Every finding on record at Ashley Healthcare Center

Based on interview and record review, the facility failed to accurately document the code status for 1 resident (R18) of 1 resident reviewed for advance directives.Findings include:Review of an admission Record revealed R18 admitted to the facility on [DATE] with pertinent diagnoses which included paranoid schizophrenia and dependence on supplemental oxygen. Further review revealed he had a court appointed guardian.Review of R18's Care Conference Report note, dated 1/7/2026, revealed he planned to continue as full code status (full resuscitation and life sustaining treatment).Review of R18's Resident Code Status form, signed by his court appointed guardian 6/27/2025, revealed he wished to be full code.Review of R18's Physician's Orders, active 2/23/2026 revealed an order for R18 to be DNR (Do Not Resuscitate).In an interview on 2/23/2026 at 2:25 PM, Registered Nurse (RN) K stated I think he (R18) is full code. RN K then viewed his Medication Administration Record alert and Physician's Orders and reported he was DNR.In an interview on 2/23/2026 at 2:30 PM, R18 reported he wished his heart to be started if it stopped.In an interview on 2/23/2026 at 2:36 PM, the Director of Nursing (DON) reviewed R18's Physician's Orders and Resident Code Status form and reported the order was probably placed incorrectly as DNR because R18 should be full code. The DON reported the Physician's Order for DNR was placed by Minimum Data Set (MDS) RN D.In an interview on 2/23/2026 at 2:44 PM, MDS RN D reviewed R18's Resident Code Status and stated, I must have placed this incorrectly.Review of facility policy/procedure Communication of Code Status, reviewed 1/7/2026, revealed .this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information.

Based on interview and record review, the facility failed to ensure the discharge needs were met for 1 resident (R23) of two residents reviewed for discharge concerns. Findings include:Review of an admission Record revealed R23 admitted to the facility on [DATE] with pertinent diagnoses which included type II diabetes mellitus, major depressive disorder, and hoarding disorder. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R23, with a reference date of 10/11/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R23 was cognitively intact. In an interview on 2/23/26 at 10:00 AM, R23 reported that she did not belong at the facility. R23 stated she was quite a distance from her home, and she had requested multiple times that she would like to move closer to where her family resides, possibly in a senior apartment. R23 reported that she visited with the staff and felt like there were no alike residents to talk to in the facility. R23 reported that in the past she had requested her guardian to be dissolved through the court system and she was appointed a different guardian. R23 stated she had not seen her new guardian face to face since the guardian was appointed (11/11/25). R23 stated my rights are being violated. Review of a Point of Care History documentation revealed that between 1/1/2026 and 1/31/2026 R23 was independent for bed mobility, transfers, ambulation, movement on and off the unit, dressing, eating, toileting, and bathing. In an interview and record review on 2/24/26 at 2:09 PM, the Director of Nursing (DON) stated that there were some concerns for R23 that discharge planning had not been started or discussed at a facility level. R23 had voiced to facility staff her wishes to discharge near her home or a senior living apartment. DON stated that R23 was independent in her room and able to complete daily tasks independently. DON stated that R23 self-administers medications and can manage her diabetic device for blood sugar checks without difficulty. Review of a Care Conference dated 9/10/2025 and 1/7/2026 Social Work Tech (SWT) A documented R23 intends to transfer to a facility closer to home. In an interview and record review on 2/24/26 at 2:51 PM, SWT A responded nothing when asked what had been completed toward the discharge planning for R23 to move closer to her home or to a senior apartment. SWT A stated that they had told her not to start the discharge process for R23. When asked who they were SWT A stated the court or the independent medical examiner that was assisting in R23's case. SWT A could not locate documentation for R23's case and could not locate documentation to show that R23 was not capable of being discharged to a facility closer to her home or to a senior apartment. SWT A stated the process for resident discharge planning started in the facility's morning meeting and the team discusses residents that are ready for discharge. SWT A stated I have not been told to begin discharge planning for this resident. SWT A asked if she should have had follow up notes related to discharge planning for R23, SWT A stated yes. Review of facility Job description Social Work Tech revealed .Job summary.assists team members with discharge planning activities.Core responsibilities. to begin discharge planning for residents on admission and ongoing, working with all aspects of the interdisciplinary team to ensure an appropriate and safe resident discharge. In an Interview and record review on 2/24/26 at 3:04 PM, the Nursing Home Administrator (NHA) stated common sense would indicate that R23 should be reevaluated for the opportunity to live independently. The NHA stated the facility needed to reach out to the guardian and ask if the facility could look at other avenues for R23. The NHA was unable to locate documentation that R23 could not re-locate closer to home or be assessed for a senior living apartment. The NHA attempted to reach out to R23's guardian with no answer and a voicemail box that was already full. The NHA stated that it is the facility's due diligence to reach out to the guardian to express R23's wishes. Review of facility policy/procedure Discharge Planning Process, revealed .Discharge planning is a process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge.if discharge to community is determined to not be feasible, the facility will document in the clinical record who made the determination and why.in cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the interdisciplinary team will treat this situation similarly to refusal of care: a. Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location. b. Offer other, more suitable options of locations that are equipped to meet the needs of the residents. Document any discussions related to the options presented. c. Document refusals of other options that could meet the resident's needs.

Based on observation, interview and record review, the facility failed to implement a patient centered care plan for pain and pressure ulcers for 1 Resident (R1) of 13 residents reviewed for care plans.Findings included: Review of R1's undated face sheet, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: osteomyelitis, pressure ulcer of right upper back, urinary tract infection, diabetes mellitus, morbid (severe) obesity, chronic pain, and pressure ulcer of unspecified part of back, unstageable. He was his own responsible party.During an interview with R1 in his room on 1/23/26 at 1:20 PM, R1 complained about staff not getting him placed correctly in bed. R1 said he is 6 feet tall, and staff do not get him high enough into bed. R1 was sitting in a recliner next to his bed during this interview. R1 said when staff put him on the bed his butt is not placed high enough for him to bend properly and it causes more pain to his tailbone. R1 said staff do not listen or assist him to become more comfortable. R1 said he would go back to bed more often if staff would listen and help him the way he wanted to be helped. R1 said he has a pressure ulcer on his back and coccyx.R1 was observed being transferred from his wheelchair to his bed with a full body lift on 2/23/26 at 2:28 PM. R1 required the assistance of 3 people, Certified Occupational Therapist Assistant (COTA) F, Registered Nurse (RN) D and Certified Nurse Aide (CNA) J. R1 yelled in pain with all movement and could not tolerate lying flat in bed or on his left side. R1 again reported he cannot stay in bed due to severe pain. He is only able to be comfortable sitting or on his right side when in bed. He reported transferring is extremely painful. COTA F said she had just started educating staff on how to transfer R1 on 2/20/26. R1 said staff did not transfer him as COTA F had directed staff to on 2/20/26 over the weekend. COTA F denied notifying R1's physician that he could not tolerate lying on his back, left side and unbearable pain with transfers.R1 was observed in bed lying on his right side on 2/26/26 at 8:10 AM. R1 reported he went to bed around 2:00 AM. R1 reported he was frustrated because staff did not get him up for breakfast or change his brief after he was placed in bed at 2:00 AM. R1s' room smelled like urine and his top sheet and bottom sheet were wet in the area around his brief. R1 said he cannot eat in bed because he cannot be on his back in bed.During an interview with Certified Nurse Aide (CNA)H on 2/26/26 at 8:15 AM in the main dining room, CNA H confirmed she was assigned to R1 this morning since 6:00 AM. CNA H reported she was not aware R1 wanted to be out of bed for breakfast. CNA H was asked about R1's care plan related to his preferences and times he wanted to be out of bed. CNA H said R1's care plan did not indicate he wanted to be up. CNA H went to get CNA I and Unit Manager (UM) B to assist her getting R1 out of bed. When they got to his room R1 said he wanted to have his pain medication prior to getting out of bed. R1 said when he moves it feels like 10,000 volts of electricity going from his back to his legs. UM B said R1's nurse was on the locked unit and would need to be notified of R1's request for medicationOn 2/26/26 at approximately 8:45 AM, the DON, CNA H and I transferred R1 from his bed to the recliner in his room with a full body electronic lift. R1 assisted with rolling in bed, by grabbing the bed rails to roll. R1 reported he required the head of his bed to elevate approximately 30 degrees due to intolerable pain when he was flat in bed. During the transfer R1 was observed yelling about pain with all movement.During an interview with the Director of Nursing (DON) on 2/24/26 at 12:29 PM, R1's pain concerns were discussed. The DON said when she reviewed R1's pain medication orders she discovered he was not taking all his prn (as needed) pain medications and confirmed R1 has times of confusion and may not know when he is able to have his next dose of pain medication. The DON confirmed they had not met with R1 and discussed his pain medication schedule needs or made attempts to provide medication related to his mobility needs.Review of R1's care plan revealed there were no specific instructions for transfers, no indication of R1's tolerance or preference for positioning or eating meals in his chair. There was no care plan in place for skin or pressure ulcers until after the survey started. R1 pain control was not addressed in his care plan. R1's preferences for pressure relief and positioning were not addressed in his care plan.

Based on observation, interview and record review, the facility failed to follow physician orders to treat and monitor health conditions for 1 Resident (R2) of 1 Resident reviewed for medical complaints.Findings included: Review of R2's undated face sheet, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: mild cognitive impairment, atypical facial pain, post-traumatic stress disorder and mild neurocognitive disorder. R2 was not his own responsible party.During an interview with R2 on 2/23/26 at 11:38 AM, R2 complained about his right ear hurting and buzzing. R2 said he has reported it to staff, but nothing is being done about it.During an interview with facility Social Worker (SW) A, SW A said R2 had complained about his ears ringing sometime in the last week. The Surveyor requested information on how the facility followed up with R2's concerns about his right ear.On 2/24/26 at 1:08 PM, Social Worker A provided a note form R2's physician dated 1/14/26, noting R2 had ear pain and ordered for R2's ear to be irrigated.Review of a handwritten note dated, 1/14/26 for R2 revealed, Resident complaint of pain - right ear/right neck after completing ABT/PO (antibiotic orally) and debriding of ear wax in ER/hospital. Requesting re-evaluation of right ear/right neck pain. Under Doctor Recommendation was written, Ear wax present, ok to irrigate ear. Signed by R2's physician on 1/15/26.Review of R2's physician orders revealed, 1/20/26, May irrigate rt (right) ear for s/s (signs and symptoms) of discomfort as needed.During an interview with Unit Manager (UM) B on 2/24/26 at 1:12 PM, UM B reviewed R2's order for his ear to be irrigated dated 1/20/26. UM B could not find any documentation in R2's medical record that staff had followed the physician order to irrigate R2's right ear. UM B said the order was still current and she would have staff address R2's right ear discomfort.On 2/24/26 at 1:12 PM, UM B asked Registered Nurse (RN) G to check R2's ears. RN G initially could not find a functional otoscope on the nursing unit. Once a functional otoscope was secured RN G checked both of R2's ears and they were both full of old wax. RN G reported he would get orders to treat R2's wax build up in both ears and after the wax was softened, he would irrigate his ears.

Based on interview and record review, the facility failed to recognize, assess and respond to an acute change of condition for 1 (R29) resident of 2 residents reviewed for change of condition. Findings include:Review of an admission Record revealed R29 originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia, psychotic disturbance, anxiety, and insomnia. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R29, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13, out of a total possible score of 15, which indicated R29 was cognitively intact. Further documentation revealed was there evidence of an acute change in mental status from the resident's baseline, marked yes. Review of a Resident Code Status dated [DATE] revealed R29 was a Full code (Full resuscitation and life sustaining treatment desired). Review of a Hospice Comprehensive Assessment Plan of Care Update Report dated [DATE], revealed Advance directives - full code. Review of a Care Conference dated [DATE] and [DATE] revealed R29 would continue as a full code. Review of R29's Progress Note dated [DATE] at 12:28 AM revealed .at 1912 called (local) hospice r/t (related to) resident nonresponsive, VS 97.5-54-136/77-92%-15, they are attempting to get ahold of her son regarding her code status, they will continue to work on this, hospice stated if we have to send her to hos (hospital) d/t (due to) coding we can send her. Review of R29's Progress Note dated [DATE] at 9:48 AM revealed .Resident received shower from hospice aide. No new skin issues noted. Resident noted to be very lethargic. Bed linens changed. Review of R29's Progress Note dated [DATE] at 5:41 PM revealed .Resident not eating much during meals. Resident changed to assisted feed, and resident ate greater then 75% for dinner. Hospice notified. Review of R29's Progress Note dated [DATE] at 6:39 PM revealed .Resident has been difficult to arouse, able to arouse enough take medications this morning. Nutritional and fluid intake poor during shift. Resident resting quietly in bed with no s/s (signs and symptoms) of discomfort noted. Turned and repositioned q2hrs and PRN (as needed), check and change, incontinent of bowel and bladder. Review of R29's Progress Note dated [DATE] at 5:09 AM revealed .Resident slept throughout shift, was able to get medications in. however was difficult to arouse. no other oral intake throughout shift. Review of R29's Progress Note dated [DATE] at 12:32 PM revealed .Writer called RP (responsible party), Son and left message to talk with resident regarding code status and declining condition. Await return call. Review of R29's Progress Note dated [DATE] at 6:32 PM revealed .Resident has not been responsive during shift. Very little fluids accepted as resident is not responsive enough to swallow fluid. Tried some thickened liquids also and unable to swallow. Respirations shallow, mouth open, mouth breathing. Resting quietly and comfortably, turned and repositioned Q 2-hr and PRN. Called Hospice to inform them of resident's current condition and code status. Hospice nurse stated she was aware of full code status and understands if resident has to be sent out to go ahead and do so and keep them informed. Information communicated with oncoming nurse. No return call from RP as of this time. Review of R29's Progress Note dated [DATE] at 12:31 AM revealed .at 1900 spoke with her son regarding her decline in her condition and code status, she appeared to be actively dying, unable to hear her B/P (blood pressure), educated him about the CPR that it would entail breaking her ribs and then there is a possibility she will die anyway, he stated to keep her a full code and do CPR on her, explained she would be sent out to the hospital, he stated ok, resident was non responsive, couldn't hear her B/P, and her breathing was 40, called ambulance, (local fire department) came and evaluated her first, then (local ambulance service) came and transported her to (local hospital) at 1945, [NAME] nurse spoke with ER at midnight and she is intubated and being taken to ICU. Review of R29's Vital Sign Record revealed vital signs obtained on [DATE], [DATE], [DATE], [DATE], [DATE], which were noted to be within normal limits. There were no other records that revealed vital signs or assessments in R29's Electronic Medical Record (EMR). Review of R29's hospital Chief Complaint-Reason for Admission dated [DATE] revealed .has been actively dying over the past 2 days with agonal respiration (gasping irregular breaths) and tachycardia (fast heartbeat over 100 beats per minute) on hospice and was brought to the emergency department for altered mental status. ED (Emergency Department) physician contacted the patient's son who resides in (out of state) and the son indicated that he wishes full resuscitation and intubation mechanical ventilation support and the patient was intubated. (R29) was found in respiratory failure and intubated and was found to have right lower lobe pneumonia with thick secretions suctioned and also tested positive for Covid-19 infection. (R29) was found to have severe acidosis (too much acid in body fluids) with hyperkalemia (high potassium levels in the blood) and admitted to intensive care unit with septic shock started on Intravenous fluid and broad-spectrum antibiotic. In an interview and record review on [DATE] at 1:47 PM, the Director of Nursing (DON) stated that R29's condition went back and forth. The DON reviewed progress notes from [DATE] and stated she was unsure why staff would not have sent R29 to the hospital on [DATE] after hospice directed the transfer if R29's condition required it. Upon review of R29's EMR, the DON was unable to locate any documentation of an acute assessment for R29 or acute monitoring for a change of R29's condition. R29 was unresponsive on [DATE] with continued decline until transfer to the hospital on [DATE]. R29's vital signs were taken 5 times within that 14-day period. The DON stated the facility needed to start an SBAR (situation-background-assessment-recommendation) program (used to ensure concise, accurate, and rapid information exchange during critical situations, handoffs, or shifts) and put acute residents with condition changes on a watch list and if the resident needs to be sent to the hospital for treatment the facility should do so. When asked if there should have been acute documentation and a transfer sooner than [DATE] for R29, the DON stated yes. Review of facility policy/procedure Change in a Resident's Condition or Status, revised [DATE] revealed .the nurse supervisor/charge nurse will notify the resident's family or representative when.it is necessary to transfer the resident to a hospital.will promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical condition.

Based on observations, interviews, and record reviews, the facility failed to thoroughly assess skin on admission, do ongoing assessments, implement an effective treatment plan, and prevent the worsening of pressure ulcers for 1 resident (R1) of 2 residents reviewed for pressure ulcers, resulting in the worsening of a pressure ulcer.Findings included:A review of R1's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included osteomyelitis, pressure ulcer of the right upper back, urinary tract infection, diabetes mellitus, morbid (severe) obesity, chronic pain, and pressure ulcer of an unspecified part of the back, unstageable. He was his own responsible party.During an interview with R1 in his room on 1/23/26 at 1:20 PM, R1 complained about staff not getting him placed correctly in bed. R1 said he is 6 feet tall, and they do not get him high enough into bed. R1 was sitting in a recliner next to his bed during this interview. R1 said when staff put him on the bed, his butt is not placed high enough for him to bend properly, and it causes more pain to his tailbone. R1 said staff do not listen to him and assist him to become more comfortable. R1 said he would go back to bed more often if staff would listen to him and help him the way he needs to be helped. R1 said he has a pressure ulcer on his back and coccyx.R1 was observed being transferred from his wheelchair to his bed with a full body lift on 2/23/26 at 2:28 PM. R1 required the assistance of 3 people: Certified Occupational Therapist Assistant (COTA) F, Registered Nurse (RN) D and Certified Nurse Aide (CNA) J. R1 yelled in pain with all movement and could not tolerate lying flat in bed or on his left side. R1 again reported he cannot stay in bed due to severe pain. He is only able to be comfortable sitting or on his right side when in bed. He reported transferring is extremely painful. He expressed frustration because of the way staff transferred him and did not listen to him, which was preventing him from going back to bed more often. COTA F said she had just started educating staff on how to transfer R1 on 2/20/26. R1 said staff did not transfer him as COTA F had directed staff to on 2/20/26 over the weekend. COTA F denied notifying R1's physician that he could not tolerate lying on his back, left side, and unbearable pain with transfers. COTA F had not implemented a care plan for R1's transfer needs.R1 was observed in bed lying on his right side on 2/26/26 at 8:10 AM. R1 said he went to bed around 2:00 AM. R1 was frustrated because staff did not get him up for breakfast or change his brief after he was placed in bed at 2:00 AM. R1's room smelled like urine, and his top sheet and bottom sheet were wet in the area around his brief, and the outer edge of the wet spot was a light brown color. The wet area was greater than 12 inches around. R1 said he cannot eat in bed because he cannot be on his back in bed.During an interview with Certified Nurse Aide (CNA) H on 2/26/26 at 8:15 AM in the main dining room, CNA H confirmed she was assigned to R1 this morning since 6:00 AM. CNA H reported she was not aware R1 wanted to be out of bed for breakfast. CNA H said R1's care plan did not indicate he wanted to be up for breakfast. CNA H went to get CNA I and Unit Manager (UM) B to assist her in getting R1 out of bed. When they got to his room, R1 said he wanted to have his pain medication prior to getting out of bed. R1 said when he moves, it feels like 10,000 volts of electricity are going from his back to his legs. UM B said R1's nurse was on the locked unit and would need to be notified of R1's need for medication. UM B left the room and returned with pain medication after the Director of Nursing (DON) did the dressing change on R1's coccyx.On 2/26/26 at approximately 8:30 AM the Director of Nursing (DON) came in and changed the dressing on R1's coccyx and said the wound measured 2.0 x 0.3 x 0.1 cm. She said she would do the wound on the back of his right shoulder when he was up in his chair.On 2/26/26 at approximately 8:45 AM, the DON, CNA H and I transferred R1 from his bed to the recliner in his room with a full-body electronic lift. R1 assisted with rolling in bed by grabbing the bed rails to roll. He required the head of his bed to elevate approximately 30 degrees when he was on his back due to intolerable pain when he was flat in bed. He yelled out in pain with all movement.On 2/26/26 at 11:00 AM Unit Manager (UM) B came in and changed the dressing on R1's back near his right shoulder. The old dressing was not dated. UM B measured the wound and said it was 3.5 cm x 3.0 cm.Review of R1's Observation Detail List Report dated 1/27/26 at 05:15 PM revealed on page 11, Number and describe each pressure ulcer 'injury,' Stage 1 on coccyx x 3 cm. There was no indication of a pressure ulcer on his back. R1's face sheet indicates he had a pressure ulcer on his back on admission.Review of R1's Weekly Skin Assessment, dated 1/28/26 at 10:41 AM, revealed the box No identified concerns was checked.Review of R1's progress note dated 1/31/26 at 3:19 PM revealed, Upon changing the resident this morning, the CNAs (Certified Nurse Aides) noted an open area to the resident's coccyx. The area measures 3.4 cm x 0.8 cm x 0.1 cm. No odor, no drainage, no tunneling, no undermining, Peri skin is intact and pink.A review of R1's progress note dated 2/6/26 at 15:27 (3:27 PM) revealed, Wound NP (Nurse Practitioner) in to see resident and evaluate wounds on rt (right) back/shoulder and coccyx. Rt (right) shoulder wound measuring 5.0 x 5.0 x 0.1 cm. Noted light serous drainage with no presence of odor. New tx (treatment) order to cleanse wound with wound cleanser, pat dry apply Hydro [NAME] Blue to wound bed and cover with boarder foam dressing. X3 weekly and PRN. Wound sacrum measuring 2.0 x 0.7 x 0.1 cm, light amount of serous drainage, peri wound with noted peeling skin. Tx (treatment) order to cleanse area with wound cleanser, pat dry apply Hydro Ferr Blue to wound bed and cover with boarder foam gauze. Resident aware of wounds and is agreeable to treatment orders.A review of R1's progress note dated 2/25/26 at 8:43 AM revealed, Wound observed on coccyx measuring 2.0 x 0.3 x 0.1 cm. Wound bed open, pink in nature, slit to coccyx with no presence of drainage, Peril wound intact, normal in color, with dry flakey skin surrounding. Treatment administered placing hydro [NAME] blue on wound bed, cover with boarder foam dressing.A review of R1's care plan revealed there were no specific instructions for transfers and no indication of R1's tolerance or preference for positioning or eating meals in his chair. There was no care plan in place for skin or pressure ulcers until after the survey started.During an interview with the Director of Nursing (DON) on 2/23/26 at 1:22 PM, the DON said R1's wound on the back of his right shoulder and buttock was present on admission. The DON reviewed R1's Electronic Medical Record (EMR) and could not locate measurements on admission or weekly measurements. When R1 entered the facility, they were using a different EMR's. The DON said they normally have residents reviewed weekly by an outside company providing wound services, and she was aware R1 had refused some treatment. A request for all wound measurements and wound treatment refusals, physician notification of refusals, and education related to refusing wound treatment was made. During an interview with the Nursing Home Administrator (NHA) on 2/25/26 at 1:32 PM, the NHA could not locate any wound measurements for the wound on the back of R1's right shoulder from admission to prior to the start of the survey. The NHA found one measurement of R1's coccyx pressure ulcer done on admission indicating it was stage 1 and measured 3 cm. Upon exit, the NHA also located coccyx wound measurements for 1/31/26 and 2/6/26. NHA could not locate education or refusal documents related to R1's wound care that had been done prior to this survey.Review of the facility, Pressure Injury Prevention and Management policy dated 11/1/2022 revealed, 3. Assessment of Pressure Injury Risk. A. Licensed nurses will conduct a pressure injury risk assessment, using the (fill in blank for designated tool), on all residents upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly. C. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly and after any newly identified pressure injury. Findings will be documented in the medical record. 4. Interventions for Prevention and Promote Healing. A. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.

Based on observations, interviews and record review the facility failed to assess, monitor and implement a respiratory care plan for 1 Resident (R1) on Continuous Positive Airway Pressure (CPAP). Findings include: Review of R1's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: osteomyelitis, pressure ulcer of the right upper back, urinary tract infection, diabetes mellitus, morbid (severe) obesity, chronic pain, and pressure ulcer of unspecified part of back, unstageable. He was his own responsible party. During an interview conducted on 1/23/26 at 1:20 PM in his room, R1 complained that the facility never cleaned his CPAP machine or provided cleaning equipment or supplies. Review of R1's medical record did not reveal a physician order for the use of the CPAP machine or its care and cleaning. Further review of the medical record did not reveal a respiratory care plan for the use and care of the CPAP machine or ongoing respiratory assessments. Review of the Treatment Administration Record (TAR) section of the medical record did not reveal scheduled care or maintenance of the CPAP machine belonging to R1. During an interview conducted 2/25/26 at 2:20 PM, the Director of Nursing (DON) confirmed R1 should have had physician's orders for his CPAP machine. The DON reported that the facility normally placed cleaning and use orders in the TAR. The DON acknowledged they failed to ensure R1 had physician orders in place of R1's CPAP machine. Review of the facility's CPAP/BiPAP Cleaning policy dated 11/2/2022 revealed, It is the policy of this facility to clean CPAP/BiPAP equipment in accordance with current CDC guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection. The policy continued with a list of Weekly cleaning activities.

Based on observations, interviews and record review, the facility failed to adequately treat 1 Resident (R1) for pain of 1 Resident reviewed for pain.Findings included: Review of R1's undated face sheet, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: osteomyelitis, pressure ulcer of right upper back, urinary tract infection, diabetes mellitus, morbid (severe) obesity, chronic pain, and pressure ulcer of unspecified part of back, unstageable. He was his own responsible party.During an interview with R1 in his room on 1/23/26 at 1:20 PM R1 complained about staff not getting him placed correctly in bed. R1 said he is 6 feet tall, and staff do not get him high enough into bed. R1 was sitting in a recliner next to his bed during this interview. R1 said when staff put him on the bed his butt is not placed high enough for him to bend properly and it causes more pain to his tailbone. R1 said staff do not listen or assist him in becoming more comfortable. R1 said he would go back to bed more often if staff would listen to him and help him the way he needs to be helped. R1 said he has a pressure ulcer on his back and his coccyx. R1 said he wanted the physician to address his pain medication.R1 was observed being transferred from his wheelchair to his bed with a full body lift on 2/23/26 at 2:28 PM. R1 required the assistance of 3 people, Certified Occupational Therapist Assistant (COTA) F, Registered Nurse (RN) D, and Certified Nurse Aide (CNA) J. R1 yelled in pain with all movement and could not tolerate lying flat in bed, or on his left side. R1 reiterated he could not stay in bed due to the pain. R1 reported he is only able to be comfortable sitting or on his right side when in bed, and that transfers are extremely painful. COTA F reported she recently initiated staff training on how to transfer R1 but had not informed the physician of the pain R1 experiences with poor bed positioning and transfers. COTA F said she had just started educating staff on how to transfer R1 on 2/20/26. R1 said staff did not transfer him as COTA F had directed staff to on 2/20/26 over the weekend.During an interview with Certified Nurse Aide (CNA)H on 2/26/26 at 8:15 AM in the main dining room, CNA H confirmed she was assigned to R1 this morning since 6:00 AM. CNA H reported she was not aware R1 wanted to be out of bed for breakfast. CNA H said R1's care plan did not indicate he wanted to be up for breakfast. CNA H went to get CNA I and Unit Manager (UM) B to assist her getting R1 out of bed. When they got to his room, R1 requested pain medication prior to getting out of bed. R1 said when he moves it feels like 10,000 volts of electricity going from his back to his legs.On 2/26/26 at approximately 8:45 AM, the DON, CNA H, and I, transferred R1 from his bed to the recliner in his room with a full body electronic lift. R1 assisted with rolling in bed by grabbing the bed rails to roll. R1 reported he required the head of his bed to elevate approximately 30 degrees when he was on his back due to intolerable pain when he was flat in bed. During the transfer, R1 exhibited signs of pain with all movement.R1's care plan did not reflect specific instructions for transfer or preferences for positioning. The care plan did not reflect consideration for the Resident's pain with transfers, bed positioning, or mobility.Review of R1's physician orders revealed, 2/2/2026, Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg, give 1 tablet by mouth every 6 hours as needed for Chronic Pain, not to exceed 3000 mg of Acetaminophen in 24-hr from all sources.Review of R1's February 2026, Medication Administration Record (MAR) Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg, give 1 tablet by mouth every 6 hours as needed for Chronic Pain, not to exceed 3000 mg of Acetaminophen in 24-hr from all sources, start date, 02/02/2026. R1 did not receive any Hydrocodone- Acetaminophen on, 2/3/26, 2/5/26, 2/10/26, 2/17/26, 2/18/26, 2/20/26, 2/21/26. R1 only received one dose on 2/2/26, 2/4/26, 2/6/26, 2/8/26. 2/12/26, 2/13/26,2/22/26, 2/23/26. R1 received 2 doses on 2/7/26, 2/9/26, 2/11/26,2/15/26, 2/16/26, 2/19/26. R1 Received 3 doses on 2/14/26. R1 never received the 4 doses of pain medication he was allowed to receive.During an interview with the Director of Nursing (DON) on 2/24/26 at 12:29 PM, R1's pain concerns were discussed. The DON said when she reviewed R1's pain medication orders she discovered he was not taking all his prn (as needed) pain medications and confirmed R1 has times of confusion and may not know when he is able to have his next dose of pain medication. The DON confirmed they had not met with R1 to discuss his pain concerns.

Based on interview and record review, the facility failed to provide laboratory services to meet the needs of one resident (R9) of one resident reviewed for laboratory services. Findings include:Review of the Electronic Medical Record (EMR) admission record reflected R9 was admitted to the facility 9/18/2025 with diagnoses that included bipolar disorder.Review of the EMR Progress Notes for R9 reflected an entry dated 2/19/2026 at 9:44 AM. The entry reflected, (Name of Physician) in to evaluate and treat patient for recent increase in behaviors. Gave order to perform urinalysis and collect (comprehensive metabolic panel (CMP) serum blood draw) Orders entered. Will collect urine.Review of the EMR Physician Orders for R9 did not reveal the orders had been entered as indicated by the Progress Note of 2/19/2026 at 9:44 AM.Further review of the EMR did not reveal any further documentation that lab specimens were obtained, lab results, monitoring for lab results, or attempts to determine the root cause of the recent increase in behaviors of R9.On 2/25/2026 at 1:25 PM, an interview was conducted with Registered Nurse (RN) E. RN E reported she entered the Progress Note of 2/19/25 at 9:44 AM and indicated she had placed the Physician's Orders into the EMR, as well. During the interview RN E reviewed the EMR but did not locate the Physician's Order for the lab work for R9. RN E provided a laboratory requisition form dated 2/20/2026 that included the name of R9. The laboratory requisition form reflected CMP was circled and Additional Tests reflected a handwritten entry for a urinalysis with a culture and sensitivity. RN E reported the form was faxed to the lab. RN E was unable to locate any other documentation that the lab had been completed. RN E indicated no mechanism was in place to ensure ordered lab work had been completed other than nurse shift to shift report.On 2/26/2026 at 1:45 PM, Unit Manager (UM) B reported that neither the CMP serum draw or the urine specimen was obtained. UM B reported staff had placed a hat into the commode to collect a urine specimen but R9 did not void. UM B reported RN E told her when lab came to the facility, she observed lab staff walking toward the room of R9 and assumed the CMP serum specimen had been obtained. UM B reported she had contacted the lab and was told the serum specimen for the CMP had not been obtained. UM B reported the facility is in transition to a new EMR system and the former system automatically notified the lab of the order, but the new system does not. UM B added since the new system does not notify the lab of Physician Orders a lab requisition form is now faxed to the lab. UM B could not provide any further information on a process to ensure laboratory services had been provided as ordered.

Based on interview and record review, the facility failed to maintain an accurate, clear, and concise Electronic Medical Record (EMR) for 2 residents (R18, and R9) of 14 residents reviewed.Findings include:R9 Review of the Electronic Medical Record (EMR) admission record reflected R9 was admitted to the facility 9/18/2025 with diagnoses that included bipolar disorder. Review of the EMR Progress Notes for R9 reflected an entry dated 2/19/2026 at 9:44 AM. The entry reflected, (Name of Physician) in to evaluate and treat patient for recent increase in behaviors. Gave order to perform urinalysis and collect (comprehensive metabolic panel (CMP) serum blood draw) Orders entered. Will collect urine. Review of the EMR Physician Orders for R9 did not reveal the orders had been entered as indicated by the Progress Note of 2/19/2026 at 9:44 AM. Further review of the EMR did not reveal any further documentation that lab specimens were obtained, of lab results, monitoring of the Resident, monitoring for lab results, or attempts to determine the root cause of the recent increase in behaviors of R9. On 2/25/2026 at 1:25 PM, an interview was conducted with Registered Nurse (RN) E. RN E reported she entered the Progress Note of 2/19/25 at 9:44 AM and indicated she had placed the physician's orders into the EMR, as well. During the interview RN E reviewed the EMR but did not locate the Physician's Order for the lab work for R9. RN E was unable to locate any other documentation that the lab had been completed or that the change in behavior of R9 identified on 2/19/2025 had been conveyed to subsequent nursing staff for continuity of care. On 2/26/2026 at 1:45 PM, Unit Manager (UM) B reported that neither the CMP serum draw or the specimen for the urinalysis for R9 was obtained. UM B could not provide any further documentation or information since the Progress Note entry of 2/19/2026 when a change in resident behavior had been identified and a plan for further evaluation had been indicated. R18 Review of an admission Record revealed R18 admitted to the facility on [DATE] with pertinent diagnoses which included paranoid schizophrenia and dependence on supplemental oxygen. Further review revealed he had a court appointed guardian. In an interview on 2/23/2026 at 10:21 AM, R18 reported he wished to be transferred to a facility closer to his family. R18 reported he had discussed this desire with the facility social worker, but nothing had been done to assist him with this transfer request. Review of R18's Social Work Progress Note, dated 8/6/2025 at 4:37 PM, revealed the court instructed the guardian to find placement for R18 closer to his home and family. In an interview on 2/24/2026 at 2:45 PM, Social Worker A reported the court ordered R18's guardian to find placement closer to home for him in August of 2025 and she had discussions with R18 regarding his transfer request. Social Worker A reported she would look for documentation regarding these discussions. In an interview on 2/24/2026 at 3:47 PM, the Nursing Home Administrator (NHA) reviewed a concern form for R18 dated 12/16/2025 in which R18 requested to transfer to a facility closer to home and the facility had sent several referrals to facilities to initiate the transfer process. The NHA reported there were no progress notes in the EMR regarding these transfer discussions or referrals. Social Worker A reported she could find no documentation in the EMR regarding the transfer discussions that had taken place at the facility. In an interview on 2/24/2026 at 4:12 PM, the NHA reported there should be progress notes documented in the EMR and Care Conference documentation regarding the resident's request to transfer and the work the facility had done to facilitate this. Review of facility policy/procedure Documentation in Medical Record, reviewed 2/18/2026, revealed .Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observations, interview and record review, the facility failed to clean 1 resident's (R1) Continuous Positive Airway Pressure (CPAP) machine of 1 Resident on CPAP.Findings included: Review of R1's undated face sheet, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: osteomyelitis, pressure ulcer of the right upper back, urinary tract infection, diabetes mellitus, morbid (severe) obesity, chronic pain, and pressure ulcer of unspecified part of the back, unstageable. He was his own responsible party.During an interview with R1 in his room on 1/23/26 at 1:20 PM, R1 reported that he cleaned and cared for his Continuous Positive Airway Pressure (CPAP) machine when he was at home, but no one has cleaned it since he was admitted to the facility. No cleaning equipment or supplies were visible in the room, and the machine was sitting on the windowsill with the tube still connected to the machine.During an interview with the Director of Nursing (DON) on 2/25/26 at 2:20 PM, the DON confirmed that R1 should have orders for CPAP cleaning and it would be documented in R1's medical recorded in the Treatment Administration Record (TAR) section if the facility had been cleaning the machine. The DON could not locate any documentation that R1's CPAP had been cleaned since his admission to the facility.Review of R1's medical record revealed no documentation related to the cleaning of R1's CPAP machine.Review of the facility CPAP/BiPAP Cleaning policy dated 11/2/2022 revealed, It is the policy of this facility to clean CPAP/BiPAP equipment in accordance with current CDC guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection. Definitions: CPAP, or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth. 7. Weekly cleaning activities: a. Wash headgear/straps in warm, soapy water and air dry. B. Wash tubing with warm, soapy water and air dry. 8. Following manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine.

Based on interview and record review, the facility failed to operationalize the facility infection control policy to provide influenza and pneumococcal vaccines timely for two newly admitted Residents (R1 and R21) of six residents reviewed for immunizations. Findings include:R1Review of the Electronic Medical Record (EMR) admission record reflected R1 was admitted to the facility 1/27/2026 and made their own medical decisions.Review of the EMR for R1 revealed the facility document titled Resident - Vaccine Consent. The document dated 1/28/2026 reflected R1 has signed the consent form to accept the influenza and pneumonia vaccines.Review of the EMR Physicians Orders for R1 reflected an order dated 2/2/2026 May have Pneumococcal and May have annual Influenza Vaccine and to administer vaccines to patients who have not already received it unless contraindicated.Review of the EMR immunization record of R1 reflected documentation of the Mantoux Skin Test but no immunizations for influenza or pneumonia.Review of the Progress Notes for R1 did not reveal documentation the influenza and pneumonia vaccines were contraindicated for the Resident.R21Review of the Electronic Medical Record (EMR) admission record reflected R21 was admitted to the facility 1/23/2026 and was their own responsible party.Review of the EMR for R21 revealed the facility document titled Resident - Vaccine Consent. The document dated 1/28/2026 reflected R21 had completed the consent form to accept the influenza and pneumonia vaccines.Review of the EMR Physicians Orders for R21 reflected an order dated 1/23/2026 that Per CDC guidelines, administer vaccines requested to patients who have not already received it unless contraindicated .The EMR immunization record of R21 was reviewed. This record reflected documentation of the Mantoux Skin Test but no immunizations for influenza or pneumonia were recorded.Review of the Progress Notes for R21 did not reveal documentation the influenza and pneumonia vaccines were contraindicated for the Resident.On 2/24/2026 at 1:14 PM, an interview was conducted with the Director of Nursing (DON) who is also the facility Infection Preventionist (IP). The DON IP was informed that consents and physician orders for immunizations were noted in the EMR but that the record did not reflect these were administered, The DON IP reported that residents must be reviewed in Michigan Care Improvement Registry (MCIR - a State of Michigan system for tracking immunizations administered within the state) to determine what immunizations residents are eligible for. The DON IP reported she had not been in the DON IP position very long and did not have access to MCIR yet to review resident immunization eligibility. The policy provided by the facility titled Infection Prevention and Control Program last reviewed and revised 5/7/2025 was reviewed. The policy reflected, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy reflected Policy Explanation and Compliance Guidelines to include: .7. Influenza and Pneumococcal Immunization:a. Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time.b. Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere.c. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines.d. Residents will have the opportunity to refuse the immunizations.e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations.

Based on interview and record review the facility failed to operationalize the facility infection control policy to provide Covid-19 vaccine timely for two newly admitted Residents (R1 and R21) of six residents reviewed for immunizations and failed to implement a process to track and monitor staff Covid-19 education and immunization status. Findings include:R1Review of the Electronic Medical Record (EMR) admission record reflected R1 was admitted to the facility 1/27/2026 and made their own medical decisions.Review of the EMR for R1 revealed the facility document titled Resident - Vaccine Consent. The document dated 1/28/2026 reflected R1 had signed the consent form to accept the Covid-19 Series/Vaccine and the Recommended Annual Covid -19 Booster.Review of the EMR Physicians Orders for R1 reflected an order dated 2/2/2026 to administer vaccines requested to patients who have not already received it unless contraindicated.Review of the EMR immunization record of R1 did not reflect the Covid-19 series/vaccine had been initiated.Review of the Progress Notes for R1 did not reveal the Covid-19 vaccination was contraindicated for the Resident.R21Review of the Electronic Medical Record (EMR) admission record reflected for R21 was admitted to the facility 1/23/2026 and was their own responsible party.Review of the EMR for R1 revealed the facility document titled Resident - Vaccine Consent. The document dated 1/28/2026 reflected R21 had completed the consent form to accept the Covid-19 Series/Vaccine and the Recommended Annual Covid -19 Booster.Review of the EMR Physicians Orders for R21 reflected an order dated 1/23/2026 that Per CDC guidelines, administer vaccines requested to patients who have not already received it unless contraindicated .The EMR immunization record of R21 was reviewed. This record did not reflect the Covid-19 vaccine/series had been initiated.Review of the Progress Notes for R21 did not reveal documentation the Covid-19 vaccine was contraindicated for the Resident.On 2/24/2026 at 1:14 PM an interview was conducted with the Director of Nursing (DON) who is also the facility Infection Preventionist (IP). The DON IP was informed that consents and physician orders for immunizations were noted in the EMR but that the record did not reflect these were initiated, The DON IP reported that residents must be reviewed in Michigan Care Improvement Registry (MCIR - a State of Michigan system for tracking immunizations administered within the state) to determine which vaccinations residents were eligible for. The DON IP reported she had not been in the DON IP position very long and did not have access to MICR yet to review resident immunization eligibility. The policy provided by the facility titled Infection Prevention and Control Program last reviewed and revised 5/7/2025 was reviewed. The policy reflected, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy reflected Policy Explanation and Compliance Guidelines to include: 8. COVID-19 Immunization:a. Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility.b. Residents and staff will be screened prior to offering the vaccination for prior immunization, medical precautions and contraindications to determine candidacy for the vaccination.c. Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine.e. Residents or resident representatives will have the opportunity to accept or refuse a COVID-19 vaccination, and change their decision based on current guidance.g. The resident's medical record includes documentation that indicates, at a minimum, the following:i. That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; andii. Each dose of COVID-19 vaccine administered to the resident, oriii. If the resident did not receive the COVID-19 vaccine due to medication contraindications orrefusal. Facility Employee Covid-19 Tracking During the interview conducted on 2/24/2026 at 1:14 PM with the DON IP it was reported she did not maintain documentation of Covid-19 screening, education or the Covid-19 vaccination status of facility staff. In a follow-up interview conducted 2/25/2026 at 2:43 PM the DON IP reported that, outside of the new employee orientation packet, new staff do not receive initial additional training on Covid-19. On 2/25/2026 at 2:27 PM the Nursing Home Administrator (NHA) reported she was not aware if the facility had maintained documentation of the Covid-19 immunization status of staff. During an interview conducted 2/25/2026 at 2:33 PM Human Resources Coordinator (HRC) L reported she does not maintain a record of staff Covid-19 offering or immunization status. HRC L reported new staff are offered covid-19 education and vaccination but only read the education if they accept the vaccination. HRC L reported documentation of the vaccination would be placed in their employee file. HRC L reported since she had been in the position no new employee had accepted the information or the vaccination. HRC L reported yearly Covid-19 education is provided along with other topics but reported she did not know what month of the year it is presented. HRC L reported she had never been told she needed to maintain a record of the Covid-19 vaccination status of staff. Review of the Infection Prevention and Control Program cited above reflected: h. The facility will maintain documentation related to staff COVID-19 vaccination that includes at a minimum, the following;i. That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine;ii. Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; andiii. The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

This citation pertains to intake 2621833Based on interview and record review, the facility failed to protect the resident's (Resident #301) right to be free from physical abuse by a resident (Resident #300).Findings:Resident #300 (R300)Review of an admission Record revealed R300 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: major depressive disorder severe along with major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance and Psychotic Mood Disorder including mania and depression with psychotic features (per her psychiatric evaluation note).Review of R300's hospital Discharge Summary Note dated 8/19/25 revealed, .The patient was brought into the ER (emergency room) on 5/6/25 by her sister who reported that the patient has been aggressive and acting out more at home. On day of discharge, the patient was doing fair. There was no hallucinations or suicidal or homicidal ideation or intent. She had no physical agitation or aggression.Review of R300's Electronic Medical Record (EMR) revealed:*08/22/2025 at 2:07 AM, Resident has been physically abusive to staff member and observed calling another resident stupid. Resident educated to not call others names and redirected away from others. R300's Care Plan was updated on 8/22/25 with the problem I exhibit socially inappropriate disruptive behavioral symptoms. I have entitlement behavior and have tendencies of feeling like I am the boss/owner of places that I reside at. I will boss others around; say they are lazy, stupid, or other verbally inappropriate or disrespectful things and the approach to Determine if mood endangers myself or others and intervene; remove other peers if necessary. The Care Plan was not updated with interventions for R300's physically abusive behaviors.*08/27/2025 at 3:11 PM, .Becomes upset with other residents' behaviors.Does not like anyone in her personal space.The facility did not initiate enhanced supervision and R300's Care Plan was not updated with interventions to prevent behavior escalation in regards to other residents' behaviors and protection of her personal space. *On 08/28/2025 at 9:57 AM the physician documented, (R300) was seen due to increased behaviors. She is increasing in threatening behaviors. She is threatening other residents with physical harm. We must adjust medication to manage before she injures another resident, herself or staff. R300's antipsychotic medication (Seroquel) was increased at that time.*On 08/28/2025 at 5:41 PM, R300 was moved from the locked Memory Care Unit to the Main Unit. Staff attempted to place a WanderGuard bracelet on the resident however, when reattempted R300 threatened each time she will knock out the staff or kick them in the F*ck*ng face if they try. R300's Care Plan dated 8/19/25 revealed, I will admit to the MCU (Memory Care Unit) for monitoring of wanderings also preventing me from leaving my area of safety. I may need possible protection devices for safety until further evaluated by nurse/therapy for appropriateness. Created: 08/19/2025. The Care Plan was not updated to reflect that R300 was now on the Main Unit or with interventions for increased supervision/monitoring related to her refusal to wear a WanderGuard.*08/29/2025 at 9:40 AM psychiatric consultant Psychiatry Initial Evaluation note revealed R300 was being seen for depression, agitation, irritability, refusal of care. Staff reports that the patient has been agitated and combative at times, she did recently start yelling at staff.IMPULSE CONTROL- Impulse control is impaired, Patent is agitated and combative at times, Patient has threatened staff and other residents.HOMICIDAL IDEATION- Threatening behavior toward staff and other residents.MOOD- Mood is irritable, Patient easily agitated.*08/29/2025 at 4:46 PM, Resident was going into another resident's room cena (Certified Nursing Assistant) attempted to redirect resident and resident punched cena in the stomach. Aide attempted to redirect resident, but resident was becoming increasingly more agitated. Resident redirected to common area. Resident began threatening staff and threatening to kill others. Physician contacted. New order received for Ativan (antianxiety medication) 1mg po (by mouth) one time dose for aggression/agitation. Confirming R300's behaviors escalated to homicidal threats and entering other resident rooms. Additionally, no long-term medication changes/additions were discussed or initiated at that time.*08/29/2025 at 5:34 PM, R300's Behavior Log revealed, threatening other patients with cutting and catching them on fire.hit staff. The facility did not initiate enhanced supervision and R300's Care Plan was not updated with interventions for physically abusive behaviors, homicidal threats, or increased agitation.*08/30/2025 at 2:25 AM, R300's Behavior Log revealed, res (resident) in others rooms taking things that don't belong to her like food, drinks, clothes, paperwork ect. *On 08/30/2025 a dose of as needed Seroquel 25mg was administered at 9:57 PM for Resident verbally frustrated with other residents.*08/30/2025 at 10:07 PM, Statements made by resident: I need scissors to protect myself. I wish I had a gun, I'm angry as hell. Requires frequent redirection to stay out of others' rooms. Indicating an increase in R300's paranoia (need to protect herself) and escalation of behavior of entering resident rooms. *08/31/2025 at 1:26 AM, R300's Behavior Log revealed, res unplugged roommates TV and took remote. res taking others shoes and clothing then screaming (at) others for being in there (sic) own rooms. *08/31/2025 at 11:10 PM, .Has been wandering into others' rooms off and on this shift. Can be redirected. *09/01/2025 at 10:23 PM, Resident noted to be wandering up and down hallways, going into other residents rooms on arrival to my shift. Not easily redirected. Verbally abusive towards other residents when they spoke to her. Resident concerned about other residents and staff in hallways. During an interview on 09/24/2025 at 8:46 AM, Registered Nurse (RN) K reported she worked on 09/01/2025 and confirmed that throughout that evening R300 was aggressive and in residents and staff members faces and was difficult to redirect.There was no documentation that the IDT and/or provider was notified of R300's behaviors rising to the level of verbal abuse towards other residents.*09/03/2025 at 12:47 AM written by RN J, .Continuously ambulating in the hallways and getting into Resident's rooms .Writer was called to the East Hallway, stated that this Resident heat (hit [sic]) her room mate (sic) on her L (left) hand, she denies the incident. Indicating an allegation of resident-to-resident abuse with the violence committed by R300. There was no documentation that the abuse coordinator was notified of the allegation of physical abuse or that the IDT and/or provider conducted a behavior management evaluation. During an interview on 09/24/2025 at 8:00 AM, RN J reported that R300 should have been transferred to the hospital immediately when she started to become physically aggressive and assaulting staff (08/22/2025 was the first documented physical assault against staff members.) RN J reported that R300 was difficult for staff to care for due to her psychiatric symptoms and the level of staff members training. RN J reported that she was not on an adequate amount of medication to manage her behaviors and only one medication change was instituted while she was at the facility. RN J reported that she was physically abusive from day one and her behaviors progressively worsened. The facility did not initiate enhanced supervision and R300's Care Plan was not updated with interventions for R300's behavior of wandering into other resident rooms. No new interventions were implemented to prevent the wandering despite documentation of the escalation of the behavior on 8/29/25, 8/30/25, 8/31/25, 9/1/25, and 9/3/25.*09/04/2025 at 01:20 PM, [Recorded as Late Entry on 09/05/2025 02:59 PM] I heard yelling in the hallway. I walk into the room I hear the yelling come from. what I witnessed was a resident lying on the floor kicking at an aide. the aide and a family member of a different resident trying to help patient off the floor. I was able to calm the patient, get her from the floor and redirect her. aide stated that the patient was in another patient room and rummaging through her things. the aide and family member was trying to redirect the patient. the patient turns around and hits aide in her arm and threw herself on the floor and began yelling. floor nurse notified physician and guardian. No new orders from the provider noted at that time. Confirming increased behaviors now included self-harm (throwing self to the floor.)The facility did not initiate enhanced supervision and R300's Care Plan was not updated with interventions for R300's physically abusive behaviors or self-harm during behavioral episodes.*09/04/2025 at 03:55 PM, .Resident heads toward all areas in building believing she runs the facility. Upon rounds resident noted to be lying in another resident bed that was empty.*09/04/2025 at 9:01 PM, R300's Behavior Log revealed, Was the Ensure Resident Safety intervention effective? No indicating the need for modification and/or additional safety measures to ensure R300 and other residents remained safe in the facility. *On 09/05/2025 a dose of as needed Seroquel 25mg was administered at 3:52 AM and was documented as Not Effective. There was no documentation that the provider was notified of the ineffectiveness of the medication or that increased supervision/monitoring was initiated. This medication had not been previously documented as Not Effective. (R300 had received a total of 7 doses of the as needed Seroquel since her admission on [DATE]).*09/05/2025 at 07:45 PM, [Recorded as Late Entry on 09/10/2025 03:27 PM] Resident was in the hall by the nurse's station. Nurse called stating that she heard another resident yell out. She stated she was not sure if this resident made contact with other resident or not all she witnessed was her hand up. Video surveillance was immediately reviewed and noted that this resident was shaking her left hand closed fisted in front of other residents face, other resident wheeled her wheelchair to go past this resident and used her right hand and made contact with other resident's lower left jaw line. It was unable to make out if she had her hand open or closed. Nurse responded immediately and separated this resident from others while having her on a 1 to 1 for supervision.There was no documentation that the provider was notified of R300's increased agitation, aggressiveness, or behaviors from 08/29/2025 until the notification of the incident when she threw herself on the floor on 09/04/2025. There was no documentation that the provider had assessed R300 since 08/28/2025. There was no documentation that the provider had evaluated the effectiveness of R300's psychotropic medications, changed her medication regimen, or ordered additional pharmacological interventions since 08/29/2025. Confirmed by the Timeline provided by the Nursing Home Administrator (NHA).There was no documentation that the Interdisciplinary Team (IDT) had discussed R300 in any behavioral meetings while she resided at the facility. Review of R300's Care Plan revealed:*Interventions related to R300's wandering were not initiated until 09/04/2025 despite identifying the behavior on 08/29/2025 and the subsequent escalation of the behavior. *On 09/10/2025 multiple new interventions were initiated related to R300's physical behavioral symptoms toward others (e.g., hitting, kicking, pushing, scratching, abusing others sexually) following her transfer to the hospital on [DATE].Review of the Timeline provided by the Nursing Home Administrator (NHA) revealed: 9/3 note from nurse addresses the wandering and clarifies that it is rounding in others rooms. The timeline did not reflect that a care planned intervention for rounding (wandering) was implemented at that time. 9/3 Nurse note identified that Resident has possible sleep interruptions resident slept in during a.m. However, a Progress Note dated 08/24/2025 at 12:51 PM revealed, .Does not like to be awakened in a.m . Indicating sleeping in was not a new symptom/behavior for R300. There was no documentation that the facility explored the possibility of sleeping in as R300's preference. 9/3 (contracted psychiatric consultant group) Social worker saw her. However, there was no indication in R300's EMR or the psychiatric consultant social worker's note that the facility had discussed with the social worker that there had been concerns with R300's sleeping patterns/interruptions. Review of the psychiatric social work consultant's note dated 09/03/2025 at 9:20 AM, revealed the social worker met with R300 for a supportive therapy session centered on exploring mood and offering emotional support. The session focused on creating space for the patient to process feelings, with interventions including active listening, open-ended questions, mood validation, and words of encouragement to highlight existing strengths. R300's sleep interruptions were not addressed during the session and the patient reports good sleep without any issues was documented. R300's Care Plan was not updated to reflect the interventions recommended from the therapy session (active listening, open-ended questions, mood validation, and words of encouragement.) 9/4 Private room was suggested to assist with residents mood, due to possible sleep interruptions with being woke during night from nurses 9/3 note. NHA reported that R300 declined the room change when therapy staff showed her private room options. There was no documentation in the EMR regarding the interaction between R300 and the therapy staff member or a declination of a room change. A Witness Statement was received on 09/24/2025 at 4:40 PM referencing the interaction. 9/5 Roommate was moved to another room to provide a more peaceful sleep routine. NHA provided a census report which revealed R300's roommate was moved out of her room on 09/05/2025 01:30 PM. R300 was transferred to the hospital prior to the implementation of the intervention as she was transferred to the hospital on [DATE] at 07:25 PM and had not spent the night in her room without a roommate. R300's Care Plan was not updated to reflect possible sleep interruptions. R300's Care Plan for pain was updated on 09/04/2025 to MONITOR FOR ANY CHANGES IN SLEEP PATTERNS in the context of pain identification and not for sleep interruptions.R300's EMR revealed no documentation that sleep monitoring was initiated, the provider was notified for the purpose of the reevaluation of R300's medication regimen, or that the IDT reviewed and addressed the new concern of sleep interruptions.Resident #301 (R301)Review of an admission Record revealed R301 was an [AGE] year-old female, admitted to the facility on [DATE]. Review of R301's Progress Notes revealed:*09/05/2025 at 11:50 PM, Late entry for 9/5/25 at 1930 (7:30 PM): Neuros initiated related to another resident making physical contact with this resident's left jaw area. Jaw range of motion is good. Resident complains of tenderness to area. Cool compress applied and resident verbalized increased comfort. Resident can open mouth fully without pain/discomfort. No swelling or bruising observed to area.*09/06/2025 at 12:01 AM, .No redness or bruising noted to left jaw. Ice applied.The use of ice was initiated for non-pharmacologic pain relief indicating ongoing discomfort from the physical assault.Review of the Facility Reported Incident (FRI) investigation revealed, (R300) has a history of being verbally aggressive with other residents. She thinks she owns the facility and feels she can go into other rooms and get rid of resident possessions of her choosing.She has a hx (history) of being aggressive with staff but not physically aggressive with residents. (The allegation of R300 physically assaulting her roommate went unreported with no investigation to conclude she had not previously assaulted a resident).Summary Report of Facility's Conclusion. have concluded that the incident did in fact include contact, by review of the video footage.Since admission she (R300) has shown heightened aggression to staff.During an interview on 09/24/2025 at 9:37 AM, NHA reported that the IDT usually meets weekly (includes behavior management) but had not been meeting consistently due to the hiring of a new Director of Nursing around the beginning of August 2025. NHA reported that resident Progress Notes were reviewed daily and confirmed the IDT was aware of R300's increased behaviors. NHA reported that due to R300's increased behaviors it was decided to move R300 from the MCU to the East Unit (on 08/28/2025). NHA reported IDT/behavior management meeting notes are documented in the resident Progress Notes. NHA was notified that there were no notes pertaining to the meetings in the EMR and she reported she would provide the IDT notes if available. No IDT/behavior management notes were received as of 09/24/2025 at 5:30 PM indicating the meetings did not take place for R300.NHA confirmed that R300's Care Plan was not updated with behavioral interventions until after she was transferred to the hospital on [DATE]. NHA reported she implemented new interventions (on 09/10/2025) in preparation for her return to the facility from her hospitalization if she is able to return. Review of the facility policy Abuse, Neglect and Exploitation implemented 11/1/22 (no review/revision date) revealed: Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment.B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. 1. An assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission. 2. The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment.D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur.

This citation pertains to intake 2621833Based on interview and record review, the facility failed to implement their abuse policy resulting in an allegation of physical abuse to go unreported with no investigation.Findings:Resident #203 (R203)Review of an admission Record revealed R203 was a [AGE] year-old female, admitted to the facility on [DATE].Resident #300 (R300)Review of an admission Record revealed R300 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: major depressive disorder severe along with major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance and Psychotic Mood Disorder including mania and depression with psychotic features (per her psychiatric evaluation note).Review of R300's Progress Note dated 09/03/2025 at 12:47 AM written by Registered Nurse (RN) J revealed, .Writer was called to the East Hallway, stated that this Resident heat (hit [sic]) her room mate (sic) on her L (left) hand, she denies the incident. Indicating an allegation of resident-to-resident abuse with the violence committed by R300. There was no documentation indicating the nurse reported the allegation of abuse to the abuse coordinator.During an interview on 09/24/2025 at 8:00 AM, RN J reported that R300 should have been transferred to the hospital immediately when she started to become physically aggressive and assaulting staff (08/22/2025 was the first documented physical assault against staff members.) RN J reported that R300 was difficult for staff to care for due to her psychiatric symptoms and the level of staff members training. RN J reported that she was not on an adequate amount of medication to manage her behaviors and only one medication change was instituted while she was at the facility. RN J reported that she was physically abusive from day one and her behaviors progressively worsened. RN J reported that R203 reported that R300 had hit her hand but there was no witness to the alleged physical abuse. RN J reported that R300 was physically abusive to staff but had never physically assaulted any residents up to that point. RN J reported that R300 and R203 had a good report and R203 would refer to R300 as grandma so she did not believe the physical assault had occurred but documented it in R300's Progress Note as a reference in case something came of it. Further explaining that she was going to keep an eye on R203's left hand and if she identified an injury over her shifts she would have reported it to the required people. During an interview on 09/24/2025 at 8:26 AM, Nursing Home Administrator (NHA) reported she had not been made aware of the allegation of resident-to-resident abuse between R300 and R203 on 09/03/2025. NHA reported the expectation was for staff to immediately report any allegation of resident abuse. During an interview via email on 0 9/24/2025 at 4:24 PM, NHA provided a follow up Witness Statement related to the allegation of abuse between R300 and R203.Review of Registered Nurse (RN) J's Witness Statement transcribed by RN A and received on 9/24/25 revealed, I contacted (RN J) via phone on to clarify and get information related to Progress note in the chart of (R300) on 09/03/2025 at 12:47 AM. (RN J) stated (R300) frequently doted on (R203) playing with her with her toys, trying to take care of her, helping her, and talking to her. She stated upon arriving at the residents shared room after being notified that the resident hands had come in contact. She states she asked (R300) if she had hit the resident's hand, which the resident denied. (R203) resident then stated She hit my hand and started laughing. (RN J) then assessed resident with no marks, redness, injury noted. (RN J) asked the resident if it hurts and (R203) continued laughing. Resident (R203) will cry if there is a problem. (RN J) stated she felt they were playing and spending time together like they have done in the past. (RN J) stated that (R203) called (R300) grandma and they have a very play (sic) relationship. She did not feel there was any abuse that occurred and encouraged (R300) to go to her side of the room and go to bed as it was middle of night. (RN J) felt this was the 2 residents spending time together and playing. When asked why she did not put this information in the chart (RN J) stated she thought that would be too much information.Review of the facility policy Abuse, Neglect and Exploitation implemented 11/1/22 (no review/revision date) revealed: Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse.b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse.and resident abuse prevention.3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator.

This citation pertains to intake #2579353. Based on observation, interview, and record review the facility failed to ensure fall interventions were implemented for 1 resident (R203) of three residents reviewed for falls resulting in R203 falling from her raised bed to the floor and sustaining a fracture of her femur. Findings include:Review of an admission Record revealed R203 admitted to the facility on [DATE] with pertinent diagnoses which included autism, anxiety, and developmental disorder. Review of current fall Care Plan interventions for R203, with a start date of 3/11/2025, directed staff to utilize a fall mat on the left side of bed and keep bed in lowest position when not providing care. Further review revealed another intervention started 3/8/2025 directed staff to keep frequently used items including the call light within reach while in room. Review of MI-FRI #61119 facility investigation report revealed R203 fell from her raised bed to the floor the afternoon of 7/20/2025 when Certified Nursing Assistant (CNA) J walked away from her bed while providing care and R203 rolled off the bed and onto the floor sustaining a fracture of her right femur. Resident #203 was documented as having a history of being able to roll herself out of bed. During an interview on 8/13/2025 at 9:05 AM, the Nursing Home Administrator (NHA) reported CNA J was educated that you cannot leave the bedside of R203 with the bed elevated. The NHA reported R203 had a history of rolling herself out of bed. Review of CNA J's Discipline Record Form, dated 7/29/2025, revealed .Providing care for resident when stepping out to grab hoyer, bed was still at hip level. Resident fell out of bed and ended in a fracture. Review of R203's nursing Progress Note, dated 7/20/2025 at 6:49 PM, revealed .CENA (CNA) was changing resident and getting her up for lunch, she had a sling under her, bed was mid-way up, the CENA left the room to obtain the lift to get up the resident.the CENA heard a thud and observed resident lying on her R (right) side on the floor. In an observation and interview on 8/13/2025 at 9:38 AM in an empty room, CNA J re-acted R203's fall that occurred on 7/20/2025. CNA J raised the bed to hip level and reported she left the bedside with the bed still raised and walked to the doorway. CNA J stated, Before I got to the doorway, I heard a thud and R203 had fallen to the floor. In an observation on 8/13/2025 at 9:16 AM in R203's room, R203 was in her bed and the call light was on the bedside table and out of reach. In an interview on 8/14/2025 at 9:20 AM, CNA E reported R203's call light should be left within reach as she was able to use her call light. Review of facility policy/procedure Fall Prevention Program, reviewed 6/26/24, revealed .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. provide additional interventions as directed by the resident's assessment. interventions will be monitored for effectiveness. the plan of care will be revised as needed.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 resident (R203) of 7 residents reviewed. Findings include:Review of an admission Record revealed R203 admitted to the facility on [DATE] with pertinent diagnoses which included autism, anxiety, and gastrostomy. Review of current Care Plan interventions for R203, with a start date of 4/10/2025, revealed R203 was on EBP and directed staff to follow Centers for Disease Control guidelines. Review of R203's Physician's Orders revealed an active order for EBP started 4/8/2025. Further review revealed R203 required tube feedings through a gastrostomy. Review of facility policy/procedure Enhance Barrier Precautions, revised 2/26/2025, revealed .an order for enhanced barrier precautions will be obtained for residents with any of the following. feeding tubes. make gown and gloves available immediately near or outside of the resident's room. PPE (Personal Protective Equipment) is only necessary when performing high-contact care activities. high-contact resident care activities include. dressing, bathing, transferring, providing hygiene, changing linens. In an observation in R203's room on 8/12/2025 at 2:35 PM, Certified Nursing Assistant (CNA) E and CNA I provided incontinence care to R203 without wearing a gown. The signage on the door showed R203 required EBP. In an interview on 8/12/2025 at 3:00 PM, CNA E reported she did not normally work that hall and was not aware R203 required EBP. CNA E reported residents with EBP require gown and gloves when providing care related to the reason for the precautions such as tube feeding. CNA E reported CNAs were not required to use EBP while providing incontinence care. In an interview on 8/13/2025 at 9:31 AM, Registered Nurse (RN) K reported R203 was on EBP because of her tube feeding and CNAs were not required to use EBP because they did not do anything with the tube feeding. The definition of high contact resident care activities from facility signage was reviewed with RN K which stated gown and gloves were necessary when performing close contact care such as incontinence care and transfers for residents in EBP.

This citation pertains to intake # MI00153789 and #MI00152893 Based on interview and record review, the facility failed to provide quality care to one of three residents reviewed (Resident #100) resulting in the delay of on-going assessments including pain assessments and providing adequate pain relief, the initiation of potential hip fracture mobility interventions, and emergency medical treatment, following a fall that resulted in a fractured hip. Findings: Resident #100 (R100) Review of a Face Sheet revealed R100 was an [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's disease. Review of a Brief Interview for Mental Status (BIMS) completed on 06/16/25 reflected a score of 4 out of 15, that indicated R100 had severe cognitive impairment. During an interview on 06/25/25 at 11:45 AM, R100's durable power of attorney (DPOA)/family member K stated that on 06/17/25 around 2:08 PM the facility called and reported that R100 (a) had fallen sometime around 1:30 PM that afternoon, (b) could not put any weight on the right leg, (c) that the right leg was rotated out (externally), and (d) had reported severe pain in the right hip. Review of a Post-Fall Assessment for R100, time stamped as completed on 06/17/25 at 5:29 PM reflected the following nursing assessment: (a) the resident complained of severe pain in the right hip, (b) there was abnormal alignment and rotation noted to the right leg, (c) range of motion was painful and limited in the right lower extremity, (d) the resident was put into a sitting position in a recliner, (e) the care plan had been updated, and (f) interventions (immediate measures taken) included analgesics (acetaminophen), rest, and x-ray. During an interview on 07/02/25 at 10:30 AM the Director of Nursing indicated that the x-ray ordered on 06/17/25 for R100 post-fall did not get completed prior to R100's transfer to the hospital on [DATE] at 8:55 AM. Review of an Electronic Medication Administration Record (Emar) for R100 dated June 2025 reflected that only one assessment of the resident's pain was obtained on 06/17/25 from the time of the fall until 6 PM that day. That pain rating was noted to be 10/10. Only one pain assessment for R100 was noted starting at 6 PM on 06/17/25 through 6 AM on 06/18/25. That pain rating was noted to be 8/10. Review of a facility Pain Assessment described the pain scale ratings from zero to 10 as the following: 0/10: No pain, 4/10: Moderate pain-distressing/miserable, 7/10: Severe Pain-horrible/intense, and 10/10: Excruciating pain-worst possible. Review of an Emar for R100 dated June 2025 reflected an order for the pain medication acetaminophen (Tylenol) 325 milligrams (mg), two tablets (tabs) every 6 hours, start date 06/16/25. Post-fall R100 received the following medications for pain: Acetaminophen 325 mg 2 tabs at noon on 06/17/25 around the time of the fall, Acetaminophen 325 mg 2 tabs at 6 PM on 06/17/25, Acetaminophen 325 mg 2 tabs at midnight on 06/17/25, and Acetaminophen 325 mg 2 tabs at 6 AM on 06/18/25. R100 received no other medications to treat the reported severe excruciating pain. Review of a Care Plan specific to falls for R100 revealed the following: (a) start date 06/16/25 and created on 06/18/25 (b) Falls: (R100) is at risk for falls related to .(no additional information was provided such as the risk factors of being in a new environment, impaired vision, a diagnoses of Alzheimer's with a BIMS that reflected severe cognitive impairment, etc, (c) no update was made to the care plan at the time of the fall, and (d) no interventions to treat pain and immobility issues were provided in the care plan post-fall. Review of a Skilled/Medicare Daily Nurses Note for R100, time stamped as completed on 06/17/25 at 11:03 PM revealed the following nursing assessment: (a) the resident was able to independently move herself in bed, (b) the resident was able to eat independently, (c) pain was rated as severe, and (d) acetaminophen was given for the pain and the treatment was non-effective. Review of a Facility Reported Incident reflected the following findings by the facility after investigating R100's fall on 06/17/25: (a) the fall was unwitnessed and (b) the plan of care was followed. Review of a Mobile Medical Response (ambulance) run sheet dated 06/18/25 revealed the facility provided the paramedic (EMS) with the following information regarding R100's fall the day before: Upon arrival, facility staff told crew that the patient had fallen yesterday and now was unable to bear weight on her right knee .staff reported the fall was witnessed .the patient was laying in bed with a pillow under the right knee. Review of an emergency room Report dated 06/18/25 at 9:24 AM reflected the following assessments of R100: (a) the right leg is externally rotated and appears shortened, (b) CT scan showed a comminuted, displaced, angulated fracture of the right hip, (c) an orthopedic (bone doctor) surgeon was consulted and surgery was scheduled, (d) physician comments: it is unknown why the patient was not brought to the emergency department immediately after the fall as she was having severe pain and upon x-rays in the hospital was found to have a significantly displaced and comminuted hip fracture, and (e) the patient experienced severe pain with any attempted motion of the right lower extremity. According to the Mayo Clinic, the most important factor when caring for someone who may have a broken hip is to protect them from further injury: keep the person lying on their back and immobilize the leg to prevent further injury .If an elderly person experiences a fall and you suspect a broken hip, call 911 immediately. All hip fractures are medical emergencies that require prompt medical attention .Only trained healthcare professionals should move, lift, or transport someone who has a broken hip. Signs and Symptoms of a broken hip include pain in the hip or upper leg, swelling and bruising around the hip and upper leg, not being able to stand or put weight on the affected hip and leg, difficulty moving the hip and leg, and the affected leg is at an odd angle or is shorter than the unaffected leg. https://www.mayoclinic.org>syc20373468.

Based on observation, interview and record review, the facility failed to monitor for outdated medications and maintain proper storage of insulin in the facility medication room refrigerator, resulting in the storage of discontinued and outdated insulin and the potential for outdated medication to be administered to facility residents. Findings: On 1/8/25 at 10:22 AM a review of the medication room refrigerator was conducted with Registered Nurse (RN) F. The review revealed a vial of Novolin N for R37 dated as opened and placed in service on 9/1/24. RN F reported this medication had been discontinued and should have been discarded. Review of the Doctor's Orders for R37 reflected Humulin N had been ordered for R37 on 8/31/24 and discontinued on 9/2/24. Review of the manufacturer's package insert for Novolin N reflected, Novolin(R) N in use: Vials Keep at room temperature below 77 F (25 C) for up to 6 weeks (42 days) . Throw away an opened vial after 6 weeks (42 days) of use, even if there is insulin left in the vial. The policy provided by the facility titled Medication Storage, last reviewed 9/27/23 was reviewed. The policy reflected, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations .

Based on observation, interview, and record review, the facility failed to maintain proper infection control procedures in one room (room [ROOM NUMBER]) and for 3 of 6 residents ( R37, R48, and R52) in isolation for COVID-19, potentially affecting 14 of 51 residents, resulting in the potential for cross contamination and the spread of COVID-19. Findings include: R37 A review of R37's Face Sheet, undated, revealed R37 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R37's Face Sheet revealed multiple diagnoses that included dementia, anxiety, and depression. A review of the facility's CMS (Centers for Medicare and Medicaid Services) Form 802, undated but provided to the survey team on 1/7/25, revealed R37 was listed as having COVID under the Infections column. During an observation on 01/08/25 at 08:30 AM, R37's room door was wide open, and staff were not visible in the room. There was a sign on the outside of R37's room door that revealed staff were to use Airborne Contact Precautions (i.e., clean hands before entering and leaving the room, wear a gown when entering the room and remove it before leaving the room, wear an N95 or higher respirator before entering the room and remove it after exiting the room, and wear gloves when entering the room and remove them before leaving the room, and use additional personal protective equipment (PPE) as required). In addition, the sign revealed that staff were to keep R37's room door closed in order to maintain negative pressure (prevent airborne viral particles from being sucked out of the room when people/equipment pass by the room). A second sign on the outside of R37's room door that was published by the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC) revealed for Airborne Precautions Everyone must . Put on a fit-tested N-95 or higher level respirator before room entry. Remove respirator after exiting the room and closing the door. Door to room must remain closed. During an interview on 01/08/25 at 9:50 AM, Registered Nurse (RN) F stated, They've (staff) been leaving the [room] doors open (for residents in Airborne Contact Precautions isolation). She stated there are signs on the individual room doors that alert people that the resident(s) in the room are on isolation, what type of precautions (e.g., airborne) that are needed, and what type of PPE to wear when entering the room. She also stated the PPE is on the individual room doors, with instructions on donning and doffing (putting on and taking off) the PPE, so anyone going into the room has easy access to it. During an interview on 01/09/25 at 12:00 PM, the Director of Nursing (DON) (who was also the Infection Control Preventionist) stated that staff can leave the room doors open for residents that are in Airborne Contact Precautions isolation for COVID-19. She stated it can be traumatic enough for residents to be in isolation without closing their doors. The DON further stated that she did not see an issue with leaving the room doors open because residents are restricted to their rooms, so there is a slim chance of the COVID-19 virus being transmitted outside of their rooms if staff and visitors follow the PPE guidelines when they visit residents in those rooms. R48 A review of R48's Face Sheet, dated 1/9/25, revealed R48 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R48's Face Sheet revealed multiple diagnoses that included late onset Alzheimer's disease, anxiety, and obsessive-compulsive behavior. A review of R48's Social Work progress note, dated 1/7/25, revealed R48 tested positive for COVID-19. During an observation on 1/8/25 at 02:20 PM, certified nursing assistant (CNA) A exiting R48's room with an N95 respirator over top of a surgical mask. CNA A disposed of the N95 respirator in a biohazard bag and cleansed her hands with hand sanitizer, but continued down the hallway still wearing the same surgical mask that she had been wearing in R48's room. A sign on the outside of R48's room door revealed a surgical mask or above (e.g., an N95 respirator) must be removed after exiting an isolation room. During an interview on 01/09/25 at 12:00 PM, the DON stated staff can double mask with a surgical mask underneath an N95 respirator when they go into a room where the resident(s) are on Airborne Contact Precautions. She stated that offers a double layer of protection. The DON further stated if staff wear a surgical mask under their N95 respirator, then they need to dispose of the surgical mask and the N95 respirator after they exit the resident's room and put on a fresh surgical mask before walking down the hallway. R52 A review of R52's Face Sheet, dated 1/9/25, revealed R52 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R52 had multiple diagnoses that included dementia and depression. A review of R52's Social Work progress note, dated 1/7/25, revealed R52 tested positive for COVID-19. During an observation on 01/07/25 02:30 PM, R52's room door was wide open, and staff were not visible in the room. There was a sign on the outside of R52's room door that revealed staff were to use Airborne Contact Precautions. In addition, the sign revealed that staff were to keep R52's room door closed in order to maintain negative pressure. A second sign on the outside of R52's room door that was published by the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC) revealed for Airborne Precautions Everyone must . Put on a fit-tested N-95 or higher level respirator before room entry. Remove respirator after exiting the room and closing the door. Door to room must remain closed. A third sign on the outside of R52's room door that explained donning and doffing of PPE revealed for eye protection use goggles or a face shield. During a second observation on 01/08/25 at 08:30 AM, R52's room door was wide open, and staff were not visible in the room. During an observation on 01/09/25 at 01:40 PM, CNA B was observed exiting R52's room without goggles or a face shield. As she exited the room, she stated to another CNA that she had forgot to put on her goggles. During an interview on 01/09/25 at 01:45 PM, CNA B stated that she knew she was supposed to wear goggles when she went in R52's room, but forgot to put them on. She stated that she was unaware that she was not wearing her goggles until she exited the room after providing care to R52. CNA B further stated she usually will wear N95 respirators instead of surgical masks. CNA B stated she removes her respirator and puts on a fresh one before she enters an isolation room. She stated she will then dispose of the one that she wore in the isolation room when she exits the room and put on a fresh one before walking down the hall. CNA B stated as far as she knows, staff can wear a surgical mask under their N95 respirator when they go into an isolation room, or they can just switch from the surgical mask to an N95 and back to the surgical mask after they leave the isolation room. She stated if a staff member does wear both a surgical mask and an N95 respirator in an isolation room, then when they exit the room they need to dispose of the surgical mask and the N95 respirator and put on a fresh surgical mask. CNA B stated staff cannot just wear the surgical mask they had on in an isolation room and walk down the hallway because of contamination (airborne droplets of the COVID virus could be on the surgical mask from when the staff member was in the room). A review of the facility's COVID-19 Prevention, Response and Reporting policy, reviewed 1/8/25, revealed healthcare personnel who enter the room of a resident with COVID-19 should adhere to standard precautions and use an N95 or higher respirator, gown, gloves, and eye protection. A review of the Centers for Disease Control and Prevention's (CDC) website infographic, undated, revealed surgical face masks are loose fitting; does not provide the wearer with a reliable level of protection from inhaling smaller airborne particles and is NOT considered respiratory protection; and leakage occurs around the edge of the mask when user inhales. However, an N95 respirator is tight fitting; Filters out at least 95% of airborne particles including large and small particles; is required to be fit tested (tested to make sure it properly fits the individual's face); and when properly fitted and donned, minimal leakage occurs around edges of the respirator when user inhales (https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf). Therefore, wearing a surgical mask underneath the N95 respirator would prevent the N95 respirator from properly sealing/fitting around the individual's face, would defeat the purpose of the N95 respirator, and could expose the individual to infectious organisms (e.g. COVID-19). 31771 R37 A review of the facility's Form 802 (matrix) provided to the survey team on 1/7/25, revealed R37 was listed as having COVID under the Infections column. During an observation and interview conducted 1/8/25 at 2:54 PM, the door of the room of R37 revealed the room had been identified as an isolation room with the directive for all entering to wear specific personal protective equipment (PPE) available in a isolation supply cart by the doorway. Certified Nurse Aide (CNA) I was performing person care with R37 who was in her bed. It was observed that CNA I was wearing the required COVID PPE except for the proper mask. CNA I was wearing a surgical mask and not the N95 or higher respirator as indicated on the signage on the Resident's door. CNA I acknowledged she should be wearing an N95 mask that was available from the isolation cart. room [ROOM NUMBER] On 1/8/25 at 9:55 AM a record review of the facility 802 matrix and an observation of the doorway of room [ROOM NUMBER] revealed this room was identified as a COVID-19 room. Signage on the door reflected specific personal protective equipment (PPE) must be worn when entering this room. The required PPE included an N95 mask, gown, gloves and eye protection. This equipment was available in the storage cart beside the doorway. Another sign on the door outlined the procedure for putting on and taking off (donning and doffing) the PPE. On 1/8/25 at 2:04 PM, Laundry staff were observed entering room [ROOM NUMBER] carrying cleaned clothes. The Laundry staff member was not wearing any of the required PPE but only a surgical mask. On 1/9/25 at 1:18 PM the Director of Nursing (DON) identified the Laundry staff member as Laundry Staff (LS) and indicated all staff are to wear the required PPE when in any COVID-19 room.

Based on observation, interview, and record review, the facility failed to prevent, assess, measure, and monitor a pressure ulcer for 1 of 2 residents, Resident #14 (R14) reviewed for pressure ulcers. This deficient practice resulted in R14 developing a Stage 3 pressure ulcer that deteriorated, became infected, and required antibiotic therapy. Findings include: R14 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R14 admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of (but not limited to) Dementia (memory and safety impairment), Atrial Fibrillation (irregular heart rhythm), and high blood pressure. Brief Interview for Mental Status (BIMS) reflected a score of 10 out of 15 which represents R14 had moderate cognitive impairment. R14 required staff assistance of 1-2 with all activities of daily living. Pressure ulcer definition used in the State Operating Manual last revised on 2/3/23 reflects, Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis. 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 .Stage 3 Pressure Ulcer: Full-thickness skin loss. Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss . During an observation of a dressing change on 2/14/24 at approximately 1:20 PM, Licensed Practical Nurse (LPN) J was observed as she changed the dressing to R14's left foot. R14 had an open area to the left heel that was approximately 2.5 cm x 3.0 cm, the open area had depth to one side of the wound and odor was noted. According to the readmission skin assessment dated [DATE] the right and left heels were mushy/bogginess. According to the Safety Events-Pressure Sore dated 12/10/23 reflected a new Stage II pressure ulcer to the left heel that measured 2.4 cm x 5.8 cm x 0.1 cm. Listed under Orders reflected, Pressure Sore: Measure and Document progress weekly. The Evaluation noted Blister to left heel. The facility provided a copy of the Podiatrist evaluation dated 12/14/23 for review. The noted reflected, Objective: The left heel postermedially has a grade I stage III ulceration. The area has darkened in the center and appears to be healing. There is some blister material at the periphery and appears slightly reddened but viable and has good heeling tissue . A record review of Weekly Skin Assessment's were reviewed from 12/6/23 - 1/10/24. During this 6-week period only 3 assessments were available for review. The facility completed them on the following days: 12/6/23 12/27/23 (21 days later) 1/9/24 (13 days later) According to the Weekly Skin assessment dated [DATE] reflected no skin issues which is inaccurate due to the Podiatry evaluation on 12/14/24 with the presence of a Stage III pressure ulcer to the left heel. The policy/procedure for Pressure Injury Prevention Guideline dated 11/22/22 was provided for review. The policy reflected, 8. Compliance with interventions will be documented in the medical record .b. For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modification include: a Development of a new pressure injury. b. Lack of progression towards healing or changes in wound characteristics. The progress notes were reviewed from 12/6/23 - 2/12/24 reflected the following entries related to the left heel pressure ulcer: 12/11/23 noted a blister that had burst, and a dressing was applied. 1/9/24 noted a scab to the left heel. 1/18/24 noted a scab that had torn, and drainage was noted. 1/23/24 noted the left heel wound is still draining and measures approximately 3 cm round. 1/25/24 noted the antibiotic, Bactrim DS was being used for a wound infection. 1/31/24 noted wound has black eschar (thickened dark covering). 1/31/24 noted resident was wearing Crocs (a slide on shoe with heel strap) that rubbed the wound dressing and eschar off leaving exposed 4 cm x 3 cm x 0.5 cm open wound. A wound consult was placed. 2/6/24 noted an approximate wound measurement of 2.5 with eschar covering the wound bed. 2/8/24 noted the wound cultures were received and the antibiotic was changed from Bactrim DS to Doxycycline for 10 days. The Surveyor requested the weekly wound measurements from 12/6/23 until 2/14/24 from the Director of Nursing (DON) on 2/15/24 at 12:40 PM. The DON provided a handwritten copy of a document titled Wound Rounds. The document reflected R14's name and 2 undated measurements that reflected 3 x 3 x 0.5 and 2.5 x 3 0.5. The DON stated that she did not know the exact dates of the measurements. The DON stated the wound initially started because R14 wears Croc's with a heel strap that rubbed and caused a blister. When asked if the date of onset was 12/10/23, the DON stated, Yes. The DON stated that the facility asked the Podiatrist to look at it on 12/14/23. The Podiatry note from 12/14/23 reflected the presence of a Stage III pressure ulcer. The DON stated that it presented as a blister, then it burst, and appeared dry for a time. The DON stated it deteriorated, became infected, required a wound culture and antibiotics. When asked if there were any additional weekly skin assessment between 12/6/23 and 12/27/23 (3 weeks), the DON reviewed the record and stated, No. The DON provided 2 additional Wound Specialist notes dated 2/1/24 and 2/7/24 for review. The note dated 2/1/24 reflected a measurement of 3 cm x 3 cm x 0.5 cm and a new order for a chemical debridement ointment with each dressing change. The noted dated 2/7/24 reflected that the wound was mechanically debrided using a sharp instrument and it measured 2.5 cm x 3.0 cm x 0.5 cm. The DON reviewed the care plan with the Surveyor. The care plan reflected, Problem Start Date: 1/1/2024 for the problem of I have a wound to my left heel. Listed under the goal and all 5 approaches reflected a created date of 2/8/24. Confirmed with the DON that the care plan for the wound was created on 2/8/24 and DON stated, Yes. The facility failed to ensure accurate weekly skin checks, weekly wound measuring and monitoring and care planning was in place to prevent and promote the healing of a Stage III pressure ulcer.

This citation pertains to intake number MI00136972. Based on observation, interview, and record review, the facility failed to prevent falls for 1 resident, Resident #1 (R1) reviewed for falls. This deficient practice resulted in R1 continuously ambulating without care planned assistive devices and sustaining a fall with serious injury when appropriate assistance was not provided with transfers. Findings include: R1 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with a readmitted [DATE], with diagnosis of (but not limited to) dementia, muscle weakness and a history of falling. Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represented R1 had severe cognitive impairment. R1 required the assistance of 2 staff members with all activities of daily living. During an interview on 7/5/23 at approximately 11:30 AM, the NHA stated that the nurse and CNA first noted a painful swollen area to R1's right thigh/hip during AM cares on 5/18/23 just after 7 AM. The nurse obtained an order for an Xray which was positive for a fracture. The NHA stated the facility initiated an investigation. NHA stated that CNA B initially stated that she worked the midnight shift and R1 did not get out of bed during her shift. The NHA stated the video was reviewed and revealed R1 was out of bed 3 times during the night and wandered into the hall. NHA stated at 5:10 AM, R1 was observed wandering into the hall and CNA B taking her by the arm back to her room and did not get out of bed until the day shift staff noted her injury. NHA stated that she reinterviewed CNA B and CNA B admitted that R1 had got her legs twisted and fell on her way back to her bed. CNA B then reported that she assisted R1 up off the floor and into bed and failed to report fall to the nurse. According to a Facility Reported Incident dated 5/18/23, R1 sustained a fall and CNA B failed to report the fall timely. According to the X-ray report dated 5/18/23, R1 sustained a fracture to the right femoral neck that required surgery to repair. The report reflected that CNA B was terminated from the facility for not reporting the fall immediately to the nurse. The facility staff received education following the incident. The Activities of Daily Living Care plan was updated on 5/24/23 with the following new interventions while R1's femoral fracture healed: transfer with extensive assistance of 2, extensive assistance of 2 required for toileting, no ambulation at this time, and weight bearing as tolerated. The facility provided 3 additional fall reports for R1 since returning from the hospital on 5/23/23: -6/3/23 at 2:38 PM fell when another resident was assisting her from the wheelchair to the recliner. -6/19/23 at 6:04 AM had an unwitnessed fall next to the bed. -6/28/23 at 12:45 AM had an unwitnessed fall next to the bed and sustained an abrasion to her back. During an observation of the memory care unit on 7/5/23 from approximately 2:30-2:45 PM, CNA A was observed transferring R1 from the wheelchair to the toilet with one assist and no gait belt. CNA A then exited R1's bathroom and went down the hall, gathered towels from the linen closet and went into the shower room to assist another resident. After a few minutes this Surveyor observed R1 transfer herself without any staff assistance from the toilet to the wheelchair. After a few more moments, CNA A exited the shower and went back into R1's bathroom. R1 was already seated in her wheelchair in the bathroom when CNA A entered the room. During an interview and record review on 7/5/23 at approximately 3:27 PM, the DON reviewed the care plan and stated that R1 was only to ambulate with therapy at this time. The DON stated she required the extensive assistance of 2 staff members and the use of a gait belt to transfer from the wheelchair to the toilet and back again. The DON added that R1 should not be left alone in the bathroom because she is a fall risk. The facility failed to follow the care plan to provide adequate supervision and the assistance required to prevent falls.

This Citation Pertains to intake #: MI00133943 Based on interview and record review, the facility failed to ensure chemical restraints were not utilized for staff convenience for R117. On 2/7/23 R117 was administered Roxanol (used for the treatment of severe pain) without clinical indication that R117 was experiencing pain and for the purpose of treating R117's behaviors of anxiety, restlessness, and agitation. This deficient practice resulted in an immediate jeopardy beginning on 2/7/23 when R117 arrived to the Emergency Department lethargic, minimally responsive, hypotensive, hypoxic, with bradypenia and pinpoint pupils suspect related to overmedication and places all residents who present with behaviors at high risk to experience serious harm, injury and/or death from use of chemical restraints. Findings: Resident #117 (R117) Review of an Admission Record revealed R117 was a [AGE] year-old female, originally admitted to the facility on [DATE], readmitted on [DATE], with pertinent diagnoses which included: dementia, unspecified severity, with other behavioral disturbance, unspecified symptoms and signs involving cognitive functions and awareness, anxiety disorder, autistic disorder, bipolar II disorder, and insomnia. Review of a Minimum Data Set (MDS) assessment for R117, with a reference date of 2/5/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, out of a total possible score of 15, which indicated R117 was severely cognitively impaired. During an interview on 2/28/23 at 10:58 AM, Court Appointed Guardian (CAG) V reported Director of Nursing had approached her multiple times since R117's readmission on 1/30/23 regarding changing R117's code status to DNR and changing her to comfort care or hospice because of her behaviors only. CAG V reported that R117 had been sent to 4 psychiatric hospitals over the last year and she wanted R117 to remain in the facility because of how disruptive and upsetting being transferred out to different facilities was for R117. CAG V reported she was willing to consent to medication changes to keep R117 stable but became concerned and questioned the rationale of new medications and medication changes when the DON demanded that R117 be made a DNR and begin hospice/comfort care so facility staff could control her behaviors. CAG V questioned why the facility's contracted psychiatrist could not assess R117 and make changes and why the DON was demanding comfort medications for psychiatric diagnoses. CAG V reported there was no rationale provided to her and she became increasingly concerned that the facility staff were going to keep R117 overmedicated and sedated resulting in a poor quality of life. CAG V did not report that R117 had a history of pain requiring the use of opioid analgesic medications. CAG V reported that in the afternoon on 2/7/23 the DON stated that if CAG V did not consent to the use of the roxanol, change R117's Code Status, and allow additional comfort medications then R117 would be sent to the hospital and could not return. CAG V stated that the DON called me and said they had given it (Roxanol) to her (R117) 40 minutes prior and she was still out of control and sent her to the hospital (refer to Nursing Progress Note dated 2/7/23 at 2:05 PM and 2/7/23 at 2:25 PM). CAG V reported that the hospital physician notified her that upon arrival to the Emergency Department R117 was almost comatose and nonresponsive with a dangerously low blood pressure. CAG V reported that the hospital physician felt that her conditional upon arrival was critical. Review of R117's Care Plan revealed no entries related to overall behaviors (interventions to implement when R117 is having increased behaviors, non-pharmacologic interventions for behaviors). Review of R117's Falls Care Plan created 12/10/22 revealed, Resident frequently puts herself on the floor .If (R117) puts self on floor staff to monitor for safety. Indicating R117 had a history of the behavior of placing self on floor. Review of R117's MDS assessment dated [DATE] revealed opioid medications were not administered in Section N-Medications and Pain was not triggered in Section V-Care Area Assessment (CAA) Summary. Review of R117's MDS assessment dated [DATE] revealed opioid medications were not administered in Section N-Medications and Pain was not triggered in Section V-Care Area Assessment (CAA) Summary. Review of R117's Care Plan revealed no entries related to pain and/or pain management (pain medications, non-pharmacologic interventions.) Review of R117's Hospital Records from hospital stay 1/19/23-1/30/23 revealed no documentation of pain. Discomfort noted related to constipation which resolved. Review of R117's Hospital Progress Note for discharge, dated 1/29/23 at 5:15 PM revealed, [AGE] year-old F (female) from (name omitted) Neuropsych unit with past medical history of autism, neurocognitive disorder, Seizure disorder presented with respiratory distress .She has sitter (one on one staff person that remains with resident at all times for safety) .She is stable and plan has been to discharge back to (psychiatric unit name omitted), per (name omitted) neuropsych request, Psychiatrist consulted however now we have been notified that per (name omitted) hospital, patient has finished management there and should go back to her NH (nursing home) in Ml (Michigan) and case manager has started the process .Assessment/Plan .Continue sitter . Confirming that at the time of discharge from the hospital R117 required 1:1 (sitter) staff monitoring. Review of R117's Admission Nursing Comprehensive Evaluation dated 1/30/23 at 7:50 PM revealed a pain assessment resulting in 0 of 10 No Pain. Review of R117's Physician Readmission note/H&P (History and Physical) dated 1/31/23 at 10:33 AM revealed, (R117) is being seen at (facility) for readmission and for following of chronic conditions. She is post hospitalization for geriatric psychiatric problems. Comorbid conditions include HTN (hypertension), dyslipidemia (high cholesterol), generalized weakness and others. There have not been appetite changes. There have not been any new health care changes .Current emotional concerns includes dementia and bipolar disorder and anxiety . General: She is not in acute distress . Assessment and Plan: (R117) was seen today for follow-up. Diagnoses and all orders for this visit: Dementia with behavioral disturbance (Primary) Bipolar affective disorder, remission status unspecified (HCC) Anxiety Essential hypertension, benign-Dyslipidemia-Generalized weakness-Unsteady gait-Return in about 1 month (around 2/28/2023). Pain was not identified during the comprehensive assessment conducted by Medical Director (MD) F. Review of R117's Nursing Progress Note dated 1/31/23 at 2:05 PM, written by Director of Nursing (DON), revealed, This writer called and spoke to (R117's) Guardian (Court Appointed Guardian (CAG) V). This writer wanted to discuss (R117's) condition and increased behaviors. This writer spoke about possible Hospice/comfort measures for restlessness. (CAG V) was not wanting to discuss comfort measures. (CAG V) stated you are not just going to drug her up to make your job easier .(CAG V) still continued to state you cannot put her on Hospice. I spoke with your Nurse this morning. (CAG V) was again told that (R117's) behaviors have started already, and she was putting herself and others at risk with her aggression. (CAG V) continued to state No. She will not qualify for Hospice .(CAG V) was not wanting to discuss comfort measures stated she would get back with this writer . (Clarification obtained with DON regarding the name of R117's guardian documented in the progress note. DON confirmed R117's guardian as CAG V.) Review of R117's Nursing Progress Note dated 2/1/23 at 1:37 PM, written by DON, revealed, This writer spoke with (Community Mental Health Case Worker (CMHCW W). CMHCW W wants (R117) not to be sent out of facility again. This writer explained to (CMHCW W) that I had spoken to (CAG V) R/T (related to) comfort measures and that (CAG V) was not willing to agree to comfort measures. (CMHCW W) had asked what it would take to keep (R117) at the facility. This writer explained that while (R117) was out to Psych hospital her Guardian would not ok for increased medications as her medications were not working. (R117) was still agitated and restless. When (R117) returned to (facility) she continued to be agitated and restless and the Psych Hospital had decreased her meds R/T her Guardian who insisted She is not to be drugged up. (CMHCW W) stated she would speak with (R117) Guardian and call back. DON did not provide documentation (psychiatric hospital discharge notes, email correspondence with psychiatric facility, legal documentation, etc) prior to survey exit to support the allegation that CAG V refused medication changes at the psychiatric hospital. Review of R117's Hospital Progress Notes from 1/19/23-1/30/23 revealed R117 was sent from the neuropsychiatric unit to the hospital on 1/19/23 for a medical emergency following a seizure. Multiple psychiatric medication changes were made during R117's hospital stay through discharge back to the facility. Psychiatric medication changes during hospital course included: stop clonazepam (antianxiety medication), stop haloperidol (antipsychotic medication), dose decrease for risperdal (antipsychotic medication), and dose decrease for ativan (antianxiety medication). Hospital documentation did not reveal that CAG V refused medication changes. Review of R117's Nursing Progress Note dated 2/1/23 at 1:49 PM, written by DON, revealed, (CMHCW W) from CMH did call back after she had spoken to (R117's) Guardian. (CMHCW W) stated that Guardian was on board with the medication changes. Dr. was notified and new orders received. Ativan 1mg TID (three times a day) and Norco TID. Will monitor for tolerance and effectiveness. Review of R117's Physician Order dated 2/1/23 revealed an order for Hydrocodone-acetaminophen (Norco) 5-325mg 1 tablet three times a day to be administered at 8:00am, 2:00pm, and 8:00pm. Review of R117's Electronic Health Record revealed no documentation of pain from time of admission on 1/30/23-2/2/23. Daily pain assessments from 1/31/23-2/2/23 revealed a pain score of 0 out of 10 (no pain). R117's Electronic Health Record revealed no comprehensive assessment indicating R117 was experiencing pain (provocation/palliation, quality/quantity, region/radiation, severity, verbal and nonverbal cues) nor a rationale for beginning a new opioid analgesic to be administered routinely and not as needed for pain. Review of R117's Physician Order dated 2/1/23 revealed an order for lorazepam (Ativan) 1mg tablet three times a day to be administered at 8:00am, 2:00pm, and 8:00pm. Hospital discharge order was for Ativan 0.5mg 2 times a day as needed for anxiety Max Daily Amount: 1 mg. Review of R117's Nursing Progress Notes revealed R117 began to have increased behaviors beginning on 2/5/23. * 2/5/23 at 6:00 AM Resident on the floor on her back 0530. No injuries .Resident was up all night, last dose of Ativan was not given. New schedule for last dose in place. Will continue to monitor. *2/6/23 at 8:07 PM res (resident) one on one most of day. arching back, maneuvering bottom to attempt to slide out of chair . *2/6/23 at 10:20 PM Resident continuously screaming, attempting to get out of bed, throwing her legs over the side, needing to be repositioned every 15 minutes or less . *2/7/23 at 3:20 AM Resident extremely restless throughout the night, needing to be repositioned several times. Staff observed resident nearly on the floor x3 throughout shift from scooting to the very edge of the bed .She appears to need 1:1 assistance to ensure safety. *2/7/23 at 10:35 AM .she was extremely restless, throwing her legs over the side of the bed, rocking back and forth and yelling out. Staff were unable to understand what (R117) was saying. (R117) was assisted into her chair. She then began to scoot towards the front of the chair, trying to scoot self to the floor. (R117 had a known behavior of placing self on floor as evidenced by Fall Care Plan dated 12/10/22). Review of R117's Nursing Progress Note dated 2/7/23 at 10:59 AM, written by DON revealed, This writer along with another Nurse Manger called (R117's) Guardian R/T (related to) her decline/increased behaviors/restlessness, multiple incidents of (R117) putting self on floor. (CAG V), Guardian, was not wanting any medications added at this time .This writer was very clear and stated multiple times to (CAG V) if she did not assist the facility with the proper care for (R117), we would not be able to meet her needs. (CAG V) requested a phone call from Dr. Will continue to monitor. Review of R117's Nursing Progress Note dated 2/7/23 at 11:57 AM, written by DON revealed, .Facility is having difficulties working with Guardian who does not want (R117's) medications increased or changed. Also, left VM for (CAG V), Guardian, to inform of increase of Risperdal in hopes of making (R117) more comfortable as she is still extremely restlessness. (Note: the DON reported CAG V would not allow medication changes despite documenting a new increase in Risperdal). Review of R117's Nursing Progress Note dated 2/7/23 at 2:05 PM, written by DON revealed, This writer spoke with (CMHCW W). (CMHCW W) was informed that (R117) was being sent back out to the hospital as staff could not get her comfortable and Guardian was not willing to work with staff as far as ordering more comfort medications . Review of R117's Nursing Progress Note dated 2/7/23 at 2:25 PM, written by DON revealed, This writer called (CAG V), Guardian, again to discuss the comfort medication Roxinol. (CAG V) did agree to the lowest dose to be given. 0.25ml Roxinol was given with no effect. (CAG V) was informed that (R117) would be sent out to the hospital again for further evaluation. (R117) continued to be a 1:1 and at this time facility could not meet her needs or safety concerns for herself or others .This writer explained that if she, (CAG V), was not willing to change (R117's) code status or allow comfort medications then facility could not meet her needs . At this point (R117) was still a 1:1 and facility could not accommodate that if all were not on the same page. (CAG V) stated yeah I know. You are not going to just give her drugs. This writer again attempted to explain it was not about drugs it was about getting (R117) comfortable. It was explained again that (R117) was extremely agitated and restless. (R117) was continuously screaming open!!!owww!!! (CAG V) continued to Deny comfort medications. (R117) was sent to (name omitted) hospital at this time. (Note: the DON reported CAG V would not allow comfort medications despite documenting CAG V consented to the administration of Roxanol). Review of R117's Controlled Medication Prescription dated 2/7/23 revealed, Roxanol (morphine sulfate) 20mg/ml (milligrams per milliliter) .Directions: 0.25ml (5mg) q2* prn (every 2 hours as needed). There was no clinical indication documented in the order for the use of the Roxanol. Review of the Food and Drug Administration (FDA) prescribing information for morphine sulfate (Roxanol) revealed Morphine sulfate is an opioid agonist indicated for the management of pain not responsive to non-narcotic analgesics. Indicating morphine/roxanol is clinically indicated to manage pain and not for the use of behavior management, restlessness, or agitation. Review of R117's Medication Administration Record revealed Roxanol (morphine sulfate) was administered on 2/7/23 at 12:21 PM for anxiety; restlessness. No pain assessment or documentation was completed at the time of the Roxanol administration confirming the Roxanol was administered to control behavior and not for pain control. Review of R117's Electronic Health Record revealed no documentation of a root cause analysis for R117's increased behaviors: physical assessment, pain assessment, laboratory testing, diagnostic testing, or medication tolerance/effectiveness. During an interview on 3/2/23 at 9:17 AM, Licensed Practical Nurse (LPN) Y reported that she was R117's licensed nurse on 2/7/23. On the day the morphine was administered (2/7/23 at 12:21 PM) R117 had increased behaviors. LPN Y reported that R117 was non-stop moving and attempting to throw herself on the ground. LPN Y reported that R117 had required a 1:1 to keep her in her gerichair. LPN Y reported that R117 had to have a 1:1 at all times and with the number of scheduled staff it was not feasible. LPN Y reported that R117 was not tested for a Urinary Tract Infection (UTI), and they (facility staff) did not feel that was the cause of her increased behaviors. No other testing (labs, xrays, etc) or assessments (pain assessment or comprehensive physical assessment) were completed on 2/7/23. LPN Y reported that the morphine was not effective in controlling R117's restlessness and agitation and R117 was sent to the hospital. Confirming the administration of Roxanol was for staff convenience to control behaviors and due to the insufficient number of staff to provide R117 with a 1:1. During an interview on 3/16/23 at 2:20 PM, Staff Scheduler (SS) I verified that on 2/7/23 there were 2 nurses scheduled and 1 nurse on orientation, 2 CNAs (Certified Nursing Assistants) scheduled on the Memory Care Unit, and 2 CNAs scheduled on the East/West/Central Units. 3 CNAs were scheduled from 6am-6pm and 1 CNA scheduled from 6am-2pm and 1 CNA scheduled 2pm-6pm. R117 resided on the East/West/Central Units. During an interview on 3/2/23 at 3:22 PM, Nursing Home Administrator (NHA) reported that she was familiar with R117 and her condition prior to her transfer to the hospital on 2/7/23. NHA reported that the provider ordered the Roxanol for R117 because she was so agitated. NHA reported there were no additional Progress Notes following the administration of the Roxanol from the provider and the only documentation related to the rationale for the administration of the Roxanol was from the Nursing Progress Notes. During an interview on 3/3/23 at 12:36 PM, Director of Nursing (DON), with survey team present, DON reported that R117 had been a 1:1 because of her increased behaviors prior to her transfer to the hospital on 2/7/23. DON reported R117 had severe psych issues and was uncomfortable and exhibited a lot of agitation and restlessness. She was uncomfortable but don't know if it was psych or physical. DON reported that one day R117 was yelling out oww oww oww (documented x1 on 2/7/23 at 2:25 PM at the time of transfer to hospital). DON could not provide a medical diagnosis confirming a terminal illness and referred to R117's psychiatric distress only. DON reported that admitting R117 to a hospice program would allow R117 to receive more 1:1 care from hospice staff and additional medications could be utilized. When asked why R117 could not have medication changes for psychiatric stabilization and symptom management without being placed on hospice/comfort care, DON did not provide an explanation. When asked if the physician and nurses completed a comprehensive assessment and evaluation to identify the root cause of R117 being uncomfortable both mentally and/or physically DON stated, we missed that. DON reported that R117's behaviors were endangering herself and nurses and had escalated to R117 biting and breaking the skin of a facility nurse. Review of R117's Electronic Health Record revealed the behavior reported by the DON occurred on 12/12/22 (Nursing Progress Note dated 12/12/22 at 8:53 AM) resulting in R117's transfer to the hospital and subsequent transfer to an Indiana psychiatric facility on 12/13/22 (R117 did not return to the facility until 1/30/23) and did not occur between 1/30/23-2/7/23. On 3/16/23 at 12:08 PM, an interview was conducted with NHA, DON, with the survey team and survey manager present. DON reported that Roxanol was not administered as a chemical restraint and was used to get R117 comfortable. DON had previously stated she (R117) was uncomfortable. DON was asked to describe what was meant by the term uncomfortable relating to R117. DON stated, she was just uncomfortable for some reason shape or form. DON was asked why Norco 5/325 mg was ordered and why it was ordered to be administered 3 times a day and not as needed as there had been no documentation that R117 had a history of pain since her original admission to the facility and no clinical indication that R117 was in pain. DON reported that the Norco was started for pain and the scheduling of the medication would be up to MD F and provided no other rationale. DON was asked how it was determined R117 was experiencing pain and the effectiveness of Norco as there were no comprehensive pain assessments documented by the provider or the nursing staff. DON reported that there was documentation that R117 was restless and agitated which could be a non-verbal sign of pain. DON was asked what other non-verbal cues of pain R117 exhibited and stated, the continuous screaming out would be a form of pain and arching back throwing feet over the bed. The DON was asked if R117 displayed non-verbal signs of pain such as grimacing and guarding and did not provide an answer. DON stated, kind of hard to do a full assessment on someone biting punching and kicking you, you could not palpate this woman and reported those behaviors are documented. DON reported that R117 had bit a licensed nurse resulting in a break in her skin. DON was notified that this incident was from prior to her readmission to the facility on [DATE] and was verified by NHA. DON was notified at that time that the behaviors she was describing were not documented and attempts to perform a comprehensive assessment were also not documented. DON confirmed that there was no documentation of a comprehensive pain assessment and reevaluation of the use of Norco completed for R117. (Additional behavior documentation was not provided prior to survey exit.) DON stated, basically what you are saying is that there was not a pain assessment done. Reported to DON that the concern was that a resident without a history of pain now displayed symptoms that led DON to believe she was in pain. Norco was started without a rationale from the provider nor a pain assessment, efficacy of the medication was not evaluated, and it was reported by the DON that R117 continued to be in discomfort and yet no root cause analysis was completed: no diagnostic testing, no laboratory testing, and no provider notification and assessment. Then on 2/7/23 Roxanol, used to treat severe pain, was ordered without clinical indication for use, without documentation that R117 was experiencing pain, and administered to control R117's behaviors. DON did not provide a response and remained silent. *R117 required staff to complete incontinence care (brief changes), bathing and transfers with no documentation that R117 refused care or displayed those behaviors while receiving care in her Electronic Health Record nor MDS assessment dated [DATE]. *Only documentation of kicking staff prior to 2/7/23 was on 2/1/23 at 4:04 PM kicking table to move herself back in the wheelchair . *Only documentation of R117 Screaming was on 2/6/23 at 10:20 PM and 2/7/23 at 2:25 PM (at the time of transfer.) *Only documentation of R117 Biting was of her biting down on a spoon during meals on 2/1/23 at 4:04 PM and 2/6/23 at 12:10 PM. There was no documentation that she had attempted to bite staff from 1/30/23-2/7/23. *Review of R117's MDS assessment dated [DATE] revealed: MDS Section E-Behaviors revealed R117 did not exhibit physical behavioral symptoms directed toward others (e,g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and did not exhibit other behavioral symptoms not directed toward others. Verbal behaviors were identified. The MDS reflected that R117's behaviors did not put the resident at significant risk for physical illness or injury, did not significantly interfere with the resident's care and did not put others at significant risk for physical injury. The MDS reflected R117 did not reject evaluation or care which would include: (bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being . The MDS reflected that R117's behaviors had improved compared to prior assessment. *Hospital records dated 2/7/23 revealed R117 was administered Norco in the event that she is in pain and unable to communicate so. Confirming the lack of clinical indication for the use of the opioid. Review of the Emergency Department Provider Note dated 2/7/23 at 2:07 PM revealed, HISTORY OF PRESENT ILLNESS: The patient is a [AGE] year-old female who has a history of bipolar disorder, dementia, and hypertension. She has a legal guardian. History and review of systems is limited secondary to dementia and altered mental status. The history provided was obtained by the guardian (CAG V) and her primary nurse (facility). She has been seen at (facility) intermittently over the last year. In reality, she has been in and out of multiple psychiatric facilities secondary to behavioral disturbances. Her most recent Admission was last week. Since returning to (facility), she has had increased behavior disturbances again. She has been flailing around, hitting at staff, screaming out loud, throwing herself on the floor, disturbing other residents. Her Risperdal has been increased, they have also change her lorazepam from as needed to scheduled, they also started Norco in the event that she is in pain and unable to communicate so. Today, they added 5mg Roxanol. They waited approximately 45 minutes prior to transfer. However she continued to have behavioral disturbances and was then sent here. Per EMS, she has been essentially sleeping. Upon arrival, she is minimally responsive. She does open her eyes with painful stimuli or verbal stimuli, however she does not follow commands . Pulmonary: Effort: Bradypnea present. Breath sounds: Decreased breath sounds present . Neurological: Mental Status: She is lethargic and disoriented . Review of R117's Admission History and Physical dated 2/7/23 at 6:25 PM revealed, Assessment and plan: The patient is a [AGE] year-old female who has a past medical history of bipolar disorder and dementia. She is well-known for severe behavioral disturbances. She has been in and out of multiple psychiatric facilities over the last year. She has been back at her current assisted living center for the last week. During this time they have noted worsening behavioral disturbances. She has had increases in her medications including her Risperdal dose, her lorazepam was when necessary but is now scheduled, she has also been started on Zyprexa. Today, they added when necessary Roxanol. Prior to arrival, she did receive 5 mg of morphine. Initially, patient was minimally responsive, opening eyes and moving extremities to painful stimuli. She was mildly hypoxic (low oxygen level) in the mid 80s. Pinpoint pupils were present. Suspect this is related to overmedication .Workup today does show an acute urinary tract infection. Rocephin has been ordered. In addition, she has a hypernatremia which is changed since December when she had a hyponatremia. Although this may be related to her dehydrated state, trending the comprehensive metabolic panel will be indicated. Throughout her visit, she has been intermittently hypoxic .She also remains obtunded although improved. I suspect that this is related to polypharmacy and overmedication. However, patient will need to be weaned off of oxygen . Clinical Impressions as of 02/07/23 1724 (5:24 PM) *Altered mental status, unspecified altered mental status type *Dementia with behavioral disturbance *Acute UTI *Hypoxemia *Polypharmacy *Hypernatremia . During an interview on 3/01/23 at 3:18 PM, Hospital Social Worker (HSW) T reported that when R117 arrived at the Emergency Department on 2/7/23 she was lethargic and overly sedated because she had been overmedicated at the facility. HSW T stated that it was reported that R117 was administered morphine for behavioral control and the facility was pursuing hospice care in order to manage her behaviors. HSW T reported that R117 was diagnosed with an acute UTI and Clostridioides difficile (c-diff infection is a severe and sudden infection in the colon) and when those infections were treated R117 returned to her physical and mental baseline. During an interview on 2/24/23 at 8:36 AM, Hospital Unit Manager (HUM) S reported that R117 had increased behaviors while at the facility resulting in the facility increasing medications and adding new medications. HUM S reported that when R117 arrived at the Emergency Department on 2/7/23 she was overmedicated and obtunded. HUM S reported that once she was admitted to the hospital, the physician had to stop her medications and slowly add medications back to ensure R117 was on an appropriate regimen of medication and did not become overmedicated again. HUM S reported that R117 was diagnosed with an acute UTI which was likely the cause of her behavioral issues. HUM S reported that when R117 was admitted to the hospital she was a little squirrely but once her medication regimen was adjusted and her UTI was treated, her behaviors resolved, and she no longer required a 1:1 sitter. (Elderly patients with UTIs often experience behavioral symptoms and confusion). Review of the Drug Interaction Report revealed the concomitant use of Ativan (lorazepam), Norco (hydrocodone/acetaminophen), and Roxanol (morphine sulfate) has the potential to result in profound sedation, respiratory depression, coma, and death. Review of R117's Medication Administration Record (MAR) and Controlled Drug Record (CDR) revealed that on 2/7/23, R117 received the following controlled substances: *Roxanol (morphine) 5mg at 12:20 PM per CDR and MAR *Norco (hydrocodone/acetaminophen) 5/325mg documented as administered at 8:00 AM on MAR and documented as administered at 1:30 PM on CDR. *Ativan 1mg documented as administered at 8:00 AM and 1:30 PM on CDR. Review of R117's Controlled Drug Record for Ativan (lorazepam) 1mg tab 1 tab by mouth three times a day revealed 2 entries on 2/7/23 at 8:00 AM and 1:30 PM. No additional Controlled Drug Record for Ativan 1mg TID provided although initially ordered on 2/1/23 and documented as administered in R117's MAR on 2/1/23 at 8:00 PM, 2/2/23 at 8:00 AM, 2:00 PM, and 8:00 PM, 2/3/23 at 8:00 AM and 2:00 PM, and 2/6/23 at 2:00 PM and 8:00 PM. Did not receive prior to survey exit. (Requested via email to NHA all of R117's CDR's for 6 months on 3/2/23 at 12:42 PM and was not provided with all of R117's CDRs. Requested via email to NHA specifically the CDR for Ativan 1mg TID with dates listed above on 3/3/23 at 12:11 PM and requested via email to NHA all CDRs for R117 from 1/31/23 to 2/7/23 on 3/15/23 at 9:11 AM.) Review of R117's Electronic Health Record revealed no comprehensive assessment, medical diagnosis, nor documentation from other medical providers/institutions indicating R117 was terminally ill (with a life expectancy of 6 months or less) and required hospice care nor a serious/life threatening disease where comfort care (palliative care) should be implemented to improve quality of life. On 3/15/23 at 1:30 PM the Administrator was verbally notified and received written notification of the immediate jeopardy that was identified on 2/7/23 due to the facility's failure to ensure chemical restraints were not utilized for staff convenience. A written plan for removal for the immediate jeopardy was received on 3/15/23 and the following was verified on 3/17/23: The following was implemented immediately as listed: *Resident 117 no longer resides at the facility *All Residents on Ro[TRUNCATED]

This citation pertains to intakes M100133539, M100131917, and M100135028. Based on interview and record review, the facility failed to acknowledge, identify, and provide adequate supervision to prevent an elopement and ensure the safety of 1 of 7 residents (Resident #111) at risk for wandering, resulting in an Immediate Jeopardy on 11/24/22 at approximately 10:00 PM, when R111 eloped from the facility unbeknownst to staff. R111 was found outside the facility after a citizen call to the police at 10:13 PM. R111 gave her [NAME] name to police who contacted the facility who did not recognize R111 was missing. Police then drove R111 to a gas station approximately 15 miles away. R111 was not discovered missing by facility staff until 12:45 AM (nearly 3 hours later). At 1:35 AM facility staff called the police who knew the last location of R111 and returned R111 to the facility at approximately 2:00 AM. Findings include: Resident #111 (R111) Review of a Face Sheet revealed R111 originally admitted to the facility on [DATE] with pertinent diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbances, unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence. Review of the Minimum Data Set (MDS) dated [DATE] revealed R111 had a Brief Interview for Mental Status (BIMS) indicating she was cognitively intact with no behaviors and independent with cares. Review of the MDS dated [DATE] revealed R111 had a Staff Assessment for Mental Status indicating she was independently and consistently able to make decisions. She rejected care with no other behaviors and independent with cares. In an interview on 2/22/23 at 12:40 PM, Complainant C1 reported R111 has Alzheimer's disease and dementia. Prior to admission to the facility, the resident was found wandering in a field with all her money that she withdrew from the bank in her sock. R111 went to the hospital and the Power of Attorney (POA) was activated in 6/2022. It is unclear if the resident eloped from the facility because the facility did not communicate that with the POA. In an interview on 2/23/23 at 11:04 AM, Licensed Practical Nurse (LPN) D reported R111's moods would go back and forth depending on the time of day and can be loud and short tempered. The day the resident left the facility, she chose to leave and called for transportation herself. In an interview on 2/24/23 at 9:53 AM, Family Member FM1 who is R111s daughter and emergency appointed guardian, that was her original appointed advocate in 2021, reported that the resident had been a Certified Nurses Aide for [AGE] years in nursing homes and knows a lot. FM1 reported several incidents prior to admission to the facility about the resident unsafely and uncharacteristically wandering in the city and had other behaviors that were not safe and poor decision making. Prior to admission to the facility, R111 had her POA activated in June 2022 at the hospital. R111 signed the Five Wishes in 2021 that made FM1 her patient advocate. R111 is giving the facility a hard time because of her background history of being a CNA for so many years. FM1 reported R111 escaped from the facility in either October or November and heard she went to one of the residential houses and told them to call the police and gave them her [NAME] name. When the police came, they took her to the police station and somehow found her somewhere else in the middle of the night. FM1 reported she received a voicemail sometime during that night that her mother eloped and thinks it may have happened on the night of Thanksgiving. In an interview on 2/24/23 at 11:00PM, the Nursing Home Administrator (NHA) reported R111 did leave the building on 11/24/22 but she did not elope because she was her own person and just wanted to get some potato chips and a pop. So, she called the police to come pick her up. She did not report the incident to the State Agency because it was not an elopement. The resident failed to sign herself out on the Leave of Absence (LOA) book. When asked if there was an incident report for this incident, the NHA provided a summary that was in her soft file in her office. Review of the Summary provided by the NHA regarding R111 leaving the facility revealed R111 was not in the facility on 11/25/22 when staff went into her room around 12:00 AM. The nurse last saw R111 around 11:00 PM (11/24/22) and around 11:30 PM the nurse received a phone call from the police asking if she had a resident with the same first name but a different last name. The nurse told the police they did not have a resident by that name. The police informed the nurse that someone called and said they needed to be picked up in front of the building because they had been thrown out of a vehicle and wanted to make sure this was not their resident. Around 11:45 PM, the nurse locked the front door and saw EMS (emergency medical services) outside and did not think anything about it. The summary concluded R111 did not sign herself out and at an unknown time, the nurse realized the resident was not in her room and searched outside. At approximately 12:45 AM the Director of Nursing (DON) was notified that R111 was not in the building and the police were notified. The police identified the person they picked up in front of the facility was R111 and would be in route to bring her back after she got her coffee and snacks. When R111 arrived at the facility, the NHA educated the resident about signing out on the LOA book and initiated 15-minute checks due to her noncompliance with care and they would know if she left the building without signing out again. No interviews from staff provided, no camera footage available, and no sensical detailed timeline provided. In an interview on 3/1/23 at 9:46 AM, Social Worker (SW) O reported she no longer works at the facility as of 12/28/22. SW O reported R111 would walk around in the parking lot at the facility alone because she was her own person, she did not need supervision and has that right. She would stay outside the building and staff would peek through the windows to check on her. The night of the elopement, R111 wanted some snacks so she called the police to take her to get some snacks. When queried if she knew a resident was walking around at night in the cold and the dark, would you let them? SW O said No, but she was her own person and could go outside because she has that right. In an interview on 3/3/23 at 9:13 AM, the Director of Nursing (DON) was queried about R111 leaving the facility and if she thought that she eloped and the DON replied, I plead the 5th! The DON was read the excerpt in the State Operations Manual (SOM) the definition of an elopement A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. The DON reported she was looking at R111's situation from a capacity view and could understand that by that definition it would be considered an elopement. When queried about a reasonable person's concept for wandering outside alone on a cold dark night, the DON agreed that a reasonable person would not go outside alone at 10:00 PM for chips and a pop. The DON felt that R111 did not spend time with her family on Thanksgiving Day and eat dinner with them which may have triggered her anger and desire to leave the facility. In an interview on 3/9/23 at 4:33 PM, the Fire Chief (FC) P reported he was informed R111 called 911 herself and when they arrived on the scene, he was informed she was kicked out of a car. She was on the ground on the corner not far from the facility (about 100 yards) and had her cane and thinks she had some of her belongings. He called the nursing facility who denied a resident with the last name he gave them that was given by the resident, and then asked the facility if they were missing a resident, and the facility denied missing a resident. His first impression of R111 when he arrived was that she would answer things very well, but none of the information she gave made sense even though it was consistent. It made no sense why she was there. She had no complaints of injury. The police arrived on the scene and was aware they were going to take her to the County Sheriff headquarters. In an interview on 3/9/23 at 5:08 PM, Certified Nursing Assistant (CNA) Q verified she worked the night of 11/24/23 when R111 left the facility. CNA Q reported they were short staffed that night and did not recall seeing R111 near the front doors that night or acting suspicious. CNA Q reported she has never personally seen R111 leave her room. CNA Q thinks R111 got out of the building when another resident came back to facility around 11:00 PM from visiting family. That resident was a 2 person assist back to bed and needed to be changed but that only took about 5 minutes. CNA Q and the nurse that was working that unit were the only ones on that side who assisted the resident to bed and changed him. The other 2 staff were on the memory care unit and the front doors were not locked. CNA Q reported she remembered when they were getting ready to lock the front doors, she saw the EMS outside of the assisted living center next door. CNA Q confirmed R111 got out of the building, and they did not even know it. When they finally realized she was missing, they called the administrator first and then they called the police. When the police brought the resident back to the facility, they put her on 15-minute checks, and she was not happy about it. R111 was on the memory care unit in the past but she did not like being there and would get aggressive, so she went back to the other unit where she is now. R111 would also refuse the wander guard in the past. Since the surveyors have been in the building, she has a wander guard now but does not like it to be checked. CNA Q reported she was told that the resident in the past was in a facility in Muskegon when R111 left and walked an hour away. When queried if R111 answers questions appropriately, CNA Q reported she answers basic questions appropriately. Review of the Police Report with a dispatch date of 11/24/22 at 10:13 PM, arrival time of 10:31 PM, and a clear time of 2:39 AM for a suspicious situation involving R111 revealed: On 11/24/2022 at approximately (10:13 PM), I (Deputy) was dispatched to the intersection of S. Park St./ W. [NAME] St. for a medical complaint. Dispatch advised a woman was thrown from a vehicle and needed assistance. Prior to my arrival, (the Fire Department) arrived on scene and made contact with the woman. (The Fire Department) state, the woman does not appear to have been thrown from a vehicle and is sitting in someone's yard without injuries. The resident reported she was dropped off by her daughter and another male and gave the officer a different last name and date of birth. The officers then took her to a gas station in Ithaca at 11:08 PM per the resident's request. At approximately 1:35 AM, Dispatch received a call from (Nursing Facility) stating one of their patients ran away from the facility. The officer then returned to the gas station in Ithaca and confirmed the resident was the missing person from the facility and brought her back. Review of a map revealed Highway 57 is approximately a half a mile away from the facility. The police officers drove her approximately 15 miles away to a gas station in Ithaca where the resident was there unsupervised for approximately 2 1/2 to 3 hours before being transported back to the facility. Review of the weather report for [NAME], Michigan on 11/24/22 revealed a high of 55 degrees and a low of 28 degrees. Review of a Wandering Risk Scale assessment for R111 with an effective date of 7/28/22 and an admitted [DATE] at 3:00 AM revealed she was rated as a High Risk to Wander. Another Wandering Risk Scale assessment with an effective date of 7/28/22 and an admitted [DATE] at 11:49 AM revealed R111 was At Risk to Wander. Review of a Wandering Risk Scale assessment for R111 with an effective date of 8/15/22 and an admitted [DATE] revealed the resident was a High Risk to wander. Review of a Wandering Risk Scale assessment for R111 with an effective date of 9/15/22 and an admitted [DATE] revealed she was a Low Risk for elopement. Section E. History of Wandering was marked as not having a history of wandering, making this assessment inaccurate. Review of an Elopement Evaluation dated 12/14/22 for R111 upon readmission to the facility revealed the resident was ambulatory and had risk factors marked for Resident is cognitive impaired, poor decision-making skills, and/or pertinent diagnosis (Example, dementia, Organic Brain syndrome, Alzheimer's, delusions, hallucinations, anxiety disorder, depression, manic depression, and schizophrenia). The boxes marked for the resident having a history of wandering into unsafe areas and making statements that they are leaving were marked. The Elopement Care Plan not initiated was marked and to see comments - Own responsible person. Review of a Resident Elopement Assessment for R111 dated 2/28/23 revealed the resident is At Risk for an elopement. Review of an email correspondence dated 3/13/23 from the NHA revealed R111 did not have a LOA safety assessment to leave the facility by herself or any education provided to her or her representative. Review of the Care Plan for R111 revealed no indication she was a previous CNA at a Nursing Home Facility or being at risk for wandering/elopements. On 8/3/22 revealed a focus for Behavioral Symptoms due to her diagnoses of Dementia with behavioral disturbances. On 9/1/22 another focus for Behavioral Symptoms due to the resident using psychotropic medications. The care plan overall is not a person focused care plan. On 2/28/23 at 1:00 PM, the Nursing Home Administrator NHA was notified of an Immediate Jeopardy that began on 11/24/22 when Resident #111, who was identified as an elopement risk, eloped from the facility unbeknownst to facility staff. On 3/1/23, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 2/28/23 a new elopement assessment was added to the observation task in Matrix by Corporate Social Worker. The DON and Admin were educated on the process of this assessment. Elopement policy was reviewed and deemed appropriate at this time. 2. On 2/28/23, Nurse 1 and 2 were educated by DON on new elopement assessment and scoring system. 3. Beginning on 2/28/23, Nurse 1 and 2 began all elopement assessments for residents to be completed by 3/1/23. 4. Beginning on 2/28/23 all residents will that were determined at risk will have an assessment, anyone at risk for exit seeking or wandering will have a wander guard placed if not on the memory care unit. Residents on the memory care unit do not require wander guards due to it being a secured unit. Care plans updated and revised as appropriate. 5. Beginning on 3/1/23, residents that are their own responsible parties and not at risk for elopement or are approved by responsible parties to go on LOAs will be reviewed to be following policy. 6. Beginning on 2/28/23, re-education will be provided by the regional corporate compliance nurse/Designee to the administrator regarding definition of an elopement. All staff will be re-educated on elopements and residents at risk and how to report concerns. 7. On 3/1/23 Elopement books placed on units for resident identification of elopement risk with face sheet and elopement assessment. The Social worker will be responsible for upkeep. 8. On 2/28/23, Resident #1 (R111) was notified of the concern. 9. On 2/28/23, the Medical Director was informed of the concern and agrees with the plan. Although the immediate jeopardy was removed on 3/1/23, the facility remained out of compliance at a scope of isolated and no harm that is not an Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency, all education had not yet been completed regarding elopements.

This citation pertains to intakes MI000132840 and MI000132219 Based on interview and record review, the facility failed to ensure 1 resident (Resident #114) was free from significant medication errors resulting in an Immediate Jeopardy (IJ) when transcription errors resulted in 1. Multiple dose changes of Clozaril without adequate laboratory monitoring or clinical rational, 2. A transcription error resulted in a dose reduction of a medication used to treat hypotension without adequate blood pressure monitoring and 3. When a transcription error resulted in a dose of Cymbalta that exceeded FDA guidelines without clinical rational. This deficient practice resulted in the high likelihood for R114 to experience over sedation, medication administration without physician knowledge and over-sight and lack of side effect monitoring when administering antipsychotic, antidepressant and cardiac medication and for R114 to experience psychiatric decompensation, newly emerging psychosis, rapid onset of agitation, neutropenia, and decreased efficacy of Clozaril when the medication is titrated again. This deficient practice continues to have a high likelihood to cause serious harm, injury and or death to all residents receiving medications in the facility. Findings: Review of the manufacturer guidelines Clozapine Rems revealed, Clozapine/Clozaril is a prescription medicine to treat people with schizophrenia who have not responded to other medicines. Clozapine may also reduce the risk of suicidal behavior . Clozapine can cause a blood condition (severe neutropenia), which can lead to serious infections and death. Neutropenia occurs when you have too few of a certain type of white blood cells called neutrophils. This makes it harder for your body to fight infections . Getting your blood tested is important because a low number of neutrophils may not cause any symptoms until you have an infection. Having a blood test helps your doctor know if you are more likely to get an infection. You must have regular blood tests before you start taking clozapine and during your treatment. This test is called absolute neutrophil count (ANC). If the number of neutrophils, or ANC, is too low, you may have to stop clozapine. Your doctor will decide if or when it is safe to restart clozapine . The Clozapine REMS will keep track of your blood test results so your doctor and pharmacist know if it is safe to fill your clozapine prescription. Remember: You must get your blood tested before you can receive clozapine from your pharmacy . Midodrine works by constricting (narrowing) the blood vessels and increasing blood pressure. Midodrine is used to treat low blood pressure (hypotension) that causes severe dizziness or a light-headed feeling, like you might pass out. midodrine is for use only when low blood pressure affects daily life. Midodrine may not improve your ability to perform daily activities. (accessed from Midodrine Uses, Side Effects & Warnings - Drugs.com on 3/24/23 at 8:00 AM) Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor antidepressant (SSNRI). Duloxetine affects chemicals in the brain that may be unbalanced in people with depression.Cymbalta is used to treat major depressive disorder in adults. It is also used to treat general anxiety disorder in adults and children who are at least 7 years old. Cymbalta is also used in adults to treat nerve pain caused by diabetes (diabetic neuropathy), or chronic muscle or joint pain (such as low back pain and osteoarthritis pain). Usual Adult Dose for Depression: Initial dose: 20 mg to 30 mg orally 2 times a day Maintenance dose: 60 mg per day, given either once a day OR 30 mg orally 2 times a day Maximum dose: 120 mg/day. Overdose symptoms may include vomiting, dizziness or drowsiness, seizures, fast heartbeats, fainting, or coma. (accessed from Cymbalta Uses, Dosage, Side Effects & Warnings - Drugs.com on 3/24/2023 at 8:00 AM) Review of the Fundamentals of Nursing revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition. Resident #114 (R114) Review of a facility Admission Record reflected R114 admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type, idiopathic hypotension, repeated falls, muscle weakness, candidiasis, hereditary motor and sensory neuropathy, intellectual disabilities, hyperlipidemia, restless leg syndrome, open-angle glaucoma, major depressive disorder, encephalopathy, somnolence, cerebral infarction, age related osteoporosis without current pathological fracture, hypothyroidism and anxiety. Review of an OBRA Admission Minimum Data Set (MDS) assessment dated [DATE] reflected R114 admitted to the facility from the community (Assisted Living Center) on 7/22/2022. A Brief Interview for Mental Status (BIMS) assessment determined R114 was cognitively intact as evidenced by a score of 13/15. The assessment indicated R114 was independent with bed mobility, transfers and walking; needed set up help only for eating, needed supervision and set up help only for dressing and toilet use and limited assistance from one person for personal hygiene. Review of an OBRA Quarterly MDS assessment dated [DATE] (three months after the admission assessment) reflected R114 was severely cognitively impaired as evidenced by a BIMS score of 7/15. R114 required supervision and one person to physically assist for bed mobility, required extensive assistance from one person for transfers, dressing and toilet use needed one person to physically assist her with walking once or twice in the lookback period. R114 was not steady but able to stabilize with human assistance with moving from a seated to standing position, walking and turning around and facing the opposite direction while walking and when moving on an off the toilet or during surface-to-surface transfers. Review of R114's referral pre-admission Medication Orders from an Assisted Living facility reflected the following pertinent orders: 1. Clozapine 25MG ODT (Oral Disintegrating Tab) Flazco 25 MG ODT Tab Give 3 tablets (=75MG) by mouth in the morning and give 1 tablet by mouth at bedtime. 2. Clozapine 100/ODT Tab Fazaclo 100/ODT Tab Give 2 tablets (=200MG) by mouth at bedtime. The total dose of Clozapine = 300MG/day 3. Duloxetine HCL 30 MG Cap Cymbalta 30 MG cap Give one Capsule by mouth in the morning. 4. Duloxetine HCL 60 MG Cymbalta 60 MG Cap Give 1 capsule by mouth in the morning. The total dose of Duloxetine = 90 MG/day 5. Midodrine HCL 5MG PO Tab Take 1 tablet 3 times daily morning, mid-day & 4 hours before bedtime. The total dose of Midodrine = 15 MG/day Review of R114's Medication Administration Record (MAR) for the month of July 2022 reflected the following orders: Clozaril Tablet 25MG (cloZAPine) Give 3 tablet by mouth one time a day for schizophrenia-Start Date-7-23-2022 0700-D/C Date-08/02/2022 cloZAPine Tablet Disintegrating 25MG Give 1 tablet by mouth at bedtime related to schitzoaffective disorder bipolar type(F25.0) -Start Date-7/28/2022 1900 cloZAPine Tablet Disinegrating 25MG Give 3 tablets by mouth one time a day related to schizoaffective disorder bipolar type (F25.0_-Start Date-07/29/2022 0700 FazaClo Tablet Disinegrating 100MG (cloZAPine) Give 200MG by mouth at bedtime for schizoaffective disorder -Start Date-7/22/2022 1900 -D/C Date-7/28/2022 1623 In summary, from 7/22/2022-7/27/2022 R114 received a total of 275MG of Clozaril. On 7/28/2022 R114 was given 100MG of Clozaril. On 7/29/2022 R114 began receiving 175MG of Clozaril per day. No documentation in the clinical record accounted for the significant dose reduction or increase. No evidence there was an increase in laboratory monitoring was found. Review of R114's MAR for the month of August 2022 reflected the following orders: cloZAPine Tablet Disintegrating 25MG Give 1 tablet by mouth at bedtime related to schizoaffective disorder bipolar type (F25.0)-Start Date-7/28/2022 1900 cloZAPine Tablet Disintegrating 25MG Give 3 tablet by mouth one time a day related to schizoaffective disorder bipolar type (F25.0)-Start Date 7/29/2022 0700 cloZAPine Tablet Disintegrating Give 200MG by mouth at bedtime related to schizoaffective disorder bipolar type (F25.0)-Start Date-08/02/2022 1900-D/C Date-8/11/2022 1808 cloZAPine Tablet Disintegrating Give 25MG by mouth at bedtime for mood related to schizoaffective disorder bipolar type (F25.0)-Start Date-8/11/2022 1900: Clozaril Tablet 25MG (cloZAPine) Give 3 tablet a day for schizophrenia -Start Date-7/23/2022 0700 -D/C Date-8/02/2022 1445 In summary: R114 received 175MG of Clozaril on 8/01/2022 then 375MG of Clozaril on 8/2/2022. R114 was hospitalized from 8/3/2022 until 8/11/2022. On 8/11/2022 R114 was given 50MG of Clozaril. Starting 8/12/2022 R114 was given a total of 125MG of Clozaril per day. No rational for the significant dose reductions and significant dose increases were found in the clinical record. No evidence R114's ANC was monitored more frequently after the significant dose increases were found. Review of R114's September 2022 MAR reflected the following orders: cloZAPine Tablet Disintegrating 25MG Give 1 Tablet by mouth at bedtime related to schizoaffective disorder, bipolar type (F25.0)-Start Date-7/28/2022 cloZAPine Tablet Disintegrating 25MG Give 3 tablet by mouth one time a day related to schizoaffective disorder, bipolar type (F25.0)-Start Date-7/29/2022 0700 cloZAPine Tablet Disintegrating Give 25MG by mouth at bedtime for mood related to schizoaffective disorder, bipolar type (F25.0)-Start Date-8/11/2022 In summary: R114 received a total of 125MG/day of Clozaril for the month of September 2022. Review of R114's October 2022 MAR from PCC reflected the following orders: cloZAPine Tablet Disintegrating 25MG Give one tablet by mouth at bedtime related to schizoaffective disorder bipolar type (F25.0) -Start date- 7/28/2022 1900 cloZAPine Tablet Disintegrating 25MG Give 3 tablet by mouth one time a day related to schizoaffective disorder bipolar type (F25.0)-Start Date- 7/29/2022 0700 cloZAPine Tablet Disintegrating 25MG by mouth at bedtime for mood related to schizoaffective disorder bipolar type (F25.0)-Start Date-8/11/2022 1900 Duloxetine HCl Capsule Delayed Release Sprinkle 30MG Give 1 capsule by mouth one time a day for major depressive disorder-Start Date-8/13/2022 0700 Duloxetine HCl Capsule Delayed Release Sprinkle 60MG Give 60MG by mouth one time a day for major depressive disorder-Start Date-7/23/2022 0700 Midodrine HCl Tablet 5MG Give 1 tablet by mouth 3 times a day for hypotension-Start Date-7/22/2022 1900 In summary: R114 was receiving 125MG/day of cloZAPine, 90MG/day of Duloxetine and 15MG/day of Midodrine. Review of R114's October 2022 MAR from the new electronic health record (EHR) reflected the following orders: clozapine tablet, disintegrating; 25MG; Amount to Administer: 75MG; oral Once a Day Start Date-End Date 10/03/2022-10/21/2022 (DC Date) clozapine tablet, disintegrating; 25MG; Amount to Administer: 3 tablets; oral Once a Day StartDate-EndDate 10/21/2022-Open Ended duloxetine capsule, delayed rlease (DR/EC); 30 mg; Amount to administer: 30 MG oral Once a Day StartDate-EndDate 10/3/2022-10/21/2022 duloxetine capsule, delayed release (DR/EC); 30 MG; Amount to administer: 3 capsules; oral Once a Day StartDate-EndDate 10/21/2022-Open Ended duloxetine capsule, delayed release (DR/EC); 60 MG; Amount to Administer: 60 MG; oral at bedtime StartDate-EndDate 10/03/2022-12/13/2022 midodrine tablet; 5MG; Amount to administer: 5MG; oral Twice a Day StartDate-End Date 10/3/2022-Open Ended In Summary: R114 was being given 75MG of Clozaril a day. No rational in the clinical record was found to describe the significant dose reduction. R114 also began receiving 150MG of duloxetine, a significant dose increase of the antidepressant without clinical rational. Finally, R114 was only given 10MG of the Midodrine beginning in October with the implementation of the new electronic health record. No evidence in the clinical record was found to explain the dose reduction of the blood pressure medication. No evidence was found that facility staff were monitoring R114's blood pressures on a regular basis. Review of a consultant psychology progress note dated 12/13/2022 reflected At this time would recommend D/C (discontinuation) of 60MG QHS (at bedtime) dose of Cymbalta as maximum recommended dosage is 120MG/day. Patient had been doing well on 90MG QD (every day) previously. Review of a Community Mental Health (CMH) Psychiatry note dated 12/14/2022 reflected Patient (R114) with a history of schizophrenia, who was seen by (name of a CMH physician) in the past for medication management, apparently patient psychotropic medications was managed at a rehabilitation facility, staff (CMH staff) has concerns about medication management and brought her to me to help with her psychotropic medications. There is also concern about her physical wellbeing as well, obviously during this quick encounter I cannot corroborate if there is any neglect or physical abuse per se, but the staff have concern about that. From a psychiatric standpoint, the patient is barely oriented x3, she seemed to be pleasant, she denies any auditory hallucination, but she has major cognitive limitations. I do not know what her baseline is, but at the moment she is unable to manipulate information, her fund of knowledge is poor, but she says she feels okay, noticeable upper extremity tremor, patient uses a walker to help her with her gait, her left arm has limited movement. I got most of the information from the chart and the staff, since the patient has major cognitive limitation. Patient with a history of treatment resistant schizophrenia, apparently dosing of medications has been changed during her admission to rehabilitation. I recommend the dosing of medications that worked for her in the first place, as stated above, as of now I am not sure where patient is to get psychiatric treatment, I recommend she continue with us here to manage her psychotropic medications, on any occasion the dose of Cymbalta at 150 mg as being given to he is above the FDA (Food and Drug Administration) guidelines, and thus has to be reduced to 90 mg which was a dose that she was taking previously, Clozaril has to be titrated up to the dose that she was taking previously, see medication list. During a telephone interview on 3/10/2023 at 9:41 AM, the Consultant Pharmacist reported that he would come to the facility for monthly reviews of resident medication regimens. The Pharmacist reported that he did not notice any issues with the Clozaril and would not pay close attention to that as it is required the prescribing physician and pharmacy must be registered in the Clozapine/REMS program. Review of documentation related to the medication transcription errors reflected the following conclusions as indicated by notes made by the Nursing Home Administrator as follows: The explanation for the Midodrine dose change from 15MG/day to 10MG/day was Matrix (EHR) change over was put in wrong by nurse order should have read 3 times a day. Clozapine was put in Matrix incorrectly by nurse order should have read 75MG AM and 25MG HS (hour of sleep) Discontinue original order at NOC (night) d/t (due to) day med (duloxetine) being at 90MG did not need NOC med at 60MG too. Review of Monitoring History required for the Clozapine/REMS program for R114 reflected that R114 did not have increased laboratory monitoring after significant dose increases. The record revealed an ANC (Absolute Neutrophil Count) was calculated and reported on 7/07/22, 8/04/22, 8/21/22, 9/29/22. An ANC was not reported in October or November 2022. The record reflected that R114 refused to have labs drawn in December 2022 with the records indicating Not reported(Patient Refused). On 3/14/2023 the Administrator was verbally notified and received written notification of the Immediate Jeopardy that was identified on 3/14/23 due to the facility's failure to ensure medications were transcribed and administered appropriately and following FDA dispensing regulations for Clozaril. A written plan for removal for the immediate jeopardy was received on 3/14/23 and the following was verified on 3/16/23: 1. All residents are at risk with this concern (transcription errors). 2. On 3/14/23 all residents on Clozaril were reviewed to ensure all labs were in place and monitored at appropriate frequency. 3. On 3/14/23 all residents on Clozaril were reviewed to ensure orders were correct. 4. On 3/14/2023 all residents on Clozaril were reviewed to ensure all orders matched the MAR. 5. On 3/14/2023 all residents on Clozaril were reviewed for any adverse effects if concerns with medications were found. 6. On 3/14/2023 all residents on Cymbalta were reviewed to ensure current monitoring orders were correct. 7. On 3/14/23 all residents on Cymbalta were reviewed to ensure orders were correct 8. On 3/14/23 all residents on Cymbalta were reviewed to ensure orders matched the MAR 9. On 3/14/23 all residents on Cymbalta were reviewed for any adverse effects if concerns with medications were found. 10. On 3/14/23 all residents on Midodrine were reviewed to ensure all blood pressure checks were in place. 11. On 3/14/23 all residents on Midodrine were reviewed to ensure orders were correct. 12. On 3/14/23 all residents on Midodrine were reviewed to ensure all orders matched the MAR 13. On 3/14/23 all residents on Midodrine were reviewed for any adverse effects if concerns with medications were found. 14. On 3/14/23 all resident orders were reviewed to ensure they matched the MAR. 15. Beginning 3/14/23 all residents that are requiring labs were reviewed to ensure labs were ordered as appropriate. 16. Beginning 3/14/23 all residents with orders were reviewed to ensure appropriate parameters/monitoring are in place for medications ordered. 17. Beginning 3/14/23 licensed nurses were educated on proper medication administration, review of narcotic dispensing, lab ordering, blood pressure monitoring, proper processing of new medication orders and the 5 rights of medication administration. 18. On 3/14/23 the Medical Director was notified of deficient practice and in agreement with plan. 19. On 3/14/23 an Ad-Hoc QA (Quality Assurance) meeting was held with the NHA (Nursing Home Administrator), DON (Director of Nursing), medical director and nurse consultant to review action steps and results to ensure compliance. Although the Immediate Jeopardy was removed on 3/14/2023, the facility remained out of compliance at a scope of pattern and severity of likelihood for harm due to the fact that not all facility staff have received education and sustained compliance has not been verified by the state agency.

Based on observation, interview and record review, the facility failed to prevent abuse, and protect residents from continued abuse, due to widespread system failures beginning with the failure to complete a facility assessment to determine resident acuity and appropriate number of staff and the lack of properly trained, certified, and orientated staff in sufficient numbers to provide care. This deficient practice resulted in an Immediate Jeopardy (IJ) beginning on 9/4/21 when the facility failed to prevent resident to resident abuse between R4 and R23 and for Residents R2, R5, R27, R93, and R43, as a result of the facility's failure to prevent, thoroughly identify, protect residents, investigate, and report abuse to the State Agency. This deficient practice created the high likelihood for all residents residing in the facility at risk for serious harm, injury, and/or death from abuse. Findings: Review of the facility policy Resident Abuse/Neglect last revised 1/30/2019 reflected The facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to the Administrator or to the Director of Nursing Services immediately. The policy defined abuse and neglect and detailed the Abuse Prevention Program that incorporated all required elements of an effective abuse and neglect prevention program consistent with CFR 483.12 Freedom from Abuse, Neglect, and Exploitation regulatory groups for Long Term Care Facilities. Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 (R5) Review of an Admission Record revealed R5 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 01/23/22 at 01:09 P.M., R2 was visibly agitated, aggressive, and destructive of facility property. R2 was wielding a butter knife and used it to remove the key pad off of the wall and was using the knife to attempt to break through the lock on the double doors. During an interview and observation 01/23/22 at 01:30 P.M., CNA PP reported that she was the only staff member on the MCU for 11 Residents. CNA V was pulled to the East/West Unit. There was 1 LPN on the unit. At that time, R2 continued to be behavioral/destructive. CNA PP reported that she was working with a resident that had increased behaviors (Resident #41) which placed the rest of the residents at increased risk because of the lack of supervision. CNA PP reported more staff were needed to keep the residents on the Memory Care Unit safe. Review of R2's Behavior Note dated 1/23/22 at 4:28 P.M. revealed, Resident became agitated during lunch time. She went to her room and packed her clothes up in a bag and box. She went to the electronic/keypad box attached to the wall and took out a butter knife she had kept from her meal tray and began trying to pry the box off the wall using the butter knife. Staff noticed what she was doing and began walking towards her to intervene, but she managed to pull the box completely off the wall. One Staff member stayed with resident as she was repeatedly shoving at the door handles in an attempt to open them, and the other staff member went to get assistance from maintenance to repair the torn off electronic box. Resident refused to give staff the butter knife. Maintenance repaired the box on the wall. Resident took her things back to her room, unpacked, and butter knife was removed from room. Resident redirected with ice cream and apple juice. Refused to participate in activities. Will continue to monitor and follow up as needed. (Indicating an increase in aggressive behaviors.) R2 and R5 remained roommates on 1/23/22 and 1/24/22 despite observed and documented threatening behaviors from R2, placing other residents at risk for abuse. During an interview on 01/24/22 at 12:30 P.M., R5 reported to this surveyor that her roommate (R2) had assaulted her the previous day (1/23/22). R5 was tearful and anxious when reporting the allegation of resident to resident abuse. On 01/24/22 at 12:45 P.M. this surveyor reported to the NHA the allegation of R2 assaulting R5. Review of R5's Incident Note dated 1/24/22 at 6:15 P.M. revealed, (R5) stated that her roommate placed her hand on R5's right wrist. She demonstrated a clasped hand over her right wrist. No Injury noted. R5 denied discomfort or fear. When questioned more (R5) stated that it happened last night around bedtime. She stated that her roommate wanted her clothes. (R5) requested to move rooms .(R5) stated she didn't tell anyone the night before . This note was struck out indicating a cancellation of the entry. During an interview on 01/25/2022 at 1:23 P.M., The Director of Nursing (DON) reported she was told to strike out the note and fill out the concern form per the Nursing Home Administrator. DON reported she did not have access to reporting to the State Agency. DON reported that allegations of abuse are to be reported to the State Agency within 2 hours. Review of an Interdisciplinary Team Note dated 1/31/22 04:43 A.M. (8 days after the abuse), revealed, On 1/24/22 at approx 330pm it was reported by her roommate that (R2) had gripped the right wrist of her roommate at that time. According to the roommate, she was in (R2's) pathway in front of her closet blocking her clothes. Her roommate stated that (R2) was trying to get her clothes. The two residents were immediately separated by staff. The roommate's room was changed. (R2) has been monitored for any changes. No mood, appetite or behavior changes were noted in the last 72 hours. Her care plan was updated to reflect that she is to only use spoons on her meal trays for safety. (Psychiatric Contracted Group) and the physician have evaluated her mood and behaviors. (R2) can be understood at times with short sentences and phrases in English. Activities continues to work with her 1:1 when she participates. She has been observed sleeping in her room without a roommate since this incident. Guardian aware. No further incidents or behaviors has been noted at this time. Staff continues to anticipate and meet her needs and keep her and others safe. (This note indicated R2 had no mood, appetite or behavior changes noted in the last 72 hours but was unclear as to the time frame being referenced. On 1/23/22 R2 exhibited dangerous behavior using a butter knife and was difficult to redirect). During an interview on 2/1/22 at 11:41 A.M. (9 days after the abuse), Physician Z reported that he completed an assessment on R2 following the allegation of abuse. Physician Z reported that she exhibited behaviors of having a difficult past with keeping her items packed and becoming protective of her items. Physician Z reported that because of her possessive behaviors with her items and her space she would have benefited from having a private room. Physician Z reported that R2 may have become overwhelmed to the point she felt she had to protect her items which resulted in the physical altercation between R2 and R5. Review of R2's Physician Note dated 2/1/22 revealed, (R2) was seen today in regard to a recent resident to resident in which she grabbed another residents arm. (R2) is noted to have severe dementia and paranoia. There is a history of her with increased anxiety each day near noon. it is apparent that there was no ill intent. I would suggest she be in her own room so that she does not feel the need to protect her belongings. Psych will continue to follow. Review of the Facility Reported Incident sent to the State Agency revealed the Date/Time Incident Discovered 1/24/22 at 3:30 PM .Date/Time Incident Occurred 1/23/22 at 11:00 PM .Submitted Date/Time: 1/24/2022 at 4:00 PM . (Indicating an inaccurate time the abuse was discovered and abuse not reported within the 2 hours per the regulatory requirements.) Resident #4 (R4) Review of an Admission Record revealed R4 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 (R23) Review of an Admission Record revealed R#23 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's Nursing Note dated 9/4/21 at 9:40 A.M. revealed, Upon assessment writer observed an indentation in the front left side of resident's head. Writer palpated entire head and no other injuries noted. Resident does state It hurts when you do that .Writer asked resident what happened? Resident stated Last night (R23) came in my room and took my blue blanket. I (sic) grabbed it from me and he started hitting me. I just blocked. I didn't hit him back. Writer informed manager of information provided by resident. Doctor made aware. Review of R4's Nursing Note dated 9/4/21 at 11:00 A.M. revealed, This writer was notified by (Licensed Practical Nurse LPN EEE) that (R4) had stated that he had gotten into a fight. This writer questioned resident who stated (R23), the guy who walks around and goes through people's stuff. He wanted my blue blanket. Per (LPN EEE), resident stated that (R23) had punched him repeatedly and that resident had blocked these punches. (LPN EEE) reported that resident stated this happened last night but was not reported by ad staff to her. Resident with two abrasions on his face from previous documented incident (bridge of nose and right eyebrow). (LPN EEE) noted indentation on left frontal lobe region that she had not noticed on previous shift .Call placed to DON (Previous DON FFF) who stated that this area is not a new finding and his (sic) been present since admission. No staff witnessed alleged incident .Call placed to (Previous NHA HHH), administrator and informed her of all above findings. Instructed (LPN EEE) to contact Dr to notify of incident. Review of the facility Incident and Accident Investigation dated 9/4/21 at 11:15 P.M. revealed, Alleged Incident .Nurse (RN GGG) called and stated (R4) stated he had gotten into a fight. Statement from all staff stated nothing unusual happened .Reporting-To whom was it reported: (Previous DON FFF) Date 9/4/21 Time 11AM .2. Was the resident affected by the incident interviewed-NO . Review of the facility Investigation Follow-Up dated 9/4/21 revealed, (RN GGG) called and said she thought there was a resident to resident altercation .Family Notified 9/2/21 at 11:15pm .Physician Notified 9/2/21 (Time Blank). Review of the State Agency Facility Reported Incident Portal revealed this allegation of Resident-to-Resident abuse was not reported to the State Agency. Verified that it was not reported to the State Agency as of 2/10/22. Review of R23's Care Plan revealed it was not updated following the allegation of resident-to-resident abuse. Review of R4's Care Plan revealed it was not updated following the allegation of resident-to-resident abuse. Resident #27 (R27) Review of an Admission Record revealed R27 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R27's Nursing Note dated 12/18/21 revealed, Resident becoming increasingly aggressive despite changes in psychiatric meds. CNA (Certified Nursing Assistant) observed him whipping another resident in the face with a pair of sweatpants this shift .Contacted (Previous DON FFF) to notify her of transfer status and residents DPOA (Power of Attorney). Review of the facility Temporary Separation from Other assessment dated [DATE] revealed, per nurses note the resident became increasingly aggressive and was observed whipping another resident in the face with a pair of sweatpants .injury to the other residents face could have occurred. Fear could have occurred .(R27) will be referred to (Psychiatric Consulting Group.) Review of the Facility Reported Incident sent to the State Agency revealed the Date/Time Incident Occurred 12/18/21 .Submitted Date/Time: 1/24/2022 at 9:30 PM . (Indicating the abuse was not reported within the 2 hours per the regulatory requirements.) During an interview on 01/25/22 at 10:02 A.M., CNA PP reported that it was difficult to manage the residents' behaviors with insufficient staff. CNA PP reported that in the mornings there were only 2 CNA's scheduled to work and when 1 CNA went on break it left the other CNA to care for all of the residents on the Memory Care Unit. CNA PP reported that it was difficult to manage the residents' behaviors with insufficient staff. During an observation and interview on 1/26/22 at 2:02 P.M., CNA V reported that he was alone on the unit because CNA OO was on break. CNA V reported he was doing the best he could but the lack of staff resulted in the worsening of resident behaviors which occurred daily. Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. During an interview on 1/23/22 at 1:00 P.M., R93 reported a nurse was very rude to her and flipped out over pills left in a medication cup at her bedside and the nurse accused her of selling drugs. According to R93, she does not want that nurse in her room again because she made her feel depressed and jittery and has been so upset about it that she called her husband crying about the incident. R93 reported that CNA P witnessed the abuse. During an interview on 1/23/22 at 2:42 P.M., CNA P reported that on 1/21/22 R93 had asked CNA P to remove wraps from her legs and RN I told R93 that if she didn't eat so much and would get out of bed, she wouldn't have these problems which left R93 in tears. CNA P said R93 told RN I to be nicer to her when she gives her medications. CNA P said she reported the abuse to RN/Unit Manager G immediately. CNA P said that RN G said she would take care of it. CNA P said she did not notify the Nursing Home Administrator (NHA) of the alleged abuse because she did not have her phone number. CNA P said she was never asked to provide a statement about the abuse after making her report to RN G. CNA P said that she reported the allegation of abuse to RN G immediately but had been educated that she has between 12-24 hours to report allegations of abuse and neglect. During an interview on 1/24/21 at 9:12 A.M., the NHA reported that she started as interim administrator on 12/21/21 and did not have any open Facility Reported Incidents (FRI's). The NHA said she was the facility abuse prevention coordinator and was responsible for reporting all allegations of abuse or neglect. The NHA said she was not aware of an allegation of abuse perpetrated by RN I and reported by CNA P to RN G on 1/21/22. Review of a facility (Facility Name) Center Staffing Reports from 1-23-22-1-24-22 reflected that RN I continued to work at the facility despite the alleged report of resident verbal abuse. Review of a Grievance Form dated 1/24/22 reflected R93 reported A nurse made her 'feel awful', 'I felt depressed'. When asked if she remembered who it was and what the nurse looked like she replied, It was (name of a nurse other than RN I). She has dark long hair and wears it back and wears glasses. Her voice is medium-deep? I told my husband last week and I told the state people. When asked about the nurse currently working with her (RN I) she stated, 'I like (RN I)'. Review of an Investigation Follow-Up form dated 1/24/22 reflected a description of the situation as noted in the Grievance Form. The summary of the investigation reflected Agency nurse (RN I) on shift was interviewed. CNA (CNA P) was interviewed via phone from 9:40 a.m. -9:52 a.m. with UM (RN G) present via phone. Agency Nurse (RN I) sent home pending investigation. (R93) was interviewed with UM (RN G) from 9:33 a.m. - 9:40 a.m. in room door closed. (R93) husband was interviewed via phone 12:45 p.m.-12:54 p.m. Another nurse was interviewed with similar description. Review of a Suspension Notice reflected RN I was suspended for alleged verbal abuse pending investigation on 1/24/22. No evidence that another nurse interviewed with similar description (as noted in the Investigation Follow-Up form) was suspended pending investigation was provided. No documented witness statements pertaining to the interviews conducted were provided. Additionally, only three residents were interviewed about concerns pertaining to abuse and neglect. Resident #43 (R43) Review of a facility Admission Record reflected R43 admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a discharge Minimum Data Set (MDS) assessment dated [DATE] reflected R43 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15 and needed extensive assistance from two people for bed mobility and transfers and required extensive assistance from one person for locomotion on and off the unit, dressing, toilet use and personal hygiene. Section E-Behavior reflected R43 did not exhibit hallucinations or delusions indicating [CONDITION(S)]; did not display behavioral symptoms such as physical or verbal behaviors directed toward others or other behavioral symptoms. The assessment did not reflect R43 rejected care, wandered or behaved in such a way as to significantly impact the care of others or disrupt the care or living environment. Review of an Elopement Evaluation dated 10/4/21 at 5:00 P.M. reflected R43 was assessed as being at risk for eloping from the facility due to a history of attempts to leave the facility without informing staff, verbally expressing a desire to go home, with wandering behavior likely to affect the privacy, safety or well-being of self/others. Review of a Nursing Note dated 10/5/21 at 1:06 A.M. reflected (R43) had an altercation with roommate. Resident went through roommate's belongings. Resident showed increased aggression. Resident was moved to a separate room. (MD Z) notified of behavior and ordered resident to get a nicotine patch for withdrawal. [MEDICATION(S)] 50 mg to help resident with [CONDITION(S)]. Review of a Physician Note dated 10/6/21 at 12:41 P.M. revealed Note Text: Admission not-Resident was seen on 10/5/21 at 8:00 a.m. The note specified Last night he (R43) had a problematic interaction with another resident. Review of a Behavior Note dated 10/5/21 at 3:46 A.M. reflected R43 was again observed going into other resident rooms/area looking for things. R43 threw a trash can at a nurse and became aggravated when additional staff attempted to calm the resident. The note specified It is a struggle to keep him out of other resident's rooms. He is very mobile in his wheelchair and moves himself about as he wants to. Review of a Behavior Note dated 10/6/21 at 12:03 P.M. reflected Resident locked himself in breakroom, hitting, pinching, spitting at staff. Resident went through others belongings calling residents names. Intervention that was used 1:1 Review of a Nursing Note dated 10/6/21 at 3:53 P.M. reflected Resident noted in breakroom with door closed. Resident is wandering threw staff items (sic). Resident obtained staff member's medication and purse. Resident is combative with staff, bruised staff member arm, ripped staff member shirt. Resident spat on staff, Resident is undirect able (sic). Resident has multiple move swings within twenty to thirty minutes (sic). From violet outbreaks to uncontrollable laughing crying (sic). Resident was petition to psych hospital. 911 called. Resident transported via ambulance x2 attendance. Review of ED (Emergency Department) Provider Notes-Encounter Notes dated 10/6/21 at 10:58 A.M. reflected (R43) Presents from (Name of Facility) for agitation. Patient arrived from acute care hospital in Detroit on evening of 10/4. Known to have behavioral issues and [CONDITION(S)] at baseline. Aggressive with staff starting night of arrival. Struck another resident on 1st night. Placed in private room. Struck staff. Spit at staff. Ripped a staff member's blouse off. Verbally and physically abusive to residents and staff. Locked himself in a room, stating he was going to die. Attempted to take an employee's HCTZ (hydrochlorothyizide-a prescription medication used to treat high blood pressure and fluid retention) and [MEDICATION(S)] (a prescription medication used to treat gout and kidney stones) from their locker. Staff able to get patient to spit out all but 1 pill of each. Counted pills and confirmed ingestion amount. Patient would not allow EMS (Emergency Medical Services) or ED RN to take vitals. Mumbling here. Requests for incident and accident reports and evidence the facility had completed a Facility Reported Incident (FRI) to the state agency pertaining to the resident-to-resident altercations was made via email communication on 2/1/22. As of the time of exit on 2/3/22, the Acting NHA said she did not have any of the requested information pertaining to R43. The facility administrative team was notified on 01/31/22 at 10:53 A.M. of the Immediate Jeopardy that was identified on 1/27/22 and began on 9/4/2021 when the facility failed to prevent abuse, and protect residents from continued abuse, due to widespread system failures beginning with the failure to complete a facility assessment to determine resident acuity and appropriate number of staff and the lack of properly trained, certified, and orientated staff in sufficient numbers to provide care. This deficient practice resulted in an Immediate Jeopardy (IJ) beginning on 9/4/21 when the facility failed to prevent resident to resident abuse between R4 and R23 and for Residents R2, R5, R27, R93, and R43, as a result of the facility's failure to prevent, thoroughly identify, protect residents, investigate, and report abuse to the State Agency. This deficient practice created the high likelihood for all residents residing in the facility at risk for serious harm, injury, and/or death from abuse. As of 2/3/22 the facility had not submitted an acceptable plan to remove the Immediate Jeopardy and the State Agency was unable to verify the residents living at the facility were safe from serious injury, serious harm and/or death.

Based on observation, interview and record review, the facility failed to provide an environment which supported and enhanced each resident's Quality of Life, resulting in an Immediate Jeopardy that began on 1/23/2022 due to the cumulative, dehumanizing, and widespread effect of noncompliance identified at but not limited to abuse, staffing, qualified staff, ADL care, social services, unnecessary [CONDITION(S)] meds, accidents and hazards and governing body. This noncompliance was found to be pervasive throughout the facility and created an environment that reflected a complete disregard of one or more residents' individuality and Quality of Life, which has caused or is likely to cause serious harm related to one or more residents' physical and psychosocial health, self-worth, self-esteem, and well-being. Findings: An unannounced onsite annual recertification and complaint survey was started on 1/23/22 at 10:00 A.M. During an annual survey conducted from one 1/23/22 through 2/3/22, the following findings constituting Immediate Jeopardy were identified: 1. The facility failed to prevent physical abuse, and protect residents from continued abuse, due to widespread system failures beginning with the failure to complete an annual facility assessment to determine resident acuity and appropriate number of staff and the lack of properly trained, certified, and orientated staff in sufficient numbers to provide care to meet resident needs (Refer to noncompliance cited at 483.12, F600-Abuse). 2. The facility failed to ensure residents were provided timely and consistent care for activities of dailing living (ADL) including assistance with feeding, grooming, personal and oral hygiene, incontinence care and bathing or showers for residents per the standards of practice. (Refer to noncompliance cited at 483.24, F677-ADL Care). 3. The facility failed to (a) ensure that daily staffing levels were based on acuity and residents needs, (b) failed to identify and implement indivualized interventions and functional systems to protect residents at risk for elopement, (c) failed to identify and implement interventions to prevent choking hazards, falls, and provide a working call light system for a cognitively impaired resident, and (d) ensure one of two crash carts were in full functioning order and all staff knew where to locate the crash carts. (Refer to noncompliance cited at 483.25, F689-Accidents and Hazards). 4. The facility failed to provide necessary oxygen care according to standards of practice when 1 resident was not receiving ordered oxygen, nursing was notified and did not assess the resident, and the resident became cyanotic. (Refer to noncompliance cited at 483.25, F695-Respiratory Care). 5. The facility failed to provide an adequate amount of staff to meet the basic needs of the residents related to: 1) ADL care, 2) pressure ulcer prevention/healing, 3) medication administration, 4) dementia care, 5) food service, and 6) financial management and administrative duties (social work, business office management, accounts payable). (Refer to noncompliance cited at 483.35, F725-Sufficient Staffing). 6. The facility failed to ensure residents receiving anti-psychotic medications were closely monitored for adverse effects, were educated on the risk versus benefits of the medications, and were provided a gradual dose reduction,or documented rationale for why gradual dose reduction should not be attempted at that time, resulting in the potential for prolonged use and/or unnecessary use of antipsychotic medications. (Refer to noncompliance cited at 483.45, F758-Unnecessary/[CONDITION(S)] Medication Use). 7. The facility failed to store, prepare, distribute, and serve food in a manner that ensured resident safety from foodborne illness. Staff in the kitchen were not able to demonstrate basic food service knowledge, including proper holding and cooking temperatures, a process for reheating foods, or sanitizing procedures for equipment. Potentially hazardous foods were not being cooked to proper temperatures, not being held at proper holding temperatures, and not being reheated to proper temperatures to prevent foodborne illness. Food service equipment was not sanitized. (Refer to noncompliance cited at 483.60, F812-Food Procurement, Store/Prepare/Serve-Sanitary). 8. The Governing Body failed to ensure the facility was managed and functioned in a manner that ensured residents attained/maintained their highest practicable well-being as evidenced by: 1. inadequate number of and unqualified staff to meet the residents daily needs, 2. no facility educator in place and no skills checklist/adequate orientation for new hires to ensure they are adequatley trained and able to meet the resident needs, 3. failure to ensure staff were properly trained to meet the unique needs of each resident and ensure residents were turned/repositioned timely and consistent ADL care was provided to prevent redevelopment/development and/or worsening of pressure ulcers; 4.) failure of corporate managers to not only be in place but to be accessible to staff and unaware of day to day resident/staff needs, 5) Failure to provide sufficient quantities of basic necessities such as food and linens. (Refer to noncompliance cited at 483.70, F837-Governing Body). 9. The facility failed to implement individualized care planned interventions to meet R5 and R2's dementia/behavioral care needs, addressing de-escalation techniques, known behaviors, and diversional activities resulting in a resident to resident physical abuse (R2 assaulted R5, R2 also displayed aggressive, knife wielding assaultive behavior on 1/23/22). This deficient practice resulted in diminished quality of life for residents with mental illness and dementia. All 11 residents on the unit were potentially at risk for serious harm (Refer to noncompliance cited at 483.40, F744-Treatment and Services for Dementia). 10. The facility failed to provide medically related social services to attain and maintain the mental and psychosocial health of residents due to the absence of a qualified employee working in this role since 12/6/21 resulted in absence of a behavior management program for residents with behavioral issues; a system to monitor residents on anti-psychotic medications; coordination and transition of care and the maintenance of resident right and quality of life.(Refer to noncompliance cited at 483.40, F745-Medically Related Social Services). In addition to the above referenced Immediate Jeopardies identified, systemic noncompliance was also found pertaining to Resident Rights (F568, F578, F580, F582, and F584), Abuse (F607, F609, and F610), Comprehensive Resident Centered Care Plans (F656, F657, and F658), Quality of Life (F679), Quality of Care (F684, F686, F691, F692, and F693), Nursing Services (F726 and F730), Pharmacy Services (F760), Administration (F838), QAPI (F867), and Infection Control (F880). Facility administration was notified on 1/31/2022 at 10:53 A.M. of the Immediate Jeopardy identified on 1/27/22 at F675 due to the failure to provide an environment which supported and enhanced each resident's Quality of Life. The facility administration was notified that the Immediate Jeopardy began on 1/23/2022 due to the cumulative, widespread effect of noncompliance identified at but not limited to abuse, sufficient staffing, qualified staff, ADL care, social services, unnecessary [CONDITION(S)] meds, accidents and hazards and governing body. This noncompliance was found to be pervasive and created an environment reflecting a complete disregard of one or more residents' Quality of Life, which has caused or is likely to cause serious harm related to one or more residents' physical and psychosocial health, self-worth, self-esteem, and well-being. As of the date of the survey exit, 2/3/22 at 4:00 P.M., the facility had not developed an approved plan to remove the Immediate Jeopardy and the State Agency was not able to verify the residents living at the facility were free from the high likelihood for serious injury, serious harm and or death.

Based on observation, interview, and record review, the facility failed to provide timely and consistent ADL (activities of daily living) care to 9 residents (Resident #42, Resident #148, Resident #145, Resident #20, Resident #143, Resident #146, Resident #151, Resident #17, and Resident #93, R#28), resulting in an immediate jeopardy, when beginning on 01/23/22, the facility failed to provide staffing to meet the ADL needs of the residents and allowed residents to (a) lay in their urine and feces for extended periods of time, (b) not receive meals timely or eating assistance if required, (c) go un-bathed, unkempt, and to be malodorous, (d) remain in bed for over 24 hours, and (e) unnecessarily utilize a bed pan for toileting. This deficient practice also resulted in feelings of embarrassment, humiliation, and diminished self esteem. Findings: Resident #42 (R42) Review of an Admission Record revealed R42 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R42, with a reference date of 11/30/21 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R42 was cognitively impaired. Review of the Functional Status revealed that R42 required extensive 2-person assistance for bed mobility, transferring, and toileting. During an observation on 01/23/22 at 10:27 A.M., R42 was in her room sitting up in a wheelchair. The left side from her armpit to her ankle was saturated with urine and the bed linen was saturated with urine. R42's room smelled strongly of urine. R42 cried and voiced frustration and humiliation at the lack of assistance to the bathroom and lack of staff to assist with incontinence care. During an interview on 02/01/22 at 12:15 P.M., Certified Nurse Aide (CNA) BBB reported that facility CNA's were ordered to give all resident in the facility a shower beginning 01/31/22 but were not educated on the reason why all residents needed a shower. CNA BBB reported that they were given a skin assessment sheet on 01/31/22 to begin using to track and assess residents skin. CNA BB reported being directed by the corporate staff to give residents showers even if they refused and if residents refused showers they should be sent to the hospital for a psychiatric evaluation. Resident #148 (R148) Review of an Admission Record revealed R148 was a [AGE] year-old male, originally admitted to the facility on [DATE], following a 63-day hospitalization for aspiration pneumonia, urinary tract infection and altered mental status. R148 had a gastrostomy tube for hydration and nutrition and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 01/24/22 at 9:50 A.M., R148's brief, gray sweatpants, bed sheet, and blue pad were saturated with urine. During an observation on 01/24/22 at 10:33 A.M. and 10:51 A.M., R148's brief, gray sweatpants, bed sheets, and blue pad were saturated with urine and the room had a strong urine smell. During an observation on 01/24/22 at 11:48 A.M., R148's brief, gray sweatpants, bed sheets, blanket, and blue pad were saturated with urine and the room had a very strong odor of urine. During an observation on 01/24/22 at 12:43 P.M., R148's brief, gray sweatpants, bed sheets, blanket, and blue pad were saturated with urine and the room had a very strong odor of urine. During an observation on 01/24/22 at 2:08 P.M., R148's brief, gray sweatpants, bed sheets, blanket, and blue pad were saturated with urine and the room had a very strong odor of urine. During an observation on 01/24/22 at 2:50 P.M., R148's brief, gray sweatpants, bed sheets, blanket, and blue pad were saturated with urine and the room had a very strong odor of urine. During an interview on 01/26/2022 at 4:59 P.M., CNA D reported that many residents were left wet for extended periods of time due to the lack of staffing. CNA D also indicated that R148's scrotum was bright red with possible MASD (moisture associated skin damage) because R148 was often found in a urine saturated brief. During an observation on 01/31/22 at 08:06 A.M., R148's sheets and gown were soaked in urine. At 8:12 A.M., CNA DDD entered the room and provided peri care. With R148 laid flat, naked, and fully exposed, CNA DDD left the room to retrieve a clean gown and sheets. Resident #145 (R145) Review of an Admission Record revealed R145 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 01/24/22 at 1:37 P.M., the call light was activated for R145. During an observation on 01/24/22 at 2:08 P.M., the call light for R145 remained activated. During an observation on 01/24/22 at 02:29 P.M., the call light for R145's room remained activated. When asked about the residents' needs, the R145 responded I'm really wet, please help me. During an observation on 01/24/22 at 02:50 P.M., the call light remained on for R145. During an observation on 01/26/22 at 05:43 P.M., the call light activated for R145. Corporate Nurse (CN) JJ asked R145 what the need was and the R145 responded I'm wet. CN JJ responded, ok, I will get an aide to help you. At 6:00 P.M., the surveyor asked CN JJ if an aide had been alerted to the needs of R145 and CN JJ responded, No, I was just gonna tell someone. Resident #20 (R20) Review of an Admission Record revealed R20 was a [AGE] year old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20 was dependent on staff for all ADL care. During observations on 01/23/22 from 10:00 A.M. to 4:30 P.M., R20 remained in bed. During an observation on 01/24/22 at 8:09 A.M., R20 laid in bed, was unkempt, hair was greasy, and the resident was malodorous. During observations on 01/24/22 from 7:30 A.M. to 5:00 P.M., R20 remained in bed. During an observation on 01/25/22 at 10:20 A.M., R20 laid in bed, was unkempt, hair was greasy, resident was malodorous and wearing the same shirt as 1/24/22. During an observation on 01/25/22 from 7:50 A.M. to 11:49 A.M., R20 remained in bed. Resident #143 (R143) Review of an Admission Record revealed R143 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 01/26/22 at 9:57 A.M., R143 loudly cried and screamed I need to poop. At 10:07 A.M., CNA O obtained a bed pan and assisted R143 onto the bed pan. CNA O stated that R143 does not normally use a bed pan but there wasn't enough staff to get the resident to the bathroom safely. R143 required 2 staff persons to transfer to the bathroom. During an observation on 02/01/22 at 11:00 A.M., R143 yelled help several times. R143's call light laid on the floor out of reach and out of sight of the resident. No staff were visible on the unit and the alarm at the nurse desk sounded loudly, making R143's screams for help inaudible at the nurses desk. Out of concern for R143's safety, the surveyor alerted staff. Staff entered R143's room and stated, oh (R143) needs to get off the bed pan. Resident #146 (R146) Review of an Admission Record revealed R146 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R146 was dependent on staff for hygiene, eating, transfers, and going to the bathroom. During an observation on 01/23/22 at 11:52 A.M., R146 tried to communicate a need, reached down to the brief and slid a hand down into the brief. R146 stated yeah the brief needed to be changed. During an observation on 01/23/22 at 12:01 P.M., R146 tugged at the brief, stated bath and held her nose and pointed toward the groin. During an observation on 01/23/22 at 1:19 P.M., R146 had not yet received a lunch tray. At 1:29 P.M., after all other residents on the west hall had completed lunch, staff entered the residents room and assisted R146 with lunch. During an observation on 01/25/22 at 10:20 A.M., R146 wore the same shirt as 01/24/22, still soiled with food stains. During an observation on 01/31/22 at 09:13 A.M., staff provided R146 with assistance to eat breakfast. Staff indicated that R146 eats last on the hall because staff are required to provide assistance and due to lack of staff, R146 had to wait until everyone else had breakfast. Resident #151 (R151) Review of an Admission Record revealed R151 was a [AGE] year old male, admitted to the facility for long term care on 01/11/22, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R151 was contracted and the elbows and wrists, required 2 staff person assistance with a mechanical lift for transfers, and required assistance from 1 staff person to eat and drink. During an observation on 01/23/22 at 1:16 P.M., R151 had not yet received lunch, while the other residents on the hall had completed lunch. At 1:31 P.M., CNA O assisted R151 with lunch and stated that there was not enough staff to assist everyone with lunch in a timely manner. During multiple observations on 01/24/22, R151 laid in bed continuous for 8.5 hours. During multiple observations on 01/25/22, R151 laid in bed continuous for 9 hours. When asked R151 acknowledged being in bed for over 24 hours and could not remember the last time being out of bed. During an interview on 01/25/22 at 10:02 A.M., CNA PP reported they could not shower, reposition, and change residents as required because of the lack of staff. Resident #17 (R17) Review of a facility Admission Record reflected R17 admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission Minimum Data Set (MDS) assessment dated [DATE] reflected R17 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15 and needed extensive assistance from two people for bed mobility and transfers and required extensive assistance from one person for dressing, toilet use and personal hygiene and bathing. During an interview on 1/23/22 at 4:10 P.M., R17 reported she has not been getting showers. According to R17, she finally got a bed bath last week Friday (1/21/22) after not getting a shower in three weeks. In addition to not getting regular showers, R17 reported she was not washed up daily. During a follow-up interview on 1/31/22 at 8:01 A.M., R17 said she should be getting showers on Tuesdays and Fridays but that they are not done and that makes her feel dirty. Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. During an interview and observation on 1/23/22 at 4:41 P.M., R93 was lying in bed wearing a hospital gown, her hair was matted and clumped with residue. R93 reported she had not been showered or had her hair washed since admitting to the facility on [DATE] (45 days). During an interview on 1/25/22 at 1:58 P.M., Psychologist QQ reported he had just met with R93 and noticed her matted hair. According to Psychologist QQ, the impact on a resident left sitting wet or soiled or not being showered regularly would be self-evident, It would be horrible. Review of the Fundamentals of Nursing revealed, Personal hygiene affects patients' comfort, safety, and well-being. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities such as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation, foster a positive self-image, promote healthy skin, and help prevent infection and disease. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #28 (R28) Review of an Admission Record revealed R28 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R28, with a reference date of 10/20/21 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated R28 was cognitively impaired. Review of the Functional Status revealed that R28 required extensive 2 person assist with transferring and toileting. Review of R28's Care Plan last revised on 5/3/21 revealed, URINARY/BOWELS: I am incontinent of bladder d/t (due to) my inability to feel the urge to void. I will let staff know if I need to have a bowel movement, however this is not consistent. I do receive a diuretic which increases my frequency, I rely on staff for my toileting needs throughout the day. I use incontinence products, but my incontinence puts me at risk for skin breakdown . Staff will assist me with toileting regularly and PRN (as needed) .Toileting: extensive assist x2 staff . Review of R28's Braden Scale for Predicting Pressure Ulcer Risk revealed that R28 was at risk for skin breakdown. During an observation and interview on 2/1/22 at 1:03 P.M., CNA ZZ was the only CNA working on the Memory Care Unit. CNA ZZ attempted to call the East/West Units for assistance and no staff would answer. CNA ZZ reported that there were 4 residents that required 2-person assist on the Memory Care Unit including R28. CNA ZZ reported that R28 had been requesting to use the bathroom prior to lunch and was incontinent of urine, but because she required 2-person assistance she would have to wait in her urine until another staff member arrived in the unit. The facility Administrative team was notified, on 01/31/22 at 10:53 A.M., of the Immediate Jeopardy (IJ) that was identified on 1/27/22 and began on 01/23/22, when the facility failed to provide timely and consistent ADL care. This deficient practice placed all residents, who required staff assistance for the maintenance of ADL's, residing in the facility at risk for serious harm, injury, and/or death. As of date of exit, 2/3/22 at 4:00 P.M., the facility had not developed an approved plan to remove the Immediate Jeopardy and the State Agency was not able to verify the residents living at the facility were free from the potential for serious injury, serious harm and or death.

Based on observation, interview and record review, the facility failed to prevent accidents and hazardous situations for 17 residents (Resident #148, Resident #144, Resident #42, Resident # 8, Resident #153, all 11 residents on the locked memory care unit, Resident #6, and Resident #3) resulting in an Immediate Jeopardy, when beginning on 01/23/22, the facility failed to (a) follow a strict ordered diet of NPO (nothing by mouth) and provide a functioning call light system for Resident #148, (b) implement standard safety protocols to prevent a fall and correctly assess for neurological changes after an unwitnessed fall for Resident #144, (c) safely transport Resident #8 and Resident #42 in a wheelchair, and assess Resident #42's level of staff assistance needed to safely complete activities of daily living, (d) follow the physician order to check wanderguard placement twice daily for Resident #153 and provide a system for staff to quickly identify which residents were at risk for elopement, (e) provide a system for staff in the locked memory care unit to, (1) access health records, (2) locate the crash cart, and (3) contact other staff in case of an emergency, and maintain and audit for properly stocked crash carts, (f) develop a plan of care to prevent a fall with fracture for Resident #6, and (g) secure a shower room on the locked memory unit, to prevent Resident #3 from accessing the shower room independently. Findings: Resident #148 (R148) Review of an Admission Record revealed R148 was a [AGE] year-old male, originally admitted to the facility on [DATE], following a 63-day hospitalization for aspiration pneumonia, urinary tract infection and altered mental status. R148 had a gastrostomy tube for hydration and nutrition and an order for NPO. Review of an Admission Dietary Nutrition Assessment, dated 01/14/22, revealed that the assessment was not complete and was void of information regarding the following for R148: (a) weight on admission and weight history, (b) recent lab values, (c) estimated protein needs, (d) fluid requirements, and (e) current dietary order. Review of a Speech Therapy Evaluation and Speech Therapy Treatment Notes reflected the following concerns/information for R148: (a) (R148) would like to drink again, (b) was referred for speech therapy due to NPO status and tube fed, (c) had reduced cognitive communication skills (BIMS score 7/15), (d) oral motor structure and function-impaired, (e) insight-impaired, and (f) swallowing abilities-severe impairment. During an observation on 01/23/22 at 12:50 P.M., R148 did not have a call light system to use. There was no cord attached to the call light wall receptacle nor was there any other type of system (a bell for example) for R148 to alert staff of any needs. During an observation on 01/23/22 at 1:11 P.M., R148 had a blue water cup, with a lid on it and a straw in it, half full of thin liquid, on the bedside table within reach of the resident. When asked if staff had supplied R148 with something to drink, R148 stated yes. When asked if R148 had been drinking fluids form the cup, R148 stated yes. Licensed Practical Nurse (LPN) N was questioned about R148's oral intake status and confirmed the order for NPO. During an observation on 01/24/22 at 11:47 A.M., R148 did not have a call light system to use. There was no cord attached to the call light wall receptacle nor was there any other type of system (a bell) for R148 to alert staff of any needs. During an observation on 01/25/22 at 9:10 A.M., R148 had received the roommates breakfast tray and was sitting on the edge of the bed eating food by hand. There was no staff supervision for R148. The observation was immediately reported to the Director of Nursing (DON) out of concern for R148's high risk of choking and not having a call light system. During multiple observations on 01/25/22 from 9:10 A.M. through 5:30 P.M., R148 did not have a call light system to use. There was no cord attached to the call light wall receptacle nor was there any other type of system (a bell) for R148 to alert staff of any needs. During multiple observations on 01/26/22 from 7:50 A.M. through 6:20 P.M., R148 did not have a call light system to use. There was no cord attached to the call light wall receptacle nor was there any other type of system (a bell) for R148 to alert staff of any needs. During an observation on 02/01/22 at 09:26 A.M. R148 had been moved to a new room. The new room did have a call light system in place, however, the call light was wrapped around the bedside table drawer handle, out of sight and out of reach of the resident. Resident #144 (R144) Review of an Admission Record revealed R144 was a [AGE] year-old female, admitted to the facility on [DATE] following a hospitalization to treat pneumonia, with pertinent diagnoses of [CONDITION(S)], diabetes mellitus, history of a stroke, and weakness. Review of hospital discharge paperwork dated 01/19/22, the following was noted regarding R144's condition: R144 was (a) unable to state where she was, (b) at times not making any sense, (c) mentation varies during treatment, sometimes talking appropriately then making no sense, and (d) recommended for skilled nursing due to confusion and safety concerns. Review of a facility Nursing Admission Assessment, completed 01/20/22, reflected that R144 had an unsteady gait and poor balance. Review of the Electronic Medical Record for R144 reflected that a Fall Risk Assessment had not been completed for R144 at admission. Review of a Bedside Kardex for R144 revealed the following safety intervention: make sure call light is within reach when the resident is in the room. During an observation on 1/23/22 at 1:22 P.M., R144's call light laid on the meal tray from lunch, out of reach of the resident. During an observation on 01/24/22 at 8:15 A.M., R144's call light laid on the floor at the head of the bed, out of sight and out of reach. During an observation on 01/24/22 at 12:42 P.M., R144 could be heard at the nurses station, retching in the room. No available staff were visible on the unit to respond to R144. During an observation on 01/24/22 at 1:30 P.M., R144 was observed sitting up on the floor next to the bed, reaching for the wheelchair. R144 did not have any footwear on and was dressed in a hospital gown. The call light was on the floor at the head of the bed and out of reach of the resident (out of reach regardless of whether R144 was in bed or on the floor). Despite multiple call lights activated on the west hall, no staff were visible for 10 minutes. At that time and out of concern for R144's health and safety, the surveyor notified Registered Nurse-Unit Manager (RN/UM) G of the observation. RN/UM G and RN H responded and began assessing R144. At 1:45 P.M. and while RN/UM G was out of the room procuring a different blood pressure cuff, R144's LOC (level of consciousness) was assessed and found to be oriented to name and date of birth only. R144's speech was somewhat slurred and at times incoherent, and R144 could not state the name of the facility, what day of the week it was, nor identify the correct month of the year. After several unsuccessful attempts to obtain a blood pressure (due to lack of properly functioning equipment), R144 was assisted back to bed with the use of a gait belt and 2-person assist. Staff searched the resident's room and could not locate any type of footwear including grippy socks. Review of a Neuro Checks form initiated for R144 on 01/24/22 at 1:45 P.M., reflected 3 hourly checks that were scheduled to start at 3:30 P.M. and continue until 5:30 P.M., were not completed. The Neuro Check form only monitored blood pressure and the position of the resident when the blood pressure was obtained, respirations, pulse and type, and temperature. The Neuro Checks form used by the facility does not meet the standard of practice for the monitoring of a resident who had an unwitnessed fall. The standard of practice for the nursing assessment of a resident with an unwitnessed fall includes level of consciousness, pupillary reaction, motor function and vital signs: ([NAME], W. J., [NAME], F. D., [NAME], J. K., [NAME], J. F., & Neighbors, M. (2019) Medical-Surgical Nursing Health and Illness Perspectives (11th ed.). St. Louis: Mosby.) During an observation on 01/25/22 at 10:48 A.M., R144's call light was activated and R144 stated, I can't wait any longer, my stomach hurts, I have to lay down. R144 self transferred to bed, laid on top of the covers, and the oxygen cannula was displaced from the nares. During an observation on 01/25/22 at 11:44 A.M., R144 laid under the covers, 02 cannula in place, and the call light laid on the floor out of sight and out of reach. During an observation on 01/31/22 at 8:09 A.M. R144 sat in a wheelchair positioned bedside. The call light was tucked down between the mattress and the bed frame at the head of the bed, out of sight and out of reach. Review of a facility policy Resident Safety, last reviewed 12/20/20, reflected the following: (1) All residents will have access to a nurse call device while in their room. The device will be operable by the resident with consideration for any physical disabilities or limitations they may have. (2) All staff members have responsibility to respond to nurse call alerts, (3) Nursing staff are responsible for assuring that call light cords are within reach of all residents, (4) It is the responsibility of staff to round throughout the shift to assure call lights remain within reach of residents, and (5) resident call must be addressed immediately, call lights must be answered quickly. Resident #8 (R8) Review of an Admission Record revealed R8 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of traumatic brain bleed, Down's Syndrome, and moderate intellectual disabilities. Review of R8's Care Plans reflected the following information related to the plan of care and interventions required by staff to ensure the resident's safety: (a) does not communicate immediate needs; staff need to anticipate all needs, (b) main mode of transportation is: wheelchair with total assistance x 1 staff, (c) foot pedal strap to bilateral foot pedals, to aide in feet positioning during transportation. During an observation on 01/24/22 at 2:37 P.M. an unidentified staff person pushed R8 in a wheelchair from the dinning area to the resident's room. The footpedals were on the wheelchair but R8's feet were dragging on the floor between the foot pedals. Resident #42 (R42) Review of an Admission Record revealed R42 was a [AGE] year-old female, admitted to the facility for skilled rehabilitation services following a right ankle fracture. R42 admitted to the facility with relevant diagnoses of diabetes mellitus, history of falls, muscle weakness, and cognitive communication deficit. During an observation on 01/31/22 at 11:59 A.M., R42 returned to the facility from an outside appointment and was being pushed in a wheelchair by employee A without the use of any foot pedals. Review of a Bedside Kardex, used to alert staff of specific residents' needs in order to complete certain activities of daily living (ADL's), reflect the following care needs were not assessed for R42, relative to how much assistance and how many staff persons were needed to safely perform: (a) bathing/showering, (b) bed mobility, (c) getting dressed, (d) use of supportive devices such as crutches, canes or splints, (e) ambulating, (f) eating, (g) going to the bathroom, and (h) complete personal hygiene. Resident #153 (R153) Review of an Admission Record revealed R153 was an [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of [CONDITION(S)] ([CONDITION(S)]), dyspnea (difficulty breathing), [CONDITION(S)], and dementia. Review of an Etar for R153, dated 1/01/2022 - 1/31/2022, revealed an order for: wanderguard to left ankle; check placement every shift two times a day for safety. Documentation reflected that placement was not checked on 6 different shifts. Review of the facility policy/procedure Elopements and Wandering Residents, last revised 11/22/2019, reflected the following: The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents by .(a) review physical plant to be sure door alarms are properly locked to prevent resident entry, (b) the facility is equipped with door locks/alarms to help avoid elopement, (c) alarms are not a replacement for necessary supervision, and (d) the facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including the assessment and identification of hazards and risk . Review of elopement log book documentation Test operation of doors, locks, and alarms, reflected that the last audit completed of the facilities 16 doors and alarmed exits took place on 07/28/21. During an interview on 01/26/22 at 3:45 P.M., Certified Nurse Aide (CNA) P could not locate the elopement book that identified all residents assessed to be at risk for elopement. During an interview on 01/26/22 at 4:00 P.M., the DON was questioned about the residents who had been assessed for and identified as elopement risks. The DON could not locate the elopement book and ran an order listing report that identified 3 residents (R153, R42, and R5) who currently utilized a wander-guard device. After reviewing the order listing report, the DON suggested there may be additional residents who utilized a wander-guard (but were not listed on the report) and the DON commenced a room to room check, to verify which residents had a wander guard. After completing the room to room check of all residents in the facility, the DON identified 3 additional residents (R35, R12, and R40) that utilized a wander-guard. After running the order listing report and completing a room to room check of all the residents in the facility, R144 still had not been identified as a person who was an elopement risk, despite wearing a wander guard and having a care plan in place (initiated 01/20/22) related to being an elopement risk. Locked Unit During an interview on 01/24/22 at 12:22 P.M., CNA O reported that there was not a back up system in place, on the locked memory care unit, for staff to be able to determine a residents code status. If the Electronic Health Record (EHR) went down there would be no way to access that information. During an interview and observation on 01/24/22 at 12:28 P.M., CNA Y reported not having access to the Electronic Health Record and did not know how else to determine a resident's code status. CNA Y stated that the only phone on the Memory Care Unit was not plugged in because of a resident's behaviors. CNA Y reported that the walkie talkies did not work, and did not have a key fob to exit the Memory Care Unit. CNA Y was asked what steps would be taken in an emergency, or if a resident coded, and responded, That's a really good question. During an interview on 01/25/22 at 10:02 A.M., CNA PP reported that the Man Down button, walkie talkies, and the phone on the locked unit (Memory Care Unit) did not work. The phone cord was removed because of a resident's behaviors. CNA PP reported having a key fob to exit the unit, (the doors remained locked and use of the key flab was the only way to exit the unit) but the coworker did not. CNA PP reported that it was dangerous and would not know what to do in an emergency if left alone on the unit (CNA PP indicated being the only staff person on the unit many times). CNA PP reported the Memory Care Unit was unsafe and voiced concerns about what would happen if a resident coded on the unit without the ability to communicate with other units or have staff to assist. During an interview on 01/25/22 at 10:05 A.M., CNA OO stated today was the first day as a CNA at this facility and had not been given access to the EHR (electronic health record) to determine a resident's code status. CNA OO did not have a key fob to exit the unit and when CNA PP would go on break, CNA OO was left alone on the unit, without orientation, without a way to communicate with the other staff, and without the ability to document in or access the EHR. During an observation and interview on 01/26/22 at 2:15 P.M., Dietary Aide (DA) S attempted to bring a resident tray to the Memory Care Unit. DA S was let in by the surveyor and reported that most staff did not have a key fob to gain access to the unit, there was no known code to type in to unlock the doors, and indicated that during an emergency very few staff would be able to access the Memory Care Unit to assist. Crash Carts During an observation on 01/26/22 at 12:01 P.M. the emergency oxygen tank on the crash cart for the East/West halls was empty. The daily check list used by staff to check the crash cart was not located on the cart but rather in a book behind the nurses desk. Documentation showed that the crash cart was last checked on 01/13/22. During an interview on 1/26/22 at 12:08 P.M., the Director of Nursing did not know if there was a crash cart on the locked memory unit or, if there was one, where it was located. At the time of the interview, there was not a nurse working on the locked memory unit. Resident #6 (R6) Review of a facility Admission Record reflected R6 originally admitted to the facility on [DATE] with diagnoses that included a history of a stroke, [CONDITION(S)], major depressive disorder, high cholesterol, high blood pressure, conversion disorder with seizures or convulsions, drug induced Parkinsonism, [CONDITION(S)] of the knee, [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)] with lower urinary tract symptoms, [CONDITION(S)] and gastro-[CONDITION(S)] reflux disease. Review of an admission Minimum Data Set (MDS) dated [DATE] reflected R6 was cognitively intact as evidenced by a Brief Interview for Mental Status assessment score of 13/15 and needed limited assistance from one person for transfers, dressing, toilet use, personal hygiene, and bathing. Review of Census Data in the EMR reflected R6 admitted to the facility on [DATE], discharged to the hospital from 10/28/21-11/2/21, readmitted to the facility on [DATE], discharged to the hospital again from 11/12/21-11/18/21, readmitted to the facility on [DATE]. R6 had an unpaid hospital leave on 12/6/21, returned to the facility the same day and was hospitalized again from 12/18/21-12/31/21. Review of a COMS ® Post Fall Evaluation note dated 9/15/21 at 3:49 p.m. reflected Called to resident (R6's) room. Resident found in wheelchair with grippy socks in place. He stated that he had fallen in the bathroom after trying to transfer unassisted. Denied pain. Skin assessment completed and no issues noted. Educated on call light use and waiting for assistance. (MD AA) and family member (name) notified of fall. No new orders obtained. According to the report the call light had been activated but R6 did not wait for assistance. No further details surrounding the fall were documented and additional interventions to prevent another fall were not added to the care plan. Review of the Care Plan Report, canceled in its entirety on 11/11/21 after R6 was hospitalized reflected that on 9/9/21 (date of admission), R6 was identified as needing assistance with Activities of Daily Living (ADLs), however the plan did not specify how many staff or what level of assistance was needed for bed mobility, transfers, personal hygiene, eating, bed mobility or toileting. The canceled care plan indicated that R6 was at risk for falls related to conversion disorder with seizures or convulsions and secondary Parkinsonism with the goal (R6) will have no serious injury related to falls AEB (as evidenced by) documentation thru next review. Interventions to meet the stated goal included Assistive Devices (non-specific); ensure call light or bathroom call light are answered promptly; ensure call light is within reach; monitor for signs and symptoms of fatigue; encourage rest periods as needed; nurse will assess resident for changes in physical or mental status and notify Dr. as needed and follow up with recommendations. Review of a Physical Therapy PT Discharge Summary for the dates of service 9/17/21-10/28/21 reflected that R6 had been discharged from physical therapy due to being discharged to the hospital. Review of the report reflected R6 had not met the majority of short or long-term goals, including reducing the risk for falls. According to the report a short-term goal was that R6 would Safely ambulate on level surfaces 150 feet using two wheeled walker with CGA (Contact Guard Assistance) with normalized gait pattern 90% of the time to facilitate increased participation in functional activity was not met. Review of an Order Recap Report for the date range 9/01/21-1/29/22 reflected R6 was prescribed [MEDICATION(S)] Tablet 5 MG (milligram) Give 5 mg by mouth three times a day for muscle pain for 5 days. Started on 12/13/21 and discontinued on 12/14/21. A second order for [MEDICATION(S)] Tablet 5 MG (milligram) Give 5 mg by mouth two times a day for muscle pain for 5 days started on 12/14/21 and ended on 12/19/2021. [MEDICATION(S)] is a muscle relaxer with side effects that include but are not limited to dry mouth or throat, headache, blurred vision, drowsiness, dizziness and fatigue. Review of an Incident Note dated 12/18/21 at 3:05 A.M. reflected CNA (Certified Nurse Aide) doing rounds down hallway when coming back up hallway heard noise then yell. Found resident (R6) lying inside bathroom door facedown with feet just outside of door and lying up against the wall left side. When asked resident what happened he stated got dizzy and passed out but tried to catch himself on the wall with his left hand. Resident call light was not in use and he does have urinal at bedside that was empty. He also took off his oxygen and saturation was 90%, did have increased confusion A&Ox2 (alert and oriented to person and place). During assessment resident was assisted onto his right side where he yelled out in pain and unable to move his left leg at the hip, pain level 8/10 at this time. Other nurse notified doctor, the DON (Director of Nursing) and 911 was called. Resident also had hematoma to left side of forehead it is raised approximately measuring 5 cm x 3 cm, abrasion to left elbow and hematoma present. Resident was transported via (ambulance company) to (hospital). Attempted to contact family members one number no in service and left message with other contact. Review of a Hospital Discharge Summary dated 12/31/21 reflected [AGE] year old male with PMHx (previous medical history) of [CONDITION(S)] (high blood pressure), [CONDITION(S)] on 2L NC (2 liters via nasal cannula), Afib ([CONDITION(S)]) (on [MEDICATION(S)]), [CONDITION(S)], heart failure, s/p PPM (status-post permanent pacemaker), acute decompensated HF (heart failure) with preserved EF (ejection fraction) admitted following mechanical fall. Imaging showed left intertrochanteric fracture of the left femur, S/P Left hip ORIF (open reduction, internal fixation) with nail placement surgery. Following surgery, he was found to be hypotensive and in [CONDITION(S)] was started on Phenylphrine and received two liters of IVF (intravenous fluid) boluses and was transferred to ICU (intensive care unit) for close monitoring. Review of the Electronic Medical Record (EMR) for evidence of care planning reflected R6 did not have an active care plan in place for any focus areas. Attempts to open a current care plan or Kardex (an at a glance care guide) resulted in documents annotated No Data Found. Further review of the EMR revealed a historic care plan that had been canceled as of 11/11/21 due to R6 discharged from the facility for a hospitalization [DATE]-[DATE]. No evidence a new care plan had been developed or implemented upon readmission to the facility on [DATE] was found. On 1/24/22 the DON was asked to provide the fall incident report dated 12/18/21 and the accompanying investigation. According to the DON, only the incident report was available and no additional information could be found. Attached to the incident report was an Investigation Follow-Up form that was not filled out. Circumstances surrounding the fall were not reviewed and without a care plan in place, no interventions had been developed or implemented prior to the fall that may have prevented the serious injury. Resident #3 (R3) Review of an Admission Record revealed R3 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: [CONDITION(S)] disorder and [CONDITION(S)]. Review of a Minimum Data Set (MDS) assessment for R3, with a reference date of 9/2/21 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated R3 was cognitively impaired. Review of the Functional Status revealed that R3 required supervision with one person for personal hygiene/showering. Review of R3's Care Plan last revised on 10/11/21 revealed, FALLS: I am at risk for falls r/t (related to) SOB (shortness of breath), [CONDITION(S)] disorder, and [CONDITION(S)] . Review of R3's Care Plan last revised on 8/27/21 revealed, Resident requires (assistance level) X (how many staff) for Bathing/Showering. (It did not specify the number of staff nor the level of assistance needed for Bathing/Showering) During an observation on 1/26/22 at 12:28 P.M., the shower door on the Memory Care Unit was not functional. During an observation on 1/31/22 at 8:03 A.M., R3 entered the unlocked shower room on the Memory Care Unit alone and closed the door. An unidentified CNA who had stayed over from 3rd shift observed R3 enter the shower room, and on two occasions put an ear to the door to listen for R3. At 8:12 A.M., R3 exited the shower room. Review of the facility Repair Requisition dated 1/21/22 for the Memory Care Unit revealed, Shower Room lock don't lock anymore. On 1/31/22 at 10:53 A.M. the facility administration was notified of the Immediate Jeopardythat was identified on 1/27/22 at F-689 as the result of the facility failure to prevent accidents and hazardous situations for 17 residents (Resident #148, Resident #144, Resident #42, Resident # 8, Resident #153, all 11 residents on the locked memory care unit, Resident #6, and Resident #3), resulting in an Immediate Jeopardy, when beginning on 01/23/22, the facility failed to (a) follow a strict ordered diet of NPO (nothing by mouth) and provide a functioning call light system for Resident #148, (b) implement standard safety protocols to prevent a fall and correctly assess for neurological changes after an unwitnessed fall for Resident #144, (c) safely transport Resident #8 and Resident #42 in a wheelchair, and assess Resident #42's level of staff assistance needed to safely complete activities of daily living, (d) follow the physician order to check wanderguard placement twice daily for Resident #153 and provide a system for staff to quickly identify which residents were at risk for elopement, (e) provide a system for staff in the locked memory care unit to, (1) access health records, (2) locate the crash cart, and (3) contact other staff in case of an emergency, and maintain and audit for properly stocked crash carts, (f) develop a plan of care to prevent a fall with fracture for Resident #6, and (g) secure a shower room on the locked memory unit, to prevent Resident #3 from accessing the shower room independently. As of date of exit, 2/3/22 at 4:00 P.M., the facility had not developed an approved plan to remove the Immediate Jeopardy and the State Agency was not able to verify the residents living at the facility were free from the potential for serious injury, serious harm and or death.

Based on observation, interview, and record review, the facility failed to ensure systems were in place to provide sufficient staffing to meet resident needs (incontinence care, pressure ulcer prevention, oxygen therapy, ADL care, supervision, [CONDITION(S)] medication monitoring) for 6 residents (R143, R146, R151, R28, R93, and R17) reviewed for staffing, resulting in an Immediate Jeopardy when, beginning on 1/23/22, facility staff did not meet the basic needs of residents. This deficient practice placed all residents residing in the facility at risk for serious harm, injury, and/or death. Findings: Resident #143 (R143) Review of an Admission Record revealed R143 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 01/26/22 at 9:57 A.M., R143 loudly cried and screamed I need to poop. At 10:07 A.M., CNA O obtained a bed pan and assisted R143 onto the bed pan. CNA O stated that R143 does not normally use a bed pan but there wasn't enough staff to get the resident to the bathroom safely. R143 required 2 staff persons to transfer to the bathroom. Resident #146 (R146) Review of an Admission Record revealed R146 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R146 was dependent on staff for hygiene, eating, transfers, and going to the bathroom. During an observation on 01/31/22 at 09:13 A.M., staff provided R146 with assistance to eat breakfast. Staff indicated that R146 eats last on the hall because staff are required to provide assistance and due to lack of staff, R146 had to wait until everyone else had breakfast. Resident #151 (R151) Review of an Admission Record revealed R151 was a [AGE] year old male, admitted to the facility for long term care on 01/11/22, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R151 was contracted and the elbows and wrists, required 2 staff person assistance with a mechanical lift for transfers, and required assistance from 1 staff person to eat and drink. During an observation on 01/23/22 at 1:16 P.M., R151 had not yet received lunch, while the other residents on the hall had completed lunch. At 1:31 P.M., CNA O assisted R151 with lunch and stated that there was not enough staff to assist everyone with lunch in a timely manner. Resident #28 (R28) Review of an Admission Record revealed R28 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R28, with a reference date of 10/20/21 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated R28 was cognitively impaired. Review of the Functional Status revealed that R28 required extensive 2 person assist with transferring and toileting. During an observation and interview on 2/1/22 at 1:03 P.M., CNA ZZ was the only CNA working on the Memory Care Unit. CNA ZZ attempted to call the East/West Units for assistance and no staff would answer. CNA ZZ reported that there were 4 residents that required 2-person assist including R28. CNA ZZ reported that R28 had been requesting to use the bathroom prior to lunch and was incontinent of urine, but because she required 2-person assistance she would have to wait in her urine until another staff member arrived in the unit. R30 was observed at that time saturated with urine. CNA ZZ reported that she could not assist him with incontinence care either because of the lack of staff on the unit. CNA ZZ reported that when staff were assisting a resident in their room it left the other behavioral residents unattended and without supervision. Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. During an interview on 1/26/22 at 4:30 P , Physician AA reported he would treat patients with CHF symptomatically and evaluate for evidence of shortness of breath, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Physician AA denied being informed that R93 had increased [CONDITION(S)] and said that R93 would be a candidate for frequent weight monitoring related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview and observation on 1/24/22 that began at 8:20 A.M., R93 reported she did not know the signs or symptoms of [CONDITION(S)] or [CONDITION(S)] and denied refusing medications as RN I had indicated she would document. R93 did not know whether or not other nurses were adjusting her insulin orders without her knowledge and said, I take what they give me. When asked what she would do if she started to feel shaky or sweaty, increased hunger, fatigue, nausea or vomiting or lightheadedness (some signs of [CONDITION(S)]), R93 said she would push the button. RN I was still at the bedside, in full view of the resident, and placed her hand over her mouth, shook her head and said, If you could do that here, the implication being that staff would not respond in a timely manner. Resident #17 (R17) Review of a facility Admission Record reflected R17 admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission Minimum Data Set (MDS) assessment dated [DATE] reflected R17 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15 and needed extensive assistance from two people for bed mobility and transfers and required extensive assistance from one person for dressing, toilet use and personal hygiene and bathing. During an interview on 1/23/22 at 11:44 A.M., R17 reported there was not enough staff and felt that administration was doing that on purpose. During an interview on 1/23/22 at 4:10 P.M., R17 reported she has not been getting showers. According to R17, she finally got a bed bath last week Friday (1/21/22) after not getting a shower in three weeks. In addition to not getting regular showers, R17 reported she was not washed up daily. R17 reported that a nurse was going to quit which made her feel stressed and worried. R17 reported 3 CNA's quit in the last 3 weeks and nurses walk off the job leaving only 1 nurse on duty. During an interview and observation on 01/23/22 at 10:17 A.M., Certified Nursing Assistant (CNA) V reported that he was the only staff member on the locked Memory Care Unit (MCU) for 11 Residents. CNA V reported that the other CNA working was on break, leaving him alone on the unit. During an interview on 01/23/22 at 11:07 A.M., Registered Nurse (RN) I reported she was the only nurse working 2 units which consisted of her caring and passing medications for 30 residents. Reported it was unsafe for a nurse to be responsible for 30 residents and she was late passing medications. During an interview on 01/23/22 at 11:10 A.M., CNA P and CNA O reported that they were the only CNA's working for the East and West Unit. CNA P and CNA O reported that they could not reposition, change, and shower residents. CNA P and CNA O reported that there were not enough staff to meet the needs of the residents and provide care and/or quality care. During an interview and observation 01/23/22 at 01:30 P.M., CNA PP reported that she was the only staff member on the Memory Care Unit for 11 Residents. CNA V was pulled to the East/West Unit. There was 1 LPN on the unit. At that time a resident was attempting to break through the locked doors and was exhibiting distressed behaviors (Resident #2). The LPN became a 1:1 for the resident at that time. CNA PP reported that she was working with a resident that had increased behaviors (Resident #41) which placed the rest of the residents at increased risk because of the lack of supervision. CNA PP reported more staff were needed to keep the residents on the MCU safe. During an observation and interview on 01/23/22 at 01:41 P.M., Registered Nurse (RN) I stated to R19, I got to check your sugar, I know it's (blood sugar assessment) late. RN I reported that the blood sugar was to be assessed prior to meals but because she was the only nurse covering 2 units, she was unable to get all meds passed, vitals assessed, and blood sugars obtained timely. During an interview on 01/24/22 at 9:50 A.M., RN H reported that the nurse to patient ratios were unsafe and residents were not receiving quality care. RN H reported that additional nurses were needed in the morning to pass out medications and complete treatments. RN H reported that at times treatments could not be completed because nursing staff could not get to all of the medication pass and treatments in their shift. RN H reported that blood sugars are not obtained prior to residents eating and routine medications are passed late because of the staffing shortage. RN H reported that residents are not given the care that they need and require because of the staffing shortage and management staff were aware of the concerns. RN H reported that the night shift nurse (prior to his shift) was the only nurse in the facility and was unable to pass all medications. During an interview and observation on 01/24/22 at 11:52 A.M., CNA Y reported that she was the only licensed aide in the Memory Care Unit. CNA Y reported that Activity Aide (AA) RR was on the unit to help when able but was unable to assist with residents that required 2 person assistance because she was not licensed to do so. During an interview on 01/24/22 at 12:28 P.M., CNA O reported that there was only 1 CNA working at that time and the administration would be pulling Medical Records/CNA Scheduler (MRS) D and Activity Director (AD) R to work the floor as CNA's and as Dietary Aides due to staffing shortage. CNA O reported that staff were often requested to perform job duties outside of their scope of practice. CNA O reported that in the past he had been asked to administer nebulizers and skin treatments. CNA O reported that housekeeping had been pulled to provide care, work in the kitchen, and feed residents. CNA O reported that residents are not safe in the facility because of the staffing shortage. During an interview on 01/25/22 at 8:50 A.M., Physical Therapy Assistant (PTA) C and Occupation Therapist (OT) XX reported that staff have made complaints that their checks had bounced and had quit because of it. PTA C and OT XX reported that there were no activities and no restorative care because of the lack of staff. OT XX reported that the lack of staff was affecting patient care. During an interview on 01/25/22 at 10:02 A.M., CNA PP reported that it was difficult to manage the residents' behaviors with insufficient staff. CNA PP reported that in the mornings there were only 2 CNA's scheduled to work and when 1 CNA went on break it left the other CNA to care for all of the residents on the Memory Care Unit. CNA PP reported they could not shower, reposition, and change residents as required because of the lack of staff. CNA PP reported that it was difficult to manage the residents' behaviors with insufficient staff. During an interview on 01/25/22 at 11:45 A.M., Licensed Practical Nurse (LPN) SS reported that the morning medications that were to be administered between 7am-10am had not all been administered for the residents on the Memory Care Unit at that time because of staffing shortages. During an observation and interview on 1/26/22 at 12:08 P.M., CNA V was pulled from the Memory Care Unit to the East and West Unit to assist with mealtime which left CNA OO alone on the Memory Care Unit on her 2nd day working at the facility. CNA OO was visibly concerned because of her lack of access to the Electronic Health Record and her lack of knowledge of the residents' needs. At 12:12 P.M., Housekeeping (H) T and H YY arrived in the unit to assist CNA OO on the unit per H T. H T and H YY were not certified nursing assistants and could not assist with resident care/feeding. H T reported that if the facility was short staffed, he would be asked to assist on the Memory Care Unit. At 12:17 P.M. DON came to the unit and reported that CNA OO should not be left alone on the Memory Care Unit and Housekeeping staff were not certified/licensed to assist with resident care. There was a resident on the Memory Care Unit saturated with urine but there were no staff available to assist him with incontinence care. During an observation and interview on 1/26/22 at 2:02 P.M., resident meals were brought to the Memory Care Unit. CNA V reported that the meals were frequently brought to the Memory Care Unit late. CNA V reported that he was alone on the unit because CNA OO was on break. During the time that CNA V was feeding R23, R19 grabbed R28's plate which cause R28 to become visibly upset and crying, immediately following that interaction, R22 grabbed R40's drink which caused R22 to become agitated. Because CNA V was alone and assisting a resident with feeding he was unable to monitor and redirect negative resident behaviors. CNA V reported he was doing the best he could but the lack of staff resulting in resident behaviors occurred daily. During an interview on 1/26/22 at 2:54 P.M., Activities Director (AD) R and Medical Records/CNA Scheduler (MRS) D reported that there were not enough staff to meet the resident needs. AD R reported that there were nearly 20 residents admitted to the facility in the last month when there were already not enough staff to meet the needs of the residents. AD R and MRS D reported that they felt residents were in danger because of the lack of staff. Medical Records/CNA Scheduler (MRS) D reported that the new CNA hires were not educated, did not have proper orientation before being thrown on the floor, did not have annual competency evaluations, and did not have the required yearly education. MRS D reported that the training for the CNAs was not sufficient, and the CNAs were not completing their duties following professional standards of practice. During an interview and observation on 1/26/22 at 4:00 P.M., CNA O and CNA P reported that because of the lack of staff in the kitchen, there were no clean cups to pass waters to residents. During an interview on 01/27/22 at 10:45 A.M., Previous Employee (PE) WW reported that residents were not being cared for properly because of the lack of staff. PE WW reported that she was not a CNA, or a Licensed Nurse and she would often be sent to the Memory Care Unit to work as a CNA which included toileting and providing care to residents. PE WW reported that she was told by the owner that she was able to work as a CNA and that it was okay by law because of the pandemic. PE WW reported that at times she would be working with no other staff in the Memory Care Unit with no experience. PE WW reported that they could not meet the needs of the residents because of the staffing shortage. During an interview on 02/01/22 at 12:15 P.M., CNA BBB reported that she would often go home crying because I feel like I've neglected the residents because there aren't enough staff to provide quality care to the residents. During an observation and interview on 02/1/22 at 1:26 P.M., Confidential Informant (CI) AAA reported that when working night shift on the Memory Care Unit there would often only be 1 CNA. CI AAA reported that residents that required 2 person assist would be assisted by only 1 CNA because of the lack of staff available. CI AAA reported that they had transferred a resident with a hoyer alone on several occasions. During an interview on 02/03/22 at 01:17 P.M., Unit Manager (UM) G reported that P Z was putting in parameters for all residents that have blood glucose monitoring. UM G reported that the staff should be following the parameters set for the [MEDICATION(S)] and insulins. UM G reported that abnormal vital signs should be immediately reassessed and if no improvement the physician should be notified, and medications should not be held without a physician order. UM G reported that she and the DON frequently must work as a floor nurse and cannot perform their management duties which included ensuring medications were given on time and correctly following parameters. UM G reported it was chaotic because of the staffing shortage and nursing manager duties were difficult to complete. Review of the Daily Report dated 12/13/21 revealed, Need Housekeeper Bad-Facility unclean only 1 housekeeper total-maintenance being pulled to (sister facility) multiple days .call light system needs replaced .oven door wont go all the way down-needs new hinge wont replace due to past bills .social work-Don't have/need in house MDS-Kitchen need cooks/aides . The facility administrative staff were notified on 1/31/22 at 10:53 A.M. of the Immediate Jeopardy identified on 1/27/22 at F725 as the result of failing to ensure systems were in place to provide sufficient staffing to meet resident needs (incontinence care, pressure ulcer prevention, oxygen therapy, ADL care, supervision, [CONDITION(S)] medication monitoring) for 6 residents (R143, R146, R151, R28, R93, and R17) reviewed for staffing, resulting in an Immediate Jeopardy when, beginning on 1/23/22, facility staff did not meet the basic needs of residents. This deficient practice placed all residents residing in the facility at risk for serious harm, injury, and/or death. As of date of exit, 2/3/22 at 4:00 P.M., the facility had not developed an approved plan to remove the Immediate Jeopardy and the State Agency was not able to verify the residents living at the facility were free from the potential for serious injury, serious harm and or death.

Based on observation, interview, and record review, the facility failed to ensure facility staff met the requirements for dementia/behavior care education, ensure sufficient and qualified staff, and create and implement comprehensive individualized care plans to meet residents dementia/behavioral care needs for 10 out of 11 residents (R2, R5, R22, R19, R23, R30, R41, R40, R16, and R3), resulting in an Immediate Jeopardy beginning on 1/24/22 when R2 physically assaulted R5. This deficient practice resulted in diminished quality of life for residents with mental illness and dementia and the potential for additional instances of resident to resident abuse due to care planned interventions not being accurate, outdated, or missing. Findings: Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's Physician Note dated 2/1/22 revealed, (R2) was seen today in regards to a recent resident to resident in which she grabbed another residents arm. (R2) is noted to have severe dementia and paranoia. There is a history of her with increased anxiety each day near noon. It is apparent that there was no ill intent. I would suggest she be in her own room so that she does not feel the need to protect her belongings. Psych will continue to follow . During an interview on 2/1/22 at 11:41 A.M., Physician Z reported that he completed an assessment on R2 following the allegation of abuse. Physician Z reported that she exhibited behaviors of having a difficult past with keeping her items packed and becoming protective of her items. Physician Z reported that because of her possessive behaviors with her items and her space she would have benefited from having a private room. Physician Z reported that R2 may have become overwhelmed to the point she felt she had to protect her items which resulted in the physical altercation between R2 and R5. Review of R2's Care Plans revealed no care plans for known behaviors of protective behaviors for belongings, increased behaviors around noon, and paranoia. Review of R2's Care Plan revealed no care plan for Dementia Care. Review of R2's Care Plan revealed, Behavior (no further documentation for the focus) Created on: 8/30/2021. I will not have any behaviors throughout the next review . I may become overstimulated. please take me to a calm environment if this happens . Offer activities of choice . Review of R2's Care Plan revealed, Psychosocial well being (sic) (no further documentation for the focus) Created on: 8/30/2021 .I will be up and dressed daily. and remain in a calm and happy appearance. throughout the next review date . Review of R2's Care Plan revealed, I am on antipsychotic medication .I will be monitored on behavior management . Staff will document behaviors when observed . During an observation on 01/23/22 at 01:09 P.M., R2 was visibly agitated, aggressive, and destructive of facility property. R2 was wielding a butter knife and used it to remove the key pad off of the wall and was using the knife to attempt to break through the lock on the double doors. LPN M was blocking her path and was not communicating (verbal or non-verbal) with her in an attempt to deescalate the situation. During an interview and observation 01/23/22 at 01:30 P.M., CNA PP reported that she was the only staff member on the MCU for 11 Residents. CNA V was pulled to the East/West Unit. There was 1 LPN on the unit. At that time, R2 continued to be behavioral/destructive. CNA PP reported that she was working with a resident that had increased behaviors (Resident #41) which placed the rest of the residents at increased risk because of the lack of supervision. CNA PP reported more staff were needed to keep the residents on the Memory Care Unit safe. Review of R2's Behavior Note dated 1/23/22 at 4:28 P.M. revealed, Resident became agitated during lunch time. She went to her room and packed her clothes up in a bag and box. She went to the electronic/keypad box attached to the wall and took out a butter knife she had kept from her meal tray and began trying to pry the box off the wall using the butter knife. Staff notice what she was doing and began walking towards her to intervene, but she managed to pull the box completely off the wall. One Staff member stayed with resident as she was repeatedly shoving at the door handles in an attempt to open them, and the other staff member went to get assistance from maintenance to repair the torn off electronic box. Resident refused to give staff the butter knife. Maintenance repaired the box on the wall. Resident took her things back to her room, unpacked, and butter knife was removed from room. Resident redirected with ice cream and apple juice. Refused to participate in activities. Will continue to monitor and follow up as needed. (Indicating an increase in aggressive behaviors.) During an interview on 01/24/22 at 12:30 P.M., R5 reported to this surveyor that her roommate (R2) had assaulted her the previous day (1/23/22). R5 was tearful and anxious when reporting the allegation of resident to resident abuse. Resident #5 (R5) Review of an Admission Record revealed R5 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 01/26/22 at 5:25 P.M., R5 was visibly upset/anxious/tearful and pacing the Memory Care Unit. There were no staff members observed on the unit (assisting resident in their rooms). R5 tearfully reported that she wanted to call her guardian (a known behavior for R5) but was unable to do that at that time. R5 reported if she could do something such as an activity or have someone 1:1 to talk to it would take her mind off of calling her guardian. R5 reported that there was nothing to do on the Memory Care Unit. Review of R5's Care Plan revealed, Behavior: (R5) exhibits exit seeking and attention seeking behaviors. Requires constant redirection and 1:1 attention . All staff to document behaviors if observed in behavior book . Offer (R5) 1:1 programs such as: conversation, short walks, coloring pages, and her favorite tv shows( bewitched, I dream of genie) . SW (Social Work) to monitor on behavior management Monitored behavior management and checked daily by SW. Document all behaviors in book provided by SW to keep track of behaviors . Review of R5's Care Plan revealed, Anti-Psychotic Medication use: (R5) receives [MEDICATION(S)], and [MEDICATION(S)]. (R5) is at risk for side effects r/t (related to) medication use . Document all behaviors in behavior books provided by SW to keep track of behaviors . (R5) will be monitored on behavior management daily by social services. Review of R5's Care Plan revealed, Antidepressant Medication use: (R5) receives [MEDICATION(S)]. (R5) is at risk for side effects r/t Antidepressant medication use . Document all side effects or signs and symptoms of depression daily in the behavior book . Monitored behavior management and checked daily by SW. Resident #22 (R22) Review of an Admission Record revealed R22 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation and interview on 1/26/22 at 2:02 P.M., resident meals were brought to the Memory Care Unit. CNA V reported that the meals were frequently brought to the Memory Care Unit late. CNA V reported that he was alone on the unit because CNA OO was on break. During the time that CNA V was feeding R23, R19 grabbed R28's plate which cause R28 to become visibly upset and crying, immediately following that interaction, R22 grabbed R40's drink which caused R22 to become agitated and stated, Don't let her touch my food. Because CNA V was alone and assisting a resident with feeding he was unable to monitor and redirect negative resident behaviors. CNA V reported he was doing the best he could but the lack of staff resulted in the worsening of resident behaviors which occurred daily. Review of R22's Care Plan revealed, Behavior: (R22) on occasion has combative behaviors r/t DX of Dementia. She is usually redirectable. Can become overwhelmed with to much simulation . All staff to document any signs of depression or behavior in behavior book. SW (social worker) to check daily . Review of R22's Care Plan revealed no entry for dementia care. Resident #19 (R19) Review of an Admission Record revealed R19 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R19's Nursing Note dated 10/24/21 revealed, Resident is being combative with cares . Review of R19's Nursing Note dated 12/8/21 revealed, Resident was very combative towards staff as we were trying to change her and get her up and dressed for the day, her behavior improved during the afternoon and became worse at dinner again . Review of R19's Nursing Note dated 12/20/21 revealed, (R19) was found in another residents room last night licking empty dinner dishes last night. Review of R19's Nursing Note dated 12/23/21 revealed, While staff were completing HS (nighttime) cares resident was combative. She was trying to bite, hit, and scratch . Review of R19's Nursing Note dated 12/24/21 revealed, (R19) was found in another residents bathroom tonight flushing objects down the toilet. Review of R19's Care Plan revealed no entry for combative behaviors, entering other residents rooms, or dementia care. Resident #23 (R23) Review of an Admission Record revealed R23 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's Nursing Note dated 9/4/21 at 11:00 A.M. revealed, This writer was notified by (Licensed Practical Nurse LPN EEE) that (R4) had stated that he had gotten into a fight. This writer questioned resident who stated (R23), the guy who walks around and goes through people's stuff. He wanted my blue blanket. Per (LPN EEE), resident stated that (R23) had punched him repeatedly and that resident had blocked these punches . Review of R23's Nursing Note dated 12/19/21 revealed, Please have resident evaluated by (physician) for progression of dementia symptoms. He continues to decline in the evening and consistently attempts to self-ambulate, creating a safety situation for him. Review of R23's Nursing Note dated 12/25/21 revealed, Resident exhibiting signs of delusions, primarily in the overnight, causing potential risk to his safety. He is becoming increasingly anxious, restless, and agitated . Review of R23's Care Plan revealed no entry for aggressive behavior resulting in a resident to resident altercation, increased paranoia, restlessness, or agitation. Resident #30 (R30) Review of an Admission Record revealed R30 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's Behavior Note dated 12/24/21 revealed, (R30) is showing signs of agitation and aggression. He attempted to hit a CNA tonight during cares. He is slowly becoming more restless and paranoid. Review of R30's Care Plans revealed no entry for combative behavior, aggression, paranoia, or dementia care. Resident #41 (R41) Review of an Admission Record revealed R41 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and observation 01/23/22 at 01:30 P.M., CNA PP reported that R41 had increased behaviors and frequently required 1:1 attention which included walking the hall with R41. Review of R41's Physician Note dated 1/24/21 revealed, .intermittent aggressive behavior and prior elopement risk . Review of R41's Care Plan revealed, The resident uses [CONDITION(S)] medications r/t Behavior management . Monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol . Review of R41's Care Plans revealed no entry for aggressive behavior, pacing, 1:1 care, or dementia care. Resident #40 (R40) Review of an Admission Record revealed R40 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . ([MEDICATION(S)] is a Benzodiazepines · Sedative-Hypnotic) Review of R40's Care Plans revealed no entry regarding monitoring for a Benzodiazepines/Sedative-Hypnotic, behavior management, or her mental health diagnosis. Resident #16 (R16) Review of an Admission Record revealed R16 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R16's Care Plan revealed, Anti psychotic; (R16) has a DX: of delusional DO. He currently receives [MEDICATION(S)] and is at risk for adverse side effects r/t medication use .All staff to document behaviors in behavior book. SS to check daily . Will be monitored on behavior management . Resident #3 (R3) Review of an Admission Record revealed R3 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R3's Behavior Note dated 12/24/21 revealed, Resident has been observed ambulating through the hallways she also has been going into other residents rooms this evening and urinating in their toilets when staff tries to redirect she will come out and just sit on the floor in the hallway . Review of R3's Care Plans revealed no entry regarding R3's wandering into other residents rooms. During an interview on 01/25/22 at 10:02 A.M., CNA PP reported that it was difficult to manage the residents' behaviors with insufficient staff. CNA PP reported that in the mornings there were only 2 CNA's scheduled to work and when 1 CNA went on break it left the other CNA to care for all of the residents on the Memory Care Unit. CNA PP reported that it was difficult to manage the residents' behaviors with insufficient staff. During an interview on 01/25/22 at 10:05 A.M., CNA OO reported that it was her first day as a CNA at the facility and she did not have access to the EHR .CNA OO reported she was unaware of where to document behaviors or who to notify of behaviors. Additionally, without the ability to access the EHR, CNA OO was unable to access resident Care Plans putting residents at risk when care planned interventions were not initiated/implemented. During an interview on 1/26/22 at 2:54 P.M., Activities Director (AD) R reported that there had been no social worker since December 6th, 2021, and she was told she would be assigned to social work tasks. AD R reported it was out of her scope of practice and she was not given time to complete the tasks because she had her duties as the Activities Director, was often pulled to work as a CNA on the units and was recently given the Resident Trust responsibilities. AD R reported that all Social Work assignments were on hold. AD R reported that the social worker was also responsible for making appointments (podiatry, optometry, dental, and changes in providers.) AD R reported that there were many overdue social work assignments in the Electronic Health Records. (Indicating there was no behavioral management program in place.) During an interview on 02/03/22 at 01:17 P.M., Unit Manager (UM) G reported that a social worker would be responsible for behavior management duties. UM G reported that there was no Social Worker in the facility. During an interview on 01/25/2022 at 12:19 P.M., Physician (P) Z reported that because of the high psychiatric needs of the residents residing in the facility, the facility needs to hire a social worker to ensure standards of practice are being met in regard to assessments, labs, consents etc. for resident on [CONDITION(S)] medications. During an interview on 01/25/22 at 02:03 P.M., Psychologist (P) QQ reported that the facility did not have a social worker and had not had one In quite a while. P QQ reported that the previous social worker would complete AIMS assessments, monitor labs, obtain consents, behavior management, and monitor GDR's (Gradual Dose Reductions.) P QQ reported that the DON was monitoring residents on [CONDITION(S)] medications at that time, and it was difficult for her to manage because she has so many other duties. P QQ stated, it's important to get someone (social worker) out here .I consider it useful and important. During an interview on 01/26/22 5:30 P.M., Medical Director AA reported that nonpharmacological interventions should be in place and initiated to control behaviors without increasing [CONDITION(S)] medications. MD AA reported that it was helpful to have meaningful activities to prevent behaviors in addition to increased staff presence. During an interview on 02/03/22 at 11:02 A.M., Interim NHA reported that she was unable to locate documentation of monthly IDT (interdisciplinary team) meetings related to behavior management/[CONDITION(S)] medication. During an interview on 01/24/22 4:38 P.M., Human Resources (HR) F was asked to review employee files with this surveyor. HR F reported that she was unable to locate orientation checklists, yearly competencies/evaluations, or education in the employee files. HR F reported there was no Nurse Educator hired in the facility and therefore no education tracking to ensure yearly requirements were met. During an interview on 02/03/22 at 08:33 A.M., Activity Director (AD) R reported that that she was beginning education to the activity staff regarding behaviors and dementia care but was uncertain if other departments were providing education. AD R reported that CNAs should be receiving 12 hours of education yearly and the education should include dementia care and behaviors. During an interview on 01/25/22 at 10:05 A.M., CNA OO reported that she had not had a background check for the facility, had not completed orientation, and did not have a skills evaluation prior to working the Memory Care Unit. During an interview on 2/1/22 at 1:03 P.M., CNA ZZ reported that she had not received yearly performance evaluation or regular in-service education since she was employed at the facility. During an interview on 01/23/22 at 11:10 A.M., CNA P and CNA O reported that they did not receive yearly competency evaluations or the 12 hour required education each year. During an interview on 1/26/22 at 2:54 P.M., Medical Records/CNA Scheduler (MRS) D reported that the new CNA hires were not educated, did not have proper orientation before being thrown on the floor, did not have annual competency evaluations, and did not have the required yearly education. MRS D reported that the training for the CNAs was not sufficient, and the CNAs were not completing their duties following professional standards of practice. There was no behavior book available for review for residents residing in the Memory Care Unit. Review of the Fundamentals of Nursing revealed, Managing Behavioral and Psychological Symptoms of Dementia o Identify social and environmental triggers of negative behavioral symptoms. Symptoms are individualized responses to the dementia disease process and can vary widely. Implement nonpharmacological practices that are tailored to the individual's needs. These include: Sensory practices: aromatherapy, massage, multisensory stimulation, and bright light therapy. Psychosocial practices: validation therapy, reminiscence therapy, music therapy, pet therapy, and meaningful activities. Structured care protocols (bathing and mouth care) Hand in Hand is a training course for direct care providers on safe, effective strategies for caring with persons with dementia. Recommendations for Staffing. Provide a thorough orientation that focuses on the care of individuals diagnosed with dementia. Provide consistent staff so that the staff member can learn more about the person, as well as the person and their family being able to develop a relationship with staff members. Encourage patients, families, and staff to develop and sustain professional, caring relationships. Providing a Supportive and Therapeutic Environment Promote safety, comfort, and dignity. Allow for choice for those with dementia to promote safe independence .Promote timely and effective communication across care settings. Utilizing transfer reports available in the electronic medical record can enhance the quality and timeliness of information sharing. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 182). Elsevier Health Sciences. Kindle Edition. Reassessment allows you to validate a patient's nursing diagnoses, review the care plan, and determine whether the nursing interventions remain the most appropriate for a patient's needs. If a patient's status has changed and the nursing diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An out-of-date or incorrect care plan compromises the quality of nursing care. Review and modification enable you to provide timely nursing interventions to best meet a patient's needs. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. The facility Administrative team was notified, on 01/31/22 at 10:53 A.M., of the Immediate Jeopardy (IJ) identified on 1/27/22 and that began on 01/23/22, failed to ensure facility staff met the requirements for dementia/behavior care education, ensure sufficient and qualified staff, and create and implement comprehensive individualized care plans to meet residents dementia/behavioral care needs for 10 out of 11 residents (R2, R5, R22, R19, R23, R30, R41, R40, R16, and R3), resulting in an Immediate Jeopardy beginning on 1/24/22 when R2 physically assaulted R5. This deficient practice resulted in diminished quality of life for residents with mental illness and dementia and the potential for additional instances of resident to resident abuse due to care planned interventions not being accurate, outdated, or missing. As of date of exit, 2/3/22 at 4:00 P.M., the facility had not developed an approved plan to remove the Immediate Jeopardy and the State Agency was not able to verify the residents living at the facility were free from the potential for serious injury, serious harm and or death.

Based on observation, interview and record review, the facility failed to provide medically related social services to attain and maintain the mental and psychosocial health for 12 resident (R6, R93, R11, R2, R19, R30, R41, R22, R23, R40, R16, and R3) due to the facility did not have a qualified employee working in this role resulting in a lack of a behavior management program; a system to monitor residents on anti-psychotic medications, coordination and transition of care and the maintenance of resident rights and quality of life. This deficient practiced resulted in an Immediate Jeopardy beginning on [DATE] when it was identified medically related social services were not in place creating the high likelihood for serious harm, serious injury and/or death for all residents residing in the facility. Findings: Review of a facility policy Advanced Directives last revised [DATE] reflected Advanced directives will be respected in accordance with state law and facility policy. According to the policy 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medial or surgical treatment and the right to formulate advanced directives .3. Prior to or upon admission of a resident, the Social Services Director of designee will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives. 4. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record .7. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive .17. The Director of Nursing Services or designee will notify the attending physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care. The attending physician will not be required to write orders for which he or she has an ethical or conscientious objection. Resident #6 (R6) Review of a facility Admission Record reflected R6 originally admitted to the facility on [DATE]. The section of the Admission Record pertaining to Advanced Directives was blank. Review of a facility Resident Code-Treatment Options Form signed on [DATE] reflected I (R6) specifically indicate my wishes regarding the following treatments in the event that I am unable to express my choices: No transfer to hospital; No CPR (Cardiopulmonary Resuscitation) including chest compressions and artificial breathing; No respirator/ventilator; No I.V. Hydration; No antibiotics; No Code Do Not Resuscitate (NO CPR) Review of an Order Recap Report for R6 for the date range [DATE]-[DATE] did not reflect an order specifying R6's wishes to remain a No Code Do Not Resuscitate (NO CPR) Review of the Electronic Medical Record (EMR) for evidence of care planning reflected R6 did not have an active care plan in place for any focus areas. Attempts to open a current care plan or Kardex (an at a glance care guide) resulted in documents annotated No Data Found. Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE]. The section of the Admission Record pertaining to Advanced Directives specified that R93 was a Full Code (CPR). Review of the entire Care Plan first initiated on [DATE] did not specify any Advanced Directives had been identified for R93. Review of an Advanced Directive signed by R93 on [DATE] reflected in the section pertaining to Cardiopulmonary Resuscitation (CPR) the R93 chose not to have CPR as evidenced by an X next to the choice I do not want CPR but instead want to allow natural death. Review of R93's Order Recap Report for the date range [DATE]-[DATE] reflected an order Advanced Directive: Full Code (CPR) ordered on [DATE]. Further review of the EMR did not reflect any reason for the change in code status from the Advanced Directive choices made by R93 and signed by R93 on [DATE]. During an interview on [DATE] at 11:45 a.m., Licensed Practical Nurse (LPN) M reported that if she needed to quickly find a resident's code status, she would look at the resident banner at the top of the resident information in the EMR. LPN M said the facility did not maintain any separate documentation for identifying a person's code status and that if that area of the EMR was left blank she would assume the resident was to be a Full Code. A request for a list of residents and their code status was requested via email communication to the facility administrative team on [DATE] at 8:31 a.m. During an interview on [DATE] at 10:45 a.m., the acting Nursing Home Administrator reported that she had not been able to run a report in the EMR for easily identifying any given resident's code status and did not have the requested information available. As of the date and time of exit from the facility on [DATE] at 4:30 p.m., the requested information was not provided to the survey team. Resident #11 (R11) Review of an Admission Record revealed R11 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes and hypertension. Review of a Minimum Data Set (MDS) assessment for R11, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated R 11 was moderately cognitively impaired. Review of the Facility Bulletin Board in the Electronic Health Record revealed, [DATE] (R11) was very upset this evening stating he wants to leave this facility. Resident states he has asked for a different Dr. (doctor) multiple times and no one has done anything for him. Resident also states he needs to see an eye Dr. so that he can get new glasses. I assured him his request would be made known. Review of R11's Progress Notes revealed no documentation that an appointment was made or that an appointment had been completed for an eye appointment or that a change in his primary provider had been completed Review of R11's Admission Record as of [DATE] revealed R11 continued to have MD AA assigned as his physician. Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: restlessness, agitation, altered mental status, and anxiety. Review of R2's Physician Order dated [DATE] revealed, [MEDICATION(S)] Tablet 25 MG ([MEDICATION(S)]) and [MEDICATION(S)] Tablet 5 MG ([MEDICATION(S)]). (antipsychotic medications). Resident #19 (R19) Review of an Admission Record revealed R19 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke, dementia, and depression. Review of R19's Physician Order dated [DATE] revealed [MEDICATION(S)] Tablet 50 MG. Resident #30 (R30) Review of an Admission Record revealed R30 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, psychotic disorder, and adjustment disorder. Review of R30's Physician Order dated [DATE] revealed, [MEDICATION(S)] Tablet 25 MG. Resident #41 (R41) Review of an Admission Record revealed R41 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with behavioral disturbances and [CONDITION(S)]. Review of R41's Physician Order dated [DATE] revealed, [MEDICATION(S)] Tablet 0.25 MG ([MEDICATION(S)]). Resident #22 (R22) Review of an Admission Record revealed R22 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with behavioral disturbances. Review of R22's Physician Order dated [DATE] revealed, [MEDICATION(S)] Tablet 0.25 MG ([MEDICATION(S)]). (Antipsychotic medication). Resident #23 (R23) Review of an Admission Record revealed R23 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: delusional disorder, dementia, and anxiety. Review of R23's Physician Order dated [DATE] revealed, [MEDICATION(S)] Tablet 5 MG. Resident #40 (R40) Review of an Admission Record revealed R40 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: altered mental status and alcoholism. Review of R40's Physician Order dated [DATE] revealed, [MEDICATION(S)] Tablet 5 MG. Resident #16 (R16) Review of an Admission Record revealed R16 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and delusional disorder. Review of R16's Physician Order dated [DATE] revealed, [MEDICATION(S)] Tablet 5 MG ([MEDICATION(S)]). Resident #3 (R3) Review of an Admission Record revealed R3 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: [CONDITION(S)] disorder and [CONDITION(S)] disorder. Review of R3's Physician Order dated [DATE] revealed, [MEDICATION(S)] Tablet 20 MG. Physician risk versus benefit, monthly IDT (interdisciplinary team) documentation/Behavior Monitoring, completed activity logs, laboratory results/vital sign monitoring, EKG, AIMS assessments, guardian consent documentation, and GDR documentation was requested for R2, R19, R30, R41, R22, R23, R40, R16, R3 on [DATE] at 8:31 A.M., [DATE] at 2:57 P.M., [DATE] at 8:30 A.M., and on [DATE] at 4:00 P.M. On [DATE] at 4:45 P.M., the Interim Nursing Home Administrator provided documentation via email of the following: R19: A1C result dated [DATE], [DATE], an EKG dated [DATE] R23: A1C, TSH, Lipid Panel, and GFR dated [DATE] and a Dose Reduction History (not signed by the physician) dated [DATE] R22: A1C dated [DATE], EKG dated [DATE], and Dose Reduction History (not signed by the physician) dated [DATE] and [DATE]. No other documents were received prior to the survey exit. During an interview on [DATE] at 12:36 P.M., Interim NHA reported that any residents on antipsychotic medication should be followed by psych services. Interim NHA reported that there was a breakdown somewhere. During an interview on [DATE] at 11:02 A.M., Interim NHA reported that she was unable to locate documentation for physician risk versus benefit, monthly IDT (interdisciplinary team) documentation, completed activity logs, laboratory results/vital sign monitoring (blood sugars 2x month, ortho blood pressures monthly, electrocardiogram, HbA1C), AIMS assessments, guardian consent documentation, and GDR documentation (gradual dose reduction) for R2, R19, R30, R41, R22, R23, R30, R16, R3. Interim NHA reported that there was no social worker ensuring residents with anti-psychotic medication were routinely monitored and assessed and all other required documents were completed. Interim NHA reported that a contracted team specializing in [CONDITION(S)] medications would be completing full assessments on all residents residing in the facility on [CONDITION(S)] medication. During an interview on [DATE] at 2:54 P.M., Activities Director (AD) R reported that there had been no social worker since [DATE]th, 2021, and she was told she would be assigned to social work tasks. AD R reported it was out of her scope of practice and she was not given time to complete the tasks because she had her duties as the Activities Director, was often pulled to work as a CNA on the units and was recently given the Resident Trust responsibilities. AD R reported that all Social Work assignments were on hold. AD R reported that the social worker was also responsible for making appointments (podiatry, optometry, dental, and changes in providers.) AD R reported that there were many overdue social work assignments in the Electronic Health Records. During an interview on [DATE] at 12:19 P.M., Physician (P) Z reported that because of the high psychiatric needs of the residents residing in the facility, the facility needs to hire a social worker to ensure standards of practice are being met in regard to assessments, labs, consents etc for resident on [CONDITION(S)] medications. During an interview on [DATE] at 02:03 P.M., Psychiatrist (P) QQ reported that the facility did not have a social worker and had not had one In quite a while. P QQ reported that the previous social worker would complete AIMS assessments, monitor labs, obtain consents, behavior management, and monitor GDR's (Gradual Dose Reductions.) P QQ reported that the DON was monitoring residents on [CONDITION(S)] medications at that time, and it was difficult for her to manage because she has so many other duties. P QQ stated, it's important to get someone (social worker) out here .I consider it useful and important. During an interview on [DATE] at 01:17 P.M., Unit Manager (UM) G reported that a social worker ensures beauty appointments, podiatry/optometry/specialty appointments are followed up with and made and ensures that resident preferences with physicians are followed. UM G reported that there was no Social Worker in the facility. Review of the facility Nursing Reference Book revealed, .A consent form needs to be signed by the resident or responsible party PRIOR to administering any of the above (antipsychotic) medications .ANTIPSYCHOTIC MEDS-APPROPRIATE DIAGNOSES (IF NOT LEAVE NOTE FOR SOCIAL SERVICES) ORTHOSTATIC B/P'S (blood pressures) MONTHLY, BS (blood sugar) CHECKS MONTHLY BID (twice a day), LIPID PANEL YEARLY, LFT Q 6 MO (liver function test every 6 months), HGBA1C Q 3 MONTHS (glycohemoglobin test/blood sugar test every 3 months). ANTIANXIETY, ANTIDEPRESSANT, ANTIPSYCHOTIC CONSENT SIGNED. (SEE FACT SHEET FOR LIST OF [CONDITION(S)] MEDICATIONS) . The facility Administrative team was notified, on [DATE] at 10:53 A.M., of the Immediate Jeopardy (IJ) that was identified on [DATE] and began on [DATE], when the facility failed to provide medically related social services to attain and maintain the mental and psychosocial health for 12 resident (R6, R93, R11, R2, R19, R30, R41, R22, R23, R40, R16, and R3) due to the facility did not have a qualified employee working in this role resulting in a lack of a behavior management program; a system to monitor residents on anti-psychotic medications, coordination and transition of care and the maintenance of resident rights and quality of life. This deficient practiced resulted in an Immediate Jeopardy beginning on [DATE] when it was identified medically related social services were not in place creating the high likelihood for serious harm, serious injury and/or death for all residents residing in the facility. As of date of exit, [DATE] at 4:00 P.M., the facility had not developed an approved plan to remove the Immediate Jeopardy and the State Agency was not able to verify the residents living at the facility were free from the potential for serious injury, serious harm and or death.

Based on interview and record review, the facility failed to obtain consent for the use of a [CONDITION(S)] medication prior to the administration of the medication, failed to attempt a Gradual Dose Reduction (GDR), failed to monitor vital signs and adverse effects, and failed to routinely assess/address concerns in behavior meetings for 9 residents (R2, R19, R30, R41, R22, R23, R40, R16, and R3) reviewed for [CONDITION(S)] medications, resulting in an Immediate Jeopardy beginning on 12/06/21 when it was identified that there was no system in place to monitor residents receiving antipsychotic medications, resulting in the high likelihood for serious harm, serious injury and/or death. Findings: Review of the facility Nursing Reference Book revealed, .A consent form needs to be signed by the resident or responsible party PRIOR to administering any of the above (antipsychotic) medications .ANTIPSYCHOTIC MEDS-APPROPRIATE DIAGNOSES (IF NOT LEAVE NOTE FOR SOCIAL SERVICES) ORTHOSTATIC B/P'S (blood pressures) MONTHLY, BS (blood sugar) CHECKS MONTHLY BID (twice a day), LIPID PANEL YEARLY, LFT Q 6 MO (liver function test every 6 months), HGBA1C Q 3 MONTHS (glycohemoglobin test/blood sugar test every 3 months). ANTIANXIETY, ANTIDEPRESSANT, ANTIPSYCHOTIC CONSENT SIGNED. (SEE FACT SHEET FOR LIST OF [CONDITION(S)] MEDICATIONS) . During an interview on 02/01/22 at 12:36 P.M., Interim NHA reported that any residents on antipsychotic medication should be followed by psych services. Interim NHA reported that there was a breakdown somewhere. During an interview on 02/03/22 at 11:02 A.M., Interim NHA reported that she was unable to locate documentation for physician risk versus benefit, monthly IDT (interdisciplinary team) documentation, completed activity logs, laboratory results/vital sign monitoring (blood sugars 2x month, ortho blood pressures monthly, electrocardiogram, HbA1C), AIMS assessments, guardian consent documentation, and GDR documentation (gradual dose reduction) for R2, R19, R30, R41, R22, R23, R30, R16, R3. Interim NHA reported that there was no social worker ensuring residents with anti-psychotic medication were routinely monitored and assessed and all other required documents were completed. Interim NHA reported that a contracted team specializing in [CONDITION(S)] medications would be completing full assessments on all residents residing in the facility on [CONDITION(S)] medication. During an interview on 1/26/22 at 2:54 P.M., Activities Director (AD) R reported that there had been no social worker since December 6th, 2021, and she was told she would be assigned to social work tasks. AD R reported it was out of her scope of practice and she was not given time to complete the tasks because she had her duties as the Activities Director, was often pulled to work as a CNA on the units and was recently given the Resident Trust responsibilities. AD R reported that all Social Work assignments were on hold. AD R reported that the social worker was also responsible for making appointments (podiatry, optometry, dental, and changes in providers.) AD R reported that there were many overdue social work assignments in the Electronic Health Records. During an interview on 01/25/2022 at 12:19 P.M., Physician (P) Z reported that because of the high psychiatric needs of the residents residing in the facility, the facility needs to hire a social worker to ensure standards of practice are being met in regard to assessments, labs, consents etc for resident on [CONDITION(S)] medications. During an interview on 01/25/22 at 02:03 P.M., Psychiatrist (P) QQ reported that the facility did not have a social worker and had not had one In quite a while. P QQ reported that the previous social worker would complete AIMS assessments, monitor labs, obtain consents, behavior management, and monitor GDR's (Gradual Dose Reductions.) P QQ reported that the DON was monitoring residents on [CONDITION(S)] medications at that time, and it was difficult for her to manage because she has so many other duties. P QQ stated, it's important to get someone (social worker) out here .I consider it useful and important. During an interview on 02/03/22 at 01:17 P.M., Unit Manager (UM) G reported that a social worker would be responsible for behavior management duties. UM G reported that there was no Social Worker in the facility. Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: restlessness, agitation, altered mental status, and anxiety. Review of R2's Physician Order dated 8/27/21 revealed, [MEDICATION(S)] Tablet 25 MG ([MEDICATION(S)]) and [MEDICATION(S)] Tablet 5 MG ([MEDICATION(S)]). (antipsychotic medications). Resident #19 (R19) Review of an Admission Record revealed R19 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke, dementia, and depression. Review of R19's Physician Order dated 5/20/21 revealed [MEDICATION(S)] Tablet 50 MG. Resident #30 (R30) Review of an Admission Record revealed R30 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, psychotic disorder, and adjustment disorder. Review of R30's Physician Order dated 1/10/22 revealed, [MEDICATION(S)] Tablet 25 MG. Resident #41 (R41) Review of an Admission Record revealed R41 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with behavioral disturbances and [CONDITION(S)]. Review of R41's Physician Order dated 11/23/21 revealed, [MEDICATION(S)] Tablet 0.25 MG ([MEDICATION(S)]). Resident #22 (R22) Review of an Admission Record revealed R22 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with behavioral disturbances. Review of R22's Physician Order dated 11/23/21 revealed, [MEDICATION(S)] Tablet 0.25 MG ([MEDICATION(S)]). (Antipsychotic medication). Resident #23 (R23) Review of an Admission Record revealed R23 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: delusional disorder, dementia, and anxiety. Review of R23's Physician Order dated 1/11/22 revealed, [MEDICATION(S)] Tablet 5 MG. Resident #40 (R40) Review of an Admission Record revealed R40 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: altered mental status and alcoholism. Review of R40's Physician Order dated 1/11/22 revealed, [MEDICATION(S)] Tablet 5 MG. Resident #16 (R16) Review of an Admission Record revealed R16 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and delusional disorder. Review of R16's Physician Order dated 9/29/21 revealed, [MEDICATION(S)] Tablet 5 MG ([MEDICATION(S)]). Resident #3 (R3) Review of an Admission Record revealed R3 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: [CONDITION(S)] disorder and [CONDITION(S)] disorder. Review of R3's Physician Order dated 8/27/21 revealed, [MEDICATION(S)] Tablet 20 MG. Physician risk versus benefit, monthly IDT (interdisciplinary team) documentation/Behavior Monitoring, completed activity logs, laboratory results/vital sign monitoring, EKG, AIMS assessments, guardian consent documentation, and GDR documentation was requested for R2, R19, R30, R41, R22, R23, R40, R16, R3 on 2/1/22 at 8:31 A.M., 2/1/22 at 2:57 P.M., 2/3/22 at 8:30 A.M., and on 2/3/22 at 4:00 P.M. On 2/3/22 at 4:45 P.M., the Interim Nursing Home Administrator provided documentation via email of the following: R19: A1C result dated 8/17/21, 11/16/21, an EKG dated 6/3/21 R23: A1C, TSH, Lipid Panel, and GFR dated 10/19/21 and a Dose Reduction History (not signed by the physician) dated 7/7/21 R22: A1C dated 6/19/20, EKG dated 3/13/20, and Dose Reduction History (not signed by the physician) dated 1/20/21 and 4/21/21. No other documents were received prior to the survey exit. The facility Administrative team was notified, on 01/31/22 at 10:53 A.M., of the Immediate Jeopardy (IJ) that was identified on 1/27/22 and began on 12/6/21, when the facility failed to obtain consent for the use of a [CONDITION(S)] medication prior to the administration of the medication, failed to attempt a Gradual Dose Reduction (GDR), failed to monitor vital signs and adverse effects, and failed to routinely assess/address concerns in behavior meetings for 9 residents (R2, R19, R30, R41, R22, R23, R40, R16, and R3) reviewed for [CONDITION(S)] medications, resulting in the high likelihood for serious harm, serious injury and/or death. As of date of exit, 2/3/22 at 4:00 P.M., the facility had not developed an approved plan to remove the Immediate Jeopardy and the State Agency was not able to verify the residents living at the facility were free from the potential for serious injury, serious harm and or death.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an Immediate Jeopardy (IJ) beginning on [DATE] as the result of the widespread and systemic breakdown in sanitary conditions creating the high likelihood for cross contamination of food and foodborne illness. This deficient practice has the high likelihood of affecting all residents who receive oral food meal services out of the facility's total census of 48 residents. Findings include: 1. On [DATE] at 11:44 AM, five containers of raw shell eggs were observed stored over the top of seven gallons of milk in the walk-in cooler. On [DATE] at 11:45 AM, the surveyor inquired with the Dietary Manager, staff B, if items were stored in any specific way in the walk-in cooler to which they replied, yes, raw on the bottom, but we don't have written policy on that. I can print off a sign and post it as a reminder. We normally only use pasteurized eggs, but we couldn't get them on our last delivery. On [DATE] at 8:05 AM, six containers of raw shell eggs were observed stored over the top of open boxes containing individual packets of condiments such as assorted salad dressings, mayonnaise, ketchup, mustard, and barbeque sauce in the walk-in cooler. At this time no sign was observed posted on the interior or exterior of the unit identifying the proper storage of items. On [DATE] at 8:15 AM, upon interview with the Certified Dietary Manager (CDM), staff II, on the facility's expectation on how items should be stored in the walk-in cooler to prevent against foodborne illness they stated, I do my checks throughout the day, but everyone helps put things away so mistakes can happen, and we have a lot of new staff that have never worked in a kitchen before. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation directs that: (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(c) below, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables, P and (b) Cooked READY-TO-EAT FOOD 2. On [DATE] at 11:44 AM, two cans of marinara sauce and two cans of mandarin oranges were observed with dents on their surfaces ranging from ½ to 2 inches in diameter on the ready for use storage rack. On [DATE] at 11:45 AM, the surveyor inquired with the Dietary Manager, staff B, on how the facility handles receiving damaged food items to which they stated, we used to try and return them for credit, but we are not getting deliveries like we used too. I will set these aside so we don't use them. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].15 Package Integrity directs that: FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. 3. On [DATE] at 11:30 AM, the kitchen's steam table was observed leaking from its lower left-hand corner into a pan on the floor. On [DATE] at 11:44 AM, upon interview with the Dietary Manager, staff B, on the current state of the steam table they stated, we need a new one. It's been like this since I started in December. I don't think we have placed an order for a new one yet though. Our steamer doesn't work at all. On [DATE] at 11:53 AM, the kitchen's steamer was observed with its temperature dial in the on position, however inspection of the interior of the unit revealed no heat coming from the unit. On [DATE] at 11:57 AM, Dietary Aide, staff S, was observed using a pair of pliers to turn a knob on an electrical switch next to the dishmachine. Upon observation the surveyor inquired with staff S on the purpose of the pliers to which they stated, the switch broke off, now this is the only way we can make the disposal work. At this time staff B stated, Maintenance is aware of it, but I think they are waiting to replace the disposal at the same time. We have been having issues with it not working all of the time. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Good Repair and Proper Adjustment directs that: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts ,d+[DATE] and ,d+[DATE]. 4. On [DATE] at 11:48 AM, six quarts of 40% heavy whipping cream were observed ready for use and past the manufacture's expiration date of [DATE]. At this time the surveyor inquired with the Dietary Manager, staff B, on who was responsible for checking the expiration dates of the food products in the facility to which they replied, I am. I just checked everything yesterday after talking with one the other surveyors that came in here. I'm so short I couldn't see the labels on the top shelf until they pointed them out to me. I missed these, I will throw them out now. On [DATE] at 11:49 AM, staff B was observed discarding of the expired products. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition directs that: (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen 5. On [DATE] between 11:30 AM, and 12:17 PM, during a tour of the dietary environment the following non-food contact surfaces were observed soiled and with an accumulation of dust and debris: On the gas stove top. On the sides of the ovens. On the flooring in the main kitchen preparation area. On the interior of the two-door reach in refrigerator. Underneath the dish machine. On the dry storage rack. On the flooring and shelving in the walk-in cooler. Within the pullout utensil drawers on the back side of the cook line. On the interior of the juice dispensing machine. On the flooring under the steam well serving table. On [DATE] between 11:30 AM, and 12:17 PM, during a tour of the dietary environment the following food contact surfaces were observed soiled and with an accumulation of dust and debris: On the electronic can openers blade. On the manual handheld can opener On three portioning scoops. Within the interior of the kitchen's microwave. On [DATE] at 12:19 PM, upon interview with the Dietary Manager, staff B, on the current state of the kitchen flooring they stated, we do the best we can to keep to the cleaning schedule. We do keep cleaning logs, but I know they are not filled out every day. At this time the surveyor requested the cleaning logs to review to which staff B stated, Sure, I have them right here on this clipboard. On [DATE] at 12:21 PM, upon record review of one document entitled, weekly cleaning schedule and, one document entitled, daily cleaning schedule the surveyor confirmed that the facility has policies in place to achieve a clean and sanitary environment in the kitchen throughout the week, however no tasks were initialed to identify their completion on over the previous week on either form. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, directs that: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 6. On [DATE] at 12:30 PM, at 12:44 PM, and at 1:13 PM, Cook, staff HH, was observed taking off gloves, adjusting their mask, and putting on a new pair of gloves without washing their hands while assembling meal trays and plating meals for lunch service. On [DATE] at 1:26 PM, Dietary Aide, staff S, was observed donning gloves prior to washing their hands after touching refrigerator door handles, prep counters, and baking sheets. On [DATE] at 11:59 AM, and at 12:11 PM, Activities Director, Staff R, was observed removing and donning new pairs of gloves during food preparation and the plating of meals for lunch service prior to washing their hands. On [DATE] at 8:19 PM, and at 8:26 PM, Wound Care Nurse, Staff KK, was observed removing and donning new pairs of gloves while plating meals for dinner service prior to washing their hands. On [DATE] at 8:34 PM, Nursing Supervisor, staff JJ, was observed removing and donning new pairs of gloves while plating meals for dinner service prior to washing their hands. On [DATE] at 7:48 AM, Cook, staff LL, was observed donning gloves prior to washing their hands after touching their clothing, their mask, refrigerator door handles, thermometers, a container of butter, a bag of bread, a knife, a toaster, and food prep counters. On [DATE] at 7:54 AM, the surveyor inquired with CDM, staff II, on the hand hygiene expectations for staff when they choose to use gloves as a hand barrier to which they replied, wash their hands before they put them on. On [DATE] at 11:45 AM, Dietary Aide, staff S, was observed donning gloves prior to washing their hands after touching their face, their mask, and refrigerator door handles. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].14 When to Wash directs that: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § ,d+[DATE].12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands 7. On [DATE] at 10:20 AM, Dietary Manager, staff B, was asked to run a Thermolabel (irreversible temperature strip) through the high temperature dish washer. Staff B stated they did not have a log demonstrating the kitchen staff were checking the dish machine temperature daily and had to leave the kitchen to go to an office at the front of the building to obtain test strips. The first test strip was run at 10:30 AM, and did not register the dish machine had reached 160 degrees Fahrenheit. A second test strip was run and also did not reflect the proper temperature for sanitizing dishes had been reached. The temperature gauge on the dish machine was observed during both tests reaching a maximum temperature of 130 degrees. Staff B stated, the facility would work around the problem by sanitizing clean dishes in a quaternary solution until maintenance could look into the problem. On [DATE] at 11:55 AM, and at 12:07 PM, Dietary Aide, staff S was observed disassembling a food processor after pureeing chicken, rinsing the parts with the overhead spray wand from the dirty side of the dishmachine and then assembling the parts back together without washing or sanitizing the items prior to adding broccoli into the food processor and continue working. On [DATE] at 12:09 PM, during an interview with the Dietary Manager, staff B, the surveyor asked how the staff would normally clean and sanitize pieces of equipment prior to use to which they replied, well, normally we would just run it through our dish machine, but it's not sanitizing at the moment. Right now, we are still sending items though it and then taking them to the 3-compartment sink to sanitize them. At this time the surveyor asked staff B if all the staff have been educated on this change in the cleaning procedure to which they replied, not all of them, but we do have a new employee that just started today. At this time staff B was observed by the surveyor educating the dietary staff present in the kitchen on this change in the cleaning procedure. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Before Use After Cleaning directs that: UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be sanitized before use after cleaning. 8. On [DATE] at 12:12 PM, the surveyor inquired with Dietary Manager, staff B, if they could test to the sanitizing compartment of the 3-compartment sink to verify its concentration to which they replied, of course, we just changed it out a little bit ago. We try and make sure it is swapped out about every two or three hours. On [DATE] at 12:13 PM, testing of the sanitizer concentration by staff B via a test strip revealed a concentration of zero. Upon observation staff B placed their hand in the solution and stated, oh this is cold. I will remake it now. On [DATE] at 12:17 PM, testing of the sanitizer concentration by staff B via a test strip revealed a concentration of 300 ppm to which they stated, much better with warm water. We try to keep always keep it between 200 ppm and 400 ppm. I'll talk to my staff and try and catch anything recently used in this sink and have it sent back. On [DATE] at 12:18 PM, upon further investigation the surveyor observed a blank log titled, three compartment sink sanitizing solution PPM log posted on the wall next to the 3-compartment sink dated [DATE] which displayed chemical concentration parameters for proper sanitizing to occur. Upon observation the surveyor asked staff B if this was a facility policy to be followed to which they replied, we should. If it was before we haven't been using it. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization Temperature, pH, Concentration, and Hardness directs that: A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under ,d+[DATE].11(C) shall meet the criteria specified under §,d+[DATE].11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), (2) Have a concentration as specified under § ,d+[DATE].11 and as indicated by the manufacturer's use directions included in the labeling, P and (3) Be used only in water with 500 MG/L hardness or less or in water having a hardness no greater than specified by the EPA-registered label use instructions; 9. On [DATE] at 1:09 PM, multiple staff members were observed placing meal trays on a wheeled speed rack commonly used for cooling practices in a walk-in cooler or a walk-in freezer. On [DATE] at 1:10 PM, upon interview with Dietary Aide, staff S, on what the purpose of this cart was to which they stated, this is the only one we have left. Once we use the other two covered ones, we have to start using this one because the other ones don't come back to the kitchen in time, and we have more meals to serve. At this time the surveyor asked staff S as a result of using this style of cart to transport meals if they thought it had the same level of protection as the other carts to which they replied, no, not really, but we don't have anything to cover it with. We could wrap the silverware and sippy cup lids. Sometimes we have trays sent back because the food gets too cold so we have to heat them up in the microwave. Ever since we started adding people into the west wing we have to use it because can't keep up. On [DATE] between 1:13 PM and 1:23 PM, the surveyor verified that proper hot and cold holding temperatures were in compliance per the current FDA food code with all the trays on the cart. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Miscellaneous Sources of Contamination directs that: FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] -,d+[DATE]. 10. On [DATE] at 1:39 PM, employee designated personal storage areas were observed not being consistently utilized as multiple employee beverages were observed stored on the food preparation line and assembly area. One employee personal cell phone, its charger, a bottle of hand lotion, two jackets and a box of tissues were observed stored on the dry storage rooms wire shelving above and next to food and single use items. On [DATE] at 1:42 PM, upon interview with the Dietary Manager, staff B, it was confirmed that staff are aware of the designated areas to be used for employee storage, however the facility has no written policy in place discussing the proper storage location(s) of employee items while working in the kitchen. Staff B then stated, We could post a sign and add a shelf, but their lockers are right next door. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Designated Areas directs that: (A) Areas designated for EMPLOYEES to eat, drink, and use tobacco shall be located so that FOOD, EQUIPMENT, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES are protected from contamination. 11. On [DATE] at 2:00 PM, a test tray was requested by the surveyor from Cook, staff HH, to which they replied, sure, we are just about done. I've got enough for one more tray. On [DATE] at 2:07 PM, inspection of the test tray revealed a chicken breast holding at a temperature of 93 degrees F via the surveyor's thermometer. On [DATE] at 2:08 PM, the surveyor asked staff HH what temperatures they would normally cook and hold a chicken breast at to which they replied, I'd boil everything if I could. I like things hot. I'm not sure on how hot that it needs to be, but I like our food steaming. So much so we have to turn our steam table down so it doesn't get too hot. On [DATE] at 2:09 PM, the surveyor took a temperature reading of the glass of milk on the tray which revealed a holding temperature of 62 degrees F. At this time the surveyor inquired with the Dietary Manager, staff B, on what the expectation would be for a food product found holding at this temperature to which they stated, throw it out. On [DATE] at 11:00 AM, a tray was returned to the kitchen from CNA, staff V, and received by Dietary Aide, staff S. At this time staff V asked staff S, could you warm this up for me? They are awake now and the tray has been sitting. On [DATE] at 11:01 AM, the surveyor observed staff S beginning to place individual plates of food in the microwave, removing them one at a time and placing them back on the tray. On [DATE] at 11:03 AM, the surveyor inquired with staff S if they had an opportunity to check the temperature of the food before placing the items in the microwave and taking them out to which they said, no. I usually just put them in for 30 seconds, but we have one more plate I didn't put in yet that we can temp. At this time staff S grabbed an alcohol prep pad and a thermometer and began taking an internal temperature of pureed sausage. On [DATE] at 11:04 AM, the thermometer revealed an internal temperature of 80 degrees F. At this time the surveyor inquired with staff S on what they would normally do with a product holding at this temperature to which they replied, I don't know what you mean. The surveyor then asked staff S if there was any particular temperature that needed to be achieved prior to being served to ensure the foods safety to which they stated, no one has ever told me it needs to be at a certain temperature. I just hit 30 seconds. If it looks like I need to stir it, I usually just put it in for another ten seconds after that. At this time the surveyor asked if staff S would mind taking additional temperatures of the items they just took out of the microwave to which they replied, of course. On [DATE] at 11:05 AM, the thermometer revealed an internal temperature of pureed eggs to be at 140 degrees F, cream of wheat to be at 137 degrees F, and a glass of milk to be at 61 degrees F. At this time CNA, staff V, asked the surveyor what temperatures the food should be at, to which the surveyor then provided direction for the staff on how locate the requirements in the 2013 U.S. Public Health Service Food Code, Chapters ,d+[DATE].11 and ,d+[DATE].16. On [DATE] at 11:08 AM, staff S stated, I didn't know that. I'll make them hotter to which Staff V added, I work in the kitchen sometimes when they need me, and I never knew that either. I don't know if anyone would have if you hadn't shown us. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding directs that: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §,d+[DATE].19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in ,d+[DATE].11(B) or reheated as specified in ,d+[DATE].11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5ºC (41ºF) or less. P Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Reheating for Hot Holding directs that: (B) Except as specified under (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74oC (165oF) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. 12. On [DATE] at 12:09 PM, during an interview with the Dietary Manager, staff B, the surveyor asked how the staff would normally clean and sanitize pieces of equipment prior to use to which they replied, well, normally we would just run it through our dish machine, but it's not sanitizing at the moment. Right now, we are still sending items though it and then taking them to the 3-compartment sink to sanitize them. At this time the surveyor asked staff B if all the staff have been educated on this change in the cleaning procedure to which they replied, not all of them, but we do have a new employee that just started today. On [DATE] at 12:13 PM, testing of the sanitizer concentration by staff B via a test strip revealed a concentration of zero. Upon observation staff B placed their hand in the solution and stated, oh this is cold. I will remake it now. On [DATE] at 12:17 PM, testing of the sanitizer concentration by staff B via a test strip revealed a concentration of 300 ppm to which they stated, much better with warm water. We try to keep always keep it between 200 ppm and 400 ppm. I'll talk to my staff and try and catch anything recently used in this sink and have it sent back. On [DATE] at 12:18 PM, upon further investigation the surveyor observed a blank log titled, three compartment sink sanitizing solution PPM log posted on the wall next to the 3-compartment sink dated [DATE] which displayed chemical concentration parameters for proper sanitizing to occur. Upon observation the surveyor asked staff B if this was a facility policy to be followed to which they replied, we should. If it was before we haven't been using it. On [DATE] at 12:19 PM, upon interview with the Dietary Manager, staff B, on the current state of the kitchen flooring they stated, we do the best we can to keep to the cleaning schedule. We do keep cleaning logs, but I know they are not filled out every day. At this time the surveyor requested the cleaning logs to review to which staff B stated, Sure, I have them right here on this clipboard. On [DATE] at 12:21 PM, upon record review of one document entitled, weekly cleaning schedule and, one document entitled, daily cleaning schedule the surveyor confirmed that the facility has policies in place to achieve a clean and sanitary environment in the kitchen throughout the week, however no tasks were initialed to identify their completion on over the previous week on either form. On [DATE] at 2:08 PM, the surveyor asked Cook, staff HH, on what temperatures they would normally cook and hold a chicken breast at to which they replied, I'd boil everything if I could. I like things hot. I'm not sure on how hot that it needs to be, but I like our food steaming. On [DATE] at 11:03 AM the surveyor asked Dietary Aide, staff S, if there was any particular reheating temperature of food that needed to be achieved prior to being served to ensure the foods safety to which they stated, no one has ever told me it needs to be at a certain temperature. I just hit 30 seconds. If it looks like need to stir it, I usually just put it in for another ten seconds after that. On [DATE] at 11:08 AM, upon direction from the surveyor to specific reheating requirements in the current FDA food code staff S stated, I didn't know that. I'll make them hotter to which V added, I work in the kitchen sometimes when they need me, and I never knew that either. I don't know if anyone would have if you hadn't shown us. On [DATE] at 8:15 AM, upon interview with the Certified Dietary Manager, staff II, on the facility's expectation on how items should be stored in the walk-in cooler to prevent against foodborne illness they stated, I do my checks throughout the day, but everyone helps put things away so mistakes can happen, and we have a lot of new staff that have never worked in a kitchen before. On [DATE] at 12:27 PM, the surveyor asked PM Cook, staff NN, if the facility had provided any training to them on how to safely thaw food items to which they replied, no. I just came in last night and this is my second day in the kitchen. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Person in Charge directs that: The PERSON IN CHARGE shall ensure that: (D) EMPLOYEES are effectively cleaning their hands, by routinely monitoring the EMPLOYEES' handwashing; Pf (E) EMPLOYEES are visibly observing FOODS as they are received to determine that they are from APPROVED sources, delivered at the required temperatures, protected from contamination, UNADULTERED, and accurately presented, by routinely monitoring the EMPLOYEES' observations and periodically evaluating FOODS upon their receipt; Pf (F) EMPLOYEES are verifying that FOODS delivered to the FOOD ESTABLISHMENT during non-operating hours are from APPROVED sources and are placed into appropriate storage locations such that they are maintained at the required temperatures, protected from contamination, unADULTERATED, and accurately presented;Pf (G) EMPLOYEES are properly cooking TIME/TEMPERATURE CONTROL FOR SAFETY FOOD, being particularly careful in cooking those FOODS known to cause severe foodborne illness and death, such as EGGS and COMMINUTED MEATS, through daily oversight of the EMPLOYEES' routine monitoring of the cooking temperatures using appropriate temperature measuring devices properly scaled and calibrated as specified under § ,d+[DATE].11 and ,d+[DATE].11(B); Pf (J) EMPLOYEES are properly SANITIZING cleaned multiuse EQUIPMENT and UTENSILS before they are reused, through routine monitoring of solution temperature and exposure time for hot water SANITIZING, and chemical concentration, pH, temperature, and exposure time for chemical SANITIZING; Pf (M) EMPLOYEES are properly trained in FOOD safety, including FOOD allergy awareness, as it relates to their assigned duties;Pf (O) Written procedures and plans, where specified by this Code and as developed by the FOOD ESTABLISHMENT, are maintained and implemented as required. Pf 13. On [DATE] at 1:16 PM, the surveyor observed the last meal tray served to the residents for the days lunch. At this time the surveyor overheard Dietary Aide, staff S, state to Activities Director, staff R, that, I'm supposed to be done at 2 o'clock, do you know if we have anyone coming in this afternoon? to which staff R replied, last I talked to the Administrator, no. And I have to go back to being a CNA now. On [DATE] at 2:04 PM, the surveyor observed two full carts filled with trays of eaten and partially eaten meals along with numerous plates, bowls, trays, silverware, adaptive equipment and used napkins on the counter surface of the dirty side of the dish machine stacked over two feet in height. On [DATE] between 2:05 PM and 2:40 PM, the surveyor was unable to locate any Dietary staff in the building. On [DATE] at 3:01 PM, upon interview with Staff R the surveyor asked if they were planning on working in the kitchen again today or knew if there was a plan for the nights meal service to which they replied, I'm supposed to be working as a CNA today, and it's not fair to my residents if I keep getting pulled away from them. I just spoke with my Administrator after lunch letting them know we have no one working in the kitchen now, so no, honestly we have no plan. On [DATE] at 3:05 PM, upon interview with the Administrator on the current state of the kitchen and the Dietary staff they stated, We will do something. I don't know what, but we will do something. Everything is happening all at once. I will let you know more when I figure it out. On [DATE] at 4:35 PM, upon interview with the Administrator on the current state of the kitchen and the lack of dietary staff they stated, I have some staff from corporate driving in now to help with the staffing. I will be ordering pizza, breadsticks and salad for dinner once I can get everyone's orders and compare it with their dietary needs. On [DATE] at 5:39 PM, the surveyor again observed two full carts filled with trays of eaten and partially eaten meals along with numerous plates, bowls, trays, silverware, adaptive equipment and used napkins on the counter surface of the dirty side of the dish machine stacked over two feet in height. On [DATE] at 5:47 PM, Corporate Administrator, staff CCC, entered the kitchen and stated to the surveyor, I'm here to help with the dishes for dinner tonight and I have more help with me. On [DATE] at 7:57 PM, the first meal was observed being served to the residents by the surveyor. On [DATE] at 9:15 PM, the last meal was observed by the surveyor being served to the residents. On [DATE] at 9:31 PM, the surveyor observed trays of eaten and partially eaten meals along with numerous plates, bowls, trays, silverware, adaptive equipment and used napkins on the counter surface of the dirty side of the dish machine stacked over one and a half feet in height remaining from the days lunch and dinner service. On [DATE] at 7:04 AM, the surveyor observed trays of eaten and partially eaten meals along with numerous plates, bowls, trays, silverware, adaptive equipment and used napkins on the counter surface of the dirty side of the dish machine stacked over one and a half feet in height. On [DATE] at 7:06 AM, an interview was conducted with AM Cook, staff LL, on the current state of the area they stated, it's all from yesterday, but this is my first day back from when I used to work here so I had nothing to do with that. We are using all single use containers and plastic ware this morning. On [DATE] at 7:14 AM, upon interview with CDM, staff II, on the current state of the dish area they stated, I know it's not good. We have some more staff coming in today. We'll get it clean up after breakfast, it's going to take some time, but we can correct these things. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Equipment Food-Contact Surfaces and Utensils directs that: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (5) any time during the operation when contamination may have occurred. (C) Except as specified in (D) of this section, if used with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD, EQUIPMENT FOODCONTACT SURFACES and UTENSILS shall be cleaned throughout the day at least every 4 hours. 14. On [DATE] at 12:26 PM, PM Cook, staff NN, was observed placing a frozen boneless smoked ham into a metal pan, and then lifting the pan up to the instant hot water

Based on observation, interview and record review, the facility's governing body failed to meaningfully engage in operational oversight of the facility, resulting in Immediate Jeopardy (IJ) due to systemic, widespread non-compliance as evidence by inadequate number of and unqualified staff to meet the residents' needs (ADL Care, Comprehensive Assessments, Medication Administration, Pressure Ulcer Prevention, Oxygen Administration, [CONDITION(S)] Care, Peg Tube Care, Abuse Prevention, and Unnecessary Antipsychotic Medications), absence of skills checklist/adequate orientation for new hires to ensure the ability to meet the resident needs, and inability to support and enhance resident quality of life resulting in an Immediate Jeopardy beginning on 1/23/22. This deficient practice resulted in the likelihood of serious harm, serious impairment, and/or death for all residents residing in the facility. Findings: During an interview on 01/24/22 at 12:28 P.M., CNA O reported that staff quit because of insufficient funds and bounced checks. CNA O reported that he and other staff have had to pay for food in the kitchen because of facility's poor credit history and insufficient funds. During an interview on 01/25/22 at 8:50 A.M., Physical Therapy Assistant (PTA) C and Occupation Therapist (OT) XX reported that staff have made complaints that their checks had bounced and had quit because of it. PTA C and OT XX reported that there were no activities and no restorative care because of the lack of staff. OT XX reported that the lack of staff was affecting patient care. During an interview on 01/27/22 at 10:45 A.M., Previous Employee (PE) WW reported that multiple staff had their checks bounce because of the lack of funds and direct deposit was not available. PE WW reported that many staff quit because of the inconsistent pay checks/check bouncing. PE WW reported that she had to buy bread for the facility because the vendor would only deliver if he was paid in cash because of previous incidents with insufficient funds. During an interview on 1/24/22 at 11:45 A.M., Laundry Aide U reported that washcloths were missing because she thought CNA's were throwing them away. LA U also reported that the facility was low on laundry detergent and were out of bleach because the facility didn't pay the bill to the supplier last week and the ordered supplies were not delivered. According to LA U she has had a paycheck bounce and have heard of other staff who also had to deal with bounced paychecks from the facility. During an interview on 01/25/22 at 11:57 A.M., Product Vendor (PV) VV reported that the facility was 120 days past due for products received. PV VV reported that the company had been working corporate for several months now and the vendor was not getting a response. PV VV reported that the facility receives cleaning products the vendor and the vendor would no longer be delivering items to the facility. PV VV reported that the facility owed $1,590.65. During an interview on 01/24/22 at 2:46 P.M., Staffing Agency (SA) TT reported that the facility's contract was ending on February 5th and would not be renewed. SA TT reported that he had been trying to work with Corporate to get issues worked out. SA TT reported that multiple invoices had been sent out and the facility was behind in payments, and he had been trying to get a payment plan in place to no avail. SA TT reported that the facility owed a total of $48,532.50 but had a current past due balance of $23,000 from the billing cycle of 11/17/21-12/15/21. During an interview on 01/24/22 at 2:59 PM., Food Vendor (FV) UU reported that the facility had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . FV UU reported that there had also been concerns with insufficient funds here and there. During an interview on 01/24/22 3:33 P.M., Human Resources (HR) F reported that all invoices are sent to corporate for payment. Reported she had had some vendors reach out multiple times for payment. HR F reported that the corporate management had wanted her to take on the tasks of the Business Office Manager, but she was uncomfortable taking over a position she was not trained in. During an interview on 01/25/22 at 10:36 A.M., On-Call Business Office Manager (BOM) BB reported that she had quit working at the facility because of the issues she had with getting invoices paid. BOM BB reported that she had to pay a food vendor out of her pocket because they required Cash on Delivery and there was no available money. BOM BB reported she had concerns with the owner of the facility's ability to manage money. BOM BB reported the owner would bring in admissions even though it was evident there were not enough staff to meet the needs of the residents. BOM BB reported they did not have proper equipment (feeding tube supplies) to meet the needs of the residents. BOM BB reported there were many vendors that had not been paid for their services. During an interview on 01/25/2022 at 12:19 P.M., Physician (P) Z reported that he had not been paid for services provided since October 1, 2021. During an observation and interview on 01/24/22 at 08:26 A.M., Director of Nursing (DON) reported that she was working as a direct care nurse on the Memory Care Unit because there was a call in. DON was unable to fulfill the DON duties at that time. During an interview on 01/24/22 at 9:50 A.M., RN H reported that on multiple occasions nursing staff had requested a tube feeding pump, IV pumps, and a bladder scanner to reduce the risk of medication errors and unnecessary procedures. RN H reported that because there was no bladder scanner, residents would be straight catheterized unnecessarily. During an annual survey conducted from one 1/23/22 through 2/3/22, the following Immediate Jeopardies were identified: 1. The facility failed to prevent abuse, and protect residents from continued abuse, due to widespread system failures beginning with the failure to complete a facility assessment to determine resident acuity and appropriate number of staff and the lack of properly trained, certified, and orientated staff in sufficient numbers to provide care (Refer to noncompliance cited at 483.12, F600-Abuse). 2. The facility failed to ensure residents were provided timely and consistent ADL care including feeding assistance, grooming, personal and oral hygiene, incontinence care and bathing or showers for residents per the standards of practice. (Refer to noncompliance cited at 483.24, F677-ADL Care). 3. The facility failed to (a) provide staffing levels based on acuity and residents needs, (b) failed to ensure functional systems were in place for residents at risk for elopement, (c) failed to prevent choking hazards, falls, and provide a working call light system for a cognitively impaired resident, and (d) ensure crash carts were in full functioning order and all staff knew where to locate the crash carts. (Refer to noncompliance cited at 483.25, F689-Accidents and Hazards). 4. The facility failed to provide necessary oxygen care according to standards of practice. (Refer to noncompliance cited at 483.25, F695-Respiratory Care). 5. The facility failed to provide an adequate amount of staff to meet the needs of the residents 1) ADL care, 2) pressure ulcer prevention/healing, 3) medication administration, 4) dementia care, 5) food service, and 6) financial management and administrative duties (social work, business office management, accounts payable). (Refer to noncompliance cited at 483.35, F725-Sufficient Staffing). 6. The facility failed to ensure residents receiving anti-psychotic medications were closely monitored for adverse effects, were educated on the risk versus benefits of the medication, and were provided a gradual dose reduction, resulting in the potential for prolonged use and/or unnecessary use of an antipsychotic medication. (Refer to noncompliance cited at 483.45, F758-Unnecessary/[CONDITION(S)] Medication Use). 7. The facility failed to store, prepare, distribute, and serve food in a manner to ensure resident safety from foodborne illness. There are no staff in the kitchen able to demonstrate basic food service knowledge, including proper holding and cooking temperatures, reheating foods, or sanitizing procedures for equipment. Food is not being cooked to proper temperatures, not being held at proper holding temperatures, and not being reheated to proper temperatures. Food service equipment is not being sanitized. (Refer to noncompliance cited at 483.60, F812-Food Procurement, Store/Prepare/Serve-Sanitary). 8. The facility failed to administer the facility to ensure residents attained/maintained their highest practicable well-being as evidenced by: 1. inadequate number of and unqualified staff to meet the residents needs, 2. no facility educator in place and no skills checklist/adequate orientation for new hires to ensure they are able to meet the resident needs, 3. failed to ensure properly trained staff and consistent staffing levels to ensure residents are turned/repositioned and consistent ADL care was provided to prevent redevelopment/development and/or worsening of pressure ulcers; 4.) corporate managers in place but inaccessible to staff and unaware of day to day resident/staff needs, 5) Failed to provide sufficient quantities of basic necessities such as food and linens. (Refer to noncompliance cited at 483.70, F837-Governing Body). 9. The facility failed to implement individualized care planned interventions to meet R5 and R2's dementia/behavioral care needs, addressing de-escalation techniques, known behaviors, and diversional activities resulting in a resident to resident physical abuse (R2 assaulted R5, R2 also displayed aggressive, knife wielding assaultive behavior on 1/23/22). This deficient practice resulted in diminished quality of life for residents with mental illness and dementia. (Refer to noncompliance cited at 483.40, F744-Treatment and Services for Dementia). 10. The facility failed to provide medically related social services to attain and maintain the mental and psychosocial health of residents due to the facility did not have a qualified employee working in this role resulting in a lack of a behavior management program; a system to monitor residents on anti-psychotic medications; coordination and transition of care and the maintenance of resident right and quality of life. (Refer to noncompliance cited at 483.40, F745-Medically Related Social Services). In addition to the above referenced Immediate Jeopardies identified, systemic noncompliance was also found pertaining to Resident Rights (F568, F578, F580, F582, and F584), Abuse (F607, F609, and F610), Comprehensive Resident Centered Care Plans (F656, F657, and F658), Quality of Life (F679), Quality of Care (F684, F686, F691, F692, and F693), Nursing Services (F726 and F730), Pharmacy Services (F760), Administration (F838), QAPI (F867), and Infection Control (F880). The facility Administrative team was notified, on 01/31/22 at 10:53 A.M., of the Immediate Jeopardy (IJ) identified on 1/27/22 and that began on 01/23/22, when the facility failed to meaningfully engage in operational oversight of the facility resulting in Immediate Jeopardy (IJ) due to systemic, widespread non-compliance as evidence by inadequate number of and unqualified staff to meet the residents' needs (ADL Care, Comprehensive Assessments, Medication Administration, Pressure Ulcer Prevention, Oxygen Administration, [CONDITION(S)] Care, Peg Tube Care, Abuse Prevention, and Unnecessary Antipsychotic Medications), absence of skills checklist/adequate orientation for new hires to ensure the ability to meet the resident needs, and inability to support and enhance resident quality of life. This deficient practice resulted in the likelihood of serious harm, serious impairment, and/or death for all residents residing in the facility. As of date of exit, 2/3/22 at 4:00 P.M., the facility had not developed an approved plan to remove the Immediate Jeopardy and the State Agency was not able to verify the residents living at the facility were free from the potential for serious injury, serious harm and or death.

Based on observation, interview, and record review, the facility failed to provide necessary oxygen care according to the standards of practice for 4 residents (Resident #153, Resident #148, Resident #144, and Resident #17) resulting in an immediate jeopardy, when beginning on 01/26/22, the facility failed to assess and treat, in a timely manner, a resident in respiratory distress. Findings: Resident #153 (R153) Review of an Admission Record revealed R153 was an [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Electronic Treatment Administration Record (Etar) for R153, dated 1/1/2022 - 1/31/2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation required staff to assess for oxygen use and reflected from 01/11/22 to 1/31/22 there were 7 blank charting opportunities. During an observation on 01/26/22 at 4:00 P.M., R153 sat in a wheelchair near the nurse's station with an oxygen nasal cannula placed in the nares, the oxygen tubing was disconnected from the portable oxygen tank and laid on the floor, and the portable oxygen tank was empty. The Registered Nurse/Unit Manager, (RN/UM) G, who was working as the floor nurse on west hall, was told that R153's oxygen tank was empty. RN/UM G did not assess R153 nor change out the empty portable oxygen tank. During an observation on 01/26/22 at 4:27 P.M., R153's oxygen tank remained empty, and the oxygen tubing laid on the floor. During an observation on 01/26/22 at 5:00 P.M., R153 complained of shortness of breath and difficulty breathing. RN/UM G was again advised that R153 was out of oxygen and was now experiencing respiratory distress. During an observation on 01/26/22 at 5:09 P.M., RN/UM G was told R153 was cyanotic (starting to turn blue around the lips) and was reporting increased difficulty breathing. The surveyor advised RN/UM G that R153 required immediate medical attention. Only then did RN/UM G intervene to assess the resident and secure oxygen delivery to R153. Review of Nursing Progress Notes for R153 reflected that a progress note had not been entered into the record describing the above events the evening of 01/26/22, if a physician was notified, and what additional monitoring was completed for R153. Further review of Nursing Progress Notes for R153 revealed no nursing progress notes were entered into the record for R153 on 01/27/22. Review of a Care Plan for R153 reflected a focus area for OXYGENATION, a goal of I will not have signs and symptoms of decreased oxygenation, and an intervention of nurse will assess any changes. Resident #148 (R148) Review of an Admission Record revealed R148 was a 77- year-old male, originally admitted to the facility on [DATE], following a 63-day hospitalization for aspiration pneumonia, urinary tract infection and altered mental status. R148 was dependent on oxygen. During an observation on 01/23/22 at 1:10 P.M., the oxygen tubing for R148 did not have a date on the tubing indicating when the oxygen tubing had last been changed. During an observation on 01/26/22 at 9:35 A.M., the oxygen tubing for R148 did not have a date on it and the nasal cannula laid on the floor near R148's bed, the concentrator was on. Between 9:35 A.M. and 1:00 P.M. on 01/26/22, multiple observations were made of staff entering R148's room and at no time did staff identify that R148 was not receiving oxygen and restart the delivery of oxygen. R148 did not have use of a call light system to alert staff of respiratory distress or any other concerns. Review of an Etar for R148, dated 1/1/2022 - 1/31/2022, reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of documentation in the Etar reflected that the physician order was not started until night shift on 1/29/22. Resident #144 (R144) Review of an Admission Record revealed R144 was a [AGE] year-old female, admitted to the facility on [DATE] following a hospitalization to treat pneumonia, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 01/24/22 at 8:16 A.M., R144's oxygen nasal cannula laid on the floor, the concentrator ran, and the oxygen tubing was not dated. During an observation on 01/26/22 at 9:35 A.M., the oxygen nasal cannula for R144 laid on the floor out of reach of the resident. The oxygen tubing was not dated. R144 could not alert staff at that time, of any concerns, because the call light laid on the floor near the head of the bed, out of sight and out of reach. Review of an Etar and physician order summary for R144 reflected there was no order for oxygen administration nor parameters for oxygen saturation maintenance. Review of the electronic medical record for R144 revealed that oxygen saturation was not monitored until 1/28/22, at the request of speech therapy. Review of the facility policy Oxygen Administration, last revised 04/27/2018, reflected .before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: signs or symptoms of [CONDITION(S)] (skin turning blue, increased heart rate, increased breathing rate, sweating, restlessness or confusion and difficulty breathing) .ensure the resident is comfortable and the call light is within reach .perform a pulse oximeter check. Resident #17 (R17) Review of a facility Admission Record reflected R17 admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission Minimum Data Set (MDS) assessment dated [DATE] reflected R17 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15 and needed extensive assistance from two people for bed mobility and transfers and required extensive assistance from one person for dressing, toilet use, and personal hygiene. Review of a Nurses Cheat Sheet, undated, reflected guidelines for order entry related to new admissions. The section pertaining to C-Pap/[CONDITION(S)] reflected C-Pap/[CONDITION(S)]-Order to include setting, and frequency of use. Order for cleaning equipment -Daily wipe mask daily with damp cloth, rinse out humidifier and refill it with distilled water. Weekly-wash mask and headgear in warm water, rinse thoroughly, air dry, and make sure mask is dry before use. DO NOT use alcohol, bleach or cleansing solutions containing alcohol, or strong household cleaners; submerse the foam cushion of the mask into the warm soapy water. Wipe off foam cushion with a damp cloth. Wash out the humidifier with soap and water, rinse thoroughly. Monthly-soak mask, tubing and humidifier in one part distilled white vinegar and two parts water for thirty minutes. Rinse thoroughly and air dry. Refill humidifier with distilled water. Rinse out filter with running water. Cleaning: Unplug unit; using a cloth slightly dampened with water wipe the outside of the unit; let the unit completely dry before plugging it in and returning it to normal operations. Machine maintenance: clean filter once a month and replace every six months. Maintain unit per operational instructions. Further review of the Nurses Cheat Sheet also reflected O2 (oxygen)-O2 rate, O2 sats (saturations) daily x3 days on room air, then weekly. O2 rate (cannot be a range, must be specific) O2 is to be placed on the MAR (Medication Administration Record). O2 tubing changes weekly per (name of oxygen supply company) placed on TAR (Treatment Administration Record). Review of R17's Order Recap Report dated 9/01/2021-1/29/2021 reflected the following active orders as of 9/29/21 Oxygen 4L (4 liters) via nasal cannula continuous every day and night shift for respiratory failure; [CONDITION(S)] at bedtime-[CONDITION(S)] settings (25/12 cm H2O) at bedtime for respiratory failure; Rinse Bi-Pap water chamber and mask with warm water each night before use at bedtime for cleaning. The Order Recap Report did not reflect oxygen tubing changes or specify instructions for the operation and cleaning of the [CONDITION(S)] per written instructions noted above. During an observation and interview on 1/31/22 at 8:01 A.M., R17's Bi-Pap mask was noted to be wedged uncovered between the wall and the back of the [CONDITION(S)] machine. There was condensation noted in the tubing and in the empty humidifier. R17 wore oxygen tubing that was not dated and a second nasal cannula attached to a portable tank secured to an electric wheelchair was also not dated, the nasal cannula laid on the dirty wheelchair tires. No distilled water was observed in R17's room amongst several other personal care items stored in the vicinity. R17 reported that since she admitted to the facility, no one had ever cleaned her [CONDITION(S)] machine and that the last time it was used, R17 had to fill the humidifier with Propel water believing it was the same as distilled water. During an interview on 1/31/22 at 8:20 A.M., Registered Nurse (RN) G reported not being sure what the protocol was for cleaning R17's [CONDITION(S)] but thought there should be specific orders pertaining to the use and maintenance of the equipment. RN G was not able to locate distilled water in R17's room and stated the mask should be stored in a plastic bag. The facility Administrative team was notified, on 01/31/22 at 10:53 A.M., of the Immediate Jeopardy (IJ) that was identified on 1/27/22 and began on 01/26/22, when the facility failed to provide necessary oxygen care according to the standards of practice. This deficient practice placed all residents receiving oxygen therapy residing in the facility at risk for serious harm, injury, and/or death. As of date of exit, 2/3/22 at 4:00 P.M., the facility had not developed an approved plan to remove the Immediate Jeopardy and the State Agency was not able to verify the residents living at the facility were free from the potential for serious injury, serious harm and or death.

Based on interview and record review, the facility failed to implement established abuse and neglect prohibition policies and procedures for 7 residents (Resident #2, #5, #4, #23, #27, #93 and #43), resulting in the potential for ongoing abuse, neglect and/or mistreatment due to the inability of staff to recognize abuse and neglect, provide resident protection, report to the State Agency, and thoroughly investigate to prevent the reoccurrence of instances of abuse and neglect. Findings: Review of the facility policy Resident Abuse/Neglect last revised 1/30/2019 reflected The facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to the Administrator or to the Director of Nursing Services immediately. The policy defined abuse and neglect and detailed the Abuse Prevention Program that incorporated all required elements of an effective abuse and neglect prevention program consistent with CFR 483.12 Freedom from Abuse, Neglect, and Exploitation regulatory groups for Long Term Care Facilities. Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. During an interview on 1/23/22 at 1:00 P.M., R93 reported a nurse was very rude to her and flipped out over pills left in a medication cup at her bedside and the nurse accused her of selling drugs. According to R93, she does not want that nurse in her room again because she made her feel depressed and jittery and has been so upset about it that she called her husband crying about the incident. R93 reported that Certified Nurse Aide (CNA) P witnessed the abuse. During an interview on 1/23/22 at 2:42 P.M., CNA P reported that on 1/21/22 R93 had asked CNA P to remove wraps from her legs and RN I told R93 that if she didn't eat so much and would get out of bed, she wouldn't have these problems which left R93 in tears. CNA P said R93 told RN I to be nicer to her when she gives her medications. CNA P said she reported the abuse to RN/Unit Manager G immediately. CNA P said that RN G said she would take care of it. CNA P said she did not notify the Nursing Home Administrator (NHA) of the alleged abuse because she did not have her phone number. CNA P said she was never asked to provide a statement about the abuse after making her report to RN G. CNA P said that she reported the allegation of abuse to RN G immediately but had been educated that she has between 12-24 hours to report allegations of abuse and neglect. During an interview on 1/24/21 at 9:12 A.M., the NHA reported that she started as interim administrator on 12/21/21 and did not have any open Facility Reported Incidents (FRI's). The NHA said she was the facility abuse prevention coordinator and was responsible for reporting all allegations of abuse or neglect. The NHA said she was not aware of an allegation of abuse perpetrated by RN I and reported by CNA P to RN G on 1/21/22. Review of a facility (Facility Name) Center Staffing Reports from 1-23-22-1-24-22 reflected that RN I continued to work at the facility despite the alleged report of resident verbal abuse. Review of a Grievance Form dated 1/24/22 reflected R93 reported A nurse made her 'feel awful', 'I felt depressed'. When asked if she remembered who it was and what the nurse looked like she replied, It was (name of a nurse other than RN I). She has dark long hair and wears it back and wears glasses. Her voice is medium-deep? I told my husband last week and I told the state people. When asked about the nurse currently working with her (RN I) she stated, 'I like (RN I)'. Review of an Investigation Follow-Up form dated 1/24/22 reflected a description of the situation as noted in the Grievance Form. The summary of the investigation reflected Agency nurse (RN I) on shift was interviewed. CNA (CNA P) was interviewed via phone from 9:40 a.m. -9:52 a.m. with UM (RN G) present via phone. Agency Nurse (RN I) sent home pending investigation. (R93) was interviewed with UM (RN G) from 9:33 a.m. - 9:40 a.m. in room door closed. (R93) husband was interviewed via phone 12:45 p.m.-12:54 p.m. Another nurse was interviewed with similar description. Review of a Suspension Notice reflected RN I was suspended for alleged verbal abuse pending investigation on 1/24/22. No evidence that another nurse interviewed with similar description (as noted in the Investigation Follow-Up form) was suspended pending investigation was provided. No documented witness statements pertaining to the interviews conducted were provided. Additionally, only three residents were interviewed about concerns pertaining to abuse and neglect. Resident #43 (R43) Review of a facility Admission Record reflected R43 admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a discharge Minimum Data Set (MDS) assessment dated [DATE] reflected R43 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15 and needed extensive assistance from two people for bed mobility and transfers and required extensive assistance from one person for locomotion on and off the unit, dressing, toilet use and personal hygiene. Section E-Behavior reflected R43 did not exhibit hallucinations or delusions indicating [CONDITION(S)]; did not display behavioral symptoms such as physical or verbal behaviors directed toward others or other behavioral symptoms. The assessment did not reflect R43 rejected care, wandered or behaved in such a way as to significantly impact the care of others or disrupt the care or living environment. Review of an Elopement Evaluation dated 10/4/21 at 5:00 P.M. reflected R43 was assessed as being at risk for eloping from the facility due to a history of attempts to leave the facility without informing staff, verbally expressing a desire to go home, with wandering behavior likely to affect the privacy, safety or well-being of self/others. Review of a Nursing Note dated 10/5/21 at 1:06 A.M. reflected (R43) had an altercation with roommate. Resident went through roommate's belongings. Resident showed increased aggression. Resident was moved to a separate room. (MD Z) notified of behavior and ordered resident to get a nicotine patch for withdrawal. [MEDICATION(S)] 50 mg to help resident with [CONDITION(S)]. Review of a Physician Note dated 10/6/21 at 12:41 P.M. revealed Note Text: Admission not-Resident was seen on 10/5/21 at 8:00 a.m. The note specified Last night he (R43) had a problematic interaction with another resident. Review of a Behavior Note dated 10/5/21 at 3:46 A.M. reflected R43 was again observed going into other resident rooms/area looking for things. R43 threw a trash can at a nurse and became aggravated when additional staff attempted to calm the resident. The note specified It is a struggle to keep him out of other resident's rooms. He is very mobile in his wheelchair and moves himself about as he wants to. Review of a Behavior Note dated 10/6/21 at 12:03 P.M. reflected Resident locked himself in breakroom, hitting, pinching, spitting at staff. Resident went through others belongings calling residents names. Intervention that was used 1:1 Review of a Nursing Note dated 10/6/21 at 3:53 P.M. reflected Resident noted in breakroom with door closed. Resident is wandering threw staff items (sic). Resident obtained staff member's medication and purse. Resident is combative with staff, bruised staff member arm, ripped staff member shirt. Resident spat on staff, Resident is undirect able (sic). Resident has multiple move swings within twenty to thirty minutes (sic). From violet outbreaks to uncontrollable laughing crying (sic). Resident was petition to psych hospital. 911 called. Resident transported via ambulance x2 attendance. Review of ED (Emergency Department) Provider Notes-Encounter Notes dated 10/6/21 at 10:58 A.M. reflected (R43) Presents from (Name of Facility) for agitation. Patient arrived from acute care hospital in Detroit on evening of 10/4. Known to have behavioral issues and [CONDITION(S)] at baseline. Aggressive with staff starting night of arrival. Struck another resident on 1st night. Placed in private room. Struck staff. Spit at staff. Ripped a staff member's blouse off. Verbally and physically abusive to residents and staff. Locked himself in a room, stating he was going to die. Attempted to take an employee's HCTZ (hydrochlorothyizide-a prescription medication used to treat high blood pressure and fluid retention) and [MEDICATION(S)] (a prescription medication used to treat gout and kidney stones) from their locker. Staff able to get patient to spit out all but 1 pill of each. Counted pills and confirmed ingestion amount. Patient would not allow EMS (Emergency Medical Services) or ED RN to take vitals. Mumbling here. Requests for incident and accident reports and evidence the facility had completed a Facility Reported Incident (FRI) to the state agency pertaining to the resident-to-resident altercations was made via email communication on 2/1/22. As of the time of exit on 2/3/22, the Acting NHA said she did not have any of the requested information pertaining to R43. Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 (R5) Review of an Admission Record revealed R5 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 and R5 were roommates on 1/23/22 and 1/24/22. During an observation on 01/23/22 at 01:09 P.M., R2 was visibly agitated, aggressive, and destructive of facility property. R2 was wielding a butter knife and used it to remove the key pad off of the wall and was using the knife to attempt to break through the lock on the double doors. During an interview and observation 01/23/22 at 01:30 P.M., CNA PP reported that she was the only staff member on the MCU for 11 Residents. CNA V was pulled to the East/West Unit. There was 1 LPN on the unit. At that time, R2 continued to be behavioral/destructive. CNA PP reported that she was working with a resident that had increased behaviors (Resident #41) which placed the rest of the residents at increased risk because of the lack of supervision. CNA PP reported more staff were needed to keep the residents on the Memory Care Unit safe. During an interview on 01/24/22 at 12:30 P.M., R5 reported to this surveyor that her roommate (R2) had assaulted her the previous day (1/23/22). R5 was tearful and anxious when reporting the allegation of resident to resident abuse. On 01/24/22 at 12:45 P.M. this surveyor reported to the NHA the allegation of R2 assaulting R5. Review of R2's Behavior Note dated 1/23/22 at 4:28 P.M. revealed, Resident became agitated during lunch time. She went to her room and packed her clothes up in a bag and box. She went to the electronic/keypad box attached to the wall and took out a butter knife she had kept from her meal tray and began trying to pry the box off the wall using the butter knife. Staff notice what she was doing and began walking towards her to intervene, but she managed to pull the box completely off the wall. One Staff member stayed with resident as she was repeatedly shoving at the door handles in an attempt to open them, and the other staff member went to get assistance from maintenance to repair the torn off electronic box. Resident refused to give staff the butter knife. Maintenance repaired the box on the wall. Resident took her things back to her room, unpacked, and butter knife was removed from room. Resident redirected with ice cream and apple juice. Refused to participate in activities. Will continue to monitor and follow up as needed. (Indicating an increase in aggressive behaviors.) Review of an Interdisciplinary Team Note dated 1/31/22 04:43 A.M., revealed, On 1/24/22 at approx 330pm it was reported by her roommate that (R2) had gripped the right wrist of her roommate at that time. According to the roommate, she was in (R2's) pathway in front of her closet blocking her clothes. Her roommate stated that (R2) was trying to get her clothes. The two residents were immediately separated by staff. The roommate's room was changed. (R2) has been monitored for any changes. No mood, appetite or behavior changes were noted in the last 72 hours. Her care plan was updated to reflect that she is to only use spoons on her meal trays for safety. (Psychiatric Contracted Group) and the physician have evaluated her mood and behaviors. (R2) can be understood at times with short sentences and phrases in English. Activities continues to work with her 1:1 when she participates. She has been observed sleeping in her room without a roommate since this incident. Guardian aware. No further incidents or behaviors has been noted at this time. Staff continues to anticipate and meet her needs and keep her and others safe. (This note indicated R2 had no mood, appetite or behavior changes noted in the last 72 hours. However, on 1/23/22 R2 exhibited dangerous behavior using a butter knife and was difficult to redirect). Review of R5's Incident Note dated 1/24/22 at 6:15 P.M. revealed, (R5) stated that her roommate placed her hand on R5's right wrist. She demonstrated a clasped hand over her right wrist. No Injury noted. R5 denied discomfort or fear. When questioned more (R5) stated that it happened last night around bedtime. She stated that her roommate wanted her clothes. (R5) requested to move rooms .(R5) stated she didn't tell anyone the night before . This note was struck out indicating a cancellation of the entry. During an interview on 01/25/2022 at 1:23 P.M., The Director of Nursing (DON) reported she was told to strike out the note and fill out the concern form per the Nursing Home Administrator. DON reported she did not have access to reporting to the State Agency. DON reported that allegations of abuse are to be reported to the State Agency within 2 hours. During an interview on 2/1/22 at 11:41 A.M., Physician Z reported that he completed an assessment on R2 following the allegation of abuse. Physician Z reported that she exhibited behaviors of having a difficult past with keep her items packed and becoming protective of her items. Physician Z reported that because of her possessive behaviors with her items and her space she would have benefited from having a private room. Physician Z reported that R2 may have become overwhelmed to the point she felt she had to protect her items which resulted in the physical altercation between R2 and R5. Review of R2's Physician Note dated 2/1/22 revealed, (R2) was seen today in regard to a recent resident to resident in which she grabbed another residents arm. (R2) is noted to have severe dementia and paranoia. There is a history of her with increased anxiety each day near noon. it is apparent that there was no ill intent. I would suggest she be in her own room so that she does not feel the need to protect her belongings. Psych will continue to follow. Review of the Facility Reported Incident sent to the State Agency revealed the Date/Time Incident Discovered 1/24/22 at 3:30 PM .Date/Time Incident Occurred 1/23/22 at 11:00 PM .Submitted Date/Time: 1/24/2022 at 4:00 PM . (Indicating an inaccurate time the abuse was discovered and abuse not reported within the 2 hours per the regulatory requirements.) Resident #4 (R4) Review of an Admission Record revealed R4 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 R(23) Review of an Admission Record revealed R23 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's Nursing Note dated 9/4/21 at 9:40 A.M. revealed, Upon assessment writer observed an indentation in the front left side of resident's head. Writer palpated entire head and no other injuries noted. Resident does state It hurts when you do that .Writer asked resident what happened? Resident stated Last night (R23) came in my room and took my blue blanket. I grabbed it from me and he started hitting me. I just blocked. I didn't hit him back. Writer informed manager of information provided by resident. Doctor made aware. Review of R4's Nursing Note dated 9/4/21 at 11:00 A.M. revealed, This writer was notified by (Licensed Practical Nurse LPN EEE) that (R4) had stated that he had gotten into a fight. This writer questioned resident who stated (R23), the guy who walks around and goes through people's stuff. He wanted my blue blanket. Per (LPN EEE), resident stated that (R23) had punched him repeatedly and that resident had blocked these punches. (LPN EEE) reported that resident stated this happened last night but was not reported by ad staff to her. Resident with two abrasions on his face from previous documented incident (bridge of nose and right eyebrow). (LPN EEE) noted indentation on left frontal lobe region that she had not noticed on previous shift .Call placed to DON (Previous DON FFF) who stated that this area is not a new finding and his (sic) been present since admission. No staff witnessed alleged incident .Call placed to (Previous NHA HHH), administrator and informed her of all above findings. Instructed (LPN EEE) to contact Dr to notify of incident. Review of the facility Incident and Accident Investigation dated 9/4/21 at 11:15 P.M. revealed, Alleged Incident .Nurse (RN GGG) called and stated (R4) stated he had gotten into a fight. Statement from all staff stated nothing unusual happened .Reporting-To whom was it reported: (Previous DON FFF) Date 9/4/21 Time 11AM .2. Was the resident affected by the incident interviewed-NO . Review of the facility Investigation Follow-Up dated 9/4/21 revealed, (RN GGG) called and said she thought there was a resident to resident altercation .Family Notified 9/2/21 at 11:15pm .Physician Notified 9/2/21 (Time Blank). Review of the Facility Reported Incident revealed this allegation of Resident-to-Resident abuse was not reported to the State Agency. Verified that it was not reported to the State Agency on 2/10/22. Resident #27 (R27) Review of an Admission Record revealed R#27 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R27's Nursing Note dated 12/18/21 revealed, Resident becoming increasingly aggressive despite changes in psychiatric meds. CNA (Certified Nursing Assistant) observed him whipping another resident in the face with a pair of sweatpants this shift .Contacted (Previous DON FFF) to notify her of transfer status and residents DPOA (Power of Attorney). Review of the facility Temporary Separation from Other assessment dated [DATE] revealed, per nurses note the resident became increasingly aggressive and was observed whipping another resident in the face with a pair of sweatpants .injury to the other residents face could have occurred. Fear could have occurred .(R27) will be referred to (Psychiatric Consulting Group.) Review of the Facility Reported Incident sent to the State Agency revealed the Date/Time Incident Occurred 12/18/21 .Submitted Date/Time: 1/24/2022 at 9:30 PM . (Indicating the abuse was not reported within the 2 hours per the regulatory requirements.) During an interview on 01/25/22 at 10:02 A.M., CNA PP reported that it was difficult to manage the residents' behaviors with insufficient staff. CNA PP reported that in the mornings there were only 2 CNA's scheduled to work and when 1 CNA went on break it left the other CNA to care for all of the residents on the Memory Care Unit. CNA PP reported that it was difficult to manage the residents' behaviors with insufficient staff. During an observation and interview on 1/26/22 at 2:02 P.M., CNA V reported that he was alone on the unit because CNA OO was on break. CNA V reported he was doing the best he could but the lack of staff resulted in the worsening of resident behaviors which occurred daily.

Based on interview and record review, the facility failed to ensure allegations of abuse and neglect were made to the facility abuse prevention coordinator and the State Agency in a timely manner for 7 residents (Resident #93,#43, #2, #5, #4, #23, and #27), resulting in the potential for ongoing abuse and neglect for those residents and all residents in the building. Findings: Review of the facility policy Resident Abuse/Neglect last revised 1/30/2019 reflected The facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to the Administrator or to the Director of Nursing Services immediately. The policy defined abuse and neglect and detailed the Abuse Prevention Program that incorporated all required elements of an effective abuse and neglect prevention program consistent with CFR 483.12 Freedom from Abuse, Neglect, and Exploitation regulatory groups for Long Term Care Facilities. Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. During an interview on 1/23/22 at 1:00 P.M., R93 reported a nurse was very rude to her and flipped out over pills left in a medication cup at her bedside and the nurse accused her of selling drugs. According to R93, she does not want that nurse in her room again because she made her feel depressed and jittery and has been so upset about it that she called her husband crying about the incident. R93 reported that Certified Nurse Aide (CNA) P witnessed the abuse. During an interview on 1/23/22 at 2:42 P.M., CNA P reported that on 1/21/22 R93 had asked CNA P to remove wraps from her legs and RN I told R93 that if she didn't eat so much and would get out of bed, she wouldn't have these problems which left R93 in tears. CNA P said R93 told RN I to be nicer to her when she gives her medications. CNA P said she reported the abuse to RN/Unit Manager G immediately. CNA P said that RN G said she would take care of it. CNA P said she did not notify the Nursing Home Administrator (NHA) of the alleged abuse because she did not have her phone number. CNA P said she was never asked to provide a statement about the abuse after making her report to RN G. CNA P said that she reported the allegation of abuse to RN G immediately but had been educated that she has between 12-24 hours to report allegations of abuse and neglect. During an interview on 1/24/21 at 9:12 A.M., the NHA reported that she started as interim administrator on 12/21/21 and did not have any open Facility Reported Incidents (FRI's). The NHA said she was the facility abuse prevention coordinator and was responsible for reporting all allegations of abuse or neglect. The NHA said she was not aware of an allegation of abuse perpetrated by RN I and reported by CNA P to RN G on 1/21/22. Review of a facility (Facility Name) Center Staffing Reports from 1-23-22-1-24-22 reflected that RN I continued to work at the facility despite the alleged report of resident verbal abuse. Review of a Grievance Form dated 1/24/22 reflected R93 reported A nurse made her 'feel awful', 'I felt depressed'. When asked if she remembered who it was and what the nurse looked like she replied, It was (name of a nurse other than RN I). She has dark long hair and wears it back and wears glasses. Her voice is medium-deep? I told my husband last week and I told the state people. When asked about the nurse currently working with her (RN I) she stated, 'I like (RN I)'. Review of an Investigation Follow-Up form dated 1/24/22 reflected a description of the situation as noted in the Grievance Form. The summary of the investigation reflected Agency nurse (RN I) on shift was interviewed. CNA (CNA P) was interviewed via phone from 9:40 a.m. -9:52 a.m. with UM (RN G) present via phone. Agency Nurse (RN I) sent home pending investigation. (R93) was interviewed with UM (RN G) from 9:33 a.m. - 9:40 a.m. in room door closed. (R93) husband was interviewed via phone 12:45 p.m.-12:54 p.m. Another nurse was interviewed with similar description. Review of a Suspension Notice reflected RN I was suspended for alleged verbal abuse pending investigation on 1/24/22. No evidence that another nurse interviewed with similar description (as noted in the Investigation Follow-Up form) was suspended pending investigation was provided. No documented witness statements pertaining to the interviews conducted were provided. Additionally, only three residents were interviewed about concerns pertaining to abuse and neglect. Resident #43 (R43) Review of a facility Admission Record reflected R43 admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a discharge Minimum Data Set (MDS) assessment dated [DATE] reflected R43 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15 and needed extensive assistance from two people for bed mobility and transfers and required extensive assistance from one person for locomotion on and off the unit, dressing, toilet use and personal hygiene. Section E-Behavior reflected R43 did not exhibit hallucinations or delusions indicating [CONDITION(S)]; did not display behavioral symptoms such as physical or verbal behaviors directed toward others or other behavioral symptoms. The assessment did not reflect R43 rejected care, wandered or behaved in such a way as to significantly impact the care of others or disrupt the care or living environment. Review of an Elopement Evaluation dated 10/4/21 at 5:00 P.M. reflected R43 was assessed as being at risk for eloping from the facility due to a history of attempts to leave the facility without informing staff, verbally expressing a desire to go home, with wandering behavior likely to affect the privacy, safety or well-being of self/others. Review of a Nursing Note dated 10/5/21 at 1:06 A.M. reflected (R43) had an altercation with roommate. Resident went through roommate's belongings. Resident showed increased aggression. Resident was moved to a separate room. (MD Z) notified of behavior and ordered resident to get a nicotine patch for withdrawal. [MEDICATION(S)] 50 mg to help resident with [CONDITION(S)]. Review of a Physician Note dated 10/6/21 at 12:41 P.M. revealed Note Text: Admission not-Resident was seen on 10/5/21 at 8:00 a.m. The note specified Last night he (R43) had a problematic interaction with another resident. Review of a Behavior Note dated 10/5/21 at 3:46 A.M. reflected R43 was again observed going into other resident rooms/area looking for things. R43 threw a trash can at a nurse and became aggravated when additional staff attempted to calm the resident. The note specified It is a struggle to keep him out of other resident's rooms. He is very mobile in his wheelchair and moves himself about as he wants to. Review of a Behavior Note dated 10/6/21 at 12:03 P.M. reflected Resident locked himself in breakroom, hitting, pinching, spitting at staff. Resident went through others belongings calling residents names. Intervention that was used 1:1 Review of a Nursing Note dated 10/6/21 at 3:53 P.M. reflected Resident noted in breakroom with door closed. Resident is wandering threw staff items (sic). Resident obtained staff member's medication and purse. Resident is combative with staff, bruised staff member arm, ripped staff member shirt. Resident spat on staff, Resident is undirect able (sic). Resident has multiple move swings within twenty to thirty minutes (sic). From violet outbreaks to uncontrollable laughing crying (sic). Resident was petition to psych hospital. 911 called. Resident transported via ambulance x2 attendance. Review of ED (Emergency Department) Provider Notes-Encounter Notes dated 10/6/21 at 10:58 A.M. reflected (R43) Presents from (Name of Facility) for agitation. Patient arrived from acute care hospital in Detroit on evening of 10/4. Known to have behavioral issues and [CONDITION(S)] at baseline. Aggressive with staff starting night of arrival. Struck another resident on 1st night. Placed in private room. Struck staff. Spit at staff. Ripped a staff member's blouse off. Verbally and physically abusive to residents and staff. Locked himself in a room, stating he was going to die. Attempted to take an employee's HCTZ (hydrochlorothyizide-a prescription medication used to treat high blood pressure and fluid retention) and [MEDICATION(S)] (a prescription medication used to treat gout and kidney stones) from their locker. Staff able to get patient to spit out all but 1 pill of each. Counted pills and confirmed ingestion amount. Patient would not allow EMS (Emergency Medical Services) or ED RN to take vitals. Mumbling here. Requests for incident and accident reports and evidence the facility had completed a Facility Reported Incident (FRI) to the state agency pertaining to the resident-to-resident altercations was made via email communication on 2/1/22. As of the time of exit on 2/3/22, the Acting NHA said she did not have any of the requested information pertaining to R43. Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 (R5) Review of an Admission Record revealed R5 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 01/24/22 at 12:30 P.M., R5 reported to this surveyor that her roommate (R2) had assaulted her the previous day (1/23/22). R5 was tearful and anxious when reporting the allegation of resident to resident abuse. On 01/24/22 at 12:45 P.M. this surveyor reported to the NHA the allegation of R2 assaulting R5. Review of an Interdisciplinary Team Note dated 1/31/22 04:43 A.M., revealed, On 1/24/22 at approx 330pm it was reported by her roommate that (R2) had gripped the right wrist of her roommate at that time. According to the roommate, she was in (R2's) pathway in front of her closet blocking her clothes. Her roommate stated that (R2) was trying to get her clothes. The two residents were immediately separated by staff. The roommate's room was changed. (R2) has been monitored for any changes. No mood, appetite or behavior changes were noted in the last 72 hours. Her care plan was updated to reflect that she is to only use spoons on her meal trays for safety. (Psychiatric Contracted Group) and the physician have evaluated her mood and behaviors. (R2) can be understood at times with short sentences and phrases in English. Activities continues to work with her 1:1 when she participates. She has been observed sleeping in her room without a roommate since this incident. Guardian aware. No further incidents or behaviors has been noted at this time. Staff continues to anticipate and meet her needs and keep her and others safe. Review of R5's Incident Note dated 1/24/22 at 6:15 P.M. revealed, (R5) stated that her roommate placed her hand on R5's right wrist. She demonstrated a clasped hand over her right wrist. No Injury noted. R5 denied discomfort or fear. When questioned more (R5) stated that it happened last night around bedtime. She stated that her roommate wanted her clothes. (R5) requested to move rooms .(R5) stated she didn't tell anyone the night before . This note was struck out indicating a cancellation of the entry. Review of the Facility Reported Incident sent to the State Agency revealed the Date/Time Incident Discovered 1/24/22 at 3:30 PM .Date/Time Incident Occurred 1/23/22 at 11:00 PM .Submitted Date/Time: 1/24/2022 at 4:00 PM . (Indicating an inaccurate time the abuse was discovered and abuse not reported within the 2 hours per the regulatory requirements.) Resident #4 (R4) Review of an Admission Record revealed R4 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 (R23) Review of an Admission Record revealed R#23 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's Nursing Note dated 9/4/21 at 9:40 A.M. revealed, Upon assessment writer observed an indentation in the front left side of resident's head. Writer palpated entire head and no other injuries noted. Resident does state It hurts when you do that .Writer asked resident what happened? Resident stated Last night (R23) came in my room and took my blue blanket. I grabbed it from me and he started hitting me. I just blocked. I didn't hit him back. Writer informed manager of information provided by resident. Doctor made aware. Review of R4's Nursing Note dated 9/4/21 at 11:00 A.M. revealed, This writer was notified by (Licensed Practical Nurse LPN EEE) that (R4) had stated that he had gotten into a fight. This writer questioned resident who stated (R23), the guy who walks around and goes through people's stuff. He wanted my blue blanket. Per (LPN EEE), resident stated that (R23) had punched him repeatedly and that resident had blocked these punches. (LPN EEE) reported that resident stated this happened last night but was not reported by ad staff to her. Resident with two abrasions on his face from previous documented incident (bridge of nose and right eyebrow). (LPN EEE) noted indentation on left frontal lobe region that she had not noticed on previous shift .Call placed to DON (Previous DON FFF) who stated that this area is not a new finding and his (sic) been present since admission. No staff witnessed alleged incident .Call placed to (Previous NHA HHH), administrator and informed her of all above findings. Instructed (LPN EEE) to contact Dr to notify of incident. Review of the facility Incident and Accident Investigation dated 9/4/21 at 11:15 P.M. revealed, Alleged Incident .Nurse (RN GGG) called and stated (R4) stated he had gotten into a fight. Statement from all staff stated nothing unusual happened .Reporting-To whom was it reported: (Previous DON FFF) Date 9/4/21 Time 11AM .2. Was the resident affected by the incident interviewed-NO . Review of the facility Investigation Follow-Up dated 9/4/21 revealed, (RN GGG) called and said she thought there was a resident to resident altercation .Family Notified 9/2/21 at 11:15pm .Physician Notified 9/2/21 (Time Blank). Review of the Facility Reported Incident revealed this allegation of Resident-to-Resident abuse was not reported to the State Agency. Verified that it was not reported to the State Agency on 2/10/22. Resident #27(R27) Review of an Admission Record revealed R#27 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R27's Nursing Note dated 12/18/21 revealed, Resident becoming increasingly aggressive despite changes in psychiatric meds. CNA (Certified Nursing Assistant) observed him whipping another resident in the face with a pair of sweatpants this shift .Contacted (Previous DON FFF) to notify her of transfer status and residents DPOA (Power of Attorney). Review of the facility Temporary Separation from Other assessment dated [DATE] revealed, per nurses note the resident became increasingly aggressive and was observed whipping another resident in the face with a pair of sweatpants .injury to the other residents face could have occurred. Fear could have occurred .(R27) will be referred to (Psychiatric Consulting Group.) Review of the Facility Reported Incident sent to the State Agency revealed the Date/Time Incident Occurred 12/18/21 .Submitted Date/Time: 1/24/2022 at 9:30 PM . (Indicating the abuse was not reported within the 2 hours per the regulatory requirements.)

Based on interview and record review, the facility failed to conduct a thorough investigation and prevent the reoccurrence of alleged abuse, neglect and mistreatment for 7 residents (Resident #93, #43, #2, #5, #4, #23, and #27), resulting in the potential for ongoing abuse, neglect and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of the facility policy Resident Abuse/Neglect last revised 1/30/2019 reflected The facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to the Administrator or to the Director of Nursing Services immediately. The policy defined abuse and neglect and detailed the Abuse Prevention Program that incorporated all required elements of an effective abuse and neglect prevention program consistent with CFR 483.12 Freedom from Abuse, Neglect, and Exploitation regulatory groups for Long Term Care Facilities. Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. During an interview on 1/23/22 at 1:00 P.M., R93 reported a nurse was very rude to her and flipped out over pills left in a medication cup at her bedside and the nurse accused her of selling drugs. According to R93, she does not want that nurse in her room again because she made her feel depressed and jittery and has been so upset about it that she called her husband crying about the incident. R93 reported that Certified Nurse Aide (CNA) P witnessed the abuse. During an interview on 1/23/22 at 2:42 P.M., CNA P reported that on 1/21/22 R93 had asked CNA P to remove wraps from her legs and RN I told R93 that if she didn't eat so much and would get out of bed, she wouldn't have these problems which left R93 in tears. CNA P said R93 told RN I to be nicer to her when she gives her medications. CNA P said she reported the abuse to RN/Unit Manager G immediately. CNA P said that RN G said she would take care of it. CNA P said she did not notify the Nursing Home Administrator (NHA) of the alleged abuse because she did not have her phone number. CNA P said she was never asked to provide a statement about the abuse after making her report to RN G. CNA P said that she reported the allegation of abuse to RN G immediately but had been educated that she has between 12-24 hours to report allegations of abuse and neglect. During an interview on 1/24/21 at 9:12 A.M., the NHA reported that she started as interim administrator on 12/21/21 and did not have any open Facility Reported Incidents (FRI's). The NHA said she was the facility abuse prevention coordinator and was responsible for reporting all allegations of abuse or neglect. The NHA said she was not aware of an allegation of abuse perpetrated by RN I and reported by CNA P to RN G on 1/21/22. Review of a facility (Facility Name) Center Staffing Reports from 1-23-22-1-24-22 reflected that RN I continued to work at the facility despite the alleged report of resident verbal abuse. Review of a Grievance Form dated 1/24/22 reflected R93 reported A nurse made her 'feel awful', 'I felt depressed'. When asked if she remembered who it was and what the nurse looked like she replied, It was (name of a nurse other than RN I). She has dark long hair and wears it back and wears glasses. Her voice is medium-deep? I told my husband last week and I told the state people. When asked about the nurse currently working with her (RN I) she stated, 'I like (RN I)'. Review of an Investigation Follow-Up form dated 1/24/22 reflected a description of the situation as noted in the Grievance Form. The summary of the investigation reflected Agency nurse (RN I) on shift was interviewed. CNA (CNA P) was interviewed via phone from 9:40 a.m. -9:52 a.m. with UM (RN G) present via phone. Agency Nurse (RN I) sent home pending investigation. (R93) was interviewed with UM (RN G) from 9:33 a.m. - 9:40 a.m. in room door closed. (R93) husband was interviewed via phone 12:45 p.m.-12:54 p.m. Another nurse was interviewed with similar description. Review of a Suspension Notice reflected RN I was suspended for alleged verbal abuse pending investigation on 1/24/22. No evidence that another nurse interviewed with similar description (as noted in the Investigation Follow-Up form) was suspended pending investigation was provided. No documented witness statements pertaining to the interviews conducted were provided. Additionally, only three residents were interviewed about concerns pertaining to abuse and neglect. Resident #43 (R43) Review of a facility Admission Record reflected R43 admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a discharge Minimum Data Set (MDS) assessment dated [DATE] reflected R43 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15 and needed extensive assistance from two people for bed mobility and transfers and required extensive assistance from one person for locomotion on and off the unit, dressing, toilet use and personal hygiene. Section E-Behavior reflected R43 did not exhibit hallucinations or delusions indicating [CONDITION(S)]; did not display behavioral symptoms such as physical or verbal behaviors directed toward others or other behavioral symptoms. The assessment did not reflect R43 rejected care, wandered or behaved in such a way as to significantly impact the care of others or disrupt the care or living environment. Review of an Elopement Evaluation dated 10/4/21 at 5:00 P.M. reflected R43 was assessed as being at risk for eloping from the facility due to a history of attempts to leave the facility without informing staff, verbally expressing a desire to go home, with wandering behavior likely to affect the privacy, safety or well-being of self/others. Review of a Nursing Note dated 10/5/21 at 1:06 A.M. reflected (R43) had an altercation with roommate. Resident went through roommate's belongings. Resident showed increased aggression. Resident was moved to a separate room. (MD Z) notified of behavior and ordered resident to get a nicotine patch for withdrawal. [MEDICATION(S)] 50 mg to help resident with [CONDITION(S)]. Review of a Physician Note dated 10/6/21 at 12:41 P.M. revealed Note Text: Admission not-Resident was seen on 10/5/21 at 8:00 a.m. The note specified Last night he (R43) had a problematic interaction with another resident. Review of a Behavior Note dated 10/5/21 at 3:46 A.M. reflected R43 was again observed going into other resident rooms/area looking for things. R43 threw a trash can at a nurse and became aggravated when additional staff attempted to calm the resident. The note specified It is a struggle to keep him out of other resident's rooms. He is very mobile in his wheelchair and moves himself about as he wants to. Review of a Behavior Note dated 10/6/21 at 12:03 P.M. reflected Resident locked himself in breakroom, hitting, pinching, spitting at staff. Resident went through others belongings calling residents names. Intervention that was used 1:1 Review of a Nursing Note dated 10/6/21 at 3:53 P.M. reflected Resident noted in breakroom with door closed. Resident is wandering threw staff items (sic). Resident obtained staff member's medication and purse. Resident is combative with staff, bruised staff member arm, ripped staff member shirt. Resident spat on staff, Resident is undirect able (sic). Resident has multiple move swings within twenty to thirty minutes (sic). From violet outbreaks to uncontrollable laughing crying (sic). Resident was petition to psych hospital. 911 called. Resident transported via ambulance x2 attendance. Review of ED (Emergency Department) Provider Notes-Encounter Notes dated 10/6/21 at 10:58 A.M. reflected (R43) Presents from (Name of Facility) for agitation. Patient arrived from acute care hospital in Detroit on evening of 10/4. Known to have behavioral issues and [CONDITION(S)] at baseline. Aggressive with staff starting night of arrival. Struck another resident on 1st night. Placed in private room. Struck staff. Spit at staff. Ripped a staff member's blouse off. Verbally and physically abusive to residents and staff. Locked himself in a room, stating he was going to die. Attempted to take an employee's HCTZ (hydrochlorothyizide-a prescription medication used to treat high blood pressure and fluid retention) and [MEDICATION(S)] (a prescription medication used to treat gout and kidney stones) from their locker. Staff able to get patient to spit out all but 1 pill of each. Counted pills and confirmed ingestion amount. Patient would not allow EMS (Emergency Medical Services) or ED RN to take vitals. Mumbling here. Requests for incident and accident reports and evidence the facility had completed a Facility Reported Incident (FRI) to the state agency pertaining to the resident-to-resident altercations was made via email communication on 2/1/22. As of the time of exit on 2/3/22, the Acting NHA said she did not have any of the requested information pertaining to R43. Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 (R5) Review of an Admission Record revealed R5 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 and R5 were roommates on 1/23/22 and 1/24/22. During an observation on 01/23/22 at 01:09 P.M., R2 was visibly agitated, aggressive, and destructive of facility property. R2 was wielding a butter knife and used it to remove the key pad off of the wall and was using the knife to attempt to break through the lock on the double doors. During an interview and observation 01/23/22 at 01:30 P.M., CNA PP reported that she was the only staff member on the MCU for 11 Residents. CNA V was pulled to the East/West Unit. There was 1 LPN on the unit. At that time, R2 continued to be behavioral/destructive. CNA PP reported that she was working with a resident that had increased behaviors (Resident #41) which placed the rest of the residents at increased risk because of the lack of supervision. CNA PP reported more staff were needed to keep the residents on the Memory Care Unit safe. During an interview on 01/24/22 at 12:30 P.M., R5 reported to this surveyor that her roommate (R2) had assaulted her the previous day (1/23/22). R5 was tearful and anxious when reporting the allegation of resident to resident abuse. On 01/24/22 at 12:45 P.M. this surveyor reported to the NHA the allegation of R2 assaulting R5. Review of R2's Behavior Note dated 1/23/22 at 4:28 P.M. revealed, Resident became agitated during lunch time. She went to her room and packed her clothes up in a bag and box. She went to the electronic/keypad box attached to the wall and took out a butter knife she had kept from her meal tray and began trying to pry the box off the wall using the butter knife. Staff notice what she was doing and began walking towards her to intervene, but she managed to pull the box completely off the wall. One Staff member stayed with resident as she was repeatedly shoving at the door handles in an attempt to open them, and the other staff member went to get assistance from maintenance to repair the torn off electronic box. Resident refused to give staff the butter knife. Maintenance repaired the box on the wall. Resident took her things back to her room, unpacked, and butter knife was removed from room. Resident redirected with ice cream and apple juice. Refused to participate in activities. Will continue to monitor and follow up as needed. (Indicating an increase in aggressive behaviors.) Review of an Interdisciplinary Team Note dated 1/31/22 04:43 A.M., revealed, On 1/24/22 at approx 330pm it was reported by her roommate that (R2) had gripped the right wrist of her roommate at that time. According to the roommate, she was in (R2's) pathway in front of her closet blocking her clothes. Her roommate stated that (R2) was trying to get her clothes. The two residents were immediately separated by staff. The roommate's room was changed. (R2) has been monitored for any changes. No mood, appetite or behavior changes were noted in the last 72 hours. Her care plan was updated to reflect that she is to only use spoons on her meal trays for safety. (Psychiatric Contracted Group) and the physician have evaluated her mood and behaviors. (R2) can be understood at times with short sentences and phrases in English. Activities continues to work with her 1:1 when she participates. She has been observed sleeping in her room without a roommate since this incident. Guardian aware. No further incidents or behaviors has been noted at this time. Staff continues to anticipate and meet her needs and keep her and others safe. (This note indicated R2 had no mood, appetite or behavior changes noted in the last 72 hours. However, on 1/23/22 R2 exhibited dangerous behavior using a butter knife and was difficult to redirect). Review of R5's Incident Note dated 1/24/22 at 6:15 P.M. revealed, (R5) stated that her roommate placed her hand on R5's right wrist. She demonstrated a clasped hand over her right wrist. No Injury noted. R5 denied discomfort or fear. When questioned more (R5) stated that it happened last night around bedtime. She stated that her roommate wanted her clothes. (R5) requested to move rooms .(R5) stated she didn't tell anyone the night before . This note was struck out indicating a cancellation of the entry. During an interview on 01/25/2022 at 1:23 P.M., The Director of Nursing (DON) reported she was told to strike out the note and fill out the concern form per the Nursing Home Administrator. DON reported she did not have access to reporting to the State Agency. DON reported that allegations of abuse are to be reported to the State Agency within 2 hours. During an interview on 2/1/22 at 11:41 A.M., Physician Z reported that he completed an assessment on R2 following the allegation of abuse. Physician Z reported that she exhibited behaviors of having a difficult past with keep her items packed and becoming protective of her items. Physician Z reported that because of her possessive behaviors with her items and her space she would have benefited from having a private room. Physician Z reported that R2 may have become overwhelmed to the point she felt she had to protect her items which resulted in the physical altercation between R2 and R5. Review of R2's Physician Note dated 2/1/22 revealed, (R2) was seen today in regard to a recent resident to resident in which she grabbed another residents arm. (R2) is noted to have severe dementia and paranoia. There is a history of her with increased anxiety each day near noon. it is apparent that there was no ill intent. I would suggest she be in her own room so that she does not feel the need to protect her belongings. Psych will continue to follow. Review of the Facility Reported Incident sent to the State Agency revealed the Date/Time Incident Discovered 1/24/22 at 3:30 PM .Date/Time Incident Occurred 1/23/22 at 11:00 PM .Submitted Date/Time: 1/24/2022 at 4:00 PM . (Indicating an inaccurate time the abuse was discovered and abuse not reported within the 2 hours per the regulatory requirements.) Resident #4 (R4) Review of an Admission Record revealed R4 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 Review of an Admission Record revealed R#23 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's Nursing Note dated 9/4/21 at 9:40 A.M. revealed, Upon assessment writer observed an indentation in the front left side of resident's head. Writer palpated entire head and no other injuries noted. Resident does state It hurts when you do that .Writer asked resident what happened? Resident stated Last night (R23) came in my room and took my blue blanket. I grabbed it from me and he started hitting me. I just blocked. I didn't hit him back. Writer informed manager of information provided by resident. Doctor made aware. Review of R4's Nursing Note dated 9/4/21 at 11:00 A.M. revealed, This writer was notified by (Licensed Practical Nurse LPN EEE) that (R4) had stated that he had gotten into a fight. This writer questioned resident who stated (R23), the guy who walks around and goes through people's stuff. He wanted my blue blanket. Per (LPN EEE), resident stated that (R23) had punched him repeatedly and that resident had blocked these punches. (LPN EEE) reported that resident stated this happened last night but was not reported by ad staff to her. Resident with two abrasions on his face from previous documented incident (bridge of nose and right eyebrow). (LPN EEE) noted indentation on left frontal lobe region that she had not noticed on previous shift .Call placed to DON (Previous DON FFF) who stated that this area is not a new finding and his (sic) been present since admission. No staff witnessed alleged incident .Call placed to (Previous NHA HHH), administrator and informed her of all above findings. Instructed (LPN EEE) to contact Dr to notify of incident. Review of the facility Incident and Accident Investigation dated 9/4/21 at 11:15 P.M. revealed, Alleged Incident .Nurse (RN GGG) called and stated (R4) stated he had gotten into a fight. Statement from all staff stated nothing unusual happened .Reporting-To whom was it reported: (Previous DON FFF) Date 9/4/21 Time 11AM .2. Was the resident affected by the incident interviewed-NO . Review of the facility Investigation Follow-Up dated 9/4/21 revealed, (RN GGG) called and said she thought there was a resident to resident altercation .Family Notified 9/2/21 at 11:15pm .Physician Notified 9/2/21 (Time Blank). Review of the Facility Reported Incident revealed this allegation of Resident-to-Resident abuse was not reported to the State Agency. Verified that it was not reported to the State Agency on 2/10/22. Resident #27 Review of an Admission Record revealed R#27 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R27's Nursing Note dated 12/18/21 revealed, Resident becoming increasingly aggressive despite changes in psychiatric meds. CNA (Certified Nursing Assistant) observed him whipping another resident in the face with a pair of sweatpants this shift .Contacted (Previous DON FFF) to notify her of transfer status and residents DPOA (Power of Attorney). Review of the facility Temporary Separation from Other assessment dated [DATE] revealed, per nurses note the resident became increasingly aggressive and was observed whipping another resident in the face with a pair of sweatpants .injury to the other residents face could have occurred. Fear could have occurred .(R27) will be referred to (Psychiatric Consulting Group.) Review of the Facility Reported Incident sent to the State Agency revealed the Date/Time Incident Occurred 12/18/21 .Submitted Date/Time: 1/24/2022 at 9:30 PM . (Indicating the abuse was not reported within the 2 hours per the regulatory requirements.) During an interview on 01/25/22 at 10:02 A.M., CNA PP reported that it was difficult to manage the residents' behaviors with insufficient staff. CNA PP reported that in the mornings there were only 2 CNA's scheduled to work and when 1 CNA went on break it left the other CNA to care for all of the residents on the Memory Care Unit. CNA PP reported that it was difficult to manage the residents' behaviors with insufficient staff. During an observation and interview on 1/26/22 at 2:02 P.M., CNA V reported that he was alone on the unit because CNA OO was on break. CNA V reported he was doing the best he could but the lack of staff resulted in the worsening of resident behaviors which occurred daily.

Based on observation, interview, and record review, the facility failed to provide quality care based on professional standards and resident assessments in a consistent and timely manner for 10 residents (R6, R8, R11, R19, R20, R22, R29, R34, R40, R93), resulting in the potential for, and actual harm from unrecognized changes in condition and avoidable declines in health status. Findings: Resident #6 (R6) Review of a facility Admission Record reflected R6 originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) dated [DATE] reflected R6 was cognitively intact as evidenced by a Brief Interview for Mental Status assessment score of 13/15 and needed limited assistance from one person for transfers, dressing, toilet use, personal hygiene and bathing. Review of an Order Recap Report for the date range 9/01/2021-1/29/2022 reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Weight Summary from 9/9/2021-1/1/2022 reflected R6 admitted to the facility on [DATE] weighing 174.2 pounds and was weighed according to the order. On 10/7/2021 R6 weighed 181.6 pounds. On 11/8/2021 at 5:22 P.M., R6 weighed 205.1 pounds (a 23.5-pound weight gain). R6 was reweighed on 11/8/2021 at 6:59 P.M. and weighed 207.0 pounds (an additional weight gain of 1.9 pounds, reflecting a total weight gain of 27 pounds in a month). Review of Progress Notes reflected that on 11/7/2021 R6 complained of feeling weak and overall not well. A Urine Analysis with Culture and Sensitivity (UA with CS) was ordered to rule out a [CONDITION(S)] (urinary tract infection). On 11/8/2021 R6 continued to complain of pain. A Physician Note on 11/9/2021 entered by Physician Z did not reflect a review of R6's 27-pound weight gain despite a note that Vitals were reviewed. A Nursing Note dated 11/9/21 at 2:53 P.M. reflected R6 continues to be lethargic throughout shift. No indication a physician was notified of R6's 27-pound weight gain in a month was found in the record. Review of a hospital record reflected R6 admitted to the hospital on 11/12/2021 from the facility with a chief complaint of Dyspnea (difficult or labored breathing). The History of Present Illness reflected (R6) is a [AGE] year-old who presented to the hospital on 11/12/21 for a chief complaint of shortness of breath. He has a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . (R6) states that for the past 24 hours he has had progressively worsening dyspnea on all movements. He states that he has had to have oxygen on 24 hours when he usually does not need it .While in the ED (Emergency Department), (R6) was found to be hypoxic. He did have an elevated D-Dimer (a protein fragment made when a blood clot dissolves in your body) and was sent for CT PE (a scan to evaluate for a blood clot in the lungs). CT revealed large bilateral pleural effusions (a buildup of fluid between the tissues that line the lungs and the chest) and a similar consolidation picture to the previous admission. The Impression/Plan reflected Pleural Effusion; Acute Hypoxic [CONDITION(S)] suspect 2/2 (secondary to) Pleural Effusion and CHF (Congestive Heart Failure) .ankle swelling .patient states he has gained 12-15 lbs (pounds) over 2 weeks. Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. Review of an Order Recap Report for the date range 11/01/21-1/31/22 reflected R93 was ordered [MEDICATION(S)] Tablet 40 MG (a diuretic) Give 1 tablet by mouth in the morning for CHF (Congestive Heart Failure) on 12/10/2021. R93's Diet Order reflected she was to have a Modified Diabetic Diet Regular texture, Regular consistency, Consistent Carb diet. No fluid restrictions were noted. Additionally, R93 was to have Daily Wt x 3 days, weekly x 3 week then per Dietary Recommendation as of 12/9/2021. Review of a Weight Summary reflected that R93 had been weighed on 12/9/2021. No further weights were obtained. Review of Progress Notes dated 12/9/21-2/2/22 did not reflect a Dietary Recommendation pertaining to R93's weight and did not indicate R93's weight was ever evaluated despite the ordered monitoring. Review of a Behavior Note dated 12/11/21 at 6:50 P.M. reflected (R93) was refusing to follow fluid restriction orders, requesting lots of additional fluid. Patient was educated on CHF and fluid restriction reasoning. Patient verbalized understanding, will continue to monitor. Review of a Nursing Note dated 12/12/21 at 2:51 P.M. reflected R93 was again requesting extra fluids. No indication the nurse notified the physician about the concern was made. Review of a Nursing Note dated 12/29/21 reflected (R93) complaining of BLE (bilateral lower extremity) hurting due to ACE wraps. When assessed had pitting [CONDITION(S)] +3. Educated the resident on drinking too many fluids and eating too much salt, at bedside has 2 bags of pretzel, saltine crackers, chips, she responded with 'Oh OK', will continue to monitor. No evidence a physician was notified of the 3+ pitting [CONDITION(S)] was found. During an interview on 1/26/22 at 4:30 P.M., Physician AA reported he would treat patients with CHF symptomatically and evaluate for evidence of shortness of breath, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Physician AA denied being informed that R93 had increased [CONDITION(S)] and said that R93 would be a candidate for frequent weight monitoring related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 (R8) Review of an Admission Record revealed R8 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The boxes in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 had no routine blood pressure monitoring to ensure safe medication administration. Blood Pressure last assessed on 9/1/21 (105/72) and 11/22/21 (108/62). Resident #34 (R34) Review of an Admission Record revealed R34 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R34's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Both medications were scheduled to be administered at 8:00 A.M. At 10:39 A.M. R34 had not received either blood pressure medication and a blood pressure was not obtained/documented. Review of R34's Progress Notes revealed no documentation that the physician was notified of the late medication administration. Resident #29 (R29) Review of an Admission Record revealed R29 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R29's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .Hold if systolic BP is 100 or higher .On 1/23/22 at 8:00 PM, R29's Blood Pressure was 118/70 and the [MEDICATION(S)] was administered, on 1/19/22 R29's Blood Pressure was 120/64 at 2:00 PM and the [MEDICATION(S)] was administered, on 1/19/22 at 8:00pm R29's BP was 108/64 and the [MEDICATION(S)] was administered, on 1/9/22 at 8:00 PM R29's blood pressure was 102/60 and the [MEDICATION(S)] was administered. Additionally, R29's [MEDICATION(S)] and BP assessment were to be completed at 8:00 A.M. and on 1/26/22 at 10:39 R29 had not received the BP nor the medication. Resident #6 (R6) Review of an Admission Record revealed R6 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R6's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/8/22 at 3AM R6's BP was 120/60 and he received a dose of [MEDICATION(S)], on 1/18/22 at 3AM R6's BP was 141/64 and he received a dose of [MEDICATION(S)], on 1/1/22 at 7PM R6's BP was 107/71 and he received a dose of [MEDICATION(S)], on 1/13/22 at 7PM R6's BP was 107/56 and he received a dose of [MEDICATION(S)], on 1/17/22 at 7PM R6's BP was 132/72 and he received a dose of [MEDICATION(S)], on 1/21/22 at 7PM R6's BP was 138/74 and he received a dose of [MEDICATION(S)], on 1/24/22 at 7PM R6's BP was 124/72 and he received a dose of [MEDICATION(S)], and on 1/25/22 at 7pm R6's BP was 128/72 and he received a dose of [MEDICATION(S)]. Resident #20 (R20) Review of an Admission Record revealed R20 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R20's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no documented blood pressures or admission/withholding documentation in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/1/22 R20's BP was 97/59 and his [MEDICATION(S)] was administered, on 1/13/22 R20's BP was 132/70 and his [MEDICATION(S)] was administered, on 1/25/22 R20's BP was 115/70 and his [MEDICATION(S)] was administered, and on 1/29/22 R20's BP was 114/70 and his [MEDICATION(S)] was administered. Resident #22 Review of an Admission Record revealed R22 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R22's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/3/22 at 11AM, 1/5/22 at 3AM and 11AM, 1/6/22 at 3AM, 1/8/22 at 11AM, 1/9/22 at 11AM, 1/10/22 at 11AM, 1/11/22 at 3AM/11AM/7PM, 1/12/22 at 3AM and 11AM, 1/13/22 at 3AM/11AM/7PM, 1/14/22 at 11AM, 1/15/22 at 11AM and 7PM, 1/16/22 at 3AM, 1/18/22 at 11AM there was a 7 documented in the MAR boxes indicating the medication was not administered because R22 was sleeping. There was no order to withhold the medication if R22 was sleeping and there were no Progress Notes indicating the physician was notified of the withholding of the prescribed medication. This resulted in the withholding of R22's [MEDICATION(S)] a total of 20 times without a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #40 (R40) Review of an Admission Record revealed R40 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R40's Blood Pressure Summary revealed 12/13/21 a blood pressure of 159/104 Systolic High of 139 exceeded and Diastolic High of 89 exceeded. As of 2/3/22 R40's blood pressure had not been reassessed. Review of R40's Progress Notes revealed the physician was not notified of the abnormally high blood pressure. Resident #11 (R11) Review of an Admission Record revealed R11 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R11's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R11's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/20/22 at 6am R11's BS was 63, on 1/27/22 and 1/30/22 at 6am R11's BS was not assessed. On 1/19/22 at 9pm R11's BS was 55. Review of R11's Progress Notes revealed no documentation that the physician was notified of the abnormal blood sugars or rationale for the lack of blood sugar assessment. Resident #19 (R19) Review of an Admission Record revealed R19 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R19's Blood Sugar Log revealed the following: on 1/11/22 R19's BS was 51, 1/12/22 R19's BS was 53, 1/13/22 R19's BS was 471, 1/14/22 R19's BS was 407, 1/16/22 R19's BS was 49, 42, 43, and 54, 1/23/22 R19's BS was 593, 1/26/22 R19's BS was 423, and 1/30/22 R19's BS was 448. Review of R19's Progress Notes revealed no notes indicating the physician was notified of these abnormally low and high results. During an observation and interview on 01/23/22 at 01:41 P.M., Registered Nurse (RN) I stated to R19, I got to check your sugar, I know it's (blood sugar assessment) late. RN I reported that the blood sugar was to be assessed prior to meals but because she was the only nurse covering 2 units, she was unable to get all meds passed, vitals assessed, and blood sugars obtained timely. During an interview on 01/25/2022 at 12:19 P.M., Physician (P) Z reported that blood sugars must be assessed prior to eating to ensure accurate trends are reviewed. During an interview on 01/26/22 5:30 P.M., Medical Director AA reported that insulin's were adjusted based on blood sugar trends and therefore blood sugars should be assessed prior to eating a meal. MD AA reported he expected to be notified of blood sugars less than 70 and greater than 250 and adjusted insulin accordingly. MD AA reported that uncontrolled blood sugars could cause delayed wound healing and hypoglycemic episodes could result in death. During an interview on 02/03/22 at 01:17 P.M., Unit Manager (UM) G reported that P Z was putting in parameters for all residents that have blood glucose monitoring. UM G reported that the staff should be following the parameters set for the [MEDICATION(S)] and insulin's. UM G reported that abnormal vital signs should be immediately reassessed and if no improvement the physician should be notified, and medications should not be held without a physician order. UM G reported that she and the DON frequently must work as a floor nurse and cannot perform their management duties which included ensuring medications were given on time and correctly following parameters. UM G reported it was chaotic because of the staffing shortage and nursing manager duties were difficult to complete.

Based on interviews and record review, the facility failed to ensure there was sufficient skilled and competent nursing staff to provide nursing and related services in 2 of 27 residents (Resident #20 and #148) reviewed for competent staffing, resulting in the potential for harm and serious injury when staff were not educated, or competency evaluated according to professional standards for resident specific diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: Review of the Facility Assessment, updated [DATE], revealed no comprehensive assessment/plan for staff training/education and competencies (hiring, education, training, competency instruction, and testing policies). During an interview on [DATE] 4:38 P.M., Human Resources (HR) F was asked to review employee files with this surveyor. HR F reported that she was unable to locate orientation checklists, yearly competencies/evaluations, or education in the employee files. HR F reported there was no Nurse Educator hired in the facility and therefore no education tracking to ensure yearly requirements were met. HR F reported she was recently hired and had concerns with how the HR department was handled prior to her arrival. HR F reported that the previous HR staff member was relieved of her duties and now works as kitchen staff. HR F reported that the previous HR staff was not qualified for the HR position. During an interview on [DATE] at 09:48 A.M., HR F reported there was no tracking system or record of Licensed Nurses Cardiopulmonary Resuscitation (CPR) certifications. HR F and the DON were working on obtaining those documents. During an interview on [DATE] at 11:06 A.M., HR F reported that she was unable to locate 4 employee files and she was notified they were at the sister facility. HR F reported that LPN M did not have a background check or employee file available or completed for the facility, and had been working with residents. HR F stated, there is no excuse for not having a background check and they should have been completed. HR F reiterated that the employee files available did not contain required education, orientation checklists, or competency evaluations. Resident #20 (R20) Review of an Admission Record revealed R20 was a [AGE] year old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on [DATE] at 11:54 A.M., R20's [CONDITION(S)] bag was noted to be half full of stool and completely full of gas. During an observation on [DATE] at 9:01 A.M., R20's [CONDITION(S)] bag was full of stool and gas and R20 indicated that no it had no been changed last night or this morning. During an observation on [DATE] at 11:48 A.M., R20's [CONDITION(S)] bag remained full of stool and gas. There was no date written on the wafer to indicate when it had last been changed. Review of an Electronic Medication Administration Record (Emar) and an Electronic Treatment Administration Record (Etar), dated [DATE] - [DATE], reflected no orders for nursing to assess, monitor, clean, or change the [CONDITION(S)] appliance for R20. Review of an Emar and an Etar, dated [DATE] - [DATE], reflected no orders for nursing to assess, monitor, clean, or change the [CONDITION(S)] appliance for R20. Review of a Kardex for R20 reflected no instructions for direct care staff to monitor or assess the [CONDITION(S)] including: when to clean the drainage bag, what to do if there is a leak, who to report to any skin concerns and what kind of skin concerns to report that are specific to colostomies, and the signs of an infection at the ostomy. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Care Plan for R20 regarding use of a [CONDITION(S)] for the elimination of stool revealed no interventions regarding the assessment of and the care needed for a [CONDITION(S)]: (such as) (a) how often to change the bag, (b) how often to change the wafer, (c) who is allowed to change/empty the bag (nursing only or nurse aides), (d) how frequently to assess and where to document the condition of the stoma and surrounding skin, (e) what is the best/preferred time of the day for the resident to change appliances and, (f) how often to burp the bag. No documentation could be located in R20's electronic medical record that reflected staff were providing ongoing education and emotional support to R20 after having the [CONDITION(S)] in [DATE]. Resident #148 (R148) Review of an Admission Record revealed R148 was a [AGE] year-old male, originally admitted to the facility on [DATE], following a 63-day hospitalization for aspiration pneumonia, urinary tract infection and altered mental status. R148 had a gastrostomy tube (tube feed) for hydration and nutrition and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on [DATE] at 8:12 A.M., Certified Nurse Aide (CNA) DDD entered the room to change R148 and the following occurred: (a) R148 laid in bed with the tube feed running, (b) CNA DDD lowered the head of bed flat, and (c) peri-care was provided as the tube feed continued to run. During an observation on [DATE] at 11:53 A.M., CNA DDD stood bedside of R148 providing peri care. The head of the bed was flat and the tube feed was running. CNA DDD indicated (a) that today was the first day on the job, (b) had not received any specific training related to the safe positioning of a resident with a tube feed, and (c) they just told me to show up on Monday so I did. During an observation on [DATE] at 9:25 A.M., tube feed bottle did not have the resident's name, date and time started, and ordered rate. During an observation on [DATE] at 10:45 A.M., the tube feed was running for R148 and the head of the bed was at 17 degrees. During an observation on [DATE] at 12:20 P.M., the tube feed was running for R148 and the head of the bed remained at 17 degrees. Licensed Practical Nurse (LPN) N entered the room and when asked, stated that the head of the bed looked to be about 30 degrees and R148 was positioned at about 25 degrees. When shown that the head of the bed was actually at 17 degrees, LPN N responded oh. LPN N processed to lay the head of the bed flat and then turned off the tube feed, before providing peri care. Review of a Kardex reflected the following information for Eating/Nutrition: Diet order-(nothing specified), and HS (bedtime) snacks .and for Safety: nothing reflected that R148 was a tube feed, how to safely position the resident,what the head of the bed should be, when and how to turn off the tube feed, and what concerns to report to nursing. Review of a Care Plan for R148 was void of all safety interventions related to the tube feed. (No interventions for: (aspiration precautions, height of head of bed, checking for residual, type and rate of tube feed ordered, when to contact the physician, etc)

Based on interview, and record review, the facility failed to complete a comprehensive facility-wide assessment that included an assessment of the physical environment, equipment, training programs, policies/procedures, and health information technology resources, resulting in the potential for unidentified resources necessary to provide care and services to the resident population. Findings: Review of the Facility Assessment, updated 8/2/21, revealed no comprehensive evaluation of the facility's training program. Under the section Staff Training/Education and Competencies. No additional information was included in the facility assessment to describe the identified areas or address how training needs are met for all new and existing staff, contracted employees, and volunteers. Review of the Facility Assessment, updated 8/2/21, revealed no comprehensive evaluation of policies and procedures that may be required to provide care to the residents consistent with professional standards. No additional information was included in the facility assessment to describe how these policies and procedures are maintained and evaluated to ensure compliance with current professional standards of practice. Review of the Facility Assessment, updated 8/2/21, revealed no information related to the use of health information technology or electronic medical records, and no information related to management of resident records. Review of the Facility Assessment, updated 8/2/21, revealed no comprehensive evaluation of the physical environment necessary to meet the needs of the residents, or how that environment would be maintained to promote the health and safety of the residents. During an interview on 02/03/22 at 11:05 A.M., Interim Nursing Home Administrator reported she was looking for the current Facility Assessment to make the changes required for compliance.

Based on observation, interview and record review, the facility failed to ensure its Quality Assessment Process Improvement (QAPI) committee addressed known, self-identified deficiencies meaningfully and effectively, resulting in repeated failings related to the delivery of care and services at the facility that caused serious harm, serious injury and has the high likelihood to impact all residents at the facility. Findings: During an interview on 2/3/22 at 11:44 a.m., the acting Nursing Home Administrator (NHA) reviewed the facility Quality Assurance Process Improvement (QAPI) documents available since August 2021 when new ownership of the facility was established. The NHA reported that maintenance issues were identified in the kitchen, nursing staff were not completing incident reports, there were concerns with labs and standing orders, it was identified there was not a resident trust process and resident financial files were non-existent. Additionally, sign-in sheets for the month of August 2021 indicated the facility assessment was not complete and there were concerns related to supplies. The September 2021 QAPI sign-in sheet reflected a change in Medical Directors. The NHA reported she was unable to locate evidence of systemic identification and evaluation of critical facility system and said there was no leadership to help implement QAPI program and no follow-up for known issues that were noted. During an annual survey conducted from one 1/23/22 through 2/3/22, the following Immediate Jeopardies were identified: 1. The facility failed to prevent abuse, and protect residents from continued abuse, due to widespread system failures beginning with the failure to complete a facility assessment to determine resident acuity and appropriate number of staff and the lack of properly trained, certified, and orientated staff in sufficient numbers to provide care (Refer to noncompliance cited at 483.12, F600-Abuse). 2. The facility failed to ensure residents were provided timely and consistent ADL care including feeding assistance, grooming, personal and oral hygiene, incontinence care and bathing or showers for residents per the standards of practice. (Refer to noncompliance cited at 483.24, F677-ADL Care). 3. The facility failed to (a) provide staffing levels based on acuity and residents needs, (b) failed to ensure functional systems were in place for residents at risk for elopement, (c) failed to prevent choking hazards, falls, and provide a working call light system for a cognitively impaired resident, and (d) ensure crash carts were in full functioning order and all staff knew where to locate the crash carts. (Refer to noncompliance cited at 483.25, F689-Accidents and Hazards). 4. The facility failed to provide necessary oxygen care according to standards of practice. (Refer to noncompliance cited at 483.25, F695-Respiratory Care). 5. The facility failed to provide an adequate amount of staff to meet the needs of the residents 1) ADL care, 2) pressure ulcer prevention/healing, 3) medication administration, 4) dementia care, 5) food service, and 6) financial management and administrative duties (social work, business office management, accounts payable). (Refer to noncompliance cited at 483.35, F725-Sufficient Staffing). 6. The facility failed to ensure residents receiving anti-psychotic medications were closely monitored for adverse effects, were educated on the risk versus benefits of the medication, and were provided a gradual dose reduction, resulting in the potential for prolonged use and/or unnecessary use of an antipsychotic medication. (Refer to noncompliance cited at 483.45, F758-Unnecessary/[CONDITION(S)] Medication Use). 7. The facility failed to store, prepare, distribute, and serve food in a manner to ensure resident safety from foodborne illness. There are no staff in the kitchen able to demonstrate basic food service knowledge, including proper holding and cooking temperatures, reheating foods, or sanitizing procedures for equipment. Food is not being cooked to proper temperatures, not being held at proper holding temperatures, and not being reheated to proper temperatures. Food service equipment is not being sanitized. (Refer to noncompliance cited at 483.60, F812-Food Procurement, Store/Prepare/Serve-Sanitary). 8. The facility failed to administer the facility to ensure residents attained/maintained their highest practicable well-being as evidenced by: 1. inadequate number of and unqualified staff to meet the residents needs, 2. no facility educator in place and no skills checklist/adequate orientation for new hires to ensure they are able to meet the resident needs, 3. failed to ensure properly trained staff and consistent staffing levels to ensure residents are turned/repositioned and consistent ADL care was provided to prevent redevelopment/development and/or worsening of pressure ulcers; 4.) corporate managers in place but inaccessible to staff and unaware of day to day resident/staff needs, 5) Failed to provide sufficient quantities of basic necessities such as food and linens. (Refer to noncompliance cited at 483.70, F837-Governing Body). 9. The facility failed to implement individualized care planned interventions to meet R5 and R2's dementia/behavioral care needs, addressing de-escalation techniques, known behaviors, and diversional activities resulting in a resident to resident physical abuse (R2 assaulted R5, R2 also displayed aggressive, knife wielding assaultive behavior on 1/23/22). This deficient practice resulted in diminished quality of life for residents with mental illness and dementia. (Refer to noncompliance cited at 483.40, F744-Treatment and Services for Dementia). 10. The facility failed to provide medically related social services to attain and maintain the mental and psychosocial health of residents due to the facility did not have a qualified employee working in this role resulting in a lack of a behavior management program; a system to monitor residents on anti-psychotic medications; coordination and transition of care and the maintenance of resident right and quality of life. (Refer to noncompliance cited at 483.40, F745-Medically Related Social Services). In addition to the above referenced Immediate Jeopardies identified, systemic noncompliance was also found pertaining to Resident Rights (F568, F578, F580, F582, and F584), Abuse (F607, F609, and F610), Comprehensive Resident Centered Care Plans (F656, F657, and F658), Quality of Life (F679), Quality of Care (F684, F686, F691, F692, and F693), Nursing Services (F726 and F730), Pharmacy Services (F760), Administration (F838), QAPI (F867), and Infection Control (F880).

Based on observation, interview and record review, the facility failed to implement an adequate and appropriate Infection Control and Prevention (ICP) program and implement adequate and appropriate infection control and prevention protocols resulting in the potential for cross contamination, the spread of disease-causing pathogens and complications from facility acquired (nosocomial) infections and the spread of COVID-19 throughout the facility. Findings: During an interview on 2/3/22 at 12:05 P.M., Registered Nurse (RN) G reported she was the facility Infection Control Preventionist (ICP) and had proof of education/certificate for the IP role per the Centers for Disease Control and Prevention (CDC). According to RN G she started at the facility on January 7th without a job description and was transitioning into the ICP role with Licensed Practical Nurse (LPN) E who had been managing the ICP program but was not certified by the CDC to do so. RN G reported she had not had the chance to review the facility policies and procedures for the ICP. RN G said that since she started at the facility, she had not had the chance to organize or implement the ICP due to having to work as a charge nurse in between COVID-19 testing and vaccinations for employees and residents. RN G said she did not have line listings or daily monitoring for infections and relied on the nurses to screen for COVID-19 symptoms and reported she still did not have a system for entering vital signs into the Electronic Medical Record (EMR) for monitoring of signs and symptoms of any infections. RN G was not able to report what criteria would need to be documented as present for any infection (e.g., McGreer's Criteria) and was not aware of any assessments or forms that could be used in the EMR to aid in data collection and antibiotic stewardship. Review of a December 2021 Infection Log reflected 3 residents (R1, R15 and R93) with Urinary Tract Infections ([CONDITION(S)]) without symptoms listed or an organism identified despite an antibiotic prescription. Review of a November 2021 Infection Log reflected 2 residents with a [CONDITION(S)]. One of the resident's did not have an antibiotic listed on the report despite notation that the infection was acquired in facility with symptoms present on admission. The other resident was prescribed an antibiotic without symptoms and the report indicated the infection was acquired in facility. Review of an October 2021 Infection Report reflected 2 residents with a [CONDITION(S)]. An organism was not listed on the report despite both residents being prescribed an antibiotic without symptoms listed on the report. Further review of the report reflected in the section pertaining to Number of Infections by Site that one resident had a skin infection (three residents were listed on the log with skin infections), two residents had eye infections (not listed on the log), 3 residents had [CONDITION(S)] with catheter (not listed on the log) and 4 residents had [CONDITION(S)] without catheter (only two residents were listed on the log with [CONDITION(S)] without catheter status specified), 5 residents had Gastrointestinal infections (not listed on the log), 6 residents had lower respiratory infections (not listed on the log), 7 residents had upper respiratory infections (only one listed on the log) and eight residents were listed with an Other infection (not listed on the log). No causative organism was listed on the log for any infection, no residents were listed as requiring transmission-based precautions. Resident #10 (R10) Review of an Admission Record reflected R10 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Note dated 12/25/21 at 6:55 A.M. reflected Resident (R10) has a rash that started under his breast and on bilateral 4 AM it has now spread to his back neck head and belly (sic). Call on call doctor new orders to start [MEDICATION(S)] (a cream used to treat scabies) use as directed 1 dose today then again in a week. Resident is on ISO (isolation) for 48 hours. Review of a document signed by the Director of Nursing (DON) on 1-24-21 reflected she had been notified on 12/25/21 that R10 had been diagnosed with scabies and indicated she sent the nurse a copy of the facility policy for Scabies and no further residents or staff were impacted by the scabies infection. Review of the December 2021 Infection Log did not reflect R10 has been added to the log for the scabies infection he was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . No evidence other residents or staff were assessed for a scabies infection or evaluated for similar symptoms. Resident #148 (R148) Review of an Admission Record revealed R148 was a 77- year-old male, originally admitted to the facility on [DATE], following a 63-day hospitalization for aspiration pneumonia, urinary tract infection, and altered mental status. R148 was dependent on staff for hygiene and utilized a tube feed for nutrition and hydration. During an observation on 01/31/22 at 08:12 A.M., CNA DDD completed pericare for R148 and without removing dirty gloves, adjusted the nasal cannula on R148's face. During an observation on 01/31/22 at 11:53 A.M., CNA DDD provided pericare for R148 and again adjusted the nasal cannula on R148's face without removing the same gloves worn to clean up a bowel movement. During an observation on 02/01/22 at 12:20 P.M., Licensed Practical Nurse (LPN) N provided peri care for R148, who had a bowel movement. After completing peri care, LPN N did not remove the soiled gloves before handling bed linens and the bed control. Resident #143 (R143) Review of an Admission Record revealed R143 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 01/25/22 at 11:14 A.M., R143's floor mat, used as a fall mat next to R143's bed, had a torn and frayed top layer, a surface that could not be completely sanitized. Resident #11 (R11) Review of an Admission Record revealed R11 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R11's Health Status Note dated 1/27/22 revealed, Resident has been having diarrhea resulting in accidents this shift. He has also had a urinary accident this HS (night). He has been calling out for help all evening instead of using his call light. He is requiring two people for transferring and is showing increased weakness. Contacted (physician) who ordered CBC (blood test), CMP (blood test) and C.Diff (stool sample) labs. Labs entered into (Hospital) for collection . During observations from 1/23/22-2/3/22, R11 was not in Isolation/Contact Precautions. During an interview on 02/03/22 at 12:24 P.M., Infection Control Nurse (ICN) G reported that R11 should have been placed in Contact Precautions immediately after the possibility of C. Diff was discussed. ICN G reported that there were no results for the C. Diff test, and she was unable to determine if the stool sample was obtained and sent for testing. Review of the Fundamentals of Nursing revealed, .C. difficile (which is transmitted by the fecal-oral route) is harder to eliminate from the environment. It is a spore-forming microorganism, meaning it can remain on surfaces (e.g., bedside table, stethoscope) in a dormant state for long periods. To reduce the risk of cross-contamination among patients, use Contact Precautions in addition to Standard Precautions . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 441). Elsevier Health Sciences. Kindle Edition. On 1/25/22 at 10:41 AM, the drinking fountain adjacent to the main nurses station was observed covered in a plastic bag. Upon observation the surveyor inquired with RN, Staff J, on the purpose of the bag on the drinking fountain to which they replied, COVID concerns, less exposure. On 1/26/22 at 10:56 AM, the memory care unit's drinking fountain was observed uncovered with visible water droplets in is basin. Upon observation the surveyor inquired with Maintenance Director, staff A, on if the drinking fountain is functional to which they replied, it is, but I'm not sure how often it gets used. On 1/26/22 at 3:05 PM, upon interview with the Nursing Home Administrator regarding the current state of the memory care drinking fountain they stated, I understand it is a concern, we will put a bag on it. On 2/1/22 at 2:34 PM, upon the surveyors exit from the facility the memory care unit's drinking fountain was observed functional and uncovered. On 1/26/22 at 10:50 AM, in the memory care dining room an N95 respirator face mask with visible makeup on the interior of it was observed on the countertop along with two unattended coffee carafes, a store-bought cup coffee, and a opened can of cherry coke with four residents present in the room. At this time the surveyor inquired with staff A on who would be a good staff member to ask about the items on this countertop to which they replied, I'll grab a CNA. On 1/26/22 at 10:54 AM, upon interview with CNA, staff V, on the current state of the countertop they stated, yeah we can get this cleaned up, we normally don't have all this stuff on it. On 1/26/22 at 10:57 AM, a stained bandage was observed stuck to the restroom door frame of resident room [ROOM NUMBER]. At this time closer inspection of the restroom by the surveyor revealed one roll of toilet paper on the floor, one roll of toilet paper on top of the wall mounted sharps container, and two clothes hangers hanging from the toilet surround grab bar. On 1/26/22 at 10:59 AM, the surveyor inquired with staff A on the current state of the area to which they stated, I'm not sure, but I can get housekeeping in here. I'm sure someone asked for more toilet paper and didn't know where to put it. On 1/26/22 11:10 AM, the hopper and utility sink were observed heavily soiled in the main soiled holding room with a noticeable odor present in the room. Upon observation the surveyor inquired with staff A on the current state of the hopper and sink to which they stated, regardless of the unit, housekeeping should be coming in and cleaning along with daily checks by staff. At this time the surveyor reviewed a posted sign dated 1/3/2016 entitled, Personal Protective Equipment Hazard Assessment Certification with the Area or Job Being Assessed as, Nursing- Soiled linen with eye, face, hand and body highlighted as hazards. On 1/26/22 between 11:12 AM, and 11:17 AM, neither the surveyor nor staff A could locate any personal protective equipment available for staff to use in this room to which staff A commented at 11:18 AM, we'll get some. On 1/26/22 between 4:44 PM, and 4:50 PM, in the facility's laundry room an accumulation of dust and debris was observed behind and on the sides of both washing machines, on the ceiling vent cover, under both dryers and on each filter, and the designated handwashing sink was observed with a wrench in its sink basin and with its P trap drain removed and laying on the floor. On 1/26/22 at 4:50 PM, upon interview with Laundry worker, staff U, on how they conduct handwashing in this area they stated, the sink has been broken for a while, all we have is hand sanitizer right now. When we need to wash our hands we have to use the bathroom by our lockers. At this time the surveyor inquired about gloves, protective eye wear and gowns being available for staff to use to which they stated, I don't think we have any here. On 1/26/22 between 4:51 PM, and 4:56 PM, neither the surveyor nor staff U could locate any personal protective equipment available for staff to use in either the clean or dirty sides of the laundry to which staff U commented at 4:57 PM, you're right, I'll see about getting some gloves and the other stuff. On 1/26/22 at 10:50 AM, the memory care unit's resident refrigerator, and at 5:30 PM, the main resident refrigerator, were observed soiled with dried food debris and visible staining on their interior surfaces. On 1/26/22 at 5:32 PM, upon interview with CNA, staff D, on the current state of the refrigerator they stated, I think something spilled and nobody cleaned it up. Maybe whoever checks the temperature could wipe it down at the same time? This looks like more than just from today.

Based on observation, interview and record review, the facility failed to competently assess and monitor for changes in condition and notify the physician of pertinent findings in a timely manner for 2 residents (Resident #6 and Resident #93) resulting in the potential for and actual harm from unrecognized, clinically significant changes in condition and, significant medication administration and omission errors. Findings: A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. ([NAME] & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved May 19, 2011, from http://www.hgexperts.com/article.) The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). In Legal and Ethical Issues in Nursing by G. [NAME] (2001), it documents that Documentation must show continuity of care, interventions that were used, and patient responses to the therapies implemented. Nurse's notes are to be concise, clear, timely, and complete. (pg. 171) It states that A [NAME] can infer that no observation of the patient was conducted if there is no mention of a change in condition of the patient. (pg. 171) Resident #6 (R6)-Change in Condition Review of a facility Admission Record reflected R6 originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) dated [DATE] reflected R6 was cognitively intact as evidenced by a Brief Interview for Mental Status assessment score of 13/15 and needed limited assistance from one person for transfers, dressing, toilet use, personal hygiene and bathing. Review of an Order Recap Report for the date range 9/01/2021-1/29/2022 reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Weight Summary from 9/9/2021-1/1/2022 reflected R6 admitted to the facility on [DATE] weighing 174.2 pounds and was weighed according to the order. On 10/7/2021 R6 weighed 181.6 pounds. On 11/8/2021 at 5:22 P.M., R6 weighed 205.1 pounds (a 23.5-pound weight gain). R6 was reweighed on 11/8/2021 at 6:59 P.M. and weighed 207.0 pounds (an additional weight gain of 1.9 pounds, reflecting a total weight gain of 27 pounds in a month). Review of Progress Notes reflected that on 11/7/2021 R6 complained of feeling weak and overall not well. A Urine Analysis with Culture and Sensitivity (UA with CS) was ordered to rule out a [CONDITION(S)] (urinary tract infection). On 11/8/2021 R6 continued to complain of pain. A Physician Note on 11/9/2021 entered by Physician Z did not reflect a review of R6's 27-pound weight gain despite a note that Vitals were reviewed. A Nursing Note dated 11/9/21 at 2:53 P.M. reflected R6 continues to be lethargic throughout shift. No indication a physician was notified of R6's 27-pound weight gain in a month was found in the record. Review of a hospital record reflected R6 admitted to the hospital on 11/12/2021 from the facility with a chief complaint of Dyspnea (difficult or labored breathing). The History of Present Illness reflected (R6) is a [AGE] year-old who presented to the hospital on 11/12/21 for a chief complaint of shortness of breath. He has a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . (R6) states that for the past 24 hours he has had progressively worsening dyspnea on all movements. He states that he has had to have oxygen on 24 hours when he usually does not need it .While in the ED (Emergency Department), (R6) was found to be hypoxic. (R6) did have an elevated D-Dimer (a protein fragment made when a blood clot dissolves in your body) and was sent for CT PE (a scan to evaluate for a blood clot in the lungs). CT revealed large bilateral pleural effusions (a buildup of fluid between the tissues that line the lungs and the chest) and a similar consolidation picture to the previous admission. The Impression/Plan reflected Pleural Effusion; Acute Hypoxic Respiratory Failure suspect 2/2 (secondary to) Pleural Effusion and CHF (Congestive Heart Failure) .ankle swelling .patient states he has gained 12-15 lbs (pounds) over 2 weeks. Resident #93 (R93)-Unmonitored and unreported clinically significant change in condition Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. Review of an Order Recap Report for the date range 11/01/21-1/31/22 reflected R93 was ordered [MEDICATION(S)] Tablet 40 MG (a diuretic) Give 1 tablet by mouth in the morning for CHF (Congestive Heart Failure) on 12/10/2021. R93's Diet Order reflected she was to have a Modified Diabetic Diet Regular texture, Regular consistency, Consistent Carb diet. No fluid restrictions were noted. Additionally, R93 was to have Daily Wt x 3 days, weekly x 3 week then per Dietary Recommendation as of 12/9/2021. Review of a Weight Summary reflected that R93 had been weighed on 12/9/2021. No further weights were obtained. Review of Progress Notes dated 12/9/21-2/2/22 did not reflect a Dietary Recommendation pertaining to R93's weight and did not indicate R93's weight was ever evaluated despite the ordered monitoring. Review of a Behavior Note dated 12/11/21 at 6:50 P.M. reflected (R93) was refusing to follow fluid restriction orders, requesting lots of additional fluid. Patient was educated on CHF and fluid restriction reasoning. Patient verbalized understanding, will continue to monitor. Review of a Nursing Note dated 12/12/21 at 2:51 P.M. reflected R93 was again requesting extra fluids. No indication the nurse notified the physician about the concern was made. Review of a Nursing Note dated 12/29/21 reflected (R93) complaining of BLE (bilateral lower extremity) hurting due to ACE wraps. When assessed had pitting [CONDITION(S)] +3. Educated the resident on drinking too many fluids and eating too much salt, at bedside has 2 bags of pretzel, saltine crackers, chips, she responded with 'Oh OK', will continue to monitor. No evidence a physician was notified of the 3+ pitting [CONDITION(S)] was found. During an interview on 1/26/22 at 4:30 P , Physician AA reported he would treat patients with CHF symptomatically and evaluate for evidence of shortness of breath, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Physician AA denied being informed that R93 had increased [CONDITION(S)] and said that R93 would be a candidate for frequent weight monitoring related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #93 (R93)-unreported clinically significant blood glucose readings and medication administration and omission errors. Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. Review of a Care Plan Report including revision history initiated on 12/9/21 reflected no care plan focus areas had been developed for R93 that pertained to diabetes. Review of an Order Recap Report for the date range 12/01/21-2/28/22 reflected R93 was prescribed [MEDICATION(S)] KwikPen Solution Pen-injector 100 UNIT/ML (Insulin [MEDICATION(S)] (1 Unit Dial)) Inject 28 unit subcutaneously with meals related to TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS (E11.8) Notify Physician if blood sugar is below 90 and greater than 250. During an interview and observation on 1/24/22 at 8:20 A.M., Registered Nurse (RN) I was at R93's bedside preparing to administer morning medications. RN I said she was not going to give R93 prescribed [MEDICATION(S)] (a fast-acting insulin) because R93's blood sugar reading was 130 mg/dl that morning and she wasn't comfortable with that and would document that R93 refused the insulin. RN I said she had not notified the physician (MD AA) and did not make a note in a Physician Binder at the nurse desk for the physician to review because she alleged MD AA never looked at it. RN I said MD AA typically only comes in at night and said, He has to sleep sometime! RN I then contradicted her statement about not wanting to call MD AA to report concerns with an order by saying MD AA is available by phone 24/7. RN I then asked R93 to explain what other nurses do. R93 did not understand what RN I was asking her and RN I said, The other nurses adjust the dose of insulin based on what they think R93 needs and not the physician order. During the interview and observation on 1/24/22 that began at 8:20 A.M., R93 reported she did not know the signs or symptoms of [CONDITION(S)] or [CONDITION(S)] and denied refusing medications as RN I had indicated she would document. R93 did not know whether or not other nurses were adjusting her insulin orders without her knowledge and said, I take what they give me. When asked what she would do if she started to feel shaky or sweaty, increased hunger, fatigue, nausea or vomiting or lightheadedness (some signs of [CONDITION(S)]), R93 said she would push the button. RN I was still at the bedside, in full view of the resident, and placed her hand over her mouth, shook her head and said, If you could do that here, the implication being that staff would not respond in a timely manner. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -1/8/22 at 5:00 P.M. the [MEDICATION(S)] was given despite a blood sugar (BS) reading of 83 mg/dL. -1/13/22 at 12:00 P.M. the [MEDICATION(S)] was given despite a BS reading of 88 mg/dL. -1/15/22 at 5:00 P.M. the [MEDICATION(S)] was NOT given despite a BS reading of 177 mg/dL. -1/21/22 RN I documented on R93 refused the [MEDICATION(S)] at every meal despite BS readings of 191 mg/dL at breakfast and 170 mg/dL at noon. A blood sugar was not documented as checked at 5:00 p.m. on 1/21/22. -1/23/22 RN I documented R93 refused [MEDICATION(S)] at breakfast despite a BS reading of 193, gave the noon dose for a BS reading of 212 and again documented R93 refused the 5:00 P.M. dose of [MEDICATION(S)] despite a BS reading of 141 mg/dL. -1/24/22 RN I documented R93 refused her [MEDICATION(S)] at breakfast for a BS reading of 130 mg/dL. Further review and comparison of R93 Blood Glucose readings recorded in the Vital Signs section of the Electronic Medical Record (EMR) and the MARs for the months of December 2021-January 2022 reflected multiple additional BS readings outside of physician parameters set for the administration of the short-acting insulin. Review of Progress Notes for the date range 12/9/21-1/24/22 did not reflect any notifications to the physician about concerns pertaining to R93's blood sugar readings or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/26/22 at 4:30 P.M., MD AA reported that it is not okay for a nurse to give or withhold medications outside of prescribed parameters without calling him first.

Based on observation, interview and record review, the facility failed to develop and implement comprehensive resident focused care plans based on a comprehensive assessment for 9 residents (Resident #2, #3, #6, #17, #19, #22, #42, #93 #148), resulting in unidentified care needs and hospitalization as the result of complications from inadequate provision of care according to standards of practice. Findings: Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's Care Plan last revised 10/11/21 revealed, SKIN INTEGRITY: I am at risk for skin breakdown .Nurse will check skin weekly and document on skin assessment and treat per facility policy . Review of R2's Weekly Skin Assessments revealed R2's last assessment was completed on 12/5/21 Resident #3 (R3) Review of an Admission Record revealed R3 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R3, with a reference date of 9/2/21 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated R3 was cognitively impaired. Review of the Functional Status revealed that R3 required supervision with one person for personal hygiene/showering. Review of R3's Care Plan last revised on 8/27/21 revealed, Resident requires (assistance level) X (how many staff) for Bathing/Showering. Resident #6 (R6) Review of a facility Admission Record reflected R6 originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) dated [DATE] reflected R6 was cognitively intact as evidenced by a Brief Interview for Mental Status assessment score of 13/15 and needed limited assistance from one person for transfers, dressing, toilet use, personal hygiene, and bathing. Review of Census Data in the EMR reflected R6 admitted to the facility on [DATE], discharged to the hospital from 10/28/21-11/2/21, readmitted to the facility on [DATE], discharged to the hospital again from 11/12/21-11/18/21, readmitted to the facility on [DATE]. R6 had an unpaid hospital leave on 12/6/21, returned to the facility the same day and was hospitalized again from 12/18/21-12/31/21. Review of a COMS ® Post Fall Evaluation note dated 9/15/21 at 3:49 p.m. reflected Called to resident (R6's) room. Resident found in wheelchair with grippy socks in place. He stated that he had fallen in the bathroom after trying to transfer unassisted. Denied pain. Skin assessment completed and no issues noted. Educated on call light use and waiting for assistance. (MD AA) and family member (name) notified of fall. No new orders obtained. According to the report the call light had been activated but R6 did not wait for assistance. No further details surrounding the fall were documented and additional interventions to prevent another fall were not added to the care plan. Review of the Care Plan Report, canceled in its entirety on 11/11/21 after R6 was hospitalized reflected that on 9/9/21 (date of admission), R6 was identified as needing assistance with Activities of Daily Living (ADLs), however the plan did not specify how many staff or what level of assistance was needed for bed mobility, transfers, personal hygiene, eating, bed mobility or toileting. The canceled care plan indicated that R6 was at risk for falls related to conversion disorder with seizures or convulsions and secondary Parkinsonism with the goal (R6) will have no serious injury related to falls AEB (as evidenced by) documentation thru next review. Interventions to meet the stated goal included Assistive Devices (non-specific); ensure call light or bathroom call light are answered promptly; ensure call light is within reach; monitor for signs and symptoms of fatigue; encourage rest periods as needed; nurse will assess resident for changes in physical or mental status and notify Dr. as needed and follow up with recommendations. Review of a Physical Therapy PT Discharge Summary for the dates of service 9/17/21-10/28/21 reflected that R6 had been discharged from physical therapy due to being discharged to the hospital. Review of the report reflected R6 had not met the majority of short or long-term goals, including reducing the risk for falls. According to the report a short-term goal was that R6 would Safely ambulate on level surfaces 150 feet using two wheeled walker with CGA (Contact Guard Assistance) with normalized gait pattern 90% of the time to facilitate increased participation in functional activity was not met. Review of an Order Recap Report for the date range 9/01/21-1/29/22 reflected R6 was prescribed [MEDICATION(S)] Tablet 5 MG (milligram) Give 5 mg by mouth three times a day for muscle pain for 5 days. Started on 12/13/21 and discontinued on 12/14/21. A second order for [MEDICATION(S)] Tablet 5 MG (milligram) Give 5 mg by mouth two times a day for muscle pain for 5 days started on 12/14/21 and ended on 12/19/2021. [MEDICATION(S)] is a muscle relaxer with side effects that include but are not limited to dry mouth or throat, headache, blurred vision, drowsiness, dizziness and fatigue. Review of an Incident Note dated 12/18/21 at 3:05 A.M. reflected CNA (Certified Nurse Aide) doing rounds down hallway when coming back up hallway heard noise then yell. Found resident (R6) lying inside bathroom door facedown with feet just outside of door and lying up against the wall left side. When asked resident what happened he stated got dizzy and passed out but tried to catch himself on the wall with his left hand. Resident call light was not in use and he does have urinal at bedside that was empty. He also took off his oxygen and saturation was 90%, did have increased confusion A&Ox2 (alert and oriented to person and place). During assessment resident was assisted onto his right side where he yelled out in pain and unable to move his left leg at the hip, pain level 8/10 at this time. Other nurse notified doctor, the DON (Director of Nursing) and 911 was called. Resident also had hematoma to left side of forehead it is raised approximately measuring 5 cm x 3 cm, abrasion to left elbow and hematoma present. Resident was transported via (ambulance company) to (hospital). Attempted to contact family members one number no in service and left message with other contact. Review of a Hospital Discharge Summary dated 12/31/21 reflected [AGE] year old male with PMHx (previous medical history) of [CONDITION(S)] (high blood pressure), [CONDITION(S)] on 2L NC (2 liters via nasal canula), Afib ([CONDITION(S)]) (on [MEDICATION(S)]), [CONDITION(S)], heart failure, s/p PPM (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Imaging showed left intertrochanteric fracture of the left femur, S/P Left hip ORIF (open reduction, internal fixation) with nail placement surgery. Following surgery, he was found to be hypotensive and in [CONDITION(S)] was started on Phenylphrine and received two liters of IVF (intravenous fluid) boluses and was transferred to ICU (intensive care unit) for close monitoring. Review of the Electronic Medical Record (EMR) for evidence of care planning reflected R6 did not have an active care plan in place for any focus areas. Attempts to open a current care plan or Kardex (an at a glance care guide) resulted in documents annotated No Data Found. Further review of the EMR revealed a historic care plan that had been canceled as of 11/11/21 due to R6 discharged from the facility for a hospitalization [DATE]-[DATE]. No evidence a new care plan had been developed or implemented upon readmission to the facility on [DATE] was found. On 1/24/22 the DON was asked to provide the fall incident report dated 12/18/21 and the accompanying investigation. According to the DON, only the incident report was available and no additional information could be found. Attached to the incident report was an Investigation Follow-Up form that was not filled out. Circumstances surrounding the fall were not reviewed and without a care plan in place, no interventions had been developed or implemented prior to the fall that may have prevented the serious injury. Resident #17 (R17) Review of a facility Admission Record reflected R17 admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission Minimum Data Set (MDS) assessment dated [DATE] reflected R17 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15 and needed extensive assistance from two people for bed mobility and transfers and required extensive assistance from one person for dressing, toilet use and personal hygiene. Review of the entire Care Plan Report initiated on 9/29/2021 did not reflect Focus areas, Goals or Interventions were developed or implemented that pertained to R17's need for oxygen therapy or the use of a [CONDITION(S)] machine related to pulmonary disease or sleep apnea. The care plan did not reflect specific requirements for Assistance with Daily Living (ADL) care such as the need for [CONDITION(S)] care, bed mobility, transfer status or bathing preferences. Review of a Care Plan initiated on 10/12/21 reflected (R17) is at nutritional risk related to obesity with a BMI (Body Mass Index) of 61.0 She has numerous food allergies. She has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R17) chooses not to follow a diabetic diet or fluid restrictions. One goal of the Care Plan was that R17 would not consume any food that she is allergic to. An intervention on the Care Plan specified (R17) will not be served pineapple, nuts, kiwi, honey, fish, aspartame, chestnuts, chocolate, cinnamon, shellfish, strawberries, sucrolose or tomato products. Review of a Nursing Note dated 1/13/22 at 6:49 A.M. reflected Patient took medications with pop and resident stated that she didn't realize that she had bought sugar free pop which contains aspartame. Patient stated that 'her throat was swelling up', patient's eyes and lips swelled up. An [MEDICATION(S)] was given patient was still unresponsive and started responding again after 911 was contacted and she was sent to the ER (emergency room ). Doctor and mother notified. Review of a Nursing Note dated 1/17/22 at 2:35 P.M. reflected Patient was found at 1400 (2:00 P.M.) having difficulty breathing after having fish at lunchtime. Patient reported that she did not eat much fish. Patient had difficulty breathing and speaking and reported tightness in her chest. Patient was given an [MEDICATION(S)], patient stated little effect. Patient offered Benadryl, but unable to swallow. Ambulance called, patient was sent to (name of hospital), leaving by ambulance at 1435 (2:35 P.M.). Physician (MD Z) and family notified. During an interview on 1/31/22 at 8:01 A.M., R17 recalled the allergic reactions from earlier that month and stated Oh yeah, that's the week they tried to kill me! R17 said she purchased a diet soda by mistake, believing the beverage was a regular cream soda because of the labeling. R17 said she set it aside to give to one of the CNA's and didn't realize what she was drinking when the nurse handed it to her to swallow her medications with on 1/13/22. R17 reported that she never would have chosen to eat fish and that her allergies are supposed to be listed on her meal card, but on 1/17/22 she was served fish. R17 explained that she thought the fish was chicken but was concerned about how pale and white it was. R17 said that when she went to take a forkfull of the meat, it flaked off near her mouth causing a second serious allergic reaction. Resident #19 (R19) Review of an Admission Record revealed R19 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R19's Care Plan last revised 8/26/21 revealed, SKIN INTEGRITY: I am at risk for skin breakdown .Nurse will check skin weekly and document on skin assessment and treat per facility policy . Review of R19's Weekly Skin Assessments revealed they were not completed as ordered. R19's Weekly Skin Assessments were completed on 11/4/21, 11/18/21, 12/2/21, 12/30/21, and 1/20/22. Resident #22 Review of an Admission Record revealed R22 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R22's Care Plan last revised 4/20/21 revealed, SKIN INTEGRITY: I am at risk for skin breakdown r/t (related to): decrease in mobility .Nurse will check skin weekly and document on skin assessment and treat per facility policy. Review of R22's Weekly Skin Assessments revealed R22's last assessment was completed on 12/3/21. Resident #42 (R42) Review of an Admission Record revealed R42 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R42's Care Plan last revised 12/5/21 revealed, SKIN INTEGRITY: I am at risk for skin breakdown r/t: impaired mobility and I have bilateral casts to my lower extremities. Nurse will check skin weekly and document on skin assessment and treat per facility policy . Staff will check resident routinely and PRN, if soiled cleanse and apply a skin barrier . Wash and dry skin thoroughly following each incontinence. Review of R42's Nursing Note dated 12/29/21 revealed, Resident had a f/u (follow up) appointment with (Orthopedic Provider) today At her appointment her BLE (bilateral lower extremity) cast were removed . During an observation on 01/23/22 at 10:27 AM, R42 was in her room sitting up in a wheelchair. She was able to self-propel in her wheelchair and did not have orthopedic casting on her bilateral lower extremities. Review of an Admission Record revealed R42 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R42's Care Plan last revised 12/5/21 revealed, SKIN INTEGRITY: I am at risk for skin breakdown r/t: impaired mobility .Nurse will check skin weekly and document on skin assessment and treat per facility policy . Review of R42's Weekly Skin Assessments revealed R42's last assessment was completed on 12/1/21 and not again until 12/1/22. Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. Review of a Care Plan Report including Revision history initiated on 12/9/21 reflected no care plan focus areas had been developed for R93 that pertained to her diabetes or congestive heart failure. R93 was identified as having limited physical mobility related to weakness but no interventions pertaining to transfers or locomotion were specified. A care plan was not developed for R93 pertaining to ADL care despite the MDS assessment reflecting R93's need for extensive assistance. Resident #148 (R148) Review of an Admission Record revealed R148 was a [AGE] year-old male, originally admitted to the facility on [DATE], following a 63-day hospitalization for aspiration pneumonia, urinary tract infection and altered mental status. R148 had a gastrostomy tube (tube feed) for hydration and nutrition and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Care Plan for R148 revealed it was void of all safety interventions related to the tube feed. (No interventions for aspiration precautions, height of head of bed, checking for residual, type and rate of tube feed ordered, when to contact the physician, etc.).

Based on observation, interview and record review, the facility failed to review and revise the comprehensive plan of care for 9 residents (R2, R23, R10, R11, R19, R30, R41, R40, and R3), resulting in harm from resident to resident abuse and the potential for ongoing resident to resident abuse and complications from unmet care needs. Findings: Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's Physician Note dated 2/1/22 revealed, (R2) was seen today in regards to a recent resident to resident in which she grabbed another residents arm. (R2) is noted to have severe dementia and paranoia. There is a history of her with increased anxiety each day near noon. It is apparent that there was no ill intent. I would suggest she be in her own room so that she does not feel the need to protect her belongings. Psych will continue to follow . During an interview on 2/1/22 at 11:41 A.M., Physician Z reported that he completed an assessment on R2 following the allegation of abuse. Physician Z reported that she exhibited behaviors of having a difficult past with keeping her items packed and becoming protective of her items. Physician Z reported that because of her possessive behaviors with her items and her space she would have benefited from having a private room. Physician Z reported that R2 may have become overwhelmed to the point she felt she had to protect her items which resulted in the physical altercation between R2 and R5. Review of R2's Care Plans revealed no care plans or revisions for known behaviors of protective behaviors for belongings, increased behaviors around noon, and paranoia. Review of R2's Care Plan revealed, Behavior (no further documentation for the focus) Created on: 8/30/2021. I will not have any behaviors throughout the next review . I may become overstimulated. please take me to a calm environment if this happens . Offer activities of choice . Review of R2's Care Plan revealed, Psychosocial well being (sic) (no further documentation for the focus) Created on: 8/30/2021 .I will be up and dressed daily. and remain in a calm and happy appearance. throughout the next review date . During an observation on 01/23/22 at 01:09 P.M., R2 was visibly agitated, aggressive, and destructive of facility property. R2 was wielding a butter knife and used it to remove the key pad off of the wall and was using the knife to attempt to break through the lock on the double doors. LPN M was blocking her path and was not communicating (verbal or non-verbal) with her in an attempt to deescalate the situation. Review of R2's Behavior Note dated 1/23/22 at 4:28 P.M. revealed, Resident became agitated during lunch time. She went to her room and packed her clothes up in a bag and box. She went to the electronic/keypad box attached to the wall and took out a butter knife she had kept from her meal tray and began trying to pry the box off the wall using the butter knife. Staff notice what she was doing and began walking towards her to intervene, but she managed to pull the box completely off the wall. One Staff member stayed with resident as she was repeatedly shoving at the door handles in an attempt to open them, and the other staff member went to get assistance from maintenance to repair the torn off electronic box. Resident refused to give staff the butter knife. Maintenance repaired the box on the wall. Resident took her things back to her room, unpacked, and butter knife was removed from room. Resident redirected with ice cream and apple juice. Refused to participate in activities. Will continue to monitor and follow up as needed. (Indicating an increase in aggressive behaviors.) During an interview on 01/24/22 at 12:30 P.M., R5 reported to this surveyor that her roommate (R2) had assaulted her the previous day (1/23/22). R5 was tearful and anxious when reporting the allegation of resident to resident abuse. Resident #23 (R23) Review of an Admission Record revealed R23 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's Nursing Note dated 9/4/21 at 11:00 A.M. revealed, This writer was notified by (Licensed Practical Nurse LPN EEE) that (R4) had stated that he had gotten into a fight. This writer questioned resident who stated (R23), the guy who walks around and goes through people's stuff. He wanted my blue blanket. Per (LPN EEE), resident stated that (R23) had punched him repeatedly and that resident had blocked these punches . Review of R23's Nursing Note dated 12/19/21 revealed, Please have resident evaluated by (physician) for progression of dementia symptoms. He continues to decline in the evening and consistently attempts to self-ambulate, creating a safety situation for him. Review of R23's Nursing Note dated 12/25/21 revealed, Resident exhibiting signs of delusions, primarily in the overnight, causing potential risk to his safety. He is becoming increasingly anxious, restless, and agitated . Review of R23's Care Plan revealed no entry or revision for aggressive behavior resulting in a resident to resident altercation, increased paranoia, restlessness, or agitation. Resident #10 (R10) Review of an Admission Record reflected R10 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Note dated 12/25/21 at 6:55 a.m. reflected Resident (R10) has a rash that started under his breast and on bilateral 4 AM it has now spread to his back neck head and belly (sic). Call on call doctor new orders to start [MEDICATION(S)] (a cream used to treat scabies) use as directed 1 dose today then again in a week. Resident is on ISO (isolation) for 48 hours. Review of a Care Plan including revision history originally initiated 9/16/21 did not reflect the transmission based precautions and related treatments needed to manage his scabies diagnosis. Resident #11 (R11) Review of an Admission Record revealed R11 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R11's Health Status Note dated 1/27/22 revealed, Resident has been having diarrhea resulting in accidents this shift. He has also had a urinary accident this HS (night). He has been calling out for help all evening instead of using his call light. He is requiring two people for transferring and is showing increased weakness. Contacted (physician) who ordered CBC (blood test), CMP (blood test) and C.Diff (stool sample) labs. Labs entered into (Hospital) for collection . During observations from 1/23/22-2/3/22, R11 was not in Isolation/Contact Precautions. During an interview on 02/03/22 at 12:24 P.M., Infection Control Nurse (ICN) G reported that R11 should have been placed in Contact Precautions immediately after the possibility of C. Diff was discussed. ICN G reported that there were no results for the C. Diff test, and she was unable to determine if the stool sample was obtained and sent for testing. Review of the Fundamentals of Nursing revealed, .C. difficile (which is transmitted by the fecal-oral route) is harder to eliminate from the environment. It is a spore-forming microorganism, meaning it can remain on surfaces (e.g., bedside table, stethoscope) in a dormant state for long periods. To reduce the risk of cross-contamination among patients, use Contact Precautions in addition to Standard Precautions . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 441). Elsevier Health Sciences. Kindle Edition. Review of Review of a Care Plan including revision history originally initiated 10/10/21 did not reflect the transmission based precautions and related treatments needed to manage his gastro-intestinal illness and potential c.diff infection. Resident #19 (R19) Review of an Admission Record revealed R19 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R19's Nursing Note dated 10/24/21 revealed, Resident is being combative with cares . Review of R19's Nursing Note dated 12/8/21 revealed, Resident was very combative towards staff as we were trying to change her and get her up and dressed for the day, her behavior improved during the afternoon and became worse at dinner again . Review of R19's Nursing Note dated 12/20/21 revealed, (R19) was found in another residents room last night licking empty dinner dishes last night. Review of R19's Nursing Note dated 12/23/21 revealed, While staff were completing HS (nighttime) cares resident was combative. She was trying to bite, hit, and scratch . Review of R19's Nursing Note dated 12/24/21 revealed, (R19) was found in another residents bathroom tonight flushing objects down the toilet. Review of R19's Care Plan revealed no entry or revision for combative behaviors or entering other residents rooms. Resident #30 (R30) Review of an Admission Record revealed R30 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's Behavior Note dated 12/24/21 revealed, (R30) is showing signs of agitation and aggression. He attempted to hit a CNA tonight during cares. He is slowly becoming more restless and paranoid. Review of R30's Care Plans revealed no entry or revision for combative behavior, aggression, or paranoia. Resident #41 (R41) Review of an Admission Record revealed R41 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and observation 01/23/22 at 01:30 P.M., CNA PP reported that R41 had increased behaviors and frequently required 1:1 attention which included walking the hall with R41. Review of R41's Physician Note dated 1/24/21 revealed, .intermittent aggressive behavior and prior elopement risk . Review of R41's Care Plans revealed no entry or revision for aggressive behavior, pacing, or 1:1 care. Resident #40 (R40) Review of an Admission Record revealed R40 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . ([MEDICATION(S)] is a Benzodiazepines · Sedative-Hypnotic) Review of R40's Care Plans revealed no entry or revision regarding monitoring for a Benzodiazepines/Sedative-Hypnotic, behavior management, or her mental health diagnosis. Resident #3 (R3) Review of an Admission Record revealed R3 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R3's Behavior Note dated 12/24/21 revealed, Resident has been observed ambulating through the hallways she also has been going into other residents rooms this evening and urinating in their toilets when staff tries to redirect she will come out and just sit on the floor in the hallway . Review of R3's Care Plans revealed no entry or revision regarding R3's wandering into other residents rooms.

Based on interview and record review, the facility failed to meet professional standards of quality for 5 residents (R6, R40, R11, R19, and R93) reviewed, resulting in hospitalization from an unrecognized, untreated, clinically significant change in condition and the lack of assessment, monitoring, and documentation and the potential for the worsening of a health condition. Findings: Resident #6 (R6) Review of a facility Admission Record reflected R6 originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) dated [DATE] reflected R6 was cognitively intact as evidenced by a Brief Interview for Mental Status assessment score of 13/15 and needed limited assistance from one person for transfers, dressing, toilet use, personal hygiene and bathing. Review of an Order Recap Report for the date range 9/01/2021-1/29/2022 reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Weight Summary from 9/9/2021-1/1/2022 reflected R6 admitted to the facility on [DATE] weighing 174.2 pounds and was weighed according to the order. On 10/7/2021 R6 weighed 181.6 pounds. On 11/8/2021 at 5:22 P.M., R6 weighed 205.1 pounds (a 23.5-pound weight gain). R6 was reweighed on 11/8/2021 at 6:59 P.M. and weighed 207.0 pounds (an additional weight gain of 1.9 pounds, reflecting a total weight gain of 27 pounds in a month). Review of Progress Notes reflected that on 11/7/2021 R6 complained of feeling weak and overall not well. A Urine Analysis with Culture and Sensitivity (UA with CS) was ordered to rule out a [CONDITION(S)] (urinary tract infection). On 11/8/2021 R6 continued to complain of pain. A Physician Note on 11/9/2021 entered by Physician Z did not reflect a review of R6's 27-pound weight gain despite a note that Vitals were reviewed. A Nursing Note dated 11/9/21 at 2:53 P.M. reflected R6 continues to be lethargic throughout shift. No indication a physician was notified of R6's 27-pound weight gain in a month was found in the record. Review of a hospital record reflected R6 admitted to the hospital on 11/12/2021 from the facility with a chief complaint of Dyspnea (difficult or labored breathing). The History of Present Illness reflected (R6) is a [AGE] year-old who presented to the hospital on 11/12/21 for a chief complaint of shortness of breath. He has a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . (R6) states that for the past 24 hours he has had progressively worsening dyspnea on all movements. He states that he has had to have oxygen on 24 hours when he usually does not need it .While in the ED (Emergency Department), (R6) was found to be hypoxic. (R6) did have an elevated D-Dimer (a protein fragment made when a blood clot dissolves in your body) and was sent for CT PE (a scan to evaluate for a blood clot in the lungs). CT revealed large bilateral pleural effusions (a buildup of fluid between the tissues that line the lungs and the chest) and a similar consolidation picture to the previous admission. The Impression/Plan reflected Pleural Effusion; Acute Hypoxic [CONDITION(S)] suspect 2/2 (secondary to) Pleural Effusion and CHF (Congestive Heart Failure) .ankle swelling .patient states he has gained 12-15 lbs (pounds) over 2 weeks. Resident #40 (R40) Review of an Admission Record revealed R40 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R40's Blood Pressure Summary revealed 12/13/21 a blood pressure of 159/104 Systolic High of 139 exceeded and Diastolic High of 89 exceeded. As of 2/3/22 R40's blood pressure had not been reassessed. Review of R40's Progress Notes revealed the physician was not notified of the abnormally high blood pressure. Resident #11 (R11) Review of an Admission Record revealed R11 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R11's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R11's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/20/22 at 6am R11's BS was 63, on 1/27/22 and 1/30/22 at 6am R11's BS was not assessed. On 1/19/22 at 9pm R11's BS was 55. Review of R11's Progress Notes revealed no documentation that the physician was notified of the abnormal blood sugars or rationale for the lack of blood sugar assessment. Resident #19 (R19) Review of an Admission Record revealed R19 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R19's Blood Sugar Log revealed the following: on 1/11/22 R19's BS was 51, 1/12/22 R19's BS was 53, 1/13/22 R19's BS was 471, 1/14/22 R19's BS was 407, 1/16/22 R19's BS was 49, 42, 43, and 54, 1/23/22 R19's BS was 593, 1/26/22 R19's BS was 423, and 1/30/22 R19's BS was 448. Review of R19's Progress Notes revealed no notes indicating the physician was notified of these abnormally low and high results. During an observation and interview on 01/23/22 at 01:41 P.M., Registered Nurse (RN) I stated to R19, I got to check your sugar, I know it's (blood sugar assessment) late. RN I reported that the blood sugar was to be assessed prior to meals but because she was the only nurse covering 2 units, she was unable to get all meds passed, vitals assessed, and blood sugars obtained timely. During an interview on 01/25/2022 at 12:19 P.M., Physician (P) Z reported that blood sugars must be assessed prior to eating to ensure accurate trends are reviewed. Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. Review of an Order Recap Report for the date range 11/01/21-1/31/22 reflected R93 was ordered [MEDICATION(S)] Tablet 40 MG (a diuretic) Give 1 tablet by mouth in the morning for CHF (Congestive Heart Failure) on 12/10/2021. R93's Diet Order reflected she was to have a Modified Diabetic Diet Regular texture, Regular consistency, Consistent Carb diet. No fluid restrictions were noted. Additionally, R93 was to have Daily Wt x 3 days, weekly x 3 week then per Dietary Recommendation as of 12/9/2021. Review of a Weight Summary reflected that R93 had been weighed on 12/9/2021. No further weights were obtained. Review of Progress Notes dated 12/9/21-2/2/22 did not reflect a Dietary Recommendation pertaining to R93's weight and did not indicate R93's weight was ever evaluated despite the ordered monitoring. Review of a Behavior Note dated 12/11/21 at 6:50 P.M. reflected (R93) was refusing to follow fluid restriction orders, requesting lots of additional fluid. Patient was educated on CHF and fluid restriction reasoning. Patient verbalized understanding, will continue to monitor. Review of a Nursing Note dated 12/12/21 at 2:51 P.M. reflected R93 was again requesting extra fluids. No indication the nurse notified the physician about the concern was made. Review of a Nursing Note dated 12/29/21 reflected (R93) complaining of BLE (bilateral lower extremity) hurting due to ACE wraps. When assessed had pitting [CONDITION(S)] +3. Educated the resident on drinking too many fluids and eating too much salt, at bedside has 2 bags of pretzel, saltine crackers, chips, she responded with 'Oh OK', will continue to monitor. No evidence a physician was notified of the 3+ pitting [CONDITION(S)] was found. During an interview on 1/26/22 at 4:30 P , Physician AA reported he would treat patients with CHF symptomatically and evaluate for evidence of shortness of breath, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Physician AA denied being informed that R93 had increased [CONDITION(S)] and said that R93 would be a candidate for frequent weight monitoring related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #93 (R93)-unreported clinically significant blood glucose readings and medication administration and omission errors. Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. Review of a Care Plan Report including revision history initiated on 12/9/21 reflected no care plan focus areas had been developed for R93 that pertained to diabetes. Review of an Order Recap Report for the date range 12/01/21-2/28/22 reflected R93 was prescribed [MEDICATION(S)] KwikPen Solution Pen-injector 100 UNIT/ML (Insulin [MEDICATION(S)] (1 Unit Dial)) Inject 28 unit subcutaneously with meals related to TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS (E11.8) Notify Physician if blood sugar is below 90 and greater than 250. During an interview and observation on 1/24/22 at 8:20 A.M., Registered Nurse (RN) I was at R93's bedside preparing to administer morning medications. RN I said she was not going to give R93 prescribed [MEDICATION(S)] (a fast-acting insulin) because R93's blood sugar reading was 130 mg/dl that morning and she wasn't comfortable with that and would document that R93 refused the insulin. RN I said she had not notified the physician (MD AA) and did not make a note in a Physician Binder at the nurse desk for the physician to review because she alleged MD AA never looked at it. RN I said MD AA typically only comes in at night and said, He has to sleep sometime! RN I then contradicted her statement about not wanting to call MD AA to report concerns with an order by saying MD AA is available by phone 24/7. RN I then asked R93 to explain what other nurses do. R93 did not understand what RN I was asking her and RN I said, The other nurses adjust the dose of insulin based on what they think R93 needs and not the physician order. During the interview and observation on 1/24/22 that began at 8:20 A.M., R93 reported she did not know the signs or symptoms of [CONDITION(S)] or [CONDITION(S)] and denied refusing medications as RN I had indicated she would document. R93 did not know whether or not other nurses were adjusting her insulin orders without her knowledge and said, I take what they give me. When asked what she would do if she started to feel shaky or sweaty, increased hunger, fatigue, nausea or vomiting or lightheadedness (some signs of [CONDITION(S)]), R93 said she would push the button. RN I was still at the bedside, in full view of the resident, and placed her hand over her mouth, shook her head and said, If you could do that here, the implication being that staff would not respond in a timely manner. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -1/8/22 at 5:00 P.M. the [MEDICATION(S)] was given despite a blood sugar (BS) reading of 83 mg/dL. -1/13/22 at 12:00 P.M. the [MEDICATION(S)] was given despite a BS reading of 88 mg/dL. -1/15/22 at 5:00 P.M. the [MEDICATION(S)] was NOT given despite a BS reading of 177 mg/dL. -1/21/22 RN I documented on R93 refused the [MEDICATION(S)] at every meal despite BS readings of 191 mg/dL at breakfast and 170 mg/dL at noon. A blood sugar was not documented as checked at 5:00 p.m. on 1/21/22. -1/23/22 RN I documented R93 refused [MEDICATION(S)] at breakfast despite a BS reading of 193, gave the noon dose for a BS reading of 212 and again documented R93 refused the 5:00 P.M. dose of [MEDICATION(S)] despite a BS reading of 141 mg/dL. -1/24/22 RN I documented R93 refused her [MEDICATION(S)] at breakfast for a BS reading of 130 mg/dL. Further review and comparison of R93 Blood Glucose readings recorded in the Vital Signs section of the Electronic Medical Record (EMR) and the MARs for the months of December 2021-January 2022 reflected multiple additional BS readings outside of physician parameters set for the administration of the short-acting insulin. Review of Progress Notes for the date range 12/9/21-1/24/22 did not reflect any notifications to the physician about concerns pertaining to R93's blood sugar readings or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/26/22 at 4:30 P.M., Medical Director (MD) AA reported that it is not okay for a nurse to give or withhold medications outside of prescribed parameters without calling him first. During an interview on 01/26/22 5:30 P.M., MD AA reported that insulin's were adjusted based on blood sugar trends and therefore blood sugars should be assessed prior to eating a meal. MD AA reported he expected to be notified of blood sugars less than 70 and greater than 250 and adjusted insulin accordingly. MD AA reported that uncontrolled blood sugars could cause delayed wound healing and hypoglycemic episodes could result in death. During an interview on 02/03/22 at 01:17 P.M., Unit Manager (UM) G reported that P Z was putting in parameters for all residents that have blood glucose monitoring. UM G reported that the staff should be following the parameters set for the [MEDICATION(S)] and insulin's. UM G reported that abnormal vital signs should be immediately reassessed and if no improvement the physician should be notified, and medications should not be held without a physician order. UM G reported that she and the DON frequently must work as a floor nurse and cannot perform their management duties which included ensuring medications were given on time and correctly following parameters. UM G reported it was chaotic because of the staffing shortage and nursing manager duties were difficult to complete. Review of the Fundamentals of Nursing revealed, The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure ulcers and implement treatments and monitoring for pressure ulcer prevention and healing for 6 residents (Resident #93, #22, #28, #42, #2 and #19) resulting in avoidable development and worsening of pressure ulcers. Findings: Resident #93 (R93) Review of a facility Admission Record reflected R93 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS dated [DATE] reflected R93 was assessed by staff as having intact short- and long-term memory and needed extensive assistance from two people for bed mobility, transfers and toilet use and was totally dependent on two staff for dressing and bathing. Section M-Skin Conditions of the assessment reflected R93 was at risk of developing pressure ulcers and admitted to the facility with a stage 3 pressure ulcer. Review of a Care Plan Report initiated on 12/9/21 reflected (R93) has stage 3 pressure ulcer to left buttock or potential for pressure ulcer development related to disease process, history of ulcers, immobility. (R93) prefers to lay on her back. The goal of the care plan was for R93's pressure ulcer to show signs of healing and remain free from infection. Interventions included Administer medications as ordered. Monitor/document for side effects and effectiveness; Administer treatments as ordered and monitor for effectiveness; encourage and educate to turn off her back; follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Nursing Skin Observation dated 12/9/2021 reflected that a Slit at the coccyx (upper gluteal cleft) had a pressure sore measuring 1 x 0.3 (1.0 cm x 0.3 cm, without depth). No further details pertaining to this area were specified. Further review of additional Nursing Skin Observation assessments revealed R93 did not have another skin assessment until 1/1/22. Review of Weekly Skin Assessments dated 1/1/22, 1/8/22, 1/15/22 and 1/28/22 reflected inconstant documentation and back staging of the wound. Review of an R93's Order Recap Report for the date range 11/01/21-01/31/2022 reflected that on 1/01/22 the physician ordered cleanse with soap and water to crease of buttock, then lightly pack with packing strip cover with foam dressing, at bedtime during for wound care. During an observation of wound care on 1/25/22 at 11:24 A.M., Registered Nurse (RN) G removed a bandage covering [MEDICATION(S)] gauze that had been packed into a coccyx wound located at the top of R93's gluteal cleft. RN G removed the gauze that was saturated with serosanguinous drainage then used sterile saline and 4x4 gauze to clean the wound (not soap and water as prescribed). RN G measured the wound and found it to be 0.75 cm deep x 2.75 cm long and 0.5 cm wide, demonstrating a worsening of the wound. During the treatment, R93 reported that the last time she got out of bed was with therapy several weeks ago. Resident #22 (R22) Review of an Admission Record revealed R22 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R22, with a reference date of 12/14/21 revealed R22 required extensive 2 person assist for transferring and extensive 1 person assist for toileting. Review of R22's Care Plan last revised 4/20/21 revealed, SKIN INTEGRITY: I am at risk for skin breakdown r/t (related to): decrease in mobility. I am variable in my ability to move frequently and reposition myself, I have not been eating well, but I am continent most of the time of my bowel and bladder .Nurse will check skin weekly and document on skin assessment and treat per facility policy. Review of R22's Braden Scale for Predicting Pressure Ulcer Risk revealed no assessment had been completed. Review of R22's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R22's Weekly Skin Assessments revealed R22's last assessment was completed on 12/3/21. Indicating the pressure ulcer prevention policy and care planned intervention were not put in place for R22 and a facility skin assessment was not completed after notification from hospice of new/worsening skin breakdown. Review of R22's Nursing Note dated 2/1/22 revealed, Hospice in to see patient today. Hospice nurse found redness in place of previous wound to bottom . Resident #28 (R28) Review of an Admission Record revealed R28 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R28, with a reference date of 10/20/21 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated R28 was cognitively impaired. Review of the Functional Status revealed that R28 required extensive 2 person assist with transferring and toileting. Review of R28's Care Plan last revised on 5/3/21 revealed, URINARY/BOWELS: I am incontinent of bladder d/t (due to) my inability to feel the urge to void. I will let staff know if I need to have a bowel movement, however this is not consistent. I do receive a diuretic which increases my frequency, I rely on staff for my toileting needs throughout the day. I use incontinence products, but my incontinence puts me at risk for skin breakdown . Staff will assist me with toileting regularly and PRN (as needed) .Toileting: extensive assist x2 staff . Review of R28's Braden Scale for Predicting Pressure Ulcer Risk revealed that R28 was at risk for skin breakdown. During an observation and interview on 2/1/22 at 1:03 P.M., CNA ZZ was the only CNA working on the Memory Care Unit. CNA ZZ attempted to call the East/West Units for assistance and no staff would answer. CNA ZZ reported that there were 4 residents that required 2-person assist on the Memory Care Unit including R28. CNA ZZ reported that R28 had been requesting to use the bathroom prior to lunch and was incontinent of urine, but because she required 2-person assistance she would have to wait in her urine until another staff member arrived in the unit. Resident #42 (R42) Review of an Admission Record revealed R42 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R42, with a reference date of 11/30/21 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R42 was cognitively impaired. Review of the Functional Status revealed that R42 required extensive 2-person assistance for bed mobility, transferring, and toileting. Review of R42's Care Plan last revised 12/5/21 revealed, SKIN INTEGRITY: I am at risk for skin breakdown r/t: impaired mobility .Nurse will check skin weekly and document on skin assessment and treat per facility policy . Staff will check resident routinely and PRN, if soiled cleanse and apply a skin barrier . Wash and dry skin thoroughly following each incontinence . Review of R42's Braden Scale for Predicting Pressure Ulcer Risk revealed no assessment had been completed. Review of R42's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R42's Weekly Skin Assessments revealed R42's last assessment was completed on 12/1/21 and not again until 2/1/22. During an observation on 01/23/22 at 10:27 AM, R42 was in her room sitting up in a wheelchair. Her left side from her armpit to her ankle was saturated with urine and her bed linen was saturated with urine. R42's room smelled strongly of urine. R42 was crying and voiced frustration and humiliation at the lack of assistance to the bathroom and lack of staff to assist her with incontinence care. Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's Care Plan last revised 10/11/21 revealed, SKIN INTEGRITY: I am at risk for skin breakdown .Nurse will check skin weekly and document on skin assessment and treat per facility policy . Review of R2's Braden Scale for Predicting Pressure Ulcer Risk revealed no assessment had been completed. Review of R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's Weekly Skin Assessments revealed R2's last assessment was completed on 12/5/21. Resident #19 (R19) Review of an Admission Record revealed R19 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R19's Care Plan last revised 8/26/21 revealed, SKIN INTEGRITY: I am at risk for skin breakdown .Nurse will check skin weekly and document on skin assessment and treat per facility policy . Review of R19's Braden Scale for Predicting Pressure Ulcer Risk revealed no assessment had been completed. Review of R19's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R19's Weekly Skin Assessments revealed they were not completed as ordered. R19's Weekly Skin Assessments were completed on 11/4/21, 11/18/21, 12/2/21, 12/30/21, and 1/20/22. During an interview on 01/23/22 at 11:10 A.M., CNA P and CNA O reported that they were the only CNA's working for the East and West Unit. CNA P and CNA O reported that they could not reposition, change, and shower residents. CNA P and CNA O reported that there were not enough staff to meet the needs of the residents and provide care and/or quality care. During an interview on 01/25/22 at 10:02 A.M., CNA PP reported they could not shower, reposition, and change residents as required because of the lack of staff. During an interview on 02/01/22 at 12:15 P.M., CNA BBB reported that facility CNAs were ordered to give all resident in the facility a shower beginning 01/31/22 but were not educated on the reason why all residents needed a shower. CNA BBB reported that they were given a skin assessment sheet on 01/31/22 to begin using to track and assess residents skin. CNA BB reported that she was directed by the corporate staff to give residents showers even if they refused and if residents refused showers, they should be sent into the hospital for a psychiatric evaluation.

Based on observation, interview, and record review, the facility failed to provide care according to the standards of practice for 1 Resident (Resident #148) with an enteral tube feed, resulting in the potential for abdominal pain and distention, vomiting, choking, aspiration pneumonia, and death. Findings: Resident #148 (R148) Review of an Admission Record revealed R148 was a [AGE] year-old male, originally admitted to the facility on [DATE], following a 63-day hospitalization for aspiration pneumonia, urinary tract infection and altered mental status. R148 had a gastrostomy tube (tube feed) for hydration and nutrition and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 01/31/22 at 8:12 A.M., Certified Nurse Aide (CNA) DDD entered the room to change R148 and the following occurred: (a) R148 laid in bed with the tube feed running, (b) CNA DDD lowered the head of bed flat, and (c) peri-care was provided as the tube feed continued to run. During an observation on 01/31/22 at 11:53 A.M., CNA DDD stood bedside of R148 providing peri care. The head of the bed was flat and the tube feed was running. CNA DDD indicated (a) that today was the first day on the job, (b) had not received any specific training related to the safe positioning of a resident with a tube feed, and (c) they just told me to show up on Monday so I did. During an observation on 02/01/22 at 9:25 A.M., tube feed bottle did not have the resident's name, date and time started, and ordered rate. During an observation on 02/01/22 at 10:45 A.M., the tube feed was running for R148 and the head of the bed was at 17 degrees. During an observation on 02/01/22 at 12:20 P.M., the tube feed was running for R148 and the head of the bed remained at 17 degrees. Licensed Practical Nurse (LPN) N entered the room and when asked, stated that the head of the bed looked to be about 30 degrees and R148 was positioned at about 25 degrees. When shown that the head of the bed was actually at 17 degrees, LPN N responded oh. LPN N proceeded to lay the head of the bed flat and then turned off the tube feed, before providing peri care. Review of a Kardex reflected the following information for Eating/Nutrition: Diet order-(nothing specified), and HS (bedtime) snacks (R148 was NPO) .and for Safety: nothing reflected that R148 was a tube feed, how to safely position the resident,what the head of the bed should be, when and how to turn off the tube feed, and what concerns to report to nursing. Review of a Care Plan for R148 was void of all safety interventions related to the tube feed. (No interventions for: (aspiration precautions, height of head of bed, checking for residual, type and rate of tube feed ordered, when to contact the physician, etc.) Review of a facility policy Enteral Feedings-Safety Precautions, last revised 08/01/2016, reflected the following: The facility will remain current in and follow accepted best practices in enteral nutrition .On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order .always elevate the head at least 30-45 degrees during tube feeding and at least 1 hour after .

Based on observation, interview, and record review, the facility failed to update and implement interventions on careplans for 1 Resident (R 2) reviewed for pressures ulcers, resulting in R 2 developing 2 unstageable facility acquired pressure ulcers, one on his buttock and one on his left heel. Findings include: Review of R 2's face sheet dated 8/31/21 revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 2 had a guardian. Review of R 2's Kardex dated 8/31/21 revealed interventions for skin that included: Turn resident side to side using wedge cushions while in bed Q1h (every hour) and PRN (as needed) as resident allows. Encourage resident to not lay on his back. Review of R 2's ADL (activities of daily living) care plan date of revision 3/24/21 revealed he required extensive assistance of 2 people for bed mobility especially with lower extremities dated, 10/11/19. For eating he was independent with set up, I am needing monitoring as I decline in my swallowing abilities dated, 10/11/19. Review of R 2's pain care plan dated revision 6/21/21 revealed, I have pain to my lower back and bilateral lower extremities. I often report relief with main management interventions and laying down in my bed. I do have complaints of pain when I sit up for long periods of time. My [MEDICATION(S)] patch in place for pain management has been increased and I am able to vocalize my pain management needs. I have pain to my lower extremities and buttock. My current pain med orders are fully effective but prefer not to increase the dosages. My acceptable level of pain is 7/10. Interventions included, encourage me to request pain medication before pain becomes unbearable, dated 10/11/19. Monitor and record any non-verbal signs of pain (e.g., Crying, guarding, moaning). Review of R 2's skin integrity care plan dated 11/6/19 and revised on 2/22/19 revealed a history of venous ulcers both lower extremities. There was no indication of a pressure ulcer on his heel or his buttock. Review of R 2's full care plan revealed no care plan was implemented for his pressure ulcers. R 2 was observed on his back in bed on 8/31/21 at 9:40 AM, (breakfast is served around 8:00 am). On 8/31/21 at 10:00 AM, Licensed Practical Nurse (LPN) P said she normally changes R 2's dressing on his buttock between 10:00 AM and 11:00 AM daily. LPN P said she gives he narcotic pain medication around 8:00 AM as she was aware that turning and the dressing change was painful for R2. LPN P said the Director of Nursing (DON) had been doing wound measurements. LPN P and Certified Nurse Aide (CNA) L turned R 2 on his right side to do his dressing change. When R 2's brief was removed there was no dressing over the coccyx. The coccyx was covered by several red saturated 2 x 2 gauze pads. LPN P said R 2 was having a bowel movement and they would have to wait to do the dressing change. On 8/31/21 at 10:10 AM, the DON said R 2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said she had been doing the weekly wound measurements but did not have time to chart the measurements. The DON had a dressing with dates and sizes marked. The DON said she would do a late entry with the wound measurements. On 8/31/21 at 10:50 AM, the DON measured R 2 coccyx wound 2.6 cm x 2.2 cm by 2.0 cm deep. The DON said the wound was narrower but deeper. Review of R 2's order revealed an order dated 8/19/21 at 4:45 PM [MEDICATION(S)]/AntAcid/DesitinCream, Apply to testicles and bilateral gluteal folds TID (3 times a day) and PRN. Review of R 2's orders revealed an order dated 8/23/21 at 2:30 PM, Cleanse coccyx with normal saline, pat dry, apply opticell ag to wound bed, and cover with bordered foam dressing every day shift for wound care AND as needed for wound care. (This was not in place for observation 8/31/21 at 10:00 AM). Review of R 2's progress note dated 7/29/21 at 3:01 PM revealed, Resident continues with increase in [MEDICATION(S)] (narcotic pain medication) for complaints of pain. Resident did complain of some buttock discomfort relieved with repositioning. Treatment changed to buttocks. Noted excoriation to right buttock, 2 areas. One area 1 cm x 2 cm and the other area 1 cm x 1.5 cm. Left buttock 1 cm x 0.5 cm. Overall fragile area 8.5 cm x 7.5 cm. New treatment [MEDICATION(S)] Gentle SA foam applied to area every 7 days. No wound assessment charting located in R 2's medical record could be located for this wound. The next progress notes for R 2's wound on his buttock was dated 8/19/21 at 5:24 PM and was signed by the DON. Review of R 2's progress noted dated 8/19/21 at 5:24 PM revealed, Resident with 2.5 x 3.5 unstageable pressure ulcer to coccyx. Medium amount of serous drainage. No odor noted. Resident continues to decline. New order cleanse coccyx with normal saline, pat dry, apply opticell ag cove with border foam dressing everyday and prn. Guardian notified and updated on resident's condition. Guardian was asked about prior recommendations to hospice. Options were discussed and guardian wishes to meet with name of hospice to sign resident on for services Monday at 10 am. No wound assessment was located in the assessment section for this wound. This was the last note in the progress note section of R 2's electronic medical record as of 9/1/21. Review of R 2's History and Physical dated 8/6/21 revealed under Assessment and Plan: 1. Coccyx large excoriation, surrounding [CONDITION(S)] continued wound car, clean with NS (normal saline), Magic Butt Cream ([MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]) and Heel protectors, follow with wound care, turning patient and protein supplementation. (No measurement of open areas as noted on 7/29/21). The DON provided a typed timeline of R 2's pressure ulcers: No wound measurements for May, June and July 5/19/21 Magic butt cream order PRN every 12 hours for excoriation. 7/29/21 Treatment initiated to cleanse bilateral buttock and apply [MEDICATION(S)] gentle foam every 7 days and prn for excoriation. 8/11/21 Treatment changed to cleanse coccyx with wound cleanser pat dry apply therahoney sheet cut to fit and cover with [MEDICATION(S)] daily. 8/19/21 Unstageable pressure ulcers noted to coccyx 2.5 cm x 3.5 cm. 8/19/21 New treatment initiated to cleanse coccyx with normal saline pat dry apply opticell ag to wound bed and cover with bordered foam dressing daily 8/25/21 unstageable pressure ulcer to the left heel 1.0 cm x 1.5 cm. 8/25/21 New treatment initiated to left heel to apply sin prep TID. 8/31/21 Pressure ulcer to coccyx remains unstageable due to center of wound being necrotic. Necrotic area decreasing. 2.6 cm x 2.2 cm x 2.0 cm overall size of wound decreased wound improving. Depth increased, width decreased, and length decreased. During an interview with the DON on 9/2/21 at 10:20 AM, the timeline she provided for R 2 was reviewed. The DON admitted the facility did not have proper wound measurements, evidence of prevention and treatment in place prior to the wound and once the wounds were noted. The DON was not sure when the pressure ulcer started and said skin assessments did not indicate when the ulcer started. At this time surveyor requested the pressure ulcer care plan, all wound assessments/treatments/orders. Upon exit these documents were not provided.

Based on observation, interview and record review, the facility failed to prevent, assess, and treat 1 Resident (R 2) for pressures ulcers, resulting in R 2 developing 2 unstageable facility acquired pressure ulcers, one on his buttock and one on his left heel. Findings include: Review of R 2's face sheet dated 8/31/21 revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 2 had a guardian. Review of R 2's Kardex dated 8/31/21 revealed interventions for skin that included: Turn resident side to side using wedge cushions while in bed Q1h (every hour) and PRN (as needed) as resident allows. Encourage resident to not lay on his back. Review of R 2's ADL (activities of daily living) care plan date of revision 3/24/21 revealed he required extensive assistance of 2 people for bed mobility especially with lower extremities dated, 10/11/19. For eating he was independent with set up, I am needing monitoring as I decline in my swallowing abilities dated, 10/11/19. Review of R 2's pain care plan dated revision 6/21/21 revealed, I have pain to my lower back and bilateral lower extremities. I often report relief with main management interventions and laying down in my bed. I do have complaints of pain when I sit up for long periods of time. My [MEDICATION(S)] patch in place for pain management has been increased and I am able to vocalize my pain management needs. I have pain to my lower extremities and buttock. My current pain med orders are fully effective but prefer not to increase the dosages. My acceptable level of pain is 7/10. Interventions included, encourage me to request pain medication before pain becomes unbearable, dated 10/11/19. Monitor and record any non-verbal signs of pain (e.g., Crying, guarding, moaning). Review of R 2's skin integrity care plan dated 11/6/19 and revised on 2/22/19 revealed a history of venous ulcers both lower extremities. There was no indication of pressure ulcer on his heel or his buttock. Review of R 2's full care plan revealed no care plan was implemented for his pressure ulcers. R 2 was observed on his back in bed on 8/31/21 at 9:40 AM, (breakfast is served around 8:00 am). On 8/31/21 at 10:00 Licensed Practical Nurse (LPN) P said she normally changes R 2's dressing on his buttock between 10:00 AM and 11:00 AM daily. LPN P said she gives he narcotic pain medication around 8:00 AM as she was aware that turning and the dressing change was painful for R2. LPN P said the Director of Nursing (DON) had been doing wound measurements. LPN P and Certified Nurse Aide (CNA) L turned R 2 on his right side to do his dressing change. When R 2's brief was removed there was no dressing over the coccyx. The coccyx was covered by several red saturated 2 x 2 gauze pads. LPN P said R 2 was having a bowel movement and they would have to wait to do the dressing change. On 8/31/21 at 10:10 AM, the DON said R 2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said she had been doing the weekly wound measurements but did not have time to chart the measurements. The DON had a dressing with dates and sizes marked. The DON said she would do a late entry with the wound measurements. On 8/31/21 at 10:50 AM, the DON measured R 2 coccyx wound 2.6 cm x 2.2 cm by 2.0 cm deep. The DON said the wound was narrower but deeper. Review of R 2's order revealed an order dated 8/19/21 at 4:45 PM, [MEDICATION(S)]/AntAcid/DesitinCream, Apply to testicles and bilateral gluteal folds TID (3 times a day) and PRN. Review of R 2's orders revealed an order dated 8/23/21 at 2:30 PM, Cleanse coccyx with normal saline, pat dry, apply opticell ag to wound bed, and cover with bordered foam dressing every day shift for wound care AND as needed for wound care. (This was not in place for observation 8/31/21 at 10:00 AM). Review of R 2's progress note dated 7/29/21 at 3:01 PM revealed, Resident continues with increase in [MEDICATION(S)] (narcotic pain medication) for complaints of pain. Resident did complain of some buttock discomfort relieved with repositioning. Treatment changed to buttocks. Noted excoriation to right buttock, 2 areas. One area 1 cm x 2 cm and the other area 1 cm x 1.5 cm. Left buttock 1 cm x 0.5 cm. Overall fragile area 8.5 cm x 7.5 cm. New treatment [MEDICATION(S)] Gentle SA foam applied to area every 7 days. No would assessment charting located in the assessment of R 2's medical record could be located for this wound. The next progress notes for R 2's wound on his buttock was dated 8/19/21 at 5:24 PM and was signed by the DON. Review of R 2's progress noted dated 8/19/21 at 5:24 PM revealed, Resident with 2.5 x 3.5 unstageable pressure ulcer to coccyx. Medium amount of serous drainage. No odor noted. Resident continues to decline. New order cleanse coccyx with normal saline, pat dry, apply opticell ag cove with border foam dressing everyday and prn. Guardian notified and updated on resident's condition. Guardian was asked about prior recommendations to hospice. Options were discussed and guardian wishes to meet with name of hospice to sign resident on for services Monday at 10 am. No wound assessment was located in the assessment section for this wound. This was the last note in the progress note section of R 2's electronic medical record as of 9/1/21. Review of R 2's History and Physical dated 8/6/21 revealed under Assessment and Plan: 1. Coccyx large excoriation, surrounding [CONDITION(S)] continued wound car, clean with NS (normal saline), Magic Butt Cream ([MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]) and Heel protectors, follow with wound care, turning patient and protein supplementation. (No measurement of open areas as noted on 7/29/21). The DON provided a typed timeline of R 2's pressure ulcers: No wound measurements for May, June and July 5/19/21 Magic butt cream order PRN every 12 hours for excoriation. 7/29/21 Treatment initiated to cleanse bilateral buttock and apply [MEDICATION(S)] gentle foam every 7 days and prn for excoriation. 8/11/21 Treatment changed to cleanse coccyx with wound cleanser pat dry apply therahoney sheet cut to fit and cover with [MEDICATION(S)] daily. 8/19/21 Unstageable pressure ulcers noted to coccyx 2.5 cm x 3.5 cm. 8/19/21 New treatment initiated to cleanse coccyx with normal saline pat dry apply opticell ag to wound bed and cover with bordered foam dressing daily 8/25/21 unstageable pressure ulcer to the left heel 1.0 cm x 1.5 cm. 8/25/21 New treatment initiated to left heel to apply sin prep TID. 8/31/21 Pressure ulcer to coccyx remains unstageable due to center of wound being necrotic. Necrotic area decreasing. 2.6 cm x 2.2 cm x 2.0 cm overall size of wound decreased wound improving. Depth increased, width decreased, and length decreased. During an interview with the DON on 9/2/21 at 10:20 AM, the timeline she provided for R 2 was reviewed. The DON admitted the facility did not have proper wound measurements, evidence of prevention and treatment in place prior to the wound, and once the wounds were noted. The DON was not sure when the pressure ulcer started and said skin assessments did not indicate when the ulcer started. At this time surveyor requested the pressure ulcer care plan, all wound assessments/treatments/orders. Upon exit these documents were not provided.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan that reflected the comprehensive assessment and residents needs for supervision to prevent falls for two Residents (Resident #1 and #2) resulting in Resident #1 falling and fracturing his hip and Resident #2 falling and sustaining a laceration to her head. Findings include: Resident #1 According to the Admission Minimum Data Set (MDS), a nursing assessment tool, dated 10/17/19 Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. He required limited assistance of one person for transfers and walking. According to the Brief Interview of Mental Status (BIMS) score dated 10/17/19 Resident #1 scored 5/15 (severe cognitive impairment). According to the incident report dated 11/8/19 at 8:37 AM, Resident #1 had an unwitnessed fall in his room. Resident #1 said he was attempting to go to the bathroom. Resident #1 complained of right hip pain and was sent to the emergency room for evaluation. According to Resident #1's Fall care plan, dated 10/11/19 and revision on 11/14/19, for Resident #1, I am at risk for falls r/t (related to) my fall history, I had a fall in the hospital prior to my admission, along with a fall while here at the facility on 11-8-19 that resulted in a rt (right) hip displaced fx (fracture) and rt hip non-displaced fracture requiring surgery, returning to the facility on [DATE] for aftercare following. Resident is non-compliant with safety interventions, refuses to use call light. Has had to be redirected a number of times when observed transferring, walking without assistance. (The care plan did not include any interventions to increase supervision or assistance once they were aware Resident #1 was not using his call light and continued to self-transfer and walk without assistance. The facility had assessed Resident #1 and were aware he required limited assistance with transfers/walking and were aware he was severely cognitively impaired). The approach listed offer an assist with toileting at a minimum of every 2-hr during awake hours was started after the fall on 11/11/19. During an interview with the Director of Nursing (DON) on 12/4/19 at 8:10, the DON informed the Surveyor that Resident #1 was no longer in the facility and he had passed away recently at the hospital due to cardiac issues. Hospital medical record were reviewed and confirmed Resident #1 did pass in the hospital related cardiac issues. During an interview with Registered Nurse (RN) D on 12/4/19 at 12:26 PM, RN D said she was working when Resident #1 was found on the floor in his room on 11/8/19. RN D was aware Resident #1 had a history of [REDACTED]. RN D was asked if she added any interventions to Resident #1's care plan to ensure staff would be able to anticipate Resident #1's needs or to prevent transfers/walking without assistance. RN D said she was not told to make care plan changes when there were safety concerns. During an interview with Licensed Practical Nurse (LPN) C on 12/4/19 at 1:00 PM, LPN C said she was working when Resident #1 fell on [DATE]. LPN C said she heard a thump and when she went to the room. LPN C said Resident #1 was the only one in the room. Resident #1 said he was going to the bathroom when he fell . LPN C said, Resident #1 was known to take himself to the bathroom and did not use his call light. LPN C was asked if she added any safety interventions in Resident #1's care plan when she became aware, he was self-transferring and walking independently. LPN C the MDS nurse does the care plan. According to the MDS, dated [DATE] (after the [MEDICAL CONDITION]) Resident #1 required extensive assistance of 2 people for bed mobility, transfers and walking. Resident #2 According to the face sheet dated 12/4/19 Resident #2 was an [AGE] year-old female, admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #2 was not her own responsible party. According to the Minimum Data Set (MDS), nursing assessment tool, dated 11/22/19 Resident #2 required supervision with toilet use. The Brief Interview of Mental Status (BIMS) was 5/15 (severe cognitive impairment). Resident #2 was observed in the main dining room on the secured unit on 12/4/19 at 8:50 AM. Resident #2 had medial tape over a wound on her right eyebrow. The Surveyor asked Resident #2 if she had fallen. Resident #2 put her fingers on the wounded right eyebrow and said, no, I don't know how I did that. On 12/4/19 at 8:52 AM, the Surveyor asked Certified Nurse Aide (CNA) I if Resident #2 had fallen and CNA I said, yes, Resident #2 fell last night on the other unit but did not know the details. On 12/4/19 at 11:00 AM, the Surveyor asked the Director of Nursing (DON) if Resident #2 should have been left alone in the bathroom when she fell on [DATE] and the DON said she should not have been left alone. The DON confirmed Resident #2 care plan and Kardex did not indicate Resident #2 should not be left alone in the bathroom at the time of the fall. The surveyor reviewed Resident #2's MDS dated [DATE] with the DON and the DON said she was not aware Resident #2 had been assessed to have supervision with toilet use. The DON added supervision while in the bathroom to Resident #2's care plan on 12/3/19 (after the fall). According to the ADL (activities of daily living) care plan dated 11/14/19 Resident #2 was independent with toileting (this did not match the MDS assessment dated [DATE]. According to the Kardex dated 12/4/19, Resident #2 was independent with toileting (did not match the last MDS assessment). No safety concerns were identified on Resident #2's Kardex. According to the incident report dated 12/2/19 at 21:30 (9:30 PM) Resident #2 had an un-witnessed fall in the bathroom across from the dining room. She had spots of blood on the floor by the door and the front of her pants were wet. Resident #2 had a small cut below her right eyebrow, minimal depth, 2 cm x 2 cm. Under witnesses documented, Certified Nurse Aide (CNA) E reported to this RN (registered nurse) that resident went to the bathroom on her on (sic), after she was in there 4-5 minutes, she opened the door to check on her, and she was observed on the floor sitting on her knees. Blood noted on the floor, and she was incontinent of urine on her pants and floor. The Surveyor called CNA E on the telephone on 12/4/19 to attempt an interview. CNA E voice mail was full, and no message was able to be left. CNA E was not able to be contacted during the investigation. No witness statement signed by CNA E could be located. According to the incident report dated 12/2/19 for Resident #2 under notes, Resident admitted to name of facility on 11/15/19. She is cognitively impaired, able to make simple day to day decisions and communicate with staff consistently. Spends a great deal of time packing and unpacking clothing believing she is going home. Resident had been recently moved to the memory care unit on 11/26/19, r/t her physical capabilities to being ambulatory adlib and exit seeking tendencies, although a wander ward (sic) was in place for safety. On 12/2/19 according to staff interviews resident had indicated need to us (sic) the BR (bathroom). She was up near the DR (dining room) at the time of incident so the staff allowed her to go into the BR near the DR. She was allowed to go in by herself and staff stated they went to check on her within 3-4 minutes when opening the door she was observed on floor on hands and knees with noted blood drops on floor coming from a cut on right eye Resident was unable to tell staff what occurred other than saying I'm alright. Resident had an recent increase of Klonopin (medication) on 11/26/19 for anxiety, total dose remains less then what receiving while at home according to family. With change in environment and hx (history) of anxiety, and constant pacing and packing/unpacking clothing feel increased of medication was necessary. Believe resident should have been supervised when using the attended BR as door would be heavy for resident to open on own. Staff instructed to stay with resident when toileting if she will allow or to have door cracked to According to the fall care plan dated 11/14/19 and revision on 12/4/19 for Resident #2, I am at risk for falls r/t (related to) Dx (diagnosis) of Alzheimer's dementia, CAD ([MEDICAL CONDITION]), Hypertension, [MEDICAL CONDITION] and being on medication that may cause dizziness, lethargy or light headedness. Along with the fact I have come from a home environment and this environment is unfamiliar to me. I have a hx (history) of liking to sit on the floor, usually to organize my cloths. I am ambulatory independently, gait steady. I may need assistance with direction to meals BR (bathroom) etc. The intervention to Direct to BR (bathroom) and stay either with resident if she will allow or have the door cracked where resident is visible if in need of assistance was dated 12/3/19. (this was added after the fall).

Based on interview and record review the facility failed to provide adequate supervision and interventions to prevent falls for two Residents (Resident #1 and #2), resulting in Resident #1 falling and fracturing his hip and Resident #2 falling and sustaining a laceration to her head. Findings include: Resident #1 According to the Admission Minimum Data Set (MDS), a nursing assessment tool, dated 10/17/19 Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. He required limited assistance of one person for transfers and walking. According to the Brief Interview of Mental Status (BIMS) score dated 10/17/19 Resident #1 scored 5/15 (severe cognitive impairment). According to the incident report dated 11/8/19 at 8:37 AM, Resident #1 had an unwitnessed fall in his room. Resident #1 said he was attempting to go to the bathroom. Resident #1 complained of right hip pain and was sent to the emergency room for evaluation. According to Resident #1's Fall care plan, dated 10/11/19 and revision on 11/14/19, for Resident #1, I am at risk for falls r/t (related to) my fall history, I had a fall in the hospital prior to my admission, along with a fall while here at the facility on 11-8-19 that resulted in a rt (right) hip displaced fx (fracture) and rt hip non-displaced fracture requiring surgery, returning to the facility on [DATE] for aftercare following. Resident is non-compliant with safety interventions, refuses to use call light. Has had to be redirected a number of times when observed transferring, walking without assistance. (The care plan did not include any interventions to increase supervision or assistance once they were aware Resident #1 was not using his call light and continued to self-transfer and walk without assistance. The facility had assessed Resident #1 and were aware he required limited assistance with transfers/walking and were aware he was severely cognitively impaired). The approach listed offer an assist with toileting at a minimum of every 2-hr during awake hours was started after the fall on 11/11/19. During an interview with the Director of Nursing (DON) on 12/4/19 at 8:10 the DON informed the Surveyor that Resident #1 was no longer in the facility and he had passed away recently at the hospital due to cardiac issues. Hospital medical record were reviewed and confirmed Resident #1 did pass in the hospital related cardiac issues. During an interview with Registered Nurse (RN) D on 12/4/19 at 12:26 PM, RN D said she was working when Resident #1 was found on the floor in his room on 11/8/19. RN D was aware Resident #1 had a history of [REDACTED]. RN D was asked if she added any interventions to Resident #1's care plan to ensure staff would be able to anticipate Resident #1's needs or to prevent transfers/walking without assistance. RN D said she was not told to make care plan changes when there were safety concerns. During an interview with Licensed Practical Nurse (LPN) C on 12/4/19 at 1:00 PM, LPN C said she was working when Resident #1 fell on [DATE]. LPN C said she heard a thump and when she went to the room. LPN C said Resident #1 was the only one in the room. Resident #1 said he was going to the bathroom when he fell . LPN C said, Resident #1 was known to take himself to the bathroom and did not use his call light. LPN C was asked if she added any safety interventions in Resident #1's care plan when she became aware, he was self-transferring and walking independently. LPN C the MDS nurse does the care plan. According to the MDS, dated [DATE] (after the [MEDICAL CONDITION]) Resident #1 required extensive assistance of 2 people for bed mobility, transfers and walking. Resident #2 According to the face sheet dated 12/4/19 Resident #2 was an [AGE] year-old female, admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #2 was not her own responsible party. According to the Minimum Data Set (MDS), nursing assessment tool, dated 11/22/19 Resident #2 required supervision with toilet use. The Brief Interview of Mental Status (BIMS) was 5/15 (severe cognitive impairment). Resident #2 was observed in the main dining room on the secured unit on 12/4/19 at 8:50 AM. Resident #2 had medial tape over a wound on her right eyebrow. The Surveyor asked Resident #2 if she had fallen. Resident #2 put her fingers on the wounded right eyebrow and said, no, I don't know how I did that. On 12/4/19 at 8:52 AM, the Surveyor asked Certified Nurse Aide (CNA) I if Resident #2 had fallen and CNA I said, yes, Resident #2 fell last night on the other unit but did not know the details. On 12/4/19 at 11:00 AM the Surveyor asked the Director of Nursing (DON) if Resident #2 should have been left alone in the bathroom when she fell on [DATE] and the DON said she should not have been left alone. The DON confirmed Resident #2 care plan and Kardex did not indicate Resident #2 should not be left alone in the bathroom at the time of the fall. The surveyor reviewed Resident #2's MDS dated [DATE] with the DON and the DON said she was not aware Resident #2 had been assessed to have supervision with toilet use. The DON added supervision while in the bathroom to Resident #2's care plan on 12/3/19 (after the fall). According to the ADL (activities of daily living) care plan dated 11/14/19 Resident #2 was independent with toileting (this did not match the MDS assessment dated [DATE]. According to the Kardex dated 12/4/19, Resident #2 was independent with toileting (did not match the last MDS assessment). No safety concerns were identified on Resident #2's Kardex. According to the incident report dated 12/2/19 at 21:30 (9:30 PM) Resident #2 had an un-witnessed fall in the bathroom across from the dining room. She had spots of blood on the floor by the door and the front of her pants were wet. Resident #2 had a small cut below her right eyebrow, minimal depth, 2 cm x 2 cm. Under witnesses documented, Certified Nurse Aide (CNA) E reported to this RN (registered nurse) that resident went to the bathroom on her on (sic), after she was in there 4-5 minutes, she opened the door to check on her, and she was observed on the floor sitting on her knees. Blood noted on the floor, and she was incontinent of urine on her pants and floor. The Surveyor called CNA E on the telephone on 12/4/19 to attempt an interview. CNA E voice mail was full, and no message was able to be left. CNA E was not able to be contacted during the investigation. No witness statement signed by CNA E could be located. According to the incident report dated 12/2/19 for Resident #2 under notes, Resident admitted to name of facility on 11/15/19. She is cognitively impaired, able to make simple day to day decisions and communicate with staff consistently. Spends a great deal of time packing and unpacking clothing believing she is going home. Resident had been recently moved to the memory care unit on 11/26/19, r/t her physical capabilities to being ambulatory adlib and exit seeking tendencies, although a wander ward (sic) was in place for safety. On 12/2/19 according to staff interviews resident had indicated need to us (sic) the BR (bathroom). She was up near the DR (dining room) at the time of incident so the staff allowed her to go into the BR near the DR. She was allowed to go in by herself and staff stated they went to check on her within 3-4 minutes when opening the door she was observed on floor on hands and knees with noted blood drops on floor coming from a cut on right eye Resident was unable to tell staff what occurred other than saying I'm alright. Resident had an recent increase of Klonopin (medication) on 11/26/19 for anxiety, total dose remains less then what receiving while at home according to family. With change in environment and hx (history) of anxiety, and constant pacing and packing/unpacking clothing feel increased of medication was necessary. Believe resident should have been supervised when using the attended BR as door would be heavy for resident to open on own. Staff instructed to stay with resident when toileting if she will allow or to have door cracked to According to the fall care plan dated 11/14/19 and revision on 12/4/19 for Resident #2, I am at risk for falls r/t (related to) Dx (diagnosis) of Alzheimer's dementia, CAD ([MEDICAL CONDITION]), Hypertension, [MEDICAL CONDITION] and being on medication that may cause dizziness, lethargy or light headedness. Along with the fact I have come from a home environment and this environment is unfamiliar to me. I have a hx (history) of liking to sit on the floor, usually to organize my cloths. I am ambulatory independently, gait steady. I may need assistance with direction to meals BR (bathroom) etc. The intervention to Direct to BR (bathroom) and stay either with resident if she will allow or have the door cracked where resident is visible if in need of assistance was dated 12/3/19. (this was added after the fall).

Based on interview and record review, the facility failed to provide wound care per physician orders [REDACTED].#1) of 4 residents reviewed for pressure ulcers and wound care of a total sample of 11 residents, resulting in delayed healing, the high potential for infection, unnecessary antibiotic usage with possible hospitalization . Findings Include: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment), dated 2/16, physician and nurses note's and physician orders, dated 2/16 through 3/16, revealed Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE], totally dependent on staff for all her Activities of Daily Living (ADL's), non-ambulatory, was transferred per mechanical lift and received Hospice services. The resident's [DIAGNOSES REDACTED]. The resident had a pressure ulcer on her coccyx area which had daily dressing changes. Review of Resident #1's Pressure Areas care plan, dated 2/1/17, stated Follow up with Dr. /Hospice (physician) recommendations (orders). Staff were to follow physician orders [REDACTED]. Review of the residents wound care order dated 2/1/17, stated [MEDICATION NAME] AG (wound treatment) apply to coccyx affected area p (after) cleansing c (with) N/S (normal saline) and cover c (with) drg (dressing) twice daily (q (every) shift) and PRN (as needed) for soiling. The physician order [REDACTED]. Review of the residents Treatment Sheet (dated 2/1/17 through 2/28/17), revealed documentation revealing on 2/1/17, 2/2/17, 2/4/17, 2/5/17, 2/6/17, 2/8/17, 2/10/17, 2/11/17, 2/12/17, 2/13/17 and 2/15/17, on second shift (7:00 p.m. to 7:00 a.m.) circled staff signatures representing the coccyx wound dressing changes had not been completed per physician orders [REDACTED]. Review of the back of the Treatment Sheet (dated 2/1/17 through 2/28/17), revealed no comments or explanation of why the residents dressing had not been completed per physician orders. Review of the residents coccyx Wound/Skin Care Management Documentation sheet (dated 12/16 through 4/12/17), revealed on 2/1/17 her coccyx pressure ulcer measured 1.2 x 0.5 (cm), width and 0.3 (cm) depth and on 2/8/17, it measured 1.2 x 0.5 (cm) width and 0.3 depth. The resident's coccyx pressure ulcer had gotten large and had more depth from 2/1/17 to 2/8/17, representing a delay in healing due to the physicians wound care order not being followed. During an interview on 4/26/17 at 3:45 p.m., staff member L (Charge Nurse, former Treatment Nurse, RN) stated I found it (the documentation that wound care was not completed per physician orders [REDACTED]. During an interview done on 4/26/17 at 2:25 p.m., staff member B (the Director of Nursing/DON) was asked by this surveyor why Resident #1's coccyx wound care was not completed for a total of 11 days in 2/17, and she stated it should have been done, I have no explanation why it was circled (representing the wound care was not completed). During an interview done on 4/27/17 at 7:00 a.m., staff member K (Charge Nurse, RN) said she was the only nurse at night with 3 Nursing Assistants for the whole facility and stated I got no breaks, I didn't have time to do her dressings (Resident #1's coccyx wound care). During a phone interview done on 4/27/17 at 1:20 p.m., staff member D (Charge Nurse, LPN) stated another nurse covered the floor and she did not do the dressing's, I just circled it and put my initials. It was hard to get things done, we only had one nurse, not enough time. During a phone interview done on 4/28/17 at 8:30 a.m., staff member C (Charge Nurse, LPN) stated There were times I just could not get things done. I didn't report it to management, it was really a rough time (2/17). Review of the facility RN/LPN Job Description (un-dated), stated Unit Nurse, Charge Nurse: Administer treatments (including wound care) in accordance with physicians orders. The professional nurses scope of practice includes the administration of medications and treatments (including sound care) as prescribed by a person licensed by a state regulatory board to prescribe medications and treatments (physician). Nursing Practice Act (Chapter 335 RSMo), health.mo.gov/living/lpha/phnursing/physicianorders.php

Based on observation, interview and record review, the facility failed to supervise 4 residents to prevent 2 falls and 2 injuries (sampled Residents #2, #6, #7 and #9) of 7 residents reviewed for falls and safety of a total sample of 11, resulting in 2 injuries, bruising (Resident #2) and a fracture (Resident #7) with the potential for severe injury, hospitalization and pain. Resident #9: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment), dated 4/12/17, nurses note's dated 4/14/17, physician note's dated 4/14/17 through 4/26/17, hospital History and Physical Report dated 7/24/13, revealed Resident #9 was a [AGE] year-old female, admitted to the facility on [DATE], resided on the Dementia Unit, alert with confusion and was not able to make her own health care decisions, totally dependent on staff for all Activities of Daily Living (ADL's) and required a rolling walker for ambulation. Review of Resident #9's MDS (dated 4/12/17), revealed during ambulation on the unit she was to have extensive assist of one person using her rolling walker at all times. Review of the residents Fall care plan, dated 8/31/16, stated staff will offer walker when Res (Resident #9) is ambulating, staff will encourage use and provide cueing to use FWW (front wheeled walker) for ambulation. Review of the facility Incident/Accident report and Investigation (dated 4/26/17), revealed Resident #9 had a fall on 4/26/17, at 7:00 p.m., and stated she did not have her walker, keep walker at resident side and assist at all times. Observation of the facility video done on 4/27/17 at 11:00 a.m., accompanied by staff member A (Administrator) that was dated 4/26/17 at approximately 7:00 p.m., revealed Resident #9 being left alone in the dining room of the Dementia unit, getting up from a chair, unable to reach her walker due to it being folded and put behind a folding chair out of her reach, walking alone using a table and chairs to stabilize herself and falling at the dining room doorway after looking down the hall for staff. The resident fell backward and hit her head on the tiled floor. The resident was left unsupervised in the dining room with her walker folded by staff member N (Nursing Assistant/CNA) and put behind a folding chair, out of her reach. During an interview done on 4/27/17 at 2:00 p.m., staff member N (CNA) said the residents fall could have been prevented and stated, her (Resident #9) walker should have been with her, I should have put her walker in front of her. During a phone interview done on 4/27/17 at 10:40 a.m., staff member O (CNA) revealed she was working on the Dementia unit when Resident #9 fell (on 4/26/17, second shift) and stated, yes, she (the resident) should have her walker with her at all times. During an interview done on 4/28/17 at 7:00 a.m., staff member K (Charge Nurse, RN) revealed she was the Charge Nurse on 4/26/17 when Resident #9 fell and stated, we were in the middle of shift change, yes it could have been prevented (the residents fall). Review of the Employee Warning Notice, dated 4/27/17, revealed a verbal warning was given to staff regarding Resident #9's fall on 4/27/17 and stated removed residents walker out of reach, resident then got up and walked which resulted in a fall, care plan not followed. Review of the facility Fall Prevention Policy up-dated on 10/19/16, stated that the nurse will assess for any potential environment hazards and will remove and or reorganize said environmental hazards (the residents walker removed form her reach). Review of the facility staff education Safety dated 3/31/17, stated If a resident is restless and wandering, it is your responsibility to monitor them, to keep them safe. Resident #7: The April 2017 monthly physician orders [REDACTED]. Resident 7's Significant change Minimum Data Set (MDS) assessment reflected she had a Brief Mental Status Score of 3 out of a possible 15, which indicated severe cognitive impairment and required limited assistance of one person for ambulation and used a wheelchair for ambulation. On 4/27/17 at 4:00 PM, during a family interview, Resident 7's family member stated he was told Resident 7 fractured her finger when someone moved her wheelchair. Resident 7's family member said when it first happened her finger was swollen and each day the bruise got darker, by the 3rd day he brought to the attention of staff that they better take a look at this. Nurses notes, dated 12/29/16 at 4:30 PM, reflect a late entry for 12/27/16, CENA (Certified Educated Nurse Aide) reported bruise to left thumb/base area, resident does not indicate pain with this propelling wheelchair per self using left hand, most probable when CENA was assisting with redirection of wheelchair, Left thumb was caught in wheel well, incident notified husband . of bruising, notified Dr. will monitor site. Accident/Incident report, dated 12/26/17, reflected the time of the incident was between 6:00 AM and 6:30 AM on the West hallway. The description of the incident indicated CENA redirecting res. in w/c (wheelchair) started push w/c, res. Lt. (left) thumb got caught in wheel well. According to their Accident/Incident report dated 12/26/16 both Nurse Aides Y and Z her left thumb in the wheel well. That bruise to left thumb was noted during shower 12/26/16 which was crossed out and changed to 12/27/16. That Resident 7 stated ouch at the time; but there was no indication of pain afterwards. The immediate safety intervention was to Ensure fingers on lap/arm rests before propelling res. w/c (wheelchair). On 12/29/16 Resident 7's X-ray results reflected There is a fracture at the proximal metaphysis of the proximal phalanx. The conclusion was fracture of the proximal phalanx of the thumb. Arthritic changes notes. Typewritten notes dated 12/28/16 written by Registered Nurse X (ex-Director of Nursing) reflected Addendum: On 12/28/16 at 5:30 PM husband showed this nurse resident's left thumb and stated that he had just noted bruising that afternoon; I told him the nurse had noted bruising and had observed this on 12/27/16 and I also told him that her thumb had caught in the wheel well Monday morning; observed bruising was darker red and more dispersed to top of left hand than previous, resident did not indicate having left hand/thumb pain and was using her left hand to self-propel w/c (wheelchair). RN X had additional notes dated 12/29/16 at 4:30 PM husband showed this nurse resident's left thumb again; noted that the knuckle of left thumb was swollen with purple bruising, she was not able to bend it and it was painful to touch. This nurse had not noted this with prior observation of left thumb. At that point an x-ray was ordered and showed fracture at proximal phalanx. She continues to use left hand to self-propel w/c. Dr. BB on call for Dr. AA, said to follow up with splint and ask Dr. AA to look at it to determine if displaced and/or ortho consult. On 4/27/17 during an interview with DON B when asked why did it take 2 to 3 days before Resident 7 was x-rayed, and if nurses did an assessment including range of motion of the left thumb at the time the injury was discovered? DON B replied that was before I worked here. Resident #6: The 5-day Minimum Data Set Assessment (MDS), dated [DATE], reflected a Brief Interview for mental status (BIMS) score of 10 out of a possible 15 and the Quarterly Minimum Data Set assessment dated [DATE] reflected a BIMS score of 9 out of a possible 15, both assessments indicated moderate cognitive impairment. Resident 6's cognition care plan reflected on 12/6/16 two physicians determined resident was unable to make informed medical decisions. According to Resident 6's fall care plan dated 11/16/16 Resident fell at home on 11/7/16 and was a High Fall Risk. The word high was crossed out before given, with no date of when it was crossed out. Nevertheless this same care plan reflected Resident 6 had 3 falls between 1/2/17 and 2/5/17. The fall care plan was only updated to 3/29/17 and the information on 3/29/17 was cut off. The Occupational Therapy Discharge Summary, dated from 11/19/16 to 12/16/16, recommended Resident 6 needed 24 hour care and the equipment recommended was a wheelchair and a four wheeled walker. A fall investigation summary for a fall on 2/5/17 reflected a Sunshine Unit CENA (certified educated nurse aide) responded to a sounding alarm in room 36 and observed resident standing from her recliner. The CENA reports she instructed resident (#6) to wait for her walker. CENA proceeded to get resident's walker, which was sitting at the end of the resident's bed, and while doing so, the CENA reports she was also removing her gait belt to use for the resident. Before CENA was able to get the walker to the resident (#6), she observed resident taking a step, spinning around so she was facing bed 1 and then descending to the floor, coming to rest, face down, near the head of bed 1. The Fall Scene Investigation Report dated 2/5/17 reflected Resident 6 hit her head on the bed, coming to rest face down. First Aid was given and Resident 6 was sent to the emergency room . On 4/28/17 in the morning of DON B agreed that the fall on 2/5/17 could have been avoidable if the nurse went to assist the resident first, instead of going for the walker. There was an update in Resident 6's fall care plan dated 2/6/17 indicating If/when res. is observed ambulating/transferring without walker, staff to provide immediate assist and then either call for assist to obtain walker or ambulate with resident to her walker. Resident #2: The monthly 4/2017 physician orders [REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated 2/14/17, reflected Resident 2 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, which reflected she was cognitively intact and was totally dependent for transfers. The Incident Accident Investigation Analysis dated 4/16/17 reflected there were two staff transferring Resident 2 using a mechanical lift. As Resident 2 was being lowered into the chair the lift tipped. Nurse Aides were able to correct the lift, but Resident 2's finger was pinched between self and sling. This investigation indicates Resident 2 was being transferred from the bed to the chair. According to this investigation the plan of care was being followed however, the facility provided all nurse aides with education on lift transfers. The education that was provided was keeping legs of the lift open with transfers. It appeared Resident 2 was positioned too far to one side.

Based on observation, interview and record review the facility failed to ensure the safety and prevent multiple falls with injury for 9 residents (Residents #39, #42, #46, #47, #48, #49. #50, #51 & #52) by not ensuring that clearly identified interventions were in place to prevent the falls. The facility further failed to properly supervise Resident #46, who was at high risk for falls. Resident #46 had two falls, both with serious injury which caused multiple fractures, on [DATE]. Resident #46 died on [DATE]. This deficient practice places all residents, identified as being at risk for falls, at risk for serious harm, injury and/or death. Immediate Jeopardy was identified at F-323 on [DATE]. Review of the facility CNA orientation check list, dated [DATE],revealed the ask personal safety alarms was to be completed and assessed by a unit manager before a new employee is allowed to start working independently. Review of the facility Certified Nursing Assistant responsibilities, no date, listed answers fall sensors, follows established safety precautions in the performance of all duties, reports all accidents and incidents as observed on the shift they occur and performs all assigned tasks/duties in accordance with established polices and procedures, as instructed by your supervisor. Review of the Shift change policy, dated [DATE] and revised on ,[DATE] with revisions in italics, 1. the charge nurse will check at the beginning of every shift that nurse aide has their transfer belt on them to ensure compliance. 2. Care staff to ensure all personal safety alarms in place and functioning properly. 3. Huddles involving nurses and nurse aides at shift change to discuss resident care. According to the facility fall policy, dated [DATE] and revised on [DATE] (with revisions in italics), 1. A Fall Risk Assessment will be done on all new admissions by the admitting nurse. If the Resident scores over a 10 or is admitted with a [DIAGNOSES REDACTED]. Nurse will assess Resident's room for potential environmental hazards and will remove Resident's at risk of falls status and placement of assistive safety alarms. The At risk falls information and the initiation of assistive safety devices will be addressed with the oncoming staff through verbal report and the 24 hour sheet will be updated and care staff will document on the 2 hour alarm sheet that ensures the safety intervention is in place and functioning properly. 2. A Fall Risk Assessment is done on all residents quarterly and as needed. Residents with a score of greater than 10 or with a recent history of falls will be evaluated and a care plan will be implemented by the MDS nurse. The Fall Risk Assessment Tool will be initiated and completed the the designated Safety Officer and signed by the physician. 3. If a Resident has a fall with injury, the Administrator will be notified immediately by the charge nurse. 4. The event committee will meet M-F to review falls to assure they are properly investigated, assessed and new/revised interventions are planned according to prevent future falls. The event committee will consist of the Administrator, Director of Nursing, designated Safety Nurse, MDS coordinator, Restorative nurse, Nurse Manager, Social Service Worker, and Activities director. The Event committee will meet monthly and as necessary to review fall and investigations. The committee will: a. Perform a post fall investigation . *Review history of falls, *Review patient record for medications, combinations of medications or changes in medications that could predispose Resident to falls, *Assess Functional status-including changes in balance and gait, use of assistive devices, review bowel and bladder continence, *Neurological status-assess for conditions that impair vision, sensor deficits, *Psychological factors-Review impaired cognition, judgement, memory, safety awareness and decision making capacity, *Environmental factors- Assess presence of environmental factors that could cause or contribute to falls _Assess whether patients foot wear may be contributing to fall risk. *Situational factors- Assess recent admission, return from hospital, responding to toileting issues, time of day, *Root cause analysis of fall will be determined. b. Notify physician if post fall investigation reveals necessary medical intervention. c. update fall risk assessment. d. evaluate and implement interventions to either try to limit opportunity for falling or try to limit the consequences of falling, which may include but not limited to: *update Resident Care plan with new/revised safety intervention *monitor new interventions for effectiveness and Resident response *Evaluate Risk vs Benefits of limiting mobility 5. The Event committee will meet monthly and as necessary to review fall and investigations. The monthly safety meeting will: *Review and evaluate investigations and interventions for appropriateness. *Review falls to look for trends and patterns *Review Residents who are identified as a High Risk for falls to assure adequate measures are in place for fall prevention prior to incident/fall and review for appropriateness of continuing of High Risk falls ID program *Will look for common factors to evaluate the need for systems or revisions of current systems *The event committee will report all findings to Quality Assurance. The facility policy regarding very high fall risk indicators states, identified on red paper with each resident name at the top of the paper and kept in the ADL book with the the following information on each individual sheet: This resident is a VERY HIGH FALL RISK !! Please review and follow safety interventions as outlined on their kardex. Please check safety devices for proper functioning (if using). Please make every effort to monitor resident for any unsafe acts and redirect them. Please notify charge nurse, nurse manager or safety nurse of any concerns regarding resident's safety. On [DATE] at 3:05 PM, Safety Officer Licensed Practical Nurse (LPN) D was asked how the investigations of the falls were initiated and responded, I read the statements of the staff that were present. The information I gather is read in the morning meeting. LPN D was asked so you do not interview the individual staff, and responded no not usually, I will talk to the staff on the floor. LPN D was asked if recurrent falls were discussed at those meetings and stated not specifically everyone knows about them. LPN D was asked if a root cause analysis for the falls is discussed and responded at times I do, but not every time no, if it is clear in my head of what caused it, no. LPN D was asked if you do not bring up past falls how do you establish a pattern, and responded, By my memories of things. LPN D was asked if the rest of the group or committee participated or provided any feedback and responded, Typically not. LPN D was asked if information was documented during the meeting and stated I just read the report. On [DATE] at 8:35 AM, Administrator A reported that 6 residents (Residents # 55, #56, #57, #58, #59, and #60) had a Fall Risk assessment completed by Safety Officer LPN D and were identified as at high risk for falls and had not previously been identified prior to this assessment. On [DATE] at approximately 4:00 PM, LPN D and Administrator A were both requested to review and provided the facility's investigations for their monthly meeting. The requested information was not provided by the time of exit. Resident #46: Resident #46 was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment, dated [DATE], the resident had Brief Interview for Mental Status (BIMS) cognitive assessment score of 7, indicating moderate cognitive impairment. According to the 24-hour report Resident #46's falls on [DATE] were documented at 12:30 AM and at 6:35 PM. On [DATE] at 9:40 AM, Administrator A and Director of Nursing (DON) B requested to have a discussion related to Resident #46. DON B stated, we need to talk now, you are reviewing the chart so, I better tell you now, because you are going to find out any ways. Resident had a fall on [DATE] at 12:15 AM and was reported to have fallen on his face trying to close the door so the puppy wouldn't get out per resident. Resident was reported to have returned at 3:30 AM, with no acute findings according to a CT that had been done at that time. The resident was reported to have had another fall in the facility at around 6:35 PM, fell and hit the back of his head, did not lose consciousness and was transferred to the hospital at 7:05 PM, with a sustained head injury according to the the CT with a subdural hematoma and frontal lobe fracture and prognosis was very poor. DON B and NHA A reported they had met with the family last night and resident was returning to the facility on hospice services. Administrator A reported she had not been notified until she came in on Monday [DATE], that resident had fallen 2 times over the weekend. Resident #46 had five (5) reported falls, since his admission to the facility on [DATE]. According to the facility incident report, the first reported fall occurred on [DATE] at 10:30 AM in the facility dining room. A review of a care plan revision, dated [DATE], revealed an intervention that staff will maintain a bed alarm and magnet string alarms. According to the facility incident report, the second reported fall occurred on [DATE] at 3:00 PM, in the resident's bathroom. A review of a care plan revision, dated [DATE], revealed an intervention that the facility would maintain very high fall risk indicators to include staying with the resident, while he uses the bathroom and, also, provide explanations as to why he needs staff assistance. According to the facility incident report, the third reported fall occurred on [DATE] at 12:45 PM in the resident's room. A review of an incident report, dated [DATE] at 12:45 PM, revealed that Resident #46 was In resident's room, observed lying on the floor. According to the facility investigation, Resident #46 had a string alarm that was attached to the w/c (wheel chair) but not clipped on resident, prior to the fall. A review of a care plan revision, dated [DATE], revealed an intervention that the resident would not be in his room unassisted, unless he was in bed. The fourth reported fall occurred on [DATE] at 12:15 AM in the resident's room, between the resident's bed and the bathroom door. A review of the facility Incident Report and hospital records, dated [DATE], revealed that Resident #46 had a fall on [DATE] at 12:15 AM, when he was found prone in his room, between his bed and the bathroom door. At 1:00 AM, Resident #46 was transported to Sparrow Hospital Carson City and returned from the hospital to the facility at 3:30 AM. The Sparrow Hospital (Carson City) Computerized Tomography (CT) scan report for Resident #46 ' s head, dated [DATE] at 1:09 AM was reviewed. The report revealed, No acute bleed, mass effect for midline shift. No skull fracture Laceration/injury at the right forehead. According to the facility incident report, the fifth reported fall occurred on [DATE] at 6:35 PM in the facility dining room. Resident #46 was reported to have fallen again in the dining room on [DATE] at 6:35 PM and sustained a wound to the back of his head. The resident was returned to the hospital by ambulance. Review of the incident report, dated [DATE] at 6:35 PM, revealed that Resident 46 fell in dining room, was in wheel chair. According to the facility investigation, Resident #46 had been wearing grippy socks, on his feet. The magnet string alarm was attached to the resident's w/c but the clip was not noted to be attached to the resident at the time of the incident so the alarm was not sounding. On [DATE] at 7:00 PM, Resident #46 was transported to Sparrow Hospital Carson City and transshipped to Sparrow Hospital in Lansing, arriving at 9:56 PM on [DATE]. The Sparrow Hospital (Lansing) CT scan report for Resident #46's head, dated [DATE] at 11:51 PM, was reviewed. This was approximately 11 hours after the fourth fall and 5 ,[DATE] to 6 hours after the fifth fall, when resident returned the second time to the hospital. The report revealed, Findings: Large irregularly-shaped parenchymal hemorrhages in the left frontal and temporal regions. Collection in the frontal lobe measures 6.5 x 5.3 x 3.8 cm (centimeters). collection in the left temporal lobe measures about 5.0 x 4.7 x 2.4 cm in maximal cross-section. Smaller areas of parenchymal hemorrhage in the right frontal lobe. Marked mass effect with deformity of the left lateral ventricle and transmidline shift of the lateral ventricles toward the right approximating 13 to 14 mm (millimeters). Intraventricular hemorrhage. Small subdural hematoma on the left side. Maximal thickness approximates 5 mm. Small subdural hematoma also along the falx cerebri in the interhemispheric fissure region. Subarachnoid blood also seen. Nondepressed skull fracture in the midline of the frontal region. The Sparrow Hospital (Lansing) CT report for Resident #46's head, dated [DATE] at 4:59 AM, was reviewed. The report revealed, Impression: Interval worsening of multi compartmental intracranial hemorrhage, causing a midline shift to the right now measuring 1.7 cm with worsening subfalcine herniation. Resident #46 was discharged from the hospital and transported back to the facility, arriving at 5:20 PM on [DATE], where he was placed in hospice care. A review of the care plans revealed no new assessments or interventions were implemented after [DATE] following the 2 falls on [DATE]. In an interview conducted on [DATE] at 12:55 PM, Resident #46's Guardian stated that he (Resident #46) didn't know the string was there and had not attempted to remove it. The Guardian reported they had visited at least 3 times a week. Guardian stated, I had asked him (Resident #46) what is this (string to string alarm) and he had stated, I don't know. Guardian reported he (Resident #46) had not been observed to attempt to remove it during any of their visits. In an interview conducted on [DATE], at 10:30 AM, Certified Nursing Assistant (CNA) F was asked if she and her partner, CNA J, had completed rounds at shift change. CNA F responded that they only check and change (briefs). CNA F was asked if, during daily rounds daily, she normally checks the alarm and string. CNA F replied, No that is the only alarm we have. I didn't know that was my responsibility. CNA F was asked if she could see the residents, when she was charting in the dining room with her back to them. CNA F responded, I could not see them. The Sparrow Hospital (Lansing) CT report for Resident #46's head, dated [DATE] at 4:59 AM, was reviewed. The report revealed, Impression: Interval worsening of multi compartmental intracranial hemorrhage, causing a midline shift to the right now measuring 1.7 cm with worsening subfalcine herniation. Resident #46 was discharged from the hospital and transported back to the facility, arriving at 5:20 PM on [DATE], where he was placed in hospice care. Resident #46 died at the facility on [DATE] at approximately 11:12 AM. Immediate Jeopardy is due to the facility's failure to ensure the safety and prevent multiple falls with injury for Resident #46 by ensuring that clearly identified interventions were in place to prevent the falls with injury and the facility's failure to properly supervise Resident #46, who was at high risk for falls. This deficient practice places all facility residents, identified as being at risk for falls, at risk for serious harm, injury, and/or death. ( ) The Administrator was informed orally on [DATE] and in writing on [DATE] of the Immediate Jeopardy, which was identified on [DATE]. On [DATE], the surveyors verified that Ashley Care Center had initiated the following remedies to remove the immediacy: Ashley Care Center Removal of IJ Updated [DATE] 1. The corrective action that has been or will be accomplished for those residents affected by the deficient practice. a. [DATE]rd and 4th, 2016 discontinued 4 out of the 4 remaining magnet string alarms in use and these were replaced with chair alarms. b. On [DATE] the Fall Prevention Policy was updated and includes post fall risk assessment done on admission, quarterly and as needed. Fall ID Program for high and very high risk for falls was reviewed. c. On [DATE] Shift Change Policy was updated to include alarm checks to be done during rounds with oncoming nurse aide and off-going nurse aide both signing the two hour check sheet at the 6 am and 6 PM hour and nurse and nurse aide huddles at shift change effective immediately. On [DATE] sign-in for shift change huddle report was initiated. d. On [DATE]th and 5th, 2016, 14 very high fall risk residents were audited with fall risk assessments completed and the kardex and care plans reviewed to verify accuracy, with 17 residents total having had fall risk assessments completed. 2. How has the facility identified or will identify other residents who have the potential to be affected by this deficient practice. a. All residents who reside in a long term care facility have a potential to be affected by this deficient practice. b. The Safety Coordinator and MDS Coordinator will review diagnoses, medications, history, documentation, observations, and reports of resident conduct to determine resident fall risk at admission, quarterly, and as needed. 3. The measure that has been or will be put into place, or systemic changes made to ensure the deficient practice does not occur. a. On [DATE]th and 5th, 2016, 15 of 15 nurses were in-serviced to call the Administrator with any fall. The Accident/Incident report sheet has been updated to include notification of the Administrator. b. On [DATE]th and 5th, 2016, 89 employees received in-servicing on policy changes and interventions for fall prevention; the remaining 9 employees will be in-serviced prior to their next working shift. c. As of [DATE], 95 employees have received in-servicing on policy changes and interventions for fall prevention; the remaining 3 employees will be in-serviced prior to their next working shift. d. MDS Coordinator will complete fall risk assessment audit of all current residents for the MDS and Safety Coordinator will complete fall risk assessment audit after each fall. e. Effective after [DATE] Nursing Home Administrator, Director of Nursing, and facility management team will audit 2 hour alarm check sheets daily. f. MDS Coordinator will audit completed fall risk assessments quarterly and as needed, and Safety Coordinator will complete the fall risk assessment after each fall. g. On [DATE] 2 hour alarm check sheets updated to include nurse signature at 6 am and PM to ensure all alarm checks being completed correctly. h. On [DATE] Random 2 hour alarm check audits will be done by the charge nurses every shift ongoing. i. All resident at very high risk for fall care plans will be audited weekly for 4 weeks and then quarterly by MDS coordinator. Nurse aide manager will audit very high fall risk resident kardexes weekly for 4 weeks and quarterly to ensure that interventions are appropriate. The Nurse Aide manager reviews and/or updates all resident kardexes weekly ongoing. j. The safety coordinator will ensure that the Fall ID Program is implemented for every resident and communicate with nurse aide manager and direct care staff the safety interventions which have been in place per the resident ' s kardex and care plan. k. The safety coordinator will ensure that new safety interventions for individual residents are effective by communicating with staff and Social Worker. Social Worker will assess resident after intervention is in place to ensure that new behaviors are not safety intervention related. l. Director of Nursing and Assistant Director of Nursing will ensure 2 hour alarm checks are being completed by staff and will complete weekly audits for 4 weeks, then monthly for 3 months, and then quarterly. 4. How will the facility monitor its corrective actions to ensure that the deficient practice is corrected and will not reoccur? a. Safety coordinator, Administrator, DON, ADON, MDS coordinator, social services, activities, dietary, restorative rehab and nurse aide manager will review all falls. b. PT and/or OT will be contacted to screen, evaluate and treat, if indicated. c. Ongoing reviews and updates of the fall care plans and kardexes for all residents will be completed by the MDS coordinator, Safety Coordinator and Nurse Aide Manager as falls occur and with quarterly MDS assessments. d. All fall investigations will be presented and discussed at the monthly Quality Assurance meeting. e. Relias training for Fall Prevention will be implemented bi-annually and as needed for all staff. On [DATE] a Relias training module for fall prevention was assigned for all staff to complete by [DATE]. f. Fall Prevention training will be initiated upon hire. g. Policies and Procedures for falls will be reviewed and revised annually and as needed. h. Ongoing evaluation of staffing needs according to resident ' s fall risk needs. i. Nurse consultant hired to assist department staff with implementing an updated Fall Prevention Program. Although the immediacy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for than minimal harm that is not immediate jeopardy, until sustained compliance can be verified by the State Agency. ( ) Resident #42: According to Resident #42's 60 day Minimum Data Set (MDS) assessment dated [DATE], Resident was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #42's Nurse Aide care guide dated [DATE], revealed Resident had a chair alarm and was a very high fall risk. Review of facility fall risk evaluation revealed an assessment on [DATE] with an evaluation of 16 there was no other evaluation following any of the 5 falls until [DATE] with an evaluation of 21. Resident #42 had 5 falls since her admission on [DATE]. Review of Resident #42's fall investigation dated [DATE] revealed a fall dated [DATE] at which time she attempted to self-transfer from her recliner. Review of Resident #42's second fall was on [DATE] at 7:45 AM, observed lying on lt side on floor mat . According to the facility investigation the chair alarm was sounding and the floor mat was in place. Resident #42's Care plan dated [DATE] was updated with an intervention res (resident) is not to be in room unassisted unless she is in bed during the meal time hours, until all staff have returned to the floor from the DR (dining room). Review of Resident #42's third fall was on [DATE] at 5:20 PM, according to the incident report Resident was found kneeling next to bed on floor mat holding floor rail was educated on the use of the call light system and to call for help res (resident) voiced understanding. According to the facility investigation, intervention included bed in the lowest position with floor mat at the bedside with a bed wedge to be initiated at the open side of the bed along with the existing body pillow, placing the bed wedge behind resident's back with the body pillow placed below, along the open side of bed. This intervention was not noted on the care plan. Review of Resident #42's fourth fall was on [DATE] at 4:20 PM, Resident observed on floor in bathroom next to toilet . unwitnessed. Resident stated I need to go to the bathroom. According to the facility investigation One of resident's shoes was noted to be off and lying on the floor by the sink. The CENA reports that the resident was last toileted at 2:30 PM and then assisted in to her recliner. The call light was in reach while the resident was in her recliner but not activated. The chair alarm was in place and sounding the alarm was noted to be quieter than normal. Interventions were to check for chair alarm for proper functioning and check shoes for proper fit. This intervention was not noted on the care plan. Review of Resident #42's fifth fall was on [DATE] at 4 PM, Resident witness at end of recliner on knees . unwitnessed. When asked what she was doing stated, Well, that is a good question! Son was just a short distance down the hall when alarm was heard. Resident was wearing her grippy socks. It was most probable that resident was attempting to self-transfer from her recliner, possibly to follow her son. There was no updated interventions to distract Resident #42 when family was leaving the facility on the care plan. Review of Resident #42's 2 hour alarm check dated [DATE], revealed documentation was not completed to indicate the alarm was checked at 12 AM, 2 AM, 4 AM or 6 AM. On [DATE] at 8 PM and 10 PM revealed documentation had not been completed for Resident #49's alarm for placement or proper functioning. ( ) Resident #47: According to Resident #47's quarterly Minimum (MDS) data set [DATE] Resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #47's incident reports revealed Resident had a fall on [DATE] ambulating in hallway with CNA fell forward hitting head on door hinge. Resident received a laceration to the forehead approximately 3 cm. (centimeters), hematoma on left forehead center. According to the facility investigation due to resident's rapid pacing and poor posture (leaning forward with head down and tripped on her own foot, losing her balance, coming to rest on the floor and striking her head on the near by door hinge, in front of her. The incident was not reported until after it was discussed with the office and beyond the 24 hour time limit. Review of the facility reported incident dated [DATE] at revealed the facility failed to report the incident in a timely manner. Review of Resident #47's Fall Risk Evaluation dated [DATE] was evaluated at a 23 and was considered a very high fall risk. Resident was revaluated on [DATE] following the fall on [DATE] at a 21. Review of Resident #47's care plan revealed an intervention for staff will encourage res (resident) to wear soft protective helmet. Remove for cares BID. Staff will wash helmet weekly and PRN . Intervention noted to have been discontinued on [DATE]. Review of Resident #47's nurse notes dated [DATE] revealed d.o. (doctor order) obtained to D/C soft protective helmet. There was no explanation why helmet was discontinued. On [DATE] at 4:40 PM, at Director of Nursing (DON) B reported Resident #47's protective helmet was discontinued because resident was getting upset putting the helmet on so an order was obtained to discontinue the helmet. DON B was asked if there was any other intervention attempted to put the helmet on Resident #47 and there was no response. On [DATE] at 3:05 PM, Safety Officer Licensed Practical Nurse (LPN) D was asked what interventions were put in place to prevent a reoccurrence and stated, Resident was to receive 1:1 supervision. Safety Officer LPN D as asked if there was any intervention to have staff walk between doors and Resident and responded, No. LPN D was asked, So how is this intervention going to help her not to fall against the door again? LPN D had no answer. ( ) Resident #49: According to Resident #49's 30 day Minimum Data Set (MDS) assessment dated [DATE], Resident was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #49's Nurse Aide care guide dated [DATE], revealed Resident had a chair alarm and was a very high fall risk. Review of Resident #49's incident reports revealed he had a fall 4 falls since admission. The first fall was dated on [DATE] found on knees on mat beside bed. According to the investigation was assessed with [REDACTED]. UA was done due to increased confusion and behaviors. The second fall was dated [DATE] at 2:10 PM, Resident's room in between bed and recliner. Resident educated on using call light not getting out of bed on own, 15 min checks. According to the investigation reopened the abrased area. no other injuries. Resident's bed in low position, alarm in place and sounding. On [DATE] Resident C/O back (flank pain) with PRN Tylenol given for pain management with relief. [DATE] , resident within creased C/O's back pain and noted to have increased aggressive behaviors. Orders were received to increase Tylenol #3 back to TID and to obtain labs and a one time dose of Ativan. Safety checks were not noted on Resident #49's care plan. Review of Resident #49's third fall dated [DATE] at 8:15 PM, Resident laying on Rt side Rt arm under him in front of bathroom door head next to edge of bathroom door. According to the facility investigation He had been previously identified as a very high fall risk with his last fall being on [DATE] at 2:10 PM at which time he attempted to self-transfer from his bed. Resident requires hoyer for transfer and w.c with one assist for mobility but will self-propel at times. He is being followed by PT/OT. His current safety interventions include frequent safety checks, high/low bed with floor mat, winged mattress, bed alarm, magnet string alarm in chair, and bathroom door alarm . Review of Resident #49's fourth fall dated [DATE] at 5:15 PM Resident noted on floor by CNA. According to the report pain voiced in left hip, back and back of head. sent to ER for eval and treatment. According to the facility investigation Resident's alarm was in place but not sounding. The call light was in reach but not activated. Resident was wearing socks on his feet. Charge nurse reports that resident was exhibiting increased confusion, swearing attempting to hit staff when cares offered, calling out for the nurse, his wife and his children and that he was unwilling to take his PRN pain medication. Review of facility fall risk evaluation revealed an assessment on [DATE] with an evaluation of 21 there was no other evaluation following any of the 4 falls until [DATE] with an evaluation of 20. On [DATE] at 8:30 AM, Director of Nursing reported Resident #49's had a fall on [DATE]. Review of Resident #49's care plan was not updated until [DATE] following the fifth fall that occurred on [DATE] when a floor mat with alarm, on top of floor mat, when in bed was initiated. On [DATE] at 11:30 AM, a review of Resident # 49's 2 hour alarm check sheet revealed on [DATE] documentation was not completed to indicate the alarm was checked at 8 AM or at 10 AM. A previous review of the 2 hour alarm check review on [DATE] revealed documentation had not been completed on [DATE] at 12 AM, 2 AM

This citation pertains to MI 353 and MI 393. Based on observation, interview and record review, the facility failed to provide supervision to prevent the elopement and ensure the safety of 1 resident (Resident 101) who was assessed by the facility to be severely cognitively impaired and confused. Resident #101 was self ambulatory and had a history of [REDACTED]. Resident #101 was 1 of 7 sampled residents assessed to be at risk for elopement, including 2 residents (Residents #105 and #106) fitted with wander guard alarm bracelets (an alarm device for notification of elopement) out of a total sample of 7 residents, resulting in placing residents at high risk for injury, serious harm or death. Findings include: Immediate Jeopardy began on [DATE] at 9:30 a.m., when staff member H (Nursing Assistant/CNA) saw Resident #101 walking alone, unsupervised on a busy two lane 55 mile an hour road (M-57) and called the facility to inquire if the resident was missing. The facility was not aware Resident #101 had eloped (on [DATE]) until staff member H (CNA) called to inquire about his whereabouts. Facility staff did a resident check and were unable to locate the resident, so staff member C (CNA) was sent to go and get him from M-57, and he was returned to the facility at 10:00 a.m. The resident was assessed by the facility as at risk for elopement and had a wander guard bracelet on (an electronic device for notification of residents going through a wander guard alarmed door). The resident eloped from the facility through the main dining room exit door, which did not have any alarms. Staff were unaware the door had been opened by the resident. The resident eloped from the facility on [DATE], going through the main dining room exit door into the resident courtyard, through gate #1, across the uneven parking lot, onto a country road for ,[DATE] a mile and directly onto M-57 where he was picked up by staff approximately 3 miles from the facility. The Nursing Home Administrator was notified of the Immediate Jeopardy situation on [DATE] at 3:40 p.m. Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated [DATE], nurses note's dated [DATE] to [DATE], Social Service note's dated [DATE] to [DATE], Risk of Elopement/Wandering Review dated [DATE] to [DATE], Admission Data dated [DATE], Physician order [REDACTED].#101 was a [AGE] year old male, self-ambulatory without assistive devices, confused, unable to make his own decisions and required staff assistance with his personal hygiene and toileting. The resident's [DIAGNOSES REDACTED]. Review of the Hospital Records dated [DATE] and [DATE] and the facility CAA (Care Area Assessment, part of the (MDS) dated [DATE], revealed Resident #101 lived at home with his wife until [DATE], when the local police picked him up walking alone at night on M-57 (busy, two lane road with a 55 MPH speed limit), took him home and found his house to be un-livable with approximately 40 cats (some dead), feces on the floor, having all spoiled food in the refrigerator and no hot water. The resident and his wife were taken to the hospital where his wife died on [DATE]. The resident was then released to staff member I (Nursing Assistant/CNA and family member). Review of Resident #101's facility MDS dated [DATE], revealed a BIMS (cognitive assessment tool) of 5, which indicated he was severely cognitively impaired. Review of the facility nursing Admission Data dated [DATE], revealed the resident was assessed to be withdrawn, restless and anxious. Review of Resident #101's facility Mentally Incapacitated record (declaring the resident to be cognitively incapable of making his own decisions), had one physician signature dated [DATE] (prior to his elopement on [DATE]) and the other physician signature was dated [DATE]. The facility had identified on [DATE] that Resident #101 was not capable of making his own decisions, two physician signatures are required on the Mentally Incapacitated record. Review of the residents facility's Risk of Elopement/Wandering assessment dated [DATE] (prior to the residents elopement), revealed he had a pattern of wandering behavior, eloped while living at home prior to admission and his family had voiced concerns that he may have wandering tendencies and stated Resident at risk for elopement/wandering. Upon admission the resident was placed on the locked unit (secured unit) and staff were made aware that he was a wander risk. Review of the residents facility initial care plan regarding his behaviors and cognition dated [DATE], stated Res (Resident #101) was admitted from the community after he was involved with APS (Adult Protective Service), (Resident #101) was not able to answer what his address was, only parts, he was not able to count out money, he did not know the date. (Resident #101) has been found wandering and getting lost in (city in Michigan) and (city in Michigan), both about ,[DATE] miles away from his house. During the week of [DATE] (Resident #101) was found wandering at night in the middle of M-57 by the police and brought home. APS felt (Resident #101) was a danger to himself and others with the wandering and getting lost. Review of the residents facility Elopement care plan dated [DATE] (prior to [DATE]), stated Res (Resident #101) is at risk for elopement secondary to cognition impairments, independently ambulatory and hx (history) of multiple elopements from home and from (staff member I, CNA and family member) house. Goal: Staff will minimize the risk for elopement and injury. Review of the facility Incident Report dated [DATE] and investigation (un-dated), revealed on [DATE] at 9:30 a.m., staff member J (Charge Nurse, RN) received a phone call from staff member C (Nursing Assistant/CNA, who was not working at the facility at the time, on [DATE]) saying she had just passed a man that looked like Resident #101 walking alone on M-57 and asked if the resident was in the facility. Upon searching the facility and premises, it was discovered that Resident #101 was missing. The last time staff had observed the resident was at 8:00 a.m., in the main dining room. Staff member H (CNA) was instructed to go find the resident and she found him walking alone, unsupervised on M-57 and returned him to the facility. The resident said he was looking for his daughter. The resident was put on the locked unit and assessed by staff. The resident was wearing a wander guard when he eloped out of the main dining room exit door, which did not have a wander guard alarm system or any type of alarm on the door on [DATE]. Review of the physician order [REDACTED]. Review of facility nurses note's dated [DATE] at 9:30 a.m., stated Received phone call from an employee (staff member H, Nursing Assistant/CNA) that one of the residents (was) walking down M-57. We then searched facility. Res. (Resident #101) wasn't in the building. We sent (staff member C, CNA) a CNA and Res (Resident #101) returned at 10:00 a.m. Review of facility Social Service note's dated [DATE] at 5:50 p.m., stated Regarding elopement this a.m. this nurse spoke to resident about leaving the facility unaccompanied Res states if I get a chance, I will do it again, he was looking for his daughter and also reports that he will let you know when he gets ready to go again, expresses concern about his dogs, reassured that friend is taking care of animals. Observation and interview was done on [DATE] at 1:48 p.m., with the alarm company Technician 1. Technician #1 was installing a wander guard alarm system to the main dining room's exit door. During an interview done on [DATE] at 1:48 p.m., Technician 1 stated no there was no wander guard alarm (on the main dining room door), I am installing one now (a total of 9 days after the resident had eloped). Observation of the main dining room exit door (done on [DATE] at 1:48 p.m.) did revealed there was a key pad alarm connected to the door itself with a string and per interview done on [DATE] at 1:49 p.m., the Administrator said she had bought the key pad alarm after Resident #101 had eloped from the facility (on [DATE]) and put it on the exit door on Monday ([DATE]) at 8:00 a.m. The Administrator said prior to Monday ([DATE]), there was no alarm at all on the main dining room exit door (leading to the courtyard and gate #1). Observation of the path the resident took on [DATE] after eloping from the facility was done on [DATE] at 1:50 p.m., accompanied by the Administrator and staff member B (Director of Maintenance). Resident #101 walked approximately 3 miles in total. He went out the un-alarmed main dining room exit door, through the courtyard gate (gate #1), into the uneven parking lot behind the facility, down a grassy incline of about 3 feet, across the edge of a farmer's field directly onto the two lane country road for approximately ½ a mile then onto M-57. M-57 was a two lane, 55 mile per hour very busy road which had ditches on both that were approximately 10 feet deep which lead to an overpass and a major highway. Resident #101 had crossed over a bridge (on M-57) with water and large rocks underneath it and continued walking until he was picked up by facility staff and returned to the facility on [DATE] at 10:00 a.m. An interview was done on [DATE] at 9:25 a.m., with staff member H (Nursing Assistant/CNA). Staff member H stated (a family member) and I were on our way home around 9:30 a.m. (on Sunday, [DATE]) driving on M-57. I looked up and noticed someone walking and I thought it could have been (Resident #101). I knew he had a history of [REDACTED]. I called the facility and asked if (Resident #101) was there. I saw him past Bear Creek (a bridge covering a creek with water and rocks) and they (the facility) sent an Aide (staff member C, CNA) out to check. An interview was done on [DATE] at 2:30 p.m., with staff member C (CNA). Staff member C stated (staff member D, Charge Nurse, RN) said she got a call from (staff member H, CNA) that she saw a gentleman that resembled (Resident #101) walking on M-57, so we (staff) went out with (staff member J, Charge Nurse, RN) to check the patio area (directly outside of the main dining room exit door, the courtyard were the resident eloped through the gate from), we couldn't find him. Staff member C said facility staff then did a resident count and they were unable to locate Resident #101. Staff member C then asked the charge nurse if she wanted her to go look for the resident with her car and stated, I went to look for him (the resident), east on M-57, I seen him walking on the right hand side of the road, just past (road), by a bridge. He (the resident) had a cap on and was caring a tan coat, he had on a red checkerboard shirt, he was walking on the white line (the white line on the right hand side of the road, at the edge of the road where traffic was). He said he was on his way to (staff member I/Family Members house), he didn't know who I was. He had a wander guard (elopement alarm) on his right ankle that day (on [DATE]), but the main dining room exit door did not have a wander guard alarm, the others did. Review of staff member C's (CNA) written statement dated [DATE], revealed she saw Resident last (on [DATE]) in the main dining room at 8:00 a.m., before he eloped from the dining room exit door. An interview was done on [DATE] at 10:35 a.m., with staff member E (CNA). Staff member E said that she was laying residents down after breakfast on [DATE] and could not recall the last time she Resident #101 in the facility. Staff member E stated, It was hectic that day, I had 10 (assigned to 10 residents), most were 2 person transfers or Hoyer's (mechanical lift used). An interview was done on [DATE] at 11:50 a.m., with staff member D (Charge Nurse, RN). Staff member D stated there was never any alarm on that door (regarding the main dining room exit door). I was back in the unit (the locked unit), staff could not find him (the resident on [DATE] when he eloped), we (staff) looked and didn't find him. An interview was done on [DATE] at 9:25 a.m., with staff member J (Charge Nurse, RN). Staff member J the last time I saw him (the resident, on [DATE]) was in the main dining room at 7:30 a.m. at a table with his hat and coat on, he always wears his hat and coat. Around 9:30 a.m., (staff member D (Charge Nurse) came out and said one CNA called and asked us if he (the resident) was still a resident. We looked in the facility everywhere. (Staff member C, CNA) said she'd go get him, I called (the Administrator). The main dining room door didn't have a alarm, we never had anyone attempt to go out the door to leave, if the door would have had an alarm on it, we would of heard it. An interview was done on [DATE] at 11:30 a.m., with the Director of Nursing/DON. The DON said the last time staff saw the resident on [DATE] was at 8:00 a.m. and there was no alarm on the main dining room exit door because it was handy cap assessable and no one ever intentionally tried to leave the premises. An interview was done on [DATE] at 8:20 a.m., with staff member A (MDS Nurse, LPN). Staff member A stated I did the elopement care plan upon admission, he (Resident #101) was put in the Sunshine Unit (locked unit) because of his elopement risk, he had a history of [REDACTED]. An interview was done on [DATE] at 8:40 a.m., with staff member F (Social Service). Staff member F said the resident had a history of [REDACTED]. Staff member F stated he (the resident) had a BIMS of 5, which is severely cognitively impaired with a [DIAGNOSES REDACTED]. An interview was done on [DATE] at 9:50 a.m., with staff member I (CNA and Family Member of Resident #101). Staff member I stated he (Resident #101) is demented, he did get lost walking on M-57 a couple or more times before he was admitted , I did inform the facility. He (the resident) told me he took the grass part (when he eloped on [DATE], walking alongside a farmer's field). He (the resident) was doing ok (in the locked unit), then he was hugging and kissing female residents (while in the locked unit), there was a complaint. The DON (Director of Nursing) talked to me to try to bring him to the main unit (non-locked unit) to see how he would do. Review of the Social Service note dated [DATE] at 1:00 p.m., stated Res (Resident #101) approaching other female residents and will hug, kiss foreheads and tell them he loves them. Female res. (residents) also cognitively impaired and reciprocate interaction, spoke to DPOA (responsible party/family member, staff member I) and transferred to Rm (room # given). An interview was done on [DATE] at 10:05 a.m., with Resident #101, accompanied by staff member I (CNA and Family Member) in the facility's locked unit. Resident #101 stated I walked by a bunch of people, it was easy, they didn't say nothing to me. I didn't eat no breakfast, I was ready to travel, I had a coat and hat on. I opened that gate (gate #1 in the courtyard outside), walked just past them, I was fast. I waited for them (staff) to be busy, I planned it. I didn't have my inhaler. Review of Resident #101 ' s Medication Administration Record (MAR) dated ,[DATE] and physician order [REDACTED]. Review of the residents facility Allergy Asthma clinics note ' s dated [DATE], stated (Resident #101) comes in to day with complaints of asthma. (Resident #101) has had asthma since he was a child and uses ProAir (medication for asthma for ease of breathing) twice daily if he is outside, and occasionally if he feels that he needs it. Review of the facility Elopement Policy and Procedure dated [DATE], stated that the facility would take measures to prevent residents from eloping from the building, the whereabouts of each resident will be observed by the staff person assigned to care for the resident. Review of the facility Wander Guard policy dated [DATE], stated all residents with wander guards are to be monitored closely. The immediate jeopardy was abated on [DATE], based on confirmation during observation, interviews and record review conducted on [DATE] at 4:00 p.m. that the facility had implemented the following to remove the immediate jeopardy. 1. On [DATE] when notified that Resident #101 was missing, the facility searched the building and premises, 7 of 8 residents at risk for elopement were accounted for and it was confirmed Resident #101 was missing (Resident #101 was the 8 th facility resident assessed to be at risk of elopement). 2. On [DATE] at 9:47 a.m., staff notified the Administrator of Resident #101's elopement. 3. On [DATE] at 9:50 a.m., staff member C (Nursing Assistant/CNA) was sent to look for Resident #101. 4. On [DATE] at 10:00 a.m., Resident #101 was returned to the facility, assessed by nursing with no injuries found and was transferred to the locked unit. 5. On [DATE], after Resident #101 eloped from the facility, staff monitored the main dining room exit door leading to the courtyard and no facility resident was allowed into the courtyard without staff supervision. 6. On [DATE] at 10:15 a.m., the resident's family member (staff member I, CNA) was notified of his elopement. 7. On [DATE] at 10:20 a.m., the resident's primary physician was notified of his elopement and assessment findings, with no new orders given. 8. On [DATE] at 10:30 a.m., the Administrator was notified of the resident's return to the facility and of being put on the locked unit. 9. On [DATE] at 5:50 p.m., the Director of Nursing/DON interviewed the resident to determine his well-being, recognition of events and probability for recurrence. 10. On [DATE] at 8:00 a.m., maintenance installed a key pad door alarm to the main dining rooms exit door leading to the courtyard. 11. On [DATE] at 8:30 a.m., the Administrator conducted an interview with the resident to determine his well-being. 12. On [DATE] Resident #101's elopement care plan was reviewed and up-dated with changes made to include the discontinuation of his wander guard and being placed in the locked unit. 13. On [DATE] at 2:00 p.m., Social Service conducted an interview with the resident to determine his well-being and continued to tract his behaviors and document them in the facility Mood and Behavior Log per policy. 14. On [DATE], an alarm company was contacted to install a wander guard alarm system to the main dining room exit door leading to the courtyard. 15. On [DATE], an elopement risk assessment audit was completed for all facility residents. All residents continued to be assessed for elopement upon admission, quarterly and per need by the MDS Nurse. 16. On [DATE], all residents assessed to be at risk for elopement (a total of 8, including Resident #101) care plans were reviewed and up-dated as needed by Social Service. 17. On [DATE], maintenance installed alarms on all windows and exit doors in the locked unit where Resident #101 was. 18. On [DATE], a brightly colored binder consisting of a brief profile and picture was created by the DON for residents determined to be at risk for elopement and placed at the nurse's station (the facility had one nurses station). 19. On [DATE], the alarm company installed a wander guard alarm system to the main dining room exit door. 20. As of [DATE], 70 employees (77%) had been in serviced on all changes and up-dates by the DON; the remaining 21 employees will be in serviced prior to their next shift by the in service coordinator. 21. Maintenance will continue to ensure proper functioning of all wander guard doors weekly and record it in the log book per facility policy; wander guard doors were all tested and found to be in working order by Maintenance on [DATE]. 22. Charge Nurses will continue to use the Code Alert transmitter tester to check the function of all resident wander guards daily and record it in the Medication Administration Records per facility policy. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern, and severity of no actual harm with the potential for more than minimum harm pending completion of in service training by all staff not yet in serviced and the facility's ability to sustain compliance as verified by the State Agency. It was further confirmed by this surveyor, during observations made on [DATE] (between 10:17 a.m. and 10:23 a.m.), that all 10 facility exit doors alarm systems were in proper functioning condition. Observations of the two residents that fitted with wander guards (sampled Residents #105 and #106) during the survey ([DATE] to [DATE]) was made on [DATE], at 10:25 a.m., confirmed Resident #105 had his wander guard on his left ankle and in working condition and at 10:28 a.m., confirmed Resident #106 had his wander guard on his right wrist and in working condition. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION IN ACCORDANCE TO THE CARE PLAN TO PREVENT A FALL WITH FRACTURE FOR 1 RESIDENT (#1) AND 2 FALLS WITHOUT INJURY FOR 1 RESIDENT (#6) OUT OF 3 RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 14 RESIDENTS RESULTING IN A FRACTURED LEFT DISTAL FEMUR (BONE ABOVE THE KNEE) FOR RESIDENT #1 AND 2 PREVENTABLE FALLS FOR RESIDENT #6. FINDINGS INCLUDE: BASED ON THE ADMISSION FACE SHEET, DATED 9/22/12, THE HOSPITAL DISCHARGE SUMMARY, DATED 8/10/12 AND THE MINIMUM DATA SET ASSESSMENTS (MDS), dated [DATE] AND 8/16/12, RESIDENT #1 WAS AN ALERT AND ORIENTED [AGE] year OLD FEMALE WHOSE [DIAGNOSES REDACTED]. THE MDS, dated [DATE], REFLECTED RESIDENT #1 WAS DEPENDENT ON STAFF FOR ALL CARE EXCEPT EATING AND REQUIRED EXTENSIVE ASSIST OF 2 STAFF FOR TRANSFERS. THE "FALL RISK ASSESSMENT", DATED 6/8/12, REFLECTED HER SCORE OF 9 WITH A SCORE OF 10 REPRESENTING A HIGH RISK FOR FALLS. THE FACILITY "ACCIDENT/INCIDENT REPORT", DATED 7/30/12 AT 6:00 PM, REFLECTED RESIDENT #1 STOOD UP TO TRANSFER TO THE COMMODE FROM THE WHEELCHAIR IN HER BATHROOM WHEN HER LEGS GAVE OUT AND SHE WAS LOWERED TO THE FLOOR BY NURSING AIDE "H". RESIDENT #1 HAD LEFT LEG PAIN AFTER BEING LOWERED TO THE FLOOR. AN XRAY OF THE LEFT HIP ON 7/30/12 WAS NEGATIVE FOR A FRACTURE. BASED ON THE NURSING NOTES DATED 7/31/12 AT 6:15 PM AND 8/1/12 AT 7:30 AM, 12:00 PM AND 11:00 PM, RESIDENT #1 CONTINUED TO COMPLAIN OF LEFT HIP PAIN. A SECOND XRAY OF THE LEFT HIP AND PELVIS WAS OBTAINED AT 7:00 PM. THE XRAY RESULT WAS REPORTED AS NEGATIVE FOR FRACTURES IN THE NURSING NOTES ON 8/2/12 AT 4:00 AM. THE NURSING NOTES FROM 8/3/12 AT 8:00 AM-8/4/12 AT 2:00 PM REFLECTED CONTINUED LEFT LEG PAIN AND AN INCREASED USE OF THE NARCOTIC PAIN MEDICATION VICODIN. THE ROUTINE PAIN MEDICATION VICODIN WAS INCREASED TO TWICE DAILY ON 8/4/12 ACCORDING TO THE PHYSICIAN ORDERS. ON 8/4/12 AT 9:15 PM THE NURSING NOTES REFLECTED CONTINUED LEFT LEG PAIN AND THE SOFT TISSUE BETWEEN THE HIP AND THE KNEE WAS SWOLLEN AND HARD (INDICATING INJURY). AN XRAY OF THE LEFT FEMUR (THE LARGE BONE BETWEEN THE KNEE AND THE HIP) WAS OBTAINED AND THE REPORT FROM THE SAME DATE REFLECTED "...A MILDLY DISPLACED FRACTURE OF DISTAL (END OF THE BONE TOWARDS THE KNEE) SHAFT OF FEMUR..." RESIDENT #1 WAS TRANSFERRED TO THE HOSPITAL ABOUT 1:30 AM ON 8/5/12 ACCORDING TO THE NURSING NOTES. BASED ON THE HOSPITAL DISCHARGE SUMMARY, DATED 8/10/12, THE FRACTURE WAS SURGICALLY REPAIRED ON 8/7/12 AND THE RESIDENT RETURNED to the facility on [DATE]. THE "CENA (COMPETENCY EVALUATED NURSE AIDE) INCIDENT/ACCIDENT REPORT", DATED 7/30/12, REFLECTED "RESIDENT ASKED TO GO TO BATHROOM AFTER SUPPER SO I TOOK HER INTO BATHROOM PUT GAIT BELT ON AND SHE STOOD UP AT BAR (GRAB BAR ON THE WALL). WHILE I WAS TRYING TO PUT COMMODE UNDER HER, HER LEGS GAVE OUT SO I TRIED HANGING ON BUT COULDN'T KEEP HER UP SO I LOWERED HER TO THE FLOOR..." THE "FALLS MANAGEMENT INVESTIGATION-POST FALL TOOL" , DATED 7/31/12 AND SIGNED BY REGISTERED NURSE (RN) UNIT MANAGER "F", ITEM 13 "NEW SAFETY INTERVENTIONS" REFLECTED "RE-EDUCATION OF STAFF FOR 2 ASSIST FOR ALL T/FS (TRANSFERS) WITH GAIT BELT, RETRAINING FOR STAFF PERSON, COUNSELING MEMO, REFERRED TO PT (PHYSICAL THERAPY)/OT (OCCUPATIONAL THERAPY) FOR TRANSFERS EVALUATION". THE CARE PLAN FOR "...RISK FOR DECLINES IN JOINT MOBILITY AND TRANSFERS...", DATED 1/20/12 AND IN USE AT THE TIME OF THE FALL, REFLECTED THE APPROACH "...RESIDENT WILL BR (BEAR) WT (WEIGHT) ON BIL (BILATERAL) LE (LOWER EXTREMITIES) FOR TRANSFERS TAKING A FEW STEP AS ABLE WITH 2 ASSIST AND T (TRANSFER/GAIT)-BELT." THE "EAST RESIDENT KARDEX", DATED 12/2/11, AND IN USE AT THE TIME OF THE FALL, USED BY THE NURSING AIDES WHEN GIVING CARE REFLECTED UNDER THE "TRANSFER" COLUMN THAT RESIDENT #1 WAS TO HAVE "2 ASSIST WITH T-BELT, STAND AND PIVOT" DURING TRANSFERS. THE FACILITY "TRANSFERRING & REPOSITIONING POLICY", DATED 10/1/03 AND REVIEWED AND REVISED 8/23/12, ITEM 2 REFLECTED "ALL CENAS AND LICENSE (SIC) STAFF ARE TO OBTAIN AMOUNT OF ASSISTANCE NEEDED FOR PROPER TRANSFER OF RESIDENT BEFORE TRANSFER IS INITIATED". ON 9/13/12 AT 9:40 AM RN UNIT MANAGER "F" STATED AT THE TIME OF THE FALL ON 7/30/12 NURSING AIDE "H" HAD RESIDENT #1 STAND AT THE GRAB BAR FACING THE WALL IN THE BATHROOM WHILE THE COMMODE WAS BEING POSITIONED FOR USE. WHEN THE RESIDENT'S LEGS GAVE OUT THE NURSING AIDE WAS BEHIND THE RESIDENT AND LOWERED HER TO THE FLOOR. RESIDENT #1'S LEGS WERE BENT AT THE KNEES AS SHE WENT TO THE FLOOR. RN UNIT MANAGER "F" STATED THE RESIDENT WAS TO HAVE 2 PERSONS ASSISTING HER WITH TRANSFERS AND THE NURSING AIDE DID NOT FOLLOW THE RESIDENT'S CARE PLAN. BASED ON THE MDS ASSESSMENT, DATED 6/8/12, RESIDENT #1 WAS CONTINENT OF BOWEL AND OCCASIONALLY INCONTINENT OF BLADDER, REQUIRED EXTENSIVE ASSIST OF 2 STAFF FOR TRANSFERS, LIMITED ASSIST OF 1 PERSON FOR LOCOMOTION IN HER ROOM AND WAS INDEPENDENT WITH SET UP FOR LOCOMOTION OUT OF HER ROOM AND EATING. AFTER THE FALL THE MDS ASSESSMENT, DATED 8/16/12, REFLECTED RESIDENT #1 WAS ALWAYS INCONTINENT OF BOWEL AND BLADDER, TOTALLY DEPENDENT FOR TRANSFERS WITH 2 STAFF ASSIST AND DEPENDENT FOR LOCOMOTION WITH 1 STAFF ASSIST. IN ADDITION, RESIDENT #1 DID NOT AMBULATE IN HER ROOM AND REQUIRED LIMITED ASSISTANCE OF 1 STAFF FOR EATING. ON 9/13/12 AT 9:50 AM RESIDENT #1 WAS OBSERVED DURING A TRANSFER FROM THE BED TO HER WHEELCHAIR IN HER ROOM. TWO NURSING AIDES LIFTED RESIDENT #1 FROM THE BED USING A MECHANICAL LIFT WITH THE RESIDENT IN A CLOTH SLING. RESIDENT #1 STATED THAT SHE "HATED" THE LIFT BECAUSE IT CAUSED PAIN IN HER LEFT LEG. RESIDENT #1 STATED HER LEFT LEG HURT DURING THE TRANSFER EVEN THOUGH THE LEG WAS SUPPORTED BY ONE OF THE NURSING AIDES DURING THE TRANSFER. RESIDENT #1 DECLINED TO BE FURTHER INTERVIEWED DURING THE SURVEY. ON 9/13/12 AT 9:40 AM RN UNIT MANAGER "F" STATED TRANSFER SAFETY HAD BEEN REVIEWED AT THE 5/3/12 STAFF MEETING AND THE "EMPLOYEE IN-SERVICE" SHEET, DATED 5/2012, REFLECTED NURSING AIDE "H" HAD SIGNED THE FORM INDICATING RECEIPT OF THE "MAKE-UP PACKET". THE "GENERAL STAFF ORIENTATION" FORM, DATED 4/11/12 AND SIGNED BY RN UNIT MANAGER "F", REFLECTED NURSING AIDE "H" HAD DEMONSTRATED COMPETENCY WITH "FALLS PREVENTION AND FALLS ID PROGRAM". RESIDENT #1 SUSTAINED A FRACTURE OF THE LEFT FEMUR DURING A TRANSFER WHEN THE CARE PLAN FOR A 2 PERSON ASSIST DURING TRANSFERS WAS NOT FOLLOWED. RESIDENT #1 DEMONSTRATED A DECLINE IN HER TOILETING, TRANSFER, LOCOMOTION AND EATING INDEPENDENCE AFTER THE FRACTURE. BASED ON THE MINIMUM DATA SET ASSESSMENT, DATED 8/15/12, AND THE "PATIENT ENCOUNTER DETAILS" (FOR OPTOMETRY), DATED 7/5/11, RESIDENT #6 WAS A [AGE] year OLD MODERATELY COGNITIVELY IMPAIRED (BRIEF INTERVIEW FOR MENTAL STATUS SCORE OF 11 OUT OF 15) FEMALE WHOSE [DIAGNOSES REDACTED]. THE MDS ASSESSMENTS, DATED 5/17/12 WITH THE LAST DATE OF DATA COLLECTION ON 5/10/12 AND 8/15/12, REFLECTED THE RESIDENT REQUIRED EXTENSIVE ASSIST OF 1 PERSON FOR TRANSFERS. THE "ACCIDENT/INCIDENT REPORT", DATED 5/9/12 AT 7:15 PM, REFLECTED RESIDENT #6 WAS BEING TRANSFERRED FROM THE RECLINER TO THE WHEELCHAIR IN HER ROOM WHEN THE RESIDENT BEGAN TO SIT DOWN BEFORE SHE REACHED THE WHEELCHAIR AND WAS LOWERED TO THE FLOOR BY NURSING AIDE "I". THE "FALLS MANAGEMENT INVESTIGATION-POST FALL TOOL", DATED 5/10/12 AND SIGNED BY RN UNIT MANAGER "F", ITEM 13 "NEW SAFETY INTERVENTIONS" REFLECTED "RE-EDUCATION OF STAFF TO USE 2 ASSIST AND GAIT BELT". THE "NURSING TO THERAPY COMMUNICATION FORM", DATED 5/15/12 AND SIGNED BY THE PHYSICAL THERAPY ASSISTANT, REFLECTED THE RECOMMENDATION TO "RE-EDUCATION WITH T/F'S (TRANSFERS) TO STAFF". THE CARE PLAN RELATED TO REHABILITATION AND COMPLETED BY THE RESTORATIVE NURSING STAFF, DATED 6/6/10 AND REVIEWED ON 2/17/12 REFLECTED THE GOAL OF "RESIDENT WILL COMPLETE SIT TO STAND WITH 2 ASSIST AND DEVICES..." THE APPROACHES ON THE SAME CARE PLAN REFLECTED "...2 PERSON ASSIST WITH T (TRANSFER)-BELT..." ON 9/13/12 AT 9:40 AM RN UNIT MANAGER "F" STATED THAT RESIDENT #6 REQUIRED THE ASSISTANCE OF 2 STAFF FOR TRANSFERS PRIOR TO THE 5/9/12 FALL. THE "ACCIDENT/INCIDENT REPORT", DATED 7/22/12 AT 10:15 PM, REFLECTED RESIDENT #6 WAS OBSERVED LAYING ON HER LEFT SIDE ON THE FLOOR OF THE EAST HALLWAY. THE "INVESTIGATION FINDINGS" REPORT OF THE SAME DATE REFLECTED "CNA (CERTIFIED NURSE AIDE "J") WAS PULLING RES (RESIDENT) BACKWARD IN WHEEL CHAIR WITH NO FOOT PEDALS. CNA STATES RES WAS LEANING FORWARD. CNA GRABBED RES. SHOULDERS TO STOP HER FROM FALLING. RES CONTINUED TO FALL ONTO HER KNEES AND LANDED ON LEFT SIDE HEAD FACING TOWARD UNIT DOORS FEET TOWARD NURSES STATION..." THE "FALLS MANAGEMENT INVESTIGATION-POST FALL TOOL", DATED 7/23/12 AND SIGNED BY RN UNIT MANAGER "F", ITEM 13 "NEW SAFETY INTERVENTIONS" REFLECTED "MAGNET STRING ALARM, RULE OUT MEDICAL ORTHO (ORTHOSTATIC) BP (BLOOD PRESSURE) X (TIMES) 3 DAYS." THE "NURSING TO THERAPY COMMUNICATION FORM", DATED 7/25/12 AND SIGNED BY THE PHYSICAL THERAPY ASSISTANT, REFLECTED THE RECOMMENDATION FOR "FOOT PEDALS AND STRING ALARM". THE CARE PLAN RELATED TO REHABILITATION AND COMPLETED BY THE RESTORATIVE NURSING STAFF, DATED 6/6/10 AND REVIEWED ON 5/16/12 REFLECTED NO CHANGES IN THE RESIDENT'S TRANSFER STATUS. THE FACILITY "TRANSFERRING & REPOSITIONING POLICY", DATED 10/1/03 AND REVIEWED AND REVISED 8/23/12, ITEM 2 REFLECTED "ALL CENAS (COMPETENCY EVALUATED NURSE AIDE) AND LICENSE (SIC) STAFF ARE TO OBTAIN AMOUNT OF ASSISTANCE NEEDED FOR PROPER TRANSFER OF RESIDENT BEFORE TRANSFER IS INITIATED". ON 9/13/12 AT 9:40 AM RN UNIT MANAGER "F" STATED THAT RESIDENT #6 SHOULD NOT HAVE BEEN PULLED BACKWARDS IN HER WHEELCHAIR AND SHOULD HAVE BEEN USING FOOT PEDALS ON THE WHEELCHAIR AS SHE WAS NOT PROPELLING HERSELF. ON 9/14/12 REVIEW OF THE "CENA COMPETENCY EVALUATION", DATED 5/24/11, NURSING AIDE "I" HAD DEMONSTRATED COMPETENCY WITH RESIDENT TRANSFER TECHNIQUES. NURSING AIDE "J" HAD DEMONSTRATED COMPETENCY WITH RESIDENT TRANSFER TECHNIQUES BASED ON THE "CENA COMPETENCY EVALUATION", DATED 7/5/12. IN ADDITION, THE STAFF MEETING MINUTES, DATED 5/3/12, REFLECTED TRANSFER SAFETY HAD BEEN REVIEWED AND THE "EMPLOYEE IN-SERVICE" SHEET, DATED 5/2012, REFLECTED NURSING AIDES "I" AND "J" HAD SIGNED AS PRESENT. 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This citation pertains to MI# 434 Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive device to 1 of 3 sampled (#101) residents, resulting in resident #101 who had a bed alarm in place, was heard yelling out and found out of bed on the floor by staff, with no alarm sounding which resulted in a fracture of left hip. Findings include: Record review of the facility accident/incident report dated 2/15/11 revealed resident #101 was hollering aloud, certified nurse assistants (CNA's) responded, noted resident laying on back/side with feet towards wardrobe and head laying towards the door. Resident was noted to complain of pain to her left lower extremities (LLE) with movement. Resident was sent to local emergency room for evaluation and treatment of [REDACTED]. Record review of resident #101's falls care plan dated 12/16/10 revealed that the resident was care planned for falls and on 1/7/11 a bed alarm was added to the care plan. Record review of the facility "Assistive Devices-Policy and Procedure" (undated) revealed that CNA's are to check assistive device alarms and sensor pads prior to each use for proper function. The re-set button also functions as a battery tester. The CNA will ensure the safety of the resident and report to the charge nurse with any non-functioning assistive safety devices immediately. An interview on 3/8/11 at 9:00 AM with staff #4 revealed that she was the direct care giver for resident #101 on 2/15/11 the day the resident sustained [REDACTED].#101 "always eats breakfast at bed, her alarm went off because she sat up from being in bed, I hit the reset button on her pressure pad alarm and she sat up and ate". The resident did not get up from the bed. Staff #4 then stated that she left resident #101's room and returned to the dining room area to assist other residents eat and then cleaned up the dining room. Staff #4 revealed that she and Staff #5 had taken a male resident to the restroom and was placing the male resident back into a recliner located in the dining/activity room when she heard resident #101 screaming "help, help". Staff #4 reported entering resident #101's room and observed the resident on the floor with one shoe on and no alarm sounding. Staff #5 came to the room also, and when staff #5 leaned down to look for the second shoe she touched the bed, and the bed alarm sounded. An interview on 3/8/11 at 9:30 AM with staff #5 revealed that she heard a chilling scream from out of the hallway and that both staffs #4 and #5 took off down the hall checking rooms. Staff #5 revealed that when she got to resident #101's room there was no fall alarm sounding, and the resident had been up in the room because the bedding/linens were piled in the corner of the room and resident #101 was observed on the floor. An interview on 3/8/11 at 12:05 PM with staff #2 revealed that "Alarm didn't work, didn't go off. Staff didn't remember alarm sounding. But, when staff pushed on the sensor pad on the bed it did sound. Staff admitted not checking the alarm (after reset). It's standard of practice to check alarm with each use. Yes, resident was out of bed for a few minutes because her linens were put in the corner (of room). The resident sleeps in her shoes, kicked one off and must have been looking for the shoe in the linens and fell ". Observation on 3/8/11 at 8:40 AM of resident #101 revealed an elderly woman in a wheelchair with an alarm intact to her chair. #