Every finding on record at Beaconshire Nursing Centre

Based on observation, interview, and record review the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings include: On 03/31/2026 at 9:45 AM interview with Maintenance Director (MD) 'C' regarding the facility Water Management Program (WMP). MD 'C' said the administrator will have any program materials. When asked about implementing the WMP/legionella prevention he said he is new in this role since January 2026 and is still learning the job and the building systems. MD 'C' said has not attended any Water Management team (WMT) meetings, did not indicate any WMP controls currently in place, and there is not any routine fixture flushing or checking disinfectant residual. MD 'C' indicated being interested in learning more on the WMP guidance. MD 'C' said some of the water piping was recently replaced and a new boiler for the heating system was installed just before he started. When asked about the water heater set point, MD 'C' said he's not sure, he does not do regular monitoring of water temps. When asked about hot water distribution/resident safe hot water temperature, MD 'C' said 75F. On 03/31/2026 at 9:51 AM interview with the Nursing Home Administrator (NHA) regarding the WMP. When asked for any program documentation it wasn't located at the time but said that she would find electronic documents and would put into the file sharing. NHA said she has been in current role about 6 months. When asked about expectations related to WMP, she indicated that some flushing of unused fixtures should happen. She said there are unused hoppers, the salon is not used but has sinks, and (2) bathtubs in shared resident bathrooms are not used. When asked about WMT she said with the new MD in place, they are re-implementing WMT meetings. She was told that the WMT was meeting with the previous administrator but has not been able to locate any records/documentation/minutes. On 04/01/2026 at 7:30 AM interview with the Infection Preventionist (IP) 'G' regarding any WMT involvement. IP 'G' said they have had no legionella cases in her time here and she has no involvement with the WMT. IP 'G' suggested to ask the Director of Nursing (DON) or the MD and said, that's a maintenance thing. On 04/01/2026 at 8:48 AM observed the boiler gauge partially filled with water and condensation collected on the internal surface in the boiler room. An interview with Maintenance Director (MD) C at this time found they were not sure what the boiler is set to. A gauge on the hot water tank read 120 degrees F. On 04/01/2026 at 9:02 AM observed a sink fixture with the hot water faucet nonfunctional in the first-floor south clean linen room, indicating possible stagnant water. On 04/01/2026 at 9:07 AM observed an inoperable drinking fountain on the first-floor south hall, indicating a possible stagnant water line. On 04/01/2026 at 9:28 AM observed the sink hot water faucet nonfunctional and the cold water releasing a trickle in the first-floor north soiled linen room. On 04/01/2026 at 9:32 AM observed a hopper with no water in the bowl indicating infrequent use of the fixture in the first-floor north soiled linen room. A straw was observed in the bowl of the hopper, and the hot water faucet was nonfunctional. When the cold-water faucet was turned on, brown water ran for a few seconds before running clear. On 04/01/2026 at 9:54 AM observed a brown stained ring in the hopper bowl in the second-floor north clean linen room. The flush apparatus was observed to be nonfunctional. On 04/01/2026 at 9:59 AM observed a nonfunctional bathtub in the second-floor south bathroom, indicating possible stagnant water. On 04/01/2026 at 10:07 AM observed nonfunctional water fountain in the second-floor south hall, indicating possible stagnant water. On 04/01/2026 at 10:16 AM observed a hopper bowl with a shallow pool of brown murky water in the second- floor soiled linen room. The spray hose was observed submerged in the hopper bowl water. There were no handles attached to the fixture for cold and hot water. On 4/1/2026 at 10:30 AM interview with Corporate Operations Officer (COO) F to inquire about any additional WMP documentation. COO 'F' said additional materials would be provided for review. On 04/01/2026 at 11:55 AM observed the hot and cold water faucets nonfunctional at the sink in the second-floor south soiled linen room. The adjacent sink was observed with an uncapped pipe leaving a small, exposed opening to the pipe coming from the wall. On 04/01/2026 at 1:57 PM an interview with Director of Nursing (DON) was conducted regarding water management. DON indicated the team meets periodically as part of interdisciplinary team (IDT) meetings, and the old administrator was good with having the team meet. DON indicated a consultant came to the facility last fall to look at water management. DON was asked for additional documentation related to the consultant. When asked last time there was a formal meeting, DON indicated it was six months ago they had a formal meeting. On 04/01/2026 at 2:54 PM an interview with Maintenance Aid D and Maintenance Director C found they were unsure if the sink fixtures and drinking fountains are shut off at the valve or the main water line and indicated they are still learning the building. When asked about flushing any fixtures, MD C stated they were not flushing fixtures at this time. Record review of the facility provided binder entitled Beaconshire Water Management Program includes a policy entitled Water Management Policy this policy includes, Designated Water Management Team Environmental Services Director Dietary/Kitchen Director Director of Nursing Nursing Infection Control Manager Housekeeper. Potential Hazardous Areas Kitchen Laundry Boiler- (Located in the Basement) Heaters Ice Machine Room Dishwasher- Kitchen Shower Rooms Shower Heads & Aerators Empty resident rooms or plumbing areas not in use. All potentially hazardous areas will be monitored by the DWMT. The policy also includes inspection areas and procedures, Weekly Inspections: The water softener inspection will include a visual inspection of the brine tank for any corrosion, proper amount of salt, and that the softeners are working properly. The main water connection, and fire suppression system will have a visual inspection to check for any leaks or stagnant water. Water heaters, and boiler inspection will include a temperature check. They are programed to run above 125 degrees to decrease the risk of legionella. The salon will have a weekly inspection. Water will run for over a minute. Under the sinks will be checked for any leaks or stagnant water sources. The spa tubs will all be run and go through a thorough disinfectant each use. If the spa tubs are not being used, we will run disinfectant through all the lines. Lines will be checked for any leaks or stagnant water. Empty resident rooms or areas not used will have a weekly inspection. Sinks will run for over a minute, toilets will be flushed, and showers will run for over a minute. Monthly Inspections: The reverse osmosis system will have the water flow checked monthly, shutoffs exercised, and check drain to sewer for proper flow. The filters will be changed out twice a year or sooner if needed. Quarterly Inspections: The ice machine will be cleaned quarterly. If there is any build up or concern the water line going into the system will be removed and tested. All shower heads and sink aerators will be removed, disinfected, and reapplied. Record review of the facility provided binder entitled Beaconshire Water Management Program includes a document titled Legionella Surveillance with a date revised/revised date of 1/19/2026. The binder also contains legionella test results dated 11-Sep-2024, no 2025 results were recorded in the binder. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Eliminate dead legs, which are sections of no- or low-water flow.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises including plumbing, handrails, and bathroom surfaces. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for all residents. Findings Include: On 04/01/2026 at 8:26 AM observed a four-inch pipe running along the ceiling between two dryers in the laundry room. Insulation around the pipe was observed peeling and with loose fibers exposed. An interview with Housekeeping Manager (HM) E at this time found they were unsure of what the pipe was and speculated it was an old water line. On 04/01/2026 at 8:32 AM observed a bucket beneath the handsink drain line in the laundry room. A pool of water was observed in the bucket. HM E indicated they would let maintenance know about the leak. On 04/01/2026 at 8:34 AM observed black residue along the wall adjacent to the shelves in the chemical storage closet in the laundry room. Further observation of the closet found several missing floor tiles leaving the floor mastic visible. On 04/01/2026 at 8:58 AM an interview with Maintenance Director (MD) C regarding the pipe that is above the dryers in the laundry room found they were unaware of the pipe or what it was used for. On 04/01/2026 beginning at 9:01 AM a facility tour was conducted with HM E. On 04/01/2026 at 9:02 AM observed a handwashing sink with no hot water in the 1st floor south clean linen room. On 04/01/2026 at 9:09 AM observed the ice machine drain line going directly into a pump with no air gap in the 1st floor nourishment room. On 04/01/2026 at 9:22 AM observed wrappers and paper on the floor of the 1st floor south bathroom. HM E indicated housekeeping has not come up yet. An interview at this time with HM E found they have staff do spot checks where the staff will walk around and see what needs to be done immediately during their normal cleaning schedule. Further observation found two wet washcloths and a Styrofoam cup in the bathtub. HM E indicated it is the nursing staff's job to clean up the tub area after resident care. On 04/01/2026 at 9:28 AM observed the sink hot water nonfunctional and the cold water releasing a low-pressure trickle in the 1st floor North soiled linen room. Further observation found no paper towel in the room. An interview with HM E at this time found they are in the process of ordering new paper towel dispensers now and indicated they did not have the paper towel for these dispensers. On 04/01/2026 at 9:33 AM observed that the handsink has been removed adjacent to the toilet in the 1st floor north shower room. HM E indicated they were unsure if the facility was planning to replace it. An interview with HM E at this time regarding cleaning expectations for shower rooms found that shower rooms need to be cleaned every 24 hours, during showers it is the nursing staff responsibility to clean up. Further observation found a pool of standing water on the opposite side of the drain in the shower stall and a used washcloth on the shower handrail. Tiles along the wall of the entrance to the shower stall were observed broken and missing leaving rough edges exposed. A used towel was observed on the back of the toilet seat. On 04/01/2026 at 9:39 AM observed a utility sink connected to a chemical dispensing system and the faucet left on in the 1st floor North janitor closet. This set up puts back pressure on the faucet's atmospheric vacuum breaker (AVB), which can compromise the integrity of the mechanism. There was no vented/wasting T device to relieve backpressure on the AVB. Water was observed leaking from the AVB. An interview with HM E at this time found staff leave water on normally and push the button to dispense chemicals and confirmed seeing the leaking water at the AVB.On 04/01/2026 at 9:50 AM observed a utility sink in the 2nd floor North janitor closet located across from the nurse station. Upon opening the door, a strong mildew odor was present. A layer of brown debris was observed at the base of the sink. The perimeter of the door and threshold were lined with dust. An interview with HM E indicated they did not use the sink currently. At this time a nursing staff member came over from the desk and sprayed surfaces in the closet with a bleach disinfectant product and indicated that they can smell the odor from this closet at their workstation. On 04/01/2026 at 9:54 AM observed a brown stained ring in the hopper bowl in the 2nd floor North clean linen room. Further observation found no soap or paper towel available at the handsink in this room. On 04/01/2026 at 9:59 AM observed a bathtub with the water supply shut off in the 2nd floor South bathroom. Tiles were observed missing around the toilet plumbing line leading into the wall. Further observation found a thick caulk layer around the sink with a gap in the caulk seal where the sink was pulling away from the wall. On 04/01/2026 at 10:04 AM observed wooden shelving units for equipment and supply storage in 2nd floor south supply room. Shelves were observed worn and rough to the touch. On 04/01/2026 at 10:13 AM observed a utility sink with a chemical dispensing system in place and the faucet left on in the 2nd floor south janitor closet. No wasting/vented T device present. Creating backpressure on the faucet AVB. On 04/01/2026 at 10:23 AM observed black particulate inside the tub in the 2nd floor south bathroom. When the faucet was turned on at the hand sink, a low-pressure stream was released for hot and cold water. An interview at this time with HM E indicated that residents had let a formerly employed maintenance staff know about this. It had not yet been resolved. On 04/01/2026 at 11:35 AM observed multiple handrails missing endcap sections leaving the sides open and sharp edges exposed in the 1st floor North hall. Observed miscellaneous debris placed into the openings at the missing endcaps. Also, at one handrail in this area, loose screws remained in place with the sharp ends exposed on the back side of the rail. On 04/01/2026 at 11:40 AM observed multiple handrails missing endcap sections and broken on the 2nd floor south hall. HM E stated there should be covers on the side of the handrails. On 04/01/2026 at 11:42 AM observed white debris accumulated on the underside of the shower bed in the 2nd floor south hall shower room. Dried brown residue was observed on the shower bed mat. An interview with HM E at this time found it is the nursing staffs' responsibility to wipe down and clean the shower bed. When asked about deep cleaning of shower rooms, HM E stated they do deep cleans for resident rooms but have been thinking they want to implement a deep clean schedule for the shower rooms. In the shower area, black mold-like substance observed on several tiles near the floor. When wiped with a paper towel it came off on the towel. Further observation found the air vent soiled with dust. On 04/01/2026 at 11:51 AM observed the hot water at the hand sink was nonfunctional and the cold water leaking from the handle when turned on in the 2nd floor south shower room. On 04/01/2026 at 11:52 AM an interview with nursing staff H found the shower bed is wiped down after use with a bleach wipe from the nursing station. On 04/01/2026 at 11:55 AM observed the hot and cold water faucets nonfunctional at the sink in the 2nd floor south soiled linen room. The adjacent sink was observed with an uncapped pipe where the faucet has been removed leaving an exposed rusty hole. On 04/01/2026 at 12:04 PM observed multiple handrails missing an endcap leaving the sides open in the 1st floor south hall. On 04/01/2026 at 12:06 PM observed toilet loose to mount and able to move around in the 1st floor south bathroom. Caulk along the perimeter of the toilet base was observed degraded and discolored brown. On 04/01/2026 at 1:40 PM observed a pull cord box attached to the wall next to the toilet with no pull cord in the 1st floor south shower room. On 04/01/2026 at 2:03 PM an interview with Corporate Operating Officer (COO) F found they have plans to get the sink replaced in the 1st floor north shower room.On 04/01/2026 at 2:10 PM an interview with Nursing Home Administrator (NHA) found they have no policies addressing cleaning of the shower rooms.

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per Resident in multiple resident bedrooms, affecting five Resident rooms (111, 115, 119, 219, and 231). Findings include: Observation of the Resident rooms on 4/1/26 beginning at 11:45 AM, and review of the facility documentation revealed the following: ROOM # SQ. FT # OF BEDS # of Residents 111 157 2 2115 157 2 2119 157 2 2219 157 2 2231 159 2 2 During an interview on 4/1/26 at 12:15 PM, R8 said that their room (room [ROOM NUMBER]) was too crowded and that they felt as if there was not enough room. During an interview and observation on 4/1/26 at 1:21 PM, R43 was outside on the facility front porch. R43 said that there was not enough room in their room (room [ROOM NUMBER]). R43 complained that the position of their roommate's bed prevents R43 from opening their dresser drawer. On 4/2/26 at 8:59 AM, R43 was observed in their room sitting in a wheelchair reading a book. R43 indicated that wheelchair access to the chest of drawers was obstructed by lack of space on the window side of the bed. The current furniture placement appeared to obstruct wheelchair access to the dresser for R43. During an interview on 4/2/26 at 12:39 PM, the Nursing Home Administrator (NHA) indicated they were aware of rooms that do not meet the minimum square foot requirement. The NHA was unaware of R43's concern. The NHA indicated they will try to reconfigure the furniture in R43's room so that R43 can access the chest of drawers while sitting in the wheelchair. On 4/2/26 at 3:05 PM during the exit conference, the NHA and Director of Nursing did not offer additional information regarding this concern.

The facility failed to implement interventions for residents at-risk for unplanned weight loss for one (R2) of six residents reviewed for nutrition status. Findings include:On 3/31/2026 at approximately 10:00 AM, R2 was observed in their room in bed. R2 voiced no complaints. On 4/1/2026 at approximately 8:37 AM, R2 was observed in their room eating breakfast. On the breakfast tray there was cold cereal, grits, orange juice, and raisin toast. The meal ticket on the tray read, regular diet, thin liquids. A record review was completed and revealed that R2 originally admitted to the facility on [DATE], transferred to a local hospital on 2/6/2026, and re-admitted to the facility from the hospital on 2/11/2026. Admitting diagnoses included behavioral syndromes associated with physiological disturbances, personality disorder, psychotic disorder with delusions, depression, obesity, and hypertension. Section C of the Minimum Data Set with an Assessment Reference Date of 2/13/2026 revealed R2 scored a 10/15 on the Brief Interview for Mental Status assessment - indicative of moderate cognitive impairment. Section GG: Eating - revealed R2 needed set-up assistance with meals. A care plan focus was initiated by the Registered Dietitian (RD A) on 1/31/2026 which read, At risk for altered nutritional status - unplanned weight loss - at risk for wt. (weight) fluctuation. Labs, diet order, weight weekly x4, then monthly. R2's documented weights in the Electronic Health Record (EHR) revealed the following:3/4/2026: 199.8 lbs. (pounds)2/4/2026: 202.6 lbs.1/28/2026: 197.0 lbs.1/6/2026: 206.4 lbs. 12/5/2025: 232.2 lbs. 11/5/2025: 228.2 lbs.A nursing progress note dated 2/2/2026 documented, Writer completed a mini nourishments assessment on resident. Resident is at risk for being malnourished. A Nurse Practitioner note date 2/5/2026 revealed the following: Following for nutrition eval. Patient has variable appetite; patient deemed at risk for malnutrition and At risk for malnutrition. Education on compliance with meals, verbalized understanding. Start multivitamins, monitor weight, optimize nutrition, continue current diet, RD follows.A significant change in status dietary assessment was completed by RD A on 2/4/2026. The assessment revealed, Weight change in the last 180 days: 7.5% to 10%, On a planned weight loss program: no, and Nutritional supplements: none. On 4/2/2026, RD A was queried regarding R2's weight loss. RD A confirmed that R2 had significant weight loss in six months. When asked if R2's weight loss was planned or desirable by the resident, RD A said no. RD A confirmed that weekly weights initiated in January 2026 per the care plan were not completed. When asked if the weekly weights should have been continued upon R2's return from the hospital, RD A said yes. On 4/2/2026 at approximately 10:15 AM, the Director of Nursing (DON) was interviewed regarding R2's unplanned significant weight loss. The DON said it was their expectation that interventions be put into place to address the weight loss by the primary care provider and Registered Dietitian. In addition, the RD can assess and implement additional interventions. When queried as to why weight monitoring is an important intervention for a person with significant unplanned weight loss, the DON stated, Because it's a key indicator of health status. A policy titled, Weight Monitoring dated 3/2/2026 revealed the following: Residents with weight loss - monitor weight weekly and Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.

Based on observation, interview, and record review the facility failed to ensure a resident was assessed to self-administer medications for one (R71) of one reviewed for self-administration of medication.Findings include:On 3/31/2026 at approximately 10:40 AM, during an observation of R71's room, a single blue pill in a medication cup was observed on R71's bedside table. The pill appeared dry. R71 was not in their room at the time of the observation. R71's roommate was in their bed but did not respond to questions.At approximately 10:45 AM, LPN I was informed of the medication observed at the bedside. Upon entering R71's room, LPN I stated, That shouldn't be there. LPN I removed the medication from the room. When queried as to the cognitive status of R71, LPN I said they were confused. When asked if R71 had an assessment or physician order to self-administer medications, LPN I said they were unsure. On 3/31/2026 at approximately 11:30 AM, R71 was queried about the medication but did not respond. A record review was completed on 4/1/2026 and indicated R71 was originally admitted to the facility on [DATE] with diagnoses that included psychosis, anxiety, schizophrenia, altered mental status, and hypertension. Section C of the Minimum Data Set with an Assessment Reference Date of 2/4/2026 revealed R71 scored a 13/15 on the Brief Interview for Mental Status assessment - indicative of no cognitive impairment. A review of physician orders in the electronic medical record revealed no orders allowing for self-administration of medications. There was no evidence in the electronic medical record of an interdisciplinary team assessment for self-administration of medications, nor did the care plan address self-administration of mediations. The care plan revealed R71 presented with impaired cognition as evidenced by episodes of confusion, impaired decision making, diagnosis of avoidant personality disorder, and poor safety awareness. Further record review revealed R71 had an order dated 12/10/2025 for omeprazole oral tablet Delayed Release 20mg, which read: give 1 tablet by mouth one time a day for heartburn.On 4/1/2026 at approximately 1:45 PM, the Director of Nursing (DON) was queried regarding the medication at bedside. The DON confirmed that R71 did not have an order to self-administer medications.

Based on observation, interview, and record review, the facility failed to follow standards of practice for medication administration for one resident (R71) of one resident reviewed for medication administration.Findings include: On 3/31/2026 at approximately 10:40 AM, during an observation of R71's room, a single blue pill in a medication cup was observed on R71's bedside table. The pill appeared dry. R71 was not in their room at the time of the observation. R71's roommate was in their bed but did not respond to questions.At approximately 10:45 AM, LPN I was informed of the medication observed at the bedside. Upon entering R71's room, LPN I stated, that shouldn't be there. LPN I removed the medication from the room. When queried as to the cognitive status of R71, LPN I said they were confused. When queried as to the cognitive status of the roommate, LPN I said they were somewhat confused. When asked if R71 had an assessment or physician order to self-administer medications, LPN I said they were unsure. On 3/31/2026 at approximately 11:30 AM, R71 was queried about the medication but did not respond. A record review was completed on 4/1/2026 and indicated R71 was originally admitted to the facility on [DATE] with diagnoses that included psychosis, anxiety, schizophrenia, altered mental status, and hypertension. Section C of the Minimum Data Set with an Assessment Reference Date of 2/4/2026 revealed R71 scored a 13/15 on the Brief Interview for Mental Status assessment - indicative of no cognitive impairment. A review of physician orders in the electronic medical record revealed no orders allowing for self-administration of medications. There was no evidence in the electronic medical record of an interdisciplinary team assessment for self-administration of medications, nor did the care plan address self-administration of mediations. The care plan revealed R71 presented with impaired cognition as evidenced by episodes of confusion, impaired decision making, diagnosis of avoidant personality disorder, and poor safety awareness. On 4/1/2026 at approximately 1:45 PM, the Director of Nursing (DON) was queried regarding the medication at bedside. The DON confirmed the medication was omeprazole (a medication used to treat heartburn) and said that the resident did not want to take the medication, so they regurgitated it after the nurse left the room. The DON confirmed that R71 did not have an order to self-administer medications. A further record review revealed R71 had an order dated 12/10/2025 for omeprazole oral tablet Delayed Release 20mg, which read: give 1 tablet by mouth one time a day for heartburn. The February 2026 and March 2026 Medication Administration Record for R71 was reviewed and revealed no missed medications, no refusals, and no 'spit out drug' codes for the omeprazole. A policy titled, Medication Administration dated 3/24/2026 revealed, Policy: Medications are administered by licensed nurses.in accordance with professional standards of practice; 15. Observe resident consumption of medication, and 19. Report and document any adverse side effects or refusals.

This deficient practice pertains to 1232811.Based on observation, interview, and record review the facility failed to don appropriate personal protective equipment (PPE) for one resident (R407) of three resident reviewed for enhanced-barrier precautions resulting in the potential for the transmission of infectious organisms.Findings include:On 9/16/2025 at 10:50 AM, Licensed Practical Nurse (LPN) A was observed to perform wound care and peri care on R407. LPN A was assisted by Certified Nurse Assistant (CNA) B. LPN A and CNA B did not put on a gown during patient care despite there being an Enhanced Barrier Precaution (EBP) sign on the door indicating R407 was on (EBP).During this time LPN C (unit manage) enter R407 room while wound care was being performed.On 9/16/2025 at 11:15 AM, CNA B was interviewed about (EBP) and said a gown should be worn when a resident has a foley catheter, wound and doing personal care.On 9/16/2025 at 11:17 AM, LPN A was interviewed and queried about the care they had performed on R407. LPN A said she should have worn a gown because R407 had an open wound and a foley catheter.On 9/16/2025 at 11:49, AM LPN C was interviewed and acknowledged when they entered the room during patient care they did not see LPN A nor CNA B wearing a gown. LPN C said they should have been wearing a gown because R407 was on EBP.On 9/16/2025 at 1:00 PM, the Director of Nursing (DON) was interviewed and said they had the signs posted on door R407. The DON also acknowledged there were orders in R407 chart indicating they were on EBP, but staff did not follow the orders or signs. The DON said they would expect staff to follow the orders.Record review revealed R407 was initially admitted on [DATE] and readmitted on [DATE]. R407 had the following diagnosis: urinary tract infection, osteomyelitis (bone infection), pressure ulcer stage IV, unspecified injury at C4 and neurogenic bowel.Review of Minimum Data Set (MDS) for R407 from the Quarterly Review dated 7/19/2025 noted R407 Brief Interview for Mental Status was a 15 out of 15 indicating R407 was cognitively intact.Review of facility policy titled, Enhanced Barrier Precautions with a review date of 9/16/2025 noted, It is the policy of this facility to implement enhanced barrier precautions for the prevention transmission of multidrug-resistant organisms. Documented under implementation of enhanced barrier precautions indicated Personnel Protection Equipment (PPE), is for EBP is only necessary when performing high- contact care activities. High contact care activities included providing hygiene, changing linen device care which included urinary catheter and wound care.

This citation pertains to intake MI00152716. Based on observation, interview and record review, the facility failed to ensure a call light was available and in place for 6 residents (R503, R508, R509, R510, R511, and R512) of 91 residing in the facility resulting in the potential for unmet needs, harm or serious injury. Findings include: The State Agency received a complaint that R503 did not have a call light or a way to notify staff that assistance was needed. On 6/4/25 at 11:50 AM R503's private room was observed to not have a call light cord plugged into the call light outlet. There was no desk bell or any other way to notify staff that assistance may be needed. R503 was not in the room at this time. Certified Nursing Assistant (CNA) B entered the room and was asked where the call light was. CNA B could not find the call light cord or a bell. At this time Licensed Practical Nurse (LPN) A was asked where the call light was for R503. The room was searched and no call light or bell was found in the room. On 6/4/25 at approximately 12:00 PM nurse unit manager, LPN C was asked about the lack of a call light for R503 and replied, Some of the call lights were not functioning properly and we are getting that repaired. In the meantime we have provided desk bells for the residents whose call lights are not functioning. LPN C confirmed that R503 did not have a call light or desk bell. At 12:06 PM R503 was observed and in the day-room and did not voice any concerns regarding the lack of the call light in their room. An inspection of the facility determined that in addition to R503, the following residents did not have call lights or any additional way to notify staff that assistance was needed; R508, R509, R510, R511, and R512. During the time of the observations all of the residents were not in their room. The residents were in common areas or dining rooms and did not report any concern with the lack of the call light or desk bell in their room. On 6/4/25 at approximately 2:00 PM the Nursing Home Administrator (NHA) said the facility was in the process of repairing the call light system and all residents that were identified to have malfunctioning call lights should have had a desk bell or cow bell to alert staff that assistance was needed. The NHA was unable to provide a list of malfunctioning call lights at this time but provided an undated invoice for repair of the facility's call light system. The NHA said there was no policy for call lights.

This citation pertains in intake: MI00153399 and MI00153424. Based on observation, interview, and record review the facility failed to ensure staff reported a bruise of unknown origin for one (R503) of five residents reviewed for abuse, resulting in an unreported incident of potential abuse. Findings include: The State Agency (SA) received a complaint on 6/1/2025 that the resident had a bruises of unknown origin to the body and left breast. On 6/4/25 at 1:00 PM R503 was observed seated in the dining room eating lunch and interacting with other residents. R503 had bruises to both lateral upper arms at the same area where the resident's arms were touching and resting on the wheelchair's armrests. Upon interview the resident denied anyone hitting her or having pain to either upper arm area. The resident declined to go to her room for further skin assessment. On 6/4/25 at 1:15 PM Licensed Practical Nurse (LPN) B reported they were unaware of any bruising to R503's upper arms. LPN B said the resident was on blood thinners and a skin assessment would be completed when the resident completed her lunch. A review of R503's Electronic Health Record (EHR) revealed that R503 had initially admitted to the facility on [DATE] with multiple diagnoses that included bipolar disorder, psychotic disorder with delusions and schizophrenia. The resident was identified to have moderately impaired cognition with a Brief Interview for Mental Status Score of 8/15. The Medication administration record indicated that R503 was receiving Eliquis, a blood thinner twice a day. A skin assessment dated [DATE] did not identify any bruises to the resident's body. On 6/5/25 at 10:00 AM R503 was observed in the day room interacting with other staff and residents during an activity. R503 was agreeable to a skin assessment in their room. Certified Nursing Assistant (CNA) E assisted R503 to her room and was present for the observation of the resident's left breast. A purplish red bruise that was approximately the size of a soft ball was observed underneath and on the resident's left breast. R503 denied anyone hitting or hurting them at this time. R503 denied any abuse or pain at the site. CNA E was asked if the bruise was present at the time of AM care and replied, Yes, I told the nurse about it. At this time LPN F interviewed and said, I have no idea about the resident having a bruise to her left breast. Nurse unit manager, LPN C was interviewed about R503's bruising. LPN C reported that they were unaware of the resident's multiple bruises until now. LPN C completed a skin assessment at this time and confirmed that the bruises were of unknown origin and initiated an investigation. LPN C could not explain why the skin assessment dated [DATE] did not identify any bruising. On 6/5/25 at 12:45 PM R503 was observed in the day room eating lunch and interacting with other residents. Upon interview R503 continued to deny abuse or concerns about the bruise to their left breast area or bilateral arms. On 6/5/25 at approximately 1:00 PM during an interview with the Director of Nursing (DON) they said an investigation was being conducted and an incident was reported to the State Agency at this time. The DON could not explain the delay in initiating an investigation for bruises of unknown origin. They confirmed it was the facility's policy to report and investigate any bruises in potential areas of abuse such as the breast. The DON said R503 had been to the emergency room (ER) on 6/2/25 and the bruises could have resulted during transportation or while in the ER. The DON could not explain why a skin assessment on 6/4/25 did not identify any bruises or why the State Agency received a complaint on 6/1/25 regarding the bruising of the left breast. According to the facility's policy for Abuse, Neglect and Exploitation last reviewed 6/5/2025 in part reads: IV. Identification of Abuse, Neglect and Exploitation. B. Possible indicators of abuse include, but are not limited to: 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident ' s body 3. Physical injury of a resident, of unknown source V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: VI. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review the facility failed to provide a safe and sanitary laundry room and clean linen closet resulting in the potential for the spread of infection and disease transmission to residents and staff. Findings include: On 1/27/25 at 4:08 p.m. the clean linen closet located on the first floor had the following observations: 1. A folded gown and sheet were on the floor that was dusty and dirty. 2. A clean linen cart with clean linen was not covered. The cover was observed jumbled in a corner on the floor. 3. A heavily soiled sheet was on the floor next to the folded linen that was on the floor. 4. Employee's personal items (a jacket and purse) was on the floor behind the clean linen cart. On 1/28/25 at 4:58 p.m. the clean linen closet on the first floor was observed for the second time with the following observations: 1. Used gloves, straws, plastic wrapping, and dust was on the floor in various places in the closet. 2. The clean linen cart with clean linen was not covered. 3. A clean linen cart cover was jumbled in the corner on the floor. On 1/28/25 at 5:07 p.m. Housekeeping Supervisor M was queried about the unsanitary condition of the clean linen closet observations. Housekeeping Supervisor M said housekeeping staff are to ensure all linen closets are cleaned daily, it is part of their daily task. Housekeeping Supervisor M was not able to explain why the clean linen cart cover was on the floor. Review of the facility's policy titled Infection Prevention and Control Program dated 8/15/24 documented in part the following: Linens: Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection . Clean linen shall be stored on all resident care units on covered carts, shelves . linen closets . 47964 On 1/28/25 at 2:20 PM an environmental tour of the facility's Laundry Service was conducted with Housekeeping Supervisor (HS) M. The following items were noted: Washer/Dryer Room: Five housekeeping carts were stored in the laundry room. The housekeeping carts were observed to have soiled (dirty) mop water and there was garbage observed inside the cart's trash can. The washing machines and drying machines were in use. When queried regarding storing the soiled housekeeping carts in the washer/dryer room HS M replied, We store the carts in here because there isn't anywhere else to store them. When queried how clean laundry is transported to the clean linen room for folding and storage HS M said clean linens are removed from the dryer and placed into a cart and then taken to a separate clean linen room for processing. HS M pointed to a laundry cart on wheels next to a soiled housekeeping cart. HS M stated, This is what we use to transport clean linens to across the hall. Clean Linen Room observations: 1. Bed sheets on a storage rack were not covered. 2. Clean linen cart containing resident blanket were uncovered. 3. Clean socks were uncovered. 4. Observed resident clothes uncovered hanging on a barrel. On 1/28/25 at approximately 2:30 PM, HS M was interviewed and agreed clean linens should be covered when transported and stored. There were no other staff present in the clean linen room. HS M also agreed dirty housekeeping carts should not be stored in the laundry room when the laundry room is in use due to possible cross contamination. On 1/29/25 at 10:15 AM the Nursing Home Administrator (NHA) was interviewed and agreed dirty housekeeping carts should not be kept in the washer/dryer room and that clean linens should be covered when stored. A policy related to housekeeping carts was requested but not provided by the end of the survey. Review of the facility policy titled Laundry reviewed/revised 11/4/2024 revealed in part: The facility launders linens and clothing in accordance with current CDC (Center for Disease Control) guidelines to prevent transmission of pathogens. Soiled laundry shall be kept separate from clean laundry at all times. Review of the facility policy titled Handling Clean Linen reviewed/revised 11/4/2024 revealed in part: It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Linen can become contaminated with pathogens from environmental contaminants. Clean linen shall be delivered to resident care units on covered linen carts with covers down.

Based on observation, interview, and record review, the facility failed to (1) ensure desserts delivered to three unidentified residents were properly covered and (2) failed to maintain the ice machine in a clean and sanitary condition. Findings include: During lunch observations on 1/28/25 at 12:16 PM, a meal cart was delivered to the far end of the 1st floor residential unit. Certified Nurse Aide (CNA) B and CNA C delivered meal trays to the residents eating in their rooms at the far end of the hall. Beginning at 12:18 PM, CNA B and CNA C carried meal trays from the meal cart at the end of the hallway to the residents' dining room which was located half-way down the hall and down a shorter hall around a corner. Three meals trays were observed delivered to the dining room each with the dessert, cheese cake, uncovered. On 1/29/25 at 11:40 AM, Dietary Manager (DM) F said that all food should be covered on the tray. The CNAs should have brought the cart closer to the dining room prior to passing the trays to the residents eating in the dining room. DM F said food should be covered to prevent possible contamination. On 1/29/25 at 2:04 PM, the Nursing Home Administrator (NHA) said all the food was supposed to be covered. The NHA stated, Why didn't they take the cart to the dining room? On 1/29/25 at 4:40 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked. 38230 On 1/27/25 at 4:54 p.m. the ice machine located on the first floor of the facility was observed with LPN L. An unknown substance (rust colored) was on the inside hinge of the ice machine's door. The unknown substance was shown to LPN L. On the inside of the ice machine, the ice dispenser's hood (which was white in color), was observed with numerous black speckles. The outside of the machine was observed with drip stains of an unidentified substance on both sides. LPN L was queried about the unsanitary conditions of the ice machine. LPN L could not identify the unknown substances and did not know the department responsible for maintaining the cleanliness of the ice machine. LPN L confirmed the ice machine supplies ice for the entire facility. On 1/29/25 at 2:05 p.m. Housekeeping Supervisor M was queried about maintaining the cleanliness of the ice machine. Housekeeping Supervisor M stated, Housekeeping is not responsible for cleaning the ice machine. The dietary department is supposed to keep it clean. On 1/29/25 at 2:40 p.m. DM F was interviewed about the ice machine and said the ice machine is cleaned every six months by an outside company. The dietary department is responsible for keeping the outside of the ice machine clean, and the maintenance department is responsible for cleaning the inside in between the six-month cleanings as needed. On 1/29/25 at 2:54 p.m. Maintenance Supervisor E was queried about the ice machine and stated, I didn't know it needed to be cleaned. It's a company that comes in to clean it. According to the 2013 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.

Based on observation, interview, and record review the facility failed to properly dispose of refuse and maintain cleanliness of garbage and refuse areas resulting in the potential harborage of pests. This deficient practice has the potential to affect all 92 residents in the facility. Findings include: On 1/28/25 at 5:29 p.m. during an observation of the environment, the following observations at the rear of the facility were made: Plastic cups, paper, used gloves, and cigarette butts were on the ground. 1. A wooden palette, electric fan cover, and a red storage container were propped against the building. The red storage bin was not covered, and revealed used gloves, soiled linen, and trash. 2. A large broken bed frame, used gloves, plastic soda bottles, and trash was near a back door. 3. Eight plastic storage bins, some were right side up and some were turned down stacked against the wall near the rear door. There was trash, used gloves and other debris around them on the ground 4. A container that was covered in a yellow tarp had frozen standing water in it with trash in it. There was a plastic lid sitting on top of the container. There was a rusted shovel on the ground and trash on the ground around it. 5. There were used gloves and straws in a pile, frozen to the ground. 6. There was a large grey bin with empty plastic bottles, empty milk cartons, plastic cups, pieces of plaster, and other trash in it. The bin was not covered. On 1/29/25 at 1:50 p.m. Maintenance Supervisor E was queried about the trash and debris at the rear of the facility. Maintenance Supervisor E stated, I walk and clean the grounds every day. I couldn't get the trash on the ground because it was frozen. You know it's been snowing. Trash shouldn't be put on the ground by anyone in the first place. All palettes are put in the back to be picked up at the end of shift. Some of the other stuff you saw was just put out there. Review of the facility's policy titled Disposal of Garbage and Refuse dated 11/4/24 documented in part: The facility shall properly dispose of kitchen garbage and refuse . Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized . Dumpsters shall be emptied according to the facility contract. Garbage should not accumulate or be left outside the dumpster . The schedule for garbage pick-up should be revised, as needed, based on the volume of refuse . Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. According to the 2017 FDA Food Code Section 5-501.110 Storing Refuse, Recyclables, and Returnable. REFUSE, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. According to the 2017 FDA Food Code 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area and enclosure for REFUSE, recyclables, or returnable. shall be maintained free of unnecessary items, and clean.

Based on observation, interview, and record review, the facility failed to ensure the three-compartment sink was properly air gapped, resulting in this food equipment not being protected against contamination from sewage or other sources of contamination. Findings include: On 1/27/25 at 8:58 a.m. during a kitchen observation, a pipe underneath the three-compartment sink was observed. The pipe led to a drain in the floor that appeared to have three inches of space between them. However, a black cover was observed that was approximately 4-5 inches from the floor over the drain. The three inch air gap was surrounded by the black floor drain cover. On 1/28/25 at 2:10 p.m. the Dietary Manager (DM) F and Registered Dietician (RD) U were queried about the sink having the proper air gap. DM F stated, There hasn't been a sewage backup since I been here, so I'm not sure. RD U acknowledged the sink should have the proper air gap to prevent sewage from backing up into the pipe that could go into (contaminate) the sink. On 1/29/25 at 8:00 AM, Maintenance Director E acknowledged that the kitchen's three-compartment sink was not properly air-gapped. On 1/29/25 at 4:40 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked. The 2013 FDA Food Code was reviewed and revealed the following in Section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program. Findings include: On 1/29/25 at 1:00 PM, the Nursing Home Administrator (NHA) was interviewed about the facility's QAPI program and process. The NHA identified having enough linen available was an area of concern and opportunity for improvement. The NHA said the QA committee developed a plan to have enough linen in the building and have enough staff to process it. The NHA stated, the QAPI effort involving linen included consistent monitoring and establishing a par level (a minimum amount of inventory that should be on hand to meet resident needs) to maintain. A facility document titled QAPI Action Plan documented in part the following as an area of improvement: Action Plan: Order linen and supplies once a week Responsible Person(s): Housekeeping supervisor Target Date: 6/30/24 Outcome: On going A facility document titled, QA Agenda - Housekeeping - June, dated 7/25/24, documented in part, Make (sure [sic]) my weekly orders are placed. A facility document titled, QA Agenda - Housekeeping - July, dated 8/30/24, documented in part, Make (sure [sic]) my monthly and weekly orders are placed. The NHA indicated QA monitoring of the availability of adequate linen supplies consisted of speaking with nurses and Certified Nurse Aides about the linen and going to check herself. When asked about the data gathered and presented to the QA committee, the NHA provided a linen inventory dated 8/30/24. The NHA was unable to provide data gathered and presented to the QA committee for subsequent months. The NHA was unable to provide documentation that the linen concern was discussed during the September 2024 QA committee meeting or subsequent QA committee meetings. When the NHA was informed that having adequate linen was identified as an area of non-compliance by the current survey team, the NHA had no explanation. When queried about QAPI efforts related to nursing, the NHA indicated that lab draws were not occurring as ordered. The NHA provided documentation that for October 2024, lab draws were not occurring as ordered. Seven out of 15 lab orders were not completed as ordered, while two were due to refusals. The NHA was unable to provide documentation that this nursing concern was discussed and evaluated in the November 2024 QA meeting or subsequent QA committee meetings. The NHA stated, We need to recap everything that was achieved or if it wasn't achieved what else can we do. That is what we're trying to do now. The NHA indicated that a report recapping QAPI activities was not available for review and there was no tracking of data. A review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), dated 8/1/24, documented in part the following: - The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include but is not limited to: -- Systems and reports demonstrating systemic identification, reporting, investigation, analysis, and prevention of adverse events. -- Data collection and analysis at regular intervals. -- Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. A review of the facility policy titled, QAPI Monitoring, dated 12/27/24, documented in part the following: - It is the policy of this facility to systematically monitor performance indicators as part of the QAPI program. - The facility QA Committee analyzes data collected through planned and routine data collection activities. On 1/29/25 at 4:40 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to properly secure protected health information for two residents (R198 and R28) resulting in the potential for unauthorized disclosure and access. Findings include: On 1/29/25 at 12:47 PM, the laptop computer on a 1st floor nursing medication cart, located in the unit's commonly accessible hallway, was observed unlocked, and the electronic health record (EHR) for R198 was opened. R198's order for haloperidol deconoate (an injectable antipsychotic medication used for schizophrenia) was visible on the computer screen. There was no nurse visible near the 1st floor nursing medication cart. On 1/29/25 at 12:49 PM, Licensed Practical Nurse (LPN) D approached the cart. When queried about the opened EHR, LPN D said it was a HIPPA (Health Insurance Portability and Accountability Act) violation to expose resident information. A review of R198's medical record documented an initial admitted [DATE] and readmitted [DATE]. R198's diagnoses included schizophrenia. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. On 1/29/25 at 2:06 PM, the Director of Nursing (DON) was interviewed and stated, We follow HIPPA protocol (meaning) that no patient health information is left exposed. On 1/29/25 at 4:40 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked. 50634 On 1/27/25 at 11:50 AM, a computer on a medication cart was observed opened to R28's Electronic Medical Record, (EMR). Social Worker, (SW) Q was coming down the hall and stopped when directed to look at the resident's information on the computer screen. SW Q alerted the nurse that was coming down the hall that the computer was left opened. SW Q was then queried about R28's EMR being opened in the hallway so anyone walking by could see it and said it was a violation of the resident's privacy. On 1/27/25 at 11:55 AM, License Practical Nurse, (LPN) I was interviewed about leaving R28's EMR open and said that was not the normal computer they use. LPN I said they understand R28's EMR should not have been left open and they know it is a violation of R28's privacy. On 1/29/25 at 12:00 PM, the DON was interviewed about R28's EMR left opened. The DON said it was a violation of HIPPA. R28 was initially admitted on [DATE] with a pertinent diagnosis of Psychosis, Muscle Weakness, Schizophrenia, Vascular Dementia and Cerebral Infarction (stroke). The quarterly assessment dated [DATE] for Brief Interview for Mental Status, (BIMS) revealed R28 had severe cognitive impairment.

Based on observation and interview the facility failed to make timely repairs for the residents residing in rooms [ROOM NUMBER] resulting in unsafe, unhomelike, and dysfunctional paper towel dispenser. Findings include: On 1/27/25 at 11:30 a.m. room [ROOM NUMBER] was observed with the heating vent cover propped against the vent. The vent was observed with thick dust and dirt. The resident in bed one said the cover was taken off when maintenance was repairing the heat some time ago, I don't know why they haven't put it back on. The resident in bed two said when using the wheelchair, the cover gets knocked over. When that occurs, the resident propped it back against the vent. The residents also complained the temperature in the room gets cold. There was plastic on the windows, but maintenance took it off and didn't put it back up. There was a small heating unit (approximately the size of a personal space heater) mounted on the wall next to the window. There was some heat coming from it, but not blowing out strong. On 1/29/25 at 11:47 a.m. Maintenance Director E was interviewed about the environment conditions in room [ROOM NUMBER] at stated, I didn't know the room was still cold. The residents haven't said anything to me. I think one of the residents may have knocked the cover off with the wheelchair. Maintenance Director E was queried about being notified of when repairs are needed. Maintenance Director E said the staff are supposed to log repairs in the Maintenance Log located on each unit but most times is made aware when walking by the resident or staff, then put in the Maintenance Director's personal note pad. On 1/29/25 at 11:52 a.m. the CEO of Operations was interviewed and said they were aware of the many environment concerns and currently trying to address them. Review of the facility's policy titled Safe and Homelike Environment dated 9/3/24 documented in part: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Review of the facility's policy titled Maintenance Inspection dated 11/24 documented in part: It is the policy of this facility to utilize a maintenance inspection checklist to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public . The Director of Maintenance Services will perform routine inspections of the physical plant using the Maintenance Checklist . The Administrator, or designee, will perform random inspections of the physical plant using the Maintenance Checklist . All opportunities will be corrected immediately by maintenance personnel. 39465 On 1/27/2025 at 9:55 a.m., the shared bathroom of rooms [ROOM NUMBERS] were observed with a broken paper towel dispenser and an orange construction cone supporting the bathroom sink. CNA O entered room [ROOM NUMBER] and was interviewed. CNA O said that the orange cone wrapped around the bathroom sink pole was to keep the pole from dislodging from the sink. CNA O added the resident in room [ROOM NUMBER] used the bathroom independently. On 1/29/2025 at 2:13 p.m. Housekeeper P was interviewed regarding the bathroom of rooms [ROOM NUMBERS]. Housekeeper P demonstrated not being able to pull down the paper towel from the dispenser said the residents would not be able to pull the paper towels down either. Housekeeper P said the dispenser had been broken for a long time. Housekeeper P confirmed the orange construction cone in the bathroom of rooms [ROOM NUMBERS] was to hold up the bathroom sink. On 1/29/2025 at 3:09 p.m., the Director of Nursing said during an interview that residents should have access to paper towel. and the housekeepers should check every day to may sure it's available. On 1/29/2025 at 4:15 PM, Maintenance Director (MD) E was asked about the condition of the shared bathroom of rooms [ROOM NUMBERS] and stated, I will look into it (the bathroom sink). It should have been fixed. It's not secure for the residents.

Based on observation and record review, the facility failed to provide at least 80 square feet per resident for five rooms (#'s 111, 115, 119, 219, and 231) resulting in the potential for resident dissatisfaction with their living space and not having adequate space available for care. Findings include: Rooms 111, 115, 119, and 219 were each 157 square feet. Two residents resided in each room which yielded 78.5 square feet per resident. room [ROOM NUMBER] was 159 square feet. Two residents resided in this room which yielded 79.5 square feet per resident. Resident interviews and observations did not reveal any overt concerns related to the room size. On 1/29/25 at 4:40 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.

This citation pertains to intake MI00149479. Based on observation, interview, and record review, the facility failed to provide adequate supervision for one resident (R401) on oxygen with a known history of unsupervised smoking and noncompliance with smoking policy out of four residents reviewed for safety with smoking, which led to a fire resulting in a 2nd degree facial burns((an injury that damages the outer layer of skin (epidermis) and part of the underlying layer(dermis)) and hospitalization in the burn unit. The Immediate Jeopardy began on 1/10/25 when an untrained facility staff (sitter) failed to properly supervise R401during a smoke break leading to the R401 obtaining a lighter and cigarette. Later, R401 (while inhaling oxygen through a nasal canula) attempted to smoke in his bathroom unsupervised and lit his face on fire. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy (IJ) on 1/22/25 at 3:50 PM. The IJ was removed on 1/22/25, but noncompliance remains at a potential for harm due to sustained compliance that has not been verified by the State Agency. Findings include: On 1/13/2025 at 11:34 AM the State Agency received a complaint that on 11/10/2025 R401 lit a cigarette while on oxygen and lit his face on fire. Record review of R401's Electronic Health Record (EHR) revealed the resident admitted to facility on 3/6/2024 with a most recent readmission on 1/19/2025 with diagnoses which included subdural hemorrhage, chronic obstructive pulmonary disease (COPD), schizophrenia, adjustment disorder with mixed anxiety and depressed mood. Review of the Minimum Data Set (MDS) dated [DATE] for R401 revealed a Brief Interview for Mental Status (BIMS) of 10/15 which indicated moderate cognitive impairment and partial/moderate assistance for transfers. On 1/15/2025 at 10:50 AM R401's guardian A was interviewed and said a staff member from the facility called to notify him on 1/11/25 or 1/12/25 that R401 lit his face on fire smoking again in his bathroom and was at hospital C. R401 had previously Review of the facility progress note dated 1/10/2025 at 10:30 PM revealed, writer observed injury when rounding on resident. Resident stated he fell in the bathroom. Writer assessed resident vital signs as follow 148/74 pulse 98, respirations 18, oxygen saturation 96% via nasal cannula. Temperature 97.8. Wound care provided resident tolerated well. Review of the facility progress note dated 1/11/2025 at 13:33 revealed, new order for stat x-ray of the optic and nasal bone to rule out a fracture 2 views per doctor. Review of the facility progress note dated 1/11/25 at 15:08 revealed, resident requested to transfer to the hospital physician and guardian notified. Review of the facility progress note dated 1/11/25 20:42 revealed, resident is transferred to (Hospital B) at 7:15PM as per instructions provided by outgoing nurse and doctor, writer received recent xray result, xray report stated the orbit demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues. Record review of the hospital B emergency Treatment note dated 1/11/2025 at 21:10 revealed, (R401) with a history of COPD on home oxygen presents emergency department facial burn. Patient states last night (1/10/25) he was on his nasal canula oxygen and attempted to smoke a cigarette causing the nasal cannula to light on fire burning his face. Second degree burns to upper and lower lip, right face, nose. Periorbitol (around eye) swelling and edema of the lips. Patient will require transfer to a burn center. Disposition transferred to Hospital C. Record review of the hospital C progress note dated 1/13/25 revealed R401 presents to the emergency department as a transfer after a facial burn sustained while smoking on home oxygen. Sustained ~1.5% partial thickness burns to right side of face. admitted to burn service. Integumentary: warm, dry ~1.5 % partial thickness burns to right side of face. Lips swollen with some partial thickness burns. On 1/15/25 at 2:55 PM Licensed Practical Nurse (LPN) D was interviewed and said she was called to R401's room on 1/10/25 by Sitter E. LPN D stated, R401 said he fell in the bathroom. His face appeared red. He was wearing his oxygen when I arrived, the oxygen tubing was intact. On 1/15/25 at 3:45 PM LPN F was interviewed and said that on 1/11/15 R401 requested to go to the hospital. R401 told me he fell the night before (1/10/25), I saw that his face was swollen. On 1/15/25 at 4:00 PM the facility's Chief Operating Officer (COO) I provided hospital C progress notes and acknowledged R401 was treated in the hospital for facial burns. On 1/15/25 at 4:50 PM Sitter E was interviewed by phone and said that she worked with R401 on 1/10/24 from 3PM to 11PM. Around 10:30 PM R401 went to the bathroom by himself and yelled. He was wearing his oxygen. He said he fell . Sitter E said she did not smell smoke, nor did she see any burns on R401's face. Sitter E said she took R401 out to smoke on 1/10/25 around 8:00 PM by herself. Sitter E interrupted the interview and did not respond to further attempts for an interview. On 1/16/25 at 2:15 PM and 3:33 PM Sitter E was called for an interview. Left messages with no return call. On 1/16/25 at 10:54 AM LPN G was interviewed and said she was the was the nurse supervisor on 1/10/25 and on 1/11/25. On 1/11/25 she put in a stat (immediate) order for an xray of R401's face due to his complaints of pain. LPN G said when she saw R401 on 1/11/25 R401 had swelling to his right eye and He had grease on his face like Vaseline. LPN G further said that R401 had a sitter for behavioral issues but could not specifically state the reason why R401 had a sitter. On 1/16/25 at 12:07 PM LPN H was interviewed and said that he observed emergency medical services pick up R401 on 1/11/25 to take him to the hospital. LPN H said R401 did not have any open wounds on his face when he was transported to the hospital but R401's face was swollen. On 1/16/25 at 2:50 PM Certified Nursing Assistant (CNA) J was interviewed and said that she worked with R401 on 1/11/25 day shift from 7AM to 3PM. CNA J said she saw R401at approximately 1:30 PM on 1/11/25. CNA J stated, I thought R401 went to the hospital because his face it looked bad. He was drooling, he couldn't close his mouth. His face was pink including his lips. Everything was pink around his oxygen canula. On 1/16/25 at 3:49 PM the Director of Nursing (DON) was interviewed and said R401 was sent to the hospital following his fall per the resident request. The DON said R401 experienced combustion in August 2024, smoking while on oxygen and set his face on fire. When asked what was put in place to prevent further smoking incidents with R401 the DON said a 24-hour sitter was added. When asked were the sitters made aware for what to watch for with R401 the DON replied, The sitter is aware that there is some type of safety concerns, but I'm not sure of the specific reason why they are there is shared with them. The DON agreed the specific reason why the sitter is needed should be shared with the sitters to provide resident safety. On 1/16/25 at 3:55 PM the NHA was interviewed and said sitters should be told the specific reason why they are there to monitor residents so that it is clear why the resident needs supervision. Review of R401's care plan revealed Focus: I am a smoker, and I am aware that I need to follow the smoking policy. I have violated the smoking policy, and it resulted in me being injured. Date initiated 8/30/24. Goal: I will follow the smoking policy. Thru next review date. Date initiated 8/30/24. Target date 3/3/25. Interventions: I am aware that a lighter nor cigarettes can be keep on my person or in my room or possession. Date initiated 10/3/24. I am aware that I can only smoke at smoking times with supervision. Date initiated 10/10/24. I am aware that I will be offered a smoking patch or smoking gum if I violated the policy. Date initiated 10/3/24. I require a sitter at my bedside for safety date initiated 11/27/24. I understand if I violated the smoking policy that I will lose my smoking privileges for 7 days or I maybe involuntary discharge from the facility. Date initiated 10/3/24. Further review of R401's care plan revealed Focus: The resident has oxygen therapy related to a diagnosis of COPD as evidenced by low oxygen saturation and shortness of breath. Date initiated 8/21/24. Goal I will be complaint with oxygen therapy. My oxygen saturation will be between 95 and 100 percent. Date initiated 8/21/24 Target date 3/3/25. Intervention: I was educated about the importance of not using flammables around oxygen therapy. Date initiated 8/30/24. On 1/16/25 at 4:45 PM the facility's COO I was interviewed and R401's care plan was reviewed. The COO I said that the DON created the I require a sitter at my bedside for safety date initiated 11/27/24 on 1/15/25. The COO I agreed R401's care plan was not revised to have a sitter until 1/15/25. Review of R401's orders revealed: Cleanse face with normal saline, apply tiple antibiotic ointment and leave open to air created on 1/11/25 at 12:17 AM. STAT (immediate) x-ray of the optic and nasal bone to rule out a fracture 2 views per MD (medical doctor) created on 1/11/25 at 1:53 PM. Cleanse face with normal saline, apply tiple antibiotic ointment and leave open to air created on 1/11/25 at 2:07 PM. Transfer to hospital Created 1/11/25 at 3:07 PM. Transfer to Receiving Hospital created on 1/11/25 at 3:07 PM. Review of R401's most recent smoke assessment dated [DATE] revealed, safe to smoke with supervision. On 1/21/25 at 12:30 PM Medical Doctor (MD) K was interviewed and said R401 had been hospitalized for facial burns. When asked how he was informed of R401's hospitalization MD K replied I was told by a nurse from the facility that R401 was in the hospital with facial burns. MD K stated I assume R401 smoked in his bathroom just like he did last time he got a burn because residents don't wear oxygen outside when they smoke. On 1/21/24 at 2:00 PM R401 was interviewed at Hospital L. R401 was observed as an African American male with dark colored skin. R401's tip of nose was pink in color missing skin, top lip pink in color missing skin, bottom lip was scabbed. Both lips appeared swollen. R401's right cheek appeared pink in color missing skin. R401 knew he was at hospital L, his name and the date. When asked what happened on 1/10/25 R401 replied I lit a cigarette in my bathroom while wearing my oxygen and lit my face on fire. I told everyone that I fell and injured my face, but they knew what happened. I didn't fall. I didn't want the staff to get in trouble for what I did. I had my own cigarette and lighter from earlier in the day. The sitter didn't take back my cigarette and lighter from the earlier smoke break. On 1/22/25 at 9:45 AM Activities Director (AD) M was interviewed and said that she completes a resident assessment before a resident is allowed to smoke to make sure residents are safe. AD M said activities staff keep residents' cigarettes and lighters locked up when not in use and smoke breaks occur daily at 9:45 AM, 1:15 PM and 6:30 PM. Only staff handles the lighter, residents do not get to use the lighter. AD M said security monitors the evening smoke break at 6:30 pm. AD M stated, The only staff authorized and trained to take residents out to smoke are nurses, activities staff and security staff. When asked did you train Sitter E on how to monitor residents for smoking AD M replied No I did not train her (Sitter E). On 1/22/25 at 10:41 AM Activities assistant N was interviewed and said she worked and monitored the morning and afternoon smoke breaks on 1/10/25 and that R401 did not participate in either smoke break. On 1/22/25 at 12:01PM Security Staff (SS) O was interviewed and said he worked the evening shift on 1/10/25 and that R401 did not go out for the 6:30 PM scheduled smoke break. SS O stated I have seen sitters go out with R401 to supervise him smoke by themselves not during a scheduled smoke break. He (R401) was the only guy I know with a sitter who smokes. I have given cigarettes and a lighter to the sitter to go out with R401to smoke. SS O said R401 was not allowed to go on leaves of absence and that he expected the sitters to monitor the resident during smoke breaks for safety. On 1/22/25 at 1:20 PM the NHA was interviewed and said nursing, activities staff and security are the only employees trained and authorized to take residents out to smoke. The NHA said the staff educator and activities director are the only staff allowed to train employees to supervise residents who smoke. On 1/22/25 at 1:35 PM the Staff Educator (SE) P said that sitters are not trained and/or authorized to take out residents to supervise smoking. When asked if Sitter E was trained to independently take a resident out to smoke SE P replied, Sitter E was not specifically trained to supervise smokers. On 1/22/25 at 1:38 PM the NHA said the only staff authorized and trained to supervise residents who smoke are nurses, activities staff and security personnel. No one else. A review of the facility policy titled Smoking Policy, revised 8/30/24 revealed in part: The policy of this facility is to provide a safe smoking environment for residents who can smoke and are deemed a safe smoker based on a comprehensive smoking safety assessment. All cigarettes and lighters will be labelled with resident's name and kept in a box at the security station and the staff member assigned to supervise smoking will be responsible for obtaining the box and distributing cigarettes and lighters to residents as well as collecting them an (sic) returning the box to the security office. If you do not make it out to smoke break on time you will have to wait for the next smoke break! No exception! The Immediate Jeopardy that began on 1/10/25 was removed on 1/22/25 when the facility took the following actions to remove the immediacy: -Beginning 1/22/25- The Director of Nursing/designee began an in-service with licensed nursing staff on independent smoker and dependent smokers, including resident choice of time smoking. -Beginning 1/22/25- All residents who smoke will be in-serviced by the Director of Nursing/designee on the smoking policy during a special resident council meeting to include the nonadherence to the policy that may result in revoking privileges and/or initiating a discharge plan care (sic). -Beginning 1/22/25 - Smoking signs were implemented asking families and visitors to not give residents smoking materials for the safety of our residents and turn in all smoking materials to be used only during scheduled smoking times. -Beginning 1/22/25 Staff was in-service on the updated smoking policy; to report any residents with smoking material immediately, staff includes security and sitters, and the updated policy includes reporting immediately to the charge nurse and management if any resident have any smoking materials and residents will be searched immediately. -Beginning 1/22/25 unscheduled smoking times will not be permit (sic) without approval from administration. Residents that smoke will be offered a nicotine patch or offered to be taking (sic) out to smoke with a nurse or Cena.

This citation pertains to intake MI00149479. Based on observation, interview, and record review, the facility failed to ensure staff reported an injury related to fire to the abuse coordinator for one resident (R401) out of four residents reviewed for accidents, resulting in an unreported incident of potential neglect. Findings include: On 1/13/2025 at 11:34 AM the State Agency received a complaint that on 11/10/2025 R401 lit a cigarette while on oxygen and lit his face on fire. On 1/15/2025 at 10:50 AM R401's guardian A was interviewed and said a staff member from the facility called to notify him on 1/11/25 or 1/12/25 that R401 lit his face on fire smoking again in is bathroom and was at hospital C. On 1/21/24 at 2:00 PM R401 was interviewed at Hospital L. R401 was observed as an African American male with dark colored skin. R401's tip of nose was pink in color missing skin, top lip pink in color missing skin, bottom lip was scabbed. Both lips appeared swollen. R401's right cheek appeared pink in color missing skin. R401 knew he was at hospital L, his name and the date. When asked what happened on 1/10/25 R401 replied I lit a cigarette in my bathroom while wearing my oxygen and lit my face on fire. I told everyone that I fell and injured my face, but they knew what happened. I didn't fall. I didn't want the staff to get in trouble for what I did. I had my own cigarette and lighter from earlier in the day. The sitter didn't take back my cigarette and lighter from the earlier smoke break. The facility called EMS the next day after I kept asking them to send me to the hospital because my face hurt from the burns, and I couldn't breathe good. Record review of R401's Electronic Health Record (EHR) revealed the resident admitted to the facility on [DATE], with most recent readmission on 1/19/2025, with diagnoses which included subdural hemorrhage, chronic obstructive pulmonary disease (COPD), schizophrenia, adjustment disorder with mixed anxiety, and depressed mood. Review of the Minimum Data Set (MDS) dated [DATE] for R401 revealed a Brief Interview for Mental Status (BIMS) of 10/15 which indicated moderate cognitive impairment and partial/moderate assistance for transfers. Review of the facility progress note dated 1/10/2025 at 10:30 PM revealed, Writer observed injury when rounding on resident. Resident stated he fell in the bathroom. Writer assessed resident vital signs as follow 148/74 pulse 98, respirations 18, oxygen saturation 96% via nasal cannula. Temperature 97.8. Wound care provided resident tolerated well. Review of the facility progress note dated 1/11/2025 at 13:33 (1:33 PM) revealed, new order for stat x-ray of the optic and nasal bone to rule out a fracture 2 views per doctor. Review of the facility progress note dated 1/11/25 at 15:08 (3:08 PM) revealed, resident requested to transfer to the hospital physician and guardian notified. Review of the facility progress note dated 1/11/25 at 20:42 revealed, resident is transferred to (hospital B) at 7:15PM as per instructions provided by outgoing nurse and doctor, writer received recent Xray result, xray report stated the orbit demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues, medical doctor and Guardian A are notified. Review of the Prehospital Care Report by Emergency Medical Services (EMS) dated 1/11/25 revealed, EMS responded to priority 2 to facility for difficulty breathing. EMS arrived on location with no incident. EMS entered the building and located the patient room. EMS received report from the nursing. EMS entered the room and made patient contact. Patient was found standing using an oxygen concentrator as a brace. Patient was hooked up on oxygen flowing at 8LPM via nasal cannula. Patient presented baseline with no current complaints of pain. Patient had burn marks on his face from the prior night, nursing home staff informed EMS that the burns were from a cigarette from the prior night. EMS began transport to [NAME] Grace Hospital emergency room (ER) priority 1 for facial burns. EMS swapped the patients nasal cannula for a non-rebreather mask due to patient complaint of difficulty breathing. EMS arrived at [NAME] Grace ER with no incident. Patient arrived at Destination Date/Time 2025-01-11 20:28:24. Record review of the Hospital B emergency Treatment note dated 1/11/2025 at 21:10 revealed, R401 with a history of COPD on home oxygen presents emergency department facial burn. Patient states last night (1/10/25) he was on his nasal canula oxygen and attempted to smoke a cigarette causing the nasal cannula to light on fire burning his face. Second degree burns to upper and lower lip, right face, nose. Periorbitol (around eye) swelling and edema of the lips. Patient will require transfer to a burn center. Disposition transferred to (Hospital C.) Record review of the Hospital C progress note dated 1/13/25 revealed, R401 presents to the emergency department as a transfer after a facial burn sustained while smoking on home oxygen. Sustained ~1.5% partial thickness burns to right side of face. admitted to burn service. Integumentary: warm, dry ~1.5 % partial thickness burns to right side of face. Lips swollen with some partial thickness burns. On 1/15/25 at 2:55 PM Licensed Practical Nurse (LPN) D was interviewed and said she was called to R401's room on 1/10/25 by Sitter E. LPN D stated, R401 said he fell in the bathroom. His face appeared red. He was wearing his oxygen when I arrived, the oxygen tubing was intact. When asked did R401 have facial burns LPN D replied The only thing I saw was redness to his face. On 1/15/25 at 3:45 PM LPN F was interviewed and said that on 1/11/15 R401 requested to go to the hospital. When asked did R401 have facial burns LPN F replied, R401 told me he fell the night before (1/10/25) I saw that his face was swollen. On 1/15/25 at 4:00 PM the facility's Chief Operating Officer (COO) I provided Hospital C progress notes and acknowledged R401 was hospitalized for facial burns. When queried, COO I reported being unaware of R401 setting his face on fire while on oxygen, in the bathroom. On 1/15/25 at 4:50 PM Sitter E was interviewed by phone and said that she worked with R401 on 1/10/24 from 3PM to 11PM. Around 10:30 PM R401 went to the bathroom by himself and yelled. He was wearing his oxygen. He said he fell . I called for nurse LPN D. Sitter E said she did not smell smoke, nor did she see any burns on R401's face. Sitter E said she took R401 out to smoke on 1/10/25 around 8:00 PM by herself. Sitter E abruptly ended the interview and did not respond to further attempts for an interview. On 1/16/25 at 2:15 PM and 3:33 PM Sitter E was called for an interview. Left messages with no return call. On 1/16/25 at 10:00 AM the Nursing Home Administrator/Abuse Coordinator (NHA) was interviewed and said she was told R401 fell and injured his face which is the reason R401 was sent to the hospital on 1/11/25. On 1/16/25 at 10:54 AM LPN G was interviewed and said she was the was the nurse supervisor on 1/10/25 and on 1/11/25. On 1/11/25 she put in a stat (immediate) order for an Xray of R401's face due to his complaints of pain. LPN G said when she saw R401 on 1/11/25 R401 had swelling to his right eye and He had grease on his face like Vaseline. On 1/16/25 at 12:07 PM LPN H was interviewed and said that he observed EMS pick up R401 on 1/11/25 to take him to the hospital. LPN H said he assisted EMS for the hospital transfer. LPN H stated, R401 did not have any open wounds on his face when he was transported to the hospital but R401's face was swollen. On 1/16/25 at 2:50 PM Certified Nursing Assistant (CNA) J was interviewed and said that she worked with R401 on 1/11/25 day shift from 7AM to 3PM. CNA J said she saw R401at approximately 1:30 PM on 1/11/25. CNA J stated, I thought R401 went to the hospital because his face it looked bad. He was drooling, he couldn't close his mouth. His face was pink including his lips. Everything was pink around his oxygen canula. On 1/16/25 at 3:49 PM the Director of Nursing (DON) and the NHA/Abuse Coordinator were interviewed. The DON said R401 was sent to the hospital following his fall per the resident request. The DON said R401 experienced combustion in August 2024, smoking while on oxygen and set his face on fire. The DON acknowledged R401 was admitted to the hospital with facial burns. During the interview the DON and the NHA/Abuse Coordinator reported not being aware of any incidents of fire prior to R401 being admitted to the hospital for facial burns. Review of R401's EHR for January 2025 did not reveal any documentation of a facial burn or an acute care transfer sheet (to be completed by facility nursing staff) completed for 1/11/25. Review of R401's care plan revealed Focus: I am a smoker, and I am aware that I need to follow the smoking policy. I have violated the smoking policy, and it resulted in me being injured. Date initiated 8/30/24. Goal: I will follow the smoking policy. Thru next review date. Date initiated 8/30/24. Target date 3/3/25. Interventions: I am aware that a lighter nor cigarettes can be keep on my person or in my room or possession. Date initiated 10/3/24. I am aware that I can only smoke at smoking times with supervision. Date initiated 10/10/24. I am aware that I will be offered a smoking patch or smoking gum if I violated the policy. Date initiated 10/3/24. I require a sitter at my bedside for safety date initiated 11/27/24. I understand if I violated the smoking policy that I will lose my smoking privileges for 7 days or I maybe involuntary discharge from the facility. Date initiated 10/3/24. Further review of R401's care plan revealed Focus: The resident has oxygen therapy related to a diagnosis of COPD as evidenced by low oxygen saturation and shortness of breath. Date initiated 8/21/24. Goal I will be complaint with oxygen therapy. My oxygen saturation will be between 95 and 100 percent. Date initiated 8/21/24 Target date 3/3/25. Intervention: I was educated about the importance of not using flammables around oxygen therapy. Date initiated 8/30/24. On 1/21/25 at 12:30 PM Medical Doctor (MD) K was interviewed and said R401 had been hospitalized for facial burns. When asked how he was informed of R401's hospitalization MD K replied I was told by a nurse from the facility that R401 was in the hospital with facial burns. Review of the facility policy titled Abuse, Neglect and Exploitation date reviewed/revised revealed in part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. 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 Federal requirements related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies(e.g. law enforcement when applicable) within specified timeframes: a Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2 Assuring that reporters are free from retaliation or reprisal; 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to the following: a. Analyzing the occurrence to determine why abuse, neglect, misappropriation of resident property of exploitation occurred, and what changes are needed to prevent further occurrences.

This citation pertains to intake MI00149479. Based on observation, interview, and record review the facility failed to maintain complete and accurate medical records for one resident (R401) out of three residents reviewed for accidents, resulting in the absence of accurate documentation of R401's facial burns. Findings Include: On 1/13/2025 at 11:34 AM the State Agency received a complaint that on 11/10/2025 R401 lit a cigarette while on oxygen and lit his face on fire. On 1/15/2025 at 10:50 AM R401's guardian A was interviewed and said a staff member from the facility called to notify him on 1/11/25 or 1/12/25 that R401 lit his face on fire smoking again in is bathroom and was at hospital C for the treatment of facial burns. On 1/21/24 at 2:00 PM R401 was interviewed at Hospital L. R401 was observed as an African American male with dark colored skin. R401's tip of nose was pink in color missing skin, top lip pink in color missing skin, bottom lip was scabbed. Both lips appeared swollen. R401's right cheek appeared pink in color missing skin. R401 knew he was at Hospital L, his name and the date. When asked what happened on 1/10/25, R401 replied I lit a cigarette in my bathroom while wearing my oxygen and lit my face on fire. I told everyone that I fell and injured my face, but they knew what happened. I didn't fall. I didn't want the staff to get in trouble for what I did. I had my own cigarette and lighter from earlier in the day. The sitter didn't take back my cigarette and lighter from the earlier smoke break. The facility called EMS the next day after I kept asking them to send me to the hospital because my face hurt from the burns, and I couldn't breathe good. Record review of R401's Electronic Health Record (EHR) revealed admitted to facility on 3/6/2024 with most recent readmission on 1/19/2025 with diagnoses which included subdural hemorrhage, chronic obstructive pulmonary disease (COPD), schizophrenia, adjustment disorder with mixed anxiety and depressed mood. Review of the Minimum Data Set (MDS) dated [DATE] for R401 revealed a Brief Interview for Mental Status (BIMS) of 10/15 which indicated moderate cognitive impairment and partial/moderate assistance for transfers. Review of the facility progress note dated 1/10/2025 at 10:30 PM revealed, Writer observed injury when rounding on resident. Resident stated he fell in the bathroom. Writer assessed resident vital signs as follow 148/74 pulse 98, respirations 18, oxygen saturation 96% via nasal cannula. Temperature 97.8. Wound care provided resident tolerated well. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. Review of Skin Observation Tool dated 1/10/2025 at 10:57 PM revealed, Skin Tear to nose, upper lip and forehead, site Face type skin tear. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. Review of the facility progress note dated 1/11/2025 at 13:33 (1:33 PM) revealed, New order for stat x-ray of the optic and nasal bone to rule out a fracture 2 views per doctor. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. Review of the facility progress note dated 1/11/25 at 15:08 (3:08 PM) revealed, Resident requested to transfer to the hospital physician and guardian notified. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. Review of R401's EHR revealed neurological checks were documented on 1/10/25 and 1/11/25. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. Review of the facility progress note dated 1/11/25 at 20:42 revealed, Resident is transferred to hospital B at 7:15PM as per instructions provided by outgoing nurse and doctor, writer received recent Xray result, xray report stated the orbit demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues, medical doctor and Guardian A are notified. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. Review of the Prehospital Care Report by Emergency Medical Services (EMS) dated 1/11/25 revealed, EMS responded to priority 2 to facility for difficulty breathing. EMS arrived on location with no incident. EMS entered the building and located the patient room. EMS received report from the nursing. EMS entered the room and made patient contact. Patient was found standing using an oxygen concentrator as a brace. Patient was hooked up on oxygen flowing at 8LPM via nasal cannula. Patient presented baseline with no current complaints of pain. Patient had burn marks on his face from the prior night, nursing home staff informed EMS that the burns were from a cigarette from the prior night. EMS began transport to [NAME] Grace Hospital emergency room (ER) priority 1 for facial burns. EMS swapped the patients nasal cannula for a non-rebreather mask due to patient complaint of difficulty breathing. EMS arrived at [NAME] Grace ER with no incident. Patient arrived at Destination Date/Time 2025-01-11 20:28:24. Record review of the Hospital B emergency Treatment note dated 1/11/2025 at 21:10 revealed, (R401) with a history of COPD on home oxygen presents emergency department facial burn. Patient states last night (1/10/25) he was on his nasal canula oxygen and attempted to smoke a cigarette causing the nasal cannula to light on fire burning his face. Second degree burns to upper and lower lip, right face, nose. Periorbitol (around eye) swelling and edema of the lips. Patient will require transfer to a burn center. Disposition transferred to (Hospital C.) Record review of the Hospital C progress note dated 1/13/25 revealed, (R401) presents to the emergency department as a transfer after a facial burn sustained while smoking on home oxygen. Sustained ~1.5% partial thickness burns to right side of face. admitted to burn service. Integumentary: warm, dry ~1.5 % partial thickness burns to right side of face. Lips swollen with some partial thickness burns. On 1/15/25 at 2:55 PM Licensed Practical Nurse (LPN) D was interviewed and said she was called to R401's room on 1/10/25 by Sitter E. LPN D stated, R401 said he fell in the bathroom. His face appeared red. He was wearing his oxygen when I arrived, the oxygen tubing was intact. When asked did R401 have facial burns LPN D replied, The only thing I saw was redness to his face. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. On 1/15/25 at 3:45 PM LPN F was interviewed and said that on 1/11/15 R401 requested to go to the hospital. When asked did R401 have facial burns LPN F replied, (R401) told me he fell the night before (1/10/25) I saw an abrasion on his face and his face was swollen. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. On 1/15/25 at 4:00 PM the facility's Chief Operating Officer (COO) I provided Hospital C progress notes and acknowledged R401 was hospitalized for facial burns. On 1/15/25 at 4:50 PM Sitter E was interviewed by phone and said that she worked with R401 on 1/10/24 from 3PM to 11PM. Around 10:30 PM R401 went to the bathroom by himself and yelled. He was wearing his oxygen. He said he fell . I called for nurse LPN D. Sitter E said she did not smell smoke, nor did she see any burns on R401's face. Sitter E said she took R401 out to smoke on 1/10/25 around 8:00 PM by herself. Sitter E abbruptly ended the interview and did not respond to further attempts for an interview. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. On 1/16/25 at 2:15 PM and 3:33 PM Sitter E was called for an interview. Left messages with no return call. On 1/16/25 at 10:00 AM the Nursing Home Administrator (NHA) was interviewed and said she was told R401 fell and injured his face. On 1/16/25 at 10:54 AM LPN G was interviewed and said she was the was the nurse supervisor on 1/10/25 and on 1/11/25. On 1/11/25 she put in a stat (immediate) order for an Xray of R401's face due to his complaints of pain. LPN G said when she saw R401 on 1/11/25 R401 had swelling to his right eye and He had grease on his face like Vaseline. LPN G further said that R401 had a sitter for behavioral issues but could not specifically state the reason why R401 had a sitter. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. On 1/16/25 at 12:07 PM LPN H was interviewed and said that he observed EMS pick up R401 on 1/11/25 to take him to the hospital. LPN H said he assisted EMS for the hospital transfer. LPN H stated, R401 did not have any open wounds on his face when he was transported to the hospital but R401's face was swollen. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. On 1/16/25 at 2:50 PM Certified Nursing Assistant (CNA) J was interviewed and said that she worked with R401 on 1/11/25 day shift from 7AM to 3PM. CNA J said she saw R401at approximately 1:30 PM on 1/11/25. CNA J stated, I thought R401 went to the hospital because his face it looked bad. He was drooling, he couldn't close his mouth. His face was pink including his lips. Everything was pink around his oxygen canula. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. On 1/16/25 at 3:49 PM the Director of Nursing (DON) was interviewed and said R401 was sent to the hospital following his fall per the resident request. The DON said R401 experienced combustion in August 2024, smoking while on oxygen and set his face on fire. The DON agreed R401 was admitted to the hospital with facial burns. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. Review of R401's EHR for January 2025 did not reveal any documentation related to facial burns. In addition, an acute care transfer sheet (provided by the facility) was not completed or available for review as requested, for the hospital transfer on 1/11/25. The acute care transfer sheet would have documented the reason for R401's transfer to an acute care facility. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. On 1/21/25 at 12:30 PM Medical Doctor (MD) K was interviewed and said R401 had been hospitalized for facial burns. When asked how he was informed of R401's hospitalization MD K replied, I was told by a nurse from the facility that R401 was in the hospital with facial burns. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident. Review of the facility policy titled, Documentation in Medical Record date reviewed/revised 1/16/25 revealed in part: 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. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy . 4. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented. B. Documentation shall be accurate, relevant, and complete, containing sufficient details about resident's care/or responses to care.

This citation pertains to Intakes MI001444419, MI00145071, and MI00145216. Based on interview and record review the facility failed to provide adequate supervision for one resident (R402) of three residents reviewed for elopements, resulting in a moderately cognitively impaired resident with behavior issues exiting a second-floor window and falling to the ground causing a left tension pneumothorax (collapsed lung), multiple acute rib fractures, left clavicle and scapulae fractures, and thoracic vertebrae fractures. Findings include: Review of the facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 4/26/24, revealed that it was reported R402 exited the facility to the outside through his second-floor bedroom window between 10:30 PM and 10:45 PM. R402 was brought back into the facility by Licensed Practical Nurse (LPN) C and transported to the hospital at 11:02 PM. Review of the clinical record documented R402 was admitted into the facility on [DATE] to a first floor standard room (not located on a lockdown unit) with diagnoses that included left calcaneus fracture (non-weight bearing), schizophrenia, and convulsions. According to the Minimum Data Set assessment dated [DATE], R402 had moderate cognitive impairment, and required substantial/maximal assistance for sit to stand. The clinical record also revealed R402 had a guardian with the correct working phone number listed on the face sheet. Review of the care plan date initiated 4/17/24, documented: Focus: I am at risk for injury due to behaviors and impaired cognition. Interventions: I will have a sitter with me when my nurse identify I am at risk for injury or appear to be anxious/restless. Resident has impaired ability to complete activities of daily living care and needs assistance related to behavioral concerns, impaired cognition, impaired coordination, impaired mobility. Resident is at risk for falls and injury related to behavioral concerns, impaired cognition, impaired mobility, noncompliance with safety measure I had a fall on 4/18/24, 4/21/24 and 4/26/24. Interventions Nursing staff will provide me supervision and cueing as needed to maintain safety. Review of the following progress notes documented: 4/17/24 at 18:55 Resident observed in the bed at the beginning of shift. 1/2 hour later resident on both knees at the bedside. 4/18/24 at 19:34 Observed patient sliding on butt next to bedside bed sitting upright. Patient has feces on finger and nails. Gown on with soiled brief. Patient asked where was the gold. 4/21/24 at 14:43 It was reported to the writer that resident was observed on the ground outside. 4/21/24 at 14:46 resident is A&Ox2 continues to stand and walk with unsteady gait. Resident has sudden episodes of unwanted anger. Writer unable to redirect resident physician notified order for Xanax every 8 hrs as needed. 4/21/24 at 14:50 Late Entry Resident had fall when outside on smoke break with staff and other residents. Review of LPN C written statement dated 4/26/24 revealed in part . patient arrived on unit (lockdown unit requiring passcode to enter/leave) placed in room (on the second floor212 from a first floor standard room). Resident placed in bed at 10:30. Bedroom checked at 10:45. Window noted in up position. Resident not in bed. Writer proceeded to outside of building. Resident noted resting on knees, both hands touching the ground. Abrasions noted treatment implement. Resident placed into wheelchair and taken inside of building. Resident transported to hospital at 11:02 PM. Doctor, Guardian, Director of Nursing (DON) Administrator called at 11:00 PM and notified. On 7/23/24 at 2:05 PM the Nursing Home Administrator (NHA) stated LPN D had the (R402) moved to the second-floor lockdown unit because the resident needed more supervision. On 7/23/24 at 2:06 PM the DON said that the only remaining employee from the incident was LPN D. When asked the reason for moving R402 form the first floor to the second-floor lockdown unit the DON replied, I don't recall. On 7/25/24 at 3:14 PM an attempt to interview LPN D via telephone was made. A message was left on the voicemail for a return call. On 7/25/24 at 3:15 PM Guardian E was interviewed and stated I don't have a record of anyone from the nursing home requesting permission to move my resident to the lockdown unit or to change rooms. I did not receive a phone call from the nursing home telling me my resident went to the hospital. I got a call from the hospital on 4/27/24 to inform me that the R402 was in the hospital with injuries due to fall out the window. We get calls after business hours, and they are recorded and transcribed. Review of the Emergency Department Hospital Admission/Discharge record revealed in part .R402 was admitted to hospital on 4/26/24 and discharged to a skilled nursing facility on 5/14/24. Diagnosis listed as schizoaffective disorder, bipolar type. Overview note This patient with a history of schizoaffective disorder was brought into the hospital after jumping out of second story window. It seems that patient may have underlying psychosis and acted on delusions. It did not seem to be a suicidal attempt. Patient was evaluated in the emergency department and found have a left tension pneumothorax (collapsed lung), multiple acute and chronic left rib fractures, left clavicle and scapula fractures, and L T7 and T9 (thoracic spine) fractures. Review of the facility policy Abuse, neglect and Exploitation reviewed/revised 7/11/24 revealed in part .III Prevention of Abuse, Neglect and Exploitation B. identifying, correcting and intervening in situations in which neglect is more likely to occur with deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms.

This citation pertains to intakes MI00136501 and MI00136279. Based on observation, interview and record review, the facility failed to ensure money was safe from misappropriation for two residents (R201 and R202) of three residents reviewed, resulting in $6,130.00 of unauthorized ATM (Automated Teller Machine) transactions for Resident #201 and theft of $10,200.00 from Resident #202's room (financial loss) and subsequent psychological distress. Findings include: R201 A review of a Facility Reported Incident (FRI) dated 5/1/2023 documented the following: On 4/4/2023 at approximately 9:30 AM, Activity Aide (AA) L accompanied Resident #201 (R201) to the bank to make a withdrawal. The bank teller informed R201 that there was not enough money in the account to make a withdrawal. R201 requested a printout of her transactions. Upon review, R201 noticed multiple unauthorized ATM transactions on her account. R201 informed the bank that she never used an ATM card. R201 requested that her debit card be deactivated. The bank started an investigation into the unauthorized transactions. The bank also restored the total amount of money withdrawn from R201's bank account pending her cooperation with the investigation. The FRI continued and documented that on 4/21/23, AA L and R201 made a return trip to the bank to followed up on the investigation. The bank shared pictures of the perpetrator. AA L telephone the Nursing Home Administrator (NHA) from the bank and indicated the pictures of the perpetrator appeared to be Business Office Manager (BOM) E (a previous BOM that no longer worked at the facility. R201 identified the perpetrator as BOM E as well. Further review of the FRI revealed a 4/27/2023 bank print out that listed sixteen transactions: 1. 10/14/2022 - $500.00 2. 10/21/2022 - $300.00 3. 10/26/2022 - $600.00 4. 11/3/2022 - $1000.00 5. 11/14/2022 - $430.00 6. 11/16/2022 - $500.00 7. 11/22/2022 - $460.00 8. 11/28/2022 - $180.00 9. 1/9/2023 - $700.00 10. 1/10/2023 - $300.00 11. 1/13/2023 - $160.00 12. 1/17/2023 - $160.00 13. 1/26/2023 - $300.00 14. 1/30/2023 - $220.00 15. 2/1/2023 - $120.00 16. 2/6/2023 - $200.00 Unauthorized ATM withdrawals totaled $6130.00. The facility's investigation Conclusion documented: .At this time, given the evidence from the bank and the statements taken from staff abuse of misappropriation of funds is substantiated. An attempt to contact the local police department was made on 5/17/2023 at 10:40 AM. A message was left but no return call was received. According to the electronic medical record, R201 was admitted to the facility on [DATE] with diagnoses of Ventricular fibrillation, fracture of ribs right side, anemia, Parkinson's disease, schizophrenia, and anxiety disorders. R201's annual Minimum Data Set (MDS) with a reference date of 2/9/2023 indicated R201 was cognitively intact with a BIMS (brief interview for mental status) score of 14/15. During an interview on 5/16/2023 at approximately 4:20 PM R201 stated, I had an ATM card when I was in Georgia with my daughter, but I haven't had an ATM card since I been here (in the facility). R201 said she went to the bank on 10/13/2022 and made a withdrawal of $15,000 to pay the facility for her stay. R201 stated, I did not agree to other withdrawals. I am working with the head of the bank now. R201 said they paid her the money back but all of it will not be available until the investigation is concluded. R201 stated, I went back to the bank, and they showed me the camera (footage) of the business guy (Business Office Manager- BOM E) that works here. It was him. The activity person that went with me said it was him too. He had all my (financial and personal) information. R201 expressed frustration and disappointment that she was unable to fully handle her financial responsibilities. R201 explained that the facility made multiple attempts to collect money that was due to them. R201 was observed with her head down while covering her mouth and became emotionally distraught because she was unable to pay for much needed dental care. R201 described disappointment in not having money for dental work. The Facility Nursing Home Administrator (NHA) was interviewed on 5/17/2023 at 10:59 a.m. regarding R201's missing funds. The NHA was asked if BOM E still worked in the facility. The NHA said the employee was terminated before March 2023 due to poor work performance. The NHA was asked how did BOM E get R201's ATM card. The NHA stated, I don't know how the employee got access to the resident's ATM card. I was under the impression that she didn't have an ATM card. The NHA reviewed the bank's printout sheet of withdrawals from 10/14/2022 through 2/6/2023. The NHA stated, He had to have had her information to get an ATM card. He had access to all her information. During an interview on 5/23/2023 at 2:56 p.m., the Senior Bank Manager (SBM) D confirmed there was an investigation ongoing with R201's missing money but could not go into details due to bank policy. R202 On 5/11/2023 the facility submitted a report of an allegation of a resident's (R202) missing money. On 5/17/23 at 3:20 p.m. the NHA was queried regarding R202's missing money. The administrator stated, My staff called me at home and told me that R202 wanted to call the police and report somebody stole fifty-five hundred dollars from him. I believe that was on a Thursday May 11th. It was around 8 PM when the MDS (Minimum Data Set) Nurse (MDSN C) called me. I told the MDSN C to go help him (R202) to call the police to make a report. My MDS Nurse (MDSN C) said (R202) said (CNA B) stole it. (R202) said he sent (CNA B) to get him some Pepsi and she saw the one-hundred-dollar bills when he went to get a twenty to give her to pay for his Pepsi. R202 said he had ten thousand and two hundred dollars all in one-hundred-dollar bills that he kept on his bed in a pillowcase. I called (CNA B) and interviewed her. I spoke with the police over the phone when they got there. The administrator said she interviewed some staff but had not completed the full investigation at the time of the interview. On 5/17/2023 at approximately 3:50 p.m. R202 was interviewed regarding the missing money. R202 stated, (CNA B) is a girl who works here. She took $5500.00 from me. She took it out of my pillowcase. She waited until I fell asleep and took it. (Security Guard A) took the other $4700.00 that I gave him to keep for me. All together it was $10,200.00 exactly, all one-hundred-dollar bills. I took the money out of the bank because they said the bank was closing. I've been hiding it for the last three years. I was keeping the money safe until I came here, then people started to steal from me. (Before arriving at this facility), I used the money for hotels and use some to eat with. I made a mistake when I wanted to buy me a Pepsi and pulled out the only twenty-dollar bill I had. (CNA B) saw it and stole $5500.00 of it. I called the police and made a police report. I saw (CNA B) come into my room three or four times that same night. (Security A) is head of security, I told (security A) about the missing money, (Security A) said, you should have given it to me to put it in a safe place. R202 confirmed the other nursing facilities was keeping the money and provide receipt upon discharge. R202 stated, They stole the receipt here too. During the interview R202 was observed with his head held downward. R202 spoke in a soft voice as repeatedly stated he have no money to buy sodas and cigarettes. In addition, R202 reported he had no friends or family to bring sodas and cigarettes to the facility. R202 repeatedly expressed the importance of having his own money especially since he spent most of his time on the street and slept in his truck. According to the electronic medical record, Resident #202 (R202) was admitted on [DATE] and readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, history of repeat falls, hypertension, cervicalgia, spinal stenosis, lumbar region without neurogenic claudication, diabetes mellitus type two, peripheral vascular disease, atherosclerotic heart disease, and major depressive disorder. No available Minimum Data Set assessment was available. Review of the Admission Neurological assessment dated [DATE] documented as following: - Temporal orientation: Able to report correct year, month and day of the week correctly. - Recall: yes, no cue required with two of the three words. During an interview on 5/17/2023 at 4:06 p.m., NHA M of R202's previous nursing home was contacted and said R202 stayed at that facility between 3/28/2023 and 4/26/2023. NHA M was asked did she have any knowledge of R202 having a large sum of money during his stay at the facility? NHA M stated, There was no knowledge of (R202) having a large sum of money when he was in the facility, but he did have some money. The Social Services Director (SSD) J confirmed R202 did have a large sum of money all in one-hundred-dollar bills when he was in their facility (3/28/2023 to 4/26/2023) because he was part of the facility's Stand Down meeting and made staff aware that R202 had large sums of money. SSD J explained the Activity Director reported to him about R202 large sum of money. During an interview on 5/17/2023 at approximately 4:15 p.m. NHA N was interviewed and stated, (R202) was admitted [DATE] through 3/13/2023. NHA N was asked was there any knowledge of R202 having a large sum of money during his stay and was there ever a complaint made from R202 of missing money. NHA N stated, Yes, he did have a lot of money that we kept while he was here and gave him a receipt at the time he was discharged from the facility. It was in the thousands of dollars. He left with the money. He had a stack of rolled up one- hundred- dollar bills. I will scan a copy of the amount and the document of it tomorrow morning (5/18/2023). On 5/19/2023 NHA N provided a copy of R202's receipt in the sum of ten-thousand-one-hundred dollars dated 3/13/2023 prior to discharge from the facility. On 5/18/2023 at 10:35 a.m. SG A was interviewed via telephone regarding R202's missing funds. SG A was asked did he had a conversation with R202 on 5/11/2023 regarding missing money, SG A stated, Yes. SG A was asked to explain the conversation. SG A explained (MDSN C) came outside and asked to see me between 6:30 p.m. and 7:30 p.m. on that Thursday (5/11/2023). MDSN C said she found a large sum of money on R202. MDSN C had the money in her hand and counted it. MDSN MSDN C counted forty-seven hundred dollars and showed a receipt that had R202's name on it for ten-thousand-two hundred dollars. SG A stated, I asked her did she call the administrator because he (R202) was talking about some young lady had stolen some of the money already. SG A was asked what happened to the money. SG A reported that the police arrived at the facility, escorted R202 back to his room, counted R202's money, and provided R202 with a police report. On 5/18/2023 at approximately 2:34 p.m. MDSN C was interviewed via telephone regarding R202's missing money. MDSN C explained R202 came to the MDS office and reported that someone stole fifty-one- or fifty-two-hundred-dollar bills from him and wanted to call the police. MDSN C then described R202 pulled money out of his pocket. MDSN C stated, I counted the money twice with (R202) and (SG A) and it was forty-seven hundred dollars all in one-hundred-dollar bills . On 5/18/2023 at approximately 3:00 p.m. the first-floor hallway camera was reviewed for the date of 5/11/2023 and revealed staff entered and exited R202's room at the following times: - CNA B and LPN H entered at 10:24 a.m. and exited at 10:32 a.m. -CNA B and LPN H entered at 10:34 a.m. and exited at 10:40 a.m. -Wound nurse K entered at 10:40 a.m. and exited 10:46 a.m. -CNA B brought what appeared to be soda in a bottle at 12:28 p.m. in the front lobby door and entered R202's room at 12:41 p.m. - Therapist F. entered at 1:00 p.m. with a wheelchair while CNA B remains in R202's room and CNA B exited out with Therapist F pushing R202 in a wheelchair at 1:18 p.m. -R202 was observed coming back sitting in a wheelchair in front of the room at 1:35 p.m. alone. -R202 observed at 2:07 p.m. sitting in the lobby in a wheelchair. On 5/18/2023 at approximately 4:00 p.m., another interview was conducted with the facility and confirmed R202's room was searched, and no money was found. The facility NHA verbalized that R202 was never offered an opportunity to secure his funds. When asked, the facility NHA surmised the following, Either one of the staff members have it or he still have it. This is the only two conclusions. However, R202 continue to report missing ten-thousand-two-hundred dollars. According to the facility's policy titled Abuse, neglect and exploitation revised on 4/1/2023: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect exploitation and misappropriation of resident property . Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident 's belongings or money without the resident's consent.

This citation pertains to MI 177. Based on interview and record review, the facility failed to ensure proper wheelchair transport for one resident (R537) out of two residents reviewed for accidents, resulting in an abrasion, opened wound, hematoma, and an emergency hospital encounter. Findings include: It was reported to the State Agency that during a wheelchair transport a resident fell out of the wheelchair face forward and was then transported to the hospital. On 10/6/2022 at 1:51 PM, Resident #537's (R537) Concerned Family Member (CFM) stated they were present when the resident fell out of the wheelchair. CFM said when staff transported R537 down a ramp face forward, the resident fell out of the wheelchair scraping his hand and fingers, the surgical wound on his amputated leg hit the ground and reopened, the resident's head hit the ground causing a bruise to form, and the resident was sent to the hospital. A review of the Face Sheet for R537 revealed an admitted [DATE] and discharge date of [DATE] with diagnoses that included [CONDITION(S)] and peripheral vascular disease. A review of hospital discharge documents dated 9/7/2022 documented in part the following: gangrene of right foot (status/post) right above knee amputation of 8/12/2022. A review of R537's care plans documented in part the following, Resident is at risk for falls and injury related to impaired mobility, newly admitted , new surroundings. Date initiated 9/7/2022. Review of nursing progress notes, skin observations, incident/accident report, and post-fall assessment documented in part the following: 1. 9/7/2022 at 6:45 PM: Patient arrived via ambulance at 6:30 pm alert and oriented x4 able to make needs known .Resident is a right leg [CONDITION(S)] above the knee and a [CONDITION(S)] patient. 2. 9/8/2022 at 11:35 AM: (Patient) .admitted to (Facility Name) on 9-7-2022 from the hospital where he .had a right leg AKA (above knee amputation) (Patient) sent to hospital for care after acute fall and laceration . 3. 9/8/2022 at 2:43 PM: writer assessed resident, resident has an open area on the right stump. Encounter measurements are 5.5cm (centimeter) length x 5cm width x 0.5cm depth. Wound bed is pink. There was a moderate amount of (sanguineous) drainage coming from the area. The area does have an odor. Writer contacted the wound team and obtained an order for (Dakins) to the area. Resident isn't in any pain nor discomfort at this time. 4. 9/8/2022 at 3:51 PM: Writer was made aware that resident had a fall outside while being transported to [CONDITION(S)]. Writer completed assessment .resident had c/o (complaint of) pain in (his right) arm. Writer noted a hematoma on resident's right side of forehead; an abrasion on residents (right) elbow and skin tear on the fingers of residents (right) hand. Resident and family who was present requested that resident be sent to the hospital for further assessment. Resident was transported to (local hospital). MD notified. 5. Skin Observation Tool, dated 9/7/2022, upon admission: Skin intact: Yes. Bruise: Right wrist Left lower leg (front and rear): scaly skin 6. Skin Observation Tool, dated 9/8/2022, post fall: Skin intact: No. Resident had a previous wound on right stump. Face: Hematoma Right Hand: Skin tear Right elbow: Abrasion 7. Incident/Accident Report, dated 9/8/2022: Incident Description - Nursing: Writer was called to the porch, writer observed resident laying on his right side on the ground. Incident Description - Resident: Resident stated that he slid out the chair. Immediate Action Taken: (R537) receive a skin, pain & neurological assessment. Resident was placed back in his wheelchair. Physician notified about the incident and ordered resident be sent to the hospital. Writer and staff stayed with resident until EMS arrived. Injuries Observed at Time of Incident: Right elbow abrasion; right hand (palm) skin tear; face hematoma. 8. Interdisciplinary Post-Fall Assessment, dated 9/8/2022: Description of fall: Resident stated that he slid out of chair Injury description: right elbow abrasion, hematoma to face, right hand skin tear Mental status: alert and orientated Gait balance deficits: wheelchair bound / non-ambulatory Activity at time of fall: Staff assisted Consider a probable cause for this fall based on review and investigation: Resident was moving quickly in wheelchair. Recommendations from review by IDT (interdisciplinary team) and primary/attending physician: Resident to be taken down declining ramp backwards with staff assistance. During an interview and record review on 10/6/2022 at 4:27 PM, the Nursing Home Administrator (NHA) reviewed R537's post-fall assessment and stated, He had a fall. The NHA was unable to answer 'how' and 'why' R537 fell out of the wheelchair. The NHA said there were no interviews available for review. During an interview on 10/6/2022 at 4:41 PM, the Director of Nursing (DON) stated R537 fell on his way to an appointment. The resident was full of energy and somehow slid out of his chair. The DON did not have written statements from the transportation driver or family member present. During an interview on 10/6/2022 at 4:50 PM, Transportation Driver (TD) I said R537's nurse cleared the resident to go to his [CONDITION(S)] appointment. The resident was agitated and cursing. TD I stated, I was taking (R537) to his hemodialysis appointment and was pushing him in his wheelchair. TD I said while she was pushing R537 slowly down the ramp he stated, I'm not going. R537 then slid himself out of the wheelchair. TD I said while she was pushing him down the ramp face forward in the wheelchair, she had one hand on his shoulder to hold him in the wheelchair. TD I said she was unsure of what part of R537's body hit the ground first but reported that his leg and hand hit the ground and then his face. During an interview on 10/6/2022 at 5:07 PM, Therapy Director, Occupational Therapist EE stated, You take a resident down the ramp backwards, so they are facing away from the decline. Therapy Director EE added the resident would be more at risk for sliding out of the chair when they are facing towards the decline. During an interview on 10/7/2022 at 10:15 AM, the DON said that it's possible the fall could have been prevented if the resident had been turned backwards while going down the ramp. The DON stated, (TD I) was taking the resident down face forward. The resident should have been turned the opposite way. The facility policy titled, Incidents and Accidents, dated 10/7/2022 was reviewed and revealed in part the following: - It is the policy of this facility for staff to utilize Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. - Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. - If an incident/accident was witnessed by other people, the supervisor or designee with obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or administrator. On 10/7/2022 at 6:00 PM during the exit conference, the NHA and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

This citation pertains to MI 509 and MI 557. Based on observation, interview, and record review, the facility failed to provide adequate security and supervision to prevent an elopement from the facility, for one sampled resident (#23) who was moderately cognitively impaired and had diagnoses of paranoid [CONDITION(S)] and diffuse [CONDITION(S)]. Resident #23 (R23) eloped from the facility on 5/16/2022 at 3:06 AM from the front door which was left ajar by a rug. R23 was found approximately 50 minutes later wandering a major street resulting in the likelihood for serious injury, harm, or death. The Immediate Jeopardy (IJ) started on 5/16/2022 and was identified on 6/22/2022. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 6/22/2022 at 2:43 PM and was asked for a plan to remove the immediacy. The IJ was removed on 6/22/2022 at 5:35 PM based on the facility's implementation of the removal plan as verified onsite on 6/22/2022. Although the immediacy was removed, the facility deficient practice remained isolated with the potential for harm that is not immediate jeopardy. Findings include: During an observation on 6/22/2022 at 9:15 AM, rugs were noted placed at the two front entrance doors to the facility. During an observation on 6/22/2022 at 10:25 AM, R23 was observed sitting near the nursing station on the lockdown unit. A review of the clinical record documented R23 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R23's diagnoses included paranoid [CONDITION(S)], diffuse [CONDITION(S)], and dementia with behavioral disturbance. A Minimum Data Set assessment of 3/4/2022 documented moderate cognitive impairment and supervision with one-person physical assistance for movement about the housing unit. On the date R23 eloped from the facility, he did not reside on a lockdown unit. An Elopement Risk assessment dated [DATE] documented R23 was not an elopement risk. A review of the facility's Investigative Summary regarding R23's elopement revealed in part the following: On 5/16/2022 it was reported to NHA C (the previous NHA) at approximately 7:13 AM that R23 had left the facility. At 7:53 AM NHA C was informed that R23 was located at a local hospital. NHA C spoke with R23's physician who confirmed that R23 was at a local hospital and was admitted at 4:30 AM. NHA C viewed the facility's camera, and it was witnessed that R23 left the facility at 3:06 AM through the front door. The front door was ajar due to being caught on a rug and did not close all the way. The rug was removed immediately. According to the hospital notes R23 approached EMTs (Emergency Medical Technicians) and they took him to the hospital. During an interview on 6/22/2022 at 12:40 PM, Social Work Manager K from the local hospital, reviewed the hospital's clinical notes and the EMS (Emergency Medical Service) run sheet related to R23's hospital admission of 5/16/2022 and reported the following: EMTs found R23 wandering on a main road in a major city approximately .9 mile from the facility. R23 was found soaked from the rain and exhibited an altered mental status. The EMTs transported R23 to the local hospital. R23 arrived in the Emergency Department at 4:27 AM on 5/16/2022. The local hospital contacted the nursing home and informed them of R23's admission. R23 was discharged from the hospital on 5/18/2022. According to the website www.timeanddate.com, the weather at the time and location where R23 was found on 5/16/2022 was rain, fog, and 57 ºF (Fahrenheit). During an interview on 6/22/2022 at 10:00 AM, Licensed Practical Nurse (LPN) G arrived at the facility at 7:00 AM on 5/16/2022 and was told R23 was gone. LPN G stated, They were looking for (R23) inside and outside. (R23) was housed on the second floor. During an interview and record review on 6/22/2022 at 1:30 PM with NHA A the following was revealed: None of the staff witness statements regarding R23's elopement indicated the time staff discovered that R23 was missing. NHA A stated, I got a call around 7 AM from (NHA C) telling me to come to work immediately because she was just notified that there was an elopement. NHA A indicated Certified Nurse Aide (CNA) L worked the midnight shift on the housing unit were R23 resided on 5/16/2022. During an interview on 6/22/2022 at 1:44 PM, CNA L stated about R23's elopement, He ran away. It was raining that Sunday. He kept going to the elevator. He always did that. I found out he was missing. I don't know what time it was. I looked in all the rooms. I told the nurse. (R23) had on blue pants and a sweatshirt (the day he eloped). During an interview on 6/22/2022 at 3:15 PM, NHA A stated if a resident was trying to get on the elevator on the midnight shift that would send up smoke signals and staff should have notified someone. We have done so many elopement drills. Staff should know better. The facility policy titled, Elopements and Wandering Residents, reviewed 5/16/2022, documented in part the following: - This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. - Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. - Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so. - The facility is equipped with door locks/alarms to help avoid elopements. - The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment or risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. A written plan for removal for the IJ was received and verified on 6/22/2022. Residents at Risk - Resident #23 still resides in the facility and has not suffered any ill or adverse affects. - He continues with his plan of care and life enrichment activities. - All residents are at risk of this deficient practice of elopement. Identifying other residents at risk 1. Beginning 5/16/22, and again on 6/23/2022, all residents are at risk for this deficient practice. 2. Beginning 6/23/2022 all admissions and re-admissions will be evaluated for the potential of elopement. 3. Beginning 5/16/22, and again on 6/23/2022, All staff were educated on elopement and elopement precautions. 4. Beginning 5/16/22, and again on 6/23/2022, The facility conducted an audit all residents that have the potential to be affected. The facility has identified 21 residents who are at risk for elopement. Care plans have been reviewed and revised as necessary. Reassessment for elopement for all residents has been completed. Processes Implemented to prevent further occurrence 1. Policy entitled: Elopement and Wandering Residents has been reviewed by Administrator and DON (Director of Nursing) and deemed appropriate on 6/22/2022. 2. The elopement book was reviewed on 6/22/2022. 3. Beginning 5/16/2022, and also on 6/23/2022, the facility medical director has been notified and received the components of the plan of correction for approval. 4. Beginning 5/16/2022, and again on 6/22/2022, the Administrator had the rugs from the front entryway removed. The staff have been educated by the Administrator, again on removal of the rugs from the front entryway, on 6/22/2022. 5. On 6/22/2022, an emergency QA (quality assurance) was held to review processes related to elopement and all elements outlined in this abatement plan. 6. Beginning 6/23/2022 an additional audit of residents at risk for elopement was initiated /completed and all concerns identified were corrected immediately. 7. Beginning 5/16/2022, a 3rd shift security officer was hired to mitigate the risk of a resident's ability to leave the premises. That position remains filled. 8. Beginning 6/23/2022, all entry and exit doors to the dementia unit have been evaluated and found to be in appropriate and working order. 9. Beginning 6/22/2022 entry ways to the dementia unit shall be checked twice daily/PRN (as needed). 10. Beginning 6/23/2022 all staff have been re-educated on the policy for elopement, specifically as to when to notify the Administrator, DON and or/designee of the alleged incident. 11. Beginning 6/23/2022 any staff that have not received education related to this tag will receive this education via telephone, and again in person on their next scheduled day of work. Monitoring 1. Beginning 6/22/2022, the Administrator created an audit tool for monitoring residents at risk for elopement and will checked 3X weekly for compliance, X4 weeks, and then monthly X3 months. 2. Beginning 6/23/2022 elopement assessments will be completed quarterly, annually, and with changes indicating exit seeking behaviors. 3. Beginning 6/23/22 Results from the audits will be reported to the QA committee for monitoring and follow up. 4. Beginning 6/22/2022 The Administrator and/or designee will conduct audits for completion and appropriate follow up twice weekly X 4 weeks than monthly X 2 months/PRN. Beginning 6/22/2022 the Administrator is responsible for substantial compliance with this plan of action. On 6/23/2022 at 3:15 PM, NHA A and DON B were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no substantially new information was provided.

This citation pertains to intake numbers MI 895. Based on interview and record review, the facility failed to properly assess, document, care plan and implement timely pressure ulcer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Complainant for (R#102) reported to the State agency that pressure sores developed while at the facility and that R#102's pressure sore was Infected. R#102- On 3/3/2021 at 10:35 a.m., per review of the clinical record, R#102 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] ., [CONDITION(S)] disease, and [CONDITION(S)]. The quarterly Minimum Data Set (MDS) completed 12/20/2020 noted R#102 had moderately impaired cognition, required supervision for transfers and independent bed mobility and had no skin breakdown on admission. The facility's Skin Observation Tool dated 12/01/2020, 12/08/2020, and 12/15/2020 noted R#102's skin intact with no previously identified skin concern observed. On 2/8/2021, R#102's noted, Skin eschar on toes with pink area to right great toe, slit to buttocks midline. The facility's Skin Observation Tool did not reveal a skin observation occurred after 12/15/2020 through the month of January 2021 for R#102. Review of Resident #102's Risk for Pressure Ulcer care plan dated 9/23/2018 documented, Risk for pressure ulcers formation related to: generalized debility and weakness as evidenced by: decreased mobility in bed and wheelchair, occasional incontinence of bladder, need for assistance with transfers . Interventions .Monitor for any areas of redness or non-blanching skin (Gently press the reddened area if it blanches white (As the blood is pushed out of the capillaries) then goes red again (As the capillaries refill) this is a normal reaction, monitor skin condition, alert nurse and physician of any changes in skin condition immediately .monitor skin daily during care for [CONDITION(S)] (Fluid Buildup), redness, excoriation (To scratch or wear off the skin resulting in an abrasion), or breakdown. Preventative skin care to be done every shift an as needed with any incontinence episodes .weekly nursing skin assessments. Daily Certified Nursing Assistance (CNA) skin checks. Notify Physician of any skin changes. No updated Skin care plan for R#102 was found. Review of the requested facility's Treatment Administration Record' for the month of February documented, No order data found for treatment administration record. Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's First Floor scheduled Showers documented, R#102's weekly day shift scheduled showers were Wednesday's and Saturday's. On 3/3/2021 at 1:45 p.m., the Director of Nursing (DON) and the Administrator was asked to present R#102's scheduled shower sheets for the month of February. R#102's shower sheet was not presented to the surveyor prior to exiting the facility. A record review of R#102's nursing note dated 2/9/2021 at 7:28 a.m., Patient observed having black toes on right foot, with reddened on great toe and wound consult ordered. There were no documented nurses' notes regarding the identified skin changes on (2/8/2021), and no treatment orders for further care. The Nurses Progress Notes dated 2/9/2021 at 09:25 a.m. documented, Resident request to be transferred to the hospital. Resident complained of increased pain level, but denied pain relief measures .On 2/9/2021 at 10:00 a.m. transported resident to Hospital .On 2/26/2021 at 22:28 (10:28 p.m.) resident received from hospital .On 2/27/2021 resident noted to have fresh blood from right stump .instructed to send out to hospital, 911 called and arrived to transport resident to hospital . On 3/3/2021 at 3:35 p.m., the DON and the Administrator was asked, was the Wound Nurses responsible for skin assessment of the residents? The DON stated, They do the residents skin assessment upon admission/re-admission, and if something is going on with the resident. The floor nurses are to look at the resident's skin on their scheduled shower days. The DON was asked, to explain the process of how the floor nurses assess the resident's skin on their scheduled shower days. The DON stated, When the CNA's take the residents in the shower room, the nurses are to go into the shower room to do a head-to-toe skin assessment. If the resident wants a bed bath, they should still go into their room and do a skin assessment on their scheduled shower days. If there are any skin issues, they should notify the doctor. The wound physician comes Tuesday's and Thursday's. The DON was asked, how many showers a week does the residents received? The DON stated, They get two showers a week. The CNA also should be doing the resident's skin assessment when they are giving care daily. The Administrator and the DON was informed of R#102's pressure ulcer to the right great toe and buttocks prior to discharged . The DON validated the midnight nurse should have started a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked should the nurse who identified the wounds have started the treatment? The DON stated, Yes, I agree with you, she should have, and I will address it. The DON stated, I didn't know he had no skin issues when he left the facility. A review of the facility's policy titled Pressure Injury Prevention and Management reviewed/revised dated 2021 documented, This facility's is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries .2.The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underling risk factors; monitoring the impact of the interventions: and modifying the interventions as appropriate .3. Assessment of Pressure Injury Risk: a) Licensed nurse will conduct a pressure injury risk assessment, using the .designated tool on all residents upon admission/re-admission, weekly x four weeks, then monthly or whenever the resident's condition changes significantly .Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task .

Based on observation, interview, and record review, the facility failed to properly maintain infection control practices during a COVID-19 Infection Control Survey resulting in the risk of serious harm to three sampled resident (R#1, 2 and 3) out of a total sample of three reviewed for infection control practices. The surveyor identified the Immediate Jeopardy (IJ) on 4/2/20 at 12:25 PM and determined that the IJ began on 4/2/20 as a result of R#1 being in respiratory isolation (droplet precaution) for presumptive [MEDICAL CONDITION] (COVID-19) symptoms which included cough, temp 100.4, lethargy, diarrhea, nausea and vomiting and staff using inadequate Personal Protective Equipment (PPE), subsequently observed entering in and out of two resident rooms. The Director of Nursing (DON) was notified of the Immediate Jeopardy (IJ) on 4/2/20 at 3:40 PM. A plan to remove the immediacy was requested. The IJ was removed on 4/2/20 at 4:57 PM. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with risk of serious harm. Findings include: Resident #1 Record review revealed that R#1 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] noted the resident's cognition was moderately impaired. Nurses progress notes documented the following: -3/31/2020 08:50; Resident is lethargic and not eating. Resident had cough. Skin is hot and dry to touch. Temp 100.4. (name of physician) notified and orders received to transfer resident to the hospital. Orders noted and resident ready for transport to the hospital. -3/31/2020 11:47; Unable to transfer resident to the hospital because hospital's are not accepting new patients . -3/31/2020 15:01; Resident having episodes of nausea and vomiting. Also having diarrhea. Ambulance called for resident transport to the hospital. Resident continues to be lethargic and is not eating or taking fluids. Temp 99.7 . -3/31/2020 23:25; Resident moved to (private room) from previous room (shared room). Resident is more lethargic. Responds to verbal stimuli. Presents with dry, non productive cough. Lungs clear to auscultation and diminished throughout .Will continue to monitor. -4/1/2020 06:59; Resident received alert and responsive ,contact precautions in progress . -4/1/2020 11:49; Resident is alert and verbal with confusion, on antibiotic in progress . A care plan dated 3/31/20 documented: I am at risk for exposure to the COVID-19 virus, due to my clinical state. COVID-19 precautions with an approach of place on droplet contact and airborne precautions resident is to remain in isolation until no s/s (signs or symptoms) of COVID-19 are observed. At 11:45 a.m., Unit Manager B reported Resident #1 was the only resident in the building with respiratory symptoms. At 12:25 pm, observation was made of Certified Nurse Assistant (CENA F) in R#1's room feeding the resident her lunch. Observation was made of PPE equipment in a bin out side of the resident's room. There was no posting on the door indicating to visitors, staff or other residents what type of isolation precautions R#1 was in. While observing from the doorway, CENA was noted to be eating her own food while feeding R#1. The CENA had no gloves or gown on (creating the potential for uniform contamination-the presence of an impurity or undesirable element that spoils or corrupts). The CENA had her face mask pulled down under her chin (not covering her mouth so that she could consume her own food). Upon entering the room observation was made of a divided plate of pureed textured food which CENA F was feeding to the resident. Also noted sitting on the meal tray (not on a plate) was a regular textured half eaten piece of chicken, a half eaten roll and a completely eaten piece of corn on the cob. No paper products were observed in use. When the CENA was asked if she was eating she stated, No. I mean Yes, me and (name of resident) are having lunchy, lunch. We are having a lunch date. I have lunch with her because she is in isolation and in here by herself. The CENA was asked where she got the food she was eating to which she responded, from the kitchen. At this time Staff Nurse E was asked to come to the room. Nurse E said that R#1 was in Contact isolation precautions (used for infections that spread by touching. Healthcare workers should wear gown and gloves while in the patient's room). Upon entering the room Nurse E told CENA F, throw that food away. Where are your gloves? Where is your gown? CENA F responded, I didn't think we were suppose to wear gloves when we feed residents. At 12:38 pm, observed CENA F coming out of room belong to R#2. Continued observation revealed CENA F going into the room belonging to R#3. The CENA was noted entering R#3's room and adjusting the nasal cannula (tubing for the delivery of Oxygen) saying (Name of resident) you need to wear your oxygen. Resident #2 Review of a Admission Record revealed, Resident #2 readmitted to the facility on [DATE] and with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment, with a reference date of 1/14/20, revealed Resident #2 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14, out of a total possible score of 15. Review of Progress Note on 4/2/20 at 2:30 p.m. revealed, the Physician diagnosed Resident #2 with a Urinary Tract Infection on 3/29/20. Resident #3 Review of a Admission Record revealed, Resident #3 readmitted to the facility on [DATE] and with pertinent [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, with a reference date of 12/16/19, revealed Resident #3 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14, out of a total possible score of 15. At 1:00 p.m., in interview, Infection Control Nurse C reported Resident #1 was in Respiratory (droplet) isolation precautions (used for diseases that are spread through particles that are exhaled. Healthcare workers having contact with or exposure to such patient are required to wear a mask) because of respiratory symptoms. At 1:12 p.m., the Director of Nursing (DON) confirmed Resident #1 had respiratory symptoms and was in Respiratory isolation precautions. At 2:15 PM observation was made of a Contact Precautions (not Respiratory Precautions) posting hanging on the door of the room belonging to R#1. In an interview on 4/2/20 at 2:21 p.m., the DON reported there should be a posting for Respiratory isolation precautions on Resident #1's door, not Contact isolation precautions. Review of the policy titled, COVID-19 Outbreak Containment dated 3/3/20 documented, Staff will follow infection prevention and control measures to prevent and control COVID-19 transmission .a. Persons who develop acute respiratory illness symptoms, fever, cough, nausea, vomiting or diarrhea. b. Note: Elderly persons and other residents, including those who are medically fragile, may manifest atypical signs and symptoms with COVID-19 virus infection, and may not have fever .The following infection prevention and control measures, recommended by the CDC (Centers for Disease Control), will be followed to prevent person-to-person transmission of COVID-19 and to control infectious outbreaks: When a resident develop acute respiratory illness symptoms, fever, cough, nausea, vomiting or diarrhea their physician will be called immediately. Respiratory isolation will be implemented until the physician has deemed the resident not infectious. Place a sign on the door that says please see staff before entering room. The resident will be serviced meals in their room while in isolation, paper products will be used and discarded after meals. Staff will don PPE prior to entering the room and discard PPE in the resident's room before leaving the room. Use alcohol rub prior to leaving. WASH HANDS WHEN YOU COME OUT OF THE ROOM .Place resident in a private room. If a private room is not available, place (cohort) suspected COVID-19 residents with other residents suspected of having COVID-19; cohort confirmed COVID-19 residents with other residents confirmed to have COVID- 19. Staff will wear a surgical mask upon entering the resident's Remove the mask when leaving the resident's room and dispose of the mask in a waste container. Abatement: Removal plan for Immediate Jeopardy 4/2/20 Action taken for resident Resident #1 remains on droplet precautions. She was assessed for changes in her condition her vital signs remain within normal limits. There is no noted decline related to this practice. Her physician was notified and her guardian company was called, her vital signs will be monitored every 2 hours to monitor for changes, x24 hours. 2 signs have been posted on the outside of her door and one sign posted inside the room to reflect the resident is on droplet precautions. There is also a notice posted to check with nurse prior to room entry. Resident #1 room was cleaned by staff. Action taken for staff The Identified CENA was immediately removed and was given a 1:1 education on droplet precautions, proper use of PPE, and Covid-19 prevention by the DON. The identified cena completed infection control transition based precautions on Health care Academy as well. The CENA was sent home. The Unit Manager was assigned to take over the CENA's duties for the remainder of her shift. On the spot education was given to staff members present regarding proper use of PPE, infection control policy regarding droplet precautions as well Covid-19 prevention outtakes and containment. The remaining staff will be educated on these policies/guidelines, prior to the start of their shifts until complete.

This citation pertains to Intake MI 750. Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision, effective monitoring, effective search procedures, and maintain functional perimeter equipment for one resident (R401), who exited the facility through the back door and outdoor entrance gate, of two residents that were reviewed for elopement/wandering risk, resulting in an immediate jeopardy on 2/25/19 at approximately 3:00 a.m., when R401 eloped from the facility undetected by staff and was discovered about an hour later at a local fast food restaurant. This deficient practice placed all residents at high risk for further undetected elopements, significant harm, injury and/or death. Findings include: On 3/13/19 at 8:02 a.m., review of R401's clinical record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set assessment dated [DATE], the Resident was severely cognitively impaired and required limited assistance with most activities of daily living (ADLs). The MDS also documented the Resident exhibited wandering behavior 1-3 days within a 7 day look back period. R401 was also independent with ambulation (walked independently without an assistive device). On 3/13/19 at 8:05 a.m., further record review of R401's medical record revealed that in the hospital discharge documents dated 8/14/19, Elopement risk due to dementia, has sitter. This was circled. The hospital record also noted the Resident had a [DIAGNOSES REDACTED]. An elopement assessment was completed by the facility on 8/20/18 documenting R401 was 'at risk' for elopement. An elopement care plan was also initiated and implemented on 8/27/18. Review of the facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 2/25/19, revealed that it was reported R401 exited the facility through the back door at approximately 3:00 a.m. and out of the outdoor entrance gate around 3:30 a.m. The Resident was discovered not to be in the facility at approximately 4:00 a.m. after an alarm was heard going off by a nurse aide. After the search of each room on the unit, R401 was discovered not to be accounted for and the nurse aide notified the nurse. After the attending nurse was notified, the Elopement Protocol was not initiated nor was the Administrator or Director of Nursing (DON) notified. At 4:07 a.m., an oncoming nurse saw a fire truck trying to enter the gate. The nurse also noticed the outdoor gate partially opened. Upon arrival into the facility, the oncoming nurse was notified immediately of the missing resident. The oncoming nurse then proceeded to notify the Director of Nursing at 4:20 a.m. The Administrator was notified at 4:41 a.m. The facility's investigation concluded: R401 left the building via the back stairway after pushing the exit door for fifteen seconds. The alarm sounded on the stairway. The Resident then proceeded down the back stairway and pushed on the exit door and walked down the ramp. The Resident proceeded through the gate. The front gate malfunctioned earlier on 2/24/19, at 11:00 p.m. The malfunction resulted in the front gate being partially open. The malfunction allowed the Resident to walk out of the parking lot, through the gate. It was then believed the Resident walked 0.6 miles (approximately 1.25 city blocks) to a local fast food restaurant, which was located across a major road. The Elopement Code (Code E) was not called as per policy. The Administrator nor the Director of Nursing were notified by staff on shift. The Resident was observed at the front gate, returning to the facility, inside of an EMS (Emergency Medical Services) vehicle. The Resident was subsequently transferred to the hospital and diagnosed with [REDACTED].) Temperature on 2/25/19 at 3 a.m. reported as 27 degrees Fahrenheit). The Resident did not return to the facility and was transferred to another facility post hospital stay per the legal guardian's request. On 3/12/19 at 11:06 a.m., the witness statement from the Security Guard F was reviewed. The witness statement documented the Security Guard F stated on 2/25/19 at 3:30 a.m., A lady knocked on my window while I was sitting in the office. The lady said, 'I'm looking for(NAME)Mc(NAME), she had a fall off the third floor'. I called the second-floor nurse, whom stated he did not know of any residents named(NAME)Mc(NAME). I then called the first-floor nurse whom stated she not know of a patient named [NAME]. The nurse requested me to make the lady leave the building. The lady had on shoes, pants, hat, and a shirt, no coat. At 4:00 a.m., the fire department came and asked me if I had a missing patient. At this time, I did not know if I had a missing person. The Security Guard F was terminated on 2/28/19. He was also unavailable for interviewing. On 3/13/19 at 3:14 p.m., The Administrator was asked if the lady asking for(NAME)Mc(NAME) was R401. The Administrator stated, I'm not one hundred percent sure, but I'm going to assume it was (R401). The witness statement from the first-floor midnight shift nurse, Nurse G was reviewed. The witness statement documented the Nurse G stated on 2/25/19 at 3:00 a.m., I received a call from the front desk asking if I had a patient named(NAME)Heart. I stated that I did not have a patient named [NAME]. I called upstairs to se if they had a patient named(NAME) but they did not. I then called the front desk back and told him no one was here by that name. At 3:13 a.m., I went to the front desk to check on the person at the door, but they were gone. At 4:05 a.m., the aid came from upstairs and stated that there was a patient missing. The aid stated the patient's name. Once she stated the name, I connected the two and realized that it may have been the person at the front door. I remember hearing an alarm at 3:10 a.m., but I did not have the code to the doors. I did not call the DON or the Administrator. The witness statement further documented that at 11:00 p.m., Nurse G noticed the outside gate was open. Nurse G was terminated on 2/28/19 and unavailable for interviewing. The witness statement from the second-floor midnight shift nurse, Nurse H (the Resident's nurse) was reviewed. The witness statement documented on 2/25/19 at 3:00 a.m., The aid came and got me and stated that the alarm was going off. I got up and went to check the door. I was on 2 South (locked unit). I looked to see if I could see a patient but did not. I checked the stairs, hallways, each of the rooms, and bathrooms. I noticed (R401) was missing. I last saw the Resident between 2:00 a.m. and 2:30 a.m. sleeping in bed. The witness statement also documented that Nurse H was aware of the Elopement Protocol but did not use it. Nurse H also did not call the DON or the Administrator. Nurse H was terminated on 2/28/19 and unavailable for interviewing. On 3/13/19 at 10:21 a.m., the rear door R401 was alleged to have exited from was observed. The rear door lead to the rear side of the facility which lead to the parking lot. The Administrator was asked to activate the door alarm. The Administrator activated the door alarm. The alarm made a moderate volume beeping sound. The Administrator stated, The other alarm was quieter before we replaced it with this one. Once the alarm was activated, it alarmed for about thirty seconds before staff responded. A staff member from maintenance, who was already outside, did respond to see why the alarm was going off. However, no one from the inside of the building responded to the alarm. On 3/13/19 at 10:24 a.m., the stairway was exited onto the first floor. Once the door was closed, the rear door alarm could be faintly heard, then a blaring noise came from the alarm alerting several staff. The alarm on the first floor was disabled as well as the rear door. On 3/13/19 at 10:28 a.m., R401's room was observed on the second floor. The second floor was also the Dementia Unit. The floor was divided into two sections, with the Dementia Unit located about 75-100 feet from the stairway and through locked double doors. However, R401's room was located approximately five feet from the stairway. The Administrator was asked to activate the alarm. The alarm was activated by pushing on the door. The alarm also had a moderate volume beeping sound. After fifteen seconds, the door opened and continued to beep until deactivated by key pad. The Administrator was asked would the nurse be able to hear the alarm if on the locked unit. The Administrator stated, No. He would not have heard it, but the nurse aide should have heard it. On 3/13/19 at 3:14 p.m., the Administrator was interviewed. The Administrator was asked if the Elopement Book (binder located on each unit and the front desk containing information about residents including a photo in the event the resident elopes) had R401's information in it prior to the elopement. The Administrator stated the book contained R401's information including a photo. The Administrator was asked how often the gate has malfunctioned within the last three months. The Administrator stated, The gate malfunctioning is a rarity. That day, it was cold and possibly frozen. Once maintenance was notified, he came in and reset the gate immediately. There have been no issues since then. The Administrator was then asked what the procedure for reporting maintenance concerns is. The Administrator stated, All staff are instructed to notify maintenance immediately if the gate malfunctions as well as other building concerns. My phone number and the Maintenance Director's phone number are posted. The Administrator was then asked why the Administrator, DON, or Code E were not called immediately, once the Resident was noticed missing. The Administrator stated, All staff were in-serviced on elopement and I'm not sure why that didn't occur on that day. The Resident's nurse resigned during the investigation and would not give any information. The other nurse could not offer an explanation other than 'I just didn't'. On 3/13/19 at 3:42 p.m., the Maintenance Director was interviewed. The Maintenance Director was asked was he made aware of the gate malfunctioning when it was initially noticed. The Maintenance Director stated, I was not made aware until I was called after (R401) got out. I came here immediately to fix the gate. That was about 5:00 a.m. The Maintenance Director was then asked if the gate was completely closed, would a Resident been able to get out. The Maintenance Director stated, The only way the gate opens automatically from the inside is with a vehicle. No one would be able to walk out the gate unless it was open. On 3/13/19 at 2:45 p.m., the facility's policy titled Elopements and Wandering Residents date implemented 1/7/18, date reviewed/revised 2/7/19 included: This facility ensures that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . The secured unit is equipped with door locks/alarms to help avoid elopements . Alarms are not a replacement for necessary supervision. Staff should be vigilant in responding to alarms in a timely manner . Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: Adequate supervision will be provided to help prevent accidents and elopements . Procedure for Locating Missing Resident . Any staff becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code) . The designated facility staff will look for the resident . If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department . Prevention of Elopements: Room placement for easy observation . Review physical plant to be sure door alarms are working and that unauthorized areas are properly locked to prevent resident entry . The immediate jeopardy was identified on 3/12/19 at 1:50 p.m. The immediate jeopardy began on 2/25/19 at 3:00 a.m. when the resident exited the facility undetected by staff through the back door. The Administrator was notified of the Immediate Jeopardy on 3/12/19 at 1:50 p.m. and a plan for removal was requested. The surveyor verified the removal of the immediacy on site by record review and interview on 3/13/19, when the facility had the following in place: The following Steps were completed on 2/25/19 unless otherwise stated. 1. Audited all residents to determine if they are at risk for elopement. 2. Update/review care plans for residents at risk. 3. Update/review care guides for residents at risk. 4. Audit all elopement books to determine residents at risk are placed in the book along with a picture and description. 5. Reviewed all door alarms to ensure alarms are in working condition. 6. Elopement Drills conducted (MONTH) 26, 2019. 7. Added an alarm to the bottom stairwell door. 8. Staff given new badges to remind them of the elopement process. 9. A Facesheet book was developed and placed at the front desk. 10. The Admission Director give security notice of a new admit and time of arrival. 11. Employees Licensed Practical Nurse (LPN) H, LPN G and Security Guard F were suspended (MONTH) 25, 2019 and terminated (MONTH) 28, 2019. 12. Gate fixed by the Maintenance Director on 2/25/19 at 0600. 13. Due to the staff not responding appropriately to the elopement or calling a Code E, administration started the in-servicing process with staff. Staff were in-serviced on the elopement policy on 2/25/19. Although the Immediate Jeopardy was removed on 3/13/19, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

This citation pertains to Intake # MI 133. Based on observation, and interview the facility failed to follow safe food handling practices by preparing, distributing and serving food that was exposed to a potential pathogen source (ground seepage water located under the stove, oven, fryer and food prep table) resulting in the likelyhood for an outbreak of a food borne illness resulting in immediately jeopardy affecting 79 residents that received meals from the kitchen. Immediate Jeopardy was identified: On 9/4/18 at 10:20 AM. The Administrator was notified of the Immediate Jeopardy on 9/4/18 at 1:23 pm. The facility was requested for a written plan of correction for abatement. Although the immediate jeopardy was abated on 9/4/18 at 12:25 pm, the facility remained out of compliance with a scope and severity of wide spread, no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to sustained compliance that could not be verified by the state agency. On 9/4/18 at 8:07 a.m., during a tour of the kitchen with the Dietary Manager (Staff A) observation was made of standing seepage water located underneath the food prep sink, the fryer, the stove and the oven. Pockets of seepage water were also noted around the drain located in front of a reach in refrigerator. There was a faint sewage odor noted in the immediate area. The floor tiles in front of the reach in refrigerator were bucked up and some of the floor tiles were missing. Upon stepping on the floor tiles, seepage water squished out from under them. Staff A was asked about the standing water and stated, I believe the water is seeping up under the tiles because of a broken hot water pipe under the floor. We did have two broken pipes. A company came out and gave us a quote to repair the two broken pipes, but only one was repaired (pointing to an area near the tray line approximately 6 feet from the affected area). We had a flood and it buckled up the floor tile in front of the refrigerator, that is why some tiles are missing. I've been telling the administration about it since (MONTH) (2018), we have had a couple of new Administrators since that time and it's not being taken care of. Staff A was asked if the standing water posed a health risk in the preparation of food to which she responded, I think it could. I don't know if the water is clean or dirty. To my knowledge it's dirty because is has come into contact with pipes, the ground and the floor tiles. My staff keep mopping it up, but it just keeps coming back. At 8:52 a.m., along with the Maintenance Director (Staff B) during a tour of the kitchen he was asked about the observed standing seepage water under the food preparation appliances (food prep table, fryer, stove and oven). Staff B provided a documented repair quote from a plumbing, electrical and mechanical company dated 12/1/17 documenting, (Name of company) will provide the necessary parts and labor to replace the damaged cast iron drain line in the kitchen floor .excavate concrete to expose the existing 3 or 4 inch cast iron drain line .line runs from near refrigerator to clean out by the storage rack .remove spoils, replace up to 20 linear feet of cast iron drain line with [MEDICATION NAME] chloride (PVC-synthetic plastic) .inspect existing drain line with camera .backfill and cement floor to rough grade only .Pricing for 20 foot of pipe repair: (amount) .Pricing for 10 foot of pipe repair (amount). Staff B said that one drain line pipe was repaired on 3/3/18 in the kitchen, but the second repair had not been authorized to be completed. Observation in the kitchen at 10:25 a.m., revealed a pan of corn on the cob cooking on the top of the stove as well as hamburgers, pork loin and bacon cooking in the oven. Under the stove and oven where the food was being prepared was standing seepage water. Small puddles of water were noted around the adjacent floor drain. Cook C was asked about the standing seepage water under the cooking appliances to which she stated, We have been dealing with it for awhile now. The water is worse when the grease traps backed up. Observation in the kitchen at 11:30 a.m., revealed a pan of gravy, a pot of butter, and a pan of pureed chicken on the top of the stove. The hamburgers, pork loin and bacon were still in the oven. A kitchen staff member was slicing up watermelon on the food prep table. Observation was made of standing seepage water under the cooking appliances, under the food prep table and around the adjacent floor drain where the food was being prepared. At 12:10 p.m., observation of the tray line revealed kitchen staff distributing the food items (that were previously observed being prepared around the potentially contaminated water source) onto plates, then loading the trays onto a cart to be taken to the residents for consumption. At 12:20 p.m., the food cart was taken to the second floor dining room. Nurse F removed a food tray containing the potentially contaminated food (a cheeseburger with bacon and a slice of watermelon) and proceeded to serve the food to a waiting resident when the tray delivery service was stopped. At 12:25 p.m., Staff A shut the kitchen down. At 12:30 p.m., during an interview with the facility's Administrator she indicated that she was newer to the facility and could not explain why all the drain lines in the kitchen floor were not repaired. Review of the facility's policy titled, Food Preparation Area revised 12/08, 10/2013 documented, Our facility will maintain a clean, sanitary, and safe food preparation area.

Based on observation, interview, and record review, the facility failed to provide appropriate and consistent assessment, monitoring and treatment for [REDACTED]. Findings include: On 1/16/18 at 10:30 AM, during a tour of the facility, Resident #405 (R405) was observed sitting on the side of his bed with his pants pushed down around his ankles. When R405 was queried about the care he received at the facility, he said, I want staff to be on time (to change my dressing). I'm waiting for them to change my dressing. Is that why you are here? A 4 x 5 pad was observed on the lateral part of the right knee. R405 further added, Last month my knee was leaking really bad. On 1/16/18 at 10:35 AM, a wound care observation on R405 was conducted with Wound Care Nurse, Staff A. When staff A was queried about her observations during the wound care, she said, The bandage that was removed was undated and unsigned. There was no leakage from the bandage. The entire bandage was soiled from drainage from the wound. On 1/16/18 at 10:50 AM a review of the clinical record for R405 was begun. R405 was initially admitted to the facility on [DATE] with a readmission date of [DATE]. R405's [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented intact cognition and one person limited physical assistance for transfers. Further review of R405's clinical record documented the following in the nurse progress notes: --12/6/17: Resident (on leave of absence for) appointment for right knee hardware replacement, to be admitted overnight . --12/8/17: Resident readmitted from hospital .Diagnosis: [REDACTED]. --12/9/17: Resident status [REDACTED]. Medicated for complaint of pain with effective results. Will continue to monitor for any changes. --The 12/15/17 nursing notes at 9:00 AM and 1:00 PM referenced resident choosing to not have treatment completed. --12/16/17: Resident noted with some serosanguinous drainage from his right L/E (lower extremity) wound. There was a moderate amount of drainage with no odor. Resident had 2+ [MEDICAL CONDITION] to the bilateral L/E's and there was a small pool of blood next to the resident's bed. Writer had resident get into bed and his bilateral L/E's were elevated on pillows. Writer applied pressure to the area and the drainage stopped after a couple of minutes. The blood on the floor did not coagulate related to the drainage being more fluid than blood. There were no (signs/symptoms) of infection noted and the steri-strips were intact. A new dressing was applied. There was a negative homans sign (a sign of [MEDICAL CONDITION] and resident denied any .increased pain to the area. No further bleeding was noted. Oncoming nurse was made aware. --12/17/17: Resident right L/E had no bleeding this shift. The area was cleaned and a new dressing was applied. There was 1+ [MEDICAL CONDITION] noted to the bilateral L/E`s and they were again elevated on pillows . --12/20/17: Wound team in to assess resident, MD made aware wound to right L/E warm to touch, reddened area, swollen, heavy serosanguinous malodorous drainage noted at site. Obtained order to send resident to hospital. --12/21/17: Patient transferred to hospital for (right) replacement knee infection. --12/21/17: (R405) arrived from hospital .[DIAGNOSES REDACTED]. Medicated for complaint of pain 10/10 with effective results. A Nurse Practitioner note of 12/21/17 for R405 documented: (R405) being seen for (follow up) on (right) knee wound infection, he is with (complaint of) pain to the knee and is receiving his meds for that (Right) knee wound infection - ordered keflex. (Continue) current pain med. Further review of R405's clinical record did not reveal a physician's orders [REDACTED]. Additionally, a review of the electronic Medication Administration Record [REDACTED]. On 1/16/18 at 9:15 AM, a closed record review on Resident #406 (R406) was begun. R406 was admitted into the facility on [DATE] and discharged on [DATE]. His [DIAGNOSES REDACTED]. A MDS dated [DATE] documented intact cognition and one person limited physical assistance for transfers. A review of the November and December 2017 TARs for R406 documented, Cleanse left ankle wound with normal saline. Apply Santyl, cover with dry dressing daily. Ordered 11/22/17. A review of R406's November 2017 TAR documented wound care was performed on 12/26 and 12/30. The 11/17 TAR indicated the following exception for wound care: 11/25 - resident refused. A review of R406's December 2017 TAR documented wound care was performed on December 12/3, 12/4, and 12/12. Resident was discharged on [DATE]. The December 2017 TAR indicated the following exceptions for wound care: 12/9 - resident refused, 12/10 - withheld per Dr/RN orders, 12/14 - resident out of the facility. A review of nursing progress notes revealed no reference to R406's skin care or skin condition between 12/5/17 to 12/13/17 with the exception of an Interdisciplinary Team (IDT) progress note dated 12/6/17 that documented, IDT met and discussed wound to left lateral leg and intact sutures to left big toe related to toe being amputated. Daily skin treatment in place. On 1/16/18 at 1:00 PM, when Wound Care Nurse Staff A was queried about the typical contents of Skin/Wound notes, she said, I would document the size and condition of the wound in the progress notes. When a review of R405's clinical record was conducted with Staff A and revealed there were no Skin/Wound progress notes, she said, I am supposed to chart once a week. Sometimes it's been once every two weeks before I get to it. A review of R406's clinical record with Staff A documented one Skin/Wound progress note dated 11/27/17. On 1/16/18 at 1:10 PM, when queried about her TAR documentation, Staff A said, I document in the (backup) book because I get locked out of QuickMAR. On 1/16/18 at 1:26 PM, the Director of Nursing (DON) said, There is a book on each unit that contains the TARs for the current month. We document on the (paper) TARs if the system fails, if the nurse loses access, or as needed for some other reason. When queried if the paper TAR should be used for routine documentation, the DON said, There should not be routine documentation in that book. When queried if Staff A had been locked out of documenting skin/wound treatments in the electronic medical record (e-MAR), the DON said, I cannot recall her expressing concerns about documentation in QuickMAR. On 1/16/18 at 2:30 PM, when the e-MAR/TAR for R405 was reviewed with the DON, it revealed no TAR had been initiated for December 2017 following his readmission on 12/8/17. When the DON was queried about R405's medical history, she said, (R405) had a tumor in his knee. (When he went to the hospital on [DATE]), they were redoing his knee. He came back with a surgical wound. There should have been some physician orders [REDACTED]. If the physician didn't order it, the nurses should have followed up and gotten an order. The DON further added, There should be daily documentation about the wound. I expect to see (a reference) to the color, size, drainage, and measurements from the wound nurse. I want to know if the wound is healing, draining, or if there is a need for treatment change. A review of the physician's orders [REDACTED]. On 1/16/18 at 4:10 p.m., Staff A produced a handwritten TAR, dated December 2018, which documented wound treatments starting 12/21. There was no documentation for wound treatments for the period between 12/8/17 and 12/20/17. Staff A said, There should have been an order for [REDACTED]. If no orders, there would not be a treatment. Resident #403- On 1/16/18 at 10:15 AM, the resident was observed ambulating to the elevator with a walker on his way to a [MEDICAL TREATMENT] treatment for [REDACTED]. Director of Nursing (DON). The resident was wearing regular hard-soled, closed-in shoes. A dressing was removed from the right great toe dated 1/12/18 that was heavily soiled with beige drainage. There was an open wound on the bottom of the toe that appeared like a partially ruptured blister. When asked how often the dressing was supposed to be changed, nurse 'A' said, I think every two days. When asked why it had not been changed timely, nurse 'A' said, I don't know. I changed it last on the 12th (1/12/18-a Friday) and I work Monday through Friday. The nurses were supposed to change it over the weekend. The DON responded, I have to look into that. The resident said, This happened when I put on that shoe (pointing to a hard, black, slide-type slipper). It was rubbing. Nurse 'A' said that the resident had the wound upon admission. The DON said, He just got here, however the resident said, No, I was here when the wound occurred. An antibiotic ([MEDICATION NAME]) ointment was applied and a clean, dry dressing. The resident repeated three times, I need shoes with the toe out so my foot can get some air to help it heal. I don't have those. That's what I need, referring to an open-toe, soft, breathable, specialty-type shoe. When asked why the resident did not have a specialty-type shoe, nurse 'A' said, I have to get an order and did not respond why the physician was not already notified. The DON said, I will talk to the doctor about it and get an order right away. At approximately 12 noon, the resident's clinical record was reviewed with nurse unit manager 'B' at the nursing station. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident was cognitively intact and had no wounds. When asked about the resident's wound, nurse 'B' provided an incident report written by her, which noted that on 1/2/18, a skin tear occurred to the resident's right great toe when he slid his foot into his slipper after a shower. The corrective action: Resident should dry foot before putting on slipper There was no mention of open toe shoes to help prevent reoccurrence. However, progress notes revealed: On 12/31/17- Resident had a skin tear on his right big toe. Resident states that he saw it after taking shower. Dry dressing was applied. Treatment nurse ('A') is not aware (of) it. On 1/2/18, nurse 'B' wrote: Resident's right great toe with large skin tear with loose hanging skin and that the resident had a dry callous to the area from previous injury prior to admission. The nurse did not clarify when the incident actually occurred, when asked. On 1/2/18, an order was written for a consultation with the facility's contracted wound care specialist regarding the resident's toe. There was no documented wound care on the resident's treatment records until 1/4/18. When asked why the resident did not have open-toe shoes, nurse 'B' presented one that was at the nursing station and said, It just came in. When asked why it took so long to arrive, she explained, An order has to be written. The doctor has to sign it then it goes to therapy (department) and they have to order it. At 12:35 PM, when asked about the timeliness in obtaining the shoe, the therapy manager (staff 'C') said, I was just told about it. There was one in the closet. I cleaned it off and gave it to them. Staff 'C' said that footwear of that type had to be ordered if they were unavailable in the therapy supply closet. At 4 PM, wound documentation was reviewed with nurse 'A' and the DON. On 1/4/18, the wound specialist noted: The wound was a diabetic ulcer measuring 3 centimeters (cm) by 1.5 cm. There was no mention of a skin tear. [MEDICATION NAME] and a dressing were prescribed daily for 7 days and open toe shoes. When asked what was to be expected after 7 days treatment wise, the DON said, The nurses should have gotten a new order and said, I didn't have to call the doctor to order the shoe because he already had an order. There were no documented wound treatments after the treatment noted on 1/12/18 provided by nurse 'A'. There was no documented wound assessment and no progress notes of the wound by nurse 'A'. When asked why, the DON said, I don't have an answer for that. Resident #404- On 1/16/18 at 10:55 AM, the resident was observed in a wheelchair wearing regular hard-soled, closed-in shoes. An undated dressing was removed from the right foot by nurse 'A' and revealed ulcers to the anterior 2nd and 3rd toes. When asked about an open-toe specialty shoe for the resident, nurse 'A' said that the resident had an open-toe shoe in the past, but when the ulcers reoccurred this time, The physician did not mention wearing the shoe. At 4 PM, per review of the resident's clinical record with nurse 'A' and the DON, the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], noted the resident had no cognitive deficit, was non-ambulatory and required extensive assistance for transfers and repositioning. Monthly renewal orders for 12/2017 and 1/2018 noted an order for [REDACTED]. The first documented note by nurse 'A' and the wound specialist regarding the resident's toe ulcers, was dated 12/6/17. Per the notes, the wounds on both toes were venous stasis ulcers (typically caused by poor circulation) that had bridged together measuring 1.5 cm by 4 cm in total. There was no mention or recommendation of wearing a specialty shoe in the notes. On 12/13/17 and 12/20/17, per notes, the ulcers measured 1.5 cm by 3 cm and 1 cm by 2.5 cm respectively, with no mention of a specialty shoe. Per nurse 'A', the wound specialist didn't come the week of 12/27/17 and there were no documented notes by nurse 'A' that week. On 12/29/17, a primary care physician wrote: Chronic non healing of right 2nd toe ulcer-could be diabetic or not changing socks regularly with wearing of non breathing (regular closed-in) shoes. On 1/4/18, the resident was seen by the wound specialist for a leg wound with no mention of the toe ulcers and no documented notes by the wound specialist during the week of 1/10/18. There were no further documented wound notes by nurse 'A' after 12/20/17. When asked why, nurse 'A' said, I didn't get to it. There were no documented treatments on the resident's 1/2018 wound treatment records on 1/1 thru 1/4/18, 1/6 thru 1/8/18, 1/10/18 and 1/13 thru 1/15/18. The DON looked at the record and said, I see the holes (missing documentation indicating that treatments were not done). I don't know what to tell you. It's not there. A policy and procedure for wound management was requested, but the facility provided a procedure only titled Wound Care dated 5/2011, which was reviewed on 1/17/18 at 8 AM and revealed: Review the resident's care plan to assess for any special needs of the resident The following information should be recorded in the resident's medical record: The type of wound care given. The date and time the wound care was given All assessment data obtained when inspecting the wound Report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to identify the correct code status; failed to initiate cardiopulmonary resuscitation (CPR); and failed to immediately contact emergency medical services (EMS) for one (#701) of three sampled residents who were identified with full code status, from a total sample of three residents, resulting in a one hour delay in initiating CPR and an Immediate Jeopardy (IJ) to the health and safety of Resident #701. The Immediate Jeopardy was identified on [DATE] at 7:30 PM, when the facility failed to immediately initiate CPR. The administrator was notified of the Immediate Jeopardy on [DATE] at 5:00 p.m. at which time a plan of correction was requested to remove the Immediate Jeopardy. The Immediate Jeopardy was removed on [DATE] when the facility implemented plans to remove the immediacy, that was verified on-site during the partial extended survey. Although the Immediate Jeopardy was removed, the facility's deficient practice remained at isolated that was actual harm that was not Immediate Jeopardy. Findings include: On [DATE] at 9:00 a.m., the Director of Nursing (DON) was interviewed about a Facility Reported Incident where a resident was found non-responsive and whose code status was designated Full Code. The DON stated Resident (#701) was found non-responsive on [DATE] at 7:30 p.m. by a Certified Nursing Assistant (CNA B). The CNA (B) alerted (Nurse E). Nurse E failed to follow facility's policy to initiate cardiopulmonary resuscitation (CPR) on a Resident (#701), who was identified as Full Code. Nurse E identified that Resident #701 had no vital signs and pulse, she failed to check the residents code status and initiate CPR. Nurse E documented in Resident #701's clinical record that the resident expired and Nurse E contacted a hospice company, only to find out that there was no record of Resident #701 receiving hospice services. The DON stated , through her investigation, it was identified that Nurse E believed Resident #701 was receiving Hospice benefits and that was the reason Nurse E contacted hospice. Nurse E thought she was following the wishes of the resident since the resident was on hospice. Nurse E acknowledged during the investigation that she did not check the resident's code status nor initiate CPR. On [DATE] at 9:45 a.m. review of the clinical record revealed that resident # 701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admitting Nursing Comprehensive Evaluation, dated [DATE], Resident #701 had cognitive impairments and was alert and oriented to self only. There was no documentation in the Advance Directive/Code Status section of the chart. On [DATE] at 10:00 a.m., the Social Service Director A was interviewed and indicated that Social Services was responsible for reviewing advance directives and code status with residents and their responsible parties on admission, however in the case of Resident #701, he was admitted after 5:00 p.m. However, if a resident is admitted on the weekend, and only in the facility on Monday through Friday, then I have to catch up with the responsible parties on the following Monday. When asked if there was a conversation with Resident #701's responsible party Monday ([DATE]), the Social Service Director responded, I visited the Resident (#701), but he was non-verbal and unaware at the time. I never saw the family in the facility that day. I received a referral for hospice later in the day and started some paperwork for that. Review of Resident #701's Advance Directive/Code Status section of the clinical chart was reviewed with the Social Service Director and the section was empty. Social Service Director A explained, If a resident is made a Do Not Resuscitate (DNR), then there would be a signed piece of paper in that section. Full Codes get a form stating Full Code, although it's not signed. When there's nothing in that section, it goes to Full Code by default, I thought everyone knew that. On [DATE] at 11:00 a.m. review of nurse's note from Nurse E, dated [DATE] at 7:45 p.m., read: Certified Nursing Assistant (CNA) D called nurse to come into room. Patient was not breathing and there was no pulse. Hospice was called at this time. No information was found for Resident #701 in their data base. Nurse was informed to call 911 by Assistant Director of Nursing (ADON). Nurse's note, dated [DATE] at 9:00 p.m., read: 911 responded here to call. Family was notified. Dr. was notified. On [DATE] at 11:30 a.m., review of the facility's staffing assignments for the second shift (3 p.m.- 11 p.m.) on [DATE] revealed that Resident #701 was assigned to Nurse E and CNA D. On [DATE] at 1:00 p.m., CNA D was interviewed about the incident that occurred on [DATE] with Resident #701 and stated, I went into Resident #701's room to give care to the roommate. I called Resident #701's name and there was no response. I called out for the nurse. Nurse E came in and checked the Resident's pulse and said, He's gone. Nurse E left the room and I cleaned Resident #701 up before Emergency Medical Service (EMS) got there with the help of CNA B. The Resident's neck was still warm to the touch and his neck moved easily. When asked if Nurse E attempted to initiate CPR, CNA D said, no, she didn't do anything like that. During an interview on [DATE] at 2:10 p.m., CNA B was asked about the incident involving Resident #701 on [DATE] and indicated that the first she knew of Resident #701's passing was when CNA D called her into the room to help clean up the Resident for transfer out by EMS. Nurse C was identified as the second nurse assigned to work the afternoon of [DATE] and was interviewed on [DATE] at 3:00 p.m. Nurse C stated that he did not know there was any problem with Resident #701 until the EMS got here around 8:30 p.m. because there was no Code called. On [DATE] at 3:30 p.m., the Assistant Director of Nursing (ADON) was interviewed about the incident involving Resident #701 and stated, She (Nurse E) called me on [DATE] about Resident #701 and I told her to call 911 and initiate CPR. She didn't (do that)-- that's why she doesn't work here anymore. The ADON reported that she interviewed Nurse E after the incident and Nurse E reported that she did not do CPR because she had empathy for the resident. The DON explained that through interviews, Nurse E had indicated that she didn't follow procedures because she felt that the resident was on hospice and she was acting on behalf of the resident. Nurse E was unavailable during the survey on [DATE] by phone with multiple attempts made at 2:00 p.m., 3:00 p.m., and 3:30 p.m. On [DATE] at 4:00 p.m., review of the facility's undated policy, titled Code Blue (Medical Emergencies) indicated, The first person on the scene confirms the emergency, calls for HELP loudly and initiates emergency assistance as indicated within the scope of practice or obtain a licensed nurse. Each nurse responding must independently verify Advance Directive prior to responding to a medical emergency which is located in the hard chart. CPR is initiated during the Code Blue, it must be continued until EMS personnel arrives and assumes CPR responsibility. CPR will be performed in accordance with the current guidelines as established by the American Heart Association and/or American Medical Association. On [DATE] at 4:05 p.m. review of the facility's undated policy titled, Advance Directives indicated, Upon admission to the facility--Admissions is to ask the person and/or representative about Advance Directives. If the patient does not have an advance directive, the patient will be offered information on advance directives. Any copies of Advance Directives supplied to Admissions will be given to the Social Worker or filed under the Advance Directive Tab. If the patient wishes to remain full code a green piece of paper with their name on it will be placed under Advance Directive tab. The Social Worker will ask on admission assessment about Advance Directives and document as appropriate the resident's wishes and (this document) will be reviewed and updated yearly by social worker If you are a DNR- a DO NOT RESUSCITATE ORDER FORM WILL BE FILLED OUT and your name will be placed on a red piece of paper with the DNR form. This is the ONLY time a form will be in place with a signature under the Advance Directive tab. If nothing is under the advance directives tab or in the chart about advance directives, you are by default a full code. The facility submitted the following plan of correction to remove the Immediate Jeopardy: ELEMENT #1 How corrective action has been or/will be accomplished for those residents found to have been affected by the deficient practice. Resident #701 no longer resides in the facility. Element #2 Residents who may have the potential to be affected by this practice. · To ensure that no other resident was affected in-service on how to respond to an unresponsive resident was initiated beginning with nursing staff and will continue until all employees have been in-serviced. · Immediately in-servicing on CPR protocol began and will continue to all nursing staff is in-serviced. · The social worker immediately reviewed the code status of all residents currently in the building. · The social worker contacted via phone and fax all guardians, families and residents and informed them of changes to the advanced directives policy and sent out new medical treatment advanced directive forms to all current residents. 40 of 82 consents have been signed by the family/guardian/resident and the process will be completed by [DATE]. 22 families were contacted and ask to come in by [DATE], Guardian care (9) residents were contacted and all consents were returned from guardian care. All residents without advanced directives are defaulted to full code until advanced directives are received. · The facility immediately began to In-service Licensed Registered and Practical Nurses on how to identify the correct code status, when to initiate cardiopulmonary resuscitation (CPR) and how to activate emergency medical services (EMS) and will continue until all nurses have been in-serviced, currently 19 of 21 nurses have been in-serviced. Inservice will be completed by [DATE]. · The facility has reviewed and updated the advanced directive policy and has begun in-servicing all staff, resident, families, and guardians. Forty of eighty complete. · On [DATE] Residential hospice conducted an in-service on the admission process for hospice services and how to identify the code status of hospice patients and · CPR policy was reviewed and training classes are being scheduled for refresher course · Mock code was initiated on [DATE] and will be continued and results will be taken to Quality Assurance Committee for review. · All hospice patients ' charts were reviewed to determine clear evidence of advanced directive and all were in compliance. · Residential Hospice was consulted and provided an in-service on the admission process and how to identify the code status of a hospice resident. 19 of 21 nurses participated and new class scheduled for [DATE] and the remaining nurses will be inserviced. · The facility also conducted an audit of all other residents for completion of advanced directions and if none available were listed as a full code. Element #3 What measures have been or will be put into place or systemic changes made to ensure that the deficient practice will not recur. · In-service training on identifying code status for residents, policy and procedure for initiation of CPR and how to activate emergency medical services for all licensed nurses has begun and will continue until all nurses have been in-serviced. · All orientation for new hires will continue to receive the above mentioned in-services and inservice on CPR protocol, Advanced Directives, and code status will be conducted quarterly. · The Social worker will audit five charts per week to maintain compliance with the advanced directive policy times 3 months and then quarterly after that time period. · Mock codes will be performed weekly on random shifts time four weeks and then quarterly on all shifts to ensure compliance with the policy and procedure. · Refresher course will be given to all current licensed nurses and all new hires. · Advanced directive, CPR Protocol, and Code Status mass inservice will be held [DATE] for completion. Element #4 Facility will monitor its corrective action as follows: Staff will continue to be in serviced PRN on CPR, Code Status, Advanced Directives, and activating emergency medical services. Quality Assurance Committee will monitor compliance with all audits and the above policies and results of CPR Mock codes. The Director of Nursing will perform audits to ensure compliance with policies. ( ) ( )

This citation pertains to intake #MI 330. Based on interview and record review, the facility failed to maintain engagement of bed safety devices (wheel locks) on a resident's bed for one (#701) of four sampled residents reviewed for falls, from a total sample of five residents, resulting in uncontrolled bed movement while repositioning, a fall with laceration to the left side of head, a large hematoma, and subsequent acute intraventricular hemorrhage (bleeding into the ventricles of the brain) which required hospitalization . Findings include: On 3/12/15 at 2:00 p.m., review of the clinical record revealed Resident #701 was initially admitted into the facility on [DATE], readmitted on [DATE], had been discharged to the hospital on [DATE] and had not yet returned. [DIAGNOSES REDACTED]. Review of the most recent Annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #701 was severely cognitively impaired, required total care of two people for transfers, and required total care of one person for dressing. Review of an "Incident/Accident Report" dated 3/4/15 reflected, "CNA (certified nursing assistant) was giving care, bed was unlock and moved, resident rolled out of bed and hit her Lt (left) forehead on the floor. Lt upper eyebrow with swelling contusion and abrasion; no change in level of consciousness". The section which read, "Additional comments and/or steps taken to prevent recurrence: Staff to make sure bed locked". Review of the facility's undated "Investigative Analysis" which was completed by the Director of Nursing (DON) reflected, "Date of Occurrence: March 4, 2015; Time of Occurrence: 5:15 a.m.; Investigation: I was notified at approximately 5:25 AM on 3/4/15 that Resident #701 had a fall from her bed. According to Registered Nurse (RN "C") the resident had a hematoma above the brow line of the left eye...Order to send to (name of local hospital) to ER (emergency room ) for a CT (computed tomography - uses x-rays to make detailed pictures of structures inside the body) was received from Physician "D"...I interviewed CNA "E" regarding the incident. He stated that while giving care the resident's bed moved and she rolled on the floor...After interviewing the Nurse, the resident and the CENA it does appear that the bed locks were not engaged properly allowing the bed to move..." Review of Resident #701's ADL (Activity of Daily Living) care plan dated 1/9/15 reflected, "I require staff assistance with all my care..." Interventions included, "Assist me with 2 persons with my bed mobility/turning and repositioning and my transfers; Assist me with one person with...dressing..." On 3/12/15 at 2:15 p.m., the DON was interviewed regarding the fall incident with Resident #701 and confirmed the facility identified a concern that the bed safety (wheel) locks had not been engaged, which resulted in Resident #701's fall from bed, and subsequent injuries. At that time, The DON was requested to provide CT scan results for Resident #701. On 3/12/15 at 2:40 p.m., an interview was conducted with CNA "E" by phone. At that time, CNA "E" was queried about Resident #701's fall on 3/4/15 and stated, "What happened is she was undressed around 4 or so I was providing care. I locked bed when providing care and then unlocked. I rolled her over the side to pull shirt down and that's when she fell away from me. I rolled her over and moved her, she rolled when the bed moved. When queried about why the bed safety lock had to be disengaged in the first place and whether that was a normal procedure, CNA "E" stated, "Well no. There was a socket (outlet plug) at the edge of the wall and when you move the bed down you have to move the bed away and then move it back. I was about to move the bed. When she fell I think she landed on her forehead on the left side. There was a cut on her forehead and some swelling. Me and the nurse in charge put ice over the swollen area but she kept refusing." On 3/12/15 at 3:40 p.m., an interview was conducted with Physician "D" by phone. At that tine, Physician "D" was queried about Resident #701's fall and medical status. Physician "D" reported that she had been Resident #701's attending physician while she was at the facility and had also followed the resident while in the hospital. Physician "D" stated, "She did have intracranial hemorrhage,a black eye, left frontal hematoma and laceration with an open wound." Physician "D" reported that she would have the hospital records faxed to the facility. On 3/12/15 at 5:30 p.m., review of Resident #701's hospital records provided reflected, "Consultation Note; date of service: 03/04/2015; Consulting Service: Neurosurgery; Reason for Consultation: Intraventricular hemorrhage...Assessment and Plan: 1. Intraventricular hemorrhage, status [REDACTED]. CT brain with small intraventricular hemorrhage layering in the left occipital horn..." Review of the "CT Facial Bones/Head w/o Contrast" dated 3/4/15 documented, "...Impression: Small amount of acute intraventricular hemorrhage in the dependent posterior horn of the left lateral ventricle; left frontal extracranial scalp hematoma with laceration, extending to the left preseptal region..." On 3/12/15 at 5:40 p.m., review of the facility's "CENA Responsibilities" document dated 3/15/06 included, "Make rounds on your assigned residents to ensure that your residents are safe, dry, and turned and positioned in good alignment..." ( )

THIS REGULATION HAS TWO DEFICIENT PRACTICES. DEFICIENT PRACTICE #1. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT HOT WATER TEMPERATURES AT THE HANDWASHING SINKS WERE WITHIN A SAFE TEMPERATURE RANGE BETWEEN 105 AND 120 DEGREES FAHRENHEIT. THE HOT WATER TEMPERATURES RANGED BETWEEN 123.0 AND 126.5 DEGREES FAHRENHEIT FOR 12 ROOMS (#s: 107, 109, 112, 116, 119, 121, 123, 125, 127, 227, 231, AND 233). THE HOT WATER TEMPERATURES HAD THE POTENTIAL TO AFFECT THREE (#'s: 710, 711, AND 713) OF 17 SAMPLED RESIDENTS AND 11 (#'s: 6, 8, 12, 13, 28, 31, 32, 33, 53, 54, AND 58) SUPPLEMENTAL SAMPLED RESIDENTS, RESULTING IN THE POTENTIAL FOR SERIOUS HARM, INJURY OR DEATH FROM SCALDING. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 6/18/13 AT 2:30 P.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 6/18/13 AT 5:30 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 6/18/13 BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 6/18/13, AS VERIFIED ONSITE ON 6/19/13. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE REMAINED AS A PATTERN. NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT WAS NOT AN IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 6/18/13 AT 9:35 A.M., HOT WATER TEMPERATURES WERE OBSERVED ON THE INITIAL TOUR. THE FOLLOWING HOT WATER TEMPERATURES WERE FOUND TO EXCEED THE MAXIMUM ALLOWABLE TEMPERATURE OF 120 DEGREES FAHRENHEIT (DF) FOR THE FOLLOWING HANDWASHING SINKS: UNIT ROOM DEGREES FAHRENHEIT 1 ST FL. 112 125.0 DF 121 123.9 DF 2 ND FL. 227 & 229 123.9 DF 231 & 233 123.0 DF ON 6/18/13 BETWEEN 12:00 P.M. AND 1:00 P.M., HOT WATER TEMPERATURES WERE OBSERVED AS FOLLOWS: UNIT ROOM DEGREES FAHRENHEIT 1 ST FL. 107 & 109 123.1 DF 112 125.0 DF 116 123.0 DF 119 124.7 DF 121 123.9 DF 123 123.0 DF 125 124.3 DF 127 124.3 DF 2 ND FL. 227 123.9 DF 231 & 233 122.9 DF ON 6/18/13 AT 1:55 P.M., DURING AN INTERVIEW, ASSISTANT MAINTENANCE DIRECTOR "K" STATED, HE WAS NOT AWARE OF THE FACILITY'S HOT WATER TEMPERATURES. ON 6/18/13 AT 2:00 P.M., DURING AN OBSERVATION OF THE FACILITY'S MIXING VALVE (A VALVE WHICH MIXES COLD WATER WITH THE HOT WATER FROM THE HOT WATER TANKS FOR DELIVERY TO THE RESIDENTS' ROOMS) WITH MAINTENANCE ASSISTANT "A," THE MIXING VALVE TEMPERATURE GAUGE WAS OBSERVED AT 126.0 DF. MAINTENANCE ASSISTANT "A" VERIFIED THIS OBSERVATION AND STATED "I'VE TURNED THE GAUGE DOWN TWICE THIS MORNING SINCE I WAS TOLD THE TEMPERATURE WAS TOO HOT COMING OUT OF THE SINKS." AT THAT TIME, HOT WATER TEMPERATURES WERE VERIFIED ALONG WITH MAINTENANCE STAFF "A" AND "K". THE HOT WATER TEMPERATURES OBSERVED EXCEEDED THE MAXIMUM ALLOWABLE TEMPERATURE OF 120 DF FOR THE FOLLOWING HANDWASHING SINKS: UNIT ROOM DEGREES FAHRENHEIT 1 ST FL. 112 126.5 DF 125 & 127 124.3 DF 2 ND FL. 227 & 229 123.0 DF 231 & 233 122.0 DF ON 6/18/13 AT 2:30 P.M., DURING AN INTERVIEW, THE FIRST FLOOR UNIT MANAGER "F" VERIFIED SAMPLED RESIDENT (#s 710, 711, AND 713) AND SUPPLEMENTAL SAMPLED RESIDENTS (#s 6, 8, 12, 13, 28, 31, 32, 33, 53, 54, AND 58) USED THE HANDWASHING SINKS IN THE RESIDENTS ROOMS AND REQUIRED REDIRECTION AND ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADLs). THIS MADE ALL OF THE RESIDENTS AT RISK FOR SERIOUS HARM. CLINICAL RECORD REVIEW REVEALED SAMPLED RESIDENT (#s 710, 711 AND 713) AND SUPPLEMENTAL SAMPLED RESIDENT (#s 6, 8, 12, 13, 28, 31, 32, 33, 53, 54, AND 58) ARE FURTHER AT RISK FOR INJURY FROM HOT WATER TEMPERATURES AT HANDWASHING SINKS RELATED TO MULTIPLE COMORBIDITIES MAKING THEM MORE SUSCEPTIBLE TO NEUROPATHIES (DAMAGE TO NERVES WHICH CAN RESULT IN ALTERED SENSATION), ALTERED COGNITIVE STATUS RELATED TO DEMENTIA, PSYCHIATRIC MEDICATION REGIMES AS FOLLOWS: FIRST FLOOR RESIDENTS: RESIDENT #710 IN ROOM 121 BED B -PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #711 IN ROOM 127 BED B- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. PER RECORD REVIEW OF THE PSYCHIATRIC NOTE DATED 3/6/13 THE RESIDENT IS DOCUMENTED AS " COGNITIVELY IMPAIRED. " RESIDENT #713 IN ROOM 112 BED A- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #6 IN ROOM 116 BED D- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #8 IN ROOM 119 BED B- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #12 IN ROOM 123 BED B- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #13 IN ROOM 125 BED B- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #53 IN ROOM 107 BED A- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #54 IN ROOM 107 BED B- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #58 IN ROOM 109 BED B- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. SECOND FLOOR RESIDENTS: RESIDENT #28 IN ROOM 227- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #31 IN ROOM 231 BED A- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #32 IN ROOM 231 BED B- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #33 IN ROOM 233- PER MEDICAL RECORD FACESHEET WAS admitted WITH [DIAGNOSES REDACTED]. ON 6/18/13 AT 3:20 P.M., A REVIEW OF THE FACILITY'S HOT WATER TEMPERATURE LOGS REVEALED THAT FOR THE MONTH OF JUNE 2013, HOT WATER TEMPERATURES WERE CHECKED FROM 6/3/13 TO 6/13/13. THE FACILITY DID NOT MONITOR OR MAINTAIN HOT WATER TEMPERATURE LOGS FOR INDIVIDUAL RESIDENT ROOMS UNTIL 6/18/13, AFTER HOT WATER TEMPERATURES EXCEEDED THE MAXIMUM ALLOWABLE TEMPERATURE OF 120.0 DF ON 6/18/13 AT 4:30 P.M., WHEN QUERIED ABOUT THE HOT WATER TEMPERATURES, THE ADMINISTRATOR STATED, "HOT WATER TEMPERATURES SHOULD HAVE BEEN CHECKED FRIDAY, 6/14/13 AND MONDAY, 6/17/13. TEMPS ARE TAKEN IN THE MORNINGS." ADDITIONALLY, THE ADMINISTRATOR STATED, "THE MIXING VALVE WAS ADJUSTED WHEN THE SURVEY TEAM FOUND HOT TEMPS." THE ADMINISTRATOR FURTHER STATED, "I ASKED THE COOLING COMPANY TO TAKE A LOOK AT THE MIXING VALVE AFTER HOT TEMPS WERE IDENTIFIED." A REVIEW OF THE FACILITY'S UNDATED POLICY TITLED "HOT WATER TEMPERATURE" DOCUMENTED THE FOLLOWING: POLICY..."TO PROVIDE AN INTERDISCIPLINARY APPROACH TO MAINTAIN ACCEPTABLE WATER TEMPERATURES WITHIN STATE AND FEDERAL GUIDELINES TO ENSURE THAT HOT WATER TEMPERATURES ARE BEING MONITORED ON A REGULAR BASIS FOR PREVENTION OF POSSIBLE RESIDENT AND/OR STAFF INJURY DUE TO HOT WATER TEMPERATURES EXCEEDING 120.0 DF." PROCEDURE: "1. DAILY HOT WATER TEMPERATURE CHECKS WILL OCCUR ON AT LEAST 2 ROOMS ON THE 1ST FLOOR AND 1 ROOM ON THE 2ND FLOOR. 6. DOCUMENT IN HOT WATER TEMPERATURE LOG DAILY." THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE FACILITY IMPLEMENTED THE FOLLOWING: "1. RESIDENT #3 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND IS UNABLE TO ACCESS THE HAND WASHING SINK IN THE BATHROOM. STAFF ASSISTED WITH CARE. RESIDENT #6 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND REQUIRES STAFF TO ASSIST WITH CARE. RESIDENT #8 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND STAFF ASSISTED WITH HANDWASHING. RESIDENT #12 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND WAS INFORMED OF THE INCREASED WATER TEMPERATURE AND SOUGHT ASSISTANCE FROM STAFF FOR CARE AS NEEDED. RESIDENT #13 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND OUT FOR A DOCTOR APPOINTMENT IN THE AFTERNOON. RESIDENT #16 IN ROOM THROUGHOUT THE DAY INFORMED OF INCREASED WATER TEMPERATURE AND RESIDENT SOUGHT ASSISTANCE FROM STAFF FOR CARE. RESIDENT #28 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND WAS REDIRECTED AS NEEDED BY STAFF. STAFF PROVIDES CARE. RESIDENT #31 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND WAS ALSO INFORMED OF THE INCREASED WATER TEMPERATURE. STAFF ASSISTED WITH CARE. RESIDENT #32 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND INFORMED OF THE INCREASED WATER TEMPERATURE AND REDIRECTED AS NEEDED. RESIDENT #33 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND WAS ASSISTED BY STAFF WITH CARE. RESIDENT #53 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND WAS INFORMED OF THE INCREASED WATER TEMPERATURE. RESIDENT #54 ATTENDED ACTIVITIES THROUGHOUT THE DAY AND WAS INFORMED OF THE INCREASED WATER TEMPERATURE. RESIDENT #58 ATTENDED ACTIVITIES AND SLEPT THROUGHOUT THE DAY AND WAS ASSISTED BY STAFF FOR CARE. NO ADVERSE AFFECTS WERE NOTED FOR ANY OF THE IDENTIFIED RESIDENTS. 2. ALL RESIDENTS HAVE THE POTENTIAL TO BE AFFECTED. STAFF WERE IMMEDIATELY RE-EDUCATED ON SAFETY RELATED TO HOT WATER TEMPERATURES TO ENSURE SAFETY FOR ALL RESIDENTS. RESIDENTS TAKEN TO ACTIVITIES AND KEPT UNDER CLOSE OBSERVATION TO PREVENT CONTACT WITH HOT WATER IN HANDWASHING SINKS. RESIDENTS REVIEWED FOR ALERTNESS AND/OR ABILITY TO ACCESS HANDWASHING SINKS. RESIDENTS' HANDS AND ARMS WERE ASSESSED FOR CHANGES AND NO ADVERSE AFFECTS WERE NOTED. 3. HOT WATER TEMPERATURES WERE TAKEN FROM HANDWASHING SINKS AS ADJUSTMENTS WERE MADE TO THE MIXING VALVE. DURING THE COURSE OF MONITORING TEMPERATURES THE HOT WATER TEMPERATURE DROPPED FROM 125 DEGREES F TO 121.6 DEGREES AT 1:00 P.M. AND IT WAS BELIEVED THAT THE HOT WATER TEMPERATURE PROBLEM WAS RESOLVED AND WOULD RETURN TO WITHIN NORMAL LIMITS OF 105-120 DEGREES. BECAUSE DIETARY UTILIZES THE SAME HOT WATER HOLDING TANKS AND STARTED DOING LUNCH DISHES AT 1:15 P.M. FOR APPROXIMATELY ONE HOUR ACCURATE TEMPERATURES COULD NOT BE OBTAINED AND THEN ALLOWING FOR RECOVER TIME OF THE HOLDING TANKS ACCURATE HOT WATER TEMPS WERE NOT ATTAINABLE UNTIL APPROXIMATELY 3:45 P.M. ADJUSTMENTS TO THE MIXING VALVE CONTINUED UNTIL IT WAS DETERMINED THAT ADJUSTMENTS BELOW 121.6 DEGREES F COULD NOT BE OBTAINED; THE PLUMBER WAS CONTACTED AT 5:59 P.M. TO MAKE REPAIRS. PLUMBER ARRIVED AT 6:30 P.M., AND REPAIRS WERE COMPLETED AT 7:00 P.M. PROPER TEMPERATURE WAS ACHIEVED AT 8:00 P.M. ORDER FOR NEW MIXING VALVE WAS PLACED WHILE PLUMBER WAS ON PROPERTY. HOURLY HOT WATER TEMPERATURES WERE RECORDED FROM THE HANDWASHING SINKS IN EACH RESIDENT'S ROOM STARTING AT 9:00 P.M. UNTIL MIDNIGHT WITH ONLY ONE ROOM RECORDING A TEMPERATURE OF 120.1 DEGREES, THAT HOT WATER TAP WAS IMMEDIATELY SHUT OFF AND NHA WAS CALLED AND INSTRUCTED STAFF TO RECHECK AT NEXT SCHEDULED TIME. NEXT CHECK FOUND TEMPERATURE TO BE 118.3, TAP WAS LEFT ON AND NO FURTHER HIGH TEMPERATURES WERE RECORDED. WITH NO FURTHER INCIDENTS OF HIGH TEMPERATURES MONITORING DECREASED TO EVERY TWO HOUR. MAINTENANCE STAFF WAS RE-EDUCATED ON THE IMPORTANCE OF MAINTAINING RESIDENT SAFETY BY MONITORING HOT WATER TEMPERATURES AND ASSURING THAT THE TEMPERATURES ARE WITHIN 105-120 DEGREES AND ANY TEMPERATURE OUTSIDE THE SET PARAMETER IS TO BE IMMEDIATELY REPORTED TO THE ADMINISTRATOR. HOT WATER POLICY WAS REVIEWED BY ADMINISTRATOR. 4. MAINTENANCE PERSONNEL OR DESIGNEE WILL BE AUDITING TEMPERATURES EVERY TWO HOURS FOR THE REMAINDER OF THIS WEEK. AS LONG AS TEMPERATURES REMAIN BELOW 120 DEGREES, TEMPERATURES WILL THEN BE AUDITED TWICE DAILY UNTIL MIXING VALVE IS REPLACED AND FOR TWO WEEKS AFTER REPLACEMENT AND THEN TO A NORMAL SCHEDULE OF 3 RANDOM ROOMS PER FLOOR ON A DAILY BASIS. ANY ABNORMAL RESULTS WILL BE REPORTED TO THE ADMINISTRATOR IMMEDIATELY. 5. MAINTENANCE PERSONNEL OR DESIGNEE ARE RESPONSIBLE FOR DAILY COMPLIANCE OF RECORDING WATER TEMPERATURES. 6. ANY DEFICIENCIES WILL BE REPORTED TO THE QA COMMITTEE. THE ADMINISTRATOR IS RESPONSIBLE FOR CONTINUED COMPLIANCE. 7. NEW MIXING VALVE HAS BEEN ORDERED AND WILL BE INSTALLED ON 6/20/2013. THE ADMINISTRATOR IS RESPONSIBLE FOR OVERALL SUSTAINED COMPLIANCE. COMPLETION DATE IS 06/18/2013, 8:00 P.M." ( ) ( ) ( ) ( ) ( ) DEFICIENT PRACTICE #2. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MAINTAIN CLEAN CLOTHES DRYER FILTERS IN THE LAUNDRY ROOM, RESULTING IN THE POTENTIAL FOR AN ACCIDENTAL FIRE. THIS HAS THE POTENTIAL TO AFFECT ALL RESIDENTS, STAFF, AND VISITORS. FINDINGS INCLUDE: ON 6/21/13 AT 12:40 P.M., DURING A TOUR OF THE FACILITY'S LAUNDRY ROOM WITH LAUNDRY/HOUSEKEEPER SUPERVISOR "G", TWO 50 POUND CLOTHES DRYER FILTERS WERE OBSERVED FULL OF THICK LINT AS WELL AS LINT ON THE BOTTOM BASES OF THE DRYERS. AT THAT SAME TIME, STAFF "G" WAS QUERIED AS TO WHEN THE LAST TIME LINT WAS REMOVED FROM THE FILTERS OF THE CLOTHES DRYERS. STAFF "G" STATED, "SHE HASN'T CLEANED IT. IT'S SUPPOSED TO BE CLEANED BY THE LAUNDRY AIDES. THEY SHOULD BE CLEANED TWICE PER SHIFT." STAFF "G" WAS QUERIED IF THERE WERE MAINTENANCE LOGS OR A CLEANING SCHEDULE FOR THE CLOTHES DRYERS. STAFF "G" STATED, "I JUST STARTED IMPLEMENTING CLEANING VENT LOGS. WE DON'T HAVE THE LOGS YET. THEY (FACILITY) NEVER HAD THIS PRIOR." ON 6/21/13 AT 12:45 P.M., DURING AN INTERVIEW WITH LAUNDRY AIDE "L", WHEN QUERIED ABOUT THE CLEANING OF THE CLOTHES DRYER FILTERS, LAUNDRY AIDE "L" STATED, "VENTS ARE CLEANED THREE TIMES A DAY, ONCE EACH SHIFT." LAUNDRY/HOUSEKEEPER SUPERVISOR "G", LAUNDRY AIDES "L" AND "N" AGREED THAT BOTH CLOTHES DRYERS HAD NOT BEEN CLEANED SINCE THE AFTERNOON SHIFT ON 6/20/13. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 971. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE SAFETY FOR ONE (#502) OF 3 SAMPLED RESIDENTS REVIEWED FOR ADEQUATE SUPERVISION AND SAFETY DEVICES FROM A TOTAL SAMPLE OF FIVE RESIDENTS, RESULTING IN AN UNSUPERVISED FALL WITH A WRIST FRACTURE. FINDINGS INCLUDE: ACCORDING TO THE FACILITY INCIDENT REPORT DATED 04/02/2013 AT 5:40 A.M., "OBSERVE RESIDENT (#502) ON THE FIRST FLOOR DINING ROOM, COMPLAIN OF PAIN ON HER LEFT WRIST. WRITER NOTICED THAT WRIST IS SWOLLEN." ACCORDING TO THE CLINICAL, RECORD RESIDENT #502 WAS AN [AGE] year OLD FEMALE admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE] DOCUMENTED THAT RESIDENT #502 REQUIRED SUPERVISION FOR TRANSFERS, AND FOR WHEN SHE WALKED IN THE CORRIDOR AND FOR LOCOMOTION ON THE UNIT. THE UNDATED FALL RISK EVALUATION NOTED A TOTAL SCORE OF 13, WITH A SCORE OF 10 OR ABOVE REPRESENTING HIGH RISK FOR FALLS. AN INTERVIEW WAS CONDUCTED WITH DIRECTOR OF NURSING (DON) #2 ON 04/11/2013 AT 9:30 A.M. DON #2 EXPLAINED THAT "(RESIDENT #502) IS ONE OF OUR WANDERING RESIDENTS. SHE WEARS A WANDER GUARD. SHE RESIDES ON THE SECOND FLOOR OF THE FACILITY, BUT WAS ON THE FIRST FLOOR AT THE TIME OF THE INCIDENT. SHE TRIPPED OVER THE 'WET FLOOR' SIGN." WHEN ASKED IF RESIDENT #502 WAS BEING MONITORED AS SHE AMBULATED FROM THE SECOND TO THE FIRST FLOOR, DON #2 EXPLAINED THAT "AT THAT TIME OF MORNING, STAFF ARE PROVIDING MORNING CARE TO RESIDENTS IN THEIR ROOMS. THERE WAS NOBODY MONITORING THE RESIDENT (#502) ON THE SECOND FLOOR." WHEN ASKED IF THE RESIDENT WAS MONITORED FOR SAFETY WHEN SHE MADE IT DOWN TO THE FIRST FLOOR, THE DON REPORTED THAT LICENSED PRACTICAL NURSE (LPN) #8 WAS SITTING AT THE NURSES' STATION WHEN RESIDENT #502 ARRIVED ON THE FIRST FLOOR. DON #2 COULD NOT EXPLAIN WHY LPN #8 DID NOT STOP RESIDENT #502 OR REDIRECT RESIDENT #502 BEFORE RESIDENT #502 WALKED INTO THE DINING ROOM THAT HAD JUST BEEN FRESHLY WAXED. REVIEW OF LPN #8'S NURSE'S NOTE, DATED 04/02/2013 AT 7:30 A.M., REVEALED "MIDNIGHT NURSE NOTIFIED WRITER OF INCIDENT AND ACCIDENT THIS MORNING WITH RESIDENT (#502). RESIDENT (#502) RECEIVED UP IN DINING ROOM. RESIDENT COMPLAINED OF PAIN TO LEFT WRIST...INCREASED AGITATION NOTED." REVIEW OF THE WITNESS STATEMENT WRITTEN BY THE MIDNIGHT SHIFT REGISTERED NURSE (RN) DATED 04/02/2013 REVEALED "RESIDENT IN ROOM 103A WAS IN DINING ROOM AND WRITER HEARD HER YELL FOR HELP. SHE SAID SOMEBODY ON FLOOR. WRITER WENT IN THE DINING ROOM AND RESIDENT FROM SECOND FLOOR (223) WAS SITTING ON THE FLOOR. WRITER CALLED THE NURSE UPSTAIRS AND SHE CAME HEAD TO TOE ASSESSMENT WAS DONE AND SHE WAS ASSISTED BACK ON HER FEET ....FLOOR STILL WET WITH WAX." DURING AN INTERVIEW ON 04/11/2013 AT 11 A.M., LPN #3 EXPLAINED THAT SHE WAS THE SECOND FLOOR UNIT MANAGER. WHEN QUERIED ABOUT THE INCIDENT WITH RESIDENT #502, LPN #3 STATED THAT "SHE (RESIDENT #502) WAS LIVING ON THE SECOND FLOOR ON THE DAY OF THE INCIDENT, BUT THE INCIDENT OCCURRED ON THE FIRST FLOOR. I (LPN #3) WAS TOLD THAT THE FLOOR SEEMED TO BE WET AND THE RESIDENT TRIPPED OVER THE SIGN." WHEN ASKED HOW RESIDENT #502 WAS ABLE TO AMBULATE FROM HER ROOM ON THE SECOND FLOOR, WAIT IN THE HALLWAY TO GET ON THE ELEVATOR TO THE FIRST FLOOR AND WALK FROM THE ELEVATOR ON THE FIRST FLOOR, PAST THE FIRST FLOOR NURSING STATION TO THE FIRST FLOOR DINING ROOM WITHOUT BEING SEEN BY STAFF, LPN#3 STATED "THEY (FACILITY STAFF) SHOULD HAVE BEEN MONITORING (RESIDENT #502)." LPN #3 WAS ASKED IF LPN #8 WAS PRESENT AT THE TIME OF THE INCIDENT, AND LPN #3 EXPLAINED THAT "(LPN #8) WAS NOT IN THE BUILDING AT THE TIME OF THE FALL." ON 04/12/2013 AT 12:55 P.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH LPN #8 WHO EXPLAINED. "I (LPN #8) WAS NOT IN THE BUILDING AT THE TIME OF THE INCIDENT (WHEN RESIDENT #502 fell ). I CAME AFTER THE INCIDENT AT ABOUT 6:30 A.M. I SPOKE TO THE MIDNIGHT SHIFT NURSE AND ASKED WHY THE WET FLOOR SIGN WAS UP IN THE DINING ROOM. SHE TOLD ME THE DINING ROOM FLOOR HAD BEEN WAXED AND THAT ONE OF THE RESIDENTS FROM UPSTAIRS JUST SLIPPED AND fell IN THERE. SO I ASKED IF SHE (#502) WAS HURT AND WAS TOLD THAT SHE (#502) COMPLAINED OF PAIN TO HER ARM." FURTHER REVIEW OF NURSES' NOTES FOR RESIDENT #502 DATED 04/02/2013 AT 10:37 A.M. REVEALED "...X-RAY NOTED SUSPICIOUS FRACTURE WITH NO EVIDENCE OF DISLOCATION TO LEFT FOREARM AND WRIST..." ON 04/11/2013, AN INTERVIEW WAS CONDUCTED WITH DON #2, WHO EXPLAINED THAT "WHEN THE X-RAYS RESULTS CAME BACK AS A SUSPICIOUS FRACTURE, I DECIDED THAT SHE (#502) NEEDED TO BE SENT OUT. THE RESIDENT (#502) HAD SWELLING TO HER ARM. SHE DID FRACTURE HER WRIST AND THEY HALF CASTED HER WRIST." DON #2 FURTHER EXPLAINED THAT BECAUSE SHE (#502) "FREELY GOES UP AND DOWN STAIRS (USING THE ELEVATOR), THE STAFF DOESN'T PAY TOO MUCH ATTENTION TO HER. YOU CAN'T HEAR THE ELEVATOR DOOR WHEN IT OPENS, IT DOESN'T MAKE A SOUND. MY CONCERN WAS WHY DIDN'T ANYBODY SEE HER?" DURING THE INVESTIGATION, MULTIPLE ATTEMPTS WERE MADE TO CONTACT THE FIRST FLOOR MIDNIGHT SHIFT NURSE. PHONE MESSAGES LEFT BY THE SURVEYOR WERE UNRETURNED. AN INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSING ASSISTANT (CNA) #11, WHO WAS ASSIGNED TO CARE FOR RESIDENT #502 ON 04/01/2013 (MIDNIGHT SHIFT). CNA #11 STATED, "I (CNA #11) WAS IN ANOTHER ROOM, RENDERING CARE TO ANOTHER RESIDENT. I DIDN'T KNOW THAT SHE (#502) WAS OUT OF HER ROOM. THE RESIDENT (#502) HAD JUST MOVED UP TO THE SECOND FLOOR FROM THE FIRST FLOOR AND SHE WOULD SOMETIMES TRY TO GO BACK TO HER OLD ROOM (ON THE FIRST FLOOR). HER ROOM IS DIRECTLY ACROSS FROM THE ELEVATOR AND THE ONLY WAY TO SEE THE RESIDENT IS IF SOMEONE HAPPENED TO BE IN THE HALLWAY." IT WAS UNCLEAR WHY A WANDERING RESIDENT WOULD BE PLACED IN A ROOM DIRECTLY ACROSS FROM THE ELEVATOR OUTSIDE THE VISUAL FIELD OF THE NURSES' STATION. ACCORDING TO THE POLICY ON THE 'FALLING STAR PROGRAM,' "RESIDENTS IN THE PROGRAM INCLUDE THOSE WHO HAVE A FALL RISK ASSESSMENT SCORE GREATER THAN OR EQUAL TO 8...(INTERVENTION LISTED) REDIRECT THE RESIDENT (AWAY) FROM DANGER AND UNAUTHORIZED AREAS..." ( )

This citation pertains to intake # MI 120 Based on interview and record review, the facility failed to prevent the misappropriation of property for one (#501) of 4 sampled residents reviewed for abuse, from a total sample of four residents, resulting in the loss of thousands of dollars belonging to resident #501 without her knowledge or consent. Findings include: On 05/17/12 at approximately 8:30 a.m., an interview was conducted with the facility administrator (FA), who explained that on 05/04/2012, the son (temporary guardian) of Resident #501 informed the facility that fraudulent activity had occurred with the resident's bank account. On 05/07/2012, Resident #501's son presented bank documents to the facility administration that indicated changes to the address and telephone number had been made on the resident's accounts. The facility administrator reported that the fraudulent activity on the resident bank account amounted to over $25,000. The administrator explained that the new address and telephone number on Resident #501's account matched those on record for of CNA #9. They suspected that CNA #9 took credit and debit cards belonging to resident #501 and began using the cards without the resident's consent. The CNA in question was reportedly on medical leave at the time of the investigation. The FA further stated that the Detroit Police Department (DPD) was conducting an investigation so the nurse aide involved had not been contacted about the incident so as not to interfere with the DPD investigation. The nurse aide had not yet been terminated from her position at the facility. The FA was asked if the resident had been informed of the fraudulent bank transactions and she (the FA) stated, "not yet." On 05/17/12 at approximately 11:00 a.m., the Social Worker (SW) was queried about the incident of misappropriation of funds that involved Resident #501. The SW explained that the resident was admitted into the facility on [DATE] and had several debit/credit cards in her possession. According to the SW, "The resident's son was advised to take the credit/debit cards home with him for safekeeping. The resident's son reportedly said that his mother would not willingly give the cards to him. Staff retrieved the bank/credit cards on 03/28/2012 and they were placed in the facility safe. On 03/30/2012 the cards were removed from the safe and given to the resident's son, who put them in his brief case." Resident #501 reportedly took the cards and other documents out of her son's briefcase when he walked away from the case and left it unattended. The SW explained that the resident's son did inform the facility that the resident had taken the cards back. Weeks later, the resident's son informed the facility on 05/07/2012, that he received mail from a credit card company that indicated a possible fraudulent account had recently been opened in his mother's name. He (the resident's son) also informed the social worker that a letter was received from his mother's banking institution which indicated that a change to his mother's mailing address and telephone number was made with his mother's bank. Additionally, the son received bank statements with multiple transactions that took place during the time period that his mother was in the facility. The information was provided to the facility for follow-up. The SW said, "I cross referenced the telephone number and address provided by the resident's son and found a match with one of the facility Certified Nurse Aides (CNA)." The SW was queried about whether the resident was informed of the incident and he stated, "I told her that we have been trying to straighten out some problems with her accounts, but she wouldn't remember anyway. Her memory is poor." On 05/21/2012 at 9:00 a.m. a telephone interview was conducted with the son of Resident #501. The son explained that he currently had temporary guardianship/conservatorship for his mother. He confirmed that the bank/credit cards were given to him from a facility staff person, and his mother retrieved them back from his briefcase. The facility was informed that the resident had retrieved the cards. The resident's son explained that a police report was made with the Detroit Police Department once he was made aware of the fraudulent activity on his mother accounts. He further stated that "so far, there has been over $14,000 with one bank and over $1,600 with another bank stolen from my mother." He explained that initially, he informed the administrator that the amount of money stolen from his mother was over $25,000, but the bank representative clarified the transactions and explained that it had been around $14,000 taken. The resident's son further stated that he went to the post office to request a change of address so that his mother's mail could be forwarded to his home and was informed that someone had gone online and made a change of address for his mother to an address that he was not familiar with. The address was given to the SW who discovered that it belonged to one of the facility staff members. On 05/21/2012, review of records revealed that Resident #501, a [AGE] year old female, was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment revealed that the resident had moderately impaired cognition with long and short term memory problems. On 05/21/2012 at approximately 10 a.m., an interview was conducted with Resident #501 who explained that she would be leaving the facility soon and that she did not understand how she came to be in the facility in the first place. The resident denied any form of mistreatment by the staff and she also denied ever having had anything taken from her in the facility. An interview was conducted on 05/21/2012 at approximately 12:00 p.m. with the Security Supervisor who confirmed that she and the admissions coordinator retrieved the cards from the resident's room on 03/28/2012 to be locked up in the facility safe. An interview was conducted with the Admissions Coordinator at 12:15 p.m. on 05/21/2012 who explained, "I admitted (Resident #501) into the facility on [DATE] and the following day her son informed me that his mother had credit cards, but she would not give the cards to her son. So myself and the Security Supervisor went to her room and she allowed us to look in her black purse. We found an envelope containing 5 to 7 credit cards which we confiscated and took to the business office to be locked up. Her son informed me later that his mom took the credit cards back. After we were informed of activity on the resident's bank account, myself and the SW went and did a sweep of the residents room, but there were no cards to be found." On 05/21/2012, the business office manager verified that the cards were brought to her on 03/28/2012 and locked in the safe. "I gave the cards to (Resident #501's son) on 03/30/2012. On 05/21/2012, further review of records revealed bank documents that confirmed fraudulent activity on Resident 501's bank account that occurred from 04/11/2012 through 05/04/2012. The resident was admitted into the facility on [DATE] and remained in the facility until the time of the investigation on 05/21/2012. Her pending date of discharge was 05/22/2012. The bank statements revealed multiple cash withdrawals and purchases made during the period that the resident was in the nursing home. The activity included the following: On 04/11/2012, $14,632 was transferred from Resident 501's CDA account into her checking account. On 04/12/2012, $11,632 was transferred from the resident's checking account into a CDA account, leaving the balance in the resident checking account at $2,832. Two cash withdrawals and five purchases were made on 04/12/2012 leaving the balance at $594.00 On 04/13/2012 two more purchases were made using the funds from the resident's checking account and her balance was $24.26. On 04/16/2012 another purchase of 23.85 was made leaving the balance at $0.41. On 04/18/2012, $11,632 was transferred from Resident #501's CDA (account) into her checking account. One cash withdrawal was made on that date leaving the balance at $11,530. On 04/19/2012 three purchases and one cash withdrawal occurred which left the balance at $7,170. On 04/20/2012 there were three cash withdrawals and five purchases were made. The balance was $4,978. On 04/23/2012 there were four cash withdrawals and 20 purchases made using the funds from the resident's checking account leaving the balance at $1,631. On 04/24/2012, there was one cash withdrawal and five purchases made on the resident's account leaving the balance at $847. On 04/25/2012, there were four transactions made leaving the balance at $682. On 04/26/2012, there was one cash withdrawal and three transactions leaving the balance at $91.19. On 04/27/2012 two transactions were made which caused the residents account to have a negative balance of $-41.48. On 05/03/2012 cash withdrawals, transactions and overdraft fees continued causing the balance to be $-664.95. On 05/04/2012 transactions and overdraft fees continued resulting in a negative balance of $-882.14. Additionally, resident 501's son provided a letter from a credit card company dated 04/03/2012 which noted, "...possible fraudulent (credit card) account that has recently been opened using some or all of your personal information. You may be a victim of identity theft in which your personal information could have been used by someone else to obtain credit." A letter dated 04/11/2011, from Resident #501's banking institution noted, "effective 04/11/2011, our records have been updated to reflect a change in your mailing address." The administrator confirmed that the address was changed to an address belonging to CNA #9. On 05/21/2012, the incident report for the misappropriation allegation was requested but not provided by the facility. The facility administrator explained that an incident report had not been completed for this event. The investigative summary was also requested but was not provided. A document dated 05/21/2012 was provided which detailed the actions taken by the facility administrator when she was informed of the incident. However, the document did not depict a thorough investigation. The FA explained that a full investigation was not conducted because she (the FA) thought that it was a law enforcement matter and would have been handled by the DPD. On 05/22/2012 an interview was made at the 8th precinct office of the DPD. An interview was conducted with Sergeant #12 who explained that the case had not yet been assigned to a detective to investigate. The suspect in question (CNA #9) was not interviewed because of the pending police investigation. Review of the undated facility policy entitled, "Abuse and Neglect Prohibition Policy" revealed, "Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. ( )

REFER TO INTAKE NUMBERS: #MI 805 AND #MI 249 BASED ON OBSERVATION, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE SUPERVISION TO 2 (#101 AND #105) OF 5 SAMPLED RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 5, RESULTING IN INJURY (FOREHEAD LACERATION FOR RESIDENT #101 AND RIGHT FEMUR FRACTURE FOR RESIDENT #105) WHEN BOTH RESIDENTS WHO WERE AT RISK FOR FALLS WERE LEFT IN THEIR ROOMS UNSUPERVISED AFTER MAKING ATTEMPTS TO GET OUT THEIR RESPECTIVE BEDS. THE FACILITY ALSO FAILED TO IMPLEMENT SAFETY MEASURES AND PROPERLY USE THE TAB ALARM SYSTEM FOR 23 NON-SAMPLED RESIDENTS OUT OF 36 RESIDENTS WHO WERE CARE PLANNED FOR TAB ALARM AND WERE IDENTIFIED AS HIGH RISK FOR FALLS, RESULTING IN THE POTENTIAL FOR FALLS AND INJURY. FINDINGS INCLUDE: RESIDENT #101: RESIDENT #101 WAS REadmitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. SHE RECEIVED NUTRITION VIA PEG TUBE, BUT WAS ALSO SERVED A "PLEASURE TRAY." THE PREADMISSION SCREENING/ANNUAL RESIDENT REVIEW DATED 3/24/11 REVEALED THAT RESIDENT #101 HAS DEMENTIA AND ROUTINELY RECEIVED PSYCHOTROPIC MEDICATIONS REMERON AND RISPERDAL. THE MDS (MINIMUM DATA SET) DATED 3/8/12, REVEALED THAT RESIDENT #101 HAD SHORT TERM AND LONG TERM MEMORY PROBLEM, WAS TOTALLY DEPENDENT ON STAFF FOR ADLS (ACTIVITIES OF DAILY LIVING) SUCH AS BED MOBILITY, TRANSFERS, BATHING AND TOILET USE, REQUIRING 2 PERSON ASSISTANCE. RESIDENT #101 WAS NON AMBULATORY AND WAS INCONTINENT OF BOTH BLADDER AND BOWEL. A FALL ASSESSMENT TOOL, DATED 12/12/11, DOCUMENTED THAT RESIDENT #101 HAD A SCORE OF 11, INDICATING AT RISK FOR FALL. ACCORDING TO THE INCIDENT/ACCIDENT REPORT DATED 3/14/12 AT 9:15 AM, RESIDENT #101 fell FACE DOWN, OUT OF HER WHEELCHAIR. THE NURSE HEARD THE TAB ALARM SOUNDING AND FOUND RESIDENT #101 FACE DOWN ON THE FLOOR. RESIDENT #101 SUSTAINED A LACERATION TO HER FOREHEAD THAT WAS ABOUT 3.5 CM BY 1.5 CM. HOSPITAL RECORDS DATED 3/14/12 WERE REVIEWED. RESIDENT #101 WAS EXAMINED AND EVALUATED FOR A SCALP LACERATION REQUIRING SUTURES. SHE RETURNED TO THE FACILITY FROM THE HOSPITAL THE SAME DAY. CERTIFIED NURSING ASSISTANT (CNA) #7 WAS INTERVIEWED ON 4/2/12 AT 3:18 PM. CNA #7 STATED THAT ON THE DAY RESIDENT #101 fell AND SUSTAINED THE LACERATION TO HER FOREHEAD, SHE (#7) HAD BEEN INSTRUCTED BY NURSE #6 TO GET RESIDENT #101 UP EARLIER THAN WAS USUAL AND TAKE THE RESIDENT (#101) TO THE DINING ROOM AFTER THE RESIDENT HAD FINISHED WITH HER TUBE FEEDING. ACCORDING TO CNA #7, THIS WAS A CHANGE IN RESIDENT #101'S ROUTINE. NURSE AIDE #7 RECALLED THAT RESIDENT #101 WAS "USUALLY A LATE START. SHE (#101) USUALLY GETS UP AT 11:30 AM BUT THAT DAY SHE HAD SEVERAL ATTEMPTS TO TRY TO GET UP AND OUT OF BED." CNA #7 STATED THAT AS SHE (#7) WAS TAKING RESIDENT #101 TO THE DINING ROOM, THE NURSE (#6) REQUESTED THAT RESIDENT #101 BE RETURNED TO HER ROOM FOR MEDICATION ADMINISTRATION AND TO OBTAIN VITAL SIGNS. CNA #7 STATED THAT "BOTH NURSES WERE OUTSIDE THE RESIDENT'S DOOR WHEN I PUT HER BACK INTO THE ROOM AND MADE SURE THAT HER LEGS WERE ON BOTH ON THE LEG REST." ACCORDING TO CNA #7, SHE (#7) LEFT TO ATTEND TO OTHER RESIDENTS ASSIGNED TO HER AND DID NOT RETURN TO TAKE RESIDENT #101 TO THE DINING ROOM. CNA #7 DID NOT SAY IF SHE (#7) HAD BEEN ASKED TO ENSURE THAT RESIDENT #101 WAS PLACED IN THE DINING ROOM AFTER THE RESIDENT HAD RECEIVED HER MEDICATIONS AND HAD HER VITAL SIGNS TAKEN. NURSE #6 WAS INTERVIEWED ON 4/2/12 AT 2:30 PM. ACCORDING TO NURSE #6, RESIDENT #101 WAS MAKING ATTEMPTS OF "GETTING OUT OF BED THAT DAY." NURSE #6 RECALLED THAT SHE INSTRUCTED NURSE AIDE #7 TO GET HER (#101) UP EARLIER THAN USUAL THAT DAY DUE HER IMPULSIVE BEHAVIOR OF "GETTING OUT OF BED." NURSE #6 SAID THAT SINCE RESIDENT #101 SEEMED TO NOT WANT TO STAY IN BED, IT WOULD BE BETTER FOR HER (#101) TO BE IN THE DINING ROOM FOR ACTIVITIES, BUT NEEDED HER (#101) IN HER ROOM FOR MEDICATION ADMINISTRATION AND TO CHECK HER VITAL SIGNS. NURSE #6 STATED THAT SHE (#6) WAS ORIENTING A NEW NURSE EMPLOYEE ON 3/14/12. THEY (NURSE #6 AND THE ORIENTEE NURSE) HAD FINISHED WITH RESIDENT #101 AND WERE OUTSIDE THE RESIDENT ' S ROOM WHEN SHE (#101) fell . NURSE #6 SAID THAT HER (#6) BACK WAS FACING THE RESIDENT'S DOOR. SHE HEARD THE TAB ALARM SOUNDING AND FOUND THE RESIDENT ON THE FLOOR FACE FORWARD. SHE (#6) WAS NOT SUPERVISING THE RESIDENT BECAUSE SHE (#6) WAS ORIENTING THE NEW NURSE WHO WAS DISPENSING MEDICATION WHEN THE FALL OCCURRED. NURSE #6 DID NOT SAY IF SHE (#6) HAD ASKED CNA #7 TO MAKE SURE THAT RESIDENT #101 WAS NOT LEFT IN HER ROOM, UNATTENDED, AFTER THE NURSES WERE FINISHED WITH HER. # RESIDENT #105: RESIDENT #105 WAS admitted to the facility on [DATE]. A history and physical examination [REDACTED]. THE PREADMISSION SCREENING/ANNUAL RESIDENT REVIEW DATED 6/18/10 DOCUMENTED THAT RESIDENT #105 HAD [DIAGNOSES REDACTED]. RESIDENT #105 ROUTINELY RECEIVED THE PSYCHOTROPIC MEDICATIONS ARICEPT, RISPERDAL AND LEXAPRO. ACCORDING TO THE MDS (MINIMUM DATA SET) assessment dated [DATE], RESIDENT #105 REQUIRED EXTENSIVE ASSISTANCE FOR BED MOBILITY, TRANSFERS DRESSING AND TOILET USE REQUIRING PHYSICAL ASSISTANCE. RESIDENT #105 WAS NOT AMBULATORY AND WAS INCONTINENT OF BOTH BOWEL AND BLADDER. RESIDENT #105 HAD A SCORE OF 10 ACCORDING TO A FALL ASSESSMENT TOOL DATED 3/12/12, WHICH INDICATED SHE WAS AT RISK FOR FALLING. RESIDENT #105 HAD EXPERIENCED A FALL WITHOUT INJURY ON 3/9/12, WHEN SHE WAS FOUND SITTING ON THE FLOOR IN THE HALLWAY. ACCORDING TO THE FACILITY ' S INVESTIGATION OF THE INCIDENT, DATED 4/2/12 AT 4:45 PM, A CNA (#10) OBSERVED RESIDENT #105 "TRYING TO GET OUT OF BED . . . WHEN HE NOTICED HER LEG DID NOT LOOK RIGHT." THE NURSE ARRANGED FOR AN XRAY TO BE TAKEN. THE RESULTS OF THE XRAY CAME BACK AS AN "OBLIQUE FRACTURE OF THE RIGHT FEMUR." NURSE'S NOTES DATED 4/1/12 AT 7:50 PM, REVEALED "CENA (NURSE AIDE #10) ENTER RESIDENT ROOM, RESIDENT WAS AT THE FOOT OF THE BED. HE (#10) NOTICED HER RIGHT THIGH WAS SWOLLEN ABOVE THE KNEE. RESIDENT STATED SHE HIT HER RIGHT THIGH (ON) THE FOOT OF THE (BED) AND HER THIGH IS PAINFUL UPON MOVE." CNA #11 WAS INTERVIEWED AT 12:30 PM ON 4/5/12. CNA #11 STATED THAT SHE WAS NOT ASSIGNED TO CARE FOR RESIDENT #105 ON 4/1/12, BUT RESPONDED WHEN SHE SAW RESIDENT #105 ATTEMPTING TO GET UP. CNA #11 STATED THAT SHE REMINDED RESIDENT #105 NOT TO GET UP OUT OF BED. CNA #11 WENT ON TO SAY THAT SHE REPOSITIONED RESIDENT #105 IN THE BED SO THAT THE RESIDENT COULD WATCH TELEVISION. ACCORDING TO CNA #11, SHE (#11) IMMEDIATELY TOLD NURSE AIDE #10, WHO WAS ASSIGNED TO CARE FOR RESIDENT #105, TO KEEP A CLOSE EYE ON THE RESIDENT BECAUSE SHE (#11) JUST CAUGHT HER (#105) TRYING TO GET UP OUT OF BED. CNA #11 STATED, "NEXT THING I KNEW, (CNA #10) CAME TO ME AND SAID THAT (RESIDENT #105) JUST fell ." CNA #11 DID NOT SAY IF SHE INFORMED THE NURSE ON DUTY THAT RESIDENT #105 WAS MAKING ATTEMPTS TO GET OUT OF BED. CNA #10 WAS INTERVIEWED BY TELEPHONE ON 4/6/12 AT 11:30 AM. WHEN ASKED ABOUT THE EVENTS LEADING UP TO RESIDENT #105'S FALL, CNA #10 STATED THAT "IT HAPPENED SO QUICKLY THAT REQUIRED A QUICK ACTION." CNA #10 STATED THAT HE RESPONDED TO A BED ALARM AT AROUND 6:30 PM AND FOUND RESIDENT #105 REACHING FOR SOMETHING IN THE DRAWER OF THE NIGHT STAND. CNA #10 STATED THAT HE COULD TELL THAT RESIDENT #105 WAS ABOUT TO FALL OUT OF BED WHILE HER FOOT WAS TWISTED UP IN THE BED SHEETS. RESIDENT #105 WAS HOLDING ON TO THE DRAWER OF THE NIGHT STAND, PULLING AT THE TELEVISION SET AND THE NIGHT STAND WHICH WERE ABOUT TO FALL ONTO HER. CNA #10 DESCRIBED HOW HE TRIED TO BREAK RESIDENT'S #105'S FALL WHILE AT THE SAME TIME HE TRIED TO PREVENT THE TELEVISION AND THE NIGHT STAND FROM FALLING ONTO THE RESIDENT. HE WAS UNSURE OF HOW HE GRABBED THE RESIDENT TO PREVENT HER FROM FALLING ON THE FLOOR BUT RECALLED RESIDENT #105'S FOOT AND ANKLE WERE TWISTED AND WRAPPED INTO THE SHEETS. RESIDENT #105'S BODY WAS PARTIALLY ON THE BED AND PARTIALLY OUT OF BED. CNA #10 TRIED TO GRAB RESIDENT #105 AND HOLD HER UP. CNA #10 WENT ON TO SAY THAT RESIDENT #105 HAD ONLY ONE FUNCTIONING ARM AND THAT THE OTHER ARM WAS PARALYZED. CNA #10M DESCRIBED RESIDENT #105, SAYING, "SHE IS FAIRLY A BIG LADY ALMOST 200 PLUS POUNDS." NURSE AIDE #10 EXPLAINED TO THE SURVEYOR THAT RESIDENT #105 DID NOT TOUCH THE FLOOR, AND THEREFORE, RESIDENT #105 HAD NO FALL. CNA #10 STATED THAT HE CALLED THE NURSE TO ASSESS THE RESIDENT WHO OBSERVED BRUISING TO THE RIGHT KNEE AND PAIN UPON MOVEMENT. CNA #10 DID NOT SAY IF HE HAD INFORMED THE NURSE ON DUTY THAT RESIDENT #105 WAS TRYING TO GET UP OUT OF BED ON THAT DAY (4/1/12). CNA #10 ALSO DID NOT SAY HOW HE IMPLEMENTED CNA #11'S ADVICE TO CLOSELY WATCH RESIDENT #105 BECAUSE SHE (#105) WAS TRYING TO GET OUT OF BED. # DURING THE OBSERVATION TOUR ON 4/4/12 BETWEEN 11:50 AM TO 1:10 PM, ACCOMPANIED BY NURSE MANAGER #3, SURVEYOR # MADE OBSERVATIONS OF THE 36 RESIDENTS IN THE BUILDING THAT THE FACILITY HAD IDENTIFIED AS HIGH RISK FOR FALLS AND HAD A CURRENT UPDATED CARE PLAN FOR THE USE OF A PERSONAL TAB ALARM TO MAINTAIN SAFETY. DURING THE OBSERVATION, 23 RESIDENTS OUT OF 36 IDENTIFIED WITH TAB ALARM EITHER DID NOT HAVE A TAB ALARM ATTACHED TO THE RESIDENT (FOUND 11 RESIDENTS), TAB ALARM WAS NOT SECURELY PLACED TO ACTIVATE THE ALARM (FOUND 2 RESIDENTS) OR DID NOT HAVE A TAB ALARM UNIT WITH THEM AT ALL (FOUND 10 RESIDENTS). THE 10 HIGH RISK RESIDENTS IDENTIFIED WITHOUT THE TAB ALARM UNIT WERE: NON-SAMPLED RESIDENTS #A2, A3, A5, A6, A8, A9, A12, A13, A18, A21. NON-SAMPLED RESIDENTS WITH ALARMS BUT WITH INAPPROPRIATE PLACEMENT (THE UNIT WAS NOT APPROPRIATELY PLACED ON A SECURED FIXTURE) WERE: NON-SAMPLED RESIDENTS #A7 AND A11. THERE WERE 11 OTHER RESIDENTS DEEMED HIGH RISK FOR FALLS, WHO WERE CARE PLANNED FOR THE USE OF A TAB ALARM BUT THE ALARM WAS FOUND TO BE NOT CLIPPED OR ATTACHED WERE: SAMPLED RESIDENT #102, AND NON-SAMPLED RESIDENTS #A1, A4, A10, A14, A15, A16, A17, A19, A20 AND A22. NURSE #3 AND NURSE #4 CONFIRMED THESE OBSERVATIONS AND AGREED THAT THESE OBSERVATION WAS A FACILITY WIDE PROBLEM THAT NEEDED IMMEDIATE CORRECTIVE ACTION AND INTERVENTION FOR ALL RESIDENT'S SAFETY. CNA #5 WAS OBSERVED IN THE RESTORATIVE DINING ROOM ON 4/4/12 AT 1:00 PM, ASSISTING RESIDENTS. CNA #5 STATED THAT THEY (CNAS) WERE INSTRUCTED BY NURSING MANAGEMENT TO REMOVE THE CLIPS OFF THE RESIDENT'S ALARM UNIT DURING MEAL TIME. CNA #5 STATED, "THIS HAS BEEN ONGOING FOR A LONG TIME." THE DON (DIRECTOR OF NURSING), NURSE #3 AND NURSE #4 ON 4/4/12 AT 1:15 PM DENIED KNOWLEDGE ABOUT THE INSTRUCTIONS OF RELEASING OR REMOVING THE TAB ALARM CLIP DURING MEAL TIME. THE FACILITY'S FALLING STAR PROGRAM DATED FEBRUARY 17, 2004 WAS REVIEWED. PLACEMENT OF TAB ALARMS CLEARLY SPECIFIED THAT "TAB ALARMS SHOULD BE CLIPPED ONTO CLOTHING THAT WILL ALLOW CORD TO BE PULLED AND THE ALARM TO SOUND WHEN RESIDENT ATTEMPTS TO EXIT THE CHAIR OR BED." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 602 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE CARE AND TREATMENT TO PREVENT PRESSURE SORES FOR ONE RESIDENT (#501) OF 4 SAMPLED RESIDENTS REVIEWED FOR APPROPRIATENESS OF CARE FROM A TOTAL SAMPLE OF 4, RESULTING IN THE DEVELOPMENT OF A NEW PRESSURE SORE AND THE POTENTIAL FOR DELAYED HEALING OF CURRENT PRESSURE SORES. FINDINGS INCLUDE: ON 3/21/12 AT 10:40 A.M., RESIDENT #501 WAS OBSERVED IN HER ROOM LAYING IN BED IN A SUPINE POSITION (BACK LYING). RESIDENT #501 STATED, "...SEEMS LIKE THE BED IS WET..." THE ASSISTANT DIRECTOR OF NURSING (ADON), WHO WAS PRESENT AT THE TIME, STATED, "...SHE (CERTIFIED NURSING ASSISTANT/CNA #1) SAID SHE TOOK CARE OF YOU ALREADY..." ON 3/21/12 AT 10:45 A.M., CNA #2 AND CNA #3 ENTERED THE ROOM TO PROVIDE INCONTINENT CARE. A NEWLY IDENTIFIED SORE WAS OBSERVED TO RESIDENT #501'S SACROCOCCYGEAL AREA. CNA #2 REPORTED, "...I'LL TELL THE TREATMENT NURSE (LPN #2) SO SHE CAN PUT A DRESSING ON IT..." ON 3/21/12 AT 10:53 A.M., DURING AN INTERVIEW, LPN #2 REPORTED, "...SHE (#501) WAS readmitted WITH WOUNDS TO HER SACRUM AND LEFT BUTTOCK..." ON 3/21/12 AT 11:00 A.M., THE ASSISTANT DIRECTOR OF NURSING (ADON) WAS QUERIED AND ASKED HOW OFTEN RESIDENT #501 WAS ASSISTED WITH GETTING OUT OF BED IN ORDER TO RELIEVE PRESSURE TO HER BUTTOCK AND SACRAL AREA. THE ADON REPLIED, "...SHE (#501) DOESN'T WANT TO GET UP. SHE ONLY GETS OUT OF BED (OOB) ON DEEP CLEANING DAYS..." WHEN ASKED HOW OFTEN RESIDENT #501 IS OFFERED THE OPPORTUNITY TO GET OOB, THE ADON SAID, "...WE HAVE A CARE PLAN THAT SAYS SHE REFUSES TO GET OOB. WE ASK HER DAILY IF SHE WANTS TO GET UP. WHY DO WE HAVE TO KEEP ASKING HER IF WE HAVE A CARE PLAN IN PLACE? ..." ON 3/21/12 AT 11:10 A.M., THE SURVEYOR ASKED THE ADON AND DIRECTOR OF NURSING (DON) WHO WAS ALSO PRESENT, FOR DOCUMENTED EVIDENCE OF OFFERS AND ATTEMPTS TO GET RESIDENT #501 OOB ALONG WITH DOCUMENTATION OF ANY REFUSALS. NEITHER THE DON OR THE ADON COULD PROVIDE ANY DOCUMENTED EVIDENCE THAT RESIDENT #501 WAS CONSISTENTLY OFFERED AND ENCOURAGED TO GET OUT OF BED IN ORDER TO RELIEVE PRESSURE FROM HER BACK SIDE AND SUBSEQUENTLY AVOID ACQUIRING NEW PRESSURE SORES AND DELAYED HEALING OF HER CURRENT PRESSURE SORES. THE DON REPORTED, "...I UNDERSTAND. WE SHOULD HAVE HAD MORE DOCUMENTATION OF STAFF ATTEMPTS TO GET HER (#501) OUT OF BED." AT 11:15 A.M., THE SURVEYOR REQUESTED RESIDENT #501'S CLINICAL RECORD. PRIOR TO GIVING THE SURVEYOR RESIDENT #501'S CLINICAL RECORD, LPN #1 WHO WAS ALSO PRESENT DURING THE CONVERSATION WITH THE DON AND ADON, DOCUMENTED IN #501'S CLINICAL RECORD, "...WRITER OFFERED RESIDENT TO GET UP A LITTLE EARLY FOR DOCTOR'S APPOINTMENT..." ON 3/21/12 AT 11:36 A.M., THE ADON SUBMITTED DOCUMENTATION OF THE FACILITY'S PREVIOUS DEEP CLEANING SCHEDULES AND STATED THE FOLLOWING, "...THESE WERE THE DAYS WE HAD THE ROOMS DEEP CLEANED. SHE (#501) GOT OUT OF BED THEN..." ON 3/21/12, A REVIEW OF THE "DEEP CLEANING LIST" DOCUMENTED REVEALED THAT RESIDENT #501'S ROOM HAD BEEN DEEP CLEANED ON 1/12/12 AND 2/8/12. ACCORDING TO THE ADON, THE LAST TIME RESIDENT #501 WAS OUT OF BED WAS ON 2/8/12. ON 3/21/12 AT 11:40 A.M., DURING AN OBSERVATION, RESIDENT #501 WAS ASKED IF SHE WANTED TO GET OUT OF BED. RESIDENT #501 REPLIED, "...HOW LONG DO I HAVE TO STAY UP? I'LL GET UP ABOUT 2:00 P.M..." AT NO TIME, DURING THE INTERVIEW, DID RESIDENT #501 DECLINE TO GET OUT OF BED. ON 3/21/12 AT 1:55 P.M., DURING AN INTERVIEW WITH THE FACILITY'S TREATMENT NURSE (LPN #2), IT WAS REPORTED, "...DURING HER (#501) PREVIOUS ADMISSION, HER WOUNDS WERE HEALED ON 12/8/11. SHE WAS readmitted WITH THE CURRENT WOUNDS TO HER BUTTOCKS AND COCCYX. I PUT A DRESSING ON THE NEWLY IDENTIFIED AREA OBSERVED THIS MORNING." LPN #2 PROVIDED DOCUMENTATION OF THE NEWLY IDENTIFIED AREA TO RESIDENT #501'S SACROCOCCYGEAL AREA WHICH MEASURED, "...1.5 CM (CENTIMETERS) BY 0.2 CM, PALE PINK BASE WITH MINIMAL SEROSANGUINEOUS DRAINAGE..." A REVIEW OF THE "RESIDENT-DATA COLLECTION" SHEET DATED 1/13/12 REVEALED THAT RESIDENT #501 WAS REadmitted to the facility on [DATE] WITH STAGE 2 PRESSURE SORES TO HER SACRAL AREA AND LEFT BUTTOCK. ACCORDING TO THE FACILITY FACE SHEET, RESIDENT #501 WAS A [AGE] year OLD FEMALE WHO WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. A REVIEW OF THE physician's orders [REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT RESIDENT #501 WAS ALERT AND ORIENTED X 3 (PERSON, PLACE AND TIME) AND WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TOILETING, PERSONAL HYGIENE AND BATHING. THE AREA ON THE MDS REGARDING TRANSFERS WAS CODED "...8, ACTIVITY DID NOT OCCUR-ACTIVITY WAS NOT PERFORMED BY RESIDENT OR STAFF AT ALL OVER THE ENTIRE 7-DAY PERIOD..." A REVIEW OF RESIDENT #501'S ADL CARE PLAN DATED 1/13/12 REVEALED "...TURN AND REPOSITION EVERY 2 HOURS AND PRN (AS NEEDED) WITH PILLOWS FOR ALIGNMENT AND COMFORT. EXAMINE SKIN DURING BATHING FOR SIGNS AND SYMPTOMS OF BREAKDOWN..." RESIDENT #501'S MOBILITY CARE PLAN DATED 1/13/12 REVEALED, "...MOBILITY IMPAIRED RELATED TO [MEDICAL CONDITION] SECONDARY TO GSW (GUN SHOT WOUND) AND COMPLICATING CONTRACTURES TO LOWER EXTREMITIES AND SHOULDERS/ARMS. DECLINES TO ALLOW ROM (RANGE OF MOTION) OR GET OUT OF BED, DECLINES TO BE POSITIONED ON SIDES AND WANTS TO STAY ON BACK STATING UNCOMFORTABLE..." RESIDENT #501'S MOBILITY CARE PLAN REVEALED THE FOLLOWING INTERVENTION, "...CONTINUE TO REMIND RESIDENT OF THE COMPLICATIONS OF CONTINUED BEDREST AND RESISTANCE TO ROM..." A REVIEW OF RESIDENT #501'S PRESSURE SORE CARE PLAN DATED 1/12/12 REVEALED, "...readmitted WITH SKIN BREAKDOWN WHICH HEALS AND REOPENS WITH RISK FOR NEW SKIN BREAKDOWN OR REOPENING OF PREVIOUS SITES DUE TO IMMOBILITY, INCONTINENCE, CONTRACTURES..." RESIDENT #501'S PRESSURE SORE CARE PLAN REVEALED THE FOLLOWING INTERVENTIONS, "...POSITION WITH PILLOWS TO REDUCE PRESSURE A NEEDED, EXPLAIN COMPLICATIONS OF NON-COMPLIANCE WITH TURNING AND MEAL COMPLIANCE..." A REVIEW OF RESIDENT #501'S BEHAVIORAL CARE PLAN DATED 1/13/12 REVEALED "...RESIDENT PREFERS TO NOT PARTICIPATE IN TURNING SCHEDULE OR TO BE WEIGHED. THE FOLLOWING INTERVENTIONS WERE REVEALED, "...PROVIDE RESIDENT WITH OPTIONS WHEN POSSIBLE; DOCUMENT ANY PRECIPITATING EVENTS OR TRIGGERS TO REFUSAL OF CARE; GIVE CHOICES IN DAILY CARE..." THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORD THAT STAFF HAD ENCOURAGED RESIDENT #501 TO GET OUT OF BED. FURTHER, THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORD OF ANY REFUSALS TO GET OUT OF BED IN ORDER TO RELIEVE PRESSURE TO RESIDENT #501'S BACKSIDE. A REVIEW OF THE FACILITY'S "PRESSURE ULCER RISK ASSESSMENT" POLICY REVISED 10/10 REVEALED THE FOLLOWING: "...PRESSURE ULCERS ARE OFTEN MADE WORSE BY CONTINUAL PRESSURE..." "...THE AT RISK RESIDENT NEEDS TO BE IDENTIFIED AND HAVE INTERVENTIONS IMPLEMENTED PROMPTLY TO ATTEMPT TO PREVENT PRESSURE ULCERS..." "...EXTRINSIC RISK FACTORS FOR PRESSURE ULCERS INCLUDE: PRESSURE - THE RESIDENT IS NOT CAPABLE OF MOVING WITHOUT ASSISTANCE, IS CONFINED TO BED, AND OR REQUIRES A REGULAR SCHEDULE OF TURNING..." "...MULTIPLE FACTORS, INCLUDING PRESSURE INTENSITY, PRESSURE DURATION, AND TISSUE TOLERANCE, SIGNIFICANT;Y AFFECT THE POTENTIAL FOR THE DEVELOPMENT AND HEALING OF PRESSURE ULCERS..." "...THE FOLLOWING INFORMATION SHOULD BE RECORDED IN THE RESIDENT'S MEDICAL RECORD: THE POSITION IN WHICH THE RESIDENT WAS PLACED UPON COMPLETION OF THE ASSESSMENT, ANY PROBLEMS OR COMPLAINTS MADE BY THE RESIDENT RELATED TO THE PROCEDURE, IF THE RESIDENT REFUSED THE ASSESSMENT AND THE REASONS WHY..." THE FACILITY ADMINISTRATIVE AND NURSING STAFF OFFERED NO VIABLE EXPLANATION OF WHY RESIDENT #501 HAD NOT BEEN ASSISTED OUT OF BED FOR OVER A MONTH (2/8/12) AND WHY THEY FAILED TO DOCUMENT ANY ATTEMPTS OR REFUSALS.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ONE (#412) OF 14 SAMPLED RESIDENTS ADJUSTMENT TO A NEW FACILITY WAS ASSESSED, AND INTERVENTIONS TO ACCLIMATE THE RESIDENT TO HER NEW SURROUNDINGS WERE IMPLEMENTED, RESULTING IN A CHANGE IN MENTAL STATUS TO INCLUDE CONFUSION AND AGITATION, AS WELL AS INCONTINENCE, LETHARGY AND FALLS. FINDINGS INCLUDE: DURING A MONITORING VISIT ON 5/24/11 AT 11:30 AM, RESIDENT #412'S CLINICAL RECORD WAS REVIEWED AND THE RESIDENT WAS OBSERVED. THE RESIDENT WAS TRANSFERRED FROM FACILITY #1 TO THIS FACILITY (FACILITY #2) ON 5/13/11. RESIDENT #412 WAS ORIGINALLY admitted TO THE TRANSFERRING FACILITY ON 6/20/06 WITH [DIAGNOSES REDACTED]. THE PREVIOUS FACILITY NOTED ON THE TRANSFER FORM: THE RESIDENT'S VISION WAS "NORMAL," MENTAL STATUS WAS "ALWAYS ALERT," "INDEPENDENT" WITH ELIMINATION, ATTITUDE WAS "COOPERATIVE," AND AMBULATORY STATUS WAS "INDEPENDENT." ON 5/24/11 AT 12:00 PM, WHEN OBSERVED, RESIDENT #412 WAS FOUND TO REACT IN THE FOLLOWING MANNER: WAS ALERT BUT CONFUSED, AND UNABLE TO APPROPRIATELY ANSWER QUESTIONS, INCLUDING WHERE SHE WAS. THE RESIDENT WAS IN A WHEELCHAIR WITH A SELF RELEASE SEATBELT, BUT WAS UNABLE TO FIGURE OUT HOW TO RELEASE THE BELT UPON REQUEST. THE RESIDENT WAS INITIALLY UNCOOPERATIVE. ACCORDING TO AN INCIDENT/ACCIDENT (I/A) REPORT FOR RESIDENT #412 DATED 5/13/11, AND NURSES NOTES: AT 7:30 PM, THE RESIDENT CALLED STAFF TO HER ROOM AND STATED THAT SHE HAD FALLEN ON THE FLOOR. SHE WAS HOLDING THE RIGHT SIDE OF HER FACE AND COMPLAINED OF PAIN. ON 5/13/11 AT 11 PM, THE RESIDENT ASKED STAFF, "WHERE AM I? HOW DID I GET HERE?" ON 5/14/11 (NO TIME NOTED), THE RESIDENT WAS NOTED TO HAVE "SOME DIFFICULTY FINDING DINING ROOM." SHE WAS "UPSET ABOUT CHANGE" AND STATED, "I'VE GOT TO GO HOME." SHE WAS NOTED TO FEEL "BETTER WHEN REASSURED AND INFORMED (THE PHYSICIAN AT THE PREVIOUS FACILITY) WOULD BE HERE." AT 11 PM, THE RESIDENT WAS UP AND AMBULATING IN HER ROOM WITH A "STEADY" GAIT. ON 5/15/11 AT 12:15 PM, RESIDENT #412'S BLOOD PRESSURE WAS 129/69 AND PULSE WAS 60. AT 2:15 PM, THE RESIDENT WAS SITTING ON THE TOILET AND "CRIED OUT....COMPLAINING OF WEAKNESS AND BENT OVER...." HER BLOOD PRESSURE WAS 108/62, PULSE WAS 56, AND FINGERS WERE COOL TO THE TOUCH. AT 2:20 PM, THE BLOOD PRESSURE WAS 146/69, PULSE WAS 60, AND FINGERS WERE WARM. THE PHYSICIAN WAS NOTIFIED AND STATED THAT HE WOULD COME TO SEE THE RESIDENT. AT 4 PM, THE "RESIDENT APPEARED TO BE LETHARGIC, REFUSED TO EAT DINNER." OXYGEN WAS ADMINISTERED. HER BLOOD PRESSURE WAS 110/68 AND PULSE WAS 68. PER AN I/A REPORT AND NURSES NOTES, DATED 5/17/11 AT 8:45 AM, THE RESIDENT WAS OBSERVED ON THE FLOOR IN HER ROOM. SHE WAS PLACED IN A WHEELCHAIR WITH A SELF RELEASE SEAT BELT AND AN ALARM. THE RESIDENT HAD A THERAPY SCREEN (EVALUATION) FOR FALLS WHICH NOTED NO PROBLEMS WITH BALANCE OR MOBILITY. AT 9 PM, "RESIDENT APPEARS TO HAVE PROBLEMS SEEING OBJECTS AND PUTTING FOOD INTO HER MOUTH AS IF SHE CAN'T FIND HER MOUTH OR SEE HER FOOD, WILL FEEL AROUND FOR IT." AT 10 PM, THE PHYSICIAN SAW THE RESIDENT AND ORDERED STAT (IMMEDIATE) LAB WORK. AT 11 PM, THE RESIDENT WAS "EASILY AGITATED." ON 5/18/11 AT 3 AM, RESIDENT #412 WAS AGITATED AND RESTLESS. THE RESIDENT, WHO WAS "INDEPENDENT" WITH ELIMINATION PER THE TRANSFER FORM, REQUIRED AN INCONTINENT BRIEF. SHE WOULD NOT ALLOW STAFF TO CHANGE IT OR TO TOUCH HER. STAFF PROVIDED ONE TO ONE SUPERVISION UNTIL 5:30 AM DUE TO AGITATION DURING WHICH TIME THE RESIDENT WAS REMOVING THE SAFETY ALARM AND THROWING IT IN THE WASTEBASKET. DURING A PHONE INTERVIEW ON 5/24/11 AT 1 PM, THE OFFICE COORDINATOR FOR RESIDENT #412'S GUARDIAN SAID THE FOLLOWING: "WE WERE NOTIFIED ON MAY 10 TH (2011) THAT THE TRANSFER WAS TEMPORARY THEN ON MAY 24 TH (2011), WE RECEIVED A FAX FROM (FACILITY #1'S ADMINISTRATOR) THAT THE MOVE WAS PERMANENT BUT THAT WAS NOT THE INITIAL AGREEMENT! IF WE HAD KNOWN IT WAS PERMANENT, WE WOULD NOT HAVE AGREED. (RESIDENT #412) HAD A VERY HARD TIME ADJUSTING TO THE TRANSFER FROM HOME TO (FACILITY #1) IN THE FIRST PLACE. AFTER BEING THERE (AT FACILITY #1) SO LONG, WE DON'T KNOW HOW SHE WILL BE AFFECTED (AT FACILITY #2)." ON 5/24/11 AT 2:30 PM, THE CASE MANAGER FOR RESIDENT #412, SAID THE FOLLOWING: "HAD I KNOWN THE MOVE WAS GOING TO BE PERMANENT, I WOULD HAVE SENT THEM ELSEWHERE. I WANTED A SMALLER VENUE FOR (RESIDENT #412) THAT WOULD BE MORE APPROPRIATE FOR HER. HOW CAN I GET HER TRANSFERRED? THE GUARDIAN MAKES THESE DECISIONS. IF THEY CAN'T GO BACK, THEN I WANT SOMEPLACE ELSE. I HAVE BEEN IN THIS BUSINESS FOR 36 AND A HALF YEARS! I FEEL LIKE I HAVE BEEN HAD! YOU CAN GIVE ME A PILL, DOESN'T MEAN I HAVE TO SWALLOW IT! I MAKE THE CHOICE." ON 5/26/11 AT 2 PM, THE CASE MANAGER/GUARDIAN'S OFFICE STAFF CALLED BY PHONE AND STATED THAT THEY WANTED RESIDENT #412 "PLACED ELSEWHERE," FACILITY #1 WOULD NOT TAKE THE RESIDENTS BACK, AND ASKED HOW THIS COULD BE ARRANGED. ( )

THIS CITATION PERTAINS TO INTAKE # MI 620. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION, AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS IN 2 OF 7 SAMPLED RESIDENTS (#104 AND #106) RESULTING IN REPEATED AVOIDABLE FALLS, RESIDENT #106'S INTRACRANIAL BLEED, AND THE POTENTIAL FOR FUTURE FALLS WITH INJURY. FINDINGS: RESIDENT # 104: ACCORDING TO THE FACE SHEET DATED 2/10/2011, RESIDENT # 104 HAS LIVED IN THE FACILITY SINCE JANUARY 2007. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #104 WAS A [AGE] year OLD FEMALE WITH IMPAIRED COGNITIVE ABILITIES. RESIDENT #104 REQUIRED SUPERVISION ANS ASSISTANCE FOR TRANSFERS. RESIDENT #104 HAD SEVERAL [DIAGNOSES REDACTED]. THE CARE PLAN FOR RESIDENT #104 DATED 9/23/2010, IDENTIFIED THE POTENTIAL FOR FALLS AND IMPAIRED COGNITION AS AREAS FOR CONCERN AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING ASSIST WITH TRANSFERS AND OBSERVE WHEN AMBULATING FOR BALANCE AND GAIT DISTURBANCES. ACCORDING TO THE INCIDENT / ACCIDENT REPORT DATED 1/17/2011 FACILITY STAFF FAILED TO PROVIDE ASSISTANCE WITH TRANSFERS AND SUPERVISION WITH AMBULATION FOR RESIDENT #104. RESIDENT #104 SAID SHE GOT OFF THE TOILET AND fell TO THE FLOOR ACCORDING TO THE NURSE'S NOTES DATED 1/17/2011 RESIDENT #104 COMPLAINED OF FACIAL PAIN AS A RESULT OF THIS FALL. ACCORDING TO THE INCIDENT / ACCIDENT REPORT DATED 1/17/2011 " ...STEPS TAKEN TO PREVENT REOCCURRENCE ... " WAS BLANK. NO EVIDENCE COULD BE FOUND IN RESIDENT # 104'S CLINICAL RECORD TO INDICATE ANY CHANGES WERE MADE TO ENSURE RESIDENT #104 RECEIVED THE SUPERVISION REQUIRED. ON 3/4/2011 AT 1:40 PM THE DIRECTOR OF NURSING (DON) AND ASSISTANT DIRECTOR OF NURSING (ADON) REVIEWED RESIDENT # 104'S CLINICAL RECORD. THE DON WAS NOT ABLE TO PROVIDE EVIDENCE THAT RESIDENT # 104 RECEIVED THE SUPERVISION RESIDENT #104 REQUIRED TO ENSURE HER SAFETY. THE ADON SAID A FALLS MEETING WAS HELD, THERE WAS "...NO CHANGE IN PLAN OF CARE...BECAUSE WE DID NOT CHANGE THE CARE PLAN, WE CAN EXPECT MORE FALLS WILL OCCUR..." RESIDENT # 106: ACCORDING TO THE FACE SHEET DATED 1/28/2011, RESIDENT #106 LIVED IN THE FACILITY SINCE 12/22/2010. THE CARE PLAN FOR RESIDENT #106 DATED 12/22/2010, IDENTIFIED THE POTENTIAL FOR FALLS AND IMPAIRED COGNITION AS AREAS FOR CONCERN AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING A PERSONAL ALARM, LOW BED, FLOOR MAT, BED BOLSTERS, A GERI-CHAIR WITH TABLE TOP AND PREVENT UNASSISTED TRANSFER OR AMBULATION. RESIDENT #106 HAD SEVERAL [DIAGNOSES REDACTED]. ACCORDING TO THE CLINICAL RECORD, THE RESIDENT # 106 fell on FOUR SEPARATE OCCASIONS, 12/27/2010, 12/28/2010, 1/10/2011 AND 2/1/2011. ACCORDING TO THE INCIDENT / ACCIDENT REPORT DATED 12/27/2010 FACILITY STAFF FAILED TO SUPERVISE OR PREVENT UNASSISTED TRANSFER OR AMBULATION AND RESIDENT #106 fell OUT OF THE GERI-CHAIR. RESIDENT #106 SUSTAINED NO APPARENT INJURIES AS A RESULT OF THIS FALL. ACCORDING TO THE INCIDENT / ACCIDENT REPORT DATED 12/27/2010 "...STEPS TAKEN TO PREVENT PROCURANCE ... " WAS BLANK. NO EVIDENCE COULD BE FOUND IN RESIDENT # 106'S CLINICAL RECORD TO INDICATE ANY CHANGES WERE MADE TO ENSURE RESIDENT #106 RECEIVED THE SUPERVISION REQUIRED. ACCORDING TO THE FACILITY ' S ROUTINE " 72 HOUR POST FALL CHARTING " DATED 12/28/2010 RESIDENT #106 REQUIRED CONSTANT SUPERVISION AND THE NURSE IMPLEMENTED A CERTIFIED NURSE ASSISTANT (CNA) TO SIT AND WATCH RESIDENT # 106 TO ENSURE HIS SAFETY. ACCORDING TO THE INCIDENT / ACCIDENT REPORT DATED 12/28/2010 AT 8:00 PM NO CNA WAS ENSURING RESIDENT # 106 ' S SAFETY AND FACILITY STAFF FAILED TO SUPERVISE OR PREVENT UNASSISTED TRANSFER OR AMBULATION AND RESIDENT #106 AGAIN fell OUT OF THE GERI-CHAIR. RESIDENT #106 SUSTAINED NO APPARENT INJURIES AS A RESULT OF THIS FALL. . ACCORDING TO THE INCIDENT / ACCIDENT REPORT DATED 12/28/2010 " ...STEPS TAKEN TO PREVENT PROCURANCE ... " WAS BLANK. NO EVIDENCE COULD BE FOUND IN RESIDENT # 106 ' S CLINICAL RECORD TO INDICATE ANY CHANGES WERE MADE TO ENSURE RESIDENT #106 RECEIVED THE SUPERVISION REQUIRED. ACCORDING TO THE NURSE ' S NOTES DATED 12/29/2010 RESIDENT # 106 ' S FALL WAS REVIEWED AND " ...NO CHANGES ... " WERE MADE TO THE PLAN OF CARE. ACCORDING TO THE NURSE ' S NOTES DATED 1/10/2011 RESIDENT # 106 ' S WAS OBSERVED SITTING IN A HALLWAY IN A WHEELCHAIR ALONE AT 7:20 PM. ACCORDING TO THE INCIDENT / ACCIDENT REPORT DATED 1/10/2011 AT 7:30 PM FACILITY STAFF FAILED TO SUPERVISE OR PREVENT UNASSISTED TRANSFER OR AMBULATION AND RESIDENT #106 fell OUT OF THE WHEELCHAIR. RESIDENT #106 SUSTAINED NO APPARENT INJURIES AS A RESULT OF THIS FALL. " ...STEPS TAKEN TO PREVENT PROCURANCE ... " WAS BLANK. NO EVIDENCE COULD BE FOUND IN RESIDENT # 106 ' S CLINICAL RECORD TO INDICATE ANY CHANGES WERE MADE TO ENSURE RESIDENT #106 RECEIVED THE SUPERVISION REQUIRED. AS A RESULT OF THE INVESTIGATION ON 1/13/2011 THE FACILITY INVESTIGATED RESIDENT # 106 ' S FALL AND MODIFIED THE CARE PLAN TO INCLUDE A HIGH BACK WHEELCHAIR WITH A SEAT BELT. ON 1/13/2011 PHYSICAL THERAPY ASSESSED RESIDENT #106 AND FOUND THAT RESIDENT #106 REQUIRED "...SUPPORT AND SUPERVISION TO FOR GOING TO BATHROOM...TO PREVENT FALLS..." ACCORDING TO THE INCIDENT / ACCIDENT REPORT DATED 2/1/2011 AT 11:20 AM FACILITY STAFF FAILED TO PROVIDE AMBULATION SUPERVISION, OR SUPERVISION TO FOR GOING TO BATHROOM AND RESIDENT #106 fell TO THE FLOOR NEXT TO THE BATHROOM. ACCORDING TO THE INCIDENT / ACCIDENT REPORT STAFF CAME INTO THE ROOM BECAUSE THEY HEARD A " ...LOUD THUD ..." NO ALARM WAS NOTED ON RECORD. RESIDENT #106 FOUND ON FLOOR, UNRESPONSIVE WITH A LACERATION TO LEFT TEMPLE. RESIDENT #106 WAS TRANSFERRED TO HOSPITAL FOR FURTHER EVALUATION WHERE IT WAS FOUND HE SUFFERED FROM AN INTRACRANIAL BLEED. ON 3/4/2011 AT 1:40 PM THE DON AND ADON REVIEWED RESIDENT # 106'S CLINICAL RECORD. THE DON WAS NOT ABLE TO PROVIDE EVIDENCE THAT RESIDENT # 106 RECEIVED THE SUPERVISION REQUIRED TO ENSURE HIS SAFETY. THE DON SAID "...LOOKS LIKE WE SHOULD HAVE HAD THE SITTER AROUND THE CLOCK UNTIL HE WAS STABLE ... " THE ADON SAID RESIDENT # 106 REQUIRED SUPERVISION FOR AMBULATION AND TOILETING, BUT THERE WAS NO INTERVENTION PUT IN PLACE TO PROVIDE ASSISTANCE AND SUPPORT. THE DON SAID THAT IF RESIDENT # 106 HAD RECEIVED THE SUPERVISION THE FALL ON 2/1/2011 COULD HAVE BEEN PREVENTED. ( )