Every finding on record at Allegria Village

This citation pertains to intake 2807638.Based on interview and record review the facility failed to ensure adequate supervision for one resident (R907) out of three residents reviewed for elopement. As a result, R907 eloped from the facility, placing R907 at risk for harm.Findings include:Record review of facility reported incident revealed that R907 eloped from the facility on 3/8/26.Record review of R907's electronic medical records (EMR) revealed the resident was admitted to the facility on [DATE] with a pertinent diagnosis of myocardial infarction (heart attack).Record review of Brief Interview for Mental Status (BIMS) dated 2/27/26 revealed R907 scored 10 out of 15, indicating moderate cognitive impairment.Record review of Elopement Evaluation dated 3/3/26 revealed R907 scored 6 out of 10, indication the resident was at risk for elopement.Record review of Elopement care plan dated 3/7/26 documented interventions that included distracting the resident from wandering through pleasant diversions, structured activities, monitor for fatigue and weight loss, Provide structured activities, implementing reorientation strategies and ensure resident wore Wander Alert (alarm bracelet).An interview was conducted on 7/17/26 at 3:17 PM with Registered Nurse (RN) A, it was reported that the resident repeatedly removed wander guard from ankle, a one-to-one sitter was placed with the resident on 3/7/26.An interview was conducted on 7/17/26 at 3:32 PM with Certified Nursing Assistant (CNA) B, It was reported that while providing one to one supervision with R907, another resident required assistance with a brief change. CNA B asked CNA C to monitor R907 while assisting the other resident. CNA B reported that after completing the brief change and returning, an alarm was sounding and R907 was no longer present. When asked how R907 eloped. CNA B reported that CNA C left resident unattended to assist another resident, allowing R907 to leave the facility. An interview was conducted on 7/17/26 at 3:43 PM, it was reported that after agreeing to monitor R907, CNA C heard another resident call out for assistance. CNA C left R907 unattended to respond to another resident. While assisting that resident, an alarm sounded and staff discovered R907 had eloped. CNA C acknowledged that leaving R907 unattended provided the opportunity for the resident to leave the facility.An interview was conducted on 3/17/26 at 4:00 PM with Director of Nursing (DON), it was reported that CNA C should have not left the resident unattended. The DON acknowledged that the resident required continuous supervision and that leaving the resident was inconsistent with the resident's supervision needs.Record review of facility's policy Wandering and Elopements (no date) documented, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included review and update resident-specific care plan, reassess residents for elopement risk, educate staff on elopement prevention policy, verify exit alarms/Wander Guard devices are functioning, reinforce shift-to-shift communication regarding at-risk residents, conduct environmental safety review. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to ensure an effective means of communication was established in a timely manner for one resident (R89) out of one resident reviewed for communication, resulting in language barriers and resident frustration. Findings include: On 9/22/25 at 11:23 AM, R89 was observed sitting in her wheelchair in her room. R89's Resident Representative (RR) was sitting in the room also. R89's RR said that R89 understands and speaks Arabic, but not English. R89's RR said he is present with R89 from 7:30 AM to 7:30 PM and that the facility should have Arabic-speaking staff available to interpret for R89 at other times. According to R89's RR, there was no method provided for communicating with R89 when he was away from the facility. On 9/22/25 at 11:40 AM, Patient Advocate B entered R89's room. Patient Advocate B confirmed that R89 should have been provided with a communication board upon arrival on Friday (9/19/25). Patient Advocate B added, We have staff that speak Arabic that can interpret for (R89). R89's RR said there was no Arabic speaking staff available this past weekend. On 9/23/25 at 11:30 AM, a laminated document (communication board) with pictures and English descriptive words underneath each picture was observed on R89's bedside table. R89's RR indicated that R89 would have difficulty using this document. On 9/23/25 at 11:38 AM, Licensed Practical Nurse (LPN) D said because R89 does not speak English she would use nonverbal communication, including gestures and pointing to assess R89's needs. Additionally, LPN D said there were Arabic-speaking staff available that could interpret what R89 wanted. LPN D was accompanied to R89's room. R89 was awake and lying in bed. LPN D used the available communication board to interact with R89. Following this effort, LPN D said the communication board was not useful. On 9/23/25 at 11:51 AM, Registered Nurse/Unit Manager (RN/UM) E explained that a communication board was used to facilitate two-way communication between staff and residents, and it helps us to provide care and address what the resident needs. We assess communication needs for each resident upon admission. RN/UM E was informed of LPN D's earlier attempt to communicate with R89. RN/UM E said R89 was given a communication device that R89 couldn't use. RN/UM E added we have Arabic-speaking staff available to interpret for residents. On 9/23/25 at 12:01 PM, R89's RR informed RN/UM E that R89 can read Arabic and that R89 may be able to use a communication board that contains pictures and Arabic writing. A review of the clinical record for R89 documented an admission date of 9/19/25 with diagnoses that included chronic obstructive pulmonary disease, unspecified dementia, atrial fibrillation, and heart failure. R89's Risk for Impaired Communication care plan initiated on 9/21/25 documented the following interventions: Consult speech therapy per order; Evaluate the resident's ability to comprehend; and Provide resident with verbal feedback and updates on care. A progress note dated 9/22/25 documented a BIMS (Brief Interview for Mental Status: a tool used to assess a resident's current cognitive function) score of 4 which was indicative of severe cognitive impairment. On 9/23/25 at 12:13 PM, in the presence of the State Surveyor and RN/UM E, Speech Language Pathologist (SLP) F, an Arabic-speaker, interviewed R89. During this interview, R89 correctly stated her age, the number of children she has, and the name of the street and city in which she lives. R89 was unable to identify the current month and year. RN/UM E said she will assist in getting R89's BIMS reassessed. On 9/23/25 at 12:25 PM, Social Worker (SW) G said she completed R89's BIMS evaluation. SW G acknowledged she did not attempt to interview R89 because of the language barrier. SW G said she had a conversation with R89's RR for the BIMS assessment. SW G confirmed the availability of Arabic-speaking interpreters at the facility but acknowledged that she did not use them. On 9/23/25 at 1:42 PM, the Director of Nursing (DON) said that a resident's communication capabilities should be evaluated at the time of admission in order to provide quality care, ensure safety, and meet the resident's needs. If R89's communication board was not effective, staff should contact the family. If the family was unavailable, an Arabic-speaking staff member would provide assistance. The DON said they should have put a communication board in place upon admission. We should have assessed the language barrier and handled it upon admission because we cannot always ensure that family will be available to communicate for the resident. The facility provided a list of on-site Arabic-speaking staff from 9/19/25 to 9/21/25. During this period, Arabic-speaking staff were available only between 6:00 AM and 2:30 PM each day. On 9/24/25 at 10:29 AM, R89's RR expressed concern for R89 if R89 could not communicate with staff in his absence. R89's RR believes a communication board with both pictures and Arabic words would work well for R89. On 9/24/25 at 11:48 AM, SLP F assisted in a R89 interview. R89 was asked about her feelings when her son was not there to help communicate. R89 appeared frustrated and through interpreter SLP F said staff don't understand her when she's talking. SLP F stated, That creates a barrier to providing care. On 9/24/25 at 1:23 PM, the Nursing Home Administrator (NHA) said that a resident's communication ability is assessed upon admission. The admission communication assessment for R89, completed by SW G was reviewed and documented the following: Communication method: verbal. Makes self understood: Understood. Ability to understand others: Understands. List any barriers patient may have: none identified. The NHA said a language barrier should have been identified in the admission assessment. This would have triggered the need for a communication board, translation services, and a more thoughtful care plan. The NHA reviewed R89's clinical record and was unable to find a completed speech evaluation. The NHA indicated it was a big concern that R89's language barrier went unrecognized, given that residents must have the means to communicate effectively. The NHA acknowledged that R89's care plan did not address the language barrier nor establish effective communication methods. On 9/24/25 at 1:30 PM, Assistant Administrator C confirmed during the period of 9/19/25 to 9/21/25, that Arabic-speaking staff were only available between 6:00 AM and 2:30 PM each day. A review of a facility policy titled, Translation and/or Interpretation of Facility Services, dated 2020, was reviewed and revealed in part the following:- The facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility.- When encountering LEP individuals, staff members will conduct an initial language assessment.- It is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual. On 9/24/25 at 3:30 PM during the exit conference, the NHA and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported all requested documents had been provided

Based on observation, interview, and record review, the facility failed to follow standards of practice for one (R89) of five residents reviewed for Medication Administration resulting in R89 having medications held without a physician's orders and one medication order not being correctly transcribed on the Medication Administration Record.Findings include: On 9/23/2025 at 8:38 AM during observation of R89's medication administration, Licensed Practical Nurse (LPN) D said they were holding some medications because the resident's Blood Pressure (BP) was low at 109/58. (According to the American Heart Association 2017; Low blood pressure is considered less than 90/66 mm/Hg - millimeters of mercury.) LPN D withheld the following three medications from R89: 1) Isosorbide Mononitrate Extended Release (ER) 30 mg 24-hour release, 2) Metoprolol Succinate ER 50 mg, and 3) Amiodarone 100 mg. R89's Physician's orders and Medication Administration Record (MAR) were reviewed with LPN D. It was confirmed there were no Physician's orders to hold those medications. There were no blood pressure parameter orders for when those medications could be administered. LPN D was then asked why they held those medications when there were no orders to do so and replied, It's my nursing judgement. LPN D proceeded to hold the medications from R89. There was no attempt to notify the physician the medications were held. According to R89's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and dementia. The physician's medication orders were reviewed and included the following. Isosorbide Mononitrate ER 30 mg 24-hour release, for coronary artery disease with stable angina.Metoprolol Succinate ER 50 mg 24-hour tablet for Atrial Fibrillation.Amiodarone 100 mg for Atrial Fibrillation.There were no parameters (measurable factor or condition) prescribed to administering any of the medications. Continuation of R89's medication reconciliation revealed the following Physician's order on 9/19/25 was not transcribed onto the Medication Administration Record; Tiotropium 2.5 MCG (microgram)/ACT (breath actuated) inhaler, 2 Inhalations by inhalation daily. R89 did not receive that medication for three consecutive days 9/20/25, 9/21/25, and 9/22/25. On 9/23/25 at 9:45 AM during an interview with Director of Nursing (DON) Nurse Unit Manager Registered Nurse (RN) E regarding holding the medications for R89 the DON said, There are no parameters for those medications to be held. Those medications should have been given. A Blood Pressure of 109/59 isn't considered low. I can't explain why the nurse did not give those medications. The physician will be notified. During the interview regarding R89's transcription error RN E confirmed that R89 was prescribed two inhalers upon admission, but only one was transcribed on the MAR. RN E said, Yes the Tiotropium 2.5 MCG/ACT was missed and not put on the MAR. I think there was a discussion about that with the doctor, but I can't recall and there is no documentation about it. I will call the doctor for clarification. According to the facility's Administering Medications policy last revised 4/2019 in part reads: Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.According to the facility's Medication Holds policy last revised 4/2007 in part reads: A temporary medication hold may be ordered by the resident's attending physician.

Based on observation, interview, and record review the facility failed to have a medication error rate below 5%.Findings include:During the medication administration task nine errors were observed from 34 opportunities and subsequently a 26.47% medication error rate. R89 On 9/23/2025 at 8:38 AM during observation of R89's medication administration, Licensed Practical Nurse (LPN) D withheld the following three medications from R89 without an order to do so: 1) Isosorbide Mononitrate Extended Release (ER) 30 mg 24-hour release, 2) Metoprolol Succinate ER 50 mg, and 3) Amiodarone 100 mg. Continued observation of R89's medication administration revealed the following three medications were not given because LPN D said they were not available: 4) Vitamin B-12 oral tablet, 5) Omega-3 1000 mg capsule, 6) Ferrous Sulfate 325 mg tablet. There was no attempt to search the medication cart, go to the medication room or back-up box, notify the nurse unit manager, pharmacy, or resident's physician of the missing medications. LPN D marked the medications were not given on the R89's MAR and proceeded to the administer medication to the next resident. R89's Physician's orders and Medication Administration Record (MAR) were reviewed with LPN D. It was confirmed there were no Physician's orders to hold those medications. There were no blood pressure parameter orders for when those medications could be administered. LPN D was then asked why they held those medications when there were no orders to do so and replied, It's my nursing judgement. LPN D proceeded to hold the medications from R89. There was no attempt to notify the physician the medications were held. LPN D was asked about the missing medications and said, I'll have to see where they are. Most of them are floor stock and should be somewhere. LPN D confirmed the facility had a back-up box with medications but made no attempt to acquire the missing medications. According to R89's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and dementia. The physician's medication orders were reviewed and included the following. 1) Isosorbide Mononitrate ER 30 mg 24-hour release, for coronary artery disease with stable angina.2) Metoprolol Succinate ER 50 mg 24-hour tablet for Atrial Fibrillation.3) Amiodarone 100 mg for Atrial Fibrillation. There were no parameters (measurable factor or condition) prescribed to administering the above three medications.4) Aspirin 81 milligrams (mg) 1 tablet daily by mouth.5) Omega-3 1000 mg capsule 1 time a day by mouth6) Ferrous Sulfate 325 mg tablet 1 time a day by mouth. R48: On 9/23/2025 at 8:58 AM during observation of R48's medication administration, Licensed Practical Nurse (LPN) D did not administer the following three medications. LPN D said, There is no aspirin in the cart, and the Metformin and Losartan are missing. There was no attempt made by LPN D to locate the ordered medications. According to R48's EHR the resident admitted to the facility on [DATE] with multiple diagnoses that included A-fib and Diabetes, type 2. The physician's medication orders were reviewed and included the following. 7) Metformin HCL 500 mg 1 tablet by mouth 2 x day. 8) Losartan Potassium 100 MG Oral Tablet give 1 time a day by mouth. 9) Aspirin 81 mg 1 time a day by mouth. On 9/23/25 at 9:45 AM during an interview with Director of Nursing (DON) and Nurse Unit Manager Registered Nurse (RN) E R89's Electronic Health Record (EHR) was reviewed. The DON was queried about RN D holding the medications for R89. The DON said, There are no parameters for those medications to be held. Those medications should have been given. A Blood Pressure of 109/59 isn't considered low. I can't explain why the nurse did not give those medications. The physician will be notified. Further inquiry regarding R89's missing medications was reviewed with RN E. They said, Aspirin, Omega-3, and Iron (Ferrous Sulfate) are all floor stock. They are in the cart, or we can get them from our medication room. RN E inspected the medication cart, and all three medications (Aspirin 81 mg, Omega-3 1000 mg, and Ferrous Sulfate 325 mg) were observed in the medication cart. RN E could not explain why LPN D did not give those medications. RN E then proceeded to the medication room and obtained the following medications for R48 in the back-up box; Metformin 500 mg and Losartan Potassium 100 mg. According to the facility's Administering Medications policy last revised 4/2019 in part reads: Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.According to the facility's Medication Holds policy last revised 4/2007 in part reads: A temporary medication hold may be ordered by the resident's attending physician.

Based on observation, interview, and record review the facility failed to ensure one (R89) of four residents reviewed for Medication Administration was free from a significant medication error resulting in R89 missing three doses of a prescribed inhaler; Tiotropium 2.5 MCG (microgram)/ACT (breath actuated) inhaler.Findings include:On 9/23/2025 at 8:38 AM, R89 was selected for observation of medication administration with Licensed Practical Nurse (LPN) D. During R89's medication reconciliation review it was determined the following Physician's order on 9/19/25 was not transcribed onto the Medication Administration Record; Tiotropium 2.5 MCG (microgram)/ACT (breath actuated) inhaler, 2 Inhalations by inhalation daily. R89 did not receive that medication for three consecutive days 9/20/25, 9/21/25, and 9/22/25. According to R89's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and dementia. The hospital physician's admission orders on 9/19/25 were reviewed and included the following order: Tiotropium 2.5 MCG (microgram)/ACT (breath actuated) inhaler, 2 Inhalations by inhalation daily. There were no progress notes regarding the change in medication orders. There were no progress notes regarding the change in admission orders. The admission orders were documented by Unit Manager Registered Nurse (RN) E.On 9/23/25 at 9:45 AM during an interview with Director of Nursing (DON) and RN E, RN E confirmed that they completed the admission orders for R89 and had reviewed the medications with the physician. RN E confirmed that R89 was prescribed two inhalers upon admission, but only one was transcribed on the MAR. RN E said, Yes the Tiotropium 2.5 MCG/ACT was missed and not put on the MAR. I think there was a discussion about that with the doctor, but I can't recall and there is no documentation about it. I will call the doctor for clarification. The DON confirmed that R89 had missed three doses of the Tiotropium inhaler on 9/20/2025, 9/21/2025, and 9/22/2025.According to the facility's Administering Medications policy last revised 4/2019 in part reads: Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview and record review the facility failed to provide meals that were palatable for three residents (R7, R9 and R22) out of three resident that consumed meals in rooms, resulting in cold and visually unappealing foods. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings Include: R9 On 8/20/2024 at 11:20 AM, R9 was quiered about meals. R9 said, that he does not care for the food and often skips meals. R9 explained, sometimes the food is cold and it does not taste that good. Record review revealed R9 was admitted into facilty on 7/26/24 with a pertinent diagnosis of Type ll diabetes. According to Brief Interview for Mental Status, (BIMS) dated 8/1/24, R9 scored of 15 out of 15 (intact cognition). R22 On 8/20/2024 at 2:30 PM, R22 was interviewed and reported not being able to eat the food because it is cold. Record review revealed R22 was admitted into the facility on [DATE] with a pertinent diagnosis of necrotizing fascitis(flesh eating bacteria). According to BIMs dated 7/18/24, R22 scored 15 out of 15 (intact cognition). 15194 R7 On 8/20/24 at 11:30 A.M and on 8/21/24 at 1:10 P.M., R7 complained the food was cold and served with a clear piece of tightly, fitted wrap to cover the food. R7 stated, the clear wrap left food soggy at times. The resident indicated eating meals in the room and did not want to eat in the dining room. Review of the Admission Face sheet indicated R7 was admitted to the facility on [DATE] for hospice care with diagnoses that included: heart failure, hypertension, and Chronic obstructive pulmonary disease (COPD). R7 had a BIMS (Brief interview for status) of 13 of 15 for cognition and required one person assist to complete Activities of Daily living. On 8/22/24 at 1:00 P.M. a lunch test tray was performed on the First floor. Temperatures taken were as follows: Chopped Steak with gravy- 103.2 Degrees (D) Fahrenheit (F). Au Gratin Potatoes -110 D.F Peas and Carrots-83- D.F Vanilla Pudding- 53.2-D.F. Each food item was served in Styrofoam containers and covered with clear saran wrap. The saran wrap was tightly wrapped over the entree causing excess condensation (water) and food to appear mashed and merged. Supervisor A who was present during the testing was queried concerning the use of any heating element used to maintain the food temperature. The supervisor reported the heating system previously used to maintain the food temperature was broken for approximately two years and was unsure of the status of repair or replacement. Supervisor A was informed of the food complaints received related to cold food and food served smashed from the tight saran wrap, particularly residents who ate their meals in their rooms. Supervisor A reported the status of the equipment repair would have to be addressed with the administrator in the absence of the Director of the department. On 8/22/24 at 2:15 P.M. the Administrator was made aware of the concerns related to the cold food but provided no evidence when the heating unit would be repaired or replaced. On 8/22/24 at 2:00 P.M. and 3:30 P.M. a policy was requested but not provided. Upon exiting the facility at 4:35 P.M. no other information was presented pertaining to the cold food.

Based on observation, interview and record review the facility failed to maintain functional equipment and a sanitary environment 1) Replace the floor carpeting of the halls on the first, second and third floor of the facility 2) Clean the ceiling air vents in three kitchenettes, 3) replace and or repair the broken heating system for resident's food and 4) Ensure functional water faucets were attached to the hand washing sinks properly. These deficient practices had the potential to affect all 69 residents in the facility. Findings include : On 8/20/24 at 9:00 A.M. through 8/22/24 at 3:20 P.M. the carpeting on the first, second and third floor was observed heavily soiled, stained and severely worn. Visible collections of dust and lint were noted around the edges of the flooring. On 8/22/24 at 11:08 A.M.Maintenance Director E was interviewed concerning the cleaning of the carpet and said his department was not responsible for cleaning of the carpet, however indicated the housekeeping department could address the concern. On 8/22/24 at 2:55 P.M. interview with Housekeeping Director C revealed the facility did not have a cleaning rotation for the carpet. In the past the carpet was cleaned every three months and as needed for stains. Housekeeping Director C indicated carpeting had been removed in the Assisted living of the building but had no specific time frame when the carpeting would be addressed in the long-Term Care portion of the building. On 8/21/24 at 1:00 P.M., during observation in the kitchen and kitchenette of the facility the following concerns were identified: 1. In the main Kitchen area-a broken dish machine. Reported by Dining Supervisor A it was not replaceable or repairable since it broke on July 11,2024. 2. Approximately 4 Missing Freezer curtain slots in the main freezer near the dock area, no rubber gasket around lower bottom of the freezer door, causing accumulated ice and frost on the door and entry. The missing bottom rubber gasket allowed potential entry of rodents and foreign matter 3. Broken heating system (Conduction system) used to maintain resident food temperatures during serving. Dining Supervisor reported heating system had not been functional and used in 2 years. 4. Floor ceiling plate cover in the kitchen area adjacent to the B elevator was detached leaving an opening in the floor. Kitchenettes 1. Ceiling vents in two of three kitchenettes (First and third floor) were heavily soiled with lint, dust and grease. On the first-floor visible spider webs were noted suspended over the food cart during service. 2. Second floor coffee machine- broke. 3. Ice machine on the third floor not functioning. 4. On the first and third floor the left hand faucet of the hand washing sinks and eye washing apparatus was not working properly. 50634 R9 On 8/20/2024 at 11:20 AM, R 9 was queired about if he had any concerns with the facility. R9 explained they had previously been a resident of the facility and it has gone down in the upkeep. R9 said, it used to be much cleaner now it appears that the staff do not clean the way they use to. R9 said sometimes things are dropped on the floor and staff just walk over them intead of picking them up. Record review revealed R9 was admitted into facilty on 7/26/24 with a pertinent diagnosis of Type ll diabetes. According to Brief Interview for Mental Status, (BIMS) dated 8/1/24, R9 scored of 15 out of 15 (intact cognition). R22 On 8/20/2024 at 2:30 PM, R22 was inteviewed and explained staff could do a better job of cleaning. Record review revealed R22 was admitted into the facility on [DATE] with a pertinent diagnosis of necrotizing fascitis(flesh eating bacteria). According to BIMs dated 7/18/24, R22 had scored 15 out of 15 (intact cognition). On 8/22/24 At 2:56 P.M. the Administrator was interviewed concerning the broken equipment. The Administrator said, a requisition for replacement/rental contract of the dish machine had just been approved (8/15/24), however review of the document revealed there was no evidence of any implementation date of service or installation. The Administrator acknowledged concerns related to the other broken equipment but provided no explanation when the facility would address the issues observed during the tour.

Based on observation, interview, and record review the facility failed to provide a clean and comfortable environment for one resident (R291) out of one resident reviewed for safe, clean, homelike environment resulting in resident dissatisfaction and a tripping hazard. Findings include: On 8/20/24 at 10:32 AM, R291 was observed in bed. When asked about living conditions in the facility R291 said there is a hole in the floor near my bed and my tray table keeps getting stuck in it. I'm afraid when I start to walk more, I will trip because of the hole. When asked if R291 reported the hole in the flooring to staff members R291 reported Yes, the faciltity is aware of it. There was an approximate four by eight-inch patch of missing floor covering observed near R291's bed. On 8/21/24 at 9:33 AM, R291 was observed sitting in a wheelchair next to bed with bedside table wheel resting in hole in the flooring. R291 demonstrated tipping bedside table in the hole in the flooring. Record review of R291's Electronic Health Record (EHR) revealed admission to the facility on [DATE] with diagnoses which included muscle weakness and seizures. Review of R291's Brief interview for Mental Status (BIMS) assessment performed on 8/19/24 revealed a BIMS of 15/15 intact cognition. Review of R291's Fall risk assessment dated [DATE] revealed a score of 19 indicating at risk for falls. On 8/21/24 at 2:01 PM in an observation of R291's floor with Licensed Practical Nurse (LPN) G, it was reported the facility was aware of the hole in the flooring. On 8/22/24 at 3:12 PM Maintenance Director (MD) E was interviewed and said when a resident discharges from a room, maintenance completes a room audit and completes any repairs needed. MD E stated, I'm aware that there is a hole in the floor. When asked for the maintenance room audit for June, July and August of 2024 MD E was not able to produce the documentation. MD E agreed the hole in the flooring was a tripping hazard and cannot be properly cleaned. On 8/22/24 at 1:09 PM the Director of Nursing (DON) was interviewed and agreed the hole in R291's room floor was a trip hazard and infection control concern since the flooring could not be cleaned properly. Review of the facility policy titled Maintenance Service revised 2009 revealed in part . Maintenance service shall be provided to all areas of the building, grounds, and equipment. Maintenance personnel maintain the building in good repair and free form hazards.

Based on observation, interview and record review, the facility failed to provide a toilet transfer for one resident (R291) of four residents reviewed who were dependent on staff for performance of activities of daily living (ADLs), resulting in unmet care needs and resident dissatisfaction. Findings include: On 8/21/24 at 1:08 PM, R291 was interviewed about care in the facility and stated, The aide last night Certified Nursing Assistant (CNA) H told me I couldn't use the toilet and to pee on myself instead. So, I wet myself. It's embarrassing and I'm upset. R291 was observed crying and stated, I can use the toilet with help, but she didn't want to help me. Record review of R291's Electronic Health Record (EHR) revealed admission to the facility on [DATE] with diagnoses which included muscle weakness and seizures. Review of R291's Brief interview for Mental Status (BIMS) assessment performed on 8/19/24 revealed a BIMS of 15/15 intact cognition. Review of R291's Fall risk assessment dated [DATE] revealed a score of 19 indicating at risk for falls. Review of R291's physical therapy note dated 8/20/24 revealed: Bed Mobility Roll left and right = Partial/moderate assistance Sit to lying = Substantial/maximal assistance Lying to sitting on side of bed = Substantial/maximal assistance Transfers Sit to stand = Partial/moderate assistance Chair/bed-to-chair transfer = Substantial/maximal assistance Toilet transfer = Partial/moderate assistance Ambulation Walk 10 feet = Partial/moderate assistance Gait Distance = 40 feet; Assistive Device = Two-wheeled Walker Review of R291's ADL Task- Toilet form revealed one-person physical assist for toilet transfer on 8/20/24. On 8/21/24 at 1:51 AM not applicable was documented by CNA H and at 8:14 AM set up help was documented by CNA K. On 8/21/24 at 2:09 PM Licensed Practical Nurse G was interviewed and said CNAs should assist R291 to the toilet. On 8/22/24 at 11:22 AM Occupational Therapy Assistant I and Physical Therapy Assistant J were interviewed and said R291 required moderate assistance (50% assistance from staff) to transfer and can use the toilet with moderate assistance from an aide when using a wheelchair. On 8/22/24 at 1:07 PM the Director of Nursing (DON) was interviewed and said, CNAs should help R291 empower themselves to use the toilet. Review of the facility policy titled Activities of Daily Living (ADL), Supporting revised March 2018 revealed in part .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

This citation pertains to intakes MI00146255 and MI00146314. Based on interview and record review the facility failed to provide adequate supervision for one resident (R77) out of one resident reviewed for elopement, resulting in the potential for heat exposure and being struck by a motor vehicle when R77 left an appointment unsupervised. Findings include: Record review of facility's Investigation Summary and Conclusion (no date), revealed R77 was taken to an appointment on 7/31/24 at approximately 8:30 AM via facility bus transportation. R77 was left unattended. At approximately 3:51 PM the facility was made aware that R77 was not present for pick-up. Further review revealed that R77 was found at 8:30 PM and returned to the hospital. Record review of R77's electronic medical record (EMR) revealed admission into the facility on [DATE] with a pertinent diagnosis of aphasia following a cerebral infarction (unable to comprehend language related to a stroke). According to the Brief Interview for Mental Status (BIMS) dated 7/12/24, R77 scored 11/15 (impaired cognition). Review of Minimum Data Set (MDS) dated [DATE], R77 required partial to substantial assistance with Activities of Daily Living (ADLS). Further review of EMR revealed resident did not have a guardian in place. Record review of temperatures for Detroit on 7/31/24 documented a high of 90 degrees Fahrenheit. During an interview on 8/21/24 at 2:15 PM with Director of Nursing (DON), it was reported that R77 was taken to an appointment and was not escorted with supervision. When asked if the resident should have had supervision related to impaired cognition, DON said, R77 should have had been provided with supervision. When asked was there a potential the resident could have been struck by a vehicle or impaired by heat exposure, DON said, Yes. During an interview on 8/21/24 at 3:14 PM with Nursing Home Administrator (NHA), it was reported that the resident was found by an ambulance service walking along I-94 expressway and was taken back to the hospital. It was then reported that residents with a BIMs of 12 or below will now receive an escort for supervision when going to outside appointments. Record review of facility policy Safety and Supervision (no date) documented, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Further review of policy found no interventions in policy to escort residents that are cognitively or physically impaired to appointments outside of the facility.

Based on interview and record review, the facility failed to ensure three residents (R4, R18, and R25) out of five residents reviewed for immunizations were provided pneumococcal and influenza vaccination and education, resulting in the potential for development and spread of influenza and pneumonia among vulnerable residents in the facility. Findings include: On 8/22/2024 at 10:08 AM the Infection Preventionist (IP) D was interviewed and reported the following residents R4 and R18 did not have documentation of a current pneumococcal immunization or refusal and R25 did not have documentation of current influenza immunization or refusal. Review of the Electronic Health Record (EHR) for R4 revealed admission to the facility on [DATE] with diagnosis of dementia and cerebral infarction (stroke). Further review of EHR revealed R4 did not have documentation to indicate that the pneumococcal vaccine was offered or was contraindicated. Review of the EHR for R18 revealed admission into the facility on [DATE] with diagnosis of muscle weakness and dementia. Further review of EHR revealed R18 did not have documentation to indicate that the pneumococcal vaccine was offered or was contraindicated. Review of the EHR for R25 revealed admission into facility on 8/22/2022 with diagnosis of hypertensive heart disease and cerebral infarction. Further review of EHR revealed R25 did not have documentation to indicate that the influenza vaccine was offered or was contraindicated. On 8/22/2024 at 1:12 PM the Director of Nursing (DON) was interviewed and agreed both R4 and R18 should have been educated and offered the pneumococcal vaccine and that R25 should have been offered the influenza vaccine for the 2023/2024 flu season. Review of the facility policy titled Vaccine Policy and Procedure undated, revealed in part: .The facility is required to offer the Flu, Covid-19, and Pneumonia vaccines to residents during the flu season, providing education on these vaccines to those who decline them.

Based on interview and record review, the facility failed to ensure two residents (R4 and R18) out of five residents reviewed for immunizations were provided Covid-19 vaccinations and education resulting in the potential for development and spread of Covid-19 among vulnerable residents in the facility. Findings include: On 8/22/2024 at 10:08 AM the Infection Preventionist (IP) D was interviewed and reported the following residents R4 and R18 did not have documentation of a current Covid-19 immunization or refusal. Review of the Electronic Health Record (EHR) for R4 revealed admission into the facility on [DATE] with diagnosis of dementia and cerebral infarction (stroke). Further review of EHR revealed R4 did not have documentation to indicate that the Covid-19 vaccine was offered or was contraindicated. Review of the EHR for R18 revealed admission into the facility on [DATE] with diagnosis of muscle weakness and dementia. Further review of EHR revealed R18 did not have documentation to indicate that the Covid-19 vaccine was offered or was contraindicated. On 8/22/2024 at 1:12 PM the Director of Nursing (DON) was interviewed and agreed both R4 and R18 should have been educated and offered the Covid-19 vaccine. Review of the facility policy titled Vaccine Policy and Procedure undated revealed in part .The facility is required to offer the Flu, Covid-19, and Pneumonia vaccines to residents during the flu season, providing education on these vaccines to those who decline them.

This citation pertains to intake numbers MI00143709. Based on interview and record review, the facility failed to provide scheduled showers for two residents (R506 and R508) out of three residents reviewed for activities of daily living (ADL's), resulting in the potential for unmet hygiene needs, loss of dignity, and emotional distress. Findings include: R506 Review of an Admission Record revealed, R506 readmitted to the facility on [DATE] with pertinent diagnosis which included Dementia and Multiple Fractures of Pelvis. R506 was discharged to the hospital on 5/2/24. Review of a Minimum Data Set (MDS) assessment dated of 4/19/24 revealed R506 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 8 out of 15. Review of a bathing task revealed, R506 had no documented showers or bed baths for the last 30 days (April 2024). Review of the 1st floor shower schedule revealed, R506's scheduled showers days were Wednesday and Saturday on the 6-2 shift. On 5/2/24 at 12:41p.m., R506 and R508's shower documentation was requested from the NHA via email. R508 On 5/2/24 at approximately 9:30 am, R508 declined an interview with the surveyor. Review of an Admission Record revealed, R508 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Enterocolitis due to C-Diff (inflammation in small intestine and colon) and Displaced Intertrochanteric Fracture of Left Femur. Review of a MDS assessment dated of 1/25/24 revealed R508 had no cognitive impairment with a BIMS score of 14 out of 15. Review of a bathing task revealed, R508 had no documented showers or bed baths for the last 30 days (April 2024). Review of the 3rd floor shower schedule revealed, R508's scheduled showers days were Monday and Thursday on 2-10 shift. On 5/2/24 at 1:51 p.m., the NHA provided a progress note dated 2/8/24 indicating R508 declined a shower and a bed bath. The NHA did not provided documented showers for R506 or R508 for the last 30 days. In an interview on 5/2/24 at 2:15 p.m. Licensed Practical Nurse (LPN) C reported the nurse should complete a skin observation on scheduled shower days and the CNAs (Certified Nursing Assistant) should chart in POC (care charting system). In an interview on 5/2/24 at 2:16 p.m. Unit Manager D reported showers should be documented in POC and nurses should complete a skin assessment. In an interview on 5/2/24 at 2:27 p.m. CNA E reported showers are documented in the POC. In an interview on 5/2/24 at 2:31p.m. Unit Manager F reported showers are documented in the POC by the CNAs. Unit Manager F then reported the nurse documents the shower on the skin assessment and should document all refusals. In an interview on 5/2/24 at 2:34 p.m. the Director of Nursing (DON) reported showers are documented in by POC by the CNAs. The DON then reported the nurses should complete a skin assessment on shower days. The DON reported there was no shower documentation found for R506 or R508. Review of a Activities of Daily Living (ADL), Supporting policy revised March 2018 documented the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

This citation pertains to intake MI00142789. Based on interview and record review, the facility failed to properly assess (obtain vital signs and complete neurological checks) after a reported, unwitnessed fall for one resident (R603) out of six residents reviewed for falls. R603 was on anti-coagulant therapy. R603's fall was followed by hospitalization for a brain bleed and subsequent death. Findings include: Review of an Admission Record in the EHR (Electronic Health Record) revealed, R603 admitted to the facility on [DATE] with pertinent diagnoses which included chronic atrial fibrillation and abnormalities of gait and mobility. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed R603 had no cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15. Review of a progress note with a date of [DATE] at 2:23 p.m., documented, Around 1:50 PM, assigned CNA (Certified Nursing Assistant) reported to writer that resident told her that he fell . CNA did not observed resident on the floor, he was in bed, and call light on. Writer went in with co-worker, alert and oriented with periods of confusion, checked resident skin, no new skin issues noted, informed staff that he hit his head at the door, he doesn't know how he got to the door, nothing noted to the scalp . Unit manager notified . On coming nurse notified to monitor resident for any changes . Review of a progress note with a date of [DATE] at 10:56 p.m., revealed, Resident received 5pm meds and tolerated well . Resident didn't complain of any discomfort or appear to be in any distress. A few moments later EMT (Emergency Medical Transportation) arrived stating that they were here for (R603's room) . On call Provider notified that resident called 911 for his self. Daughter called and notified us that he was currently in emergency surgery that he had bleeding on the brain. Writer called on call provider notified . Review of Physician orders revealed R603 had an order for Warfarin (blood thinner/anticoagulant) 5 mg (milligrams) by mouth at bedtime (9 pm). Review of a February 2024 Medication Administration Record (MAR) revealed R603 received Warfarin on ,d+[DATE] and [DATE] at 9 pm. Review of an incident report, dated [DATE] revealed, R603 reported falling and hitting his head. Review of vital signs in the EHR revealed R603 did not have any documented blood pressure readings between 9 am and 6 pm on [DATE], on the date of the reported fall. However, review of a hospital document, dated of [DATE] at 6:11 p.m., revealed R603 presented to the emergency department following a fall where he reported hitting his head. R603 was hypertensive (increased blood pressure) and tachycardic (increased pulse rate) upon arrival. A CT scan (used to diagnose internal injuries or damage) was performed and found R603 had a large brain bleed. In an interview on [DATE] at 2:16 p.m., the Nursing Home Administrator (NHA) A reported R603 did not have any neurological checks (used to assess changes in mental status and level of consciouness, pupil response, motor strength, sensation, and gait) performed on [DATE]. In an interview on [DATE] at 2:26 p.m., the Director of Nursing (DON) reported R603 had an unwitnessed fall. The off-going nurse was leaving and endorsed to oncoming nurse to monitor R603. The Director of Nursing (DON) reported when a resident falls and hits their head neurological checks (neuro checks) should be completed. The DON reported neuro checks should be completed to assess the resident for changes. The DON reported R603's family called the facility and told them R603 had a brain bleed and died . In an interview on [DATE] at 8:53 a.m. CNA E reported R603 had on the call light which prompted her to go to the room. CNA E reported R603 was in bed and reported the fall and that he hit his head on the door. CNA E then reported telling the nurses about what R603 reported. In an interview on [DATE] at 10:20 a.m. Licensed Practical Nurse (LPN) C reported during shift report at approximately 2 pm, LPN I reported R603 fell and hit his head. LPN C then reported LPN I asked her to monitor R603 during the shift for neurological changes. LPN C reported she did not observe R603 until medication pass at approximately 5pm. LPN C reported the EMT's arrived on the unit when she walked to the medication cart after exiting R603's. Review of the Change in Condition policy revised February 2021, documented in part the following, Prior to notifying the physician or healthcare provider, the nurse will make a detailed observations and gather relevant information and pertinent information for the provider . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Review of a Guidelines & Risk Management for Falls policy (undated) documented, Instruction for completion . Residents should be assessed head to toe. Note any injury. Unwitnessed falls initiate neuro checks immediately. Contact DON for all residents on anti-coagulants. Contact the doctor, the family/emergency contact, DPOA and Guardian to inform of fall and whether to send to hospital .

This citation pertains to intake MI00142789. Based on interview and record review, the facility failed to inform family of a fall for one resident (R603) of six residents reviewed for falls. Findings include: Review of an Admission Record revealed, R603 admitted to the facility on [DATE] with pertinent diagnoses which included chronic atrial fibrillation and abnormalities of gait and mobility. R603's family was listed as the emergency contact. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R603 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14, out of a total possible score of 15. Review of a progress note with a date of 2/17/24 at 2:23 p.m., revealed Around 1:50 PM, assigned CNA (Certified Nursing Assistant) reported to writer that resident told her that he fell . CNA did not observed resident on the floor, he was in bed, and call light on. Writer went in with co-worker, alert and oriented with periods of confusion, checked resident skin, no new skin issues noted, informed staff that he hit his head at the door . On coming nurse notified to monitor resident for any changes . In an interview on 3/6/24 at 2:31p.m. the Director of Nursing (DON) reported a resident's family should be notified when they fall. The DON confirmed R603's family was not notified of the fall. In an interview on 3/7/24 at 9:32 a.m. Concerned Family Member (CFM) F reported the facility did not notify them that R603 had a fall or was transferred to the hospital. CFM F reported the hospital called and informed them that R603 was in the ER with a brain bleed. Review of the facility document Guidelines & Risk Management for Falls (undated) revealed, Instruction for completion . Contact the doctor, the family/emergency contact, DPOA and Guardian to inform of fall and whether to send to hospital .

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 59 residents. Findings include: On 8/1/23 at 10:12 AM, four live flies were observed in the kitchen's dishwashing area. On 8/1/23 at 10:19 AM, seven live flies were observed near the kitchen's janitors closet and waste receptacle holding area. Upon observation the surveyor inquired with Dining Director, staff D on the current state of the insects in this area to which they responded, I think they come in when they take out the trash and the doors are open. It's usually not too bad. On 8/1/23 at 10:21 AM, the surveyor requested the facility's pest control policy to review to which staff D responded, I am not the best one talk to about that, but I will make sure that we will get what we have to you. On 8/1/23 at 11:06 AM, two live flies were observed near the kitchen's walk in coolers in the basement hallway. On 8/3/23 at 10:58 AM, six live flies were observed near the kitchen's janitors closet and waste receptacle holding area. Upon observation the surveyor inquired with staff D on the current state of the insects in this area to which they responded, the pest company just came out Tuesday afternoon and treated the building. At this time the surveyor asked if staff D would accompany them to where the trash is disposed of to which they stated, of course. On 8/3/23 at 11:02 AM, upon inspection of the trash compactor and loading dock area the surveyor observed both loading dock garage style doors fully opened, uncovered waste receptacles with visible waste on the interior of them, numerous live flies swarming throughout the area, and strong odor present. On 8/3/23 at 11:13 AM, record review of the facility's most recent pest control service record dated, 8/1/23 revealed that the targeted pests treated at facility on this date were ants, rats, mice and spiders. No mention of flies, or application areas in the basement or kitchen were observed by the surveyor while reviewing this document. Review of 2017 U.S. Public Health Service Food Code, Chapter 6-501.111 Controlling Pests, directs that: The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (B)Routinely inspecting the PREMISES for evidence of pests;

Based on observation, interview and record review, the facility failed to (1.) properly monitor the temperature of one medication storage refrigerator out of two refrigerators reviewed for medication storage, (2.) properly date two opened insulin pens stored in the medication cart, and (3.) failed to ensure an unopened insulin pen was refrigerated as indicated per manufacturer's instructions for one medication cart out of three medication carts reviewed for medication storage, resulting in the potential to administer unsafe, ineffective, and outdated medications. Findings include: During an observation and interview on 8/2/2023 at approximately 9:18 a.m., the first-floor medication storage room refrigerator was observed with thick ice covering the top where ice trays were to be stored. RNM (Registered Nurse Manager) I confirmed midnight shift nurses were to monitor the refrigerator's temperature every night, log it on the temperature log, and thaw out the refrigerator freezer. After reviewing the temperature log, RNM I indicated that there was an out-of-range documented temperature of 29 degrees and that the refrigerator temperature range should be between 31 degrees to 41 degrees. RNM I acknowledged that the refrigerator temperature was out of range for medication and stated, They (nursing staff) should have thawed the refrigerator when they saw all the ice buildup. A copy of the first-floor refrigerator temperature log was requested for review but not provided by the end of the survey. A review of the second floor Refrigerator Temperature and Cleaning Log documented the following: - Night Nurse will record the temperature in the temp. column and will initial that this has been completed in the initial column. - If action is necessary, such as adjusting the temperature because the refrigerator is too cold or too hot, the corrective action will recorded in the action column. - The refrigerator Must Be cleaned nightly, and nurse must initial that the refrigerator was cleaned according to policy. Record the initials of the staff that cleaned the refrigerator in the box under the column Cleaned. On 8/2/2023 at approximately 10:30 a.m., the contents of the second floor high end medication cart were observed with Licensed Practical Nurse (LPN) J. Two Insulin pens (one Lispro and one Glargine) were observed opened and undated. LPN J was unable to state when the Lispro insulin and Glargine insulin pens were opened and how long they could be stored in the medication cart before expiring. LPN J said Resident #427 (R427) still received insulin and added R427 received two units from the undated Lispro insulin pen this morning for sliding scale coverage. In addition, the packaging for one unopened and undated Lispro insulin pen was documented with R427's room number and the date delivered by the pharmacy. LPN J confirmed the unopened insulin pen should have been in the refrigerator until opened and the opened Lispro and Glargine should have been dated with the date they were opened. The High Alert' instructions on the insulin pen bags were reviewed with LPN J and revealed, Refrigerate until opened, once opened, store at room temperature for twenty-eight days of date opened. According to the electronic medical record, R427 was initially admitted into the facility on [DATE] with diagnoses that included diabetes mellitus type two and Alzheimer's disease. Review of R427's Physician's orders documented, Insulin Glargine subcutaneous solution pen-inject twenty-eight units subcutaneous and insulin Lispro solution pen per sliding scale coverage (sliding scale coverage insulin is given to cover high abnormal blood sugars). A review of the facility policy, Refrigerator and Freezer, dated November 2022, revealed: - The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation . Storage of Medications: - The nurse's staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Temperature must not exceed 41 degrees Fahrenheit. If the refrigerator is temping above this, please adjust the temperature. TEMPERATURE SHOULD BE IN RANGE OF 36-46 DEGREES. - The refrigerator MUST BE cleaned nightly and ensure ice building up is not present in freezer. Nurse must initial that the refrigerator was cleaned and checked for buildup according to policy . A review of the facility policy, Pharm Script, dated August 2020, revealed: - 1. Expiration dates (beyond-use-dates) of dispensed medication shall be determined by the pharmacist a the time of dispensing. - 3. Certain medications or package types, such as Intravenous solutions, multiple dose injectable vials .requires an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency.

This citation pertains to Intake #MI00133266. Based on interview and record review, the facility failed to notify the court appointed legal guardian/family member before discharging out of the facility for one resident (R325) out of three residents reviewed for discharge, resulting in the guardian/family being unaware of where their loved one was relocated and not being involved in the discharge planning. Findings include: Review of the clinical record for Resident #325 (R325) revealed the resident was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included pneumonia, metabolic encephalopathy, hypertension, respiratory failure, and a history of falls. According to the Minimum Data Set (MDS) assessment dated [DATE], R325 was moderately cognitively impaired and required assistance with Activities of Daily Living. Review of the Order Regarding Appointment of Temporary Legal Guardian of Incapacitated Individual, provided by the facility during the survey, revealed that Guardian C was granted Guardianship to R325 for dates 11/3/22 until 12/8/22. In an interview on 8/7/23 at 12:43 PM Guardian C stated, The facility let my family member leave with a stranger and didn't notify me. I had no idea where my family member was until (R325) called me and told me where they were. The discharge plan was for (R325) to discharge from the facility directly to an apartment on the same property complex. I was not told of the change in discharge. I was very upset and concerned about the welfare of my family member. Record review of R325's discharge progress note dated 11/27/22 revealed that Guardian C was not contacted regarding R325's discharge out of the facility and to a friend's home. Review of a late entry progress note dated 12/8/22 failed to document the date and time that Guardian C was contacted about R325's discharge. In an interview on 8/7/23 at 11:21 AM the Nursing Home Administrator (NHA) said R325 was discharged on [DATE] to a friend's home until her apartment was scheduled to be ready on 12/1/22. When asked did anyone from your facility contact Guardian C regarding the change in discharge plans, the NHA stated, We tried but (Guardian C) did not return our calls or messages. When asked to provide evidence of attempts to notify Guardian C of the revised discharge plan to a friend's home, the NHA provided notification of R325's discharge directly to the apartment on the facility campus not of the discharge to the friend's home. Review of the facility policy, Discharging the Resident, revised 12/2016, revealed: - That his or her family will be informed of the discharge and where the resident will be living. - If the resident is being discharged home, ensure that the resident and/or responsible party receive teaching and discharge instructions.

Based on interview and record review, the facility failed to assess the effectiveness of administered anti-diarrheal medication and communicate incidents of loose stools/diarrhea for one resident (R32) of one resident reviewed for diarrhea/constipation, resulting in resident frustration and incidents of loose stools/diarrhea going untreated. Findings include: During an interview on 8/1/2023 at 12:30 PM, when Resident #32 (R32) was queried if diarrhea or constipation was a concern, she said she had diarrhea. R32 added the nurse gave her a pill for it. R32 said when the diarrhea continued and she requested another pill, none was provided. A review of R32's clinical record documented an admitted [DATE] with diagnoses that included heart disease, spinal stenosis, and peripheral vascular disease. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition and total physical dependence on staff for toilet use. A review of physician orders documented to provide Anti-Diarrheal 2 gm tab, one tablet by mouth every eight hours as needed for diarrhea with a start date of 4/3/2023. A review of R32's August 2023 Medication Administration Record (MAR) documented the administration of one tablet of anti-diarrheal medication on 8/1/2023. The effectiveness of the anti-diarrheal medication was marked U which signified unknown. No subsequent anti-diarrheal medication had been administered. A review of Certified Nurse Assistant (CNA) documentation of R32's bowel movement consistency during August 2023 revealed the following: 8/1/2023 at 9:54 PM: normally formed stool. 8/2/2023 at 10:52 AM: resident bowel incontinence - stool consistency not documented. 8/3/2023 at 8:24 AM: resident bowel incontinence - stool consistency not documented. 8/4/2023 at 3:14 AM: loose/diarrhea. 8/4/2023 at 1:24 PM: resident bowel incontinence - stool consistency not documented. 8/4/2023 at 9:26 PM: loose/diarrhea 8/5/2023 at 9:59 AM: resident bowel incontinence - stool consistency not documented. 8/5/2023 at 9:59 PM: loose/diarrhea 8/6/2023 at 11:53 AM: normally formed stool. 8/6/2023 at 9:59 PM: loose/diarrhea 8/7/2023 at 5:59 AM: loose/diarrhea A review of nursing notes between 8/1/2023 and 8/6/2023 revealed the following reference to the administration of the anti-diarrheal medication: Order administration note of 8/1/23 at 9:33 PM documented to early to see if medication is effective. PRN Administration was: Unknown. The review of nursing notes revealed staff did not assess, monitor, document, or follow-up on R32's response to the administration of the anti-diarrheal medication or her continued incidents of loose stool/diarrhea. During an interview and record review on 8/7/2023 at 11:33 AM, the Director of Nursing (DON) said that R32's loose stools/diarrhea had not been triggered for her. R32's August 2023 MAR, bowel elimination documentation, and nursing progress notes were reviewed with the DON. The DON said nursing should have assessed the effectiveness of the administered anti-diarrheal medication on 8/1/2023 to see if they needed to do something different. The DON added the physician should have been notified regarding R32's loose/diarrheal stools in case they wanted to order some other test. The DON said there should have been some communication between the CNAs and nurses regarding R32's stool consistency.

Based on observation, interview and record review, the facility failed to properly secure indwelling catheter tubing for one resident (R40) of three residents reviewed for urinary catheters, resulting in the potential for genital trauma. Findings include: In an observation on 8/1/23 at 10:20 a.m., Resident #40 (R40) laid in bed and had a urinary catheter. Tea colored urine was observed in the tubing. Review of an admission record revealed, R40 admitted to the facility on [DATE] with pertinent diagnosis of a right humerus fracture and right and left pelvic fractures. Review of a Minimum Data Set assessment, dated 7/30/23, revealed R40 was cognitively impaired and required an indwelling catheter. In an observation and interview on 8/3/23 at 8:30 AM, Certified Nursing Assistant (CNA) B was observed performing ADL care for R40. CNA B stated, The foley isn't attached (anchored) to his leg and the catheter bag is on the floor. CNA B said R40 should have an anchor or leg strap on the catheter and the catheter bag should be off the floor. In an interview on 8/3/23 at 8:55 AM Licensed Practical Nurse (LPN) A stated, There is blood in (R40's) catheter line and looks like sediment too. There is blood at the opening of the penis where the foley catheter line inserts. I will put an actual leg strap on after his shower since the anchor isn't attached. Review of R40's care plan did not include foley catheter management. In an interview on 8/3/23 at 2:59 PM the Director of Nursing (DON) agreed R40's catheter bag should not be on the floor and the catheter line (tubing) should be anchored to their leg. The DON explained if the foley tubing isn't anchored it can pull on the genitalia. Review of the facility policy, Catheter Care, Urinary, dated August 2022, revealed: - Ensure that the catheter remains secured with a securement device to reduce friction and movements at the insertion site. - Be sure the catheter tubing and drainage bag are kept off the floor.

This citation pertains to intake #MI 66. Based on observation, interview and record review, the facility failed to properly assess and provide timely and appropriate pain medication for three (#s 602, 605, 606) of three sampled residents reviewed for pain management, resulting in grimacing, moaning, wincing and crying due to prolonged, uncontrolled discomfort and pain. Findings include: The complainant reported to the State agency that a pain medication was not provided timely for resident #602, resulting in delay in prescribed treatment of [REDACTED]. Resident #602- On 10/30/19, review of the resident's clinical record revealed: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. She had a subsequent hospital procedure resulting in a surgical wound to the perineal (between the anus and vagina) area and was then transported to the facility. On 10/18/19, [MEDICATION NAME] ointment was prescribed: Apply to affected area 4 times daily as needed for pain (apply to perineal wound). [MEDICATION NAME] is used to create temporary numbness for pain relief. [MEDICATION NAME] (narcotic pain pill) was also prescribed every 4 hours as needed. Medication administration records noted that [MEDICATION NAME] was administered at 8:45 PM on 10/18/19 and at 5:05 AM, 1:23 PM, 5:24 PM and 9 PM on 10/19/19. On 10/19/19 at 7:35 AM, a nurse noted during an initial admission skin assessment: The resident had a drainage tube in the right abdomen, a [MEDICAL CONDITION] bag to the left abdomen, a surgical site to rectum, was complaining of pain 10/10 (meaning at a level of 10 from a scale of 1-10 with 10 being the worse pain) to rectum and was given [MEDICATION NAME]. The resident's assigned nurse noted on 10/20/19 at 8:09 AM: Writer approached per cena (certified nurse assistant). Cena stated that resident wanted another pain pill, as well as pain cream ([MEDICATION NAME]). Writer gave patient her second pain pill for the shift. Writer checked computer under regular orders for any type of pain cream she was ordered. Writer located order for prn (as needed) [MEDICATION NAME] cream. Writer was unable to locate [MEDICATION NAME] cream in treatment cart. Writer informed patient that [MEDICATION NAME] cream was not in (skin/wound) treatment cart, and that I would call pharmacy for it. Writer received call from security desk stating that family was at door to see (the resident). Family came in to facility. Requested [MEDICATION NAME] cream for resident. Family stated that [MEDICATION NAME] cream was in regular medication cart earlier. Writer located cream. Cream was administered to resident. Family to nurses desk stating that they want (resident) transferred back to hospital because they felt her pain was not under control. Family stated that resident was not acting normal. The physician was notified and the resident was transported to the hospital on [DATE]. There was no documented indication that the resident had received [MEDICATION NAME] after 9 PM on 10/19/19 or that [MEDICATION NAME] cream was applied at anytime during admission, per the resident's wound treatment administration record. (During a phone conversation with the complainant on 10/28/19, they reported that when they told the nurse where the cream was located, the Cena took the cream and applied it herself right away, rather than the nurse, since (the resident) had been waiting for it so long.) There was no indication why the nurse was unaware the cream was in the medication cart or why she did not look for it there before deciding to call the pharmacy. The nurse was not present and unavailable for comment by phone. On 10/31/19 at 1:35 PM, when queried, the Director of Nursing (DON), who had been on the job for two days, could not explain why the family had to come to the facility and tell the nurse where the medication, was causing a delay in pain control. Resident #605- On 10/30/19 at 9:30 AM, the resident was alert and lying in bed frowning. She said, Oh my back is killing me. She was asked if the nurse knew she was in pain and said, Oh, they all know! Her assigned nurse (C) was immediately told the resident was in pain. Nurse C then directed a nurse trainee to give the resident a pain pill. The trainee said she was helping another resident and walked into a room across the hall from resident #605. At 9:40 AM, nurse C entered resident #605's room and took the resident's blood pressure. There was no pain assessment done. Nurse C left the room and was asked what the resident had prescribed for pain. He said [MEDICATION NAME] (narcotic pain pill) every 6 hours PRN (as needed), last received on 10/29/19 at 8:45 PM, and [MEDICATION NAME] (narcotic-like pain reliever for moderate pain) every 8 hours PRN. At 9:43 AM, he returned to the room and took the resident's temperature. At 9:45 AM, nurse C and the trainee returned to the room, knocked on the closed door and said they would return later because nurse aide G was in the room providing care. Aide G was observed changing the resident's [MEDICAL CONDITION] bag and then turning her from side to side changing her incontinence brief. The resident winced and moaned when turned. Aide G asked if she was in pain and the resident said, My back. At 9:55 AM, the aide stepped out of the door to ask someone to get nurse C to look at a pressure sore on the resident's coccyx. At 10:05 AM, nurse Unit Manager D entered the room to look at the sore. The resident moaned when turned to her side and back. At 10:15 AM, nurse D returned with wound supplies. The resident moaned again when turned for the wound care. Aide G told the nurse, She has a lot of back pain. Nurse C and the trainee were observed retrieving [MEDICATION NAME] from the medication cart for the resident. At 10:17 AM, the resident was sat up on the side of the bed being dressed by the aide. Nurse C entered and gave the pill. The resident started crying. Nurse C asked, Are you crying because you're in pain or do you have anxiety? The resident said, Pain. The nurse then conducted a pain assessment 'after' the pill was given by asking, What is your pain level and where is it located? The resident said, nine, in my lower back. After nurse C left the room, the resident was overheard telling the aide, The pain is getting worse all the time. They won't operate anymore. I've already had two operations. At 10:25 AM, the aide was observed positioning a lift machine in front of the resident, standing her up, pulling up her pants and transferring her from the bed to a wheelchair. The resident said, Oh, oh, it hurts so bad and began to cry again when placed in the chair. Nurse C was then queried as to how he decided to give [MEDICATION NAME] versus [MEDICATION NAME] without first conducting a pain assessment and said, That's what she takes everyday. When asked why it took from 9:30 to 10:17 AM to give the resident a pain pill, nurse C said, because they (aide G and nurse D) got busy with her care. On 10/31/19 at 8:45 AM, the resident was observed alert and lying on her back in bed with a frown. She said, My back is killing me. Could you please move this pillow up a bit. The resident moaned and winced when the pillow was moved. The resident's Controlled Substance (narcotic) records were reviewed with nurse D. Per the record [MEDICATION NAME] was last given the previous night at 8:30 PM. The resident's clinical record noted: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted minimal cognitive impairment, non-ambulatory and extensive assistance required for care. The narcotic records for [MEDICATION NAME] noted that from 9/25 to 10/30/19, 57 PRN pills were given. When asked why the resident was not placed on scheduled pain medication, rather than PRN, since they were taken so frequently, nurse D said, I can call the doctor and see if we can get it scheduled. We discussed it at her Care Conference. Nurse D said she attended the care conference meeting and was asked to see notes of the discussion. However, she looked in the computer then said, Her family could not come, so it got canceled and then said she did not attend the meeting because it did not take place. On 10/31/19 at 11:20 AM, the DON and the resident's Primary Care Physician (PCP) were shown the narcotic records and asked about pain management for the resident. The DON said there needed to be an interdisciplinary team approach, mentioned changing or scheduling the pain medication or trying a pain patch. The PCP said, Many things have been tried with her in the past. She has many problems. Maybe there can be some adjustments. Resident #606- On 10/30/19 at 9:20 AM, the resident was observed alert and sitting in a recliner chair with legs elevated. The resident was complaining of pain in the right leg. She said, I fell yesterday and I yelled and yelled a hundred times for help. I don't know what happened. I was stuck right here (between the bed and night stand). They finally came and got me up. I can't straighten this leg. The resident's right knee was slightly flexed and an old, healed surgical scar was observed to the left knee. When asked if she told anyone that she was in pain and if she wanted a pain pill, she said she could not remember and that she wanted something for pain. The resident's call light was activated and her assigned nurse aide (H) responded. When told that the resident wanted something for pain, aide H said, She was saying she was in pain during her shower. When asked how long ago that was, aide H said, I just brought her back from the shower and put her there (in the chair). When asked if she told the nurse the resident had pain, aide H said, No, I didn't see the nurse. I'll let her know and mentioned that the nurse may be off the unit. The resident's clinical record was reviewed with nurse Unit Manager E. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted moderate cognitive impairment, non-ambulatory and extensive assistance required for care. She was prescribed [MEDICATION NAME] every 8 hours PRN and extra strength Tylenol every 6 hours PRN. Nurse [NAME] said the resident had a fall two days prior and complained of right leg pain. Staff was unable to complete range of motion to the leg, a Stat (immediate) x-ray was taken and [MEDICATION NAME] was given for pain. The x-ray was negative for fracture Per the staff assignment, the resident's assigned nurse's schedule was split between that nursing unit and a unit on another floor. Nurse [NAME] was told that the resident was complaining of pain during her shower, but aide H did not report it because of not seeing the resident's nurse. Nurse [NAME] could not explain why it was not reported and said there was a second nurse and herself available on the unit at all time that the aide could have reported the resident's pain to when the assigned nurse was off the unit.

Based on observation, interview and record review the facility failed to ensure a proper transfer was performed for one (#101) of five residents reviewed for abuse, resulting in the resident sustaining a left femoral fracture and subsequent open reduction external fixation (ORIF). Findings include: Review of the Face Sheet for Resident (R) #101 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], indicated R#101 was cognitively impaired in decision making skills required extensive assistance with two person physical assist with transferring. On 12/12 at 11:15 A.M., per the Five Day Report on 11/22/18 at approximately 1:00 A.M., R#101 was in bed yelling out. Upon the nurse entering the room the resident was screaming out in pain and bracing her right leg. Upon assessment the nurse contacted the physician and received an order to transfer R#101 to the hospital for further evaluation. On 12/12/18 at 11:30 A.M., review of the Intake Information received 11/27/18, stated, The Director of Nursing, was notified on 11/26/18 that R#101 was transferred to the hospital on [DATE] at approximately 2:00 A.M., for new onset pain to her left leg and hip. After further evaluation at a local hospital on (11/23/18) it was determined that R#101 had sustained a subcapital fracture to the left femur (bone that extends from pelvis to the knee). The cause of R#101's fracture was unknown in origin. An investigation was conducted with the staff and it was concluded that R#101 was transferred improperly on the night of 11/21/18 when Certified Nurse Aide (CNA) J transferred the resident from her wheel chair with one person instead of two person assist. Certified Nurse Aide J who cared for R#101 on 11/20/18 and 11/21/18 on her shift acknowledged at 8:00 P.M. The resident was transferred from her wheel chair to the bed with one person assist instead of two persons assist as indicated in the Care Guide. The resident did not display any signs of pain on 11/22/18 at 10:15 P.M. during incontinent care but the following check at approximately 1:00 A.M. the resident displayed pain, yelling and discomfort. Review of the Care Guide updated 11/16/18 revealed R#101 required maximum assist, required 2 people or sit to stand instead of one person assist, which was used on the night of 11/21/18. According to the clinical record R#101 had experienced a recent decline in muscle strength requiring more assistance with transfers. The resident did not have any falls or traumatic event in the two days leading up to her transfer to the hospital. R#101 was observed by staff self ambulating up and down the halls without any signs and symptoms of pain and discomfort . On 12/12/18 at 3:00 P.M. during interview with the Director of Nursing, she reported the resident had returned to the facility and was currently receiving Physical Therapy.

REFER TO INTAKE #MI 990 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADMINISTER THE CORRECT DOSAGE OF [MEDICATION NAME] AS ORDERED FOR 1 (RESIDENT #100) OF 5 SAMPLED RESIDENTS AND 5 OBSERVED UNSAMPLED RESIDENTS RESULTING IN RESIDENT #100 TO HAVE DIFFICULTY IN OBTAINING THE THERAPEUTIC RANGE FOR INR (INTERNATIONAL NORMALIZED RATIO) AND POTENTIAL FOR INTERNAL BLEEDING. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INCIDENT REPORT DATED 6/6/13, "PROBABLE MEDICATION ADMINISTRATION ERROR IN THE AMOUNT OF 17.5 MG (MILLIGRAMS) [MEDICATION NAME] VERSUS THE ORDERED 7.5 MG.OF [MEDICATION NAME] BY LPN #1 ON 6/5/13, SECONDARY TO THE INCORRECT ELECTRONIC (EMR) ENTRY OF [MEDICATION NAME] ORDERS.UPON ADMISSION ON 5/31/13 BY NURSE (#2)." RESIDENT #100'S physician's orders [REDACTED]. [MEDICATION NAME] 10 MG. PO HS SATURDAY AND SUNDAY. RESIDENT #100 WAS [AGE] years OLD, ALERT ORIENTED X3, admitted to the facility on [DATE]. HISTORY AND PHYSICAL DATED 6/3/13, REVEALED THAT RESIDENT HAD LEFT TOTAL KNEE REPLACEMENT, [MEDICAL CONDITION] (DEEP VEIN [MEDICAL CONDITION]) [MEDICATION NAME] ON [MEDICATION NAME], IN ADDITION TO OTHER DIAGNOSES. PASSR (PRESCREENING ANNUAL RESIDENT REVIEW ) DATED 5/30/13 SHOWED RESIDENT #100 WAS BEING treated for [REDACTED]. DURING THE INTERVIEW WITH THE RESIDENT #100 CONDUCTED ON 6/11/13 AT 3:00 PM, SHE STATED THAT SHE RECALLED THE INCIDENT VERY WELL AND SHE KNEW SHE WAS GIVEN TOO MANY PILLS BY THE NURSE. HOWEVER, WHEN SHE POINTED THIS OUT TO THE NURSE, SHE WAS TOLD "THAT'S WHAT YOUR DOCTOR ORDERED." RESIDENT #100 VERBALIZED BEING ANXIOUS AND VERY UPSET REGARDING THE INCIDENT AND SAID THAT SHE WAS FEARFULTHAT ANOTHER ERROR COULD HAPPEN AND MAY CAUSE HER TO BLEED INTERNALLY. RESIDENT# 100 WAS AWARE OF HER INR RESULTS AND KNEW THAT HER GOAL WAS TO REACH THE THERAPEUTIC AMOUNT SO SHE COULD GO BACK HOME. JUNE 2013 ELECTRONIC MEDICATIONS ADMINISTRATION RECORD (EMAR) SHOWED EVIDENCE THAT ON 6/5/13 AT 6:00 PM, BOTH [MEDICATION NAME] 7.5 MG AND [MEDICATION NAME] 10 MG WAS ADMINISTERED AND WAS SIGNED ELECTRONICALLY BY LICENSED PRACTICAL NURSE (LPN) #1. NO ADDITIONAL DOCUMENTATION IN THE NURSES' NOTES WERE DOCUMENTED. ACCORDING TO MOSBY'S MANUAL OD DIAGNOSTIC AND LABORATORY TESTS, 2ND ED., PAGANA, 2002. P 397- 398. "A THERAPEUTIC INR IS USUALLY CONSIDERED TO BE 2.0-3.5. RESIDENT #100'S ANTICOAGULANT FLOW SHEET WERE THE FOLLOWING: ALL VALUES ARE BELOW THE THERAPEUTIC LEVEL. 6/5/13= 1.6 MG. (17.5 MG.[MEDICATION NAME] WAS ADMINISTERED) 6/6/13= 1.7 MG. 6/7/13= 1.7 MG. 6/8/13= 1.3 MG. 6/9/13= 1.2 MG. 6/10/13=1.3 MG 6/11/13=1.7 MG LPN #1 WAS INTERVIEWED BY TELEPHONE ON 6/13/13 AT 3.52 PM. SHE STATED THAT SHE NOTICED THAT BOTH 10 MG. AND 7.5 MG DOSAGES BOTH POPPED GREEN (MEANING BOTH WERE DUE AT 5:00 PM). SHE REALIZED IT WAS TOO MUCH DOSAGE BUT DID NOT CHECK THE DOCTOR'S ORDER IN THE CHART, DENIED VERIFYING WITH THE NURSE MANAGER/AFTERNOON SUPERVISOR OR ANOTHER NURSE ON DUTY. SHE ALSO STATED THAT SHE DID NOT REPORT THE [MEDICATION NAME] ORDER IN QUESTION TO THE MIDNIGHT SHIFT NURSE DURING CHANGE OF SHIFT. SHE EXPLAINED: "IT SLIPPED MY MIND. I WAS THE ONLY NURSE WORKING THAT SHIFT AND I DID NOT MAKE AN EFFORT IN NOTIFYING ANYONE" AFTER GIVING THE DOSAGE IN QUESTION. SHE DENIED CALLING THE PHYSICIAN TO VERIFY THE CORRECT DOSAGE. LPN #1 STATED THAT WHAT SHE DID WAS TO LOOK AT HER INR RESULT FOR THAT DAY TAKEN BY THE PREVIOUS SHIFT AND GAVE THE APPROPRIATE AMOUNT BASING ON THE INR. SHE DENIED GIVING THE 17.5 MG DOSAGE. RN (REGISTERED NURSE) #2 WAS UNAVAILABLE FOR INTERVIEW AT THE FACILITY AND DID NOT RESPOND TO THE VOICEMAIL LEFT ON 6/13/13 AT 4:00 PM. ACCORDING TO THE ACTING DON (DIRECTOR OF NURSING)/1ST FLOOR RN SUPERVISOR #3, ON 6/11/13 AT 11:30 AM, RESIDENT #100 IDENTIFIED LPN #1 AS THE NURSE THAT ADMINISTERED THE INCORRECT DOSAGE. RESIDENT #100 REMAINED AT SUBTHERAPEUTIC LEVEL AFTER THE INCORRECT DOSAGE OF [MEDICATION NAME] WAS ADMINISTERED. NURSING STAFF ARE MONITORING HER INR AT A DAILY BASIS AS WELL AS SIGNS AND SYMPTOMS OF BLEEDING. RN SUPERVISOR #3 EXPLAINED THAT: "THE ERROR STARTED FROM THE ADMITTING NURSE RN #2, WHO INCORRECTLY ENTERED THE ORDER INTO THE COMPUTER. RESIDENT #100 WAS TO RECEIVE 10 MG OF [MEDICATION NAME] TAB ON SATURDAY AND SUNDAY ONLY AND 7.5 MG MONDAY, TUESDAY, WEDNESDAY, THURSDAY AND FRIDAY. INSTEAD RN #2 PUT BOTH DOSAGES DAILY WITHOUT ASSIGNING THE APROPRIATE DAYS FOR THE APPROPRIATE DOSAGES. SO BOTH 10 MG. AND 7.5 MG. WILL BE DUE TO BE GIVEN EVERY 5:00 PM EVERYDAY." THE DON (DIRECTOR OF NURSING) SAID ON 6/11/13 AT 12:30 PM, SHE WAS OFF ON VACATION AND LEARNED ABOUT THE INCIDENT UPON HER RETURN. RESIDENT #100 STILL REMAINS IN SUBTHERAPEUTIC LEVEL AND WE ARE MONITORING THE LEVELS DAILY AS ORDERED. RESIDENT #100 CAREPLAN FOR RISK OF BLEEDING WAS NOT INITIATED SPECIFIC FOR THE INCIDENT ON 6/5/13. ( )

THIS CITATION PERTAINS TO INTAKE: MI 232 BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE SUPERVISION AND ADAPTIVE EQUIPMENT TO 1 OF 8 RESIDENTS, (#101) IN A TOTAL SAMPLE OF 8, ALL REVIEWED FOR THE ABILITY TO SAFELY HANDLE HOT LIQUIDS, RESULTING IN AN IMMEDIATE JEOPARDY FOR RESIDENT #101, WHO SPILLED HOT SOUP ON HERSELF AND SUSTAINED TWO LARGE 2ND DEGREE BURNS (BLISTERS, WITH PARTIAL LOSS OF SKIN) ON HER INNER THIGHS THAT REQUIRED INSERTION OF AN INDWELLING URINARY CATHETER (FOLEY), ORAL AND TOPICAL ANTIBIOTICS, PAIN MEDICATIONS, AND POSITIONING CUSHIONS TO PROMOTE HEALING. IN ADDITION TO THE RESIDENT (#101) IN IMMEDIATE JEOPARDY, THE FACILITY FAILED TO PROVIDE ADAPTIVE EQUIPMENT RESULTING IN THE HIGH POTENTIAL FOR HARM (BURNS) THAT IS NOT IMMEDIATE JEOPARDY TO 4 SAMPLED RESIDENTS, (#102, #103, #104, #105), WHO WERE REVIEWED FOR THE ABILITY TO SAFELY HANDLE HOT LIQUIDS. FINDINGS INCLUDE: ON 10/26/11 A 2:00 P.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 10/13/11 AT 6:00 P.M., AND WAS IDENTIFIED ON 10/25/11, WHEN STAFF FAILED TO PROVIDE FEEDING ASSISTANCE TO RESIDENT #101, AND SHE (#101) SPILLED HOT SOUP ONTO HER LAP CAUSING 2ND DEGREE BURNS. ACCORDING TO THE FACILITY'S "RESIDENT INCIDENT FORM," DATED 10/13/11 AT 9:40 P.M., COMPLETED BY LICENSED PRACTICAL NURSE (LPN) #8, RESIDENT #101 WAS OBSERVED TO HAVE 2 LARGE BLISTERS, 1 ON EACH INNER THIGH (LEFT THIGH: 14.0 CM X 8.0 CM, RIGHT THIGH: 15.0 CM X 6.0 CM) OF UNKNOWN ORIGIN. DURING THE INVESTIGATION CONDUCTED BY THE FACILITY, IT WAS DETERMINED THAT RESIDENT #101 HAD SPILLED HOT SOUP ONTO HER LAP DURING THE DINNER MEAL AT APPROXIMATELY 6:00 P.M., THAT EVENING (10/13/11). THE RESIDENT DID NOT COMPLAIN OF ANY PAIN THROUGHOUT THE EVENING AND STAFF DID NOT ASSESS THE AREA OR CHANGE THE RESIDENT'S SOILED CLOTHING, UNTIL AFTER 9:00 P.M.,WHILE PREPARING RESIDENT #101 FOR BED. ON 10/25/11 AT 11:20 A.M., RESIDENT #101 WAS OBSERVED TO BE SEATED AT THE NURSE'S STATION IN HER WHEELCHAIR WITH A POSITIONING CUSHION BETWEEN HER KNEES AND A FOLEY CATHETER IN PLACE. RESIDENT #101 WAS INTERVIEWED AND SAID SHE USUALLY SPILLS FOOD ON HERSELF AT EVERY MEAL. RESIDENT #101 COULD NOT RECALL THE SPECIFIC INCIDENT THAT CAUSED THE BLISTERS, BUT DENIED ANY PAIN TO THE AREA AT THIS TIME. RESIDENT #101 WAS MOVED TO THE PRIVACY OF HER ROOM AND THE BLISTERED AREAS WERE OBSERVED TO HAVE THE PRESCRIBED TOPICAL OINTMENT (SILVADENE) AND ADAPTIC DRESSINGS (NON-STICK) APPLIED. THE LEFT INNER THIGH BURNED AREA WAS FREE FROM SYMPTOMS OF INFECTION AND MEASURED 12.0 CM X 6.0 CM. THE RIGHT INNER THIGH BURNED WAS FREE FROM SYMPTOMS OF INFECTION AND MEASURED; 14.0 CM X 6.0 CM. A REVIEW OF THE MEDICAL RECORD REVEALED THAT RESIDENT #101 WAS A [AGE] year OLD FEMALE, WHO WAS admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS), dated [DATE], IDENTIFIED RESIDENT #101 AS REQUIRING SUPERVISION WITH EATING. A CARE PLAN FOR NUTRITION, DATED 6/30/11, HAD IDENTIFIED RESIDENT #101 AS HAVING DIFFICULTY CONVEYING FOOD TO HER MOUTH AND THE FOLLOWING INTERVENTIONS WERE LISTED: "FINGER FOODS," AND TO "SERVE SOUP IN A HANDLED MUG (NOT BOWL WITH SPOON)." THERE WAS NO ADDITIONAL ASSESSMENT OR EVALUATION BY NURSING OR THERAPY STAFF TO DETERMINE IF THE RESIDENT COULD SAFELY HANDLE HOT LIQUIDS IN THE MUG WITH HANDLES. DURING AN INTERVIEW ON 10/25/11 AT 1:20 P.M., CERTIFIED NURSING ASSISTANT (CNA) #7 SAID THAT ON 10/13/11, SHE ASSISTED RESIDENT #101 INTO THE DINING ROOM, PLACED HER (#101) AT HER ASSIGNED TABLE, AND THEN LEFT TO ASSIST OTHER RESIDENTS INTO THE DINING ROOM. CNA #7 SAID SHE DID NOT WITNESS THE RESIDENT SPILL THE SOUP. WHEN SHE (#7) RETURNED TO THE DINING ROOM, RESIDENT #101 HAD ALREADY BEEN SERVED HER SOUP IN A HANDLED MUG BY THE DIETARY STAFF. CNA #7 SAID SHE DID NOT KNOW THE RESIDENT HAD SPILLED THE SOUP ONTO HER LAP BECAUSE, ALTHOUGH THERE WAS SPILLED SOUP ON THE TABLE, RESIDENT #101 DID NOT VOICE COMPLAINTS OF PAIN OR OF BEING WET. CNA #7 SAID SHE DID NOT THINK THIS WAS UNUSUAL BECAUSE RESIDENT #101 ALWAYS SPILLED HER FOOD ON HERSELF. THEREFORE, SHE (CNA #7) PROCEEDED TO ASSIST WITH FEEDING OTHER RESIDENTS IN THE DINING ROOM BEFORE SHE RETURNED TO RESIDENT #101. AFTER THE DINNER MEAL, WHEN SHE (#7) BRUSHED THE FOOD PARTICLES OFF RESIDENT #101'S CLOTHING AND LAP AREA, THE RESIDENT SAID, "OUCH, THAT BURNS." CNA #7 SAID THAT RESIDENT #101 WAS WEARING DARK COLORED PANTS AND SHE (#7) DID NOT SEE OR FEEL ANY SIGNS OF SPILLED SOUP ON RESIDENT #101. CNA #7 SAID SHE TOLD LPN #8, THAT RESIDENT #101 COMPLAINED OF PAIN WHEN SHE (#7) TOUCHED HER (#101) LAP AREA. SHE (#7) THEN PLACED HER (RESIDENT #101) WHEELCHAIR IN FRONT OF THE NURSE'S STATION FOR CONTINUED OBSERVATION BY THE NURSE. DURING AN INTERVIEW ON 10/25/11 AT 12:50 P.M., LPN #8 SAID RESIDENT #101 WAS KNOWN TO SPILL FOOD AT ALMOST EVERY MEAL, BUT WAS ASSESSED TO BE INDEPENDENT WITH MEALS BECAUSE SHE COULD STILL FEED HERSELF. LPN #8 SAID THAT RESIDENT #101 USUALLY HAD A BLANKET OR AFGHAN PLACED ON HER LAP DURING MEALS TO PROTECT HER CLOTHING FROM SPILLS. HOWEVER, ON 10/13/11 DURING THE DINNER MEAL, RESIDENT #101 DID NOT HAVE ANYTHING PROTECTING HER LAP AND WORE DARK COLORED PANTS THAT DID NOT SHOW ANY WETNESS OR SPILLAGE FROM THE SOUP. RESIDENT #101 WAS SEATED NEAR THE NURSE'S STATION AFTER THE DINNER MEAL AND DID NOT COMPLAIN OF DISCOMFORT, PAIN OR DISPLAY ANY CHANGES IN HER CONDITION. LPN #8 SAID SHE DID NOT RECALL BEING TOLD THAT RESIDENT #101 HAD SPILLED SOUP ON HERSELF UNTIL AFTER THE BLISTERS WERE DISCOVERED. THE PHYSICIAN AND FAMILY WERE NOTIFIED IMMEDIATELY AFTER THE BLISTERS WERE DISCOVERED AND THE RESIDENT WAS treated for [REDACTED]. DURING AN INTERVIEW ON 10/25/11 AT 2:30 P.M., THE ADMINISTRATOR SAID RESIDENT #101 WAS ASSESSED TO ONLY REQUIRE SUPERVISION DURING MEALS, AND RECEIVED HER SOUP IN A HANDLED MUG TO PROMOTE INDEPENDENCE WITH EATING. THE ADMINISTRATOR COULD NOT EXPLAIN WHY A RESIDENT WHO WAS KNOWN TO SPILL FOOD/SOUP AT EVERY MEAL WAS NOT ASSESSED FOR THE ABILITY TO HANDLE HOT LIQUIDS, OR HAD A CARE PLAN WITH ADDITIONAL INTERVENTIONS TO PROMOTE SAFETY. THE ADMINISTRATOR COULD NOT PRODUCE A FACILITY POLICY, PROTOCOL, OR ASSESSMENT TOOL THAT WAS UTILIZED BY STAFF TO DETERMINE IF A RESIDENT COULD SAFELY HANDLE HOT LIQUIDS. ON 10/25/11 AT 3:00 P.M., THE ADMINISTRATOR SAID THAT AS OF 10/14/11, RESIDENT # 101 NO LONGER RECEIVED SOUP AT HER MEALS, AND UTILIZED A "SNORKEL CUP (TIGHTLY FITTED LID WITH PERMANENT STRAW ATTACHED, LIKE A SIPPY CUP)" FOR LIQUIDS TO PREVENT ANY SPILLAGE. IN REGARDS TO THE TEMPERATURE OF HOT BEVERAGES AND MENU ITEMS SUCH AS SOUP, THE ADMINISTRATOR WENT ON TO SAY THAT THE FACILITY'S KITCHEN STAFF LOGGED THE SOUP TEMPERATURES WHILE STILL IN KITCHEN. THE SOUP WOULD THEN BE TRANSPORTED IN AN INSULATED CART TO THE RESIDENT DINING ROOMS. THE DINING STAFF ARE TO OFFER RESIDENTS THE AVAILABLE MENU ITEMS AND IF SOUP IS SELECTED, A DINING STAFF MEMBER LADLES THE SOUP INTO SHALLOW SOUP BOWLS, OR HANDLED MUGS, AS NECESSARY, AND THEN SERVES IT TO THE RESIDENTS. THE SOUP DOES NOT LEAVE THE KITCHEN AREA UNTIL IT COOLS TO BELOW 175 DEGREES FAHRENHEIT (F), AND THE COFFEE BREWERS ARE SET AT TEMPERATURES NO HIGHER THAN 145 F. A REVIEW OF THE TEMPERATURE LOGS FOR THE KITCHEN REVEALED THE SOUP TEMPERATURES WERE BELOW 180 F BEFORE LEAVING THE KITCHEN AREA. ON 10/25/11 AT 1:00 P.M., THE 2ND FLOOR COFFEE TEMPERATURE WAS MEASURED AT 144 F AND 147 F. THE SOUP TEMPERATURE WAS MEASURED TO BE 163 F. RESIDENT #101 RECEIVED HER BURN FROM SOUP SERVED IN THE 2ND FLOOR DINING ROOM. ON 10/26/11 AT 1:15 P.M., THE 2ND FLOOR COFFEE TEMPERATURE WAS MEASURED TO BE 142 F AND THE SOUP 163 F. ON 10/26/11 A 2:00 P.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 10/13/11 AT 6:00 P.M., AND WAS IDENTIFIED ON 10/25/11, WHEN STAFF FAILED TO PROVIDE FEEDING ASSISTANCE TO RESIDENT #101, AND SHE (#101) SPILLED HOT SOUP ONTO HER LAP CAUSING 2ND DEGREE BURNS TO BOTH HER INNER THIGHS. ON 10/26/11 AT 2:15 P.M., THE SURVEYOR CONFIRMED THAT THE FOLLOWING ACTIONS WERE IMPLEMENTED ON THE DATES INDICATED TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 10/13/11 AT 9:50 P.M., RESIDENT #101 RECEIVED treatment for [REDACTED]. 2. ON 10/14/11 AT THE BREAKFAST MEAL, RESIDENT #101 BEGAN RECEIVING ALL LIQUIDS IN A LIDDED CUP WITH A STRAW. 3. ON 10/19/11, OCCUPATIONAL THERAPY COMPLETED AN ASSESSMENT FOR RESIDENT #101 TO DETERMINE SAFETY WITH HOT LIQUIDS. OCCUPATIONAL THERAPY UPDATED RESIDENT #101'S CARE PLANS TO INCLUDE LIDDED CUPS AND INCREASED ASSISTANCE WITH FEEDING 4. ON 10/20/11, NURSING STAFF COMPLETED SAFETY ASSESSMENT FOR ALL RESIDENTS IN THE FACILITY TO DETERMINE WHO IS 'AT RISK' FOR SPILLING LIQUIDS AND WHO IS ABLE TO SAFELY HANDLE HOT LIQUIDS. FOUR ADDITIONAL RESIDENTS (#102, #103, #104, #105), WERE DETERMINED TO BE "AT RISK" FOR SPILLING LIQUIDS, AND REQUIRED ADDITIONAL SAFETY ASSESSMENT BY THE OCCUPATIONAL THERAPY DEPARTMENT TO DETERMINE INTERVENTIONS. 5. ON 10/20/11, RESIDENT #101 HAD THE FOLLOWING ADDITIONAL INTERVENTIONS ADDED TO HER CARE PLAN TO PREVENT FURTHER INJURY FROM HOT LIQUIDS; LAP BLANKET OVER RESIDENT'S LAP WITH ALL MEALS, SNORKEL CUP AND THE RESIDENT WAS NOT TO RECEIVE SOUP AT MEALS. RESIDENT #101 ALSO HAD HER MEAL TICKETS REFLECT THE NEED FOR THE SNORKEL CUP AND NO SOUP. 6. ON 10/25/11, THE FACILITY'S POLICY AND A SCREENING TOOL FOR ASSESSING RESIDENTS' ABILITY TO SAFETY HANDLE HOT LIQUIDS WAS DEVELOPED AND TRAINING BEGAN IMMEDIATELY. 7. ON 10/25/11, OCCUPATIONAL THERAPY STAFF COMPLETED ASSESSMENTS FOR THE 4 ADDITIONAL RESIDENTS. THE 4 ADDITIONAL RESIDENTS HAD THEIR CARE PLANS UPDATED TO INCLUDE THE FOLLOWING INTERVENTIONS TO PREVENT INJURY FROM HOT LIQUID SPILLS: INCREASED SUPERVISION DURING MEALS, AND LIDDED CUPS OR BUILT UP UTENSILS TO PROMOTE SAFETY DURING MEALS. 8. ON 10/26/11 AT 1:15 P.M., IT WAS OBSERVED THAT ALL 5 RESIDENTS IDENTIFIED TO BE "AT RISK" FOR SPILLING LIQUIDS (#101, #102, #103, #104, #105) HAD THEIR SAFETY INTERVENTIONS IN PLACE (SNORKEL CUP, LIDDED CUP WITH /STRAW, BUILT UP UTENSILS, AND SUPERVISION) FOR THE LUNCH MEAL. 9. AS OF 10/25/11, TRAINING FOR NURSING AND KITCHEN/WAIT STAFF ON THE FACILITY'S NEW "HOT LIQUIDS" POLICY AND SAFETY ASSESSMENT TOOL WAS INITIATED. AS OF 10/26/11, MOST, BUT NOT ALL OF THE NURSING STAFF AND KITCHEN/WAIT STAFF HAD BEEN TRAINED. THE ADMINISTRATOR AND UNIT MANAGER ARE RESPONSIBLE TO ENSURE THAT REMAINING STAFF RECEIVE THE TRAINING PRIOR TO DELIVERING DIRECT CARE TO RESIDENTS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 10/25/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "PATTERN " AND SEVERITY OF "NO ACTUAL HARM, BUT POTENTIAL FOR MORE THAN MINIMAL HARM" BECAUSE ALL FACILITY STAFF HAD NOT BEEN TRAINED ON THE NEW FEEDING ASSESSMENT/SCREENING TOOLS AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )