Every finding on record at Aria Nursing and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 91 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include: On 07/21/2026 at 2:00 P.M., A common area environmental tour was conducted with Housekeeping & Laundry Director (HLD) D. The following items were noted:On 07/21/2026 at 2:10 P.M., The following item was noted within the 2 East Unit:Soiled Utility Room: The return air exhaust ventilation grill was observed heavily soiled with accumulated dust/dirt deposits. (HLD) D indicated she would have housekeeping staff thoroughly clean and sanitize the ventilation grill assembly as soon as possible.On 07/21/2026 at 2:20 P.M., The following item was noted within the 2 [NAME] Unit:Soiled Utility Room: The return air exhaust ventilation grill was observed moderately soiled with accumulated dust/dirt deposits. (HLD) D indicated she would have housekeeping staff thoroughly clean and sanitize the ventilation grill assembly as soon as possible.On 07/21/2026 at 2:30 P.M., The following items were noted within the 3 [NAME] Unit:Janitor Closet: The perimeter wall/floor coving strip was observed missing. The missing coving strip measured approximately 4 feet long. The perimeter wall/floor coving strip was also observed loose to mount. (HLD) D indicated she would contact maintenance for necessary repairs as soon as possible.Soiled Utility Room: 1 of 2 overhead clear plastic light lens covers were observed cracked and broken.On 07/21/2026 at 2:47 P.M., An interview was conducted with Housekeeping & Laundry Director (HLD) D regarding the facility maintenance work order system. (HLD) D stated: We have the (name of the electronic maintenance monitoring) software system.On 07/21/2026 at 4:30 P.M., An environmental assessment of resident room [ROOM NUMBER] was conducted. The resident room was observed soiled and in disarray (paper wrappers, food residue, portable bedside commode with aromatic human liquid (urine) and solid (feces) waste within catch basin, etc.) The bed linen sheets (flat and fitted) were also observed soiled and stained with feces and urine. The restroom commode was additionally observed plugged and would not flush. The restroom hand sink basin was further observed draining slowly. The Portable Terminal Air Conditioning (PTAC) Unit was additionally observed non-functional. A temporary portable air conditioning unit was also observed functioning providing cool air to the room.On 07/22/2026 at 9:35 A.M., A common area environmental tour was conducted with Maintenance Director (MD) E. The following items were noted:On 07/22/2026 at 9:40 A.M., The following items were noted within the 1 East Unit:Dining Room: The one-half inch quarter round base shoe was observed loose-to-mount. The damaged quarter round base shoe measured approximately six feet long. (MD) E indicated he would perform necessary repairs as soon as possible.Occupational/Physical Therapy: The microwave oven interior surface was observed (pitted, stained, corroded, etched). The interior surface was also observed yellowed and darkened from extensive use. (MD) E stated: I will remove and replace the microwave today.On 07/22/2026 at 9:50 A.M., The following items were noted within the 2 [NAME] Unit:Shower Room: The shower stall ceramic tile flooring surface was observed missing 24 tiles. The damaged flooring surface measured approximately 3-inches-wide by 5-feet-long. (MD) E stated: Corporate told me the shower room is going to be completely remodeled soon.Oxygen Room: The flooring surface was observed to be soiled with dust/dirt deposits and debris (plastic port covers, paper tags, etc.).On 07/22/2026 at 10:00 A.M., The following items were noted within the 3 [NAME] Unit:Shower Room: The commode base was observed loose-to-mount. The commode support assembly and seat were also observed loose-to-mount. The commode support assembly could be moved from side to side approximately 4-6 inches. (MD) E indicated he would perform necessary repairs as soon as possible.Dining Room: Two 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained and warped from previous moisture exposure. 2 of 2 return-air exhaust ventilation grills were also observed soiled with accumulated and encrusted dust/dirt deposits.Resident room [ROOM NUMBER] was observed in complete disarray. Paper candy wrappers and empty food cardboard boxes were observed resting directly on the flooring surface. The bed sheet (fitted) was observed threadbare and heavily soiled/stained with human waste and liquid urine. The bedside commode was further observed partially full of aromatic human solid (feces) and liquid (urine) waste.On 07/24/2026 at 10:00 A.M., Record review of the Policy/Procedure entitled: Maintenance Department dated 9/19/2024 revealed under Policy: To assure proper maintenance of the physical plant.On 07/24/2026 at 10:15 A.M., Record review of the Policy/Procedure entitled: Housekeeping Services dated 7/8/2025 revealed under Policy: To promote a sanitary environment: (II) Routine Cleaning of Horizontal Surfaces: (A) In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs.On 07/24/2026 at 10:30 A.M., Record review of the Electronic Maintenance Monitoring Software System work orders for the last 90 days revealed no specific entries related to the aforementioned maintenance concerns.

This citation pertains to intake 3047057. Based on observation, interview, and record review, the facility failed to provide bath/showers for one Residents (#2) of three Residents reviewed. and six out of seven residents during confidential group meeting reported not receiving regularly scheduled showers.Findings Included: Resident #2 (R2) Review of the medical record revealed R2 was admitted [DATE] with diagnoses that included thrombocytopenia (low blood platelet count), monoclonal gammopathy (blood disorder abnormal plasma cells), neuromuscular dysfunction (impairment of the peripheral nervous system), bladder dysfunction, visuospatial deficit (brain disorder affecting depth perception, spatial orientation, and object recognition), protein calorie malnutrition, muscle wasting, chronic obstructive pulmonary disease (COPD), aftercare following surgery on digestive system, chronic kidney disease, Neoplasm (abnormal growth) of ascending colon, congestive heart failure (CHF), and ventral hernia without obstruction or gangrene. Review of R2's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/23/2026, revealed a Brief Interview for Mental Status (BIMS) of 8 (moderate cognitive impairment) out of 15. Section GG- Functional Abilities, of the MDS with the same ARD, revealed R2 is dependent on shower/bathing. During observation and interview on 07/23/2026 at 10:07 a.m. R2 was observed sitting in her wheelchair in her room. R2 explained that she was scheduled to receive showers on Sunday and Tuesday of each week. R2 explained that she has not being receiving her showers at least twice per week. R2 could not recall the last time that she had received a shower. Review of R2's medical record revealed Point Of Care task entitled Task; Shower/Bathing- Did the resident received a shower/bath/bed bath?. Review of task for the shower/bathing task revealed yes on 07/09/2026 and no on 07/02/2026. Other dates 06/25/2026, 06/29/2026, 07/13/2026, 07/20/2026 were documented as not applicable. No other dates were listed for shower/bathing. During an interview on 07/23/2026 at 10:13 a.m. Certified Nuse Aide (CNA) S explained that resident showers are performed on the days shift and the afternoon shift. CNA S explained that resident showers are listed in a notebook, which is located at the nurse's station. CNA S explained once a shower is completed staff would complete a document titled Skin Monitoring: CNA Shower Sheet. CNA S explained that the sheet would be delivered to the nurse when completed. CNA S also explained that shower/baths were to be documented in the resident's computerized chart, entitled POC- Plan Of Care Task. Certified Nurse Aide (CNA) S explained that she had been taught that not applicable was not to be charted. During an interview on 07/23/2026 at 10:24 a.m. Director of Nursing (DON) B explained that it was her expectation that residents received a shower/bath at least twice per week. DON B explained that Certified Nurse Aides (CNA) would review the shower book, which is located at the nurse's station. DON B explained that once a shower is given the CNA would complete a Skin Monitoring: CNA Shower Sheet and turn those sheets into the Nurse responsible for that resident. DON B explained that those sheets are then turned into herself. DON B could not answer if the showers were being monitored for completion. DON B explained that it was the expectation that the staff nurse would complete a progress note if a resident did not have a shower completed. DON B provided a shower notebook that list R2's was to have showers completed on the day shift Sunday and Tuesday. DON B reviewed R2's documented shower task and confirmed, during the last 30 days of documentation, R2 had only received two showers/baths in the 30-day period. DON B could not explain why R2 had not received showers/bathing at least twice per week. DON B explained that she would attempt to locate R2's Skin Monitoring: CNA Shower Sheet that should have been documented on shower/bath days. On 07/23/2026 at 10:55 a.m. Director of Nursing (DON) B provided one Skin Monitoring: CNA Shower Sheet, dated 07/02/2026. DON B was unable to provide any documentation as to why R2 had not received her shower/bath at least twice per week. During the confidential group meeting held on 7/22/26 at 1:00 PM 6 of 7 of the group participants reported they do not receive regularly scheduled showers. One resident reported they were to receive a shower and have their bed linen changed twice a week but would like to have this done three times a week. Other residents openly chuckled at this, stating they can't even get the two showers on a weekly basis let alone three times a week. The group participants reported this is not a new problem and despite complaints made they still can't get showered routinely. Residents did not understand why they were only allowed two showers a week. On 07/24/2026 at 10:21 AM during an interview with Activity Director N who assists in running the monthly Resident Council meetings, acknowledged the list of ongoing and unresolved concerns including residents not getting showers. Activity Director N stated this has been discussed on a routine basis. On 07/24/2026 at 10:50 AM, during an interview with Nursing Home Administrator (NHA) A she reported she had been the NHA since April of this year and could not account for any information prior to that and was working on things. On 07/24/2026 at 11:15 AM during an interview with the Director of Nursing (DON) B she reported being the DON for one week but was employed at the facility prior to becoming DON and was aware of the concerns brought forth by Resident Council members and reported a teaching session was done with staff in May 2026 on customer service. When queried if she was aware that this was still an issue, DON B stated yes.

Based on observation, interview and record review, the facility failed to follow professional standards for insulin administration for R76, during medication administration observation. Findings include:On 7/24/26 at 8:10 AM, LPN Y was observed preparing R76's insulin. LPN Y dialed the insulin pen to the prescribed 28 units without priming the insulin needle first. LPN Y verbally confirmed her action of dialing the insulin pen to 28 units and then was observed administering R76's insulin without priming the needle. On 7/24/26 at 8:23 AM, LPN Y was asked if the insulin pen needles should be primed before administering the prescribed dose to the resident, LPN Y was unsure what priming meant and stated she didn't think so. On 7/24/26 at 10:58 AM, during an interview with Director of Nursing (DON) B, she reported that the expectation for insulin administration with an insulin pen was that the needle be primed with 2 units prior to dialing up and administering the prescribed dose. According to The Cleveland Clinic website (https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections), when using an insulin pen you should wipe the rubber stopper with an alcohol wipe. Attach a new pen needle to the insulin pen.Prime the insulin pen. Priming means removing air bubbles from the needle. It ensures that the needle is open and working. You must prime the pen before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears. Select the dose of insulin that has been prescribed for you by turning the dosage knob.

Based on observation, interview and record review the facility failed to follow infection control standards during medication administration observations. Findings include:On 7/24/26 at 8:08 AM LPN Y was observed exiting a resident room with a glucometer that she reported to have just used to test a resident's blood sugar. LPN Y was observed placing the used glucometer on the prep surface of the medication cart without disinfecting it first. When asked the typical process for disinfecting a glucometer, she reported they use a bleach wipe. LPN Y was then observed using a Super Sani-Cloth Germicidal Disposable Wipe to clean the glucometer, then wrapped the glucometer in the wipe, placed it in a plastic cup and placed it in the top drawer of the medication cart. LPN Y was then observed prepping an insulin pen for administration. Prior to screwing on the insulin pen needle, LPN Y failed to clean the tip of the pen where the needle connects to the insulin pen. LPN Y was asked if anything should have been done prior to attaching the needle to the pen. LPN Y then removed the first needle, discarded it, cleansed the tip with an alcohol pad and placed a new needle. On 7/24/26 at 10:58 AM, during an interview with Director of Nursing (DON) B, she reported that the expectation is for a used glucometer to be disinfected prior to placing it on the medication administration cart and that an insulin pen would be cleaned prior to placing the insulin needle. A review of the facilities policy titled Glucometer and PT/INR (Prothrombin Time/ International Normalized Ratio-blood tests for clotting) Decontamination updated 4/30/26, documented in part Since glucometers & PT/INRs may be contaminated with blood and body fluids as well as other pathogens, such as would be encountered in contact precautions, this facility has chosen a disinfectant wipe that is EPA (Environmental Protection Agency) registered as tuberculocidal; therefore, it is effective against HIV (human immunodeficiency virus), HBV (hepatitis B virus), and a broad spectrum of bacteria. The glucometer & PT/INR shall be decontaminated with the facility approved wipes following use on each resident. According to The Cleveland Clinic website (https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections), when using an insulin pen you should wipe the rubber stopper with an alcohol wipe. Attach a new pen needle to the insulin pen.

This citation pertains to intake #2986758 Based on observation, interview, and record review, the facility failed to develop fall interventions and implement fall interventions for one (R30) out of three reviewed for fall care plans. Findings include:Review of the medical record reflected R30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle wasting and atrophy, Aspasia following cerebral infarction (stroke). The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/29/26, reflected R30 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 6/10/26 at 12:51 pm, R30 was observed seated in a wheelchair in the dining room with both feet resting on the foot pedals. The wheelchair did not have anti-tippers in place. During an interview conducted at the same time, R30's Family Member J reported that R30 had experienced falls at the facility, including one that resulted in a bump to his forehead. Review of an incident report dated 3/22/26 revealed that R30 sustained a fall in the therapy room after pushing backward while seated in his wheelchair, causing the wheelchair to tip backward.The care planned intervention for this fall, per R30's Fall care plan stated, Anti tippers applied to wheelchair with an initiation date of 03/24/2026.In an observation on 6/11/26 at 8:05 am, R30 was observed in bed. R30's call light was draped over his bedside table, out of R30's reach. Review of R30's Fall care plan indicated the following; Put the call light within reach and encourage him to use it for assistance as needed with an initiation date of 03/13/2026.Review of an incident report dated 4/16/26 at 6:05 am revealed that R30 was found sitting on the floor beside the bed with a laceration above his lip.Review of R30's Fall care plan revealed no added intervention were implemented after the 4/16/26 fall. In an interview on 6/11/26 at 11:43 AM, Director of Nursing (DON) B reported that she had recently taken over the position of DON at the facility. DON B stated that the process for falls that she would be implementing would be for nursing staff to put in an immediate intervention after a resident sustains a fall, which is something she is providing ongoing education for. DON B stated that the expectation for care planned intervention would be that that staff follow the interventions that are put into place as stated on the care plan.

Based on observation, interview, and record review the facility failed to timely obtain diagnostic imaging following a residents fall in one (Resident #50) out of 3 reviewed for falls resulting in the delay in treatment for a left wrist fracture, uncontrolled pain, and loss of function. Findings include: Review of the medical record reflected R50 was admitted to the facility on [DATE], with diagnoses that included repeated falls. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/27/26, reflected R50 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 6/10/26 at 11:18 AM, R50 was observed being wheeled out of her room by a Certified Nursing Assistant. R50 had a purple cast on her left arm. Review of a Nurses Note dated 5/21/2026 9:46 PM, CNA (certified nursing assistant) informed writer at 2015 (8:15 pm) that resident (R50) was observed on the floor of her room. Upon entering room, writer observed resident sitting on her buttocks in front of the closet. The bathroom door was open, and the resident's personal walker was in the bathroom. She had previously requested to use it and was notified that therapy needed to evaluate her first and to ask for assistance prior to transferring. Resident verbalized understanding of these instructions .Resident c/o (complaining of) pain in left wrist rated 9/10 using numeric scale. Left wrist is swollen, discolored, and noticeably misaligned. provider contacted, images of resident's wrist sent with incident details. Provider conducted video call, and sent orders for xray, and pain medication. The resident remains in the dayroom for close supervision. Review of a Provider note dated 5/21/26 at 9:01 PM revealed Nursing reports resident was ambulating without assist and fell causing pain and swelling to left wrist with decreased ROM (range of motion) .Left wrist has obvious swelling/deformity noted. Nursing reports resident reports it is sore and hurts to move .She has tylenol scheduled TID (three times a day) but hasn't received tonight yet Ibuprofen 600mg PO Q6H x 2 days for pain/swelling. STAT XR Left hand/wrist/arm up to elbow. Review of Physician orders reveal an order dated 5/22/2026 at 00:47 x-ray of left hand, wrist, forearm up to elbow STAT for pain, swelling. The order for a stat x-ray was entered nearly four hours after the Physicians verbal order for the stat x-ray. Review of a Nurses Note dated 5/22/2026 at 07:02 stated at 6:30 am this writer telephoned [x-ray company] x-ray regarding x-ray dispatcher stated that tech would arrive at facility within 30 min, this writer went into resident's room to assess resident's wrist and hand (L) wrist swollen resident unable to move writst [sic] this writer telephoned Np (Nurse Practitioner) regarding time of x-ray and resident unable to move wrist new order received to transfer resident to hosptial [sic]. On 6/11/26 at 8:18 am, R50 was observed in her room in room. R50 recalled the details of the fall stating that she was instructed to use her call light, however, took herself to the bathroom and sustained a fall on her way out of the bathroom. R50 confirmed that she received Tylenol for pain after the fall, however, did not get sent out to the hospital until the next morning and her arm hurt like hell all night. R50 confirmed that her left wrist was fractured as a result of the fall. In an interview on 6/11/26 at 12:00 PM, Director of Nursing (DON) B stated that the expectation for a stat x-ray would be to have it completed within 4 hours. DON B acknowledged that there was a delay in obtaining the x-ray and explained that the nurses did not communicate the need for a stat x-ray order during shift change. Both nurses received education relating to the expectation of communication during shift change.

This citation pertains to intake 2795386 and 2803405.Based on observation, interview and record review, the facility failed to protect R2's right to be free from physical abuse by R6 and R4's right to be free from verbal abuse by staff. Findings Include:R2:Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included multiple sclerosis and epilepsy (seizure disorder). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/2/26, reflected R2 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had upper and lower extremity (arms and legs) impairments on both sides that interfered with daily functions or placed them at risk of injury in the last seven days.On 3/25/26 at 4:25 PM, R2 was observed seated in a wheelchair, in the day room. R2 was assisted to her room, by staff. R2 alleged that approximately three weeks prior, in the day room, R6 was intoxicated and choked her. R2 alleged R6 then slapped her on the left arm really hard, which left red marks. R2 reported prior to the alleged incident, R6 had been talking in a normal tone. R2 reported R6 used one hand to choke her, grabbing the front of her neck, and she was unable to breathe. R6:Review of the medical record reflected R6 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included thyrotoxicosis and atrial fibrillation. The admission MDS, with an ARD of 1/5/26, reflected R6 scored 12 out of 15 (moderate cognitive impairment) on the BIMS.On 3/26/26 at 10:52 AM, R6 was observed seated in his wheelchair, in the hallway. R6 self-propelled his wheelchair back to his room. R6 reported knowing R2, stating R2 called the police and pressed charges. R6 stated, I guess I smacked her. R6 stated he had been drinking beer at a family member's house before being dropped off at the facility. R6 stated he did smack R2's arm but did not remember doing it. R6 stated it was an open-hand smack, from what he was told. R6 denied putting his hands on any other part of R2's body, including her neck. A facility investigation reflected that on 2/26/26 at approximately 8:00 PM, in the first-floor day room, R6 hit R2 on the left arm. R2 was noted to have a red mark on her left upper arm. According to the investigation, R6 appeared intoxicated at the time of the alleged incident and had an open can of beer next to him, in his wheelchair. Registered Nurse (RN) E was at the medication cart, just outside the day room when she heard a noise that sounded like a slap, and R2 called out. R2 stated R6 had just hit her on the arm. RN E noted that R6 was in his wheelchair, next to R2, at the time. Certified Nurse Aide (CNA) F was standing in the day room, with his back to the R2, when he heard a slapping noise and R2 call out. CNA F turned and saw R6 sitting next to R2. In a phone interview on 3/26/26 at 8:34 AM, RN E reported while passing medications, she heard a slap-like sound and heard R2 say ouch. RN E reported she ran into the day room. According to RN E, she could see on R2's face that she was hurt, and there was mild redness on her left arm that night. R6 had been dropped off at the facility by a family member and was noted to be intoxicated, according to RN E. She reported catching R6 drinking alcohol a couple minutes before hearing the slap-like sound. RN E stated R2 had been talking to another male resident, which R6 was watching and did not like. When the other male resident went outdoors to smoke, R6 approached R2. She reported CNA F was in the day room at the time of the interaction but was not facing the residents. According to RN E, R2 did not allege that R6 grabbed her around the neck or attempted to choke her. CNA F was unable to be reached for an interview during the onsite survey. According to the facility's investigation, resident to resident physical abuse, as a result of R6 hitting R2 in the left upper arm, was substantiated. Per R6's own admission, he had been drinking beer prior to returning to the facility and did not recall the incident. The investigation reflected the allegation of choking could not be substantiated. R4:Review of the medical record reflected R4 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic diastolic (congestive) heart failure, diabetes and unspecified dementia. The Quarterly MDS, with an ARD of 3/3/26, reflected R4 scored seven out of 15 (severe cognitive impairment) on the BIMS. According to a facility investigation, on 2/5/26, former Nursing Home Administrator (NHA) K self-reported that staff alleged he yelled/raised his voice at a resident. According to the facility's investigation, the interview with former NHA K reflected it had been reported to former NHA K that R4 had taken another resident's wallet, with money in it. The nurse and CNAs tried to get the wallet from R4, but he would not allow it. It was reported R4 was in his room, hollering, swearing and making a big commotion, and staff needed former NHA K to go see R4. Social Services Assistant (SSA) C, former NHA K and Scheduler G entered the room of R4, who was upset, cursing and hollering at the top of his voice, according to the investigation. R4 kept saying it was his money. After trying to get R4 to speak with staff, and his constant hollering, former NHA K raised his voice at R4 and said, [R4] quit hollering, we don't need to be hollering. According to the statement, that calmed the situation enough so staff could continue. Scheduler G asked R4 about the wallet, and R4 said it was his wallet, his money, and he had it for a long time. According to the investigation statement, two CNAs were asked to enter the room due to being familiar with R4. The statement reflected former NHA K opened the wallet, removed $24, which he counted in front of SSA C. R4 stated it was his f**king money. Former NHA K gave R4 the money, which he put in his pocket. According to the investigation, it was in fact R4's wallet that was in his possession. In an interview on 3/25/26 at 11:10 AM, Scheduler G reported that during the interaction pertaining to the wallet, R4 was swearing at former NHA K and calling him a mother f**ker. Scheduler G reported former NHA K turned around and called R4 a mother f**ker. Scheduler G reported she grabbed former NHA K's arm and tried to guide him out of the room, twice. In an interview on 3/25/26 at 11:33 AM, CNA H reported observing the interaction between former NHA K and R4 from the doorway of R4's room, pertaining to the wallet. CNA H stated R4 called former NHA K a name. Former NHA K got in R4's face, pointed, told R4 he was not going to talk to him like that, then called R4 a mother f**ker. CNA H stated former NHA K seemed mad, and his face turned red. In a phone interview on 3/25/26 at 1:05 PM, former NHA K denied using profanity or calling R4 names. NHA K denied being frustrated during the interaction with R4 and just raised his voice to stop R4 from hollering. In a phone interview on 3/25/26 at 2:42 PM, CNA I reported directly witnessing the interaction between former NHA K and R4 pertaining to a wallet. CNA I stated she could not recall all of what was said, but former NHA K definitely called R4 a mother f**ker. On 3/25/26 at 1:40 PM, R4 was observed sitting in a wheelchair, in his room. When queried about his recollection of an incident involving a wallet, R4 stated I had it, and the man thought I stole it. R4 reported swearing at the man, who then came back and swore at him. When describing the interaction, R4 began raising his voice. R4 reported he forgot what the man said to him but reported cussing words were used towards him. When asked if he was called any names, R4 stated, cussing words .

This citation pertains to intake: 2717790Based on observation, interview and record review the facility failed to: 1.) ensure the safety, and 2.) implement care-planned interventions during staff assisted care in 1 of 3 sampled residents (Resident #102) reviewed for falls, resulting in R102 fall from elevated bed during care, where R102 required immediate transport to the hospital related to significant leg laceration, 24 sutures, and pain.Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R102 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included chronic heart failure, diabetes, morbid obesity, major depression and anxiety disorder. The MDS reflected R102 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she was dependent on staff for toileting, dressing, bathing and rolling left and right in bed.During a telephone interview on 1/30/26 at 1:58 p.m., Certified Nurse Aid (CNA) C reported was working on 1/9/26 around 6:00 a.m. when R102 fell out of bed. CNA C reported was alerted that R102 had fallen out of bed by CNA D. CNA C reported arrived to R102 room and observed R102 face down next to elevated bed, about hip height, with right lower leg that appeared split open and bleeding. CNA C reported R102's leg wound was larger than size of open hand and R102 was complaining of back and leg pain. CNA C reported CNA D had told CNA C she was assisting R102 with incontinence care and R102 rolled out of bed during care. CNA C reported R102 was alert and oriented and able to make needs known. CNA C reported was unsure of R102 care needs at the time of the fall and reported was not assigned to R102 but reported staff are expected to follow the Kardex.Review of R102's Nursing Progress Note, dated 1/9/26 at 7:12 a.m., reflected, Nurse and CNA were in the dayroom when another CNA urgently asked for help. Upon arrival at resident's room, the resident observed lying face down on the floor to the left side of her bed with blood pooling under her right knee. 911 was called at 0605, Paramedics arrived at 0615, Patient rolled into Hoyer sling after initial first aid was performed by paramedics.Review of R102's Nurse Progress Note, dated 1/10/26 at 2:35 p.m., reflected, Resident was transferred to hospital following a fall from bed on 1/9/26, and returned on the afternoon of 1/9/25 following care for laceration of right leg sustained during the fall.Review of R102's Nurse Progress Note, dated 1/11/26 at 3:55 p.m., reflected, Hospital DC [discharge] instructions for care of right lower leg wound transcribed. DC instructions indicate that the resident has had drains placed inside the wound in order to prevent collection of fluid which could lead to infection. Clarification for removal of internal drains in wound will be addressed by the providers. Drains are not visible The laceration is located on the lateral aspect of the right lower leg from knee level to mid calf area, and measures 112 cm L x 0.2 cm W. There are 24 intact sutures present. Scant amount of serosanguineous drainage present during dressing change noted. Periwound intact with mild bruising present. The area is tender to touch.Review of R102's Nurse Progress Note, dated 1/27/26, reflected, Resident continue on Clindamycin HCl[antibiotic] Capsule 300 MG every 8 hours for cellulitis[infection] for 10 Days.During an interview on 2/4/26 at 9:25 a.m. Nursing Home Administrator (NHA) A reported the facility completed a Facility Reported Incident for R102's fall on 1/9/26. This surveyor requested the complete investigation for review. During an interview and record review on 2/4/26 at 9:35 a.m. NHA A provided a folder and verified was the complete investigation for R102 fall on 1/9/26.Review of R102 Care Plans, dated 1/2/26, reflected, [named R102] has a functional ability deficit and requires assistance with self care/mobility R/T[related to]: morbid obesity, weakness with need for assist with safe transfers.BED MOBILITY: Resident is Dependent This is including rolling side to side, lying to sitting on side of bed and sitting to lying. 2 person assist.Review of R102 Medication Administration Record, dated 12/1/25 through current, reflected increased use of narcotic pain control and anxiety medications after R1/9/26 fall.During a telephone interview on 2/4/26 at 1:01 p.m., Certified Nurse Assistant (CNA) D reported R102 fell out of bed while she was assisting R102 with incontinence care. CNA D reported had rolled R102 away from her and R102 fell out of bed, that was between knee and hip height, and began screaming of pain in right leg. CNA D reported immediately alerted nurse and other staff of fall. CNA D reported completed written witness statement and received education to follow Kardex and to roll residents towards not away during care. CNA D reported R102 Kardex indicated one assist with hygiene prior to fall so thought R102 only required one assist. During an interview on 2/4/26 at 2:40 p.m., NHA A again verified facility had provided this surveyor with complete investigation of R102 fall on 1/9/26 and he did not have any written witness statements. Director of Nursing (DON) B was present and reported had additional documents and would provide. During an interview and record review on 2/4/26 at 2:48 p.m., DON B provided Past Non-Compliance binder for R102 fall with alleged compliance date of 2/6/26(after current date 2/4/26 with no time of compliance). DON B reported the facility failed to follow the Care Planned interventions that led to R102 fall with injury. DON B reported that was the complete investigation and verified did not include any written statements. During a telephone interview on 2/4/26 at 3:03 p.m., Licensed Practical Nurse (LPN) E reported was working morning of 1/9/26 when R102 had fallen from the bed but was working on a different unit. LPN E reported was alerted of R102 fall and entered R102 room and observed R102 face down on floor next to the bed that was about waist height. LPN E reported CNA D had reported R102 had fallen out of bed while providing care to R102 with one assist. LPN E reported CNA D had reported R102 was assist of one with bed mobility and reported did not verify. LPN E reported educated CNA D to always roll residents toward self and not away during care. LPN E reported observed blood on floor but was unsure where it was coming from and advised staff to make R102 comfortable on the floor and Emergency Services were called and arrived quickly. LPN E reported R102 was complaining of leg pain. During an observation and interview on 2/4/26 at 3:30 p.m., R102 was lying in bed with lights off and door partially open and appeared calm, pleasant and well groomed. R102 pleasantly declined to speak of fall and requested to allow her to rest. During an interview on 2/4/26 at 3:45 p.m., DON B reported would expect staff to follow Care Plans and Kardex. DON B reported R102 fall occurred on 1/9/26 and had intervention added to Care Plans 1/2/26 for two person assist with bed mobility because had increase difficulty with one person mobility in bed. DON B reported would expect staff to check prior to care and would also expect if providing care to residents in bed with one person assist would expect staff to roll residents towards them and not away.

This citation pertains to intake: 2722185Based on observation, interview, and record review the facility failed to prevent significant medication errors for one resident (#101) out of three residents reviewed for medication errors. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included insulin dependent diabetes, anxiety and depression. The MDS reflected that R101 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact.Review of the complaint submitted to the State of Michigan, dated 1/21/26, reflected the facility allegedly failed to administer insulin according to the physician orders.Review of the Electronic Medical Record on 1/30/26 reflected that R101 was not currently at the facility and had been hospitalized .During a telephone interview on 1/30/26 at 3:58 PM, R101 daughter F reported was very unhappy with care at the facility and verified had received several calls from the facility including insulin medication error and several recent admissions to the hospital. R101 daughter F reported R101 was currently at admitted to hospital related to urinary tract infection. During a telephone interview on 1/30/26 at 4:25 PM, Registered Nurse (RN) G reported R101 did have insulin error and RN G reported had accidentally given fast acting insulin instead of long acting and reported to DON immediately. RN G reported received education after incident and R101 was transferred to the hospital with no negative outcome.Review of R101 Nurse Progress Note, dated 11/5/25 at 7:47 PM, reflected, Resident returned back to facility via stretcher and 2 EMS[Emergancy Medical Service] at 1935 [7:35 p.m.]. EMS reports resident blood glucose never dropped below 100 and was uneventful. Per paperwork no changes to medications or new orders. Resident request this RN report to daughter [named] that she had returned back to the facility. Resident is happy to be home.Review of R101 Physician Note, dated 11/6/25, reflected, Chief Complaint / Nature of Presenting Problem: DM [Diabetes Mellitus] Emergency department evaluation History of Present Illness: [AGE] year-old female with chronic medical conditions including obstructive sleep apnea, breast cancer, diabetes mellitus type 2, hypertension and cholecystitis who is here for long-term stay. Staff feels patient is overall stable.Staff notes patient is a baseline mentation. Patient feels good no complaints staff notes patient was transferred to the emergency department yesterday after mis-administration of 52 units short acting insulin.During an interview on 1/30/26 at around 5:00 p.m. Director of Nursing (DON) B reported R101 did not have any Incident accident reports and verified had a medication error recently and would follow up with surveyor.During a telephone interview on 1/30/26 at 5:15 p.m., R101 son H reported was currently in the hospital with R101 who was admitted for urinary tract infection with plans to discharge back to the facility with hospice services soon. R101 son H verified R101 had been transferred to hospital in November after large amount of fast acting insulin had been given to R101 instead of long-acting insulin. Review of R101 Medication and Treatment Errors and Omissions document, dated 11/5/25 at 10:00 a.m., provided 1/30/26 at 5:32 p.m., reflected R101 was administered wrong medication and wrong strength/quantity. The document reflected R101 was administered 52 units of Novolog insulin (short acting) instead of long-acting insulin.During an observation and interview on 2/4/26 at 1:45 p.m., R101 was lying in bed with R101 son H at bedside. R101 appeared non-verbal with eyes open but non-responsive to questions. R101 son H verified R101 now has hospice services. During an interview on 2/4/26 at 5:10 p.m., DON B reported R101 would expect staff to follow physician orders including medication orders. DON B reported if a medication error occurs would expect nurse notifies DON along with Physician immediately.

This citation pertains to intake MI00152962 Based on observation, interview, and record review, the facility failed to ensure one resident (R1) was treated with dignity and respect out of five reviewed. Findings include: Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, anxiety disorder, major depressive disorder, and post-traumatic stress disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/16/25 revealed R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R1's Kardex (care guide) revealed R1 required two-person assistance with activities of daily living. The Kardex revealed Approach in a calm, quiet manner. Review of R1's behavior care plan revealed an intervention of approach/speak in a calm manner. On 6/20/25 at 8:23 AM, R1 was observed in bed. R1 reported there was an incident last month where Certified Nursing Assistant (CNA) H used pretty obscene language. R1 reported CNA H stated things such as Why do you wait until the last f*cking minute to get in your chair and I don't play with your mother f*cking ass. R1 reported there was a housekeeper in the hallway who heard the interaction and got help. In a telephone interview on 6/23/25 at 10:26 AM, CNA H reported the day of the incident (5/5/25, R1 called CNA H all types of names including mother f*cker. CNA H reported they responded to R1 by saying I'm not going to be too many more of your mother f*ckers and until you calm down, I'm going to leave. In an interview on 6/23/25 at 11:54 AM, Housekeeper I, with the translation assistance of Activities staff J, reported on 5/5/25, CNA H slammed R1's door and then CNA H was heard inside R1's room very loudly saying f*ck, f*ck, f*ck. Houskeeper I reported they understood the word that was said and knew it was cursing. Housekeeper I reported it was CNA H and not R1 saying those words. In an interview on 6/23/25 at 12:04 PM, Nursing Home Administrator (NHA) A reported the facility determined that CNA H used inappropriate language in the presence of R1 and therefore, CNA H's employment was terminated. Review of the facility's investigation revealed Facility did substantiate that staff member was verbally inappropriate.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported timely to the State Agency for one (R1) of three reviewed. Findings include: Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, anxiety disorder, major depressive disorder, and post-traumatic stress disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/16/25 revealed R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Facility Reported Incident revealed 5/5/25 2p [2:00 PM] Housekeeper hears CNA [Certified Nursing Assistant] saying the words [F*ck] you multiple times in the residents [sic] room while the resident was present in the room. The housekeeper notified the housekeeping supervisor and the administrator of the incident. The Facility Reported Incident revealed the incident occurred on 5/5/25 at 2:00 PM, was discovered on 5/5/25 at 2:15 PM, and was reported to the State Agency on 5/5/25 at 9:23 PM. In an interview on 6/24/25 at 10:31 AM, Nursing Home Administrator (NHA) A agreed the incident occurred on 5/5/25 at 2:00 PM and was not reported to the State Agency until 5/5/25 at 9:23 PM. NHA A did not have an explanation as to why the allegation of abuse was not reported to the State Agency within two hours.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 05/12/25 at 02:50 P.M., A common area environmental tour was conducted with Director of Maintenance (DM) H. The following items were noted: 1 East: CNA Storage Closet: The vanity cabinet kickplate was observed missing. One of two base cabinet door hinges were also observed disconnected, allowing the door to not close evenly. Shower Room: The shower wand assembly was observed missing an atmospheric vacuum breaker. (DM) H stated: I will have one installed. Day Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. Staff Break Room: The Toshiba microwave oven interior was observed (etched, scored, particulate, corroded). (DM) H stated: I am going to throw this out now. Service Corridor: Red Room: The box fan was observed soiled with accumulated and encrusted dust/dirt deposits. The Men's Locker Room: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. 2-West Main Dining Room: Pantry: Three acoustic ceiling tiles were observed (stained, warped) from previous moisture exposure. Shower Room: The commode base seat was observed loose-to-mount. The commode base caulking was also observed (etched, scored, stained). The return-air-exhaust ventilation grill was additionally observed soiled with accumulated and encrusted dust/dirt deposits. On 05/12/25 at 04:15 P.M., An interview was conducted with (DM) H regarding the facility maintenance work order system. (DM) H stated: We have the TELS system. On 05/13/25 at 10:35 A.M., An environmental tour of the facility Laundry Service was conducted with Housekeeping Director (HD) F. The following items were noted: Folding Room: The air supply grill and adjacent wall surfaces were observed soiled with accumulated and encrusted dust/dirt deposits. The folding room flooring surface was observed (etched, scored, stained, particulate). The folding room measured approximately 15 feet-wide by 22 feet-long. Soiled Laundry Room: The flooring surface was observed (etched, scored, stained, particulate). The damaged flooring surface measured approximately 15 feet-wide by 22 feet-long. The automatic door closer was also observed out-of-adjustment, allowing the door closer assembly to contact the entrance door top surface, creating a loud popping noise. (HD) F stated: I will place a work order in (TELS). Par Linen Room: The polyvinyl chloride (PVC) four tier storage rack protective vinyl mesh cover was observed (etched, scored, particulate). (HD) F stated: I will have the cover replaced. 2-West Nursing Station: One fabric cushioned chair was observed soiled with accumulated and embedded dust/dirt deposits. (HD) F stated: I have an upholstery extractor. 3-West Janitor Closet: The flooring surface was observed missing ceramic tile squares. The damaged and missing tile flooring measured approximately 12-inches-wide by 48-inches-long. (HD) F stated: The flooring tile has been missing since I started (6/2022). On 05/13/25 at 01:25 P.M., A common area environmental tour was continued with (HD) F. The following items were noted: 2-East Shower Room: 2 of 2 shower wand assemblies were observed missing an atmospheric vacuum breaker. (HD) F indicated she would place a work order into the TELS software system. Floor Pantry: Three acoustic ceiling tiles were observed (etched, scored, stained) from previous moisture exposure. Vacant Office: The restroom commode base seat was observed (etched, scored, particulate). (HD) F indicated she would place a maintenance work order into the TELS software system as soon as possible. Day Room: The drywall corner surfaces were observed (etched, scored, particulate). The damaged drywall corner surfaces measured approximately 10 feet-long. The drywall surface, adjacent to the entrance door, was also observed (etched, scored, particulate). The damaged drywall surface measured approximately 12 inches-wide by 5 feet-long. 2 of 2 return-air-exhaust ventilation grills were further observed soiled with accumulated and encrusted dust/dirt deposits. 3-West Unisex Restroom: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. Shower Room: The commode support was observed loose-to-mount. The commode support could be moved from side-side approximately 6-8 inches. The commode seat was also observed loose-to-mount. The commode seat could be moved from side to side approximately 6-8 inches. The hand sink polyvinyl chloride (PVC) drainpipe was additionally observed leaking water, adjacent to the plumbing trap assembly. Day Room: Two acoustic ceiling tiles were observed (stained, warped, etched) from previous moisture exposure. The damaged acoustic ceiling tiles measured approximately 24 inches-wide by 24 inches-long. Laboratory Room: The laboratory specimen refrigerator interior and exterior surfaces were observed soiled with accumulated and encrusted dust/dirt residue. On 05/13/25 at 03:15 P.M., An environmental tour of sampled resident rooms was conducted with (HD) F. The following items were noted: 119: The restroom commode base caulking was observed (etched, scored, stained, particulate). The restroom hand sink was also observed draining very slowly. 212: The restroom commode base caulking was observed (etched, scored, stained, particulate). The Bed 1 overbed light assembly was also observed non-functional. 220: The restroom commode base caulking was observed (etched, scored, stained, particulate). 229: The restroom commode base caulking was observed (etched, scored, stained, particulate). The Portable Terminal Air Conditioning (PTAC) Unit air filters were also observed soiled with accumulated and encrusted dust/dirt deposits. 231: The restroom commode base caulking was observed (etched, scored, stained, particulate). 238: The restroom commode base caulking was observed (etched, scored, stained, particulate). The (PTAC) Unit air filters were also observed soiled with accumulated and encrusted dust/dirt deposits. 319: The restroom commode base caulking was observed (etched, scored, stained, particulate). 322: The restroom commode base caulking was observed (etched, scored, stained, particulate). 324: The (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. The restroom grab bar was also observed loose-to-mount, adjacent to the commode base. 329: The restroom hand sink was observed draining very slowly. 333: The restroom commode base caulking was observed (etched, scored, stained, particulate). 336: The restroom commode base caulking was observed (etched, scored, stained, particulate). The Bed 1 overbed light assembly was also observed non-functional. The Bed 1 overbed light assembly pull string extension was additionally observed missing. On 05/15/25 at 10:15 A.M., Record review of the Policy/Procedure entitled: Housekeeping Services dated 02/28/2025 revealed under Policy: To promote a sanitary environment. (II) Routine Cleaning of Horizontal Surfaces: (A) In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. On 05/15/25 at 11:15 A.M., Record review of the Direct Supply TELS Work Orders for the last 180 days revealed no entries related specifically to the aforementioned maintenance concerns.

Based on observations, interviews, and record reviews, the facility failed to: (1) clean and maintain food service equipment, and (2) date mark potentially hazardous ready-to-eat food products affecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 05/12/25 at 09:13 A.M., An initial tour of the food service was conducted with Dietary Director (DD) E. The following items were noted: The Avantco 2-Door Reach-In Cooler interior light bulb was observed non-functional. (DD) E stated: I will place a work order into (TELS). The Vulcan convection oven(s) interior light bulbs were observed non-functional. The 2022 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. White Refrigerator 1: The interior door gasket and exterior unit top surface was observed soiled with accumulated and encrusted (dust, dirt, food residue). White Refrigerator 2: The interior door gasket and exterior unit top surface was observed soiled with accumulated and encrusted (dust, dirt, food residue). The can opener assembly was observed soiled with accumulated and encrusted food residue. (DD) E indicated she would have dietary staff thoroughly clean and sanitize the can opener assembly as soon as possible. The Vulcan convection oven(s) interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. (DD) E stated: The top unit is cleaned on Saturday morning and the bottom unit is cleaned on Sunday evening weekly. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. One gallon (3/4 full) of [NAME] Select 2% Milk was observed without and effective open or discard date, within the Avantco 2-Door Reach-In Cooler. The container manufacturer's use-by-date was observed to read 5-24-25. One 5-pound container (1/8 full) of Prairie Farms Small Curd Cottage Cheese was observed without an effective open or discard date, within the Avantco 2- Door Reach-In Cooler. The container manufacturer's use-by-date was observed to read 5-5-25. The 2022 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. 20 of 25 overhead clear plastic light lens covers were observed soiled with accumulated and encrusted (dust, dirt, debris). (DD) E indicated she would place a work order into the TELS software system as soon as possible. 2 of 2 ceiling mounted return-air-exhaust ventilation grills were observed soiled with accumulated and encrusted dust/dirt deposits. The mechanical dish machine ventilation hood return-air-exhaust grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The 2022 FDA Model Food Code section 4-602.13 states: NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. On 05/15/25 at 11:30 A.M., Record review of the Policy/Procedure entitled: Dietary Cleaning and Sanitation dated 11/12/2021 revealed under Policy: It is the policy of this facility to maintain the sanitation of the kitchen through proper cleaning and sanitizing stationary food service equipment and food contact surfaces to minimize the growth of microorganisms that may result in food contamination. On 05/15/25 at 11:45 A.M., Record review of the Policy/Procedure entitled: Food Handling and Production dated 11/12/2021 revealed under Policy: It is the policy of this facility to comply with strict time and temperature requirements and use proper food handling techniques to prevent foodborne illness. Record review of the Policy/Procedure entitled: Food Handling and Production dated 11/12/2021 further revealed under Procedure: (1) The kitchen and equipment will be maintained in a clean, neat, and orderly manner to minimize bacteria formation and food contamination.

Based on observations, interviews, and record reviews, the facility failed to: (1) maintain 2 of 3 outdoor waste receptacles, and (2) clean the outdoor waste receptacle concrete pad surface affecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and pest attraction/harborage. Findings include: On 05/12/25 at 09:13 A.M., An initial tour of the food service was conducted with Dietary Director (DD) E. The following item was noted: On 05/12/25 at 10:40 A.M., The outdoor waste receptacle concrete pad was observed with accumulated dirt and debris (paper products, plastic bottles, plastic milk crate, wooden pallet, etc.). 1 of 4 receptacle plastic lids were also observed missing. 1 of 4 receptacle slider panels were additionally observed broken. The damaged slider panel contained a hole measuring approximately 6-inches-wide by 6-inches-long. (DD) E indicated she would place a work order into TELS as soon as possible. On 05/15/25 at 10:00 A.M., Record review of the Policy/Procedure entitled: Housekeeping Services dated 02/28/2025 revealed under Policy: To promote a sanitary environment. VII. TRASH (A) Trash will be removed from all areas on a specific schedule to prevent spillage and odors. (B) The area surrounding the dumpster will be kept free of debris. When transporting garbage to the dumpster staff will ensure the area is clean and free of debris. On 05/15/25 at 11:00 A.M., Record review of the Direct Supply TELS Work Orders for the last 180 days revealed no entries related specifically to outdoor waste receptacles and/or the concrete pad surface.

Based on observation, interview, and record review the facility failed to inform one resident (46) of five residents' benefits, risks, and alternatives for the prescribing of psychotropic medication. Findings Included: Resident #46 (R46) Review of the medical record revealed R46 was admitted to the facility 10/12/2024 with diagnoses chronic kidney disease, muscle weakness, atrial fibrillation, thoracic aorta aneurysm, congestive heart failure (CHF), gastro-esophageal reflux disease, sleep disorder, restless leg syndrome, depression, anxiety, chronic pain, mitral valve insufficiency, anemia (low red blood cells count), osteoarthritis, history of myocardial infarction (heart attack), peripheral vascular disease (PVD), chronic obstructive pulmonary disease (COPD), bipolar disorder, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/27/2025, revealed R46 had a Brief Interview of Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. Review of R46's medical record demonstrated a physician order, written 04/23/2025, Olanzapine Oral Tablet Disintegrating 5mg (milligrams) one time per day. Review of MedlinePlus ,at medlineplus.gov, Olanzapine is an antipsychotic medication that may be used to treat bipolar disorder (manic depressive disorder). R46's medical record did not demonstrate any consent documents or information that R46 or his responsible party was informed of the risk or benefits for the use of the antipsychotic Olanzapine. In an interview on 05/13/2025 at 02:52 p.m. Social Worker (SW) O explained that it was her responsibility to review all the orders for psychotropic medication. She explained that she would review the psychotropic medication order to ensure that it contained the appropriate diagnoses, the appropriate monitoring for side effects, behavior monitoring for the targeted behavior, and make sure that the residents or their responsible party had been provided with a consent document explaining the risk and benefits of using the psychotropic medication. SW O was asked to review R46's medical record and provided a consent for the use of Olanzapine (antipsychotic medication). SW O could not provide a consent or any documentation demonstrating that R46 or his responsible party had been given information regarding the risk of benefits of using Olanzapine. SW O could not explain why consent had not been obtained for the use of Olanzapine. In an interview on 05/13/2025 at 03:37 p.m. Director of Nursing (DON) B explained that it was her expectation that the Social Worker reviewed the medical record of Residents that are prescribed an antipsychotic medication. DON B explained that a consent would be obtained that explained the risk and benefits for the use of the antipsychotic medication ordered. DON B confirmed that a consent was not present for the use of Olanzapine (antipsychotic medication) in R46's medical record. During observation and attempted interview on 05/15/2025 at 11:25 a.m. R46 was observed sitting up on the side of his bed. R46 explained that he had just returned from the hospital, where he had been since 5/12/2025, related to a recent fall. R46 could not provide an answer as to why he was currently receiving antipsychotic medications but did explain that he had a history of depression. Review of facility policy Psychoactive Medication Management, dated 07/01/1014 and last revised 04/22/2025, revealed Procedure #6. Before initiating or increasing psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.

Based on interview and record review, the facility failed to act promptly on grievances reported in resident council meetings and provided responses to grievances in 6 of 9 residents, as reported during a confidential resident council interview, in a total sample of 18 residents and a total census of 83 residents, resulting in unresolved resident concerns, frustration and decreased quality of life. Findings include: A record review of the past six months of resident council meeting minutes revealed concerns/grievances that were not addressed and resolved. Complaints go from month to month with a lack of documentation to reflect that the problem was resolved. This writer reviewed grievances from January 2025 to the current time of survey. Grievance forms were not filled out completely to reflect the complaint/grievance was resolved and did not have the residents' signature to show they are happy with the outcome. Review of the facilities Grievance Policy called Care Program last updated 06/11/2024. .If a resident, a resident's representative, or another interested person with a concern (including missing items), a staff should encourage and assist the resident, or person on resident's behalf to file a written concern/grievance with the facility . .During the morning interdisciplinary team meeting following the day of receipt, the team will decide who will investigate the concern if the investigation has not been initiated. The department manager/designee assigned will have 5-7 business days following the receipt of the concern to complete the investigation and document his/her conclusions. The investigation and report should be completed using a Resident, Family, Employee and Visitor Assistance form and forwarded to the Administrator . .The facility representative will continue to complete quality rounds as scheduled to continue to ensure concerns are resolved . During a Resident Council meeting held on 05/14/25 at 11:00 AM with nine residents attending, frustration was shared over the lack of follow-through with the grievance process. Confidential residents stated they have had clothes missing for weeks if not months. Two of the nine residents shared that they saw other residents wearing their clothes. When staff were notified by this, they did nothing about it. Three other residents stated they didn't know if their clothes were marked with their name or not. Two residents stated they were served food that they cannot eat, even with it written on their tray ticket. One resident stated they are tired of peanut butter and jelly sandwiches as an alternative to the prepared meal served. Three residents stated the phone was removed from the small dining room which allowed privacy. Three of nine residents stated they receive cold food, sour milk and food they are allergic to. All nine residents shared in frustration that their concerns/grievances have not been resolved. During an interview on 05/13/25 at 1:22 PM, Activity Director (AD) D stated the resident council minutes are in the survey binder. Writer asked AD D to schedule resident council meeting tomorrow morning, and AD D asked if 11:00am would work, writer in agreed to the meeting at 11:00am in 3 [NAME] dining room. During an interview on 05/14/25 at 11:38 AM, AD D stated the grievance forms were within reach for all resident in a central location. AD D also stated residents can give those completed forms to anyone to turn in or ask for assistance with filling it out. AD D stated during the morning meetings, those are discussed, and any abuse allegations goes directly to LNA A. AD D stated the forms related to missing clothing goes to Housekeeping Director (HD) F. AD D stated ideally, those grievances need to be addressed within 72 hours. AD D stated she hands them out to department heads. Writer asked how the grievances were resolved, and residents were satisfied with the resolution. AD D stated that it was notified it was resolved. This writer asked how she knew the residents were happy with the outcome. This writer reviewed the form, and noted not all fields were filled, nor completed. AD D stated she didn't realize the form needed to be completed any differently than it was. During an interview on 05/14/25 at 12:44 PM, DON B stated AD D handed them to the unit managers to address then they get turned into LNA A. During an interview on 05/15/25 at 9:50 AM, LNA A stated any concerns/complaints/grievances that cannot be resolved on the spot, goes on a grievance form to track for Quality Assurance (QA). LNA A stated If its money missing or something significant, he puts it on a form due to being reportable to the state. LNA A stated if it was reportable, staff call him immediately, and he will address immediately. This writer asked LNA A about the grievance form they were using and the fact that the form was not completed showing the resident was satisfied with the outcome. LNA A stated he spoke to AD D about that, and they would be completing the form to include the residents signature showing the concern/complaint/grievance was addressed and resolved to the resident's satisfaction moving forward. LNA A stated they had received many complaints/grievances related to food. LNA A stated Dietary Manager (DM) E was on the food committee to make changes to the food and menu as requested by residents. During an interview on 05/15/25 at 12:11 PM, Housekeeping Director (HD) F stated the laundry process was, the clothes come down to laundry from each floor, CNAs were supposed to be bagging the laundry and put the residents name on a piece of paper in the bag, so that laundry can mark the clothes after they are washed and dried. HD F stated the personal item list was in every admission packet, but it was not being filled out or turned in listing the clothing items they were admitted with. HD F stated when those clothes were sent down to be laundered unlabeled, they were put on the end of the rack unidentified, and the laundry aide must ask every resident on each hall to find the owner. HD F also stated after it was hung on the rack for a few weeks unidentified after 3 months it went to the lost and found rack waiting for someone to identify it, if it stays on the rack longer than that, it goes into donation bin. HD F stated this was discussed at every morning meeting and nothing had changed in the process of filling out the personal item listing clothes brought into the facility with them, sending the clothes down to laundry department with their name on a piece of paper in the bag so it can be marked with their name.

Based on interview and record review the facility failed to ensure three out of five residents (Resident #46, 53, and 69) reviewed for unnecessary medications had proper documentation. Findings Included: Resident #69 (R69): Per the facility face sheet R69 was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, major depression disorder, and anxiety dated 11/7/2024. Review of a progress note dated 11/9/24, for Psychological Services PSYCHOSOCIAL EVALUATION Supportive Care, revealed an initial evaluation was conducted on 11/9/2024, and revealed a documented diagnosis of, unspecified dementia without behavioral disturbance The mental health exam revealed R69 did not have delusions, hallucinations, behaviors, she was alert to herself, and oriented. The exam did not have any findings that R69 had psychotic features. Review of a Physician's order dated 11/8/2024, revealed R69 was ordered to receive Risperidone 0.5 mg one tablet one time a day for antipsychotic. This order was discontinued on 11/8/2024. Medication regimen review (MRR) dated 11/8/2024, revealed pharmacy made the physician aware that the Risperidone was an ordered drug without indication for use, and the recommended action for the provider was: this resident is receiving the antipsychotic agent, but lacks an allowable diagnosis to support its use. Appropriate diagnoses were listed and the physician underlined, .depression with psychotic features/treatment. The Physician signed the recommendation on 11/11/2024. Review of the Physician's orders dated 11/9/2024, revealed that a new order was placed for Risperidone 0.5 mg give two tablets one time a day for antipsychotic. This order was discontinued on 11/11/2024. Review of another Physician's dated 11/12/2024, revealed R69's Risperidone order was changed to 0.5 mg two tablets one time a day for depression with psychotic features. This order is indefinite. Review of a Minimum Data Set (MDS) dated with an Assessment Reference Date of 11/14/2024 revealed under Section I-Active Diagnoses: Bipolar, Schizophrenia, and Psychotic disorder were not coded as any diagnoses for R69. Review of a medication administration record (MAR) dated 11/12/2024, revealed that R69 was ordered to start taking Risperidone Oral Tablet 0.5 MG one time a day for depression with psychotic features. The diagnosis of psychotic features was documented on the Physician's order, and the Medication Administration Record (MAR) as of 11/12/2025, however was never added to R69's medical diagnoses list. According to the National Alliance on Mental Illness (NAMI), www.nami.org Risperidone is an antipsychotic medication used to treat schizophrenia. Per NAMI symptoms of schizophrenia include delusions and hallucinations. Review of a consent titled, INFORMED CONSENT FOR USE OF PSYCHOTROPIC MEDICATION, that was signed by R69's responsible party on 11/7/2024, revealed Multiple side effects or adverse effects listed under, Possible side effects or adverse effects from this medication . that nursing was to be aware of and assess R69 for while R69 was taking the Risperidone. Those include: blurred vision, color change of the skin, constipation, darkening of urine, delirium, difficult urination, disorientation/confusion, disturbed gait, dry mouth, hypotension, hypothermia, increase agitation, involuntary movement of mouth, tongue, face or jaws, lethargy, sedation, loss of balance/falls, loss of independent mobility, loss of muscle tone, motor restlessness, muscle spasm or stiffness in the neck, back, face, or eyes, nasal congestion, orthostatic hypotension, pelvic thrusting, profuse drooling, reduced social contact, seizures, skin rash slowed involuntary movement of hands, feet, toes, and fingers, sore throat, stooped posture, tremors (hands, arms, head), upper respiratory infection), weight gain, and yelling of skin. Review of R69's Medication Administration Record and Treatment Administration Record (MAR) (TAR) revealed that the only side effects listed on the TAR for staff to be aware of were while R69 was taking the Risperidone was, dry mouth, constipation, blurred vision, disorientation/confusion, difficulty in urinating, hypotension, dark urine, yellow skin, nausea and vomiting, lethargy, drooling, extrapyramidal symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). The TAR did not list all the informed consent listed possible side effects for staff to watch and assess R69 while taking the Risperidone. Review of a Social Service Assessment & History dated 11/7/2024, revealed the assessment was not completed, but only had a summary notation which revealed R69 had possible mild depression. The question regarding Behavior Factors, Social Factors, Dignity Factors, Trauma Informed Care, Strength and Coping Skills, Referrals, discharge planning, and possible need for equipment we not answered. Review of a Care Plan conference Summary dated 12/12/2024, revealed Social Services was the only staff member that was in attendance along with R69's responsible party. The summary revealed that R69's responsible party shared that R69 had no history of depression, no past trauma, no psychological hospitalization , just had anxiety. Review of R69's documented behaviors, as evident by staff initials, from November 2024 to present 5/15/2025, revealed R69 only had behaviors documented 14 times from November 2024 to present, and that was in the months of January and February 2025, these were the behavioral documents provided when upon asking for behavioral documentation for R69. Review of a pharmacy MRR dated 5/5/2025, revealed the last gradual dose reduction (GDR) for R69's Risperidone was in November of 2024. The pharmacy's recommendation was to attempt to decrease current dose of 1 mg to 0.5 mg everyday of R69's Risperidone. On 5/14/2025 during the review of this document no physician had signed that they had reviewed or acknowledged the recommendation. Review of Physician's orders for the month of May 2025 revealed no order to decrease, change, or attempt a GDR of R69's Risperidone. In an interview on 5/14/2025 at 1:01 PM, Administrator A stated he was not able to locate a documented GDR regarding the 5/5/2025 MRR, and stated it was never followed up on when pharmacy wrote the recommendation on 5/5/2025. Review of a Physician's progress note dated 12/12/2024 revealed under diagnoses, 4. Unspecified dementia without behavioral disturbance. The list of diagnoses did not have depression with psychotic features as a diagnosis. In an interview on 5/15/2025 at 10:06 AM, Social Services O (SS) stated that she did not receive the MRRs, but said she had requested that the MRR did come to her. SS O said she wants the process to change so she can monitor the psychotropic/antipsychotic medications appropriately and said that things were being missed and not running smoothly. SS O said the Assistance Director of Nursing (ADON) was taking care of all the MRR for now which was temporary. In an interview on 5/15/2025 at 11:19 AM, Director of Nursing (DON) B said when the pharmacy MRR would come in they would go to the Physician for decline or agree, then to SS O who was the one who over sees the process, and then the nurses or the Unit Managers would write the order. DON B said her expectation was that SS O did all the monitoring and tracking for the MRR and psychotropic/antipsychotic medications. Resident #53 (R53): Per the facility face sheet R53 was admitted on [DATE]. Review of R53's Physician's orders revealed R53 received Ativan (antianxiety medication) 0.5 mg by mouth every six hours as needed for anxiety. The order was a PRN (as needed) order with a start date of 2/17/2025 and an end date of 4/2/2025, which is outside of the 14 days for a PRN antianxiety medication per regulation. Another PRN order for Ativan was noted to give R53 0.25 mg every four hours as needed starting 2/21/2025 and ending 3/11/2025, , which is also outside of the 14 days for a PRN antianxiety medication per regulation. Another PRN order for Ativan was noted to give R53 0.5 mg every four hours as needed starting 3/26/2025 and ending 4/1/2025, , which is again outside of the 14 days for a PRN antianxiety medication per regulation. 45038 Resident #46 (R46): Review of the medical record revealed R46 was admitted to the facility 10/12/2024 with diagnoses chronic kidney disease, muscle weakness, atrial fibrillation, thoracic aorta aneurysm, congestive heart failure (CHF), gastro-esophageal reflux disease, sleep disorder, restless leg syndrome, depression, anxiety, chronic pain, mitral valve insufficiency, anemia (low red blood cells count), osteoarthritis, history of myocardial infarction (heart attack), peripheral vascular disease (PVD), chronic obstructive pulmonary disease (COPD), bipolar disorder, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/27/2025, revealed R46 had a Brief Interview of Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. Review of R46's medical record demonstrated physician orders for Olanzapine Oral Tablet Disintegrating 5mg (milligrams) one time per day, written 04/23/2025 and trazodone HCL (hydrochloride) oral tab 150 mg give at bedtime, written 04/23/205. Review of MedlinePlus ,at medlineplus.gov, Olanzapine is an antipsychotic medication that may be used to treat bipolar disorder (manic depressive disorder) and Trazadone is an antidepressant. R46's medical record did not demonstrate any orders for the monitoring of antipsychotic mediation side effects or antidepressant medication side effects. In an interview on 05/13/2025 at 03:37 p.m. Director of Nursing (DON) B explained that it was her expectation that antipsychotic and antidepressant medication were to be monitored for side effects by the nursing staff. DON B explained that an order would be entered into the resident's medical record explaining what side effect symptoms should be monitored. Those orders are entered on the residents' Medication Administration Record and recorded as appropriate. DON B confirmed that R46 had orders for an antipsychotic and an antidepressant. DON B could not demonstrate a physician order for the monitoring of side effects for R46 use of an antipsychotic or use of an antidepressant. DON B could not explain why monitoring of side effects for an antipsychotic or side effects for antidepressant were not being completed. During observation and attempted interview on 05/15/2025 at 11:25 a.m. R46 was observed sitting up on the side of his bed. R46 explained that he had just returned from the hospital, where he had been since 5/12/2025, related to a recent fall. R46 explained that he had depression in the past but could not answer any further questions regarding his medication for depression. Review of information provided by Director of Nursing (DON) B R46 should have had an order for monitoring of antidepressant medication that stated, Antidepression medication- monitoring for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document; 'N' if monitored and none of the above observed. 'Y' monitored and any of the above was observed, select chart code 'Other/see Nurses Notes' and progress note findings. Review of information provided by Director of Nursing (DON) B R46 should have had an order for monitoring antipsychotic medication that stated, Antipsychotic medication-Monitoring for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, Nausea/vomiting, lethargy, drooling, EPS (extrapyramidal symptoms) (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). Document: 'N' if monitored and none of the above observed.; Y if monitored and any of the above was observed, select charge code 9 other/see nurses notes and document findings. Review of facility policy Psychoactive Medication Management, dated 07/01/1014 and last revised 04/22/2025, revealed Procedure #9: Monitor medication for efficacy, side effects and adverse consequences of the medication. Notify practitioner of adverse consequences or side effects.

Based on observation, interview, and record review the facility failed to ensure one (Resident #17) of two residents reviewed for care plans, had a comprehensive care plan that was revised for resident care needs, resulting in the potential for additional falls and care needs not being met. Findings Include; Resident #17 (R17) Review of the medical record reflected R17 was an initial admission to the facility on [DATE], readmitted on [DATE] and on 05/10/202. Diagnoses of repeated falls, diabetes, left hip pain, bi-polar and dementia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/08/2025 revealed R17 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R17 requires assistance with personal care and uses a walker or wheelchair as an assistive device. Record reviews revealed R17 had eight falls in the last six months. 11/27/24-R17 fell on the bathroom floor trying to get to the bathroom with his pants pulled down to his knees. No injuries. No new care plan interventions. 12/22/24- R17 fell on the bathroom floor trying to get to the bathroom. No injuries. No new care plan interventions. 01/04/25- R17 fell on the bathroom floor trying to go to the bathroom, with visible feces and urine on the floor. R17 complaint of right shoulder and left hip pain, X-ray ordered. Care plan dated 01/06/25, Ensure resident toilets after meals. No new care plan interventions. 01/09/25- R17 fell in his bedroom trying to get to his chair. No injuries. Care plan updated on 02/04/25. Anti rollback bars applied to wheelchairs. Ensure gripper socks on while in bed. Ensure resident toilets prior to going to bed. No new care plan interventions. 02/10/25- R17 fell in the bathroom trying to get from the toilet and lost his balance. No injuries. No new care plan interventions. 03/01/25- R17 fell in his bathroom trying to get off the toilet and lost his balance. No injuries. No new care plan interventions. 04/29/25- R17 was lowered to the floor in the bathroom to prevent further injury while transferring off the toilet. R17 had a 3cm abrasion above his left eyebrow. Referral to Physical Therapy (PT) initiated. Care plan updated on 05/05/25. TOILET USE: I require assistance with (2) staff for toileting. Use a raised toilet seat for toileting. Keep in his bathroom. Updated 04/30/25. TRANSFER: I require assistance from (2) staff to move between surfaces. No new care plan interventions. 05/10/25- R17 fell attempting to self-transfer from bed and fell attempting to self-ambulate and hit his head, currently on Eliquis 5mg 2 x a day. Sent out for an MRI. Care plan dated 05/10/25. Frequent rounding at to ensure resident redirection and assistance to restroom as needed. No new care plan interventions. 05/14/25- Care Plan updated, educated resident to use call light, resident agrees Pt is at his baseline orientation and ROM-but sustained 3 cm laceration above left eyebrow w/ dime size knot, laceration has no depth. No new care plan interventions. During an interview on 05/14/25 at 10:09 AM, Certified Nursing Assistant (CNA) stated that R17 would fall when he would self-transfer from his wheelchair to the bathroom and that's how he has had the previous falls. CNA C stated the CNA's try to toilet him and anticipate his needs. Care Plan dated 05/14/25. Social services to reach out to his guardian to get resident nonskid slippers. During an interview on 05/14/25 at 12:34 PM, DON B stated R17 was non-complaint, care planned, fell [DATE], he was trying to get up by himself, he did not have any shoes on, last update on 1/14/25, no update after 5/10 fall. Reviewed progress notes and stated they go over these incidents every morning, no care plan update to interventions. During an interview on 05/14/25 at 1:00 PM, DON B came to the conference room and handed this writer a fall report that indicated that they discussed transferring resident out of bed into the unit dayroom with nursing staff, but nothing was added to the care plan or implemented.

Based on observation, interview, and record review, the facility failed to label medication in accordance with accepted professional principles, dating of open medication for one out of four medication carts reviewed and failed to ensure proper medication storage of medications for one Resident (#51) out of 83 current residents residing at the facility. Findings Included: During an observation on 05/12/25 at 10:58 AM, R51 was laying in bed with door partially open and granted this surveyor permission to enter room. R51 appeared alert and oriented and able to answer questions. A medication cup with four to five pills was located on R51's bedside table. R51 reported the nurse had brought medicaitons in about 30 minutes prior and left on bedside table while she was sleeping. Continued observation of the unit reflected mostly short term stay residents with several residents who were able to self ambulate or propel on own. During an interview on 05/14/25 at 9:54 AM, Director of Nursing DON B reported had been at facility for about three months. DON B reported would expect nurses to observe residents take medications and not leave at the bedside because of several different reasons including possibility of medication errors. DON B reported residents not able ot self administer medications. Review of R51 Electronic Medical Record, dated 4/24/25(admission) to current (5/14/25) reflected no evidance R51 was assessed for self administration of oral medications. 45038 During observation of the 2 [NAME] medication cart of 05/14/2024 at 08:45 a.m. it was observed that Fluticasone Propionate Inhalation Aerosol 220 MCG (Micrograms), a multi dose inhaler was open and did not have a date placed on the container of the medication. During interview on 05/14/2025 at 08:45 a.m. Registered Nurse (RN) I explained that it was facility practice that all medication that was received from the pharmacy should be dated when the medication was opened. RN I could not explain why the Fluticasone Propionate Inhalation Aerosol 220 MCG (Micrograms) was found in the 2 [NAME] medication cart not dated when opened. RN I explained that the undated medication would be discarded, and another would be ordered from pharmacy. In an interview on 05/14/2025 at 09:55 a.m. Director of Nursing (DON) B explained that it was her expectation and professional practice that all multi-dose medication should be dated when the container is opened. DON B could not explain why the multi-dose inhaler of Fluticasone Propionate Inhalation Aerosol 220 MCG (Micrograms) had not been dated.

This citation pertains to intake #: MI00145322 and MI00144471 Based on observation, interview, and record review, the facility failed to ensure residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 2 of 5 residents (Resident #1 and #6) reviewed for pressure injuries, resulting in the worsening of R1's wound and subsequent hospitalization . Findings: Resident #1 (R1) Review of an Admission Record revealed R1 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Type II Diabetes, muscle weakness, need for assistance with personal care, and heart disease. Review of a Minimum Data Set (MDS) assessment for R1, with a reference date of 4/6/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R1 was cognitively intact. Review R1's MDS dated [DATE], Section M- Skin Conditions revealed R1 did not have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device upon admission to the facility. Review of R1's Activity Note dated 4/28/24 revealed, When resident requested RN (Registered Nurse) to apply socks on, RN noted Blister on Left heel measuring W (width) 4.5cm, L (length) 5cm .Will refer to wound team . Review of R1's Wound Consultation Note dated 05/02/2024 revealed, .Wound-Left heel stage 2 pressure Measurements- 2.5 (length) x 1.7 (width) x 0.1 (depth) cm (measured in centimeters) . Overall Wound Condition- stable Wound Plan Of Care- adaptic (petrolatum emulsion dressing)/ABD (absorptive dressing)/kerlix (gauze wrap) daily and prn (as needed) . (Per the State Operations Manual a Stage 2 Pressure Ulcer is a partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister.) Review of R1's Wound Consultation Notes dated 05/09/2024-5/23/24 revealed R1's Stage II left heel pressure injury was improving with the Wound Plan Of Care-adaptic/ABD/kerlix daily and prn . Review of R1's Order Summary revealed, Wound care: Blister to Left Heel, cleanse with wound cleanser, pat dry. Apply oil emulsion dressing cut to fit wound bed and cover with an abd secured with kerlix daily and as needed. every day shift. Order started on 05/03/2024 and was discontinued on 05/30/2024. Review of R1's Wound Consultation Note dated 05/30/2024 revealed, .Wound-Left heel stage 2 pressure Measurements- 3.3 x 2.9 x 0.1cm . Overall Wound Condition- stable Wound Plan Of Care- collagen/bordered gauze T-Th-Sat and prn . Review of R1's Order Summary revealed, Wound care: Blister to Left Heel, cleanse with wound cleanser, pat dry. Apply dermacol to fit wound bed and cover with a bordered gauze dressing every Tuesday, Thursday, Saturday, and as needed. Order started on 05/30/2024 and was discontinued on 6/6/2024. Review of R1's Wound Clinic Note dated 6/6/24 revealed, .Wound #7 Location: Calcaneus (heel); Left, Posterior *Cleanser-Anasept Antimicrobial Skin & Wound Cleanser 1 x Per Day .*Peri-Wound Care-Povidone-Iodine Swabsticks-Frequency: 1 x Per Day .Primary Dressing-Foam-Hydrofera Blue Ready Foam, 4x5 (in/in)-Frequency: 1 x Per Day NOTES: Apply to wound bed as directed. Please cut slits into foam to allow for drainage. *Secondary Dressing-ABD pad 5x9-Dermacea 5x9 (in/in)-Frequency: 1 x Per Day .*Secured with -Gauze Roll-Kerlix Roll Sterile, 4.5x4.1 (in/yd)-Frequency: 1 x Per Day .*Secured with-Tape 3M Medipore H Soft Cloth Surgical Tape, 4 x 10 (in/yd) .*Compression Wrap-Medigrip, Size F . The wound clinician directed the following interventions to prevent the worsening of the pressure injury, May shower with protection but do not get wound dressing(s)wet. Protect dressing(s)with water repellant cover (for example, large plastic bag) and may then take shower. NOTES: Please keep dressings dry and intact .Elevate legs to the level of the heart or above for 30 minutes daily and/or when sitting, a frequency of: NOTES: Multiple times daily Review of R1's Wound Consultation Note dated 06/06/2024 revealed, .Wound-Left heel stage 2 pressure Wound- Left heel stage 2 pressure Measurements- 3 x 2.4 x 0.1cm . Wound Plan Of Care- collagen/ABD/kerlix daily and prn . Review of R1's Order Summary revealed, Wound care: Left Heel, cleanse with wound cleanser, pat dry. Apply Povidone- Iodine Swabstick to peri wound. Apply Hydofera Blue ready foam to wound bed. Please cut slits into foam to allow for drainage. Cover with 5x9 abd pad, wrap with kerlix, secure with tape. Apply Medigrip Size F every Tuesday, Thursday, Saturday, and as needed. Order date 06/07/2024. Review of R1's Treatment Administration Record revealed R1 received the left heel wound treatment (transcribed above) on 6/8/24, 6/11/24, and 6/13/24. The wound treatment was not completed daily as ordered by the wound clinic provider and wound consultant. There were no PRN treatments completed. Review of R1's Wound Consultation Note dated 06/13/2024 (prior to wound clinic appointment) revealed, .Wound-Left heel unstageable pressure Measurements- 3 x 2.4 x 0.1cm Tissue type- slough/eschar Peri Wound- fragile/periwound blistering . Overall Wound Condition- deterioration . (Per the State Operations Manual an Unstageable Pressure Ulcer is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar .If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed.) Review of R1's Wound Clinic Note dated 6/13/24 revealed an order for Bactrim DS (antibiotic) PO BID (by mouth twice a day) x 14 days.Wound #7: Calcaneus (heel); Left, Posterior *Cleanser-Anasept Antimicrobial Skin & Wound Cleanser 1 x Per Day .*Peri-Wound Care-lotrisone-Frequency 1 x Per day .*Topical-Santyl Ointment-Frequency: 1 x Per Day NOTES: Apply nickel-thick layer to wound bed only *Secondary Dressing-ABD pad 5x9-Dermacea 5x9 (in/in)-Frequency: 1 x Per Day .*Secured with -Gauze Roll-Kerlix Roll Sterile, 4.5x4.1 (in/yd)-Frequency: 1 x Per Day .*Secured with- Tape 3M Medipore H Soft Cloth Surgical Tape, 4 x 10 (in/yd) .*Compression Wrap-Medigrip, Size F . The wound clinician again directed the interventions to prevent the worsening of the pressure injury, May shower with protection but do not get wound dressing(s)wet. Protect dressing(s)with water repellant cover (for example, large plastic bag) and may then take shower. NOTES: Please keep dressings dry and intact .Elevate legs to the level of the heart or above for 30 minutes daily and/or when sitting, a frequency of: NOTES: Multiple times daily R1 was to be evaluated at the Wound Clinic again on 6/27/24. Review of R1's Order Summary revealed the above wound treatment was not ordered in the Electronic Medical Record (EMR) and the incorrect treatment ordered on 6/7/24 continued. Review of R1's Treatment Administration Record revealed R1 continued to receive the incorrect left heel wound treatment (ordered on 6/7/24) on 6/15/24 and 6/18/24. There were no PRN treatments completed. Review of R1's Wound Consultation Note dated 06/20/2024 revealed, .Wound-Left heel unstageable pressure Measurements- 4.2 x 3.3 x unable to determine true depth . Overall Wound Condition- stalled Wound Plan Of Care- cleanse with wound cleanser, pat dry. Apply Povidone-Iodine Swabstick to peri wound. Apply 1/4 strength dakin's soaked gauze to wound bed secured with ABD/kerlix daily and prn . Review of R1's Physician Progress Note dated 2:26 PM revealed, Requested to acutely eval patient for possible GI (gastrointestinal) bleed .He is requesting to go to the hospital to be evaluated for possible GI bleed. Review of R1's hospital Discharge Summary revealed R1 was admitted to the hospital on 6/20/24-7/16/24.upon general surgery evaluation he was noted to have left heel wound which was then made aware to the emergency department team .Hospital course-Patient admitted and treated for Diabetic ulcer of foot with bone involvement without evidence of necrosis MRI was obtained and showed posterior hindfoot/heel ulcer with localized cellulitis and findings supportive of osteomyelitis of the posterior body of the calcaneus. Podiatry was consulted and pt underwent incision and drainage with left heel wound debridement on June 28/24. During an interview on 07/16/2024 at 12:06 PM, Wound Nurse Practitioner (WNP) D reported he was the provider that completed weekly wound evaluations on R1 (Wound Consultation Note documented above.) WNP D reported that he would make treatment adjustments as needed for the deterioration and/or stalling of the left heel pressure injury on the weeks R1 was not seen at the wound clinic (6/6/24 and 6/13/24.) WNP D confirmed he deferred to the wound clinic treatment orders. WNP D reported that approximately 2 weeks prior to R1's hospital transfer on 6/20/24 the wound clinic provider made a treatment change to hydrofera blue however, R1's left heel pressure injury began to deteriorate (had previously been documented as improving/stable). WNP D reported that on 6/20/24 he ordered a treatment for chemical debridement of R1's heel due to the slough and deterioration of the wound. During an interview on 07/15/2024 at 3:21 PM, Doctor of Podiatric Medicine (DPM) A reported that R1's wound developed during the course of his stay at the facility. When R1 arrived to the hospital on 6/20/24 it was discovered that he had developed osteomyelitis (bone infection) in his left heel that required surgical intervention. DPM A reported that it appeared as though his wounds were neglected at the facility. Review of R1's Electronic Medical Record (EMR) comprehensive Care Plan and revisions reflected a Focus of I have impaired skin integrity r/t (related to) Stage II PI (pressure injury) to L (left) heel diabetic ulcer ot Left planter foot .and was initiated on 03/20/2024 and revised on 05/20/2024. The Goal was to continue to show signs of healing through review date and was initiated on 03/20/2024 and revised on 05/20/2024. Neither the Focus nor Goal of the Care Plan reflected revisions were made despite R1's left heel pressure injury deterioration from a Stage II to unstageable documented in the wound assessments. The Interventions/Task did not reflect the wound clinician's recommendations of May shower with protection but do not get wound dressing(s) wet. Protect dressing(s) with water repellant cover .elevate legs to the level of the heart of above for 30 minutes .multiple times daily and had not been revised since 5/15/24. During an interview on 07/16/2024 at 4:39 PM, DON confirmed R1's treatment order was not changed/updated and the antibiotic had not been ordered/administered following the wound clinic appointment on 6/13/24. DON confirmed the incorrect treatment order (not ordered daily) on 6/6/24 and was administered until his hospitalization on [DATE]. Resident #6 (R6) Review of an Admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness and morbid obesity. Review of a Minimum Data Set (MDS) assessment for R6, with a reference date of 5/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R6 was cognitively intact. Review of R6's Weekly Skin Assessment documented in the Treatment Administration Record revealed on 7/3/24 and 7/10/24 R6 had no skin breakdown. Review of the Physician Communication Binder located at the 3 [NAME] Nurses' Station revealed an entry regarding R6 on 7/13/24 pressure sore on post. (posterior) left thigh + a new red spot on right buttock. cleaned + dressed. Review of the column Medical Provider Comments revealed no physician signature or date indicating the provider had not reviewed the entry/resident concern. Review of R6's Skin/Wound Note dated 7/13/24 at 5:00 PM revealed, Resident has a large posterior bed sore on the right thigh. I cleansed the wound and applied a cushion dressing. Has a small upcoming bed sore on the left buttock. Needs to be positioned and have the wound dressing changed daily. Review of R6's Electronic Medical Record as of 7/16/24 at 10:00 AM revealed: *No wound assessment (measurements or description of the wound) *No Guardian notification *No treatment ordered or completed upon identification of the pressure injury *No updated interventions for R1's Care Plan Review of R6's Provider Note dated 7/15/24 and signed at 4:54 PM revealed, .Staff notes patient has open area on left upper thigh .Skin: Warm, dry and intact. Small open area left upper thigh posterior likely secondary to (shear) .Open wound of left thigh, subsequent encounter Likely secondary to shear. No infectious process noted today. Will defer to wound team for further evaluation and treatment . 2 days after the identification of skin breakdown/pressure injury. (Per the State Operations Manual shearing occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage.) During an interview on 07/16/2024 at 9:12 AM, Guardianship Office Manager (GOM) B reported there was no documentation that the facility staff had contacted R6's guardian and/or the office regarding pressure injuries. During an interview on 07/16/2024 at 10:34 AM, Registered Nurse (RN) J reported that she was unaware of any pressure injuries/skin breakdown for R6 and reported there were no treatment orders pertaining to R6's pressure injuries. During an observation and interview on 07/16/2024 at 10:53 AM, R6's posterior thighs and buttocks were assessed with Director of Nursing (DON) and Nurse Consultant (NC) L. A small open area was identified on R6's left upper posterior thigh, near gluteal crease. R6 reported the area felt itchy and it felt like a bruise when pressed upon. Additionally, there was a raised reddened area on R6's right upper posterior thigh along the brief line. NC L confirmed the raised reddened area was along R6's brief line. Review of R6's Order Summary dated 7/16/24 at 11:52 AM revealed, Wound care: Cleanse excoriation to left posterior medial upper thigh with wound cleanser, pat dry and apply dermaseptin twice daily and PRN. every morning and at bedtime. Review of R6's Activity Note dated 7/16/2024 at 1:24 PM, revealed, Resident skin assessed due to nurse concern for open area. Small area of excoriation noted to medial posterior left upper thigh. Physician assessed area yesterday with no new treatment orders. Another small, raised area on right posterior thigh noted and physician informed with no new treatment order at this time. Resident had current order already for cream to area that was changed to utilize Dermaseptin for 2 weeks. Resident uses a wooden scratcher to scratch her skin. Therapy was asked if there were any other items to use that would be less harsh to the skin. Therapy also asked to evaluate resident for use of mobility bars to increase ability to help with turning. Brief size evaluated and is appropriate for resident. Guardian notified via email of new skin issue and for consent of mobility bars. During an interview on 07/16/2024 2:20 PM, DON reported that upon finding areas of skin breakdown R6's provider and guardian should have been notified, measurements obtained, and treatment initiated. Review of the facility policy Skin Management Guidelines-Prevention of Pressure Ulcers/Injuries last reviewed April 2024 revealed, .3. If a new skin injury is identified, a. Notify medical provider and obtain treatment orders b. Notify resident/resident representative c. Nurse to document the above in medical record .Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .TREATMENT AND MONITORING .2. Treatments are ordered by a medical provider .

Based on observation, interview, and record review the facility failed to provide prompt medical attention after a fall with multiple fractures for 1 of 3 sampled residents (R61) reviewed for falls, resulting in delay in treatment (21 hours wait prior to hospital transfer for right shoulder fractures), prolonged pain, and suffering. Findings include: Resident #61(R61) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R61 was a [AGE] year old female admitted to the facility on [DATE], with recent hospital readmission post facility fall resulting in two left humerus(upper arm) fractures. Additional diagnoses included cerebral vascular accident with left side weakness, hypertension (high blood pressure), peripheral vascular disease(decreased blood flow), anxiety disorder and depression. The MDS reflected R61 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. During an observation and interview on 4/02/24 at 12:16 PM, R61's door was observed closed. Permission to enter was granted by R61. R61 was sitting on the edge of the bed eating meal independently with cast to left arm. R61 appeared calm and able to answer questions without difficulty. During observation and interview on 4/03/24 at 9:50 AM, R61 was observed in bed with full cast on left arm. R61 reported recent fall by bed after self transferring from the commode back to the bed. R61 reported landed on left side and yelled for help. R61 reported 10 out of 10 pain for 3 days before facility staff sent her to hospital. R61 reported the day she was sent to the hospital nurse arrived to shift and sent R61 to hospital related to increased uncontrolled pain. Review of R61 Progress Note, dated 3/18/2024 at 6:08 p.m., reflected, Resident heard calling for help from room. When this nurse entered, resident noted on floor next to bed. Resident states she got dizzy while trying to get to her commode from bed. Resident assessed and vitals taken. No bruising or injuries noted. Resident states pain to left shoulder, but no more than usual. Resident transferred from floor to wheelchair after assessment and helped into bed. Administrator, DON, Unit Manager, and Physician notified. Review of the Progress Note, dated 3/18/2024 at 7:00 p.m., reflected, The resident reported to the oncoming nurse that she thinks she broke her arm and she needed to go to hospital on call notified and ordered Stat X-Ray to left shoulder. Ultra.X said they won't be able to do it tonight it will be early in the morning. Pain medication given, will continue monitoring the resident. Review of R61 on call Physician Progress note, dated 3/18/24 at 8:35 p.m., reflected, Date of Service: 03/18/2024 6:20 PM CT Details: Nurse Name : [named nurse working at time of fall Licensed Practical Nurse Z] .Primary Chief Complaint : Acute on Chronic Pain. History Present Illness : [AGE] year-old patient complaining of left shoulder pain. Patient had a fall earlier on during the day which was addressed by primary attending. Patient denied any pain following the fall but currently complaining of acute on chronic left shoulder pain. Patient has a known history of chronic left shoulder pain .Pain Level: 6 .MSK: Left shoulder pain with movement .Assessment/Plan .Pain in left shoulder(Primary) This is an acute new problem. The patient's condition is stable. Patient is complaining of acute on chronic left shoulder pain. Stat X-ray of the left shoulder. Call MD with results. Orders : Stat X-ray of the left shoulder. Call MD with results . Review of R61 Physician Progress note, dated 3/19/2024, reflected, Date of Service: 03/19/2024 .Chief Complaint / Nature of Presenting Problem: Follow-up left arm pain and radiology study .Staff notes patient suffered a fall likely mechanical. Staff notes patient complained of left arm pain on-call service ordered stat x-ray which revealed left humeral neck fracture, this is patient's affected side from previous CVA. Staff notes persistent pain complaints request for as needed pain medication .Pain Level: 9; 3/19/2024 1:59:18 PM .Diagnosis and Assessment Assessment .Closed fracture of neck of left humerus, initial encounter Secondary to a fall. Radiology reviewed. Significant edema. Will transfer to emergency department for further follow-up with orthopedic surgery. This is patient's affected hemiparetic arm. Continue to monitor awaiting transfer . Review of the Nursing Progress Note, dated 3/19/2024 at 4:00 PM, for R61, reflected, Neuros continued this shift and wnl for resident. Pain 9/10 to left shoulder,resident elevating arm on pillows. No new skin issues observed this shift. Review of R61 Progress Note, dated 3/19/2024 4:16 p.m., reflected, Resident with abnormal x-ray to left shoulder indicates Left Humoral head fracture. Per [named provider] NP send to ER for eval and tx. Resident aware and in agreement .Call placed to 911 for nonemergent transport at 1615. Awaiting transport at this time. Request for R61 Incident/Accident Reports along with complete investigation on 4/3/24 at 2:01 p.m. Review of the Incident Accident Report on 4/3/24 at 3:15 p.m., dated 3/18/24 at 5:01 pm, reflected alert and oriented R61 had unwitnessed fall during self transfer in room and found on the floor with complaints of left arm pain. The Report reflected R61 was transferred from the floor to the wheelchair. The report reflected no observed injuries at the time of the fall. The reported reflected no evidence of investigation including witness statements, interventions that were or were not in place(foot wear, level of bed, call light on or off, resident last observed, how resident was moved off floor, resident assessment .) Review of R61 Hospital Orthopaedic Consult, dated 3/19/24, reflected, [named R61] is a 60 y.o. female that presents with left shoulder and elbow pain after a ground level fall that she reports happened on Sunday 3/17/24, 2 nights ago. She has a history of CVA with left upper extremity hemiplegia. She notes pain in the left shoulder and elbow, but is unable to move either at baseline .Assessment: Left proximal humerus fracture, Left distal humerous fracture .Plan: Patient presenting with multiple left upper extremity fractures .maintain long arm splint ad sling to LUE. Elevate & ice to LUE. Pain control . Review of the hospital, Trauma Services Discharge Summary, dated 3/21/24, reflected R61 was admitted to the hospital on 3/19/24 at 4:58 p.m with discharge diagnoses that included, Traumatic closed displaced fracture of left shoulder with anterior dislocation. During an interview on 4/03/24 at 4:00 PM, Certified Nurse Aid(CNA) Y reported was working 3/18/24, when R61 fell in room. CNA Y reported nurse asked for her assistance around dinner time after R61 had been found on the floor. CNA Y entered R61 room and observed R61 on the floor complaining left arm, hurt really bad. CNA Y reported told the nurse and CNA Y she thought it was broke. CNA Y reported the nurse and CNA Y used a gait belt and staff on each side of R61 and lifted R61 under both arms and gait belt back to bed. CNA Y reported R61 call light was on when she entered the room. CNA Y reported R61 was independent in room prior to the fall according to the Kardex. CNA Y reported completed witness statement(not provided with investigation). Review of R61 Care Plan, dated 9/1/21, reflected intervention that included, TRANSFER: 1 person assistance. Remind me to turn towards my strong side when transferring and turning, and encourage me to use call light for assistance. I often self transfer and do not use call light to ask for assistance. During an interview on 4/3/24 at 5:40 p.m., Assistant Director of Nursing (ADON) K reported was not present when R61 fell on [DATE]. ADON K reported R61 was her own person and chooses to self ambulate, however, required one person assist prior to fall. ADON K reported educated R61 post fall about dangers of self transfer and verified R61 had additional fall 3/24/24. ADON K wound expect nurse to do complete assessment prior to transfer resident post fall and use hoyer to transfer. ADON K reported witness statements were part of investigation for R61 fall. During an interview 4/03/24 at 5:40 PM, Director of Nursing(DON) B reported did have witness statements from R61 fall on 3/18/24. DON B reported was unsure at that time what caused delay in x ray services and would expect STAT X-ray to be completed in fours hours. DON B reported R61 was own responsible person and frequently chose to self transfer and was care planned for one person assist with transfers. DON B verified R61 had additional fall on 3/24/24, after fall with fracture on 3/18/24. DON B reported wound expect nurse staff to complete assessment prior to transferring residents post fall and use hoyer to transfer off the floor. During an interview and record review on 4/05/24 at 4:06 PM, Unit Manager(UM) G reported nurse who was present for R61 fall on 3/18/24 at 5:01 p.m. entered the order for STAT X-ray on 3/18/24 at 7:32 p.m. After review of R61 EMR UM G reported the facility received R61 X ray results on 3/19/24 at 10:26 a.m. UM G reported would expect STAT X-rays to be completed within four hours and physician to be notified as soon as results are available of abnormal results including acute fractures. UM G verified R61 X-ray results included, Acute fracture of the left humeral neck. UM G was unable to answer why R61 was not transferred to the hospital until after 3/19/24 at 4:15 p.m. UM G reported nurses have access to Radiology reports and are expected to notify physicians immediately and was unable to determine when physician was notified of R61 acute fracture.

This citation pertains to intake # MI00143255 Based on observation, interview and record review, the facility failed to 1) ensure enteral feedings were provided as ordered to meet hydration and nutritional needs for one (Resident #86); 2) ensure fluids were freely accessible and provided to three (Resident #41, #43, and #86) and 3) prevent significant weight loss for one (Resident #68) of five reviewed for nutrition and hydration, resulting in weight loss, not receiving the ordered tube feeding formula, not receiving the total tube feeding volume ordered, feelings of distress, hospitalization , and the potential for unmet nutritional needs and continued weight loss. Findings Include: Resident #86 (R86) Review of the Admission Record reflected R86 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis which included gastrostomy status (creation of an artificial external opening into the stomach for nutritional support), retention of urine, dementia with agitation and anxiety, need for assistance with personal care, delirium, and dysphagia (difficulty in swallowing food or liquid). The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/7/23, reflected R86's Brief Interview for Mental Status (BIMS) was scored 4 out of 15, indicating severe cognitive impairment. The Care plan reflected that R86 did not walk, required extensive assistance of two or more people for toileting and transferring, had an indwelling foley catheter due to retention of urine, and required assistance of one staff member for consuming meals and fluids. R86 no longer resided in the facility. Review of the Nutrition Discharge paperwork from the Hospital dated 11/1/23 reflected that R86 had difficulty swallowing food and drink, however, was safe enough to consume his meals if the food was in a puree texture and the liquids were nectar thick. The Registered Dietician at the hospital also recommended elevating the head of the bed and offering small bites at a slow rate. Liquids should be administered via teaspoon. R86 was to receive medications and supplemental nutrition through his PEG tube (percutaneous endoscopic gastrostomy- a tube that delivers nutrition directly into your stomach) if he consumed less than 75% of his meal. Review of a Physician order dated 11/1/23 revealed Enteral Feeding order 4 times a day Isosource 1.5. This order was discontinued on 11/3/23. Review of a Dietary Note dated 11/3/23 at 2:13 PM revealed RD (Registered Dietician) made aware that resident is not tolerating current TF (tube feed) orders .Resident refused bolus via PEG tube, he started yelling and was combative hitting at nurse . His hospital discharge orders state that his goal is to use bolus feeds a supplemental if he consumes less than 75% of his meal orally. RD to change diet order to reflect this. Staff to encourage oral intake and use bolus feeds PRN (as needed) as residents allows. Review of the Care Plan revealed a Nutritional Focus area dated 11/3/23 which stated R86 had a nutritional problem or potential nutritional problem related to dysphagia, delirium, dementia, and gastrostomy. I am receiving supplemental enteral nutrition .I receive supplemental tube feed via PEG related to dysphagia, weight loss, PO (by mouth) intake and appetite . Interventions dated 11/3/23 included Diet as ordered: Regular Diet/Puree texture/NO liquids. Supplemental Enteral Nutrition if oral intake is less than 75% (Enteral nutrition (EN), also called tube feeding, is a way of providing nutrition directly into the gastrointestinal tract through an enteral access device (feeding tube). Enteral nutrition is a special liquid food mixture containing all of the nutrients required to meet nutrition needs, such as protein, carbohydrates, fats, vitamins, minerals, and other nutrients) and diet as ordered: NPO (nothing by mouth) initiated on 11/3/23 and revised on 12/19/23. Review of the Kardax (portion of the electronic medical record that informs Certified Nursing Assistants of care needs) reflected that R86 eating/nutrition section stated EATING: I am totally dependent on (1) staff for eating. Small bites, slow rate, upright during meals and 20-30 minutes after meals. The Care Plan or Kardax did not reflect that R86 could be offered fluids or to encourage oral intake and the diet orders reflected that R86 was unable to have liquids. Review of a General Diet Physician Order dated 11/1/23 at 5:13 PM revealed Puree texture (for food), nectar consistency (for liquids) for dysphagia. Supplement meal with one can of Isosource 1.5 (enteral nutrition for tube feeding) if meal intake less than 75%. Review of an Enteral Feed Order dated 11/1/23 reflected every shift flush feeding tube with 30 ml (milliliters) of water before and after medication administration flush feeding tube with 5 ml of water between each medication. Further review of the Physician Orders revealed no additional hydration sources for R86. Review of the Task documentation for R86's food intake for the dates of 11/3/23 until 11/10/23 reflected the following: On 11/4/23 at 8:00 AM, 100% of meal consumed. At 1:00 PM 75% of meal consumed. At 6:00 PM there was no documentation for the percent of meal consumed. Review of the Medication Administration Record revealed no ordered as needed supplemental meal was administered for the day. On 11/5/23 at 8:00 AM, 50% of the meal was consumed. At 1:00 PM 50% of the meal was consumed. At 6:00 PM 50% of the meal was consumed. Review of the Medication Administration Record revealed no ordered as needed supplemental meal was administered for the day. On 11/6/23 at 8:00 AM, 0% of the meal was consumed. At 1:00 PM, 25% of the meal was consumed. At 6:00 PM, 0% of the meal was consumed. Review of the Medication Administration Record revealed no ordered as needed supplemental meal was administered for the day. On 11/7/23 at 8:00 AM, 25% of the meal was consumed. At 1:00 PM, 25% of the meal was consumed. At 6:00 PM, there was no documentation for the percent of meal consumed. Review of the Medication Administration Record revealed no ordered as needed supplemental meal was administered for the day. On 11/8/23 at 8:00 AM, 0% of the meal was consumed and was marked as resident refused. At 1:00 PM, 25% of the meal was consumed. At 6:00 PM, 75% of the meal was consumed. The Medication Administration Record revealed that one supplemental as needed nutrition was administered at 10:23 PM. On 11/9/28 at 8:00 AM, 0% of the meal was consumed. At 1:00 PM, 0% of the meal was consumed. At 6:00 PM, 0% of the meal was consumed. The Medication Administration Record revealed that one supplemental as needed nutrition was administered at 8:23 PM. On 11/10/23 at 8:00 AM, 0% of the meal was consumed. Review of the Medication Administration Record revealed no ordered as needed supplemental meal was administered for the day. Review of a Behavior Note at 11/10/23 at 6:00 AM revealed Resident yelled out throughout the shift, frequent reminders given to use his call light. He only used the light several times and the rest continued to yell out for help. When writer or other staff answered his calls for help resident had no needs. One statement he shared with CNA's (Certified Nursing Assistant) was I don't want to die in this place. Resp (respirations)22, T(temperature):99.6 (Fahrenheit), damp cool cloth placed on his forehead. Portable air turned on d/t (due to) room very warm and stuffy . BP (blood pressure) 93/46, pulse 98 . writer rechecked b/p which 95/57. Writer to monitor and report to oncoming nurse. Review of a Health Status Note dated 11/10/2023 at 8:40 AM reflected Resident's B/P is 66/38 ((hypotensive: a blood pressure reading below the specified limit (90/60 millimeters of mercury (mmHg)). He appears non diaphoretic is arousable and communicated with writer that he does not want breakfast. On call provider called, and recommended monitoring vs (vital signs) every 15 minutes and encourage oral fluids. Will continue to monitor. R86's Vital Signs were as follows: 11/10/2023 08:40 AM 66 / 38 mmHg 11/10/2023 08:55 AM 72 / 41 mmHg 11/10/2023 09:34 AM 87 / 38 mmHg 11/10/2023 10:00 AM 70 / 30 mmHg Review of a Health Status note dated 11/10/2023 at 10:09 AM reflected Resident's blood pressure dropped to 70/30, became unresponsive and was only arousable by sternal rub. He started to have hematuria (blood in urine) in his foley catheter, order was given to send him to the ER (Emergency Department) . Review of the Hospital Paperwork dated 11/10/23 revealed that R86 presented to the emergency department with decreased responsiveness. Per report, [R86] was unresponsive and hypotensive. His blood pressure was 55/40 and 70/30 when Emergency Medical Services arrived. Upon presentation to the emergency room , [R86] required 4 liters of intravenous fluid to improve his blood pressure. Further review of the same Hospital Paperwork revealed that R86 had a serum sodium level of 144 milliequivalents per liter (mEq/L), which indicated that R86's serum sodium levels were on the higher range of the scale. Normal ranges are 135-145 mEq/l). Review of a Nutrition Note during hospitalization dated 11/11/23 revealed R86 had inadequate energy intake related to decreased ability to consume adequate .as evidenced by documented intake from previous admission, patient reportedly sleeping most of the day, visible fat and muscle wasting and need for enteral nutrition via peg tube. The Dietician recommended scheduled tube feedings and scheduled water flushes to ensure R86 received the nutrition and hydration required. The document also reflected that R86 had thick oral secretions and weight loss as evidenced by the observation of muscle and fat wasting. Review of the Weights reflected on 11/1/23, R86 weighted 171 lbs (pounds) and upon readmission to the facility on [DATE], weighed 160.5 lbs which is a 6% weight loss in two weeks. In an interview on 04/05/24 at 1:43 PM, Registered Dietitian (RD) I reported that she did not have concerns for R86 as far as not meeting his nutrition and hydration needs because he received nutrition and fluids through his PEG tube. When asked if hydration needs were monitored such as reviewing intake and output or urine characteristics, RD I stated that she did not use intake and output or urine characteristic to ensure hydration needs were being met. When asked if there should be required documentation for someone with a nutrition and hydration risk, RD I reported that providing fluids was a standard of care and therefore, did not require additional documentation. After review of the meal consumption task and order for a PRN supplemental meal bolus, RD I acknowledged that R86 had missed several required feedings. In an interview on 04/10/24 at 11:44 AM, Director of Nursing B stated that she would expect that the Certified Nursing Assistants report to the nursing staff what the percentage of meal consumption was so that the nurses could administer the as needed supplemental feeding. 27446 Resident #41(R41): Per the facility face sheet R41 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Diagnoses included stroke. Review of R41's care plans revealed, I (R41) have an ADL (activities of daily living) self-care performance deficit r/t (related to) recent CVA (stroke) with dysphagia (difficulty swallowing ), date initiated 11/29/2023, and revised on 1/10/2024. The care plan, under Interventions/Tasks revealed, R41 required staff assistance to walk and transfer. Review of R41's Kardex (document Certified Nurse Aids [CNA] use to know how to provide care to a resident) revealed in the EATING/NUTRITION section, .I (R41) need assistance of (1) staff for eating orally. In an observation and interview on 4/02/2024 at 2:54 PM, R41 was observed in bed, and no drinking water was observed in R41's room. A sign was observed on wall which revealed Pudding Thick Liquids .) During the same observation and interview R41 asked if she could get some water. A staff member was informed of R41's request. At 3:00 PM a Styrofoam cup with a lid was observed to have been placed on a bedside table that was in the bed one area. R41 resided in bed 2. The cup was way out of reach for R41, the straw was laying next to the cup, the water was not pudding thick and had ice in it. On 4/02/2024 at 3:05 PM, R41 was heard to be crying, and stated she wanted her water. On 4 /03/2024 at 2:40 PM, R41 was observed in her bed with door partial closed. An over the bed table that was out of reach for R41 was observed to have thickened water and juice in two small juice cups. Upon entering R41's room, R41 asked for a drink of water, and began to cry because she wanted a drink of water. On 4/04/2024 at 10:18 AM, R41 was observed in her bed crying, and stated she was thirsty. Pudding thick water and orange juice was observed to be on the over the bed table but out of reach for R41. Review of a physician's order dated 3/29/2024 revealed, that after each meal if R41 ate less than 50% of the meal she was to receive a tube feeding bolus (one time not continuous), which included a total of 180 ml (milliliters) of water. Review of a nutritional evaluation dated 3/29/2024, revealed R41 required 1636 ml of water per day. In an interview on 4/04/2024 at 10:28 AM, CNA N stated R41 was to be checked on every 30 minutes, and said staff would give R41 a spoonful of water at that time. CNA N said she did not know how R41's fluid intake was monitored to assure she received her required 1636 ml of water per day. In an interview on 4/04/2024 at 10:40 AM, Registered Nurse (RN) W, who was also the Unit Manager, stated that the CNA's would document in R41's electronic medical record (EMR) that they gave R41 a drink,. RN W stated she was not sure how it was assured R41 received her daily water requirement of 1636 ml a day. Record review of R41's EMR revealed there was no CNA documentation of each drink of water they provided for R41. Review of R41's treatment administration record (TAR) for the month of March and April 2024 revealed no documentation of the drinks of water staff gave to R41. Resident #43 (R43): In an observation and interview on 4/02/2024 at 9:40 AM, R43 was observed in her bed, a Styrofoam cup of water was observed to be on the bedside table, that was not within reach from the bed, with a straw in it, but the paper the straw came in was still on the top part of the straw. R43 was asked if she could reach her water, R43 did not understand, and did not attempt to reach for water. The cup was full of water and was not dated. Another Styrofoam cup of water was observed on the bedside table, full to the top of water, had no ice, and no date to determine when it was fresh water. On 4/04/2024 at 10:56 AM, R43 was observed in bed, a full Styrofoam cup of water was observed on the over the bed table. R43 was asked if she knew where her water was located, but she did not respond to the question just mumbled. R43 was asked if she could reach her water, but did not respond. Review of a care plan in place revealed R43 had a care plan in place dated 5/8/2018 and revised on 12/30/23, that identified she had the potential for dehydration, and would drink independently. The interventions included, encourage fluids dated 5/8/2018 and revised on 5/11/2023, and ensure R43 had access to fluids. Review of a care plan dated 5/1/2018 and revised on 12/30/2023, that addressed R43's ADLs revealed R43 required staff assistance to walking, and transferring. In an interview on 4/05/2024 at 1:28 PM, Registered Dietician (RD) I stated that it was her expectation that the staff were giving or offering drinks through out the day and with meals, and every two hours if the resident could not take a drink themselves. RD I said she would only get a resident's fluid intake from talking to UM W, and said fluid intake was not documented anywhere, not even for residents who could not take their own drink and depend on staff. 38383 Resident #68 (R68): Review of the medical record reflected R68 admitted to the facility on [DATE], with diagnoses that included diabetes, dysphagia (difficulty swallowing) and history of transient ischemic attack (TIA) and cerebral infarction. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/16/24, reflected R68 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/02/24 at 11:57 AM, R68 was seated on the edge of his bed. He reported the facility's food was terrible, and he could not eat it. R68 reported he had lost weight since his admission to the facility, and he was tired of going hungry. When asked what made the food terrible, R68 reported he did not have any teeth, and the facility was aware of that. On 04/03/24 at 08:35 AM, R68 was observed in bed. R68 stated he did not have any teeth and was working on getting new dentures before admitting to the facility. R68 reported he had seen the dentist at the facility. He reported difficulty eating due to not having any teeth or dentures. A dental consult note for 9/28/23 reflected, .Edentulous [no teeth] .does not have dentures, unhappy with his chewing ability; oral mucosa appears pink and shiny . A dental consult note for 10/20/23 reflected, .Patient has no dental concerns .Patient has had dentures made in the past but they didn't fit and could not be worn. He is having trouble chewing and would like to have new ones made. This will benefit his nutrition and general health . Took preliminary upper and lower impressions for complete dentures . During an interview on 04/05/24 at 11:13 AM, UM G reported she had contacted the facility's dental group, and was informed they had not started R68's dentures. UM G was told the process for new dentures was started through someone else, and the facility's dental provider could not start a new process for dentures until the old one was discontinued. UM G stated the facility's dental provider reported they would be looking into how to get the old group to discontinue that process so they could start it. UM G reported the facility's dental provider group had never conveyed to the facility that R68 was in the process of getting dentures with another dental group. According to the medical record, on 09/11/2023, R68 weighed 204.7 pounds (lbs). On 03/07/2024, R68 weighed 183.1 pounds, which is a -10.55 percent weight loss. On 4/3/24, R68 weighted 182.2 pounds. A Nutrition Evaluation for 9/12/24 reflected, .Resident not satiated by facilities meal serving sizes. Reports he is still hungry . A Nutrition Evaluation for 12/13/24 reflected, .Resident has expressed in the past that he either does not like the facility's food or does not receive enough food. He currently receives double portions with all meals and occasionally forgets that he ate d/t [due to] his mentation. Staff is encouraged to offer additional food if this happens . R68's weight history since admission reflected the following: 9/11/2023: 204.7 Lbs 9/18/2023: 205.3 Lbs 9/25/2023: 206.0 Lbs 10/1/2023: 203.2 Lbs 11/28/2023: 200.4 Lbs 12/4/2023: 201.3 Lbs 1/2/2024: 193.8 Lbs 1/29/2024: 187.0 Lbs 2/6/2024: 189.2 Lbs 3/7/2024: 183.1 Lbs 4/3/2024: 182.2 Lbs Physician's Orders, dated 2/11/24, reflected R68 was to receive a no sugar added mighty shake two times a day with breakfast and lunch and a magic cup daily with dinner. A Physician Order with a start date of 9/12/23 and revision date of 3/7/24 reflected R68 was to have a consistent carbohydrate (CCD) diet, mechanical soft texture, double portions, ground meat, pureed fruit and extra sauce/gravy with ground meats. On 04/05/24 at 09:29 AM, R68 was observed lying in bed. He reported he had already eaten breakfast, and his tray had already been taken. He reported having scrambled eggs, two cartons of milk, two chocolate shakes and rice krispies cereal. R68 reported consuming all of his eggs and cereal and consuming both of his shakes. R68 reported he did not get a double portion of eggs on his breakfast plate. R68 stated he did not get full from breakfast that morning. Additionally, R68 stated he was not always getting his double portions at meals. A breakfast tray ticket was observed on his over-bed table and reflected double portions were to be provided. During an observation and interview on 04/05/24 at 12:44 PM, Registered Dietitian (RD) I reported R68 was one of the residents that was never satisfied with the food. He would say he did not receive things, and they would find them in his drawer. RD I removed R68's plate cover. The plate consisted of ground chicken parmesan with marinara sauce and noodles, cauliflower and one piece of toasted bread that had been cut in half. A bowl of peaches, appearing half full, was also observed. RD I reported the meal was a double portion. When asked if R68's meal had extra sauce, as noted on his tray ticket, RD I stated, I would not say that is extra sauce by any means. The tray ticked also reflected that R68 was to have a no sugar added mighty shake on his tray. RD I confirmed that the shake had not been provided with the meal. The tray ticket reflected tomato soup was to be provided with lunch, which was not observed to be served with R68's meal. During an interview on 04/05/24 at 01:50 PM, RD I reported R68 had a history of saying he did not eat when he did or saying he did not receive certain foods that would be found in his drawer. RD I reported R68's weight loss over six months was significant because it was an 11% loss. Anything over a 10% weight loss over six months was considered significant. She reported that after assessing his six month weight loss, R68 would be placed on weekly weights for four weeks, which would continue until his weight was stabilized. RD I reported that as of 3/7/24, R68 was considered to have significant weight loss of 10.6% in six months. She reported R68 should have been placed on weekly weights around 3/7/24. RD I stated she had heard R68 say he did not receive double portions at meals, and she sent an email to the Dietary Manager, reminding that he needed double portions.

This citation pertains to intake MI00140401. Based on observation, interview and record review, the facility failed to maintain professional standards of practice in ensuring activities of daily living care met resident needs in two of three residents reviewed for falls (Resident #2 & #6), resulting in a serious head injury (Resident #2) and the potential for accidents/injuries (Resident #6). Findings include: Resident #2 (R2) Incident Report dated 1/26/24 at 10:09 AM indicated Licensed Practical Nurse (LPN) H responded to a resident scream and Certified Nurse Assistant (CNA) G calling for help. R2 was found lying on the floor, on the right side of her bed, was bleeding from the right side of her face and had sustained head trauma. R2 fell from bed during perineum care provided by CNA G. The same report revealed R2's bed was in the highest position at the time of the fall. R2's Activities of Daily Living (ADL) care plan dated 1/07/19 instructed the assistance of 2 staff for bathing, clothing management, positioning, personal hygiene; and 2 staff assist when turning and repositioning R2 in bed. The same care plan instructed to transfer R2 with a mechanical lift using a size large sling with assistance of 2 staff. R2's annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/13/23 revealed she admitted to the facility on [DATE]; had a brief interview for mental status (BIMS), a short performance-based cognitive screener, score of 14 (13-15 cognitively intact). The same MDS revealed R2 had functional limitations in range of motion (ROM) on one side of her upper extremity (shoulder, elbow, wrist, hand); and on both sides of her lower extremities (hip, knee, ankle, foot). R2 was dependent (staff does all of the effort, resident does none of the effort to complete the activity) on staff in ability to roll left and right and transfer from a bed to a chair. R2's same MDS revealed she had the diagnoses of multiple sclerosis (MS), seizure disorder, depression, anxiety, and diabetes. In review of the daily assignment schedule dated 1/26/24, LPN H; and CNA's F, G, and J were assigned to the unit where R2 lived. CNA F was interviewed on 2/01/24 at 10:40 AM and stated at the time of R2's fall, CNA F was assisting another resident with care. CNA F stated she did not assist CNA G with R2's shower or any transfers on the morning of 1/26/24. CNA F stated in the same interview, prior to R2's fall on 1/26/24, she had not had any competency evaluations upon hire or during her employment at the facility. On 2/01/24 at 11:01AM CNA J stated she had worked at the facility since August of 2023 and had provided care for R2 prior to 1/26/24. CNA J stated on 1/26/24, she was sitting at the nurse's station when CNA G called out for help from R2's room. The nurse responded to R2's fall at the same time. CNA J stated when she responded to R2's fall on 1/26/24, R2 was lying on the floor on the right side of her bed, between her bed and the air conditioning unit. CNA J stated CNA G had not asked her nor did she assist her with any transfers or shower for R2 on the morning of 1/26/24. CNA J stated prior to 1/26/24, she had been assigned to provide R2 with ADL care. CNA J stated prior to R2's fall she was transferred from bed to chair or shower bed with assist of two staff. CNA J stated R2 would be transported to the shower room on the shower bed. CNA J stated she would have another staff member assist in getting R2 into the shower room, and then complete R2's shower without another staff person assisting. CNA J stated she had not had a CNA skills competency evaluation at the nursing home prior to 1/26/24. CNA G was interviewed on 2/01/24 at 9:47 AM and stated she was in the process of changing R2's brief when R2 fell from her bed. CNA G stated she was reaching back for R2's protective ointment when R2 fell from her bed. CNA G ended the telephone call, or the call was dropped, when asked if she had another staff member assist her with R2 during her shower or during her transfers with the mechanical lift prior to her fall that day. CNA G did not answer any additional phone calls or respond to messages during the survey, after the interview ended on 2/01/24. During an interview on 2/02/24 at 9:54 AM, LPN H stated during her assessment of R2 after the fall on 1/26/24, she believed she had hit her head on a table. LPN H stated R2 was care planned for a floor mat on the left side of the bed but did not have a floor mat on the floor on the right side of the bed. LPN H stated she was aware CNA G had given R2 a shower and stated CNA G did not ask her for assistance with R2's shower or transfers prior to R2's fall on 1/26/24. Director of Nursing (DON) B was interviewed on 2/01/24 at 11:35AM and stated nurse assistant competency skills were evaluated upon hire and then annually. During an interview on 2/01/24 at 11:55 AM, DON B stated she was unable to locate a competency skills evaluation for CNA G and confirmed she was hired at the facility in June 2023. During an interview on 2/02/24 at 12:06 PM, DON B stated the facility was putting together a past noncompliance for incidents and accidents and did not have a date for compliance. DON B stated staff were educated on bed positioning and following the care plan after R2's fall on 1/26/24. DON B stated the interdisciplinary team would be auditing 10 staff a week on bed mobility. DON B stated she would have to ask staff if R2 was assisted with 2 staff for her transfer with the mechanical lift from her bed to the shower bed, in the shower, and then the transfer from the shower bed into the bed on 1/26/24. DON B stated when R2's Kardex (care plan) indicated 2 staff to assist with showers; her expectation would be 2 CNAs would assist R2 throughout the entire shower. Hospital Trauma Report/Discharge Summary dated 1/30/24 revealed R2 was admitted to the hospital on 1/26/24 and received treatment for a subdural hematoma (caused by a head injury, blood vessels burst, and can cause pooled blood to push on the brain) after a fall from her bed at the nursing home. R2 was discharged from the hospital with pain medications on 1/30/24 and did not return to the nursing home. Resident #6 (R6) R6's MDS dated [DATE] revealed a BIMS score of 14 (13-14 Cognitively Intact); had a functional ROM limitation in her lower extremity on one side; and was dependent in chair/bed-to-chair transfer (ability to safely come to a standing position from sitting in a chair or on side of the bed). R6's risk for falls care plan revised 1/03/24 and activities of daily living care plan (ADL) revised 1/24/24 indicated she had a history of falling, stroke, mild intellectual disability, tardive dyskinesia (uncontrolled jerky movements), and diabetic neuropathy (numbness, burning feeling in feet or hands). The same care plans indicated R6 was to use a Geri-chair (specialized recliner chair) for mobility, required extensive assistance of two staff for transfer between surfaces; and was totally dependent on two staff for turning/repositioning in bed. R6's fall care plan dated 1/03/24 indicated she was to have a floor mat on the right side of the bed to reduce injuries from falls. Nurse Practitioner (NP) I and Unit Manager Licensed Practical Nurse (LPN) C were observed transferring R6 from a wheelchair to her bed on 2/01/24 at 1:50 PM for wound care treatment. R6's bed was in low position prior to the transfer (below level of knees when standing). LPN C attempted to raise the bed from the floor, prior to the transfer, and the bed control did not work. LPN C and NP I placed their arms under R6's arms; and LPN C grabbed onto the back of R6's slacks. R6 was transferred from her wheelchair to her bed without a gait belt or bed in the appropriate height increasing the risk of injuries to staff and the resident. R6 was not transferred in a dignified manner. During an interview on 2/02/24 at 12:06 PM, DON B stated use of a Gait belt was not a requirement, and transferring a resident under their arms and or holding them up by their pants was acceptable depending on the person helping with the transfer. During an interview on 2/02/24 at 12:36 PM Unit Manager/LPN C confirmed R6's care plan was not correct, R6 as of two weeks ago when she was readmitted to the facility, no longer used a Geri-chair for mobility, she now used a wheelchair, and would update R6's care plan. In review of the Safe Lifting and Moving Residents policy revised July 2017, revealed resident safety, dignity, comfort and medical condition would be incorporated into goals and decisions, regarding the safe lifting and moving of residents. The same policy revealed staff responsible for direct resident care would be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.

This citation pertains to intake: MI00140602 Based on interview and record review the facility failed to obtain and administer anti-seizure medication, as ordered by a physician, for one resident (#1) of three residents reviewed resulting in actual harm demonstrated by resident #1 having a Grand mal seizure (a seizure that involves loss of consciousness and violent muscle contractures) and requiring hospitalization . Finding Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility 10/08/2023 with diagnoses that included Lennox-Gastaut Syndrome (a severe form of epilepsy resulting in multiple types of seizures), bacteremia (bacteria in the blood), cerebral palsy (impaired muscle coordination), impulse disorder, dysphagia (difficulty swallowing), erythema nodosum (inflammatory disease causing painful bumps under the skin), post-traumatic stress disorder (PTSD), anxiety, hyperlipidemia (high fat content in blood), panniculitis (inflammation in the bottom layers of the skin), and edema (swelling cause by too much fluid in body tissue). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/14/2023, revealed R1 had a Brief Interview for Mental Status (BIMS) of 00 (unable to assess because of no response) out of 15. R1 was discharged to the hospital on 10/16/2023 related to seizures and has not returned to the facility as of survey exit date. In a telephone interview on 11/06/2023 at 04:12 p.m. complainant C explained that R1 had been admitted to the facility 11/08/2023. He explained that during the entire time that R1 was at the facility he had not received a certain anti-seizure medication that was necessary to prevent R1 from having seizures. Review of R1 medical record demonstrated physician orders for the following anti-seizure medication: Clonazepam oral Tablet 0.5 Milligrams (mg) give 1 tablet by mouth at bedtime for seizures (order written 10/13/2023), Lamotrigine 150 mg Tablet give 2 tablets by mouth two times a day for seizure (order written 10/08/2023), Cenobamate oral tablet 200 mg by mouth at bedtime for seizures (written 10/08/2023), Zonegran oral capsules 100 mg give 4 capsule by mouth in the evening for seizure (written 10/08/2023), and Banzel Oral Tablet 200 mg give 200 mg by mouth two times a day for Lennox-Gastaut Syndrome LGS take with meals (written 10/08/2023). Review of R1's Medication Administration Record (MAR) demonstrated documentation that Cenobamate 200 mg was not given and documented as 9 (see progress notes) for 10/08/2023, 10/09/2023, 10/11/2023, 10/12/2023, 10/12/2023, 10/13/2023, 10/14/2023, and 10/15/2023. R1's MAR demonstrated documentation that Clonazepam 0.5 mg was not given and document as 9 (see progress notes) on 10/13/2023. R1's MAR demonstrated documentation Banzel 200 mg was not given and documented 9 see progress note) 10/08/2023 times one dose, 10/09/2023 times two different dose and 10/10/2023 times for two different doses. Review of R1's medical record progress notes demonstrated 10/09/2023 19:42 [07:42 p.m.] Orders - Administration Note Text: Cenobamate Oral Tablet 200 mg [milligram] give 200 mg by mouth at bedtime for seizures med [medication] n/a [not available] on order, 10/11/2023 19:36 [07:36 p.m.] Orders - Administration Note Text: Cenobamate Oral Tablet 200 mg Give 200 mg by mouth at bedtime for seizures on order, 10/12/2023 20:00 [08:00 p.m.] Orders - Administration Note Text: Cenobamate Oral Tablet 200 mg Give 200 mg by mouth at bedtime for seizures on order, 10/13/2023 21:46 [09:46 p.m.] Orders - Administration Note Text: Cenobamate Oral Tablet 200 mg Give 200 mg by mouth at bedtime for seizures On order, 10/14/2023 20:56 [08:56 p.m.]Orders - Administration Note Text: Cenobamate Oral Tablet 200 mg Give 200 mg by mouth at bedtime for seizures On order, 10/15/2023 21:32 [09:32 p.m.] Orders - Administration Note Text: Cenobamate Oral Tablet 200 mg Give 200 mg by mouth at bedtime for seizures on order. Review of R1's medical record progress notes demonstrated Banzel 10/08/2023 18:12 [06:12 p.m.] Orders - Administration Note Text: Banzel Oral Tablet 200 mg [milligram], Give 200 mg by mouth two times a day for LGS [ Lennox-Gastaut Syndrome] take with meals, not available. , 10/09/2023 12:02 [12:02 p.m.] Orders - Administration Note Text: Banzel Oral Tablet 200 mg Give 200 mg by mouth two times a day for LGS take with meals med unavailable ,10/09/2023 19:30 [0730 p.m.] Orders - Administration Note Text: Banzel Oral Tablet 200 mg Give 200 mg by mouth two times a day for LGS take with meals, 10/10/2023 09:28 [09:28 a.m.] Orders - Administration Note Text: Banzel Oral Tablet 200 mg Give 200 mg by mouth two times a day for LGS take with meals not available, pharmacy contacted, 10/10/2023 16:56 [04:56 p.m.] Health Status Note Text: Pharmacy contacted regarding Banzel not being sent. Was informed that it must be sent from a local pharmacy and that it will be delivered today., 10/10/2023 17:08 [05:08 p.m.] Orders - Administration Note Text: Banzel Oral Tablet 200 MG Give 200 mg by mouth two times a day for LGS take with meals not available. Review of R1's physician progress notes demonstrated a progress note that was created on 10/16/2023 at 09:48 p.m. and with an effective time as 01:00 a.m. which stated Cenobamate was not administered from his admission through this am due to unavailability. We will transfer patient to ED for urgent evaluation as patient is at high risk for rapid decompensation and recurrent seizures. Review R1's medical record demonstrated a progress note that was entered on 10/16/2023 at 02:29 p.m. which stated Resident had a Grand Mal Seizure. Mom, UM [Unit Manager], NP [Nurse Practitioner} and RN [Registered Nurse} were in the room. 911 called. In an interview on 11//8/2023 at 08:00 a.m. Registered Nurse (RN) D explained that resident medication is ordered through a computerized system called PCC (Point [NAME] Care) and those orders are transmitted directly to pharmacy. She explained that if medication is not available in the facility and was supposed to be delivered earlier by pharmacy that the staff has access to Pharmscripts, which is the direct system for pharmacy, to inquire about the medication delivery. She explained that pharmacy will drop ship medication immediately or have it delivered from anther pharmacy. RN D explained that it if there was a delay in the medication arriving at the facility was necessary to complete an incident report and contact the physician and to enter a progress note in the medical record of the resident. In an interview on 11/18/2023 at 08:07 a.m. Registered Nurse (RN) E explained that resident medication is ordered through a computerized system called PCC (Point [NAME] Care) and those orders are transmitted directly to pharmacy. She explained that if medication is not available in the facility and was supposed to be delivered earlier by pharmacy that the staff has access to Pharmscripts, which is the direct system for pharmacy, to inquire about the medication delivery. She explained that pharmacy will drop ship medication immediately or have it delivered from anther pharmacy. RN E explained that it if there was a delay in the medication arriving at the facility was necessary to complete an incident report and contact the physician and to enter a progress note in the medical record of the resident. RN E explained that some medication was available in the back up box located in the facility and those medications were high risk medications. She explained that an example of high risk medication would be an anti-seizure medication. In an interview on 11/08/2023 at 08:32 a.m. Director of Clinical Services B was acting as the Director of Nursing (DON) for the facility as the DON was currently out of the facility ill. She explained that she was aware of R1 not receiving Cenobamate Oral Tablet 200 mg (milligrams) during his stay at the facility. She explained that an investigation was completed and found that since Cenobamate oral tablet 200mg is a scheduled II control that it required a written prescription from the physician. She explained that a signed prescription was never sent to pharmacy regarding this issue. She could not explain if the DON was made aware prior to R1 having an seizure and being sent to the hospital for treatment. Director of Clinical Services B explained that it was the expectation that nursing staff would contact the physician if a medication is not available. Director of Clinical Services B reviewed R1's medical record and could not demonstrate that R1's physician had been made aware of R1 not receiving Cenobamate Oral Tablet 200 mg as ordered. She did confirm that anti-seizure medication was considered a high risk medication. Director of Clinical Services B could not explain why R1 had not received Banzel Oral Tablet 200 mg for three days when he was admitted .

This citation pertains to intake numbers MI 437 and MI 342. Based on interview and record review the facility failed to ensure one out of five residents (Resident #5) was free of significant medication errors, resulting in Immediate Jeopardy when Resident #6 received another resident's eight medications, which resulted in Resident #6 receiving Cardiopulmonary Resuscitation (CPR), subsequently being transferred to the hospital, and placing all 91 residents who resided in the facility at risk for serious harm, injury, and/or death. Findings Included: Resident #6 no longer resided at the facility at the time of the investigation. Per the facility face sheet Resident #6 (R6) was admitted to the facility on [DATE], and readmitted on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a :Minimum Data Set (MDS) dated [DATE], revealed R6 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated R6 had a moderate impairment in cognition. Review of R6's Medication Administration Report: (MAR) for the month of [DATE], revealed that on [DATE] at 6:00 PM, he received [MEDICATION(S)] 1 mg tablet times two (a blood thinner) and [MEDICATION(S)] 500 mg (an anti-diabetic medication) Record review of a Medication Error Report revealed that on [DATE] at 8:00 PM, R6 was administered the following medications that belonged to R8 in error: [MEDICATION(S)] 70 mg (used to treat opioid addiction or pain), [MEDICATION(S)] 0.25 mg (to treat anxiety), [MEDICATION(S)] 0.4 mg (used to treat [CONDITION(S)]), [MEDICATION(S)] 150 mg (an antidepressant and nerve pain medication), [MEDICATION(S)] 20 mg (to treat high cholesterol), [MEDICATION(S)] 2.5 mg (a blood thinner), magnesium 400 mg (a supplement), and [MEDICATION(S)] 500 mg (anti-diabetic medication). The error report revealed that the Physician was notified, and ordered a neurological assessment every two hours for 48 hours, blood sugar checks every four hours for 12 hours, hold R6's [MEDICATION(S)], place R6 on bleeding precautions, and on [DATE] obtain a complete blood count (CBC-blood test that can reveal whether a person had a lose of blood from bleeding, and how well a person's blood clots, not an exhausted list), comprehensive metabolic panel (CMP-blood test that reveals the level of glucose [sugar] in the blood, not an exhausted list), and an international normalized ratio (INR-blood test performed when a person takes a blood thinner medication, such as [MEDICATION(S)] and [MEDICATION(S)], for proper dosing of the blood thinner). Record review of R6's progress notes dated [DATE], revealed Resident (R6) was administered meds by error at @2000 (8:00 PM) on [DATE] that include [MEDICATION(S)] 70mg, [MEDICATION(S)] 20mg, xanax0.25mg, [MEDICATION(S)] 0.4mg, [MEDICATION(S)] 150mg, [MEDICATION(S)] 2.5mg, magnesium 400mg, and [MEDICATION(S)] 500mg. Notified o/c (on call) clinician at 2040 (8:40 PM). Received the following orders, neuro checks (assessment of a person's mental status) q2 (every two) hours x48 hours, blood sugar check q4 (every fours) hours x12hours, hold [MEDICATION(S)] today ([DATE]), CBC, CMP, and INR tomorrow, and bleeding precautions. Also notified DON (Director of Nursing) (name extracted) at 2100 (9:00 PM). VS (vital signs) at 2105 (9:05 PM) ,d+[DATE], 73, 17, 97.0, pulse ox (oxygen level) 95% on RA (room air). Resident was alert with spontaneous eye movement and followed neuroassessment commands appropriately. At 2130 (9:30 PM) resident (R6) was lying in bed with eyes closed and opened his eyes when his shoulder was touched and his name spoken simultaneously. At 2200 (10:00 PM) resident (R6) was pale and clammy and not responding to voice or sternal rub (rubbing of knuckles on the chest to obtain a response). Did not observe any respirations and unable to palpate (feel) a pulse. Called 911. Initiated compressions (chest compressions) and rescue breathing (assisted breathing). AED (Automated External Defibrillator) placed, no shock advised. Noted emesis (vomit), suction set up. EMS (Emergency Medical Services) entered room and assumed care. At 2300 (11:00 PM) notified residents emergency contact. Record review of hospital emergency room documentation, dated [DATE], revealed R6 arrived to the emergency room (ER) due to becoming unresponsive after receiving the wrong medications. The documentation further revealed, Accidental overdose of medications included [MEDICATION(S)] and [MEDICATION(S)] plus other medications .on EMS (Emergency Medical Services) arrival to facility, staff reported that CPR was initiated for 5 minutes at the rehab facility .EMS administered 2mg of [MEDICATION(S)] (medication used to treat narcotic overdose in an emergency situation) via IV (intravenous) and patient (R6) became minimally responsive. On EMS arrival to ED (emergency department), patient minimally responsive with medics (paramedics) were bagging (providing respirations) patient . Review of hospital records revealed that on [DATE], [DATE] R6 received additional doses of [MEDICATION(S)], and on [DATE] was placed on a continuous IV infusion of [MEDICATION(S)]. Review of Registered Nurse (RN) C employee file revealed the start date of RN C facility employment was on [DATE]. Furthermore, RN C file revealed she had not been checked off on a medication pass competency until [DATE]. In an interview on [DATE] at 10:52 AM, Administrator D, who was the previous Administrator and did not work at the facility any longer, stated she received notice of the significant medication error the morning of [DATE]. Administrator D said RN C was a newly hired nurse who was orientating with RN E on the second floor. Administrator D said the second floor resident were split between RN C and RN E, and each RN was passing medications to approximately ,d+[DATE] residents. Administrator D said while RN C was pulling R8's medications form the medication cart she needed to contact pharmacy to clarify of one of R8's medications. Administrator D said RN C then put R8's pills, she had placed into a medication cup, into the top drawer of the medication cart. Administrator D said RN C had written down R8's date of birth, but upon speaking to the pharmacy she gave the pharmacy R6's name and R8's date of birth. Administrator D further stated that when RN C returned to the medication cart she removed the medications that were in the medication cup, and administered R8's medications to R6. Administrator D also stated it was when R8 approached RN C for his [MEDICATION(S)] that RN C realized she had given R8's medications to R6. In an interview on [DATE] at 3:07 PM, RN E said that on [DATE] it was the second day she was training RN C. RN E said on the first time she trained RN C was the day before ([DATE]), and said RN C passed resident's their medications with her right beside her. RN E stated that the next day ([DATE]) RN C wanted to pass resident's their medication on one side of the hall on her own. RN E said there was only one computer available for both herself and RN C to use to pass resident medications, and stated they had to flip back and forth between her resident and RN C's residents. In an continued interview RN E said RN C had told her at approximately 8:30 PM, that at about 8:25 AM she had given R8's medications to R6 in error. RN E stated that RN C then called R6's Physician, reported the medication error, and received orders from the Physician. RN E said that when RN C called the pharmacy to clarify a medication for R8, she had written R8's date of birth next to R6's name. In a further interview RN E said RN C had not told her until later on that evening that she had left R8's medications in the medication cart when she went to call the pharmacy. RN E stated that it was not the facility's policy and procedure to lock resident medications that had already been pull in a medication cup in the medication cart. RN E further stated R6 was checked on every 15 minutes, and upon RN C checking on R6 at approximately ,d+[DATE]:30 PM, RN C found R6 unresponsive. RN E said when RN C came out of R6's room she had told her that R6 was not doing well. RN E said a Certified Nurse Aid (CNA) then brought the crash cart (emergency cart) into R6's room, and RN C had started CPR. In an interview on [DATE] at 9:09 AM, RN C stated that she was pulling R8's 6:00 PM medications from the medication cart when she realized R8 had a change in his order for one of his medications, and she needed to call the pharmacy for clarification. RN C said she then locked R8's medication that were in a medication cup in the narcotic box in the medication cart. RN C further stated that she did not label the medication cup with R8's name, room number, or name of the medications in the cup. In a further interview RN C said she had written down R8's date of birth and R6's name, and when she called the pharmacy she had given the pharmacy R8's date of birth and R6's name, which caused the pharmacy to no be able locate the correct resident (R8) in their system. RN C said she ended the call, went back to the medication cart, retrieved the medications, and then proceeded to administer the medications to R6. RN C said she put the medication cup on R6's table and R6 tool the medications. RN C stated she did not ask R6 his name prior to administering the medications to him, and said R6 was not able to identify himself due to confusion. RN C then stated that she would look at the name plate that was outside of the room doors, and the top resident name was the resident residing in bed one and the bottom name was the resident in bed two, and that was how she identified residents. RN C said she had looked at R8's picture that was in his electronic medication record (EMR) once, but did not look at it again. RN C said she had not been told what the facility's process was for identifying residents. RN C said she did not know who R8 was being that it was only her second say working at the facility. Review of R8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview RN C said that after she had given R6 R8's medications she proceeded to administer two to three other residents their medications when R8 approached her and asked her about his medications, and why he had not received them. RN C stated that she asked R8 his name, and upon reviewing R8's MARs she noticed that the medications R8 was asking for she had administered to R6. RN C said she reported the error to RN E, contacted R6's Physician, and received orders to perform neuro checks every two hours for 48 hours, blood sugar checks every four hours for 12 hours, hold R6's [MEDICATION(S)], obtain a CBC, CMP, and INR on [DATE], and put R6 on bleeding precautions, and further stated she notified the Director of Nursing (DON) B at 9:05 PM of the error. RN C said she checked on R6 several times, but said when she checked on him at 9:30 PM he was cold, clammy, unresponsive, and she was not able to feel a pulse. RN C said she then ran down the hall and told RN E to call a code (used to announce that a resident is in [CONDITION(S)]), while she called 911. RN C said she went back into R6's room and began chest compressions, and another staff member used an Ambu bag (used to provide manual breaths) to deliver breaths to R6 until the Emergency Medical Services (EMS) arrived and transferred R6 to the hospital. At 12:16 PM, right after completion of the interview with RN C, RN C called back and stated that even though she was not checked off on her medication pass competency, she had worked the day before ([DATE]) with RN E who was right by her side when she passed resident's medications and she did fine. On [DATE], at 9:50 AM, the Administrator was notified of the Immediate Jeopardy that was identified on [DATE], and on began on [DATE], when on [DATE] Resident #6 received eight of R8's medications, which resulted in Resident #6 receiving Cardiopulmonary Resuscitation (CPR), and subsequently being transferred to the hospital. On [DATE] it was verified that the facility implemented the following to remove the Immediate Jeopardy: On [DATE] Nurse (name omitted-RN C) was suspended pending investigation. Beginning [DATE] all nurses educated on the rights of medication administration, same name alert. ,d+[DATE] nurses completed by [DATE] remaining 3 nurses will be educated upon first shift back to facility. Beginning [DATE], 13 out of 25 nurses have been observed for medication administration. Remaining 12 nurses will be observed upon first shift back to facility. On [DATE], ,d+[DATE] residents residing on the 2 West unit were assessed to ensure correct medication administration. An Ad Hoc QAPI with root cause analysis was completed on [DATE] where the team identified key factors. Key factors that were identified have been corrected to include: A. On [DATE] Similar name alert stickers have been added to doorways of residents with similar names/like names to alert staff upon entry of potential name confusion. B. On [DATE] a laptop has been set up for med pass training to provide each nurse separate log in access to PCC. C. On [DATE] Physician on call support was given PCC (Point Click Care [EMR]) access to review medications or resident notes at time of reporting incident. 11. New Policies or procedures that have been reviewed or updated: A. On [DATE] the process for nurse onboarding (training of new staff). Upon completion of general orientation to the facility nurses are given an orientation schedule with a nurse preceptor guided by DON. As the nurse progresses through orientation and nurse competency checklist is completed. Upon completion of checklist DON reviews to determine completion of orientation and ability to work independently. B. On [DATE] the policy Physician services was reviewed and deemed appropriate by the QAPI (Quality Assurance and Performance Improvement) committee. The Medical Director educated on call support staff on [DATE]. Nurse (name omitted-RN C) was competency evaluated on [DATE] and found competent to complete medication administration. Her check off was reviewed and found to be complete with satisfactory performance. She will continue orientation for the next 3 shifts worked. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not been verified by the state agency. On [DATE] the facility provided and requested Past Non-Compliance which was determined to be appropriate by the state agency for this citation. Plan of corrected outlined below: On [DATE] the facility identified a significant medication error had occurred with R6 when R6 received another resident's medications. On [DATE] Nurse (name omitted-RN C) was suspended pending investigation. Twenty five out of 25 nurses were educated on the rights of medication administration, same name alert. Twenty five out of 25 nurses had been observed for medication administration. Nurse (name omitted-RN C) was competency evaluated on [DATE] and found competent to complete medication administration. Her check off was reviewed and found to be complete with satisfactory performance. She will continue orientation for the next 3 shifts worked. All 26 out of 26 residents residing on the 2 West unit were assessed to ensure correct medication administration. An Ad Hoc QAPI with root cause analysis was completed on [DATE] where the team identified key factors. Key factors that were identified have been corrected to include: A. On [DATE] Similar name alert stickers have been added to doorways of residents with similar names/like names to alert staff upon entry of potential name confusion. B. On [DATE] a laptop has been set up for med pass training to provide each nurse separate log in access to PCC (Point Click Care [EMR]). C. On [DATE] Physician on call support was given PCC access to review medications or resident notes at time of reporting incident. 11. New Policies or procedures that have been reviewed or updated: A. On [DATE] the process for nurse onboarding (training of new staff). Upon completion of general orientation to the facility nurses are given an orientation schedule with a nurse preceptor guided by DON. As the nurse progresses through orientation and nurse competency checklist is completed. Upon completion of checklist DON reviews to determine completion of orientation and ability to work independently. B. On [DATE] the policy Physician services was reviewed and deemed appropriate by the QAPI committee. The Medical Director educated on call support staff on [DATE]. 12. Ongoing medication pass observations will be conducted with a minimum of eight per week. The DON will submit findings to the QAPI committee monthly. The QAPI committee will determine the ongoing frequency of training opportunities. 13. Six quiz opportunities will be conducted with nurses weekly on the key points of medication administration will be conducted. The DON will submit findings to the QAPI committee monthly. The QAPI committee will determine the ongoing frequency of training opportunities. The Immediate Jeopardy was removed on [DATE], the facility Past Non-Compliance was verified on [DATE]. The facility was determined to be in substantial compliance on [DATE].

This citation pertains to MI 678 and MI 761. Based on interview and record review, the facility failed to provide all necessary care and services necessary for one of three reviewed for quality of life Resident #3, resulting in Resident #3 (R3) not maintaining her highest practicable well-being, delayed her choice to be discharged to the community and endangering her life. Findings include: According to the Minimum Data Set (MDS), dated [DATE], Resident #3 (R3) was admitted from the hospital on [DATE], was severely cognitively impaired, needed extensive assistance of 2 or more staff with bed mobility, received Physical Therapy 2/07/20 - 3/24/20 and Occupational Therapy 2/07/20 - 3/13/20, was totally dependent on two or more staff for transfers, had no pressure ulcers and had [DIAGNOSES REDACTED]. However, R3 did not return to the facility. Review of R3's Care Plan, dated 2/09/20 and revised on 3/03/20, revealed, I wish to be discharged to the community. My referral has been sent to Tri-County Office on Aging to assist with placement . According to a Complaint Intake (anonymous complainant), dated 09/18/2020 at 9:21 AM, Patient (R3) was in the office today to follow up with PCP (Primary Care Physician) office. During this time, I was called to the visit to meet with patient as she was brought in by stretcher which has not been her baseline. She was accompanied by her Son (V) and Daughter in law (W) who all shared the same concern .(R3) is VERY deconditioned . Part of my role is helping patients coordinate care and obtain the services that they need. In my time of 8 years doing this job I have NEVER heard of a SAR (sub-acute unit) not doing PT (Physical Therapy/OT (Occupational Therapy), that is the whole point of staying at one to work you back to get you living independently as safe as possible. Many items were very concerning and apparent during her visit with our office. 1. Back in March patient had an MRI (imaging scan) completed that showed: suspect pathologic enhancement at margins of conus or along cauda equina, nonmasslike in appearance. Diagnostic considerations include [MEDICAL CONDITION]/infectious as well as neoplastic process. Clinical and laboratory correlation recommended. CSF (cerebro spinal fluid) analysis may provide additional information. 2. This report was called and shared with (name of facility). It suggests that antibiotics were needed but that there is also a chance [MEDICAL CONDITION] growth. This has never been followed up on and it is now September. Report was called to the PCP of (name of facility) who was handling her care and never followed up. 2. Pt has significant deconditioning as evidence by not being able to sit up off the stretcher on her own or even roll side to side. Pt states that she cannot walk at this point and is so very weak. She states she has been left in her wheelchair just sitting in her room for 8+ hours and many times well past midnight. She could not even roll herself side to side when we were trying to evaluate skin breakdown . we sent her to the hospital from our office .There was also significant vaginal blood in brief as well . 5. (R3) has been having vaginal bleeding and relies on cream to help this, 6. Pt states that she wants to get better and wants to work on therapies, but she is consistently encouraged to stay in bed. Often being left most of the day without anyone checking in on her . (R3) has been with (facility) since February and not made any meaningful gains . (Son V and Daughter-in law W) have not been able to come into the facility and see her due to COVID but have lots of concerns as well. From our office we have direct admitted patient the hospital based on the MRI from March, her deconditioning . and overall concern for her health. We have recommended to the patient and family to not go back to the facility. There is major concerns for the treatment of [REDACTED]. (R3) and family have both shared experiences that are concerning. Then finding supportive evidence during an exam leads to great concern on the treatment and care these patients are receiving. According to a second Complaint Intake, dated 9/14/20, (different anonymous complainant), .(R3) was promised physical therapy after a physical assessment a few weeks ago . (R3) wants to leave and have home health care. However, (R3) is not being allowed to leave . According to a third Complaint Intake, dated 9/18/20, (a third anonymous complainant), . an MRI of the lumbar spine was done . in March 2020 that was never properly followed-up on or treated . Review of R3's Hospital Discharge orders and admission orders [REDACTED]. Review of R3's Medication Administration Records revealed she was administered Jakafi 20 mg 1 time a day 2/08/20 - 4/09/20, but none since 4/09/20 during her admission at the facility. According to Incyte Corporation (Pharmaceutical company), 4/2020, Jakafi is a prescription medicine used to treat adults with [DIAGNOSES REDACTED] who have already taken a medicine called [MEDICATION NAME] and it did not work well enough or they could not tolerate it. Jakafi is used to treat adults with certain types of [DIAGNOSES REDACTED] (bone [MEDICAL CONDITION]) If you have been prescribed Jakafi for an FDA-approved use and you experience a delay in coverage, we may be able to provide a free 30-day supply of medicine. No purchase contingencies or other obligations apply. <https://www.incytecares.com/jakafi/home.aspx> According to Incyte Corporation (Pharmaceutical company), 8/2020, [DIAGNOSES REDACTED] (polly-sigh-THEE-me-ah-VAIR-Ah), or PV, is a rare, chronic [MEDICAL CONDITION] where the bone marrow produces too many red blood cells. You may also have too many white blood cells and platelets (blood clotting cells) in your blood but having too many red blood cells causes most of the problems associated with this condition. PV is part of a group of diseases called myeloproliferative neoplasms, or MPNs. Too many red blood cells can cause the blood to thicken. Thicker blood doesn't flow normally through arteries and veins. Increased blood thickness and decreased blood flow, as well as abnormalities in your platelets and white blood cells, may increase your risk of blood clots. Blood clots can cause a stroke, [MEDICAL CONDITION], or blockage of an artery in your lungs or in a vein deep within a muscle in your arms or legs. PV usually develops slowly. But as the symptoms get worse, they can take a toll on you and affect your daily life. In a very small number of people, PV leads to other blood diseases, such as [DIAGNOSES REDACTED] (MF) (a disease in which scar tissue develops in the bone marrow) or [MEDICAL CONDITION]. [DIAGNOSES REDACTED] (PV) is a chronic [MEDICAL CONDITION]. This means it lasts a long time and may never go away. Some people with PV may not have symptoms. Others have severe symptoms that interfere with their daily lives. PV is also a progressive disease. This means that it may advance or get worse over time. It is important to talk to your Healthcare Professional about controlling your blood counts and disease-related symptoms. Knowing how PV is affecting you gives your Healthcare Professional important information to help manage your care. [DIAGNOSES REDACTED] (PV) symptoms include: Tiredness (fatigue) Itching (especially after a warm shower) Headache Sweating (at night or during the day) Blurred vision or blind spots Painful burning or numbness of the hands or feet Bleeding from the gums and heavy bleeding from small cuts Bone pain Shortness of breath Abdominal pain or discomfort Early feeling of fullness when eating Pain under the left ribs Problems concentrating Dizziness, [MEDICAL CONDITION], lightheadedness [MEDICAL CONDITION] Reddening of the face, or a burning feeling on the skin [MEDICAL CONDITION] (chest pain) Ringing in the ears Your spleen (see below) helps your body fight infection and filter unwanted material, such as old or damaged blood cells. For a number of reasons, [DIAGNOSES REDACTED] can cause your spleen to grow and become bigger. An enlargement of the spleen is known as [DIAGNOSES REDACTED] (splee-nuh-MEG-uh-lee). Symptoms of an enlarged spleen can include: Pain or discomfort in your abdomen or under your left ribs Feeling full when you haven't eaten or have eaten very little Hematocrit is a measure of the volume of red blood cells in the blood and is stated as a percentage. Signs that your PV is not being controlled can include a hematocrit level above 45%. Medical research suggests that an elevated hematocrit level can increase the risk of serious health problems, such as blood clots leading to [MEDICAL CONDITION] or stroke. Your Healthcare Professional may have a different hematocrit target for you based on your individual case and may periodically order blood tests to monitor your condition. In addition to hematocrit, your Healthcare Professional may look at your red blood cell count, white blood cell count, and platelet count. Keeping your blood counts-particularly your hematocrit-at the right levels is an important goal in managing your condition. Study findings have shown that for some patients, stabilizing blood counts can help lessen the chance of serious complications. >https://www.voicesofmpn.com/polycythemia-vera.aspx?utm_source=bing&utm_medium=cpc&utm_campaign=ENG_PV_Condition_Exact__%3BS%[MEDICAL CONDITION]%3BUB%3BHEM%3BDTC%3BCON&utm_content=G_PV_General_E&utm_term=polycythemia+vera&gclid=CLSgztPmtuwCFYPJswodUgYHGQ&gclsrc=ds> According to Medterms online Medical Dictionary, Spleen: An organ that is located in the upper-left part of the abdomen, not far from the stomach, that produces lymphocytes, which are important elements in the immune system. The spleen is the largest lymphatic organ in the body. The spleen also filters blood, serves as a major reservoir for blood, and destroys blood cells that are aged (or abnormal, as in the case of [MEDICAL CONDITION] cells).< https://www.medicinenet.com/script/main/art.asp?articlekey=5531> Review of R3's Hospital Discharge orders and admission orders [REDACTED]. Give 1 tablet by mouth one time a day every Mon, Wed, Fri (15 tablets. 0 refills). Review of R3's Medication Administration Records (MARS), revealed she had been administered Bactrim DS (double strength antibiotic) Tablet 800-160 MG. Give 1 tablet by mouth one time a day every Mon, Wed, Fri for [MEDICATION NAME] every day during her admission (over seven months). However, review of R3's medical record, including physician orders, physician progress notes [REDACTED]. According to the Association for Professionals in Infection Control and Epidemiology, 2020, Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by [MEDICAL CONDITION]. Misuse and overuse of antimicrobials is one of the world's most pressing public health problems. Infectious organisms adapt to the antimicrobials designed to kill them, making the drugs ineffective. People infected with antimicrobial-resistant organisms are more likely to have longer, more expensive hospital stays, and may be more likely to die as a result of an infection. Review of Physical Medicine and Rehabilitation (PM&R) Progress Notes, dated 3/17/2020 14:47, revealed, . (Son V) reports difficulty with transportation . and notes dated, 3/24/20 and 4/08/20, revealed, .She has bilateral lower extremity weakness, right leg more than left. MRI lumbar spine . MRI lumbar spine also noted suspected pathologic enhancement at margins of conus or along cauda equina, nonmasslike in appearance . are recommending immediate follow up . Neurological evaluation .MRI [MEDICATION NAME] spine ordered, however it does not appear this was completed She is no longer receiving PT/OT; however, I did note recertifications from therapies in the chart. Pending her medical course, she would definitely benefit from re-evaluation and further therapies simply to maintain current function . In an interview, on 10/14/20 at approximately 12:00 PM, Nurse Aide (CNA) SS said she had not done or assisted with range of motion exercised for R3 because it was not on her Care Guide (Kardex). CNA SS said, There is no Restorative Therapy here . there's been no restorative program since I've been here. Review of R3's Care Plans revealed no interventions for range of motion or other restorative physical therapies. In an interview, on 10/14/20 at 1:31 PM, Physical Therapist (PT) EE reported she had worked at the facility since April 2020 but did not recommend restorative exercises when R3's therapy ended because: I haven't referred anyone with leg exercise with staff .There are home exercises I give out to the residents, but not those residents with cognitive deficits because they won't be able to follow them . I am under the impression we don't have Restorative Therapy here. Where I worked before, we would train the floor staff. I was not aware of that option for long term care residents here . (R3) was in therapy 2/06/20 -3/24/2000 and was dependent (on staff for) transfer. I know they were using the Hoyer (mechanical) lift on her. There was no comment regarding leg strength at discharge . At discharge she had made progress with rolling in bed, mod assist; dependent for lying to sitting to side of bed but at discharge she was moderate assist; dependent for sit to stand. No ambulation. My evaluation on 9/04/20 - to me she presented like [MEDICAL CONDITION] (declined). RLE (right lower extremity) 1 strength, LLE (Left Lower Extremity) 3; anything under 5 is extreme weakness. While we were trying to get authorization for more therapy (not until 9/05/20 per Therapy records), she went out and never came back. The request to reevaluate came because there was a request from (R3) stating that she didn't want staff to use the machine to transfer, wants to be able to transfer without the lift. PT EE said she was aware that R3 had been living alone at home, using a walker, but could not say when the last time R3 walked. PT EE said, (R3) has been non-ambulatory since admit in February, (2020). In an interview, on 10/15/20 at 10:15 AM, Admissions Coordinator X stated she knew R3 was taking [MEDICAL CONDITION] medication (Jakafi) at the time of her admission. Admissions Coordinator X said, Specialty Medication factors into admission process. Yes, I recall her being on a specialty medication at the time of admission. Her med was not dispensed by our pharmacy. I had to get permission from (Director of Business Development Y) and (Owner Z) for her admission. That is the process . her admission went through the admission approval process. I don't know if there is a policy they go by regarding admitting residents on specialty medications . (Hospital) records . shows (R3) need for f/u (follow up) on 2/27/at 11:20 AM. Hospital discharge paperwork dated 2/06/20 shows f/u appointments with (Internal Medicine Physician AA on 2/27/at 11:20 AM but there was no evidence the facility facilitated this appointment or the appointment was kept. In an interview, on 10/15/20 at 12:08 PM, R3's Son V reported, My mother is doing a lot better now. Is at (a different facility). Son V said the appointment scheduled for 4/30/20 was a video call between (Oncologist II) and the facility. I was not invited. The doctor at (the facility) said she would never walk again and said they decided she didn't need any more therapy. When I would call (Social Worker C), I would get voice mail. When I did speak with her, she told me she would have the nurse to call me. I would wait but nobody would call me. I would have her buzz the nurse and no one would come, then I would call down to the receptionist desk, they would transfer me, and I would have to leave a message. (SW C) would tell me I will have the nurse call back in 20 minutes, but it would never happen . I did not refuse to take her to appointment with (Oncologist II). No face-to-face. I had to get her a phone because the phone she had she didn't know how to use. That was a problem. A couple of ladies were really nice and let her use their personal phones . (SW C) said she had an appointment with ob/gyn. I asked, how long has this been happening and she said a couple of weeks. No one told me. I didn't know she had these appointments until the day before or the day of. They didn't tell me in enough time. Caused me a lot of stress . When I called the nurse's station, they wouldn't answer. I would stay on the phone for 1 ½ hours and no one would come in. Yes, she is on Jakafi now. I got it for her when she went into the hospital . they talked to (Oncologist II) and her neurologist, they made sure she got that medicine. I told (the facility) she is supposed to take it every day and they said she didn't need it. I told them (Oncologist II) said she needed it every day for the rest of her life. (R3) in Physical Therapy right now . Therapy is going great; she can slide over and get to wheelchair with a little assistance. She can stand up, not sure how long. She did that in the hospital . In an interview, on 10/15/20 at 1:17 PM, Social Worker (SW) C reported, (R3) was (Jakafi) when she first came in. I don't know the details of her coming off of it . I don't know anything about appointment in April. I can't remember. I was not involved in her appointments . I don't remember anyone here saying why it was discontinued. It was restarted at the end of her stay. I remember her saying vaginal bleeding was from not taking Jakafi. Second floor UM would have been (former second floor Unit Manger CC). and (third floor Unit Manager DD) in the last couple of weeks. In a lengthy interview, on 10/15/20 from 1:55 PM - 3:29 PM, Medical Director (MD) P reported the facility did not have all records from R2'[MEDICAL CONDITION] doctors (affiliated with Hospital 2) where he reported her Jakafi was originally prescribed. MD P said R3's last visit to the oncologists (cancer doctors) was in July 2019, that she had a short stay at a different nursing home and also went home for a couple of days in 2019 before she was admitted to Hospital 2 in January 2020, just prior to her admission to the facility on [DATE] with no records except from the hospital . MD P stated the facility contracted Physical Medicine and Rehabilitation Physician GG ordered an MRI (imaging study) of R3's [MEDICATION NAME] and lumbar spine because of weakness of unknown origin in R3's lower extremities, but for unknown (and uninvestigated) reason, only the MRI of the lumbar spine was done by radiology. MD P said, For one reason or other, [MEDICATION NAME] was not done. Issues we need to clarify. According to MD P the lumbar MRI revealed a suspected pathological enlargement . and it was recommended she have follow-up. Review of R3's MRI Lumbar Spine report, dated 3/13/2020: IMPRESSION: . Suspect pathologic enhancement at margins of conus or along cauda equina, nonmasslike in appearance. Diagnostic considerations include [MEDICAL CONDITION]/infectious as well as neoplastic process. Clinical and laboratory correlation recommended. CSF (cerebral spinal fluid) analysis may provide additional information. Interview with MD P continued with him saying, Apparently, unbeknownst to me, PMR GG arranged with (Oncologist II from Hospital 2) to tele-visit with (R2), that was not coordinated through me or the Nurse Practitioner (HH) . They were going to prescribe her (Jakafi). From that point what happened, it is not clear, we were not involved. When it became clear in June we hadn't heard from (Oncologist II), (Physician Assistant HH) scheduled a consultation with (Hospital 1) . MD P stated R2's Hospital Discharge instructions included a follow up visit with the neurologist but R3 had not yet seen neurologist. That hasn't happened. This was confirmed in a hospital Neuro consult, dated 2/05/20, that read, The patient would benefit from further neuropsychological testing after discharge. MD P reported his thoughts regarding R3's condition at discharge, saying, .We did monitor her red blood count, did lab testing and no evidence of inflammation . Vaginal bleeding, we sent to her to and OB/GYN (obstetrics and gynecology) 8/ 13/20. There was no change in her condition while she was here. MD P said R3's Son V was not taking care of his needs of R3 and the lack of communication with (Hospital 2 specialist) were the root cause of R3 not having Jakafi available for R3's care. Review of a Health Status Note, dated 4/09/20 at 10:54 AM, revealed, This nurse spoke with nurse at (Oncologist II's) office in regard to medication, Jakafi refill. Nurse informed this nurse that at this time this med isn't to be refilled until (R3) is seen by in office. (R3) isn't scheduled to be seen until June sometime. Med to be d/c (discontinued) until (R3) seen by (that office). However, the facility had no evidence that this appointment was made or kept. Review of a Fax, dated 4/21/20, from Oncologist II to the facility, revealed, (R3) is scheduled for a phone visit with our clinic providers on 4/30 at 12:20 pm. Please have patient available to speak with the physician. We will also send a note to her family regarding appointment date and time in case they would like to be present for the call . (The facility had no evidence they facilitated a tele-visit on 4/30/20). This fax also requested Please draw labs as soon as possible and have results faxed to clinic . Review of Progress Notes from Oncologist Physician II, faxed to the facility, on 10/15/20 at 10:35 AM (during the survey), revealed conflicting and non-confirming information as to whether tele-med visit(s) actually occurred. The faxed Progress Note dated 6/19/20 at 10:14 AM revealed, Today, 4/30/30 (not 6/19/20), 5 months after her last visit, we had a phone call visit dictated by the circumstance of COVID 19 Pandemic. The patient is in a nursing home confined to bed and not walking, she wishes not to stay there and to go home . Laboratory: she appears to have well controlled P. vera with normal hemoglobin and platelets and normal blood chemistries (this document did not list the values or say what date the laboratory data was done), at this point we do not require any treatment modification. However, another note in the same fax, dated 6/19/20 at 10:44 AM (30 minutes later) revealed, Impossible to connect with patient. The phone doesn't ring - disconnected? However, review of laboratory data revealed R3's platelet count (normal range: 150 - 400) increased after she quit taking Jakafi on 4/09/20: 4/23/20 - 390 (normal range) 5/28/20 - 371 (normal range) 6/23/20 - 474 (High) 6/25/20 - 482 (High) 7/07/20 - 500 (High) 7/21/20 - 602 (High) 7/28/20 - 634 (High) 8/27/20 - 571 (High) 9/18/20 - 735 (High) Review of laboratory data revealed R3's hematocrit levels (normal range 36 - 45) increased: 4/23/20 - 42.7 (normal range) 5/05/20 - 44.2 (normal range) 6/23/20 - 44.9 (normal range) 7/28/20 - 45.5 (High) 8/27/20 - 46.1 (High) 9/18/20 - 46.3 (High) Review of laboratory data revealed R3's red blood cells (normal range 3.5 - 5.55) increased: 4/23/20 - 5.17 (normal range) 5/05/20 - 5.51 (normal range) 6/23/20 - 6.23 ((High) 7/28/20 - 6.66 (High) 8/27/20 - 6.90 (High) 9/18/20 - 7.02 (High) Review of laboratory data revealed R3's white blood cells (normal range 4.0 - 12.0) increased: 4/23/20 - 10.0 (normal range) 5/05/20 - 10.0 (normal range) 6/23/20 - 12.1 (High) 7/28/20 - 12.0 (High) 8/27/20 - 12.2 (High) 9/18/20 - 12.5 (High) Review of PM&R Progress Notes, dated 3/17/20, revealed R3 suffered from: -Right greater than left L4-L5 lumbosacral radiculopathy (lower back pain) -Bilateral lower extremity weakness, R>L -Right leg pain -Right ankle pain -Left knee locking -Neuropathic (nerve) pain Review of R3's MARs revealed R3 reported increasing pain levels: February - no reports of moderate or severe pain. March - moderate pain 4 times (no severe pain) April - 3 times pain moderate and 2 severe May - 3 times moderate and 3 severe June - 14 times moderate, 6 severe and 1 very severe July - 13 times moderate and 8 severe August - 17 times moderate, 6 severe and 1 very severe September (only 18 days) - 7 times moderate, 14 severe and 1 very severe Review of R3's Admission Pain Assessment (2/06/20) showed her pain levels ranged between 2 -5 (low - moderate pain) but the location of the pain was not documented. A Pain Assessment, dated 5/06/20 revealed pain levels were 4 -6 (moderate - severe) but did not state the location of the pain, and a Pain Assessment, dated 8/06/20, revealed location of pain was right ankle now score between low and very severe. According to R3's Pain Care plan, dated 2/09/20 and revised on 5/18/20, I am at risk for pain r/t weakness, dx of neuro[DIAGNOSES REDACTED] (see below), OA, DJD, [DIAGNOSES REDACTED] . I will remain pain free . The care plan did not list the location of R3's pain. According to the National Institute of Neurological Disorders and Stroke, 3/27/19, Neuro[DIAGNOSES REDACTED] is a manifestation of [DIAGNOSES REDACTED] in the nervous system. [DIAGNOSES REDACTED] is a chronic [MEDICAL CONDITION] disorder . primarily affects the lungs but can also impact almost every other organ and system in the body. Neuro[DIAGNOSES REDACTED] is characterized by inflammation and abnormal cell deposits in any part of the nervous system - the brain, spinal cord, or peripheral nerves . It can cause headache, [MEDICAL CONDITION], memory loss, hallucinations, irritability, agitation, and changes in mood and behavior . Doctors generally recommend corticosteroid therapy as first-line therapy for individuals with the condition . <https://www.ninds.nih.gov/Disorders/All-Disorders/Neuro[DIAGNOSES REDACTED]-Information-Page In an interview, on 10/21/20 at 11:03 AM [PHONE NUMBER] former Unit manager KK reported, I remember it being reported (R3) would (R3's pain was) mostly in her lower back. That's why she wanted to get in the chair early in the morning because staying in bed would hurt her back. According to the Hospital 1Admission History and Physical, dated 9/18/20 at 8:34 PM, (R3) is a 75 y.o. (year old) female with a PHM (past medical history) significant for [DIAGNOSES REDACTED] (JAK2+ follows with (Hospital 2, ruxolitinib) (see below), chronic urinary incontinence, [MEDICAL CONDITION] who was sent today to (Hospital 1) from (Hospital 2) clinic . Per the sign out, it was stated that patient had MRI in (3/13/2020) that shows evidence of multilevel mid - lover lumbar severe foraminal encroachment with possible compression of exiting nerve roots, with suspicion for pathologic enhancement at margins of conus or along cauda quina that's possibly considered for [MEDICAL CONDITION]/infectious or neoplastic process. Additionally, (R3) has ongoing vaginal bleeding despite previous Total abdominal hysterectomy for more than a month. She mentioned that her bleeding started as cupful continuous bleeding, that decreased later in amount, but still on going. When I called (facility), patient was still on Xarelto (blood thinner) despite the vaginal bleeding . (R3) stated that last time she was ambulating was in December 2019, and she was a (Hospital 2) after that time and was discharged to (facility) in January, and since that time, per patient she didn't have much physical therapy and was bedridden. Later in the day, I received a phone call from (Medical Director P), who's the physician from the facility, who stated that the patient was diagnosed with [REDACTED]. In an interview, on 10/20/20 at 2:38 PM, Nurse Aide (CNA) LL reported she was assigned to care for R3 the evening of 9/17/20 and said although R3 developed a pressure ulcer during her stay it was healed. Nurse Aide LL said, Yes, her bottom was looking good. A wound on her coccyx was healed when she left here. (Review of Wound Records revealed a Stage II wound on R2's sacrum began on 6/16/20 and resolved on 6/30/20. Review of R3's TARs revealed a protective dressing was being applied 8/06/20 - discharge.) I work second shift. I had to call someone to help me because she wasn't moving good. She couldn't move her lower part since she'd been on third floor. She was a total 2-person assist. She could move her arms. On second shift, she would tell us if she wanted to stay up or lay down. Her (adult) brief was sometimes soaked with urine and lots of blood and blood clots - with heavy clots like someone on a heavy period. (Nurse Aide LL held up her hand and showed a circle the size larger than a golf ball). She kept bleeding down there. I notified the nurse. The first two days slightly bleeding, after that it was heavy. I put in an alert to the nurse She could tell if she had a bowel movement and would say I need a change. No complaints from her about not being laid down, gotten up, moved, etc. Sometimes she would put the call light on and say she was in pain. She wouldn't tell me - would say it's none of your business, get me the nurse. I'm in pain, go get the nurse. According to a Health Status Note, dated 7/19/2020 at 5:38 PM, CNA alerted LPN to blood in resident's brief. Upon inspection, about 50ml of serosanguinous fluid in resident's brief, as well as 7-10 mL of blood and mucus in brief. Fluid and amount in brief was verified with LPN on floor with supervising RN on 2 West. Patient was educated on potential signs and symptoms of hypovolemic shock . Review of R3's MARs revealed Xarelto (blood thinner) 20 mg one tab by mouth was ordered/administered 2/07/20 - 9/21/20. There were no Pharmacy Recommendations related to the use of Xarelto and the unusual bleeding. According to (Hospital 1) Discharge History and Physical, dated 10/8/2020, . Presented with B/L LE (both lower legs) Weakness (R/right > L/left), diagnosed as Neuro[DIAGNOSES REDACTED] (as of Hospital 2 records), Neurology were consulted, recommended MRI (imaging report), EMG (electrical muscle test) and follow with LP (lumbar puncture) which showed increase protein. Neurology obtained patient's record from (Hospital 2 Neuroimmunology) to correlate clinical finding and both concluded on a [DIAGNOSES REDACTED]. (R3) completed a IV [MEDICATION NAME][MEDICATION NAME] (steroid) 5 day course and then start a course of steroids taper with 60mg [MEDICATION NAME] daily on 10/4 for one week, to be tapered down by 10mg weekly until reaching maintenance dose of 10mg daily . (R3) was started on [MEDICATION NAME] (Immunosuppressant) 500 mg twice daily x 7 days. Starting on 10/13, increase [MEDICATION NAME] to 750mg twice daily x 7 days. After 10/20, can titrate up to 1000mg twice daily. To keep [MEDICATION NAME] at the dose she can tolerate if patient has GI symptoms. Patient will need CBC (bloodwork) monitoring for leukopenia (low white blood cells) while on [MEDICATION NAME] . Patient home dose of xarelto (blood thinner) was discontinued as she had persistent vaginal spotting on admission . Patient had a distended [MEDICAL CONDITION] bladder seen on CT abd/pelvis (imaging report of abdomen and pelvis), Urology was consulted and recommended outpatient follow-up at urology clinic. A UA showed positive UTI (urinary tract infection) f/u Urine culture showed significant K ([DIAGNOSES REDACTED] pneumoniae). Pneumonia and Proteus (bacteria) mirabilis growth and urine cytology showed No malignant cells identified in a background of sheets of acute inflammation. Patient completed a 10-day course of appropriate antibiotics with [MEDICATION NAME]. Patient was asymptomatic of a UTI. Discharge Medications included Ruxolitinib [MEDICATION NAME] (JAKAFI) (TRUNCATED)

This citation pertains to intake MI 090. Based on observation, interview and record review, the facility failed to ensure that one of two residents (#5) evaluated for falls was transferred with two-staff assistance in a total mechanical lift, resulting in a fall from the lift, skull fracture, multiple contusions to the face and pain. Findings include: A review of care plan reflected Resident #5 (R5) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the care plan, R5 was dependent on two staff for total mechanical lift transfers, showers and bed mobility; extensive assist of one staff for dressing, personal hygiene, oral care, toileting and set-up for eating. R5 is incontinent of bowel. A total mechanical lift, or Hoyer, used a sling to cradle and lift/lower the resident for transfers. There are three looped straps on either side of the sling that must be securely clipped to the lift frame. According to the incident investigation for the 10/30/19 fall, R5 had minimal cognitive impairment. According to the incident report, on 10/30/19 at 4:00 pm, R5 was being transferred to a shower chair with the assist of Certified Nurse Assistant (CNA) C and a total mechanical lift. R5 slid out of the lift sling and fell face down on the floor with his abdomen resting across the metal base legs of the lift. R5 sustained a bump on the left side of his head/forehead, a laceration above the right eye and face, abrasions to his right knee and left stump; bruises to his hand and right forearm and a bloody nose. The left hinge on his glasses were broken. Registered Nurse (RN) I assessed R5 for further minor injuries: skin tear to right knee/shin and right second toe; abrasion right ankle. R5 was transported to the hospital and CNA C was suspended. R5 not know how he fell , just that the sling slipped off the lift. He also said there were always two staff when he was transferred with the lift. According to the investigation, on 10/31/19 the hospital advised the facility R5 sustained a skull fracture from the fall. On 12/5/19 at 1050 am, R5 was interviewed in his room. R5 was wearing a hospital gown and was in an extra large bed. His glasses were taped at the left hinge. When asked, R5 remember the fall. He was getting up for a shower, and was one-half way out of bed, up high and the sling busted. They sent me to the hospital for about a week. I hurt my face and head, and was sore all over for a week or two, R5 said. When asked if there was one or two staff in the room during the transfer when he fell , R5 said there were two. They always have two gals. When asked, R5 said that he was worried about using the lift after the fall, but I gotta use it. On 12/5/19 at 2:23 pm, Nurse I was interviewed via phone about R5's fall on 10/30/19 as followed: I was called into room and R5 was lying on the wheel of the lift. The CNA was alone. Nurse I assessed R5 and began to clean off the blood on his face, head and nose; he had a laceration near his eye and some wounds on his legs. R5 was sent to the hospital about an hour later. One other time, Nurse I said she'd observed CNA J using a Hoyer lift to transfer a resident without a second staff person. I stayed to spot her (assist), and told her not to do it again. Nurse I said she also observed CNA C transfer R5 without a second staff person, and I educated her. In (MONTH) or (MONTH) all nursing staff was trained on the total lifts. I didn't report either CNA because, I like to give everyone a chance. I was let go because I didn't report the CNAs the first times they transferred alone, said Nurse I. On 12/5/19 at 2:48 pm, CNA C was interviewed via phone about R5's fall as followed: CNA C said she did the transfer alone, and couldn't remember if she had ever done a transfer without a second staff person prior. It was my fault, she said. When asked what influenced her decision to do the lift transfer alone, CNA C said that there were usually two aides for the entire second floor (two units). Call lights were going off everywhere. Nurse C was worried R5 wouldn't get his shower if she didn't do it right then. CNA J was to take her break at about 4:00 pm, but was going to wait until R5's shower was done. His shower takes a long time, and then it would be dinner time. When asked, CNA C said there were probably eight residents that needed two staff assist for cares. Three aides makes everything much easier Nurses will help but Nurse I was in a room with a resident. There's only one nurse for the 2nd floor on all three shifts. When asked if all residents get the care that they should, CNA C said, We have to prioritize resident needs; a bowel movement trumps someone who's just wet. CNA C was let go due to failure to follow the facility policy for lifts and R5's plan of care. According to the facility document titled, Safe Lifting and Movement of Residents, revised 10/30/19, Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation .4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Two staff members will provide assistance when lifting and moving residents.

This citation pertains to MI 798. Based on observation, interview and record review, the facility failed to implement interventions to prevent a fall with major injury for 2 (Residents #3 and 4) of 3 reviewed for falls, resulting in both residents sustaining falls with fractures. Findings include: Resident #3 Review of the medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #3 had clear speech, was cognitively intact, and required extensive assistance of 2 persons for transfers. Review of an incident note dated 4/15/19 revealed, At 0805 (8:05 a.m.) CNA (Certified Nursing Assistant F) came to RN (Registered Nurse G) and reported that (Resident #3) slid out of her wheelchair onto bottom after hoyer transfer. RN noted resident on bottom in front of wheelchair with sling underneath .STAT (immediate) x-rays ordered for right hip and lumbar areas . Review of the nurses noted dated 4/15/2019 at 9:35 revealed, (Resident #3) transferred into w/c (wheelchair) via hoyer lift, lowered in to the chair too close to the edge of the chair, resident slid on hoyer sling to the floor. Staff education provided to assure resident is seated to the back of the w/c with transfers . Review of Resident #3's Activities of Daily Living (ADLs) care plan revised 10/12/18 revealed the intervention, Resident is a 2 person assist with total lift (hoyer) . Review of the nurses note dated 4/18/2019 at 6:12 p.m. Revealed, (Resident #3's) son informed day nurse he would like his mother to be sent to (Name of Hospital) R/T (related to) to pain . Review of the hospital discharge summary dated 4/20/19 revealed Resident #3 was admitted to the hospital on [DATE] with the admission [DIAGNOSES REDACTED].Principal Problem: Fall . Review of the radiology results dated 4/18/19 revealed, Impression: .An anterior corner fracture between L1 and L2 is noted . During an interview on 5/2/19 at 11:15 a.m., Resident #3 was lying in her bed. When asked about her fall, Resident #3 stated, There was just one person, supposed to be two, but there was just one. She was rushing so she could get to the other one, she was rushing. When asked if she slipped out of the wheelchair, Resident #3 stated, I didn't slip, I fell . During an interview on 5/3/19 at 8:09 a.m, when asked about Resident #3's fall, CNA F stated, It was a very busy morning, it was time to get (Resident #3) up, I proceeded to get her things and get her ready, I got her dressed and put the sling (hoyer sling) under her .(RN G) was right by the door, she was passing pills, and I told her I was going to transfer the resident. I had transferred her to her chair, the sling was still under her, and when I went to slide her up, she slid off the chair down onto the floor, she was not back in the chair far enough. When asked if the resident was transferred using 2 staff, would the resident had been back in the chair far enough, and not slid out, CNA F stated, Defiantly, she wouldn't have slipped out. I knew there was supposed to be two people, but I was kind of stuck, I knew I had to get her up for breakfast. During an interview on 5/3/19 at 11:00 a.m, when asked about Resident #3's fall, RN G stated, I was passing meds (medications). At one point (CNA F) stepped out of the room, she said can you come in because the resident fell , (Resident #3) was between the hoyer and the wheelchair, and the sling was still underneath her. When asked why Resident #3 fell , RN G stated, The CNA did not directly ask any other staff members for help, the resident was on the edge of the chair, and she slid off the wheelchair. During an interview on 5/3/19 at 8:22 a.m,, when asked about Resident #3's fall, Director of Nursing (DON) B stated, (CNA F) didn't ask for help. When asked if the nurse that was caring for the resident would have knew the resident's transfer status, DON B stated yes. When asked if a CNA said to a nurse that they were going to get Resident #3 up, if they should help, DON B stated, Yes, that would be the expectation. Resident #4 Review of the medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment revealed Resident #4 had clear speech, was cognitively intact and required the supervision of 1 person for transfers and ambulation. Review of the incident note dated 4/23/19 revealed, (Resident #4) had been incontinent of urine. (CNA E) changed bed linens and when she began to assist resident, he became upset and refused her help. Resident attempted to change himself and was observed on the floor. Review of the hospital discharge summary dated 4/29/19 revealed Resident #4 was admitted to the hospital on [DATE] the [DIAGNOSES REDACTED]. Review of Resident #4's Activities of Daily Living (ADLs) care plan revised 3/19/19 revealed the following interventions: -DRESSING: I require extensive assistance by (1) staff to dress -Extensive assist of two with ambulation in room using FWW (four wheeled walker) -TOILET USE: I require extensive assistance of 2 staff for toileting -TRANSFER: I require ext (extensive) assistance of 2 staff to move between surfaces During an interview on 5/3/19 at 12:00 p.m., when asked about the fall that took place on 4/23/19, Resident #4 stated that he was trying to get to the bathroom to get cleaned up and to change his pants, and he fell . During an interview on 5/2/19 at 1:47 p.m. when asked about Resident #4's fall, CNA [NAME] stated, I wasn't his aide, but was working that (name of Resident #4's unit). I was doing my rounds, I saw (Resident #4) leaned over in his bed and looked uncomfortable. I went in and noticed he had pee everywhere, his whole entire bed, all over the floor, his shirt and his pants. I wanted to help him. I am an agency aide (not an employee of the facility) and I did not have access to the Kardex (computer system which list care interventions for residents), so I was just going by what others told me, the other aide was late so I couldn't ask them. I was told that he was independent in his room, and could take care of himself. I got him up and tried to get him cleaned up. I cleaned his bed and got clean linen on. I got out clean clothes, changed his shirt but not his pants and underwear. I cleaned him up as best as I could, he wouldn't let me clean him down there. I just set up everything for him to clean himself and change him. That was the first time working that unit, so I had to go off what others were telling me the nurse said he was independent. I was told he was independent, but I didn't think he should do things independently, he was struggling, so I went to tell the nurse that he needed to be reassessed of his care needs. I told the nurse that his Kardex should be changed from independent because he had a hard time standing. Between the time I went down to tell the nurse, and then returned to the resident to check on him, he had fallen onto the floor. He fell by the bathroom door, he had tried to walk to the bathroom, he had his pants down and had started cleaning himself. During a telephone interview on 5/2/19 at 1:30 p.m., when asked about Resident #4's fall, Licensed Practical Nurse (LPN D) stated, I was working that night and was the nurse taking care of (Resident #4). When (CNA E) did their check and change, (Resident #4) was incontinent of urine, I guess quite a bit of urine. The CNA was able to move him off the bed, he wet his bed completely. (CNA E) then went to assist him with changing, and he wanted no part of that, it's almost like 'you little girls don't need to be changing me and seeing my man parts.' He has a lot of dignity, and doesn't want others doing that. The CNA got his clothes out, let him chose what he wanted to wear, she offered to help, and she left. Later she came up to me and said the resident was on the floor. I went down and asked him how he got down there (to the floor) and he said he fell .he said he lost his balance. Review of Resident #4's care plan did not reveal any interventions regarding the point the resident did not like others cleaning and changing him. The only interventions that were in place all required the assistance of staff for ADL cares. During an interview on 5/3/19 at 8:22 a.m., when asked about Resident #4's fall, DON B stated that CNA [NAME] had gone in to assist Resident #4, he is a private man, and he doesn't like assistance. DON B stated that CNA [NAME] went down to tell the nurse that the resident needed more help and he fell . When asked what new interventions were put into place after the fall, DON B stated that assistance of 2 staff was added. This surveyor pointed out the fact that intervention was already in place. DON B stated then it was reviewed. DON BD also stated that check every 2 hours was also an intervention, but then agreed that checking on residents every 2 hours is a standard of practice. When asked if the fact that Resident #4 was a private man, and did not like assistance with being cleaned up was care planned, DON B stated I would have to check. DON B was asked if during the fall's investigation, if she had talked to Resident #4's aide, she stated, No, I did not talk to her. When asked if she was aware that CNA [NAME] did not have access to the Kardex while she was working the night of Resident #4's fall, DON B stated, I learned that yesterday.

This citation pertains to MI 901 Based on interview and record review, the facility failed to prevent significant weight loss for one resident (Resident #105) out of 2 residents reviewed for weight loss from a total sample of 7 residents resulting in significant ongoing weight loss. Findings include: According to a facility face sheet dated 3/7/28 at 11:10 AM, Resident #105 was a [AGE] year old male admitted to the facility on [DATE] with the cumulative Diagnoses: [REDACTED]. According to a Minimum Data Set (MDS) significant change assessment dated [DATE], Resident #105 was 66 (inches) and 115 lbs. (pounds) with weight loss that was not prescribed. Review of weights for Resident #105 reflected, 8/31/17 134. 4 lbs. 10/11/17 122.6 lbs. 11/9/17 118.8 lbs. 1/10/18 110/5 lbs. 2/21/18 109 lbs. During an interview on 3/7/18 at 10:20 AM with Registered Dietician (RD) X and Z, RD X confirmed that Resident #105 had lost over 17 5 % (percent) and 18 % since (MONTH) (YEAR) (7 months). Resident #105 had experienced a significant weight loss. RD X was asked if the physician was aware of Resident #105's weight loss and she added Resident #105 was on [MEDICATION NAME] (a medication that can help with appetite). Review of a document titled, Nutrition Evaluation Michigan for Resident #105 dated 8/31/17 at 2:26 PM reflected, Resident admitted status [REDACTED]. Resident is at risk for alteration in nutritional status due to [DIAGNOSES REDACTED]. No labs at this time .Height 66 (inches) and BMI (body mass index) is 21.5 classified as adequate. Goal is for weight maintenance. Review of a document titled, Nutrition Evaluation Michigan for Resident #105 dated 11/19/17 at 10:26 AM reflected, .(Name of Resident #105) weight has trended down as of early November: 11/9/17 119 lbs., 10/11/17 122.6 lbs current interventions: 2 health shakes a day. New intervention started as of 11/14/17: 2 oz. (ounces) of Med Pass (a high calorie protein supplement) BID (twice a day). Goal: no further significant weight loss. Slow gain towards a BMI in range of 21 to 23 would be ideal. No new labs were noted. Review of a document titled, Nutrition Evaluation Michigan for Resident #105 dated 12/15/17 at 1:10 PM reflected, Readmitted [DATE] .with [DIAGNOSES REDACTED]. 13% loss in 3 months .(Name of Resident #105) tolerates his current diet but his oral intake is not enough to prevent weight loss. (Name of Resident #105) recently had a significant weight loss (13% loss in 3 months). New intervention: 3 oz. of Hi Cal TID (three times a day). This is an additional 300 kcal (kilocalorie)/day from Med Pass compared to when he was receiving only 2 oz. BID (twice a day). Goal: Weight to stabilize and have no signs or symptoms of malnutrition or dehydration through the next review date. No new labs were noted. Review of a document titled, Nutrition Evaluation Michigan for Resident #105 dated 2/21/18 at 11:58 AM reflected, 5.3 lbs. or 4.5% loss in 1 month (significant weight loss). Monthly NAR (Nutrition at Risk) Assessment. Resident continues receiving Regular/Puree/Thin liquid diet due to dysphagia. Resident tolerating diet. PO (Oral) intake improving according to chart 75 to 100 % of meals in 1 week recorded. Resident receives Mighty Shake TID (three time a day) (200 kcal/6 gram protein each, 600 kcal and 18 gram of protein a day). Hi Cal 3 oz. TID (three times a day) (540 kcal, 23 gram of protein/day) to provide additional calories and protein to help meet needs and prevent further weight loss. Noted mostly 100% acceptance of Mighty Shake recorded and noted mostly 100% Hi Cal acceptance most days. Receives yogurt at breakfast, cottage cheese at lunch and ice cream at dinner according to preference to promote intake. Reviewed medication-note daily multi vitamin, [MEDICATION NAME], and vitamin B 12 supplementation. Skin intact. Current weight 110 lbs. BMI 17.8 (low) .Goal of intake continuing to be at least 50 to 100% to meet estimated nutrient needs. Weight to remain stable or with gradual gain towards usual body weight of 130 lbs . No new labs were noted. Review of a document titled, Nutrition at Risk Meeting for Resident #105 dated, 3/2/18 at 3:12 PM reflected, Resident reviewed at NAR related to weight loss. Resident current weight 2/21/18 109 lbs. BMI 17.6. Oral intake recorded seemed to be improving. Continuing current supplements: Mighty Shake TID (three times a day) .Hi Cal 3 oz. TID .Receives yogurt at breakfast, cottage cheese at lunch and ice cream at dinner according to preferences to promote intake. No new interventions at this time. Will continue to monitor. Review of the requested 3 month dietary intake for Resident #105 was reviewed. The facility provided documentation 12/7/17 to 3/6/18, the following was noted: What percentage of the meal was consumed? 12/16/17 9:39 AM, 50%. There was no documentation regarding offering of an alternative. 12/22/17 there were two notations of percentages eaten at 10:26 AM and 1:48 PM but no documentation of an evening meal. 12/25/17 9:22 AM and 2:12 PM, there were two notations of percentages eaten but no documentation of an evening meal. 1/4/18 at 1:17 PM, Resident refused. There was no documentation regarding offering of an alternative meal. 1/19/18 at 12:48 PM Resident Refused. There was no notation regarding offering of an alternative meal. 1/21/18 at 9:20 AM, Resident Refused. There was no notation regarding offering of an alternative meal. 1/25/18 there were two notations of percentages eaten at 12:54 PM and 12:57 PM (no documentation which meal) but no third meal documented. 1/27/18 at 11:06 AM, resident refused. No documentation if an alternate meal was offered. 2/3/18 at 09:45 AM, resident refused. No documentation if an alternate meal was offered. 1:19 PM 25 % and no documentation if an alternative meal was offered. 2/5/18 at 1:37 PM 50 % and no documentation if an alternate meal was offered. 2/9/18 there are two notations, one at 8:58 AM and 6:33 PM. There is no documentation on the mid day meal. 2/10/18 there are 2 percentages documented at 2:08 PM. 75% and 50 %. There was no documentation if an alternative meal was offered. There is no notation if this was a duplicate entry. 2/14/18 there are two entries at 12:56 PM and 12:57 PM. This documentation doesn't indicate which meal percentage. 2/18/18 at 2:13 PM there are two entries. There is no documentation on a third meal. There is no documentation if this was a duplicate entry. 2/28/18 at 9:05 AM and 8:39 PM. There is no documentation of a mid day meal. At 8:39 PM Resident #105 consumed 50% but there was no documentation if an alternative was offered. 3/4/18 at 8:00 AM 25 %. No documentation if an alternative meal was offered. 1:00 PM, 50% and no documentation if an alternative meal was offered. 3/6/18 at 2:23 PM 25 % and no documentation was noted of an alternative meal offered. There was no documentation of any snacks that were offered mid day or evening and if accepted. There was no differentiation between protein, fruits and vegetables, starches, desserts taken to be able to develop interventions to prevent weight loss. There was no documentation after 2/21/18 of the interventions: yogurt at breakfast, cottage cheese at lunch or ice cream at dinner consumed to determine if the interventions were successful. In choosing meal intake estimating method for a facility, the following should be considered: the method where the meal tray assessed as a whole and assigned a value of 0%, 25%, 50%, 75% or 100 % consumed is inherently flawed and unlike to yield sufficiently accurate estimates of resident intake .Because no method for estimating meal intake has been shown to be valid under routine nursing home conditions . (http://nutrition.fiu.edu/Center_Initiatives/publications/JADA%20Inherent%20flaws%20in%20a%20method.pdf) Review of a facility document titled, Medication Administration Record [REDACTED]. Start 10/20/17. Discontinue 1/18/18. Each day at 8:00 AM, 12:00 PM and 6:00 PM there was a check mark (except on 12/9/17 to the evening of 12/12/17 due to hospitalization ) with initials indicating this supplement was given. This supplement was only to be given twice a day per this order and it was placed on the meal tray. No documentation regarding intake of the supplement was documented to know if this intervention was successful. Review of a facility document titled, Medication Administration Record [REDACTED]. Start 10/20/17. Discontinue 1/18/18. Each day at 8:00 AM, 12:00 PM and 6:00 PM there was a check mark (except on 1/5/18 and 9 on 1/14/18 at 6:00 PM indicating other). This supplement was only to be given twice a day per this order and it was placed on the meal tray. No documentation regarding intake of the supplement was documented to know if this intervention was successful.

Based on observation, interview and record review the facility failed to A) monitor portable oxygen tank level availability for 1 of 3 residents (Residents #4) reviewed with oxygen tanks from a total of 15 sampled residents resulting in anxiousness, labored breathing, difficulty breathing and the potential for [MEDICAL CONDITION] for Resident #4 and B) failed to change nasal cannula oxygen tubing bi-weekly as ordered for 1 of 5 sampled Residents (#10) reviewed for oxygen use, from a total sample of 15 residents, resulting in the potential for infection for Resident #10. The facility was placed in Immediate Jeopardy (IJ) on 7-27-16 as a result of the facilities failure to monitor oxygen tank levels on a resident (#4) with a known history of chronic [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Findings include: On 7/26/16 the following was noted: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) completed on 7/5/16 reflected Resident #4 had a Brief Interview of Mental Status (BIMS) score of 8 out of 15 (8-12 moderately cognitively impaired), and could transfer himself independently. At approximately 6:45 AM Resident #4 was observed self-propelling himself in the hallway. He was noted to have a shirt and pants on. He had a nasal cannula in his nose infusing oxygen, and an oxygen tank attached to the back of his wheelchair. Licensed Practical Nurse (LPN K) revealed during the initial tour of the facility that Resident #4 had [MEDICAL CONDITION]. At 8:16 AM Resident #4 was observed in the dining room on the second floor, his oxygen level was noted to be just above the red empty line (red zone). At 2:32 PM Resident #4 was observed to self-propel himself to the nurse ' s station from his room. Resident #4 requested a Certified Nursing Assistant, CNA V to check his oxygen tank level. The oxygen tank level was observed to be at 0 empty (in the red). Resident #4 was noted to be anxious and having labored breathing. He was bent over, leaning forward, using accessory muscles, mouth breathing and verbalized it was hard to breath. His respiratory rate was between 36-40 breaths per minute. At this time a second CNA (R) stated she would go get the nurse. A pulse oximeter was placed on the resident by CNA V which reflected an oxygen saturation rate of 73%. At around 2:34 PM CNA R returned and stated she would take Resident #4 to his room. An attempt was made to access oxygen from the emergency crash cart for Resident #4, but the oxygen tank was observed to be without the adapter for use. CNA R then assisted Resident #4 to his room and connected him to his oxygen concentrator at 2 Liters. The pulse oximeter oxygen rate ranged between 73-78%. After approximately 3-4 minutes, the pulse oximeter oxygen rate read at 90-92%. Resident #4 was no longer laboring to breath, and had a respiratory rate of 16. CNA R stated Resident #4 had had his oxygen tank connected to his wheelchair at a rate of 6 L (liters). However, the oxygen tank setting dial, reflected a rate of 2L. At 2:49 PM, a nurse had yet to come to assess Resident #4 after his adverse respiratory episode and the resident was alone in his room. At 2:53 PM LPN K was asked what the plan was to assess Resident #4's adverse respiratory episode reported by CNA R. LPN K stated she had just changed Resident #4's tank, and that she was upstairs. LPN K had a full tank noted in the oxygen holder to change out Resident #4's empty tank. LPN K stated Resident #4 would change his oxygen rate settings. When asked if Resident #4 changed his oxygen rate setting often. LPN K stated, Yes, he does. We have talked to him about it, but I think he gets anxious and forgets. On 7/27/16 the following was noted: At 11:03 AM the oxygen tank room was observed to have 14 full oxygen tanks. The tank gauge reflected full at 2000 PSI, with a maximum volume of 3000 PSI. At 11:10 AM Resident #4 was observed near the medication cart (just outside of the 200 Hall dining room) with his eyes closed, head down to his chin, and appeared to be sleep. He was clothed in a shirt, shorts and regular socks (non-gripper socks). His oxygen tank was observed to be in the RED section reflecting a low volume at 400 PSI. At 11:50 AM Resident #4 was observed in the 200 east dining room. His oxygen tank volume was noted to be at zero 0 empty (red zone). At 12:35 PM Resident #4 was observed in the 200 Hall dining room eating his lunch. The oxygen tank had no change, still at a volume of zero 0 empty. At 12:55 PM CNA R was observed with an oxygen tank, in a tank holder walking from the 200 Hall nursing station (2 East) toward 2 West. CNA R was followed to the oxygen room and observed to put the empty tank in the room. CNA R was asked if she had changed Resident #4's oxygen tank. CNA R stated, No, I didn't the nurse did. When asked when did the nurse change it, CNA R stated about 3 minutes ago. NA R stated Resident #4 told her, It was empty and that I'm dying. CNA R was asked if Resident #4 was laboring to breathe, when his tank was empty. She said he was not, not like yesterday. NA R was asked to retrieve a pulse oximeter to check his oxygen saturation. At 12:58 PM the pulse oximeter was placed on Resident #4 by CNA R, and reflected a heart rate of 80 beats per minute and an oxygen rate starting at 87%. Once the new tank was changed the resident reached 94% in 2 minutes. Resident #4 was asked how he felt before the nurse changed his oxygen tank. He replied, I was short of breath. Resident #4 was asked how often his oxygen tank had to be change. Resident #4 stated it had to be changed every day. Resident #4 was asked if he had been told by facility staff to not adjust the rate nodule, he stated Yes. When asked how often staff told him not to adjust the rate nodule, Resident #4 stated Everyday. At about 1:00 PM LPN (Q) was asked when she changed Resident #4's oxygen tank. She replied, give or take 3-4 minutes ago. LPN Q was asked how long a full oxygen tank would last. LPN Q stated, It usually runs for 4 hours. When asked how often she had to change Resident #4's tank, LPN Q stated it was relative. LPN Q stated, 90% of the time Resident #4 comes to us and ask us to check his tank. LPN Q stated at around 9:00 AM his oxygen tank was half full. I will put in for an order to assess his oxygen tank every 4 hours, and add to his care plan. He likes to adjust his oxygen as he sees fit. He has put it up to 8L. At 3:19 PM LPN (S) was asked who was responsible for changing the oxygen tanks when empty, the nurses or the nursing assistants. LPN S stated, We (the nurses) are responsible for changing the tanks. At 3:40 PM LPN (T) working on the east 200 hall (where Resident #4 resided) was asked, who was responsible for changing residents oxygen tanks. LPN T stated, Nurses are responsible for changing them. When asked who on the hall had an oxygen tank, LPN T stated Resident #4, but could not recall the other residents' names at the time. LPN T stated, Resident #4 is non-compliant with oxygen and will turn it way up. He is supposed to be on 2L, and will run out. LPN T stated, they would check on him. Also, that the he knew when his oxygen was getting low and would come out and let staff know. LPN T stated, We check his oxygen saturation each shift, and I check his more often . When asked how often his tank had to be changed on her shift. LPN T stated at least once, sometimes twice. At 3: 48 PM LPN (U) was asked who was responsible for changing the oxygen tanks. LPN U stated, The nurses are responsible for changing oxygen tanks. When asked if any resident on west 200 hall had oxygen tanks, she could not recall at the time. When asked if any Residents on east 200 hall had oxygen tanks LPN U stated, Yes Resident #4. LPN U revealed she at times worked the east 200 east hall, and had Resident #4 as a resident. When asked how often she had to change his oxygen tank LPN U revealed, she would have to change his oxygen tank during her shift. LPN U stated Resident #4 received 2L of oxygen, and Every time we walk by his wheelchair we check it, to give us a general idea of where it's at. He will tell us and we will check it for air. If it is low we will change it. If his oxygen is not low we continue to check it. The Oxygen Therapy related to End-Stage [MEDICAL CONDITION] care plan initiated dated 2/23/16 reflected the following interventions: · Resident #4 has a tendency to adjust his own oxygen delivery, often increasing the rate of delivery. Because of this, he may become short of breath or run out of oxygen more quickly than anticipated. Observe his delivery rate with each interaction. Notify nurse and check pulse oximetry if oxygen delivery is set higher than 2L/min. Date initiated: 3/18/16 · .Pulse oximetry between 89% and 93% may be the best that he can achieve. Date initiated 2/24/16 · Notify doctor or designee of abnormalities as needed. Date initiated 2/24/16 · Observe for s/sx of respiratory distress and report to nurse or MD PRN: Difficult or abnormal respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis .accessory muscle usage and/or blue or dusky skin color. Date initiated 2/24/16 · Obtain pulse oximetry at least Q shift. Notify nurse or MD of pulse oximetry less than 89%. Date initiated 2/24/16 After writer questioning the following intervention was added: · Observe oxygen tank with each interaction when Resident #4 is up in his chair. Provide a fresh tank as needed. Date initiated 7/27/17 None of the interventions reflected to educate Resident #4 about adjusting his oxygen rate and the side effects of it. On 7/27/16 at around 4:30 PM the facility was requested to provide a policy related to oxygen availability and monitoring, and at 5:50 PM the facility revealed one was not available. The facility implemented the following interventions to address the immediate jeopardy: On 7/27/16 at 7:10 p.m. D.O.N. assessed resident and found resident lying in his bed with O2 concentrator on 2L. Pulse Ox was 96% and Heart Rate was 80. Assisted at his request to his wheel chair and was changed to a portable O2 tank at 2L which showed to be full in the GREEN. O2 sats at that time were 94% immediately after transfer to wheel chair and heart rate was 82. Resident propelled self down the hall. On 7/27/16 at 8:00 p.m. and continuing: An Inservice was presented to nursing staff by D.O.N. and/Nurse Managers relating to monitoring and documenting for Resident #4 on a minimum of a two hour basis the O2 sats and current remaining tank capacity on portable O2 tanks while in use to ensure the resident is showing no sign of distress. Those nursing staff members not present at the time will be contacted to receive this inservice and will not be allowed to work until inservice is complete. D.O.N. or designee will monitor on weekly that the corrective actions are in place. As of 7/28/16, 30 nursing staff out of 61 were inserviced. Inservicing will be completed by 8/1/16. On 7/27/16 at 8:30p.m. Call placed to facility oxygen supplier Facility Owner to assess O2 tank gauges. On 7/27/16 at 9:30p.m. facility oxygen supplier technician reported that of the 9 empty tanks. One of the tanks that had been placed in the front of the rack had a faulty gauge showing that the tank was empty however, the tank was full. There are Five (5) residents on oxygen. Four (4) of the residents primarily utilize a concentrator for oxygen delivery. One (1) resident #4 uses portable oxygen tanks to mobilize throughout the facility. On 7/28/16 at 7:15am D.O.N. assessed resident propelling in wheel chair in hall way in no distress with O2 tank on 2L. Resident ' s O2 sat was 92% and HR was 92 as well. Resident was reminded to not adjust his O2 litre flow r/t his [DIAGNOSES REDACTED]. NHA will discuss with Care Linc representative a process for having the O2 delivery driver check O2 gauges on a random basis. On 7/28/16 at 1:00p.m. The Oxygen delivery Care plan along with Mood/Behavior care plan for resident #4 was reviewed by D.O.N. and Nurse Management. Social Work added an individual behavior log for Resident #4 to address his behavior that he changes his Oxygen flow rate. The behavior log will be reviewed at AM meeting by Interdisciplinary Team. On 7/28/16 at 3:00p.m. The NHA/D.O.N. revised the oxygen policy entitled Oxygen Administration (revised on 7/28/16) to include use of portable cylinders including the frequency to monitor to ensure tank is not empty. Changes discussed with Medical Director by telephone. While the Immediate Jeopardy was removed on 7-28-16, the facility remains out of compliance at an isolated scope with no actual harm with potential for no more than minimal harm that is not immediate jeopardy as substantial compliance could not be verified by the state agency. ( ) Resident #10 According to the Oxygen Administration policy and procedure, dated October 2010, reflected under, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration .Steps in the Procedure: .15. Tubing to be changed weekly and prn . Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #10 was a [AGE] year of male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #10 had a BIMS(assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact. In an observation and interview on 7/27/16 at 2:35 p.m. Resident #10 was in bed with a nasal cannula in place with oxygen tubing connected to a room concentrator with several oxygen extensions attached. The oxygen tubing was labeled 7/7/16 at all of the connections. Resident #10 reported the staff change the tubing every 2 weeks. In an interview on 7/26/16 at 6:00 a.m. LPN (Licensed Practical Nurse) FE reported during the initial facility tour that oxygen tubing is changed every week. ( )

This citation pertains to MI 805, MI 819 and MI 943. Based on observation, interview and record review, the facility failed to protect 2 (Resident #8 and Resident #40) of 12 residents reviewed for abuse (Residents #8, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49 and #52) and 1 supplemental resident (Resident #51) from a total sample of 13 residents, resulting in Resident #40 being anxious, frightened and a depressed mood, Resident #8 having a tray of food thrown at him causing a laceration near his right eye with the potential for embarrassment and negative physical, psychosocial and mental outcomes. Findings Include: Review of Resident #47's facility Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 6/20/14, physician progress notes [REDACTED]. behaviors", alert to person and place with confusion, poor attention span, poor impulse control and a history of harm to others who required assistance from staff for his Activities of Daily Living (ADL's). The resident's [DIAGNOSES REDACTED]. Resident #47 was not at the facility at the time of the investigation (7/22/14 through 7/25/14). Review of the Hospital Behavioral Health History and Physical dated 5/9/14, revealed prior to admission to the facility, Resident #47 had "hit another resident with a broomstick which resulted in an emergency room evaluation (at another facility)." Review of Resident #47's facility Speech Therapy Plan of Care dated 5/26/14 (prior to the 6/16/14 and 6/17/14 incidents of physical abuse towards Residents #41 and #8); revealed Resident #47 had deficits in his cognition, communication, problem solving, reasoning, safety awareness and judgment. Review of the facility Psychiatric Evaluation and Management record dated 6/10/14 revealed Resident #47's judgment, memory, insight, orientation, attention and concentration were all "poor" and stated he "verbally threatens others." Review of the facility physician progress notes [REDACTED]. (Resident #47) combative, agitated, he hit another resident with a broomstick." An interview was done in the Administrators office on 7/23/14 at 12:50 p.m., with staff member "A" (Assistant Director of Nursing/ADON) and staff member "B" (Social Services). Per review of Resident #47's clinical record and facility incident reports dated 6/16/14 and 6/17/14, revealed Resident #47 had been transferred back and forth between the facility's 2 Dementia units (on 1st and 2nd floors) while at the facility (from 5/23/14 to 7/2/14), being transferred from the 2nd floor unit to the 1st floor unit and back again to the 2nd floor unit. Upon admission to the facility, Resident #48 was put on the 2nd floor Dementia unit. On "6/4/14", the resident was put on the 1st floor Dementia unit due to supplemental Resident #51 agitating him with her yelling. Staff member "B" stated, "On 6/4/14, (supplemental Resident #51) is a yeller, she yells out b---h and residents who yell make him (Resident #47) agitated." It was at this point the facility was aware that residents who screamed or yelled out were triggers for Resident #47 aggressive behaviors of resident-to-resident physical abusive. On 6/16/14, Resident #47 slapped a resident in the face (sampled Resident #41), so he was transferred back to the 2nd floor Dementia unit. Staff member "B" stated "(Resident #41) was getting into (Resident #47's) space and (Resident #47) slapped (Resident #41) in the face." Then on 6/17/14, Resident #47 was in the dining room unsupervised when he threw his breakfast tray with food on it at Resident #8, who was sitting at the same table as he was, causing a laceration near his right eye. On 7/2/14, Resident #47 was transferred to the hospital and had not returned to the facility at the time of the investigation. Staff member "B" stated "He (Resident #47) has pent-up anger." Observations were made on 7/23/14 (at 1:00 p.m. and 1:25 p.m.), of Residents #41 and #8. Resident #41 was awake in his wheelchair; he was not able to recall the incident of being slapped by Resident #47 on 6/16/14, with no marks or bruises noted on his face. Resident #8 was sleeping and no marks or bruises were noted on his face or near his right eye. Neither Resident was able to interviewed due to decreased cognition and memory. Incident on 6/16/14, involving Resident #41 and #47: Review of the incident report dated 6/16/14, revealed on 6/16/14 at 1:00 p.m., sampled Resident #41 got too close to sample Resident #47 on the 1st floor Dementia unit and Resident #48 slapped Resident #41 in his face. No injuries occurred and staff separated the two residents, transferring Resident #47 to the 2nd floor unit and stated "Res (Resident #47) is currently on 1:1 (one-on-one) supervision due to an unrelated incident." Review of the incident report (dated 6/16/17), revealed the only intervention taken by the facility was to move Resident #47 to the 2nd floor Dementia unit, where he was prior to 6/16/17, when he had gotten agitated with another resident (un-sampled resident) who was a screamer/yeller and the intervention at that time was to move him to the 1st floor Dementia unit. Review of Resident #47's Nurse's note stated, "Late Entry 6/16/14. At 1320(1:20 p.m.) (Resident #47) got into a verbal fight with another resident (Resident #41). Near to the nurse's station. (Resident #41) was swearing loudly at (Resident #47). (Resident #47) threaten to physically hurt (Resident #41)." Review of Resident #41's Nurse's note dated 6/23/14 at 1:51 p.m., stated "Note Text: 6/16/14 at 1320 (Resident #41) got into a verbal/physical fight with another resident (Resident #47). Near to the nurse's station. (Resident #41) was swearing at (Resident #47). (Resident #47) threaded to physically hurt (Resident #41)." Review of Resident #41's Social Service note dated 6/18/14 at 16:54 (4:54 p.m.) (Error in date, incident occurred on 6/16/14) stated "This resident (Resident #41) was slapped by another resident (by Resident #47) on the Alzheimer's/Dementia unit. There has been some documentation of this resident being more agitated towards others." Review of Resident #41's Face Sheet, MDS dated [DATE] and [DIAGNOSES REDACTED]. His [DIAGNOSES REDACTED]. Review of Resident #41's Behavioral Care Plan dated 4/28/14 stated "The resident has potential to demonstrate physical behaviors related to DX (diagnosis) of dementia and poor impulse control. (Resident #41) hit another resident in the arm on 4/27/14 that was rubbing his back. Analyze: if key times, places, circumstances, triggers, and what de-escalates behavior." Review of Resident #47's facility physician progress notes [REDACTED]. (Resident #47) acts up 1:1 (one-on-one)." Per interview done in the Administrators office on 7/23/14 at 12:50 p.m., staff members "A" and "B" confirmed Resident #47 was not made a "one-on-one" supervision until after the 2nd incident of resident-to-resident abuse, on 6/17/14. Review of Resident #47's facility Behavioral Care Plan dated 6/6/14 (prior to 6/16/14 and 6/17/14), stated the resident was "with risk for harm to others R/T (related to) dementia, poor impulse control, history of harm to others. Provide distant, intermittent supervision while (Resident #47) is on the unit. He prefers to have at least 2-3 feet of personal space unhindered by others. Remove (Resident #47) from public areas or areas where other residents or families are congregated." Resident #41 was allowed by staff to be near Resident #47 on 6/16/14, in front of the Nurse's station (a public area in front of the Nurse's station and entrance/exit door of the unit), despite documentation and Behavioral Care Plans regarding both residents history of aggression towards other residents and care plan interventions given to decrease incidents of resident-to-resident abuse. An interview was done in private at the 1st floor nurse's station on 7/23/14 at 1:10 p.m., with staff member "C" (Charge Nurse, LPN). Staff member "C" stated "I was working on 6/16/14, it was around 1:15 p.m. to 1:20 p.m., and I heard two guys yelling in front of the nurse's station. (Resident #41) might have ran into (Resident #47), they're both quick to temper, (Resident #41) yells. We took (Resident #41) to his room, (Resident #47) went to his room. I called the managers (the DON and ADON); they thought separating them was enough, so they moved him (Resident #47) up-stairs (on the 2nd floor Dementia Unit). The young to the cognitively aware residents are not to be on the 1st floor (1st floor Dementia Unit), he (Resident #47) shouldn't of been here." An interview was done in an empty resident room in private on the 1st floor Dementia Unit on 7/23/14 at 12:00 p.m., with staff member "D" (Nursing Assistant/CNA). Staff member "D" stated "no yellers or screamers should be by (Resident #47). I heard a bunch of yelling (on 6/16/14); they (Residents #41 and #47) were in front of the nurse's station in the hall. I heard (Resident #41) say he (Resident #47) slapped me and (Resident #47) said "yes and I will do it again". They took (Resident #47) to his room. If he (Resident #47) was a one-on-one that day they (facility management) would have put it on the assignment schedule, he was not a one-on-one." This surveyor showed staff member "D" the staff assignment schedule dated 6/16/14; Resident #47 did not have documentation by his name that he was a one-on-one. Staff member "D" stated "I'm not surprised he was not made a one-on-one" and agreed the two residents should not have been allowed to be by each other in front of the Nurse's station on 6/16/14, given both of their histories of becoming physically aggressive towards other residents when agitated. An interview was done in private in the TV room on 1st floor Dementia Unit on 7/23/14 at 12:10 p.m., with staff member "E" (CNA). Staff member "E" stated "I heard ((Resident #48) hit him (Resident #41) in the face. He (Resident #48) was not made a one-on-one that day because he just came down here (to the 1st floor Dementia Unit) from another floor." Staff member "E" denied she saw Resident #47 hit Resident #41 in the face but confirmed she and the staff on the 1st floor Dementia unit were aware of Resident #47's aggressive behaviors towards staff and other facility residents prior to 6/16/14 and agreed they should not have been allowed to be by each other in front of the Nurse's station on 6/16/14. Incident on 6/17/14, involving Resident #8 and Resident #47: Review of the facility incident report dated 6/17/14, revealed on 6/17/14 during breakfast on the 2nd floor Dementia unit, Resident #47 threw his breakfast tray with food on it at Resident #8, hitting him in the face and causing a laceration near his right eye. Review of Resident #47's Nurse's note dated 6/17/14 at 4:08 p.m., stated "Resident (Resident #47) threw a meal tray at a resident unprovoked causing a laceration next to the other resident's eye. (Resident #47) was placed on a 1:1 (one-on-one)." Review of Resident #8's Nurse's note dated 6/17/14 at 4:00 p.m., stated "Resident (#47) threw a meal tray at this resident unprovoked causing a laceration next to resident's eye. Resident (#47) stated that he would do it again and that he wasn't kidding." Review of the Resident #47's physician progress notes [REDACTED]. (patient) seen for eval (evaluation), Pt. has been having increased behaviors, increased agitation, threw a tray at another Pt., no injuries." Review of Resident #8's Face Sheet, MDS dated [DATE] and Mood/Behavior Care Plan dated 8/22/12, revealed the resident was a [AGE] year old male admitted to the facility on [DATE], dependent on staff for all ADL's and transfers and hard of hearing. The resident's [DIAGNOSES REDACTED]. Review of the Resident #8's Mood/Behavioral Care Plan (dated 8/22/12), stated "Resident may display sx's (signs)crying, increased isolation, sad affect, increased anxiety, statements of being scared, and statements of being lonely." Review of the residents Impaired Cognitive Care Plan dated 8/22/12, revealed he was alert and orientated "1-2" (person and place). Review of Resident #8's Social Service note dated 6/18/14 at 5:08 p.m., stated "This Resident (Resident #8) yells out for help, but does not know what he needs help with when asked." A second observation of Resident #8 was done on 7/25/14 at 9:11 a.m., by surveyor (# ) in his room on the 2nd floor Dementia Unit. The resident was observed yelling "help", he wanted to lay down. The surveyor was called to sampled Resident #49's room, where the resident stated "what are you going to do about that, it goes on 3 to 4 hours a day, 7 days a week", pointing to Resident #8's room. Resident #49 requested a room change due to Resident #8's yelling out. Review of Resident #47's Mood/Behavior Care Plan dated 6/5/14, stated "Behavior: verbal behavior symptoms directed toward others, physical behavior symptoms directed towards others, throwing items at others, when agitated, with risk for harm to others R/T (related to) dementia, poor impulse control, history of harm to others. He prefers to have at least 2-3 feet of personal space unhindered by others." Review of Resident #47's Psychiatric note dated 6/24/14, stated "This is a [AGE] year old male admitted to the facility from (psychiatric facility) 5/23/14. Resident has history of significant physical aggression; he has thrown objects and assaulted others multiple times since original admission." An interview was done in the Administrators office on 7/23/14 at 10:16 a.m., with staff member "A" (ADON). Staff member "A" stated the following regarding the incident on 6/17/14, "the charge nurse brought (Resident #8) to me, it was a small skin tear under his right eye, the resident didn't even recall the event. At the time there was no yelling, no events at all prior to the incident." No documentation of any staff member witnessing this incident was found in the resident's clinical/electronic record or given to this survey by the facility during the investigation. An interview was done on 2nd floor Dementia unit in private in the dining room with staff member "F" (CNA). Staff member "F" stated the following regarding the incident on 6/17/14, "I was out for break at the time, I set breakfast up for him (Resident #48), (Resident #8) was sitting at the same table (in the dining room alone and un-supervised). (Resident #8) yells out most of the time "I'm cold, I need help, turn the heat on, where's everybody. I set his tray up and left it with him (Resident #47). Someone is to be in the dining room if someone is eating. He was not a one-on-one before the incident on 6/17/14." When this surveyor asked if both residents should have been left together unsupervised in the dining room at the same table, staff member "F" agreed Resident #47 and Resident #8 should not have been in the dining room at the same table, nor in the same room together without staff supervision. Staff member "F" confirmed he was aware of Resident #47's history of aggression towards staff and other residents prior to 6/17/14. An interview was done in private on the 3rd floor in the Day Room on 7/24/14 at 12:00 p.m., with staff member "H" (CNA). Staff member "H" stated "he (Resident #47) got up and went to the dining room (on 6/17/14), (Resident #8) and him (Resident #47) both eat in the same dining room. One person, a nurse or CNA is to be in the dining room when residents are eating. CNA's are to pass trays, be in the dining room and answer call lights at the same time. (Resident #8) yells out, the yelling does make (Resident #47) mad, it gets on his nerves, than he goes after people. We (staff) were up-set, even the nurse (staff member "G") said why would they put him (Resident #47) here (on the 2nd floor), he'll do it again." A phone interview was done in the conference room in private on 7/24/14 at 2:48 p.m., with staff member "G" (Charge Nurse, LPN). Staff member "G" stated "I said they (management) are dumping him (Resident #47) here with us (on the unit). We (nursing staff) try to tell them (management), they make the decisions, our census was low so they took anyone they could, they only want to make money. The (incident on 6/17/14) could have been prevented; I would have put him (Resident #47) on one-on-one after the first incident (on 6/16/14)." An interview was done in the conference room on 7/25/14 at 8:10 a.m., with the Director of Nursing/DON. When this surveyor asked the DON if Resident #47 should have been put on a one-on-one or 15 minute checks immediately after he hit Resident #41 in the face on 6/16/14, she stated "I don't know if they (staff) should have put (Resident #47) on one-on-one, I was not involved in this investigation at all, I was not physically in Michigan, I don't know." When this surveyor asked the DON if the two incidents could have been prevented (on 6/16/14 and 6/17/14), she said "no." Review of the facility Abuse, Prevention and Prohibition policy dated 7/11, stated "Investigation: The facility Administrator and/or Director of Nursing will thoroughly investigate alleged violations of individual rights and document appropriate action." Review of the facility "Resident Behavior Monitoring" policy dated 2/09 (given to this surveyor on 7/23/14, by the ADON as the facility's "one-on-one policy) stated "It is the policy of the facility to monitor residents after exhibiting behaviors that could possibly endanger either themselves or other residents. Any resident with behavior that has been identified that would present a potential danger to either himself or other residents will be placed on at least 15-minute checks." Review of the facility "Handout Abuse Prevention" (un-dated, found by this surveyor in the Nurse's Policy book on 2-West nurse's station), stated "Prevention: Resident has the right to be free from verbal, mental, sexual, or physical abuse. Protection: From another resident or from staff. Another resident: interventions will be instituted." ( ) This citation was written for intake #MI 943. According to the behavior care plan initiated 4/28/14 and revised 7/21/14, Resident #40 was a [AGE] year old female who was admitted to the facility on [DATE]. Resident #40 was at risk for mood and behavior fluctuation secondary to [DIAGNOSES REDACTED]. The focus portion of the behavior care plan described Resident #40 as having behavior symptoms that may include crying, increased anxiety, statements of being scared and lonely and statement of wanting to die or harm self. Resident #40 made statements about her daughter who was murdered years back. Resident #40 could become paranoid, verbally and physically aggressive at times. This same care plan revised 7/21/14 reflected 3 altercations Resident #40 was involved in, 1) a resident to resident altercation on 6/4/14 in which a male resident (#45) walked up to Resident #40 and put his hands around her neck, then stated "I'm going to kill you" to Resident #40. 2) On 6/28/14 the same male resident (#45) put his hands around Resident #40's neck. 3) On 7/4/14 Resident #40 was grabbed by Resident #41 (another male resident) and pulled to the ground. The Admission Minimum Data Set (MDS) assessment dated [DATE], reflected Resident #40 had a Brief Interview for Mental Status score of 5 of 15, reflecting severe cognitive impairment. The Admission MDS dated [DATE] reflected Resident #40 had impaired vision and no behavior issues and had mood score of 04, which indicated she felt bad about herself. The nurses notes dated 5/31/14 stated Resident #40 had been "adjusting to her new environment (at the facility) very well and stated again today, I like it here the people are very nice." The facility's incident report dated 6/4/14 at 7:10 PM, noted that RN "K" heard yelling "help, help" and RN "K" was 10 feet away from the nurses station. Resident #40 "was standing in the hallway in front of the desk with a frightened look on her face; her entire face was red. RN ("K") asked what happened & resident stated, 'he choked me and said he was going to kill me.' She was pointing and referring to Resident #45. Resident #40 stated 'I don't know why he did it, I didn't do anything to him.' Redness resolving from neck..." In the witness statement portion of the incident report dated 6/4/14, Nurse Aide "L" wrote "I was informed (Resident #45) grabbed (Resident #40) & told her he was going to kill her. I was assigned one-on-one with (Resident #45). He (Resident #45) was very angry & kept saying he was going to kill her." Resident #45 then "grabbed my (Nurse Aide "L") wrists & called me a 'stupid [***] ' when I refused to go into a room with him..." The follow up portion of the incident report dated 7/1/14 reflected Resident #45 was sent out to "geropsych" for a medical clearance and evaluation. Resident #45 was evaluated at the facility for an intimal psychiatric evaluation and management on 6/10/14, when it was determined that his mood was pleasant and cooperative and the incident on 6/4/14 may be an isolated incident of aggression and 1:1 supervision was unnecessary. After 6/10/14, Resident #45 was no longer on 1:1 supervision, but was on 15 minute checks daily through 6/28/14. Nurses notes from 6/12/14 to 6/28/14 reflected that Resident #45 wanders in the unit, sometimes into other resident rooms and was aggressive with staff. Nurses notes dated 6/12/14 reflected Resident #45 was "very combative with staff going into other resident rooms. Nurses notes dated 6/18/14 reflected he took hold of a Cena (certified educated nurse aide) and shook her. Nurses notes dated 6/22/14 reflected Resident #45 was "very aggressive" and was also yelling and had both hands on one nurse aide's arm and would not let go. Nurses notes dated 6/25/14 reflect Resident #45 had a baseline of wandering in the hall, refusing care and was attempting to hit/kick staff members. Nurses' notes dated 6/28/14 reflected that at 8:15 AM, Resident #45 was found choking (Name of Resident #40) that Resident #45 was heard saying "you are my wife." Resident #45 was "very mad and very combative." The follow up section for incident that occurred on 6/28/14 was dated 7/22/14, which reflected Resident #40 stated Resident #45 wanted her to come with him, he wanted his old Ford car, he grabbed her neck and said "I want to kill you." Resident #40's neck was slightly red. The geriatric psychological evaluation and assessment completed on 7/15/14, reflected Resident #40 "wanders halls of the dementia unit and recently has had several physical altercations with male peers, she was not the aggressor in either situation... and appears to be without lingering effects." The incident report dated 7/4/14 reflected Resident #40 was involved in another incident where Resident #41 grabbed her and pulled her down to the floor. Resident #40 fell and hit her head and had a small 1 inch bump on the back of her head and a skin tear on her left hand that was 2 inches by 1 inch triangular shape. Social Work notes completed the week of the survey and dated 7/23/14 for a late entry date of 7/7/14, 7/9/14 and 7/10/14. The Social Work notes referred to the incident that took place on 7/4/14. "This resident (#40) appeared to be doing well at the beginning of the week, but was displaying some depression/anxiety SX'x (symptoms) last two visits. This resident was making statements of wanting to have her Sister visit her and expressed that she, 'did not want the boy to put her down anymore." The social worker explained to the resident the "boy that put her down" is no longer around, "which seemed to decrease her worry." Nurses notes dated 6/28/14 reflected Resident #40 was very upset when Resident #45 grabbed her neck and stated "I want to kill you." On 7/24/14 at 2:50 PM, during an interview with Nurse Unit Manager "J" of the locked unit, was asked how was Resident #45 able to harm Resident #40 since they were both on 15 minute checks? Nurse Unit Manager "J" replied that incidents can happen quickly. Nurse Unit Manager "J" stated that staff had visual rounds on Resident #45 and when he had 1:1 supervision, it was exclusive to Resident #45, and the nursing staff were trying to take care of him (Resident #45) the best they could, but in both instances Resident #45 was unprovoked. Nurse Unit Manager "J" also explained that residents who are violent with psychiatric history were admitted because the facility believes in giving everybody a chance. On 7/25/14 at 9:00 AM, during an interview with Administrator "M," he stated the facility takes residents who are violent with a psychiatric history because everyone deserves a chance. Then Administrator "M" was asked how does he prepare his staff to care for violent residents with psychiatric histories. Administrator "M" replied the staff were informed when residents are coming to the locked unit. Administrator "M" was asked what else does the facility do to prepare their staff to care for violent, aggressive residents with dementia. Administrator "M" was asked does the facility provide any specialized training and adequately staff the unit for close monitoring or supervision on the locked unit? Administrator "M" stated the locked unit was always staffed with a Unit Manager, a charge nurse, 3 nurse aides and an activity aide. Administrator "M" was asked about the events that took place with Resident #45 on 6/28/14. Administrator "M" stated the Unit Managers do not work on the weekends and this happened on a Sunday (6/28/14 was on Saturday) lights were going off and the nurse aides were all busy, the activity aide was supervising residents in the dining room and the charge nurse was calling the doctor and the family. On 7/24/14 at 1:39 pm, during an interview with confidential Charge Nurse "G" she stated she did not witness the altercation between Resident #40 and Resident #45 but sometimes monitored them. Confidential Charge Nurse "G" stated "they're short staffed and our demands are so great," that at times the staff on the locked unit were unable to meet the needs of the residents. The nursing staff have reported their concerns to the facility, but there have been no changes. Confidential Charge Nurse "G" stated with just one person supervising an altercation can happen so quickly, we do our best. Confidential Charge Nurse "G" stated she use to work in a psychiatric unit and was aware of what type of people the facility is admitting, the the people they "are admitting are not appropriate for the facility." Confidential Charge Nurse "G" stated it was difficult to do their work and keep residents safe. Confidential Nurse "G" stated the facility was taking in residents with a psychiatric history because their census was low. The psychiatric residents "are harmful to residents and staff." Administrator "M" did not comment on any specific training the staff on the locked unit received to assist them in handling aggressive or escalated behaviors, Administrator "M" replied "it doesn't happen everyday." Administrator "M" stated he was called in, when he arrived he provided 1:1 supervision of Resident #45. Then he asked why was it necessary for him to provide supervision. Administrator "M" was asked did he believe the altercations that happened to Resident #40 were avoidable or unavoidable, Administrator "M" replied "I am not in a position to determine if a situation was avoidable or unavoidable." The facility failed to put appropriate interventions in place to protect Resident #40 who was assaulted on 3 separate occasions, 6/4/14, 6/28/14 and 7/1/14 resulting in depressed mood, anxiety and fear. ( )

This citation pertains to MI 171. Based on observation, interview and record review, the facility failed to utilize a gait belt to prevent falls in 1 of 2 residents (#1) assessed for falls from a total sample of 4, resulting in a fall and fracture. Findings include: According to the facility Admission Record, dated 5/3/13, Resident #1 was an [AGE] year old female admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Resident #1 was readmitted on [DATE] after a fall resulting in a left distal (near the knee) femur (thigh bone) fracture requiring joint arthroplasty (replacement). According to Physician's Progress Notes, dated 6/4/13, Resident #1 was noted to have gait dysfunction and right lower extremity weakness. According to the Quarterly Minimum Data Set (resident assessment), dated 9/4/13, Resident #1 required stand-by assist of 1 staff for ambulation with a 2-wheel walker, bed mobility and set-up for eating. Resident #1 required hands-on assist of 1 staff for transfers, showers, hygiene, dressing and toileting. There was no indication of depression. According to a facility Social Services Progress Note, dated 9/30/13, Resident #1 was noted to have an uneven gait. According to Nurses Notes dated 10/5/13, Resident #1's walking was described as having, "weakness, impaired balance and more assistance required for transfers". According to a facility document titled, "Occurrence Report", dated 10/8/13, Resident #1 was ambulating with her walker and the physical therapist. Resident #1's right knee "gave out" and she fell , landing on both knees, and was sent to the emergency room for evaluation. According to the hospital x-ray report, dated 10/8/13, Resident #1 sustained a comminuted (bone broken into fragments) of the distal end of the left femur, and the old knee joint hardware was displaced. There was no mention of use of a gait belt (canvas belt worn around the trunk of the body to assist with safety during ambulation and transfers). According to the Significant Change Minimum Data Set, dated dated [DATE], Resident #1's functional abilities had declined to requiring 2 staff for transfers, bed mobility and dressing. Resident #1 was unable to ambulate with nursing staff and required increased assistance of 1 staff to shower and toilet. Resident #1 scored increased signs of depression. On 10/25/13 at 10:25 am, Resident #1 was observed wheeling herself from one therapy room to the other. Resident #1's was dressed in blue jeans and a blouse, and was wearing white tennis shoes. Resident #1's left leg was elevated on the wheel chair foot rest, and she was wearing a bulky appliance on her left leg, beneath her blue jeans. When asked, Resident #1 could recall nothing about her fall and fractured left knee, and shook her head back and forth. On 10/25/13, at 11:10 am, Physical Therapy Staff "C" was interviewed in the activity room. When asked to describe what happened, Physical Therapy Staff "C" stated Resident #1 fell during her 5th week of physical therapy, but she had been progressing. Physical Therapy Staff "C" stated he had not intended to walk Resident #1, but he came upon her in the hall and Resident #1 wanted to walk. Therapy Staff "C" was walking with Resident #1 when her knees gave out and she fell , landing on her knees. When asked if he applied a gait belt around Resident #1's waist before walking, Physical Therapy Staff "C" said, "No". When asked if not using the gait belt was a mistake, Therapy Staff "C" said, "I'll say, yeah". Upon request, the Director of Nurses (DON) "A" provided sign-in sheets from recent inservices. The inservices were about falls and gait belts, and were done because of a previous preventable fall and fracture of a resident during a transfer with staff. The sign-in sheets reflected that Physical Therapy Staff "C" attended on 8/8/13 and 8/23/13. DON "A" stated part of the information conveyed during the in-service was that the gait belt was considered part of the uniform, and was to be on every staff person at all times. On 10/25/13 at 11:35 am, Therapy Director "B" was interviewed. When asked if gait belts were required when ambulating a resident, Therapy Director "B" said, "Yes". Therapy Director "B" confirmed that a consent was required when a resident refused a gait belt. Therapy Director "B" said Physical Therapy Staff "C" had not intended to walk Resident #1 at that time of the fall, but Physical Therapy Staff "C" met Resident #1 in the hallway and she wanted to walk. Therapy Direcotor "B" stated that Physical Therapy Staff "C" did not have his gait belt with him, and rather than go get it, ambulated Resident #1 without it. When asked if therapy staff was to have a gait belt on or with them at all times, Director "B" said, "Yes". Even after a previous fall with fracture related to non-use of a gait belt resulting in injury with staff transfer of a resident, and ensuing staff re-education; Resident #1 sustained a preventable fall with therapy staff failing to use a gait belt to assist with safety during ambulation resulting in a comminuted fracture of the left femur requiring joint arthroplasty. ( )

This citation pertains to MI 508. Based on, interview, and record review, the facility failed to provide a safe environment and adequate supervision to prevent injuries in 1 of 6 residents reviewed for falls (Resident #102), from a total of 6 sampled residents, resulting in Resident #102 falling and sustaining a right hip fracture. Findings include: According to the Face Sheet dated 5/16/13 and the most recent MDS dated [DATE], Resident #102 was an [AGE] year old female with [DIAGNOSES REDACTED]. Review of the facility "Progress Note, Admit" dated 5/16/2013, revealed Resident #102 had a [DIAGNOSES REDACTED]. Review of the facility "Resident Fall Risk Assessment" dated 5/15, revealed Resident #102 had a fall risk score of 31, and according to the document a total score over 20 points indicated a high risk for falls. Review of the facility "Occurrence Report" dated 6/12/2013, revealed that Resident #102 "was ambulating w/ (with) walker from the bathroom to bed she slipped and fell "hard" on her tailbone". The report revealed that Resident #102 showed signs of pain, grimacing, saying "ow" and pointing to her right groin area, the paramedics were called and the resident was transferred to an acute care facility. Review of the hospital discharge summary dated 6/19/2013, revealed Resident #102 was admitted to the hospital on [DATE] and was diagnosed with [REDACTED].#102) showed significant right hip pain...evaluated with orthopedics and recommendation was for MRI (Magnetic Resonance Imaging)...Post MRI, the opinion was the patient does have right subcapital hip fracture and this was followed by open reduction and internal fixation." Review of the hospital radiology x-ray results dated 6/12/2013, revealed, "No right hip fracture seen. If this remains of continued clinical concern CT (computed tomography, an advanced x-ray) could be performed". Review of the hospital radiology CT results dated 6/12/2013, revealed, "...subtle linear lucent line in the inferior portion of the right humeral head felt to be a subtle nondisplaced fracture (right hip fracture)". Review of the hospital MRI report dated 6/15/2013, revealed "nondisplaced right subcapital hip fracture". Review of the facility "Order Listing Report" dated 5/1/2013 - 6/12/2013, revealed Resident #102 required 2 person assist with gait belt for transfers and one person assist with walker. Review of the "Risk for Injury R/T (related to) Falls" care plan dated 5/28/2013, revealed Resident #102 could ambulate short distances with front-wheeled walker and extensive assist of 2 people. Review of the "Physical Therapy Plan of Care" dated 5/16/2013, revealed Resident #102 could ambulate 15 feet with front wheeled walker on even surfaces requiring moderate assistance of 2 people. Review of the "Occupational Therapy Plan of Care" dated 5/18/2013, revealed Resident # 102 required maximum assistance to negotiate front wheeled walker in resident's room and bathroom. During an interview on 7/29/2013 at 2:55 PM, Physical Therapist (PT) #7 stated Resident #102 required 1 person assist with ambulating and transferring. PT #7 stated that 1 person assist means the resident should be wearing a gait belt, and the individual assisting the resident should be holding the gait belt the entire time the resident is transferring or ambulating. PT #7 stated that Resident #107 required 1 person assist because of balance issues and fear of falling, "this was not new for the resident". During an interview on 7/29/2013 at 3:10 PM, Certified Nursing Assistant (CNA) #10 stated that her and another CNA assisted Resident #102, with her walker, to the bathroom. CNA #10 stated the other CNA left the room while Resident #102 was on the toilet. CNA #10 stated she did not know Resident #102 required 2 persons for assistance, "I did not look at the careplan, everybody said (Resident #102) was a 1 person assist". CNA #10 stated that 1 person assist meant "only one CNA needed to be in the room to assist" the resident. CNA #10 stated she assisted Resident #102 from the toilet to her walker, and Resident #102 started to ambulate out of the bathroom. CNA #10 stated she was not holding Resident #102 by the gait belt when the resident fell . During an interview on 7/30/2013 at 10:15 AM, Registered Nurse (RN) #14 stated that CNA #12 came to her explaining that Resident #102 had fallen. RN #14 stated she went into Resident #102's room and found Resident #102 laying on the floor. RN #14 stated she tested Resident #102's range of motion, and determined there was a possible fracture, instructed the CNAs not to move the resident, and then RN #14 called for an ambulance. RN #14 stated the ambulance arrived and then Resident #102 was taken to the hospital. During an interview on 7/31/2013 at 1:40, via translator, Resident #102 stated the day she fell she was not feeling very good. Resident #102 stated she tried to tell the aides that she wanted to use the wheelchair to transfer to the bathroom, but the aides didn't understand, and wanted her to use the walker. Resident #102 stated when she fell , a gait belt was on her, but nobody was holding on to the gait belt. Resident #102 stated, after she fell , she stayed laying on the floor, then the ambulance came and she was taken to the hospital. ( )

This citation pertains to MI 275 Based on observation, interview, and record review, the facility failed to ensure that alarms functioned for 2 residents (Resident #102 and Resident #109) of 4 residents reviewed for falls and alarms out of a total sample of 9 residents, resulting in: 1) Resident #102 sustaining a hematoma and laceration requiring sutures to the head after a fall where the bed alarm did not sound and 2) the potential for injury for Resident #109 after she was found with a non-functioning bed alarm. Findings: Resident #102: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #102 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #102's cognitive skills for daily decision making were moderately impaired and she needed limited staff assistance with transfers and walking. Review of the "Resident Fall Risk Assessment" dated 12/12/12, revealed Resident #102 was a high risk for falls. Review of Resident #102's "Physician Admission Order Sheet" dated 12/12/12, revealed an order for [REDACTED]. Review of Resident #102's "Admission Care Plan" dated 12/12/12 revealed fall interventions included the use of bed and chair alarms. Review of the Nurse's Notes dated 12/12/12 at 9:50 PM, revealed Resident #102 was "lying on the floor of her bedroom on her back. Resident bleeding from head wound...Hematoma (collection of blood under the skin) noted back of head...Resident's bed alarm on but not sounding..." Review of the "Resident Transfer Form" dated 12/12/12, revealed Resident #102 had an open area on the back of her head. During a telephone interview on 1/30/13, Certified Nursing Assistant (CNA) #15 reported he went to Resident #102's room and "found her lying on her back on the floor". CNA #15 reported the bed alarm switch was in the on position, but the alarm was not sounding. During a telephone interview on 1/30/13 at 2:40 PM, Registered Nurse (RN) #23 reported Resident #102 was on the floor and had a large hematoma to the back of her head. RN #23 reported the staff who found Resident #102 told her that Resident #102's alarm was not sounding. Review of a facility investigation statement written by CNA #24, dated 12/12/12, revealed "the bed alarm failed and wasn't working. All night we had trouble with it". This surveyor attempted to contact CNA #24 by telephone and left voicemail messages on 1/30/13 at 9:55 AM and at 11:13 AM. No return call was received from CNA #24. Review of the Hospital Emergency Physician Record dated 12/13/12 at 12:00 AM, revealed Resident #102 sustained a hematoma and a 4 centimeter stellate (star-shaped) laceration (tear/cut) to the back of her head which was repaired with "1 corner stitch through each corner". Resident #109: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #109 was an [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #109 scored 8/15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS), required extensive physical assistance by 1 staff member for transfers, walking, and toilet use, and Resident #109's balance during transitions and walking was not steady and she was only able to stabilize with staff assistance. Review of the monthly Physician Order's dated 1/2/13, revealed an order for [REDACTED]. Review of the "Risk For Injury Related To Falls" Care Plan dated 7/16/12, revealed Resident #109 transferred with extensive assistance of 1 staff member, ambulated short distances with a walker and limited assistance of 1 staff member, was provided limited assistance of 1 staff member for toilet use, and had bed and chair alarms to alert staff for the need for assistance. Placement and function of alarms were to be checked at least every shift. Review of Resident #109's "Resident Status Sheet" (CNA care guide), revealed placement and function of the bed and chair alarm were to be checked every shift. An observation on 1/30/13 at 1:50 PM, revealed Resident #109's call light was sounding and flashing. Resident #109 was observed seated at the edge of her bed, visiting with Senior Companion #1. Licensed Practical Nurse (LPN #21) answered the call light and transferred Resident #109 from the bed to the wheelchair. At that time, Resident #109's bed alarm did not sound. During an interview on 1/30/13 at 3:00 PM, Senior Companion #1 reported Resident #109 was lying in bed and sat herself up when Senior Companion #1 arrived into Resident #109's room. During an interview on 1/30/13 at approximately 1:52 PM, LPN #21 reported that Resident #109 was a fall risk. LPN #21 reported she did not turn the bed alarm box off prior to transferring Resident #109 into the wheelchair. When queried if the alarm would have sounded if Resident #109 transferred herself, LPN #21 stated "probably not". LPN #21 reported the alarm was on, but it must have slid down so that Resident #109 was not placing any weight on the bed alarm pad. During an interview on 1/30/13 at 1:55 PM, CNA #22 reported she transferred Resident #109 into the bathroom at approximately 1:30 PM and left her there alone. When queried why the bed alarm was not functioning, CNA #22 stated "she (Resident #109) probably walked back to bed herself". During an interview on 1/30/13 at 2:00 PM, LPN #21 reported it was not a usual thing to leave Resident #109 in the bathroom alone and Resident #109 needed supervision, with the door ajar while in the bathroom. Review of the "S.A.F.E. Fall Prevention Program" policy and procedure (revised 9/12) revealed there was no instructions for facility staff on how to care for resident safety alarms. On 1/30/13 at 2:45 PM and 3:30 PM, this surveyor requested any policies regarding alarms from Administrator #1. At 3:35 PM, Director of Nursing (DON) #2 reported they did not have an alarm policy. ( )

This citation pertains to intake number MI 422. Based on observation, interview, and record review, the facility failed to prevent the elopement and ensure the safety of 1 of 6 sampled residents (Resident #101), from a total sample of 12 residents, resulting in an Immediate Jeopardy (IJ) when, on 9/30/12 at 8:44 AM, Resident #101, who was identified as an elopement risk and wore a WanderGuard alarm, exited the facility after Receptionist (#5) disarmed the front door alarm and allowed Resident #101 to exit the facility. Resident #101's WanderGuard alarm did not sound. Resident #101 was returned to the facility on [DATE] at 1:37 PM by the facility staff. This deficient practice placed 12 additional residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #101 had moderate cognitive impairment and required minimal assistance with activities of daily living. The Face Sheet revealed Resident #101 has a legal guardian. Review of "Determination of Inability to Participate in Financial Decisions or Medical Treatment Decisions", dated 4/19/12, revealed Resident #101 was "unable to participate in financial decisions or medical treatment decisions." Review of the "Occurrence Report", dated 9/30/12 at 1:45 PM, revealed, Receptionist #5 let Resident #101 out through the front door on 9/30/12 at 8:44 AM. Facility staff recognized Resident #101 walking down the sidewalk of Cedar Street (approximately a quarter mile from the facility) independently and gave her a ride back to the facility at 1:37 PM. In an interview on 10/9/12 at 9:30 AM, Resident #101 stated, "I wanted to go to Meijer's and get a few things...I just told the girl at the desk where I was going and she asked me some stuff then let me go out." Review of a written statement, dated 9/30/12, revealed that Receptionist #5 asked Resident #101 if Resident #101 was her own person and checked out and Resident #101 said, "Yes." Receptionist #5 then pushed the handicap button (to the front door) and let Resident #101 out. Receptionist #5 did not remember pushing the WanderGuard alarm button off. Two different attempts were made with no success, to contact Receptionist #5 before the end of this survey. In an interview on 10/9/12 at 3:30 PM, Registered Nurse (RN) #3 stated while on her way to work on 9/30/12 at approximately 1:20 PM, she saw Resident #101 on Cedar Street (approximately a quarter mile from the facility), walking down the sidewalk, pushing a shopping cart with her (Resident #101's) walker folded up inside. RN #3 stated that she pulled over, called the facility and stayed with Resident #101. In an interview on 10/9/12 at 2:00 PM, Certified Nursing Aide (CNA) #4 stated that he was asked by his manager on 9/30/12 to drive to Cedar Street, pick up Resident #101 and bring her back to the facility. CNA #4 stated, upon return the facility, he escorted Resident #101 back through the front door and the WanderGuard alarm did not activate. CNA #4 stated that he walked Resident #101 out the door and back in again but the WanderGuard still did not alarm. CNA #4 stated he escorted Resident #101 directly to the Unit Manager and reported the non-functioning WanderGuard bracelet. Review of video recording from the facility camera that faces the front entrance revealed Resident #101 exited the facility at 8:44 AM and re-entered at 1:37 PM pushing her front wheeled walker escorted by CNA #4. Review of "Resident Elopement Assessment", dated 4/26/12, 7/17/12, and 10/1/12 indicated Resident #101 was at risk for elopement. Review of care plan for "Behavior/Mood/Well Being", dated 4/26/12, identified Resident #101 as being at risk for elopement with the goal for Resident #101 "will not leave unit unaccompanied" and the following intervention of "photo ID on record." According to the facility "Resident Elopement" policy, last revised on 2/2010, "The responsible party shall sign the resident out of the facility on a resident sign-out sheet" and a list of residents with photo will be available at each nurse's desk and the front reception area. In an interview on 10/9/12 at 10:30 AM, Resident #101's Guardian #7 stated that he did not sign out or have knowledge of Resident #101's elopement until he was notified after Resident #101 was returned to the facility. Resident #101's Guardian #7 stated that he does not want Resident #101 to leave the facility unattended or unsupervised. On 10/11/12 at 11:42 AM, the Administrator #1 was notified of the Immediate Jeopardy that began on 9/30/12 and was identified on 10/10/12, when the facility failed to prevent the elopement and ensure the safety of Resident #101, who had been identified as an elopement risk and who eloped from the facility on 9/30/12 at 8:44 AM, when Receptionist #5 disarmed the front door alarm. Resident #101's WanderGuard alarm did not sound. Resident #101 was returned to the facility at 1:37 PM escorted by staff. On 10/11/12, this surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. On 9/30/12, Resident #101 was assessed by the charge nurse and no injury was noted. 2. On 9/30/12, Resident #101's non-functioning WanderGuard was replaced. 3. On 9/30/12, Resident #101 was placed on 15 minute checks. 4. On 9/30/12 the facility staff completed a 100 % head count of all residents and no other residents were affected. 5. On 9/30/12 the facility checked all door alarm units, and resident personal units for proper functioning. No further issues were identified. 6. On 9/30/12 the facility initiated 100% of all staff being re-educated on the elopement policy, door alarm checks, and personal checks of individual WanderGuard units and identification of residents at risk. 7. Any facility staff not able to attend re-education would not be allowed to return to duty until the Director of Nursing has provided the re-education. 8. On 9/30/12 the Administrator re-educated and counseled Receptionist #5 and placed that employee on suspension on 9/30/12 for not following the Elopement Policy/Procedures of checking the elopement risk book that is kept at the front reception area, before allowing a resident to exit the facility. 9. Beginning on 9/30/12, Human Resources Representative will educate all new staff on the facility elopement policy prior to starting work within the facility. 10. On-going education on the facility elopement policy by the Administrator will be increased to at least twice a year for all facility staff. 11. On 9/30/12 all residents' elopement assessments were reviewed by the nurse management team to ensure all residents at risk have been identified. New residents will be assessed for elopement risk at the time of admission or re-admission. 12. On 9/30/12, Charge Nurses will continue to check personal WanderGuard units for placements at least every shift and for function at least every midnight shift and document the check. This will be verified by the nurse managers. Although the Immediate Jeopardy was removed on 9/30/12, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. (# )

This citation pertains to intake MI 051 and MI 755. Based on observation, interview, and record review, the facility failed to protect residents from physical abuse in 2 of 16 sampled residents (#105 and #116), of a total sample of 16 resident, resulting in bruising to Resident #105's right forearm, pain and fear, and Resident #116 sustaining pain and fear. Findings include: Resident#105: Review of Resident #105's medical record revealed she was an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #105's minimum data set ((MDS) dated [DATE] indicated she had moderately impaired cognitive skills, required supervision only for transfers, ambulation, dressing and hygiene. Mood/Behavior tracking form for Resident #105 for the months of March, April, and May 2012 indicated that Resident #105 did not exhibit any behaviors during that time. CNA (Certified Nurse Aide) skin assessment Sheet dated 5/4/12 for Resident #105 indicated Resident #105 had a resolved skin issue on her right forearm, but did not indicate any size, color, or type of skin issue. Resident #105's mood/behavior plan of care indicated on 4/18/12 she was kicked by another resident with interventions to include watch closely for signs of isolation or depressed mood, allow resident to voice concerns, social service intervention as needed. Facility incident report dated 4/18/12 indicated Resident #105 was kicked by Resident #104, with Resident #104 to be placed on 15 minute checks. Review of Resident #104's plan of care of mood/behavior does not locate any additions on 4/18/12. Resident #105's mood/behavior plan of care dated 5/3/12 indicated resident #105 stated another resident slapped her arm and caused a bruise, with interventions to include watch closely for signs of isolation or depressed mood, allow resident to voice concerns, social service intervention as needed, and Resident requested to be on list for a private room on another unit. Facility Incident report dated 5/2/12 indicated Resident #105 was hit in the arm by Resident #104. Facility 24 Incident report dated 5/2/12 indicated Resident #105 reported during an interview with Social Services that Resident #104 had blocked her doorway and as Resident #105 passed by Resident #104, Resident #104 punched Resident #105. The incident report indicated Resident #105 was assessed and Resident #105 had a 2 centimeter by 1/5 centimeter bruise on her right forearm, which is where Resident #105 indicated Resident #104 hit her. Resident #104's mood/behavior plan of care indicated on 5/12/12 that Resident #104 was involved in a Resident to Resident and that Resident #104 slapped another resident. Interventions listed include watch closely for signs of isolation or depressed mood, allow resident to voice concerns, social service intervention as needed. During an interview on 6/ 7/12 at 8:15 am, Resident #105 was observed in her room, in a wheelchair, self propelling independently around her room. Resident #105 was able to correctly identify the President of the United States, the current date, the name of the facility, and how long she had resided there. Resident #105 stated Resident #104 had been taunting her for a long time, and used to sit in the doorway of her room, and not let her in or out of her room. Resident #105 stated Resident #104 used to keep her from going to activities and therapy. Resident #105 stated Resident #104 was sitting in her doorway on that day, and she (Resident #105) wanted to get out, but Resident #104 wouldn't move, so she (Resident #105) tried to squeeze by and Resident #104 punched her in the arm with her fist. Resident #105 said she hollered out, "Hey, she hit me", but nobody came, so she waited and told the social work lady when she came a few days later. Resident #105 stated it hurt pretty bad when Resident #104 hit her in the arm, and she knows they moved her to a different unit, but they still go to activities and meals in the same dining room. Resident #105 stated the staff are supposed to keep Resident #104 away from her, but she is still afraid of Resident #104. In an interview on 6/7/12 at 8:45 am, CNA #14 stated prior to Resident #104 hitting Resident #105, Resident #104 used to sit in front of Resident #105's room so Resident #105 could not get out of her room, and Resident #104 would use her wheelchair to try and block Resident #105 from going to activities. In an interview on 6/7/12 at 8:55 am, RN #22 stated Resident #104 would sit by Resident #105's room door and agitate Resident #105, and there was a history of tension between the two residents. In an interview on 6/6/12 at 1:25 pm, CNA #20 stated she is filling in for a Social worker who is off on sick leave and during an MDS (Minimum Data Set) interview with Resident #105, she reported to her (CNA #20) that Resident #104 had blocked her doorway (Resident #105's doorway), and when Resident #105 attempted to get by Resident #104, Resident #104 had punched Resident #105 in the right forearm. CNA #20 stated she observed a bruise on Resident #105's right forearm and reported the incident to the unit manager. CNA #20 stated staff have been told to keep Resident #104 and Resident #105 on opposite sides of the dining room because they still go to the same dining room. In an interview on 6/7/12 at 10:35 am, Licensed Practical Nurse (LPN) #4 stated she interviewed Resident #105 and that Resident #105 stated Resident #104 had punched her in the arm approximately a week ago while Resident #105 was trying to pass Resident #104 near the door of her room. LPN #4 stated she had seen the bruise on Resident #105's right forearm, but did not document it in the nurse's notes of Resident #105's medical record, because it looked too fresh to match Resident #105's story. Resident #116: Review of Resident #116's medical record revealed she was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #116's minimum data set ((MDS) dated [DATE] indicated she was cognitively intact and required extensive assistance with transfers, dressing and hygiene. A Facility incident report dated 5/24/12 indicated Resident #104 went up to Resident #116 and sat in front of Resident #116, blocking her way. The incident report indicated Resident #116 told Resident #104 to get out of the way and Resident #104 hit Resident #116 with her fist on Resident #116's left upper arm. In an interview on 6/7/12 at 11:55 am, Resident #116 was observed by the surveyor to be alert and oriented to person, place and time. Resident #116 stated she remembered the incident with Resident #104, and when it occurred she was sitting with Resident #103 visiting near the nurse's station when Resident #104 wheeled up in her wheelchair. Resident #116 stated everything was fine until she (Resident #116) attempted to wheel herself in her wheelchair toward her room to use the bathroom, and Resident #104 blocked her path. Resident #116 stated she told Resident #104 to get out of the way and tried to go around Resident #104, and then Resident #104 hit her in the upper left arm with her fist. Resident #116 stated it hurt really bad, and Resident #103 saw it happen. Resident #116 stated she moved away from Resident #104, and Resident #104 threw a bunch of dirty tissues at her. Resident #116 stated after the incident she told staff about it, and they moved Resident #104 to another unit, but she still attends activities in the same room. Resident #116 stated she is "very damned scared" of Resident #104, and worried Resident #104 may hurt other residents. Resident #116 stated she had seen Resident #104 "taunt" Resident #105 in the dining room last week. Resident #116 stated staff were supposed to stay in the dining room once Resident #104 is in there, but they don't. During an interview on 6/7/12 at 3:40 pm, Resident #103 was observed by the surveyor to be alert and oriented to person, place and time and correctly identified the President of the United States and the name of the facility. Resident #103 stated she witnessed Resident #104 block the path of Resident #116 for no reason, shake her (Resident #104) fist at Resident #116 with her middle finger up, and hit her with a fist in the arm. Resident #103 stated it scared her when it happened and Resident #116 was quite upset. Resident #103 stated she wasn't sure if there was any staff that saw it happen but they came pretty quick. During an observation on 6/7/12 at 3:45 pm, Resident #104 was observed in the dining room on the second floor of the facility watching a movie, with 5 other residents in the room. The lights were turned off in the room, the doors to the dining room were closed, and there were no staff members present in the room. During an interview on 6/7/12 at 4:00 pm, Social Worker (SW) #3 stated that there is not a lot of documentation regarding Resident #104's behaviors because staff are so used to Resident #104's behaviors. SW #3 stated when Resident #104 wants someone's attention she will shake her fist and put up her middle finger, which can offend other residents. When asked by the surveyor what interventions have been put into place to keep residents safe from Resident #104's behaviors of punching, kicking, and throwing things, SW #3 stated Resident #104 was placed on 15 minute checks temporarily, moved to different units, and now eats in the day room while watching television. The surveyor asked SW #3 if Resident #103 punched Resident #105 or Resident #116 while eating a meal, and SW#3 stated no. The surveyor asked SW #3 if any staff member's witnessed Resident #104 hit Resident #116 and SW#3 stated she didn't think so. Facility policy and procedure titled "Abuse, prevention and prohibition of" provided to the surveyor by the facility Director of Nursing indicated under "Statement of Intent" Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. #

This citation pertains to intake MI 957 Based on interview and record review, the facility failed to follow the standards of care and the facility policy regarding the provision of emergency medical treatment in 1 of 9 sampled residents (Resident #104) reviewed for a potential acute change of condition from a total sample of 13 residents resulting in an Immediate Jeopardy when Resident #104 showed signs of an acute change of condition on [DATE] at approximately 12:00 PM and facility staff did not seek emergency medical treatment until [DATE] at 7: 45 PM, 7 hours and 45 minutes after the first signs of an acute change of condition, resulting in Resident #104 suffering a severe stroke. Resident #104 subsequently died . These deficient practices place all 110 residents at risk for serious harm, injury, and/or death. Findings include: According to the Mayo Foundation for Medical Education and Research, ,[DATE], "It should be noted when signs and symptoms of a stroke begin, because the length of time they have been present may guide treatment decisions. Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem to fluctuate or disappear. Call 911 or your local emergency number right away. Every minute counts. Don't wait to see if symptoms go away. The longer a stroke goes untreated, the greater the potential for brain damage and disability. To maximize the effectiveness of evaluation and treatment, it's best that you get to the emergency room within 60 minutes of your first symptoms." The professional standard of quality for notifying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated [DATE]). According to the American Stroke Association (2001), warning signs of a stroke include: sudden numbness or weakness of the face, arm or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; sudden or severe headache with no known cause. Immediately call 911 or the emergency medical services (EMS) to be transported to the hospital for medical treatment. Review of the Facility "Notification and Significant Change of Condition Policy", dated [DATE], revealed that, if a resident has an acute change of condition, facility staff are to "contact the physician immediately regardless the time of day. If the physician cannot be immediately reached in any emergency, the medical director will be called. If that physician cannot be reached, the Director of Nursing, or the change nurse can make arrangements for transportation to the emergency department." Resident #104 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #104 was a [AGE] year-old female, who was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #104 was completely dependent on staff for activities of daily living. On [DATE] at 11:20 AM, Resident #104 was observed in bed with her eyes closed. Review of the "Admission Nursing Assessment" dated [DATE], revealed Resident #104 was cooperative, and answered questions readily. Review of Nurses' Notes, dated [DATE] at 3:58 PM (late charting), revealed Registered Nurse (RN) Charge Nurse #8 documented that Resident #104 had "marked facial droop which makes it difficult to eat. Monitor continues." In an interview on [DATE] at 1:50 PM, RN Charge Nurse #8 stated that the first time she saw Resident #104 on [DATE] was around lunch time, and this was the first time she had seen Resident #104 since her readmission from the hospital on [DATE]. When asked about the facial droop noted in Resident #104, RN Charge Nurse #8 said she thought Resident #104 had "already went to the hospital for a stroke," and that "she (Resident #104) came back with a facial droop." RN #8 stated that she did no further assessment on Resident #104 after noting the right-sided facial droop. In an interview on [DATE] at 3:32 PM, Restorative CNA #6 stated when she first saw Resident #104 on [DATE] at 5:00 PM, she noticed a "big difference." Resident #104 was slumped over in her chair, unable to talk, or recognize Restorative CNA #6, which she was normally able to do. Restorative CNA #6 stated she notified the nurses on duty (LPN Charge Nurse #5 and LPN Charge Nurse#11) and the on-call manager (Marketing Director #15). In an interview on [DATE] at 11: 36 AM, Marketing Director #15 stated that she was informed on [DATE] around 5:30 PM or 6:00 PM by Restorative CNA #6 that Resident #104 was not acting right and that she (Restorative CNA #6) was worried. Marketing Director #15 stated Restorative CNA #6 said that she had already informed the nurses on duty of Resident #104's change of condition, but they were not concerned about these changes. In an interview on [DATE] at 12:48 PM, LPN Charge Nurse #5 stated she was first alerted to the change in condition in Resident #104 by a "Restorative Aide" on [DATE] around 5:30 PM. LPN Charge Nurse #5 stated she assessed Resident #104 in the dinning room and then had a "CNA" bring Resident #104 to her room and lay her (Resident #104) down. LPN Charge Nurse #5 stated she did a more through assessment of Resident #104 once in her room. LPN Charge Nurse #5 stated Resident #104 displayed difficulty swallowing, right-sided facial droop, eyes deviated to the right, and stiffness in her right leg. LPN Charge Nurse #5 said, "The first thing that came to mind was (Resident #104) was having a stoke." LPN Charge Nurse #5 did not seek emergency medical treatment for [REDACTED].#104's change of condition. LPN Charge Nurse #5 stated she attempted to contact the on-call physician a few times by using the answering service system, but did not attempt to contact the Medical Director. Review of Nurses' Notes, dated [DATE] at 6:00 PM, revealed LPN Charge Nurse #5 documented "physician paged, presently awaiting call to send resident (Resident #104) to ER for evaluation." Review of Nurses' Notes, dated [DATE] at 6:30 PM, revealed, LPN Charge Nurse #5 documented "physician paged again, still awaiting return call." Review of Nurses Notes, dated [DATE] at 7:00 PM, revealed, LPN Charge Nurse #5 documented "physician paged again, still awaiting return call." Review of Nurses Notes, dated [DATE] at 7:20 PM, revealed, LPN Charge Nurse #5 documented "received return phone call from on-call physician (#4) who requested to send resident (Resident #104) to ER (emergency room ) for evaluation and treatment. Review of the Physician Answering Service Paging Record, dated [DATE], revealed the on-call physician was paged only twice, once at 6:17 PM and the other at 7:18 PM. Review of the Ambulance Run Sheet, dated [DATE], revealed a call was received from the facility for emergency transportation to the hospital for Resident #104 at 7:29 PM, 7 hours and 29 minutes after Resident #104 first showed signs and symptoms of stroke. Review of the Nurses' Notes written by LPN Charge Nurse #5, dated [DATE] at 7:45 PM, revealed Resident #104 was transferred to the emergency room , 7 hours and 45 minutes after the first signs and symptoms of stroke were noted by RN #8. Review of the Nurses' Notes, dated [DATE], revealed Resident #104 returned to the facility on [DATE] at approximately 12:15 PM after suffering an extensive stroke with midline shift. Resident #104 returned with a code status of DNR (Do Not Resuscitate) and was placed on hospice. Review of the Radiology Consultation, Head CT Scan (Image of Brain), dated [DATE], revealed, Resident #104 suffered a "large acute infarct which has developed since the previous study involving the right occipital lobe and portions of the right temporal, parietal and frontal lobes. This produces at least seven to 8 mm of midline shift from the right towards the left. " Review of the Certificate of Death, dated [DATE], revealed Resident #104 expired on [DATE] due to a [MEDICAL CONDITION] Infarction ([MEDICAL CONDITION]), and a [MEDICAL CONDITION] (stroke) The Administrator and Assistant Director of Nursing (ADON) were notified on [DATE] at 4:30 PM of the Immediate Jeopardy that began on [DATE] as a result of the facility's failure to follow the standards of care and the facility policy regarding the provision of emergency medical treatment in one resident (Resident #104), when Resident #104 showed signs of an acute change of condition on [DATE] and facility staff did not seek emergency medical treatment until approximately 7 hours and 45 minutes after the first signs of an acute change of condition resulting in Resident #104 suffering a severe stroke. Resident #104 subsequently died . These deficient practices place all 110 residents at risk for serious harm, injury, and/or death. On [DATE] at 8:45 AM the Surveyor confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. On [DATE] Resident #104 was transferred to the hospital and returned to the facility on [DATE] on hospice. 2. On [DATE], all nurses began in-services on the facility policy for Notification and Significant Change of Condition and the procedure for physician notification of the change of condition. Any nurse not in-serviced, will received the in-service prior to the start of their next shift. 3. On [DATE], calls were made to notify all nurses of the mandatory in-services. 4. On [DATE], the Director of Nursing (DON) contacted the nurses involved, LPN Charge Nurse #5, LPN Charge Nurse #11 and RN Charge Nurse #8, to inform them that they were suspended until an investigation could be completed and interviews were scheduled. 5. On [DATE], the Notification and Significant Change policy was reviewed and revised to include an immediate notification to the Administrator if the physician or Medical Director cannot be reached. 6. On [DATE], the Medical Director was notified of the Immediate Jeopardy and a special Quality Assurance Committee Meeting was held to review issues identified in the survey and the progress on the plan of correction 7. Beginning [DATE], all new hires will be educated and receive the Policy and Procedure for Notification and Significant Change of Condition. 8. Beginning [DATE], the DON and ADON or designee will monitor the 24 hour Report at least 5 times a week and any problems noted will be addressed immediately and any patterns or trends will be reviewed in the QA Clinical Sub-Committee Meeting. 9. Beginning [DATE], the facility licensed staff began assessing resident for the potential for an acute change of condition. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not been verified by the State Agency and all staff had not yet been in-serviced. ( )

This citation pertains to intake MI 957 Based on interview and record review, the facility failed to maintain the highest practicable physical well-being in 1 of 9 sampled residents (Resident #104), reviewed for a potential acute change of condition from a total sample of 13 residents resulting in an Immediate Jeopardy when Resident #104 showed signs of an acute change of condition on [DATE] at approximately 12:00 PM and facility staff did not seek emergency medical treatment until [DATE] at 7: 45 PM, 7 hours and 45 minutes after the first signs of an acute change of condition, resulting in Resident #104 suffering a severe stroke. Resident #104 subsequently died . These deficient practices place all 110 residents at risk for serious harm, injury, and or death. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #104 was a [AGE] year-old female, who was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #104 was completely dependent on staff for activities of daily living. On [DATE] at 11:20 AM, Resident #104 was observed in bed with her eyes closed. Review of the Hospital Discharge Summary, dated [DATE], revealed Resident #104 was admitted to the hospital on [DATE] and treated for [REDACTED]. Resident #104 was discharged back to the facility on [DATE]. Review of the "Admission Nursing Assessment", dated [DATE], revealed Resident #104 was cooperative, and answered questions readily. Review of the physician progress notes [REDACTED]. The physician noted Resident #104 had generalized weakness in the physical examination with no other abnormal symptoms noted. In an interview on [DATE] at 1:30 PM, Licensed Practical Nurse (LPN) Charge Nurse #16 stated she worked the day shift on [DATE] and recalled that Resident #104 was having some difficulty taking her morning medications, but she "didn't see any signs of a stroke or anything like that." In an interview on [DATE] at 10:42 AM, LPN Charge Nurse #13, stated he worked with Resident #104 on [DATE] on the afternoon shift. LPN Charge Nurse #13 stated he monitored Resident #104 throughout his shift due to her having difficulty eating that night, but stated he thought Resident #104 was "just fatigued from returning from the hospital." LPN Charge Nurse #13 stated he noted nothing else different about Resident #104 on his shift. Review of Nurses' Notes dated [DATE] at 3:58 PM (late charting), revealed Registered Nurse (RN) Charge Nurse #8 documented that Resident #104 had "marked facial droop which makes it difficult to eat. Monitor continues." In an interview on [DATE] at 1:50 PM, RN Charge Nurse #8 stated that the first time she saw Resident #104 on [DATE] was around lunch time, and this was the first time she had seen Resident #104 since her readmission from the hospital on [DATE]. When asked about the facial droop noted in Resident #104, RN Charge Nurse #8 said she thought Resident #104 had "already went to the hospital for a stroke," and that "she (Resident #104) came back with a facial droop." According to the American Stroke Association (2001), warning signs of a stroke include: sudden numbness or weakness of the face, arm or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; sudden or severe headache with no known cause. Immediately call 911 or the emergency medical services (EMS) to be transported to the hospital for medical treatment. In an interview on [DATE] at 1:50 PM, RN #8 stated that she did no further assessment on Resident #104 after noting the right-sided facial droop. According to the Mayo Foundation for Medical Education and Research, ,[DATE], "It should be noted when signs and symptoms of a stroke begin, because the length of time they have been present may guide treatment decisions. Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem to fluctuate or disappear. Call 911 or your local emergency number right away. Every minute counts. Don't wait to see if symptoms go away. The longer a stroke goes untreated, the greater the potential for brain damage and disability. To maximize the effectiveness of evaluation and treatment, it's best that you get to the emergency room within 60 minutes of your first symptoms." In an interview on [DATE] at 3:31 PM, Restorative Certified Nurses Aide (CNA) #6 stated on the day Resident #104 returned from the hospital, on [DATE], she saw Resident #104 laying in bed, and again on [DATE], but did not work directly with Resident #104 on either days ([DATE] or [DATE]). In an interview on [DATE] at 3:32 PM, Restorative CNA #6 stated when she first saw Resident #104 on [DATE] at 5:00 PM, she noticed a "big difference." Resident #104 was slumped over in her chair, unable to talk, or recognize Restorative CNA #6, which she was normally able to do. Restorative CNA #6 stated she notified the nurses on duty (LPN Charge Nurse #5 and LPN Charge Nurse#11) and the on-call manager (Marketing Director #15). In an interview on [DATE] at 11: 36 AM, Marketing Director #15 stated that she was informed on [DATE] around 5:30 PM or 6:00 PM by Restorative CNA #6 that Resident #104 was not acting right and that she (Restorative CNA #6) was worried. Marketing Director #15 stated Restorative CNA #6 said that she had already informed the nurses on duty of Resident #104's change of condition, but they were not concerned about these changes. In an interview on [DATE] at 12:48 PM, LPN Charge Nurse #5 stated she was first alerted to the change in condition in Resident #104 by a "Restorative Aide" on [DATE] around 5:30 PM. LPN Charge Nurse #5 stated she assessed Resident #104 in the dinning room and then had a "CNA" bring Resident #104 to her room and lay her (Resident #104) down. LPN Charge Nurse #5 stated she did a more through assessment of Resident #104 once in her room. LPN Charge Nurse #5 stated Resident #104 displayed difficulty swallowing, right-sided facial droop, eyes deviated to the right, and stiffness in her right leg. LPN Charge Nurse #5 said, "The first thing that came to mind was (Resident #104) was having a stoke." LPN Charge Nurse #5 did not seek emergency medical treatment for [REDACTED].#104's change of condition. LPN Charge Nurse #5 stated she attempted to contact the on-call physician a few times by using the answering service system, but did not attempt to contact the Medical Director. Review of the Facility "Notification and Significant Change of Condition Policy" dated [DATE], revealed that, if a resident has an acute change of condition, facility staff are to "contact the physician immediately regardless the time of day. If the physician cannot be immediately reached in any emergency, the medical director will be called. If that physician cannot be reached, the Director of Nursing, or the change nurse can make arrangements for transportation to the emergency department." Review of Nurses' Notes, dated [DATE] at 6:00 PM, revealed LPN Charge Nurse #5 documented "physician paged, presently awaiting call to send resident (Resident #104) to ER for evaluation." Review of Nurses' Notes, dated [DATE] at 6:30 PM, revealed, LPN Charge Nurse #5 documented "physician paged again, still awaiting return call." Review of Nurses Notes, dated [DATE] at 7:00 PM, revealed, LPN Charge Nurse #5 documented "physician paged again, still awaiting return call." Review of Nurses Notes, dated [DATE] at 7: 20 PM, revealed, LPN Charge Nurse #5 documented "received return phone call form on-call physician (#4) who requested to send resident (Resident #104) to ER (emergency room ) for evaluation and treatment. The professional standard of quality for notifying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated [DATE]). Review of the Physician Answering Service Paging Record, dated [DATE], revealed the on-call physician was paged only twice, once at 6:17 PM and the other at 7:18 PM. Review of the Ambulance Run Sheet, dated [DATE], revealed a call was received from the facility for emergency transportation to the hospital for Resident #104 at 7:29 PM, 7 hours and 29 minutes after Resident #104 first showed signs and symptoms of stroke. In a second interview on [DATE] at 1:39 PM, LPN Charge Nurse #5 stated at the time of the event with Resident #104, on [DATE] at approximately 5:30 PM, Nurse Practitioner (NP) #17 was present at the nurses' station. LPN Charge Nurse #5 stated that she recalled NP #17 saying the reason, why Resident #104 was acting the way she was, was possibly due to the Urinary Tract Infection and she (NP #17) said if you send her (Resident #104) they (the hospital) are going to send her right back to the facility. In an interview on [DATE] at 10:18 AM, NP #17 stated that she was present during the discussion regarding Resident #104 on [DATE]. NP #17 stated she may have made a comment that the symptoms Resident #104 was exhibiting were possibly related to the Urinary Tract Infection, but would have never given medical advice, as she is a Psychiatric NP, with no privileges outside the psychiatric field at the facility. NP #17 stated she never saw and or examined Resident #104 on [DATE]. Review of the Nurses' Notes written by LPN Charge Nurse #5, dated [DATE] at 7:45 PM, revealed Resident #104 was transferred to the emergency room , 7 hours and 45 minutes after the first signs and symptoms of stroke were noted. Review of the Nurses' Notes, dated [DATE], revealed Resident #104 returned to the facility on [DATE] at approximately 12:15 PM after suffering and extensive stroke with midline shift. Resident #104 returned with a code status of DNR (Do Not Resuscitate) and was placed on hospice. Review of the Radiology Consultation, Head CT Scan (Image of Brain), dated [DATE], revealed, Resident #104 suffered a "large acute infarct which has developed since the previous study involving the right occipital lobe and portions of the right temporal, parietal and frontal lobes. This produces at least seven to 8 mm of midline shift from the right towards the left. " Review of the Certificate of Death, dated [DATE], revealed Resident #104 expired on [DATE] due to a [MEDICAL CONDITION] Infarction ([MEDICAL CONDITION]) and a [MEDICAL CONDITION] (stroke) The Administrator and Assistant Director of Nursing (ADON) were notified on [DATE] at 4:30 PM of the Immediate Jeopardy that began on [DATE] as a result of the facilities failure to maintain the highest practicable physical well being of one resident (Resident #104), when Resident #104 showed signs of an acute change of condition on [DATE] and facility staff did not seek emergency medical treatment until approximately 7 hours and 45 minutes after the first signs of an acute change of condition resulting in Resident #104 suffering a severe stroke. Resident #104 subsequently died . These deficient practices place all 110 residents at risk for serious harm, injury, and or death. On [DATE] at 8:45 AM the Surveyor confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. On [DATE], Resident #104 was transferred to the hospital and returned to the facility on [DATE] on hospice. 2. On [DATE], all nurses began in-services on the facility policy for Notification and Significant Change of Condition and the procedure for physician notification of the change of condition. Any nurse not in-serviced, will received the in-service prior to the start of their next shift. 3. On [DATE], phone calls were made to notify all nurses of the mandatory in-services. 4. On [DATE], the Director of Nursing (DON) contacted the nurses involved, LPN Charge Nurse #5, LPN Charge Nurse #11 and RN Charge Nurse #8, to inform them that they were suspended until an investigation could be completed and interviews were scheduled. 5. On [DATE], the Notification and Significant Change policy was reviewed and revised to include an immediate notification to the Administrator if the physician or Medical Director cannot be reached. 6. On [DATE], the Medical Director was notified of the Immediate Jeopardy and a special Quality Assurance Committee Meeting was held to review issues identified in the survey and the progress on the plan of correction 7. Beginning [DATE], all new hires will be educated and receive the Policy and Procedure for Notification and Significant Change of Condition. 8. Beginning [DATE], the DON and ADON or designee will monitor the 24 hour Report at least 5 times a week and any problems noted will be addressed immediately and any patterns or trends will be reviewed in the QA Clinical Sub-Committee Meeting. 9. Beginning [DATE], the facility licensed staff began all assessing residents for the potential for an acute change of condition. Although, the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not been verified by the State Agency and all staff had not yet been in-serviced. ( )