Every finding on record at Boulevard Temple Care Center, LLC

Based on observation, interview, and record review, the facility failed to ensure safe preparation and storage of food, cleaning and sanitation of surfaces and equipment, and upkeep of equipment, resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 07/14/2026 at 8:51 AM, a container of sliced oranges was observed without a date or label in the walk-in cooler. In an interview at this time with [NAME] I, serving as the person in charge, [NAME] I indicated they do not think the person put a date on the container and indicated anytime you cut fruit there should be a date. On 07/14/2026 at 8:55 AM, a container of mechanically altered chicken with a facility marked use by date of 7/10 was observed in the walk-in cooler. On 07/14/2026 at 8:56 AM, black build up was observed accumulated on the surfaces of the wire storage racks in the walk-in cooler.On 07/14/2026 at 8:57 AM, Dietary Manager (DM) J arrived, and the tour continued.On 07/14/2026 at 9:03 AM, an area of wall paint was observed peeling and lifting along the side wall in the dry storage room.On 07/14/2026 at 9:14 AM, food debris was observed at the bottom of the utensil bin in the kitchen. In an interview at this time, DM J indicated the drawers are cleaned weekly.On 07/14/2026 at 9:17 AM, metal shavings were observed accumulated behind the blade of the can opener, and some food debris was on the blade. In an interview at this time, DM J indicated the can opener may have not been cleaned after it was used this morning. When asked how often it is cleaned, DM J indicated after every use. On 07/14/2026 at 9:20 AM, in an interview with DM J regarding the reach in cooler, DM J indicated they recently put in for a new one. Paint was observed peeled and corrosion present on multiple shelving racks. Further observation found a half cut onion with a facility marked use by date of 7/10. On 07/14/2026 at 9:22 AM, observed grease caked onto the interior surface of the fryer and internal components. In an interview at this time, when asked if the [NAME] is used, DM J indicated yes. When asked how often it is cleaned, DM J indicated it is cleaned once a week.On 07/14/2026 at 9:30 AM, moisture and water droplets were observed inside of several stacked metal pans on the storage rack in the kitchen. In an interview at this time, when asked about the procedure for drying equipment, DM J indicated staff turn items to the side, and when no water is visible, it is stacked. DM J indicated sometimes staff put the pans away too soon. On 07/14/2026 at 9:46 AM, black marks were observed on the surface of two cutting boards. When wiped with a paper towel, a small amount of black residue transferred onto the towel. In an interview at this time, when asked about cleaning of the cutting boards, DM J indicated they scrub them in the three-compartment sink and sanitize. On 07/14/2026 at 9:51 AM, paint was observed absent on the microwave front panel, with corrosion on the upper interior surface and front panel in the third-floor pantry. On 07/14/2026 at 10:00 AM, in an interview with DM J, when asked who maintains the ice machine, DM J indicated maintenance is responsible for the ice machine on the floor. Observation of the ice scoop found frayed plastic peeling on the entirety of the surface. DM J indicated they were not sure why it was peeling. Further observation of the ice machine found an accumulation of brown specs and small white spots on the upper internal metal surface near the door hinge. DM J acknowledged the observation. On 07/14/2026 at 2:06 PM, in an interview with DM J when asked how often the storage racks in the walk-in cooler are cleaned, DM J indicated once a month. Black buildup was observed on the shelving units in the walk-in cooler, and DM J acknowledged the buildup.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.According to the 2022 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. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.According to the 2022 FDA Food Code section 6-501.11 Repairing, PHYSICAL FACILITIES shall be maintained in good repair.According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.

Based on observation, interview and record review, the facility failed to (1) consistently implement a comprehensive infection control program that conducted proper facility surveillance and utilized maps or other processes to readily identify trends of infections, and (2) to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in missed opportunities for corrective actions and the potential for spread of infectious organisms throughout the facility, and an increased risk of respiratory infection affecting all the residents in the facility.Findings include: On 7/16/2026 at 10:05 AM, a meeting was held with Licensed Practical Nurse/Infection Preventionist (LPN/IP) C, and Licensed Practical Nurse/Interim Infection Preventionist (LPN/IP) H. LPN/IP C said that she was off July through December 2025 and during that time frame LPN/IP H acted as the facility infection preventionist. When asked for documentation regarding infection identification, tracking, monitoring, analysis of surveillance data, and responding follow-up activity, LPN/IP C and LPN/IP H indicated this information was not completed for July 2025 to December 2025. On 7/16/2026 at 12:08 PM, the Director of Nursing (DON) was interviewed and said it was important to have a consistently implemented and comprehensive infection program for the facility to be aware of the state of infections in the facility, preempt outbreaks, detect any patterns, and proactively address outbreak of infections. A review of the facility policy titled, Infection Prevention Program Overview, revised 2/28/2025, documented in part the following: - This facility has established a program under which it investigates, identifies, prevents, reports and controls infections and communicable diseases for all residents, staff, contractors, consultants, volunteers, visitors and others who provided care and services to the residents on behalf of the facility, and follows accepted national standards. Maintains a record of incidents and corrective actions related to infections. Antibiotic Stewardship is addressed and maintained On 07/14/2026 at 9:55 AM, a water line approximately two feet in length was observed coming from the wall and terminating on the ground in the fourth-floor pantry. In an interview with Dietary Manager (DM) J at this time, DM J indicated the line previously connected to an ice machine that had broken and been removed. On 07/15/2026 at 8:51 AM, a hopper was observed with the spray hose intact and the foot pedal controls missing in the fifth-floor soiled utility room. In an interview at this time, Director of Housekeeping and Laundry (DHL) L indicated the hoppers were previously utilized and are currently not used. On 07/15/2026 at 9:05 AM, observed hair and black debris in the hopper bowl in the fourth-floor soiled utility room. The spray hose was observed intact, and the foot pedal controls were missing, indicating possible stagnant water in the line. The hot water faucet was observed partially turned off and the cold-water faucet was off. Further observation found a dishwasher unit integrated with the utility sink cabinet. In an interview at this time, DHL L stated there is a dishwasher on every floor, and they haven't been used in 50 years. On 07/15/2026 at 9:16 AM, a therapy tub was observed with the water line intact in the fourth-floor bathroom. DHL L indicated that the tubs are not used anymore and there are plans to renovate the bathroom. Black residue was accumulated at the bottom of the shower tub. On 07/15/2026 at 9:30 AM, a plastic bag was observed over the hopper bowl in the third-floor soiled utility room. The spray hose was observed intact, and the foot pedal controls were missing. DHL L indicated the hopper is no longer used. Further observation found the hot and cold water fixtures of the hopper off, indicating possible stagnant water in the lines. On 07/15/2026 at 9:33 AM, a therapy tub was observed with the water lines intact in the third floor bathroom. DHL L indicated they are redoing the bathroom. On 07/15/2026 at 9:56 AM, a hopper was observed with the spray hose intact and the foot pedal controls missing in the second floor soiled utility room. The hot and cold water fixtures were observed off, indicating possible stagnant water in the lines. On 07/15/2026 at 10:06 AM, the cold water and disinfectant hoses were observed attached to the wall and the tub absent in the second floor bathroom. A strong unpleasant odor was present upon entering the room. On 07/15/2026 at 10:13 AM, the hot and cold fixtures were observed off at the hand sink in the first floor women's bathroom. On 07/15/2026 at 10:50 AM, an interview with Nursing Home Administrator (NHA) and a phone interview with Maintenance Director (MD) M was conducted. When asked about control measures the facility takes to reduce the growth of legionella, MD M indicated they turn on the water monthly and check three different low use areas, including mechanical room and shower rooms. When asked about chlorine testing, MD M indicated they perform chlorine testing and indicated they look for a range around 0-0.7 Parts Per Million (ppm). When asked about the eyewash stations, MD M indicated they have bottle stations. When asked about the hoppers that are turned off, MD M indicated they keep the hoppers off and flush them, MD M stated they recently flushed them last month. On 07/15/2026 at 11:13 AM, in an phone interview with MD M, when asked about chlorine testing, MD M indicated they test monthly and believe they take combined chlorine samples. On 07/15/2026 at 10:14 AM, observation of the chlorine test strips used to take chlorine samples found a total and free chlorine test option. On 07/15/2026 at 1:45 PM, in an interview, when asked if there is a cooling tower at the facility, NHA indicated they were not sure. At this time a phone interview was conducted with MD M. When asked if the tubs on the floors are flushed, MD M indicated no. Record review of the facility provided policy titled Water Management Program last revised, 2/1/2024, states, Legionella can grow in parts of the buildings water systems that are continually wet. Listed under general principle of an effective water management program states, Preventing water stagnation and Ensuring adequate disinfection. Record review of the facility provided program titled LEGIONELLA WATER MANAGEMENT PLAN identifies areas where legionella could grow and spread, including Hot water tanks, water heater, faucets, shower heads, hose, pipes, valves and fitting . Eye wash stations. The program does not include tub, or hopper fixtures present in the facility. Record review of facility provided logs titled Water Testing noted chlorine testing results. The logs lists a target range (02-1.0) beside Chlorine. The most recent entries dated 4/27/2026, 3/17/2026, 2/27/2026, 2/20/2026 each documented a chlorine reading of zero. 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 interview and record review the facility failed to maintain a continuous Antibiotic Stewardship Program that includes monitoring antibiotic usage, tracking resistance, preventing emergence of resistance, and following protocols for antibiotic use, which has the potential to affect all residents residing in the facility. Findings include:On 7/16/2026 at 10:05 AM, a meeting was held with Licensed Practical Nurse/Infection Preventionist (LPN/IP) C, and Licensed Practical Nurse/Interim Infection Preventionist (LPN/IP) H. LPN/IP C said that she was off July through December 2025 and during that time frame LPN/IP H acted as the facility infection preventionist.When asked for documentation regarding the facility's antibiotic stewardship program, LPN/IP C and LPN/IP H indicated this information was not completed for July 2025 to December 2025.On 7/16/2026 at 12:08 PM, the Director of Nursing (DON) was interviewed and said it was important to have a consistently implemented and comprehensive infection program for the facility to be aware of the state of infections in the facility, preempt outbreaks, detect any patterns, and proactively address outbreak of infections.A review of the facility policy titled, Infection Control Antibiotic Stewardship, revised 4/17/2025, documented in part the following:- The infection preventionist will be responsible for promoting and overseeing antibiotic stewardship activities in the facility. Responsibilities include educating employees about the importance of antibiotic stewardship and adhering to programs that prevent the spread of infection and improve antibiotic use.

Based on observation, interview, and record review, the facility failed to maintain general cleanliness, repair, and safe operation of equipment on the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 07/14/2026 at 8:39 AM, a vertical crack was observed extending approximately five feet in the wall adjacent to the glass door in the library. Further observation found a window pane missing from the large glass window.On 07/14/2026 at 9:53 AM, the counter top in front of the hand sink was observed with broken pieces and chipped laminate on the underside in the third floor pantry.On 07/14/2026 at 9:58 AM, observed the cabinet under the hand sink out of alignment and leaning forward. The front edge of the cabinet base was resting on the floor and one door was misaligned in the fifth floor pantry. On 07/14/2026 at 2:11 PM, brown discoloration stains and evidence of water damage were observed on three ceiling tiles in the laundry room by the washing machines.On 07/14/2026 at 2:32 PM, the hand sink base was observed pulled away from the wall, leaving a visible gap along the rear edge in the laundry washing room. When the cold water faucet was turned on, a leak was observed at the fixture. Director of Housekeeping and Laundry (DHL) L indicated they need to report that.On 07/15/2026 at 8:20 AM, observed a janitor sink with a chemical pre-dispensing system in place and the water on in the janitor closet across from the employee lounge in the basement. This set up puts undue back pressure of the faucet's atmospheric vacuum breaker (AVB), which can compromise the integrity of the system.On 07/15/2026 at 8:22 AM, observed a corner section approximately four by four inches of the flooring peeled up, exposing the wood surface below, in one of the communal elevators.On 07/15/2026 at 8:39 AM, in an interview, when asked who is responsible for cleaning the shower rooms, DHL L indicated housekeeping staff clean the shower rooms once or twice a day and nursing staff are responsible for cleaning shower equipment.On 07/15/2026 at 8:40 AM, a water fixture with no shower head was observed in the fifth floor men's shower room. When turned on, water flowed in a direct stream onto the floor. DHL L indicated they would get it fixed. Further observation of the room found black buildup accumulated along the floor wall caulking edge around the perimeter of the shower stall. On 07/15/2026 at 8:56 AM, black buildup was observed accumulated along the floor wall juncture and lower shower stall wall surfaces in the fourth floor women's shower room. Black particulate was observed on the shower stall walls, and black discoloration and yellow staining was present on the lower portions of the walls in the shower stall. In an interview at this time, when asked who is responsible for cleaning the walls in the shower room, DHL L indicated it would fall on housekeeping. Further observation found a shower chair with yellow residue caked on the underside and legs, as well as black spotting present on the back rest of the chair netting. DHL L indicated nursing staff is in charge of ordering chairs, and they would like to get rid of the chair.On 07/15/2026 at 8:58 AM, black particulate was observed in the upper corner of the shower stall ceiling and extending down the wall in the fourth floor women's shower room. An area of black buildup was observed in the center of the ceiling, and a small hole was adjacent to the light fixture.On 07/15/2026 at 9:00 AM, a section of floor tiles approximately one inch by one inch were observed missing on the floor in the fourth floor men's shower room. Two wall tiles were observed missing and one tile was cracked, creating a sharp edge in the shower stall and exposing the underlying wall framing. Black and brown buildup was observed accumulated along the floor wall juncture caulking. DHL L indicated they assign a staff member to work on it. The light fixture cover was observed missing, exposing the light bulbs. Further observation found the toilet assisting device arm cushions cracked along the edges, with the internal cushioning material visible. On 07/15/2026 at 9:04 AM, observed the light fixture cover cracked down the center in the fourth floor supply room. DHL L acknowledged the crack.On 07/15/2026 at 9:07 AM, black spots and residue buildup was observed coating the internal basin surfaces of the utility sink in the fourth floor soiled utility room.On 07/15/2026 at 9:10 AM, the light fixture cover was observed missing exposing the bulbs in the fourth floor clean linen room. Further observation found paint peeling from the wall in a continuous strip approximately three feet long. The air vent was observed with brown particulate accumulated on the exterior of the vent.On 07/15/2026 at 9:19 AM, evidence of water damage with plaster peeling and flaking was observed on the ceiling in the third floor women's shower room. Black buildup and small holes were visible in multiple areas of the ceiling. On the adjacent wall, a large area of black buildup was present on the ceiling with water droplets accumulated around it. DHL L acknowledged the condition of the ceiling. The shower stall light was noticeably dim, and black buildup was accumulated along the floor wall caulking edges and vertical caulking in the stall. Further observation found the wooden bench adjacent to the shower stall with the front piece of wood unattached and the surface behind the bench with rust spots and spotty paint.On 07/15/2026 at 9:24 AM, black buildup was observed accumulated along the floor wall juncture caulking in the shower stall of the third floor men's shower room. [NAME] staining and some cracked paint was observed in the corner ceiling indicating water damage. The wooden bench adjacent to the shower stall was observed to be worn and without a protective coating. The hand sink caulking was observed peeling around the edge, DHL L indicated it needs to be caulked.On 07/15/2026 at 9:41 AM, three tiles along the baseboard were observed to be unattached and able to be moved in the second floor women's shower room. The overhead light was observed dim in the shower stall. Further observation found a hole in the ceiling next to the light fixture with paint peeling around the area.On 07/15/2026 at 9:47 AM, the overhead light fixture cover was observed with cracked and missing pieces in the second floor men's shower room. An approximate two foot area of ceiling paint showed brown discoloration and peeling. An adjacent wall section of the ceiling was observed to have significant peeling of paint and some brown discoloration. A bag of cloths, shoes, and cushions were observed on the shower bench. In an interview at this time, DHL L indicated staff leave things on the bench. Hair and debris was observed matted in the shower drain, and brown buildup was on the shower stall floor and along the floor wall juncture caulking. Further observation found a section of wall below the pull cord with peeling paint and visible holes near the floor. On 07/15/2026 at 9:53 AM, two cracked lighting fixture covers were observed in the second floor supply room. DHL L acknowledged the fixtures.On 07/15/2026 at 9:54 AM, observed the overhead light nonfunctional in the second floor oxygen storage room. DHL L indicated the light is automatic and must have gone out.On 07/15/2026 at 10:02 AM, observed the utility sink faucet missing in the second floor janitors closet. In an interview at this time, when asked how staff fill their cleaning buckets, DHL L indicated they go down to the basement to fill their buckets. When asked how long it has been out of order, DHL L indicated they could not put a time on it.On 07/15/2026 at 10:10 AM, in an interview, DHL L indicated residents will use the bathrooms on the first floor during activities. Observation of the first floor bathroom adjacent to the atrium found two light covers missing around the overhead light fixture. The hand sink countertop was observed with chipped laminate on the underside.On 07/15/2026 at 10:12 AM, paint was observed peeling in one of the bathroom stalls in the first floor women's bathroom.On 07/15/2026 at 12:23 PM, the hand sink was observed slow to drain, and a leak was present from the hot water faucet when turned on in the bathroom of unoccupied room [ROOM NUMBER].On 07/15/2026 at 12:40 PM, a section of baseboard was observed peeling from the wall in the fourth floor resident lounge. Further observation found paint chipping around the bottom portion of the air duct.On 07/15/2026 at 1:07 PM, plaster was observed applied to the wall, measuring approximately two feet by two feet, behind the bed in room [ROOM NUMBER]. The application was rough and remained unpainted. Further observation of the bathroom found the bottom corner of wallpaper pulled away from the wall and hanging loosely. On 07/15/2026 at 1:16 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken and recorded at 87 F.On 07/15/2026 at 1:52 PM, a phone interview was conducted with Maintenance Director (MD) M regarding hot water temperature testing. MD M indicated they take water temperatures daily and rotate fixtures from shower rooms and resident rooms. When asked what temperature range they look for, MD M indicated under 120 F and around 113 F.On 07/15/2026 at 2:56 PM, the sink was observed pulled away from the wall and caulking around the fixture peeling in resident room [ROOM NUMBER].On 07/15/2026 at 3:06 PM, the light above the hand sink was observed to be nonfunctional in resident room [ROOM NUMBER]. Further observation found the overhead light fixture cover partially attached and hanging.On 07/15/2026 at 3:57 PM, in an interview, Nursing Home Administrator (NHA) indicated maintenance requests throughout the facility are submitted on an electronic form.Record review of the facility provided policy titled, Housekeeping Services last revised 7/8/2025, states, Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. Under resident bathroom, the policy directs staff to, Clean walls and around the toilet . Clean shower, faucets, shower wands, and drains.

Based on observation, interview, and record review, the facility failed to ensure safe and comfortable water temperatures, increasing risk of high water temperature related injuries to residents on the second, third, fourth and fifth floors. Findings include:On 07/15/2026 at 9:08 AM, a hot water temperature of the utility sink was taken, and recorded at 132 F in the fourth floor soiled utility room.On 07/15/2026 at 12:11 PM, a hot water temperature of the sink in the fifth floor communal women's shower room was taken, and recorded at 126 F.On 07/15/2026 at 12:26 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken, and recorded at 131 F.On 07/15/2026 at 12:30 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken, and recorded at 135 F.On 07/15/2026 at 12:42 PM, a hot water temperature of the hand sink in the fourth floor communal men's shower room was taken, and recorded at 123 F.On 07/15/2026 at 12:44 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken, and recorded at 133 F.On 07/15/2026 at 12:47 PM, a hot water temperature of the hand in occupied resident room [ROOM NUMBER] was taken, and recorded at 130 F.On 07/15/2026 at 12:52 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken, and recorded at 131 F. Steam was observed coming from the sink basin when hot water was turned on.On 07/15/2026 at 12:54 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken, and recorded at 134 F.On 07/15/2026 at 1:02 PM, a hot water temperature of the hand sink in the second floor communal women's shower room was taken, and recorded at 124 F.On 07/15/2026 at 1:04 PM, a hot water temperature of the hand sink in the second floor communal men's shower room was taken, and recorded at 122 F.On 07/15/2026 at 1:27 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken, and recorded at 132 F.On 07/15/2026 at 2:52 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken, and recorded at 127 F.On 07/15/2026 at 3:03 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken, and recorded at 126 F.On 07/15/2026 at 3:12 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken, and recorded at 123 F.On 07/15/2026 at 3:18 PM, a hot water temperature of the hand sink in occupied resident room [ROOM NUMBER] was taken, and recorded at 123 F.On 07/15/2026 at 1:52 PM, a phone interview was conducted with Maintenance Director (MD) M regarding hot water temperature testing. MD M indicated they take water temperatures daily and rotate fixtures from shower rooms and resident rooms. When asked what temperature range they look for, MD M indicated under 120 F and around 113 F.Record review of the facility provided document titled F-689 Accidents - Water Temperatures states, Please note that Long Term Care residents may be more susceptible to burns than other individuals due to several factors . Each state will have its own regulation on maximum water temperature allowed, but it typically will fall between 105 to 115 degrees F.Record review of the facility provided logs titled, Test and log the hot water temperatures recorded the hot water temperature taken from the second, third, fourth and fifth floor shower rooms consistently recorded at 113 F on weekdays ranging from 4/6/2026 to 5/1/2026 and 5/18/2026 to 7/3/2026. A hot water temperature for room [ROOM NUMBER] was recorded at 116 F from 6/15/2026 to 6/19/2026.

This citation pertains to intake 3003803 and 3006486.Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff. Findings include: On 7/14/2026 at approximately 12:10PM, R27 was interviewed in their room. R27 was observed to be alert and communicative, well groomed, and did not appear in any distress. R27 said that a few months ago, a nurse wrapped her hands around their neck, hit them, and threw them to the ground. R27 said that the incident occurred in the dining area where other residents and staff witnessed it. R27 said they reported the altercation to the facility receptionist that same day. R27 denied any injuries from the incident and said they felt safe in the facility but were still angry that the incident occurred. A review of R27's electronic health record revealed they originally admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, muscle wasting and atrophy, insomnia, paroxysmal atrial fibrillation, hypertension, congestive heart failure, hypothyroidism, type II diabetes, depression, and adjustment disorder with disturbance of conduct. Section C of the Minimum Data Set (MDS) with an Assessment Reference Date of 4/23/2026 indicated R27 scored 12/15 on the Brief Interview for Mental Status questionnaire - indicative of no cognitive impairment. Section GG of the same MDS indicated R27 needed supervision for most activities of daily living. R27's care plan was reviewed and revealed the following focus initiated on 5/21/2025 and revised on 5/1/2026: (R27) has actual fluctuations in mood R/T (regards to) DX (diagnosis): depression and adjustment d/o (disorder) with disturbance of conduct. (R27) has potential for feeling down regarding recent alleged abuse incident on 4/29/2026. An intervention on the care plan was initiated on 4/29/2026 which revealed, Staff, SW (social work), and Psych services to provide emotional support. A nursing progress note dated 4/26/2026 at 12:46PM written by Licensed Practical Nurse (LPN) K revealed the following: Resident is yelling in dining area to go on elevator while staff are tending to other residents, when trying to remove resident from area (R27) begin to yell and grab at wheelchair brakes and cause for wheelchair to lock, resident slid forward out of chair sliding throws [sic] the floor, staff was able to slow fall with chair, resident still yelling very hard to calm down once calmed down staff was able to safely place (R27) back into (R27) chair, bp:124/80 p:55, r:20, resident assisted down stairs to relax, resident stated has no pain, resident stated did not hit head. no new skin tears observed.A nursing progress note dated 4/26/2026 at 2:18PM revealed the following: Neuro checks has started, resident is calm, no pain reported. Dr. notified of fall no new orders given.A nursing progress note dated 4/26/2026 at 4:06PM revealed a late entry indicating R27 was transferred to the hospital on 4/26/2026. On 7/15/2026 at approximately 11:30AM, an interview with Certified Nursing Assistant (CNA) E and witness to the incident was conducted. CNA E said they came out of a resident room when they heard arguing in the dining room. Upon entering the dining room, CNA E observed LPN K holding R27s hands over their head. CNA E then said to LPN K, what is going on? LPN K replied, I want (R27) out of my (expletive) dining room. CNA E then observed LPN K put her knee on the back of R27's wheelchair and tip the chair forward - resulting in R27 falling to the floor and hitting their head. On 7/15/2026 at approximately 11:45AM, an interview with CNA D was conducted via telephone. CNA D said they entered the dining area and observed LPN K trying to pull R27's wheelchair backwards. CNA D said that while pulling the wheelchair backwards, LPN K lifted the wheelchair off the ground and R27 fell forward, hitting his head on the floor. On 7/15/2026 at approximately 2:55PM, an interview was conducted with CNA F who also witnessed the incident. CNA F said they heard yelling and arguing around the nursing station/dining area. When CNA F entered the area, they observed LPN K and R27 going back and forth, with LPN K trying to move R27's wheelchair saying, I don't give a (expletive) if you fall out of the chair. On 7/15/2026 a voicemail was left on LPN K s telephone asking for a return call. There was no return call upon exit from the facility on 7/16/2026. On 7/15/2026 at approximately 10:40AM, an interview was conducted with facility Social Worker (SW) A regarding R27's recent incident. SW A said they were notified of the incident and that wellness visits were provided to R27 for three days afterward. SW A said they did not observe any negative psychosocial harm outcomes but that a trauma assessment was completed, a referral made to the facility mental health/behavioral health services provider, and the care plan revised and updated. The SW confirmed R27 continues to be at their baseline after the incident. On 7/16/2026 at approximately 11:30AM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA confirmed they were the designated facility Abuse Coordinator and completed the investigation into the incident between LPN K and R27. The NHA reported they were made aware of the incident on 4/26/2026 by the facility receptionist. The NHA suspended LPN K that day and initiated an investigation which included contacting the local police department and notification to the state agency. The NHA said that through gathering witness statements and the statement of R27, they substantiated that abuse had occurred. The NHA then confirmed that LPN K was terminated from employment with the facility on 4/30/2026. A policy titled, Abuse Prohibition last revised 9/9/2022 was provided by the facility and revealed the following: Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience that are not required to treat the guest's/resident's medical condition.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included a review of the Abuse Prohibition Policy, re-education of staff on the facility abuse policy with an emphasis on identifying the different types of abuse, reporting allegations of abuse to the Abuse Coordinator and in accordance with state and federal guidelines, initiation of investigations timely, and implementing interventions to prevent the reoccurrence of potential abuse and to protect other residents. The facility has conducted ongoing monitoring and auditing which included interviewing residents and staff on abuse. These audits are reviewed during the monthly Quality Assurance Performance Improvement meeting to identify any further concerns. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview and record review, the facility failed to ensure the Director of Nursing, a required member of the Quality Assessment and Assurance (QAA) committee, attended quarterly QAA meetings. Findings include:On 7/16/2026 at approximately 11:45AM, the Nursing Home Administrator (NHA) was interviewed regarding the facility Quality Assessment and Assurance Committee (QAA) and Quality Assurance Performance Improvement activities. The NHA said they conduct monthly meetings which include reviewing data and feedback on various facility systems and processes. The NHA was asked to show evidence demonstrating that the required members of the committee attended the meetings. A review of quarter 2025 monthly meeting sign-in sheets revealed the following:QAA meeting October 30, 2025- no Director of Nursing attendanceQAA meeting November 20, 2025 - no Director of Nursing attendanceThere was no QAA meeting held in December 2025, as confirmed by the NHA.When asked if the NHA was aware that the Director of Nursing was a required member of the committee, they responded yes. When asked why the Director of Nursing did not attend any quarter three 2025 meetings- the NHA was unable to provide a rationale. The NHA further stated, Required members need to be in attendance because the sharing of information and data is vital to the building so that we can ensure we take good care of the residents and improve our operations. A policy titled, Quality Assurance Performance Improvement Committee last revised 3/5/2025 was provided by the facility and revealed the following: The committee consists of the Director of Nursing, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role and the infection control and prevention officer.

Based on interview and record review, the facility failed to provide pneumococcal vaccination for two residents (R68 and R10) out of five residents reviewed for immunizations resulting in the potential for respiratory infection.Findings include: On 7/16/2026 at 10:05 AM, Licensed Practical Nurse/Infection Preventionist (LPN/IP) C was interviewed and said the following residents R68 and R10 did not have documentation of a current pneumococcal immunization or refusal and were eligible.Review of the Electronic Health Record (EHR) for R68 revealed admission to the facility on 1/16/2026 with diagnoses of Cerebral Infarction due to Embolism of unspecified Middle Cerebral Artery (Stroke). R68 had a signed consent for the pneumococcal vaccine dated 1/16/2026.Review of the EHR for R10 revealed admitted on [DATE] with diagnoses of Other Viral Pneumonia, Chronic Obstructive Pulmonary Disease. R10 had a signed consent for the pneumococcal vaccine dated 4/7/2026.On 7/16/2026 at 12:08 PM, the Director of Nursing (DON) was interviewed and said residents should receive immunizations within a couple of days of the signed consent form. The DON further said immunizations were important to prevent the spread of infections.Review of the facility's policy titled, Immunizations: Pneumococcal Vaccination (PPV) of residents, last revised 11/4/2024, revealed in part .All residents of our facility should receive the pneumococcal vaccine if they are [AGE] years of age or older or younger than 65 years with underlying conditions that are associated with increased susceptibility to infection or increased risk for serious disease and its complications.

This citation pertains to intake 2706021.Based on interview and record review, the facility failed to obtain legal consent and failed to provide education for the Covid-19 vaccination for one resident (R101) out of three residents reviewed for immunizations. Findings include: Review of immunizations revealed an administration date of 12/12/2024 of the Covid-19 vaccination. Route of administration- Intramuscularly, Dose and Unit 0.5 ml, administered by Infection Preventionist (IP) A. Review of R101's Electronic Health Record (EHR) revealed: Immunization- SARS-COV-2 (COVID-19) Status-Complete-Consent Confirmed By, (IP) A, Confirmation Date 12/12/2024, Education Provided.On 04/15/26 at 2:30pm, Family Member B was interviewed regarding complaint about the administration of the Covid-19 vaccination. Family Member B stated, I would never consent to the Covid-19 immunization for R101 due to R101's medical condition. I did not give verbal or written consent for this immunization and R101 was unable to provide consent for himself. Family Member B also said that Covid-19 education was not provided to Family Member B or to R101. Record review revealed a consent signed by R101 for the Covid 19 vaccination dated 10/20/2024. Record review further revealed R101 was deemed incapacitated on August 6, 2024, through a statement of capacity supporting the inability to make informed medical decisions.Record review also revealed a consent signed by (IP) A acknowledging verbal consent obtained by Family Member B dated 10/20/2024. This consent identified Family Member B as R101's legal guardian. Record review revealed guardianship of R101 was not established by Family Member B until 12/5/24. On 04/15/2026 at 2:30pm, Family Member B denied providing verbal consent for this vaccination. Family Member B said she did not provide verbal consent and would not have consented due to concerns regarding this vaccination and the medical issues of R101. Family Member B said due to R101's medical history of Myocardial Infraction Type 2, Covid-19 consents are declined due to cardiovascular related side effects associated with this vaccine.On 04/15/26 at 3:00 pm, (IP) A was interviewed and stated, I received verbal consent for the Covid-19 vaccination from Family Member B on 10/20/2024. I thought she was the legal guardian at that time. IP A: was queried about consents signed by resident's deemed incapacitated. (IP) A stated, Incapacitated residents cannot provide consent. On 04/15/2026 at 3:15 pm, the Nursing Home Administrator (NHA) was queried regarding expectations of vaccination consents. The NHA stated, Verbal or written consent from the resident or their legal guardians are needed for vaccinations.Review of the facility policy titled, Covid19 Vaccination Policy last revised on 10/6/25, revealed in part:The facility will obtain a signed consent form for the administration of the Covid-19 vaccine from the resident or the resident's designated health care representative(s). A declination form will be signed if consent is not given.For residents who are incapable of consenting to the Covid-19 vaccine and have no health care representative, two physicians may consent for and order the Covid-19 vaccine after reviewing the resident's medical chart.Prior to the vaccine administration the Vaccine Coordinator or designee will validate that consent has been obtained, a physician order received for the resident, and education has been provided. No additional information was provided regarding Covid-19 consents prior to exit.

Based on observation, interview, and record review, the facility failed to ensure medications were administered properly and per physician's orders for one resident (R108) of three residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken or administered properly. Findings include: In an observation and interview on 12/15/25 at 9:35 AM, R108 was awake and lying in bed. While grimacing and holding her stomach, R108 said her stomach hurts. R108 said she reported her stomach pain to Certified Nurse Aide (CNA) J. On 12/15/25 at 9:37 AM, CNA J indicated that she told Registered Nurse (RN) I that R108 was in pain. On 12/15/25 at 9:45 AM, RN I denied being informed that R108 was in pain. RN I and the State Surveyor went into R108's room. R108 again stated that she had pain in her stomach. While in R108's room, seven unidentified oral medications were observed on R108's overbed table; two tablets were loose on the overbed table and five were contained in a clear plastic medicine cup. RN I removed the pills from the overbed table and stated to R108, You didn't take all your pills. On 12/15/25 at 9:50 AM, RN I identified the pills left at R108's bedside as follows:Sucralfate, Metoprolol, Pantoprazole, Levothyroxine., Acetaminophen. Atorvastatin, and the last pill was not identified by RN I. When RN I noted that R108 had not taken the sucralfate and pantoprazole tablets (both medications were prescribed for gastrointestinal concerns), he stated, That's why her stomach hurts. RN I acknowledged that R108 did not have a physician's order for atorvastatin. On 12/15/25 at 10:20 AM, the pills obtained from R108's overbed table were compared with R108's Medication Administration Record (MAR) with RN/Unit Manager (RN/UM) D. The following was documented:The two loose pills on the overbed table were documented as:1. Sucralfate tablet. 1 gm. Give 1 tablet by mouth two times a day for gastric protection at 9:00 AM and 5:00 PM2. Metoprolol succinate extended-release tablet. Give one tablet by mouth one time a day for hypertension at 9:00 AM Per RN/UM D the sucralfate and metoprolol were documented as being administered on 12/15/25 at 9:09 AM.The five pills in the clear plastic medicine cup were documented as:1. Pantoprazole sodium 40 mcg oral tablet delayed release. Give 1 tablet by mouth two times a day for GERD (gastroesophageal reflux disease) at 6:00 AM and 9:00 PM.2. Levothyroxine sodium oral tablet 25 mcg. Give one tablet by mouth in the morning for hypothyroidism. Take on an empty stomach at 6:00 AM.3. Acetaminophen oral tablet 500 mg. Give one tablet every six hours as needed for pain.4. Atorvastatin. A review of physician orders for R108 revealed that atorvastatin had not been prescribed for R108.5. The pill in the cup not identified by RN I was oxycodone hydrochloride 5 mg. Give one tablet by mouth every four hours as needed for pain.RN/UM D said involved staff will receive education and discipline. The facility needs to put something in place to make sure this does not happen again. Medications are not to be left at bedside. Nurses are to make sure medications are swallowed by the residents. RN/UM D added that resident medications come pre-packaged from the pharmacy and was unable to explain why the atorvastatin was given to R108. RN/UM D said oxycodone was a controlled narcotic and not included in the pre-packaged medications. On 12/16/25 beginning at approximately 12:30 PM, the December 2025 MAR for R108, obtained on 12/15/25 at 10:19 AM, was reviewed with the Assistant Director of Nursing (ADON) and revealed the following:The 9AM dose of Sucralfate was documented administered by RN I.The 9AM dose of Metoprolol was documented administered by RN I.The 6AM dose of Pantoprazole was documented administered by nurse initialed mnbt.The 6AM dose of Levothyroxine was documented administered by nurse initialed mnbtThe ADON reported that RN I had documented an administration of oxycodone 5 mg tablet for 12/15/25 on the controlled substance narcotic sheet but not on the MAR. The ADON added that nurses were to follow the five Rs when administering medication: right person, right time, right drug, right route, and right dose. Nurses should remain with the residents until they are sure the medications have been completely swallowed. The ADON indicated that R108 had not been evaluated and approved to self-administer medications. A review of the clinical record for R108 documented an initial admission date of 4/19/23 and readmission date of 4/9/25. R108's diagnoses included peripheral vascular disease, hypertension, alcoholic cirrhosis of liver, hypothyroidism, and irritable bowel syndrome. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of the facility policy titled, Medication Administration, dated 10/17/23 was reviewed and documented in part the following:- Resident medications are administered in an accurate, safe, timely, and sanitary manner.- Medications are administered in accordance with written orders of the attending physician.- Follow infection control practices. Place medications into a souffle or medicine cup.- Verify the medication label against the medication administration record for resident name, time, drug, dose, and route.- Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved.- Observe that the resident swallows the oral medication. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication. During the exit conference on 12/16/25 at 5:20 PM, the Nursing Home Administrator and ADON 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 new information was provided.

This citation pertains to Intakes 2628767 and 2674347. Based on interview and record review, the facility failed to timely submit documentation of completed investigations to the State Agency for alleged resident-to-resident sexual abuse for two residents (R101 and R102) and alleged resident-to-resident physical abuse for two residents (R102 and R103) out of six residents reviewed for abuse, resulting in the potential delay for opportunities to implement corrective measures and interventions. Findings include: R101, R102A facility self-reported incident (FRI) was received by the State Agency (SA) on 8/8/25. The FRI documented that on 8/8/25 at approximately 2:30 PM, it was witnessed that R102 was in his wheelchair rolling towards his room. R101 was in her wheelchair rolling in the direction of R102. When the two residents rolled past each other, R102 reached his arm over to move R101's head towards him and then R102 kissed R101 on the mouth. R102 then rolled to his room and R101 rolled to the dining room. R101 could not recall the event. R102 denied doing anything. R102 was moved to another floor. A review of the clinical record for R101 documented an initial admission date of 4/10/23 and readmission date of 5/2/24. R101's diagnoses included Alzheimer's Disease. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment. A review of the clinical record for R102 documented an initial admission date of 1/11/23 and readmission date of 12/1/25. R102's diagnoses included convulsions. A MDS assessment dated [DATE] documented moderate cognitive impairment. On 12/15/25 at 3:17 PM, the Nursing Home Administrator (NHA) acknowledged that the five-day complete investigation was submitted to the SA on 8/19/25. The NHA said he was out of town and the Director of Nursing (DON), who was the back-up Abuse Coordinator, was unable to log into the reporting system to submit the investigation. The NHA was unable to provide documentation of communication with the SA regarding the inability to access the reporting system. R103, R104A FRI was received by the SA on 10/12/25. The FRI documented that on 10/12/25 at approximately 10:30 AM, a maintenance staff person observed R104 hitting R103 with a banana. When the maintenance staff walked over to the situation, R103 rolled away to his room and R102 rolled to the dining room. The maintenance staff reported the incident to the charge nurse. R103 showed no signs or symptoms of pain or discomfort. R104 was moved to another floor. A review of the clinical record for R103 documented an initial admission date of 2/14/25 and readmission date of 7/21/25. R103's diagnoses included hypertensive emergency and vascular dementia. A MDS assessment dated [DATE] documented severe cognitive impairment. A review of the clinical record for R104 documented an initial admission date of 9/13/17 and readmission date of 6/12/24. R104's diagnoses included atherosclerotic heart disease and unspecified dementia. A MDS assessment dated [DATE] documented moderate cognitive impairment. On 12/15/25 at 3:24 PM, the NHA indicated the five-day complete investigation was submitted to the SA on 10/21/25. The NHA said the delay in the 5-day submission of the completed investigation was an oversight on his behalf. The NHA added, I got it in late. A review of the facility policy titled, Abuse Prohibition Policy, dated 10/14/22, was reviewed and revealed in part the following: The Administrator or designee will notify the State or Federal agencies of allegations per state guidelines. At the conclusion of the investigation, and no later than five working days of the incident, the facility must report the results of the investigation and if the alleged violation is verified, take corrective action. Federal Regulation S483.12(c)(4) documented the following: Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident . During the exit conference on 12/16/25 at 5:20 PM, the NHA and Assistant Director of Nursing 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 2677888. Based on interview and record review, the facility failed to report an incident of injury of unknown source to the State Agency in a timely manner for one resident (R105), out of six residents reviewed for abuse, resulting in the potential for unresolved resident concerns. Findings include:The facility self-reported incident (FRI) was received on 11/11/25. The incident was discovered on 11/7/25. A review of the facility's 5-Day investigation documented in part the following: On 11/7/25 at approximately 9:15 AM, R105 went to the nurses station and showed the nurse her left arm. There was a bruise on her left arm. It was purplish in color and was 3 1/2 inches by 2 inches on the forearm above the elbow. R105 told the nurse that she woke up with the bruise. R105 could not give an explanation of how she received the bruise. Staff that worked on the days before 11/6/25 and 11/7/25 did not see a bruise on R105's arm. R105 did go out on a LOA (leave of absence) with her guardian. The guardian said that R105 went on the LOA to get her hair done. After the hair appointment, R105 was brought back to the facility. R105 did not report any pain due to the bruise. On 11/7/25, Nurse A notified the Director of Nursing (DON). The DON notified the Administrator via cell phone. The NHA was out of town when it was reported to him. A review of the clinical record for R105 documented an initial admission date of 12/1/23 and readmission date of 12/6/23. R105's diagnoses included encephalopathy and psychotic disorder with delusion. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. On 12/15/25 at 3:23 PM, the Nursing Home Administrator (NHA) said the facility called him on 11/7/25 and reported the incident but he was at the airport. The DON, who was the back-up Abuse Coordinator, could not get into the reporting system. The DON reportedly was not able to log into the reporting system even after reaching out for technical assistance. The NHA previously reported that the DON was unable to log into the reporting system in August 2025. It was acknowledged by the NHA that there was a lack of follow-up concerning the DON's reporting system access between August and November 2025. A facility policy titled, Abuse Prohibition Policy, dated 10/14/22, was reviewed and documented in part the following: The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown sourced to the Administrator and DON immediately. The Administrator or designee will notify the State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours. During the exit conference on 12/16/25 at 5:20 PM, the NHA and Assistant Director of Nursing 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 new information was provided.

This citation pertains to intake 2635308.Based on observation, interview, and record review, the facility failed to properly secure a television for one resident (R101) out of four residents reviewed for accidents resulting in R101 receiving a head injury.Findings include:On 10/8/2025 at 10:15 AM R101 was observed seated in a wheelchair in the common area with a bump on her forehead. When R101 was asked about the bump she was unable to explain how she received it.Record review of R101's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease and Dementia.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R101 had severe cognitive impairment with a Brief interview for Mental Status (BIMS) score of one out of 15 and was dependent for mobility except for eating where she required set up.On 10/8/2025 at 11:10 AM, Certified Nursing Assistant (CNA) B was interviewed and said she was assigned to work with R101 when the incident occurred on 9/30/25. When asked about the incident CNA B said she heard R101 yelling for help and when CNA B went to check on R101, R101 was found in bed with a television laying on top of her. CNA B said she picked the television off R101 and got the nurse. CNA B stated, The television was stored on R101's overbed table. Earlier in the day I noticed the television was leaning. CNA B further said R101 was able to reach and grasp for objects. Review of the Progress Note dated 9/30/25 revealed, Writer alerted to room where resident in bed with large tv in bed with her and large hematoma, no bleeding noted on left side of forehead. Call made to Dr (doctor) and received order to transfer resident out for evaluation. (Transportation service) stated it will be 1-2 hours before transportation. 911 phoned. Resident stated that she was ok and wants to get in wc (wheelchair). 144/89 89 97.7 18 98% ra (room air). Ice applied to hematoma by writer and cna. Cna stayed in room until emts arrived. Call made to guardian and informed of transfer to hosp.Review of R101's care plan revealed, Focus R101 has a history of falls and remains at risk for fall/injury related to generalized weakness, poor balance, low endurance, incontinence diagnosis: Dementia, Parkinsons. Date initiated 4/18/25. Goal. Will have risk minimized in an effort to reduce likelihood of falls/fall related injuries through the review date. Interventions Keep the residents environment as safe as possible with: even floors free from spills and/or clutter, adequate lighting, call light within reach, avoid repositioning furniture and keep the bed in the appropriate position.On 10/8/2025 at 1:30 PM, the Director of Maintenance (DM) C was interviewed and said staff stored R101's 32-inch television on the overbed table. DM C further said it was not ideal to store that large of a television on the overbed table because the table was not sturdy enough. On 10/8/2025 at 1:40 PM the Nursing Home Administrator was interviewed and said residents' televisions should not be stored on overbed tables since the tables are not sturdy enough to safely hold a television. Review of the facility policy titled Federal & State - Resident Rights & Facility Responsibilities last revised 5/14/2024 revealed in part.Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

This citation pertains to intake MI00153561. Based on observation, interview and record review the facility failed to ensure adequate supervision for one resident (R902) out of one resident with severe cognitive impairment, resulting in three residents (R901, R903, and R904) verbalizing lack of privacy and security. Findings include: Record review of allegation sent to State Agency revealed R902 had entered R901's room several times without invitation. An interview was conducted on 6/17/25 at 11:04 AM with R901 on the second floor of facility, it was reported that R902 at the time that the allegation was reported, had wandered into the resident's room multiple times. R902 would pick up and look at resident's belongings and had covered the resident with blankets while in the bed. R901 further reported not feeling safe when R902 would enter the room. Record review of 901's electronic medical records revealed admission into the facility on 6/27/23 with a pertinent diagnosis of paraplegia (paralysis). According to Brief Interview for Mental Status (BIMS) dated 5/23/25, R901 scored 15 out of 15 (cognitively intact). An interview was conducted on 6/17/25 at 11:12 AM with R903 on the second floor of the facility, it was reported that R902 would wander into the resident's room multiple times a day and would pick up her belongings. R903 further reported a preference that R902 would not come into room uninvited. Record review of 903's electronic medical records revealed admission into the facility on [DATE] with a pertinent diagnosis of diabetes. According to Brief Interview for Mental Status (BIMS) dated 6/9/25, R903 scored 13 out of 15 (cognitively intact). An interview was conducted on 6/17/25 at 11:50 AM with R902, the resident was unable to respond to questions related to decreased cognition. Resident was observed wandering around the third floor of the facility. Record review of 902's electronic medical records revealed admission into the facility on 1/30/25 with a pertinent diagnosis of vascular dementia. According to Brief Interview for Mental Status (BIMS) dated 5/23/25, R902 scored 1 out of 15 (severe impairment). Record review of R902's Wandering Care plan dated 3/11/25, it was documented to Observe wandering and attempt diversional interventions . Record review of R902's Elopement Assessment dated 3/26/25, Resident Scored 13 (At Risk). Documented under section 3- Wandering-Behavior of this type occurred daily. An interview was conducted on 6/17/25 at 11:30 AM with R904 on the third floor of facility, it was reported that R902 was entering resident's room uninvited, it was further reported by R904, It is creepy when that man (R902) comes in your room and sits on my bed and is eating food, I don't like it at all. Record review of 904's electronic medical records revealed admission into the facility on [DATE] with a pertinent diagnosis of acute pancreatitis (inflammation of pancreas). According to Brief Interview for Mental Status (BIMS) dated 6/9/25, R904 scored 15 out of 15 (cognitively intact). An interview was conducted on 6/17/25 at 12:34 with Unit Manager (UM) A. It was reported that R902 was moved to the third floor after R901 complained about the resident. It was further reported that the facility was aware that R902 continued to wander into other resident's rooms after being transferred to another floor. When asked if the current interventions were working, UM A replied, No not if other residents are complaining. Additionally, it was reported that residents should feel safe, and their area should remain private. An interview was conducted on 6/17/25 at 1:15 PM with the Director of Nursing (DON), It was reported that residents should have privacy and feel secure in the facility. It was further reported that diversional interventions should be expanded on to prevent R902 from wandering into other resident's rooms.

Based on interview and record review the facility failed to employ a qualified social worker on a full-time basis to meet the psychosocial, mental, and behavioral health care needs of residents in a facility with more than 120 beds. This deficient practice had the potential to affect all residents that reside within the facility. Findings include: An interview was conducted on 5/12/25 at 1:30 PM with the Director of Nursing. It was reported that the facility did not have a social worker available. An interview was conducted on 5/13/25 at 1:30 PM with the Nursing Home Administrator (NHA). It was reported that the facility had 124 beds online. It was further reported that the facility does not currently employ a full-time social worker and has not had one since the week of Easter (April 21, 2025). During a phone interview on 5/14/25 at 1:45 PM the Medical Director reported no knowledge that the facility did not have a full-time social worker available at this time. Review of facility policy Social Service Program dated 9/7/2023, it was documented, The facility will provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Residents will be encouraged to attain or maintain mental and psychosocial health. 1. Each facility will meet the psychosocial needs of each resident. Facilities with greater than 120 beds will employ a full-time staff person to fill this role. The staff person fulfilling this role will have a minimum of a bachelor's degree in social work or bachelor's degree in a human service field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology, and one year of supervised social work experience in a health care setting working directly with individuals .

Based on observation, interview, and record review, the facility failed to: 1. Properly date-label food in the freezer; 2. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, macaroni and cheese; 3. Recognize unpasteurized shell eggs were used for the preparation of over easy eggs; 4. Ensure kitchen staff properly used hair restraints; and 5. Ensure pans were allowed to air dry before stacking. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 5/12/25 beginning at 8:40 AM, the initial tour of the kitchen began with Dietary Aide (DA) O and the following was observed in the reach-in freezer: three undated opened bags of French fries and one undated opened bag of chicken. The following was observed inside of the walk-in cooler: One half-size pan of previously cooked macaroni and cheese dated 5/11 and 5/14. One opened case of shelled eggs dated 4/3/25 which were not marked as pasteurized. DA O said the kitchen makes eggs to order. On 5/12/25 at 8:59 AM, [NAME] P and DA Q were observed working in the kitchen. [NAME] P and DA Q both had facial hair that was not covered with a beard guard. DA Q's long hair was not contained with a hair restraint. During an interview on 5/12/25 at 9:00 AM, [NAME] P said R39 receives sunny side up eggs daily for breakfast. [NAME] P said the egg yolks were soft. On 5/12/25 at approximately 9:15 AM, Certified Dietary Manager (CDM) R was present for the completion of the initial kitchen tour. CDM R said the macaroni and cheese was cooked on 5/11/25. When asked for the cooling log for the macaroni and cheese, CDM R said it was not done. Three half-size pans and one 1/3-size pan stacked in the clean pot/pan storage area were observed to have droplets of water. During an interview on 5/12/25 at 10:54 AM, R39 said he ate the following for breakfast: French toast, bacon, and eggs. R39 said every morning he gets his eggs prepared over-easy with the yolk a little 'runny.' During an interview on 5/12/25 at 12:27 PM, CDM R was unsure if the shelled eggs in the walk-in cooler were pasteurized or not. During an interview on 5/13/25 at 8:11 AM, CDM R corrected [NAME] P in that R39 received eggs served over-easy not sunny side up. CDM R reported that the eggs used were unpasteurized. CDM R said that pasteurized eggs were ordered, but the food supply and distribution company substituted unpasteurized eggs. CDM R stated, Management did not catch it. It was my fault. CDM R said there was another case of eggs behind the unpasteurized eggs dated 5/6/25. The facility uses the FIFO (first in, first out) system. Therefore, it was likely that the case of unpasteurized eggs dated 4/3/25 and stored in front of the case of eggs dated 5/6/25, were used in the preparation of R39's over easy eggs. During an interview and observation on 5/13/25 at 8:42 AM, R39 was observed eating breakfast. R39's meal included two over easy eggs. When the egg yolks were broken, they were not fully cooked. The yolks were slightly creamy but still runny. During an interview on 5/13/25 at 9:23 AM, [NAME] P said he has been cooking for a month or two. [NAME] P said he had picked up morning shifts and would cook R39 three eggs for breakfast. [NAME] P said the egg preparation included flipping the eggs (i.e. eggs over easy). When queried about the difference between pasteurized and unpasteurized eggs, [NAME] P stated, Pasteurized eggs come from a farm. [NAME] P was unsure of where unpasteurized eggs came from. [NAME] P said that the eggs cooked for R39 for breakfast on 5/12/25 probably came from the case of eggs in the front (the unpasteurized eggs) because it was the first box available. During an interview on 5/13/25 at 3:42 PM, CDM R said the macaroni and cheese should have been cooled down to at least 70 F (Fahrenheit) in the first two hours and within a four-hour period, the macaroni and cheese should be 40 F or below. CDM R was unable to provide documentation that the macaroni and cheese had been cooled properly. CDM R said that kitchen staff should have their facial hair covered. A review of the clinical record for R39 documented an admitted [DATE] with diagnoses that included acute respiratory failure with hypoxia, diabetes mellitus-type 2, atrial fibrillation, congestive heart failure, and hypertension. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. R39 was [AGE] years of age at the time of this survey. Record review of R39's Functional ability deficit and requires supervision/partial/moderate assistance with self care/mobility R/T (related to): Weakness care plan revised 11/6/24 documented in part, Eating: requires set-up to eat. R39 was prescribed a consistent carbohydrate, no added salt diet of regular texture. During an interview on 5/13/25 at 4:05 PM, the Nursing Home Administrator said kitchen staff should have checked the case of eggs to make sure they were pasteurized. The following facility policies were reviewed and documented in part the following: 1. Food Purchasing and Storage, dated 12/10/24. The stock will be rotated when stored. All food items will be dated with the In Date (or Delivery Date). Dating facilitates proper rotation of stock. 2. Food Temperatures, dated 1/9/25. Shell, liquid, frozen, dry eggs and egg products shall be used only for cooking and baking purposes. Only pasteurized eggs are allowed for eggs that are made to order. According to the 2013 FDA Food Code: Section 2-402, Hair Restraints. Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Section 3-101.11, Safe, Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented. Section 3-501.14, Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. Section 3-801.11, Pasteurized Foods, Prohibited Re-Service, and Prohibited Food. In a food establishment that serves a highly susceptible population: (c) the following foods may not be served or offered for sale in a ready-to-eat form: (2) a partially cooked animal food such as lightly cooked fish, rare meat, soft-cooked eggs that are made from raw eggs, and meringue. Section 4-901.11, Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils shall be air-dried. According to the United Stated Department of Agriculture (USDA): https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/eggs/egg-products-and-food-safety The USDA does not recommend eating raw shell eggs that are not cooked or are undercooked due to the possibility that Salmonella may be present. According to the Centers for Disease Control and Prevention (CDC): https://www.cdc.gov/salmonella/about/index.html Anyone can get a Salmonella infection. But some groups of people have an increased chance of infection, and some people may become seriously ill. These groups include: Adults who are [AGE] years and older with underlying medical problems, such as heart disease and adults who are 65 and older.

Based on interview and record review, the facility failed to provide follow-up to the (Department of Community Health/ form 3877/78) during annual review and to ensure the form was submitted to the local Community Mental Health Services Program (CMHSP) for a level two OBRA (Omnibus Budget Reconciliation Act) evaluations annually for six (R28, R48, R77, R96, R97 and R99) of six residents reviewed for Preadmission Screening/Annual Resident Review (PASARR). Findings include: R28 A clinical record review revealed R28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia, Psychotic Disorder with Hallucination, Adjustment Disorder with Depressed Mood and Pulmonary Fibrosis. According to the Minimum Data Set (MDS) assessment dated [DATE], R26 scored a 00/15 on the Brief Interview for Mental Status (BIMS) score which indicated severely impaired cognition. Further review of the most current 3877 triggered the need for a 3878 form to be completed. R48 A clinical record review revealed R48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Bipolar II Disorder, Hoarding Disorder, Depressive Disorder and Kidney Failure. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicated an intact cognition. Further review of R48's medical record revealed the most current level II was dated 10/27/23 and the next one was due 10/27/24. An updated level II was requested and not available. R77 A clinical record review revealed R77 was admitted to the facility on [DATE] with a diagnoses of Thyotoxicosis, Attention Deficit Disorder, and Anoxic Brain Damage. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicated an intact cognition. Further review of R77's medical record revealed the most current 3877 was dated 12/05/24 with no level II assessment requested. An updated level II was requested and not available. R96 A review of the clinical record revealed R96 was admitted into the facility on [DATE] with diagnosis of social phobia, post traumatic stress disorder, depression, and lymphedmia. According to the Minimum Data Set (MDS) assessment dated [DATE], R96 scored a 15/15 score on the Brief Interview for Mental Status (BIMS) which indicated an intact cognition. Further review of R96's clinical record revealed an OBRA PASARR Correspondence dated 4/18/24 as the most current Obra information. An updated 3877/78 form was requested but not recieved. R99 A review of the clinical record revealed R969 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnosis of Psychosis, Type II diabetes Mellitus and Antiphospholipd Syndrome. According to the Minimum Data Set (MDS) assessment dated [DATE], R99 scored a 8/15 score on the Brief Interview for Mental Status (BIMS) which indicated moderately impaired cognition. Further review of R99's clinical record revealed a Pre-Admission OBRA 3877 dated 10/18/24. A request was made for the Level II request for mental health services OBRA PASARR Correspondence dated 4/18/24 as the most current OBRA information. An updated 3877/78 form was requested but not recieved. 49699 R97 A review of the Electronic Medical Record (EMR) revealed that R97 had a Level I PASARR and Level II PASARR screening were both dated for 9/10/2024. An Omnibus Budget Reconciliation Act of 1987(OBRA) determination letter was not available. A review of the EMR revealed R97 was originally admitted on [DATE], with a readmission on 5/6/2025 with pertinent diagnoses of Major Depressive Disorder, Extrapyramidal and Movement Disorder, and End Stage Renal Disease. Further review revealed a Brief Interview for Mental Status score of 15/15 indicated intact cognition. On 5/14/25 at 1:30 PM the Nursing Home Administrator (NHA) was queried regarding the missing PASARR forms and Level II assessment request. The NHA stated that they do not have a full time social worker on staff at this time. NHA was asked about their expectation for timely PASARR documentation and [NAME] II assessments. The NHA stated, It is the expectation that the forms are completed timely per policy. A review of the facility policy titled Pre-Admission Screening and Guest/Resident Review - PASRR Michigan dated 11/12/21 revealed the following: The PASARR process was established in 1987, as part of the OBRA ruling to screen all individuals admitted for nursing care to ensure that needs are met to assist the individual in reaching their highest potential. All persons seeking admission to a nursing facility, who are seriously mentally ill and /or have an intellectual /developmental disability, are required to be evaluated to determine if a nursing facility is the appropriate place to recieve services.

Based on observation, interview and record review the facility failed to revise the care plan for one (R97) of one resident reviewed for updated care plans when a resident diagnoses was corrected and changed. Findings include: Review of the Electronic Medical Record (EMR) revealed R97 was originally admitted on [DATE], with a readmission on 5/6/2025 with pertinent diagnoses of Post Traumatic Stress Disorder. Further review revealed a Brief Interview for Mental Status score of 15/15 indicated intact cognintion. A review of the care plan revealed a focus of Post Traumatic Stress Disorder. On 5/13/2025 a review of the care plan was made with the Minimum Data Set (MDS) Nurse S regarding R97's diagnoses of Post Traumatic Stress Disorder. MDS Nurse S revealed a Psychiatric Evaluation dated 11/26/24 without a diagnosis of Post Traumatic Stress Disorder and that a correction had been made on the MDS at that time. Further review of the EMR revealed a care plan with an initiation date of 9/19/2024 by Social Services and a revision by MDS Nurse S with a target goal date of 6/20/2025. All interventions were developed on 10/22/2024 and 10/28/2024. An interview with MDS Nurse S indicated the Care Plan should have been updated. An interview with the Director of Nursing (DON) on 5/14/2025 at approximately 12:30 PM revealed care plans should be updated and/or resolved in a timely manner when appropriate.

Based on observation, interview, and record review the facility failed to provide one to one meal assistance for one resident (R24) out of five residents reviewed for nutrition. Findings include: On 5/12/25 at 1:10 PM, staff were observed delivering a meal tray to R24's room. The tray was set up and staff left the room. Continued observation made until 1:21 PM, staff entered the room and only opened R24's ice cream package and then left the room. Review of R24's dietary slip documented resident was 1:1 (one to one) for meal assistance. On 5/12/25 at 1:38 PM, an interview was conducted with Certified Nursing Assistant (CNA) T who reported, I tried to feed her, but she often feeds herself. On 5/13/25 at 9:10 AM, staff were observed delivering a meal tray to R24. The tray was set up and staff then left the room. Continued observation until 9:20 AM, no staff were present to provide one-on-one assistance with meal. Record review of R24's electronic medical records (EMR) revealed admission into the facility on [DATE] with a diagnosis of low-tension glaucoma (disease that affects the optic nerve), and dementia. Further review of Minimum Data Set, dated dated dated [DATE] revealed R24 scored 8 out of 15 (moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS) and required substantial/maximal assistance with Activities of Daily Living (ADLs). Review of Alteration in nutritional and/or hydration status care plan documented and dated on 3/19/25, 1:1 feeding assistance /encouragement with meals r/t (related to) vision impairment. Review of Kardex (list of care needs) dated 5/14/25 documented Eating/Nutrition-1:1 feeding assistance /encouragement with meals r/t (related to) visual impairment. Review of Physician Orders dated 3/19/25, it was documented 1:1 feeding assistance with meals r/t to visual impairment. During an interview on 5/14/25 at 8:48 AM with Unit Manager (UM) A it was reported when a resident is 1:1 for feeding assistance staff should sit and assist the resident during the meal. During an interview on 5/14/25 at 8:58 AM with Registered Dietitian (RD) C it was reported that R24's care plan was updated in March 2025 and was related to the resident's diagnoses of dementia and declining eyesight. R24 required 1:1 assistance with feeding. It was further reported that when the meal is delivered staff should sit with the resident and manually feed or give encouragement until the resident has completed the meal. During an interview on 5/14/25 at 1:32 PM with the Director of Nursing (DON) it was reported staff should sit with the residents and assist them until the residents have completed their meal.

Based on observation, interview, and record review the facility failed to ensure that medications were not left at resident bedside for two (R93 and R108) of thirty-three residents reviewed regarding medications found at bedside. Findings include: On 5/12/2025 at 10:58 AM, during an observationn and interview, R108 was observed retrieving a yelow/orange capsule from the bedside table. R108 placed the capsule into thier mouth and sipped water from their water cup. An inquiry was made, what was that you just took? R108 replied, it was gabapentin. A review of R108's Electronic Medical Record (EMR) revealed R108 was admitted on [DATE] with the following pertinent diagnoses of Huntington's Disease (a progressive neurologic deterioration). Further review revealed a Brief Interview of Mental Status score of 14/15 indicated intact cognition. Further review of the EMR for R108 revealed the resident had an active order for gabapentin 300 mg. On 5/12/25 at 11:25 AM, during observation and interview with R93, a medicine cup was noted sitting on an overbed table at the foot of the bed in the corner of the room containing four pills. R93 revealed they were from a few days ago and that today's morning medication had been taken in the dining room. A review of R93's EMR revealed they were admitted on [DATE] with pertinent diagnoses of Encephalopathy, Dementia, Seizures, Psychotic Disorder and Violent Behavior. Further review revealed R93's Brief Interview for Mental Status of 10/15 indicating moderate cognitive impairment. On 5/12/25 at 12:00 PM, Licensed Practical Nurse (LPN) M was asked to enter R93's room and explain why medications were left at the bedside. LPN M revealed they had given R93 their prescribed medication during breakfast in the dining room. LPN M retrieved the medication cup with 4 medications, a large blue pill (identified as Vimpat for seizures), Yellow/orange capsule (identified as gabapentin for neurological symptoms), a small round yellow tablet (identified as Lovastatin for cholesterol), and a half of a large white round tablet (without identifying marks). LPN M removed the medication cup and disposed of the medication. On inquiry, LPN M revealed, to their knowledge, no one on the 4th floor is on self-medication (able to administer medications to self). On 5/13/25 at 8:45 AM, an observation was made of R93's room and a medicine cup with a large blue pill (previously identified as Vimpat). The Unit Manager (UM) G was invited to observe the medication. UM G removed the medication from the room indicating that there are no residents on the unit who are authorized for self-administration and that medication should never be left at the bedside. An interview with the Director of Nursing (DON) on 5/13/2025 at approximately 12:30 PM revealed there were no residents on the 4th floor who were authorized to self-administer medication. The DON further revealed the nurse was to watch the resident consume medication when it was given and any refused medications should be disposed of properly in the drug buster and medications should not be at resident bedside. A review of the Policy Medication Administration last revised on 10/17/2023, documented the following: Observe that the resident swallows the oral medications. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication.

Based on interview and record review the facility failed to perform life saving measures to a resident that was documented as a full code (When a person has no heartbeat and not breathing, CPR/cardiopulmonary resuscitation should be administered). This deficient practice resulted in an Immediate Jeopardy on [DATE] when nursing staff failed to perform CPR on R19 or call emergency services (911) when found with no heartbeat and was not breathing. This deficient practice placed all 95 residents at risk for the likelihood of serious injury, harm, and/or death from code status not being followed by staff. Findings include: Record review of R19's face sheet revealed admission into the facility on [DATE] with a pertinent diagnosis of benign neoplasm of meninges (tumors growing in membranes around the brain). According to the Minimum Data Set, dated dated dated [DATE], R19 had impaired cognition and was extensive assist with Activities of Daily Living (ADLS). Record review of Resident Code Status revealed a document that was signed by facility staff on [DATE]. The following choice was initialed and documented the following: Full Resuscitation and life sustaining treatment (Includes all treatment items outlined below under Selective Code Selective Resuscitation) as designated by facility because another code status cannot be designated due to incapacity of resident and/or lack of a healthcare legal decision maker or lack of authority of healthcare legal decision maker to designate another code. Record review of End Stage Illness care plan documented as an intervention Resident is Full Code initiated on [DATE]. Record review of physician orders revealed a full code (default) order. Record review of R19's Nursing Notes dated [DATE] at 8:49 AM, documented the following, Writer entered room to round on resident, resident was not responsive writer assessed, no breath sounds, no reading from v/s (vital sign) machine, sternum rub given, no response, writer called staff RN to assess and call time of death. Hospice team notified. Electronically signed by Licensed Practical Nurse (LPN) C. Record review of Nursing Notes dated [DATE] at 10:39 AM documented the following: Writer called to resident room; Writer unable to obtain v/s; Floor nurse and staff nurse also unable to obtain v/s; Time of death called at 0857 am by writer. Electronically signed by Registered Nurse (RN) D. During an interview on [DATE] at 1:30 PM with RN D, when asked actions that should be taken when a resident is found with no heartbeat and is not breathing, RN D said, You should check their code status. When asked if the resident is a full code or a full code by default what actions should take place, RN D said, CPR should be started and 911 called. When asked if she had pronounced the death of R19, RN D said, Yes. When asked why the code status was not checked first, RN D said, I was called to floor by (LPN B) and told that they needed an RN to pronounce R19's death. I was told she was a hospice patient. When asked if the code status was checked before pronouncing R19's death, RN D said, No. During an interview on [DATE] at 1:50 PM with LPN C, it was confirmed that R19 was under her care when she expired. When asked if a resident is a full code or a full code by default should CPR be performed, LPN C stated, Yes. When asked if CPR and 911 was called when R19 was found to have no heartbeat and not breathing, LPN C said, No, she was hospice. When asked if R19's code status was checked, LPN C said, No. During an interview on [DATE] at 01:56 PM with LPN B, it was confirmed that she was one of the unit managers. It was confirmed that R19 had been a full code. When asked what actions should be taken if a resident is a full code, LPN B said, You have to do CPR if there are no vital signs. When asked if CPR was performed and 911 was called for R19, LPN B said, Not to my knowledge, CPR was not performed. When asked should it have been performed on that resident, LPN B said, Yes. When asked did you call RN D and tell her to go pronounce R19's death, LPN B stated, I called and told (RN D) to go up and pronounce resident. I am not sure why they did not perform CPR. When (LPN C) called me, she said resident had passed and she needed someone to pronounce her death. I was not aware at the time she was a full code; I was aware she was hospice. During an interview on [DATE] at 2:15 pm with Hospice Registered Nurse (HN) E when asked if called when the resident had passed, HN E said, Yes. When asked if R19 was a full code, HN E said Yes. When asked if instructions were given to the facility not to perform CPR, HN E said, No, it would be the responsibility of the facility to follow their protocols. During an interview on [DATE] at 2:30 PM with Director of Nursing (DON) when asked if a resident is hospice and is a full code, should CPR be administered when the resident is found with no vital signs, DON said, Yes. After reviewing information with DON regarding R19 it was confirmed that CPR should have been administered and emergency services called. During an interview on [DATE] at 2:45 PM with Nursing Home Administrator (NHA), it was confirmed that CPR should have been administered at the time of R19's death. When asked if conversations should have been held with hospice addressing actions to be taken before the resident's death related to R19's code status, NHA, said, Yes. Record review of policy Death of a Guest/Resident last reviewed [DATE] documented the following, . if the guest/resident is Full Code status, CPR is started, and emergency 911 services are activated. On [DATE] 3:35 PM, the Nursing Home Administrator was notified of the Immediate Jeopardy (IJ) that began on [DATE] due to the facilities failure to provide life saving measures to R19. A written plan of removal for the immediate jeopardy was received and verified on [DATE]. The facility removal plan documented the following: (Facility Name) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy for F678 regarding the facility's alleged failure to perform cardiopulmonary resuscitation (CPR) on resident (redacted resident facility number) (R 19), who was a full code. 1. Resident identified to be affected by the alleged deficient practice. (redacted resident facility number) (R19) no longer resides in the facility. 2. Residents with the potential to be affected by the alleged deficient practice. On [DATE], the 3 residents that resided in the facility that expired in the facility were reviewed to ensure CPR was performed in accordance with resident preferences. 3 out of 3 residents had a no CPR order. On [DATE] there are 95 residents currently residing in the facility and 95 out of 95 resident charts were reviewed to ensure the code status reflects the resident preferences. One resident is a full code hospice, his chart was reviewed, and licensed nurses are aware that he is full code hospice. 3. Systemic Measures The facility policy on Death of a Guest/Resident was reviewed and deemed appropriate on [DATE] and no changes were made to the policies. Licensed staff will be educated on checking code status on residents regardless of their payer source. There are currently 35 licensed Nurses on staff at the facility. The re-education began on [DATE] at 2:00 pm with staff that was in the facility regarding the Death of a resident and guest as of 3:30 pm on [DATE] there are 21 out 35 nurses educated. 7 of the 21 are flex and were notified via phone as well as mailing the policy, they will be educated upon return. The remaining licensed nurses will be re-educated prior to the start of their next shift scheduled. 4. Quality Assurance An Ad Hoc QA meeting was held on [DATE] with the Medical Director, Director of Nursing and Administrator to review the policies on Death of a guest or resident. The administrative nurses will review residents who have expired in the facility weekly for 4 weeks and monthly for 2 months to ensure CPR was performed in accordance with the resident's preferences. Any areas of non- compliance will be addressed immediately and will be reported to QAPI Committee for further recommendations. The Administrator is responsible for sustained compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance had not yet been verified by the State Agency.

This citation pertains to intakes MI 275, MI 403, MI 417. Based on interview and record review the facility failed to provide necessary supervision for one resident (3) with known impaired cognition causing an elopement (leaving a safe area or premises) and unknown whereabouts from facility on 8/5/22 at 3:12 PM for 47 minutes where he was found a mile away at a friend's home after he traveled on a 4 lane, 45 mph road., affecting one resident (R3) out of five residents reviewed for elopement, resulting in an elopement and the likelihood to cause serious injury, serious harm, serious impairment and/or death. Findings Include: Record review revealed R3's face sheet revealed admission into the facility on [DATE] with a pertinent diagnosis of cerebral infarction (stroke), According to Minimum Data Set (MDS) dated [DATE], R3 was moderately impaired. Record review of document Statement of Capacity dated 3/24/22 documented the following: This is to certify the above guest/resident has been examined by me and I have reviewed the medical record. I find this guest/resident: To be incapable and unable to make his/her informed medical decisions. Document was signed by a Medical Doctor (MD) H and a Psychologist (PSY) G. During phone interview on 8/30/22 at 10:50 AM with R3's adult son (AS) F, when asked if family or friends picked up resident on 8/5/22, AS F said, No. When asked if R3 should have been able to leave the facility on his own, AS F stated, No. When asked if R3 should be able to make his own decisions, ASF stated, No. When asked how he was made aware that resident had left facility, ASF said, I was at work and my cousin let me know. During an interview on 8/30/22 at 11:54 AM with Director of Nursing (DON), when asked if R3 had eloped from the facility on 8/5/22, DON stated, Yes. When asked how long resident was missing before the facility was aware of the elopement, DON said, We (facility) know that he received a medication at 12:00 PM that day. When asked how the elopement was discovered, DON said, A family member called at 4:00 PM, and said he had a U-Haul truck and was heading to Kentucky. When asked when residents are found to be incapacitated or have impaired cognition should they receive supervision, DON stated, Yes. Record review Nursing Progress Notes, dated 8/5/22 at 4:00 PM, documented the following: Resident left facility did not notify anyone he was leaving. During rounds resident was noted not in his room, Scheduler E came to the 3rd floor and stated, she received a call from family stating he was on his way to Kentucky. During interview on 8/30/22 at 12:57 PM with Unit Manager (UM) A, when asked of R3 had eloped from the facility on 8/5/22, UM A stated, Yes. When asked what time you think resident left facility, UM A, said, According to the LOA (Leave of Absence) Log, he (R3) was signed out at 3:12 PM. Record review of LOA Log documented that resident R3 signed out at 3:12 PM. When asked to explain the purpose of the 'LOA log', UM A said, When residents go on LOAs, or want to go downstairs or outside they (residents) sign the log. When asked if R3 could sign himself out for and LOA related to his cognitive impairment, UM A said, No, he (R3) was only supposed to sign out when going downstairs for activities or going to the parking lot. When asked if residents that are found to have impaired cognition should be supervised, UM A stated, Yes. On 08/30/2022 at 12:21 PM, during interview with Administrator, when asked should residents be supervised when they are found to be incompetent. She stated Yes. Record review of Nurse Progress Note dated 8/5/22 at 5:00 PM by DON documented the following: Resident left the facility without notifying the staff. Spoke with daughter he is with a friend of the family house family at Clairmont and 3rd . During an interview on 8/30/22 at 1:22 PM with Director of Nursing (DON), When asked if there was supervision provided outside for residents, DON stated, There were people out there. When asked if a staff member had been delegated to supervise R3, she said, No. When asked do you know how R3 left the premises, DON said, I think family picked him up. When asked did you or any staff member see R3 get picked up, DON stated, No, When asked approximately how far Clairmont and Third street was from the facility, DON said, About a mile. Record review of policy Elopement last reviewed 4/26/22 documented the following: It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/ residents from the facility . Record review of policy Nursing Rounds/Licensed Nurses last reviewed 4/26/22 documented the following: To ensure the safety and comfort of the guest/resident. To assist in continuity of care. To identify potential change in condition. The Administrator was notified of the Immediate Jeopardy (IJ) on 8/30/22 at 3:46 PM due to the facilities failure to provide necessary supervision resulting in an elopement of R3. A written plan of removal for the immediate jeopardy was received and verified on 8/30/22. Element 1: DON spoke with R3 and his son on 8/5/22 on the telephone around 5pm. The son stated that R3. was safe with him. R3's son. came to the facility and met with the charge Nurse and stated that his dad was with him. Element 2: On 8/5/22 a head count was performed on all current residents residing at Boulevard Temple. All residents were accounted for. Residents were reviewed on 8/30/22, 17 out of 88 were identified as incompetent and will have supervision while on outings, loa's, appointments, etc. Supervised outside activities were started on 8/8/22. Element 3: The Elopement and Nursing Rounds policies were reviewed and deemed appropriate on 8/5/22. 58 out of 98 staff members were in-serviced on Nursing Rounds and the elopement policy on 8/5/22 through 8/8/22. 52 out of 98 staff members were educated on the need for incompetent residents to have supervision while on outings, loa's, appointments, etc. All nurses and cna's will be in- serviced before returning to work. Element 4: The DON or designee will conduct random audits weekly x 4 then monthly x 3 to ensure staff are performing nursing rounds and residents are accounted for (started on 8/15/22. Going forward the Social Worker will identify any new residents deemed incompetent, notify the IDT team and Supervision will be placed on the resident's profile. The DON or designee will audit weekly for new residents deemed incompetent starting 8/31/22 The Administrator will be responsible for compliance. Although the immediate jeopardy was removed on 8/30/22, the facility remained out of compliance at a scope of isolated and severity of no actual harm, with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance had not yet been verified by the State Agency.

This citation pertains to intakes MI 433, MI 464, MI 564. Based on interview and record review the facility failed to prevent Resident #2 (R2) from fondling one Resident #1(R1) of six residents reviewed for abuse resulting in sexual abuse and R1 being afraid, scared, and unsafe. Findings include: On 8/31/22 at 11:47 AM a phone interview with R1, it was confirmed that R1 had been inappropriately touched. When asked what happened, R1 stated, That man fondled me. When asked if she gave him permission to do that, R1 stated, No. When asked how that made her feel at the time of the incident, R1 stated, I was afraid and scared. When asked her current location she said, I am at another nursing home where I feel safe. On 8/30/22 at 11:36 AM, during an interview with Registered Nurse (RN B), it was confirmed that she was the nurse for R1, and she witnessed R2 with his hand down the front of R1's pants. When asked during her assessment, did you ask R1 if she gave permission or consent for R2 to put his hand in her pants, RN B said, (R1) told me that it was not consensual. On 08/31/2022 10:25 AM, during a phone interview with Nurse Practitioner (NP D) It was confirmed that a physical assessment was conducted after the incident, and she gave orders to send R1 to hospital for further assessment. When asked if she questioned R1 if the incident was consensual, NP D said, She told me that it was unwanted. Record review of Interview with R2 dated 8/10/22 at 12:10 PM, the handwritten interview was conducted by the Administrator and RN B. It documented the following: . I asked R2 what had happened, he looked down toward the floor and said, I had my hand down her pants. I asked did she give you permission, he stated, No. I asked him why you did that, he stated, I don't know. Resident asked, did he know what he did, he stated, Yes. Record review of hospital records, Consultation dated 8/11/22 at 11:27 AM, . She (R1) reported that she would like to see a psychiatrist as event was traumatic. During interview on 8/30/22 at 1:22 PM with Director of Nursing (DON), when asked if residents should be free from sexual abuse, she stated, Yes. Record review of R1's face sheet revealed admission into the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .). According to the Minimum Data Set (MDS) dated [DATE], documented R1 had intact cognition and required limited assist with most Activities of Daily Living (ADLS) Record review of R2's face sheet revealed admission into the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of facility's Abuse Prohibition Policy last reviewed 4/24/22, documented the following 1. Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience that are not required to treat the guest's/resident's medical symptoms. 2.To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents. 3.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 4.Sexual Abuse is non-consensual sexual contact of any type with a guest/resident. Sexual abuse is defined as non-consensual sexual contact of any type with a guest/resident. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area; all types of sexual assault or battery, such as rape, sodomy, fondling and/or intercourse or coerced nudity; forced observation of masturbation and/or pornography; and taking sexually explicit photographs and/or audio/ video recordings of a guest/resident(s) and maintaining and/or distributing them (e.g., posting on social media).

This citation pertains to intake MI 573 Based on observation, interview and record review the facility failed to assess, monitor, and ensure pain medications were administered for 2 of 4 residents, (Resident #31, #90) reviewed for pain, resulting in inadequate pain management. Findings include: Resident #31 Review of an Admission Record revealed, Resident #31 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 8/12/21 revealed Resident #31 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15 and had a scheduled pain medication regimen. In an observation and interview on 10/20/21 at 9:55 a.m., Resident #31reported they have not had [MEDICATION(S)] (pain medication) in four days. Resident #31 reported they had pain in the back and was very painful. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #31 had a pain level of 9/10 on 10/18/21 at 2:00 p.m. Review of Progress notes from 10/17/21 to 10/21/21 revealed, Resident #31 had no documentation to explain the missed [MEDICATION(S)] doses. Review of a care plan revealed focus, (Resident #31) is at risk for pain and discomfort r/t (related to) [CONDITION(S)] disease of lumbar spine .[CONDITION(S)] disease of cervical spine with disc bulging and generalized discomfort with a revised date of 2/22/21. Interventions included . Administer [MEDICATION(S)] per physicians orders. Observe effectiveness . with a revised date of 12/2/20. Review of a Pain Evaluation revealed, Resident #31 had no pain evaluation after 9/24/19. In an observation and interview on 10/21/21 at 9:39 a.m., Resident #31 in laid in bed and a untouched breakfast sat on the bedside table. Resident #31 reported pain and has still not received pain medication. In an interview on 10/21/21 at 9:45 a.m., Licensed Practical Nurse (LPN) E reported Resident # 31 did not have [MEDICATION(S)] in the medication cart. LPN E reported she worked over the weekend and Resident #31 was out of [MEDICATION(S)]. LPN E then reported the physician and Unit Manager A was notified that Resident #31 did not have the pain medication. LPN E then reported she rubbed pain cream on Resident #31's back but it was not effective. In an interview on 10/21/21 at 1:36 p.m., LPN E reported Resident #31's [MEDICATION(S)] was not available and a new order for Tylenol #3 (pain medication) was received. In an interview on 10/21/21 at 1:37 p.m., Unit Manager A reported Resident # 31's [MEDICATION(S)] had to be reordered. Unit Manager A reported the pharmacy was called they reported the [MEDICATION(S)] was sent to the facility. Unit Manager A then reported they could not find the [MEDICATION(S)] and a new order was received for Tylenol #3. In an interview on 10/21/21 at 2:01 p.m., Director of Nursing (DON) BB reported she discovered Resident #31's [MEDICATION(S)] was missing today. DON BB verified Resident #31 had [MEDICATION(S)] in the medication cart until 10/15/21. In an interview on 10/21/21 at 4:51 p.m., Resident #31 reported a pain level of eight and had not received pain medication. In an interview on 10/25/21 at 1:08 p.m., DON BB reported pain assessments completed on admission and quarterly. Resident #90 On 10/20/21 at 2:17 p.m. review of electronic medical record face sheet document R90 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the quarterly MDS assessment dated [DATE], R90 was cognitively intact (BIMS=14) and required extensive one - person assistance with activities of daily living. The pain assessment documented R90 also received PRN (as needed) pain medications, pain was frequently present, and had a pain intensity of 7 (very severe). Review of the Pain care plan dated 4/9/21 documented, Resident has episodes of lower back pain and [CONDITION(S)]. Intervention: Administer medication as ordered. On 10/21/21 at 11:23 a.m. R90 was observed in the room, resting in bed. R90 presented as alert, oriented to person, place and situation. R90 was interviewed regarding the allegation of not receiving pain medication due to it not being reordered in a timely manner. R90 was interviewed and stated, I didn't get my [MEDICATION(S)] for about four days. I had to sit here in pain. I have chronic back pain and take it just about every day. I kept asking for it everyday and was just told it hadn't come in yet. On 10/21/21 at 1:57 p.m. Witness F was interviewed and verified, The [MEDICATION(S)] delivered to the facility on [DATE]. On 10/21/21 at 4:05 p.m. review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one tablet by mouth every 4 hours as needed for pain. Start date: 4/2/21. Review of the Medication Administration Report (MAR) for the month of October documented on 10/9/21-10/13/21, the medication had not been administered. Review of the nurse's progress notes dated 10/13/2021 07:43: Spoke with (Doctor's name) concerning resident needing C2 (Control Substance, Schedule II Script) for [MEDICATION(S)] 10-325mg, states to fax C2 to office, carried out, reported to oncoming shift. On 10/25/21 at 4:14 p.m. the DON was interviewed and stated, I was unaware it was not reordered. Nothing was said about it. The medication should have been reordered by or before 10/6/21. The medication was available in the back up narcotics box, but still was not administered. Review of a Pain Management policy with a revised date of 8/2016 revealed, The facility will evaluate and identify residents for pain, determine the type, location and severity and develop a care plan for pain management . Procedure 1. Upon admission, re-admission, quarterly, with significant change in condition and PRN (as needed) residents will be assessed for pain by the licensed nurse . 3. Observe resident for indicators of pain . Individualized interventions related to that resident's individual control of pain management should include both pharmacological, non-pharmacological and include Complementary and Alternative Medicine (CAM) pain management interventions .

Based on observations, interviews, and record reviews the facility failed to provide a timely therapy evaluation and treatment in the form of a compression sleeve and hand splint to prevent a decrease in Range of Motion (ROM) for one of six (#15) residents from a total of 25, resulting in R#15 developing a contracture in her right 2nd, 3rd, and 4th fingers. Findings include: During observation and interview on 03/11/18 at approximately 9:00 AM, R#15 said that she is 'unhappy' with what has happened to her right hand. Upon observation, R#15's right 2nd, 3rd, and 4th fingers were contracted at the second joint. R#15 said her right hand hurts at times, and 'looks like a claw'. R#15 said that the Doctor ordered her to have a splint and something on her arm, but she had not received anything yet. R#15 reported that said that she no longer gets therapy. According to the medical record review, conducted on 3/11/18, R#15 had a BIMS (brief interview for mental status) score of 14/15, and a recent hospitalized from [DATE] with a re-admission date of [DATE], that included a new [DIAGNOSES REDACTED]. The Nurse Practitioner (NP) noted on 12/20/17 that R#15 had right sided facial droop, right foot drop, and 2-3 bilateral hand grasp. On 12/25/17, the Nurse's notes documented that the NP was notified of R#15's increased pain and swelling of the right arm. Pain medications were given. On 12/28/17, the NP noted that R#15 had 3+ [MEDICAL CONDITION] (swelling of the arm, leaving a 6 millimeter deep impression on the arm with a 10-12 second rebound time) along with contractures to the right 3rd, 4th, and 5th fingers, and ordered a compression sleeve to the right arm. There is no documentation in the Doctor's progress notes, NP notes, nurse's notes, care plan, or treatment administration record (TAR) to indicate this was provided to R#15. On 2/23/18, the Physician ordered for a Physical Therapy Evaluation for a splint to the right hand. There is no documentation in the Doctor's progress notes, NP notes, nurse's notes, care plan, or treatment administration record (TAR) to indicate this was provided to R#15. A continued medical record review revealed the following: Doctor's progress notes dated 1/9/18, Right Upper Extremity (RUE) with 2+ [MEDICAL CONDITION], right hand contracted 2 - 4th fingers. Nurse's notes dated 1/16/18, awaiting compression sleeve for right arm for 3rd spacing (too much fluid moves out of the blood vessels into the soft tissue) from TIA. Nurse's notes dated 1/19/18, received order to elevate R#15's right arm on pillows until sleeve arrives. NP notes on 1/23/18, awaiting compression sleeve, RUE with 2+ [MEDICAL CONDITION], right fingers 2nd, 3rd, and 4th contracted. NP notes on 2/1/18, awaiting compression sleeve, RUE with 2+ [MEDICAL CONDITION], right fingers 2nd, 3rd, and 4th contracted. Restorative nursing notes on 2/13/18, indicated that R#15 is discharged from restorative therapy program, because has met her goals. ' able to perform sit-to-stand transfers and perform AROM (active range of motion) without difficulty. 'Resident can be reevaluated if there are any changes'. There is no further documentation in regard to R#15's right arm swelling, pain, and right 2nd - 4th finger contractures. Doctor orders on 2/23/18; Physical Therapy (PT) evaluation, for splint to right hand. There were no further documentations to indicate that R#15 had a PT evaluation for the right hand splint. During an interview on 3/12/18 at 10:35 AM, Nurse Unit Manager, LPN 'A', was asked about R#15's compression sleeve, PT evaluation, and right hand splint. LPN 'A' reviewed the medical record and reported that she could not see any documentation that either of these orders were carried out. At 10:45 AM, LPN 'A' said that she contacted the Therapy department and they said those orders had 'been missed'. During an interview on 3/13/18 at 09:45 AM, Therapy department manager 'staff B' and the Occupation Therapist (OT), 'staff 'C' they said that R#15 did not receive her compression sleeve for the right arm, when it was ordered, nor did she receive a PT evaluation for the right hand splint. Staff 'B' said the orders were missed, but that an evaluation was conducted yesterday, and a splint was ordered. Staff 'B' and Staff 'C' could not offer any explanations regarding the discontinuation of the 'restorative therapy'. According to R#15's initial Minimum Data Set ((MDS) dated [DATE], R#15 admitted with a left tibia fracture ( left shin bone) and received PT and OT. According to section 'G', (functional status) R#15 was independent with eating and required 'set-up' assistance only. On the quarterly MDS, dated [DATE], section 'G' indicated that R#15 had declined with ability to eat independently and now required supervision and one person assistance. The PT and OT care plans dated 9/20/17 are for the following focus; slow decline secondary to left tibia fracture, and included the following interventions; adaptive equipment, and ADL retraining. There are no updates to include the new TIA/right arm pain [DIAGNOSES REDACTED]. There were no 'updates' to any of R#15's care plans to indicate she needed further assistance with ADL's after her hospitalization and new [DIAGNOSES REDACTED]. During an observation and interview on 03/13/18 at 08:39 AM, R#15 was in bed with geri sleeve on, no splint. R#15 reported that her hand is still 'stinging'. She said that yesterday she received therapy and did some exercises, and it helped. R#15 said she wants to make sure she gets a splint on her hand because maybe it will help with the pain in her hand. On 3/13/18 at 01:30 PM, during an interview with the Director of Nursing (DON) was asked why the resident was discharged from Restorative Therapy on 2/13/18. The DON said she thought because the resident had 'met her goals'. The DON could not provide an explanation as to why or how restorative therapy was discontinued when a new [DIAGNOSES REDACTED]. On 3/13/18 at 01:45 PM, during a phone interview with the resident's attending Doctor, he said he was unaware that R#15 did not receive any restorative therapy or the splint for her right hand. The Doctor said that he did note that R#15 now has contractures to her right 2nd - 4th fingers, and that was a result of the TIA. He said the resident is a candidate for therapy. According to the facility's policy for 'restorative nursing' revised 8/2016, the facility strives to attain and maintain the highest level of practicable level of physical, mental, and psychosocial well-being. Restorative nursing is available 6-7 days per week an is provided for residents meeting restorative program criteria. 2) Determine Criteria, includes: a) contracture prevention and management, including passive range of motion, active range of motions, splint/brace assistance.

This citation has 3 deficient practice statements. Deficient Practice #1: Based on observation, interview, and record review the facility failed to address one sampled resident (#804) of 17 resident's complaints of pain and discomfort in a timely manner from a total of 24 residents resulting in on-going pain of the right foot, right leg, lower left back discomfort and painful urination. Findings include: On 2/13/17 at 9:35 a.m., Resident #804 was observed in bed and when queried stated, My leg keeps hurting. My pee stings my bottom - that pee hurts me so bad. I try to talk to the nurse, but the nurse said she don't have time. On 2/13/17 at 1:15 p.m., Resident #804 was observed in bed and stated, My toenails haven't been cut here (at the facility), my toenails are going down into the meat (skin). My feel hurt I've been telling them (nursing staff). On 2/13/17 at 2:00 p.m., Resident #804 was observed in bed on her back. Nurse 'G' entered the room to perform a skin assessment. Resident #804 was observed to be in a guarded position, she presented board-like and performed very little movement. Resident #804 was interviewed and explained that she was experiencing pain in her right foot, I had a nail that turned into the meat (skin) and it made the foot swell up and it hurt really bad. It was pus in that foot before and I do not want it to swell up like that again. Resident #804 rated her pain a 7 out of 10 on the Wong Baker Scale, where 1 indicates little to no pain and 10 represents the worst pain ever experienced. Nurse 'G' assessed both feet, as she reapplied the sock to Resident #804's right foot she touch the right big toe and Resident #804's entire body made a jerking motion and she quickly retracted the right toe away from the sock and stated, Oooo that hurts as she grimaced. Nurse 'G' proceeded to reapply the sock and Resident #804 continued to explain that she had been in pain and that It just hurts and wanted to know what was wrong with her. Resident #804 suddenly stopped and stated, Hold on a minute. I got to make water (urinate) now. Oooo Lord. [MEDICAL CONDITION] I make water. At that time Resident #804 was observed to get into a guarded position, her eyes closed tightly, and she began to grimace. Resident #804 was observed to make a whimpering sound after urinating and stated, I told the nurse about it, but she hasn't done anything. My back hurts and it hurts between my legs. Just take a look at it and tell me what you see. It's got to be something there! At this time, Certified Nurse Assistant (CNA) 'C' entered the room to assist in completion of the skin assessment. Resident #804 was positioned onto her side and revealed a reddened area. Nurse 'G' described the area that was approximately 6 inches by 8 inches to the lower left back as possible bruising. CNA 'C' pointed at the area and stated, I noted that already and reported it the nurse. (However, there was no documented evidence that this occurred). As Resident #804 was repositioned onto her back a Bengay (pain) patch was observed on each of Resident #804's knees. At this time Resident #804 reported that her legs hurt all the time, especially the right leg and knee. When queried, Nurse 'G' observed the patches, noted that the date they were applied as 2/10 and acknowledged that patches applied for the relief of pain are normally applied daily. Clinical record review revealed Resident #804 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per the Minimum Data Set ((MDS) dated [DATE], Resident #804 had intact cognition, was able to express her needs and be understood by others, required extensive to total physical assistance with all activities of daily living, had limited range of motion to both bilateral extremities, and was frequently incontinent of bowel and bladder. The Admission Nursing Assessment, dated 12/11/17 documented that Resident #804 did not experience any pain at the time of admission. A care plan dated 12/12/16 was initiated that addresses [MEDICAL CONDITION] (pain) and [MEDICAL CONDITION] pain. However, there were no new interventions implemented to address Resident #804's specific complaints of pain foot, knee, and pain. In addition, though Resident #804 was admitted with a history of Urinary Tract Infections, there was no care plan that addressed how staff were to monitor Resident #804 for the reoccurrence of UTI's. The MDS pain assessment dated [DATE] indicated that Resident #804 had experienced pain and rated it a 6 out of 10. A pain assessment dated [DATE] indicated that Resident #804 rated her highest pain at an 8, however there was no documented evidence that the pain was addressed. A skin assessment dated [DATE] revealed no concerns related to skin. However, Resident #804 complained of discomfort to this area and a reddened area was observed on 2/13/17. A physician's orders [REDACTED]. A nurses noted dated 2/4/17 documented that Resident #804 was to receive Bengay patches at night due to more pain laying in bed. Review of the Medication Administration Record for the month of February 2016 revealed that nursing staff signed out that the Bengay Patches were applied at 6 p.m. on 2/11/17 and 2/12/17 and was documented as removed at 6 am on 2/11/17, 2/12/17, and 2/13/17. However, the patches dated 2/10/17 were observed to still be in place on 2/13/17 at 2:30 p.m On 2/15/17 at 11:20 a.m., the clinical record was reviewed with Unit Manager 'F' and when queried Unit Manager 'F' explained that she was unaware of Resident #804's complaints of pain upon urination and bruising to the lower left back and that the nurse, Should have followed up on that. When queried further regarding the foot concerns with Resident #804, Unit Manager 'F' explained that a podiatry consult was made in December 2016 and that the podiatrist visits monthly. When asked if Resident #804 was seen in January 2017, Unit Manager 'F' stated, No and then explained that the podiatry consult should have been done Monday (2/13/17) when the concern (regarding Resident #804's feet) came up. On 2/15/17 at 11:45 a.m., Unit Manager 'F' and Physician 'M' was interviewed at Resident #804's bedside and revealed that Unit Manager 'F was not informed of Resident #804's concerns on 2/13/17 when she verbalized the complaints of pain and discomfort to Nurse 'G' and CNA 'C.' Physician 'M' diagnosed Resident #804 with contact [MEDICAL CONDITION] to her lower back and ordered a urinalysis to determine if Resident #804's painful urination was due to a urinary tract infection. On 2/15/17 at 3:45 pm, the Director of Nursing (DON) was informed that Resident #804 complained of a painful right foot that was observed to be painful to the touch, complained of burning when urinating, and reported that she informed the regular nurse and nothing was done. The DON was informed that Resident #804 verbalized these concerns while being cared for by Nurse 'G' and CNA 'C.' In addition, the DON was informed that Resident #804 reported these complaints of pain to staff prior to the observation made on 2/13/17 at 2:00 p.m. and that staff did not report or act on Resident #804's complaints of pain upon urination, foot pain, leg/knee discomfort, or the discomfort to the left lower back until 2/15/17 when Unit Manager 'F' was queried regarding Resident #804's concerns. The DON was queried regarding the events and explained that she would expect that if a resident makes a complaint to the CNA or if the CNA sees some change in the resident's skin she should report that to the nurse so that a further assessment could be made. The DON also explained that when a resident voices complaints to a nurse that the nurse should perform an assessment and inform the physician at the time of the complaint. The DON was unable to explain why staff who were aware of Resident #804's concern did not address Resident #804's concerns in a timely manner. The DON was unable to explain why Resident #804 did not receive her Bengay patches to her knees as ordered. The DON then explained that any skin discoloration should be reported to her and that Resident #804's painful urination was a suspected UTI, I would have called the physician to get a U/A (urinalysis, test for a urinary tract infection). The DON acknowledged that changes in any resident's condition should be promptly addressed. On 2/15/17 at 4:30 p.m., the facility provided a document entitled, Change in status, identifying and communicating, long-term care (undated), noted In a long-term care setting, it's important to identify and address any change in a resident's status from baseline. A resident is more likely to return to baseline status and avoid complications when you recognize and treat the condition early. Upon recognition of a potentially life-threatening condition or significant change in status, the nurse must communicate with other health care providers to meet the needs of the resident. Deficient Practice #2 Based on observation, interview, and record review, the facility failed to ensure medication to relieve pain was applied according to physician's orders [REDACTED].#804 and 806) of 10 residents reviewed for having pain out of a total of 24 sampled residents, resulting in the potential for unrelieved discomfort. Finding include: Resident #804 On 2/13/17 at 2:00 p.m., during a skin assessment performed by Nurse 'G', Resident #804 was repositioned onto her back and revealed the presence of a Bengay (pain) applied to each of Resident #804's knees. At this time Resident #804 reported that her legs hurt all the time, especially the right leg and knee. When queried, Nurse 'G' observed the patches, noted that the date they were applied as 2/10 and acknowledged that patches applied for the relief of pain are normally applied daily. Clinical record review revealed Resident #804 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per the Minimum Data Set ((MDS) dated [DATE], Resident #804 had intact cognition, was able to express her needs and be understood by others, required extensive to total physical assistance with all activities of daily living, and had limited range of motion to both bilateral extremities A physician's orders [REDACTED]. A nurses noted dated 2/4/17 documented that Resident #804 was to receive Bengay patches at night due to more pain laying in bed. Review of the Medication Administration Record for the month of February 2016 revealed that nursing staff signed out that the Bengay Patches were applied at 6 p.m. on 2/11/17 and 2/12/17 and was documented as removed at 6 am on 2/11/17, 2/12/17, and 2/13/17. However, the patches dated 2/10/17 were observed to still be in place on 2/13/17 at 2:30 p.m Resident #806 On 2/13/137 at 12:27 PM, a review of the clinical record revealed that Resident #806 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #806 was cognitively intact but, required extensive physical assistance from staff to complete activities of daily living. The pain assessment, dated 12/2/16, documented that Resident #806 had back pain. The physician orders, dated January 2017, documented that Resident #806 was supposed to have a Bengay Patch applied to his lower back at 6:00 AM every day and removed at 6:00 PM the same day. On 2/13/17 at 1:22 PM, during the wound care observation, Resident #806 was observed to have a patch on his lower back that was dated 1/12/17. At 4:00 PM, a review of the Electronic Medication Administration Record (eMAR) revealed that a nurse had initialed that that Bengay Patch had been removed on the 1/12/17 at 6:00 PM and a new patch had been applied on 1/13/17. On 2/13/17 at 5:05 PM, Nurse A was asked about the Patch. Nurse A checked the eMAR and revealed the patch on Resident #806's lower back was his Bengay patch and was supposed to removed at 5:59 PM. Nurse A looked at the patch on Resident #806's lower back and and said, It was supposed to come off yesterday at 6 PM and another one put on at 6 AM today. I will take this one off now. On 2/15/17 at 10:41 AM, the Director of Nursing (DON) was asked about the above observation. The DON stated, Okay. I see. No explanation was given why the nurses had not removed and applied a new Bengay patch according to the physician's orders [REDACTED].>On 2/15/17 at 2:00 PM, a review of the facility's policy titled Pain Management, revised 8/2016, stated, The facility will evaluate and identify residents for pain, determine the type, location and severity and develop a care plan for pain management .The staff will implement the care plan, monitor the resident, and administer therapeutic interventions for pain, if ordered . Deficient Practice #3 Based on observation, interview, and record review, the facility failed to ensure Antiembolism Stockings were applied according to physician's orders [REDACTED].#806) of one resident reviewed with antiembolism stockings out of a total of 24 sampled residents, resulting in the potential for unrelieved swelling ([MEDICAL CONDITION]) in the lower extremities. Findings include: On 2/13/137 at 12:27 PM, a review of the clinical record revealed that Resident #806 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #806 was cognitively intact but, required extensive physical assistance from staff to complete activities of daily living. The physician orders, dated February 7, 2017, documented that Resident #806 was supposed to have antiembolism stockings (TED Hose) applied at 6:00 AM every day and removed at 6:00 PM the same day due to [MEDICAL CONDITION] in the legs. The physician's orders [REDACTED].#806 was supposed to have his legs elevated. On 2/13/17 at 1:22 PM, 2:55 PM, and 5:05 PM, Resident #806 was observed lying in bed. There were no TED Hose on his legs and the legs were not elevated. On 2/14/17 at 8:20 AM, Certified Nurse Aide (CNA) B was in the process of getting Resident #806 dressed and was observed up in the wheelchair in the dining room at 8:42 AM. Resident #806 did not have on TED Hose. At 8:42 AM, CNA B was asked about Resident 806's TED Hose. CNA B revealed that information would be on the Kardex, which is used to inform CNA's of residents' care needs . CNA B revealed she had checked the Kardex that morning, but was not aware that Resident #806 was supposed to wear TED Hose. CNA B then checked the Kardex, and revealed instructions that Resident #806 was to wear TED hose as ordered. However, the Kardex did not document the specific time they were supposed to be applied. Resident #806 was observed up in the wheelchair until 6:00 PM. Nurse A revealed she was aware that he was supposed to were them and showed a pair of TED hose that were in the drawer in the resident's room. On 2/15/17 at 10:41 AM, the DON was asked about the application of Resident #806's TED Hose, but had no explanation why they had not been applied. On 2/15/17 at 2:15 PM, a review of the facility's policy from Lippincott Procedures titled Antiembolism stockings, revised July 10, 2015, stated, Antiembolism stockings help prevent venous [MEDICAL CONDITION], a disorder that includes [MEDICAL CONDITION] and [MEDICAL CONDITION] embolism (blood clots) .

This refers to intake: # MI 048 Based on interview, and record review, the facility failed ensure a staff member did not turn her back on a resident and lowered the resident's bed to a "lower position" after providing personal care to one (#901) of three sampled resident's reviewed for falls, from a total of three sampled residents, resulting in Resident #901 rolling out of bed when the certified nursing assistant's back was turned to the resident, and falling to the floor, sustaining a hip fracture. Findings include: On 11/10/14 at 9:20 a.m. a Facility Reported Incident involving Resident #901 was discussed with the Director of Nursing (DON) and the Administrator. During the discussion, a review of the incident and accident report reavealed Resident #901 sustained a fractured left hip when the Certified Nursing Assistant (CNA) turned her back to the resident and the resident fell from the bed on 10/26/14. The section of the Incident Report titled, "Fall description details" identified the height of the bed was "not appropriate;" however there was no documentation indicating how high off the floor the bed was at the time of the fall. The incident report read: "the resident fell to the floor...on her left side" and a "stat" (immediate) pelvic x-ray was ordered due to swelling and edema noticed on the left hip. X-ray results for 10/26/14 revealed Resident #901 sustained an acute intertrochanteric femur fracture at the left hip. During this interview, the DON stated, "the CNA, (CNA"A") should have put the bed down when she went to get the wheelchair, which was near the bathroom door" and added, "CNA "A" was retrained on resident safety following the incident." On 11/10/14 at 10:00 a.m. during a telephone interview with Certified Nursing Assistant (CNA) "A", it was reported that she was with Resident #901 at the time Resident #901 fell from the bed. CNA "A" reported she was providing care to Resident #901 on the day of the fall, (10/26/14 at 11:20 a.m.) and stated, "I had finished giving the resident (#901) care and the resident was lying in bed. I forgot to let her bed down (lower the height of the bed)." When queried regarding the height of the bed when care was being provided to Resident #901, CNA "A" stated, "I don't know exactly how high it was but it was high enough so I would'nt have to bend over to do her (Resident #901) care. Information gathered from observing the beds in the facility revealed the bed was raised approximately 3 1/2 feet from the floor. The bed adjustment at a "lower" position revealed the bed height was "inches" from the floor. Investigation revealed Resident #901 had a fall mat positioned on the side of the bed, as ordered by the physician. CNA "A"stated, "I turned to get the wheelchair that was next to the bathroom door. When I turned around with the wheelchair (toward the resident), the resident rolled from the bed to the floor mat. CNA "A" added, "I should have had the chair closer." On 11/10/14 at 10:30 a.m. during a review of Resident #901's closed clinical record, it was noted that Resident #901 no longer resided at the facility and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] described that Resident #901 scored a "2" on the Brief Interview of Mental Status (BIMS--A score of "2" represented "severely" impaired cognition for decision-making skills). Resident #901 required extensive to total physical assistance from two staff members for transfers and bed mobility and was totally dependent and required the assistance of one staff member for mobility, bathing, and dressing. According to Resident #901's care plan, revised on 5/21/14, Resident #901 was "at risk" for falls. Interventions listed on the care plan included: "low bed position". A review of the the CNA Care Guide (no date) on 11/10/14 at 1:30 p.m. included the safety precaution intervention listed in the comprehensive care plan: "low bed position". A facility procedure for maintaining safety of resident's during personal care was requested on 11/10/14 at 2:00 p.m. however, no policy was provided. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 707 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROPERLY ADDRESS A SIGNIFICANT CHANGE IN CONDITION (LETHARGIC, SLUGGISH, ALTERED MENTAL STATUS) FOR ONE RESIDENT (#508) OF TWO REVIEWED FOR APPROPRIATE MONITORING, FROM A TOTAL OF ELEVEN SAMPLED RESIDENTS, RESULTING IN FURTHER DECLINE AND RESIDENT #508 BEING FOUND UNRESPONSIVE REQUIRING hospitalization . FINDINGS INCLUDE: ACCORDING TO THE FACILITY FACE SHEET, #508 WAS REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED [DATE] DOCUMENTED THAT #508 REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, DRESSING, TOILETING, PERSONAL HYGIENE AND BATHING. ACCORDING TO THE FACILITY'S "PATIENT TRANSFER FORM" DATED [DATE], RESIDENT #508 WAS TRANSFERRED TO A NEARBY HOSPITAL VIA AMBULANCE WITH [DIAGNOSES REDACTED]. RESIDENT'S NORMAL IS ALERT AND ORIENTED X 3 (PERSON, PLACE AND TIME). RESIDENT CURRENTLY NOT ALERT, NOT RESPONDING TO VERBAL STIMULI. HR (HEART RATE ELEVATED THIS A.M. RESIDENT HAS POOR APPETITE. BLOOD SUGAR THIS A.M. 221..." A REVIEW OF RESIDENT #508'S HOSPITAL RECORDS DATED [DATE] (LABEL ON NOTE) REVEALED, "...THIS IS A 82 Y/O (YEAR OLD) FEMALE PATIENT WITH PAST medical history of [REDACTED]. PATIENT IS USUALLY ALERT AND ORIENTED TO ONE BUT THIS MORNING, SHE WAS NOT RESPONSIVE. IN THE ER (emergency room ), PATIENT WAS FOUND TO HAVE URINE SUGGESTIVE OF UTI (URINARY TRACT INFECTION) AND CXR (CHEST X-RAY) SUGGESTIVE OF PNEUMONIA..." A REVIEW OF THE HOSPITAL "DISCHARGE SUMMARY" DATED [DATE] REVEALED, "...THE PATIENT CONTINUED TO DECLINE AND died PEACEFULLY ON [DATE] AT 12:30 A.M..." A "NURSE'S NOTES" DATED [DATE] DOCUMENTED, "...OBSERVED RESIDENT SLUGGISH, SHOW TO VERBAL STIMULI. UNABLE TO HOLD PLASTIC CUP OF WATER WHEN PROMPTED BY WRITER (LPN #2), RESIDENT HAS DISPLAYED A LOSS IN APPETITE, THAT IN THE WRITER'S OPINION, THE RESIDENT HAS (IS) DISPLAYING AN ALTERED STATUS (MENTAL)..." ANOTHER NURSE'S NOTE DATED [DATE] 4:00 A.M., DOCUMENTED, "...RESPONSIVE AND ALERT, VERY LETHARGY, WILL NOT TALK..." AN ADDITIONAL NURSE'S NOTE (UNDATED) DOCUMENTED, "RESIDENT (#508) ASSESSED BY NP (NURSE PRACTITIONER), GIVEN ORDERS TO TRANSFER RESIDENT TO HOSPITAL DUE TO [MEDICAL CONDITION](#508'S HEART RATE WAS 124), MENTAL STATUS CHANGE, R/O (RULE OUT)[MEDICAL CONDITION] OR STROKE. RESIDENT IS NOT RESPONDING TO VERBAL STIMULI..." ON [DATE] AT 3:00 P.M., DURING AN INTERVIEW, LPN #2 REPORTED, "...THERE WAS A CHANGE IN HER (#508) MENTAL STATUS. I INITIALLY WENT IN TO GIVE HER MEDS. I SPOKE TO HER (#508) TO ELICIT A VERBAL RESPONSE. SHE WAS LISTLESS, SLUGGISH AND SLOW TO RESPOND. THAT WAS NOT HER NORM. I SAW THAT HER VITAL SIGNS WERE FINE FROM EARLIER..." WHEN ASKED IF A CURRENT SET OF VITAL SIGNS HAD BEEN TAKEN IN ORDER TO ASSESS #508'S CURRENT STATUS, LPN #2 REPORTED (WHILE REVIEWING THE NURSE'S NOTES), "...VITALS SIGNS ARE TAKEN EARLIER IN THE DAY AND THEY SEEMED FINE. I CAN'T BE SURE IF I TOOK THEM AGAIN. I OBSERVED HER. SHE WAS NOT HERSELF. THERE WAS DEFINITELY A MENTAL STATUS CHANGE..." LPN #2 FURTHER REPORTED, "...I CALLED THE DOCTOR BECAUSE I KNOW SHE WAS TAKING [MEDICATION NAME] (PAIN MEDICATION). THAT COULD CAUSE SLUGGISHNESS SO I ASKED THE DOCTOR IF WE COULD JUST REDUCE HER PAIN MEDICATION SO THE DOCTOR SAID TO REDUCE HER PAIN MEDICATION FROM TWO TO ONE. AFTER THAT, I WROTE THE INFORMATION IN THE 24-HOUR REPORT BOOK AND LOGGED IT IN THE DOCTOR'S BOOK AND ENDORSED TO THE MIDNIGHT NURSE..." WHEN ASKED WHY #508 WAS NOT SENT OUT TO THE HOSPITAL FOR EVALUATION AND TREATMENT, LPN #2 SAID, "...SHE WASN'T EATING FOR A COUPLE DAYS BUT ASIDE FROM THAT, I DIDN'T THINK HER PRESENTATION WARRANTED ME SENDING HER OUT. IT WAS MY JUDGMENT THAT CALLING THE DOCTOR AND TELLING HIM WHAT THE RESIDENT WAS TAKING WAS SUFFICIENT..." LPN #2 WAS REMINDED OF HIS PREVIOUS ASSESSMENT IN THAT #508 WAS SLUGGISH, LISTLESS, SLOW TO RESPOND, HAD ALTERED MENTAL STATUS AND THAT HE HAD NEVER SEEN HER LIKE THAT BEFORE, YET CHOSE NOT TO SEND #508 OUT FOR EVALUATION AND TREATMENT. WHEN ASKED TO RESPOND, LPN #2 OFFERED NO RESPONSE. WHEN ASKED IF HE (LPN #2) DESCRIBED #508'S CLINICAL PICTURE TO THE DOCTOR (SLUGGISH, LISTLESS, MENTAL STATUS CHANGE, NOT HER NORM) TO THE PHYSICIAN AS OPPOSED TO ASKING FOR A CHANGE IN MEDICATION, LPN #2 OFFERED NO RESPONSE. AFTER REVIEW OF THE NURSE'S NOTES DOCUMENTED BY THE MIDNIGHT NURSE ON [DATE] 4:00 A.M., LPN #2 REPORTED, "...I'M FURIOUS! I SEE NOW THAT I CAN'T RELY ON ANOTHER NURSE TO ACT ON MY BEHALF. ONCE SHE SAW MY DOCUMENTATION, SHE SHOULD HAVE SENT HER OUT TO THE HOSPITAL..." WHEN DISCUSSED WITH LPN #2 THAT HE WAS THE FIRST TO NOTICE #508'S SIGNIFICANT CHANGE IN CONDITION AND HAD THE RESPONSIBILITY TO ENSURE THAT HER HEALTH ISSUES WERE ADDRESSED, LPN #2 RESTATED THAT IT WAS THE ONCOMING NURSE'S RESPONSIBILITY TO SEND HER (#508) OUT FOR EVALUATION AND TREATMENT. ON [DATE] AT 3:57 P.M., WHEN ASKED WHY STAFF HAD CHOSEN NOT TO SEND RESIDENT #508 TO THE HOSPITAL FOR EVALUATION OF HER SIGNIFICANT CHANGE OF CONDITION INCLUDING AN ALTERED MENTAL STATUS, THE DON REPORTED, "...THEY COULD HAVE..."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 084 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PREVENTIVE INTERVENTIONS TO PREVENT THE DEVELOPMENT OF PRESSURE SORES FOR ONE RESIDENT (#505) OF FIVE RESIDENTS REVIEWED FOR PRESSURE SORES, FROM A TOTAL OF ELEVEN SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF A NEW PRESSURE ULCER. FINDINGS INCLUDE: LICENSED PRACTICAL NURSE (LPN) #4, WHO WAS RESPONSIBLE FOR TREATMENTS IN THE FACILITY WAS INTERVIEWED ON 6/13/12 AT 9:35 P.M. LPN #4 IDENTIFIED RESIDENT #505 AS HAVING A PRESSURE ULCER. WHEN QUERIED ABOUT #505'S PRESSURE ULCER TO HER (#505) LEFT HEEL, LPN #4 REPORTED, "...SHE GOT THE ULCER DUE TO EXCESSIVE PRESSURE ON HER HEELS. SHE HAD [MEDICAL CONDITION] (DEEP VEIN [MEDICAL CONDITION]) AND WASN'T MOVING AROUND MUCH WHEN SHE CAME FROM THE HOSPITAL. SHE'S UP AND AT 'EM NOW. IT'S (PRESSURE ULCER) STABLE AND DRY. IT'S GOT ESCHAR TO IT BUT IT'S STABLE..." A REVIEW OF THE FACILITY ADMISSION SHEET REVEALED THAT #505 WAS INITIALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 5/27/12 DOCUMENTED THAT #505 HAD SEVERELY IMPAIRED COGNITION FOR DECISION MAKING, HAD LONG AND SHORT TERM MEMORY PROBLEMS AND REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING, BED MOBILITY, TRANSFERS, DRESSING, HYGIENE, BATHING AND TOILETING. A REVIEW OF THE "NURSING COMPREHENSIVE EVALUATION" DATED 3/30/12 REVEALED THAT #505 WAS readmitted TO THE FACILITY WITH A [DIAGNOSES REDACTED]. WHEN ASKED WHERE #508'S PRESSURE ULCER ORIGINATED, LPN #4 SAID, "...IT ORIGINATED HERE (AT THE FACILITY). IT WAS IDENTIFIED ON 5/1/12..." WHEN ASKED IF THERE WERE ANY PREVENTIVE INTERVENTIONS IN PLACE PRIOR TO THE DEVELOPMENT OF #505'S PRESSURE ULCER, LPN #4 SAID, "...SHE DIDN'T HAVE ANYTHING IN PLACE PRIOR TO HER GETTING THE SORE..." UPON REVIEW OF THE CLINICAL RECORD, THERE WAS NO DOCUMENTED EVIDENCE THAT PREVENTIVE INTERVENTIONS WERE PUT INTO PLACE TO DECREASE EXCESSIVE PRESSURE. ON 6/13/12 AT 9:50 A.M., DURING A TOUR OF THE FACILITY, WITH THE TREATMENT NURSE (LPN #4) PRESENT, #505 WAS OBSERVED IN HER ROOM SEATED IN A WHEELCHAIR. RESIDENT #508 HAD WHITE SOCKS ON AND ONE BLACK SHOE ON HER RIGHT FOOT. THERE WAS NO SHOE ON #505'S LEFT FOOT. RESIDENT #505'S LEFT FOOT WAS DIRECTLY ON THE FLOOR. A REVIEW OF THE TREATMENT RECORDS REVEALED THAT #505 WAS TO HAVE ON A HEEL PROTECTOR AND DRY DRESSING. #505 DID NOT HAVE ON A HEEL PROTECTOR AND NO DRESSING COVERED HER LEFT HEEL ULCER AS INDICATED IN THE TREATMENT RECORDS. WHEN ASKED WHY #505 WAS NOT WEARING HER HEEL PROTECTOR AND WHY THERE WAS NO DRESSING ON HER LEFT HEEL PRESSURE ULCER, LPN #4 REPORTED, "...I CAN'T ANSWER THAT. THERE IS NO REASON WHATSOEVER..." LPN #4 PROCEEDED TO LOOK THROUGH #505'S CLOSET AND NIGHT STAND DRAWERS FOR THE HEEL PROTECTOR. THERE WAS NO HEEL PROTECTOR APPLIED TO #508'S LEFT HEEL/FOOT AS ORDERED OR ANYWHERE IN #508'S ROOM. DURING A DRESSING APPLICATION AND WOUND CARE OBSERVATION IT WAS OBSERVED THAT #505'S LEFT HEAL WAS COVERED WITH ESCHAR (DEAD TISSUE) WITH NO DRAINAGE. THE AFFECTED AREA WAS CLEANSED WITH SKIN INTEGRITY (NORMAL SALINE CLEANING SOLUTION) AND A DRY DRESSING WAS APPLIED. THE WOUND EDGES WERE NOTED TO BE LIFTING. A REVIEW OF AN "INTERDISCIPLINARY PROGRESS NOTE" DATED 5/1/12 REVEALED "...LEFT HEEL HAS ESCHAR AND MEASURES 6.0 CM (CENTIMETERS) X (BY) 8.5 CM. HAS DRY DISCOLORED BASE..." A physician's orders [REDACTED]. CHANGE EVERY TWO DAYS AND AS NEEDED. HEEL PROTECTOR TO LEFT HEEL. HEELS UP CUSHION WHILE IN BED..." A WOUND CARE SPECIALIST NOTE DATED 5/1/12 DOCUMENTED, "...LEFT HEEL 6.0 X 8.5 CM DRY DISCOLORED BASE. RIGHT HEEL IS INTACT. ESCHAR LEFT HEEL. PRESSURE REDUCTION MATTRESS, FREQUENTLY REPOSITION..." THE FACILITY STAFF COULD NOT EXPLAIN WHY THEY FAILED TO IMPLEMENT PREVENTIVE INTERVENTIONS TO PREVENT THE DEVELOPMENT OF #508'S LEFT HEEL ULCER. THE FACILITY'S PRESSURE SORE POLICY WAS REQUESTED BUT NOT SUBMITTED DURING THE INVESTIGATION.

THIS CITATION CONTAINS MULTIPLE DEFICIENT PRACTICES: DEFICIENT PRACTICE #1: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION TO PREVENT FALLS FOR ONE (#401) OF SIX RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL OF 23 SAMPLED RESIDENTS , RESULTING IN A RESIDENT SUSTAINING A FRACTURED ARM AFTER TIPPING OVER IN A WHEELCHAIR. FINDINGS INCLUDE: ON 4/3/12 AT 9:00 A.M., DURING THE TOUR OF THE SECOND FLOOR NURSING UNIT WITH UNIT MANAGER "A", RESIDENT #401 WAS NOT OBSERVED IN HER ROOM. AN ARM SLING WAS OBSERVED IN THE CHAIR NEXT TO RESIDENT #401'S BED. WHEN QUERIED ABOUT THE SLING, UNIT MANAGER "A" REPORTED THE SLING WAS PRESCRIBED AFTER THE resident sustained [REDACTED]. UNIT MANAGER "A" ALSO STATED THE RESIDENT "SOMETIMES USES THE SLING AND IT IS CARE PLANNED AND THERE'S A PHYSICIAN 'S ORDER." ON 4/3/12 AT 9:05 A.M., RESIDENT #401 WAS OBSERVED IN THE DINING ROOM IN A WHEELCHAIR WEARING A SELF-RELEASING SEATBELT. THE RESIDENT WAS UNABLE TO RELEASE THE SEATBELT WHEN REQUESTED. AN INCIDENT AND ACCIDENT REPORT (I&A) FOR RESIDENT #401 WAS REVIEWED WITH THE DIRECTOR OF NURSING (DON) ON 4/05/12 AT 12:15 P.M. THE I/A REPORT, DATED 2/3/12, DOCUMENTED RESIDENT #401 "...IN WHEELCHAIR TILTED OVER ON LEFT-SIDE--SITTING IN WHEELCHAIR AT DINING ROOM TABLE...SEATBELT REMAINED INTACT." THE DON STATED, "I FOUND UPON MY INVESTIGATION OF THE INCIDENT THAT THE RESIDENT WAS CLIMBING OUT OF THE BED ALL NIGHT AND REQUIRED CLOSER SUPERVISION ...THE NURSE ASSIGNED STATED SHE WASN'T GONE LONG...WENT TO ANSWER A LIGHT..." WHEN THE NURSE RETURNED TO THE DINING ROOM, RESIDENT #401 WAS OBSERVED ON HER LEFT SIDE THE FLOOR--STILL ATTACHED TO HER WHEELCHAIR. ACCORDING TO A NURSING PROGRESS NOTE, DATED 2/03/12 AT 2:15 P.M. X-RAY RESULTS WERE DOCUMENTED AS FOLLOWS: "LEFT (L) FOREARM ACUTE NON-DISPLACED FRACTURE (FX) OF DISTAL RADIUS..." THE FACILITY'S INVESTIGATION REPORT WAS REQUESTED FOR REVIEW; HOWEVER, ONLY A SINGLE SHEET OF PAPER CONTAINING THREE TYPED WITNESS STATEMENTS WAS PROVIDED. ON 4/5/12 AT 3:00 P.M., STAFF "C" WAS INTERVIEWED REGARDING THE FALL ON 2/3/12 AND REPORTED THE NURSE INSTRUCTED HER TO GET THE RESIDENT UP--BETWEEN 4:00 A.M. AND 4:15 A.M. THAT MORNING BECAUSE RESIDENT #401 WAS "RESTLESS" AND MADE REPEATED ATTEMPTS TO GET OUT OF BED. STAFF "C" REPORTED SHE DRESSED RESIDENT #401, PUT HER IN A WHEELCHAIR, SECURED THE SELF-RELEASING SEATBELT ATTACHED TO THE CHAIR, AND TRANSPORTED THE RESIDENT TO THE DINING ROOM WHERE SHE WAS SEATED AT A TABLE. STAFF "C" REPORTED THERE WERE TWO CERTIFIED NURSING ASSISTANTS (CNA) WORKING THAT NIGHT. AT THE TIME OF THE INCIDENT, STAFF "C" STATED, "I WAS RENDERING AM CARE. THE NURSE CALLED US...WHEN I GOT TO THE DINING ROOM, THE RESIDENT WAS ALREADY FLIPPED OVER IN THE CHAIR WITH THE SEAT BELT STILL ON." REVIEW OF A STATEMENT FROM THE OTHER CNA ASSIGNED TO THE MIDNIGHT SHIFT ON 2/03/12, STAFF "J " REPORTED SHE WAS IN A RESIDENT ROOM "WHEN THE NURSE CAME BACK TO GET ME...TOLD ME SHE NEEDED HELP TO GER (RESIDENT #401'S NAME) OFF THE FLOOR..." ON 4/9/12 AT 1:00 P.M., A PHONE INTERVIEW WAS CONDUCTED WITH STAFF "D" REGARDING THE FALL OF RESIDENT #401 ON 2/3/12. STAFF "D" WAS THE NURSE ON DUTY AT THE TIME OF THE FALL. STAFF "D" REPORTED RESIDENT #401 "SEEMED TO BE CALMING DOWN" AND SHE LEFT THE RESIDENT IN THE DINING ROOM BECAUSE SHE HAD TO ANSWER A CALL LIGHT. STAFF "D" STATED, "I MIGHT HAVE BEEN GONE FIVE MINUTES. I WOULD NOT NORMALLY LEAVE A RESIDENT LIKE THAT ALONE. I THOUGHT I RECALLED THE CNA THERE." REVIEW OF STAFF "D'S" STATEMENT REVEALED THE RESIDENT SAID, "HER ARM HURTS." ON 4/6/12 AT 10:40 A.M., THE ADMINISTRATOR AND DON WERE QUERIED AND UNABLE TO PROVIDE FURTHER INFORMATION OR EXPLANATION OF RESIDENT #401'S FALL, FRACTURE, AND INTERVENTIONS IDENTIFIED BY THE FACILITY TO PREVENT THIS TYPE OF ACCIDENT FROM RECURRING. REVIEW OF RESIDENT #401'S CLINICAL RECORD ON 4/5/12 AT 12:15 P.M., DOCUMENTED THAT THE RESIDENT WAS admitted INTO THE FACILITY ON 7/14/10 AND readmitted on 3/26/11 WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], DESCRIBED RESIDENT #401 AS SEVERELY COGNITIVELY IMPAIRED AND REQUIRED TOTAL ASSISTANCE FROM ONE PERSON FOR HYGIENE AND BATHING. RESIDENT #401 HAD LIMITED RANGE OF MOTION OF AN UPPER EXTREMITY (ONE SIDE) AND BILATERAL LOWER EXTREMITIES. THE RESIDENT WAS INCONTINENT OF URINE AND STOOL. THE MDS dated [DATE] AND 9/26/11 BOTH DOCUMENTED RESIDENT #401 EXPERIENCED ONE FALL EACH QUARTER AND A TRUNK RESTRAINT WAS USED DAILY FOR THE RESIDENT WHEN OUT OF BED OR IN A CHAIR . THE FALL RISK assessment dated [DATE], DOCUMENTED THE RESIDENT HAD SCORED SIX ITEMS OUT OF SEVEN WHICH INDICATED A "HIGH RISK" FOR FALLS. REVIEW OF INTERVENTIONS LISTED ON CARE PLAN ADDRESSING FALLS, DATED 12/19/11 AND UPDATED 2/16/12, PROBLEM: "AT RISK FOR FALLS DUE TO DIAGNOSIS (DX) DEBILITY, GLAUCOMA" INSTRUCTED STAFF TO "BRING OUT TO COMMON AREA FOR SUPERVISION...." REVIEW OF A X-RAY REPORT DATED 2/03/12, REVEALED RESIDENT #401 SUSTAINED "AN ACUTE NON-DISPLACED FRACTURE OF THE DISTAL RADIAL METAPHYSIS." REVIEW OF THE FACILITY POLICY ENTITLED "FALL MANAGEMENT" DATED 5/10 REVEALED, THE FACILITY WAS RESPONSIBLE TO DEVELOP AND IMPLEMENT A CARE PLAN TO MINIMIZE FALLS BY "PROVIDING THE RESIDENT WITH ADEQUATE SUPERVISION..." ( ) DEFICIENT PRACTICE #2: BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ONE OF TWO MEDICATION CARTS OBSERVED ON THE FIFTH (5TH) FLOOR, FROM A TOTAL OF EIGHT MEDICATION CARTS IN THE FACILITY, WERE LOCKED TO PREVENT UNAUTHORIZED ACCESS TO MEDICATIONS, RESULTING IN THE POTENTIAL FOR ACCIDENTAL INGESTION OF MEDICATIONS. THIS HAD THE POTENTIAL TO AFFECT 26 (#89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 199, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, AND 114) OF 26 RESIDENTS WHO LIVED ON THE FIFTH FLOOR. FINDINGS INCLUDE: ON 4/4/12 AT 3:09 P.M. UNTIL 3:18 P.M., THE "HIGH END" MEDICATION CART ON THE 5TH FLOOR NURSING UNIT WAS OBSERVED IN THE HALLWAY WITH NO NURSE ATTENDING IT AND THE MEDICATION CART WAS UNLOCKED. AT APPROXIMATELY 3:18 P.M., A CERTIFIED NURSING ASSISTANT WALKED PAST THE UNLOCKED MEDICATION CART, NOTICED THAT THE CART WAS NOT LOCKED, THEN LOCKED IT. ON 4/6/12 AT 11:05 A.M., THE 5TH FLOOR UNIT MANAGER "E" WAS INTERVIEWED AND STATED, "ALL MEDICATION CARTS SHOULD BE LOCKED WHILE NOT ATTENDED BY NURSING STAFF." ON 4/6/12 AT APPROXIMATELY 12:45 P.M., THE FACILITY'S POLICY ENTITLED, "STORAGE AND EXPIRATION/DATING OF MEDICATIONS, BIOLOGICALS, SYRINGES AND NEEDLES" REVISION DATE 5/10/10, "...ENSURE THAT ALL MEDICATIONS AND BIOLOGICALS, INCLUDING TREATMENT ITEMS, ARE SECURELY STORED IN A LOCKED CABINET/CART OR LOCKED MEDICATION ROOM THAT IS INACCESSIBLE BY RESIDENTS AND VISITORS." ( )