 12:38 AM, Pulse of 58 bpm. A review of the progress notes for Resident #52 revealed a lack of assessment, contacting the practitioner and follow-up interventions or monitoring by rechecking the heart rate of the abnormal heart rates obtained. On [DATE] at 9:07 AM, an interview was conducted with the Nurse Practitioner (NP) “O” regarding Resident #52’s care. The NP was asked about abnormal pulse rates and reported that parameters for below 60 on a regular basis and above 90 on a regular basis with abnormal and communicated to the practitioner. When queried regarding assessment of the Resident, the NP indicated that the vitals would be rechecked and if it remained high or low then call the practitioner. The pulses for Resident #52 were reviewed. The NP indicated that at 50 and asymptomatic, need to do assessment to see if asymptomatic or having symptoms, at 37 and 42, if rechecked and stayed low, “I would send her out.” The NP indicated that with the abnormal pulse rate, the nurse would need to recheck, do an assessment and notify the practitioner. On [DATE] at 1:19 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #52’s abnormal pulse readings. Resident #52’s abnormal pulses were reviewed with the DON. When asked about facility policy, the DON reported that vital signs were to be obtained in the morning before medications are administered and in the evening before the medication pass. The DON reported that if the vital signs were out of range, the provider would be contacted. Resident #52’s medical record was reviewed with the DON, and it was determined that the vital signs were documented into the medical record when staff were charting and not necessarily when the vital signs were taken. Resident #52’s documentation lacked timely reassessment of the abnormal results, assessment of the Resident symptomatic or asymptomatic and the notification of the practitioner. Resident #63 (R63): A record review of Resident 63's (R63) medical chart included medical diagnoses: Cellulitis of the left lower limb (infection of the skin), non-pressure chronic ulcer of left lower leg, Urinary tract infection (UTI), Anxiety, Diabetes Mellites 2 (DM2), need for assistance with personal care. R63 was admitted to facility on [DATE] for rehabilitation. On [DATE] at 10: 40 AM, during an observation of R63 is sitting in a wheelchair in room, and reportedly had just returned from physical therapy, is alert and oriented. During an interview R63 said she was supposed to continue antibiotics when she came to the facility from the hospital for rehabilitation. There was a 3-day delay receiving them. When R63 asked the nurse on duty about the antibiotics, she was told it was because it was not on her medication list. On [DATE] at 10:48 AM, An interview with R63, clarified when she was admitted and she confirmed it was [DATE]; she stated, “I did see the facility doctor the day after I got here ([DATE]) and was told he confirmed my orders for the antibiotics, and they were being ordered that day”. R63 stated, “I did not get the antibiotic until Monday night ([DATE]). I was not happy that it took 3 additional days to get the antibiotics, it is important for healing my infection up”. On [DATE] at 11:59 AM, in an interview with director of nursing (DON) about the process for physician rounds and orders, she stated, “Usually myself or the floor nurse follows with the doctor. All new orders are verbal orders and are entered into at the time of the visit. They may or may not end up as a written order”. On [DATE] at 12:28 PM, in an interview with Nurse manager “A”, she was asked about the process for physician rounding and stated, “Doctor (Dr “E”) comes in 2-3 times a week usually in the early morning; Dr “F” and his Nurse practitioner (NP “G”) round 2-3 times weekly as well”. She stated, “They come in and check in with the nurse on the floor and tell them who they plan to see”. When asked about any orders that come from that visit she stated, “If there are new orders, they stop at the desk and tell the nurse before they leave”. The DON was asked when the orders are put in the computer and she stated, “That varies by the nurse but at a minimum by the end of their shift”. On [DATE] at 1:50 PM, an interview was conducted with the Medical Director and admitting doctor Dr “E”, who was asked about frequency and process for rounding. He stated, “I round 2 times a week, the time and day varies depending on the admissions and needs of facility, within 48 hours of admissions is the standard. All the admissions go through me personally” and “I prioritize the order of my visits by admissions, residents with issues noted in my book, and then my scheduled routine visits”. Dr “E” stated, “As far as the process goes, I come into the facility and talk to the nurse on duty. I ask for any updates on the residents I am seeing. I see the residents. If there are any new orders, I discuss them with the nurse on duty, and they enter them. If I am ordering a controlled substance medication, I sign those orders at that time as well”. His response to the expectation of when the ordered medications should be ordered and begin was, “If stock (medications on hand at the facility) then they should start right away and pull from there (the stock on hand), if oral antibiotics are ordered then they should be ordered expedited. the pharmacy delivers 2 times a day so they should get that next dose”. [DATE] at 2:20 PM, in an interview with Assistant Director of Nursing (ADON), she was asked about the process for physician rounding and stated, “the doctor comes in to do rounds and talks to the nurse on duty. If there are orders he tells the nurse. The nurse enters the orders, and a progress note into the system”. The ADON was asked to look at the R63 admission date and she stated, “8/7” and then she was asked the date of the progress note of the physician visit and stated, “8/8”. The ADON was asked to view the order date for the antibiotic, and she stated, “8/11”. She stated, “I put that order in because I had to call the doctor about it”. The ADON was asked, why did you have to call about the order? “Well, the resident asked about her missing antibiotic, so I called the doctor to ask for clarification. We did not realize the antibiotic wasn’t on the discharge med list (medication), so it was not ordered or given. I ordered it, and she got a dose that night”. The ADON was asked to confirm that it was the night of [DATE] and she replied, “Yes”. The ADON was asked if the nurses review the physician progress notes, or the discharge plan for admission to the facility and she stated, “No, we just look at the medication list”. A record review of R63’s discharge paperwork from the hospital, dated [DATE], on the progress note, dated [DATE], in plan section states, “Left lower extremity cellulitis Reports bumping her left leg about 3 days prior to presentation and suddenly noticing worsening erythema (redness) denies any fever or chills wound continues to weep, however surrounding erythema. patient initially on ceftriaxone and Zyvox (both are antibiotics), ceftriaxone discontinued and started on meropenem (antibiotic) continue routine wound care, CT lower extremity … Plan is to discharge on p.o. (per os/ by mouth) Zyvox the next 24 hours”. Review of final discharge summary from the hospital on [DATE], plan states “Left lower extremity cellulitis . Patient has been started on ceftriaxone and Zyvox in the emergency room, and appears to be improving white blood count (WBC) count continues to trend downward… Cat Scan (CT) of lower extremity 8/3 demonstrated extensive subcutaneous edema with cellulitis, no evidence of abscess of the left leg, continued with zyvox (started on 7/31) and meropenem (started on 8/4)…”. The resident was discharged from the hospital on [DATE] with lower left extremity cellulitis and a Urinary tract infection (UTI) and was receiving Zyvox and Meropenem. A record review of R63’s admission progress notes from Physician Dr “E” from [DATE] with a late entry that was written on [DATE], “Antibiotic therapy was initiated for the cellulitis, with infectious disease involvement. The patient is currently continuing with Zyvox… Her left lower extremity still shows some redness…”. A record review of the physician's orders for R63 revealed, “Linezolid Oral Tablet 600 MG (Zyvox) Give 1 tablet by mouth two times a day for Cellulitis, UTI for 10 Days Pharmacy Active [DATE] at 20:00 -stop [DATE]”. According to the facility's medication administration policy, the purpose stated is, “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…”. Change of Condition Resident #65: On [DATE] at 12:15 PM, Confidential Person “J” was interviewed about Resident #65. She said she visited the resident 2 days ([DATE]) after Resident #65 was admitted to the facility on [DATE]. The Confidential Person said the room was hot that day and there was no fan. She said in the hospital the resident was alert, walking with assistance, talking and sitting in a bedside chair. The Confidential Person “J” said she visited the resident again on [DATE] and the facility staff said Resident #65 had not been out of bed and the resident appeared to be declining. A record review of the electronic medical record indicated Resident #65 was admitted to the facility on [DATE] with diagnoses: recent hernia surgery, pain, diarrhea, and COPD/emphysema. A Brief Interview for Mental Status/BIMS score of 15, indicating full cognitive abilities was assessed on [DATE] after admission. A record review of the progress notes identified the following: [DATE] at 12:42 PM, a “Physician Extender” note “History of Present Illness: (Resident #65) a [AGE] year-old female with a history of COPD, was admitted to (the facility) for physical conditioning following hospitalization for an incarcerated right inguinal hernia. The patient initially presented to the hospital with complaints of abdominal pain and was diagnosed with an incarcerated inguinal hernia in the right lower quadrant. On [DATE]th, she underwent a right inguinal hernia repair with mesh and a small bowel resection. During her hospital stay, she developed an ileus, from which she has since recovered. Currently (the resident) is experiencing severe nausea and vomiting… She is alert and oriented with stable vital signs… Ordered stat abdominal x-ray to rule out ileus or obstruction…” A record review of the vital signs for Resident #65 revealed the following: Blood Pressure: Identified low on [DATE] at 11:48 PM- 93/57; high on [DATE] at 12:56 AM 140/100; very low on 7/26//2025 71/51. Pulse: high on [DATE] at 11:42 AM 111 beats/per minute (bpm); [DATE] at 7:53 PM 118 bpm, [DATE] 109 bpm. Temperature: high 99.6 [DATE] and 100.4 [DATE] at 11:42 AM. Respiratory Rate: high on [DATE] at 11:42 AM 24 breaths/min; high [DATE] 26 breaths/min. Oxygen saturation rate: Low [DATE] at 11:42 AM 92% room air; Low [DATE] at 5:10 PM 93% room air; [DATE] at 10:46 AM 91% room air. Pain: “8” high on [DATE] at 2:34 PM. Resident #65 had abnormal vital signs beginning [DATE]. Further review of the progress notes for Resident #65 identified the following: [DATE] at 2:25 PM, a “Health Status Note, “NP (Nurse Practitioner) notified of patient nausea and inability to take the Zofran pill due to it making the nausea worse…” [DATE] at 6:46 PM, a “Health Status Note revealed, “NP (Nurse practitioner) in doing rounds. New orders. STAT Flat plate 2 view of abdomen”. [DATE] at 3:54 AM, a “Health Status Note- X-ray completed at 9:07 PM awaiting results.” [DATE] at 11:27 AM, a “Health Status Note” provided, “Received X-ray results small bowel ileus vs obstruction…” A review of the STAT X-ray ordered for Resident #65 identified the order did not indicate it was to be completed STAT. The “Radiology Results Report” indicated the examination date was [DATE] at 4:20 PM and the results were reported to the facility on [DATE] at 6:40 PM. This was approximately 24 hours after the orders for the STAT X-ray were mentioned. The STAT (immediately) X-ray was ordered on [DATE] at 6:46 PM, per the progress notes. The results were documented in the medical record on [DATE] at 11:27 AM. This was greater than 1 ½ days later and Resident #65 continued to complain of abdominal pain, nausea and vomiting. An additional progress note for Resident #65 dated [DATE] at 1:25 PM provided, “Health Status Note, patient c/o (complains of) abdominal pain and nausea, stated has vomited bile. Requesting to go to the hospital… order received to send to hospital…” On [DATE] at 3:47 PM, the Director of Nursing/DON was interviewed about Resident #65. Reviewed with the DON, that the resident had repeatedly complained of increasing abdominal pain. Reviewed the resident’s vital signs with very low blood pressure, high pulse, increased respiratory rate, decreased oxygen saturation. The nurses did not document they were aware of the abnormal vital signs or what interventions were enacted. Reviewed the order documenting that a STAT abdominal X-ray was to be completed ([DATE]). The X-ray was completed on [DATE] at 4:20 PM and reported to the facility on [DATE] at 6:40 PM and reviewed in a progress note on [DATE] at 11:27 AM. The X-ray was not completed STAT (immediately) and the resident’s abnormal vital signs were not reviewed in the assessments or notes. Resident #65’s condition continued to decline, and she was transferred to the hospital emergency room on [DATE] at approximately 1:25 PM. The DON reviewed the resident’s medical record and identified the date [DATE] at 4:20 PM that the X-ray was completed for Resident #65. She also reviewed the time the results were provided to the facility ([DATE] at 6:40 PM). She said the results were sent to the facility on a fax and she was not sure when the nurses would have received them. Reviewed the resident’s condition was declining and the X-ray results were not mentioned in the progress notes until the next day [DATE] and then the resident was transferred to the hospital. A review of the facility policy titled, “Change of Condition,” review date [DATE] provided, “Policy: It is the policy of (the facility) to enable staff to evaluate and manage residents at the facility and avoid transfer to a hospital or emergency room by recognizing an Acute Change of Condition and identifying its nature, severity, and causes… An acute change of condition is defined as a sudden, clinically important deviation from a patient’s baseline in physical, cognitive, behavioral, or functional domains… The licensed nurse completes an assessment of the resident and based on the findings notifies the physician of any change of condition… Continued monitoring and assessment of the resident is documented in the resident’s clinical record.”

Based on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than 5% when nine (9) medication errors were observed from a total of 25 opportunities for three residents (Resident #1, Resident #29 and Resident # 57) of five (5) residents observed for medication administration, resulting in an error rate of 36.0%. Findings Include: On 8/13/25 at 7:45 AM, Registered Nurse K was observed administering the medication at the [NAME] End Nurse's Station.RN 'K' gave R57 the Chewable Aspirin (ASA) tablet, which was placed with three other oral medications in one medicine cup. R# was observed taking all her medications whole at once and swallowing them after a small cup of water. Resident #57 (R57) A review of R57 Face Sheet revealed R57 was admitted at the facility on 8/9/ 25 with the following diagnoses: Osteoporosis, Venous insufficiency, and pathological Fracture in addition to other diagnoses.On 08/13/2025 at 7:45 AM, RN K was observed preparing R57's morning medication. The following medications were:Chewable Aspirin (ASA) MultivitaminsSpironolactone Vit. COral ASA Chewable tablet was mixed with other medications and taken orally without being separated, distinguishing it as a chewable tablet.The Metamucil powder was mixed with water and administered with the four (4) oral medications in a small medication cup. Resident #1(R1) R1, according to the facility face sheet, was [AGE] years old and admitted to the facility on [DATE] with the diagnosis of Chronic Systolic Congestive Heart Failure, Acute Respiratory Failure with Hypoxia, Lobar Pneumonia, Essential Hypertension, and History of Transient Ischemic Attack (TIA) and Cerebral Infarction, in addition to other diagnoses.A medication administration (Med Pass) observation was conducted on 08/13/2025 at 7:50 AM. RN K was observed administering eight oral medications and one inhaler puff to R1. The following eight (8) medications were due at 8:00 AM:Glimepiride (Amaryl) 2mg 1 tabHydrochlorothiazide (Hydrodiuril) 1tab 25 mglosartan tab (Cozaar) 100 mgNifedipine ER (Procardia) Tab 90 mgAspirin chew tab 81 mgCitalopram (Celexa) tab 40 mgClopidogrel (Plavix) 75 mgFerrous Sulfate FC tab 325 It was observed that the chewable Aspirin (ASA) was mixed and given along with the rest of the oral medication, placed in a single med cup. R1 took all eight (8) oral pills, including the Aspirin, and swallowed them all at once. The chewable Aspirin was not chewed as the doctor ordered. Resident #29 (R29) R29 was [AGE] years old initially admitted on [DATE] with the diagnosis of Type 2 Diabetes Mellitus with foot ulcer, Other Cerebral Infarction due to occlusion or stenosis of small artery, atherosclerotic heart disease of Native Coronary Artery Without Angina Pectoris, and Essential Hypertension in addition to other diagnoses. R29, during Medication Administration, was in the hallway of the [NAME] Wing Nursing Station when he asked if his meds would be given after his therapy so he wouldn't be tired during the therapy session. RN K said okay and went on to the following resident. The following seven (7) medications were held without notifying the Provider MD:R29 Bag 1 contained:Acidophilus Cap 500 mg (Probiotic) in addition to other diagnoses.Aspirin EC Tab 81 mg 1 tab (minor aches and pains)Carvedilol (Coreg)Tab 3.125 mg (Alpha and beta-blocker to treat serious heart and blood vessel conditions)Clopidogrel (Plavix) Tab 75 mg (antiplatelet conditions to prevent blood clot formation)R29 Bag 2 contained:Entresto Tab 24/26 mg (Use to treat chronic heart failure)Jardiance 1 tab (Type 2 diabetes treatment)Vitamin D3 Cap 5000U (1225 MCG) X 2 capsules (for bones and calcium absorption) On 8/13/25 at 10:45 AM. A follow-up with the RN K revealed that she had administered R29's pills at around 10:30 AM. She admitted it was a late med pass. RN K was asked if the doctor was informed about the late medication, and RN K said No. Later in the afternoon on 8/13/25 at 3:00 PM, RN K was asked if she had notified the doctor or had noted the late medication administration in R29's clinical record. She said, I did not have time to do that yet, but I will definitely inform the physician about the Resident's 8:00 AM medication.The nurse held seven (7) medications without a physician's notification of the delay. The nurse did not explain the consequences if the due medications are held to the resident (R29). R29's seven (7) oral medications were reviewed, including heart medications and blood thinners, scheduled at 8:00 AM. The surveyor was informed that all medications due at 8:00 AM were given by RN K at approximately 10:30 AM. The delay in medication observation was discussed with RN K, who administered medication late on 8/13/25 at 10:30 PM. The DON and Administrator were notified at 3:30 PM, thereafter, regarding the error.Upon data entry, the medication error was 36% over 25 observations. On 8/14/25 at 9:20 AM, policies were asked regarding medication administration and the PICC line care policy, which is to administer Antibiotics and flush after . In addition to a 36% Medication Error that was established on 8/13/25 at 10:30 AM, another late medication administration incident was observed in the [NAME] Wing Nursing Station the following morning on 8/14/25 at 10:30 AM. On 08/14/2025 at 10:23 AM, Nurse L, The Medcart's computer screen had a lot of reds colored boxes. When Nurse L was asked what the red shaded boxes mean, she revealed that It means the medication is 'overdue. Nurse L explained that R58's medication was not available from the Pharmacy and that she was running behind with passing R58's 8:00 AM medications. Nurse L furthermore stated, We have 22 Residents with just one nurse administering all their meds due to. Resident #58 (R58) According to a Review of R58 Face Sheet, R58 was admitted from a nearby hospital to the facility on 8/11/25, with the following diagnoses: Acute Renal Failure, Urinary Tract Infection (UTI), Metabolic Encephalopathy, Paroxysmal Atrial Fibrillation, Essential Hypertension, Gastro-esophageal Reflux Disease (GERD), and Atherosclerotic Heart Disease in addition to other diagnoses.Seven (7) medications were shown in red on the computer screen, which said they were due by 8:00 AM, but were administered at 10:23 AM on 8/14/25. Nurse L denied calling the doctor for the late administration of R58, scheduled morning medication.Upon review of R58's list of noted medications, the following significant medications were delayed:Eliquis (Apixaban)Oral Tablet 2.5 mg was ordered to be given one tablet twice daily. Eliquis is an anticoagulant (blood thinner) used to prevent and treat dangerous blood clots.Coreg (Carvedilol)Oral Tablet 3.125 mg was ordered, one tablet twice daily. Coreg is an Alpha and Beta-blocker used to treat serious heart and blood vessel conditions. The facility's policies for Medication Pass Guidelines and Medication Error were requested and reviewed. Medication Pass Guidelines with a revised date of September 2023 indicated the following: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: Medications are administered in accordance with orders of the attending physician.Procedure:.5. Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. The Policy for Medication Errors, with the release date of February 2023, was reviewed on 8/14/25 at 3:30 PM. It indicated,Policy:It is the policy of this facility to provide protections for the health, welfare, and rights of each Resident by ensuring residents receive care and services safely in an environment free of significant medication errors.Policy Explanation and Compliance Guidelines:The facility shall ensure that medications will be administered as follows:According to the physician's orders.Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines:Resident's condition.Drug category.Frequency of Error: If an error is occurring repeatedly, such as an omission of a resident's medication several times.

Based on observation, interview and record review, the facility failed to ensure the appropriate backflow prevention was installed on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to a backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility. Findings include: On 08/12/2025 at approximately 9:30AM observed a hose with an attached spray nozzle connected to the water line downstream of an atmospheric vacuum breaker (AVB) located in the kitchen near the dishwasher. On 08/12/2025 at approximately 1:30PM during the environmental tour of the facility, an interview was conducted with the Director of Maintenance I on the cross connection related to the attached spray nozzle in the kitchen. The Director of Maintenance I was knowledgeable about the cross connection and removed the hose with the attached spray nozzle. On 08/12/2025 at approximately 1:45 PM observed chemical feed dispenser supplied by the utility sink with an atmospheric vacuum breaker without an attached wasting tee, located in the janitor's closet in the basement, [NAME] hallway, and Morning [NAME] hallway. When interviewed about the cross connection, the Director of Maintenance I was unfamiliar with wasting [NAME] (or bleeder device). According to the 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve). According to the 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.

Based on observation, interview, and record review, the facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice and ensure medication refrigerator temperatures outside of acceptable parameters were addressed, resulting in the potential for contamination of medications, a lack of therapeutic benefits necessary to promote healing for residents, increased potential for adverse effects. Findings include:On 8/14/25, starting at 8:20 AM, two medication carts were checked and observed, and the narcotics were reconciled. Two medication rooms were inspected, which included the refrigerator that holds the medication requiring refrigeration per the manufacturer's recommendation, such as reconstituted IV solution, insulin, vaccinations, and suppositories.During Medication Storage inspection, Nurse L on 8/14/25 10:45 AM opened the refrigerator in the [NAME] Wing Medication Room, and the inside thermometer read 50 degrees Fahrenheit. Although Nurse L argued that it was 48 degrees a second ago, she reread and agreed it held at 50 degrees. When Nurse L was asked what temperature the refrigerator in the med room should be maintained at? Nurse L replied, 48 degrees. The refrigerator appeared to have been thawing with obvious water accumulation on the bottom drawer from the condensation. The contents of the refrigerator were as follows: Two (2) large plastic bags containing a total of 9 (Meropenem) Intravenous (IV) Solution Reconstitution 2GM antibiotic bulbs. Staff counted nine (9) bulbs specially prepared for a resident needing antibiotics bolus infusion through an IV Peripherally Inserted Central Catheter (PICC) Line. Other medications found in the refrigerator were: insulin (Lantus, Lispro & Humalog) pens assigned to various residents in the [NAME] Wing, Engerix-B vaccine, and packs of suppositories labeled as Bisacodyl and Acetaminophen.The bottom drawer holding the insulin pens and suppositories had water in the drawer bin. The base of the refrigerator was wet, and the floor had a water leak. The two (2) boxes of suppositories were soaked in clear fluid. According to the Centers for Disease Control and Prevention CDC (August 10.2024) https://www.cdc.govEngerix-B storage guidelines:Approved use: The Engerix-B vaccine is used to prevent hepatitis B in both children and adults.Storage Temperature: The vaccine must be stored in a refrigerator that maintains temperatures between 36 degrees Fahrenheit (2 degrees Celsius and 8 degrees Celsius.Handling: You should not freeze the vaccine or expose it to freezing temperatures, as this can destroy its potency.Monitoring: The Centers for Disease Control and Prevention (CDC) recommends continuous temperature monitoring using a digital data logger (DDL).If out of range: If the temperature falls outside the recommended range, the vaccine should be marked Do Not Use and isolated from other vaccines until further guidance from the manufacturer or health department is received.Temperature: Refrigerator Temp. Store between 2 degrees Celsius and 8 degrees Celsius, 36 degrees Fahrenheit and 46 degrees Fahrenheit.Monitoring refrigerator temperature for vaccines is critical to ensure their safety and effectiveness .The Director of Nursing was made aware on 8/14/25 at 10:40 AM and stated, there were no reports of temperature not within range received. All contents will be thrown out. We don't know how long the refrigerator was down. On 8/14/2025 at 10:46 AM, the Maintenance Director was in the Med Storage room and stated, The refrigerator broke. It does not work. He did not receive any complaint or report regarding the refrigerator all day. He assured the surveyor that the fridge would be replaced.Facility Policy was reviewed, entitled: Medication Room Refrigerators Policy (Revision Date: August 2023)Policy: It is the Policy of (Facility Name) to comply with the CDC recommendation for the storage of medications. Medications will be stored in an appropriate refrigerator. Refrigerators in each medication room will have a temperature reading and be recorded twice daily. Temperature will be maintained at 36 to 46 degrees.

Based on interview and record review, the facility failed to ensure Code Status was accurately assessed, documented and accessible in the medical record and plan of care for 4 residents (#9, #27, #28, #45 ) , resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Resident #27 (R27) A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated R27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Unspecified Dementia, severe with other behavioral disturbance, Delusional Disorders, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Obstructive and Reflux Uropathy in addition to other diagnoses. A review of R27's assessment for Code status preferences titled, Advance Care Planning Form, revealed No was checked for Cardiopulmonary Resuscitation (CPR). Yes was marked for Artificial Nutrition (tube feedings), Yes to Artificial Hydration (IV, Hypodermoclysis) and Diagnostic Testing (Lab, X-rays, Imaging), and Yes for Infection Control Outbreak Testing (Covid-19, Influenza Testing, etc.). R27 signed the document on [DATE]. A review of the electronic medical record for R27 identified DNR (Do not resuscitate) on the resident's Face sheet (main page). There was no mention of the specific choices the resident had chosen on the Advance Care Planning Form. On [DATE] at 4:00 PM, a review of the Medical Incapacity determination form entitled MEDICAL revealed R27 is unable to participate in decisions regarding medical or mental health treatment. Signed by R27's Primary Physician on [DATE] and a Licensed Physician/Psychologist on [DATE]. A review of the physician's DO-NOT-RESUSCITATE (DNR) orders for R27 identified the following: DNR: no directions specified, signed by R27 on [DATE]. There was no mention of the specific choices the resident had chosen on the Advance Care Planning Form. Section B. Resident Advocate (MDPOA) Consent was left blank. The DNR order form was not up to date with R27's current status. No signature by the Medical Durable Power of Attorney was obtained in R27's DNR Order Form. A review of the Care Plans for R27 revealed that there was no mention of R27's Code status preferences in the care. The Social Worker (SW H) was interviewed on [DATE] at 4:36 PM, and revealed: The SW H indicated that All DNR Status did not have a care plan in place because it does not say so in the policy. There is an MD (Physician) Order, and the DNR Form is uploaded in the chart. We do not Care Plan the DNR status. SW H stated that both the MD and the Psychologist deemed the resident medically and mentally incapacitated in [DATE]. When asked about the date the Psychologist had signed the form, the SW insisted it was July, although the date written was [DATE]. The SW H further stated it appears to be a 9 (referring to September), but that's how he writes a 7. SW H indicated she had reached out to the DPOA regarding the Activation of the DPOA and DNR Forms, but with no success. When asked if she had entered the notes reflecting those changes and attempts to reach the DPOA, she said yes. A review of the SW Notes on [DATE] at 3:00 PM (before the SW interview) revealed that there was no mention of DNR and obtaining a signature from the DPOA in the R27's record from June to [DATE] Progress Notes. The following day, on [DATE], the surveyor reviewed the progress notes and apparently noted that three (3) late entries were added in R27's progress notes. LATE ENTRY: was entered on [DATE] for [DATE] e-signed by the SW. LATE ENTRY: was entered on [DATE] for [DATE] e-signed by the SW. LATE ENTRY: was entered on [DATE], time 16:49 (4:49) for [DATE] e-signed by the SW These LATE ENTRY notes were compared to the previously reviewed progress notes and were entered after the SW interview was conducted on [DATE], after 4:30 PM. Policy The facility's Policy and Procedure of Advance Directive, revised on 02/2024, revealed: 1. Identity. Upon Admission, the facility will determine whether the resident has executed advance directives (e.g., a living will and/or Patient Advocate Designation). Each Resident DPOA will then complete the Advance Care Planning form. If the resident is unable to complete the Advance Care Planning Form, and has no activated DPOA, they will remain a full-code. 1b. DNR-Patient Advocate. The patient advocate may sign the DNR form for the resident as long as the Patient Advocate Designation grants them the authority to request DNR status. The same procedure applies for completing the DO-NOT RESUSCITATE ORDER form and obtaining a verbal order for the DNR status as above. 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 resident's attending physician and another physician or a licensed psychologist, that the individual does not have the capacity to make health care decisions. 8. Periodically Re-evaluate. The resident's code status will be reviewed with the resident and/or representative at least quarterly and documented in the medical record. In the event that the resident and/or representative did not attend the care conference, they will be contacted either by telephone or mail to review the resident's treatment choices. The resident may change treatment choices at any time. The resident's physician will be notified as appropriate, and the resident's plan of care will be revised accordingly. Advance Directives Resident #9 A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated Resident #9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: history of a stroke, right sided weakness, schizophrenia, dementia, depression, and heart disease. The MDS assessment dated [DATE], revealed the resident had severe memory loss. Resident #9 was receiving Hospice services. A review of Resident #9's assessment for Code status preferences titled, Advance Care Planning Form, revealed No was checked for Cardiopulmonary Resuscitation and Artificial Nutrition (tube feedings) and Yes to Artificial Hydration (IV, Hypodermoclysis) and Diagnostic Testing (Lab, X-rays, Imaging). The document was signed by the resident's Guardian on [DATE]. A review of the electronic medical record identified DNR (Do not resuscitate) on the resident's Face sheet (main page). There was no mention of the specific choices the resident had chosen on the Advance Care Planning Form. A review of the physician orders for Resident #9 identified the following: DNR: no directions specified dated [DATE]. There was no mention of the specific choices the resident had chosen on the Advance Care Planning Form. A review of the Care Plans for Resident #9 revealed there was no mention of Resident #9's Code status preferences. Resident #28 A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated Resident #28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, anxiety, COPD, diabetes, depression, Bipolar disorder, hypothyroidism, heart disease, GERD and gout. A review of Resident #28's assessment for Code status preferences titled, Advance Care Planning Form, revealed No was checked for Cardiopulmonary Resuscitation and Artificial Nutrition (tube feedings) and Yes to Artificial Hydration (IV, Hypodermoclysis) and Diagnostic Testing (Lab, X-rays, Imaging). The document was signed by the resident's Guardian on [DATE]. The physician order for DNR was written prior to the Guardian signing the Advance Care Planning Form. A review of the electronic medical record for Resident #28 identified DNR (Do not resuscitate) on the resident's Face sheet (main page). There was no mention of the specific choices the resident had chosen on the Advance Care Planning Form. A review of the physician orders for Resident #28 identified the following: DNR: no directions specified dated [DATE]. There was no mention of the specific choices the resident had chosen on the Advance Care Planning Form. A review of the Care Plans for Resident #28 revealed there was no mention of Resident #28's Code status preferences. Resident #45 A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated Resident #45 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, End stage kidney disease, dependence on renal dialysis, depression, heart disease, anxiety, COPD, claustrophobia and history of a stroke. A review of Resident #45's assessment for Code status preferences titled, Advance Care Planning Form, revealed No was checked for Cardiopulmonary Resuscitation and Artificial Nutrition (tube feedings) and Yes to Artificial Hydration (IV, Hypodermoclysis) and Diagnostic Testing (Lab, X-rays, Imaging). The document was signed by Resident #45 on [DATE]. A review of the electronic medical record for Resident #45 identified DNR (Do not resuscitate) on the resident's Face sheet (main page). There was no mention of the specific choices the resident had chosen on the Advance Care Planning Form. A review of the physician orders for Resident #45 identified the following: DNR: no directions specified., dated [DATE]. There was no mention of the specific choices the resident had chosen on the Advance Care Planning Form. A review of the Care Plans for Resident #45 revealed there was no mention of Resident #45's Code status preferences. On [DATE] at 3:18 PM, Social Worker H was interviewed about the residents' Code Status. She said the nurse looked at the Code status form and obtained a physician's order for DNR. She said DNR was also placed on the resident's Face sheet in the electronic medical record. Reviewed with the Social Worker H that DNR did not identify each of the resident's specific wishes/choices. She said the nurse would need to look in the electronic chart at the assessment document. The Social Worker was asked how the staff would have time to do that during an emergency. The Social Worker said there was a binder at the desk, and they could look it up there, as she placed the information in the binder. The Social Worker was asked if the resident's specific information was identified in the resident's Care plans and she said it was not on the care plans.

Based on observation, interview and record review the facility failed to prevent significant medication errors for two (2) resident (Resident #29 and Resident #58) of five (5) residents reviewed for medication errors resulting in potential for serious adverse effects for delayed medication without physician notification of the delay in medication as prescribed and potential for decline or worsening of medical condition.FacilityBased on observation, interview and record review the facility failed to prevent significant medication errors for two (2) resident (Resident #29 and Resident #58) of five (5) residents reviewed for medication errors resulting in potential for serious adverse effects for delayed medication without physician notification of the delay in medication as prescribed and potential for decline or worsening of medical condition. Findings include:Resident #29 (R29) R29 was [AGE] years old initially admitted on [DATE] with the diagnosis of Type 2 Diabetes Mellitus with foot ulcer, Other Cerebral Infarction due to occlusion or stenosis of small artery, atherosclerotic heart disease of Native Coronary Artery Without Angina Pectoris, and Essential Hypertension in addition to other diagnoses. R29, during Medication Administration, was in the hallway of the [NAME] Wing Nursing Station when he asked if his meds would be given after his therapy so he wouldn't be tired during the therapy session. RN K said okay and went on to the following resident. The following seven (7) medications were held without notifying the Provider MD:R29 Bag 1 contained:Acidophilus Cap 500 mg (Probiotic) in addition to other diagnoses.Aspirin EC Tab 81 mg 1 tab (minor aches and pains)Carvedilol (Coreg)Tab 3.125 mg (Alpha and beta-blocker to treat serious heart and blood vessel conditions)Clopidogrel (Plavix) Tab 75 mg (antiplatelet conditions to prevent blood clot formation)R29 Bag 2 contained:Entresto Tab 24/26 mg (Use to treat chronic heart failure)Jardiance 1 tab (Type 2 diabetes treatment)Vitamin D3 Cap 5000U (1225 MCG) X 2 capsules (for bones and calcium absorption) On 8/13/25 at 10:45 AM. A follow-up with the RN K revealed that she had administered R29's pills at around 10:30 AM. She admitted it was a late med pass. RN K was asked if the doctor was informed about the late medication, and RN K said No. Later in the afternoon on 8/13/25 at 3:00 PM, RN K was asked if she had notified the doctor or had noted the late medication administration in R29's clinical record. She said, I did not have time to do that yet, but I will definitely inform the physician about the Resident's 8:00 AM medication.The nurse held seven (7) medications without a physician's notification of the delay. The nurse did not explain the consequences if the due medications are held to the resident (R29). R29's seven (7) oral medications were reviewed, including heart medications and blood thinners, scheduled at 8:00 AM. The surveyor was informed that all medications due at 8:00 AM were given by RN K at approximately 10:30 AM. The delay in medication observation was discussed with RN K, who administered medication late on 8/13/25 at 10:30 PM. The DON and Administrator were notified at 3:30 PM, thereafter, regarding the error.Upon data entry, the medication error calculation was 36% over 25 observations. On 8/14/25 at 9:20 AM, policies were asked regarding medication administration and the PICC line care policy, which is to administer Antibiotics and flush after . In addition to a 36% Medication Error that was established on 8/13/25 at 10:30 AM, another late medication administration incident was observed in the [NAME] Wing Nursing Station the following morning on 8/14/25 at 10:30 AM. On 08/14/2025 at 10:23 AM, Nurse L, The [NAME] Wing's Medication cart computer screen had a lot of reds colored boxes. When Nurse L was asked what the red shaded boxes mean, she revealed that It means the medication is 'overdue. Nurse L explained that R58's medication was not available from the Pharmacy and that she was running behind with passing R58's 8:00 AM medications. Nurse L furthermore stated, We have 22 Residents with just one nurse administering all their meds due to. Resident #58 (R58) According to a Review of R58 Face Sheet, R58 was admitted from a nearby hospital to the facility on 8/11/25, with the following diagnoses: Acute Renal Failure, Urinary Tract Infection (UTI), Metabolic Encephalopathy, Paroxysmal Atrial Fibrillation, Essential Hypertension, Gastro-esophageal Reflux Disease (GERD), and Atherosclerotic Heart Disease in addition to other diagnoses.Seven (7) medications were shown in red on the computer screen, which said they were due by 8:00 AM, but were administered at 10:23 AM on 8/14/25. Nurse L denied calling the doctor for the late administration of R58, scheduled morning medication.Upon review of R58's list of noted medications, the following significant medications were delayed:Eliquis (Apixaban)Oral Tablet 2.5 mg was ordered to be given one tablet twice daily. Eliquis is an anticoagulant (blood thinner) used to prevent and treat dangerous blood clots.Coreg (Carvedilol)Oral Tablet 3.125 mg was ordered, one tablet twice daily. Coreg is an Alpha and Beta-blocker used to treat serious heart and blood vessel conditions. The facility's policies for Medication Pass Guidelines and Medication Error were requested and reviewed. Medication Pass Guidelines with a revised date of September 2023 indicated the following: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: Medications are administered in accordance with orders of the attending physician.Procedure:.5. Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. The Policy for Medication Errors, with the release date of February 2023, was reviewed on 8/14/25 at 3:30 PM. It indicated,Policy:It is the policy of this facility to provide protections for the health, welfare, and rights of each Resident by ensuring residents receive care and services safely in an environment free of significant medication errors.Policy Explanation and Compliance Guidelines:The facility shall ensure that medications will be administered as follows:According to the physician's orders.Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines:Resident's condition.Drug category.Frequency of Error: If an error is occurring repeatedly, such as an omission of a resident's medication several times.

Based on observation, interview and record review, the facility failed to provide necessary management and care of an indwelling urinary catheter drainage bag to ensure it was not sitting on the floor for 1 resident (#62), resulting in the potential for complications including infection, obstruction of urine and a decline in condition. Urinary Catheter Resident #62 On 8/12/2025 at 11:41 AM, Resident #62 was observed lying in bed sleeping. His bed was in a very low position and the urinary catheter bag was in a white cloth bag on the floor; it was not hanging freely to drain and was pushed against the floor. A record review of the Face sheet and electronic medical record indicated Resident #62 was admitted to the facility on [DATE] with diagnoses: Parkinson's disease, stage 4 sacral pressure ulcer, osteomyelitis of vertebra, sacral and coccygeal region, neuromuscular dysfunction of the bladder, right lower leg contracture, diarrhea, and aphasia. The resident was receiving Hospice services. On 8/13/2025 at 10:35 AM, Resident #62's urinary catheter bag was observed on the floor in a cloth bag. A review of the physician orders for Resident #62 identified the following: Catheter care q (every) shift and PRN (as needed). Apply strap to secure placement of catheter tubing and ensure dignity bag is placed on drainage bag, date revised and started 8/8/2025. There was no mention of the urinary catheter bag was not touching the floor to ensure unobstructed urine flow and prevent potential contamination. According to the Centers for Disease Control and Prevention/CDC: Indwelling Urinary Catheter Insertion and Maintenance: . Maintain Unobstructed Urine Flow: Maintain the bag below the level of the bladder. Keep the urine bag off the floor. A review of the Care Plans for Resident #62 identified the following: I have 16fr 30cc indwelling Foley Catheter: Neuromuscular dysfunction of bladder, date initiated 8/8/2025 and revised 8/11/2025. A review of the interventions indicated there was no mention of keeping the catheter bag off the floor. On 8/14/2025 at 1:10 PM, Resident #62 was observed lying in bed, awake. The resident's urinary catheter bag was sitting on the floor with no dignity bag. The urine in the tubing was very dark and the room had a very strong odor. The Infection Prevention and Control Nurse/IPC AA was present during the observation and reviewed with her the urinary catheter bag was on the floor each day of the survey: 8/12/25, 8/13/25, 8/14/25. The IPC Nurse said the urinary catheter bag should not have been on the floor and she would talk to the staff. A review of the facility policy titled, Indwelling Catheter Care, dated revised October 2017 provided, Policy: Routine catheter care helps prevent infections and other complications and is usually performed daily. Inspect the catheter and tubing periodically to detect compression or kinking that could obstruct urine flow. 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 provide adequate supervision and safely assist residents to prevent falls with injury for one resident (Resident #7) of four residents reviewed for accidents with falls, resulting in R7 falling from their wheelchair, requiring a hospital emergency room visit with laceration repairs.Findings include: Resident #7 (R7):Record review of Resident 7's (R7) quarterly Minimum Data Set /MDS revealed Brief Interview of Mental Status (BIMS) of 99, defined as severely cognitively impaired never/rarely made decisions. R7 was assessed as dependent in all activities of daily living (ADL) and transfers. Medical diagnoses included: End Stage Renal Disease, Cardiac Defibrillator, Anxiety Disorder, Major Depressive Disorder, Dementia with Behavioral Disturbance. R7 was in long term care/LTC at the facility and was admitted to their hospice care on 7/23/2025.On 8/12/2025 at 2:50 PM, an observation was made of R7 who was in the hallway by the west hall nursing station and sitting in a Geri chair (a large reclining mobile chair) that was in a slightly reclined position with his feet up on footrest. He is yelling out give me 2 of them and I want to go as staff and visitors pass through the area. On 8/13/2025 at 8:10 AM, R7 was observed in his room. He was resting quietly with his eyes closed and sitting in a Geri chair that is in a reclined position, his feet up on the footrest. Soft touch call light was sitting on the bed out of reach.A record review of the video clip from the facility's cameras on 7/12/2025 was timestamped starting at 2:08:04. This was time prior to and just after the recording of R7's fall. The following is a summary of the videos review: Nurse on Duty LPN D was standing behind the nursing station on the west hall at the desk. CNA C was sitting in a chair to the right back side of the nursing station; she is looking down at a cell phone and appears to be reading/scrolling through its contents. CNA C has a water bottle with her and is seen drinking from it while continuing to look at the phone. LPN D is seen leaving the desk area and proceeded to walk down west hall toward residents' rooms. At this point in the video, R7 can be seen using his feet to propel himself in the wheelchair and he was heading from the area in the back right section of the nursing station going toward west hall resident rooms. As the video continues, CNA C is seen sitting in the same chair and did not look up from the cell phone. R7 continued to propel himself and was heading towards another resident that was resting in a Geri chair by the front right area of the west hall nursing station. In the video, R7 collided into a resident that appeared to be there sleeping in a Geri chair. R7 kept going forward in his wheelchair and hit the other Geri chair 3-4 times. At this point the video showed that CNA C gets up from their chair, walked over to R7's wheelchair and grabbed the handles. The CNA did a 3-point turn (diagonally, back and forth) appearing to try and turn R7 around. They were in a small area on the right side of the west hall nurses' station. She pulled back to turn the resident for the third time and R7's feet appeared to become tucked under the front of the wheelchair and in the last forward motion of the turning lunged the resident forward out of his wheelchair. R7 did not make any attempt to stop/brace or protect himself and he fell forward to the floor; face first on the front/left side of his body, where he continued to stay for the remainder of the video.During R7's fall, CNA C could be seen with a delayed partial reach toward the resident but R7 was already too far forward in the forward motion to assist. After witnessing R7's fall to the ground, the CNA C did not motion toward R7 to render care directly, she looked at him, walked back toward the west hall and looked down the hall. She grabbed a vital signs machine (monitor for heat rate, blood pressure, temperature and oxygen saturation) and walked in the direction of R7 as LPN D came back into the video frame walking from down the west hall and returned to the nursing station desk. After LPN D saw CNA C, she hurried over to R7 who was laying in the same position as when he originally fell, the video clip ends. (there was no audio to this footage)A record review of the facility reported incident (FRI) and the investigation report provided by the facility indicated CNA C s written statement in the 5-day report to be, CNA C was pushing R7 back to his room. R7 leaned forward and fell at the wheelchair hitting his head on floor and that LPN D's verbal statement was indicated to be, I was giving meds to another resident. When I was returning from doing that the Agency CNA (CNA C) asked me to come around to the nurse's station. I came around the corner to find R7 on the floor face first. I asked her what happened, she said he fell forward out of the wheelchair. I immediately called the other nurse to come and help and called for an ambulance. The agency CNA C said, he was self-propelling, and I assisted him in re-directing him away from the other resident sitting at the nurse's station. LPN D's statement further exclaimed, I did not witness the fall. and I observed he did not have his foot pedals on and although the Agency CNA (CNA C) indicated he was self-propelling I provided verbal education to her on foot pedal use. As for myself, I do not know what happened. I believed this to be an accident.On 8/13/25 at 11:50 AM, A call was placed to CNA C. The message received was, (Cellular provider) wireless is no longer able to connect the calls to this number. On 8/13/25 at 12:04 PM, During a follow up interview with the Administrator, she was asked about how staff received education and in-services, and she stated, The staff does quarterly education in a (computer-based education program). She was asked how the facility verified that agency staff had received educational trainings and reviewed policies and procedures, she responded We have a contract with the agencies, it ensures that the onboarding process has been done, it is a mini orientation to the facility policy and procedures and education requirements. I preview those files; I do not hold those employee files here they are kept with their agencies. The administrator stated, Unfortunately that the staffing agency CNA C worked for went out of business on July 27th. Requested the Administrator to provide any contract, education, orientation documents for this CNA and agency into (an electronic document storing system).On 8/14/2025 at 11:00 AM, during an interview the Director of Nursing/DON was asked if she had any reported issues about CNA C and she stated, This was the first and only time she worked here at this facility. She was asked about if and how the facilities policy and procedures, and education requirements are applied to the agency staff, she stated All facility policy & procedures and education requirements apply to the agency staff, they have been completed at the agency and agreed upon in the signed contracts with the agency.On 08/14/2025 at ~12:30 PM observation was made of R7 in his room, he is sitting in his wheelchair eyes closed, there is a meal tray attached to the front of the chair, and it is holding a partially covered uneaten plate of food.On 8/14 at 1:00 PM, according to the interview with LPN D nurse in charge of west hall on 7/12/2025 prior to R63 fall that early morning, I was at the nurse's station and left to go pass a medication to a resident down the west hall, when I walked away the resident was still sitting up by the desk. Asked LPN D why R7 was at the desk instead of bed at 2 am and she stated, because he was having some behaviors that evening, like he does often. She continued I came back down the hall, and the agency CNA (CNA C) was standing in the hall opening at the desk and she told me he (R7) just leaned forward and fell. LPN D further explained that she walked around the desk to see what was going on and R7 was laying on the floor and she could see that he needed assistance, I started to assess the resident (R7) and called for help from the other nurse, I also called for the ambulance. She states, that when she was assessing R7 she, noticed the wheelchair foot petals were attached but not in use, they were off to the side and I did say to her later that we need to use foot pedals when transporting a person in a wheelchair. Asked LPN D if CNA C offered to or assisted with resident after the fall and she said, No, and that is why I called for additional assistance. Asked LPN D had she ever worked with CNA C before? she replied, No, she was an agency CNA and this was her first time working here, I did not know her prior to that shift. Asked LPN D, Did you observe CNA C eating, drinking or on any personal devices other than on her break? She replied, I believe she was on her phone at some point, but I can't be sure. She stated, she was surprised but felt that CNA C was very nonchalant and showed a lack of empathy after R7's fall, as if she was unaffected. A record review of R7's chart revealed he had fallen from his wheelchair on 7/12/2025 and again on 8/6/2025. After both occurrences R7 was sent out to the emergency department and received closure with staples and sutures for lacerations obtained during those falls. The hospital notes from 7/12/2025 indicated, Pt arrives from (the facility) for a fall out of a wheelchair. The hospital notes from 8/6/2025 indicated, ER for a fall . Per EMS, the patient threw himself out of his wheelchair which apparently is not an uncommon occurrence for him .A record review of R7's care plan indicates areas of focus as, I have a risk for falling r/t Weakness, difficulty walking, Interventions: As much as possible, based on my habits, help me anticipate and meet my needs; For my safety, I require anti roll back brakes on my wheelchair; and For my safety, I require anti tippers on my wheelchair. A record review of R7's progress note from 7/11/25 at 15:38 PM, Patient was returned from dialysis this morning and has been self-propelling/wandering since that time, yelling out and chanting phrases repetitively.A record review of R7's progress notes 7/12/2025 at 03:25 AM, Note Text: This nurse writer had gone to respond to a request for a prn sleeping pill at 02:08 a.m. and when returning to nursing station area on duty agency aide was standing there and states resident had fell. Upon coming around nurse's station resident was observed lying face first in front of wheelchair on floor with a significant amount of blood noted. When on-duty agency aide (CNA C) was asked what happened she states, I was pushing him in w/c his feet grabbed, and he went forward. Resident noted to have no wheelchair pedals at time of occurrence. Call for assistance from additional staff made and resident was log rolled to side and a large laceration mid forehead was noted as well as pupil's unequal at this time. 911 called. A record review or R7's progress notes from 8/6/2025 at 17:30 PM, Note Text: Nurse was on lunch break when page came over system stating there had been a fall. Nurse and other nurse from unit ran to assess resident. Upon entering the resident's room nurse saw copious amounts of blood on floor and resident on floor yelling. Aide verbally told nurse that resident had fallen out of wheelchair. Aide stated he had rounded on resident and toileted him less than an hour previous and resident was waiting in room for dinner tray with door open to keep an eye on him as he toileted other patients. A record review of the facility job description for the LPN updated 7/30/2020, stated under position summary, Provide quality nursing care to residents; Implement specific procedures and programs; coordinate work within the department, as well as other departments; Report pertinent information to the immediate supervisor: respond to inquiries or requests for information; assist the immediate supervisor with tasks to support department operations and according to LPN essential job functions, Responsible for the supervision of all nursing activities on the unit and Responsible for the interpretation and adherence of the policies and procedures for the personnel, patients, medical staff and public. With the acknowledgement of, Acceptable job performance includes completion of the job responsibilities as well as compliance with the policies, procedures rules and regulations.A record review of the facility job description for the CNA updated 7/30/2020, stated under position summary, Provide quality nursing care to residents; Implement specific procedures and programs; coordinate work within the department, as well as other departments; Report pertinent information to the immediate supervisor: respond to inquiries or requests for information; assist the immediate supervisor with tasks to support department operations and under knowledge and skills lists, Efficient time management and prioritization of work and Communicate and interact effectively and tactfully with resident.peers and supervisors. According to essential job duties, Knowledgeable of the individualized care plan for the residents and provide support to the resident according to the care plan. and Attend the individual needs of residents which may include.transferring.communication, or other needs in keeping with individuals care requirements; Adhere to all organization and site-specific policies and procedures. With the acknowledgement of, Acceptable job performance includes completion of the job responsibilities as well as compliance with the policies, procedures rules and regulations.According to a record review of the facility's Cell phone and electronic devices guidelines that Personal cell phones should not be used in patient care areas or other employees work areas throughout the building.

Based on observation, interview and record review, the facility failed to 1.) evaluate and contact provider with abnormal laboratory findings prior to medication administration of Potassium supplement for Resident #52; 2.)provide assessment, monitoring, and treatment for a Resident with a PEG (percutaneous endoscopic gastrostomy) tube for Resident #27; and 3.) follow standards of practice for Midline intravenous flushing for Resident #29, of three reviewed for standard of practice.Resident #27 (R27) On [DATE] at 9:00 AM, a record review of the R27's Face Sheet and Minimum Data Set/MDS assessment indicated R27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Unspecified Dementia, severe with other behavioral disturbance, Delusional Disorders, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Obstructive and Reflux Uropathy in addition to other diagnoses. R27's Brief Interview of Mental Status (BIMS) Score on [DATE] was 13/15. A score of 13 indicates intact cognitive function. He has a Urinary Catheter and a PEG (Percutaneous Endoscopic Gastrostomy) Tube. In R27 MDS assessment Section GG dated [DATE], revealed no impairment with upper and lower extremities; however, was deemed dependent with eating, toilet hygiene/shower, and lower body dressing, including putting on footwear. Dependent means the helper does all of the effort. The ability to dress and undress above the waist required a Partial/moderate assist, which means the helper does LESS THAN HALF the effort to complete an activity. The helper lifts or supports limbs or trunk and provides more than half the effort. R27, who was noted to have a hearing impairment, was asked to observe his peg tube site on [DATE] at 1:00 PM. R27 had a PEG Tube in place, located on the upper left quadrant of the abdomen. Although there was redness surrounding the PEG site, he denied discomfort at that time. Aside from the redness on the skin area around the site, brownish crusting, dried blood, and yellowish discharge were noted around the site. R27 denied any treatment or dressing change done daily. The Care Plan for R27 was reviewed on [DATE], at 1:00 PM. It revealed: I require tube feeding r/t Dysphagia. Date initiated:[DATE]. Revised on [DATE]. Goal: I will remain free of side effects or complications related to tube feeding through the review date. Date initiated [DATE], Target date: [DATE]. I have an alteration in gastrointestinal status r/t gastrostomy status. Date initiated: [DATE]. Revision on [DATE]. Goals: I have minimized my risk factors contributing to discomfort, complications, or increased signs and symptoms of gastrointestinal alterations through the review date. Date Initiated: [DATE]. Revision on [DATE] and Target Date: [DATE]. I am on Enhanced Barrier Precautions (EBP) r/t Foley and PEG Tube. Date initiated [DATE]. Revision on: [DATE]. Goal: I will remain free from infection. Date initiated: [DATE]—revision on: [DATE], and Target Date [DATE]. I am currently NPO r/t dx of Dysphagia and am receiving enteral feeds via PEG tube. Date initiated [DATE]. Revision on [DATE]. Goal: I will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through the review date. Date initiated: 12/01/ 2021, Revision on: [DATE] Target Date: [DATE] A review of the Treatment Administration Record and Physician's Order on [DATE], at 1:00 PM revealed that no daily treatment, monitoring, or dressing change was ordered for the PEG site found for R27. According to the Administrator's interview on [DATE] at 3:30 PM, the Administrator replied: There are no current residents with a Feeding Tube in the facility. But let me double-check with staff. The CMS 802 Form did not reflect any resident with a feeding tube. However, during the initial tour on [DATE], R27 was noted to have a peg tube. R27's CarePlan was reviewed and revealed: Care Plan I require tube feeding r/t Dysphagia. Date initiated:[DATE]. Revised on [DATE]. Goal: I will remain free of side effects or complications related to tube feeding through the review date. Date initiated [DATE], Target date: [DATE]. I have an alteration in gastrointestinal status r/t gastrostomy status. Date initiated: [DATE]. Revision on [DATE]. Goals: I have minimized my risk factors contributing to discomfort, complications, or increased signs and symptoms of gastrointestinal alterations through the review date. Date Initiated: [DATE]. Revision on [DATE] and Target Date: [DATE]. I am on Enhanced Barrier Precautions (EBP) r/t Foley and PEG Tube. Date initiated [DATE]. Revision on: [DATE]. Goal: I will remain free from infection. Date initiated: [DATE]—revision on: [DATE], and Target Date [DATE]. I am currently NPO r/t dx of Dysphagia and am receiving enteral feeds via PEG tube. Date initiated [DATE]. Revision on [DATE]. Goal: I will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through the review date. Date initiated: 12/01/ 2021, Revision on: [DATE] Target Date: [DATE] Nurse P stated that they did not apply a dressing to the site. The PEG rube is not being used and not flushed. Nurse P said, There has been no treatment ordered to the site. We don't flush because it is not in use. The certified Nurse aide (CNA) reports any abnormalities to the nurse; however, since we don't use the PEG for feeding or medication, we don't get to see the site often. When asked why the treatment/care of the Peg site was performed without the surveyor's presence, despite having requested to be present, Nurse P replied that the request may have been misunderstood. She thought I was there to observe the flush. The nurse attempted to flush and tugged on the tube to check the site on [DATE], at 11:30 AM. R27 yelled, stating, It hurt. The peg area was covered with a newly applied dressing, and around the tube is saturated drainage (moderate amount) as it was absorbed by the T-gauze pad, seen described by Nurse P as serosanguinous discharge on the T-sponge dressing secured with a tape at the peg tube site. She stated that they had just applied the dressing to the site because they noticed drainage with a tinge of blood on it. The Doctor has been notified of the findings. The CNA assigned to R27 was interviewed on [DATE] at 11:30 AM and indicated that there was no treatment and no daily dressing, as she had noticed. Noted on [DATE]A NEW treatment orders were added: One time only, an Order was noted on [DATE] at 9:15 AM: Cleanse the Peg tube site with normal saline, pat dry. Apply T drain and secure with tape. Cleanse the skin surrounding the PEG tube site with normal saline and pat dry. Apply T drain and secure with tape. Notify Provider of any signs of infection or drainage. Every night shift and as needed. The Order was written as active on [DATE] at 9:45 AM (After the surveyor inquired and requested to see the peg site and the flush on [DATE] at 8:00 AM) Flush the Peg tube with 30 mL every 8 hours for maintenance. The Order was placed and active on [DATE], at 16:00. After the surveyor inquired on [DATE], it was revealed by the DON and Administrator that there was no flushing or treatment at the site because the tube was not in use for feeding. Monitor the Peg tube site for signs of infection and notify the Provider accordingly every shift/ Night. Order Start Date was [DATE] Noted NEW Peg tube related treatment orders were entered [DATE] and [DATE]. There were no treatment orders prior. On [DATE] at 9:31 AM, the Director of Nursing wrote in the progress note: When the nurse assessed the PEG Tube site today, scabbing and crusted drainage were noted. MD (Name mentioned) notified via phone. New orders to clean the area surrounding the PEG site with normal saline. Nurse cleansed site with the light serosanguinous drainage was noted. Policy on Peg tube Care was requested and reviewed. on [DATE]. The Policy entitled Enteral Nutrition Guidelines (Revised Date: [DATE] indicated: Purpose: A feeding tube is used to deliver a liquid feeding formula directly to the stomach, duodenum, or jejunum. This applies to both nasogastric and gastrostomy feedings. Procedure: 19. The skin around a gastrostomy or jejunostomy is kept clean and free from irritation and/or infection. The site is evaluated for signs of: erythema tenderness drainage and erosion . Documentation . 3. Physician orders are documented in the medical record and must include the following: .Stoma care (if a gastrostomy or jejunostomy .4. The care plan includes specific details on: a. who should provide the care. and how often; b. what supplies and equipment needed; c. how the care is undertaken; d. immediate and long-term goals of the enteral feeding; and e. anticipated duration of enteral feeding . R27's Plan of Care did not reflect any of the above Facility Peg tube Policy (Enteral Nutrition Guidelines) specifically to his PEG Tube site care. Resident #29 (R29) During Medication Administration observation conducted on [DATE] at 8:15 AM, R29 was observed during Medication Pass. Nurse K stated R29 started infusion of his scheduled IV medication through Midline ne at 7:45 AM. It is therefore due to be removed and done with infusion. It usually takes an hour for it to completion. Nurse K was at the [NAME] Wing Hallway by the MedCart across the Nurses station. Nurse K was observed while she unhooked the empty antibiotic bulb by the IV Port Line without wearing PPE (gloves.). Nurse K examined if the reconstuted medication inside the bulb has been completely emptied. After verifying that the antibiotic infusion was completed and emptied, without gloves on, she discarded the [NAME] to the medcart trash, peeled the alcohol wipes and flushed the line wit a 10 cc of sterile normal saline irrigation syringe. Nurse K did not realize doing the flushing in the hallway without gloves and in front of others to see (visitors, other residents and staff). Nurse K did not wash or sanitize her hands and did not wear gloves. Nurse K wiped the end cap of the IV Midline with alcohol wipes with her bare hands. R29 also received a nasal spray administered through both his nostrils in the hallway after his PICC Line antibiotic was unhooked. Nurse K was observed not wearing gloves upon administering the nasal spray. According to R29 EMR reviewed on [DATE] at 12:00 PM, it revealed that R29 was admitted to the facility on [DATE]. He was [AGE] years old, admitted with a diagnosis of Type 2 diabetes Mellitus with Foot Ulcer, Non-Pressure chronic Ulcer of the Left Heel and Midfoot with unspecified severity, and osteomyelitis of the left foot and ankle, in addition to other diagnoses. R29 was prescribed the following: Lantus Solostart Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Glargine) 10 units, Piperacillin Sodium-Tazobactam Solution Reconstituted 3-0.375 GM q8hours, and Flonase Allergy Relief Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) scheduled at 8:00 AM. RN K on [DATE] at 8:45 AM indicated that she forgot about maintaining the resident's dignity and privacy by avoiding medication administration in the public areas, such as the hallways and the dining area. A review of the Med Pass Guidelines and Nasal Inhaler Policy was conducted on [DATE] at 3:00 PM: Medication Administration for Nasal Inhaler, spray, and pump Administration Policy: To administer nasal Medications in a safe and accurate manner. Supplies needed: inhalation or spray medication. tissue or gauze glove Medication Administration Record (MAR) Procedure: . 3. Provide for resident privacy.Explain the procedure to the resident and inform him about what medication is being administered 5. Wash hands (examination gloves may be worn) . 19. Wash hands . The Medication Pass Guidelines (Revised Date: [DATE]) was reviewed. Purpose: To assure the most complete and accurate implementation of physician's medication orders and 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. Procedure:1. Follow infection control practices. complete hand hygiene prior to medication preparation for each medication pass between resident medication administrations, after direct resident contact and at the completion of medication pass . Use sterile syringes and needles for all injections . According to homecare.med.umich.edu your midline lumen must be flushed to prevent infection and keep the blood from clotting. Cleaning your hands explained in various ways by 1. washing hands with soap and water,2. using a hand sanitizer 3. and instructions on hot to handle sterile supplies was emphasized with great importance. The purpose of the Midline Flush Protocol is to:1. Prevent clots: Regular flushing prevents blood from clotting in the catheter lumen. 2. Prevent infection: Aseptic technique used during flushing helps prevent microbial contamination. 3. Ensure Patency: Flushing confirms the catheter is open and functioning correctly for medication or fluid administration. A midline flush protocol involves: aseptically flushing a midline catheter . Key steps include washing hands, scrubbing the catheter cap with alcohol pad, connecting the prefilled saline syringe, followed by hand hygiene . Resident #52 A review of Resident #52's medical record revealed an admission into the facility on [DATE] and date of discharge [DATE] with diagnoses that included fracture of right humerus and greater trochanter of right femur, chronic kidney disease, heart failure, atrial fibrillation, and hyperkalemia (a medical condition where the body has high levels of potassium in the blood). A review of Resident #52's medical record of a progress note dated [DATE] revealed the Resident had died at the facility: Resident was visiting family and family came and got staff to toilet resident at 1350 (1:50 PM). Resident used the bathroom and stated to the staff that she had no power to get up and that she couldn't stand up-it took three staff to get resident up off the toilet- and place her back in her bed at 1352 (1:52 PM). Staff notified nurse and nurse went to grab the vital cart to take her vitals when staff alert nurse that she went unresponsive. Nurse initiated CPR (cardiopulmonary resuscitation) straight away and a code was code (called) for all nurses to report to her room. 1408 (2:08 PM) MMR (mobile medical response) arrived. CPR continued. Time of death called 1447 (2:47 PM). A review of Resident #52's laboratory test with a collection date on [DATE] at 9:30 AM, received date on [DATE] and a reported date on [DATE] at 15:42 (3:42 PM), revealed a Basic Metabolic Panel (BMP) completed with Potassium of 5.8 mEq/L with a reference range of 3.5-5.3, flagged as H high. A review of the progress notes dated [DATE] at 8:28 PM revealed, Note Text: Results from labs ordered with xray 7/29. Sodium (L (low)) 134, Potassium (H (high)) 5.8, Anon Gap (L) 10.8, Glucose (H) 122, GFR (L) 48, BNP (CH (critical high)) 730.7-NP (Nurse Practitioner) called with CH repeat in 2 weeks both BMP and BNP. A review of Resident #52's medication orders revealed an order for Potassium Chloride ER (extended release) 20 MEQ. Give 1 tablet by mouth one time a day for low potassium, with a start date [DATE] and discontinue date [DATE] at 2:00 PM. A review of the Medication Administration Record revealed the medication was ordered for 8:00 AM and the Resident received the potassium medication in the morning on [DATE]. The medication had not been discontinued after the abnormal high laboratory Potassium level was received at the facility on [DATE] and had been administered in the morning on [DATE]. On [DATE] at 11:36 AM, an interview was conducted with the Director of Nursing regarding Resident #52's laboratory results for Potassium high at 5.8 received on [DATE], the order for medication Potassium was not discontinued and Nurse K administered the medication on [DATE] in the morning. The DON was asked why the Potassium was given when lab results were high. The DON responded that she had seen the potassium was high and stated, I don't know why the NP didn't discontinue the Potassium when they were called with the labs. When asked what the Nurse should have done, the DON reported that the Practitioner could have discontinued it, It should have been passed on in report that her potassium was elevated, the Nurse could have held it and called the doctor prior to giving the medication. The DON stated, We discontinued it that morning, she only got that morning dose then it was discontinued. On [DATE] at 12:08 PM, an interview was conducted with Nurse K who had administered Resident #52's medication in the morning on [DATE] that included the Potassium supplement. The Nurse was asked if she was aware of the high Potassium laboratory value prior to administration of medication to Resident #52. The Nurse reported she had not received the information in report and had not reviewed the laboratory results. The Nurse stated, Had I known (of the high potassium level) I would not have given the Potassium and reached out to the provider. The Nurse was asked when she became aware of the elevated Potassium level and reported she had not been aware until now and reported that a high level like that would be passed on in report, so they are aware of the results. The Nurse confirmed she had access to laboratory results in the medical record. On [DATE] at 9:07 AM, an interview was conducted with Nurse Practitioner (NP) O regarding Resident #52's report of abnormal Potassium level. The NP was asked if they were made aware of the Potassium laboratory levels with the BNP levels. The NP was unsure and reported ordering for repeat labs for the BNP elevated level. A review of the Resident admitting to the facility with list of medication to hold the bumetanide (a diuretic medication) and spironolactone (potassium-sparing diuretic), but the Potassium was continued. The NP indicated that usually when the diuretic was stopped, then the potassium supplement was discontinued as well, but the Resident could have other conditions to verify the need for the Potassium supplement to be continued. The NP reported that the physician would review the medications upon admission. The NP reported that routinely they would hold the potassium with an abnormal high lab value, assess the resident and treat if symptomatic or transfer to the hospital if needed.

Based on observation, interview and record review, the facility failed to ensure choices on meals are honored and prompt response to call lights for Resident #6 (R6), maintain the resident's confidentiality of an emergency plan for Resident #49 (R49) and provide resident's privacy during medication administration for Resident #29 (R29) for three residents (R6, R49 and R29) of three reviewed for dignity. Findings include:Resident #49 (R49):A review of the Electronic Medical Record (EMR) conducted on August 12, 2025, at 3:00 PM revealed that R49 was admitted to the facility on [DATE]. She is currently under hospice care. Her Brief Interview of Mental Status (BIMS) Score dated July 2, 2025, was undetermined. The score box was left blank. However, staff indicated in the assessment that R49 had a memory problem (both short-term and long-term memory), a problem with recalling (names, faces, seasons, and locations), and her cognitive skills for daily decision making, according to the facility, were severely impaired. Her Minimum Data Set Assessment Section GG (dated July 2, 2025) revealed that R49 is dependent on staff for eating, oral hygiene, toileting, showering and bathing, dressing, and personal hygiene.According to the facility's RightsADLOn 08/12/2025 at 10:14 AM, R49's ADLs were being done in another resident's room. R49 was observed coming out of Rm112. R49 was greeted and was addressed by the name of the person residing in room [ROOM NUMBER]. The Certified Nurse Aide (CNA M), who was pushing R49 out of the room, corrected the surveyor and explained that the resident was not the person belonging to room [ROOM NUMBER]. CNA M explained that she used room [ROOM NUMBER] to cleaned and washed R49, who resides next door (Room # 114) CNA furthermore stated that she has been using room [ROOM NUMBER] to provide ADL Care for R49 because R49's roommate does not want R49's ADLs done in the room (#114), so she does it next door in room [ROOM NUMBER] since the resident in room [ROOM NUMBER] is out in the hall. When the surveyor asked, CNA M did not know if it was acceptable to use another resident's room to wash up another resident and complete their ADL task for another resident who belonged to a different room.On 8/12/2025 at 10:15 AM, an attempt to interview R49 revealed that although R49 was alert, she was not able to answer the surveyor's questions.An interview with Certified Nurse Aide (CNA) M was conducted on 8/12/25 at 10:15 AM. CNA M came out of the room, pushing R49, and stated that the resident who lived in room [ROOM NUMBER] was not in the room. They explained that R49's room is next door, but R49 had decided to use another resident's room. CNA was unsure whether she could use another resident's room to wash up another resident. She did not understand the reason why or why not. CNA# explained that she used another room for R49's ADL because R49's roommate does not want us to clean her up in her room. If you have met her roommate, you will know why.Advanced DirectivesUpon entering R49's room on 8/12/24 at 10:15 AM, R49's Emergency Plan was posted on the wall of her room right next to her bed for everyone to see. R49's name was handwritten with a black Sharpie pen, and the contents of the posted Emergency Plan specified:The Patient Name,The patient is currently receiving hospice care. Please call the Hospice Nurse for changes in patient status and comfort levels.In Bold Letters and All Caps- DO NOT CALL 911Following line written: Do NOT Resuscitate. R49's Nurse N was interviewed on 8/12/25 at 11:30 AM, Nurse N validated that the emergency plan was posted on the wall. Nure N stated she did not see anywhere else except for R49's room and did not know the reason behind whether it was her Advanced Directive status or because she was receiving hospice care.According to R49's roommate on 8/12/25 at 10:21 AM, she denied issues with the staff doing her roommate's (R49) ADLs in the room. Although she was bothered by the posted note taped on the wall that says Emergency Plan Do Not Call 911. Because it was R49's roommate's birthday recently, a lot of visitors came and were asking about the note on the wall. R49's roommate felt R49's privacy was violated and had stated that she does not want that paper posted on her wall. The roommate indicated that her own family was concerned and asked about the note when someone sees it.Upon review of the form on 8/12/25 at 10:30 AM, the form is from the facility hospice care agency notifying staff of her advanced directive status.The Social Worker (SW O) on 8/13/25 at 4:40 PM and the surveyor visited R49's room and noticed that the form was removed from the wall. Entering R49's room, the roommate stated that the form had come off this morning. R49's roommate was excited and said, Hallelujah! and was glad that it was no longer there. The SW O validated on 8/13/25 at 4:45 PM, that the form needed to come off the wall and did not need to be posted either.The Administrator, on August 13, 2025, at 4:45 PM, during an interview, revealed that the facility owns the hospice. However, the sheet was left there, and we instructed the hospice not to place it there for privacy reasons. Despite this, hers remained. Resident #6 (R6):R6 was admitted to the facility on [DATE] with a diagnosis of Congestive Heart Failure (CHF), Essential Hypertension, Chronic Pulmonary Edema, and General Anxiety Disorders in addition to other diagnoses. The Minimum Data Set (MDS) assessment for R6, dated July 18, 2025, revealed a Brief Interview of Mental Status Score of 15/15. A score of 15 means that R6 is cognitively intact. R6 Kardex as of 8/14/25 indicated that she is incontinent with bowel and bladder with a plan of care of checking upon rising, before meals, and at HS (bedtime) and as required for incontinence. Wash, rinse, and dry the perineum. Change clothing PRN (as needed) after incontinence episodes. It also revealed that R6 wears an incontinence brief. And was care planned to wash, rinse, and dry the perineum. Apply barrier cream.Call lightOn August 12, 2025, at 11:02 AM, an interview with R6 was conducted. R6 stated that just this past week, she waited for an hour for someone to answer her call light. When asked what happened next, she said that if you waited an hour long, what do you think would happen? I had an accident. Eventually, they cleaned me up. It doesn't happen most of the time. But that night it happened a couple of times. It's mostly during the night. I have some redness on my bottom. The aides put a sab and powder. I reported it, but I'm not sure if the staff member is still employed here. Every night we get somebody new.ChoicesWhen asked about choices, R6 said that food is a concern. There have been lots of substitutes lately, or they've run out of ideas. They let you pick some food choices, but they don't follow what you circled (pre-selected). I'm not sure why. Instead, they offer an alternate, and they are not bad. Sometimes I get a hot dog for supper or grilled cheese. They don't follow what you have picked from the menu. I just then eat what is there. Resident #29 (R29):During Medication Administration observation conducted on 8/12/25 at 8:30 AM, R29 was observed receiving his Lantus injection on his left deltoid given by the RN while he was at the [NAME] Avenue dining room with other residents waiting for their breakfast tray. A few minutes before this observation, at around 815 AM on 8/13/25, the nurse unhooked the empty antibiotic bulb from the PICC (Peripherally Inserted Central Catheter) Line after antibiotic infusion was completed and flushed in the hallway. Nurse K did not wash or sanitize her hands and did not wear gloves. Wiped the end cap of the PICC line with alcohol wipes with bare hands. R29 also received a nasal spray administered through both his nostrils in the hallway after his PICC Line antibiotic was unhooked. Nurse K did not wear gloves either when administering the nasal spray.According to R29 EMR reviewed on 8/13/25 at 12:00 PM, it revealed that R29 was admitted to the facility on [DATE]. He was [AGE] years old, admitted with a diagnosis of Type 2 diabetes Mellitus with Foot Ulcer, Non-Pressure chronic Ulcer of the Left Heel and Midfoot with unspecified severity, and osteomyelitis of the left foot and ankle, in addition to other diagnoses. R29 was prescribed the following: Lantus Solostart Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Glargine) 10 units, Piperacillin Sodium-Tazobactam Solution Reconstituted 3-0.375 GM q8hours, and Flonase Allergy Relief Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) scheduled at 8:00 AM.RN K on 8/13/25 at 8:45 AM indicated that she forgot about maintaining the resident's dignity and privacy by avoiding medication administration in the public areas, such as the hallways and the dining area.A review of the Resident's Rights and Facility's Responsibilities (Undated) Policy was conducted on 8/14/25 at 3:00 PM:Residents RightsThe resident has a right to a dignified existence, self- determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.Dignity, Respect and Quality of LifeA facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observation, interview and record review, the facility failed to ensure assessment of measurements for a midline catheter was completed and the midline catheter was flushed appropriately for one Resident #29, of one reviewed for intravenous catheters.A review of Resident #29's medical record revealed an admission into the facility on 7/23/25 with diagnoses that included acquired absence of right toe(s), diabetes with foot ulcer, ulcer of left heel and midfoot, and acute osteomyelitis, left ankle and foot. Further review of the medical record revealed the Resident had a Midline catheter that was used to administer intravenous (IV) antibiotics. On 8/12/25 at 12:45 PM, Resident #29 was observed in their room, laying on the bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about receiving antibiotics. The Resident reported getting IV antibiotics through a midline catheter. An observation was made of a Midline catheter dressing to the right arm. The Midline catheter had an external catheter, and the insertion site was covered with a dressing. The dressing and the external catheter were covered with stretchy dressing. The date of when the dressing was changed was not visualized on the dressing, the Resident reported they had changed the dressing but was unsure of the day. A review of Resident #29's medical record of the Treatment Administration Record (TAR) revealed a dressing change was completed on 7/24/25, 7/31/25 and 8/7/25. The order for the dressing change was to Change Midline dressing every 7 days. Measure external catheter length and arm circumference on admission, weekly, with each dressing change, CM=External catheter length in centimeters, ARM=Arm Circumference in centimeters, every night shift every 7 day(s) for dressing change. The documentation for the Midline dressing change for 7/24/25 and 8/7/25, lacked documentation of the external catheter length and the arm circumference. A review of Resident #29's progress notes dated 7/31/25, revealed measurements of 1 cm (centimeter) and 31 cm. A review of the Admit/Readmit Screener, dated 7/24/25, revealed Section C. Skin Integrity, description: midline to RUE (right upper extremity) 18 g (gauge). There was a lack of documentation of the measurements of the external catheter and the arm circumference. A review of Resident #29's care plan revealed a Focus: I have an 18g midline to my right upper arm. I have the potential for catheter related bloodstream infection, phlebitis, deep vein thrombosis, catheter occlusion, and catheter migration, dated 7/24/25. An intervention included: Measure external catheter length on admission, weekly, with each dressing change and prn (as needed). On 8/14/25 at 12:36 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #29's assessment of the measurements of the Midline catheter. The TAR with the lack of measurements was reviewed. The DON indicated that the measurements should be documented in the progress notes. The measurements in the progress notes for 7/31/25 of the external catheter measurement of 1 cm was reviewed with the DON, who indicated the measurement was possibly a typo. The DON was asked about facility policy on measurement assessments for Midline catheters. The DON reported the facility policy for Midline IV catheters was that dressing changes were completed on admission, within 24 hours on admission, and that the measurements would be completed during the dressing changes on admission and every seven days. The DON confirmed the lack of measurements with the dressing changes on 7/24 and 8/7 for Resident #29. An observation was made with the DON of Resident #29's Midline catheter to confirm the external catheter was greater than 1 cm.

Based on observation, interview and record review, the facility failed to 1) Ensure a safe, clean and sanitary environment (Stachybotrys/black-mold and Chaetomium mold), and 2). Maintain and clean the facility kitchen ice machine for resident's, family members, visitors and staff, resulting in the likelihood for respiratory infections, increased bacterial infections, with exposure to molds: damage to nose, throat esophagus, lungs and blood stream, increased antibiotic usage, and unsafe environments. Findings Include: During the initial facility environmental tour done on [DATE] at 10:00 a.m., the following concerns were observed: -At 10:04 a.m., the kitchen ice machine was found to have a black substance (mold-like) all over the seal tape inside the cover and in the inside back of the machine was observed a dried yellow substance approximately 6 inches near the ice. During an interview done on [DATE] at 10:10 a.m., maintenance assistance F stated It looks like mold to me (the black substance on the seal tape of the inside cover of ice machine). Review of the kitchen Ice Machine Bin Cleaning documentation dated [DATE] through [DATE], revealed the ice machine was to be cleaned every month. The last time it showed it was cleaned was over a month ago ([DATE]); it was late to be cleaned. -At 10:20 a.m., in the public bathroom [ROOM NUMBER] (across from the main dining room on the first floor), there was no paper towels at all, management was informed. -At 4:00 p.m., still no paper towels in public bathroom [ROOM NUMBER], Infection Control Nurse C informed. -At 10:28 a.m., on the Garden View unit, a running white fan was found to have black dirt on the blades, it was observed to be blowing toward the nursing station next. -At 10:30 a.m., on the Garden View unit in the soiled utility room was observed 2 large blue bins filled with soiled linens, and both tops were off sitting on the floor. -At 10:31 a.m., on the Garden View unit, a running dehumidifiers filter was found to have heavy dust on it. Infection Control Nurse C went to check it out, and rubbed his hand over the dirty filter and dust fell out onto the floor. -At 10:37 a.m., on the Garden View unit, in the small shower room (it was not used as a shower room, crash cart in room) was noted to have a heavy sewer-like smell. The shower was no longer in use and the drain was open. During an interview done on [DATE] at 10:37 a.m., Nurse, LPN D stated it (the small shower room) smells like sewer. -At 10:50 a.m., on the Garden View unit a running fan was blowing air between 201 and 204; it was found to have black dirt on the blades. -On [DATE] at approximately 12:30 p.m., during catheter care observation, room [ROOM NUMBER] had right and left floor mats for safety; the left floor mat was noted to have a total of 12 small rips/tears in it. The resident was in bed at the time. During the basement (used for nursing meetings, staff orientation and staff education) environmental tour done on [DATE] at 2:40 p.m., accompanied by Maintenance Director A and Corporate maintenance G and H, the following concerns were observed: -At 2:43 p.m., in the medical records room above stored boxes records was noted 2 buckets, one with approximately 6 inches of water in it and the other had old pealed of pipe wrappings in it. There was three areas were the pipes from the ceiling were visibly wet and dripping; these ceiling area's had a black colored mold-like on them. One thin active data cord was stretched across the ceiling and touching one of the wet areas. During an interview done on [DATE] at 2:45 p.m., Maintenance Director A stated I have been here for [AGE] years, that's always been that way, it's (the pipe dripping and black mold-like) the building. -At 2:46 p.m., in the hallway outside of therapy storage room and down the hall toward staff education room, was observed approximately 6 large areas of back mold-like on the ceiling tiles. During an interview done on [DATE] at 2:48 p.m., Maintenance Director A stated I replace the tiles every month, the Administrator knows it. We are out of tiles or I would have replaced them; we don't have a policy for changing the tiles if I am not here. -At 2:50 p.m., in the staff education room, was observed a large area on the ceiling of black mold-like by the back window, on the right side. A computer and paper work was sitting directly under this area (staff were working in this area, sitting directly below the mold-like large area). -At 2:55 p.m., in the basement therapy equipment room, a large area of black mold-like circular area on the ceiling tiles directly over a uncovered resident wheeled walker was found. Review of the environmental independent lab report dated [DATE], stated (the company) conducted a limited visual inspection for mod growth. The pipe wrap is asbestos containing. mold growth on some of the ceiling tiles. The results indicated mold levels in the all three areas were above acceptable levels at the time of the sampling event. Chaetomium (exposure can cause respiratory symptoms, and skin irritation) and Stachybotrys (also known as black mold; can exposure can cause damage to the nose, throat, esophagus, lungs and blood stream) were detected in the medical records room air sample. There are no acceptable levels for Chaetomium or Stachybotrys. There are 20 documented species of Stachybotrys and at least two are reported to be toxigenic; if not speculated, the [NAME] Stachybotrys should be assumed to be toxigenic. Specifically, it can produce the mycotoxin Trichothecene, which can have adverse health effects. -At approximately 3:05 p.m., in the boiler room was observed the State Boiler license's, all of them were expired (expiration dates of 2019 through 2022). During an interview done on [DATE] at 3:05 p.m., Maintenance Director A stated I have been calling them (the State of Michigan boiler inspectors), I just gave-up. The facility boilers are each over a million BTU's (licenses are required). Review of the facility Environmental Service Manager job description dated [DATE], stated Essential Duties: Insure the building, rounds and equipment are maintained in a manner that protects the safety and health of all residents, employees and visitors.

Based on observation, interview and record review, the facility failed to maintain a clean and sanitary kitchen and kitchen ice machine, resulting in the likelihood to affect up to 53 residents who currently consumed meals prepared in the facility kitchen, from a census of 53 residents. Findings Include: According to the Michigan Modified Food Code 2012, stated Clean equipment and utensils shall be stored: In a self-draining that allows air drying. All kitchen food prep areas and equipment are to be clean and sanitary. Initial Tour of the Facility Kitchen: On 07/23/24 at 9:46 a.m., a kitchen tour done with Dietary Manager F was done; the following concerns were found: -At 9:47 a.m., the kitchen hand sink closet to the ice machine and dish area was found to not have any soap nor paper towels. During an interview done on 7/23/24 at 9:48 a.m., Dietary Manager F stated Housekeeping is out on rounds right now. Dietary Manager F waited for housekeeping and did not replenish the soap or paper towels herself. -At 9:47 a.m., the large metal can opener was found to have stuck on wet and dry food on the blade and the paint was also chipping off the blade. -At 9:48 a.m., the Robot Coupe (food processor) was clean, ready for use and was found to have water still inside on the bottom, and the blades had food particles still on them. -At 9:50 a.m., the heavy duty blender that was clean and ready for use was found to have dust on top. -At 9:51 a.m., a large silver metal pan filled to the top with individual wrapped stake's was sitting out without any dates or times on it. When this surveyor touched to wrapped meat, it was found to be room temperature. During an interview done on 7/23/24 at 9:52 a.m., Dietary Manager F stated it should not be out like that. During an interview done on 7/23/24 at 9:53 a.m., [NAME] I stated It's (the pan pf raw meat) has been out for about an hour. -At 9:54 a.m., a clean and ready for use half-pan was found to be wet inside; it was stacked on another pan on the pan rack. -At 9:55 a.m., the large white plastic bin that had thickener in it was not labeled with no dates on it. During an interview done on 7/23/24 at 9:55 a.m., Dietary Manager F stated It's thickener; we put it in this morning and forgot to date it. -At 9:56 a.m., a small trash bin with trash up to the top was observed sitting on top of the silver metal food prep table, next to open bacon and gravy (without lids). -At 9:57 a.m., x 11 spice containers were found to be sticky and dirty on the sides and tops of them. -At 10:00 a.m., 3 clean and ready for use white plates and a plastic pitcher were found to have dried food on them and were also wet. The plates were stacked on top of one another on the plate rack. -At 10:04 a.m., the kitchen ice machine was found to have a black substance (mold-like) all over the seal tape inside the cover and in the inside back of the machine was observed a dried yellow substance near the ice. During an interview done on 7/23/24 at 10:10 a.m., maintenance assistance F stated It looks like mold to me (the black substance on the seal tape of the inside cover of ice machine). Review of the kitchen Ice Machine Bin Cleaning documentation dated 12/29/22 through 6/13/24, revealed the ice machine was to be cleaned every month. The last time it showed it was cleaned was over a month ago (6/13/24); it was late to be cleaned. Review of the facility kitchen cleaning checklists revealed the last one filled out had several blank area's were no staff had documented the duties had been done, and there was no date on the sheet. During an interview done on 7/23/24 at 10:14 a.m., Dietary Manager F stated they are supposed to fill out the job duties (kitchen daily job documentation sheets) every day. We don't have one for today. A policy for kitchen ice machine and cleaning policy was requested, and not received during the survey.

Based on interview and record review, the facility failed to provide a complete Notice of Medicare Non-Coverage (NOMNEC) and the Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for one (Resident #300) of three residents reviewed for Beneficiary Notice, resulting in resident and/or a representative not being informed of the right to appeal and the potential for undue emotional and financial hardships. Findings include: On 07/24/24 at 11:25 AM, three residents were selected, and names were given to Staff S, who was the accounts payable and was in charge of informing the resident and the resident's representative. Upon review of the electronic medical record (EMR) on 7/25/24 at 12:39 PM, R300's SNF-ABN was not included in her notification file. R300 was admitted with Med A Part B that started on 1/12/24, with the last covered day on February 12, 2024. R300 was alert and oriented at the age of [AGE] years old with a Brief Mental Status Score of 15/15 assessed on 2/13/2024. She remained her own responsible person during her entire stay at the facility. Although the NOMNEC was provided and issued to R300 on February 8, 2024, it was issued on 2/8/24, too early, for the last covered day was February 12, 2024. R300 was admitted on [DATE]. R300's last covered day was February 12, 2024. However, R300's Face Sheet revealed that she did not go home after the assigned last covered day. R300 opted to stay in, pay out-of-pocket, and was discharged [DATE] under private pay insurance status. On 7/25/24 at 9:30 AM, an interview with the accounts payables Staff S. She stated that she was responsible for issuing the NOMNEC letters to the residents; however, the ABN's are issued by the social workers. According to Staff S, since R300 decided to be discharged home, we did not think we should issue the ABN. We did not give her the ABN Notification. The Social Services Manager Staff T on 7/25/24 at 11:30 AM revealed that since the resident opted to go home, they did not need to issue the R300 and ABN Notification. A Late Entry for the progress note dated 2/12/2024 entered by Staff T was reviewed. It noted: NOMNEC is not needed at this time, due to resident stating she did not want to continue therapy, at this time and designating her own discharge date home. E-signed by Staff T. On 7/25/24, at around 12:45 PM, The Administrator followed up on the ABN request from Staff S. The administrator admitted they missed it. The ABN was not issued to R300. A review of the electronic medical record dated 2/14/24 revealed that R300 remained at the facility after the last covered day (2/13/24) and was discharged home on 2/15/25. R300's payment status after 2/13/24 was private pay. The facility policy for Beneficiary Notice of Medicare Non-Coverage (NOMNEC) and the Advanced Beneficiary Notice of Non-Coverage (SNF ABN) was requested on 7/25/24 at 12:45 PM. Still, it was not received before or upon the survey exit date. The facility's policy entitled Resident's Rights and Facility Responsibilities was reviewed. On page 30 of the policy under Notice of Rights, it stated: The facility must provide a notice of rights and services to the resident prior to or upon admission and during the resident's stay. The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the State-developed notice of Medicaid rights and obligations, if any. Receipt of such information, and any amendments to it, must be acknowledged in writing .

Based on observation, interview and record review, the facility failed to ensure that insulin pen administration was completed per professional standards of practice for one resident (Resident #11) of one resident reviewed for insulin administration, resulting in the likelihood of decreased insulin absorption and continued misadministation. Findings include: Resident #11: On 7/25/24, at 9:20 AM, During medication administration task, Nurse N was observed gathering Resident #11's morning insulin. Nurse N removed the insulin pen, placed a needle on the pen, dialed to 2 units and wasted the 2 units. Nurse N then dialed the insulin to the 4 units ordered. Nurse N entered Resident #11's room and prepared their abdomen for administration. Nurse N inserted the needle, pushed the plunger down and removed the needle. The entire process took only 3 seconds. Nurse N did not wait the required 5 to 10 seconds after the plunger was fully pushed in. On 7/25/24, at 10:00 AM, the Director of Nursing (DON) was alerted of Resident #11's insulin administration and that Nurse N failed to leave the needle inserted the required time. The DON was asked to provide the competency and the facility insulin pen administration instructions. On 7/25/24, at 10:30 AM, a record review of Resident #11's Physician orders revealed an order for NovoLOG FlexPen subcutaneous solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 4 unit subcutaneously . Start Date 7/2/2024 On 7/25/24, at 12:30 PM, a record review of the facility provided Insulin and Non-Insulin Pen Quick Reference Guide . After pushing the dose button to inject the medication, hold pen in skin for an additional time period per manufacturer specific instructions (5 - 10 seconds) before withdrawing the needle from skin to allow sufficient time for entire dose to dispense from pen into subcutaneous tissue .

Based on observation, interview and record review, the facility failed to ensure that a continuous positive airway pressure machine/CPAP mask was cleaned and bagged after use for 1 resident of 1 resident reviewed (Resident #103) for CPAP's, and ensure that oxygen was on the resident as ordered and update the oxygen care plan for 1 of 2 residents reviewed (Resident #12) for oxygen, resulting in the likelihood of low oxygen, compromised respiratory status, increased lung infection, and increased antibiotic usage for respiratory infection with hospitalization . Findings Include: Resident #103: Review of the Face Sheet, diagnosis list, care plans and physician orders revealed, Resident #103 was [AGE] years old, alert and his own person, admitted to the facility on [DATE] from the hospital for rehab services after hip surgery. The residents diagnosis included, right hip replacement, diabetes, high blood pressure, chronic heart failure, heart disease, obstructive sleep apnea (required a CPAP at night), history of thrombosis (blood clot), a history of asthma, and required assistance with daily activities of daily living/personal care. The resident was a full code. Review of the facility Nursing Admission Screener dated 7/20/24, revealed under respiratory, apnea was not addressed, nor checked however, CPAP was checked (generating a care plan) and order for cleaning and maintenance. Review of the electronic medical record, revealed the resident used a CPAP at home and in the hospital at night. Upon admission to the facility physician orders for CPAP daily cleaning was required by this facility. Per observation and interview done on 7/23/24 at 11:07 a.m., the residents CPAP was noted to be sitting out on bedside table, not in a bag. The CPAP was observed to be dirty in the mask and the tube, Resident #103 stated, I usually clean it, no one offered to clean it, last Thursday (prior to surgery) I cleaned it (7/18/24, a total of 6 days without being cleaned, a total of 4 of the days while at the facility). Review of the residents physician orders, revealed on 7/23/24 (the day the surveyor noted the dirty CPAP mask and tube and it was not bagged), an order to clean the CPAP was obtained. Review of the CPAP care plan revealed it was also dated 7/23/24, no CPAP care plan was put in place until the first day of the recertification survey. Review oaf the order dated 7/23/24, stated CPAP daily cleaning every day shift, daily wipe the CPAP mask and wipe down tubing with a clean, damp paper towel. Rinse out the humidifier and refill it with distilled water. 39059 Resident #12: On 7/23/24, at 10:06 AM, Resident #12 was resting in their bed with a visitor at bedside. Resident #12 did not have their oxygen nasal annular on. The oxygen tubing and nasal cannula was inside a clear plastic bag hooked to their wheelchair. On 7/24/24, at 8:00 AM, a record review of Resident 12's electronic medical record revealed an readmission on 11/30/2023 with diagnoses that included Chronic ischemic heart disease, Chronic Obstructive Pulmonary Disease (COPD) and Alzheimer's disease. Resident #12 required assistance with Activities of Daily Living and their cognition fluctuates at times. A review of the physician orders revealed . Oxygen at 3LPM (liters per minute) continuously every shift . Start Date 1/18/2024 . A review of the I use Continuous Oxygen Therapy PRN r/t (related to) COPD and chronic respiratory failure with hypoxia . Goal I will have no s/s (signs and symptoms) of poor oxygen absorption through the review date . Interventions . OXYGEN SETTINGS: I have O2 via nasal prongs @ 3 L (liters) PRN (as needed) Revision on: 07/06/2021 . On 7/24/24, at 8:41 AM, Resident #12 was sitting at a dining table in the main dining room. Their lips and skin surrounding their lips had a dusky grey appearance. Resident #12's portable oxygen tank was hooked to the back of their wheelchair and was off. Resident #12 was asked how they felt and at the same time had reached behind them and dialed their oxygen tank to 1 liter. Resident #12 then stood up and pulled their oxygen tubing out from under their bottom. Resident #12 was sitting on their tubing. Resident #12 had placed their oxygen on and had placed the nasal cannula on correctly. On 7/24/24, at 8:43 AM, Nurse J was asked if they could obtain a pulse oximetry reading of Resident #12's oxygen level. Nurse J placed the pulse oximeter on Resident #12 and revealed the oxygen level to be 90%. Nurse J reassured the resident their tank was full and should last them through lunch and walked away. The oxygen tank remained dialed to only 1 liter. On 7/24/24, at 8:45 AM, Nurse K was alerted that Resident #12 had been sitting on their oxygen tubing and the tank remained dialed to only 1 liter. Nurse J reminded the resident of the need for assistance and dialed the oxygen tank to 3 liters. Resident #12 offered, I though I turned it 3. On 7/24/24, at 12:47 PM, Resident #12 was lying in their bed knitting. Their oxygen was not on. The oxygen concentrator was dialed to 3 liters and the tubing was coiled on the floor. The oxygen tank on their wheelchair was dialed to 3 liters and the oxygen tubing was coiled in a plastic bag. Nurse J was down the hallway at their medication cart and was asked if they had observed Resident #12 since lunch and Nurse J stated, no. Nurse J was alerted that Resident #12 was in their bed both oxygen sources were running and that the resident did not have either oxygen tubing on. Nurse J offered they would go put it on the resident. According to the facility provided OXYGEN ADMINISTRATION Release Date: March 2013 policy Purpose A resident will receive oxygen per physician orders .

Based on observation, interview and record review, the facility failed to 1) Follow care planned interventions; 2) Notify the physician of a significant weight loss; 3) Notify the family of a significant weight loss; and 4) Provide meals as ordered for one resident (Resident #1), resulting in unassessed weight loss, meals not provided as ordered with the likelihood of hunger and continued weight loss. Findings include: Resident #1: On 7/23/24, at 9:55 AM, Resident #1 was lying in bed resting. Their breakfast tray remained at bedside and was untouched. On 7/23/24, at 1:03 PM, an observation of Resident #1's lunch offered. The tray was set up on the overbed table and consisted of 2 milks, a chocolate ice cream, peaches and cottage cheese. There was no main lunch meal and no grilled cheese offered. On 7/23/24, at 02:02 PM, a record review of Resident #1's electronic medical record revealed a readmission on 07/10/2023 with diagnoses that included Stroke, Dementia and Multiple Sclerosis. Resident #1 required assistance with all Activities of Daily Living and had severely impaired cognition. A review of the I prefer to stay in bed for meals . At times I refuse meals . Goal I am able to tolerate diet consistency . Interventions . Provide and serve diet as ordered: Regular diet, regular texture, thin liquids . Grilled cheese for lunch daily per request Cottage cheese daily with lunch . Report my weight monthly. Report changes to physician as needed . A review of Resident #1's weights revealed: On 12/05/2023, the resident weighed 132.8 lbs (pounds) and on 07/23/2024, the resident weighed 119.2 pounds which is a -10.24 % Loss. There were no weights for January and February. A review of the progress notes revealed the most recent Type: Dietary/Nutrition Note Effective Date: 06/18/2024 revealed Reweight obtained, current weight 119.2 pounds is reflective of 11.18 % loss x 90 days, 10.25 % loss x 180 days, Nursing stated resident has decreased appetite and meal intake, frequently refusing food and meals when offered. Average meal intake 16 % x 32 meals recorded with 8 refusal x past 14 days . Resident also stated that she enjoys cottage cheese and would like to receive daily; meal ticket updated to reflect preferences. Will continue to monitor PO intake and weight trends, goal is for weight stability, prevention of further weight loss as able. There was no documentation the physician was made aware of the 11.18 % weight loss. On 7/24/24, at 12:58 PM, Resident #1 was lying in bed awake. Resident #1 was asked if they ate and enjoyed their lunch meal. Resident #1 stated, I don't know. Their lunch meal appeared untouched on the overbed table and consisted of 1 bowl of cottage cheese approximately 1 cup, small bowl of jello, 1 piece of cake and 2 milks (1 was opened). There was no lunch plated meal and no grilled cheese. On 7/24/24, at 1:38 PM, an observation along with the Director of Nursing (DON) of Resident #1 and their lunch meal was conducted. Resident #1 was lying flat in bed. The bowl of cottage cheese was empty. The jello, cake and milk was untouched. The DON asked the resident if they wanted a drink of water and Resident #1 stated, I don't know. The DON asked the resident if they were still hungry. Resident #1 answered yes and no to the question. The DON asked the resident if they wanted more cottage cheese and the resident stated, oh yes. On 7/24/24, at 1:44 PM, Server L was interviewed regarding Resident #1's meal service and why they weren't served a lunch meal and a grilled cheese. Server L offered, that they spoke with the CNA's and were told the resident wasn't eating well. Server L offered that they provided a magic cup and cottage cheese to the lunch meal. Server L was asked why they didn't provide the grilled cheese and a full lunch tray and Server L offered, I gave her a little piece of chicken, a little rice and that they had downsized her portions. Server L was alerted that the lunch meal that was given to Resident #1 did not have a plate of food; no chicken, rice or roll and Server L stated, she's not a big bread eater. Server L was asked if they follow the meal ticket and Server L stated, yes. Server L was asked if grilled cheese was written on the meal ticket for day prior why they were not offered a grilled cheese and Server L stated, she wanted a grilled cheese. Server L was asked why Resident #1 didn't receive a grilled cheese for the lunch meal this day and Server L offered, they didn't have that meal ticket. On 7/24/24, at 1:52 PM, Resident #1 was lying in bed. Their lunch tray now had a second bowl of cottage cheese which was empty. On 7/24/24, at 1:55 PM, Nurse J was asked if they received in report that Resident #1 was not eating well and Nurse J stated, the night nurse fills out the 24 hour report sheet. A record review of the nurse report sheet along with Nurse J revealed refused care next to Resident #1's name. On 7/24/24, at 2:30 PM, a further record review of Resident #1's most recent physician visit . Date 7/18/2024 Created Date 07/23/2024 . revealed no mention of the significant weight loss. On 7/25/24, at 7:55 AM, Registered Dietician (RD) M was interviewed regarding Resident #1's weight loss. RD M offered that they did add Ensure twice a day and that Resident #1 is one that refuses a lot including their January and February weight checks. RD M offered that Resident #1's appetite is down and had been liking the Ensure. A review of the nutritional care plan along with RD M was conducted and RD M was asked if grilled cheese was on their care plan why wasn't it being offered and RD M stated, it is on the care plan. RD M explained that they did just add the cottage cheese to the meal ticket on June 18th but was unsure why the grilled cheese was not on the meal ticket if it was on their care plan. RD M was alerted that the resident did not receive a full lunch meal the two days prior and was asked if the grilled cheese and cottage cheese was considered an alternate meal and RD M stated, she should be getting the full tray plus the cottage cheese and grilled cheese. RD M was asked to provide documentation that the physician was alerted of the weight loss and the meal service policy. On 7/25/24, at 12:42 PM, RD M entered the conference room and offered that they discussed with the staff and apparently Resident #1 gets overwhelmed when provided a full lunch meal although they need to provide the full meal and it's up to the resident if she wants it or not. RD M explained the grilled cheese was added to the meal ticket and that the staff was told to offer the entire meal plus the extra's. RD M was asked if the physician was notified of Resident #1's weight loss and RD M stated, no. A review of the facility provided WEIGHT MEASURMENTS Revision Date: July, 2023 revealed . Documentation . Record date and times of physician and family/responsible party notification .

This Citation pertains to Intake Number MI00145715 Based on observation, interview and record review, the facility failed to do complete investigations for injuries of unknown origin (2 skin tears for Resident #27, fracture for Resident #11) and follow, update, and implement care plan interventions for two residents (Resident #11, Resident #27), resulting in incomplete investigations with the likelihood of the injuries to reoccur. Findings include: Resident #27: On 7/23/24, at 10:52 AM, a record review of Resident #27's electronic medical record revealed an admission on 06/16/2021 with diagnoses that included History of falling, Diabetes and Dementia. Resident #27 required assistance with Activities of Daily Living and had severely impaired cognition. A review of the incident report Skin Issue Date: 6/21/2024 09:15 Incident Location: Dining Room . Nursing Description: CNA reported blood coming from resident, This writer observed 2 skin tears 3.5x3cm (centimeters), 3x3cm to left outer leg this am, dried blood black in color draining down le, no skin protectors on . Resident Unable to give Description . Immediate Action Taken . Cleansed with NS (normal saline) applied foam dressings, applied skin protectors to upper and lower ext, (extremity) education for staff to have skin protectors AAT (at all times) and bunny boots on as tolerated . Injuries Observed at Time of Incident . No Injuries observe at time of incident . Predisposing Physiological Factors . Confused and Impaired Memory was check marked . Predisposing Situation Factors . Using Wheelchair was check marked . Statements No Witnesses found . A review of the Progress Notes revealed Effective Date: 6/21/2024 09:37 Health Status Note . CNA reported seeing blood coming from resident, this writer observed 2 skin tears to left outer leg 3.5x3cm, 3x3cm, no skin protectors observed, cleansed with NS applied foam dressings, applied skin protectors to upper and lower ext, education for staff to have skin protectors AAT and bunny boots on as tolerated. Notified PCP, DON, POA . A review of the Interdisciplinary Team (IDT) documentation revealed an IDT progress note Effective Date: 06/24/2024 14:17 Data: IDT reviewed report of new skin issue observed on 6/21/24 @ 9:15. The CNA notified the nurse of blood coming from resident's leg. Resident observed to have 2 skin tears to her left outer leg, 1 measuring 3.5CMx3CM and the other 3CMx3CM. Dried, black blood observed draining down leg. Resident unable to state what happened, no s/s of pain. Area was cleansed with normal saline, foam dressing applied, skin protectors applied. The nurse educated staff on skin protectors due to resident not have skin protectors on when skin issues was observed. PCP and POA notified. Action: Per IDT review, maintenance inspected resident's w/c for any sharp/jagged edges. Response: Care Plan updated accordingly. Author (ADON). On 7/24/24, at 4:25 PM, the facility was asked to provide any further documentation as to how Resident #1 got their 2 skin tears. On 7/25/24, at 10:58 AM, a record review of the Incident Report for Resident #27's 2 skin tear injuries along with The Director of Nursing (DON) was conducted. The DON offered that the ADON did the incident follow up. The DON was asked how Resident #27 injured themselves and the DON stated, the resident was unable to state what happened. The DON was asked what intervention was placed for the resident and the DON stated, they applied the skin protectors and educated the staff as the resident did not have the foam skin protectors on at the time of the injuries. The DON was asked when the foam skin protectors were added to the plan of care and the DON stated, a while back. The DON was asked if they investigated as to how the resident was injured and the DON stated, we figured it happened when she transferred out of bed. The DON was asked what staff member assisted the resident out of bed that morning and the DON stated, I don't know but could look at the charting to see who cared for the resident that day. The DON was asked to review the incident report as to what the resident was doing when the staff recognized the bleeding skin tears and the DON stated, she was using her wheelchair. The DON was asked if the skin tears occurred from the assisted transfer out of the bed or were they from the wheelchair itself and the DON offered they were not sure. The DON was asked if the CNA's were interviewed or if the staff had statements regarding the injuries and the DON stated, No. The DON was asked if they felt the investigation was thorough and the DON stated, No, we probably should have interviewed the CNA. The DON was asked again to provide any additional documentation for Resident #27's injuries/skin tears. A review of the Maintenance Work Order . Assigned on Jun 24, 2024 revealed Wheelchair During morning meeting I was asked to check wheelchair for sharp edges because resident got two skin tears, checked wheelchair over and found no sharp edges . Resident #11 (R11): On July 23, 2024, at 1:30 PM, R11 was observed lying in bed in her room. When asked how she was doing today, R11 replied that she was in pain. When asked where it hurt, she lifted her right leg to show the pink lower extremity cast. R11 said, I broke my ankle when I rolled out of bed. A review of R11's electronic medical record (EMR) revealed that R11 was alert and oriented. Her Brief Interview of Mental Status (BIMS) score was 11/15, assessed on 5/11/24. R11 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, Dementia, Type 2 Diabetes, and Generalized Anxiety Disorders, in addition to other diagnoses. On 6/27/24, she continued to complain of extreme pain. After an x-ray of her right ankle, the x-ray result found: 1) Displaced Segmental fracture of shaft of Right Tibia, initial encounter for closed fracture, and 2) other fracture of upper and lower end of right fibula, initial encounter for closed fracture. During the record review on 7/24/24 at 08:00 AM, no Incident Report (I/A) was created in the EMR for the event on 6/27/24. The Incident Report dated 6/10/24, revealed that R11 fell on [DATE]. R11 complained of pain after the fall on her right ankle. X-ray was performed on 6/10/24 and revealed no acute or recent fracture was found after the fall. R11 complained of pain daily regularly. Because of the fall on 6/10/24, R11 was evaluated by Physical Therapy (PT) on 6/12/24, and PT treatment started on 6/14/24. According to the Rehab Manager (Staff Q) on 7/24/24 at 4:54 PM, during an interview conducted, R11 was showing signs of progress during therapy sessions from 6/12/24 to 6/25/24. However, on 6/27/24, it was noted in the physical therapy notes that during the early morning session, the swelling, discoloration, and guarding pain that was noted was apparent and was different from the previous days of treatment. A repeat x-ray was performed and revealed an acute fracture of the right ankle. R11 was sent to the hospital for further evaluation and treatment. R11 returned with a right lower extremity cast. An Incident/ Accident (I/A) Report was not created in the EMR when the fracture was confirmed on 6/27/24. Upon request for the I/A from the Administrator on 7/25/24 at 9:37 AM, she stated there was no I/A created in the EMR. According to the Administrator, the facility started an investigation and reported it to the state. They concluded that the fracture happened during the fall on June 10, 2024. When asked about the results taken during the 6/10/24 x-ray that was negative compared to the results taken on 6/27/24, which was positive for fracture, the administrator said, Yes, but according to our investigation, we have concluded that the ankle fracture was considered an injury from an unknown source caused by the fall that occurred on June 10, 2024. Nurse N was interviewed on 7/23/24 at 1:32 PM. Nurse N stated she was the nurse when R11 fell out of bed on June 10, 2024. The Certified Nurse Aide (CNA) and Nurse N found R11 sitting on the floor mat. Nurse N did an assessment and got R11 up and back in bed. There were no abnormalities, skin discoloration, or swelling, although she complained of pain on the right side when we got her up. An x-ray was performed, but no recent fracture was found. A few days later, R11 continued to complain of the usual pain. But on 6/27/24, there was more pain, this time with swelling and bruising to the right ankle. R11, described by Nurse N, was observed cuddling her right ankle. When Nurse N asked her what had happened, R11 could not tell her story but continued to complain of pain. A second x-ray was ordered on 6/27/24 and showed a fracture. R11 was sent to the hospital immediately due to increased swelling, increased pain, and apparent bruising. Nurse N did not recall any incident, although she is care planned for self-transferring. There were no reports of falls or incidents after 6/10/24 until 6/27/24, when the pain increased, and other symptoms of fracture appeared. The facility, on 6/27/24, performed an X-ray, and the results and findings were the following: Date of service: 6/27/24 at 15:28 (3:28 PM) Procedure: Tibia and Fibula 2V (2 views) Reason for Study: Acute Pain due to trauma Findings: Tibia and Fibula 2 V Right Comparison to June 11, 2024. Fracture distal tibia appears recent. Cephalad to the patient's fixation hardware . Conclusion: Fracture tibia shaft appears separate from the patient's prior trauma. Correlation with the clinical findings suggested follow-up . Radiologist findings dated 6/27/24 at 10:27 AM, sent electronically, revealed: Findings: Images of the right ankle are submitted. There is a recent spiral fracture involving the distal tibial metadiaphysis with very mild displacement. There are old fixated and healed bimalleolar fractures. Joint alignment is maintained . Conclusion: Recent spiral fracture of the distal tibia . Another x-ray was performed, this time at the Urgent Care at the nearby hospital on the same day (dated 6/27/24 at 7:30 PM). Results concluded: Impression: 1. Acute, mildly displaced proximal fibular diaphyseal fracture. There is an acute, mildly displaced distal tibial diaphyseal fracture with approximately 4 mm posterior displacement of the main distal fragment. 2. Acute minimally displaced proximal fibular diaphyseal fracture. According to the Director of Nursing (DON), on 7/25/24 at 10:30 AM, she revealed that she did the investigation for 6/27/24 for an injury of an unknown origin and submitted the final investigation summary to the state. It was concluded that R11's fracture was caused by the original fall on 6/10/24. The DON had indicated that she had requested a comparative study with R11's x-rays taken on June 10, 2024, comparing it to June 27, 2024, to see if they had missed the fracture but did not get a reply from the x-ray company, not the radiologist. The DON was asked if she disagreed with the x-ray results on 6/27/24, both the facility x-ray and hospital x-ray. The DON did not answer. According to the record review, the facility investigations did not have interviews, clinical input, and record review with the rehab department after the fracture was discovered on 6/27/24. R11 was under Physical Therapy from 6/12/24 through 6/28/24. The facility investigations did not have interviews, clinical input, and record review with the rehab department after the fracture was discovered on 6/27/24. R11 was under Physical Therapy from 6/12/24 through 6/28/24. The surveyor interviewed Rehab staff who had actively participated in R11 care and PT treatment from June 12 to June 28 were not included in the facility investigation: CNA P was interviewed on 7/25/24 at 10:54 AM. CNA P stated she was not working when R11 fell on [DATE]. CNA P heard about her fall when she came back. After the June 10 incident, CNA P recalled that R11 returned to her usual, continued to be her caregiver three days a week, and stated, because I am always assigned to her. CNA P described that at that time, between 6/10/24 and 6/27/24, R11 was doing most of her daily tasks, such as even putting her shoes on by herself. CNA P added with set up, of course. She was doing her transfer with one person assistance. There were no reported falls or incidents. On June 27, CNA P observed increased swelling and pain in R11's right ankle. The reason why she thought it was different is because R11 couldn't put on her slip-on sneakers. It did not fit her shoes. CNAP reported to PT R that she was guarding or babying her right ankle, and PT ordered a full max assist and no weight bearing on the right foot that day. They did an x-ray that day on 6/27th, and there was a fracture. Pain compared to her usual was more on the right foot on 6/27/24. R11 was sent to the emergency roiagnom on [DATE]. R11 returned with a cast on her right ankle and foot with an order of no weight bearing on her right leg. The Rehab Manager (Staff Q) was interviewed on 7/26/24 at 4:54 PM. Staff Q stated they were aware of R11's case because she was under our care from 6/12-6/28 when the fracture was found. PT evaluation was done on 6/12, PT Evaluation only*, and started therapy treatment on the following dates: 6/14/24 for 55 mins 6/17/24 for 55 mins 6/18/24 for 60 mins 6/19/24 for 40 mins 6/20/24 for 60 mins, Bilateral Strengthening Exercises 6/25/24 for 60 mins, Bilateral Strengthening Exercises 6/27/24 for 60 mins, Therapeutic Exercise (Left side only) 6/28/24 for 30 mins, did the left side only with no notes on the right lower extremities. Physical Therapy Service was discontinued due to a newly diagnosed fracture and the order for no weight bearing. Staff Q continued to explain that the goal was to strengthen R11's ability to transfer from lying in bed to sitting on the side of the bed, with no back support with supervision and no back assistance to help R11 get in and out of bed. R11 received therapeutic exercises and treatment. R11 was showing improvement with PT until an increase in pain and fracture was discovered on 6/27/24. When Staff Q was asked what a bilateral strengthening exercise consists of, Staff Q explained that bilateral strengthening exercises focus on active exercises in a seated position with 12 repetitions and three sets without resistance response. R11 significantly improved her usual pain because she could easily tolerate the therapeutic exercises. R11 was discharged from physical therapy on 6/28/24 because there were notes from nursing, and we received the morning report that R11 had a broken right tibia and fibula, and an order for No Weight Bearing (NWB) was put in place. A PT R was working with R11 on 6/27 and scheduled an interview for 7/27/24 in AM The Physical Therapist (PT R) was interviewed by telephone on 7/25/24 at 8:01 AM. PT R recalled R11 as having memory issues. Some days she can do exercises well and some days don't. She described R11's visit on 6/27th vividly because R11 complained of a lot of pain. After reviewing the notes from June 14 through June 27, R11's treatment and exercises consistently showed progress. One of the treatments was effleurage, which was tolerated well by R11. During the treatment sessions, her pain was at baseline, and she was a one-person assist during transfers, but because of R11's cognition, she may continue to self-transfer. PT R explained what therapy treatments were performed on R11, including effleurage. PT R stated, It is a type of massage performed to increase circulation to the area of the body intended to promote circulation and healing. R11 tolerated the massage, and PT R did not recall anything unusual during the sessions. PT R that another PT staff saw R11 on 6/27/24. On 6/27, 2024, R11 received PT only on the left side. It was noted that a 60-minute exercise was given to R11 focusing on the left leg because of complaints of increasing pain in the right ankle. R11 was unable to tolerate standing up with right-sided pain on 6/27/24. The PT Assistant wrote on the Rehab progress notes dated 6/27/24, that there was swelling and much more pain that day, different from previous therapy sessions in the past. The PT R notes indicated that R11 was improving with the treatments and exercises, but not sure what happened and how the fractures came about on 6/27/24. On 7/25/24 at 8:20 AM, Staff Q explained what Effleurage was about and that it: is a type of massage where, in this case, the Physical Therapist (PT) applies light pressure on a focused body part using fingers and flat hands. The purpose is to increase blood circulation, and the strokes are necessary to help increase the temperature of the soft tissues . Upon review of the facility's submitted R11 Facility Report Investigation on 7/23/24 at 3:30 PM, The interviews conducted with staff did not show evidence that the facility did a thorough investigation by obtaining an actual interview and written statements from staff members with pertinent details such as the date and time when the statements were collected. A review of the Summary of Investigation conducted on 7/25/24 at 10:00 AM revealed (with no name and date indicated the investigation was completed to its conclusion. It did not have a date of the inquiry to demonstrate the timeliness of the investigation. The staff interviews were written on a 2-page paper with first names listed and the word no next to the name. The 2-page list did not have a date and time and did not have any title/topic or purpose of the list of names and what actually no means next to the staff names. The Assistant Director of Nursing ADON was interviewed on 7/25/24 at 10:06 AM. The ADON agreed that he did all the interviews and described that he went to every staff member and asked them if they had witnessed anything unusual to R11 during care. He wrote no next to the staff name if they didn't. The ADON was asked if he had collected actual statements and had the staff sign them with the date and time of the interview. ADON stated he only went around and asked staff. I did not go further after the staff said no. The Administrator was interviewed on 7/25/24 at 9:37 AM. She stated that they ended up reporting the injury of unknown origin. The administrator admitted that she was unfamiliar with the current facility's investigation process. The administrator was unaware that an I/A report was not created in R11's EMR dated 6/27/24. However, she indicated that an investigation was thorough and concluded that the new fracture found on 6/27/24 was from the fall that occurred on June 10, 2024. After reviewing the Investigation Summary, the Administrator was questioned on who did the investigation and the completion date and time. She stated, The investigation summary was incomplete because there should have been the author who did the investigation's writing, collection, and conclusion, and was missing the date the summary was completed. The Administrator admitted there was no name, signature, or investigation date. The Administrator agreed that the timeliness of the investigation from start to conclusion was undetermined. The interviews collected did not have the complete names, dates, and the staff job/position. When the Administrator was shown the interview portion, she commented that it was unacceptable and that staff interviews should contain the statements, which must be followed by a signature and the date the staff made the statements. The DON on 7/25/24 at 10:30 AM stated she did the investigation and the investigation summary. She did not sign and date as the author upon completion of the investigation. She agreed that no date was specified in the completion/conclusion summary. She stated that the interviews were delegated to the ADON, which is not the recommended practice for doing interviews. The DON stated that the interview process was not acceptable for the investigation. That is not how it should be done. The facility policies for investigating and reporting abuse, including injuries from unknown origin and the I/A Report, were reviewed on 7/25/24 at 1:00 PM. 39059

Based on observation, interview, and record review, the facility failed to review and revise care plans with resident changes to ensure that interventions necessary for care services for pain were provided for one resident (Resident #11) of 3 residents reviewed for care plans, resulting in the potential for unmet needs, pain, and suffering. Findings include: Resident #11 (R11): A review of R11's electronic medical record (EMR) revealed that R11 was alert and oriented. Her Brief Interview of Mental Status (BIMS) score was 11/15, assessed on 5/11/24. R11 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, Dementia, Type 2 Diabetes, and Generalized Anxiety Disorders, in addition to other diagnoses. On July 23, 2024, at 1:30 PM, R11 was observed lying in bed in her room. When asked how she was doing today, R11 replied that she was in pain. When asked where it hurt, she lifted her right leg to show the pink lower extremity cast. R11 said, I broke my ankle when I rolled out of bed. A review of records on 7/23/24 at 4:00 PM showed, on 6/27/24, R11 persisted to complain of extreme pain to the right ankle. After an x-ray of her right ankle, the x-ray result found: 1) Displaced Segmental fracture of shaft of Right Tibia, initial encounter for closed fracture, and 2) other fracture of upper and lower end of right fibula, initial encounter for closed fracture. Radiologist findings dated 6/27/24 at 10:27 AM, sent electronically, revealed: Findings: Images of the right ankle are submitted. There is a recent spiral fracture involving the distal tibial meta-diaphysis with very mild displacement. There are old fixated and healed bimalleolar fractures. Joint alignment is maintained . Conclusion: Recent spiral fracture of the distal tibia . Another x-ray was performed, this time at the Urgent Care at the nearby hospital on the same day (dated 6/27/24 at 7:30 PM). Results concluded: Impression: 1. Acute, mildly displaced proximal fibular diaphyseal fracture. There is an acute, mildly displaced distal tibial diaphyseal fracture with approximately 4 mm posterior displacement of the main distal fragment. 2. Acute minimally displaced proximal fibular diaphyseal fracture. During the record review on 7/24/24 at 08:00 AM, no Incident Report (I/A) was found in R11's EMR for the event on 6/27/24. The Incident Report dated 6/10/24 revealed that R11 fell on [DATE]. R11 complained of pain after the fall on her right ankle. An X-ray was performed on 6/10/24, and no acute or recent fracture was found after the fall. R11 complained of pain daily regularly. Because of the fall on 6/10/24, R11 was evaluated by Physical Therapy (PT) on 6/12/24, and PT treatment started on 6/14/24. According to the Rehab Manager (Staff Q) on 7/24/24 at 4:54 PM, during an interview conducted, R11 was showing signs of progress during therapy sessions from 6/12/24 to 6/25/24. However, on 6/27/24, it was noted in the physical therapy notes that during the early morning session, the swelling, discoloration, and guarding pain that was reported was apparent and was different from the previous days of treatment. A repeat x-ray was performed and revealed an acute fracture of the right ankle. R11 was sent to the hospital for further evaluation and treatment. R11 returned with a right lower extremity cast. Medication Administration Record (MARS) recorded R11's pain level from 6/8/24 to 6/30/24: Pain Scale level from zero (no pain) up to 10 (worst pain imaginable) Pain Levels from June 8 to June 30 were recorded as follows: On 6/8/24=0, 6/9/24= 0, 6/10/24=0, 6/11/24=2, 6/12/24=9, 6/13/24=8, 6/14/24=0, 6/15/24=10, 6/16/24=10, 6/17/24=0, 6/18/24=0, 6/19/24=10, 6/20/24=10, 6/21/24=0, 6/22/24=2, 6/23/24=0, 6/24/24=10, 6/25/24=8, 6/26/24=10, 6/27/24=2, 6/28/24=8, 6/29/24=0, 6/30/24=8. No follow-up after pain medication/intervention/Administration for relief or effectivity was found documented in the MARS. During a review of R11's medication orders on 67/25/24 at 11:30 AM, it revealed the following orders for pain management: Started Revised date Pain management orders: 7/6/2024 7/5/2024 Tramadol HCL oral tablet 50 mg 7/1/2024 7/1/2024 Monitor Right Leg cast, monitor toes for color . 7/1/2024 7/1/2024 Monitor Right forearm bump 4/1/2024 3/31/2024 Celebrex Oral Capsule 200 mg 1 capsule by mouth . 5/11/2024 4/15/2024 Quarterly Assessments due to Fall, Pain, Braden . 3/19/24 3/19/24 Lidoderm External Patch 5%(Lidocaine) apply to Rt Hip 7/25/23 7/25/23 Ibuprofen Tab 200 mg. 2 tabs . 6/28/23 6/28/2023 Non-Pharmacological Pain Interventions . 11/16/2022 11/16/2022 Assess Pain twice daily for pain On 7/25/24 at 10:30 PM, R11's Care Plan for Pain was reviewed with the Director of Nursing (DON). It was noted that: Date initiated: 02/27/2018, with the revision was made: 5/17/2024. Focus: I have chronic back, hip, shoulder, and leg pain, neuropathy and trigeminal neuralgia, and trigger finger-left ring finger. My pain assessments are the same prior to medication administration and non-pharmacological interventions and after. Goal: 1. I will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date (5/17/2024) Interventions: 1. Administer pain medication as per physician orders. (Date initiated: 2/27/2018) 2. Evaluate for pain every shift and as needed. (Date initiated: 2/27/2018) 3. Evaluate the effectiveness of pain interventions as needed. According to the Director of Nursing (DON), on 7/25/24 at 10:30 AM, she revealed that she did the investigation for 6/27/24 for an injury of an unknown origin and submitted the final investigation summary to the state. According to the DON, it was concluded that R11's fracture was caused by the original fall on 6/10/24. The Care Plan for pain was discussed. The DON had indicated that the fracture was discovered when R11 complained of severe pain that took place on June 27, 2024. A second and third X-ray concluded a spiral fracture of the right fibula and tibia. R11 was sent to the hospital for further evaluation and treatment. The DON stated that the fracture was attributed to the fall that occurred on June 10, 2024. The DON admitted that they failed to make revisions of the pain care plan despite R11 experiencing severe pain due to fractures and injuries from an unknown origin. No revisions were made from June 11, 2024, a record until July 24, 2024, when the state was present for the recertification survey. There were no pain care plan revisions within the time of the fall on 6/10-24 until 7/24/24. The facility's Comprehensive Care Plan Policy (Revision Date: April 2023) was reviewed on 7/25/24 at 1045 AM. Policy: It is the policy of the facility (facility name mentioned) to initiate care plans for all residents in accordance with federal regulations and the identified needs of the resident. Procedure: .7. Initiate a person-centered care plans according to identified needs including measurable goals and individualized approaches. 8. Review Care plans and revise as needs change and in coordination with the MDS schedule. 9. Communicate to staff all care plan needs . The Resident's Rights Policy/ Admission Booklet submitted by the facility was reviewed on 7/25/24 at 1047 am. It is noted in the section: Right to Adequate and Appropriate Pain and Symptom Management It was noted: A resident is entitled to adequate and appropriate pain and symptom management as a basic and essential element of his or her medical treatment.

Based on observation, interview and record review, the facility failed to 1) Ensure dignity during a physician's visit for Resident #10, 2) Respond to call lights timely per a Confidential Resident Group Meeting, and 3) Respond to a grievance from Resident #8, resulting in embarrassment and loss of dignity. Findings include: Resident #10: On 7/24/24, at 3:05 PM, Physician O was observed in the main dining room leaning towards Resident #10. Physician O was overhead discussing with Resident #10 regarding their pain and if it was controlled. Resident #10 was asked if they needed any medication and Resident #10 replied, no I don't need anything. Resident #10 was seated closely next to other residents. On 7/24/24, at 3:15 PM, visitor K who was seated in the main dining room was asked if they overhead Physician O talking with the resident and Visitor K stated, yes and offered it seemed quite personal and wouldn't have liked that if it was them. On 7/25/24, at 12:05 PM, the Director of Nursing (DON) was asked if Physician O had an actual visit with Resident #10 and the DON responded that yes, and would document the note by 3:00 PM that day.

This Citation pertains to Intake Numbers MI00119459, MI00119621 and MI00113949. Based on observation, interview, and record review the facility failed to complete post fall assessments for two residents (Resident#1 and Resident #2) and follow care planned interventions for bed mobility for one resident (Resident #4), resulting in Resident #1 and Resident #2 sustaining multiple falls without proper post-fall assessments and interventions. In addition, Resident #4 rolled off the bed during incontinence care and fractured his left hip requiring surgical intervention. The incontinence care was being provided by one Certified Nursing Assistant (CNA), when the care plan dictated a two-person assist. The facility was cited at Past Non-Compliance with a Compliance Date of [DATE]. Findings Include: Resident #4: On [DATE] at 11:50 AM, Resident #4 was observed watching television in his room. He was observed to have three, large healing skin tares on his left forearm that were sustained in his fall. Resident #4 reported he fell while he was at the hospital and scrapped his arms underneath the bed and broke his hip. On [DATE] at 12:02 PM, Nurse A and Nurse B reported Resident #4 readmitted to the facility about 10 days ago and has recently returned to his baseline. They reported he did contract COVID and was moved into an isolation room shortly before his fall and that is why he believes he fell at the hospital. Nurse A and B added his skin tares are healing wonderfully as they were sustained during his fall. On [DATE] at approximately 12:20 PM, a review was completed of Resident #4's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia, Diabetes, Heart Disease and Kidney Disease. Further review was completed of his medical record and the following was found: Care Plan: I require 2 staff extensive assist to re position and turn in bed . revised on [DATE] but initially added to his care plan on [DATE]. Bedside Kardex: Transferring: I am dependent with staff assist x2 with the mechanical maxi lift for all transfers. Toileting: I am dependent x2 to use toilet with use of mechanical life. Dressing: I require 2 staff extensive assist to dress . Mobility: I require 2 staff extensive assist to reposition and turn in bed . Progress Notes: [DATE] at 21:00: Patient has been discharged from the facility and sent to the hospital after a fall. Patient c/o back pain and it is noted that he is bleeding from multiple places. He will be further evaluated and treated in the ER. [DATE] at 00:29: Resident noted lying on the floor, next to his bed - resident thought back was broken- resident was bleeding multiple places from b/l arms and right foot. pain level 10- notified PCP- order to send to ER for eval. [DATE] at 15:17: IDT reviewed report of resident lying on the floor next to his bed that occurred on [DATE] @ 1900. The CNA was providing care to the resident when the resident rolled out of bed. The nurse entered resident's room and resident was lying on the floor next to his bed, resident had skin tears to left outer ankle, left forearm, and right forearm. Resident stated I think my back is broken, complaints of ,d+[DATE] pain. PCP and resident's wife notified. [DATE] at 15:09: Resident admitted at 1440 from Covenant on stretcher via MMR, Resident is alert and happy to be back, Dx left hip fx (fracture) . On [DATE] at 3:18 PM, an interview was conducted with CNA D regarding Resident #4's fall. CNA D reported there was an assist light on and she and another aide went down the hall and found a fall had occurred. Once they entered the room, they saw Resident #4 was on the floor in between the wall and bed, but was facing toward the door. CNA D explained both of his arms were skinned and there was a copious amount of blood. She reported where Resident #4 fell , there was a wooden cover over the pipe and they think the resident hit the ledge of the covering when he fell , as the covering was no longer affixed to the wall. CNA D stated they were moving him as gently as they could and as they were assisting him to sit up they heard a pop and assumed it from his hip. CNA D reported Resident #4 is a two person assist and has been that level of assistance for some time. On [DATE] at 4:17 PM, an interview was conducted with CNA C regarding her involvement with Resident #4's fall. She reported another aide alerted her to the fall and she informed the nurse. Resident #4 was on the COVID unit, so they had to don appropriate PPE (Personal Protective Equipment) prior to entering his room. CNA C observed Resident #4 on the floor between the bed and the window and his body was positioned oddly. Resident #4 had three skin tares on his left arm from his elbow to the wrist and there was a lot of blood from those injuries. Resident #4 was complaining of back and knee pain and they moved the bed out the way to provide more room for them to assess and assist him. CNA C explained she used her body to help support Resident #4 after they sat him up as the nurse was completing her assessment. CNA C stated CNA F was visibly upset about what occurred. CNA F informed her she went to reach for wipes at the foot of the bed and he rolled off. CNA C reported Resident #4 has always been a two person assist with Maxi lift since she has been employed at the facility. On [DATE] at 4:50 PM, an interview was conducted with Nurse E regarding Resident #4's fall on [DATE]. Nurse E was assigned to the COVID unit, she received report and began to pass her medications. Soon after someone they had a fall and simultaneously Nurse H came over and asked if she needed any assistance. Nurse E asked Nurse H if she could handle the fall as she did not expect the resident would need to be sent out. Nurse E continued to pass her medications and then checked in with Nurse H and was informed Resident #4 had to be sent to the emergency room . Nurse E reported she contacted the physician, paramedics and brought the treatment cart. Nurse E reported she did ask CNA F what occurred and was informed as she was reaching for wipes, he rolled off the bed. Nurse E reported Resident #4 was a two person assist and she did inform the CNA of this when she told her what occurred. On [DATE] at 8:30 AM, an interview was conducted with CNA F regarding Resident #4's fall. CNA F stated she arrived to work and was assigned to the COVID unit and had about 9 residents. About 6:15 PM/6:30 PM CNA F was caring for Resident #4's roommate (completing vitals and cleaning up the resident). Resident #4 informed CNA F as she was still providing care to his roommate that he needed to be changed and was somewhat upset and demanding she provide care to him at that moment. CNA F assured Resident #4 she would take care of him as soon as she finished with his roommate. She added even the resident she was providing care for chimed in and told Resident #4 that she (CNA F) was doing the best she could. CNA F reported once she finished with the roommate, she decided to check Resident #4 and change him to satisfy him in that moment as she knew they were busy that evening. CNA F reported she pulled down Resident #4's brief as he was laying flat in bed as he stated he had a bowl movement. She then turned him slowly toward the window to prepare to change and clear his coccyx, with her left hand lightly holding him and as she reached for the wipes he was not able to sustain his own bodyweight and he rolled off the bed and onto the floor. CNA F explained as he fell , he hit the wooden board (that protrudes from the wall) first and then the floor. She continued the board was already loose and hanging from the wall and other staff were aware of this. CNA F was aware Resident #4 was a 2 person assist for transfers but not bed mobility. She admitted she did not look at the care card prior to doing care and stated Resident #4 was persistent and she wanted to meet his needs timely. CNA F stated as he was being assessed by the nurse, they heard a pop and all assumed it was his hip. On [DATE] at 9:00 AM, this writer and Maintenance Director G observed room [ROOM NUMBER] (the room Resident #4 fell in). The room is currently occupied by another resident who was observed watching television during the observation of the room. On the wall by the window, next to the register was a wooden box cover for the HVAC pipe that was hanging off the wall with nails exposed. Director G reported he was unaware it was not attached to the wall as he never received a work order for it. He reported they built those boxes to protect the HVAC pipes and added he is not sure if the condition of the box occurred before or after Resident #4 fell . The resident reported since he moved into the room the pipe cover was not affixed to the wall. The resident moved into the room on [DATE], 5 days after Resident #4 fell and sustained a hip fracture. The condition of the HVAC cover was not discovered until this writer observed the room in the presence of Maintenance Director G. On [DATE] at 11:00 AM, an interview was conducted with Nurse H regarding her involvement with Resident #4's fall. Nurse D reported she took some medications over to Nurse E and asked if she could assist with anything. Nurse E informed her Resident #4 fell and asked if she could handle that for her. Nurse H reported she did not think much of it as she did not anticipate him needing to be sent out to the hospital. Nurse H walked in, and Resident #4 was on the floor between the bed and window. She assessed the resident as he was responding normally but his arms were bloody from large skin tares. She reported two aides assisted in sitting him up and they supported his bodyweight while she assessed him further, once he was sitting up he expressed pain and stated he thought he broke his hip. Nurse H reported she stuck her head out the door and asked Nurse E to bring the treatment cart and to contact paramedics and physician. Nurse H reported she cleaned up his arms and wrapped them prior to EMS arriving. Prior to them arriving he expressed increased pain and began to dry heave, when EMS arrived, they administered Ketamine for pain management. Nurse H reported the resident cannot hold himself up and is a two person assist. Further review was completed of Resident #4's medical record and the following was found: Discharge Summary: Fall, left hip fracture .patient presented to the ED following an unwitnessed fall from bed at (Nursing Home). Following the fall the patient complained of severe left hip pain. (EMS) was called and patient was given 20mg Ketamine for the pain .XR hip was completed showing a mildly displaced left intertrochanteric fracture . On [DATE] at approximately 10:30 AM, a review was completed of the facility FRI (Facility Reported Incident) investigation regarding Resident #4's fall with hip fracture. At the time of the investigation the facility was unaware that while Nurse E was assigned to Resident #4 that evening, Nurse H assessed, monitored, and provided treatment to the resident immediately following his fall. The following was reviewed: 5 Day Report .On [DATE], around 1900 long term resident, (Resident #4) requested that he needed his brief changed while (CNA F), was in the room caring for his roommate. Once finished caring for the roommate, (CNA F) went to assist (Resident #4). (CNA F) rolled (Resident #4) onto his right side in the bed and reached to grab a wipe and began providing care., At that time (Resident #4) rolled out of bed onto the floor, landing on his left side. (CNA F) attempted to sop him from rolling off the bed but was unable. (CNA F) immediately called for assistance. (Nurse E), assessed resident and observed skin tares to his right arm and right foot. (Resident #4) had complaints of pain ,d+[DATE] to his back, stating, I think my back is broken. (CNA C) reports she entered the room at roughly 1900 and observed resident laying on the floor between the bed and wall with skin tears on his arms and complaints of pain all over .On [DATE] at 0815 . notified DON that resident had a mildly displaced left intertrochanteric fracture that would require surgery .Resident underwent surgery on [DATE] for an Open Reduction Internal Fixation Left Intertrochanteric Hip Fracture .After full investigation the facility has determined that (Resident #4) is dependent and requires two-person assistance with toileting, bed mobility, and dressing and the plan of care was not followed. (CNA F) was immediately educated at the time of the occurrence and a final discipline was issues on [DATE] . Statement from CNA F: On [DATE] I was taking vitals and answering call lights. Upon entering room [ROOM NUMBER], resident in bed 1 said he needed his pants off so he could use the bathroom. I took bed one's vitals. Resident in bed two (Resident #4), began to holler that he needed to be changed. I assured him that I would help him as soon as I was done helping bed one. (Resident #4) repeated that he needed assistance. When I finished with bed one, I went to check on (Resident #4) and his brief needed to be changed. I rolled him over to check his bottom. While I had him rolled over I reached for wipes, cleared his bottom, and he just rolled out of the bed. I tried to grab him but he kept rolling out of the bed toward the window. I put the call light on and moved the bed. Then I went to the door and called for help stating a resident was down on the floor . On [DATE] at 12:10 PM, an interview was completed with the DON (Director of Nursing) and Consultant Nurse I regarding Resident #4's fall that resulted in a hip fracture. The DON was contacted once Resident #4 was stabilized and being transported to the emergency room for treatment. The DON was informed Resident #4 rolled out bed as CNA F was providing care alone. It was expressed the resident has always been a two-person assist and the aide used inappropriate assistance when completing incontinence care. The DON stated they were informed the next day Resident #4 fractured his hip and required surgery to repair it. She reported Resident #4 had just moved to isolation because he had COVID and was demanding and yelling for CNA F to change him. The aide admitted she did not look at his Kardex prior to providing care for him. The CNA was immediately educated by the nurse prior to them initiating education to all facility staff. The DON and Consultant Nurse I reeducated all facility staff on checking the care plan prior to providing care and their nurses complete random audits of aides while they are providing care to ensure they follow the appropriate level of assistance. They have seen staff are communicating more with one another about assistance level required. We further discussed that Nurse H was not interviewed during their FRI investigation and they explained they were not aware she was the nurse who provided aid to Resident #4 after his fall. During the abbreviated survey the facility was found to be out of compliance with their regulatory requirement. But they recognized the deficient practice, completed a process change, education, and audits prior to survey entry and during the survey they were found to be currently compliant. Therefore, Past Noncompliance will be granted with the compliance date [DATE]. On [DATE] at 1:00 PM, a review was completed of the facility policy entitled, Turning a Dependent Resident Away from the Caregiver, revised [DATE]. The policy stated, .Using a draw sheet adjust the residents position by pulling resident as close to caregiver as possible before turning resident on their side. 6. Cross the residents' arms over chest, Cross the leg nearest to you over the leg farthest from you, unless contraindicated .7. Place one hand under the residents' shoulder and the other under the hip. Using good body mechanics roll the resident gently and smoothly away from you. Maintain contract with resident to ensure resident is securely positioned . 37666 Resident #1: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's dementia, anxiety, arthritis, depression, heart disease, atrial fibrillation, pulmonary hypertension, history of falls with history of left hip fracture. The MDS assessment dated [DATE] indicated the resident had a memory problem and needed assistance with all care. The resident died on [DATE]. A review of a Facility Reported Incident (FRI) indicated Resident #1 complained of right-sided abdominal pain with facial grimacing and guarding of the right abdomen on [DATE] at 5:05 AM. The resident was assessed by nursing with all vital signs normal except for an elevated heart rate of 105 beats per minute and her oxygen saturation rate was 93% (the lower end of normal). The resident was transferred to the hospital at 1:48 PM on [DATE]. The FRI investigation revealed the resident returned from the hospital on the same day [DATE] with diagnosis of a fracture of one rib (the fourth) on the right side. At that time, Resident #1 also was identified to have- purple bruising on the left anterior leg, right breast, under the right arm, right mid-back, and right upper buttock. The resident began receiving Morphine as needed, a Lidocaine patch and Tylenol. Per the investigation, the resident was assisted out of bed at approximately 5:00 AM on [DATE], by Nurse P and Certified Nursing Assistant/CNA O with no complaints of pain. Then at approximately 8:50 AM she began to complain of pain to Nurse B with guarding of the right side. After lunch [DATE] she yelled Help and when assisted to bed by Nurse B and CNA Q, the resident screamed out in pain, and stated, I feel like I'm going to get sick and yelled out Help me. A review of an Incident and Accident Report for Resident #1 dated [DATE] at 1805 (6:06 PM) indicated the resident fell , Patient was observed on the floor by kitchen staff. The incident occurred in the dining room and the resident had been sitting in her wheelchair prior to falling. She obtained a skin tear to her left temple. On the Incident and Accident Report dated [DATE], the heading List any interventions that can be added that may prevent further occurrence was blank. The Interdisciplinary team made documented a recommendation to Move table in dining room to prevent chair from getting stuck. There was no mention of other interventions. Dietary Aide R's statement [DATE] at 1805 (6:05 PM), I was bussing (tables) in the front of the main dining room when I heard some one say Ouch. I turned around and she (Resident #1) was on the floor. I ran to get nurses. A review of the fall assessments for Resident #1 revealed a Fall Risk Assessment was completed on Readmission [DATE] and the resident was assessed to be High Risk for falls with a score of 20. The next Fall Risk Assessment was completed on [DATE] with the Quarterly MDS assessment. Resident #1 was again assessed to be High Risk for falls with a score of 17. The [DATE] Fall Risk Assessment asked History of Falls within last six months: 'Multiple Falls,' was checked. The section titled, Medication Use only had Antihypertensives checked. The resident also received routine narcotics and psychotropic medications, but they were not checked on the assessment form. In addition, the resident was receiving Reglan, a medication that can cause many side effects in elderly residents including, drowsiness, loss of strength or energy, muscle pain or weakness, restlessness and unusual weak feeling. There was no Fall Risk Assessment completed after Resident #1 fell on [DATE] and obtained a skin tear to her left temple. A review of the progress notes revealed the following: [DATE] at 4:27 PM, Patient was found on the floor in the dining room. Patient did not state what she was doing, and the fall was not witnessed. Patient has a 0.9 cm skin tear to the left side of her forehead . [DATE] at 11:21 AM, . resident's glasses were broken from her fall yesterday. Notified POA to contact residents eye doctor to order a new pair. [DATE] at 3:57 PM, a provider note, Seeing patient today after a fall she had on [DATE]. Patient does have a bruise to the left eyebrow area with small skin tear . A review of the Care Plans for Resident #1 identified the following: I have a risk for falling r/t (related to) confusion, fluctuating cognition, wandering, self-transferring, deconditioning, gait/balance problems, incontinence, medication, psychoactive medications, unaware of environmental factors . date initiated [DATE] and revised with cancellation on [DATE]. The interventions were not updated after the resident fell and injured her forehead on [DATE]. A post-fall Fall Risk Assessment was not completed after Resident #1 fell on [DATE] and the Care Plan was not updated. Resident #2: A record review of the Face sheet and MDS assessment indicated Resident #2 was admitted to the facility on [DATE] with diagnoses: Dementia, heart failure, history of respiratory failure, and hypertension. The MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment and needed 2-person assistance with transfers and 1-person assistance with toileting and ambulation. The resident died on [DATE]. A review of a Facility Reported Incident (FRI) investigation indicated Resident #2 fell on [DATE]. She was observed on the floor of her room and complained of pain in her left hip. She was assessed and had a bruise on her left hip and left hip. An x-ray of the left hip was ordered on [DATE] and completed on [DATE] with results of a left hip fracture. A review of the progress notes revealed the following: [DATE] at 4:53 PM, Patient reported to therapy that she had fallen last night and got herself back up and into bed . A bruise measuring 1.5cm x 1.5cm x 0 was observed to her left knee . [DATE] at 8:40 AM, CNA (Certified Nursing Assistant) observed resident on the floor . observed to be laying on her back by the end of the first bed . was persistent on her left hip hurting and later turned into her let groin . bruise was found to left elbow and left hip . a few hours later patient became very anxious and in pain to where she was constantly calling out, asking staff to sit with her, she didn't want to be alone . she couldn't get comfortable and was in pain . [DATE] at 9:32 AM, a note by the provider, . fell last night and broke her left hip . [DATE] at 2:33 pm, received order to increase morphine . also received order for Norco ,d+[DATE] mg every 6 hours for pain management . [DATE] at 3:34 PM, a note indicated Resident #2 had died . A record review of the Incident and Accident Reports for Resident #2 indicated the resident had fallen twice after she was admitted to the facility: [DATE] and [DATE]. The Incident and Accident Report dated [DATE] revealed, Patient stated she was trying to get into bed and slipped and fell . There were no witnesses, and she obtained a left knee bruise measuring 1.5 cm x 1.5 cm x 0. Patient stated she was in her wheelchair . Self-transfers frequently. Rearrange room, moved across from nurse's station. A review of the Fall Risk Assessments for Resident #2 identified one completed on admission [DATE]. There was no completion of Fall Risk Assessments after the resident fell on [DATE] to aid in preventing additional falls; Resident #2 fell again on [DATE] and fractured her left hip. There was no fall risk reassessment after the fall with fracture on [DATE]. A review of the Care Plans for Resident #2 revealed, I have a risk for falling related to confusion, fluctuating cognition, wandering . gait balance problems, incontinence, Medication . date initiated [DATE] and updated after discharge [DATE]: Interventions updated [DATE],For my safety, I require a room close to the nurses station, date initiated [DATE]; [DATE] updated Offer to toilet me at the start of shift and at the end for my safety, as I am known to self transfer . On [DATE] at 12:50 PM, the DON and Corporate Clinical Nurse were interviewed related to the lack of a reassessment of fall risk after Resident #2 fell on [DATE] and incurred an injury (change of condition), the Corporate Clinical Nurse Resident #2 should have had a completed Fall risk assessment after the fall. Also discussed the fall Resident #2 had on [DATE] when she sustained a left hip fracture. The Corporate Clinical Nurse was asked why the facility waited until the resident had fallen twice and sustained injuries both times to provide an intervention to toilet the resident. In the Care Plan it was noted on [DATE] that she attempted to transfer self and was incontinent. On the [DATE] Incident and Accident Report it noted, Due to my cognition, I sometimes self-transfer without assistance . There was no explanation why a toileting plan was not initiated sooner. A review of the policy titled, Fall Management Guidelines, dated revised [DATE] provided, 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 . Residents will be assessed for fall risk upon admission, quarterly, annually and with a change of condition . Residents identified at risk for falls will have a care plan developed and implementation of appropriate fall prevention interventions .

This citation pertains to Intake Number: MI 484. Based on interview and record review the facility failed to prevent verbal and mental abuse that included an inappropriate photograph being taken and distributed, using social media on a personal cellphone, by facility staff of a legally blind and cognitively impaired resident's nude lower body and in a compromised position for one (Resident #18) of three residents reviewed for abuse resulting in a reasonable person experiencing psychosocial harm such as feelings of mental anguish, humiliation, fear, shame, dehumanization, increased agitation/anxiety, and/or degradation. Findings include: A facility reported incident report was submitted to the state agency on 1/3/19 at 4:25 PM for a verbal and mental abuse incident that occurred on 12/7/18; date confirmed by the NHA (Nursing Home Administrator) during an interview on 03/13/19 at 01:15 PM. Review of Resident #18's face sheet, dated 1/3/19, indicated the [AGE] year old had [DIAGNOSES REDACTED]. Resident #18's toileting care plan, revised 2/1/19, stated Involuntary of urine and stool, check and change upon arising, before meals, at bedtime, and as needed. Wash, rinse and dry perineum (The space between the anus and scrotum in the male and between the anus and the vulva in the female). Apply protective ointment after each incontinent episode. Change clothing PRN (as needed) after incontinence episodes as needed. Resident #18's anxiety care plan, revised 2/6/19, stated .She will become anxious and restless, she will make repetitive sounds, fidget, suck/bite on her lip to the point of swelling at times, suck/bite her fingers and clothing, and be unable to relax or settle down. She becomes easily overwhelmed and anxious is (if) the environment around her is loud, bright, and overstimulating. The anxiety care plan included interventions of If Resident #18 is exhibiting signs of anxiety, hold her hand, and talk in a calm, soft voice to her. This helps reassure her and relax., She is receiving an antidepressant to aid in her anxiety., and She is receiving anti-anxiety medication .Resident #18's most recent brief interview for mental status score, dated 12/20/18, was zero, reflecting severe cognitive impairment and was rarely/never understood. The facility incident report, submitted 1/3/19, stated, On 1/2/19, the NHA (nursing home administrator) was notified by (CNA (Certified Nursing Assistant) G) that before Christmas she had witnessed (CNA H) take a picture of resident, (Resident #18)' s soiled brief with part of her buttock exposed while cleaning her up in the shower room and sent the picture to her mother via (social media application). (CNA G) stated that CNA H said I am sorry, but I have to send this to my mom so she can see the (explicit term for feces) I have to deal with on a daily basis .(CNA G) notified the nurse (Nurse I), LPN of the situation who then notified Nurse Manager, (Nurse J), LPN. (Nurse J) stated that there was really nothing that could be done as it was on (social media application) and the picture disappears within seconds. No further follow-up or notification occurred at that time. Resident, (Resident #18) has a [DIAGNOSES REDACTED]. The demeaning verbal statement was made within hearing distance of the legally blind and cognitively impaired Resident #18. Due to Resident #18's impaired cognitive status applying the reasonable person concept, a reasonable person would experience feelings of mental anguish, humiliation, fear, shame, dehumanization, agitation, and/or degradation from the mental and verbal abuse that occurred. Resident #18's anxiety care plan, initiated 3/27/18, stated She becomes easily overwhelmed and anxious is (if) the environment around her is loud, bright, and overstimulating., which indicated Resident #18 had a history of [REDACTED]. Review of CNA H's Employee Discipline Form, dated 1/4/19, stated It was brought to the attention of the Administrator on Wednesday, (MONTH) 2, 2019 that CNA H was observed in the shower room where she took a picture of the left side of a resident's (Resident #18) buttock that had feces on it, with her cell phone, and then uploaded the picture to the social media site (social media application) with the comment this is the (explicit word for feces) that I have to deal with and posted it. In a conversation with CNA H on Thursday, (MONTH) 3, 2019, she stated that people use phones all the time and everyone is on (social media application), (social media application), (social media application) or whatever. CNA H also admitted to having her phone on her person and always does. Based on her statements we can reasonably conclude that she did take a picture of the resident and post it on (social media application). This is, not only disrespectful to the resident, but also a State reportable incident. Review of an undated hand written note, within the facility's reported incident investigation folder, stated Sent to mom while laughing I am sorry, I have to show her what I deal w/ (with) everyday. This note indicated CNA H laughed at Resident #18, as she was partially naked, toileting, and in a compromised position while being within hearing distance. This showed lack of respect and dignity towards Resident #18 and was an act that dehumanized and degraded Resident #18. A reasonable person, and one who was dependent on staff for toileting care, would experience psychosocial harm if their caregiver laughed at them while taking a photograph of them partially naked while bowel movement activities were being addressed, and further distributed that photograph to others. During an interview on 03/13/19 at 01:04 PM, Nurse I recalled and reported what CNA G had reported to her the day the abuse occurred to Resident #18. Nurse I reported that she then reported the incident Right away, that night to Nurse J, and that Nurse J didn't report the incident to the NHA. Nurse I reported CNA G told her that the abuse of Resident #18 occurred in the large bathroom in long hall of morning glory, Resident #18 was seated on a commode chair positioned above the toilet, CNA H crouched down and took a photo from underneath the commode aimed upwards at the exposed Resident #18's private area and buttocks, and the resulting photo would have been a picture of her bottom, and the bowel movement. Nurse I confirmed Resident #18 was blind and that based on what she was told that CNA H stated this is the (explicit term for feces) I deal with and I'm sending this to my mom . During an interview on 03/13/19 at 01:15 PM, The NHA reported the abuse incident occurred on 12/7/18, but was reported to her on 1/2/19 as no staff from the 12/7/18 shifts reported it to her that day. NHA reported no staff should have phones on them, except for designated work phones for particular staff members, while working and that personal phones can only be used in the break room or their automobile. The phone use as described in the 12/7/18 abuse incident was not appropriate or in any way work related. NHA reported that the local police department was contacted and came out 1/3/19 to investigate. Record review of the facility's Abuse and Neglect Prohibition Policy, revised 1/2018, stated Residents have the right to be free from abuse, neglect, exploitation . Record review of the facility's Communications Policy, revised 7/30/18, stated All communications should be professional, .appropriate, and not disrupt .patients, residents and clients we serve., The use of cell phones in patient care areas is prohibited ., Must not use social media in any way to attack or abuse other .residents/clients or their families, and Must not post any .resident/client confidential information.

This citation pertains to MI 064. Based on observation, interview, and record review, the facility failed to perform a comprehensive assessment that identified all of the risk factors for dehydration, implement care plans to prevent dehydration for one resident (Resident #42) and assure water was in reach for three residents (Residents #40, #41, and #42) out of four residents reviewed for hydration in a sample of four residents resulting in one resident (Resident #43) requiring readmission to a hospital for [DIAGNOSES REDACTED]. According to the Mayo Clinic Patient Care and Health Information website, (accessed 7/5/2016 at http://www.mayoclinic.org/diseases-conditions/dehydration/basics/definition/con- 056), dehydration occurs when more fluids are lost from the body than are taken in. The elderly, people with Diabetes or infections, people with cognitive impairments that may not realize they are thirsty or people with physical impairments be unable to obtain fluids, and people who take certain medications are at an increased risk of developing dehydration. Complications of dehydration can include imbalances in the electrolytes that regulate bodily functions, low blood volume shock, [MEDICAL CONDITION], kidney damage, and even coma and death. According to the Admission Record, printed from the electronic medical record (EMR) on 6/29/2016, Resident #42 was an [AGE] year-old male originally admitted to the facility on [DATE] for a short term stay following a fall and fracture and surgical repair of the right hip joint with an artificial implant. The Admission Record listed additional diagnoses, dated 2/18/2016, of Diabetes Mellitus, [MEDICAL CONDITION], pneumonia, ileus (a problem with the function of the bowel), severe [MEDICAL CONDITION], a urinary tract infection, and cognitive communication deficit. The Care Area Worksheet (CAA), dated 2/29/2016 (the day Resident #42 was transferred to the hospital), identified Resident #42 as having a potential problem for dehydration/fluid maintenance because of recent pneumonia, [MEDICAL CONDITION], and a urinary tract infection. The CAA, dated 2/29/2016, reported that Resident #42 had scored 6 of 15 on the brief interview for mental status indicating severe cognitive deficits and impaired ability to made daily decisions. A care plan was initiated related to the potential for dehydration (due to the nature of the computer software, the date initiated was recorded as the date the care plan was printed, 6/29/2016). The care plan interventions, dated 2/29/2016 (the day Resident #42 was transferred to the hospital), included: Encourage/Assist me with fluids on a regular basis. Monitor/document bowel sounds and frequency of BM: provide medication per order. Provide me with bedside water. During a telephone interview with a family member of Resident #42 on 6/29/2016 at 8:15 am, it was reported that the family visited with the resident on a daily basis and on many occasions Resident #42's water glass was set where he could not reach it. According to a progress note, dated 2/29/2016, Resident #42 was transferred to the hospital on that date at 6:20 pm after an assessment by a Nurse Practitioner. The progress note recorded that Resident #42 had been declining over the past two days. According to a physician consultation recorded in the hospital record on 3/1/2016, Resident #42 had acute kidney injury on top of the [MEDICAL CONDITION] and was very volume depleted and dehydrated. According to a physician progress notes [REDACTED].#42 had also been found to have a fecal impaction, constipation, and diverticulitis (an inflamed bowel) when he had presented to the hospital on [DATE]. Resident #42 had been given enemas and placed on laxatives while he had been in the hospital. According to the facility progress notes, Resident #42 was readmitted to the facility on [DATE] at 10:35 am. A review of the care plan for the potential for dehydration for Resident #42 revealed that no additional interventions or additional monitoring strategies had been implemented. On 6/29/2016 at 9:00 am, Resident #40 was observed laying in the bed in his room. Resident #40's call light was on the floor to the left of him. Resident #40's water glass was out of his reach sitting on the window sill. According to Resident #40's Minimum Data Set Assessment (MDS), dated [DATE], he required the assistance of two people to move in his bed and to transfer into and out of bed. On 6/29/2016 at 9:10 am, Resident #41 was observed in her room sitting in her wheelchair. Resident #41's water glass was out of her reach on her overbed table and a walker was sitting between her and the table. According to Resident #41's MDS, dated [DATE], she required the assistance of two people to transfer in and out of her wheelchair, did not walk, and required assistance of one person to move about in her wheelchair. ( )

This citation pertains to MI 064. Based on interview and record review, the facility failed to prevent and treat constipation for one resident (Resident #42) out of one resident reviewed for bowel protocol in a sample of four residents resulting in the hospitalization of Resident #42 for conditions including dehydration, constipation, and fecal impaction. Findings include: According to the Admission Record, printed from the electronic medical record (EMR) on 6/29/2016, Resident #42 was an [AGE] year-old male, who was originally admitted to the facility on [DATE] for a short term stay following a fall and fracture and surgical repair of the right hip joint with an artificial implant. The Admission Record listed diagnoses, dated 2/18/2016, of Diabetes Mellitus, [MEDICAL CONDITION], pneumonia, ileus (a problem with the function of the bowel), severe [MEDICAL CONDITION], a urinary tract infection, and cognitive communication deficit. The Admission Record documented Resident #42's last hospital stay as 2/29/2016 to 3/8/2016 when he was readmitted with [DIAGNOSES REDACTED]. According to the facility procedure for Bowel Protocol, revised date April 2013, the policy was intended to monitor residents bowel patterns daily to prevent the development of constipation and/or bowel impaction. The protocol instructed that if a resident had gone two days without a bowel movement, the nurse was to give 30 cubic centimeters (CC's) of Milk of Magnesia at bed time of the second day. If the resident had not had a bowel movement by the morning of the third day, an additional 30 cc's of Milk of Magnesia was to be administered on that morning. If the resident still had no bowel movement by the evening of the third day, a [MEDICATION NAME] suppository was to be administered at bed time. If there were no results from the suppository, the physician was to be called for further orders. According to the bowel movement report for Resident #42 for February of 2016, no bowel movement was documented for 2/18/2016, 2/19/2016, and 2/20/2016. A medium sized bowel movement was recorded at 3:07 pm on 2/21/2016. According to the protocol, Resident #42 should have received 30 cc's of Milk of Magnesia on 2/20/2016 and on the morning of 2/21/2016. No Milk of Magnesia was recorded as administered on the February 2016 Medication Administration Record (MAR) to Resident #42 on either 2/20/2016 or on 2/21/2016. No bowel movement was documented for Resident #42 on 2/22/2016, 2/23/2016, 2/24/2016, or 2/25/2016. No Milk of Magnesia was documented as administered to Resident #42 until 11:10 am on 2/26/2016. The results of the Milk of Magnesia were recorded as Ineffective. A small bowel movement was documented for Resident #42 on 2/26/2016 at 1:51 pm. No further bowel movements were documented for 2/27/2016, 2/28/2016, or 2/29/2016. On 2/28/2016 at 8:34 am, 30'ccs of Milk of Magnesia were documented on the MAR, and the results were recorded as Ineffective. On 2/28/2016 at 11:53 am, the MAR indicated that a [MEDICATION NAME] suppository was administered with the results recorded as Unknown. On 6/30/2016 at 2:40 pm, The Assistant Director of Nursing, Registered Nurse (RN) Staff B and the Unit Manager, Licensed Practical Nurse (LPN) Staff C were asked what was meant by Ineffective and Unknown, how could the results of a suppository be Unknown? After a long pause, LPN Staff C finally said, I don't know. According to Mosby's Seventh Edition of the Medical-Surgical Nursing textbook, constipation can be defined as a decrease in the frequency or volume of bowel movements and/or the retention of stool in the rectum. Signs and symptoms of constipation can vary from discomfort to severe pain in the abdomen. Other signs and symptoms include abdominal distention or bloating, poor appetite, headache, and nausea. When the bowels stop moving, a fecal impaction can occur as a result of the constipation and perforation of the bowel may occur. This condition is life threatening and causes pain, nausea, vomiting, fever, and elevated white blood cell counts. According to the Progress notes dated 2/27/2016 at 7:45 am, Resident #42 complained of not feeling well and stated he was nauseous. The MAR indicated that a medication for nausea was administered to Resident #42 on 2/27/2016 at 9:38 am and it had been effective. The Daily nurses note for the day shift of 2/27/2016 documented that Resident #42 had bowel sounds present, his abdomen was soft and nontender, and that he denied nausea and vomiting. The date of the last bowel movement was recorded as 2/27/2016 on this note which did not match the Bowel Movement Report. A nursing Progress Note dated 2/28/2016 documented that Resident #42 had complained of nausea and had a small emesis at 11:42 am. A nursing Progress Note, dated 2/29/2016 at 6:15 pm, documented that Resident #42 had been declining over the past two days. The note stated that a Nurse Practitioner had assessed Resident #42 and wanted him to be sent to the emergency room . The family had been contacted and an ambulance transported Resident #42 to the emergency room at 6:20 pm. According to a hospital physician's consultation report, dated 3/3/2016, Resident #42 had a fecal impaction and mild diverticulitis noted on a cat scan performed after he arrived at the hospital on [DATE]. According to the consultation report, Resident #42 had been given an enema with good results and the distention of his abdomen had improved. After Resident #42 had been readmitted to the facility on [DATE], the bowel movement Report indicated that no more than one day had lapsed between bowel movements from 3/8/2016 through 3/18/2016, the date of his transfer to a local hospital. ( )

This citation pertains to intake MI 9823. Based on observation, interview, and record review, the facility failed to perform assessments of pressure sores upon admission for two residents (#31 and #33), develop a plan of care and treatment, and prevent the development of a pressure sore for one resident (#31) and inform the responsible party of the pressure ulcer development for one resident (#31) resulting in a stage four pressure ulcer with visible bone being left untreated for [REDACTED]. Findings include: According to the facility's Skin Management Facility Guidelines, revised May, 2015, A baseline head-to-toe skin assessment was to be conducted on each resident upon admission and readmission. Residents who were admitted with skin impairments were to have appropriate interventions implemented to promote healing; a physician's orders [REDACTED]. The documentation was to include the location and staging of the pressure ulcer including the size with the depth and the extent of any undermining noted, a description of any wound drainage, a description of the base of the wound, and a description of the wound edges and surrounding tissue. A care plan was to be developed upon admission to address the contributing risks for skin breakdown, preventative devices, the resident's physical activity, positioning requirements, and proper body alignment. The facility's procedure for Facility-Acquired Pressure Ulcers, revised December 2011, had objectives that included the assessment of residents with identified pressure ulcers and implementation of interventions to reduce further pressure ulcers and treat identified pressure ulcers and to ensure that adequate facility interventions are implemented for reduction and treatment of [REDACTED]. The process for the procedure directed that each resident was to have a head-to-toe skin check upon admission and readmission. Residents identified as at risk for developing a pressure ulcer were to have a care plan initiated with interventions to reduce the risk. Those residents identified as having a pressure ulcer were to have a care plan initiated, a treatment order for the pressure ulcer, and an assessment of the wound to include the size, stage, location, drainage, and odor. Additionally, the licensed nurse was to communicate to the resident's family or responsible party the presence of a pressure ulcer and to document that communication in the resident's medical record. The facility's undated Admission Checklist instructed that a Admit/Readmit Screener, which included a section to describe any alterations in the skin, must be completed on same day as admit. Any skin issues were to be measured and described and a treatment implemented. Care plans were to be completed within 24 hours of admission for the potential for pressure ulcers, and, if needed, impaired skin integrity. According to the Admission Record, printed on 6/15/2016, Resident #31 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Discharge Summaries from the previous healthcare facility, dated 6/10/2016, revealed that Resident #31 had abdominal surgeries on 4/17/2016 and 4/27/2016 and wound reclosure with retention sutures performed on 5/2/2016, placement of a percutaneous gastric tube for feeding, abnormal blood laboratory values, severe deconditioning, and a stage four sacral pressure ulcer with some necrotic tissue. According to the National Pressure Ulcer Advisory Panel's publication, treatment of [REDACTED]. Eschar (dead necrotic tissue) may be present. Stage four wounds often include undermining and tunneling. Stage four ulcers can extend into muscle and/or supporting structures making infections likely to occur. According to the Progress Note, entered into the electronic medical record on 6/10/2016 by Registered Nurse (RN) Staff E, Resident #31 was admitted to the facility at 11:40 am on 6/10/2016. The skin integrity section of the Admit/readmit screener was dated as completed on 6/13/2016 by Licensed Practical Nurse (LPN) Staff D. On 6/15/2016 at 2:20 pm, RN Staff E was interviewed by telephone. RN Staff E stated that she had been on duty when Resident #31 was admitted on [DATE]. RN Staff E stated that she had started the Admit/readmit screener on that day and had performed a head-to-toe assessment of Resident #31 but had not removed the wound dressings that had been present on Resident #31's abdomen or sacrum. RN E stated that she had not looked at or measured those wounds. RN E said that she had told the oncoming nurse that she had not removed the dressings and looked at the wounds and that the oncoming nurse was told that wound assessments needed to be done. On 6/15/2016 at 9:35 am, RN Staff H was interviewed. RN Staff H stated that he had cared for Resident #31 on 6/11/2016 and 6/12/2016 on the day shift. RN Staff H stated that he was not aware on those days that Resident #31 had a pressure ulcer. RN Staff H stated that he had seen the dressing on Resident #31's abdomen while providing care for her but had not performed any dressing changes. RN Staff H stated that the nurse who reported off to him on the mornings of 6/11/2016 and 6/12/2016 had not given him any information about Resident #31's wounds during report and nothing had been noted on the written report sheets about the wounds. On 6/15/2016 at 10:30 am, LPN Staff D was interviewed. LPN Staff D stated that the first time she had cared for Resident #31 was on the day shift on 6/13/2016. LPN Staff D said that she had not been told that Resident #31 had a pressure ulcer. LPN Staff D had asked the nursing assistants to lay Resident #31 down, she was in a wheelchair, and prepare her for a skin assessment. LPN Staff D did not recall what time this had occurred on 6/13/2016, but said, that was the same time that you saw her. (That was 4:00 pm on 6/13/2016.) LPN Staff D stated that she had removed Resident #31's dressing on her abdomen, and when she saw the retention sutures they were something new to her so she called the wound nurse, LPN Staff C to come assist her right away. LPN D said that when LPN C arrived, she had taken over the assessment of Resident #31 while she, LPN D assisted. On 6/13/2016 at 4:00 pm, LPNs C and D were observed in the room of Resident #31 as they completed at dressing change and treatment to the pressure ulcer on her sacrum. The old dressing had already been partially removed and a large wound that had dark brown/black eschar was observed that covered Resident #31's sacrum, coccyx, and a major part of her buttocks. The old dressing was observed to be soaked with dark colored and bloody drainage. On the Admit/readmit screener the section describing the skin integrity, dated 6/13/2016, described the abdominal incision as measuring 18 centimeters (cm) up and down with 5 retention sutures with the wound having a depth of 1 to 1.5 cm. The sacrum had a wound bed that measured 10 cm by 11.5 cm and 1.7 cm. deep. The right heel had a blister that measured 5 cm by 5 cm. The skin/wound progress note documented, Stage IV pressure injury to sacral region. Small area of bone visible where some of eschar has lifted, but greater than 75 % of wound remains covered with dark brownish black leathery necrotic tissue. Exuding serosanguinous drainage. Purple halo of 1-3 cm. width outside wound edges. On 6/15/2016 at 8:35 am, Resident #31 was observed in her room. A large fluid filled purplish colored blister was observed on her right heel. Resident #31 had a heels-up device under her legs, but her heels were resting on the device, not hanging over the end of it as the device was intended so no pressure would be on her heels. A review of the Order Summary Report, printed on 6/15/2016, revealed that there were no current or discontinued treatment orders for Resident #31's stage four sacral pressure ulcer, the open abdominal surgical wound, or the suspected deep tissue injury-depth unknown pressure ulcer on her right heel. A review of Resident #31's care plan revealed that no care plan had been put in place for the treatment of [REDACTED]. A review of Resident #31's treatment records revealed that no treatment had been documented to the abdominal surgical incision until 6/13/2016, three days after her admission. No treatment to the pressure ulcer wound on her sacrum had been documented until a progress note entry on 6/13/2016, three days after her admission to the facility. No treatment was documented to Resident #31's right heel until 6/13/2016. During an interview with the wound care nurse, LPN Staff C, on 6/15/2016 at 10:45 am, she stated that the first time she had evaluated Resident #31's wounds was on 6/13/2016. LPN Staff C stated that Resident #31 had been admitted with the pressure wounds on her sacrum and her heel. LPN C was asked to provide documentation that the pressure ulcer on Resident #31's heel was present on admission because the surveyor had not located such information in the medical record. LPN C was unable to provide documentation that Resident #31's heel pressure injury did not develop during the time she was a resident of the facility. LPN C stated that Resident #31 did not have orders spelled out for the treatment of [REDACTED].#31's admission to the facility. LPN C said she did not recall if the dressing she had removed from Resident #31's sacrum on 6/13/2016 had a date on it but did recall that it did have a lot of drainage coming out of the edges. LPN C stated that she had initiated the care plan for the pressure ulcers on 6/13/2016, and that she had obtained a special mattress and the heels up device for Resident #31 to off-load pressure. LPN C further stated that she had not spoken to the family/responsible party about the status of Resident #31's pressure wounds. On 6/15/2016 at 2:35 pm, the husband of Resident #31 was interviewed. Resident #31's husband identified himself as the contact person/responsible party for his wife. Resident #31's husband stated that he was unaware of the blister on Resident #31's heel until he saw the nurse wipe something on it this morning. Resident #31's husband said he had not been contacted regarding the heel blister. According to the documentation, Resident #31 was admitted to the facility with a stage four pressure ulcer 6/10/2016 and had no assessment, treatment, or plan of care for the wound until 6/13/2016. There was no documentation that identified Resident #31 was admitted to the facility with a pressure injury to her right heel as there was no documentation regarding the fluid filled blister on her heel until 6/13/2016. ( ) According to the admission face sheet, dated 3/30/16, with a readmitted [DATE], Resident #33, was a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. According to the Minimum Data Set, MDS dated , 5/31/16, Resident #33 was dependent on staff for all Activities of Daily (ADL) Care to include bed mobility. The MDS also revealed that Resident #33 had a Pressure Ulcer. An interview was conducted with the Director of Nursing, Staff B on 6/15/16, at 11:00 Am, inquiring about how Resident #33 received pressure ulcer. Staff B said that Resident #33 was sent out of the facility on 5/16/16, to the hospital due to an infection and returned to the facility on [DATE], with an unstageable Pressure Ulcer to the sacrum (up above buttocks) area and only had moisture associated damage to sacrum while in the facility and was not aware of any other concerns to sacrum other than moisture associated damage to his skin. Staff B said Resident #33 skin was not opened prior to discharge. An observation was made on 6/15/16, at 11:10 AM, of a dressing change to the sacrum area for Resident #33. Upon removal of the old dressing by the nurse in charge of Resident #33's care that day, it was noted that Resident #33 had a very large open area to his coccyx that was round with 80 percent slough (yellow dead tissue) and 20 percent with scattered granulation noted to wound bed. There was also some tan/grey/ black tissue noted to the outer left rim of the wound. It was also noted to have a moderate amount of serous sanguinous drainage (watery/bloody) from the wound, with a slight odor. Review was done on 6/15/16, of electronic medical record Non- Pressure Healing Assessment dated, 4/7/16, 4/13/16, and 4/18/16, documented Resident #33 sacrum area as Sacrum/buttock area as moisture irritation to sacrum pink and blanchable, skin intact.On 4/28/16, documented Sacrum/buttock area as: Moisture irritation to right buttock/sacral area of concern measures 3 cm (centimeters) by 3 cm. There are three areas that each measure 0.5 cm by 0.5 cm by 0.1 cm, that are pink, moist, but no active drainage, skin between the open sites is pale pink, entire area is blanchable , no peeling skin.On 5/5/16, documented: Sacral/buttock area as moisture irritation area of concern to sacrum/buttock area measures 4 cm by 2 cm, no peeling present but there are scattered open areas, moist, pinkish/brown color present, scant serous drainage. On 5/12/16, documented: Sacrum/buttock area moisture breakdown to sacrum/buttock measures 4 cm by 3 cm by 0.1 cm, oval shaped, hard yellowish wound bed with scattered pink granulation, moderate serous drainage, edges intact, no peeling skin. (Resident #33 was sent out of the facility and returned on 5/24/16, per Director of Nursing.) On 5/24/16, Resident #33 returned to the facility according to admission face sheet. Review was done on 6/15/16, of Admit/readmit screener dated 5/24/16, under the skin integrity section there was no documentation on the readmission assessment related to skin integrity except for some bruising areas. There was no documentation related to the Sacrum wound, no description, measurements, location, staging, or size of wound documented. On 5/25/16, under Weekly Pressure ulcer Healing Assessment documented: Sacrum: Pressure 4.9 Length, 4.3 width, Stage as unstageable. The Interview continued with Staff B Director of Nursing, on 6/15/16, related to documentation on the skin assessments. Staff B agreed that Resident #33 skin was opened up before he was discharged out of the facility on 5/16/16, and did verbalize the wound got worse during his stay at the hospital but was not able to find any documentation from the day of readmission from Staff J skin assessment of the sacral wound. A phone interview was conducted on 6/15/16, at 4:10 PM, with Licensed Practical Nurse, Staff J who was the nurse in charge of Resident #33 upon return on 5/24/16. Staff J was asked if she looked at Resident #33 sacrum area upon his return to the facility. Staff J said she did not recall looking at his skin. I recall that was a busy day that day, and I am not sure if I did, I think I did. Staff J was asked why there was no documentation on the skin assessment section related to the sacrum upon his return. Staff J verbalized that another nurse had helped her with the admission and that Staff J did the medication portion and his labs and the other nurse also helped with the medications and labs but did not recall doing head to toe skin assessment on Resident #33. Review was done of the Facility's Admission Checklist on 6/15/16. Under orders to be entered: section Admission Assessments documented these must be entered on the same day as admit and listed Admit/readmit screener, Braden Assessment, Fall Risk, Pain Assessment, and four other assessments listed to be completed. It also listed for Skin Issues not to specify pressure (stage) or skin tear, etc. Describe area, including measurements, and implement a treatment, and then notify the wound care nurse. There was no documentation on the Admission Assessment describing the sacral wound on 5/24/16. .

This citation pertains to intake number MI 001. Based on interview and record review, the facility failed to provide supervision and follow the plan of care to prevent a bone fracture during the provision of care for one resident (Resident #101) out of three residents reviewed for accidents in a sample of four residents, resulting in a fracture of the right leg that required surgical intervention, caused severe pain and decreased the resident's ability to stand and transfer. Findings include: According to the Admission Record, dated 4/25/2016, Resident #101 was an [AGE] year-old female originally admitted to the facility on [DATE] and who had been in the hospital from 4/13/2016 until 4/16/2016. The Admission Record, dated 4/25/2016, listed [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment (MDS), dated [DATE], indicated that Resident #101 was usually understood, and usually understood what was said to her. The MDS, dated [DATE], recorded that Resident #101 was unable to walk and required extensive assistance from two persons to transfer. Resident #101's care plan, initiated on 8/19/2014 and cancelled on 4/14/2016, upon her discharge from the facility to the hospital, revealed that she was at moderate risk for falls because of gait and balance problems and a history of a stroke. The care plan interventions included follow facility fall protocol. Resident #101's care plan for self performance deficit due to limited mobility, initiated on 8/17/2014 and cancelled 4/14/2016, upon her discharge to the hospital, directed that she required the assistance of two people with a gait belt to stand at the grab bar in the large bathroom for toileting. The facility Fall Management Guidelines, with a revision date of December 2011, stated 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. Resident's will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. A nursing progress note for Resident #101, dated 4/13/2016 and written by Licensed Practical Nurse (LPN) Staff L, documented At approximately 1320 (1:20pm) was called into the resident bathroom by a CNA (certified Nursing Assistant) stated that resident was calling out in pain. Upon this writer arriving to the bathroom resident was hollering oh dear oh dear and grabbing at the right leg. Resident was questioned about what happened and is aphasic so yes or no questions were asked. I was able to understand that there was a problem with the transfer and she stated that she was dropped by staff upon transfer from chair to toilet. She kept saying tall guy zoom zoom. During an interview with LPN Staff L on 4/25/2016 that began at 12:15 pm, she confirmed the events she had documented and stated that although the physician had ordered stat x-rays to be done at the facility for Resident #101, the x-rays were cancelled and Resident #101 was sent to the hospital because of continued pain and abnormal positioning of the right leg. LPN L stated that she had learned that a temporary agency CNA, Staff M had been involved with Resident #101's transfer in the bathroom and when he had returned from lunch after the incident she had asked him what had happened and he had told her I didn't drop her and that Resident #101 had lost her balance and he had to put her in the chair quickly. LPN L reported that she had asked all staff who may have been involved in the incident to record written statements. LPN L stated that Resident #101 required the assistance of two people to transfer and that it was facility policy for staff to use gait belts for all transfers. In a statement dated 4/13/2016, temporary agency CNA Staff M had written while transferring resident (#101) while toileting, the resident slipped upon which I held & transferred directly in wheel chair. At no point did the resident physically touch the ground. In a statement dated 4/15/2016, temporary agency CNA Staff M had written that he had assisted another CNA to transfer Resident #101 to the toilet and when Resident #101 was done on the toilet, he had transferred her back to her wheel chair. CNA M had written that I had her reach for holding bar. I approached her affected (weak) side, stood her up, wiped bottom doing so she began to slip, in which I, pushed the toilet commode backwards, out of the way, and grabbed the residents wheel chair which was near by. reaching for the chair I quickly placed chair behind resident. The resident fell back into the chair, leg bending (slightly). I slowly recorrected her body. resident began panting. I asked if she was ok. Resident continued heavy breathing. continually asked if she were ok. Waiting about 5-7 minutes, I asked (CNA Staff N) if she would assist me with transferring. The statement continued by recording that CNA N had assisted to stand Resident #101 and adjust her clothing and he had then gone on his lunch break. In a statement dated 4/13/2016, CNA Staff N had written, temporary agency CNA staff M stuck his head out of shower room and said can I get some help. As I entered the shower room I saw (Resident #101) on the commode in a slant position leaning to the right saying Oh God, Oh God I got on (Resident #101)'s left side while (CNA M) was on her right side. I asked what happened and (CNA M) said nothing. When we lifted her off the commode and into the wheel chair she yelled Oh God Oh God. Upon putting her in the wheel chair I placed her right foot on the foot pedal and she screamed. I lefted (sic) out of the shower room to get the nurse. CNA Staff N was interviewed on 4/26/2016 beginning at 2:20 pm. CNA N stated that she had worked at the facility for [AGE] years and was familiar with Resident #101. CNA N stated that she had helped to transfer Resident #101 to the toilet in the shower room on a number of occasions prior to 4/13/2016. CNA N said that Resident #101 would stand by grabbing the hand rail and required the assistance of two staff for transfers. Once Resident #101 was standing at the rail, the staff would move the wheel chair and put a commode with wheels behind her and then assist her to sit on the commode.CNA N said that although Resident #101 was weak on her right side, she could stand and usually did very well with the transfers when the hand rail was used. During the interview on 4/26/2016 beginning at 2:20 pm, CNA N was asked to describe the event that occurred in the shower room with Resident #101 on 4/13/2016. CNA N stated that at about 1:10 pm on 4/13/2016, CNA M had asked for assistance in the shower room and when she entered the room, Resident #101 was sitting on the commode slanted, with her bottom on the front edge of the seat, and slumped over to her right side (her bad side) with her right arm hanging down. Resident #101 was saying Oh God, Oh God over and over. CNA N was asked if she was sure that Resident #101 was on the commode and not in the wheel chair as was recorded in the statement of temporary agency CNA M, and she replied, yes, the commode. CNA N stated that she had asked CNA M what had happened and he had replied, I don't know. CNA N said that the commode was not up next to the hand rail and was turned diagonally from the wall where the hand rail was and that Resident #101's wheel chair was behind the commode. CNA N said she had quickly gone to Resident #101's left side and had pulled the commode up to the hand rail (the commode had wheels) and the two of them had stood Resident #101 up at the hand rail. CNA N said that when Resident #101 stood, the tone of her voice changed and she yelled more loudly Oh God, Oh God. CNA N said that they quickly removed the commode and pulled the wheel chair behind Resident #101 and sat her down without even adjusting her clothing. CNA N said that CNA M then left the room to go to lunch and she put Resident #101's right foot up on the wheel chair pedal and Resident #101 really screamed - Oh God, Oh God. CNA N said she went to get the nurse right away and returned to the shower room and listened as LPN L had asked Resident #101 what had happened. CNA N said that Resident #101 said tall, tall, Zoom, Zoom as she made a sliding motion downward with her left arm and then said floor. CNA N said that CNA M had been very tall. According to the facility Transfer/Discharge Report, dated 4/13/2016, Resident #101 left the facility for the hospital at 2:48 pm. The hospital Operative Report, dated 4/14/2016, revealed that Resident #101 had surgery to place screws to repair the right subtrochanteric femur fracture. According to the facility Investigation follow-up to a fall occurrence form, dated 4/13/2016, under the question Were preventative interventions care planned and being followed? the answer was recorded as, Yes care planned and No to being followed. During an interview with the Director of Nursing, Staff B on 4/25/2016 at 3:25 pm, she stated that something had happened in the shower room when CNA M had transferred Resident #101 by himself instead of following the care plan for a two person transfer. The Director of Nursing, Staff B stated that Resident #101 was receiving therapy services since her readmission to the facility following hip surgery and currently was transferred with a mechanical lift because she was not able to consistently perform a safe transfer by standing. On 4/26/2016 at 4:00 pm, The Director of Nursing, Staff B stated that since Resident #101's readmission to the facility on [DATE], she has been prescribed the narcotic medication Norco (Hydrocodone-Acetaminophen 5-325 milligrams 1 tablet) every four hours for pain control. ( )

This citation pertains to Intake # MI 183. Based on observation, interview and record review, the facility failed to provide the necessary assistance during meal time to a dependent resident in order to prevent a hot liquid spill, and failed to respond immediately to minimize the severity of the burns for 1 of 5 sampled residents (Resident #102) reviewed for safety from a total sample of 10 residents, resulting in painful second degree burns for Resident #102 on her right upper inner thigh, and first degree burns on her left upper inner thigh, from hot coffee, and placing her in immediate jeopardy to her health and safety and at increased risk for complications potentially associated with burns, including infection. Additionally, there were 19 other facility residents in the facility's census of 87 residents who had been assessed as requiring assistance to safely handle hot liquids. These residents were also placed at increased risk for burns due to staff's lack of knowledge regarding the level of assistance needed for each resident during meals and the need to respond immediately in the event of a hot liquid spill coming into contact with a resident's skin. The immediate jeopardy began on [DATE] at approximately 4:45 p.m., when Dietary aide (Staff Member A) gave Resident #102 (who had been previously assessed as requiring assistance in order to safely handle hot liquids, and who had a known recent history of spilling hot liquids on herself) a hot coffee beverage, and, at around 5:25 p.m. (approximately 25 minutes later) noticed that the coffee mug was lying in the resident's lap and her pants were wet. Facility staff did not react immediately to remove the clothing covering the area or pour cold water over the affected area and, as a result, the wet clothing held the heat against the resident's skin, resulting in potential worsening of the severity of the burns (first and second degree burns to her inner thighs). According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Lippincott), 9th Edition, a scald burn (as would be sustained from a hot liquid spill) is consistent with a second degree burn. It appears as a blistered or mottled red area on the skin, which can leave scarring, is typically painful, and typically follows a two to four week recovery process during which infection (if it occurs) can complicate and/or extend the recuperative course. A first degree burn is a less invasive burn and generally follows a typical recovery period of less than one week. Findings Include: Review of Resident #102's Admission Face Sheet, the Minimum Data Set (MDS) assessment dated [DATE] and [DATE], physician note's dated ,[DATE] through [DATE], therapy notes dated [DATE] through [DATE], nurses note's dated [DATE] through [DATE], and Social Services and behavioral note's dated [DATE] through [DATE], revealed Resident #102 was an [AGE] year old female, admitted to the facility on [DATE]. She was severely cognitively impaired, with a BIMS (Brief Interview for Mental Status) score of 6 out of a possible 15. She was dependent on staff for all activities of daily living (ADL's). The resident's [DIAGNOSES REDACTED]. Review of Resident #102's Hot Food/Liquid Risk assessment dated [DATE] (the day she was burned), revealed the resident had exhibited musculoskeletal weakness in her upper extremities and/or hands, had poor posture, motor control and coordination, had tremors, was unable to understand safe food/liquid handling strategies, was unable to hold and bring a cup to and from her mouth without spilling and was cognitively impaired. Review of facility nurse's note's (signed by Staff Member E, Charge Nurse, LPN) dated [DATE] at 11:32 p.m., documented the events of that evening: Kitchen aid (Staff Member A, Dietary Aide) stated that she gave resident (Resident #102) coffee at 1700 (5:00 p.m.), around 1725 (5:25 p.m.) she said she noticed that the coffee mug was lying in her lap and her pants was wet. The kitchen (Staff Member A, Dietary Aide) told a CNA (Certified Nursing Assistant, Staff Member B) at 1730 (5:30 p.m.) that the resident spilled coffee on lap. The CNA (Staff Member B) then ran to her table and took the patient to the bathroom to take her pants off, it was red and a small blister was on the right inner thigh, educated the kitchen aids (sic) and the CNA that if someone waste (spilled) hot liquids on themselves to act fast by poring (sic) cold water in (on) it immediately and to take off clothing because cloths hold heat. I also (informed staff) to never give a feeder (i.e., a resident who required assistance with feeding and hot liquids) liquids until they are ready to be fed. An interview was done on [DATE] at 9:50 a.m., and a second phone interview was done at 3:35 p.m., with Staff Member A (Dietary Aide). Staff Member A said she gave Resident #102 a cup of coffee with a light weight white plastic cover (similar to a fast food cup lids) on [DATE] prior to supper. Staff Member A (Dietary Aide) stated, she (the resident) was on the feeder side (assist with feeding side of the dining room), no one was on the assisted side, they (staff) were passing trays to non-assist residents. I put her coffee in that cup because it was on her table at the time, I put the top on because she spilled before (on [DATE]), she had spilled her coffee on herself. I was right there, it didn't have a top on the 1st time. I think there's a list on the juice cart, what the resident's diets are or if special cups. It's not up-to-date, some of the names, the people have died , we don't pay attention to the list. I didn't see her spill the coffee, it was about 20 minutes after I gave her the coffee that I saw her lap was wet and her coffee cup was empty on her lap. I asked her if she burned herself and she said yes, she said it was hot. It was about 20 minutes, then I talk with (Staff Member B, CNA), and she took over, she called the nurse. Review of a facility OT (Occupational Therapy) daily note for Resident #102, dated [DATE], stated: Patient required total assist for managing feeding utensils and max assist for management of coffee cup. Review of the OT daily note dated [DATE], stated: total assist for feeding at lunch. Review of the hand written statement dated [DATE], signed by Staff Member A (Dietary Aide), read: near 4:45 (p.m.) I gave (Resident #102) a coffee in a light weight cup with a plastic cover and came back around later, (the resident's) coffee cup in her lap. When I asked if her legs were hot she replied yes and I told the nearest CNA (Staff Member B) that (the resident) burned herself. During an interview done on [DATE] at 2:15 p.m., Staff Member H (Occupational Therapist /OT) stated, I did not feel the white lid (the thin lid on the resident's coffee cup on [DATE]) was safe for her (Resident #102). When I observed her using the gray cup with the white lid, it (coffee) was dripping from the sides of her mouth, the issue is she needed (to be) a feeder and she was alone, she was a max assist with set-up with recommendations for assist feeding, the day she got burned. Review of the Occupational Therapy (OT) Initial Assessment and Plan of Care dated [DATE], stated decline in ADL tasks including self feeding-due to increased cognitive deficits, decreased activity tolerance, strength and problem solving, decreased safety and an increased need for assistance. Cognition orientation, person (x 1), cognition memory severe, cognition safety awareness, severely impaired, visual perceptual attention concentration, severely impaired. Patient required max assist for self-feeding after set up while seated up to table in w/c (wheelchair). Review of the OT e-mail, dated [DATE] (4 days prior to [DATE]), stated OT recommending someone feed her (Resident #102) and sit with her in order to increase her intake. She (the resident) did finish her entire meal with one person assist, she would benefit with having a feeder. This e-mail was addressed to Staff Member I (the facility's Restorative Supervisor, RN), Staff Member J (MDS Nurse, RN), Staff Member C (Dietary Manager) and the Director of Nursing (DON). Review on [DATE] at 10:00 a.m. of the facility's Meal Time Supplements (a list of resident's names with their dietary instructions and supplements sheet) failed to reflect the OT's recommendations or comments. The list documented, next to Resident #102's name: plastic fork/spoon NO knives. There was no documentation found on the sheet that the resident needed assistance with feeding and hot liquids. On [DATE] at 10:20 a.m. review of the Dining Services Book (a black note book) located in the main dining room, with a white card with information on it regarding Resident #102's diet and adaptive devices for meals, read: white water pitcher (mug) for hot liquids. There was no documentation found regarding instructions for the resident to be assisted with feeding and hot liquids. Review of the facility Incident Report dated [DATE], and nurse's note's dated [DATE] at 5:08 p.m., revealed that the incident on [DATE] was the second time Resident #102 had spilled her coffee on her lap in the dining room. The [DATE] Incident report documented: Resident (#102) spilled a cup of coffee in her lap during supper. During an interview done on [DATE] at 11:11 a.m., Staff Member I (Restorative Supervisor) said that Resident #102's ADL care plan on [DATE], still said she was independent to handle hot liquids, I am the one who revised it (after the incident and burns that occurred on [DATE]), that's how I know that. Review of the Resident #102's ADL care plan (dated for [DATE]) revealed on [DATE] interventions initiated for Eating were: I am safe to handle food/liquid independently; I wear corrective lenses. Review of her ADL care plan with the revision date of [DATE] documented: Eating: I require staff assistance to handle hot liquids; I wear corrective lenses. During an interview done on [DATE] at 11:10 a.m., Staff Member E (Charge Nurse) revealed she was passing medications on the evening of [DATE] and (staff member B, CNA) came up to her and informed her that the resident (#102) had spilled her coffee. She (Charge Nurse E) then got (Staff Member F, Treatment Nurse) and they went to the shower to assess the resident. Staff Member E (Charge Nurse) stated, she (Resident #102) didn't recall what happened, her legs were red on both sides, I asked (Staff Member A , Dietary Aide) did you pour cold water on it, she said, no. I don't think she (the resident) should of got the coffee, no one should of given her that coffee. Review of the skin/wound note's dated [DATE] at 5:40 p.m., stated This nurse (Staff Member F, Treatment Nurse, LPN) called into unit shower room where resident (Resident #102) had been taken to remove her clothing and to assess skin following coffee spill. Reddened skin noted to bilateral thighs, more toward medial aspects. Slight puckering/wrinkling of skin near center of left thigh red area. Right reddened area beginning to form clear fluid-filled blister in an oblique line no more than 5 cm long or 2 mm (cm) wide at this time. During an interview done on [DATE] at 3:17 p.m., Staff Member B (CNA) stated, I came into the dining room and (Staff Member A, Dietary Aide) said (Resident #102) spilled her coffee on her pants, I touched her pants and they felt cool. Staff Member B asked Staff Member A why she did not put water on the resident's pants and get her pants removed right away and Staff Member A (Dietary Aide) told Staff Member B (CNA), I didn't want to make a fuss about it. Review of the facility's Burns First Aid policy (dated ,[DATE]) revealed, upon notification of a resident burn, immediate emergency action is taken: remove garments and jewelry, immerse burned area in cool water for 20 minutes. Review of the facility incident report and investigation dated [DATE], stated on [DATE] at 5:32 p.m., The kitchen Aide (Staff Member A, Dietary Aide) stated she gave (Resident #102) coffee at 5 p.m., around 5:25 p.m., she said she noticed that her coffee cup was in her lap and her pants were wet. The kitchen aide put the cup on the table and then informed the CENA (Certified Nursing Assistant, Staff Member B). The CENA (Staff Member B) took (the resident) to the bathroom to take pants off and noticed that her inner thigh was red. When asked (the resident) what happened, she was unable to recall. Review of the incident report dated [DATE], stated Date, Time, Name of Physician notified and documentation of notification in MR (medical record): [DATE]. No documentation was found that the resident's primary physician (Physician #1) was notified about the resident's burn until [DATE]. Review of the nurses note's dated [DATE], revealed no documentation found dated [DATE] to indicate that the resident's primary physician (Physician #1) had been notified of her burns. During an interview done on [DATE] at 8:20 a.m., Physician #1 (Resident #102's primary physician) said he was not notified until [DATE] of the resident's burns. During an interview done on [DATE] at 11:10 a.m., Staff Member E (Charge Nurse, LPN) stated I didn't call the doctor, I can't tell you why, I'm a new nurse, this was my 1st big deal and I just forgot. During an interview was done on [DATE] at 11:55 a.m., Staff Member D (Charge Nurse, RN) stated, I called the doctor on [DATE] to get an order (regarding Resident #102's burns). Review of the physician order [REDACTED]. However, the resident's treatment (silvadene cream) was delayed due to the facility not informing the physician of the burn the day it happened in accordance with facility policy. Observation of Resident #102 was done on [DATE] at 8:30 a.m., at the breakfast meal in the main dining room. Resident #102 was trying to drink her coffee from a white plastic mug with a lid on it. When the resident brought her coffee mug up to drink with her right hand, she was observed to have slight tremors and had a difficult time drinking by herself, staff had to assist her to hold the mug. The resident was not able to be interviewed due to decreased cognitive status. A second observation of Resident #102 was done on [DATE] at 5:03 p.m., in the shower room, accompanied by 2 staff members of the burned areas on both upper inner thigh areas. The resident had a light red-pinkish with spots of light purple colored irregular shaped area on her right inner upper thigh measuring 4.3 cm in length and 4.9 cm in width (15 days after the burn). The facility's Safety for Serving Hot Food and Liquid policy (dated ,[DATE]) revealed if a resident is burned by hot liquid, staff notify the physician and responsible party per policy. Review of the facility's Change of Condition policy (dated ,[DATE]) revealed, upon a resident's change in condition (i.e., a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), the physician is to be notified and staff are to follow instructions (orders). Review of the facility Food Temperature Logs dated [DATE] to [DATE], revealed, on [DATE] at the supper meal, the coffee served to residents was 152 degrees F (Farenheit). A review of the Department of Community Health Alert on scalding injuries caused by excessive hot water, food and hot beverage temperatures, dated [DATE], revealed a water temperature of 152 degrees F takes less than 2 seconds to cause a second-degree burn. On [DATE] at 1:36 p.m., notification of the immediate jeopardy that began on [DATE] at 4:45 p.m. was given to the facility Administrator, as a result of the facility's failure to prevent burns and ensure the safety of Resident #102. The immediate jeopardy was removed on [DATE], as confirmed by the surveyor on [DATE] at 1:30 p.m., when the following were verified: 1. On [DATE], Resident #102 was assessed and first aid was provided to the affected areas on her left and right upper inner thighs, she was also assessed for pain. 2. On [DATE], Resident #102 was reassessed for risk of Hot Food/Liquids and her care plans were reviewed and revised with interventions to receive total staff assistance with feeding in the assist side of the main dining room. 3. On [DATE], starting with breakfast, Resident #102 began receiving assistance with feeding and handling of hot liquids according to her plan of care. She also received daily wound treatments to her affected left and right thigh areas and was monitored for pain. 4. On [DATE], the policy and procedure for Safety for Serving Hot Food and Liquid was reviewed. 5. On [DATE], management staff initiated dining room audits during all mealtimes to ensure residents at risk for hot foods/liquids were not being served unless a CNA or licensed nurse was present to assist per facility policy. 6. On [DATE], Hot Food/Liquid risk assessments were reviewed and updated for all residents residing in the facility and care plans were developed or revised. 19 residents were identified to have difficulty with the management of hot beverages. Associated disciplines recommendations for dietary safety will be followed by the Interdisciplinary Team (IDT) and reflected in the residents care plan. 7. Upon admission, quarterly and with a significant change, residents are assessed by therapy, nursing staff and the IDT for the ability to handle hot food/liquid with care plans developed or revised and the dining services book up-dated. 8. On [DATE], nursing staff were educated on the policy and procedure for Safety for Serving Hot Food and Liquid and to follow the individual resident's plan of care to identify residents at risk. 100% of staff were educated. 9. On [DATE], the Staff Member C (Dietary Manager) revised the list of residents requiring assistance to handle hot foods/liquids. Directions for safe serving of hot liquids for individual residents are located in the dining services book in each dining room (the main dining room on 1st floor and the dining room on 2nd floor). 10. On [DATE], all staff were educated on the procedure for hot liquid spills. Staff responsible for serving hot foods and liquids were educated on the safety for serving hot food and liquids policy. 100% of staff were educated. Newly hired staff will be educated on the policy Safety for Serving Hot Food/Liquid during the orientation process. 11. On [DATE], daily, Monday through Friday at morning the IDT meeting, feedback from the dining room monitoring audits are reviewed to identify trends or concerns that need to be addressed. It is the Director of Nursing/Designee to ensure corrections are implemented. 12. On [DATE], Resident #102 was assessed by Physician #1 (the residents primary physician), with evidence that her burns were healing. 13. On [DATE], the policy for Safety for Serving Hot Food and Liquid was revised to include designated seating with the dining services book up-dated. Staff education on the revised policy began on [DATE] and on [DATE], 75% of staff had been in serviced. The remainder of staff will receive education prior to the beginning of their next shift by the Assistant Director of Nursing/Designee. 14. Weekly the Administrator will review the dining room audits. Audits findings will be reported to the QA committee monthly until the committee determines sustained compliance. The Administrator is responsible for sustained compliance. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy, pending the completion of staff inservicing and the facility's ability to demonstrate sustained compliance as verified by the state agency. ( )

This citation refers to Intake # MI 770. Based on interview and record review, the facility failed to implement the agreed upon safety interventions, deliver care assistance in accordance with standards of practice, and initiate all of the corrective actions necessary to prevent an avoidable fall and minimize the risk for additional injuries for one of three residents (#101) reviewed for falls out of a total sample of five residents, resulting in a fall and fracture of the left hip, a significant decline in functional mobility, and an increased risk for additional injuries. Findings include: According to the face sheet, dated 12/5/2013, in Resident #101's medical record, Resident #101 was a [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 12/5/2013 at 12:30 PM, a record review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #101 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 points indicating Resident #101 had no cognitive (mental) impairment. In addition, it was noted that Resident #101 was documented to ambulate with one person limited assistance. The MDS following Resident #101's readmission to the facility on [DATE] (post fall) was in progress and was not available for viewing on the facility's computer system. On 12/5/2013 at 1:30 PM, a record review of the Incident/Accident Report, dated 11/24/2013, completed by Registered Nurse (RN) "F" described Resident #101's fall. RN "F" documented the following: "CENA (CNA "C") was assisting resident back to bed with walker and CENA (CNA "C") standing at her rt (right) side. Then resident (Resident #101) tripped and started to fall down. CENA (CNA "C") tried to grab resident (Resident #101) but she (CNA "C") tripped and they both fell down together. Resident (Resident #101) landed on her left hip. Resident (Resident #101) stated decreased range of motion but hard to assess." Under the topic of "Location of Injury", RN "F" documented: "Lt (left) hip discomfort." Pain assessment documentation noted Resident #101 had "moderate pain (grimacing)." The immediate intervention was "Dr (doctor) called and resident (Resident #101) sent to ER (emergency room ) for x-ray." On 12/5/2013 at 1:30 PM, a record review of the x-ray results, dated 11/25/2013, documented Resident #101 had an "impacted subcapital fracture of the left femoral neck." On 12/5/2013 at 1:30 PM, a record review of the history and physical notes, dated 12/1/2013 and dictated by attending physician "O", indicated Resident #101 had an open reduction and internal fixation surgery to repair the fractured left femur which was sustained after a fall in the facility. On 12/5/2013 at 1:30 PM, a record review of Resident #101's care plan revealed the following information. Before Resident #101 fractured her left hip, the "ADL Self Care Performance Deficit related to Limited Mobility and Left Hemiparesis Focus", dated 9/27/2013 and revised on 10/1/2013, documented Resident #101 "required 1 person staff participation, GB/RW (gait belt and rolling walker) to and from the bathroom." After returning to the facility on [DATE], from a local hospital, a new entry, dated 12/2/2013 indicated "no ambulation at this time." In addition, it was documented Resident #101 "required 2 person assist to reposition and turn in bed." On 12/5/2013 at 12:00 PM, Director of Nursing (DON) "B" was interviewed. She stated on November 24, 2013 at 8:00 PM, Resident #101 had requested assistance to the bathroom. CNA "C" got Resident #101 out of bed and to the bathroom, but did not follow the care plan and use a gait belt for assistance with ambulation. DON "B" said that on the way back from the bathroom, Resident #101 began to fall towards her left side, which was paralyzed after she suffered a stroke in the past. According to DON "B", CNA "C" was supporting Resident #101's right (strong) side and, as a result of the non-support to the paralyzed left (weak) side, both Resident #101 and CNA "C" fell to the floor. According to DON "B", CNA "C" did not immediately notify the charge nurse of Resident #101's fall but, with the assistance of CNA "D" and CNA "E", manually lifted Resident #101 from the floor and placed her into her bed, without a physical assessment by Registered Nurse (RN) "F" prior to the resident being moved. The attending physician was notified, and an x-ray of the left hip revealed a fractured left hip. Resident #101 was transferred to a local hospital where she underwent a surgical repair of the fracture. On 12/5/2013 at 2:30 PM, RN "F" was interviewed. RN "F" stated she was passing her 8:00 PM medications, on the evening of 11/24/13, when she was approached by CNA "E" and was told Resident #101 had fallen and was laying on the floor. When RN "F" entered Resident #101's room, Resident #101 was in the bed and not on the floor. RN "F" asked CNA "C" why the resident had been put to bed without first being assessed by a nurse, and CNA "C" said she didn't know, when a resident fell , the nurse was supposed to assess the resident's condition before moving the resident to a bed. According to Fundamentals of Nursing, The Art and Science of Nursing Care (Lippincott, Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, 2008), the use of a gait belt snugly secured around the patient's waist helps the patient maintain an erect posture and prevents unintentionally pulling the patient to one side. The nurse stands on the patient's weaker side and grasps the gait belt. The patient may hold a cane on the stronger side. On 12/5/2013 between 3:10 PM and 3:30 PM, four CNAs ("G", "H", "I" and "J") were interviewed at random. They were asked, "which side of a resident would they support when assisting a resident to the bathroom if the resident was paralyzed on the left side of the body?" Two CNAs indicated, correctly, they needed to support the weakened side (left side) and two CNAs said, incorrectly, they needed to support the strong side (right side not affected by a stroke) when transferring a resident with a weak/paralyzed left side to the bathroom. On 12/5/2013 at 3:30 PM, Resident #101 was interviewed. She recalled being assisted to the bathroom and falling to the floor on her way back to bed. She stated she "tips a lot when she uses her walker." Resident #101 stated CNA "C" was holding the back of her pants as she returned to her bed and CNA "C" did not use a gait belt. On 12/5/2013 at 3:45 PM, in an interview with DON "B", she was asked to identify what went wrong (root cause) with the transfer of Resident #101. DON "B" stated she identified that CNAs needed to check the ambulatory status of residents on the kardex (care plan reference) and use a gait belt as ordered. In addition, DON "B" said CNAs needed to be educated to notify the nurse immediately after a resident falls, before transferring a resident back into bed. DON "B" did not identify the need to support the weakened/paralyzed side of a resident when transferring or ambulating a resident to the bathroom. On 12/5/2013 at 4:00 PM, a record review of the November CNA Meeting agenda indicated CNAs were informed they must follow the care plan/kardex and use a gait belt when indicated for transferring and ambulating residents in the facility. In addition, they were told to "NOT attempt to move a resident after a fall until the resident has been assessed by a nurse." However, there was no indication in the agenda regarding training the CNAs about how to transfer a resident if one side of the resident's body had been weakened or paralyzed after a stroke. On 12/6/2013 at 2:00 PM, CNA "D" was interviewed. CNA "D" stated he was on his break the evening of 11/24/13 when he had heard CNA "C" yelling for help, because a resident had fallen. When CNA "D" entered the room, Resident #101 was on the floor laying on her left side and screaming in pain. CNA "C" told CNA "D" to help her (CNA "C") get Resident #101 back into bed. Resident #101 was yelling and complaining of pain in her left hip area. CNA "D" helped CNA "C" get Resident #101 back into bed. As soon as a third CNA (CNA "E") entered the room, CNA "D" left the room and went back to his unit for the rest of the shift. On 12/6/2013 at 3:10 PM, Physical Therapist (PT) "M" was interviewed. He was asked, if a resident had paralysis or weakness on the left side of the body due to a stroke, which side of the body needed support during ambulation? PT "M" said the left (weakened side) side of the body should be supported during ambulation. PT "M" indicated Resident #101 needed a gait belt when ambulating with assistance. On 12/6/2013 at 3:50 PM, CNA "E" was interviewed. CNA "E" said, on 11/24/2013, she was working with CNA "C" caring for residents on the 100 hall. Around 8:00 PM, CNA "E" saw CNA "C" running and screaming for help down the hall. CNA "D" was at the nurse's station and immediately ran with CNA "C" to Resident #101's room. A few minutes later, CNA "E" went into Resident #101's room and observed Resident #101 sitting on the side of the bed. Resident #101 was screaming for help and complaining of pain in her left hip. CNA "E" asked CNA "C" and CNA "D" why the resident was in the bed since the nurse had not assessed the resident after the fall. CNA "C" said she needed to get Resident #101's vital signs before informing the nurse. CNA "E" left the room and informed RN #6 that Resident #101 had fallen. According to the Discharge Care Plan, dated 9/11/13, Resident #101 was admitted for rehabilitation services with a potential for returning back to her home after improvement to her ability to perform activities of daily living. Before her fall, Resident #101 was able to ambulate with her walker and one person assistance. At the time of the investigation, Resident #101 was on hip precautions and needed 2 person assistance to be turned and repositioned in bed. In an interview with Resident #101 on 12/5/2013 at 3:30 PM, Resident #101 indicated she had no immediate plans to return home as she needed to recovery from her fractured left hip. ( )

This citation pertains to intake MI 534. Based on observation, interview and record review, the facility failed to assess one resident (#2) out of a sample of seven residents who were reviewed for falls from a total sample of 7, and failed to implement safety interventions to prevent falls; and the facility failed to maintain alarms for three residents (#3, 5, 7), out of five sampled residents needing alarms from the total sample of seven, and four supplemental sample residents (#8, 10, 11, 12), resulting in an avoidable fall and fractures with pain (for resident #2) and an increased potential for falls with injuries and pain (for residents #3,5,7, 8, 10, 11 and 12). Findings Include: According to the electronic face sheet dated 10-9-2013, resident #2 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #2's facility "Incident/Accident Report - Unusual Occurrence Form" dated 8-8-13 at 1:45 A.M. reflected that resident #2 was "...observed (resident) sitting on floor mat leaning against bed on right hip." An "Incident/Accident Report - Unusual Occurrence Form" dated 8-22-13 at 1945 (7:45 p.m.) stated: "...Resident was sitting in wheel chair. she stood up by herself. When she started to move, she fell on to the floor on her right side. Her head hit the floor. She did not lose consciousness. She remains confused and alert. c/o (complains of) pain to right shoulder. Refuses to wiggle rt (right) fingers...Resident sent to E.R. (emergency room ) for evaluation RLT (related to) R (right)hip/shoulder pain per MD (medical doctor) order." Review of the "ED (Emergency Department) Clinical Report dated 8/23/13, stated Resident #2 had a "fall from standing height at nursing home, getting out of wheelchair, has humerus (upper arm bone) fx (fracture) and hip fx (fracture). Pt (patient) complains of right shoulder pain, right hip pain, head and neck pain. Review of the hospital History and Physical dated 8-23-13, for resident #2, stated: "Assessment and Plan: 1. Fall on Coumadin (coumadin is a medication that thins the blood) with right humerus fracture and then a right greater trochanteric (the thick area at the upper outside of the femur/thigh bone) fracture...5. Urinary tract infection. Rocephin (antibiotic) started in emergency department 1 gram IV (intravenous) every 24 hours." The ED report concluded that the resident, who was on a blood thinning medication (and therefore more susceptible to bruising and internal bleeding), had a fall with two fractures and was also treated for [REDACTED]. On 10-7-13 at 1:40 p.m., a phone interview was done with family member #1. Family member #1 said, (resident #2) had Alzheimer's, short term memory problems and was only one week away from going home. Family member #1 said she (resident #2) would take a long time to get up out of a chair. When asked what happened, Family member #1 said, she (resident #2) was left alone in the hallway with no one around. She stood up and tried to take a few steps, but was too weak and fell . Family member #1 said she (resident #2) was in a lot of pain after her fall and had passed away after leaving the hospital. During an interview on 10-8-13 at 3:15 p.m., Certified Nursing Assistant (CNA) "BK" was asked to tell what had occurred the day of 8-22-13 when resident #2 fell . CNA "BK" said, (resident #2) had increased confusion and was sitting in a wheel chair at the nurses station. CNA "BK" said another aide needed assistance with another resident, so she left (resident #2) at the nurses station. When CNA "BK" came out of the other resident's room, she heard the alarm and saw (resident #2) stand up. CNA "BK" said she called her name and told to her sit down, but she fell before the she could get to her. CNA "BK" said she thought she (resident #2) tripped over the wheel chair foot pedals. When asked what the resident was like, she said she (resident #2 ) was talking in German, she was confused, and was trying to get up out of the wheel chair. She had tried to get up about two hours prior to the fall. CNA "BK" was asked if there were any activities for resident #2 to do at night, and CNA "BK" said there were no activities, and there were no activity staff at the facility at night. The surveyor asked CNA "BK" if she had told anyone that resident #2 was confused, and kept trying to get up out of wheel chair, prior to her falling on 8/22/13. CNA "BK" said she had told the nurse she (resident #2) kept trying to get up. When asked if she thought the fall could have been prevented, CNA "BK" stated, "if she (resident #2) had a seat belt alarm." ( ) During an interview on 10-9-13 at 11:45 A.M., Nurse "AD" stated she was working the night that the resident (resident #2) fell . Nurse "AD" said resident #2 was more confused then usual on 8/22/13, the night of the fall, and the CNAs had reported to her that the resident had been more agitated and confused on 8/22/13, first shift, than she had been the prior week. When the surveyor asked specifically how resident #2 seemed more agitated, Nurse "AD" said the resident was restless, getting up, and wanting to walk. Nurse "AD" was asked if she had done an assessment of Resident #2 after the aides told her the resident was more agitated and confused. Nurse "AD" stated, "No." Nurse "AD" was asked if she (the nurse) could have checked resident #2 for a urinary tract infection. Nurse "AD" said, yes, if a resident had symptoms according to the protocol (i.e., the criteria for treating infection). ( ) Based on facility policy review, the facility policy "Urinary Tract Infection" dated January 2010 stated: "...infection may be characterized by ...changes in mental status." During the interview on 10-9-13 at 11:45 A.M., Nurse "AD" said about a half hour prior to resident #2's fall (on 8/22/13), she (resident #2) was sitting at the nurses' station in her wheelchair, and had gotten up out of her wheel chair, and took two steps towards the nurse station. Nurse "AD" said she put the resident back in her wheelchair. Nurse "AD" stated, "her foot pedals were up, but not taken off, we didn't take her foot pedals off because you have to have somewhere to put them. She was a confused person, I believe there was no injuries, no complaints, no marks. She was more confused with this fall, there was nobody who could sit with her, I was passing meds (medications) and there was no one there to sit with her at that time, she was getting up more. I did not think it was warranted to call the DON (Director of Nursing) for a one-on-one (staff member to be with the resident)." When asked why the resident was transferred to the hospital, Nurse "AD" stated, "her pain was in her right shoulder." When asked what she would have done differently, she stated, "I suppose I would have had someone there with her." ( ) An interview was done on 10/9/13 in the therapy room at 2:50 p.m., with Therapy Program Director "HU". Therapy Program Director "HU" said all residents with foot pedals on their wheelchairs were supposed to have the pedals in proper position (not in the up position), with the residents feet on them, or they were to be "completely taken off the wheelchair," so the resident would not trip over them if they stood up. ( ) An interview was done on 10/9/13 in the in service office at 3:00 p.m., with Staff Education/Infection Control RN "EP". Education/Infection Control RN "EP" stated "they (the residents) have blue leather bags on the back of their wheelchairs" (to put the foot pedals in) and revealed all nursing staff had been educated to remove the foot pedals when not in use. ( ) On 10/10/13 at 2:50 p.m. the facility Director of Nursing (DON) was interviewed in room 131. The DON said she was made aware of resident #2's fall the next morning (8/23/2013) and called the aides for a report. The DON was asked if a nurse had the option to assign an aide to do a one-on-one with a resident. The DON said a nurse could call her, or the Assistant Director of Nursing (ADON), and they would offer suggestions to address any concerns the nurse had. They would offer suggestions, such as assessing the resident for pain; they could arrange a staff person to be with a resident if needed. The DON was asked if a nurse had access to a lap buddy or alarming seat belt. The DON said the nurse would have to call her and talk about alternative interventions and she would help her problem solve. The DON said the facility had a supervisor working at the time of the fall. ( ) On 10/10/13 at 3:30 p.m. the evening supervisor "W" was interviewed in room 131. Evening supervisor "W" said she did not remember if she was working the day of (resident #2's name) fall. Evening supervisor "W" said if a resident was agitated or restless, and having behaviors, they (staff) would call her, and had in the past, for direction or advice or help. Evening supervisor "W" continued to state that she had sat with residents and could do one-on-one with them. If nurses needed alarms or a lap buddy, she had gone downstairs and gotten the item, the nurse just needed to call. ( ) The facility failed to assess resident #2 related to the resident's increased agitation and confusion and failed to implement interventions to maintain safety and prevent a fall that resulted in fractures. ( / ) Review of the falls care plan dated 9/25/13, revealed sample resident #3 had a history of [REDACTED]. Review of resident #3's Activity of Daily Living (ADL) care plan dated 9/24/13, CNA care plan (un-dated) and the facility round sheet dated 10/7/13, revealed the she was supposed to have bed and chair pressure alarms. On 10/7/13 at 10:50 a.m., Resident #3 was observed by SW (Social Service) "FV" and this surveyor, sitting in a chair in her room, unsupervised, with her chair alarm under her. When SW "FV" stood the resident up, her chair alarm failed to activate/alarm. During an interview done on 10/7/13 at 10:50 a.m. SW "FV" agreed the resident's alarm should have activated (alarmed) when the resident stood up. ( ) Observation was made on 10/7/13 at 12:45 p.m. of sample resident #5 in her room, by Nurse LPN "GF" and this surveyor. Resident #5 was observed sitting in her chair with no alarm on her chair. Review of the nurse's notes dated 9/9/13 at 3:26 p.m. and Incident/Accident report dated 9/9/13, revealed, on 9/9/13 at 3:15 p.m., the resident had a fall and was found sitting on the floor in her room by staff. Review of the CNA care plan (un-dated), dementia care plan dated 7/8/13, Psych care plan dated 7/8/13 and ADL care plan dated 10/11/12 revealed the resident had a history of [REDACTED]. During a private interview on 10/7/13 at 12:45 p.m., Nurse LPN "GF" stated, "yes she should have an alarm on her chair." During a private interview on 10/7/13 at 12:50 p.m., Nurse LPN "CT" stated, "she's supposed to have an alarm on when in the chair." During a private interview on 10/7/13 at 1:10 p.m., CNA "CW" stated, "she should have a pressure alarm in bed and chair." ( ) An observation was made on 10/7/13 at 11:50 a.m., by Nurse LPN "HF" and the surveyor of sample resident #7 in the main dining room on first floor. Review of the facility round sheet dated 10/7/13 and CNA care plan (un-dated), revealed the resident had decreased safety awareness and was to have bed and chair pressure alarms in place. Observation of resident #7 on 10/7/13 at 11:50 a.m. in the main dining room revealed the chair alarm she was sitting on was not connected (not in working condition). Nurse LPN "HF" was observed to connect her chair alarm. During an interview done on 10/7/13 at 11:55 a.m., Nurse LPN "HF" stated "yes, it should have been connected." ( ) Observation was made on 10/7/13 at 10:58 a.m., by SW "FV" and this surveyor, of supplemental sample resident #8 in her room, in bed, with a bed alarm on her bed that was not connected (not in working condition). SW "FV" stated in an interview done on 10/7/13 at 10:58 a.m., "all new admits (newly admitted residents)get alarms and she is a new admit." During an interview on 10/7/13 at 11:20 a.m., ADON (Assistant Director of Nursing)"AE" revealed the resident was admitted over the weekend (a new admit) and ADON "AE" agreed that all newly admitted residents got an alarm, until therapy screened them. During an interview on 10/7/13 at 11:25 a.m., Therapy "HQ" said she had just screened the resident and wrote a new directive that the the resident did not need an alarm and stated, "I just wrote it a few minutes ago." However, when the resident was observed by this surveyor, she had not yet been screened and was still supposed to have had bed and chair alarms in place due to being a newly admitted resident. ( ) Observation was made on 10/7/13 at 12:05 p.m. in the main dining room on first floor of supplemental sample resident #10, by CNA "EV" and this surveyor. Review of the facility round sheet dated 10/7/13 and the CNA care plan (un-dated) revealed the resident had decreased safety awareness and was supposed to have a pressure alarm in her wheelchair and a separate pressure alarm in her dining room chair. Observation of resident #10 on 10/7/13 at 12:05 p.m. in the main dining room on first floor revealed she was sitting in a regular chair in the dining room with no alarm on her chair. An interview was done on 10/7/13 at 12:05 p.m., with CNA "EV" in private. CNA "EV" agreed the resident should have had an alarm on her chair while in the dining room and stated, "yes, she should have one on, I have just been busy, I did not think of it." ( ) Observation was made on 10/7/13 at 12:14 p.m., by CNA "U" and this surveyor, of supplemental sample resident #11, in the main dining room on first floor. Review of the nurse's notes dated 7/30/13 at 10:44 p.m. and 7/31/13 at 4:16 p.m., and the Incident/Accident report dated 7/30/13, revealed the resident had a fall on 7/30/13 at 10:20 p.m.; she was found by staff on the floor next to her bed. Review of the facility round sheet dated 10/7/13 and CNA care plan (un-dated), revealed the resident was to have a pressure alarm on her bed and chair. Observation of resident #11 in the dining room revealed she was sitting in a regular chair at a table, with no chair alarm. An interview was done on 10/7/13 at 12:18 p.m., with CNA "U" in private, in the main dining room on first floor. CNA "U" revealed, if the resident refused her alarm, staff were instructed to notify the charge nurse immediately. CNA "U" stated, "she's supposed to have an alarm; I don't know if I told the nurse this morning, we are short today." According to CNA "U", there were two nurses on 10/7/13, covering the unit the resident was on: Nurse RN "AF" and Nurse LPN "HF". An interview was done on 10/7/13 at 12:26 p.m., with Nurse RN "AF". When the surveyor asked if CNA "U" had notified her (on 10/7/13) that resident #11 had refused to have her alarm put on her chair in the dining room, Nurse RN "AF" stated, "no one notified me, I got here at 9:00 a.m." An interview was done on 10/7/13 at 12:35 p.m., with Nurse LPN "HF". When the surveyor asked if CNA "U" had notified him (on 10/7/13) that resident #11 had refused her alarm, Nurse LPN "HF" stated, "she did not tell me she refused her alarm this morning." ( ) Observation was made on 10/7/13 at 12:30 p.m. by facility Nurse "GF", restorative Nurse "CT" and this surveyor of supplemental sample resident #12 sitting in his recliner chair with a pressure alarm. The pressure alarm box was sitting next to resident #12 on the bed-side table and was observed not to be flashing. (A flashing light would have indicated it was on and working.) Restorative Nurse "CT" was observed to pick up the alarm box, unplug the alarm, and then re-plug it in. Restorative nurse "CT" confirmed it had not been completely plugged in, which had prevented the alarm from working. Review of resident #12's fall care plan revealed resident #12 was at high risk for falls related to being unaware of safety needs and was to have chair/bed electronic alarms. The fall care plan for resident #12 stated: "please ensure the alarm device is in place as needed." ( ) An interview was done on 10/7/13 at 11:45 a.m., with CNA "CZ" in private in the main dining room on first floor. CNA "CZ" said all CNAs were supposed to check their residents' alarms at the beginning of every shift to see if they were working and stated, "we check for all alarms to see if they're on." ( ) Review of the facility's Fall Management inservice, dated 11/28/13 to 12/25/13, revealed nursing staff had been educated on fall prevention. The inservice materials stated, "tab alarms or sensor pads are the first choice for the wheelchair bound resident who tends to try to get up frequently. Sensor pads are usually placed on the wheelchair, room chair and bed." ( ) Review of the Alarm/Restraint Free Devices policy, dated 10/12, stated "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." ( , )

This citation pertains to intake numbers #MI 574 and #MI 020. Based on observation, interview and record review the facility failed to ensure that the residents environment remained as free of accident hazards as possible in 2 of 5 sampled residents (Resident #101 and Resident #102) reviewed for falls and safety, from a total sample of 5 residents, resulting in a fall with injury requiring hospitalization for both Resident #101 and #102, and the potential for falls in 21 of 100 residents who have sensor pad fall alarms due to the malfunctioning delay of the alarms. Findings include: Resident #101 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was an [AGE] year old female who had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Face Sheet revealed Resident #101 had been readmitted to the facility from a hospital stay due to a fall with a hip fracture on 3-14-13 with a new [DIAGNOSES REDACTED]. The MDS indicated Resident #101 was moderately cognitively impaired, had history of behavioral physical aggression, required limited assist with transfers, walking, dressing, hygiene and toileting prior to the fall. Review of the Fall Care Plan dated 3-19-2012 revealed Resident #101 was a high risk for falls. Resident #101's Fall Care Plan interventions were listed as: "Be sure my call light is within reach and encourage me to used it for assistance as needed; I need a safe environment with even floors free from spills and or clutter, adequate glare free light, a working and reachable call light, high low bed, safety floor mat, handrails on wall and personal items with reach; I use chair/bed caregiver key type alarm. Ensure the device is in place and working properly. Please notify central supply or nursing supervisor if alarm box needs to be replaced." Review of the Fall Risk assessment dated [DATE] revealed Resident #101 was a moderate risk of falls. Review of the Incident and Accident report for Resident #101 dated 3-10-13 at 8:30 pm, revealed "Patient stated she slipped out of her wheelchair to the floor, that the assigned nurse was walking in the hallway and heard the patient yelling for help. The assigned nurse, Licensed Practical Nurse (LPN #13) found the patient laying on her buttocks by the side of her bed. The Certified Nurses Aide (CNA # 11) and LPN (#13) lifted resident off the floor and put back into her wheelchair, and upon putting in wheelchair, the patient stated it was hard for her to move her left thigh, grimacing pain was noted." In an interview on 4-3-13 at 4:30 pm, LPN #13 reported that on 3-10-13 she had heard Resident #101 yelling for help, she (LPN #13) went into Resident #101's room and found her on the floor next to the bed. LPN #13 reported that Resident #101 said that she had been sitting on the edge of her wheelchair and had fell to the floor. LPN #13 reported she went for assist and flagged down CNA #11 to come and assist her. LPN #13 reported that she did assess Resident #101 prior to getting her off of the floor and that she had notable decreased range of motion (ROM) in the left hip and that Resident #101 said "Ouch" when she attempted to perform range of motion to the left leg. LPN #13 reported that "No fall alarm went off, that the fall sensor pad alarm was in her wheelchair and the green alarm box was on the wheelchair hooked up. The fall alarms have a delay and don't go off." When asked if the issue with the fall alarms not working properly had been reported to management, LPN #13 reported, "Yes, (said name) the Director of Nursing (DON) knew that these fall alarms were not going off correctly." LPN #13 reported that she and CNA #11 got Resident #101 back into bed by 2 person transfer and gait belt, but that the resident did not bear any weight to the left leg. LPN #13 reported that the left hip had a bulge noted and pain to the area, some slight bruising was starting on the left hip, leg and buttocks. LPN #13 reported she immediately called the doctor and got an order for [REDACTED]. LPN #13 reported that an ray had been completed, and she gave shift report to the oncoming shift, who obtained the positive left hip fracture x ray report and shipped Resident #101 to the local emergency room for evaluation and treatment and subsequently required surgery ORIF of the left hip. In an interview on 4-3-13 at 2:30 pm, CNA #11 reported that on 3-10-13 around 8:30 pm, she was in another residents room assisting another resident when she was called for assist by LPN #13. CNA #11 reported that Resident #101 had been up in the wheelchair, that Resident #101 had taken her self up and down the hall in wheelchair, and when she went into Resident #101's room LPN #13 was performing an assessment and doing ROM on Resident #101. CNA #11 reported she took vital signs and they were stabile, and assisted LPN transfer Resident #101 with a two person transfer and gait belt to the bed. CNA #11 reported she took Resident #101 clothes off and gave her a bed bath, and performed a skin check and noted the left hip had a bulge, bruising was starting on the left hip, leg and resident complained of pain to the left hip. CNA #11 reported that LPN #13 had went to the desk to call the doctor. CNA #11 reported that the fall sensor pad alarm had been hooked up to the wheelchair, and she did not hear the alarm go off as she was in another room, but that LPN #13 told her (CNA #11) that the fall sensor alarm in the wheelchair did not go off. CNA #11 reported that the fall alarm had a delay and that "We all have witnessed the alarms not working well." CNA #11 reported that if the battery is low, the green box will beep non stop to alert to change the battery. CNA #11 reported that the fall interventions in place for Resident #101 prior to the fall were, a mat sensor pad on the floor next to the bed, a chair sensor pad and a bed sensor pad. CNA #11 reported that a book at the desk has all the careplans, kardexs in them, and it tells the CNA's how to transfer each resident, and what alarms they have in place, and every Thursday the plan of care is updated with any changes. In an observation and interview on 4-3-13 at 9:20 am, Resident #101 was laying in bed with her head of the bed slightly elevated. Resident #101 was slightly confused, losing train of thought. Resident #101 reported that she remembered that she slipped and fell , trying to get out of bed, that she was not able to get up on her own and walk and she did not know if her fall alarms had worked the day of the fall. During the observation, Resident #101's call light was lying on the floor out of her reach. The bed was in the low position with the left side up against the wall. A fall pad sensor alarm was on the floor next to the bed and sensor alarm was on the bed and one on the wheelchair. A motion detector sensor was in the corner of the room on a dresser. Bilateral enabler bars were on the bed. Resident #101 room was the last room at the end of the hall corridor, furthest away from the nurses desk. In an observation on 4-4-13 at 8:40 am, and 12:05 pm, while making rounds on the units, the surveyor observed Resident #101 was up in her wheelchair in her room. The call light was lying on the bed across the pillow area, hidden under the pillow and blanket, out of sight and reach of Resident #101. Review of the Facility Fall Policy dated December 2011 revealed #9 The IDT (interdisciplinary team) will review resident falls within 24-72 hours at the morning meeting to evaluate, investigate the circumstances and root cause of the fall. Resident #101 Incident and Accident report investigation and follow up made no mention that Resident #101's fall alarm did not function, or any root cause related to the fall. ( ) Resident #102 Review of the Face Sheet and MDS dated [DATE] revealed Resident #102 had been admitted to the facilty on 5-7-2010 and readmitted to the facility from hospital on 1-30-13 post fall and new stroke diagnosis. Resident #102 had [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #102 was a [AGE] year old female who was moderately cognitively impaired with a Brief Mental Score (BIMS) of 10. Review of the Fall Care Plan dated 11-8-2012 revealed a problem of "I am a high risk of falls related to unaware of safety needs, confusion and deconditioning." Interventions listed were: "Be sure my call light is within reach; the bed in lowest position, handrails on wall, and personal items within reach; self releasing alarming seat belt in my wheelchair; I use hi-lo bed, pressure alarm in bed, safety side mattress and safety floor mats ensure the devices are in place as needed." Review of the Fall Risk assessment dated [DATE] revealed Resident #102 was a moderate risk of falls with a score of 12. Review of the Incident and Accident Report dated 1-27-13 at 10:20 am revealed Resident #102 had a fall in her room out of her bed resulting in a head injury, laceration and profuse bleeding to the head and a need for hospitalization for evaluation and treatment of [REDACTED].#12 heard someone yell, "Help me" when a visitor said someone had fallen. LPN #12 and CNA # 9 and LPN # 8 all noted that Resident #102's bed was elevated and the control to the bed was at the foot of the bed. Staff observed blood pooling around Resident #102's head and immediately called 911 for ambulance. CNA #9 and LPN #8 stayed with the resident until ambulance had arrived approximately 20 minutes later. In an interview on 4-4-13 at 2:00 pm, CNA #10 reported that on 1-27-13 at around 9:00 am, she (CNA #10) had toileted Resident #102, transferred her to her bed, placed the fall alarm sensor on her, put the bed in low position and placed the bed control at the foot of the bed on top of the covers. CNA #10 reported that she had never seen or known of Resident #102 using the control to move the bed up and down. CNA #10 reported she then went on break and when she came back from break, Resident #102 had fallen and staff were in attending to her, so she (CNA #10) went on and answered call lights and assisted other residents. In an interview on 4-3-13 at 1:30 pm, LPN #8 reported that went she went in Resident #102's room and found her on the floor, Resident #102 bed was in the highest position. LPN #8 states that earlier in the shift she had observed the bed in low position. LPN #8 reported that she was the first staff to enter the room, that Resident #102 was laying on her right side on the floor and she was bleeding a lot. "I said to the others, don't move her. We had staff stay in the room with her until the ambulance came. I cannot say for sure if the fall alarm was ringing. (Resident #102) did not lose consciousness, she was yelling for help, asking for momma." LPN #8 reported she did not notice anything abnormal as if she had signs or symptoms of an acute stroke. LPN #8 said, "I did not do neurological checks on her, and I have never known her to use her bed control to raise or lower the bed." In an interview on 4-3-13 at 2:10 pm, CNA #9 reported that CNA #10 had toileted Resident #102 after breakfast and laid her down in the bed. CNA #9 reported that one of the nurses had given Resident #102 her medications after she was laid down in bed. CNA #10 reported that she did hear the bed sensor alarm go off after Resident #102 was already on the floor, "As if it had a delay in the alarm." CNA #10 reported that Resident #102 was bleeding a lot, that she was writing down vital signs for the nurse and that nurse #8 had been assessing Resident #102. CNA #9 reported that she had seen other fall alarms have a delay in them and not working properly. CNA #9 reported a police officer was the first responder and he stayed until the ambulance arrived approximately 20 minutes after the 911 call was made. In an interview on 4-3-13 at 3:15 pm, LPN #12 reported that at around 9:00 am she had just come in to work her shift, that she had given Resident #102 her medications while in the bed. LPN #12 reported that a man visitor yelled help, and the staff observed Resident #102 on the floor in her room laying on her right side with her head and shoulders under the other bed, and that Resident #102's bed was raised high in the air. LPN #12 reported that she did not recall any fall alarms ringing upon entering the room. LPN #12 reported she went to get paperwork around and waited at the front door for the ambulance to come and that LPN #8 had assessed Resident #102 and stayed with her until the ambulance arrived. LPN #12 reported that she had heard the aides say that the fall alarms have a delay in them and that they don't always ring. ( ) Delayed alarms On 4-4-13 at 2:00 pm a list of residents who have fall alarms in use was obtained from the ADON. The list indicated 21 resident have fall alarms, all the same brand of sensor pad and green boxes, placing all 21 at risk of the fall alarm having a delay in the alarm and not functioning properly. In an interview on 4-4-13 at 2:00 pm, CNA #10 reported that she knew that some of the fall alarms had a delay noted in them, that she had witnessed residents attempting to get up out of wheelchairs or beds and that the fall alarms had not rang. CNA #10 reported that if the battery is low, a blue light blinks on the green alarm box. In an interview on 4-4-13 at 3:15 pm, LPN #12 reported that she had heard the CNA's say that the sensor pad fall alarms have a delay and that they don't always function properly. In an interview on 4-4-13 with Director of Nursing (DON) #2 and Assistant Director of Nursing (ADON) #3, it was reported by DON #2, "Yes we knew we have a problem with the fall alarms, that some of the blue flashing lights to indicate a low battery on the green boxes, were not lighting up, a sign that the alarm was not working." DON #2 reported that the facility bought several alarms, all the same kind and that they were able to return some of the alarm boxes and get them replaced by the manufacturer. DON #2 reported that the facility has restorative staff and central supply clerk check the fall alarms weekly for functioning and if the alarm box's are not working, they will be replaced. DON #2 reported that she found out about the problem with the alarm boxes not functioning and that they have a delay in the alarm ringing or that the alarms don't ring at all, about 2 months ago. DON #2 reported that all new residents have fall alarms placed on the bed and chair for 48-72 hour upon admit, until the interdisciplinary team can evaluate the residents fall risk. In an interview on 4-4-13 at 2:30, the Central Supply Clerk #14 reported when asked, "Yes the green fall box alarms have a delay setting internally." Central Supply Clerk #14 showed the surveyor the green fall alarm box and how it had a small screw in the back of it. Central Supply Clerk #14 reported that she personally checks every fall alarm box when the boxes come in new, unscrews the back of the box, sets the alarm to a "0" zero setting, which means no delay in the fall alarm sounding off should occur. Central Supply Clerk #14 also reported that she sets the alarm ring tone setting to an alarm sound and takes the factory setting of a song off of them and also sets the setting of loudness to HI. Central Supply Clerk #14 reported that all sensor pads are dated and they are good for 1 year, then disposed of. Central Supply Clerk #14 reported that "Yes, I have had to send some boxes back to the supplier, they were under warranty and not working. Yes, I know some of the alarms are not working properly, the are delayed in alarming when a resident gets up off of it, it is not supposed to delay from the settings I set on the green boxes."

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT DEVELOPMENT OF PRESSURE ULCERS FOR 2 OF 8 RESIDENTS (#15 AND 1) REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 21 RESIDENTS, RESULTING IN HARM FOR A PREVENTABLE UNSTAGEABLE BILATERAL BUTTOCK PRESSURE ULCERS WITH PAIN FOR RESIDENT #15 AND A RAPID-ONSET UNSTAGEABLE LEFT HEEL PRESSURE ULCER ACCOMPANIED BY DISCOMFORT FOR RESIDENT #1. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET (PRINT DATE OF 1/24/2013) RESIDENT #15 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE]. THE HOSPITAL RECORD DATED 12/5/12 REFLECTED RESIDENT #15 HAD FALLEN AT HOME, LANDING ON HER RIGHT SIDE, SUSTAINED A RIGHT WRIST FRACTURE, A RIGHT SCALP HEMATOMA AND A BRUISE OF HER RIGHT SHOULDER. RESIDENT #15'S MEDICAL HISTORY INCLUDED [MEDICAL CONDITION], FREQUENT FALLS, CARDIOMEGALY, HYPERTENSION, [MEDICAL CONDITION], URINARY INCONTINENCE, [MEDICAL CONDITIONS], DEPRESSION, URINARY TRACT INFECTION, [MEDICAL CONDITION], ALTERED MENTAL STATUS, MALAISE AND FATIGUE. THE ADMISSION MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED RESIDENT #15 HAD A BRIEF INTERVIEW FOR MENTAL STATUS (BIM) SCORE OF 6 FROM A TOTAL POSSIBLE SCORE OF 15, MEANING SHE HAD IMPAIRED COGNITION. HOWEVER, DURING AN INITIAL TOUR OF THE FACILITY ON 1/23/13 AT 10:30 A.M., ASSISTANT DIRECTOR OF NURSING, (STAFF "E" ) STATED THAT THE RESIDENT WAS ALERT AND DEFINITELY INTERVIEWABLE. STAFF " E " ADDED THAT RESIDENT #15 HAD BEEN LIVING ALONE IN THE ASSISTED LIVING PART OF THE FACILITY UNTIL SHE fell AND BROKE HER ARM. UNDER THE BLADDER AND BOWEL SECTION FROM THE MDS dated [DATE], RESIDENT #15 WAS CODED AS "1", MEANING SHE WAS OCCASIONALLY INCONTINENT OF BLADDER AND CODED " 0", MEANING SHE WAS ALWAYS CONTINENT OF BOWEL. UNDER THE FUNCTIONAL STATUS RESIDENT #15 WAS MOSTLY CODED AS "3", INDICATING SHE REQUIRED EXTENSIVE ASSISTANCE WITH HER BED MOBILITY, TRANSFER, DRESSING, EATING, TOILETING AND PERSONAL HYGIENE. UNDER THE SKIN CONDITIONS RESIDENT #15 WAS CODED AS "1", MEANING SHE WAS AT RISK OF DEVELOPING PRESSURE ULCERS. RESIDENT #15 HAD TWO BRADEN SCALES (ASSESSMENT FOR PREDICTING PRESSURE SORE RISK) DONE ON 12/5/12 AND 1/11/13 WITH SCORES OF 20 AND 18 RESPECTIVELY, BOTH REPRESENTING A VERY LOW RISK OF DEVELOPING PRESSURE ULCERS. THE PROGRESS NOTES UTILIZED BY ALL MEMBERS OF THE INTERDISCIPLINARY TEAM, DATED 1/6/13 REFLECTED RESIDENT #15 HAD "AN OPEN AREA ON LEFT BUTTOCKS THAT MEASURES 1 CM X 1 ? CM X <0.1 CM. APPLIED [MEDICATION NAME]". THE TREATMENT ADMINISTRATION RECORD (TAR) DATED JANUARY 2013 REFLECTED RESIDENT #15 WAS ADMINISTERED [MEDICATION NAME] CREAM TO HER LEFT BUTTOCK DAILY FROM 1/6/13 THROUGH 1/14/13 AND TWICE DAILY FROM 1/15/13 THROUGH 1/23/13. HOWEVER, THERE WAS NO FURTHER DOCUMENTATION IN THE PROGRESS NOTES REGARDING THE STATUS OF HER LEFT BUTTOCK WOUND EXCEPT THE FIRST ENTRY ON 1/6/13. ON 1/25/13 AT 9:30 A.M., THE WOUND NURSE, (STAFF " F ") STATED THE LAST TIME SHE HAD LOOKED AT THE WOUND WAS ON 1/19/13; APPROXIMATELY 13 DAYS PASS THE FIRST TIME IT WAS IDENTIFIED. THE "WEEKLY PRESSURE ULCER HEALING ASSESSMENT" DOCUMENTED BY A WOUND CARE NURSE, DATED 1/19/13 REFLECTED RESIDENT #15'S LEFT BUTTOCK WOUND MEASURED 1.0 CM LONG AND 1.0 CM WIDE WITH NO DEPTH AND IT WAS STAGED AS A STAGE 1 (INTACT SKIN WITH NON-BLANCHABLE REDNESS). UNDER THE COMMENT SECTION RESIDENT #15 WAS DESCRIBED AS LYING FLAT ON HER BACK CONTINUOUSLY AND SHE WAS EDUCATED ON IMPORTANCE OF REPOSITIONING. ON 1/24/13 AT 1:30 P.M., RESIDENT #15 WAS OBSERVED EATING HER LUNCH IN HER ROOM WHILE SITTING STRAIGHT UP IN BED. THE RESIDENT WAS USING BOTH OF HER HANDS, TRYING TO FEED HERSELF AWKWARDLY DUE TO THE CAST ON HER RIGHT HAND. RESIDENT #15 WAS ASKED WHICH HAND SHE NORMALLY USED TO FEED HERSELF. SHE STATED, "MY RIGHT HAND". SHE ADDED, " YOU SEE I AM LEARNING TO USE BOTH HANDS TO EAT, BUT AS YOU CAN SEE I MAKE A LOT OF MESS". RESIDENT #15 WAS ASKED ABOUT THE SORE ON HER BUTTOCK. SHE SAID, " OH, THAT IS PAINFUL"! IMMEDIATELY AFTER RESIDENT #15 FINISHED HER LUNCH THE NURSING AIDE, (STAFF "D") CHANGED THE RESIDENT'S BRIEF. AS SHE WAS ADVISED TO TURN ON HER RIGHT SIDE RESIDENT #15 WAS MOANING AND GROANING DUE TO SEVERE DISCOMFORT AND PAIN WHICH RESIDENT #15 ACKNOWLEDGED. THERE WERE 2 BLACK SCABBED AREAS ONE ON EACH BUTTOCK AND ONE OPEN AREA ON RIGHT BUTTOCK NEXT TO THE BLACK SCAB. BOTH BLACK SCABBED AREAS MEASURED APPROXIMATELY 2 CM X 2 CM AND WERE SHAPED LIKE AN IRREGULAR CIRCLE. THE OPEN AREA ON THE RIGHT BUTTOCK NEXT TO THE BLACK SCAB MEASURED 1 CM X 0.5 CM AND LOOKED LIKE AN OPENED BLISTER. STAFF "D" WAS ASKED HOW LONG THE RESIDENT HAD THOSE ULCERS. STAFF "D" STATED IT HAD BEEN ABOUT A WEEK. STAFF "D" CLEANED BOTH BUTTOCKS WITH WIPES AND APPLIED [MEDICATION NAME] CREAM. STAFF "D" WAS ASKED IF SHE HAD REPORTED HER FINDINGS TO THE NURSES. SHE JUST SHRUGGED HER SHOULDERS AND SAID THAT SHE DOCUMENTED HER OBSERVATIONS IN THE NURSE AIDES CHARTING (ELECTRONIC RECORD). THE MEASUREMENTS OF THE PRESSURE ULCERS HAD WORSENED. ON 1/24/13 AT 3:00 P.M., THE DIRECTOR OF NURSING (DON) STATED THAT IF RESIDENTS WERE FOUND TO HAVE NEW SKIN BREAKDOWNS OR CHANGES OF THE WOUNDS, THE NURSE AIDES WERE SUPPOSED TO REPORT AND DOCUMENT THEIR SKIN OBSERVATIONS EVERY SHIFT. THE ELECTRONIC RECORD CALLED " FOLLOW UP QUESTION REPORT " DATED 1/1/13 THROUGH 1/24/13 REFLECTED RESIDENT #15 HAD OPEN AREAS, DISCOLORATION, SKIN TEAR, BRUISE OR RED AREAS ON DIFFERENT PARTS OF HER BODY SUCH AS BUTTOCKS, HANDS, RIGHT ARM, LEFT ARM, HEAD, RIGHT LEG, BACK AND HEAD, DOCUMENTED ON DIFFERENT TIMES AND DIFFERENT SHIFTS. HOWEVER, IT WAS EXTREMELY DIFFICULT TO CORRELATE SKIN ISSUES TO SPECIFIC LOCATIONS OR WHAT TIME PERIOD THE RESIDENT WAS OBSERVED FOR FACILITY STAFF TO ASSIST IN ASSESSING AND MONITORING THE PROGRESS OR LACK OF FOR THE PRESSURE ULCERS. ON 1/24/13 AT 2:45 P.M., LICENSED PRACTICAL NURSE, (STAFF "C" ) STATED THAT SHE OBSERVED RESIDENT #15'S LEFT BUTTOCK WOUND A WEEK AGO. SHE ADDED AT THAT TIME IT WAS ON THE THE RESIDENT'S LEFT BUTTOCK ONLY AND IT WAS JUST SUPERFICIAL SKIN BREAKDOWN. ON 1/25/13 AT 9:30 A.M., THE WOUND NURSE, (STAFF "F" ) STATED THAT THE LAST TIME SHE OBSERVED THE WOUND WAS 1/19/13. STAFF " F " ADDED THAT THE WOUND LOOKED ALMOST CLOSED, EXPLAINING WHY SHE HAD STAGED THE WOUND AS A STAGE 1. STAFF " F " STATED THAT SHE HAD SUSPECTED THE WOUND GOT WORSE BECAUSE THE RESIDENT WAS NOT EATING WELL AND LAID ON HER BACK CONSTANTLY. STAFF "F" COULD NOT EXPLAIN WHY NO ONE ELSE DISCOVERED THE NEW DEVELOPMENT OF RIGHT BUTTOCK PRESSURE ULCERS WHEN THE TREATMENT WAS ADMINISTERED ON A DAILY BASIS. THE " WEIGHT SUMMARY " DATED 12/12/12 THROUGH 1/24/13 REFLECTED RESIDENT #15 HAD A SIGNIFICANT WEIGHT LOSS (>5 % IN ONE MONTH) FROM 118.4 POUNDS ON 12/12/12 TO 104.8 POUNDS ON 1/10/13. SHE WAS 60 INCHES (5 FEET) TALL. THE DIETITIAN'S NOTE DATED 1/4/13 REFLECTED, "RESIDENT HAS HAD 9 % WEIGHT LOSS OVER THE PAST 30 DAYS RELATED TO POOR APPETITE. SHE REPORTS HER APPETITE IS STARTING TO IMPROVE AND SHE KNOWS SHE NEEDS TO EAT TO MAINTAIN HER WEIGHT ...NOTED RESIDENT WITH DIFFICULTY SWALLOWING HER PILLS ...LARGE AMOUNT OF PHLEGM NOTED ... ALSO STATED SHE WANTS TO EAT IN HER ROOM BECAUSE OF THE PHLEGM AND BECAUSE SHE IS A MESSY EATER WITH THIS CAST ON ... " NUTRITION DEFICIT IS AN IMPORTANT CONSIDERATION IN THE DEVELOPMENT AND LACK OF HEALING FOR PRESSURE ULCERS. THE NURSING CARE PLAN REGARDING PRESSURE ULCER INITIATED 1/11/13 STATED RESIDENT #15'S " ULCER TO THE LEFT BUTTOCK WILL BE HEALED WITHIN 30 DAYS". THE ONLY INTERVENTION WAS LISTED AS "REPOSITION EVERY 2 HOURS, [MEDICATION NAME] AFTER EACH INCONTINENCE EPISODE AND AS NEEDED". ON 1/25/13 AT 9:30 A.M., THE WOUND NURSE, (STAFF "F ") STATED SHE HAD WRITTEN THE PRESSURE ULCER CARE PLAN, WHEN THE PRESSURE ULCER WAS FIRST DISCOVERED. STAFF "F" ADDED SHE WAS NOT AWARE SHE NEEDED TO INCLUDE PREVENTIVE MEASURES FOR THE RESIDENT WHO WAS AT RISK OF DEVELOPING PRESSURE ULCERS. RESIDENT #15 WAS FIRST IDENTIFIED AS HAVING AN OPEN AREA ON HER LEFT BUTTOCK ON 1/6/13. ON 2/24/13, 18 DAYS LATER SHE DEVELOPED 2 ADDITIONAL, PREVENTABLE UNSTAGEABLE PRESSURE ULCERS ON BOTH BUTTOCKS. DESPITE THE DOCUMENTATION OF TREATMENT TO THE WOUND BY THE LICENSED STAFF ON A DAILY BASIS AND THE NURSE AIDES SKIN OBSERVATION DOCUMENTATION, NONE OF THE NURSES DOCUMENTED THE CURRENT STATUS OF RESIDENT #15'S PRESSURE ULCER. THERE WAS NO EVIDENCE THE PRESSURE ULCERS WERE MONITORED OR EVALUATED IN A TIMELY MANNER WHICH WOULD INCLUDE MODIFICATIONS OR UPDATES TO THE CARE PLAN. IN ADDITION, RESIDENT #15 IS EXPERIENCING PAIN AND DISCOMFORT ASSOCIATED WITH THE PRESSURE ULCERS WHICH SHE DID NOT HAVE WHEN admitted . ( ) ACCORDING TO THE FACE SHEET WITH A PRINT DATE OF 1/23/2013, RESIDENT #1 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE]. HOWEVER, THE LIST OF [DIAGNOSES REDACTED]. THE LIST OF [DIAGNOSES REDACTED]. THE ANNUAL MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED RESIDENT #1 HAD A BIM (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF 15 OUT OF POSSIBLE 15 SCORES, MEANING SHE HAD NO COGNITIVE IMPAIRMENT. THE CARE AREA ASSESSMENT (CAA) WORKSHEET DATED 7/30/12 REFLECTED RESIDENT #1 WAS EXTENSIVE ASSIST TO DEPENDENT WITH MOST OF HER ADL(S) (ACTIVITIES OF DAILY LIVING). THE RESIDENT WAS ABLE TO FEED HERSELF AND HAD NO PRESSURE ULCERS. THE CAA FURTHER REFLECTED RESIDENT #1 WAS NOT ABLE TO GET HERSELF IN OR OUT OF BED OR CHAIR AND SHE WAS TRANSFERRED WITH THE "ENCORE," MECHANICAL LIFT BECAUSE SHE WAS NOT ABLE TO WALK. UNDER THE PRESSURE ULCER HEADING THE CAA IDENTIFIED RESIDENT #1 AS BEING AT RISK OF DEVELOPING PRESSURE ULCERS DUE TO NEEDING EXTENSIVE ASSISTANCE WITH BED MOBILITY AND BOWEL AND BLADDER INCONTINENCE. THE QUARTERLY BRADEN SCALES FOR PREDICTING PRESSURE SORE RISK DATED 4/25/12 THROUGH 12/26/12 RANGED BETWEEN 13 AND 16, INDICATING RESIDENT #1 HAD A MODERATE RISK OF DEVELOPING PRESSURE ULCERS. UNDER THE ACTIVITY CATEGORY IN DETERMINING THE RISK RESIDENT #1 WAS CONSISTENTLY CHECKED AS BEING CHAIRFAST. UNDER THE MOBILITY CATEGORY RESIDENT #1 WAS CONSISTENTLY CHECKED AS BEING VERY LIMITED. ON 1/24/13 AT 10:00 A.M., RESIDENT #1 WAS OBSERVED SITTING IN A RECLINER WITH HER FEET ELEVATED AND WATCHING TELEVISION IN A DAY ROOM. THE RESIDENT'S WHEELCHAIR WAS PUSHED BY THE NURSE AIDES, WHENEVER SHE NEEDED TO GO TO A DIFFERENT LOCATION. THE "PROGRESS NOTES," UTILIZED BY ALL MEMBERS OF THE INTERDISCIPLINARY TEAM, DATED 12/17/12 REFLECTED RESIDENT #1 HAD "WHITE BLISTER NOTED LEFT HEEL-5 X 3.8 CM. CLEANED AND COVERED WITH ALLEVYN DRESSING. SURROUNDING SKIN MEDIUM PINK COLOR. HEELS ELEVATED UP OFF MATTRESS WITH HEELS UP PAD". THE NEXT ENTRY REGARDING THIS WOUND WAS DOCUMENTED ON 12/26/12. THE NOTE REFLECTED, "...UPON REMOVING THE OPEN HEEL BOOT ON LEFT FOOT IT WAS OBSERVED THAT SHE HAD A VERY LARGE INTACT BLISTER (8 X 11 CM) WITHOUT REDNESS TO SURROUNDING TISSUE. THE BLISTER HAS A BLACKISH DISCOLORATION TO IT ...HAS 2 + LEFT PEDAL, ANKLE, AND LOWER LEG [MEDICAL CONDITION] ..." THE PROGRESS NOTES DATED 12/31/12 AT 3:00 P.M. REFLECTED, RESIDENT #1'S " RIGHT (ERROR) HEEL CONTINUES TO HAVE A BLISTER, AREA IS A BLACK COLOR, NO LONGER HAS PURPLE EDGES. NO DRAINAGE, AREA CONTINUES TO BE INTACT AND IS PUFFY/FLUID FILLED, PAINFUL". THE PRESSURE ULCER WAS IDENTIFIED TO BE ON THE LEFT HEEL. THE PROGRESS NOTES " DATED 12/31/12 AT 10:45 P.M. REFLECTED, "LARGE SEROUS SANGUINEOUS DRAINAGE NOTED ALL OVER BOOT. PATIENT'S HEEL BLISTER POPPED". THE WOUND NOTE DATED 1/1/13 REFLECTED RESIDENT #1'S LEFT HEEL WOUND MEASURED 8.0 CM X 13 CM AND IT WAS LABELED AS A STAGE 2 (PARTIAL THICKNESS LOSS OF DERMIS) PRESSURE ULCER. THE RESIDENT'S PAIN LEVEL WAS RATED AS "8," WITH 10 BEING THE MOST SEVERE PAIN. THE WOUND NOTE DATED 1/12/14 REFLECTED RESIDENT #1'S LEFT HEEL WOUND WAS MEASURED 6.0 CM X 2.0 CM AND IT WAS LABELED AS AN UNSTAGEABLE (FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS COVERED BY SLOUGH OR ESCHAR). THE RESIDENT'S PAIN LEVEL WAS RATED AS "5", WITH 10 BEING THE MOST SEVERE PAIN. THE MOST RECENT MEASUREMENT OF THE RESIDENT'S LEFT HEEL WOUND WAS DONE ON 1/18/13 AT 6 CM X 2.5 CM, A SLIGHT INCREASE IN SIZE. ON 1/24/13 AT 10:25 A.M., THE DRESSING CHANGE TO RESIDENT #1'S LEFT HEEL PRESSURE ULCER WAS OBSERVED IN HER ROOM WHILE THE RESIDENT WAS SEATED IN HER RECLINER WITH HER BOTH FEET ELEVATED. LICENSED PRACTICAL NURSE, (STAFF "B") REMOVED THE DRESSING FROM THE RESIDENT'S LEFT HEEL WOUND, WHILE REGISTERED NURSE, (STAFF "A") HELD THE RESIDENT'S LEFT LEG. THERE WAS A MODERATE AMOUNT OF DARK BROWNISH SEROSANGUINEOUS DRAINAGE NOTED ON THE OLD DRESSING. THE HEEL WOUND HAD 2 LARGE LOOSELY CONNECTED IRREGULARLY SHAPED BLACK PIECES OF ESCHAR EXTENDING FROM THE LATERAL ASPECT TO THE OPPOSITE INNER ASPECT OF THE LEFT HEEL. THE SURROUNDING TISSUE WAS RED. THE RESIDENT'S ENTIRE FOOT WAS PALE WHITE AND HER ANKLE LOOKED PUFFY. STAFF "B" CLEANED THE WOUND WITH " SURE PREP " AND APPLIED AN "ABD" BANDAGE, AND SECURED IT WITH STOCKINET (COVERING THAT LOOKS LIKE A FISH NET STOCKING). ON 1/24/13 AT 10:45 A.M., REGISTERED NURSE, (STAFF "A" ) WAS ASKED WHAT MAY HAVE CAUSED RESIDENT #1'S HEEL ULCER. STAFF "A" STATED THAT THE RESIDENT WAS IMMOBILE, STAYING MOST OF HER TIME IN A LAZY BOY CHAIR, BEING INCONTINENT OF BLADDER, BEING PARALYZED IN ONE SIDE, AND SHE WAS DEPRESSED. STAFF "A" ADDED THAT THE FACILITY CONDUCTED A BODY AUDIT ON ADMISSION AND ANYTIME THERE WAS AN ISSUE ANOTHER ASSESSMENT WAS DONE WEEKLY FOR 4 WEEKS. HOWEVER, THERE WAS NO VERIFICATION THAT BODY AUDITS WERE DONE FOR RESIDENT #1 DESPITE THREE DIFFERENT READMISSION'S (3/21/11, 11/28/12 AND 5/30/12) AND INSPITE OF A NEW DEVELOPMENT OF THE PRESSURE ULCER. ON 1/24/13 AT 4:00 P.M., RESIDENT #1'S FAMILY MEMBER STATED THAT HE CAME EVERY DAY AND SPENT 3 TO 3 ? HOUR WITH THE RESIDENT. THE FAMILY MEMBER ADDED THAT THE RESIDENT WOULD HAVE A LOT OF PAIN ON HER LEFT SIDE INCLUDING HER LEFT FOOT AND HE HAD NEVER NOTICED THAT THE STAFF EVER REPOSITIONED THE RESIDENT WHILE SHE WAS IN A RECLINER. ( SEE ALSO F 279) ( )

This intake pertains to intake #MI 731 Based on interview and record review the facility failed to ensure that 1 (#101) of 3 sampled Residents of a total of 3 sampled Residents, remained free of accidents and had all items care planned to prevent falls in place, resulting in Resident #101 getting out of bed independently and suffering a pelvic fracture. Findings include: Review of the Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. According to her [DIAGNOSES REDACTED]. According to the fall care plan dated 11-8-09 had interventions included: motion sensor by bed, a personal alarm in bed and the bed in low position when in bed. According to the Unusual Occurrence (UO) report for Resident #101 dated 9-20-11 at 3 PM, Under occurrence, item #3 it stated, "SW observed her on the floor in her room." Under occurrence item #8 stated, "Left hip pain." Under assessment, item #7 it stated, "sent to emergency department to evaluate.". Under Documentation, item #7 stated, "Educate husband on proper use of alarms and sensors, to inform staff when he leaves bedside, and staff to check alarms after husband leaves." According to the Facility Investigation Report - 5 Working Days, dated 9-22-11, it stated under summarize facility investigation, " September 21, 2011, name of facility staff notified via hospital that Resident #101 was diagnosed with [REDACTED]." Under Action taken by facility it stated, "On September 22, 2011, RN #1, spoke to Resident #101 Responsible Party. He indicated he was visiting on September 20, 2011 prior to Resident #101's fall. He commented, "You don't have to say anything , I didn't turn the alarms back on." During an interview with the Director of Nursing (DON) on 10-4-11, at 1:50 PM, the DON explained that the day Resident #101 was found on the floor it was discovered that her bed alarms were not functioning and during the investigation they had discover that Resident #101's Responsible Party had not turned the alarms on as he usually did when he leaves." During an interview with SW #1 on 10-4-11, at 2 PM, SW #1 described finding Resident #101 on the floor near her bedroom door (greater than 10' from her bed). SW#1, was not able to recall any alarms sounding when she found Resident #101 on the floor. During an interview with the Director of Nursing (DON) on 10-5-11, at 8:30 AM, the DON provided the Surveyor with a typed document with some hand written notes that provided the names of staff that worked with Resident #101 on September 20 th and interview information the DON obtained from the staff. According to the interview and note, CNA #1 was the primary caregiver on 1st shift, on 9-20-11. CNA #1 said that she did not put Resident #101 in bed on 9-20-11. CNA #1 said, " Resident #101 was in bed a when she checked on her at 2 PM and she did not check the bed alarms." According to the document CNA #2 worked 1st and 2nd shift on 9-20-11. CNA #2 was interviewed on 10-5-11, at 9:30 AM, and confirmed she worked 1st and 2nd shift on 9-20-11. CNA #2 said she did not check Resident #101's bed alarms on first or second shift and she was not sure how Resident #101 got into bed on 9-20-11. LPN #1 was interviewed on the telephone, on 10-5-11, at 10 AM. LPN #1 recalled assisting with assessing Resident #101 when she was found on the floor on 9-20-11. LPN #1 said Resident #101 was in a strange position on the floor by the door. In further explanation LPN #1 said Resident #101 had to have fallen from a standing positron due to the placement of her legs and body. (LPN #1 thought Resident #101 may have used furniture in the room to stand and walk toward the door). LPN #1 was not sure how Resident #101 got into bed on 9-20-11 but had observed Resident #101's Responsible Party put her to bed in the past." ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO THOROUGHLY INVESTIGATE ALLEGATIONS OF ABUSE MADE BY 3 OF 11 RESIDENTS IN ATTENDANCE AT THE GROUP INTERVIEW, ALLEGATIONS MADE BY 1 HOUSEKEEPER (STAFF "N") AND 4 (#15, 24, 25 AND 26) OF 27 SAMPLED RESIDENTS REVIEWED FOR ABUSE. IN ADDITION, THE FACILITY FAILED TO GENERALLY REPORT ANY ALLEGATIONS OF ABUSE AND NEGLECT TO THE STATE RESULTING IN AN ONGOING CONDITION OF RESIDENTS FEELING NERVOUS, BELITTLED, ISOLATED, AND FEARFUL. FINDINGS INCLUDE: DURING THE GROUP INTERVIEW WITH 11 RESIDENTS ON 4-27-2011, BEGINNING AT 10:00 AM, 3 OF THE 4 RESIDENTS PRESENT FROM THE MORNING GLORY LANE UNIT STATED THAT A CERTIFIED NURSING ASSISTANT ON THE MIDNIGHT SHIFT WAS RUDE AND WAS ROUGH WITH THEM. THREE OUT OF 4 RESIDENTS STATED THAT THEY HAD ASKED THAT STAFF "O" NOT TAKE CARE OF THEM. THREE OF 4 RESIDENTS STATED THAT STAFF "O" TURNED OFF THEIR CALL LIGHTS AND DIDN'T HELP THEM. THE SAME NUMBER OF RESIDENTS STATED THAT STAFF "O" IS "ROUGH" WITH THEM AND RUDE. THEY STATED THEY HAD COMPLAINED ABOUT STAFF "O" TO THE DIRECTOR OF NURSING, STAFF "D", BUT THE CERTIFIED NURSING ASSISTANT STILL CARED FOR THE RESIDENTS AND THERE HAD BEEN NO IMPROVEMENT IN THE treatment of [REDACTED]. RESIDENT #15 WAS A [AGE] year OLD FEMALE. A PROGRESS NOTE ENTRY DATED 4-26-2011 REFLECTED THAT RESIDENT #15 SCORED 15 OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS INDICATING NO PROBLEMS WITH MEMORY OR COMPREHENSION. RESIDENT #15 STATED IN AN INTERVIEW IN HER ROOM ON 4-28-2011 AT ABOUT 10:55 AM. THAT SHE HAD TOLD THE DIRECTOR OF NURSING, STAFF "D", THAT SHE DID NOT WANT CERTIFIED NURSING ASSISTANT STAFF "O" TO CARE FOR HER BECAUSE SHE WAS TOO "ROUGH" AND SHE WAS RUDE. RESIDENT #15 STATED THAT A FEW MORNINGS PRIOR TO THE INTERVIEW STAFF "O" HAD ASSISTED ONE OF HER ROOMMATES. THE ROOMMATE, SHE REPORTED, HAD WANTED TO BRUSH HER TEETH AFTER BREAKFAST BUT STAFF "O" INSISTED SHE HAD TO BRUSH HER TEETH BEFORE BREAKFAST. RESIDENT #15 SHARED ANOTHER INCIDENT WHERE ONE OF HER OTHER ROOMMATES HAD SET OFF THE PERSONAL ALARM ON HER CHAIR BY STANDING AND STAFF "O" ENTERED THE ROOM AND YELLED AT THE ROOMMATE SAYING "YOU CAN'T KEEP GETTING UP AND DOWN". RESIDENT #15 STATED THAT SHE HAD REPORTED STAFF "O"'S BEHAVIOR TO THE DIRECTOR OF NURSING, STAFF "D", THREE OR FOUR TIMES BUT THAT THIS SURVEYOR WAS THE FIRST PERSON TO COME AND TALK TO HER ABOUT STAFF "O". THE FACILITY DID NOT OFFER DOCUMENTATION OF A THOROUGH INVESTIGATION OF THESE ALLEGATIONS AND DID NOT SHOW EVIDENCE OF REPORTING THE ALLEGATIONS TO THE STATE. A MINIMUM DATA ASSESSMENT, DATED 2-23-2011, REFLECTED THAT RESIDENT #24 SCORED 15 OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS INDICATING NO PROBLEMS WITH MEMORY OR COMPREHENSION. RESIDENT #24 STATED IN AN INTERVIEW ON 4-28-2011 AT ABOUT 11:00 AM THAT SHE HAD TOLD THE DIRECTOR OF NURSING, STAFF "D", SHE DID NOT WANT STAFF "O" TO CARE FOR HER. RESIDENT #24 STATED STAFF "O" HAS BEEN NASTY TO HER AND TOLD HER SHE CAN DO THINGS FOR HERSELF WHEN SHE CANNOT. RESIDENT #24 STATED STAFF "O" WILL RELUCTANTLY PERFORM TASKS FOR HER AND AS AN EXAMPLE STATED THAT WHEN SHE HAD BROUGHT HER BACK FROM THE RESTROOM DURING THE NIGHT, STAFF "O" TOLD HER TO LIFT HER OWN FEET INTO THE BED. DURING THE INTERVIEW, RESIDENT #24'S LOWER LEGS, ANKLES, AND FEET WERE OBSERVED TO BE VERY SWOLLEN. RESIDENT #24 STATED SHE TOLD STAFF "O" SHE COULD NOT AND STAFF "O" THREW HER FEET UP AND OVER ONTO THE BED. RESIDENT #24 ALSO STATED "I AM [AGE] years OLD, I KNOW WHAT I CAN AND CAN'T DO". RESIDENT #24 STATED WHEN SHE REPORTED STAFF "O" TO THE DIRECTOR OF NURSING, STAFF "D" SHE WAS TOLD THAT THE DIRECTOR OF NURSING HAD HEARD THE SAME STORIES FROM OTHER PEOPLE. THE FACILITY DID NOT OFFER DOCUMENTATION OF A THOROUGH INVESTIGATION OF THESE ALLEGATIONS AND DID NOT SHOW EVIDENCE OF REPORTING THE ALLEGATIONS TO THE STATE. A MINIMUM DATA SET ASSESSMENT, DATED 1-26-2011, REFLECTED THAT RESIDENT #25 SCORED 15 OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS INDICATING THAT THE RESIDENT HAD NO MEMORY PROBLEMS. RESIDENT #25 WAS INTERVIEWED IN HER ROOM ON 4-29-2011 AT 9:00 AM. RESIDENT #25 STATED SHE DID NOT WANT STAFF "O" TO TAKE CARE OF HER BECAUSE SHE IS NOT NICE. RESIDENT #25 STATED, I WISH STAFF "O" WOULD RETIRE OR TRANSFER TO ANOTHER UNIT. RESIDENT #25 STATED THAT STAFF "O" HAD ONCE YELLED HER NAME ABOUT TEN TIMES AND SAID, "DO YOU UNDERSTAND?" RESIDENT #25 STATED THAT STAFF "O" TELLS THE RESIDENT SHE CAN DO THINGS FOR HERSELF WHEN SHE CAN'T. RESIDENT #25 FURTHER STATED THAT STAFF "O" WOULD TURN OFF THE CALL LIGHT AND NOT HELP, STAFF "O"WILL SAY TO ME "I WAS JUST IN HERE, WHY DIDN'T YOU TELL ME YOU NEEDED TO GO (TO THE BATHROOM) THEN?" RESIDENT #25 STATED THAT SHE HAD SPOKEN WITH THE DIRECTOR OF NURSES ABOUT STAFF "O". RESIDENT #25 STATED THAT SHE HAD BEEN AFRAID TO SPEAK TO THE DIRECTOR OF NURSES, STAFF "D", BY HERSELF AND WENT WITH ANOTHER RESIDENT WHO ALSO HAD BEEN MISTREATED BY STAFF "O". THE FACILITY DID NOT OFFER DOCUMENTATION OF A THOROUGH INVESTIGATION OF THESE ALLEGATIONS AND DID NOT SHOW EVIDENCE OF REPORTING THE ALLEGATIONS TO THE STATE. RESIDENT #26'S MENTAL STATUS WAS FULLY ORIENTED ACCORDING TO THE COGNITIVE, MOOD, AND BEHAVIORAL PROGRESS NOTE, DATED 3-24-2011. DURING AN INTERVIEW ON 4/27/11 AT 3:25 PM RESIDENT # 26, WHO ASKED TO REMAIN ANONYMOUS, STATED STAFF "R", A CERTIFIED NURSING ASSISTANT, SAID TO HER, "I KNOW HOW TO DEAL WITH YOU ELDERLY PEOPLE". RESIDENT # 26 STATED, "I ASKED THAT STAFF "R" NOT TAKE CARE OF ME. THE FACILITY DID NOT OFFER DOCUMENTATION OF A THOROUGH INVESTIGATION OF THIS ALLEGATION AND DID NOT SHOW EVIDENCE OF REPORTING THE ALLEGATION TO THE STATE. DURING AN INTERVIEW WITH STAFF "N", A HOUSEKEEPER ON THE MORNING GLORY LANE UNIT, ON 4-27-2011 AT ABOUT 10:50 AM, STAFF "N", STATED THAT SHE HAD REPORTED TO THE DIRECTOR OF NURSING, STAFF "D", WHEN RESIDENT #25 HAD TOLD HER THAT A CERTIFIED NURSING ASSISTANT, STAFF "O", WHO WORKED THE MIDNIGHT SHIFT ON THE MORNING GLORY LANE UNIT, HAD BEEN VERBALLY ABUSIVE AND A LITTLE ROUGH WHEN CARING FOR HER. THE FACILITY DID NOT OFFER DOCUMENTATION OF A THOROUGH INVESTIGATION OF THIS ALLEGATION AND DID NOT SHOW EVIDENCE OF REPORTING THE ALLEGATIONS TO THE STATE. THE DIRECTOR OF NURSING WAS ASKED TO PROVIDE THE DOCUMENTATION OF ALL ALLEGATIONS OF ABUSE IN THE 6 MONTHS PRIOR TO THE SURVEY. SEVERAL FOLDERS OF INFORMATION WERE OFFERED. IN AN INTERVIEW ON 4/29/11 AT ABOUT 3:30 P.M., THE DON STATED SHE HAD PROVIDED TO THIS SURVEYOR ONLY A SELECTION OF ALL THE COMPLAINTS REQUESTED. A REVIEW OF EVERYTHING OFFERED REVEALED THAT ONLY 1 ALLEGATION HAD BEEN REPORTED TO THE STATE AND NONE HAD BEEN PROPERLY INVESTIGATED WHEN THESE ALLEGATIONS NEEDED TO BE REPORTED AND INVESTIGATED. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ASSURE THAT FIVE (#15, 24, 25, 26, AND 27) OF 27 SAMPLED RESIDENTS REVIEWED FOR POTENTIAL ABUSE WERE PROTECTED FROM ABUSIVE TREATMENT INFLICTED BY TWO FACILITY NURSE AIDES (NURSE AIDE "O" AND NURSE AIDE "R"), RESULTING IN THOSE RESIDENTS VERBALIZING FEELING NERVOUS, BELITTLED, ISOLATED, AND/OR FEARFUL. FINDINGS INCLUDE: DURING THE GROUP INTERVIEW WITH 11 RESIDENTS ON 4-27-2011, BEGINNING AT 10:00 AM, 3 OF THE 4 RESIDENTS PRESENT FROM THE MORNING GLORY LANE UNIT (ALL OF WHOM WISHED TO REMAIN CONFIDENTIAL) REPORTED CONCERNS THAT A CERTIFIED NURSING ASSISTANT ON THE MIDNIGHT SHIFT WAS RUDE AND ROUGH WITH THEM. THREE OF THE 4 RESIDENTS STATED THAT THEY HAD ASKED THAT STAFF "O" NOT TAKE CARE OF THEM. THREE OF THE 4 RESIDENTS STATED THAT STAFF "O" HAD TURNED OFF THEIR CALL LIGHTS, BUT HAD NOT HELPED THEM. THE SAME NUMBER OF RESIDENTS STATED THAT STAFF "O" WAS "ROUGH" WITH THEM AND RUDE. THEY STATED THAT THEY HAD COMPLAINED ABOUT STAFF "O" TO THE DIRECTOR OF NURSING (STAFF "D"), BUT THE CERTIFIED NURSING ASSISTANT WAS STILL CARING FOR RESIDENTS AND THERE HAD BEEN NO IMPROVEMENT IN HER treatment of [REDACTED]. DURING ENVIRONMENTAL ROUNDS ON 4-29-2011, BEGINNING AT 12:00 PM, IT WAS VERIFIED THROUGH OBSERVATION THAT A CALL LIGHT TURNED ON IN A RESIDENT ROOM ON THE MORNING GLORY LANE UNIT COULD BE CANCELLED AT THE NURSES STATION WITHOUT REQUIRING A STAFF PERSON TO GO INTO THE RESIDENT'S ROOM TO TURN IT OFF. THE FOLLOWING ADDITIONAL OBSERVATIONS, INDIVIDUAL RESIDENT INTERVIEWS AND RESIDENT RECORD REVIEWS WERE CONDUCTED: ACCORDING TO THE FACE SHEET, DATED 10-2-2009, RESIDENT #26 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] AND REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE COGNITIVE, MOOD, AND BEHAVIORAL PROGRESS NOTE, DATED 3-24-2011 IN THE RESIDENT'S RECORD, RESIDENT #26'S MENTAL STATUS WAS FULLY ORIENTED. ON 4/27/11 AT 3:25 PM RESIDENT # 26, WHO ASKED TO REMAIN ANONYMOUS, STATED THAT STAFF "R" (A CERTIFIED NURSING ASSISTANT) HAD SAID TO HER, "I KNOW HOW TO DEAL WITH YOU ELDERLY PEOPLE". IN ADDITION, RESIDENT #26 STATED, "AFTER I ASKED THAT SHE (STAFF "R") DOESN'T TAKE CARE OF ME, I WOULD TRY AND TALK TO HER. SHE WOULD ONLY SAY 'I DON'T WANT TO TALK TO YOU. I NEED TIME TO HEAL'." RESIDENT # 26 ALSO MADE THE FOLLOWING STATEMENT REGARDING NURSING ASSISTANT "O": "I ASKED THAT (STAFF "O") NOT TAKE CARE OF ME. SHE NOW TAKES CARE OF MY ROOMMATE AND GLARES AT ME WHENEVER SHE COMES IN THE ROOM." RESIDENT #26 STATED THAT STAFF "O" WAS RUDE AND MADE HER FEEL HELPLESS, USELESS AND ISOLATED BECAUSE OF THE WAY SHE TALKED TO HER. DURING THE CONVERSATION, RESIDENT #26 BECAME TEARFUL AND SPOKE WITH A QUIVERING VOICE. THE RESIDENT NEEDED A FEW MINUTES TO COMPOSE HERSELF AND CONTINUE WITH THE INTERVIEW. RESIDENT #26 ALSO STATED THAT SHE HAD TRIED TO FIND OUT THE LAST NAMES OF THE TWO AIDES WITH WHOM SHE HAD PREVIOUSLY HAD PROBLEMS, AND SHE WAS TOLD BY THE DIRECTOR OF NURSING (STAFF "D") THAT SHE COULD GO AND LOOK AT THEIR BADGES TO SEE WHAT THEIR LAST NAMES WERE. THE FACE SHEET, DATED 10-10-2008, REFLECTED THAT RESIDENT #25 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE]. RESIDENT #25 REQUESTED THAT SHE REMAIN CONFIDENTIAL. THE MINIMUM DATA SET ASSESSMENT, DATED 1-26-2011, REFLECTED THAT RESIDENT #25 SCORED 15 OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS INDICATING THAT THE RESIDENT HAD NO MEMORY PROBLEMS. RESIDENT #25 WAS INTERVIEWED IN HER ROOM ON 4-29-2011 AT 9:00 AM. RESIDENT #25 STATED THAT SHE DID NOT WANT STAFF "O" TO TAKE CARE OF HER BECAUSE HER TOUCH WAS NOT THE SAME AS THAT OF OTHER STAFF AND SHE WAS NOT NICE. RESIDENT #25 STATED, THAT SHE WISHED THAT STAFF "O" WOULD RETIRE OR TRANSFER TO ANOTHER UNIT. RESIDENT #25 STATED THAT STAFF "O" HAD ONCE YELLED HER NAME ABOUT TEN TIMES AND SAID, "DO YOU UNDERSTAND?" RESIDENT #25 STATED THAT STAFF "O" TOLD HER THAT SHE COULD DO THINGS FOR HERSELF WHEN SHE COULD NOT DO THEM. RESIDENT #25 FURTHER STATED THAT STAFF "O" WOULD TURN OFF THE CALL LIGHT AND NOT HELP, AND WOULD SAY TO HER, "I WAS JUST IN HERE, WHY DIDN'T YOU TELL ME YOU NEEDED TO GO (TO THE BATHROOM) THEN?" RESIDENT #25 STATED THAT, SOMETIMES, WHEN STAFF "O" HELPED HER TO THE COMMODE, STAFF "O" MADE HER SO NERVOUS THAT SHE WAS UNABLE TO URINATE. RESIDENT #25 STATED THAT SHE HAD SPOKEN WITH THE DIRECTOR OF NURSES ABOUT STAFF "O". RESIDENT #25 STATED THAT SHE HAD BEEN AFRAID TO SPEAK TO THE DIRECTOR OF NURSES BY HERSELF, AND WENT WITH ANOTHER RESIDENT WHO ALSO HAD BEEN MISTREATED BY STAFF "O". RESIDENT #25 STATED THAT IT HAD BEEN HER INTENTION TO NOT HAVE STAFF "O" TAKE CARE OF HER EVER AGAIN. RESIDENT #25 SAID THAT SHE WAS TOLD BY THE DIRECTOR OF NURSES THAT SHE (THE DIRECTOR OF NURSES) WOULD SPEAK TO STAFF "O" BUT ASKED RESIDENT #25 TO CONTINUE TO LET STAFF "O" PROVIDE HER CARE. RESIDENT #25 STATED THAT STAFF "O" STILL PROVIDED HER CARE. RESIDENT #25 REPEATED THAT IT "FELT DIFFERENT" WHEN STAFF "O" CARED FOR HER, AND THAT HER TOUCH WAS NOT AS CARING OR AS GENTLE AS THE OTHER STAFF. THE FACE SHEET FOR RESIDENT #25 , DATED 10-10-2008, REFLECTED THAT RESIDENT #25 HAD [DIAGNOSES REDACTED]. THE PHYSICIAN ORDER [REDACTED].# 25 WAS PRESCRIBED THE NARCOTIC [MEDICATION NAME]-[MEDICATION NAME] 10-325 MILLIGRAMS THREE TIMES A DAY FOR PAIN AND THE PAIN MEDICINE [MEDICATION NAME] 50 MILLIGRAMS TWICE A DAY. THE MEDICAL ROUTINE PROGRESS NOTE, DATED 4-20-2011, REFLECTED THAT RESIDENT #25 CONTINUED TO SUFFER WITH CHRONIC PAIN ALL OVER THAT WORSENED WITH MOVEMENT BUT THE RESIDENT PREFERRED TO TOLERATE SOME PAIN RATHER THAN TAKE STRONGER MEDICINE. THE MINIMUM DATA SET ASSESSMENT, DATED 1-26-2011, REFLECTED THAT RESIDENT #25 REPORTED OCCASIONAL PAIN THAT HAD MADE IT HARD FOR HER TO SLEEP AT NIGHT. WHEN RESIDENT #25 WAS VISITED IN HER ROOM ON 4-29-2011 AT ABOUT 9:00 AM, SHE WAS OBSERVED SITTING IN HER CHAIR WITH A BENT BACK THAT CAUSED HER CHIN TO NEARLY REST ON HER CHEST AND REQUIRED RESIDENT #25 TO MAKE EYE CONTACT WITH THIS SURVEYOR, WHO WAS SEATED, BY SHIFTING HER EYES UPWARD. AT THE CONCLUSION OF THE INTERVIEW, RESIDENT #25 IMPLORED THIS SURVEYOR NOT TO IDENTIFY HER TO THE FACILITY BECAUSE SHE WAS AFRAID OF WHAT MIGHT HAPPEN IF THE FACILITY STAFF KNEW SHE HAD COMPLAINED. AN ENTRY ON THE BEHAVIOR REPORT SHEET, DATED 3-29-2011, COMPLETED BY STAFF "O", REFLECTED THAT AT 4:50 AM THE NURSING ASSISTANT DOCUMENTED A BEHAVIOR OR MOOD SYMPTOM FOR RESIDENT #25 AS FOLLOWS: "...TRIED TO ENCOURAGE RESIDENT #25 TO USE THE HANDLE BARS TO PUSH HER BODY BACK TO THE MIDDLE OF THE BED BUT THE RESIDENT SAID SHE COULDN'T". THE CERTIFIED NURSING ASSISTANT ALSO RECORDED THAT SHE ASKED RESIDENT #25 TO PUT HER LEGS UP IN THE BED AND RESIDENT #25 SAID THAT SHE COULD NOT. STAFF "O" THEN RECORDED THAT SHE REPORTED THE INTERACTION TO THE NURSE. THE NEXT ENTRY WAS MADE AT 5:00 AM, BY STAFF "O", AND LISTED THE BEHAVIOR OR MOOD SYMPTOM AS: "...USED YELLOW SLING FOR TRANS. (TRANSFER) TO BSC (BED SIDE COMMODE)-RES WHINED (SIC) THIS SLING IS TOO TIGHT ON HER- BUTT STILL HANGS OUT". (NOTE: BEHAVIOR REPORT SHEETS ARE INTENDED TO REFLECT RESIDENTS' BEHAVIORS AS MEASURABLE AND OBJECTIVE; THEY ARE NOT SUPPOSED TO REFLECT THE SUBJECTIVE PERSONAL OPINIONS OF STAFF. THE DOCUMENTATION THAT THE RESIDENT HAD WHINED WAS A SUBJECTIVE COMMENT BY STAFF "O". FURTHERMORE, THE DOCUMENTATION REFLECTED NEGATIVELY UPON THE RESIDENT'S RIGHT TO EXPRESS HER OPINION ABOUT HER OWN CARE AND REPORT THAT THE SLING WAS TOO TIGHT.) STAFF"O" FURTHER RECORDED THAT SHE HAD REPORTED HER ENCOUNTER WITH RESIDENT #25 TO THE NURSE. ANOTHER ENTRY ON THE BEHAVIOR REPORT SHEET FOR 2-8-2011 RECORDED THAT THE RESIDENT'S KNEES HAD BUCKLED DURING A TRANSFER. THE INTERVENTION RECORDED BY STAFF "O" WAS "CONVERSATION", AND THE OUTCOME RECORDED WAS THAT RESIDENT #25 "STATED SHE WOULD DO BETTER." THE FACE SHEET REFLECTED THAT RESIDENT #24 WAS A [AGE] year-old FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #24 REQUESTED THAT HER INTERVIEW STATEMENTS REMAIN CONFIDENTIAL. THE MINIMUM DATA ASSESSMENT, DATED 2-23-2011, REFLECTED THAT RESIDENT #24 SCORED 15 OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS. THE physician's orders [REDACTED].#24 RECEIVED ONE EXTRA STRENGTH [MEDICATION NAME] TWICE A DAY AND TWO AT BED TIME FOR PAIN. THE MINIMUM DATA SET ASSESSMENT, DATED 2-23-2011, REFLECTED THAT RESIDENT #24 HAD REPORTED OCCASIONAL PAIN AND RATED THAT PAIN AT A 6 OF 10. THE MINIMUM DATA SET ASSESSMENT, DATED 2-23-2011, REFLECTED THAT RESIDENT #24 REQUIRED ONE PERSON TO PHYSICALLY ASSIST WITH BATHING ACTIVITY AND HAD IMPAIRMENT IN THE RANGE OF MOTION OF ONE UPPER EXTREMITY. ONE OF THE CARE PLANS FOR RESIDENT #24 REFLECTED THAT THE RESIDENT HAD EXPERIENCED A DECLINE WITH HER STRENGTH AND AMBULATION. AN ENTRY BY STAFF "O" ON THE BEHAVIOR REPORT LOG REFLECTED THAT RESIDENT #24 DID NOT WIPE HERSELF AFTER HAVING A BOWEL MOVEMENT AND THAT RESIDENT #24 HAD TOLD STAFF "O" THAT WAS WHY SHE WAS THERE TO HELP. THE RECORDED INTERVENTION WAS "CONVERSATION", AND STAFF "O" RECORDED THAT THE OUTCOME WAS THAT RESIDENT #24 HAD APOLOGIZED. DURING AN INTERVIEW WITH RESIDENT #24 ON 4-28-2011 AT ABOUT 11:00 AM, RESIDENT #24 STATED THAT SHE HAD TOLD THE DIRECTOR OF NURSING THAT SHE DID NOT WANT STAFF "O" TO CARE FOR HER. RESIDENT #24 STATED THAT STAFF "O" HAD BEEN NASTY TO HER AND TOLD HER THAT SHE COULD DO THINGS FOR HERSELF WHEN SHE COULD NOT DO THEM. RESIDENT #24 STATED THAT STAFF "O" WOULD RELUCTANTLY PERFORM TASKS FOR HER AND, AS AN EXAMPLE, STATED THAT WHEN SHE HAD BROUGHT HER BACK FROM THE RESTROOM DURING THE NIGHT, STAFF "O" TOLD HER TO LIFT HER OWN FEET INTO THE BED. DURING THE INTERVIEW, RESIDENT #24'S LOWER LEGS, ANKLES, AND FEET WERE OBSERVED TO BE VERY SWOLLEN. RESIDENT #24 STATED SHE TOLD STAFF "O" SHE COULD NOT, AND STAFF "O" THREW HER FEET UP AND OVER ONTO THE BED. RESIDENT #24 ALSO STATED, "I AM [AGE] years OLD, I KNOW WHAT I CAN AND CAN'T DO". RESIDENT #24 STATED THAT WHEN SHE REPORTED STAFF "O" TO THE DIRECTOR OF NURSING, SHE WAS TOLD THAT THE DIRECTOR OF NURSING HAD HEARD THE SAME STORIES FROM OTHER PEOPLE. RESIDENT #24 STATED THAT EVEN THOUGH SHE HAD ASKED THAT STAFF "O" NOT CARE FOR HER, STAFF "O" WAS STILL PROVIDING HER CARE. THE PHYSICIAN ORDER [REDACTED]. A PROGRESS NOTE ENTRY DATED 4-26-2011 REFLECTED THAT RESIDENT #15 SCORED 15 OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS. RESIDENT #15 WAS INTERVIEWED IN HER ROOM ON 4-28-2011 AT ABOUT 10:55 AM. RESIDENT #15 STATED THAT SHE HAD TOLD THE DIRECTOR OF NURSING THAT SHE DID NOT WANT CERTIFIED NURSING ASSISTANT, STAFF "O", TO CARE FOR HER BECAUSE SHE WAS TOO "ROUGH" AND SHE WAS RUDE. RESIDENT #15 STATED THAT ALTHOUGH STAFF "O" NO LONGER PROVIDED HER CARE, SHE CONTINUED TO PROVIDE CARE FOR HER ROOMMATES. RESIDENT #15 STATED THAT, A FEW MORNINGS AGO, STAFF "O" HAD ASSISTED ONE OF HER ROOMMATES IN THE MORNING. THE ROOMMATE, SHE REPORTED, HAD WANTED TO BRUSH HER TEETH AFTER BREAKFAST BUT STAFF "O" HAD INSISTED THAT SHE HAD TO BRUSH HER TEETH BEFORE BREAKFAST. RESIDENT #15 SHARED ANOTHER INCIDENT WHERE ONE OF HER OTHER ROOMMATES HAD SET OFF THE PERSONAL ALARM ON THEIR CHAIR BY STANDING UP, AND STAFF "O" HAD ENTERED THE ROOM AND YELLED AT THE ROOMMATE SAYING: "YOU CAN'T KEEP GETTING UP AND DOWN". RESIDENT #15 STATED THAT SHE HAD REPORTED STAFF "O"'S BEHAVIOR TO THE DIRECTOR OF NURSING THREE OR FOUR TIMES, BUT THIS SURVEYOR WAS THE FIRST PERSON TO COME AND TALK TO HER ABOUT STAFF "O". DURING AN INTERVIEW WITH STAFF "N", A HOUSEKEEPER ON THE MORNING GLORY LANE UNIT, ON 4-27-2011 AT ABOUT 10:50 AM, STAFF "N", STATED THAT SHE HAD REPORTED TO THE DIRECTOR OF NURSING WHEN RESIDENT #25 HAD TOLD HER THAT A CERTIFIED NURSING ASSISTANT (STAFF "O"), WHO WORKED THE MIDNIGHT SHIFT ON THE MORNING GLORY LANE UNIT, HAD BEEN VERBALLY ABUSIVE AND A LITTLE ROUGH WHEN CARING FOR HER. THE HOUSEKEEPER FURTHER STATED THAT SHE DID NOT UNDERSTAND WHY THIS NURSING ASSISTANT WAS STILL EMPLOYED, BECAUSE THE RESIDENTS CONTINUED TO COMPLAIN ABOUT POOR TREATMENT FROM THE NURSING ASSISTANT. THE HOUSEKEEPER REQUESTED THAT SHE NOT BE IDENTIFIED BECAUSE SHE WAS AFRAID OF RETALIATION FROM OTHER STAFF IF IT WAS KNOWN THAT SHE HAD SPOKEN TO A SURVEYOR. ( / ) DURING AN INTERVIEW ON 4/29/11 AT ABOUT 3:30 P.M., THE DIRECTOR OF NURSING (STAFF "D") WAS PROVIDED AN OPPORTUNITY TO SHOW WHY THE ALLEGATIONS REPORTED BY RESIDENTS #15, #24, #25, #26 AND #27 WERE NOT REPRESENTATIVE OF ACTUAL ABUSE OF RESIDENTS BY STAFF. THE DIRECTOR OF NURSING PROVIDED NO EVIDENCE TO SUPPORT THAT THE FACILITY HAD IDENTIFIED, INVESTIGATED, OR RULED OUT, ABUSE CONCERNS PERTAINING TO ANY OF THE FIVE RESIDENTS. ( ) RESIDENT #27 WAS IDENTIFIED ON THE FACE SHEET IN HER MEDICAL RECORD AS AN [AGE] year OLD FEMALE. ACCORDING TO A SOCIAL SERVICE NOTE OF 3/10/11 IN HER MEDICAL RECORD, SHE SCORED 12 OF A POSSIBLE 15 ON A BRIEF MENTAL STATUS TEST INDICATING THAT SHE WAS MILDLY CONFUSED. SHE WAS DESCRIBED IN AN MDS (MINIMUM DATA SET ASSESSMENT) NOTE OF 3/07/11 AS BEING "ALERT AND ORIENTED X 3". SHE WAS INTERVIEWED ON 4/28/11 AT 11:00 IN HER ROOM. AT THAT TIME, SHE WAS ASKED IF THE STAFF TOOK GOOD CARE OF HER. SHE STATED THAT MOST OF THEM DID, BUT ONE WAS SO MEAN THAT SHE WAS AFRAID TO ASK FOR HELP BECAUSE THE AIDE JUST "HOLLERS" AT HER. THE RESIDENT STATED THAT WHEN SHE ASKED FOR HELP GOING TO THE BATH ROOM, SHE WAS TOLD, "YOU JUST WENT. YOU DON'T HAVE TO GO AGAIN". SHE STATED THAT SHE HAD MADE GOOD PROGRESS IN THERAPY AND COULD WALK A SHORT DISTANCE WITH A WALKER BUT FEARED FALLING. WHEN SHE ASKED FOR HELP WALKING TO THE BATHROOM MOST OF THE AIDES HELPED HER, BUT ONE AIDE WOULD TELL HER, "YOU CAN DO IT YOURSELF". SHE STATED THAT HER PAIN WAS CONTROLLED WITH MEDICATION, BUT SOMETIMES THE MEDICATION DID NOT ALWAYS WORK AND SHE NEEDED MORE. SHE STATED THAT, IF THE "SNARKY" AIDE WAS ASSIGNED TO HER, SHE JUST DID NOT ASK HER TO TELL THE NURSE SHE NEEDED A PAIN MEDICATION BECAUSE THE AIDE WAS RUDE AND "SNARKY", AND SHE WOULD RATHER JUST WAIT FOR THE NEXT SHIFT. SHE WAS UNABLE TO IDENTIFY THE AIDE OTHER THAN TO SAY THAT SHE USUALLY WORKED ON THE NIGHT SHIFT. THE RESIDENT ASKED THAT HER NAME NOT BE USED. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE AN ADMINISTRATION THAT EFFECTIVELY AND EFFICIENTLY UTILIZED RESOURCES TO ENSURE THE FACILITY'S ABUSE AND NEGLECT PROGRAM WAS IN PLACE RESULTING IN 5 OF 27 SAMPLED RESIDENTS (#15, #24, #25, #26 AND #27) WHO WERE REVIEWED BY THE SURVEY TEAM FOR POTENTIAL ABUSE CLAIMING PSYCHOSOCIAL HARM AND #5 AND 10 OUT OF 11 RESIDENTS VOICING NEGLECT AND MISTREATMENT. ADDITIONALLY, THE FACILITY'S FAILURE TO DEVELOP AND OPERATIONALIZE ABUSE PREVENTION POLICIES INCREASED THE POTENTIAL FOR ALL FACILITY RESIDENTS TO EXPERIENCE SOME FORM OF ABUSE AND RESULTED IN SUBSTANDARD QUALITY OF CARE. FINDINGS INCLUDE: DURING THE GROUP INTERVIEW WITH 11 RESIDENTS ON 4-27-2011, BEGINNING AT 10:00 AM, 3 OF THE 4 RESIDENTS PRESENT FROM THE MORNING GLORY LANE UNIT (ALL OF WHOM WISHED TO REMAIN CONFIDENTIAL) REPORTED CONCERNS THAT A CERTIFIED NURSING ASSISTANT ON THE MIDNIGHT SHIFT WAS RUDE AND ROUGH WITH THEM. THREE OF THE 4 RESIDENTS STATED THAT THEY HAD ASKED THAT STAFF "O" NOT TAKE CARE OF THEM. THREE OF THE 4 RESIDENTS STATED THAT STAFF "O" HAD TURNED OFF THEIR CALL LIGHTS, BUT HAD NOT HELPED THEM. THE SAME NUMBER OF RESIDENTS STATED THAT STAFF "O" WAS "ROUGH" WITH THEM AND RUDE. THEY STATED THAT THEY HAD COMPLAINED ABOUT STAFF "O" TO THE DIRECTOR OF NURSING (STAFF "D"), BUT THE CERTIFIED NURSING ASSISTANT WAS STILL CARING FOR RESIDENTS AND THERE HAD BEEN NO IMPROVEMENT IN HER treatment of [REDACTED]. THE FOLLOWING ADDITIONAL OBSERVATIONS, INDIVIDUAL RESIDENT INTERVIEWS AND RESIDENT RECORD REVIEWS WERE CONDUCTED: ACCORDING TO THE COGNITIVE, MOOD, AND BEHAVIORAL PROGRESS NOTE, DATED 3-24-2011, RESIDENT #26'S MENTAL STATUS WAS FULLY ORIENTED. ON 4/27/11 AT 3:25 PM RESIDENT # 26, WHO ASKED TO REMAIN ANONYMOUS, STATED THAT STAFF "R" (A CERTIFIED NURSING ASSISTANT) HAD SAID TO HER, "I KNOW HOW TO DEAL WITH YOU ELDERLY PEOPLE". IN ADDITION, RESIDENT #26 STATED, "AFTER I ASKED THAT SHE (STAFF "R") DOESN'T TAKE CARE OF ME, I WOULD TRY AND TALK TO HER. SHE WOULD ONLY SAY 'I DON'T WANT TO TALK TO YOU. I NEED TIME TO HEAL'." RESIDENT # 26 ALSO MADE THE FOLLOWING STATEMENT REGARDING NURSING ASSISTANT "O": "I ASKED THAT (STAFF "O") NOT TAKE CARE OF ME. SHE NOW TAKES CARE OF MY ROOMMATE AND GLARES AT ME WHENEVER SHE COMES IN THE ROOM." RESIDENT #26 STATED THAT STAFF "O" WAS RUDE AND MADE HER FEEL HELPLESS, USELESS AND ISOLATED BECAUSE OF THE WAY SHE TALKED TO HER. DURING THE CONVERSATION, RESIDENT #26 BECAME TEARFUL AND SPOKE WITH A QUIVERING VOICE. THE RESIDENT NEEDED A FEW MINUTES TO COMPOSE HERSELF AND CONTINUE WITH THE INTERVIEW. RESIDENT #26 ALSO STATED THAT SHE HAD TRIED TO FIND OUT THE LAST NAMES OF THE TWO AIDES WITH WHOM SHE HAD PREVIOUSLY HAD PROBLEMS, AND SHE WAS TOLD BY THE DIRECTOR OF NURSING (STAFF "D") THAT SHE COULD GO AND LOOK AT THEIR BADGES TO SEE WHAT THEIR LAST NAMES WERE. ACCORDING TO THE FACE SHEET, DATED 10-10-2008, RESIDENT #25 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE]. RESIDENT #25 REQUESTED THAT SHE REMAIN CONFIDENTIAL. THE MINIMUM DATA SET ASSESSMENT, DATED 1-26-2011, REFLECTED THAT RESIDENT #25 SCORED 15 OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS INDICATING THAT THE RESIDENT HAD NO MEMORY PROBLEMS. RESIDENT #25 WAS INTERVIEWED IN HER ROOM ON 4-29-2011 AT 9:00 AM. RESIDENT #25 STATED THAT SHE DID NOT WANT STAFF "O" TO TAKE CARE OF HER BECAUSE HER TOUCH WAS NOT THE SAME AS THAT OF OTHER STAFF AND SHE WAS NOT NICE. RESIDENT #25 STATED, THAT SHE WISHED THAT STAFF "O" WOULD RETIRE OR TRANSFER TO ANOTHER UNIT. RESIDENT #25 STATED THAT STAFF "O" HAD ONCE YELLED HER NAME ABOUT TEN TIMES AND SAID, "DO YOU UNDERSTAND?" RESIDENT #25 STATED THAT STAFF "O" TOLD HER THAT SHE COULD DO THINGS FOR HERSELF WHEN SHE COULD NOT DO THEM. RESIDENT #25 FURTHER STATED THAT STAFF "O" WOULD TURN OFF THE CALL LIGHT AND NOT HELP, AND WOULD SAY TO HER, "I WAS JUST IN HERE, WHY DIDN'T YOU TELL ME YOU NEEDED TO GO (TO THE BATHROOM) THEN?" RESIDENT #25 STATED THAT, SOMETIMES, WHEN STAFF "O" HELPED HER TO THE COMMODE, STAFF "O" MADE HER SO NERVOUS THAT SHE WAS UNABLE TO URINATE. RESIDENT #25 STATED THAT SHE HAD SPOKEN WITH THE DIRECTOR OF NURSES ABOUT STAFF "O". RESIDENT #25 STATED THAT SHE HAD BEEN AFRAID TO SPEAK TO THE DIRECTOR OF NURSES BY HERSELF, AND WENT WITH ANOTHER RESIDENT WHO ALSO HAD BEEN MISTREATED BY STAFF "O". RESIDENT #25 STATED THAT IT HAD BEEN HER INTENTION TO NOT HAVE STAFF "O" TAKE CARE OF HER EVER AGAIN. RESIDENT #25 SAID THAT SHE WAS TOLD BY THE DIRECTOR OF NURSES THAT SHE (THE DIRECTOR OF NURSES) WOULD SPEAK TO STAFF "O" BUT ASKED RESIDENT #25 TO CONTINUE TO LET STAFF "O" PROVIDE HER CARE. WHEN RESIDENT #25 WAS VISITED IN HER ROOM ON 4-29-2011 AT ABOUT 9:00 AM, SHE WAS OBSERVED SITTING IN HER CHAIR WITH A BENT BACK THAT CAUSED HER CHIN TO NEARLY REST ON HER CHEST AND REQUIRED RESIDENT #25 TO MAKE EYE CONTACT WITH THIS SURVEYOR, WHO WAS SEATED, BY SHIFTING HER EYES UPWARD. AT THE CONCLUSION OF THE INTERVIEW, RESIDENT #25 IMPLORED THIS SURVEYOR NOT TO IDENTIFY HER TO THE FACILITY BECAUSE SHE WAS AFRAID OF WHAT MIGHT HAPPEN IF THE FACILITY STAFF KNEW SHE HAD COMPLAINED. ACCORDING TO THE FACE SHEET, RESIDENT #24 WAS A [AGE] year-old FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #24 REQUESTED THAT HER INTERVIEW STATEMENTS REMAIN CONFIDENTIAL. THE MINIMUM DATA ASSESSMENT, DATED 2-23-2011, REFLECTED THAT RESIDENT #24 SCORED 15 OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS. THE MINIMUM DATA SET ASSESSMENT, DATED 2-23-2011, REFLECTED THAT RESIDENT #24 REQUIRED ONE PERSON TO PHYSICALLY ASSIST WITH BATHING ACTIVITY AND HAD IMPAIRMENT IN THE RANGE OF MOTION OF ONE UPPER EXTREMITY. ONE OF THE CARE PLANS FOR RESIDENT #24 REFLECTED THAT THE RESIDENT HAD EXPERIENCED A DECLINE WITH HER STRENGTH AND AMBULATION. DURING AN INTERVIEW WITH RESIDENT #24 ON 4-28-2011 AT ABOUT 11:00 AM, RESIDENT #24 STATED THAT SHE HAD TOLD THE DIRECTOR OF NURSING THAT SHE DID NOT WANT STAFF "O" TO CARE FOR HER. RESIDENT #24 STATED THAT STAFF "O" HAD BEEN NASTY TO HER AND TOLD HER THAT SHE COULD DO THINGS FOR HERSELF WHEN SHE COULD NOT DO THEM. RESIDENT #24 STATED THAT STAFF "O" WOULD RELUCTANTLY PERFORM TASKS FOR HER AND, AS AN EXAMPLE, STATED THAT WHEN SHE HAD BROUGHT HER BACK FROM THE RESTROOM DURING THE NIGHT, STAFF "O" TOLD HER TO LIFT HER OWN FEET INTO THE BED. DURING THE INTERVIEW, RESIDENT #24'S LOWER LEGS, ANKLES, AND FEET WERE OBSERVED TO BE VERY SWOLLEN. RESIDENT #24 STATED SHE TOLD STAFF "O" SHE COULD NOT, AND STAFF "O" THREW HER FEET UP AND OVER ONTO THE BED. RESIDENT #24 ALSO STATED, "I AM [AGE] years OLD, I KNOW WHAT I CAN AND CAN'T DO". RESIDENT #24 STATED THAT WHEN SHE REPORTED STAFF "O" TO THE DIRECTOR OF NURSING, SHE WAS TOLD THAT THE DIRECTOR OF NURSING HAD HEARD THE SAME STORIES FROM OTHER PEOPLE. RESIDENT #24 STATED THAT EVEN THOUGH SHE HAD ASKED THAT STAFF "O" NOT CARE FOR HER, STAFF "O" WAS STILL PROVIDING HER CARE. THE PHYSICIAN ORDER [REDACTED]. A PROGRESS NOTE ENTRY DATED 4-26-2011 REFLECTED THAT RESIDENT #15 SCORED 15 OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS. RESIDENT #15 WAS INTERVIEWED IN HER ROOM ON 4-28-2011 AT ABOUT 10:55 AM. RESIDENT #15 STATED THAT SHE HAD TOLD THE DIRECTOR OF NURSING THAT SHE DID NOT WANT CERTIFIED NURSING ASSISTANT, STAFF "O", TO CARE FOR HER BECAUSE SHE WAS TOO "ROUGH" AND SHE WAS RUDE. RESIDENT #15 STATED THAT ALTHOUGH STAFF "O" NO LONGER PROVIDED HER CARE, SHE CONTINUED TO PROVIDE CARE FOR HER ROOMMATES. RESIDENT #15 STATED THAT, A FEW MORNINGS AGO, STAFF "O" HAD ASSISTED ONE OF HER ROOMMATES IN THE MORNING. THE ROOMMATE, SHE REPORTED, HAD WANTED TO BRUSH HER TEETH AFTER BREAKFAST BUT STAFF "O" HAD INSISTED THAT SHE HAD TO BRUSH HER TEETH BEFORE BREAKFAST. RESIDENT #15 SHARED ANOTHER INCIDENT WHERE ONE OF HER OTHER ROOMMATES HAD SET OFF THE PERSONAL ALARM ON THEIR CHAIR BY STANDING UP, AND STAFF "O" HAD ENTERED THE ROOM AND YELLED AT THE ROOMMATE SAYING: "YOU CAN'T KEEP GETTING UP AND DOWN". RESIDENT #15 STATED THAT SHE HAD REPORTED STAFF "O"'S BEHAVIOR TO THE DIRECTOR OF NURSING THREE OR FOUR TIMES, BUT THIS SURVEYOR WAS THE FIRST PERSON TO COME AND TALK TO HER ABOUT STAFF "O". DURING AN INTERVIEW WITH STAFF "N", A HOUSEKEEPER ON THE MORNING GLORY LANE UNIT, ON 4-27-2011 AT ABOUT 10:50 AM, STAFF "N", STATED THAT SHE HAD REPORTED TO THE DIRECTOR OF NURSING WHEN RESIDENT #25 HAD TOLD HER THAT A CERTIFIED NURSING ASSISTANT (STAFF "O"), WHO WORKED THE MIDNIGHT SHIFT ON THE MORNING GLORY LANE UNIT, HAD BEEN VERBALLY ABUSIVE AND A LITTLE ROUGH WHEN CARING FOR HER. THE HOUSEKEEPER FURTHER STATED THAT SHE DID NOT UNDERSTAND WHY THIS NURSING ASSISTANT WAS STILL EMPLOYED, BECAUSE THE RESIDENTS CONTINUED TO COMPLAIN ABOUT POOR TREATMENT FROM THE NURSING ASSISTANT. THE HOUSEKEEPER REQUESTED THAT SHE NOT BE IDENTIFIED BECAUSE SHE WAS AFRAID OF RETALIATION FROM OTHER STAFF IF IT WAS KNOWN THAT SHE HAD SPOKEN TO A SURVEYOR. ( / ) RESIDENT #27 WAS IDENTIFIED ON THE FACE SHEET IN HER MEDICAL RECORD AS AN [AGE] year OLD FEMALE. ACCORDING TO A SOCIAL SERVICE NOTE OF 3/10/11 IN HER MEDICAL RECORD, SHE SCORED 12 OF A POSSIBLE 15 ON A BRIEF MENTAL STATUS TEST INDICATING THAT SHE WAS MILDLY CONFUSED. SHE WAS DESCRIBED IN AN MDS (MINIMUM DATA SET ASSESSMENT) NOTE OF 3/07/11 AS BEING "ALERT AND ORIENTED X 3". SHE WAS INTERVIEWED ON 4/28/11 AT 11:00 IN HER ROOM. AT THAT TIME, SHE WAS ASKED IF THE STAFF TOOK GOOD CARE OF HER. SHE STATED THAT MOST OF THEM DID, BUT ONE WAS SO MEAN THAT SHE WAS AFRAID TO ASK FOR HELP BECAUSE THE AIDE JUST "HOLLERS" AT HER. THE RESIDENT STATED THAT, WHEN SHE ASKED FOR HELP GOING TO THE BATH ROOM, SHE WAS TOLD "YOU JUST WENT. YOU DON'T HAVE TO GO AGAIN." SHE STATED THAT SHE HAD MADE GOOD PROGRESS IN THERAPY AND COULD WALK A SHORT DISTANCE WITH A WALKER BUT FEARED FALLING. WHEN SHE ASKED FOR HELP WALKING TO THE BATHROOM MOST OF THE AIDES HELPED HER, BUT ONE AIDE WOULD TELL HER, "YOU CAN DO IT YOURSELF". SHE STATED THAT HER PAIN WAS CONTROLLED WITH MEDICATION, BUT SOMETIMES THE MEDICATION DID NOT ALWAYS WORK AND SHE NEEDED MORE. SHE STATED THAT, IF THE "SNAKY" AIDE WAS ASSIGNED TO HER, SHE JUST DID NOT ASK HER TO TELL THE NURSE SHE NEEDED A PAIN MEDICATION BECAUSE THE AIDE WAS RUDE AND "SNAKY", AND SHE WOULD RATHER JUST WAIT FOR THE NEXT SHIFT. SHE WAS UNABLE TO IDENTIFY THE AIDE OTHER THAN TO SAY THAT SHE USUALLY WORKED ON THE NIGHT SHIFT. THE RESIDENT ASKED THAT HER NAME NOT BE USED. DURING AN INTERVIEW ON 4/29/11 AT ABOUT 3:30 P.M., THE DIRECTOR OF NURSING (STAFF "D") WAS PROVIDED AN OPPORTUNITY TO SHOW WHY THE ALLEGATIONS REPORTED BY RESIDENT S #15, #24, #25, #26 AND #27 WERE NOT REPRESENTATIVE OF ACTUAL ABUSE OF RESIDENTS BY STAFF. THE DIRECTOR OF NURSING PROVIDED NO EVIDENCE TO SUPPORT THAT THE FACILITY HAD INVESTIGATED, OR RULED OUT, ABUSE CONCERNS PERTAINING TO ANY OF THE FIVE RESIDENTS. ON 4/27/11 AT 10 AM A GROUP INTERVIEW WAS CONDUCTED. 5 OUT OF 11 RESIDENTS STATED THE PODIATRIST WAS UNPROFESSIONAL. "HE JUST GOES DOWN THE LINE AND CLIPS YOUR NAILS. HE DOESN'T SAY HI OR TALK WITH YOU. HE DOESN'T CLEAN UP THE TOENAILS. SOMEONE ELSE USUALLY HAS TO DO THAT". "HE NEVER SHAKES YOUR HAND OR INTRODUCES HIMSELF". "HE COMES IN AT 5 A.M., LOOKS AT MY FEET, AND JUST LEAVES." 10 OUT OF 11 RESIDENTS AT THE GROUP INTERVIEW ON 4/27/2011 BEGINNING AT 10:00 AM, STATED THAT STAFF TELLS THEM TO BE PATIENT BECAUSE OF SHORT STAFFING. "THEY TELL US TO BE PATIENT BECAUSE THEY ARE SHORT". ON THE BEHAVIOR REPORT SHEET FOR RESIDENT #25 (UNDATED) , STAFF "O" DOCUMENTED THAT RESIDENT #25 HAD PUT HER CALL LIGHT ON AT 4:30 AM AND THAT RESIDENT #25 HAD TO WAIT FOR CARE UNTIL 5:00 AM BECAUSE THE NURSING ASSISTANTS WERE BUSY TAKING CARE OF OTHER RESIDENTS. ON 4/27/11 AT 10 AM DURING GROUP INTERVIEW, 10 OUT OF 11 RESIDENTS STATED THAT THE AIDES WERE LAZY". THEY ARE ALWAYS TALKING ON THEIR CELL PHONES. THEY TALK OR PLAY GAMES ON THEM AT THE DESK, IN RESIDENT'S ROOMS AND BATHROOMS, AND WHEN PROVIDING CARE. THEY TALK ABOUT THEIR PERSONAL LIVES (E.G. PREGNANCY, SEX, WHAT THEY ' RE DOING LATER) WHERE WE AND OTHER RESIDENTS CAN HEAR THEM". ON 4/26/11 AT 3:30 PM, RESIDENT #5'S FAMILY STATED, AND RESIDENT CONFIRMED, "THE NURSES AND AIDES DON'T CLEAN MY DAD'S DENTURES OR TAKE THEM OUT AT NIGHT. IF THEY TAKE THEM OUT, THEY FORGET TO PUT THEM BACK IN- IN THE MORNING AND HE HAS TO EAT HIS BREAKFAST WITHOUT HIS DENTURES. WE'VE HAD TO MAKE SURE HIS DENTURES ARE IN AND TAKE THEM OUT AT NIGHT. WE USUALLY HAVE TO CLEAN THEM". THE FACILITY POLICY ON ABUSE PREVENTION, DATED 3/2010, REFLECTED THAT THE FACILITY PROHIBITED THE USE OF ELECTRONIC DEVICES, INCLUDING CELLULAR PHONES IN RESIDENT CARE AREAS WHICH WERE NOT FOLLOWED AS REPORTED BY THE RESIDENTS. ON 4/29/11 AT 11 AM, RESIDENT #26 STATED,"I TURNED ON MY LIGHT LAST NIGHT AND THEY TURNED IT OFF. NO ONE CAME. WHEN NO ONE ANSWERS MY LIGHT OR SHUTS IT OFF WITHOUT SEEING WHAT I WANT, IT MAKES ME FEEL USELESS AND ISOLATED. IT MAKES ME FEEL HELPLESS. I CRY A LOT BECAUSE OF IT. I KNOW I'M A CRY BABY, BUT IT UPSETS ME SO MUCH WHEN I ASK FOR SOMETHING AND I'M IGNORED. IF I COULD TAKE CARE OF MYSELF, I WOULD. AT NIGHT THE AIDES PUT MY WHEELCHAIR AWAY SO I CAN'T GET UP MYSELF. WHEN I CALL FOR HELP, I NEED IT". IN ADDITION, RESIDENT #26 STATED, "THE AIDES GO IN THE BATHROOM AND USE THEIR CELL PHONES. THEY ARE GETTING PAID TO TAKE CARE OF US. I DON'T THINK IT'S RIGHT THAT THEY TALK ON THE PHONE". RESIDENT #26 ARTICULATED PSYCHOSOCIAL HARM AS A CONSEQUENCE OF BEING DEHUMANIZED AND FELT LINGERING DISTRESS. DURING ENVIRONMENTAL ROUNDS ON 4-29-2011 BEGINNING AT 12:00 PM, IT WAS OBSERVED THAT A NURSE CALL LIGHT THAT WAS TURNED ON IN A RESIDENT ROOM ON THE MORNING GLORY LANE UNIT CAN BE CANCELLED AT THE NURSES STATION WITHOUT RESPONDING AND SEEING TO THE RESIDENT'S NEEDS PRIOR TO TURNING THE CALL LIGHT OFF. ( / ) .

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROTECT THE RESIDENTS FROM BEING NEGLECTED AND MIStreated for [REDACTED]. IN ADDITION, BASED ON INTERVIEW, THE FACILITY FAILED TO PROVIDE BASIC CARE TO 2 OUT OF 2 RESIDENTS WHO VOICED THEIR PROBLEMS RESULTING IN NEGLECT OF RESIDENT #5'S DENTURES AND MIStreatment of [REDACTED]. FINDINGS INCLUDE: ON 4/27/11 AT 10 AM A GROUP INTERVIEW WAS CONDUCTED. 5 OUT OF 11 RESIDENTS STATED THE PODIATRIST WAS UNPROFESSIONAL. "HE JUST GOES DOWN THE LINE AND CLIPS YOUR NAILS. HE DOESN'T SAY HI OR TALK WITH YOU. HE DOESN'T CLEAN UP THE TOENAILS. SOMEONE ELSE USUALLY HAS TO DO THAT". "HE NEVER SHAKES YOUR HAND OR INTRODUCES HIMSELF". "HE COMES IN AT 5 A.M., LOOKS AT MY FEET, AND JUST LEAVES." 10 OUT OF 11 RESIDENTS AT THE GROUP INTERVIEW ON 4/27/2011 BEGINNING AT 10:00 AM, STATED THAT STAFF TELLS THEM TO BE PATIENT BECAUSE OF SHORT STAFFING. "THEY TELL US TO BE PATIENT BECAUSE THEY ARE SHORT". ON THE BEHAVIOR REPORT SHEET FOR RESIDENT #25 (UNDATED) , STAFF "O" DOCUMENTED THAT RESIDENT #25 HAD PUT HER CALL LIGHT ON AT 4:30 AM AND THAT RESIDENT #25 HAD TO WAIT FOR CARE UNTIL 5:00 AM BECAUSE THE NURSING ASSISTANTS WERE BUSY TAKING CARE OF OTHER RESIDENTS. ON 4/27/11 AT 10 AM DURING GROUP INTERVIEW, 10 OUT OF 11 RESIDENTS STATED THAT THE AIDES WERE LAZY". THEY ARE ALWAYS TALKING ON THEIR CELL PHONES. THEY TALK OR PLAY GAMES ON THEM AT THE DESK, IN RESIDENT'S ROOMS AND BATHROOMS, AND WHEN PROVIDING CARE. THEY TALK ABOUT THEIR PERSONAL LIVES (E.G. PREGNANCY, SEX, WHAT THEY ' RE DOING LATER) WHERE WE AND OTHER RESIDENTS CAN HEAR THEM". ON 4/26/11 AT 3:30 PM, RESIDENT #5'S FAMILY STATED, AND RESIDENT CONFIRMED, "THE NURSES AND AIDES DON'T CLEAN MY DAD'S DENTURES OR TAKE THEM OUT AT NIGHT. IF THEY TAKE THEM OUT, THEY FORGET TO PUT THEM BACK IN- IN THE MORNING AND HE HAS TO EAT HIS BREAKFAST WITHOUT HIS DENTURES. WE'VE HAD TO MAKE SURE HIS DENTURES ARE IN AND TAKE THEM OUT AT NIGHT. WE USUALLY HAVE TO CLEAN THEM". THE FACILITY POLICY ON ABUSE PREVENTION, DATED 3/2010, REFLECTED THAT THE FACILITY PROHIBITED THE USE OF ELECTRONIC DEVICES, INCLUDING CELLULAR PHONES IN RESIDENT CARE AREAS WHICH WERE NOT FOLLOWED AS REPORTED BY THE RESIDENTS. ON 4/29/11 AT 11 AM, RESIDENT #26 STATED,"I TURNED ON MY LIGHT LAST NIGHT AND THEY TURNED IT OFF. NO ONE CAME. WHEN NO ONE ANSWERS MY LIGHT OR SHUTS IT OFF WITHOUT SEEING WHAT I WANT, IT MAKES ME FEEL USELESS AND ISOLATED. IT MAKES ME FEEL HELPLESS. I CRY A LOT BECAUSE OF IT. I KNOW I'M A CRY BABY, BUT IT UPSETS ME SO MUCH WHEN I ASK FOR SOMETHING AND I'M IGNORED. IF I COULD TAKE CARE OF MYSELF, I WOULD. AT NIGHT THE AIDES PUT MY WHEELCHAIR AWAY SO I CAN'T GET UP MYSELF. WHEN I CALL FOR HELP, I NEED IT". IN ADDITION, RESIDENT #26 STATED, "THE AIDES GO IN THE BATHROOM AND USE THEIR CELL PHONES. THEY ARE GETTING PAID TO TAKE CARE OF US. I DON'T THINK IT'S RIGHT THAT THEY TALK ON THE PHONE". RESIDENT #26 ARTICULATED PSYCHOSOCIAL HARM AS A CONSEQUENCE OF BEING DEHUMANIZED AND FELT LINGERING DISTRESS. DURING ENVIRONMENTAL ROUNDS ON 4-29-2011 BEGINNING AT 12:00 PM, IT WAS OBSERVED THAT A NURSE CALL LIGHT THAT WAS TURNED ON IN A RESIDENT ROOM ON THE MORNING GLORY LANE UNIT CAN BE CANCELLED AT THE NURSES STATION WITHOUT RESPONDING AND SEEING TO THE RESIDENT'S NEEDS PRIOR TO TURNING THE CALL LIGHT OFF. ( / ) . A BLINKING EMERGENCY CALL LIGHT WAS HEARD AND OBSERVED AT THE ROOM NEXT TO 119 ON 4/27/11 AT 12:12 P.M. NUMEROUS STAFF WERE AT THE NURSING STATION AND IN THE OFFICE LOCATED BEHIND THE NURSING STATION. STAFF "T" WAS OBSERVED AT 12:18 P.M., AS SHE PROCEEDED TO THE BLINKING EMERGENCY CALL LIGHT FROM THE HALLWAY LOCATED AT THE WEST OF THE NURSING STATION. THE LIGHT WAS OBSERVED TO STOP BLINKING AT 12:19 P.M. STAFF "T" WAS ASKED WHEN SHE RETURNED TO THE NURSING STATION IF SHE WAS ABLE TO ASSIST AN INDIVIDUAL. STAFF "T" VERBALIZED,"THE LIGHT WAS THE BATHROOM. THEY WANTED OFF OF THE TOILET". ( )